Prospective crossover evaluation of four methods of clinical management of tinnitus

This article summarizes data obtained from 34 tinnitus-afflicted patients who participated in and completed a prospective crossover evaluation of four methods of clinical management of tinnitus. The methods included a 2-week trial with each of the following: a tinnitus masker, a tinnitus instrument (a combination device consisting of a tinnitus masker and a hearing aid), a hearing aid, and conventional environmental controls. The relative effectiveness of each method of treatment was assessed by interview. The data presented summarize respondents' preferences for each method of treatment. Use of a tinnitus masker, tinnitus instrument, and hearing aid is related to stability of auditory thresholds. Comments are made on our experience with clinical management of the patient afflicted with tinnitus, and observations are offered on continued investigation in this area.     

Study of the possibility of an effect of biliary disease on the occurrence of chronic pancreatitis

The authors report a series of patients suffering from chronic pancreatitis and underline the high frequency of biliary pathology in these subjects. The authors remind, then a research performed, some years ago, by one of them. In such a research the performing of an anastomosis between the pancreatic duct and the biliary common duct in a series of experimental animals caused an acute pancreatitis or in the surviving animals a chronic pancreatitis. The authors believe that a biliary pathology may be responsible not only of an acute pancreatitis but also of a chronic pancreatitis.     

Comparison of costs of different anaesthetic techniques

The costs of anaesthetic drugs, intravenous agents as well as gases, were studied for different anaesthetic techniques in a medium-sized operative procedure, cholecystectomy. Three anaesthetic breathing systems were used: a non-rebreathing system, a circle absorber system with medium fresh gas flows of 3-6 l/min, and a low-flow circle system. Anaesthesia without volatile inhalation agents used with a low-flow technique was the least expensive, and anaesthesia with isoflurane in a non-rebreathing system was the most expensive. The costs of anaesthesia without volatile inhalation agents in a non-rebreathing system, enflurane anaesthesia in a circle system with medium fresh gas flows, and isoflurane anaesthesia with low-flow technique were similar.     

Imaging of early stages of osteonecrosis of the knee

Osteonecrosis of the knee can present as a spontaneous and primary or a secondary clinical entity. The natural history of osteonecrosis follows a course of several sequential stages, and the later stages of both entities seem to be irreversible. Early diagnosis of osteonecrosis is crucial: the earlier the stage of the lesion at the time of diagnosis, the better the prognosis.Clinically, early diagnosis and treatment of osteonecrosis might prevent unnecessary surgery in cases with a concomitant degenerative meniscal tear. Early-stage osteonecrosis should be ruled out before surgery, because arthroscopy has lately been associated with osteonecrosis. Not every imaging method is equally suitable for detecting pathognomonic changes in each stage of osteonecrosis. Early-stage osteonecrosis is difficult to diagnose,because various differential diagnoses must be kept in mind. Moreover, there is a diagnostic window between the onset of symptoms and the appearance of pathognomonic changes on plain radiographs and MRI.     

Three cases of bipartition of the atlas

Background contextA bipartite atlas is a rare coincidental finding, and it is reported in only 0.1% of the general population. It is a congenital disorder characterized by incomplete fusion of the anterior and the posterior arches of C1, and it is important to differentiate it from a Jefferson fracture.Study design/settingCase report and literature review.PurposeTo report three cases of patients with bipartition of the atlas with a focus on imaging. To review the literature on these fusion defects, the embryologic basis, and the differentiation from a Jefferson fracture.MethodsWe report three cases of patients with a bipartite atlas as a coincidental finding in a trauma setting. The bipartite atlas was assessed by multidetector computed tomography (CT). The first case, for example, describes a 36-year-old patient who was struck by a moped. The CT of the skull showed a bipartite atlas as an additional finding. The embryologic development of C1 is reviewed and also the imaging features and the management. Furthermore, a CT image of a Jefferson fracture is provided for comparison.ResultsThe CT scans of the three patients show midline clefts of the anterior and the posterior arches of C1 with similar imaging features: smooth margins lined by cortical bone and no lateral offset. The patients had no neurological symptoms relating to the C1 abnormality, and no follow-up was performed. The clefts at level C1 are the result of the failure of three ossification centers to fuse properly. Anterior and posterior clefts are caused by hypoplasia of the hypochordal bow and lateral parts of the C1 sclerotome, respectively. Because of the risk of instability, assessing atlantoaxial stability is advised. However, patients usually have no symptoms and require no specific treatment.ConclusionsA bipartite atlas is a rare congenital abnormality, caused by a failure of anterior and lateral ossification centers to fuse. It needs to be differentiated from a Jefferson fracture in a trauma setting. It usually requires no specific treatment.     

