Editorial Commentary: To Scope or Not to Scope: Labral Tears in the Early Arthritic Hip

As hip arthroscopy is increasingly performed, the indications for surgery still remain unclear. How much arthritis is too much? How do we judge this? At this juncture, we need to better define inclusion and exclusion criteria in our studies, and further studies are needed to shed light on which patients are the best candidates for this procedure.     

Changing perceptions of beauty: a surgeon's perspective

Beauty is a mystery that has been with us for ages. Scholars and scientists have investigated its roots and effects, and its presence is ubiquitous. Has the construct of beauty changed over time? Is our sense of beauty learned or innate? What IS beauty, and can we quantify it? A substantial amount of work supports a Darwinian theory of selection, which predicts a survival advantage based on physical attractiveness. However, there is evidence that certain perceptions of beauty change with time. Indeed, the recent globalization of modern society has wrought changes in our perceptions of beauty. Are patients electing cosmetic surgery procuring a survival advantage, or are they bypassing genetics and setting a new standard for beauty? As facial plastic surgeons, we must be poised to respond to this metamorphosis and understand its roots. Although there is some equivocation and debate about this elusive subject, it is our duty to stay abreast of the current dynamic to make sound judgments that are in the best interests of our patients.     

First colored illustration and detailed description of hermaphroditism by a Turkish surgeon, Serefeddin Sabuncuoğlu, in the 15th century

Cerrahiyyetü'l-Haniyye (Imperial Surgery), written by the surgeon Serefeddin Sabuncuo?lu in the 15 century, is the first illustrated surgical book in Turkish-Islamic literature containing human figures. Sabuncuo?lu had begun a new era by demonstrating for the first time the application of many surgical methods on human beings, with illustrations in the style of miniatures in his handwritten work. This was a first in medical history, and, owing to this property, Sabuncuo?lu's book was one of the most important original works of that period. In this study in which we aim to examine Sabuncuo?lu's surgical book, in particular with regard to the disease of hermaphroditism, we first demonstrated the historical development of the subject through general sources. From sources concerning Sabuncuo?lu, we gathered information on his life and works. Then, examining the information on hermaphroditism in Sabuncuo?lu's work, we discussed this information in light of our current knowledge.     

The IgA nephropathy treatment dilemma

Although IgA nephropathy (IgAN) is the most common form of primary glomerulonephritis worldwide, our understanding of the pathogenesis of this complex disease remains limited. IgA nephropathy may appear with a variety of clinical presentations, a number of different clinical and histopathologic risk factors for progressive renal disease, and a very variable course over time. Thus, it is not surprising that a single therapeutic treatment plan has not been established. Many of the studies dealing with IgAN are retrospective, lack statistical significance, or have confounding designs, which hinder their general acceptance. Nevertheless, a number of well-designed studies have been performed. This paper reviews currently available therapeutic options for IgAN. It attempts to address several important questions: Why do we treat patients with IgAN? How do we decide which patients should be treated? What are the general treatment guidelines for all IgAN patients? What is the role of specific therapy such as fish oils, tonsillectomy, and immunosuppression in the treatment of patient with IgAN? It also addresses several on-going trials and goals for future therapeutic studies for IgAN patients.     

Zur Meßsicherheit der oszillometrischen Blutdruckmeßgeräte Dinamap 1846 und HP M-1008B

