Does the time of administration (morning or evening) affect the tolerability or efficacy of tamsulosin?

OBJECTIVE: To determine whether the time of dosing (morning or evening) affects the tolerability or efficacy of tamsulosin in the treatment of lower urinary tract symptoms. PATIENTS AND METHODS: Data were analysed from an open-label, observational study in which patients were treated with 0.4 mg tamsulosin once daily for 12 weeks. Treatment effects were determined using the Benign Prostatic Hyperplasia Impact Index, the quality-of-life question of the International Prostate Symptom Score, a similarly phrased question about sexual satisfaction, the maximum urinary flow rate, the postvoid residual urine volume, and the overall efficacy and tolerability. The results were analysed statistically for differences between dosing times, using analysis of covariance for the quantitative variables and logistic regression for the qualitative variables. RESULTS: While no specific recommendation about the dosing time was given in the trial, the retrospective analysis showed that 4420 and 2087 patients received tamsulosin in the morning and evening, respectively. Both groups had similar values for all variables before treatment. The efficacy and tolerability of tamsulosin treatment was also similar in both groups; there were small advantages for morning dosing, which were statistically significant because there were many patients. CONCLUSION: In contrast to other alpha-blockers, night-time dosing is not necessary to improve the tolerability or efficacy of tamsulosin.     

Tumors of the ampulla of Vater--local or radical resection?

Duodenal ampulla is a complex anatomical and histological site and a tumor may arise from one of three types of epithelium: duodenal mucosa, pancreatic duct and distal common bile duct. Neoplasia from each of these locations may exhibit different growth models and though it is difficult to establish their origin before operation, surgical treatment for all resectable tumors is essentially alike. The outcome of these tumors is vitally influenced by the type of epithelium from which they derive. Benign adenomas appear to be a frequent precursor of carcinoma of the ampulla of Vater, therefore, a local resection can lead to an under treated early cancer which would have benefited from a radical excision, with a much better long term result. We consider acceptable to perform an ampullectomy whenever is possible to safely state the benignity of the tumor or when a major procedure is hazardous.     

Thickening of the synovium of the digital flexor tendons: cause or consequence of the carpal tunnel syndrome?

Using a monofilament wire suture, the radial and ulnar edges of the flexor retinaculum were approximated in 14 white New Zealand rabbits. As a result, the volume of the carpal tunnel was diminished, and "carpal tunnel syndrome" was produced. At various intervals after this procedure the animals were sacrificed. The median nerve and all the digital flexor tendons passing through the carpal tunnel were excised "en bloc", and sent for histological examination. Vascular proliferation with perivascular round cell infiltration and oedema, and large areas of fibroblastic activity were observed around the digital flexor tendons. This was probably due to increased vascular permeability secondary to ischaemic endothelial damage. These findings are similar to those observed in the synovium of patients operated on for carpal tunnel syndrome.     

Remodeling of the spine in spondylodiscitis of children at the age of 3 years or younger

Spondylitis/spondylodiscitis is still an uncommon diagnosis often with a delay in diagnosis and treatment due to the uncharacteristic symptoms. The aim of this study is to increase the awareness and outline a patter of investigation and treatment. We present six children with an average age of 23 months (19–33 months) at time of diagnosis, conservative treated and with a mean follow-up of 31 months (12–65 months). The evaluation included past medical history, clinical symptoms, X-rays, MRI-investigations and laboratory studies [CRP, erythrocytes sedimentation rate (ESR), white blood count (WBC) and blood cultures] during the course of treatment and follow-up. The predominate clinical findings were: limp, refusal to walk and/or back pain. The mean duration of symptoms until presentation at our clinic was 24 days (4–42 days), the final diagnosis was set after an average of 12 days (7–14 days). Laboratory findings were unspecific but ESR best correlated with the clinical symptoms during the therapy. Five patients were treated by parenteral antibiotics for a minimum of 3 weeks, followed by oral antibiotics adapted to the clinical and laboratory findings. One child received a combined antituberculous chemotherapy after positive skin test for tbc. All six children were immobilized with a body-plaster-cast for an average time of 15 weeks (5–26 weeks). Four patients additionally were treated by further corset therapy for an average of 10 months (3–18 months). Radiological findings on plane X-rays (a.p. and lateral views) at time of diagnosis were decreased height of the disk space and erosions of adjacent vertebral endplates and residues of these radiological changes with signs of bony healing (sclerotic vertebral endplates or partial fusion) were seen at the latest follow-up. There was no case of instability or deformity like scoliosis or kyphosis. The MRI showed the earliest detectable typical vertebral bone involvements and confirmed the diagnosis in combination with laboratory findings and clinical symptoms. Spondylitis/spondylodiscitis should be considered as diagnosis in children with refusal to walk or gait disturbances especially in combination with elevated ESR. MRI is the tool of choice to set the diagnosis early. With an adequate and early therapy of bracing (body-plaster-cast), antibiotics and clinical monitoring good long-term result without spine instability or deformity can be achieved.     

On the origin of the toughness of mineralized tissue: microcracking or crack bridging?

