Early Follow-up Evaluation Research Articles

PERCIST-like response assessment with FDG PET based on automatic segmentation of all lesions in metastatic breast cancer.

e13057 Background: In metastatic breast cancer (MBC), treatment response is often assessed with FDG PET per PERCIST which evaluates changes in SULpeak of the single hottest tumor lesion identified on the baseline and follow-up images. PERCIST therefore does not consider tumor heterogeneity. This work aims to compare responses determined with the automatic segmentation of all lesions to response determined manually per PERCIST. Methods: 10 MBC patients (61±14 y/o) undergoing either chemo- or hormonotherapy were randomly selected from the prospective EPICURE study (NCT03958136). A baseline and two follow-up FDG PET were acquired at pre-, early- (1 month) and mid-treatment times for each patient. All metastatic lesions on all images were manually segmented by experts. Using the Advanced Normalization Tools (ANTs) image registration method, we wrapped baseline lesion segmentations to automatically obtain the follow-up ones. These registered segmentations were compared to the ones done manually using standard biomarkers: SULpeak, lesion size and Total Lesion Glycolysis (TLG). Differences between baseline and follow-up images were visually represented by coloring the follow-up segmentations: in green for responsive lesions (decreasing SULpeak) and in red for progressive ones (increasing SULpeak). Two expert physicians were then asked to evaluate treatment response while seeing these colored segmentations. They assessed the FDG PET images in pairs, evaluating for each patient the baseline and one of the corresponding follow-ups in a blinded manner: either the early- or the mid-treatment follow-up. Evaluations were then compared: i) early- vs mid-treatment response and ii) follow-up response vs patient’s clinical outcome. Results: Biomarkers extracted from the registered segmentations were similar to the ones extracted from the manual segmentations, with a Lin correlation coefficient of 0.92, 0.87 and 0.95 for the SULpeak, lesion size and TLG respectively. These findings were obtained within ̃10min, whereas the manual segmentation of the three PET images for any given patient took ̃1h. With the use of colored segmentations, early follow-up evaluations were predictive of mid-treatment response in 65% of the cases. The blinded physicians agreed with the clinical outcomes 85% and 95% of the time for the early- and mid-treatment images respectively. Conclusions: With segmentations automatically derived from ANTs registration, we managed to extract biomarkers that are comparable to the ones obtained with manual segmentations; both segmentations carried similar information. ANTs fast registration and biomarkers computation can make it a useful tool in clinical routine. In addition, lesion coloring helped evaluate treatment response and early-treatment follow-up images were shown to be predictive of mid-treatment response. Clinical trial information: NCT03958136.

MRI Findings of Early Osteoarthritis in Patients Who Sustained Septic Arthritis of the Knee After ACL Reconstruction.

Background:Although a rare complication, septic arthritis (SA) after anterior cruciate ligament (ACL) reconstruction has potentially devastating consequences for the knee joint.Purpose:To prospectively analyze, at a mean 4-year follow-up, subjective, clinical, radiographic, and magnetic resonance imaging (MRI) findings between patients with SA and those with no septic complication after ACL reconstruction.Study Design:Cohort study; Level of evidence, 2.Methods:Of 2006 ACL reconstructions performed between 2004 and 2014, a total of 20 patients experienced SA. All patients were treated with arthroscopic irrigation and graft-retaining debridement immediately after diagnosis and at least 6 weeks of antibiotic treatment. After the exclusion process, 18 patients were included in the SA group and 20 in the control group. At final follow-up at a mean 48 months, a physical examination, KT-1000 arthrometer laxity test, Lysholm knee score, Tegner activity score, and International Knee Documentation Committee radiographic score were completed and then compared with preoperative data. The Boston-Leeds Osteoarthritis Knee Score was used for MRI evaluation at final follow-up to note chondral changes.Results:No significant differences between the SA and control groups were observed in pre- and perioperative variables that could indicate a higher incidence of early osteoarthritis (OA). Although range of motion and knee stability were not significantly different between the groups at final follow-up, the Lysholm score (mean ± SD, 79.8 ± 13.1 vs 90.9 ± 8.6; P < .01) and Tegner score (6.0 ± 1.1 vs 7.0 ± 1.4; P = .03) were significantly lower in the SA group as compared with the control group. MRI evaluation at final follow-up demonstrated a significantly higher degree of early knee OA in the SA group versus the control group. However, no differences in the degree of OA were seen on plain radiographs at final follow-up between the groups.Conclusion:MRI evaluation provided signs of worsened chondral state in the SA group, which could be associated with reduced functional outcome and return to sports. In contrast to radiograph analyses, MRI was excellent at distinguishing damage to the cartilage and can be useful in early follow-up evaluation of patients with SA after ACL reconstruction.

