Reverse dorsal digital and intercommissural flaps used for digital reconstruction.

Reverse dorsal digital and intercommissural flaps offer a simple and versatile option for skin cover of distal finger defects, especially when other local flaps are not available. Twenty-one reverse dorsal digital flaps were used, on an outpatient basis, to cover dorsal soft tissue defects over or beyond the PIP joint. All the flaps were transposed as reverse island flaps. The average size of the defects was 2.5 cm(2) and they were all used to cover exposed tendon, bone, joint or a combination. Twenty flaps survived completely and did not present any feature of circulatory difficulty. Marginal necrosis of one flap was noticed, while two patients complained of swollen finger 6 months later. No morbidity was reported and the patients maintained good range of motion. Various other types of flaps that have been used to reconstruct distal digital skin defects are reviewed and compared with the reverse dorsal digital and metacarpal flaps.     

Primary paratesticular adult ganglioneuroma

Granulocytic sarcoma is a rare tumor composed of neoplastic blood cells, typically occurring during the course of, or before the onset of, acute nonlymphoblastic leukemia. We present a case of a 37-year-old man with acute testicular pain who was found to have a testicular mass diagnosed as granulocytic sarcoma (GS). Because GS virtually always progresses to leukemia, he underwent postoperative radiotherapy and chemotherapy. He was free of disease 6 months after treatment. This case highlights a rare hematologic cancer that urologists and pathologists should be aware of because it can present as a testicular mass.     

Genetic background of osteonecrosis: associated with thrombophilic mutations?

Intravascular coagulation is considered a major pathogenetic mechanism for nontraumatic osteonecrosis. The aim of our study was to evaluate the association of thrombophilic factor V G1691A mutation (factor V Leiden) and G20210A prothrombin mutation with the disease. Mutation presence was investigated by polymerase chain reaction techniques in a study population of 72 adult Caucasian patients with osteonecrosis of the femoral head and 300 healthy Caucasian control subjects. The disease was considered idiopathic in 23 patients and secondary in 49. The factor V Leiden mutation was present in 18% of patients, compared with 4.6% of control subjects, resulting in a statistically significant odds ratio of 4.5. The prothrombin mutation was not significantly increased in the idiopathic osteonecrosis subgroup (8.7% versus 2.6%) with an odds ratio of 3.5. Overall, either of these coagulation disorders was present in 22.2% of patients and in 7.3% of control subjects resulting in a significant odds ratio of 3.6. Factor V Leiden, a genetic risk factor for venous thrombosis, is associated with nontraumatic osteonecrosis of the femoral head, supporting the hypothesis that intravascular coagulation is a major pathogenetic mechanism of the disease.     

The mosaic of equestrian-related injuries in Greece

BACKGROUND: This study aims to estimate the burden and describe the profile of equestrian injuries in Greece, where horses, donkeys, and mules are still used in agriculture and where horse riding is a popular leisure activity. METHODS: Prospectively collected information on 140,823 injuries reported in the national Emergency Department Injury Surveillance System was examined and 244 equestrian-related injuries that occurred during farming, equestrian sports, or horse racing were analyzed. RESULTS: The estimated countrywide injury incidence for farming and equestrian sports combined was 21 per 100,000 person-years, but it was 160 times higher for horse-racing personnel. Men had higher rates of racing injuries and women had higher rates of equestrian sport injuries. Fractures accounted for 39.0% of injuries in horse racing and 30.5% in farming; head injuries accounted for approximately 50% of injuries among farmers. Farming injuries were more serious, with 25% requiring hospitalization. Analysis through the Barell matrix pointed to the role of spurs in the causation of ankle fractures and dislocations and the likely contribution of helmets in preventing traumatic brain injuries. CONCLUSION: Equestrian-related injuries are a serious but underappreciated health problem and merit targeted prevention efforts for each category affected.     

Carboplatin-based chemotherapy for refractory and recurrent Ewing's tumours

BACKGROUND: Failure of first line therapy for the Ewing's family of tumours (EFT) is associated with a very poor outlook. Studies of second line chemotherapy are therefore necessary to identify active agents and drug combinations. Cisplatin-based therapy is frequently used in these circumstances but there are few studies to clearly define activity and toxicity. This report details outcome in a cohort of patients with poor risk EFT treated with a carboplatin-based combination. PROCEDURE: Between 1990 and 1998, 23 males and 16 females aged between 6 and 48 years (median 23) with relapsed or refractory EFT were treated with carboplatin-based chemotherapy. Previous chemotherapy had included ifosfamide and doxorubicin in all but two patients. Twenty patients were treated at the time of recurrence, and 19 after a poor response to initial chemotherapy. Treatment comprised of carboplatin to give an area under the plasma carboplatin concentration versus time curve of (AUC) 6 mg/ml, etoposide 120 mg/m2 for 3 days, and cyclophosphamide 500-750 mg/m2 for 2 days, repeated every 21 days. RESULTS: A total of 105 cycles were given, median 2 per patient (range 1-5). Overall response was 26%, with one complete response and nine partial responses. Median time to progression was 10 weeks (range 2-54). Haematological toxicity was severe requiring dose reductions in 53% of patients. Six patients proceeded to high dose consolidation treatment with bone marrow or peripheral stem cell rescue. CONCLUSIONS: This combination results in a substantial response rate in previously treated patients but with significant toxicity. Responses are, however, relatively short.     

