A multicentre comparative study between laparoscopic and open surgery for intussusception in adults

AIM

Intussusception in adults is rare and requires surgery in most cases. While abdominal laparoscopic surgery (LS) is becoming more popular, there are few reports on the outcomes of adult intussusception treated with LS. This study compared the feasibility of LS vs open surgery (OS) for adult intussusception.

METHOD

We reviewed retrospectively the medical records of adult patients with intussusception from three tertiary hospitals between 2000 and 2016. The patients were divided into LS and OS groups, and their surgical outcomes were compared.

RESULTS

Surgery was indicated in 71 patients with intussusception (41 LS and 30 OS). The median age of the patients was 49.0 and 51.5 years in the LS and OS groups, respectively (P = 0.930). Overall, nine (12.7%) patients had a negative laparotomy or laparoscopy with spontaneous reduction of the intussusception. Conversion to OS from LS was necessary in one patient (2.4%). The operative time and intra-operative and postoperative complication rates were not significantly different. However, there were more serious complications such as bowel perforation and major vessel injury in the LS group. The patients in the LS group had a shorter time to first food intake and hospital stay vs patients in the OS group (4.0 vs 6.0 days, P < 0.001, and 7.0 vs 10.5 days, P < 0.001, respectively).

CONCLUSION

LS may be feasible for adult intussusception; there may be more severe intra-operative complications than in OS.

Atypical Femoral Fracture: 2015 Position Statement of the Korean Society for Bone and Mineral Research

Bisphosphonate (BP) is a useful anti-resorptive agent which decreases the risk of osteoporotic fracture by about 50%. However, recent evidences have shown its strong correlation with the occurrence of atypical femoral fracture (AFF). The longer the patient takes BP, the higher the risk of AFF. Also, the higher the drug adherence, the higher the risk of AFF. It is necessary to ask the patients who are taking BP for more than 3 years about the prodromal symptoms such as dull thigh pain. Simple radiography, bone scan, and magnetic resonance imaging (MRI) are good tools for the diagnosis of AFF. The pre-fracture lesion depicted on the hip dual energy X-ray absorptiometry (DXA) images should not be missed. BP should be stopped immediately after AFF is diagnosed and calcium and vitamin D (1,000 to 2,000 IU) should be administered. The patient should be advised not to put full weight on the injured limb. Daily subcutaneous injection of recombinant human parathyroid hormone (PTH; 1-34) is recommended if the patient can afford it. Prophylactic femoral nailing is indicated when the dreaded black line is visible in the lateral femoral cortex, especially in the subtrochanteric area.

Etoricoxib in the treatment of Korean patients with osteoarthritis in a double-blind, randomized controlled trial

OBJECTIVE

We evaluated the COX-2 inhibitors, etoricoxib and celecoxib, in Korean patients with osteoarthritis (OA).

METHODS

This study included patients (≥ 40 years of age) with a clinical and radiographic diagnosis of knee OA. Patients were randomized to etoricoxib 30 mg (qd) or celecoxib 200 mg (qd) in a 12 week randomized, controlled, double-blind study. Prior NSAID users were to demonstrate a worsening of symptoms upon withdrawal of medication. Efficacy endpoints included the time-weighted average change from baseline in the WOMAC VA 3.0 Pain Subscale (100 mm Visual Analog Scale [VAS]; primary endpoint), the WOMAC VA 3.0 Physical Function Subscale (100 mm VAS), and Patient Global Assessment of Disease Status (PGAD) (100 mm VAS). The primary hypothesis was that etoricoxib 30 mg is non-inferior to celecoxib 200 mg as assessed by the primary endpoint (the non-inferiority margin was set at 10 mm VAS). Adverse events (AEs), laboratory parameters, and vital signs were monitored.

RESULTS

There were 239 patients (89.5% female; mean age: 63.3 years) randomized to etoricoxib 30 mg (n = 120) and celecoxib 200 mg (n = 119). The differences (etoricoxib vs celecoxib) in least square (LS) mean change (95% CI) for WOMAC Pain, WOMAC Physical Function, and PGAD were -1.63 mm (-5.37, 2.10), -1.32 mm (-4.88, 2.23), and -1.09 mm (-5.48, 3.30), respectively. Drug-related clinical AEs occurred in 6.7% (etoricoxib) and 2.5% (celecoxib) of patients. This study was limited because it was not designed or powered to adequately capture and evaluate rare AEs associated with NSAID treatment.

CONCLUSIONS

Etoricoxib 30 mg administered once daily in Korean patients with knee OA demonstrated non-inferior clinical efficacy to celecoxib 200 mg over 12 weeks of treatment as assessed by all primary and secondary outcomes. Etoricoxib 30 mg qd and celecoxib 200 mg qd were generally safe and well tolerated.

