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Basic Sciences, Miscellaneus: general


Pediatric anorectal impalement with bladder rupture: case report and review of the literature.
Kim S, Linden B, Cendron M, Puder M
J Pediatr Surg. 2006 Sep;41(9):E1-3.

Rectal impalement involves foreign body trauma to the anus or rectum resulting in intra- or extraperitoneal rupture. Evaluation of suspected rectal impalement injury involves careful history and physical examination. Ruling out rectal perforation in patients with reported impalement is critical even if there is no evidence of trauma to the perineum. There are few reports on pediatric impalement and only 1 reported case of pediatric rectal impalement with bladder rupture. We report a rectal impalement with extraperitoneal bladder injury in a 12-year-old boy and review the literature on treatment of these injuries.

[Penetrating injuries to the pelvis.]
Doll D, Lenz S, Exadaktylos AK, Stettbacher A, Degiannis E, Dusel W, Siewert JR
Chirurg. 2006 Aug 12;.

As criminality and weapon use increase, general and military surgeons are increasingly confronted with penetrating pelvic injuries both at home and on peacekeeping missions. Penetrating injuries to the iliac vascular axis are associated with considerable mortality, and thus the majority of these emergency patients arrive in a state of deep hypovolemic shock. Concomitant bowel injuries are present in one of five cases, resulting in contamination of the damaged area. Surgical options are simple lateral repair, ligation of the veins, temporary shunt insertion, and prosthetic graft interposition in the injured artery. In extremis ligation of the common or external iliac artery may be the only option to save the patient's life. Surgeons must be aware that damage control surgery and related methods may be needed early on to enable patient survival.

Perineal sensation: an important predictor of long-term outcome in open spina bifida.
Oakeshott P, Hunt GM, Whitaker RH, Kerry S
Arch Dis Child. 2006 Aug 30;.

OBJECTIVES: to see if perineal sensation in infants with open spina bifida is associated with a better long term outcome, particularly in terms of survival, renal related deaths and incontinence. DESIGN: 40 year prospective cohort study PARTICIPANTS: Complete cohort of 117 consecutive cases of open spina bifida whose backs were closed non- selectively at birth between 1963 and 1971. Meticulous neurological examination in infancy showed 33 (28%) had perineal sensation defined as intact sensation to pinprick in at least one dermatome on one side in the saddle area S2-4). METHODS: We used data recorded within 48 hours of birth and during six reviews between 1972 and 2002. Details of deaths were obtained from medical records and the Office of National Statistics. RESULTS: By December 2005 57% (67/117) of the cohort had died. There were 50 survivors aged 38 (+/-3) years. The majority of those with perineal sensation survived (23/33 compared with 27/84 p<0.001). This difference was mainly due to 19 renal deaths in those lacking perineal sensation. Crucially there were no renal related deaths in those with perineal sensation (0/33 compared with 19/84 p=0.003). Among the survivors those with perineal sensation were more likely than the remainder to be continent of urine and faeces (10/23 compared with 1/27 p<0.001; 18/23 compared with 9/27 p=0.002). They were also more likely to be able to walk at least 50 metres (11/23 compared with 5/27 p=0.027) and never to have suffered from pressure sores (15/23 compared with 9/27 p=0.025). CONCLUSIONS: Simple assessment of perineal sensation in infancy predicts long-term outcome in terms of survival, renal prognosis and incontinence in open spina bifida.

July


Bladder-sparing surgery in locally advanced nonurological pelvic malignancy.
Siva Prasad G, Chacko KN, Antony D, Lionel G, Kekre NS, Gopalakrishnan G
Urol Int. 2006;77(1):18-21.

INTRODUCTION: The urinary bladder is commonly involved in pelvic malignancy. The incidence of apparent extension into adjacent organs in locally advanced colorectal malignancy is 5-12%. It is not known with other pelvic malignancy. No guidelines are available for its management. Often a dilemma exists between cystectomy and a bladder-sparing procedure. We studied the validity of bladder-sparing surgery (BSS) in locally advanced nonurological pelvic malignancy. METHODS: Hospital records of patients who underwent BSS along with other surgeries (abdomino-perineal resection, anterior resection, anterior exenteration, debulking surgery and total pelvic exenteration) from January 1992 to May 2003 were reviewed. RESULTS: BSS was done in 15 patients. 10 had locally advanced colorectal malignancy, 3 with soft tissue masses of the lateral pelvic wall, 1 had ovarian malignancy and the other had residual mass following radiotherapy and chemotherapy of cancer cervix. In those with locally advanced colorectal malignancy, symptoms suggestive of lower urinary tract involvement were present in 8 (80%). Urine examination and ultrasonography was not helpful in suggesting bladder involvement, unlike CT scan of abdomen and pelvis. Preoperative cystoscopy showed endoscopic evidence of bladder involvement in 7 (87.5%). Bladder was involved supratrigonally in 7. Partial cystectomy was done in 9 patients. The left ureter was involved in 6 patients, and they required ureteric reimplantation. Palliative transurethral resection was done in 1 patient with tumor infiltration at the bladder neck and prostate. 50% patients had bothersome lower urinary tract symptoms at 1 year. One patient died in the immediate postoperative period due to a nonurological cause. Overall 3-year survival rate was 40%. CONCLUSION: Unlike primary bladder cancers these lesions are not multifocal and hence en block conservative bladder-sparing surgery can be offered. Preoperative CT scan or MRI can predict lower urinary tract involvement and help in decision-making by both surgeon and patient. The ultimate decision for bladder sparing is based on intraoperative findings. Sparing the bladder might provide better quality of life by avoiding urinary diversion without altering survival.

Predictive risk score for infection after inguinal hernia repair.
Pessaux P, Lermite E, Blezel E, Msika S, Hay JM, Flamant Y, Deepak V, Arnaud JP
Am J Surg. 2006 Aug;192(2):165-71.

BACKGROUND: Identification of subgroups of patients at high and low risk for global infectious complications (GIC) after inguinal hernia repair without mesh. METHODS: A database of 1254 patients who underwent inguinal hernia repair without mesh, issued from 3 prospective multicenter randomized trials, has been established (group A). After multivariate analysis, a score for GIC was calculated and tested using data from a similar prospective randomized multicenter study (group B). RESULTS: A risk score for GIC was constructed: -4.7 + (0.95 x age >/=75 years) + (1.1 obesity) + (2.1 x urinary catheter). In case of score less than -4.2 (low-risk group), the GIC rate was 2.7%; therefore, in case of score more than -4.2 (high-risk score), the GIC rate was 14.3% (P < .001). In the low-risk group, the administration of antibiotic prophylaxis did not reduce the infectious complication rate, while in high-risk group the administration of antibiotic prophylaxis significantly reduced the rates of surgical site infection, GIC, and urinary infection by 72%, 67%, and 76.8%, respectively. CONCLUSIONS: This study demonstrates the efficacy of antibiotic prophylaxis in inguinal hernia surgery in the subgroup of high-risk patients.

Contemporary management of pelvic fractures.
Durkin A, Sagi HC, Durham R, Flint L
Am J Surg. 2006 Aug;192(2):211-23.

BACKGROUND: Pelvic fractures occur when there is high kinetic energy transfer to the patient such as would be expected in motor vehicle crashes, auto-pedestrian collisions, motorcycle crashes, falls, and crush injuries. High-force impact implies an increased risk for associated injuries to accompany the pelvic fracture, as well as significant mortality and morbidity risks. Choosing the optimum course of diagnosis and treatment for these patients can be challenging. The purpose of this review is to supply a contemporary view of the diagnosis and therapy of patients with this important group of injuries. METHODS: A comprehensive review of the medical literature, focusing on publications produced in the last 10 years, was undertaken. The principal sources were found in surgical, orthopedic, and radiographic journals. CONCLUSIONS: The central challenge for the clinician evaluating and managing a patient with a pelvic fracture is to determine the most immediate threat to life and control this threat. Treatment approaches will vary depending on whether the main threat arises from pelvic fracture hemorrhage, associated injuries, or both simultaneously. Functional outcomes in the long-term depend on the quality of the rigid fixation of the fracture, as well as associated pelvic neural and visceral injuries.

Cutaneous, perivulvar and perianal ulcerations induced by nicorandil.
Claeys A, Weber-Muller F, Trechot P, Cuny JF, Georges MY, Barbaud A, Schmutz JL
Br J Dermatol. 2006 Aug;155(2):494-6.

Autologous full-thickness skin substitute for healing chronic wounds.
Gibbs S, van den Hoogenband HM, Kirtschig G, Richters CD, Spiekstra SW, Breetveld M, Scheper RJ, de Boer EM
Br J Dermatol. 2006 Aug;155(2):267-74.

