Treatment of war injuries of the shoulder with external fixators

In this retrospective study, 18 patients with war injuries of the shoulder were reviewed to evaluate the technical problems associated with external fixation and to analyze the incidence of infection and late functional results. The average patient age was 28.5 years. All patients were male. Thirteen patients had explosive wounds, whereas five wounds were caused by gunshot missiles. All injuries were extensive in terms of bone and soft tissue defects. Six patients presented with complex injuries involving neurovascular structures. Sixteen patients were treated with external fixation. Application of the proximal pins of the external fixator through the humeral head was possible in eight patients, the scapula served as the site of proximal fixation in four patients, only the clavicle was available for placement of pins in two patients, and both the scapula and the clavicle had to be pinned to achieve proximal stabilization in two patients. In two patients, fixation was not possible and early amputation was performed. Infection was eventually eradicated in all patients, allowing for adequate soft tissue coverage of the wounds. Analysis of functional results at an average of 6 years after the injury showed a considerable degree of functional deficit in most patients.     

Outcome of aortic valve repair in children with congenital aortic valve insufficiency

OBJECTIVE: Surgical aortic valvotomy has a long history of providing excellent palliation for aortic stenosis in infancy and childhood. The fate of aortic valve repairs for dominant aortic regurgitation in this same age group is considerably less clear. METHODS: From 1990 to 2000, a total of 21 patients underwent aortic valve repair for aortic regurgitation at our institution. Seventeen patients were younger than 17 years at the time of repair (3-17 years, mean 8.1 +/- 3.7 years). Of these 17 children, 6 (35%) had bicuspid valves and 11 (65%) had tricuspid valves. Type of repair varied with valve type, but repair generally consisted of commissure resuspension, partial commissure closure, triangular resection of redundant leaflets, or some combination. RESULTS: There were no deaths. Follow-up ranged from 1 to 11 years (mean 5.3 +/- 2.4 years). At present 3 of 17 (17.6%) have mild aortic regurgitation according to echocardiography and 6 (35.2%) have moderate aortic regurgitation. In 8 of 17 cases (47.1%) the repair clearly failed, requiring reoperation from 0.5 to 73 months after the original operation (mean 18.9 months). Reoperation consisted of 6 Ross procedures and 2 mechanical aortic valve replacements. There were no deaths at the secondary operation. CONCLUSION: Aortic valve repair in children with a dominant feature of aortic insufficiency tended to fail progressively and at a high rate. Leaflet thickening was associated with higher risk of repair failure in this series. The threshold for aortic valve replacement should remain low.     

The effects of cardiovascular dynamics monitoring in the outpatient management of pregnancy hypertension

OBJECTIVE: Our purpose was to assess the effects of the adjunctive use of cardiovascular dynamics monitoring in the ambulatory management of 199 pregnant patients with severe hypertension. STUDY DESIGN: A prospective, observational study was performed. Determinants of mean arterial pressure were computed by using the Hon monitor. Indicators of arterial compliance and effective blood volume were developed. All patients were monitored in the outpatient clinic; additionally, 19 patients self-tested at home. No rigid medication protocol was followed, but furosemide was used in most cases when cardiovascular dynamics monitoring patterns were consistent with volume loading. Otherwise, vasodilators were prescribed. The t test for independent samples was used to compare the home-monitored subgroup with the outpatient-only group. RESULTS: Pregnancy was prolonged by 74 +/- 63.9 days (mean +/- SD). Mean gestation was 37.6 +/- 2.9 weeks, and mean birth weight was 2882.4 +/- 837 g. The primary cesarean delivery rate was 23.7%, but only 15 (7.5%) cesarean deliveries were performed because of failed therapy. The 19 home-monitored patients gained 108 +/- 75 days (83.1 +/- 42.2 days beyond 20 weeks). CONCLUSION: Adjunctive cardiovascular dynamics monitoring may have a role in the evaluation and management of hypertension during pregnancy.     

Peroxisome proliferator-activated receptor ligands as antiatherogenic agents: panacea or another Pandora's box?

