Laparoscopic sigmoid and rectal resection using an electrothermal bipolar vessel sealing device

BACKGROUND: Laparoscopic colonic resection has gained popularity as a method to treat colonic diseases. The electrothermal bipolar vessel sealer (EBVS; LigaSure Atlas) is a modern device that allows the secure sealing of vessels with a diameter of up to 7 mm. The aim of the present study was to evaluate the suitability of the device for laparoscopic colonic surgery. METHODS: The immediate outcome of 114 consecutive patients who underwent a sigmoid or rectal resection was prospectively analyzed. The intention was to perform all operations with the EBVS for dissection and ligation of the mesenterial vessels. Details on patient characteristics, peroperative and postoperative complications, and postoperative recovery were recorded prospectively and analyzed. RESULTS: One hundred and fourteen patients were scheduled for elective left-sided colonic or rectal resection. Massive intra-abdominal adhesions in 1 patient required a conversion of the laparoscopic procedure to an open one; In total, 113 laparoscopic operations were thus performed. The mean operative time was 87.7 +/- 2.8 minutes, and the mean time for patients to tolerate solid food was 3.4 +/- 0.1 days and the time to discharge from hospital was 4.6 +/- 0.2 days. There were nine (8.0%) general complications, and additionally, 10.6% of patients suffered from surgical complications. CONCLUSIONS: The electrothermal bipolar vessel sealer is suitable and safe for laparoscopic sigmoid and rectal resections. The use of the device probably reduces the operative time.     

Parental alcohol misuse is a powerful predictor for the risk of traumatic brain injury in childhood

Background: Although the positive relationship between parental alcohol use and children's injuries is well established, it is not known whether parental alcohol misuse is a risk factor for traumatic brain injuries (TBIs) of their children and whether subjects with childhood TBI have hazardous drinking habits in adolescence.

Methods: The authors conducted a longitudinal cohort study at Oulu University Hospital. The cohort consisted of 12 058 subjects born in 1966, of which 207 had sustained TBI before the age of 14 years. Data on parental alcohol problems were obtained from the Finnish Hospital Discharge Register and the adolescents' drinking habits were analysed based on a postal inquiry at the age of 14 years.

Results: Parental alcohol misuse (RR 1.99, CI 1.19-3.33) and male gender (RR 1.53, CI 1.12-2.08) significantly predicted the risk of childhood TBI. Drinking to intoxication at the age of 14 was significantly associated with parental alcohol misuse (RR 1.62, CI 1.34-1.96), belonging to a one-parent family (RR 1.80, CI 1.61-2.02) and mild TBI (RR 1.67, CI 1.20-2.33).

Conclusions: It was observed that parental alcohol misuse is a major risk factor for TBI in children and drinking to intoxication is a common drinking pattern of adolescents who have sustained TBI in childhood.     

The A1330V polymorphism of the low-density lipoprotein receptor-related protein 5 gene (LRP5) associates with low peak bone mass in young healthy men

INTRODUCTION: Polymorphisms in the gene coding for low-density lipoprotein receptor-related protein 5 (LRP5) contribute to variation in bone mass in the general population. Whether this is due to influence on bone mass acquisition or on bone loss thereafter has not been established. METHODS: We studied the association of LRP5 polymorphisms with peak bone mass in young men. The study included 235 Finnish men, aged 18.3 to 20.6 years. Lifestyle factors and fracture history were recorded. Bone mineral content (BMC), density (BMD) and scan area were measured for the lumbar spine and proximal femur by dual energy X-ray absorptiometry (DXA). Blood and urine were collected for determination of bone turnover markers, serum 25-OHD and PTH. Genomic DNA was extracted from peripheral blood for genetic analysis of LRP5. Ten single nucleotide polymorphisms in LRP5 were analyzed and correlated with bone parameters. RESULTS: Only the A1330V polymorphism of LRP5 significantly associated with bone parameters. In comparison with subjects with the AlaAla genotype (n=215), those with AlaVal genotype (n=20) had lower femoral neck BMC (P=0.029) and BMD (P=0.012), trochanter BMC (P=0.0067) and BMD (P=0.015), and total hip BMC (P=0.0044) and BMD (P=0.0089). Fracture history was similar for the genotypes. CONCLUSION: The polymorphic valine variant at position 1330 of LRP5 was significantly associated with reduced BMC and BMD values in healthy young Finnish men. The results provide evidence for the crucial role of LRP5 in peak bone mass acquisition.     

No difference in clinical outcome after posterolateral lumbar fusion between patients with isthmic spondylolisthesis and those with degenerative disc disease using pedicle screw instrumentation: a comparative study of 112 patients with 4 years of follow-up

We compared the clinical outcome after spinal fusion between patients with isthmic spondylolisthesis and those with degenerative disc disease of the lumbar spine, using multiple logistic regression analysis. A questionnaire describing medication, pain, vocational status and patient satisfaction was mailed to all the patients at a median interval of 4 years after their operation. Fusion was evaluated on plain radiographs at a minimum of 12 months after surgery, and patients were classified as fused or not fused. The overall satisfaction rate was 70%. The results of the present study showed no difference in the outcome after spinal fusion between the two groups of patients. The factors that significantly increased the likelihood of an optimal result - defined as patient satisfaction, return to work, and reduced medication - were male gender, being in work prior to surgery, and being a non-smoker. Since spinal fusion is an expensive treatment with potentially serious risks, and leaves one-third of the patients with an unsatisfactory result, we believe that more studies focusing on the indications for surgery should be performed.     

