LOWER POLE I: A PROSPECTIVE RANDOMIZED TRIAL OF EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY AND PERCUTANEOUS NEPHROSTOLITHOTOMY FOR LOWER POLE NEPHROLITHIASIS—INITIAL RESULTS

PURPOSE: The efficacy of shock wave lithotripsy and percutaneous stone removal for the treatment of symptomatic lower pole renal calculi was determined. MATERIALS AND METHODS: A prospective randomized, multicenter clinical trial was performed comparing shock wave lithotripsy and percutaneous stone removal for symptomatic lower pole only renal calculi 30 mm. or less. RESULTS: Of 128 patients enrolled in the study 60 with a mean stone size of 14.43 mm. were randomized to percutaneous stone removal (58 treated, 2 awaiting treatment) and 68 with a mean stone size of 14.03 mm. were randomized to shock wave lithotripsy (64 treated, 4 awaiting treatment). Followup at 3 months was available for 88% of treated patients. The 3-month postoperative stone-free rates overall were 95% for percutaneous removal versus 37% lithotripsy (p <0.001). Shock wave lithotripsy results varied inversely with stone burden while percutaneous stone-free rates were independent of stone burden. Stone clearance from the lower pole following shock wave lithotripsy was particularly problematic for calculi greater than 10 mm. in diameter with only 7 of 33 (21%) patients becoming stone-free. Re-treatment was necessary in 10 (16%) lithotripsy and 5 (9%) percutaneous cases. There were 9 treatment failures in the lithotripsy group and none in the percutaneous group. Ancillary treatment was necessary in 13% of lithotripsy and 2% percutaneous cases. Morbidity was low overall and did not differ significantly between the groups (percutaneous stone removal 22%, shock wave lithotripsy 11%, p =0.087). In the shock wave lithotripsy group there was no difference in lower pole anatomical measurements between kidneys in which complete stone clearance did or did not occur. CONCLUSIONS: Stone clearance from the lower pole following shock wave lithotripsy is poor, especially for stones greater than 10 mm. in diameter. Calculi greater than 10 mm. in diameter are better managed initially with percutaneous removal due to its high degree of efficacy and acceptably low morbidity.     

Juxtafacet Cyst of the Lumbar Spine. Clinical, Radiological and Therapeutic Aspects in 28 Cases

Summary  Object. A consecutive series of 28 “operated” juxtafacet cysts is reported. We emphasize the clinical and radiological aspects leading to diagnosis. We also discuss the results of the surgical treatment.  Material and Methods. Medical information and radiological studies involving 28 patients were analyzed. Each patient has been operated on by decompressive laminectomy and resection of the cyst. The diagnosis was always confirmed by a pathological examination. The cyst most frequently occurred at the L4-L5 level (n=18), and seldom at the L5-S1 (n=6) or L3-L4 (n=4) levels.  Results. The differential diagnosis from other pathological causes responsible for a radicular compression could not be done by physical examination. Spine X-rays or myelogram were nonspecific. Computed Tomography or CT-myelography could help in the diagnosis but MR imaging was the most sensitive. In our series, the respective sensitivities of these techniques are 56, 42 and 77%. The preoperative diagnosis was correct in 18 patients (64%). The cyst was sometimes adherent to the underlying dura, then significantly increasing the risk of dural tear and spinal fluid leak, especially when located at L3-L4 level. Surgical ablation lead to a complete recovery or an important improvement in 26 patients.  Conclusions. The diagnosis of the juxtafacet cyst of the lumbar spine is better achieved by MRI. Surgery is the gold standard treatment, safe and long-term effective. When a total cyst removal with an internal facetectomy are performed, recurrence is exceptional.     

