Anterior hip dislocations have been reported to account for approximately 5% to 10% of all hip dislocations.¹ Epstein and Wiss² originally divided anterior hip dislocations into superior (type I, including pubic or subspinous) and inferior (type II, including obturator and perineal) dislocations. This classification was further subdivided based on the presence of either no associated fracture (type A), fracture of the femoral head or neck (FNF; type B), or fracture of the acetabulum (type C).³ Of all anterior hip dislocations, it has been reported that the inferior or obturator type of dislocation is more common, constituting approximately 70% of all anterior dislocations.⁴ In 1943, Pringle⁵ described the mechanism of obturator dislocation as simultaneous abduction, flexion, and external rotation of the hip. Our literature search found only 2 case reports in non-English-language journals of a complete FNF associated with an attempted reduction of an anterior hip dislocation.^6,7 Indentation fractures of the femoral head have been more commonly reported than FNFs, with a reported incidence of 35% to 55% after anterior dislocation.^4,8 DeLee and colleagues⁸ also found that those patients with indentation fractures were at a higher risk for developing avascular necrosis of the femoral head in addition to being more likely to report poor or fair function of the hip 2 years after reduction.

There have been a number of different reduction maneuvers for anterior dislocation of hips published in the literature. Epstein and Harvey⁹ advocated reduction by traction in the line of the femur with the hip flexed and in gentle internal rotation and abduction while the patient was under general anesthesia. Toms and Williams,¹⁰ however, recommended adduction with gradual release of the longitudinal traction. Polesky and Polesky¹¹ described a reduction method involving sharp internal rotation, which was found to be associated with FNF. The patient provided written informed consent for print and electronic publication of this case report, and approval was obtained from the Emory University Institutional Review Board.

Case Report

The patient was a 73-year-old woman, an independent ambulator with minimal antecedent hip pain, who, as a pedestrian, was struck by a heavy-duty pickup truck at low velocity. She was flown to our level I trauma center from an outside hospital. The patient arrived hemodynamically stable, with a Glasgow Coma Scale score of 15 and with major complaints of right shoulder and right hip pain. She had a positive Focused Assessment with Sonography for Trauma (FAST), and underwent a subsequent urgent chest, abdomen, and pelvis computed tomography (CT) scan for further investigation. CT showed a grade 1 liver laceration. Her anteroposterior (AP) pelvic radiograph and pelvic CT scan showed an anterior hip dislocation with the femoral head located adjacent to the obturator foramen (Figures 1, 2). The AP pelvic radiograph and pelvic CT scan were scrutinized extensively before reduction to rule out a possible FNF. Comparing the right and left femoral necks through multiple axial CT images showed no obvious differences between the 2 sides (Figures 3, 4). Her only other orthopedic injury was an inferior shoulder dislocation. It is not routine for the general surgery trauma team to obtain a pelvic CT scan prior to involvement of the orthopedic service and prompt reduction of a hip dislocation. Upon initial examination of her right hip, it was fixed in slight flexion and external rotation; she was neurovascularly intact.

After being cleared by the trauma service, the patient provided informed consent for closed reduction of the hip and shoulder under conscious sedation, performed by the emergency department (ED) staff. She received intravenous fentanyl and midazolam, and the reduction was attempted. The reduction maneuver was performed with gentle inline traction, adduction, and internal rotation and extension. There was an audible clunk, and the hip was thought to be reduced and stable. The right leg lower extremity was placed into a knee immobilizer and she remained neurovascularly intact. The shoulder was reduced. After the procedure, the patient had an episode of hypoxia requiring oxygenation via a bag valve mask by the ED staff. Postreduction radiographs confirmed reduction of the right shoulder; however, they also showed a FNF with the femoral head retained near the obturator foramen (Figures 5, 6). The patient and her family were informed of the fracture, and a total hip arthroplasty (THA) was recommended, given her pre-injury mild symptomatic osteoarthritis in the hip and her age. The patient was admitted to the intensive care unit for cardiopulmonary monitoring and was found to have a troponin leak on hospital day 1. She was evaluated by the cardiology service; serial electrocardiograms and troponins ruled out acute myocardial infarction. The patient was cleared for surgery on hospital day 4.

On hospital day 5, she underwent a right THA via a Kocher-Langenbeck approach. The patient’s femoral head was found to be anterior and laterally adjacent to her ischial tuberosity with an indentation fracture. The sciatic nerve was identified and found to be intact. A metal-on-polyethylene Stryker Accolade femoral component and Trident acetabular shell were implanted, and a posterior capsular repair was performed (Figure 7).

The patient tolerated the procedure well, and her postoperative course was uneventful. She was discharged to a subacute rehabilitation facility on postoperative day 3. The patient returned for her 2-week postoperative visit ambulating without assistance. At her last follow-up visit, approximately 6 weeks after surgery, she was a functionally independent community ambulator. Phone conversations with her private orthopedist at 6 months confirmed continued ambulation without problems.

Discussion

This case report of a complication that occurred in our institution has resulted in a change in our protocol for treatment of geriatric anterior hip dislocations. Our institution is a level I trauma center, and traumatic hip dislocations are relatively common, occurring usually in young patients with high-energy trauma. Although somewhat controversial, it is generally assumed that the incidence of avascular necrosis of the femoral head after dislocation of the hip is correlated with the time interval from dislocation to reduction of the hip. Therefore, our protocol for hip dislocations of the hip in young trauma patients is urgent reduction in the ED under appropriate analgesia and muscle relaxation.

In this case report, the patient was older than 65 years with radiographic evidence of possible impingement and postsurgical evidence of impingement of the femoral head in the obturator foremen (Figures 1, 2, 8). In addition, the patient was significantly osteopenic radiographically. An attempted reduction in the ED resulted in FNF requiring THA (Figures 5, 6, 9). After discussion of this complication in our institution’s morbidity and mortality conference, we have developed a protocol for the geriatric patient (older than 65 years) with a traumatic hip dislocation. These patients will undergo attempted reduction under controlled analgesia and muscle relaxation in the operating room (OR) with an attending surgeon present, ideally, an attending surgeon comfortable with arthroplasty in a terminally cleaned OR room. Our institution’s surgical site infection rate after total joint arthroplasty has significantly decreased with improved patient selection and the use of terminally cleaned OR rooms. Because our policy is to perform closed reduction of dislocated hips in an urgent manner, if there is not a terminally clean room or an arthroplasty-trained attending orthopedic surgeon available, then informed consent with discussion of the possibility of fracture requiring a subsequent arthroplasty should be obtained from the patient before the attempted reduction.

After review of the available literature, we believe that this case highlights some of the important treatment principles when treating anterior hip dislocations in the ED. The relatively high incidence of indentation fractures of the femoral head with obturator dislocations puts these fractures at higher risk for possible impingement around the obturator ring. This impingement, coupled with preexisting osteopenia, can predispose these dislocations to FNF, if appropriate analgesia and sedation are not obtained and gentle reduction is not performed. In addition, while it may not be time- or cost-effective to perform closed reduction on every hip dislocation, we bring geriatric patients with radiographic osteopenia to the OR for more controlled reductions. In the informed consent discussion, the possibility of FNF is mentioned, and the patient and family are told that an elective total hip replacement will be performed if this complication occurs.

We consider the following to be risk factors for closed reductions of anterior hip dislocations: (1) preexisting osteopenia on plain films, (2) age greater than 65 years, and (3) radiographic femoral head impingement on the surrounding bony pelvis. We continue to consider closed reduction of both anterior and posterior hip dislocations as urgent (within 6 hours from time of dislocation). This case adds to the existing literature on the risk of FNF with closed reduction of obturator hip dislocations, and we hope that it will encourage further study into the safest and most cost-effective reduction protocol.

Anterior hip dislocations have been reported to account for approximately 5% to 10% of all hip dislocations.¹ Epstein and Wiss² originally divided anterior hip dislocations into superior (type I, including pubic or subspinous) and inferior (type II, including obturator and perineal) dislocations. This classification was further subdivided based on the presence of either no associated fracture (type A), fracture of the femoral head or neck (FNF; type B), or fracture of the acetabulum (type C).³ Of all anterior hip dislocations, it has been reported that the inferior or obturator type of dislocation is more common, constituting approximately 70% of all anterior dislocations.⁴ In 1943, Pringle⁵ described the mechanism of obturator dislocation as simultaneous abduction, flexion, and external rotation of the hip. Our literature search found only 2 case reports in non-English-language journals of a complete FNF associated with an attempted reduction of an anterior hip dislocation.^6,7 Indentation fractures of the femoral head have been more commonly reported than FNFs, with a reported incidence of 35% to 55% after anterior dislocation.^4,8 DeLee and colleagues⁸ also found that those patients with indentation fractures were at a higher risk for developing avascular necrosis of the femoral head in addition to being more likely to report poor or fair function of the hip 2 years after reduction.

There have been a number of different reduction maneuvers for anterior dislocation of hips published in the literature. Epstein and Harvey⁹ advocated reduction by traction in the line of the femur with the hip flexed and in gentle internal rotation and abduction while the patient was under general anesthesia. Toms and Williams,¹⁰ however, recommended adduction with gradual release of the longitudinal traction. Polesky and Polesky¹¹ described a reduction method involving sharp internal rotation, which was found to be associated with FNF. The patient provided written informed consent for print and electronic publication of this case report, and approval was obtained from the Emory University Institutional Review Board.

Case Report

The patient was a 73-year-old woman, an independent ambulator with minimal antecedent hip pain, who, as a pedestrian, was struck by a heavy-duty pickup truck at low velocity. She was flown to our level I trauma center from an outside hospital. The patient arrived hemodynamically stable, with a Glasgow Coma Scale score of 15 and with major complaints of right shoulder and right hip pain. She had a positive Focused Assessment with Sonography for Trauma (FAST), and underwent a subsequent urgent chest, abdomen, and pelvis computed tomography (CT) scan for further investigation. CT showed a grade 1 liver laceration. Her anteroposterior (AP) pelvic radiograph and pelvic CT scan showed an anterior hip dislocation with the femoral head located adjacent to the obturator foramen (Figures 1, 2). The AP pelvic radiograph and pelvic CT scan were scrutinized extensively before reduction to rule out a possible FNF. Comparing the right and left femoral necks through multiple axial CT images showed no obvious differences between the 2 sides (Figures 3, 4). Her only other orthopedic injury was an inferior shoulder dislocation. It is not routine for the general surgery trauma team to obtain a pelvic CT scan prior to involvement of the orthopedic service and prompt reduction of a hip dislocation. Upon initial examination of her right hip, it was fixed in slight flexion and external rotation; she was neurovascularly intact.

After being cleared by the trauma service, the patient provided informed consent for closed reduction of the hip and shoulder under conscious sedation, performed by the emergency department (ED) staff. She received intravenous fentanyl and midazolam, and the reduction was attempted. The reduction maneuver was performed with gentle inline traction, adduction, and internal rotation and extension. There was an audible clunk, and the hip was thought to be reduced and stable. The right leg lower extremity was placed into a knee immobilizer and she remained neurovascularly intact. The shoulder was reduced. After the procedure, the patient had an episode of hypoxia requiring oxygenation via a bag valve mask by the ED staff. Postreduction radiographs confirmed reduction of the right shoulder; however, they also showed a FNF with the femoral head retained near the obturator foramen (Figures 5, 6). The patient and her family were informed of the fracture, and a total hip arthroplasty (THA) was recommended, given her pre-injury mild symptomatic osteoarthritis in the hip and her age. The patient was admitted to the intensive care unit for cardiopulmonary monitoring and was found to have a troponin leak on hospital day 1. She was evaluated by the cardiology service; serial electrocardiograms and troponins ruled out acute myocardial infarction. The patient was cleared for surgery on hospital day 4.

On hospital day 5, she underwent a right THA via a Kocher-Langenbeck approach. The patient’s femoral head was found to be anterior and laterally adjacent to her ischial tuberosity with an indentation fracture. The sciatic nerve was identified and found to be intact. A metal-on-polyethylene Stryker Accolade femoral component and Trident acetabular shell were implanted, and a posterior capsular repair was performed (Figure 7).

The patient tolerated the procedure well, and her postoperative course was uneventful. She was discharged to a subacute rehabilitation facility on postoperative day 3. The patient returned for her 2-week postoperative visit ambulating without assistance. At her last follow-up visit, approximately 6 weeks after surgery, she was a functionally independent community ambulator. Phone conversations with her private orthopedist at 6 months confirmed continued ambulation without problems.

Discussion

This case report of a complication that occurred in our institution has resulted in a change in our protocol for treatment of geriatric anterior hip dislocations. Our institution is a level I trauma center, and traumatic hip dislocations are relatively common, occurring usually in young patients with high-energy trauma. Although somewhat controversial, it is generally assumed that the incidence of avascular necrosis of the femoral head after dislocation of the hip is correlated with the time interval from dislocation to reduction of the hip. Therefore, our protocol for hip dislocations of the hip in young trauma patients is urgent reduction in the ED under appropriate analgesia and muscle relaxation.

In this case report, the patient was older than 65 years with radiographic evidence of possible impingement and postsurgical evidence of impingement of the femoral head in the obturator foremen (Figures 1, 2, 8). In addition, the patient was significantly osteopenic radiographically. An attempted reduction in the ED resulted in FNF requiring THA (Figures 5, 6, 9). After discussion of this complication in our institution’s morbidity and mortality conference, we have developed a protocol for the geriatric patient (older than 65 years) with a traumatic hip dislocation. These patients will undergo attempted reduction under controlled analgesia and muscle relaxation in the operating room (OR) with an attending surgeon present, ideally, an attending surgeon comfortable with arthroplasty in a terminally cleaned OR room. Our institution’s surgical site infection rate after total joint arthroplasty has significantly decreased with improved patient selection and the use of terminally cleaned OR rooms. Because our policy is to perform closed reduction of dislocated hips in an urgent manner, if there is not a terminally clean room or an arthroplasty-trained attending orthopedic surgeon available, then informed consent with discussion of the possibility of fracture requiring a subsequent arthroplasty should be obtained from the patient before the attempted reduction.

After review of the available literature, we believe that this case highlights some of the important treatment principles when treating anterior hip dislocations in the ED. The relatively high incidence of indentation fractures of the femoral head with obturator dislocations puts these fractures at higher risk for possible impingement around the obturator ring. This impingement, coupled with preexisting osteopenia, can predispose these dislocations to FNF, if appropriate analgesia and sedation are not obtained and gentle reduction is not performed. In addition, while it may not be time- or cost-effective to perform closed reduction on every hip dislocation, we bring geriatric patients with radiographic osteopenia to the OR for more controlled reductions. In the informed consent discussion, the possibility of FNF is mentioned, and the patient and family are told that an elective total hip replacement will be performed if this complication occurs.

We consider the following to be risk factors for closed reductions of anterior hip dislocations: (1) preexisting osteopenia on plain films, (2) age greater than 65 years, and (3) radiographic femoral head impingement on the surrounding bony pelvis. We continue to consider closed reduction of both anterior and posterior hip dislocations as urgent (within 6 hours from time of dislocation). This case adds to the existing literature on the risk of FNF with closed reduction of obturator hip dislocations, and we hope that it will encourage further study into the safest and most cost-effective reduction protocol.

Anterior hip dislocations have been reported to account for approximately 5% to 10% of all hip dislocations.¹ Epstein and Wiss² originally divided anterior hip dislocations into superior (type I, including pubic or subspinous) and inferior (type II, including obturator and perineal) dislocations. This classification was further subdivided based on the presence of either no associated fracture (type A), fracture of the femoral head or neck (FNF; type B), or fracture of the acetabulum (type C).³ Of all anterior hip dislocations, it has been reported that the inferior or obturator type of dislocation is more common, constituting approximately 70% of all anterior dislocations.⁴ In 1943, Pringle⁵ described the mechanism of obturator dislocation as simultaneous abduction, flexion, and external rotation of the hip. Our literature search found only 2 case reports in non-English-language journals of a complete FNF associated with an attempted reduction of an anterior hip dislocation.^6,7 Indentation fractures of the femoral head have been more commonly reported than FNFs, with a reported incidence of 35% to 55% after anterior dislocation.^4,8 DeLee and colleagues⁸ also found that those patients with indentation fractures were at a higher risk for developing avascular necrosis of the femoral head in addition to being more likely to report poor or fair function of the hip 2 years after reduction.

