Transverse sacral fractures: case series and literature review.

OBJECTIVES: To report experience with transverse sacral fracture, an uncommon injury frequently associated with neurologic deficit, and to perform a meta-analysis of the literature in order to define the role of decompression for the management of sacral fractures. DESIGN: A review of 7 cases. SETTING: A university-affiliated tertiary care centre. PATIENTS: Seven patients with transverse fractures of the sacrum. The mean follow-up was 13 months. INTERVENTIONS: A review of the clinical data and a search of the literature for studies that reported on 4 or more patients with a transverse sacral fracture. MAIN OUTCOME MEASURES: Mechanism of injury, type of neurologic deficit and its management. RESULTS: The most common mechanism in the 7 study patients was a fall from a height. Six patients had neurologic deficits, mostly in the form of bowel or bladder disturbance. Five of these were treated with surgical decompression, and 4 of them had an improvement in neurologic function. The 7 original studies from the literature dealt with a total of 55 patients. As in the study patients, falls from a height and motor vehicle accidents predominated as the mechanisms of injury. In contrast to patients in this study, 20 of 48 patients in the literature review with neurologic deficits were treated conservatively. CONCLUSIONS: The outcomes in this study are similar to those reported in the literature. The place of surgical decompression for patients with neurologic deficit cannot be clearly determined from the evidence currently available.     

Synergistic effects of sildenafil on relaxation of rabbit and rat cavernosal smooth muscles when combined with various vasoactive agents.

OBJECTIVE: To evaluate which vasoactive agents have synergistic effects on the cavernosal smooth muscles of rabbits and rats when the agents are combined with sildenafil. MATERIALS AND METHODS: Relaxation responses of cavernosal smooth muscle to single agents (phentolamine, moxisylyte, sodium nitroprusside, forskolin, vasoactive intestinal peptide, VIP, papaverine and sildenafil) in the rabbit, and prostaglandin-E1 and sildenafil in the rat, and to combinations of each agent plus sildenafil, were assessed in vitro. The response to sildenafil of the rabbit strips with and without incubation with l-arginine (1 mmol/L) for 20 min was also evaluated. The effective concentrations for a half-maximal response of single agents and combination solutions were compared. RESULTS: All single agents induced concentration-dependent relaxation of the rabbit and rat cavernosal smooth muscles. There was significant synergism on rabbit cavernosal smooth muscle when the sildenafil was combined with forskolin, sodium nitroprusside, VIP or phentolamine. There was also significant synergism with sildenafil plus prostaglandin-E1 in rat cavernosal muscles. There were no synergistic effects of combinations of sildenafil plus moxisylyte, papaverine or l-arginine. CONCLUSIONS: These results suggest potentially effective combined therapies of sildenafil and intraurethral or intracavernosal prostaglandin-E1, intracavernosal forskolin or VIP, or oral phentolamine for patients with erectile dysfunction who have no success after monotherapy with these agents.     

Current status and future perspectives on chemotherapy in patients with gastric cancer: can the clinical data from Japan lead to a standard international therapy?]

From a meta-analysis of clinical studies in Japan and the West, although no survival benefit for stage I gastric cancer was observed in patients who received postoperative adjuvant chemotherapy, the survival benefit for patients with stage II and III disease was small and marginal effect, respectively, since the odds ratios were between 0.80 and 0.82 with a 95% confidence interval of less than 1.0. Anticancer drugs used for combination therapy included mitomycin C, anthracyclines, alkylating agents, and 5-fluorouracil. Increased long-term survival and the prevention of peritoneal recurrence were found in some patients who received combination therapy with mitomycin C, 5-fluorouracil, and nonspecific immunomodulators such as PSK and OK-432. Regarding chemotherapy for advanced and recurrent cases, administration of biochemical modulators such as low-dose FP and the new dehydropyrimidine dehydrogenase inhibitory fluoropyrimidine agent S 1 resulted in increased response rates, improved quality of life, and prolongation of survival. The development of rigorous trials and personalized chemotherapy with molecular targeting are needed to achieve further survival benefit for patients with gastric cancer.     

