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Background Postoperative changes after axillary lymph node surgery may significantly alter breast cancer survivors’ (BCS) quality of life. Although sentinel lymph node biopsy (SLNB) has less immediate morbidity than axillary lymph node dissection (ALND), its long-term impact on shoulder abduction, arm swelling, and neurosensory changes has not been evaluated. The purpose of this study was to compare long-term morbidity after SLNB or ALND and breast-conservation surgery. Methods Female BCS who remained free of disease at least 3 years after ALND or SLNB for Stage I–III unilateral breast cancer completed a symptom questionnaire and a brief neurosensory physical examination of the upper arm and axilla (range of motion, arm circumference, and sensation to light touch with cotton and needle). Results The mean age of the 187 participating BCS was 62 years. At a mean follow-up of 6.6 years after ALND and 4.9 years after SLNB, most BCS had full abduction; only 10 cases (8 ALND, 2 SLNB) had a ≥2 cm proximal and/or distal circumference difference on the ipsilateral side compared with the contralateral side. ALND was associated with a significantly greater likelihood of subjective arm numbness ( P  < .001), chest or axillary numbness ( P  < .001), arm or hand swelling ( P  < .001), and objective neurosensory changes in the posterior axilla, medial and distal upper arm ( P  < .001). Operative procedure was the only significant predictor of neurosensory changes ( P  < .001). Conclusion SLNB is associated with significantly less subjective and objective long-term morbidity than ALND.

Melanoma frequently metastasizes to the central nervous system (CNS). The diagnosis of CNS metastases typically is made following the onset of clinical symptoms. Thus, more sensitive diagnostic approaches are needed to identify subclinical CNS metastases. Currently, standard cytologic analysis of the cerebrospinal fluid (CSF) is limited by its poor sensitivity. A more sensitive assay was therefore developed using multiple reverse transcriptase-polymerase chain reaction (RT-PCR) markers. CSF was collected and assessed by RT-PCR for three known melanoma-associated markers (MAGE-3, MART-1, and tyrosinase) to detect occult metastatic melanoma cells in the CSF of 37 American Joint Committee on Cancer (AJCC) stage IV melanoma patients. Cytologic analysis of CSF was performed on all patients, and immunohistochemistry (IHC) analysis was performed on 33 CSF samples using anti-S100 and anti-HMB-45 antibodies. Only one patient (3%) had tumor-positive CSF cytology and IHC upon entry into the study, whereas 12 patients (32%) were positive for at least one RT-PCR marker. The correlation between CSF RT-PCR positivity of MART-1 and/or MAGE-3 and the development of CNS metastases at 3 mo was significant (p = 0.04). Fifteen of 37 patients (41%) had either positive MRI and/or positive RT-PCR results. Multimarker RT-PCR is more informative and sensitive than cytology/IHC in assessing the CSF of melanoma patients.

The complex and often variable clinical presentations of patients with hereditary neoplasia syndromes mandates a multidisciplinary approach to management. The involvement of surgeons in the assessment and management of these patients is essential, in that the majority of patients affected with hereditary neoplasms will, at some point, require resection of the target organs affected by specific gene mutations, with prophylactic or therapeutic intent, or both. As the pathogenesis of the known hereditary neoplasia syndromes becomes better understood at the molecular level, innovative targeted therapies will, inevitably, supplant or replace surgery as the primary treatment modality for these diseases. Until that time, however, surgeons will continue to play a prominent role in the care of patients with hereditary neoplasia syndromes. As is already occurring within many other clinical specialties, the incorporation of at least a basic understanding of the genetic mechanisms of disease transmission and expression are essential within the surgical specialties, as the two cases presented herein demonstrate. In this paper, we present two cases that illustrate many of the challenges inherent in the surgical management of patients with hereditary neoplasia syndromes: a patient with attenuated familial adenomatous polyposis syndrome, and a patient with multiple endocrine neoplasia syndrome, type 2–B.

