Cranial sutures and craniometric points detected on MRI

The main goal of the study was to determine on MRI the cranial sutures, the craniometric points and craniometric measurements, and to correlate these results with classical anthropometric measurements. For this purpose, we reviewed 150 cerebral MRI examinations considered as normal (Caucasian population aged 2049 years). For each examination we individualized 11 craniometric landmarks (Glabella, Bregma, Lambda, Opisthocranion, Opisthion, Basion, Inion, Porion, Infra-orbital, Eurion) and three measurements. Measurements were also calculated independently on 498 dry crania (Microscribe 3-DX digitizer). To validate the MRI procedure, we measured four dry crania by MRI and with compass or digital caliper gauges. Cranial sutures always appeared without signal (black), whatever the MRI sequence used, and they are better visualized with a 5 mm slice thickness (compact bone overlapping). Slice dynamic analysis and multiplanar reformatting allowed the detection of all craniometric points, some of these being more difficult to detect than others (Porion, Infra-orbital). The measurements determined by these points were as follows: VertexBasion height=135.66±6.56 mm; EurionEurion width=141.17±5.19 mm; GlabellaOpisthocranion length=181.94±6.40 mm. On the midline T1-weighted sagittal image, all median craniometric landmarks can be individualized and the GlabellaOpisthocranion length, VertexBasion height and parenchyma indices can be calculated. Craniometric points and measurements between these points can be estimated with a standard cerebral MRI examination, with results that are similar to anthropometric data.     

Bilateral extraperitoneal uterosacral vaginal vault suspension: a 2-year follow-up longitudinal case series of 123 patients

Introduction and hypothesis  The objective of this study is to assess anatomical and functional results of the extraperitoneal uterosacral ligament suspension (USL) in women with post-hysterectomy vaginal vault prolapse. Methods  One hundred and twenty-three consecutive women were included. Concurrent procedures were anterior colporraphy with fascial repair (20%) and mesh reinforcement (49%), posterior colporraphy with fascial repair (38%) and mesh reinforcement (56%) and a sling procedure (29%). Women were assessed using Baden and Walker and pelvic organ prolapse quantification classification pre- and post-operatively. Results  One hundred and ten patients (89%) were available for follow-up. Mean follow-up was 2 years. Objective success rate regarding the vaginal cuff is 95.4%. Global anatomical success rate was 85.5%. Urinary, coital and bowel symptoms were improved following surgery. Mesh exposure rate was 19.3%, with all cases managed conservatively or with minor interventions. Conclusion  Bilateral extraperitoneal USL is an effective operation to restore apical support with low morbidity, which avoids potential risks associated with opening the peritoneal cavity.     

A prospective randomised double-blind controlled trial evaluating the effect of trans-sacral magnetic stimulation in women with overactive bladder

Overactive bladder (OAB) is a prevalent condition with 16% of adults having one or more symptoms that significantly affect quality of life. Transcutaneous electrical nerve stimulation and neuromodulators have had success in treating OAB but are expensive, invasive, and sometimes cumbersome. We developed an alternative neuromodulatory technique that involves electromagnetic stimulation of the sacral nerve roots with a portable electromagnetic device to produce trans-sacral stimulation of the S3 and S4 sacral nerve roots. The aim of this study was to evaluate the impact of this device on OAB symptoms in women with a prospectively randomised double-blind controlled study. Following a power analysis, women with symptoms of OAB were prospectively recruited with ethical approval for randomisation to an active treatment (n = 33) or placebo group (n = 30) in a double-blind trial. The patient, at home, used the belt device daily for 20 min over 12 weeks. Outcome measures included a 3-day voiding diary, 1 h pad test, visual analogue score (VAS) for symptom impact (0–100%), Kings Health Questionnaire (KHQ) and Australian Quality of Life questionnaire (AQOL) at baseline, 6 and 12 weeks. Overall, no difference was found between groups for any of the research questions. Specifically, we were unable to demonstrate any difference between the active and sham device groups in frequency, nocturia, urinary leakage, or quality of life, nor was there any evidence of a placebo effect. The quality of the data was high with the number of missing observations (especially for disease specific KHQ and general AQOL) being few. This attempt to promote trans-sacral electromagnetic neuromodulation with a specially created device was ineffective on the symptoms of OAB.     

Vaccines in Multiple Sclerosis

Vaccinations help prevent communicable disease. To be valuable, a vaccine’s ability to prevent disease must exceed the risk of adverse effects from administration. Many vaccines present no risk of infection as they are comprised of killed or non-infectious components while other vaccines consist of live attenuated microorganisms which carry a potential risk of infection—particularly, in patients with compromised immunity. There are several unique considerations with respect to vaccination in the multiple sclerosis (MS) population. First, there has been concern that vaccination may trigger or aggravate the disease. Second, disease-modifying therapies (DMTs) employed in the treatment of MS may increase the risk of infectious complications from vaccines or alter their efficacy. Lastly, in some cases, vaccination strategies may be part of the treatment paradigm in attempts to avoid complications of therapy.     

