A patient-reported outcome measure to identify occurrence and distress of post-surgery symptoms of WOMen with vulvAr Neoplasia (WOMAN-PRO) - a cross sectional study.

OBJECTIVE The aim of the study was to describe the (a) symptom experience of women with vulvar intraepithelial neoplasia and vulvar cancer (vulvar neoplasia) during the first week after hospital discharge, and (b) associations between age, type of disease, stage of disease, the extent of surgical treatment and symptom experience. METHODS This cross-sectional study was conducted in eight hospitals in Germany and Switzerland (Clinical Trial ID: NCT01300663). Symptom experience after surgical treatment in women with vulvar neoplasia was measured with our newly developed WOMAN-PRO instrument. Outpatients (n=65) rated 31 items. We used descriptive statistics and regression analysis. RESULTS The average number of symptoms reported per patient was 20.2 (SD 5.77) with a range of 5 to 31 symptoms. The three most prevalent wound-related symptoms were 'swelling' (n=56), 'drainage' (n=54) and 'pain' (n=52). The three most prevalent difficulties in daily life were 'sitting' (n=63), 'wearing clothes' (n=56) and 'carrying out my daily activities' (n=51). 'Tiredness' (n=62), 'insecurity' (n=54) and 'feeling that my body has changed' (n=50) were the three most prevalent psychosocial symptoms/issues. The most distressing symptoms were 'sitting' (Mean 2.03, SD 0.88), 'open spot (e.g. opening of skin or suture)' (Mean 1.91, SD 0.93), and 'carrying out my daily activities' (Mean 1.86, SD 0.87), which were on average reported as 'quite a bit' distressing. Negative associations were found between psychosocial symptom experience and age. CONCLUSIONS WOMAN-PRO data showed a high symptom prevalence and distress, call for a comprehensive symptom assessment, and may allow identification of relevant areas in symptom management.

Immunohistochemical demonstration of lumbar intervertebral disc innervation in the dog.

Low back pain is a common ailment in dogs, particularly in specific breeds such as the German shepherd dog. A number of structures such as facet joint capsules, ligaments, dorsal root ganglia, periosteum, vertebral endplates and meninges have been associated with this condition. Yet, in spite of all diagnostic efforts, the origin of pain remains obscure in a substantial proportion of all cases. A further structure often being involved in vertebral column disorders is the intervertebral disc. The presence of nerves, however, is a precondition for pain sensation and, consequently, structures lacking innervation can be left out of consideration as a cause for low back pain. Nerve fibres have been demonstrated at the periphery of the intervertebral disc in man, rabbit and rat. With regard to the dog, however, the extent of intervertebral disc innervation is still being disputed. The goal of the present study, therefore, was to substantiate and expand current knowledge of intervertebral disc innervation. Protein gene product (PGP) 9.5 was used for immunohistochemical examination of serial transversal and sagittal paraffin sections of lumbar discs from adult dogs. This general marker revealed nerve fibres to be confined to the periphery of the intervertebral discs. These results indicate that even limited pathological processes affecting the outer layers of the intervertebral disc are prone to cause low back pain.

Clinical primary flexor tendon repair and rehabilitation: The Bern Experience

In this chapter we present our experience with treatment of zone 2 flexor tendon repair using a six-strand repair technique combined with postoperative place-and-hold exercise. The six-strand Lim/Tsai repair technique combined with place-and-hold exercises demonstrated better digital function compared to a two-strand repair without place-and-hold exercises. Range of motion in the Lim/Tsai repair group appeared to be increased without a higher rate of ruptures but with a shorter rehabilitation period. The fact that the two groups differed in both suture techniques and rehabilitation programs made it impossible to know whether the better results in the group of Lim/Tsai were due to the six-strand repair or the place-and-hold exercises or both. Despite the obvious benefit of early active mobilization, an active motion protocol may not always be possible to apply in a substantial number of patients due to concomitant injuries, the quality of the surgical repair or patient factors (swelling, pain, limited compliance). Since August 2006 a staged rehabilitation program (“stop and go”) was introduced within our unit using early active controlled flexion (green), place-and-hold (yellow), or passive flexion exercises (red) introduced by Kleinert-Duran. Our experience using the six-strand suture repair technique and “stop and go” is outlined.

Temporary anchorage device usage: a survey among Swiss orthodontists.

