Bridge plating in the setting of radiocarpal instability:Does distal fixation to the second or third metacarpal matter?A cadaveric study

BACKGROUND Radiocarpal dislocations are rare but potentially devastating injuries.Poorer outcomes are associated with inadequate or lost reduction,such as ulnar translocation,but no consensus exists on the ideal fixation technique.Dorsal bridge plate fixation has been described for various settings in the treatment of complex distal radius fractures and can be fixed distally to the second or third metacarpal,but its application for radiocarpal dislocations has not been established.AIM To determine whether distal fixation to the second or third metacarpal matters.METHODS Using a cadaveric radiocarpal dislocation model,the effect of distal fixation was studied in two stages:(1)A pilot study that investigated the effect of distal fixation alone;and(2)a more refined study that investigated the effect of described techniques for distal and proximal fixation.Radiographs were measured in various parameters to determine the quality of the reduction achieved.RESULTS The pilot study found that focusing on distal fixation alone without changing proximal fixation results in ulnar translocation and volar subluxation when fixing distally to the second metacarpal compared with the third.The second iteration demonstrated that anatomic alignment in coronal and sagittal planes could be achieved with each technique.CONCLUSION In a cadaveric radiocarpal dislocation model,anatomic alignment can be maintained with bridge plate fixation to the second metacarpal or the third metacarpal if the described technique is followed.When considering dorsal bridge plate fixation for radiocarpal dislocations,the surgeon is encouraged to understand the nuances of different fixation techniques and how implant design features may influence proximal placement.

Effectiveness of the Service Mapping Method in Re-designing the Bariatric Surgery Clinical Pathway of a Public Hospital

Background： Nowadays obesity is the world＇s common disease. Bariatric surgery is the only therapy that providessignificant cost savings within Public Health Service, but the lack of diagnostic paths universally accepted causes enormous waste ofresources and disruptions. Service Mapping is the ideal methodology to describe work＇s organization and to plan a new service model.Methods： The Service Mapping has been used to represent the actual state of the bariatric surgery service and starting from the criticalaspects found, we have developed a desirable state of the service. Results： Experience-based design has given centrality to thebeneficiary, making the bariatric service sensitive to patient＇s needs and expectations. The micro-organization of work has improvedprofessionals＇ integration, avoiding the creation of new operational entities or additional costs. The service has been simplified both forclinicians and hospital managers. The strategic repositioning of the dietician and general practitioner＇s recognition within the bariatricpath allowed us to achieve better clinical outcomes. Conclusions： Service Mapping has highlighted clinicians＇ difficulties in providingthe service, emphasizing the importance of the beneficiary. The iconic representation is a powerful explicit framework, fundamental formanagement purposes, to understand the role of every subject involved in the service, to rationalize work＇s organization, and integratehealthcare activities.

Endoscopic assessment and management of sporadic duodenal adenomas: The results of single centre multidisciplinary management

AIM To review the role of multidisciplinary management in treating sporadic duodenal adenomas(SDA).METHODS SDA managed at North Shore Hospital between 2009-2014 were entered into a prospective database. Pathology, endoscopic and surgical management as well as follow up were reviewed.RESULTS Twenty-eight patients(14 male: Median age 68 years) presented with SDA [18 were classified as non ampullary location(NA), 10 as ampullary location(A)]. All SDA were diagnosed on upper gastrointestinal endoscopy and were imaged with a contrast enhanced CT scan of the chest, abdomen and pelvis. Of the NA adenomas 14 were located in the second part, 2 in the first part and 2 in the third part of the duodenum. Two patients declined treatment, 3 patients underwent surgical resection(2 transduodenal resections and 1 pancreaticoduodenectomy), and 23 patients were treated with endoscopic mucosal resection(EMR). The only complication with endoscopic resection was mild pancreatitis post procedure. Patients were followed with gastroduodenoscopy for a median of 22 mo(range: 2-69 mo). There were 8 recurrences treated with EMR with one patient proceeding to pancreaticodeuodenectomy because of high grade dysplasia in the resected specimen and 2 NA recurrences were managed with surgical resection(distal gastrectomy for a lesion in the first part of the duodenum and a transduodenal resection of a lesion in the third part of the duodenum).CONCLUSION SDA can be treated endoscopically with minimal morbidity and piecemeal resection results in eradication in nearly three quarters of patients. Recurrent SDA can be treated with endoscopic reresection with surgical resection indicated when the lesions are large(> 4 cm in diameter) or demonstrate severe dysplasia or invasive cancer.

