Outcomes of fixation of Vancouver B periprosthetic fractures around cemented versus uncemented stems.

BACKGROUND: The incidence of periprosthetic femur fracture (PPFF) in the setting of total hip arthroplasty (THA) is steadily increasing. We seek to address whether there is a difference in outcomes between Vancouver B fracture types managed with ORIF when the original stem was a press-fit stem versus a cemented stem. METHODS: In this retrospective cohort study at a level 1 trauma center, we identified 136 patients over 65 years-of-age with Vancouver B-type fractures sustained between 2005 and 2019. Patients were treated by ORIF and had either cemented or press-fit stems prior to their injury. Outcomes were subsidence of the femoral implant, time to full weight bearing, rate of the hip implant revision, estimated blood loss (EBL), postoperative complications, and the one-year mortality rate. RESULTS: A total of 103 (75.7%) press-fit and 33 (24.3%) cemented patients were reviewed. Patient baseline characteristics, Vancouver fracture sub-types, and implant characteristics were not found to be significantly different between groups. The difference in subsidence rates, postoperative complications, and time to weight bearing were not significantly different between groups. EBL and one-year mortality rate were significantly higher in the cemented group. CONCLUSIONS: In geriatric patients with Vancouver B type periprosthetic fractures managed with ORIF, patients with an originally press fit stem may have lower mortality, lower estimated blood loss, and similar subsidence and hospital length of stays when compared to those with a cemented stem.

Artificial neural networks for the prediction of transfusion rates in primary total hip arthroplasty.

BACKGROUND: Despite advancements in total hip arthroplasty (THA) and the increased utilization of tranexamic acid, acute blood loss anemia necessitating allogeneic blood transfusion persists as a post-operative complication. The prevalence of allogeneic blood transfusion in primary THA has been reported to be as high as 9%. Therefore, this study aimed to develop and validate novel machine learning models for the prediction of transfusion rates following primary total hip arthroplasty. METHODS: A total of 7265 consecutive patients who underwent primary total hip arthroplasty were evaluated using a single tertiary referral institution database. Patient charts were manually reviewed to identify patient demographics and surgical variables that may be associated with transfusion rates. Four state-of-the-art machine learning algorithms were developed to predict transfusion rates following primary THA, and these models were assessed by discrimination, calibration, and decision curve analysis. RESULTS: The factors most significantly associated with transfusion rates include tranexamic acid usage, bleeding disorders, and pre-operative hematocrit (< 33%). The four machine learning models all achieved excellent performance across discrimination (AUC > 0.78), calibration, and decision curve analysis. CONCLUSION: This study developed machine learning models for the prediction of patient-specific transfusion rates following primary total hip arthroplasty. The results represent a novel application of machine learning, and has the potential to improve outcomes and pre-operative planning. LEVEL OF EVIDENCE: III, case-control retrospective analysis.

Feasibility of Machine Learning in the Prediction of Short-Term Outcomes Following Anterior Cervical Discectomy and Fusion.

BACKGROUND: Increased emphasis is being placed on efficiency and resource utilization when performing anterior cervical discectomy and fusion (ACDF), and accurate prediction of complications is increasingly important to optimize care. This study aimed to compare predictive models for postoperative complications following ACDF using machine learning (ML) models based on traditional comorbidity indices. METHODS: In this retrospective case series, the American College of Surgeons National Surgical Quality Improvement Program database was queried between 2011 and 2017 for all elective, primary ACDF cases. Levels of surgery, use of interbody implants, and graft selection were calculated by procedural codes. Six ML algorithms were constructed using available preoperative and intraoperative features. The overall dataset was randomly split into training (80%) and validation (20%) subsets wherein the training subset optimized the model, and the validation subset was evaluated for accuracy. ML models were compared with models constructed from American Society of Anesthesiologists classification and frailty index alone. RESULTS: There were 42,194 ACDF cases eligible for inclusion. Mean age was 47.7 ± 11.6 years, body mass index was 30.4 ± 6.7, and levels of operation were 1.6 ± 0.7. ML algorithms uniformly outperformed comorbidity indices in predicting complications. Logistic regression ML algorithm was the best performing for predicting any adverse event (area under the curve [AUC] 0.73), transfusion (AUC 0.90), surgical site infection (AUC 0.63), and pneumonia (AUC 0.80). Gradient boosting trees ML algorithm was the best performing for predicting extended length of stay (AUC 0.73). CONCLUSIONS: ML algorithms modeled the development of postoperative adverse events with superior accuracy to that of comorbidity indices and may guide preoperative clinical decision making before ACDF.

