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Introduction: Femoral head fractures with associated acetabular fractures are uncommon injuries usually resulting from high-energy mechanisms such as motor vehicle collisions. Outcomes of Pipkin type IV fractures have been historically poor, with high rates of osteonecrosis, post-traumatic arthritis, and heterotopic ossification. The objective of this study was to define the outcomes of operatively treated Pipkin type IV fractures In addition, we reviewed the available literature of this uncommon injury pattern. Methods: A retrospective chart review at a single level 1 trauma center from 2007 to 2016 identified 10 patients with Pipkin IV femoral head fractures. Demographic information, fracture type, associated injuries, operative details, and complications were evaluated. Clinical and radiological outcomes were assessed at latest follow-up including conversion to total hip arthroplasty. Results: Six of the seven patients were treated with open reduction and internal fixation of the femoral head fracture and acetabular fracture through a Kocher–Langenbeck approach aided by a trochanteric flip and one had fragment excision. Six patients (87.5%) developed post-traumatic arthritis. Four (57.1%) later underwent conversion to total hip arthroplasty (THA) a mean of 20.5 months after index procedure. Conclusion: Our study shows a rate of osteonecrosis and osteoarthritis that is even higher than the previously reported studies. The former may relate to longer-term follow-up and the latter possibly due to associated comminuted posterior wall fracture. [ABSTRACT FROM AUTHOR]

Objective:To investigate the evidence for balloon dilatation of the eustachian tube using a transtympanic approach.Methods:A systematic search of several databases was conducted (using the search terms ‘dilation’ or ‘dilatation’, and ‘balloon’ and ‘eustachian tube’). Only studies that used a transtympanic approach for the procedure were included. These studies were then assessed for risk of bias.Results:Three studies were included. Each of these studies was a limited case series, with two performed on human subjects and one on human cadavers. Results of safety and efficacy are conflicting. There is a high risk of bias overall.Conclusion:At present, there is a very narrow evidence base for transtympanic balloon dilatation of the eustachian tube. There are a number of advantages and disadvantages of the technique. Previously identified and theoretical safety concerns will need to be addressed thoroughly in future studies prior to wider clinical use. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the complications associated with anterior pelvic external fixation and the success of this device in maintaining reduction when used in conjunction with sacroiliac screws. Methods: Through a retrospective clinical study at an academic Level I Trauma Center, 129 patients fit the criteria for inclusion with a mean duration of anterior pelvic external fixation of 62 days and mean follow-up of 360 days. Charts were reviewed for complications postoperatively. The symphysis diastasis, vertical displacement and posterior displacement of each hemipelvis were quantified from pelvic radiographs. Results: Of the 129 patients receiving anterior pelvic external fixation, 14 (10.9 %) presented to an emergency department for problems with their anterior pelvic external fixation. Of these 14 patients, 7 (5.4 %) required readmission, all for infectious concerns necessitating IV antibiotics. 6 (4.7 %) required formal operative debridement and device removal. 13 patients (10.1 %) had superficial pin site infections successfully treated with oral antibiotics. Reduction was maintained (rated as fair, good or excellent) in all patients with radiographic follow-up ( n = 74, average radiographic follow-up of 216 days) following removal of their anterior pelvic external fixation. 38 patients (30.4 %) had their anterior pelvic external fixation removed in clinic, while 87 (69.6 %) had formal removal in the operating room. Conclusion: While previous data suggest high complication rates in definitive anterior pelvic external fixation, we present the largest cohort of patients receiving anterior pelvic external fixation and sacroiliac screws, demonstrating a low complication rate while maintaining reduction of the pelvic ring. In addition, we found that these devices could be reliably removed in a clinic setting. [ABSTRACT FROM AUTHOR]

