Thoracoscopic interbody fusion with percutaneous posterior stabilization for thoracic and thoracolumbar injuries

Background context

Traumatic thoracolumbar discoligamentous injuries and partial burst fractures are commonly managed through posterior-only stabilization. Many cases present later with failure of posterior implant and progressive kyphotic deformities that necessitates major surgeries. Anterior interbody fusion saves the patients unnecessary long-segment fixation and provides a stable definitive solution for the injured segment.

Purpose

The purpose of this study is to assess the clinical and radiographic outcomes of combined minimal invasive short-segment posterior percutaneous instrumentation and anterior thoracoscopic-assisted fusion in thoracolumbar partial burst fractures or discoligamentous injuries.

Study design

Prospective observational study.

Patient sample

Thirty patients with acute thoracic or thoracolumbar injuries operated upon between December 2007 and January 2009.

Outcome measures

Oswestry Disability Index (ODI), clinical and neurological examination for clinical assessment. Plain X-ray for radiological evaluation.

Methods

Preoperative evaluation included clinical and neurological examination, plain X-rays, computed tomography (CT), and magnetic resonance imaging (MRI). Posterior short-segment percutaneous stabilization plus anterior thoracoscopically assisted fusion in prone position were done. The minimum follow-up period was 2 years (range 24–48 months).

Results

The mean age was 44 years. The commonest affected segment was between T10 and L1 (22 patients, 73 %). The mean total operative time was 103 min. The mean operative blood loss was 444 ml. Interbody fusion cage was used in 28 patients while iliac graft in two cases. Fusion rate at the final follow-up was 97 % (29 patients); one patient did not show definitive fusion although he was clinically satisfied. The mean final follow-up ODI was 12 %. The mean preoperative kyphosis angle was 22° improved to 6.5° postoperatively and was 7.5° at final follow-up. There were no major intraoperative or postoperative complications.

Conclusion

Combined anterior thoracoscopic fusion and short-segment posterior percutaneous instrumentation showed good clinical and radiographic outcomes in cases of thoracolumbar injuries through limiting the instrumented levels and preventing progress of posttraumatic kyphosis.     

Hepatobiliary rhabdomyosarcoma mimicking choledochal cyst: Lessons learned

INTRODUCTION

The differential diagnosis of hepatic cystic lesions is a challenging process especially in case of hepatic rhabdomyosarcoma (HRMS) presenting as hepatic cyst.

PRESENTATION OF CASE

We introduce our experience with a case of HRMS in a 3-year-old female patient who was misdiagnosed to have type IV-A choledochal cyst and definitive correct diagnosis was reached after the pathological and immunohistochemical examination of the surgically resected lesion. This case presentation is followed by important practical messages to hepatobiliary surgeons regarding HRMS.

DISCUSSION

HRMS is a rare pediatric tumor. Jaundice is the most common presentation of HRMS followed by abdominal pain and vomiting. Great effort is needed to differentiate the tumor from choledochal cyst and infectious hepatitis. Through evaluation using available imaging studies together with clinical anticipation is mandatory for establishing the correct diagnosis.

CONCLUSION

Differentiation of HRMs from choledochal cyst mandates through evaluation and clinical anticipation. HRMS should be suspected in any child with obstructive jaundice. Once diagnosis is established, multidisciplinary treatment is the best management strategy and it has proved better surgical outcome and long term survival.     

Dioxin-Like Polychlorinated Biphenyls,Polychlorinated Dibenzo-p-Dioxins,and Polychlorinated Dibenzofurans in Seafood Samples from Malaysia: Estimated Human Intake and Associated Risks

A total of 127 and 177 seafood samples from Malaysia were analyzed for polychlorinated dibenzo-p-dioxins/dibenzofurans (PCDD/Fs) and dioxin-like polychlorinated biphenyls (dl-PCBs), respectively. The World Health Organization-toxic-equivalency quotients (WHO-TEQ) of PCDD/Fs varied from 0.13 to 1.03 pg TEQ g^?1, whereas dl-PCBs ranged from 0.33 to 1.32 pg TEQ g^?1. Based on food-consumption data from the global environment monitoring system—food contamination monitoring and assessment programme, calculated dietary exposures to PCDD/Fs and dl-PCBs from seafood for the general population in Malaysia were 0.042 and 0.098 pg TEQ kg^?1 body weight day^?1, respectively. These estimations were quite different from the values calculated using the Malaysian food-consumption statistics (average of 0.313 and 0.676 pg TEQ kg^?1 body weight day^?1 for PCDD/Fs and PCBs, respectively). However, both of the dietary exposure estimations were lower than the tolerable daily intake recommended by WHO. Thus, it is suggested that seafood from Malaysia does not pose a notable risk to the health of the average consumer.     

