A mini-incision carpal tunnel release technique to prevent pillar pain: A technical note

Pillar pain represents one of the most common complications of classic open carpal tunnel release (CTR). This complication causes a sense of discomfort worse than the compression syndrome itself. We, herein, introduce a new treatment method for CTR through a mini-incision, which allows subcutaneously cutting the transverse carpal ligament (TCL) and releasing the median nerve without neurovascular complications. This mini-incision approach can allow the direct visualization and preservation of the thenar motor branch in those rare cases where it has an aberrant origin. For the past 10 years, we have consecutively performed this technique in the surgical treatment of 318 patients with the diagnosis of primary CTS, without developing any neurovascular and tendon injuries as well as pillar pain.     

Tumor necrosis factor-alpha -308 promoter polymorphism contributes independently to HLA alleles in the severity of rheumatoid arthritis in Mexicans

The aim of this study was to determine the frequency and potential relevance of the promoter polymorphisms of the tumor necrosis factor-alpha (TNF-alpha) in the severity of rheumatoid arthritis (RA) in Mexicans. HLA-DR and polymorphisms at positions -238 and -308 of TNF-alpha gene were determined in 137 Mexican RA patients (44 with severe and 93 with non-severe RA) as well as in 169 healthy controls (99 were typed for HLA-DR). We observed an increased frequency of HLA-DR4 in severe RA compared to healthy controls (pC=0.02, OR=2.33). TNF polymorphism analysis showed a significant increased frequency of TNF -238 GG genotype in the whole group of RA patients when compared to healthy controls (pC=0.007, OR=4.71). When the analyses were carried out separately in severe and non-severe RA patients, the increased frequency of -238 GG genotype only was observed in patients with non-severe forms of the disease. Analysis of -308 polymorphism showed increased frequency of -308 T2 (A) allele in severe RA when compared to non-severe disease (pC=0.011, OR=3.29) and to healthy controls (pC=0.002, OR=3.97). The data demonstrate that -308 T2 (A) allele is associated with susceptibility to develop severe RA in Mexicans. This association could be independent from HLA-DR alleles and might be used as a prognostic marker for severe RA.     

Variation in smoking-related lung cancer risk factors by cell type among men in Argentina: a case-control study

A high mortality rate for lung cancer (62.7 per 100,000) is found in Rosario, Argentina. To investigate the reasons for this high rate, a case-control study was carried out among 215 male cases with histologically confirmed lung cancer and 433 hospitalized controls for conditions unrelated to tobacco consumption. Odds ratios (OR) of squamous cell (SQ), adenocarcinoma (AD), and small cell (SM) carcinoma of the lung associated with different characteristics of the smoking habit were quantified. Ninety-eight percent of the cases had smoked regularly. Smokers were significantly younger at diagnosis than ex-smokers (P<0.0001), a pattern consistent for all cell types. The ORs for the heaviest cf the lowest consumption categories were 15.3 for SQ, 11.6 for AD, and 11.6 for all lung cancer (P<0.0001). Risks associated with the use of unfiltered cigarettes were three to five times higher than those for filtered cigarettes, depending on cell types. For ex-smokers, risks after 10 years of nonsmoking were about 12 times lower than those of current smokers (P<0.001). To halt further increases in lung cancer, preventive measures in Argentina should be directed primarily towards smoking control.Ms Pezzotto and Drs Bay, Morini, and Poletto are with the Institute of Immunology, School of Medicine, National University of Rosario, Argentina. Dr Mahuad is with Hospital Italiano Rosario, Argentina. Address correspondence to Ms Pezzotto, Inst. Inmunologia, Facultad de Medicina, Santa Fe 3100, 2000 Rosario, Argentina.     

