We report our experience with two patients with myoepithelial carcinoma (MEC) of the extremity. An 83-year-old male and a 35-year-old female were treated with standard isolated limb infusion (ILI), using melphalan and dactinomycin. The first patient had a complete response (CR) that was sustained for two and a half years, until he developed a regional lymph node metastasis. The second patient had a 4.7 cm tumor located on her left hand with metastasis to the ipsilateral axillary lymph nodes. Initial treatment consisted of ILI and left axillary lymphadenectomy. The primary tumor regressed and showed signs of central necrosis, measuring 2.8 cm after 1 month. Though she was continuing to respond, a decision was made by her orthopedic surgeon to administer neoadjuvant radiation followed by surgical resection.
Aims The aim of this study was to assess orthopaedic oncologic patient morbidity resulting from COVID-19 related institutional delays and surgical shutdowns during the first wave of the pandemic in New York, USA. Methods A single-centre retrospective observational study was conducted of all orthopaedic oncologic patients undergoing surgical evaluation from March to June 2020. Patients were prioritized as level 0-IV, 0 being elective and IV being emergent. Only priority levels 0 to III were included. Delay duration was measured in days and resulting morbidities were categorized into seven groups: prolonged pain/disability; unplanned preoperative radiation and/or chemotherapy; local tumour progression; increased systemic disease; missed opportunity for surgery due to progression of disease/lost to follow up; delay in diagnosis; and no morbidity. Results Overall, 25 patients met inclusion criteria. There were eight benign tumours, seven metastatic, seven primary sarcomas, one multiple myeloma, and two patients without a biopsy proven diagnosis. There was no priority level 0, two priority level I, six priority level II, and 17 priority level III cases. The mean duration of delay for priority level I was 114 days (84 to 143), priority level II was 88 days (63 to 133), and priority level III was 77 days (35 to 269). Prolonged pain/disability and delay in diagnosis, affecting 52% and 40%,respectively, represented the two most frequent morbidities. Local tumour progression and increased systemic disease affected 32% and 24% respectively. No patients tested positive for COVID-19. Conclusion COVID-19 related delays in surgical management led to major morbidity in this studied orthopaedic oncologic patient population. By understanding these morbidities through clearer hindsight, a thoughtful approach can be developed to balance the risk of COVID-19 exposure versus delay in treatment, ensuring optimal care for orthopedic oncologic patients as the pandemic continues with intermittent calls for halting surgery. Cite this article: Bone Jt Open 2021;2(4):236–242.
Myelinoclastic diffuse sclerosis (MDS, Schilder's disease) is a rare CNS demyelinating disorder affecting mainly children and usually presenting as an intracranial mass lesion. We report the first case of recurrent intracranial MDS where the third episode of demyelination involved the cervical spinal cord. This may represent a subset of the disease, which should be considered as Schilder's variant (childhood form) of multiple sclerosis.
Background: As hand surgeons, tendon injuries and lacerations are a particularly difficult problem to treat, as poor healing potential and adhesions hamper optimal recovery. Adipose-derived stem cells (ADSCs) have been shown to aid in rat Achilles tendon healing after a puncture defect, and this model can be used to study tendon healing in the upper extremity. We hypothesized that ADSCs cultured with growth differentiation factor 5 (GDF5) and platelet-derived growth factor (PDGF) would improve tendon healing after a transection injury. Methods: Rat Achilles tendons were transected and then left either unrepaired or repaired. Both groups were treated with a hydrogel alone, a hydrogel with ADSCs, or a hydrogel with ADSCs that were cultured with GDF5 and PDGF prior to implantation. Tissue harvested from the tendons was evaluated for gene expression of several genes known to play an important role in successful tendon healing. Histological examination of the tendon healing was also performed. Results: In both repaired and unrepaired tendons, those treated with ADSCs cultured with GDF5/PDGF prior to implantation showed the best tendon fiber organization, the smallest gaps, and the most organized blood vessels. Treatment with GDF5/PDGF increased expression of the protenogenesis gene SOX9, promoted cell-to-cell connections, improved cellular proliferation, and enhanced tissue remodeling. Conclusions: Adipose-derived stem cells cultured with GDF5/PDGF prior to implantation can promote tendon repair by improving cellular proliferation, tenogenesis, and vascular infiltration. This effect results in a greater degree of organized tendon healing.
Most cases of de Quervain tenosynovitis can be managed with nonoperative measures, and the mainstay of treatment is corticosteroid injection (CSI). The use of ultrasound may improve the accuracy of injections and can help to identify and localize injections to separate subcompartments.For patients who are in the third trimester of pregnancy or breastfeeding, there is no contraindication to CSI as studies have shown that it can provide optimal symptomatic relief to the mother without impacting the baby.When nonoperative treatment is unsuccessful, surgical release of the first dorsal compartment (FDC) can provide excellent symptom relief. Open release performed through a longitudinal incision allows for better visualization of the underlying anatomy, resulting in fewer injuries to underlying structures and a lower incidence of hypertrophic scarring compared with a transverse incision.For surgeons who are comfortable performing endoscopic techniques, endoscopic FDC release can result in quicker symptom improvement, superior scar cosmesis, and a lower incidence of radial sensory nerve injury.Studies have shown that FDC release can safely and effectively be performed using the WALANT (wide-awake local anesthesia no tourniquet) technique, which has the potential for cost savings without compromising quality or patient comfort.
[Excerpt] This article has three specific purposes: first, to show the importance of the ADA to hospitality practitioners; second, to illustrate the need for hospitality educators to take a leading role in addressing issues regarding the employment of disabled people; and finally, to illustrate how hospitality educators can use this case method to not just discuss the substance of the law itself, but to actually involve students in issues surrounding this legislation. Only in this way will students begin to develop the strategies necessary to deal with the interpersonal implications and complexities of managing in the ADA era. This article describes the major provisions of the legislation. Then it presents a classroom module, and follows with a case that can be used to stimulate discussion in almost any management class.
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