Nonunion of fractures of the subtrochanteric region of the femur

There are no large clinical series to guide the clinician treating a subtrochanteric nonunion. Deformity, bone loss from previous hardware, and the high stresses in the subtrochanteric region all pose challenges to achieving successful bony union with reoperation. The purpose of this study was to retrospectively review a consecutive series of patients treated with reoperation using contemporary techniques for subtrochanteric nonunion. Between 1992 and 2002, 23 patients with a mean age of 55 years (range, 16-88 years) with 23 subtrochanteric nonunions were treated with additional attempts to achieve union. Two patients were lost to followup. The remaining 21 patients were followed up for a mean of 12 months (range, 6-39 months). Implants used for revision internal fixation were as follows: eight patients were treated with a cephalomedullary nail, seven patients were treated with a standard antegrade femoral nail, five patients were treated with a 95 degree angled blade plate, one patient was treated with a sliding hip screw, one patient was treated with a 95 degree dynamic condylar screw, and one patient was treated with dual large fragment plates. Eighteen of 23 patients had bone grafting: eight had autograft, six had allograft, and both were used in three patients. One patient had free vascularized fibular transfer. Twenty of 21 nonunions healed (95%). At last followup, all patients with healed fractures had no or minimal pain. All were ambulatory. There were no intraoperative complications. There was one postoperative complication (4%), an adynamic ileus that was treated medically. Revision internal fixation and selected bone grafting for subtrochanteric nonunion led to a high rate of fracture union and functional improvement. Intramedullary devices with fixation into the femoral head and neck and fixed angled devices were effective in achieving stable fixation of the proximal bony fragment.     

Indications and results of surgical treatment of cavernous hemangioma of the liver

Over a period of 6.5 years, 29 patients with liver hemangiomas have been examined. In 8 patients, the most frequent symptom was pain; in 11, a tumor was found. The diagnosis was made by means of scintigraphy with 99mTc, followed by real-time sonography, computed tomography using a contrast medium, and selective arteriography. In 16 patients (15 women, 1 man), the tumor radius was more than 6 cm and in 9 of these, more than 10 cm. In 3 patients, a left lobectomy was carried out, and in 5 a right lobectomy; in an additional 5 patients, a extended right lobectomy (three segments excised) was done. In the rest, a medial lobectomy, a segmentectomy on the left side, or a segmentectomy on the right was performed. The only complications observed in the whole series were: pleural effusion (1 case), subphrenic abscess (1), and transitory biliary fistula (1). All hemangiomas with a radius of more than 10 cm should be removed operatively, as should smaller symptomatic hemangiomas and tumors that are not clearly benign.     

Mode of action of depolarizing agents

It has been shown that with suitable doses of decamethonium, succinylcholine, or succinylmonocholine, a two-phase neuromuscular block can always be seen in isolated human intercostal muscle.
The first phase consists of a neuromuscular block of rapid onset which reaches a maximum in about 15 minutes and then recovers spontaneously in spite of the continued presence of C₁₀ in the same concentration. Recovery is maximum at approximately 60 minutes, after which time the second phase begins.
The second phase consists of a slow, progressive neuromuscular block which reaches a steady reproducible state after 6 to 8 hours. If undisturbed, this state remains constant for hours. This phase represents a true competitive neuromuscular block, as evidenced by the fact that it can be reversed by a suitable dose of neostigmine.
Experiments have been described in which these two phases were modified by the addition of d-tubocurarine and neostigmine. Attempts are made to explain various phenomena on a molecular basis. The clinical significance of this work is presented.     

