Clinical results of meniscus repair in patients 40 years and older

The critical role that the meniscus plays in the knee along with the advantages of preserving as much of the meniscus as possible have both been well documented. Whenever possible, meniscus repair has become the procedure of choice for treatment of meniscal tears. However, some researchers have reported less favorable results in older patients. To determine the results of meniscus repair in older patients, patients 40 years and older who underwent arthroscopically assisted meniscus repair were prospectively followed up. Thirty-seven patients were included in the study, all of which had a minimum 2-year follow-up (average, 26.5 months). The average age of the patients at the time of the repair was 44.2 years (range, 40 to 52 years); 26 were males and 11 were females. There were 19 left knees and 18 right knees included in the study. Twenty-two patients had associated anterior cruciate ligament reconstructions. Physical examination at follow-up included swelling, joint line tenderness, locking, and McMurray testing and radiographs. Five of 37 menisci repaired (13.5%) were symptomatic at latest follow-up. All of these patients had joint line tenderness and two had a positive McMurray test. Three of these patients had repeat arthroscopy confirming that the meniscus had not healed. Because of the small number of patients with symptoms at follow-up, the authors feel that meniscus repair in patients 40 years and older is an effective treatment for peripherally located meniscus tears. With 86.5% of the patients having good clinical results, these findings are comparable with other studies with a younger population and signify that repair of peripheral tears is indicated in this age group especially in conjunction with anterior cruciate ligament reconstruction. The findings suggest that the location and meniscal tear, rather than the age of the patient, determine the potential for successful repair.     

Continuous tracheal gas insufflation enables a volume reduction strategy in hyaline membrane disease: technical aspects and clinical results

OBJECTIVE: Instrumental dead space wash-out can be used to improve carbon dioxide clearance. The aim of this study was to define, using a bench test, an optimal protocol for long-term use, and to assess the efficacy of this technique in neonates. DESIGN: A bench test with an artificial lung model, and an observational prospective study. Dead space wash-out was performed by continuous tracheal gas insufflation (CTGI), via six capillaries molded in the wall of a specially designed endotracheal tube, in 30 preterm neonates with hyaline membrane disease. SETTING: Neonatal intensive care unit of a regional hospital. RESULTS: The bench test study showed that a CTGI flow of 0.5 l/ min had the optimal efficacy-to-side-effect ratio, resulting in a maximal or submaximal efficacy (93 to 100%) without a marked increase in tracheal and CTGI circuit pressures. In the 30 newborns, 15 min of CTGI induced a significant fall in arterial carbon dioxide tension (PaCO2), from 45 +/- 7 to 35 +/- 5 mmHg (p = 0.0001), and in 14 patients allowed a reduction in the gradient between Peack inspirating pressure and positive end-expiratory pressure from 20.8 +/- 4.6 to 14.4 +/- 3.7 cmH2O (p < 0.0001) while keeping the transcutaneous partial pressure of carbon dioxide constant. As predicted by the bench test, the decrease in PaCO2 induced by CTGI correlated well with PaCO2 values before CTGI (r = 0.58, p < 0.002) and with instrumental dead space-to-tidal volume ratio (r = 0.54, p < 0.005). CONCLUSION: CTGI may be a useful adjunct to conventional ventilation in preterm neonates with respiratory disease, enabling an increase in CO2 clearance or a reduction in ventilatory pressure.     

Clinical results of the staged Fontan procedure in high-risk patients

BACKGROUND: For high-risk Fontan candidates, the introduction of a bidirectional Glenn shunt before total cavopulmonary connection (a two-staged strategy) may extend the indications for the Fontan procedure. The clinical results of the two-staged and one-staged Fontan procedure were thus reviewed and compared. METHODS: Between November 1991 and July 1996, the two-staged strategy was performed in 40 high-risk Fontan candidates with a mean interval of 17.2 months after introducing the bidirectional Glenn shunt (staged group). We considered a young age (<2 years), high mean pulmonary arterial pressure (> or =20 mm Hg), high pulmonary vascular resistance (> or =3 Wood units), small pulmonary artery (Nakata index <200 mm2/m2), atrioventricular valve incompetence (> or = moderate), distortion of pulmonary artery, anomalous pulmonary venous return, and poor ventricular function as risk factors for the successful completion of Fontan circulation. During the same period, 68 patients underwent the modified Fontan procedure in a one-step fashion (primary group). RESULTS: In the staged group after the bidirectional Glenn shunt, the mean pulmonary arterial pressure and ventricular end-diastolic pressure were both found to have decreased significantly to the same level as those in the primary group, whereas the pulmonary artery demonstrated a significantly smaller size than that in the primary group. Operative morbidity was similar in both groups. Operative mortality was also similar and low in both groups (1.5% in the primary group and 0% in the staged group). CONCLUSIONS: A bidirectional Glenn shunt was found to be a useful interim palliation in high-risk Fontan candidates. This two-staged strategy may extend the operative indications for the Fontan procedure.     

