Radiosurgery for large cerebral arteriovenous malformations

Background  Radiosurgery is an effective treatment option for patients with small to medium sized arteriovenous malformations. However, it is not generally accepted as an effective tool for larger (>14 cm³) arteriovenous malformations because of low obliteration rates. The authors assessed the applicability and effectiveness of radiosurgery for large arteriovenous malformations. Method  We performed a retrospective study of 46 consecutive patients with more than 14 ml of arteriovenous malformations who were treated with radiosurgery using a linear accelerator and gamma knife (GK). They were grouped according to their initial clinical presentation—17 presented with and 29 without haemorrhage. To assess the effect of embolization, these 46 patients were also regrouped into two subgroups—25 with and 21 without preradiosurgical embolization. Arteriovenous malformations found to have been incompletely obliterated after 3-year follow-up neuroimaging studies were re-treated using a GK. Findings  The mean treatment volume was 29.5 ml (range, 14.0–65.0) and the mean marginal dose was 14.1 Gy (range, 10.0–20.0). The mean clinical follow-up periods after initial radiosurgery was 78.1 months (range, 34.0–166.4). Depending on the results of the angiography, 11 of 33 patients after the first radiosurgery and three of four patients after the second radiosurgery showed complete obliteration. Twenty patients received the second radiosurgery and their mean volume was significantly smaller than their initial volume (P = 0.017). The annual haemorrhage rate after radiosurgery was 2.9% in the haemorrhage group (mean follow-up 73.3 months) and 3.1% in the nonhaemorrhage group (mean follow-up 66.5 months) (P = 0.941). Preradiosurgical embolization increased the risk of haemorrhage for the nonhaemorrhage group (HR, 28.03; 95% CI, 1.08–6,759.64; P = 0.039), whereas it had no effect on the haemorrhage group. Latency period haemorrhage occurred in eight patients in the embolization group, but in no patient in the nonembolization group (P = 0.004). Conclusions  Radiosurgery may be a safe and effective arteriovenous malformation treatment method that is worth considering as an alternative treatment option for a large arteriovenous malformation.     

Laparoscopic-Assisted Combined Colon and Liver Resection for Primary Colorectal Cancer with Synchronous Liver Metastases: Initial Experience

BACKGROUND: Laparoscopic approaches have become increasingly used in selected patients with either colorectal or liver cancer. However, the feasibility of laparoscopic-assisted combined colon and liver resection in primary colorectal cancer with synchronous liver metastases remains unknown. The aim of the present study was to determine the feasibility of laparoscopic-assisted combined colon and liver resection for primary colorectal cancer with synchronous liver metastases. METHODS: Laparoscopic surgery involving intestinal anastomosis was performed for primary colorectal cancer. The liver was then mobilized with the assistance of a hand inserted through the upper midline incision. For minor resections, the parenchymal transection was performed laparoscopically. For major resection involving a hilar dissection, transection was performed according to the standard open techniques under direct vision through the incision. Resected specimens were retrieved directly through the midline incision. RESULTS: Ten patients with primary colorectal cancer and synchronous liver metastases underwent the above procedure between September 2006 and April 2007. Surgical procedures for colorectal cancer included 5 low anterior resections, 3 anterior resections, 1 right hemicolectomy, and 1 subtotal colectomy. Combined hepatic surgery included 6 major hepatectomies, 3 segmentectomies, and 1 tumorectomy. All procedures were successful, with no conversions to open surgery required. The median operation time was 439 min (range: 210-690 min), and the median estimated blood loss was 350 ml (range: 300-1,200 ml). There was no surgical mortality or major morbidity, except in one patient in whom postoperative bleeding at the site of para-aortic node dissection was promptly controlled. CONCLUSIONS: Laparoscopic-assisted combined colon and liver resection is a feasible and safe procedure for the treatment of primary colorectal cancer with synchronous liver metastases.     

Optimal Prediction of Bone Mineral Density with Ultrasonic Measurements in Excised Human Femur

Bone mineral density (BMD) measured with dual energy X-ray absorptiometry (DXA) techniques is the current gold standard for osteoporotic fracture risk prediction. Quantitative ultrasound (QUS) techniques in transmission measurements are, however, increasingly recognized as an alternative approach. It is feasible to select different QUS methods, one type being optimized to assess microarchitectural properties of bone structure and another to assess BMD. Broadband ultrasonic attenuation (BUA) and ultrasonic velocity (UV) measured on the proximal human femur have been shown to be both significantly correlated with BMD. However, a great diversity of algorithms has been reported to measure the time-of-flight used to derive UV values. The purpose of this study was to determine which procedure results in the optimal BMD prediction at the proximal femur from ultrasound measurements. Thirty-eight excised human femurs were measured in transmission with a pair of focused 0.5−MHz central frequency transducers. Two-dimensional scans were performed and radiofrequency (RF) signals were recorded digitally at each scan position. BUA was estimated and eight different signal processing techniques were performed to estimate UV. For each signal-processing technique UV was compared to BMD. We show that the best prediction of BMD was obtained with signal-processing techniques taking into account only the first part of the transmitted signal (r²_BMD-SOS = 0.86). Moreover, we show that a linear multiple regression using both BUA and speed of sound (SOS) and applied to site-matched regions of interest improved the accuracy of BMD predictions (r²_BMD-SOS/BUA = 0.95). Our results demonstrate that selecting specific signal-processing methods for QUS variables allows optimal assessment of BMD. Correlation is sufficiently high that this specific QUS method can be considered as a good surrogate of BMD.     

