Evaluation of two- and three-dimensional visualization for endoscopic endonasal surgery using a novel stereoendoscopic system in a novice: a comparison on a dry laboratory model

Background

Three-dimensional (3-D) stereoscopic vision is theoretically superior to two-dimensional (2-D) vision in endoscopic endonasal surgery. However, only few reports have quantitatively compared endoscopic performance under the two visual conditions. We introduced a newly designed stereoendoscopic system with a “dual-lens and single camera” for endoscopic endonasal surgery and objectively compared the performances under 3-D and high-definition 2-D visualizations on a dry laboratory model.

Methods

Thirty subjects without experience performing endoscopic surgery, computer-simulated training or any 3-D video system were recruited and divided into two groups (Group A and Group B) for performing two different tasks. The novel 4.7-mm-diameter stereoendoscope provided high-definition (HD) images. In Task 1, Group A started the task under the 3-D condition followed by the 2-D condition, and Group B vice versa. In Task 2, Group A started the task under the 2-D condition followed by the 3-D condition, and Group B vice versa. The performance accuracy and speed under the two visual conditions were analyzed.

Results

Significant improvement in performance accuracy and speed was seen under 3-D conditions in the both “3-D first” and “2-D first” subgroups during both tasks (P?<?.001). Regardless of order, the inaccuracy rate and performance time under 3-D conditions was significantly lower than that under 2-D conditions in each subject.

Conclusions

We demonstrated the advantage of 3-D visualization over 2-D visualization for inexperienced subjects. Further quantitative clinical studies are required to confirm whether stereoendoscopy actually provides benefits in clinical settings.     

Different episiotomy techniques, postpartum perineal pain, and blood loss: an observational study

Introduction and hypothesis

The lateral episiotomy technique has been postulated to cause more postpartum perineal pain and blood loss compared to the midline and mediolateral episiotomy technique. The aim of the study was to explore the association with postpartum perineal pain and blood loss between different episiotomy techniques.

Methods

Clinical evaluation of episiotomy was performed 0–3 days after delivery on 300 participating women. Episiotomy technique was classified by millimeter distance from the incision point to the posterior fourchette and by angle from the sagittal plane in degrees. Postpartum perineal pain was scored on a visual analogue scale (VAS) the first day after delivery. Blood loss data were collected from medical charts. Different episiotomy techniques and different episiotomy incision point groups were compared in relation to perineal pain perception and blood loss.

Results

We found no difference between midline, mediolateral, and lateral episiotomy techniques in perineal pain perception the first postpartum day (p?=?0.74) or in estimated blood loss (p?=?0.38). No differences were found in perineal pain or blood loss between midline and lateral incision points. Mediolateral angles were significantly narrower than lateral angles (p?<?0.005). Physicians performed longer episiotomies than midwives (p?<?0.005), but episiotomy angle did not vary between professions (p?=?0.075).

Conclusions

No differences in perineal pain perception the first postpartum day and no differences in estimated blood loss were found when comparing different episiotomy techniques or when comparing midline and lateral incision points.     

Manual mobilization of the wrist: A pilot study in rehabilitation of patients with a chronic hemiplegic hand post-stroke

Study designProspective pilot cohort study, quasi-experimental design.IntroductionRestricted hand mobility, limitation in activities and participation, due to relative immobilization of the hemiplegic hand are frequently reported after stroke.Purpose of the studyTo establish whether manual mobilization of the wrist has an additional value in the treatment of the hemiplegic hand.MethodsEighteen patients received treatment twice a week for a period of 6 weeks. Both treatment groups received therapy based upon the Dutch guidelines for stroke. In the intervention group, a 10-min manual mobilization of the wrist was integrated. The primary outcomes were active and passive wrist mobility and activity limitation. The secondary outcomes were spasticity, grip strength, and pain. Data were collected at 0, 6 and 10 weeks. Statistical analysis was performed using the Friedman's test, related t-test, Wilcoxon test, independent t-test, and Mann–Whitney U-test.ResultsStatistically significant differences were found in the intervention group; between T0 and T2 measurements in active wrist extension (+18°; p < 0.001), in passive wrist extension (+15°; p < 0.001), and in the Frenchay Arm Test (+2 points, 18%; p = 0.038). This significant improvement was not found in the control group. Statistically significant differences were found between the two groups in active and passive wrist extension (p < 0.001; p = 0.002), as well as a change in Frenchay Arm Test (p = 0.01).ConclusionThis study suggests that manual mobilization of the wrist has a positive influence on the recovery of the hemiplegic hand. Replication of the results is needed in a large scale randomized controlled trial.Level of evidence4.     