Using the PTB simulator, which emits real signals from patients, we examined the precision of the oscillometric blood pressure measurement with the Dinamap 1846 (Critikon) and the HP M-1008B (Hewlett Packard). For this purpose we simultaneously registered invasive arterial pulsewave, cuff pressure and cuff pressure oscillations of 20 patients from our intensive care unit and stored them in the database of the simulator. The invasive reference blood pressure values were determined following the recommendations given by the Association for the Advancement of Medical Instrumentation. The invasive system showed a cut-off frequency of 35?Hz; the damping constant was 0.21. With 49 record signals from patients we carried out 15 simulated measurements each. From a total of 49 bio-signals from patients the Dinamap 1846 was able to process 41 signals and the HP M-1008B 47 signals. The mean error of the oscillometric blood pressure measurement of the systolic, diastolic and mean arterial pressure amounted to ?2.50?mmHg, 3.35?mmHg (P<0.05) and 1.51?mmHg with the Dinamap 1846 and to ?8.5?mmHg (P<0.001), ?5.15?mmHg (P<0.001) and ?5.58?mmHg (P<0.001) for the HP M-1008B. The 95% confidence limit for the systolic, diastolic and the mean arterial pressure amounts to 56?mmHg, 30?mmHg and 35?mmHg for the Dinamap 1846 and 50?mmHg, 38?mmHg and 35?mmHg for the HP M-1008B. The differences between that two instruments could be caused by the different algorithms for the calculation of blood pressure values and different artefact detection and elimination techniques. The results of the performance tests we achieved with the PTB simulator correspond to the results of other clinical examinations. The American Association for the Advanecement of Medical Instrumentation recommends a maximum mean error of 5±8?mmHg. None of the examined instruments lay within these limits. Due to the systematic and stochastic errors, we think that the Dinamap 1846 (Critikon) and the HP M-1008B (Hewlett Packard) do not achieve performance levels that are adequate for measuring critically ill patients.     

Engineered growth factors and cutaneous wound healing: Success and possible questions in the past 10 years

In the past 10 years, many engineered growth factors, including recombinant human epidermal growth factor, basic fibroblast growth factor, and platelet‐derived growth factor, have been produced and used in the clinic. After screening the results from different centers, some results are found to be encouraging, while others are discouraging. Although the interpretation of these results may depend on your perspective, it may also depend on different criteria, different wounds, and even different aims. In this article, successful experiences and failures concerning the use of growth factors and cutaneous wound healing are summarized. Based on this information and our clinical experience, we address people's concerns such as whether growth factors have altered clinical practice thus far and whether growth factor treatments have solved all problems involved in wound healing. Is there a need for exogenous application of growth factors in acute or chronic wounds, and if so, is it safe to use growth factors to promote wound healing? Last, can we achieve perfect wound healing in those wounds treated with growth factors?     

Grenzen der Medizin – Medizin als Arzt ohne Grenzen

In western medicine, borders of life are increasingly pushed to its limits. A patient who was inoperable a few years ago can nowadays successfully be operated. High-risk patients can be treated with enormous efforts and high cost. But where are the limits in medicine? Is everything we are capable of doing also beneficial for the patient? Looking at Africa can broaden our horizon. The situation in South Sudan is complicated. Only a quarter of the population has access to basic health care. In 2010 more than 588,000?patients were treated by Doctors without Borders (??Médecins sans Frontières??). I worked with this organisation at a clinic in Pieri, South Sudan, in 2009. This was the only access to health care for more than 160,000?people. At this clinic, 10?international and 110?national staff treated up to 4,000?patients/month. In order to make a diagnosis, we had only our experience and senses to rely on. During 2009, there were also a large number of intertribal fightings. More than 2,900 people were killed and there were many wounded. It was a difficult task to treat so many wounded patients with only the limited resources available. Working under difficult and unstable circumstances is a very big challenge. But even then, one can gather invaluable medical experience. For many of the patients in South Sudan, much could be achieved with our presence and very simple means. Western medicine can offer a wide range of therapeutic options. However, we should ensure that basic health care is accessible to all people of the world, which itself is one of the largest challenges.     

Patients treated by peritoneal dialysis: a heterogeneous group of patients. Profile of PD patients

Often, one gathers together under the denomination "peritoneal dialysis" patients with various clinical profiles. To quantify this "heterogeneity" we analysed the clinical characteristics of 32,975?patients treated by dialysis at 31?December 2008?in 22?French regions, participating to the REIN registry. This cross-sectional study confirms our initial hypothesis of a great heterogeneity of patients' profiles in peritoneal dialysis. As in hemodialysis, there is a gradation between modalities: from assisted continuous ambulatory peritoneal dialysis which concerns the frailty patients to autonomous automated peritoneal dialysis for more healthy patients, through assisted automated peritoneal dialysis and autonomous continuous ambulatory peritoneal dialysis.     

