Spinal cord infarction secondary to intervertebral foraminal disease

STUDY DESIGN: The 5 year review of patients referred to one center. OBJECTIVE: To report spinal cord infarction secondary to vascular occlusion from disease in a lower thoracic intervertebral foramen. METHOD: The clinical and imaging findings of two cases with acute spinal cord dysfunction are presented. SETTING: Midlands Centre for Spinal Injuries, England. RESULTS: The CT and MR imaging features revealed lower thoracic unilateral foraminal occlusion due to acute facet joint septic arthritis in a diabetic patient, and secondary to chronic hypertrophic osteophytes in a second hypertensive individual. The presumed mechanism of infarction was occlusion of the artery of Adamkiewicz. CONCLUSION: Foraminal disease in the lower thoracic levels needs to be entertained in cases of unexplained nontraumatic acute spinal cord dysfunction.     

The use of human dura mater as an interposition graft in the treatment of vesicovaginal fistula

PURPOSE: In this prospective study we aimed to describe our new technique; dehydrated human dura mater as an interposition graft in patients undergoing benign vesicovaginal fistula repair (VVF). PATIENTS AND METHODS: Eleven patients with benign VVFs aged 38-73 years were operated with dura mater interposition technique at our institution between July 1996 and February 2002. In all patients fistula were secondary to abdominal hysterectomies with benign diseases and two had undergone previous transvaginal surgery. Patients were operated 8-15 (mean 12) weeks after previous surgery. A suprapubic cystotomy was performed and the fistula was not excised. The bladder wall is widely dissected from underlying vagina. Dura-mater was placed over the vaginal suture line to close the fistulous tract, cytostomy was inserted and the bladder was closed. An 18 F Foley catheter was left in the bladder for 5 days. A successful repair is defined as no leakage by cystogram at 14 days postoperatively and completely dry by patient report. RESULTS: An overall success rate of 100% was achieved in all patients. All patients remain dry at the follow-up which ranges from 7 to 60 (mean 26) mounts. Patients were discharged at 14 to 26 (mean 16) days postoperatively. No major complications or side effects were observed during the follow-up period. CONCLUSIONS: The use of human dura mater as an interposition graft in the treatment of vesicovaginal fistula is an alternative for VVF repairs because of its excellent tissue compability, stability, good elasticity and absorbability.     

Conventional and sutureless techniques for management of the pulmonary veins: Evolution of indications from postrepair pulmonary vein stenosis to primary pulmonary vein anomalies

OBJECTIVE: We have previously reported a limited but favorable experience with a novel sutureless technique for surgical management of postoperative pulmonary vein stenosis occurring after repair of total anomalous pulmonary venous drainage. Because this technique requires integrity of the retrocardiac space for hemostasis, extension of the technique to the primary repair of pulmonary vein anomalies requires evaluation. This analysis reviews our experience with the sutureless technique in patients with postrepair pulmonary vein stenosis, as well as our extension of the technique into primary repair of pulmonary vein anomalies. METHODS: Retrospective univariable-multivariable analysis of all pulmonary vein stenosis procedures and sutureless pulmonary vein procedures over a 20-year period was performed. Cox proportional hazards modeling was used to identify variables associated with freedom from reoperation or death. RESULTS: Sixty patients underwent 73 procedures, with pulmonary vein stenosis present in 65 procedures. The sutureless technique was used in 40 procedures. Freedom from reoperation or death at 5 years after the initial procedure was 49%. Unadjusted freedom from reoperation or death was greater with the sutureless technique for patients with postrepair pulmonary vein stenosis ( P = .04). By using multivariable analysis, a higher pulmonary vein stenosis score was associated with greater risk of reoperation or death. After adjustment, the sutureless repair was associated with a nonsignificant trend toward greater freedom from reoperation or death ( P = .12). Despite the absence of retrocardiac adhesions, operative mortality was not increased with the sutureless technique ( P = .64). Techniques to control bleeding (intrapleural hilar reapproximation) and improve exposure (inferior vena cava division) were identified. CONCLUSION: The sutureless technique for postrepair pulmonary vein stenosis is associated with encouraging midterm results. Extension of the indications for the technique to primary repair appears safe with the development of simple intraoperative maneuvers.     