Background. Splenectomy is an uncommon procedure in children, and data on children who underwent splenectomy in South Africa are sparse. Objective. To describe the profile, operative management and outcomes of children undergoing splenectomy. Methods. The records for all children aged 0 to 16 years who underwent splenectomy at Charlotte Maxeke Johannesburg Academic (CMJAH) and Chris Hani Baragwanath Academic (CHBAH) hospitals between 2000 and 2015 were reviewed. Student's t-tests and ϰ² tests were used to analyse the data. Results. The mean age at surgery was 9.9 years (range 3-16). Most splenectomies (91%; n=30/33) were performed for haematological disorders and were open (67%; n=22/33). The mean post-operative length of stay (LOS) was shorter in the laparoscopic (4.5 days) than the open (7.1 days) groups (p<0.05). Surgical complications were more common in the laparoscopic (36%, 4/11) than open (9%; n=2/22) group, and in children older than the mean age at time of surgery. No cases of overwhelming post splenectomy infection (OPSI) were noted. At study completion, 61% (n=20/33) of patients were alive, 9% (n=3/33) had demised, and 30% (n=10/33) were lost to follow-up. Conclusion. Local indications for paediatric splenectomy mirror those found in international literature. Mean and median postoperative lengths of stay (LOS) were shorter in the laparoscopic than open group, but relatively longer for both groups than reported internationally. Laparoscopy is not currently the preferred technique for splenectomy in our setting. All mortalities were due to progression of underlying disease and no cases of OPSI were recorded. The high loss-to-follow-up rate in this study is a significant barrier to accurate data collection, analysis and reporting. [ABSTRACT FROM AUTHOR]

Background:Mastoid surgery carried out to treat chronic otitis media can lead to improvement in objective and subjective measures post-operatively. This study investigated the subjective change in quality of life using the Glasgow Benefit Inventory relative to the type of mastoid surgery undertaken.Method:A retrospective multicentre postal survey of 157 patients who underwent mastoid surgery from 2008 to 2012 was conducted.Results:Eighty-three questionnaire responses were received from patients who underwent surgery at one of three different hospitals (a response rate of 53 per cent). Fifty-seven per cent of patients had a Glasgow Benefit Inventory score of 0, indicating no change in quality of life post-operatively. Thirty-five per cent scored over 50, indicating significant improvement. The only significant difference found was that women fared worse after surgery than men.Conclusion:The choice of mastoid surgery technique should be determined by clinical need and surgeon preference. There is no improvement in quality of life for most patients following mastoid surgery. [ABSTRACT FROM PUBLISHER]

Background: Oxytocics are routinely used in an attempt to prevent excessive blood loss during cesarean section. Misoprostol, a potent uterotonic agent, has been reported to be useful in the prevention and treatment of postpartum hemorrhage by several investigators but its use during cesarean section has not been described. The objective of this study was to randomly compare the effectiveness of oral misoprostol with intravenous syntocinon on blood loss during elective cesarean sections under regional anesthesia.Methods: Sixty pregnant women were randomized either to receive misoprostol 400 micrograms orally or syntocinon 10 IU intravenously during cesarean section. The primary outcome measure was intra-operative blood loss as estimated by physicians, and by values of preoperative and postoperative hemoglobin concentration and hematocrit. Demographic characteristics of the subjects and outcomes were compared using chi-square test for categorical and two-sample t-test for continuous data.Results: Baseline characteristics in terms of age, body weight, parity, gestational age and indications for cesarean section were similar in both groups. The estimated blood loss was 545 ml (CI 476-614) in misoprostol group and 533 ml (CI 427-639) in syntocinon group (p = 0.85). Differences in preoperative and postoperative hemoglobin and hematocrit values were also similar in both groups. Two women in the misoprostol group and three in the syntocinon group (p=0.64) required additional oxytocics. One patient in each group required blood transfusion. No serious side effects were noted in either group.Conclusion: Oral misoprostol appears to be safe and as effective as intravenous syntocinon in reduction of intra-operative blood loss during elective cesarean section under regional anesthesia and merits further investigation. [ABSTRACT FROM AUTHOR]

