Comparison of conventional and highly-sensitive troponin I measurement in ultra-marathon runners

Cardiac troponins are a mainstay in the diagnostic approach of patients with suspected acute coronary syndrome. Along with other causes of cardiac injury, strenuous aerobic exercise is an important source of troponin leakage from myocardium. Due to recent immunoassays development, there is no information on variation of highly-sensitive (HS) troponin I (TnI) in ultra-marathon runners. We studied 15 healthy trained Caucasian athletes before and immediately after completion of a 60 km, ultra-marathon. TnI was measured with both the conventional AccuTnI and the novel HS-AccuTnI immunoassays. At the end of the ultra-marathon the concentration of HS-AccuTnI significantly increased from the baseline value (19.2 ± 4.2 vs. 5.2 ± 0.8 ng/l; P = 0.001). The number of athletes displaying HS-AccuTnI values exceeding the 99th percentile of the reference limit was 2 (13%) pre-exercise, increasing significantly to 12 (80%; P < 0.001) post-exercise. Measurable value of AccuTnI were found in 1 (7%) and 12 (80%; P < 0.001) athletes pre- and post exercise, respectively. All AccuTnI values were below the 99th percentile reference limit pre-exercise, whereas this cut-off was overcome in 20% of athletes, post-exercise. These results suggest that the myocardium release of TnI during strenuous aerobic exercise mirrors that of troponin T. Moreover, the improved sensitivity of the HS-AccuTnI over the conventional assay makes it more suited for detecting even minor elevations of TnI in blood.     

Masked hypertension and echocardiographic left ventricular hypertrophy: an updated overview

Masked hypertension (MH) is an emerging clinical entity predisposing to subclinical organ damage and to increased cardiovascular risk. We sought to review the recent literature focusing on the association between MH and echocardiographic left ventricular hypertrophy (LVH). A MEDLINE search was performed in order to identify relevant papers using the key words such as 'masked hypertension', 'ambulatory hypertension', 'left ventricular hypertrophy', 'cardiac damage', 'target organ damage', 'left ventricular dysfunction'. Full articles published in English language in the last decade, namely from 1 December 1999 to 31 July 2011, reporting studies in adult or elderly individuals, were considered. Checks of the reference lists of selected papers complemented the electronic search. A total of 13 studies, including 966 patients with MH (sample size range 17-222 patients, mean age range 30-70 years; men 71%) and 2640 controls with sustained normotension, controlled hypertension, and white coat hypertension were considered. The prevalence of LVH, defined according to six criteria, ranged from 7 to 66% in MH and from 0.4 to 42% in non-MH counterparts (average 29 vs. 9%, P<0.01). In conclusion, available evidence linking a selective blood pressure elevation outside office to echocardiographic LVH in clinically normotensive individuals is supported by limited evidence. Further studies are needed to expand our knowledge in this area and to explore the beneficial effects of antihypertensive treatment on subclinical cardiac damage in patients with MH.     

Videocapillaroscopy study of post traumatic lower limb loss of tissue treated with and without acellular dermal substitute

A 46 years old male with a post traumatic loss of tissue localized on the anterior surface of the right thigh and knee due to a road accident, was treated with different surgical reconstructive techniques. Combined use of autologous skin graft and acellular dermal substitute Integra? allowed the satisfactory recovery of the patient who was discharged after 82 days from the trauma. To analyse the characteristics and the quality of the healing tissues we performed a videocapillaroscopy study to assess the microcirculatory pattern of the autologous skin grafted on the dermal substitute in comparison with the autologous skin grafted on granulation tissue. The videocapillaroscopy was performed in the zone skin grafted directly on granulation tissue, Zone 1 (Z1); on the region of the lesion in the knee, treated with dermal substitute and autologous skin graft, Zone 2 (Z2), and on the undamaged controlateral knee skin. Zone 3 (Z3). The results showed that the capillary density was similar between Z2 and Z3, while in Z1, the zone skin grafted on the granulation tissue without Integra? the capillary density was significatively reduced. These preliminary observations within the clinical data may be an useful contribute to better understand the tissue healing process.     

Can Bridge to Recovery Help to Reveal the Secrets of the Failing Heart?

Despite several decades of research and clinical experience, the basic mechanisms of the failing heart remain largely a secret. While pharmacological therapy can induce limited reverse remodeling, left ventricular assist device (LVAD) therapy offers the opportunity to induce significant improvements to the structure and function of the heart, with major clinical implications. LVAD therapy also provides significant insight into which changes have an impact on function and which do not, and could therefore reveal some of the secrets of the failing heart. In addition, LVAD-induced mechanical unloading may unlock further myocardial properties hitherto unknown such as the proliferation of the stem cell compartment. It may also serve as an important platform for emerging therapies such as gene and cell therapies. In this review, we highlight the most recent novel discoveries related to LVAD therapy and bridge to recovery (BTR). Discovering the integrated network of events that underlies BTR could unravel the secrets of the failing heart.     

Treatment of type III middle phalangeal neck fractures through a palmar approach: a case report

Phalangeal neck fractures occur almost exclusively in children. We present the case of a 49 years old man with a dislocated fracture of the neck of the middle phalanx with the distal fragment rotated at 180°, due to a traumatic circular saw injury to the left index, which was solved by anatomical reduction and bone fixation with two 1.5 mm Synthes screws and a temporary transarticular Kwire at the distal interphalangeal joint. Zone Iflexor digitorum profundus repair was performed using a modification of the Kessler 4-strands core suture and a full-thickness skin graft from the hypothenar eminence was taken to cover the skin gap. At 6-month follow-up the patient was pain-free and with a total active movement equivalent to 190°. No radiological signs of avascular necrosis of the head of the middle phalanx or nonunion of the distal fragment was detectable with recovery to the previous manual work. Owing to the position of the phalangeal head maintained in position by the collateral ligaments an anatomic reduction from dorsal approach is difficult to be performed and a longitudinal traction can render the reduction harder too. The volar approach permits an easier reduction of the fracture through a derotation of the distal fragment facing palmar.     

