Repeated grip strength at one month interval and detection of voluntary submaximal effort

This study was set up to test our hypothesis that using the Jamar dynamometer a voluntary submaximal effort has a greater variability compared to a real maximal effort, especially when there is a long interval between different measurements. We tested 32 volunteers without a history of upper limb injury or operation in our hospital, with an interval of four to five weeks between tests. Each volunteer was asked to grip first right-handed then left-handed, first with a real maximal effort and then with a submaximal effort. This test was performed twice during the same session. The same individuals were seen again one month later and were studied using the same protocol. Sensitivities and specificities for the grip test were calculated using six different criteria to indicate a submaximal effort. Repeated grip testing with a time interval of one month cannot reliably detect voluntary submaximal effort in healthy volunteers.     

肝移植术中连续温度稀释法监测心排血量的准确性

目的 评价肝移植术中连续温度稀释法监测心排血量(CO)的准确性.方法 13例非静脉-静脉转流原位肝移植术病人,术中采用Abbott Opti-Q CCO/SvO2连续心排血量仪监测CO(CCO);并于麻醉诱导后20、40、60、90、120 min、下腔静脉阻断5、15、25、35、45 min和下腔静脉开放5、15、25、60、90、120min时采用单次温度稀释法监测CO(BCO),连续测定3次,取其平均值;于BCO测定前后取两次CCO的平均值为该时点的CCO.计算各时点CCO与BCO间的相关系数,采用Bland-Altman法进行一致性检验.结果 共收集196对CO数据,CCO范围为1.9～17.9 L/min,BCO范围为2.1～18.3L/min.与其余时点比较.下腔静脉阻断5 min和下腔静脉开放5 min时CCO和BCO间的相关系数较低,偏离度较大,CCO监测存在明显的响应时间延迟现象;其他时点CCO和BCO间的偏离度为-0.18L/min,95%可信区间为-0.32～-0.03 L/min,一致性界限为-2.09～1.73 L/min,其下限的95%可信区间为-2.34～-1.84 L/min,其上限的95%可信区间为1.48～1.99 L/min.CCO和BCO的重复系数分别为0.36和0.86 L/min.CCO与BCO的平均值与CCO的差值为(0.09±0.49)L/min,CCO的相对误差为4.6%±1.7%.结论 肝移植术中血液动力学改变显著时,CCO存在明显的响应时间延迟现象;而在血液动力学相对稳定时,CCO和BCO之间缺乏良好的一致性,但CCO监测在临床上是可接受的.     

Effect of contact avoidance or treatment with oral prednisolone on bronchoalveolar lavage surfactant protein A levels in subjects with farmer's lung.

BACKGROUND: Surfactant protein A (SP-A) acts as an immune system modulator in the lungs and may therefore be involved in the pathogenesis of hypersensitivity pneumonitis. METHODS: The levels of SP-A in bronchoalveolar lavage (BAL) fluid were measured in 20 subjects with acute farmer's lung, 16 asymptomatic dairy farmers, and 14 normal controls. Eight patients had a second evaluation after one month of treatment by either contact avoidance (n = 3) or oral prednisolone (20 or 25 mg/day, n = 5). Chest radiographs and lung function measurements were also obtained in all farmers, twice in those re-evaluated after treatment. RESULTS: Patients with acute farmer's lung had significantly higher levels of SP-A than asymptomatic farmers and normal controls (p = 0.005) with mean (SE) values of 1.43 (0.29) micrograms/ml, 0.62 (0.09) microgram/ml, and 0.68 (0.11) microgram/ml, respectively. In eight subjects tested after one month of treatment the level of SP-A was unchanged although all were clinically improved. No correlations were seen between levels of SP-A in BAL fluid and numbers of BAL cells, lung function measurements, or chest radiographic scores. CONCLUSION: Although the level of SP-A is increased in the BAL fluid of patients with acute farmer's lung, it is not correlated with clinical abnormalities of this disease.     

Experience with an ultrasonic aspirator in neuroendoscopy.