Closure of the Equine Nephrosplenic Space Using a Single LED Powered Trocar via Standing Mini-Laparotomy

Objective: To evaluate a technique using a custom-developed LED powered Single Port Trocar for closure of the nephrosplenic space via a standing mini-laparotomy. Design: Prospective case series. Animals: 60 client-owned horses with a history of nephrosplenic entrapment. Procedures: The nephrosplenic space was closed under direct visualization through a specifically designed LED powered Single Port Trocar in standing sedated horses having experienced recurrence or previous surgical correction of a nephrosplenic entrapment. Obliteration of the space was performed in a cranial to caudal direction in a simple continuous fashion. Time required for suturing the nephrosplenic space, as well as per and post-operative complications were recorded. Clients and referring veterinarians were asked to communicate any complication that occurred after discharge. Results: Surgical time ranged from 23 to 45 min. No complication except for self-limited spleen capsule bleeding occurred during the procedure. Minor wound discharge was noted in 2 cases, and another 2 horses developed post-surgical sweating patches close to the incision. All horses were allowed to progressively resume exercise, starting 1 month post discharge from the hospital. Cosmetic results were considered satisfactory and no recurrence of left dorsal displacement of the colon was reported post-surgery. Conclusions and clinical relevance: A Single Port LED powered Trocar is a technique that allows effective, fast, and safe closure of the nephrosplenic space in the standing horse with minimal instrumentation.

Role of diaphragm in pancreaticopleural fistula

A pancreatic pleural effusion may result from a pancreatopleural fistula. We herein discuss two interesting issues in a similar case report of a pleural effusion caused after splenectomy, which was recently published in the World Journal of Gastroenterology . Pancreatic exudate passes directly through a natural hiatus in the diaphragm or by direct penetration through the dome of the diaphragm from a neighboring subdiaphragmatic collection. The diaphragmatic lymphatic "stomata" does not contribute to the formation of such a pleural effusion, as it is inaccurately mentioned in that report. A strictly conservative approach is recommended in that article as the management of choice. Although this may be an option in selected frail patients, there has been enough accumulative evidence that a pancreaticopleural fistula may be best managed by early endoscopy in order to avoid complications causing prolonged hospitalization.

Energetic etiologies of acute pancreatitis: A report of five cases

There are several common causes of acute pancreatitis, principally excessive alcohol intake and gallstones, and there are many rare causes. However, cases of pancreatitis still occur in the absence of any recognizable factors, and these cases of idiopathic pancreatitis suggest the presence of unrecognized etiologies. Five cases of acute pancreatitis in four patients came to attention due to a strong temporal association with exposure to nerve stimulators and energy drinks. Given that these cases of pancreatitis were otherwise unexplained, and given that these exposures were not clearly known to be associated with pancreatitis, we performed a search for precedent cases and for mechanistic bases. No clear precedent cases were found in Pub Med and only scant, weak precedent cases were found in public-health databases. However, there was a coherent body of intriguing literature in support of a mechanistic basis for these exposures playing a role in the etiology of pancreatitis.

氨甲蝶呤抑制小鼠巨噬细胞一氧化氮合酶表达

研究氨甲蝶呤 (MTX)在小鼠巨噬细胞 (RAW2 6 4 7)对一氧化氮合酶 (NOS)表达的抑制作用。本试验应用内毒素 (LPS)、干扰素 (IFNr)、MTX、二氨基 羟基嘧啶 (DAHP) ,四氢生物喋呤 (BH4 )刺激 8h后 ,用Northern杂交检测NOSmRNA水平和GTP CH 1mRNA水平表达 ,并用Griessreaction方法检测NO2- NO3- 浓度 ,用Duch方法测定GTP CH 1活性值。我们发现 ,MTX在小鼠巨噬细胞 (RAW2 6 4 7)对NOSmRNA水平和GTP CH 1mRNA水平表达有轻度抑制作用 ,对NO2- NO3- 浓度和GTP CH 1活性抑制作用较弱。MTX和DAHP联合应用不仅对NOSmRNA水平和GTP CH 1mRNA水平表达抑制作用较强 ,而且对NO2- NO3 浓度和GTP CH 1活性抑制较大。BH4的加入可以减少MTX和DAHP对一氧化氮 (NO)生成的抑制作用。

