Gut Microbiome - Should we treat the gut and not the bones?

Gut microbiome (GM) forms an integral part of homeostasis of an individual. Due to the recent development of metagenomics, the plausibility of sequencing GM and its therapeutic ability for various diseases has been explored. Dysbiosis or disequilibrium or pertubations of GM leads to disruption of intercommunication signaling among gut-bone axis, gut-bone-brain axis, and gut-disc axis resulting in the progression of various chronic diseases. The therapeutic interventions to restore the GM like prebiotics and probiotics, bacteriophage therapy, fecal microbiota transplantation, and physical biomodulation have been identified. This review throw the lime light on the effect of gut dysbiosis in musculoskeletal diseases.     

Cyclic supraventricular tachycardia in the parturient: to treat or not to treat?

Cardiac arrhythmias are more common in pregnant women than in non-pregnant women. In the asymptomatic pregnant patient with a stable fetus, watchful waiting might be the best strategy. Herein, we describe the first reported case of a pregnant patient who developed cyclic supraventricular tachycardia during labor. No treatment was prescribed, with a good maternal and fetal outcome.     

What is the best way not to treat prostate cancer?

Introduction

Selective treatment approaches for prostate cancer (PCa) are warranted given the highly varied nature of the disease and the consequences associated with definitive therapy.

Does testosterone deficiency exaggerate the clinical symptoms of Peyronie's disease?

Serum testosterone (T) influences wound healing and levels are decreased in the age group at risk of Peyronie's disease (PD). The aim of the present study was to evaluate the severity of penile deformity in men with PD in relation to T levels. One-hundred and six patients with PD and T deficiency (serum T <3.5 ng/mL; Group 1) and those with normal T levels (Group 2) were compared according to the duration of PD, the size and location of the plaques, penile curvature, pain on erection, and the severity of erectile dysfunction. The mean degree of penile curvature in Group 1 was significantly greater than in Group 2 (32.0 ± 15.9° vs 21.8 ± 15.4°, respectively). The mean Group 1 score on the International Index of Erectile Function (IIEF)-5 was lower than the score for Group 2 (7.4 ± 3.7 vs 10.8 ± 4.8, respectively). The percentage of patients who complained of pain on erection did not differ between the two groups. Plaque size in Group 1 was larger than in Group 2 (3.0 ± 1.2 vs 2.0 ± 1.2 cm, respectively), whereas there was no significant difference in plaque location. Although there was a lower percentage of responders to medical treatment in Group 1, there were no differences in surgical outcomes between the two groups. These findings suggest that the presence of T deficiency in patients with PD exaggerates the severity of PD by affecting penile deformity, plaque size, and erectile dysfunction. Further studies are needed to confirm this relationship.     

GIST identified during bariatric surgery: to treat or not to treat?

BackgroundGastrointestinal stromal tumors (GIST) are rare GI tumors that compose 1% of GI tumors. With the rise in obesity, bariatric surgery is becoming an increasingly common procedure and the incidental GISTs in this population have been noted more often than in the general population.ObjectiveWe evaluated and characterized the incidental GISTs in our bariatric surgical population.SettingThe study was completed at a Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program–accredited academic hospital system.MethodsAll GISTs identified during Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy between January 1, 2005 and December 31, 2016 were evaluated. Typical demographic, clinicopathologic, treatment, follow-up, and outcome data were recorded.ResultsWithin the 2655 bariatric surgeries at our institution, 17 GISTs were identified (.64%). Mean age was 54 years; 94% of lesions were identified intraoperatively. Lesions were identified in the fundus (29.4%) or body (70.6%), were unifocal, and <1 cm; 94.1% of resections had clear margins. Histology revealed 88.2% spindle cell and 11.8% mixed histology with <5 mitoses/50 fields, portending a low malignancy potential. Follow-up included the bariatric surgeon and oncology consult; 17.6% were recommended by oncology for computed tomography surveillance. No recurrences were recorded.ConclusionWe present the largest cohort to date of incidental GISTs in a bariatric population. A diligent intraoperative examination of the serosa in the left-behind portion of the remnant in bypass and the discarded remnant in sleeves allows the bariatric surgeon the opportunity to leave the patient cancer-free after removal of incidental tumor.     