BACKGROUND The aim of the survey was to obtain information on the treatment plan preferences, mechanics and characteristics of temporary anchorage device (TAD) application using a single case presented to orthodontists in Switzerland. METHODS A structured questionnaire to be completed by all study participants with case-specific (treatment plan including mechanics and TAD usage) and general questions (general fixed appliance and TAD usage as well as professional, educational and demographic questions) together with an orthodontic borderline case was utilised. The case was a female adult with dental Class II/2, deep bite and maxillary anterior crowing, who had been treated in childhood with extraction of four premolars and fixed appliance followed by wisdom tooth extraction. RESULTS The response rate was 24.4% (108 out of 443). The majority (96.3%, 104) proposed comprehensive treatment, while 3.7% (4) planned only alignment of maxillary teeth. 8.3% (9) included a surgical approach in their treatment plan. An additional 0.9% (1) combined the surgical approach with Class II mechanics. 75.1% (81) decided on distalization on the maxilla using TADs, 7.4% (8) planned various types of Class II appliances and 3.7% (4) combined distalization using TADs or headgear with Class II appliances and surgery. Palatal implants were the most popular choice (70.6%, 60), followed by mini-screws (22.4%, 19) and mini-plates on the infrazygomatic crests (7.0%, 6). The preferred site of TAD insertion showed more variation in sagittal than in transversal dimension, and the median size of mini-screws used was 10.0-mm long (interquartile range (IQR) 2.3 mm) and 2.0-mm wide (IQR 0.3 mm). CONCLUSIONS Distalization against palatal implants and then distalization against mini-screws were the most popular treatment plans. Preferred site for TAD insertion varied depending on type and size but varied more widely in the sagittal than in the transversal dimension.

Proximity of premolar roots to maxillary sinus: a radiographic survey using cone-beam computed tomography.

INTRODUCTION The proximity of the roots of the posterior maxillary teeth to the maxillary sinus is a constant challenge to the dental practitioner. Because the majority of studies have assessed the relationship regarding molars, the present study focused on premolars. METHODS Cone-beam computed tomographic images of 192 patients were reconstructed in sagittal, coronal, and axial planes to quantify the distances between the root apices of the maxillary premolars and the adjacent maxillary sinus. Measurements were taken for each root, and data were correlated with age, sex, side, and presence of both or absence of 1 of the 2 premolars. RESULTS A total of 296 teeth (177 first and 119 second premolars) were evaluated. The mean distances from buccal roots of the first premolars to the border of the maxillary sinus in the sagittal, coronal, and axial planes ranged from 5.15 ± 2.99 to 8.28 ± 6.27 mm. From palatal roots, the mean distances ranged from 4.20 ± 3.69 to 7.17 ± 6.14 mm. The mean distances of second premolars were markedly shorter in buccal roots between 2.32 ± 2.19 and 3.28 ± 3.17 mm and in palatal roots between 2.68 ± 3.58 and 3.80 ± 3.71 mm, respectively. The frequency of a premolar root protrusion into the maxillary sinus was very low in first premolars (0%-7.2%) but higher in second premolars (2.5%-13.6%). Sex, age, side, and presence/absence of premolars failed to significantly influence the mean distances between premolar roots and the maxillary sinus. CONCLUSIONS Based on the calculated mean distances of the present study, only few premolars (and if so second premolars) would present a risk of violating the border of the maxillary sinus during conventional or surgical endodontic treatment or in case of tooth extraction.

Three-dimensional study of nasopalatine canal morphology: a descriptive retrospective analysis using cone-beam computed tomography

PURPOSE For dental implant treatment planning and placement, a precise anatomic description of the nasopalatine canal (NC) is necessary. This descriptive retrospective study evaluated dimensions of the NC and buccal bone plate (BBP) and the tridimensional association of the anatomic variants of NC, using cone-beam computed tomography (CBCT). METHODS This study included 230 CBCTs. Sagittal slices were used for measurements of the NC and BBP and to evaluate shape and direction-course of the NC. Coronal slices were used to assess NC shape and axial slices to assess number of incisive foramina and foramina of Stenson. RESULTS Mean NC length was 12.34 ± 2.79 mm, statistically significant differences were detected between genders (p < 0.001). Mean BBP length was 20.87 ± 3.68 mm, statistically significant differences were found for the dental status (p < 0.001) and mean BBP width was 6.83 ± 1.28 mm, significant differences were detected between genders (p < 0.001). Mean nasopalatine angle was 73.33° ± 8.11°, significant differences were found in sagittal and coronal classifications. The most prevalent canal was: cylindrical sagittal shape (48.2 %); slanted-straight direction-course (57.6 %); Ya-type coronal shape (42.4 %); and one foramen incisive with two Stenson's foramina (1-2) (50.9 %). Sagittal shape was associated with sagittal direction-course (p < 0.001). Coronal shape was associated with axial classification (p < 0.001). CONCLUSIONS The NC anatomy is highly variable. Gender is related to the NC length and BBP width, while dental status is related to BBP length. There was an association between the different sagittal classifications of the NC and between the coronal shape and axial classification.

