Insufficiency fracture of the femoral neck during osteoporosis treatment: a case report

 A case of insufficiency fracture of the femoral neck that occurred during treatment for osteoporosis is reported. A 77-year-old woman (height 150 cm, body weight 43 kg) with osteoporosis associated with high bone turnover was treated with oral cyclical etidronate (400 mg/day for 2 weeks every 3 months). Three months after the treatment was started the patient experienced pain in the right hip joint while walking despite no evidence of trauma. Although radiographs were normal, weight-bearing was not possible because of pain. T2-weighted magnetic resonance (MR) imaging was used to detect a fracture line localized on the inferior aspect of the femoral neck. Because on bone marker measurement bone resorption was increased and bone formation was decreased from baseline, treatment was switched to oral alendronate (5 mg/day, daily). Pain resolved 3 weeks after the fracture was evident, and free gait was possible during the following 3 weeks. Follow-up radiographs, obtained 3 and 6 months after the fracture was evident, showed bony sclerosis on the aspect in which the fracture line was observed on the T2-weighted MR image. The dissociation (imbalance) of bone formation and resorption was also alleviated. A possibility of increased bone fragility should be kept in mind when oral cyclical etidronate is applied to elderly Japanese, small-physique women with osteoporosis at a daily dose of 400 mg (higher dose). Received: March 22, 2002 / Accepted: June 19, 2002 Offprint requests to: J. Iwamoto     

A Placebo-Controlled Comparison of Bupivacaine and Ropivacaine Instillation for Preventing Postoperative Pain After Laparoscopic Cholecystectomy

Purpose The aim of this study was to determine the effect of local anesthetic instillation, to compare bupivacaine and ropivacaine in patients undergoing a laparoscopic cholecystectomy. Methods A total of 80 patients were randomly assigned to four groups to receive the intraperitoneal instillation of 21 ml of either 100 mg bupivacaine (Group B), 100 mg ropivacaine (Group R1), 150 mg ropivacaine (Group R2) or saline with epinephrine 1/200 000 at the end of the surgery. The postoperative pain was evaluated and the analgesic requirement was also assessed. Results The intraperitoneal instillation of 100 mg bupivacaine, 100 mg ropivacaine, or 150 mg ropivacaine at the end of a laparoscopic cholecystectomy significantly reduced the morphine consumption during the first 24 h. For preventing postoperative pain 150 mg ropivacaine proved to be significantly more effective than either 100 mg bupivacaine or 100 mg ropivacaine. Conclusion We herein showed that the intraperitoneal instillation of local anesthetic during laparoscopic cholecystectomy is a noninvasive, rapid, safe and simple analgesic technique that reduces the total morphine consumption during first 24 h.     

High bone mineral density in pycnodysostotic patients with a novel mutation in the propeptide of cathepsin K

