Relation of urinary tract infection and vesicoureteral reflux to scars: follow-up of thirty-eight patients

A prospective study compared the outcome of vesicoureteral reflux and recurrent urinary tract infections in children (3 boys, 62 girls) who received medical prophylaxis or underwent surgical correction of reflux. Thirty-eight children returned for reevaluation 6 to 13 years (average 9.5 years) after entry. There was a marked decrease in prevalence and severity of reflux. At entry, 13 had significant scarring that had progressed at follow-up. New scars were documented by dimercaptosuccinic acid scan at follow-up in eight children on the medical regimen and two who were initially treated with surgical correction of reflux. Four patients with high-grade sterile reflux were followed for 6 to 10 years without the development of cortical scars. Our data support the role of urinary tract infection and vesicoureteral reflux, but not sterile reflux, in the pathogenesis of chronic pyelonephritis and reflux nephropathy.     

Management of the acute respiratory distress syndrome

Significant advances have occurred in the knowledge of the pathogenesis of ARDS. It is now recognized that ARDS is a manifestation of a diffuse process that results from a complicated cascade of events following an initial insult or injury. Mechanical ventilation and PEEP are still important components of supportive therapy. To avoid ventilator-associated lung injury there is emphasis on targeting ventilator management based on measurement of pulmonary mechanics. For those with resistant hypoxia and severe pulmonary hypertension adjunctive modalities, such as prone positioning and low-dose iNO, may provide important benefit. Alternative modes of supporting gas exchange, such as with partial liquid ventilation and extracorporeal gas-exchange, may serve as rescue therapies. Advances in cell and molecular biology have contributed to a better understanding of the role of inflammatory cells and mediators that contribute to the acute lung injury and the pathophysiology of the syndrome that manifests as ARDS. Based on this new understanding, the potential targets for intervention to ameliorate the systemic inflammatory response have proliferated. Examples include the cytokine network and its receptors, antioxidants, and endothelins. Apart from the challenge of testing these agents in experimental models, it seems likely that determination of the optimum combination of agents will become an equally important endeavor. A particular challenge is to develop better methods of predicting which of the many at-risk patients will go on to full-blown ARDS and MODS, thereby targeting subgroups of patients most likely to benefit from anti-inflammatory therapies. Similarly, the adverse effects of immunosuppressive therapy may be diminished by improved, perhaps molecular, techniques to detect microbial pathogens and permit differentiation between Systemic inflammatory response syndrome and sepsis.     

A prospective evaluation of novel methods to intraoperatively distinguish parathyroid tissue utilizing a parathyroid hormone assay

BACKGROUND: Frozen section analysis has traditionally been used to confirm the identity of parathyroid tissue intraoperatively; however, it is time-consuming and costly and requires the excision of a significant portion of tissue. An intraoperative biopsy and analysis with a parathyroid hormone (PTH) assay is a possible alternative; however, this technique has not been perfected. METHODS: Two hundred twenty-three tissue specimens were collected prospectively from patients undergoing neck exploration. Each specimen was sampled intraoperatively using three different biopsy techniques: a fine-needle aspiration (FNA) with 10 passes of a needle (FNA10), a FNA with 20 passes of a needle (FNA20), and a tissue biopsy of approximately 1.0 mm3 (BIOPSY). The PTH concentration of each sample was determined via the Elecsys 1010 PTH immunoassay. The final tissue diagnosis was determined by histology or operative data. RESULTS: Parathyroid samples from all techniques had higher median PTH concentrations than nonparathyroid samples. However, the accuracies for the detection of parathyroid tissue varied markedly (PTH cutoff of 1000 pg/ml): the accuracies of the FNA10 and FNA20 were 71 and 80%, respectively, while the BIOPSY was 99% accurate. CONCLUSIONS: This is the first prospective study evaluating multiple methods to diagnose parathyroid tissue intraoperatively using a rapid PTH assay. We conclusively show that the BIOPSY technique is 99% accurate for the diagnosis of parathyroid tissue, and therefore, should be the method of choice when the intraoperative confirmation of parathyroid tissue is needed.     

Incipient intraepidermal cutaneous squamous cell carcinoma: a proposal for reclassifying and grading solar (actinic) keratoses

Actinic keratoses (AKs) are primarily induced by ultraviolet (UV) radiation and are often identified as premalignant lesions. In our opinion, AKs are proliferations of transformed, neoplastic keratinocytes confined to the epidermis that may eventually extend into the dermis, at which point they are termed squamous cell carcinoma (SCC). In contrast to AKs, SCCs have the potential to metastasize and kill. This process is analogous to that of evolving carcinoma of the uterine cervix that has been termed cervical intraepithelial neoplasia (CIN), a time-tested and reliable classification that provides clinicians with accurate information on which to base treatment decisions regarding cervical neoplasms following biopsy testing. A similar classification scheme could provide guidance to clinicians for the diagnosis and treatment of evolving SCC of the skin and as such, we propose a similar classification using the terminology keratinocytic intraepidermal neoplasia (KIN). This system is more reflective of the histology and natural history of SCC and eliminates ambiguity in the terminology of lesions currently referred to as AKs. The KIN classification defines features by which individual specimens can be objectively graded and specific treatment recommendations are made based on the grade of the lesion. We propose that the term keratinocytic intraepidermal neoplasia (KIN) be used to define and describe evolving SCC of the skin and that the term actinic (solar) keratosis be eliminated.     

Is Sub-occipital Padding Necessary to Maintain Optimal Alignment of the Unstable Spine in the Prehospital Setting? A Preliminary Report

Background

As prehospital emergency rescuers prepare cervical spine-injured adult patients for immobilization and transport to hospital, it is essential that patients be placed in a favorable position. Previously, it was recommended that patients with cervical spine injuries be immobilized in a slightly flexed position using pads placed beneath the head. However, it is unknown how neck flexion created with pad placement affects the unstable spine.

Objective

To determine the effects of three different head positions on the alignment of unstable vertebral segments.

Methods

Five cadavers with a complete segmental instability at the C5 and C6 level were included in the study. The head was either placed directly on the ground (or spine board) or on foam pads. Three conditions were tested: no pad; pads 2.84 cm thick; and pads 4.26 cm thick. Pads were positioned beneath the head to determine their effect on spinal alignment. Anterior-posterior translation, flexion-extension motion, and axial displacement across the unstable segment were compared between conditions.

Results

Although statistical tests failed to identify any significant differences between pad conditions, some meaningful results were noted. In general, the “no pad” condition aligned the spine in a position that best replicated the intact spine.

Conclusions

Because the goal of emergency rescuers is to conserve whatever physiologic or structural integrity of the spinal cord and spinal column that remains, the outcome of this study suggests that this goal may be best achieved using the “no pad” condition. However, it is recommended that more research be conducted to confirm these preliminary findings.     

Long-term survival after post-hepatectomy liver failure for colorectal liver metastases

Background

While post-hepatectomy liver failure (PHLF) accurately predicts short-term mortality, its role in prognosticating long-term overall survival (OS) remains unclear.