Precision grip function after free toe transfer in children with hypoplastic digits.

Although toe-to-hand transfer has a defined role in the management of congenital hand deformities, it remains unclear how well children integrate the transferred digits into physiological grasping. We analysed fingertip forces in the precision grip of 13 patients when lifting a test object more than three years after free toe transfer for absent or hypoplastic digits. Clinically, most patients showed normal sensibility of transferred digits, but active motion and pinch strength were limited as compared to the normal hand. For the control of fingertip forces, two key features of the normal two-digit opposition grip were seen in all operated hands: adaptation of grip force to object weight and parallel coordination of lift and grip forces. These physiological grasping strategies developed independently of the patients' age at the time of operation, which ranged from one to 13 years. In four patients, we observed increased tangential load forces with the operated hand due to misalignments in the application of fingertips on the grasp surfaces. Such forces lead to increased grip force requirements on both fingers that may overload transferred digits with limited motor function. The need for optimal alignment of the grip axis during toe-transfer surgery is emphasised.     

The role of neuroticism and conscientiousness on mortality risk in older adults after child and spouse bereavement

Objective: Bereavement effects on mortality risk were investigated in 1150 randomly selected participants, aged 60–104, in the Swedish National Study of Aging and Care.

Method: Cox proportional hazards models, controlling for age, gender, functional ability, the personality traits neuroticism and conscientiousness as well as time since the latest loss were used to predict mortality risk.

Results: Having lost a child, spouse or both child and spouse did not predict mortality risk. An indirect link between bereavement and mortality was found showing for each year since loss the mortality risk decreased by about 1%. Neuroticism, but not conscientiousness, was associated with mortality risk, with a small-effect size.

Conclusions: The different bereavements did not predict mortality risk while an indirect link was found showing that mortality risk decreased with time.     

Brace treatment resulting in overcorrection of adolescent idiopathic scoliosis

Brace treatment for idiopathic scoliosis in skeletally immature children is the only effective nonoperative modality for the control of curve progression. The Charleston bending brace is a custom-molded spinal orthosis that holds the patient in a completely corrected or overcorrected position while worn at night. A 9-year-old girl presented with 10° right upper thoracic and 7° left lower thoracic curves and was Risser sign 0. Nighttime treatment with a Charleston bending brace was initiated when the left lower thoracic curve progressed to 19°. After 27 months of nighttime brace wear, the lower thoracic curve was 21° to the right. Further investigation, including magnetic resonance imaging of the spine, failed to diagnose an identifiable explanation for this atypical occurrence. Conservative treatment may improve radiographic and cosmetic appearance. Overcorrection of the curve, although not likely, is possible when part-time or nighttime bracing is implemented as a means of conservative management.     

SLEEVEPASS: A randomized prospective multicenter study comparing laparoscopic sleeve gastrectomy and gastric bypass in the treatment of morbid obesity: preliminary results

Background

The long-term efficacy of laparoscopic Roux-en-Y gastric bypass (RYGB) in the treatment of morbid obesity has been demonstrated. Laparoscopic sleeve gastrectomy (SG) as a single procedure has shown promising short-term results, but the long-term efficacy of SG has not yet been demonstrated. The aim of this study was to determine the preliminary 30-day morbidity and mortality of RYGB and SG in a prospective multicenter randomized setting.

Methods

A total of 240 morbidly obese (BMI?=?35–66?kg/m2) patients evaluated by a multidisciplinary team were randomized to undergo either RYGB or SG. There were 117 patients in the RYGB group and 121 in the SG group; two patients had to be excluded after randomization. Both study groups were comparable regarding age, gender, BMI, and comorbidities.

Results

There was no 30-day mortality. The median operating time was significantly shorter in the SG group (66?min vs. 94?min, p?p?=?0.292). Nine (7.4 %) SG patients and 20 (17.1 %) RYGB patients had minor complications (p?=?0.023). The overall morbidity was 13.2 % after SG and 26.5 % after RYGB (p?=?0.010). There were three (2.5 %) early reoperations after SG and four (3.3 %) after RYGB (p?=?0.719).

Conclusions

At 30-day analysis SG is associated with a shorter operating time and fewer early minor complications compared to RYGB. There were no significant differences in major complications or early reoperations. Long-term follow-up is required to determine the effect on weight loss, resolution of obesity-related comorbidities, and improvement of quality of life.     