Comprehensive morphometry of subcortical grey matter structures in early‐stage Parkinson's disease

Previous imaging studies that investigated morphometric group differences of subcortical regions outside the substantia nigra between non‐demented Parkinson's patients and controls either did not find any significant differences, or reported contradictory results. Here, we performed a comprehensive morphometric analysis of 20 cognitively normal, early‐stage PD patients and 19 matched control subjects. In addition to relatively standard analyses of whole‐brain grey matter volume and overall regional volumes, we examined subtle localized surface shape differences in striatal and limbic grey matter structures and tested their utility as a diagnostic marker. Voxel‐based morphometry and volumetric comparisons did not reveal significant group differences. Shape analysis, on the other hand, demonstrated significant between‐group shape differences for the right pallidum. Careful diffusion tractography analysis showed that the affected parts of the pallidum are connected subcortically with the subthalamic nucleus, the pedunculopontine nucleus, and the thalamus and cortically with the frontal lobe. Additionally, microstructural measurements along these pathways, but not along other pallidal connections, were significantly different between the two groups. Vertex‐wise linear discriminant analysis, however, revealed limited accuracy of pallidal shape for the discrimination between patients and controls. We conclude that localized disease‐related changes in the right pallidum in early Parkinson's disease, undetectable using standard voxel‐based morphometry or volumetry, are evident using sensitive shape analysis. However, the subtle nature of these changes makes it unlikely that shape analysis alone will be useful for early diagnosis. Hum Brain Mapp 35:1681–1690, 2014. © 2013 Wiley Periodicals, Inc.     

Comparison between the endoscopic scores of bolgerization versus partial resection of the middle turbinate for management of the postoperative lateralization in the early follow-up period after endoscopic frontal sinusotomy: A randomized controlled study

BackgroundFrontal sinusotomy is a challenging procedure that needs meticulous handling due to its unique anatomical position. Postoperative middle turbinate lateralization is critical comorbidity for the success rate, and many techniques are adopted to prevent it. The study aimed to compare the effect of middle turbinate bolgerization and partial resection on the postoperative endoscopic scores and assess their impact on the middle meatus and the frontal recess outcome.Patient and methodsThis prospective study was conducted on forty-one patients undergoing bilateral frontal sinusotomy for chronic frontal sinusitis. Nasal cavities were randomized so that partial middle turbinate resection technique was done alternately with bolgerization approach in every patient. Each participant acted as their control. Both sides were compared using Lund Kennedy Endoscopic Score (LKES) and Perioperative Sinus Endoscopy Score (POSE) at the baseline, 1st, 3rd, and 12th-month intervals postoperatively. Also, middle turbinate status was assessed at the end of the 12th-month interval using POSE score.ResultsThe total frontal sinus patency rate was 82.9% (63/76 operated sinus). Baseline scores, LKES (3.79 ± 0.777 vs 4.05 ± 0.769, p = 0.142, for the side of resection and the side for bolgerization respectively) and POSE (1.79 ± 0.413 vs 1.82 ± 0.393, p = 0.777, for the side of resection and the side for bolgerization respectively). Regarding LKES, the differences between both operated sides were fluctuating with p values: 0.001*, 0.171, and 0.044* for the 1st, 3rd, and 12th months follow-up intervals, respectively. Regarding the POSE score of the frontal sinus, the difference between both groups was steadily increasing with p values: 0.318, 0.119, and 0.017* for the 1st, 3rd^, and 12th months follow-up intervals. The middle turbinate's POSE score at the 12th month was significantly higher in the side allocated for bolgerization (p-value = 0.008*).ConclusionPartial middle turbinate resection showed favorable endoscopic outcomes than bolgerization at the 12th month follow up period in patients undergoing primary ESS for chronic frontal sinusitis.     

Predictors of poor outcome of decompressive craniectomy in pediatric patients with severe traumatic brain injury: a retrospective single center study from Pakistan

Objective

This study aimed to determine the risk factors associated with poor outcome of decompressive craniectomy (DC) for severe traumatic brain injury (TBI) in pediatric patients.

Methods

This retrospective study is conducted on pediatric population (age 1–15 years) presenting with TBI who underwent DC at our institute between January 2000 and 2010. Based on Glasgow outcome score (GOS) at a minimum follow-up of 5 months, patients were divided into two groups, namely poor outcome (GOS 1, 2, and 3) and good outcome (GOS 4 and 5). Records were reviewed and analyzed for preoperative and intraoperative predictors.

