“Deflected” calyx sign

Despite the introduction of nephrotomography and renal angiography, routine excretory urography still is the main diagnostic tool in radiology that provides the necessary evidence for the diagnosis of renal tuberculosis. The “deflected” calyx sign results from stricture of an infundibulum which ultimately leads to complete obstruction and a space-occupying (pseudotumor) mass produced by a debris filled dilated calyx. Since no contrast medium enters the obstructed calyx, the normal middle calyx frequently appears to be “deflected”. When other typical radiographic evidence is absent, this sign should suggest renal tuberculosis.     

“Burried strip” versus “tube” in hypospadias repair: Analysis of 82 consecutive cases

The goal of this study was to analyze, discuss, and compare risks and results obtained with the “buried strip” and two “tube” techniques for hypospadias repair in a personal series. From 1976 through 1982, 82 patients underwent complete two-stage repair of hypospadias using either the Denis Browne procedure (23 patients) or the Belt-Fuqua technique (41) and Byars procedure (18), respectively. Only those patients with originally distal and mid shaft hypospadias plus chordee were included in this series. The mean age at the time of repair was 4.9 years, with a range of two to sixteen years. The overall complication rate was 13.4 per cent (11 of 82 The tube procedures alone had a complication rate of 6.8 per cent (4 of 59) compared with 30 per cent (7 of 23) with the Denis Browne technique. Complications noted were: fistulas 6 (Denis Browne 5, Belt-Fuqua 1); meatal stenosis 4 (Denis Browne 2, Byars 2); urethral stricture 1 (Belt-Fuqua Our results confirm the general belief that tube techniques have a higher reliability than does the Denis Browne procedure. Each procedure improves with the experience of the surgeon, although the tube technique appears to cause less trouble in our hands. The running subcutaneous and intracutaneous sutures give a far smoother healing. We believe this study supports the virtues of two-stage tube repairs.     

Subcapsular urinoma: Unusual form of “Page kidney” in newborn

The first case of renal hypertension resulting from a urinoma in a kidney secondary to vesicoureteral reflux from posterior urethral valves in a newborn is presented. High-pressure reflux resulted in formation of a subcapsular urinoma. Removal of the nonfunctioning “Page kidney” cured the persistent hypertension.     

Primary flexor tendon repair in “no man's land”

Fifty-eight patients with 67 fingers with flexor tendon injuries in Bunnell's “no man's land” treated with primary repair were re-examined 14–84 months after surgery. Thirty-five fingers had repair of both tendons, and in thirty-two fingers the superficialis tendon was excised and only the profundus tendon was repaired. Postoperatively thirty-one fingers were treated by Kleinert's rubber band traction, and in thirty-six fingers a dorsal plaster of Paris was applied. The functional end-result was evaluated according to the method of Buck-Gramcko. Seventy-four per cent of fingers with suture of both tendons and 47 per cent of fingers with suture of only the prof undus tendon attained an excellent or good result. The fingers treated by Kleinert's rubber band traction achieved the most favourable functional result, but many inconstant factors had influence upon this evaluation. The number of re-operations were significantly higher after repair of only the profundus tendon.     

Adjuvant chemotherapy for breast cancer—“one fits all”?

Adjuvant breast cancer therapy and early diagnosis will improve breast cancer outcome. The Eurocare studies have demonstrated large differences in breast cancer incidence and mortality in different regions and countries and underlined the importance of access and quality in the management of early disease. So far, the very important survival gains by adjuvant therapy have been obtained by “one fits all”-like strategies, resulting in therapy in vain for many patients and unnecessary therapy for large cohorts. Present adjuvant strategies have focused on group statistical risk analysis, mainly using tumour stage, histological grade and receptor status. Five retrospective studies have revealed a worse outcome for patients receiving adjuvant chemotherapy without toxicity. In one of these studies the breast cancer survival was improved by 10% for patients who received grade 2/3 neutropenia; this is equivalent to the described survival gains by the addition of anthracyclines and taxanes to cyclophosphamide, methotrexate, 5-fluorouracil (CMF) combinations. Prospectively, this has been explored in the Scandinavian Breast Group (SBG) 9401-, SBG 2000-1- and presently in the SBG 2004-1 studies using tailored chemotherapy dosage strategies, aimed at avoiding under-dosage and diminishing acute side effects. For the future, we need several predictive factors for therapy, allowing better and more tailored therapy selections for individuals at risk. The present explorations of tumour RNA expression profiles are most likely to be useful in identifying therapy-predictive profiles for these individuals. Pharmacokinetic and pharmacodynamic data reveal marked differences in effect and tolerance of used drugs. The development of single nucleotide polymorphism technology are also likely to be important for optimising dosing strategies, aiming and increasing the effect, as well as decreasing toxicity. Taken together these strategies will be very different from the present “one fits all” concept.     