Challenges in recertification

We must now face perhaps one of the great changes that is emerging in our practice of medicine of this century: recertification, based not on testing of cognitive skills, but focused on a quality assurance program for clinical performance and satisfactory outcome criteria. Certification is not the same as recertification; each serves a necessary function. For recertification we need to be able to assess physician performance in practice. Standard testing practices in graduate medical education work well in the setting for which they were developed. However, we now need to devise better ways to measure the continuing accrual of knowledge and the consequences of the application of that knowledge in the practice of modern medicine. How can such a determination be made? Who will administer the programs? How can we as physicians assure the public that we are capable of maintaining high standards of performance throughout a physician's practice career?     

Humanitarian aesthetic surgery

Must a face be disfigured by a terrible tropical disease, in order to make us realise that the well being of our gesture is aesthetically acceptable? Must our reparative motivation remain the only trace of our skill and our humanity? During a plastic surgery mission, so-called humanitarian mission, can this surgery be aesthetic? Can aesthetic surgery be humanitarian? We learnt from aesthetic surgery on humanitarian missions, that aesthetic is only a technic to assist the reparation aspect. There is no need to justify aesthetic by reconstruction, because aesthetic belongs, in its entirety, to reparation. There is no need either to feel guilty, when our technical gesture is aesthetic, since what really motivates our intervention is not for us to decide. Is the reparation of the cleft lip of a little Asian girl, a reparation gesture or only an aesthetic approach? You may think that this will be a reparation gesture, because it will be more "popular" or because you will reconstruct the muscular belt. This child will most probably look for a more beautiful or aesthetic lip (in any case, she ignores the intricacies of facial growth principles). Therefore, it will be an aesthetic intervention. Never mind the motivation, since your technic will be the same, and you will try to do your very best and the most aesthetically you can. Only the very intention behind an intervention will decide whether it is an aesthetic or a plastic intervention, whereas your technical gesture will remain the same. All this illustrates that our definitions are of a minor importance, compared with the mere satisfaction of our little Asian girl, which, hopefully, will be a "beautiful" satisfaction. In fact, we have learnt not to do aesthetic surgery, but to give an aesthetic approach to our surgery, even during our humanitarian missions. The form aesthetic surgery will take is very subjective and only the final result will have the last say. Hopefully this surgical result will be aesthetically and humanly acceptable.     

Toward a common language: surgical wound bed preparation and debridement

Wound management encompasses a number of disciplines. As new concepts and innovative technologies develop within this exciting field, it is important to share them in spite of the divergence of clinical perspectives between the expert disciplines. One such divergence exists between surgeons and nonsurgical wound specialists. As a result, there is a need to develop a common language between these two groups. How can we develop a common language that unites surgical expertise within medical wound management? One route may be through the principles of wound bed preparation, which we believe have great potential for the communication of effective surgical techniques. Another is through sharing our concepts of surgical debridement as it is applied to different wounds by a variety of surgical disciplines. In this monograph, we try to bring these two themes together. We discuss how wound bed preparation has added to our understanding of the pathophysiology of the nonhealing wound and has provided us with some general clinical concepts. We discuss what role debridement, and then specifically surgical debridement, has to play within wound bed preparation, before analyzing the importance of surgical debridement in tissue preservation and the control of infection. We finally look at ongoing work that examines the cost of various surgical debridement techniques. We will also review a new hydrosurgery system (VERSAJET^®, Smith and Nephew, Hull, UK), which we believe has an important role to play in the surgical preparation of the wound. We also expect that this paper will remind our medical colleagues about the critical role played by surgery in wound management.     