Results

We found 25 patients who were eligible as per selection criteria. Mean age at presentation was 6?±?4 years and there was male preponderance (84 %). Fall (60 %) was the most common mechanism of injury followed by gunshots and road traffic accident. On univariate analysis, presenting GCS ≤5 (p value?=?0.009), delay in presentation of more than 150 min (p value?=?0.010), DC performed after more than 4 h of arrival in hospital (p value?=?0.042), and intraoperative blood loss exceeding 300 ml (p value?=?0.001) were significant predictors of poor outcome.

Conclusion

Our study suggests that DC in children is not only a life-saving procedure, but also leads to a good functional outcome after severe injury. However, patient selection still remains an important aspect, and the above-mentioned factors should be considered while deciding for DC to improve survival. Further prospective studies on larger sample size are warranted to validate our results.     

Mineralocorticoid receptor and heat shock protein expression levels in peripheral lymphocytes from war trauma-exposed men with and without PTSD

Alterations in the number and functional status of mineralocorticoid (MR) and glucocorticoid receptors (GR) may contribute to vulnerability to posttraumatic stress disorder (PTSD). Corticosteroid receptors are chaperoned by heat shock proteins Hsp90 and Hsp70. We examined relations between corticosteroid receptor and heat shock protein expression levels, and related them with war trauma exposure, PTSD and resilience to PTSD. Relative levels of MR, Hsp90 and Hsp70 were determined by immunoblotting in lymphocytes from war trauma-exposed men with current PTSD (current PTSD group, n=113), with life-time PTSD (life-time PTSD group, n=61) and without PTSD (trauma control group, n=88), and from non-traumatized healthy controls (healthy control group, n=85). Between-group differences in MR, Hsp90 and Hsp70 levels and in MR/GR ratio were not observed. The level of MR was correlated with both Hsp90 and Hsp70 levels in trauma control and healthy control groups. On the other hand, GR level was correlated only with Hsp90 level, and this correlation was evident in current PTSD and trauma control groups. In conclusion, PTSD and exposure to trauma are not related to changes in lymphocyte MR, Hsp90 or Hsp70 levels, but may be associated with disturbances in corticosteroid receptors interaction with heat shock proteins.     

Effects of trimetazidine on the Akt/eNOS signaling pathway and oxidative stress in an in vivo rat model of renal ischemia-reperfusion

Renal ischemia reperfusion (I/R) injury, which occurs during renal surgery or transplantation, is the major cause of acute renal failure. Trimetazidine (TMZ), an anti-ischemic drug, protects kidney against the deleterious effects of I/R. However its protective mechanism remains unclear. The aim of this study is to examine the relevance of Akt, endothelial nitric oxide synthase (eNOS), and hypoxia inducible factor-1α (HIF-1α) on TMZ induced protection of kidneys against I/R injury. Wistar rats were subjected to 60?min of warm renal ischemia followed by 120?min of reperfusion, or to intraperitoneal injection of TMZ (3?mg/kg) 30?min before ischemia. In sham operated group renal pedicles were only dissected. Compared to I/R, TMZ treatment decreased lactate dehydrogenase (845?±?13 vs. 1028?±?30?U/L). In addition, creatinine clearance and sodium reabsorption rates reached 105?±?12 versus 31?±?11?μL/min/g kidney weight and 95?±?1 versus 68?±?5%, respectively. Besides, we noted a decrease in malondialdehyde concentration (0.33?±?0.01 vs. 0.59?±?0.03?nmol/mg of protein) and an increase in glutathione concentration (2.6?±?0.2 vs. 0.93?±?0.16?µg GSH/mg of protein), glutathione peroxidase (95?±?4 vs. 61?±?3?µg GSH/min/mg of protein), and superoxide dismutase (25?±?3 vs. 11?±?2?U/mg of protein) and catalase (91?±?12 vs. 38?±?9?μmol/min/mg of protein) activities. Parallely, we noted a significant increase in p-Akt, eNOS, nitrite and nitrate (18?±?2 vs. 8?±?0.1?pomL/mg of protein), HIF-1α (333?±?48 vs. 177?±?14?µg/mg of protein) and heme oxygenase-1 (HO-1) levels regarding I/R. TMZ treatment improves renal tolerance to warm I/R. Such protection implicates an activation of Akt/eNOS signaling pathway, HIF-1α stabilization and HO-1 activation.