PMID- 19934820 TI - In vivo toxicity testing of methyl blue and aniline blue as vital dyes for intraocular surgery. AB - PURPOSE: To investigate the biocompatibility of methyl blue and aniline blue as vital dyes for vitreoretinal surgery in an in vivo rat model and to evaluate the effect of these dyes on retinal structure and function. METHODS: Adult Brown Norway rats received intravitreal injections of 0.1%, 0.2%, and 2% methyl blue or aniline blue dissolved in balanced salt solution with balanced salt solution serving as a control. Retinal toxicity was assessed 7 days thereafter by means of retinal ganglion cell counts, light microscopy, and electroretinography. RESULTS: No significant decrease in retinal ganglion cell counts at concentrations up to 0.2% was observed. At 2%, however, a significant retinal ganglion cell loss was detected with both dyes (more pronounced for aniline blue). Light microscopy showed no structural changes in the central retina for concentrations up to 0.2%. Electroretinographies detected no adverse effects of methyl blue or aniline blue on rod- or cone-driven responses at concentrations up to 0.2%. CONCLUSION: Methyl blue and aniline blue are very biocompatible and may, therefore, be usable for intraocular surgery. Further testing with other animal models will be necessary to confirm this. The safety margin of methyl blue is possibly higher than that of aniline blue. PMID- 19934821 TI - Experimental evaluation of aniline and methyl blue for intraocular surgery. AB - PURPOSE: The purpose of this study was to investigate the biocompatibility of aniline and methyl blue in a well-established cell culture model and assess the staining properties of these dyes at the level of the internal limiting membrane (ILM) in human donor eyes. METHODS: Dye-related toxicity was evaluated by a colorimetric test (MTT) measuring the inhibition of retinal pigment epithelium (ARPE-19 and primary human retinal pigment epithelium) cell proliferation. Cell viability was also quantified based on a two-color fluorescence assay (Life-Dead Assay). Aniline blue and methyl blue at a concentration of 0.2% was applied over the macula during vitrectomy in human donor eyes to evaluate the staining properties at the level of the ILM. RESULTS: Both dyes and dye concentrations of 0.1% and 0.2% showed no toxic effect on ARPE-19 and primary human retinal pigment epithelium cell proliferation for exposure times of 1 and 10 minutes, respectively. Cell viability was also not affected at all. Both dyes provided a good contrast at the level of the ILM and allowed for a controlled removal of the ILM during surgery. No penetration into deeper retinal layers was noted. CONCLUSION: Our results indicate that aniline blue and methyl blue might be applicable for intraocular surgery, providing a very good biocompatibility and required selective staining characteristics at the level of the ILM. PMID- 19934822 TI - Vitreous nonsteroidal antiinflammatory drug concentrations and prostaglandin E2 levels in vitrectomy patients treated with ketorolac 0.4%, bromfenac 0.09%, and nepafenac 0.1%. AB - PURPOSE: To assess vitreous concentrations of nonsteroidal antiinflammatory drugs (NSAIDs) and prostaglandin E(2) in patients treated with NSAIDs before vitrectomy. METHODS: This was an investigator-masked, randomized, multicenter study. Patients received ketorolac 0.4% 4 times a day, bromfenac 0.09% 2 times a day, nepafenac 0.1% 3 times a day, or no NSAID for 3 days before surgery. Nonsteroidal antiinflammatory drugs and prostaglandin E(2) levels were determined in vitreous samples collected at the beginning of surgery. RESULTS: Thirty-one patients were included in the analyses. The mean (SD) vitreous concentrations were as follows: ketorolac 2.8 (3.2) ng/mL, bromfenac 0.96 (0.31) ng/mL, nepafenac 1.1 (0.6) ng/mL, and amfenac 2.0 (0.8) ng/mL aligned with the initial concentrations of the topical NSAIDs. Mean (SD) vitreous prostaglandin E(2) levels of the control patients and those treated with ketorolac 0.4%, bromfenac 0.09%, or nepafenac 0.1% were 270.6 (91.7) pg/mL, 189.6 (50.2) pg/mL, 247.2 (38.3) pg/mL, and 267.7 (99.7) pg/mL, respectively. Patients treated with ketorolac 0.4% had significantly lower prostaglandin E(2) levels than those treated with no NSAID (P = 0.047) or nepafenac 0.1% (P = 0.028). CONCLUSION: All three NSAIDs penetrated into the vitreous cavity. Topical therapy with ketorolac may lower preoperative vitreous prostaglandin E(2) levels, which may have a clinical impact on the management of prostaglandin-mediated diseases, including cystoid macular edema. PMID- 19934823 TI - Comparison of a novel confocal scanning laser ophthalmoscopy algorithm with optical coherence tomography in measurement of macular thickness and volume. AB - PURPOSE: To evaluate macular thickness and volume measurements using a novel Heidelberg Retinal Tomograph (HRT3) algorithm and to compare the results with optical coherence tomography (StratusOCT). METHODS: This was a prospective, comparative, clinical noninterventional study. Fifty-two eyes were examined using both methods: 16 normal eyes, 12 eyes with diabetic macular edema (DME), and 24 eyes with age-related macular degeneration (AMD). The HRT3 macular thickness and volume were compared with those from the StratusOCT automated software. In addition, the distances between the retinal surface and the base of subretinal pathologic changes were measured using the StratusOCT manual-caliper technique and were compared with the HRT3 measurements in AMD eyes. RESULTS: No statistically significant difference in macular thickness and volume measurements was observed between the two methods for normal (P = 0.89 and P = 0.33, respectively) and DME eyes (P = 0.86 and P = 0.31, respectively). However, in AMD eyes, the differences in both measurements were statistically significant between the two methods (P < 0.0001 and P < 0.0001, respectively). The HRT3 thickness measurements were in good agreement with the manual StratusOCT measurements (P = 0.4). CONCLUSION: In normal and DME eyes, the HRT3 measurements correlated well with the automatic StratusOCT measurements. In AMD eyes, the HRT3 measurements correlated well only with the manually corrected measurements of the retinal subretinal pathologic changes. PMID- 19934824 TI - Solar retinopathy: comparison of optical coherence tomography (OCT) and fluorescein angiography (FA). AB - PURPOSE: To compare optical coherence tomography with fluorescein angiography in 11 patients (21 eyes) with central foveal damage from solar retinopathy. METHODS: Retrospective, observational case series of 11 patients with solar retinopathy. Dilated funduscopic examination was performed as well as photographic, fluorescein angiography, optical coherence tomography, and Humphrey visual field assessment. RESULTS: Significant foveal pathology was identified in each of the 21 eyes (11 patients). Visual acuity in affected eyes ranged from 20/25 to 20/200. Optical coherence tomography demonstrated foveal atrophy associated with a characteristic defect at the level of the inner and outer segment junction of the photoreceptors in all 21 affected eyes, whereas fluorescein angiography identified classic window defects in 19 eyes (10 of 11 patients). There was a modest correlation between foveal thickness and visual acuity. CONCLUSION: Fluorescein angiography did not detect lesions characteristic of solar retinopathy in all patients with a definitive history of sungazing and visual loss. Conversely, optical coherence tomography did detect significant foveal atrophy in all affected eyes and a characteristic defect at the photoreceptor retinal pigment epithelium junction. Optical coherence tomography improves the diagnosis and assessment of the degree and nature of foveal damage in patients with solar retinopathy and may be an important tool in identifying foveal damage not detected by standard fluorescein angiography. PMID- 19934825 TI - Effects of intravitreal bevacizumab in repeated doses: an experimental study. AB - PURPOSE: To evaluate the effects of repeated 1.25-mg intravitreal bevacizumab injections on cornea and uveoretinal tissues using histologic and biochemical analyses. METHODS: Twenty-four New Zealand albino rabbits were used. Twelve rabbits received an injection of bevacizumab in their right eyes three times with an interval of 25 days (Group 1); their contralateral eyes served as controls (Group 2). Six rabbits had an injection of vehicle in both eyes (Group 3), with the same regimen as bevacizumab, and six rabbits' eyes were used as a sham group (Group 4). Enucleated eyes were used for histologic and biochemical analyses, which included the activities of caspase 3 and 8 enzymes, glutathione content, catalase activity, and malondialdehyde content. RESULTS: No inflammation in aqueous humor and no sign of corneal or uveoretinal toxicity was found in bevacizumab-injected eyes. The difference of activity of corneal caspase 8 enzyme between Groups 1 and 2 and between Groups 1 and 4 was statistically significant (P < 0.05). In the uveoretinal tissue, in Group 1, the activities of caspase 3 and 8 enzymes were the lowest, and uveoretinal malondialdehyde content was also significantly lower than Group 4. CONCLUSION: A repeated dose of intravitreal bevacizumab injection did not cause a toxic effect on cornea and uveoretinal tissue. Biochemically, it also did not cause any apoptosis, oxidative reaction, or lipid peroxidation. Instead, bevacizumab injection caused a considerable decrease in the apoptotic enzyme activities and lipid peroxidation in the uveoretinal tissue. Further studies are needed to be conducted for possible detrimental side effects and apoptotic and oxidative effects of repeated bevacizumab injections on both the injected and the contralateral eyes. PMID- 19934826 TI - Manual small incision 20-gauge pars plana vitrectomy. PMID- 19934827 TI - The use of intraoperative indocyanine green dye to assist in epiretinal membrane removal: a novel application of indocyanine green surgical use. PMID- 19934828 TI - Diagnostic and therapeutic challenges. PMID- 19934829 TI - Ocular paraneoplastic syndrome: a case of bilateral diffuse uveal melanocytic proliferation. PMID- 19934830 TI - Comment on "fundus autofluorescence and multiple evanescent white dot syndrome". PMID- 19934833 TI - Comment on "Off-label use of intravitreal bevacizumab (Avastin) for salvage treatment in progressive threshold retinopathy of prematurity". PMID- 19934834 TI - Healthy People beyond 2010. PMID- 19934835 TI - Inequities in health and healthcare viewed through the ethical lens of critical social justice: contextual knowledge for the global priorities ahead. AB - The authors use the backdrop of the Healthy People 2010 initiative to contribute to a discussion encompassing social justice from local to national to global contexts. Drawing on findings from their programs of research, they explore the concept of critical social justice as a powerful ethical lens through which to view inequities in health and in healthcare access. They examine the kind of knowledge needed to move toward the ideal of social justice and point to strategies for engaging in dialogue about knowledge and actions to promote more equitable health and healthcare from local to global levels. PMID- 19934836 TI - Penetrating the dark silence. AB - This study articulates women's lifeworld experience of unexplained and unexpected fatigue. Interpretive phenomenology situated within the perspective of Maurice Merleau-Ponty provides the study framework. Using purposive sampling, the study investigated the unexplained fatigue of 12 women in a southeastern state. Data analysis of interviews revealed a lost voice within the phenomenon of fatigue, providing new insights into this diffuse and dehumanizing experience. Ethical considerations are addressed for recognizing, hearing, and caring for women living with disabling fatigue to extend the goals of Healthy People 2010 by addressing new ethical priorities for quality of life over the next decade. PMID- 19934837 TI - Sojourner syndrome and health disparities in African American women. AB - Despite improvements in many aspects of health, African American women experience early onset of disease and disability and increased mortality because of health disparities. African American women experience stress and health disadvantages because of the interaction and multiplicative effects of race, gender, class, and age. Sojourner Syndrome is an illustrative and symbolic representation that describes the multiple roles and social identities of African American women on the basis of historical referents and adaptive behaviors that fostered survival and resilience under oppressive circumstances. Adaptive behaviors also precipitated health risks due to chronic active coping. Weathering describes the cumulative health impact of persistent stress and chronic active coping that contributes to early health deterioration and increased morbidity, disability, and mortality in African American women. An emancipatory knowing nursing perspective provides a viewpoint from which to examine social injustices that create conditions for the excessive health burdens experienced by African American women and to frame nursing actions that create opportunities to promote health and eliminate health disparities. PMID- 19934838 TI - Recognizing health with pregnant Cambodian American women by finding meaning in relationship. AB - Late entry to prenatal care is a complex problem disproportionately affecting immigrant and refugee women living in Western-style countries. Improving the health and well-being of these women and their children is a critical need. Utilizing Newman's praxis research approach, this study explored engaging 6 Cambodian American women living with pregnancy in the process of finding meaning. Dialoguing on important events and relationship from childhood to present day, patterns of health emerged. Considering data across participants, 3 preliminary themes were illuminated. Study provides new knowledge about environmental disruptions and promoting health. PMID- 19934839 TI - Exploring the concept of medication discrepancy within the context of patient safety to improve population health. AB - Medication discrepancy is a concept often used in discussions about medication safety but has neither been fully explained nor clearly defined in the literature. This article explores medication discrepancy as it relates to patient safety and population health in the management of medications. Literature review reveals 2 main aspects of discrepancies in medication management; prescribing issues and patient adherence to regimens. Further development of the concept of medication discrepancy can be beneficial to the theorist, researcher, or clinician. Conceptual clarity about the various aspects of medication discrepancy in the context of patient safety has the potential to enhance quality improvement efforts and patient outcomes to improve population health. PMID- 19934840 TI - Ingenuity and innovation. PMID- 19934845 TI - Vertical plication of attenuated orbital septum: a modification for reduction of lower lid bulge. AB - Aesthetic surgery for correction of the lower lid bulge can be classified into 3 groups of subtractive surgery, redraping, and repositioning. The authors present a new repositioning technique with vertical plication of the orbital septum for correction of lower lid bulge. This procedure was performed on 30 individuals during a 3-year period between March 2003 and March 2006. The length of follow-up varied from 3 months to 1 year, with an average of 6 months. There was no lower lid retraction or ectropion. Contour was smooth without any visible deformation or palpable suture line along the vertical plication. In the follow-up visits of minimum of 3 months, no recurrence of bulge was present and the scar was inconspicuous. Vertical plication of the orbital septum is an effective way to reposition the orbital fat inside the orbit. It anatomically corrects lower lid bulge, preserves the orbital fat pad and the vertical dimension of the lower lid, and provides a smooth contour in the periorbital area without the need to penetrate the orbital septum or manipulate the fat pad. Morbidity is minimal and transient, and the results are satisfactory. We suggest this technique for correction of lower lid bulge when there is excess lower lid skin and a subciliary approach is selected. PMID- 19934846 TI - Cross-face nerve transfer for established trigeminal branch II palsy. AB - Reconstruction for trigeminal nerve II palsy is challenging. Cross-face nerve transfer from the contralateral trigeminal nerve facilitates this reconstruction. However, the microanatomy and techniques required for nerve sutures cause problems for many surgeons. Following the recent development of supramicrosurgical techniques appropriate for the microanatomy of peripheral nerves, a new method of intraoral "cross-face nerve transfer" was successfully used for repairing trigeminal nerve II palsy. Two cases of trigeminal nerve II palsy were repaired with contralateral trigeminal nerve transfer without any nerve graft. Affected upper labial sensory recovery was 1.65 to 2.44 (Semmes Weinstein values) and 15 to 30 mm (moving 2-point discriminations) at 1 to 1 1/2 years after surgery. The advantages of this method are excellent nerve regeneration and the lack of donor site morbidity. It is a brief and simple operation in comparison to free nerve grafts. The disadvantage is a need for a supramicrosurgical technique, using a needle less than 80 microm wide. PMID- 19934847 TI - A new design for superficial temporal fascial flap for reconstruction of the eyebrow, upper and lower eyelids, and lacrimal system in one-stage procedure: medusa flap. AB - Reconstruction of the eyebrows, eyelids, and destroyed lacrimal drainage system is a challenging procedure for plastic and reconstructive surgeons. In the case presented, a superficial temporal fascial flap was designed for reconstruction of the eyebrow, upper and lower eyelids, and lacrimal drainage system in a one-stage procedure in facial burn patient. To the authors' knowledge, this is the first combined reconstruction of the eyebrow, upper and lower eyelids, and lacrimal drainage system in one surgical procedure with pedicled superficial temporal fascial flap including skin island and buccal mucosal graft. During the 1-year follow-up period, no complication was encountered and patient healed uneventfully. PMID- 19934848 TI - Extended mesh repair with external oblique muscle reinforcement for abdominal wall contour abnormalities following TRAM flap. AB - Many patients undergoing reconstructive surgery after mastectomy opt for reconstruction with the transverse rectus abdominis myocutaneous (TRAM) flap. Among the morbidities related to TRAM flap reconstruction is the development of abdominal wall contour abnormalities, including bulges or hernias. Several repair techniques at the flap abdominal wall donor site have been described for use at the time of flap harvest in an attempt to reduce the risk of such abdominal wall complications. For patients that develop abdominal wall contour abnormalities, numerous reconstructive options have been reported, with mixed results. Ten patients were identified as having abdominal wall contour abnormalities after a TRAM flap and underwent an extended mesh repair with external oblique muscle reinforcement. The mesh was secured to the bony landmarks of the lower abdomen and the abdominal wall fascia. All patients achieved complete resolution of abdominal wall bulging. In the follow-up period, no recurrences, infections, or seromas were noted. One patient, who failed an earlier repair at the inferior abdominal wall, reported symptoms consistent with a scar neuroma. Symptoms were treated successfully with gabapentin and a nonsteroidal anti-inflammatory drug. We propose a novel and reliable method of lower abdominal wall reconstruction for patients with post-TRAM flap abdominal wall contour abnormalities. This technique incorporates the use of a large Marlex mesh reinforced with bilateral external oblique muscle flaps. We report a series of 10 patients who have achieved resolution of their symptoms and have regained a natural, flat-appearing abdominal wall contour. PMID- 19934850 TI - Reconstruction in RDEB patients. PMID- 19934853 TI - Opiates, sleep, and pain: the adenosinergic link. PMID- 19934854 TI - Postconditioning and controlled reperfusion: the nerve of it all. PMID- 19934855 TI - Perioperative comparative effectiveness research: an opportunity calling. PMID- 19934857 TI - Too much of a good thing is wonderful: observational data for perioperative research. PMID- 19934858 TI - Perioperative platelet activation and the inhibitory effect of milrinone. PMID- 19934859 TI - Pain assessment, sedation, and analgesic administration in the intensive care unit. PMID- 19934860 TI - To our authors. PMID- 19934862 TI - Neuroprotection against spinal cord ischemia-reperfusion injury induced by different ischemic postconditioning methods: roles of phosphatidylinositol 3 kinase-Akt and extracellular signal-regulated kinase. AB - BACKGROUND: The authors compared the neuroprotective effects induced by two ischemic postconditioning methods and sought to determine the roles of phosphatidylinositol 3-kinase-Akt and extracellular signal-regulated kinase (ERK) in this neuroprotection. METHODS: Spinal cord ischemia was induced in rabbits by occlusion of the infrarenal aorta with a balloon catheter for 25 min. Postconditioning was accomplished by either five cycles of 1-min occlusion and 1 min reperfusion (standard postconditioning) or control of the perfusion pressure between 45 and 55 mmHg at the first 10 min of reperfusion (modified postconditioning). Motor function was assessed with the Tarlov score during a 28 day observation period. Histologic examination of lumbar spinal cords was performed. Expressions of Akt and ERK in the spinal cord were evaluated by Western blot. RESULTS: Compared with the controls, the two postconditioning methods markedly increased Tarlov scores 1, 3, 7, and 28 days after spinal cord ischemia and number of intact motor neurons in the lumbar spinal cord. No significant difference in Tarlov scores and number of intact motor neurons was detected between the two postconditioning method groups. The two postconditioning methods enhanced the expressions of phospho-Akt and phospho-ERK in spinal cords. The neuroprotective effects and the increases in phospho-Akt and phospho-ERK were abolished by administration of phosphatidylinositol 3-kinase-Akt inhibitor LY 294002 or ERK inhibitor PD-98059. CONCLUSIONS: The two postconditioning methods possess comparable neuroprotective effects on the spinal cord and share a common molecular mechanism, in which phosphatidylinositol 3-kinase and ERK pathways play crucial roles. PMID- 19934863 TI - Perioperative outcomes after unilateral and bilateral total knee arthroplasty. AB - BACKGROUND: The safety of bilateral total knee arthroplasties (BTKAs) during the same hospitalization remains controversial. The authors sought to study differences in perioperative outcomes between unilateral and BTKA and to further compare BTKAs performed during the same versus different operations during the same hospitalization. METHODS: Nationwide Inpatient Sample data from 1998 to 2006 were analyzed. Entries for unilateral and BTKA procedures performed on the same day (simultaneous) and separate days (staged) during the same hospitalization were identified. Patient and healthcare system-related demographics were determined. The incidences of in-hospital mortality and procedure-related complications were estimated and compared between groups. Multivariate regression was used to identify independent risk factors for morbidity and mortality. RESULTS: Despite younger average age and lower comorbidity burden, procedure related complications and in-hospital mortality were more frequent after BTKA than after unilateral procedures (9.45% vs. 7.07% and 0.30% vs. 0.14%; P < 0.0001 each). An increased rate of complications was associated with a staged versus simultaneous approach with no difference in mortality (10.30% vs. 9.15%; P < 0.0001 and 0.29% vs. 0.26%; P = 0.2875). Independent predictors for in-hospital mortality included BTKA (simultaneous: odds ratio, 2.23 [95% confidence interval, 1.69-2.95]; P < 0.0001; staged: odds ratio, 2.01 [confidence interval, 1.28 3.41]; P = 0.0031), male sex (odds ratio, 2.02 [confidence interval, 1.75-2.34]; P < 0.0001), age older than 75 yr (odds ratio, 3.96 [confidence interval, 2.77 5.66]; P < 0.0001), and the presence of a number of comorbidities and complications. CONCLUSION: BTKAs carry increased risk of perioperative morbidity and mortality compared with unilateral procedures. Staging BTKA procedures during the same hospitalization offers no mortality benefit and may even expose patients to increased morbidity. PMID- 19934864 TI - Intraoperative hypotension and 1-year mortality after noncardiac surgery. AB - BACKGROUND: Intraoperative hypotension (IOH) is frequently associated with adverse outcome such as 1-yr mortality. However, there is no consensus on the correct definition of IOH. The authors studied a number of different definitions of IOH, based on blood pressure thresholds and minimal episode durations, and their association with 1-yr mortality after noncardiac surgery. METHODS: This cohort study included 1,705 consecutive adult patients who underwent general and vascular surgery. Data on IOH and potentially confounding variables were obtained from electronic record-keeping systems. Mortality data were collected up to 1 yr after surgery. The authors used two different techniques to reduce the influence of confounding variables, multivariable Cox proportional hazard regression modeling and classification and regression tree analysis. RESULTS: The mortality within 1 yr after surgery was 5.2% (88 patients). After adjustment for confounding, the Cox regression analysis did not show an association between IOH and the risk of dying within 1 yr after surgery (hazard ratio around 1.00 with high P values for different definitions of IOH). Additional classification and regression tree analysis identified IOH as a predictor for 1-yr mortality in elderly patients. When the blood pressure threshold for IOH was decreased, the duration of IOH at which this association was found was decreased as well. CONCLUSIONS: This observational study showed no causal relation between IOH and 1 yr mortality after noncardiac surgery for any of the definitions of IOH. Nevertheless, additional analysis suggested that for elderly patients, the mortality risk increases when the duration of IOH becomes long enough. The length of this duration depends on the designated blood pressure threshold, suggesting that lower blood pressures are tolerated for shorter durations. The effect of IOH on 1-yr mortality remains debatable, and no firm conclusions on the lowest acceptable intraoperative blood pressures can be drawn from this study. PMID- 19934866 TI - Phosphodiesterase 3 inhibition reduces platelet activation and monocyte tissue factor expression in knee arthroplasty patients. AB - BACKGROUND: Tissue damage during surgery activates platelets and provokes a prothrombic state. The current study attempted to determine the impact of phosphodiesterase 3 inhibitors on platelet activation, platelet-leukocyte aggregate formation, and monocyte tissue factor expression during and after total knee arthroplasty. METHODS: Thirty-four patients undergoing scheduled total knee arthroplasty were randomly assigned to receive either the phosphodiesterase 3 inhibitor milrinone or the same amount of saline perioperatively. The effects of milrinone on platelet and leukocyte function in vitro were then assessed in healthy volunteers. RESULTS: Perioperative infusion of milrinone significantly attenuated platelet activation; phosphorylation of intraplatelet p38 mitogen activated protein kinase, extracellular signal-regulated kinase 1/2, and Akt; and platelet-leukocyte aggregation. Furthermore, perioperative tissue factor expression on monocytes and fibrin monomer complex production were reduced by milrinone infusion in patients undergoing total knee arthroplasty. In vitro studies using adenosine diphosphate- and collagen-stimulated blood samples from healthy volunteers confirmed the antiplatelet effects and reduced monocyte tissue factor expression by milrinone. These studies further showed that platelet aggregation and integrin alpha(IIb)beta(3) activation were modified by intraplatelet phosphatidylinositol 3-kinase/Akt and mitogen-activated protein kinase/extracellular signal-regulated kinase pathways, and that P-selectin expression on platelets and platelet-leukocyte aggregation were modulated by intraplatelet p38 mitogen-activated protein kinase pathway. CONCLUSION: Continuous milrinone infusion has the potential to reduce platelet activation and monocyte tissue factor expression during the perioperative period in total knee arthroplasty. These events may be mediated in part by the ability of milrinone to reduce activation of intraplatelet mitogen-activated protein kinases and phosphatidylinositol 3-kinase. The clinical impact of phosphodiesterase 3 inhibition on perioperative hemostasis remains to be elucidated. PMID- 19934867 TI - Sevoflurane ameliorates gas exchange and attenuates lung damage in experimental lipopolysaccharide-induced lung injury. AB - BACKGROUND: Acute lung injury is a common complication in critically ill patients. Several studies suggest that volatile anesthetics have immunomodulating effects. The aim of the current study was to assess possible postconditioning with sevoflurane in an in vivo model of endotoxin-induced lung injury. METHODS: Rats were anesthetized, tracheotomized, and mechanically ventilated. Lipopolysaccharide (saline as control) was administered intratracheally. Upon injury after 2 h of propofol anesthesia, general anesthesia was continued with either sevoflurane or propofol for 4 h. Arterial blood gases were measured every 2 h. After 6 h of injury, bronchoalveolar lavage was performed and lungs were collected. Total cell count, albumin content, concentrations of the cytokines cytokine-induced neutrophil chemoattractant-1 and monocyte chemoattractant protein-1, and phospholipids were analyzed in bronchoalveolar lavage fluid. Expression of messenger RNA for the two cytokines and for surfactant protein B was determined in lung tissue. Histopathologic examination of the lung was performed. RESULTS: Significant improvement of the ratio of oxygen tension to inspired oxygen fraction was shown with sevoflurane (mean + or - SD: 243 + or - 94 mmHg [32.4 kPa]) compared with propofol (88 + or - 19 mmHg [11.7 kPa]). Total cell count representing effector cell recruitment as well as albumin content as a measure of lung permeability were significantly decreased in the sevoflurane lipopolysaccharide group compared with the propofol-lipopolysaccharide group in bronchoalveolar lavage fluid. Expression of the cytokines protein in bronchoalveolar lavage fluid as well as messenger RNA in lung tissue was significantly lower in the sevoflurane-lipopolysaccharide group compared with the propofol-lipopolysaccharide group. CONCLUSIONS: Postconditioning with sevoflurane attenuates lung damage and preserves lung function in an in vivo model of acute lung injury. PMID- 19934868 TI - Hepatic effects of thoracic epidural analgesia in experimental severe acute pancreatitis. AB - BACKGROUND: Thoracic epidural anesthesia (TEA) protects the intestinal microcirculation and improves perioperative outcomes. TEA also reduces mortality in acute experimental pancreatitis. Its impact on hepatic microcirculation, however, in health and critical illness is unknown. Therefore, the authors studied the effect of TEA on the liver in healthy rats and in experimental severe acute pancreatitis. METHODS: TEA was induced by 15 microl/h bupivacaine, 0.5%. Necrotizing pancreatitis was induced by intraductal infusion of 2 ml/kg taurocholic acid, 5%. Twenty-eight rats were assigned to either Sham operation, Sham + TEA, Pancreatitis, or Pancreatitis + TEA. After 15 h, mean arterial pressure, heart rate, and respiratory function were recorded. Sinusoidal width and perfusion rate and the intrahepatic leukocyte adhesion were assessed by intravital microscopy. In an additional 22 rats randomly assigned to Sham, Pancreatitis, and Pancreatitis + TEA, hepatic apoptosis was evaluated by staining for single-stranded DNA and Fas ligand-positive cells. RESULTS: TEA did not affect hepatic microcirculation and leukocyte adhesion in healthy rats. Blood pressure remained unchanged in the Sham + TEA group. In Pancreatitis, mean arterial pressure decreased from 141 + or - 6 mmHg to 127 + or - 13 mmHg but remained stable in Pancreatitis + TEA. The sinusoidal diameter decreased from 5.4 + or - 0.1 microm to 5.0 + or - 0.2 microm in Pancreatitis. This was restored in Pancreatitis + TEA. Intrahepatic leukocyte adhesion was not affected by TEA. The increased hepatocyte apoptosis in Pancreatitis was abolished in Pancreatitis + TEA. This might be mediated by inhibition of the Fas ligand pathway. CONCLUSION: TEA reduces liver injury in necrotizing acute pancreatitis. This could be related to a regional sympathetic block. TEA could thus preserve liver function in systemic inflammatory disorders such as acute pancreatitis. PMID- 19934869 TI - Differential role of Pim-1 kinase in anesthetic-induced and ischemic preconditioning against myocardial infarction. AB - BACKGROUND: Ischemic preconditioning (IPC) and anesthetic-induced preconditioning against myocardial infarction are mediated via protein kinase B. Pim-1 kinase acts downstream of protein kinase B and was recently shown to regulate cardiomyocyte survival. The authors tested the hypothesis that IPC and anesthetic induced preconditioning are mediated by Pim-1 kinase. METHODS: Pentobarbital anesthetized male C57Black/6 mice were subjected to 45 min of coronary artery occlusion and 3 h of reperfusion. Animals received no intervention, Pim-1 kinase inhibitor II (10 microg/g intraperitoneally), its vehicle dimethyl sulfoxide (10 microl/g intraperitoneally), or 1.0 minimum alveolar concentration desflurane alone or in combination with Pim-1 kinase inhibitor II (10 microg/g intraperitoneally). IPC was induced by three cycles of 5 min ischemia-reperfusion each, and animals received IPC either alone or in combination with Pim-1 kinase inhibitor II (10 microg/g intraperitoneally). Infarct size was determined with triphenyltetrazolium chloride, and area at risk was determined with Evans blue (Sigma-Aldrich, Taufkirchen, Germany). Protein expression of Pim-1 kinase, Bad, phospho-Bad, and cytosolic content of cytochrome c were measured using Western immunoblotting. RESULTS: Infarct size in the control group was 47 + or - 2%. Pim 1 kinase inhibitor II (44 + or - 2%) had no effect on infarct size. Desflurane (17 + or - 3%) and IPC (19 + or - 2%) significantly reduced infarct size compared with control (both P < 0.05 vs. control). Blockade of Pim-1 kinase completely abrogated desflurane-induced preconditioning (43 + or - 3%), whereas IPC (35 + or - 3%) was blocked partially. Desflurane tended to reduce cytosolic content of cytochrome c, which was abrogated by Pim-1 kinase inhibitor II. CONCLUSION: These data suggest that Pim-1 kinase mediates at least in part desflurane-induced preconditioning and IPC against myocardial infarction in mice. PMID- 19934870 TI - Comparison of standard polyvinyl chloride tracheal tubes and straight reinforced tracheal tubes for tracheal intubation through different sizes of the Airtraq laryngoscope in anesthetized and paralyzed patients: a randomized prospective study. AB - BACKGROUND: The authors compared the intubation success rate of straight reinforced tracheal tubes emerging from the Airtraq laryngoscope (Prodol Meditec S.A., Vizcaya, Spain) with standard preformed polyvinyl chloride tracheal tubes in anesthetized patients. METHODS: The authors randomly allocated 347 adult patients to be intubated with standard polyvinyl chloride tracheal tubes, standard straight wire-reinforced tracheal tubes, or silicone straight wire reinforced tubes, through either the larger or the smaller adult laryngoscope sizes. The possible influence of laryngoscope size, tube size, and tube type on intubation failure was examined. RESULTS: Success rates were 100% for polyvinyl chloride tracheal tubes, 78.5% for standard wire-reinforced tracheal tubes, and 75.4% for silicone wire-reinforced tubes (P < 0.01). Compared with the former, patients in the straight standard and silicone wire-reinforced tube groups required more optimization maneuvers (4.1% vs. 42.1%; P < 0.01) and more attempts at successful intubation (0% vs. 7.3%; P < 0.01). The angle created by the tube emerging from the Airtraq guiding channel was inversely correlated to the ratio of the endotracheal tube OD to the width of the channel in the standard and silicone wire-reinforced tube groups (r = -0.95 and r = -0.82, respectively; P < 0.01). Finally, a decrease in 0.1 of the above ratio was associated with a 3.1 (95% confidence interval, 1.9-5.2; P < 0.01) times increase in the odds ratio of intubation failure. CONCLUSIONS: Standard polyvinyl chloride tracheal tubes were found to be superior compared with standard and silicone straight wire-reinforced tubes for intubation through the Airtraq laryngoscope. In the latter groups, a decrease of the ratio of their OD to the width of the Airtraq guiding channel resulted in increased intubation failure. PMID- 19934872 TI - Propofol facilitates glutamatergic transmission to neurons of the ventrolateral preoptic nucleus. AB - BACKGROUND: There is much evidence that the sedative component of anesthesia is mediated by gamma-aminobutyric acid type A (GABA(A)) receptors on hypothalamic neurons responsible for arousal, notably in the tuberomammillary nucleus. These GABA(A) receptors are targeted by gamma-aminobutyric acid-mediated (GABAergic) neurons in the ventrolateral preoptic area (VLPO): When these neurons become active, they inhibit the arousal-producing nuclei and induce sleep. According to recent studies, propofol induces sedation by enhancing VLPO-induced synaptic inhibition, making the target cells more responsive to GABA(A). The authors explored the possibility that propofol also promotes sedation less directly by facilitating excitatory inputs to the VLPO GABAergic neurons. METHODS: Spontaneous excitatory postsynaptic currents were recorded from VLPO cells principally mechanically isolated, but also in slices from rats. RESULTS: In isolated VLPO GABAergic neurons, propofol increased the frequency of glutamatergic spontaneous excitatory postsynaptic currents without affecting their mean amplitude. The action of propofol was mimicked by muscimol and prevented by gabazine, respectively a specific agonist and antagonist at GABA(A) receptors. It was also suppressed by bumetanide, a blocker of Na-K-Cl cotransporter-mediated inward Cl transport. In slices, propofol also increased the frequency of spontaneous excitatory postsynaptic currents and, at low doses, accelerated firing of VLPO cells. CONCLUSION: Propofol induces sedation, at least in part, by increasing firing of GABAergic neurons in the VLPO, indirectly by activation of GABA(A) receptors on glutamatergic afferents: Because these axons/terminals have a relatively high internal Cl concentration, they are depolarized by GABAergic agents such as propofol, which thus enhance glutamate release. PMID- 19934873 TI - Susceptibility to fraud in systematic reviews: lessons from the Reuben case. AB - BACKGROUND: Dr. Scott Reuben allegedly fabricated data. The authors of the current article examined the impact of Reuben reports on conclusions of systematic reviews. METHODS: The authors searched in ISI Web of Knowledge systematic reviews citing Reuben reports. Systematic reviews were grouped into one of three categories: I, only cited but did not include Reuben reports; II, retrieved and considered, but eventually excluded Reuben reports; III, included Reuben reports. For quantitative systematic reviews (i.e., meta-analyses), a relevant difference was defined as a significant result becoming nonsignificant (or vice versa) by excluding Reuben reports. For qualitative systematic reviews, each author decided independently whether noninclusion of Reuben reports would have changed conclusions. RESULTS: Twenty-five systematic reviews (5 category I, 6 category II, 14 category III) cited 27 Reuben reports (published 1994-2007). Most tested analgesics in surgical patients. One of 6 quantitative category III reviews would have reached different conclusions without Reuben reports. In all 6 (30 subgroup analyses involving Reuben reports), exclusion of Reuben reports never made any difference when the number of patients from Reuben reports was less than 30% of all patients included in the analysis. Of 8 qualitative category III reviews, all authors agreed that one would certainly have reached different conclusions without Reuben reports. For another 4, the authors' judgment was not unanimous. CONCLUSIONS: Carefully performed systematic reviews proved robust against the impact of Reuben reports. Quantitative systematic reviews were vulnerable if the fraudulent data were more than 30% of the total. Qualitative systematic reviews seemed at greater risk than quantitative. PMID- 19934874 TI - Healthcare provider and parent behavior and children's coping and distress at anesthesia induction. AB - BACKGROUND: To date, no study has evaluated the impact of specific healthcare provider and parent behaviors on children's distress and coping during anesthesia induction. METHOD: Extensive digital video data were collected on 293 two- to ten yr-old children undergoing anesthesia induction with a parent present. Anesthesiologist, nurse, and parent behavior and children's distress and coping were coded using the Revised Preoperative Child-Adult Medical Procedure Interaction Scale administered using specialized coding software. RESULTS: Anesthesiologists and parents engaged in higher rates of most behaviors than nurses. Overall, adult emotion-focused behavior such as empathy and reassurance was significantly positively related to children's distress and negatively related to children's coping behaviors. Adult distracting behavior such as humor and distracting talk showed the opposite pattern. Medical