pQCT bone strength index may serve as a better predictor than bone mineral density for long bone breaking strength

Bone mineral density (BMD) is commonly used to predict osteoporotic fracture risk without considering the geometry of the bone. However, geometric parameters are also important in determination of bone strength. An index including both material and geometric properties may be therefore more relevant in prediction of fracture risk. We studied the correlation between parameters measured by noninvasive peripheral quantitative computed tomography (pQCT) and bone bending strength of the diaphysis of 45 fresh goat humeri and 27 femora. Multislice pQCT was used for measuring volumetric diaphyseal cortical BMD, total BMD, diaphyseal and cortical cross-sectional area (CSA), and cross-sectional moment of inertia (CSMI) and their derived bone strength indices (BSIs), including BSI_CSMI (cortical BMD × CSMI) and BSI_CSA (cortical BMD × cortical CSA). Conventional dual-energy absorptiometry (DXA) was also conducted to measure areal BMD of diaphysis for comparison. Ultimate fracture load was obtained via three-point bending test. Results showed that for femora, fracture load was correlated better with BSI_CSA (r = 0.697, P 0.001) than cortical BMD (r = 0.304, P 0.05) and total BMD (r = 0.387, P 0.05) measured using pQCT and areal BMD (r = 0.612, P 0.001) measured using DXA. For humeri, fracture load was also correlated with BSI_CSA (r = 0.579, P 0.001) but not with other pQCT parameters including cortical BMD and total BMD (r = 0.282 and 0.305, respectively; P 0.05, both). The best correlation was found with areal BMD measured by DXA (r = 0.760, P 0.001). In conclusion, pQCT noninvasive BSI_CSA derived from cortical BMD (material) and its cortical CSA (bone geometry or distribution) may serve as an important noninvasive index for predicting long bone bending strength. The bending strength was also predicted by bone mass (areal BMD) measured by DXA, an integration of bone mineral and geometry. Further clinical studies are needed to validate the predictive value of BSI in long bone osteoporotic fracture.     

Hand-assisted D2 subtotal gastrectomy for carcinoma of stomach

We report a case of hand-assisted D2 subtotal gastrectomy with Roux-en-Y reconstruction for advanced gastric cancer. This case shows the advantages of hand-assisted laparoscopic surgery for gastric cancer. Extended lymph node dissection and intracorporeal anastomosis are feasible and easier with the presence of the internal hand. Our method is an alternative to total laparoscopic radical gastrectomy.     

Strangulated appendix epiploica in paraumbilical hernia: preoperative diagnosis and laparoscopic treatment

Appendix epiploica can occasionally cause acute abdominal pain. The usual presentations are torsion or primary epiploic appendicitis. Strangulation inside a paraumbilical hernia with acute abdominal pain is seldom reported in the literature. The authors report a case of preoperative diagnosis and laparoscopic treatment of strangulated appendix epiploica in paraumbilical hernia that presented as acute abdominal pain.     

Postmastectomy reconstruction with extended latissimus dorsi myocutaneous flap for Hong Kong Chinese

Objective: Because of the smaller breast size of Chinese women, postmastectomy reconstruction without prosthesis by extended latissimus dorsi (LD) flap is potentially more applicable in the Chinese population. Methods: Patients who had undergone immediate postmastectomy breast reconstruction by extended latissimus dorsi flap without prosthesis were retrospectively studied. Surgical complications, aesthetic result and patient satisfaction were evaluated. Results: Ten Asian patients (nine Chinese and one Filipino) underwent extended LD flap for breast reconstruction after mastectomy. There was no total or partial flap failure. Operative complications included seroma in one patient and minor wound edge slough at back wounds in two patients. Simultaneous seroma and minor donor wound slough occurred in another patient. Aesthetic outcome was excellent (n = 5), good (n = 4) and poor (n = 1). Patient satisfaction with the procedure was very satisfied in four, satisfied in four and dissatisfied in two, respectively. All but two patients would recommend the same procedure to their friends or relatives. Conclusion: Extended LD flap can reliably achieve pleasing results with low morbidity. It has more potential to become a competitive alternative to transverse abdominis myocutaneous flap in most Chinese women for postmastectomy reconstruction.     

