Does the amount of tagged stool and fluid significantly affect the radiation exposure in low-dose CT colonography performed with an automatic exposure control?

Objective  

To determine whether the amount of tagged stool and fluid significantly affects the radiation exposure in low-dose screening CT colonography performed with an automatic tube-current modulation technique.     

Orbital floor reconstruction considering orbital floor slope

Orbital floor fractures are among the more challenging injuries faced by plastic surgeons. Enophthalmos is defined as backward, usually downward, displacement of the globe into the bony orbit. We describe reconstruction of the orbital floor slope in orbital floor fractures that prevents postoperative complications, especially posttraumatic enophthalmos. Thirty-three patients with orbital floor fractures were treated using reconstruction of the orbital floor slope between April 2009 and July 2010. The patients ranged in age from 12 to 54 years. There were 31 males and 2 females. All patients were operated on using a transconjunctival approach under general anesthesia. The orbital floor was reconstructed with poly-l/d-lactide sheets in all cases. Preoperatively, 23 [Float1]patients (69%) had enophthalmos, and 12 patients (36%) had symptomatic diplopia. The enophthalmos was corrected in 20 patients (86%), and the diplopia resolved in 10 (83%). Extrinsic ocular movement was impaired preoperatively in 1 patient (3%), but resolved after surgery. No patient had impaired visual acuity preoperatively or postoperatively. The results suggest that orbital floor reconstruction considering the orbital floor slope is a safe, reliable method with fewer complications that is more effective at preventing posttraumatic enophthalmos.     

Triple-combination antiviral drug for pandemic H1N1 influenza virus infection in critically ill patients on mechanical ventilation

A recent in vitro study showed that the three compounds of antiviral drugs with different mechanisms of action (amantadine, ribavirin, and oseltamivir) could result in synergistic antiviral activity against influenza virus. However, no clinical studies have evaluated the efficacy and safety of combination antiviral therapy in patients with severe influenza illness. A total of 245 adult patients who were critically ill with confirmed pandemic influenza A/H1N1 2009 (pH1N1) virus infection and were admitted to one of the intensive care units of 28 hospitals in Korea were reviewed. Patients who required ventilator support and received either triple-combination antiviral drug (TCAD) therapy or oseltamivir monotherapy were analyzed. A total of 127 patients were included in our analysis. Among them, 24 patients received TCAD therapy, and 103 patients received oseltamivir monotherapy. The 14-day mortality was 17% in the TCAD group and 35% in the oseltamivir group (P = 0.08), and the 90-day mortality was 46% in the TCAD group and 59% in the oseltamivir group (P = 0.23). None of the toxicities attributable to antiviral drugs occurred in either group of our study, including hemolytic anemia and hepatic toxicities related to the use of ribavirin. Logistic regression analysis indicated that the odds ratio for the association of TCAD with 90-day mortality was 0.58 (95% confidence interval, 0.24 to 1.42; P = 0.24). Although this study was retrospective and did not provide virologic outcomes, our results suggest that the treatment outcome of the triple combination of amantadine, ribavirin, and oseltamivir was comparable to that of oseltamivir monotherapy.     

Plain Radiograph Fails to Reflect the Alignment and Advantages of Navigation in Total Knee Arthroplasty

The study purposed to determine if a navigation in total knee arthroplasty (TKA) leads to accurate limb alignment and component position than the conventional technique as measured by full length standing radiographs and to evaluate the correlation between navigation and radiographic measurements. A total of 160 knees underwent navigation (n = 80) or conventional (n = 80) TKAs. The frontal femoral alignment was more accurate in navigation TKAs, whereas mechanical axis and frontal tibial alignment were similar in both techniques. Although the intraoperative navigation alignment showed no outliers, postoperative radiographic measure resulted as much as 20% of outliers, and there was no correlation between the two measurements. This lack of correlation and inherent limitations in measuring TKA alignment may bring to question if plain radiograph are useful to determine if alignment achieved by navigation is accurate.     

