Detection of splenic microabscesses with ultrasound as a marker for extrapulmonary tuberculosis in patients with HIV: A systematic review.

BACKGROUND: In 2015, 1.2 million new cases of tuberculosis (TB) were diagnosed in patients with HIV. Diagnostic limitations and resource shortages in endemic areas can delay diagnosis and treatment, particularly with extrapulmonary TB (EPTB). Research suggests that ultrasound can identify splenic microabscesses caused by EPTB, but data are limited on the frequency of this finding in patients with culture-proven EPTB. OBJECTIVES: To estimate the frequency of splenic EPTB microabscesses detected with ultrasound in patients with HIV and TB co-infection. METHODS: Studies published in six major databases as of November 2017 were systematically reviewed based on the PRISMA guidelines. Cohen's kappa test was used to determine inter-rater agreement. Articles included for data abstraction passed the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) evaluation. Freeman-Tukey transformation was used to calculate weighted proportions. Heterogeneity was evaluated by Forest plot and I2 calculation. RESULTS: After abstract screening, article review and QUADAS-2 evaluation, five studies were selected for data extraction. A total of 774 patients in these studies were infected with HIV. Splenic lesions were seen with ultrasound in 21.0% of patients with HIV (95% confidence interval (CI) 10.6 - 33.8). TB diagnosed by culture, biopsy, smear, or molecular methods was found to be the cause of 88.3% (95% CI 72.3 - 97.9) of splenic microabscesses seen on ultrasound in patients with HIV. CONCLUSIONS: Ultrasound evaluation of the spleen in patients with HIV and symptoms suggestive of TB in endemic regions is a viable diagnostic adjunct. Ultrasound detection of splenic microabscesses in HIV patients is probably sufficient indication to initiate TB treatment prior to obtaining culture data. Strong conclusions cannot be drawn owing to the high heterogeneity of this small number of studies.

Detection of splenic microabscesses with ultrasound as a marker for extrapulmonary tuberculosis in patients with HIV: a systematic review

Background. In 2015, 1.2 million new cases of tuberculosis (TB) were diagnosed in patients with HIV. Diagnostic limitations and resource shortages in endemic areas can delay diagnosis and treatment, particularly with extrapulmonary TB (EPTB). Research suggests that ultrasound can identify splenic microabscesses caused by EPTB, but data are limited on the frequency of this finding in patients with culture-proven EPTB. Objectives. To estimate the frequency of splenic EPTB microabscesses detected with ultrasound in patients with HIV and TB co-infection. Methods. Studies published in six major databases as of November 2017 were systematically reviewed based on the PRISMA guidelines. Cohen's kappa test was used to determine inter-rater agreement. Articles included for data abstraction passed the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) evaluation. Freeman-Tukey transformation was used to calculate weighted proportions. Heterogeneity was evaluated by Forest plot and I2 calculation. Results. After abstract screening, article review and QUADAS-2 evaluation, five studies were selected for data extraction. A total of 774 patients in these studies were infected with HIV. Splenic lesions were seen with ultrasound in 21.0% of patients with HIV (95% confidence interval (CI) 10.6 - 33.8). TB diagnosed by culture, biopsy, smear, or molecular methods was found to be the cause of 88.3% (95% CI 72.3 - 97.9) of splenic microabscesses seen on ultrasound in patients with HIV. Conclusions. Ultrasound evaluation of the spleen in patients with HIV and symptoms suggestive of TB in endemic regions is a viable diagnostic adjunct. Ultrasound detection of splenic microabscesses in HIV patients is probably sufficient indication to initiate TB treatment prior to obtaining culture data. Strong conclusions cannot be drawn owing to the high heterogeneity of this small number of studies

The effects of medial and lateral displacement calcaneal osteotomies on ankle and subtalar joint pressure distribution.