Comparison of outcome between nonoperative and operative treatment of medial epicondyle fractures

Background and purpose — Controversy exists regarding the optimal treatment for displaced medial epicondyle fractures. We compared the results of nonoperative and operative treatment and calculated the incidence of medial epicondyle fractures in the pediatric census population.Patients and methods — 112 children under 16 years old who sustained > 2 mm displaced fracture of the medial epicondyle were treated in our institution between 2014 and 2019. 80/83 patients with 81 non-incarcerated fractures were available for minimum 1-year follow-up. 41 fractures were treated with immobilization only, 40 by open reduction and internal fixation, according to the preference of the attending surgeon. Outcome was assessed at mean 2.6 years (1–6) from injury with different patient-reported outcome measures. Elbow stability, range of motion, grip strength, and distal sensation were registered in 74/80 patients. Incidence was calculated for 7- to 15-year-olds.Results — Nonoperatively treated children had less pain according to the PedsQL Pediatric Pain Questionnaire (3 vs. 15, p = 0.01) with better cosmetic outcome (VAS 95 vs. 87, p = 0.007). There was no statistically significant difference between the groups in respect of QuickDASH, PedsQL generic core scale, Mayo Elbow Performance Score, grip strength, carrying angle, elbow stability, or range of motion (p > 0.05). All 41 nonoperatively treated children returned to pre-injury sports; of the surgically treated 6/40 had to down-scale their sporting activities. The incidence of displaced (> 2 mm) fractures of the medial epicondyle in children aged 7–15 years was ≥ 3:100,000.Interpretation — Displaced fractures of the medial humeral epicondyle in children heal well with 3–4 weeks’ immobilization. Open reduction and screw fixation does not improve outcome.

Fractures of the medial humeral epicondyle have been reported to account for 12–20% of all pediatric elbow fractures, but the incidence is not known. Elbow dislocation is associated with 30–50% of these fractures (Gottschalk et al. 2012), with an incarceration rate of the fracture fragment into the elbow joint of 5–18%. Ulnar nerve lesions are registered in 10–16% of cases (Louhaem et al. 2010).Nonoperative treatment is advised in minimally displaced (< 2 mm) fractures of the medial humeral epicondyle, whereas surgery is recommended for fractures incarcerated in the elbow joint as well as for fractures that are either grossly unstable or where the ulnar nerve is entrapped (Smith 1950, Blount 1955, Maylahn and Fahey 1958, Bede et al. 1975, Gottschalk et al. 2012, Tarollo et al. 2015). Significant controversy concerning the treatment of displaced (3–15 mm) fractures exists, with some surgeons advocating early mobilization, some immobilization, and some internal fixation (Lee et al. 2005, Hughes et al. 2019, Pezzutti et al. 2020). It has also been suggested that competitive athletes or fractures occurring in combination with elbow dislocation should be treated surgically with a lower threshold than in children without sporting activities (Baety and Kasser 2014).The reported outcome of nonoperative and operative treatment in displaced fractures of the medial humeral epicondyle in terms of elbow function and complications has been similar (Farsetti et al. 2001, Biggers et al. 2015, Axibal et al. 2019).We compared subjective and objective outcomes and calculated the incidence of medial humeral epicondyle fractures in children treated either with immobilization or with open reduction and internal fixation (ORIF).     

Late occurring clinical deep vein thrombosis in joint-operated patients

In a prospective study of 4,840 patients, we determined the annual incidence of clinical deep vein thrombosis (DVT) in mobilized, discharged orthopedic-operated "high-risk" patients (hip replacement surgery, knee replacement surgery, nailed hip fracture) and assumed "low-risk" patients (diagnostic knee arthroscopy). In addition, the time from the operation to the time when the patients were readmitted with clinically suspected DVT and the distribution of radiologically-confirmed DVT were recorded. Thromboprophylaxis was routinely given for about 10 days to the high-risk groups during the hospital stay but not to patients undergoing knee arthroscopy. During 9 years, the annual incidence of DVT following major procedures was 2.1% (95% CI 1.6-2.6) vs. 0.6% (95% CI 0.2-1.1) after diagnostic knee arthroscopy. Symptoms appeared, on average, 27 (3-150) days after total hip replacement surgery, 36 (3-150) days after nailed hip fracture, 17 (6-30) days after total knee replacement and 1 (1-6) day after knee arthroscopy. In hip-operated patients, 50% of the DVT's were found in the proximal veins vs. 40% following knee arthroplasty.     