Less perilaryngeal gas leakage with SLIPATM than with LMA-ProSealTM in paralyzed patients

Purpose

The aim of this study was to compare the Streamlined Liner of the Pharynx Airway (SLIPA?) with the ProSeal Laryngeal Mask Airway (LMA-ProSeal?) in mechanically ventilated paralyzed patients undergoing laparoscopic gynecologic surgery.

Methods

One hundred and one patients were allocated randomly to SLIPA (n = 50) or to LMA-ProSeal (n = 51) treatment groups. After induction of general anesthesia and insertion of the assigned supralaryngeal airway (SLA) device, we made note of the occurrence of any gastric insufflation and perilaryngeal leakage. We then evaluated the anatomical fit of the SLA device using a fibreoptic bronchoscope, and we assessed the airway sealing pressure and respiratory mechanics with change in head position and during peritoneal insufflation. After surgery, we evaluated the severity of postoperative sore throat and the presence of blood or regurgitated fluid on the SLA device.

Results

The insertion success rate, gastric insufflation, perilaryngeal leakage, anatomical fit, airway sealing pressure, respiratory mechanics, severity of sore throat, and incidence of blood and regurgitated fluid on the device were similar between the two groups. The incidence of perilaryngeal leakage with changes in the patient’s head position was lower with the SLIPA group than with the LMA-ProSeal group (3/50 vs 11/51, respectively; P = 0.026). During peritoneal insufflation, perilaryngeal leakage did not occur with the SLIPA but occurred in four cases with the LMA-ProSeal (P = 0.045).

Conclusion

Both the SLIPA and the LMA-ProSeal can be used effectively and without severe complications in paralyzed patients undergoing laparoscopic gynecological surgery. However, the SLIPA offers the advantage of less perilaryngeal gas leakage than the LMA-ProSeal with change in head position and during insufflation of the peritoneal cavity. This trial is registered with ANZCTR (ACTRN12609000914268).     

Renoprotective efficacy of valsartan in chronic non-diabetic proteinuric nephropathies with renin-angiotensin system gene polymorphisms

Aim: The renoprotective effects of angiotensin receptor blockers vary considerably among individuals. We investigated the renoprotective effects of valsartan according to polymorphisms of the renin–angiotensin system and transforming growth factor‐b1 (TGFB1) genes in patients with chronic non‐diabetic proteinuric nephropathies. Methods: Two hundred and thirty‐nine non‐diabetic patients with proteinuria of at least 1 g/day were enrolled. Patients received 80 mg of valsartan daily, followed by 160 mg/day after 6 weeks. The follow‐up period was 18 months. The status of the angiotensin‐converting enzyme (ACE) insertion/deletion, angiotensinogen (AGT) M235T, type 1 angiotensin II receptor (ATR1) A1166C, and TGFB1 C509 and T869C polymorphisms was determined in 162 patients. Results: Valsartan treatment caused a significant reduction in proteinuria from baseline throughout the study in patients with each genotype of the ACE, AGT and TGFB1 genes. However, patients with the ATR1 AC genotype had no significant reduction in proteinuria from baseline throughout the study course. The median reductions in proteinuria after 6 months were 45.7% and 10.8% in the patients with the ATR1 AA and AC genotypes, respectively (P = 0.034). The annual change in the estimated glomerular filtration rate did not differ significantly among the genotypes for each gene. On multiple regression analysis, the change in proteinuria after 6 months of treatment was independently associated with the ATR1 genotype and the change in blood pressure (P = 0.005 and 0.019, respectively). Conclusion: Valsartan treatment significantly reduced the blood pressure and urinary protein excretion of patients with chronic non‐diabetic proteinuric nephropathies. Interindividual differences in the anti‐proteinuric effect of valsartan may be related partly to the ATR1 A1166C polymorphism.     