Hartmann's procedure in colorectal tumors. Evolutions of the indications in a series of 46 patients

The Authors report a retrospective study of 46 cases of Hartmann's operation in order to analyze the changing indications to this procedure in the management of colo-rectal cancer. The Hartmann's is operation has been performed in 46 out of 723 patients (6.4%) with colorectal cancer treated surgically from 1973 to 1997. Data concerning the indications have been analyzed in two consecutive periods, from 1973 to 1985 and from 1986 to 1997, respectively. In the first period, the procedure has been performed in patients with neoplastic perforation (40% of Hartmann's cases), and in an elective basis in patients with locally invasive tumor or intra-abdominal metastasis (20%). Indications for the procedure in the period 1986-1997 have been locally invasive tumor and/or distant metastasis (52.8% of Hartmann's procedures), neoplastic perforation (22.2%), high surgical anaesthesiologic risk (22.2%) or intestinal obstruction (2.8%). In the second period it has been noted a decrease of the number of patients that underwent Hartmann's procedure for bowel obstruction, and an increase in the number of cases in which the operation was performed for neoplastic perforation, for local and/or distant diffusion, or for high surgical risk.     

Reconstruction of the ureter: a review of operative and functional aspects

The importance of the urodynamic characteristics of the ureter are considered after plastic and reconstructive operations. Choice of the most suitable method is as important as good operative technique. The partial replacement of the lower end of the ureter by a bladder flap shows good results. Different types of bladder flap procedures do not influence the dynamics of the ureter as its continuity is preserved. Irrespective of the material used, failures of autoplastic or alloplastic segmental replacement are due to the lack of functional adaptation of the prostheses. By partial replacement good results may be obtained if vesico-ureteral reflux is avoided.     

Surgical treatment of epilepsy in tuberous sclerosis: strategies and results in 18 patients

BACKGROUND: Seizures in patients with tuberous sclerosis complex (TSC) are often intractable to antiepileptic medications and searching investigation may provide evidence that surgical treatment can be considered. OBJECTIVE: To review the results of investigation and surgical therapy, a treatment modality not generally considered in patients with medically refractory seizures and TSC. METHODS: We report 18 patients (9 male) with TSC who underwent surgical treatment of medically refractory epilepsy. Twelve patients had a well-localized epileptogenic lesion and were treated by lesionectomy or focal resection. Resections were: 7 frontal, 4 temporal, 1 frontotemporal, 1 occipital, and 1 frontoparietal. Four patients underwent more than one operation. Six patients had corpus callosotomy (CC). RESULTS: Follow-up ranged from 1 month to 47 years. Outcome of the patients treated by resection was excellent in 7 (5 were seizure-free and 2 had auras only), good in 1, fair in 3, and 1 was lost to follow-up. Best outcome was obtained in patients who had focal seizures and good imaging and EEG correlation, although they might have multiple seizure types, other imaging abnormalities, and multifocal or generalized EEG findings. When there was no such correlation, CC was found to be an option as five patients had at least some improvement and only one showed no change. CONCLUSION: Surgical treatment of patients with TSC and intractable epilepsy is most effective when a single tuber or epileptogenic area can be identified as the source of seizures and resected. This may be possible even when other tubers or diffuse EEG abnormalities are present. In patients with unlocalizable epileptic abnormalities, palliation may be obtained by CC.     