This report describes the clinical application of an ultrasonic aspirator for endoscopic neurosurgery. Eight patients with intraventricular hematoma with complete tamponade of the ventricular system and marked hydrocephalus were treated with the ultrasonic aspirator for endoscopic neurosurgery. Clinical evaluation and neuroimaging studies were obtained for one month. Removal of hematoma was confirmed on follow-up imaging. The ultrasonic aspirator is operated by electrostriction transducer on low generating power (15-30 watts). Its tube has an outer diameter of 1.8 mm. This aspirator is designed to fragment and aspirate the cattle-liver. On observing the adjacent neural and vascular structures with the neuroendoscope, the massive hematoma within the ventricles is removed with the use of this aspirator. Subtotal removal (> 90% of hematoma volume) was achieved in all patients. All patients tolerated the procedure well. However, postoperative re-rupture occurred in two patients prior to aneurysm clipping following an immediate interval. Three patients with hypertension, two patients with head trauma, and one patient after aneurysm clipping were discharged home within one month after treatment. Preliminary experience with this aspirator has demonstrated its feasibility and safety. Clinical application of this technique is expected in other fields of neurosurgery.     

Percutaneous internal fixation of scaphoid fractures via an arthroscopically assisted dorsal approach

Percutaneous internal fixation of scaphoid fractures allows for more predictable union and less morbidity than cast treatment or open internal fixation. A headless cannulated compression screw (standard Acutrak) is implanted by way of a dorsal percutaneous approach with the aid of fluoroscopy and arthroscopy to confirm screw position and fracture reduction. This technique is indicated in the correction of acute proximal pole fractures, acute waist fractures, and delayed unions that are not associated with avascular necrosis or collapse. The details of this technique are reviewed. In a consecutive series of twenty-seven fractures (seventeen waist fractures and ten proximal pole fractures) treated with arthroscopically assisted dorsal percutaneous fixation, computed tomographic scanning confirmed 100% union at an average of twelve weeks. Eighteen fractures were treated within one month after the injury, and nine were treated more than one month after the injury. In this series, the fractures that were treated early (less than one month after the injury) healed more quickly than those treated later.     

Hamstring腱在体内重塑与转归的组织学研究

目的探讨游离Hamstring腱作为替代腱重建前十字韧带（anterior cruciate ligament，ACL）后在体内的重塑与转归过程，初步确定其术后在体内成熟的时间。方法33例关节镜下自体同侧游离4-5股Hamstring腱重建ACL的患者在行关节镜下再视手术时，于移植腱体中下段取活检组织进行组织学观察。重建术至再视手术的平均时间为11．9个月。替代腱依据重建术至再视手术的时段分为1月～、4月～、7月～、10月～、13月～、18月～和25月～组。将替代腱与正常ACL和半腱肌腱组织进行对比。结果重建ACL的Hamstring腱随植入时间延长，组织结构呈现其胶原纤维由不规则排列逐步向同向排列，排列不规则的菱形成纤维细胞逐步向较规则排列的椭圆形类纤维细胞转变，且细胞数目逐渐减少，血管腔数目也不断减少。上述的重塑变化主要发现在7月～组以前，其后各组重塑变化过程缓慢。结论自体游离Hamstring腱重建ACL术后具有良好的早期存活、加快再血管化和重塑过程的组织特性。其术后的重塑与成熟过程与自体髌腱相似，自体Hamstring腱在体成熟的时间为7-9个月。     

Four or twelve months' follow-up in the evaluation of functional outcome after hip fracture surgery?

BACKGROUND AND AIMS: As a rule, follow-up for at least one year is recommended for fracture studies. This is considered the shortest reliable interval. Still, in the case of hip fractures of the elderly, shorter follow-up might be more practical, since the life expectancy of these patients is often short. The aim of this study was to see if a short four months follow-up period would be acceptable in hip fracture surveys. MATERIAL AND METHODS: Information on 196 consecutive non-pathological hip fracture patients aged 50 years or over (mean 79 years) was collected using a standardised hip fracture audit concentrating on functional measurements at admission and at four and twelve months' follow-ups. RESULTS: 167 patients were alive at four months and 152 and at one year. The patients who died between four and twelve months had poorer functional capacity in the four- month evaluation than those who survived one year. The analysis of repeated measures, including only the patients alive at the last follow-up, showed that residential status, use of walking aids and 6 out of 10 and ADL variables (bathing, toileting, shopping, household activities, doing laundry, banking) did not change significantly. Walking ability and the rest 4 ADL variables (dressing, eating, food preparation, use of transportation) improved and pain decreased. CONCLUSIONS: Due to high mortality and age-related deterioration of functioning, no steady state i.e. "final result" is ever reached after hip fracture in the elderly. Four-month follow-up is justified as the shortest possible period, because the socioeconomically most important variable, i.e. place of living, and most of the ADL functions do not change significantly after that.     