Chronic wounds represent a major problem to our society. Therefore, advanced wound-healing strategies for the treatment of these wounds are expanding into the field of tissue engineering. To develop a novel tissue-engineered, autologous, full-thickness skin substitute of entirely human origin and to determine its ability to heal chronic wounds. Skin substitutes (fully differentiated epidermis on fibroblast-populated human dermis) were constructed from 3-mm punch biopsies isolated from patients to be treated. Acellular allodermis was used as a dermal matrix. After a prior 5-day vacuum-assisted closure therapy to prepare the wound bed, skin substitutes were applied in a simple one-step surgical procedure to 19 long-standing recalcitrant leg ulcers (14 patients; ulcer duration 0.5-50 years). The success rate in culturing biopsies was 97%. The skin substitute visibly resembled an autograft. Eleven of the 19 ulcers (size 1-10 cm(2)) healed within 8 weeks after a single application of the skin substitute. The other eight larger (60-150 cm(2)) and/or complicated ulcers healed completely (n = 5) or continued to decrease substantially in size (n = 3) after the 8-week follow-up period. Wound healing occurred by direct take of the skin substitute (n = 12) and/or stimulation of granulation tissue/epithelialization (n = 7). Skin substitutes were very well tolerated and pain relief was immediate after application. Application of this novel skin substitute provides a promising new therapy for healing chronic wounds resistant to conventional therapies.

Does pregnancy change the disease course? A study in a European cohort of patients with inflammatory bowel disease.
Riis L, Vind I, Politi P, Wolters F, Vermeire S, Tsianos E, Freitas J, Mouzas I, Ruiz Ochoa V, O'Morain C, Odes S, Binder V, Moum B, Stockbrugger R, Langholz E, Munkholm P
Am J Gastroenterol. 2006 Jul;101(7):1539-45.

BACKGROUND AND AIMS: Inflammatory bowel disease (IBD) often affects patients in their fertile age. The aim of this study was to describe pregnancy outcome in a European cohort of IBD patients. As data are limited regarding the effect of pregnancy on disease course, our second objective was to investigate whether pregnancy influences disease course and phenotype in IBD patients. METHODS: In a European cohort of IBD patients, a 10-yr follow-up was performed by scrutinizing patient files and approaching the patients with a questionnaire. The cohort comprised 1,125 patients, of whom 543 were women. Data from 173 female ulcerative colitis (UC) and 93 Crohn's disease (CD) patients form the basis for the present study. RESULTS: In all, 580 pregnancies, 403 occurring before and 177 after IBD was diagnosed, were reported. The rate of spontaneous abortion increased after IBD was diagnosed (6.5% vs. 13%, p = 0.005), whereas elective abortion was not significantly different. 48.6% of the patients took medication at the time of conception and 46.9% during pregnancy. The use of cesarean section increased after IBD diagnosis (8.1% vs 28.7% of pregnancies). CD patients pregnant during the disease course, did not differ from patients who were not pregnant during the disease course regarding the development of stenosis (37% vs 52% p = 0.13) and resection rates (mean number of resections 0.52 vs 0.66, p = 0.37). The rate of relapse decreased in the years following pregnancy in both UC (0.34 vs 0.18 flares/yr, p = 0.008) and CD patients (0.76 vs 0.12 flares/yr, p = 0.004). CONCLUSIONS: Pregnancy did not influence disease phenotype or surgery rates, but was associated with a reduced number of flares in the following years.

Latex intolerance. Basic science, epidemiology, and clinical management.
English J
Br J Dermatol. 2006 Aug;155(2):498.

June


Sigmoid vaginoplasty: long-term results.
Kapoor R, Sharma DK, Singh KJ, Suri A, Singh P, Chaudhary H, Dubey D, Mandhani A
Urology. 2006 Jun;67(6):1212-5.

OBJECTIVES: To evaluate the long-term results of sigmoid vaginoplasty for Mayer-Rokitansky-Kuster-Hauser syndrome. The social and psychological acceptance of the procedure is also discussed in terms of a developing country scenario. METHODS: A total of 14 patients with Mayer-Rokitansky-Kuster-Hauser syndrome were treated at our institute from January 1995 to December 2004. Sigmoid vaginoplasty was performed in all patients. The procedure was performed using a combined abdominoperineal approach. Dissection was done between the urethra and rectum to create a bed for the neovaginal colon conduit. A 10-cm segment of sigmoid colon was raised on its vascular pedicle, delivered through the abdominoperineal tunnel, and fixed to the vaginal pit incision. The patient records were reviewed for surgical technique and postoperative complications. Patients underwent a personal interview to assess the postoperative results, social acceptance of the procedure, and sexual satisfaction. RESULTS: The mean patient age at surgery was 16.8 years. The patients who underwent sigmoid vaginoplasty had good cosmetic results without the need for routine dilation or the problem of excessive mucus production. The postoperative morbidity was minimal. During a mean follow-up of 4.1 years, no stenosis or colitis was encountered. The subjective satisfaction rate with the surgical outcomes in all the patients was 8.01 on a scale of 0 to 10 (0, very disappointed to 10, satisfied). CONCLUSIONS: Sigmoid vaginoplasty is an effective treatment for patients with vaginal atresia. Timed vaginal reconstruction in these patients allows for a better quality of life and social acceptance. It also enables the patient to lead a near-normal sexual life, with high satisfaction rates.

An unusual cause of a frozen pelvis. Diagnosis: actinomycosis.
Tou SI, David G, Thomas EA, Schneider HJ
Gut. 2006 Jul;55(7):990, 1011.

Pelvic actinomycosis: a case report.
Dunn TS, Cothren C, Klein L, Krammer T
J Reprod Med. 2006 May;51(5):435-7.

BACKGROUND: Pelvic actinomycosis is rare but can manifest with multiple presentations. CASE: A 28-year-old woman, gravida 4, para 2, conceived with a Paraguard intrauterine device (IUD) (FEI Products LLC, North Tonawanda, New York) in place. The IUD had been present for 2 years. The patient presented with an incomplete abortion at 6 weeks' gestation, and the IUD was removed. Two and one-half months later the patient presented with signs and symptoms of pelvic inflammatory disease and underwent hospitalization and exploratory laparotomy. The pathology specimen revealed diffuse actinomycosis involving the tube and ovary, appendix, and bowel mucosa. A Pap smear 3 months earlier had revealed Actinomyces. CONCLUSION: Actinomyces has been associated with IUD use and may present even after removal of the IUD. Pelvic actinomycosis is rare, and removal of the IUD may not be adequate treatment. If a patient presents with symptoms of infection, early diagnosis and aggressive antibiotics may prevent further complications.

Pediatric pelvic fractures: a marker for injury severity.
Spiguel L, Glynn L, Liu D, Statter M
Am Surg. 2006 Jun;72(6):481-4.

Pelvic fractures comprise a small number of annual Level I pediatric trauma center admissions. This is a review of the University of Chicago Level I Pediatric Trauma Center experience with pediatric pelvic fractures. This is a retrospective review of the University of Chicago Level I Pediatric Trauma Center experience with pediatric pelvic fractures during the 12-year period from 1992 to 2004. From 1992 to 2004, there were 2850 pediatric trauma admissions. Thirteen patients were identified with pelvic fractures; seven were boys and six were girls. The average age was 8 years old. The mechanism of injury in all cases was motor vehicle related; 11 patients (87%) sustained pedestrian-motor vehicle crashes. According to the Torode and Zeig classification system, type III fractures occurred in eight patients (62%) and type IV fractures occurred in six patients (31%). Associated injuries occurred in eight patients (62%). Seven of these patients (88%) had associated injuries involving two or more organ systems. Of the associated injuries, additional orthopedic injuries were the most common, occurring in 62 per cent of our patients. Neurological injuries occurred in 54 per cent of patients, vascular injuries in 39 per cent, pulmonary injuries in 31 per cent, and genitourinary injuries in 15 per cent. Five patients (38%) were treated operatively; only two patients underwent operative management directly related to their pelvic fracture. The remaining three patients underwent operative management of associated injuries. The mortality rate was 0 per cent. Although pelvic fractures are an uncommon injury in pediatric trauma patients, the morbidity associated with these injuries can be profound. The majority of pelvic fractures in children are treated nonoperatively, however, more than one-half of these patients have concomitant injuries requiring operative management. When evaluating and treating pediatric pelvic fractures, a systematic multidisciplinary approach must be taken to evaluate and prioritize the pelvic fracture and the associated injuries.

A less invasive anterior intrapelvic approach for the treatment of acetabular fractures and pelvic ring injuries.
Jakob M, Droeser R, Zobrist R, Messmer P, Regazzoni P
J Trauma. 2006 Jun;60(6):1364-70.