There have been a number of different reduction maneuvers for anterior dislocation of hips published in the literature. Epstein and Harvey⁹ advocated reduction by traction in the line of the femur with the hip flexed and in gentle internal rotation and abduction while the patient was under general anesthesia. Toms and Williams,¹⁰ however, recommended adduction with gradual release of the longitudinal traction. Polesky and Polesky¹¹ described a reduction method involving sharp internal rotation, which was found to be associated with FNF. The patient provided written informed consent for print and electronic publication of this case report, and approval was obtained from the Emory University Institutional Review Board.

Case Report

The patient was a 73-year-old woman, an independent ambulator with minimal antecedent hip pain, who, as a pedestrian, was struck by a heavy-duty pickup truck at low velocity. She was flown to our level I trauma center from an outside hospital. The patient arrived hemodynamically stable, with a Glasgow Coma Scale score of 15 and with major complaints of right shoulder and right hip pain. She had a positive Focused Assessment with Sonography for Trauma (FAST), and underwent a subsequent urgent chest, abdomen, and pelvis computed tomography (CT) scan for further investigation. CT showed a grade 1 liver laceration. Her anteroposterior (AP) pelvic radiograph and pelvic CT scan showed an anterior hip dislocation with the femoral head located adjacent to the obturator foramen (Figures 1, 2). The AP pelvic radiograph and pelvic CT scan were scrutinized extensively before reduction to rule out a possible FNF. Comparing the right and left femoral necks through multiple axial CT images showed no obvious differences between the 2 sides (Figures 3, 4). Her only other orthopedic injury was an inferior shoulder dislocation. It is not routine for the general surgery trauma team to obtain a pelvic CT scan prior to involvement of the orthopedic service and prompt reduction of a hip dislocation. Upon initial examination of her right hip, it was fixed in slight flexion and external rotation; she was neurovascularly intact.

After being cleared by the trauma service, the patient provided informed consent for closed reduction of the hip and shoulder under conscious sedation, performed by the emergency department (ED) staff. She received intravenous fentanyl and midazolam, and the reduction was attempted. The reduction maneuver was performed with gentle inline traction, adduction, and internal rotation and extension. There was an audible clunk, and the hip was thought to be reduced and stable. The right leg lower extremity was placed into a knee immobilizer and she remained neurovascularly intact. The shoulder was reduced. After the procedure, the patient had an episode of hypoxia requiring oxygenation via a bag valve mask by the ED staff. Postreduction radiographs confirmed reduction of the right shoulder; however, they also showed a FNF with the femoral head retained near the obturator foramen (Figures 5, 6). The patient and her family were informed of the fracture, and a total hip arthroplasty (THA) was recommended, given her pre-injury mild symptomatic osteoarthritis in the hip and her age. The patient was admitted to the intensive care unit for cardiopulmonary monitoring and was found to have a troponin leak on hospital day 1. She was evaluated by the cardiology service; serial electrocardiograms and troponins ruled out acute myocardial infarction. The patient was cleared for surgery on hospital day 4.

On hospital day 5, she underwent a right THA via a Kocher-Langenbeck approach. The patient’s femoral head was found to be anterior and laterally adjacent to her ischial tuberosity with an indentation fracture. The sciatic nerve was identified and found to be intact. A metal-on-polyethylene Stryker Accolade femoral component and Trident acetabular shell were implanted, and a posterior capsular repair was performed (Figure 7).

The patient tolerated the procedure well, and her postoperative course was uneventful. She was discharged to a subacute rehabilitation facility on postoperative day 3. The patient returned for her 2-week postoperative visit ambulating without assistance. At her last follow-up visit, approximately 6 weeks after surgery, she was a functionally independent community ambulator. Phone conversations with her private orthopedist at 6 months confirmed continued ambulation without problems.

Discussion

This case report of a complication that occurred in our institution has resulted in a change in our protocol for treatment of geriatric anterior hip dislocations. Our institution is a level I trauma center, and traumatic hip dislocations are relatively common, occurring usually in young patients with high-energy trauma. Although somewhat controversial, it is generally assumed that the incidence of avascular necrosis of the femoral head after dislocation of the hip is correlated with the time interval from dislocation to reduction of the hip. Therefore, our protocol for hip dislocations of the hip in young trauma patients is urgent reduction in the ED under appropriate analgesia and muscle relaxation.

In this case report, the patient was older than 65 years with radiographic evidence of possible impingement and postsurgical evidence of impingement of the femoral head in the obturator foremen (Figures 1, 2, 8). In addition, the patient was significantly osteopenic radiographically. An attempted reduction in the ED resulted in FNF requiring THA (Figures 5, 6, 9). After discussion of this complication in our institution’s morbidity and mortality conference, we have developed a protocol for the geriatric patient (older than 65 years) with a traumatic hip dislocation. These patients will undergo attempted reduction under controlled analgesia and muscle relaxation in the operating room (OR) with an attending surgeon present, ideally, an attending surgeon comfortable with arthroplasty in a terminally cleaned OR room. Our institution’s surgical site infection rate after total joint arthroplasty has significantly decreased with improved patient selection and the use of terminally cleaned OR rooms. Because our policy is to perform closed reduction of dislocated hips in an urgent manner, if there is not a terminally clean room or an arthroplasty-trained attending orthopedic surgeon available, then informed consent with discussion of the possibility of fracture requiring a subsequent arthroplasty should be obtained from the patient before the attempted reduction.

After review of the available literature, we believe that this case highlights some of the important treatment principles when treating anterior hip dislocations in the ED. The relatively high incidence of indentation fractures of the femoral head with obturator dislocations puts these fractures at higher risk for possible impingement around the obturator ring. This impingement, coupled with preexisting osteopenia, can predispose these dislocations to FNF, if appropriate analgesia and sedation are not obtained and gentle reduction is not performed. In addition, while it may not be time- or cost-effective to perform closed reduction on every hip dislocation, we bring geriatric patients with radiographic osteopenia to the OR for more controlled reductions. In the informed consent discussion, the possibility of FNF is mentioned, and the patient and family are told that an elective total hip replacement will be performed if this complication occurs.

We consider the following to be risk factors for closed reductions of anterior hip dislocations: (1) preexisting osteopenia on plain films, (2) age greater than 65 years, and (3) radiographic femoral head impingement on the surrounding bony pelvis. We continue to consider closed reduction of both anterior and posterior hip dislocations as urgent (within 6 hours from time of dislocation). This case adds to the existing literature on the risk of FNF with closed reduction of obturator hip dislocations, and we hope that it will encourage further study into the safest and most cost-effective reduction protocol.

The biceps brachii derives its name from the 2 heads of the muscle. The short head originates from the coracoid apex, with the coracobrachialis muscle. The long head of the biceps tendon (LHBT) starts within the capsule of the shoulder joint, running from the supraglenoid tubercle or labrum.¹ The tendon typically runs free along its intra-articular course, but it is also extrasynovial and ensheathed by a continuation of the synovial lining of the articular capsule that extends to the inferior-most extent of the bicipital groove.² Congenital anomalies of the LHBT are uncommon, although several atypical forms have been described. A literature search for anomalous LHBT identified several variations in anatomic descriptions, including Y-shaped variant, complete absence of tendon, extra-articular attachment, and a variety of intracapsular attachments. In all, 8 case reports of aberrant intracapsular attachment of LHBT^3-12 were identified. These cases presented with a variety of clinical manifestations and pathologic changes. Often, these anatomic variations are considered innocuous, yet some present with pathologic findings.

We present the clinical, magnetic resonance imaging (MRI), and arthroscopic findings of a relatively young athletic patient who was experiencing symptoms of bilateral superior labrum anterior to posterior (SLAP) tears that were unresponsive to conservative management. A unique anatomic variant of the LHBT that involved confluence of the LHBT with the undersurface of the anterosuperior capsule at the rotator interval, as well as a Buford complex anteriorly, was identified and treated. We believe that the tethering of the biceps tendon to the capsule combined with the Buford complex created increased stress on the superior labrum and biceps anchor variant, leading to the development of bilateral symptomatic type II SLAP tears. Knowledge of this variant, though perhaps rare, may be relevant for diagnostic recognition of young athletic patients who present with recalcitrant shoulder symptoms. The patient and the patient’s parents provided written informed consent for print and electronic publication of this case report.

Case Report

A 15-year-old healthy and active athletic boy presented with pain in the right shoulder without history of trauma. He was active in both swimming and baseball. He complained of pain that was present with activities, such as lifting weights, swimming, and throwing. His treatment prior to the office visit consisted of nonsteroidal anti-inflammatory medication, rest, and a therapy program initiated by his high school athletic trainer.

Physical examination demonstrated tenderness to palpation over the posterior capsule and biceps. Motion was full, cuff strength was normal, and SLAP signs (O’Brien, Speed, and Jobe relocation) were positive. A radiograph showed no sign of fracture or dislocation, and no evidence of bony abnormality.

The patient was sent for an MRI arthrogram, which showed a SLAP tear extending from 1 o’clock anteriorly to 10 o’clock posteriorly without intra-articular displacement. No rotator cuff tear was noted. The biceps tendon was noted to be unremarkable and located within the bicipital groove, although retrospective review of the MRI showed that the intra-articular biceps tendon was somewhat confluent with the adjacent tissues.

The patient underwent right shoulder arthroscopy. The shoulder was stable to ligamentous examination under anesthesia. Arthroscopic evaluation revealed that there was a type II SLAP tear extending from the 11-o’clock to the 2-o’clock positions. The superior glenohumeral ligament was identified as it arose from the upper pole of the glenoid labrum and then ran parallel and inferior to the tendon of the biceps towards the lesser tubercle. Surprisingly, there was a very unusual attachment of the intracapsular LHBT to the undersurface of the rotator interval, which restricted biceps excursion in relation to the rotator cuff. Additionally, there was a thick cord-like middle glenohumeral ligament anteriorly that lacked the normal glenoid attachments, thus representing a Buford complex. Interestingly, the labral tear could not only be displaced with a probe, but placing the shoulder through a range of motion also led to increased displacement of the labrum from the glenoid, likely because the biceps tendon was tethered to the undersurface of the capsule.

At the time of arthroscopy, the LHBT was released from its attachment to the capsule at the rotator interval with a radiofrequency wand and shaver. A labral repair was performed using three 2.9-mm bioabsorbable suture anchors, placing 2 posterior and 1 anterior to the biceps tendon. The integrity of the labral repair was observed while placing the shoulder through range of motion.  

Postoperatively, the patient was kept in a sling for 5 weeks. Home exercises were initiated at 2 weeks, and outpatient physical therapy was implemented at 4 weeks. The patient resumed swimming, throwing, and other activities—with minimal discomfort—at 6 months postoperatively.

Three years after his initial visit, the patient returned to the office with a similar complaint of pain and limitation of function in his left shoulder after returning to full athletic competition. Once again, there was no history of injury, and history, physical examination, and MRI arthrogram (Figures 1A, 1B) evaluation proved to be very similar to this young athlete’s right shoulder work-up.

The patient once again underwent shoulder arthroscopy and treatment. Although this was now the left shoulder, the findings were essentially identical to the right shoulder. Once again, the labrum was detached from the 11-o’clock to 2-o’clock positions, and a Buford complex was present anteriorly (Figure 2A). The labral tear was easily displaceable from the glenoid with a probe, and placing the shoulder through a range of motion led to increased displacement of the labrum from the glenoid. There was also confluence of the intra-articular LHBT with the undersurface of the capsule within the rotator interval (Figure 2B). A radiofrequency wand, shaver, and elevator were used to define the biceps tendon and separate it from the undersurface of the capsule. The SLAP repair was performed using three 2.9-mm absorbable suture anchors with 2 posterior and 1 anterior to the biceps tendon insertion. The labral repair was observed while placing the shoulder through range of motion and the shoulder was seen to be free of any undue tension on the labrum.

Postoperatively, the patient’s sling and rehabilitation protocol was identical to that of the right shoulder. The patient progressed well, was released to full activity at 6 months, and has not returned with any further complaints of left or right shoulder pain. Approximately 3 years after treatment the patient was contacted via phone and asked about symptoms, pain, and activity. He denies current symptoms of clicking or instability and has no pain that he can identify as being related to previous pathology or treatment. Since the surgery, he has ceased competitive sports and weight lifting, which he attributes to deconditioning associated with postsurgical immobilization and lack of motivation.

Discussion

Of the 8 case reports in the literature that identified variable intra-articular biceps insertional anatomy, only 2 reports represented confluence of the biceps within the rotator interval.⁷ Interestingly, of the cases identified, the single case that presented a patient with similar pathology of a type II SLAP lesion had an almost identical anatomical variant presentation consisting of both the anomalous insertion of the LHBT into the undersurface of the rotator interval and a Buford variant of the anterosuperior glenohumeral ligament complex. To our knowledge, our bilateral case of an altered intra-articular biceps insertion and a concomitant SLAP tear supports the theory that this pattern of anomalous insertion may very well have altered the biomechanics of the tendon, resulting in acquired pathology to the superior labrum.

The literature reviewed showed the prevalence of anatomic variations of the LHBT ranged from 1.9% to 7.4%.^13,14 These variations are generally considered benign; however, in some cases—as in the cases of the young athletes presented by Wahl and MacGillivray⁷ and in this report—anatomic variation may play an important role in pathogenesis of different injury patterns. The primary function of the LHBT is the stabilization of the glenohumeral joint during abduction and external rotation.¹⁵ When the insertion diverges from normal (eg, when the tendon is tethered to the undersurface of the rotator cuff), the biomechanical stresses on the tendon likely change. As a result of the anomalous position of the LHBT origin, there may be a change in the shoulder joint’s biomechanics, with increased strain on the glenohumeral ligament and its attachment onto the glenoid.¹⁶

This case report differs from publications on variable superior glenohumeral ligament attachments because a discrete superior glenohumeral ligament structure was isolated from the biceps tendon. Although a larger case series or patient cohort, as well as more involved biomechanical analysis, would certainly be necessary to prove our hypothesis, we believe that this case suggests certain anatomic LHBT and labral variations can contribute to the develop of SLAP tears in younger individuals.

The biceps brachii derives its name from the 2 heads of the muscle. The short head originates from the coracoid apex, with the coracobrachialis muscle. The long head of the biceps tendon (LHBT) starts within the capsule of the shoulder joint, running from the supraglenoid tubercle or labrum.¹ The tendon typically runs free along its intra-articular course, but it is also extrasynovial and ensheathed by a continuation of the synovial lining of the articular capsule that extends to the inferior-most extent of the bicipital groove.² Congenital anomalies of the LHBT are uncommon, although several atypical forms have been described. A literature search for anomalous LHBT identified several variations in anatomic descriptions, including Y-shaped variant, complete absence of tendon, extra-articular attachment, and a variety of intracapsular attachments. In all, 8 case reports of aberrant intracapsular attachment of LHBT^3-12 were identified. These cases presented with a variety of clinical manifestations and pathologic changes. Often, these anatomic variations are considered innocuous, yet some present with pathologic findings.

We present the clinical, magnetic resonance imaging (MRI), and arthroscopic findings of a relatively young athletic patient who was experiencing symptoms of bilateral superior labrum anterior to posterior (SLAP) tears that were unresponsive to conservative management. A unique anatomic variant of the LHBT that involved confluence of the LHBT with the undersurface of the anterosuperior capsule at the rotator interval, as well as a Buford complex anteriorly, was identified and treated. We believe that the tethering of the biceps tendon to the capsule combined with the Buford complex created increased stress on the superior labrum and biceps anchor variant, leading to the development of bilateral symptomatic type II SLAP tears. Knowledge of this variant, though perhaps rare, may be relevant for diagnostic recognition of young athletic patients who present with recalcitrant shoulder symptoms. The patient and the patient’s parents provided written informed consent for print and electronic publication of this case report.

Case Report

A 15-year-old healthy and active athletic boy presented with pain in the right shoulder without history of trauma. He was active in both swimming and baseball. He complained of pain that was present with activities, such as lifting weights, swimming, and throwing. His treatment prior to the office visit consisted of nonsteroidal anti-inflammatory medication, rest, and a therapy program initiated by his high school athletic trainer.

Physical examination demonstrated tenderness to palpation over the posterior capsule and biceps. Motion was full, cuff strength was normal, and SLAP signs (O’Brien, Speed, and Jobe relocation) were positive. A radiograph showed no sign of fracture or dislocation, and no evidence of bony abnormality.

The patient was sent for an MRI arthrogram, which showed a SLAP tear extending from 1 o’clock anteriorly to 10 o’clock posteriorly without intra-articular displacement. No rotator cuff tear was noted. The biceps tendon was noted to be unremarkable and located within the bicipital groove, although retrospective review of the MRI showed that the intra-articular biceps tendon was somewhat confluent with the adjacent tissues.