Rehabilitation after the replantation on a 2-year-old girl with both amputated legs.

We had an opportunity to perform replantation of both legs on a 2-year-old girl, and our decision to perform replantation rather than amputation surgery was carefully made taking her age, degree of crushing injury, ischaemic time and level of the amputation into consideration. Painstakingly designed rehabilitation treatments were continuously performed on this girl from the early stage after the operation, and the treatments were comprised of four parts; that is, flexion and extension exercise for the ankle in order to prevent it from stiffness or contracture, functional electrical stimulation (FES) in order to prevent muscular atrophy on the lower extremities, muscle strengthening exercise for the lower extremities, and electrical stimulation to regenerate the damaged nerves and to prevent muscular atrophy from occurring. For an objective assessment of the postoperative conditions, total active motion angles of the ankle joint were measured, and also EMG and NCV were conducted at the end of the first month as well as at the end of the 6th month. Total active motion angles of the ankle joint were increased progressively as time went on, from 15 to 60 degrees on the right and from 10 to 45 degrees on the left. NCV did not show any sensation or response from motor nerves, or amplitude decreased considerably 1 month after the operation; however, at the end of the 6th month conditions improved a great deal with both amplitude and latency. And most muscles that did not show any signals on EMG or showed less than normal at the end of the first month after the operation eventually recovered at the end of the 6th month. The patient had no particular difficulties in walking after 6 months or rather she started running in small steps showing her legs functioning superbly. An infant with both of lower extremities amputated is quite a rare case. We believe that the replantation surgery was successful due to the fact that carefully selected preoperative factors were taken into consideration and well designed postoperative rehabilitation program consisted of four parts was carried out continuously.     

Antinociception of intrathecal adenosine receptor subtype agonists in rat formalin test

Adenosine has shown antinociceptive action via spinal adenosine receptors. There are four types of adenosine receptors: A1, A2A, A2B, and A3. We characterized the nature of types of adenosine receptors for the control of nociception at the spinal level. For nociception, formalin solution (5%, 50 microL) was injected into the hindpaw of male Sprague-Dawley rats. The effects of intrathecal adenosine A1 (CPA), A2A (DPMA), and A3 (IB-MECA) receptor agonists were examined. CPA and IB-MECA produced limited or no effect on the early phase response of the formalin test, respectively, but the two drugs depressed the late phase response. DPMA suppressed both phase responses. CPA was the most potent drug among the three in the late phase. These results suggest that spinal adenosine A1 and A2A receptors may be involved in the modulation of the early and the late phase responses of the formalin test, whereas adenosine A3 receptor may be involved in the regulation of the late phase response.     

Reconstruction of Complex Abdominal Wall Defects

Introduction

Reconstruction of large abdominal wall defects not amenable to primary closure remains a challenging problem. These defects result from trauma, previous surgery, infection and tumour resection. The primary objectives of abdominal wall reconstructions are to protect abdominal contents and provide functional support. The abdominal wall reconstruction aims at providing basic component parts, i.e. skin, soft tissue and fascia. For large soft tissue defects, pedicled or free flap closure can be used. In clean wounds, fascial replacement is accomplished with synthetic mesh provided there is adequate soft tissue coverage.

Methods

We treated a total of 20 consecutive patients with complex abdominal wall defects utilizing various reconstructive procedures. There were 15 males (75%) and 5 females (25%). The aetiology included dehiscence of laparotomy wounds in eight (40%), following ablative surgery for malignant tumours in seven (35%), trauma in three (15%) and congenital defects in two (10%) cases. The reconstructive procedures consisted of onlay prolene mesh in seven (35%), Gore-Tex (PTFE) dual mesh both as inlay and onlay in five (25%), facial partition release technique in three (15%), inlay prolene mesh covered with omentum and split skin graft in two (10%), inlay prolene mesh covered with expanded skin in two (10%), and Gore-Tex dual mesh covered with latissimus dorsi myocutaneous flap in one (5%) case. Postoperatively none developed mesh infection or extrusion. Three patients with malignant aetiology received postoperative radiotherapy. During follow up, one patient developed ventral hernia cephalad to the repair and one died due to recurrence of abdominal wall malignancy.