Two major mechanisms that could potentially be responsible for toughening in mineralized tissues, such as bone and dentin, have been identified-microcracking and crack bridging. While evidence has been reported for both mechanisms, there has been no consensus thus far on which mechanism plays the dominant role in toughening these materials. In the present study, we seek to present definitive experimental evidence supporting crack bridging, rather than microcracking, as the most significant mechanism of toughening in cortical bone and dentin. In vitro fracture toughness experiments were conducted to measure the variation of the fracture resistance with crack extension [resistance-curve (R-curve) behavior] for both materials with special attention paid to changes in the sample compliance. Because these two toughening mechanisms induce opposite effects on the sample compliance, such experiments allow for the definitive determination of the dominant toughening mechanism, which in the present study was found to be crack bridging for microstructurally large crack sizes. The results of this work are of relevance from the perspective of developing a micromechanistic framework for understanding fracture behavior of mineralized tissue and in predicting failure in vivo.     

Is extended resection for adenocarcinoma of the body or tail of the pancreas justified?

Patients with body or tail tumors of the pancreas often have contiguous organ involvement or portalsplenic confluence adherence requiring extensive resection in order to obtain grossly negative margins. The aim of this study was to determine whether long-term survival is possible after contiguous organ or portal vein resection in patients with adenocarcinoma of the body or tail of the pancreas. Between 1983 and 2000, a total of 513 patients with adenocarcinoma of the body or tail of the pancreas were identified from a prospective database. Distal pancreatectomy with or without splenectomy was performed in 57 patients (11%). Extended resection was necessary in 22 patients (39%): 14 (64%) for contiguous organ involvement and eight (36%) for portal vein resection Estimated blood loss, blood transfused, and length of hospital stay were significantly greater in patients requiring extended resection compared to standard resection (P = 0.02, P = 0.01, and P = 0.02, respectively). Median follow-up for patients still alive was 84 months (range 40 to 189 months). Median survival following resection was 15.9 months compared to 5.8 months in patients who were not resected (P < 0.0001). Actual 5- and 10-year survival rates were 22% and 18%, respectively, following extended resection, 8% and 8% following standard resection, and 0% and 0% if no resection was attempted because of locally unresectable disease. Patients undergoing extended resection for adenocarcinoma of the pancreatic body or tail have long-term survival rates similar to those for patients undergoing standard resection; they also have markedly improved long-term survival compared to those who are not considered resectable because of locally advanced disease. Extended distal pancreatectomy is justified in this group of patients. Presented at the Forty-Fourth Annual Meeting of The Society for Surgery of the Alimentary Tract, Orlando, Florida, May 17–22, 2003. Supported by a grant from the Stern Foundation.     

Kissing melanoma or kissing nevus of the penis?

Divided, or so-called kissing nevi of the penis, which are separated during embryogenesis, are very rare, with only seven studies reported to date. We present a case of a 30-year-old patient with a divided nevus located at the penis that rapidly changed in size and color within 4 months. These clinical features and the histopathologic appearance of both parts led to the diagnosis of malignant melanoma. Melanoma of the penis is very rare, and the prognosis is poor. This could be the first case of a "kissing melanoma" of the penis reported in published studies.     

Management of Hemangioma of the Liver: Surgical Therapy or Observation?

Background

Elective surgery for liver hemangioma is controversial. We reviewed long-term outcomes following elective hepatectomy or observation only for symptomatic and asymptomatic liver hemangioma.

Methods

All patients (n = 307) with liver hemangioma referred to our hospital for surgical evaluation from January 1988 to December 2009 were identified, and imaging results, tumor characteristics, surgical indication, surgical mode, outcome of observation, clinical and/or postoperative outcome, and adverse events were retrospectively evaluated.

Results

Complete median follow-up for 246 patients was 124 months. Elective surgery was performed in 103 patients (symptomatic [n = 62] and asymptomatic [n = 41]). Postoperative morbidity occurred in 17 % of the patients and was significantly lower in asymptomatic patients (p = 0.002). No perioperative mortality was registered. Surgery relieved complaints in most (88 %) patients. In the observation group (n = 143), 56 % of patients had persistent or new onset of hemangioma-associated symptoms. Major hemangioma-related complications occurred in 12 patients (9 %) during the follow-up period, and 2 patients died after traumatic hemangioma rupture. Overall the rate of adverse events was by trend lower in the surgical group than in the observation group (35 versus 57 %; p = 0.08).

Conclusions

The majority of patients with liver hemangioma can be safely managed by clinical observation. In a subset of patients, especially those with giant hemangioma and/or occurrence of symptoms, surgical treatment could be considered and is justified in high-volume centers.     

The use of biodegradables in the treatment of osteochondritis dissecans of the knee: fiction or future?

The use of biodegradable fixation devices in the operative treatment of osteochondritis dissecans of the knee could avoid a second operation for removal of the hardware, but what are the disadvantages? Seven osteochondritis dissecans lesions, non-displaced in four adult knees and in one adolescent knee and displaced in two knees of adolescents, were treated by drilling and stabilisation with biodegradable pins, resulting in primary consolidation in the five non-displaced lesions and failure in the two detached lesions. However, two detached fragments in adults, primarily fixed with one metallic compression screw and three biodegradable pins both consolidated. In another adult patient, the fixation with two compression screws failed. A study of the available literature and the results of our limited experience seem to indicate that the primary operative treatment of choice of a non-detached osteochondritis dissecans lesion is drilling and fixation with biodegradable pins. However, if this regimen fails or in patients with a detached lesion, one metallic screw and a few additional biodegradable pins appear to constitute the best method of fixation. The use of biodegradable screws is still hazardous, because of the long degradation time and subsequent risk of erosion of the opposite cartilage and tissue reaction. Other resurfacing options are available for failures or fragmented or non-vital lesions.