Unusual Kirschner wire migration as a late complication of Salter innominate osteotomy in developmental dislocation of the hip

Innominate osteotomy of Salter remains the most commonly used pelvic osteotomy for children in the age of 18 months to 6 years. Kirschner wire is inserted across the osteotomy site to fix the bone graft. We present an unusual case of migration of Kirschner wire through the abdominal region. Migration of pins to the femoral head is well-known complication. To our knowledge, this is the first case reporting migration of Kirschner wire through the abdominal region.     

Regulation of growth factors in hormone‐ and drug‐resistant prostate cancer cells by synergistic combination of docetaxel and octreotide

OBJECTIVE

To evaluate the effects of combined treatment with docetaxel and octreotide, a somatostatin analogue, on human hormone‐ and drug‐refractory prostate cancer cell lines, PC‐3 and DU‐145, and on some growth factors related to tumour growth and angiogenesis in prostate cancer.

MATERIALS AND METHODS

A cell proliferation assay was used to assess the cytotoxicity of the drugs. To verify apoptosis, both DNA fragmentation (by enzyme‐linked immunosorbent assay) and caspase 3/7 activity were measured. We also investigated the effect of combined docetaxel and octreotide on growth factors secreted from prostate cancer cells using a human growth factor antibody array.

RESULTS

The combination of docetaxel and octreotide resulted in significant synergistic cytotoxic activity and apoptosis, which was dose‐ and time‐dependent. The combined treatment also resulted in significantly less secretion of stem cell factor and platelet‐derived growth factor‐AB in PC‐3 cells, and transforming growth factor‐β and basic fibroblast growth factor in DU‐145 cells, than in untreated controls.

CONCLUSION

Octreotide, a somatostatin analogue, combined with docetaxel might provide a rationale treatment option for hormone‐refractory prostate cancer cells, not only by direct inhibition of cell proliferation but also by inhibiting the secretion of growth factors.     

Tamoxifen in the Treatment of Idiopathic Retroperitoneal Fibrosis

Idiopathic retroperitoneal fibrosis (RF) is a histologically benign, nonspecific inflammatory process of the fibroadipose tissue in the retroperitoneum with an unknown etiology. It may be complicated due to encasement and obstruction of the retroperitoneal structures. Tamoxifen has been known to be an effective agent in regression of desmoid tumors which include similar mesenchymal elements to those seen in RF. Herein, we reported a case of RF presented with ureteral obstruction and acute renal failure. The patient was successfully treated with tamoxifen.     

The effects of maintenance recombinant human erythropoietin therapy on ambulatory blood pressure recordings: conventional, Doppler, and tissue Doppler echocardiographic parameters

