Complex fractures of the clivus: diagnosis with CT and clinical outcome in 11 patients

During a 20-month period, fractures of the clivus occurring after craniocerebral trauma were diagnosed with computed tomography (CT) in 11 patients. Five patients had longitudinally oriented fractures; these were fatal in four patients due to either vertebral-basilar artery occlusion, brain stem trauma, or both. Six other patients had transversely oriented fractures that extended through the carotid canal and petrous temporal bone. While less frequently contributing directly to mortality, transverse fractures were also associated with cerebrospinal fluid leaks (two patients) and a cavernous sinus-carotid fistula (one patient). They were not as frequently associated with Horner syndrome or cranial nerve deficits as suggested in the current literature. This retrospective evaluation reveals two distinct injury patterns that demonstrate a difference in related morbidity and mortality.     

Model analysis of intra-acinar gas exchange

A previously described multibranch-point model, incorporating branching asymmetry within an acinus, has been extended to include gas exchange at the alveolar surface. Using a transport equation for simultaneous convection and diffusion within the gas phase and independent perfusion of all nodes, we obtained steady-state solutions for the temporal and spatial distributions of O2 and CO2 tensions within an acinus during a respiratory cycle. Results for conditions corresponding to both rest and moderate exercise indicated a significant inhomogeneity of gas concentrations within a single acinus. The coefficient of variation of PACO2 at end-inspiration during exercise reached 11.3%. Despite this non-uniformity the computation of a negligible PAO2 - PAO2 difference indicated no impairment in gas exchange. The simulations are consistent with the hypothesis that in the normal lung the whole acinus acts functionally as a gas exchanging unit and ventilation-perfusion inequality has an interacinar basis.     

Serum sialic acid in malignant tumors,bacterial infections,and chronic liver diseases

Summary The total serum sialic acid concentration was determined in 2,264 persons with various malignant tumors, bacterial infections, rheumatic diseases, and chronic liver diseases, and in a control group. The thiobarbiturate method according to Warren was used [34].The upper limit (95% percentile) in the control group was 2.23 mol/ml. Higher values were found in the groups with neoplasms (mean: 3.04 mol/ml), inflammatory diseases (e.g., pneumonia: 3.02 mol/ml), and active rheumatoid arthritis (3.05 mol/ml). In the group with malignant diseases, the sialic acid concentration at the time of diagnosis was highest for bronchial carcinoma (3.29 mol/ml) and lowest for breast cancer (2.58 mol/ml). In chronic liver diseases the mean sialic acid level was lower than in a heterogeneous group of noninflammatory and nonneoplastic diseases.The estimation of the serum sialic acid concentration could be useful in the detection of tumor burden and metastases, and in the evaluation of the later course and prognosis of malignant neoplasms if bacterial/inflammatory and active rheumatoid processes can be excluded.     

Relationship of delayed depolarization to the QT interval after acute myocardial infarction

The relationship between conduction delay, as manifested by a prolonged QRS or late potentials (LP) detected by signal averaging, and QT prolongation was analyzed in six patients who had QTc greater than or equal to 0.42 second within 48 hours of acute myocardial infarction (AMI). Total QRS, LP, QT, and QTc durations were measured on days 2 to 3, 4 to 5, 6 to 7, and 8-9. In each recording period, the QT interval and QTc interval did not correlate with the QRS duration and LP duration (r less than or equal to 0.52 for each comparison). In 19 out of 27 instances, a sequential change in QT or QTc intervals was discordant with changes in QRS duration and/or LP, i.e., temporal changes in QT intervals were not determined by conduction. Thus, QT prolongation after AMI is not primarily due to regional slowing of conduction that results in regional delays in termination of some action potentials. Global prolongation of repolarization would seem to result from dispersion of action potential duration, not onset.     

Major bile duct injuries after laparoscopic cholecystectomy: A tertiary center experience

Bile duct injury is a severe and potentially life-threatening complication of laparoscopic cholecystectomy. Several series have described a 0.5% to 1.4% incidence of bile duct injuries during laparoscopic cholecystectomy. The aim of this study was to report on an institutional experience with the management of complex bile duct injuries and outcome after surgical repair. Data were collected prospectively from 40 patients with bile duct injuries referred for surgical treatment to our center between April {dy1998} and December 2003. Prior to referral, 35 patients (87.5%) underwent attempts at surgical reconstruction at the primary hospital. In77.5%of the patients, complex typeE1or typeE2BDIwas found. Concomitant with bile duct injury, seven patients had vascular injuries. Roux-en-Y hepaticojejunostomy was carried out in 33 patients. In two patients, Roux-en-Y hepaticojejunostomy and vascular reconstruction were necessary. Five patients, one with primary nondiagnosed Klatskin tumor, required right hepatectomy. Two patients, both with bile duct injuries and vascular damage, died postoperatively. Because of progressive liver insufficiency, one of them was listed for high-urgency liver transplantation but died prior to intervention. At the median follow-up of 589 days, 82.5% of the patients are in excellent general condition. Seven patients have signs of chronic cholangitis. Major bile duct injuries remain a significant cause of morbidity and even death after laparoscopic cholecystectomy. Because they present a considerable surgical challenge, early referral to an experienced hepatobiliary center is recommended.     

Five-year results of fissurectomy for chronic anal fissure: low recurrence rate and minimal effect on continence

Aim The aim of the study was to determine the long‐term outcome, recurrence rate and faecal incontinence score after fissurectomy for chronic anal fissure (CAF) not responding to conservative treatment. Method Fifty‐three consecutive patients (29 women) who underwent fissurectomy for a medically resistant CAF between 1998 and 2005 were included in the study. At a minimum follow‐up of 5 years a standardized questionnaire was sent to all patients, assessing recurrence, satisfaction with the operation (on a scale of 0–10) and faecal continence (Vaizey score, 0–24). The patients were compared with a control group of 50 healthy volunteers, matched for sex and age, who had never undergone anal surgery. Results Forty‐three (81%) patients (25 women) returned the questionnaire. The mean age was 40 (SD 12.1) years and median follow up was 8.2 (5.5–12.2) years. Five patients had a recurrent CAF (11.6%). Ninety per cent of patients would have consented to the operation again if necessary. The mean Vaizey score at follow‐up was 2.5 (SD ± 4.2). The mean Vaizey score of the four patients who had had a previous lateral sphincterotomy was 3.8 and for the eight patients who had reported a continence disturbance before fissurectomy it was 8.3. The mean Vaizey score of the 31 patients who were continent before fissurectomy was 0.8 compared with 0.4 in the control group (P = 0.9). Conclusion At 5 years or more fissurectomy for medically resistant CAF is effective with a low recurrence rate and minimal influence on continence.