Repair of tetralogy of Fallot with obstruction of right pulmonary artery; report of a case

Patients with tetralogy of Fallot showing unilateral obstruction of a pulmonary artery, especially the right pulmonary artery, are a high-risk group for pulmonary hypertension after repair. This case of tetralogy of Fallot with the obstruction of the right pulmonary artery received a Blalock-Taussig shunt at 7 months old, and the occluded right pulmonary artery caused empyema after surgery. At 2 years old, a cardiac catheter study showed a pulmonary artery index of 193.6 mm2/m2, so we undertook intracardiac repair. After the repair, she showed a relativery favorable clinical course. Systolic pulmonary artery pressure and right ventricular pressure were about 30 and 50 mmHg, respectively. We considered that tetralogy of Fallot with obstruction of right pulmonary artery could be repaired, as long as the pulmonary artery index was within the limits of indication and the left ventricle was well-developed.     

A case of the management of developed collateral vessels through left thoracotomy of recurrence of right bronchiectasia with hemoptysis

A 40-year-old woman, with a previous history of right S1, S2 segmentectomy and right middle lobectomy for bronchiectasis with hemoptysis at the age of 24, was admitted for frequent hemoptysis. As a result of a chest roentgenogram, a CT scan and bronchographic examination, a recurrence of bronchiectasis in the right ventral segment of the upper lobe (S3) and the right superior segment of the lower lobe (S6) was diagnosed. The bronchial arteriogram and aortogram showed four vessels going into this region and a shunt lesion was located on located on the proximal side of the pulmonary artery. If a right pneumonectomy had been done, pulmonary function would have gotten worse. If a right thoracotomy had been performed, there would have been much bleeding from the entering vessels. Therefore, a left thoracotomy was preformed and those vessels ligated. The patient is doing well one year after the operation without hemoptysis.     

Results of operative treatment of fractures of the posterior wall of the acetabulum

BACKGROUND: The purpose of this study was to determine the clinical outcome in patients in whom a displaced fracture of the posterior wall of the acetabulum had been treated by open reduction and internal fixation. METHODS: One hundred patients who had had open reduction and internal fixation of an unstable unilateral fracture of the posterior wall of the acetabulum were studied. Ninety-four patients were assessed at a mean of five years (range, two to fourteen years) after the injury. Six patients with a poor result were followed for less than two years. The functional outcome was evaluated with use of the clinical grading system adopted by Letournel and Judet with incorporation of modifications by Matta. Patient, fracture, and radiographic variables were analyzed to identify possible associations with functional outcome. RESULTS: The reduction of the fracture, as determined with plain radiography, was graded as anatomic in ninety-seven patients and as imperfect in three. The clinical outcome at the time of final follow-up was graded as excellent in fifty-five patients, very good in twenty-five, good in nine, fair in one, and poor in ten. The radiographic result was excellent in eighty-one patients, good in five, fair in four, and poor in ten. There was a strong association between the clinical outcome and the final radiographic grade. Variables identified as risk factors for an unsatisfactory clinical result included a delay of greater than twelve hours before reduction of an associated hip dislocation, an age of fifty-five years or older at the time of injury, intra-articular comminution, and osteonecrosis. CONCLUSIONS: The uncomplicated radiographic appearance and relatively simple operative approach for fractures of the posterior acetabular wall belie the risk of poor results. Prompt reduction of an associated hip dislocation is imperative. Fractures in elderly patients and those with extensive comminution are more likely to have a poor clinical result. However, a high likelihood of a long-term good-to-excellent result can be expected following anatomic reduction and internal fixation of these fractures.     

Management of dislocations of both ends of the clavicle

We treated six patients who had a dislocation of both ends of the clavicle (an anterior dislocation of the sternoclavicular joint and a posterior dislocation of the acromioclavicular joint). Two patients who had fewer demands on the shoulder--an elderly woman and a woman who had had an ipsilateral amputation of the hand--did well; they had only minor symptoms after non-operative management. The other four patients (all men) had continuing pain at the acromioclavicular joint; each had a reconstruction of the joint, which resulted in a painless, full range of motion and return to normal activity. No patient had continuing pain in the sternoclavicular joint.     