Calendar of events

We compared serum creatine kinase (CK) levels between spinobulbar muscular atrophy (SBMA) and amyotrophic lateral sclerosis (ALS) and reviewed available histochemical studies of frozen sections of muscle biopsies. CK levels and the frequency of patients with elevated CK levels were significantly higher in the SBMA group when compared with the ALS group. CK levels occasionally approached values up to 8 times the upper limit of normal in the SBMA group. In addition to the chronic neurogenic changes in the muscle biopsy, all SBMA patients showed one or more myopathic changes. Increased numbers of markedly hypertrophic fibers were consistently seen in all patients. It is not clear whether the elevated CK level is directly related to the increased number of hypertrophic fibers or to other myopathic features. Based on these findings, we recommend genetic testing for SBMA in cases of male patients with motor neuron disease who present with a significantly elevated serum creatine kinase level, even when other characteristic clinical features of SBMA are absent. Muscle Nerve 40: 126–129, 2009     

Measurement of brain atrophy in subcortical vascular disease: a comparison of different approaches and the impact of ischaemic lesions

Measurement of brain atrophy has been proposed as a surrogate marker in MS and degenerative dementias. Although cerebral small vessel disease predominantly affects white and subcortical grey matter, recent data suggest that whole brain atrophy is also a good indicator of clinical and cognitive status in this disease. Automated methods to measure atrophy are available that are accurate and reproducible in disease-free brains. However, optimal methods in small vessel disease have not been established and the impact of ischaemic lesions on different techniques has not been explored systematically. In this study, three contrasting techniques -- Statistical Parametric Mapping 5 (SPM5), SIENAX and BrainVisa -- were applied to measure cross-sectional atrophy (brain parenchymal fraction or BPF) in a large (n=143) two-centre cohort of patients with CADASIL, a genetic model of small vessel disease. All three techniques showed similar sensitivity to trends in BPF associated with age and lesion load. No single technique was particularly vulnerable to error as a result of lesions. Provided major errors in registration were excluded by visual inspection, manual correction of segmentations had a negligible impact with mean errors of 0.41% for SIENAX and 0.46% for BrainVisa. BPF correlated strongly with global cognitive function and physical disability, independent of the technique used. Correlation coefficients with the Minimental State Examination score were: BrainVisa 0.58, SIENAX 0.58, SPM5 0.60 (for all, p<0.001). These results suggest that all three methods can be applied reliably in patients with ischaemic lesions. Choice of analysis approach for this kind of clinical question will be determined by factors other than their robustness and precision, such as a desire to explore subtle localised changes using extensions of these processing tools.     

Nalbuphine after enflurane or fentanyl--effect on circulation and respiration

The agonistic and antagonistic properties of nalbuphine were examined in 80 surgical patients after anaesthesia consisting essentially of flunitrazepam/enflurane or flunitrazepam/fentanyl. After the operation the intubated and still unconscious patients were breathing either N2O/O2/enflurane 0.4 Vol.% or N2O/O2 (FIO2 0.33). The mean fentanyl requirement during operation was 0.55 microgram/kg body weight/10 min anaesthesia. The respiratory minute volumes (RMV) were similar in all groups and ranged between 77-89% of the calculated normal value. The respiratory rate was 18-23/min in the enflurane groups and 11-12/min in the fentanyl groups. After reaching a circulatory and respiratory steady state, nalbuphine was administered i.v. in the doses of 2.5, 5, 10 or 20 mg. In the enflurane groups nalbuphine produced a pure depressant effect on respiratory parameters. The RMV decreased by 27 +/- 3%, the calculated alveolar ventilation by 20-24% and the breathing rate by 6 breath/min. A new steady state was reached within 10 min. The well-known ceiling effect was observed. In contrast to the observations in awake patients the maximum depressant effect was already reached after a dose of only 5 mg nalbuphine. Arterial blood pressure decreased by 4-5 mmHg and heart rate by 5 beats/min. After fentanyl, however, nalbuphine in all doses exhibited a stimulating effect on respiration and circulation. A steady state was reached after 10 min as well. A maximum effect on alveolar ventilation (+ 39 +/- 8%) was obtained after 5 mg nalbuphine and did not increase further with increasing doses. The effects on RMV and on respiratory rate were dose dependent. Arterial blood pressure increased slightly as did heart rate.(ABSTRACT TRUNCATED AT 250 WORDS)     

The implications of lighted ureteral stenting in laparoscopic colectomy.

OBJECTIVE: The placement of indwelling ureteral catheters during colorectal surgery has been recommended for prevention of ureteral injuries. With the advent of laparoscopic colectomy (LCo), the role of preoperative placement of lighted ureteral stents (LUS) has also become commonplace. We sought to evaluate the value of lighted ureteral stent placement in laparoscopic colectomy. METHODS: Sixty-six patients underwent LCo with LUS inserted preoperatively. Stents were removed in the immediate postoperative period. Two surgeons performed all the colectomies; 32 patients were males and 34 were females. Fifty patients underwent sigmoid colectomy, 4 had abdominoperineal resection, 4 had right colectomy, and 1 each had transverse or subtotal colectomy. Eighteen patients had a diagnosis of cancer, 34 had diverticular disease, and 14 had neoplastic polyps. Forty patients had bilateral and 26 had unilateral stent placement. A review of the incidence of ureteral injuries, hematuria, and anuria as the cause of acute renal failure was accomplished, comparing the unilateral and bilateral stented groups. RESULTS: One (1.5%) patient suffered a left ureteral laceration during sigmoid colectomy. This was managed successfully with stent reinsertion. Sixty-five (98.4%) patients had gross hematuria lasting 2.93 days (1 to 6 days). The cost of bilateral stent placement was $1,504.32. A statistically significant difference occurred in the duration of hematuria (days) between patients who had unilateral (2.5 +/- 0.82) and bilateral stent placement (3.37 +/- 1.05), (P < 0.001). Four patients suffered from anuria, 2 required renal support needing hemodialysis for 3 to 6 days, 3 (75%) had bilateral stents, and 1 (25%) had a unilateral stent. CONCLUSIONS: We recommend the placement of lighted ureteral stents as a valuable adjunct to laparoscopic colectomy to safeguard ureteral integrity. Transient hematuria is common but requires no intervention. Reflux anuria occurs infrequently and is reversible.