BACKGROUND: The ilioinguinal approach by Letournel has fundamentally contributed to the successful treatment of acetabular fractures. Since most of the present complications arise from soft tissue structures in the inguinal part, it would be desirable to avoid the surgical dissection of this region. We have therefore developed a less invasive anterior intrapelvic approach consisting of a suprapubic access combined with the lateral window of the ilioinguinal approach. METHODS: Between January 2000 and October 2002, 14 patients with acetabular fractures and 6 patients with pelvic ring injuries were consecutively operated using our technique. The patients were prospectively followed up clinically and by standard X-rays for 1 year. RESULTS: In 19 patients the technique was successful and only one patient was converted to an ilioinguinal approach due to difficulties in reducing the fracture. Our access allowed good visibility but reduction manoeuvres were sometimes difficult and the development of a new reduction forceps became necessary. Anatomical and satisfactory reduction was achieved in 13 acetabular fractures and 4 pelvic ring injuries. One cutaneous femoris neurapraxy and one superficial infection occurred related to the approach and both resolved with conservative treatment. Clinical outcome at one year was good to excellent in 17 patients (modified Merle d'Aubigne/Postel score). In 3 patients the result was fair to poor for reasons unrelated to the approach. CONCLUSIONS: Our approach permits visualisation of the entire anterior column and pelvic ring without the necessity to dissect the inguinal neurovascular structures. Our preliminary results demonstrate that safe reduction and stable fixation of selected acetabular- and pelvic ring fractures are possible.

[Rehabilitation after abdominal surgery.]
Bonnet F, Szymkiewicz O, Marret E, Houry S
Presse Med. 2006 Jun;35(6 Pt 2):1016-22.

A combined strategy of anesthetic and surgical care defines postoperative rehabilitation, which aims to accelerate recovery from surgery, shorten convalescence, and reduce postoperative morbidity. Preoperative and early postoperative oral feeding, a relatively "dry" fluid regimen, and the avoidance of or early removal of drains, gastric tubes and bladder catheters all contribute to decreasing postoperative morbidity after abdominal surgery. Postoperative pain control, prevention of nausea and vomiting, shortening the duration of postoperative ileus, and early ambulation can also help to decrease postoperative morbidity. The use of multimodal fast-track clinical rehabilitation programs should improve outcomes and quality of life, reduce hospital stays, and save money.

[Smoking and surgery.]
Dureuil B, Dautzenberg B, Masquelet AC
Presse Med. 2006 Jun;35(6 Pt 2):1009-15.

Smokers have an elevated risk of perioperative respiratory distress and of transfer to intensive care. Tobacco smoke substantially alters the healing process and constitutes a documented risk factor for postoperative complications (anastomotic leakage, delayed healing etc.). Risk of postoperative infection is also higher in smokers. When patients stop smoking 6 to 8 weeks before surgery, the incidence of complications related to tobacco smoke drops nearly to zero. Even stopping for a short period reduces the risk of complications, although the benefits of stopping increase with length of time. Preoperative smoking cessation should take place as early as possible. The general practitioner and the surgeon both have essential roles to play. Identification of smokers must be accompanied by measures to help the patient stop smoking, including advice, and if necessary, nicotine substitutes. Anxiety levels are higher in smokers than nonsmokers. Nonetheless smoking cessation for hospitalization does not increase these levels, even without nicotine substitutes. There is no interaction between anesthetic agents and nicotine substitutes: the latter may be continued through the morning of surgery and reinitiated in the immediate postoperative period. PATIENTS: who stop smoking for surgery should be encouraged to continue to stop, permanently. The general practitioner's support is essential for this.

Acute generalised exanthematous pustulosis induced by the herbal remedy Ginkgo biloba.
Pennisi RS
Med J Aust. 2006 Jun 5;184(11):583-4

Acute generalised exanthematous pustulosis (AGEP) is a clinical reaction pattern that is induced, in over 90% of cases, by systemic drugs (most frequently antibacterial drugs). This is the first reported case of AGEP caused by the herbal remedy Ginkgo biloba.

Negative pressure wound therapy: an important adjunct to wound care.
Mendonca DA
South Med J. 2006 Jun;99(6):562-3.

Rapid growth of a fetal sacrococcygeal teratoma in an HIV-infected woman: a case report.
Ghazi L, Ko F, Bathgate SL, Larsen JW, Macri C
J Reprod Med. 2006 May;51(5):431-4.

BACKGROUND: Sacrococcygeal teratoma, the most common congenital neoplasm of the newborn, associated with fetal hydrops and high morbidity and mortality related to the secondary effects of the tumor mass, is of unknown etiology. Prompt diagnosis and early treatment have proven to be effective. CASE: A 24-year-old woman, gravida 3, para 2, at 385/7 weeks' gestation, with a pregnancy complicated by HIV diagnosed during pregnancy, seizure disorder and tobacco use, presented with premature rupture of membranes. Ultrasound examination at 17 weeks' gestation showed normal fetal anatomy. Cesarean delivery was complicated by difficulty delivering a live infant with a large sacral mass. Successful surgical excision of a 650-g mass and stabilization of the infant occurred in the neonatal period. CONCLUSION: This is the first case report to describe a rapidly growing sacrococcygeal teratoma in a neonate from a pregnancy complicated by HIV. Ultrasound in the first and second trimesters identified no fetal abnormalities of the spine. Further research concerning sacrococcygeal teratoma and HIV in pregnancy is necessary for prompt and early diagnosis and treatment of antepartum and peripartum complications.

Beautiful Buttocks: Characteristics and Surgical Techniques.
Cuenca-Guerra R, Lugo-Beltran I
Clin Plast Surg. 2006 Jul;33(3):321-332.

Preface.
Young VL, Roberts TL 3rd
Clin Plast Surg. 2006 Jul;33(3):xi-xii.

History of gluteal augmentation.
de la Pena JA, Rubio OV, Cano JP, Cedillo MC, Garces MT
Clin Plast Surg. 2006 Jul;33(3):307-19.

Classification system for gluteal evaluation.
Mendieta CG
Clin Plast Surg. 2006 Jul;33(3):333-46.

Autologous gluteal augmentation with circumferential body lift in the massive weight loss and aesthetic patient.
Centeno RF
Clin Plast Surg. 2006 Jul;33(3):479-96.

Buttocks lifting: how and when to use medial, lateral, lower, and upper lifting techniques.
Gonzalez R
Clin Plast Surg. 2006 Jul;33(3):467-78.

Complications of buttocks augmentation: diagnosis, management, and prevention.
Bruner TW, Roberts TL 3rd, Nguyen K
Clin Plast Surg. 2006 Jul;33(3):449-66.

Submuscular gluteal augmentation: 17 years of experience with gel and elastomer silicone implants.
Hidalgo JE
Clin Plast Surg. 2006 Jul;33(3):435-47.

Intramuscular gluteal augmentation technique.
Mendieta CG
Clin Plast Surg. 2006 Jul;33(3):423-34.

Subfascial gluteal augmentation.
de la Pena JA, Rubio OV, Cano JP, Cedillo MC, Garces MT
Clin Plast Surg. 2006 Jul;33(3):405-22.

Gluteal recontouring with combination treatments: implants, liposuction, and fat transfer.
Aiache AE
Clin Plast Surg. 2006 Jul;33(3):395-403.

"Universal" and Ethnic Ideals of Beautiful Buttocks are Best Obtained by Autologous Micro Fat Grafting and Liposuction.
Roberts TL 3rd, Weinfeld AB, Bruner TW, Nguyen K
Clin Plast Surg. 2006 Jul;33(3):371-94.

Universal allure of the hourglass figure: an evolutionary theory of female physical attractiveness.
Singh D
Clin Plast Surg. 2006 Jul;33(3):359-70.

Clinical anatomy in aesthetic gluteal body contouring surgery.
Centeno RF, Young VL
Clin Plast Surg. 2006 Jul;33(3):347-58.

Vitamin E: patterns of understanding, use, and prescription by health professionals and students at a University Teaching Hospital.
Curran JN, Crealey M, Sadadcharam G, Fitzpatrick G, O'Donnell M
Plast Reconstr Surg. 2006 Jul;118(1):248-52.

BACKGROUND: Vitamin E is a generic term used to describe the many derivatives of tocol and tocotrienol. It is the major lipid-soluble antioxidant in the skin and has been used as treatment for many skin conditions, including scarring. Studies have shown that vitamin E provides no benefit to the cosmetic outcome of scars. METHODS: The authors constructed and distributed a questionnaire among staff and students at their institution. Their aim was to determine patterns of use and prescription of vitamin E among staff and students and to determine the understanding of the properties and biological functions of vitamin E. RESULTS: Questionnaires were completed by 208 staff and students, including 110 nonconsultant hospital doctors (52.89 percent), 61 nurses (29.33 percent), and 27 medical students (12.98 percent). Nearly 68 percent thought that vitamin E could be of use in improving the cosmetic appearance of scars, while 25 percent actually recommended vitamin E to patients to improve the cosmetic outcome of scars. Just under 40 percent were aware of the biological function of vitamin E, while 16.35 percent thought vitamin E had absolutely no effect on scarring. Of respondents, 21.64 percent had used vitamin E for their own scars; 31.11 percent of these said it was suggested by a doctor, while 6.67 percent said a pharmacist suggested it. CONCLUSIONS: Without scientific basis, health professionals continue to recommend vitamin E for use on scars. Such recommendations should not be made in the absence of evidence-based medicine.

