Hip cortical thickness assessment in postmenopausal women with osteoporosis and strontium ranelate effect on hip geometry

The aims of this study were to assess the relationship between hip geometry and the 5-yr risk of hip fractures in postmenopausal osteoporotic women and the effects of strontium ranelate on these parameters. Using the 5-yr data of a randomized placebo-controlled trial of strontium ranelate (Treatment of Peripheral Osteoporosis Study [TROPOS]), we reanalyzed the hip dual-energy X-ray absorptiometry scans to determine the role of hip geometry in the risk of hip fractures (placebo group, n=636) and to analyze the effects of strontium ranelate (n=483). The outcomes included the hip structure analysis (HSA) parameters: cross-sectional area (CSA), section modulus, cortical thickness, and buckling ratio, measured at femoral neck, intertrochanteric (IT) region, and proximal shaft. The geometric parameters associated with an increased risk of hip fracture over 5yr were IT CSA and femoral shaft cortical thickness independent of age and total-hip bone mineral density (BMD). Using Bonferroni adjustment, IT cortical thickness was associated with the risk of hip fracture. Over 5yr, significant decreases in some femoral dimensions of the placebo group contrast with significant increases in strontium ranelate group after adjustment for age and BMD. Using Bonferroni adjustment, differences between placebo and strontium ranelate groups were no longer significant after adjustment on 5-yr BMD changes. Some HSA parameters have predictive value for hip fracture risk in postmenopausal osteoporotic women. Strontium ranelate improves some HSA parameters, through the BMD increase.     

Esophagogastrectomy: The influence of stapled versus hand-sewn anastomosis on outcome

Successful anastomosis is essential for favorable esophagogastrectomy outcomes. Before July 2002, almost all esophagogastric anastomoses at our institution were hand-sewn. We then began using linear stapled anastomotic techniques. This review compares patient outcomes with both techniques. From July 2001 to June 2004, 280 consecutive esophagogastrectomy patients (235 men and 45 women) were reviewed (median age, 65 years). The anastomosis was intrathoracic in 206 patients (74%) and cervical in 74 (26%). Anastomoses were hand-sewn in 205 patients (73%) and linear stapled in 75 (27%). Stapled anastomoses were intrathoracic in 33 patients (16%) and cervical in 42 (57%). Anastomotic leaks occurred in 30 patients (11%); 26 (12.7%) in the hand-sewn and 4 (5.3%) in the linear stapled group (P = .008). Leaks were asymptomatic in 17 patients (57%). Dilatation was required in 70 hand-sewn anastomoses (34%) and in 11 stapled (14.6%) (P = .001). Hand-sewn anastomoses were more likely to leak and require dilatation; odds ratios and 95% confidence intervals were 5.35 (1.67–19.27) and 3.58 (1.66–8.34), respectively. A linear stapled anastomosis is safe and associated with both a significantly lower leak rate and the need for dilatation compared with hand-sewn anastomosis. This nonrandomized series suggests that linear stapled anastomosis is the preferred technique regardless of anastomotic location. Presented at the Forty-Sixth Annual Meeting of The Society for Surgery of the Alimentary Tract, Chicago, Illinois, May 14–18, 2005 (oral presentation).     

Indomethacin for prevention of heterotopic ossification after hip arthroplasty: A randomized comparison between 4 and 8 days of treatment

In a randomized, parallel group study, we evaluated the efficacy of a 4-day versus an 8-day course of indomethacin (50 mg, 3 times per day), given as prophylaxis against heterotopic ossification after formation. cementless total hip arthroplasty in 209 patients with arthrosis. Patients receiving the prophylaxis for 8 days had less (p = 0.03) severe heterotopic bone     

