Transscaphoid–transtriquetral–transhamate perilunate fracture–dislocation: case report

A transscaphoid–transtriquetral–transhamate perilunate fracture–dislocation is a very rare pattern of injury among the known spectrum of perilunate dislocations and perilunate fracture–dislocations, and the details of the initial treatment and outcome of this injury have never been reported. We present the case of a 24-year-old, right-handed man, who presented in the emergency department with acute fracture at the waist of the scaphoid, fracture avulsion at the proximal pole of the triquetrum, and fracture of the hamate body with an associated dorsal perilunate dislocation after a fall from 3 m onto his outstretched left hand. Under general anesthesia, closed reduction was attempted with axial traction. After anatomical reduction was achieved, osteosynthesis of the scaphoid was performed using a cannulated screw, and after this was done, percutaneous pinning of the hamate with a K-wire and reconstruction of the scapholunate ligament was performed using an anchor for reinforcement of the scapholunate ligament through a minimally invasive volar approach. A short arm thumb cast splint was applied for 4 weeks, and part-time splinting was continued for another additional 4 weeks. The patient subsequently underwent 3 months of intensive range-of-motion and muscle-strengthening exercises. At the final follow-up examination, 60 months after the initial operation, the range of motion of the left wrist was 145° (extension plus flexion arc), and grip strength, 47 kg, were 91 and 98 % of the values for the unaffected wrist, respectively. Radiographs showed a bony union of the scaphoid, triquetrum, and hamate, and no sign of avascular necrosis in the proximal scaphoid fragment, as well as other carpal bones. No midcarpal or radiocarpal degenerative arthritis was observed, and the normal carpal bone relationships were still maintained, with a scapholunate angle of 49° and a scapholunate distance of 1.5 mm. We recommend closed reduction and minimally invasive volar approach for screw fixation of the scaphoid, as well as percutaneous pinning of the hamate in this case and reconstruction of the disrupted carpal ligaments to minimize the interruption of the blood supply to the carpus and also to obtain rigid fixation during the procedure.     

Erbium, chromium:yttrium–scandium–gallium–garnet laser-assisted sinus graft procedure

The possibility of using lasers in the field of dentistry has been a subject of investigation. There are few reports that any laser systems have been used for bony window osteotomy by direct sinus grafting. In this study, erbium, chromium:yttrium–scandium–gallium–garnet (Er,Cr:YSGG) laser of various laser systems was used for 12 sinus bone grafts in ten patients, and the efficiency of the laser was evaluated according to the osteotomy time and the rate of sinus membrane perforation in the clinical results; the mechanism is described. Eight of the 12 procedures were performed by direct sinus grafting with the Er,Cr:YSGG laser without membrane perforation (perforation ratio 33.3%). Operating time for bony window osteotomy with laser alone was 2–7 minutes [3 min 24 s on average; 3.4 ± 1.4 min (mean ± standard deviation)], and all the implants placed immediately were successful.     

Hypothalamic–pituitary–adrenal function: anaesthetic implications

Surgery, trauma and critical illness evoke a series of hormonal and metabolic changes commonly referred to as the stress response. Activation of the hypothalamic–pituitary–adrenal axis results in increased secretion of hormones such as cortisol. Anaesthesia can suppress adrenocortical secretion either by an effect at the hypothalamus, for example by a decrease in neural input with regional anaesthesia, or by a direct effect on the adrenal cortex, for example by etomidate. For patients undergoing routine surgery an increase in cortisol secretion is unnecessary, uneventful recovery occurs in the presence of circulating cortisol concentrations within the normal range. Patients often present for surgery taking corticosteroids for a variety of medical conditions, but excessive supplementation with hydrocortisone is unnecessary, and can cause side effects. The use of steroids in critically ill patients remains contentious. Furthermore, the immune system and neuroendocrine system are closely related and the metabolic response to surgery involves both hormonal and inflammatory processes. Attempts have also been made to obtund the perioperative inflammatory response.     