CLINICAL TRIAL REGISTRATION

NCT01554163.

Evaluation of Protein Expression in Housekeeping Genes across Multiple Tissues in Rats

Background

Housekeeping genes, which show constant protein expression patterns between different tissue types, are very important in molecular biological studies as an internal control for protein research.

Methods

The protein expression profiles of seven housekeeping genes (HPRT1, PPIA, GYS1, TBP, YWHAZ, GAPDH and ACTB) in various rat tissues (cerebrum, cerebellum, cardiac ventricle and atrium, psoas muscle, femoral muscle, liver, spleen, kidney, and aorta) were analyzed by Western blot and compared by coefficient of variation (CV).

Results

HPRT1 was stably expressed (CV≤10%) in six tissues (cerebrum, cerebellum, ventricle, femoral muscle, spleen, and kidney), PPIA was stably expressed in five tissues (cerebrum, cerebellum, ventricle, spleen and kidney), YWHAZ was stably expressed in three tissues (cerebrum, cerebellum, and kidney), and GAPDH was stably expressed in four tissues (cerebrum, ventricle, psoas muscle, and kidney). In comparison, GYS1, TBP, and ACTB were found to have CV values over 10% in all tissues. Of the seven genes examined, four (HPRT1, PPIA, YWHAZ, and GAPDH) were found to be stably expressed across multiple organs, with low CV values (≤10%).

Conclusions

These results will provide fundamental information regarding internal controls for protein expression studies and can be used for analysis of postmortem protein degradation patterns in forensic medicine.

Computed tomography-guided removal of a misplaced acetabular screw

Open reduction and internal fixation with multiple screws and plates is the treatment of choice in patients with complex acetabular fractures. Two cases of a misplaced acetabular screw were detected on post-operative imaging, and referred to us for CT-guided removal of the misplaced screw. With the patients in the decubitus position, preliminary images were obtained to determine the puncture site and angle of approach. A k-wire was advanced to the head of the screw, over which we inserted a cannulated screwdriver and removed the screw. At each step all procedures were monitored with CT. The average total procedure time was 30 min. We observed no significant complications during or after the procedure. CT-guided removal of a misplaced acetabular screw seems to be a simple and safe procedure.

Experience of severe desaturation during anesthetic induction period in an obese adult patient with Prader-Willi syndrome -A case report-

Prader-Willi syndrome is characterized by infantile hypotonia, childhood-onset obesity, short stature, mental retardation, hyperphagia, hypogonadism. After infantile hypotonia phase, patient is prone to morbid obesity due to hyperphagia. Complications associated with morbid obesity are recognized as the main risk factors for death the lifespan of patients with Prader-Willi syndrome. We experienced desaturation and bronchospasm during arteriovenous fistula surgery in an obese adult with Prader-Willi syndrome.

Ultrasound-guided Lateral Femoral Cutaneous Nerve Block in Meralgia Paresthetica

Meralgia paresthetica is a rarely encountered sensory mononeuropathy characterized by paresthesia, pain or sensory impairment along the distribution of the lateral femoral cutaneous nerve (LFCN) caused by entrapment or compression of the nerve as it crossed the anterior superior iliac spine and runs beneath the inguinal ligament. There is great variability regarding the area where the nerve pierces the inguinal ligament, which makes it difficult to perform blind anesthetic blocks. Ultrasound has developed into a powerful tool for the visualization of peripheral nerves including very small nerves such as accessory and sural nerves. The LFCN can be located successfully, and local anesthetic solution distribution around the nerve can be observed with ultrasound guidance. Our successfully performed ultrasound-guided blockade of the LFCN in meralgia paresthetica suggests that this technique is a safe way to increase the success rate.

Epidural anesthesia for the patient with type IV spinal muscular atrophy -A case report-

Spinal muscular atrophy (SMA) is a rare lower motor neurone disease in which anesthetic management is often difficult as a result of muscle weakness, hypersensitivity to non-depolarizing neuromuscular blocking agent, and succinylcholine induced hyperkalemia. We describe a 50-year-old patient with type IV SMA for synovectomy. We decided to use an epidural technique to avoid muscle relaxants and tracheal intubation. After operation, there was no exacerbation of neurologic signs and symptoms.

Combined spinal-epidural anesthesia for cesarean section in a patient with Moyamoya disease -A case report-

Moyamoya disease is a rare progressive occlusive disease of the internal carotid arteries. We report a case of combined spinal-epidural anesthesia in a patient with Moyamoya disease presenting for Cesarean section. Hypotension associated with spinal anesthesia for Cesarean section is the most common and serious adverse effect despite the use of uterine displacement and volume preload. We continuously infused phenylephrine and ephedrine to prevent hypotension. The intraoperative hemodynamic state was stable. The patient had no significant postoperative complications.

