Outcomes following surgical management of inguinal-related groin pain in athletes: a case series

To determine the outcomes of a limited surgical intervention, consisting of neurolysis, inguinal wall repair and/or adductor debridement of adhesions based on intraoperative findings. Retrospective case series. Outpatient orthopedic/general surgery clinic. Fifty-one athletes treated surgically for inguinal-related groin pain from 2009 to 2015. Limited surgical intervention, consisting of neurolysis, inguinal wall repair and/or adductor debridement based on intra-operative findings. Ability to return to sport at the same level, time to return to play. Fifty-one athletes were included in the study with an average follow-up of 4.42 years (range 2.02–7.01). The average age was 24.2 years (range 16–49) and consisted of 94.0% males and 6.0% females. Nerve entrapment was demonstrated in 96.2% of cases with involvement of the ilioinguinal in 92.5%, the iliohypogastric in 30.8% and the genitofemoral in 13.2%. Attenuation of the posterior inguinal wall was present and repaired in 79.3% of cases. Scar tissue was present around the adductor origin and required debridement in 56.7% of cases. Forty-nine (96.1%) athletes returned to sport at the same level of play at an average of 5.9 weeks. Two athletes required a revision surgery. High rates of return to sport were achieved after surgery for inguinal-related groin pain that addresses the varying pathology and associated nerve entrapment.

Hip and Core Muscle Injuries in Soccer

Soccer is the most popular sport in the world and has the fourth highest number of sports injuries. Hip and groin injuries account for 14% of soccer injuries and can be difficult to recognize and treat as they often require a high level of suspicion and advanced imaging. Groin pain can be separated into 3 categories: (1) defined clinical entities for groin pain (adductor-related, iliopsoas-related, inguinal-related [sports hernias/athletic pubalgia], and pubic-related groin pain), (2) hip-related groin pain (hip morphologic abnormalities, labral tears, and chondral injuries), and (3) other causes of groin pain. Conservative approaches are typically the first line of treatment, but operative intervention has been reported to result in higher rates of return to sport in athletes with hip-related and inguinal-related groin pain injuries. In patients with concurrent hip-related and inguinal-related groin pain, the failure to recognize the relationship and treat both conditions may result in lower rates of return to sport. Preseason screening programs can identify high-risk athletes, who may benefit from a targeted prevention program. Further study on exercise therapy, early surgical intervention, and potential biologic intervention are needed to determine the most effective methods of preventing groin injuries in athletes.

Overseas nurses are welcome assets to British hospitals

Nursing students and qualified nurses should stop moaning about overseas nurses working in the UK. They have often travelled many thousands of miles to take up posts when there was a shortage of skilled nurses. They have proved to be caring, skilful and hard working. They are an asset to any hospital.

One hundred consecutive cases of sentinel lymph node mapping in early colorectal carcinoma: detection of missed micrometastases

Almost one third of patients with "node-negative" colorectal carcinoma (CRC) develop systemic disease. This implies that these patients have occult disease that is inadequately treated by surgery alone. We have coupled sentinel lymph node mapping and a focused pathologic examination to detect occult nodal micrometastases in CRC. Since 1996, sentinel lymph node mapping has been performed in 100 consecutive patients undergoing colectomy for CRC. Peritumoral injection of 0.5 to 1.0 ml of isosulfan blue dye was performed to demonstrate the sentinel node(s). All lymph nodes in the resection specimen were examined by routine hematoxylin and eosin staining. In addition, a focused examination of multiple sections of the sentinel nodes was performed using both hematoxylin and eosin and cytokeratin immunohistochemical analysis (CK-IHC). Overall, lymphatic mapping successfully demonstrated one to four sentinel lymph nodes in 97 (97%) of 100 patients. These sentinel nodes accurately reflected the status of the nodal basin in 92 (95%) of 97 patients. All five of the false negative cases occurred in T3/T4 tumors, and three of the five occurred during the first 30 cases in the experience. Unexpected lymphatic drainage was encountered in eight patients (8%) and altered the operative approach. Twenty-six patients were node positive by routine hematoxylin and eosin staining. Of the remaining 74 patients with hematoxylin and eosin-negative nodes, an additional 18 patients (24%) were upstaged by identification of occult nodal micrometastases that were missed on routine hematoxylin and eosin staining but detected on multiple sections (n = 5) or by CK-IHC (n = 13). The sentinel lymph nodes were the only positive nodes in 19 cases. Sentinel lymph node mapping may be performed in CRC with a high degree of success and accuracy. A focused pathologic examination of the sentinel node detects micrometastatic disease that is missed by conventional techniques in a significant proportion of patients with early CRC. Further studies are necessary to elucidate the clinical relevance of these micrometastases.