The effect of jaw relaxation on pain anxiety during burn dressings: Randomised clinical trial

Aim

The purpose of this randomised clinical trial (RCT) was to determine the effect of jaw relaxation on pain anxiety related to dressing changes in burn injuries.

Introduction

Patients hospitalised with burns experience high levels of anticipatory anxiety during dressing changes, which cannot be completely managed by anxiolytic drugs. Nurses as members of the burn care team contribute to pain management by using relaxation techniques as one of the most frequently used approaches to pain anxiety management. However, there is not enough information about the effects of these techniques on pain anxiety of patients with burns. The aim of this study was to determine the effect of jaw relaxation on pain anxiety related to dressing changes in burn injuries.

Methods

It was a randomised clinical trial with a control group. A total of 100 patients hospitalised in Shahid Motahari Burn Centre affiliated with Tehran University of Medical Sciences were recruited by convenience sampling and were randomly assigned to either experimental or control groups using minimisation. With institutional approval and written consent, the experimental group practiced jaw relaxation for 20 min before entering the dressing room. Data were collected by the Burn Specific Pain Anxiety Scale (BSPAS) during July–December 2009 and analysed using Statistical Package for the Social Sciences (SPSS)-PC (17).

Results

An independent t-test showed no significant difference between mean pain anxiety scores in the experimental and control group before intervention (p = 0.787). A dependent t-test showed significantly less pain anxiety after intervention (before dressing) in the experimental group (p < 0.05). Moreover, the independent t-test showed that the post-dressing pain anxiety of the experimental group was less than the control group (p < 0.05). However, the dependent t-test showed no significant difference between before and after dressing pain anxiety (after intervention) in the experimental group (p = 0.303).

Conclusion

Nurses can independently decrease the pain anxiety of patients with burns and its subsequent physical and psychological burden by teaching the simple and inexpensive technique of jaw relaxation. Further research is needed to study the effect of this technique on pain anxiety of patients suffering from other painful procedures.     

Perfusion brain SPECT in assessing motor improvement after deep brain stimulation in Parkinson’s disease

Background

High-frequency deep brain stimulation (DBS) of the subthalamic nucleus (STN) has become an established therapeutic approach for the management of patients with late-stage idiopathic Parkinson’s disease (PD). The aim of the present study was to assess regional cerebral blood flow (rCBF) changes related to motor improvement.

Methods

Twenty-one PD patients underwent two rCBF SPECT studies at rest, once preoperatively in the off-meds state and the other postoperatively (at 6?±?2 months) in the off medication/on stimulation state. Patients were classified according to the UPDRS and H&Y scale. NeuroGam software was used to register, quantify, and compare two sequential brain SPECT studies of the same patient in order to investigate rCBF changes during STN stimulation in comparison with preoperative rCBF. The relationship between rCBF and UPDRS scores was used as a covariate of interest.

Results

Twenty patients showed clinical improvement during the first months after surgery, resulting in a 44 % reduction of the UPDRS motor score. The administered mean daily levodopa dose significantly decreased from 850?±?108 mg before surgery to 446?±?188 mg during the off-meds state (p?<?0.001, paired t test). At the 6-month postoperative assessment, we noticed rCBF increases in the pre-supplementary motor area (pre-SMA) and the premotor cortex (PMC) (mean rCBF increase = 10.2 %, p?<?0.05), the dorsolateral prefrontal cortex and in associative and limbic territories of the frontal cortex (mean rCBF increase = 8.2 %, p?>?0.05). A correlation was detected between the improvement in motor scores and the rCBF increase in the pre-SMA and PMC (r?=?0.89, p?<?0.001).

Conclusions

Our study suggests that STN stimulation leads to improvement in neural activity and rCBF increase in higher-order motor cortical areas.     

Ultrasound-guided regional anesthesia simulation and trainee performance

The objective of this study was to measureand record trainee performance during an ultrasound-guided femoral nerve block (FNB) with a novel high fidelity feedback based simulator device. The method decribes a novel phantom simulator that was built, capable of objectively recording trainee performance and providing visual and audio feedback on the completion of a successful FNB. Overall, 33 subjects were comprised of medical students and residents performed 2 separate ultrasound simulation sessions, and were placed in 1 of 3 groups: light emitting diode and piezoelectric buzzer feedback (LED and PBZ), voice feedback alone, or no feedback. This phantom simulator measured 2 separate performance parameters including; the time (in seconds) to carry out a FNB and the number of needle passes. Each trainee was then evaluated with a global rating scale. Trainee confidence in ultrasound-guided procedures was also recorded.All trainees improved their performance in the simulated block time (p < 0.005) and gained significant confidence in ultrasound-guided procedures (p < 0.0005). The LED and PBZ group improved the most in block time performance (p < 0.0001). Only the LED and PBZ group improved in visualizing the simulated nerve and advancing needle (p < 0.05), as well as simultaneously visualizing the needle reach the simulated nerve target (p < 0.005). For all groups there was robust correlation (−0.72, p < 0.0001) between the time to carry out a FNB and correct visualization of the needle during a successful FNB.The high fidelity ultrasound phantom simulator used in this study, recorded and improved performance, and confidence in ultrasound guided procedures carried out by novice trainees.     