Anesthetic experience of a patient with tracheomegaly -A case report-

Tracheomegaly or tracheobronchomegaly is a rare syndrome that consists of marked dilatation of the trachea and the major bronchi, and this is usually due to a congenital defect of the elastic and muscle fibers of the tracheobroncheal tree. Physicians have had only limited experience with performing anesthesia in patients with this type of syndrome. This syndorme is diagnosed by roentenological investigation and this condition is frequently associated with chronic respiratory infection and partial airway obstruction. In this report, we present a case of performing tracheostomy for a patient with tracheomegaly, and this was probably secondary to mechanical ventilator therapy. The regular tracheostomy tube did not provided sufficient length to allow the cuff to lie properly in the trachea in this patient. Because of the peri-cuff air leakgae and hypercapnea after tracheostomy, we needed a longer tracheostomy tube. But we didn't have such a tube and we didn't know any other method, so we couldn't perform tracheostomy. Therefore, we introduced a method of reducing the length of the endotracheal tube to a suitable size until a longer tracheostomy tube can be obtained for those patients having tracheomegaly.

Cardiac arrest in the prone position with the Andrews frame during lumbar spine surgery: A case report

The prone position during anesthesia sometimes causes hemodynamic changes such as a decrease in blood pressure. These changes are caused by a decrease in venous return from venous pooling in the legs, and decreased left ventricular compliance secondary to increased intrathoracic pressure, when patients are placed prone with an Andrews frame. We report on a patient who experienced cardiac arrest in the prone position with the Andrews frame during lumbar laminectomy and posterior lumbar interbody fusion. After 1.25 h in the prone position, bradycardia and hypotension occurred. Ephedrine, atropine and epinephrine were infused intravenously, but bradycardia and hypotension progressed to asystole. Cardioinhibitory reflex was likely triggered by decreased venous return and increased intrathoracic pressure, and the patient developed cardiac arrest as a result.

Musculoskeletal injuries in break-dancers

BACKGROUND

Since no epidemiologic studies have been reported about musculoskeletal injuries in break-dancers, there are no data on the rates and patterns of musculoskeletal injuries in this population that clinicians can use to find ways to decrease injury rate.

HYPOTHESIS

We believe that the incidence of injuries in break-dancers is higher than assumed and that injury rates and patterns differ between professional and amateur dancers.

STUDY DESIGN

Descriptive epidemiologic study.

MATERIALS AND METHODS

Of a total of 42 study subjects, 23 were professional dancers and 19 were amateur dancers. Injury frequency, site and type, along with the presence of supervised training, the use of protective devices and warm-up exercises done were recorded.

RESULTS

Of the 42 study subjects, excluding two amateur dancers, 40 (95.2%) had had musculoskeletal injuries at more than one site. The mean number of sites per dancer was 4.60. The frequency of injury depended on the site and was as follows: wrist (69.0%), finger (61.9%), knee (61.9%), shoulder (52.4%), lumbar spine (50.0%), elbow (42.9%), cervical spine (38.1%), ankle (38.1%), foot (28.6%) and hip (16.7%). Sprain, strain and tendinitis were the most common injuries, accounting for the most cases. Of the 42 dancers, 13 (31%) had had fractures or dislocations. Eight (19.1%) learned break-dancing under supervised instruction, 17 (40.5%) used protective devices and 28 (66.7%) performed warm-up exercises before dancing. There were significant differences in age, dance career length, amount of dance training, mean number of injury sites and the presence of supervised training between professionals and amateurs (P<0.05).

CONCLUSION

Clinicians must inquire thoroughly into the nature of the activities that result in both unusual and common injuries in break-dancers and educate them about safety. Careful screening, instruction and supervised training of break-dancers will help to prevent injuries.

Anesthetic management in a pediatric patient with infantile phase Prader-Willi Syndrome: A case report

Prader-Willi syndrome is a genetic disorder characterized by infantile hypotonia, childhood obesity, characteristic facial appearance, mental retardation, hypogonadism and short stature. It is described as a 2-stage disorder with an infantile hypotonic phase, followed by a childhood obese phase. The first phase, during the newborn and infancy period, is characterized by marked hypotonia, poor sucking, swallowing, coughing, crying, and episodes of asphyxia. Since these signs of poor strength cause poor reversal in the postoperative period, muscle relaxants should be used cautiously, especially in patients in the first phase of the syndrome. We experienced the anesthetic management of a 5-month-old female patient with Prader-Willi syndrome under general anesthesia, without muscle relaxant for excision of BCG lymphadenitis and a preauricular mass.

