Clinical and radiographic results of balloon kyphoplasty for treatment of vertebral body metastases and multiple myelomas

Kyphoplasty is a minimally invasive procedure that is used to augment vertebral body strength. This technique has been commonly used to treat osteoporotic, vertebral body compression fractures. The technique was also used to augment painful metastatic vertebral fractures. The objective of this study was to review the clinical and radiological results after kyphoplasty in patients with vertebral body compression fractures due to spinal metastasis and multiple myeloma and to determine factors that may affect outcome. Thirty-one patients had 41 vertebral body fractures secondary to spinal metastasis or multiple myeloma. A kyphoplasty procedure was performed on 39 levels. The pain and neurological status were evaluated using the visual analogue scale (VAS) score and the American Spinal Injury Association classification scale scores, respectively. Radiological evaluations were used to measure vertebral body height loss (VBHL) and the segmental kyphosis angle before and after surgery. The major symptoms that patients presented with included pain (25 patients); and neurological deficit (four patients). Two patients presented with no symptoms because the metastases were found during cancer screening. The mean (±standard deviation [SD]) VAS score was 7.2 ± 2.2 before surgery and 1.6 ± 1.3 after surgery. The mean preoperative VBHL was 27.8 ± 11.3% for the thoracic spine and 27.7 ± 12.5% for the lumbar spine. VBHL values were reduced to 22.4 ± 10.0% and 18.4 ± 10.4% for the thoracic and lumbar spine after surgery, respectively. The segmental kyphosis angles decreased from 21.2 ± 11.4° to 17.0 ± 9.8° for the thoracic spine and from 15.3 ± 8.8° to 10.4 ± 7.2° for the lumbar spine after surgery. There was a correlation between the symptom duration and VBH restoration rate. There was no correlation between the amount of injected polymethylmethacrylate and pain relief. We concluded that kyphoplasty is a safe and effective procedure for treating painful vertebral body fractures caused by metastasis and multiple myeloma. It can restore VBH and correct the kyphosis angle. While the increased amount of the injected PMMA led to its leakage, it did not contribute to restoration of the VBH or kyphosis correction. Therefore, one should avoid injection of excessive amounts of PMMA.     

The feasibility of recording blink reflexes under general anesthesia

Until now, there have been no reports on eliciting the blink reflex (BR) during anesthesia at a depth compatible with surgery. We introduce a novel method for eliciting the R1 component of the BR under inhalation or total intravenous anesthesia by using a short train of four to seven stimuli applied over the supraorbital nerve. Recording is done from the ipsilateral orbicularis oculi muscle. We set out to record the BR in 27 patients (age 1–78 years) without involvement of the facial nerve, trigeminal nerve, or brainstem. The BR could not be recorded in only 4 patients (recordability: 86.2%). All patients received at least one bolus of propofol while in surgery. Using this method, the BR was recorded on 4 awake healthy subjects. Boluses of propofol and muscle relaxants should be avoided in order to successfully record the responses. BR recording is feasible in patients under general anesthesia by using this novel technique. Muscle Nerve 39: 642–646, 2009     

Hungry bone syndrome after parathyroidectomy caused by an ectopic parathyroid adenoma

Hungry bone syndrome (HBS), i.e., persistent hypocalcemia and hypophosphatemia as a result of extensive remineralization, is rarely encountered in children after parathyroid surgery. Herein, we report a 12-year-old girl who was diagnosed to have an ectopic parathyroid adenoma, and HBS was observed in the postsurgical follow-up. The diagnosis and the risk factors are discussed in the light of the literature.     

