Long-term outcomes in patients with advanced adrenocortical carcinoma after image-guided locoregional ablation or embolization.

BACKGROUND: To evaluate outcomes and survival rates in patients with metastatic adrenocortical carcinoma (ACC) who were treated with image-guided locoregional treatments (IGLTs). PURPOSE: To evaluate the overall survival (OS) and clinical impact of IGLT in the management of patients with advanced metastatic ACC. METHODS: Retrospective review of 39 patients treated with IGLT between 1999 and 2018 was performed. Short- and long-term efficacy of treatments were defined based upon imaging and clinical data. Subgroup survival analysis was performed on patients with metastatic disease at diagnosis (N = 17) and compared with the same stage group from the most recent National Cancer Database (NCDB) report. Statistical analysis was performed using Cox proportional hazards model. RESULTS: Treatments were performed at different anatomic sites including liver (N = 46), lung (N = 14), retroperitoneum (N = 5), bone (N = 4), subcutaneous (N = 2), and intracaval (N = 1). Radiofrequency, microwave, cryoablation, or a combination of two modalities (45, 18, 3, 3, respectively) were used in 69 ablation sessions. Intra-arterial procedures were performed in 12 patients in 18 treatment cycles (range 1-3 per patient). As of a 2019 analysis, 11 patients were alive with a mean follow-up of 169 months (range 63-292 months) from diagnosis. Two- and 5-year OS rates for all patients were 84.5% and 51%, respectively, and 76.5% and 59% for patients with metastatic disease at diagnosis (N = 17). This compares favorably with an NCDB report of 35% 5-year survival rate for patients with metastatic disease. Female gender and longer time from diagnosis to first IGLT were found to be predictors of prolonged survival with hazard ratios of 0.23 (p < 0.001) and 0.66 (p = 0.001), respectively. CONCLUSION: IGLT may be associated with prolonged life expectancy in select patients with metastatic ACC.

Do non-weight-bearing knee radiographs for chronic knee pain result in increased follow-up imaging?

OBJECTIVE: While weight-bearing radiographs are considered the optimal method for evaluation of joint spaces in osteoarthritis, non-weight-bearing radiographs are often performed. The purpose of this study is to evaluate the rate of follow-up radiographs in patients receiving non-weight-bearing radiographs for chronic knee pain in the outpatient setting, compared with patients receiving weight-bearing radiographs. MATERIALS AND METHODS: Consecutive patients who received non-weight-bearing knee radiographs for chronic knee pain between January 1, 2018, and June 15, 2019, were included. Exclusion criteria included trauma, concern for infection or tumor, and post-surgical radiographs. An age- and sex-matched control group of 100 patients who received weight-bearing knee radiographs was compiled. The proportion of follow-up radiographs within 1 year was compared between the study and control groups with chi-squared tests. RESULTS: Four hundred non-weight-bearing knee radiographic examinations were included. There were 74/400 (18.5%) follow-up radiographs within 12 months. All follow-up radiographs were weight-bearing. In the control group, 4/100 (4%) had follow-up weight-bearing radiographs within 1 year (p < 0.001). CONCLUSION: Outpatients who underwent non-weight-bearing knee radiographs for chronic pain had a higher frequency of repeat imaging than those who initially underwent weight-bearing knee radiographs. These results suggest that non-weight-bearing knee radiographs are of lower clinical utility compared with weight-bearing radiographs.

A Rare Complication of Thymoma: Pure White Cell Aplasia in Good's Syndrome.

Pure white cell aplasia (PWCA) is a rare manifestation of thymoma. It is characterized by agranulocytosis with absent myeloid precursors in the bone marrow and normal hematopoiesis for other cell lines. Here we describe a 65-year-old female patient who presented with three days of fever and night sweat. Chest CT revealed an anterior mediastinal mass. A biopsy of the mass confirmed a diagnosis of thymoma mixed type A and B2. The patient developed a severe neutropenia, and her bone marrow revealed significantly decreased neutrophil-lineage cells, rare to absent B cells, and defective T cells, consistent with PWCA. Following thymectomy, a complete resolution of PWCA was achieved via multimodality therapy of intravenous immunoglobulins, granulocyte colony-stimulating factor, and immunosuppressant. This report highlights the care complexity regarding treatment choices and decision to perform thymectomy in patients presenting with PWCA.

Increased signal in the proximal patellar tendon: normal or pathologic?