We compared the pressure distribution in the ankle and posterior facet of the subtalar joint following 1 cm medial and lateral displacement calcaneal osteotomies to the pressure distribution in the intact foot. Six cadaver specimens were loaded in neutral alignment while pressure measurements were recorded. A 1-cm medial displacement osteotomy shifted the average center of force in the ankle 1.0 mm medially (p = 0.36) while a lateral displacement osteotomy shifted the center of force 1.1 mm laterally (p = 0.42). There was also a slight shift in the percentage of pressure toward the side of the talus to which the calcaneus was shifted. For the lateral displacement osteotomy, the pressure increased 4.0% in the lateral-most quadrant (p = 0.05), while the medial osteotomy increased the pressure 1.3% in the medial quadrant (p = 0.30). In the subtalar joint, a medial displacement osteotomy shifted the pressure distribution slightly medially (5.9%, p = 0.06) and more anteriorly (9.6%, p = 0.02) while the distribution was shifted laterally (5.9%, p = 0.17) and anteriorly (5.6%, p = 0.03) with a lateral displacement osteotomy. These shifts of percentage of pressure between quadrants of the joints were slight-less than 5% in the ankle and less than 10% in the subtalar joint. Significant translation of the calcaneal tuberosity appears to have only a small effect on pressure distribution in the ankle and posterior facet of the subtalar joint in a weighted cadaver model.

Applications of ring fixators in complex foot and ankle trauma.

There is a growing base of literature that supports the use of external ring fixators in the treatment of complex foot and ankle fractures. Clinical studies that determine definitively the optimal treatment for particular injuries are absent. Small wire ring fixators have a growing role in allowing the stabilization of complex skeletal injuries with a minimum of iatrogenic soft tissue injury. Ring fixators should be considered in the algorithm of treatment of complex lower extremity fractures with associated significant soft tissue injury. One of the cornerstones of trauma management is the preservation of reconstructive options after injury. As interest in ankle arthroplasty increases and experience broadens, such options may be available to patients who sustain severe tibial plafond or talus fractures. It is imperative that hindfoot alignment and height be maintained and infection avoided so that reconstructive osteotomy, arthrodesis, and arthroplasty remain as options for patients who sustain severe trauma.

Histology of herniations through the body wall and cuticle of zooplankton from the Laurentian Great Lakes.

Zooplankton of the Laurentian Great Lakes developed hernial protrusions whose gross appearance matches those on zooplankton described elsewhere in the world. We have carried out a histologic and cytologic analysis of the protrusions and found that they are composed of apparently degenerating or necrotic tissue(s) that has been expressed from the organism through the process of herniation. At their base the protrusions are continuous with viable tissue(s) within the organism through a fissure in the exoskeleton. Our observations lead us to suspect that these hernial protrusions are lethal. The development of such protrusions in zooplankton may be a worldwide phenomenon, but the cause of the herniation remains a mystery.

Primary diagnosis of whipple disease manifesting as lymphadenopathy: use of polymerase chain reaction for detection of Tropheryma whippelii.

Whipple disease is a rare, chronic multisystem disease associated with the recently characterized organism Tropheryma whippelii. Extraintestinal manifestation involving the central nervous system, heart, and joints occasionally occurs. Involvement of the abdominal lymph nodes, especially the mesenteric and periaortic nodes, is not uncommon. However, peripheral lymphadenopathy as the sole clinical manifestation of Whipple disease is rare. We describe 2 patients with Whipple disease whose initial manifestation was lymphadenopathy. Lymph nodes from both patients showed infiltration of the sinuses by macrophages containing periodic acid-Schiff-positive, diastase-resistant, sickle-like structures. Electron microscopic evaluation confirmed the presence of rod-like organisms. DNA from each sample was amplified by the polymerase chain reaction using a specific set of oligonucleotide primers developed against the 16S ribosomal RNA coding sequence of T. whippelii. The histopathologic features and differential diagnosis of lipogranulomatous lymphadenopathy secondary to Whipple disease, as well as use of molecular-based assays, are discussed.

The arabidopsis DELAYED DEHISCENCE1 gene encodes an enzyme in the jasmonic acid synthesis pathway.

delayed dehiscence1 is an Arabidopsis T-DNA mutant in which anthers release pollen grains too late for pollination to occur. The delayed dehiscence1 defect is caused by a delay in the stomium degeneration program. The gene disrupted in delayed dehiscence1 encodes 12-oxophytodienoate reductase, an enzyme in the jasmonic acid biosynthesis pathway. We rescued the mutant phenotype by exogenous application of jasmonic acid and obtained seed set from previously male-sterile plants. In situ hybridization studies showed that during the early stages of floral development, DELAYED DEHISCENCE1 mRNA accumulated within all floral organs. Later, DELAYED DEHISCENCE1 mRNA accumulated specifically within the pistil, petals, and stamen filaments. DELAYED DEHISCENCE1 mRNA was not detected in the stomium and septum cells of the anther that are involved in pollen release. The T-DNA insertion in delayed dehiscence1 eliminated both DELAYED DEHISCENCE1 mRNA accumulation and 12-oxophytodienoate reductase activity. These experiments suggest that jasmonic acid signaling plays a role in controlling the time of anther dehiscence within the flower.

