Risk of developing metachronous colon neoplasm after polypectomy: comparison of one-stage versus two-stage polypectomy

Background

The impact of one-stage polypectomy (removal of all neoplasms during diagnostic colonoscopy) versus two-stage polypectomy (removal of all neoplasms during therapeutic colonoscopy following the initial diagnostic colonoscopy) on the development of metachronous neoplasms is poorly understood. Our aim was to compare the effects of one- versus two-stage polypectomy on the development of metachronous neoplasms

Methods

We retrospectively reviewed the medical records of 249 patients in a tertiary center who underwent one-stage polypectomy, which was followed by one or more surveillance colonoscopy. The development of metachronous neoplasm in this group was compared with that of an age- and sex-matched two-stage polypectomy group consisting of 498 patients

Results

In total, 346 (46.3 %) patients developed any metachronous neoplasm and 29 (3.9 %) patients developed advanced metachronous neoplasm. The 5 years cumulative incidences of any and advanced metachronous neoplasm were 46.2 and 5.0 %, respectively, in the one-stage group, which are not significantly different from the rates of 50.7 and 3.3 % in the two-stage group (p = 0.94 and 0.30, respectively). The only significant risk factor for developing any metachronous neoplasm was ≥3 neoplasms at the baseline polypectomy [hazard ratio (HR) 1.75; 95 % confidence interval (CI) 1.41–2.17; p < 0.001]. The only significant risk factor for developing advanced metachronous neoplasm was advanced neoplasm at the baseline polypectomy (HR 2.37; 95 % CI 1.16–4.84; p = 0.01). One- and two-stage polypectomy did not affect the development rates of metachronous neoplasm

Conclusions

The risks of developing metachronous neoplasm may be similar following one- and two-stage polypectomy.     

Tension wire fixation for mallet fracture after extension block pinning failed

Introduction

Various surgical treatments such as extension block pinning have been proposed for acute bony mallet finger. We evaluated the clinical results of tension wire fixation technique for the treatment of nonunion of mallet fracture after failed mallet finger surgery.

Materials and methods

Nine male patients were treated with open tension wire fixation for chronic nonunion of mallet fracture after extension block pinning surgery failed. The mean age was 29.3 years (range 18–47). We assessed bone union in simple radiographs. Crawford’s and Bischoff functional score was used to assess the functional outcome.

Results

The mean follow-up period was 45.8 months (range 18–74). Clinical and radiographic bone unions were achieved in eight of nine patients with average time of 31 days (range 23–41). Mean extension lag at final follow-up was 7° (range 0–25). Four patients showed excellent, three patients showed good and two patients showed fair results on the Crawford’s score scale. With Bischoff functional score, all patients were categorized as excellent.

Conclusions

Tension wire fixation can be a good second-line reconstructive surgery for the treatment of mallet fracture after extension block failed, so that patients can avoid arthrodesis or complex tendon transfer as a salvage procedure.     

Classifying errors in preventable and potentially preventable trauma deaths: a 9-year review using the Joint Commission's standardized methodology

Background

Benchmarking and classification of avoidable errors in trauma care are difficult as most reports classify errors using variable locally derived schemes. We sought to classify errors in a large trauma population using standardized Joint Commission taxonomy.

Methods

All preventable/potentially preventable deaths identified at an urban, level-1 trauma center (January 2002 to December 2010) were abstracted from the trauma registry. Errors deemed avoidable were classified within the 5-node (impact, type, domain, cause, and prevention) Joint Commission taxonomy.

Results

Of the 377 deaths in 11,100 trauma contacts, 106 (7.7%) were preventable/potentially preventable deaths related to 142 avoidable errors. Most common error types were in clinical performance (inaccurate diagnosis). Error domain involved primarily the emergency department (therapeutic interventions), caused mostly by knowledge deficits. Communication improvement was the most common mitigation strategy.

Conclusion

Standardized classification of errors in preventable trauma deaths most often involve clinical performance in the early phases of care and can be mitigated with universal strategies.     

Positional change of hyoid bone after anesthesia in anterior surgery of upper cervical spine

Background contextThe hyoid bone is used as a landmark in anterior upper cervical spine operations and is supposed to represent the level of C3 body. However, this correspondence between hyoid bone position and cervical level is not static and changes during surgery (extension after anesthesia).PurposeTo find the cervical level corresponding to the position of hyoid bone before and after anesthesia and to evaluate the adequacy of its usage as a surgical landmark.Study designA retrospective study.Patient sampleOne hundred twenty-eight patients with degenerative cervical diseases who had undergone anterior cervical discectomy and fusion.Outcome measureRadiologic measure.MethodsFor each patient, preanesthesia neutral, preanesthesia extension, and postanesthesia induction extension C-spine lateral image were obtained. The level of cervical vertebra that midline of hyoid bone indicated was measured by radiological method. A cervical vertebra was divided into three segments, consisting of upper half, lower half, and disc space, and each of these segments was considered as one level. The differences between pre- and postanesthesia induction hyoid positions were classified as minimal change (one level or less) and significant change (two levels or greater). Relationship between positional change of hyoid bone to gender, obesity, and age were respectively investigated.ResultsThere were 20 cases of one-level distal displacement of the hyoid bone, 40 cases of two-level distal displacement, 34 cases of three-level distal displacement, 16 cases of 4-level distal displacement, and two cases of five-level distal displacement. In eight cases, there was no level change, and in the remaining 8 cases, the hyoid bone had been displaced proximally. There were 34 cases of minimal change. The remaining 94 cases (73.4%) had significant changes. No respective relationship was found between sex, obesity, age and pre-and postanesthesia induction positional change of hyoid bone.ConclusionsAmong the 128 cases studied, 73.4% hyoid bone positions had changed by more than one cervical vertebra body between the pre- to postanesthesia induction X-ray images. Sex, age, and body mass index were not associated with statistically significant differences in these positions. The hyoid bone should not be trusted as a landmark for upper cervical operations, and the cervical level to be operated should be confirmed by a radiological method before a skin incision is made.     

