Brazilian Total Ankle Replacement Experience.

Brazil experiences a late participation in total ankle arthroplasty, which could have positive and negative aspects. The positive view argues about the modern implants that Brazil has received in the past years, skipping the early total ankle replacement generation who present more complications and low survival rate in the literature. The negative aspects are related to gap of experience with Brazilian surgeons unable to participate in the development of the technique and implant designs during these years. This article discusses the aspects of the Brazilian experience with total ankle replacement since the earliest procedures performed.

Combined Spring and Deltoid Ligament Repair in Adult-Acquired Flatfoot.

BACKGROUND: Adult-acquired flatfoot deformity (AAFD) is usually due to a combination of mechanical failure of the osteoligamentous complex that maintains the medial longitudinal arch of the foot and attenuation or complete tear of the posterior tibial tendon. Magnetic resonance imaging studies in patients with flatfoot deformities have reported the posterior tibial tendon to be pathologic in up to 100% of patients, the spring ligament in up to 87%, and the deltoid ligament in 33%. Many studies in the literature describe reconstruction of the spring ligament or the deltoid ligament associated with AAFD, but there is no study in which both (spring and deltoid) ligaments are reconstructed at the same time. We describe a novel technique to reconstruct the deltoid ligament and the spring ligament at the same time. METHODS: We described the technique and evaluated 10 consecutive patients with AAFD and insufficient ankle and midfoot ligaments. RESULTS: We found no postoperative complications, stiffness, or loss of correction. CONCLUSION: We present a novel technique to reconstruct the failed deltoid and spring ligament during flatfoot correction. It is unique in that it uses internal brace augmentation with FiberTape® to help and protect the soft tissue healing. LEVEL OF EVIDENCE: Level IV, retrospective case series.

1-hexyl n-cyanoacrylate compound (Neucrylate™ AN), a new treatment for berry aneurysm. III: Initial clinical results.

INTRODUCTION: As part of an institutionally approved research protocol, patients with cerebral berry aneurysm were enrolled in a clinical trial designed to evaluate the safety of the new moldable liquid embolic agent Neucrylate AN. METHODS: Twelve patients with aneurysms judged to be suboptimal for treatment by standard endovascular or surgical approaches were treated with Neucrylate AN. The agent was injected during temporary balloon occlusion at the neck of the aneurysm. The immediate angiographic percentage of aneurysm occlusion and periprocedural adverse events were assessed for each patient. Six-month follow-up angiographic studies were obtained for nine of the 12 patients. RESULTS: Ten of the 12 aneurysms treated (83%) were large to giant (>1.0 cm in diameter), nine (75%) were wide-necked (dome/neck ratio <2.0) and three (25%) were dissecting aneurysms. There were four (33%) periprocedural neurological events. Immediate aneurysm occlusion of >90% was obtained in nine of the 12 cases (75%). There were five recurrences (55.5%) at 6 months. CONCLUSION: This preliminary clinical series shows that it is feasible to achieve a high percentage of immediate aneurysm occlusion with limited patient morbidity and mortality in the setting of morphologically challenging aneurysms. These preliminary data support larger trials assessing the safety and efficacy of this agent.

An educational improvement project to track patient encounters: toward a more complete understanding of third-year medical students' experiences.

BACKGROUND: At the University of Missouri School of Medicine (MUSOM), "commitment to improving quality and safety in healthcare" is one of eight key characteristics set as goals for our graduates. As educators, we have modelled our commitment to continuous improvement in the educational experiences through the creation of a method to monitor and analyse patient encounters in the third year of medical school. This educational improvement project allowed course directors to (1) confirm adequate clinical exposure, (2) obtain prompt information on student experiences, (3) adjust individual student rotations to meet requirements and (4) ascertain the range of clinical experiences available to students. DISCUSSION: Data illustrate high levels of use and satisfaction with the educational innovation. We are in our second year using the new Patient Log (PLOG) process and are now considering expanding the use of PLOG into the fourth year of medical school.

[Carney complex. Clinical, pathological and genetic features in two generations of a family]. / Carney-Komplex. Klinik, Pathologie und Genetik bei 2 Generationen einer Familie.