Plantarflexion torque following reconstruction of Achilles tendinosis or rupture with flexor hallucis longus augmentation.

Nine patients treated surgically for Achilles tendon rupture (7 patients) or tendinosis (2 patients) with primary repair or debridement and augmentation with the flexor hallucis longus muscle-tendon unit were evaluated at a mean of 19 months postoperative. Subjective evaluation revealed a high level of satisfaction. All patients returned to work and only two patients reported limitation in their recreational activities. The mean post-operative AOFAS Ankle-Hindfoot Score was 90 points. Four patients reported mild occasional pain and one patient complained of moderate daily pain. Motion assessment showed a 20% increase in the hallux MTP dorsiflexion compared to the non-operative side (p = 0.045). No difference in ankle motion was noted. Cybex II+ dynamic evaluation of plantarflexion peak torque was complete on both extremities. The torque deficit on the reconstructed extremity was 20% (p = 0.01) at 120 degrees per second and 26% (p = 0.003) at 30 degrees per second. There is no significant difference between the torque deficit recorded for patients with Achilles rupture and those with Achilles tendinosis. A trend toward improved torque production with longer follow up was observed.

Predictive markers for response to chemotherapy, organ preservation, and survival in patients with advanced laryngeal carcinoma.

OBJECTIVE: A systematic retrospective study of the largest randomized trial of induction chemotherapy and radiation for advanced laryngeal cancer was undertaken to determine whether specific tumor or biologic factors were predictive of chemotherapy response, organ preservation, or survival. METHODS: The variables analyzed included clinical and histologic factors, immunohistochemical expression of proliferating cell nuclear antigen and p53, and adjusted DNA index measurements. Variables were evaluated for correlation with outcomes of tumor response, organ preservation, and survival. RESULTS: Multivariate analysis revealed that the best predictor of complete response to induction chemotherapy was low T class. The full multivariate model for predicting larynx preservation in patients treated with induction chemotherapy plus radiation shows that T class, p53 overexpression, and elevated proliferating cell nuclear antigen index were independent predictors of successful organ preservation. CONCLUSIONS: These predictive markers should be included in future clinical trials of advanced laryngeal cancer to determine their usefulness prospectively.

Posterior tibial tendon insufficiency: diagnosis and treatment.

Posterior tibial tendon insufficiency is the most common cause of acquired adult flatfoot deformity. Although the exact etiology of the disorder is still unknown, the condition has been classified, on the basis of clinical and radiographic findings, into four stages. In stage I, there is no notable clinical deformity; patients usually present with pain along the course of the tendon and evidence of local inflammatory changes. Stage II is characterized by a dynamic deformity of the hindfoot. Stage III involves a fixed deformity of the hindfoot and typically also a fixed forefoot supination deformity but no obvious evidence of ankle abnormality. In stage IV, ankle involvement is secondary to long-standing fixed hindfoot deformities. The initial treatment of patients in any stage should be nonoperative, with immobilization, a nonsteroidal anti-inflammatory drug, and perhaps an orthotic device. Corticosteroid injections continue to be controversial. When nonoperative management fails, the treatment options consist of soft-tissue procedures alone or in combination with osteotomy or arthrodesis. Stage I insufficiency is generally treated with debridement and tenosynovectomy. Soft-tissue transfer does not appear to correct the underlying deformity in stage II disease; however, there is growing interest in joint-sparing operations that attempt to compensate for the underlying deformities with osteotomies or arthrodeses, supplemented with dynamic transfers to replace the insufficient posterior tibial tendon. Subtalar, double, or triple arthrodesis is the procedure of choice for stage III disease, frequently in conjunction with heel-cord lengthening. Tibiocalcaneal arthrodesis or pantalar arthrodesis is most commonly used to treat stage IV disease.

Clinical outcome of arthrodesis of the ankle using rigid internal fixation with cancellous screws.