Six dogs with accidental paresis were subjected to neurological limb response examination. The reflexes of rear limb were evaluated and graded as per standard clinical methods. Therapeutics efficacy of Methyl prednisolone sodium succinate was evaluated in treating dogs with accidentally paresis. Hind limb reflexes like patellar reflex showed improvement in 13.8% of the cases for left limb and 16.6% of the cases of right limb. There was 8.3% improvement in gastrocnemius reflex of left rear limb and 2.7% in right rear limb. For anterior tibial and flexor reflex there was improvement in 8.3% and 22.2% of cases after treatment, respectively. Therapeutic efficacy of combination of Methyl prednisolone sodium succinate, Vitamin B-complex and physiotherapy was effective in curing cases of accidental paralysis with a success rate of 50.0%. [ABSTRACT FROM AUTHOR]

Bortezomib, a proteasome inhibitor, offers effective desensitization in heart transplant candidates.. We reviewed our center's experience using bortezomib as desensitization therapy for highly sensitized patients to assess pre- and post-transplant outcomes. We assessed 43 HTx candidates 2010-2021 who were highly sensitized with cPRA greater than 50%, underwent bortezomib desensitization, and were subsequently transplanted. Enrolled patients received a course of up to four doses of bortezomib (1.3 mg/m2) over 2 weeks in conjunction with plasmapheresis. The efficacy of bortezomib was assessed by comparing the pre- vs post-desensitization therapy in cPRA, panel reactive antibodies to HLA Class I or Class II antigens, and reduction in immunodominant DSA via MFI. 1-year survival, 1-year freedom from antibody-mediated rejection (AMR), 1-year freedom from hyperacute rejection, 1-year freedom from hemodynamic compromise rejection, and 1-year freedom from the development of de novo DSA were also assessed. The average cPRA prior to bortezomib treatment was 94.5%. Bortezomib did not lower cPRA, Class I or Class II antibodies or lower the immunodominant antibody. However, these highly sensitized patients who underwent HTx had 95% 1-year survival, 76% freedom from 1-year AMR and 65% freedom from 1-year de novo DSA development. Side effects of bortezomib included thrombocytopenia and/or pancytopenia (43%), treated infection (28%) and self-limited neuropathy (12%). The use of bortezomib in highly sensitized patients does not appear to be clinically effective in lowering circulating antibodies prior to heart transplantation. However, its use may have contributed to acceptable post-transplant outcomes. [ABSTRACT FROM AUTHOR]

Colorectal cancer is the fourth most prevalent cancer in the UK. Fortunately, with modern surveillance programmes, more patients are being diagnosed at an earlier stage. Although surgical excision remains the gold standard, many patients have co-morbidities that preclude them from having radical surgery. Additionally, a number of patients do not wish to live with a permanent colostomy. Radiotherapy has an established role in the non-surgical treatment of patients with rectal cancer. Increasing the radiation dose to the tumour increases the chance of local control. Using contact X-ray brachytherapy (CXB) it is possible to escalate the dose to the tumour and minimise the dose received by surrounding normal tissues. The aim of this study was to evaluate the outcomes of patients from our centre who have undergone CXB with or without external beam radiotherapy. A prospectively maintained and locally managed colorectal database was used to collect clinical details and outcomes for colorectal cancer patients. All patients who were treated with CXB at our institution from the commencement of the service in April 2014 to the end of December 2019 were analysed. There was a minimum of 18 months of follow-up. One hundred and ninety-three patients received at least one fraction of CXB. The median age at first treatment was 72 years (range 33–103 years). Seventy-three per cent of patients were male. Of the operable or high surgical risk patients, 105 were treated radically with radiotherapy, 28 were treated radically with radiotherapy after local resection and 22 patients were medically unfit for surgery. Most patients received external beam radiotherapy 45 Gy/25 fractions (87/146) or 25 Gy in five fractions (35/146). Forty-seven patients received CXB as sole treatment (51% had previous radiotherapy). Of those with a response assessment, with a median follow-up of 35 months, 78% of all patients achieved a clinical complete response (cCR) or a near cCR, 6% had a partial response and 16% had persistent disease. Of 154 radically treated patients with a response assessment, 84% achieved cCR or near cCR, 19% (24/129) of these subsequently relapsed. This series shows that CXB is a well-tolerated and effective treatment in a diverse cohort of patients with rectal cancer. Comparable favourable oncological outcomes were seen, in keeping with previously published work. • Contact brachytherapy (CXB) increases rates of organ preservation in rectal cancer. • A cohort of 193 patients from a single centre treated with CXB is presented. • 85% of 95 patients treated with radical intent achieved complete or near response. • Local relapse occurred in 14% and disease-free survival was 75% at 5 years. • 100% of 28 patients treated with CXB after local excision had complete response. [ABSTRACT FROM AUTHOR]