Abstract: Cardiovascular disease is the major cause of mortality in maintenance hemodialysis patients. Left ventricular dysfunction is present in approximately 80% of these patients and is highly predictive of future ischemic heart disease, cardiac failure, and death. Anemia has been identified as one of several risk factors responsible for cardiac complications. The treatment of renal anemia with recombinant human erythropoietin (rHuEpo) and consequent improvement of cardiac performance may reverse pathological changes in left ventricular geometry. In this study, the acute and chronic effects of rHuEpo administration on 24‐hour ambulatory blood pressure recordings and echocardiographic parameters in 30 rHuEpo‐naïve maintenance hemodialysis patients were examined. Twenty‐four‐hour ambulatory blood pressure monitoring was performed prior to and after 1 week and 6 months of rHuEpo administration. The patients underwent echocardiographic examination prior to and after 6 months of rHuEpo administration. One week treatment with rHuEpo did not cause any significant change in 24‐hour ambulatory blood pressure recordings. After 6 months of therapy, serum hemoglobin levels increased from 8.8 ± 0.66 g/dL to 10.8 ± 0.70 g/dL (P < 0.05). Echocardiographic examination revealed elevation in ejection fraction (62.26 ± 6.84% vs. 69.90 ± 8.98%, P < 0.05) with reductions in fractional shortening (36.70 ± 4.96% vs. 35.96 ± 6.32%, P < 0.05), interventricular septum thickness (1.21 ± 0.16 vs. 1.00 ± 0.16 cm, P < 0.05), and left ventricular mass index (148.2 ± 46.5 g/m² vs. 93.6 ± 17.2 g/m², P < 0.05). Doppler echocardiography and tissue Doppler imaging provided additional information in comparison with conventional echocardiography. Before treatment, mitral flow E wave (E, 0.64 ± 0.27 vs. 0.82 ± 0.17 cm/s), mitral flow A wave (A, 0.80 ± 0.21 vs. 0.70 ± 0.21 cm/s), early diastolic velocity of lateral wall (Lateral E′, 11.2 ± 2.8 vs. 12.4 ± 2.3 cm/s), late diastolic velocity of lateral wall (Lateral A′, 6.7 ± 2.5 vs. 7.8 ± 2.1 cm/s), early diastolic velocity of septal wall (Septal E′, 9.7 ± 2.9 vs. 11.3 ± 1.1 cm/s), and late diastolic velocity of septal wall (Septal A′, 6.4 ± 2.1 vs. 7.8 ± 2.0 cm/s) were significantly lower in patients than in the controls. Patients and controls have similar deceleration time of mitral flow E wave (E Dec, 186 ± 57.8 vs. 192 ± 62.4 ms), isovolumic left ventricular relaxation time (IVRT, 111.9 ± 30.7 vs. 91.1 ± 32 ms), systolic velocity of lateral wall (Lateral S′, 7.8 ± 2.3 vs. 8.1 ± 2.0 cm/s), and systolic velocity of septal wall (Septal S′, 7.5 ± 1.9 vs. 7.7 ± 1.4 cm/s) values. Therapy with rHuEpo did not cause significant changes in E (0.64 ± 0.27 vs. 0.76 ± 0.29 cm/s), A (0.80 ± 0.21 vs. 0.79 ± 0.23 cm/s), E Dec (186 ± 57.8 vs. 165.8 ± 60.1 ms), IVRT (111.9 ± 30.7 vs. 101.6 ± 36.2 ms), Lateral E′ (11.2 ± 2.8 vs. 11.5 ± 4.4 cm/s), Lateral A′ (6.7 ± 2.5 vs. 7.4 ± 2.1 cm/s), Lateral S′ (7.8 ± 2.3 vs. 8.1 ± 2.0 cm/s), Septal E′ (9.7 ± 2.9 vs. 10.0 ± 1.1 cm/s), Septal A′ (6.4 ± 2.1 vs. 6.6 ± 2.0 cm/s), and Septal S′ (7.5 ± 1.9 vs. 7.9 ± 1.4 cm/s) indicating persistence of diastolic dysfunction. In 6 months time, 24‐hour ambulatory blood pressure recordings, however, tended to be higher (systolic: 125.16 ± 21.02 mm Hg vs. 134.36 ± 23.98 mm Hg; diastolic: 77.40 ± 14.47 mm Hg vs. 83.26 ± 14.89 mm Hg, P < 0.05). Correction of anemia with rHuEpo results in the elevation of blood pressure and reduction in left ventricular mass index. Myocardial contraction and relaxation velocities did not improve following regression of left ventricular hypertrophy, suggesting the persistance of diastolic dysfunction. Doppler echocardiography with tissue Doppler imaging reflects the real situation of diastolic function in patients on maintenance hemodialysis.     

Proanthocyanidin Protects Intestine and Remote Organs Against Mesenteric Ischemia/Reperfusion Injury

Background  Intestinal ischemia/reperfusion (IR) induces a systemic inflammatory response and releases harmful substances that may affect the function and integrity of distant organs such as lung, liver, and kidney. We conducted this study to find out if proanthocyanidins (PA) has protective effects against mesenteric IR injury and mesenteric IR-induced intestinal and distant organ injury. Materials and methods  Thirty-two Sprague-Dawley rats were divided into four groups: control, control + PA, IR, IR + PA. The IR and IR + PA groups were subjected to mesenteric arterial ischemia for 60 min and reperfusion for 6 h. The Control + PA and IR + PA groups were administered PA (100 mg/kg/day via oral gavage) for 7 days prior to injury insult. We collected ileal and distant organ tissues, such as pulmonary, hepatic, and kidney specimens to measure tissue levels of malondialdehyde (MDA), superoxide dismutase (SOD), glutathione peroxidase (GPx), and nitrite plus nitrate (NO_x), and we then evaluated histological changes. Results  In the IR group, significant increases in MDA and NO_x levels and significant increases in SOD and GPx activities of intestine, liver, kidney, and lung were observed. The MDA and NO_x levels were significantly lower, as were the SOD and GPx activities in the IR + PA group than that in the IR group. Although the intestine and distant organs damage scores were significantly higher in the IR group, these injuries were prevented by PA in the IR + PA group. Conclusions  This study demonstrates that PA has a significant effect in the protection of the intestine and the remote organs against mesenteric IR injury.     

