<Superscript>1</Superscript>H MAS and <Superscript>1</Superscript>H → <Superscript>31</Superscript>P CP/MAS NMR Study of Human Bone Mineral

Chemical structure of human bone mineral was studied by solid-state nuclear magnetic resonance (NMR) with magic-angle spinning (MAS). Trabecular and cortical bone samples from adult subjects were compared with mineral standards: hydroxyapatite (HA), hydrated and calcined, carbonatoapatite of type B with 9 wt% of CO ₃ ^2– (CHA-B), brushite (BRU) and mixtures of HA with BRU. Proton spectra were acquired with excellent spectral resolution provided by ultra-high speed MAS at 40 kHz. 2D ¹H-³¹P NMR heteronuclear correlation was achieved by cross-polarization (CP) under fast MAS at 12 kHz. ³¹P NMR was applied with CP from protons under slow MAS at 1 kHz. Appearance of ³¹P rotational sidebands together with their CP kinetics were analyzed. It was suggested that the sidebands of CP spectra are particularly suitable for monitoring the state of apatite crystal surfaces. The bone samples appeared to be deficient in structural hydroxyl groups analogous to those in HA. We found no direct evidence that the HPO ₄ ^2– brushite-like ions are present in bone mineral. The latter problem is extensively discussed in the literature. The study proves there is a similarity between CHA-B and bone mineral expressed by their similar NMR behavior.     

Die Bedeutung des Advanced Trauma Life Support<Superscript>®</Superscript> (ATLS<Superscript>®</Superscript>) im Schockraum

INTRODUCTION: There is clinical evidence, that a standardized management of trauma patients in the emergency room improves outcome. METHODS: The ATLS training course teaches a systematic approach to the trauma patient in the emergency room. The aim is a rapid and accurate assessment of the patient's physiologic status, the treatment according to priorities and the decision making if transfer to a trauma center is necessary. The German Trauma Society has taken over the course concept from the American College of Surgeons (ACS) and is authorized to organize ATLS courses in Germany. RESULTS: A standardized management in the emergency room helps to prevent secondary injury, to realize timing as a relevant factor in the initial treatment and to assure a high standard of care. The ATLS course provides the participant with knowledge, skills and attitudes and is open to doctors of all specialties involved in the initial management of severely injured patients. CONCLUSION: ATLS teaches a standardized and established approach to the trauma patient in the emergency room. It has been transferred to 46 countries and the content is reviewed regularly to consider new scientific evidence. Germany has the chance to participate in this international standard of care and to introduce own experiences into the review process.     

Off-pump hemostasis for left ventricular rupture after myocardial infarction with Hydrofit<Superscript>®</Superscript> and Surgicel<Superscript>®</Superscript>

Left ventricular free wall rupture (LVFWR) is a catastrophic complication of myocardial infarction. In these cases, cardiopulmonary bypass (CPB) should be performed for left ventricular repair, but can impact hemodynamic stability. An 87-year-old man presented with acute shock. He was diagnosed with LVFWR after myocardial infarction. We describe a simple, effective, and reproducible technique to achieve hemostasis at the LVFWR site during emergency operation using Hydrofit^® and Surgicel^® surgical hemostatic agents. We simply placed and manually pressed the Hydrofit^® and Surgicel^® composite on the bleeding site. This technique provides complete hemostasis without CPB establishment.     

Regulatory mechanism of “K<Superscript>+</Superscript>-recycling” for Na<Superscript>+</Superscript>-reabsorption in renal tubules

Hypertension is one of the predominant risk factors for the progression of renal impairment, and the most common disorder in industrialized societies. Because reduction of the systemic blood pressure in hypertension can halt the progression of renal impairment, it is imperative to appropriately control the systemic blood pressure. Recent genetic analysis has reconfirmed that renal maladjustment of Na⁺-homeostasis, which determines the extracellular fluid volume, is a key element in the pathogenesis of hypertension. The distal tubules adjust the net Na⁺-excretion according to Na⁺-ingestion and maintain the Na⁺-homeostasis. The distal convoluted tubules and the connecting tubules are the predominant sites for the adjustment in individuals with a modern lifestyle. In these tubules, Na⁺-reabsorption depends on “K⁺-recycling”, which is conducted through K⁺ channels. Because the functional expression of K⁺ channels in these tubules is regulated by signal motifs for intracellular localization, the adjustment of “K⁺-recycling” through the modification of signal motifs could be a new target for the treatment of hypertension.     

