Clinical patterns of spontaneous recovery of paralyzed triceps brachii associated with C5 to C7 injuries of the brachial plexus

Some patients who sustain C5 to C7 nerve root injuries may demonstrate a natural recovery of elbow extension via the lower trunk; however the surgical effect of the reinnervation of the triceps brachii in such cases is still unknown. This study aims to determine the incidence of spontaneous recovery of the tricipital function and to identify the clinical and/or radiological predictors of poor spontaneous functional rehabilitation of elbow extension resulting from injuries of the upper roots of the brachial plexus. We conducted a review of the charts of 24 subjects sustaining an upper trunk syndrome with complete elbow extension palsy and who did not undergone any intervention for reinnervation of the triceps brachii in the primary brachial plexus surgery. Two years posttrauma, the muscle was scored as M0 in 12 patients (50%), M1 in 3 (12.5%), M2 in 1 (4.1%), M3 in 4 (16.6%), and M4 in 4 subjects (16.6%). The number of avulsed roots and the preoperative power of the latissimus dorsi did not demonstrate any significance in predicting the outcome of spontaneous elbow extension recovery; whereas the preoperative paralysis of the muscles for wrist extension was determined to be reliable predictive parameter for poor natural recovery of tricipital function.     

Colorectal cancer in nonagenarians

Aim The aim of the study was to analyze the short‐term and long‐term outcomes of nonagenarians treated for colorectal cancer. Method A retrospective analysis was performed of 74 patients, ≥ 90 years of age, diagnosed with colorectal cancer during the period 1986–2009. Comorbidity, American Society of Anesthesiology (ASA) grade, symptoms, diagnosis, treatment, mortality, morbidity and survival were analyzed. Results Of the 74 patients, 48 (65%) were women. Twenty‐two patients were classified as ASA grade I–II, 26 as ASA grade III and 26 as ASA grade IV–V. Thirty‐one (42%) had intestinal obstruction at the time of diagnosis. Twenty‐two (30%) patients were diagnosed during the period 1986–2000 and 52 (70%) were diagnosed between 2001 and 2009. Forty‐four (59%) patients underwent surgery, of whom 19 (49%) were treated as an emergency. Eleven (25%) patients died postoperatively, with mortality rates of 12% (3/25) for elective surgery and 42% (8/19) for emergency surgery. Surgical mortality for ASA grade I and grade II patients was 5% (1/20) and their 5‐year survival rate (postoperative mortality excluded) was 44%, whereas 5‐year survival for ASA grade III patients who underwent surgery was 12.5% and surgical mortality was 25% (4/16). There were no survivors beyond 36 months among patients who did not receive surgery. Conclusion Our results indicate that elective and emergency colorectal surgery can be performed with acceptable rates of mortality and morbidity on nonagenarian patients in good general condition with low perioperative risk. The 5‐year survival rate was related to ASA grade and to the use of surgery.     

Racial differences in rate of decline in bone mass in older men: the Baltimore men's osteoporosis study.

Older black men have higher adjusted BMD than older white men. Using data from a longitudinal cohort study of older men followed for a mean of 18.8 +/- 6.5 (SD) months, we found that older black men have a higher rate of decline in femoral neck and total hip BMD and femoral neck BMAD than older white men. INTRODUCTION: Older black men have higher adjusted BMD compared with older white men. The difference in BMD may be caused by having attained higher peak bone mass as young adults and/or having a slower rate of decline in bone mass as adults. There are few published longitudinal data on change in bone mass in older white men and no published data for older black men. MATERIALS AND METHODS: Three hundred forty-nine white men and 119 black men 65 of age (mean age, 75 +/- 5.7 and 72 +/- 5.6 years, respectively) who participated in the longitudinal component of the Baltimore Men's Osteoporosis Study returned for a second visit after a mean of 18.8 +/- 6.5 (SD) months and were not taking medications used to treat low bone mass at either visit. BMD was measured at the femoral neck and total hip by Hologic-certified technicians using a QDR 2000 at the baseline visit (V1) and QDR 4500 at the first follow-up visit (V2). Participants also completed self-administered and interviewer-administered questionnaires and underwent standardized clinic examinations. Bone mineral apparent density (BMAD) at the femoral neck was calculated as an estimate of volumetric BMD. Annual crude and multiple variable adjusted percent changes in BMD and BMAD were calculated. RESULTS: In univariate analyses, black men had lower percent decline in femoral neck and total hip BMD and femoral neck BMAD than white men. In addition, older age at baseline, lower baseline weight, current smoking, and lower baseline BMD were associated with greater percent decline per year in femoral neck BMD; older age at baseline, current smoking, and lower baseline BMD were associated with greater percent decline per year in total hip BMD; and older age at baseline and lower baseline femoral neck BMAD were associated with greater percent decline per year in femoral neck BMAD. Racial differences in bone loss persisted in multiple variable models that controlled for other factors associated with change in BMD and BMAD. CONCLUSIONS: Older black men seem to lose bone mass at a slower rate than older white men. These differences in the rate of bone loss may account, in part, for the racial disparities in BMD and BMAD and risk of osteoporotic fractures among older men.     