Inguinal hernia repair: which suture?

Two hundred and fifty six consecutive inguinal hernia repairs in one hospital over a 15 month period have been reviewed. There was a significant association (P less than 0.00001) between the length of history and postoperative complication rate. The use of braided suture was associated with an apparent increase in sepsis and recurrence rate (P less than 0.1). Synchronous bilateral repair was not associated with an increase in complications. It is concluded that the use of braided suture material in an inguinal hernia repair may result in an unacceptable level of sepsis and recurrence. It is also concluded that attempts to reduce the interval between the onset of an inguinal hernia and operative repair will result in lower complication rates.     

Transient diminished airway protection after transhiatal esophagectomy

Fifteen consecutive patients undergoing transhiatal esophagectomy for esophageal carcinoma were studied cineradiographically to evaluate postoperative pharyngeal function. Cinepharyngo-esophagograms were obtained preoperatively and 1 week (range: 6 to 10 days) and 1 month (range: 18 to 52 days) postoperatively. One week after transhiatal esophagectomy, new radiographic swallowing abnormalities were identified in 10 patients (67%). The most common abnormalities observed were laryngeal penetration or aspiration (seven patients, 47%) and incomplete laryngeal elevation (five patients, 33%). Abnormal epiglottic tilt was seen in only two patients (13%). No postoperative pharyngeal retention and no cricopharyngeal obstruction to swallowed contrast was observed. One month after transhiatal esophagectomy, all radiographic swallowing abnormalities had resolved or improved. Laryngeal penetration or aspiration is common after transhiatal esophagectomy and is a consequence of diminished airway protection with incomplete laryngeal elevation rather than a result of esophageal obstruction with "spill-over" aspiration. These changes resolve or improve within the first postoperative month.     

Prevention of transient urinary incontinence in peri-operative period of modified holmium laser enucleation of the prostate (HoLEP)

From February 2005 to April 2007, 48 consecutive patients with BPH underwent holmium laser enucleation of the prostate (HoLEP) combined with mechanical morcellation. The first 14 cases (group 1) underwent HoLEP according to Gilling's method. In the next consecutive 17 cases (group 2), in addition to HoLEP performed as in group 1, the urethral external sphincter was stimulated electrically with a needle electrode inserted in a transperineal manner to prevent sphincteric injury. In the latter 17 consecutive cases (group 3), we used a modified HoLEP procedure, which partially preserved the apical adenoma in the 10-to 2-o'clock position. International Prostate Symptom Score, quality of life index, urinary flow (Qmax) data, and postvoid residual urine were significantly improved postoperatively in each group, there being no differences among them with the exception that group 3 had better Qmax data than group 3 at one month after operation. On the other hand, postoperative transient urinary incontinence was significantly reduced in group 3 on the day of discharge and 1 month after the operation. These results demonstrate that our modified HoLEP procedure is a promising method to avoid postoperative transient urinary incontinence.     

Intraoperative use of a new angle-independent Doppler system to measure arterial velocities after carotid endarterectomy

