Experience with covered stents for the management of hemodialysis polytetrafluoroethylene graft seromas

Prosthetic graft seromas is a rare complication that has been traditionally managed with open methods using partial graft replacement and open drainage. We report the first two cases of hemodialysis graft seromas successfully treated with a covered stent. Both patients underwent arteriovenous graft placement from the brachial artery to the axillary vein using a standard wall, tapered 4 to 7 mm polytetrafluoroethylene graft, but developed a seroma at the arterial end of the graft. Unsuccessful attempts were made to treat these seromas with percutaneous and open drainage. In both patients, an 8 mm x 50 mm Wallgraft (Boston Scientific, Natick, Mass) was retrogradely deployed "bareback" at the arterial end of the graft allowing for complete resolution of the graft seromas.     

Outcomes of Pheochromocytoma Management in the Laparoscopic Era

Background Laparoscopic adrenalectomy (LA) is the preferred surgical approach for pheochromocytomas. We have investigated the changes in diagnosis, management and outcome of pheochromocytomas treated since the widespread advent of LA. Methods Data were collected retrospectively from 96 patients with pheochromocytomas that had been surgically treated at three tertiary referral centers. Results There were 53 females. Mean age was 47 years (10–81). Tumors were found incidentally in 40% of patients. Of the 96 patients, 12 (13%) had familial syndromes. CT or MRI localized the adrenal lesion in all patients. MIBG scans obtained from 32 patients were concordant with the CT/MRI in 19, were false negative in 9 and misleading in 1, and altered management in only 3 patients. Mean tumor size was 5.6 cm (1.8–17). There were 92 adrenal pheochromocytomas and 9 paragangliomas. Laparoscopy was successful in 67 of 74 (91%) patients, with 20 of 67 (30%) having tumors of 6 cm or greater in size. Conversions to open procedures were performed in patients with 4 left, 2 right pheochromocytomas and 1 paraganglioma. Of the patients, 22 had an open procedure due to suspicion of malignancy or large tumors. Malignancy was observed in 4 of 92 (4.3%) pheochromocytomas and 4 of 9 (44%) paragangliomas. Average follow-up was 22 months (1–122). There were seven recurrences. Postoperative biochemical tests available in 64 patients were normal in 90%. Conclusions The diagnosis of pheochromocytoma was made incidentally in 40% of patients. MIBG is not necessary for unilateral non-hereditary pheochromocytomas localized by CT/MRI. LA is possible with excellent results in most patients, including for treatment of lesions 6 cm or greater in size with no signs of invasion. Laparoscopy should be used cautiously for paragangliomas because of a high rate of malignancy.     

Exome Sequence Data From Multigenerational Families Implicate AMPA Receptor Trafficking in Neurocognitive Impairment and Schizophrenia Risk

Schizophrenia is a mental disorder characterized by impairments in behavior, thought, and neurocognitive performance. We searched for susceptibility loci at a quantitative trait locus (QTL) previously reported for abstraction and mental flexibility (ABF), a cognitive function often compromised in schizophrenia patients and their unaffected relatives. Exome sequences were determined for 134 samples in 8 European American families from the original linkage study, including 25 individuals with schizophrenia or schizoaffective disorder. At chromosome 5q32–35.3, we analyzed 407 protein-altering variants for association with ABF and schizophrenia status. For replication, significant, Bonferroni-corrected findings were tested against cognitive traits in Mexican American families (n = 959), as well as interrogated for schizophrenia risk using GWAS results from the Psychiatric Genomics Consortium (PGC). From the gene SYNPO, rs6579797 (MAF = 0.032) shows significant associations with ABF (P = .015) and schizophrenia (P = .040), as well as jointly (P = .0027). In the Mexican American pedigrees, rs6579797 exhibits significant associations with IQ (P = .011), indicating more global effects on neurocognition. From the PGC results, other SYNPO variants were identified with near significant effects on schizophrenia risk, with a local linkage disequilibrium block displaying signatures of positive selection. A second missense variant within the QTL, rs17551608 (MAF = 0.19) in the gene WWC1, also displays a significant effect on schizophrenia in our exome sequences (P = .038). Remarkably, the protein products of SYNPO and WWC1 are interaction partners involved in AMPA receptor trafficking, a brain process implicated in synaptic plasticity. Our study reveals variants in these genes with significant effects on neurocognition and schizophrenia risk, identifying a potential pathogenic mechanism for schizophrenia spectrum disorders.Key words: schizophrenia, cognition, SYNPO, WWC1, synaptic plasticity     

Antinociceptive Effect of Low-Dose Intrathecal Neostigmine Combined with Intrathecal Morphine following Gynecologic Surgery

Background: The purpose of this study was to determine whether combination of 1-5 [mu]g intrathecal neostigmine would enhance analgesia from a fixed intrathecal dose of morphine.

