Effects of implanted Doppler flowmeters on femoral vein autografts.

Thirteen femoral vein autografts were placed into the corresponding ipsilateral femoral arteries of 8 mongrel dogs. Cuff-type Doppler (ultrasonic) flowmeters were placed around six of the grafts. None of the vessels thrombosed. Blood flow velocities were measured in all vessels up until the time of sacrifice (mean 95 +/- 5 days after surgery) or accidental death (one dog, 49 days after surgery). The only case of graft failure was attributed to infection at the flowmeter site. With this single exception, the vein grafts exhibited uniformity in histological appearance from dog to dog. These data suggest that implantation of properly designed Doppler flow transducers may have clinical applications. This technique permits continuous or intermittent assessment of blood flow characteristics through a graft without additional trauma or cost to the patient. It is free of the many inherent disadvantages of chronically implanted electromagnetic flowmeters and may negate the need in some instances for followup angiographic studies.     

Osteomalacia and femoral neck fractures in the elderly patient

In a series of over 1000 elderly patients with femoral neck fracture, who were routinely screened by iliac crest bone biopsy, a 2% prevalence of osteomalacia was found. This low figure suggests that osteomalacia is not a significant predisposing factor in the development of these fractures and that routine screening is not cost-effective.     

A hemodialysis patient with secondary hyperparathyroidism in whom primary parathyroid adenoma was resected 27 years previously

We report here a dialysis patient with secondary hyperparathyroidism who had a history of parathyroidectomy for primary hyperparathyroidism 27 years previously. The patient was a 48-year-old male. In 1974, he was diagnosed as having primary hyperparathyroidism and an adenoma was completely resected in the Department of Urology, Osaka University Hospital. In 1997, he started hemodialysis for chronic renal failure by diabetic nephropathy. Since his intact-PTH was high, we started intravenous vitamin-D pulse therapy, but intact-PTH did not decrease. We could not detect any parathyroid glands by ultrasonography and 201TlCl-99mTcO4-scintigraphy around the thyroid gland. Finally, chest-CT and 99mTc-MIBI scintigraphy revealed a ectopic parathyroid gland in the mediastine, and the ectopic parathyroid gland was successfully resected in July, 2001. In order to distinguish whether the resected ectopic parathyroid gland was due to primary adenoma or secondary hyperplasia, we used an immunohistochemical technique to examine the expression of PRAD1/cyclin D1, Ki67, and p27 and sequence analysis of the MEN1 gene. As a result, the labeling index (LI) of PRAD1/cyclin D1 was 4, LI of Ki67 was 36, and LI of p27 was 257. Moreover, germline-mutation and somatic-mutation of MEN1 gene was not detected. These findings suggested that the resected parathyroid gland was a nodular hyperplasia of secondary hyperparathyroidism. In conclusion, immunohistochemical findings of parathyroid tissue and sequence analysis of MEN1 gene could be useful for the differential diagnosis of primary adenoma and secondary hyperplasia.     

The complex problem of the interprosthetic femoral fracture in the elderly patient

An ageing population and greater number of hip and knee replacements performed have led to an increasing number of patients with ipsilateral hip and knee replacements in situ. This often physiologically suboptimal population is at risk for periprosthetic fracture. An interprosthetic femoral fracture represents a unique challenge to the surgeon and requires a detailed multidisciplinary management strategy involving both fracture fixation and often complex revision. We have identified the largest series to our knowledge of patients presenting for surgical management of an unstable fracture between a hip and knee prosthesis. Institutional approval was granted for prospective study of these patients. We present the detailed management, outcome and review the known literature of the best practice for such a complex surgical case. We have outlined 9 fractures in 8 patients presenting to a single trauma unit. A variety of surgical options, often more than one, were employed. One patient died during the study period. All fractures progressed to union. There was a female preponderance with a mean age of 78 years. All patients had established systemic and metabolic bone morbidity. We believe this fracture pattern presents to the general orthopaedic surgeon a unique challenge, which bridges the expertise of the trauma and revision surgical spectrum. It is obvious that this will become an increasing issue with the median age of the population increasing. This case series highlights the need for ready availability of biological, arthroplasty and trauma systems to address such.     

