The ‘antiphospholipid syndrome’ and the ‘lupus anticoagulant’

In recent years an association has been described between, on the one hand, an in vitro prolongation of phospholipid-dependent coagulation tests (the lupus anticoagulant) or the demonstration of antiphospholipid antibodies and, on the other, clinical events, particularly recurrent thrombosis (usually venous but sometimes arterial), thrombocytopenia, and also recurrent mid-term fetal loss. Other less well-documented associations with haemolytic anaemia, livedo reticularis, strokes and other neurological syndromes have been suggested. The antibodies are present temporarily in many infections, are usually of IgM isotype and thrombosis does not occur. However, they are persistently present and mainly of IgG isotype in a number of auto-immune disorders associated with thrombosis, in particular systemic lupus erythematosus, in which 50% of patients will show antibody of one isotype or another. The strongest association is with antinuclear factor-negative lupus and lupus-like disorders in which a full diagnosis of classical lupus cannot be made. The clotting test abnormality and antiphospholipid antibodies may be found also in otherwise normal individuals suffering thrombosis or fetal loss — the so-called primary antiphospholipid syndrome. These data raise important questions for management, but many details are controversial despite a decade's work; this review examines the present position and outlines some of the difficulties, particularly from the point of view of nephrology and paediatrics.     

The ‘scrubbed surgeon’ in robotic surgery

One of the principal reasons for the rapid progress of robotic surgery has been its advantage in allowing laparoscopy naïve surgeons to offer minimal access surgery to their patients. While this may continue to be an advantage of this modality, it has to be remembered that this has often been possible primarily due to the availability of an assistant who has at least basic laparoscopy skills that permit the performance of critical patient side tasks. We review the literature on the role of the assistant or the ‘scrubbed surgeon’ in robotic surgery and discuss the advantages of a properly trained assistant in a developing and established robotic surgery program.     

The ‘Saw Tooth’ operation for giant fibroadenomas

Fibroadenomas are the most common benign breast lesions affecting adolescents and young women. Cosmesis is an important factor when considering surgical management for these masses.Giant fibroadenomas (>5 cm), because of their size, may require larger incisions resulting in significant scarring and scar complications in these young women. Several approaches have been employed, usually involving large incisions, when performing a lumpectomy for giant fibroadenomas. In this report, we highlight a new technique for removal of these masses, which allows the removal of large fibroadenomas through a relatively small, cosmetically acceptable, circumareolar incision.     

The bridging of large osteoperiosteal gaps using ‘Decalbone’

Summary Decalbone was prepared by partial decalcification of human bones obtained from recently amputated specimens. It was then stored in 80 to 90% ethanol in a domestic refrigerator. The decalbone was used to fill large osteoperiosteal gaps in 25 patients. The commonest lesion was a giant cell tumour (21 cases) and various long bones were affected. There were 6 failures with recurrence of the tumour in 3 and uncontrolled infection in 3. The remaining 19 cases were followed up for from 2 1/2 to 7 years. In 10 the decalbone incorporated well, but further reconstructive procedures were needed in 9. Our studies showed that incorporation began at around 6 to 9 months and was complete at about 2 years in the upper limb and 4 years in the lower limb. There was no clinical evidence of an immune response.

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Résumé Le «Decalbone» provient de la décalcification partielle d'os humains obtenus à partir de pièces d'amputation récentes. Ils sont ensuite conservés dans l'éthanol à 80 ou 90% dans un réfrigérateur usuel. Le Decalbone a été utilisé pour combler de vastes pertes de substance chez 25 malades. La lésion la plus fréquente était la tumeur à cellules géantes (21 cas) et divers os longs étaient atteints. Il y a eu 6 échecs, 3 par récidive tumorale et 3 par infection. Les 19 autres cas ont été suivis de 2 ans et demi à 7 ans. Dix fois le Decalbone s'est parfaitement incorporé, mais 9 fois il a fallu recourir à d'autres procédés de reconstruction. Nos observations montrent que l'incorporation débute entre le 6e et le 9e mois et qu'elle est complète vers la 2e année au membre supérieur et vers la 4e au membre inférieur. Il n'y a jamais eu de problèmes immunologiques.

     

Study of the response of the urinary bladder to stimulation of the cervix uteri and clitoris — The ‘genitovesical reflex’: An experimental study

There is a debate as to whether, during the sexual act, some women eject a fluid that could be urine. As a part of investigation into this subject, the effect of stimulation of the clitoris and cervix on urinary bladder pressure and external urethral sphincter (EUS) activity was studied in 12 bitches. The clitoris and cervix were stimulated both electrically and mechanically. Upon clitoral or cervical stimulation, the vesical pressure dropped (P<0.05) and the EMG activity of EUS increased; action potentials increased and latency decreased when the stimulation frequency increased. No fluid came out of the external urethral orifice or the vagina. Stimulation of the anesthetized clitoris and cervix effected no vesical pressure or EUS response. These results were reproducible. The study has shown that on clitoral and cervical stimulation, which closely simulates the conditions during coitus, the bladder neck was firmly closed by EUS contraction, whereas the vesical detrusor was relaxed. A constant and reproducible reflex relationship existed between the clitoris, or the cervix, and the urinary bladder, which the author calls the genitovesical reflex and which probably acts to prevent urinary leak during coitus. The genitovesical reflex may prove to be of diagnostic significance in genitourinary disorders.Editorial Comment: This is a very interesting study on the effects of clitoral and cervical stimulation on the bladder and external urethral sphincter. It points out that in the normal female dog (and possibly in the normal female patient) cervical and clitoral stimulation, as might occur with coitus, should bring about relaxation of the bladder and an increase in the tone of the external urethral sphincter to prevent urine loss. I think this points out that urine loss associated with orgasm should be considered pathologic, and may be a symptom of detrusor instability. The pathologic association of urinary incontinence with orgasm and detrusor instability was pointed out by Hilton in 1988 and Khan in 1988. This paper complements these studies by demonstrating a reflex in the female dog which produces bladder relaxation and external urethral sphincter tone increase during coital-type stimulation.     

Impingement-free Hip Motion: The ‘Normal’ Angle Alpha after Osteochondroplasty

Femoroacetabular impingement is considered a cause of hip osteoarthrosis. In cam impingement, an aspherical head-neck junction is squeezed into the joint and causes acetabular cartilage damage. The anterior offset angle α, observed on a lateral crosstable radiograph, reflects the location where the femoral head becomes aspheric. Previous studies reported a mean angle α of 42° in asymptomatic patients. Currently, it is believed an angle α of 50° to 55° is normal. The aim of this study was to identify that angle α which allows impingement-free motion. In 45 patients who underwent surgical treatment for femoroacetabular impingement, we measured the angle α preoperatively, immediately postoperatively, and 1 year postoperatively. All hips underwent femoral correction and, if necessary, acetabular correction. The correction was considered sufficient when, in 90° hip flexion, an internal rotation of 20° to 25° was possible. The angle α was corrected from a preoperative mean of 66° (range, 45°–79°) to 43° (range, 34°–60°) postoperatively. Because the acetabulum is corrected to normal first, the femoral correction is tested against a normal acetabulum. We therefore concluded an angle α of 43° achieved surgically and with impingement-free motion, represents the normal angle α, an angle lower than that currently considered sufficient. Each author certifies that he or she has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article. Each author certifies that his or her institution has approved the human protocol for this investigation and that all investigations were conducted in conformity with ethical principles of research.