Laparoscopic Management of Lap-Band<Superscript>®</Superscript> Slippage

Background. The Lap-Band^? is generally associated with a low morbidity rate. Although gastric slippage through the band remains a concern, the rate has diminished with new band placement techniques. Methods. Between November 2000 and June 2002, 198 Lap-Band? Systems were inserted in patients in the Houston, Texas, area. 4 of these patients, plus an additional patient whose Lap-Band^? had been inserted by another surgeon, developed slippages, and in each case the gastric slip was corrected and the band was salvaged and repositioned laparoscopically. To facilitate dissection and repositioning of the band in 3 of these patients, the band had to be unlocked using a simple laparoscopic technique. Results. All patients were discharged the morning following surgery with no complications and good position of the band as evidenced by esophagogram study and resolution of symptoms. After 2 to 12 months follow-up, all 5 patients remain symptom-free and continue to lose weight. Conclusions. Gastric slippage with the Lap-Band^? can be managed by laparoscopic salvage and repositioning of the slipped band.     

Accuracy of screw fixation using the O-arm<Superscript>®</Superscript> and StealthStation<Superscript>®</Superscript> navigation system for unstable pelvic ring fractures

Purpose

Screw fixation for unstable pelvic ring fractures is generally performed using the C-arm. However, some studies reported erroneous piercing with screws, nerve injuries, and vessel injuries. Recent studies have reported the efficacy of screw fixations using navigation systems. The purpose of this retrospective study was to investigate the accuracy of screw fixation using the O-arm^® imaging system and StealthStation^® navigation system for unstable pelvic ring fractures.

Methods

The participants were 10 patients with unstable pelvic ring fractures, who underwent screw fixations using the O-arm StealthStation navigation system (nine cases with iliosacral screw and one case with lateral compression screw). We investigated operation duration, bleeding during operation, the presence of complications during operation, and the presence of cortical bone perforation by the screws based on postoperative CT scan images. We also measured the difference in screw tip positions between intraoperative navigation screen shot images and postoperative CT scan images.

Results

The average operation duration was 71 min, average bleeding was 12 ml, and there were no nerve or vessel injuries during the operation. There was no cortical bone perforation by the screws. The average difference between intraoperative navigation images and postoperative CT images was 2.5 ± 0.9 mm, for all 18 screws used in this study.

Conclusion

Our results suggest that the O-arm StealthStation navigation system provides accurate screw fixation for unstable pelvic ring fractures.

     

Na<Superscript>+</Superscript>, K<Superscript>+</Superscript>, Cl<Superscript>−</Superscript>, acid–base or H<Subscript>2</Subscript>O homeostasis in children with urinary tract infections: a narrative review

Guidelines on the diagnosis and management of urinary tract infections in childhood do not address the issue of abnormalities in Na⁺, K⁺, Cl^? and acid–base balance. We have conducted a narrative review of the literature with the aim to describe the underlying mechanisms of these abnormalities and to suggest therapeutic maneuvers. Abnormalities in Na⁺, K⁺, Cl^? and acid–base balance are common in newborns and infants and uncommon in children of more than 3 years of age. Such abnormalities may result from factitious laboratory results, from signs and symptoms (such as excessive sweating, poor fluid intake, vomiting and passage of loose stools) of the infection itself, from a renal dysfunction, from improper parenteral fluid management or from the prescribed antimicrobials. In addition, two transient renal tubular dysfunctions may occur in infants with infectious renal parenchymal involvement: a reduced capacity to concentrate urine and pseudohypoaldosteronism secondary to renal tubular unresponsiveness to aldosterone that presents with hyponatremia, hyperkalemia and acidosis. In addition to antimicrobials, volume resuscitation with an isotonic solution is required in these children. In secondary pseudohypoaldosteronism, isotonic solutions (such as 0.9 % saline or lactated Ringer) correct not only the volume depletion but also the hyperkalemia and acidosis. In conclusion, our review suggests that in infants with infectious renal parenchymal involvement, non-renal and renal causes concur to cause fluid volume depletion and abnormalities in electrolyte and acid–base balance, most frequently hyponatremia.     