Location of correction within the lumbar spine impacts acute adjacent-segment kyphosis.

OBJECTIVEThe surgical correction of adult spinal deformity (ASD) often involves modifying lumbar lordosis (LL) to restore ideal sagittal alignment. However, corrections that include large changes in LL increase the risk for development of proximal junctional kyphosis (PJK). Little is known about the impact of cranial versus caudal correction in the lumbar spine on the occurrence of PJK. The goal of this study was to investigate the impact of the location of the correction on acute PJK development.METHODSThis study was a retrospective review of a prospective multicenter database. Surgically treated ASD patients with early follow-up evaluations (6 weeks) and fusions of the full lumbosacral spine were included. Radiographic parameters analyzed included the classic spinopelvic parameters (pelvic incidence [PI], pelvic tilt [PT], PI-LL, and sagittal vertical axis [SVA]) and segmental correction. Using Glattes' criteria, patients were stratified into PJK and noPJK groups and propensity matched by age and regional lumbar correction (ΔPI-LL). Radiographic parameters and segmental correction were compared between PJK and noPJK patients using independent t-tests.RESULTSAfter propensity matching, 312 of 483 patients were included in the analysis (mean age 64 years, 76% women, 40% with PJK). There were no significant differences between PJK and noPJK patients at baseline or postoperatively, or between changes in alignment, with the exception of thoracic kyphosis (TK) and ΔTK. PJK patients had a decrease in segmental lordosis at L4-L5-S1 (-0.6° vs 1.6°, p = 0.025), and larger increases in segmental correction at cranial levels L1-L2-L3 (9.9° vs 7.1°), T12-L1-L2 (7.3° vs 5.4°), and T11-T12-L1 (2.9° vs 0.7°) (all p < 0.05).CONCLUSIONSAlthough achievement of an optimal sagittal alignment is the goal of realignment surgery, dramatic lumbar corrections appear to increase the risk of PJK. This study was the first to demonstrate that patients who developed PJK underwent kyphotic changes in the L4-S1 segments while restoring LL at more cranial levels (T12-L3). These findings suggest that restoring lordosis at lower lumbar levels may result in a decreased risk of developing PJK.

The effect of implant macro-thread design on implant stability in the early post-operative period: a randomized, controlled pilot study.

Available literature suggests there is a transient drop in implant stability from approximately week 0 to week 3-4 as a result of peri-implant bone remodeling as it transitions from a primary, mechanical stability to a secondary, biological stability. Research investigating the influence of macro-thread design on this process is scant. The specific aim of this study was to evaluate the role of macro-thread design on implant stability in the early post-operative healing period using resonance frequency analysis (RFA). Seven patients, each missing at least two posterior teeth in the same arch, were included in the study. Three patients qualified for four implants resulting in a total of 10 matched pairs. All sites were healed (>6months), non-grafted sites with sufficient bone to place implants. Each site in a matched pair was randomly assigned to receive either a control (Megagen EZ Plus Internal; EZ) or test (Megagen AnyRidge; AR) implant. The test implant incorporates a novel thread design with a wide thread depth and increased thread pitch. RFA was used to determine implant stability quotient (ISQ) values for each implant at the time of placement and weekly for the first 8weeks. Implants consistently achieved a relatively high insertion torque (30-45N/cm) and high initial ISQ value (79.8±1.49). Baseline ISQ values for test (AR; 79.55±1.61) and control (EZ; 80.05±1.37) implants were similar. A general pattern of stability from baseline through all eight follow-up evaluations was observed for the test implants. A pattern of decreasing ISQ values was observed for the control implants across the early follow-up evaluations up to week four, where the value plateaued. There was a statistically significant main effect due to implant type (P<0.01) and a statistically significant interaction between implant type and time (P<0.01), indicating that the test and control implants performed differently at certain time points. Within the limitations of this study, macro-thread design appears to play a role in implant stability in the early post-operative healing period as assessed by RFA. These findings may have important implications related to immediate or early loading protocols.

