Transmandibular approach to polycentric recurrent pleomorphic adenoma of the parapharyngeal space

Surgery for tumors of the parapharyngeal space PPS) requires adequate exposure to identify and protect vital structures. Thus transcervical and transcervical-transparotid approaches to the PPS may be enhanced by mandibulotomy for better visualisation. We have chosen this approach with single mandibulotomy just in front of foramen mentale and without lip incision. We present a 39 years old male who was undergone surgery for policentric recurrency of a pleomorphic adenoma of the parapharyngeal space.     

Inducible 70 kDa heat shock protein does not protect spermatogenic cells from damage induced by cryptorchidism

Accumulation of inducible heat shock proteins (e.g. Hsp70i) during cellular stress confers thermotolerance, reduces the consequences of damage and facilitates cellular recovery, while abrogation of Hsp70i expression renders sensitivity to apoptosis. Testis translocation into abdominal cavity, which results in temperature elevation, does not induce expression of the Hsp70i proteins. Despite constitutive expression of testis-specific Hsp70 proteins, spermatocytes are very sensitive to damage at elevated temperatures. To test whether Hsp70i protein could protect testes from heat-induced damage, we have engineered transgenic mice that over-express this protein selectively in spermatocytes and spermatids. We demonstrate that the testes of cryptorchid transgenic mice, like those of wild-type mice, exhibit reduced weight and smaller sizes of their seminiferous tubules, disorganization of their germinal epithelium structures, appearance of multinucleated giant cells, and reduced populations of germ cells. The data show that constitutive expression of Hsp70i does not protect the seminiferous epithelium against cryptorchidism-induced damage.     

Intragastric pressure and its relevance to protective cricoid force

Cricoid pressure is frequently used to protect the anaesthetised and paralysed patient from passive regurgitation. Although intragastric pressure (Pga) drives regurgitation, its relevance in the setting of protective cricoid force has been largely ignored. We sought to define the likely range of Pga encountered in the population at risk. We studied 100 consecutive patients presenting for surgery requiring mechanical ventilation. We measured respiratory swings in Pga during mechanical ventilation in the paralysed state following rapid sequence induction (n = 24) and routine induction of anaesthesia (n = 76). Pga (mmHg) in the whole group recorded at end-inspiration (Pga-In) and end-expiration (Pga-Ex) was [mean (SD)]: Pga-In 6.48 (2.60) mmHg and Pga-Ex 3.23 (2.24) mmHg. We found no correlation between Pga and body mass index (r2 = 0.018). These findings have implications for the level of cricoid force required to protect a patient during the induction of anaesthesia.     

HIV vaccine research--South Africa's ethical-legal framework and its ability to promote the welfare of trial participants.

An effective ethical-legal framework for the conduct of research is critical. We describe five essential components of such a system, review the extent to which these components have been realised in South Africa, present brief implications for the ethical conduct of clinical trials of HIV vaccines in South Africa and make recommendations. The components of an effective ethical-legal system that we propose are the existence of scientific ethical and policy-making structures that regulate research; research ethics committees (RECs) that ethically review research; national ethical guidelines and standards; laws protecting research participants; and mechanisms to enforce and monitor legal rights and ethical standards. We conclude that the ethical-legal framework has, for the most part, the necessary institutions, and certain necessary guidelines but does not have many of the laws needed to protect and promote the rights of persons participating in research, including HIV vaccine trials. Recommendations made include advocacy measures to finalise and implement legislation, development of regulations, analysis and comparison of ethical guidelines, and the development of measures to monitor ethical-legal rights at trial sites.     

Editorial Commentary: The Shoulder Transpectoralis Portal for Arthroscopic Latarjet: Medial to the Coracoid Can Also Be a Safe Side!