Renal dysfunction is the most important predictor of the extent and severity of coronary artery disease in patients with diabetes mellitus

OBJECTIVES: Diabetic patients tend to have more extensive and diffuse coronary artery disease (CAD) that may contribute to the less favorable outcomes in them. The aim of this study was to elucidate the predictors of the angiographic severity and extent of CAD in patients with diabetes. METHODS: A total of 203 diabetic patients (116 men; mean age, 61.9+/-10.8) who were referred for a first coronary angiogram were included. The extent and severity of CAD was assessed in several ways. The first was a simple classification in one-vessel, two-vessel, and three-vessel disease scoring system. The total numbers of segments with > or = 20 and > or = 50% stenosis were calculated as CASS 20 and CASS 50 scores, respectively. Hamsten and Gensini scores were also calculated. RESULTS: Of the 203 patients included in the study, 175 (86.2%) had CAD. Multivariate ordinal logistic regression analysis showed that age (Wald 5.741, P=0.017), glomerular filtration rate (Wald 5.032, P=0.025), previous myocardial infarction (Wald 10.955, P=0.001), and family history of CAD (Wald 7.236, P=0.007) were independent predictors of the severity of CAD, as assessed by the clinical zero-vessel to three-vessel disease scoring system. On stepwise multiple linear regression analysis, glomerular filtration rate was an independent predictor of the CASS 20 (r=-0.221, P=0.004), CASS 50 (r=-0.239, P=0.005), Gensini (r=-0.328, P<0.001), and Hamsten (r=-0.320, P<0.001) scores. Previous myocardial infarction was an independent predictor of the CASS 50 (r=0.355, P<0.001), Gensini (r=0.350, P<0.001), and Hamsten (0.256, P<0.001) scores. Age and sex were independent predictors for the CASS 50 (r=0.174, P=0.039; r=0.172, P=0.016, respectively) and Hamsten (r=0.212, P=0.011; r=0.244, P=0.001, respectively) scores. CONCLUSION: Renal function is one of the most important factors associated with the extent and severity of coronary atherosclerosis, whereas classical coronary risk factors and the degree of metabolic control were not associated with the severity of coronary atherosclerosis in diabetic patients.     

Serum YKL-40 levels in patients with coronary artery disease

Atherosclerosis is considered to be an inflammatory disease in which the initial process is the augmented infiltration of monocytes into the vessel wall and their subsequent differentiation from macrophages into lipid-laden foam cells. Human cartilage glycoprotein-39 (YKL-40) is a new inflammatory marker found to be secreted by lipid-laden macrophages inside human atherosclerotic vessel wall. The aim of this study was to investigate the association of serum YKL-40 levels with the presence and extent of coronary artery disease (CAD) assessed by coronary angiography. We also studied the relation of high-sensitivity C-reactive protein with the presence and angiographic severity of CAD. A total of 200 participants undergoing to coronary angiography was divided into four subgroups: control patients without CAD (n=53), and those with one-vessel disease (n=52), two-vessel disease (n=47), or three-vessel disease (n=48). Serum YKL-40 levels were measured by enzyme-linked immunosorbent assay. Both serum YKL-40 levels and high-sensitivity C-reactive protein concentrations in patients with CAD were significantly higher than in control participants (P<0.001). We also found a significant association between the levels of YKL-40 and the extent of CAD defined by the number of stenosed vessels (P<0.001). The relationship between the serum YKL-40 level and atherosclerosis may represent a new opportunity for the possible utility of serum YKL-40 as an inflammatory marker for coronary artery disease. Moreover, our findings revealed that plasma YKL-40 measurement might also be regarded as a quantitative indicator of disease extent besides being a marker of disease presence.     

