Total knee arthroplasty without patella resurfacing leads to worse results in patients with patellafemoral osteoarthritis Iwano Stages 3-4: a study based on arthroplasty registry data.

PURPOSE: To determine whether the preoperative degree of degeneration of the patellofemoral joint really affects the outcome of total knee arthroplasty (TKA) surgery without patella resurfacing and thus to establish a parameter that might serve as a guiding factor to decide whether or not to perform retropatellar resurfacing. It was hypothesized that patients with preoperative mild patellofemoral osteoarthritis (Iwano Stages 0-2) would significantly differ from patients with preoperative severe patellofemoral osteoarthritis (Iwano Stages 3-4) in terms of patient-reported outcome (Hypothesis 1) and revision rates/survival (Hypothesis 2) after TKA without patella resurfacing. METHODS: Application of a retrospective-comparative design on the basis of Arthroplasty Registry data that included patients with primary TKA without patella resurfacing. Patients were allocated to the following groups based on preoperative radiographic stage of patellofemoral joint degeneration: (a) mild patellofemoral osteoarthritis (Iwano Stage ≤ 2) and (b) severe patellofemoral osteoarthritis (Iwano Stages 3-4). The Western Ontario and MacMaster Universities Osteoarthritis Index (WOMAC) score was assessed preoperative and 1 year postoperative (0: best, 100 worst). In addition, implant survival was calculated from the Arthroplasty Registry data. RESULTS: In 1209 primary TKA without patella resurfacing, postoperative WOMAC total and WOMAC subscores did not differ significantly between groups, but potentially suffered from type 2 error. Three-year survival was 97.4% and 92.5% in patients with preoperative mild and severe patellofemoral osteoarthritis, respectively (p = 0.002). Five-year survival was 95.8% vs. 91.4% (p = 0.033) and 10-year survival was 93.3% vs. 88.6% (p = 0.033), respectively. CONCLUSIONS: From the study findings, it is concluded that patients with preoperative severe patellofemoral osteoarthritis have significantly higher risks for reoperation than do those with preoperative mild patellofemoral osteoarthritis-when treated with TKA without patella resurfacing. Hence, it is recommended that patella resurfacing be applied in patients with severe Iwano Stage 3 or 4 patellofemoral osteoarthritis during TKA. LEVEL OF EVIDENCE: III, Retrospective comparative.

Transporous hernia mesh fixation with fibrin sealant in an in vitro model of spray application.

BACKGROUND: The spray application of fibrin sealant (FS) is widely used for atraumatic mesh fixation in open and laparoscopic hernia surgery. Studies focusing on the optimization of sealant distribution are rare. This study elucidates the impact of spray distance and pressure, the thrombin concentration of the FS, as well as the mesh design on the spray process and the resulting sealant distribution. Furthermore, the effect of interrupting the spray process on sealant distribution was investigated. MATERIAL AND METHODS: Three different meshes were sprayed in a vertical test arrangement with 0.4 mL FS. Fibrin sealants containing 4 and 500 IU/mL thrombin (Tisseel and Artiss; Vienna, Austria) provided by Baxter Biosciences were used. The application distances varied from 5 to 8 cm. The relative fibrin sealant distribution on the individual mesh surfaces was evaluated and compared, as well as loss of FS and patterns of clot formation. RESULTS: Spray distances between 5 and 8 cm led to a homogenous sealant distribution. Lower thrombin concentrations led to significant losses of FS due to slower polymerization. Differences of the fibrin sealant distribution and mesh pore sizes were found. No differences between continuous and discontinuous application were observed. CONCLUSION: The spray application of FS provides a uniform sealant film in a defined range of distances. However, design and pore size of different meshes substantially impact sealant distribution. These findings should be considered when selecting prosthesis for hernia repair. In general, the amount of sealant should not exceed 0.08 mL per cm(2) to avoid obstruction of mesh pores.

Cognitive functioning in at-risk mental states for psychosis and 2-year clinical outcome.