The rarity of medulloblastoma in the adult population limits information on optimal treatment and clinical outcomes. Adjuvant chemoradiation has been correlated to improved overall survival (OS) in a recent National Cancer Database (NCDB) analysis. We performed a retrospective safety and efficacy analysis of radiation (RT) +/- adjuvant chemotherapy (aCTH) in young adult patients with medulloblastoma to better understand outcomes, prognostic factors, and possibly optimal treatment strategies. We conducted an IRB-approved retrospective chart review on young adult (age ≥18 - 39 years old) patients with medulloblastoma treated at our institution (1992-2018) with a minimum follow-up of 6 months from completion of therapy. We gathered data on patient and disease characteristics, treatment, and clinical outcomes, including OS, progression-free survival (PFS), local control (LC), and freedom from distant metastasis (FDM). We employed Cox regression model for univariable and multivariable analyses and Kaplan-Meier (KM) test methods for survival analyses, using JMP version 15.0 software. Thirty-one patients were treated with postoperative RT including craniospinal irradiation (median dose: 2340 cGy/13 fractions) followed by tumor bed/posterior fossa (median total dose: 5580 cGy/31 fractions) either alone (n = 9; 29%) or with adjuvant chemotherapy (aCTH: n = 22; 71%); mostly as per COG A9961 Regimen A: oral lomustine, intravenous cisplatin, and intravenous vincristine (n = 12). 54.6% (n = 12) were known to complete the full aCTH course. Common RT acute toxicities included G1-2 nausea and/or vomiting (N/V; n = 8) and G1-2 fatigue (n = 6). Common aCTH acute toxicities included G1-2 N/V (n = 7) and peripheral neuropathy: G1-2 (n = 6) and G3 (n = 3). Late adverse events were primarily G1-2 peripheral neuropathy and gait imbalance (22.6%), G1-2 hormonal disturbances (19.4%) and G1-2 neurocognitive impairment (16.1%). Male patients had worse OS, PFS, FDM, and LC. Age at diagnosis, tumor location (lateral vs. central), and completion of aCTH course were shown on uni- and multi-variable analysis to be significantly associated with OS; p<0.05. KM survival analysis revealed superior 10-year PFS and OS in patients who completed aCTH compared to those who received RT alone or did not complete aCTH: 72.9% vs 59.3% vs 42%, p = 0.461, and 74.1% vs 63.5% vs 40%, p = 0.033, respectively. A similar trend was noted for LC and FDM. Our series provides a report of acute and late side effects of treatment of young adult patients with medulloblastoma. Significant OS and PFS advantage are seen of aCTH completion in this patient population. Since optimal treatment of these patients is still an unmet need, prospective studies for this rare disease entity are needed. [ABSTRACT FROM AUTHOR]

Patients with severe heart disease may develop end-stage biventricular heart failure. These patients may require the placement of a total artificial heart (TAH). In many programs, chronic kidney disease (CKD) has been a relative contraindication for those patients with severe biventricular heart disease needing a total artificial heart. For these patients, kidney dialysis (if needed) is not available for outpatients. Furthermore, it is not known if CKD in TAH patients compromises post-transplant outcomes. Between 2011 and 2019, we assessed 20 TAH patients who developed CKD defined as GFR less than 60 mL/min 90 days apart prior to transplant listing. At transplant listing, these patients have GFR less than 30 mL/min. These patients would be listed for combined heart-kidney transplantation (HKTx) being on the TAH. Study endpoints included: 3- and 6-month waitlist mortality and 30-day and 1-year post-transplant survival were recorded. A control group was comprised of patients with TAH placement listed for transplant with heart alone. 3- and 6-month waitlist mortality were similar for TAH patients with CKD compared to TAH patients without CKD. Post-transplant, the two groups had similar survival at 30 days and 1 year. Patients needing chronic dialysis in the first-year post-transplant was similarly observed in 13.3% of TAH patients with CKD and 8.1% of TAH patients without CKD. (See table) Chronic kidney disease is not a contraindication for TAH or subsequent heart transplantation. [ABSTRACT FROM AUTHOR]

