The Acquired Chiari Malformation and Syringomyelia Following Spinal CSF Drainage: A Study of Incidence and Management

Summary Firstly, 14 patients are described who developed either an acquired Chiari malformation (ACM) alone (7 cases) or ACM and syringomyelia (7 cases) after lumbar subarachnoid space (SAS) shunting or in one case, epidural anaesthesia with SAS penetration. Four groups are considered: 3 cases with craniofacial dysostosis and communicating hydrocephalus (CH), 4 cases with CH alone, 3 cases with pseudotumour cerebri (PTC) and a miscellaneous group (4 cases). Initial treatment was varied: resiting the shunt to ventricle or cisterna magna [6], adding an H-V valve [1], syrinx shunting [4] and posterior fossa decompression [3]. Further treatment was required in 6 cases. Secondly, incidence was examined in 87 patients with PTC initially treated either by lumbar SAS shunting [70] or cisterna magna shunting [17]. In the first sub-group, 11 cases (15.7 percent) developed an ACM, 3 symptomatic (as above) and eight asymptomatic with 1 case also having syringomyelia whereas 1 case occurred in the second group with a questionanably symptomatic ACM. While accurate for symptomatic lesions, these figures are tentative with respect to asymptomatic lesions due to inadequate pre-treatment radiology and detailed MR follow-up. The main conclusions are, first, that the incidence of symptomatic ACM and/or syringomyelia is not high enough to warrant abandoning SAS shunting; second that asymptomatic lesions need not neccessarily be treated and third, that when treatment is required, shunt resiting is the first choice.     

Bilateral combined femoral neck and acetabular fractures due to cerebro-vascular ischaemic induced convulsion

Summary Skeletal fractures and joint dislocations secondary to sustained myoclonic activity occur infrequently. Fractures at or around the hips resulting from seizures are extremely rare. Causes have included: 1. electroconvulsive therapy [1], 2. idiopathic epilepsy [2], 3. hyponatraemia [3, 4], 4. eclampsia [5], 5. alcohol withdrawal [6], 6. Renal failure [7], and 7. prolonged, sustained myoclonus [8]. We report a unique case with an unusual skeletal injury pattern secondary to an unusual cause.     

Transcervical videoscopic esophageal dissection in minimally invasive esophagectomy

Background  

Minimally invasive esophagectomy (MIE) may involve video-assisted thoracoscopic surgery (VATS) for mediastinal esophageal dissection. Usually, VATS requires single-lung ventilation and has associated cardiopulmonary morbidity [1–3]. Alternatively, transhiatal dissection can be performed, although its complications include vocal cord palsy [4], cardiac arrythmias [5], and increased bleeding [5, 6], the latter associated with mortality after esophagectomy [2]. Therefore, the feasibility of MIE using transcervical videoscopic esophageal dissection (TVED) in swine was investigated. A simultaneous laparoscopic and TVED approach may decrease operative time and blood loss while improving visualization and avoiding single-lung ventilation.     

Epidemiology,Aetiology, and Pathogenesis of Renal Cell Carcinoma

Significant advances in molecular medicine have made renal cell carcinoma (RCC) the prototype solid organ malignancy for targeted medical cancer treatment. Theseis new options have made it possible to prolong the life of patients with metastatic disease. However, we are far away from thoroughly understanding the molecular processes of RCC development let alone from being able to cure advanced renal cancer. RCC is the most common renal neoplasia and it remains a very aggressive and often fatal disease.There are several known histologic subtypes of this heterogeneous tumor entity with associated distinct molecular alterations and different clinical outcomes [1], [2], [3], [4]. The clear cell renal cell carcinoma (ccRCC) is the most common and apparently most aggressive RCC subtype with the highest rates of local invasion, metastasis and mortality. It constitutes 70–80% of all renal cancers [1], [5]. It is estimated that more than 30% of patients with RCC have metastatic disease at the time of diagnosis and 30% of organ-confined RCCs will develop metastatic disease after local treatment [6]. Thus, RCC remains a very major challenge.     