BACKGROUND: Cognitive impairment is prevalent in at-risk mental states (ARMS) for psychosis. METHOD: We studied cognitive functioning at baseline in ARMS individuals and investigated its power to predict ARMS persistence and remission at 2-year follow-up. RESULTS: 196 patients were recruited. At baseline the ARMS population included 26 subjects meeting basic symptom (BS) criteria and 73 subjects fulfilling ultra-high risk (UHR) criteria. Two control groups were defined: 48 patients in a first episode of psychosis (FE), and 49 help-seeking patient controls (PCO). In 144 patients follow-up data were obtained. The 2-year risk of conversion to psychosis was 20%. Remission from an initial UHR state occurred in two thirds of the follow-up sample. UHR patients that converted to psychosis or did not remit during the follow-up (UHR(n-rem)) showed similar impairment in global cognitive functioning at baseline as the FE group, whereas global cognitive functioning in UHR patients with subsequent remission (UHR(rem)) approximated performances of the BS and PCO groups. UHR(n-rem) and UHR(rem) patients differed significantly on immediate verbal memory, but showed similarly impaired executive functions. Normal immediate verbal memory uniquely predicted remission from an at-risk state with a positive predictive value of 82%. CONCLUSIONS: Cognitive deficits are a characteristic feature of true ARMS patients. Verbal memory function appears critical in determining outcome.

Different duration of at-risk mental state associated with neurofunctional abnormalities. A multimodal imaging study.

OBJECTIVES: Neurofunctional alterations are correlates of vulnerability to psychosis, as well as of the disorder itself. How these abnormalities relate to different probabilities for later transition to psychosis is unclear. We investigated vulnerability- versus disease-related versus resilience biomarkers of psychosis during working memory (WM) processing in individuals with an at-risk mental state (ARMS). EXPERIMENTAL DESIGN: Patients with "first-episode psychosis" (FEP, n = 21), short-term ARMS (ARMS-ST, n = 17), long-term ARMS (ARMS-LT, n = 16), and healthy controls (HC, n = 20) were investigated with an n-back WM task. We examined functional magnetic resonance imaging (fMRI) and structural magnetic resonance imaging (sMRI) data in conjunction using biological parametric mapping (BPM) toolbox. PRINCIPAL OBSERVATIONS: There were no differences in accuracy, but the FEP and the ARMS-ST group had longer reaction times compared with the HC and the ARMS-LT group. With the 2-back > 0-back contrast, we found reduced functional activation in ARMS-ST and FEP compared with the HC group in parietal and middle frontal regions. Relative to ARMS-LT individuals, FEP patients showed decreased activation in the bilateral inferior frontal gyrus and insula, and in the left prefrontal cortex. Compared with the ARMS-LT, the ARMS-ST subjects showed reduced activation in the right inferior frontal gyrus and insula. Reduced insular and prefrontal activation was associated with gray matter volume reduction in the same area in the ARMS-LT group. CONCLUSIONS: These findings suggest that vulnerability to psychosis was associated with neurofunctional alterations in fronto-temporo-parietal networks in a WM task. Neurofunctional differences within the ARMS were related to different duration of the prodromal state and resilience factors.

Learned irrelevance and associative learning is attenuated in individuals at risk for psychosis but not in asymptomatic first-degree relatives of schizophrenia patients: translational state markers of psychosis?

Learned irrelevance (LIrr) refers to a form of selective learning that develops as a result of prior noncorrelated exposures of the predicted and predictor stimuli. In learning situations that depend on the associative link between the predicted and predictor stimuli, LIrr is expressed as a retardation of learning. It represents a form of modulation of learning by selective attention. Given the relevance of selective attention impairment to both positive and cognitive schizophrenia symptoms, the question remains whether LIrr impairment represents a state (relating to symptom manifestation) or trait (relating to schizophrenia endophenotypes) marker of human psychosis. We examined this by evaluating the expression of LIrr in an associative learning paradigm in (1) asymptomatic first-degree relatives of schizophrenia patients (SZ-relatives) and in (2) individuals exhibiting prodromal signs of psychosis ("ultrahigh risk" [UHR] patients) in each case relative to demographically matched healthy control subjects. There was no evidence for aberrant LIrr in SZ-relatives, but LIrr as well as associative learning were attenuated in UHR patients. It is concluded that LIrr deficiency in conjunction with a learning impairment might be a useful state marker predictive of psychotic state but a relatively weak link to a potential schizophrenia endophenotype.

