C-OnSite® for intraoperative 3D control of pedicular screw positions

Background

Two-dimensional image guidance and navigation can help to reduce the number of misplaced pedicle screws, but do not completely prevent misplacement. This experimental, retrospective, non-inferiority study was designed to evaluate and compare the efficacy of a novel 3D imaging technique versus conventional postoperative CT-scan, for intra-operative determination of pedicle screw position accuracy.

Methods

The capacity of C-OnSite® to intraoperatively assess screw placement was evaluated in 28 clinical cases and 23 deliberately misplaced screws in a cadaver model, and compared to placement accuracy determined by standard CT. The position of each implant, as viewed by both modalities, was graded by three neurosurgeons, one orthopaedic-surgeon and one radiologist. The intermodal variance determined the difference between CT- and C-OnSite® results for each observer, while the inter-observer variance measured the difference between ratings of the same modality by different observers.

Results

C-OnSite® successfully assessed 120/138 screws (25/28 cases). Mean procedural fluoroscopy time was 132?±?51s, and 40?±?16s per C-OnSite® scan. The average inter-modality variance was ,15 % with mismatches >1° between C-OnSite® and the gold-standard imaging technique in only 2 % of the comparisons. Average inter-observer variances were about similar (12 % for CT and 18 % for C-OnSite®), with deviations of >1° reaching 1 % for CT and 3 % for C-OnSite®. Individual variances between experienced only observers differed even less.

Conclusions

C-OnSite® is a feasible, reliable and intuitive means of intraoperatively visualizing pedicle screw positions and might render the majority of postoperative CTs superfluous. C-OnSite® might help avoid re-operations for screw re-positioning.     

A Critical Role for Thioredoxin-Interacting Protein in Diabetes-Related Impairment of Angiogenesis

Impaired angiogenesis in ischemic tissue is a hallmark of diabetes. Thioredoxin-interacting protein (TXNIP) is an exquisitely glucose-sensitive gene that is overexpressed in diabetes. As TXNIP modulates the activity of the key angiogenic cytokine vascular endothelial growth factor (VEGF), we hypothesized that hyperglycemia-induced dysregulation of TXNIP may play a role in the pathogenesis of impaired angiogenesis in diabetes. In the current study, we report that high glucose–mediated overexpression of TXNIP induces a widespread impairment in endothelial cell (EC) function and survival by reducing VEGF production and sensitivity to VEGF action, findings that are rescued by silencing TXNIP with small interfering RNA. High glucose–induced EC dysfunction was recapitulated in normal glucose conditions by overexpressing either TXNIP or a TXNIP C247S mutant unable to bind thioredoxin, suggesting that TXNIP effects are largely independent of thioredoxin activity. In streptozotocin-induced diabetic mice, TXNIP knockdown to nondiabetic levels rescued diabetes-related impairment of angiogenesis, arteriogenesis, blood flow, and functional recovery in an ischemic hindlimb. These findings were associated with in vivo restoration of VEGF production to nondiabetic levels. These data implicate a critical role for TXNIP in diabetes-related impairment of ischemia-mediated angiogenesis and identify TXNIP as a potential therapeutic target for the vascular complications of diabetes.     

Pancreaticoduodenectomy for malignancies in children

Purpose

Malignant tumors of the common bile duct or of the pancreas head are uncommon in childhood [Perez EA, Gutierrez JC, Koniaris LG, Neville HL, Thompson WR, Sola JE. Malignant pancreatic tumors: incidence and outcome in 58 pediatric patients. J Pediatr Surg. 2009; Jan; 44 (1): 197–203]. With radical surgery being the standard cure for nonmetastatic diseases, pancreaticoduodenectomy (PD) is the best choice when the tumor is localized in the head of the pancreas, or in the lower portion of the common bile duct. The purpose of the present study is to describe five consecutive children managed by PD, and reviewing the particular aspects and results of this rare procedure in children.

Methods

Between 2007 and 2010, five patients (median age: 7 years) underwent PD for nonmetastatic malignant tumors. In two cases, PD was performed en bloc with a right hepatectomy in order to achieve the radical resection of a recurrent biliary sarcoma. Four patients benefited from a “pylorus-preserving” PD procedure. In two patients, resection of the portal vein and vascular reconstruction was performed, and in one case, an extended resection of the biliary ductal system was necessary.

Results

All resection margins were clear. The postoperative course was uneventful, with no pancreatic or biliary leakage in all of the patients. Oral refeeding was achieved by the eighth postoperative day. In two cases, a late revision of pancreatic–jejunal anastomosis was performed because of mild steatorrea and a suspected anastomotic stricture. Two of the patients, who were subsequently operated on second hand, for biliary sarcoma, died from the recurrence; while three of the others, with pancreatic malignancies, are alive and well, with a good functional outcome.

Conclusions

Surgical resection is the treatment of choice for tumors of the pancreatic head area. In the absence of regional or metastatic extension, the radicality of primary intervention is associated with favorable outcomes. Good functionality results were observed after the PD was limited to the head of the pancreas and subject to pylorus-preserving techniques.     

Surgical specialty and outcomes for carotid endarterectomy: evidence from the National Surgical Quality Improvement Program

Background

Carotid endarterectomy (CEA) has been performed since the 1950s and remains one of the most common surgical procedures in the United States. The procedure is performed by cardiothoracic, general, neurologic, and vascular surgeons. This study uses data from the National Surgical Quality Improvement Program (NSQIP) to examine the outcomes after CEA when performed by general or vascular surgeons.