老年股骨颈骨折患者的循证治疗分析

目的为老年股骨颈骨折患者制定倨证治疗方案。方法在充分评估患者病情后,进行临床提问,计算机检索Cochrane图书馆（2008年4月）,PubMed（2002年至2010年）,Medline（2000年至2010年）和Embase（2000年至2010年）,Tripdatabase,Oviddatabase和ACP（AmericanCollegeofphysicians）onlinejournal关于股骨颈骨折治疗的循证临床指南,RCT（Randomizedcon—trolledtrial）,系统评价和Meta分析,并评价其质量,获取最佳证据用于临床治疗。结果共检出关于股骨颈骨折的8篇系统评价,9篇Meta分析,1篇循证治疗指南,2篇RCT。结合患者实际情况,制定出儋证治疗方案。结论采用儋证治疗方法,可为患者确定合理而安全的治疗方案。     

Temporary and permanent biventricular pacing via left ventricular epicardial leads implanted during primary cardiac surgery

OBJECTIVES: Biventricular pacing (BVP) is a new strategy for treating patients with severe congestive heart failure (CHF) and intraventricular conduction delay, but its full potential and technicalities of BVP require further evaluation. We evaluated BVP benefits in 4 patients in whom we implanted a left ventricular lead during primary cardiac surgery. METHODS: Four CHF patients treated surgically between October 2000 and August 2001 underwent, at primary surgery, the implantation of leads in the right atrium, right ventricle, and left ventricle (LV) for postsurgical BVP. All patients had severe LV dysfunction and dilatation with intraventricular conduction delay. Surgeries involved CABG alone (n = 1), CABG + Dor's operation (n = 2), and tricuspid valve replacement + Maze procedure (n = 1). BVP was begun immediately after surgery in all 4 patients. Hemodynamic variables with BVP were compared to those without BVP for each patient, and the utility and technical aspects of implantation were evaluated. RESULTS: BVP increased mean systemic blood pressure by 11% and mean LV stroke work index by 19% in the acute postsurgery period, and reduced mitral regurgitation. Two of the patients were implanted with a generator for permanent BVP, one at 1 month and the other at 6 months after surgery. The threshold of the LV epicardial lead of these 2 patients was below 2 V during follow-up, and BVP was successful. CONCLUSIONS: Temporary BVP during the short-term after cardiac surgery improved cardiac function and decreased mitral regurgitation in all 4 of our patients. Epicardial lead implantation may thus be a useful option during surgical treatment of patients with CHF and intraventricular conduction delay if long-term permanent BVP is indicated.     

Ventriculovascular shunts via the femoral vein: a temporary feasible alternative in pediatric hydrocephalus

Ventriculovascular shunts via the femoral vein have been described as a feasible alternative for cerebrospinal fluid diversion in those complex cases of hydrocephalus in which other accesses are discarded. However, experience is short. To our knowledge, only 4 cases have been reported in the literature to date. We report 2 cases of hydrocephalic children who were developed several complications related to ventriculoperitoneal and ventriculoatrial shunts and who successfully managed by means of ventriculovascular shunts via the femoral vein. Both patients underwent vascular catheter placement through a venotomy performed in the common femoral vein. Catheter advance was controlled under fluoroscopic guidance. Distal catheters were joined by means of a straight connector, and a loop was accommodated in a subcutaneous pocket in the inguinal region to avoid future complications. The femoral vein is a successful alternative approach for distal catheter placement in ventriculovascular shunts when other accesses are ruled out.     

Management of glaucoma in the implanted patient

Implanting an intraocular lens in an eye with controlled open angle glaucoma or angle closure glaucoma does not adversely affect the eye's status. Furthermore, it is extremely rare for primary glaucoma to develop in an eye postimplantation. Secondary glaucoma is certainly more common, although its incidence is not substantially greater than that in nonimplanted eyes. Special considerations with respect to medical therapy and surgical treatment of secondary glaucoma in pseudophakia are discussed.     

Pacing activity, patient and lead survival over 20 years of permanent epicardial pacing in children

BACKGROUND: We report on pediatric epicardial pacing activity, patient and lead survival for more than two decades in a single center. METHODS: The data cover 96 pacing leads implanted in 59 patients. Median age at implantation was 1.9 years (1 day to 18.2 years). Forty-four percent had structural cardiac disease. Most frequent indications for pacing were postoperative (42%) and congenital complete heart block (42%). RESULTS: Median activity was 3 pacing leads per year; 326 patient pacing years were observed (median 11.9 years; range, 1.1 to 22 years). Death due to pacemaker failure occurred in a single patient. Lead failure occurred in 33 of 96 leads (median of 28 months postimplantation) with lead fracture the commonest cause (47%). Risk factors for lead failure were decade of implant and nonsteroid eluting leads. Acute implant energy thresholds were significantly lower for steroid than nonsteroid eluting leads but did not predict subsequent lead failure. CONCLUSIONS: The epicardial approach has offered an effective solution to pacing problems in the pediatric age range. Lead survival has improved with more than 75% of modern steroid eluting leads surviving to 5 years.