Scintigraphy in the evaluation of the “clinical” scaphoid fracture

In a prospective study we performed bone scans on 84 patients who had sustained a wrist injury and in whom a scaphoid fracture was clinically suspected but could not be confirmed on the original set of five routine “scaphoid view” radiographs. In 40 patients the bone scan was normal and in 25 there was increased uptake in areas other than the scaphoid. In 19 there was localized increased uptake in the scaphoid bone. In seven of these a scaphoid fracture was subsequently demonstrated on repeat radiographs (five cases) or a CT scan (two cases). In the remaining 12 no fracture could be demonstrated.     

“Suspension plasty”: Trapeziometacarpal joint reconstruction using abductor pollicis longus

Painful arthrosis of the trapeziometacarpal joint (thumb basal joint) is the most common degenerative condition leading to dysfunction of the critical thumb ray. An arthroplastic reconstruction of this joint should be simple in concept, use only autogenous tissue, achieve pain relief, maintain thumb ray length and mobility at the metacarpal base, restore stability for power pinch and grasp function, and achieve predictable, reproducible long-term results. “Suspensionplasty,” as described in this report, has been used by the author since 1981. Initially, the technique was conceived as a method for salvaging failed silicone trapezium implant arthroplasties. Since 1982, Suspensionplasty has been used as the author's procedure of choice for trapeziometacarpal reconstruction of the thumb. It has proven to satisfy the above criteria for arthroplastic reconstruction.     

The “Footprint” Anterior Cruciate Ligament Technique: An Anatomic Approach to Anterior Cruciate Ligament Reconstruction

To address the technical limitations of the conventional transtibial technique and the steep learning curve associated with double-bundle anterior cruciate ligament (ACL) reconstruction, we have defined a novel “footprint” technique that reliably allows for anatomic single-bundle ACL reconstruction with minimal technical complications. The technique merges the principles of carefully defining the ACL footprint anatomy with the use of a modified anteromedial portal reaming technique with a flexible guidewire and reaming system. The procedure offers the advantages of an anatomic ACL reconstruction by use of anteromedial portal reaming techniques while avoiding the significant technical risks and pitfalls associated with double-bundle reconstruction. Our experience in over 100 footprint ACL reconstructions has been met with excellent clinical success with minimal intraoperative or postoperative complications. The purpose of this article is to outline the key steps of our defined procedure that are critical to achieving a successful outcome.     

Posterior urethral stenosis in newborn with renal nonfunction syndrome

A newborn male infant presented with the “renal nonfunction syndrome” and subsequently was found at autopsy to have congenital stenosis of the posterior urethra. Additional urinary tract malformations included a prostatic diverticulum, bladder hypertrophy, bilateral hydroureter, and bilateral renal hypoplasia with dysplasia. Autopsy evidence suggested that the urethral stenosis had manifested itself very early during embryologic development and accounted for the associated urinary anomalies. The infant had the physical stigmata, clinical course, and pulmonary hypoplasia commonly observed in “Potter’s” or the “renal nonfunction syndrome.”     

Motorcyclist “biker couples”: A descriptive analysis of orthopaedic and non-orthopaedic injuries

The term “biker couple” is becoming an increasingly common site in emergency departments. The purpose of this study was to identify orthopaedic and non-orthopaedic injury patterns among this unique patient group. A 14-year (1993–2006) retrospective review of a Level I Trauma Institute Registry was performed. Patient demographic and injury data were obtained from 21 confirmed biker couples (n = 42). Nineteen of 21 biker couple pairs (90.5%) included a male driver and a female passenger. Drivers were more likely to have a positive blood alcohol concentration/toxicology test. Drivers had a greater incidence of scapular and rib fractures than passengers. Both drivers and passengers who sustained scapular fractures had a greater incidence of clavicle, rib, pelvis, and fibula fractures. Drivers with scapular fractures had a greater incidence of thoracic spine fractures, while passengers with scapular fractures had a greater incidence of arm–forearm–wrist–hand, femur, tibia, and foot–ankle fractures. Overall, biker couple drivers and passengers did not differ for head injury, pulmonary system, road rash, aortic injury or visceral injury. Both drivers and passengers with scapular fractures had a greater incidence of head injuries, and passengers had a greater incidence of pulmonary system, visceral injury and road rash. Both drivers and passengers who were not wearing a helmet had a greater incidence of head injuries. Unhelmeted drivers were more likely to sustain head injury than passengers. When a scapular fracture was present both drivers and passengers had a greater incidence of head injuries. Prospective investigations are needed to better delineate the precise mechanisms for these injury patterns.     