The efficacy of a commercial beta-glucan preparation, EcoActiva, on stimulating respiratory burst activity of head-kidney macrophages from pink snapper (Pagrus auratus), Sparidae

This study investigated the in vitro effects of a commercial beta-glucan preparation, EcoActiva, on the respiratory burst activity of head-kidney macrophages isolated from pink snapper (Pagrus auratus), a marine fish cultured in Australia. Macrophages incubated with EcoActiva displayed morphological characteristics of activation, and were stimulated to produce superoxide. Pre-incubation with low levels of EcoActiva significantly increased the response to phorbol myristate acetate (PMA) and lipopolysaccharide (LPS), indicating that EcoActiva could prime these macrophages. Co-culturing macrophages with both LPS and PMA, or EcoActiva and PMA, increased burst activity compared with the response to PMA alone, however, this increase was additive and not synergistic. These results suggest that EcoActiva is able to stimulate non-specific immunity in snapper through increased respiratory burst activity of macrophages, an important component of the host defence network.

Validation of lymphatic mapping in colorectal cancer: in vivo, ex vivo, and laparoscopic techniques

BACKGROUND

The use of lymphatic mapping (LM) is being investigated to improve the staging of colorectal cancer (CRC) and thereby identify patients who might benefit from adjuvant chemotherapy. This study evaluated in vivo, laparoscopic, and ex vivo approaches for the ultrastaging of CRC.

METHODS

Seventy-five CRC patients were enrolled in a study of LM with peritumoral injection of isosulfan blue dye. LM was undertaken during open colon resection (OCR) in 64 patients, during laparoscopic colon resection (LCR) in 9 patients, and after specimen removal (ex vivo) in 2 patients. Ex vivo LM was also undertaken in 6 patients after unsuccessful in vivo LM. All nodes were examined by hematoxylin and eosin (H&E) staining; in addition, sentinel lymph nodes (SNs) were multisectioned and examined by immunohistochemical staining with cytokeratin (CK-IHC).

RESULTS

At least one SN was identified in 72 patients (96%). In vivo LM identified SNs in 56 of 64 (88%) patients undergoing OCR and in 9 of 9 (100%) patients undergoing LCR. Ex vivo LM was undertaken as the initial mapping procedure in 2 cases of intraperitoneal colon cancer and after in vivo LM had failed in 6 cases of extraperitoneal rectal carcinoma; an SN was identified in 7 of the 8 cases. Focused examination of the SN correctly predicted nodal status in 53 of 56 OCR cases, 9 of 9 LCR cases, and 6 of 7 ex vivo cases. Multiple sections and CK-IHC identified occult micrometastases in 13 patients (17%), representing 10 OCR, 1 LCR, and 2 ex vivo cases.

CONCLUSIONS

LM of drainage from a primary CRC can be accurately performed in vivo during OCR or LCR. Ex vivo LM can be applied when in vivo techniques are unsuccessful and may be useful for rectal tumors. During LCR, colonoscopic injection can be used to mark the primary tumor and define the lymphatic drainage so that adequate resection margins are obtained. These LM techniques improve staging accuracy in CRC.

