Prolapse surgery in octogenarians: are we pushing the limits too far?

Purpose

To report our experience with pelvic reconstructive surgery with transobturator mesh implants in elderly women.

Materials and methods

A total of 32 women aged >75 years with pelvic organ prolapse receiving anterior and/or posterior repair using transobturator mesh implants were included. Concomitant mid-urethral sling procedure was performed in 78 % women. Postoperative outcome data and quality-of-life measurements were recorded prospectively. Patients were followed for up to 24 months.

Results

Mean age at surgery was 82.8 ± 3.1 years. A total of 15 anterior repairs, 8 posterior repairs, and 9 posterior and anterior repairs were performed using transobturator mesh implants. Concomitant synthetic mid-urethral transobturator sling procedure was performed in 25 women (78 %). Mean operating time was 47.2 ± 22.3 min, and the mean hospitalization period was 5.9 ± 1.6 days. There were no systemic complications related to anesthesia or surgery. Two patients required intraoperative bladder suturing due to iatrogenic bladder lesion. There were no rectal injuries, no bleeding necessitating transfusion, voiding dysfunction, or erosions of synthetic implants. Pelvic floor testing at 24 months postoperatively showed 15 % of the patients presenting with stage II vaginal wall prolapse. Further, quality-of-life parameters, as measured by SF-36 questionnaire, were improved compared to baseline values.

Conclusions

Pelvic reconstructive surgery in elderly women is safe and enhances the quality of life. However, special caution should be paid to risks and benefits of such surgery in this patient population.     

Preoperative peritonsillar infiltration of dexamethasone and levobupivacaine reduces pediatric post-tonsillectomy pain: a double-blind prospective randomized clinical trial

Background

Preoperative corticosteroids reduce post-tonsillectomy morbidities. The present study was performed to compare the effect of peritonsillar dexamethasone infiltration to intravenous injection together with peritonsillar levobupivacaine infiltration before tonsillectomy on postoperative pain in children.

Methods

One hundred twenty children, ASA I–II, aged 6–12 years, scheduled for adenotonsillectomy were enrolled in the study. They were randomized equally into two equal groups; 60 children each. Group A received peritonsillar infiltration with dexamethasone and levobupivacaine, and group B received i.v. dexamethasone and peritonsillar levobupivacaine infiltration. Rest and swallowing pain in the first postoperative day using a visual analogue scale, time to first rescue analgesia, cumulative paracetamol dose, vomiting, and adverse effects related to both interventions during the first postoperative day were recorded. Children care givers were asked to score pain using a verbal rating scale and to disclose complications as halitosis, headache, fever and otalgia during the first postoperative week.

Results

Time to first rescue analgesia was significantly longer in group A. Rest and swallowing pain in the first postoperative day, cumulative paracetamol dose, pain in the second and third postoperative days, and otalgia were significantly lower in group A. None of children developed postoperative bleeding, or complications related to dexamethasone or levobupivacaine infiltration. There was no significant difference in postoperative emesis, fever and halitosis between the groups.

Conclusion

Addition of dexamethasone to levobupivacaine for preoperative peritonsillar infiltration has better postoperative analgesic effects than i.v. dexamethasone combined with peritonsillar levobupivacaine infiltration in children.     

Familial resemblance of bone turnover rate in men aged 40 and over—the MINOS study

Familial resemblance of bone mineral density (BMD) is well known in both sexes. Fewer data concern the familial resemblance of bone turnover markers (BTMs) and bone size in men. Our aim was to assess the correlation of BMD, bone size, BTM levels and hormones regulating bone turnover in 50 pairs of brothers aged ≥ 40 and 50 pairs of unrelated men matched for age, weight and height. BMD was measured at the lumbar spine, hip, forearm and whole body. We measured serum osteocalcin (OC), bone-specific alkaline phosphatase (bone ALP), N-terminal propeptide of type I procollagen (PINP) and C-terminal telopeptide of type I collagen (CTX-I) as well as urinary free and total deoxypyridinoline (DPD) and CTX-I. After adjustment for age, weight, bioavailable 17β-estradiol, and parathyroid hormone, all the BTMs (except bone ALP) were significantly correlated in the brothers (ICC = 0.36–0.64). Most of these correlations were significantly stronger than in the unrelated men. Bone size correlated significantly between the brothers (ICC = 0.55–0.65). These correlations were significantly stronger than in the unrelated men. BMD correlated between the brothers at most of the skeletal sites and, for some of them, more strongly than in the unrelated men. Serum levels of LDL-cholesterol and triglycerides were significantly correlated in the brothers, but not more strongly than in the unrelated men. BTM levels correlated independently in the brothers aged ≥ 40, when their shared environment was limited. These data suggest a substantial hereditary determinism of the BTM levels in men.     

