Arthroscopic treatment of femoroacetabular impingement following slipped capital femoral epiphysis

Slipped capital femoral epiphysis (SCFE) may lead to symptomatic femoroacetabular impingement (FAI). We report our experience of arthroscopic treatment, including osteochondroplasty, for the sequelae of SCFE. Data were prospectively collected on patients undergoing arthroscopy of the hip for the sequelae of SCFE between March 2007 and February 2013, including demographic data, radiological assessment of the deformity and other factors that may influence outcome, such as the presence of established avascular necrosis. Patients completed the modified Harris hip score (mHHS) and the non-arthritic hip score (NAHS) before and after surgery. In total, 18 patients with a mean age of 19 years (13 to 42), were included in the study. All patients presented with pain in the hip and mechanical symptoms, and had evidence of FAI (cam or mixed impingement) on plain radiographs. The patients underwent arthroscopic osteoplasty of the femoral neck. The mean follow-up was 29 months (23 to 56). The mean mHHS and NAHS scores improved from 56.2 (27.5 to 100.1) and 52.1 (12.5 to 97.5) pre-operatively to 75.1 (33.8 to 96.8, p = 0.01) and 73.6 (18.8 to 100, p = 0.02) at final follow-up, respectively. Linear regression analysis demonstrated a significant association between poorer outcome scores and increased time to surgery following SCFE (p < 0.05 for all parameters except baseline MHHS). Symptomatic FAI following (SCFE) may be addressed using arthroscopic techniques, and should be treated promptly to minimise progressive functional impairment and chondrolabral degeneration.

TAKE HOME MESSAGE

Arthroscopy of the hip can be used to treat femoroacetabular impingement successfully following SCFE. However, this should be performed promptly after presentation in order to prevent irreversible progression and poorer clinical outcomes.

Multimodal and time-lapse skin registration

BACKGROUND/PURPOSE

Computational skin analysis is revolutionizing modern dermatology. Patterns extracted from image sequences enable algorithmic evaluation. Stacking multiple images to analyze pattern variation implicitly assumes that the images are aligned per-pixel. However, breathing and involuntary motion of the patient causes significant misalignment. Alignment algorithms designed for multimodal and time-lapse skin images can solve this problem. Sequences from multi-modal imaging capture unique appearance features in each modality. Time-lapse image sequences capture skin appearance change over time.

METHODS

Multimodal skin images have been acquired under five different modalities: three in reflectance (visible, parallel-polarized, and cross-polarized) and two in fluorescence mode (UVA and blue light excitation). For time-lapse imagery, 39 images of acne lesions over a 3-month period have been collected. The method detects micro-level features like pores, wrinkles, and other skin texture markings in the acquired images. Images are automatically registered to subpixel accuracy.

RESULTS

The proposed registration approach precisely aligns multimodal and time-lapse images. Subsurface recovery from multimodal images has misregistration artefacts that can be eliminated using this approach. Registered time-lapse imaging captures the evolution of appearance of skin regions with time.

CONCLUSION

Misalignment in skin imaging has significant impact on any quantitative or qualitative image evaluation. Micro-level features can be used to obtain highly accurate registration. Multimodal images can be organized with maximal overlap for successful registration. The resulting point-to-point alignment improves the quality of skin image analysis.

Successful management of highly drug resistant tuberculosis with individualised drug susceptibility testing

INTRODUCTION

Many tuberculosis (TB) patients have resistance patterns intermediate between multidrug-resistant (MDR) and extensively drug-resistant (XDR). We defined MDR+ as resistance to rifampin (RMP), isoniazid (INH) and at least one more drug other than fluoroquinolone (FQ) and second-line injectable agent (IA); and Pre-XDR as MDR with additional resistance to either FQ or IA. Such patients too, have compromised treatment options that require various combinations of second line drugs (SLD). The aim of our study was to assess the clinical outcome of patients having such resistance patterns, managed on the basis of prior drug exposure and drug susceptibility testing (DST).

METHODOLOGY

52 consecutive patients were studied. Treatment regimen was devised as per DST and predominantly consisted of a second-line injectable agent (IA), para-aminosalicylic acid (PAS) and clofazimine. Additionally, cycloserine, linezolid, co-amoxiclav and clarithromycin were used to complete a regimen of four to five drugs. Clinical and radiological outcome was evaluated at follow-up and at the end of treatment.

RESULTS

49/52 (94%) patients had good outcome. However, 34 different regimens had to be used, as options for individual patients were limited.

