The etiology of adolescent idiopathic scoliosis

The etiology of adolescent idiopathic scoliosis (AIS), the most common form of scoliosis, is unclear. Researchers with divergent perspectives have tried to better define this etiology. Genetics, growth hormone secretion, connective tissue structure, muscle structure, vestibular dysfunction, melatonin secretion, and platelet microstructure are major areas of focus. In this article, we review the literature in these areas and present the consensus on proposed hypotheses. Studies that simplify the etiology to a single factor have been inconclusive or unsuccessful. Most likely, the etiology is multifactorial, and reported associations are links in pathogenesis rather than etiologic factors. Research is needed to better define the role of all factors in AIS development.     

Adult-to-adult living donor liver transplantation at the Asan Medical Center,Korea

Between February 1997 and December 2001, 311 adult-to-adult living donor liver transplants (A-A LDLTs) were performed at the Asan Medical Center for patients above 20 years of age. Indications for A-A LDLT were: chronic hepatitis B (203), chronic hepatitis C (5), hepatocellular carcinoma (64), alcoholic cirrhosis (9), cryptogenic cirrhosis (4), secondary biliary cirrhosis (5), primary biliary cirrhosis (1), Wilson' s disease (2), autoimmune hepatitis (1), hepatic tuberculosis (1), cholangiocarcinoma (1), fulminant hepatic failure (14) and primary non-function of cadaveric liver graft (1). Of 311 A-A LDLTs, 36 were of medical high urgency, 20 were for acute and subacute hepatic failure, 15 were for hepato-renal syndrome and 1 was for primary non-function. Recipient age ranged from 27 to 64 years. Donor age ranged from 16 to 62 years. There was no donor mortality. Implanted liver grafts were categorized into seven types: 175 modified right lobe (MRL), 70 left lobe, 32 right lobe, 20 dual grafts, 10 left lobe plus caudate lobe, three extended right lobe and one posterior segment. In MRL, the tributaries of the middle hepatic vein were reconstructed by interpositioning a vein graft. Indication for dual graft implantation was the same as single graft A-A LDLT, and four of 20 were emergency cases. Of 20 dual grafts, 14 received two left lobes, four received a left lobe and a lateral segment, one received a right lobe and a left lobe and one received a lateral segment and a posterior segment. Graft volume ranged from 28% to 83% of the standard liver volume of the recipients. There were 33 (10.6%) in-hospital mortalities (< 4 months) among the 310 patients after 311 A-A LDLTs. Of the 36 patients receiving emergency transplants, 31 survived. These encouraging results justify the expansion of A-A LDLT in coping with increasing demands, even in urgent situations. We have aimed to introduce the establishment of the efficacy of A-A LDLT in various end-stage chronic and acute liver diseases, as well as new technical advances to overcome small graft-size syndrome by using dual-graft implantation and MRL, both of which were first developed in our department.     

Solid Organ Transplantation From Hepatitis B Virus–Positive Donors: Consensus Guidelines for Recipient Management

Use of organs from donors testing positive for hepatitis B virus (HBV) may safely expand the donor pool. The American Society of Transplantation convened a multidisciplinary expert panel that reviewed the existing literature and developed consensus recommendations for recipient management following the use of organs from HBV positive donors. Transmission risk is highest with liver donors and significantly lower with non‐liver (kidney and thoracic) donors. Antiviral prophylaxis significantly reduces the rate of transmission to liver recipients from isolated HBV core antibody positive (anti‐HBc+) donors. Organs from anti‐HBc+ donors should be considered for all adult transplant candidates after an individualized assessment of the risks and benefits and appropriate patient consent. Indefinite antiviral prophylaxis is recommended in liver recipients with no immunity or vaccine immunity but not in liver recipients with natural immunity. Antiviral prophylaxis may be considered for up to 1 year in susceptible non‐liver recipients but is not recommended in immune non‐liver recipients. Although no longer the treatment of choice in patients with chronic HBV, lamivudine remains the most cost‐effective choice for prophylaxis in this setting. Hepatitis B immunoglobulin is not recommended.     

Intravenous Lidocaine for Effective Pain Relief After a Laparoscopic Colectomy: A Prospective,Randomized, Double-Blind,Placebo-Controlled Study