Insurance Payer Type Affects Outcomes after Revision Total Joint Arthroplasty: A Matched Cohort Analysis.

Background: The aim of this study is to evaluate the potential effects of insurance payer type on the postoperative outcomes following revision TJA. Methods: A single-institution database was utilized to identify 4,302 consecutive revision THA and TKA. Patient demographics and indications for revision were collected and compared based on patient insurance payer type: (1) Medicaid, (2) Medicare, and (3) private. Propensity score matching and, subsequent, multivariate regression analyses were applied to control for baseline differences between payer groups. Outcomes of interest were rates of complications occurring perioperatively and 90 days post-discharge. Results: After propensity-score-based matching, a total of 2,328 patients remained for further multivariate regression analyses (300 [12.9%] Medicaid, 1022 [43.9%] Medicare, 1006 [43.2%] private). Compared to privately insured patients, Medicaid and Medicare patients had 71% (P<0.01) and 53% (P=0.03) increased odds, respectively, for developing an in-hospital complication. At 90 days post-discharge, compared to privately insured patients, Medicaid and Medicare patients had 88% and 43% odds, respectively, for developing overall major complications. Conclusion: Our propensity-score-matched cohort study found that, compared to privately insured patients, patients with government-sponsored insurance were at an increased risk for developing both major or minor complications perioperatively and at 90-days post-discharge for revision TJA. This suggests that insurance payer type is an independent risk factor for poor outcomes following revision TJA.

The Utility of Machine Learning Algorithms for the Prediction of Early Revision Surgery After Primary Total Hip Arthroplasty.

BACKGROUND: Revision total hip arthroplasty (THA) is associated with increased morbidity, mortality, and healthcare costs due to a technically more demanding surgical procedure when compared with primary THA. Therefore, a better understanding of risk factors for early revision THA is essential to develop strategies for mitigating the risk of patients undergoing early revision. This study aimed to develop and validate novel machine learning (ML) models for the prediction of early revision after primary THA. METHODS: A total of 7,397 consecutive patients who underwent primary THA were evaluated, including 566 patients (6.6%) with confirmed early revision THA (<2 years from index THA). Electronic patient records were manually reviewed to identify patient demographics, implant characteristics, and surgical variables that may be associated with early revision THA. Six ML algorithms were developed to predict early revision THA, and these models were assessed by discrimination, calibration, and decision curve analysis. RESULTS: The strongest predictors for early revision after primary THA were Charlson Comorbidity Index, body mass index >35 kg/m2, and depression. The six ML models all achieved excellent performance across discrimination (area under the curve >0.80), calibration, and decision curve analysis. CONCLUSION: This study developed ML models for the prediction of early revision surgery for patients after primary THA. The study findings show excellent performance on discrimination, calibration, and decision curve analysis for all six candidate models, highlighting the potential of these models to assist in clinical practice patient-specific preoperative quantification of increased risk of early revision THA.

Artificial intelligence algorithms accurately predict prolonged length of stay following revision total knee arthroplasty.

PURPOSE: Although the average length of hospital stay following revision total knee arthroplasty (TKA) has decreased over recent years due to improved perioperative and intraoperative techniques and planning, prolonged length of stay (LOS) continues to be a substantial driver of hospital costs. The purpose of this study was to develop and validate artificial intelligence algorithms for the prediction of prolonged length of stay for patients following revision TKA. METHODS: A total of 2512 consecutive patients who underwent revision TKA were evaluated. Those patients with a length of stay greater than 75th percentile for all length of stays were defined as patients with prolonged LOS. Three artificial intelligence algorithms were developed to predict prolonged LOS following revision TKA and these models were assessed by discrimination, calibration and decision curve analysis. RESULTS: The strongest predictors for prolonged length of stay following revision TKA were age (> 75 years; p < 0.001), Charlson Comorbidity Index (> 6; p < 0.001) and body mass index (> 35 kg/m2; p < 0.001). The three artificial intelligence algorithms all achieved excellent performance across discrimination (AUC > 0.84) and decision curve analysis (p < 0.01). CONCLUSION: The study findings demonstrate excellent performance on discrimination, calibration and decision curve analysis for all three candidate algorithms. This highlights the potential of these artificial intelligence algorithms to assist in the preoperative identification of patients with an increased risk of prolonged LOS following revision TKA, which may aid in strategic discharge planning. LEVEL OF EVIDENCE: IV.