A Prospective Proteomic-Based Study for Identifying Potential Biomarkers for the Diagnosis of Cholangiocarcinoma

Background

Cholangiocarcinoma (CCA) is becoming a common fatal hepatic tumor. Early detection of CCA is hampered by the absence of a sufficiently accurate and noninvasive diagnostic test. Proteomic analysis would be a powerful tool to identify potential biomarkers of this cancer.

Aims

This study aims to identify new protein markers that are specific for CCA using proteomic approaches and to evaluate the performance of S100 calcium-binding protein A9 (S100A9) and chaperonin-containing TCR1, subunit 3 (CCTγ) as diagnostic markers for screening test of CCA.

Methods

Two-dimensional differential gel electrophoresis (2-D DIGE) coupled with matrix-assisted laser desorption/ionization time-of-flight (MALDI-TOF) mass spectrometry were used to analyze and screen biomarker candidates in the proteomes of five human CCA samples and five healthy control samples. Subsequently, two potential biomarkers, S100A9 and CCTγ, were chosen for validation and analysis by immunohistochemical methods using CCA tissue microarrays.

Results

Twenty protein spots were significantly elevated and five protein spots were downregulated in all patients (p?<?0.05). The positive rate was significantly higher in patients with CCA (48?±?35 %) compared with the normal liver control group (5?±?10 %, p?<?0.001), the hepatocellular carcinoma group (15?±?20 %, p?<?0.001), and the cirrhosis group (12?±?16 %, p?<?0.001). A greater proportion of patients with CCA were positive for CCTγ (72?±?18 %) compared with the normal liver control group (43?±?22 %, p?<?0.001), the hepatocellular carcinoma group (45?±?20 %, p?<?0.001), and the cirrhosis group (39?±?25 %, p?<?0.001).

Conclusions

Combined comparative proteomic analysis using 2-D DIGE and MALDI-TOF is an effective method for identifying differentially expressed proteins in CCA tissues. The expression of S100A9 and CCTγ showed promise as novel diagnostic markers for CCA.     

Vergleichsstudie verschiedener 2-D- und 3-D-Sichtsysteme in der minimal-invasiven Chirurgie

Zusammenfassung. Ziel dieser Studie war es, subjektive und objektive Daten darüber zu gewinnen, für welche Arten von Operationen 3-D-Sicht von Vorteil ist, bzw. wo die Vor- und Nachteile von 3-D-Systemen liegen. Ein Parcours mit fünf standardisierten Aufgaben wie N?hen und Greifen wurde aufgebaut, um objektive Zahlenwerte über Ausführungsdauer und Fehlerrate zu erlangen. Bei der Gesamtauswertung aller übungen zeigte sich eine statistisch signifikante (p < 0,001) Fehlerreduktion von 43 % und eine Zeitersparnis von 32 % unter 3-D-Sicht, gegenüber 2-D-Sicht. Im Trainingszentrum für Minimal Invasive Chirurgie arbeiteten die Teilnehmer im Kurs für die laparoskopische Cholecystektomie (LC) und im Kurs für Naht- und Knotentechniken (N&K) im Rotationsverfahren mit 2-D- und 3-D-Sichtsystemen. Anschlie?end bewerteten sie in Frageb?gen die Durchführung der einzelnen Operationsschritte jeweils unter 2-D- und 3-D-Sicht und beantworteten Fragen zum Arbeiten mit dem 3-D-System. Die statistische Auswertung ergab, da? die Durchführung der einzelnen Operationsschritte in beiden Trainingskursen unter 3-D-Sicht signifikant (p < 0,001) besser bewertet wurde, als unter 2-D-Sicht. Bei richtiger Anwendung und normalem stereoskopischem Sehverm?gen, kann der Chirurg vor allem komplexere Aufgaben unter 3-D-Sicht sicherer und schneller bew?ltigen. Schlüsselw?rter: 3-D-Videosysteme – 3-D-Sichtsysteme – Stereoskopie.