The patient underwent right shoulder arthroscopy. The shoulder was stable to ligamentous examination under anesthesia. Arthroscopic evaluation revealed that there was a type II SLAP tear extending from the 11-o’clock to the 2-o’clock positions. The superior glenohumeral ligament was identified as it arose from the upper pole of the glenoid labrum and then ran parallel and inferior to the tendon of the biceps towards the lesser tubercle. Surprisingly, there was a very unusual attachment of the intracapsular LHBT to the undersurface of the rotator interval, which restricted biceps excursion in relation to the rotator cuff. Additionally, there was a thick cord-like middle glenohumeral ligament anteriorly that lacked the normal glenoid attachments, thus representing a Buford complex. Interestingly, the labral tear could not only be displaced with a probe, but placing the shoulder through a range of motion also led to increased displacement of the labrum from the glenoid, likely because the biceps tendon was tethered to the undersurface of the capsule.

At the time of arthroscopy, the LHBT was released from its attachment to the capsule at the rotator interval with a radiofrequency wand and shaver. A labral repair was performed using three 2.9-mm bioabsorbable suture anchors, placing 2 posterior and 1 anterior to the biceps tendon. The integrity of the labral repair was observed while placing the shoulder through range of motion.  

Postoperatively, the patient was kept in a sling for 5 weeks. Home exercises were initiated at 2 weeks, and outpatient physical therapy was implemented at 4 weeks. The patient resumed swimming, throwing, and other activities—with minimal discomfort—at 6 months postoperatively.

Three years after his initial visit, the patient returned to the office with a similar complaint of pain and limitation of function in his left shoulder after returning to full athletic competition. Once again, there was no history of injury, and history, physical examination, and MRI arthrogram (Figures 1A, 1B) evaluation proved to be very similar to this young athlete’s right shoulder work-up.

The patient once again underwent shoulder arthroscopy and treatment. Although this was now the left shoulder, the findings were essentially identical to the right shoulder. Once again, the labrum was detached from the 11-o’clock to 2-o’clock positions, and a Buford complex was present anteriorly (Figure 2A). The labral tear was easily displaceable from the glenoid with a probe, and placing the shoulder through a range of motion led to increased displacement of the labrum from the glenoid. There was also confluence of the intra-articular LHBT with the undersurface of the capsule within the rotator interval (Figure 2B). A radiofrequency wand, shaver, and elevator were used to define the biceps tendon and separate it from the undersurface of the capsule. The SLAP repair was performed using three 2.9-mm absorbable suture anchors with 2 posterior and 1 anterior to the biceps tendon insertion. The labral repair was observed while placing the shoulder through range of motion and the shoulder was seen to be free of any undue tension on the labrum.

Postoperatively, the patient’s sling and rehabilitation protocol was identical to that of the right shoulder. The patient progressed well, was released to full activity at 6 months, and has not returned with any further complaints of left or right shoulder pain. Approximately 3 years after treatment the patient was contacted via phone and asked about symptoms, pain, and activity. He denies current symptoms of clicking or instability and has no pain that he can identify as being related to previous pathology or treatment. Since the surgery, he has ceased competitive sports and weight lifting, which he attributes to deconditioning associated with postsurgical immobilization and lack of motivation.

Discussion

Of the 8 case reports in the literature that identified variable intra-articular biceps insertional anatomy, only 2 reports represented confluence of the biceps within the rotator interval.⁷ Interestingly, of the cases identified, the single case that presented a patient with similar pathology of a type II SLAP lesion had an almost identical anatomical variant presentation consisting of both the anomalous insertion of the LHBT into the undersurface of the rotator interval and a Buford variant of the anterosuperior glenohumeral ligament complex. To our knowledge, our bilateral case of an altered intra-articular biceps insertion and a concomitant SLAP tear supports the theory that this pattern of anomalous insertion may very well have altered the biomechanics of the tendon, resulting in acquired pathology to the superior labrum.

The literature reviewed showed the prevalence of anatomic variations of the LHBT ranged from 1.9% to 7.4%.^13,14 These variations are generally considered benign; however, in some cases—as in the cases of the young athletes presented by Wahl and MacGillivray⁷ and in this report—anatomic variation may play an important role in pathogenesis of different injury patterns. The primary function of the LHBT is the stabilization of the glenohumeral joint during abduction and external rotation.¹⁵ When the insertion diverges from normal (eg, when the tendon is tethered to the undersurface of the rotator cuff), the biomechanical stresses on the tendon likely change. As a result of the anomalous position of the LHBT origin, there may be a change in the shoulder joint’s biomechanics, with increased strain on the glenohumeral ligament and its attachment onto the glenoid.¹⁶

This case report differs from publications on variable superior glenohumeral ligament attachments because a discrete superior glenohumeral ligament structure was isolated from the biceps tendon. Although a larger case series or patient cohort, as well as more involved biomechanical analysis, would certainly be necessary to prove our hypothesis, we believe that this case suggests certain anatomic LHBT and labral variations can contribute to the develop of SLAP tears in younger individuals.

The biceps brachii derives its name from the 2 heads of the muscle. The short head originates from the coracoid apex, with the coracobrachialis muscle. The long head of the biceps tendon (LHBT) starts within the capsule of the shoulder joint, running from the supraglenoid tubercle or labrum.¹ The tendon typically runs free along its intra-articular course, but it is also extrasynovial and ensheathed by a continuation of the synovial lining of the articular capsule that extends to the inferior-most extent of the bicipital groove.² Congenital anomalies of the LHBT are uncommon, although several atypical forms have been described. A literature search for anomalous LHBT identified several variations in anatomic descriptions, including Y-shaped variant, complete absence of tendon, extra-articular attachment, and a variety of intracapsular attachments. In all, 8 case reports of aberrant intracapsular attachment of LHBT^3-12 were identified. These cases presented with a variety of clinical manifestations and pathologic changes. Often, these anatomic variations are considered innocuous, yet some present with pathologic findings.

We present the clinical, magnetic resonance imaging (MRI), and arthroscopic findings of a relatively young athletic patient who was experiencing symptoms of bilateral superior labrum anterior to posterior (SLAP) tears that were unresponsive to conservative management. A unique anatomic variant of the LHBT that involved confluence of the LHBT with the undersurface of the anterosuperior capsule at the rotator interval, as well as a Buford complex anteriorly, was identified and treated. We believe that the tethering of the biceps tendon to the capsule combined with the Buford complex created increased stress on the superior labrum and biceps anchor variant, leading to the development of bilateral symptomatic type II SLAP tears. Knowledge of this variant, though perhaps rare, may be relevant for diagnostic recognition of young athletic patients who present with recalcitrant shoulder symptoms. The patient and the patient’s parents provided written informed consent for print and electronic publication of this case report.

Case Report

A 15-year-old healthy and active athletic boy presented with pain in the right shoulder without history of trauma. He was active in both swimming and baseball. He complained of pain that was present with activities, such as lifting weights, swimming, and throwing. His treatment prior to the office visit consisted of nonsteroidal anti-inflammatory medication, rest, and a therapy program initiated by his high school athletic trainer.

Physical examination demonstrated tenderness to palpation over the posterior capsule and biceps. Motion was full, cuff strength was normal, and SLAP signs (O’Brien, Speed, and Jobe relocation) were positive. A radiograph showed no sign of fracture or dislocation, and no evidence of bony abnormality.

The patient was sent for an MRI arthrogram, which showed a SLAP tear extending from 1 o’clock anteriorly to 10 o’clock posteriorly without intra-articular displacement. No rotator cuff tear was noted. The biceps tendon was noted to be unremarkable and located within the bicipital groove, although retrospective review of the MRI showed that the intra-articular biceps tendon was somewhat confluent with the adjacent tissues.

The patient underwent right shoulder arthroscopy. The shoulder was stable to ligamentous examination under anesthesia. Arthroscopic evaluation revealed that there was a type II SLAP tear extending from the 11-o’clock to the 2-o’clock positions. The superior glenohumeral ligament was identified as it arose from the upper pole of the glenoid labrum and then ran parallel and inferior to the tendon of the biceps towards the lesser tubercle. Surprisingly, there was a very unusual attachment of the intracapsular LHBT to the undersurface of the rotator interval, which restricted biceps excursion in relation to the rotator cuff. Additionally, there was a thick cord-like middle glenohumeral ligament anteriorly that lacked the normal glenoid attachments, thus representing a Buford complex. Interestingly, the labral tear could not only be displaced with a probe, but placing the shoulder through a range of motion also led to increased displacement of the labrum from the glenoid, likely because the biceps tendon was tethered to the undersurface of the capsule.

At the time of arthroscopy, the LHBT was released from its attachment to the capsule at the rotator interval with a radiofrequency wand and shaver. A labral repair was performed using three 2.9-mm bioabsorbable suture anchors, placing 2 posterior and 1 anterior to the biceps tendon. The integrity of the labral repair was observed while placing the shoulder through range of motion.  

Postoperatively, the patient was kept in a sling for 5 weeks. Home exercises were initiated at 2 weeks, and outpatient physical therapy was implemented at 4 weeks. The patient resumed swimming, throwing, and other activities—with minimal discomfort—at 6 months postoperatively.

Three years after his initial visit, the patient returned to the office with a similar complaint of pain and limitation of function in his left shoulder after returning to full athletic competition. Once again, there was no history of injury, and history, physical examination, and MRI arthrogram (Figures 1A, 1B) evaluation proved to be very similar to this young athlete’s right shoulder work-up.

The patient once again underwent shoulder arthroscopy and treatment. Although this was now the left shoulder, the findings were essentially identical to the right shoulder. Once again, the labrum was detached from the 11-o’clock to 2-o’clock positions, and a Buford complex was present anteriorly (Figure 2A). The labral tear was easily displaceable from the glenoid with a probe, and placing the shoulder through a range of motion led to increased displacement of the labrum from the glenoid. There was also confluence of the intra-articular LHBT with the undersurface of the capsule within the rotator interval (Figure 2B). A radiofrequency wand, shaver, and elevator were used to define the biceps tendon and separate it from the undersurface of the capsule. The SLAP repair was performed using three 2.9-mm absorbable suture anchors with 2 posterior and 1 anterior to the biceps tendon insertion. The labral repair was observed while placing the shoulder through range of motion and the shoulder was seen to be free of any undue tension on the labrum.

Postoperatively, the patient’s sling and rehabilitation protocol was identical to that of the right shoulder. The patient progressed well, was released to full activity at 6 months, and has not returned with any further complaints of left or right shoulder pain. Approximately 3 years after treatment the patient was contacted via phone and asked about symptoms, pain, and activity. He denies current symptoms of clicking or instability and has no pain that he can identify as being related to previous pathology or treatment. Since the surgery, he has ceased competitive sports and weight lifting, which he attributes to deconditioning associated with postsurgical immobilization and lack of motivation.

Discussion

Of the 8 case reports in the literature that identified variable intra-articular biceps insertional anatomy, only 2 reports represented confluence of the biceps within the rotator interval.⁷ Interestingly, of the cases identified, the single case that presented a patient with similar pathology of a type II SLAP lesion had an almost identical anatomical variant presentation consisting of both the anomalous insertion of the LHBT into the undersurface of the rotator interval and a Buford variant of the anterosuperior glenohumeral ligament complex. To our knowledge, our bilateral case of an altered intra-articular biceps insertion and a concomitant SLAP tear supports the theory that this pattern of anomalous insertion may very well have altered the biomechanics of the tendon, resulting in acquired pathology to the superior labrum.

The literature reviewed showed the prevalence of anatomic variations of the LHBT ranged from 1.9% to 7.4%.^13,14 These variations are generally considered benign; however, in some cases—as in the cases of the young athletes presented by Wahl and MacGillivray⁷ and in this report—anatomic variation may play an important role in pathogenesis of different injury patterns. The primary function of the LHBT is the stabilization of the glenohumeral joint during abduction and external rotation.¹⁵ When the insertion diverges from normal (eg, when the tendon is tethered to the undersurface of the rotator cuff), the biomechanical stresses on the tendon likely change. As a result of the anomalous position of the LHBT origin, there may be a change in the shoulder joint’s biomechanics, with increased strain on the glenohumeral ligament and its attachment onto the glenoid.¹⁶

This case report differs from publications on variable superior glenohumeral ligament attachments because a discrete superior glenohumeral ligament structure was isolated from the biceps tendon. Although a larger case series or patient cohort, as well as more involved biomechanical analysis, would certainly be necessary to prove our hypothesis, we believe that this case suggests certain anatomic LHBT and labral variations can contribute to the develop of SLAP tears in younger individuals.

Xanthogranulomatous osteomyelitis (XO) is a type of chronic inflammatory process that is characterized by the collection of foamy macrophages along with mononuclear cells in the tissue.¹ Xanthogranulomatous osteomyelitis is characterized by the presence of granular, eosinophilic, periodic acid–Schiff–positive histiocytes in the initial stages, followed by the mixture of foamy macrophages and activated plasma cells and, last, by the presence of suppurative foci and hemorrhage. This is an uncommon process best known to occur in the gallbladder, kidney, urinary bladder, fallopian tube, ovary, vagina, prostate, testis, epididymis, colon, and appendix.^2-4 Very rarely, it can affect lungs, brain, or bone. Only 5 cases of XO have been reported in the literature.^5-8

We report XO of the proximal femur in a 65-year-old woman who initially had a clinical and radiologic diagnosis of aneurysmal bone cyst; however, histopathologic examination confirmed the diagnosis of XO. Xanthogranulomatous osteomyelitis mimics a neoplastic pathology in gallbladder, kidney, and prostrate on gross clinical and radiologic examination.⁹ The pathogenesis of XO is best characterized by a delayed type of hypersensitivity reaction.¹⁰ The differential diagnosis includes chronic recurrent multifocal osteomyelitis, xanthoma, infiltrative storage disorder, malakoplakia, Langerhans cell histiocytosis, fibrohistiocytic tumor, Erdheim-Chester disease, and metastatic renal cell carcinoma.^11-14 The patient provided written informed consent for print and electronic publication of this case report.

Case Report

A 65-year-old hypertensive woman presented with complaints of pain in the right hip for a duration of 6 months. Pain was radiating from the right hip region to the anteromedial aspect of the knee and progressively increasing, with a history of pain at rest suggestive of a nonmechanical pathology in the hip. There was no history of fever, weight loss, loss of appetite, pain in any other joint, or morning stiffness. The patient was mobile without support and was able to squat and sit cross-legged; however, the stance phase on the right side was less than on the left side, suggestive of an antalgic component in the gait.

On examining the patient, there was anterior hip joint tenderness with no local sign of any infective or inflammatory pathology. Trochanteric tenderness was present, but there was no irregularity, broadening, or thickening of the trochanter. There was no restriction in the range of motion, and no coronal or sagittal plane deformity in the right hip. There was no limb-length discrepancy. However, the patient was not able to raise her leg actively, probably because of pain in the right hip.

On plain radiographs of the pelvis with bilateral hips, a well-defined nonexpansile uniloculated lytic lesion with sclerotic margins was present in the neck of the right femur, extending to the intertrochanteric area (Figure 1). Ground-glass appearance was also noted. Considering the benign nature of the lesion radiologically and clinically, a differential diagnosis of hyperparathyroidism, renal osteodystrophy, multiple myeloma, and fibrous dysplasia was considered. Hematologic investigations, skeletal survey, and magnetic resonance imaging (MRI) of the bilateral hips were performed to rule out the differential diagnosis.

The patient’s hemoglobin level was 11.8 g/dL with total white blood cell count of 10,300/µL. Renal and hepatic functions were within normal limit. Serum erythrocyte sedimentation rate (ESR) was 12 mm/h and C-reactive protein level was normal. Serum parathyroid level was 32 pg/mL, which was within normal limits, with an alkaline phosphatase level of 101 U/L. The skeletal survey showed no other bony lesion in the body. T1-weighted MRI of both hips showed a well-defined hypointense lesion in the neck and intertrochanteric area of the right hip, which was hyperintense on T2-weighted MRI, suggestive of aneurysmal bone cyst (Figure 2).

Normal ESR, hemoglobin, alkaline phosphatase, and serum parathyroid levels and normal skeletal survey almost ruled out multiple myeloma and hyperparathyroidism. Normal renal profile ruled out renal osteodystrophy and the osteitis fibrosa cystica lesion associated with it. We planned for prophylactic internal fixation of the lesion to prevent a pathologic fracture. According to Mirels,¹⁵ if there is a lytic lesion covering more than two-thirds of the circumference of the bone in the peritrochanteric area, the chances of a pathologic fracture are high and such fractures should be fixed.