The 1–2–3 Approach to Abdominal Packing

Background

Abdominal packing (AP) in damage-control laparotomy (DCL) is a lifesaving technique that controls coagulopathic hemorrhage in severely injured trauma patients. However, the impact of the duration of AP on the incidence of re-bleeding and on intra-abdominal infections in penetrating abdominal trauma is not clear. The objective of the present study was to evaluate the complications related to the duration of AP and to determine the optimal time for AP removal.

Methods

Prospectively collected/retrospectively analyzed data at an urban level I trauma center from January 2003 to December 2010 were used as the basis for this study. Inclusion criteria were adults (≥18?years old) with penetrating abdominal trauma, who had survived both the initial DCL procedure and their first re-laparotomy. All initial DCL patients included in the study underwent abdominal packing for coagulopathic hemorrhage control. The outcome measures of this study were re-bleeding after packing removal, intra-abdominal infection, and 30-day cumulative mortality. We considered time after packing as an independent variable. This was defined as the total amount of time (in days) that the packs were left in the patient’s abdomen. Patients were grouped according to the duration in days of their AP in <1, 1–2, 2–3, and >3?days.

Results

Of 503 patients with penetrating abdominal trauma, 121 underwent DCL and AP. The mean age was 30.1?±?11.5?years, and the male to female ratio was 9:1. The mean Acute Physiology and Chronic Health Evaluation (APACHE II) score was 17.6?±?7.2. The mean Injury Severity Score (ISS) score was 24.9?±?9.1. The right upper quadrant was packed in 39 (32.2?%) patients, retroperitoneum in 70 (57.8?%), pelvis in 13 (10.7?%), and left upper quadrant in 9 (7.4?%). Fifty-one patients (42.1?%) had associated colon injuries and 58 (47.9?%) had small bowel injuries. Twenty-six patients (21.5?%) had AP <1?day, 42 patients (34.7?%) had AP between 1 and 2?days, 35 patients (28.9?%) had AP between 2 and 3?days, and 18 patients (14.8?%) had AP >3?days. The re-bleeding rate in patients packed for 1–2?days compared to those packed for <1?day was a third lower, 14.3?%, (95?% confidence interval [95?%?CI]: 8.06, 20.5) versus 38.5?% (95?% CI: 25.4, 51.5). Conversely, an increasing trend toward intra-abdominal infection occurred as time after packing increased. The infection rate tripled from 16.7?% (95?% CI: 6.6, 26.7) to 44.4?% (95?% CI: 31.03, 57.7) when comparing 1–2?days versus >3?days. Overall mortality was 16.5?%. Of these deaths, 8.26?% were attributable to re-bleeding, and 13.2?% to intra-abdominal infection. Deaths secondary to re-bleeding seemed to decrease with time of AP, whereas intra-abdominal infection deaths increased with time of AP (Chi square for trend p value?=?0.04).

Conclusions

The present study suggests that AP used in the setting of DCL for coagulopathic hemorrhage control should not be removed prior to the first postoperative day because of the increased risk of re-bleeding. The ideal length of AP is 2–3?days, and AP left in longer than 3?days is associated with a significantly increased risk of infectious complications.     

Ileum neovaginoplasty for Mayer–Rokitansky–Küster–Hauser: Review and case series

Objective

To review treatment modalities of Mayer–Rokitansky–Küster–Hauser syndrome, and to present further evidence on the successful use of ileum segment as an additional procedure for the creation of a neovagina.

Bactericidal activity of erbium, chromium:yttrium–scandium–gallium–garnet laser in root canals

The aim of this study was to investigate the effectiveness of the erbium, chromium:yttrium–scandium–gallium–garnet (Er,Cr:YSGG) laser by measuring its bactericidal effect inside root canals experimentally colonized with Enterococcus faecalis. We also determined the optimal conditions for the Er,Cr:YSGG laser to achieve the maximal bactericidal effect. An Er,Cr:YSGG Waterlase^TM laser was used, and its antimicrobial effect was compared with that of sodium hypochlorite (NaOCl) at various concentrations as widely used in clinics. This laser emits photons at a wavelength of 2.78 μm. It is a pulsed laser operating at 20 Hz (20 pulses/s). Significant differences between measurements in the different groups (P < 0.05) were observed, depending on time and power used. The use of NaOCl 5% was the most effective procedure, with NaOCl 0.5% being the least effective; however, laser treatment was as effective as NaOCl 5% when applied at 2 W for 60 s.     

