A Prospective Pilot Study to Identify a Myocarditis Cohort who may Safely Resume Sports Activities 3 Months after Diagnosis.

International cardiovascular society recommendations to return to sports activities following acute myocarditis are based on expert consensus in the absence of prospective studies. We prospectively enrolled 30 patients with newly diagnosed myocarditis based on clinical parameters, laboratory measurements and cardiac magnetic resonance imaging with mildly reduced or preserved left ventricular ejection fraction (LVEF) with a follow-up of 12 months. Cessation of physical activity was recommended for 3 months. The average age was 35 (19-80) years with 73% male patients. One case of non-sustained ventricular tachycardia was recorded during 48-h-Holter electrocardiogram. Except for this case, all patients were allowed to resume physical exercise after 3 months. At 6- (n = 26) and 12-month (n = 19) follow-up neither cardiac events nor worsening LVEF were recorded. The risk of cardiac events at 1 year after diagnosis of myocarditis appears to be low after resumption of exercise after 3 months among patients who recover from acute myocarditis.

Evidence for the modulation of nociception in mice by central mast cells.

BACKGROUND: Hyperalgesia that develops following nerve ligation corresponds temporally and in magnitude with the number of thalamic mast cells located contralateral to the ligature. We tested the possibility that mast cells modulate nociception centrally, similar to their role in the periphery. METHODS: We examined the central effect of two hyperalgesic compounds that induce mast cell degranulation and of stabilized mast cells using cromolyn. RESULTS: Thermal hyperalgesia (tail flick) induced by nerve growth factor (NGF, a neurotrophic compound) and mechanical hyperalgesia (von Frey) induced by dynorphin A (1-17) (opioid compound) each correlated with the per cent of thalamic mast cells that were degranulated. Degranulation of these mast cells by the central injection of compound 48/80, devoid of neurotrophic or opioid activity, was sufficient to recapitulate thermal hyperalgesia. Stabilization of mast cells by central injections of cromolyn produced no analgesic effect on baseline tail flick or von Frey fibre sensitivity, but inhibited thermal hyperalgesia produced by compound 48/80 and tactile hyperalgesia induced by dynorphin and by Freund's complete adjuvant. Finally, chemical nociception produced by the direct activation of nociceptors by formalin (phase I) was not inhibited by centrally injected cromolyn whereas chemical nociception dependent on central sensitization (formalin-phase II and acetic acid-induced abdominal stretches) was. CONCLUSIONS: These convergent lines of evidence suggest that degranulation of centrally located mast cells sensitizes central nociceptive pathways leading to hyperalgesia and tonic chemical sensitivity. SIGNIFICANCE: Hyperalgesia induced by spinal nerve ligation corresponds temporally and in magnitude with degranulation of thalamic mast cells. Here, we provide evidence that hyperalgesia induced by NGF, formalin and dynorphin also may depend on mast cell degranulation in the CNS whereas cromolyn, a mast cell stabilizer, blocks these effects in mice.

Patient and nurse evaluation of recombinant human follicle-stimulating hormone administration methods: comparison of two follitropin injection pens.

OBJECTIVE: Ovarian stimulation by injection of gonadotrophins is an essential part of assisted reproductive technology (ART) protocols. Two studies (a German pilot study and an Australian study) aimed to assess and compare the ease-of-use, safety and efficacy of two follitropin injection pens. METHODS: Patient satisfaction (questionnaire) and safety were assessed in patients undergoing ART at a German centre for in vitro fertilisation (IVF), randomised either to the follitropin alfa pen or to the follitropin beta pen. Patient satisfaction (questionnaire) was assessed in patients undergoing ART at an Australian IVF centre, using the follitropin alfa pen, and previous experience with the follitropin beta pen was compared. The experience of IVF nurses with both pens was assessed using a similar questionnaire. Statistical significance was not determined in either study. RESULTS: In the German study (n = 31), patients favored the follitropin alfa pen over the follitropin beta pen because they found preparation faster, were more confident of accurate dosing and had to make fewer dose adjustments. Treatments delivered by both pens were well tolerated; eight adverse events (AEs) occurred, two AEs (including one case of ovarian hyperstimulation syndrome, OHSS) in two patients using the follitropin alfa pen and six AEs (including three cases of OHSS, one of which was serious) in six patients using the follitropin beta pen. Patients (n = 140) and nurses (n = 11) in the Australian study scored the follitropin alfa pen highly and patients favored it over the follitropin beta pen; the risk of OHSS was also considered greater in the follitropin beta pen group, with nearly a twofold higher rate of cycle cancellation due to OHSS risk compared with the follitropin alfa pen group. CONCLUSIONS: Taken together, results from these two small studies suggest that the follitropin alfa pen was effective, well tolerated, and patient and nurse acceptance appeared to be higher for the follitropin alfa pen versus the follitropin beta pen, which may benefit compliance, leading to improved outcomes.