Fructose intake as a risk factor for kidney stone disease

Taylor and Curhan report that consumption of fructose is independently associated with an increased risk of incident kidney stones. What could be the mechanisms underlying the relation between fructose intake and stone risk? And how should we incorporate this finding into the dietary advice that we give to our patients to prevent kidney stone formation?     

Is proximal femoral nailing a good procedure for teaching in orthogeriatrics?

Background

Proximal femoral nailing is a common operation in orthogeriatrics and a highly standardized procedure. For teaching purposes, this operation is often performed by residents and supervised by attending physicians. The objective of this study is to investigate if teaching this operation influences the surgical in-house complication rate.

Patients and methods

All patients who received a proximal femoral Targon PF nail (Aesculap AG, Tuttlingen, Germany) for trochanteric fractures were included in a cohort at our urban academic teaching hospital between 1998 and 2010. To evaluate potential effects of patient age, we separately analyzed several age groups. Complications including wound infection, hematoma, intraoperative malreduction or implant malpositioning causing revision, pain, cut-out and readmission due to nonunion were recorded.

Results

Our collective consists of 1,516 patients (m/f: 410/1,106). The mean age was 78.7?years (range: 19–103?years). The overall complication rate was 7.9?%. In 857 cases operated by attending physicians, the complication rate was 6.9?%. However in the 659 operations performed by residents, we found a higher complication rate of 9.3?%. Further investigating this difference by χ² test, we found no significance (p?=?0.09). Whilst analyzing the complication rates for the different age groups, we did not find a statistically significant difference except in the age group between 71 and 80?years, for which the odds ratio indicated a 2.6-fold increased complication risk for operations performed by residents (p?=?0.01). Further analysis revealed that this increased complication rate was mainly due to increased numbers of cut-out.

Conclusion

We conclude that proximal femoral nailing is an operation suitable for teaching purposes. However, patients between 71 and 80?years of age seem to be at an increased risk for cut-out if operated by a resident.     

Humanitarian surgical mission. Coming home

Every mission questions our motivation, our skills, and our efficiency through the discovery of a disconcerting world. Three points should be considered to keep a lucid commitment: to evaluate what we have done, which requires modesty; to testify to the courage, the beauty, the violence we have seen; to seek a meaning to the mission beyond the surgical frame: questioning our selves; isn't there a mission going farther the mission?     

Why should I change my practice of anaesthesia: neuromuscular blocking agents

BACKGROUND: Recently, four neuromuscular blocking agents have been introduced into clinical practice. The drug companies claim that these new drugs offer several important advantages. But is this true? Do the new neuromuscular blocking agents add anything to our clinical practice, and will their introduction really benefit our patients? Or will it only benefit the economy of the companies? PURPOSE OF THE LECTURE: In this lecture I shall try to update you on these new drugs and give you my personal bias on when to use the different (new and old) neuromuscular blocking agents.     

Three-dimensional insights into dermal tissue as a cue for cellular behavior

Scar formation after injury is a big problem, which influences the skin function and esthetic appearances. Recent researchers have hinted many directions, one of which has shown that scar formation is related to the loss of integrity in dermal tissues. The structure of dermal tissue, which contains mostly collagen, is not only crucial for the mechanical stability of skin, but also acts as a dermal template, providing contact guidance for regulating cell behavior and restoring normal structure and function to skin that has been damaged by injury. These findings suggest a series of questions. How does contact guidance regulate cell behavior? What is the three-dimensional (3D) architecture of the dermal tissue? How does the native 3D architecture influence cell behavior in vivo? In this paper, combing our recent research, we will review the recent advances in this field, that is, the phenomenon of contact guidance and explore the possible mechanism behind it.     

