Serum aluminum levels in dialysis patients after sclerotherapy of internal hemorrhoids with aluminum potassium sulfate and tannic acid

Purpose

Aluminum potassium sulfate and tannic acid (ALTA) is an effective sclerosing agent for internal hemorrhoids. However, it is contraindicated for patients with chronic renal failure on dialysis, because the aluminum in ALTA can cause aluminum encephalopathy when it is not excreted effectively. We conducted this study to measure the serum aluminum concentrations and observe for symptoms relating to aluminum encephalopathy in dialysis patients after ALTA therapy.

Methods

Ten dialysis patients underwent ALTA therapy for hemorrhoids. We measured their serum aluminum concentrations and observed them for possible symptoms of aluminum encephalopathy.

Results

The total injection volume of ALTA solution was 31 mL (24–37). The median serum aluminum concentration before ALTA therapy was 9 μg/L, which increased to 741, 377, and 103 μg/L, respectively, 1 h, 1 day, and 1 week after ALTA therapy. These levels decreased rapidly, to 33 μg/L by 1 month and 11 μg/L by 3 months after ALTA therapy. No patient suffered symptoms related to aluminum encephalopathy.

Conclusions

Although the aluminum concentrations increased temporarily after ALTA therapy, dialysis patients with levels below 150 μg/L by 1 week and thereafter are considered to be at low risk of the development of aluminum encephalopathy.     

Metal Ion Levels in Young,Active Patients Receiving a Modular,Dual Mobility Total Hip Arthroplasty

Background

Dual mobility total hip arthroplasty (THA) components improve stability, yet use of a modular cobalt alloy acetabular liner may be associated with metal ion release. This study's purpose was to measure blood metal ion levels in young, active patients receiving a dual mobility THA prosthesis.

Reconstruction of the rotation center of the hip after oblong cups in revision total hip arthroplasty

Background

The preoperative bone defect and the reconstruction of the center of rotation of the hip are critical in acetabular revision surgery. Uncemented oblong cups are employed in order to manage these issues. We analyzed the clinical results and rates of revision of two different uncemented oblong cups, the reconstruction of the center of rotation of the hip, as well as the rate of radiological loosening and possible risk factors.

Materials and methods

Forty-five patients (46 hips) underwent acetabular revision surgery using two different uncemented oblong cups. We assessed the clinical results and the survival rate for revision and aseptic loosening. Intraoperative bone loss was classified according to Paprosky, and acetabular reconstruction was assessed according to Ranawat. The mean follow-up was 7.2 years (range 4–11 years).

Results

There were four re-revisions (three due to aseptic loosening); the survival rate for re-revision due to aseptic loosening was 60.1 % at seven years. The mean distance between the center of the femoral head prosthesis and the approximate center of the femoral head improved from 21.5 to 10.2 mm. Thirteen cups showed radiological loosening; the survival rate for radiological loosening at seven years was 40.54 %. A smaller postoperative horizontal distance was correlated with cup loosening.

Conclusions

Although optimal acetabular reconstruction can be achieved by using oblong uncemented cups in revision hip surgery, the clinical and radiological results are not encouraging. Excessive medialization of the cup may increase the rate of loosening.     

S100B,intraoperative neuromonitoring findings and their relation to clinical outcome in surgically treated intradural spinal lesions

Background

Neurophysiological monitoring (IOM) consisting of somatosensory (SEPs), muscle (MEPs) and spinal motor evoked (D-wave; spinal MEPs) potentials is used to indicate injury related to surgical treatment of intradural and intramedullary lesions. Combining spinal and muscle MEPs reliably predicts long-term motor deficit. If spinal MEPs recording is not possible, additional markers—e.g. S100B, a serum marker for glial injury—may be a helpful adjunct. Thus, serial serum S100B measurements were related to both the intraoperative IOM recordings and the long-term neurological outcome in patients surgically treated for cervical and thoracic intradural lesions.

Methods

In 33 patients (9 men, 24 women, 54?±?17 years) during intramedullary (8) or intradural (25) cervical or thoracic spinal surgeries significant intraoperative SEP-amplitude decrement >50 % or MEP loss and serial S100B serum concentration (perioperative days 0, 1-3, 5) were related to outcome (>1 year after discharge, grouped into improved and unchanged/altered neurological symptoms).

