Divergent Effects of Glucocorticoids on Cortical and Trabecular Compartment BMD in Childhood Nephrotic Syndrome

Glucocorticoid (GC) effects on skeletal development have not been established. The objective of this pQCT study was to assess volumetric BMD (vBMD) and cortical dimensions in childhood steroid‐sensitive nephrotic syndrome (SSNS), a disorder with minimal independent deleterious skeletal effects. Tibia pQCT was used to assess trabecular and cortical vBMD, cortical dimensions, and muscle area in 55 SSNS (age, 5–19 yr) and >650 control participants. Race‐, sex‐, and age‐, or tibia length‐specific Z‐scores were generated for pQCT outcomes. Bone biomarkers included bone‐specific alkaline phosphatase and urinary deoxypyridinoline. SSNS participants had lower height Z‐scores (p < 0.0001) compared with controls. In SSNS, Z‐scores for cortical area were greater (+0.37; 95% CI = 0.09, 0.66; p = 0.01), for cortical vBMD were greater (+1.17; 95% CI = 0.89, 1.45; p < 0.0001), and for trabecular vBMD were lower (?0.60; 95% CI, = ?0.89, ?0.31; p < 0.0001) compared with controls. Muscle area (+0.34; 95% CI = 0.08, 0.61; p = 0.01) and fat area (+0.56; 95% CI = 0.27, 0.84; p < 0.001) Z‐scores were greater in SSNS, and adjustment for muscle area eliminated the greater cortical area in SSNS. Bone formation and resorption biomarkers were significantly and inversely associated with cortical vBMD in SSNS and controls and were significantly lower in the 34 SSNS participants taking GCs at the time of the study compared with controls. In conclusion, GCs in SSNS were associated with significantly greater cortical vBMD and cortical area and lower trabecular vBMD, with evidence of low bone turnover. Lower bone biomarkers were associated with greater cortical vBMD. Studies are needed to determine the fracture implications of these varied effects.     

Open vertebral cement augmentation combined with lumbar decompression for the operative management of thoracolumbar stenosis secondary to osteoporotic burst fractures

Osteoporotic burst fractures with neurologic symptoms are typically treated with neural decompression and multilevel instrumented fusion. These large surgical interventions are challenging because of patients' advanced ages, medical co-morbidities, and poor fixation secondary to osteoporosis. The purpose of this retrospective clinical study was to describe a novel technique for the treatment of osteoporotic burst fractures and symptomatic spinal stenosis via a limited thoracolumbar decompression with open cement augmentation [vertebroplasty (VP) or kyphoplasty (KP)]. Indications for decompression and cement augmentation were intractable pain at the level of a known osteoporotic burst fracture with symptoms of spinal stenosis. As such, 25 patients (mean age, 76.1 years) with low-energy, osteoporotic, thoracolumbar burst fractures (7 males, 18 females; 39 fractures) were included. In all cases, laminectomy of the stenotic level(s) was followed by vertebral cement augmentation (9 VP; 16 KP). When a spondylolisthesis at the decompressed level was present, instrumentation was applied across the listhetic level (n = 9). Clinical outcome (1 = poor to 4 = excellent) was assessed on last clinical follow-up (mean, 44.8 wks). In addition, a modified MacNab's grading criteria was used to objectively assess patient outcomes postoperatively. Radiographic analysis of sagittal contour was assessed preoperatively, immediately postoperatively, and at final follow-up. The average time from onset of symptoms to intervention was 19 weeks (range, 0.3-94 wks). A mean of 1.6 fractures/patient was augmented (range, 1-3 fractures) and 2.8 levels were decompressed (range, 1-6 levels). No statistical difference in anatomic distribution or number of fractures between the VP and KP groups or in the instrumented versus noninstrumented patients was noted (P > 0.05). An overall subjective outcome score of 3.4 was noted. Twenty of 25 patients were graded as excellent/good according to the modified MacNab's criteria. The choice of augmentation procedure or use of instrumentation did not predict outcome (P = 0.08). Overall, 1.7 degrees of sagittal correction was obtained at final follow-up. One patient was noted to have progressive kyphosis after KP. The use of a limited-posterior decompression and open cement augmentation via VP or KP is a safe treatment option for patients who have osteoporotic burst fractures and who are incapacitated from fracture pain and concomitant stenosis. After thoracolumbar decompression, open VP/KP provides direct visualization of the posterior vertebral body wall, allowing for safe cement augmentation of burst fractures, stabilizing the spine, and obviating the need for extensive spinal reconstruction. Although clinically successful, this technique warrants careful patient selection.     