Using physiology to improve surgical wound outcomes.
Ueno C, Hunt TK, Hopf HW
Plast Reconstr Surg. 2006 Jun;117(7 Suppl):59S-71S.

Despite major advances in surgical management and approaches, including aseptic techniques, prophylactic antibiotics, and laparoscopic surgery, surgical wound infection and wound failure remain common complications of surgery. In a review of the literature, the authors found that a growing body of literature supports the concept that patient factors are a major determinant of wound outcome after surgery. In particular, wounds are exquisitely sensitive to hypoxia, which is both common and preventable. Perioperative management can be adapted to promote postoperative wound healing and resistance to infection. The most important factors are fluid management, temperature management, pain control, increased arterial oxygen tension, and, as has been long recognized, appropriate sterile techniques and administration of prophylactic antibiotics. This article reviews how knowledge of and attention to physiology can improve quality of care in both acute and chronic wounds.

Nutrition and wound healing.
Arnold M, Barbul A
Plast Reconstr Surg. 2006 Jun;1
17(7 Suppl):42S-58S.
The relationship between nutrition and wound healing--after injury or surgical intervention--has been recognized for centuries. There is no doubt that adequate carbohydrate, fat, and protein intake is required for healing to take place, but research in the laboratory has suggested that other specific nutritional interventions can have significant beneficial effects on wound healing. Successful translation into the clinical arena, however, has been rare. A review of normal metabolism as it relates to wound healing in normoglycemic and diabetic individuals is presented. This is followed by an assessment of the current literature and the data that support and refute the use of specialized nutritional support in postoperative and wounded patients. The experimental evidence for the use of arginine, glutamine, vitamins, and micronutrient supplementation is described. Most of the experimental evidence in the field supporting the use of specialized nutritional support has not been borne out by clinical investigation. A summary of the clinical implications of the data is presented, with the acknowledgment that each patient's plan of care must be individualized to optimize the relationship between nutrition and wound healing.

Chronic wound pathogenesis and current treatment strategies: a unifying hypothesis.
Mustoe TA, O'Shaughnessy K, Kloeters O
Plast Reconstr Surg. 2006 Jun;117(7 Suppl):35S-41S.

Most chronic wounds can be classified into three major types: pressure ulcers, venous ulcers, and diabetic ulcers. The authors propose a unifying hypothesis of chronic wound pathogenesis based on four main causative factors: local tissue hypoxia, bacterial colonization of the wound, repetitive ischemia-reperfusion injury, and an altered cellular and systemic stress response in the aged patient. Traditional strategies for the treatment of chronic wounds have shown limited success. The authors explore potential treatment regimens specifically aimed at each individual determinant of chronic wound pathogenesis. Furthermore, they explore a combined therapeutic approach that collectively targets all the components of chronic wound pathology. These innovative ideas and therapies could be of substantial interest for clinicians and researchers, while further offering significant benefit to patients with chronic wounds.

The basic science of wound healing.
Broughton G 2nd, Janis JE, Attinger CE
Plast Reconstr Surg. 2006 Jun;117(7 Suppl):12S-34S.

Understanding wound healing today involves much more than simply stating that there are three phases: "inflammation, proliferation, and maturation." Wound healing is a complex series of reactions and interactions among cells and "mediators." Each year, new mediators are discovered and our understanding of inflammatory mediators and cellular interactions grows. This article will attempt to provide a concise report of the current literature on wound healing by first reviewing the phases of wound healing followed by "the players" of wound healing: inflammatory mediators (cytokines, growth factors, proteases, eicosanoids, kinins, and more), nitric oxide, and the cellular elements. The discussion will end with a pictorial essay summarizing the wound-healing process.

A brief history of wound care.
Broughton G 2nd, Janis JE, Attinger CE
Plast Reconstr Surg. 2006 Jun;11 7(7 Suppl):6S-11S.

Since the caveman, man has been tending to his wounds. Wound care evolved from magical incantations, potions, and ointments, to a systematic text of wound care and surgery from Hippocrates and Celsus. These advances were lost after the fall of the Roman Empire. In Europe, the Middle Ages were a regression of wound care back to potions and charms. It was'nt until the time of large armies using muskets and cannons that surgical wound care emerged again. This article will briefly highlight major milestones in wound care.

May


Easyloop knot: a simple and safe extracorporeal knot.
Pattas M, Theodorou D, Lagoudianakis E, Filis K, Menenakos E, Leandros E
Am J Surg. 2006 Jun;191(6):821-2

Thorough knowledge of laparoscopic suturing is of great importance to the laparoscopic surgeon, especially during the performance of advanced laparoscopic procedures. Intracorporeal and extracorporeal knot tying enhances the technical capabilities of the laparoscopic access, thus extending the spectrum of laparoscopic procedures to that of open surgery. We describe herein a new extracorporeal knot designed with an emphasis on simplicity and safety.

Surgery for osteitis pubis.
Mehin R, Meek R, O'brien P, Blachut P
Can J Surg. 2006 Jun;49(3):1
70-6.
Background: Osteitis pubis is a rare and self-limited condition. Surgery may be necessary in 5%-10% of cases. The outcome after surgery for osteitis pubis is not known. Methods: To determine the success of surgical intervention for osteitis pubis, we used a computerized data registry to identify patients (10 women [mean age 40 yr]) who underwent surgery for osteitis pubis. A retrospective chart review was carried out. We also searched the literature for all cases of osteitis pubis managed surgically and identified 73 cases. Results: The 10 patients in our series had had symptoms for a mean of 4 years preoperatively. Onset of pain was insidious in 4 patients, it followed childbirth in 4 and it followed trauma in 2. Depending on the surgeon's preference, either a wedge resection of the symphysis pubis was performed or a symphysiodesis. At the latest follow-up (average 26 mo), although all patients had some improvement, only 6 of 10 patients were satisfied with the outcome. From the literature review, we identified 3 categories of patients with osteitis pubis: elite athletes, patients with postoperative or infectious osteitis pubis and the remainder, which would include the patients in our series. Conclusions: Four types of surgical intervention are described: curettage, arthrodesis, wedge resection and wide resection. The elite athletes respond well to curettage. Patients with osteitis pubis following urologic or gynecologic procedures or have a proven infection require surgery in roughly 50% of cases. The third group has an unpredictable outcome.

April


Perineal reconstruction after total pelvic evisceration and excision of pelviperineal soft tissues for recurrent vulvar carcinoma.
Rinaldi M, Cormio N, Bucaria V, Di Tonno P, Marino F, Altomare DF
Tech Coloproctol. 2006 Mar;10(1):79.

Anterior sacral meningocele simulating ovarian cyst.
Erdogmus B, Yazici B, Ozdere BA, Safak AA
J Clin Ultrasound. 2006 May 3;34(5):244-246.

Anterior sacral meningocele is a rare condition characterized by the herniation of meningeal membranes and cerebrospinal fluid through a defect in the anterior aspect of the sacrum. We report a case of an anterior sacral meningocele that was mimicking an ovarian cyst.

The effect of opioids on the development of postoperative intra-abdominal adhesions.
Khorram-Manesh A, Ardakani JV, Behjati HR, Nylund G, Delbro D
Dig Dis Sci. 2006 Mar;51(3):560-5.

People addicted to opium rarely develop intra-abdominal adhesions after abdominal surgery. We aimed to evaluate the effect of opium or morphine on preventing postoperative adhesions in rats. Sixty-three rats were randomly divided into a control group, opium-addicted group, and morphine-addicted group in a double-blind study. Drug dependency was checked by using naloxone. Animals were then operated on and the cecum was abraded. At reoperation 3 weeks later the magnitude of adhesions was evaluated by a scoring system. There was a significant difference between the control, opium-addicted, and morphine-addicted groups with regard to the length (P < .001), thickness (P < .05), and severity of adhesions (P < .05). Opium or morphine reduces the severity of postoperative adhesions. Elucidation of the opioid receptor(s) involved in this process would enable the use of selective ligands and offer a pharmacologic strategy in preventing adhesion formation.

Delivering cancer stem cell therapies - A role for nanomedicines?
Schatzlein AG
Eur J Cancer. 2006 May 6;.

Cancer stem cells (CSCs), i.e. cancer cells that can self-renew, constitute only a minority of the cells of a tumour, but, because of their ability to initiate and repopulate tumours, failure to control CSCs can potentially lead to tumour re-growth, even though the bulk tumour may have been treated successfully. Nanomedicines improve spatio-temporal control over drug kinetics and distribution, thus opening the prospect of safer and more specific therapies to address the challenges posed by CSCs. In particular, these systems have the potential to facilitate CSC-aware therapy by overcoming resistance to conventional cytotoxic drugs and by targeting novel therapies to the tumour and CSC-marker positive cells. This review examines the implications of the CSC paradigm specifically for the development of nanomedicines, i.e. therapies based on macromolecules or supramolecular aggregates.