The all-arthroscopic Latarjet is gaining popularity among shoulder surgeons, although the procedure is technically demanding and potentially dangerous, placing the brachial plexus and axillary vessels at risk when using screws for fixation of the bone block from the front. Matsen once wrote that “lateral to the coracoid is the safe side, while medial to the coracoid is the suicide.” However, creation of a portal medial to the coracoid during arthroscopic reconstruction of the glenoid is needed to permit accurate positioning of the screws (parallel to the glenoid surface) and coracoid bone block (flush to the glenoid surface). Our own clinical experience with the arthroscopic Latarjet over the last decade has shown us that the safety of the arthroscopic medial transpectoralis portal depends on 3 technical considerations: (1) the portal should always be established in an outside-in fashion from anterior to posterior; (2) passing through the pectoralis major muscle with a relatively superficial trajectory, using a switching stick oriented with a 45° orientation toward the tip of the coracoid; and (3) under visual control of the anterior extra-articular subdeltoid space to end up lateral to the coracoid process. If these conditions are respected, surgeons should not worry: medial to the coracoid can also be a safe side! An inside-out technique (introducing a switching stick from posterior to anterior) is forbidden, as this would end up piercing the neurovascular structures. Once the coracoid has been osteotomized and the conjoint tendon retracted distally, all instruments passing though the transpectoral portal are directly in contact with the neurovascular structures. This is why working through the medial transpectoralis portal should be done only with the help of a cannula or half-pipe. Ideally, the transpectoral portal should not be used as a “working portal” but as a “protecting portal” instead, placing a stick or spreader to protect the neurovascular structures. To avoid working through the anterior medial portal, we have proposed a much safer alternative that consists of drilling the glenoid from posterior to anterior (using a guide and remaining inside the glenohumeral joint) and using cortical-buttons (instead of screws) for coracoid fixation. In this modern technique, the transpectoral portal makes the arthroscopic safe as it allows the introduction of a spreader to retract the subscapularis muscle and protect the neurovascular structures during transfer and fixation of the coracoid bone block.     

Resurfacing of a complex upper extremity injury: An excellent indication for the dorsal thoracic fascial flap

We report a case of a 24‐year‐old patient who sustained a mutilating crush injury to the left forearm. After thorough debridement and stabilization of the skeletal injury, the dorsal thoracic fascial flap was used to resurface the circumferential wound, protect the underlying structures, and provide a gliding surface for the exposed tendons. The flap was safely transected during revision surgery, and at 6‐months follow‐up, excellent functional and cosmetic results were achieved. The dorsal thoracic fascia is a thin, durable, and pliable tissue that is based on a long vascular pedicle. We consider the dorsal thoracic fascial flap as a valuable option for coverage of complex upper extremity injuries and highly recommend its use. © 2008 Wiley‐Liss, Inc. Microsurgery, 2009.     

Resurfacing tophaceous gout in the foot with anterolateral thigh flap

We report the case of a 46‐year‐old patient who suffered from huge tophus masses involving the metatarsal joints of the big toes of both feet, with infection and skin necrosis secondary to chronic tophaceous gout. After conventional curettage and debridement of each lesion, a free anterolateral thigh flap (ALTF) was used to resurface the circumferential wound, protect the underlying structures, and provide a gliding surface for the exposed tendons. The flap was safely raised and debulked during revision surgery, and excellent functional and cosmetic results were apparent at the 2‐year follow‐up. We consider ALTF to be a valuable option for the coverage of necrotic skin over tophi after adequate debridement. © 2009 Wiley‐Liss, Inc. Microsurgery 2010.     

Shrinking Upper and Lower Eyelid Skin with a Novel Radiofrequency Tip

BACKGROUND Many subjects wish to have tightening of eyelid skin but are reluctant to undergo aesthetic blepharoplasty surgery. We wanted to perform a small pilot study to test the efficacy and safety of a 0.25-cm² monopolar radiofrequency tip in a prospective noncomparative study as a novel nonsurgical method to safely tighten upper and lower eyelid skin in subjects of differing ethnicity and sex.
METHODS Twenty adult subjects were enrolled in this prospective pilot study. All received symmetrical monopolar radiofrequency treatments in multiple passes to the pretarsal, preseptal, and lateral orbital skin. All subjects wore a protective plastic haptic contact lens to protect their vision during the radiofrequency treatment. (Haptic contact lenses fit over the entire anterior surface of the globe from superior to inferior and medial to lateral fornix. The purpose of using such a large contact lens was to protect the globe itself from radiofrequency energy.) Standardized color digital photography with eyes both open and closed was taken on each visit. Treatment efficacy was evaluated by both the expert observer and the subject at each visit.
RESULTS At 6-month follow-up, according to the expert observer, 26 upper lids (87%) showed 25% or more tightening. Twenty lower lids (67%) showed 25% or more tightening. Two subjects (3.33%) had 51% to 75% upper lid tightening at 6 months. There were no adverse events beyond one subject with minimal corneal epithelial punctate defects on the treatment day. These resolved over several hours.
CONCLUSIONS The use of this new tip was shown to be safe. Effectiveness at shrinking eyelid skin was at best mild to moderate.     