reinterpretation by anesthesiologists was significantly positively related to children's coping behaviors, but the same behavior by parents was significantly positively related to children's distress. CONCLUSIONS: The data presented here provide evidence for a relation between adult behaviors and children's distress and coping at anesthesia induction. These behaviors are trainable, and hence it is possible to test whether modifying physician behavior can influence child behavior in future studies. PMID- 19934875 TI - Xenon attenuates excitatory synaptic transmission in the rodent prefrontal cortex and spinal cord dorsal horn. AB - BACKGROUND: The molecular mechanisms of the inhalational anesthetic xenon are not yet fully understood. Recently, the authors showed that xenon reduces both N methyl-d-aspartate (NMDA) and alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) receptor-mediated synaptic transmission in a brain slice preparation of the amygdala. In the current study, the authors examined the effects of xenon on synaptic transmission in the prefrontal cortex and the spinal cord dorsal horn (substantia gelatinosa). METHODS: In rodent brain or spinal cord slice preparations, the authors used patch clamp technique to investigate the impact of xenon on NMDA and AMPA receptor-mediated excitatory postsynaptic currents, as well as on gamma-aminobutyric acid type A receptor-mediated inhibitory postsynaptic currents. The currents were either evoked upon electrical stimulation (NMDA-eEPSCs and AMPA-eEPSCs) or upon photolysis of caged L-glutamate (p-NMDA-Cs and p-AMPA-Cs). In addition, the authors investigated the effects of xenon on AMPA receptor-mediated miniature excitatory postsynaptic currents. RESULTS: In both central nervous system regions, xenon had virtually no effect on inhibitory postsynaptic currents. In the prefrontal cortex (spinal cord), xenon reversibly reduced NMDA-eEPSCs to approximately 58% (72%) and AMPA-eEPSCs to approximately 67% (65%) of control. There was no difference in the xenon-induced reduction of NMDA-eEPSCs and p-NMDA-Cs, or AMPA-eEPSCs and p-AMPA-Cs. Xenon did not affect the frequency of miniature excitatory postsynaptic currents but reduced their amplitude. CONCLUSIONS: In the current study, the authors found that xenon depresses NMDA and AMPA receptor-mediated synaptic transmission in the prefrontal cortex and the substantia gelatinosa without affecting gamma aminobutyric acid type A receptor-mediated synaptic transmission. These results provide evidence that the effects of xenon are primarily due to postsynaptic mechanisms. PMID- 19934877 TI - Pain assessment is associated with decreased duration of mechanical ventilation in the intensive care unit: a post Hoc analysis of the DOLOREA study. AB - BACKGROUND: Critically ill patients frequently experience pain, but assessment rates remain below 40% in mechanically ventilated patients. Whether pain assessment affects patient outcomes is largely unknown. METHODS: As part of a prospective cohort study of mechanically ventilated patients who received analgesia on day 2 of their stay in the intensive care unit (ICU), the investigators performed propensity-adjusted score analysis to compare the duration of ventilator support and duration of ICU stay between 513 patients who were assessed for pain and 631 patients who were not assessed for pain. RESULTS: Patients assessed for pain on day 2 were more likely to receive sedation level assessment, nonopioids, and dedicated analgesia during painful procedures than patients whose pain was not assessed. They also received fewer hypnotics and lower daily doses of midazolam. Patients with pain assessment had a shorter duration of mechanical ventilation (8 vs. 11 days; P < 0.01) and a reduced duration of stay in the ICU (13 vs. 18 days; P < 0.01). In propensity-adjusted score analysis, pain assessment was associated with increased odds of weaning from the ventilator (odds ratio, 1.40; 95% confidence interval, 1.00-1.98) and of discharge from the ICU (odds ratio, 1.43; 95% confidence interval, 1.02-2.00). CONCLUSIONS: Pain assessment in mechanically ventilated patients is independently associated with a reduction in the duration of ventilator support and of duration of ICU stay. This might be related to higher concomitant rates of sedation assessments and a restricted use of hypnotic drugs when pain is assessed. PMID- 19934878 TI - Differential effects of buffered hypercapnia versus hypercapnic acidosis on shock and lung injury induced by systemic sepsis. AB - BACKGROUND: Acute hypercapnic acidosis protects against lung injury caused by nonseptic insults and after both pulmonary and systemic sepsis. The authors wished to dissect the contribution of the acidosis versus hypercapnia per se to the effects of hypercapnic acidosis on the hemodynamic profile and severity of lung injury induced by systemic sepsis. METHODS: In the hypercapnic acidosis series, adult male Sprague-Dawley rats were randomized to normocapnia or hypercapnic acidosis-produced by adding 5% carbon dioxide to the inspired gas-and cecal ligation and puncture performed. In the buffered hypercapnia series, animals were first randomized to housing under conditions of environmental normocapnia or hypercapnia-produced by exposure to 8% carbon dioxide-to allow renal buffering. After 96 h, cecal ligation and puncture was performed. In both series, the animals were ventilated for 6 h, and the severity of the lung injury and hemodynamic deterioration were assessed. RESULTS: Both hypercapnic acidosis and buffered hypercapnia attenuated the development and severity of hypotension and reduced lactate accumulation compared to normocapnia. Hypercapnic acidosis reduced lung injury and inflammation, decreased mean (+ or - SD) bronchoalveolar lavage protein concentration (232 + or - 50 versus 279 + or - 27 microg x ml(-1)) and median neutrophil counts (3,370 versus 9,120 cells x ml(-1)), and reduced histologic lung injury. In contrast, buffered hypercapnia did not reduce the severity of systemic sepsis induced lung injury. CONCLUSIONS: Both hypercapnic acidosis and buffered hypercapnia attenuate the hemodynamic consequences of systemic sepsis. In contrast, hypercapnic acidosis, but not buffered hypercapnia, reduced the severity of sepsis-induced lung injury. PMID- 19934880 TI - Pronociceptive effects of remifentanil in a mouse model of postsurgical pain: effect of a second surgery. AB - BACKGROUND: Remifentanil anesthesia enhances postoperative pain in animals and humans. The authors evaluated the impact of the dose (microg x kg(-1) x min(-1)) and duration of remifentanil infusion, and the effects of a second surgery on postoperative pain sensitization. METHODS: Mice received different doses of remifentanil over 30 or 60 min. The authors assessed thermal (Hargreaves) and mechanical hyperalgesia (von Frey) at 2, 4, 7, and 10 days. In other experiments, mice had a plantar incision during sevoflurane with or without remifentanil anesthesia that was repeated 27 days later, when nociceptive thresholds returned to baseline. Linear mixed models were used for statistical analysis. RESULTS: Remifentanil induced dose-dependent pronociceptive effects with calculated ED(50)s of 1.7 (95% confidence interval, 1.3-2.1) and 1.26 (1.0-1.6) microg x kg( 1) x min(-1) for thermal and mechanical hyperalgesia, respectively, which lasted longer with higher doses (P < 0.001). The duration of infusion did not alter the pronociceptive effects of remifentanil when administered at a constant dose of infusion. When given during surgery, high (2.66 microg x kg(-1) x min(-1)) or low (0.66 microg x kg(-1) x min(-1)) remifentanil increased the extent (P < 0.05) and duration (P < 0.01) of thermal and mechanical hyperalgesia. The latter was further enhanced after a second surgery performed in the same experimental conditions (P < 0.05). Surgery or remifentanil infusion, each one individually, induced significant mechanical hyperalgesia, which was greater when repeated (P < 0.05). CONCLUSIONS: In this model of incisional pain, remifentanil induces pronociceptive effects, which are dose dependent but unaltered by the duration of administration. A second surgery performed on the same site and experimental conditions induces greater postoperative hyperalgesia that is enhanced when remifentanil is used as an anesthetic. PMID- 19934879 TI - Opioid-induced decreases in rat brain adenosine levels are reversed by inhibiting adenosine deaminase. AB - BACKGROUND: Opioids disrupt sleep and adenosine promotes sleep, but no studies have characterized the effects of opioids on adenosine levels in brain regions known to regulate states of arousal. Delivering opioids to the pontine reticular formation (PRF) and substantia innominata (SI) region of the basal forebrain disrupts sleep. In contrast, administering adenosine agonists to the PRF or SI increases sleep. These findings encouraged the current study testing the hypothesis that microdialysis delivery of opioids to the PRF or SI decreases adenosine levels in the PRF or SI, respectively. METHODS: A microdialysis probe was placed in the PRF of isoflurane anesthetized rats and perfused with Ringer's solution (control) followed by Ringer's solution containing morphine (0, 10, 30, 100, or 300 microm), fentanyl (100 microm), morphine (100 microm) and the adenosine deaminase inhibitor EHNA (100 microm), or naloxone (10 microm) and morphine (100 microm). Additional experiments measured adenosine levels in the SI before and during microdialysis delivery of morphine, fentanyl, and morphine plus EHNA. RESULTS: Morphine caused a significant (P < 0.05) concentration-dependent decrease in PRF adenosine levels. The significant decrease (-20%) in adenosine caused by 100 microm morphine was blocked by coadministration of naloxone. Fentanyl also significantly decreased (-13.3%) PRF adenosine. SI adenosine levels were decreased by morphine (-26.8%) and fentanyl (-27.4%). In both PRF and SI, coadministration of morphine and EHNA prevented the significant decrease in adenosine levels caused by morphine alone. CONCLUSIONS: These data support the interpretation that decreased adenosine levels in sleep-regulating brain regions may be one of the mechanisms by which opioids disrupt sleep. PMID- 19934881 TI - Serious complications associated with external intrathecal catheters used in cancer pain patients: a systematic review and meta-analysis. AB - BACKGROUND: Potential risks of intrathecal catheters in cancer patients include infection, bleeding, and neurologic injury. METHODS: A systematic review and a pooled analysis of observational studies were performed. Articles reporting on adverse events (infections, bleeding, granuloma, and death) associated with intrathecal catheters and external pumps in cancer patients were identified. Electronic searches of PubMed, MEDLINE, and EMBASE were conducted. Observations from different studies were pooled using a generalized mixed-effect model. Model estimates and their standard errors (SEs) were used for calculating 95% confidence intervals (CIs) on the overall proportion. RESULTS: The analysis identified 10 articles, including a total of 821 patients. Twenty catheter related infections were identified. Of these, 10 were superficial and 10 were deep infections, with rates of 2.3% (95% CI, 0.8-6.1) and 1.4% (95% CI, 0.5-3.8), respectively. Furthermore, the authors calculated that every 71st patient had a deep infection after an average catheter duration of 54 days. The risk of bleeding was found to be 0.9% (95% CI, 0-2.0), and for neurologic injury 0.4% (95% CI, 0-1.0). The infection rates are comparable to other intrathecal catheter techniques. CONCLUSIONS: Serious complications are rare in both hospitalized and homebound patients with intrathecal catheters. This analysis supports the reasoning that the potential benefit of intrathecal catheters in the treatment of severe cancer pain is likely to outweigh the potential for serious complications associated with this technique. Therefore, an external intrathecal catheter can be considered an effective and low-cost solution for the control of pain in such patients. PMID- 19934882 TI - Modulation of morphine-induced antinociception in acute and chronic opioid treatment by ibudilast. AB - BACKGROUND: Opioid analgesics are effective in relieving chronic pain, but they have serious adverse effects, including development of tolerance and dependence. Ibudilast, an inhibitor of glial activation and cyclic nucleotide phosphodiesterases, has shown potential in the treatment of neuropathic pain and opioid withdrawal. Because glial cell activation could also be involved in the development of opioid tolerance in rats, the authors studied the antinociceptive effects of ibudilast and morphine in different models of coadministration. METHODS: Antinociception was assessed using male Sprague- Dawley rats in hot plate and tail-flick tests. The effects of ibudilast on acute morphine-induced antinociception, induction of morphine tolerance, and established morphine tolerance were studied. RESULTS: Systemic ibudilast produced modest dose-related antinociception and decreased locomotor activity at the studied doses of 2.5-22.5 mg/kg. The highest tested dose of 22.5 mg/kg produced 52% of the maximum possible effect in the tail-flick test. It had an additive antinociceptive effect when combined with systemic morphine. Coadministration of ibudilast with morphine did not attenuate the development of morphine tolerance. However, in morphine tolerant rats, ibudilast partly restored morphine-induced antinociception. CONCLUSIONS: Ibudilast produces modest antinociception, and it is effective in restoring but not in preventing morphine tolerance. The mechanisms of the effects of ibudilast should be better understood before it is considered for clinical use. PMID- 19934883 TI - Neurotoxicity of general anesthetics: cause for concern? PMID- 19934884 TI - Succinylcholine-induced hyperkalemia and beyond. 1975. PMID- 19934885 TI - Does B-type natriuretic peptide or its gene polymorphism predict patient outcome after coronary artery bypass graft surgery? PMID- 19934887 TI - Learning disabilities may be related to undetected hypoxia. PMID- 19934888 TI - Learning disability and repeated anesthetics: drugs or airway management issues? PMID- 19934889 TI - The elephant in the room. PMID- 19934890 TI - If the odds are a million to one against something occurring, chances are 50-50 it will. PMID- 19934891 TI - Anesthesia in infancy linked to later disabilities: causation, association, or coincidence? PMID- 19934892 TI - Surgical diagnosis is an important variable to consider in postanesthesia exposure-associated learning disabilities. PMID- 19934893 TI - Hyperoxia in pediatric anesthesia: time for reconsideration? PMID- 19934896 TI - The need for perspective. PMID- 19934898 TI - "Innocent prattle" and the quality of scientific discourse. PMID- 19934900 TI - Outpatients do not need to void after short neuraxial blocks. PMID- 19934901 TI - High positive end-expiratory pressure and mortality in acute respiratory distress syndrome. PMID- 19934904 TI - Is it time for a Glidescope letter? PMID- 19934911 TI - Increasing the rates of complete response to neoadjuvant chemoradiotherapy for distal rectal cancer: results of a prospective study using additional chemotherapy during the resting period. AB - OBJECTIVES: Addition of chemotherapy in the resting period between radiotherapy completion and response assessment during neoadjuvant treatment for distal rectal cancer could potentially increase rates of complete tumor regression. The purpose of this study was to evaluate toxicity rates and the impact of an extended neoadjuvant chemoradiation regimen on complete response rates. METHODS: Thirty four consecutive patients with nonmetastatic distal rectal cancer were prospectively included. Patients were managed by 5,400 Gy of radiation and 5 fluorouracil/leucovorin-based chemotherapy given for three consecutive days every 21 days for six cycles (three cycles concomitant with radiotherapy). Tumor response assessment was performed at ten weeks from radiation completion. Patients with complete clinical response were strictly monitored and were not immediately operated on. Patients with incomplete clinical response were referred to surgery. RESULTS: Twenty-nine patients had completed 12 months of follow-up and were included in this preliminary analysis. Twenty-eight (97%) successfully completed treatment. Fifteen of 16 patients had Grade III toxicities that were skin-related (93%). Median follow-up was 23 months. Fourteen patients (48%) were considered as complete clinical responders sustained for at least 12 months (median, 24 months) after chemoradiation completion by clinical assessment alone. An additional five patients (17%) were considered as complete responders with ypT0 results after full-thickness local excision. Overall, the complete response rate was 65%. CONCLUSIONS: The addition of chemotherapy during the resting period after neoadjuvant chemoradiation is associated with acceptable toxicity and high tolerability rates. The considerably high rates of complete response in this preliminary series requires further follow-up, but they may provide valuable information for future prospective, randomized trials. PMID- 19934912 TI - Fluid management for laparoscopic colectomy: a prospective, randomized assessment of goal-directed administration of balanced salt solution or hetastarch coupled with an enhanced recovery program. AB - INTRODUCTION: No consensus exists regarding the optimal fluid (crystalloid or colloid) or strategy (liberal, restricted, or goal directed) for fluid management after colectomy. Prior assessments have used normal saline. This is the first assessment of standard, goal-directed perioperative fluid management with either lactated Ringer's or hetastarch/lactated Ringer's, with use of esophageal Doppler for guidance, in laparoscopic colectomy with an enhanced recovery protocol. METHODS: A double-blinded, prospective, randomized, three-armed study with Institutional Review Board approval was used for patients undergoing laparoscopic segmental colectomy assigned to the standard, goal-directed/lactated Ringer's and goal-directed/hetastarch groups. A standard anesthesia and basal fluid administration protocol was used in addition to the goal-directed strategies guided by esophageal Doppler. RESULTS: Sixty-four patients undergoing laparoscopic colectomy (22 standard, 21 goal-directed/lactated Ringer's, 21 goal directed/hetastarch) had similar operative times (standard, 2.3 hours; goal directed/lactated Ringer's, 2.5 hours; goal-directed/hetastarch, 2.3 hours). The lactated Ringer's group received the greatest amount of total and milliliters per kilogram per hour of operative fluid (standard, 2,850/18; goal-directed/lactated Ringer's, 3,800/23; and goal-directed/hetastarch, 3,300/17; P < 0.05). The hetastarch group had the longest stay (standard, 64.9 hours; goal directed/lactated Ringer's, 71.8 hours; goal-directed/hetastarch, 75.5 hours; P < 0.05). The standard group received the greatest amount of fluid during hospitalization (standard, 2.5 ml/kg/h; goal-directed/lactated Ringer's, 1.9 ml/kg/h; goal-directed/hetastarch, 2.1 ml/kg/h; P < 0.05). There was one instance of operative mortality in the goal-directed/hetastarch group. CONCLUSIONS: Goal directed fluid management with a colloid/balanced salt solution offers no advantage and is more costly. However, goal-directed, individualized intraoperative fluid management with crystalloid should be evaluated further as a component of enhanced recovery protocols following colectomy because of reduced overall fluid administration. PMID- 19934913 TI - Gene expression signature and the prediction of lymph node metastasis in colorectal cancer by DNA microarray. AB - PURPOSE: Lymph node metastasis is an important factor in determining the outcome of colorectal cancer. If we can predict the presence of lymph node metastasis before surgery, it may help in deciding the need for surgical lymph node dissection or additional preoperative treatment modalities that might improve survival. Our objective here was to identify a set of discriminating genes that can be used for characterization and prediction of lymph node metastasis. METHODS: Eighty-nine colorectal cancer patients were studied. Gene expression profiles of cancer were determined by human U133 Plus 2.0 GeneChip, and patients with and without lymph node metastasis were compared. RESULTS: We identified 73 novel discriminating genes in which expression was significantly different between patients with and without lymph node metastasis. Using this gene set, we were able to establish a new model to predict the presence of lymph node metastasis with an accuracy of 88.4%. Discriminating genes were associated with various functions, including receptor activity and transcription regulatory activity. The list of genes included transmembrane glycoprotein, which has been reported to have a close relationship with lymph node metastasis in prostate cancer. Transmembrane glycoprotein showed significantly higher expression in patients with lymph node metastasis. CONCLUSIONS: The present study suggests the possibility that gene expression profiling may be useful in predicting the presence of lymph node metastasis. Thus, gene expression profiling could help to establish individualized tailored therapy for colorectal cancer and provide insights into the development of novel therapeutic targets. PMID- 19934914 TI - Is the phenotype mixed or mistaken? Hereditary nonpolyposis colorectal cancer and hyperplastic polyposis syndrome. AB - PURPOSE: Hereditary nonpolyposis colorectal cancer is a hereditary syndrome defined by personal and family history of colorectal and other cancers. Some patients with this condition have multiple serrated polyps, which are the hallmark of hyperplastic polyposis syndrome, a rare colorectal cancer syndrome characterized by multiple hyperplastic/serrated polyps and an increased risk of colorectal cancer. We hypothesized that this may represent a unique group of patients, and this study investigates a possible association between the two syndromes. METHODS: A hereditary colorectal cancer registry was reviewed for patients who fit hereditary nonpolyposis colorectal cancer or familial colorectal cancer and hyperplastic polyposis syndrome criteria. RESULTS: Twelve patients from seven families were identified. Four families had more than one person meeting the criteria. All patients were white, and four were women. Ten of 12 patients fit Amsterdam criteria, and two were designated with familial colorectal cancer. The median cumulative number of hyperplastic polyps resected per patient was 6, half of which were located in the right colon. Seven of the 12 patients developed colorectal cancer. Ten patients had personal or family history of other cancers: prostate, breast, testicular, salivary gland, lung, and Hodgkin's disease. CONCLUSIONS: Patients meeting criteria for hereditary nonpolyposis colorectal cancer may also carry a diagnosis of hyperplastic polyposis syndrome. Possible explanations include: 1) two hereditary syndromes are present in the same patient, 2) serrated polyps are part of the phenotype of hereditary nonpolyposis colorectal cancer, or 3) hereditary nonpolyposis colorectal cancer is potentially misdiagnosed in some families who do, in fact, have hyperplastic polyposis. PMID- 19934915 TI - Simulated laparoscopic sigmoidectomy training: responsiveness of surgery residents. AB - PURPOSE: This study aimed to evaluate the responsiveness of surgery residents to simulated laparoscopic sigmoidectomy training. METHODS: Residents underwent simulated laparoscopic sigmoidectomy training for previously tattooed sigmoid cancer with use of disposable abdominal trays in a hybrid simulator to perform a seven-step standardized technique. After baseline testing and training, residents were tested with predetermined proficiency criteria. Content validity was defined as the extent to which outcome measures departed from clinical reality. Content valid measures of trays were evaluated by two blinded raters. Simulator-generated metrics included path length and smoothness of instrument movements. Responsiveness was defined as change in performance over time and was assessed by comparing baseline testing with unmentored final testing. RESULTS: For eight weeks, eight postgraduate year 3/4 residents performed 34 resections. Overall operating time (67 vs. 37 min; P = 0.005), flexure (10 vs. 5 min; P = 0.005), inferior mesenteric vessel (8 vs. 5 min; P = 0.04), and ureter (7 vs. 1 min; P = 0.003) times improved significantly. Content-valid measures from trays remained unchanged. Path length (27,155.2 mm) and smoothness (3,575.5 cm/s3) of instrument movement remained unchanged. There were two bowel perforations and 19 anastomotic leaks. Leak rate decreased from 87% to 12.5%. Strong correlation was found between path length and smoothness of instrument movements (r = 0.9; P < 0.001). There was no correlation between simulator-generated metrics and content-valid outcome measures. Interrater reliability was 1.0 for all measures except anastomotic leak (k = 0.56). There was a linear relationship between residents' clinical advanced laparoscopic case volume and responsiveness (r = -0.7; P = 0.04). CONCLUSIONS: Simulated laparoscopic sigmoidectomy training affected responsiveness in surgery residents with significantly decreased operating time and anastomotic leak rate. PMID- 19934916 TI - Wound complications in rectal cancer patients undergoing primary closure of the perineal wound after abdominoperineal resection. AB - PURPOSE: Perineal wound complications have a significant impact on postoperative morbidity after excision of the rectum and anus. The aim of this study is to evaluate factors affecting perineal wound complications after primary closure of the wound following abdominoperineal resection. METHODS: Data were reviewed from all patients who underwent abdominoperineal resection for rectal carcinoma between 1982 and 2007. Data pertaining to demographics, tumor characteristics, and use of preoperative neoadjuvant therapy were retrieved. Complications studied included delayed wound healing, wound infection, dehiscence, abscess or sinus, reoperation, and perineal hernias. Patients who developed perineal wound complications (Group A) were compared with the remaining patients (Group B) to evaluate factors associated with the development of perineal wound complications. RESULTS: Six hundred ninety-six patients (59% male) met the inclusion criteria. The mean age was 63 years (standard deviation, 13), and the mean body mass index was 28.9 kg/m2 (standard deviation, 7.8). Two hundred seventy-three patients (39.2%) received neoadjuvant chemoradiation. The overall rate of wound complications was 16.2%, and reoperation was required in 5.2% of patients. Group A and Group B patients were similar with respect to age (P = 0.1), gender (P = 0.7), grade (P = 0.4), and stage of disease (P = 0.5). A greater proportion of Group A patients had associated comorbidity (P = 0.001), obesity (0.04), neoadjuvant chemoradiation (0.02), and intraoperative bleeding (0.04). In multivariate analysis, comorbidity was the only independent factor associated with the development of perineal complications (odds ratio, 1.8 (1.09-2.96)). CONCLUSIONS: Most patients have perineal wound healing without complications after abdominoperineal resection. In multivariate analysis, comorbidity was the only significant factor that predicted perineal wound complications. PMID- 19934917 TI - Outcome of salvage surgery for ileal pouches referred with a diagnosis of Crohn's disease. AB - INTRODUCTION: Technical complications after ileal pouch-anal anastomosis may be mislabeled as Crohn's disease. The purpose of our study is to evaluate the presentation, treatment, and outcomes of patients with a potential misdiagnosis of Crohn's disease who have undergone redo ileal pouch-anal anastomosis. METHODS: We evaluated a historical cohort of patients, initially referred from outside institutions with a diagnosis of Crohn's disease of the pouch, who subsequently had redo ileal pouch-anal anastomosis (redo pouch or pouch revision for pouch failure) at our institution. With the use of validated questionnaires, the functional outcomes and quality of life of this cohort were compared with a control group of patients who underwent primary ileal pouch-anal anastomosis to assess whether a change in the diagnosis from Crohn's disease to technical complications was appropriate. RESULTS: Thirty-three patients underwent a redo pouch procedure for a previous diagnosis of Crohn's disease of the pouch. Precolectomy diagnosis included ulcerative colitis (31 patients) and indeterminate colitis (2 patients). Findings on our further evaluation and subsequent indications for repeat pouch surgery included pouch fistula (20 patients), pelvic sepsis or anastomotic leak (17 patients), stricture (4 patients), refractory pouchitis (2 patients), long exit conduit (1 patient), and retained rectal stump (1 patient). All patients had medical treatment for Crohn's disease before referral. Median time between primary and redo pouch was 2.1 years (interquartile range, 1.8-4.9). Median follow-up was 1.7 years (interquartile range, 1.0-3.5). Pouch retention rate was 84.8%. Five patients (15.2%) had pouch failure. Seven patients (21.2%) ultimately had pathology consistent with Crohn's disease. Comparison of the redo pouch and control groups revealed that functional outcomes and quality of life were similar between groups. CONCLUSION: Patients identified as having Crohn's disease need to be carefully reevaluated because some of these patients may actually have surgery-associated complications and can have a favorable long-term outcome after redo ileal pouch-anal anastomosis. PMID- 19934918 TI - Sepsis is a major predictor of failure after ileal pouch-anal anastomosis. AB - PURPOSE: This study aimed to determine the risk of ileal pouch-anal anastomosis failure and factors predictive of failure overall and in patients with septic complications. METHODS: Patients were identified through a prospectively maintained patient registry. All patients registered in the Mount Sinai Hospital Inflammatory Bowel Disease database who had an ileal pouch-anal anastomosis for more than 12 months were included in the study. Pouch failure was defined as ileal pouch-anal anastomosis excision or permanent diversion. Cox proportional hazard models with death as a competing risk were created, modeling time to failure as the outcome of interest for all patients and for the subgroup of patients with septic complications. RESULTS: The study included 1,554 patients. One hundred six patients experienced an ileal pouch-anal anastomosis failure (6.8%), 49 (46.2%) of these failures were caused by septic complications. Independent predictors of failure included Crohn's disease (hazard ratio 7.5, 95% confidence interval [4.7, 12.0]) and postoperative sepsis (hazard ratio 6.6, 95% confidence interval [4.4, 9.8]). In the subgroup of patients with failure due to postoperative septic complications, independent predictors of failure were Crohn's disease (hazard ratio 2.7, 95% confidence interval [1.3, 5.7]) and presence of a pouch fistula (hazard ratio 2.6, 95% confidence interval [1.3, 5.2]). CONCLUSION: Septic complications are the most common cause of ileal pouch anal anastomosis failure. Careful patient selection and the prevention of septic complications may decrease the risk of this failure. PMID- 19934919 TI - Invited commentary. Gender influences treatment and survival in colorectal cancer surgery. PMID- 19934920 TI - Preferences for outcomes of treatment for rectal cancer: patient and clinician utilities and their application in an interactive computer-based decision aid. AB - PURPOSE: To quantify the importance that patients and clinicians assign to specific quality-of-life outcomes associated with the treatment of rectal cancer and to demonstrate a clinical application of these data in a computer-based multidimension decision aid (Annalisa). METHODS: For patients, a researcher administered questionnaire using the time trade-off method was used to quantify the importance of nine outcomes. Information was ascertained from clinicians by use of a self-administered questionnaire. Responses were ranked and compared between groups. Mean values for each outcome were entered into Annalisa. RESULTS: Overall, 103 patients, 87 colorectal surgeons, 97 medical oncologists, and 80 radiation oncologists participated. For all groups, local cancer recurrence in the pelvis and fecal incontinence (mean utility scores 0.53 and 0.57, respectively) were the two outcomes to most avoid. In Annalisa, the "best fit" treatment for patients and surgeons was a low anterior resection with postoperative chemotherapy, whereas for medical and radiation oncologists the best-fit treatment was surgery alone. CONCLUSION: Local recurrence and fecal incontinence are considered the worst outcomes by patients and clinicians alike, but values for other outcomes vary. Decision aids that incorporate patients' individual values with evidence-based data hold considerable potential to optimize treatment decision-making. PMID- 19934921 TI - Invited commentary. Preferences for outcomes of treatment for rectal cancer: patient and clinician utilities and their application in an interactive computer based decision aid. PMID- 19934922 TI - Preoperative radiotherapy is associated with worse functional results after coloanal anastomosis for rectal cancer. AB - PURPOSE: This study was designed to evaluate functional outcome in patients treated with preoperative radiotherapy after low anterior resection and a coloanal anastomosis for low rectal cancer. METHODS: Functional outcome data from patients enrolled in a prospective randomized trial comparing 3 reconstructive procedures were evaluated with respect to administration of preoperative radiotherapy. Incontinence was assessed with a questionnaire on bowel function including the Fecal Incontinence Severity Index; sexual function was assessed with the Sexual Health Inventory for Men and a gender-specific questionnaire for women. Quality of life was assessed with SF-36 scores. RESULTS: Of 364 patients enrolled, 153 (42%) had no radiotherapy or chemotherapy, and 211 (58%) had preoperative radiotherapy; 186 (51%) had chemotherapy in addition to radiotherapy. Comparison of irradiated vs. nonirradiated patients showed no significant differences in postoperative morbidity (29.9% vs. 35.3%; P = 0.27). Two-year follow-up of 297 patients showed greater impairment of bowel function in irradiated patients (n = 170) vs. nonirradiated patients (n = 127): e.g., mean number of daily bowel movements at 12 months, 4.2 +/- 3.5 vs. 3.5 +/- 2.6, P = 0.032; urgency, 85% vs. 67%, P = 0.002). Antidiarrheal use was significantly higher in irradiated patients vs. nonirradiated patients at 4 (P = 0.043), 12 (P = 0.002), and 24 (P = 0.001) months. Sexual Health Inventory for Men scores indicated poorer function in irradiated patients at 24 months (P = 0.039). Preoperative radiotherapy had no deleterious effects on quality of life. Multivariate analyses showed that negative effects of preoperative radiotherapy on urgency at 4 months (P = 0.002) and antidiarrheal use at 24 months were independent of reconstruction technique, but a positive effect of reconstruction with a J-pouch was still observed in patients who received radiotherapy. CONCLUSION: Preoperative radiotherapy does not increase overall morbidity but is associated with poorer functional outcome after low anterior resection with coloanal anastomosis. Preoperative radiotherapy and the J-pouch are nonconfounding predictors of functional outcome up to 24 months after surgery. PMID- 19934923 TI - Invited commentary. Preoperative radiotherapy is associated with worse functional results after coloanal anastomosis for rectal cancer. PMID- 19934924 TI - Prognostic value of peritoneal cytology and the combination of peritoneal cytology and peritoneal dissemination in colorectal cancer. AB - PURPOSE: The value of positive peritoneal cytology in colorectal cancer has been controversial. In this study, we aimed to clarify the prognostic significance of peritoneal cytology and the impact of the combination of peritoneal dissemination and peritoneal cytology on the prognostic evaluation of colorectal cancer. METHODS: From January 1997 to December 2005, intraoperative peritoneal cytology was performed on 410 patients who had at least serosal invasion. RESULTS: Thirty one patients (7.6%) had positive peritoneal cytology. Patients with negative cytology showed a significantly better survival rate at five years than those with positive cytology (negative cytology, 68.0%; positive cytology, 20.6%; P < 0.0001). Multivariate analysis revealed that peritoneal cytology is one of the significant prognostic factors. Sixty percent of patients with positive cytology and 30.4% of patients with negative cytology recurred (P = 0.08). Regarding the recurrence site, patients with positive cytology showed a significantly higher recurrence rate of peritoneal dissemination than those with negative cytology (P = 0.0038). Some patients with positive cytology but without evident peritoneal dissemination achieved long-term survival. Additionally, some patients with macroscopic peritoneal dissemination and negative peritoneal cytology also achieved long-term survival. But for those patients with both positive cytology and evident macroscopic peritoneal dissemination, the five-year survival rate was zero. CONCLUSIONS: Patients with negative peritoneal cytology had a significantly better five-year survival rate than those with positive peritoneal cytology. In some cases in which either peritoneal cytology or peritoneal dissemination was negative, long-term survival could be achieved. PMID- 19934925 TI - Outcomes after fistulotomy: results of a prospective, multicenter regional study. AB - PURPOSE: This study aimed to determine the outcomes and healing rate after fistula surgery across a broad spectrum of colorectal practices. METHODS: A prospective, multicenter outcomes registry was created by the New England Regional Chapter of The American Society of Colon and Rectal Surgeons. All consecutive patients undergoing surgical treatment of an anal fistula by a participating surgeon from October 1, 2007 to September 30, 2008, were entered. Demographics, fistula characteristics including Parks' classification, smoking history, previous vaginal deliveries, diagnosis of Crohn's disease, Fecal Incontinence Severity Index, and operations performed were noted. A follow-up datasheet recorded postoperative complications, healing at one and three months, and postoperative continence scores. Factors associated with healing and treatment success were compared by use of Fisher's exact test. RESULTS: Twenty five surgeons at 13 hospitals entered 245 patients (162 male, 83 female) in the registry. Seventy-five patients had recurrent fistulas, 51 had multiple tracts, 62 were smokers, and 24 had Crohn's disease. The overall healing rate was 19.5% at one month and 63.2% at three months. Female gender (P = 0.04) and recurrent fistula (P = 0.03) were associated with nonhealing, and 28.4% of patients required additional surgery. The best healing rate was associated with fistulotomy (87%), whereas a plug had the worst healing rate (32%, P = 0.001). CONCLUSIONS: Surgical treatment of an anal fistula is associated with a substantial risk of nonhealing at three months. Fistulotomy had a high success rate, whereas the bioprosthetic plug had the lowest success rate. Multicenter studies comparing treatment options for similar fistulas are needed. PMID- 19934926 TI - Prognostic role of vasculogenic mimicry in colorectal cancer. AB - PURPOSE: Angiogenesis, as measured by degree of microvessel density, has been associated with tumor progression in many tumor types but does not always correlate with clinical outcome. In 1999, aggressive tumor cells were shown to form blood-conducting tubes not lined by endothelial cells, and this phenomenon was termed vasculogenic mimicry. We investigated angiogenesis and the presence of vasculogenic mimicry in colorectal carcinoma in relation to tumor stage, patient survival, and genetic indicators of tumor cell plasticity. METHODS: Paraffin embedded tissue samples were examined from a study of 117 patients with colorectal carcinoma with a 12-year follow-up. Immunohistochemical analysis was used to measure microvessel density and proliferating endothelial cells and to detect vasculogenic mimicry (scored by 3 independent observers). Cell cultures from 7 colon cell lines, real-time polymerase chain reaction (PCR) on cell lines, frozen tissue material from 4 colorectal cancer patients with and 4 without vasculogenic mimicry, and fresh colorectal cancer tissue from 2 patients were used to investigate the relationship between vasculogenic mimicry and tumor cell plasticity. RESULTS: Microvessel density was not a prognostic marker in our patients. We found vasculogenic mimicry in 23 (19.7%) of 117 colorectal tumor samples. Cell culture experiments and real-time PCR on human colorectal carcinoma material showed evidence for vasculogenic mimicry with overexpression of EPHA2 and LAMC2, known to be important for the tube-forming capacity of melanoma tumor cells. The presence of vasculogenic mimicry was associated with significantly shortened survival, both overall (P < 0.0001) and within intermediate cancer stages (Dukes B, P = 0.0277; Dukes C, P < 0.0001). CONCLUSIONS: Vasculogenic mimicry can occur in colorectal carcinoma and appears to be comparable to vasculogenic mimicry described in other tumors. Moreover, vasculogenic mimicry in colorectal carcinoma may be a strong independent prognostic marker for survival. PMID- 19934927 TI - Surgical treatment of complicated pilonidal sinus with a fasciocutaneous V-Y advancement flap. AB - PURPOSE: In this study, we investigated the value of fasciocutaneous V-Y advancement flap reconstruction in the treatment of complicated or recurrent sacrococcygeal pilonidal sinus. METHODS: Patients with complicated pilonidal sinus treated with a V-Y advancement flap from July 2002 through December 2005 were studied. The duration of inpatient stay, early wound complications, time of return to active work, recurrence, and patient satisfaction with the operation were recorded. RESULTS: Forty-three patients were treated for