Lack of fifth anchoring point and violation of the insertion of the rotator cuff during antegrade humeral nailing: pitfalls in straight antegrade humeral nailing.

Antegrade nailing of proximal humeral fractures using a straight nail can damage the bony insertion of the supraspinatus tendon and may lead to varus failure of the construct. In order to establish the ideal anatomical landmarks for insertion of the nail and their clinical relevance we analysed CT scans of bilateral proximal humeri in 200 patients (mean age 45.1 years (sd 19.6; 18 to 97) without humeral fractures. The entry point of the nail was defined by the point of intersection of the anteroposterior and lateral vertical axes with the cortex of the humeral head. The critical point was defined as the intersection of the sagittal axis with the medial limit of the insertion of the supraspinatus tendon on the greater tuberosity. The region of interest, i.e. the biggest entry hole that would not encroach on the insertion of the supraspinatus tendon, was calculated setting a 3 mm minimal distance from the critical point. This identified that 38.5% of the humeral heads were categorised as 'critical types', due to morphology in which the predicted offset of the entry point would encroach on the insertion of the supraspinatus tendon that may damage the tendon and reduce the stability of fixation. We therefore emphasise the need for 'fastidious' pre-operative planning to minimise this risk.

Radialer externer Fixateur zur geschlossenen Behandlung problematischer suprakondylärer Humerusfrakturen Typ III und IV bei Kindern und Jugendlichen

Operationsziel Geschlossene, anatomische Reposition und sichere Fixation von problematischen suprakondylären Typ-III- und Typ-IV-Humerusfrakturen, die mit den herkömmlichen Operationsmethoden nur schwierig geschlossen zu behandeln sind. Indikationen Gemäß der AO-Kinderklassifikation der suprakondylären Humerusfrakturen vom Typ III und IV: Frakturen, welche nicht geschlossen mittels üblicher Repositionsmethoden reponierbar sind sowie Frakturen, die nicht mittels der üblichen, gekreuzten perkutanen Kirschner-Draht-Technik zu fixieren sind. Bei schweren Schwellungszuständen, offener Fraktur oder initial neurologischen und/oder vaskulären Problemen („pulseless pink hand“) sowie bei mehrfachverletzten Kindern, welche eine optimale Rehabilitation benötigen und die Extremität gipsfrei sein sollte. Bei Kindern mit Komorbiditäten (z. B. Anfälle, Spastizität), die eine bessere Stabilität benötigen. Kontraindikationen Prinzipiell keine Kontraindikationen Operationstechnik Im nichtreponierten Zustand unter Durchleuchtungskontrolle Einbringen einer einzelnen Schanz-Schraube in den lateralen (radialen) Aspekt des distalen Fragments, welches sich in der streng seitlichen Röntgenprojektion als „Sand-Uhr“- bzw. Kreisform des Capitulum humeri darstellt. Je nach Größe dieses distalen Fragments kann die Schanz-Schraube rein epiphysär oder metaphysär liegen. Danach in absolut streng seitlicher Projektion des distalen Humerus im Bereich des meta-diaphysären Übergangs Einbohren einer 2. Schanz-Schraube unabhängig von der Ersten, die möglichst rechtwinklig zur Längsachse des Humerus in der a.-p.-Ebene zu liegen kommen sollte, um spätere Manipulationen mittels „Joy-Stick“-Technik zu erleichtern. Sind die beiden Schanz-Schrauben mehr oder weniger in beiden Ebenen parallel, so ist die Fraktur praktisch anatomisch reponiert. Nach erreichter Reposition Feinjustierung aller Achskomponenten. Sicherung der Flexion/Extension mittels einem von radial, distal eingebrachten sog. Anti-Rotations-Kirschner-Drahts, der die Stabilität signifikant erhöht und eine Drehung des distalen Fragments um die einzelne Schanz-Schraube verhindert. Postoperative Behandlung Keine zusätzliche Gipsruhigstellung notwendig. Es sollte eine funktionelle Nachbehandlung erfolgen. Ergebnisse Gemäß unserer Langzeitstudien bewegen die meisten Kinder bereits zum Zeitpunkt der ambulanten Pin-Entfernung in der Frakturambulanz ihren Ellbogen weitgehend normal. Bei einer Follow-up-Zeit über 40 Monate hatten 30/31 Kindern eine seitengleiche Achse und Beweglichkeit.