Determinants of hospital admission among HIV-positive people in British Columbia

BACKGROUND: This study was initiated to evaluate the demographic and clinical determinants of admission to hospital among HIV-positive men and women receiving antiretroviral therapy in British Columbia. METHODS: The analysis was restricted to participants enrolled in the HIV/AIDS Drug Treatment Program between September 1992 and March 1997 who had completed an annual participant survey, had a viral load determination and had signed a consent form allowing electronic access to their inpatient hospital records. A record linkage was conducted with the BC Ministry of Health to obtain all records of hospital admissions from April 1991 to March 1997. Statistical analyses were carried out using parametric and nonparametric methods and multivariate logistic analyses. RESULTS: The study sample comprised 947 participants (859 men, 88 women). Of these, 165 (17%) were admitted to hospital during the study period from May 1, 1996, to Mar. 31, 1997. The median number of admissions was 1 (interquartile range [IQR] 1-2 admissions), and the median length of stay per admission was 3 days (IQR 1-8 days). Admission to hospital was associated with being unemployed (82% of those admitted v. 58% of those not admitted), being an injection drug user (24% v. 17%), reporting a fair or poor health status (46% v. 29%) and having a physician experienced in the management of HIV/AIDS (31% v. 24%). Examination of clinical determinants demonstrated that hospital admission was associated with a previous admission (72% v. 46%), a high viral load (median 74,000 v. 14,000 HIV-1 RNA copies/mL), a low CD4 count (median 0.16 v. 0.27 x 10(9)/L) and an AIDS diagnosis (44% v. 24%). Multivariate logistic regression analysis revealed that being admitted to hospital was independently associated with being unemployed (odds ratio [OR] 2.64, 95% confidence interval [CI] 1.66-4.20), having been previously admitted to hospital (OR 2.30, 95% CI 1.53-3.46), having a high viral load at baseline (OR 1.45, 95% CI 1.16-1.80), being an injection drug user (OR 1.63, 95% CI 1.02-2.62) and having an experienced physician (OR 1.98, 95% CI 1.29-3.03). INTERPRETATION: Hospital admission among participants in this study was found to be associated with marginalization and poor health status.     

Percutaneous drainage of infected pancreatic necrosis: an alternative to surgery

AIM OF THE STUDY: To describe a technique of percutaneous CT guided catheter drainage of infected pancreatic necrosis and to report the results of this technique compared with those of the conventional surgical treatment and of other percutaneous drainage series. PATIENTS AND METHODS: Between 1992 and 1997, the series included 32 patients who had a severe acute necrotizing pancreatitis with a mean Ranson score of 4.6, scored into grade D (n = 10), and grade E (n = 22), according to the Balthazar radiological staging. Modified Van Sonnenberg 24 F double lumen catheters were used for continuous irrigation and aspiration. RESULTS: Forty-nine drains were inserted for 41 infected necroses and eight abscesses. Among the 32 patients, the proof of infected necrosis was obtained in 26 patients by fine needle aspiration and culture (enterococcus, staphylococcus, pseudomonas). The average delay of catheter insertion was 23 days after onset of pancreatitis; the mean duration of drainage was 43 days, and an average of three catheters per patient was required. Five patients (15%) died, and among the survivors, 16 (59%) presented 21 complications including 14 enterocutaneous or pancreatic fistulas. A subsequent surgical procedure including two necrosectomies was necessary in six patients. CONCLUSION: This study demonstrates that percutaneous drainage of infected pancreatic necrosis with a 15% mortality and 70% success rate, represents an interesting alternative to conventional surgery.     

Recent progress in the curative surgical treatment of stomach cancer

Surgical resection is currently the only potentially curative treatment for gastric cancer. Nodal extension, present in 3/4 of the patients, is related to topography and penetration of the tumor and is progressive, beginning by the perigastric proximal lymph nodes N1 to the perivascular distal nodes N2. A subtotal gastrectomy is possible for distal cancers and total gastrectomy is necessary for cancers of the middle and upper portions. D1 lymphadenectomy is the resection of the N1 perigastric nodes (> 15) and D2 lymphadenectomy is the resection fo the N2 perivascular nodes (> 25). In Japan, 5 year survival after D2 resection is very high, around 60%, but all the series are retrospective with a high proportion of superficial cancers. In several recent European controlled studies, D2 resection is responsible for a high mortality rate (> 10%) and the reported 45% survival is not statistically different from the D1 resection. In Western patients an "in-between" lymphadenectomy without spleno-pancreatectomy can be recommended with analysis of at least 15 nodes, and with a mortality lower than 5%. Pathological analysis of the operative specimen allows to use the new TNM classification where the number of positive lymph nodes is the main independent prognostic factor.     