Distribution of Na<Superscript>+</Superscript>/I<Superscript>–</Superscript> Symporter in Thyroid Cancers in an Iodine-deficient Population: An Immunohistochemical Study

Background There are significant differences in the prevalence and behavior of differentiated thyroid cancers (DTC) in the iodine-deficient areas (IDA) and iodine-sufficient areas (ISA) of the world. The sodium iodide symporter (NIS), mediates active transport of iodide across the basolateral aspect of the thyroid follicular cell. However, no study had specifically addressed the issue of expression of sodium iodide symporter (NIS) in thyroid cancer specimens from IDA. The aim of the present study was to find an expression pattern of NIS in DTC in an iodine-deficient population, and to correlate it with histological subtypes, i.e., papillary carcinoma (PTC), follicular carcinoma (FTC), poorly differentiated carcinoma (PDTC), as well as with clinicopathological risk factors and iodine (¹³¹I) uptake by distant metastases. Methods Immunohistochemistry was carried out in 39 cases of thyroid cancer (41 samples) including PTC (15), FTC (10), PDTC (9), anaplastic cancer (5), and resected metastases (2). Expression was correlated with the patient’s age, sex, tumor size, presence or absence of extrathyroidal invasion, distant and lymph node metastases, and whole body radioiodine scan. Results Overall, 61.8% of DTC patients showed NIS expression. There was no significant difference in expression rate between PTC (73.3%) and FTC (70.0%). However, expression was significantly less in PDTC (33.3%). There was no correlation between NIS expression and any clinicopathological risk factor (p > .05). The results of NIS expression were not concordant with ¹³¹I uptake by metastases in 4 of 10 cases. ¹³¹I uptake was absent in one case despite the finding that a metastatic site itself showed NIS expression in that case, whereas in the remaining 9 cases ¹³¹I uptake was present although three cases did not show NIS expression. Conclusions In our experience, overall expression of NIS was comparable to other studies from ISA. We conclude that expression may not accurately predict radioactive iodine (RAI) uptake by metastases. This study was supported by an intramural grant provided by Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India.     

Codification of Techniques for Reoperation After Lap-Band<Superscript>®</Superscript>

Background: The Lap-Band^? is a safe, reversible, minimally invasive, and effective bariatric technique, whose main late complications are herniation/dilation of the pouch, erosion/migration of the band, and problems with the adjustment system (subcutaneous access port and connection tubing). We describe the surgical timing and techniques for dealing with the principal complications. Methods: Between October 1995 and September 2001, we treated 540 patients (mean age 43 years, mean BMI 42.6 kg/m²). All operations were completed laparoscopically, with no intra-operative complications or mortality. Late complications were: problems with the band adjustment system (n=35); herniation/dilations of the pouch (n=14); erosions/migration of the band into the stomach (n=3). Results: We dealt successfully with all complications using a minimally invasive technique. Herniation/dilations of the pouch necessitated 15 successful repositionings of the band, and 2 removals of the band at the patients' request. Erosion/migration was treated by endo-laparoscopic band removal. Problems with the band adjustment system had to be corrected laparoscopically, under general anesthesia in 17 patients. Conclusion: While emphasizing the rarity of complications, we have codified re-operation techniques to help Lap-Band^? users solve them using a minimally invasive procedure. In particular, problems with the port and connection tubing system can be completely avoided with a transverse subcutaneous positioning in a straight line.     

Repositioning the Lap-Band<Superscript>®</Superscript> for Proximal Pouch Dilatation

Background: Laparoscopic adjustable gastric banding (LAGB) procedures have proved their efficiency and reproducibility in several studies. The most frequent late complication is proximal pouch dilatation, with possible progression to total food intolerance. Materials and Methods: In a series of 727 laparoscopic bandings using the Lap-Band^? System, 54 patients presented proximal pouch dilatation and required laparoscopic reposition of the band. 2 patients who had had LAGB placed in another hospital received the same treatment. Results: No particular intra- or postoperative complications occurred during laparoscopic repositioning of the band. 2 conversions were necessary in the beginning of the experience to safely unlock the band. After a median follow-up of 74 months, there has been no recurrence of proximal dilatation. Conclusions: Laparoscopic repositioning of the Lap-Band^? System for proximal pouch dilatation is a safe and reproducible procedure which can be proposed as an interesting alternative to its replacement by a new one. An initial perigastric placement of the band allows, during the redo, safe dissection in a virgin pars flaccida tunnel. The calibration of the tiny proximal pouch, the presence of postoperative adhesions, and maintainance of strict control of dietary behavior are probably the reasons for the absence of recurrence of pouch dilatation.     

Abdominal wall hernia repair: a comparison of Permacol<Superscript>®</Superscript> and Surgisis<Superscript>®</Superscript> grafts in a rat hernia model

Background

This study compared two porcine-derived grafts Permacol (Tissue Science Laboratory, Covington, GA, USA) and Surgisis (Cook Surgical, Bloomington, IN, USA) in terms of strength of incorporation (SOI), incorporation of host tissue, and adhesion formation using a rat model.