Sex differences in temporal summation of pain and aftersensations following repetitive noxious mechanical stimulation

The SF-36 is a well-validated health status instrument measuring eight different health concepts. One aim of this study was to compare health status as measured by SF-36 in subjects from the general population with no chronic pain (NCP), chronic regional pain (CRP), and chronic widespread pain (CWP). A second aim was to assess if SF-36 could reflect changes in pain status over time. A third aim was to study if health status at baseline, measured by SF-36, could predict pain status 3 years later. The study was designed as a 3-year follow up with a postal questionnaire, including the SF-36 health survey, to 2357 subjects from the general population aged 20-74 years. The results were controlled for age, sex, co-morbidity, and socio-economic status. At baseline, all eight health concepts of SF-36 discriminated between subgroups with NCP, CRP and CWP. Changes in SF-36 over the 3-year follow up time coincided with improvement or deterioration of pain status. Baseline SF-36 scores predicted pain outcome 3 years later. These results support that both physical and mental aspects of health status as measured by SF-36 are affected by the burden of musculoskeletal pain, are sensitive to changes in pain status, and also predict the further development of pain.     

Can Patients' Likelihood of Benefiting from Primary Chemotherapy for Breast Cancer Be Predicted Before Commencement of Treatment?

PURPOSE: Primary chemotherapy is commonly used in patients with breast cancer to downstage the primary tumour prior to surgery. There is a need to establish, prior to commencement of chemotherapy, predictors of clinical and pathological response, which may then be surrogate markers for patient survival and thus allow identification of patients who are most likely to benefit from such treatment. PATIENTS AND METHODS: A total of 104 patients with large and locally advanced breast cancers received an anthracycline/docetaxel-based regimen prior to surgery. Immunohistochemistry was carried out on pre-treatment core biopsies of the tumour to detect hormone receptors (oestrogen-ER; progesterone-PR), a proliferation marker (MIB-1), the oncoprotein Bcl-2, an extracellular matrix degradation enzyme (cathepsin D), p53, and an oestrogen associated protein (pS2). Both clinical and pathological response were assessed following completion of chemotherapy. RESULTS: Patients whose tumours did not express oestrogen receptor (p = 0.02) or did not express Bcl-2 (p < 0.01) had a better pathological response in a univariate analysis. However, in a multivariate model, it was only the absence of detectable Bcl-2 protein that predicted a better pathological response (p = 0.001). CONCLUSIONS: This study has identified that patients whose breast cancers are most likely to experience the greatest degree of tumour destruction by primary chemotherapy do not express either oestrogen receptors or Bcl-2. This may have important implications in the selection of patients with breast cancer for primary chemotherapy who are most likely to gain a survival benefit.     

Raloxifene decreases serum IGF-I in male patients with active acromegaly

OBJECTIVE: Most patients with acromegaly require additional treatments after trans-sphenoidal surgery. Although traditional methods of treatment aim at suppressing GH hypersecretion from the pituitary tumor, recent studies on the use of the GH receptor antagonist have shown that targeting the action of GH on peripheral tissues may be more effective. Estrogens and the selective estrogen receptor modulator tamoxifen have been used previously to suppress circulating IGF-I levels in patients with acromegaly. Positive effects of raloxifene in women with active acromegaly have been reported recently. This study was designed to examine the potential role of raloxifene in the treatment of acromegaly in male patients. DESIGN: We studied eight men with active acromegaly despite the fact that they were receiving traditional treatments. All subjects were treated with raloxifene (60 mg twice a day) for a median of 5 weeks. METHODS: The effects of raloxifene on GH secretion were assessed by obtaining 24-h GH profiles and studying the response of GH to various stimuli before and after treatment with raloxifene. Serum IGF-I was measured before and after raloxifene treatment. RESULTS: Raloxifene did not affect basal GH secretion or response of GH to TRH, GHRH or glucose, but it decreased circulating IGF-I by 16+/-4% (P=0.001), and normalized plasma IGF-I in two patients. No changes in clinical parameters were observed. Prolactin levels, the prolactin response to TRH and free testosterone levels remained unchanged. Raloxifene was well tolerated. CONCLUSION: Raloxifene might be useful in the treatment of male patients with active acromegaly, but longer term studies are clearly needed.     

Comparison of long-term effect of coronary artery bypass grafting in patients with ischemic cardiomyopathy with viable versus nonviable left ventricular myocardium

In this study, 63% of patients with a substantial amount of viable myocardium showed an increased left ventricular ejection fraction (LVEF) 12 +/- 3 months after coronary artery bypass grafting. In 93% of these patients, increased LVEF persisted at 4.5 +/- 1 years of follow-up. Conversely, in nonviable patients, LVEF did not increase at 12 +/- 3 months or at follow-up of 4.5 +/- 1 years.