The results of repair of massive tears of the rotator cuff

BACKGROUND: Massive tears of the tendons of the rotator cuff cause atrophy and fatty degeneration of the rotator cuff muscles and painful loss of function of the shoulder. Repair of massive rotator cuff tears is often followed by retears of the tendons, additional muscular degeneration, and a poor clinical outcome. The purposes of this study were to determine whether a new method of repair of rotator cuff tendons can yield a lower retear rate and a better clinical outcome than previously reported methods, to assess the muscular changes following repair of massive tears of the musculotendinous units, and to correlate findings on magnetic resonance imaging with the clinical results. METHODS: Twenty-nine massive rotator cuff tears involving complete detachment of at least two tendons were repaired operatively with use of a new laboratory-tested technique in a prospective study. At least two years (average, thirty-seven months; range, twenty-four to sixty-one months) postoperatively, twenty-seven patients were evaluated clinically and with magnetic resonance imaging to determine the clinical outcome, the integrity of the repair, and the condition of the rotator cuff muscles. RESULTS: The age and gender-adjusted Constant score improved from an average of 49 percent preoperatively to an average of 85 percent postoperatively, corresponding to a subjective shoulder value of 78 percent of that of a normal shoulder. Pain-free flexion improved from an average of 92 degrees to an average of 142 degrees, and abduction improved from an average of 82 degrees to an average of 137 degrees. Pain decreased and performance of activities of daily living improved significantly (p < 0.05). The seventeen patients who had a structurally successful repair all had an excellent clinical outcome. Muscle atrophy could not be reversed except in successfully repaired supraspinatus musculotendinous units. Fatty degeneration increased in all muscles. CONCLUSIONS: The method of repair of massive rotator cuff tears that was used in this study yielded a comparatively low retear rate and good-to-excellent clinical results; however, the repair did not result in substantial reversal of muscular atrophy and fatty degeneration. Retears occurred more often in patients who had had a shorter interval between the onset of the symptoms and the operation (p < 0.05). Patients who had a retear had improvement of the shoulder compared with the preoperative state, but they had less improvement than did those who had a successful repair.     

Fractures of the hook of the hamate--a failure of clinical diagnosis

Two cases of a fracture of the hook of the hamate are described in which the diagnosis was clinically missed even though a fracture of the hook was considered. In one patient, the clinical diagnosis was thought to be ulnar wrist instability, and in the other, a pisiotriquetral injury. In one case, the diagnosis was confirmed only by a computerized tomography scan even though lateral tomograms were negative.     

Model of prognosis of outcome of burn trauma on the basis of probit-analysis

On the basis of probit-analysis of results of treatment of 10,670 burned patients a prognostic model of the trauma outcome was created as a coordinate network. The model is very accurate, sensitive, specific and simple in use that allows it to be applied for prognosis of burn trauma outcomes in the early period after trauma, especially in organization of medical-evacuation work in places of appearance of mass burns. The model is a standard for the assessment of new protocols of treatment and can serve a criterion of the efficiency of work of intensive care units in burn centers.     

Status of percutaneous catheter drainage of abscesses

The definitive role of catheter drainage in the therapy of abscesses has not yet been totally elucidated. The resolution rate of intra-abdominal infection with catheter drainage is highly variable, depending on the inclusion criteria employed. Certain infections are very effectively treated (i.e., abscesses that are single, not communicating with abdominal viscera, noncancerous, and bacterial) with simple catheter drainage, whereas others (i.e., infected pancreatic tumor phlegmon) prove to be much more resistant to simple catheter drainage. When all intra-abdominal "abscesses" are collected, the success of catheter drainage ranges from 47 per cent to 73 per cent. The wide variation should be seen not so much as a reflection of differences in technical ability of the radiologist to introduce a catheter, but rather as emblematic of the highly variable nature of the cause of intra-abdominal infection and the definition of an abscess. Hospitals with a large number of complex problems such as malignancy, transplant and other immunosuppressed patients, and referrals of patients with complex long-standing intra-abdominal infections are likely to have a much lower rate of success with percutaneously placed catheters than are those institutions that derive their series from post-traumatic or primary diseases such as appendiceal or diverticular disease. In the former series, a higher morbidity and mortality rate would be expected from any form of treatment when compared to a series from a practice based on more primary care problems. Intra-abdominal infections are a heterogeneous set of processes, and the role of interventional radiology in the diagnostic and therapeutic approach cannot be underestimated. In planning for the care of a patient with a presumed intra-abdominal infectious process, percutaneous aspiration of a fluid mass is an effective tool for establishing the diagnosis of an abscess. The brief introduction of a catheter has rarely led to contamination of an otherwise sterile collection. However, it often effects dramatic symptomatic relief if the fluid collection is infected. It has therefore been an evolving recommendation to employ the techniques of interventional radiology aggressively in a diagnostic capacity. Subsequently, therapeutic interventions can be undertaken in joint agreement among the physician, surgeon, and radiologist. The diagnosis and treatment of intra-abdominal infections can often times be carried out in a relatively easy and non-morbid manner that effects cure in a significant percentage of patients.(ABSTRACT TRUNCATED AT 400 WORDS)     

