Juvenile Granulosa Cell Tumor Mimicking HAIR-AN in a 4-Year-Old: A Case Report.

Predominantly androgen secreting juvenile granulosa cell tumors (JGCT) are uncommon and few reports exist in the literature. We present a case of a JGCT which presented with signs of prepubertal hyperandrogenism and insulin resistance to highlight the possible interaction between hyperandrogenemia and hyperinsulinism. We conducted chart review of a rare androgen secreting JGCT accompanied by hyperinsulinemia in a prepubertal patient. A 4-year-old girl presented with acanthosis nigricans and hyperinsulinism mimicking the Hyperandrogenism Insulin Resistance and Acanthosis Nigricans (HAIR-AN) syndrome at an age much younger than is typical for this diagnosis. Laboratory studies revealed elevated insulin, inhibin A and B, and total testosterone. All laboratory results normalized after unilateral salpingo-oophorectomy. The final diagnosis was Stage IA JGCT. This case highlights the importance of including ovarian tumors in the differential diagnosis when considering causes of virilization and insulin resistance. Our case illustrates the potential relationship between excess testosterone secretion and hyperinsulinemia and strengthens evidence that hyperandrogenemia may promote hyperinsulinism in ovarian disease.

Impact of bariatric surgery on the development of diabetic microvascular and macrovascular complications.

BACKGROUND: While bariatric surgery has been shown to improve type 2 diabetes (DM) control in the obese population, the effect on long-term DM complications has been less thoroughly investigated. The purpose of this study was to assess the development of microvascular and macrovascular complications in obese DM patients undergoing bariatric surgery. METHODS: New York patients' records from the SPARCS database in years 2006-2012 were used to identify obese patients with DM. Patients undergoing bariatric surgery were compared with patients managed medically, matched for age and gender. Patients were grouped based on baseline presence of controlled or uncontrolled DM and followed over time for the development of micro- and macrovascular complications. Cumulative incidence of complications was estimated with death treated as a competing risk event. Multivariable proportional sub-distribution hazards models were used to compare the risk of complications among different patient groups after adjusting for possible confounding factors. RESULTS: A total of 88,981 patients were reviewed, including 15,585 (18%) that were treated with bariatric surgery. Surgery patients had significantly lower risk of microvascular complications compared to non-surgery patients (controlled diabetes: HR = 0.40, 95% CI 0.37-0.42; uncontrolled diabetes: HR = 0.51, 95% CI 0.37-0.71). Similarly, the surgical patients were noted to have a significantly lower risk for macrovascular complications compared to non-surgery patients (controlled diabetes: HR = 0.43, 95% CI 0.40-0.46; uncontrolled diabetes: HR = 0.44, 95% CI 0.28-0.69). Cumulative incidence of microvascular complications was lower at 1, 5 and 9 years for the surgical groups for controlled and uncontrolled DM. Similar trends were observed for the macrovascular complications. CONCLUSIONS: Bariatric surgery appears to prevent complications of DM. Bariatric surgery patients with DM experienced significantly lower rates of microvascular and macrovascular complications, compared to non-surgically treated comparison group. Bariatric surgery was noted to offer protective benefits for both complicated and non-complicated DM patients. This reduced rate of complications was sustained in the long term.

Hospital utilization 4 years after bariatric surgery: sleeve gastrectomy versus Roux-en-Y gastric bypass.

BACKGROUND: While sleeve gastrectomy (SG) has lower perioperative risk compared with Roux-en-Y gastric bypass (RYGB), long-term data about their differential impact on overall health are unclear. Hospital use after bariatric surgery is an important parameter for improving peri- and postoperative care. OBJECTIVE: This present study was aimed to compare SG and RYGB in terms of their effect on long-term hospital-based healthcare utilization. SETTING: Multicenter, statewide database. METHODS: A retrospective cohort study of adult patients who underwent SG and RYGB between 2009 and 2011, with follow-up until 2015 and 2-year presurgery information. Propensity score-matched SG and RYGB groups were created using preoperative demographic characteristics, co-morbidities, and presurgery hospital use, measured by cumulative length of stay (LOS) and frequency of emergency department visits. Postsurgery yearly LOS, incidence of hospital visits, and the reason for the visit were compared. Primary outcomes included postoperative hospital visits during years 1 to 4 after bariatric surgery and cumulative LOS. Secondary outcomes included specific reasons for hospital use. RESULTS: There were 3540 SG and 13,587 RYGB patients, whose mean (95% confidence interval [CI]) LOS was 1.3 (1.3-1.4), .9 (.8-1), 1 (.9-1.1), and 1.2 (1-1.3) days at years 1 through 4, respectively. Postoperative yearly LOS was similar between the 2 propensity-matched groups. The risk of hospitalizations (odd ratio .73, 95% CI .64-.84, P < .0001) and emergency department visits (odds ratio .84, 95% CI .75-.95, P = .005) was significantly lower for SG, during the first postoperative year. The reverse was seen at the fourth postoperative year, with higher risk of emergency department use after SG (odds ratio 1.16, 95% CI 1.01-1.33, P = .035). CONCLUSION: Postoperative 4-year hospital utilization remains low for both SG and RYGB. The previously established lower early perioperative risk of SG was not appreciated for longer-term hospital use compared with RYGB.