OBJECTIVE: The purpose of this study was to assess the intraoperative use of a new angle-independent ultrasound scan device (EchoFlow [EF]) in measurement of carotid artery velocities after endarterectomy. Specifically, the purpose was to determine the reproducibility of velocity measurements obtained with EF and to compare these measurements with the velocity measurements obtained with duplex ultrasound scan. METHODS: Velocity measurements of the common, internal, and external carotid arteries were performed by the operative surgeon with EF in 65 consecutive patients after carotid endarterectomy (36 female, 29 male; mean age, 71 years). Three velocity measurements were obtained from each of the arteries with EF and compared with the velocity measurements obtained with duplex ultrasound scan performed by a radiologist. RESULTS: Velocity measurements obtained with the EF device were reproducible in the common, internal, and external carotid arteries (intrapatient correlation coefficients, 0.95, 0.96, and 0.95, respectively). Seventy-five percent of common, 88% of internal, and 78% of external carotid velocity measurements obtained with the angle-independent ultrasound scan device were within 25 cm/s of the velocities measured with duplex ultrasound scan. The mean differences in velocity measurements between EF and duplex scan were -12 cm/s in the common, -8 cm/s in the internal, and -11 cm/s in the external carotid arteries. Differences between the EF device and duplex scan velocity measurements correlated with increasing arterial velocities in each of the three arteries measured (P <.05). CONCLUSION: Reproducible measurements of carotid artery velocity may be obtained with a new angle-independent Doppler system after endarterectomy. Most measurements obtained with the EF system are clinically comparable with those obtained with standard duplex ultrasound scan. This novel low-cost device may be useful in the intraoperative assessment of hemodynamic adequacy of carotid endarterectomy.     

Radiosurgery of growth hormone-producing pituitary adenomas: factors associated with biochemical remission

OBJECT: The authors reviewed outcomes after stereotactic radiosurgery for patients with acromegaly and analyzed factors associated with biochemical remission. METHODS: Retrospective analysis was performed for 46 consecutive cases of growth hormone (GH)-producing pituitary adenomas treated by radiosurgery between 1991 and 2004. Biochemical remission was defined as a fasting GH less than 2 ng/ml and a normal age- and sex-adjusted insulin-like growth factor-I (IGF-I) level while patients were not receiving any pituitary suppressive medications. The median follow up after radiosurgery was 63 months (range 22-168 months). Twenty-three patients (50%) had biochemical remission documented at a median of 36 months (range 6-63 months) after one radiosurgical procedure. The actuarial rates of biochemical remission at 2 and 5 years after radiosurgery were 11 and 60%, respectively. Multivariate analysis showed that IGF-I levels less than 2.25 times the upper limit of normal (hazard ratio [HR] 2.9, 95% confidence interval [CI] 1.2-6.9, p = 0.02) and the absence of pituitary suppressive medications at the time of radiosurgery (HR 4.2, 95% CI 1.4-13.2, p = 0.01) correlated with biochemical remission. The incidence of new anterior pituitary deficits was 10% at 2 years and 33% at 5 years. CONCLUSIONS: Discontinuation of pituitary suppressive medications at least 1 month before radiosurgery significantly improved endocrine outcomes for patients with acromegaly. Patients with GH-producing pituitary adenomas should not undergo further radiation therapy or surgery for at least 5 years after radiosurgery because GH and IGF-I levels continue to normalize over that interval.     

THE VALUE OF DUPLEX SCANNING IN SURVEILLANCE OF INFRA-INGUINAL VEIN AND SYNTHETIC GRAFTS

The contribution of duplex scanning to improving early diagnosis of graft stenosis was evaluated in 195 patients after infra-inguinal bypass procedures. Over a 31 month period, 406 duplex scans were obtained on 232 limbs with 191 vein and 41 polytetrafluoroethylene (PTFE) grafts. Peak systolic velocities > 200cm/s with spectral broadening and lumen reduction on B-mode image were the criteria adopted for identification of a haemodynamically significant (> 50%) stenosis. Sixty-one stenoses were identified in 55 of the grafted limbs. Thirty-three of the 55 limbs had a subsequent angiogram. The angiogram showed graft occlusion in six limbs, graft stenosis in 18, and native artery stenosis in four. Twenty-one of the grafts had the angiogram within 1 month after the duplex had detected graft stenosis, and one (4.76%) became occluded in this interval. Seven had an angiogram more than 1 month after the duplex study, and five (71.4%) had become occluded. The angiographic study did not confirm a graft stenosis in five limbs. Three were submitted to operation and stenosis was confirmed. Seventeen graft thromboses were detected by duplex scanning. Graft thrombosis was demonstrated following a previous negative duplex scan in one of the 106 vein grafts (0.94%), and in four of 30 PTFE grafts (13.3%). Duplex scanning is effective in the detection of graft stenosis. The precise anatomical location is less accurate when in the region of an anastomosis. Early attention should be taken when duplex studies suggest critical graft stenosis because there is a high risk of occlusion. Polytetrafluoroethylene grafts tend to thrombose without a precursory focal stenosis.     

