Periurethral injection of autologous fat for the treatment of post-fistula repair stress incontinence: A preliminary report

The aim of the study was to asses the effectiveness of periurethral injection of autologous fat for the treatment of stress incontinence caused by inherent sphincter weakness in women following the repair of obstetric urogenital fistulae. Ten patients with symptomatic stress incontinence following repair of vesicovaginal or urethrovaginal fistula of obstetric origin were assessed clinically, by cystourethroscopy, and by Valsalva leak-point pressure (VLPP). Four showed some degree of bladder neck mobility and were treated by bladder neck suspension procedures. Six appeared to have pure sphincter weakness and were treated by periurethral injection of autologous fat. For logistic reasons, the initial follow-up was undertaken 2 weeks postoperatively, including clinical assessment and VLPP. Two patients were subjectively cured, 2 improved and 2 perceived no change in their symptoms following the procedure. The symptomatic changes correlated with the operative appearance, and with the subsequent changes in VLPP. Although numbers are small and follow-up short, we feel that these preliminary results justify further investigation of the technique in this most difficult group of patients.EDITORIAL COMMENT: The authors report an original concept for the treatment of intrinsic sphincter deficiency following obstetrical vesicovaginal fistula repair. Although preliminary, based on the authors' experience with a small group of patients and with minimal follow-up, this pilot study paves the way for future work in this area. The patients served have limited options for treatment from several aspects, including the severity of their incontinence, tissue health in the urogenital area, overall health, limited availability of other surgical options and general inaccessibility of medical care. The use of autologous fat for periurethral injection in this population of patients, where medical resources are limited, represents a simple, minimally invasive and relatively inexpensive option with possibly realistic success rates. Further investigation on the use of this technique to treat post-vesicovaginal fistula repair of intrinsic sphincter deficiency is needed to fully assess its applicability and success.     

Prevalence of osteoporosis in women referred for bone density testing: utility of multiple skeletal sites.

The objective of this study was to determine retrospectively the prevalence of osteoporosis in a referral population and to compare the effectiveness of measuring multiple skeletal sites for identifying osteoporosis. Although osteoporosis is considered to be a major public health problem in the United States, and there are reliable methods for diagnosis based on bone densitometry, fewer than 25% of cases are currently identified. There is no consensus about which skeletal site(s) should be measured for optimal results. In this study, bone mineral density (BMD) was measured by dual energy X-ray absorptiometry (DXA) at the radius (proximal site), lumbar spine, femoral neck, and total proximal femur regions in 537 consecutive white females age 50 and older referred by community physicians for bone densitometry. The prevalence of osteopenia and osteoporosis (based on the World Health Organization definitions) was determined, as well as the incidence of misclassification of patients based on different skeletal sites. Overall, 53.3% had osteoporosis, an additional 37.7% had osteopenia, and only 8.7% had normal BMD at all measurement sites. The prevalence was similar at all measurement sites and the incidence of misclassification was low. Given the magnitude of undetected osteoporosis and the efficacy of bone densitometry at any skeletal site, these data have important implications for the optimal deployment of bone density measurement facilities.     

Anterior anal fissures are associated with occult sphincter injury and abnormal sphincter function

