Patient-reported, clinical and radiological factors associated with the result after non-surgical management of acute AC joint dislocation Rockwood type III and V.

PURPOSE: The treatment of Rockwood type III and V acromioclavicular (AC) joint dislocations is controversial, and an individualized treatment algorithm is yet to be developed. The objective of this study was to investigate the association of demographical, clinical, patient-reported and radiological variables with the Western Ontario Shoulder Instability Index (WOSI) score and risk of surgery. METHODS: Inclusion criteria for this prospective cohort study were patients aged 18-60 with an acute AC joint dislocation with >25% increase in the coracoclavicular distance on bilateral Zanca radiographs. Patients were treated non-surgically with 3 months of home-based training and the option of delayed surgical intervention. The outcomes were the WOSI score and surgery yes/no. Demographical, clinical, patient-reported (WOSI and Shoulder Pain and Disability Index [SPADI]) and radiological variables were collected at baseline and 6 weeks after the injury and investigated for association with the outcomes at 3 months, 6 months and 1 year. RESULTS: Ninety-five patients with Rockwood type III/V AC joint dislocation were included. Pre-injury participation in overhead/collision sports was a risk factor for surgery with an odds ratio of 5 (p = 0.03). Reduced range of motion (ROM) at baseline was associated with reduced WOSI scores and increased risk of surgery. At 6 weeks, reduced ROM, increased SPADI and increased pain during cross-over were associated with the outcomes. Radiological measurements were not correlated with the result. At the 6 weeks follow-up, patients eventually requiring surgery could be detected with a sensitivity of 100% and a specificity of 94% based on a SPADI score of >30 and a ROM ≤ 140° in shoulder flexion or abduction. CONCLUSION: ROM was the only variable consistently associated with both WOSI and risk of surgery. Six weeks after the injury, it was possible to detect patients in need of surgery based on ROM and SPADI with a sensitivity of 100% and a specificity of 94%. LEVEL OF EVIDENCE: Level II.

The ISAKOS subclassification of Rockwood type III AC joint dislocations in a stable type A and an unstable type B is not clinically relevant.

PURPOSE: The treatment of Rockwood type III AC joint dislocations has been debated for decades. In 2014, the International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine (ISAKOS) Upper Extremity Committee suggested a subclassification of the injury into type A, considered stable and best treated nonsurgically, and type B, considered unstable and best treated surgically. Type B is defined by the presence of scapular dyskinesis and overriding of the clavicle to the acromion on a modified lateral radiograph. The objective of the study was to investigate if this subclassification is clinically relevant. METHODS: This was a prospective cohort study. Inclusion criteria were patients aged 18-60 years with acute AC joint dislocation and a baseline Zanca radiograph with an increase in the CC distance of >25% compared to the uninjured side. All patients were treated nonsurgically with 3 months of home-based training and with the option of delayed surgical intervention. Patients were assessed at baseline and at follow-ups 6 weeks, 3 months, 6 months and 1 year after the injury. At the 6-week follow-up, patients were graded as stable and unstable according to the ISAKOS criteria. Outcomes were the Western Ontario Shoulder Instability Index (WOSI) and referral for surgery. RESULTS: At 6 weeks of follow-up, 20 patients were classified as stable type A and 69 were classified as unstable type B. The ISAKOS subclassification was not clinically relevant, but patients graded as stable had statistically significantly better WOSI scores at 6 months compared to the unstable group (p = 0.03) but not at 3 months or 1 year. Nine patients (9.5%), all from the unstable group, were referred for surgery. No patients from the stable group underwent surgery (n.s). CONCLUSION: The ISAKOS subclassification of Rockwood type III in a stable type A and an unstable type B is not clinically applicable. LEVEL OF EVIDENCE: Level II.

Precision Medicine Approach for Cardiometabolic Risk Factors in Therapeutic Apheresis.