Muir–Torre syndrome

Muir–Torre syndrome is a rare autosomal dominant disorder characterized by sebaceous neoplasms of skin and one or more malignancies of the visceral organs. The sebaceous neoplasms include sebaceous adenoma, sebaceous epithelioma, basal cell epithelioma, and sebaceous carcinoma [1]. Since these sebaceous neoplasms occur rarely, when they are recognized, consideration of Muir–Torre syndrome is important. Recent identification of the main genes made it possible to employ molecular studies in affected patients. A case ultimately diagnosed as Muir–Torre syndrome because of mucoepidermoid carcinoma of the parotid gland, prostate adenocarcinoma and sebaceous cell carcinoma of the upper eyelid will be presented.     

Shwachman–Diamond syndrome

Shwachman–Diamond syndrome (SDS) is a rare autosomal recessive disorder with exocrine pancreatic insufficiency, bone marrow failure and skeletal abnormalities. Patients frequently present failure to thrive, susceptibility to infections and short stature. A persistent or intermittent neutropenia occurs in 88–100% of patients. Bone marrow biopsy usually reveals a hypoplastic specimen with varying degrees of hypoplasia and fat infiltration. Some patients may develop myeloblastic syndrome and acute myeloblastic leukemia. The genetic defect in SDS has been identified in 2002. The osteoporosis is increased in patients with SDS, and also, bone malformations are included among the primary characteristics of the syndrome. The severity and location change with age and sexes. The typical characteristics include the following: secondary ossification centers delayed appearance, metaphysis enlargement and irregularity (very common in childhood, particularly in coastal and femur), growth cartilage progressive thinning and irregularity (possibly asymmetric growth), generalized osteopenia with cortical thinning. We describe a clinical case regarding an SDS patient with severe bone abnormalities and treated surgically for corrective osteotomy. The persistent or intermittent neutropenia that characterized this disease and the consequent risk of infection is a contraindication for short stature correction and limbs lengthening.     

Renin–angiotensin–aldosterone system inhibitors in pediatric focal segmental glomerulosclerosis

Background  

Conventional immunosuppressive therapy for primary pediatric focal segmental glomerulosclerosis (FSGS) is potentially toxic and only moderate evidence supports its effectiveness. Renin–angiotensin–aldosterone (RAAS) inhibition monotherapy is anecdotally used in selected patients as an alternative to conventional therapy.     

Clinical–pathological implication of human leukocyte antigen-F–positive gastric adenocarcinoma

Background

Human leukocyte antigen (HLA)-F is a nonclassical HLA class I molecule that shows aberrant expression in cancer cells. Although the clinical implications of HLA-F expression in cancer patients have been described, the specific significance of this antigen in gastrointestinal cancer remains unclear. The present study examined the expression pattern and clinical implications of HLA-F in gastric adenocarcinoma.

Patients and methods

HLA-F expression was assessed in 179 patients by immunohistochemistry, and its association with clinical parameters including patient survival was analyzed.

Results

HLA-F expression was positive in 30.7% (55/179) of patients and in 50.0% (90/179) of peritumoral infiltrating lymphocytes. HLA-F expression in gastric adenocarcinoma was significantly correlated with the depth of invasion, nodal involvement, and lymphatic and venous invasions (P < 0.01, all). HLA-F positivity of infiltrating cells near the tumor showed no correlation with clinicopathological features. HLA-F–positive patients had a significantly worse prognosis than HLA-F–negative patients (P = 0.012). However, HLA-F expression was not an independent prognostic factor in multivariate analysis.