It has been reported from the ISHLT registry that women have less optimal outcome after heart transplantation (HTx) compared to men. It is not known whether this difference is due to rejection, NF-MACE, or decreased survival. Between 2010 and 2020, we assessed 1071 HTx patients and divided them by male and female sex. 309 females and 762 males were included in the study. Post-transplant outcomes included 1-year survival, 1-year freedom from cardiac allograft vasculopathy (CAV, stenosis ≥30% by angiography), 1-year freedom from non-fatal major adverse cardiac events (NF-MACE: myocardial infarction, new congestive heart failure, percutaneous coronary intervention, implantable cardioverter defibrillator/pacemaker implant, stroke), 1-year freedom from rejection (acute cellular rejection [ACR], antibody-mediated rejection [AMR]), and 1-year freedom from de novo DSA production. Women were divided into two groups, sensitized (PRA >10%) or non-sensitized. When comparing women to men, women had similar survival, freedom from CAV, and freedom from NF-MACE, but significantly lower freedom from ATR, AMR, and de novo DSA production. Women who were sensitized had similar survival but lower freedom from rejection and DSA production compared to non-sensitized women. 26% of our female patients were sensitized. Major post-transplant outcomes are similar for women and men. However, sensitization may be the reason for more AMR in women but it does not affect short-term major outcomes. Longer follow-up and impact of these outcomes need to be assessed. [ABSTRACT FROM AUTHOR]

Simultaneous heart-kidney transplantation (HKTx) has been increasing over the past 10 years with approximately 5.5% of heart transplants (HTx) being HKTx. Due to the heart being transplanted first and then the kidneys, there is question regarding the incidence and degree of delayed graft function (DGF) in the kidney. In HKTx, it is not uncommon to have fluid shifts and labile hemodynamics perioperatively post-HTx that may require the support of inotropes and vasopressors. It is not known whether these agents can affect the donor kidney which is transplanted immediately after HTx. This may result in varying degrees of DGF and the need for dialysis. Therefore, we reviewed our experience of DGF and compared this to a cohort of patients who underwent kidney transplant (KTx) alone from the UNOS database. Between 2010 and 2020, we assessed 134 HKTx patients. These patients were assessed for DGF (need for dialysis within the first 7 days post-operatively). This study group was compared to a control group of patients who received KTx alone (n=192,134 from the UNOS database) during the same period. In addition, post-transplant outcomes included 1-year survival and patients who resumed chronic dialysis for failed donor kidney. Patients who underwent simultaneous HKTx compared to patients who underwent KTx alone had a significant increase in the development of DGF. However, post-transplant 1-year survival and the percent of patients that resumed chronic dialysis was similar between groups. (see table) Simultaneous HKTx has increased risk for DGF which is most likely related to intraoperative labile hemodynamics commonly requiring the use of inotropes/pressors. However, despite higher incidence for DGF, HKTx has comparable outcomes. [ABSTRACT FROM AUTHOR]

In the past, light chain (AL) amyloid has been associated with poor outcomes after heart transplantation (HTx), mainly due to its complicated course. Many AL amyloid patients will require stem cell transplant following HTx. It is not known whether these patients have acceptable outcomes after HTx. Between 2008 and 2020, we assessed all AL amyloid patients undergoing HTx. Patients were divided into those that required stem cell therapy and those that did not. Both groups were compared to age-matched control that did not have amyloid. Endpoints included 1-year survival, freedom from cardiac allograft vasculopathy (CAV), non-fatal major adverse cardiac events (NF-MACE), and rejection (any treated rejection [ATR], acute cellular rejection [ACR], antibody-mediated rejection [AMR], biopsy-negative rejection [BNR]). There was no difference between AL amyloid patients with and without stem cell therapy in 1-year survival, or freedom from CAV, NF-MACE, or ATR. Compared to matched controls, post-transplant outcomes were similar. (See table.) In the current era, therapies for AL amyloid post-heart transplant appear successful with acceptable outcome compared to non-amyloid patients. AL amyloid is not a contraindication for heart transplantation. [ABSTRACT FROM AUTHOR]