Closed reduction and internal fixation of displaced unstable lateral condylar fractures of the humerus in children

BACKGROUND

Open reduction and internal fixation of a displaced unstable fracture of the lateral condyle of the humerus in a child usually produces a good result. Only a few reports have focused on closed reduction and internal fixation of these fractures. We prospectively studied closed reduction and internal fixation to determine its usefulness as the initial treatment for displaced unstable fractures of the lateral condyle of the humerus.

METHODS

We classified lateral condylar humeral fractures into five groups according to the degree of displacement and the fracture pattern as determined on four radiographic views and created an algorithm for the treatment of these fractures on the basis of this classification system. We prospectively treated sixty-three unstable fractures (in forty-two boys and twenty-one girls) and assessed the quality of closed reduction.

RESULTS

Thirteen of seventeen stage-3 fractures were reduced to < or =1 mm of residual displacement. Thirty of forty stage-4 fractures and three of six stage-5 fractures were reduced to < or =2 mm of displacement. In ten of forty stage-4 fractures and three of six stage-5 fractures, closed reduction to within 2 mm failed and open reduction and internal fixation was performed. There were no major complications such as osteonecrosis of the trochlea or capitellum, nonunion, malunion, or early physeal arrest.

CONCLUSIONS

Closed reduction and internal fixation is an effective treatment for unstable displaced lateral condylar fractures of the humerus in many children. If fracture displacement after closed reduction exceeds 2 mm, open reduction and internal fixation is recommended.

Internal oblique radiographs for diagnosis of nondisplaced or minimally displaced lateral condylar fractures of the humerus in children

BACKGROUND

Several radiographic criteria based on only standard anteroposterior and lateral radiographs have been suggested for predicting the stability of lateral condylar fractures of the humerus in children. Despite adherence to these guidelines, further displacement often occurs after the initial diagnosis and stability assessment. The purpose of this study was to define the usefulness of an internal oblique radiograph in the assessment of these fractures.

METHODS

We prospectively studied fifty-four lateral humeral condylar fractures in fifty-four children seen between March 2002 and December 2004 to determine the efficacy of internal oblique radiographs in gauging the amount of displacement and the fracture pattern. Plain anteroposterior, lateral, internal oblique, and external oblique radiographs were initially made for all fifty-four patients, and three-dimensional computed tomography scans were performed for seven patients.

RESULTS

A large percentage (70%) of the fractures were seen to have different amounts of displacement on the anteroposterior and internal oblique radiographs, and a large percentage (75%) were seen to have different fracture patterns, according to the criteria suggested by Finnbogason et al., on the two views. The internal oblique radiograph was more accurate for demonstrating the fracture gap (thirty cases were seen to have more displacement on that view) and for demonstrating the fracture pattern (twenty cases were seen to have more instability on the internal oblique view). We also confirmed the direction of the fracture line and the location of the fragment more accurately with three-dimensional computed tomography.

CONCLUSIONS

It is not optimal to evaluate the amount of displacement and the stability of a lateral condylar fracture of the humerus in children on the basis of just anteroposterior and lateral elbow radiographs. Classifications should be based on the greatest displacement seen on at least three radiographic views, especially the internal oblique view.

Selective inhibition of polymorphonuclear neutrophils by resuscitative concentration of hypertonic saline

OBJECTIVES

This study investigated the effect of hypertonic saline on the role of polymorphonuclear neutrophils (PMNs) in the inflammatory response and the effect of hypertonic saline infused at different phases in relation to an inflammatory stimulus.

MATERIALS AND METHODS

PMNs were isolated from peripheral blood of healthy volunteers (Boyum's method) and cultured in three different media ([Na+] = 140 mmol/l, 180 mmol/l, and 200 mmol/l). PMNs were then stimulated with fMLP (N-formyl-methionyl-leucyl-phenylalanine) and H2O2 synthesis was quantified by flow cytometry at 5, 30, 60, 120, and 180 minutes. PMNs were treated with hypertonic saline before, simultaneously with, and after fMLP stimulation, and H2O2 synthesis quantified again.

RESULTS

H2O2 synthesis was two or three times higher in fMLP stimulated than in non-stimulated PMNs, and it reached maximum level at 120 minutes. In the absence of fMLP stimulation, there was no significant difference between control and hypertonic saline with regard to activity of H2O2 synthesis. In the presence of fMLP stimulation, H2O2 synthesis significantly decreased in PMNs treated with hypertonic saline. There was no significant difference between the two hypertonic saline solutions ([Na+] = 180 mmol/l and 200 mmol/l) with regard to H2O2 synthesis. However, H2O2 synthesis decreased in PMNs treated with hypertonic saline before and simultaneously with fMLP stimulation, but was not significantly decreased in the cells treated with hypertonic saline after fMLP stimulation.

CONCLUSIONS

Hypertonic saline appears to decrease H2O2 in stimulated neutrophils. This may be a further beneficial role of hypertonic saline when used clinically as an early resuscitation fluid.