Results

Differences in S100B levels between patients with improved and unchanged/altered neurological outcome were significantly on postoperative days 2 (0.085?±?0.08 μg/l vs 0.206?±?0.07 μg/l, p?=?0.005) and 3 (0.076?±?0.03 μg/l vs 0.12?±?0.05 μg/l, p?=?0.007). All patients with permanent altered neurological symptoms developed S100B levels >0.08 μg/l (0.09–0.35 μg/l). Eighty-one percent of patients with improved neurological symptoms presented with S100B levels ≤0.08 μg/l (0.02–0.08 μg/l). Nine out of ten patients (90 %) without changes in EP and S100B had an improved long-term outcome, whereas 9/13 patients (69 %) with changes in EP and S100B had altered neurological symptoms in long-term outcome.

Conclusion

Intraoperative stable EPs and S100B?≤0.08 μg/l may be used as a marker to predict long-term neurological improvement, whereas EP-changes and elevated S100B levels on the 3rd postoperative day may be useful as a marker to predict long-term neurological alteration. In summary, the combined use of S100B and EPs might be helpful in the prediction of the severity of adverse spinal cord affection following surgery and guidance of patients.     

Elevated CEA Levels and Low Distance of the Tumor from the Anal Verge are Predictors of Incomplete Response to Chemoradiation in Patients with Rectal Cancer

Background

The objective of this study was to evaluate pretreatment clinical parameters as predictive factors for complete pathological response after long-term chemoradiotherapy (RCT) for rectal cancer. Tumor downstaging after RCT for rectal cancer can be obtained in half of cases, whereas a complete pathological response (CPR) is reported to range between 15 and 30 %. It is not possible to foresee before therapies who will respond.

Methods

Patients with stage II–III rectal cancer that had undergone RCT and rectal resection between January 1995 and October 2010 were considered. Patients were divided in those who achieved a CPR, “CR” group, and those who did not achieve a CPR, “NCR” group. Univariate and multivariate analyses between groups were performed considering the clinical parameters: gender, age, ASA score, preoperative hematic CEA, tumor grading; distance of the tumor from the anal verge, maximum tumor diameter, TNM stage, and neoadjuvant treatment details.

Results

Among 260 patients, 43 (16.5 %) achieved a CPR. The two groups resulted homogeneous for age, sex, pretreatment status, and tumor stage. A CEA <5 ng/dl and distance from anal verge >5 cm were correlated with CPR at multivariate analysis. Patients with both these conditions presented a significantly higher CPR rate (30.6 %) as well as improved 5-year survival. CPR was also correlated with improved survival.

Conclusions

Very low tumors with a high serum CEA are very unlikely to reach a CPR. The predictive value of these easily available clinical factors should not be underestimated, and better therapeutic strategies for these tumors are needed.     

The Exeter method—acetabular impaction grafting with cemented reimplantation

Objective

Restoration of acetabular anatomy and biomechanics at revision hip surgery by replacing deficient acetabular bone through impaction of allograft and/or autograft bone chips.

Indications

Aseptic loosening of the socket due to osteolysis, bone loss from infection, iatrogenic bone loss due to implant removal, and in the primary setting protrusio acetabuli, dysplasia and previous acetabular fracture.

Contraindications

Large segmental peripheral acetabular defects which cannot be contained, the presence of untreated infection, unstable acetabular fractures, previous radiotherapy to the affected hip area.

Surgical technique

Sound exposure of the acetabulum with delineation of the bony defect. Creation of a host environment suitable for bone graft and containment of segmental defects using rim mesh or porous augments. Impaction grafting using layered allograft or autograft bone chips of 0.8–1 cm³, packed using hemispherical impactors, followed by cementing of a polyethylene acetabular component with pressurisation.

Postoperative management

Partial weight bearing 6 weeks, modified depending on level of containment and intra-operative findings.

Results

A successful and reproducible technique with survival up to 87?% at 20 years for aseptic loosening in the revision setting.     

Criteria for the glucagon provocative test in the diagnosis of gastrinoma

Introduction

The glucagon provocative test is useful for the diagnosis of gastrinoma. The aim of this study was to determine the criteria for the glucagon provocative test.

