Video-Assisted Thyroidectomy Significantly Reduces the Risk of Early Postthyroidectomy Voice and Swallowing Symptoms

Background Voice and swallowing symptoms are frequently reported after thyroidectomy even in absence of objective voice alterations. We evaluated the influence of the video-assisted approach on voice and swallowing outcome of thyroidectomy. Methods Sixty-five patients undergoing total thyroidectomy (TT) were recruited. Eligibility criteria were: nodule size ≤30 mm, thyroid volume ≤30 ml, no previous neck surgery. Exclusion criteria were: younger than aged 18 years and older than aged 75 years, vocal fold paralysis, history of voice, laryngeal or pulmonary diseases, malignancy other than papillary thyroid carcinoma. Patients were randomized for video-assisted (VAT) or conventional (CT) thyroidectomy. Videostrobolaryngoscopy (VSL), acoustic voice analysis (AVA), and maximum phonation time (MPT) evaluation were performed preoperatively and 3 months after TT. Subjective evaluation of voice (voice impairment score = VIS) and swallowing (swallowing impairment score = SIS) were obtained preoperatively, 1 week, 1 month, and 3 months after TT. Results Fifty-three patients completed the postoperative evaluation: 29 in the VAT group, and 24 in the CT group. No laryngeal nerves injury was shown at postoperative VSL. Mean postoperative MPT, F ₀, F _low, F _high, and the number of semitones were significantly reduced in the CT group but not in the VAT group. Mean VIS 3 months after surgery was significantly higher than preoperatively in CT group but not in the VAT group. Mean SIS was significantly decreased 1 and 3 months after VAT but not after CT. Conclusions The incidence and the severity of early voice and swallowing postthyroidectomy symptoms are significantly reduced in patients who undergo VAT compared with conventional surgery. Presented at the ISW2007—IAES free paper session, Montreal, Canada, August 26–30, 2007.     

Malignant pleural mesothelioma: utility of 18 F-FDG PET

Malignant Pleural Mesothelioma is a rare tumour that arise from the mesothelial cells of the pleura and in recent time the incidence of this disease is rising. Because of the implications for management and therapy, it is important to assess the accurate staging. 18F-fluorodeoxiglucose Positron Emission Tomography (18F-FDG PET) is become a useful tool in the diagnosis of many neoplasms, such as Malignant Pleural Mesothelioma. In particular it has been shown to be useful in the evaluation of the extent of pleural disease, in the establishment of lymph node involvement, in the evaluation of tumour invasion into the lung and thoracic wall, in the diagnosis of extrathoracic metastases, in the assessment of the response to treatment, and in planning radiotherapy. Developments in system technology, like improvements in hybrid system (integrated Positron Emission Tomography/Computed Tomography) and the discovery of new radiopharmaceuticals, promise to make PET much more useful and versatile in the future.     

Biomechanical analysis of screw-augmented intramedullary fixation for tibiotalocalcaneal arthrodesis

BACKGROUND: This study compared intramedullary (IM) fixation for tibiotalocalcaneal arthrodesis with and without a tibiotalocalcaneal augmentation screw. METHODS: Each specimen in six matched pairs of fresh frozen cadavers underwent tibiotalocalcaneal arthrodesis with an IM nail. One specimen from each pair also received a tibiotalocalcaneal augmentation screw. Initial and final stiffness, load to failure, and construct deformation at failure were calculated with dorsiflexion loading. Bone mineral density of each pair was determined. Statistical analysis was done using a paired Student t-test and a Pearson correlation. RESULTS: Initial and final stiffness and load to failure were significantly higher for the tibiotalocalcaneal screw augmented fixation group as compared with the specimens with no additional screw (initial stiffness, 128.0 versus 78.4 N/mm, p = 0.04; final stiffness, 230.9 versus 164.7 N/mm, p = 0.04; load to failure, 875.5 versus 660.2 N, p = 0.03). There was a significant negative correlation between bone mineral density and average construct deformation in the samples without the added tibiotalocalcaneal screw (r = -0.90, p = 0.02). CONCLUSIONS: In tibiotalocalcaneal arthrodesis with intramedullary nail fixation, a tibiotalocalcaneal augmentation screw provides more stable fixation. CLINICAL RELEVANCE: Use of an augmentation screw as described in this study may lead to lower complication rates, particularly in patients with osteopenic bone.     