Experiences with the Cologne treatment plan in epiphyseolysis capitis femoris juvenilis

From the results obtained we conclude that standardized radiograms in two planes were able to demonstrate the full extent of the basic lesion and thereby to facilitate planning of accurate therapy. Operative fixation of low grade dislocation as inaugurated by Imh?user and intertrochanteric corrective osteotomy of higher grade dislocations, respectively, have been proved useful as well; whether or not the critical angle is to be assumed at 30 degrees cannot be proved by our material and won't be able to be proved until our own longstanding epicritical observations are available as well as the results of patients treated by different regimens. Based on our experiences with patients treated at other places we believe in operative fixation of the "healthy" contralateral hip in accordance with Imh?user. This statement can be made as a result of our experiences with 83 patients suffering from chronic dislocation of the upper femoral epiphysis. In future it appears desirable to concentrate on the problem of primary chondrolysis because chondrolysis as well as the remaining residual deformity after treatment appears to be decisive for the fate of the joint.     

达芬奇系统在门静脉高压症手术中的应用及评价

贲门周围血管离断或联合脾切除术是治疗门静脉高压症最主要外科术式。近年来,随着微创理念及外科器械的进步,腹腔镜贲门周围血管离断联合脾切除术作为我国学者的一项创新并有前景的手术方式,逐渐被国内外学者接受。但受巨脾特点、手术视野、操作空间及患者凝血状态等因素的影响,腹腔镜贲门周围血管离断联合脾切除术仍然是一项高风险、高难度手术。Da Vinci手术机器人有效弥补了腹腔镜技术在视野、操作灵活性等方面的局限性,突破了腹腔镜的应用瓶颈,增加了门静脉高压症微创手术的安全性与可行性。现总结本单位实施的2例达芬奇门静脉高压症手术的过程及结果,为Da Vinci手术机器在本疾病的应用提供浅薄的经验,供外科同道参考借鉴。     

Unterschiedliche Hauptverletzungszonen des schwerverletzten Zweiradfahrers

Background

The incidence of severely injured bicyclists and motorcyclists is nearly the same; however the pattern of injuries seems to vary. The aim of this retrospective study was to differentiate the pattern of injuries in these two collectives of severely injured two-wheeled drivers.

Methods

Over a period of 80 months, we recorded all injuries of severely injured bicyclists and motorcyclists (Injury Severity Score [ISS] ≥?16) after admission in our emergency room. Documentation was performed after diagnostics were completed. Prior to beginning the study, we defined injury regions to which the individual injuries were assigned.

Results

There were 33 bicyclists with a mean ISS of 30.8?±?14.5 and 202 injuries compared to 19 motorcyclists with a mean ISS of 33.4?±?17.3 and 96 injuries. Injuries of the head were significantly more common in bicyclists (p?<?0.001). Especially injuries of the brain led to this difference. In motorcyclists, fractures led to significant differences in the regions of the upper and lower extremities (p?<?0.001). Injuries of the thorax, spine, abdomen, pelvis and other injury consequences were not significantly different.

Conclusion

The most relevant injury region of severely injured bicyclists was the head, whereas extremity injuries were the most frequent reason for classification as “severely injured” (ISS ≥?16) in severely injured motorcyclists.     

Famous faces activate contextual associations in the parahippocampal cortex

The parahippocampal cortex (PHC) has been traditionally implicated both in place processing and in episodic memory. How could the same cortical region mediate these cognitive functions that seem quite different? We have recently proposed that the PHC should be seen as more generally mediating contextual associative processing, which is required for both navigation and memory. We therefore predicted that any associative objects should activate the PHC. To test this generalization, we investigated the extent to which common stimuli that are nonspatial by nature, namely faces, activate the PHC, although their perception is typically associated with other cortical structures. Specifically, we compared the activation elicited by famous faces, which are highly associated with rich pictorial and contextual information (e.g., Tom Cruise) and are not associated with a specific place, with activation elicited by unfamiliar faces. Consistent with our prediction, contrasting famous with unfamiliar faces revealed significant activation within the PHC. Taken collectively, these findings indicate that the PHC should be regarded as mediating contextual associations in general and not necessarily spatial or episodic information.