Methods

A prospective randomized study using 48 Sprague–Dawley rats. A standardized 1.5 × 5 cm fascial defect was created and repaired with either Permacol or Surgisis grafts. The rats were then sacrificed at 3, 14, 28, or 60 days. The specimens were examined for SOI, neovascularization, collagen deposition, collagen organization, and adhesion formation.

Results

Surgisis had significantly greater SOI than Permacol at 28 (0.115 vs. 0.0754 Mpa) and 60 days (0.131 vs. 0.635 Mpa). Surgisis had significantly more collagen deposition and neovascularization than Permacol at 60 days. The area of adhesions was not significantly different between Surgisis and Permacol.

Conclusion

Surgisis is superior to Permacol in terms of SOI and tissue ingrowth at 60 days. Furthermore, Surgisis strengthened over time whereas Permacol decreased in strength.

     

Laparoscopic revision from LAP-BAND<Superscript>®</Superscript> to gastric bypass

Background

While the majority of patients achieve good outcomes with the LAP-BAND^®, there is a subset of patients who experience complications or fail to lose sufficient weight after the banding procedure. This study examines the feasibility and outcome of performing laparoscopic Roux-en-Y gastric bypass (RYGBP) as a single-step revision surgery after a failed LAP-BAND procedure.

Methods

In the past five years we have performed more than 1400 LAP-BAND procedures. We laparoscopically converted 33 (30 females) of these patients (mean age = 43.8 years) from LAP-BAND to RYGBP because of inadequate weight loss and/or complications. Key steps in the revision procedures were (1) identification and release of the band capsule; (2) careful dissection of the gastrogastric sutures; (3) creation of a small gastric pouch; and (4) Roux-en-Y anterior colic anterior gastric pouch-jejunum anastomosis. Revisions took place at a mean 28.2 months (range = 11–46; SD = 11.3) after the original gastric banding. Change in body mass index (BMI) between pre- and postrevision was evaluated with paired t tests.

Results

Among the 33 patients who would undergo revision surgery, the mean BMI before the LAP-BAND procedure was 45.7 kg/m² (range = 39.9–53.0; SD = 3.4) and the mean weight was 126 kg (range = 99–155; SD = 17). The lowest BMI achieved by this group with the LAP-BAND before revision was 39.7 kg/m² (range = 30–49.2; SD = 4.9); however, the mean BMI at the time of revision was 42.8 kg/m² (range = 33.1–50; SD = 4.8). The mean revision operative time was 105 min (range = 85–175), and the mean hospital stay was 2.8 days (range = 1–10). Complications included one patient who underwent open reoperation and splenectomy for a bleeding spleen and one patient who required repair of an internal hernia. After conversion to RYGBP, mean BMI decreased to 33.9 kg/m² at 6 months (p < 0.001) and 30.7 kg/m² (range = 22–39.6; SD = 5.3) at 12 months or more of followup (average = 15.7 months; p < 0.0001).

Conclusions

Laparoscopic conversion from LAP-BAND to RYGBP is safe and can be an alternative for patients who failed the LAP-BAND procedure. However, revision surgery is technically challenging and should be performed only by surgeons who have completed the learning curve for laparoscopic RYGBP.

     

73<Superscript>rd</Superscript> Meeting — American College of Rheumatology (ACR) 44<Superscript>th</Superscript> Meeting — Association of Rheumatology Health Professionals (ARHP)

Reportages Photographiques / Photographs from Recent Meetings

73^rd Meeting — American College of Rheumatology (ACR) 44^th Meeting — Association of Rheumatology Health Professionals (ARHP) Philadelphie (états-Unis) / 16–21 Octobre 2009     

Self-pressurized air-Q<Superscript>®</Superscript> intubating laryngeal airway <Emphasis Type="Italic">versus</Emphasis> the LMA<Superscript>®</Superscript> Classic™: a randomized clinical trial

Purpose

The self-pressurized air-Q® (air-Q SP) intubating laryngeal airway is a relatively new supraglottic airway (SGA) device. The intracuff pressure of air-Q dynamically equilibrates with the airway pressure and adjusts to the patient’s pharyngeal and periglottic anatomy, potentially providing improved airway fit and seal. The aim of this prospective randomized study was to compare the clinical performance of air-Q to the LMA® Classic? SGA.