Conclusion

The reconstruction of an abdominal wall defect requires a comprehensive plan of preoperative and post operative care of the patient and aims toward restoration of abdominal structural integrity by a variety of procedures. The use of new biomaterials and tissue expanders provides reliable and durable abdominal wall closure along with good aesthetic results.Key Words: Abdominal wall defect, Mesh repair, Abdominal wall reconstruction     

PATIENT SATISFACTION IN PROSTHETIC REHABILITATION PROGRAMME

Patient satisfaction is an important outcome measure independent of other outcomes. Its measurement is important to assess the effectiveness of a programme and to gain insight into the patients'' perception of the programme. In this study conducted in a large rehabilitation centre it was found that majority of patients express satisfaction with care inspite of perceived discomfort. Various demographic factors, severity or duration of the disability or the level of rehabilitation do not influence patient satisfaction. Patients express more concern with aspects such as delay in issue of the prosthesis, or hotel component of the hospital services. Patients did not appear too concerned about the level of information provided. Patient satisfaction is an individual reaction to the overall care process and is influenced by the initial expectation level of the patient. Emotional response of the patient appears to be more important determinant of patient satisfaction than the cognitive evaluation. Periodical assessment of patient satisfaction should be an important component of any programme evaluation exercise.KEY WORDS: Amputation, Patient satisfaction, Programme evaluation, Prosthesis, Quality of care, Rehabilitation     

USEFULNESS OF EVALUATION OF ANTIMEASLES ANTIBODIES IN PRETERM BABIES

As per WHO recommendations, measles vaccine is administered at the age of 9 months which is based on studies demonstrating seroconversion (from positive to negative) at this age. However this contention may not hold good in preterm babies since they may have lower initial levels of passively transferred IgG antimeasles antibodies of maternal origin. To explore this possibility, 50 preterm babies (gestational age less than 37 weeks) were studied for antimeasles antibodies. Serum samples were collected at birth and then at 3 months and 5 months of age in all the cases. Antimeasles antibody assay was done in all the serum samples using ELISA kits. At birth 32% of infants were positive for antimeasles antibodies whereas 60% were weakly positive and 8% were negative. At 3 months of age 50% were sero negative, 2% positive and 40% weakly positive. The sero negativity was found to be 98% at 5 months with only 2% remaining positive. Since seroconversion is seen to occur in this vast majority of preterm infants at the age of 5 months, antimeasles vaccine should be administered at this age to this subset of more vulnerable babies.KEY WORDS: Antimeasles antibodies, Preterm babies, Seroconversion     

宁夏智障儿童社会支持现状调查分析

目的:探讨宁夏地区智障儿童社会支持现状和相关影响因素.方法:随机抽取宁夏银川市60多名特殊儿童为研究对象,采用韦氏儿童智力量表、社会支持评定量表、儿童适应行为评定量表进行测试.结果:特殊儿童社会支持偏低,均分仅29.60分,不同家庭类型的主观支持和社会利用存在显著差异,大家庭的主观支持高于核心家庭的主观支持,核心家庭高于单亲家庭,而社会支持利用刚好相反,核心家庭的社会利用度高于大家庭(P＜0.05);父母文化程度为高中的家庭主观支持最高(P＜0.05),而社会支持利用度中本科学历利用度最高(P＜0.05);经济状况一般的家庭获得社会支持高于家庭贫困者;大家庭中智障儿童的社会适应高于核心家庭,也高于单亲家庭(P＜0.05),父母文化程度为中专的孩子社会自制力强(P＜0.05);家庭经济相对贫困的家庭的智障儿童社会适应高于家庭经济相对一般的家庭(P＜0.05).结论:特殊儿童的家庭类型、家庭经济环境、家长文化程度对智障儿童的社会适应以及社会支持具有重要的影响.     

中药芪红合剂对肾间质纤维化模型大鼠肾组织中基质金属蛋白酶组织抑制剂-1表达的影响

目的：探讨中药苠红合剂对。肾间质纤维化模型大鼠肾组织中基质金属蛋白酶组织抑制剂-1（TIMP-1）表达的影响，及其对肾间质纤维化的作用机制。方法：采用单侧输尿管结~L（uuo）致肾问质纤维化的动物模型．40只雄性Wistar大鼠随机分为4组：假手术组（A组）、手术模型组（B组）、芪红合剂组（C组）、依那普利组（D组）。术后14d处死各组大鼠，收集血清测定血肌酐（Scr）、尿素氮（BUN）水平，取结扎侧肾组织分别用HE、Masson染色，采用免疫组化和原位杂交方法分别检测肾组织中基质金属蛋白酶组织抑制剂-1（TIMP-1）、纤维连接蛋白rFN）和TIMP-1mRNA的表达，并用计算机图像分析系统进行分析。结果：手术模型组大鼠肾组织中FN、TIMP-1和TIMP～1mRNA的表达较假手术组显著升高，两治疗组较模型组明显降低。手术模型组大鼠血肌酐、尿素氮水平较假手术组明显增高，两治疗组较手术模型组显著下降。结论：中药芪红合剂可降低大鼠血尿素氮、血肌酐水平，并可通过抑制基质金属蛋白酶组织抑制剂-1（TIMP-1）和FN的表达，而起到减轻肾间质纤维化病变程度的作用。推测其抑制TIMP-1表达上调的作用可能是其抗肾小管间质纤维化的作用机制之-。