Surgical repair of type A aortic dissection by the circulatory arrest-graft inclusion technique in sixty-six patients

During an 8-year period (1984 to 1991) 66 patients (mean age 59 years, range 26 to 84 years) with type A aortic dissection (60 ascending aorta tears, 6 arch tears; 35 acute, 31 chronic) had surgical repair by a continuous suture-graft inclusion technique. Hypothermic circulatory arrest (16 degrees C) was used in 58 patients (35/35 acute, 23/31 chronic; mean arrest time 26 minutes, range 10 to 55 minutes). Fifty-two patients had hemiarch repair and 6 had total arch replacement. Aortic valve disease necessitated treatment in 38 patients (1 valved conduit, 20 valve replacements, 17 valve repairs). Recently 11 patients had valve repair by reconstruction of the native aortic root, by means of techniques similar to those used for homograft valve insertion. Operative mortality was 9% (14% acute, 3% chronic). Stroke occurred in 2 patients (3%) and was fatal in both. Variables suggestive of increased operative risk by univariate analysis were acuteness (p = 0.12), visceral ischemia (p = 0.12), and preoperative shock (p = 0.13). No variable was significant by multivariate analysis. Overall actuarial survival at 48 months was 77%, with 3 late deaths from a ruptured distal aneurysm. Late computed tomography or magnetic resonance imaging scan was done in 28 patients at a mean interval of 33 months. These studies identified 1 patient with a pseudoaneurysm requiring reoperation and 3 patients with contained flow between the graft and the wrap. Three patients required late operation: 1 for pseudoaneurysm, 1 for arch dissection, and 1 for repair of a distal aneurysm.     

Ratio of male and female characters in a dream series

The present study investigated the change in gender ratio of dream characters in relation to the dreamer's environment in waking-life and found a preponderance of male characters in the subject's dream while living in a 'male' environment which was not present while living in a 'female' environment. The results support the continuity hypothesis of dreaming and stress the importance of situational factors rather than personality factors in the explanation of the gender ratio of dream characters.     

Surgical management of thoracic manifestations in human immunodeficiency virus-positive patients: indications and results

PURPOSE: To quantify color Doppler (CD) signals reflected by breast lesions to improve differential diagnosis and serial comparisons. MATERIALS AND METHODS: Frame-grabbed color-capture scans were remapped to original velocities on a pixel-by-pixel basis for statistical analysis. Total CD area and its percentage, peak and mean velocities, standard deviation of velocity, and integral CD velocity and its percentage were calculated. These indexes were applied to scans of 44 cancers, 16 fibroadenomas, and 14 benign breast changes in 74 patients. RESULTS: With the region of interest confined to the lesion and a 5-mm margin, no CD signals were reflected by the benign breast changes. All carcinomas and 12 fibroadenomas (those that were vascular) reflected CD signals, and, except for mean and peak velocity, all scores for cancers were significantly higher than for fibroadenomas (P < .0001). Integral CD velocity was the best discriminator, with no overlap between carcinomas (range, 1,128-50,228 cm3/sec) and fibroadenomas (range, 0-1,027 cm3/sec). CONCLUSION: Automatic CD quantification improved differential diagnosis of breast masses.     

MRI of the heart: morphological and functional aspects

The performances of cardiac magnetic resonance imaging have been recently improved by the possibility of obtaining functional information by means of gradient echo sequences. Cavity volumetry and wall thickness and mass measurements are now possible. Ultrarapid sequences are useful for the analysis of myocardial perfusion and methods for measuring blood flow and temporal labelling of the ventricular wall open up new prospects for functional evaluation of the heart. In clinical practice, MRI can be useful for the exploration of cardiac parietal and intracavitary masses, constrictive pericarditis, hypertrophic and restrictive cardiomyopathy and cardiac malformations. Assessment of valvular and coronary heart disease is based on new techniques and is currently under evaluation.     

Modified-Mathieu''s technique: a variation of the classic procedure for hypospadias surgical repair

For years, a wide and deep excision of primary cutaneous melanomas has been recommended to achieve a better care and to decrease the risk of local recurrence of the disease. However, recent studies indicate that removal of peritumoral tissue beyond complete excision of the primary neoplasm does not decrease significantly the risk of local metastases. In addition, it confers no benefit to the patient survival.     