Epidermal stem cells and cancer stem cells: Insights into cancer and potential therapeutic strategies.
Finlan LE, Hupp TR
Eur J Cancer. 2006 May 5;.

Therapeutic potential of adult stem cells.
Serakinci N, Keith WN
Eur J Cancer. 2006 May 4;.

The aim of cell-based therapies is to replace or repair damaged tissues and organs. A diverse number of disorders are amenable to this approach, including haematopoietic, neurological and cardiovascular diseases, as well as bone defects and diabetes. Central to the success of cell therapy is the necessity to be able to identify, select, expand and manipulate cells outside the body. Recent advances in adult stem cell technologies and basic biology have accelerated therapeutic opportunities aimed at eventual clinical applications. Adult stem cells with the ability to differentiate down multiple lineages are an attractive alternative to human embryonic stem cells (hES) in regenerative medicine. In many countries, present legislation surrounding hES cells makes their use problematic, and indeed the origin of hES cells may represent a controversial issue for many communities. However, adult stem cells are not subject to these issues. This review will therefore focus on adult stem cells. Based on their extensive differentiation potential and, in some cases, the relative ease of their isolation, adult stem cells are appropriate for clinical development. Recently, several observations suggest that multipotential adult stem cells are capable of producing a whole spectrum of cell types, regardless of whether or not these tissues are derived from same germ layer; highlighting the opportunity to manipulate stem cells for therapeutic use.

Telomeres and telomerase in cancer stem cells.
Ju Z, Rudolph KL
Eur J Cancer. 2006 Apr 24;.

Alterations in telomere dynamics both suppress and facilitate malignant transformation by regulating genomic stability and cell lifespan. Checkpoints induced by telomere dysfunction play a major role in tumour suppression, whereas telomere shortening contributes to the initiation of cancer by inducing chromosomal instability. Since stem cells are exposed to various tumourigenic agents and stresses throughout their lifetime, the ageing stem cell is a major target of malignant transformation. This review summarises our knowledge of telomere length and telomerase activity in stem cells during ageing and carcinogenesis.

Stem cell properties and epithelial malignancies.
Mackenzie IC
Eur J Cancer. 2006 Apr 24;.

Stem cell plasticity and tumour formation.
Alison MR, Lovell MJ, Direkze NC, Wright NA, Poulsom R
Eur J Cancer. 2006 Apr 20;.

Stem cell plasticity refers to the ability of certain stem cells to switch lineage determination and generate unexpected cell types. This review applies largely to bone marrow cells (BMCs), which appear to contribute positively to the regeneration of several damaged non-haematopoietic tissues. This beneficial effect on regeneration may be a direct result of BMCs giving rise to organ parenchymal cells. Alternatively, it could be due to BMCs fusing with existing parenchymal cells, or providing paracrine growth factor support, or contributing to neovascularisation. In the context of oncology, BMC derivation of the tumour stroma and vasculature has profound biological and therapeutic implications, and there are several examples of carcinomas seemingly being derived from BMCs.

Prostate cancer stem cells.
Collins AT, Maitland NJ
Eur J Cancer. 2006 Apr 20;.

Prostate cancer is the most frequently diagnosed cancer in men. Despite recent advances in the detection of early prostate cancer there is little effective therapy for patients with locally advanced and/or metastatic disease. The majority of patients with advanced disease respond initially to androgen ablation therapy. However, most go on to develop androgen-independent tumours that inevitably are fatal. A similar response is seen to chemotherapeutic and radiotherapy treatments. As a result, metastatic prostate cancer remains an incurable disease by current treatment strategies. Recent reports of cancer stem cells have prompted questions regarding the involvement of normal stem/progenitor cells in prostate tumour biology, their potential contribution to the tumour itself and whether they are the cause of tumour initiation and progression. Although still controversial, the cancer stem cell is likely to be the most crucial target in the treatment of prostate cancer, and a thorough understanding of its biology, particularly of how the cancer stem cell differs from the normal stem cell, might allow it to be targeted selectively and eliminated, thus improving therapeutic outcome.

Mechanisms of self-renewal in human embryonic stem cells.
Stewart R, Stojkovic M, Lako M
Eur J Cancer. 2006 Apr 18;.

Embryonic stem cells (ESCs) are the pluripotent cell population derived from the inner cell mass of pre-implantation embryos and are characterised by prolonged self-renewal and the potential to differentiate into cells representing all three germ layers both in vitro and in vivo. Preservation of the undifferentiated status of the ESC population requires the maintenance of self-renewal whilst inhibiting differentiation and regulating senescence and apoptosis. In this review, we discuss the intrinsic and extrinsic factors associated with self-renewal process, together with possible signalling pathway interactions and mechanisms of regulation.

Normal stem cells and cancer stem cells: the niche matters.
Li L, Neaves WB
Cancer Res. 2006 May 1;66(9):4553-7.

Scientists have tried for decades to understand cancer development in the context of therapeutic strategies. The realization that cancers may rely on "cancer stem cells" that share the self-renewal feature of normal stem cells has changed the perspective with regard to new approaches for treating the disease. In this review, we propose that one of the differences between normal stem cells and cancer stem cells is their degree of dependence on the stem cell niche, a specialized microenvironment in which stem cells reside. The stem cell niche in adult somatic tissues plays an essential role in maintaining stem cells or preventing tumorigenesis by providing primarily inhibitory signals for both proliferation and differentiation. However, the niche also provides transient signals for stem cell division to support ongoing tissue regeneration. The balance between proliferation-inhibiting and proliferation-promoting signals is the key to homeostatic regulation of stem cell maintenance versus tissue regeneration. Loss of the niche can lead to loss of stem cells, indicating the reliance of stem cells on niche signals. Therefore, cancer stem cells may arise from an intrinsic mutation, leading to self-sufficient cell proliferation, and/or may also involve deregulation or alteration of the niche by dominant proliferation-promoting signals. Furthermore, the molecular machinery used by normal stem cells for homing to or mobilizing from the niche may be "hijacked" by cancer stem cells for invasion and metastasis. We hope this examination of the interaction between stem cells and their niche will enhance understanding of the process of cancer development, invasiveness, and metastasis and reveal possible targets for cancer treatment.

March


[Psoas muscle abscess: bibliographic review]
Navarro Gil J, Regojo Zapata O, Elizalde Benito A, Hijazo Conejos JI, Murillo Perez C, Sanchez Zalabardo JM, Valdivia Uria JG
Arch Esp Urol. 2006 Jan-Feb;59(1):73-7.

OBJECTIVES: To report the clinical characteristics, diagnosis and treatment of psoas abscess. METHODS/RESULTS: We report the case of a 77 year old female patient who was diagnosed of psoas abscess. Due to the unspecific symptoms, she was initially treated as a renal colic. Ultrasound was the test that oriented us to the diagnosis. Percutaneous drainage was effective, checking the resolution using CT Scan. CONCLUSIONS: Psoas abscess is an uncommon pathology the presenting features of which are usually unspecific. CT Scan is the astronomer diagnostic tests and percutaneous drainage has good results and is less aggressive therapeutic option for this disease.

Gluteal injections in increasingly obese population: needle length for intramuscular injections.
Anthony BJ
BMJ. 2006 Apr 1;332(7544):795.

Intestinal vaginoplasty: is it optimal treatment of vaginal agenesis? A pilot study. Surgical method of sigmoid colon vaginoplasty in vaginal agenesis.
Karateke A, Gurbuz A, Haliloglu B, Kabaca C, Koksal N
Int Urogynecol J Pelvic Floor Dysfunct. 2006 Jan;17(1):40-5. Epub 2005 Jul 5.

The outcome of 11 cases with vaginal agenesis who underwent intestinal vaginoplasties are presented. Patients were between 18 and 37 years old. Ileum vaginoplasty and sigmoid colon vaginoplasty were carried out in two and nine cases, respectively. Ileum necrosis at donor site requiring ileum resection and bilateral ileostomy encountered in one of the cases was the major complication. Mild stenosis responsive to finger dilatation had been detected in two women with sigmoid vaginoplasty. Excess mucous production, long operation time, and shortness of mesentery of ileum led us to abandon ileum vaginoplasty, and sigmoid colon vaginoplasty was performed in the following cases with vaginal agenesis. All of the neovaginas were patent and functional. We suggest sigmoid colon vaginoplasty as the treatment of choice because of its large lumen, thick walls resistant to trauma, adequate secretion allowing lubrication, not necessitating prolonged dilatation, short recovery time compared with ileum vaginoplasties; and in patients reluctance to prolonged use of dilatators or in those who experienced previous failure of the other treatment modalities.