Introduction Pycnodysostosis is typically associated with short stature, multiple fractures without adequate trauma and high bone density on x-ray. The increased bone density is due to a genetic defect of cathepsin K, leading to dysfunctional osteoclastic bone resorption and bone remodeling. We wanted to know how this defect influences the trabecular and cortical volumetric bone mineral density of long bones as measured quantitatively by pQCT. Methods Three siblings of a consanguineous family were admitted to our hospital because of multiple fractures. Pycnodysostosis was diagnosed based on the clinical presentation with the characteristic dense appearance of their bones on x-ray. The distal and proximal radius of the patients and of control subjects was scanned using a Stratec XCT-2000 pQCT scanner and data were processed using the software provided by the manufacturer. Genomic DNA was extracted from blood samples of all three patients and their parents. The coding exons of the cathepsin K gene (CTSK) were amplified and sequenced. Results The patients displayed the typical features of pycnodysostosis: Short stature, delay of closure of the fontanelles, hypoplasia of the maxilla, spondylolysis of the lumbar spine, stubby hands and feet and a history of multiple fractures. Volumetric bone density was much higher in pycnodysostotic bone than in the control bones 686 ± 28 mg/cm³ in patients vs. 290 ± 6 mg/cm³ in controls; p = 0.001), especially in the trabecular compartment (733 ± 26 mg/cm³ in patients vs. 195 ± 8 mg/cm³ in controls; p < 0.001), but also in the cortical bone (1108 ± 22 in patients vs. 1020 ± 17 in controls; p < 0.01). In contrast to this finding, the patients displayed an elevation of alkaline phosphatase in the serum and free deoxypyridinoline-crosslinks (DPD) in the urine, suggesting osteomalacia. Sequencing of the cathepsin K gene revealed homozygosity for a novel missense mutation in all three patients predicting the amino acid exchange from arginine to tryptophan at position 46 (R46W). Conclusion We present here for the first time quantitative data on the mineral density of bones of pycnodysostotic patients with a novel mutation in the propeptide of cathepsin K. The elevated bone mineral density in the cortex and the changes in the serum markers suggest an effect of cathepsin K not only on bone volume, but also on bone mineralization. This might in part explain the increased susceptibility to fractures of patients with pycnodysostosis. AFS and CM contributed equally and therefore share first authorship. Funding MA was supported by a grant of the Deutsche Forschungsgemeinschaft (AM 103/9-1).     

Calcitonin for treating acute and chronic pain of recent and remote osteoporotic vertebral compression fractures: a systematic review and meta-analysis

Vertebral collapse is a common fracture associated with osteoporosis. Subsequent pain may be severe and often requires medications and bed rest. Several studies have suggested the use of calcitonin for the treatment of fracture pain. We sought to determine the analgesic efficacy of calcitonin for acute and chronic pain of osteoporotic vertebral compression fractures (OVCF). We searched for randomized, placebo, and controlled trials that evaluated the analgesic efficacy of calcitonin for pain attributable to OVCFs. We performed meta-analyses to calculate standardized mean differences (SMDs) using a fixed or random effects model. The combined results from 13 trials (n = 589) determined that calcitonin significantly reduced the severity of acute pain in recent OVCFs. Pain at rest was reduced by week 1 [mean difference (MD) = −3.39, 95% confidence interval (CI) = −4.02 to −2.76), with continued improvement through 4 weeks. At week 4, the difference in pain scores with mobility was even greater (SMD = −5.99, 95% CI = −6.78 to −5.19). For patients with chronic pain, there was no statistical difference between groups while at rest; there was a small, statistically significant difference between groups while mobile at 6 months (SMD = 0.49, 95% CI = −0.85 to −0.13, p = 0.008). Side effects were mild, with enteric disturbances and flushing reported most frequently. Although calcitonin has proven efficacy in the management of acute back pain associated with a recent OVCF, there is no convincing evidence to support the use of calcitonin for chronic pain associated with older fractures of the same origin.     

How painful is multichannel urodynamic testing?

Introduction and hypothesis  Multichannel urodynamic testing is considered to be the gold standard for evaluation of lower urinary tracts symptoms in women. The objective of this study was to assess the level of pain associated with this test. Methods  We reviewed charts of women who underwent multichannel urodynamic testing for lower urinary tract symptoms and recorded pain levels using a validated visual analog pain scale of 0–10 before, during, and 1.5 h after the test. Results  We identified 50 patients who underwent the test. Pain level increased mildly but significantly during the urodynamic test (1.24 ± 0.9 vs 0.02 ± 0.14 p < 0.001) and decreased thereafter (0.1 ± 0.35, p < 0.001). Conclusions  Multichannel urodynamic testing is associated with a low but significant level of pain, which generally abates shortly after the procedure. No correlation seems to exist between the degree of pain and various clinical and pelvic floor parameters.     