Extranodal extension in node-positive bladder cancer: the continuing controversy

Study Type – Therapy (case series)
Level of Evidence 4 What’s known on the subject? and What does the study add? Although extranodal extension in node‐positive patients may provide prognostic information in certain urological malignancies, contradictory results have been reported in node‐positive patients after radical cystectomy for bladder cancer. We examined whether extranodal extension could have an impact on the outcomes of node‐positive patients who underwent radical cystectomy for bladder cancer in a single large tertiary hospital. We have shown that the presence of extranodal extension was not an independent prognostic factor in node‐positive patients after radical cystectomy and pelvic lymphadenectomy for bladder cancer.

OBJECTIVE

? To examine whether extranodal extension (ENE) has an impact on the outcome of node‐positive patients who underwent radical cystectomy for bladder cancer.

PATIENTS AND METHODS

? Of 543 consecutive patients who underwent radical cystectomy for urothelial carcinoma of the bladder between 1990 and 2007, 112 patients with lymph node metastasis detected on histological examination were evaluated with regard to recurrence‐free survival (RFS) and disease‐specific survival (DSS) based on ENE status.

RESULTS

? The overall 5‐year RFS and DSS rates were 22.3% and 33.8%, respectively. ENE was observed in 41 (36.6%) of the 112 patients. ? The presence of ENE was associated with advanced pathological nodal status (P= 0.004), more positive lymph nodes (P= 0.006), and higher lymph node density (P < 0.001). ? The incidence of positive ENE increased with large positive lymph node diameter (P < 0.001). ? Multivariate analysis showed that lymph node density (hazard ratio (HR) = 2.39, 95% CI 1.09–5.24, P= 0.029; and HR = 3.13, 1.43–6.84, P= 0.004) and use of adjuvant chemotherapy (HR = 1.80, 1.02–3.20, P= 0.041; and HR = 2.07, 1.13–3.79, P= 0.018) were significant predictors of RFS and DSS, respectively. ? After adjustment for other prognostic factors, ENE was not significantly related to RFS (P= 0.825) and DSS (P= 0.961) by multivariate analysis.

CONCLUSIONS

? The presence of ENE was not an independent prognostic factor in node‐positive patients after radical cystectomy for bladder cancer. ? Additional prospective studies are needed to determine the independent prognostic role of ENE.     

Biliary lipids and cholesterol crystal formation in leptin-deficient obese mice

Background. Obesity is often associated with increased biliary cholesterol secretion resulting in cholesterol gallstone formation. We have previously demonstrated that leptin-deficient C57Bl/6J Lep ob obese mice have abnormal biliary motility and are prone to cholesterol crystal formation. In addition, others have demonstrated that leptin-deficient mice when fed a lithogenic diet for eight weeks are not prone to gallstone formation. However, the biliary lipid and in vivo cholesterol crystal response of homozygous and heterozygous leptin-deficient mice to four weeks on a lithogenic diet has not been studied. Therefore, we tested the hypothesis that lithogenic diets influence gallbladder bile composition, serum lipids and cholesterol crystal formation in homozygous and heterozygous leptin-deficient mice compared to normal lean controls. Methods. 319 female lean control mice, 280 heterozygous lep ob obese mice and 117 homozygous lep ob obese mice were studied. Mice were fed either a lithogenic or control non-lithogenic chow diet for four weeks. Gallbladder volumes were measured, and bile was pooled to calculate cholesterol saturation indices. Serum cholesterol, glucose, and leptin levels were determined. Hepatic fat vacuoles were counted, and bile was observed microscopically for cholesterol crystal formation. Results. The lithogenic diet and mouse strain influenced body and liver weights, gallbladder volume, cholesterol crystal formation, serum cholesterol, glucose and leptin levels and hepatic fat vacuole numbers. However, only diet, not strain, altered biliary cholesterol saturation. Conclusion. The association among obesity, leptin, and gallstone formation may be primarily related to altered gallbladder motility and cholesterol crystal formation and only secondarily to biliary cholesterol saturation.