Safety of bariatric surgery in patients older than 65 years.

BACKGROUND: The increase in life expectancy along with the obesity epidemic has led to an increase in the number of older patients undergoing bariatric surgery. There is conflicting evidence regarding the safety of performing bariatric procedures on older patients. OBJECTIVE: The purpose of this study was to compare the safety of laparoscopic sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) for older patients (>65 yr). SETTING: Nationwide analysis of accredited centers. METHODS: The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program 2015 to 2017 database was used to identify nonrevisional laparoscopic RYGB and SG procedures. Comparisons were made based on patient age. Clinical outcomes included postoperative events and mortality. RESULTS: There was a total 13,422 and 5395 matched pairs for SG and RYGB in comparing patients aged 18 years to those aged 65 and >65 years, respectively, and 5395 matched RYGB and SG procedures performed in patients >65 years. The complication rate was higher in older patients undergoing RYGB compared with SG (risk difference = 2.39%, 95% confidence interval: 1.57%-3.21%, P < .0001). When comparing older to younger patients, the older group had a higher complication rate for SG but not for RYGB (SG: risk difference = 1.01%, 95% confidence interval: .59%-1.43%, P < .0001, RYGB: risk difference = .59%, 95% confidence interval: -.29% to 1.47%, P = .2003). CONCLUSIONS: Overall complication rates of bariatric surgery are low in patients >65 years. SG appears to have a favorable safety profile in this patient population compared with RYGB. The overall complication rate for RYGB is not significantly different between the older and younger groups.

Surgical trainee impact on bariatric surgery safety.

BACKGROUND: Roux-en-Y-gastric bypass (RYGB) and sleeve gastrectomy (SG) are commonly performed bariatric procedures that are associated with a significant learning curve. The effect of surgeon experience on perioperative outcomes and safety is established, but the effect of trainee participation remains unclear. The purpose of this study was to assess the impact of trainees on early perioperative safety of bariatric surgery. METHODS: Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database for 2015 was used to identify non-revisional laparoscopic and robotic RYGB and SG procedures. Comparisons were made based on assistant level. Multivariable logistic and linear regression methodology was used to compare clinical outcomes. RESULTS: There were 35,354 laparoscopic RYGB, 2896 robotic RYGB, 79,717 laparoscopic SG, and 5449 robotic SG procedures examined. 21,257 (17%) and 11,322 (9%) of all procedures were performed with a resident or fellow, respectively. Fellow presence was independently associated with the development of complications for all procedure types except robotic SG when compared to non-trainee [odds ratio (OR) 1.31, 2.20, 1.28 for laparoscopic RYGB, robotic RYGB, and laparoscopic SG, respectively]. The most common events were urinary tract and superficial surgical site infections. This negative impact of fellow on overall complications was eliminated after accounting for operative duration. In laparoscopic SG, resident participation was associated with higher leak rate (OR 1.61), readmission (OR 1.18), re-intervention (OR 1.4), and complication rate (OR 1.32) compared to non-trainee, even after accounting for procedural duration. In robotic SG, there was no impact of trainee on outcomes. CONCLUSIONS: Although fellow training is associated with higher overall complication rate, there is no such impact on major safety benchmarks, including leak rate and re-operation. In contrast, the impact of resident trainees on SG outcomes is substantial. Operative involvement of trainees in bariatric surgery leads to different outcomes based on trainee level and should be judiciously considered during the programmatic design of bariatric educational curricula.

Biomechanical Role of Capsular Continuity in Superior Capsule Reconstruction for Irreparable Tears of the Supraspinatus Tendon.