How to decrease pain at rapid injection of propofol: effectiveness of flurbiprofen

Purpose Many studies have been conducted on how to decrease propofol injection pain, but none has been completely successful. In the present study, the most effective method was investigated by adding lidocaine or a nonsteroidal antiinflammatory drug or by changing the solvent. Methods A total of 250 patients scheduled for general anesthesia were divided into five groups. Anesthesia was induced with intravenous administration of flurbiprofen 50 mg followed immediately by propofol in a long-chain triglyceride (LCT) 2 mg·kg⁻¹ (flurbiprofen group, n = 50), flurbiprofen 50 mg followed by propofol LCT 2 mg·kg⁻¹ 1 min later (flurbiprofen 1 group, n = 50), 2% lidocaine 40 mg followed immediately by propofol LCT 2 mg·kg⁻¹ (lidocaine group, n = 50), propofol LCT 2 mg·kg⁻¹ alone (LCT group, n = 50), or propofol in a mixture of medium-chain triglyceride (MCT) and LCT 2 mg·kg⁻¹ (MCT/LCT group, n = 50). Pain at injection was assessed 10 and 20 s after starting the propofol infusion. Results The numbers of patients with severe and mild pain were larger in the order: LCT group (10 and 31 patients, respectively) > flurbiprofen 1 group (3 and 19) ≥ MCT/LCT group (1 and 14) ≥ lidocaine group (2 and 11) > flurbiprofen group (0 and 0). Conclusions Flurbiprofen 50 mg i.v. just before propofol injection completely abolished propofol injection pain. When it was administered 1 min before propofol injection it was less effective.     

Evaluation of Pain Measurement Practices and Opinions of Peripheral Nerve Surgeons

The purpose of this study was to evaluate the opinions and practices of peripheral nerve surgeons regarding assessment and treatment of pain in patients following nerve injury. Surgeons with expertise in upper extremity peripheral nerve injuries and members of an international peripheral nerve society were sent an introductory letter and electronic survey by email (n = 133). Seventy members responded to the survey (49%) and 59 surgeons completed the survey (44%). For patients referred for motor or sensory dysfunction, 31 surgeons (52%) indicated that they always formally assess pain. In patients referred for pain, 44 surgeons (75%) quantitatively assess pain using a verbal scale (n = 24) or verbal numeric scale (n = 36). The most frequent factors considered very important in the development of chronic neuropathic pain were psychosocial factors (64%), mechanism of injury (59%), workers’ compensation or litigation (54%), and iatrogenic injury (48%). In patients more than 6 months following injury, surgeons frequently see: cold sensitivity (54%), decreased motor function (42%), paraesthesia or numbness (41%), fear of returning to work (22%), neuropathic pain (20%), and emotional or psychological distress (17%). Only 52% of surgeons who responded to the survey always evaluate pain in patients referred for motor or sensory dysfunction. Pain assessment most frequently includes verbal patient response, and assessment of psychosocial factors is rarely included. Predominately, patient-related factors were considered important in the development of chronic neuropathic pain.     

Guidelines for diagnosis and management of Paget's disease of bone in Japan

We here propose guidelines for the diagnosis and management of Paget's disease of bone (PDB) in Japan. These guidelines provide basic information on the epidemiology, pathophysiology, clinical signs and symptoms, diagnosis, indications for treatment, and available therapy, including orthopedic surgery. PDB is a chronic disorder characterized by focal abnormalities of bone turnover. The characteristic feature of PDB is excessive osteoclastic bone resorption coupled to increased and disorganized bone formation. The most common symptom of PDB is pain in involved bones. The most serious complication of PDB is malignant bone or soft-tissue tumor. PDB is uncommon in Japan; our survey in 2003 found 169 patients with PDB. The prevalence of PDB in Japan is 0.15/100 000; in patients aged 55 years or more, the proportion reaches 0.41/100 000. A careful medical history and physical examination are essential for the diagnosis. The diagnosis of PDB is based on finding the typical features on radiographs. Bone scintigraphy and measurement of serum alkaline phosphatase are sensitive means of screening for PDB. Since PDB is a rare disease in Japan, bone biopsy is quite often used to exclude bone metastases. The only evidence-based indication for treatment of PDB is pain in involved bones. In Japan, etidronate and calcitonin are approved by the Ministry of Health, Labour and Welfare for treating PDB, but currently risedronate is also under development for treating PDB in Japan. Indications for surgical intervention in PDB include unstable fractures, osteoarthritis, malignant soft-tissue tumor, osteosarcoma, and bone deformity.     