I型胶原对III型胶原基因在切口疝病人培养的成纤维细胞中的表达

目的探索细胞外基质在疝组织改变或由于成纤维细胞转?缺陷导致切口疝发生过程中培养的成纤维细胞中I型胶原mRNA和III型胶原mRNA表达。方法成纤维细胞来自切口疝病人和复发性切口疝病人,对照组来自正常健康组织而没有经过手术皮肤病人和虽有切口癍痕但无临床表现切口疝病人。用RT-PCR和North-ern B lotting确定I型胶原mRNA对III型胶原mRNA比率。结果RT-PCR结果表明了I型胶原mRNA在切口疝病人(0.90±0.04)和复发性切口疝病人(1.19±0.04)组中,标相应地在癍痕组织(0.54±0.02)和健康组织(0.43±0.01)。然而III型胶原mRNA在切口疝病人显著增加至4.13±0.04和复发性切口疝病人增加至6.02±0.03,而在癍痕组织2.29±0.04,在健康组织中为1.72±0.03。疝病人的成纤维细胞I型胶原mRNA对III型胶原mRNA比率显著减少(P<0.01)。结论在培养的皮肤成纤维细胞中I型胶原mRNA对III型胶原mRNA的比率减少,表明在切口疝病人存在胶原蛋白代谢紊乱。因此一个损伤的伤口愈合过程可能解释临床缝合修补疝组织不尽满意结果的原因。

AME证据系列001--转化医学协会:脓毒症诊断和早期识别的临床实践指南

脓毒症是一种由感染引起的异质性疾病,感染触发了一系列复杂的局部或者全身的免疫炎症反应,引起多器官功能衰竭,发病率和病死率显著升高。由于至今仍然没有诊断脓毒症的金标准,所以脓毒症的临床诊断仍是一个难题。因此,脓毒症的临床诊断需要不断改变来满足临床和研究的要求。然而,尽管有许多新型的生物标记和筛选工具去预测脓毒症发生的风险,但是这些措施的诊断价值和有效性不足以让人满意,并且没有充分的证据去建议临床使用这些新技术。因此,脓毒症的临床诊断标准需要定期更新去适应不断产生的新证据。这篇综述旨在呈现当前脓毒症的诊断和早期识别方面的最新研究证据。临床运用不同的诊断方法的推荐意见依赖于推荐、评价、发展和评估分级体系(Grades of Recommendation Assessment,Development and Evaluation,GRADE),因为大部分的研究是观察性研究,并没有对这些方法进行可靠评估,采用的是两步推理方法。未来需要更多研究来确认或者反驳某一特殊的指标检测,同时应该直接采用相关病人的结果数据。

Pancreatic insulinomas:laparoscopic management

Insulinomas are rare pancreatic neuroendocrine tumors that are most commonly benign,solitary,and intrapancreatic. Uncontrolled insulin overproduction from the tumor produces neurological and adrenergic symptoms of hypoglycemia. Biochemical diagnosis is confirmed by the presence of Whipple's triad,along with corroborating measurements of blood glucose,insulin,proinsulin,C-peptide,β-hydroxybutyrate,and negative tests for hypoglycemic agents during a supervised fasting period. This is accompanied by accurate preoperative localization using both invasive and non-invasive imaging modalities. Following this,careful preoperative planning is required,with the ensuing procedure being preferably carried out laparoscopically. An integral part of the laparoscopic approach is the application of laparoscopic intraoperative ultrasound,which is indispensable for accurate intraoperative localization of the lesion in the pancreatic region. The extent of laparoscopic resection is dependent on preoperative and intraoperative findings,but most commonly involves tumor enucleation or distal pancreatectomy. When performed in an experienced surgical unit,laparoscopic resection is associated with minimal mortality and excellent long-term cure rates. Furthermore,this approach confers equivalent safety and efficacy rates to open resection,while improving cosmesis and reducing hospital stay. As such,laparoscopic resection should be considered in all cases of benign insulinoma where adequate surgical expertise is available.