We planned for curettage of the lesion with bone grafting and in situ intramedullary fixation of the lesion. Curettage was done according to the plan and the sample was sent for histopathologic examination. In situ internal fixation and bone grafting were performed by using a proximal femoral intramedullary nail. To our surprise, the biopsy sample was reported as xanthogranuloma, with multiple foamy macrophages mixed with inflammatory cells and aggregates of lymphocytes (Figure 3). Mycobacterial and routine bacterial cultures were reported as negative. The patient was kept on oral antibiotics (cefixime and moxifloxacin) for 6 weeks, and she made an uneventful recovery. At 6-month follow-up, a radiograph of the right hip showed a healed lesion with proximal femoral nail in situ (Figure 4).

Discussion

To the best of our knowledge, a total of 5 cases of XO have been reported in the literature. The earliest of these reports were by Cozzutto and Carbone,¹ who reported 2 cases of XO of the first rib and of the epiphysis of the tibia, respectively. The importance of these lesions to diagnosis is their confusion with a neoplastic disease, as XO is itself a benign disorder. These lesions can mimic a neoplastic lesion in clinical and radiologic presentation and the only way to differentiate the lesion from a neoplastic disease is by histopathologic examination of the tissue. Hypothetically, xanthogranulomatous disorders can be related to trauma or infection.

In 2007, Vankalakunti and colleagues⁶ reported XO of the ulna in a 50-year-old postmenopausal woman. In that case, progressive swelling was present on the extensor aspect of her right forearm for a period of 2 years, for which curettage and bone grafting were performed, using autograft from the ipsilateral iliac crest. The tissue culture was sterile, and XO was diagnosed as a result of the histopathologic examination. In 2009, Cennimo and colleagues⁷ reported XO of the index finger and wrist of a man complaining of pain and swelling for 1 year, which was unresponsive to antibiotics. The diagnosis of XO was confirmed histopathologically, when the culture of the same tissue grew Mycobacterium marinum. Radical synovectomy of the lesion was performed, after which minocycline, clarithromycin, and ethambutol were administered. In 2012, Borjian and colleagues⁸ reported a case of XO of the proximal humerus and proximal fibula in a 14-year-old child. The child, who presented with fever, pain, and restriction of shoulder movements, was started on oral antibiotics as the tissue culture grew Staphylococcus aureus; the patient did not complete the course of treatment in the hospital. No surgical intervention was done in this case. The diagnosis of XO was confirmed by microscopic examination of the tissue.

An association between bacterial infection and xanthogranulomatous inflammation has existed in several organs, such as the kidneys, and in the gastrointestinal system, but such an association of the 2 is yet to be determined for bone.^5,10,16-19 Because of the paucity of literature on the disease, a management protocol for XO of bone has not been defined, and decisions have to be made considering the natural history of the disease in other organs. We present this case primarily because of its rarity, curability, and its close resemblance to bone tumors. While XO is benign, it can mimic a neoplastic bone lesion in its imaging and clinical manifestations, and appropriate differentiation is crucial. Currently, histopathologic examination of lesions is the most specific and is the gold standard for diagnosis.

Conclusion

Xanthogranulomatous osteomyelitis is a very rare entity, and only a few cases have been reported in the English-language literature. Though rare, XO warrants greater emphasis than it receives in the literature. It is a chronic inflammatory disease having a close resemblance to bone tumors. A high index of suspicion must be practiced to differentiate XO from tumors. Histopathologic examination is mandatory to establish definitive diagnosis and correct treatment.

Xanthogranulomatous osteomyelitis (XO) is a type of chronic inflammatory process that is characterized by the collection of foamy macrophages along with mononuclear cells in the tissue.¹ Xanthogranulomatous osteomyelitis is characterized by the presence of granular, eosinophilic, periodic acid–Schiff–positive histiocytes in the initial stages, followed by the mixture of foamy macrophages and activated plasma cells and, last, by the presence of suppurative foci and hemorrhage. This is an uncommon process best known to occur in the gallbladder, kidney, urinary bladder, fallopian tube, ovary, vagina, prostate, testis, epididymis, colon, and appendix.^2-4 Very rarely, it can affect lungs, brain, or bone. Only 5 cases of XO have been reported in the literature.^5-8

We report XO of the proximal femur in a 65-year-old woman who initially had a clinical and radiologic diagnosis of aneurysmal bone cyst; however, histopathologic examination confirmed the diagnosis of XO. Xanthogranulomatous osteomyelitis mimics a neoplastic pathology in gallbladder, kidney, and prostrate on gross clinical and radiologic examination.⁹ The pathogenesis of XO is best characterized by a delayed type of hypersensitivity reaction.¹⁰ The differential diagnosis includes chronic recurrent multifocal osteomyelitis, xanthoma, infiltrative storage disorder, malakoplakia, Langerhans cell histiocytosis, fibrohistiocytic tumor, Erdheim-Chester disease, and metastatic renal cell carcinoma.^11-14 The patient provided written informed consent for print and electronic publication of this case report.

Case Report

A 65-year-old hypertensive woman presented with complaints of pain in the right hip for a duration of 6 months. Pain was radiating from the right hip region to the anteromedial aspect of the knee and progressively increasing, with a history of pain at rest suggestive of a nonmechanical pathology in the hip. There was no history of fever, weight loss, loss of appetite, pain in any other joint, or morning stiffness. The patient was mobile without support and was able to squat and sit cross-legged; however, the stance phase on the right side was less than on the left side, suggestive of an antalgic component in the gait.

On examining the patient, there was anterior hip joint tenderness with no local sign of any infective or inflammatory pathology. Trochanteric tenderness was present, but there was no irregularity, broadening, or thickening of the trochanter. There was no restriction in the range of motion, and no coronal or sagittal plane deformity in the right hip. There was no limb-length discrepancy. However, the patient was not able to raise her leg actively, probably because of pain in the right hip.

On plain radiographs of the pelvis with bilateral hips, a well-defined nonexpansile uniloculated lytic lesion with sclerotic margins was present in the neck of the right femur, extending to the intertrochanteric area (Figure 1). Ground-glass appearance was also noted. Considering the benign nature of the lesion radiologically and clinically, a differential diagnosis of hyperparathyroidism, renal osteodystrophy, multiple myeloma, and fibrous dysplasia was considered. Hematologic investigations, skeletal survey, and magnetic resonance imaging (MRI) of the bilateral hips were performed to rule out the differential diagnosis.

The patient’s hemoglobin level was 11.8 g/dL with total white blood cell count of 10,300/µL. Renal and hepatic functions were within normal limit. Serum erythrocyte sedimentation rate (ESR) was 12 mm/h and C-reactive protein level was normal. Serum parathyroid level was 32 pg/mL, which was within normal limits, with an alkaline phosphatase level of 101 U/L. The skeletal survey showed no other bony lesion in the body. T1-weighted MRI of both hips showed a well-defined hypointense lesion in the neck and intertrochanteric area of the right hip, which was hyperintense on T2-weighted MRI, suggestive of aneurysmal bone cyst (Figure 2).

Normal ESR, hemoglobin, alkaline phosphatase, and serum parathyroid levels and normal skeletal survey almost ruled out multiple myeloma and hyperparathyroidism. Normal renal profile ruled out renal osteodystrophy and the osteitis fibrosa cystica lesion associated with it. We planned for prophylactic internal fixation of the lesion to prevent a pathologic fracture. According to Mirels,¹⁵ if there is a lytic lesion covering more than two-thirds of the circumference of the bone in the peritrochanteric area, the chances of a pathologic fracture are high and such fractures should be fixed.

We planned for curettage of the lesion with bone grafting and in situ intramedullary fixation of the lesion. Curettage was done according to the plan and the sample was sent for histopathologic examination. In situ internal fixation and bone grafting were performed by using a proximal femoral intramedullary nail. To our surprise, the biopsy sample was reported as xanthogranuloma, with multiple foamy macrophages mixed with inflammatory cells and aggregates of lymphocytes (Figure 3). Mycobacterial and routine bacterial cultures were reported as negative. The patient was kept on oral antibiotics (cefixime and moxifloxacin) for 6 weeks, and she made an uneventful recovery. At 6-month follow-up, a radiograph of the right hip showed a healed lesion with proximal femoral nail in situ (Figure 4).

Discussion

To the best of our knowledge, a total of 5 cases of XO have been reported in the literature. The earliest of these reports were by Cozzutto and Carbone,¹ who reported 2 cases of XO of the first rib and of the epiphysis of the tibia, respectively. The importance of these lesions to diagnosis is their confusion with a neoplastic disease, as XO is itself a benign disorder. These lesions can mimic a neoplastic lesion in clinical and radiologic presentation and the only way to differentiate the lesion from a neoplastic disease is by histopathologic examination of the tissue. Hypothetically, xanthogranulomatous disorders can be related to trauma or infection.

In 2007, Vankalakunti and colleagues⁶ reported XO of the ulna in a 50-year-old postmenopausal woman. In that case, progressive swelling was present on the extensor aspect of her right forearm for a period of 2 years, for which curettage and bone grafting were performed, using autograft from the ipsilateral iliac crest. The tissue culture was sterile, and XO was diagnosed as a result of the histopathologic examination. In 2009, Cennimo and colleagues⁷ reported XO of the index finger and wrist of a man complaining of pain and swelling for 1 year, which was unresponsive to antibiotics. The diagnosis of XO was confirmed histopathologically, when the culture of the same tissue grew Mycobacterium marinum. Radical synovectomy of the lesion was performed, after which minocycline, clarithromycin, and ethambutol were administered. In 2012, Borjian and colleagues⁸ reported a case of XO of the proximal humerus and proximal fibula in a 14-year-old child. The child, who presented with fever, pain, and restriction of shoulder movements, was started on oral antibiotics as the tissue culture grew Staphylococcus aureus; the patient did not complete the course of treatment in the hospital. No surgical intervention was done in this case. The diagnosis of XO was confirmed by microscopic examination of the tissue.

An association between bacterial infection and xanthogranulomatous inflammation has existed in several organs, such as the kidneys, and in the gastrointestinal system, but such an association of the 2 is yet to be determined for bone.^5,10,16-19 Because of the paucity of literature on the disease, a management protocol for XO of bone has not been defined, and decisions have to be made considering the natural history of the disease in other organs. We present this case primarily because of its rarity, curability, and its close resemblance to bone tumors. While XO is benign, it can mimic a neoplastic bone lesion in its imaging and clinical manifestations, and appropriate differentiation is crucial. Currently, histopathologic examination of lesions is the most specific and is the gold standard for diagnosis.

Conclusion

Xanthogranulomatous osteomyelitis is a very rare entity, and only a few cases have been reported in the English-language literature. Though rare, XO warrants greater emphasis than it receives in the literature. It is a chronic inflammatory disease having a close resemblance to bone tumors. A high index of suspicion must be practiced to differentiate XO from tumors. Histopathologic examination is mandatory to establish definitive diagnosis and correct treatment.

Xanthogranulomatous osteomyelitis (XO) is a type of chronic inflammatory process that is characterized by the collection of foamy macrophages along with mononuclear cells in the tissue.¹ Xanthogranulomatous osteomyelitis is characterized by the presence of granular, eosinophilic, periodic acid–Schiff–positive histiocytes in the initial stages, followed by the mixture of foamy macrophages and activated plasma cells and, last, by the presence of suppurative foci and hemorrhage. This is an uncommon process best known to occur in the gallbladder, kidney, urinary bladder, fallopian tube, ovary, vagina, prostate, testis, epididymis, colon, and appendix.^2-4 Very rarely, it can affect lungs, brain, or bone. Only 5 cases of XO have been reported in the literature.^5-8

We report XO of the proximal femur in a 65-year-old woman who initially had a clinical and radiologic diagnosis of aneurysmal bone cyst; however, histopathologic examination confirmed the diagnosis of XO. Xanthogranulomatous osteomyelitis mimics a neoplastic pathology in gallbladder, kidney, and prostrate on gross clinical and radiologic examination.⁹ The pathogenesis of XO is best characterized by a delayed type of hypersensitivity reaction.¹⁰ The differential diagnosis includes chronic recurrent multifocal osteomyelitis, xanthoma, infiltrative storage disorder, malakoplakia, Langerhans cell histiocytosis, fibrohistiocytic tumor, Erdheim-Chester disease, and metastatic renal cell carcinoma.^11-14 The patient provided written informed consent for print and electronic publication of this case report.

Case Report

A 65-year-old hypertensive woman presented with complaints of pain in the right hip for a duration of 6 months. Pain was radiating from the right hip region to the anteromedial aspect of the knee and progressively increasing, with a history of pain at rest suggestive of a nonmechanical pathology in the hip. There was no history of fever, weight loss, loss of appetite, pain in any other joint, or morning stiffness. The patient was mobile without support and was able to squat and sit cross-legged; however, the stance phase on the right side was less than on the left side, suggestive of an antalgic component in the gait.

On examining the patient, there was anterior hip joint tenderness with no local sign of any infective or inflammatory pathology. Trochanteric tenderness was present, but there was no irregularity, broadening, or thickening of the trochanter. There was no restriction in the range of motion, and no coronal or sagittal plane deformity in the right hip. There was no limb-length discrepancy. However, the patient was not able to raise her leg actively, probably because of pain in the right hip.

On plain radiographs of the pelvis with bilateral hips, a well-defined nonexpansile uniloculated lytic lesion with sclerotic margins was present in the neck of the right femur, extending to the intertrochanteric area (Figure 1). Ground-glass appearance was also noted. Considering the benign nature of the lesion radiologically and clinically, a differential diagnosis of hyperparathyroidism, renal osteodystrophy, multiple myeloma, and fibrous dysplasia was considered. Hematologic investigations, skeletal survey, and magnetic resonance imaging (MRI) of the bilateral hips were performed to rule out the differential diagnosis.

The patient’s hemoglobin level was 11.8 g/dL with total white blood cell count of 10,300/µL. Renal and hepatic functions were within normal limit. Serum erythrocyte sedimentation rate (ESR) was 12 mm/h and C-reactive protein level was normal. Serum parathyroid level was 32 pg/mL, which was within normal limits, with an alkaline phosphatase level of 101 U/L. The skeletal survey showed no other bony lesion in the body. T1-weighted MRI of both hips showed a well-defined hypointense lesion in the neck and intertrochanteric area of the right hip, which was hyperintense on T2-weighted MRI, suggestive of aneurysmal bone cyst (Figure 2).

Normal ESR, hemoglobin, alkaline phosphatase, and serum parathyroid levels and normal skeletal survey almost ruled out multiple myeloma and hyperparathyroidism. Normal renal profile ruled out renal osteodystrophy and the osteitis fibrosa cystica lesion associated with it. We planned for prophylactic internal fixation of the lesion to prevent a pathologic fracture. According to Mirels,¹⁵ if there is a lytic lesion covering more than two-thirds of the circumference of the bone in the peritrochanteric area, the chances of a pathologic fracture are high and such fractures should be fixed.

We planned for curettage of the lesion with bone grafting and in situ intramedullary fixation of the lesion. Curettage was done according to the plan and the sample was sent for histopathologic examination. In situ internal fixation and bone grafting were performed by using a proximal femoral intramedullary nail. To our surprise, the biopsy sample was reported as xanthogranuloma, with multiple foamy macrophages mixed with inflammatory cells and aggregates of lymphocytes (Figure 3). Mycobacterial and routine bacterial cultures were reported as negative. The patient was kept on oral antibiotics (cefixime and moxifloxacin) for 6 weeks, and she made an uneventful recovery. At 6-month follow-up, a radiograph of the right hip showed a healed lesion with proximal femoral nail in situ (Figure 4).

Discussion

To the best of our knowledge, a total of 5 cases of XO have been reported in the literature. The earliest of these reports were by Cozzutto and Carbone,¹ who reported 2 cases of XO of the first rib and of the epiphysis of the tibia, respectively. The importance of these lesions to diagnosis is their confusion with a neoplastic disease, as XO is itself a benign disorder. These lesions can mimic a neoplastic lesion in clinical and radiologic presentation and the only way to differentiate the lesion from a neoplastic disease is by histopathologic examination of the tissue. Hypothetically, xanthogranulomatous disorders can be related to trauma or infection.