On-pump beating heart versus hypothermic arrested heart valve replacement surgery

BACKGROUND: Comparison of neurological parameters in patients undergoing prosthetic heart valve replacement with two operating techniques-either cardioplegic arrest of the heart under hypothermic cardiopulmonary bypass (CPB) or the heart beating on normothermic bypass, with or without cross-clamping the aorta, without cardioplegic arrest. methods: Fifty valvular surgery patients were randomly assigned into three groups. Sixteen patients underwent beating heart valve replacement with normothermic bypass without cross-clamping the aorta, 17 patients underwent the same procedure with cross-clamping the aorta and retrograde coronary sinus perfusion, and the remaining 17 patients had conventional surgery with hypothermic bypass and cardioplegic arrest. RESULTS: Two-channel electroencephalography (EEG) was recorded to assess changes in cerebral cortical synaptic activity and 95% spectral edge frequency values were recorded continuously. Bispectral monitoring was used to measure the depth of anesthesia. Blood flow rates in middle cerebral artery (MCA) were measured by transcranial Doppler (TCD). Reduction in spectral edge frequency (>50%) or bispectral index (BIS) (<20) or transcranial Doppler flow velocity (>50%) was detected in four patients in Group 1, five patients in Group 2, and three patients in Group 3. BIS or EEG values never reached zero, which indicates isoelectric silence during surgery. Gross neurological examinations were normal in all patients postoperatively. CONCLUSION: There is no difference regarding neurological monitoring results between on-pump beating heart and hypothermic arrested heart valve replacement surgery. Also no significant difference was encountered among the groups regarding the clinical outcomes.     

Tethered cord syndrome in adulthood

OBJECTIVE/BACKGROUND: The standard treatment for tethered cord syndrome (operative vs nonoperative management) that presents in adulthood remains controversial. A comparative study of tethered cord syndrome in adulthood is needed. DESIGN: A retrospective chart-based analysis. METHODS: Patients admitted to Gulhane Military Medical Academy Department of Neurosurgery for management of caudal spinal cord tethering from June 1999 through December 2006 (N = 22). RESULTS: Conus level was normal in 1 patient with split cord malformation and dermal sinus. Tight terminal filum was found in 21 patients, including postrepair myelomeningocele tethered cord in 4, lipomyelomeningocele/meningocele in 8, split cord malformation in 3, dermal sinus in 7, and syringomyelia in 3. The most common complaints were back pain (15 patients, 68.1%), bladder dysfunction (8, 36.3%), fecal incontinence (2, 9.09%), and leg pain (7, 31.8%). One patient had hydrocephalus (4.5%). Ten of 22 patients underwent surgery; 8 of 10 patients had detethering; and 12 patients refused surgery. Postoperative cerebrospinal fluid leakage requiring reinforcement sutures occurred in 1 patient. There were no infectious complications. Neurologic status and outcomes were compared with preoperative findings. CONCLUSIONS: Some patients refuse surgery despite severe neurologic disturbances. Neurosurgeons should fully explain the risks and benefits of surgery for tethered cord to the patient and family. A much larger and prospective randomized series is needed to determine the effects of operative vs nonoperative management of tethered cord syndrome in adulthood.     

Percutaneous transluminal balloon angioplasty in stenosis of native hemodialysis arteriovenous fistulas: technical success and analysis of factors affecting postprocedural fistula patency

PURPOSE

We aimed to determine the predictors of technical success and patency after percutaneous transluminal angioplasty (PTA) of de novo dysfunctional hemodialysis arteriovenous fistulas (AVF).

METHODS

We performed a retrospective analysis of first time PTA in 228 patients (129 men, 99 women; mean age, 56.8±14.6 years). Anatomical (location, length, grade, and number of stenoses) and clinical variables (sex, age, prior AVF, diabetes mellitus, AVF age, side, and location) were reviewed.