Cholesterol absorption and synthesis in pediatric kidney, liver, and heart transplant recipients

BACKGROUND: Hypercholesterolemia after organ transplantation is common. Previously, we observed higher serum total cholesterol (TC) concentrations in our pediatric kidney than liver or heart transplant recipients. To find an explanation to the observed difference, our kidney recipients' cholesterol synthesis and absorption efficiency was compared to those of liver and heart recipients. METHODS: Serum noncholesterol sterol ratios (10 x mmol to the mol of TC, surrogate estimates of hepatic cholesterol synthesis and intestinal absorption) were studied in 50 pediatric kidney, 25 liver and 12 heart transplant recipients without diabetes or cholestasis, and in 29 controls. RESULTS: The kidney recipients had lower Delta-cholesterol (P=0.031), similar lathosterol and higher desmosterol ratios (markers of cholesterol synthesis) (P=0.020), and similar campesterol and sitosterol ratios (markers of cholesterol absorption) when compared to the controls. The liver recipients had lower campesterol ratios than the kidney recipients and controls (P=0.002). Glomerular filtration rates were not associated with the ratios of noncholesterol sterols. Multivariate analysis showed markers of cholesterol synthesis to be lower and absorption to be higher in the kidney than the liver or the heart transplant recipients. Weight-adjusted dosages of immunosuppressive agents were associated with some ratios of noncholesterol sterols and cholestanol though these varied between the transplant recipient groups. CONCLUSIONS: Serum TC concentration in kidney recipients was not significantly associated with absorption efficiency or synthesis of cholesterol, though kidney transplantation was associated with low synthesis and high absorption efficiency of cholesterol. Immunosuppressive therapy with cyclosporine and methylprednisolone may modulate absorption efficiency and synthesis of cholesterol.     

High Adenosine Deaminase Level Among Healthy Probands of Diamond Blackfan Anemia (DBA) Cosegregates With the DBA Gene Region on Chromosome 19q13

Phenotypic characterization of Diamond Blackfan Anemia (DBA)patients and their relatives was performed in 54 families. Complete blood count, fetal hemoglobin level, erythrocyte i antigen expression, and erythrocyte adenosine deaminase (eADA) activities were quantitated in patients and relatives. eADA was elevated in 28 of 34 transfusion-independent DBA patients, whereas persistence oferythrocyte i antigen was noticed in only 10 of 20 DBA patients. HigheADA activities were also found in 14 of 149 healthy family members,allowing us to identify an isolated high eADA phenotype in thesefamilies. In contrast, increase in erythrocyte i antigen expression,elevated fetal hemoglobin levels, and macrocytosis were much lessfrequently noted in nonaffected members of the DBA familiesstudied. Importantly, isolated high eADA phenotype was found to besignificantly associated with genetic markers on chromosome 19 thatsegregate with the DBA phenotype. Isolated high eADA phenotype thusseems to reflect a silent phenotype of DBA in affected families. Thesefindings suggest that elevated eADA activity in unaffected individuals needs to be taken into account during genetic assessment of DBA families and could be used for accurate assessment of mode of inheritance.     

Once-daily topical metronidazole cream formulations in the treatment of the papules and pustules of rosacea

BACKGROUND: The papules and pustules of rosacea can be effectively treated with topical metronidazole. The optimal concentrations of metronidazole and optimum frequencies of application are uncertain. Traditionally, twice-daily applications have been advised, based on the pharmacokinetic profile of metronidazole. Once-daily applications may be safer and less expensive, and they may enhance patient compliance. OBJECTIVE: We compared the efficacy and safety of 2 commercially available topical metronidazole formulations (0.75% metronidazole cream formulation and 1.0% metronidazole cream formulation) when both were used in a once-daily regimen. METHODS: A multicenter, randomized, investigator-blind, parallel group trial was conducted at 3 separate clinical sites located in 3 US cities. The study enrolled 72 rosacea patients with at least 8 to 50 inflammatory facial lesions (pustules and papules) and moderately severe facial erythema. Patients were randomly assigned to receive either 0.75% metronidazole cream or 1.0% metronidazole cream and instructed to apply the medication once daily for 12 weeks. Patients' lesions were evaluated at baseline and at weeks 3, 6, 9, and 12. RESULTS: There were no significant differences between treatment groups for any of the efficacy parameters evaluated. The overall median percentage change in lesion count at end point for patients in the 0.75% metronidazole cream treatment group was -62% compared with -60% for the 1.0% metronidazole cream treatment group. The overall percentage change in erythema scores at endpoint for patients in the 0.75% metronidazole cream treatment group was -26% compared with -30% for patients in the 1.0% metronidazole cream treatment group. Regarding physician assessment of global severity, 57% of subjects (20/35) in the 0.75% metronidazole cream group compared with 37% of subjects (13/35) in the 1.0% metronidazole cream group were rated as having a clear to mild condition at end point. Both drugs were well tolerated; there was no significant difference in the number of drug-related adverse events between the two agents. CONCLUSION: This controlled trial demonstrates that both 0.75% metronidazole cream and 1.0% metronidazole cream, when used once daily, provide well-tolerated efficacy for moderate to severe rosacea.