In 2007, Vankalakunti and colleagues⁶ reported XO of the ulna in a 50-year-old postmenopausal woman. In that case, progressive swelling was present on the extensor aspect of her right forearm for a period of 2 years, for which curettage and bone grafting were performed, using autograft from the ipsilateral iliac crest. The tissue culture was sterile, and XO was diagnosed as a result of the histopathologic examination. In 2009, Cennimo and colleagues⁷ reported XO of the index finger and wrist of a man complaining of pain and swelling for 1 year, which was unresponsive to antibiotics. The diagnosis of XO was confirmed histopathologically, when the culture of the same tissue grew Mycobacterium marinum. Radical synovectomy of the lesion was performed, after which minocycline, clarithromycin, and ethambutol were administered. In 2012, Borjian and colleagues⁸ reported a case of XO of the proximal humerus and proximal fibula in a 14-year-old child. The child, who presented with fever, pain, and restriction of shoulder movements, was started on oral antibiotics as the tissue culture grew Staphylococcus aureus; the patient did not complete the course of treatment in the hospital. No surgical intervention was done in this case. The diagnosis of XO was confirmed by microscopic examination of the tissue.

An association between bacterial infection and xanthogranulomatous inflammation has existed in several organs, such as the kidneys, and in the gastrointestinal system, but such an association of the 2 is yet to be determined for bone.^5,10,16-19 Because of the paucity of literature on the disease, a management protocol for XO of bone has not been defined, and decisions have to be made considering the natural history of the disease in other organs. We present this case primarily because of its rarity, curability, and its close resemblance to bone tumors. While XO is benign, it can mimic a neoplastic bone lesion in its imaging and clinical manifestations, and appropriate differentiation is crucial. Currently, histopathologic examination of lesions is the most specific and is the gold standard for diagnosis.

Conclusion

Xanthogranulomatous osteomyelitis is a very rare entity, and only a few cases have been reported in the English-language literature. Though rare, XO warrants greater emphasis than it receives in the literature. It is a chronic inflammatory disease having a close resemblance to bone tumors. A high index of suspicion must be practiced to differentiate XO from tumors. Histopathologic examination is mandatory to establish definitive diagnosis and correct treatment.

This issue of The Hospitalist, features perspectives on medical education, hospitalist consults, and the latest in hospital medicine clinical literature.

[audio mp3="http://www.the-hospitalist.org/wp-content/uploads/2015/08/2015-August-Hospitalist-Highlights.mp3"][/audio]

This issue of The Hospitalist, features perspectives on medical education, hospitalist consults, and the latest in hospital medicine clinical literature.

[audio mp3="http://www.the-hospitalist.org/wp-content/uploads/2015/08/2015-August-Hospitalist-Highlights.mp3"][/audio]

This issue of The Hospitalist, features perspectives on medical education, hospitalist consults, and the latest in hospital medicine clinical literature.

[audio mp3="http://www.the-hospitalist.org/wp-content/uploads/2015/08/2015-August-Hospitalist-Highlights.mp3"][/audio]

Presenters: Dr. Patrick Brady, Dr. Michele Saysana, Dr. Christine White, and Dr. Mark Shen.

Session analysis:

QI is about making positive changes in the delivery of healthcare. Multiple QI interventions are been implemented daily throughout our hospitals. Some of those interventions result in positive changes and affect specific outcomes the way we want. It is our job, as hospitalists, to share them with our colleagues so patients can benefit from them.

Some of the barriers to publishing QI as identified by the group are: lack of time, resources available and administrative support, lack of mentorship, and unrecognized value of QI in the academic world. The group also identified some strategies to be successful at writing and publishing QI, including: blocking time in the schedule and labeling it "writing days," joining a collaborative, reaching out to Journal editors and becoming familiar with the SQUIRE guidelines. Some key points as discussed by the experts that will aid during the process of writing QI are:

1. A specific goal/aim statement needs to be identified,
2. The measurement needs to match your goal/aim,
3. Always start with writing your methods since you know exactly what you did,
4. Plot data over time using a run chart, and
5. Keep a notebook with documentation of dates all interventions started.

It is also important for everyone to know there are multiple quality and safety journals willing to review QI manuscripts for publication.

Presenters: Dr. Patrick Brady, Dr. Michele Saysana, Dr. Christine White, and Dr. Mark Shen.

Session analysis:

QI is about making positive changes in the delivery of healthcare. Multiple QI interventions are been implemented daily throughout our hospitals. Some of those interventions result in positive changes and affect specific outcomes the way we want. It is our job, as hospitalists, to share them with our colleagues so patients can benefit from them.

Some of the barriers to publishing QI as identified by the group are: lack of time, resources available and administrative support, lack of mentorship, and unrecognized value of QI in the academic world. The group also identified some strategies to be successful at writing and publishing QI, including: blocking time in the schedule and labeling it "writing days," joining a collaborative, reaching out to Journal editors and becoming familiar with the SQUIRE guidelines. Some key points as discussed by the experts that will aid during the process of writing QI are:

1. A specific goal/aim statement needs to be identified,
2. The measurement needs to match your goal/aim,
3. Always start with writing your methods since you know exactly what you did,
4. Plot data over time using a run chart, and
5. Keep a notebook with documentation of dates all interventions started.

It is also important for everyone to know there are multiple quality and safety journals willing to review QI manuscripts for publication.

Presenters: Dr. Patrick Brady, Dr. Michele Saysana, Dr. Christine White, and Dr. Mark Shen.

Session analysis:

QI is about making positive changes in the delivery of healthcare. Multiple QI interventions are been implemented daily throughout our hospitals. Some of those interventions result in positive changes and affect specific outcomes the way we want. It is our job, as hospitalists, to share them with our colleagues so patients can benefit from them.

Some of the barriers to publishing QI as identified by the group are: lack of time, resources available and administrative support, lack of mentorship, and unrecognized value of QI in the academic world. The group also identified some strategies to be successful at writing and publishing QI, including: blocking time in the schedule and labeling it "writing days," joining a collaborative, reaching out to Journal editors and becoming familiar with the SQUIRE guidelines. Some key points as discussed by the experts that will aid during the process of writing QI are:

1. A specific goal/aim statement needs to be identified,
2. The measurement needs to match your goal/aim,
3. Always start with writing your methods since you know exactly what you did,
4. Plot data over time using a run chart, and
5. Keep a notebook with documentation of dates all interventions started.

It is also important for everyone to know there are multiple quality and safety journals willing to review QI manuscripts for publication.

Treatment with the thrombopoietin receptor agonist eltrombopag led to a sustained platelet response in 40% of children and adolescents with chronic immune thrombocytopenia, compared with only 3% of the placebo group, according to a randomized multicenter trial published online in The Lancet.

Eltrombopag is approved in the United States for adults with chronic immune thrombocytopenia (CIT) who have not responded adequately to corticosteroids, immunoglobulins, or splenectomy, but few trials have assessed CIT therapies in children, said Dr. John Grainger of the Royal Manchester Children’s Hospital and the University of Manchester (England) and his associates.

Their multicenter, international study included 92 patients up to age 17 with CIT. During the 13-week double-blinded period of the study, patients received once-daily placebo or eltrombopag dosed at 0.89-1.2 mg/kg for patients aged 1-5 years and at 25-50 mg for patients aged 6-17 years. Dosing ranges were adjusted for ethnicity as well as body weight because east Asians have higher eltrombopag exposures and need lower starting doses, the investigators noted. After the double-blinded period, all patients entered 24 weeks of open-label treatment with eltrombopag (Lancet. 2015 Jul 29. doi: 10.1016/S0140-6736(15)61107-2.).

A total of 25 (40%) patients who received eltrombopag achieved platelet counts of at least 50 × 10⁹ per L for at least 6 of the last 8 weeks of the double-blinded period, compared with only one patient (3%) on placebo (odds ratio, 18; 95% confidence interval, 2.3-140.9; P = .0004), said the researchers. Based on the World Health Organization bleeding scale, the percentage of patients who experienced grade 1-4 bleeding events fell from 63% at the start of the open-label period to 24% at the end, and clinically significant (grade 2-4) bleeding events dropped from 20% to 6%. Seven of 87 patients were able to stop all other drugs they were taking for CIT without needing rescue therapy during open-label treatment, the researchers said.

Two patients stopped eltrombopag because of elevated liver aminotransferases. Rates of nasopharyngitis, rhinitis, upper respiratory tract infection, and cough were more common for eltrombopag than placebo, the investigators reported. However, serious adverse events were more common with placebo (14% vs. 8%), and there were no deaths, thrombotic events, or malignancies. Safety trends were similar during the double-blinded and open-label study periods, they added.

GlaxoSmithKline funded the study. Dr. Grainger reported receiving honoraria from GlaxoSmithKline, Amgen, and Baxter. Eleven coauthors reported financial conflicts of interest with GlaxoSmithKline and a number of other pharmaceutical companies.

Treatment with the thrombopoietin receptor agonist eltrombopag led to a sustained platelet response in 40% of children and adolescents with chronic immune thrombocytopenia, compared with only 3% of the placebo group, according to a randomized multicenter trial published online in The Lancet.

Eltrombopag is approved in the United States for adults with chronic immune thrombocytopenia (CIT) who have not responded adequately to corticosteroids, immunoglobulins, or splenectomy, but few trials have assessed CIT therapies in children, said Dr. John Grainger of the Royal Manchester Children’s Hospital and the University of Manchester (England) and his associates.

Their multicenter, international study included 92 patients up to age 17 with CIT. During the 13-week double-blinded period of the study, patients received once-daily placebo or eltrombopag dosed at 0.89-1.2 mg/kg for patients aged 1-5 years and at 25-50 mg for patients aged 6-17 years. Dosing ranges were adjusted for ethnicity as well as body weight because east Asians have higher eltrombopag exposures and need lower starting doses, the investigators noted. After the double-blinded period, all patients entered 24 weeks of open-label treatment with eltrombopag (Lancet. 2015 Jul 29. doi: 10.1016/S0140-6736(15)61107-2.).

A total of 25 (40%) patients who received eltrombopag achieved platelet counts of at least 50 × 10⁹ per L for at least 6 of the last 8 weeks of the double-blinded period, compared with only one patient (3%) on placebo (odds ratio, 18; 95% confidence interval, 2.3-140.9; P = .0004), said the researchers. Based on the World Health Organization bleeding scale, the percentage of patients who experienced grade 1-4 bleeding events fell from 63% at the start of the open-label period to 24% at the end, and clinically significant (grade 2-4) bleeding events dropped from 20% to 6%. Seven of 87 patients were able to stop all other drugs they were taking for CIT without needing rescue therapy during open-label treatment, the researchers said.

Two patients stopped eltrombopag because of elevated liver aminotransferases. Rates of nasopharyngitis, rhinitis, upper respiratory tract infection, and cough were more common for eltrombopag than placebo, the investigators reported. However, serious adverse events were more common with placebo (14% vs. 8%), and there were no deaths, thrombotic events, or malignancies. Safety trends were similar during the double-blinded and open-label study periods, they added.

GlaxoSmithKline funded the study. Dr. Grainger reported receiving honoraria from GlaxoSmithKline, Amgen, and Baxter. Eleven coauthors reported financial conflicts of interest with GlaxoSmithKline and a number of other pharmaceutical companies.

Treatment with the thrombopoietin receptor agonist eltrombopag led to a sustained platelet response in 40% of children and adolescents with chronic immune thrombocytopenia, compared with only 3% of the placebo group, according to a randomized multicenter trial published online in The Lancet.

Eltrombopag is approved in the United States for adults with chronic immune thrombocytopenia (CIT) who have not responded adequately to corticosteroids, immunoglobulins, or splenectomy, but few trials have assessed CIT therapies in children, said Dr. John Grainger of the Royal Manchester Children’s Hospital and the University of Manchester (England) and his associates.

Their multicenter, international study included 92 patients up to age 17 with CIT. During the 13-week double-blinded period of the study, patients received once-daily placebo or eltrombopag dosed at 0.89-1.2 mg/kg for patients aged 1-5 years and at 25-50 mg for patients aged 6-17 years. Dosing ranges were adjusted for ethnicity as well as body weight because east Asians have higher eltrombopag exposures and need lower starting doses, the investigators noted. After the double-blinded period, all patients entered 24 weeks of open-label treatment with eltrombopag (Lancet. 2015 Jul 29. doi: 10.1016/S0140-6736(15)61107-2.).

A total of 25 (40%) patients who received eltrombopag achieved platelet counts of at least 50 × 10⁹ per L for at least 6 of the last 8 weeks of the double-blinded period, compared with only one patient (3%) on placebo (odds ratio, 18; 95% confidence interval, 2.3-140.9; P = .0004), said the researchers. Based on the World Health Organization bleeding scale, the percentage of patients who experienced grade 1-4 bleeding events fell from 63% at the start of the open-label period to 24% at the end, and clinically significant (grade 2-4) bleeding events dropped from 20% to 6%. Seven of 87 patients were able to stop all other drugs they were taking for CIT without needing rescue therapy during open-label treatment, the researchers said.

Two patients stopped eltrombopag because of elevated liver aminotransferases. Rates of nasopharyngitis, rhinitis, upper respiratory tract infection, and cough were more common for eltrombopag than placebo, the investigators reported. However, serious adverse events were more common with placebo (14% vs. 8%), and there were no deaths, thrombotic events, or malignancies. Safety trends were similar during the double-blinded and open-label study periods, they added.

GlaxoSmithKline funded the study. Dr. Grainger reported receiving honoraria from GlaxoSmithKline, Amgen, and Baxter. Eleven coauthors reported financial conflicts of interest with GlaxoSmithKline and a number of other pharmaceutical companies.

Session: “Teaching and Supervising a PHM Fellow: The Transition from Learner to Instructor."

Analysis:  The session was led by Sarah Denniston, MD, FAAP, of Children’s Hospital of San Antonio/Baylor College of Medicine, and a collaboration of presenters ranging from fellowship directors to new pediatric hospitalist fellows. It was a very interactive discussion that prompted shared stories and encouraged changes in the way hospital medicine views a fellow. Presenters reviewed current evidence-based approaches to effective teaching, while supervision of senior residents and fellow-level trainees rounded out the discussion.

As the number of pediatric hospital medicine fellowships increases, so does the variability in each program. This session focused on the unique challenges PHM fellowships face, a balance of supervision and autonomy, specifically:

• Limited faculty development
• Resident exposure to fundamental PHM core competencies
• No national standards
• Resident transition directly into PHM attending role

Looking at survey responses from fellowship programs, Dr. Denniston described multiple program variables in defining the role of the PHM fellow, specifically if they were billable providers, what type of supervision they have, and what training is provided to the faculty who work with the PHM fellows.

Supervision was the hottest topic. Many of the fellows in the audience were able to share their thoughts and encourage session attendees to discuss with their home institutions the idea of autonomy. The billing provides a challenge, but ways to provide increased autonomy as a fellow progresses in the fellowship were addressed. From independent rounding to “running the list” as a daily check in, this can be accomplished even if the fellow is not able to provide billing. If at least two hospitalist teams are within the structure of the daily rounding, the discussion encouraged independent rounding and check in with a senior hospitalist.

Other hot topics were faculty development and senior hospitalist leadership. Many programs have a large enough staff pool to allow for more senior hospitalists to be the “supervisor” for the fellow, reporting that from a fellow standpoint they valued the mentorship and guidance elicited from the experience of a senior hospitalist. The junior or newer hospitalists also agreed that it is a challenge to feel adequate in providing the education and mentorship to a fellow.

Overall, faculty development is a necessary engagement process in creating a strong PHM fellowship, and both attendees and presenterd cited the need for clear expectations—not only for the faculty but the fellows as well.

Rounding out the session was a short didactic on principles of learning and understanding the generational differences in learners. It is important for all educators to recognize different teaching methods as ways to promote autonomy and enhance not only fellow experience, but senior resident as well.

Setting expectations was a theme, encouraging personal and program responsibility to education.

Key Takeaways:

• PHM fellows need autonomy as they progress towards the role of an independent attending.
• PHM fellowship programs need to establish very clear faculty and fellow expectations, noting the need for senior hospitalist experience.
• Educators need to be aware of generational differences in learning and utilize different learning styles.

Dr. Pestak is a pediatric hospitalist and associate program director for the pediatric residency program at Cleveland Clinic Children’s.

Session: “Teaching and Supervising a PHM Fellow: The Transition from Learner to Instructor."

Analysis:  The session was led by Sarah Denniston, MD, FAAP, of Children’s Hospital of San Antonio/Baylor College of Medicine, and a collaboration of presenters ranging from fellowship directors to new pediatric hospitalist fellows. It was a very interactive discussion that prompted shared stories and encouraged changes in the way hospital medicine views a fellow. Presenters reviewed current evidence-based approaches to effective teaching, while supervision of senior residents and fellow-level trainees rounded out the discussion.