Thirty consecutive patients underwent arthrodesis of the ankle using rigid internal fixation with cancellous screws between 1992 and 1996. One patient died of causes unrelated to the surgery before bony union. Primary fusion occurred in 27 of the remaining 29 patients (93%). The average time to primary union was 9 weeks. Two patients developed a delayed union and were treated with an additional bone-grafting procedure. Ultimately, each of the 29 patients went on to fusion. Use of tobacco during the postoperative period had no apparent effect on the rate of fusion or time to fusion. Twenty-five patients were available for clinical evaluation at an average of 24 months after surgery. Subjective evaluation using questionnaires revealed a high level of satisfaction. All patients stated that they would undergo the procedure again. The mean postoperative score on the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale was 81 points, compared with 48 points preoperatively (of a possible 100). Constant pain was the reason given by all patients for seeking treatment. After the arthrodesis, pain was reported as absent in 13 and occasional in 12 patients. All patients noted less pain in the hindfoot after fusion of the ankle. Active litigation and Workers' Compensation claims during the perioperative period had a significant negative effect on scores on the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale and seemed to decrease patients' perceived ability to return to work.

Great toe neuroarthropathy: a report of two cases.

Two cases of diabetic neuroarthropathy of the great toe are presented. The differential diagnosis is emphasized, and the literature regarding this unusual site for symptomatic disease is reviewed.

Late syndesmosis reconstruction: a case report.

Late syndesmosis reconstruction was performed on a recreational athlete. The functional outcome of the patient after 2 years is reported, and the relevant literature is discussed.

Useful boundaries of the subacromial bursa.

The anatomic boundaries the subacromial bursa may serve as a useful guide for surgical orientation and safety. The goals of this study were to measure the minimum distance between the subdeltoid reflection of the subacromial bursa and the circumflex branch of the axillary nerve and to identify relationships between the margins of the subacromial bursa and the acromion, rotator cuff, and acromioclavicular joint. Seventeen fresh-frozen cadavers (mean age, 69 years), were included. Eleven cadavera were dissected only after the subacromial bursa was injected with a latex solution to define the peripheral boundaries of the bursa. The bursal margins were always 2 cm or more from the anterolateral corner of the bursal acromial surface and the bursa lined the anterior half of the anteroposterior distance of the acromion. The mean distances from all points of the acromion to the axillary nerve averaged approximately 5 cm. The mean minimum distance from the subdeltoid bursal reflection to the axillary nerve was 0.8 +/- 0.5 cm with a range of 0.0 to 1.4 cm. In the unelevated extremity, the inferior bursal reflection was always cephalad to the axillary nerve even when the two structures were apposed. Surgeons should exercise caution when approaching the inferior boundary of the subdeltoid bursal reflection because of the proximity to the axillary nerve. We recommend coupling previously reported "safe deltoid-split" distances to this useful anatomic landmark to prevent nerve injury. Furthermore, the central location of the anterolateral corner of the acromion within the bursal space can be applied to needle placement for injection, arthroscopic diagnosis or treatment and mini-open rotator cuff repairs.

Modified adductor muscle transfer in cerebral palsy.

Eighty-five patients with cerebral palsy had modified adductor muscle transfers. A study of associated patient characteristics suggests that comparing adductor transfer with adductor release using postoperative radiographs, need for subsequent surgery, or postoperative motor skills is flawed by multiple variables. Adductor release and adductor transfer are best compared by measuring the abduction obtained at surgery and maintained over time. A follow-up of 141 modified adductor transfers with no prior or concomitant hip surgery demonstrated an averaged initial improvement in abduction of 43 degrees and maintenance of abduction with a low incidence of recurrence.

An unusual cause of posterior tibial tendon degeneration.

A case demonstrating a mechanical cause of posterior tibial tendon degeneration is reported. The possible etiologies for degeneration of the posterior tibial tendon are discussed.

Attachment and growth of anchorage-dependent cells on a novel, charged-surface microcarrier under serum-free conditions.