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Summary. The aim of this comparative study was to gain subjective and objective data to determine for which operative tasks it is useful to work with 3-D rather than 2-D vision systems and to show the advantages and disadvantages of 3-D systems. A series of five standardized tasks like sewing and tying knots was set up to measure performance times objectively and to count errors. Compared with 2-D vision, the performance time was 32 % shorter and 43 % fewer errors were made under 3-D vision (P < 0.001). In our endoscopic training centre, surgeons involved in basic and advanced laparoscopic courses trained using both 2-D and 3-D vision systems. They subsequently completed analogue scale questionnaires to record a subjective impression of comparative ease of operation tasks under 2-D and 3-D vision, and to identify perceived deficiencies in the 3-D system. In both courses, all operative tasks were judged significantly easier under 3-D vision (P < 0.001). It was concluded that users with a normal capacity for spatial perception can work faster and safer under 3-D vision, especially for more complicated surgical manoeuvres.

     

The Effect of Isolated Phlebectomy on Reflux and Diameter of the Great Saphenous Vein: A Prospective Study

ObjectivesTo evaluate the effect of phlebectomy on venous reflux and diameter of the great saphenous vein (GSV).DesignProspective cohort study.MethodPatients presenting with reflux in the GSV resulting in varicose veins were included in this series. Patients were treated by phlebectomy for dilated and incompetent tributaries of the GSV with conservation of the incompetent GSV. We measured reflux duration (RD), peak reflux velocity (PRV) and the diameter of the GSV using duplex ultrasound imaging at inclusion and 1 month after surgery.PatientsWe included 55 limbs in 54 patients (30 women and 24 men) aged from 37 to 83 (mean age 63) years.ResultsFollowing treatment we observed a significant reduction of the mean RD (0.81s vs. 1.5 s p < 0.01, t-test), mean PRV (120 mm s^?1 vs. 249 mm s^?1 p < 0.01, t-test) and mean diameter of the GSV (SFJ = 5.6 mm vs. 6.7 mm, p < 0.01, sub-terminal valve 4.8 mm vs. 4.4 mm p < 0.05, mid-thigh 5.0 mm vs. 4.2 mm, p < 0.01, knee 4.0 mm vs. 5.3 mm p < 0.01, mid-calf 2.7 mm vs. 4.0 mm, p < 0.01, t-test).ConclusionsWe noted reduced reflux in the GSV after phlebectomy with a significant reduction in RD and PRV. Phlebectomy also led to a significant reduction in GSV diameter. These data suggest that the haemodynamics and the diameter of the SV can be improved by using a treatment focussing on the saphenous tributaries.     

Denervation and atrophy of paraspinal muscles after open lumbar interbody fusion is associated with clinical outcome—electromyographic and CT-volumetric investigation of 30 patients

Background

Different studies have shown that atrophy of paraspinal muscles arises after open dorsal lumbar fusion, and the reasons for this atrophy are still not yet fully clarified. This prospective study investigates the extent of atrophy of the lumbar paraspinal muscles after open lumbar interbody fusion, its possible causes, and their association with clinical outcome measures.

Methods

Thirty consecutive patients were prospectively included (13 male, 17 female, median age 60.5 years, range 33–80 years). Mono or bisegmental, posterior lumbar interbody fusion and instrumentation was performed applying a conventional, open lumbar midline approach. Clinical outcome was assessed by the Short Form (36) Health Survey (SF-36) questionnaire and visual analogue scale. Needle electromyography of paraspinal muscles was performed preoperatively, at 6 and 12 months. Serum values of creatine kinase, lactate dehydrogenase and myoglobin were determined preoperatively, at day 2 after surgery and at discharge. Paraspinal muscle volume was determined by volumetric analysis of thin-slice computed tomography scans preoperatively and 1 year after surgery.

Results

There was a significant increase of electromyographic denervation activity (p =0.024) and reduced recruitment of motor units (p?=?0.001) after 1 year. Laboratory studies showed a significant increase of CK (p?<?0.001) and myoglobin (p < 0.001) serum levels at day 2 after surgery. The paraspinal muscle volume decreased from 67.8 to 60.4 % (p < 0.001) after 1 year. Correlation analyses revealed a significant negative correlation between denervation and muscle volume (K = -0.219, p = 0.002). Paraspinal muscle volume is significantly correlated with physical outcome (K = 0.169, p = 0.020), mental outcome (K = 0.214, p = 0.003), and pain (K = 0.382, p < 0.001) after 1 year.

Conclusions

Atrophy of paraspinal muscles after open, posterior lumbar interbody fusion seems to be associated with denervation, as well as direct muscle trauma during surgery. While muscle atrophy is also correlated with a worse clinical outcome, it seems to be a determining factor for successful lumbar spine surgery.     