BACKGROUND: Patients with irreparable rotator cuff tears have a defect of the superior capsule, which creates discontinuity of the shoulder capsule in the transverse direction (anterior-posterior direction). This effect is one of the causes underlying shoulder instability after rotator cuff tears. PURPOSE/HYPOTHESIS: The purpose of this study was to assess the effects of anterior and posterior continuity on shoulder biomechanics after superior capsule reconstruction (SCR). The hypothesis was that capsular continuity in the transverse direction would improve glenohumeral stability after SCR. STUDY DESIGN: Controlled laboratory study. METHODS: Seven fresh-frozen cadaveric shoulders were tested by using a custom shoulder testing system. Subacromial peak contact pressure, glenohumeral superior translation, glenohumeral compression force, and glenohumeral range of motion (ROM) were compared among 5 conditions: (1) intact shoulder, (2) simulated irreparable supraspinatus tendon tear, (3) SCR without side-to-side suturing, (4) SCR with posterior side-to-side suturing, and (5) SCR with both anterior and posterior side-to-side suturing. RESULTS: The creation of an irreparable supraspinatus tear significantly increased glenohumeral superior translation (0° of abduction: 254% of intact [P = .04]; 30° of abduction: 200% of intact [P = .04]) and subacromial peak contact pressure (0° of abduction: 302% of intact [P = .0001]; 30° of abduction: 239% of intact [P = .0006]), decreased glenohumeral compression force (0° of abduction: 85% of intact [P = .004]; 30° of abduction: 87% of intact [P = .0002]; 60° of abduction: 88% of intact [P = .0001]), and increased total ROM (0° of abduction: 16° increase [P = .008]). SCR without side-to-side suturing significantly decreased subacromial peak contact pressure (0° of abduction: 79% of intact [P = .0001]; 30° of abduction: 91% of intact [P = .001]; 60° of abduction: 55% of intact [P = .04]) but did not inhibit glenohumeral superior translation. By adding posterior side-to-side sutures, both glenohumeral superior translation (0° of abduction: 93% of intact [P = .02]; 30° of abduction: 110% of intact [P = .04]) and subacromial peak contact pressure decreased significantly (0° of abduction: 56% of intact [P = .0001]; 30° of abduction: 83% of intact [P = .0003]; 60° of abduction: 46% of intact [P = .04]). Neither SCR with nor SCR without side-to-side suturing ameliorated the tear-associated decrease in glenohumeral compression force and increase in total ROM. Adding anterior side-to-side sutures did not change any measurements compared with SCR with posterior side-to-side suturing. CONCLUSION: SCR with side-to-side suturing completely restored the superior stability of the shoulder joint by establishing posterior continuity between the graft, residual infraspinatus tendon, and underlying shoulder capsule. CLINICAL RELEVANCE: Side-to-side suturing between the graft, residual infraspinatus tendon, and underlying shoulder capsule is recommended for SCR in patients with irreparable supraspinatus tendon tears to restore superior stability after surgery.

Biomechanical Effects of Acromioplasty on Superior Capsule Reconstruction for Irreparable Supraspinatus Tendon Tears.

BACKGROUND: Acromioplasty is increasingly being performed for both reparable and irreparable rotator cuff tears. However, acromioplasty may destroy the coracoacromial arch, including the coracoacromial ligament, consequently causing a deterioration in superior stability even after superior capsule reconstruction. PURPOSE/HYPOTHESIS: The purpose of this study was to investigate the effects of acromioplasty on shoulder biomechanics after superior capsule reconstruction for irreparable supraspinatus tendon tears. The hypothesis was that acromioplasty with superior capsule reconstruction would decrease the area of subacromial impingement without increasing superior translation and subacromial contact pressure. STUDY DESIGN: Controlled laboratory study. METHODS: Seven fresh-frozen cadaveric shoulders were evaluated using a custom shoulder testing system. Glenohumeral superior translation, the location of the humeral head relative to the glenoid, and subacromial contact pressure and area were compared among 4 conditions: (1) intact shoulder, (2) irreparable supraspinatus tendon tear, (3) superior capsule reconstruction without acromioplasty, and (4) superior capsule reconstruction with acromioplasty. Superior capsule reconstruction was performed using the fascia lata. RESULTS: Compared with the intact shoulder, the creation of an irreparable supraspinatus tear significantly shifted the humeral head superiorly in the balanced muscle loading condition (without superior force applied) (0° of abduction: 2.8-mm superior shift [P = .0005]; 30° of abduction: 1.9-mm superior shift [P = .003]) and increased both superior translation (0° of abduction: 239% of intact [P = .04]; 30° of abduction: 199% of intact [P = .02]) and subacromial peak contact pressure (0° of abduction: 308% of intact [P = .0002]; 30° of abduction: 252% of intact [P = .001]) by applying superior force. Superior capsule reconstruction without acromioplasty significantly decreased superior translation (0° of abduction: 86% of intact [P = .02]; 30° of abduction: 75% of intact [P = .002]) and subacromial peak contact pressure (0° of abduction: 47% of intact [P = .0002]; 30° of abduction: 83% of intact [P = .0005]; 60° of abduction: 38% of intact [P = .04]) compared with after the creation of a supraspinatus tear. Adding acromioplasty significantly decreased the subacromial contact area compared with superior capsule reconstruction without acromioplasty (0° of abduction: 26% decrease [P = .01]; 30° of abduction: 21% decrease [P = .009]; 60° of abduction: 61% decrease [P = .003]) and did not alter humeral head position, superior translation, or subacromial peak contact pressure. CONCLUSION: Superior capsule reconstruction repositioned the superiorly migrated humeral head and restored superior stability in the shoulder joint. Adding acromioplasty decreased the subacromial contact area without increasing the subacromial contact pressure. CLINICAL RELEVANCE: When superior capsule reconstruction is performed for irreparable rotator cuff tears, acromioplasty may help to decrease the postoperative risk of abrasion and tearing of the graft beneath the acromion.

