Epidural blood patch under fluoroscopic control: non-surgical treatment of lumbar cerebrospinal fluid fistula following implantation of an intrathecal pump system.

The treatment of lumbar cerebrospinal fluid fistula in the presence of an intrathecal catheter is known to be difficult. Open revision surgery is recommended in the literature, although the rate of recurrence is high. The epidural blood patch technique is well established as a successful treatment for post-dural-puncture headaches. Recent work about the distribution of the injected blood and theoretical considerations about the mechanism of action make this method suitable for the occlusion of spinal leakage even in the presence of an intrathecal catheter. In this note technical details are given for a successful therapy of lumbar cerebrospinal fluid fistula including the right positioning of the opening of the needle (cerebrospinal fluid can be expected intrathecally and epidurally) by injection of contrast medium first for myelography then for epidurography. In this procedure the (epidural) distribution of autologous blood can be indirectly controlled by compression of the dural sac. The method is easy to perform, and the possible risks are small.     

Eighteen years of liver transplantation experience in patients with advanced Budd-Chiari syndrome.

The long-term results of liver transplantation for Budd-Chiari syndrome (BCS) and timely indication for the procedure are still under debate. Innovations in interventional therapy and better understanding of underlying diseases have improved therapy strategies. The aim of this study was the analysis of patient and disease characteristics, outcome, and specific complications. Between September 1988 and December 2006 we performed 42 orthotopic liver transplantations (OLTs) in 39 patients with BCS. A total of 29 (74%) women and 10 men (26%) had a median age of 35 years; the median follow-up period was 96 months. Etiologically, 27 patients had a preoperative diagnosis of hematologic disease, including myeloproliferative disorders (MPD), followed by factor V Leiden mutation and antiphospholipid syndrome. The actuarial 5-year and 10-year survival rates were 89.4% and 83.5%, respectively, compared to 80.7% and 71.4%, respectively, for other indications (n = 1742). Retransplantation was necessary in 3 patients (7.1%) with portal vein thrombosis or recurrent BCS. Although the number of bleeding events was similar, incidence of vascular complications was significantly higher in patients with BCS. Thrombosis of the portal vein was observed in 4.8% versus 0.8% of the patients, whereas liver veins were affected in 7.1% versus 0.2%. Our data shows that severe acute or chronic forms of BCS with liver failure can be successfully treated by OLT. Despite higher rates of vascular complications, patient and graft survival are similar or even better compared to other indication groups. In conclusion, patients with reversible hepatic damage should be treated by combined strategies, including medical therapy and surgical or interventional shunting.     

Popliteales Entrapmentsyndrom

Popliteal entrapment syndrome (PES) can be a rare cause of chronic or acute lower limb ischemia. PES is characterized as an abnormal relationship between the neurovascular and tendomuscular structures within the popliteal fossa. This mallocation may lead to progressive injury of the popliteal artery. In the case of a 7-year-old boy, PES led to a popliteal artery aneurysm (PAA) with a concomitant acute embolization into the peripheral arteries of the lower limb. Embolectomy and resection of the PAA with interposition of a saphenous graft did not establish a durable therapy. Six months after the operation, we observed a recurrence of the PAA (within the saphenous interposition graft). Only the lateralization (here, of the graft) into an orthotopic location led to long-term success. PES is a progressive disease in which surgical transposition of the popliteal artery with or without saphenous interposition is the treatment of choice.     

Response to Preoperative Chemotherapy Predicts Survival in Patients Undergoing Hepatectomy for Liver Metastases from Gastric and Esophageal Cancer

Background

The role of hepatectomy for patients with liver metastases from gastric and esophageal cancer (GELM) is not well defined. The present study examined the morbidity, mortality, and long-term survivals after liver resection for GELM.

Methods

Clinicopathological data of patients who underwent hepatectomy for GELM between 1995 and 2012 at two European high-volume hepatobiliary centers were assessed, and predictors of overall survival (OS) were identified. In addition, the impact of preoperative chemotherapy for GELM on OS was evaluated.

Results

Forty-seven patients underwent hepatectomy for GELM. The primary tumor was located in the stomach, cardia, and distal esophagus in 27, 16, and 4 cases, respectively. Twenty patients received preoperative chemotherapy before hepatectomy. After a median follow-up time of 76 months, 1-, 3-, and 5-year OS rates were 70, 37, and 24 %, respectively. Postoperative morbidity and mortality rates were 32 and 4 %, respectively. Outcomes were comparable between the two centers. Preoperative chemotherapy for GELM (5-year OS: 45 vs 9 %, P?=?.005) and the lack of posthepatectomy complications (5-year OS: 34 vs 0 %, P?P?=?.045).

Conclusion

For selected patients with GELM, liver resection is safe and should be regarded as a potentially curative approach. A multimodal treatment strategy including systemic therapy may provide better patient selection resulting in prolonged survival in patients with GELM undergoing hepatectomy.     