Lipoprotein apheresis (LA) is currently the most powerful intervention possible to reach a maximal reduction of lipids in patients with familial hypercholesterolemia and lipoprotein(a) hyperlipidemia. Although LA is an invasive method, it has few side effects and the best results in preventing further major cardiovascular events. It has been suggested that the highly significant reduction of cardiovascular complications in patients with severe lipid disorders achieved by LA is mediated not only by the potent reduction of lipid levels but also by the removal of other proinflammatory and proatherogenic factors. Here we performed a comprehensive proteomic analysis of patients on LA treatment using intra-individually a set of differently sized apheresis filters with the INUSpheresis system. This study revealed that proteomic analysis correlates well with routine clinical chemistry in these patients. The method is eminently suited to discover new biomarkers and risk factors for cardiovascular disease in these patients. Different filters achieve reduction and removal of proatherogenic proteins in different quantities. This includes not only apolipoproteins, C-reactive protein, fibrinogen, and plasminogen but also proteins like complement factor B (CFAB), protein AMBP, afamin, and the low affinity immunoglobulin gamma Fc region receptor III-A (FcγRIIIa) among others that have been described as atherosclerosis and metabolic vascular diseases promoting factors. We therefore conclude that future trials should be designed to develop an individualized therapy approach for patients on LA based on their metabolic and vascular risk profile. Furthermore, the power of such cascade filter treatment protocols may improve the prevention of cardiometabolic disease and its complications.

Effect of high pressure treatment on the color of fresh and processed meats: A review.

High pressure (HP) treatment often results in discoloration of beef, lamb, pork, and poultry. The degree of color changes depends on the physical and chemical state of the meat, especially myoglobin, and the atmospheric conditions during and after pressurization. A decreased redness is attributed to a large degree to the oxidation of the bright red oxymyoglobin or the purplish deoxymyoglobin into the brownish metmyoglobin, as well as to the denaturation of myoglobin. Surely, the high myoglobin content makes beef more exposed to this discoloration compared to the white chicken meat. In addition, HP treatment causes denaturation of myofibrillar proteins followed by aggregation, consequently, changing the surface reflectance and increasing lightness. Other intrinsic and extrinsic factors may affect the pressure-induced color changes positively or negatively. In this review, the pressure-induced color changes in meat are discussed in relation to modification of the myoglobin molecule, changes in the meat microstructure, and the impact of the presence of different chemical compounds and physical conditions during processing.

Arthroscopic management of suprascapular neuropathy of the shoulder improves pain and functional outcomes with minimal complication rates.

PURPOSE: The purpose of this study was to systematically assess the arthroscopic management of suprascapular neuropathy, including the aetiology, surgical decision-making, clinical outcomes, and complications associated with the procedure. METHODS: Three databases [PubMed, Ovid (Medline), and Embase] were searched. Systematic literature screening and data abstraction was performed in duplicate to present a review of studies reporting on arthroscopic management of suprascapular neuropathy. The quality of the included studies was assessed using level of evidence and the MINORS (Methodological Index for Nonrandomized Studies) checklist. RESULTS: In total, 40 studies (17 case reports, 20 case series, 2 retrospective comparative studies, and 1 prospective comparative study) were identified, including 259 patients (261 shoulders) treated arthroscopically for suprascapular neuropathy. The most common aetiology of suprascapular neuropathy was suprascapular nerve compression by a cyst at the spinoglenoid notch (42%), and the decision to pursue arthroscopic surgery was most commonly based on the results of clinical findings and investigations (47%). Overall, 97% of patients reported significant improvement in or complete resolution of their pre-operative symptoms (including pain, strength, and subjective function of the shoulder) over a mean follow-up period of 23.7 months. Further, there was a low overall complication rate (4%) associated with the arthroscopic procedures. CONCLUSION: While most studies evaluating arthroscopic management of suprascapular neuropathy are uncontrolled studies with lower levels of evidence, results indicate that such management provides patients with significant improvements in pain, strength, and subjective function of the shoulder, and has a low incidence of complications. Patients managed arthroscopically for suprascapular neuropathy may expect significant improvements in pain, strength, and subjective function of the shoulder. LEVEL OF EVIDENCE: Level IV, systematic review of level II to IV studies.