Mechanisms of motor vehicle crashes related to burns—An analysis of the German In Depth Accident Study (GIDAS) database

Background

Patients of motor vehicle crashes (MVCs) suffering burns are challenging for the rescue team and the admitting hospital. These patients often face worse outcomes than crash patients with trauma only. Our analysis of the German In-depth Accident Study (GIDAS) database researches the detailed crash mechanisms to identify potential prevention measures.

Methods

We analyzed the 2011 GIDAS database comprising 14,072 MVC patients and compared individuals with (Burns) and without (NoBurns) burns. Only complete data sets were included. Patients with burns obviously resulting of air bag deployment only were not included in the Burns group. Data acquisition by an on call team of medical and technical researchers starts at the crash scene immediately after the crash and comprises technical data as well as medical information until discharge from the hospital. Statistical analysis was done by Mann–Whitney-U-test. Level of significance was p < 0.05.

Results

14,072 MVC patients with complete data sets were included in the analysis. 99 individuals suffered burns (0.7%; group “Burns”). Demographic data and injury severity showed no statistical significant difference between the two groups of Burns and NoBurns. Injury severity was measured using the Injury Severity Score (ISS). Direct frontal impact (Burns: 48.5% vs. NoBurns: 33%; p < 0.05) and high-energy impacts as represented by delta-v (m/s) (Burns: 33.5 ± 21.4 vs. NoBurns: 25.2 ± 15.9; p < 0.05) were significantly different between groups as was mortality (Burns: 12.5% vs. NoBurns: 2.1%; p < 0.05). Type of patients’ motor vehicles and type of crash opponent showed no differences.

Conclusions

Our results show, that frontal and high-energy impacts are associated with a frequency of burns. This may serve automobile construction companies to improve the burn safety to prevent flames spreading from the motor compartment to the passenger compartment. Communities may impose speed limits in local crash hot spots.     

Incidence of Side Effects Using Carbon Dioxide–Oxygen Foam for Chemical Ablation of Superficial Veins of the Lower Extremity

ObjectivesTo determine the incidence of side effects following treatment of varicose veins with carbon dioxide–oxygen (CO₂/O₂) foam sclerotherapy, and to compare results with historical controls using CO₂- or air-based foams.DesignCohort study with prospective data collection, private clinic setting.PatientsThe patient population consisted of one hundred patients, 95% women, age 52 SD 13 years-old, CEAP class C₂EpAsPr.MethodsPatients underwent ultrasound-guided foam sclerotherapy following thermal ablation of saphenous trunks; 1–3% polidocanol and 70%CO₂–30%O₂ gas were mixed in a 1:4 proportion. Volume injected averaged 22 SD 11 (range: 2–46) mL. Vital signs were monitored for 1 h; side effects were recorded up to 24 h post treatment. Incidence of side effects was compared to CO₂- and air-based foam data.ResultsHeart rate decreased from 73 SD 11 at the start to 68 SD 9 bpm (p < 0.001, paired t-test) following the procedure. Systolic and diastolic pressures, 127/75 SD 18/14 mmHg, respiratory rate, 15 SD 4 rpm and pO₂, 98 SD 2%, did not change significantly. Itching (7) or leg pain (24) reporting was similar to that for air-based foam (p = NS). Lack of reported chest tightness and/or dry cough was superior to our previous data with CO₂ or air foam (p < 0.05). Reporting of dizziness (1) was less than that for air-based foam (p = 0.002). The incidence of visual disturbance (2%), was comparable with that for CO₂ (3%) or air (8%) foam, but too few cases were available for meaningful statistical analysis.ConclusionsFoam sclerotherapy using CO₂/O₂ foam was well tolerated by patients and resulted in fewer side effects than similar treatment using air foams.     

Large and giant vestibular schwannomas: does cisterna magna hyperproteinorrhachia influence visual status?

Background

Hyperproteinorrhachia associated with vestibular schwannomas (VSs) may influence visual status independent of the effect caused by raised intracranial pressure. The role of cisterna magna CSF protein levels (CMCP) in determining visual outcome in patients with large to giant vestibular schwannomas (VSs) was prospectively investigated.

Methods

The mean CMCP levels in VSs and control group; and, levels in VSs with or without visual deterioration were compared. Spearman’s rank correlation coefficient tested for relationships between CMCP level with symptom duration and tumour volume (Kawamoto’s method). Vision was regarded as normal when visual acuity was >6/18; and, deteriorated when it was between 6/18 and PL negative in the worse eye. Papilloedema (n?=?26)/secondary optic atrophy (n?=?6) and hydrocephalus (based on Evan’s ratio, mild to moderate: n?=?22; none: n?=?18) were also recorded. The analysis of factors predicting diminished vision was done using logistic regression analysis (p?<?0.05 significant).