The Window Sign: An Aid in Laparoscopic and Robotic Radical Prostatectomy

Aim:Certain steps of laparoscopic radical prostatectomy (LRP) and robotic radical prostatectomy (RRP), such as identification of seminal vesicles, bladder neck and retroprostatic dissections are technically challenging specially during initial experience. We describe an important land mark : “Window sign”, which helps significantly during the procedure. Methods: The seminal vesicles can be dissected either through the transperitoneal, subperitoneal or extraperitoneal approach. In transperitoneal approach the vas deferens, seminal vesicles and Denonvillier’s fascia are dissected posteriorly, and this plane is re-entered after division of the prostate from the posterior bladder neck, and with division of the Denonvillier’s fascia. The communication between the anteriorly and posteriorly dissected planes in the retrovesical and retroprostatic space is termed “the window.” Alternatively, in the RRP technique, bladder neck is divided anteriorly and posteriorly and vas deferens and seminal vesicle pulled out through this window. We have found that this window in transperitoneal, subperitoneal or extraperitoneal approach whether done during laparoscopic or robotic radical prostatectomy, allows to retract the vas deferens and seminal vesicles to elevate the prostate, facilitates control of the prostatic pedicles, helps in dissection of the prostate and assists in the identification and careful avoidance of the neurovascular bundles. Results: This window sign was identified on the basis of our experience of over 450 cases of laparoscopic and robotic anatomical radical prostatectomies. We have followed this step in all of the cases by either technique. Conclusion: The “window sign” is an important aid while performing laparoscopic and robotic radical prostatectomy. This technique helps the surgeon to achieve both the anatomic and oncologic goals of the nerve sparing, during anatomic radical prostatectomy.     

Reversed “C” ministernotomy for aortic valve replacement

The technique of aortic valve replacement through a reversed “C” sternotomy incision is described. The sternal incision extends between the second and the fifth intercostal space and provides excellent exposure of the ascending aorta, the aortic root, and the right atrial appendage. The procedure can be performed with standard cannulation for cardiopulmonary bypass and conventional surgical instruments.     

Applying “cell surgery” to nerve repair: A preliminary report on the first ten human cases

We have applied a new technique of nerve repair, based on the principles of “cell surgery”, to ten nerve lesions of the upper limb. Eight lesions were recent, five to 36 hours; they were divisions of the ulnar nerve (1), median nerve (2), sensory radial nerve (1), palmar and digital nerves (4). One lesion was 15 days old (median nerve). One eight-month-old loss of 4.5 cm. of the median nerve was grafted.In nine out of the ten cases, the short-term results were encouraging. Poor local conditions (fibrosis of the nerve bed) or poor general health (chronic alcoholism) had no adverse influence on the results. In the remaining case, the protocol was not followed in its entirety: it was not possible to crystallise properly the nerve, and trimming was done with scissors in the conventional way instead of smoothly trimming the solidified tips. The functional result in this case is a failure. These preliminary results seem to indicate that correctly applying the technique in its entirety may be more important than local conditions.We think that this technique can be applied to the majority of nerve lesions. The appropriate equipment is absolutely necessary in order to apply the method.     

Unrecognized congenital posterior urethral minivalves in men

Removal of small congenital posterior urethral valves, unrecognized in prior urologic investigations of 10 men, relieved “prostatic” symptoms in 9. In follow-ups (5–20 years, average 12.5 years), 3 have experienced a recurrence attributed to bladder neck obstruction in 2 and to unknown causes in 1. Bladder neck incision carried out in 2, cured 1. The other was lost to follow-up.     

“Swiss cheese” septal defects: surgical closure using a single patch with intermediate fixings

Background. Residual ventricular septal defects and ventricular and septal dysfunctions are surgical drawbacks of “Swiss cheese” defects. We developed a technique that uses a single patch with intermediate fixings to cover the right side of the septum without producing a septal bulging, through a right atriotomy.

Methods. Since April 1993, 5 children with “Swiss cheese” defects have been operated on using this procedure (mean age, 17 ± 12 months). Three patients had associated lesions including tetralogy of Fallot, Taussig Bing heart, and mitral stenosis.

Results. There have been no early or late deaths. The mean follow-up time is 29 ± 18 months. All patients are asymptomatic. Echocardiography revealed either an intact septum (n = 4) or insignificant color jets at the apical portion of the septum (n = 1). The septal wall motion was preserved in 4 children and was hypokinetic in the fifth child.

Conclusions. This technique can be an additional tool to provide a secure closure of “Swiss cheese” defects even in the presence of associated cardiac lesions. Long-term consequences of this procedure on septal wall motion remain to be determined.     