Tamoxifen flare hypercalcemia: an additional support for gallium nitrate usage

In 12 of 93 hypercalcemic patients with metastatic advanced breast cancer treated with tamoxifen the most common life-threatening metabolic complication of flare hypercalcemia developed. All the hypercalcemic patients had osteolytic or mixed lytic and blastic bone metastases. In patients with advanced breast cancer, hypercalcemia develops within the first few weeks of initiation of tamoxifen therapy. In our study group, calcium levels were measured frequently in both serum and urine samples by a semi-autoanalyzer and an autoanalyzer, using standard methods. Elevation of calcium levels was noticed in the tamoxifen-receiving hypercalcemic breast cancer patients, and levels returned to normal when tamoxifen was withdrawn. The median duration of flare hypercalcemia was 9 days (range, 4–16 days). The median calcium value was 13.6 mg/dl (range, 11.7–15.8). The diagnosis of tamoxifen flare hypercalcemia was based on the normal pretreatment serum or urine calcium values and the occurrence of hypercalcemia within the first few weeks of tamoxifen initiation. There are no specific treatment recommendations for hormone flare hypercalcemia, except for tamoxifen withdrawal, which is usually temporary, and the introduction of a low dose of an antihypercalcemic drug. We evaluated the effect of such a drug, gallium nitrate, on flare hypercalcemia. All the patients were treated with hydration, and 6 patients, whose calcium level was above 13.6 mg/dl, were treated with a moderate dose of gallium nitrate (200 mg/m² per kg) for 5 consecutive days, they achieved normocalcemia and continued with tamoxifen. The median time from hormonal drug initiation to flare hypercalcemia was 17.5 days, and median duration was 9 days. The above result indicates that the serious metabolic complication of hypercalcemia develops due to the iatrogenic effect of tamoxifen, but it can be controlled with an antihypercalcemic drug, gallium nitrate, while continuing tamoxifen therapy. It seems that the use of gallium nitrate in the treatment of flare hypercalcemia could allow safe readministration of tamoxifen and prevent premature tamoxifen discontinuance or withdrawal.     

Irinotecan plus low-dose cisplatin for alpha-fetoprotein-producing gastric carcinoma with multiple liver metastases: report of two cases

α-Fetoprotein (AFP)-producing gastric carcinoma generally causes multiple liver metastases and has an extremely poor prognosis. There is no standard chemotherapy for this disease. Two recent consecutive patients who had AFP-producing gastric carcinoma were treated with a novel chemotherapy regimen: irinotecan hydrochloride (100 mg/body over 90 min) plus low-dose cisplatin (10 mg/body) by intravenous infusion. Treatment was done weekly during admission and once every 2 weeks on an outpatient basis. Both patients had multiple liver metastases with high serum levels of AFP, and one demonstrated resistance to 5-fluorouracil. In both patients, liver metastases showed a dramatic complete response to chemotherapy, and the serum AFP levels returned to normal. No significant toxicities were observed. These preliminary results suggest that the present regimen may cause fewer side effects while retaining its synergistic antitumor activity. This regimen may therefore be worth trying as first-line chemotherapy for patients with metastatic AFP-producing gastric carcinoma. Received: October 10, 2001 / Accepted: May 7, 2002 Acknowledgment. This work was supported in part by Grants-in-Aid (Nos. 11671254 and 12877194) for Scientific Research from the Japanese Ministry of Education. Reprint requests to: M. Ogawa     