Revisional Bariatric Surgery by Conversion to Gastric Bypass or Sleeve—Good Short-Term Outcomes at Higher Risks

This is a retrospective study of prospectively collected data from 34 patients who had revisional bariatric surgery at a single centre. The aim was to report the indications for revisional surgery, operative time, conversion to open surgery, mortality, hospital stay, early and late complications, reoperations and short-term efficacy. From 2006 to 2011, 31 patients who formerly had been operated for morbid obesity with restrictive operations and 3 patients who had been operated in the upper abdomen for other morbidities (fundoplications 2, Heller's myotomy 1) underwent a revisional Roux-en-Y gastric bypass operation (n = 30) or sleeve gastrectomy (n = 4). Demographic data, perioperative characteristics and follow-up data were entered prospectively in the hospital's database for bariatric patients. Twenty-five operations were done by laparoscopic and nine by open technique. The mean operative time was 113.17 (33.98, 54–184) min. The mean postoperative hospital stay was 3.25 (5.71, 1–32) days. Intra-operative complications occurred in six patients (17.65%), postoperative complications in nine (26.47%), and major complications in three patients (8.82%), including leakage in the gastrojejunal anastomosis in two (5.88%) patients. The conversion rate to open surgery was 2.94% (one emergency patient). There was no mortality. Excess weight loss (%, ±SD) at 3 months follow-up averaged 42.31%, ±21.54. Revisional bariatric surgery can be performed with an increased but acceptable risk, with at least short-term weight loss comparable to primary operations.     

The effects of isoflurane-induced electroencephalographic burst suppression on cerebral blood flow velocity and cerebral oxygen extraction during cardiopulmonary bypass

We investigated the effects of isoflurane-induced burst suppression, monitored with electroencephalography (EEG), on cerebral blood flow velocity (CBFV), cerebral oxygen extraction (COE), and autoregulation in 16 patients undergoing cardiac surgery. The experimental procedure was performed during nonpulsatile cardiopulmonary bypass (CPB) with mild hypothermia (32 degrees C) in fentanyl-anesthestized patients. Middle cerebral artery transcranial Doppler flow velocity, right jugular vein bulb oxygen saturation, and jugular venous pressure (JVP) were continuously measured. Autoregulation was tested during changes in mean arterial blood pressure (MAP) within a range of 40-80 mm Hg, induced by sodium nitroprusside and phenylephrine before (control) and during additional isoflurane administration to an EEG burst-suppression level of 6-9/min. Isoflurane induced a 27% decrease in CBFV (P < 0.05) and a 13% decrease in COE (P < 0.05) compared with control. The slope of the positive relationship between CBFV and cerebral perfusion pressure (CPP = MAP - JVP) was steeper with isoflurane (P < 0.05) compared with control, as was the slope of the negative relationship between CPP and COE (P < 0.05). We conclude that burst-suppression doses of isoflurane decrease CBFV and impair autoregulation of cerebral blood flow during mildly hypothermic CPB. Furthermore, during isoflurane administration, blood flow was in excess relative to oxygen demand, indicating a loss of metabolic autoregulation of flow. IMPLICATIONS: The effects of isoflurane on cerebral blood flow velocity (CBFV) and oxygen extraction (COE) as a function of perfusion pressure were studied. When added to fentanyl anesthesia, isoflurane induced a 27% and 13% decrease in CBFV and COE, respectively. CBFV became more pressure-dependent with isoflurane indicating an impaired autoregulation.     

Complement activation following optic nerve crush in the adult rat

Activation of the complement cascade following peripheral nerve axotomy and following traumatic brain injury has been demonstrated in previous studies. This study investigates the temporal pattern of microglia/macrophages and complement activation following axotomy of sensory CNS neurons, using a standardized experimental crush injury of the optic nerve in adult rats. Numerous ED1-labeled macrophages were found at the lesion site and distal to the injury at 7 days post injury (dpi). Complement C3-mRNA was upregulated 2-28 days post lesion, indicating local synthesis of complement in the optic nerve. Furthermore, increased immunoreactivity (IR) for the end product of the complement cascade, the membrane attack complex (MAC), was detected along disintegrating axons co-labeled with anti-neurofilament distal to the injury. Double-labeling for microglia show MAC-immunoreactivity expressed in their immediate vicinity, indicating a key role of microglia/macrophages in complement activation. The complement regulator Clusterin was upregulated in astrocytes at the lesion site as well as in the distal portion of the injured optic nerve, suggesting activation of a defense response to endogenous complement attack. A crush injury of the optic nerve leads to complement activation at the site of lesion and along the distal portion of the nerve, as well as upregulation of the complement inhibitor Clusterin at least in astrocytes. Reactive microglial cells seem to have a key role in complement activation as a local source of C3. We suggest that the balance between complement activation and their regulators may have impact on axonal degeneration following optic nerve injury.     