OBJECTIVE: To determine the clinical significance of T2 signal hyperintensity in the proximal patellar tendon seen on MRI of the knee. MATERIALS AND METHODS: MRIs of 100 patients who underwent MRI of the knee between 1 May 2018 and 15 July 2018 were retrospectively evaluated. All examinations were performed on 3-Tesla MRI scanners with a dedicated knee coil and in accordance with our institution's standard knee MRI protocol. The presence of increased T2 signal was assessed on both sagittal and axial T2-weighted fat-saturated images. The amount of increased signal in the proximal patellar tendon on T2-weighted images was characterized as: none, mild, moderate, or severe. A corresponding chart review of the referring physicians' notes was performed to determine the presence of clinical symptoms of patellar tendinopathy. Patellar tendinopathy was considered present if the clinical notes described tenderness on palpation of the inferior patellar pole, infrapatellar tenderness, or patellar tendinosis/tendinitis. RESULTS: The majority (66%) of knee MRIs demonstrated the presence of increased T2 signal in the proximal patellar tendon. Only 4.5% of these patients had associated clinical findings of patellar tendinopathy. CONCLUSION: Although increased T2 signal in the proximal patellar tendon is a common finding, only in rare cases are there associated clinical symptoms. Thus, increased T2 signal in the proximal patellar tendon may not be a pathological finding in the absence of clinical findings of patellar tendinopathy.

Elbow Arthroplasty: From Normal to Failure.

Total elbow arthroplasty is currently an established surgical treatment for several pathologies of the elbow. Although initially used primarily in the treatment of rheumatoid arthritis, indications for total elbow arthroplasty have expanded and now include trauma, primary and secondary osteoarthritis, fracture nonunion, and following neoplasm resection. Desired outcomes of elbow arthroplasty include decreasing patient pain, restoration of function and mobility, and prevention of or treatment for instability. In comparison with total elbow arthroplasty, radial head replacements are most commonly performed following trauma. An additional technique, capitellar resurfacing arthroplasty, was developed in an effort to prevent early-onset osteoarthritis secondary to altered elbow biomechanics following radial head replacement. Complications of these surgeries include loosening, fracture, instability and dissociation, bushing wear, and particle disease.

Intraprocedural and postprocedural perigraft arterial sac embolization (PASE) for endoleak treatment.

Intervention may be necessary in up to one-third of patients with endoleaks after endovascular aortic aneurysm repair (EVAR). Perigraft arterial sac embolization (PASE) to induce aneurysm thrombosis was performed by intrasac injection of thrombin and gelfoam slurry. Thirteen patients were treated with PASE since 2006. Eight patients underwent immediate PASE, and five patients were treated during surveillance following EVAR. The median follow-up is 23.9 months (range, 2.6-66.1 months) for the entire cohort; 24.4 and 23.1 months for the immediate and delayed group, respectively. No patients had further aneurysm growth. One (8%) patient maintained stable aneurysm size with a persistent type II endoleak, and 11 (85%) patients had aneurysm shrinkage. PASE to induce sac thrombosis after EVAR is an alternative for the treatment of endoleaks. Further study is required to define optimal patient selection, safety, long-term efficacy and potential cost-savings of this technique.

Five residents speak: the meaning of living with dying in a long-term care home.

Personal meanings given to the experience of living with nursing home death were shared by 5 nursing home residents. Data were collected using semi-structured interviews. Using M. van Manen's (1990) hermeneutic phenomenology, the lived experience of residents emerged as a compilation of 5 dynamically occurring themes, including (a) mapping relations, (b) pacing oneself (c) maintaining belongingness, (d) reconciling death as part of life, and (e) engaging in preparatory review. The overarching essence of the lived experienced was defined as reflection toward resolution of dying as a "resident" in a sea of life gains and losses. Residents' expressions revealed that living with peers' dying in a nursing home is closely entwined with how life is experienced during one's final days.

Inflammation and central nervous system Lyme disease.

Lyme disease, caused by the bacterium Borrelia burgdorferi, can cause multi-systemic signs and symptoms, including peripheral and central nervous system disease. This review examines the evidence for and mechanisms of inflammation in neurologic Lyme disease, with a specific focus on the central nervous system, drawing upon human studies and controlled research with experimentally infected rhesus monkeys. Directions for future human research are suggested that may help to clarify the role of inflammation as a mediator of the chronic persistent symptoms experienced by some patients despite antibiotic treatment for neurologic Lyme disease.

Antipsychotic polypharmacy: is there evidence for its use?

Antipsychotic polypharmacy occurs frequently in clinical practice; however, there is a lack of controlled clinical studies testing the efficacy of the combinations used. The purpose of this literature review was to examine studies and other reports that have assessed the incremental benefits and deficits of combination antipsychotic therapy versus monotherapy. A PUBMED search covering a 26-year period from 1976 to 2002 was conducted. The search was limited to clinical trials, case series, and reports. Fifty-two reports were identified that systematically assessed the efficacy of combination therapy as opposed to monotherapy: 4 double-blind studies, 13 open-label clinical trials, and 35 case reports. Only one open-label trial and 2 case reports met the design criteria of having trials of each medication and the combination in the same patients and using some type of standardized assessment to evaluate outcome. The most frequent combination was clozapine-risperidone. Of the clinical trials, 75% (3/4) of the double-blind studies and 69% (9/13) of the open-label trials found that combination therapy was effective in reducing symptoms, while 37% (13/35) of case reports documented an overall positive outcome. Currently, the clinical practice of antipsychotic polypharmacy is not evidence-based; however, there is also no evidence against its use. Expanded systematic research to assess this clinical practice is needed.