Results of non-operative and operative treatment of humeral shaft fractures. A series of 104 cases

The aim of this study was to examine the results of different modalities applied in the treatment of 104 fresh diaphyseal fractures of the adult humerus treated in the department between January 1994 and March 1997. These results were classified according to the criteria described by Stewart and Hundley. 32 patients (30.8%) were treated non-operatively using a sling and a moulded plaster splint. The type of treatment had to be changed in 12 of these patients due to 14 different complications that occurred during the course of non-operative treatment. Thus, 20 patients (62.5%) underwent non-operative treatment until fracture-union. The results in this group were: very good in 12 cases (60%), good in 5 cases (25%), fair in 3 cases (15%). 28 fractures were treated using plates and screws. 4 events (14%) occurred during in the post-operative period and, apart from 2 cases of non-union, the overall result in the 26 patients in whom the fracture united was: very good in 23 cases (88.5%) and good in 3 cases (11.5%). 22 patients (21.1%) underwent fixation using multiple flexible intramedullary wires via a supracondylar approach. Apart from one case of non-union, the final result in the 21 patients in whom the fracture united was: very good in 9 cases (42.8%), good in 9 cases (42.8%), fair in 2 cases (9.5%) and poor in 1 case (4.9%). 22 fractures were treated using an intramedullary Seidel nail. The final result in these patients was: very good in 11 cases (50%), good in 9 cases (41%) and poor in 2 cases (9%). The indications for treatment should be eclectic. Non-operative treatment remains the method of choice for undisplaced or minimally-displaced fractures or comminuted fractures with multiple parallel longitudinal fracture-lines over the middle-third, while surgical treatment is considered for displaced fractures and essentially depends upon the type and level of the fracture. Transverse and short oblique fractures are treated using a plate or a Seidel nail. Fractures with a third fragment require plate osteosynthesis. Multiple flexible intramedullary wires are used for segmental fractures or for diaphyseal fractures associated with fractures of the neck of the humerus. Comminuted fractures are realigned using an intramedullary Seidel nail or multiple flexible wires. As far as the site of fracture is concerned, those of the proximal and middle thirds of the humerus are well treated using an intramedullary nail or multiple wires or with a plate, while plating is most often the method of choice for fractures of the distal-third.     

Circulating irisin levels reflect visceral adiposity in non-diabetic patients undergoing hemodialysis

Background: Recent evidence suggests that increased visceral adiposity is a strong independent risk factor for cardiovascular death and all-cause mortality in hemodialysis (HD) patients. Irisin, which is a novel myokine, can play critical roles in diabetes and adiposity. The purpose of our study was to investigate whether serum irisin levels are associated with body mass index, waist circumference (WC), and total fat mass in non-diabetic patients undergoing maintenance HD.

Methods: This cross-sectional study included 108 non-diabetic HD patients and 40 age- and sex-matched apparently healthy subjects. Serum irisin concentrations were determined using an enzyme-linked immunosorbent assay. Body fat composition (TBF-410 Tanita Body Composition Analyzer) was measured and calculated.

Results: Serum irisin levels did not differ between HD patients and the healthy controls (523.50?±?229.32 vs. 511.28?±?259.74, p?=?0.782). Serum irisin levels were associated with age (r?=?0.314; p?=0.006), HOMA-IR (r?=?0.472; p?=?0.003), WC (r?=?0.862; p?r?=?0.614; p?β?=?1.240, p?β?=?0.792, p?=?0.015) were the variables that were significantly associated with irisin concentrations (R^2?=^?0.684, p?Conclusions: These results suggest that serum irisin levels are related to visceral adiposity in non-diabetic HD patients.     

Cam impingement of the posterior femoral condyle in unicompartmental knee arthroplasty

Purpose

There has been much emphasis on the importance of cam impingement, which is a cause of pain and knee hyperflexion restriction in unicompartmental knee arthroplasty (UKA). This study aimed to correlate cam impingement in the posterior femoral condyle with an α-angle showing the severity of the impingement.