The wonders of BMP9:From mesenchymal stem cell differentiation,angiogenesis,neurogenesis,tumorigenesis,and metabolism to regenerative medicine

Although bone morphogenetic proteins(BMPs)initially showed effective induction of ectopic bone growth in muscle,it has since been determined that these proteins,as members of the TGF-b superfamily,play a diverse and critical array of biological roles.These roles include regulating skeletal and bone formation,angiogenesis,and development and homeostasis of multiple organ systems.Disruptions of the members of the TGF-b/BMP superfamily result in severe skeletal and extra-skeletal irregularities,suggesting high therapeutic potential from understanding this family of BMP proteins.Although it was once one of the least characterized BMPs,BMP9 has revealed itself to have the highest osteogenic potential across numerous experiments both in vitro and in vivo,with recent studies suggesting that the exceptional potency of BMP9 may result from unique signaling pathways that differentiate it from other BMPs.The effectiveness of BMP9 in inducing bone formation was recently revealed in promising experiments that demonstrated efficacy in the repair of critical sized cranial defects as well as compatibility with bone-inducing bio-implants,revealing the great translational promise of BMP9.Furthermore,emerging evidence indicates that,besides its osteogenic activity,BMP9 exerts a broad range of biological functions,including stem cell differentiation,angiogenesis,neurogenesis,tumorigenesis,and metabolism.This review aims to summarize our current understanding of BMP9 across biology and the body.

D-galactosamine based canine acute liver failure model

Background: Appropriate preclinical evaluation of a bioartificial liver assist device (BAL) demands a large animal model, as presented here, that demon- strates many of the clinical features of acute liver failure and that is suitable for clinical qualitative and quantitative evaluation of the BAL. A lethal canine liver failure model of acute hepatic failure that re- moves many of the artifacts evidenced in prior canine models is presented. Methods: Six male hounds, 24-30 kg, under isoflu- rane anesthesia, were administered 1.5 g/kg D- galactosamine intravenously. Canine supportive care followed a well-defined management protocol that was guided by electrolyte and invasive monitoring consisting of arterial pressure, central venous pres- sure, extradural intracranial pressure (ICP), pul- monary artery pressure, and end-tidal CO_2. The animals were treated until death-equivalent, defined as inability to sustain systolic blood pressure>80 mmHg for 20 minutes despite maximal fluids and 20 μg·kg^(-1)·min^(-1) dopamine infusion. Results: The mean survival time was 43.7±4.6 hours (mean±SE). All animals showed evidence of progressive liver failure characterized by increasing liver enzymes (aspartate transaminase from 26 to 5977 IU/L; alanine transaminase from 32 to 9740 IU/L), bilirubin (0.25 to 1.30 mg/dl), ammonia (19. 8 to 85. 3 μmol/L), and coagulopathy (pro- thrombin time from 8.7 to 46 s). Increased lability and elevations in intracranial pressures were ob- served. All animals were refractory to maintenance of cerebral perfusion pressure even with only mode- rately elevated intracranial pressure. Severe neuro- logic obtundation, seen in 2 of 6 animals, was associ- ated with elevations of ICP above 50 mmHg. Post- mortem liver histology showed evidence of massive hepatic necrosis. Postmortem blood and ascites mi- crobial growth was consistent with possible transloca- tion of intestinal microbes. Conclusions: The improved lethal canine liver failure model presented here reproduces many of the clinical features of acute liver failure. The model may prove useful for qualitative and quantitative evaluation of BALs.

Pathological factors affecting gastric adenocarcinoma survival in a Caribbean population from 2000-2010

AIM: To investigate pathological factors related to long term patient survival post surgical management of gas-tric adenocarcinoma in a Caribbean population.METHODS: This is a retrospective, observational study of all patients treated surgically for gastric adenocarci-noma from January 1st 2000 to December 31 st 2010 at The University Hospital of the West Indies, an urban Jamaican hospital. Pathological reports of all gastrecto-my specimens post gastric cancer resection during the specified interval were accessed. Patients with a final diagnosis other than adenocarcinoma, as well as pa-tients having undergone surgery at an external institu-tion were excluded. The clinical records of the selected cohort were reviewed. The following variables were analysed; patient gender, patient age, the number of gastrectomies previous performed by the lead surgeon, the gross anatomical location and appearance of the tumour, the histological appearance of the tumour, infil-tration of the tumour into stomach wall and surround-ing structures, presence of Helicobacter pylori and the presence of gastritis. Patient status as dead vs alive was documented for the end of the interval. The effect of the aforementioned factors on patient survival were analysed using Logrank tests, Cox regression models, Ranksum tests, Kruskal-Wallis tests and Kaplan-Meier curves.RESULTS: A total of 79 patients, 36 males and 43 fe-males, were included. Their median age was 67 years(range 36-86 years). Median survival time from surgery was 70 mo with 40.5% of patients dying before the termination date of the study. Tumours ranged from 0.8 cm in size to encompassing the entire stomach speci-men, with a median tumour size of 6 cm. The median number of nodes removed at surgery was 8 with a maximum of 28. The median number of positive lymph nodes found was 2, with a range of 0 to 22. Patients' median survival time was approximately 70 mo, with 40.5% of the patients in this cohort dying before the terminal date. An increase in the incidence of cardiac tumours was noted compared to the previous 10 year interval(7.9% to 9.1%). Patients who had serosal involvement of the tumour did have a significantly shorter survival than those who did not(P = 0.017). A significant increase in the hazard ratio(HR), 2.424, for patients with circumferential tumours was found(P = 0.044). Via Kaplan-Meier estimates, the presence of venous infiltration as well as involvement of the circum-ferential resection margin were found to be poor prog-nostic markers, decreasing survival at 50 mo by 46.2% and 36.3% respectively. The increased HR for venous infiltration, 2.424, trended toward significant(P = 0.055) Age, size of tumour, number of positive nodes found and total number of lymph nodes removed were not useful predictors of survival. It is noted that the results were mostly negative, that is many tumour character-istics did not indicate any evidence of affecting patient survival. The current sample, with 30 observed events(deaths), would have about 30% power to detect a HR of 2.5.CONCLUSION: This study mirrors pathological factors used for gastric cancer prognostication in other popu-lations. As evaluation continues, a larger cohort will strengthen the significance of observed trends.