Healing patterns of bladder injuries incurred at laparoscopic hysterectomy: a histologic assessment.
Cogan S, Bedaiwy MA, Paraiso MF, Biscotti C
Int Urogynecol J Pelvic Floor Dysfunct. 2006 Mar 18;.

The objective of this study was to describe histologic healing patterns of bladder injuries during laparoscopic hysterectomy. This was a prospective experimental analysis (Canadian Task Force classification II-1) performed at the Cleveland Clinic Foundation, Minimally Invasive Surgery Center animal laboratory using virgin female mongrels. Sixteen animals divided into groups of four underwent laparoscopic hysterectomy and bladder injury. In group 1, the bladder injury consisted of a 1-cm bladder base injury with bipolar electrosurgical current. In group 2, suture placement through full thickness bladder was performed during closure of the vaginal cuff. A 1-cm bladder base laceration with monopolar cautery was induced and repaired laparoscopically in group 3; group 4 underwent a similar injury to that of group 3 but the repair incorporated full thickness anterior vaginal cuff. Animals were euthanized at least 28 days after the surgery; the bladders and vaginas were harvested en bloc for histologic tissue preparation. Histologic qualifications of inflammation, fibrosis, granuloma formation, necrosis, cautery artifact, granulation tissue, the presence of arteritis, recanalization thrombus, foreign body giant cells, and fistula formation were evaluated at the sites of bladder injury. When analyzed separately, the difference in these post-injury histologic manifestations was not statistically significant. The same was true when comparison was made between groups 1 and 2 (no bladder laceration) vs groups 3 and 4 (monopolar-induced bladder base lacerations). After a healing period of at least 28 days, the histologic manifestations of the various bladder injuries in all groups are similar.

January

[Psoas muscle abscess: bibliographic review]
Navarro Gil J, Regojo Zapata O, Elizalde Benito A, Hijazo Conejos JI, Murillo Perez C, Sanchez Zalabardo JM, Valdivia Uria JG
Arch Esp Urol. 2006 Jan-Feb;59(1):73-7.

OBJECTIVES: To report the clinical characteristics, diagnosis and treatment of psoas abscess. METHODS/RESULTS: We report the case of a 77 year old female patient who was diagnosed of psoas abscess. Due to the unspecific symptoms, she was initially treated as a renal colic. Ultrasound was the test that oriented us to the diagnosis. Percutaneous drainage was effective, checking the resolution using CT Scan. CONCLUSIONS: Psoas abscess is an uncommon pathology the presenting features of which are usually unspecific. CT Scan is the astronomer diagnostic tests and percutaneous drainage has good results and is less aggressive therapeutic option for this disease.

Gluteal injections in increasingly obese population: needle length for intramuscular injections.
Anthony BJ
BMJ. 2006 Apr 1;332(7544):795.

Intestinal vaginoplasty: is it optimal treatment of vaginal agenesis? A pilot study. Surgical method of sigmoid colon vaginoplasty in vaginal agenesis.
Karateke A, Gurbuz A, Haliloglu B, Kabaca C, Koksal N
Int Urogynecol J Pelvic Floor Dysfunct. 2006 Jan;17(1):40-5. Epub 2005 Jul 5.

The outcome of 11 cases with vaginal agenesis who underwent intestinal vaginoplasties are presented. Patients were between 18 and 37 years old. Ileum vaginoplasty and sigmoid colon vaginoplasty were carried out in two and nine cases, respectively. Ileum necrosis at donor site requiring ileum resection and bilateral ileostomy encountered in one of the cases was the major complication. Mild stenosis responsive to finger dilatation had been detected in two women with sigmoid vaginoplasty. Excess mucous production, long operation time, and shortness of mesentery of ileum led us to abandon ileum vaginoplasty, and sigmoid colon vaginoplasty was performed in the following cases with vaginal agenesis. All of the neovaginas were patent and functional. We suggest sigmoid colon vaginoplasty as the treatment of choice because of its large lumen, thick walls resistant to trauma, adequate secretion allowing lubrication, not necessitating prolonged dilatation, short recovery time compared with ileum vaginoplasties; and in patients reluctance to prolonged use of dilatators or in those who experienced previous failure of the other treatment modalities.

Healing patterns of bladder injuries incurred at laparoscopic hysterectomy: a histologic assessment.
Cogan S, Bedaiwy MA, Paraiso MF, Biscotti C
Int Urogynecol J Pelvic Floor Dysfunct. 2006 Mar 18;.

The objective of this study was to describe histologic healing patterns of bladder injuries during laparoscopic hysterectomy. This was a prospective experimental analysis (Canadian Task Force classification II-1) performed at the Cleveland Clinic Foundation, Minimally Invasive Surgery Center animal laboratory using virgin female mongrels. Sixteen animals divided into groups of four underwent laparoscopic hysterectomy and bladder injury. In group 1, the bladder injury consisted of a 1-cm bladder base injury with bipolar electrosurgical current. In group 2, suture placement through full thickness bladder was performed during closure of the vaginal cuff. A 1-cm bladder base laceration with monopolar cautery was induced and repaired laparoscopically in group 3; group 4 underwent a similar injury to that of group 3 but the repair incorporated full thickness anterior vaginal cuff. Animals were euthanized at least 28 days after the surgery; the bladders and vaginas were harvested en bloc for histologic tissue preparation. Histologic qualifications of inflammation, fibrosis, granuloma formation, necrosis, cautery artifact, granulation tissue, the presence of arteritis, recanalization thrombus, foreign body giant cells, and fistula formation were evaluated at the sites of bladder injury. When analyzed separately, the difference in these post-injury histologic manifestations was not statistically significant. The same was true when comparison was made between groups 1 and 2 (no bladder laceration) vs groups 3 and 4 (monopolar-induced bladder base lacerations). After a healing period of at least 28 days, the histologic manifestations of the various bladder injuries in all groups are similar.

Metastasis to the uterine cervix from a rectal cancer.

Trastour C, Rahili A, Avallone S, Karimdjee BS, Chevallier A, Bongain A, Benchimol D
Eur J Obstet Gynecol Reprod Biol. 2006 Feb 28;.

Involvement of PPAR nuclear receptors in tissue injury and wound repair.
Michalik L, Wahli W
J Clin Invest. 2006 Mar;116(3):598-606.

Tissue damage resulting from chemical, mechanical, and biological injury, or from interrupted blood flow and reperfusion, is often life threatening. The subsequent tissue response involves an intricate series of events including inflammation, oxidative stress, immune cell recruitment, and cell survival, proliferation, migration, and differentiation. In addition, fibrotic repair characterized by myofibroblast transdifferentiation and the deposition of ECM proteins is activated. Failure to initiate, maintain, or stop this repair program has dramatic consequences, such as cell death and associated tissue necrosis or carcinogenesis. In this sense, inflammation and oxidative stress, which are beneficial defense processes, can become harmful if they do not resolve in time. This repair program is largely based on rapid and specific changes in gene expression controlled by transcription factors that sense injury. PPARs are such factors and are activated by lipid mediators produced after wounding. Here we highlight advances in our understanding of PPAR action during tissue repair and discuss the potential for these nuclear receptors as therapeutic targets for tissue injury.

Laparoscopic ventral hernia repair without sutures--double crown technique: our experience after 140 cases with a mean follow-up of 40 months.
Morales-Conde S, Cadet H, Cano A, Bustos M, Martin J, Morales-Mendez S
Int Surg. 2005 Jul-Aug;90(3 Suppl):S56-62.

It has been reported that avoidance of recurrences after laparoscopic ventral hernia repair (LVHR) depends on using sutures to secure the mesh. We developed a successful sutureless LVHR. The "Double Crown" LVHR using ePTFE mesh (overlap, 23 cm) was done in 140 cases. Tacks were placed 1 cm apart at the edge of the mesh. A second crown of tacks was placed at the edge of the defect. Three conversions (2.14%) and five bowel perforations occurred intraoperatively (3.57%). Postoperative complications were prolonged ileus (two cases), hematoma (two cases), seroma requiring drainage (three cases), and reoperation in one case for mesh intolerance, three cases for bowel perforation, and one case for small bowel ischemia. The recurrence rate (mean follow-up of 40 months) was 2.14%. The Double Crown LVHR is a safe alternative to LVHR using sutures, with a similar recurrence rate, less pain, fewer incisions and infections, and a shorter operating time.

Laparoscopic ventral hernia repair--managing and preventing complications.
Ramshaw B
Int Surg. 2005 Jul-Aug;90(3 Suppl):S48-55.

Laparoscopic ventral hernia repair was first reported over 10 years ago. Since that time, the procedure has gained widespread acceptance as an appropriate option for the management of ventral hernias of all types. Most published series, including one multicenter study of >800 cases, document that the procedure is safe and effective with low recurrence and wound complication rates. In studies comparing laparoscopic ventral hernia repair to open techniques, the majority show the benefit of the laparoscopic approach in terms of recurrence rates, wound complication rates, and length of hospital stay. The laparoscopic approach does, however, lend itself to potential complications that may be more likely or more difficult to deal with compared with open techniques. This paper will describe these specific complications, including potential disasters, with strategies to manage them, or hopefully, avoid them altogether.