Predictors of survival following open and endovascular repair of abdominal aortic aneurysms

Clinical decision making for asymptomatic abdominal aortic aneurysms (AAAs) weighs risk of aneurysm rupture, treatment hazards, and overall survival expectations. AAA diameter is the primary parameter in assessing rupture risk. Perioperative risk assessment has been extensively studied, and in-hospital mortality has been reduced to less than 8% with higher-risk open repair and less than 3% with endovascular repair. The purpose of this report is to determine risk factors that predict 2-year survival following open and endovascular AAA repair. We studied 334 patients enrolled in a multicenter clinical trial evaluating an endovascular graft in comparison to standard open repair of infrarenal AAA. Demographic, medical history, physical examination, laboratory, anatomic, procedural, and standardized risk score system variables were analyzed in a multivariable Cox proportional hazard model. Overall survival was 89% at 2 years. Heart disease, cancer, and stroke were the most common causes of death, and no deaths were due to AAA rupture. Cox modeling demonstrated that there were several independent predictors for death after AAA repair: smaller body mass index (p=0.005), Society for Vascular Surgery pulmonary risk score >or=1 (p=0.005), history of erectile dysfunction (p=0.008), history of heart valve replacement (p=0.008), lower preoperative platelet count (p=0.012), larger ratio of AAA diameter/proximal neck diameter (p=0.020), and lower ankle-brachial index (p=0.031). Age, gender, and open or endovascular treatment group are not significant independent risk factors for 2-year mortality in this study. Clinical, laboratory, and anatomic factors predict survival after open and endovascular repair of AAAs. With progressive reduction of in-hospital mortality, assessment of patient longevity after AAA repair has become a more important factor in clinical decision making. Use of valid predictors of patient survival will optimize resource utilization and improve overall patient outcomes. Better selection of patients for any method of repair may improve overall utility more than choice of open or endovascular techniques.     

Learning the lessons from conflict: Pre-hospital cervical spine stabilisation following ballistic neck trauma

Background

Current ATLS protocols dictate that spinal precautions should be in place when a casualty has sustained trauma from a significant mechanism of injury likely to damage the cervical spine. In hostile environments, the application of these precautions can place pre-hospital medical teams at considerable personal risk. It may also prevent or delay the identification of airway problems. In today's global threat from terrorism, this hostile environment is no longer restricted to conflict zones. The aim of this study was to ascertain the incidence of cervical spine injury following penetrating ballistic neck trauma in order to evaluate the need for pre-hospital cervical immobilisation in these casualties.

Methods

We retrospectively reviewed the medical records of British military casualties of combat, from Iraq and Afghanistan presenting with a penetrating neck injury during the last 5.5 years. For each patient, the mechanism of injury, neurological state on admission, medical and surgical intervention was recorded.

Results

During the study period, 90 casualties sustained a penetrating neck injury. The mechanism of injury was by explosion in 66 (73%) and from gunshot wounds in 24 (27%). Cervical spine injuries (either cervical spine fracture or cervical spinal cord injury) were present in 20 of the 90 (22%) casualties, but only 6 of these (7%) actually survived to reach hospital. Four of this six subsequently died from injuries within 72 h. Only 1 (1.8%) of the 56 survivors to reach a surgical facility sustained an unstable cervical spine injury that required surgical stabilisation. This patient later died as result of a co-existing head injury.

Conclusions

Penetrating ballistic trauma to the neck is associated with a high mortality rate. Our data suggests that it is very unlikely that penetrating ballistic trauma to the neck will result in an unstable cervical spine in survivors. In a hazardous environment (e.g. shooting incidents or terrorist bombings), the risk/benefit ratio of mandatory spinal immobilisation is unfavourable and may place medical teams at prolonged risk. In addition cervical collars may hide potential life-threatening conditions.     

Structural and functional analysis of the semitendinosus tendon after harvest for soft tissue reconstructive procedures: a dynamic ultrasonographic study

Purpose

To assess the potential for regeneration of the hamstring tendons after harvesting for various soft tissue reconstructive procedures, this study uses dynamic, high-resolution ultrasound to evaluate the presence of any tissue in the harvest gap and to characterize tissue functionality.