Mineral Metabolism in Obese Patients Following Vertical Banded Gastroplasty

Background Bone disease has been described in patients after surgical treatment for obesity, but few studies have dealt with the impact of vertical banded gastroplasty on mineral metabolism. We have examined bone mineral metabolism in morbidly obese patients before and after 3 months after vertical banded gastroplasty without vitamin D supplementation. Methods Sixteen morbidly obese patients (14 women, 2 men) with a mean (±SD) age of 38 ± 9 years and a body mass index (BMI) of 47.1 ± 8.1 kg/m² were studied. No vitamin D supplementation was given. Body weight, fat mass, calcium, 25OHD, iPTH, bone remodeling markers, and leptin levels were measured at baseline and after weight loss. Results Mean weight loss was 28 ± 11 kg; BMI and body fat mass decreased by 20 and 35%, respectively. Bone resorption markers and albumin-corrected serum calcium increased after operation, whereas iPTH fell. Serum 25OHD levels rose. Leptin levels decreased. Serum iPTH was positively correlated with weight, BMI, and fat mass before operation (p < 0.05), and its decline after weight reduction was negatively associated with the increase in bone resorption markers (p < 0.01). Leptin concentration was correlated with BMI and body fat mass (p < 0.05) both before and after surgery. Conclusions Weight reduction obtained in morbidly obese subjects 3 months after vertical banded gastroplasty increases bone turnover markers and decreases PTH secretion. Serum 25OHD levels rose. Therefore, no reasons for a metabolic bone disease related to hypovitaminosis D were readily apparent. However, an increase in bone turnover, which is generally regarded as a potential risk factor for osteoporosis, was observed. Further work is needed to clarify the importance of this turnover increase in the long run.     

Mycophenolate mofetil versus cyclosporine for remission maintenance in nephrotic syndrome

We performed a multi-centre randomized controlled trial to compare the efficacy of mycophenolate mofetil (MMF) to that of cyclosporine A (CsA) in treating children with frequently relapsing nephrotic syndrome and biopsy-proven minimal change disease. Of the 31 randomized initially selected patients, seven were excluded. The remaining 24 children received either MMF 1200 mg/m² per day (n = 12) or CsA 4–5 mg/kg per day (n = 12) during a 12-month period. Of the 12 patients in the MMF group, two discontinued the study medication. Evaluation of the changes from the baseline glomerular filtration rate showed an overall significant difference in favour of MMF over the treatment period (p = 0.03). Seven of the 12 patients in the MMF group and 11 of the 12 patients in the CsA group remained in complete remission during the entire study period. Relapse rate in the MMF group was 0.83/year compared to 0.08/year in the CsA group (p = 0.08). None of the patients reported diarrhea. Pharmacokinetic profiles of mycophenolic acid were performed in seven patients. The patient with the lowest area under the curve had three relapses within 6 months. In children with frequently relapsing minimal change nephrotic syndrome, MMF has a favourable side effect profile compared to CsA; however, there is a tendency towards a higher relapse risk in patients treated with MMF.     

Pain after minimally invasive videoassisted and after minimally invasive open thyroidectomy—results of a prospective outcome study

Background Substantial modifications in surgical treatment of thyroid disease have changed the postoperative management of thyroidectomized patients. The reduction of postoperative pain permit a short-stay surgery. Materials and methods We have analyzed the patients treated in our Unit from July 2006 to December 2006, with minimally invasive cervicotomy and mini-invasive video-assisted thyroidectomy. We have registered the postoperative pain applying an evaluation protocol numeric scale. The results were analyzed by t test. Results One hundred thirteen patients were divided in two groups: group A, minimally invasive cervicotomy (15 male and 46 female patients); group B, mini-invasive video-assisted thyroidectomy (9 male and 43 female patients). Upon returning to the ward, the pain scale group A vs B was 2.77 ± 1.16 vs 2.5 ± 0.762 (p = 0.22) .At 24 h after surgery, the pain scale in group A was 1.82 ± 1.258 vs 1.031 ± 0.8608 (p < 0.005). Conclusions Both methods are safe, but mini-invasive video-assisted thyroidectomy gives not only a better cosmetic result but a reduction of postoperative pain especially at 24 h.     