Conclusions

The present study provides the first evidence that neo-HLA-F expression is of clinical significance in gastric adenocarcinoma. HLA-F expression in gastric adenocarcinoma may promote the aggressive behavior of tumors by suppressing the activity of antitumor immune effector cells.     

Nephrological findings and genotype–phenotype correlation in Beckwith–Wiedemann syndrome

Beckwith-Wiedemann syndrome (BWS), an overgrowth disorder with several congenital abnormalities, encompasses nephrourological anomalies. The objective of the report is to analyze the latter and related genotype-phenotype correlations. The study was a retrospective review of nephrourological investigations and genotype in 67 BWS patients. Imaging and laboratory studies have been correlated with the molecular anomalies typical of BWS. Thirty-eight (56.7%) patients had a total of 61 nonmalignant nephrourological findings, including nephromegaly (n = 24), collecting system abnormalities (n = 14), cryptorchidism (n = 11), nephrolithiasis (n = 5), cysts (n = 5), and dysplasia (n = 1). Four patients had Wilms' tumor, all associated with renal hyperplasia. Renal findings were almost consistent in the BWS(IC1) group, with nephromegaly in all patients and collecting system abnormalities in half of them. BWS(UPD) and negative patients also had frequent anomalies (63.6% and 61.9% respectively), whereas only 36.0% of BWS(IC2) had renal findings (p = 0.003). Cryptorchidism was associated with abdominal wall defects (p < 0.001) appearing more frequently in BWS(IC2) (p = 0.028). Urinary tract infections were observed in 17.9% of patients, with two resulting in life-threatening sepsis. Hypercalciuria was present in 10% of cases. 55.5% of BWS patients have renal findings. Although variegate, these anomalies disclose a genotype-phenotype correlation.     

Vibrations produced during erbium:yttrium–aluminum–garnet laser irradiation

The purpose of this study was to evaluate vibrations induced by an erbium:yttrium–aluminum–garnet (Er:YAG) laser in the non-contact mode and compare the vibrations with different pulse durations and energy parameters. The experiment was conducted on an extracted tooth built up in silicone impression material. The vibrations were measured by piezoelectric accelerometer for a super-short pulse (SSP), a very short pulse (VSP), and a short pulse (SP) at a frequency of 5 Hz for 1 s. For VSP and SP, the energy parameters tested were 200 mJ, 300 mJ, and 400 mJ. Measurements were performed 15 times for each individual irradiation energy level. The highest values of vibrations were measured for SP (0.160 ± 0.04 m/s²), and the lowest were measured for VSP mode at the energy parameter 200 mJ (0.05 ± 0.02 m/s²). There was a statistically significant (P < 0.01) difference between the various laser pulse modes (SSP, VSP, SP) at different energy parameters. At energy levels of 300 mJ and 400 mJ, the least amount of vibration during cavity preparations with the non-contact Er:YAG laser was produced by SSP mode.     

Evaluation of mineral content of enamel prepared by erbium, chromium:yttrium–scandium–gallium–garnet laser

The aim of this study was to evaluate the mineral content of enamel etched at two different power settings with an erbium, chromium:yttrium–scandium–gallium–garnet (Er,Cr:YSGG) laser. Buccal, lingual and mesial or distal surfaces of five premolar teeth were cut, and three enamel slabs were obtained from each tooth. Fifteen enamel specimens were divided into three groups (1 W, 2 W and control) of five specimens each and subjected to Er,Cr:YSGG laser. The mean percentage weights of the five elements [calcium (Ca), potassium (K), magnesium (Mg), sodium (Na) and phosphorus (P)] in each slab were measured by inductively coupled plasma-atomic emission spectrometry (ICP-AES). One way analysis of variance (ANOVA) was used to analyze differences among the groups (1 W, 2 W and control). There were no significant differences among the groups (1 W, 2 W and control) for Ca, K, Mg, Na, or P, or for the Ca/P ratio (P > 0.05). Scanning electron microscopy (SEM) photographs indicated that the surface irregularities increased with increased power setting. Laser treatment did not affect the mean percentage weights of Ca, K, Mg, Na, and P, or the Ca/P ratio, in any group.