Outcomes After Operative Fixation of Vancouver B2 and B3 Type Periprosthetic Fractures.

OBJECTIVES: The incidence of periprosthetic femur fracture in the setting of total hip arthroplasty is steadily increasing. Although the traditional dogma is that loose femoral components must be revised, we propose that in a frail geriatric population, anatomic reduction and fixation of Vancouver B2 and B3 periprosthetic fracture variants can restore stem stability and provide similar outcomes as revision arthroplasty. DESIGN: Retrospective cohort study. SETTING: Level 1 trauma center, tertiary academic medical center. PATIENTS/PARTICIPANTS: We identified 94 patients over 65 years of age with Vancouver B2 and B3 fractures sustained between 2005 and 2019. INTERVENTION: Patients were treated by either open reduction and internal fixation (ORIF) or revision arthroplasty (RA) with or without fixation. MAIN OUTCOME MEASUREMENTS: Outcomes were mortality, time to full weight-bearing after surgery, intraoperative estimated blood loss, perioperative complications, reoperation, subsidence rate, and Patient-Reported Outcomes Measurement Information System pain and physical function scores. RESULTS: A total of 75 (79.8%) ORIF and 19 (20.2%) RA patients were reviewed. One-year mortality for our cohort was 26.3%, and there was no significant difference between groups. Mean time to weight bear and surgical complication rates were similar between groups. The ORIF group had a significantly shorter time to surgery than the RA group. The RA group had greater incidence and amount of subsidence as well as estimated blood loss than the ORIF group. CONCLUSIONS: In geriatric patients with Vancouver B2 and B3 type periprosthetic fractures with known loose stems, ORIF may offer a similarly safe method of treatment than revision arthroplasty. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Current Requirements and Attitudes Toward Research: A Survey-Based Analysis of Orthopedic Surgery Programs.

Objective The Accreditation Council for Graduate Medical Education (ACGME) guidelines require scholarly activity but do not specify what research-related activity is necessary to meet this requirement. The current components and opinions regarding research and its implementation that qualify as scholarly activity are unknown among US orthopedic surgery programs. We aimed to survey program directors of orthopedic surgery programs to evaluate and better understand the current state of research during training. Design A survey was sent to the program directors of all ACGME-accredited orthopedic surgery between 2019 and 2020 with questions evaluating each program's research requirements and barriers to improvement. Results One-hundred eighteen (N=118) surveys were collected from 94 academic (79.6%) and 24 community (21.4%) programs. Although nearly all (97.5%) programs required research for graduation, only 45% of them allotted protected time: 52 academic programs (55.3%) allotted a median of nine weeks (interquartile range (IQR): 8-12 weeks) of dedicated time and 13 community programs (54.2%) allotted six weeks (IQR: 4-28 weeks) (p=0.595). We distinguished dedicated research as either consecutive weeks or a formal research track for a year. All programs indicated a desire for an increased focus on basic science compared to the current focus on outcomes-based research (p=0.04). The greatest identified obstacle to research improvement reported by community programs was faculty and resource commitment (p=0.003). The overall level of satisfaction with the current research experience among directors is 50.8%. Conclusion Despite differences between academic and community programs, directors agree on shifting the focus of research toward basic science. To improve preclinical research, additional time may be required, and individualized improvement plans should be undertaken at academic and community programs alike.

Preoperative Serum C-Reactive Protein/Albumin Ratio Is a Predictor of Complications After Single-stage Revision for the Treatment of Periprosthetic Joint Infection.

