Cardio-renal-axis--physiology,pathophysiology, and clinical relevance?

It has been known for years that variations in atrial stretch and intrathoracic blood volume may affect kidney function. Interestingly, little information on this topic can be found in the recent literature of critical care medicine and anesthesiology. Hence, this review focuses on the role of low pressure cardiopulmonary and arterial baroreceptors in the regulation of kidney function and the neuro-endocrine mechanisms behind the so-called "cardio-renal axis". The physiological mechanisms presented in this review may have clinical impact with regard to strategies for the prevention and treatment of acute renal failure and question the usefulness of diuretics to improve kidney function during several shock states.     

The cerebral palsy transition clinic: administrative chore,clinical responsibility,or opportunity for audit and clinical research?

Purpose

The majority of children with orthopaedic conditions in childhood survive to adult life, and there is a need for many of them to transition to adult services. This includes children with disorders such as club foot or developmental dislocation of the hip as well as those with complex syndromic conditions, bone dysplasias or neuromuscular disorders such as cerebral palsy and myelomeningocele. In many tertiary paediatric centres, transition has become a formal process in which clinicians document and communicate the status of patients who have been under their care to ensure a smooth transfer to adult services. The purpose of this report is to support the need for clear communication when children with cerebral palsy transition to adult services and to suggest that this transition represents a significant opportunity for audit and clinical research.

Methods

Some of the factors to be considered in developing a minimum data sheet for the transfer or transition of children with cerebral palsy to adult services are described.

Conclusion

Using the model of adolescents with cerebral palsy transitioning to adult services, orthopaedic surgeons can be encouraged to develop similar methodology and documentation for many other conditions for the purposes of communication, facilitation of transition, audit and clinical research.     

Eagle’s syndrome: embryology,anatomy, and clinical management

Background  

Eagle’s syndrome refers to a rare constellation of neuropathic and vascular occlusive symptoms caused by pathologic elongation or angulation of the styloid process and styloid chain. First described in 1652 by Italian surgeon Piertro Marchetti, the clinical syndrome was definitively outlined by Watt Eagle in the late 1940s and early 1950s.     

Total antioxidant capacity—Relevance,methods and clinical implications

Oxidative stress is pre-empted by an adequate level of antioxidants, which scavenge oxidants when they are produced in excess by different sources, including leukocytes and immature spermatozoa. Enzymatic antioxidants, such as superoxide dismutase, catalase and glutathione peroxidase, and several non-enzymatic antioxidants (proteins, vitamins and minerals), working as oxidant scavengers and cofactors of enzymatic antioxidants have been identified in seminal plasma. The total antioxidant capacity (TAC) is a diagnostic test that can be utilised in the male infertility workup. TAC measures the amount of total antioxidants in seminal plasma. Therefore, it provides an assessment of the reductive potential in seminal plasma. Several studies have investigated the diagnostic application of TAC in various andrology conditions. There is substantial evidence in the literature to show that infertile patients have lower seminal TAC in comparison with fertile men. Moreover, there is a positive correlation between TAC and seminal parameters, such as sperm concentration, motility and morphology. Evaluation of TAC together with reactive oxygen species (ROS) and sperm DNA fragmentation index (DFI) may be beneficial in the diagnosis of male infertility.     

Müller's superior tarsal muscle: anatomy, physiology, and clinical significance

Müller's superior tarsal muscle has been extensively studied by anatomists and physiologists but has been largely ignored by surgeons. This muscle is considered from the standpoint of both gross and finer anatomy. Concepts regarding the uncertain course of its sympathetic nerve supply fibers are reviewed, and "semi-conclusions" are given. The physiology of the muscle, both normal and pathological, is considered in view of both accepted and controversial concepts. Methods of weakening an overactive Müller's muscle medically and surgically are discussed. Some methods that have attempted to utilize the lid-elevating power of Müller's muscle are described, and the muscle's potential in this regard is considered. This small muscle is deserving of more appreciation and of a higher surgical status than it has received in the past.     