As the number of pediatric hospital medicine fellowships increases, so does the variability in each program. This session focused on the unique challenges PHM fellowships face, a balance of supervision and autonomy, specifically:

• Limited faculty development
• Resident exposure to fundamental PHM core competencies
• No national standards
• Resident transition directly into PHM attending role

Looking at survey responses from fellowship programs, Dr. Denniston described multiple program variables in defining the role of the PHM fellow, specifically if they were billable providers, what type of supervision they have, and what training is provided to the faculty who work with the PHM fellows.

Supervision was the hottest topic. Many of the fellows in the audience were able to share their thoughts and encourage session attendees to discuss with their home institutions the idea of autonomy. The billing provides a challenge, but ways to provide increased autonomy as a fellow progresses in the fellowship were addressed. From independent rounding to “running the list” as a daily check in, this can be accomplished even if the fellow is not able to provide billing. If at least two hospitalist teams are within the structure of the daily rounding, the discussion encouraged independent rounding and check in with a senior hospitalist.

Other hot topics were faculty development and senior hospitalist leadership. Many programs have a large enough staff pool to allow for more senior hospitalists to be the “supervisor” for the fellow, reporting that from a fellow standpoint they valued the mentorship and guidance elicited from the experience of a senior hospitalist. The junior or newer hospitalists also agreed that it is a challenge to feel adequate in providing the education and mentorship to a fellow.

Overall, faculty development is a necessary engagement process in creating a strong PHM fellowship, and both attendees and presenterd cited the need for clear expectations—not only for the faculty but the fellows as well.

Rounding out the session was a short didactic on principles of learning and understanding the generational differences in learners. It is important for all educators to recognize different teaching methods as ways to promote autonomy and enhance not only fellow experience, but senior resident as well.

Setting expectations was a theme, encouraging personal and program responsibility to education.

Key Takeaways:

• PHM fellows need autonomy as they progress towards the role of an independent attending.
• PHM fellowship programs need to establish very clear faculty and fellow expectations, noting the need for senior hospitalist experience.
• Educators need to be aware of generational differences in learning and utilize different learning styles.

Dr. Pestak is a pediatric hospitalist and associate program director for the pediatric residency program at Cleveland Clinic Children’s.

Session: “Teaching and Supervising a PHM Fellow: The Transition from Learner to Instructor."

Analysis:  The session was led by Sarah Denniston, MD, FAAP, of Children’s Hospital of San Antonio/Baylor College of Medicine, and a collaboration of presenters ranging from fellowship directors to new pediatric hospitalist fellows. It was a very interactive discussion that prompted shared stories and encouraged changes in the way hospital medicine views a fellow. Presenters reviewed current evidence-based approaches to effective teaching, while supervision of senior residents and fellow-level trainees rounded out the discussion.

As the number of pediatric hospital medicine fellowships increases, so does the variability in each program. This session focused on the unique challenges PHM fellowships face, a balance of supervision and autonomy, specifically:

• Limited faculty development
• Resident exposure to fundamental PHM core competencies
• No national standards
• Resident transition directly into PHM attending role

Looking at survey responses from fellowship programs, Dr. Denniston described multiple program variables in defining the role of the PHM fellow, specifically if they were billable providers, what type of supervision they have, and what training is provided to the faculty who work with the PHM fellows.

Supervision was the hottest topic. Many of the fellows in the audience were able to share their thoughts and encourage session attendees to discuss with their home institutions the idea of autonomy. The billing provides a challenge, but ways to provide increased autonomy as a fellow progresses in the fellowship were addressed. From independent rounding to “running the list” as a daily check in, this can be accomplished even if the fellow is not able to provide billing. If at least two hospitalist teams are within the structure of the daily rounding, the discussion encouraged independent rounding and check in with a senior hospitalist.

Other hot topics were faculty development and senior hospitalist leadership. Many programs have a large enough staff pool to allow for more senior hospitalists to be the “supervisor” for the fellow, reporting that from a fellow standpoint they valued the mentorship and guidance elicited from the experience of a senior hospitalist. The junior or newer hospitalists also agreed that it is a challenge to feel adequate in providing the education and mentorship to a fellow.

Overall, faculty development is a necessary engagement process in creating a strong PHM fellowship, and both attendees and presenterd cited the need for clear expectations—not only for the faculty but the fellows as well.

Rounding out the session was a short didactic on principles of learning and understanding the generational differences in learners. It is important for all educators to recognize different teaching methods as ways to promote autonomy and enhance not only fellow experience, but senior resident as well.

Setting expectations was a theme, encouraging personal and program responsibility to education.

Key Takeaways:

• PHM fellows need autonomy as they progress towards the role of an independent attending.
• PHM fellowship programs need to establish very clear faculty and fellow expectations, noting the need for senior hospitalist experience.
• Educators need to be aware of generational differences in learning and utilize different learning styles.

Dr. Pestak is a pediatric hospitalist and associate program director for the pediatric residency program at Cleveland Clinic Children’s.

Veterans with PTSD who participated in a mindfulness-based stress reduction program experienced greater decrease in symptom severity, compared with those who participated in present-centered group therapy, according to a randomized, controlled trial. However, the magnitude of the average improvement was considered modest.

“The quality of scientific evidence supporting the efficacy of mindfulness-based interventions has recently been criticized,” researchers led by Melissa A. Polusny, Ph.D., reported on Aug. 4. “This study improves on shortcomings of previous trials by comparing mindfulness-based stress reduction with an active, credible control condition, taking steps to ensure treatment fidelity, and using both patient-reported and blinded clinician ratings of PTSD outcomes.”

©stanciuc/thinkstockphotos.com

From March 2012 to December 2013, Dr. Polusny of the Minneapolis VA Medical Center and her associates randomly assigned 116 veterans with PTSD to one of two treatment groups: 58 to mindfulness-based stress reduction therapy (MBSR) and 58 to patient-centered group therapy (PCT), each delivered in nine weekly group sessions (JAMA. 2015 Aug 4;314(5):456-65.). The MBSR sessions focused on teaching patients to attend to their thoughts, emotions, and sensations with an attitude of nonjudgment, kindness, and curiosity. The PCT sessions focused on teaching patients to tap into their existing skills and strengths to cope effectively with current stressors that might be exacerbated by PTSD symptoms.

The primary outcome was change in PTSD severity over time as measured by the PTSD Checklist (PCL) at weeks 3, 6, 9, and 17 (the 2-month follow-up). Possible PCL scores ranged from 17 to 85, with higher scores indicating more severe PTSD symptoms. Secondary outcomes included diagnosis and symptom severity of PTSD based on the Clinician-Administered PTSD Scale (CAPS) at baseline, week 9, and week 17, as well as improvements in depressive symptoms, quality of life, and mindfulness.

The mean age of study participants was 59 years, and 84% were white. Between baseline and week 9, PCL scores among patients in the MBSR group improved from 63.6 to 55.7, while scores among patients in the PCT group improved from 58.8 to 55.8, which translated into a between-group difference of 4.95 (P = .002). Between baseline and week 17, PCL scores among patients in the MBSR group improved from 63.6 to 54.4, while scores among patients in the PCT group improved from 58.8 to 56, which translated into a between-group difference of 6.44 (P less than .001).

As for secondary outcomes, patients in the MBSR group were more likely to demonstrate significant improvement in self-reported PTSD symptom severity at week 17, compared with their counterparts in the PCT group (48.9% vs. 28.1%, respectively, for a between-group difference of 20.9%; P = .03). However, they were no more likely to have loss of PTSD diagnosis (53.3% vs. 47.3%, respectively, for a between-group difference of 6%; P = .55).

Using a 10-point or greater reduction on the CAPS as a benchmark, the researchers found that both groups were similar in the percentage of participants showing clinically significant improvement in interview-rated PTSD symptom severity at 2-month follow-up (66.7% among patients in the MBSR group vs. 54.5% in the PCT group, for a between-group difference of 12.1%; P = .22). In addition, similar percentages of participants reported clinically significant improvement in depressive symptoms on the PHQ-9 (27.7% among patients in the MBSR group, vs. 22.8% in the PCT group, for a between-group difference of 4.9%; P = .57).

“Findings from the present study suggest that veterans who received mindfulness-based stress reduction therapy reported significant improvement in mindfulness skills after treatment, while there appeared to be little change in mindfulness skills reported by veterans who received present-centered group therapy,” the researchers wrote. “Moreover, findings suggest that greater reductions in PTSD symptom severity were associated with changes in mindfulness over the course of treatment. Improvements in quality of life made during treatment appeared to be maintained through the 2-month follow-up for participants receiving mindfulness-based stress reduction therapy, but reports of quality of life appeared to return to baseline levels for present-centered group therapy participants during this same follow-up period. Taken together, these findings suggest that mindfulness-based stress reduction may provide veterans with internal tools for promoting self-management of PTSD symptoms and quality of life.”

They acknowledged certain limitations of the study, including the fact that even though groups were structurally equivalent in number of weekly sessions, “therapist training and qualifications, and group format, present-centered group therapy may not have fully accounted for all nonspecific factors present in mindfulness-based stress reduction (e.g., therapist expectations) and was unequal in duration of sessions.”

The study was supported by the Minneapolis VA Health Care System and a grant from the Department of Veterans Affairs. The researchers reported having no financial disclosures.

[email protected]

Veterans with PTSD who participated in a mindfulness-based stress reduction program experienced greater decrease in symptom severity, compared with those who participated in present-centered group therapy, according to a randomized, controlled trial. However, the magnitude of the average improvement was considered modest.

“The quality of scientific evidence supporting the efficacy of mindfulness-based interventions has recently been criticized,” researchers led by Melissa A. Polusny, Ph.D., reported on Aug. 4. “This study improves on shortcomings of previous trials by comparing mindfulness-based stress reduction with an active, credible control condition, taking steps to ensure treatment fidelity, and using both patient-reported and blinded clinician ratings of PTSD outcomes.”

©stanciuc/thinkstockphotos.com

From March 2012 to December 2013, Dr. Polusny of the Minneapolis VA Medical Center and her associates randomly assigned 116 veterans with PTSD to one of two treatment groups: 58 to mindfulness-based stress reduction therapy (MBSR) and 58 to patient-centered group therapy (PCT), each delivered in nine weekly group sessions (JAMA. 2015 Aug 4;314(5):456-65.). The MBSR sessions focused on teaching patients to attend to their thoughts, emotions, and sensations with an attitude of nonjudgment, kindness, and curiosity. The PCT sessions focused on teaching patients to tap into their existing skills and strengths to cope effectively with current stressors that might be exacerbated by PTSD symptoms.

The primary outcome was change in PTSD severity over time as measured by the PTSD Checklist (PCL) at weeks 3, 6, 9, and 17 (the 2-month follow-up). Possible PCL scores ranged from 17 to 85, with higher scores indicating more severe PTSD symptoms. Secondary outcomes included diagnosis and symptom severity of PTSD based on the Clinician-Administered PTSD Scale (CAPS) at baseline, week 9, and week 17, as well as improvements in depressive symptoms, quality of life, and mindfulness.

The mean age of study participants was 59 years, and 84% were white. Between baseline and week 9, PCL scores among patients in the MBSR group improved from 63.6 to 55.7, while scores among patients in the PCT group improved from 58.8 to 55.8, which translated into a between-group difference of 4.95 (P = .002). Between baseline and week 17, PCL scores among patients in the MBSR group improved from 63.6 to 54.4, while scores among patients in the PCT group improved from 58.8 to 56, which translated into a between-group difference of 6.44 (P less than .001).

As for secondary outcomes, patients in the MBSR group were more likely to demonstrate significant improvement in self-reported PTSD symptom severity at week 17, compared with their counterparts in the PCT group (48.9% vs. 28.1%, respectively, for a between-group difference of 20.9%; P = .03). However, they were no more likely to have loss of PTSD diagnosis (53.3% vs. 47.3%, respectively, for a between-group difference of 6%; P = .55).

Using a 10-point or greater reduction on the CAPS as a benchmark, the researchers found that both groups were similar in the percentage of participants showing clinically significant improvement in interview-rated PTSD symptom severity at 2-month follow-up (66.7% among patients in the MBSR group vs. 54.5% in the PCT group, for a between-group difference of 12.1%; P = .22). In addition, similar percentages of participants reported clinically significant improvement in depressive symptoms on the PHQ-9 (27.7% among patients in the MBSR group, vs. 22.8% in the PCT group, for a between-group difference of 4.9%; P = .57).

“Findings from the present study suggest that veterans who received mindfulness-based stress reduction therapy reported significant improvement in mindfulness skills after treatment, while there appeared to be little change in mindfulness skills reported by veterans who received present-centered group therapy,” the researchers wrote. “Moreover, findings suggest that greater reductions in PTSD symptom severity were associated with changes in mindfulness over the course of treatment. Improvements in quality of life made during treatment appeared to be maintained through the 2-month follow-up for participants receiving mindfulness-based stress reduction therapy, but reports of quality of life appeared to return to baseline levels for present-centered group therapy participants during this same follow-up period. Taken together, these findings suggest that mindfulness-based stress reduction may provide veterans with internal tools for promoting self-management of PTSD symptoms and quality of life.”

They acknowledged certain limitations of the study, including the fact that even though groups were structurally equivalent in number of weekly sessions, “therapist training and qualifications, and group format, present-centered group therapy may not have fully accounted for all nonspecific factors present in mindfulness-based stress reduction (e.g., therapist expectations) and was unequal in duration of sessions.”

The study was supported by the Minneapolis VA Health Care System and a grant from the Department of Veterans Affairs. The researchers reported having no financial disclosures.

[email protected]

Veterans with PTSD who participated in a mindfulness-based stress reduction program experienced greater decrease in symptom severity, compared with those who participated in present-centered group therapy, according to a randomized, controlled trial. However, the magnitude of the average improvement was considered modest.

“The quality of scientific evidence supporting the efficacy of mindfulness-based interventions has recently been criticized,” researchers led by Melissa A. Polusny, Ph.D., reported on Aug. 4. “This study improves on shortcomings of previous trials by comparing mindfulness-based stress reduction with an active, credible control condition, taking steps to ensure treatment fidelity, and using both patient-reported and blinded clinician ratings of PTSD outcomes.”

©stanciuc/thinkstockphotos.com

From March 2012 to December 2013, Dr. Polusny of the Minneapolis VA Medical Center and her associates randomly assigned 116 veterans with PTSD to one of two treatment groups: 58 to mindfulness-based stress reduction therapy (MBSR) and 58 to patient-centered group therapy (PCT), each delivered in nine weekly group sessions (JAMA. 2015 Aug 4;314(5):456-65.). The MBSR sessions focused on teaching patients to attend to their thoughts, emotions, and sensations with an attitude of nonjudgment, kindness, and curiosity. The PCT sessions focused on teaching patients to tap into their existing skills and strengths to cope effectively with current stressors that might be exacerbated by PTSD symptoms.

The primary outcome was change in PTSD severity over time as measured by the PTSD Checklist (PCL) at weeks 3, 6, 9, and 17 (the 2-month follow-up). Possible PCL scores ranged from 17 to 85, with higher scores indicating more severe PTSD symptoms. Secondary outcomes included diagnosis and symptom severity of PTSD based on the Clinician-Administered PTSD Scale (CAPS) at baseline, week 9, and week 17, as well as improvements in depressive symptoms, quality of life, and mindfulness.

The mean age of study participants was 59 years, and 84% were white. Between baseline and week 9, PCL scores among patients in the MBSR group improved from 63.6 to 55.7, while scores among patients in the PCT group improved from 58.8 to 55.8, which translated into a between-group difference of 4.95 (P = .002). Between baseline and week 17, PCL scores among patients in the MBSR group improved from 63.6 to 54.4, while scores among patients in the PCT group improved from 58.8 to 56, which translated into a between-group difference of 6.44 (P less than .001).

As for secondary outcomes, patients in the MBSR group were more likely to demonstrate significant improvement in self-reported PTSD symptom severity at week 17, compared with their counterparts in the PCT group (48.9% vs. 28.1%, respectively, for a between-group difference of 20.9%; P = .03). However, they were no more likely to have loss of PTSD diagnosis (53.3% vs. 47.3%, respectively, for a between-group difference of 6%; P = .55).

Using a 10-point or greater reduction on the CAPS as a benchmark, the researchers found that both groups were similar in the percentage of participants showing clinically significant improvement in interview-rated PTSD symptom severity at 2-month follow-up (66.7% among patients in the MBSR group vs. 54.5% in the PCT group, for a between-group difference of 12.1%; P = .22). In addition, similar percentages of participants reported clinically significant improvement in depressive symptoms on the PHQ-9 (27.7% among patients in the MBSR group, vs. 22.8% in the PCT group, for a between-group difference of 4.9%; P = .57).