Influence of systemic bone mineral density on atlantoaxial subluxation in patients with rheumatoid arthritis.

Osteopenia and osteoporosis were independent predictive factors for higher atlantoaxial subluxation occurrence in patients with lower body mass index. Our findings suggest that patients with rheumatoid arthritis with osteopenia or osteoporosis, particularly those with lower body mass index (BMI), should be screened regularly to determine the status of their cervical spines. INTRODUCTION: Cervical spine involvement in rheumatoid arthritis (RA) patients may cause serious adverse effects on quality of life and overall health. This study aimed to evaluate the association between atlantodental interval (ADI), atlantoaxial subluxation (AAS), and systemic bone mineral density (BMD) based on BMI variations among established patients with RA. METHODS: The ADI was transformed to the natural log scale to normalize distributions for all analyses. Multivariable linear regression analyses were used to identify independent predictive factors for ADI based on each BMD classification. Multivariate Cox regression analyses were also performed to identify independent predictive factors for the risk of AAS, which were classified by tertile groups of BMI. RESULTS: A total of 1220 patients with RA who had undergone at least one or more cervical radiography and BMD assessments were identified and enrolled. We found that the association between BMD and ADI (ß, -0.029; 95% CI, -0.059 to 0.002; p = 0.070) fell short of achieving statistical significance. However, the ADI showed a 3.6% decrease per 1 BMI increase in the osteoporosis group (ß, -0.036; 95% CI, -0.061 to -0.011; p = 0.004). The osteopenia and osteoporosis groups showed about a 1.5-fold and a 1.8-fold increased risk of AAS occurrence among the first tertile of the BMI group. CONCLUSIONS: Our study showed a possible association between lower BMD and AAS occurrence in patients with RA with lower BMI. Further studies are needed to confirm our findings.

Sarcoidosis and tuberculosis: a connection to the human leukocyte antigen system.

Infectious, genetic factors, and autoimmunity have been considered as potential causes of sarcoidosis (SA). Pathological similarities between SA and tuberculosis (TB) suggest M. tuberculosis antigen(s) as causative agent(s). Our published comparative analysis of the human leukocyte antigens (HLA) system in patients with SA or TB in the same ethnic group revealed that some antigens were connected with high risk of developing of SA or TB, but other were comparable in both patient populations. Is it possible that the predominating occurrence of HLA antigens characteristic for TB may cause tuberculosis in patients with SA? To answer this question we evaluated the HLA class I and II alleles frequency by PCR amplification with sequence-specific primers in three women with histopathologically proven pulmonary SA, who developed bacteriologically confirmed TB on a corticosteroids (CS) therapy. Analysis of HLA in every case separately revealed a trend for higher occurrence of both alleles predisposing and protecting from TB than SA, in comparison with healthy individuals in our previously mentioned HLA genotyping study. Overall, the number of alleles predisposing to TB was statistically greater than the number of alleles connected with a high risk of developing SA. Also, the frequency of protecting alleles was statistically higher for TB than for SA. Therefore, SA in these patients developed at first, and the presence of additional environmental factors, e.g., age, CS might decrease an immune response and provoked TB. There is a possibility that the occurrence of HLA antigen more associated with high risk of developing TB than SA causes the development of tuberculosis in our patients with sarcoidosis.

Organisational standards for the delivery of intensity-modulated radiation therapy in Ontario.

