Anisotropic Bladder Planning Target Volume in Bladder Radiation Therapy

Purpose

This study aimed to investigate 3 planning target volume (PTV) margin expansions and determine the most appropriate volume to be used in bladder preservation therapy when using daily cone beam computed tomography (CBCT). We aimed to establish whether a smaller PTV expansion is feasible without risking geographical miss.

Pediatric valve replacement, 15 years experience in Oman

Background Despite improving surgical techniques, treatment of heart valve disease in children remains controversial. Somatic growth and adequate anticoagulation are of concern when children undergo valve replacement. We conducted this study to evaluate the performance of valves in this age group. Methods 42 children under the age of 13 years who underwent valve replacement were included in this study. Totally, 50 valves were implanted in 42 patients: 48 were mechanical prostheses, two were bioprosthetic both in pulmonary position. 37 (74%) valves were implanted in mitral position, 10 (20%) in aortic position, 1 (2%) in tricuspid position and 2 (4%) in pulmonary position. Preoperatively, 14 (33,3%) patients were in New York Heart Association (NYHA) class IV, while 27 (64.2%) were in NYHA class III. Results There were 2 (4.7%) hospital deaths and 2 (4.7%) late deaths while 2 (4.7%) patients were lost to follow up. The mean follow up period was 9.4 yrs. 35 (83.3%) patients are in NYHA Class I and free of all medications except warfarin. 3 (7.1%) patients have undergone 5 successful pregnancies. The median INR was 2.23. Major thrombo-embolic episode occurred in 1 (2.3%) patient. Conclusions In view of the problems of sizing, anticoagulation and need for re-operation at an early age, there is a reluctance to replace valves in children. This study shows that despite these problems, valve replacement can be undertaken safely and successfully in children, when repair has failed or not technically feasible.     

Reconstruction of the wrist pseudoarthrosis due to radioulnar fractures with vascularized fibular graft in a child with neurofibromatosis

Nonunion in the forearm following a radioulnar fracture is one of the nightmares of the orthopedic surgeon. Fortunately, it is rare. We treated a large bone defect of the forearm, using a vascularized fibular graft after excision of the unhealed bone segment in a 10-year-old boy with neurofibromatosis. This situation followed a double fracture that had been operated on several times using conventional methods. Following the debridement of the unhealthy tissues in the pseudoarthrotic region, the vascularized fibula was placed on the dorsal surface of the proximal radius fragment. The distal fragment of the radius was inserted into the fibular cavity and fixation was established with a Kirschner wire distally and with a plate proximally. Only two screws were used to fix the plate. The peroneal artery was anastomosed with the radial artery; one of its venae comitantes was anastomosed with the cephalic vein in an end-to-end fashion. After surgery, the elbow was immobilized at 90 degrees of flexion with a splint for 6 weeks. One year after surgery, forearm stabilization and elbow and hand functions were very satisfactory. However, because the distal epiphyses of the bones were destroyed following the repeated surgery and the original trauma itself, a very prominent difference between the two forearms occurred, suggesting the need for bone lengthening in the future. By presenting this case we would like to conclude that one can expect good bone healing with a vascularized bone transfer in these cases when there is not enough space to place screws, but support can be provided by an external splint and K wire.     

Neonatal necrotizing enterocolitis

PURPOSE: A retrospective, 12-year review of neonatal necrotizing enterocolitis was undertaken at a county hospital, with emphasis on presentation signs and symptoms. METHODS: Eighty-two patients with presence of intramural air were included in the study. The following signs and symptoms were studied: evidence of respiratory distress, use of umbilical catheters, white blood cell count and temperature at presentation, time interval from birth to diagnosis and time interval from diagnosis to operative intervention, presence of intramural air, air in biliary tree or free air, changes in abdominal girth, and presence of occult or gross blood in stools. Comparison was done among infants who had surgical or medical treatment, premature and full-term infants, and infants who had neonatal necrotizing enterocolitis less than or more than 20 days after birth. RESULTS: Eleven patients had a fatal outcome, with an overall survival of 87 percent. Sixty-four patients were treated medically and 18 had operative treatment. Mortality of the surgically treated group was 44 percent. Neonates who had surgical intervention had a left shift of the white blood cell count more commonly present, and all had documented abdominal distention. There were 62 premature and 20 full-term neonates in the group. Full-term neonates developed neonatal necrotizing enterocolitis earlier after birth (5.3 days compared with 15.3 days in the premature neonate group). Full-term neonates had a better prognosis in our series. Presentation of symptoms more than 20 days after birth did not change outcome. CONCLUSION: Our results reflect the experience of a community-based hospital. Clinical acumen remains the cornerstone of diagnosis and management.     

Glyceraldehyde-3-phosphate dehydrogenase: Nuclear translocation participates in neuronal and nonneuronal cell death

Glyceraldehyde-3-phosphate dehydrogenase (GAPDH) protein levels increase in particulate fractions in association with cell death in HEK293 cells, S49 cells, primary thymocytes, PC12 cells, and primary cerebral cortical neuronal cultures. Subcellular fractionation and immunocytochemistry reveal that this increase primarily reflects nuclear translocation. Nuclear GAPDH is tightly bound, resisting extraction by DNase or salt treatment. Treating primary thymocytes, PC12 cells, and primary cortical neurons with antisense but not sense oligonucleotides to GAPDH prevents cell death. Because cell-death-associated nuclear translocation of GAPDH and antisense protection occur in multiple neuronal and nonneuronal systems, we propose that GAPDH is a general mediator of cell death and uses nuclear translocation as a signaling mechanism.     