“Findings from the present study suggest that veterans who received mindfulness-based stress reduction therapy reported significant improvement in mindfulness skills after treatment, while there appeared to be little change in mindfulness skills reported by veterans who received present-centered group therapy,” the researchers wrote. “Moreover, findings suggest that greater reductions in PTSD symptom severity were associated with changes in mindfulness over the course of treatment. Improvements in quality of life made during treatment appeared to be maintained through the 2-month follow-up for participants receiving mindfulness-based stress reduction therapy, but reports of quality of life appeared to return to baseline levels for present-centered group therapy participants during this same follow-up period. Taken together, these findings suggest that mindfulness-based stress reduction may provide veterans with internal tools for promoting self-management of PTSD symptoms and quality of life.”

They acknowledged certain limitations of the study, including the fact that even though groups were structurally equivalent in number of weekly sessions, “therapist training and qualifications, and group format, present-centered group therapy may not have fully accounted for all nonspecific factors present in mindfulness-based stress reduction (e.g., therapist expectations) and was unequal in duration of sessions.”

The study was supported by the Minneapolis VA Health Care System and a grant from the Department of Veterans Affairs. The researchers reported having no financial disclosures.

[email protected]

When are you Dr. versus Mr./Mrs./Miss?

I try to keep a pretty solid wall between my two identities. When I’m outside the office, I’m not happy about suddenly having to change hats.

I run into patients at restaurants and stores, like everyone else. Most of the time, we just exchange waves or nods. (I’m sure some of them don’t want to acknowledge me, either.)

But there are always those who consider catching me in public as a chance to get their questions answered or meds refilled without having to call the office, and don’t care if the whole establishment hears them.

I’m pretty much blind without my glasses, so, unless asleep, I am never without them. My wife has learned that when I suddenly take them off in public, it means I’ve sighted a patient I don’t want seeing me. It’s the easiest way to quickly change my appearance.

Some will still recognize me and come over with questions, descriptions, new symptoms, or concerns about what they saw on TV, read on the Internet, or heard from a lady at the store. Provided that nothing is urgent, I tell them that, at the moment, I’m not Dr. Block. I’m Dad, or husband, or basketball fan. I suggest they call my office with their questions, and Dr. Block or his staff will get back to them. Most will, though I’ve had a few get angry and accuse me of being unreasonable or uncaring.

I don’t really care. Like everyone else, I have at least two personas (work and home) and try to keep them as separate as possible. Part of it is for practical reasons, but mostly, it’s personal. None of us want to be in the doctor role at home, or in the home persona while seeing patients.

I ask patients and family to respect this. I don’t like getting the non-urgent texts or calls from my kids when I’m at the office, either. There I’m trying to focus on patients and their problems, and distractions aren’t welcome.

We each draw this line somewhere, depending on our own comfort level. You can’t be both all the time. It’s bad for your sanity.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

When are you Dr. versus Mr./Mrs./Miss?

I try to keep a pretty solid wall between my two identities. When I’m outside the office, I’m not happy about suddenly having to change hats.

I run into patients at restaurants and stores, like everyone else. Most of the time, we just exchange waves or nods. (I’m sure some of them don’t want to acknowledge me, either.)

But there are always those who consider catching me in public as a chance to get their questions answered or meds refilled without having to call the office, and don’t care if the whole establishment hears them.

I’m pretty much blind without my glasses, so, unless asleep, I am never without them. My wife has learned that when I suddenly take them off in public, it means I’ve sighted a patient I don’t want seeing me. It’s the easiest way to quickly change my appearance.

Some will still recognize me and come over with questions, descriptions, new symptoms, or concerns about what they saw on TV, read on the Internet, or heard from a lady at the store. Provided that nothing is urgent, I tell them that, at the moment, I’m not Dr. Block. I’m Dad, or husband, or basketball fan. I suggest they call my office with their questions, and Dr. Block or his staff will get back to them. Most will, though I’ve had a few get angry and accuse me of being unreasonable or uncaring.

I don’t really care. Like everyone else, I have at least two personas (work and home) and try to keep them as separate as possible. Part of it is for practical reasons, but mostly, it’s personal. None of us want to be in the doctor role at home, or in the home persona while seeing patients.

I ask patients and family to respect this. I don’t like getting the non-urgent texts or calls from my kids when I’m at the office, either. There I’m trying to focus on patients and their problems, and distractions aren’t welcome.

We each draw this line somewhere, depending on our own comfort level. You can’t be both all the time. It’s bad for your sanity.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

When are you Dr. versus Mr./Mrs./Miss?

I try to keep a pretty solid wall between my two identities. When I’m outside the office, I’m not happy about suddenly having to change hats.

I run into patients at restaurants and stores, like everyone else. Most of the time, we just exchange waves or nods. (I’m sure some of them don’t want to acknowledge me, either.)

But there are always those who consider catching me in public as a chance to get their questions answered or meds refilled without having to call the office, and don’t care if the whole establishment hears them.

I’m pretty much blind without my glasses, so, unless asleep, I am never without them. My wife has learned that when I suddenly take them off in public, it means I’ve sighted a patient I don’t want seeing me. It’s the easiest way to quickly change my appearance.

Some will still recognize me and come over with questions, descriptions, new symptoms, or concerns about what they saw on TV, read on the Internet, or heard from a lady at the store. Provided that nothing is urgent, I tell them that, at the moment, I’m not Dr. Block. I’m Dad, or husband, or basketball fan. I suggest they call my office with their questions, and Dr. Block or his staff will get back to them. Most will, though I’ve had a few get angry and accuse me of being unreasonable or uncaring.

I don’t really care. Like everyone else, I have at least two personas (work and home) and try to keep them as separate as possible. Part of it is for practical reasons, but mostly, it’s personal. None of us want to be in the doctor role at home, or in the home persona while seeing patients.

I ask patients and family to respect this. I don’t like getting the non-urgent texts or calls from my kids when I’m at the office, either. There I’m trying to focus on patients and their problems, and distractions aren’t welcome.

We each draw this line somewhere, depending on our own comfort level. You can’t be both all the time. It’s bad for your sanity.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Incident stroke is associated with an acute decline in cognitive function and accelerated and persistent cognitive decline over six years, according to a study published July 7 in JAMA. Researchers used data from 23,572 cognitively healthy participants age 45 or older from the Reasons for Geographic and Racial Differences in Stroke study. Participants resided in the United States, were enrolled in the study from 2003 through 2007, and were followed up through March 31, 2013. In all, 515 participants survived expert-adjudicated incident stroke, and 23,057 remained stroke-free. Stroke was associated with acute decline in global cognition, new learning, and verbal memory. Participants with stroke, compared with those without stroke, had faster declines in global cognition and executive function, but not in new learning and verbal memory, compared with prestroke changes.

Childhood adversities are associated with migraine, and greater numbers of adversities are associated with increasing odds of migraine, according to a study published online ahead of print June 23 in Headache. Researchers used a representative sample of 10,358 men and 12,638 women and performed gender-specific logistic regression analyses to determine the association between number and type of self-reported childhood adversities and migraine, while controlling for sociodemographics, comorbid adversities, health behaviors, depression, and anxiety. Overall, 6.5% of men and 14.2% of women reported migraines. Physical abuse, witnessing parental domestic violence, and sexual abuse were significantly associated with migraine for both genders, even after controlling for variables. Men reporting all three adversities had more than three times the odds of migraine, compared with those without childhood adversities.

Full truncal vagotomy is associated with a decreased risk for subsequent Parkinson’s disease, suggesting that the vagal nerve may be involved in the pathogenesis of Parkinson’s disease, according to a study published online ahead of print May 29 in Annals of Neurology. Researchers constructed cohorts of all patients in Denmark who underwent vagotomy from 1977 through 1995, and a matched general population cohort. Investigators used Cox regression analysis to compute hazard ratios for Parkinson’s disease, adjusting for potential confounders. Risk of Parkinson’s disease was decreased in patients who underwent truncal vagotomy, compared with superselective vagotomy. Risk of Parkinson’s disease also was decreased following truncal vagotomy when compared with the general population cohort. In patients who underwent superselective vagotomy, risk of Parkinson’s disease was similar to that of the general population.

In women with acute ischemic stroke treated with alteplase, uric acid reduced infarct growth in selected patients and was better than placebo for reaching excellent outcome, according to a study published online ahead of print July 9 in Stroke. Researchers reanalyzed 2014 data from the randomized, double-blind URICO-ICTUS trial of patients admitted to Spanish stroke centers. Participants included 206 women and 205 men. All participants received therapies to remove the clots, while half in each gender group also received either 1,000 mg of uric acid IV or placebo. Uric acid doubled the effect of placebo to achieve excellent outcome in women, but not in men. The interactions between treatment and serum uric acid levels or allantoin–uric acid ratio on infarct growth were significant only in women.

Women with epilepsy are at a heightened risk for adverse outcomes during their delivery hospitalizations, according to a study published online ahead of print July 6 in JAMA Neurology. Researchers examined a retrospective cohort study of pregnant women identified through delivery hospitalization records from the 2007 through 2011 Nationwide Inpatient Sample. Investigators obtained a weighted sample of delivery hospitalizations from 69,385 women with epilepsy and 20,449,532 women without epilepsy. Women with epilepsy had a risk of death during delivery hospitalization of 80 deaths per 100,000 pregnancies, compared with six deaths per 100,000 pregnancies among controls. Women with epilepsy also were at increased risk for pre-eclampsia, preterm labor, and stillbirth. They also had increased health care utilization, including an increased risk of cesarean delivery and prolonged hospital stay.

Eight-hour sleep duration may help consolidate newly learned procedural and declarative memories and ensure full access to them during periods of subjective stress, according to a study published online ahead of print June 22 in Sleep. For this study, 15 healthy young men learned object locations and a finger tapping sequence in the evening. Participants either had the opportunity to sleep for eight hours or could sleep between the hours of 3:00 am and 7:00 am. Retrieval of both memory tasks was tested in the morning after each sleep condition, both before and after stress exposure. Post-sleep memory changes did not differ between sleep conditions. Men who received less sleep, however, had reduced recall ability after exposure to stress, while post-stress recall was not affected in those who received a full night of sleep.

Cognitive impairment may manifest in the preclinical phase of Alzheimer’s disease substantially earlier than previously established, according to a study published online ahead of print June 24 in Neurology. A composite cognitive test score based on tests of episodic memory, executive function, and global cognition was constructed in a prospective population-based sample of 2,125 participants ages 65 and older. In all, 442 participants developed clinical Alzheimer’s disease over 18 years of follow-up. Lower composite cognitive test scores were associated with the development of Alzheimer’s disease. The magnitude of association between composite cognitive test score and development of Alzheimer’s disease dementia increased from an odds ratio of 3.39 at 13.0 to 17.9 years to an odds ratio of 9.84 at 0.1 to 0.9 years, per standard deviation increment.

Shared biological processes contribute to the risk of migraine and coronary artery disease, but this commonality is restricted to migraine without aura, according to a study published online ahead of print July 2 in Neurology Genetics. Researchers analyzed two large genome-wide association studies of migraine and heart disease. The migraine study involved 19,981 people with migraine and 56,667 people without migraine. Also included were 21,076 people with heart disease and 63,014 people without heart disease. Investigators found a significant overlap of genetic risk loci for migraine and coronary artery disease. When stratified by migraine subtype, this overlap was limited to migraine without aura. The overlap was protective, in that patients with migraine had a lower load of coronary artery disease risk alleles than controls did.

Women with stimulant dependence have significant changes in gray matter volume after prolonged abstinence, but men do not, according to a study published online ahead of print July 14 in Radiology. For this prospective, parallel-group study, 127 age- and sex-matched participants underwent T1-weighted spoiled gradient-echo inversion recovery MRI of the brain at 3 T. Compared with female control subjects, women with stimulant dependence had significantly lower gray matter volume in various brain regions. There were no significant differences in gray matter volume between male control subjects and men with stimulant dependence. Dependence symptom count negatively correlated with gray matter volume in the nucleus accumbens in women. Behavioral approach and impulsivity correlated negatively with frontal and temporal gray matter volume changes in women with stimulant dependence.

The FDA has approved Fycompa (perampanel) CIII for adjunctive therapy in the treatment of primary generalized tonic-clonic seizures. The approval is based on a phase III, randomized, double-blind, placebo-controlled clinical trial of 162 patients taking one to three antiepileptic drugs. Patients treated with Fycompa achieved a 76% median reduction in primary generalized tonic-clonic seizure frequency. In addition, 64% of patients treated with Fycompa had a 50% or greater reduction in primary generalized tonic-clonic seizure frequency versus 40% with placebo. The most frequently reported adverse events in patients treated with Fycompa were dizziness, fatigue, headache, somnolence, and irritability. The adverse event profile was similar to that in the controlled phase III partial-onset seizure trials of the drug. Eisai, headquartered in Woodcliff Lake, New Jersey, manufactures Fycompa.

Imaging biomarkers, including white matter disruption, may help explain some of the heterogeneity in postinjury outcome among children with traumatic brain injury (TBI), according to a study published July 15 in Journal of Neuroscience. Researchers used high angular resolution diffusion-weighted imaging to evaluate the structural integrity of the corpus callosum following brain injury in a sample of 32 children with moderate-to-severe TBI at one to five months post injury, and in healthy control children. A subset of children with TBI had markedly impaired functioning and structural integrity in the corpus callosum. These impairments were associated with poor neurocognitive functioning. The children with impaired functioning also had significantly slower interhemispheric transfer times than the control group did, as measured using event-related potentials.

Longitudinal CSF biomarker patterns consistent with Alzheimer’s disease are first detectable during early middle age and are associated with later amyloid positivity and cognitive decline, according to a study published online ahead of print July 6 in JAMA Neurology. Cognitively normal middle-aged participants enrolled in the Adult Children Study at Washington University underwent serial CSF collection and longitudinal clinical assessment at three-year intervals. A subset of patients underwent longitudinal amyloid PET imaging with Pittsburgh compound B (PiB) in the same period. The researchers found no consistent longitudinal patterns in Aβ40. Longitudinal reductions in Aβ42 were observed in some individuals as early as middle age, and low Aβ42 levels were associated with the development of cortical PiB-positive amyloid plaques. The patterns were more apparent in at-risk carriers of the ε4 allele.

Men with high exposure to formaldehyde at work had an almost three times greater rate of amyotrophic lateral sclerosis (ALS) mortality than men with no exposure, according to a study published online ahead of print July 13 in the Journal of Neurology Neurosurgery & Psychiatry. Researchers examined data for 794,541 men and 674,694 women included in the National Longitudinal Mortality Study who were 25 or older when surveyed. They used a formaldehyde exposure matrix constructed by industrial hygienists at the National Cancer Institute. Exposure to formaldehyde differed between males and females. All men with high-intensity exposure were funeral directors. Few women had high-exposure jobs, and there were no ALS deaths among women with such jobs. Participants with exposure were poorer and less educated than those without exposure.

—Kimberly Williams

Incident stroke is associated with an acute decline in cognitive function and accelerated and persistent cognitive decline over six years, according to a study published July 7 in JAMA. Researchers used data from 23,572 cognitively healthy participants age 45 or older from the Reasons for Geographic and Racial Differences in Stroke study. Participants resided in the United States, were enrolled in the study from 2003 through 2007, and were followed up through March 31, 2013. In all, 515 participants survived expert-adjudicated incident stroke, and 23,057 remained stroke-free. Stroke was associated with acute decline in global cognition, new learning, and verbal memory. Participants with stroke, compared with those without stroke, had faster declines in global cognition and executive function, but not in new learning and verbal memory, compared with prestroke changes.

Childhood adversities are associated with migraine, and greater numbers of adversities are associated with increasing odds of migraine, according to a study published online ahead of print June 23 in Headache. Researchers used a representative sample of 10,358 men and 12,638 women and performed gender-specific logistic regression analyses to determine the association between number and type of self-reported childhood adversities and migraine, while controlling for sociodemographics, comorbid adversities, health behaviors, depression, and anxiety. Overall, 6.5% of men and 14.2% of women reported migraines. Physical abuse, witnessing parental domestic violence, and sexual abuse were significantly associated with migraine for both genders, even after controlling for variables. Men reporting all three adversities had more than three times the odds of migraine, compared with those without childhood adversities.