By minimising the effect of irradiation on surrounding tissue, intensity-modulated radiation therapy (IMRT) can deliver higher, more effective doses to the targeted tumour site, minimising treatment-related morbidity and possibly improving cancer control and cure. A multidisciplinary IMRT Expert Panel was convened to develop the organisational standards for the delivery of IMRT. The systematic literature search used MEDLINE, EMBASE, the Cochrane Database, the National Guidelines Clearing House and the Health Technology Assessment Database. An environmental scan of unpublished literature used the Google search engine to review the websites of key organisations, cancer agencies/centres and vendor sites in Canada, the USA, Australia and Europe. In total, 22 relevant guidance documents were identified; 12 from the published literature and 10 from the environmental scan. Professional and organisational standards for the provision of IMRT were developed through the analysis of this evidence and the consensus opinion of the IMRT Expert Panel. The resulting standards address the following domains: planning of new IMRT programmes, practice setting requirements, tools, devices and equipment requirements; professional training requirements; role of personnel; and requirements for quality assurance and safety. Here the IMRT Expert Panel offers organisational and professional standards for the delivery of IMRT, with the intent of promoting innovation, improving access and enhancing patient care.

Defining advanced practice in radiation therapy: A feasibility assessment of a new healthcare provider role in Ontario, Canada.

INTRODUCTION: This study assesses the feasibility of a new role for radiation therapists in Ontario, Canada, called the Advanced Practice Radiation Therapist (APRT), which would address health service pressures and improve patients' access to care. METHODS: A literature search and expert consensus were used to define advanced practice. A standardized template was used to record each APRTs activities/competencies, along with the requisite knowledge, skills and judgment required to perform these competencies. A thematic analysis of the lists was undertaken to develop a single competency profile. Seven APRTs were deployed at four cancer centres to gather contextual information on the development and integration of the new role. RESULTS: The definition of AP consists of seven key traits and includes a framework identifying stages of practice from entry-level practitioner through expert to advanced practitioner. The competency profile consists of clinical, technical and professional domains which further define the scope of practice and shepherd the role through stages of implementation. Role testing showed support for the role and demonstrated that APRTs can deliver specialized services, perform delegated tasks and their work can lead to program efficiencies and new services. The new role may also lead to improved radiation therapist recruitment rates and work satisfaction. CONCLUSIONS: This feasibility assessment served as the foundation for the future long-term implementation of the Clinical Specialist Radiation Therapist (CSRT) Project. As of 2018, there were 24 CSRTs in Ontario. The APRT role is a natural progression for a readying profession which can play a transformative role in addressing health human resource shortages.

Biochemotherapy for the treatment of metastatic malignant melanoma: a clinical practice guideline.

QUESTIONS: What is the role of biochemotherapy in the treatment of metastatic malignant melanoma?What are the adverse effects and effects on quality of life of biochemotherapy as a treatment option?For the purposes of this report, "biochemotherapy" is defined as a therapeutic regimen that includes, at a minimum, chemotherapy (either single-agent or combination) and interleukin-2. PERSPECTIVES: Although early detection, appropriate surgery, and in some cases adjuvant therapy have improved outcomes, at least one third of patients with early-stage melanoma will develop metastases. Recently, in an effort to potentially maximize outcomes, the combination of chemotherapy and immunotherapy (biochemotherapy) was evaluated. The level of interest that this approach has generated, particularly with regard to the apparently high response rates seen in this otherwise devastating illness, was sufficient to merit closer examination by the Melanoma Disease Site Group (dsg) of Cancer Care Ontario's Program in Evidence-based Care (pebc). OUTCOMES: Outcomes of interest include response rate, diseasefree survival, overall survival, quality of life, and incidence of grades 3 and 4 toxicities. METHODOLOGY: Evidence was selected and reviewed by three members of the pebc's Melanoma dsg and by two methodologists. The present practice guideline report was reviewed and approved by the Melanoma dsg, which comprises medical and radiation oncologists, surgeons, and dermatologists. External review by Ontario practitioners was obtained through a mailed survey, the results of which were incorporated into the practice guideline. Final approval of the original guideline report was obtained from the pebc's Report Approval Panel. RESULTS: Clinical recommendations were drafted based on the evidence identified through a systematic review. The practice guideline report with draft recommendations was mailed to Ontario practitioners for external review and to the Report Approval Panel. Feedback from both groups was incorporated into this report to create the final practice guideline. PRACTICE GUIDELINE: The recommendations that follow apply to adult patients with metastatic malignant melanoma. Because of the inconsistent results of the available studies with regard to benefit (response, time to progression, and survival) and consistently high toxicity rates, biochemotherapy is not recommended for the treatment of metastatic melanoma.