Isolated revision meniscal repair – failure rates,clinical outcome,and patient satisfaction

Background

Failure of isolated primary meniscal repair must be expected in approximately 10–25% of cases. Patients requiring revision surgery may benefit from revision meniscal repair, however, the results of this procedure remain underreported. The purpose of this study was therefore to evaluate the outcome and failure rates of isolated revision meniscal repair in patients with re-tears or failed healing after previous meniscal repair in stable knee joints.

Methods

A chart review was performed to identify all patients undergoing revision meniscal repair between 08/2010 and 02/2016. Only patients without concomitant procedures, without ligamentous insufficiency, and a minimum follow-up of 24?months were included. The records of all patients were reviewed to collect patient demographics, injury patterns of the meniscus, and details about primary and revision surgery. Follow-up evaluation included failure rates, clinical outcome scores (Lysholm Score, KOOS Score), sporting activity (Tegner scale), and patient satisfaction.

Results

A total of 12 patients with a mean age of 22?±?5?years were included. The mean time between primary repair and revision repair was 27?±?21?months. Reasons for failed primary repairs were traumatic re-tears in 10 patients (83%) and failed healing in two patients (17%). The mean follow-up period after revision meniscal repair was 43 (± 23.4) months. Failure of revision meniscal repair occurred in 3 patients (25%). In two of these patients, successful re-revision repair was performed. At final follow-up, the mean Lysholm Score was 95.2 (± 4.2) with a range of 90–100, representing a good to excellent result in all patients. The final assessment of the KOOS subscores also showed good to excellent results. The mean Tegner scale was 6.8?±?1.8, indicating a relatively high level of sports participation. Ten patients (83%) were either satisfied or very satisfied with the outcome.

Conclusion

In patients with re-tears or failed healing after previous isolated meniscal repair, revision meniscal repair results in good to excellent knee function, high level of sports participation, and high patient satisfaction. The failure rate is slightly higher compared to isolated primary meniscal repair, but still acceptable. Therefore, revision meniscal repair is worthwhile in selected cases in order to save as much meniscal tissue as possible.

     

Full facial retransplantation in a female patient—Technical,immunologic, and clinical considerations

There is limited experience with facial retransplantation (fRT). We report on the management of facial retransplantation in a facial vascularized composite allotransplant recipient following irreversible allograft loss 88 months after the first transplant. Chronic antibody-mediated rejection and recurrent cellular rejection resulted in a deteriorated first allograft and the patient underwent retransplantation. We summarize the events between the two transplantations, focusing on the final rejection episode. We describe the surgical technique of facial retransplantation, the immunological and psychosocial management, and the 6-month postoperative outcomes. Removal of the old allograft and inset of the new transplant were done in one operation. The donor and recipient were a good immunological match. The procedure was technically complex, requiring more proximal arterial anastomoses and an interposition vein graft. During the first and second transplantation, the facial nerve was coapted at the level of the branches. There was no hyperacute rejection in the immediate postoperative phase. Outcomes 6 months postoperatively are promising. We provide proof-of-concept that facial retransplantation is a viable option for patients who suffer irreversible facial vascularized composite allograft loss.     

Etiology, classification and clinical evaluation of partialthickness tears of rotator cuff

ince partial-thickness tears of the rotator cuffwere described well by Codmanl in 1934, theyhave been extensively discussed in all kinds ofliteratures. Partial-thickness tears of the rotator cuffare now considered to play a more significant role thanpreviously in inducing patients‘ disability. Partial     