Anatomic foveal reconstruction of the triangular fibrocartilage complex with a tendon graft

An acute injury to the triangular fibrocartilage complex (TFCC) with avulsion of the foveal attachment can produce distal radioulnar joint (DRUJ) instability. The avulsed TFCC is translated distally so the footprint will be bathed in synovial fluid from the DRUJ and will become covered in synovitis. If the TFCC fails to heal to the footprint, then persistent instability can occur. The authors describe a surgical technique indicated for the treatment of persistent instability of the DRUJ due to foveal detachment of the TFCC. The procedure utilizes a loop of palmaris longus tendon graft passed through the ulnar aspect of the TFCC and into an osseous tunnel in the distal ulna to reconstruct the foveal attachment. This technique provides stability of the distal ulna to the radius and carpus. We recommend this procedure for chronic instability of the DRUJ due to TFCC avulsion, but recommend that suture repair remain the treatment of choice for acute instability. An arthroscopic assessment includes the trampoline test, hook test, and reverse hook test. DRUJ ballottement under arthroscopic vision details the direction of instability, the functional tear pattern, and unmasks concealed tears. If the reverse hook test demonstrates a functional instability between the TFCC and the radius, then a foveal reconstruction is contraindicated, and a reconstruction that stabilizes the radial and ulnar aspects of the TFCC is required. The foveal reconstruction technique has the advantage of providing a robust anatomically based reconstruction of the TFCC to the fovea, which stabilizes the DRUJ and the ulnocarpal sag.

Pitfalls and premature failure of the Freedom SOLO stentless valve.

OBJECTIVES This study reports a series of pitfalls, premature failures and explantations of the third-generation Freedom SOLO (FS) bovine pericardial stentless valve. METHODS A total of 149 patients underwent aortic valve replacement using the FS. Follow-up was 100% complete with an average observation time of 5.5 ± 2.3 years (maximum 8.7 years) and a total of 825 patient-years. Following intraoperative documentation, all explanted valve prostheses underwent histological examination. RESULTS Freedom from structural valve deterioration (SVD) at 5, 6, 7, 8 and 9 years was 92, 88, 80, 70 and 62%, respectively. Fourteen prostheses required explantation due to valve-independent dysfunction (n = 5; i.e. thrombus formation, oversizing, aortic dilatation, endocarditis and suture dehiscence) or valve-dependent failure (acute leaflet tears, n = 4 and severe stenosis, n = 5). Thus, freedom from explantation at 5, 6, 7, 8 and 9 years was 95, 94, 91, 81 and 72%, respectively. An acute vertical tear along the non-coronary/right coronary commissure to the base occurred at a mean of 6.0 years (range 4.3-7.3 years) and affected size 25 and 27 prostheses exclusively. Four FS required explantation after a mean of 7.5 years (range 7.0-8.3 years) due to severe functional stenosis and gross calcification that included the entire aortic root. CONCLUSIONS The FS stentless valve is safe to implant and shows satisfying mid-term results in our single institution experience. Freedom from SVD and explantation decreased markedly after only 6-7 years, so that patients with FS require close observation and follow-up. Exact sizing, symmetric positioning and observing patient limitations are crucial for optimal outcome.

The Freedom SOLO bovine pericardial stentless valve

Abstract: The third-generation bovine pericardium Freedom SOLO (FS) stentless valve emerged in 2004 as a modified version of the Pericarbon Freedom stentless valve and as a very attractive alternative to stented bioprostheses. The design, choice of tissue, and anticalcification treatment fulfill most, if not all, requirements for an ideal valve substitute. The FS combines the single-suture, subcoronary implantation technique with the latest-generation bovine pericardial tissue and novel anticalcification treatment. The design allows imitation of the native healthy valve through unrestricted adaption to the patient's anatomy, reproducing a normal valve/root complex. However, despite hemodynamic performance superior to stented valves, we are approaching a critical observation period as superior durability, freedom from structural valve deterioration, and nonstructural failure has not been proven as expected. However, optimal performance and freedom from structural valve deterioration depend on correct sizing and perfect symmetric implantation, to ensure low leaflet stress. Any malpositioning can lead to tissue fatigue over time. Furthermore, the potential for better outcomes depends on optimal patient selection and observance of the limitations for the use of stentless valves, particularly for the FS. Clearly, stentless valve implantation techniques are less reproducible and standardized, and require surgeon-dependent experience and skill. Regardless of whether or not stentless valve durability surpasses third-generation stented bioprostheses, they will continue to play a role in the surgical repertoire. This review intends to help practitioners avoid pitfalls, observe limitations, and improve patient selection for optimal long-term outcome with the attractive FS stentless valve.

