Lamivudine monotherapy and lamivudine plus interferon alpha combination therapy in HBeAg negative chronic hepatitis B not responding to previous interferon alpha monotherapy

BACKGROUND AND STUDY AIMS: To investigate the efficacy of the combined therapy of lamivudine (LAM) plus alpha interferon (IFN) and LAM monotherapy in HBeAg negative chronic hepatitis B (CHB) patients who were unresponsive to previous IFN monotherapy, and the incidence of YMDD mutations. PATIENTS-METHODS: Forty-five HBeAg negative patients were enrolled in this study. 24 of these were treated with LAM (100 mg/day, PO, for 24 months) alone (group 1) and 21 with combined therapy (IFN-alpha-2b, 10 MU, tiw, SC, for 6 months plus LAM 100 mg/day, PO, for 24 months) (group 2). Normal alanine aminotransferase values and negativity of HBV DNA (molecular hybridization; Digene, USA) were accepted as treatment response. YMDD variants were analyzed at the end of treatment or when clinical breakthrough was observed (Inno-Lipa Innogenetic kit, Belgium). RESULTS: End of follow-up response rate was 29.2%, by ITT in group 1, 19% in group 2 (p > 0.05). Histological activity index was statistically decreased by LAM monotherapy as compared to combination therapy. YMDD mutation rates were 59% in group 1, 62.5% in group 2 (p > 0.05). CONCLUSIONS: Additional IFN-alpha therapy to LAM in HBeAg negative CHB not responding to previous IFN-alpha monotherapy does not increase the response rate compared to LAM monotherapy and does not also decrease the incidence of YMDD mutations.     

Dexmedetomidine attenuates the hemodynamic and neuroendocrinal responses to skull-pin head-holder application during craniotomy

We tested dexmedetomidine, an alpha2 agonist, for its ability to decrease heart rate, arterial blood pressure, and neuroendocrinal responses to skull-pin head-holder application during craniotomy. In a randomized, double-blinded, placebo-controlled study, 40 patients undergoing craniotomy with attachment of a pin head-holder were randomly assigned to one of 2 equal groups. The placebo group received saline, whereas the treatment group (DEX group) received a single bolus dose of dexmedetomidine (1 microg/kg) intravenously over 10 minutes before induction of anesthesia. Arterial blood pressure, heart rate, and sequential concentrations of circulating cortisol, prolactin, insulin, and blood glucose were measured. Relative to baseline and the other group, arterial blood pressure and heart rate decreased significantly after the administration of dexmedetomidine through skull pinning (P<0.05). In the placebo group, patients' heart rate and arterial blood pressure measures increased at 1 and 5 minutes after skull-pin insertion, compared with baseline and the DEX group (P<0.05). In both groups, plasma cortisol, prolactin, and blood glucose increased significantly relative to baseline after skull-pin insertion. However, the values were significantly higher in the placebo group compared with the DEX group (P<0.05). Although insulin levels were not significantly altered in the DEX group, the plasma concentrations of insulin decreased significantly after pin insertion in the placebo group. Our results suggested that, a single bolus dose of dexmedetomidine before induction of anesthesia attenuated the hemodynamic and neuroendocrinal responses to skull-pin insertion in patients undergoing craniotomy.     

Intermittent pneumatic sequential compression of the lower extremities restores the cerebral oxygen saturation during laparoscopic cholecystectomy

Background Pneumoperitoneum causes intracranial pressure elevation and blood stasis at lower extremities. This study investigates cerebral oxygen saturation changes during laparoscopy and the effects of intermittent sequential compression (ISC) of the lower extremities in patients during elective laparoscopic cholecystectomy. Patients and method Sixty patients were randomly divided into two groups according to the application of ISC to the lower extremities. Group I served as control group whereas ISC was applied to group II. Cerebral oxygen saturation, peripheral blood oxygen saturation, heart rate, mean blood pressure, and associated changes have been recorded during the operation. Results Peripheral blood oxygen saturation and mean blood pressure values did not change significantly after pneumoperitoneum. Cerebral oxygen saturation levels of the group II patients were higher in than the group I patients and the difference between the groups was statistically significant (p = 0.0001). The difference became more prominent following the 35^th minute of the operation. Mean heart rate of the patients in group II was lower than the patients in group I and the difference was also statistically significant (p = 0.0001). Conclusion In this study, it was found that the decrease in cerebral oxygen saturation was recovered with ISC application. This simple and reliable technique helps to restore cerebral oxygen saturation levels while increasing blood return from the lower extremities.     