Preoperative SRS pain score is the primary predictor of postoperative pain after surgery for adolescent idiopathic scoliosis: an observational retrospective study of pain outcomes from a registry of 1744 patients with a mean follow-up of 3.4 years

Traditionally, adolescent idiopathic scoliosis (AIS) has not been associated with back pain, but the increasing literature has linked varying factors between pain and AIS and suggested that it is likely underreported. Our objective was to investigate factors associated with post-op pain in AIS. A prospectively collected multicenter registry was retrospectively queried. Pediatric patients with AIS having undergone a fusion with at least 2 years of follow-up were divided into two groups: (1) patients with a postoperative SRS pain score ≤ 3 or patients having a reported complication specifically of pain, and (2) patients with no pain. Patients with other complications associated with pain were excluded. Of 1744 patients, 215 (12%) experienced back pain after postoperative recovery. A total of 1529 patients (88%) had no complaints of pain, and 171 patients (10%) had pain as a complication, with 44 (2%) having an SRS pain score ≤ 3. The mean time from date of surgery to the first complaint of back pain was 25.6 ± 21.6 months. In multivariate analysis, curve type (16% of Lenke 1 and 2 curves vs. 10% of Lenke 5 and 6, p = 0.002) and a low preoperative SRS pain score (no pain 4.15 ± 0.67 vs. pain 3.75 ± 0.79, p < 0.001) were significant. When comparing T2–4 as the upper instrumented vertebrae in a subgroup of Lenke 1 and 2 curves, 9% of patients had pain when fused to T2, 13% when fused to T3, and 18% when fused to T4 (p = 0.002). 12% of all AIS patients who underwent fusion had back pain after postoperative recovery. The most consistent predictive factor of increased postoperative pain across all curve types was a low preoperative SRS pain score. These slides can be retrieved under Electronic Supplementary Material.     

Risedronate reduces postoperative bone resorption after cementless total hip arthroplasty

Summary Forty-three patients who had undergone cementless THA were randomly assigned to receive no osteoactive drug or oral risedronate for 6 months. Postoperative decrease of BMD in the risedronate group was significantly lower than that seen in the control group in zones 1, 2, 3, 6, and 7. Introduction Proximal bone resorption around the femoral stem often has been observed after total hip arthroplasty (THA), could lead to late stem loosening. We previously reported the efficacy of etidronate on periprosthetic bone resorption after cementless THA. Recently risedronate is suggested to be effective for the prevention and treatment of for osteoporosis. The purpose of the present study was to evaluate the effects of risedronate on periprosthetic bone loss after cementless THA. Methods Forty-three patients who had undergone cementless THA were randomly assigned to receive no osteoactive drug (21 patients) or oral risedronate 2.5 mg/day (22 patients) for 6 months. Three patients were eliminated from the risedronate group because of dyspepsia. Periprosthetic bone mineral density (BMD) in seven regions of interest based on the zones of Gruen et al. was measured with dual energy X-ray absorptiometry at 3 weeks and 6 months postoperatively. Results At 6 months after surgery, postoperative decrease of BMD in the risedronate group was significantly lower than that seen in the control group in zones 1, 2, 3, 6, and 7 (p < 0.05, p < 0.01, p < 0.01, p < 0.05, and p < 0.05, respectively). Conclusion These outcomes suggested that risedronate might reduce the periprosthetic bone resorption after cementless THA.     