New radiopharmaceuticals for receptor scintigraphy and radionuclide therapy.

In vitro data have demonstrated a high amount of receptors for various hormones and peptides on malignant cells of neuroendocrine origin. Among these, binding sites for members of the SST-family (hSSTR1-5) are frequently found, and their expression has led to therapeutic and diagnostic attempts to specifically target these receptors. Receptor scintigraphy using radiolabeled peptide ligands has proven its effectiveness in clinical practice. In addition, initial results have indicated a clinical potential for receptor-targeted radiotherapy. Based on somatostatin (SST) receptor (R) recognition, the novel radiopharmaceuticals 111In/90Y-DOTA-lanreotide developed at the University of Vienna as well as 111In/90Y-DOTA-DPhe1-Tyr3-octreotide (NOVARTIS) both have provided promising data for diagnosis and treatment of hSSTR-positive tumors. SSTR scintigraphy using 111In-DTPA-DPhe1-octreotide has a high positive predictive value for the vast majority of neuroendocrine tumors and has gained its place in the diagnostic work-up as well as follow-up of patients. We have used 111In-DOTA-lanreotide scintigraphy in 166 patients since 1997 and have seen positive results in 93% of patients. In 42 patients with neuroendocrine tumors comparative data were obtained. As opposed to 111In-DTPA-DPhe1-octreotide and 111In-DOTA-DPhe1-Tyr3-octreotide, discrepancies in the scintigraphic results were seen in about one third of patients concerning both the tumor uptake as well as tumor lesion detection. Initial results both with 90Y-DOTA-lanreotide as well as 90Y-DOTA-DPhe1-Tyr3-octreotide has pointed out the clinical potential of radionuclide receptor-targeted radiotherapy. This new therapy could offer palliation and disease control at a reduced cost. The final peptide therapy strategy is most probably cheaper than conventional radiotherapies or prolonged chemotherapies. Overall, receptor-mediated radiotherapy with 90Y-DOTA-lanreotide/90Y-DOTA-DPhe1-Tyr3-octre otide might also be effective in patients refractory to conventional strategies.     

Tracheoesophageal fistula in an intubated patient. Treatment through exclusion and esophageal patch

Currently, acquired benign tracheoesophageal fistulas are mainly iatrogenic lesions produced by prolonged tracheal intubation. Their occurrence in intubated patients is infrequent but devastating and their therapeutic resolution is highly complex. We present the case of a patient with an extensive tracheoesophageal fistula following tracheal intubation that was surgically treated through esophageal exclusion (cervical esophagostomy and suture-stapling of the distal esophagus) and closure of the tracheal defect using the posterior esophageal wall.     

Effects of JAK3 inhibition with CP-690,550 on immune cell populations and their functions in nonhuman primate recipients of kidney allografts

BACKGROUND: Janus Kinase (JAK) 3 is a tyrosine kinase essential for proper signal transduction downstream of selected cytokine receptors and for robust T-cell and natural killer cells activation and function. JAK3 inhibition with CP-690,550 prevents acute allograft rejection. To provide further insight into the mechanisms of efficacy, we investigated the immunomodulatory effects of CP-690,550 in vitro and in vivo in nonhuman primates. METHODS: Pharmacodynamic assessments of lymphocyte activation, function, proliferation and phenotype were performed in three settings: in vitro in whole blood isolated from untransplanted cynomolgus monkeys (cynos), in vivo in blood from untransplanted cynos dosed with CP-690,550 for 8 days, and in vivo in blood from transplanted cynos immunosuppressed with CP-690,550. Cell surface activation markers expression, IL-2- enhanced IFN-gamma production, lymphocyte proliferation and immune cell phenotype analyzes were performed with multiparametric flow cytometry. RESULTS: In vitro exposure to CP-690,550 resulted in significant reduction of IL-2-enhanced IFN-gamma production by T-cells (maximum inhibition of 55-63%), T-cell surface expression of CD25 (50% inhibitory concentration (IC50); 0.18 microM) and CD71 (IC50; 1.6 microM), and T-cell proliferative capacities measured by proliferating cell nuclear antigen expression (IC50; 0.87 microM). Similar results were observed in animals dosed with CP-690,550. In addition, transplanted animals displayed significant reduction of NK cell (90% from baseline) and T-cell numbers whereas CD8 effector memory T-cell populations were unaffected. CONCLUSIONS: Potent in vitro and in vivo immunomodulatory effects of the JAK3 inhibitor CP-690,550 likely contribute to its efficacy in the prevention of organ allograft rejection.     