Intracranial aneurysms treated with the Guglielmi detachable coil: midterm clinical results in a consecutive series of 100 patients

The purpose of this study was to investigate in vitro the potential effect of type 1 collagen gel containing alpha-elastin on the proliferation of vascular smooth muscle cells and vascular endothelial cells, and on smooth muscle cell migration. Vascular smooth muscle cell and endothelial cell were cultured in 12-well plates precoated with collagen gels and alpha-elastin. Cell proliferation rates were measured by monitoring [3H]-thymidine incorporation. After 2, 3 or 4 days of culture, the proliferation rate of both smooth muscle cells and endothelial cells was significantly decreased on collagen gel containing 10 mg/ml alpha-elastin compared with collagen gel only as control. Smooth muscle cell proliferation on collagen gel containing alpha-elastin on the 4th day of culture was decreased dose-dependently, e.g. 1 mg/ml of alpha-elastin (74.8(2.3)% of control, P=n.s.); 5 mg/ml (56.7(2.1)%; P<0.05); 10 mg/ml (30.3(3.1)%; P<0.005). In the case of cultured endothelial cells, however, [3H]-thymidine incorporation was not decreased significantly in the presence of 5 mg/ml alpha-elastin (83.1(7.9)%, P=n.s.). After stimulation by platelet-derived growth factor, the smooth muscle cell migration rate on collagen gel containing alpha-elastin (5 mg/ml) was decreased over time. The area of migration on the 6th day of culture was also significantly decreased dose-dependently in the presence of alpha-elastin, e.g. 1 mg/ml (72.6(3.4)% of control, P<0.05), 5 mg/ml (56.9%(1.5)%; P<0.05); 10 mg/ml (37.3(2.7)%; P<0.0005). In conclusion, alpha-elastin inhibited the proliferation and migration of smooth muscle cell in a dose-dependent manner on collagen gel culture, however, at high concentrations of alpha-elastin (10 mg/ml), the endothelial cell proliferation rate was also inhibited. At 5 mg/ml, alpha-elastin significantly inhibited smooth muscle cell proliferation and migration but did not significantly inhibit endothelial cell proliferation. Incorporation of collagen gel containing alpha-elastin into the structure of arterial prosthesis offers the possibility of inhibiting smooth muscle cell hyperplasia without significant effect on endothelial cell formation.     

Surgical repair of fracture of the os penis in a dog

An eight-year-old male Australian cattle dog cross was presented with complete urethral obstruction secondary to fracture of the os penis which had occurred two years earlier. Obstruction was associated with callus and fibrous tissue proliferation compressing the urethra at the fracture site. The problem was satisfactorily resolved by removing excess bone and fibrous tissue and stabilising the fracture with a stainless steel finger plate.     

a/alpha-control of DNA repair in the yeast Saccharomyces cerevisiae: genetic and physiological aspects

It has long been known that diploid strains of yeast are more resistant to gamma-rays than haploid cells, and that this is in part due to heterozygosity at the mating type (MAT) locus. It is shown here that the genetic control exerted by the MAT genes on DNA repair involves the a1 and alpha 2 genes, in a RME1-independent way. In rad18 diploids, affected in the error-prone repair, the a/alpha effects are of a very large amplitude, after both UV and gamma-rays, and also depends on a1 and alpha 2. The coexpression of a and alpha in rad18 haploids suppresses the sensitivity of a subpopulation corresponding to the G2 phase cells. Related to this, the coexpression of a and alpha in RAD+ haploids depresses UV-induced mutagenesis in G2 cells. For srs2 null diploids, also affected in the error-prone repair pathway, we show that their G1 UV sensitivity, likely due to lethal recombination events, is partly suppressed by MAT homozygosity. Taken together, these results led to the proposal that a1-alpha 2 promotes a channeling of some DNA structures from the mutagenic into the recombinational repair process.     