Clinical symptoms of Carney complex occurred in two female members of one family (mother and daughter). In addition to the clinical symptoms, we describe the pathological findings in the adrenals (pigmented nodular hyperplasia of the adrenal cortex), heart (myxoma) and skin/soft tissues (superficial angiomyxomas). Genetic investigation revealed a mutation on the long arm of chromosome 17 in both patients; this mutation had previously been described only in Carney complex type 1. Unilateral adrenalectomy was performed in both these cases, 13 years ago and 7 months ago, respectively. Lifelong cardiac surveillance is mandatory to prevent death from embolism or arrhythmia.

Rapid intracranial clot removal with a new device: the alligator retriever.

BACKGROUND AND PURPOSE: Despite availability of an approved drug to treat acute cerebral ischemia, most patients with stroke do not realize a good outcome. A method that would rapidly increase or restore cerebral perfusion before irreversible cell death should improve patient outcomes. MATERIALS AND METHODS: We recently had the opportunity to treat 6 middle-aged-to-elderly patients who presented with signs and symptoms of acute cerebral ischemia, by mechanically removing their (predominantly) middle cerebral artery clots by using a new retrieval device that had been previously approved by the US Food and Drug Administration for intravascular retrieval of foreign bodies. During a 2-month period, the 6 patients were treated in 5 separate institutions. No patient had an unsuccessful attempt at clot removal. The cases were collected by personal communication with each operator. RESULTS: In all instances, use of the device resulted in rapid clot removal. Each patient had a large improvement in National Institutes of Health Stroke Scale score. Two of the 6 patients had experienced failure of another clot retrieval device, and 3 patients required no systemic thrombolytics, reducing the likelihood of one of the most feared complications of stroke therapy, intracranial hemorrhage. SUMMARY: We believe that use of this device may result in improved outcomes for patients with acute ischemic stroke. In our limited experience, it provided a rapid, safe, and effective means for achieving revascularization.

Analysis of complex framing coil stability in a wide-necked aneurysm model.

Appropriately sized 0.010- and 0.018-inch complex framing coils were placed in a wide-necked silicone aneurysm replica, and their stability was evaluated at variable physiologic flow rates using video recording. After detachment, the 0.010-inch coils demonstrated instability/prolapse that was proportional to flow rate. In contrast, 0.018-inch coils held their 3D configuration regardless of flow rate. The findings support the use of 0.018-inch coils (when possible) in aneurysms with unfavorable geometry, particularly in circulations with higher flow rates.

Complex curve microcatheters for berry aneurysm endovascular therapy.

By using images created with 3D rotational angiography or CT angiography as templates, it is possible to place anatomically correct curves on microcatheters, curves that reproduce the complex 3D vascular anatomy of individual patients. Catheters so curved conform to the anatomy of arteries leading to aneurysms and are less likely to be forced out of position as coil packing progresses.

Risk factors to tick infestations and their occurrence on horses in the state of São Paulo, Brazil.

From December 1998 to March 1999, 40 stud farms were studied in the state of São Paulo, Brazil. During visits to farms, horses reared under grazing conditions were examined for the presence of ticks. On each farm visit, horse pastures were closely inspected and a questionnaire was given to the farm supervisor with the purpose of gaining information about ecological and management variables (independent variables) that could be associated with the presence and infestation levels of ticks on the farm (dependent variables). Three tick species were found during the study. Anocentor nitens, Amblyomma cajennense and Boophilus microplus were present on horses from 38 (95%), 20 (50%) and four (10%) farms, respectively. All farms that had A. cajennense or B. microplus infestations also had A. nitens infestations. Only one of the four farms with B. microplus infestations on the horses also had A. cajennense infestations. Two farms had all horses free of ticks. There was a strong association between the presence of infestation by B. microplus on horses and the simultaneous use of a grazing area by cattle and horses (P = 0.000). There was no statistical association between any of the independent variables and the presence or infestation level of A. nitens on the horses (P > 0.20). The presence of A. cajennense was statistically associated with the presence of at least one mixed overgrowth pasture in the farm (P = 0.001). A mixed overgrowth pasture means the presence of undesired plants such as bushes and shrubs in the pasture. The presence of high levels of A. cajennense on horses was also associated with the presence of at least one mixed overgrowth pasture in the farm (P = 0.026). The regular use of acaricides was statistically associated with the presence of ticks on the horses (P < 0.05), making this procedure a result of the inefficacy of controlling ticks on the farms. The occurrence of human infestation by ticks was statistically associated with the presence of A. cajennense on the horses (P=0.000). The presence of at least one mixed overgrowth pasture on the farm was associated (P = 0.000) to either higher horse densities and to farms that did not mow all the pastures once a year, indicating that mowing all the pastures at least once a year can be considered a protective factor against the presence of mixed overgrowth pastures on the farm, and consequently, against the presence of A. cajennense on the horses.