Methods

This study reviewed 8 patients that underwent the glucagon provocative test preoperatively and in whom the diagnosis was confirmed as gastrinoma histologically. The glucagon provocative test was performed by administering glucagon (20 μg/kg) intravenously, followed by 20 μg/kg h for the next 30 min, and plasma gastrin levels were measured 3 and 1 min before and 3, 5, 7, 10, 15, 20, and 30 min after the administration of glucagon. This study evaluated the peak value of plasma gastrin and the time required to reach the peak.

Results

Two of the 8 patients had multiple endocrine neoplasm type 1. The basal plasma gastrin levels ranged from 524 to 10,300 pg/ml. The time required to reach the peak was 3–10 min for all patients. The increase in the peak from the basal value was 235–8,920 pg/ml, and the percentage of increase was 38–337 %.

Conclusions

These results suggest that a diagnosis of gastrinoma should thus be made when plasma gastrin levels peak within 10 min after glucagon administration, with an increase of greater than 200 pg/ml and greater than 35 % of the basal value.     

Herzdruckmassage im Rahmen der Laienreanimation

Background

The quality of chest compressions and early defibrillation are paramount in cardiopulmonary resuscitation (CPR). Whether real-time feedback devices may improve CPR efforts in lay person CPR is unclear.

Material and methods

Prospective randomized studies were carried out to test the influence of the electronic real-time feedback device PocketCPR? on the quality of chest compression by lay person CPR training in a mock-up cardiac arrest scenario. Altogether 42 inexperienced lay persons were randomized into 2 groups (groups A and B). The quality of chest compressions was analyzed with respect to depth and frequency in a cross-over design.

Results

PocketCPR? improved mean chest compression depth significantly (p=0.029) solely in one of both groups (44±7 versus 41±10 mm). However, both groups achieved recommended compression depths between 38–51 mm independent of device application. Also mean chest compression frequency was improved significantly (p=0.001) in one group only (100±21 versus 115±21 per min). There was no demonstrable significant potential learning effect through the application of the feedback device.

Conclusion

Real-time feedback devices do not ensure a consistent improvement of chest compression quality during mock-up lay person CPR training. Additional studies are needed to investigate potential effects for trained health care professionals.     

Axial plane coverage and torsion measurements in primary osteoarthritis of the hip with good frontal plane coverage and spherical femoral head

Introduction

Mechanical factors play a role in pathogenesis of primary osteoarthritis of the hip. Torsion measures were made to detect whether there is a causal relationship between increase or decrease of femoral anteversion, acetabular anteversion, and osteoarthritis. There are no studies in the literature indicating a relationship between axial plane coverage and osteoarthritis of the hip. Deficient axial plane coverage of femoral head may also play a role in pathogenesis of osteoarthritis.

Materials and methods

Thirty patients with primary osteoarthritis of the hip and 29 control cases were included in the study. We used the method of Anda et al. (Acta Radiol Diagn 27:443–447, 1986; Comput Assist Tomogr 15:115–120, 1991) to measure axial plane anterior, posterior coverages in patients with primary osteoarthritis of the hip. The computerized tomography sections and pelvic radiographs indicated good frontal plane coverage and spherical femoral head. In addition to anterior acetabular sector angle, posterior acetabular sector angle, horizontal acetabular sector angles for axial plane coverage detection, femoral anteversion, acetabular anteversion, and McKibbin instability index were also measured.

Results

Posterior coverage was lower at osteoarthritic hips than the control group’s hips (96.0 ± 16.7, 104.2 ± 10.6) (p < 0.05).

Conclusion

The results may indicate that in addition to other mechanical factors, axial plane coverage, especially the posterior coverage deficiency, may play a role in the pathogenesis of hip osteoarthritis.     

Hands-off-Zeiten durch AED-Sprachanweisungen

Background

Hands-off intervals during cardiopulmonary resuscitation (CPR) diminish the likelihood of success. The influence of voice prompts from an automated external defibrillator (AED) on the length of CPR interruption was investigated.

Material and methods

In a randomized, one-way blinded manikin CPR study we prospectively assessed intervals between the start of voice prompting and the start of execution by participants for a shockable and a non-shockable rhythm. Difficulties with executing AED voice prompts were assessed by a questionnaire. The influence on the length of CPR interruptions was evaluated in a post hoc analysis.