Objective The pathogenesis of chronic anal fissure (CAF) remains incompletely understood but most are associated with a high resting anal pressure and reduced perfusion at the fissure site. To date, no major distinction has been made between anterior and posterior anal fissures and their aetiology and treatment. We compared anterior and posterior fissures in patients who have failed to respond to medical treatment with respect to their underlying aetiology, anal canal pressures and sphincter muscle integrity. Method Seventy consecutive patients (54 female:16 male) with a symptomatic CAF and 39 normal controls (19 female:20 male) without evidence of significant ano‐rectal pathology were prospectively assessed by manometry and anal endosonography. Results Anterior anal fissures were identified in a younger age group [33 years (IQR 26–37) vs 41 years (IQR 36–52)] and predominantly in women. Anterior fissure patients were significantly more likely to have underlying external anal sphincter defects compared with posterior fissures [OR 10.9 (95% CI 3.4–35.4)]. Maximum resting pressure was not significantly elevated for anterior fissures compared with controls (P = 0.316) but was significantly elevated in posterior fissures (P = 0.005). The maximum squeeze pressure was significantly lower in the anterior fissure group [167 cmH₂O (IQR 126–196) vs 205 cmH₂O (IQR 174–262), P = 0.004]. A history of obstetric trauma was significantly associated with anterior fissure location [OR 13.9 (95% CI 3.4–55.7)]. Conclusions Anterior anal fissures are associated with occult external anal sphincter injury and impaired external anal sphincter function compared with posterior fissures. These findings have implications for treatment, especially if a definitive procedure, such as lateral internal sphincterotomy, is considered.     

Laparoscopic colorectal resection does not reduce incisional hernia rates when compared with open colorectal resection

Background Laparoscopic colorectal surgery has been reported to have some advantages compared with open surgery. The purpose of this study was to evaluate the incidence of incisional hernias after elective open colorectal resection versus laparoscopic colorectal resection. Methods The study group consisted of 104 patients who underwent elective colorectal resection or reversal of a Hartmann’s procedure between November 2003 and March 2005. Baseline data were prospectively recorded on all patients. All were examined by an independent observer for evidence of incisional hernia after they had reached a minimum follow up of one year. Results At a median follow up of 22 (17–26) months, nine patients had died and 95 were reviewed. Of these, 32 underwent laparoscopic resection while 63 had open surgery. Patients were well matched for all baseline characteristics. The median length of the wound in the laparoscopic group was 9 cm (IQR: 8–11 cm) while in the open group it was 20.8 cm (IQR: 17–24 cm). There was no significant difference in incisional hernia rates between the groups (3 vs. 10, p = 0.52) or in those who had symptoms from their hernia (p = 0.773). Conclusions Laparoscopic colorectal resection does not appear to reduce incisional hernia rates when compared with open surgery. Large randomised trials are required to confirm these findings.     

Osteochondral Fracture of the Fourth Metatarsal Head Treated by Open Reduction and Internal Fixation

Fracture of the metatarsal head is uncommon, and reports of isolated osteochondral fracture of the metatarsal head are rare. Because of the distal location of the fracture, it is difficult to achieve and maintain reduction, and potential complications include avascular necrosis and subchondral fatigue fracture. The authors present a case of an osteochondral fracture in a 40-year-old man, which was treated by open reduction and internal fixation with a single twist-off screw, with good results 12 months postoperatively.     

Questionnaire survey of the views of the delegates at the European Cervical Spine Research Society meeting on the administration of methylprednisolone for acute traumatic spinal cord injury

STUDY DESIGN: A questionnaire survey. OBJECTIVES: To collate and analyze the views of the delegates who attended the European Cervical Spine Research Society (CSRS) meeting on the use of methylprednisolone for acute traumatic spinal cord injury. SUMMARY OF BACKGROUND DATA: The NASCIS II and III studies reported improved neurologic recovery in patients who were treated with methylprednisolone within 8 hours of their acute traumatic spinal cord injury. A number of reported commentaries have criticized these trials. A recent audit in the authors' regional spinal injuries unit in the United Kingdom found that a large percentage of patients were not receiving methylprednisolone. The authors decided to collate the views of the delegates at the CSRS regarding the use of steroids for acute traumatic spinal cord injury. METHODOLOGY: A questionnaire was created that took into account the positive reported findings as well as the criticisms of the NASCIS studies. Delegates who attended the European CSRS meeting completed this questionnaire. RESULTS: Seventy-five percent of the delegates answered that they used or recommended methylprednisolone in the treatment of acute traumatic spinal cord injury. Nevertheless, the delegates had an average of 1.5 reservations about administering methylprednisolone. The most common reservation was that they did not think the improvement conferred to the patients by administering methylprednisolone had been clinically or functionally proven. There were reservations about the validity of the statistical analysis used in the NASCIS studies and by the omission of a placebo group in NASCIS III. The majority of the delegates thought it was not medicolegally negligent to withhold the administration of methylprednisolone in the treatment of acute traumatic spinal cord injury. CONCLUSION: The use of methylprednisolone in the treatment of acute traumatic spinal cord injury is still controversial. It would appear from a recent prospective audit at the authors' spinal injuries unit that a large percentage of patients in the United Kingdom are not receiving methylprednisolone. Because so much doubt exists, the NASCIS studies should be repeated.     