Methods

The study groups consisted of 87 knees of 74 patients operated on with phase 3 medial Oxford UKA. Postoperatively, Group A (68 knees, 78.2 %) had no remnant of cam lesion; Group B (19 knees, 21.8 %) had cam lesion remnants. In Group C (18 knees, 20.7 %), which is a subgroup of Group A, cam lesions seen preoperatively were cleaned and not seen postoperatively.

Results

The mean increase in active flexion was 20.4° (±7.3°) in Group A, 9.7° (±6.1°) in Group B and 20.8° (±7.3°) in Group C. The difference between Group A and Group B and between Group B and Group C was statistically significant (p < 0.001, p < 0.001). The mean decrease of α-angle was 11.2° (±4.1°) in Group B, and 31.1° (±3.4°) in Group C. The difference was statistically significant (p < 0.001). Mean Oxford Knee Scores were 24 preoperatively, 41 postoperatively in Group A; 22 preoperatively, 38 postoperatively in Group B; and 24 preoperatively, 40 postoperatively in Group C. The differences were not significant.

Conclusions

Posterior condylar cam lesion is an impingement which limits hyperflexion and may be an early clinical finding prior to bearing dislocation and wear. The α-angle is a marker showing the severity of this cam lesion. This problem can be overcome using intraoperative fluoroscan views during cam excison and replacing the femoral component in 105° knee flexion.

Level of evidence

II.     

Evaluation of [O-methyl-11C]RS-15385-197 as a positron emission tomography radioligand for central α2-adrenoceptors

Carbon-11 labelled RS-15385-197 and its ethylsulphonyl analogue, RS-79948-197, were evaluated in rats as potential radioligands to image central α₂-adrenoceptors in vivo. The biodistributions of both compounds were comparable with that obtained in an earlier study using tritiated RS-79948-197 and were consistent with the known localisation of α₂-adrenoceptors. The maximal signals (total to non-specific binding) were, however, reduced, in the order [¹¹C]RS-79948-197 < [¹¹C]RS-15385-197 < [³H]RS-79948-197, primarily due to the difference in radiolabel position (O-methyl for carbon-11 compared with S-ethyl for tritium). This resulted in the in-growth of radiolabelled metabolites in plasma, which, in turn, contributed to the non-specific component of brain radioactivity. Nonetheless, the signal ratio of ∼5 for a receptor-dense tissue compared with the receptor-sparse cerebellum, at 90–120 min after radioligand injection, encouraged the development of [O-methyl-¹¹C]RS-15385-197 for human positron emission tomography (PET). Unfortunately, in two human PET scans (each of 90 min), brain extraction of the radioligand was minimal, with volumes of distribution more than an order of magnitude lower than that measured in rats. Following intravenous injection, radioactivity was retained in plasma and metabolism of the radiolabelled compound was very low. Retrospective measurements of in vitro plasma protein binding and in vivo brain uptake index (BUI) in rats demonstrated a higher protein binding of the radioligand in human compared with rat plasma and a lower BUI in the presence of human plasma. It is feasible that a higher affinity of RS-15385-197 for human plasma protein compared with receptor limited the transport of the radioligand. Although one of the PET scans showed a slight heterogeneity in biodistribution of radioactivity which was consistent with the known localisation of α₂-adrenoceptors in human brain, it was concluded that [O-methyl-¹¹C]RS-15385-197 showed little promise for routine quantification of α₂-adrenoceptors in man. Received 26 October 1999 and in revised form 21 January 2000     

Evaluation of [11C]GB67, a novel radioligand for imaging myocardial α1-adrenoceptors with positron emission tomography