Methods

Patients who underwent ACL reconstruction using ipsilateral hamstring autograft were identified in the database of a single surgeon. Dynamic 12-MHz sonographic imaging was used to evaluate the ipsilateral and contralateral (control) semitendinosus tendons from their insertion sites to proximal muscle bellies. The presence or absence and echogenicity of tissue in the harvest defect, tissue appearance, degree of retraction of the proximal tendon stump, thickness of gap tissue, and motion of the proximal tendon stump were recorded. Data were analysed with Wilcoxon–Mann–Whitney, sign or binomial tests, with significance of P < 0.05.

Results

Eighteen knees in 15 patients (aged 17–51 years) were studied. The proximal amputated stump was retracted an average of 9.0 ± 7.6 cm (range, 0–18 cm; P = 0.0063). With dynamic testing, 9 of 15 knees demonstrated decreased excursion of the proximal tendon stump when compared to the native, contralateral muscle–tendon unit (P = 0.0039). Tissue was detected in the harvest gap in nine knees, five of which had harvest gap tissue with a disorganized appearance compared to the native tendon (P < 0.0001). Six of these nine knees had tissue in the gap demonstrating either less or no excursion with active knee flexion when compared to the native, contralateral side (P = 0.0313).

Conclusions

The presence of tissue in the harvest gap after ACL reconstruction is variable. When tissue is present, there is proximal retraction of the musculotendinous junction and disorganized appearance of the tissue that does not demonstrate normal excursion or physiological function similar to the native muscle-tendon unit.

Level of evidence

Case series, Level IV.     

Intraoperative hemostasis during spinal reconstructive procedures

In a consecutive sample of patients undergoing similar spinal reconstructive procedures in the thoracolumbar region, hemostatic effectiveness of a collagen-based composite (CoStasis; Cohesion Technologies, Palo Alto, Calif) n = 10) was compared with standard hemostatic methods (manual compression) (n = 9). All patients treated with CoStasis at the operative site(s) demonstrated immediate hemostasis,whereas all cases treated with gauze and sponges showed protracted bleeding (P < .01). The average perioperative blood loss was approximately twice as great among control patients compared to CoStasis patients (1322 mL versus 685 mL; P = .02). Total transfusion requirements and operative duration also were less among CoStasis patients. These findings suggest CoStasis may provide effective hemostasis in spinal reconstructive procedures such as instrumented fusion where blood loss is excessive.     

Short Bowel Syndrome After Continence-Preserving Procedures

The short bowel syndrome (SBS) can result from a variety of conditions, including postoperative complications and malignancy. Continence-preserving operations are generally performed for either ulcerative colitis (UC) or familial polyposis (FAP). These procedures can be associated with high morbidity and the potential for future malignancy. Our aim was to determine the causes and consequences of SBS in patients undergoing these procedures. Twenty-four patients (12 men and 12 women) 18 to 64 years of age were identified with SBS after continence-preserving procedures. Eighteen had pelvic procedures, and six had continent ileostomies. All SBS patients had a proximal ostomy. Remnant length measured <60 cm in five patients, 60–120 cm in ten patients, and >120 cm in nine patients. Overall 13 patients required long-term PN. Four FAP patients with desmoid tumors died. One patient with UC underwent intestinal transplant and expired. Follow-up ranges from 6 to 192 months. Overall 14 patients had UC, nine had FAP, and one had functional disease. Eight patients with an initial diagnosis of UC had subsequent Crohn’s disease necessitating further resection and pouch excision. Eight patients (five with UC, two FAP, and one with functional disease) had postoperative complications, including obstruction or mesenteric ischemia requiring resections. One UC patient developed adenocarcinoma in a continent ileostomy. Seven of the nine FAP patients required resection for desmoid tumors. Six of these underwent resection alone. Three died at 10, 11, and 13 months after SBS from liver failure and sepsis while awaiting transplant. One patient has recurrent desmoid at 30 months, another is alive and well at 48 months, and the other patient, who was not a transplant candidate, died from an unrelated cardiac operation at 23 months. A single patient underwent resection with simultaneous multivisceral transplantation. SBS can develop after continence-preserving procedures. This occurs with inflammatory bowel disease when unsuspected Crohn’s disease is present or complications occur. SBS related to desmoid tumors has a poor prognosis in patients undergoing resection alone. A more aggressive approach to intestinal transplantation in these patients may be warranted.     

