"Biorigid" interlocking after unreamed intramedullary nailing of tibial shaft fractures

Between April 1996 and December 1999, 76 tibial shaft fractures were treated at the Department of Trauma Surgery of the Justus-Liebig-University in Giessen, Germany and the Department of Orthopedic Surgery of the University of Louisville, USA with a newly developed, unreamed, solid, small diameter tibial nail interlocked "biorigidly" with screws in grooves of the nail. 69 Patients were reviewed with a minimal follow-up period of 16 months. In 65 patients, the fractures united without exchange nailing, although four of these fractures showed a delay of healing. In further four cases, non-union occurred, one of which was associated with the only break of a nail located at a distal interlocking groove of the nail. In one patient, a late medullary infection so far has not recurred following treatment. In 358 implanted interlocking screws, no implant failure was observed. First clinical experience suggests that, especially due to the low rate of material fatigue, the biorigid nail is an alternative to other implants for unreamed intramedullary nailing of the tibia.     

Contemporary cystectomy combined with ileal conduit or bladder substitution

Radical cystectomy remains one of the mainstay treatments for organ-confined invasive bladder cancer. Components of this surgery including the extent of pelvic lymph node dissection, the assessment of ureteric margins and the indications for bladder reconstruction as opposed to the simpler ileal conduit urinary diversion continue to provoke debate. This review provides a broad overview of radical cystectomy and summarises the options for bladder reconstruction. Special emphasis is given to data concerning the role of pelvic lymphadenectomy in the patient staged pre-operatively as N0M0.     

Coronary collateralization: determinants of adequate distal vessel filling after arterial occlusion

BACKGROUND: The protective effect of collateral vessels in coronary artery disease (CAD) is well established. Little is known, however, about factors that influence collateral formation. METHODS: We studied the coronary angiograms of 200 consecutive patients with single-vessel coronary artery occlusion. Patients were excluded if obstructive stenoses were present in other vessels or if prior revascularization had been undertaken. Collateral circulation to the occluded artery was graded as 'poor' (no or incomplete filling) or 'rich' (complete filling). Patient characteristics, including mode of presentation, medications and CAD risk factors, were assessed. RESULTS: Positive univariate correlates of rich collaterals included increasing age [odds ratio (OR) 1.03, P = 0.016], 'statin' use (OR 2.50, P = 0.005), nitrate use (OR 1.96, P = 0.034), calcium-channel blocker (CCB) use (OR 4.07, P < 0.001), presentation with stable angina (OR 2.34, P = 0.006), longer time since diagnosis of CAD (OR 1.12, P = 0.002) and history of hyperlipidemia (OR 3.55, P < 0.001). Significantly poorer collateralization was observed in the setting of acute myocardial infarction (MI) (OR 0.23, P < 0.001), diabetes mellitus (OR 0.33, P = 0.003), impaired left ventricular function (OR 0.64, P = 0.015) and occlusion of the left anterior descending coronary artery (LAD) (OR 0.28, P < 0.001). On multivariate analysis, rich collateralization was associated with hyperlipidemia (P = 0.003) and CCB use (P = 0.028). Independent predictors of poor collaterals were presence of diabetes (P < 0.001), LAD occlusion (P = 0.001) and presentation with acute MI (P = 0.017). CONCLUSION: Diabetes mellitus, occlusion of the LAD and presentation with acute MI are independently associated with poor distal vessel collateralization, whereas hyperlipidemia and use of CCBs are associated with rich collateralization. Factors determining coronary collateral formation may in turn influence outcomes after coronary artery occlusion.     

Evaluation of dosimetry of radioiodine therapy in benign and malignant thyroid disorders by means of iodine-124 and PET

The aim of this study was to evaluate the use of 124I positron emission tomography (PET) to determine the dosimetry of radioiodine therapy in hyperthyroidism and thyroid cancer. Phantom studies to assess the accuracy of PET were performed using an EEC phantom with spheres of different diameters filled with 3-30 MBq of 124I. Patient dosimetry was derived from PET data obtained 1-13 days after simultaneous oral administration of a therapeutic dose of 131I and a diagnostic dose of 124I. The obtained data were compared with findings from intratherapeutic probe measurements and clinical outcome. The phantom studies confirmed that 124I can be quantitated by PET (imprecision < or =10%), and volumetry is feasible for nodules <13 mm (imprecision < or =20%). Any influence of contamination with 123I or the simultaneous administration of 131I on the accuracy of the PET quantification and the probe measurements was ruled out by phantom measurements with solutions of 131I, 124I and 123I in various ratios. In autonomous nodular goitres, radioiodine uptake measured by PET varied from 25.4% to 64.3% and was not significantly different from that obtained by a scintillation probe (24.1%-73.1%, correlation coefficient r=0.91). Comparison of uptake and effective half-life in normal tissue versus autonomous nodules revealed significant differences in uptake but not in effective half-life [uptake 2.0-8.3 kBq/(ml x MBq) in normal tissue vs 12.6-29.3 kBq/(ml x MBq) in nodules; half-life 97.8-156.7 h in normal tissue vs 73.3-192.3 h in nodules]. Calculated radiation doses ranged between 177 and 633 Gy for autonomous nodules and between 47 and 126 Gy for normal tissue. In thyroid cancer patients, doses between 350 and 1,420 Gy were achieved in thyroid remnants and between 70 and 170 Gy in tumour metastases. It is concluded that 124I and PET are suitable for evaluation of the dosimetry of radioiodine therapy in benign and malignant thyroid diseases. The applied technique might be particularly useful for quantitative dose-response studies in radioiodine treatment and further investigations of stunning phenomena.     