BACKGROUND: The C-reactive protein/albumin ratio (CAR) is a marker of inflammation that has been associated with negative outcomes in the general surgery. This study investigates the potential association of preoperative CAR with postoperative complications and readmission rates in the treatment of patients with single-stage revision total joint arthroplasty for periprosthetic joint infection. METHODS: A total of 213 consecutive patients who had undergone single-stage revision for total joint arthroplasty with the preoperative diagnosis of periprosthetic joint infection and preoperative C-reactive protein and albumin values were included. The area under receiver operating characteristic curves was calculated to evaluate the CAR as a predictive value for the complications. RESULTS: Significant differences between the mean CAR were found for patients with 30- and 60-day readmissions and reinfection (P < 0.01). CAR combined with serum and synovial fluid markers demonstrated significantly higher sensitivities and specificities for the prediction of 30-day (total knee arthroplasty [TKA]: 94%; 95%; total hip arthroplasty [THA]: 91%; 96%) and 60-day readmissions (THA: 94%; 95%; TKA: 92%; 96%) and reinfections (TKA: 94%; 95%; THA: 87%; 96%), when compared with only serum and synovial fluid markers combined (83%; 84%; 85%; 87%; 85%; 88%; P <0.01). DISCUSSION: High preoperative CAR, when combined with serum and synovial fluid markers, was associated with increased risk of reinfection and 30- and 60-day readmissions, suggesting that preoperative CAR is a clinically useful predictor for postoperative complications in patients with periprosthetic hip and knee joint infections.

Shoulder arthroplasty in dwarfism: A case report of pseudoachondroplasia with 17-year follow-up.

The purpose of this case report is to report the long-term outcome following shoulder hemiarthroplasty in a patient with dwarfism. A 60-year old female with pseudoachondroplasia dwarfism presented 17 years post-operative with a Subjective Shoulder Value of 90% and minimal pain. Custom designed implants were critical for surgical success. Preoperative planning with a CT scan was important in assessing glenoid dysplasia and determining the feasibility of glenoid resurfacing. The emergence of 3D CT virtual preoperative planning tools can further assist in the recognition of deformity to determine if custom designed implants are needed. Shoulder arthroplasty in dwarfism can lead to excellent long-term outcomes.

Impact of Smoking and Drinking on Complications After Revision Total Joint Arthroplasty: A Matched Cohort Analysis.

INTRODUCTION: Smoking and drinking have been shown to impair postoperative outcomes in primary hip and knee total joint arthroplasty (TJA). This study aimed to evaluate the potential impact of smoking and drinking on complications after revision TJA. METHODS: We retrospectively evaluated a total of 4,302 consecutive patients who underwent revision TJA. Patient demographics and complications were compared between four cohorts based on smoking and drinking status: (1) nonusers (nonsmokers and nondrinkers), (2) smokers, (3) drinkers, and (4) concurrent users. RESULTS: A total of 1,924 patients were matched using propensity score analysis: 808 nonusers (42.0%), 421 smokers (21.9%), 483 drinkers (25.0%), and 212 concurrent users (11.1%). When compared with nonusers, smokers, drinkers, and concurrent users (simultaneous smokers and drinkers) exhibited higher odds for both inhospital complications (odds ratios, smokers: 2.40, drinkers: 1.55, and concurrent users: 5.13, P < 0.01). Among the user cohorts, although smokers and drinkers showed similar rates of 90-day postdischarge complications (smokers: 14.95% and drinkers: 14.80%, P = 0.95), concurrent users demonstrated the highest significant odds for these complications (odds ratio, 1.64, P = 0.02). DISCUSSION: Our propensity-score-matched cohort study results demonstrate that although the smokers and drinkers groups shared similarly poor outcomes after discharge, concurrent users were found to have the worst outcomes compared with either single user group.

MRI Characteristics of Adverse Local Tissue Reactions Associated With Intraoperative Tissue Damage and Poor Revision Surgery Outcomes: A Systematic Review.

BACKGROUND: Metal artifact reductions sequence (MARS) MRI has been established as a cross-sectional imaging modality for diagnosis of adverse local tissue reaction (ALTR). This study aims to evaluate the current literature regarding the characteristics of MARS MRI associated with intraoperative tissue necrosis and postoperative complications in patients undergoing revision THA because of ALTR. METHODS: We systematically searched the literature that included reporting MRI characteristics of ALTR in failed THA and their correlation with intraoperative findings and postoperative outcomes. RESULTS: A total of 617 studies were assessed, and 15 studies met the inclusion criteria. Synovial wall thickness correlated with increasing ALVAL grade, however, weakly with tissue necrosis. Synovial composition of mixed or solid features and the presence of abductor disruption correlated with complications and tissue necrosis. Tissue edema was a poor predictor of aseptic lymphocyte-dominant vasculitis-associated lesion (ALVAL) grade or tissue necrosis. DISCUSSION: MARS MRI synovial composition including mixed and solid features and the presence of abductor disruption provide the best prognostic characteristics associated with intraoperative soft-tissue necrosis and revision surgery outcome. These prognostic characteristics on MRI may assist surgeons with improved criteria for intervention and preoperative patient counseling.