A perioperative intravenous lidocaine infusion has been reported to decrease postoperative pain. The goal of this study was to evaluate the effectiveness of intravenous lidocaine in reducing postoperative pain for laparoscopic colectomy patients. Fifty-five patients scheduled for an elective laparoscopic colectomy were randomly assigned to 2 groups. Group L received an intravenous bolus injection of lidocaine 1.5 mg/kg before intubation, followed by 2 mg/kg/h continuous infusion during the operation. Group C received the same dosage of saline at the same time. Postoperative pain was assessed at 2, 4, 8, 12, 24, and 48 hours after surgery by using the visual analog scale (VAS). Fentanyl consumption by patient-controlled plus investigator-controlled rescue administration and the total number of button pushes were measured at 2, 4, 8, 12, 24, and 48 hours after surgery. In addition, C-reactive protein (CRP) levels were checked on the operation day and postoperative days 1, 2, 3, and 5. VAS scores were significantly lower in group L than group C until 24 hours after surgery. Fentanyl consumption was lower in group L than group C until 12 hours after surgery. Moreover, additional fentanyl injections and the total number of button pushes appeared to be lower in group L than group C (P < 0.05). The CRP level tended to be lower in group L than group C, especially on postoperative day1 and 2 and appeared to be statistically significant. The satisfaction score was higher in group L than group C (P = 0.024). Intravenous lidocaine infusion during an operation reduces pain after a laparoscopic colectomy.Key words: Analgesics, Colectomy, Pain, LidocaineBecause of a substantial increase in the incidence of benign and malignant tumors of the colon, the number of laparoscopic colorectal surgeries has increased.¹ Laparoscopic colectomy appears to be less painful, involves less bleeding, and has a faster recovery than an open colectomy.² Further, laparoscopic colorectal surgery has been proven to be beneficial in comparison with robot-assisted laparoscopic colorectal surgery in many aspects.³ However, postoperative pain because of surgical incision is still an issue that requires resolution. Therefore, various clinical applications such as intrathecal morphine, epidural analgesia, patient-controlled analgesia (PCA), and nonsteroidal anti-inflammatory drugs (NSAIDs) are used to control pain after a laparoscopic colectomy.^4,5 However, optimal management has not yet been established. A regional block can have technical difficulties and complications. The epidural failure rate has been reported up to 40%, and other drugs, such as opioids or NSAIDs, have side effects or drug allergies.^5,6Intravenous lidocaine is inexpensive, easy to inject, and a relatively safe drug.⁷ A number of studies showed that intravenous lidocaine has analgesic, anti-hyperalgesic, and anti-inflammatory properties, as well as a fast recovery, reducing the hospital stay and the time for bowel function recovery.^8–10 In addition, lidocaine in a nontoxic concentration has been reported to decrease the variant volatile anesthesia requirement in an animal study.¹⁰ Therefore, the authors aimed to determine whether a continuous infusion of intravenous lidocaine would have an adequate postoperative analgesic effect for a laparoscopic colectomy. The hypothesis of this study was that an intravenous lidocaine infusion during an operation could decrease postoperative pain.     

Impact of recurrent disease and chronic allograft nephropathy on the long‐term allograft outcome in patients with IgA nephropathy

Although recurrent IgA nephropathy (IgAN) may lead to graft dysfunction after transplantation, donation from living related donor (LRD), with whom the risk of recurrence may be higher, is not a contraindication. Herein, we evaluated the natural history of allograft in recipients with IgAN and the risk factors influencing long‐term allograft outcome. Recurrence rate and graft survival were assessed retrospectively in 221 IgAN patients, including transplants from 139 LRDs (62.9%). Ten‐year cumulative rate for recurrent IgAN was 30.8%. The operation at younger age and donation from LRD were significant for the recurrence by multivariate analysis. Ten‐year graft survival was affected by recurrent IgAN (61.0% in recurrent IgAN group vs. 85.1% in nonrecurrent, P < 0.01). However, transplants from LRDs did not show poor graft survival when compared with those from other types of donors. In transplants from LRDs, the incidence of chronic allograft nephropathy (CAN) was lower than those in grafts from deceased donors (10.8% vs. 19.5%, P < 0.05). When CAN was considered in addition to recurrence, the variance of graft survival was affected significantly by the development of CAN than by the recurrence. These results suggest that the detection and adequate management of CAN could improve graft outcome in transplant recipients with IgAN.     

Treatment failure and clinical progression after salvage therapy in men with biochemical recurrence after radical prostatectomy: radiotherapy vs androgen deprivation

Study Type – Therapy (case series)
Level of Evidence 4

OBJECTIVE

To compare the outcomes between salvage radiotherapy (RT) and androgen‐deprivation therapy (ADT), to investigate factors determining clinical progression (CP) in men with prostate cancer.

PATIENTS AND METHODS

The study comprised 121 patients with biochemical recurrence while on follow‐up by prostate‐specific antigen (PSA) measurement, without adjuvant therapy after radical prostatectomy, received RT (45) or ADT (76). Failure after salvage therapy was defined as a PSA level of >0.2 ng/mL. Clinical, pathological and treatment factors were analysed.

RESULTS

The clinicopathological characteristics were similar between the RT and ADT groups except that men in the RT group were younger (61.4 vs 65.4 years). After ADT, salvage failed in 10 (13%) after a mean (sd ) of 18.5 (4.5) months of treatment, and 6.7 months after salvage failed all patients progressed clinically. After RT, salvage failed in 22 (49%) after 30.7 (5.2) months of response. Upon RT failure, all patients received ADT, after which in three (14%) patients the treatment failed again after 20.1 months of treatment and progressed to CP after 6.5 months, while in the remaining 19 (86%) patients the PSA level remained undetectable for 37.6 (7.7) months. On multivariate analysis, pathological stage (≥T3b) and Gleason grade 5 disease were independently prognostic of CP.