Similar outcome after colonic pouch and side-to-end anastomosis in low anterior resection for rectal cancer: a prospective randomized trial

OBJECTIVES: To compare a colonic J-pouch or a side-to-end anastomosis after low-anterior resection for rectal cancer with regard to functional and surgical outcome. SUMMARY BACKGROUND DATA: A complication after restorative rectal surgery with a straight anastomosis is low-anterior resection syndrome with a postoperatively deteriorated anorectal function. The colonic J-reservoir is sometimes used with the purpose of reducing these symptoms. An alternative method is to use a simple side-to-end anastomosis. METHODS: One-hundred patients with rectal cancer undergoing total mesorectal excision and colo-anal anastomosis were randomized to receive either a colonic pouch or a side-to-end anastomosis using the descending colon. Surgical results and complications were recorded. Patients were followed with a functional evaluation at 6 and 12 months postoperatively. RESULTS: Fifty patients were randomized to each group. Patient characteristics in both groups were very similar regarding age, gender, tumor level, and Dukes' stages. A large proportion of the patients received short-term preoperative radiotherapy (78%). There was no significant difference in surgical outcome between the 2 techniques with respect to anastomotic height (4 cm), perioperative blood loss (500 ml), hospital stay (11 days), postoperative complications, reoperations or pelvic sepsis rates. Comparing functional results in the 2 study groups, only the ability to evacuate the bowel in <15 minutes at 6 months reached a significant difference in favor of the pouch procedure. CONCLUSIONS: The data from this study show that either a colonic J-pouch or a side-to-end anastomosis performed on the descending colon in low-anterior resection with total mesorectal excision are methods that can be used with similar expected functional and surgical results.     

No effect of HLA‐C mismatch after allogeneic hematopoietic stem cell transplantation with unrelated donors and T‐cell depletion in patients with hematological malignancies

HLA‐C mismatch in unrelated donor's hematopoietic stem cell transplantation (HSCT) has been associated with poor patient outcome. However, the impact of HLA‐C mismatch in the context of HSCT combined with in vivo T‐cell depletion remains unclear. We therefore performed a single‐center, retrospective analysis of the clinical outcome on patients with hematological malignancies treated with allo‐HSCT, who underwent T‐cell depletion. The majority of the patients (n=276) received a HLA‐A, HLA‐B, HLA‐DRB1‐matched graft that were either also HLA‐C matched (n=260), or patients with the permissive HLA‐C*03:03/03:04 mismatch (n=16), while the remaining patients (n=95) received a HLA‐C‐mismatched graft (excluding HLA‐C*03:03/03:04 mismatches). We did not observe any significant differences between the HLA‐C‐matched patients (including the permissive HLA‐C*03:03/03:04 mismatch) and the HLA‐C‐mismatched patients regarding cumulative proportion surviving, graft failure, relapse‐free survival, relapse, or acute graft‐versus‐host disease. Our data suggest that in the context of high dose T lymphocyte‐depleting agents, HLA‐C matching is not essential for patients with hematological malignancies.     

Capsulorhexis contraction after cataract surgery: comparison of sharp anterior edge and modified anterior edge acrylic intraocular lenses

PURPOSE: To evaluate the reduction in the anterior capsule opening after phacoemulsification, continuous curvilinear capsulorhexis, and implantation of 1 of 2 acrylic intraocular lenses (IOLs). SETTING: Department of Ophthalmology, Vejle Hospital, Vejle, Denmark. METHODS: Eighty-four patients (84 eyes) were included in a prospective randomized study. All had phacoemulsification followed by implantation of an IOL with a modified anterior edge (38 eyes) or a sharp anterior edge (46 eyes). One day (baseline) and 3 months postoperatively, the area of the anterior capsule opening was measured using retroillumination photographs. RESULTS: There was a significant reduction in the area of the anterior capsule opening from 1 day to 3 months postoperatively in both groups (P<.001). There was no significant difference in the reduction in the anterior capsule opening between the modified-edge IOL and the sharp-edged IOL (P = .313). The shrinkage was independent of the area of the anterior capsule opening at baseline. CONCLUSIONS: There was a reduction in the area of the anterior capsule opening in all patients. The design of the anterior edge of the 2 IOLs did not influence the degree of anterior capsule opening shrinkage. The shrinkage was independent of the size of the area 1 day postoperatively.