Use of extended pattern technique for initial prostate biopsy

PURPOSE: An extended prostate biopsy schema has been advocated at initial prostate biopsy to decrease the rate of false-negative cancer cases. However, critics have raised concerns that this may lead to the greater detection of clinically insignificant cancers. We examined the impact of using an extended pattern schema on cancer detection and also on the finding of smaller and clinically insignificant cancer. MATERIALS AND METHODS: Clinical data, including patient age, race, prebiopsy prostate specific antigen (PSA), digital rectal examination, prostate volume, number of needle cores and biopsy findings were abstracted from the medical records of all patients who underwent prostate biopsy in a 5-year period. Extended pattern prostate biopsy was defined as more than 10 cores. Clinically insignificant cancer was defined as a maximal tumor dimension of 1.0 cm or less, Gleason sum 6 or less and organ confined disease at radical prostatectomy. Adjusted regression models were developed to assess the independent effects of using an extended biopsy pattern on the detection of cancer overall and on the detection of clinically insignificant cancer. RESULTS: A total of 740 men with a mean age of 62.6 years were referred for prostate biopsy. Median PSA was 5.7 ng/ml and prostate volume was 39.7 cc. The OR for detecting prostate cancer was 1.55 (95% CI 1.09 to 2.19) for the extended pattern compared with standard biopsy. Of the subset of 136 patients who underwent radical prostatectomy 12.6% had clinically insignificant cancer. However, in contrast to overall cancer detection, extended pattern prostate biopsy was not found to be associated with an increased risk of detecting smaller or clinically insignificant cancer. PSA density was the single parameter found to be independently associated with the detection of clinically insignificant cancer (95% CI 0.20 to 0.98). CONCLUSIONS: Using an extended prostate biopsy pattern involving more than 10 cores increases the likelihood of detecting prostate cancer. A significant association between more needle cores at initial prostate biopsy and finding smaller and clinically insignificant cancer was not apparent.     

Postmortem molecular analysis of SCN5A defects in sudden infant death syndrome.

CONTEXT: Fatal arrhythmias from occult long QT syndrome may be responsible for some cases of sudden infant death syndrome (SIDS). Because patients who have long QT syndrome with sodium channel gene (SCN5A) defects have an increased frequency of cardiac events during sleep, and a recent case is reported of a sporadic SCN5A mutation in an infant with near SIDS, SCN5A has emerged as the leading candidate ion channel gene for SIDS. OBJECTIVE: To determine the prevalence and functional properties of SCN5A mutations in SIDS. DESIGN, SETTING, AND SUBJECTS: Postmortem molecular analysis of 93 cases of SIDS or undetermined infant death identified by the Medical Examiner's Office of the Arkansas State Crime Laboratory between September 1997 and August 1999. Genomic DNA was extracted from frozen myocardium and subjected to SCN5A mutational analyses. Missense mutations were incorporated into the human heart sodium channel alpha subunit by mutagenesis, transiently transfected into human embryonic kidney cells, and characterized electrophysiologically. MAIN OUTCOME MEASURES: Molecular and functional characterization of SCN5A defects. RESULTS: Two of the 93 cases of SIDS possessed SCN5A mutations: a 6-week-old white male with an A997S missense mutation in exon 17 and a 1-month old white male with an R1826H mutation in exon 28. These 2 distinct mutations occurred in highly conserved regions of the sodium channel and were absent in 400 control patients (800 alleles). Functionally, the A997S and R1826H mutant channels expressed a sodium current characterized by slower decay and a 2- to 3-fold increase in late sodium current. CONCLUSION: Approximately 2% of this prospective, population-based cohort of SIDS cases had an identifiable SCN5A channel defect, suggesting that mutations in cardiac ion channels may provide a lethal arrhythmogenic substrate in some infants at risk for SIDS.     

Outcomes in adults with bicuspid aortic valves

Nikolaos Tzemos, MD; Judith Therrien, MD; James Yip, MD; George Thanassoulis, MD; Sonia Tremblay, MD; Michal T. Jamorski, BSc; Gary D. Webb, MD; Samuel C. Siu, MD, SM

JAMA. 2008;300(11):1317-1325.