Peroxisome proliferator activated receptors (PPARs) are members of the nuclear receptor super family that modulate gene expression upon ligand activation. They are 3 major subtypes of PPARs: alpha, delta (also called beta), and gamma. PPAR-gamma is widely expressed in the cardiovascular system and is involved in the regulation of tissue inflammation and smooth muscle cell growth pathways as well as in lipoprotein metabolism and coagulation cascades. PPAR-gamma ligands of (e.g., rosigitazone and pioglitazone) have been shown to exert antiatherogenic effects both in vitro and in vivo. PPAR-alpha ligands (e.g., clofibrate and benzofibrate) modulate lipoprotein metabolism, and affect inflammation and coagulation cascade. These effects may be helpful in resolving the dilemma arising from studies that showed significant mortality and morbidity benefits of fibrates in the face of minimal changes in HDL-cholesterol levels. The role of PPAR-delta in atherogenesis remains largely unknown, although it appears that PPAR-delta activation affects lipoprotein metabolism. PPAR ligands appear to be promising agents in limiting atherosclerosis; however, large-scale clinical trials are required to assess their safety and efficacy before they can be added to the clinicians' arsenal of antiatherosclerotic agents.     

Dynamic 3D computer-assisted reconstruction of a metallic retrobulbar foreign body for diagnostic and surgical purposes. [Case report of orbital injury with ethmoid bone involvement

The main goal of our dynamic 3D computer-assisted reconstruction of a metallic retrobulbar foreign body following orbital injury with ethmoid bone involvement was to use 3D-information obtained from standard computed tomography (CT) data to explore and evaluate the nasal cavity, ethmoidal sinuses, retrobulbar region, and the foreign body itself by simulated dynamic computed visualization of the human head. A foreign body, 10 x 30 mm in size, partially protruded into the posterior ethmoidal cells and partially into the orbit, causing dislocation and compression of the medial rectus muscle and inferior rectus muscle. The other muscles and the optic nerve were intact. Various steps were taken to further the ultimate diagnosis and surgery. Thin CT sections of the nasal cavity, orbit and paranasal sinuses were made on a conventional CT device at a regional medical center, CT scans were transmitted via a computer network to different locations, and special views very similar to those seen on standard endoscopy were created. Special software for 3D modeling, specially designed and modified for 3D C-FESS purposes, was used, as well as a 3D-digitizer connected to the computer and multimedia navigation through the computer during 3D C-FESS. Our approach achieves the visualization of very delicate anatomical structures within the orbit in unconventional (non-standard) sections and angles of viewing, which cannot be obtained by standard endoscopy or 2D CT scanning. Finally, virtual endoscopy (VE) or a 'computed journey' through the anatomical spaces of the paranasal sinuses and orbit substantially improves the 3D C-FESS procedure by simulating the surgical procedure prior to real surgery.     

Noninvasive assessment of acute cardiopulmonary effects of an oral single dose of sildenafil in patients with idiopathic pulmonary hypertension

We aimed to assess the acute cardiopulmonary effects of a 100-mg oral single dose of sildenafil in patients with idiopathic pulmonary hypertension (IPAH) using a well-validated but less-used noninvasive echocardiographic method for the measurement of both systolic and diastolic pulmonary artery pressure (PAP), by tricuspid regurgitation (TR) velocity curve analysis. We studied 12 consecutive patients with IPAH (10 patients with New York Heart Association functional class III, and 2 patients with functional class II). A 100-mg oral single dose of sildenafil was added to previous medications of all patients and its immediate effects were evaluated 1, 5, and 12 h after treatment. Using paired analysis, administration of a 100-mg oral single dose of sildenafil led to a significant reduction in mean PAP and a remarkable increase in pulmonary acceleration time (PAT) 1 h after treatment (P = 0.000; 95% confidence interval [CI] 18.99–26.00 and P = 0.005; 95% CI −12.89 to −2.95, respectively). In addition, although the right heart dimensions (right atrium and right ventricle) showed a trend toward improvement, the differences were not statistically significant (P = 0.13 and P = 0.08, respectively). Our results demonstrated that Doppler examination of TR alone can be easily used for the estimate of systolic and diastolic PAP in patients with IPAH. This study also shows that sildenafil is the only drug given orally that can evaluate the vasodilatory capacity of the pulmonary vascular bed in patients with IPAH, with promising effects on mPAP and PAT in these patients.