Percutaneous angioplasty used to manage native and recurrent coarctation of the aorta in infants younger than 1 year: immediate and midterm results.

Balloon angioplasty (BAP) used to manage native coarctation of the aorta (CoAo) in infants remains controversial. This study aimed to compare short- and midterm results of BAP between native CoAo (NaCo) and postsurgical recoarctations (ReCo) in infants younger than 1 year. This retrospective study compared the clinical, echocardiographic, hemodynamic, and angiographic data for infants who underwent BAP between July 2003 and September 2012. The 12 NaCo and 13 ReCo patients in this study underwent BAP at 4.61 ± 3.69 and 4.88 ± 3.07 months (p = 0.84) and weighed 5.49 ± 2.57 and 6.10 ± 2.11 kg (p = 0.52), respectively. Their respective heights were 60.58 ± 10.58 and 61.15 ± 6.74 cm (p = 0.87). All the ReCo patients had their initial surgery before the age of 3 months. The minimal CoAo diameter was 2.81 ± 0.96 mm in the NaCo group and 2.86 ± 1.0 mm in the ReCo group (p = 0.90). The relative gradient reduction was 62.79 ± 32.43 % in the NaCo group and 73.37 ± 20.78 % in the ReCo group (p = 0.33). The in situ complication rate (pseudoaneurysm) was 8.33 % in the NaCo group and 7.69 % in the ReCo group (p = 0.74). During the early follow-up evaluation, five NaCo patients (41.66 %) presented with recoarctation requiring BAP reintervention within 1.75 ± 1.41 months (all had their initial BAP before 3 months of age) compared with 1 ReCo patient (7.69 %) (p = 0.165). The mean follow-up period was 3.09 ± 2.69 years for the NaCo patients and 3.6 ± 3.18 years for the ReCo patients (p = 0.69), during which the blood pressure gradient was 12.33 ± 9.67 for the NaCo patients and 7.80 ± 8.78 for the ReCo patients (p = 0.17), with corresponding Doppler peak instantaneous gradients of 21.29 ± 11.19 and 16.20 ± 10.23 (p = 0.24). The resultant diameter ratio between the minimal isthmus diameter and the aortic diameter at the diaphragmatic level was 0.81 ± 0.15 in the NaCo group and 0.85 ± 0.12 in the ReCo group (p = 0.53). The immediate and midterm results of BAP for the NaCo and ReCo infants were comparable. Accordingly, BAP seems to be an acceptable alternative to surgery for infants older than 3 months.

Acute Decompensated Heart Failure

Acute decompensated heart failure (ADHF) is a major public health problem throughout the world and its importance is continuing to grow. This article reviews the epidemiology of ADHF and the profile of patients suffering from this condition. It describes factors used in assessing prognosis and presents treatment options. Although no currently available treatments have been shown to favorably affect long-term outcomes, there are a variety of strategies and approaches to management that are expected to reduce morbidity and mortality following discharge after ADHF hospitalization. In particular, the clinician is alerted to the need to identify factors that trigger decompensation as well as to optimize treatments for chronic heart failure. The importance of the transition from hospital to the outpatient setting is described. Particular attention should be focused on providing health education to the patient and their family at an appropriate level of medical literacy as well as ensuring early follow-up evaluation after hospital discharge.