Insufficiency fractures of both femoral necks in a young adult caused by osteoporosis: a case report

Insufficiency fractures of femoral necks due to osteoporosis of unknown aetiology occurring coincidentally on both sides in young adults, have not been described in English literature so far. A 18-year-old young girl presented with a 3-month history of gradual onset of bilateral thigh pain and progressive inability to walk. At the first look, plain radiographs of both hips showed no gross abnormal findings other than some tips on reduced bone mineral density of the femoral necks. MRI was ordered upon a high suspicion of fracture and T1-weighed MRI showed a linear low signal on both femoral necks. Dual-energy X-ray absorptiometry of the lumbar spine and femoral neck showed low mineral density. She was treated surgically with in-situ internal fixation using cannulated screws. The bilateral thigh pain was resolved and walking started immediately after the treatment. Insufficiency fracture of the femoral neck due to osteoporosis should be kept in mind even in young adults complaining of atypical pain without evidence of unusual activities. We used both the terms of stress fracture and insufficiency (osteoporotic) fracture interchangeably as the mechanism of fractures resemble each other.     

Sagittal plane analysis of the open and closed methods in children with displaced supracondylar fractures of the humerus (a radiological study)

OBJECTIVES: The aim of this study was to compare the radiological outcome of open and close reduction and osteosynthesis methods in the treatment of type II and III supracondylar humerus fractures in childhood with respect to the immediate post-operative reduction quality in sagittal plane. METHOD: One hundred and forty four-pediatric patients with type IIb and III supracondylar humerus fractures treated at two centers between 1995 and 2005 were evaluated radiologically within a retrospective study. Seventy-six patients (54 boys, 22 girls, mean age 7.6, range 2-12) were treated by closed reduction and cross percutaneous pinning while 68 (49 boys, 19 girls, mean age 7.3, range 2-13) were treated by open reduction. The reduction quality of the open and closed groups was compared on immediate post-operative lateral radiographs by measuring of lateral humerocapitellar angle, anterior humeral line and anterior coronoid line criteria. The reduction quality was classified excellent, good, fair and poor according to the achievement of three, two, one or none of the criteria, respectively. Reductions classified as excellent and good were introduced as acceptable results. RESULTS: At least one criterion was achieved in all the patients of both the groups. The mean humerocapitellar angle was 30.1 degrees in closed reduction group while the mean of it was 29.8 degrees in open reduced group. Radiograph of 48 (63.1%) patients with closed reduction were found to display the anterior humeral line intersecting the middle one-third of capitellum while this criteria was 45 (66%) in open reduction group. The anterior coronoid line was disturbed in three patients in each of both the groups. The reduction quality was evaluated to be excellent in 32 patients, good in 31, fair in 13 at the closed reduction group while these evaluations were 31, 20 and 17 in open reduction group, respectively. Successful reduction was achieved in 74.9% of the patients in closed reduction group and 75% of the patients in open reduction group. CONCLUSION: It is concluded that there was no significant difference between closed and open reductions of pediatric displaced supracondylar fractures with regard to the radiological criteria of reduction quality in sagittal plane.     

A giant extrasynovial osteochondroma in the infrapatellar fat pad: end stage Hoffa’s disease

The infrapatellar fat pad of Hoffa is commonly injured but rarely discussed in the orthopaedic literature. Hoffa’s disease is the extension of various traumatic events due to impingement and inflammation of the infrapatellar fat pad and known as a vague reason for anterior knee pain. Inflammation is foreground during acute phase of the disease while impingement due to fibrosis and scar tissue of infrapatellar fat pad plays a major role in the chronic phase. The osteochondroma of the infrapatellar fat pad secondary to the Hoffa’s disease can be more problematic. Although, the fibrocartilaginous transformation and osteochondral metaplasia of infrapatellar fat pad was pointed out frequently in the literature, the published papers seem far from clarifying the relation between chronic impingement and formation of osteochondroma. We present a case of a giant ossifying chondroma in the infrapatellar fat pad that resulted from chronic Hoffa’s disease. Complete open resection was performed successfully after arthroscopic examination. The infrapatellar fat pad contains the entire progenitor cells for the development of an osteochondroma and chronic impingement may have promoter affect on this issue, thus, an osteochondroma may occur at the end-stage Hoffa’s disease.