Temozolomide for the treatment of metastatic melanoma.

QUESTIONS: What is the role of single-agent temozolomide in the treatment of patients with metastatic melanoma? In comparison with single-agent temozolomide, does the addition of interferon-alpha to temozolomide improve disease-free survival, overall survival, or response rates? In comparison with single-agent temozolomide, does the addition of thalidomide to temozolomide improve disease-free survival, overall survival, or response rates? PERSPECTIVES: Because of its oral route of administration and its ability to cross the blood-brain barrier, temozolomide is a potentially attractive chemotherapy agent for adult patients with unresectable metastatic malignant melanoma. To provide treatment recommendations for this new agent, the Melanoma Disease Site Group (dsg) of Cancer Care Ontario's Program in Evidence-Based Care (pebc) decided to review the available literature on single-agent temozolomide and on temozolomide in combination with interferon-alpha or thalidomide. OUTCOMES: Outcomes of interest included response rates, disease-free survival, overall survival, quality of life, and adverse effects. METHODOLOGY: Evidence was selected and reviewed by two members of the Melanoma dsg and by methodologists. The present practice guideline report was reviewed and approved by the Melanoma dsg, which comprises medical and radiation oncologists, surgeons, and dermatologists. External review was obtained through a mailed survey of Ontario practitioners, the results of which were reflected in revisions to the practice guideline. Final approval of the guideline report was obtained from the Report Approval Panel of the pbec. PRACTICE GUIDELINE: These recommendations apply to adult patients with unresectable metastatic malignant melanoma. It is reasonable to use temozolomide at a dose of 200 mg/m(2) orally for 5 days every 4 weeks as initial systemic treatment for patients with unresectable metastatic malignant melanoma. The addition of moderate-dose interferon-alpha 2b has produced a significantly higher response rate than has single-agent temozolomide in a large randomized phase iii study. However, overall survival was not altered, and grades 3 and 4 hematologic toxicities were higher with the combined treatment. At the present time, the addition of interferon-alpha to temozolomide is not recommended. One randomized phase ii study and six other phase ii studies showed encouraging response rates when thalidomide was combined with temozolomide. However, the doses and schedules of temozolomide in those studies differed from the conventionally prescribed doses and schedules. It is not clear whether the improved response rates were attributable to the small number of patients in the studies, the different temozolomide doses and schedules, or the addition of thalidomide. Further phase iii studies are required to confirm whether a benefit is associated with the combination of temozolomide and thalidomide. Therefore, at this time, it is not recommended that thalidomide be combined with temozolomide. QUALIFYING STATEMENTS: Dacarbazine is the only chemotherapy drug currently approved for the treatment of metastatic malignant melanoma. In large randomized trials, response rates with dacarbazine ranged from 6% to 15%. Almost all responses were partial, with a median response duration of only 7-8 months. Given these disappointing overall results, the consensus among most physicians who are treating patients with metastatic malignant melanoma is that recommending more convenient treatment or experimental treatment to these patients is appropriate. Because of oral dosing, temozolomide is a reasonable choice, particularly for patients who would have difficulty traveling to cancer centres for intravenous chemotherapy. Temozolomide has demonstrated efficacy equal to that of dacarbazine in a randomized phase iii trial. However, unlike dacarbazine, temozolomide is a convenient oral treatment that penetrates the blood-brain barrier and that has shown activity against brain metastases. Although surgery is the preferred treatment modality for patients with solitary brain metastases from melanoma, temozolomide is the preferred chemotherapy for patients with brain metastases who require systemic treatment.

Single-agent interleukin-2 in the treatment of metastatic melanoma.