Results

Mean hands-off intervals measured in 57 voluntary participants accounted for 38.5?% of the total CPR time. Hands-off intervals between defibrillation and chest compressions were significantly shorter when CPR started with a non-shockable rhythm (6.5?±?3.5 s versus 9.0?±?5.5 s, p?<?0.043) and when participants rated the voice prompts as very good or good compared to middle or bad (7.1?±?4.5 s versus 11.3?±?4.7 s, p?<?0.020).

Conclusions

Confusing voice prompts that potentially delay CPR need to be identified and modified.     

Acetabular cup positioning in revision total hip arthroplasty with Paprosky type III acetabular defects: Martell radiographic analysis

Purpose

This study evaluates acetabular cup position in the setting of revision total hip arthroplasty (THA) with severe acetabular bone defects.

Methods

With a definition of safe zone of abduction (30–50°) and anteversion (5–25°), acetabular cup position was measured by a digital image analysis program for 34 patients with Paprosky type III acetabular bone defects.

Results

There were 24 cups (71 %) for abduction and 26 cups (76 %) for anteversion located in the safe zone. Nineteen cups (56 %) were within the safe zone for both abduction and anteversion. There was no dislocation, however one cup out of the safe zone resulted in early cup failure due to aseptic loosening.

Conclusions

The acetabular cup positioning in patients with Paprosky type III defects was 'optimal' in half of the cases. The prevalence of optimal acetabular cup position was similar to those reported in primary THA, suggesting that the presence of a large acetabular bone defect may not be a significant risk factor for suboptimal acetabular cup positioning in the setting of revision THA.     

Outcome of Birmingham hip resurfacing at ten years: role of routine whole blood metal ion measurements in screening for pseudotumours

Purpose

Emerging concern has arisen because of recent papers reporting a high prevalence of pseudotumours (PTs), even in patients with surface arthroplasties with a good clinical track record. The aim of our study was to establish the ten year survivorship of Birmingham hip resurfacing (BHR), to investigate whole blood (WB) metal ion levels and prevalence of adverse reactions to metal debris (ARMeD) and to determine the association of blood metal ion levels and symptoms with ARMeD in patients operated on with BHR at our institution.

Methods

Between May 2001 and May 2004, 261 consecutive BHRs were implanted in 219 patients. All living, nonrevised patients underwent a systematic screening programme consisting of clinical examination, WB cobalt and chromium measurements and targeted cross-sectional imaging.

Results

The ten year survival for the entire cohort was 91 % (89–93 %), with any revision as the endpoint. Prevalence of ARMeD was 6.9 % in male and 8.8 % in female patients. Symptomatic patients with elevated metal ion levels evinced highest prevalence (63 %) of PTs compared with asymptomatic patients with elevated metal ion levels (42 %) and symptomatic patients with nonelevated metal ions (11 %).

Conclusions

Contradicting the current international guidelines, our results suggest that it seems beneficial to combine routine metal ion measurement with clinical assessment, even in patients with well-functioning BHRs. Further follow-up will reveal whether new PTs will develop in these patients and BHR survivorship in the longer term.     

Restdysplasie im Kleinkindesalter

Objective

Restoration of a congruent, stable, mobile hip joint with normal function.

Indications

Persistent acetabular dysplasia of congenital or neuromuscular origin in children with still open triradiate cartillage.

Contraindications

Age under 18 months, closed triradiate cartilage, femoral head deformity.

Surgical technique

Incomplete supraacetabular transiliac osteotomy, the correction is performed by reshaping the acetabulum taking advantage of the inherent flexibility of the triradiate cartilage and the periacetabular bone. A triangular bioresorbable xenograft is used to maintain the correction until bony healing.

Postoperative management

Cast immobilization is not necessary, non-weight bearing for 4 weeks after surgery, then full weight bearing.

Results

In all, 31 hips in 20 patients were surgically treated for persistent acetabular dysplasia with the Dega acetabuloplasty. The results were retrospectively studied. The mean age at surgery was 42 months (range 31–67 months). The mean follow-up was 31 months (range 12–60 months). The acetabular angle before surgery measured 31.5° (range 27–44°) and was corrected to 14° (range 8–20°) at last follow-up. All patients showed at last presentation normal hip range of motion and had no complaints. None of the patients had functional restrictions. Severe complications were not observed. Transitory inguinal swelling was observed in only 3 cases in the immediate postoperative period and resolved completely without sequelae.