Positive early clinical outcomes of bone marrow aspirate concentrate for osteoarthritis using a novel fenestrated trocar.

BACKGROUND: This study sought to assess early clinical outcomes for knee osteoarthritis (OA) patients undergoing bone marrow aspirate concentrate (BMAC) treatment using a novel closed-end, fenestrated trocar (FT) that does not require centrifugation. METHODS: A prospective cohort of 17 knee OA patients undergoing BMAC treatment with the FT system from March 2018 to March 2019 was retrospectively evaluated. Approximately 10 mL of BMAC was harvested, no centrifugation was performed, and the BMAC was injected into the affected knee. Clinical outcomes were assessed at baseline, six weeks, and 12 weeks. This study has no affiliation with/vested-interest in the FT system. RESULTS: There were significant improvements in nearly all outcomes from baseline to 12 weeks. Specific improvements included Knee Injury and OA Outcome Score (KOOS) activities-of-daily-living (61.1 ± 9.2 [mean ± 95% confidence interval] to 89.3 ± 6, p = 0.001), quality-of-life (32.7 ± 9.3 to 66.1 ± 17.9, p = 0.003), sports/recreation (36.9 ± 10.6 to 72.6 ± 26.3, p = 0.006), and pain (53.8 ± 9.3 to 83 ± 10.2, p = 0.001); Lysholm scores (55.5 ± 8.4 to 77.3 ± 10.5, p = 0.009); and visual analog pain scores (5.68 ± 1.14 to 2.07 ± 1.86, p = 0.003). Individually, at least 75% of patients exhibited improvement in all KOOS categories at six weeks and at least 85% at 12 weeks. CONCLUSIONS: BMAC treatment with an FT system that does not require centrifugation resulted in significant improvements in early pain and function scores for knee OA. The symptomatic improvements in this study were similar to or greater than what has been reported using traditional needles. These data may provide clinicians with comfort in using an FT system and provide motivation for future randomized-controlled trials comparing aspiration techniques.

The Prognostic Value of Laboratory Markers and Ambulatory Function at Presentation for Post-Treatment Morbidity and Mortality Following Epidural Abscess.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To develop a comprehensive understanding of the prognostic value of laboratory markers on morbidity and mortality following epidural abscess. SUMMARY OF BACKGROUND DATA: Spinal epidural abscess is a serious medical condition with high rates of morbidity. The value of laboratory data in forecasting morbidity and mortality after epidural abscess remains underexplored. METHODS: We obtained clinical data on patients treated for epidural abscess at two academic centers from 2005 to 2017. Our primary outcome was the development of one or more complications within 90-days of presentation, with mortality a secondary measure. Primary predictors included serum albumin, serum creatinine, platelet-lymphocyte ratio, and ambulatory status at presentation. We used multivariable logistic regression techniques to adjust for confounders. The most parsimonious set of variables influencing both complications and mortality were considered to be clinically significant. These were then examined individually and in combination to assess for synergy along with model-discrimination and calibration. We performed internal validation with a bootstrap procedure using sampling with replacement. RESULTS: We included 449 patients in this analysis. Complications were encountered in 164 cases (37%). Mortality within 1-year occurred in 39 patients (9%). Regression testing determined that serum albumin, serum creatinine, and ambulatory status at presentation were clinically important predictors of outcome, with albumin more than 3.5 g/dL, creatinine less than or equal to 1.2 mg/dL, and independent ambulatory function at presentation considered favorable characteristics. Patients with no favorable findings had increased likelihood of 90-day complications (odds ratio [OR] 5.43; 95% confidence intervals [CI] 1.98, 14.93) and 1-year mortality (OR 8.94; 95% CI 2.03, 39.37). Those with one favorable characteristic had greater odds of complications (OR 4.00; 95% CI 2.05, 7.81) and mortality (OR 5.71; 95% CI 1.60, 20.43). CONCLUSION: We developed a nomogram incorporating clinical and laboratory values to prognosticate outcomes after treatment for epidural abscess. The results can be used in shared-decision making and counseling. LEVEL OF EVIDENCE: 3.

The utility of post-operative hip radiographs in patients treated with hip hemiarthroplasty for femoral neck fractures.

