Tariquidar-induced P-glycoprotein inhibition at the rat blood-brain barrier studied with (R)-11C-verapamil and PET.

The multidrug efflux transporter P-glycoprotein (P-gp) is expressed in high concentrations at the blood-brain barrier (BBB) and is believed to be implicated in resistance to central nervous system drugs. We used small-animal PET and (R)-11C-verapamil together with tariquidar, a new-generation P-gp modulator, to study the functional activity of P-gp at the BBB of rats. To enable a comparison with human PET data, we performed kinetic modeling to estimate the rate constants of radiotracer transport across the rat BBB. METHODS: A group of 7 Wistar Unilever rats underwent paired (R)-11C-verapamil PET scans at an interval of 3 h: 1 baseline scan and 1 scan after intravenous injection of tariquidar (15 mg/kg, n = 5) or vehicle (n = 2). RESULTS: After tariquidar administration, the distribution volume (DV) of (R)-11C-verapamil was 12-fold higher than baseline (3.68 +/- 0.81 vs. 0.30 +/- 0.08; P = 0.0007, paired t test), whereas the DVs were essentially the same when only vehicle was administered. The increase in DV could be attributed mainly to an increased influx rate constant (K1) of (R)-11C-verapamil into the brain, which was about 8-fold higher after tariquidar. A dose-response assessment with tariquidar provided an estimated half-maximum effect dose of 8.4 +/- 9.5 mg/kg. CONCLUSION: Our data demonstrate that (R)-11C-verapamil PET combined with tariquidar administration is a promising approach to measure P-gp function at the BBB.     

Fraktur einer Coalitio calcaneonavicularis

The causes of chronic posttraumatic ankle pain are manifold, ranging from ligament and tendon injuries and fractures to joint degeneration. Calcaneonavicular coalition, a bridge between the calcaneus and navicular bones, is a rare disease with an incidence below 1%. The morphology of this coalition is variable. It can occur as either a fibrous, cartilaginous or bony union of the involved bones. Symptoms usually occur in adolescence with chronic pain around the ankle, mainly lateral and anterior, following distortion trauma. Patients often claim to have a lateral ankle sprain. We report 2 cases of a fracture of the calcaneonavicular coalition as the cause of chronic posttraumatic ankle pain and demonstrate the characteristics of tarsal coalitions with a review of the literature.     

Evolution of the technique in the transanal pull-through for Hirschsprung's disease: effect on outcome

Background

The transanal pull-through has become the standard operation for Hirschsprung's disease in many pediatric surgical centers. Over the past 8 years, we have modified our technique by leaving a short—rather than a long—rectal cuff and by doing routine intraabdominal colonic biopsies through an umbilical incision before beginning the anal dissection. The aim of this study was to determine if these modifications have changed the outcome for children undergoing this operation.

Methods

A retrospective cohort study of all patients who underwent transanal pull-through by a single surgeon between 1997 and 2005 was conducted.

Results

There were 23 children who had a long cuff (10-15 cm) and 22 who had a short cuff (<2 cm). The short cuff group tended to be younger (25 ± 23 vs 139 ± 67 days; P < .05) and smaller (3.5 ± 0.7 vs 6.0 ± 2.7 kg; P < .05) at the time of surgery. The operating time was shorter (167 vs 186 minutes; P = .05) in the short cuff group. Outcomes were improved in the short cuff group, as evidenced by decreased hospital stay (1.9 ± 0.6 vs 2.7 ± 0.9; P < .05), decreased incidence of enterocolitis (9% vs 30%; P = .1), and lower incidence of narrowing requiring daily dilatations (5% vs 30%; P < .05). Preliminary colonic biopsy was performed on 18 of the 45 patients. This had no significant effect on narcotic use (66% vs 70%; P = .8) and did not increase operating time (174 ± 31 vs 179 ± 34 minutes; P = .6). Hospital stay was shorter in the umbilical biopsy group (1.9 ± 0.6 vs 2.6 ± 0.9 days; P = .006).

Conclusion

Results of the transanal pull-through have improved likely as a result of a combination of experience and use of a shorter rectal muscular cuff. The use of a preliminary colonic biopsy through an umbilical incision has not increased postoperative pain, prolonged operative time, or lengthened hospital stay.     

Operationen an thorakoabdominellen Aortenaneurysmen

Because of the aging population, the incidence of thoracoabdominal aortic aneurysms (TAAAs) will increase in the next decades. These aneurysms constitute a highly lethal disease, therefore requiring treatment to prevent rupture and subsequent death. However, open surgery comprises substantial morbidity (cardiac events, pulmonary complications, renal failure, paraplegia) and mortality, necessitating extensive preoperative risk evaluation. The surgical results of TAAA repair have significantly improved during the last two decades, mainly because of adjunctive measures such as left heart bypass, cerebrospinal fluid drainage, and spinal cord monitoring. Descending thoracic aneurysms are increasingly being treated by means of endovascular techniques. Endovascular repair of TAAAs with side-branch technology has recently begun, and with future technological innovation, this approach will determine future strategies. Meanwhile, hybrid procedures combining open and endovascular techniques will decrease the extent of surgical trauma. Long-term assessment will be necessary to establish the safety and efficacy of endovascular modalities. At present, open surgery is still the gold-standard treatment for TAAA, especially in (relatively) young patients with Marfan syndrome.     