Lower pole stones: prone PCNL versus supine PCNL in the International Cooperation in Endourology (ICE) group experience

Purpose

To assess efficacy and safety of prone- and supine percutaneous nephrolithotomy (PCNL) for the treatment of lower pole kidney stones.

Methods

Data from patients affected by lower pole kidney stones and treated with PCNL between December 2005 and August 2010 were collected retrospectively by seven referral centres. Variables analysed included patient demographics, clinical and surgical characteristics, stone-free rates (SFR) and complications. Statistical analysis was conducted to compare the differences for SFRs and complication rates between prone- and supine PCNL.

Results

One hundred seventeen patients underwent PCNL (mean stone size: 19.5 mm) for stones harboured only in the lower renal pole (single stone: 53.6 %; multiple stones: 46.4 %). A higher proportion of patients with ASA score ≥ 3 and harbouring multiple lower pole stones were treated with supine PCNL (5.8 vs. 23.1 %; p = 0.0001, and 25 vs. 81.5 %; p = 0.0001, respectively, for prone- and supine PCNL). One-month SFR was 88.9 %; an auxiliary procedure was needed in 6 patients; the 3-month SFR was 90.2 %. There were 9 post-operative major complications (7.7 %). No differences were observed in terms of 1- and 3-month SFRs (90.4 vs. 87.7 %; p = 0.64; 92.3 vs. 89.2 %; p = 0.4) and complication rates (7.6 vs. 7.7 %; p = 0.83) when comparing prone- versus supine PCNL, respectively.

Conclusions

The results confirm the high success rate and relatively low morbidity of modern PCNL for lower pole stones, regardless the position used. Supine PCNL was more frequently offered in case of patients at higher ASA score and in case of multiple lower pole stones.     

A minimally invasive technique for surgical treatment of hallux valgus: simple, effective, rapid, inexpensive (SERI)

Purpose

Several bony and soft tissue procedures have been described for the treatment of hallux valgus, and currently mini-invasive surgical techniques are preferred in order to reduce surgical trauma, complications, time of surgery and to allow an earlier recovery. The aim of this study is to analyse a series of 1,000 consecutive cases of hallux valgus, surgically treated by the minimally invasive SERI technique, reporting results at mid-term follow-up.

Methods

We prospectively studied 641 patients (1,000 feet) with symptomatic hallux valgus surgically treated by SERI osteotomy. Inclusion criteria were: age between 20 and 65 years, reducible mild or moderate hallux valgus, HVA ≤ 40°, IMA ≤ 20°, and arthritis of the first metatarsophalangeal joint up to grade 2 according to the Regnauld classification.

Results

The American Orthopaedic Foot and Ankle Society (AOFAS) score rose from 46.8 ± 16.7 preoperatively to 89 ± 10.3 at last follow-up. Radiographic control at follow-up showed a complete healing of the osteotomy and remodelling of the metatarsal bone. Low rate of complication has been reported.

Conclusions

This study demonstrated that the SERI technique is effective in treating mild to moderate hallux valgus in terms of relief from symptoms and functional improvement. This technique allowed correction of the main parameters of the deformity, with durable clinical and radiographic results at a mid-term follow-up.

Electronic supplementary material

The online version of this article (doi:10.1007/s00264-013-1980-8) contains supplementary material, which is available to authorized users.     

Acute complications after laparoscopic bariatric procedures: update for the general surgeon

Background

Development and widespread use of laparoscopic bariatric surgery exposes emergency room physicians and general surgeons to face acute or chronic surgical complications of bariatric surgery.

Methods

The most common surgical emergencies after bariatric surgery are examined based on an extensive review of bariatric surgery literature and on the personal experience of the authors' practice in four high-volume bariatric surgery centers.

Results

An orderly stepwise approach to the bariatric patient with an emergency condition is advisable. Resuscitation should follow the same protocol adopted for the non-bariatric patients. Consultation with the bariatric surgeon should be obtained early, and referral to the bariatric center should be considered whenever possible. The identification of the surgical procedure to which the patient was submitted will orient in the diagnosis of the acute condition. Procedure-specific complication should always be taken into consideration in the differential diagnosis. Acute slippage is the most frequent complication that needs emergency treatment in a laparoscopic gastric banding. Sleeve gastrectomy and gastric bypasses may present with life-threatening suture leaks or suture line bleeding. Gastric greater curvature plication (investigational restrictive procedure) can present early complications related to prolonged postoperative vomiting. Both gastric bypass and bilio-pancreatic diversion may cause anastomotic marginal ulcer, bleeding, or rarely perforation and severe stenosis, while small bowel obstruction due to internal hernia represents a surgical emergency, also caused by trocar site hernia, intussusceptions, adhesions, strictures, kinking, or blood clots. Rapid weight loss after bariatric surgery can cause cholecystitis or choledocholithiasis, which are difficult to treat after bypass procedures.

Conclusions

The general surgeon should be informed about modern bariatric procedures, their potential acute complications, and emergency management.