Focused Examination of Sentinel Lymph Nodes Upstages Early Colorectal Carcinoma

Approximately 30 per cent of patients with early colorectal carcinoma (CRC) develop systemic disease. A subgroup of these patients may harbor occult micrometastatic disease and might benefit from adjuvant chemotherapy. We investigated sentinel lymph node (SLN) mapping and focused pathologic examination of the SLN as a means of detecting nodal micrometastases. Between 1996 and 2000 SLN mapping was performed in 50 consecutive patients undergoing colectomy for CRC. All lymph nodes in the resection specimen were examined via routine hematoxylin and eosin (H&E) staining. In addition multiple sections of each SLN were examined via both H&E and cytokeratin immunohistochemistry. At least one SLN was identified in 47 patients (94%). In seven patients (14%) SLN mapping identified aberrant drainage that altered the planned resection. The SLN(s) correctly predicted nodal basin status in 44 of 47 (94%) cases; there were three falsely negative SLNs. Sixteen cases had positive SLNs by conventional H&E staining. An additional 10 (20%) cases were upstaged by a focused examination of the SLNs. Micrometastases were identified in three cases by H&E staining of multiple sections of the SLN and in seven only by cytokeratin immunohistochemistry. In nine cases the SLN was the only node containing tumor cells. In this study, SLN mapping demonstrated aberrant nodal drainage patterns that altered the surgical resection in patients with CRC. Focused examination of SLNs may detect micrometastases missed by conventional techniques and thereby identify patients who might benefit from adjuvant therapy.

Focused examination of sentinel lymph nodes upstages early colorectal carcinoma

Approximately 30 per cent of patients with early colorectal carcinoma (CRC) develop systemic disease. A subgroup of these patients may harbor occult micrometastatic disease and might benefit from adjuvant chemotherapy. We investigated sentinel lymph node (SLN) mapping and focused pathologic examination of the SLN as a means of detecting nodal micrometastases. Between 1996 and 2000 SLN mapping was performed in 50 consecutive patients undergoing colectomy for CRC. All lymph nodes in the resection specimen were examined via routine hematoxylin and eosin (H&E) staining. In addition multiple sections of each SLN were examined via both H&E and cytokeratin immunohistochemistry. At least one SLN was identified in 47 patients (94%). In seven patients (14%) SLN mapping identified aberrant drainage that altered the planned resection. The SLN(s) correctly predicted nodal basin status in 44 of 47 (94%) cases; there were three falsely negative SLNs. Sixteen cases had positive SLNs by conventional H&E staining. An additional 10 (20%) cases were upstaged by a focused examination of the SLNs. Micrometastases were identified in three cases by H&E staining of multiple sections of the SLN and in seven only by cytokeratin immunohistochemistry. In nine cases the SLN was the only node containing tumor cells. In this study, SLN mapping demonstrated aberrant nodal drainage patterns that altered the surgical resection in patients with CRC. Focused examination of SLNs may detect micrometastases missed by conventional techniques and thereby identify patients who might benefit from adjuvant therapy.

Posteroventral medial pallidotomy in Parkinson's disease

There has been a resurgence in the use of functional neurosurgery for Parkinson's disease. An important factor that has played a role in this development is the recent understanding of the functional anatomy of the basal ganglia including a knowledge of the changes in the activities of neurons in the internal segment of the globus pallidus (Gpi) and the subthalamic nucleus (STN) in Parkinson's disease as well as the knowledge of the presence of segregated functional loops within the basal ganglia which include a sensory-motor loop that involves the posteromedial globus pallidus rather than the anterior GPi where earlier pallidotomy lesions had been made. Laitinen reintroduced the modern posteroventral medial pallidotomy (PVMP) in 1992. Since then it has become clear that this treatment has major effects on levodopa-induced dyskinesias and, unlike Vim thalamotomy, improves bradykinesia and rigidity as well as tremor. In this report, we review a number of topics related to PVMP including the clinical results of pallidotomy available in the literature as well as an update of our own 2 year follow-up data, studies evaluating factors that might predict the subsequent response to pallidotomy, the neuropsychological effects of the procedure, results of imaging studies including the correlation of clinical effects with lesion location, the question of bilateral pallidotomy and pallidotomy combined with deep brain stimulation and finally whether PVMP is effective in other parkinsonian disorders.