Methods: A total of 60 patients undergoing gynecologic surgery were randomized to one of five groups. Patients received 15 mg bupivacaine plus 2 ml of the test drug intrathecally (saline, 100 [mu]g morphine, or 1-5 [mu]g neostigmine). The control group received spinal saline as the test drug. The morphine group received spinal morphine as test drug. The morphine + 1 [mu]g neostigmine group received spinal morphine and 1 [mu]g neostigmine. The morphine + 2.5 [mu]g neostigmine group received spinal morphine and 2.5 [mu]g neostigmine. Finally, the morphine + 5 [mu]g neostigmine group received spinal morphine and 5 [mu]g neostigmine.

Results: The groups were demographically similar. The time to first rescue analgesic (minutes) was longer for all patients who received intrathecal morphine combined with 1-5 [mu]g neostigmine (median, 6 h) compared with the control group (median, 3 h) (P < 0.02). The morphine group (P < 0.05) and the groups that received the combination of 100 [mu]g intrathecal morphine combined with neostigmine (P < 0.005) required less rescue analgesics in 24 h compared with the control group. The incidence of perioperative adverse effects was similar among groups (P > 0.05).     

Fixation of periprosthetic femoral shaft fractures associated with cemented femoral stems: a biomechanical comparison of locked plating and conventional cable plates

To determine which of 2 techniques for the treatment of periprosthetic femoral shaft fractures is of greater stiffness. DESIGN: A laboratory study using 8 pairs of matched, embalmed femurs. METHODS: Femurs implanted with a cemented total hip prosthesis had a simulated periprosthetic femur fracture created distal to the implant. Fractures were fixed with a plate with locked screws or a plate with cables (Ogden construct). Fixation stability was compared in various loading modalities before and after cycling. Failure in torsional loading was then determined. The cement mantle was tested for crack propagation that may have occurred secondary to locked screw insertion and loading. OUTCOME MEASUREMENTS: Fixation stiffness (the ratio of applied load to displacement at the fracture site), torsional strength, mode of failure for each system, and cement mantle evaluation for cracks after screw insertion. RESULTS: Locked plating was stiffer than the Ogden construct in pre- and post-cyclic axial loading and torsion. There was no difference in lateral bending stability or torsional failure loads. CONCLUSIONS: Locked plating constructs were stiffer than the Ogden construct in axial loading and torsion. Although no differences in loads to failure during torsion were noted, locked plating constructs exhibited catastrophic failure not observed with the Ogden construct.     

A shared biomechanical environment for bone and posture development in children

Background Context

In each specific habitual standing posture, gravitational forces determine the mechanical setting provided to skeletal structures. Bone quality and resistance to physical stress is highly determined by habitual mechanical stimulation. However, the relationship between bone properties and sagittal posture has never been studied in children.

Can we influence the neurological development and hair cortisol concentration of offspring by reducing the stress of the mother during pregnancy? A randomized controlled trial

The objective was to evaluate the effects of a stress management cognitive behavioural therapy followed during pregnancy on subsequent childhood on hair cortisol at birth and on neurodevelopment and Hair Cortisol Concentrations (HCC) at 6 months of age. The study sample included 48 pregnant women, divided into two groups: 24 women in the Therapy Group (TG) and 24 women who received standard pregnancy care (control group (CG); CG). To test the therapy efficacy, an evaluation of the HCC and psychological stress, psychopathological symptomatology and resilience was conducted before and after the treatment. The level of cortisol in their hair was obtained during pregnancy and that of their babies at birth. Six months after birth, a cortisol sample was taken from the hair and the babies' neurodevelopment was evaluated based on a Bayley-III test. The TG presented reductions in psychological stress and psychopathological symptomatology after treatment. On the other hand, the CG increased their cortisol concentrations between the pre and post intervention, remaining stable in the TG. Moreover, results showed that TG babies had lower cortisol concentrations at birth and obtained significantly higher cognitive and motor development scores at 6 months. These findings support that providing psychological care to pregnant women may not only have a benefit on these women's mental state, but may also benefit the neurodevelopment of their offspring.     

The current status of locked plating: the good, the bad, and the ugly

Locked plate technology has evolved in an effort to overcome the limitations associated with conventional plating methods, primarily for improving fixation in osteopenic bone. The development of screw torque and plate-bone interface friction is unnecessary with locked plate designs, significantly decreasing the amount of soft tissue dissection required for implantation, preserving the periosteal blood supply, and facilitating the use of minimally invasive percutaneous bridging fixation techniques. The locked plate is a fixed-angle device because angular motion does not occur at the plate screw interface. The use of locked plate technology allows the orthopaedic surgeon to manage fractures with indirect reduction techniques while providing stable fracture fixation. The secure 'feel' of locked plates, ease of application, and the low incidence of complications noted in early clinical reports have contributed to the proliferation of this technology. Along with reports of clinical successes, as the use of fixed angle/locked plates has increased, clinical failures are being noticed. This review will focus on the biomechanics of locked plate technology, appropriate indications for its use, laboratory and clinical comparisons to conventional plating techniques, and potential mechanisms of locked plate failure that have been observed.     