recurrent or complicated sacrococcygeal pilonidal disease. All flaps remained viable without necrosis. However, 4 patients (9.3%) had wound infections, and 3 patients (7%) had hematoma. The mean hospital stay was 3 (range, 2-5) days, and time to return to active life was 17 (range, 13-25) days. The mean duration of follow-up was 48 (range, 27 to 69) months. Recurrence was detected in only one patient in the early period. Seven patients (16.3%), including 4 bilateral repairs, had numbness over the operative site. Thirty-nine patients (90.7%) were not satisfied with scars; 4 reported that the scar was not important. CONCLUSIONS: In selected patients, V-Y advancement flaps provide tension-free repair with minimal recurrence rates and reliable skin coverage while flattening the natal cleft that predisposes to recurrence. Because patient dissatisfaction with cosmetic results is high, potential treatment outcomes should be discussed with patients in detail before the operation. PMID- 19934929 TI - Multimedia article. Transanal endoscopic resection of the rectum with high ligation on a swine model--a novel type of natural orifice endoscopic surgery. AB - We present the video of a transanal radical resection of the rectum on a swine model (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A4). The equipment used included simple instruments used in perianal surgery and a flexible endoscope with diathermy. The equipment and skill set required for this technique is easily accessible and reproduced. The potential exists to further develop this procedure with the ultimate aim of performing an incisionless and painless radical resection of the rectum in humans. PMID- 19934930 TI - Colorectal anastomosis after laparoscopic low anterior resection with total mesorectal excision: a difficult problem made simple. AB - Laparoscopic anterior resection with total mesorectal excision for middle and lower third rectal cancer remains a difficult operation, in particular, in male patients with a narrow pelvis and bulky mesentery. In this type of patient, the available staplers do not allow an easy transection of the rectum close to the pelvic floor. A new approach that uses instruments (dilator, obturator, and pursestring anoscope) specifically designed for the technique of stapled hemorrhoidopexy and a common circular stapler can overcome all these issues. PMID- 19934931 TI - Advances in treatment of obstructed defecation: Biomesh transperineal repair. PMID- 19934936 TI - Application of contrast-enhanced constructive interference in steady state magnetic resonance imaging to Leksell GammaPlan for localizing c2-c3 aneurysms: technical note. AB - OBJECTIVE: We used gadolinium (Gd)-enhanced constructive interference in steady state (CISS) magnetic resonance imaging with the Leksell GammaPlan (LGP; Elekta AB, Stockholm, Sweden) system for accurate preoperative evaluation of the anatomic localization of intradural and/or extradural C2-C3 aneurysms. METHODS: Anatomic localization of 8 unruptured aneurysms of the C2-C3 segment was evaluated using Gd-enhanced CISS imaging with LGP. Four patients diagnosed with intradural aneurysms, 1 with a combined intraextradural aneurysm, and 1 with an intracavernous aneurysm underwent operation. The aneurysmal localizations diagnosed preoperatively by Gd-enhanced CISS imaging with LGP were compared with intraoperative findings. RESULTS: By use of Gd-enhanced CISS imaging with LGP, 3 dimensional visualization of the internal carotid artery, aneurysms at the C2-C3 segment, optic nerve, oculomotor nerve, cavernous sinus, and anterior clinoid process was possible in 8 patients. The localization of intradural or combined intra-extradural aneurysms was diagnosed on the basis of the oculomotor nerve and the cavernous sinus depicted in 3-dimensional images. The oculomotor nerve and the cavernous sinus serve as landmarks for the proximal ring on images of the carotico-oculomotor membrane. Intradural or intra-extradural localization of C2 C3 aneurysms with this novel technique was in complete agreement with intraoperative findings in 6 surgical cases. CONCLUSION: This study demonstrated the utility of Gd-enhanced CISS imaging used with LGP for accurate preoperative localization of intradural and/or extradural aneurysms at the C2-C3 segments. PMID- 19934937 TI - Extended superciliary approach for middle cerebral artery embolectomy after unsuccessful endovascular recanalization therapy: technical note. AB - OBJECTIVE: Although an intra-arterial mechanical embolectomy extends the therapeutic time window for restoration of the cerebral blood flow, its suboptimal recanalization rate also necessitates a salvage procedure if the patient is still within the therapeutic time window. As such, a surgical embolectomy can be performed in a rapid and less invasive manner for an acute middle cerebral artery (MCA) occlusion. The technical details of this procedure are discussed and demonstrated. METHODS: Four patients with an acute MCA occlusion were treated using a novel surgical embolectomy technique after unsuccessful intra-arterial mechanical recanalization therapy. Unique to the proposed surgical technique are a laterally extended superciliary approach, small (3-mm) arteriotomy, and closure of the arteriotomy using an aneurysm clip after removal of the intravascular embolus. RESULTS: Occluded MCAs were successfully recanalized using the present technique, and the operative time from skin incision to recanalization was 1 to 1.5 hours in each patient. One to 3 arteriotomies were made in each patient. Six of the 8 arteriotomies in the present series were closed using an aneurysm clip, whereas the other 2 arteriotomies were repaired using microsutures. Postoperative angiograms demonstrated patent MCAs without remarkable clip-induced stenosis. The successful recanalization provided considerable neurological improvement in all patients without procedural complications, except for 1 patient with a fatal putaminal hemorrhage resulting from a reperfusion injury. CONCLUSION: A laterally extended superciliary approach and clip application for arteriotomy closure enable a surgical embolectomy to become a rapid and less invasive procedure. PMID- 19934938 TI - In situ single-unit recording of hypothalamic hamartomas under endoscopic direct visualization. AB - OBJECTIVE: Hypothalamic hamartomas (HHs) are associated with refractory epilepsy and are amenable to surgical treatment. The gelastic seizures associated with HHs originate within the HH lesion, but the responsible cellular mechanisms are unknown. Microelectrode patch-clamp recordings from HH neurons in resected slice preparations show that small HH neurons spontaneously fire with intrinsic pacemaker-like activity. We questioned whether spontaneous firing of HH neurons was present in situ, and we hypothesized that single-unit field recordings from HH tissue could be obtained with instrumentation passed through the endoscope before surgical resection. TECHNIQUE: After informed consent was obtained, patients undergoing transventricular, endoscopic resection of an HH for intractable epilepsy were eligible for study. After placement of the endoscope, a bundled microwire (total of 9 contacts) was placed into the HH under direct visualization. Spontaneous activity was recorded for two or three 5-minute epochs, under steady-state general anesthesia. The wire was advanced 0.5 to 1 mm within the lesion between recording epochs. RESULTS: A total of thirteen 5-minute recordings were obtained from 5 patients. Noise levels were comparable to extraoperative microwire recordings for temporal lobe epilepsy. Single-neuron spike activity was isolated from a total of 5 channels obtained during recording of 3 sessions in 3 patients. CONCLUSION: We have shown that single-unit recordings from HH lesions can be successfully obtained in situ under direct endoscopic visualization. We believe that this is the first report using the working channel of a neuroendoscope to make physiological recordings of deep structures in humans. PMID- 19934939 TI - Bilateral internal carotid artery aneurysm simulating pituitary apoplexy: case report. AB - OBJECTIVE: Intracavernous internal carotid artery (ICA) aneurysms can extend into the sella and simulate pituitary adenomas. However, they are rarely associated with pituitary apoplexy. We present a rare case of bilateral intracavernous ICA aneurysms simulating a sellar mass with the clinical picture of a pituitary apoplexy. CLINICAL PRESENTATION: An 82-year-old woman presented with a classic case of pituitary apoplexy with a history of headache, nausea, vomiting, and diplopia. She was found to have an intrasellar mass simulating a large and invasive pituitary adenoma. The patient had a medical history positive for breast cancer. INTERVENTION: Because of the presentation with apoplexy and the possibility of metastatic breast cancer or pituitary adenoma, the patient was explored transsphenoidally to obtain pathological verification and possibly resect the tumor. Unusual intraoperative findings led to a microDoppler evaluation, suggesting a vascular lesion. Intraoperatively, an angiogram confirmed the presence of bilateral ICA giant aneurysms involving the ICA intracavernous component extending into the sella turcica. The patient refused further treatment. CONCLUSION: The present case indicates that an intrasellar ICA aneurysm can be misdiagnosed as a macroadenoma and even present through pituitary apoplexy. When treating intrasellar masses with the slightest suspicion of a nonpituitary origin, further workup should be considered. The possibility of a vascular lesion simulating a pituitary adenoma should always be considered by neurosurgeons and ear, nose, and throat surgeons operating in the sellar region. PMID- 19934940 TI - Minimally invasive resection of intramedullary ependymoma: case report. AB - OBJECTIVE: This report illustrates the adequacy of minimally invasive exposure for the resection of an intramedullary ependymoma. CLINICAL PRESENTATION: The patient presented with a history of upper back pain, but a lesion was found during a workup for increased back pain after a motor vehicle accident. INTERVENTION: The intramedullary ependymoma was approached using a muscle splitting retractor and extended hemilaminar exposure. The tumor was removed using conventional techniques. CONCLUSION: This minimally invasive exposure is adequate for selected intramedullary lesions and may be especially useful in patients with a high risk of postlaminectomy deformity. PMID- 19934941 TI - Cerebellopontine angle arachnoid cyst: a case of hemifacial spasm caused by an organic lesion other than neurovascular compression: case report. AB - OBJECTIVE: A rare case of cerebellopontine angle arachnoid cyst manifesting as hemifacial spasm (HFS) is reported. The patient is a 42-year-old woman with 10 month history of left HFS. A preoperative magnetic resonance imaging scan showed a well-demarcated area, hypointense on T1-weighted imaging and hyperintense on T2 weighted imaging, in the left cerebellopontine angle, without contrast enhancement, resembling an arachnoid cyst. METHODS: The cyst was excised with microneurosurgical technique and the facial, vestibular, and acoustic nerves were completely decompressed from the arachnoid wall. RESULTS: The postoperative course was uneventful, and the left HFS disappeared immediately. Histologically, the cyst wall was a typical arachnoidal membrane. Ten months after surgery, the patient is symptom free. CONCLUSION: It is well-known that in approximately 10% of cases, trigeminal neuralgia can be caused by a space-occupying mass. However, the fact that HFS can also be caused by organic lesions as well as neurovascular compression is less well-known. Although the occurrence of tumor compression causing HFS has been previously recognized, cerebellopontine angle cysts have very rarely been described. The observation of a patient with a cerebellopontine angle arachnoid cyst causing HFS prompted us to review the literature relative to HFS caused by an organic lesion rather than neurovascular compression. PMID- 19934942 TI - Tuberculous brainstem abscess: case report. AB - OBJECTIVE: Tuberculous brainstem abscess is a clinically rare condition with potentially high mortality and morbidity. We present this report to draw attention to the importance of early recognition and adequate treatment of tuberculous brainstem abscess. CLINICAL PRESENTATION: A 24-year-old man complained of longstanding fever, headache, and weakness followed by development of progressive slurred speech and hemiparesis of the right extremities. Magnetic resonance imaging revealed a large thick-walled cystic lesion lying within the brainstem. INTERVENTION: The patient demonstrated a remarkable clinical recovery after microsurgery combined with a course of antituberculous therapy. Microbiological and histological findings confirmed the diagnosis of a tuberculous abscess. CONCLUSION: Despite its rarity, the tuberculous brainstem abscess must be considered in the differential diagnosis of cystic brainstem mass lesions in vulnerable patients. When confronted with progressing neurological deterioration and poor response to antituberculous therapy, stereotactic or microsurgical management should be considered. Microsurgical excision combined with a complete course of antituberculous therapy in our patient led to a good outcome. PMID- 19934943 TI - Aggressive intracranial dural arteriovenous fistula presenting with cerebrospinal fluid rhinorrhea: case report. AB - OBJECTIVE: This is the first report of an aggressive dural arteriovenous fistula presenting with rhinorrhea. It demonstrates the importance of recognizing increased intracranial pressure, and its underlying cause, as the predisposing factor to a spontaneous cerebrospinal fluid leak because this carries implications for management. CLINICAL PRESENTATION: Ten years after minor trauma and directly after an intercontinental flight, a 43-year-old woman presented with rhinorrhea. Right-sided pulsatile tinnitus had been present for the past 9 years. Imaging demonstrated an intracranial dural arteriovenous fistula of the right transverse sinus with cortical venous reflux. Magnetic resonance imaging findings indicated long-standing increased intracranial pressure. INTERVENTION: The fistula was treated by endovascular means, using both transvenous and transarterial approaches, which led to immediate relief of the tinnitus and resolution of the rhinorrhea within 4 days. CONCLUSION: A dural arteriovenous fistula should be included in the differential diagnosis of underlying causes of increased intracranial pressure when examining a patient with a cerebrospinal fluid leak. Treatment of the fistula should precede attempts to treat the rhinorrhea, especially if the fistula has cortical venous reflux. PMID- 19934944 TI - Balloon-assisted clipping of a large paraclinoidal aneurysm: a salvage procedure. AB - OBJECTIVE: Surgical clipping and parent vessel reconstruction of wide-neck paraclinoid aneurysms can be very challenging. We report a case of a ruptured paraclinoid aneurysm which failed standard clipping techniques. We were able to reconstruct this aneurysm while providing proximal and distal control using an adjuvant endovascular balloon. CLINICAL PRESENTATION: We report the case of a 45 year-old woman presenting with a ruptured large paraclinoidal aneurysm, which involved a significant portion of the internal carotid artery wall. INTERVENTION: Repeated attempts at fenestrated clip placement resulted in slipping of the clip and occlusion of the parent artery. Ultimately, the aneurysm ruptured at the neck, and, despite trapping and direct aneurysmal suction decompression, significant bleeding was encountered. The bleeding point was packed, and, subsequently, endovascular access was obtained. A balloon was navigated and then inflated across the neck of the aneurysm using C-arm fluoroscopic guidance. The aneurysm was successfully clipped, and intraoperative angiography demonstrated no parent vessel stenosis. CONCLUSION: This case demonstrates a salvage procedure in the event of intraoperative rupture and inadequate interruption of local blood flow. Balloon inflation resulted in adequate hemostasis and provided intraluminal support for optimal clip placement while preserving the parent artery. PMID- 19934945 TI - Cranial migration of a baclofen pump catheter associated with subarachnoid hemorrhage: case report. AB - OBJECTIVE: Cephalad migration of an indwelling intrathecal catheter within the spinal canal has rarely been described. Cranial subarachnoid hemorrhage (SAH) related to movement of this type of catheter has not been described. We report a case of SAH coincident with the migration of a free fragment of a baclofen pump catheter into the prepontine cistern. CLINICAL PRESENTATION: A baclofen pump system was removed from a 47-year-old man with spasticity related to multiple sclerosis. A section retained in the spinal canal extended up to the T9 level. Ten days after the pump and lower portion of the catheter were removed, the patient presented with a severe headache and a classic aneurysmal pattern of SAH. The patient's catheter was found to have migrated adjacent to the basilar artery at the level of the superior cerebellar artery. An extensive evaluation, including computed tomography angiography, digital subtraction angiography performed twice, magnetic resonance imaging, and magnetic resonance angiography, showed no apparent cause for the hemorrhage. Initially, the catheter was left in place. However, 5 months after the SAH, the patient elected to have the catheter removed. INTERVENTION: The catheter was pulled out from below through a C6-C7 laminoplasty without complications. The patient made an excellent recovery. DISCUSSION: Cephalad catheter migration is a rare phenomenon. The mechanism of rostral migration remains unclear. The forces that propel a free fragment of catheter under these circumstances seem to be sufficient to cause a small vessel to rupture and bleed. Given the lack of an observed arterial injury, we postulate that venous bleeding caused this hemorrhage. PMID- 19934946 TI - Repair of a cerebrospinal fluid fistula using a muscle pedicle flap: technical case report. AB - OBJECTIVE: As a late complication of radiation therapy and a transoral approach, a cerebrospinal fluid (CSF) fistula between an oropharyngeal cavity and the ventral dura of the cervical spine is an extremely rare event. There are often difficulties in repairing ventral dural defects. Herein, we describe a technique that assists in feasible repair of a CSF fistula associated with ventral dural defects. CLINICAL PRESENTATION: A 36-year-old man was admitted to our institution with postnasal drip and a progressive spastic gait disturbance. Eleven years earlier, he had a recurrent chordoma of the cervical spine, which was treated by 5 open surgeries, including a transoral operation, and 6 rounds of radiation therapy. A neuroradiological examination revealed a CSF fistula between a posterior pharyngeal wall and the ventral dura of the cervical spine. INTERVENTION: We performed a repair operation of the CSF fistula using a conventional direct posterior approach. However, we were unable to repair the fistula using a dural-substitute suturing procedure. Therefore, we used a semispinalis cervicis muscle pedicle flap. The muscle pedicle flap was brought through the dural defect in the anterior part of the posterior pharyngeal wall, to which it was fixed. It was then used to reinforce the suture line that closed the fistula and to fill the fistula tract. After posterior surgery, a transoral endoscopic approach was used to augment the muscle pedicle flap with a bovine pericardial patch graft. No postoperative complications occurred, and CSF leaking ceased after surgery. There was no CSF leakage during the 1-year follow-up period. CONCLUSION: This novel muscle pedicle flap technique for repairing a CSF fistula can be used as an alternative to the direct "water-tight" closure of ventral cervical dural defects. PMID- 19934947 TI - Occipital cervical stabilization using occipital condyles for cranial fixation: technical case report. AB - OBJECTIVE: Presentation of a successful case of craniocervical stabilization involving a novel surgical technique using the occipital condyles as the sole cranial fixation points. CLINICAL PRESENTATION: A 22-year-old man presented in a delayed fashion with neck pain after a motor vehicle accident. Evaluation revealed a type 2 odontoid fracture with pseudarthrosis and displacement of the dens superiorly and cranial settling of the dens. INTERVENTION: The patient underwent posterior occipitocervical fixation with a polyaxial screw rod construct using the occipital condyle, C1 lateral mass, and C2 pars articularis for fixation. The patient had no immediate postoperative deficits. At the time of the 12-month follow-up examination, the patient was neurologically intact with a solid occipitocervical fusion. CONCLUSION: Craniocervical stabilization using occipital condyle screws as the sole cephalad fixation points is a feasible option and can be used safely without neurovascular complication in the treatment of craniocervical instability. PMID- 19934949 TI - Combination therapy improves walking in spinal cord transaction. PMID- 19934950 TI - Guiding regenerating axons to their brainstem targets. PMID- 19934951 TI - The role of bevacizumab in hearing preservation and tumor volume control in patients with vestibular schwannomas. PMID- 19934952 TI - T-cell activation in ischemic stroke: a new therapeutic target for delayed infarct expansion? PMID- 19934953 TI - Vertebroplasty: effective or not? PMID- 19934957 TI - Reduction of seizures by transplantation of embryonic GABAergic interneurons into Kv1.1 mutant mice. PMID- 19934958 TI - Dopamine and memory: the proof! PMID- 19934959 TI - Thrombin inhibition in subarachnoid hemorrhage. PMID- 19934960 TI - Cervical spine reoperation rates and hospital resource utilization after initial surgery for degenerative cervical spine disease in 12,338 patients in Washington State. AB - OBJECTIVE: Patients undergoing surgery for degenerative cervical spine disease may require future surgery for disease progression. We investigated factors related to the rate of additional cervical spine surgery, the associated length of stay, and hospital charges. METHODS: The was a longitudinal retrospective cohort study using Washington state's 1998 to 2002 state inpatient databases and International Classification of Diseases-Ninth Revision-Clinical Modification (ICD-9) codes to analyze patients undergoing degenerative cervical spine surgery. Multivariate Poisson regression to identify patient and surgical factors associated with reoperation for degenerative cervical spine disease was used. Multivariate linear regressions to identify factors associated with length of stay and hospital charges adjusted for age, sex, year of surgery, primary diagnosis, payment type, discharge status, and comorbidities were also used. RESULTS: A total of 12,338 patients underwent initial cervical spine surgeries from 1998 to 2002; the mean follow-up duration was 2.3 years, and 688 patients (5.6%) underwent a reoperation (2.5% per year). Higher reoperation rates were independently associated with younger patients (P < 0.001) and a primary diagnosis of disc herniation with myelopathy (P = 0.011). Ventral surgery (P < 0.001) and fusion (P < 0.001) were both associated with lower rates of reoperation; however, a high correlation (Spearman's rho = 0.82; P < 0.001) made it impossible to determine which factor was dominant. Longer length of stay was independently associated with nonventral approaches (+1.0 day; P < 0.001) and fusion surgery (+0.8 day; P < 0.001). Greater hospital charges were independently associated with nonventral approaches (+$2900; P < 0.001) and fusion surgery (+$9600; P < 0.001). CONCLUSION: Patients undergoing surgery for degenerative cervical spine disease undergo reoperations at the rate of 2.5% per year. An initial ventral approach and/or fusion seem to be associated with lower reoperation rates. An initial nonventral approach and fusion were more expensive. PMID- 19934961 TI - Comparison between primary angioplasty and stent placement for symptomatic intracranial atherosclerotic disease: meta-analysis of case series. AB - OBJECTIVE: To compare the short- and long-term rates of stroke-and/or-death associated with primary angioplasty alone and angioplasty with stent placement using a meta-analysis of published studies. Both primary angioplasty alone and angioplasty with stent placement have been proposed as treatment strategies for symptomatic intracranial atherosclerotic disease to reduce the risk of stroke and/or-death with best medical treatment alone. However, it remains unclear which of these endovascular techniques offers the best risk reduction. METHODS: We identified pertinent studies published between January 1980 and May 2008 using a search on PubMed and Cochrane libraries, supplemented by a review of bibliographies of selected publications. The incidences of stroke-and/or-death were estimated for each report and pooled for both angioplasty alone and angioplasty with stent placement at 1 month and 1 year postintervention and then compared using a random-effects model. The association of year of publication and 1-year incidence of stroke-and/or-death was analyzed with meta-regression. RESULTS: After applying our selection criteria, we included 69 studies (33 primary angioplasty-alone studies [1027 patients] and 36 studies of angioplasty with stent placement [1291 patients]) in the analysis. There were a total of 91 stroke-and/or-deaths reported in the angioplasty-alone-treated group (8.9%; 95% confidence interval [CI], 7.1%-10.6%), compared with 104 stroke-and/or-deaths in the angioplasty-with-stent-treated group (8.1%; 95% CI, 6.6%-9.5%) during a 1 month period (relative risk [RR], 1.1; P = 0.48). The pooled incidence of 1-year stroke-and/or-death in patients treated with angioplasty alone was 19.7% (95% CI, 16.6%-23.5%), compared with 14.2% (95% CI, 11.9%-16.9%) in the angioplasty-with stent-treated patients (RR, 1.39; P = 0.009). The incidence of technical success was 79.8% (95% CI, 74.7%-84.8%) in the angioplasty-alone group and 95% (95% CI, 93.4%-96.6%) in the angioplasty-with-stent-treated group (RR, 0.84; P < 0.0001). The pooled restenosis rate was 14.2% (95% CI, 11.8-16.6%) in the angioplasty alone group, as compared with 11.1% (95% CI, 9.2%-13.0%) in the angioplasty-with stent-treated group (RR, 1.28; P = 0.04). There was no effect of the publication year of the studies on the risk of stroke-and/or-death. CONCLUSION: Risk of 1 year stroke-and/or-death and rate of angiographic restenosis may be lower in symptomatic intracranial atherosclerosis patients treated by angioplasty with stent placement compared with patients treated by angioplasty alone. PMID- 19934962 TI - Hypertonic saline and its effect on intracranial pressure, cerebral perfusion pressure, and brain tissue oxygen. AB - OBJECTIVE: Hypertonic saline is emerging as a potentially effective single osmotic agent for control of acute elevations in intracranial pressure (ICP) caused by severe traumatic brain injury. This study examines its effect on ICP, cerebral perfusion pressure (CPP), and brain tissue oxygen tension (PbtO2). METHODS: Twenty-five consecutive patients with severe traumatic brain injury who were treated with 23.4% NaCl for elevated ICP were evaluated. Bolt catheter probes were placed in the noninjured hemisphere, and hourly ICP, mean arterial pressure, CPP, and PbtO2 values were recorded. Thirty milliliters of 23.4% NaCl was infused over 15 minutes for intracranial hypertension, defined as ICP greater than 20 mm Hg. Twenty-one male patients and 4 female patients aged 16 to 64 years were included. The mean presenting Glasgow Coma Scale score was 5.7. RESULTS: Mean pretreatment values included an ICP level of 25.9 mm Hg and a PbtO2 value of 32 mm Hg. The posttreatment ICP level was decreased by a mean of 8.3 mm Hg (P < 0.0001), and there was an improvement in PbtO2 of 3.1 mm Hg (P < 0.01). ICP of more than 31 mm Hg decreased by 14.2 mm Hg. Pretreatment CPP values of less than 70 mm Hg increased by a mean of 6 mm Hg (P < 0.0001). No complications occurred from this treatment, with the exception of electrolyte and chemistry abnormalities. At 6 months postinjury, the mortality rate was 28%, with 48% of patients achieving a favorable outcome by the dichotomized Glasgow Outcome Scale. CONCLUSION: Hypertonic saline as a single osmotic agent decreased ICP while improving CPP and PbtO2 in patients with severe traumatic brain injury. Patients with higher baseline ICP and lower CPP levels responded to hypertonic saline more significantly. PMID- 19934963 TI - Predictors of global cognitive impairment 1 year after subarachnoid hemorrhage. AB - OBJECTIVE: We sought to determine the frequency, risk factors, and impact on functional outcome and quality of life (QOL) of global cognitive impairment 1 year after subarachnoid hemorrhage. METHODS: We prospectively evaluated global cognitive status 3 and 12 months after hospitalization with the Telephone Interview for Cognitive Status in 232 subarachnoid hemorrhage survivors. Cognitive impairment was defined as a score of 30 or less (scaled 0 = worst, 51 = best). Logistic regression was performed to calculate adjusted odds ratios (AORs) for impairment at 1 year. Basic activities of daily living were evaluated with the Barthel Index, instrumental activities of daily living were assessed with the Lawton scale, and QOL was evaluated with the Sickness Impact Profile. RESULTS: The frequency of cognitive impairment was 27% at 3 months and 21% at 12 months. After the effects of age, education, and race/ethnicity were controlled for, risk factors for cognitive impairment at 12 months included anemia treated with transfusion (AOR, 3.4; P = 0.006), any temperature level higher than 38.6 degrees C (AOR, 2.7; P = 0.016), and delayed cerebral ischemia (AOR, 3.6; P = 0.01). Among cognitively impaired patients at 3 months, improvement at 1 year occurred in 34% and was associated with more than 12 years of education and the absence of fever higher than 38.6 degrees C during hospitalization (P = 0.015). Patients with cognitive impairment at 1 year had worse concurrent QOL and less ability to perform instrumental and basic activities of daily living (all P < 0.001). CONCLUSION: Global cognitive impairment affects more than 20% of subarachnoid hemorrhage survivors at 1 year, is predicted by fever, anemia treated with transfusion, and delayed cerebral ischemia, and adversely affects functional recovery and QOL. PMID- 19934964 TI - Radiosurgery in the treatment of spinal metastases: tumor control, survival, and quality of life after helical tomotherapy. AB - OBJECTIVE: The effectiveness and limitations of spinal radiosurgery using a helical TomoTherapy system for the treatment of spinal metastases are reviewed in this article. METHODS: This is a retrospective review of patients who underwent stereotactic radiosurgery for spinal metastases between July 2004 and December 2007. Radiographic follow-up consisted of magnetic resonance imaging to assess tumor growth control as well as pre- and posttreatment x-rays, which were used to measure changes in segmental angulation and deformity. Clinical performance was assessed using the Karnofsky Performance Scale, Oswestry Disability Index, and visual analog scale. RESULTS: Forty patients were treated for 110 metastatic tumors (range, 1-6 tumors per patient). The mean age at the time of radiosurgical treatment was 67 years (age range, 35-81 years). Twenty-three patients (57.5%) had undergone previous surgical resection. Pain was the most common presenting symptom, seen in 32 patients (80%). The mean Oswestry Disability Index score at presentation was 43 (range, 20-90), and the mean visual analog scale score was 6.2 (range, 0-10). The mean radiosurgical dose to the tumor was 17.3 Gy (range, 10-24 Gy). At a mean follow-up duration of 12.7 months (range, 4-32 months), decreased or stable tumor volume was seen in 90 (82%) of the tumors treated. There was improvement in pain in 34 patients (85%). The mean postradiosurgical Oswestry Disability Index score was 25 (range, 10-90), whereas the postradiosurgical visual analog scale score was 3.2 (range, 0-9). Progression of kyphosis was the most common radiographic sequela, experienced by 73% of patients alive at 12 months, with a mean change in angulation of 7.3 +/- 4.5 degrees. CONCLUSION: Radiosurgery is effective as either primary or adjunctive treatment of metastatic tumors of the spine. PMID- 19934965 TI - Fractures of the clivus: a contemporary series in the computed tomography era. AB - OBJECTIVE: We report the morbidity and mortality associated with fractures of the clivus and discuss management approaches specific to this unique diagnostic entity. METHODS: We performed a boolean search of our electronic medical record database to identify patients with fractures of the clivus that were diagnosed using computed tomography of the head. A retrospective imaging and chart analysis was completed to further characterize the fractures and to analyze outcomes. RESULTS: Between January 1999 and December 2007, 41 patients were identified with fractures of the clivus. We found a 0.21% overall incidence among all head injured patients presenting to our institution and a 2.3% incidence among those patients with a cranial fracture. Ten of 41 patients (24.4%) died, and neurological and vascular complications associated with central cranial base fractures were observed in 19 of 41 patients (46%). Furthermore, associated cranial fractures remote from the central cranial base and associated intracranial hemorrhages were observed in 40 of 41 (97.6%) and 33 of 41 (80.5%) patients, respectively. In terms of outcomes, 26 of 41 patients (63.5%) had a Glasgow Coma Scale score of 12 or greater at the time of discharge from the hospital. CONCLUSION: We demonstrate a lower than previously reported mortality rate in patients with clival fractures. Nevertheless, as a result of location, fractures of the clivus were frequently associated with a high rate of complications and neurological sequelae. PMID- 19934966 TI - Five-aminolevulinic acid for fluorescence-guided resection of recurrent malignant gliomas: a phase ii study. AB - OBJECTIVE: To assess the feasibility of 5-aminolevulinic acid (5-ALA) fluorescence guidance for resection of recurrent malignant brain tumors. METHODS: In a multicenter prospective, single-arm, uncontrolled phase II study, 36 patients with recurrent glioma (World Health Organization grade III/IV) received 5-ALA before surgery. After microsurgical resection, biopsies from pathological and nonpathological areas (as identified under conventional white light) were obtained to determine the positive predictive value (PPV) of 5-ALA-induced tissue fluorescence in detecting tumors. Adverse events, neurological examinations, and survival data were documented for a minimal follow-up of 6 months. RESULTS: The patient-based PPV, defined as the percentage of patients showing positive tumor cell identification in all biopsies taken from areas of weak and strong fluorescence was 97.2% for pathological areas and 79.4% in nonpathological areas. Within areas of strong fluorescence, PPV was higher (91.7%) compared with that of weak fluorescence (82.4%). On the biopsy level for nonpathological-appearing tissue under white light (157 biopsies), the PPV of tissue fluorescence was 93.0% compared with 99.5% in pathological-appearing tissue (197 biopsies). Again, within areas of strong fluorescence, PPV was higher (96.9%) compared with that of weak fluorescence (90.3%). There were no adverse events pertaining to the study drug. CONCLUSION: 5-ALA fluorescence has a high predictive value for the detection of tumor in recurrent gliomas. Prior treatment modalities, such as radiation or chemotherapy, do not invalidate the fluorescence guidance with 5 ALA. 5-ALA fluorescence guidance is an effective surgical adjunct in the surgery of recurrent malignant gliomas. PMID- 19934967 TI - Primary obstruction of the fourth ventricle outlets: neuroendoscopic approach and anatomic description. AB - OBJECTIVE: Primary obstruction of the foramina of Magendie and Luschka is an uncommon and still unclear cause of noncommunicating hydrocephalus. The aim of this work is the description, for the first time, of the inner aspect of these velar obstructions of the fourth ventricle outlets and the demonstration of the efficacy of neuroendoscopic treatment. METHODS: Of 240 hydrocephalic patients treated in our institution with endoscopic third ventriculostomy, a subgroup of 10 cases with closure of the fourth ventricular outlets without associated Chiari malformation and syringomyelia was selected. In all of these cases, a transaqueductal endoscopic navigation of the fourth ventricle was performed, and the obstructed outlets were inspected. All of the clinical data and, in particular, the videotape records of endoscopic operations, as well as the cine magnetic resonance imaging scans, were reviewed to evaluate their patency status. RESULTS: Various degrees of stenosis were found endoscopically: restriction of the Magendie contour with thick and opaque membrane, transparent spider web-like membrane, and dense membrane with fissures acting as valves. Endoscopic third ventriculostomy was effective in almost all patients, although we noticed an unforeseen high incidence of closure of the stoma. The restored normal cerebrospinal fluid flux after ventriculocisternostomy and magendieplasty was demonstrated by comparative study of cerebrospinal fluid flow measurements by cine-magnetic resonance imaging. CONCLUSION: This report demonstrates the effectiveness of neuroendoscopic third ventriculostomy as well as magendiestomy in cases of tetraventricular hydrocephalus attributable to primary obstruction of the outlets of the fourth ventricle and, for the first time, presents direct images of various types of outlet obstructive pathology. PMID- 19934969 TI - Hippocampus minor, calcar avis, and the Huxley-Owen debate. AB - On the bicentennial of Darwin's birth, we describe the origin of the calcar avis and summarize the debate around this structure, which played a central role in the evolution debate in the mid-19th century. We performed a comprehensive review of relevant neuroanatomic literature, bibliographic sources, and 19th century primary sources. Once known as the hippocampus minor, the structure now known as the calcar avis is an involution of the ventricular wall produced by the calcarine fissure. A heated debate raged between 2 prominent scientific theorists, Sir Richard Owen and Thomas Henry Huxley, over the presence of the hippocampus minor in apes versus humans. Owen put forward the lack of an identifiable hippocampus minor in humans as part of an attempt to debunk evolution. A bitter personal and academic rivalry ensued, as Huxley conducted his own dissections to refute Owen's claims. Huxley ultimately dismantled Owen's premises, securing the epithet "Darwin's bulldog" for his defense of the theory of evolution. Thus, this relatively obscure neuroanatomic landmark served as a pivotal point of contention in the most popularized and acrimonious evolutionary debate of the 19th century. PMID- 19934968 TI - Effect of simvastatin on glioma cell proliferation, migration, and apoptosis. AB - OBJECTIVE: In this study, we investigated the effects of simvastatin on proliferation, migration, and apoptosis in human U251 and U87 glioma cells and the underlying molecular mechanism. METHODS: We used colony formation assay to test the cell proliferation, in vitro scratch assay to examine the cell migration, and caspase-3 activity assay, annexin V staining, and cytochrome C release to evaluate the cell apoptosis. Lipid raft fractions were isolated from glioma cells. Total cholesterol content assay was used to test the change of cholesterol level in lipid raft fractions. Immunocytochemistry staining was performed to detect the changes of lipid rafts in cell membranes. Western blotting analysis was performed to examine the signal transduction both in cells and in lipid raft fractions. RESULTS: Simvastatin inhibited proliferation and migration of U251 and U87 cells dose dependently. Simvastatin induced an increase of caspase-3 activity and annexin V staining, and down-regulated the phosphatidylinositol 3-kinase (PI3K)/Akt pathway. Simvastatin also decreased cholesterol content in lipid raft fractions, suppressed caveolin-1 expression in the lipid rafts, and induced Fas translocation into lipid rafts, suggesting that simvastatin may inhibit the prosurvival PI3K/Akt pathway and trigger caspase-3 dependent apoptotic cell death through the modulation of lipid rafts. CONCLUSION: These results suggest that modulation of lipid rafts, Fas translocation, and PI3K/Akt/caspase-3 pathway are involved in the antitumor effect of simvastatin and may have a potential role in cancer prevention and treatment. PMID- 19934970 TI - Do intracranial neoplasms differ in Ollier disease and maffucci syndrome? An in depth analysis of the literature. AB - OBJECTIVE: Ollier disease (OD) and Maffucci syndrome are closely related, very rare syndromes, that are both associated with multiple sites of chondrodysplasia. They differ primarily with the additional association of Maffucci syndrome with vascular abnormalities, including hemangiomas. Both are associated with chondrosarcomas and other nonsarcomatous neoplasms (NSN), but Maffucci syndrome is thought to have greater malignancy potential. We examined whether OD and Maffucci syndrome differ in the number, histology, in the location of intracranial malignancies, and in the demographics of such patients, as reported in the medical literature. METHODS: Relevant cases were identified by electronic searches on PubMed, SciSearch, Scientific Commons, Springer Link, and Google. Translate DotNet and Babelfish were used to translate non-English text. Unpaired Student's t tests were used to compare OD and Maffucci syndrome, and chondrosarcoma and NSN patients for mean age; Pearson chi analysis was used for comparisons of gender distribution, geographical distribution (by continent), site of lesion, and for OD versus Maffucci syndrome, tumor type (chondrosarcoma versus NSN). RESULTS: Forty-six patients with 47 intracranial malignancies were identified: 24 with OD, including 