A meta-analysis of the outcome of endovascular and noninvasive therapies in the treatment of intermittent claudication

Intermittent claudication is a common symptom of peripheral arterial disease. Currently, there is a lack of consensus on the most effective therapies for this problem. We conducted a meta-analysis of randomized trials assessing the efficacy of endovascular therapy (EVT) compared with noninvasive therapies for the treatment of intermittent claudication. Randomized trials comparing the efficacy of EVT and noninvasive therapies, such as medical therapy (MT) and supervised exercise (SVE) in patients with intermittent claudication were identified by a systematic search. Data were pooled, and combined overall effect sizes (standardized differences of mean values) were calculated for a random effect model in terms of ankle-brachial index (ABI) and treadmill walking for initial claudication distance (ICD) and maximum walking distance (MWD). Nine eligible trials (873 participants) were included: two compared EVT and MT alone, four compared EVT and SVE, and three trials compared EVT plus SVE vs SVE alone. Heterogeneity between studies was marked. Quantitative data analysis suggested that EVT improved outcomes over MT alone at early follow-up evaluations. Outcomes of EVT plus SVE were better than those of SVE alone in terms of both ABI and treadmill walking at immediate, early, and intermediate follow-up. No substantial differences in outcomes of EVT alone compared with SVE alone were found. In patients with intermittent claudication, current evidence supports improved ABI and treadmill walking when EVT is added to MT or SVE during early and intermediate follow-up. There is no evidence that EVT alone provides improved outcome over SVE alone. There is low confidence in these findings for a number of reasons, including the small number of trials, the small size of these studies, the heterogeneity in study design, and the limited use of quality of life tools in assessing outcomes. More consistent data from larger, more homogenous studies, including longer follow-up, are required.

Clinical outcome after Hypofractionated Stereotactic Radiotherapy (HSRT) for benign skull base tumors

Objective: Surgical resection of skull base tumors can be associated with significant morbidity. In cases where the risks outweigh the benefits, radiation therapy can offer an alternative means to effectively control tumor growth. However, the optimal dose regime for radiation therapy remains controversial. The objective of this study was to assess the neurological outcome, local control rate and morbidity associated with a 5-fraction regime of hypofractionated stereotactic radiotherapy (HSRT) for benign skull base tumors.Methods: Twenty-six patients presenting with two of the most prevalent benign skull base tumors were included in the study. The tumors comprised 16 meningiomas and 10 acoustic neuromas. All patients exhibited preserved cranial nerve function prior to treatment, and a detailed audiological assessment was performed pre- and post-treatment for those patients with acoustic neuroma. Stereotactic radiosurgery was administered with the frameless CyberKnife Robotic Radiosurgery System. In each case, a 5-fraction HSRT regime was used: a dose of 5 Gy × 5 = 25 Gy to 6 Gy × 5 = 30 Gy was prescribed for skull base meningiomas, and 5 Gy × 5 = 25 Gy was prescribed for acoustic neuromas.Results: The clinical and radiographic median follow-up was 22 months (range: 6-54 months). Radiological assessment showed local control in all 26 tumors (100%), and in 5/26 patients (20%) the tumor showed a decrease in size. Cranial nerve function was preserved in all cases thus far studied; however, 28% of patients had transient Grade II side effects, including fatigue, headaches, unsteadiness and transient subjective worsening of hearing. In two of these patients, the period of transient worsening of hearing was associated with a temporary increase in the size of the tumor on control T2 MR images, consistent with radiation-induced edema. One patient had transient decrease in visual acuity from treatment-related edema. At the last follow-up, 3/16 patients with meningiomas (19%) and 2/10 with acoustic neuromas (20%) showed a decrease in tumor volume and improvement in hearing.Conclusion: A 5-fraction stereotactic radiotherapy regime, as used in this study, seems to be effective for local control of benign skull base tumors in this early follow-up evaluation. Neurological function preservation is excellent with this short regime in the early post-treatment period, but long-term follow-up is crucial for validation.