A model for structuring the donor discussion in emergent transplant procedures

OBJECTIVE: To investigate the potential for maximizing organ and tissue donation by identifying an empirical basis for structuring donor discussions. DESIGN: Intentions to donate organs and tissues were recorded in 2 separate samples of participants and analyzed separately by using Guttman scaling, the second sample providing a replication of the findings from the first. PARTICIPANTS: 304 participants were recruited from the Royal Society Summer Science Exhibition 2004, and 200 health professionals were recruited from the Royal Free Hospital. RESULTD: High coefficients of scalability and reproducibility in both samples indicate a one-dimensional scale for intentions to donate organs and tissues, with solid organs more likely to be donated than corneal, hand, and facial tissue. Thus donor discussions can be structured in a robust order, with the potential for reliable use of cutoff points once donation of a particular organ or tissue has been refused. CONCLUSIONS: This reliable pattern can be used to maximize organ and tissue donation rates and to underpin emergent transplant techniques.     

Proctocolectomy–Ileal Pouch-Anal Anastomosis for Ulcerative Colitis After Liver Transplantation for Primary Sclerosing Cholangitis: A Multi-institutional Analysis

Background  The association between primary sclerosing cholangitis (PSC) and ulcerative colitis (UC) often mandates their contemporaneous management. Orthotopic liver transplantation (OLTX) has emerged as the only curative therapy for PSC, and total proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the definitive treatment for refractory UC. The published experience to date describing IPAA after OLTX has been limited; we sought to examine outcomes associated with proctocolectomy-IPAA after OLTX. Materials and Methods  We reviewed our multi-institutional experience performing proctocolectomy-IPAA for UC after OLTX for PSC. Results  Twenty-two patients underwent proctocolectomy-IPAA for UC after OLTX for PSC at four academic medical centers between 1989 and 2006. No perioperative complications or allograft dysfunction were observed. During a median follow-up of 52 months, complications have included transient dehydration (n = 6), chronic pouchitis (n = 2), recurrent PSC (n = 2), small bowel obstruction (n = 2), and pouch-anal anastomotic stricture (n = 1). Median 24-h stool frequency was 5, and fecal continence was reported as satisfactory by all patients. Conclusions  This multi-institutional experience suggests that proctocolectomy-IPAA can be performed safely after OLTX. Management strategies should include optimization of small bowel length during pouch and ileostomy construction, vigorous postoperative hydration, early ileostomy closure, and careful monitoring for pouchitis.     

Use of Gliadel (BCNU) Wafer in the Surgical Treatment of Malignant Glioma: A 10-Year Institutional Experience

Background  Gliadel (polifeprosan 20 with carmustine [BCNU] implant) is commonly used for local delivery of BCNU to high-grade gliomas after resection and is associated with increased survival. Various complications of Gliadel wafers have been reported but not consistently reproduced. We set out to characterize Gliadel-associated morbidity in our 10-year experience with Gliadel wafers for treatment of malignant glioma. Methods  We retrospectively reviewed records of 1013 patients undergoing craniotomy for resection of malignant brain astrocytoma (World Health Organization grade III/IV disease). Perioperative morbidity occurring within 3 months of surgery was assessed for patients and compared between patients receiving versus not receiving Gliadel wafer. Overall survival was assessed for all patients. Results  A total of 1013 craniotomies were performed for malignant brain astrocytoma. A total of 288 (28%) received Gliadel wafer (250 glioblastoma multiforme (GBM), 38 anaplastic astrocytoma/anaplastic oligodendroglioma (AA/AO), 166 primary resection, 122 revision resection). Compared with the non-Gliadel cohort, patients receiving Gliadel were older (55 ± 14 vs. 50 ± 17, P = .001) and more frequently underwent gross total resection (75% vs 36%, P < .01) but otherwise similar. Patients in Gliadel versus non-Gliadel cohorts had similar incidences of perioperative surgical site infection (2.8% vs. 1.8%, P = .33), cerebrospinal fluid leak (2.8% vs. 1.8%, P = .33), meninigitis (.3% vs. .3%, P = 1.00), incisional wound healing difficulty (.7% vs. .4%, P = .63), symptomatic malignant edema (2.1% vs. 2.3%, P = 1.00), 3-month seizure incidence (14.6% vs. 15.7%, P = .65), deep-vein thrombosis (6.3% vs. 5.2%, P = .53), and pulmonary embolism (PE) (4.9% vs. 3.7%, P = .41). For patients receiving Gliadel for GBM, median survival was 13.5 months after primary resection (20% alive at 2 years) and 11.3 months after revision resection (13% alive at 2 years). For patients receiving Gliadel for AA/AO, median survival was 57 months after primary resection (66% alive at 2 years) and 23.6 months after revision resection (47% alive at 2 years). Conclusion  In our experience, use of Gliadel wafer was not associated with an increase in perioperative morbidity after surgical treatment of malignant astrocytoma.