6 with a chondrosarcoma and 18 with an NSN; and 22 with Maffucci syndrome, including 13 with a chondrosarcoma, 8 with an NSN, and 1 with both. The 2 syndromes were statistically different in the distribution of chondrosarcomas versus NSNs (P = 0.002). All chondrosarcomas originated at the base of the cranium. All 18 NSNs in OD were of glial cell origin, but only 5 of 9 NSNs in Maffucci syndrome were glial; other tumors included pituitary adenoma, olfactory neuroblastoma, malignant chordoma, and spindle cell hemangioendothelioma. Patients with OD were more than 10 years younger than their Maffucci syndrome counterparts (24.7 versus 34.9 years; P = 0.002), as were patients with OD and chondrosarcoma versus those with Maffucci syndrome and chondrosarcoma (24.7 versus 36.2 years; P = 0.035). The 2 syndromes did not differ in overall sex distribution. OD and Maffucci syndrome differed in geographical distribution, with 10 Maffucci syndrome but no OD patients with malignancy either in Asia (7 patients) or South America (3 patients). Among NSNs, OD and Maffucci syndrome did not differ as to site of lesion within the brain. CONCLUSION: OD and Maffucci syndrome differ with respect to the distribution of intracranial malignancies by histology, and geographical and age distribution of cases, with OD patients younger by approximately a decade, and Maffucci syndrome patients more likely to live in Asia or South America. PMID- 19934971 TI - Three-dimensional and 2-dimensional endoscopic exposure of midline cranial base targets using expanded endonasal and transcranial approaches. AB - OBJECTIVE: Endoscopic endonasal approaches provide an access method to the midline cranial base. To integrate these approaches into neurosurgical practice, the extent of their anatomic exposure must be compared with that provided by more traditional transcranial approaches. METHODS: Ten fresh cadaver heads were studied. Both endonasal and transcranial approaches to the midline cranial base were performed. The midline cranial base was divided into several areas, and the relative exposure provided by each approach was described and presented in both 2 dimensional and 3-dimensional images. Limitations and advantages of each approach are discussed. RESULTS: The endonasal approaches achieved a direct and wide exposure of the midline extracranial and intracranial cranial base anatomy. The main lateral limitations of the endonasal approaches were the optic nerves, lateral cavernous sinus, vidian nerve, internal carotid artery, abducens nerve in Dorello's canal, jugular tubercle, and hypoglossal canals. Limitations of the transcranial approaches were the neurovascular structures which lie in the operative corridor and create narrow working spaces. CONCLUSION: The endonasal approaches achieve a direct and wide exposure of the midline cranial base bilaterally. Lateral exposure, beyond the cranial nerves and carotid artery, are challenging. Transcranial approaches are limited by the narrow corridors provided by the cranial nerves, and they do not visualize the contralateral paramedian cranial base very well. Three-dimensional endoscopes augment the spatial orientation and may improve patient safety and the learning curve for endoscopic approaches to the midline cranial base. PMID- 19934972 TI - Semi-jailing technique for coil embolization of complex, wide-necked intracranial aneurysms. AB - OBJECTIVE: Stent-assisted coiling of intracranial aneurysms is performed by placing a microcatheter through a stent's interstices or jailing the microcatheter between the stent and the artery. Both approaches impede manipulation of the microcatheter during coiling. We describe a modified jailing technique that improves catheter maneuverability and report the safety and efficacy of the method for the treatment of complex, wide-necked aneurysms. METHODS: The semi-jailing technique involves the partial deployment of a retrievable stent, bridging part of the aneurysm neck while leaving space to maneuver the microcatheter. Twenty-two complex, wide-necked aneurysms, including 3 ruptured and 5 dissecting, were treated using the semi-jailing technique (15 women; mean age, 55.2 years). RESULTS: The semi-jailing technique was successfully applied in all cases. Immediate posttreatment angiograms showed total occlusion of the aneurysm in 17 cases (77%), neck remnant in 3 cases (14%), and aneurysm dome filling in 2 cases (9%). Follow-up angiography available in 10 patients at an average of 8.5 months showed progressive occlusion in 1 aneurysm and 7 remained occluded. In 2 cases of dissecting aneurysms, retreatment was required. No permanent periprocedural morbidity was encountered. One patient died of complications secondary to intracranial hemorrhage 6 days after treatment. In 2 cases (9%), thromboembolic events after final stent placement were successfully treated with intraarterial thrombolysis. No delayed stent migration was seen. CONCLUSION: Semi-jailing is a safe and effective stent-assisted coiling technique that facilitates treatment of complex, wide-necked aneurysms. PMID- 19934973 TI - Surgical management of congenital median perisellar transsphenoidal encephaloceles with an extracranial approach: a series of 6 cases. AB - OBJECTIVE: Median perisellar congenital transsphenoidal encephalocele (CTE) is a rare entity associated with multiple endocrine, visual, and respiratory deficits. The most likely causative factor for these pathological alterations is distension of neural structures (hypothalamic-pituitary system, optic pathway), resulting in protrusion of the dural sac through a sphenoid bone defect into the pharynx. The continuity with the extracranial space can be associated with an increased risk of tearing of the sac, with consequent cerebrospinal fluid leakage and subsequent increase in the risk of infection. We retrospectively reviewed the surgical treatment of CTE in our hospital using either an extracranial transoral or transnasal approach. METHODS: We retrospectively reviewed our database. Between July 1994 and June 2005, CTE we identified 6 patients. Five of them were treated by a surgical intervention. The first patient was treated via a transcranial approach but had a relapse of the prolapse 11 years later. The relapse was treated with an extracranial transpalatal approach. Four patients were treated with an extracranial surgical approach: an extracranial transoral approach was performed in 2 cases, and an extracranial transnasal approach was used in the other 2 cases. Surgery was not performed in 1 patient because the parents refused to consent to the procedure. RESULTS: Preoperative symptoms remained stable or improved in all of the patients after the surgical procedure and worsened in the patient who did not have a surgical intervention. Two patients experienced a palatal dehiscence. No mortality was recorded in this series of patients. CONCLUSION: The surgical treatment of CTE is indicated to stop the progression or improve symptoms related to this disease entity. If approached correctly, the extracranial approach is a safe procedure with subsequent low morbidity. PMID- 19934974 TI - Quantitative and qualitative analysis of the working area obtained by endoscope and microscope in various approaches to the anterior communicating artery complex using computed tomography-based frameless stereotaxy: a cadaver study. AB - OBJECTIVE: Surgical treatment of aneurysms of the anterior communicating artery complex is challenging, owing to its intricate vascular anatomy. Endoscopy is a recently rediscovered neurosurgical technique that could lend itself well to overcoming some of the vascular visualization challenges associated with this procedure. The purpose of this study was to quantify and compare the working area afforded by the microscope and the endoscope to the anterior communicating artery complex in different surgical approaches and using image guidance. METHODS: We performed a total of 9 dissections, including mini-supraorbital, pterional, and orbitozygomatic approaches bilaterally in 5 whole, fresh cadaver heads. We used computed tomography-based image guidance for intraoperative navigation as well as for quantitative measurements. We estimated the working area of the anterior communicating artery complex region, using both a rigid endoscope (4.0 mm in diameter and 18 cm long with 0- and 30-degree lenses) and an operating microscope. Operability was qualitatively assessed by the senior authors. RESULTS: In microscopic exposure, the orbitozygomatic approach provided the greatest working area (204.5 +/- 33.9 mm2), as compared with the mini supraorbital approach (114.8 +/- 26.9 mm2) and pterional approach (170 +/- 20.4 mm2; P < 0.05). Evaluation of the endoscopic working area showed that the supraorbital approach, using both 0- and 30-degree endoscopes, provided a working area greater than that of a conventional pterional approach (P < 0.05) and comparable to that of an orbitozygomatic approach (P > 0.05). CONCLUSION: In our model, use of the endoscope, in an assistive manner to microscopic surgery, provided a working area advantage without loss of microneurosurgical techniques of dissection or of depth perception in the surgical field. This advantage was most prominent when smaller craniotomies were used. PMID- 19934975 TI - Safe zone for C1 lateral mass screws: anatomic and radiological study. AB - OBJECTIVE: To evaluate the possible complications of overpenetrated C1 lateral mass screws and to identify and define a "safe zone" area anterior to the C1 vertebra. METHODS: The study was performed on 10 cadavers and 50 random patients who had undergone computed tomographic scanning with contrast medium of the neck for other purposes. Atlas lateral mass screw trajectories were plotted, and the safe zone for screw placement anterior to the atlas vertebra was determined for each trajectory. RESULTS: The trajectory of the internal carotid artery was measured from its medial wall. The trajectory of the internal carotid artery according to the ideal entrance point of the screw was 11.55 +/- 4.55 degrees (range, 2-22 degrees) in the cadavers and 9.78 +/- 4.55 degrees (range, -5 to 22 degrees) bilaterally in the patients. At 15 degrees (ideal screw trajectory), the thickness of the rectus capitis anterior muscle and longus capitis muscle was 6.69 +/- 0.83 mm (range, 5.32-7.92 mm) in the cadavers and 7.29 +/- 1.90 mm (range, 0.50-13.63 mm) bilaterally in the patients. The smallest distance from the internal carotid artery to the anterior cortex of the C1 vertebra was calculated as 4.33 +/- 2.03 mm (range, 1.15-8.40 mm) bilaterally in the cadavers and 5.07 +/- 1.72 mm (range, 2.15-8.91 mm) bilaterally in radiological specimens. CONCLUSION: The internal carotid artery trajectory is lateral to the ideal entrance point of C1 lateral mass screws. The medial angulation of a screw placed in the lateral mass of C1 seemed to increase the margin of safety for the internal carotid artery. The rectus capitis anterior and longus capitis muscles may be thought of as a safe zone area for C1 lateral mass screws. At more than 25 degrees of medial angulation, the risk of perforation of the oropharyngeal wall increases. PMID- 19934976 TI - Surgical management of spinal catheter granulomas: operative nuances and review of the surgical literature. AB - OBJECTIVE: Spinal catheter granulomas are a rare and, most likely, underreported complication of intrathecal opioid therapy. Such granulomas can be associated with devastating neurological sequelae if not treated in a timely fashion. Most neurosurgeons, however, are unlikely to have had experience in the surgical management of this condition. CLINICAL PRESENTATION: The authors present 3 surgical cases of patients with spinal catheter granulomas with neurological deficits. One patient's intraoperative video illustrates the challenges of diagnosis, radiological assessment, and surgery for spinal catheter granulomas. INTERVENTION: All 3 patients had implanted opioid pumps for management of chronic spinal pain secondary to fracture, tethered cord, and back pain. Increasing back pain and a progressive myelopathy was observed in all patients. A clear radiological diagnosis was made more difficult because of instrumentation artifact in 1 case and claustrophobia in another. Computed tomographic myelography was necessary in 1 case. The surgical findings were: 1 extradural catheter with granuloma and 2 intradural catheters encased with granuloma and adherent to the cord. The extradural catheter was trimmed of granuloma and replaced intradurally in 1 case. The patients with intradural catheter granulomas required judicious dissection of the granulomas from the dorsum of the cord, duroplasty, and catheter section. Critical intraoperative stages were recorded and are presented in digital movie format. Two patients had neurological improvement after surgery; however, 1 patient remained paraplegic. The 2 patients with catheter section required opioid withdrawal treatment. CONCLUSION: The operative management of spinal intrathecal granulomas associated with opioid infusion pumps can be challenging and depends on a high degree of clinical suspicion, imaging results, and operative findings. PMID- 19934977 TI - Operative management of spinal hemangioblastoma. AB - Hemangioblastomas occur in 2% to 15% of reported series of intramedullary spinal cord tumors. They are benign, highly vascular tumors that can be cured with surgical resection. Complete removal of these tumors with low morbidity is possible with current microneurosurgical techniques and a thorough understanding of the typical relationship of the tumor to adjacent neural structures. We describe our experience with 16 intramedullary and 2 lumbosacral nerve root hemangioblastomas and review the relevant published literature. A detailed discussion of the operative technique is provided along with an operative video. Three illustrative cases are used to demonstrate clinical considerations that can arise with these tumors, including surgery during pregnancy, symptoms related to syrinx or syringomyelia, and postoperative consequences of neurological deficits. PMID- 19934978 TI - Anterolateral approach without fixation for resection of an intradural schwannoma of the cervical spinal canal: technical note. AB - OBJECTIVE: Although an anterolateral approach is an ideal approach to the anterior part of the cervical spinal canal, it is not often used because of various technical difficulties. This article presents the case of a patient with an intradural schwannoma ventrolateral to the spinal cord and describes the technique, anterolateral surgery without fixation, that was used to remove it. CASE PRESENTATION: A 71-year-old man presented with neck pain and easy fatigability of the legs. Magnetic resonance imaging showed an intradural tumor ventrolateral to the spinal cord at the C3 level. The diagnosis was a schwannoma. TECHNIQUE: A right anterolateral approach was selected for the resection. In the dissection between the sternocleidomastoid muscle and the internal jugular vein, the accessory nerve was retracted with the fat tissue. At C3, the prevertebral aponeurosis was laterally retracted to protect the sympathetic chain. The C3 transverse process was rongeured, and the vertebral artery was shifted laterally with the venous plexus. The C2-C3 uncovertebral joint and the right third of the C3 body were removed (partial corpectomy). The tumor was easily found in the dural sac and was totally removed. The surgical wound was closed in a watertight fashion. No fixation was necessary. The symptoms improved after the operation. DISCUSSION: The anterolateral approach is one of the best approaches for resecting ventrally located intradural lesions because it allows minimally invasive surgery. Control and protection of the accessory nerve, sympathetic chain, and vertebral artery are the keys to success. PMID- 19934979 TI - Evaluation of a new bipolar coagulation forceps in a thermal damage assessment. AB - OBJECTIVE: To determine whether a novel bipolar forceps device that uses heat pipe technology to manage tissue temperature would result in less tissue injury compared with a conventional antistick forceps design. METHODS: In ex vivo and in vivo experiments, lesions were compared at generator powers of 35 and 50 Malis units and at 3- and 10-second activation times. For the ex vivo studies, lesions were produced in specimens of fresh calf liver. Tissue temperatures were measured by using thermocouples placed in the tissue and also estimated by obtaining thermal photography. Rats were used for the in vivo studies, in which lesions were produced on the surface of the exposed cerebral hemispheres and assessed by histological examination. The extent of tissue injury was determined for both the ex vivo and in vivo studies. RESULTS: Thermographic and thermometric studies revealed significant tissue temperature reductions at the tips of heat-pipe forceps compared with conventional antistick forceps. In both the ex vivo and in vivo studies, there was less tissue injury produced by the heat-pipe forceps, and this difference was most pronounced with longer activation times. CONCLUSION: Bipolar forceps containing heat pipes more effectively limits excessive thermal spread, thereby potentially reducing the risk of unintended injury to collateral or peripheral tissue. PMID- 19934980 TI - External ventricular drain insertion accuracy: is there a need for change in practice? AB - OBJECTIVE: Free-hand insertion of an external ventricular drain (EVD) is a common emergency neurosurgical procedure, mostly performed for critically ill patients. Although EVD complications have been studied thoroughly, the accuracy of EVD positioning has been audited only occasionally. METHODS: Post-EVD insertion computed tomographic scans performed in our unit over a 2-year period were analyzed for EVD tip location and intracranial catheter length. RESULTS: A total of 183 post-EVD insertion scans were reviewed. Of those, 73 EVD tips (39.9%) were in the ipsilateral frontal horn of the lateral ventricle (the desired target); of those, 18 (25%) required EVD revision/reinsertion. Of the others, 35 (19.1%) were in the third ventricle, 33 (18%) in the body of the lateral ventricle, 19 (10.4%) in the subarachnoid space, 5 (2.7%) in the contralateral frontal horn, and 18 (9.8%) within the brain parenchyma. When the EVD tip was outside the desired target, 44 of the patients (40%) required EVD revision/reinsertion procedure (P = 0.0383). CONCLUSION: Free-hand insertion of an EVD is an inaccurate procedure, and further studies are required to assess the accuracy and feasibility of the routine use of neuronavigation, ultrasonography, or other guidance techniques and the possible implication of the decreasing revision rate, complications, and length of hospital stay. PMID- 19934983 TI - Microsurgical anatomy of the temporal lobe: part 2--sylvian fissure region and its clinical application. AB - OBJECTIVE: We present observations of the anatomy of the sylvian fissure region and their clinical application in neuroimaging, microsurgery for middle cerebral artery aneurysms and insular lesions, frontobasal resections, and epilepsy surgery. METHODS: Sixty adult cadaveric hemispheres and 12 adult cadaveric heads were studied after perfusion of the arteries and veins with colored latex. The anatomic information was applied in more than 200 microsurgeries in and around the sylvian fissure region in the past 15 years. RESULTS: The sylvian fissure extends from the basal to the lateral surface of the brain and presents 2 compartments on each surface, 1 superficial (temporal stem and its ramii) and 1 deep (anterior and lateral operculoinsular compartments). The temporal operculum is in opposition to the frontal and parietal opercula (planum polare versus inferior frontal and precentral gyri, Heschl's versus postcentral gyri, planum temporale versus supramarginal gyrus). The inferior frontal, precentral, and postcentral gyri cover the anterior, middle, and posterior thirds of the lateral surface of the insula, respectively. The pars triangularis covers the apex of the insula, located immediately distal to the genu of the middle cerebral artery. The clinical application of the anatomic information presented in this article is in angiography, middle cerebral artery aneurysm surgery, insular resection, frontobasal resection, and amygdalohippocampectomy, and hemispherotomy. CONCLUSION: The anatomic relationships of the sylvian fissure region can be helpful in preoperative planning and can serve as reliable intraoperative navigation landmarks in microsurgery involving that region. PMID- 19934984 TI - En plaque sphenoid wing meningiomas: recurrence factors and surgical strategy in a series of 71 patients. AB - OBJECTIVE: En plaque sphenoid wing meningiomas are complex tumors involving the sphenoid wing, the orbit, and sometimes the cavernous sinus. Complete removal is difficult, so these tumors have high rates of recurrence and postoperative morbidity. The authors report a series of 71 patients with sphenoid wing meningiomas that were managed surgically. METHODS: The clinical records of 71 consecutive patients undergoing surgery for sphenoid wing meningiomas at Lariboisiere Hospital, Paris, were prospectively collected in a database during a 20-year period and analyzed for presenting symptoms, surgical technique, clinical outcome, and follow-up. RESULTS: Among the 71 patients (mean age, 52. 7 years; range, 12-79 years), 62 were females and 9 were males. The most typical symptoms recorded were proptosis in 61 patients (85.9%), visual impairment in 41 patients (57.7%), and oculomotor paresis in 9 patients (12.7%). Complete removal was achieved in 59 patients (83%). At 6 months of follow-up, magnetic resonance imaging scans revealed residual tumor in 12 patients (9 in the cavernous sinus and 3 around the superior orbital fissure). Mean follow-up was 76.8 months (range, 12-168 months). Tumor recurrence was recorded in 3 of 59 patients (5%) with total macroscopic removal. Among the patients with subtotal resection, tumor progression was observed in 3 of 12 patients (25%; 2 patients with grade III and 1 patient with grade IV resection). Mean time to recurrence was 43.3 months (range, 32-53 months). CONCLUSION: Surgical management of patients with sphenoid wing meningiomas cannot be uniform; it must be tailored on a case-by-case basis. Successful resection requires extensive intra- and extradural surgery. We recommend optic canal decompression in all patients to ameliorate and/or preserve visual function. PMID- 19934985 TI - The ascending pharyngeal artery and its relevance for neurosurgical and endovascular procedures. AB - OBJECTIVE: The ascending pharyngeal artery (APA), a branch of the external carotid artery (ECA), supplies the lower cranial nerves, superior cervical ganglion, and nasopharyngeal structures. The APA can also supply blood to various intracranial lesions. We studied the anatomy of the APA in the context of its neurosurgical and endovascular relevance. METHODS: The cervical origin, branching pattern, and course of the APA were studied in 20 human cadaveric craniocervical sides. The diameter of the APA, the extension of its main trunk, and the distance of its origin from the common carotid artery bifurcation were measured. The relationships between the APA and surrounding structures were also observed. RESULTS: In 80% of the specimens, the APA originated from the ECA. It originated from its medial wall in 56% and from the posterior wall in 44%. The APA originated from the internal carotid artery, common carotid artery bifurcation, occipital artery, and a trunk common to the lingual and facial arteries in 5% each. The APA was usually the third branch of the ECA (40%). The mean distance from the origin of the APA to the common carotid artery bifurcation was 15.3 mm (range, 0-32; standard deviation, +/- 8.3 mm). The APA was frequently the second smallest branch of the ECA (caliber, 1.54 mm; range, 1.1-2.1; standard deviation, +/- 0.25 mm). CONCLUSION: The APA is an important channel for supplying neural structures of the posterior fossa. Knowledge of its anatomy, variants, and anastomotic channels is essential in the treatment of lesions supplied by its branches and to avoid complications related to its inadvertent injury. PMID- 19934986 TI - Management of giant middle cerebral artery aneurysms with incorporated branches: partial endovascular coiling or combined extracranial-intracranial bypass--a team approach. AB - OBJECTIVE: Our goal was to assess the long-term anatomic and clinical outcomes in patients with giant middle cerebral artery (MCA) aneurysms treated by endovascular coil embolization alone or in combination with cerebral revascularization. METHODS: One hundred twenty-six patients with giant intracranial aneurysms were endovascularly treated at the University of California, Los Angeles, between 1990 and 2007. Of these, 9 patients had partially thrombosed MCA aneurysms with incorporated branches. Five patients presented with symptoms of mass effect, 3 had seizures, 2 had episodes of brain ischemia, and 1 presented with acute subarachnoid hemorrhage. RESULTS: Three wide neck saccular aneurysms were almost completely coil occluded, leaving only small neck remnants that were intended to preserve the patency of incorporated MCA branches. The other 6 fusiform aneurysms were effectively treated by superficial temporal artery-MCA or occipital artery-MCA bypass, followed by complete coil occlusion of these aneurysms. Immediate angiograms and mid- or long-term neuroradiological imaging follow-up examinations revealed complete obliteration or near-complete occlusion (90%-99%) of the aneurysms in all 9 patients. Seven patients had a favorable long-term clinical outcome, and 1 patient died as a result of unrelated congestive heart failure. One patient required emergent surgical aneurysm thrombectomy because of inadvertent coil occlusion of the frontal opercular artery, which was not protected by the bypass, and the patient subsequently sustained a moderate neurological disability. CONCLUSION: Giant MCA aneurysms with branch incorporations and other unfavorable features such as intraluminal thrombus, mural calcification, and fusiform configuration can be effectively treated with a team approach, using coil embolization after protective surgical bypass. When aneurysms with MCA branches incorporated into the neck rather than the dome are treated by endovascular techniques alone, long term angiographic follow-up is necessary to assess and further treat any significant remnant. PMID- 19934987 TI - Endovascular treatment of intracranial dural arteriovenous fistulae using Onyx: a case series. AB - OBJECTIVE: An endovascular approach is often the first-line treatment of dural arteriovenous fistulae (DAVFs). Information on the use of Onyx (ev3 Neurovascular, Irvine, CA) for treating DAVFs, however, is limited. Therefore, we present our early experience, technical considerations, and complications associated with the use of Onyx for DAVF embolization. METHODS: Twenty-eight patients with 29 DAVFs treated with Onyx embolization were included in this analysis. Hospital records, operative reports, and angiograms were reviewed and analyzed. RESULTS: Forty Onyx procedures, including 39 transarterial and 1 transvenous approaches, were performed. Fifty-one external carotid artery branches, 8 posterior meningeal artery branches, and 3 internal carotid artery branches were used for Onyx embolization. Branches of the middle meningeal artery were embolized 32 times, and the occipital artery was embolized 15 times. Twenty one fistulae (72%) were cured angiographically with endovascular therapy. Transarterial embolization via the middle meningeal artery cured 12 DAVFs (41%). Four complications (9.7%) were recorded, including 3 transient (7.3%) and 1 permanent neurological deficits (2.4%). Follow-up imaging, which was available for 8 fistulae with angiographic cures, showed no evidence of recurrence. CONCLUSION: Transarterial Onyx embolization of external carotid artery branches, particularly the middle meningeal artery, offers a high likelihood of cure. This technique provides a safe and effective method of embolization with few side effects and complications. However, long-term follow-up is needed to establish its efficacy. PMID- 19934988 TI - Usefulness of an ultrasonic scalpel to harvest and skeletonize the superficial temporal artery for extracranial-intracranial bypass surgery. AB - OBJECTIVE: A new method to harvest and skeletonize the superficial temporal artery (STA) using an ultrasonic scalpel is presented. The technique is simple and safe, and reduces bleeding. We also investigated histopathological changes in donor vessels and whether it is possible to shorten the time needed for STA harvesting using the ultrasonic scalpel. METHODS: Between January 1, 2005, and December 31, 2007, 31 consecutive patients underwent STA and middle cerebral artery anastomosis surgery in our hospital. All patients underwent harvesting of both the frontal and parietal branches of the STA. STA harvesting using an ultrasonic scalpel was performed in 18 of the 31 patients. We compared the time needed for STA harvesting by dividing patients into 2 groups: a non-ultrasonic scalpel group and an ultrasonic scalpel group. We also examined the histopathological changes by application of ultrasonic waves on the STA in the 6 most recent patients. RESULTS: The mean time needed for STA harvesting was 84.2 +/- 14.1 minutes for the non-ultrasonic scalpel group and 55.1 +/- 15.2 minutes for the ultrasonic scalpel group. The ultrasonic scalpel group showed a significantly shorter harvesting time than the non-ultrasonic scalpel group (P < 0.01). No histopathological change was observed in any layers of the STA. CONCLUSION: Our data suggest that STA harvesting with the ultrasonic scalpel may be useful for STA-middle cerebral artery anastomosis surgery. PMID- 19934989 TI - Blood flow imaging: an angle-independent ultrasound modality for intraoperative assessment of flow dynamics in neurovascular surgery. AB - OBJECTIVE: The objective of this study was to investigate the clinical applicability of navigated blood flow imaging (BFI) in neurovascular applications. BFI is a new 2-dimensional ultrasound modality that offers angle independent visualization of flow. When integrated with 3-dimensional (3D) navigation technology, BFI can be considered as a first step toward the ideal tool for surgical needs: a real-time, high-resolution, 3D visualization that properly portrays both vessel geometry and flow direction. METHODS: A 3D model of the vascular tree was extracted from preoperative magnetic resonance angiographic data and used as a reference for intraoperative any-plane guided ultrasound acquisitions. A high-end ultrasound scanner was interconnected, and synchronized recordings of BFI and 3D navigation scenes were acquired. The potential of BFI as an intraoperative tool for flow visualization was evaluated in 3 cerebral aneurysms and 3 arteriovenous malformations. RESULTS: The neurovascular flow direction was properly visualized in all cases using BFI. Navigation technology allowed for identification of the vessels of interest, despite the presence of brain shift. The surgeon found BFI to be very intuitive compared with conventional color Doppler methods. BFI allowed for quality control of sufficient flow in all distal arteries during aneurysm surgery and made it easier to discern between feeding arteries and draining veins during surgery for arteriovenous malformations. CONCLUSION: BFI seems to be a promising modality for neurovascular flow visualization that may provide the neurosurgeon with a valuable tool for safer surgical interventions. However, further work is needed to establish the clinical usefulness of the proposed imaging setup. PMID- 19934990 TI - Radiographic and anatomic basis of endoscopic anterior craniocervical decompression: a comparison of endonasal, transoral, and transcervical approaches. AB - OBJECTIVE: To evaluate surgical access to the craniocervical junction using 3 endoscopic approaches: endonasal, transoral, and transcervical. METHODS: Nine cadaveric specimens were used. Image guidance was used in 1 specimen for each approach; fluoroscopy was used in every case. The Vitrea imaging station (Vital Images Inc., Minnetonka, MN) was used to evaluate the angles and distances to the target of the approach, centered on the tip of the odontoid. The entry site was defined as: 1) the endonasal approach (inferior midline of the nasal bone), 2) the transoral approach (the tip of the upper incisor), and 3) the transcervical approach (the skin at the C4-C5 level). RESULTS: Adequate lower clivus and craniocervical decompression was achieved using the endonasal and transoral approaches. Lower clivus decompression was not achieved with the transcervical approach. The average distance to the surgical target was as follows: endonasal (94 mm), transoral (102 mm), and transcervical (100 mm). The angle of attack was as follows: endonasal (28 degrees), transoral (30 degrees), and transcervical (15 degrees). The working area at the base of the field was as follows: endonasal (1305 mm2), transoral (1406 mm2), and transcervical (743 mm2). CONCLUSION: The endonasal and transoral approaches allow wide exposure with large working angles to the craniocervical junction. The transcervical approach accesses the odontoid for resection from the body of C2 to the lip of the basion. The angles of attack in the transcervical approach when centered on the surgical target are limited, but this approach offers a clean, sterile operative field. Clinical investigation will be required to determine the optimal indications for each approach. PMID- 19934991 TI - Biomechanical comparison of translaminar versus pedicle screws at T1 and T2 in long subaxial cervical constructs. AB - OBJECTIVE: The first in vitro biomechanical investigation comparing the immediate and postcyclical rigidities of thoracic translaminar versus pedicle screws in posterior constructs crossing the cervicothoracic junction (CTJ). METHODS: Ten human cadaveric spines underwent C4-C6 lateral mass screw and T1-T2 translaminar (n = 5) versus pedicle (n = 5) screw fixation. Spines were then potted in polymethylmethacrylate bone cement and placed on a materials testing machine. Rotation about the axis of bending was measured using passive retroreflective markers and infrared motion capture cameras. The motion of C6 relative to T2 in flexion-extension and lateral bending was assessed uninstrumented, immediately after instrumentation, and after 40,000 cycles of 4 N.m flexion-extension and lateral bending moments at 1 Hz. The effect of instrumentation and cyclical loading on rotational motion across the CTJ was analyzed for significance. RESULTS: Compared with preinstrumented spines, pedicle and translaminar screw constructs significantly (P < 0.001) decreased motion during flexion-extension and lateral bending. After cyclical loading, rotational motion at the CTJ was significantly increased (P < 0.05) during flexion-extension and lateral bending in both groups. With flexion-extension, the mean rotational motion across the CTJ was similar in the translaminar and pedicle constructs immediately after fixation, but slightly greater (P = 0.03) after cyclical loading in the translaminar versus the pedicle screw constructs (0.39 degrees versus 0.26 degrees). Nevertheless, after cyclical loading, the mean angular motion across the CTJ remained less than one half of a degree in both groups. With lateral bending, the mean rotational motion was similar in both translaminar and pedicle screw constructs. CONCLUSION: Both upper thoracic translaminar and pedicle screws allow for rigid fixation at the CTJ. Although translaminar screw constructs demonstrated one eighth of a degree more motion at the CTJ after cycling, this minimal difference is likely less than would influence the biological fusion process. Upper thoracic translaminar screws are a biomechanically effective option to rigidly stabilize the CTJ. PMID- 19934992 TI - Posterior-only approach for total en bloc spondylectomy for malignant primary spinal neoplasms: anatomic considerations and operative nuances. AB - MALIGNANT PRIMARY SPINAL tumors are rare tumors that are locally invasive and can metastasize. The majority of these tumors have a poor response rate to chemotherapy and conventional radiotherapy. Studies have shown that long-term survival and the potential for cure is best achieved with en bloc surgical excision of these tumors with negative surgical margins. Total en bloc spondylectomy involves removal of vertebral segment(s) in whole to achieve wide tumor excision. Total en bloc spondylectomy can be performed through staged or combined anterior and posterior approaches, or from a posterior-only approach. The posterior-only approach offers the advantage of achieving complete tumor excision and circumferential spinal reconstruction in a single setting. In this report, we discuss the operative management of malignant primary vertebral tumors using the posterior-only approach for total en bloc spondylectomy. The oncological considerations and surgical nuances that allow for safe but aggressive surgical excision of primary spinal tumors to achieve favorable oncological and neurological outcomes are highlighted. PMID- 19934993 TI - Lumbar spinal stenosis: prognostic factors for bilateral microsurgical decompression using a unilateral approach. AB - OBJECTIVE: We describe a prospective cohort study that investigated the effectiveness of microsurgical bilateral decompression using unilateral laminotomy for lumbar spinal stenosis and assessed the factors influencing the outcome. METHODS: A total of 165 consecutive patients underwent decompression for lumbar spinal stenosis. They were divided into 3 age groups: A (<65 years), B (65 75 years), and C (>75 years). Further classification was performed according to body mass index (BMI): BMI 1 (<26), BMI 2 (26-30), and BMI 3 (>30), anesthesiological risk factors (American Society of Anesthesiologists), and the number of levels decompressed. The outcome was monitored by an independent observer at 1 week, 3 months, and 1 year after surgery. The following parameters were evaluated: pain (visual analog scale and analgesic consumption), functional improvement (Neurogenic Claudication Outcome Score), and walking performance, defined as walking distance x speed (treadmill). RESULTS: One week after surgery, pain decreased in 85.9% of patients, and a comparison of the pre- and postoperative use of analgesics showed that 38% of nonopioid use and 74% of opioid use were discontinued, whereas nonsteroidal anti-inflammatory drug consumption increased 13%. One year after surgery, pain remained decreased in 83.9% of patients, Neurogenic Claudication Outcome Score increased in 90.3% of patients, and walking performance improved in 92.2% of patients. BMI greater than 30 was the only negative prognostic factor for pain reduction (P = 0.012) and Neurogenic Claudication Outcome Score improvement (P = 0.019). Surprisingly, patients who underwent multilevel decompression benefitted more from surgery than those who underwent single-level decompression. CONCLUSION: Microsurgical bilateral decompression using unilateral laminotomy is an effective surgical option for lumbar spinal stenosis, even in high-risk patients with multilevel stenosis. PMID- 19934994 TI - A novel simulation model for minimally invasive spine surgery. AB - OBJECTIVE: Minimally invasive spine surgery (MISS) is among the fastest growing technologies in general neurosurgical practice. In addition, great demand exists to teach these skills to neurosurgery residents. With newly enforced work hour restrictions, opportunities to acquire these skills are limited, necessitating development of alternative strategies of education. We describe a novel simulation model for MISS supplemented by resident self-assessment analysis and evaluation. METHODS: The simulator was constructed using a nontransparent Plexiglas frame supplemented with a modified halo frame on which to affix spine specimens. Interchangeable copper tubing was affixed to a 360-degree pivot system to replicate a working portal. Deer skulls and spines were then collected and prepared accordingly. Laboratory exercises were based on the resident's level of training with emphasis on proper drilling techniques. Eight neurosurgery residents were asked to complete the exercises and complete a self-assessment survey regarding their competence level on a scale of 0 to 5, both before and after completing the skill sets. Additionally, they were asked to complete an exit survey that was used to assess the simulation exercises. RESULTS: All exercises were completed successfully with the exception of placing 2 separate pedicle screws through the same portal, which posed difficulty on some specimens because of the of lack of lordosis of the specimens, leading to unfavorable trajectories using a free-hand technique. With regard to the resident self assessment analysis, the mean confidence rating for performing an MISS laminectomy improved by a difference of 1.25 points (n = 8; 95% confidence interval, 0.66-1.84; P = 0.0015), from 2.50 to 3.75 before and after simulation exercises, respectively, and reached statistical significance. For the senior level residents, the mean confidence rating for performing MISS placement of pedicle screws using a free-hand technique improved by a difference of 1.00 (n = 3; 95% confidence interval, -1.48-3.48; P = 0.225), from 3.33 to 4.33 before and after simulation exercises, respectively. Results of the exit survey were encouraging. CONCLUSION: The MISS simulator is a feasible, inexpensive, and reproducible adjunct to neurosurgery resident training and provides a new teaching method for spine surgery. Further investigation of this technology is warranted, although multicenter, randomized, controlled trials assessing its validity may not be practical because of ethical constraints with regard to patient safety. PMID- 19934995 TI - Magnetic resonance-based deep brain stimulation technique: a series of 478 consecutive implanted electrodes with no perioperative intracerebral hemorrhage. AB - OBJECTIVE: The aim of this study was to determine the safety of a deep brain stimulation technique consisting of a combination of routine general anesthesia, magnetic resonance imaging direct targeting, and a single penetration technique in a large