Hysterectomy and patterns of osteoarthritis. The Ulm Osteoarthritis Study

OBJECTIVE: To determine the association between hysterectomy (HE) and patterns of osteoarthritis (OA) METHODS: We performed a large cross-sectional study including 504 female patients admitted for arthroplasty of knee or hip joint. Patients with OA were categorized as having bilateral or generalized OA (GOA) according to the presence of radiographic OA in the contralateral or different finger joints. Odds ratios (OR) and their 95% confidence intervals (CI) for the association between HE and OA patterns were estimated adjusting for potential confounders. RESULTS: Hysterectomy (HE) was reported by 24.9 percent of the patients. Bilateral OA was present in 86.2 percent and GOA was present in 33.3 percent of the patients. HE was not associated with bilateral OA (adjusted OR=0.9; 95% CI: 0.5-1.8) but with a lower prevalence of GOA (adjusted OR=0.6; CI: 0.3-0.99). CONCLUSION: In contrast to earlier studies our results suggest that HE might be a marker for a reduced risk for a generalized pattern of OA.     

Sports activities 5 years after total knee or hip arthroplasty: the Ulm Osteoarthritis Study

OBJECTIVE: To analyse sports activities of patients with hip or knee osteoarthritis (OA) over lifetime, preoperatively, and 5 years after arthroplasty. METHODS: In a longitudinal four centre study, 809 consecutive patients with advanced OA of the hip (420) or the knee (389) joint under the age of 76 years who required total joint replacement were recruited. A completed questionnaire about sports activities at 5 year follow up was received from 636 (79%) of the 809 patients. RESULTS: Although most patients with hip (97%) and knee (94%) OA had performed sports activities during their life, only 36% (hip patients) and 42% (knee patients) had maintained sports activities at the time of surgery. Five years postoperatively, the proportion of patients performing sports activities increased to 52% among patients with hip OA, but further declined to 34% among those with knee OA. Accordingly, the proportion of patients with hip OA performing sports activities for more than 2 hours a week increased from 8 to 14%, whereas this proportion decreased from 12 to 5% among patients with knee OA. Pain in the replaced joint was reported by 9% of patients with hip and by >16% with knee OA. CONCLUSION: Differences in pain 5 years after joint replacement may explain some of the difference of sports activities between patients with hip and knee OA. Reasons for reduction of sports activities may include the increasing age of the patients, their worries about an "artificial joint", and the advice of their surgeon to be cautious.     

Scoring prevalence and severity in gonarthritis: the suitability of the Kellgren & Lawrence scale

In clinical and epidemiological studies the Kellgren & Lawrence (K&L) scale was mainly used in the past to determine the radiological prevalence and severity of gonarthritis. The dependency of this scoring system on the presence of osteophytes has been criticised, and owing to its varying reliability, its appropriateness in cross-sectional and longitudinal studies is questioned. It was the purpose of this study to test whether the dependency of the K&L scale on the presence of osteophytes is reflected in a higher correlation of the overall score with a separate scoring of osteophytes than with other radiological features. Furthermore we compared the inter- and intrarater reliability with the reliability of individual radiological features. Knee radiographs of 40 patients were graded according to the K&L scale and for the presence and severity of five separate radiological features of osteoarthritis. We found a moderate correlation of the K&L scale with the radiological features of osteophytes, joint space narrowing and flattening of condyles. The intra- and inter-rater reliability of the K&L scale was higher than the reliability of the individual radiological features. The K&L scale seems not to be strongly dependent on the presence of osteophytes, i.e. there is not a higher correlation of the overall score with that feature than with other radiological features.     

Inhibition of N-type calcium channels by activation of GPR35, an orphan receptor, heterologously expressed in rat sympathetic neurons

GPR35 is a G protein-coupled receptor recently "de-orphanized" using high-throughput intracellular calcium measurements in clonal cell lines expressing a chimeric G-protein alpha-subunit. From these screens, kynurenic acid, an endogenous metabolite of tryptophan, and zaprinast, a synthetic inhibitor of cyclic guanosine monophosphate-specific phosphodiesterase, emerged as potential agonists for GPR35. To investigate the coupling of GPR35 to natively expressed neuronal signaling pathways and effectors, we heterologously expressed GPR35 in rat sympathetic neurons and examined the modulation of N-type (Ca(V)2.2) calcium channels. In neurons expressing GPR35, calcium channels were inhibited in the absence of overt agonists, indicating a tonic receptor activity. Application of kynurenic acid or zaprinast resulted in robust voltage-dependent calcium current inhibition characteristic of Gbetagamma-mediated modulation. Both agonist-independent and -dependent effects of GPR35 were blocked by Bordetella pertussis toxin pretreatment indicating the involvement of G(i/o) proteins. In neurons expressing GPR35a, a short splice variant of GPR35, zaprinast was more potent (EC(50) = 1 microM) than kynurenic acid (58 microM) but had a similar efficacy (approximately 60% maximal calcium current inhibition). Expression of GPR35b, which has an additional 31 residues at the N terminus, produced similar results but with much greater variability. Both GPR35a and GPR35b appeared to have similar expression patterns when fused to fluorescent proteins. These results suggest a potential role for GPR35 in regulating neuronal excitability and synaptic release.