“Reverse” superficial temporal artery-middle cerebral artery bypass

A new technical variant on the superficial temporal artery-middle cerebral artery anastomosis was performed in a patient with occlusions of both the left internal and external carotid arteries and persistent ischemic symptomatology. Instead of anastomosing the proximal segment of the superficial temporal artery to the middle cerebral artery as is conventionally done, the distal segment of the superficial temporal artery was anastomosed to a cortical branch of the left middle cerebral artery. Reconstituted flow of the left superficial temporal artery via right superficial temporal artey collateral branches proved adequate to relieve the patient's ischemic episodes. “Reverse” superficial temporal artery-middle cerebral artery anastomosis should be considered in those cases where occlusive disease of the external carotid circulation renders conventional bypass procedures ineffective in the treatment of ischemic symptomatology.     

To an understanding of the biology of sex and gender differences: “an idea whose time has come”

In 2001 the Institute of Medicine of the National Academy of Sciences United States published a report, “Exploring the Biological Contributions to Human Health: Does Sex Matter?”, which addressed and highlighted the role of biological sex differences in health and disease, including especially sex differences in non-reproductive areas of the male and female. The report aroused considerable interest and comment and had a significant role in stimulating the generation of a growing body of basic and clinical research on fundamental aspects of sex differences and its role in disease susceptibility, development, and aging. Sex is the most common human polymorphism that affects health and illness through the life cycle.This perspective provides a brief overview of the importance of the critical interlinked interactions of nature (genes and sex hormones) and nurture (environment and experience) on behavior and perception. Differences in gene expression in the male and female appear in the early embryo, before differentiation of the fetal gonads into a testis or ovary, the latter a consequence of the testis-determining SRY gene on the Y chromosome (a developmental switch). Gonadal differentiation results in a striking sex difference in the fetal sex steroid milieu and the phenotypic differences in the internal and external genital tracts that follows. Recent data provide evidence that in addition to the classic brain masculinizing effects of testosterone in the fetus, XX and XY brain cells show different patterns of gene expression even before gonadal differentiation. The functional and structural significance and magnitude of these brain sex differences are uncertain. The X chromosome contains a higher number of genes that have a major role in the development of general cognitive ability. Further, we now know that estrogen formed mainly in extragonadal tissues has an important multifaceted role in boys at puberty and in men.     

Asymptomatic Leg Atherosclerosis is Reduced by Regular Physical Activity. Longitudinal Results from the Cohort “Men Born in 1914”

Objective to study whether physical activity is associated with reduced occurrence of asymptomatic leg atherosclerosis. Design longitudinal and cross-sectional analyses of the population-based cohort “men born in 1914”. Methods comparison of the systolic ankle/arm pressure index (AAI) at age 68 in groups who were sedentary, performed some activity, and performed regular physical training at 55 and 68 years of age. Results at 55 years of age, 100 (27%) were sedentary, 209 (58%) reported some physical activity and 54 (15%) reported regular physical training. At 68 years, 194 men (53%) reported the same degree of physical activity, 127 (35%) reported a higher physical activity, and 42 (12%) reported lower physical activity. Physical activity at 55 years (p=0.03) and increased physical activity between 55 and 68 years ( p =0.03) were both associated with higher AAI at 68 after adjusting for potential confounders. At 68 years, AAI was 0.89±0.21, 1.01±0.13 and 1.05±0.11, respectively, in men who were sedentary, reported some physical activity, and regular physical training (p=0.0002). This association remained significant after adjustments for potential confounders. Conclusions regular physical activity is associated with reduced occurrence of asymptomatic leg atherosclerosis, even in men taking up exercise after age of 55.     

Contribution of thallium-201-SPECT to the grading of tumorous alterations of the brain

Single photon emission computed tomography (SPECT) with thallium-201-chloride (²⁰¹TI) was used in 22 patients to assess the grade of malignancy of brain tumors.Low- and high-grade malignant gliomas could be well differentiated by calculating the Grade Index (GI), i.e., ²⁰¹TI uptake in the tumor area relative to a contralateral brain region. Low-grade gliomas (WHO-grade I–II) usually showed a GI of <1.5. Tumors classified histologically as high-grade malignant (WHO-grade III–IV) had GI values greater than 1.42 and a mean value of 1.89.Until labelled amino-acid tracers for gamma-cameras become commercially available, thallium-201 brain-SPECT can provide an independent and complementary method to CT/MRI for the differential diagnosis of grading of brain tumors. This simple technique can help to reduce sampling errors during needle biopsies of brain tumors, particularly of high-grade lesions incorrectly graded as low-grade tumors due to inadequate biopsy material. In addition, pre- and post-therapy studies can influence the strategy of therapy itself and allow an early detection of recurrences.