Squeaking in a Delta ceramic-on-ceramic uncemented total hip arthroplasty

Squeaking is one of the main concerns related to the use of ceramic-on-ceramic total hip arthroplasty. Although it has received much recent publicity, most of the previous reports on this complication have been related to the use of the second generation of alumina ceramics combined with a cup having an elevated metal rim to protect the ceramic liner from neck impingement. We report a patient with a third-generation Biolox Delta (CeramTec AG, Plochingen, Germany) ceramic-on-ceramic uncemented total hip arthroplasty without an elevated metal rim in the cup who presented with a squeaking hip at 23 months postoperative. Although this complication was mainly related to a specific design in the literature, this case demonstrates that newer generation of ceramics can also present squeaking.     

Critical incident reporting system in emergency medicine

PURPOSE OF REVIEW: This review summarizes the knowledge of error and of critical incident reporting systems in general and especially in emergency medicine. RECENT FINDINGS: Medicine is a high-risk area and emergency medicine in particular needs consequent use of critical incident reporting systems. We need a safety culture to learn from our mistakes and we need to discuss all mistakes regardless of hierarchical structures in medicine. SUMMARY: The first step in avoiding fatalities in emergency medicine is to accept that errors do occur. The next question is how to prevent errors in medicine and not to search for personal mistakes. We need a culture of error and not a culture of blame. Critical incidents occur in all ranges of medical hierarchical structures. We have to accept the presence of mistakes and we need to recognize them every day to protect our patients.     

Early coverage of deep hand burns with groin flaps

Deep burns of the hands require skin flap coverage in order to protect the exposed vital structures. The groin flap is a safe and effective method of obtaining early closure of these defects. We have used groin flaps to cover deep hand burn defects in nine patients. In each case, groin flaps effectively covered the various defects, such as the volar aspect of the wrist, dorsum of the hand, first web space, thumb, and fingers.     

Enhanced survival during murine gram-negative bacterial sepsis by use of a murine monoclonal antibody

We developed a murine monoclonal antibody (5B10 MAb) that reacted in vitro specifically to lipopolysaccharide (LPS) obtained from Escherichia coli 0111:B4. Enzyme-linked immunosorbent assay (ELISA) titers to a variety of gram-negative bacterial whole cell and LPS antigens demonstrated that this antibody may react with the O antigen portion of 0111:B4 LPS. We then examined the ability of this antibody to protect mice in vivo against a challenge of either viable bacteria or purified LPS. One milligram of 5B10 MAb was administered intraperitoneally (IP) and protected against a lethal challenge of either viable E coli 0111:B4 or 0111:B4 LPS, but no other type of bacterial or LPS challenge. Protection occurred in an antibody dose-dependent manner, and as little as 0.01 mg of 5B10 MAb enhanced survival. We concluded that IP pretreatment with a single MAb would protect against lethal sepsis or endotoxemia in this animal model and that anti-LPS specificity was a sufficient condition for an antibody to protect during bacteremia, confirming the importance of LPS in the pathogenesis of gram-negative bacterial sepsis.     

Posterolateral Corner Reconstruction of the Knee: Surgical Technique Utilizing a Bifid Achilles Tendon Allograft and a Double Femoral Tunnel

Reconstruction of the posterolateral corner of the knee has received increased attention in the recent literature. Basic science studies have helped us determine the 3 critical structures of the posterolateral corner: the lateral collateral ligament (LCL), the popliteus tendon, and the popliteofibular ligament. We have developed an anatomic posterolateral corner reconstruction that most closely resembles these 3 key structures and is based on the work of previous authors. Our technique is performed using a single Achilles allograft. The bone plug is secured in a femoral tunnel at the anatomic attachment of the popliteus tendon with an interference screw. The Achilles tendon is then split approximately 1 to 2 cm distal to the bone plug into 2 segments: (1) the popliteofibular ligament portion that is passed through a fibular tunnel starting at the anatomic attachment of popliteofibular ligament and fixed with a biointerference screw and (2) the static portion of the popliteus tendon securing this through a tibial tunnel passed from posterior to anterior right at the musculotendinous junction of the popliteus. The anterior limb of the Achilles tendon exiting the fibula is then brought back around, secured to the fibular attachment of the LCL with a suture anchor, and is then passed through a separate femoral tunnel placed at the anatomic attachment of the LCL.     