Low-level laser therapy can reduce lipopolysaccharide-induced contractile force dysfunction and TNF-α levels in rat diaphragm muscle

Our objective was to investigate if low-level laser therapy (LLLT) could improve respiratory function and inhibit tumor necrosis factor (TNF-α) release into the diaphragm muscle of rats after an intravenous injection of lipopolysaccharide (LPS) (5 mg/kg). We randomly divided Wistar rats in a control group without LPS injection, and LPS groups receiving either (a) no therapy, (b) four sessions in 24 h with diode Ga–AsI–Al laser of 650 nm and a total dose of 5.2 J/cm², or (c) an intravenous injection (1.25 mg/kg) of the TNF-α inhibitor chlorpromazine (CPZ). LPS injection reduced maximal force by electrical stimulation of diaphragm muscle from 24.15 ± 0.87 N in controls, but the addition of LLLT partly inhibited this reduction (LPS only: 15.01 ± 1.1 N vs LPS + LLLT: 18.84 ± 0.73 N, P < 0.05). In addition, this dose of LLLT and CPZ significantly (P < 0.05 and P < 0.01, respectively) reduced TNF-α concentrations in diaphragm muscle when compared to the untreated control group.     

Rhabdomyolysis After Bariatric Surgery by Roux-en-Y Gastric Bypass: A Prospective Study

Background  Obesity is a worldwide epidemic associated to comorbidities and increased mortality. Because it is chronic and recurrent and has little response to clinical measures, surgical treatment (bariatric surgery) is a therapeutic option frequently used. Different surgical complications have been associated with this type of procedure, but there is little knowledge about neuromuscular complications. Among the latter, rhabdomyolysis (RML), described a few years ago, has not been well characterized to date. Methods  We have studied 22 consecutive patients who underwent surgical treatment with open Roux-en-Y gastric bypass (RYGBP) for morbid obesity in a university hospital. A database was created including the following information of each patient: gender, age, body mass index (BMI), comorbidities, surgical time, pre- and postoperative creatine phosphokinase (CPK) dosages, and neuromuscular symptoms after surgery. The main outcome measure was the frequency of RML using CPK dosage after 24 h of surgery. RML was diagnosed as an increase of more than five times the superior limit of normal range of CPK. Results  Fourteen women and eight men were evaluated, with median age of 39.9 ± 11.2 years, median BMI of 52.4 ± 8.0 kg/m² and mean surgical time of 253.2 ± 51.9 min. The mean value of postoperative CPK was 7,467.7 ± 12,177.1 IU/L, being greater than 5,000 IU/L in 40.9% of the patients. RML was diagnosed in 17 (77.3%) patients. No patient had renal failure caused by RML, but there was one death (4.5%) related to abdominal infectious complications. Clinical neuromuscular symptoms occurred in 45% of patients, and muscular pain was the most common one, especially in gluteus region. Comparative analyzes between patients without and with RML diagnosis showed that longer surgical time (p = 0.005), and occurrence of neuromuscular symptoms (p = 0.04) were more common in the latter. Conclusion  The results of this study are similar to few other investigations and confirm that RML in open bariatric surgery with RYGBP (Capella) is a common complication. A longer surgical time can be involved in RML pathogenesis, and muscular pain is suggestive of RML occurrence.     

Monitored Anesthesia Care with Propofol Versus Surgeon-Monitored Sedation with Benzodiazepines and Narcotics for Preoperative Endoscopy in the Morbidly Obese

Background Although still controversial, upper endoscopy is frequently performed before bariatric surgery. This study investigated the hypothesis that morbidly obese patients would prefer anesthesiologist-monitored sedation (AMS) compared to surgeon-monitored sedation (SMS) during preoperative endoscopy. Methods All patients who underwent endoscopy before their bariatric surgery were given a post-procedure survey regarding their experience with the preoperative endoscopy. The survey inquired about issues during and after the procedure. We compared patients who had AMS with IV propofol versus SMS IV narcotics and benzodiazepines. Results There were 100 patients (SMS = 49 and AMS = 51). Few patients complained of pain in the abdomen or throat during the procedure (AMS vs. SMS = 2 vs. 8% and 2 vs. 10%, respectively; p = NS). More patients complained about throat pain after the procedure (AMS vs. SMS = 37 vs. 45%; p = NS). More patients in the SMS group remembered the scope being placed in the mouth versus AMS (33 vs. 10%; p < 0.02). More patients remembered gagging during the procedure in the SMS group versus the AMS group, but this did not reach statistical significance (24 vs. 10%; p = 0.06). There was a trend that more patients in the AMS group felt they recovered in less than 1 h (53%) compared to the SMS group (37%; p = 0.1). Conclusion Patients who undergo upper endoscopy with either AMS or SMS seem to tolerate the procedure well. The preliminary benefits seen with AMS need to be further explored. AMS should be considered for patients undergoing preoperative upper endoscopy before bariatric surgery. Presented at the International Federation for the Surgery of Obesity annual meeting; August 2006; Sydney, Australia.     