Brain-sparing Holo-cranial Radiotherapy: a Unique Application of Helical Tomotherapy

Aims Diffuse and extensive involvement of the scalp/skull by malignancy mandates holo-cranial radiotherapy with the aim to deliver homogeneous doses to the planning target volume (PTV) while minimising the dose to surrounding organs at risk (OARs). Previously described techniques result in significant heterogeneity, suboptimal coverage or poor conformity and need complicated beam matching. Here we report our preliminary experience of planning and delivery of brain-sparing holo-cranial radiotherapy with helical tomotherapy. Materials and methods Three patients with extensive involvement of the scalp/skull by malignancy were planned and treated with image-guided intensity-modulated radiation therapy on helical tomotherapy. The plan evaluation was carried out using standardised dose metrics. Results Helical tomotherapy achieved highly conformal and homogeneous dose distributions with substantial OAR sparing in all three patients. The volume of PTV receiving ≥95% of prescribed dose ( V 95%) was ≥98% in all three patients. The mean (standard deviation) homogeneity index and conformity index was 0.046 (0.006) and 0.783 (0.035), respectively. The mean dose to the brain parenchyma outside the PTV was 17.32 Gy (74%), 28.76 Gy (63.9%) and 26.7 Gy (59.3%) for the three patients. The mean (standard deviation) monitor units and beam-on time was 6939 (985) and 8.10 (1.137) min, respectively. Overall the treatment was very well tolerated with no significant acute toxicity. Early follow-up evaluation revealed a good clinicoradiological response and the absence of local disease progression with no significant sequelae, implying successful application of the treatment paradigm. Conclusion Helical tomotherapy is ideally suited for brain-sparing holo-cranial radiotherapy with its exceptional ability of tangential beam delivery resulting in highly conformal and homogenous dose distribution across large, complex target volumes with substantial OAR sparing.

Postoperative Incomplete Reduction of the Sesamoids as a Risk Factor for Recurrence of Hallux Valgus

It is unknown whether postoperative incomplete reduction of the sesamoids is a risk factor for the recurrence of hallux valgus. The purpose of the present study was to clarify the relationship between the postoperative relative sesamoid position and the recurrence of hallux valgus. Dorsoplantar weight-bearing radiographs of sixty normal feet (the control group) and sixty-five feet with hallux valgus (the hallux valgus group) in a study of adult women were reviewed. The feet in the hallux valgus group were treated with a proximal metatarsal osteotomy, and the radiographs were assessed preoperatively, at the early follow-up interval (at a mean of 3.1 months), and at the most recent follow-up interval (at a mean of forty-five months). The position of the medial sesamoid was classified with a grading system ranging from I through VII as described by Hardy and Clapham. In the feet with hallux valgus, we defined a grade of IV or less as the normal position of the medial sesamoid (the normal-position group) and grade V or greater as lateral displacement of the sesamoid (the displacement group). Fifty feet (83%) in the control group were classified as grade IV or less and ten, as grade V. All feet in the hallux valgus group were classified as grade V or greater preoperatively, forty-eight feet (74%) were classified as grade IV or less at the early follow-up evaluation, and forty-two feet (65%) were classified as grade IV or less at the most recent follow-up evaluation. The average hallux valgus angle in the hallux valgus group was 38.3 degrees (range, 25 degrees to 60 degrees ) preoperatively, 11.9 degrees (range, 4 degrees to 28 degrees ) at the time of the early follow-up, and 13.9 degrees (range, 0 degrees to 33 degrees ) at the time of the most recent follow-up. There was no significant difference in the average hallux valgus angle between the early and most recent follow-up evaluations in the feet that were considered to be in the normal-position group at the time of the early follow-up (p = 0.084). In the feet that were considered to be in the displacement group at the time of the early follow-up, the average hallux valgus angle at the time of the most recent follow-up was significantly greater than that at the time of the early follow-up (19.5 degrees +/- 8.4 degrees compared with 15.0 degrees +/- 5.8 degrees ) (p = 0.0082). The feet that were in the displacement group at the time of the early follow-up had a greater risk of having recurrence of the hallux valgus at that time than did those in the normal-position group (odds ratio, 10.0; 95% confidence interval, 2.75 to 36.33). Postoperative incomplete reduction of the sesamoids can be a risk factor for the recurrence of hallux valgus. The identification of incomplete reduction of the sesamoids intraoperatively may allow modification of surgical procedures and improvement of the surgical results.