Cutaneous mucormycosis secondary to penetrative trauma

IntroductionMucormycosis is a rare but serious sequelae of penetrating trauma [1], [2], [3], [4], [5]. In spite of aggressive management, mortality remains high due to dissemination of infection. We completed a review of literature to determine the most optimal treatment of cutaneous mucormycosis which occurs secondary to penetrating trauma.MethodsWe completed a review regarding the management of mucormycosis in trauma patients. We selected a total of 36 reports, of which 18 were case-based, for review.ResultsSurgical debridement is a primary predictor of improved outcomes in the treatment of mucormycosis [3], [6], [7]. Anti-fungal therapy, especially lipid soluble formulation of Amphotericin B, is helpful as an adjunct or when surgical debridement has been maximally achieved. Further research is needed to fully evaluate the impact of topical dressings; negative pressure wound therapy is helpful.ConclusionAn aggressive and early surgical approach, even at the expense of disfigurement, is necessary to reduce mortality in the setting of cutaneous mucormycosis that results from penetrating trauma [4], [8], [9]. Anti-fungal therapy and negative pressure wound therapy are formidable adjuncts.     

Severe septic arthritis of the shoulder with an axillary nerve lesion in a 4-year-old child

Septic arthritis in children frequently affects the joints of the lower extremity, namely the hip and the knee [1–3]. Infection in the glenohumeral joint is rare [4–7], representing 4% of all joint infections [4, 5]. Arthralgia, joint swelling, fever and pseudoparalysis are the most commonly observed symptoms [1, 4, 5, 8]. Diagnosis and thus appropriate management are often delayed [4] and therefore early disease recognition and treatment play a significant role in minimising the risk of developing complications such as joint surface destruction, growth arrest, adjacent osteomyelitis, and loss of joint movement [1, 4–6]. Brachial plexopathy, is infrequently reported [13], and a lesion to the axillary nerve specifically has not yet been reported in literature to our knowledge. Treatment aims include adequate washout and debridement of the joint with the objective of relieving pain and restoring function [5]. This can be achieved either via arthrotomy or arthroscopically [2, 5]. However there is currently no clear consensus with regard to which management option leads to improved outcome [3, 8], because of the lack of studies describing the results of surgical intervention [9]. The case of a 4-year-old boy with a delayed diagnosis of septic arthritis of the right shoulder with massive abscess formation and an axillary nerve lesion is presented.     

Non specific increased expression of class I major histocompatibility complex (MHC) antigens on rat liver grafts

Major histocompatibility complex (MHC) antigens play a major role in the rejection reaction and their increased expression may increase the host response to the foreign graft [1]. Several clinical [2–5] and experimental studies [6, 7] have demonstrated increased expression of MHC antigens on the different cell components of liver allografts during rejection. However modified expression of MHC antigens may also occur in certain liver diseases [8–10], after cholestasis [11] or on a regenerating liver [11]. In this experimental study in inbred rats, we compared the expression of MHC antigens on liver cells during rejection and non-immunological situations (cholestasis, cytolysis, regeneration).     

Glutealnekrose nach Ausschaltung eines rupturierten Iliakalaneurysmas

Chronic hypoperfusion of the hypogastric arteries due to aortoiliac surgery leads to a complex of symptoms well known as Lerich's syndome. In contrast, acute ischemia of the pelvic arterial tree leads to lethal complications [2, 4, 5, 9, 10, 12, 13]. Acute interruption of the hypogastric perfusion mainly occurs after aortoiliac surgery or after selective transcatheter embolisation of the internal iliac artery for control of pelvic bleeding [1, 8]. Several complications may occur after total occlusion: urinary bladder necrosis [6], left colon ischemia, spinal cord ischemia [10], nerve palsy, necrosis of the rectum and gluteal musculature [2, 11–13]. Despite adequate therapy, mortality is over 70% [2]. We report the case of a 66-year-old patient who survived after acute occlusion of the iliac arteries with gluteal necrosis following replacement of the infrarenal aorta with an aortobiiliacal graft.     

Ventricular arrhythmias following continuous-flow left ventricular assist device implantation: A systematic review

Ventricular arrhythmias (VA) are not uncommon after continuous-flow left ventricular assist device (CF-LVAD) implantation. In this systematic review, we sought to identify the patterns of VA that occurred following CF-LVAD implantation and evaluate their outcomes. An electronic search was performed to identify all articles reporting the development of VA following CF-LVAD implantation. VA was defined as any episode of ventricular fibrillation (VF) or sustained (>30 seconds) ventricular tachycardia (VT). Eleven studies were pooled for the analysis that included 393 CF-LVAD patients with VA. The mean patient age was 57 years [95%CI: 54; 61] and 82% [95%CI: 73; 88] were male. Overall, 37% [95%CI: 19; 60] of patients experienced a new onset VA after CF-LVAD implantation, while 60% [95%CI: 51; 69] of patients had a prior history of VA. Overall, 88% of patients [95%CI: 78; 94] were supported on HeartMate II CF-LVAD, 6% [95%CI: 3; 14] on HeartWare HVAD, and 6% [95%CI: 2; 13] on other CF-LVADs. VA was symptomatic in 47% [95%CI: 28; 68] of patients and in 50% [95%CI: 37; 52], early VA (<30 days from CF-LVAD) was observed. The 30-day mortality rate was 7% [95%CI: 5; 11]. Mean follow-up was 22.9 months [95%CI: 4.8; 40.8], during which 27% [95%CI: 17; 39] of patients underwent heart transplantation. In conclusion, approximately a third of patients had new VA following CF-LVAD placement. VA in CF-LVAD patients is often symptomatic, necessitates treatment, and carries a worse prognosis.     