Colecistectomía laparoscópica en pacientes mayores de 80 años

Introduction

The increasing aging of the population also increases the prevalence of symptomatic gallbladder diseases. It is important to analyse their surgical treatment in the elderly.

Methods

All the laparoscopic cholecystectomies performed in our surgery department on patients aged 80 years-old or over from 1992 to 2007 were included in this study.

Results

Laparoscopic cholecystectomy was performed on 133 patients 80 years-old and over, with 63% of them women, and an average age of 83.23 years. Biliary colic (29%) and acute pancreatitis (44%) were the main reasons for surgery. Associated diseases were found in 73% of them. Only 7.5% needed urgent surgery, even although 71% were admitted urgently. There were 13.5% conversions to open surgery, 17% morbidity and 2.3% mortality.

Conclusions

Laparoscopic cholecystectomy can be recommended in symptomatic gallbladder disease in the elderly.     

Culture of human bone marrow-derived mesenchymal stem cells on of poly(l-lactic acid) scaffolds: potential application for the tissue engineering of cartilage

Purpose

Due to the attractive properties of poly(l-lactic acid) (PLLA) for tissue engineering, the aim was to determine the growth and differentiation capacity of mesenchymal stromal cells (MSCs) in PLLA scaffolds and their potential use in the treatment of cartilage diseases.

Methods

MSCs were cultured in PLLA films and thin porous membranes to study adherence and proliferation. Permeability and porosity were determined for the different scaffolds employed. The optimal conditions for cell seeding were first determined, as well as cell density and distribution inside the PLLA. Scaffolds were then maintained in expansion or chondrogenic differentiation media for 21 days. Apoptosis, proliferation and chondrogenic differentiation was assessed after 21 days in culture by immunohistochemistry. Mechanical characteristics of scaffolds were determined before and after cell seeding.

Results

MSCs uniformly adhered to PLLA films as well as to porous membranes. Proliferation was detected only in monolayers of pure PLLA, but was no longer detected after 10 days. Mechanical characterization of PLLA scaffolds showed differences in the apparent compression elastic modulus for the two sizes used. After determining high efficiencies of seeding, the production of extracellular matrix (ECM) was determined and contained aggrecan and collagens type I and X. ECM produced by the cells induced a twofold increase in the apparent elastic modulus of the composite.

Conclusions

Biocompatible PLLA scaffolds have been developed that can be efficiently loaded with MSCs. The scaffold supports chondrogenic differentiation and ECM deposition that improves the mechanics of the scaffold. Although this improvement does not met the expectations of a hyaline-like cartilage ECM, in part due to the lack of a mechanical stimulation, their potential use in the treatment of cartilage pathologies encourages to improve the mechanical component.     

Locoregional anesthesia in ophthalmology: update

Regional anesthesia for ophthalmic procedures has changed significantly in the past ten years. Phacoemulsification for cataract surgery through corneal microincisions, soft foldable lenses and topical anesthesia simplify surgery such that most operations can be performed on an outpatient basis. Some anesthetic blocks are performed by either anesthesiologists or ophthalmologists, who should understand the advantages and disadvantages for each patient. This review discusses anatomical aspects of interest to the anesthesiologist, the main techniques used and anesthetic innovations, complications and certain controversies such as management of the patient who is taking medications that alter hemostasis, the withdrawal of hyaluronidase in some countries and the systematic ordering of tests before the procedure.     

Validation of the Pelvic Organ Prolapse Quantification Index (POP-Q-I): a novel interpretation of the POP-Q system for optimization of POP research

Even though very precise at describing pelvic organ position, our criticism to the Pelvic Organ Prolapse Quantification (POP-Q) system is its limited ability to quantify the prolapse itself, since it still classifies prolapse into four stages, almost the same way as Baden and Walker (Clin Obstet Gynecol 15(4):1070-1072, 1972) did in 1972. As a result, the same grade can include a wide prolapse intensity range. The objective of this study was to assess inter-observer reliability in the Pelvic Organ Prolapse Quantification Index (POP-Q-I; Lemos et al., Int Urogynecol J 18(6):609-611, 2007) on a prospective randomized trial. Fifty consecutive women were prospectively examined by two members of the urogynecology staff, blinded to each other's results. Spearman's rank correlation was used to assess inter-observer reliability. Excellent correlation coefficients were observed, with an overall coefficient of 96.5% (CI: 0.889-1.042; p < 0.0001). The POP-Q-I is a method that makes POP research more efficient by directly measuring prolapse as a continuous variable, which is statistically more powerful than the categorical variables proposed by the POP-Q system. This study suggests that the POP-Q-I is applicable to clinical POP research.