Thrombopoietin or interleukin-6 has no effect on thrombocytopenia of cirrhosis

BACKGROUND/AIMS: We aimed to compare the level of thrombocytopenia in cirrhotic patients with HBV and those with HCV, and to investigate whether the reduced serum level of IL-6 in patients with HCV is responsible for the lower platelet count compared to those with HBV through the effect on serum thrombopoietin level. METHODOLOGY: Fifty-three patients with liver cirrhosis, 28 of who were HBV- seropositive (Group A), 25 of who were HCV- seropositive (Group B) and 15 healthy controls were enrolled in this study. RESULTS: Platelet count in group B [75 (1.5-99) K/microL] were lower than those of group A [140 (62-374) K/microL] (p < 0.001). The median levels of serum thrombopoietin in patients [group A: 31.9 (31-113) pg/mL and group B: 38.0 (31.2-102) pg/mL] and controls [31.3 (31-153) pg/mL] did not show statistically significant difference. The patients compared to controls, had higher serum IL-6 levels [3.6 (2-1150) vs. 2.0 (2-9.9) pg/mL], (p < 0.01), which showed similarity in group A and B patients [3.65 (2-1150) vs. 3.3 (2-45) pg/mL], (p=NS). Serum thrombopoietin level was not correlated with serum IL-6 levels in any group. Serum thrombopoietin and IL-6 levels had no relationship with platelet count and with Child-Pugh score. CONCLUSIONS: Our study showed that cirrhotic patients with HCV had lower platelet count than those with HBV and controls, and this difference does not appear to be related with either serum thrombopoietin or IL-6 level.     

Laparoscopic management of gallbladder duplication

Gallbladder duplication is a rare condition. Because laparoscopic cholecystectomy is the primary treatment modality for the diseased single gallbladders, it should be the choice of treatment for double gallbladders. However, preoperative imaging methods may be unsatisfactory for the correct diagnosis. As a result, incomplete resections may be performed. Intraoperative cholangiography should be performed in suspected cases to prevent inadvertent injury to the biliary system. In this report, we present a symptomatic patient with double gallbladders with separate cystic ducts in whom the gallbladders were successfully resected as a single specimen by laparoscopic means. The pitfalls of diagnostic modalities and surgical strategy are discussed in the context of the available literature.     

Lidocaine for prevention of propofol injection-induced pain: A prospective, randomized, double-blind, controlled study of the effect of duration of venous occlusion with a tourniquet in adults

Background: Many patients experience pain on injection of propofol. The use of lidocaine to prevent propofol injection pain is common. The analgesic effect of pre-injected lidocaine has been found to increase when a tourniquet is used.Objective: The aim of this study was to compare the effectiveness of various venous occlusion times with lidocaine analgesia to prevent pain during propofol injection.Methods: In this prospective, randomized, double-blind, controlled study, women aged 18 to 45 years, classifed as American Society of Anesthesiologists physical sta- tus I or II, who were scheduled to undergo elective surgery under general anesthesia induced with propofol, were randomly assigned to 1 of 5 groups: group 1, 2% lidocaine 20 mg in saline in a total volume of 10 mL and no venous occlusion; group 2, 2% lidocaine 20 mg in saline in a total volume of 10 mL plus venous occlusion for 15 seconds; group 3, 2% lidocaine plus venous occlusion for 30 seconds; group 4, 2% lidocaine plus venous occlusion for 60 seconds; and group 5, saline 10 mL and no venous occlusion. When the first 25% of the calculated propofol dose was administered, patients were asked about propofol-induced pain using a verbal pain scale (0 = no pain; 1 = mild pain; 2 = moderate pain; and 3 = severe pain). All patients and the anesthesiologist who evaluated pain severity were blinded to the study preparation being used.Results: The study comprised 100 women who were randomly divided into 5 groups of 20 patients each. Significantly more patients in group 5 (18 [90%] patients; P < 0.05) reported pain compared with the other treatment groups. In groups 2, 3, and 4, in which venous occlusion was applied, pain was reported during propofol injection in 6 (30%), 7 (35%), and 2 (10%) patients, respectively. The incidence of reported pain was significantly greater in group 1 (lidocaine without venous occlusion) than in group 4 (P < 0.05); however, the incidence of pain was similar in group 1 compared with groups 2 and 3.Conclusions: The present study found that pretreatment with lidocaine 20 mg with or without venous occlusion significantly reduced the incidence and the severity of pain during the injection of propofol when compared with the group with no venous occlusion administered saline. In addition, pretreatment with lidocaine 20 mg plus venous occlusion for 60 seconds significantly reduced the incidence of propofol-induced pain compared with lidocaine without venous occlusion.