Hormone Responses to an Acute Bout of Low Intensity Blood Flow Restricted Resistance Exercise in College-Aged Females

The purpose of this study was to determine whether the acute hormone response to exercise differed between low intensity blood flow restricted resistance exercise and traditional high-intensity resistance exercise in college-aged women. A total of 13 healthy women (aged 18-25 yrs), who were taking oral contraceptives, volunteered for this randomized crossover study. Subjects performed a session of low intensity blood flow restricted resistance exercise (BFR) (20% of 1-RM, 1 set 30 reps, 2 sets 15 reps) and a session of traditional high intensity resistance exercise without blood flow restriction (HI) (3 sets of 10 repetitions at 80% of 1-RM) on separate days. Fasting serum cortisol and growth hormone (GH) and blood lactate responses were measured in the morning pre and post exercise sessions. GH (Change: HI: 6.34 ± 1.72; BFR: 4.22 ± 1.40 ng·mL^-1) and cortisol (Change: HI: 4.46 ± 1.53; BFR: 8.10 ± 2.30 ug·dL^-1) significantly (p < 0.05) increased immediately post exercise for both protocols compared to baseline and there were no significant differences between the protocols for these responses. In contrast, blood lactate levels (HI: 7.35 ± 0.45; BFR: 4.02 ± 0.33 mmol·L^-1) and ratings of perceived exertion were significantly (p < 0.01) higher for the HI protocol. In conclusion, acute BFR restricted resistance exercise stimulated similar increases in anabolic and catabolic hormone responses in young women.

Key Points

• Growth hormone and cortisol levels significantly increased after a single bout of low intensity blood flow restricted resistance exercise in young women.
• There were no significant differences in hormone responses between the low intensity blood flow restricted protocol and the traditional high intensity higher total workload protocol.
• Low intensity blood flow restricted resistance exercise provides a sufficient stimulus to elicit anabolic and catabolic hormone responses in young women.

Key Words: Growth Hormone, Cortisol, blood flow restriction     

Alveolar Soft Part Sarcoma: Clinical Presentation,Treatment and Outcome in a Series of 19 Patients

Background

Alveolar soft part sarcoma (ASPS) is a rare soft tissue tumor that usually affects young patients. Because of the rarity of the disease, most reports relating to ASPS are in the form of case reports or small series.

Methods

We performed a retrospective study to evaluate the clinicopathologic features, treatment, outcome and pattern of treatment failure in a consecutive series of patients with localized or metastatic ASPS between 1996 and 2011. Demographics, tumor sizes, sites and extent of disease, treatments provided, progression-free survival, and overall survival were evaluated.

Results

A total of 19 patients were identified. The clinical assumptive diagnosis of the first medical examination doctor was benign soft tissue tumor in 5 cases (26%) and benign hemangioma in 4 cases (21%), delaying treatment. The most common location of primary tumor was the thigh. The median diameter of the mass was 55 mm (range, 10 to 130 mm). An R0 resection was obtained in 11 cases. Adjuvant radiotherapy was delivered in 8 cases; postoperative systemic chemotherapy was delivered in 10 cases. Eight out of 15 patients (53%) exhibited metastases either at presentation or later. Median overall follow-up was 54 months.

Conclusions

The treatment principle for alveolar soft tissue sarcoma is massive resection, and when the surgical margin is questionable, radiation treatment can be added for prevention of local recurrence. Also, due to discovery of metastases and local recurrence, even after 5 years of general treatment, outpatient department follow-up is needed, and we need to keep in mind that lung, intracranial, and bone metastases are common.     

Perioperative nutritional support and fluid therapy in patients with liver diseases

The prevalence of liver dysfunction and malnutrition is common among patients with obstructive jaundice or cirrhosis, the poor nutrition status in patients with indications for hepatic resection increases the risk of postoperative complications and/or mortality. Hepatic surgery significantly affects body’s metabolism and environment. Therefore, it is very important for patients with liver diseases undergoing hepatic surgery to receive essential nutritional support and fluid therapy during perioperative period. There are several principles in nutritional support and fluid therapy that surgeons need to pay attention to, for example, time, nutritional approach, fluid volume, choice of fat emulsions and amino acids. Some issues, such as albumin and plasma application, choice of crystalloid and colloid, liver protective therapy, also need further attention.     

Juvenile Osteochondritis Dissecans in a 13-year-old male athlete: A case report

Objective:

To present the clinical management of juvenile osteochondritis dissecans (OCD) of the knee and highlight the importance of a timely diagnosis to optimize the time needed for less invasive, non-operative therapy.

Clinical Features:

A 13-year-old provincial level male soccer player presenting with recurrent anterior knee pain despite ongoing manual therapy.

Intervention and Outcome:

A multidisciplinary, non-operative treatment approach was utilized to promote natural healing of the osteochondral lesion. The plan of management consisted of patient education, activity modification, manual therapy, passive modalities and rehabilitation, while being overseen by an orthopaedic surgeon.

Conclusions:

Considering the serious consequences of misdiagnosing osteochondritis dissecans, such as the potential for future joint instability and accelerated joint degeneration, a high degree of suspicion should be considered with young individuals presenting with nonspecific, recurrent knee pain. A narrative review of the literature is provided to allow practitioners to apply current best practices to appropriately manage juvenile OCD and become more cognizant of the common knee differential diagnoses in the young athletic population.