Extraforaminal ligament attachments of the thoracic spinal nerves in humans

An anatomical study of the extraforaminal attachments of the thoracic spinal nerves was performed using human spinal columns. The objectives of the study are to identify and describe the existence of ligamentous structures at each thoracic level that attach spinal nerves to structures at the extraforaminal region. During the last 120 years, several mechanisms have been described to protect the spinal nerve against traction. All the described structures were located inside the spinal canal proximal to the intervertebral foramen. Ligaments with a comparable function just outside the intervertebral foramen are mentioned ephemerally. No studies are available about ligamentous attachments of thoracic spinal nerves to the spine. Five embalmed human thoracic spines (Th2–Th11) were dissected. Bilaterally, the extraforaminal region was dissected to describe and measure anatomical structures and their relationships with the thoracic spinal nerves. Histology was done at the sites of attachment of the ligaments to the nerves and along the ligaments. The thoracic spinal nerves are attached to the transverse process of the vertebrae cranial and caudal to the intervertebral foramen. The ligaments consist mainly of collagenous fibers. In conclusion, at the thoracic level, direct ligamentous connections exist between extraforaminal thoracic spinal nerves and nearby structures. They may serve as a protective mechanism against traction and compression of the nerves by positioning the nerve in the intervertebral foramen.     

Removal of a nail from bone after nail gun injury: a case report and utility of a classic technique

Nail gun injuries are common, work-related injuries that typically involve bony impalement of an extremity with the nail. Treatment recommendations are well established, although suggestions for removing the nail itself have been lacking. In our hands, removal using typical operating room equipment has been challenging, usually resulting in nail head deformity and breakage, which makes completing the procedure even more difficult. As a result, we have revisited the tool designed solely for the purpose of nail removal, that is, a claw hammer: this tool is readily available from materials management at most hospitals, can be easily autoclaved, and is effectively used with a block or surgical pan lid to gain leverage and protect the soft tissues. We have found this method to be simple and extremely useful for nail removal for the nail-impaled patient.     

Nonerythropoietic derivative of erythropoietin protects against tubulointerstitial injury in a unilateral ureteral obstruction model.

BACKGROUND: Erythropoietin (EPO), a member of the cytokine type I superfamily, acts to increase circulating erythrocytes primarily by preventing apoptosis of erythroid progenitors, is known to protect tissues and can raise haemoglobin (Hb) concentrations. Recently, a second receptor for EPO comprising the EPO receptor and beta-common receptor has been reported to mediate EPO-induced tissue protection. EPO modified by carbamylation (CEPO) only signals through this second receptor. Accordingly, we hypothesized that treatment with CEPO, which would not increase Hb concentrations, would protect against tubular damage and thereby inhibit tubulointerstitial injuries. METHODS: We evaluated therapeutic effects of CEPO using a rat unilateral ureteral obstruction model. RESULTS: CEPO decreased tubular apoptosis and alpha-smooth muscle actin (alphaSMA) expression in the absence of polycythaemia, while the untreated obstructed kidneys exhibited increased tubular apoptosis with expanded (alphaSMA) expression. While EPO treatment similarly inhibited tubular apoptosis and alphaSMA expression, EPO treatment increased Hb concentrations and induced a wedge-shaped infarction. CONCLUSION: We established a therapeutic approach using CEPO to protect against tubulointerstitial injury. The therapeutic value of this approach warrants further attention and preclinical studies.     

Alpha-1-antichymotrypsin in renal biopsies

Alpha 1-Antichymotrypsin (alpha 1-AK) and alpha-1-antitrypsin (alpha 1-AT) represent a defense mechanism to protect the tissues from proteolytic enzyme activity. We studied the implication of alpha 1-AK and alpha 1-AT in glomeruli of patients with different nephropathies based on the analysis of 52 paraffin-embedded renal biopsies with alpha 1-AK and alpha 1-AT antisera. The results demonstrate an intense alpha 1-AK glomerular staining in renal biopsies from patients with minimal-change disease, while a minor staining of this protein was found in the other nephropathies. No significant evidence of alpha 1-AT deposits was observed in our cases. Our findings suggest that when alpha 1-AK is lacking in glomeruli the defense mechanisms against proteolytic enzymes may not be efficient enough to protect the glomerular structures and limit the damage. Since alpha 1-AK is a reactant of the acute phase of inflammation, it may be considered as a marker of activity for monocyte-macrophages in glomerular damage.     