MR imaging of facial nerve enhancement in Bell palsy or after temporal bone surgery

The authors evaluated magnetic resonance (MR) images obtained with intravenously administered gadolinium in ten patients who had facial paralysis and no facial nerve tumor. In patients with either Bell palsy (four patients) or facial paralysis after temporal bone surgery (six patients), intratemporal facial nerve enhancement was seen. Facial nerve enhancement on MR images proved to be a nonspecific finding.     

Interleukin-1-induced leukocyte extravasation across rat mesenteric microvessels is mediated by platelet-activating factor

Although our understanding of the molecular interactions that mediate the adhesion of leukocytes to venular endothelial cells has greatly expanded, very little is known about the mechanisms that mediate the passage of leukocytes across the vessel wall in vivo. The aim of the present study was to investigate the role of endogenously formed platelet-activating factor (PAF) in the process of leukocyte extravasation induced by interleukin-1 (IL-1). To determine at which stage of emigration PAF was involved, we studied the behavior of leukocytes within rat mesenteric microvessels by intravital microscopy. Rats were injected intraperitoneally with saline, recombinant rat IL-1 beta (IL-1 beta), or the peptide N-formyl-methionyl-leucyl- phenylalanine (FMLP) 4 hours before the exteriorization of the mesenteric tissue. In animals treated with IL-1 beta there was a significant increase in the number of rolling and adherent leukocytes within venules (20- to 40-micron diameter) and in the number of extravasated leukocytes in the tissue. Pretreatment of rats with the PAF receptor antagonist UK-74,505 had no effect on the leukocyte responses of rolling and adhesion, but significantly inhibited the migration of the leukocytes across the vessel wall induced by IL-1 beta (76% inhibition). A structurally unrelated PAF antagonist, WEB-2170, produced the same effect (64% inhibition). However, in contrast, UK- 74,505 had no effect on the leukocyte extravasation induced by FMLP, indicating selectivity for the response elicited by certain mediators. These results provide the first line of direct evidence for the involvement of endogenously formed PAF in the process of leukocyte extravasation induced by IL-1 in vivo.     

Sex-specific alterations in neutrophil apoptosis: the role of estradiol and progesterone

Women are conferred with greater immunologic and survival benefits compared to men. Female sex steroids contribute to this sexual dimorphism. Furthermore, during human pregnancy when female sex hormones are elevated, neutrophil apoptosis is delayed. This study examines the specific effects of estradiol and progesterone on neutrophil apoptosis and function in healthy adult men and women. We also examined the contribution of these hormones to the persistence and resolution of an inflammatory response. Spontaneous apoptosis was significantly decreased in women compared with men. Physiologic doses of estradiol and progesterone caused a further delay in spontaneous apoptosis in both men and women but did not diminish Fas antibody-induced apoptosis. The delay in apoptosis was mediated at the level of the mitochondria with decreased release of cytochrome c, which may alter caspase cleavage and activity. There were no associated alterations in neutrophil CD11b, but production of reactive oxygen intermediates (ROIs) in women was increased. Thus, female sex hormones mediate delayed neutrophil apoptosis in both sexes and enhance female intracellular production of ROIs. Modulating hormonal responses may be an effective therapeutic tool in combating inflammatory diseases.