Eye movements during mental time travel follow a diagonal line

Recent research showed that past events are associated with the back and left side, whereas future events are associated with the front and right side of space. These spatial-temporal associations have an impact on our sensorimotor system: thinking about one's past and future leads to subtle body sways in the sagittal dimension of space (Miles, Nind, & Macrae, 2010). In this study we investigated whether mental time travel leads to sensorimotor correlates in the horizontal dimension of space. Participants were asked to mentally displace themselves into the past or future while measuring their spontaneous eye movements on a blank screen. Eye gaze was directed more rightward and upward when thinking about the future than when thinking about the past. Our results provide further insight into the spatial nature of temporal thoughts, and show that not only body, but also eye movements follow a (diagonal) "time line" during mental time travel.

Magnetic resonance imaging features of sinonasal disorders in horses.

Diseases of paranasal sinuses and nasal passages in horses can be a diagnostic challenge because of the complex anatomy of the head and limitations of many diagnostic modalities. Our hypothesis was that magnetic resonance (MR) imaging would provide excellent anatomical detail and soft tissue resolution, and would be accurate in the diagnosis of diseases of the paranasal sinuses and nasal passages in horses. Fourteen horses were imaged. Inclusion criteria were lesions located to the sinuses or nasal passages that underwent MR imaging and subsequent surgical intervention and/or histopathologic examination. A low field, 0.3 tesla open magnet was used. Sequences in the standard protocol were fast spin echo T2 sagittal and transverse, spin echo T1 transverse, short-tau inversion recovery (STIR) dorsal, gradient echo 3D T1 MPR dorsal (plain and contrast enhanced), spin echo T1 fatsat (contrast enhanced). Mean scan time to complete the examination was 53 min (range 39-99 min). Lesions identified were primary or secondary sinusitis (six horses), paranasal sinus cyst (four horses), progressive ethmoid hematoma (two horses), and neoplasia (two horses). The most useful sequences were fast spin echo T2 transverse and sagittal, STIR dorsal and FE3D MPR (survey and contrast enhanced). Fluid accumulation, mucosal thickening, presence of encapsulated contents, bone deformation, and thickening were common findings observed in MR imaging. In selected horses, magnetic resonance imaging is a useful tool in diagnosing lesions of the paranasal sinuses and nasal passages.

Automated 3D Lumbar Intervertebral Disc Segmentation from MRI Data Sets

This paper proposed an automated 3D lumbar intervertebral disc (IVD) segmentation strategy from MRI data. Starting from two user supplied landmarks, the geometrical parameters of all lumbar vertebral bodies and intervertebral discs are automatically extracted from a mid-sagittal slice using a graphical model based approach. After that, a three-dimensional (3D) variable-radius soft tube model of the lumbar spine column is built to guide the 3D disc segmentation. The disc segmentation is achieved as a multi-kernel diffeomorphic registration between a 3D template of the disc and the observed MRI data. Experiments on 15 patient data sets showed the robustness and the accuracy of the proposed algorithm.

Can 3D ultrasound identify trochlea dysplasia in newborns? Evaluation and applicability of a technique.

Femoro-patellar dysplasia is considered as a significant risk factor of patellar instability. Different studies suggest that the shape of the trochlea is already developed in early childhood. Therefore early identification of a dysplastic configuration might be relevant information for the treating physician. An easy applicable routine screening of the trochlea is yet not available. The purpose of this study was to establish and evaluate a screening method for femoro-patellar dysplasia using 3D ultrasound. From 2012 to 2013 we prospectively imaged 160 consecutive femoro-patellar joints in 80 newborns from the 36th to 61st gestational week that underwent a routine hip sonography (Graf). All ultrasounds were performed by a pediatric radiologist with only minimal additional time to the routine hip ultrasound. In 30° flexion of the knee, axial, coronal, and sagittal reformats were used to standardize a reconstructed axial plane through the femoral condyle and the mid-patella. The sulcus angle, the lateral-to-medial facet ratio of the trochlea and the shape of the patella (Wiberg Classification) were evaluated. In all examinations reconstruction of the standardized axial plane was achieved, the mean trochlea angle was 149.1° (SD 4.9°), the lateral-to-medial facet ratio of the trochlea ratio was 1.3 (SD 0.22), and a Wiberg type I patella was found in 95% of the newborn. No statistical difference was detected between boys and girls. Using standardized reconstructions of the axial plane allows measurements to be made with lower operator dependency and higher accuracy in a short time. Therefore 3D ultrasound is an easy applicable and powerful tool to identify trochlea dysplasia in newborns and might be used for screening for trochlea dysplasia.