Back pain in patients with degenerative spine disease and intradural spinal tumor: what to treat? when to treat?

Background

Back pain is common in industrialized countries and one of the most frequent causes of work incapacity. Successful treatment is, therefore, not only important for improving the symptoms and the quality of life of these patients but also for socioeconomic reasons. Back pain is frequently caused by degenerative spine disease. Intradural spinal tumors are rare with an annual incidence of 2–4/1,00,000 and are mostly associated with neurological deficits and radicular and nocturnal pain. Back pain is not commonly described as a concomitant symptom, such that in patients with both a tumor and degenerative spine disease, any back pain is typically attributed to the degeneration rather than the tumor.

Objective

The aim of the present retrospective investigation was to study and analyze the impact of microsurgery on back/neck pain in patients with intradural spinal tumor in the presence of degenerative spinal disease in adjacent spinal segments.

Methods

Fifty-eight consecutive patients underwent microsurgical, intradural tumor surgery using a standardized protocol assisted by multimodal intraoperative neuromonitoring. Clinical symptoms, complications and surgery characteristics were documented. Standardized questionnaires were used to measure outcome from the surgeon’s and the patient’s perspectives (Spine Tango Registry and Core Outcome Measures Index). Follow-up included clinical and neuroradiological examinations 6 weeks, 3 months and 1 year postoperatively.

Results

Back/neck pain as a leading symptom and coexisting degenerative spine disease was present in 27/58 (47 %) of the tumor patients, and these comprised to group under study. Patients underwent tumor surgery only, without addressing the degenerative spinal disease. Remission rate after tumor removal was 85 %. There were no major surgical complications. Back/neck pain as the leading symptom was eradicated in 67 % of patients. There were 7 % of patients who required further invasive therapy for their degenerative spinal disease.

Conclusions

Intradural spinal tumor surgery improves back/neck pain in patients with coexisting severe degenerative spinal disease. Intradural spinal tumors seem to be the only cause of back/neck pain more often than appreciated. In these patients suffering from both pathologies, there is a higher risk of surgical overtreatment than undertreatment. Therefore, elaborate clinical and radiological examinations should be performed preoperatively and the indication for stabilization/fusion should be discussed carefully in patients foreseen for first time intradural tumor surgery.     

Elective laparoscopic cholecystectomy for symptomatic uncomplicated gallstone disease: do the symptoms disappear?

Background

Symptomatic gallstone disease is considered an indication for cholecystectomy. A considerable proportion of patients may experience persistent symptoms after surgery. The purpose of the present study was to find out the rate of symptom persistence after elective laparoscopic cholecystectomy (LC) performed for symptomatic uncomplicated gallstone disease and, in particular, to clarify whether the recurrence rate differs according to the severity of preoperative symptoms.

Methods

During a 10-year period (1992–2001), 1,101 patients underwent elective LC at Turku City Hospital for Surgery. A questionnaire concerning the intensity of preoperative symptoms, persistence of symptoms postoperatively, and overall satisfaction with the outcome of the procedure was sent to patients. A total of 677 patients [mean age (range) 59 (21–94) years; 554 (83.1 %) females] with uncomplicated gallstone disease returned the completed form.

Results

Overall, 380 (57 %) patients reported attacks of intense upper abdominal pain, and 287 (43 %) reported episodic mild abdominal symptoms as the prevailing preoperative symptom. Two hundred and forty-eight (37 %) patients continued to have abdominal symptoms after the operation. Among those with predominantly mild abdominal symptoms preoperatively, 119 (41 %) reported the persistence of symptoms after the operation, while in the group with mainly severe upper abdominal pain attacks, 129 (33 %) patients had recurrences (p = 0.052).