Functional results after transvaginal, transperineal and transrectal correction of a symptomatic rectocele

INTRODUCTION: The aim of this study was to compare functional outcome after transvaginal, transperineal and transrectal repair of a symptomatic rectocele and to develop the ideal surgical approach. PATIENTS AND METHOD: 28 patients (27 female, 1 male) who had undergone rectocele repair from 1996 to 2003 were analysed. Mean age was 59 years (range 30-79 years), follow-up was 24 months (range 3 to 70 months) and mean appearance of symptoms was 4 years prior to the operation (6 months-32 years). Transvaginal repair was performed in 13 cases, transperineal repair in 8 cases and transrectal repair in 7 cases. RESULTS: 24 of 28 patients (85.7 %) are satisfied with the operation-result (transvaginal 12 of 13 patients [92.3 %], transperineal 7 of 8 patients [87.5 %] and transrectal 5 of 7 patients [71.4 %]). 25 patients (89.3 %) are free of complaints or describe an evident improvement of symptoms (transvaginal 12 of 13 patients [92.3 %], transperineal 7 of 8 patients [87.5 %] und transrectal 6 of 7 patients [85.7 %]). There is one postoperative dyspareunia. DISCUSSION: Best treatment of a rectocele starts with patients selection. Considering pelvic floor as functional unity, concomitant urologic-gynaecologic lesions and proximal intraabdominal disturbances the appropriate surgical procedure is selected. CONCLUSION: Surgical approach to correct a symptomatic rectocele depends on the concomitant lesion.     

Außenmeniskusresektion unter Sicht des Arthroskops

Operationsprinzip Partielle oder totale Entfernung des Au?enmeniskus nach dem Prinzip der ?Triangulation?. Der Meniskus wird unter Sicht des Arthroskops reseziert. Ein spezielles Operationsarthroskop ist nicht erforderlich. Zusatzinstrumente werden über gesonderte Zug?nge ins Gelenk eingebracht. Die Technik orientiert sich weitgehend an der von Gillquist [1,2,3,4], berücksichtigt aber zudem Angaben von Glinz [5], Holder [6] und Klein [7].      

Prolongation of heart allograft survival in rats by interferon-specific antibodies and low dose cyclosporin A

Interferons (IFNs) are important cytokines which exhibit antiviral, antitumor, anticellular, as well as immunoregulatory activities [1]. Among these multiple activities, IFNs are potent inducers of MHC antigen expression of a great variety of cells [2–4], helper and maturation factors in B-cell antibody production [5], and macrophage function [6]. IFNs may therefore play a critical role in triggering antigen recognition and allograft rejection. Cyclosporin A (CyA) is a potent immunosuppressor which selectively inhibits helper T-lymphocyte proliferation in response to alloantigen presentation [7, 8]. CyA has been reported to inhibit interleukin 2 and IFNγ production by helper T lymphocytes [9–11]. In addition, CyA may induce monocyte production of prostaglandin E2 [12], which then reduces MHC class II expression on endothelial cells, monocytes, and macrophages [13]. However, the clinical use of CyA is plagued by its toxic (in particular nephrotoxic) side-effects. These toxic effects are clearly dose-related. It may be very important to develop new products which can act synergistically with CyA to inhibit lymphokine production. The aim of this study was to investigate the effects of combined IFN-specific antibodies and low dose CyA on cardiac allografts in inbred strains of rats.     

Arthroscopic lateral meniscectomy

Surgical Principle Partial or total arthroscopic lateral meniscectomy by triangulation. A special arthroscope is not necessary. Additional instruments are inserted through separate portals. The technique used was originally described by Gillquist [1–4] and modified based on information given by Glinz [5], Holder [6], and Klein and Schulitz [8]. Revised Version from: Operat. Orthop. Traumatol. 1 (1989), 53–61 (German Edition).     