Analysis of slipstream flow in a wide-necked basilar artery aneurysm: evaluation of potential treatment regimens.

SUMMARY: A replica of a lethal wide-necked basilar artery aneurysm was created by casting a deceased patient's brain vessels and then placing the replica in a circuit of pulsating optically clear non-Newtonian fluid. Individual fluid slipstreams were opacified with isobaric dyes, and images were recorded on film. Studies were completed on the vascular replica, then were repeated, first after placement of a stent across the aneurysm neck and then after placement of Guglielmi detachable coils into the aneurysm sac through the stent. The slipstreams entered the untreated aneurysm via the distal aneurysm neck (the inflow zone), impacting against the distal lateral aneurysm wall. When the stent was placed across the aneurysm neck, the slipstreams lost coherence and did not strike the aneurysm sidewall. Placing the coils further disturbed and reduced aneurysmal flow, especially when the coils filled the inflow zone at the distal lateral aneurysm sac.

First isolation of Sarcocystis neurona from the South American opossum, Didelphis albiventris, from Brazil.

Sarcocystis neurona was isolated from sporocysts from two of eight South American opossums, Didelphis albiventris, from Brazil. Interferon gamma gene knock out (KO) mice fed sporocysts from two opossums developed neurologic sarcocystosis. S. neurona was demonstrated in the brains of infected KO mice by immunohistochemical staining with anti-S. neurona antibody. The parasite was cultivated in cell culture and S. neurona DNA was isolated from cultured merozoites. This is the first report of isolation of S. neurona from Brazil and the first report from its new host, D. albiventris.

Isolates of Sarcocystis falcatula-like organisms from South American opossums Didelphis marsupialis and Didelphis albiventris from São Paulo, Brazil.

Isolates of Sarcocystis falcatula-like organisms from South American opossums were characterized based on biological and morphological criteria. Sporocysts from intestinal scrapings of 1 Didelphis marsupialis and 8 Didelphis albiventris from São Paulo, Brazil, were fed to captive budgerigars (Melopsittacus undulatus). Budgerigars fed sporocysts from all 9 isolates became ill and S. falcatula-like schizonts were identified in sections of their lungs by immunohistochemical staining. Sarcocystis falcatula-like organisms were cultured from lungs of budgerigars fed sporocysts from D. marsupialis and from lungs of budgerigars fed sporocysts from 3 of 8 D. albiventris. The 33/54 locus amplified by polymerase chain reaction from culture-derived merozoites contained both a HinfI endonuclease recognition site previously suggested to diagnose S. falcatula and a DraI site thought to diagnosed S. neurona. Development of the isolate from D. marsupialis was studied in cell culture; its schizonts divided by endopolygeny, leaving a residual body. Morphological and genetic variation differentiated this Sarcocystis isolate originating in D. marsupialis from the Cornell I isolate of S. falcatula. This is the first report of a S. falcatula infection in the South American opossum, D. marsupialis.

Transcatheter snare removal of acute middle cerebral artery thromboembolism: technical case report.

OBJECTIVE AND IMPORTANCE: We describe the case of a patient in whom a snare designed for the removal of foreign bodies was successfully used to retrieve a thromboembolism from the middle cerebral artery. This technique can be used to reestablish blood flow when maximal pharmacological therapies have failed. CLINICAL PRESENTATION: A 38-year-old man with scrotal squamous cell carcinoma presented with the abrupt onset of left hemiparesis and numbness. Computed tomography of the head showed no hemorrhage or hypodensity, and right middle cerebral artery thrombosis was suspected. INTERVENTION: Cerebral angiography demonstrated a near-total occlusion of the right middle cerebral artery at the M1-M2 junction. The administration of intra-arterial urokinase, systemic heparin, and systemic abciximab, and mechanical maceration failed to lyse the clot. A 4-mm goose-neck snare was guided through a microcatheter, and the clot was snared and withdrawn. Immediate postoperative angiography demonstrated the reconstitution of normal flow. Pathological examination of the snared material was consistent with clot. By postoperative Day 5, the patient had regained full strength, except for the fingers of the left hand, which remained moderately weak. Computed tomography demonstrated a right insular and extreme capsular infarct. CONCLUSION: To our knowledge, this is the first reported use of a snare to remove clot in the setting of thromboembolic stroke. As the use of intra-arterial thrombolysis increases, transcatheter snare removal of pharmacologically resistant clot may be considered as a salvage strategy.