Total Corporal Contouring with Megaliposuction (120 Consecutive Cases)

The purpose of this study is to present the authors' long-term experience with total corporal contouring with megaliposuction. The evolution of body reshaping in one operative setting including simultaneous head and neck contouring, upper and lower extremity recontouring, and creation of an aesthetic trunk and abdominal form is discussed. Patient evaluation, operative techniques, postoperative management, and long-term results are emphasized. From February 1994 to February 1997, 120 consecutive patients underwent total corporal contouring with tumescent (Hunstad formula)-technique, classic liposuction. There were 10 males and 110 females. The average age of all patients was 28 years. Preoperative evaluation emphasized corporal shape and proportions. No other open procedures were performed simultaneously in these patients. The authors' postoperative regimen is discussed. The average amount of aspirated material in these series was 14,000 ml (range, 8000–20,000 ml). No blood transfusions were required. Complications included only hypopigmentation (N= 2) and postoperative seromas requiring aspiration (N= 12). Follow-up examination took place at 3 months to 3 years, with an average of 14 months. All patients underwent a metamorphosis from an amorphic shape to one that follows the normal body contours and profiles. The goals of megaliposuction are no longer just to reduce body fat and body mass. Individually planned surgery for these patients should be based upon obtaining normal symmetrical body proportions. Total corporal contouring and reshaping can now be safely performed, offering hope and predictable outcomes to this patient population. Patient evaluation, operative technique, postoperative care, and long-term results are presented.     

Effects of selective phosphodiesterase inhibitors on platelet-activating factor- and antigen-induced airway hyperreactivity, eosinophil accumulation, and microvascular leakage in guinea pigs

There is currently interest in the potential use of selective inhibitors of cyclic nucleotide phosphodiesterases (PDE) in the treatment of asthma. In this study we examined the effects of three selective PDE inhibitors, milrinone (PDE III), rolipram (PDE IV) and zaprinast (PDE V), on the broncoconstriction produced by antigen and histamine, the airway hyperreactivity and microvascular leakage after aerosol exposure to platelet-activating factor (PAF) and antigen, and the antigen-induced eosinophil infiltration in guinea-pig lung. Inhaled rolipram (0.01–10 mg ml^–1) inhibited dose dependently the bronchospasm produced by aerosol antigen (5 mg ml^–1) an anaesthetised, ventilated guinea-pigs. Rolipram (10 mg ml^–1) produced maximal inhibition of antigen-induced bronchoconstriction but only partial inhibition of the response to aerosol histamine (1 mg ml^–1). Milrinone and zaprinast (each 10 mg ml^–1) showed weak, or no, inhibitory effects against bronchoconstriction produced by aerosol antigen or histamine. Pretreatment with rolipram (10 mg kg^–1, i.p.) prevented airway hyperreactivity to histamine which develops 24 h after exposure of conscious guinea-pigs to aerosol PAF (500 g ml^–1) or antigen (5 mg ml^–1). The pulmonary eosinophil infiltration obtained with 24 h of antigen-exposure was inhibited by rolipram. In contrast, milrinone and zaprinast (each 10 mg kg^–1, i.p.) failed to reduce either the airway hyperreactivity of the eosinophil accumulation in these animals. Rolipram (1–10 mg ml^–1) reduced the extravasation of Evans blue after aerosol PAF (500 g ml^–1) at all airway levels while a lower dose (0.1 mg ml^–1) was only effective at intrapulmonary airways. Rolipram (0.01–1 mg ml^–1) markedly reduced airway extravasation produced by inhaled antigen (5 mg ml^–1). Zaprinast (1–10 mg ml^–1) was also effective against airway microvascular leakage produced by aerosol PAF or antigen while milrinone (10 mg ml^–1) had no antiexudative effect. These data support previous suggestions that pharmacological inhibition of PDE IV results in anti-spasmogenic and anti-inflammatory effects in the airways and may be useful in the treatment of asthma.