Excursion and strain of the superficial peroneal nerve during inversion ankle sprain

BACKGROUND: Traction is presumed to be the mechanism of injury to the superficial peroneal nerve in an inversion ankle sprain, but it is not known whether the amount of strain caused by nerve traction is sufficient to cause nerve injury. We hypothesized that the superficial peroneal nerve would experience significant excursion and strain during a simulated inversion sprain, that sectioning of the anterior talofibular ligament would increase excursion and strain, and that an impact force would produce strain in a range that can structurally alter the nerve. METHODS: Differential reluctance transducers were placed in the superficial peroneal nerve in sixteen lower-extremity cadaver specimens to measure excursion and strain in situ. Static weight was applied to the foot in increments starting at 0.454 kg and ending at 4.54 kg. The anterior talofibular ligament was sectioned, and the measurements were repeated. A final impact force of 4.54 kg was applied to each specimen. Two-way repeated-measures analysis of variance was used to evaluate differences in excursion and strain. RESULTS: The mean excursion and strain of the superficial peroneal nerve increased with increases in the applied weight in both the group with the intact anterior talofibular ligament and the group in which it had been sectioned. Nerve excursion was greater in the sectioned-ligament group than in the intact-ligament group with all applied weights (p < 0.05). The mean nerve strain was greater in the sectioned-ligament group (range, 5.5% to 12.9%) than in the intact-ligament group (range, 3.0% to 11.6%) with application of the 0.454, 0.908, 1.362, and 1.816-kg weights (p < 0.05). With the ligament sectioned, the 4.54-kg impact force produced significantly higher mean nerve excursion and strain than did the 4.54-kg static weight (p < 0.05). CONCLUSIONS: The magnitude of strain with the impact force was in the lower range of values that have been shown to structurally alter peripheral nerves. The superficial peroneal nerve is at risk for traction injury during an ankle inversion sprain and is at additional risk with more severe sprains or with an insufficient anterior talofibular ligament.     

Effects of N-acetylcysteine on myoglobinuric-acute renal failure in rats

Oxygen metabolites play an important role in renal injury during myoglobinuric acute renal failure (ARF). This study was designed to determine the protective influence of N-acetylcysteine (NAC), a hydroxyl radical scavenger, and treatment in an experimental model of myoglobinuric-ARF induced by intramuscular injection of hypertonic glycerol in rats. The rats were randomly distributed into five groups: Group 0 (n = 10), was assigned to receive 2mL saline (0,9%) intraperitoneally (ip); Group 1 (n = 10), NAC ip in a dose of 0 mg/100 g of body weight 30 min before the intramuscular (im) injection of 50% glycerol (10 mg/kg); Group 2 (n = 10), received saline 0,9% ip in a equivalent volume of NAC in Group I before the im injection of glycerol; Group 3 (n = 10), received NAC ip in a dose of 10 mg/100 g after im injection of glycerol; Group 4 (n = 10), saline 0,9% ip in a equivalent volume of NAC of the Group 3 after im administration of glycerol. After 24 h rats were sacrificed and kidney morphology and renal function were determined. A severe renal failure was produced by glycerol injection in the Groups 1, 2, 3, and 4, with significant tubular proximal necrosis and cast formation, and creatinine and urea concentrations were elevated in these groups without significant differences among groups, but Group 0 where the values were significantly lower. The results of this study suggests that ip administration of NAC in rats before or after glycerol injection do not confer protection against impairment of renal function under these conditions in this model of myoglobinuric-ARF.     

Outcome and management of isolated severe renal pelvis dilatation detected at postnatal screening

The aim of this study was to evaluate the incidence and outcome of isolated severe renal pelvis dilatation (RPD; APD > 15 ≤ 20 mm) in an unselected population of 2-month-old infants prospectively followed up for 12–14 months of life. Isolated severe renal pelvis dilatation was detected in 46 of the 11,801 (0.39%) infants screened. Nephro-urological investigations were initiated if RPD persisted, or if urinary tract infection (UTI) occurred during follow-up, and antibiotic therapy was administered only when UTI occurred. At follow-up, RPD persisted in 24 infants. Of these, 8 infants presented with vesico-ureteral reflux (VUR) of grade ≥ 3 and 16 with ureteropelvic junction obstruction (UPJO). Incidence of UTI was significantly higher (p < 0.001) in infants of the study group than in infants of the control group (13.9 vs 2.5%). Our data suggest that isolated severe RPD may be a self-limiting condition and that antibiotic prophylaxis (AP) for the prevention of UTI should not be performed. Considering RDP resolution and the incidence of UTI during follow-up, investigations for uropathy in infants with isolated, severe RPD are justified in persistent cases, or when UTI occurs during follow-up. Careful clinical monitoring for signs of UTI and treatment of each episode of UTI may be sufficient and safe.     

Nutritional-inflammation status and resistance to erythropoietin therapy in haemodialysis patients.