Comparison of radiofrequency tissue volume reduction and submucosal resection with microdebrider in inferior turbinate hypertrophy.

OBJECTIVES: To compare the efficacy of submucosal temperature-controlled radiofrequency tissue volume reduction (TCRFTVR) and resection with microdebrider (SMRM) in chronic inferior turbinate hypertrophy. STUDY DESIGN: Prospective, randomized, and single-blinded clinical trial. METHODS: The study group consisted of 30 symptomatic patients who underwent simultaneous TCRFTVR and SMRM for consecutive sides. Visual analogue scale (VAS) and acoustic rhinometry (ARM) were made preoperatively and at 12th week and 6th month postoperatively; saccharine transport time (STT) and ciliary beat frequency (CBF) were performed at 12th week and 6th month postoperatively. The rate of the need for the revision operation was determined between 6 and 12 months period postoperatively. RESULTS: Significant improvement was achieved in VAS scores and ARM measurements after both procedures, whereas both parameters did not differ significantly between two procedures postoperatively. STT and CBF showed no significant post-treatment variation in comparison of the intergroup measurements. The rates of the need for revision operation were not significantly different. CONCLUSION: Identical results in objective and subjective parameters were observed for both techniques.     

Systematic follow-up after curative surgery for colorectal cancer in Norway: A population-based audit of effectiveness,costs, and compliance

In this study, we analyzed the Norwegian guidelines for systematic follow-up after curative colorectal cancer surgery in a large single institution. Three hundred fourteen consecutive unselected patients undergoing curative surgery for colorectal cancer between 1996 and 1999 were studied with regard to asymptomatic curable recurrence, compliance with the program, and cost. Follow-up included carcinoembryonic antigen (CEA) interval measurements, colonoscopy, ultrasonography of the liver, and radiography of the chest. In 194 (62%) of the patients, follow-up was conducted according to the Norwegian guidelines. Twenty-one patients (11%) were operated on for curable recurrence, and 18 patients (9%) were disease free after curative surgery for recurrence at evaluation. Four metachronous tumors (2%) were found. CEA interval measurement had to be made most frequently (534 tests needed) to detect one asymptomatic curable recurrence. Follow-up program did not influence cancer-specific survival. Overall compliance with the surveillance program was 66%, being lowest for colonoscopy (55%) and highest for ultrasonography of the liver (85%). The total program cost was € 228,117 (US $ 280,994), translating into € 20,530 (US $ 25,289) for one surviving patient after surgery for recurrence. The total diagnosis yield with regard to disease-free survival after surgery for recurrence was 9%. Compliance was moderate. Whether the continuing implementation of such program and cost are justified should be debated. Supported by the Centre for Clinical Research, Armauer Hansens House, Haukeland University Hospital, Bergen, Norway.     

Bite force and occlusal contact area changes following mandibular widening using distraction osteogenesis.

OBJECTIVE: To examine changes in bite force and occlusal contact area after mandibular widening by distraction osteogenesis using pressure-sensitive sheet (Dental-Prescale; Fuji Photo Film, Tokyo, Japan). STUDY DESIGN: Fifteen patients with transverse mandibular deficiency (6 to 9 mm, mean distraction interval: 8 mm) were examined. They were measured just before the operation and at 1 week, 1 month, 3 months, 6 months, and 1 year after the operation. Ten control subjects with normal occlusion were also measured. RESULTS: Both bite force and occlusal contact area were lowest at 1 month postoperatively. The values of bite force and occlusal contact area steadily increased thereafter. The bite force and occlusal contact area reached to the preoperative levels at 6 months after operation and slightly above the preoperative level at 12 months after operation. There were no statistically significant differences between 12 months and the control values for bite force measurements (P > .05). CONCLUSION: Although statistically not significant, this study suggests that mandibular symphyseal distraction osteogenesis increases the bite force and occlusal contact area in patients with transverse mandibular deficiency.     