Effects of luteinizing hormone and human chorionic gonadotropin on corpus luteum cells in a spheroid cell culture system.

The human corpus luteum (CL) is a highly vascularized, temporarily active endocrine gland and consists mainly of granulosa cells (GCs), theca cells (TCs), and endothelial cells (ECs). Its cyclic growth and development takes place under the influence of gonadotropic hormones. If pregnancy does occur, human chorionic gonadotropin (hCG) takes over the function of luteinizing hormone (LH) and, in contrast to LH, extends the functional life span of the CL. In this study, we investigated the effects of hCG and LH in a spheroidal cell culture model of CL development. Our data indicate that GCs secrete factors under the control of hCG that increase sprout formation of EC-spheroids. We demonstrate that the most prominent of these factors is VEGF-A. Furthermore, we found that both LH and hCG decrease sprout formation of GC-spheroids. After forming EC-GC coculture spheroids and consequently bringing GCs and ECs in close contact, sprouting increased under the influence of hCG, however not under LH. These experiments provide evidence for an hCG dependent functional switch in the GCs after coming in contact with ECs. Moreover, it demonstrates the considerably different effects of hCG and LH on GCs although their signaling is transmitted via the same receptor.

Topotecan as a continuous infusion over 14 days in recurrent ovarian cancer patients.

OBJECTIVE: In recurrent ovarian cancer the topoisomerase-1 inhibitor topotecan shows activity after prior treatment with platinum and taxanes. Overall response rates of up to 38% in combination with an acceptable toxicity profile have been reported. We performed a pilot study to evaluate the therapeutic efficacy and toxicity profile of a low-dose continuous infusion protocol of topotecan. PATIENTS AND METHODS: Twelve patients with recurrent ovarian cancer and a measurable lesion received a continuous infusion of topotecan (0.4 mg/m2/d) over 14 days, repeated every 28 days. All patients had at least one prior platinum-containing regimen of chemotherapy (range 1-7). Responses were evaluated by ultrasound, computed tomography (CT) scans and/or magnetic resonance imaging (MRI). RESULTS: A total of 57 (median 5, range 1-12) topotecan treatment cycles were administered. The overall response rate was 2/12 (17%). Four patients had stable disease (33%), among them two patients with platinum-refractory tumors. The median time to progression was 26 (range 20-100) weeks. No grade 3 or 4 hematological toxicities were observed. However, one patient developed a grade 2 allergy leading to discontinuation of topotecan. CONCLUSION: Treatment of recurrent ovarian cancer with low-dose continuous infusion of topotecan over 14 days demonstrated response rates comparable to other dosing schedules with minimal toxicity in a preliminary series of 12 patients.

Dystonia: a case report and review.

Dystonia is a movement disorder characterized by increased muscular tone for which surgical treatment has met with less than ideal results. Surgical treatment in patients with dystonia is often avoided due to the relative success of medical therapy. However, if expectations stay realistic and if the patient with dystonia is continuously evaluated, appropriate surgical measures may be taken when necessary to optimize patient satisfaction. The authors present a case of successful surgical treatment in a patient with a relatively static but crippling lower extremity deformity. A review of dystonia is included with successful surgical treatment of this compound neurologic disease causing lower extremity deformity in a young female. Diagnosis and treatment options including surgical planning and principles in the dystonic patient are highlighted.

Nonresection triple arthrodesis: a retrospective analysis.