Development of a Mouse Model of Ischemic Osteonecrosis

BackgroundAvailability of a reliable mouse model of ischemic osteonecrosis could accelerate the development of novel therapeutic strategies to stimulate bone healing after ischemic osteonecrosis; however, no mouse model of ischemic osteonecrosis is currently available.Questions/purposesTo develop a surgical mouse model of ischemic osteonecrosis, we asked, (1) if the blood vessels that contribute to the blood supply of the distal femoral epiphysis are cauterized, can we generate an osteonecrosis mouse model; (2) what are the histologic changes observed in this mouse model, and (3) what are the morphologic changes in the model.MethodsWe performed microangiography to identify blood vessels supplying the distal femoral epiphysis in mice, and four vessels were cauterized using microsurgical techniques to induce ischemic osteonecrosis. Histologic assessment of cell death in the trabecular bone was performed using terminal deoxynucleotidyl transferase mediated dUTP nick-end labeling (TUNEL) and counting the empty lacunae in three serial sections. Quantitation of osteoclast and osteoblast numbers was performed using image analysis software. Morphologic assessments of the distal femoral epiphysis for deformity and for trabecular bone parameters were performed using micro-CT.ResultsWe identified four blood vessels about the knee that had to be cauterized to induce total ischemic osteonecrosis of the distal femoral epiphysis. Qualitative assessment of histologic sections of the epiphysis showed a loss of nuclear staining of marrow cells, disorganized marrow structure, and necrotic blood vessels at 1 week. By 2 weeks, vascular tissue invasion of the necrotic marrow space was observed with a progressive increase in infiltration of the necrotic marrow space with the vascular tissue at 4 and 6 weeks. TUNEL staining showed extensive cell death in the marrow and trabecular bone 24 hours after the induction of ischemia. The mean percent of TUNEL-positive osteocytes in the trabecular bone increased from 2% ± 1% in the control group to a peak of 98% ± 3% in the ischemic group 1 week after induction of ischemia (mean difference, 96%; 95% CI, 81%–111%; p < 0.0001). The mean percent of empty lacunae increased from 1% ± 1% in the control group to a peak of 78% ± 15% in the ischemic group at 4 weeks (mean difference, 77%; 95% CI, 56%–97%; p < 0.0001). Quantitative analysis showed that the mean number of osteoclasts per bone surface was decreased in the ischemic group at 1, 2, and 4 weeks (p < 0.0001, < 0.0001, and p = 0.02, respectively) compared with the control group. The mean number of osteoclasts increased to a level similar to that of the control group at 6 weeks (p = 0.23). The numbers of osteoblasts per bone surface were decreased in the ischemic group at 1, 2 and 4 weeks (p < 0.0001 for each) compared with the numbers in the control group. The mean number of osteoblasts also increased to a level similar to that of the control group at 6 weeks (p = 0.91). Mean bone volume percent assessed by micro-CT was lower in the ischemic group compared with the control group from 2 to 6 weeks. The mean differences in the percent bone volume between the control and ischemic groups at 2, 4, and 6 weeks were 5.5% (95% CI, 0.9%–10.2%; p = 0.01), 5.3% (95% CI, 0.6%–9.9%; p = 0.02), and 6.0% (95% CI, 1.1%–10.9%; p = 0.008), respectively. A deformity of the distal femoral epiphysis was observed at 6 weeks with the mean epiphyseal height to width ratio of 0.74 ± 0.03 in the control group compared with 0.66 ± 0.06 in the ischemic group (mean difference, 0.08; 95% CI, 0.00–0.16; p = 0.03).ConclusionWe developed a novel mouse model of ischemic osteonecrosis that produced extensive cell death in the distal femoral epiphysis which developed a deformity with time.