Predictors of Excess Weight Loss in Obese Patients After Gastric Bypass: a 60-Month Follow-up

Background

The objective of this study was to analyze the factors associated with change in body mass index (BMI) and with percentage of excess weight loss (%EWL) in patients undergoing Roux-en-Y gastric bypass (RYGB). The following factors were analyzed: sex, age, surgical access (laparotomy vs. laparoscopy), preoperative BMI, waist circumference (WC), type 2 diabetes mellitus (T2DM), high blood pressure, and dyslipidemia.

Methods

Retrospective cohort study using a convenience sample of 2070 patients of both sexes, aged 18 to 65 years, undergoing RYGB between 2000 and 2013. The outcomes of interest were BMI and %EWL at 0, 6, 12, 18, 24, 30, 36, 42, 48, 54, and 60 months after RYGB.

Results

After 36, 48, and 60 months, approximately 50 % of patients had BMI >30 kg/m². As for %EWL, 60-month results were poor for 17 % of patients (%EWL <50 %), good for 40 % of patients (%EWL 50–75 %), very good for 24 % of patients (%EWL from >75–90 %), and excellent for 19 % of patients (%EWL >90 %). The four most significant predictors of BMI change 60 months after RYGB (in descending order of magnitude) were preoperative BMI, preoperative WC, surgical access, and age; and of %EWL, surgical access, preoperative BMI, preoperative WC, and age.

Conclusions

After 60 months of follow-up, the most relevant predictors of weight loss after RYGB were lower preoperative BMI and WC, videolaparoscopy as surgical access, and younger age. Further studies must be carried out to elucidate the impact of these factors on RYGB outcomes.

     

Histopathologic validation of the sentinel node concept in oral and oropharyngeal squamous cell carcinoma

BACKGROUND: In patients with head and neck squamous cell carcinoma (HNSCC), the presence of lymph node metastases is the most important prognosticator. Sentinel node (SN) biopsy has been shown to be an accurate staging technique for patients with breast cancer and melanoma and might also be suited for patients with HNSCC. This study was undertaken to determine whether the SN concept holds true for HNSCC and could be exploited for SN biopsy. METHODS: In 22 patients with T2 to T4 N0 oral or oropharyngeal squamous cell carcinoma (SCC) who were scheduled to undergo combined primary tumor excision and elective unilateral (n = 17) or bilateral (n = 5) neck dissection, SN identification was performed the day before surgery by use of lymphoscintigraphy after peritumoral injections of 99mTc-labeled colloidal albumin. After the neck dissection specimens were removed, all SNs, all other radioactive lymph nodes, and all nonradioactive lymph nodes were retrieved for histopathologic analysis, including serial sectioning at 250-microm intervals and immunohistochemical analysis (IHC). RESULTS: Overall, in 21 (78%) of 27 neck sides, an SN was identified by scintigraphy. Of the six neck sides in which SNs were not identified by scintigraphy, four were from three patients who underwent bilateral neck dissection. In another patient treated by bilateral neck dissection, the SN identified by scintigraphy could not be found in the specimen. In the remaining 20 neck dissection specimens, 23 SNs and 30 additional radioactive lymph nodes could be found. At histologic examination of the 20 neck specimens in which the SN was found, at least one SN was tumor positive in eight cases. In one neck specimen, a metastasis was detected in a nonradioactive lymph node, whereas the SN was tumor free, also at serial sectioning and IHC. In the remaining 11 neck sides in which the SN was tumor negative, none of the other radioactive (n = 13) and none of the nonradioactive (n = 279) lymph nodes contained tumor at histopathologic analysis, including serial sectioning and IHC. The sensitivity of the SN procedure for predicting lymph node metastases, therefore, was 89% (eight of nine neck specimens) when an SN was identified by scintigraphy and found in the specimen. The overall accuracy of the SN procedure for predicting the presence or absence of lymph node metastases in the neck was 95% (19 of 20 neck specimens). CONCLUSIONS: Our study seems to validate the SN hypothesis for oral and oropharyngeal cancer. The role of SN biopsy in the management of the N0 neck in such patients has yet to be established through prospective trials. SN identification (and thus biopsy) does not seem to be reliable in patients with tumors located in or close to the midline.