BACKGROUND: Patients treated with hip hemiarthroplasty for low energy femoral neck fractures routinely undergo hip radiographs at each postoperative clinic visit regardless of history and physical findings. No studies to date have evaluated the effectiveness of this accepted practice. The goal of this study was to identify the postoperative utility of both history and physical (H/P) and hip radiographs in the treatment course of patients treated with hip hemiarthroplasty for low energy femoral neck fractures. METHODS: A retrospective chart review was performed on consecutive patients treated with hip hemiarthroplasty for low energy femoral neck fractures. An abnormal H/P and hip radiographs as well as a change in treatment course were recorded at each clinic or emergency department visit. RESULTS: Five hundred and eighty-three patients met inclusion criteria, consisting of 1177 clinic and 50 emergency department (ED) visits. An abnormal radiograph in the presence of a normal H/P did not lead to a change in treatment course. An abnormal H/P alone changed treatment course in 28 (3%) clinic visits and 18 (36%) ED visits. An abnormal H/P and the presence of an abnormal hip radiograph changed the treatment course in 23 (2%) clinic visits and 18 (36%) ED visits. In only one case - 0.3% of abnormal radiographs or 0.08% of 1177 clinic visits - did an abnormal hip radiograph change treatment course in the setting of an abnormal H/P within 6 months from surgery. The average cost of a series of hip and pelvis radiographs was $242. CONCLUSIONS: Abnormal radiographs do not change treatment course in the presence of a normal H/P. Hip radiographs obtained in clinic within 6 months of surgery rarely lead to a change in treatment course and thereby are a source of excess cost and radiation exposure to the patient.

Coverage and Access for Americans with Cardiovascular Disease or Risk Factors After the ACA: a Quasi-experimental Study.

BACKGROUND: Atherosclerotic cardiovascular disease (CVD) is the leading cause of death in the USA. Many with CVD or cardiovascular risk factors (CVRFs) lacked insurance coverage and access to care before enactment of the Affordable Care Act (ACA). OBJECTIVE: To assess the effect of the ACA on insurance coverage, access to care, and racial/ethnic disparities among non-elderly adults with CVD or CVRFs. DESIGN: Quasi-experimental policy intervention. PARTICIPANTS: Nationally representative, non-institutionalized sample of 1,014,450 adults aged 18 to 64 years with CVD or at least 2 established CVRFs in the pre-ACA (2012-2013) and post-ACA (2015-2016) periods. INTERVENTION: Implementation of ACA provisions on 1 January 2014. MAIN MEASURES: Insurance coverage, having a check-up, having a personal physician, and not having to forgo a needed physician visit because of cost. KEY RESULTS: Following ACA implementation, insurance coverage increased by 6.9 percentage points (95% CI, 6.6 to 7.2), not having to forgo a physician visit increased by 3.6 percentage points (CI, 3.3 to 3.9), having a check-up increased by 2.1 percentage points (CI, 1.8 to 2.6), and having a personal physician increased by 1 percentage point (0.6 to 1.3); changes were approximately doubled for those with lower incomes (< $35,000/year). Changes in coverage varied substantially by state and all outcomes improved more in Medicaid expansion states. Although racial/ethnic minorities had greater improvements in some outcomes, approximately 13% black and 29% Hispanic adults continued to lack coverage and access to care post-ACA. CONCLUSION: The ACA increased coverage and access for adults with CVD or multiple CVRFs; substantial gaps remain, particularly for minorities and those in Medicaid non-expansion states.

Minimally invasive drainage of a giant ovarian mucinous cystadenoma associated with a mature cystic teratoma.

A 26-year-old, otherwise healthy female presented to the Emergency Room for the evaluation of abdominal pain. It was immediately apparent that she had a massively distended abdomen. History revealed progressive abdominal distension over several years. Evaluation for pregnancy was negative and a computed tomography (CT) scan demonstrated a 38 × 32 × 23 cm septated cystic mass. Careful controlled partial needle decompression of the cyst, removing 18.5 l of fluid, was followed by a mini-laparotomy with complete removal of a multi-loculated cystic ovarian mass approximately 45 lb in weight. Pathology was consistent with mucinous cystadenoma of the ovary in association with a mature cystic teratoma. This surgical technique of percutaneous drainage of the cyst, followed by mini-laparotomy is a valuable example of a safe and effective minimally invasive treatment modality for giant ovarian mucinous cystadenomas.

Relation of white matter hyperintensities and motor deficits in chronic stroke.