Surgical removal of pulmonary metastasis: prospective study in 182 patients]

Dystrophic neurites are major components of neuritic (both immature and mature) senile plaques in Alzheimer disease. Previous studies have shown strong immunoreactivity for different neuropeptides, and chromogranin A, a protein associated with dense-core vesicles, in dystrophic neurites. In the present study, antibodies to synaptophysin, synapsin, Rab3a and synaptotagmin (synaptic vesicle proteins), and SNAP-25 (synaptosomal-associated protein of 25 kD) and syntaxin (presynaptic plasma membrane proteins) have been used to learn about the dystrophic neurite equipment of proteins that are necessary for the docking and fusion of synaptic vesicles, and then for exocytosis and neurotransmission. The present results have shown that, although most neuritic senile plaques have chromogranin A- and SNAP-25-immunoreactive dystrophic neurites, only a percentage of them contain synaptophysin, and a minority contain synaptotagmin and Rab3a. Dystrophic neurites do not contain synapsin and syntaxin. These results show that dystrophic neurites of senile plaques are defective in proteins that control exocytosis and neurotransmission.     

Fine needle aspiration (FNA) in HIV+ patients: results from a series of 655 aspirates

There are many selected small series or case reports of FNAs in patients with HIV infection, but large series are rare and epidemic's characteristics have evolved over time. The current study, from a large public hospital in the USA, included women as well as men, hetero- and homosexuals, in-patients and out-patients, and deep radiologically guided aspirates as well as superficial masses. Of 655 FNAs, reactive or benign changes were present in 37% confirmed or suspected malignancy in 13%, specific infection with stainable organisms in 14%, and inflammation in 16%. Twenty percent of cases were inadequate for diagnosis. Most of the identifiable infections were associated with Mycobacterium tuberculosis, with fewer atypical mycobacteria, fungi and other bacteria. Clinically significant diagnoses were correlated with deep aspirate location and lesion size > 2 cm, confirming other studies which also identified tenderness and recent enlargement as important indicators. The liberal use of FNA in our HIV+ population has greatly reduced the necessity for surgical nodal resection, reassured clinicians in continuing observation of reactive lymphadenopathy, and allowed immediate therapy for specific infection, cyst or malignancy.     

Surgical treatment of aneurysms of the left ventricle. Immediate and long-term results. Apropos of a consecutive series of 121 cases

From 1978 to 1992, 121 cases of postinfarction left ventricular aneurysm (99 males, 22 females, mean age 60 years) were operated on. The authors insist on a high rate of clinical arhythmogenicity (31.4%) and associated mechanical complications (21%). 76% of patients were in functional NYHA class III or IV. Resection was performed in 90% of patients, plication in 10%. 58% underwent coronary artery bypass grafting (1.7 graft/patient), 16% encircling ventriculotomy, 8% mitral valve replacement and 13% closure of ventricular septal defect. Operative mortality was 14.9% (10% when other mechanical complications where excluded). 5-year survival is 67.9%. Late cardiac deaths are as follow: left ventricular failure (1.8% A/P), Sudden death (1.4% A/P), Myocardial infarction (0.6% A/P). 82% of survivals are in functional NYHA class I or II. Only functional class NYHA III or IV is predictive of late death. We conclude that postinfarction left ventricular aneurysm remains a high risk complication especially when associated with other mechanical complications. When arhythmogenicity is present we suggest rhythmologic surgery and in all cases, complete revascularization.     

Intracranial self-stimulation in female and male rats: no sex differences using a rate-independent procedure

Neopterin concentrations in diverse body fluids provide a well established indication for activation of the cell-mediated immune system. Neopterin concentrations were measured in the saliva and urine of 29 patients with varying numbers of teeth affected by periodontitis. While neopterin concentrations in urine increased slightly but not significantly in parallel with increasing numbers of affected teeth, salivary neopterin levels showed a significant and positive correlation with number of diseased teeth (linear correlation coefficient = 0.48, P = 0.012). Additionally, when the patients were grouped according to the median number of affected teeth (20), salivary specimens of subjects with one to 20 affected teeth showed significantly lower neopterin concentrations than specimens from those with more than 20 diseased teeth (P = 0.0045, Student's t-test). In contrast, urinary neopterin concentrations did not differ significantly among these two groups. This pilot study suggests that salivary neopterin concentrations may reflect local immune activation even in situations where no systemic activation can be detected.     

Surgical treatment results in patients with severe forms of the carpal tunnel syndrome

A retrospective and prospective study was undertaken to determine efficacy of carpal tunnel decompression in patients with advanced carpal tunnel syndrome (CTS). The criteria for inclusion in this study were clinical and nerve conduction studies (NCS). Between 1985-1991, 1511 NCSs performed were positive for CTS.