Retinoid signaling directs secondary lineage selection in pancreatic organogenesis

BACKGROUND/PURPOSE: Retinoid signaling plays an important role in many differentiation pathways. Retinoid signaling has been implicated in the induction of differentiation by pancreatic ductal cancer cell lines and in patients with pancreatic cancer. The authors wished to better understand the role of retinoid signaling in pancreatic development. METHODS: Embryonic pancreas was harvested from mice at serial gestational ages and immunohistochemical analysis was performed for retinoic acid receptors (RAR-alpha, RAR-beta, RAR-gamma), and retinoid X receptors (RXR-alpha, RXR-beta, and RXR-gamma). Also, early embryonic pancreases were cultured for 7 days with exogenous 9-cis retinoic acid (9cRA) or all-trans retinoic acid (atRA) and analyzed histologically and immunohistochemically. RESULTS: Retinoid receptors were expressed in a lineage-specific distribution, with stronger expression for many in the exocrine compartment. The receptors were not often expressed until late gestation. Exogenous 9cRA induced predominantly ducts instead of acini, plus more mature endocrine (islet) architecture. Exogenous atRA induced predominantly acini instead of ducts, with no apparent endocrine effect. CONCLUSIONS: Retinoids may have an important role in pancreatic differentiation, with a particular effect on secondary lineage selection between ductal and acinar phenotype. Because the control of ductal versus acinar differentiation has been implicated strongly in the pathogenesis of pancreatic ductal carcinoma, these results may lay the groundwork for studies in the mechanism of induced differentiation of pancreatic ductal cancer by retinoids.     

Subarachnoid--pleural fistulae--management with a transdiaphragmatic pedicled greater omental flap: report of two cases

STUDY DESIGN: This report describes the treatment of chronic subarachnoid--pleural fistulae using a pedicled greater omentum transfer flap. OBJECTIVE: To describe a new technique for the management of chronic subarachnoid--pleural fistulae resulting from thoracic dural tears. SUMMARY OF BACKGROUND DATA: Thoracic dural tears with leakage of cerebral spinal fluid into the pleural space can occur after thoracic spine surgery. The treatment of chronic subarachnoid--pleural fistulae using an omental flap, however, has not been reported. METHODS: The clinical, radiographic, and surgical details of two cases are described. RESULTS: Pedicled greater omentum transferred to the thoracic spine was an effective method in the treatment of intractable thoracic dural tears for two patients. CONCLUSION: These cases demonstrate that pedicled greater omentum transferred to the thoracic spine can be a safe and effective technique for the management of intractable thoracic dural tears and their complications.     

Renal biopsy in elderly patients: clinicopathological correlation in 117 Korean patients

AIM: In the elderly with renal disease, the clinical presentations are frequently inconsistent with the pathologic findings. We tried to clarify the differences in pathological findings between the young and the elderly, in Korea and in Western countries, and the usefulness of a percutaneous renal biopsy in the elderly with renal disease. PATIENTS AND METHODS: We analyzed the clinical presentations and spectrums of renal histopathology by reviewing medical records and renal biopsy reports retrospectively in 117 Korean patients aged 60 years or more with renal disease. RESULTS: 85 patients had primary renal disease. The remaining 32 patients had renal diseases associated with systemic conditions. Out of the 85 patients with primary renal disease, 61 cases presented as idiopathic nephrotic syndrome. Compared with renal biopsy results of younger adult patients (age 15-59, n = 1,908), membranous nephropathy, crescentic glomerulonephritis, membranoproliferative glomerulonephritis, amyloidosis, light chain disease, and thrombotic thrombocytopenic purpura were more prevalent, but IgA nephropathy and lupus nephritis were less common in the elderly patients. In clinical presentation, nephrotic syndrome and rapidly progressive renal failure were more prevalent, but asymptomatic urinary abnormality was less common in elderly patients. The responsiveness to treatment was good in elderly patients with minimal-change lesion (complete remission in all patients) but poor in crescentic glomerulonephritis, IgA nephropathy, and membranoproliferative glomerulonephritis. From the above findings, the clinical presentation, patterns of histopathology and responsiveness to treatment of elderly Korean patients were similar to those of the younger Korean control group and the Western elderly group. CONCLUSION: Percutaneous renal biopsy is a useful diagnostic aid and can be used as a therapeutic guideline even in elderly patients with renal disease.     

Alternative model for teaching microsurgery.