Program requirements for residency/fellowship education in neuroendovascular surgery/interventional neuroradiology: a special report on graduate medical education.

BACKGROUND AND PURPOSE: Neuroendovascular surgery/interventional neuroradiology is a relatively new subspecialty that has been evolving since the mid-1970s. During the past 2 decades, significant advances have been made in this field of minimally invasive therapy for the treatment of intracranial cerebral aneurysms; acute stroke therapy intervention; cerebral arteriovenous malformations; carotid cavernous sinus fistulas; head, neck, and spinal cord vascular lesions; and other complex cerebrovascular diseases. Advanced postresidency fellowship programs have now been established in North America, Europe, and Japan, specifically for training in this new subspecialty. METHODS: From 1986 to the present, an ad hoc committee of senior executive committee members from the American Society of Interventional and Therapeutic Neuroradiology, the Joint Section of Cerebrovascular Neurosurgery, and the American Society of Neuroradiology met to establish, by consensus, general guidelines for training physicians in this field. RESULTS: In April 1999, the Executive Committee of the Joint Section of Cerebrovascular Neurosurgery voted unanimously to endorse these training standard guidelines. In May 1999, the Executive Committee of the American Society of Interventional and Therapeutic Neuroradiology and the American Society of Neuroradiology also unanimously voted to endorse these guidelines. In June 1999, the Executive Council of the American Association of Neurological Surgeons and the Congress of Neurological Surgeons unanimously voted to endorse these guidelines. CONCLUSION: The following guidelines for residency/fellowship education have now been endorsed by the parent organization of both the interventional and diagnostic neuroradiology community, as well as both senior organizations representing neurosurgery in North America. These guidelines for training should be used as a reference and guide to any institution establishing a training program in neuroendovascular surgery/interventional neuroradiology.

Liquid acrylic adhesive agents in interventional neuroradiology.

Treating patients with brain arteriovenous malformations by the deposition of liquid embolic agents, particularly cyanoacrylates, requires judgment, technical expertise, and experience. Even though the first deposition of cyanoacrylate in human brain arteries occurred more than 25 years ago, the relative rarity of the disease and the high risk for complications has kept this procedure from being universally applied. Physicians are fortunate that, within the past year, new and better catheters have become available, and with the promise of approved cyanoacrylate devices that are now being evaluated, the future looks bright. This article reviews the history, chemistry, and uses of cyanoacrylate.

The South American opossum, Didelphis marsupialis, from Brazil as another definitive host for Sarcocystis speeri Dubey and Lindsay, 1999.

The North American opossum, Didelphis virginiana, is a definitive host for at least 3 species of Sarcocvstis: S. falcatula Stiles 1983, S. neurona Dubey, Davis, Speer, Bowman, de Lahunta, Granstrom, Topper, Hamir, Cummings, Suter 1991, and S. speeri Dubey and Lindsay 1999. In order to identify species of Sarcocystis in the South American opossum, D. inarsupialis, Sarcocystis sporocysts from the intestines of a naturally infected opossum (D. marsupialis) from Brazil were fed to 4 gamma-interferon knockout (KO) mice, a nude mouse, and 2 budgerigars (Melopsittacus undulatus). All 4 KO mice became ill and 1 died 42 days post-feeding (p.f.) of sporocysts, 1 was killed 44 days p.f. because of neurological signs, and 2 were killed 52 and 53 days p.f. because of abnormal gaits. Numerous sarcocysts were seen in the skeletal muscles of all 4 KO mice and they were structurally identical to S. speeri seen in KO mice fed sporocysts from D. virginiana from the United States and D. albiventris from Argentina. The nude mouse was killed 41 days p.f. because it appeared weak; schizonts were seen in sections of its liver and sarcocysts were seen in sections of skeletal muscles. Sarcocystis speeri was cultured in bovine turbinate cells inoculated with liver homogenate from this mouse. Sarcocystis neurona was not demonstrable in tissues of mice. The two budgerigars remained asymptomatic and S. falcatula was not found in their tissues when they were killed 29 days p.i. This is the first report of S. speeri from D. marsupialis.