Findings

There was a significant difference (p?<?0.001) in mean CMCP levels between VS (456.3 SD 213.6 mg/dl) and control groups (96.3 SD 74.3 mg/dl). The mean CMCP levels in the VS group were also markedly higher than the ventricular mean protein levels. The CMCP levels in patients with visual diminution (<6/18 to PL negative; n?=?23) was 561.4 SD 186.9 mg/dl and those without visual loss (n?=?17) was 314.2 SD 160.8 mg/dl (p?<?0.001). Their grade of visual diminution had a positive correlation with mean CMCP levels (p?<?0.001). There was a negative correlation between total duration of symptoms and CMCP levels (p?<?0.015). Logistic regression analysis using five independent factors (symptom duration, papilloedema/secondary optic atrophy, tumour volume, hydrocephalus and mean CMCP level) revealed that only CMCP level had a significant association with visual diminution.

Conclusion

Elevated cisternal CSF proteins may play an important role in determining visual outcome in large to giant VSs. Ventricular CSF analysis is often unable confirm the presence of VS-associated cisternal hyperproteinorrhachia. High CMCP levels may influence decision-making while instituting a permanent CSF diversion for postoperative hydrocephalus or recalcitrant pseudomeningocoele.     

Changes in calcitropic hormones, bone markers and insulin-like growth factor I (IGF-I) during pregnancy and postpartum: a controlled cohort study

Summary

Pregnancy and lactation cause major changes in calcium homeostasis and bone metabolism. This population-based cohort study presents the physiological changes in biochemical indices of calcium homeostasis and bone metabolism during pregnancy and lactation

Introduction

We describe physiological changes in calcium homeostasis, calcitropic hormones and bone metabolism during pregnancy and lactation.

Methods

We studied 153 women planning pregnancy (n?=?92 conceived) and 52 non-pregnant, age-matched female controls. Samples were collected prior to pregnancy, once each trimester and 2, 16 and 36 weeks postpartum. The controls were followed in parallel.

Results

P-estradiol (E₂), prolactin and 1,25-dihydroxyvitamin D (1,25(OH)₂D) increased (p?<?0.001) during pregnancy, whereas plasma levels of parathyroid hormone (P-PTH) and calcitonin decreased (p?<?0.01). Insulin-like growth factor I (IGF-I) was suppressed (p?<?0.05) in early pregnancy but peaked in the third trimester. Postpartum, E₂ was low (p?<?0.05); prolactin decreased according to lactation status (p?<?0.05). 1,25(OH)₂D was normal and IGF-I was again reduced (p?<?0.05). P-PTH and calcitonin increased postpartum. From early pregnancy, markers of bone resorption and formation rose and fall, respectively (p?<?0.001). From the third trimester, bone formation markers increased in association with IGF-I changes (p?<?0.01). Postpartum increases in bone turnover markers were associated with lactation status (p?<?0.001). During lactation, plasma phosphate was increased, whereas calcium levels tended to be decreased which may stimulate PTH levels during and after prolonged lactation.

Conclusion

The increased calcium requirements in early pregnancy are not completely offset by increased intestinal calcium absorption caused by high 1,25(OH)₂D since changes in bone markers indicated a negative bone balance. The rise in bone formation in late pregnancy may be initiated by a spike in IGF-I levels. The high bone turnover in lactating women may be related to high prolactin and PTH levels, low E₂ levels and perhaps increased parathyroid hormone-related protein levels.     

Eficácia analgésica perioperatória do bloqueio bilateral do plexo cervical superficial em pacientes submetidos à tireoidectomia: estudo clínico randomizado

IntroductionBilateral superficial cervical plexus block (BSCPB) is a common method used for analgesia in thyroid surgery. We investigated the analgesic efficacy of bilateral superficial cervical plexus block in the intraoperative and postoperative periods.Materials and methodsPatients (n = 46) undergoing thyroidectomy were randomly separated into the following 2 groups: the general anesthesia group (GA; n = 23) and the general anesthesia plus BSCPB group (GS; n = 23). The intraoperative analgesic requirement (remifentanil) visual analog scale (VAS) score at multiple time points during the postoperative period (after extubation, at 15 and 30 minutes and 1, 2, 6, 12, 24 and 48 hours post operation) were evaluated. Total tramadol and paracetamol consumption as well as the amount of ondansetron used was recorded.ResultsThe intraoperative remifentanil requirement was significantly lower in the GS Group than in the GA Group (p = 0.009). The postoperative pain scores were significantly lower in the GS Group than in the GA Group at 15 (p < 0.01) and 30 (p < 0.01) minutes and 1 (p < 0.01), 2 (p < 0.01), 6 (p < 0.01), 12 (p < 0.01) and 24 (p = 0.03) hours. The postoperative tramadol requirement was significantly lower in the GS Group than in the GA Group (p = 0.01). The number of patients that used ondansetron was significantly lower in the GS Group than in the GA Group (p = 0.004).ConclusionWe concluded that BSCPB with 0.25% bupivacaine reduces the postoperative pain intensity and opioid dependency in thyroid surgery patients.     

