Calibration of papillotomy in the surgical treatment of papillary stenosis: the “little train”

Although laparoscopic and endoscopic surgery have brought about an indisputable revolution in biliary surgery, many surgeons still prefer open surgery for lithiasis of the common bile duct, and if it is associated with a papillary pathology, they perform a papillotomy. However, great controversy regarding the site, modalities, and extension of the papillary section has now developed among surgeons. Our technique is not original; however, we do propose a calibration of the papillotomy, carried out by constructing a little train made up of several consecutive Nélatons of increasing caliber to identify the sphincter fibers and to obtain sections proportionate to the size of the bile duct. Of the 115 patients in this series who were treated by open papillotomy, only 1 developed acute pancreatitis; 2 demonstrated bleeding, 1 of whom required surgical exploration.     

Dupuytren’s disease of ring and little finger

Objective  Resection of fibrous digitopalmar connective tissues to improve finger function. Indications  Dupuytren’s disease in Tubiana’s stage >III. Partial fasciectomy: at any age, for localized involvement, unlimited degree of contracture, and for recurrences. Complete fasciectomy: extension lag <45° of an individual finger, favorable skin condition, and progressing Dupuytren’s disease. Contraindications  Poor general health. State after stroke. Infection or eczema of hand. Excessive alcohol intake. Uncooperative patient. Relative: HIV infection. Surgical Technique  Antegrade dissection of the fibrous tissue from palm to distal interphalangeal joint through a Y-shaped palmar incision or longitudinal digital incision interrupted by Z-plasties at the level of flexion creases. Dissection starts at the radial healthy side. For partial fasciectomy, the fibrous tissue is removed including a safety margin. During complete fasciectomy, the entire triangular palmar fascia including the vertical septae is excised. The so-called open palm technique is a particular form of a partial fasciectomy whereby transverse incisions are not closed as opposed to longitudinal incisions which are always sutured. Results  In a prospective study, 48/239 patients were followed up >2 years. Recurrence rate was 39.7% while hand function improved by 70–86% in ulnar type. Complications observed in a retrospective study (1982–1991) of 566 patients (two thirds partial, one third complete fasciectomy): wound healing disturbance 3%, hematoma 2.5%, vessel injury 1.2%, nerve injury 1.8%, infection 0.7%, persisting edema 0.7%, scar contracture 0.2%. 87% of all recurrences appeared within 24 months. Their incidence after 2–10 years varied after partial or complete fasciectomy between 12.5 and 66%, and 21.4 and 39.7%, respectively. Only a small percentage of these needed a revision.     

Functional absence of flexor digitorum superficialis to the little finger and absence of palmaris longus--is there a link?

We examined 150 men and 150 women aged 18-40 years to assess flexor digitorum superficialis function to the little finger and the incidence of palmaris longus absence. All patients had flexor digitorum superficialis function to the little finger assessed by standard and modified tests. The presence or absence of palmaris longus was assessed by clinical inspection. Following modified testing, ten subjects (14 hands) displayed absolute superficialis deficiency to the little finger. Forty-nine subjects had unilateral absence of palmaris longus (16%). This tendon was absent bilaterally in 26 subjects (9%). On combining the clinical findings, one subject had unilateral absence of flexor digitorum superficialis function to the little finger with contralateral absence of palmaris longus, and one subject had bilateral absence of flexor digitorium superficialis function with unilateral absence of palmaris longus. We conclude that there is no link between an absent little finger flexor digitorium superficialis and an absent palmaris longus.     

Observation of splenic trauma: when is a little too much?

A 12-year-old boy was treated conservatively for a grade II splenic laceration. On discharge, he was instructed to avoid contact sports, running, and strenuous physical activity. Thirty-eight days later, after diving off the side of a swimming pool, he had abdominal pain, nausea, and diaphoresis. On admission, he was hemodynamically unstable. Results of a diagnostic lavage showed gross blood. At laparotomy, a fractured spleen was found, and splenectomy was performed. He recovered without complication. This case questions the activity restrictions placed on patients with conservatively managed splenic trauma. Avoidance of only contact sports and heavy exertion may be inadequate.     

Compression of the outlets of the leptomeningeal veins —the cause of intracranial plateau waves

Summary A case of otitic hydrocephalus, or intracranial hypertension secondary to inflammatory thrombosis of the left lateral sinus is described. Persistently elevated intracranial pressure, which did not respond to medical treatment, led to visual deterioration. A venous bypass graft was inserted between the left lateral sinus and jugular vein and was followed by rapid resolution of the raised intracranial pressure. The indications for this procedure are discussed.     

Emerging studies of the urinary proteome: the end of the beginning?

PURPOSE OF REVIEW: Urinary proteomics is a rapidly growing field, holding the promise of discovery of biomarkers of various disease processes and elucidation of pathophysiologic mechanisms of disease states. This may be true not only for renal disease but for diseases of other organs and systemic disorders. RECENT FINDINGS: Recent advances in separation technologies and rapid, high-throughput, and accurate protein detection and identification now permit rigorous examination of complex biological fluids. This review sketches the progress achieved in recent years and the existing hurdles in describing a normal urinary proteome, its aberrations in pathological conditions, and the search for biomarkers of several renal and non-renal diseases. SUMMARY: The first wave of urinary proteomic studies has now arrived and their results are summarized. Future lines of investigation are delineated.     

Dimensions of Growth? Examining the Distinctiveness of the Five Factors of the Posttraumatic Growth Inventory

Posttraumatic growth, defined as positive transformation following trauma, is commonly measured using the Posttraumatic Growth Inventory (PTGI; Tedeschi & Calhoun, 1996) and is postulated to comprise five distinct domains: Changes in Relationships, Life Possibilities, Personal Strength, Spirituality, and Appreciation of Life. However, research has indicated that the model fit is not good and the factors are highly intercorrelated. Further, no studies have formally examined the heterogeneity of correlations of the five factors with external constructs. In an effort to examine the construct validity of the five‐factor model of the PTGI, the present study aimed to examine the degree to which the theorized five factors demonstrate meaningful differential associations with relevant external correlates. Participants were 400 undergraduate students who reported having experienced a stressful event and completed the Life Events Checklist for DSM‐5, PTGI, Posttraumatic Stress Disorder Checklist for DSM‐5, Grit Scale‐12, Connor‐Davidson Resilience Scale‐10, and Work and Social Adjustment Scale. We found few instances of significant differentiation, and effect sizes for pairwise comparisons were generally small, Cohen's qs = 0.01–0.35. Although factor analytic evidence suggests there are five distinct underlying constructs, our results indicated that these factors do not significantly differ in their associations with external correlates. Implications for use of the PTGI and future research directions are discussed.