Methods

Adult patients requiring general anesthesia for elective surgery were prospectively enrolled and randomly assigned to either air-Q SP or the LMA Classic SGA. Oropharyngeal leak pressure (primary endpoint), success rate, insertion features (insertion time, ease of insertion, requirement for device manipulation), sealing function, gastric insufflation, bronchoscopic view, and oropharyngeal complications at device insertion and following its removal (sore throat, dysphagia, dysphonia) were compared.

Results

The mean (standard deviation [SD]) oropharyngeal leak pressure just after insertion was similar in the air-Q SP and LMA [16.8 (4.9) vs 18.6 (5.5) cm H₂O, respectively; mean difference, 1.8 cm H₂O; 95% CI, ?0.5 to 4.2; P = 0.13] and did not differ at ten minutes following device insertion. Median [interquartile range (IQR)] peak inspiratory pressure just after insertion was lower in the air-Q SP (11.0 [10.0-13.0] vs 13.0 [11.0-14.0] cmH₂O, median difference, 1.0 cm H₂O; 95% CI, 0.0 to 2.0; P = 0.03) but no difference was observed at ten minutes. The median [IQR] insertion time was faster with the air-Q SP (15.9 [13.6-20.3] sec vs 24 [21.2-27.1] sec; median difference, 8.1 sec; 95% CI, 5.6 to 9.9; P < 0.001) and improved bronchoscopic viewing grade were seen with the air-Q SP immediately after insertion (P < 0.001). No differences between the groups were observed with respect to the rate of successful insertion at first attempt, overall insertion success rate, ease of insertion, and complications.

Conclusions

The air-Q SP had similar leak pressures but a faster insertion time and superior bronchoscopic viewing grade when compared with the LMA Classic. The air-Q SP is a suitable alternative to the LMA Classic in adult patients and may be a superior conduit for tracheal intubation.

Trial registration

www.clinicaltrials.gov (NCT02206438). Registered 1 August 2014.

     

Radiation exposure using the O-arm<Superscript>®</Superscript> surgical imaging system

Purpose

This study was conducted to characterise the O-arm^® surgical imaging system in terms of patient organ doses and medical staff occupational exposure during three-dimensional thoracic spine and pelvic examinations.

Methods

An anthropomorphic phantom was used to evaluate absorbed organ doses during a three-dimensional thoracic spine scan and a three-dimensional pelvic scan with the O-arm^®. Staff occupational exposure was evaluated by constructing an ambient dose cartography of the operating theatre during a three-dimensional pelvic scan as well as using an anthropomorphic phantom to simulate the O-arm^® operator.

Results

Patient organ doses ranged from 30 ± 4 μGy to 20.0 ± 3.0 mGy and 4 ± 1 μGy to 6.7 ± 1.0 mGy for a three-dimensional thoracic spine and pelvic examination, respectively. For a single three-dimensional acquisition, the maximum ambient equivalent dose at 2 m from the iso-centre was 11 ± 1 μSv.

Conclusion

Doses delivered to the patient during a three-dimensional thoracic spine image acquisition were found to be significant with the O-arm^®, but lower than those observed with a standard computed tomography examination. The detailed dose cartography allows for the optimisation of medical staff positioning within the operating theatre while imaging with the O-arm^®.

     

The Lap-Band<Superscript>®</Superscript> System in a North American Population

Background: European and Australian results with laparoscopic adjustable gastric banding (LAGB) using the Lap-Band^? (Inamed Health, Santa Barbara, CA) have been impressive, with over 100,000 procedures completed at this writing. However, prior to U.S. FDA approval in June 2001, U.S. patients had to travel out of the U.S. for this procedure. This study reports on a series of U.S. patients who requested off-shore referral for LAGB placement. Methods: 105 U.S. patients were implanted with the Lap-Band System^? in Mexico by one surgeon in a private practice. 70% were implanted with the perigastric approach, while the final 30% were implanted using the pars flaccida approach. Routine postoperative visits, including band adjustments, were completed in a private U.S. clinic where medical staff performed frequent small adjustments as necessary to optimize results. Data were collected from concurrent and retrospective chart reviews and from telephone interviews. Summary statistics provided for baseline measures included mean ± standard deviation. Postoperative measures of weight loss included mean ± standard error. Results: Weight loss results were comparable to international results: 61% EWL at 12 months (n=50), 75% EWL at 24 months (n=37), 72% EWL at 36 months (n=24), and 60% EWL at 48 months (n=7). There were few major complications. Conclusion: Attention to patient management is essential to success, and this study found that appropriately-managed U.S. LAGB patients can be as successful as their international counterparts. Frequent follow-up delivered by a bariatric team with easy access to band adjustments is essential.