Rehabilitation of the bilateral amputee

One hundred sixteen patients with bilateral amputation as a result of severe ischemia were reviewed to evaluate their rehabilitation potential. Seventy patients were male and 46 were female; ages ranged from 31 to 92 years (mean 68 years). The operative mortality rate after the second amputation was 9.5% (11 of 116 patients). The time from the first to second amputation ranged from zero to 144 months (mean 23 months). Follow-up from 1 to 14 years was available on all patients. Sixty percent of the patients surviving the postoperative period were alive at 2 years and 40% at 5 years. Of the 105 patients available for follow-up, only 27 (26%) were able to use bilateral prostheses. Twenty-three (85%) of these patients were ambulatory after their first amputation. Four patients not walking after their first amputation became ambulatory after their second. All four had bilateral below-knee amputations. Of the 78 patients unable to use a bilateral prosthesis, 68 (87%) were able to function independently and 10 became bedridden. Successful prosthetic rehabilitation in the bilateral amputee appears primarily dependent on the use of a prosthesis after the first amputation. The acceptable long-term survival and the number of patients who became independent in their activities justify an aggressive approach to the rehabilitation of the bilateral amputee.     

SMALL BOWEL FISTULA: A COMPLICATION OF PERCUTANEOUS ENDOSCOPIC GASTROSTOMY INSERTION

A 22 year old man who sustained a severe closed head injury after a high speed motor car accident underwent routine placement of percutaneous endoscopic gastrostomy (PEG) for feeding purposes. Nine days after its insertion an enterocutaneous fistula was diagnosed around the PEG tube. A loop of mid-jejunum had been transfixed during the insertion of the PEG.     

Pancreaticoduodenectomy after placement of endobiliary metal stents

Contemporary treatment programs for patients with potentially resectable pancreatic cancer often involve preoperative therapy. When the duration of preoperative therapy exceeds 2 months, the risk of plastic endobiliary stent occlusion increases. Metal stents have much better patency but may complicate subsequent pancreaticoduodenectomy (PD). We evaluated rates of perioperative morbidity, mortality, and stent complications in 272 consecutive patients who underwent PD at our institution from May 2001 to November 2004. Of these 272 patients, 29 (11%) underwent PD after placement of a metal stent, 141 underwent PD after placement of a plastic stent, 10 had PD after biliary bypass without stenting, and 92 had PD without any form of biliary decompression. No differences were found between the Metal Stent group and all other patients in median operative time, intraoperative blood loss, or length of hospital stay. No perioperative deaths occurred in the Metal Stent group versus 3 (1.2%) deaths in the other 243 patients. The incidence of major perioperative complications was similar between the two groups, including the rates of pancreatic fistula, intra-abdominal abscess, and wound infection. Furthermore, there were no differences in the perioperative morbidity or mortality rates between patients who underwent preoperative biliary decompression with a stent of any kind (metal or plastic) and those patients who underwent no biliary decompression at all. Metal stent-related complications occurred in 2 (7%) of 29 patients during a median preoperative interval of 4.1 months; in contrast, 75 (45%) of the 166 patients who had had plastic stents experienced complications, including 98 stent occlusions, during a median preoperative interval of 3.9 months (P < 0.001). We conclude that the use of expandable metal stents does not increase PD-associated perioperative morbidity or mortality, and as such an expandable metal stent is our preferred method of biliary decompression in patients with symptomatic malignant distal bile duct obstruction in whom surgery is not anticipated, or in whom there is a significant delay in the time to surgery. Presented at the Forty-Sixth Annual Meeting of The Society for Surgery of the Alimentary Tract, Chicago, Illinois, May 14–18, 2005 (oral presentation). Supported by the Lockton Fund for Pancreatic Cancer Research, The University of Texas M. D. Anderson Cancer Center, Houston, Texas.     