RESULTS

A total of 330 stenoses were found in 228 patients. PTA was technically successful in 96.3% of the stenoses (n=319). Clinical success was achieved in 97.2% (n=321). Early dysfunction (within six months) was positively correlated with patient age (P < 0.001) and diabetes (P < 0.005). Older age (P < 0.001) and diabetes (P = 0.002) were associated with a lower primary patency rate. Patient age (P < 0.001), presence of diabetes (P = 0.023), length of stenosis (P = 0.003), early recurrence (P = 0.003) and presence of residual stenosis (P = 0.014) were associated with a lower secondary patency rate.

CONCLUSION

Patency of dysfunctional hemodialysis fistulas can be maintained safely with continuous follow-up and repeated interventions without shortening the venous segment by surgical revision. Percutaneous approach to hemodialysis access stenosis is an alternative to the conventional surgical approach and PTA is an effective treatment method for dysfunctional AVF.Hemodialysis, and therefore patent hemodialysis access, is of great importance to patients with end-stage renal disease (ESRD). The preferred type of access in patients undergoing hemodialysis is an arteriovenous fistula (AVF) (1). The Kidney Disease Outcomes Quality Initiative provides evidence-based clinical practice guidelines for all stages of ESRD and reports autogenous AVF as the reference standard for primary vascular access, due to their longevity and low infection rates (2, 3). Sands et al. (4) and Schwab et al. (5) demonstrated a 10-fold increase in thrombosis rate of synthetic polytetrafluoroethylene (PTFE) accesses when compared to AVFs. Despite proven advantages of AVF over PTFE, both types of access eventually fail and contribute to multiple hospital admissions, radiological and surgical interventions, and overall morbidity associated with chronic hemodialysis. Significant stenosis causing access dysfunction is a frequent complication in hemodialysis and requires repeated percutaneous transluminal balloon angioplasty (PTA) to maintain patency (6–9). The patency of PTA is limited, however, with first year primary patency rates ranging between 26% and 62% (6–8). Many factors influencing the patency rate have been studied in previously reported series (7, 8). Our study is the first to investigate the effect of early recurrence on secondary patency.     

A Closer Look at the Recurrent Laryngeal Nerve Focusing on Branches & Diameters: A Prospective Cohort Study

Aim: We aimed to investigate the anatomical characteristics of the recurrent laryngeal nerve (RLN) highlighting on its diameter and branching pattern. Materials and Methods: We prospectively collected 215 patients (178 female, 37 male) who underwent thyroid/parathyroid surgery during over a 2-year period. Apart from demographic features and surgical data, diameter of RLNs, and their branches and as well as branching distance (distance between the point of bifurcation and the laryngeal entry of RLN) were recorded. Results: In 215 patients, 378 RLNs were assessed and 42% (n = 159) bifurcated RLNs were observed. The bifurcation rate was similar on the right and left side(s) of the neck (40% and 44%, respectively; p = 0.47). In those, who underwent bilateral exploration, in the case of bifurcation on the first side of the neck, the possibility of contralateral bifurcation was approximately 50%, whereas this rate was found to be only 30% in those with nonbranching RLNs. Mean branching distance was 18 ± 9 mm, and it was similar on the right and left sides (17 and 19 mm, respectively). Approximately 80% of bifurcations were observed within 5–24 mm of the RLN. Mean diameter of the anterior branches was found to be significantly larger compared to posterior branches (1.09 ± 0.35 and 0.82 ± 0.36 mm, respectively; p < 0.01).Conclusions: There is great variability in RLN branching. We observed that approximately two out of three bifurcations were unilateral and anterior branches were thicker compared to posterior branches. These findings should be taken into consideration to avoid any damage to the RLN during thyroid and parathyroid surgery.     

Coronary artery catheter-induced spasm

A patient developed a lesion in the proximal and mid right coronary artery during cardiac catheterization. Following the administration of nitroglycerin, repeat right coronary angiography showed a normal right coronary artery. Therefore, distal lesions associated with catheter-induced spasm in the same coronary artery should not always be considered “fixed” lesions; but rather, they may be due to spasm.