Pneumothorax, what kind of therapy is necessary? A clinical overview

Pneumothorax is defined as the accumulation of air in the pleural space. A distinction is made between a primary (idiopathic) spontaneous pneumothorax (PSP), secondary spontaneous pneumothorax (SSP) as well as between iatrogenic pneumothorax and traumatic pneumothorax. Primary spontaneous pneumothorax (PSP) occurs mainly in otherwise healthy people (mainly tall and thin young men) without any clinical sign of lung disease. In contrast, secondary pneumothorax (SSP) mostly occurs in patients with diagnosed and clinically manifested lung disease and is most frequent in older subjects (> 50?years). Smokers have a higher risk of developing pneumothorax. Most pneumothorax cases require a therapeutic intervention using thorax drainage. Observation alone is recommended for only those few patients suffering from pneumothorax without clinical symptoms. Although simple needle aspiration is often recommended as a first-line treatment, our clinical experience shows no advantage for most of the patients. All patients with symptomatic pneumothorax should be treated with immediate intercostal tube drainage. In the surgical therapy of pneumothorax, VATS (video-assisted thoracic surgery) is the current effective standard treatment. Open posterolateral thoracotomy is the recommend approach rather than the minimally invasive procedure in patient with serious illness or complications. The aim of both interventions is to reduce the recurrence rate of pneumothorax as much as possible.     

Adult-onset idiopathic hypogonadotropic hypogonadism： possible aetiology, clinical manifestations and management

We are doctors from Peking Union Medical College Hospital, Beijing, China. Male idiopathic hypogonadotropic hypogonadism （IHH） is a congenital disease that manifests as small testes, a short penis and no pubertal development. Some patients exhibit cryptorchism and ambiguous genitalia [1]. IHH has been reported being caused by gene mutations in KAL-1, FGFR1, GnRHR, GPR54, and several other ligands and receptors [2]. For these patients, gonadotropins or testosterone is the primary choice of therapy. However, adult-onset IHH,     

Colorectal clinical pathways: a method of improving clinical outcome?

OBJECTIVE: Clinical pathways are intended to improve the quality of care. In March 2001, our unit implemented a pathway for patients undergoing major colorectal surgery. The aim of this study was to assess its impact on the quality of patient care. METHODS: We reviewed 204 patients managed using this pathway in 2001, and compared their outcomes with those of a control group of 204 patients who had undergone similar procedures the year before. The endpoints measured were postoperative morbidity, length of stay and readmission rates. RESULTS: Both groups were similar in terms of patient demographics, diagnosis, and nature of surgery performed. In the study group, 61% of patients underwent elective surgery compared with 62% in the control group. The incidence of postoperative morbidity in the study group was 20% compared with 33% in the control group (p = 0.003). The rate of readmission as a result of surgical complications was 6% in the study group versus 13% in the control group (p = 0.029). The average length of stay was 10.4 days in the study group and 12.1 days in the control group (p = 0.105). CONCLUSION: The introduction of a colorectal clinical pathway significantly improved the outcome of patients undergoing major colorectal surgery.     

Electrophysiological evaluation of phrenic nerve injury during cardiac surgery – a prospective,controlled, clinical study

Background

According to some reports, left hemidiaphragmatic paralysis due to phrenic nerve injury may occur following cardiac surgery. The purpose of this study was to document the effects on phrenic nerve injury of whole body hypothermia, use of ice-slush around the heart and mammary artery harvesting.

Methods

Electrophysiology of phrenic nerves was studied bilaterally in 78 subjects before and three weeks after cardiac or peripheral vascular surgery. In 49 patients, coronary artery bypass grafting (CABG) and heart valve replacement with moderate hypothermic (mean 28°C) cardiopulmonary bypass (CPB) were performed. In the other 29, CABG with beating heart was performed, or, in several cases, peripheral vascular surgery with normothermia.

Results

In all patients, measurements of bilateral phrenic nerve function were within normal limits before surgery. Three weeks after surgery, left phrenic nerve function was absent in five patients in the CPB and hypothermia group (3 in CABG and 2 in valve replacement). No phrenic nerve dysfunction was observed after surgery in the CABG with beating heart (no CPB) or the peripheral vascular groups. Except in the five patients with left phrenic nerve paralysis, mean phrenic nerve conduction latency time (ms) and amplitude (mV) did not differ statistically before and after surgery in either group (p > 0.05).

Conclusions

Our results indicate that CPB with hypothermia and local ice-slush application around the heart play a role in phrenic nerve injury following cardiac surgery. Furthermore, phrenic nerve injury during cardiac surgery occurred in 10.2 % of our patients (CABG with CPB plus valve surgery).