Full truncal vagotomy is associated with a decreased risk for subsequent Parkinson’s disease, suggesting that the vagal nerve may be involved in the pathogenesis of Parkinson’s disease, according to a study published online ahead of print May 29 in Annals of Neurology. Researchers constructed cohorts of all patients in Denmark who underwent vagotomy from 1977 through 1995, and a matched general population cohort. Investigators used Cox regression analysis to compute hazard ratios for Parkinson’s disease, adjusting for potential confounders. Risk of Parkinson’s disease was decreased in patients who underwent truncal vagotomy, compared with superselective vagotomy. Risk of Parkinson’s disease also was decreased following truncal vagotomy when compared with the general population cohort. In patients who underwent superselective vagotomy, risk of Parkinson’s disease was similar to that of the general population.

In women with acute ischemic stroke treated with alteplase, uric acid reduced infarct growth in selected patients and was better than placebo for reaching excellent outcome, according to a study published online ahead of print July 9 in Stroke. Researchers reanalyzed 2014 data from the randomized, double-blind URICO-ICTUS trial of patients admitted to Spanish stroke centers. Participants included 206 women and 205 men. All participants received therapies to remove the clots, while half in each gender group also received either 1,000 mg of uric acid IV or placebo. Uric acid doubled the effect of placebo to achieve excellent outcome in women, but not in men. The interactions between treatment and serum uric acid levels or allantoin–uric acid ratio on infarct growth were significant only in women.

Women with epilepsy are at a heightened risk for adverse outcomes during their delivery hospitalizations, according to a study published online ahead of print July 6 in JAMA Neurology. Researchers examined a retrospective cohort study of pregnant women identified through delivery hospitalization records from the 2007 through 2011 Nationwide Inpatient Sample. Investigators obtained a weighted sample of delivery hospitalizations from 69,385 women with epilepsy and 20,449,532 women without epilepsy. Women with epilepsy had a risk of death during delivery hospitalization of 80 deaths per 100,000 pregnancies, compared with six deaths per 100,000 pregnancies among controls. Women with epilepsy also were at increased risk for pre-eclampsia, preterm labor, and stillbirth. They also had increased health care utilization, including an increased risk of cesarean delivery and prolonged hospital stay.

Eight-hour sleep duration may help consolidate newly learned procedural and declarative memories and ensure full access to them during periods of subjective stress, according to a study published online ahead of print June 22 in Sleep. For this study, 15 healthy young men learned object locations and a finger tapping sequence in the evening. Participants either had the opportunity to sleep for eight hours or could sleep between the hours of 3:00 am and 7:00 am. Retrieval of both memory tasks was tested in the morning after each sleep condition, both before and after stress exposure. Post-sleep memory changes did not differ between sleep conditions. Men who received less sleep, however, had reduced recall ability after exposure to stress, while post-stress recall was not affected in those who received a full night of sleep.

Cognitive impairment may manifest in the preclinical phase of Alzheimer’s disease substantially earlier than previously established, according to a study published online ahead of print June 24 in Neurology. A composite cognitive test score based on tests of episodic memory, executive function, and global cognition was constructed in a prospective population-based sample of 2,125 participants ages 65 and older. In all, 442 participants developed clinical Alzheimer’s disease over 18 years of follow-up. Lower composite cognitive test scores were associated with the development of Alzheimer’s disease. The magnitude of association between composite cognitive test score and development of Alzheimer’s disease dementia increased from an odds ratio of 3.39 at 13.0 to 17.9 years to an odds ratio of 9.84 at 0.1 to 0.9 years, per standard deviation increment.

Shared biological processes contribute to the risk of migraine and coronary artery disease, but this commonality is restricted to migraine without aura, according to a study published online ahead of print July 2 in Neurology Genetics. Researchers analyzed two large genome-wide association studies of migraine and heart disease. The migraine study involved 19,981 people with migraine and 56,667 people without migraine. Also included were 21,076 people with heart disease and 63,014 people without heart disease. Investigators found a significant overlap of genetic risk loci for migraine and coronary artery disease. When stratified by migraine subtype, this overlap was limited to migraine without aura. The overlap was protective, in that patients with migraine had a lower load of coronary artery disease risk alleles than controls did.

Women with stimulant dependence have significant changes in gray matter volume after prolonged abstinence, but men do not, according to a study published online ahead of print July 14 in Radiology. For this prospective, parallel-group study, 127 age- and sex-matched participants underwent T1-weighted spoiled gradient-echo inversion recovery MRI of the brain at 3 T. Compared with female control subjects, women with stimulant dependence had significantly lower gray matter volume in various brain regions. There were no significant differences in gray matter volume between male control subjects and men with stimulant dependence. Dependence symptom count negatively correlated with gray matter volume in the nucleus accumbens in women. Behavioral approach and impulsivity correlated negatively with frontal and temporal gray matter volume changes in women with stimulant dependence.

The FDA has approved Fycompa (perampanel) CIII for adjunctive therapy in the treatment of primary generalized tonic-clonic seizures. The approval is based on a phase III, randomized, double-blind, placebo-controlled clinical trial of 162 patients taking one to three antiepileptic drugs. Patients treated with Fycompa achieved a 76% median reduction in primary generalized tonic-clonic seizure frequency. In addition, 64% of patients treated with Fycompa had a 50% or greater reduction in primary generalized tonic-clonic seizure frequency versus 40% with placebo. The most frequently reported adverse events in patients treated with Fycompa were dizziness, fatigue, headache, somnolence, and irritability. The adverse event profile was similar to that in the controlled phase III partial-onset seizure trials of the drug. Eisai, headquartered in Woodcliff Lake, New Jersey, manufactures Fycompa.

Imaging biomarkers, including white matter disruption, may help explain some of the heterogeneity in postinjury outcome among children with traumatic brain injury (TBI), according to a study published July 15 in Journal of Neuroscience. Researchers used high angular resolution diffusion-weighted imaging to evaluate the structural integrity of the corpus callosum following brain injury in a sample of 32 children with moderate-to-severe TBI at one to five months post injury, and in healthy control children. A subset of children with TBI had markedly impaired functioning and structural integrity in the corpus callosum. These impairments were associated with poor neurocognitive functioning. The children with impaired functioning also had significantly slower interhemispheric transfer times than the control group did, as measured using event-related potentials.

Longitudinal CSF biomarker patterns consistent with Alzheimer’s disease are first detectable during early middle age and are associated with later amyloid positivity and cognitive decline, according to a study published online ahead of print July 6 in JAMA Neurology. Cognitively normal middle-aged participants enrolled in the Adult Children Study at Washington University underwent serial CSF collection and longitudinal clinical assessment at three-year intervals. A subset of patients underwent longitudinal amyloid PET imaging with Pittsburgh compound B (PiB) in the same period. The researchers found no consistent longitudinal patterns in Aβ40. Longitudinal reductions in Aβ42 were observed in some individuals as early as middle age, and low Aβ42 levels were associated with the development of cortical PiB-positive amyloid plaques. The patterns were more apparent in at-risk carriers of the ε4 allele.

Men with high exposure to formaldehyde at work had an almost three times greater rate of amyotrophic lateral sclerosis (ALS) mortality than men with no exposure, according to a study published online ahead of print July 13 in the Journal of Neurology Neurosurgery & Psychiatry. Researchers examined data for 794,541 men and 674,694 women included in the National Longitudinal Mortality Study who were 25 or older when surveyed. They used a formaldehyde exposure matrix constructed by industrial hygienists at the National Cancer Institute. Exposure to formaldehyde differed between males and females. All men with high-intensity exposure were funeral directors. Few women had high-exposure jobs, and there were no ALS deaths among women with such jobs. Participants with exposure were poorer and less educated than those without exposure.

—Kimberly Williams

Incident stroke is associated with an acute decline in cognitive function and accelerated and persistent cognitive decline over six years, according to a study published July 7 in JAMA. Researchers used data from 23,572 cognitively healthy participants age 45 or older from the Reasons for Geographic and Racial Differences in Stroke study. Participants resided in the United States, were enrolled in the study from 2003 through 2007, and were followed up through March 31, 2013. In all, 515 participants survived expert-adjudicated incident stroke, and 23,057 remained stroke-free. Stroke was associated with acute decline in global cognition, new learning, and verbal memory. Participants with stroke, compared with those without stroke, had faster declines in global cognition and executive function, but not in new learning and verbal memory, compared with prestroke changes.

Childhood adversities are associated with migraine, and greater numbers of adversities are associated with increasing odds of migraine, according to a study published online ahead of print June 23 in Headache. Researchers used a representative sample of 10,358 men and 12,638 women and performed gender-specific logistic regression analyses to determine the association between number and type of self-reported childhood adversities and migraine, while controlling for sociodemographics, comorbid adversities, health behaviors, depression, and anxiety. Overall, 6.5% of men and 14.2% of women reported migraines. Physical abuse, witnessing parental domestic violence, and sexual abuse were significantly associated with migraine for both genders, even after controlling for variables. Men reporting all three adversities had more than three times the odds of migraine, compared with those without childhood adversities.

Full truncal vagotomy is associated with a decreased risk for subsequent Parkinson’s disease, suggesting that the vagal nerve may be involved in the pathogenesis of Parkinson’s disease, according to a study published online ahead of print May 29 in Annals of Neurology. Researchers constructed cohorts of all patients in Denmark who underwent vagotomy from 1977 through 1995, and a matched general population cohort. Investigators used Cox regression analysis to compute hazard ratios for Parkinson’s disease, adjusting for potential confounders. Risk of Parkinson’s disease was decreased in patients who underwent truncal vagotomy, compared with superselective vagotomy. Risk of Parkinson’s disease also was decreased following truncal vagotomy when compared with the general population cohort. In patients who underwent superselective vagotomy, risk of Parkinson’s disease was similar to that of the general population.

In women with acute ischemic stroke treated with alteplase, uric acid reduced infarct growth in selected patients and was better than placebo for reaching excellent outcome, according to a study published online ahead of print July 9 in Stroke. Researchers reanalyzed 2014 data from the randomized, double-blind URICO-ICTUS trial of patients admitted to Spanish stroke centers. Participants included 206 women and 205 men. All participants received therapies to remove the clots, while half in each gender group also received either 1,000 mg of uric acid IV or placebo. Uric acid doubled the effect of placebo to achieve excellent outcome in women, but not in men. The interactions between treatment and serum uric acid levels or allantoin–uric acid ratio on infarct growth were significant only in women.

Women with epilepsy are at a heightened risk for adverse outcomes during their delivery hospitalizations, according to a study published online ahead of print July 6 in JAMA Neurology. Researchers examined a retrospective cohort study of pregnant women identified through delivery hospitalization records from the 2007 through 2011 Nationwide Inpatient Sample. Investigators obtained a weighted sample of delivery hospitalizations from 69,385 women with epilepsy and 20,449,532 women without epilepsy. Women with epilepsy had a risk of death during delivery hospitalization of 80 deaths per 100,000 pregnancies, compared with six deaths per 100,000 pregnancies among controls. Women with epilepsy also were at increased risk for pre-eclampsia, preterm labor, and stillbirth. They also had increased health care utilization, including an increased risk of cesarean delivery and prolonged hospital stay.

Eight-hour sleep duration may help consolidate newly learned procedural and declarative memories and ensure full access to them during periods of subjective stress, according to a study published online ahead of print June 22 in Sleep. For this study, 15 healthy young men learned object locations and a finger tapping sequence in the evening. Participants either had the opportunity to sleep for eight hours or could sleep between the hours of 3:00 am and 7:00 am. Retrieval of both memory tasks was tested in the morning after each sleep condition, both before and after stress exposure. Post-sleep memory changes did not differ between sleep conditions. Men who received less sleep, however, had reduced recall ability after exposure to stress, while post-stress recall was not affected in those who received a full night of sleep.

Cognitive impairment may manifest in the preclinical phase of Alzheimer’s disease substantially earlier than previously established, according to a study published online ahead of print June 24 in Neurology. A composite cognitive test score based on tests of episodic memory, executive function, and global cognition was constructed in a prospective population-based sample of 2,125 participants ages 65 and older. In all, 442 participants developed clinical Alzheimer’s disease over 18 years of follow-up. Lower composite cognitive test scores were associated with the development of Alzheimer’s disease. The magnitude of association between composite cognitive test score and development of Alzheimer’s disease dementia increased from an odds ratio of 3.39 at 13.0 to 17.9 years to an odds ratio of 9.84 at 0.1 to 0.9 years, per standard deviation increment.

Shared biological processes contribute to the risk of migraine and coronary artery disease, but this commonality is restricted to migraine without aura, according to a study published online ahead of print July 2 in Neurology Genetics. Researchers analyzed two large genome-wide association studies of migraine and heart disease. The migraine study involved 19,981 people with migraine and 56,667 people without migraine. Also included were 21,076 people with heart disease and 63,014 people without heart disease. Investigators found a significant overlap of genetic risk loci for migraine and coronary artery disease. When stratified by migraine subtype, this overlap was limited to migraine without aura. The overlap was protective, in that patients with migraine had a lower load of coronary artery disease risk alleles than controls did.

Women with stimulant dependence have significant changes in gray matter volume after prolonged abstinence, but men do not, according to a study published online ahead of print July 14 in Radiology. For this prospective, parallel-group study, 127 age- and sex-matched participants underwent T1-weighted spoiled gradient-echo inversion recovery MRI of the brain at 3 T. Compared with female control subjects, women with stimulant dependence had significantly lower gray matter volume in various brain regions. There were no significant differences in gray matter volume between male control subjects and men with stimulant dependence. Dependence symptom count negatively correlated with gray matter volume in the nucleus accumbens in women. Behavioral approach and impulsivity correlated negatively with frontal and temporal gray matter volume changes in women with stimulant dependence.

The FDA has approved Fycompa (perampanel) CIII for adjunctive therapy in the treatment of primary generalized tonic-clonic seizures. The approval is based on a phase III, randomized, double-blind, placebo-controlled clinical trial of 162 patients taking one to three antiepileptic drugs. Patients treated with Fycompa achieved a 76% median reduction in primary generalized tonic-clonic seizure frequency. In addition, 64% of patients treated with Fycompa had a 50% or greater reduction in primary generalized tonic-clonic seizure frequency versus 40% with placebo. The most frequently reported adverse events in patients treated with Fycompa were dizziness, fatigue, headache, somnolence, and irritability. The adverse event profile was similar to that in the controlled phase III partial-onset seizure trials of the drug. Eisai, headquartered in Woodcliff Lake, New Jersey, manufactures Fycompa.

Imaging biomarkers, including white matter disruption, may help explain some of the heterogeneity in postinjury outcome among children with traumatic brain injury (TBI), according to a study published July 15 in Journal of Neuroscience. Researchers used high angular resolution diffusion-weighted imaging to evaluate the structural integrity of the corpus callosum following brain injury in a sample of 32 children with moderate-to-severe TBI at one to five months post injury, and in healthy control children. A subset of children with TBI had markedly impaired functioning and structural integrity in the corpus callosum. These impairments were associated with poor neurocognitive functioning. The children with impaired functioning also had significantly slower interhemispheric transfer times than the control group did, as measured using event-related potentials.

Longitudinal CSF biomarker patterns consistent with Alzheimer’s disease are first detectable during early middle age and are associated with later amyloid positivity and cognitive decline, according to a study published online ahead of print July 6 in JAMA Neurology. Cognitively normal middle-aged participants enrolled in the Adult Children Study at Washington University underwent serial CSF collection and longitudinal clinical assessment at three-year intervals. A subset of patients underwent longitudinal amyloid PET imaging with Pittsburgh compound B (PiB) in the same period. The researchers found no consistent longitudinal patterns in Aβ40. Longitudinal reductions in Aβ42 were observed in some individuals as early as middle age, and low Aβ42 levels were associated with the development of cortical PiB-positive amyloid plaques. The patterns were more apparent in at-risk carriers of the ε4 allele.

Men with high exposure to formaldehyde at work had an almost three times greater rate of amyotrophic lateral sclerosis (ALS) mortality than men with no exposure, according to a study published online ahead of print July 13 in the Journal of Neurology Neurosurgery & Psychiatry. Researchers examined data for 794,541 men and 674,694 women included in the National Longitudinal Mortality Study who were 25 or older when surveyed. They used a formaldehyde exposure matrix constructed by industrial hygienists at the National Cancer Institute. Exposure to formaldehyde differed between males and females. All men with high-intensity exposure were funeral directors. Few women had high-exposure jobs, and there were no ALS deaths among women with such jobs. Participants with exposure were poorer and less educated than those without exposure.

—Kimberly Williams