This case series examines triple arthrodesis using articular cartilage excision without bone resection. Due to the technically demanding nature of triple arthrodesis, the authors present a nonresection technique with its perceived advantages over joint resection triple arthrodesis in the presence of reducible deformity, such as minimal shortening of bone, ease of execution, and better bony apposition. Fourteen patients with nonresection triple arthrodesis from two medical centers are included in this report. Postoperative follow-up ranged from 6 to 36 months. Evaluation of results was performed subjectively and radiographically. There was a low incidence of nonunion (2% of joints) and minimal to no bone shortening (0.1 cm mean talonavicular shortening and 0.1 cm mean increase in talocalcaneal height). Mean time to fusion of joints fixed with screws was 9.91 weeks (SD = 3.61, n = 31), while fusion time for staple or pin fixation was 8.96 weeks (SD = 4.15, n = 10). There were no significant differences in time to fusion between screw and nonscrew fixation (p = .26) nor when comparing procedures within each patient (p = .30). At follow-up, five patients reported no pain at any time (36%); two patients reported mild occasional pain (14%). Moderate, daily pain was reported by seven patients (50%). While no direct comparison with resection triple arthrodesis was made, the positive subjective and objective results support this procedure.

Acute exertional compartment syndrome of the medial foot.

A review of compartment syndrome, both acute and chronic, is presented. The pathophysiology, anatomy, diagnosis, and treatment are presented in relation to a unique case report. The case is one of acute exertional compartment syndrome of the medial foot treated by fasciotomy. This condition is uncommon in both its nature and location.

Minimal change glomerulonephritis in a 90-year-old patient: what is the ideal approach?

We report the case of a 90-year-old lady who presented with full-blown nephrotic syndrome. Percutaneous renal biopsy allowed us to confirm the diagnosis of minimal change glomerulopathy; she entered a 2-year period of remission after a 6-month course of prednisone (starting dose 1.5 mg/kg). The patient sustained minor effects of both renal biopsy and corticotherapy. Percutaneous renal biopsy is justified in the very elderly because the risk of mortality and morbidity related to corticotherapy outweigh the risk related to percutaneous renal biopsy, providing high-risk patients are excluded, such as amyloidosis or abnormal coagulation or uncontrolled arterial hypertension.

The Osteomed M3-X Fixation System: a new bone screw with applications in foot surgery.

The purpose of this article is to familiarize the reader with the Osteomed M3-X Fixation System. The authors present a description of the instrumentation and design characteristics of this system, as well as some comparisons to other similar fixation devices. The indications for the screw's use and the correct techniques of insertion are also discussed. In addition, a review of over 200 forefoot procedures utilizing this system, and performed by the podiatric surgeons at Hutzel Hospital, is presented.

Bizarre parosteal osteochondromatous proliferation. An unusual bone tumor.

Bizarre parosteal osteochondromatous proliferation of bone is a rare, benign bone tumor. The authors discuss two cases involving the bones of the feet, and review clinical, radiographic, and histopathologic characteristics. Awareness of this lesion is essential as bizarre parosteal osteochondromatous proliferation of bone can be mistaken for a malignancy.

Cheilectomy, chondroplasty, and sagittal "Z" osteotomy: a preliminary report on an alternative joint preservation approach to hallux limitus.

The surgical correction of hallux limitus can be most rewarding for both patient and surgeon when marked degenerative changes exist in older individuals. Many foot and ankle surgeons would perform an implant arthroplasty in a patient over 60 years of age with hallux limitus or rigidus. In a patient without gross first metatarsophalangeal joint arthrosis, but with limitation in range of motion, the literature is replete with biomechanically sound surgical options. However, surgical repair of the moderate-to-severe arthritic first metatarsophalangeal joint in younger individuals remains quite a challenge. The authors present the use of a sagittal plane "Z" osteotomy of the proximal phalanx along with cheilectomy and chondroplasty for the treatment of hallux limitus and rigidus in the young, active patient.

Tibialis anterior transfer "into talus" for control of the severe planus pediatric foot: a preliminary report.

Transfer of tibialis anterior into the talus has been utilized for correction of the vertical talus, as well as for paralytic valgus foot deformities with the suggestion for its use in severe flatfoot deformities. The authors present transfer of tibialis anterior through the talus for controlling the severe planus pediatric foot. The procedure is presented, and six feet having undergone this procedure are analyzed. This procedure, in combination with others, has proven successful in reconstructing this pediatric deformity clinically and radiographically.