Posteroventral medial pallidotomy in advanced Parkinson's disease

BACKGROUND

Posteroventral medial pallidotomy sometimes produces striking improvement in patients with advanced Parkinson's disease, but the studies to date have involved small numbers of patients and short-term follow-up.

METHODS

Forty patients with Parkinson's disease underwent serial, detailed assessments both after drug withdrawal ("off" period) and while taking their optimal medical regimens ("on" period). All patients were examined preoperatively and 39 were examined at six months; 27 of the patients were also examined at one year, and 11 at two years.

RESULTS

The percent improvements at six months were as follows: off-period score for overall motor function, 28 percent (95 percent confidence interval, 19 to 38 percent), with most of the improvement in the contralateral limbs; off-period score for activities of daily living, 29 percent (95 percent confidence interval, 19 to 39 percent); on-period score for contralateral dyskinesias, 82 percent (95 percent confidence interval, 72 to 91 percent); and on-period score for ipsilateral dyskinesias, 44 percent (95 percent confidence interval, 29 to 59 percent). The improvements in dyskinesias and the total scores for off-period parkinsonism, contralateral bradykinesia, and rigidity were sustained in the 11 patients examined at two years. The improvement in ipsilateral dyskinesias was lost after one year, and the improvements in postural stability and gait lasted only three to six months. Approximately half the patients who had been dependent on assistance in activities of daily living in the off period before surgery became independent after surgery. The complications of surgery were generally well tolerated, and there were no significant changes in the use of medication.

CONCLUSIONS

In late-stage Parkinson's disease, pallidotomy significantly reduces levodopa-induced dyskinesias and off-period disability. Much of the benefit is sustained at two years, although some improvements, such as those on the ipsilateral side and in axial symptoms, wane within the first year. The on-period symptoms that are resistant to dopaminergic therapy do not respond to pallidotomy.

Hyperthyroxinaemia in hepatocellular carcinoma: relation to thyroid binding globulin in the clinical and preclinical stages of the disease

Serum thyroxine was significantly higher in 59 patients with hepatocellular carcinoma than in normal subjects, patients with uncomplicated cirrhosis (48), or other primary tumours with or without hepatic metastases (50). Elevated thyroxine levels appeared attributable to high levels of thyroxine binding globulin which showed a positive linear correlation with serum thyroxine in all groups studied. Despite this hyperthyroxinaemia all patients appeared clinically euthyroid and, consistent with this, T3 was elevated in only one patient and the free thyroxine index was normal in all. Amongst a group of 25 cirrhotic patients who were followed-up for between 12 and 72 months, there was a striking dissociation between the TBG values of those destined to develop HCC and those who did not. In the former group TBG rose steadily with time whereas in the latter group levels remained stable, or, more often, fell. The rises in TBG occurred prior to any clinical signs of tumour development and may be one of the earliest serological changes to occur during carcinogenesis in the cirrhotic liver.

Social skills training with relapsing schizophrenics. An experimental analysis

A social skills training procedure was developed to strengthen the communication and community survival skills of schizophrenics who were at risk for relapse. To evaluate the effectiveness often weeks of daily social skills training with three chronic schizophrenic patients a multiple baseline design was used across three different behavioral domains, with antipsychotic medication kept constant. Improvements in the patient's performance in each of the three areas of interpersonal activity occurred as a temporal function of the introduction of the training. Additional evidence for the effect of the training came from analyses of nonverbal components of assertiveness rated "blindly" from videotapes of role-played situations. All patients showed statistically significant improvements in their conversational skills in naturalistic, untrained situations around the hospital. Nurses' ratings of ward behavior and parents' ratings showed improvements for two of the three patients.

Effect of chlorpromazine on phototactic behavior in Chlamydomonas

Chlorpromazine, an antipsychotic drug, causes a light intensity dependent reversal of phototaxis in the green alga Chlamydomonas reinhardi. At moderate light intensity, drug-treated cells swim away from the light (negative phototaxis) while untreated cells swim toward it (positive phototaxis). At low light, both treated and untreated cells exhibit normal positive phototactic responses. It appears that light and chlorpromazine may affect a common control system for phototaxis.

A NEW ANTERIOR URETHROSCOPE

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