Posttraumatische Syringomyelie

Background

Posttraumatic syringomyelia (PTS) can occur as a rare complication after traumatic spinal cord injury (tSCI) and in cases of delayed diagnosis could lead to disastrous deterioration of both motor and sensory neurological functions.

Objective

To determine influencing factors causing PTS after tSCI.

Material and methods

In a monocentric retrospective two-arm study all patients who were readmitted as inpatients due to increasing neurological impairment caused by PTS (n?=?107) in the period between 1 October 1997 and 31 December 2012 were compared with a randomised group of tSCI patients without PTS (n?=?1590) over the same time period.

Results

Included in the study were 107 patients with an average age of 30.25 years (86 male and 21 female). The most frequent clinical symptoms were changes in sensitivity, pain perception and muscle strength. Within the PTS group, patients older than 30 years had a shorter interval between the onset of SCI and the diagnosis of PTS (p?<?0.001). Both the study and control groups showed a significant age difference at the time of the accident (p?<?0.001). In addition, the number of completely paraplegic (American Spinal Injury Association impairment scale AIS type A) patients was significantly higher within the PTS group (p?<?0.001) and they also had remission to pedestrians significantly less frequently (p?<?0.001). In addition, in a group comparison significantly different neurological levels of paralysis (p?<?0.001) were observed at the time of discharge. Further results showed that younger patients with complete SCI lesions had a higher risk of developing PTS.

Conclusion

The PTS is a rare but severe complication of tSCI, frequently followed by increasing impairment of sensibility, motor function and the autonomic nervous system. As the prognosis of the disease is highly influenced by the time point of the diagnosis, in suspected cases immediate presentation at a specialized center for paraplegic patients is necessary.

     

Treatment of bone marrow edema syndrome with intravenous Ibandronate

Background

In this pilot study, we investigated the therapeutic efficacy of intravenous Ibandronate compared to pain medication on the outcome of bone marrow edemas (BME) of the knee and talus.

Patients and methods

Fifteen patients with a painful BME of the knee and 15 patients with a BME of the ankle, confirmed on MRI, were enrolled and treated with three ambulatory infusions of each 6?mg Ibandronate (group 1). A control group (group 2) of 10 patients with a BME of the knee and 10 patients with a BME of the talus was treated with pain medication and partial weight bearing. Patients were evaluated clinically at baseline and at 1, 3, 6 and 12?months after therapy start with a visual analog pain-scale (VAS) and specific joint scores (Larson knee- and Mazur ankle-score). BMEs were assessed with MRI at baseline and after 6?months in both groups.

Results

In the knee group, the mean VAS pain score decreased from 8.5 at baseline to 1.2 at 12?months (p?<?0.0001) in patients treated with Ibandronate and, respectively, from 8.1 to 4.0 in the control group (p?<?0.001). In the ankle group, the mean VAS pain score decreased from 8.2 at baseline to 0.9 at 12?months (p?<?0.0001) in patients treated with Ibandronate and, respectively, from 7.9 to 3.9 in the control group (p?<?0.001). The mean Mazur ankle score increased from 51 to 91?points (p?<?0.001) in group 1, and from 52 to 72?points in group 2 (p?<?0.01). The mean Larson knee score increased from 54 to 89?points (p?<?0.001) at 12?months in group 1, and from 51 to 70?points in group 2 (p?<?0.01). For both joints, we observed a significant clinical improvement in the Ibandronate treatment group and in the control group, but functional results were significantly more improved in the Ibandronate treatment group. Only the Ibandronate treatment group showed a significant BME regression at the 6?months MRI follow-up.

Conclusions

Intravenous Ibandronate therapy showed significantly better clinical results and BME regression rates on MR-imaging compared to analgesic medication in combination with partial weight bearing in the treatment of BME of the knee and talus and shortens the natural course of the disease.     