CONCLUSION

Salvage RT alone and combined with subsequent ADT provided PSA control in most patients, significantly increasing CP‐free survival compared with initial ADT. Patients with a short PSA doubling time (<3 months) are at high risk of failed salvage treatment after RT, and initial ADT might be considered. Regardless of salvage method, advanced pathological stage and Gleason grade 5 were factors prognostic of CP.     

Interposition grafts for difficult carotid artery reconstruction: a 17-year experience

Carotid interposition grafts (CIP) for carotid artery revascularization can be a viable alternative to carotid endarterectomy (CEA) or carotid artery stenting (CAS) for complex carotid disease. This is a retrospective review of the UCLA 17-year experience with CIP for carotid reconstruction. Carotid operations performed between 1988 and 2005 revealed 41 CIP procedures in 39 patients using polytetrafluoroethylene (PTFE, n = 31) or reversed greater saphenous vein (Vein) (n = 10). Perioperative data and long-term follow-up for each conduit were statistically compared. There were no significant differences in demographics, risk factors, operative indications, complications, or 30-day perioperative deaths. There was one postoperative stroke in each group, for an overall stroke rate of 4.9% (PTFE 3.2%, Vein 10%). There was one asymptomatic occlusion and there were two high-grade restenoses in the PTFE group compared with one asymptomatic occlusion and one high-grade restenosis in the Vein group. Overall primary patency was 90% and the assisted primary patency was 97% for the PTFE group (mean follow-up 50 months), whereas primary patency was 80% (mean follow-up 30 months) in the Vein group. CIP is a safe and effective technique with excellent long-term follow-up for complex carotid reconstruction when CEA or CAS may be contraindicated.     

Laser Punch-Out for Acne Scars

Patients with acne scars want smooth facial skin. However, achieving this is difficult with dermabrasion or chemical peeling. Nor can acne scars be covered with cosmetics, due to their ice-picked or cobblestone appearance. Laser resurfacing is more effective and safer than other conventional methods due to its precision with depth control and variable methods of surface cutting. Even depth resurfacing with a laser shows unsatisfactory results, therefore, for the deep-sited acne scar the cutting methods have to be changed according to the depth and pattern of the scar. For 2 years, starting in January 1996, we treated 71 patients with a high-powered CO₂ laser (Ultrapulse). Different resurfacing methods were applied according to the depth and pattern of the scars. For mild depressed scars, even depth resurfacing was done. For moderate-depth acne scars, the shoulder technique was also used. For the deepest and ice-picked scars, the laser punch-out was combined. Laser resurfacing was carried out at 300–500 mJ, with two to five passes. Laser punch-out was done at 500 mJ, with three to seven continuous passes on the ice-picked scar. From the pathologic findings of acne scars showing that there was thick intradermal scar, we knew that laser punch-out was necessary for improvement of acne scars. Depth-wide, the ice-picked scars improved by over 80% and the sharp demarcated margin of the acne scar faded out. Most of the patients with acne scars were satisfied with laser resurfacing. Only six patients had a second laser treatment, with an interval of 12 months. There were no hypertrophic scars after laser resurfacing, but erythema lasted for 3–12 months. Patients taking oral retinoic acid were not contraindicated for laser resurfacing but required special caution because they had atrophic skin and delayed wound healing. Laser resurfacing is the most versatile method for acne scars, with a high-powered CO₂ laser. The laser punch-out method is better than even depth resurfacing for improving deep acne scars and can be combined with the shoulder technique or even depth resurfacing according to the type of acne scar.     

Carotid endarterectomy with normal findings from a completion study: Is there need for early duplex scan?

OBJECTIVE: The objective of this study was to determine the value of early (< 6 months) duplex scanning after carotid endarterectomy (CEA) with an intraoperative completion study with normal results. Attention was paid to restenosis rates and reoperation for recurrent stenosis within the first 6 months. METHODS: A retrospective review was performed on 380 CEAs (338 patients) with intraoperative completion studies and duplex surveillance within the first 6 months. Results of completion studies, restenosis rates, and recurrent symptoms were evaluated for each operation. Studies were performed from 0 to 200 days postoperatively (median, 28). RESULTS: Intraoperative completion studies included 333 angiograms, 26 duplex scans, and 21 angiograms with duplex scans. Of the 380 intraoperative completion studies, 28 (7.5%) had abnormal findings, including 14 abnormal internal carotid arteries (ICAs). Twenty-four procedures were revised, and the findings of all repeat completion studies were normal. Of the initial completion studies, in four cases, abnormalities (3 ICAs) were insignificant and did not warrant further intervention. Follow-up ICA duplex scans had normal results after 364 (95.8%) CEAs. There were 14 mild recurrent ICA stenoses and two moderate recurrent ICA stenoses; neither had abnormal findings from the completion study. There were no severe recurrent ICA stenoses. External carotid artery (ECA) recurrent stenosis included 7 mild, 15 moderate, and 9 severe restenoses. CONCLUSIONS: Only 0.5% of CEAs developed moderate restenosis. No procedures had severe recurrent stenosis on duplex scan within the first 6 months, and none required intervention. Duplex surveillance in the first 6 months is relatively unproductive, providing that there were normal results from an intraoperative completion study for each patient. Routine surveillance can be started at 1 year.