Inguinal hernia repair with spermatex: the first 100 cases.
Nicolo E
Int Surg. 2005 Jul-Aug;90(3 Suppl):S35-9.

We evaluated 100 consecutive cases of surgical repair of inguinal hernia using SpermaTex (Davol, Cranston, RI) to assess postoperative outcome measures of early and late complications and hernia recurrence. SpermaTex is a bilayer surgical mesh prosthesis consisting of a fibrosis-inducing layer of polypropylene mesh bonded to a fibrosis-inhibiting layer of expanded polytetrafluoroethylene. One hundred male patients with unilateral primary inguinal hernia, with a mean age of 49 years, underwent hernia repair with the open anterior approach using SpermaTex. Mean operative time was 35 minutes; there was 3% morbidity and no mortality. At a 14-day follow-up, no patients had postoperative pain; within 2-8 weeks, all patients had returned to their presurgical health condition, with no inguinal pain. At follow-ups of 3 months to 4 years, all 100 patients experienced no recurrence, and all had improved, although 3 patients developed chronic sinus tracts. This series shows a favorable postoperative outcome profile for the use of SpermaTex in inguinal hernia repair.

Absorbable and nonabsorbable barriers on prosthetic biomaterials for adhesion prevention after intraperitoneal placement of mesh.
Matthews BD
Int Surg. 2005 Jul-Aug;90(3 Suppl):S30-4.

Cross-linked acellular porcine dermal collagen implant in laparoscopic ventral hernia repair: case-controlled study of operative variables and early complications.
Cobb GA, Shaffer J
Int Surg. 2005 Jul-Aug;90(3 Suppl):S24-9.

Cross-linked acellular porcine dermal collagen matrix (CPDC) is a new biological implant for use in hernia repair. This study compares operative variables and early complications of all laparoscopic ventral hernia repair (LVHR) procedures by a single surgeon using CPDC to a historical cohort from the same surgeon using composite polypropylene and expanded polytetrafluoroethylene mesh (PP/ePTFE). Eighty-four and 55 patients, respectively, initially underwent attempted LVHR with composite and CPDC prostheses. There was no significant difference between the two groups in the incidence of hernia recurrence. Severe foreign body response with or without mesh infection was noted in three composite group patients, with enterocutaneous fistula in one of these; all mandated removal of the mesh. The referring surgeon removed the CPDC implant in one case upon diagnosis of wound infection. CPDC is safe for use in LVHR and offers an alternative to composite PP/ePTFE mesh that warrants further investigation.

Comparison of three different mesh materials in tension-free inguinal hernia repair: prolene versus Vypro versus surgisis.
Puccio F, Solazzo M, Marciano P
Int Surg. 2005 Jul-Aug;90(3 Suppl):S21-3.

Using mesh or a synthetic prosthesis during tension-free inguinal hernia repair has been shown to be safe and effective. We compared the final outcome in treating inguinal hernia in 45 patients using three different prosthetic materials: 15 patients underwent tension-free inguinal hernia repair using Prolene (polypropylene) mesh, 15 using Vypro (polyglactin and polypropylene) mesh, and 15 with Surgisis-a new bioactive material derived from porcine small intestinal submucosa. The aim of this study was to evaluate the safety and efficacy of tension-free inguinal repair using Surgisis, comparing it with conventional prosthetic materials. From January 2003 to December 2003, 45 male patients underwent Lichtenstein inguinal hernia repair. Median follow-up was 12 months, with a range of 1-16 months. Each patient underwent ultrasound evaluation of the inguinal region 1 month after surgery. All the procedures were completed under local anesthesia. There were no intraoperative complications, and all patients were discharged home the same day of surgery. No recurrent hernias and wound infections were observed in our post-operative follow-up period. Postoperative pain (visual analog score) and discomfort were lower in patients with Surgisis mesh. There was no statistically significant difference between the groups in terms of overall early and late complications; however, there was a tendency toward a higher incidence of pain and discomfort in Vypro and Prolene group. The median time to full recovery was significantly shorter in the Surgisis group. Surgisis mesh seems to be a promising new prosthetic material for hernia repair. Long-term follow-up is necessary to confirm these preliminary results.

Two years of wait and 7000 miles of journey: the tale of a gossypiboma.
Debnath D, Buxton JK, Koruth NM
Int Surg. 2005 Jul-Aug;90(3):130-3.

Postoperative retention of a foreign body is an infrequent but well-recognized complication. A case of a retained swab in the abdominal cavity ("gossypiboma") has been reported. In view of the high morbidity (50%) and mortality (10%) that may result from potential complications, as well as underlying medico-legal implications, it is important to ensure that every effort is made to prevent such occurrences. Presentation of gossypiboma may vary and can be caused by pseudotumoral, occlusive, or septic syndrome. Ultrasonography that shows a "hyper-reflective mass with hypoechoic rim along with a strong posterior shadow" and computed tomography that reveals "a whirl-like spongiform pattern in a hypodense mass with a thick peripheral rim" are considered the mainstay of investigations. These findings, along with a high index of suspicion, can help make a preoperative diagnosis.

Complete genitourinary and colonic duplication: a rare presentation in an adult patient.
Shah KR, Joshi A
J Ultrasound Med. 2006 Mar;25(3):407-11.

Evaluation of FloSeal as a Potential Intracavitary Hemostatic Agent.
Klemcke HG
J Trauma. 2006 Feb;60(2):385-9.

BACKGROUND:: Noncompressible hemorrhage is a major cause of death in combat and civilian trauma. When surgery is unavailable, one potential solution to such hemorrhage might be the introduction of an agent into the closed body cavity to provide hemostasis via a combination of coagulative and tamponade effects. FloSeal is an agent containing collagen and thrombin with proven hemostatic efficacy when applied with manual pressure to a bleeding site. The current studies were conducted to analyze the ability of FloSeal to reduce blood loss and increase survival time when applied directly, immediately, and without additional pressure to a severe liver injury in rats. METHODS:: Male rats were anesthetized and catheters were placed in the carotid artery (for measurement of blood pressure) and jugular vein (for resuscitation with lactated Ringers, 3.3 mL/min/kg BW). After midventral laparotomy, the liver was exposed and caudal portions of both medial lobes ( approximately 1% of body weight) were rapidly excised. FloSeal (5 mL, 800 units Thrombin/mL) or vehicle (5 mL, 0.9% NaCl) was directly and immediately applied to the cut liver surface. The abdominal cavity was closed and resuscitation initiated. After hemorrhage-induced death, or after euthanasia at 90 minutes, fluid loss (blood + resuscitation fluid) was measured. RESULTS:: Compared with the control group, direct and immediate application of FloSeal was associated with a reduction in the amounts of fluid lost into the abdominal cavity (p < 0.01) (19.2 +/- 1.5 versus 25.1 +/- 1.5 g) and enhanced mean arterial pressure at 5, 20, and 30 minutes after injury (p = 0.02), but neither survival time (p = 0.12) nor percent survival (p = 0.17) differed between treated and control groups. CONCLUSIONS:: Reductions in fluid loss after liver injury and hemorrhage in FloSeal-treated rats in the absence of additional applied pressure are encouraging, and provide evidence for the ability of FloSeal to reduce blood loss when applied immediately and directly to a bleeding tissue.

Damage Control Management of Experimental Grade 5 Renal Injuries: Further Evaluation of FloSeal Gelatin Matrix.
Pursifull NF, Morris MS, Harris RA, Morey AF
J Trauma. 2006 Feb;60(2):346-50.

BACKGROUND:: We developed a porcine grade 5 renal laceration damage control model to evaluate the hemostatic efficacy of FloSeal gelatin matrix (Baxter Healthcare, Corp., Deerfield, Ill). METHODS:: Ten commercial swine underwent celiotomy, contralateral nephrectomy, and cooling to 32 degrees C after a well-established hypothermia protocol to simulate a damage control scenario. Following prospective randomization, a complex grade 5 renal injury was uniformly produced on the remaining kidney. Control animals (group 1, n = 5) were treated with direct manual compression with a gelatin sponge. Experimental animals (group 2, n = 5) were treated by application of FloSeal gelatin matrix followed by direct compression with a gelatin sponge. Operative blood loss and efficacy of hemostasis were compared. Creatinine levels were obtained daily until postoperative day 7. Abdominal computed tomography was performed at 10 days. RESULTS:: Use of FloSeal gelatin matrix hemostatic sealant resulted in significantly less mean blood loss than gelatin sponge bolster compression alone (202.4 mL vs. 540.4 mL, respectively, p = 0.016). Hemostasis was complete in 60% (three out of five) of experimental animals after 2 minutes, but was incomplete in all control animals. After an initial increase, serum creatinine approached baseline by postoperative day 7 in all animals. Axial imaging 10 days postoperatively revealed no evidence of significant delayed perirenal hemorrhage. CONCLUSIONS:: FloSeal gelatin matrix performed well as a rapidly deployable, effective hemostatic agent in a hypothermic grade 5 renal injury damage control model. The absence of delayed bleeding and nephrotoxicity suggests a possible increased role for FloSeal in the treatment of devastating renal injuries in damage control surgery.