population of patients undergoing operation for movement disorders. METHODS: One hundred ninety-four patients treated with deep brain stimulation between 1996 and 2007 were assessed via a computerized database for intra- and perioperative events. Most patients were young; only 62 of them were older than 40 years (mean age, 31.1 years). General anesthesia was induced in all cases before placement of a magnetic resonance imaging-compatible stereotactic frame. Electrode implantation was done under radioscopic control via a rigid immobile cannula using a single cerebral perforation. No perioperative microelectrode recording or neurostimulation testing was used. Systematic postoperative magnetic resonance imaging was performed before frame removal. RESULTS: A total of 478 electrodes were implanted in 220 procedures: 426 for dystonic-dyskinetic syndromes and 52 for Parkinson disease. The mean number of parenchymal penetrations per patient was 2.5 for the dystonic-dyskinetic syndrome group and 2.08 for the Parkinson disease group. Postimplantation magnetic resonance imaging detected no perioperative intraparenchymal hemorrhages. CONCLUSION: We consider that the risk of hemorrhagic complication is multifactorial but closely related to the chosen technique. PMID- 19934996 TI - Preliminary study in patients with obsessive-compulsive disorder treated with electrical stimulation in the inferior thalamic peduncle. AB - OBJECTIVE: Deep brain stimulation has been used in the treatment of refractory obsessive-compulsive disorder (OCD). Our principal objective was to determine the safety and effectiveness of deep brain stimulation of the inferior thalamic peduncle in the treatment of refractory OCD. METHODS: An open protocol was performed from March 2003 to April 2007 in 5 patients with OCD refractory to conventional treatments. Bilateral stereotactic implantation of tetrapolar electrodes was aimed at the inferior thalamic peduncle and corroborated by electrophysiological responses and magnetic resonance imaging. All patients were off stimulation for 1 month after implantation. In the on-stimulation period, parameters were set at 5 V, 450 microseconds, 130 Hz in bipolar and continuous mode. Clinical changes were evaluated every 3 months for 12 months by means of the Yale-Brown Obsessive Compulsive Scale and the Global Assessment of Functioning scale. Statistical significance was assessed by the Friedman and Wilcoxon tests. RESULTS: The mean Yale-Brown Obsessive Compulsive Scale score decreased from 35 to 17.8 (P < 0.001), and the mean Global Assessment of Functioning scale score improved from 20% to 70% (P < 0.0001). The neuropsychological battery did not show significant changes, and there were no side effects related to electrical stimulation in the chronic period. CONCLUSION: We conclude that inferior thalamic peduncle stimulation is a safe procedure and may be an effective alternative in the treatment of those OCD cases refractory to conventional treatments. PMID- 19934997 TI - Electrode contact configuration and energy consumption in spinal cord stimulation. AB - OBJECTIVE: To test the hypothesis that in spinal cord stimulation, an increase in the number of cathodes increases the energy per pulse, contrary to an increase in the number of anodes, which decreases energy consumption per pulse. METHODS: Patients with an Itrel III (7425; Medtronic, Inc., Minneapolis, MN) implantable pulse generator and a Pisces-Quad (3487A; Medtronic, Inc.) implantable quadripolar lead were selected for this study. A set of 7 standard contact configurations was used for each patient. Resistor network models mimicking these configurations were constructed. The University of Twente's Spinal Cord Stimulation software was used to simulate the effect of these contact configurations on large spinal nerve fibers. To allow a comparison of the measured and modeled energy per pulse, all values were normalized. RESULTS: Both the empirical and the modeling results showed an increase in energy consumption with an increasing number of cathodes. Although the patient data with 1 and 2 cathodes did not differ significantly, energy consumption was significantly higher when 3 cathodes were used instead of 1 or 2 cathodes. The average energy consumption was significantly higher when bipolar stimulation was used instead of monopolar cathodal stimulation. An increasing number of anodes caused a decrease in energy consumption. CONCLUSION: When the paresthesia area can be covered with several configurations, it will be beneficial for the patient to program a configuration with 1 cathode and either no or multiple anodes. PMID- 19934998 TI - Proximal motor branches from the tibial nerve as direct donors to restore function of the deep fibular nerve for treatment of high sciatic nerve injuries: a cadaveric feasibility study. AB - OBJECTIVE: The results of surgical repair of the fibular division of the sciatic nerve have been considered unsatisfactory, especially if grafts are necessary to reconstruct the nerve. To consider the clinical application of the concept of distal nerve transfer for the treatment of high sciatic nerve injuries, this study aimed to determine detailed anatomic data about the possible donor branches from the tibial nerve that are available for reinnervation of the deep fibular nerve at the level of the popliteal fossa. METHODS: An anatomic study was performed that included the dissection of the popliteal fossa in 12 lower limbs of 6 formalin-fixed adult cadavers. It focused on the detailed anatomy of the tibial nerve and its branches at the level of the proximal leg as well as the anatomy of the common fibular nerve and its largest divisions at the level of the neck of the fibula, i.e., the deep and superficial fibular nerves. RESULTS: The branches of the tibial nerve destined to the lateral and medial head of the gastrocnemius had a mean length of 43 mm and 35 mm, respectively. The branch to the posterior soleus muscle had a mean length of 65 mm. Intraneural dissection of the common fibular nerve, isolating its deep and superficial fibular divisions, was possible to a proximal mean distance of 71 mm. A tensionless direct suture to the deep fibular nerve was made possible by using the nerve to the lateral head of the gastrocnemius and the nerve to the posterior soleus muscle in all specimens. Direct suture of the nerve to the medial head of the gastrocnemius was possible in all cases except 1. CONCLUSION: The nerve to the lateral and medial heads of the gastrocnemius and the nerve to the posterior soleus muscle can be used as donors to restore function of the deep fibular nerve in cases of high sciatic nerve injury. However, proximal intraneural dissection of the deep fibular division of the common fibular nerve must also be performed. We recommend that the nerve to the posterior soleus muscle should be the first choice for a donor in the proposed transfer. PMID- 19935000 TI - Surface landmarks for the junction between the transverse and sigmoid sinuses: application of the "strategic" burr hole for suboccipital craniotomy. AB - OBJECTIVE: Localization of internal cranial anatomy based on superficial landmarks is paramount in identifying and avoiding various important structures and, thus, decreasing surgical morbidity. We have studied external skull bony landmarks to facilitate the placement of the initial "strategic" burr hole just inferior and medial to the junction of transverse-sigmoid venous sinuses during standard retrosigmoid craniotomy. METHODS: One hundred adult skulls (200 sides) underwent intracranial drilling of a small hole from the inside surface of the cranium, 5 mm inferior and medial to the border of the transverse sigmoid sinus junction (defined as the ideal location for the center of the strategic burr hole). Localization of this hole from the external surface of the skull was made based on easily identifiable superficial landmarks, including the mastoid process and zygomatic arch. A horizontal line was established parallel to the superior border of the zygomatic arch ("zygomatic line"), and a vertical line was fashioned by connecting the mastoid notch superiorly to the squamosal suture ("mastoid line"). RESULTS: For left sides, 81% of the strategic burr holes were inferior to the zygomatic line and 86% were medial to the mastoid line. For right sides, 91% of the strategic burr holes were inferior to the zygomatic line and 97% were medial to the mastoid line. For left and right sides, the mean distance for the center of the burr holes from the zygomatic line was 4.5 and 7.7 mm, respectively. For left and right sides, the mean distance from the mastoid line was 9.1 and 9.8 mm, respectively. CONCLUSION: Because landmark data in the literature for externally identifying the transverse sigmoid sinus junction is variable, we have attempted to refine this location with the largest sample size to date. These data can assist surgeons to localize the external cranial projection of the area just inferior and medial to the junction between the transverse and sigmoid sinuses when image guidance devices are not available. This localization is important in creation of appropriate size for craniotomy/craniectomy during the posterolateral approaches to the cranial base. PMID- 19934999 TI - Preoperative sensorimotor mapping in brain tumor patients using spontaneous fluctuations in neuronal activity imaged with functional magnetic resonance imaging: initial experience. AB - OBJECTIVE: To describe initial experience with resting-state correlation mapping as a potential aid for presurgical planning of brain tumor resection. METHODS: Resting-state blood oxygenation-dependent functional magnetic resonance imaging (fMRI) scans were acquired in 17 healthy young adults and 4 patients with brain tumors invading sensorimotor cortex. Conventional fMRI motor mapping (finger tapping protocol) was also performed in the patients. Intraoperatively, motor hand area was mapped using cortical stimulation. RESULTS: Robust and consistent delineation of sensorimotor cortex was obtained using the resting-state blood oxygenation-dependent data. Resting-state functional mapping localized sensorimotor areas consistent with cortical stimulation mapping and in all patients performed as well as or better than task-based fMRI. CONCLUSION: Resting state correlation mapping is a promising tool for reliable functional localization of eloquent cortex. This method compares well with "gold standard" cortical stimulation mapping and offers several advantages compared with conventional motor mapping fMRI. PMID- 19935001 TI - Endoscopic endonasal transclival approach and retrosigmoid approach to the clival and petroclival regions. AB - OBJECTIVE: The removal of clival lesions, mainly those located intradurally and with a limited lateral extension, may be challenging because of the lack of a surgical corridor that would allow exposure of the entire lesion surface. In this anatomic study, we explored the clival/petroclival area and the cerebellopontine angle via both the endonasal and retrosigmoid endoscopic routes, aiming to describe the respective degree of exposure and visual limitations. METHODS: Twelve fresh cadaver heads were positioned to simulate a semisitting position, thus enabling the use of both endonasal and retrosigmoid routes, which were explored using a 4-mm rigid endoscope as the sole visualizing tool. RESULTS: The comparison of the 2 endoscopic surgical views (endonasal and retrosigmoid) allowed us to define 3 subregions over the clival area (cranial, middle, and caudal levels) when explored via the endonasal route. The definition of these subregions was based on the identification of some anatomic landmarks (the internal carotid artery from the lacerum to the intradural segment, the abducens nerve, and the hypoglossal canal) that limit the bone opening via the endonasal route and the natural well-established corridors via the retrosigmoid route. CONCLUSION: Different endoscopic surgical corridors can be delineated with the endonasal transclival and retrosigmoid approaches to the clival/petroclival area. Some relevant neurovascular structures may limit the extension of the approach and the view via both routes. The combination of the 2 approaches may improve the visualization in this challenging area. PMID- 19935002 TI - Image-guided, endoscopic-assisted drilling and exposure of the whole length of the internal auditory canal and its fundus with preservation of the integrity of the labyrinth using a retrosigmoid approach: a laboratory investigation. AB - OBJECTIVE: Hearing loss after removal of vestibular schwannomas with preservation of the cochlear nerve can result from labyrinthine injury of the posterior semicircular canal and/or common crus during drilling of the posterior wall of the internal auditory meatus. Indeed, there are no anatomic landmarks that intraoperatively identify the position of the posterior semicircular canal or of the common crus. We investigated the usefulness of image guidance and endoscopy for exposure of the internal auditory canal (IAC) and its fundus without labyrinthine injury during a retrosigmoid approach. METHODS: A retrosigmoid approach to the IAC was performed on 10 whole fresh cadaveric heads after acquiring high-resolution computed tomographic scans (120 kV; slice thickness, 1 mm; field of vision, 40 cm; matrix, 512 x 512) with permanent bone-implanted reference markers. Drilling of the posterior wall of the IAC was executed with image guidance. Its most lateral area was visualized using endoscopy. RESULTS: Target registration error for the procedure was 0.28 to 0.82 mm (mean, 0.46 mm; standard deviation, 0.16 mm). The measured length of the IAC along its posterior wall was 9.7 +/- 1.6 mm. The angle of drilling (angle between the direction of drill and the posterior petrous surface) was 43.3 +/- 6.0 degrees, and the length of the posterior wall of the IAC drilled without violating the integrity of the labyrinth was 7.2 +/- 0.9 mm. The surgical maneuvers in the remaining part of the IAC, including the fundus, were performed using an angled endoscope. CONCLUSION: Frameless navigation using high-resolution computed tomographic scans and bone implanted reference markers can provide a "roadmap" to maximize safe surgical exposure of the IAC without violating the labyrinth and leaving a small segment of the lateral IAC unexposed. Further exposure and surgical manipulation of this segment, including the fundus without additional cerebellar retraction and labyrinthine injury, can be achieved using an endoscope. Use of image guidance and an endoscope can help in exposing the entire posterior aspect of the IAC including its fundus without violating the labyrinth through a retrosigmoid approach. This technique could improve hearing preservation in vestibular schwannoma surgery. PMID- 19935003 TI - Ossification of ligaments near the foramen ovale: an anatomic study with potential clinical significance regarding transcutaneous approaches to the skull base. AB - OBJECTIVE: There is paucity of information regarding the specific anatomy and clinical significance of ossified ligaments near the foramen ovale (e.g., pterygospinous and pterygoalar ligaments). The present study was undertaken to define this anatomy in more detail and to review the literature regarding these anatomic variations. METHODS: One hundred fifty-four adult human dry skulls were analyzed for the presence of ossified ligaments of pterygospinous (ligament of Civinini) and pterygoalar (ligament of Hyrtl). Measurements were made of these bony structures and observations made of their relationships to the inferior aspect of the foramen ovale and neighboring structures. RESULTS: Two ossifications each (2.6%) of the ligaments of Civinini and Hyrtl were found. One of each of these (1.3%) was completely ossified, thereby resulting in 2 complete foramina (i.e., 1 foramen of Civinini and 1 foramen of Hyrtl). A significant correlation was found between the left and right sides, with either complete or incomplete ossification of these ligaments being found on left sides (75%) (incomplete Civinini on right side and all others on left side). The complete foramen of Civinini was found to have an area of 16.7 mm, and the complete foramen of Hyrtl was found to have an area of 9.42 mm. CONCLUSION: Such anomalous bony obstructions could interfere with transcutaneous needle placement into the foramen ovale or distort anatomic relationships during approaches to the cranial base. PMID- 19935004 TI - A new technique for dural suturing with fascia graft for cerebrospinal fluid leakage in transsphenoidal surgery. AB - OBJECTIVE: One of the most common postoperative complications of surgery using a transsphenoidal approach is cerebrospinal fluid (CSF) leakage, which typically results from inadequate repair of a CSF fistula created at the time of the initial operation. Most techniques use autologous tissue grafts of fat, muscle, or fascia lata, with or without the use of postoperative lumbar CSF drainage; however, patients demonstrate a relatively high incidence of CSF rhinorrhea, especially after extended procedures. We have developed a new technique of dural suturing with fascia graft using special suture-tying microinstruments. METHODS: Twenty-one consecutive patients with suprasellar tumors underwent dural suturing with fascia graft via new suture-tying microinstruments between January 2004 and December 2007. The 21 patients were retrospectively divided into 2 groups according to the transsphenoidal technique used. Group 1 consisted of 16 patients whose large dural defects were closed with a fascia graft suture for CSF leakage during or after an extended transsphenoidal approach. Group 2 consisted of 5 patients whose dural defects were closed with a fascia graft suture for postoperative CSF rhinorrhea after a conventional transsphenoidal approach. RESULTS: None of the 21 patients developed any clinical symptoms of CSF leakage. There were no complications or infections. For 8 patients in group 1 and the 5 patients in Group 2, no postoperative lumbar drainage was performed after dural suturing with fascia graft, and none of the 13 patients developed postoperative CSF rhinorrhea. CONCLUSION: Our dural suturing technique with fascia graft may be more reliable than the conventional packing technique in achieving watertight dural closure and for the prevention of postoperative CSF rhinorrhea. Watertight dural suturing with fascia graft and the leaking point suture could allow surgeons to avoid unnecessary postoperative lumbar drainage. PMID- 19935005 TI - Large-scale bicortical skull bone regeneration using ex vivo replication defective adenoviral-mediated bone morphogenetic protein-2 gene-transferred bone marrow stromal cells and composite biomaterials. AB - OBJECTIVE: Bone marrow stromal cells (BMSCs) have great potential in bone repair. We developed an animal model to test the hypothesis that ex vivo gene transfer of human bone morphogenetic protein (BMP)-2 to BMSCs via a replication-defective (E1A-deleted) adenovirus vector (AdV) with appropriate biopolymers would enhance autologous bone formation during repair of a large-scale skull defect. METHODS: Eighteen miniature swine were treated with AdV BMP-2-transduced BMSCs in biopolymer (group 1), BMSCs in biopolymer (group 2), or biopolymer alone (group 3). After 6 months, the swine were killed, and the skull repair was examined by gross pictures, histology, 3-dimensional computed tomography, and biomechanical study. RESULTS: Group 1 showed complete solid bone formation after 6 months, and hematoxylin and eosin staining demonstrated the presence of mature, woven, well mineralized bone. Computed tomography showed wholesome repair of the skull defect. Statistical analysis demonstrated a significant difference in bone thickness between groups 1 and 2. Biomechanical testing showed a statistically significant difference in the stiffness of new bone formed in group 1 compared with group 2. CONCLUSION: The Ad5 E1A-deleted AdV may be the optimal starting vector in ex vivo gene therapy for benign skeletal diseases. Additionally, the use of the gelatin/tricalcium phosphate ceramic/glutaraldehyde biopolymer with AdV BMP-2 gene transfer strongly enhances the bony healing of critical-size bicortical craniofacial defects. This method can be used by modifying the delivery of constructs to malunion treatment, in regional osteoporosis therapy, and spinal fusion. PMID- 19935006 TI - The evolution of intramedullary spinal cord tumor surgery. AB - OBJECTIVE: Resections of intramedullary spinal cord tumors were attempted as early as 1890. More than a century after these primitive efforts, profound advancements in imaging, instrumentation, and operative techniques have greatly improved the modern surgeon's ability to treat such lesions successfully, often with curative results. METHODS: We review the history of intramedullary spinal cord tumor surgery, as well as the evolution and advancement of technologies and surgical techniques that have defined the procedure over the past 100 years. RESULTS: Surgery to remove intramedullary spinal cord tumors has evolved to include sophisticated imaging equipment to pinpoint tumor location, laser scalpel systems to provide precise incisions with minimal damage to surrounding tissue, and physiological monitoring to detect and prevent intraoperative motor deficits. CONCLUSION: Modern surgical devices and techniques have developed dramatically with the availability of new technologies. As a result, continual advancements have been achieved in intramedullary spinal cord tumor surgery, thus increasing the safety and effectiveness of tumor resection, and progressively improving the overall outcomes in patients undergoing such procedures. PMID- 19935007 TI - Navigated transcranial magnetic stimulation for preoperative functional diagnostics in brain tumor surgery. AB - OBJECTIVE: Transcranial magnetic stimulation (TMS) is a noninvasive method for analyzing cortical function. To utilize TMS for presurgical functional diagnostics, the magnetic impulse must be precisely targeted by stereotactically positioning the coil. The aim of this study was to evaluate the usefulness of TMS for operation planning when combined with a sensor-based electromagnetic navigation system (nTMS). METHODS: Preoperative functional mapping with nTMS was performed in 10 patients with rolandic tumors. Intraoperative mapping was performed with the "gold standard" of direct cortical stimulation. Stimulation was performed in the same predefined 5-mm raster for both modalities, and the results were compared. RESULTS: In regard to the 5-mm mapping raster, the centers of gravity of nTMS and direct cortical stimulation were located at the same spot in 4 cases and at neighboring spots in the remaining 6 cases. The mean distance between the tumor and the nearest motor response ("safety margin") was 7.9 mm (range, 5-15 mm; standard deviation, 3.2 mm) for nTMS and 6.6 mm (range, 0-12 mm; standard deviation, 3.4 mm) for direct cortical stimulation. CONCLUSION: nTMS allowed for reliable, precise application of the magnetic impulse, and the peritumoral somatotopy corresponded well between the 2 modalities in all 10 cases. nTMS is a promising method for preoperative functional mapping in motor cortex tumor surgery. PMID- 19935008 TI - Kaposi sarcoma related to an ectopic hypothalamic adrenocorticotropic hormone secreting adenoma: case report. AB - OBJECTIVE: We aim to report a case of Kaposi sarcoma (KS) with Cushing's syndrome caused by endogenic glucocorticoid-induced immunosuppression. CLINICAL PRESENTATION: A 43-year-old woman presented with delirium, hirsutism, fatigue, and hypertension. At the time of presentation, physical findings showed a Cushingoid appearance, with moon-like facies, hirsutism, and hyperpigmentation. Laboratory findings showed the following: adrenocorticotropic hormone, 86.7 pg/mL (normal range, 0-46 pg/mL); baseline cortisol level, 50 microg/dL (normal range, 6.2-19 microg/dL); potassium, 2.2 mEq/L (normal range, 3.5-5 mEq/L); and midnight cortisol level, 33 microg/dL. Serum cortisol levels failed to suppress after low and high doses of dexamethasone; these findings confirmed the diagnosis of ectopic adrenocorticotropic hormone production. Magnetic resonance imaging revealed a 12 x 15-mm, round, hypothalamic mass lesion in the center of the median eminence. INTERVENTION: Endoscopic biopsy from the floor of the third ventricle was performed, and pathological examination of the lesion showed a diffuse adrenocorticotropic hormone-secreting adenoma. The patient developed diffuse skin lesions that were proven to be a KS by skin biopsy while she was prepared for transcranial surgery. After surgical removal of the adenoma, she became hypocortisolemic and required cortisol replacement. Within 1 month after surgery, all KS lesions disappeared spontaneously. CONCLUSION: Excessive cortisol may induce immunosuppression. KS is one of the most common malignant tumors of patients with immunosuppression. To the best of our knowledge, this is the first case of Cushing's syndrome with KS caused by endogenous glucocorticoid-induced immunosuppression. PMID- 19935009 TI - Endoscopic transnasal resection of ectopic esthesioneuroblastoma in the pterygopalatine fossa: technical case report. AB - OBJECTIVE: Esthesioneuroblastoma is a rare, malignant neoplasm arising from the olfactory neuroepithelium in the upper nasal cavity. Even more rare is ectopic esthesioneuroblastoma developing from the region outside the olfactory epithelium. In addition, tumors occurring in the pterygopalatine fossa (PPF) are uncommon, and the endoscopic transnasal approach for the resection of malignant tumors in this region is also uncommon. CLINICAL PRESENTATION: We describe an esthesioneuroblastoma arising from the left maxillary sinus and PPF. The tumor was resected using the endoscopic transnasal approach, followed by treatment with radiotherapy. The patient showed no evidence of recurrence 12 months postoperatively. TECHNIQUE: The endoscopic transnasal approach could be successfully used for the complete removal of malignant tumors in the PPF. CONCLUSION: The PPF is an anatomic area that is difficult to access. The endoscopic transnasal approach improves access and visualization; it also has the potential to reduce complications compared with the open approach. The endoscopic transnasal approach might become the treatment of choice for malignant tumors in the PPF. PMID- 19935010 TI - Simple method for determining the need for sternotomy/manubriotomy with the anterior approach to the cervicothoracic junction. AB - OBJECTIVE: Frequently, the cervicothoracic junction can be reached through a simple anterior approach. In some cases, access to this region requires a much more aggressive surgical intervention, such as manubriotomy or sternotomy. Information regarding the need for such interventions is particularly useful to have preoperatively to guide surgical planning as well as discussions regarding surgical risks and expected morbidities. Whereas methods utilizing magnetic resonance imaging have been proposed for determining the lowest level that can be accessed through a simple low cervical approach, we describe a simple technique using sagittal computed tomographic imaging. Our technique does not require any complex geometry and has given us very consistent results. METHODS: Computed tomographic sagittal reconstruction of the cervical and upper thoracic spine that includes the entire sternum is obtained. The lowest accessible disc space is determined by a straight line passing through and parallel to the disc space that also passes above the manubrium (the intervertebral disc line). RESULTS: Sagittal computed tomographic reconstructions obtained from 50 adult patients were reviewed, and the lowest disc space accessible from an anterior low cervical approach was determined. The most common accessible level was T1-T2 (23 patients), followed by C7-T1 (13 patients), T2-T3 (10 patients), and C6-C7 (4 patients). A 35-year-old man with T2-T3 compression fractures with kyphotic deformity was treated with T2 and T3 vertebrectomies and T1-T4 fusion through an anterior approach. CONCLUSION: We propose a simple and consistent method for determining the need for manubriotomy or sternotomy for anterior approaches to the cervicothoracic junction. PMID- 19935012 TI - Rapid, simple technique to extend depth of field in microneurosurgical images: technical note. AB - OBJECTIVE: To increase the extent of the depth of field and focal sharpness in highly magnified image series from cadaveric microneurosurgical anatomic study or live surgery photographs obtained with the operating microscope, providing a higher quality and more satisfactory photographic and imaging experience. METHODS: We used a computer workstation, CombineZM software (Alan Hadley, United Kingdom, www.hadleyweb.pwp.blueyonder.co.uk/), an injected cadaver head specimen, and an operating microscope equipped with a digital single-lens reflex camera. Fifteen images were obtained of the dissection area through an anterior petrosal approach. The focus point was fixed to different points in each image. The images were loaded into CombineZM software for processing. RESULTS: The stacking process of photographs with CombineZM freeware provides significant increase in extent of depth of field and wider area of image clarity, producing a sharp, high-quality image. CONCLUSION: An image processed from a stack of photographs from cadaveric microneurosurgical studies or from the operating microscope in live surgery can be rendered to show extended 3-dimensional depth of field and clarity. This method offers improvements for editing, displaying, and publishing neurosurgical anatomic images. PMID- 19935014 TI - Great future for the green journal. PMID- 19935015 TI - Update on quadrivalent human papillomavirus vaccination and pregnancy outcomes: is contraception advisable? PMID- 19935016 TI - Pregnancy outcomes from the pregnancy registry of a human papillomavirus type 6/11/16/18 vaccine. AB - OBJECTIVE: To better describe the safety profile of pregnancy exposures to the human papillomavirus (HPV) type 6/11/16/18 vaccine by acquiring and analyzing postmarketing data on pregnancy outcomes (ie, live births, abortions, fetal deaths, and congenital anomalies). METHODS: Enrollment criteria included an identifiable patient and health care provider from the United States, France, or Canada and exposure within 1 month before the date of onset of the last menstrual period or at any time during pregnancy. Outcomes of interest were pregnancy outcomes and birth defects. Prospectively reported cases (reported before the outcome of the pregnancy was known) were used for rate calculations. RESULTS: For the 517 prospective reports with known outcome, 451 (87.2%) were live births, including three sets of twins. Of 454 neonates, 439 (96.7%) were normal. The overall rate of spontaneous abortion was 6.9 per 100 outcomes (95% confidence interval [CI] 4.8-9.6). The prevalence of major birth defects was 2.2 per 100 liveborn neonates (95% CI 1.05-4.05). There were seven fetal deaths (1.5 per 100 outcomes, 95% CI 0.60-3.09). CONCLUSION: Rates of spontaneous abortions and major birth defects were not greater than the unexposed population rates. Although no adverse signals have been identified to date, the HPV6/11/16/18 vaccine is not recommended for use in pregnant women. LEVEL OF EVIDENCE: III. PMID- 19935017 TI - Pregnancy and infant outcomes in the clinical trials of a human papillomavirus type 6/11/16/18 vaccine: a combined analysis of five randomized controlled trials. AB - OBJECTIVE: To present a combined analysis of the pregnancy outcomes for women aged up to 45 years enrolled in five phase III clinical studies of the prophylactic quadrivalent human papillomavirus 6/11/16/18 vaccine. METHODS: Twenty thousand five hundred fifty-one women aged 15-45 years received quadrivalent HPV vaccine or placebo at day 1 and months 2 and 6. Urine pregnancy tests were performed immediately before each injection; participants testing positive were not vaccinated. Women who became pregnant after enrollment were discontinued from further vaccination until resolution of pregnancy. All pregnancies were followed for outcomes. RESULTS: During the studies, 1,796 vaccine and 1,824 placebo recipients became pregnant, resulting in 2,008 and 2,029 pregnancies with known outcomes. No significant differences were noted overall for the proportions of pregnancies resulting in live birth, fetal loss, or spontaneous abortion. A total of 40 neonates born to vaccinated women and 30 neonates born to women given placebo had one or more congenital anomalies (P=.20). The anomalies were diverse and consistent with those most commonly observed in the general population. The vaccine was well tolerated among women who became pregnant. CONCLUSION: Administration of quadrivalent human papillomavirus vaccine to women who became pregnant during the phase III clinical trials did not appear to negatively affect pregnancy outcomes. The vaccine is a U.S. Food and Drug Administration pregnancy category B medication (animal studies revealed no evidence of fetal harm, but there are no adequate and well-controlled studies in pregnant women); however, vaccination is not recommended during pregnancy. Postlicensure surveillance is ongoing. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00092521, NCT00092534, NCT00092495, NCT00092547 and NCT00090220. LEVEL OF EVIDENCE: II. PMID- 19935018 TI - Role of second-trimester genetic sonography after Down syndrome screening. AB - OBJECTIVE: To estimate the effectiveness of second-trimester genetic sonography in modifying Down syndrome screening test results. METHODS: The First and Second Trimester Evaluation of Risk (FASTER) aneuploidy screening trial participants were studied from 13 centers where a 15- to 23-week genetic sonogram was performed in the same center. Midtrimester Down syndrome risks were estimated for five screening test policies: first-trimester combined, second-trimester quadruple, and testing sequentially by integrated, stepwise, or contingent protocols. The maternal age-specific risk and the screening test risk were modified using likelihood ratios derived from the ultrasound findings. Separate likelihood ratios were obtained for the presence or absence of at least one major fetal structural malformation and for each "soft" sonographic marker statistically significant at the P<.005 level. Detection and false-positive rate were calculated for the genetic sonogram alone and for each test before and after risk modification. RESULTS: A total of 7,842 pregnancies were studied, including 59 with Down syndrome. Major malformations and 8 of the 18 soft markers evaluated were highly significant. The detection rate for a 5% false-positive rate for the genetic sonogram alone was 69%; the detection rate increased from 81% to 90% with the combined test, from 81% to 90% with the quadruple test, from 93% to 98% with the integrated test, from 97% to 98% with the stepwise test, and from 95% to 97% with the contingent test. The stepwise and contingent use of the genetic sonogram after first-trimester screening both yielded a 90% detection rate. CONCLUSION: Genetic sonography can increase detection rates substantially for combined and quadruple tests and more modestly for sequential protocols. Substituting sonography for quadruple markers in sequential screening was not useful. LEVEL OF EVIDENCE: II. PMID- 19935019 TI - Endometrial cancer in postmenopausal women using estradiol-progestin therapy. AB - OBJECTIVE: To estimate the risk of endometrial cancer in all Finnish postmenopausal women using various forms of estradiol-progestin therapy. METHODS: All Finnish women (aged more than 50 years) who had used estradiol-progestin therapy in 1994-2006 for at least 6 months (n=224,015) were identified from the national medical Reimbursement Registry and linked to the Finnish Cancer Registry. A total of 1,364 type I and 38 type II endometrial cancers were recorded by the end of 2006. The incidence of endometrial cancer in estradiol progestin therapy users was compared with that in the general population in this cohort study. RESULTS: The use of a continuous estradiol-progestin therapy regimen for 3 years or more was associated with a 76% reduction of the risk for type 1 cancer (95% confidence interval [CI] 6-60%). In contrast, the use of a sequential estradiol-progestin therapy regimen for at least 5 years was accompanied with a 69% elevation (95% CI 43-96%) if the progestin was added monthly, and with a significantly higher, 276% risk elevation (95% CI 190-379%) if progestin was added at 3-month intervals. Sequential regimens containing norethisterone acetate, medroxyprogesterone acetate or dydrogesterone administered orally showed no significant differences in the endometrial safety. Oral and transdermal norethisterone acetate were associated with similar risk elevations. Women using a monthly sequential estradiol-progestin regimen tended to be diagnosed with endometrial cancer in an earlier stage than the background population. CONCLUSION: Use of a continuous rather than a sequential estradiol progestin regimen decreases the risk of endometrial cancer, whereas the route of administration or type of progestin does not differ in terms of endometrial cancer risk. LEVEL OF EVIDENCE: II. PMID- 19935020 TI - Cycle control with a 21-day compared with a 24-day oral contraceptive pill: a randomized controlled trial. AB - OBJECTIVE: To compare bleeding patterns between a 21/7-day triphasic norgestimate/ethinyl estradiol (E2) 25-microgram oral contraceptive pill (OCP) and a 24/4-day drospirenone/ethinyl E2 20-microgram OCP. METHODS: In a three cycle, open-label, multicenter study, healthy, sexually active women were assigned randomly to a 21/7-day (norgestimate/ethinyl E2) or 24/4-day (drospirenone/ethinyl E2) OCP regimen. Randomization was stratified to assure a balanced distribution between regimens for "fresh starts" and "switchers." Bleeding data were collected daily using an interactive voice-response system. Bleeding was defined according to the 2007 U.S. Food and Drug Administration's Reproductive Health Drug Advisory Committee-endorsed criteria. RESULTS: Across the three cycles, the 21/7-day OCP group (n=165) reported fewer unscheduled bleeding days than did the 24/4-day OCP group (n=167) (mean 4.6 compared with 6.1 days, P=.003). Women using the 21/7-day OCP had significantly fewer episodes of unscheduled bleeding than did those using the 24/4-day OCP (mean 1.47 compared with 2.01, P=.001). Moreover, women using the 21/7-day OCP had a significantly lower absence of scheduled bleeding at each cycle (P<.001). Both regimens were well-tolerated. CONCLUSION: A 21-day norgestimate/ethinyl E2 25-microgram regimen results in less unscheduled bleeding and more scheduled bleeding than does a 24 day drospirenone/ethinyl E2 20-microgram regimen. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.ClinicalTrials.gov, NCT00745901. LEVEL OF EVIDENCE: I. PMID- 19935021 TI - Pap testing and sexual activity among young women in the United States. AB - OBJECTIVE: To understand whether and how recency of sexual activity is associated with Pap testing rates among young women. METHODS: We analyzed data on self reported receipt of Pap testing and initiation of sexual activity among young women and girls aged 15 to 24 years using the 2002 National Survey of Family Growth, an in-person, population-based survey of reproductive-aged men and women in the United States. The primary outcome was receiving a Pap test and its relationship to initiation of sexual activity. A multivariable model was used to predict the probability of having had a Pap test in the previous 12 months. RESULTS: Thirty-three percent of the 2,513 women had never had sex. Of these, 13.9% had had a Pap test in the previous year. Sixty-seven percent of sexually active women aged 15-24 reported receiving a Pap test (corresponding to 13.1 million tests). Approximately 59% women aged 15-20 years old who reported having initiated sexual activity in the previous 3 years also reported a Pap test in the previous year. CONCLUSION: The current guidelines recommend screening 3 years after initiation of vaginal intercourse or at age 21, whichever is earlier. Contrary to the current guidelines, many young women who have not had sex or who initiated sex within the previous 3 years reported having had a Pap test. Assuming that the patterns observed in this study persist, there is an urgent need for education regarding the need to adhere to guidelines to reduce the burden of potentially unnecessary Pap tests in young women. LEVEL OF EVIDENCE: III. PMID- 19935022 TI - Paracervical block with combined ketorolac and lidocaine in first-trimester surgical abortion: a randomized controlled trial. AB - OBJECTIVE: To study the effects of a paracervical block with combined ketorolac and lidocaine on perceived pain during first-trimester surgical abortion. METHODS: A double-masked, placebo-controlled, randomized clinical trial of 50 women undergoing first-trimester surgical abortions (before 11 weeks of gestation) received either oral ibuprofen with a lidocaine-alone paracervical block or an oral placebo and paracervical block with combined ketorolac and lidocaine. Women completed a series of 100-mm visual analog scales (anchors: 0=none, 100 mm=worst imaginable) to measure their perceived pain (anticipated pain, pain during and after surgical abortion, and total satisfaction). RESULTS: Twenty-five women received preoperative oral ibuprofen followed by paracervical block with lidocaine alone, and 25 received oral placebo followed by paracervical block with combined ketorolac and lidocaine. Groups were similar with respect to sociodemographic variables. Women who received paracervical block with combined ketorolac and lidocaine reported significantly less pain after cervical dilation (59.8 compared with 74.8 mm, P<.05). The groups did not differ in perceived procedure-related or postoperative pain. There was no difference in overall satisfaction with pain control between the two groups (63.6 compared with 62.9 mm, P=.93). CONCLUSION: Paracervical block with combined ketorolac and lidocaine significantly decreases perceived pain associated with cervical dilation during first-trimester surgical abortion. This analgesic mixture may be offered as an alternative pain regimen to women seeking first-trimester surgical abortion. It may also offer improved pain control in other gynecologic procedures necessitating cervical dilation. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00617097. LEVEL OF EVIDENCE: I. PMID- 19935023 TI - Hysteroscopic sterilization in a large group practice: experience and effectiveness. AB - OBJECTIVE: To estimate device placement and tubal occlusion rates for hysteroscopic sterilization and evaluate risk factors for failure. METHODS: Women undergoing hysteroscopic sterilization at Kaiser Permanente Northern California from January 2004 to December 2006 were identified. Risk factors assessed included age, parity, body mass index (BMI), operative location, and provider experience with the technique. Occlusion was determined by hysterosalpingogram. Univariable analyses were performed to identify factors predictive of successful placement and occlusion. The Cochrane-Armitage test was performed for trend analysis. RESULTS: Hysteroscopic sterilization was attempted in 884 women by 118 physicians at 30 Kaiser Permanente Northern California facilities. The initial placement attempt was successful in 850 patients (96.2%). Patient age, nulliparity, and BMI were not predictive of successful placement. Bilateral occlusion was demonstrated by hysterosalpingogram in 687 of 739 patients (93.0%). There were no significant differences in age, nulliparity, and BMI between those with and without occlusion. Loss to follow-up before a hysterosalpingogram was obtained was 13%. There was no significant increase in occlusion rate with experience (P for trend=.6). CONCLUSION: High placement and occlusion rates were noted from the first insertions, and success was not related to age, parity, BMI, or operator experience. LEVEL OF EVIDENCE: III. PMID- 19935024 TI - Depth of cervical cone removed by loop electrosurgical excision procedure and subsequent risk of spontaneous preterm delivery. AB - OBJECTIVE: To investigate the association between cone depth of the loop electrosurgical excision procedure (LEEP) of the cervix and subsequent risk of spontaneous preterm delivery. METHODS: The study included all deliveries in Denmark over a 9-year period, 1997-2005, with information obtained from various public health registries. Of the 552,678 singleton deliveries included in the study, 19,049 were preterm and 8,180 were subsequent to LEEP. Of the 8,180 deliveries with prior LEEP, 273 were subsequent to two or more LEEPs. Of the deliveries subsequent to only one LEEP, we extracted information about cone depth on 3,605 deliveries, of which 223 were preterm (6.2%). Logistic regression analyses were used to evaluate association between cone characteristics and the subsequent risk of preterm delivery, with simultaneous adjustment for potential confounders. RESULTS: Increasing cone depth was associated with a significant increase in the risk of preterm delivery, with an estimated 6% increase in risk per each additional millimeter of tissue excised (odds ratio 1.06, 95% confidence interval 1.03-1.09). Severity of the cone histology and time since LEEP were not associated with the risk of preterm delivery. Having had two or more LEEPs increased the risk almost fourfold for subsequent preterm delivery when compared with no LEEP before delivery, and almost doubled the risk when compared with one LEEP before delivery. CONCLUSION: Increasing cone depth of LEEP is directly associated with an increasing risk of preterm delivery, even after adjustment for several confounding factors. LEVEL OF EVIDENCE: II. PMID- 19935025 TI - Treatment of periodontal disease during pregnancy: a randomized controlled trial. AB - OBJECTIVE: To investigate whether treating periodontal disease prevents preterm birth and other major complications of pregnancy. METHODS: This single-center trial was conducted across six obstetric sites in metropolitan Perth, Western Australia. Pregnant women identified by history to be at risk (n=3,737) were examined for periodontal disease. Approximately 1,000 women with periodontal disease were allocated at random to receive periodontal treatment commencing around 20 weeks of gestation (n=542) or 6 weeks after the pregnancy was completed (controls; n=540). The treatment included mechanical removal of oral biofilms together with oral hygiene instruction and motivation at a minimum of three weekly visits, with further visits if required. RESULTS: There were no differences between the control and treatment groups in preterm birth (9.3% compared with 9.7%, odds ratio [OR] 1.05, 95% confidence interval [CI 0.7-1.58], P=.81), birth weight (3,450 compared with 3,410 g, P=.12), preeclampsia (4.1% compared with 3.4%, OR 0.82, 95% CI 0.44-1.56, P=.55), or other obstetric endpoints. There were four unexplained stillbirths in the control group and no pregnancy losses in the treated group (P=.12). Measures of fetal and neonatal well-being were similar in the two groups, including abnormalities in fetal heart rate recordings (P=.26), umbilical artery flow studies (P=.96), and umbilical artery blood gas values (P=.37). The periodontal treatment was highly successful in improving health of the gums (P<.01). CONCLUSION: The evidence provided by the present study does not support the hypothesis that treatment of periodontal disease during pregnancy in this population prevents preterm birth, fetal growth restriction, or preeclampsia. Periodontal treatment was not hazardous to the women or their pregnancies. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00133926. LEVEL OF EVIDENCE: I. PMID- 19935026 TI - Factor v Leiden homozygous genotype and pregnancy outcomes. AB - OBJECTIVE: To assess the rate of early (first trimester) and late (second and third trimester) fetal loss in women who are factor V Leiden homozygous. METHODS: Between December 1995 and February 2007, consecutive, unrelated white women who were factor V Leiden homozygous and who had been pregnant at least once were recruited from 10 French hemostasis units. For reasons of comparison, we included women who were factor V Leiden heterozygous and a group of noncarriers. The frequency of early and late fetal loss was assessed retrospectively and compared among the three groups. The effect of concomitant thrombophilic abnormalities was evaluated. The overall pregnancy outcome was reported. RESULTS: We analyzed 240 thromboprophylaxis-free pregnancies in 95 women who were factor V Leiden homozygous, 425 in 195 women who were factor V Leiden heterozygous, and 182 in 73 women who were noncarriers. The risk of late fetal loss was higher in women who were homozygous (13/95, 13.7%) compared with those who were noncarriers (1/73, 1.4%, odds ratio 11.41, 95% confidence interval 1.46-89.46, P=.002), whereas it was similar in women who were heterozygous and in noncarriers (6/195, 3.1% compared with 1/73, 1.4%, P=.68). The percentage of women with early fetal loss was similar in the three groups (P=.81). The live-birth rate was 80%, 84%, and 85%, respectively, for women who where homozygous, heterozygous, and noncarriers (P=.88). CONCLUSION: The factor V Leiden homozygous genotype increases the risk of late fetal loss. However, the overall likelihood of a positive outcome is high in our series of women who were homozygous. LEVEL OF EVIDENCE: III. PMID- 19935027 TI - Women's perceptions regarding the safety of births at various gestational ages. AB - OBJECTIVES: To estimate women's understanding of the definition of full term and the gestational age at which it is safe to deliver an otherwise healthy pregnancy. METHODS: A national sample of 650 insured women who recently gave birth were surveyed about their beliefs related to the meaning of full term and the safety of delivery at various gestational ages. Descriptive statistics including means and 95% confidence intervals were calculated for the demographic variables and survey measures; multivariate logistic regression analyses were also performed. RESULTS: Twenty-four percent of women surveyed considered a baby of 34-36 weeks of gestation to be full term, and 50.8% believed full term to occur at 37-38 weeks of gestation, while only 25.2% considered full term to occur at 39-40 weeks of gestation. In response to, "What is the earliest point in pregnancy that it is safe to deliver the baby, should there be no other medical complications requiring early delivery?" 51.7% choose 34-36 weeks of gestation, and 40.7% choose 37-38 weeks of gestation, while only 7.6% choose 39-40 weeks of gestation. CONCLUSION: The American College of Obstetricians and Gynecologists recommends that elective deliveries not occur before 39 weeks of gestation. However, many women believe that full term is reached before 37 weeks of gestation, and most believe full term occurs before 39 weeks of gestation. Nearly half believe it is safe to deliver before 37 weeks of gestation, and almost all believe it is safe to deliver before 39 weeks of gestation. The data reported here suggest that many women believe that term is reached early and that a safe delivery does not require waiting to 39 weeks of gestation. LEVEL OF EVIDENCE: III. PMID- 19935028 TI - Prior adverse pregnancy outcome and the risk of stillbirth. AB - OBJECTIVE: To estimate whether a history of fetal growth restriction, abruptio placentae, preeclampsia, or live preterm birth is associated with excess risk of stillbirth in a subsequent pregnancy. We also estimated the maternal and paternal contributions to such effects. METHODS: This was a population-based cohort study from 1967 to 2005. Pairs of first and second, second and third, third and fourth, and fourth and fifth births were identified among all births from the Medical Birth Registry of Norway; 747,221 pairs with the same parents, 51,708 with the same mother and different father, and 65,602 with the same father and different mother. The associations of gestational age categories (22-27, 28-32, 33-36, and at or above 37 weeks), small for gestational age (SGA), preeclampsia, and abruptio placenta in the first pregnancy with stillbirth and late abortion in the second were assessed by odds ratios (ORs) obtained by logistic regression. RESULTS: The baseline rate of stillbirth during the study period was 1.0% of all births from 16 weeks of gestation. After births with gestational age 22-27, 28 32, and 33-36 weeks of gestation, stillbirth was six, three and two times more likely to occur than after a term birth (OR 5.7, 95% confidence interval [CI] 4.2 7.6; OR 2.6, 95% CI 2.1-3.3; and OR 1.7, 95% CI 1.5-1.9, respectively). Odds ratios of stillbirth subsequent to pregnancies with SGA, preeclampsia, and abruptio placentae were 1.7 (95% CI 1.6-1.9), 1.6 (95% CI 1.5-1.9), and 2.8 (95% CI 2.2-3.5), respectively, and increased with severity of the conditions. Gestational age below 33 weeks with preeclampsia or SGA carried 6-9 and 6-13-fold effects on later stillbirth, respectively. Men who fathered a pregnancy with preterm preeclampsia were significantly more likely to father a stillbirth in another woman (OR 2.4, 95% CI 1.1-5.5). CONCLUSION: Live preterm birth, fetal growth restriction, preeclampsia, and abruptio placenta are strongly associated with later stillbirth. LEVEL OF EVIDENCE: II. PMID- 19935029 TI - Racial differences in pelvic organ prolapse. AB - OBJECTIVE: To compare the estimated prevalence of, risk factors for, and level of bother associated with subjectively reported and objectively measured pelvic organ prolapse in a racially diverse cohort. METHODS: The Reproductive Risks for Incontinence Study at Kaiser 2 is a population-based cohort study of 2,270 middle aged and older women. Symptomatic prolapse was self-reported, and bother was assessed on a five-point scale. In 1,137 women, prolapse was measured with the Pelvic Organ Prolapse Quantification (POP-Q) system. Multivariable logistic regression analysis was used to identify the independent association of prolapse and race while controlling for risk factors. RESULTS: The participants' mean (standard deviation) age was 55 (9) years, and 44% were white, 20% were African American, 18% were Asian American, and 18% were Latina or other race. Seventy four women (3%) reported symptomatic prolapse. In multivariable analysis, the risk of symptomatic prolapse was higher in white (prevalence ratio 5.35, 95% confidence interval [CI] 1.89-15.12) and Latina (prevalence ratio 4.89, 95% CI 1.64-14.58) compared with African-American women. Race was not associated with report of moderate to severe bother. Degree of prolapse by POP-Q stage was similar across all racial groups; however, the risk of the leading edge of prolapse at or beyond the hymen was higher in white (prevalence ratio 1.40, 95% CI 1.02-1.92) compared with African-American women. CONCLUSION: Compared with African-American women, Latina and white women had four to five times higher risk of symptomatic prolapse, and white women had 1.4-fold higher risk of objective prolapse with leading edge of prolapse at or beyond the hymen. LEVEL OF EVIDENCE: II. PMID- 19935030 TI - Forecasting the prevalence of pelvic floor disorders in U.S. Women: 2010 to 2050. AB - OBJECTIVES: To estimate the number of women who will have symptomatic pelvic floor disorders in the United States from 2010 to 2050. METHODS: We used population projections from the U.S. Census Bureau from 2010 to 2050 and published age-specific prevalence estimates for bothersome, symptomatic pelvic floor disorders (urinary incontinence [UI], fecal incontinence, and pelvic organ prolapse [POP]) from the 2005 National Health and Nutrition Examination Survey. We abstracted data regarding the number of women aged 20 years or older in 20 year age groups. We assumed that the age-specific prevalences for these disorders and the population distribution of risk factors remained unchanged thru 2050. We also conducted sensitivity analyses that varied both the prevalence estimates and the population projections. RESULTS: The number of American women with at least one pelvic floor disorder will increase from 28.1 million in 2010 to 43.8 million in 2050. During this time period, the number of women with UI will increase 55% from 18.3 million to 28.4 million. For fecal incontinence, the number of affected women will increase 59% from 10.6 to 16.8 million, and the number of women with POP will increase 46% from 3.3 to 4.9 million. The highest projections for 2050 estimate that 58.2 million women will have at least one pelvic floor disorder, with 41.3 million with UI, 25.3 million with fecal incontinence, and 9.2 million with POP. CONCLUSION: The prevalence of pelvic floor disorders will increase substantially given the changing demographics in the United States. This increase has important implications for public health and the field of gynecology. LEVEL OF EVIDENCE: III. PMID- 19935031 TI - "Case-control" confusion: mislabeled reports in obstetrics and gynecology journals. AB - OBJECTIVE: To review published articles in four U.S. obstetrics and gynecology journals labeled "case-control" studies to estimate the frequency of mislabeling the type of study. METHODS: I searched PubMed from January 1970 through May 2009, using journal name and "case-control" in the title as search terms. The journals included the American Journal of Obstetrics & Gynecology, Fertility and Sterility, Journal of Reproductive Medicine, and Obstetrics & Gynecology. I reviewed the methods of each report to confirm the study design and calculated the proportion of articles labeled as "case-control" in the title that were not case-control studies. I calculated Fisher's exact 95% confidence intervals around these proportions. RESULTS: In the 124 reports identified, the proportion of mislabeled "case-control" studies was 30% overall. It varied from 13% to 36% in the four journals, a 2.8-fold difference in frequency (95% confidence interval 0.9-9.0). The frequency of this mislabeling appears to have increased over time. CONCLUSION: Retrospective cohort studies are often mislabeled as "case-control" studies. This misleads readers as to what was done. Researchers need better training in methods and terminology, and editors and reviewers should scrutinize more carefully manuscripts claiming to be "case-control" studies. LEVEL OF EVIDENCE: III. PMID- 19935032 TI - Transobturator tape compared with tension-free vaginal tape for stress incontinence: a randomized controlled trial. AB - OBJECTIVE: To compare the effectiveness of transobturator tape with tension-free vaginal tape (TVT) in terms of objective cure of stress urinary incontinence (SUI) at 12 months postoperatively. METHOD: Women with SUI were randomly allocated to either transobturator tape or TVT procedures and reviewed at 12 months after surgery. The primary outcome was objective evidence of "cure," evaluated by standardized pad test (cure defined as less than 1 g urine leaked). Other outcomes included complications, subjective cure, incontinence-related quality of life, return to usual sexual activity, and satisfaction with surgery. Primary analysis compared the proportion of patients in each group who were cured at 12-month follow-up. RESULTS: A total of 199 women participated (94 in the transobturator tape group, 105 in the TVT group). Sixty-eight women (81%) in the transobturator tape group were cured, compared with 67 (77%) in the TVT group (relative risk 1.05, 95% confidence interval 0.90-1.23, P=.577). On vaginal examination, the tape was palpable for 68 women (80%) in the transobturator tape group and for 24 (27%) in the TVT group (relative risk 0.22, 95% confidence interval 0.13-0.37, P<.001). More women in the transobturator tape group experienced groin pain during vaginal palpation (13 [15%] in the transobturator tape group and five [6%] in the TVT group, P=.044). Quality of life improved significantly from baseline in both groups (30-point improvement in IIQ-7 score for both groups). CONCLUSION: At 12 months, the majority of women had minimal leakage and their quality of life had improved significantly, but differences were not observed between groups. The presence of palpable tape, particularly among the transobturator tape group, is concerning; longer follow-up is needed to determine whether this outcome leads to extrusion or resolves over time. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00234754. LEVEL OF EVIDENCE: I. PMID- 19935033 TI - Prenatal exposure to acetaminophen and asthma in children. AB - OBJECTIVE: To estimate whether prenatal exposure to acetaminophen is associated with risk of diagnosed asthma and asthma symptoms in children. METHODS: The authors prospectively followed 1,505 pregnant women and their children until 6 years (+/-3 months) of life. Acetaminophen use in the first and third trimesters of pregnancy was assessed before 24 weeks of gestation and within 1 month of delivery, and asthma in children was assessed when the child was 6 years old. Adjusted odds ratios (aORs) were derived from logistic regression models controlling for potential confounders. RESULTS: Acetaminophen was used by 69% of women during pregnancy. Use of acetaminophen did not significantly increase the risk of asthma (aOR 0.76, 95% confidence interval [CI] 0.53-1.10). Acetaminophen use during both the first and the third trimester was associated with a significantly reduced risk of asthma (aOR 0.59, 95% CI 0.36-0.98). There was no evidence of a dose response, and consumption greater than 10,400 mg (32 tablets) a month did not increase risk (aOR 0.99, 95% CI 0.19-5.30). CONCLUSION: Our results suggest that acetaminophen use during pregnancy does not increase risk of asthma in children. LEVEL OF EVIDENCE: II. PMID- 19935034 TI - Resolution of hypertension and proteinuria after preeclampsia. AB - OBJECTIVE: To estimate the time required for hypertension and proteinuria to resolve after preeclampsia, and to estimate how this time to resolution correlates with the levels of blood pressure and proteinuria during preeclampsia and prolonging pregnancy after the development of preeclampsia. METHODS: This is a historic prospective cohort study of 205 preeclamptic women who were admitted between 1990 and 1992 at the Erasmus MC Medical Centre, Rotterdam, The Netherlands. Data were collected at 1.5, 3, 6, 12, 18, and 24 months after delivery. Hypertension was defined as a blood pressure 140/90 mm Hg or higher or use of antihypertensive drugs. Proteinuria was defined as 0.3 g/d or more. Resolution of hypertension and proteinuria were analyzed with the Turnbull extension to the Kaplan-Meier procedure. Correlations were calculated with an accelerated failure time model. RESULTS: At 3 months postpartum, 39% of women still had hypertension, which decreased to 18% at 2 years postpartum. Resolution time increased by 60% (P<.001) for every 10-mm Hg increase in maximal systolic blood pressure, 40% (P=.044) for every 10-mm Hg increase in maximal diastolic blood pressure, and 3.6% (P=.001) for every 1-day increase in the diagnosis-to delivery interval. At 3 months postpartum, 14% still had proteinuria, which decreased to 2% at 2 years postpartum. Resolution time increased by 16% (P=.001) for every 1-g/d increase in maximal proteinuria. Gestational age at onset of preeclampsia was not correlated with resolution time of hypertension and proteinuria. CONCLUSION: The severity of preeclampsia and the time interval between diagnosis and delivery are associated with postpartum time to resolution of hypertension and proteinuria. After preeclampsia, it can take up to 2 years for hypertension and proteinuria to resolve. Therefore, the authors suggest that further invasive diagnostic tests for underlying renal disease may be postponed until 2 years postpartum. LEVEL OF EVIDENCE: III. PMID- 19935035 TI - Effects of maternal obesity on duration and outcomes of prostaglandin cervical ripening and labor induction. AB - OBJECTIVE: To estimate the effect of maternal body mass index (BMI) on progress and outcomes of prostaglandin labor induction. METHODS: This study was a secondary analysis of data collected during the Misoprostol Vaginal Insert Trial, a multisite, double-blind, randomized trial of women requiring cervical ripening before induction of labor. The duration, characteristics, and outcomes of labor were analyzed after stratification by BMI categories. Multivariable regression analysis was performed on all outcomes of interest, adjusting for race, parity, and treatment group allocation. RESULTS: One thousand two hundred seventy-three patients were stratified according to BMI categories, with 418 study participants classified as lean (BMI less than 30), 644 as obese (BMI 30-39.9), and 211 as extremely obese (BMI 40 or higher). The incidence of cesarean delivery increased from 21.3% in the BMI less than 30 group to 29.8% in the BMI 30-39.9 group (odds ratio [OR] 1.57, 95% confidence interval [CI] 1.18-2.1, P=.002) and 36.5% in the BMI 40 or higher group (OR 2.12, 95% CI 1.47-3.06, P<.001). Median dose and duration of predelivery oxytocin in the lean group (2.6 units and 6.5 hours) was significantly lower than for women in either the obese (3.5 units and 7.7 hours) or the extremely obese (5.0 units and 8.5 hours) group. Median time to delivery was significantly longer in the BMI 40 or higher (27.0 hours) and BMI 30-39.9 (24.9 hours) groups compared with the BMI less than 30 (22.7 hours) group (P<.001). The relationship between maternal obesity and adverse labor and delivery outcomes persisted in a multivariable analysis that adjusted for race, parity, and treatment group allocation. CONCLUSION: Duration of labor, oxytocin requirements, and cesarean delivery rates are significantly higher with increasing maternal obesity in prostaglandin-induced women. LEVEL OF EVIDENCE: II. PMID- 19935036 TI - Epistaxis of pregnancy and association with postpartum hemorrhage. AB - OBJECTIVE: To estimate the prevalence of epistaxis among pregnant women and to investigate if epistaxis of pregnancy is associated with an increased risk of postpartum hemorrhage. METHODS: A cohort of 1,475 pregnant women presenting to labor and delivery at term were asked to complete a survey about epistaxis and other traditional risk factors for bleeding. Results were compared with those from a cohort of 275 nonpregnant women presenting for routine gynecologic care to estimate the effect of pregnancy on the prevalence of epistaxis. The association between epistaxis of pregnancy and risk of bleeding was estimated by comparing rates of postpartum hemorrhage between pregnant women with and without epistaxis. RESULTS: Final data analysis was performed on 1,470 pregnant women and 275 nonpregnant women. The prevalence of epistaxis was significantly increased in pregnant women compared with nonpregnant women (20.3% compared with 6.2%; P<.001). Women with epistaxis of pregnancy were at increased risk of postpartum hemorrhage compared with women without epistaxis (10.7% compared with 6.7%; P=.02). The increased risk of hemorrhage remained after controlling for cesarean delivery and after exclusion of women who reported epistaxis before pregnancy. Other traditional risk factors for bleeding such as gingival bleeding, O blood type, and easy bruising were not associated with increased risk of postpartum hemorrhage. CONCLUSION: Epistaxis is a common problem during pregnancy that may be associated with an increased risk of postpartum hemorrhage. As in the nonpregnant population, eliciting a history of epistaxis may help to identify women at risk of disordered hemostasis. LEVEL OF EVIDENCE: II. PMID- 19935037 TI - Pregnancy and laboratory studies: a reference table for clinicians. AB - OBJECTIVE: To establish normal reference ranges during pregnancy for common laboratory analytes. DATA SOURCES: We conducted a comprehensive electronic database review using PUBMED and MEDLINE databases. We also reviewed textbooks of maternal laboratory studies during uncomplicated pregnancy. METHODS OF STUDY SELECTION: We searched the databases for studies investigating various laboratory analytes at various times during pregnancy. All abstracts were examined by two investigators and, if they were found relevant, the full text of the article was reviewed. Articles were included if the analyte studied was measured in pregnant women without major medical problems or confounding conditions and if the laboratory marker was measured and reported for a specified gestational age. TABULATION, INTEGRATION, AND RESULTS: For each laboratory marker, data were extracted from as many references as possible, and these data were combined to establish normal reference ranges in pregnancy. When possible, the 2.5 and 97.5 percentiles were reported as the normal range. In some of the reference articles, however, the reported range was based on the minimum and maximum value of the laboratory constituent. In those cases, the minimum to maximum range was used and combined with the 2.5 and 97.5 percentile range. We found that there is a substantial difference in normal values in some laboratory markers in the pregnant state when compared with the nonpregnant state. CONCLUSION: It is important to consider normal reference ranges specific to pregnancy when interpreting some laboratory results that may be altered by the normal changes of pregnancy. PMID- 19935038 TI - Fetal monitoring bundle. AB - In 2008, the Eunice Kennedy Shriver National Institute of Child Health and Human Development published guidelines for categorizing fetal heart rate patterns. However, even if universally adopted, they will fail to improve outcomes unless they are integrated into a "bundle" of activities. Bundles reduce risks by assuring that key steps in a process are always taken. A fetal monitoring bundle would have four components: credentialed staff, an escalation policy, a known responsible party, and the capability for rapid response. The first requirement would be that all providers are qualified to appropriately interpret and respond to fetal heart rate tracings. Education should be uniform across disciplines, and there should be a credentialing process. Second is an escalation policy: an algorithm for nurses to use when getting help. It would avoid delays that occur when a nurse requesting a check on a tracing is required to call a hierarchical series of residents who must all concur before the attending who can move the patient to the operating room is called. Third, there must be an identified responsible provider at all times, ie, an obstetrician who can be readily contacted in emergent circumstances. Finally, there must be the capability of a rapid response; whenever a patient is monitored, the institution must have the obstetric, anesthesia, and pediatric resources necessary to respond to deteriorating fetal status. This bundle is a key, but not sole, piece of the perinatal safety pie; perinatal safety is advanced through a multifaceted approach anchored in a culture that values and invests in safety. PMID- 19935039 TI - The role of catheter balloon commissurotomy for severe mitral stenosis in pregnancy. AB - Mitral stenosis is one of the more commonly seen valve lesions encountered in pregnancy. The pathophysiologic implications, management strategies, and a comprehensive review of literature over the past 20 years for optimal timing of catheter balloon commissurotomy during pregnancy are discussed. Mechanical relief of obstruction is indicated for cases of severe symptomatic mitral stenosis in pregnancy refractory to medical therapy. Catheter balloon commissurotomy is the procedure of choice in a select group of these patients with suitable valve morphology. PMID- 19935040 TI - Avoidable waste in the production and reporting of research evidence. PMID- 19935042 TI - Acute renal failure caused by prolapsed leiomyoma. PMID- 19935043 TI - Eating disorders in the obstetric and gynecologic patient population. AB - The eating disorders anorexia nervosa and bulimia nervosa and eating disorders not otherwise specified disproportionately affect women, have profound effects on the overall well-being of women and their children, and can have mortality rates as high as those found with major depression. These disorders may present to obstetrician-gynecologists (ob-gyns) clinically as menstrual dysfunction, low bone density, sexual dysfunction, miscarriage, preterm delivery, or low birth weight in offspring. Ninety percent of eating disorders develop before the age of 25 in otherwise healthy young women, a group that characteristically seeks the majority of their health care from ob-gyns. For all of these reasons, ob-gyns must have a greater awareness of these disorders and a lower index of suspicion for screening their patients than they currently do. Otherwise, they may miss life-threatening illness, treat characteristic amenorrhea inappropriately, or inadvertently intervene to help these women conceive, contributing to maternal and fetal risks. As providers of both primary and specialty care for women, ob gyns have the opportunity to play a vital role in prevention and diagnosis of eating disorders and in the multidisciplinary management required to effectively manage these disorders. PMID- 19935045 TI - Incidence and characteristics of patients with vaginal cuff dehiscence after robotic procedures. PMID- 19935046 TI - The management of depression during pregnancy: a report from the American Psychiatric Association and the American College of Obstetricians and Gynecologists. PMID- 19935048 TI - Surgical reconstitution of a unilaterally avulsed symptomatic puborectalis muscle using autologous fascia lata. PMID- 19935049 TI - Route of hysterectomy influence and teaching hospital status. PMID- 19935051 TI - Weekly compared with daily blood glucose monitoring in women with diet-treated gestational diabetes. PMID- 19935054 TI - Carpenter-Coustan criteria compared with the national diabetes data group thresholds for gestational diabetes mellitus. PMID- 19935058 TI - False-negative prostate needle biopsies: frequency, histopathologic features, and follow-up. AB - Little is known about the frequency, histopathologic characteristics, and clinical consequences of false-negative prostate biopsies, that is, biopsies classified as benign but containing adenocarcinoma or atypical suspicious glands [atypical small acinar proliferations (ASAP)]. Objective of this study was to evaluate false-negative prostate biopsy in a prostate cancer screening setting. Prostate biopsy sets of 196 participants of a screening trial, which had been reported as "benign" at initial diagnosis, followed by a diagnosis of adenocarcinoma in a subsequent screening round were reviewed by 2 urologic pathologists. Adenocarcinoma was identified in 19 biopsy cores corresponding to 16 (8.2%) patients and ASAP in 24 cores, corresponding to 19 patients (9.7%). All missed prostate cancers were Gleason score 6 (3+3). After correction for patient selection, the overall false-negative biopsy rate was estimated to be 2.4%; 1.1% for prostate cancer; and 1.3% for ASAP. Clinicopathologic features at the time of initial biopsy and of subsequent prostate cancer diagnosis did not differ between patients with a false-negative or true benign biopsy. Relatively low number of atypical glands (<10 glands), intense intermingling with preexistent glands or lack of architectural disorganization were the most prominent risk factors for a false-negative diagnosis. Another potential pitfall was the presence of prostate cancer variants, as 1 adenocarcinoma was of foamy gland type and 3 of pseudohyperplastic type. Routine examination of at least 1 level of prostate biopsy sets at high magnification and awareness of histologic prostate cancer variants might reduce the risk of missing or misinterpreting a relevant lesion at prostate biopsy evaluation. PMID- 19935059 TI - Gastric stromal tumors in Carney triad are different clinically, pathologically, and behaviorally from sporadic gastric gastrointestinal stromal tumors: findings in 104 cases. AB - Carney triad, as originally described in 1977, was the association of 3 tumors: gastric epithelioid leiomyosarcoma [later renamed gastrointestinal stromal tumor (GIST)], extra-adrenal paraganglioma, and pulmonary chondroma. The disorder affected mostly young women and was not familial. We studied the clinical and pathologic features of the gastric neoplasm in 104 patients with the syndrome. Most (88%) were young women (mean age, 22 y), and the usual presentation was gastric bleeding. The tumors, commonly antral-based (61%), were multifocal, and ranged from 0.2 to 18.0 cm in dimension. Most (86%) featured round and polygonal (epithelioid) cells. Metastasis occurred in 49 patients (47%): to gastric lymph nodes (29%), liver (25%), and peritoneum (13%). Immunopositivity was detected in the tumors tested as follows: KIT, 100%; CD34, 75%; PKCtheta, 21%; PDGFRA, 90%; and smooth muscle actin, 6%. Fourteen patients (13%) died of metastatic GIST at a mean age of 45 years (range, 30 to 69 y). Estimated 10 and 40-year survivals were 100% and 73%, respectively. Median survival time was 26.5 years (range, 16 to 60 y). There was no correlation between the National Institutes of Health tumor risk classification and the tumor behavior. Compared with sporadic gastric GISTs, the gastric stromal tumor in Carney triad showed distinctive features: female predilection, young patient age, epithelioid cell predominance, multifocality, frequent lymph node metastasis, serial tumor occurrence, and unpredictable behavior. Thus, the Carney triad gastric stromal tumor is different clinically, pathologically, and behaviorally from sporadic gastric GIST. PMID- 19935060 TI - Novel antioxidant approaches to the treatment of upper airway inflammation. AB - PURPOSE OF REVIEW: Current understanding of the role of oxidative stress in airway inflammation suggests that antioxidant therapy may be important to optimize the treatment. This review summarizes recent investigations of novel antioxidant agents for upper airway inflammation, with selected studies focused on lower airway disease as additional candidate therapeutics. RECENT FINDINGS: Recently investigated antioxidant therapies for airway inflammation may be broadly grouped into three categories: endogenous metabolic agents, vitamins/nutrients, and botanical extracts. Studies examining effects in upper airway inflammation are limited and primarily consist of in-vitro human and in vivo animal models. More extensive studies have investigated the benefits of antioxidants in lower airway conditions such as allergic asthma. Existing evidence identifies antioxidant agents with potential therapeutic value, although human studies suggest that subpopulations affected by specific genetic, environmental, dietary factors, or all are most likely to benefit from antioxidant therapy. SUMMARY: Oxidative stress plays a causative role in upper airway inflammation, and novel strategies to mitigate cellular injury with antioxidant therapy may ameliorate disease in target populations. Preclinical studies demonstrate evidence of anti-inflammatory effects for a number of promising antioxidant agents. Well designed interventional human studies of the upper airway, which account for complex gene-environment-diet interactions, will be necessary to adequately examine the potential clinical benefit of antioxidant therapies for rhinosinusitis. PMID- 19935061 TI - The role of neurotrophins in the pathophysiology of allergic rhinitis. AB - PURPOSE OF REVIEW: Allergic rhinitis is characterized by allergic airway inflammation and a hyperresponsiveness to nonspecific stimuli which is partly neuronally controlled. In this regard, neurotrophins are prime candidates as mediators of neuronal and immunological plasticity and they will be the focus of the current review. RECENT FINDINGS: Neurotrophins including nerve growth factor (NGF) and brain-derived neurotrophic factor (BDNF) are expressed in the nasal mucosa. The majority of NGF expression has been found in eosinophil granulocytes, the glandular apparatus and peripheral nerves. As shown recently, nasal allergen provocation upregulates BDNF expression in nasal mucosa and NGF expression on peripheral nerves and nasal lavage in patients with allergic rhinitis. In this regard, increased BDNF expression positively correlates with the maximum increase in total nasal symptom score. The neurotrophin receptors including pan neurotrophin receptor p75, tyrosine kinase A (trkA) and trkB are expressed in nasal tissue. TrkA is expressed on endothelial, p75 on peripheral nerves and trkB on nasal mucosa mast cells that decreases after allergen provocation. The expression of these neurotrophin receptors is increased on peripheral blood eosinophils in allergic rhinitis compared with nonatopic controls. Further, BDNF and NGF exert immunomodulatory functions on eosinophils of patients with allergic rhinitis. Finally, eosinophils of patients with allergic rhinitis are capable of BDNF and NGF production. SUMMARY: Neurotrophins represent prime candidates in upper airway pathophysiology in allergic rhinitis. Research on neurotrophins in allergic rhinitis is thus becoming a progressively more exciting field and may reveal new and promising therapeutic options for the future. PMID- 19935062 TI - Ventilator-induced diaphragmatic dysfunction. AB - PURPOSE OF REVIEW: Diaphragmatic function is a major determinant of the ability to successfully wean patients from mechanical ventilation. There is increasing recognition of a condition termed ventilator-induced diaphragmatic dysfunction. The purpose of the present review is to present evidence that mechanical ventilation can itself be a cause of diaphragmatic dysfunction, to outline our current understanding of the cellular mechanisms responsible for this phenomenon, and to discuss the implications of recent research for future therapeutic strategies. RECENT FINDINGS: Many critically ill patients demonstrate diaphragmatic weakness. A large body of evidence from animal models, and more limited data from humans, indicates that mechanical ventilation can cause muscle fiber injury and atrophy within the diaphragm. Current data support a complex underlying pathophysiology involving oxidative stress and the activation of several intracellular proteolytic pathways involved in degradation of the contractile apparatus. This includes the calpain, caspase, and ubiquitin proteasome systems. In addition, there is a simultaneous downregulation of protein synthesis pathways. Studies in animal models suggest that future therapies may be able to specifically target these processes, whereas for the time being current preventive measures in humans are primarily based upon allowing persistent diaphragmatic activation during mechanical ventilation. SUMMARY: Diaphragmatic dysfunction is common in mechanically ventilated patients and is a likely cause of weaning failure. Recently, there has been a great expansion in our knowledge of how mechanical ventilation can adversely affect diaphragmatic structure and function. Future studies need to better define the evolution and mechanistic basis for ventilator-induced diaphragmatic dysfunction in humans, in order to allow the development of mechanical ventilation strategies and pharmacologic agents that will decrease the incidence of ventilator-induced diaphragmatic dysfunction. PMID- 19935063 TI - Pulmonary/renal interaction. AB - PURPOSE OF REVIEW: Acute kidney injury contributes to the development of acute lung injury and vice-versa. Volume overload that may occur during renal impairment increases pulmonary capillary hydrostatic pressure. However, experimental evidence clearly shows that lung damage occurs even in the absence of positive fluid balance. However, acute lung injury with its attendant hypoxemia, hypercapnia and mechanical ventilation worsens renal hemodynamics and function. RECENT FINDINGS: An increasing body of evidence suggests that kidney and lung interact (crosstalk) during severe insults, such as shock, trauma, and sepsis, due to a loss of the normal balance of immune, inflammatory and soluble mediators. Kidney-lung crosstalk in the critically ill constitutes a possibility to analyze mechanisms of multiple organ failure in which the kidney and the lung can play an important role. Consequently, on the clinical side, specific therapeutic options can be hypothesized for kidney/lung dysfunction. SUMMARY: Fluid management optimization and prevention of inflammation and lung stretching are currently recommended for the treatment of acute lung and renal injury. Extracorporeal CO2 removal and renal replacement associated with extracorporeal membrane oxygenation might be interesting options for a future approach to pulmonary/renal syndrome. PMID- 19935064 TI - Noninvasive