QUESTIONS: What is the role of single-agent interleukin-2 (il-2) in the treatment of adults with metastatic melanoma? If there is a role for single-agent il-2, what patient population can appropriately be considered for treatment? If there is a role for single-agent il-2, what dose and schedule are appropriate? What are the toxicities associated with il-2? PERSPECTIVES: Many agents have been investigated for antitumour activity in melanoma, but few have shown promising response rates. Early detection, appropriate surgery, and adjuvant therapy have all improved outcomes, but approximately one third of patients with early-stage disease will nevertheless develop metastases. Single-agent il-2 has attracted much attention over the past several years. A number of randomized trials and many phase ii trials investigating single-agent il-2 suggest that this systemic treatment produces durable responses in melanoma patients. Given the dismal survival of patients with meta-static melanoma and the limited availability of effective treatments, the Melanoma Disease Site Group (dsg) of Cancer Care Ontario's Program in Evidence-Based Care (pebc) felt that the durable responses seen with il-2 treatment warranted closer examination. OUTCOMES: Primary outcomes of interest included objective response rate, complete response rate, duration of response, toxicity, and quality of life. Secondary outcomes of interest included progression-free survival and overall survival. METHODOLOGY: A systematic review was developed, and clinical recommendations relevant to patients in Ontario were drafted. The practice guideline report was reviewed and approved by the Melanoma dsg, which comprises medical oncologists, surgeons, and dermatologists. External review by Ontario practitioners was obtained through a mailed survey, the results of which were incorporated into the practice guideline. Final review and approval of the practice guideline was obtained from the pebc's Report Approval Panel. RESULTS: The present practice guideline reflects the integration of the draft recommendations based on a systematic review of the available evidence with the feedback obtained from external review by practitioners and the Report Approval Panel. PRACTICE GUIDELINE: No studies have compared il-2 to the current standard of care-dacarbazine (dtic)-or to placebo in the treatment of metastatic melanoma. After reviewing and weighing the evidence that does exist, the opinion of the Melanoma dsg is that high-dose il-2 is a reasonable treatment option for a select group of patients with metastatic melanoma: Patients should have a good performance status (Eastern Cooperative Oncology Group 0-1) and a normal lactate dehydrogenase level.Patients should have fewer than three organs involved or have cutaneous and/or subcutaneous metastases only, and no evidence of central nervous system metastases should be present.In this select group of patients, il-2 treatment can produce durable complete remissions. High-dose il-2 is recommended to be given at 600,000 IU/kg per dose, delivered intravenously over 15 minutes, every 8 hours, for a maximum of 14 doses. High-dose il-2 delivery is recommended to be done in a tertiary-care facility by staff trained in the provision of this treatment and with appropriate monitoring. To facilitate treatment and to develop expertise in this therapeutic modality, the dsg recommends that high-dose il-2 programs be established in one or two centres in Ontario. QUALIFYING STATEMENTS: High-dose il-2 has response rates that are similar to those seen with standard chemotherapy. However, unlike chemotherapy, il-2 demonstrates low but durable complete response rates that may lead to years of benefit for patients with metastatic melanoma. Based on the available data assessing prognostic factors and patient selection, patients with non-visceral metastases and fewer metastatic sites have a much higher response rate. In these select patients, high dose il-2 may be considered for first-line therapy. The lack of large randomized trials comparing il-2 to dtic or other chemotherapy means that recommendations for this guideline are based largely on phase ii data and limited phase iii data. Further randomized data will not soon become available, because no randomized trials are currently ongoing or planned. Interleukin-2 is currently widely used in the United States, and it is an approved therapy in both Canada and the United States.

Best Practice Recommendations for the Retention of Radiotherapy Records.

This paper offers best practice recommendations for the maintenance and retention of radiotherapy health records and technical information for cancer programmes. The recommendations are based on a review of the published and grey literature, feedback from key informants from seven countries and expert consensus. Ideally, complete health records should be retained for 5 years beyond the patient's lifetime, regardless of where they are created and maintained. Technical information constituting the radiotherapy plan should also be retained beyond the patient's lifetime for 5 years, including the primary images, contours of delineated targets and critical organs, dose distributions and other radiotherapy plan objects. There have been increased data storage and access requirements to support modern image-guided radiotherapy. Therefore, the proposed recommendations represent an ideal state of radiotherapy record retention to facilitate ongoing safe and effective care for patients as well as meaningful and informed retrospective research and policy development.