Die Behandlung von Sehnenverletzungen an der Hand

Tendon injuries of the hand, especially flexor tendon injuries, should be treated by specially trained surgeons. Tendon injuries should be treated immediately to avoid joint stiffness or tendon adhesions, which arise predominantly at the tendon laceration. In addition to a professional operation, postoperative management is also important. As with surgery, specially trained physiotherapists should supervise the active or passive mobilization after tendon repair. A close cooperation between physiotherapist and physician is mandatory for an optimal result.     

Maligne entarteter perianaler Buschke-Löwenstein-Tumor Ausgedehnte abdominoperineale Rektumamputation und Rekonstruktion mit transpelvinem myokutanem M.-rectus-abdominis-Lappen

Introduction. The Buschke Löwenstein tumor (giant condyloma) in its perianal variant is an extremely rare disease caused by human papilloma virus. Although of histologically benign appearance, it infiltrates and destroys the surrounding tissue. There is a high risk of local recurrence and malignant transformation. The treatment of choice is wide surgical resection. Case. A 56-year-old woman presented with perianal giant condyloma infiltrating the rectum and vagina. The extensive soft tissue defect resulting from wide resection was filled with a transpelvic myocutaneous rectus abdominis flap. Histology showed a squamous cell carcinoma arising in the Buschke Löwenstein tumor with clear resection margins. Therefore, the patient was irradiated locally after uneventful primary wound healing. Conclusion. A simultaneous reconstruction of a large pelvinoperineal soft tissue defect with the transpelvic myocutaneous rectus abdominis flap allows primary healing, accelerated rehabilitation, and safe adjuvant radiotherapy without risk of serious radiation damage to the small bowel by preventing it from protruding into the pelvic defect.     

The diagnostic value of MRI in foot and ankle surgery

BACKGROUND: MRI is being used with increasing frequency and seems to have become more popular as a screening tool rather than as an adjunct to narrow specific diagnoses or plan operative interventions. Our hypothesis was that the rising accessibility of this test may be resulting in its overuse. METHODS: We retrospectively reviewed 221 consecutive patients referred over a 3-month period for treatment of a lower extremity problem to determine: (1) the number of patients who presented with an MRI already obtained from an outside source, (2) the number of patients who obtained an MRI from the foot and ankle specialist after referral, and (3) the number of times the foot and ankle specialist used these studies or found them helpful in the care of the patient. Fractures (20) were excluded. RESULTS: Of the 201 patients without fractures included in the study, 19.9% (40 of 201) had MRI scans during the course of their treatment; 15.4% (31 of 201) presented to their initial visit with an MRI scan from an outside source, and 4.5% (9 of 201) received MRI scans as ordered by the foot and ankle specialist. Eighty-seven percent (27 of 31) of the pre-referral MRI scans were thought to be unnecessary, and 48.4% (15 of 31) had radiographic interpretations that were considered either immaterial to the patient's pertinent clinical diagnosis or inconsistent with the specialist's interpretations. All nine MRI scans ordered by the specialist were useful in the care of the patient. Therefore, of the 221 consecutive patients, the foot and ankle specialist would have ordered MRI scans in only 5.9% (13 of 221). CONCLUSIONS: This study suggests that many of the pre-referral foot or ankle MRI scans obtained before evaluation by a foot and ankle specialist are not necessary. Further studies need to be performed to determine the role of MRI in the screening of foot and ankle disorders.     

Sonographic appearance of focal thyroiditis

OBJECTIVE: The purpose of this study is to report the sonographic appearance of focal thyroid nodules that prove to be lymphocytic thyroiditis on fine-needle aspiration. CONCLUSION: In a patient population undergoing sonography for palpable nodular disease without known thyroiditis, focal nodules of thyroiditis had a wide variety of appearances. They most commonly appeared as solid hyperechoic nodules with ill-defined margins. However, the echogenicity was variable, and calcification and cystic-appearing regions were also noted. The vascularity of these nodules as assessed with color Doppler and power Doppler sonography also varied widely. Biopsy of these lesions is still necessary because there are no sonographic features that can reliably diagnose these lesions as thyroiditis and differentiate them from other lesions.     

Comparative detectability of bone metastases and impact on therapy of magnetic resonance imaging and bone scintigraphy in patients with breast cancer.

OBJECTIVE: to evaluate the comparative impact of magnetic resonance imaging and bone scintigraphy in bone metastases of breast cancer. METHODS AND PATIENTS: in 81 patients with histologically proven breast cancer magnetic resonance imaging of the axial skeleton and whole-body bone scintigraphy had been performed. Images were retrospectively reviewed and compared for detection of metastases, extent of metastatic disease and therapeutic implications according to the patients' records. RESULTS: about 54/81 (67%) patients revealed bone metastases. In 7/54 (13%) patients with bone metastases, scintigraphy was false negative. In one patient a solitary sternal metastases was seen. In 26/53 [49%] patients with spinal metastases, magnetic resonance imaging showed more extensive disease. Local radiotherapy or surgery was indicated in ten patients with metastases not evident in bone scintigraphy, in 20 patients with positive results by both imaging modalities and in six patients with metastases of pelvis imaged by bone scintigraphy only. CONCLUSION: magnetic resonance imaging of the axial skeleton and pelvis appears superior for staging as only one patient had metastases merely outside the axial skeleton and local therapy was indicated even in spinal regions negative in bone scintigraphy.     

Principes généraux de la prise en charge hospitalière de la prééclampsie

The management of the PE patient requires admission in order to perform a meticulous assessment of the mothers’ and fetal state, distinguishing between the severe and the mild forms.