Animals have been widely used as a training model for teaching microsurgery. However, unlimited access to the animal laboratory is not always possible, and increased scrutiny of the ethical use of laboratory animals is a major factor to consider when teaching microsurgery. In such situations, an alternative method is required for microsurgical training techniques, such as medical grading tubes, and surgical gloves. These alternative teaching tools provide an ideal training model and present an alternative for teaching microsurgical techniques. They are readily available and abundant in the laboratory. In addition, these alternative tools can be used to provide initial training before entering the clinical setting. A practice card designed from surgical gloves and medical grading tube was used to practice simple sutures. The training progressed to a more difficult level, using medical-grade tubing for end-to-end anastomosis, end-to-side anastomosis, side-to-side anastomosis, and free graft placement. This alternative proved challenging for the trainees, but improved hand coordination was observed. The alternative models familiarized trainees with the instruments and with developing a surgical approach before moving on to more clinical settings. The use of surgical gloves and medical grading tubes resulted in a significant reduction in the numbers of laboratory animals used for teaching microsurgery, as well as reduced cost.     

Hemodynamic and catecholamine responses to laryngoscopy and tracheal intubation in patients with complete spinal cord injuries

BACKGROUND: Endotracheal intubation in patients undergoing general anesthesia often causes hypertension and tachycardia, which may be altered when the efferent sympathetic fiber to the cardiovascular system is interrupted. The aim of the current study was to investigate the effects of different levels of spinal cord injury on the cardiovascular responses to intubation. METHODS: Fifty-four patients with traumatic complete cord injuries requiring tracheal intubation were grouped into quadriplegics (above C7; n = 22), high paraplegics (T1-T4, n = 8), and low paraplegics (below T5, n = 24) according to the level of injury. Twenty patients without spinal injury served as controls. Arterial pressure, heart rate, and rhythm were recorded at intervals for up to 5 min after intubation. Plasma concentrations of catecholamines were also measured. RESULTS: The intubation increased the systolic blood pressure similarly in control, high-paraplegic, and low-paraplegic groups (P < 0.05), whereas it did not alter the blood pressure in the quadriplegic group. Heart rate was significantly increased in all groups; however, the magnitude was more pronounced in the high-paraplegic group (67%) than in the control (38%) and quadriplegic (33%) groups. Plasma concentrations of norepinephrine were significantly increased after intubation in all groups; however, values were lower in the quadriplegic group and higher in the low-paraplegic group compared with those in the control group. Incidence of arrhythmias did not differ among groups. CONCLUSIONS: The cardiovascular and plasma catecholamine changes associated with endotracheal intubation may differ according to the affected level in patients with complete spinal cord injuries.     

Pain after laparoscopic cholecystectomy: the effect and timing of incisional and intraperitoneal bupivacaine

PURPOSE: To examine the combined preemptive effects of somatovisceral blockade during laparoscopic cholecystectomy (LC). METHODS: One hundred fifty-seven patients under general anesthesia receiving local infiltration and/or topical peritoneal local anesthesia were studied. Patients were randomized to receive a total of 150 mg (0.25% 60 mL) bupivacaine via periportal (20 mL) and intraperitoneal (40 mL with 1:200,000 epinephrine) administration of each. Group A received preoperative periportal bupivacaine before incision and intraperitoneal bupivacaine immediately after the pneumoperitoneum. Group B received periportal and intraperitoneal bupivacaine at the end of the operation. Group C (preoperative) and Group D (postoperative) received only periportal bupivacaine and Group E (preoperative) and Group F (post-operative) received only intraperitoneal bupivacaine. The control group received no treatment. Pain and nausea were recorded at one, two, three, six, nine, 12, 24, 36, and 48 hr postoperatively. RESULTS: Throughout the postoperative 48 hr, incisional somatic pain dominated over other pain localizations in the control group (P <0.05). The incisional pain of groups A, B, C and D was significantly lower than that of the control group in the first and second hours. The incisional pain of groups A and C was significantly lower than that of the control group in the first three hours. CONCLUSION: Incisional pain dominated during the first two post-operative days after LC. Preoperative somato-visceral or somatic local anesthesia reduced incisional pain during the first three post-operative hours. A combination of somato-visceral local anesthetic treatment did not reduce intraabdominal pain, shoulder pain or nausea more than somatic treatment alone. Preoperative incisional infiltration of local anesthetics is recommended.