FDG-PET Detected Thyroid Incidentalomas: Need for Further Investigation?

Background Incidental thyroid abnormalities are increasingly detected in patients undergoing PET scans. The aim of this study was to review our experience with the management of PET detected thyroid incidentalomas in a large single institution series. Methods All PET scans performed from May 2003 to July 2005 were reviewed and patients with incidental thyroid abnormalities were identified. From this group, patients that underwent further investigation were analyzed. Data relating to PET scan findings, FNA diagnoses, operative details, and histopathology was reviewed. Results In 8,800 patients, 16,300 PET scans were performed of whom 263 patients (2.9% of patients and 1.6% of PET scans) had findings positive for thyroid abnormality. Thyroid malignancy was noted in 42% (24 patients) of the 57 patients that underwent FNA. In the group of 27 patients that were subjected to operative intervention, 74% (20 patients) were noted to have a malignant diagnosis. The final histopathology revealed primary thyroid carcinoma in all these 20 patients (19 patients with papillary carcinoma and one patient with primary thyroid lymphoma). The factors that correlated with an increased risk of malignancy were the presence of physical finding (p = 0.01) and focal (p < 0.01) or unilateral uptake (p < 0.01) on PET scan. The average SUV was not useful in differentiating benign (9.2) from malignant lesions (8.2, p = 0.7). Conclusions PET detected incidental thyroid abnormalities are rare. In patients with positive PET scan findings and suspicious features, the incidence of primary thyroid malignancy is very high. These patients warrant further investigation followed by possible operative intervention.     

Endoscopic subfascial surgery for incompetent perforator veins in patients with active venous ulceration

Background: Previously, subfascial ligation of perforator veins to treat venous ulceration in the lower extremities required long skin incisions through diseased skin and subcutaneous tissue. This was known as "the Linton operation." In 1985, Hauer described an endoscopic technique for ligating incompetent perforator veins; this seminal contribution marked the advent of subfascial endoscopic perforator surgery (SEPS). Methods: From 1996 to 1998, we prospectively collected data on 41 patients with chronic venous insufficiency (CVI) who underwent a SEPS procedure at our institution. Preoperative assessment consisted of color-flow duplex ultrasound scanning, as well as ascending and descending phlebography. Results: Some 45 SEPS procedures were performed on the 41 patients. Ages ranged from 42 to 84 years (mean, 60). Active venous ulcers were present in 37 legs; healing occurred within 9 weeks in 33 of them. No new ulcers developed in the follow-up period, a mean of 44 weeks. Conclusion: The results suggest that the SEPS procedure incorporated into the overall treatment plan for patients with CVI produces active healing with a minimum of postoperative complications. The study demonstrates the safety and efficiency of this procedure; it also underscores the important role incompetent perforator veins have in the formation of venous ulcers.     

A triple-blinded randomized trial comparing the hemostatic effects of large-dose 10% hydroxyethyl starch 264/0.45 versus 5% albumin during major reconstructive surgery

In Canada, hydroxyethyl starch 264/0.45 (HES 264/0.45; molar weight 264 kDa, molar substitution 0.45) has largely replaced albumin as the colloidal fluid of choice for perioperative intravascular volume expansion. The maximum recommended dose of HES 264/0.45 is 28 mL/kg; however, there are no clinical data supporting this limit. In this study we compared the hemostatic effects of HES 264/0.45 versus 5% albumin in doses up to 45 mL/kg over 24 h during major reconstructive head and neck surgery. Fifty patients were randomized to receive HES 264/0.45 or 5% human albumin from the induction of anesthesia until 24 h thereafter. Both albumin and HES 264/0.45 effectively maintained physiologic variables in the perioperative and postoperative periods. The partial thromboplastin time and international normalized ratio were significantly increased in the HES 264/0.45 group compared with the albumin group after infusion of 30 mL/kg and 45 mL/kg (P < 0.05). Factor VIII activity and von Willebrand factor level were significantly reduced in the HES 264/0.45 group compared with the albumin group after infusion of 15 mL/kg, 30 mL/kg, and 45 mL/kg (P < 0.05). Significantly more subjects in the HES 264/0.45 group received allogeneic red blood cell transfusions (P < 0.02). We conclude that HES 264/0.45 infusions >30 mL/kg over 24 h impair coagulation to a greater extent than albumin, possibly leading to more allogeneic transfusions.     