Treatment of right ventricle to coronary artery connections in infants with pulmonary atresia and intact ventricular septum

At the severe end of the spectrum of infants with pulmonary atresia and intact ventricular septum, the likelihood of significant right ventricle to coronary artery connections increases. Our purpose is to present the first series of right ventricle to coronary artery connections ligated off bypass before right ventricular decompression and to evaluate the consequences of this approach. From 1988 to 2007, 19 patients with pulmonary atresia and intact ventricular septum had a total of 69 right ventricle to coronary artery connections identified preoperatively, and 10 more were located intraoperatively. Of these, 71 were judged large enough to warrant off-pump direct ligation. Preoperative diagnosis was by transthoracic echocardiography and angiography. Transesophageal and surface echocardiography were used for intraoperative location. Direct visualization and echocardiographic assessment for regional wall motion abnormalities determined the effects of ligation. Right ventricular decompression was done in all patients. After ligation, coronary flow converted from moderately or largely retrograde to antegrade perfusion. Ligation produced no visual myocardial consequences or immediate local wall motion abnormalities. For 3 patients, however, apical-septal wall motion abnormalities appeared from 2 hours to 3 days postoperatively. Serial studies were done to assess the later effects in the 16 of 19 30-day survivors. No evidence for myocardial injury was found, and all continued on a 2-ventricle repair course. The location and ligation of right ventricle to coronary artery connections can be reliably accomplished off bypass. Coronary flow became antegrade, improving myocardial oxygenation. No myocardial damage was observed. Inapparent right ventricle to coronary artery connections occasionally enlarge secondarily after right ventricular decompression, making early follow-up evaluation necessary after ligation. Despite the initial presence of significant right ventricle to coronary artery connections, 2-ventricle repairs are possible with long-term benefits.

Laparoscopic parastomal hernia repair is feasible and safe: early results of a prospective clinical study including 55 consecutive patients

Parastomal herniation is a common complication, and its operative treatment is notoriously difficult. Recently, the authors have described a laparoscopic technique for closure and reinforcement of the hernia with a hand-made "funnel-shaped" Gore-Tex Dual Mesh. Potentially this technique combines the advantages of a mesh repair with those of minimal invasive surgery. In 2002, a multicenter trial of this new technique was started in The Netherlands. To date, 55 consecutive patients (27 men; median age, 63 years) with a symptomatic primary (n = 45) or recurrent (n = 10) parastomal hernia have undergone elective surgery using this technique. The demographic, perioperative, and early follow-up data prospectively collected for these patients are presented in this report. Of the 55 procedures, 47 (85.5%) could be completed laparoscopically (median operation time, 120 min). Conversion to laparotomy was indicated because of dense adhesions prohibiting safe dissection (n = 4) or bowel injury (n = 4). No in-hospital mortality occurred. Postoperative recovery was uneventful for 47 patients (85%), who had a median hospital stay of 4 days. Surgical and nonsurgical complications occurred, respectively, for four patients each (7.2%). Full-thickness enterotomy appeared to be the most troublesome complication. After 6 weeks, when all the patients were reexamined, one recurrence was noted. Maximal efforts should be undertaken to prevent perioperative full-thickness enterotomy. Because this was achieved for the vast majority of patients, it is concluded that laparoscopic parastomal hernia repair is feasible and safe. Although a longer follow-up period is needed for definitive conclusions to be drawn regarding the recurrence rate, early follow-up evaluation shows very promising results.

Laparoscopic redo Nissen fundoplication in infants and children

From January 1994 to December 2004, 118 patients with recurrent gastroesophageal reflux disease (GERD) after fundoplication underwent laparoscopic redo Nissen fundoplication. The patients ranged in age from 6 months to 19 years (mean, 7 years), and weighed from 6.4 to 85 kg. Of the 118 patients, 64 had previous open fundoplications, 53 had previous laparoscopic fundoplications, and 19 had more than one previous fundoplication. All the procedures had been successfully completed laparoscopically. The average operative time was 100 min. The intraoperative complication rate was 1.1%. The average time to full feeding was 1.8 days, and the average hospital stay was 2.2 days. The postoperative complication rate was 3.6%. The wrap failure rate during an average follow-up period of 48 months was 6%. Laparoscopic redo Nissen fundoplication for a failed antireflux procedure is a safe and effective procedure. It has the same benefits as a primary laparoscopic Nissen for GERD, with low morbidity and a quicker recovery. Early follow-up evaluation suggests that the long-term outcome is superior to that associated with open redo fundoplication.