The present study describes a novel microcarrier substrate consisting of a swellable, copolymer of styrene and divinylbenzene, derivatized with trimethylamine. The co-polymer trimethylamine microcarriers support the growth of a number of different cell lines - Madin Darby Bovine Kidney, Madin-Darby Canine Kidney, Vero and Cos-7 - under serum-free conditions, and human diploid fibroblasts in serum-containing medium. Cells attach to the co- polymer trimethylamine microcarriers as rapidly as they attach to other charged-surface microcarriers (faster than they attach to collagen-coated polystyrene microcarriers) and spread rapidly after attachment. All of the cells examined grow to high density on the co- polymer trimethylamine microcarriers. Furthermore, cells are readily released from the surface after exposure to a solution of trypsin/EDTA. In this respect, the co-polymer trimethylamine microcarriers are different from other charged-surface microcarriers. Madin-Darby Bovine Kidney cells grown on this substrate support production of vaccine strain infectious bovine rhinotracheitis virus as readily as on other charged-surface or collagen-coated microcarriers. Thus, the co-polymer trimethylamine microcarriers combine the positive characteristics of the currently available charged-surface and adhesion-peptide coated microcarriers in a single product. The viral vaccine production industry is undergoing considerable change as manufacturers move toward complete, animal product-free culture systems. This novel substrate should find application in the industry, especially in processes which depend on viable cell recovery.

A novel cell ablation strategy blocks tobacco anther dehiscence.

We utilized a new cell ablation strategy to ablate specific anther cell types involved in the dehiscence process. The tobacco TA56 gene promoter is active within the circular cell cluster, stomium, and connective regions of the anther at different developmental stages. We introduced a cytotoxic TA56/barnase gene into tobacco plants together with three different anticytotoxic barstar genes. The anticytotoxic barstar genes were used to protect subsets of anther cell types from the cytotoxic effects of the TA56/barnase gene. The chimeric barstar genes were fused with (1) the tobacco TP12 gene promoter that is active at high levels in most anther cell types; (2) the soybean lectin gene promoter that is active earlier in the connective, and at lower levels in the circular cell cluster and stomium, than is the TA56 promoter; and (3) the tobacco TA20 gene promoter that is active at high levels in most anther cell types but has a different developmental profile than does the TP12 promoter. Normal anther development and dehiscence occurred in plants containing the TA56/barnase and TP12/barstar genes, indicating that barstar protects diverse anther cell types from the cytotoxic effects of barnase. Anthers containing the TA56/barnase and lectin/barstar genes also developed normally but failed to dehisce because of extensive ablation of the circular cell cluster, stomium, and contiguous connective regions. Anthers containing the TA56/barnase and TA20/barstar genes failed to dehisce as well. However, only the stomium region was ablated in these anthers. The connective, circular cell cluster, and adjacent wall regions were protected from ablation by the formation of barnase/barstar complexes. We conclude that anther dehiscence at flower opening depends on the presence of a functional stomium region and that chimeric barnase and barstar genes containing promoters that are active in several overlapping cell types can be used for targeted cell ablation experiments.

p53 mutation as a prognostic marker in advanced laryngeal carcinoma. Department of Veterans Affairs Laryngeal Cancer Cooperative Study Group.

OBJECTIVE: To determine the relationship of p53 mutations in advanced laryngeal carcinomas to p53 immunohistochemistry, organ preservation, and patient survival. DESIGN: Paraffin-embedded tumor specimens were obtained from patients enrolled in the Department of Veterans Affairs Laryngeal Cancer Cooperative Study, a multi-institutional randomized clinical trial comparing induction chemotherapy (cisplatin and fluorouracil) plus radiation therapy surgery plus postoperative radiation therapy. Tumor specimens were analyzed for p53 mutations in exons 5 through 8 by using single-strand conformational polymorphism (SSCP) analysis followed by DNA sequencing of all variants. Five-year follow-up data were available for all patients studied. SUBJECTS: Forty-four patients enrolled in the Department of Veterans Affairs Laryngeal Cancer Cooperative Study from whom paraffin-embedded tumor specimens were readily available. RESULTS: p53 immunostaining did not correlate with p53 SSCP and DNA sequencing results. More than half (62% [16/26]) of the tumors that overexpressed p53 immunohistochemically did not have a detectable p53 gene mutation. Similarly, 39% (7/18) of tumors that did not overexpress p53 did have a p53 gene mutation. p53 mutations were present in 39% of tumors tested. Mutations within exon 5 made up 41% of p53 gene mutations in laryngeal carcinomas. Transitions were the most common type of mutation in this study (92% of mutations). CONCLUSIONS: The presence of a p53 mutation as detected by SSCP is associated with decreased patient survival. Further study is required to confirm this relationship and to determine whether specific p53 mutations predict organ preservation.