Outcome of percutaneous nephrostomy for the management of pyonephrosis

OBJECTIVE: The aim of this study was to evaluate the efficacy of percutaneous nephrostomy (PCN) drainage for the interim management of pyonephrosis. METHODS: Ninety-two consecutive patients [29 men, 63 women; mean age, 57 years; range, 23 to 88] who underwent PCN for the treatment of pyonephrosis from 1996 to 1999 were evaluated retrospectively. The clinical presentation, bacteriology and patient outcomes were analyzed. RESULTS: The majority [77%] of patients had underlying obstructing urinary calculi. Other causes of obstruction included strictures [9%], papillary necrosis [7%], pelvi-ureteric junction obstruction [4%] and malignant stricture [3%]. The microorganisms cultured were Escherichia coli [30%], Klebsiella [19%], Proteus [8%], Pseudomonas [5%], Enterococcus [5%], and Candida spp [5%]. The microorganisms were sensitive to gentamicin [79%], ceftriaxone [71%], cephalexin [54%], nitrofurantoin [40%], cotrimoxazole [35%], nalidixic acid [32%] and ampicillin [29%]. Only 30% of bladder urine cultures were positive for microorganisms; the addition of PCN cultures improved this yield to 58%. The antibiotic regimen was revised according to the PCN culture whenever there was a discrepancy. After PCN, 69% of patients underwent minimally invasive procedures as definitive treatment of the obstructing lesion. Only 14% of patients required open surgery. There was low procedure-related morbidity [14%] and low overall mortality [2%]. CONCLUSIONS: PCN cultures yield important bacteriological information. The procedure is associated with minimal morbidity, facilitates definitive treatment and provides therapeutic benefit.     

Risk factors for postoperative hypocalcemia after surgery for primary hyperparathyroidism

HYPOTHESIS: A variety of clinical and biochemical variables may be associated with hypocalcemia after surgery for parathyroid adenoma. DESIGN: A prospective study of patients who underwent surgery for solitary parathyroid adenoma. SETTING: A university hospital department of surgery. PATIENTS: Eighty-six consecutive patients who underwent surgery for solitary parathyroid adenoma. INTERVENTION: Parathyroidectomy according to the principles of unilateral neck exploration. MAIN OUTCOME MEASURES: Clinical and biochemical risk factors for early (< or =4 days after surgery) and late (1 year after surgery) postoperative symptomatic and biochemical hypocalcemia. RESULTS: Twenty-two patients developed early symptomatic hypocalcemia. The difference in total serum calcium levels between patients, with and without early symptomatic hypocalcemia, was evident on the third and fourth postoperative days. Serum level of osteocalcin greater than 6.0 microg/L, bilateral neck exploration, and history of cardiovascular disease were risk factors for symptomatic hypocalcemia (odds ratios [95% confidence intervals]: 4.4 [1.4-14.1], 3.8 [1.3-11.6], and 0.1 [0.02-0.60], respectively). Patients with up to 1 risk factor had a possibility of only 7% to develop early symptomatic hypocalcemia. One year after surgery, 16 patients had low levels of total serum calcium (late biochemical hypocalcemia) and were asymptomatic. Preoperative intermittent hypercalcemia was associated with an increased risk for late biochemical hypocalcemia (odds ratio, 3.9; 95% confidence interval, 1.0-16.3). CONCLUSIONS: Clinical and biochemical risk factors for early and late postoperative hypocalcemia in patients who underwent surgery for solitary parathyroid adenoma were found. A clinically useful prognostic index for early symptomatic hypocalcemia was constructed using these risk factors.     

Central nervous system germ cell tumors

Opinion statement Germ cells tumors most commonly affect children and adolescents, and occasionally arise in the central nervous system. Except for mature teratomas, they are all malignant. Pure germinomas are exquisitely sensitive to treatment and are highly curable with craniospinal radiation therapy [1], [2], [3]. Surgery plays no role other than to establish the histologic diagnosis [4]. Diagnostic confirmation includes normal levels of serum and cerebrospinal fluid alpha-fetoprotein and at most only minor elevations in beta human chorionic gonadotrophin (beta-hCG). Although it has become quite common to use chemotherapy to reduce the dose and field of radiation in the treatment of germinomas [5]-[7], longer follow-up in these patients is revealing a significant number of subarachnoid and ventricular recurrences [2], [8], [9]. A recent follow-up study in patients treated for intracranial germinomas showed no significant difference in the psychosocial functioning of those treated with chemotherapy and radiation compared with those treated with chemotherapy alone, which raises further questions about the rationale for modifying a proven successful treatment [10]. Malignant nongerminomatous germ cell tumors are much more resistant to treatment and difficult to cure [11], [12], [13]. Surgical resection appears to have prognostic significance [11], [14], although the predilection for midline structures makes complete resection difficult if not impossible at times. The best results have been obtained with platinum-based chemotherapy and full-dose craniospinal radiation therapy [15], [16]. Pure teratomas are not typically responsive to chemotherapy or radiation therapy and surgery is the only proven treatment modality.     