Context  Bicuspid aortic valve is the most common congenital cardiac anomaly in the adult population. Cardiac outcomes in a contemporary population of adults with bicuspid aortic valve have not been systematically determined.

Objective  To determine the frequency and predictors of cardiac outcomes in a large consecutive series of adults with bicuspid aortic valve.

Design, Setting, and Participants  Cohort study examining cardiac outcomes in 642 consecutive ambulatory adults (mean [SD] age, 35 [16] years; 68% male) with bicuspid aortic valve presenting to a Canadian congenital cardiac center from 1994 through 2001 and followed up for a mean (SD) period of 9 (5) years. Frequency and predictors of major cardiac events were determined by multivariate analysis. Mortality rate in the study group was compared with age- and sex-matched population estimates.

Main Outcome Measures  Mortality and cause of death were determined. Primary cardiac events were defined as the occurrence of any of the following complications: cardiac death, intervention on the aortic valve or ascending aorta, aortic dissection or aneurysm, or congestive heart failure requiring hospital admission during the follow-up period.

Results  During the follow-up period, there were 28 deaths (mean [SD], 4% [1%]). One or more primary cardiac events occurred in 161 patients (mean [SD], 25% [2%]), which included cardiac death in 17 patients (mean [SD], 3% [1%]), intervention on aortic valve or ascending aorta in 142 patients (mean [SD], 22% [2%]), aortic dissection or aneurysm in 11 patients (mean [SD], 2% [1%]), or congestive heart failure requiring hospital admission in 16 patients (mean [SD], 2% [1%]). Independent predictors of primary cardiac events were age older than 30 years (hazard ratio [HR], 3.01; 95% confidence interval [CI], 2.15-4.19; P<.001), moderate or severe aortic stenosis (HR, 5.67; 95% CI, 4.16-7.80; P<.001), and moderate or severe aortic regurgitation (HR, 2.68; 95% CI, 1.93-3.76; P<.001). The 10-year survival rate of the study group (mean [SD], 96% [1%]) was not significantly different from population estimates (mean [SD], 97% [1%]; P = .71). At last follow-up, 280 patients (mean [SD], 45% [2%]) had dilated aortic sinus and/or ascending aorta.

Conclusions  In this study population of young adults with bicuspid aortic valve, age, severity of aortic stenosis, and severity of aortic regurgitation were independently associated with primary cardiac events. Over the mean follow-up duration of 9 years, survival rates were not lower than for the general population.

     

The Third World Integrative Medicine Congress Abstracts (Excerption)

The 3rd World Integrative Medicine Congress (3rd WIMCO) was held on September 22-24, 2007 in Guangzhou, China. The Congress has showed the academic achievements of integrative medicine in the recent five years covering a wide range of fields, such as basic and experimental research; clinical research; theory, education and management research; new drug research and development; and application of evidence-based medicine.     

Autograft Ossiculoplasty in Cholesteatoma Surgery: Is It Feasible?

OBJECTIVE: To investigate whether autologous ossicles can be safely used in ossicular reconstruction in cholesteatoma surgery after attempting cholesteatoma removal under the operating microscope. STUDY DESIGN: A prospective fine-section histological study of formalin-stored ossicles, harvested from cholesteatomatous ears, to evaluate for existence of residual cholesteatoma after surface disease clearance under the operating microscope. METHODS: One hundred four ossicles were harvested from 76 patients with cholesteatoma for the study. These malleus heads and includes were categorized into three groups: group 1, ossicles with retained shape and useful bulk, treated by microscopic stripping alone; group 2, ossicles with retained shape and useful bulk, treated by microscopic stripping and drilling; and group 3, badly eroded ossicles, treated by microscopic stripping alone. These treated ossicles were then subjected to 4 microm histopathological study. RESULTS: Residual disease was identified in 6 of the 104 ossicles. Residual disease was found only in badly eroded ossicles that are not suitable for reconstruction. All the usable ossicles were free of disease. CONCLUSIONS: Autologous ossicles that have retained body and bulk are safe to use for reconstruction after surface stripping under the operating microscope. Additional burring probably adds a further margin of safety.