Repair of neglected Achilles tendon ruptures--procedure and functional results.

Surgical repair of neglected Achilles tendon ruptures presents the challenge of restoring the function of the Achilles tendon complex while repairing the large defect that is created by the delay in appropriate treatment. The authors present their preferred technique for delayed repair, and the results of four patients who were available for complete follow-up evaluation. The method of repair includes: V to Y gastrocnemius recession or advancement, excision of the fibroadipose defect, end-to-end anastomosis, plantaris tendon weaving to reinforce the anastomosis, and use of a pullout-wire suture. Each of the four patients were interviewed, examined clinically, and examined via Cybex (Cybex Corporation, Long Island, New York) isokinetic strength testing. All patients related satisfaction with results, and no reruptures were encountered. All four patients have been able to return to their preinjury activities. Cybex isokinetic strength testing demonstrated peak torque deficiencies in plantar flexion ranging from 22% to 30% as compared with the unaffected limb. This deficit is believed to be the result of the gastrocnemius recession. The overall results of the described techniques indicate that very satisfactory function of a neglected tendo Achilles rupture can be obtained. A strong, clinically functional Achilles tendon complex is restored at the cost of some decrease in peak strength as detected by Cybex.

Acute radiodermatitis following radiotherapy for classic Kaposi's sarcoma.

There is a high incidence of radiation toxicity associated with Kaposi's sarcoma. The authors review acute radiodermatitis and present a case where it occurred in the foot following radiotherapy for classic Kaposi's sarcoma.

Reduction of intermetatarsal angle following Keller arthroplasty.

A composite retrospective radiographic analysis of 71 patients who had undergone the Keller arthroplasty and 76 who had undergone the Keller with hemi-implant was performed. The combined mean preoperative intermetatarsal angle was 11.4 degrees, the mean postoperative intermetatarsal angle was 9.4 degrees, and the mean change in intermetatarsal angle was 2.0 degrees. Although the reduction of the metatarsus primus adductus deformity obtained was less than previous studies, the amount of correction was directly proportional to the magnitude of deformity. The authors conclude that through reverse buckling at the first metatarsophalangeal joint, adequate reduction in the positional component of metatarsus primus adductus can be obtained with the Keller arthroplasty alone or with a hemi-implant. These procedures are preferred over metatarsal osteotomies in the physiologically older patient, especially when a severe metatarsus primus adductus deformity exists.

The offset "V" bunionectomy using cortical screw and buried Kirschner wire fixation.

The offset "V" bunionectomy with cortical screw and buried Kirschner wire fixation offers advantages over previously described distal metatarsal procedures for correction of hallux abducto valgus. The ability to correct an increased intermetatarsal angle (IMA) as well as a proximal articular set angle (PASA) deviation allows for the eradication of postoperative deforming forces, which often lead to recurrence of the deformity. Complete soft tissue release and repair allows for the repositioning of the sesamoidal apparatus, and also reduces the tendency for recurrence. The authors have performed approximately 500 of these procedures in the past 7 years and found it to provide extremely satisfying results. Gaining experience in the aforementioned techniques has lessened the need for base osteotomies and more unstable types of distal osteotomies. The criterion for the use of this osteotomy continues to broaden as the authors gain experience with its use. The offset "V" osteotomy is now utilized as either a primary or ancillary procedure in approximately 90% of the hallux valgus patients upon whom the authors operate.

Maffucci's syndrome. Review of the literature and case report.

Maffucci's syndrome, a rarely occurring congenital disorder, may present early in life as either a pathologic fracture, an incidental radiographic finding, or primarily as multiple hemangiomas. Patients endure years of orthopedic complications, and are faced with a grim prognosis, with the majority developing either skeletal or extra-skeletal malignancies by the end of their fourth decade.

Pfeiffer syndrome: a syndrome of acrocephalosyndactyly.

The authors present a case of Pfeiffer syndrome, which differs from the classic description. Treatment consisted of surgical correction of the unusual digital deformity. The literature is reviewed in regard to acrocephalosyndactyly and related congenital disorders and deformities.