Craniocerebral epidermoid and dermoid tumours: a review of 32 cases

Summary We reviewed 22 epidermoid and 10 dermoid tumours of the skull and brain from patients operated on consecutively at Henry Ford Hospital between 1975 and 1991.There were 19 intradural (16 epidermoid, 3 dermoid) and 13 extradural (6 epidermoid, 7 dermoid) lesions. The average age at presentation was 35 years for patients with epidermoids and 15 years for those with dermoids. Common clinical presentations for patients with intradural lesions included headache, visual deficits, and seizures, whereas patients with extradural lesions harbored asymptomatic scalp masses. All patients with intradural lesions were investigated with computed tomography (CT) and cerebral angiography, and 8 patients underwent magnetic resonance imaging (MRI).Total resection was possible in 12 (92%) of 13 extradural tumours, all with excellent outcomes. Eight (42%) of the intradural tumours were completely resected.Overall, with the intradural tumours we had good to excellent results in 17 patients (90%), poor results in 1 (5%), and 1 death (5%). Re-operation was needed in 5 intradural recurrences (26%) with deterioration in only one patient's neurologic status postoperatively.From a review of ours and others' data, we conclude that 1) these tumours have an insidious onset despite significant size and mass effect as demonstrated by imaging studies; 2) CT, angiography, and particularly MRI help to define the extent of subarachnoid tumour spread and involvement of neurovascular structures, thus permitting better surgical planning; 3) a significant number of intradural tumours are difficult to excise because of their adherence to neurovascular structures, and thus are related to higher morbidity and mortality; and 4) because of extremely slow growth, complete tumour resection should not be the goal at the risk of injury to neurovascular structures.     

Pregnancy impact on uterosacral ligament and pelvic muscles using a 3D numerical and finite element model: preliminary results

Introduction and hypothesis

We studied the geometry of and changes in structures that play an important role in stabilizing the pelvic system during pregnancy using a numerical system at different gestational ages and postpartum.

Methods

We developed a parturient numerical model to assess pelvic structures at different gestational stages (16, 32, and 38 weeks) and postpartum (2 months and 1 year) using magnetic resonance imaging (MRI). Organs, muscles, and ligaments were segmented to generate a 3D model of the pelvis. We studied changes in the length of uterosacral ligaments (USL) and thickness of the puborectal portion of the levator ani muscle (LAM) during and after pregnancy. We used this model to perform finite element (FE) simulation and analyze deformations of these structures under stress from the increase in uterine weight.

Results

Analysis reveals an increase in the length of US ligaments at 16, 32, and 38 weeks. Two months after delivery, it decreases without returning to the length at 16 weeks of pregnancy. Similar changes were observed for the puborectal portion of the LAM. Variations observed in these structures are not equivalent to other anatomical structures of pelvic suspension. FE simulation with increased uterus weight does not lead to those findings.

Conclusion

This analysis brings new elements and a new focus for discussion relating to changes in pelvic balance of parturient women that are not simply linked to the increase in uterine volume.

     

Early healing after carotid endarterectomy: effect of high- and low-dose aspirin on thrombosis and early neointimal hyperplasia in a nonhuman primate model

Platelet aggregation and release phenomena are central to most postulated mechanisms of thrombosis and neointimal hyperplasia after carotid endarterectomy. Therefore high-dose aspirin (HDA) has been advocated to minimize these sources of endarterectomy failure. We have defined low-dose aspirin (LDA) that selectively blocks platelet cyclooxygenase but preserves arterial wall cyclooxygenase in the nonhuman primate, Macaca fascicularis. We compared this theoretically optimal aspirin dose with HDA and no treatment (control) in a model of carotid endarterectomy. The aspirin was started before operation and continued for 6 weeks after operation, at which time the endarterectomized vessels were excised. The patency and morphologic findings of the arteries were measured. Platelet function was monitored by bleeding time and serum thromboxane A2 determinations. LDA and HDA were associated with 100% patency, whereas the control group had 50% patency. However, HDA did not protect the vessel from developing neointimal hyperplasia, which was seen in the control group and was associated with platelet adherence to the flow surface at 6 weeks. At 6 weeks, LDA significantly decreased but did not totally prevent neointimal hyperplasia and the flow surface was healed. Therefore the genesis of neointimal hyperplasia after endarterectomy may be more complex than simply a function of platelet-vessel wall interaction.