Ghrelin and leptin elevation in postoperative intra-abdominal sepsis.
Maruna P, Gurlich R, Frasko R, Rosicka M
Eur Surg Res. 2005 Nov-Dec;37(6):354-9.

BACKGROUND: Both ghrelin and leptin are important signals in the regulation of food intake and energy balance. Leptin concentrations are elevated in the majority of obese individuals, and its levels usually correlate with adiposity and body mass index. Ghrelin as a new growth hormone (GH)-releasing peptide was discovered in 1999. Ghrelin stimulates food intake and exhibits gastroprotective properties. Many other regulatory effects of both ghrelin and leptin involving cardiovascular, gastrointestinal, renal, and endocrine systems were revealed. New experimental studies show both hormones as new acute phase reactants in animal models of inflammatory reaction. The aim of this study was to characterize the levels of circulating ghrelin and leptin in relation to systemic inflammatory response. We used a postoperative bacterial sepsis after large abdominal surgery as a model of cytokine network hyperstimulation. PATIENTS AND METHODS:The prospective study was performed on 25 surgical patients with proven postoperative intra-abdominal sepsis after large abdominal surgery. Plasma levels of ghrelin (RIA), leptin, TNF-alpha, IL-1beta, sIL-2R, IL-6 (ELISA analysis), CRP and alpha1-antitrypsin (nephelometric analysis) were analyzed. RESULTS: Authors demonstrate statistically significant elevation of plasma ghrelin (492.3+/-70.6 ng/l) and leptin (31.6+/-12.2 microg/l) compared with the control group (336.5+/-46,1, p<0.01 for ghrelin, 3.5+/-1.2 microg/l, p<0.001 for leptin). The regression coefficient was the highest for ghrelin and IL-6 (r=0,44, p<0.05), and for ghrelin and TNF (r=0.43, p<0.05) in the sepsis group. In regard to leptin, the regression coefficient was the highest for IL-6 and leptin (r=0.53, p<0.05) and for leptin and CRP (r=0.51, p<0.05). There was no significant correlation between ghrelin and IL-1beta, ghrelin and sIL-2R, and leptin and IL-1beta. CONCLUSIONS: During postoperative intra-abdominal sepsis, both ghrelin and leptin plasma levels are elevated and positively correlate with both inflammatory cytokines (TNF-alpha, IL-6) and main APP member (CRP). It supports experimental finding that TNF-alpha and IL-6 can be important regulatory factors of their synthesis. This hormonal reaction is not specific to sepsis--the significant increase of both ghrelin and leptin occurs during an uncomplicated postoperative response, although in a lesser extent than was shown in sepsis.

Chronic plaque psoriasis.
Luba KM, Stulberg DL
Am Fam Physician. 2006 Feb 15;73(4):636-44.

Chronic plaque psoriasis, the most common form of psoriasis, is a papulosquamous disease defined by erythematous plaques with a silvery scale. The diagnosis usually is clinical, but occasionally a biopsy is necessary. Psoriasis affects 0.6 to 4.8 percent of the U.S. population, and about 30 percent of affected patients have a first-degree relative with the disease. Psoriasis is a T-cell-mediated autoimmune disease, but certain medications and infections are well-known risk factors. Management of psoriasis includes education about chronicity, realistic expectations, and use of medication. Steroids and vitamin D derivatives (e.g., calcipotriene) are the mainstays of topical therapy. Topical steroids and calcipotriene together may work better than either agent alone. Patients with psoriasis involving more than 20 percent of their skin or those not responding to topical therapy are candidates for light therapy; traditional systemic therapy; or systemic treatment with immunomodulatory drugs such as alefacept, efalizumab, and etanercept.

Pelvic organ myiasis.
Shaunik A
Obstet Gynecol. 2006 Feb;107(2):501-3.

BACKGROUND: Myiasis is infestation with dipterous larvae, which feed on the host's dead or living tissue, liquid body substances, or ingested food. CASE: A 76-year-old, multiparous woman presented at a tertiary care hospital in India with vaginal discharge and itching for 3 weeks. The patient had a health care attendant who apparently failed to notice the problems she was experiencing. Pelvic examination revealed grade 2 uterine prolapse. Vaginal discharge was purulent, foul smelling, and contained several 8-10-mm white maggots of Musca domestica (housefly). Turpentine oil was instilled locally, and maggots were removed manually. The patient was treated with broad spectrum antibiotics. Maggot removal was repeated weekly for 3 weeks until no further maggots were present. Hysteroscopy was normal. The prolapsed uterus was replaced in its anatomic position with vaginal pessary. CONCLUSION: Decreased physical and mental capabilities due to old age and poor care by health providers can lead to maggot infestation of prolapsed pelvic organs.

Chronic fatigue syndrome.
Prins JB, van der Meer JW, Bleijenberg G
Lancet. 2006 Jan 28;367(9507):346-55.

During the past two decades, there has been heated debate about chronic fatigue syndrome (CFS) among researchers, practitioners, and patients. Few illnesses have been discussed so extensively. The existence of the disorder has been questioned, its underlying pathophysiology debated, and an effective treatment opposed; patients' organisations have participated in scientific discussions. In this review, we look back on several controversies over CFS with respect to its definition, diagnosis, pathophysiology, and treatment. We review issues of epidemiology and clinical manifestations, focusing on the scientific status of CFS. Modern neuroscience and genetics research offer interesting findings for new hypotheses on the aetiology and pathogenesis of the illness. We also discuss promising future issues, such as psychopathophysiology and mechanisms of improvement, and suggest multidisciplinary prospective studies of CFS and fatigue in the general population. These studies should pay particular attention to similarities to and differences from functional somatic syndromes and other fatiguing conditions.

Minimally invasive stapled surgical approach to the management of sigmoid volvulus.
Chandrasekaran TV, Al-Dahiri A, Beynon J, Carr ND
Ann R Coll Surg Engl. 2005 Sep;87(5):381-2.

A simple method for securing a surgical drain.
Shokrollahi K
Ann R Coll Surg Engl. 2005 Sep;87(5):388.

Total pelvic exenteration: The Albert Einstein College of Medicine/Montefiore Medical Center Experience (1987 to 2003).
Goldberg GL, Sukumvanich P, Einstein MH, Smith HO, Anderson PS, Fields AL
Gynecol Oncol. 2006 Jan 17;.

OBJECTIVE.: To review the trends, modifications and results of 103 consecutive total pelvic exenterations (TPE) performed at the Montefiore Medical Center and Albert Einstein College of Medicine from 1987 to 2003. METHODS.: All patients who underwent TPE from January 1987 to December 2003 were included. The medical record, complications, follow-up, clinical status and demographic information were entered in a database. The procedure performed, the method of urinary diversion, colonic diversion, pelvic floor support and vaginal reconstruction were documented. Surviving patients were surveyed regarding their satisfaction with the urinary diversion, the vaginal reconstruction and their sexual function since the surgery. RESULTS.: 103 pts were identified. Indications for TPE were recurrent cancers of the cervix (95), endometrium (2), colon and rectum (5), vulva (1). Overall 5-year survival was 47%. 5-year survival for pts with recurrent cervix cancer was 48%. Six pts (6%) recurred >5 years after the TPE. 14 pts (14%) had ureteral anastomotic leaks (no difference between ileal conduit 9/65 (14%) versus 5/38 (13%) continent conduit (P = 0.92). 34 pts (89%) with continent conduits were "continent." 14 pts (17%) had wound complications. 4 pts (4%) had parastomal hernias. 5/11 (46%) pts who had a low rectal reanastomosis developed recurrence in the pelvis. 21/39 (54%) of pts with continent conduits would choose an ileal conduit if they had the option again. Long-term renal function was similar in pts with ileal and continent conduits. Mesh of any type for pelvic floor reconstruction is associated with infection and bowel/urinary fistulas. VRAM flaps for neovagina fill the pelvic dead space, reduce the risk of fistulas and 20/36 pts (55%) are sexually active. CONCLUSIONS.: Our overall 5-year survival is encouraging, and modifications in surgical technique have improved the reconstructive phase. Low rectal anastomoses at TPE adversely affects survival. Many of our pts with continent urinary diversions would not choose this method again. Mesh of any type is associated with sepsis and bowel/urinary fistulas. VRAM for neovagina reduces fistula rate and are functional in >55% of pts. TPE remains a potentially curative option for these pts.

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