The fate of dendritic cells in a mouse model of liver ischemia/reperfusion injury

Ischemia/reperfusion during liver transplantation triggers a complex cascade of inflammatory events that may lead to organ dysfunction. Herein, we investigated the consequences of hepatic ischemia/reperfusion on liver dendritic cells. Liver damage was documented by increased levels of serum alanine aminotransferase and by histopathology showing large areas of hepatocyte cytolysis. MHC class II+ CD45-B220 F4/80 dendritic cells were detected in necrotic areas 20 hours after reperfusion. Dendritic cells freshly isolated from reperfused livers displayed a mature phenotype characterized by upregulated expression of B7 costimulatory molecules; MHC-class II, and CD1d molecules. As shown by real-time PCR, IL-10, and TGF-beta mRNA accumulated in liver dendritic cells isolated after reperfusion, whereas IL-12p40 mRNA levels were decreased and IFN-gamma mRNA levels were unchanged. These results suggest that hepatic ischemia/reperfusion results in maturation of dendritic cells, which preferentially produce inhibitory cytokines.     

Human chorionic gonadotrophin and immature fish ovary: characterization and mechanism of the in vitro stimulation of cyclic adenosine monophosphate accumulation

Human chorionic gonadotrophin (hCG) increased cyclic adenosine monophosphate (cAMP) in pieces of eel ovary in vitro. Although the ED50 (about 0.1 micrograms/ml) was the same as for carp gonadotrophin (cGTH), the maximal stimulation (close to 3 times basal level) was about 10 times lower than that for the fish hormone. The mechanism of this atypical action of hCG was studied using different approaches. Human CG did not inhibit the action of cGTH. Desensitization experiments (cGTH or hCG being injected in vivo 18 hr before the sampling of the ovary) were carried out; the in vitro action of hCG was suppressed by both pretreatments; the in vitro action of cGTH was largely reduced by in vivo cGTH and to a much lesser extent by in vivo hCG. Together with other data the results indicated that hCG acts via binding to adenylate cyclase-coupled receptors which also recognize cGTH; moreover, they suggested that among those systems only a fraction can be activated by hCG. We propose that in teleosts the pool of GTH receptors is not homogeneous but contains classes of "isoreceptors" differing by their recognition specificity at least. Parallel studies with ovine lutrophin (oLH) indicated that this hormone binds to the same adenylate cyclase-coupled receptors which are sensitive to hCG but that it does it with a much lower affinity. Other characteristics of oLH/hCG-stimulated receptor-adenylate cyclase systems include an important release of cAMP into the incubation medium. The precise physiological significance of GTH "isoreceptors" still requires clarification. The ability of hCG to induce desensitization must be considered in fish culture experiments using this hormone.     

Testicular response to human chorionic gonadotrophin in chronic hyperprolactinaemia

In order to evaluate the effect of hyperprolactinaemia on gonadal function in men, testicular stimulation by human chorionic gonadotrophin (hCG) (5000 IU/day, 3 consecutive days) was performed on 6 men with chronic hyperprolactinaemia and 6 control subjects. The following parameters were measured before and during the 4 consecutive days following the injections of hCG: the concentration in plasma of testosterone (T), oestradiol-17 beta (E2), dihydrotestosterone (DHT) and the urinary excretion of testosterone glucuronide (TG) and 5 alpha-androstane-3 alpha, 17 beta-diol glucuronide (3 alpha-Diol G). The rises in T, E2, DHT and the ratios of T/DHT and TG/3 alpha-Diol G were similar in both groups, but the rises in TG and 3 alpha-Diol G were lower in the hyperprolactinaemic group after hCG. There was no correlation between the response of T and the increment of E2 in either group. It is suggested that in men with chronic hyperprolactinaemia: 1) there is diminished testicular response to hCG; this could be due to chronic gonadotrophin deficiency or to a direct effect of hyperprolactinaemia on the testes, 2) there is no modulation of T synthesis through inhibition of aromatase activity and E2 secretion and 3) the 5 alpha-reduction of T is not deficient.     

Creating an Academy of Medical Educators: How and Where to Start

Background

While most faculty members want to improve as teachers, they neither know where their educational strengths and weaknesses lie nor where or how to begin to effect a change in their teaching abilities. The lack of actionable, directed and specific feedback, and sensible and sensitive metrics to assess performance and improvement complicates the attainment of educational excellence.