High-mobility group box 1 protein activates hepatic stellate cells in vitro

Objectives

Our previous study noticed remarkably elevated titers of anti-high-mobility group box 1 (HMGB1) antibodies in sera during the tolerance induction phase of a rat tolerogenic orthotopic liver transplantation (OLT) as well as in sera of clinically drug-free patients. We hypothesized that the release of nonhistone nuclear protein HMGB1 during rejection may play a pathogenic role in deteriorating post-OLT graft functions, such as inducing liver fibrosis. This study sought to investigate whether HMGB1 can directly activate hepatic stellate cells (HSCs) and drive them toward fibrogenesis.

Methods

The cultured HSCs were treated with recombinant HMGB1. RT-PCR and Western blotting analysis were used to measure α-smooth muscle actin (α-SMA) expression. Conditioned media were collected for gelatin zymography to monitor the activities of collagen-degrading matrix metalloproteinases (MMPs).

Results

HMGB1 at concentrations >1 ng/mL significantly stimulated HSC growth as revealed by proliferation and BrdU assays. α-SMA gene and protein expression were significantly up-regulated by HMGB1, whereas the MMP-2, but not MMP-9, activity was suppressed by HMGB1 treatment.

Conclusion

Our data suggested that HMGB1 protein, once released during the rejection phase of OLT, activated HSCs and exhibited profibrogenic effects on liver grafts either by increasing the HSC population and extracellular matrix content in liver grafts, or by transforming HSCs into myofibroblasts. Neutralization with anti-HMGB1 antibody was suggested to be a therapeutic modality applicable to prevent fibrogenesis in post-OLT liver grafts.     

Surgical management and outcome of blunt major liver injuries: Experience of damage control laparotomy with perihepatic packing in one trauma centre

Introduction

This retrospective study aimed to assess the clinical experience and outcome of damage control laparotomy with perihepatic packing in the management of blunt major liver injuries.

Materials and methods

From January 1998 to December 2006, 58 patients of blunt major liver injury, American Association for the Surgery of Trauma-Organ Injury Scale (AAST-OIS) equal or greater than III, were operated with perihepatic packing at our institute. Demographic data, intra-operative findings, operative procedures, adjunctive managements and outcome were reviewed. To determine whether there was statistical difference between the survivor and non-survivor groups, data were compared by using Mann–Whitney U test for continuous variables, either Pearson's chi-square test or with Yates continuity correction for contingency tables, and results were considered statistically significant if p < 0.05.

Results

Of the 58 patients, 20 (35%) were classified as AAST-OIS grade III, 24 (41%) as grade IV, and 14 (24%) as grade V. At laparotomy, depending on the severity of injuries, all 58 patients underwent various liver-related procedures and perihepatic packing. The more frequent liver-related procedures included debridement hepatectomy (n = 21), hepatorrhaphy (n = 19), selective hepatic artery ligation (n = 11) and 7 patients required post-laparotomy hepatic transarterial embolization. Of the 58 patients, 28 survived and 30 died with a 52% mortality rate. Of the 30 deaths, uncontrolled liver bleeding in 24-h caused 25 deaths and delayed sepsis caused residual 5 deaths. The mortality rate versus OIS was grade III: 30% (6/20), grade IV: 54% (13/24), and grade V: 79% (11/14), respectively. On univariate analysis, the significant predictors of mortality were OIS grade (p = 0.019), prolonged initial prothrombin time (PT) (p = 0.004), active partial thromboplastin time (APTT) (p < 0.0001) and decreased platelet count (p = 0.005).