BACKGROUND: Chronic kidney disease patients who are resistant to erythropoietin (EPO) treatment may suffer from malnutrition and/or inflammation. METHODS: In a cross-sectional study of haemodialysis patients, we investigated the relationship between the natural logarithm of the weekly EPO dose normalized for post-dialysis body weight and outcome measures of nutrition and/or inflammation [BMI, albumin and C reactive protein (CRP)] by means of multiple linear regression analysis. On the basis of the decile distribution of weekly EPO doses, we also evaluated four groups of patients: untreated, hyper-responders, normo-responders and hypo-responders. RESULTS: Six hundred and seventy-seven adult haemodialysis patients were recruited from five Italian centres. BMI and albumin were lower in the hypo-responders than in the other groups (21.3+/-3.8 vs 24.4+/-4.7 kg/m(2), P<0.001; and 3.8+/-0.6 vs 4.1+/-0.4 g/dl, P<0.001), whereas the median CRP level was higher (1.9 vs 0.8 mg/dl, P = 0.004). The median weekly EPO dose ranged from 30 IU/kg/week in the hyper-responsive group to 263 IU/kg/week in the hypo-responsive group. Transferrin saturation linearly decreased from the hyper- to hypo-responsive group (37+/-15 to 25+/-10%, P = 0.003), without any differences in transferrin levels. Ferritin levels were lower in the hypo-responsive than in the other patients (median 318 vs 445 ng/ml, P = 0.01). At multiple linear regression analysis, haemoglobin, BMI, albumin, CRP and serum iron levels were independently associated with the natural logarithm of the weekly EPO dose (R(2) = 0.22). CONCLUSIONS: Our findings support a clear association between EPO responsiveness and nutritional and inflammation variables in haemodialysis patients; iron deficiency is still a major cause of hypo-responsiveness.     

Use of Permacol in complicated incisional hernia

Polypropylene mesh repair is the gold standard for primary inguinal hernia and incisional hernia. Wound infection and small bowel fistulas are contraindications to polypropylene mesh repair. In addition, synthetic meshes are known to cause severe peritoneal adhesions and enteric fistulas if located close to the bowel. Porcine intestinal submucosa has been used successfully in experimental studies in dogs and rats to repair large abdominal wall defects. A new porcine dermal collagen graft has been used in man for groin hernia repair, incisional hernia repair and other surgical procedures without complications. We describe 6 cases of complicated incisional hernia operated in emergency using porcine dermal collagen grafts. In one woman the incisional hernia was associated with an enterovaginal fistula. Three cases presented severe wound infections, two of which related to a previous polypropylene mesh repair, while another had an irreducible recurrent incisional hernia and one woman presented complete evisceration. None of the patients had postoperative or porcine-graft-related complications. Over a follow-up period of 3-24 months we have had no recurrence or wound infection. The results of these few cases confirm the safety and efficacy of the porcine dermal collagen mesh also in incisional hernia repair.     

IgA glomerulonephritis: beyond angiotensin-converting enzyme inhibitors

IgA glomerulonephritis accounts for 25-50% of renal biopsy diagnoses. About 25-50% of patients progress to end-stage renal disease within 20 years of diagnosis. Angiotensin-converting enzyme inhibitors and angiotensin II type I receptor blockers slow progression of IgA nephropathy (IgAN); however, as drugs of this class are not IgAN specific and are therefore unlikely to alter significantly its natural course, many other therapeutic approaches have been proposed. Most have been tested in a relatively small number of patients and have not yet proven to be effective in the long term. Conflicting and variable data, and a lack of long-term prospective randomized studies, mean that most treatments cannot be recommended as standard therapy for IgAN. Steroids seem to be the best treatment for patients with proteinuria, as drugs in this class ameliorate this symptom and protect against deterioration of renal function. Combined treatment with corticosteroids and cytotoxic drugs has yielded interesting results in several studies, especially in progressive patients with severe IgAN. In this review, we critically analyze the data on these treatments.     

Post‐transplant lymphoproliferative disorder in adult liver transplant recipients: a South American multicenter experience

Post‐transplant lymphoproliferative disorder (PTLD) is a major and potentially life‐threatening complication after solid‐organ transplantation. The aim of this study was to describe the disease characteristics, clinical practices, and survival related to PTLD in adult orthotopic liver transplant (OLT) recipients in South America. We conducted a survey at four different transplant groups from Argentina, Brazil, and Chile. Among 1621 OLT recipients, 27 developed PTLD (1.7%); the mean age at diagnosis was 53.7 (±14) yr with a mean time of 39.7 (±35.2) months from OLT to PTLD diagnosis. Initial therapy included reduction in immunosuppression alone in 23.1% of the patients. Either rituximab or chemotherapy was employed as initial or second‐line therapy in 76.9% of the patients. PTLD location was frequently extranodal (80.7%) and mostly involving the transplanted liver (59.3%). The overall survival at one and five yr post‐PTLD diagnosis was 53.8% and 46.2%, respectively. Significant univariate risk factors for post‐PTLD mortality included lactate dehydrogenase ≥250 U/L (HR 9.66, p = 0.02), stage III/IV PTLD (HR 5.34, p = 0.004), and HCV infection (HR 7.68, p = 0.01). In conclusion, PTLD in OLT adult recipients is predominantly extranodal, and although mortality is high, long‐term survival is possible.