Laparoscopic versus open appendectomy for complicated appendicitis

BACKGROUND: Laparoscopic appendectomy has been widely practiced for uncomplicated appendicitis; various reports demonstrated its merits in assisting diagnosis, reducing postoperative pain, analgesic requirement, and incidence of wound infection. The role of laparoscopy in management of complicated appendicitis, ie, gangrenous, perforated appendicitis and appendiceal abscess, remains undefined. Currently, the choice of operative approach is mostly at the surgeons' discretion. A retrospective study was conducted in our institution to review the feasibility, safety, and efficacy of laparoscopic appendectomy for patients with complicated appendicitis. STUDY DESIGN: From January 1999 to January 2004, records of patients older than 14 years of age with diagnosis of appendicitis were retrieved from computer database for analysis. All patients underwent diagnostic laparoscopy to confirm diagnosis of complicated appendicitis, and patients subsequently underwent either laparoscopic or open appendectomies. Patients' demographics data and perioperative outcomes from the two groups were compared. RESULTS: During the study period, 1,133 patients with acute appendicitis underwent operations in our institution. Two hundred forty-four patients (21.5%) with complicated appendicitis were identified by laparoscopy, of which 175 underwent laparoscopic appendectomy (LA) and 69 had open appendectomy (OA). Both groups of patients were comparable in demographics. Mean operative time was 55 minutes for LA group and 70 minutes for the OA group (p<0.001). Mean hospital stay was 5 days and 6 days for LA and OA group respectively (p<0.001). There was one conversion patient (0.6%) in the LA group who suffered from wound infection, and there were seven (10%) wound infections in the OA group (p=0.001). There were 10 cases (5.7%) of intraabdominal collection in the LA group and 3 (4.3%) in the OA group (p=0.473). There was no mortality in the current series. CONCLUSIONS: Laparoscopic appendectomy for complicated appendicitis is feasible and safe. It is associated with a significantly shorter operative time, lower incidence of wound infection, and reduced length of hospital stay when compared with patients who had open appendectomy.     

A quantitative evaluation of sealing ability of 4 obturation techniques by using a glucose leakage test.

OBJECTIVE: The aim of this study was to evaluate the sealing ability of 4 different obturation techniques by using a glucose leakage test. STUDY DESIGN: Eighty extracted single-rooted maxillary incisors were selected for the study. The teeth were decoronated and the root canals prepared using ProFile rotary instruments to an apical dimension of size 40 (0.06 taper). The specimens were then randomly divided into 4 experimental groups (n = 15) and filled with gutta-percha and sealer by using either cold lateral compaction, warm vertical compaction, Thermafil, or the E & Q Plus system. Another 10 teeth each served as the positive and negative controls. A glucose leakage model was used for quantitative evaluation of the coronal-to-apical microleakage at 24 hours, 1, 2, 3, 5, 8, and 12 weeks. RESULTS: No significant difference in the cumulative amount of leakage was found among the 4 groups at 24 hours and 1 week (Kruskal-Wallis test, P > .05). Lateral compaction showed significantly more leakage than the other 3 techniques at longer intervals (Mann-Whitney U test, P < .008). No significant difference was found between vertical compaction, Thermafil, and E & Q Plus at all observation times. CONCLUSIONS: Warm vertical compaction, Thermafil, and the E & Q Plus system showed a better sealing result than cold lateral compaction of gutta-percha at extended observation periods. The glucose leakage method used in this study was able to provide a nondestructive, quantitative, and long-term evaluation of the sealing ability of root canal fillings.     

Peripheral administration of the melanocortin-4 receptor antagonist NBI-12i ameliorates uremia-associated cachexia in mice

We have recently shown that genetic or pharmacological blockade of the melanocortin-4 receptor (MC4-R) attenuates uremia-associated cachexia. However, the potential clinical utility of this approach has been limited by the need to deliver a peptide MC4-R antagonist into the ventricles of the brain. NBI-12i is a recently developed small molecule MC4-R antagonist, with high affinity and selectivity that penetrates the central nervous system after peripheral administration. We tested whether NBI-12i would also be effective in attenuating uremia-associated cachexia in a mouse model. Intraperitoneal administration of NBI-12i stimulated food intake and weight gain in uremic mice. Furthermore, NBI-12i-treated uremic mice gained lean body mass, fat mass, and had a lower basal metabolic rate compared to vehicle-treated and diet-supplemented uremic mice, which lost both lean body mass and fat mass and had an increase in basal metabolic rate. We found that NBI-12i normalizes the expression of uncoupling protein, which is normally upregulated in uremic mice, and we speculate that this may contribute to the drug's protective effect. These data underscore the importance of melanocortin signaling in the pathogenesis of uremia-associated cachexia and demonstrate the potential of peripheral administration of MC4-R antagonists as a novel therapeutic approach.     