Purpose

The purpose of this article was to outline a series of specific steps that medical education programs can take to enhance the quality of teaching, promote teaching excellence, elevate the status and value of medical educators, and stimulate the creation of innovative teaching programs and curricula.

Methods

To achieve these goals at the Hospital for Special Surgery, the Academy of Rheumatology Medical Educators was formed. The academy had the following goals: (1) create within our institution a mission which advances and supports educators, (2) establish a membership composed of distinguished educators, (3) create a formal organizational structure with designated leadership, (4) dedicate resources that fund mission-related initiatives and research, and (5) establish a plan for promoting teachers as well as enhancing and advancing educational scholarship.

Results

The Hospital for Special Surgery Academy of Rheumatology Medical Educators was recently formed to address these goals by promoting teaching and learning of musculoskeletal skills in an environment that is supportive to educators and trainees and provides much needed resources for teachers.

Summary

The development of a pilot academy of medical educators represents one of the high-priority goals of those institutions that wish to elevate and enrich their teaching through a structured, proven approach.     

Discitis and sacroiliitis diagnosed 15 years after iatrogenic Mycobacterium xenopi inoculation

A patient was diagnosed with discitis and sacroiliitis due to Mycobacterium xenopi. He had a history of percutaneous nucleotomy performed 15 years earlier (in 1992) at the Clinique du Sport, Paris, France, during an outbreak of nosocomial M. xenopi infection at that institution. In 1997, magnetic resonance imaging performed as part of the routine follow-up program for patients who had surgery at the Clinique du Sport during the outbreak was not interpreted as indicating discitis; this assessment was confirmed by our review of the images. Bone and joint infections due to atypical mycobacteria are rare and can develop very slowly. To our knowledge, this is the first reported case of M. xenopi discitis with secondary extension to the sacroiliac joint in an immunocompetent patient.     

Pilot study of a novel pain management strategy: evaluating the impact on patient outcomes

Background

Our objective was to evaluate the impact of a novel multimodal pain management strategy on intraoperative opioid requirements, postoperative pain, narcotic use, and length of stay.

Methods

Consecutive patients undergoing elective laparoscopic colorectal resection were managed with an experimental protocol. The protocol uses a post-induction, pre-incision bilateral TAP block and local peritoneal infiltration at port sites with long-acting liposomal bupivacaine (20 mL long-acting liposomal bupivacaine, 30 mL 0.25 % bupivacaine, 30 mL saline). Experimental patients were matched on age, body mass index, gender, comorbidity, diagnosis, and procedure to a control group that received no block or local wound infiltration. Both groups followed a standardized enhanced recovery pathway. Demographics, perioperative, and postoperative outcomes were evaluated. The main outcome measures were intraoperative opioids, postoperative pain, opioid use, and length of stay.

Results

Fifty patients were analyzed—25 experimental and 25 controls. Patients were well matched on all demographics. In both cohorts, the main diagnosis was colorectal cancer and primary procedure performed a segmental resection. Operative times were similar (p = 0.41). Experimental patients received significantly less intraoperative fentanyl (mean 158 mcg experimental vs. 299 mcg control; p < 0.01). The experimental group had significantly lower initial (p < 0.01) and final PACU pain scores (p = 0.04) and shorter LOS (3.0 vs. 4.1 days, p = 0.04) compared to controls. Experimental patients trended toward shorter PACU times and lower opioid use and daily pain scores throughout the hospital stay. Postoperative complication and readmission rates were similar across groups. There were no reoperations or mortality.

Conclusions

Our multimodal pain management strategy reduced intraoperative opioid administration. Postoperatively, improvements in PACU time, postoperative pain and narcotic use, and lengths of stay were seen in the experimental cohort. With the favorable finding from the pilot study, further investigation is warranted to fully evaluate the impact of this pain management protocol on patient satisfaction, clinical and financial outcomes.