Coccygectomy for coccygodynia: does pathogenesis matter?

BACKGROUND: Severity of vertical impact to the coccyx can range from mere contusion to a dislocated fracture of the coccyx. With early conservative management, most patients have a good prognosis and heal within weeks to months after the initial trauma. Occasionally, persisting symptoms make a surgical intervention with coccygectomy necessary. METHODS: We report on the results of patients surgically managed for traumatically induced, persisting coccygodynia and compare these to patients operatively treated for idiopathic coccygodynia. Sixteen patients with an average follow-up of 7.3 years were evaluated. Of these, eight were surgically treated for traumatic and eight for idiopathic coccygodynia. The clinical results were assessed by means of the Hambly Score and the Oswestry Low Back Pain Disability questionnaire. Patient satisfaction with the postoperative result was assessed by a visual analog scale. RESULTS: Seven of eight (88%) patients treated for traumatically induced coccygodynia had a good or excellent postoperative result, in contrast to only three of eight (38%) patients with idiopathic coccygodynia. The former group had better results in terms of sitting tolerance and general pain intensity as represented by the Oswestry Low Back Pain Disability questionnaire. According to the significantly better clinical results, personal satisfaction was clearly higher in the traumatic group. CONCLUSION: These results suggest that, in patients where all conservative treatment methods work to no avail, particularly those with traumatically induced persisting coccygodynia benefit from surgical intervention with coccygectomy.     

Operative repair in congenital diaphragmatic hernia: How long do we really need to wait?

ObjectiveTo analyze preoperative cardiopulmonary support and define preoperative stability relative to timing of surgical repair for CDH neonates not on ECMO.Study designWe retrospectively analyzed repeated measures of oxygenation index (OI; Paw*FiO₂×100/PaO₂) among 158 neonates for temporal preoperative trends. We defined physiologic stability using OI and characterized ventilator days and discharge age relative to delay in repair beyond physiologic stability.ResultsThe OI in the first 24 h of life was temporally reliable and representative of the preoperative mean (ICC 0.70, 95% CI 0.61–0.77). A pre-operative OI of ≤ 9.4 (AUC 0.95) was predictive of survival. Surgical delay after an OI ≤ 9.4 resulted in increased ventilator days (1.4, 95% CI 1.1–1.9) and discharge age (1.5, 95% CI 1.2–2.0). When prospectively applied to a subsequent cohort, an OI ≤ 9.4 was again reflective of physiologic stability prior to repair.ConclusionOI values are temporally reliable and change minimally after 24 h age. Delay in surgical repair of CDH beyond initial stability increases ventilator days and discharge age without a survival benefit.Level of evidencePrognosis study, Level III.     

Premature ejaculation: do we have effective therapy?

Introduction

Premature ejaculation (PE) is the most common sexual dysfunction, with the majority of PE patients remaining undiagnosed and undertreated. Despite its prevalence, there is a current paucity of data regarding available treatment options and mechanisms. The objective of the current investigation is to review and summarize pertinent literature on therapeutic options for the treatment of PE, including behavioral/psychologic, oral pharmacotherapy, and surgery.

Methods

A pubmed search was conducted on articles reporting data on available treatment options for PE. Articles describing potential mechanisms of action were additionally included for review. Preference was given towards randomized, controlled trials, when available.

Results

PE remains an underdiagnosed and undertreated disease process, with limited data available regarding potential underlying mechanisms and long-term outcomes of treatment options. Psychological/behavioral therapies, including the stop-start, squeeze, and pelvic floor rehabilitation techniques have demonstrated improvements in short-term series, with decreased efficacy with additional follow-up. Topical therapies, which are commonly utilized result in prolonged intravaginal ejaculatory latency time (IELT) at the expense of potential penile/vaginal Hypothesia. Oral therapies similarly demonstrate improved IELTs with variable side effect profiles and include selective serotonin reuptake inhibitors (daily or on demand), phosphodiesterase-5 inhibitors, alpha-1 adrenergic antagonists, and tramadol. Alternative therapies such as acupuncture have shown benefits in limited studies. Surgery is not commonly performed and is not recommended by available guidelines.

Conclusions

PE is a common condition, with limited data available regarding its underlying pathophysiology and treatment. Available therapies include topical, oral, behavioral/psychologic modification, or a combination thereof. Additional research is required to assess the optimal treatment strategies and algorithms as well as to better define the mechanisms for PE and its management.     

Clinical pig liver xenotransplantation: how far do we have to go?