CONCLUSION

Management on the basis of prior drug exposure and individualised DST led to good clinical outcomes. No single regimen emerged as having a wide applicability. This study supports the clinical relevance of DST of oral second line drugs.

Tumor necrosis factor-alpha polymorphisms in women with idiopathic recurrent miscarriage

We investigated the association of tumor necrosis factor-alpha (TNFalpha) gene polymorphisms with idiopathic recurrent miscarriage (RM). TNFalpha -1031T/C, -863C/A, -857C/T, -376G/A, -308G/A, -238G/A, and +488G/A single nucleotide polymorphisms (SNPs) were investigated in 204 RM women and 248 age-matched parous women by PCR-restriction fragment length polymorphism. Significantly higher frequencies of -1031C and -376A alleles were seen in RM patients; significant differences were also noted in the distribution of -1031T/C, -376G/A, and -238G/A genotypes between case and control subjects. Haploview analysis revealed high linkage disequilibrium between -857C/T and +488G/A SNPs, but was lower between the other polymorphisms. Of the possible 52 seven-locus haplotypes constructed, 10 were common, and were included in subsequent analysis. Increased frequency of CCCGGGG and CCCGGAA haplotypes, and reduced frequency of TCCGGGG and TCCGGGA haplotypes were seen in RM patients than in controls. When the Bonferroni correction was applied, differences were significant for the CCCGGAA haplotype, which was higher (OR=4.14; 95% CI=1.84-8.95), and the TCCGGGA haplotype, which were lower among RM cases (OR=0.09; 95% CI=0.02-0.68), thereby conferring RM susceptibility and protection to these haplotypes, respectively. Multivariate analysis confirmed the positive association of only CCCGGAA haplotype with RM (P=0.010; aOR=2.03; 95% CI=1.18-4.47), after controlling for a number of covariates. These results demonstrate that the TNFalpha polymorphisms, in particular the -1031T/C variant, are significantly associated with idiopathic RM. Additional replication studies on other racial groups are needed to confirm our findings.

Natural history of multiple myeloma (MM) relapsing after autologous stem cell transplantation (ASCT)

e19513

Background: The outcome of patients with MM relapsing after ASCT used early in the disease course or after failure of initial therapy, is not well defined. We undertook this study to understand treatment approaches for patients relapsing after single ASCT. Methods: Patients relapsing after single ASCT were identified from a prospectively maintained database and relevant clinical data were extracted from medical records. Relapse and treatment responses were according to IMWG Uniform Response Criteria. Patients relapsing between Jan 2000 and 2008 were included in order to capture a recent cohort contemporaneous to availability of novel drugs. Results: We studied 487 patients who had relapsed following a single ASCT, of whom 351 (72%) had an early SCT (≤ 12 mos from diagnosis). The median estimated follow up for all patients was 27 mos, 50 mos and 69 mos from relapse, SCT and diagnosis respectively. The median overall survival (OS) from the time of relapse was 30 mos for the early SCT group and 21 months for the late SCT group. The median time to relapse following transplant was 15 mos (3–119) among early SCT group and 12 mos (3–76) among the late SCT group. Longer time to relapse as well as longer time from relapse to initiation of therapy were independent predictors of better outcome. Among the early group, nearly a third of the patients achieved a PR or better to first salvage therapy (Table), with another third achieving stable disease and 25% of patients did not have response data. The median progression free survival for the first salvage regimen was 8 mos; 18 mos for those with PR or better and 5 mos for those with SD as the best response. Data on the regimen 2, 3, 4, 5, and 6 were available for 211, 133, 84, 53 and 28 patients respectively. As expected, the response rates and the response duration decreased with increasing number of relapses. Conclusions: Patients relapsing after ASCT can obtain prolonged response duration with the currently available treatments. Those with a durable response to transplant and those not requiring initiation of therapy for long periods after disease relapse have favorable disease biology and have prolonged survival after relapse. The natural history of the disease provides a valuable benchmark for evaluation of newer treatment approaches.

No significant financial relationships to disclose.

Improvement and innovation through collaborative partnerships

This paper provides a conceptual background for future research in the area of innovation and continuous improvement (CI) in the facilities management supply chain. In a modern, rapidly changing business environment, it is important for businesses to sustain innovation and continuous improvement through active collaboration with suppliers and service providers. The paper provides a synthesis of the theories of CI and an evaluation of the practical implications of its implementation and management. It also provides further insights into the different levels of CI capabilities of organisations as well as the critical success factors in forming collaborative alliances between clients, suppliers and other service providers.