Relative Contribution of the Subsheath to Extensor Carpi Ulnaris Tendon Stability: Implications for Surgical Reconstruction and Rehabilitation.

PURPOSE: To identify the varying contributions of the proximal and distal portions of the subsheath of the extensor carpi ulnaris (ECU) to its stability, evaluate the correlation of ulnar groove depth and ECU subluxation, and observe the effect of forearm and wrist positions on ECU stability. METHODS: Extensor carpi ulnaris tendon position relative to the ulnar groove was measured in 10 human cadaveric specimens with the subsheath intact, partially sectioned (randomized to distal or proximal half), and fully sectioned. Measurements were obtained in 9 positions: forearm supinated, neutral, and pronated and wrist extended, neutral, and flexed. Ulnar groove depth was measured on all specimens. RESULTS: In 7 of 10 specimens with an intact subsheath, the ECU tendon subluxated out of the groove in at least 1 forearm-wrist position. We noted the subluxation of the ECU tendon in all wrist-forearm positions with the exception of pronation-extension in at least 1 specimen. For partial subsheath sectioning, tendon displacement markedly increased after distal subsheath sectioning but not after proximal sectioning. For full subsheath sectioning, wrist flexion produced subluxation in all forearm positions, and forearm supination produced subluxation in all wrist positions. Maximum displacement occurred in supination-flexion. There was no correlation between ulnar groove depth and ECU subluxation. CONCLUSIONS: Mild tendon subluxation occurred in the intact specimens in most tested positions. Two positions were remarkable for their consistency in maintaining the tendon within the groove: pronation-neutral and pronation-extension. In fully sectioned specimens, the greatest subluxation occurred in supination-flexion, with supination and flexion independently producing subluxation. Partial sectioning demonstrated that the distal portion of the subsheath played a more important role than the proximal portion in stabilizing the ECU. CLINICAL RELEVANCE: Subsheath repair or reconstruction should target the distal portion of the subsheath. During postinjury rehabilitation or following surgical reconstruction, combined forearm supination and wrist flexion should be avoided.

Is gastroduodenal biopsy safe in patients receiving aspirin and clopidogrel?: a prospective, randomized study involving 630 biopsies.

GOALS: To assess prospectively the bleeding risk attributable to gastroduodenal biopsy in subjects taking antiplatelet medications. BACKGROUND: No prospective data exist regarding the bleeding risk attributable to endoscopic biopsy in patients taking antiplatelet agents. A majority of Western endoscopists withdraw antiplatelet agents before upper endoscopy, despite expert guidelines to the contrary. STUDY: We performed a prospective, single-blind, randomized study in healthy volunteers participating in a larger study regarding the effect of antiplatelet agents on gastroduodenal mucosal healing. Multiple gastroduodenal biopsies were performed during 2 esophagogastroduodenoscopy in subjects dosed with aspirin enteric-coated 81 mg once daily or clopidogrel 75 mg once daily. Data for endoscopic bleeding, clinical bleeding, blood vessel size, and depth of biopsy in histology specimens were collected. RESULTS: Four hundred and five antral biopsies and 225 duodenal biopsies were performed during 90 esophagogastroduodenoscopy in 45 subjects receiving aspirin or clopidogrel. Median maximum blood vessel diameter per biopsy was 31.9 µ (range: 9.2 to 133.8). About 50.8% of biopsy specimens breached the muscularis mucosa. In the clopidogrel group, no bleeding events were noted after 350 biopsies [upper confidence limit (UCL) for probability of bleeding=0.0085]. In the aspirin group, there were no clinical events (UCL=0.0106) and one minor endoscopic bleeding event (UCL=0.0169). CONCLUSIONS: Consistent with expert guidelines, the absolute risk attributable to gastroduodenal biopsy in adults taking antiplatelet agents seems to be low. Half of routine biopsies enter submucosa. The largest blood vessels avulsed during biopsy correspond to midsized and large arterioles and venules.

Brain and leptomeningeal metastases from cutaneous melanoma: survival outcomes based on clinical features.

Brain metastases (BM) are among the most devastating and debilitating complications of melanoma. This retrospective study was conducted to gain a better understanding of patient and disease characteristics that have the greatest impact on overall survival in melanoma patients with BM; therapeutic interventions were also assessed. The records of all patients diagnosed with cutaneous melanoma and BM who were seen at Memorial Sloan-Kettering Cancer Center between 1991 and 2001 were retrospectively reviewed. A variety of factors, including age at diagnosis of stage IV disease, gender, race, disease stage at diagnosis, presence of BM at diagnosis of stage IV disease, neurologic symptoms, radiographic findings, number of BM, status and site(s) of extracranial metastasis, and treatment modalities, were analyzed for correlation with overall survival using univariate and multivariate Cox regression models. The records of 355 patients with BM were included in the analysis. On univariate analysis, seven patient and disease characteristics were significantly associated with poorer survival: age > 65 years, extracranial metastases, BM at stage IV diagnosis, neurologic symptoms, four or more BM, hydrocephalus, and leptomeningeal metastases. Of these, age, extracranial metastasis, neurologic symptoms, and number of BM were significantly associated with poorer survival in a multivariate analysis. Multivariate analysis of treatment modalities suggested that patients who had surgery, radiosurgery, or chemotherapy with temozolomide had improved survival outcomes, although this analysis has limitations. The prognostic factors identified in this retrospective study should be considered when making treatment decisions for patients with BM and used as stratification factors in future clinical trials.