Conclusions

According to our data, more than one-third of patients with symptomatic uncomplicated gallstone disease experienced persistent symptoms after elective LC. Patients with mild preoperative symptoms seemed to have more recurrences than those with severe symptoms, although the difference was not statistically significant.     

Nephrocystin and ciliary defects not only in the kidney?

Cystoproteins have been recognized to play a major role in the development of cystic kidney diseases (CKDs) via interaction with the cilia/centrosome complex. We highlight our present knowledge on nephrocystin as the defective protein in nephronophthisis type I. Nephrocystin has been localized to the ciliary transition zone not only of renal tubule cells but also of respiratory and retinal cilia. Thus, multi-system involvement as in Senior–Løken-syndrome (retinal degeneration plus nephronophthisis) can be explained by a functional ciliary defect in various tissues. In addition, we illustrate that ciliated respiratory cells have a high potential for diagnostics in CKDs and will further aid understanding of the underlying molecular mechanisms.     

Why not use a small incision to treat large hydroceles?

Background: Operative treatment of large hydroceles generally requires a large incision. Methods: A technique is described which permits a traditional Jaboulay's or Lord's repair to be done through a 3 cm incision. Results: Twenty patients with large hydroceles were operated on from June 2000 to November 2001 using this technique and to date, only one patient has had a recurrence. There has been no occurrence of either scrotal wound infection or haematoma ­formation. Conclusions: A hydrocele repair of the surgeon's choice can be done safely through a 3 cm incision.     

Degenerative spondylolisthesis of the cervical spine — symptoms and surgical strategies depending on disease progress

Background Degenerative spondylolisthesis of the cervical spine is rare. Patients show signs of progredient myelopathy, radiculopathy and pain. Treatment strategies include ventral, dorsal and combined fusion techniques with or without repositioning and decompression.Methods In this study, we present 16 patients with degenerative cervical spondylolisthesis. The leading symptom was severe myelopathy in 8 patients, radiculomyelopathy in 5 patients and neck pain in 3 patients. However, neck pain was the initial symptom in all the patients and decreased when neurological symptoms became more evident. Radiographic examinations included plain radiography, MRI, CT, myelography and lateral tomography.Results Spondylolisthesis was located five times at level C3/4, C4/5 and C5/6. In three cases spondylolisthesis was located at level C7/T1. There were two patients with spondylolisthesis on two levels. Instability could be demonstrated by flexion/extension radiography in five cases. Patients were divided into three groups according to a newly introduced classification system. The surgical approach corresponded to this classification. In ten patients the spondylolisthesis could be corrected by extension and positioning, so discectomy and fusion on one or two levels with cage, plate and screws was sufficient. In five cases a corpectomy was necessary due to severe spondylosis. In one case a combined approach with dorsal decompression and release followed by ventral fusion was applied due to additional dorsal spinal cord compression. The follow-up period was 6–52 months. After surgery, none of the patients showed any signs of neurological deterioration. In all cases, a stable fusion was achieved with no signs of instability on flexion/extension radiographs. Neurological improvement was seen in 6 of 8 patients with myelopathy and 4 of 5 patients with radiculomyelopathy. The others showed stable disease. Pain relief was seen in all patients who complained of pain preoperatively.Conclusion The aims of treatment for cervical spondylolisthesis are spinal cord decompression (ventral, dorsal or both), correction and fusion. The used procedure should depend on the severity of the cervical deformity, degree and side of the spinal cord compression, and the possibility of correction by extension and positioning.     

Prehypertension and chronic kidney disease: the ox or the plow?

Nearly ten years ago, practice recommendations supported use of the clinical classification of 'prehypertension' for people with systolic blood pressure of 120-139 mm Hg or diastolic pressure of 80-89 mm Hg. This recommendation was based on observations that these ranges of blood pressure were associated with enhanced cardiovascular and cerebrovascular risks compared with blood pressure less than 120/80 mm Hg. Recent observations, including the report by Yano and colleagues, also suggest that prehypertension is an important risk factor for the development of chronic kidney disease.