Prof. Henrik Petrowsky: complex hepatobiliary and pancreatic surgery

Expert’s introduction Prof.Henrik Petrowsky(Figure 1)is a Professor of Surgery and Vice-Chair of the Department of Surgery and Transplantation at the University of Zürich,Switzerland.He serves as Program Director of the HPB Surgery and Liver Transplant Fellowship at the Swiss HPB and Transplant Center Zurich.Prof.Petrowsky is heading the Liver and Pancreas Tumor Center,which is embedded in the Comprehensive Cancer Center Zurich at the University Hospital Zurich.His current practice consists of liver transplantation and HPB surgery.His research interests have mirrored his clinical work mainly focusing on translational and outcome research in liver transplantation and hepatobiliary surgery.

直肠肛管恶性黑色素瘤:磁共振影像的术前有用性

Magnetic resonance imaging (MRI) findings in three patients with primary anorectal malignant melanoma are described. Two patients had melanotic and one had amelanotic anorectal melanoma. The findings of MRI with a pelvic coil and an endorectal coil were consistent with pathologic findings. MRI with a pelvic coil demonstrated the melanotic component as high signal intensity on T1-weighted imaging. MRI with a pelvic coil and an endorectal coil was useful for staging anorectal melanoma. This article describes the initial report of the use of an endorectal coil for malignant melanoma of the anorectum.

成人活体肝移植的挑战

1引言 尸体肝移植的供体缺乏严重限制了肝移植手术的进一步发展。扩展供体来源的各种努力使得成人活体肝移植（ALDLT）在美国1997年得以产生，并且在随后得到了迅速发展和广泛应用。较低的供者发病率和受者移植后初期的成功使人们对该项技术产生了极大的兴趣。然而，最近出现的一些问题对美国ALDLT的未来发展提出了挑战。

Reconstruction of extremity long bone defects with vascularized fibula bone grafts

Aim: Composite tissue defects encompassing bone and/or isolated bony defects can pose a surgical challenge;however, their reconstruction is critical for successful functional limb salvage. These cases become increasingly problematic as secondary defects, following multiple nonvascularized grafting attempts resulting in complex bony nonunion. Herein, our experience utilizing fibula vascularized bone grafts (VBGs) for bone restoration will be presented to demonstrate their utility in a variety of reconstructions for limb salvage. Methods: This is a case series describing a series of vascularized fibula grafts for extremity reconstruction performed by a single academic surgeon over multiple institutions in seven years. Results: Twenty-seven (27) total VBGs met inclusion criteria and underwent reconstruction for traumatic (16), oncologic (6) and chronic degenerative (5) etiologies. Bony union was achieved in 26 of 27 cases. Conclusion: The decision-making process for bony reconstruction in these scenarios is difficult and multivariable. Fibula VBGs can provide a single-stage solution for autologous bony and soft tissue replacement of large or complex bone defects and can often be superior options compared with non-vascularized bone grafts or non-bone internal fixation techniques. Their osteogenic potential is unmatched by allogenic or synthetic substitutions. These benefits are evident in a variety of clinical settings such as pediatrics, oncology and trauma.