Effective treatment of different phenotypes of chronic urticaria with omalizumab: Case reports and review of literature.

Despite the excellent efficacy and safety profile of omalizumab in chronic spontaneous urticaria (CSU), there are scarce data concerning its role in the treatment of refractory cases with different phenotypes of urticaria. We describe our experience with the therapy of nine patients with CSU co-existing with delayed pressure urticaria (DPU) or angioedema or both and refractory to treatment with high-dose antihistamines. The first patient, with severe CSU and recurrent angioedema, did not respond well to cyclosporine A or corticosteroids and suffered from numerous side effects of long-term corticosteroid therapy. The second patient presented with severe symptoms of DPU, which first of all prevented any daily activities of the professional routines. Both patients showed a complete remission of urticaria after the first injection of omalizumab. The third patient with CSU and severe DPU had been ineffectively treated for more than 20 years with various medications. Following the administration of omalizumab, the symptoms of CSU subsided but those of DPU intensified, and the drug was withdrawn after two cycles. In another four patients with refractory CSU and angioedema, the symptoms subsided after the first administration of omalizumab, and the patients have been in remission for about 5 weeks. In the remaining two patients, the symptoms did not resolve despite four 300 mg doses of omalizumab. It is important to establish a therapeutic regimen with omalizumab (150-300 mg; every 4-8 weeks) tailored to individual patient's needs and dependent on the type of urticaria; this may minimize unnecessary the medication exposure, adverse drug effects, and healthcare costs.

Clinical findings in competitive swimmers with shoulder pain.

We clinically evaluated 36 competitive swimmers who had shoulder pain; the majority were women. Twenty-three swimmers had unilateral shoulder pain and 13 had bilateral pain, making a total of 49 painful shoulders. Shoulder pain had been present significantly longer in swimmers with bilateral shoulder pain (mean, 104 weeks) than in swimmers with unilateral pain (mean, 33 weeks). Twelve shoulders exhibited signs of impingement without excessive humeral head translation. In 25 shoulders, concomitant signs of impingement and increased glenohumeral translation, together with a positive apprehension sign, were found. Four swimmers, who were generally joint hypermobile, exhibited bilateral impingement signs and excessive humeral head translation, most commonly in the anteroinferior direction. Four shoulders had excessive humeral head translation and apprehension without impingement. Lack of coordination in the scapulohumeral joint was seen significantly more often in symptomatic than in asymptomatic shoulders. Hawkin's test for impingement was more sensitive than Neer's test. Swimmers with shoulder pain have variable clinical findings. The majority demonstrate signs of impingement and increased humeral head translation in the anteroinferior direction together with a positive apprehension sign. This nontraumatic instability might result from wearing of the anteroinferior capsuloligamentous complex. The different clinical findings might represent different stages of the same condition.

Shoulder strength and range of motion in symptomatic and pain-free elite swimmers.

To evaluate differences in shoulder strength and range of motion between painful and pain-free shoulders we examined two matched groups of athletes. Fifteen competitive swimmers were allocated to two groups. Group 1 consisted of seven swimmers with unilateral shoulder pain related to swimming (Neer and Welsh phase I to II). The control group (Group 2) consisted of eight swimmers with no present or previous history of shoulder pain. Concentric and eccentric internal rotational torques were reduced in painful shoulders in between-group comparisons as well as in side-to-side comparisons. The decrease in internal rotational torque resulted in significantly greater concentric and eccentric external-to-internal rotational strength ratios of the painful shoulder in Group 1 swimmers compared with the controls. Furthermore, the functional ratio (eccentric external rotation:concentric internal rotation) was significantly greater in the painful shoulder in both between-group and side-to-side comparisons. Both groups of swimmers exhibited increased external range of motion and reduced internal range of motion compared with normalized data, but no between-group or side-to-side differences were detected. Our findings suggest that prevention or rehabilitation of swimmer's shoulder might not solely involve strengthening of the external rotators of the shoulder joint. Attention might also be drawn toward correction of a possible deficit in internal rotational strength. Changes in shoulder range of motion seem unrelated to the occurrence of shoulder pain.