BACKGROUND: Infarct size and location account for only a relatively small portion of post-stroke motor impairment, suggesting that other less obvious factors may be involved. OBJECTIVE: Examine the relationship between white matter hyperintensity (WMH) load among other factors and upper extremity motor deficit in patients with mild to moderate chronic stroke. METHODS: The magnetic resonance images of 28 patients were studied. WMH load was assessed as total WMH volume and WMH overlap with the corticospinal tract in the centrum semiovale. Hemiparetic arm function was measured using the Motor Activity Log (MAL) and Wolf Motor Function Test (WMFT). RESULTS: Hierarchical multiple regression models found WMH volume predicted motor deficits in both real-world arm use (MAL;ΔR2 = 0.12, F(1, 22) = 4.73, p = 0.04) and in arm motor capacity as measured by a laboratory motor function test (WMFT;ΔR2 = 0.18, F(1, 22) = 6.32, p = 0.02) over and above age and lesion characteristics. However, these models accounted for less than half of the variance in post-stroke motor deficits. CONCLUSION: The results suggest that WMH may be an important factor to consider in stroke-related upper extremity motor impairment. Nonetheless, the basis of the largest part of the post-stroke motor deficit remains unaccounted for by structural CNS factors. This component may be behavioral or learned, involving learned nonuse.

Phase II Randomized Controlled Trial of Constraint-Induced Movement Therapy in Multiple Sclerosis. Part 2: Effect on White Matter Integrity.

BACKGROUND: Constraint-induced movement therapy (CIMT) is a method of physical rehabilitation that has demonstrated clinical efficacy in patients with chronic stroke, cerebral palsy, and multiple sclerosis (MS). OBJECTIVE: This pilot randomized controlled trial tested whether CIMT can also induce increases in white matter integrity in patients with MS. METHODS: Twenty adults with chronic hemiparetic MS were randomized to receive either CIMT or complementary and alternative medicine (CAM) treatment (reported in the first article of this pair). Structural white matter change was assessed by tract-based spatial statistics (TBSS); measures included fractional anisotropy (FA), mean diffusivity (MD), axial diffusivity (AD), and radial diffusivity (RD). RESULTS: CIMT and CAM groups did not differ in pretreatment disability or expectancy to benefit. As noted in the companion paper, the motor activity log (MAL) improved more after CIMT than CAM ( P < .001); the within-group effect size for CIMT was 3.7 (large d' = 0.57), while for CAM it was just 0.7. Improvements in white matter integrity followed CIMT and were observed in the contralateral corpus callosum (FA, P < .05), ipsilateral superior occipital gyrus (AD, P < .05), ipsilateral superior temporal gyrus (FA, P < .05), and contralateral corticospinal tract (MD and RD, P < .05). CONCLUSION: CIMT produced a very large improvement in real-world limb use and induced white matter changes in patients with hemiparetic MS when compared with CAM. The findings suggest in preliminary fashion that the adverse changes in white matter integrity induced by MS might be reversed by CIMT. CLINICAL TRIAL REGISTRATION NUMBER: ClinicalTrials.gov (NCT01081275).

Goblet cell carcinoid of the appendix: Case report of a high grade tumor in a 20-year-old.

INTRODUCTION: Goblet cell carcinoid (GCC) is an extraordinarily rare appendiceal tumor that is usually an incidental diagnosis on post-operative histology. It typically presents in the fifth or sixth decade of life. Our patient is the only reported case study of GCC in a pediatric-young adult. Due to its potentially poor prognosis, GCC is surgically treated as an adenocarcinoma, with right hemicolectomy as the mainstay of treatment. PRESENTATION OF CASE: The patient was a 20-year-old male who presented with a history, physical exam, and work up consistent with acute appendicitis. He underwent an uneventful laparoscopic appendectomy and was diagnosed with a high grade GCC post-operatively. DISCUSSION: GCC is a rare tumor of the appendix with unique histological features including small rosettes with crescentic nuclei distended with mucin. It is often retroactively diagnosed with histology after a majority of patients present with acute appendicitis symptoms. The behavior of this tumor in pediatric-young adults is very poorly understood. CONCLUSION: We review the literature for GCC of the appendix and illustrate a case report of a young, otherwise healthy 20-year-old who presented as appendicitis. Although rare, neoplasm must be kept in mind while offering non-operative management for acute appendicitis.