diagnosis of acute rejection of renal allografts. AB - PURPOSE OF REVIEW: Acute rejection is an immune process that begins with the recognition of the allograft as nonself and ends in graft destruction. Histological features of the allograft biopsy are currently used for the differential diagnosis of allograft dysfunction. In view of the safety and the opportunity for repetitive sampling, development of noninvasive biomarkers of allograft status is an important objective in transplantation. Herein, we review some of the progress towards the development of noninvasive biomarkers of human allograft status. RECENT FINDINGS: Urinary cell and peripheral blood cell mRNA profiles have been associated with acute rejection of human renal allografts. Emerging data support the idea that development of noninvasive biomarkers predictive of antibody-mediated rejection is feasible. The demonstration that intragraft microRNA expression predicts renal allograft status suggests that noninvasively ascertained microRNA profiles may be of value. SUMMARY: We are pleased with the progress to date, and anticipate clinical trials investigating the hypotheses that noninvasively ascertained mRNA profiles will minimize the need for invasive biopsy procedures, predict the development of acute rejection and chronic allograft nephropathy, facilitate preemptive therapy capable of preserving graft function, and facilitate personalization of immunosuppressive therapy for the allograft recipient. PMID- 19935066 TI - Transnasal endoscopic skull base surgery: what are the limits? AB - PURPOSE OF REVIEW: Endoscopic skull base surgery has significantly revolutionized the management of skull base disease. Our review focuses on the recent literature relating to endoscopic skull base surgery emphasizing its limitations. RECENT FINDINGS: Current literature continues to expand the indications for endoscopic approaches to the skull base. Experience in endoscopic techniques continues to grow across the world. This is due in part to advances in instrumentation and technology, improvements in technique and, more importantly, an increase in the number of surgeons with training in endoscopic techniques. Long-term outcome data remain sparse. SUMMARY: The limitations in endoscopic skull base surgery have not been reached. Increasing experience and improvement in technology will likely expand current indications. Future studies should focus on outcome analysis. PMID- 19935065 TI - Prospects for osteoprogenitor stem cells in fracture repair and osteoporosis. AB - PURPOSE OF REVIEW: Bone regeneration and fracture repair are the complex processes of mesenchymal stem cell invasion, chondrogenesis, osteogenesis and angiogenesis. The coordinated actions of these principal processes result in the reconstruction of a normal bone and restoration of a structural unit. However, these normal bone regenerative mechanisms breakdown during fracture repair failure and postmenopausal osteoporosis. RECENT FINDINGS: Recent discoveries of circulating multipotent stem cells with mixed characteristics of endothelial cell and osteogenic capacity have raised interest in new and potentially breakthrough therapies for fracture and pathologic bone loss. The cooperative actions of other mesenchymal stem cell lineage such as adipocytes and processes such as angiogenesis in bone repair could also serve as novel therapeutic targets. Recent data suggest that anabolic parathyroid hormone therapy, already approved for the treatment of osteoporosis, may recruit osteoprogenitor cells and also have a role in fracture repair. SUMMARY: The present review will highlight recent information on stem cells and bone repair and examine potential avenues for future research. PMID- 19935067 TI - Management of orbital complications in endoscopic sinus surgery. AB - PURPOSE OF REVIEW: Minor and major complications can occur during endoscopic sinus surgery. Even though major complications are rare, orbital complication is one of the more common major complications that can lead to devastating consequences. This article summarizes the orbital complications that can occur during endoscopic sinus surgery, how to manage the complication when it occurs, and more importantly how to avoid these complications. RECENT FINDINGS: One of the orbital complications during endoscopic sinus surgery is retrobulbar hematoma. Retrobulbar hematoma can be classified as spontaneous, traumatic, and iatrogenic. Iatrogenic hematoma, which can be caused by endoscopic sinus surgery, is more likely to have an arterial source, so these hematomas have higher tonometric pressure and may require more aggressive management. However, medical management can be an option for some of these iatrogenic retrobulbar hematomas. Tonometric pressure may be the best indicator to decide which intervention to use for this complication. Another distressing orbital complication is injury to the oculomotor muscles. With prompt medical and surgical intervention, the ocular dysmotility can be compensated. SUMMARY: Consequences of orbital injury during endoscopic sinus surgery can be devastating; however, with proper medical or surgical treatment potential morbidities can be minimized. PMID- 19935068 TI - Rheumatic manifestations of endocrine diseases. AB - PURPOSE OF REVIEW: Musculoskeletal complaints accompanying or as a result of endocrine disorders are common and have been well described. This review re examines these associations in light of newer information on biology and genetics. RECENT FINDINGS: In this article, we describe the recent studies on pathophysiology of the muscular skeletal complaints in endocrine disease. In addition we report on population as well as genetic studies, which address the relationship between endocrine and rheumatologic disease, both of which are autoimmune. SUMMARY: Very often, the presentation of rheumatic manifestations is the initial presentation of endocrine disease. Being aware of the presentation as well as the unique physiology of these complaints will help alert the clinician to an early diagnosis of endocrine disease. In addition understanding whether certain endocrine disease occurs more often in rheumatologic illness will enable the clinician to investigate their occurrence early, leading to earlier intervention and resulting in decreased morbidity from these concomitant illnesses. PMID- 19935069 TI - Rheumatic manifestations of sleep disorders. AB - PURPOSE OF REVIEW: We have long assumed that rheumatic pain causes sleep problems, fatigue, and functional disability. This paper reviews the accumulating evidence from human and animal experimental research studies that show a bidirectional relationship of disordered sleep to pain and fatigue. RECENT FINDINGS: The studies demonstrate that both disturbances of sleep and sleep restriction result in increased sensitivity to noxious stimuli and musculoskeletal pain symptoms. The notion of central nervous system hypersensitivity affecting widespread pain in patients with fibromyalgia syndrome is the result of a reduction in neurophysiologic inhibition of perception of noxious stimuli that is provoked by disordered sleep. Clinical and epidemiological studies show that sleep disturbances directly influence musculoskeletal pain, fatigue, mood, and overall well-being. Indeed, the interrelationships of the sleeping/waking brain with cytokine and cellular immune functions have important implications for the understanding of rheumatic disease pathology and management with disease-modifying antirheumatic drugs. SUMMARY: The determination of how disordered sleep affects musculoskeletal pain, fatigue, mood, and behavior is important in the assessment and management of patients with rheumatic illness. The high prevalence of obstructive sleep apnea and restless legs syndromes requires more research to determine whether treatments of these sleep disorders will benefit the symptoms of rheumatic diseases. PMID- 19935070 TI - Effect of preoperative gabapentin on postoperative pain and tramadol consumption after minilap open cholecystectomy: a randomized double-blind, placebo-controlled trial. AB - PURPOSE OF REVIEW: To evaluate the efficacy of a single preoperative dose of 600 mg of gabapentin for reducing postoperative pain and tramadol consumption after minilap open cholecystectomy. METHOD: A total of 120 adult patients of either sex were randomly assigned to receive 600 mg of gabapentin or a matched placebo orally 2 h before operation in a double-blind manner. All the patients received gabapentin using the same technique. Postoperative analgesia was provided with intravenous patient-controlled analgesia with tramadol using a 50-mg initial bolus dose, 20-mg incremental dose, 15-min lockout interval and 4-h limit of 240 mg. Patients were assessed at 0, 2, 4, 8, 12, 24 and 48 h after operation for verbal analogue pain scores at rest and at movement. Consumption of tramadol on first and second postoperative days and any adverse effects were also recorded. RESULTS: Verbal analogue pain scores were significantly lower on first postoperative day at all times of observation both at rest and at movement in gabapentin group than in placebo group (P<0.01). Tramadol consumption was also reduced by 33% in gabapentin group. But pain scores and tramadol consumption were similar in two groups on second postoperative day. Sedation was common but the incidence of postoperative nausea and vomiting was significantly lower in gabapentin group. CONCLUSION: Preoperative administration of 600 mg of gabapentin resulted in significant reduction in postoperative verbal analogue pain scores at rest and at movement as well as tramadol consumption compared with placebo on first postoperative day. Lower incidence of nausea and vomiting was an additional advantage. Sedation was the commonest side effect. PMID- 19935071 TI - Addition of dexmedetomidine to bupivacaine for greater palatine nerve block prolongs postoperative analgesia after cleft palate repair. AB - BACKGROUND AND OBJECTIVE: The effect of dexmedetomidine on the duration of sensory blockade has not been studied in humans. We evaluated the effect of adding dexmedetomidine to bupivacaine on the duration of postoperative analgesia in children who underwent repair of a cleft palate. METHODS: Thirty children who were scheduled for repair of a complete cleft palate using a combination of general anaesthesia and greater palatine nerve block were allocated randomly into one of two equal groups (n = 15). In both groups, the greater palatine nerve block was performed bilaterally using 0.5 ml of solution on each side. The B group received bupivacaine 0.25%, whereas the BD group received bupivacaine 0.25% with 1 microg kg(-1) dexmedetomidine. Heart rate, systolic blood pressure, pain score, the time to the first request for analgesia, and the degree of sedation were recorded. RESULTS: There was no difference in haemodynamic variables between the two groups. The pain score was significantly higher in the B group as compared with the BD group. The time to the first request for analgesia was significantly longer in children in the BD group (mean 22 h, range 20.6-23.7 h) as compared with those who received bupivacaine alone (14.2 h, 13-15 h). Sedation scores in the postoperative period did not differ between the study groups. CONCLUSION: Greater palatine nerve block with a combination of dexmedetomidine and bupivacaine increased the duration of analgesia after repair of a cleft palate by 50% with no clinically relevant side effects. PMID- 19935072 TI - Ultrasound-guided external jugular vein cannulation for central venous access by inexperienced trainees. AB - BACKGROUND AND OBJECTIVE: The insertion of central venous catheters via the external jugular vein (EJV) is not always practical because of the relatively frequent failure rate; thus, the internal jugular approach is generally used. Data from the literature suggest that ultrasound-guided catheterization of the internal jugular vein is superior to the surface anatomy landmark technique and, therefore, should be the method of choice. We evaluated the value of ultrasound guidance in the learning process of central venous cannulation via EJV by similarly inexperienced trainees. METHODS: In this prospective randomized study, 60 patients were assigned to two groups: group SA (surface anatomy; n = 30) underwent insertion of the central venous catheter using landmark guidance and group US (ultrasound; n = 30) underwent insertion using ultrasound guidance. In all patients, catheter insertion through the right EJV was performed by trainees in their second year of training. Ultrasound guidance was carried out by the same ultrasound specialist. The following parameters were evaluated in all patients: the number of successful punctures of the right EJV, the total number of attempts and the time to vein puncture; the number of successful insertions of the central venous catheter, the number of attempts and the duration of catheterization (from puncture of EJV to external fixation of the catheter); and the incidence of complications. The study was approved by the institutional ethics committee, and all patients gave written informed consent. Data were expressed as mean +/- SD. Student's t-test, Mann-Whitney test and chi2-test were used for analysis and P < 0.05 was considered statistically significant. The power of the study was 85%. RESULTS: The EJV puncture was successful in 24 out of 30 (80%) patients from group SA and in 22 out of 30 (73%) patients from group US (P = NS). There were no statistically significant differences between the groups regarding the mean time to perform the vein puncture and the number of attempts. The insertion of the central venous catheter was performed successfully in 10 (33%) patients from group SA and six (20%) patients from group US. The success rate of central cannulation via the EJV approach was 10 out of 24 (42%) in group SA and six out of 22 (27%) in group US (P = NS). The total time for insertion and the number of attempts were similar in both groups (P = NS). Local haematoma occurred in 11 patients in group SA and in three patients in group US (P = NS). CONCLUSION: Our results demonstrate no significant differences between the conventional surface anatomy landmark technique and the ultrasound-guided technique for the insertion of a central venous catheter via EJV by inexperienced trainees. PMID- 19935073 TI - Continuous mixed venous and central venous oxygen saturation in cardiac surgery with cardiopulmonary bypass. AB - BACKGROUND AND OBJECTIVE: Replacing mixed venous oxygen saturation (SvO2) monitoring by central venous oxygen saturation (ScvO2) monitoring in order to avoid the use of a pulmonary artery catheter and its related complications is still controversial in the setting of cardiac surgery. The influence of surgery, cardiopulmonary bypass and anaesthesia drugs on the relationship between SvO2 and ScvO2 has never been studied. METHODS: Fifteen patients scheduled for cardiac surgery with cardiopulmonary bypass were included in the study. SvO2 (from the pulmonary artery) and ScvO2 (from the superior vena cava) were continuously measured with fibre-optic catheters from induction of anaesthesia to 24 h postoperatively. RESULTS: A total of 9267 pairs of measurements were recorded. Mean bias between SvO2 and ScvO2 was 4.4% with limits of agreement of -13.6 and +22.5%, respectively. Trends of SvO2 and ScvO2 values followed very different patterns for some patients. Surgery, cardiopulmonary bypass and anaesthesia drugs did not influence the relationship between the two methods. CONCLUSION: Because of the large interindividual variability in the difference between SvO2 and ScvO2, the measure of ScvO2 should not replace the measure of SvO2 with a pulmonary artery catheter for the management of patients undergoing cardiac surgery with cardiopulmonary bypass. PMID- 19935074 TI - Bilateral pneumothorax during transoral incisionless fundoplication. PMID- 19935075 TI - Rectal gonorrhea and chlamydia reinfection is associated with increased risk of HIV seroconversion. AB - INTRODUCTION: HIV infection continues to disproportionately affect men who have sex with men (MSM). Identification of modifiable risk factors for HIV infection among MSM is critical for effective prevention. METHODS: We examined the relationship between number of prior rectal Neisseria gonorrhoeae (GC) or Chlamydia trachomatis (CT) infections and HIV seroconversion in a retrospective cohort of HIV-uninfected MSM diagnosed with a rectal infection. Number of rectal CT or GC infections in the prior 2 years was the primary exposure. Univariate and multivariate Cox proportional hazards models were used to estimate the association between prior rectal infections and HIV seroconversion. RESULTS: A total of 541 MSM were observed for a total of 1197.96 person-years. Overall, 27 (4.99%) of the MSM became infected with HIV, for an estimated annual incidence of 2.25% [95% confidence interval (CI): 1.49 to 3.26]. In multivariate analysis, an early syphilis diagnosis in the past 2 years (hazard ratio = 4.04, 95% CI: 1.19 to 13.79) and 2 prior CT or GC rectal infections in the past 2 years (hazard ratio = 8.85, 95% CI: 2.57 to 30.40) were associated with incident HIV. CONCLUSIONS: Among MSM infected with rectal GC or CT, a history of 2 additional prior rectal infections was associated with an 8-fold increased risk of HIV infection. HIV-uninfected MSM with multiple rectal infections represent a population in need of innovative HIV-prevention interventions. PMID- 19935076 TI - CO liberated from a carbon monoxide-releasing molecule exerts a positive inotropic effect in doxorubicin-induced cardiomyopathy. AB - Carbon monoxide (CO) liberated by a water-soluble carbon monoxide-releasing molecule (CORM-3) induces a positive inotropic effect with a negative chronotropic effect in normal rat hearts. However, the efficacy of CORM-3 under conditions of chronic cardiac insufficiency is unknown. In a rat model of doxorubicin-induced cardiomyopathy, CORM-3 (20 microg/min) produced a positive inotropic effect as demonstrated by significant increases in systolic pressure (P < 0.05) and pressure derivative (dp/dt max) over time (P < 0.05). A similar dose of CO-depleted negative control (inactive CORM-3) failed to cause any change in these parameters. When the inotrope dobutamine was added at a dose of 10 microM following CORM-3, there was no additional increase in systolic pressure or dp/dt max. However, significant rises in systolic pressure and dp/dt max were observed after dobutamine administration to the hearts previously treated with inactive CORM-3. These results suggest that CORM-3 produces a positive inotropic effect in doxorubicin cardiomyopathy rat hearts, similar to that reported previously in normal hearts. The inotropic effect produced by CO in the doxorubicin cardiomyopathy heart was mimicked by a classical inotrope (dobutamine), suggesting that either a maximal inotropic effect is achieved at this dose of CORM-3 or both drugs utilize shared signaling pathways in cardiac muscle. PMID- 19935077 TI - Curcumin reduces angiotensin II-mediated cardiomyocyte growth via LOX-1 inhibition. AB - BACKGROUND: Curcumin, a natural polyphenolic compound, has been shown to reduce cardiomyocyte growth. Angiotensin II type 1 receptor (AT1R) and lectin-like oxidized low density lipoprotein (ox-LDL) receptor-1 (LOX-1) are major stimuli for cardiomyocyte growth via activation of oxidant signals. We postulated that curcumin may reduce Ang II-mediated cardiomyocyte growth via AT1R and LOX-1 inhibition. METHODS: Adult mouse cardiomyocytes (HL-1) were incubated overnight in serum-free medium, and then treated with solvents or curcumin, the AT1R inhibitor losartan or anti-LOX-1 antibody for 3 hours, and the cells were then stimulated with Ang II. We measured cardiomyocyte growth, and associated intracellular redox signals using reverse transcriptase-polymerase chain reaction and quantitative real-time RT-PCR. We also examined the effect of curcumin on cardiomyocyte biology with forced overexpression of LOX-1 gene. RESULTS: Curcumin (5-10 microM), losartan, and anti-LOX-1 antibody markedly attenuated Ang II mediated oxidant stress, and the expression of nicotinamide adenine dinucleotide phosphate (NADPH) oxidase and nuclear factor-kappaB (NF-kappaB). Attenuation of redox state by curcumin resulted in abrogation of Ang II-mediated cardiomyocyte growth and atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP) genes. Curcumin also reduced Ang II-mediated upregulation of AT1R and LOX-1. The forced upregulation of LOX-1 enhanced the expression of genes for AT1R, ANP, and BNP, and curcumin pretreatment reduced LOX-1 and AT1R expression and LOX-1 mediated increase in hypertrophy markers. CONCLUSIONS: Curcumin attenuates Ang II mediated cardiomyocyte growth by inhibiting LOX-1 and AT1R expression and suppressing the heightened intracellular redox state. PMID- 19935079 TI - Inhibition of calcium-calmodulin-dependent kinase II suppresses cardiac fibroblast proliferation and extracellular matrix secretion. AB - Calcium-calmodulin-dependent protein kinase II (CaMKII) is one of the main protein kinases mediating intracellular Ca changes. It is also involved in the process of cardiac diseases, such as cardiac hypertrophy, but its effects on myocardial fibrosis remain unclear. The present study investigates whether CaMKII is involved in cardiac fibroblast proliferation and extracellular matrix (ECM) secretion induced by angiotensin II (AngII) or electrical field stimulation (EFS) in cultured neonatal rat cardiac fibroblasts. Cardiac fibroblast proliferation was assessed by a cell survival assay (MTT) and manual cell enumeration. Cellular matrix production was demonstrated by matrix metalloproteinases (MMP) 1, 2, 9, and collagen I/III messenger RNA expression, MMP-2, 9 protein expression, and secretion of transforming growth factor beta1 and tumor necrosis factor alpha. Either AngII or EFS promoted cardiac fibroblast proliferation and ECM secretion, while also up-regulating expression of CaMKII deltaB and deltaC. More importantly, CaMKII inhibitors, autocamtide-2-related inhibitory peptide (AIP 5 microM) or KN93 (0.5 microM), suppressed cardiac fibroblast proliferation, inhibited the excretion of transforming growth factor beta1 and tumor necrosis factor alpha, decreased the messenger RNA expression of MMP-1, 2, 9 and collagen I/III, and decreased the protein expression of MMP-2, 9. These results suggest that CaMKII mediates cardiac fibroblast proliferation and ECM secretion induced by either AngII or EFS. PMID- 19935080 TI - Preventive effect of a proteasome inhibitor on the formation of accelerated atherosclerosis in rabbits with uremia. AB - Inflammation plays a central role in the pathogenesis of atherosclerosis. This study investigated whether the proteasome inhibitor has the same preventive effect on the formation of accelerated atherosclerosis in rabbits with uremia compared with a NF-kappaB inhibitor. New Zealand white rabbits were subjected to five-sixths nephrectomy (chronic renal failure [CRF]) or to a sham operation. Rats in each group were randomly assigned into three subgroups (n = 24 in each group) and treated with repeated intramuscular injections of proteasome inhibitor MG132 or NF-kappaB inhibitor PDTC for a specified period. Compared with sham rabbits, CRF rabbits displayed typical atherosclerotic changes (endothelial cell damage, intimal thickens, and appearance of foam cells). CRF rabbits had significantly higher levels of proteasome activity, NF-kappaB mRNA, protein, and DNA binding activity as well as tumor necrosis factor-a and proliferative cell nuclear antigen protein expression in aortic wall cells. CRF rabbits also showed lower levels of IkappaBalpha. Compared with CRF rabbits, CRF rabbits treatment with proteasome inhibitor MG132 showed restoration of IkappaBalpha mRNA and protein expression and decreased NF-kappaB DNA binding activity and tumor necrosis factor-a expression. Treatment with either proteasome inhibitor MG132 or NF-kappaB inhibitor PDTC could reverse these pathologic changes in the aortic wall cells of CRF rabbits. A comparison between the inhibitory effects of the two treatments revealed no statistical difference. These results suggest that ubiquitin-proteasome activation play a pivotal role in the pathogenesis of uremia accelerated atherosclerosis. The ubiquitin-proteasome signaling pathway in aortic cells may therefore be an important target for preventing uremia-accelerated atherosclerosis. PMID- 19935081 TI - Fatigue as a determinant of health in patients with celiac disease. AB - BACKGROUND: Symptoms of uncontrolled celiac disease impair patients' health related quality of life, which improves with the exclusion of gluten from the diet. A symptom frequently reported, but difficult to make objective, is fatigue. The Daily Fatigue Impact Scale (D-FIS) questionnaire consisting of 8 items, each scored on a 0 to 4 point scale, with lower scores reflecting greater fatigue, was employed to measure fatigue in celiac patients. GOALS: To assess the influence of fatigue on perception of health in celiac disease patients determined as their quality of life. STUDY: Prospective, cross-sectional study in celiac disease patients diagnosed by serology and histology. Instruments used were the D-FIS to measure fatigue and the generic EuroQol5D to measure quality of life. An additional question on the frequency of problems due to fatigue, scored on a 7 point Likert scale, was used to evaluate the importance of fatigue. RESULTS (IN MEDIANS): In all, 51 patients were included (13 untreated and 38 treated with a gluten-free diet). D-FIS score was significantly worse in untreated celiacs (16.0 vs. 3.0, P<0.001). Scores on the frequency scale of fatigue-related problems were also worse in untreated celiacs (2.0 vs. 6.0, P<0.001). Fatigue and quality-of life scores were inversely correlated (r=-0.6, P<0.001). Fatigue severity was also greater in patients with worse quality of life (13.0 vs. 2.0, P<0.01). Multiple regression analysis showed fatigue to be an independent determinant of quality of life. CONCLUSIONS: Fatigue is a major concern in untreated celiac disease patients, which impacts their quality of life. PMID- 19935082 TI - Patient acceptance, convenience, and efficacy of single-dose versus split-dose colonoscopy bowel preparation. PMID- 19935083 TI - An in-depth psychosocial and biochemical evaluation in transplant recipients for alcoholic liver disease should be planned. PMID- 19935084 TI - Hyponatremia in cirrhosis answers and questions. PMID- 19935085 TI - Rapid antidepressant effect of ketamine anesthesia during electroconvulsive therapy of treatment-resistant depression: comparing ketamine and propofol anesthesia. AB - BACKGROUND: Reports of the superiority of the antidepressant effect of ketamine during the conduct of electroconvulsive therapy (ECT) have been limited. We conducted an open-label trial of ketamine to determine whether ketamine as the anesthetic during ECT would provide a greater antidepressant effect than the antidepressant effect obtained with propofol. METHODS: Between April 2006 and April 2007, 31 inpatients with treatment-resistant depression gave written consent for ECT and to participate in this study. An anesthesiologist who was unaware of the mental symptoms of the subjects assigned them to receive propofol or ketamine anesthetic according to the preferences of the patients, and the patients underwent 8 ECT sessions for 4 weeks. The Hamilton Depression Rating Scale (HDRS) was valuated before ECT and after the completion of the second, fourth, sixth, and eighth ECT sessions. RESULTS: The HDRS scores improved earlier in the ketamine group, with decreases in HDRS scores that were significantly greater in the ketamine group. CONCLUSIONS: The results suggested that it is possible to improve symptoms of depression earlier by using ketamine anesthesia. PMID- 19935086 TI - Unmodified electroconvulsive therapy: the perspective of patients from a developing country. AB - BACKGROUND: The controversy that exists over the relevance of electroconvulsive therapy (ECT) in contemporary psychiatric care often excludes the opinion of patients. Optimizing ECT service delivery must include the perspectives and input of service users. In Nigeria, the opinions of patients have not been explored. AIM: To evaluate the perspective of patients who have previously received ECT toward the process of delivery and the benefits and adverse effects of unmodified ECT. METHOD: Ninety consecutive consenting stable outpatients who had received unmodified ECT between 6 and 12 months from the time of study were surveyed in a cross-sectional study design over a 3-month period using a semistructured Likert type questionnaire at a referral psychiatric hospital in Nigeria. RESULTS: Most (75.5%) of the patients did not find the procedure stressful and reported ECT being beneficial (82.2%). Most complained of deficiency in the process of ECT service delivery and reported not been adequately informed before receiving ECT (88.9%). A third reported experiencing memory impairment after ECT. Headaches and muscle pains were reported in 8.9% and 17.8% of patients, respectively. Patients who experienced headaches after ECT were more likely to perceive ECT as stressful (P < 0.005), whereas those who experienced memory impairment were less likely to receive ECT again if indicated (P < 0.001). CONCLUSIONS: Unmodified ECT is fairly well accepted among patients, although a majority complained of deficiencies in information provided about and consent toward the procedure. Improving ECT service delivery and addressing adverse effects may improve treatment acceptability. PMID- 19935087 TI - New-onset dissociative disorder after electroconvulsive therapy. AB - Electroconvulsive therapy (ECT) is an exceptionally effective treatment for a number of psychiatric conditions; however, a common adverse effect is temporary cognitive impairment, especially memory loss. The dissociative disorders also involve disturbances of memory, as well as consciousness and personal identity, but are rarely iatrogenic. We report a case in which dissociative symptoms developed after ECT. A 51-year-old woman with hypothyroidism, migraine headaches, bipolar disorder, and anorexia by history was admitted for worsening depression with suicidal ideation. After a course of 7 right-sided ECT treatments, she experienced remarkable personality change, claiming that it was 1976 and behaving as though she was 30 years younger. Neuropsychological tests were normal, and her memory and former personality spontaneously returned 2 weeks later. This case illustrates that such events may be seen in patients with certain psychiatric profiles, and further studies are needed to determine the risk factors for the occurrence of dissociative episodes after ECT. PMID- 19935088 TI - The level of serum brain-derived neurotrophic factor is associated with the therapeutic efficacy of modified electroconvulsive therapy in Chinese patients with depression. AB - OBJECTIVE: To investigate the association between the level of serum brain derived neurotrophic factor (sBDNF) and the therapeutic efficacy of modified electroconvulsive therapy (MECT) in Chinese patients with depressive disorder. METHODS: Twenty-eight patients with depressive episode and 28 healthy subjects were recruited in the current study. The sBDNF level was examined in all subjects before treatment and after a 2-week treatment with MECT in patients with depression. The severity of depression was measured according to the 17-item Hamilton Rating Scale for Depression in patients with depression. RESULTS: The severity of depression reduced significantly in patients with depression after a 2-week treatment with MECT (31.39 [SD, 4.65] vs 8.14 [5.52], P < 0.001). Serum BDNF level in patients with depression was significantly lower than that of the control group before treatment (5.66 [SD, 2.07] vs 9.17 [SD, 1.26] ng/mL, P < 0.001), then increased remarkably to the level of control subjects 2 weeks after MECT (7.90 [SD, 3.42] ng/mL). The increasing rate of sBDNF in patients with depression was significantly correlated with the decreasing rate of the total 17 item Hamilton Rating Scale for Depression score (r = 0.532, P = 0.004) and cluster scores of cognitive dysfunction (P = 0.018) and retardation (P = 0.048). CONCLUSION: The change in sBDNF is associated with the therapeutic efficacy of MECT in Chinese patients with depression. PMID- 19935089 TI - Electroconvulsive therapy-responsive catatonia in a medically complicated patient. AB - BACKGROUND: Profoundly depressed states of awareness classified as either catatonia or akinetic mutism have been reported in patients with various general medical conditions including encephalitis, frontal lobe tumors, or paraneoplastic limbic encephalitis. Catatonic features are often difficult to apprise in this context. This can result in electroconvulsive therapy (ECT) discontinuation, although it remains the most effective treatment of catatonia. CASE REPORT: We describe the case of a patient with a history of unresectable right retroorbital squamous cell carcinoma, status poststereotactic radiation and cisplatin, and subsequent pneumococcal meningitis of the temporal lobe with abscess formation who became catatonic after receiving 3 bitemporal treatments with ECT for severe depression and whose catatonia improved with continued ECT. Furthermore, she demonstrated progressive improvement in mood, interactivity, and overall neurologic function after ECT treatment was completed. CONCLUSIONS: The search for an etiology of a profound catatonic state should include the probability of underlying medical disorder. Although lorazepam may be helpful in some cases, ECT deserves early consideration in catatonia, especially in cases where the underlying cause seems to be uncertain, even if the catatonia begins in the midst of treatment. PMID- 19935090 TI - Electroconvulsive therapy for catatonia: treatment characteristics and outcomes in 27 patients. AB - OBJECTIVES: Electroconvulsive therapy (ECT) has been described as an effective treatment option for catatonia in retrospective case series. We aimed to investigate treatment characteristics and outcomes of patients with catatonia who were treated with ECT. METHODS: The medical records of 27 patients with catatonia treated with ECT (between 1991 and 2009) were scrutinized for clinical and treatment characteristics. Outcomes were measured using the Clinical Global Impression-Improvement (CGI-I) scale. Patients who improved (defined as CGI-I score "very much" or "much improved") were compared with those who did not improve (defined as a CGI-I score "no change" or "very much worse"). RESULTS: Mean age of all patients was 49 +/- 19 years, of whom 15 (56%) were women. Of all patients, 13 (48%) had a diagnosis of a mood disorder and 12 (44%) of a psychotic disorder. Electroconvulsive therapy was mostly started after ineffective pharmacotherapy (n=23; 85%) within 2 to 3 months after catatonia had been diagnosed. In total, 16 (59%) patients improved. Improvement was significantly associated with younger age (P=0.05), presence of autonomic dysregulation at baseline (P=0.02), especially higher body temperature (P=0.02), daily ECT during the first treatment week (n=15 [56%]; P=0.03), longer duration of electroencephalogram seizure activity at last ECT session (P=0.04), and less morbidity in the year after ECT (P=0.03). Three of 11 nonimproved patients died in the year after ECT compared with none of the improved patients. CONCLUSIONS: Most of our patients with catatonia benefited from ECT, especially younger patients with autonomic dysregulation. Daily administration of ECT may be more effective, whereas longer duration of seizure activity at the final ECT session was related to better response to ECT. PMID- 19935091 TI - Combination of pharmacotherapy with electroconvulsive therapy in prevention of depressive relapse: a pilot controlled trial. AB - OBJECTIVE: Relapse rates after electroconvulsive therapy (ECT) remain high with standard treatments. We aimed to test the efficacy of an early administered continuation pharmacotherapy (c-pharm early) strategy in prevention of post-ECT relapse. METHOD: A 20-week, randomized, double-blind, placebo-controlled trial. Patients aged 18 to 65 years diagnosed with Diagnostic and Statistical Manual of Mental Disorders major depressive disorder, with or without psychotic features, with initial Montgomery-Asberg Depression Rating Scale scores higher than 22, underwent 8 bilateral ECT sessions (2 per week). Randomization to c-pharm early, c-pharm late, and placebo groups in 2:2:1, respectively, was performed at the completion of the fourth ECT session. After randomization, subjects in the c pharm early group were given sertraline at 150 mg/d. Subjects in the c-pharm late group were first given placebo, which was substituted with sertraline at 150 mg/d at the completion of the eight ECT. Relapse was defined as a Montgomery-Asberg Depression Rating Scale score of 16 or higher. RESULTS: Seventy-three percent of the patients responded to the given treatment. The relapse rates were 12.5% in the c-pharm early group, 28% in the c-pharm late group, and 67% in the placebo group (P = 0.09). The c-pharm early strategy resulted in significantly lower relapse rates and longer well time compared with the placebo (P = 0.04). When the trend with the initiation of the c-pharm intervention was investigated in the 3 groups with equally spaced trend weights, the time of initiation was found to have a significant effect on the probability of the remaining well (P = 0.03). CONCLUSIONS: Comparative efficacy of c-pharm early and late strategies in providing improved protection against post-ECT relapse of major depressive disorder needs to be further explored. PMID- 19935092 TI - Absence of asystole during bifrontal stimulation in electroconvulsive therapy. AB - Cardiac action was monitored during the stimulation period of 120 consecutive electroconvulsive therapies. Electrode placement was right unilateral in 73, bitemporal in 11, and bifrontal in 36 cases. Anticholinergic premedication was routinely given. A reduction in heart rate was seen consistently with unilateral electrode placement and asystole longer than 2 seconds occurred in 63% of cases. In contrast, no asystole occurred with bifrontal electrode placement. Thus, the vagus nerve seems to be less activated during bifrontal stimulation. PMID- 19935093 TI - Continuation-maintenance electroconvulsive therapy: quality standards in 3 Australian aged psychiatry services. AB - OBJECTIVE: To check if experienced psychiatrists in Victoria, Australia, observed the standards outlined by the American Psychiatric Association and the Royal College of Psychiatrists regarding the administration and monitoring of continuation-maintenance electroconvulsive therapy (ECT). METHODS: A retrospective chart review of 60 consecutive patients given continuation maintenance ECT in 3 Victorian public aged psychiatry services. RESULTS: Practice guidelines were often not observed concerning documentation of treatment plans, mental state reviews and patients' and carers' viewpoints. CONCLUSIONS: Continuation-maintenance ECT proved highly effective in this clinical sample. Our audit identifies areas for improvement in clinical practice. It will be helpful to have a simple checklist of treatment plans, rating scale scores, and discussions with patients and carers that clinicians can complete at regular intervals. PMID- 19935094 TI - Electroconvulsive therapy in the presence of a metallic skull plate after meningioma resection. AB - Electroconvulsive therapy (ECT) is an effective and safe treatment even in the frail and in the medically ill. A case report of ECT being administered to a patient with a history of a recently resected meningioma and the presence of a metallic skull plate is presented here. The patient has a history of bipolar disorder in remission but had an acute manic episode with psychotic features after resection of suprasellar meningioma. He presented with superimposed delirium that complicated the presentation. Because there was no effective resolution with medications, ECT was administered. This case documents the safe administration of ECT in complicated situations such as these. This case also demonstrates that ECT can be successfully administered in the presence of superimposed delirium and after a recent meningioma resection. Clinical skills and expertise are required to safely and effectively administer ECT in such cases. PMID- 19935095 TI - One hundred twenty years of mental health care in Thailand and the development of electroconvulsive therapy. AB - BACKGROUND: Mental health care in Thailand was founded by King Chulalongkorn on November 1, 1889, from which time it has been managed by the Thai government. OBJECTIVE: To briefly describe the origin and the developments of mental health care and electroconvulsive therapy (ECT) in Thailand. RESULTS: Thai mental health care has undergone extensive changes over the last 120 years in the quantity and the quality of techniques, the services, and the management provided. Thai mental health development can be divided into 7 periods based on specific characteristics. Regarding biological treatment, there is a long history of such development in Thailand starting with fever therapy and insulin coma therapy initiated in 1936 and Metrazol convulsive therapy in 1939. Electroconvulsive therapy was introduced in 1950. Modified ECT was subsequently commenced in 1974. A recent survey of ECT practice in Thailand indicated an ECT use rate of 11.2 patients treated per 100,000 with 93% of all ECTs being performed in psychiatric hospitals and 94% of all ECT treatments unmodified. At present, only 5 university hospitals routinely administer modified ECT. CONCLUSIONS: Through cooperation with all available public and private agencies and through the support given to encourage active participation in the community, mental health care in Thailand continues to improve and evolve. However, regarding ECT development, little has been done despite a high ECT use rate, and as such, some form of reform is needed to achieve and maintain optimal standards in its practice. PMID- 19935096 TI - Isolated right anterior chamber relapse in a patient of acute lymphoblastic leukemia presenting with facial nerve palsy. PMID- 19935097 TI - Thalassemia intermedia with iron deficiency. PMID- 19935098 