Subclinical hallucinations in adolescent outpatients: an outcome study.

OBJECTIVE: We assessed the continued prevalence at one year and association with clinical variables of subclinical hallucinations ascertained at baseline in a cohort of adolescent outpatients referred to a specialized early psychosis service. We further assessed the prevalence of psychiatric disorders in adolescents presenting subclinical hallucinations. METHOD: 84 adolescent patients were sampled from a longitudinal, prospective study that assesses the course of clinical and neuropsychological measures in patients identified as at high clinical risk for psychosis. Subclinical hallucinations were measured using the Scale of Prodromal Symptoms (SOPS) with its companion interview manual (Structured Interview for Prodromal Symptoms, SIPS) [Miller, T.J., McGlashan, T.H., Woods, S.W., Stein, K., Driesen, N., Corcoran, C.M., Hoffman, R., Davidson, L., 1999. Symptom assessment in schizophrenic prodromal states. Psychiatr. Q. 70, 273-287; McGlashan, T.H., Miller, T.J., Woods, S.W., Rosen, J.L., Hoffman, R.E., Davidson, L., 2001. Structured Interview for Prodromal Syndromes (Version 3.0, unpublished manuscript). PRIME Research Clinic, Yale School of Medicine New Haven, Connecticut. ], and the Schizophrenia Proneness Instrument -Adult Version (SPI-A) [Schultze-Lutter, F., Addington, J., Ruhrmann, S., Klosterkötter, J., 2007. Schizophrenia Proneness Instrument (SPI-A). Giovanni Fioriti, Rome, Italy]. At one-year follow-up, only patients reporting subclinical hallucinations at initial assessment were studied. RESULTS: Full remission of subclinical hallucinations occurred in over half and at least partial remission in two thirds of these patients at one-year follow-up. Mood disorders were present in 62.5% of adolescents with subclinical hallucinations at initial assessment. SOPS measures for depression, deficient attention and for unusual/delusional thought were significantly associated with subclinical hallucinations at baseline. However, sustained experience of subclinical hallucinations at one-year follow-up was only predicted by the global level of functioning at baseline, while cannabis abuse, psychiatric and psychopharmacological treatment were not predictors. CONCLUSIONS: Subclinical hallucinations occur across a wide range of mental states in adolescents and show high rates of remission. Our results warrant that the clinical meaning of such phenomena needs to be carefully weighed against the specific developmental phenomena in this particular age range.

Cognitive functioning in the schizophrenia prodrome.

In the last decade, there has been an increasing interest in cognitive alterations during the early course of schizophrenia. From a clinical perspective, a better understanding of cognitive functioning in putative at-risk states for schizophrenia is essential for developing optimal early intervention models. Two approaches have more recently been combined to assess the entire course of the initial schizophrenia prodrome: the predictive "basic symptom at-risk" (BS) and the ultra high-risk (UHR) criteria. Basic symptoms are considered to be present during the entire disease progression, including the initial prodrome, while the onset of symptoms captured by the UHR criteria expresses further disease progression toward frank psychosis. The present study investigated the cognitive functioning in 93 subjects who met either BS or UHR criteria and thus were assumed to be at different points on the putative trajectory to psychosis. We compared them with 43 patients with a first episode of psychosis and to 49 help-seeking patient controls. All groups performed significantly below normative values. Both at-risk groups performed at intermediate levels between the first-episode (FE) group and normative values. The UHR group demonstrated intermediate performance between the FE and BS groups. Overall, auditory working memory, verbal fluency/processing speed, and declarative verbal memory were impaired the most. Our results suggest that cognitive impairments may still be modest in the early stages of the initial schizophrenia prodrome and thus support current efforts to intervene in the early course of impending schizophrenia because early intervention may prevent or delay the onset of frank psychosis and thus prevent further cognitive damage.