Pain levels in patients with osteoarthritis (OA) of the knee are commonly assessed by using a numeric scoring system, but results may be influenced by factors other than the patient's actual physical discomfort or disease severity, including psychosocial and demographic variables. We examined the possible relation between knee-pain scores and several psychosocial, sociodemographic, disease, and treatment variables in 355 patients with knee OA. The pain-evaluation instrument was a 0- to 10-point rating scale. Data obtained retrospectively from the patients' medical records were demographic characteristics, body mass index (BMI), concomitant disorders, illicit and prescription drug use, alcohol use, smoking, knee OA treatment, and severity of knee OA indicated by Kellgren-Lawrence (KL) radiographic grade. Univariate and multivariate analyses were performed to determine whether these variables correlated with reported pain scores. On univariate analysis, higher pain scores were significantly associated with Native American or Hispanic ethnicity; a higher BMI; current prescription for an opioid, antidepressant, or gabapentinoid medication; depression; diabetes mellitus; fibromyalgia; illicit drug use; lack of health insurance; smoking; previous knee injection; and recommendation by the clinician that the patient undergo knee surgery. Neither the patient's sex nor the KL grade showed a correlation. On multivariate analysis, depression, current opioid prescription, and Native American or Hispanic ethnicity retained a significant association with higher pain scores. Our results in a large, ethnically diverse group of patients with knee OA suggest that psychosocial and sociodemographic factors may be important determinants of pain levels reported by patients with knee OA.

Intelligence is associated with important life outcomes. Behavioral, genetic, structural, and functional brain correlates of intelligence have been studied for decades, but questions remain as to how genetics are related to trait expression and what intermediary role brain properties play. This study investigated these mediations in a representative sample of 434 individuals, comprising young and older adults. Polygenic scores (PGS) for intelligence were calculated. Resting-state EEG recordings were analyzed using graph theory quantifying functional connectivity across different frequencies. We tested whether global and local graph metrics like efficiency and clustering mediated the association between PGS and intelligence. PGS significantly predicted variance in intelligence and were related to frequency-specific graph metrics in areas predominantly located in parieto-frontal regions, which in turn were associated with intelligence. These findings, based on the first study linking PGS to intelligence using EEG-derived graph metrics, identify candidate pathways through which genetic variation may shape intelligence, providing a foundation for future hypothesis-driven investigations. Data for this study were collected as part of the Dortmund Vital Study ( https://www.researchprotocols.org/2022/3/e32352 ; ClinicalTrials.gov: NCT05155397).

OBJECTIVE:--About one of five patients with coronary artery disease (CAD) suffers from previously unknown, predominantly postprandial type 2 diabetes. In the process of atherogenesis and the subsequent increased cardiovascular mortality of diabetic patients, endothelial dysfunction is suspected to play an important role, and it is observed in diabetic as well as insulin-resistant states. Thus, the aim of our study was to investigate the effect of pioglitazone on endothelial dysfunction, insulin sensitivity, and glucose control in newly detected type 2 diabetic patients with CAD. RESEARCH DESIGN AND METHODS--We investigated 42 patients (39 men and 3 women, age 60.25 ± 7.5 years, HbA[subscript 1c] 6.1 ± 0.5%) with manifest CAD and newly detected type 2 diabetes. A randomized, double-blind, placebo-controlled, parallel study with pioglitazone (30 mg/day for 12 weeks) was performed. At study entry and end, we performed an oral glucose tolerance test and measurements of endothelial dysfunction by photoplethysmographic pulse wave analysis. RESULTS:--Endothelial dysfunction was severely impaired at baseline in both groups. After 12 weeks, endothelial dysfunction was significantly better in the pioglitazone group (change of reflection index 6.5 ± 5.1 vs. 1.6 ± 2.9%, P = 0.002) compared with placebo. Insulin sensitivity, as assessed by homeostasis model assessment (2.20 ± 1.62 vs. 3.61 ± 1.87, P = 0.01), or the change of insulin sensitivity index from baseline to study end (0.021 ± 0.023 vs. -0.003 ± 0.012 [micro]mol · kg⁻¹ · min⁻¹ per pmol/l, P = 0.0001) and {szligbeta}-cell function (57.42 ± 49.86 vs. 21.78 ± 18.54 mU/l per mmol/l, P = 0.0014) significantly improved in the pioglitazone group, with no change observed after placebo. CONCLUSIONS:--Pioglitazone improves endothelial dysfunction independently from the observed benefits on insulin sensitivity and {szligbeta}-cell function in patients with newly diagnosed type 2 diabetes and CAD.