Aortoiliac stent deployment versus surgical reconstruction: Analysis of outcome and cost

Purpose:The purpose of this study is to compare complication rate, primary patency, and cost of stent deployment with direct surgical reconstruction for the treatment of severe aortoiliac occlusive disease. Methods:From March 1, 1992, to May 31, 1996, 119 patients receiving treatment for aortoiliac occlusive disease were analyzed after exclusions. Sixty-five patients had stent deployment and 54 patients had surgical reconstruction. Data were evaluated within and between the groups by univariate and multivariate logistic regression, life-table, t-test, and cross tabulation with χ² analysis. Results:There was no significant difference between the groups with regard to demographic features or presenting symptoms (all p values > 0.07). Incidence of procedure-related complications was similar (p = 0.30). However, there were more systemic complications in the surgery group (15 versus 2; RR = 5.5, p < 0.01) and more vascular complications in the stent group (16 versus 3; RR = 12, p < 0.002). Incidence and type of late complications were not appreciably different (all p values > 0.05). Cumulative primary patency rate of bypass grafts was significantly better than stented iliac arteries at 18 months (93% versus 77%), 30 months (93% versus 68%) and 42 months (93% versus 68%); p = 0.002, log rank. Multivariate analysis identified female gender (RR = 4.6, p = 0.03), ipsilateral SFA occlusion (RR = 5.6, p = 0.01), procedure-related vascular complication (RR = 9.7, p = 0.002), and hypercholesterolemia (RR = 5.0, p = 0.02) as independent predictors of bypass graft or stent thrombosis. Mean total hospital cost per limb treated did not differ significantly between surgery and stent deployment groups ($9383 versus $8626, respectively; p = 0.66, t-test). Conclusions:Treatment of severe aortoiliac occlusive disease by surgical reconstruction or stent deployment has a similar complication rate. Mean hospital cost per limb treated is essentially equal. However, cumulative primary patency rate of bypass grafts is superior to stents. Therefore, considering the elements of cost and patency, surgical revascularization has greater value. The benchmark for cost-effective treatment of severe aortoiliac occlusive disease is direct surgical reconstruction. (J Vasc Surg 1998;28:94-103.)     

Harmonic long shears further reduce operation time in transanal endoscopic microsurgery

Background  Previous research indicates that application of 5-mm harmonic shears rather than diathermia significantly reduces operation time in transanal endoscopic microsurgery (TEM). Frequently, however, additional instruments were required to complete resection. We investigated whether the new 5-mm harmonic long shears (H-LS) are better equipped for TEM compared with regular harmonic shears (HS). Methods  Between 2001 and 2006, 162 tumors (117 adenomas, 42 carcinomas, and 3 other tumors; mean distance 6.6 cm, mean area 40 cm²) were excised in 161 patients (82 men, 79 women; mean age 66 years). Results  Eighty-eight resections were performed with HS and 74 with H-LS. Tumor and patient characteristics were similar except for specimen area. Tumors resected by H-LS were on average smaller than those resected by HS (34.4 versus 44.1 cm²; Mann–Whitney U-test: p = 0.027). Mean operation time was 48 min and proportional to area in both groups (univariate analysis of variance p < 0.001). Mean operation time was 54 min using HS and 41 min using H-LS (t-test: p < 0.001). After correction for area, operation time for H-LS was reduced by 14% compared with HS (t-test: p < 0.001). H-LS is singly capable of completing resection in 88% compared with 26% for HS (Mann–Whitney U-test: p < 0.001). Mean blood loss was 16 cc for HS and 3 cc for H-LS (p < 0.001). Morbidity (11%) and mortality (0.6%) were not different between the two groups (Fisher’s exact test). Conclusion  Performing transanal endoscopic microsurgery with 5-mm harmonic long shears reduces operation time compared with regular shears, and completing resection seldom requires other instruments. Presented orally at the 15th International Congress at the European Association of Endoscopic Surgery in Athena, Greece, July 5th 2007.     

The impact of objective assessment and constructive feedback on improvement of laparoscopic performance in the operating room

Objectives The study was carried out to demonstrate the impact of assessment and constructive feedback on improvement of laparoscopic performance in the operating room (OR). Design Sixteen surgical trainees performed a laparoscopic cholecystectomy in the OR. The participants were then divided into two groups. The procedure performed by group 1 was assessed by an experienced surgeon, and detailed and constructive feedback was provided to each trainee. Group 2 received no feedback. Subsequently, all subjects performed a new laparoscopic cholecystectomy in the OR. Both operative procedures were recorded on videotapes and assessed by two independent and blinded observers using a validated scoring system. Main outcome measures Error and economy of movements score assessed during the laparoscopic procedures in the OR. Results No differences in baseline assessments were found between the two groups (t-test, p > 0.5). Surgeons, who received feedback (group 1) made significantly greater improvement in their time to complete the following procedure (independent sample t-test, p = 0.022), error (t-test, p = 0.003) and economy of movement scores (t-test, p < 0.001). Conclusions Surgeons who received constructive feedback made significantly greater improvement in their performance in the OR compared with those in the control group. The study provides objective evidence that assessment is beneficial for surgical training and should be implemented in the educational programmes in the future.