Harvey Cushing's Early Operative Treatment of Skull Base Fractures

Objectives To review Dr. Harvey Cushing''s early surgical cases at the Johns Hopkins Hospital, revealing details of his operative approaches to fractures of the skull base. Design Following institutional review board approval and through the courtesy of the Alan Mason Chesney Archives, we reviewed the Johns Hopkins Hospital surgical files. Setting The Johns Hopkins Hospital, 1896 to 1912. Participants A total of 24 patients underwent operative treatment for suspected fractures of the skull base. Main Outcome Measures The main outcome measure was operative approach, postoperative mortality, and condition recorded at the time of discharge. Results Overall, 23 patients underwent operative treatment for suspected skull base fractures. The mechanisms of injury were known for 22 patients and included work-related injuries (41%), falls (23%), vehicle injuries (32%), and other trauma (5%). One patient had no mechanism of injury specified in the file. The outcome at the time of discharge from the hospital was “well” or “improved” in 12 patients (52%). The remaining 11 patients died during their admission. Conclusions Although Cushing''s experience with selected skull base pathology has been previously reported, the breadth of his contributions to operative approaches to the skull base has been neglected.     

Sialyltransferase ST3Gal-IV operates as a dominant modifier of hemostasis by concealing asialoglycoprotein receptor ligands

A number of poorly characterized genetic modifiers contribute to the extensive variability of von Willebrand disease, the most prevalent bleeding disorder in humans. We find that a genetic lesion inactivating the murine ST3Gal-IV sialyltransferase causes a bleeding disorder associated with an autosomal dominant reduction in plasma von Willebrand factor (VWF) and an autosomal recessive thrombocytopenia. Although both ST3Gal-IV and ST6Gal-I sialyltransferases mask galactose linkages implicated as asialoglycoprotein receptor ligands, only ST3Gal-IV deficiency promotes asialoglycoprotein clearance mechanisms with a reduction in plasma levels of VWF and platelets. Exposed galactose on VWF was also found in a subpopulation of humans with abnormally low VWF levels. Oligosaccharide branch-specific sialylation by the ST3Gal-IV sialyltransferase is required to sustain the physiologic half-life of murine hemostatic components and may be an important modifier of plasma VWF level in humans.     

The impact of increased cost sharing on Medicaid enrollees

Many state Medicaid programs are implementing cost-saving mechanisms, but little is known about the impact of those strategies on low-income people. Recent increases in cost sharing for Oregon Health Plan (OHP, Oregon's Medicaid program) members have created a natural experiment that is ideal for examining such impacts. Early results from an ongoing cohort study suggest that cost-sharing increases led to a large reduction in OHP membership. Those who left OHP because of the cost-sharing increase reported inferior access to needed care, used primary care less often, and used hospital emergency rooms more often than those who left OHP for other reasons.     

Spinal pelvic reconstruction after total sacrectomy for en bloc resection of a giant sacral chordoma. Technical note

Although radical resection prolongs the disease-free survival period, surgical management of primary sacral tumors is challenging because of their location and often large size. Moreover, in cases of lesions for which a radical resection necessitates total sacrectomy, reconstruction is required. The authors have previously described a modified Galveston technique in which a liaison between the spine and pelvis is achieved using lumbar pedicle screws and Galveston rods embedded into the ilia; additionally, a transiliac bar reestablishes the pelvic ring. Although this reconstruction technique achieves stabilization, several biomechanical limitations exist. In the present report the authors present the case of a patient who underwent spinal pelvic reconstruction after a total sacrectomy was performed to remove a giant sacral chordoma. They describe a novel spinal pelvic reconstruction technique that addresses some of the biomechanical limitations.     

Vertebral synovial chondromatosis. Report of two cases and review of the literature

Synovial chondromatosis is an uncommon disorder characterized by the formation of multiple cartilaginous nodules within the synovium, most commonly affecting large joints. Its involvement with the spine is rare; only six cases have been reported. The authors describe two patients with synovial chondromatosis involving the cervical spine. In the first case, synovial chondromatosis arose from the left C1-2 facet joint. This patient underwent a two-stage procedure including a posterior approach for tumor resection and occipitocervical fusion as well as a transmandibular circumglossal approach to the anterior craniocervical junction to complete the tumor removal. Interestingly, on histopathological examination, scattered foci of low-grade chondrosarcoma were intermixed within the synovial chondromatosis. To the authors' knowledge, this is the first report of secondary low-grade chondrosarcoma arising in vertebral synovial chondromatosis. In the second case, synovial chondromatosis involved the left C4-5 facet joint. Tumor resection and cervical fusion were performed via a posterior approach. In this report, the authors describe the clinical presentation, radiographic findings, operative details, histopathological features, and clinicoradiological follow-up data obtained in these two patients and review the literature pertaining to this rare entity.     

Day-surgery operative hysteroscopy with loco-regional anesthesia

BACKGROUND: Nowadays hysteroscopic surgery offers the opportunity of treating in Day Hospital even patients who cannot undergo a traditional surgery because of high anesthesiological risk. The aim of this study is to prove that minimal invasive hysteroscopic procedures in loco-regional anesthesia can replace laparotomic gynecological surgery in many intrauterine lesions with the same effectiveness on pain and outcome. METHODS: From September 1999 to December 2000 at the Obstetric and Gynecological Department in Asti 200 hysteroscopic procedures have been performed. The patients (all i.v. line inserted, ECG and pulsometer monitored, and sublingual BDZ sedated) were divided into two groups: a group of 50 patients who underwent operation on paracervical block alone, and the other one of 150 women on paracervical block plus periorificial infiltration of local anesthetic. RESULTS: Only one woman in the first group paracervical block was totally insufficient and she needed a general anesthesia. In the same group, 44% of paracervical blocks required an additional conscious sedation with Propofol and Fentanyl. In the second group only 16 % of cases required an additional sedation. In all cases outcome was very good with complete recovery of the patients dismissed the same afternoon. CONCLUSIONS: In our experience operative hysteroscopies under loco-regional anesthesia with paracervical block and periorificial infiltration is a very satisfactory alternative to general anesthesia. Moreover the type of intrauterine lesion did not influence the tolerability of the operation.