Background Treatment of traumatic knee dislocations remains controversial and challenging. Current techniques for PCL reconstruction utilize either a transtibial approach with potential risk of vascular injury from drilling toward the popliteal artery or a tibial inlay technique with prone patient positioning, which is cumbersome and adds operative time. We therefore developed a surgical technique using a supine posteromedial approach for PCL tibial inlay reconstruction for the treatment of Schenck KDIIIM (ACL/PCL/medial collateral ligament) knee dislocations. In patients undergoing this technique, we evaluated patient-reported outcome scores, ROM, stability, and complications. Description of Technique Tibial inlay PCL reconstructions were performed through a posteromedial approach with the patient supine, knee flexed, and hip externally rotated, thus avoiding prone patient positioning. The inlay approach uses the interval between the medial head of the gastrocnemius and the pes anserinus (gracilis and semitendinosus), with release of the semimembranosus tendon approximately 1 cm from its insertion on the tibia. Retraction of the medial gastrocnemius and semimembranosus allows access to the posteromedial aspect of the proximal tibia while protecting the neurovascular bundle. Methods All 11 patients sustaining a KDIIIM multiligamentous knee injury treated between 2002 and 2011 with a three-ligament reconstruction received this posteromedial approach. Seven patients were available for complete evaluation, and one completed telephone followup only. Mean followup was 6.0 years (range, 2.0–11.2 years). Clinical evaluation included Lysholm and Tegner activity scores and measurements of ROM and knee laxity. We also recorded complications. Results Mean Lysholm and Tegner activity scores were 81 and 4.9, respectively, with three patients returning to recreational or competitive sports. Mean knee flexion was 120° (range, 106°–137°); however, two patients had stiffness in flexion, lacking greater than 20° of flexion compared to the contralateral side. Five had less than 3 mm of translation. Three returned to the operating room, two for arthrofibrosis or painful hardware and a third for ACL reinjury requiring revision reconstruction; there were no vascular injuries. Conclusions Outcome scores, stability, and complications using this surgical technique were comparable to those found in other studies. The posteromedial approach for tibial inlay avoids prone positioning and the incisions are minimized, allowing safe exposure for combined medial and posterior ligament reconstruction. Further studies are needed to compare this method with others in the treatment of KDIIIM knee dislocations.

Background: Injury to the posterolateral corner (PLC) of the knee requires reconstruction to restore coronal and rotary stability. Two commonly used procedures are the Arciero reconstruction technique (ART) and the LaPrade reconstruction technique (LRT). To the authors’ knowledge, these techniques have not been biomechanically compared against one another. Purpose: To identify if one of these reconstruction techniques better restores stability to a PLC-deficient knee and if concomitant injury to the proximal tibiofibular joint or anterior cruciate ligament affects these results. Study Design: Controlled laboratory study. Methods: Eight matched-paired cadaveric specimens from the midfemur to toes were used. Each specimen was tested in 4 phases: intact PLC (phase 1), PLC sectioned (phase 2), PLC reconstructed (ART or LRT) (phase 3), and tibiofibular (phase 4A) or anterior cruciate ligament (phase 4B) sectioning with PLC reconstructed. Varus angulation and external rotation at 0º, 20º, 30º, 60º, and 90º of knee flexion were quantified at each phase. Results: In phase 3, both reconstructions were effective at restoring laxity back to the intact state. However, in phase 4A, both reconstructions were ineffective at stabilizing the joint owing to tibiofibular instability. In phase 4B, both reconstructions had the potential to restrict varus angulation motion. There were no statistically significant differences found between reconstruction techniques for varus angulation or external rotation at any degree of flexion in phase 3 or 4. Conclusion: The LRT and ART are equally effective at restoring stability to knees with PLC injuries. Neither reconstruction technique fully restores stability to knees with combined PLC and proximal tibiofibular joint injuries. Clinical Relevance: Given these findings, surgeons may select their reconstruction technique based on their experience and training and the specific needs of their patients.

Introduction : Arthroscopic surgery is the gold standard for cruciate ligament reconstruction in multi-ligament knee injuries. However, hospitals in limited-resource settings often lack arthroscopic-trained surgeons or equipment. Open approaches for treating knee dislocations can overcome many of these limitations. Methodology : This study aims to describe techniques for open approaches in a supine patient to address the cruciate ligaments in multi-ligament knee injuries and to review associated complications and clinical outcomes in a retrospective case series. Results : Ten patients with multi-ligament knee injuries who had undergone open cruciate ligament reconstruction between July 2016 and November 2018 were retrospectively identified. Open approaches were performed owing to the extravasation of arthroscopy fluid into the posterior compartment (3) or a large traumatic arthrotomy (7). Complications and patient-reported outcomes were analysed. Eight of the 10 patients were followed up at 10 months postoperatively (range, 5–23 months). None had iatrogenic neurovascular damage. Median outcomes scores were: visual analogue scale, 45 (range, 0–100); Knee Injury and Osteoarthritis Outcome Score-Physical Function Short Form, 81.4 (range, 75–100); Lysholm, 85 (range, 67–92). Discussion : Open approaches were safe and useful in treating cruciate ligaments and should be considered in arthroscopy fluid extraversion and large traumatic arthrotomies.