Biomechanical Effect of Thickness and Tension of Fascia Lata Graft on Glenohumeral Stability for Superior Capsule Reconstruction in Irreparable Supraspinatus Tears.

PURPOSE: To investigate the effects of graft length and thickness on shoulder biomechanics after superior capsule reconstruction. METHODS: Subacromial peak contact pressure and glenohumeral superior translation were measured at 0°, 30°, and 60° of glenohumeral abduction in 8 fresh-frozen cadaveric shoulders under 5 conditions: (1) intact shoulder; (2) irreparable supraspinatus tendon tear, (3) superior capsule reconstruction with a fascia lata allograft 4-mm thick and 15 mm longer than the distance from the superior glenoid to the lateral edge of the greater tuberosity, as determined during placement at 30° of glenohumeral abduction; (4) superior capsule reconstruction with a fascia lata allograft 8-mm thick and with the same 15 mm relative length determined at 10° of glenohumeral abduction, and (5) superior capsule reconstruction with a fascia lata allograft 8-mm thick and with the 15-mm relative length determined at 30° of glenohumeral abduction. To investigate the effect of graft thickness, we compared the data from conditions 1, 2, 3, and 5. To assess the effect of graft length, we compared conditions 1, 2, 4, and 5. RESULTS: With superior capsule reconstruction using a 4-mm graft, subacromial peak contact pressure (but not superior translation) was significantly lower than with irreparable supraspinatus tears (at 0° abduction: 259% decrease; P = .0002; at 30° abduction: 113% decrease; P = .01). The superior capsule reconstruction using an 8-mm graft significantly decreased both subacromial peak contact pressure (at 0° abduction: 246% decrease, P = .0002; at 30° abduction: 158% decrease; P = .0008; at 60° abduction: 57% decrease; P = .04) and superior translation (at 0° abduction: 135% decrease; P = .02; at 30° abduction; 130% decrease; P = .004). Graft length with placement at 10° glenohumeral abduction was 5 mm greater than that at 30° abduction. The 8-mm superior capsule reconstruction performed at 10° or 30° of glenohumeral abduction significantly decreased subacromial peak contact pressure (placement at 10° and 30°: 0° abduction, P = .0002 and .0002, respectively; 30° abduction, P = .0004 and .0005, respectively; 60° abduction, P = .04 and .04, respectively) and superior translation (placement at 10° and 30°; 0° abduction, P =.04 and .02, respectively; 30° abduction, P = .02 and .004, respectively) compared with irreparable supraspinatus tears. CONCLUSIONS: Superior capsule reconstruction normalized the superior stability of the shoulder joint when the graft was attached at 10° or 30° of glenohumeral abduction. An 8-mm-thick graft of fascia lata had greater stability than did a 4-mm-thick graft. CLINICAL RELEVANCE: Grafts 8-mm thick and attached at 15° to 45° of shoulder abduction (equal to 10° to 30° of glenohumeral abduction) biomechanically restore shoulder stability during superior capsule reconstruction using fascia lata.

Two regimes of the parametrically self-exciting ultrasonic standing waves.

This paper discusses a nonlinear multi-wave mechanism for the parametrically self-exciting standing waves in a plane-parallel liquid layer driven at one end of the layer. The dependence of this process on the number of parametrically self-exciting waves and the frequency detuning between the frequency "f" of the pump wave and the nearest natural frequency are analyzed. It is found that two regimes with different thresholds are possible. One of them is characterized by self-exciting subharmonic frequencies close to f/2 and the second has a much lower threshold and the presence of a self-exciting subharmonic at a frequency near to the smallest natural frequency. Three dimensionless parameters determining each regime are introduced.