Translating Evidence into Practice: The Case of Dementia Guidelines in Specialized Geriatric Services

This paper describes a process of identifying best practice guidelines for non-pharmacological management for individuals with dementia and disseminating them to a group of frontline practitioners in specialized geriatric services. Our dissemination plan involved early participation of practitioners, development of a chart summarizing five guidelines showing commonalities, contrasts, and gaps in the guidelines, and their interpretation, colour-coded for the strength of the evidence on which they were based. Two sequential workshops were held in which recommendations for action were developed. Outcomes of the process included a resource manual, a network of practitioners, and action recommendations based upon survey data. An early follow-up evaluation showed increased adoption of guidelines.

Early and Longitudinal Evaluations of Treated Infants and Children and Untreated Historical Patients with Congenital Toxoplasmosis: The Chicago Collaborative Treatment Trial

Between December 1981 and May 1991, 44 infants and children with congenital toxoplasmosis were referred to our study group. A uniform approach to evaluation and therapy was developed and is described herein along with the clinical characteristics of these infants and children. In addition, case histories that illustrate especially important clinical features or previously undescribed findings are presented. Factors that contributed to the more severe disabilities included delayed diagnosis and initiation of therapy; prolonged, concomitant neonatal hypoxia and hypoglycemia; profound visual impairment; and prolonged, uncorrected increased intracranial pressure with hydrocephalus and compression of the brain. Years after therapy was discontinued, three children developed new retinal lesions (without loss of visual acuity when therapy for Toxoplasma gondii was initiated promptly), and three children experienced a new onset of afebrile seizures. Most remarkable were the normal developmental, neurological, and ophthalmologic findings at the early follow-up evaluations of many--but not all--of the treated children despite severe manifestations, such as substantial systemic disease, hydrocephalus, microcephalus, multiple intracranial calcifications, and extensive macular destruction detected at birth. These favorable outcomes contrast markedly with outcomes reported previously for children with congenital toxoplasmosis who were untreated or treated for only 1 month.

Arthroplasty of the metacarpophalangeal joints with use of silicone-rubber implants in patients who have rheumatoid arthritis. Long-term results.

The long-term results of 144 arthroplasties of the metacarpophalangeal joints, with use of silicone-rubber implants, were reviewed for twenty-seven patients (thirty-six hands) who had rheumatoid arthritis. The operations were all performed or supervised by the same surgeon. All patients had an arthroplasty of the metacarpophalangeal joint of all four fingers, and all had subjective and objective clinical evaluation and roentgenographic assessment. Relief of pain, the cosmetic appearance of the hand, the range of motion of the metacarpophalangeal and proximal interphalangeal joints, and the presence of residual deformity were evaluated. The average duration of follow-up was eight years and six months (range, five years to sixteen years and three months). Preoperatively, the mean active-extension deficit of the metacarpophalangeal joints ranged from 53 degrees (index finger, right hand) to 70 degrees (little finger, left hand) and the mean flexion ranged from 84 degrees (index finger, right hand) to 94 degrees (little finger, left hand). At the early follow-up evaluation (average, four months postoperatively; range, two to six months), the mean extension deficit had improved to a range of 7 degrees (little finger, right hand) to 19 degrees (index finger, left hand), and mean flexion ranged from 56 degrees (little finger, left hand) to 66 degrees (ring fingers). The range of motion had improved from a non-functional arc of flexion to a more functional arc of extension. At the time of the latest follow-up visit, the motion of the metacarpophalangeal joints had not deteriorated.(ABSTRACT TRUNCATED AT 250 WORDS)