Randomized, active-controlled study of once-weekly alendronate 280 mg high dose oral buffered solution for treatment of Paget’s disease

Summary  Daily oral tablet bisphosphonate therapy for Paget’s disease of bone may cause serious upper gastrointestinal adverse events. A once-weekly alendronate 280 mg oral buffered solution was compared with an alendronate 40 mg/day tablet. While both were similarly effective, the tablet appeared to be better tolerated in this study. Introduction  Although daily doses of oral bisphosphonates are a generally safe and effective treatment for Paget’s disease of bone (PDB), some patients may experience upper gastrointestinal adverse events (UGI AEs) or find the dosing requirements inconvenient and become noncompliant. A once-weekly (OW) oral dose of bisphosphonate in buffered solution (OBS) may be as effective, better tolerated, and more convenient. Methods  Sixty-three patients were randomized to either alendronate (ALN) 280 mg OW OBS (n = 42) or an ALN 40 mg/day tablet (n = 21) during a 6-month, randomized, double-blind, active-controlled trial. The primary endpoint was the mean percent decrease in total serum alkaline phosphatase (total ALP) from baseline at 6 months. Results  There were no significant differences in total ALP between groups during the 6-month period. There was a higher incidence of clinical AEs in the ALN 280 mg OW OBS (79%) vs. the ALN 40 mg/day tablet group (67%), including drug related AEs (48% and 10%, respectively), which led to study discontinuation (19.0% and 10%, respectively). Conclusions  Although ALN 280 mg OW OBS was similarly effective as ALN 40 mg/day in reducing total ALP in patients with PDB, the ALN 40 mg/day tablet appears to be better tolerated than ALN 280 mg OW OBS.     

Idiopathic Hypertensive Anal Canal: A Place of Internal Sphincterotomy

Background  Hypertensive anal canal is frequently known to be associated with the presence of anal fissure. Based on clinical experience, we hypothesized that idiopathic anal sphincter hypertonia was a condition equivalent to anal fissure, and therefore, it could be treated the same way. Patient and methods  Sixty-three patients complaining of anal pain without any anal pathology and ten healthy volunteers were examined. All patients underwent clinical evaluation, neurological examination, anorectal manometry, and measurement of pudendal nerve terminal motor latency. All patients with hypertensive anal canal were randomized into three groups. Group I (surgical group) underwent closed lateral sphincterotomy (LS), group II using nitroglycerine ointment (GTN), and group III received injection of botulinum toxin in internal sphincter. Post-procedures data were recorded at follow-up period. Results  The mean resting anal pressure (MRAP) was significantly higher in the patient group (114.6 ± 7.4 mmHg) than control group (72.5 ± 6.6 mmHg, P < 0.001). Anal pain is the main presenting symptoms aggravated by defecation and not relived by analgesics or local anesthetics. After LS, pain visual analogue scale decreased significantly at follow-up period than after chemical sphincterotomy using GTN or BTX (P = 0.001). There was a significant decrease in MRAP postoperatively from 114.6 ± 7.4 to70.8 ± 5.5 mmHg than after using GTN or BTX (P = 0.03). Conclusion  Idiopathic hypertensive anal canal is a fact and already exists presented by anal pain aggravated by defecation. It can be managed safely by closed lateral sphincterotomy, but chemical sphincterotomy had a minor role in its management.