Materials and methods

Data included 34,493 CEAs from years 2005 to 2010 recorded in the NSQIP database. Primary outcomes measured were length of stay, 30-d mortality, surgical site infection, cerebrovascular accident, myocardial infarction, and blood transfusion requirement. Secondary outcomes measured were the remaining intraoperative outcomes from the NSQIP database.

Results

After controlling for patient and surgical characteristics, patients treated by general surgeons did not have a significantly different LOS or 30-d mortality than those treated by vascular surgeons. Patients of general surgeons had nearly twice the risk of acquiring a surgical site infection (odds ratio [OR] = 1.94; P = 0.012), >1.5 times the risk of cerebrovascular accident (OR = 1.56; P = 0.008), and >1.8 times the risk of blood transfusion (OR = 1.85; P = 0.017) than those of vascular surgeons. Patients of general surgeons had less than half the risk of having a myocardial infarction (OR = 0.34; P = 0.031) than those of vascular surgeons.

Conclusions

Surgical specialty is associated with a wide range of postoperative outcomes after CEA. Additional research is needed to explore practice and cultural differences across surgical specialty that may lead to outcome differences.     

Characterization of eleven polymorphic microsatellite markers for leafhoppers of the genus Aphrodes (Hemiptera: Cicadellidae)

Eleven microsatellite markers were developed for the leafhoppers of the genus Aphrodes using shotgun pyrosequencing and will be used to study the genetic diversity, population structure and gene flow within and between species in this genus in order to assess their conservation status. The number of alleles per locus ranged from 3 to 10, while observed and expected heterozygosity values varied from 0.421–1.000 to 0.542–0.876, respectively. Cross-species amplification was successful among the four congeners.     

Late-Onset Subcutaneous Scalp Calcifications in a Patient with Pseudo-Pseudohypoparathyroidism

Ectopic calcifications and even bone formation have been linked to GNAS gene mutations. A 51-year-old Caucasian female had been diagnosed of pseudo-pseudohypoparathyroidism (PPHP) in 1989. She has always had normal serum parathyroid hormone, calcium, and phosphorus levels. A non-contrast computed tomography of the head was done in 2013 and it showed finely speckled subcutaneous calcifications in the high convexity of the head. Cutaneous exploration did not show any abnormality. We herein report an unusual case of late-onset scalp calcifications in a patient with PPHP.     

A systematic review of the literature to support an evidence-based Precepting Program

Aim

To provide a systematic review of the literature regarding development of an evidence-based Precepting Program for nurses transitioning to burn specialty practice.

Background

Burned patients are admitted to specialty Burn Centers where highly complex nursing care is provided. Successful orientation and integration into such a specialized work environment is a fundamental component of a nurse's ability to provide safe and holistic patient care.

Design

A systematic review of the literature was performed for the period 1995–2011 using electronic databases within PUBMED and Ovid search engines.

Data sources

Databases included Medline, CINHAL, ProQuest for Dissertations and Thesis, and Cochran Collaboration using key search terms: preceptor, preceptee, preceptorship, precept*, nurs*, critical care, personality types, competency-based education, and learning styles.

Review methods

Nurses graded the level and quality of evidence of the included articles using a modified 7-level rating system and the Johns Hopkins Nursing Quality of Evidence Appraisal during journal-club meetings.

Results

A total of 43 articles related to competency (n = 8), knowledge acquisition and personality characteristics (n = 8), learning style (n = 5), preceptor development (n = 7), and Precepting Programs (n = 14).

Conclusions

A significant clinical gap existed between the scientific evidence and actual precepting practice of experienced nurses at the Burn Center. Based on this extensive review of the literature, it was determined that a sufficient evidence base existed for development of an evidence-based Precepting Program.     

Health-related quality of life (HRQoL) in cystine compared with non-cystine stone formers

Cystinuria is a genetic cause of recurrent kidney stones which may be more recurrent and larger than more common non-cystine stones. They may have a greater impact on health-related quality of life (HRQoL). We measured this impact by surveying HRQoL in patients with stones, comparing non-cystine stone formers (NCSF) to cystine stone formers (CYSF) and both groups to normative values of the US population. We used SF-36v2 via an internet instrument. CYSF patients were recruited via cystinuria-related websites, two patient advocacy groups, and an active endourology practice. NCSF patients were recruited from the same practice and by email. Total n surveyed with scorable data: 214 CYSF and 81 NCSF. The participants included 128 men and 161 women. The group of CYSF were significantly younger (39 vs. 54 years) and suffered longer from kidney stones (255 vs. 136 months). CYSF patients had significantly more episodes of stones than NCSF patients in the last year (N = 108 CYSF, N = 20 NCSF). More frequent stones in the last year and mental comorbidities most often predicted worse scores in the individual HRQoL domains. However, cystine stone composition was a significant predictor of worse scores only for role emotional. Better scores in all SF-36 domains were associated with greater time since the last kidney stone event. Although kidney stones are often transient, kidney stone formers, regardless of stone composition, have a worse HRQoL than the standard US population, which has a normative score of 50, such as general health (41.2 ± 12.8), bodily pain (46.5 ± 11.8) and mental health (45.1 ± 12.6). CYSF are more frequent and severe stone formers compared with NCSF with a resulting greater, direct impact on the HRQoL of CYSF patients. Whether preventive strategies for cystinuria are being properly utilized by practitioners, and which strategies are most effective, should be established.