TI - Coexistence of a giant splenic hemangioma and multiple hepatic hemangiomas mimicking a left adrenal neuroblastoma accompanied with multifocal hepatic metastases: pyrite answer. AB - A 4-month girl presenting with a giant mass in left adrenal region and multiple hepatic nodules was hospitalized. On the basis of computed tomography, ultrasound and epidemiology we preferred the diagnosis of a left adrenal neuroblastoma accompanied with multiple hepatic metastases preoperatively. But postoperative diagnosis was hemangiomatosis characterized by synchronous presence of a giant splenic hemangioma and multiple hepatic hemangiomas. We think that it is deservedly reported because of not only its rarity but also pitfalls of preoperative differential diagnosis and management principle. PMID- 19935099 TI - Brainstem glioma presenting as pruritus in children with neurofibromatosis-1. AB - Children with neurofibromatosis type 1 (NF1) are at increased risk of developing tumors of the nervous system. The most common intracranial tumors are low-grade astrocytomas, which most frequently involve the optic pathway, and less often, the brainstem. In cases of brainstem glioma in NF1, treatment decisions are frequently complicated by the paucity of symptoms referable to the tumor. Here, we describe 2 children with NF1 whose initial presentation of a growing brainstem glioma was localized pruritus. This unusual presentation emphasizes the importance of appreciating subtle, often hard to localize, symptoms in this high risk population. PMID- 19935100 TI - Partial occlusion during resistance exercise alters effort sense and pain. AB - The purpose of the study was to determine how manipulation of peripheral blood flow during resistance exercise using a light load affected perception and physiological measures compared with moderate load resistance exercise and a control trial. Seven subjects performed a 3 (session) by 2 (biceps curls and calf extensions) within-subjects study that was randomized and counterbalanced across 3 weeks. The 3 sessions included (a) light resistance exercise (3 sets to failure) at 30% of 1 repetition maximum (1RM) with partial occlusion (LRO), (b) moderate resistance at 70% of 1RM with no occlusion (MR), and (c) partial occlusion without exercise (OO). Ratings of perceived exertion (RPE), pain, and heart rate were assessed immediately after each set, whereas blood samples were taken before, immediately after, and 15 minutes after exercise. Results demonstrated that RPE and pain were lower in the OO condition than that in the MR and LRO conditions for biceps curls and calf extensions, Fs(2 ,24) = 22.75, 20.86, ps < 0.0001 and Fs(2,24) = 18.95, 24.52, ps < 0.01; however, no significant differences were noted between MR and LRO conditions. Heart rate was significantly higher for the LRO condition when compared with the MR trial, F(2,18) 20.12, p < 0.001. Results suggest that when partial vascular occlusion with a light load was applied, both pain and effort sense were altered to a similar degree as moderate loads but no occlusion. The practical application of results were that individuals may be better able to tolerate perceptual change at low loads with partial occlusion because joint stress may be minimized while local muscle metabolic demands increase, making resistance training maximally effective and minimally stressful on joints. Perceptual tracking of effort and pain may aid coaches who attempt this protocol. PMID- 19935101 TI - Optimal loading for the development of peak power output in professional rugby players. AB - The ability to develop high levels of muscular power is considered an essential component of success in many sporting activities; however, the optimal load for the development of peak power during training remains controversial. Our aim in the present study was to determine the optimal load required to observe peak power output during the ballistic bench throw (BBT) and squat jump (SJ) in professional rugby players. Forty-seven, professional, male, rugby players of (mean +/- SD) mass 101.3 +/- 12.8 kg and height 1.82 +/- 0.08 m volunteered and gave informed consent for this study, which was approved by a university ethics committee. Players performed BBT at loads of 20, 30, 40, 50, and 60% of their predetermined 1 repetition maximum (1RM) and SJ at loads of 0, (body mass only), 20, 30, 40, 50, and 60% of their predetermined 1RM in a randomized and balanced order. Power output (PO) was determined by measurement of barbell displacement with subsequent calculation of velocity, force, and power. Relative load had a significant effect on PO for both the BBT (effect size eta(2): 0.297, p < 0.001) and SJ (Effect Size eta(2): 0.709, p < 0.001). Peak power output was produced when the athletes worked against an external load equal to 30% 1RM for the upper body and 0% 1RM for the lower body. PMID- 19935102 TI - The effect of beta-alanine supplementation on power performance during repeated sprint activity. AB - The dipeptide carnosine has been shown to contribute to the buffer capacity of hydrogen ions (H) during intense exercise. Increasing skeletal muscle carnosine levels through beta-alanine (BA) supplementation has been shown to maintain acid base balance, delay fatigue, and improve exercise performance. We designed this study to examine the effect of 5 weeks of BA supplementation on repeat high intensity sprint performance. Nineteen, physically active, college men were divided into 2 groups (control [C], n = 10 or BA, n = 9). We performed double blind placebo-controlled study where subjects ingested 4 g per day during the first week and 6 g per day over the next 4 weeks of a placebo (rice flour) or a BA supplement. Subjects completed 2 sets of 5 5-second sprints with 45-second recovery separated by 2 minutes of active recovery. All tests were conducted on a non-motorized treadmill against a resistance of 15% of the participant's body weight. We recorded horizontal power (HP) of the running sprint. Post-exercise capillary blood samples were analyzed for lactate to determine the metabolic demands. There were no significant between-group differences (p > 0.05) in HPpeak or HPmean for the repeat sprint protocol. No significant between-group differences were found for performance decrement (% fatigue) for HPpeak or HPmean. In addition, no significant interactions were observed. Post-exercise blood lactate values were similar pre and post supplementation in both groups. The results of this study clearly indicate that 5 weeks of BA supplementation provides no benefit for repeat sprint performance. PMID- 19935103 TI - Changes in lipid peroxidation and antioxidant capacity during walking and running of the same and different intensities. AB - The aim was to investigate the changes in lipid peroxidation, antioxidant enzyme activities, and muscle damage in the same and different exercise intensities during walking and running. Fourteen healthy males participated in this study. The subjects' individual preferred walk-to-run transition speeds (WRTS) were determined. Each subject covered a 1.5-mile distance for 4 exercise tests; walking (WRTS-W) and running (WRTS-R) tests at WRTS, 2 kmxh-1 slower walking than WRTS (WRTS-2) and 2 kmxh-1 faster running than WRTS (WRTS+2). Blood samples were taken pre, immediately, and 30 minutes post each test. The changes in (MDA) and glutathione (GSH) levels and superoxide dismutase (SOD), catalase (CAT), and creatine kinase activities were measured. Oxygen uptake, carbon dioxide output, oxygen uptake per kilogram of body weight, and heart rate during exercises were significantly higher in both the WRTS-W and the WRTS+2 exercises compared with the WRTS-2 and WRTS-R. Oxygen consumption and energy expenditure were higher in walking than in the running exercise at the preferred WRTS and only WRTS-W exercise significantly increased MDA levels. Catalase activities were increased by WRTS-W, WRTS-R, and WRTS+2 exercises. Changes in SOD and CAT activities were not different between walking and running exercises at the preferred WRTS. Total plasma GSH increased in response to WRTS-W exercise, which could be associated with an increase in MDA. Also, total GSH levels 30 minutes postexercise were significantly lower than postexercise in WRTS-2, WRTS-W, and WRTS+2 exercises. Our results indicate that walking and running exercises at the preferred WRTS have different oxidative stress and antioxidant responses. PMID- 19935104 TI - Influences of body-size variables on age-related increases in isokinetic peak torque in young wrestlers. AB - The purposes of the present study were to determine the patterns of age-related changes in 1) height (HT), body weight (BW), fat-free weight (FFW), and absolute isokinetic peak torque (PT); and 2) isokinetic PT covaried separately for HT, BW, FFW, and HT and BW combined in young wrestlers. One hundred twenty-five male wrestlers (mean age +/- SD = 14.3 +/- 2.4 yr; range = 11.1-18.2 yr) volunteered to perform concentric, isokinetic leg extension and flexion at 180 degrees xs-1 on a Cybex II dynamometer to measure PT as well as underwater weighing to determine FFW. The polynomial regression analyses indicated there were significant quadratic increases across age for HT (R = 0.62), BW (R = 0.56), and FFW (R = 0.47). For leg extension, there were significant increases across age for absolute PT (quadratic, R = 0.66), PT covaried for HT (linear, r = 0.10), PT covaried for BW (linear, r = 0.12), PT covaried for FFW (quadratic, R = 0.32), and PT covaried for HT and BW combined (quadratic, R = 0.11). For leg flexion, there were significant increases across age for absolute PT (linear, r = 0.59), PT covaried for HT (linear, r = 0.07), PT covaried for BW (linear, r = 0.08), PT covaried for FFW (quadratic, R = 0.23), and PT covaried for BW and HT combined (linear, r = 0.03). The results of this study indicated that age-related increases in leg-extension and flexion PT for the current sample of young wrestlers could not be accounted for by changes in HT, BW, FFW, or HT and BW combined. These findings suggested that neural maturation may contribute to increases in leg strength across age in young wrestlers. PMID- 19935105 TI - Kinematic and kinetic comparisons of elite and well-trained sprinters during sprint start. AB - The purpose of this study was to compare the main kinematic, kinetic, and dynamic parameters of elite and well-trained sprinters during the starting block phase and the 2 subsequent steps. Six elite sprinters (10.06-10.43 s/100 m) and 6 well trained sprinters (11.01-11.80 s/100 m) equipped with 63 passive reflective markers performed 4 maximal 10 m sprint starts on an indoor track. An opto electronic motion analysis system consisting of 12 digital cameras (250 Hz) was used to record 3D marker trajectories. At the times "on your marks," "set," "clearing the block," and "landing and toe-off of the first and second step," the horizontal position of the center of mass (CM), its velocity (XCM and VCM), and the horizontal position of the rear and front hand (X(Hand_rear) and X(Hand_front)) were calculated. During the pushing phase on the starting block and the 2 first steps, the rate of force development and the impulse (F(impulse)) were also calculated. The main results showed that at each time XCM and VCM were significantly greater in elite sprinters. Moreover, during the pushing phase on the block, the rate of force development and F(impulse) were significantly greater in elite sprinters (respectively, 15,505 +/- 5,397 N.s and 8,459 +/- 3,811 N.s for the rate of force development; 276.2 +/- 36.0 N.s and 215.4 +/- 28.5 N.s for F(impulse), p < or = 0.05). Finally, at the block clearing, elite sprinters showed a greater XHand_rear and X(Hand_front) than well-trained sprinters (respectively, 0.07+/- 0.12 m and -0.27 +/- 0.36 m for X(Hand_rear); 1.00 +/- 0.14 m and 0.52 +/- 0.27 m for X(Hand_front); p < or = 0.05). The muscular strength and arm coordination appear to characterize the efficiency of the sprint start. To improve speed capacities of their athletes, coaches must include in their habitual training sessions of resistance training. PMID- 19935106 TI - Spleen artery embolization aggravates endotoxin hyporesponse of peripheral blood mononuclear cells in patients with spleen injury. AB - BACKGROUND: : Spleen artery embolization (SAE) increases the success of nonoperative management of spleen injury; however, the immune alternation after SAE is unclear. This study searched the endotoxin responses of peripheral blood mononuclear cells (PBMCs) in injured patients who received SAE. METHODS: : Patients were subsequently enrolled when their spleen injuries were confirmed by computed tomographic scan. Peripheral blood samples were obtained within first, at third, fifth, and seventh postinjury days. PBMCs were isolated; nuclear factor (NF)-kB translocations, phosphorylated I-kB expressions, and in vitro tumor necrosis factor (TNF)-alpha levels were assayed after endotoxin stimulation (ES). RESULTS: : Sixteen patients who received nonoperative managements were enrolled. Five patients received SAE (embolized patients) and 11 patients did not (nonembolized patients). Compared with those in controls, NF-kB translocations, phosphorylated I-kB expressions, and TNF-alpha levels after ES decreased significantly early in injured patients. NF-kB translocation and TNF-alpha levels after ES were indifferent at seventh day between nonembolized patients and controls, whereas significantly lower NF-kB p65 translocation and TNF-alpha levels after ES were found at seventh postinjury day in embolized patients than in controls. Compared with nonembolized patients, embolized patients had significantly lower levels of NF-kBp50 translocations after ES from first to third postinjury days and lower levels of NF-kB p65 translocations, TNF-alpha, and phosphorylated I-kB expressions after ES from first to fifth postinjury days. CONCLUSIONS: : SAE dysregulates the NF-kB system and aggravates the cytokine hyporesponse upon ES of PBMCs in patients with spleen injury. These results implicate that SAE alters immune response and may increase susceptibility to infections in injured patients. PMID- 19935107 TI - Trauma to the intracranial internal carotid artery. AB - BACKGROUND: : A 4-year retrospective review of injury to the intracranial internal carotid artery at the skull base was undertaken to assess the impact of the injuries and their consequence in both the adult and the pediatric population. METHODS: : The trauma registry followed by confirmatory chart reviews provided the total number of admissions, the mode of injury, demographics, and subdivided the trauma patients into the different groupings used in this study. RESULTS: : In our series, traumatic damage to the intracranial internal carotid artery represented 1.495% of all facial trauma seen during a 4-year period at a Level I Trauma Center. Of the 10 patients seen with injury to the intracranial internal carotid artery at the siphon, 3 were pediatric patents, and all of these ended with permanent neurologic deficits. Adults fared better, exhibiting either no neurologic symptoms or transient neurologic symptoms that resolved over time. The exception was a patient who expired in the Emergency Center from a clival fracture involving transaction of both intracranial internal carotid arteries. CONCLUSIONS: : Traumatic damage to the intracranial internal carotid artery is a rare event fraught with the difficulty of early diagnosis in the midst of major life-threatening multiorgan trauma. Within the different age groups, adults fared better than children. PMID- 19935108 TI - Comparison of the Airway Scope and Macintosh laryngoscope with in-line cervical stabilization by the semisolid neck collar: manikin study. AB - BACKGROUND: The usefulness of Airway Scope (AWS) and Macintosh direct laryngoscope (ML) for patients with trauma requiring intubation with in-line cervical stabilization for protection of the cervical spine was compared. METHODS: Thirty-three residents performed orotracheal intubation using ML and AWS in an intubation model with in-line cervical stabilization. The tracheal intubation success rate, time required for tracheal intubation, and number of trials of inserting the tracheal tube into the trachea were measured in individual residents. RESULTS: Two residents inserted the tube into the esophagus using ML (success rate: 93.9%), but all residents succeeded in tracheal intubation using AWS (success rate: 100%) (p = 0.492). The time required for intubation was similar using AWS and ML (15 seconds vs. 20 seconds, p = 0.261). The number of trials using AWS was significantly lower (2.0 times vs. 1.0 times, p = 0.001). CONCLUSION: The usefulness of AWS may be comparable with or greater than that of ML for oral intubation in trauma patients with in-line cervical stabilization. PMID- 19935109 TI - Impact of a hospital-acquired/ventilator-associated/healthcare-associated pneumonia practice guideline on outcomes in surgical trauma patients. AB - BACKGROUND: Evidence-based guidelines for managing nosocomial pneumonia were published in 2005. Subsequently, our surgical critical care service developed and implemented an adaptation of this guideline for use in our surgical trauma intensive care unit (STICU). This study examined outcomes for two STICU cohorts treated for pneumonia before and after guideline implementation. METHODS: A total of 130 charts were evaluated. The guideline cohort (GC) consisted of 65 patients with pneumonia managed by the surgical critical care service. These patients were prospectively identified for inclusion if they met specified clinical criteria for pneumonia diagnosis. The historical control cohort was identified retrospectively using ICD-9 coding. The primary outcome measure was ICU length of stay (LOS). Secondary outcome measures included overall LOS, mechanical ventilation days, mortality, and total cost of admission. The study was designed to have 80% power to detect a 1-day decrease in mean ICU LOS in a multivariable regression analysis. Descriptive differences were compared using two-sample t tests for continuous variables and chi for categorical variables. RESULTS: Baseline characteristics were not significantly different between cohorts. The multivariable regression analysis indicated a mean decrease of 4.6 days, 9.5 days, and 3.9 days for ICU LOS, overall LOS, and mechanical ventilation days, respectively, in the GC, with an expected mean cost reduction per admission of $23,322 (all significant at p or=36. LOS was higher at ISS >or=36 whereas TC was higher at 25 to 35. After controlling for study variables, rehabilitation was most strongly associated with LOS, TC, and LOS outliers. ISS 25 to 35 affected initial 48-hour TC most, while ventilation affected mortality most. "Abdomen, pelvic organs" and ISS 25 to 35 or >or=36 were more strongly associated with outcomes. CONCLUSIONS: Specific ISS and injured organs may be used to estimate resource use or mortality for monitoring quality of trauma care. To integrate a more efficient system of trauma care, variations in resource input among hospitals should be investigated. PMID- 19935112 TI - Microvascular reconstruction in children-a report of 46 cases. AB - BACKGROUND: : We report microvascular free tissue transfers in pediatric patients in a retrospective series. METHODS: : Forty-six children were treated in collaboration between the departments of Pediatric Surgery and Plastic Surgery, Helsinki University Hospital between 1986 and 2004 for microvascular free flap surgery. Trauma, tumor resection, congenital malformation, meningococcal septicaemia, and scars caused the tissue defects. The mean follow-up was 50 months. RESULTS: : The overall success rate was 96%. Twenty-five free flaps were transferred to the lower extremity. The most used flap was vascularized fibula. Preoperative angiography or intraoperative anticoagulants were not routinely used. Early reoperations were needed in four cases due to hematoma and in four cases due to thrombosis or impaired blood flow. All attempts of reanastomosis lead to salvage of the flap. CONCLUSION: : In cases of severe tissue defects in pediatric patients, microvascular free flap reconstruction is a treatment of choice. A multicenter study for guidelines on preoperative assessment and antitrombotic therapy in pediatric microsurgery is warranted. PMID- 19935113 TI - Anatomically contoured plates for fixation of rib fractures. AB - BACKGROUND: : Intraoperative contouring of long bridging plates for stabilization of flail chest injuries is difficult and time consuming. This study implemented for the first time biometric parameters to derive anatomically contoured rib plates. These plates were tested on a range of cadaveric ribs to quantify plate fit and to extract a best-fit plating configuration. METHODS: : Three left and three right rib plates were designed, which accounted for anatomic parameters required when conforming a plate to the rib surface. The length lP over which each plate could trace the rib surface was evaluated on 109 cadaveric ribs. For each rib level 3-9, the plate design with the highest lP value was extracted to determine a best-fit plating configuration. Furthermore, the characteristic twist of rib surfaces was measured on 49 ribs to determine the surface congruency of anatomic plates with a constant twist. RESULTS: : The tracing length lP of the best-fit plating configuration ranged from 12.5 cm to 14.7 cm for ribs 3-9. The corresponding range for standard plates was 7.1-13.7 cm. The average twist of ribs over 8-cm, 12-cm, and 16-cm segments was 8.3 degrees, 20.6 degrees, and 32.7 degrees, respectively. The constant twist of anatomic rib plates was not significantly different from the average rib twist. CONCLUSIONS: : A small set of anatomic rib plates can minimize the need for intraoperative plate contouring for fixation of ribs 3-9. Anatomic rib plates can therefore reduce the time and complexity of flail chest stabilization and facilitate spanning of flail segments with long plates. PMID- 19935114 TI - Therapeutic mild hypothermia: effects on coagulopathy and survival in a rat hemorrhagic shock model. AB - OBJECTIVE: : To determine the effects of therapeutic hypothermia on coagulation parameters during hemorrhagic shock (HS) and fluid resuscitation and on survival, in a rat HS model. METHODS: : Under light anesthesia and spontaneous breathing, 24 rats underwent HS (phase I) for 90 minutes, during which 2.5 mL/100 g blood was withdrawn over 15 minutes; fluid resuscitation (phase II) for 60 minutes, during which no blood was reinfused but 5.0 mL/100 g lactated Ringer's solution was infused over 30 minutes; and an observation (phase III) without anesthesia until 72 hour. After the volume-controlled hemorrhage, rats were randomized into a hypothermia group (n = 12, 33 degrees C) or a normothermia group (n = 12, 38 degrees C). The rectal temperature in each group was maintained during phases I and II. Whole blood coagulopathy was assessed by Sonoclot analysis (SA) at baseline and the end of phases I and II. Fibrinolysis parameters of thrombin antithrombin III complex and plasma-alpha-2-plasmin inhibitor complex were also monitored. RESULTS: : At 72 hour, 10 of 12 hypothermia group rats, and 5 of 12 normothermia group rats remained alive (p < 0.05). Fluid resuscitation significantly decreased hematocrit (20% +/- 5%) compared with baseline (33% +/- 5%; p < 0.05) in all rats. SA showed no significant differences between groups at the end of phase I. However, at the end of phase of II, SA revealed a decreased "clot rate" in hypothermia compared with normothermia (22 clot signal/min +/- 11 clot signal/min vs. 34 clot signal/min +/- 14 clot signal/min; p < 0.05) and a prolonged "time to peak" in hypothermia (15 minutes +/- 5 minutes versus 6 minutes +/- 2 minutes; p < 0.05). No differences in thrombin-antithrombin III complex and plasma-alpha-2-plasmin inhibitor complex values were seen between groups throughout the experiment. CONCLUSIONS: : Therapeutic mild hypothermia of 33 degrees C did not cause coagulopathy during HS, but did impair SA coagulation parameters during fluid resuscitation, probably because of dilution. Hypothermia also prolonged survival after HS. Impairments to coagulation parameters did not worsen outcomes in the rat HS model. PMID- 19935115 TI - Treatment of impacted greenstick forearm fractures in children using bandage or cast therapy: a prospective randomized trial. AB - BACKGROUND: To evaluate the relative risks and advantages of using soft bandage therapy (BT) for impacted greenstick fractures of the distal forearm compared with cast therapy (CT). METHODS: At a single center from September 2005 to October 2006 all patients with an impacted greenstick fracture were randomized to BT or CT. RESULTS: A total of 92 patients were randomized and assigned. No fracture displacement was seen. Three patients from the BT group were converted to standard treatment. A significant difference in pain was seen between both groups after 1 week in favor of the CT group. Discomfort was significantly less in the BT group compared with the CT group. After 4 weeks, the wrist function was significantly better in the BT group. After 6 weeks, the wrist functions of both the groups were comparable. CONCLUSIONS: BT for impacted greenstick fractures of the distal forearm is a safe technique, patients treated with bandage suffer greater pain at the start of the treatment, are able to return to normal activities sooner, and have less discomfort when compared with the standard CT. PMID- 19935116 TI - Evaluation of latent class analysis and decision thresholds to guide the diagnosis of pediatric tuberculosis in a Rwandan reference hospital. AB - SETTING: A pediatric ward of a university hospital in Kigali, Rwanda, a region with a high HIV seroprevalence. OBJECTIVE: To estimate the diagnostic accuracy of symptoms, signs, and paraclinical investigations for tuberculosis in children, and to propose a clinical rule based on the results. DESIGN: During a 2-year period all children with cough for more than 2 weeks and/or fever for more than 2 weeks and/or reported weight loss were prospectively included. A set of clinical and paraclinical data were analyzed with latent class analysis. Comparison of post-test probability based on this analysis with a therapeutic threshold for TB was used to develop a guideline. RESULTS: In the 309 children HIV prevalence was 56%, bacteriology was positive in 9%, and the tuberculin skin test (TST) was >10 mm in 20%. TB prevalence was 32%. Bacteriology and TST had a specificity of 97% and cough had a sensitivity of 91%. Decision analysis suggests treating children presenting one of the inclusion criteria, combined with positive bacteriology or TST >10 mm or contact with a TB patient. CONCLUSIONS: Latent class analysis confirmed earlier identified predictors for TB and allowed development of an easy to use clinical rule, applicable in reference hospitals of countries with high HIV endemicity. PMID- 19935117 TI - Survey of nonsusceptible nasopharyngeal Streptococcus pneumoniae isolates in children attending day-care centers in Brazil. AB - A survey of nasopharyngeal carriage of penicillin nonsusceptible pneumococcal (PNSp) isolates was conducted among 1192 children attending 62 day care centers in Brazil, where pneumococcal vaccination has not been routinely introduced. Nasopharyngeal pneumococcal carriage was detected in 686 (57.6%) infants, and 178 (25.9%) of them carried PNSp isolates. Being less than 24 months of age, hospitalization in the previous 3 months, and recurrent acute otitis media were independently associated with PNSp. Serotypes 14, 23F, 19A, 6A, 6B and 19F were the most common serotype isolated accounting for 80% of the PNSp. A high proportion (35/332) of non-(sero)typeable isolates was detected, 62.9% of them PNSp. Serotypes coverage projected for the pneumococcal conjugate vaccine (PCV) 13-valent vaccine (72%) was significantly higher compared with PCV7 (58.4%) and PCV 10-valent vaccine (59.3%). PMID- 19935118 TI - Test characteristics of commercial influenza assays for detecting pandemic influenza A (H1N1) in children. AB - We assessed the test characteristics of 2 influenza antigen tests, a rapid immunoassay and a direct fluorescence antibody (DFA) assay, in detecting pandemic influenza A (H1N1) in children up to 18 years of age, using polymerase chain reaction as the standard. The sensitivities of BinaxNOW (59.6%) and direct fluorescence antibody (57.3%) were similar. The specificity of each test was >99%. PMID- 19935119 TI - Perinatally human immunodeficiency virus-1 infected children born to low risk mothers who tested antibody negative during pregnancy: three cases. AB - Current Centers for Disease Control and Prevention (CDC) recommendations suggest all pregnant women have human immunodeficiency virus (HIV) antibody testing early in pregnancy. For women with specific identified risks for HIV-1 infection, the CDC recommends repeat testing in the third trimester. We report 3 cases of infants perinatally infected with HIV-1 whose mothers tested negative for HIV-1 during the first trimester of pregnancy. Because they were not considered to be "high risk" for HIV-1 infection, they did not have a third trimester HIV test. These cases suggest that repeat HIV antibody testing may be necessary to avoid cases of perinatal transmission that might be prevented with antiretroviral treatment during pregnancy. PMID- 19935120 TI - Evaluation of the compliance with recommended procedures in newborns exposed to HBsAg-positive mothers: a multicenter collaborative study. AB - BACKGROUND: Maternal-infant transmission of hepatitis B virus (HBV) during birth carries a high risk for chronic HBV infection in infants with frequent subsequent development of chronic disease. This can be efficiently prevented by early immunization of exposed newborns. The purpose of this study was to determine the compliance with official recommendations for prevention of perinatal HBV transmission in hepatitis B surface antigen (HBsAg) exposed infants. METHODS: Records of pregnant women at 4 sites in Switzerland, admitted for delivery in 2005 and 2006, were screened for maternal HBsAg testing. In HBsAg-exposed infants, recommended procedures (postnatal active and passive immunization, completion of immunization series, and serological success control) were checked. RESULTS: Of 27,131 women tested for HBsAg, 194 (0.73%) were positive with 196 exposed neonates. Of these neonates, 143 (73%) were enrolled and 141 (99%) received simultaneous active and passive HBV immunization within 24 hours of birth. After discharge, the HBV immunization series was completed in 83%. Only 38% of children were tested for anti-HBs afterwards and protective antibody values (>100 U/L) were documented in 27% of the study cohort. No chronically infected child was identified. Analysis of hospital discharge letters revealed significant quality problems. CONCLUSIONS: Intensified efforts are needed to improve the currently suboptimal medical care in HBsAg-exposed infants. We propose standardized discharge letters, as well as reminders to primary care physicians with precise instructions on the need to complete the immunization series in HBsAg-exposed infants and to evaluate success by determination of anti HBs antibodies after the last dose. PMID- 19935121 TI - Chikungunya mimicking atypical Kawasaki disease in an infant. AB - We report a 4-month-old boy with seizure, a 1-day history of fever, and a generalized maculopapular rash on the trunk and limbs. In very young children, acute chikungunya infection can mimic Kawasaki disease, and its prompt diagnosis, particularly in an endemic area like Singapore, may avoid the administration of costly and unnecessary intravenous immunoglobulin therapy. PMID- 19935122 TI - Efficacy and safety of azithromycin 1.5% eye drops for purulent bacterial conjunctivitis in pediatric patients. AB - BACKGROUND: Purulent bacterial conjunctivitis affects all ages with high frequency in newborns and children. In a subset of 150 children included in a large study having enrolled 1043 patients, our aim was to analyze in children, the efficacy and safety of azithromycin 1.5% eye-drops in the treatment of this disease. METHODS: This multicenter, randomized, investigator-masked, parallel group study, included 150 children and adolescents to study safety and compare azithromycin 1.5% eye drops twice daily for 3 days and tobramycin 0.3% 1 drop every 2 hours for 2 days then 4 times daily for 5 days. Out of 150 patients included, 58 had positive cultures and were studied for efficacy. Signs and symptoms were evaluated and cultures obtained at baseline, Days 3 and 9. Primary efficacy variable was the clinical cure (score 0 for bulbar conjunctival injection and purulent discharge) at the test of cure visit (day 9). RESULTS: Both treatments were effective with a clinical and microbiologic cure of more than 80% of children on day 9. Azithromycin therapy provided a greater bacteriologic cure on day 3 than did tobramycin (P < 0.001) and eradicated bacteria that were defined as resistant, using classical antibiogram. No adverse effects were noted on the ocular surface. CONCLUSIONS: Azithromycin 1.5% eye drops leads to a rapid clinical and microbiological cure. PMID- 19935123 TI - H1N1 in pregnancy: the wound care team called to action. PMID- 19935124 TI - Pressure ulcers and quality of care. PMID- 19935131 TI - Plantar verrucous carcinoma: an unusual case of bone invasion and osteomyelitis. PMID- 19935132 TI - Remember to review the Office of Inspector General fiscal year 2010 work plan. PMID- 19935134 TI - The use of a clindamycin 1%-benzoyl peroxide 5% topical gel in the treatment of pitted keratolysis: a novel therapy. PMID- 19935135 TI - Prevalence of wet-to-dry dressings in wound care. AB - OBJECTIVE: This retrospective descriptive study explored the prevalence of wet-to dry dressings ordered for wound care of open wounds healing by secondary intention. Research questions included the following: How frequently are healthcare providers ordering wet-to-dry dressings for wound care? Which specialties of healthcare providers are most frequently ordering wet-to-dry dressings? Are wet-to-dry dressings being ordered appropriately? METHODS: A retrospective chart review examined admission orders for 202 randomly selected Florida home care and health maintenance organization patients from 2002 to 2004. All subjects in the study had open wounds healing by secondary intention (42 partial-thickness and 160 full-thickness wounds). Frequencies are reported as the main outcome measure. RESULTS: Wet-to-dry dressings accounted for 42% of wound care orders, followed by enzymatic (7.43%) and dry gauze (6.93%). Most wounds treated with wet-to-dry dressings were surgical (69%), followed by neuropathic ulcers (10%) and pressure ulcers (5.9%). Surgical specialists preferred wet-to dry dressings (73%). Mechanical debridement was not clinically indicated in more than 78% of wounds treated with wet-to-dry dressings. Therefore, wet-to-dry dressings were inappropriately ordered in these cases. CONCLUSIONS: These findings suggest that wet-to-dry dressings (or dry gauze) are prescribed inappropriately in situations where there is little evidence to support their use. To achieve evidence-based practice in wound care, clinical decision making should be scientifically based. Future research should focus on which wound dressings are most effective in optimizing wound healing, as well as on investigating the reasons for the continued use of wet-to-dry dressings. PMID- 19935136 TI - Skin cancer: more than skin deep. AB - PURPOSE: To provide the wound care practitioner with an updated overview of the epidemiology, clinical presentation, treatment, and prevention of skin cancer. TARGET AUDIENCE: This continuing education activity is intended for physicians and nurses with an interest in skin and wound care. OBJECTIVES: After participating in this educational activity, the participant should be better able to: 1. Describe the epidemiology, pathophysiology, and clinical presentation of skin cancer. 2. Discuss the diagnosis, management, and prevention of skin cancer. PMID- 19935138 TI - Part 2: Documentation steps to support a physical assessment. PMID- 19935139 TI - Arm exercise training in patients with chronic obstructive pulmonary disease: a systematic review. AB - PURPOSE: Patients with chronic obstructive pulmonary disease (COPD) often report intolerable dyspnea when they use their arms for simple activities of daily living. Although arm exercise training is recommended in the guidelines for pulmonary rehabilitation (PR), there is limited information regarding its impact. Therefore, we undertook a systematic review of studies that have investigated the effects of an arm training program (ATP) on symptoms, exercise capacity, and health-related quality of life. METHODS: A search of electronic databases (MEDLINE, CINAHL, EMBASE, Physiotherapy Evidence Database (PEDro), and the Cochrane Library of clinical trials) was complemented by screening the reference lists of pertinent articles to identify appropriate studies. We accepted randomized controlled trials that were written in English, performed in human subjects with COPD, and investigated the effects of an ATP in patients with COPD. Included studies were reviewed by 2 independent investigators who assigned a score out of 10, using the PEDro scale for assessment of study quality. RESULTS: Of 98 reports, 5 met the study criteria. The mean PEDro score was 6.2 (SD = 1.3). The results of the studies indicate that ATP improves arm exercise capacity, but its effect on dyspnea, arm fatigue, and health-related quality of life is unclear. CONCLUSIONS: There is evidence to support the use of ATP to improve arm exercise capacity. Larger trials with standardized training methodology and outcomes are required to better understand the optimal training regimen for patients with COPD. PMID- 19935140 TI - Failure to improve cardiopulmonary fitness in cardiac rehabilitation. AB - PURPOSE: A primary goal of cardiac rehabilitation (CR) exercise is to increase cardiopulmonary fitness. The aim of this study was to identify characteristics of CR participants who fail to improve peak oxygen uptake (peakV(O(2))). METHODS: The study cohort included 385 consecutive patients with directly measured peakV(O(2)) prior to and upon completion of CR. Patients were classified as a "nonimprover" if exit peakV(O(2)) was less than or equal to entry peakV(O(2)). RESULTS: Eighty-one (21%) patients failed to improve peakV(O(2)). Baseline characteristics predicting nonimprovement included the following: lower handgrip strength, lower peak exercise respiratory exchange ratio, a nonsurgical diagnosis, female status, and more medical comorbidities. The number of sessions attended and exercise duration were similar between groups. Nonimprovers, however, exercised at lower exercise intensity despite a similar rating of perceived exertion. By multivariate analysis, independent positive correlates of percentage change in peakV(O(2)) included exercise training intensity and baseline handgrip strength. Negative correlates included baseline peakV(O(2)), comorbidity score, self-reported physical function, and a diagnosis of diabetes (cumulative total r = 0.51, adjusted R = 0.26, P < .0001). CONCLUSIONS: Twenty one percent of CR participants failed to improve peakV(O(2)) primarily due to exercise training performed at lower relative intensity despite a similar rating of perceived exertion. For patients with baseline characteristics associated with nonimprovement, alternative training protocols should be considered. PMID- 19935142 TI - Physical activity habits of cardiac patients participating in an early outpatient rehabilitation program. AB - PURPOSE: The primary purpose of the study was to assess whether physical activity (PA) habits change following 4 to 6 weeks of an early outpatient cardiac rehabilitation (CR) program. A secondary purpose was to determine whether the PA habits differ on days attending CR versus not attending CR. METHODS: Fourteen men and 8 women completed the study (age = 65.6 +/- 13.2 years, body mass index = 29.1 +/- 4.6 kg/m). Subjects wore an accelerometer during the entry and exit weeks of CR participation. Steps per day, activity counts per observation minute, percentage time spent inactive, light-intensity PA minutes per day, and moderate intensity PA minutes per day were compared both at entry and exit from CR and on days attending CR and not attending CR. RESULTS: From entry to exit of the early outpatient CR, patients increased total PA behavior (194.4 +/- 2 to 217.8 +/- 15.3 activity counts per observation minute) and time spent in moderate-intensity PA (13.9 +/- 2.3 to 18.7 +/- 2.5 min/d). Patients were more active, both in total activity (224.0 +/- 15.6 activity counts per observation minute vs 188.2 +/- 14.5 activity counts per observation minute) and in moderate intensity (19.7 +/- 3.3 min/d vs 12.8 +/- 2.0 min/d), on days they attended CR than on days they did not attend CR. CONCLUSIONS: These data support the value of early outpatient CR programs for increasing patient PA levels, particularly moderate-intensity PA on days during which patients attended CR. Because PA targets for coronary risk reduction are not being achieved when patients exit CR, referral to a maintenance CR program and support for performing PA on days they do not attend CR become essential. PMID- 19935143 TI - The effect of cardiac rehabilitation with relaxation therapy on psychological, hemodynamic, and hospital admission outcome variables. AB - PURPOSE: To examine the effect of a cardiac rehabilitation program with relaxation therapy (CPRT) in comparison with cardiac rehabilitation alone on psychological stress, hemodynamic variables, cardiac risk factors, and cardiac related hospital admissions in patients with coronary artery disease. METHODS: Patients (N = 81) were randomly assigned to either a 12-week cardiac rehabilitation program alone (CPA) or a CPRT. Perceived stress, blood pressure, heart rate, rate-pressure product value, total cholesterol level, body mass index, smoking status, and physical activity were recorded at baseline and following the 12-week intervention. Cardiac-related hospital admissions were analyzed in a 2-year follow-up. RESULTS: Perceived stress declined in both groups, although this improvement was significantly superior in the CPRT (31.5 +/ 4.9 vs 23.4 +/- 4.1; P