Clinical Relevance

The new mouse model may be a useful tool to test potential therapeutic strategies to improve bone healing after ischemic osteonecrosis.     

Evaluation of irradiation effects of near-infrared free-electron-laser of silver alloy for dental application

In the application of lasers in dentistry, there is a delicate balance between the benefits gained from laser treatment and the heat-related damage arising from laser irradiation. Hence, it is necessary to understand the different processes associated with the irradiation of lasers on dental materials. To obtain insight for the development of a safe and general-purpose laser for dentistry, the present study examines the physical effects associated with the irradiation of a near-infrared free-electron laser (FEL) on the surface of a commonly used silver dental alloy. The irradiation experiments using a 2900-nm FEL confirmed the formation of a pit in the dental alloy. The pit was formed with one macro-pulse of FEL irradiation, therefore, suggesting the possibility of efficient material processing with an FEL. Additionally, there was only a slight increase in the silver alloy temperature (less than 0.9 °C) despite the long duration of FEL irradiation, thus inferring that fixed prostheses in the oral cavity can be processed by FEL without thermal damage to the surrounding tissue. These results indicate that dental hard tissues and dental materials in the oral cavity can be safely and efficiently processed by the irradiation of a laser, which has the high repetition rate of a femtosecond laser pulse with a wavelength around 2900 nm.     

Blunt injury of duodenum with avulsion of papilla of Vater--report of a case

In a 52-year-old man, there was a complete separation of the duodenum with avulsion of the papilla of Vater from the head of the pancreas due to blunt abdominal trauma. He was successfully treated by an anastomosis of the ampulla to the jejunum of a Roux-en Y limb, after removal of the entire duodenum and partial gastrectomy, followed by gastrojejunostomy of the Billroth II-type, instead of pancreaticoduodenectomy. The patient is well at 15 months after this surgery.     

Results of polyaxial locked-plate fixation of periarticular fractures of the knee

BACKGROUND: Locked-plate fracture-fixation techniques and designs continue to evolve. Polyaxial locking plates that allow screw angulation and end-point locking have become available; however, there are no clinical data documenting their strength and efficacy, to our knowledge. The purpose of this study was to evaluate the clinical performance of a variable-axis locking plate in a multicenter series of periarticular fractures about the knee. METHODS: Between 2003 and 2005, fifty-four patients with a total of fifty-six fractures were treated with a polyaxial locked-plate fixation system (DePuy, Warsaw, Indiana). There were twenty male patients and thirty-four female patients with a mean age of fifty-seven years. There were twenty-five distal femoral fractures and thirty-one proximal tibial fractures. Twelve of the fractures were open. Clinical and radiographic data, including changes in alignment, hardware breakage, or other mechanical complications of the device, were retrospectively reviewed. Function was assessed with use of the Knee Society scores. One patient with a bilateral fracture died less than three months postoperatively, and two patients were lost to follow-up prior to union. Fifty-two fractures in fifty-one patients were followed to union or for a minimum of six months; the mean duration of follow-up was nine months (range, six to twenty-five months). RESULTS: Forty-nine (94%) of the fifty-two fractures united. There were no mechanical complications. Most importantly, there was no evidence of varus collapse as a result of polyaxial screw failure. There were three deep infections and one aseptic nonunion. No plate fractured, and no screw cut out. CONCLUSIONS: The variable-axis locking plates performed well, with a high rate of fracture union and no evidence of varus collapse due to failure of the polyaxial screw fixation, in a series of complex fractures about the knee. Complication rates were similar to those for historical controls treated with fixed-trajectory locking plates. Polyaxial locking plates offer more fixation versatility without an apparent increase in mechanical complications or loss of reduction.