Anaesthetic depth at inductionAn evaluation using clinical eye signs and EEG polysomnography

We describe the stages of non-REM sleep induced by anaesthesia with sevoflurane 8% in oxygen and relate these stages to clinical eye positions. We explored John Snow's observation (1847) that 'when voluntary movement ceases, with the eyes fixed in an upward gaze during the gas induction of anaesthesia, the patient is protected against the risk of mental suffering' (awareness). Unpremedicated ASA 1 patients undergoing elective tonsillectomy were studied using EEG polysomnographic principles and clinical eye movement tracking. The results expressed as median and range were: latency to stage 1 sleep 4.5 min [2.5–7.5], stage 2 sleep 5 min [3.5–8.5], stage 3 sleep 5.5 min [4–12] and stage 4 sleep 6 min [4.5–15.5]. Eye position 5, the point of no further eye movement, was reached after 9 min [5.5–18.5]. This was significantly longer than the time taken to reach the stage 4 sleep EEG, p < 0.01, supporting Snow's observation and encouraging investigation into eye movement tracking technology as a potential monitor of anaesthetic depth.     

A brief review of ultrasensitive prostate-specific antigen assays for the evaluation of patients after radical prostatectomy

Summary The development of immunoassays for prostate-specific antigen (PSA) and their clinical utility are summarized. Because of the complexity of the PSA molecule and anti-PSA antibodies, there is currently no standard in PSA measurement [1, 2]. Evaluating various immunoassays requires the knowledge of the lower limit of detection as well as the biological and clinical thresholds of a given assay [1]. There have been recent reports demonstrating earlier detection of residual prostate cancer after radical prostatectomy by ultrasensitive assays for PSA [3, 4]. Because of the recent evidence for non-prostatic sources of PSA such as the male urethra [5–7], the possibility of their contaminating PSA levels must be evaluated when more sensitive assays for PSA are under consideration.This work was funded in part by a grant from the American Foundation of Urologic Disease, by the American Cancer Society, by the Richard M. Lucas Cancer Foundation, and by the Veterans Administration.     

Cyclosporin A (CsA) and azathioprine (AZA) combination in renal allografts with CsA nephrotoxicity

Cyclosporin A (CsA) is a potent immunosuppressive drug whose effect is well known in the organ transplantation field. Treatment with CsA reduces the incidence of rejection and improves graft survival after renal transplantation (RT). However, to set against the clear advantages of CsA, a most important problem is nephrotoxicity [1, 3]. Scientists are therefore seeking new non-nephro-toxic Cs derivatives, but the search has not yet borne fruit. Teams working in organ transplantation attempt to avoid nephrotoxicity by switching to conventional treatment with azathioprine (AZA), starting 1, 3 or 6 months after transplantation [8, 11]. Conversion from CsA to AZA has not always been successful due to the high incidence of rejection [4]. AZA has also been started immediately after transplantation in combination with CsA at low doses [5], and in some instances no CsA is administered when oliguric acute tubular necrosis is present [10]. In a previous report [2], we presented the short-term results of the treatment with a CsA—AZA combination, reducing the CsA dose and giving a moderate dose of AZA in 21 transplanted patients not achieving acceptable graft function. In the present study we analysed the long-term results in a group of patients whose kidney biopsy examination results were compatible with CsA nephrotoxicity.     

Use of titanium cages with cancellous bone graft in hind foot fusion: literature review and case reports with complications

Titanium cylindrical surgical mesh cages have been developed for use in spine surgery as intervertebral spacers and for vertebral defect replacement [1], [2], [3], [4], [5].Their use has been extended to treat long bone segmental defects and the technique to achieve this has been reported [6]. However, there are no reports on use of these cages to achieve ankle arthrodesis in patients. We came across two cases where titanium cylindrical cages with bone graft were used to achieve ankle arthrodesis. These cases were associated with complications of infection in one and bone resorption with collapse in the other. A review of the literature on the use of titanium cages elsewhere than in spine surgery is presented.