Evaluation of flow hemodynamics by color-Doppler following two different brachial arterial repair techniques.

OBJECTIVES: We compared the clinical and hemodynamic results following surgical repair of traumatic brachial artery injury using two different techniques micro- and macrovascular repair. MATERIALS AND METHODS: This was a retrospective study of 27 patients who had sustained penetrating, clean cut injuries of the brachial artery. Macrovascular techniques and a saphenous vein graft was used in 13 patients, while 14 patients were treated by primary microsurgical technique. Postoperatively, patients were followed for a mean of 26 months. All patients had color Doppler examination of the brachial artery, digital artery pressures and transcutaneous oxygen saturation determined. RESULTS: Clinical results based on distal pulses, Allens test and digital pressures were similar in the two groups. Color Doppler showed 8/13 anastomotic stenoses in macrovascular vein grafted repairs and 2/14 in microvascular repairs (p<0.05). The ratio of flow velocity proximal compared distal to the injury was significantly decreased in patients who had macrovascular repairs. CONCLUSION: Using ratio between proximal and distal site of anastomosis maximal peak systolic velocity as a objective color Doppler parameter, we were able to demonstrate differences in the hemodynamic status following macrovascular repair with vein grafts and microvascular primary repair. The results emphasize the importance of using a standard repair technique for similar injuries rather than the preference of the surgeon.     

Non-Hodgkin's lymphoma with protein S deficiency]

Venous thrombosis is rare in children. It can be either acquired or of constitutional origin. Thrombosis during non-Hodgkin lymphoma remains exceptional and is usually locally associated to the tumoral process, raising the issue of its tumoral or cruoric nature. The treatment is based on anticoagulation concomitantly to chemotherapy. We report on a 4-year-old boy admitted for mediastinal non-Hodgkin lymphoma, who developed a thrombosis of the superior vena cava associated to protein S-deficiency. The mechanism of thrombosis may have been multifactorial: associated protein S-deficiency, vascular compression, tumoral process and chemotherapy.     

De Novo Non-Alcoholic Fatty Liver Disease Following Orthotopic Liver Transplantation

Non-alcoholic fatty liver disease (NAFLD) is an increasingly recognized clinico-pathologic entity typically associated with obesity, type II diabetes and hyperlipidemia. It has been noted to recur after orthotopic liver transplantation (OLT). We report four patients who developed de novo NAFLD within 3 months of OLT without the typical predisposing factors of diabetes mellitus or obesity. Three of the four patients underwent OLT for hepatitis C-related cirrhosis, and the other for alcoholic cirrhosis. Examination of the liver explants revealed no evidence of steatosis. No surreptitious alcohol use or a drug-induced process could be identified in these patients. Treatment of recurrent hepatitis C infection in one patient with interferon and ribavirin led to sustained suppression of the viral RNA to undetectable levels, but no improvement in histology or liver enzymes. All four patients had histologic evidence of preservation injury on the initial post-OLT biopsies, but the significance of this finding in relationship to the development of NAFLD is unknown. NAFLD can develop without any of the known predisposing conditions after transplantation, and this raises further questions about the pathogenesis of this condition .     

Undernutrition in the Nursing Home: Prevalence, Consequences, Causes and Prevention

Approximately 5% of Americans over age 65, or 1.5 million individuals, currently reside in the nations's 20,000 nursing homes. The authors present material that lead to three conclusions about this population. First, nutritional deficiencies are common underlying causes of adverse clinical outcomes. Second, nutritional deficiencies are frequently not recognized. Third, opportunities for preventing or correcting undernutrition exist, provided that the significant and reversible nature of the nutrient deficiencies are identified.     

Inflammatory regulation of extracellular matrix remodeling in calcific aortic valve stenosis.

BACKGROUND: Calcific aortic stenosis (AS), the most frequent heart valve disorder in developed countries, leads to the calcification and fibrous thickening of the valve. While several studies have addressed the process of valvular calcification, the molecular pathomechanisms of the extensive matrix remodeling remain unclear. Because inflammation is present in stenotic valves, we hypothesized that the proinflammatory cytokine tumor necrosis factor alpha (TNFalpha) might influence cell proliferation and regulate the expression and activation of matrix metalloproteinases (MMPs)--enzymes that are thought to be involved in calcific AS. METHODS: Immunohistochemistry for leukocytes, TNFalpha, MMP-1, and the endogenous MMP inhibitor tissue inhibitor of metalloproteinase (TIMP)-1 was performed on human stenotic (n = 19) and control (n = 8) valves. Primary cultures of human aortic valve myofibroblasts were incubated with and without TNFalpha, and cell proliferation was assessed. The expression and activation of MMP-1 were detected by Western blotting and a specific MMP-1 activity assay. RESULTS: Control valves showed scattered macrophages and low expression of TNFalpha, MMP-1, and TIMP-1. In stenotic valves, leukocyte infiltration and a strong, colocalized expression of TNFalpha and MMP-1 were present, while TIMP-1 remained unchanged. Double-label immunofluorescence localized TNFalpha mainly to macrophages. In cultured human aortic valve myofibroblasts, TNFalpha stimulated proliferation and induced a time-dependent increase in MMP-1 expression and activation, while TIMP-1 remained unchanged. CONCLUSION: The results indicate that matrix remodeling in calcific AS involves the expression and activation of MMPs. Activated leukocytes, by the secretion of TNFalpha, may stimulate valvular myofibroblasts to proliferate and express MMPs, thus regulating actively the matrix remodeling in calcific AS.