Conclusions

The mortality rate of surgical blunt major liver injuries remains high even with perihepatic packing. Since prolonged initial PT, APTT and decreased platelet count were associated with high risk of mortality, we advocate combination of damage control resuscitation with damage control laparotomy in these major liver injuries.     

Specific detection and semiquantitation of microorganisms in tissue by nucleic acid hybridization. II. Investigation of synovia from pigs with chronic erysipelothrix arthritis

Synovial tissues from animals with chronic Erysipelothrix arthritis were examined by a technique based on RNA-DNA hybridization in an attempt to detect the inducing organism, Erysipelothrix insidiosa (EI). Twelve synovial specimens from 5 animals whose joints lacked culturable EI also lacked EI detectable by this technique. Because the technique is capable of detecting approximately one organism per 50 mammalian cells, it is concluded that no more than this number were present in the involved tissue. Implications of these results for proposed pathogenetic mechanisms in this disorder and in human rheumatoid arthritis are discussed.     

Preservation Versus Division of Ilioinguinal Nerve on Open Mesh Repair of Inguinal Hernia: A Meta-analysis of Randomized Controlled Trials

Background

Chronic groin pain after inguinal hernia repair, a serious problem, is caused by entrapment of the ilioinguinal nerve either by mesh or development of fibrosis. Division of the ilioinguinal nerve during hernioplasty has been found to reduce the incidence of chronic groin pain. However, the traditional approach favors preservation of the ilioinguinal nerve during open hernia repair.

Methods

We conducted a systematic review and meta-analysis of randomized controlled trials that compared the outcomes of preservation versus division of the ilioinguinal nerve during open mesh repair of inguinal hernia. The primary outcome was the incidence of groin pain; secondary outcomes were numbness and sensory loss.

Results

We reviewed six trials with 1,286 patients. We found no difference between the groups for the incidence of groin pain or numbness at 1, 6, and 12 months after open mesh inguinal repair. The incidence of sensory loss or change was significantly higher in the division group than in the preservation group at 6 months [risk ratio (RR) 1.25; 95?% confidence interval (CI) 1.02–1.53] and at 12 months (RR 1.55; 95?% CI 1.01–2.37) postoperatively. No significant differences between the groups were noted at any other points in time.

Conclusions

Preservation of the ilioinguinal nerve during open mesh repair of inguinal hernia is associated with a decreased incidence of sensory loss at 6 and 12 months postoperatively compared with that of the division technique. No significant differences were found between the groups for chronic groin pain or numbness.     

Possible pathophysiology of ketamine‐related cystitis and associated treatment strategies

Ketamine‐related cystitis is characterized by ketamine‐induced urinary frequency and bladder pain. It has become a serious problem in recent years. The most typical grossly pathological bladder change with ketamine related cystitis is a contracted bladder and bladder wall thickening. Ulcerative cystitis with an easily bleeding mucosa is a common cystoscopic finding. Microscopically, the urothelium is denuded and is infiltrated by inflammatory cells, such as mast cells and eosinophils. The pathogenesis of ketamine‐related cystitis is complicated and involves many different pathways. Past evidence suggests a direct toxic effect, bladder barrier dysfunction, neurogenic inflammation, immunoglobulin‐E‐mediated inflammation, overexpression of carcinogenic genes, abnormal apoptosis and nitric oxide synthase‐mediated inflammation contribute to the pathogenesis of ketamine‐related cystitis. The first step to managing ketamine‐related cystitis is always asking patients to cease ketamine. Medical treatment might be helpful in patients with early ketamine‐related cystitis and abstinence from ketamine. Several case studies showed that the intravesical installation of hyaluronic acid and intravesical injection of botulinum toxin type A were effective for symptom relief in selected patients. For patients with irreversible pathological change, such as contracted bladder, augmentation enterocystoplasty might be the only solution to increase bladder capacity and relieve intractable bladder pain.