Volumetry of hippocampus and amygdala with high-resolution MRI and three-dimensional analysis software: minimizing the discrepancies between laboratories

Within the medial temporal lobe, both the hippocampus and amygdala are frequently targeted by researchers and clinicians for volumetric analysis based on magnetic resonance imaging (MRI). However, different data acquisition techniques, analysis software and anatomical boundaries have in the past made it difficult to compare results of MRI studies from different laboratories. In order to reduce these differences, a segmentation protocol was established with 40 healthy normal control subjects recently scanned in our laboratory. Data acquisition was performed with a three-dimensional gradient echo technique, and scans were corrected for non-uniformity and registered into standard stereotaxic space prior to segmentation. Volumetric analysis was performed manually using three-dimensional software that allows simultaneous analysis of sagittal, coronal and horizontal images. Intra- and inter-rater coefficients yielded correlation coefficients comparable with other protocols. The hippocampal volume was larger in the right hemisphere (3324 versus 3208 mm(3)), while no interhemispheric differences for the amygdala (1154 versus 1160 mm(3)) could be observed. Most importantly, results from recent segmentation protocols for hippocampus and amygdala seem to approach each other with regard to mean volumes and interhemispheric differences. This indicates that the advances in scanning technique, volume preparation and segmentation protocols allow a more precise definition of medial temporal lobe structures with MRI, and that results for mean volumes for hippocampus and amygdala from different laboratories will eventually become comparable.     

A randomised trial of peri‐operative positive airway pressure for postoperative delirium in patients at risk for obstructive sleep apnoea after regional anaesthesia with sedation or general anaesthesia for joint arthroplasty

Previous pilot work has established an association between obstructive sleep apnoea and the development of acute postoperative delirium 1 - 3 , but it remains unclear to what extent this risk factor is modifiable in the ‘real world’ peri‐operative setting. In a single‐blind randomised controlled trial, 135 elderly surgical patients at risk for obstructive sleep apnoea were randomly assigned to receive peri‐operative continuous positive airway pressure (CPAP) or routine care. Of the 114 patients who completed the study, 21 (18.4%) experienced delirium. Delirium was equally common in both groups: 21% (12 of 58 subjects) in the CPAP group and 16% (9 of 56 subjects) in the routine care group (OR = 1.36 [95%CI 0.52–3.54], p = 0.53). Delirious subjects were slightly older – mean (SD) age 68.9 (10.7) vs. 64.9 (8.2), p = 0.07 – but had nearly identical pre‐operative STOP‐Bang scores (4.19 (1.1) versus 4.27 (1.3), p = 0.79). Subjects in the CPAP group used their devices for a median (IQR [range]) of 3 (0.25–5 [0–12]) nights pre‐operatively (2.9 (0.1–4.8 [0.0–12.7]) hours per night) and 1 (0–2 [0–2]) nights postoperatively (1.4 (0.0–5.1 [0.0–11.6]) hours per night). Among the CPAP subjects, the residual pre‐operative apnoea–hypopnea index had a significant effect on delirium severity (p = 0.0002). Although we confirm that apnoea is associated with postoperative delirium, we did not find that providing a short‐course of auto‐titrating CPAP affected its likelihood or severity. Voluntary adherence to CPAP is particularly poor during the initiation of therapy.     

Development of a state measure of obsessive compulsive behavior

The Reaction Inventory-Interference was developed to identify obsessional thoughts and compulsive acts, which interfere with an individual's daily activities. The 50 items in the inventory were administered to 172 Ss. On the basis of item test correlations, 40 items were retained for subsequent analyses. The estimate of internal consistency for the 40 item inventory was 0.95. The correlation between the 40-item inventory and the “symptom” score on the Leyton Obsessional Inventory was 0.66. Factor analysis of the 40-item inventory yielded nine factors.     

Two novel loci,COBL and SLC10A2, for Alzheimer's disease in African Americans

Introduction

African Americans' (AAs) late-onset Alzheimer's disease (LOAD) genetic risk profile is incompletely understood. Including clinical covariates in genetic analyses using informed conditioning might improve study power.