Obesity has been noted as a risk factor for poor outcome after heart transplantation (HTx). Cardiac cachexia has also been reported to be a risk factor for poor outcome, however no threshold has been noted for this patient population. Body mass index (BMI) greater than 35 kg/m2 is a noted threshold for declined patients for HTx, but a lower BMI has not been established. In this study, we reviewed the UNOS database to evaluate underweight patients awaiting HTx to assess whether there is a risk for poor outcomes post-HTx. Between 2000 and 2020, we assessed 16,457 patients from the UNOS database and divided the patients according to BMI groupings below. Patients were divided by CDC BMI definitions: severely underweight (BMI less than 15.0 kg/m2), moderately underweight (15.0 to 16.0 kg/m2), mildly underweight (16.0 to 18.5 kg/m2), and healthy weight (18.5 to <25.0 kg/m2). Endpoints included 1-year survival and freedom from graft failure. There was no significant difference in BMI underweight groups compared to healthy weight group in 30-day, 6-month, and 1-year survival or freedom from graft failure. (see table) There does not appear to be decreased post-heart transplant outcome for mild, moderate, or severely underweight patients. Being severely underweight should not be an absolute contraindication for heart transplant. However, larger number of severely underweight patients are needed to confirm these findings. [ABSTRACT FROM AUTHOR]

Purpose/objective(s): Medulloblastoma is the most common malignant pediatric brain neoplasm, but its pattern of care among adult patients has not been standardized. Recent studies demonstrated that disparity in socioeconomic factors could influence treatment decision and prognosis in many cancers. This study aims to analyze the impact of insurance and socioeconomic status on the clinical outcome of adult patients with medulloblastoma in the United States.Materials/methods: Adult patients (age 18 or older) with medulloblastoma in the brain diagnosed from 2004 to 2016 were identified from the National Cancer Database (NCDB). Patients with unknown status for race, insurance, income quartile, treatment status of radiation or chemotherapy, or overall survival (OS) were excluded. OS was evaluated with the Kaplan-Meier and Cox proportional hazards methods. Logistic regression was performed to assess the effect on dichotomized dependent variable.Results: A total of 1,282 adult patients with medulloblastoma were identified. The median follow-up time was 6.9 years. The mean age was 29 years (range 18-85). 30.9% of patients were uninsured or had Medicaid, 83.2% were white, 81.9% received radiation therapy, and 59.9% received chemotherapy. Using univariate analysis, insurance status, radiation, and chemotherapy were statistically associated with OS. Uninsured/Medicaid patients were associated with poorer OS (hazards ratio [HR] 1.36, 95% CI 1.08-1.71, P < 0.01) compared to those with private insurance. Treatment with radiation therapy (HR 0.43, 95% CI 0.34-0.55, P < 0.01) or chemotherapy (HR 0.51, 95% CI 0.41-0.62, P < 0.01) portended improved OS. After adjusting for age, sex, race, and Charlson-Deyo comorbidity score, statistically significant differences in OS were seen for patients with no insurance/Medicaid (HR 1.48, 95% CI 1.17-1.86, P < 0.01). Using multivariate logistic regression, patients with either no insurance or Medicaid were less likely to receive radiation therapy (odds ratio [OR] 0.69, 95% CI 0.51-0.95, P = 0.02) compared to patients with private insurance, suggesting the mechanistic link between insurance status and pattern of care.Conclusion: Using a large national cohort of adult medulloblastoma patients, this study demonstrated the statistically significant disparity of patient outcomes with insurance status. An effort to address healthcare disparity and increase access to cancer care may improve the clinical outcome for adult patients with medulloblastoma. [ABSTRACT FROM AUTHOR]