As pigs are currently the preferred species for organ xenotransplantation, initial experience in liver xenotransplantation with wild-type (WT) pigs, advances in the development of genetically modified pigs, and recent studies using livers from them are reviewed. The xenotransplantation of livers from pigs transgenic for the human complement regulatory protein (CRP) CD55 or from α1,3-galactosyltransferase gene-knockout pigs+/- additionally transgenic for the CRP CD46 (GTKO/CD46 pigs) is associated with the survival of approximately 1 week. Satisfactory hepatic function has been documented, lending support to the concept that the pig liver might provide a bridge to allotransplantation. However, although significant features of rejection have not been documented, the development of an immediate thrombocytopenia after graft reperfusion is problematic and leads to spontaneous hemorrhage within the body cavities, native organs, and graft. Current studies are being directed to understand the factors causing the activation, aggregation, or phagocytosis of platelets, in particular the interaction between platelets and liver sinusoidal endothelial cells, hepatocytes, and Kupffer cells. If this problem can be resolved, a clinical trial of pig liver xenotransplantation as a bridge to allotransplantation may be both feasible and justified.     

Normal reference values for glomerular filtration rate: what do we really know?

In nephrology, chronic kidney disease is defined by both proteinuria and measurement of glomerular filtration rate (GFR). This article focuses on GFR and different ways to define its normal reference values. In this context, we compare two perspectives: first the reference values defined by measuring GFR in normal individuals (the 'classical way') and secondly a fixed cut-off value at 60 mL/min/1.73 m2 according to the associated mortality risk (the 'prognostic way'). Following the classical way, we can assert that normal GFR values are largely over 60 mL/min/1.73 m2 in healthy subjects, at least before the age of 70 years. However, we know that GFR physiologically decreases with age, and in adults older than 70 years, values below 60 mL/min/1.73 m2 could be considered normal. Following the 'prognostic way', the fixed cut-off of 60 mL/min/1.73 m2 has been retained in the K-DIGO guidelines. However, we challenge this concept and the fact that the variable 'age' is poorly taken into account in these data. There is an obvious discrepancy between the reference values defined either by the 'classical way' or by the 'prognostic way' which we think could be largely reduced, if age was better taken into consideration in these definitions.     

Low back pain--what do we really know?

Low back pain is one of the most frequent health problems of contemporary people. Therapy is usually conservative and symptomatic because in the most part of cases the etiology remains unknown. Evidence based medicine is putting itself in front also in the field of low back pain diagnosis and treatment. The therapy for low back pain is thoroughly and scientifically rigorously analized by the professionals from the Cochrane Collaboration. There are still not published enough randomized controlled studies to conclude about the effectiveness of most frequently used physical therapy modalities. There is a necessity for additional researching in that field.     

Women in surgery: do we really understand the deterrents?

HYPOTHESIS: Women are deterred from a surgical career owing to a lack of role models rather than lifestyle considerations. DESIGN: Survey. SETTING: University teaching hospital. PARTICIPANTS: Surgery and obstetrics/gynecology attending physicians, residents, and medical students. INTERVENTION: Questionnaire. MAIN OUTCOME MEASURES: Potential deterrents to a surgical career. RESULTS: Men and women had a similar interest in a surgical career before their surgical rotation (64% vs 53%, P = .68). A similar percentage developed a mentor (40.0% vs 45.9%, P = .40). Women were far more likely to perceive sex discrimination (46.7% vs 20.4%, P = .002), most often from male attending physicians (33.3%) or residents (31.1%). Women were less likely to be deterred by diminishing rewards (4.4% vs 21.6%, P = .003) or workload considerations (28.9% vs 49.0%, P = .02). They were also less likely to cite family concerns as a deterrent (47.8% vs 66.7%, P = .02) and equally likely to be deterred by lifestyle during residency (83.3% vs 76.5%, P = .22). However, women were more likely to be deterred by perceptions of the "surgical personality" (40.0% vs 21.6%, P = .03) and the perception of surgery as an "old boys' club" (22.2% vs 3.9%, P = .002). CONCLUSIONS: Men and women are very similar in what they consider important in deciding on a surgical career. Women are not more likely to be deterred by lifestyle, workload issues, or lack of role models. However, the perceived surgical personality and surgical culture is a sex-specific deterrence to a career in surgery for women.     

Left superior vena cava to the left atrium: do we have to change the traditional approach?

Left superior vena cava (LSVC) to the left atrium is a rare congenital cardiac complex, which may appear as an isolated anomaly, or as part of more complex cardiac anomalies. Traditionally, an intraatrial baffle was the preferred surgical technique. Although this technique has proved reliable and successful, acute ligation and extracardiac repair are simpler and easier solutions, requiring less myocardial ischemic time. We present 3 patients who underwent simple ligation and discuss the literature for other extracardiac options of surgical repair. Our patients had short transient congestion in the left upper part of their body that resolved completely after a few weeks, without further complications. We believe that either acute ligation or extracardiac repair is a much simpler yet effective solution to divert the left caval flow to the lesser circulation.