Inferior capsular shift procedure in athletes with multidirectional instability based on isolated capsular and ligamentous redundancy.

Twenty-five athletes (26 shoulders) who underwent an inferior capsular shift procedure for multidirectional glenohumeral instability based on isolated capsular and ligamentous redundancy were evaluated at a median of 54 months (range, 25 to 113) after the operation. Twenty-one athletes (84%) returned to their preinjury activity level at a median of 5 months after surgery. Of 21 athletes involved in sports using overhead motions, 16 (76%) returned to their previous sport after the operation, and 12 (57%) were still active in this sport at the preinjury level at follow-up. According to the Rowe score, 23 shoulders (88%) were excellent or good. The University of California at Los Angeles score for 24 shoulders (92%) was excellent or good. The operations on two shoulders (8%) failed. One patient had a spontaneous redislocation, and one had recurrent subluxations. Nine contralateral shoulders had a history of significant instability; four of these had undergone Bankart repair. We concluded that athletes who have multidirectional instability based on isolated capsular and ligamentous redundancy can be successfully treated by an inferior capsular shift preserving the subscapularis tendon insertion. We found a high rate of return to demanding upper extremity sports in our patients, range of motion was restored in the majority of shoulders, and the failure rate after a median of 54 months was acceptable.

Symptomatic sacral extradural arachnoid cyst associated with lumbar intradural arachnoid cyst.

A case of sacral extradural arachnoid cyst associated with lumbar intradural arachnoid cyst in a 35-year-old male is reported. The patient presented with a history of severe sacrococcygeal pain, constipation, and dysuria for several months. Computed tomographic (CT) myelograms and magnetic resonance imaging (MRI) scans showed a huge sacral cyst without neural components. A favorable outcome could be achieved by decompression of the cyst, obliteration of the fistulous channel between the cyst and the thecal sac, and fenestration of the arachnoid cyst into the subarachnoid space. The relevant literatures are also reviewed.

Expression of tenascin-C in astrocytic tumors: its relevance to proliferation and angiogenesis.

BACKGROUND: The expression and distribution of the extracellular matrix protein tenascin-C (TN-C) may be enhanced in human astrocytomas. The purpose of this study is to evaluate the expression of TN-C according to histological malignancy of tumor cells and its relevance to neoplastic angiogenesis in human astrocytic tumors. METHODS: Between 1994 and 1998, 52 astrocytic tumor specimens including 4 pilocytic astrocytomas, 13 astrocytomas, 3 anaplastic astrocytomas, and 32 glioblastomas were used in this study. A retrospective analysis was performed to evaluate a statistical correlation between TN-C expression and proliferative indices. We characterized the expression of TN-C in neoplastic vessels, around individual tumor cells as a tumor network, and in tumor cells by immunohistochemistry using antibodies against human TN-C. The proliferative indices were also investigated by immunostaining with the MIB-1 antibody against the Ki-67 proliferation antigen. RESULTS: TN-C immunoreactivity was found to be enhanced in tumor vessels and tumor networks of high-grade astrocytic tumors. The vascular TN-C deposition was greater in high-grade than in low-grade astrocytic tumors (p < 0.05). Its expression was the most intense in glioblastomas. Proliferation indices increased with tumor grade and MIB-1 labeling index (LI) was highest in glioblastomas. Moreover, expression of TN-C in tumor vessels was correlated with proliferative indices. CONCLUSIONS: Our data show that TN-C in human astrocytic tumors may be identified as a factor contributing to malignant progression. And also, enhanced expression of TN-C in tumor vessels having a high proliferative index indicates that TN-C could be involved in neoplastic angiogenesis.