La neurostimulation n’augmente pas le taux de succès du bloc du nerf saphène

PURPOSE: To evaluate neurostimulation of motor components of the vastus medialis muscle and the rectus femoris muscle, with a view to blocking the medial sensory fibres of the saphenous nerve. METHOD: First we dissected four femoral trigones, in order to select our puncture point. We were able to observe that, at the flexion crease of the thigh, the different fibers that make up the femoral nerve were clustered together and the saphenous nerve and the vastus medialis nerve had not yet separated from the femoral stem. Secondly, we conducted a prospective clinical study among 71 patients who had undergone surgery on the lower third of the leg with a sciatic block and a saphenous nerve block. The saphenous nerve block was performed using 10 mL of local anesthetic, by puncturing the flexion crease of the thigh in a bid to obtain one of two muscle responses: medial (contraction of the vastus medialis muscle) or anterior (contraction of the rectus femoris muscle and elevation of the patella). RESULTS: There was an overall success rate of 80% with the saphenous nerve block, with no statistical difference existing between the two response types. Average duration for the block to be completed was two minutes and it took an average of 15 min before the anesthesia took effect. No complications were encountered, apart from a puncture of the femoral artery, which was clinically inconsequential. CONCLUSION: Neurostimulation of the vastus medialis muscle has the same effect as neurostimulation of the rectus femoris muscle with respect to anesthesia of the saphenous nerve. Neurostimulation of the medial compartment of the femoral nerve saves local anesthetic, compared to a standard femoral block.     

Minimization of maintenance immunosuppressive therapy after renal transplantation comparing cyclosporine A/azathioprine or cyclosporine A/mycophenolate mofetil bitherapy to cyclosporine A monotherapy: a 10‐year postrandomization follow‐up study

Long‐term outcomes in renal transplant recipients withdrawn from steroid and submitted to further minimization of immunosuppressive regimen after 1 year are lacking. In this multicenter study, 204 low immunological risk kidney transplant recipients were randomized 14.2 ± 3.7 months post‐transplantation to receive either cyclosporine A (CsA) + azathioprine (AZA; n = 53), CsA + mycophenolate mofetil (MMF; n = 53), or CsA monotherapy (n = 98). At 3 years postrandomization, the occurrence of biopsy for graft dysfunction was similar in bitherapy and monotherapy groups (21/106 vs. 26/98; P = 0.25). At 10 years postrandomization, patients’ survival was 100%, 94.2%, and 95.8% (P = 0.25), and death‐censored graft survival was 94.9%, 94.7%, and 95.2% (P = 0.34) in AZA, MMF, and CsA groups, respectively. Mean estimated glomerular filtration rate was 70.4 ± 31.1, 60.1 ± 22.2, and 60.1 ± 19.0 ml/min/1.73 m², respectively (P = 0.16). The incidence of biopsy‐proven acute rejection was 1.4%/year in the whole cohort. None of the patients developed polyomavirus‐associated nephropathy. The main cause of graft loss (n = 12) was chronic antibody‐mediated rejection (n = 6). De novo donor‐specific antibodies were detected in 13% of AZA‐, 21% of MMF‐, and 14% of CsA‐treated patients (P = 0.29). CsA monotherapy after 1 year is safe and associated with prolonged graft survival in well‐selected renal transplant recipient ( ClinicalTrials.gov number: 980654).     

Comprehensive PKD1 and PKD2 Mutation Analysis in Prenatal Autosomal Dominant Polycystic Kidney Disease

Prenatal forms of autosomal dominant polycystic kidney disease (ADPKD) are rare but can be recurrent in some families, suggesting a common genetic modifying background. Few patients have been reported carrying, in addition to the familial mutation, variation(s) in polycystic kidney disease 1 (PKD1) or HNF1 homeobox B (HNF1B), inherited from the unaffected parent, or biallelic polycystic kidney and hepatic disease 1 (PKHD1) mutations. To assess the frequency of additional variations in PKD1, PKD2, HNF1B, and PKHD1 associated with the familial PKD mutation in early ADPKD, these four genes were screened in 42 patients with early ADPKD in 41 families. Two patients were associated with de novo PKD1 mutations. Forty patients occurred in 39 families with known ADPKD and were associated with PKD1 mutation in 36 families and with PKD2 mutation in two families (no mutation identified in one family). Additional PKD variation(s) (inherited from the unaffected parent when tested) were identified in 15 of 42 patients (37.2%), whereas these variations were observed in 25 of 174 (14.4%, P=0.001) patients with adult ADPKD. No HNF1B variations or PKHD1 biallelic mutations were identified. These results suggest that, at least in some patients, the severity of the cystic disease is inversely correlated with the level of polycystin 1 function.     