Angiogenic proteins in the lungs of children after cavopulmonary anastomosis

OBJECTIVE: Pulmonary arteriovenous malformations may cause progressive cyanosis after cavopulmonary anastomosis and may develop as a result of abnormal angiogenesis. We used immunohistochemistry to determine whether angiogenic proteins are increased in the lungs of children after cavopulmonary anastomosis. METHODS: Lung specimens were obtained from 13 children after cavopulmonary anastomosis and from 6 control subjects. Specimens were stained with antibodies against vascular endothelial growth factor and its receptor (flk-1/KDR), basic fibroblast growth factor, alpha-smooth muscle actin, CD31, collagen IV, fibronectin, and proliferating cell nuclear antigen. Staining was graded on a scale of 0 to 3. Vessels positive for proliferating cell nuclear antigen were counted in 10 fields per specimen, and the results were averaged. RESULTS: After cavopulmonary anastomosis, patients demonstrated increased staining for vascular endothelial growth factor (P =.03) and its receptor (P =.03) and decreased staining for CD31 (P =.004). Proliferating cell nuclear antigen staining in patients was equivalent to that for control subjects (P =.9). CONCLUSIONS: Lung biopsy specimens from children after cavopulmonary anastomosis demonstrate increased expression of vascular endothelial growth factor and its receptor. These data confirm earlier findings that blood vessels forming after cavopulmonary anastomosis may have reduced intercellular junctions (decreased CD31 staining). Despite the increased numbers of pulmonary vessels that are present in these patients, these vessels are not highly proliferative (proliferating cell nuclear antigen staining equivalent to that of control subjects). These results suggest that vascular endothelial growth factor may be a mediator of angiogenesis in the lungs of children after cavopulmonary anastomosis; however, other factors, such as vascular dilation and remodeling, may also be important.     

Elevation of the upper part of the body in acute craniocerebral traumas. Possibilities and limits of intensive therapy

13 cases of severe cerebral trauma were subjected to varying degrees of elevation of the upper trunk (0 degrees, 15 degrees, 30 degrees, 45 degrees) and to head-raising only (0 degrees, 15 degrees, 30 degrees). The intracranial pressure and mean arterial pressure were measured in these positions. On raising the upper half of the body by 15 degrees, intracranial pressure fell from a mean of 35.3 mm Hg to 28.7 mm Hg, and to 25.2 mm Hg on raising to 30 degrees. Further elevation to 45 degrees resulted in an increase in pressure. In contrast, the mean arterial pressure fell constantly as elevation increased, resulting in a decrease in cerebral perfusion pressure at levels above 30 degrees. In no cases did raising of the head alone result in a lowering of pressure. Instead, potentially dangerous increases were observed.     

"Home treatment" for mental illness. Concept definition and effectiveness

A number of projects have used home treatment (HT) for severely mentally ill people in recent years. This paper intends to define HT and show the main differences between it and other forms of psychiatric community service, present the existing evidence for HT, and discuss eligibility criteria. Studies about HT's efficacy in treating severely mentally ill adults were identified by electronic (MEDLINE, PsycLIT) and manual search. Six studies met these inclusion criteria. Compared to inpatient treatment, HT was equally or more efficacious in respect to reduction of symptom distress, social (re-)integration, and patient and carer satisfaction. Furthermore, direct costs for HT were often lower than for inpatient care. However, the number of relevant studies is limited and knowledge on the long-term effects of HT is sparse.     

Safety of coronary angioplasty to chronic total occlusions

Percutaneous transluminal coronary angioplasty (PTCA) of chronic total occlusions (CTO) is not performed routinely in some centres due to concerns of low procedural success rates and high rates of short-term complications. This retrospective study examines the safety of PTCA to CTO in 100 consecutive cases compared to 100 matched controls. Success rate was 79% for CTO versus 98% for controls (p<0.001), however 5% of CTO patients had a cardiac enzyme rise compared to 13% of controls (p<0.05) and 0% of CTO patients compared to 6% of controls had a significant enzyme rise (p=0.03). These results suggest that PTCA to CTO can be carried out successfully in the majority of patients with only a relatively small risk of myocardial necrosis.