白花蛇舌草-半枝莲药对组分对结肠腺癌Lovo细胞生物学行为的影响

摘要:目的　探讨白花蛇舌草-半枝莲药对组分对结肠腺癌Lovo细胞增殖、侵袭、迁移和凋亡的影响及作用机制。方法　将白花蛇舌草、半枝莲按质量1∶1进行3次煎煮,获得水提物,后取适量浸膏用石油醚回流脱脂,再以乙酸乙酯进行多次萃取,获得白花蛇舌草-半枝莲药对组分,并计算得率。实验分为对照组（正常培养Lovo细胞）、白花蛇舌草-半枝莲药对组分低剂量组（10 mg/L）、中剂量组（30 mg/L）及高剂量组（50 mg/L）。通过噻唑蓝比色法（MTT）检测各组细胞培养24、48、72 h后的增殖抑制率。各组细胞培养48 h后,流式细胞仪检测细胞周期分布;Transwell实验检测细胞侵袭能力;划痕实验检测细胞迁移能力;TUNEL法检测细胞凋亡情况;Western blot法检测Grb2相关结合蛋白1（Gab1）、血管内皮生长因子受体2（VEGFR-2）、磷脂酰肌醇3-激酶（PI3K）、苏氨酸激酶（Akt）、基质金属蛋白酶-9（MMP-9）、B淋巴细胞瘤-2基因（Bcl-2）、Bcl-2相关X蛋白（Bax）蛋白表达情况。结果　化学萃取后的白花蛇舌草-半枝莲药对中主要含有对羟基苯乙酮、野黄芩苷、木犀草素和芹菜素4种化合物,组分得率为0.61%。与对照组相比,低、中、高剂量组细胞增殖抑制率升高,G1期肿瘤细胞比例增加,细胞凋亡指数增高,侵袭细胞数和划痕闭合率明显减小（均P＜0.05）,细胞中Gab1、VEGFR-2、PI3K、Akt、MMP-9、Bcl-2蛋白表达降低,Bax表达升高（均P＜0.05）,且存在剂量依赖性。结论　白花蛇舌草-半枝莲药对组分可抑制结肠腺癌Lovo细胞的增殖,降低其迁移和侵袭能力,诱导细胞凋亡,其机制可能与抑制Gab1/VEGFR-2/PI3K/Akt信号通路活化有关。     

The floating cardiac fat pad—sign of occult pneumothorax

Pneumothoraces are a possible sequela of chest trauma with potential morbidity and mortality if not recognized and treated promptly. A portable supine chest radiograph is frequently the first radiologic study performed in the setting of trauma. While large pneumothoraces can be readily recognized on these radiographs, smaller pneumothoraces are missed in up to 15 % of trauma patients. There are many radiographic signs of occult pneumothoraces, and we are presenting a new radiographic sign of occult pneumothorax. The floating cardiac fat pad sign occurs when pleural air collects anteriorly and superiorly in the most non-dependent portion of the chest lifting the pericardial fat pad off the diaphragm. Lung markings are still seen surrounding the pericardial fat pad due to the inflated lower lobe of the lung resting dependently. Rapid and accurate identification of pneumothoraces is critical but often difficult on chest radiographs. Although there are many existing radiographic signs for identification of pneumothorax, prospective identification of small pneumothoraces is still relatively poor. Here, we describe an additional sign which aides in the detection of pneumothoraces, the floating cardiac fat pad. When present, this should prompt further evaluation with chest CT or upright chest radiograph.