The PROPKD Score: A New Algorithm to Predict Renal Survival in Autosomal Dominant Polycystic Kidney Disease

The course of autosomal dominant polycystic kidney disease (ADPKD) varies among individuals, with some reaching ESRD before 40 years of age and others never requiring RRT. In this study, we developed a prognostic model to predict renal outcomes in patients with ADPKD on the basis of genetic and clinical data. We conducted a cross-sectional study of 1341 patients from the Genkyst cohort and evaluated the influence of clinical and genetic factors on renal survival. Multivariate survival analysis identified four variables that were significantly associated with age at ESRD onset, and a scoring system from 0 to 9 was developed as follows: being male: 1 point; hypertension before 35 years of age: 2 points; first urologic event before 35 years of age: 2 points; PKD2 mutation: 0 points; nontruncating PKD1 mutation: 2 points; and truncating PKD1 mutation: 4 points. Three risk categories were subsequently defined as low risk (0–3 points), intermediate risk (4–6 points), and high risk (7–9 points) of progression to ESRD, with corresponding median ages for ESRD onset of 70.6, 56.9, and 49 years, respectively. Whereas a score ≤3 eliminates evolution to ESRD before 60 years of age with a negative predictive value of 81.4%, a score >6 forecasts ESRD onset before 60 years of age with a positive predictive value of 90.9%. This new prognostic score accurately predicts renal outcomes in patients with ADPKD and may enable the personalization of therapeutic management of ADPKD.     

Laparoscopic versus open right hepatectomy: a comparative study

Background

The safety of laparoscopic major liver resections is still uncertain. The aim of this study was to compare our results for laparoscopic right hepatectomy (LRH) with those for open right hepatectomy (ORH).

Methods

Patients undergoing LRH were compared with retrospectively selected patients from our ORH database. The 2 groups were well matched for sex, age, American Society of Anesthesiologists score, body mass index, liver disease, and tumor size. Surgical and postsurgical outcomes were compared.

Results

Seventy-two patients were analyzed: 22 in the LRH group and 50 in the ORH group. Operating time was similar. Blood loss was significantly less in laparoscopic resections (P = .038). Specific morbidity rates were not different, general morbidity was lower after laparoscopy (P = .04), and the severity of postsurgical complications was not different. Mean hospital stay was significantly shorter after laparoscopy (P = .009).

Comments

Laparoscopy improved surgical and postsurgical outcomes for ORH in selected patients. This is the first comparative study to demonstrate an advantage of laparoscopy for a major liver resection. Prospective randomized studies with a greater number of cases are needed to confirm the role of laparoscopy in major liver resections.     

Seat-belt injuries in children involved in motor vehicle crashes.

BACKGROUND: The efficacy of seat belts in reducing deaths from motor vehicle crashes is well documented. A unique association of injuries has emerged in adults and children with the use of seat belts. The "seat-belt syndrome" refers to the spectrum of injuries associated with lap-belt restraints, particularly flexion-distraction injuries to the spine (Chance fractures). METHODS: We describe the injuries sustained by 8 children, including 2 sets of twins, in 3 different motor vehicle crashes. RESULTS: All children were rear seat passengers wearing lap or 3-point restraints. All had abdominal lap-belt ecchymosis and multiple abdominal injuries due to the common mechanism of seat-belt compression with hyperflexion and distraction during deceleration. Five of the children had lumbar spine fractures and 4 remained permanently paraplegic. CONCLUSIONS: These incidents illustrate the need for acute awareness of the complete spectrum of intra-abdominal and spinal injuries in restrained pediatric passengers in motor vehicle crashes and for rear seat restraints that include shoulder belts with the ability to adjust them to fit smaller passengers, including older children.