Quadritherapy with cyclosporine for membranous lupus nephropathy

The therapeutic approach to patients with membranous lupus nephropathy (MLN) remains controversial. We have attempted combination therapy for MLN. Five patients with MLN (WHO class Va and Vb) and nephrotic syndrome were treated with 1 g methylprednisolone intravenously for 3 consecutive days followed by daily prednisolone at the dose of 30-40 mg plus cyclosporine at the dose of 100-200 mg and angiotensin receptor blocker(40 mg of valsartan). Initial dosage prednisolone was given for 1 month, and then tapered gradually in terms of dosage and interval. These patients were followed up for a minimum of 12 months. Complete remission was obtained in 4 patients after a mean of 7.3 +/- 2.1 months, and partial remission was obtained in the remaining patient. Daily prednisolone dosage significantly decreased from a baseline mean of 0.69 +/- 0.11 mg/kg to a mean of 0.10 +/- 0.02 mg/kg at the last follow-up. Lupus activity, as measured by SLE disease activity index, significantly decreased in all patients. Serum creatinine level and blood pressure remained stable. It was concluded that quadritherapy, including intravenous methylprednisolone, prednisolone, cyclosporine, and angiotensin receptor blocker, was beneficial in inducing remission of nephrotic syndrome, reducing lupus activity, and sparing prednisolone dosage with an acceptably low risk for side effects.     

A Novel Monthly Dosing Regimen of Risedronate for the Treatment of Postmenopausal Osteoporosis: 2-Year Data

This 2-year trial evaluated the efficacy and tolerability of a monthly oral regimen of risedronate. Postmenopausal women with osteoporosis were randomly assigned to double-blind treatment with risedronate 75 mg on 2 consecutive days each month (2CDM) or 5 mg daily. The primary end point was the percentage change from baseline in lumbar spine bone mineral density (BMD) at 12 months. Secondary end points included the change in BMD of the lumbar spine and proximal femur and in bone turnover markers as well as the number of subjects with at least one new vertebral fracture over 24 months. Among 1,229 patients who were randomized and received at least one dose of risedronate, lumbar spine BMD was increased in both treatment groups: mean percentage change from baseline was 4.2 ± 0.19 and 4.3 ± 0.19 % in the 75 mg 2CDM and 5 mg daily groups, respectively, at month 24. The treatment difference was 0.17 (95 % confidence interval ?0.35 to 0.68). There were no statistically significant differences between treatment groups on any secondary efficacy parameters. Both treatment regimens were well tolerated. Risedronate 75 mg 2CDM was noninferior in BMD efficacy and did not show a difference in tolerability compared to 5 mg daily after 24 months of treatment in women with postmenopausal osteoporosis. This monthly regimen may provide a more convenient dosing schedule to some patients with postmenopausal osteoporosis.     

Absorbability of mucosa in total replacement of urinary bladder with jejunum An experimental study

The absorption of urine components in jejunum substitute for the urinary bladder was studied experimentally in dogs. For this purpose, determination of the blood urea, creatinine, and electrolyte levels as well as measurements of the radioactivity in blood samples after intravesical instillations of radioactive iodine, were done at various intervals after total replacement of the urinary bladder with jejunum. The absorption was found to decrease greatly in one month and to be negligible one year postoperatively.     

Definitive radiation therapy of carcinoma of the prostate: A report on 15 years of experience

The charts of 310 consecutive patients with localized prostatic carcinoma treated definitively with small-field external-beam irradiation were reviewed. The 5- and 10-year uncorrected actuarial survival rates for patients with disease limited to the prostate were 72 and 48%, respectively, compared to 48 and 30% in patients with palpable extracapsular extension. Patients for whom the interval between histological diagnosis and initiation of radiotherapy was less than one year had a significantly higher survival rate than those for whom this interval was longer. Severe symptoms which persisted beyond one year after treatment developed in 5%. Sexual potency was maintained in 70% of patients not hormonally manipulated following radiotherapy.