Endotracheal intubation: the role of sterility

BACKGROUND: There is a paucity of data regarding whether sterile handling of endotracheal tubes (ETTs) impacts the incidence and prevalence of pneumonia in the emergency, urgent, or elective clinical scenarios. Intensive care units employ infection control and reduction schemes to reduce pneumonia rates. METHODS: A MEDLINE search of the English-language literature for the last 30 years was performed using the keywords "endotracheal intubation," "intubation," "pneumonia," "sinusitis," "tracheobronchitis," "nosocomial infection," and "infection." Data were limited to those papers addressing the role of sterile handling or passage of ETTs, infection with antibiotic-resistant micro-organisms, antibiotic prophylaxis, and the role of virulence determinants in supporting invasive infection. Also, a convenience sample of a single author's patients requiring tracheal intubation was undertaken. Data were acquired on tube handling, success of insertion, and subsequent occurrence of pneumonia. RESULTS: Virtually no data exist on the impact of sterile ETT handling, but unsterile manipulation of the ETT prior to insertion is common (112 of 154 intubation events). Within the limited patient sample, no conclusions may be drawn regarding the impact of unsterile handling on pneumonia rates, although sinusitis after nasotracheal intubation clearly increases the incidence of pneumonia. Biofilm generation as a facilitator of bacterial colonization of artificial airway surfaces is a ubiquitous virulence determinant that is not ameliorated by antibiotic administration. CONCLUSIONS: Unsterile ETT handling and insertion techniques are not clearly associated with pneumonia induction, but physiologically sound approaches that retard biofilm production may decrease pneumonia rates.     

Effect of tibial drill-guide angle on the mechanical environment at bone tunnel aperture after anatomic single-bundle anterior cruciate ligament reconstruction

Purpose

The tibial drill-guide angle in anterior cruciate ligament (ACL) reconstruction influences the tunnel placement and graft-tunnel force, and is potentially associated with post-operative tunnel widening. This study aimed to examine the effect of the drill-guide angle on the stress redistribution at the tibial tunnel aperture after anatomic single-bundle ACL reconstruction.

Methods

A validated finite element model of human knee joint was used. The tibial tunnel with drill-guide angle ranging from 30° to 75° was investigated. The post-operative stress redistribution in tibia under the compressive, valgus, rotational and complex loadings was analysed.

Results

Compressive loading played a leading role on the stress redistribution at intra-articular tibial tunnel aperture. After ACL reconstruction, stress concentration occurred in the anterior and posterior regions of tunnel aperture while stress reduction occurred in the lateral and posteromedial regions under the compressive loading. Stress redistribution was partially alleviated by using the drill-guide angle ranging from 55° to 65°.

Conclusions

The present study quantified the effect of bone tunnel drill-guide angle on the post-operative stress redistribution. This phenomenon potentially contributed to tunnel widening. A tunnel drill-guide angle ranging from 55° to 65° was proposed based on the biomechanical rationale. It could serve as a helpful surgical guide for ACL reconstruction.     

MRI Detection of Forearm Soft Tissue Injuries with Radial Head Fractures

Background

This study aims to evaluate the incidence of forearm soft tissue abnormalities associated with radial head fracture severity based on the Mason classification system.

Methods

Eighteen patients (age 18–45 years) were prospectively evaluated with elbow radiographs and magnetic resonance imaging (MRI) following longitudinal forearm trauma. MRI was performed within 10 days of the initial injury. Radiographs and MR images were evaluated in a blinded fashion by two musculoskeletal radiologists.

Results

Thirteen of 18 patients presented with Mason type I radial head fractures. In all patients with Mason type I fractures, the interosseous membrane (IOM) was intact. Two patients had Mason type II fractures with associated partial and compete tearing of the IOM and three patients had Mason type III fractures with complete tearing of the IOM. Edema was noted in the pronator quadratus in six of 13 type I injuries and seen in all type II and III injuries. No structural forearm soft tissue abnormalities were present in patients with Mason type I injuries. The presence of edema within the pronator quadratus correlated with distal forearm pain.

Conclusions

The severity of radial head fracture correlates with longitudinal forearm injury evidenced by the presence of IOM tearing. The findings suggest patients with Mason type II or III fractures of the radial head should undergo further evaluation of the forearm for associated soft tissue injuries. Edema within the pronator quadratus was present following forearm trauma regardless of the severity of fracture and was related to symptomatic forearm pain.