Dysfunction of the sympathetic nervous system underlies a number of myocardial disorders. Positron emission tomography (PET) offers a way of assessing receptor function non-invasively in humans, but there are no PET radioligands for assessing myocardial α-adrenoceptors. GB67, a structural and pharmacological analogue of the α₁-adrenoceptor antagonist prazosin, was labelled with positron-emitting carbon-11 (t _1/2=20.4 min) by ¹¹C-methylation of N-desmethylamido-GB67 (GB99). [¹¹C]GB67 was injected intravenously into conscious rats. Serial arterial blood samples were taken. Rats were killed and tissues removed to determine radioactivity. The percentages of unchanged [¹¹C]GB67 and its radioactive metabolites in plasma and tissues were assessed by HPLC. Plasma clearance of radioactivity was rapid. Myocardial uptake was maximal at 1–2 min and decreased slowly during 60 min. Predosing with adrenoceptor antagonists demonstrated selectivity for myocardial α₁-adrenoceptors. GB67 and prazosin blocked uptake of radioactivity; the non-selective antagonist, phentolamine, partially blocked uptake; the α₂-adrenoceptor antagonist, RX 821002, only blocked uptake at high dose and the β-adrenoceptor antagonist, CGP 12177, had no effect. Additionally, injection of prazosin at 20 min after radioligand displaced radioactivity. In vivo competition curves obtained by injecting [¹¹C]GB67 with varying amounts of either unlabelled GB67 or its precursor GB99 were fitted to a competitive binding model to provide estimates of the maximum number of binding sites (B _max) and half saturation doses (K) for myocardium. Assuming a tissue protein content of 10%, the values of B _max [∼13 pmol·(g tissue)^–1] were similar to those [50–170 fmol·(mg protein)^–1] reported for myocardial α₁-adrenoceptors assessed in vitro. Both GB67 and its precursor GB99 had high affinity for α₁-adrenoceptors [K _GB67=1.5 nmol·(kg body weight)^–1, K _GB99=4.8 nmol· (kg body weight)^–1]. HPLC demonstrated four radioactive metabolites in plasma. [¹¹C]GB67 was 80% of the radioactivity at 5 min and 50% at 45 min. No radioactive metabolites were detected in myocardium up to 60 min after injection. [¹¹C]GB67 was assessed in two male human volunteers. PET demonstrated high myocardial uptake. The profile of radioactive metabolites in plasma was comparable to that in the rat, although metabolism was slower in humans. Thus, [¹¹C]GB67 is a promising radioligand for assessing α₁-adrenoceptors in human myocardium with PET. Received 7 May and in revised form 9 August 1999     

Strain-Encoded Cardiac Magnetic Resonance for the Evaluation of Chronic Allograft Vasculopathy in Transplant Recipients

The aim of our study was to investigate the ability of Strain-Encoded magnetic resonance imaging (MRI) to detect cardiac allograft vasculopathy (CAV) in heart transplantation (HTx)-recipients. In consecutive subjects (n = 69), who underwent cardiac catheterization, MRI was performed for quantification of myocardial strain and perfusion reserve. Based on angiographic findings subjects were classified: group A including patients with normal vessels; group B, patients with stenosis <50%; and group C, patients with severe CAV (stenosis ≥ 50%). Significant correlations were observed between myocardial perfusion reserve with peak systolic strain (r =−0.53, p < 0.001) and with mean diastolic strain rate (r = 0.82, p < 0.001). Peak systolic strain and strain rate were significantly reduced only in group C, while mean diastolic strain rate and myocardial perfusion reserve were already reduced in group B and A. Myocardial perfusion reserve and mean diastolic strain rate had higher accuracy for the detection of CAV (AUC = 0.95, 95% CI = 0.87–0.99 and AUC = 0.93, 95% CI = 0.84–0.98, respectively) and followed peak systolic strain and strain rate (AUC = 0.80, 95% CI = 0.69–0.89 and AUC = 0.78, 95% CI = 0.67–0.87, respectively). Besides the quantification of myocardial perfusion, the estimation of the diastolic strain rate is a useful parameter for CAV assessment. In combination with the clinical evaluation, these parameters may be effective tools for the routine surveillance of HTx-recipients.     

Abbreviated emergency laparotomy in the non-trauma setting

Background  

Although the application of damage control surgery for trauma has been widely reported and defined, similar approach in non-trauma patients has not been well detailed.