Prevention and treatment of postburn scars and contracture

The management of postburn reconstruction is complicated by the frequent occurrence of multiple reconstructive needs in a single patient. This article presents a simple, comprehensive approach to burn scar reconstruction. The primary aim of the surgeon is to prevent burn scar deformity by rapid wound closure, correction of tissue deficiencies, and assiduous attention to postoperative splinting and compression therapy. The initial step in managing secondary deformities is to prioritize reconstructive needs. Reconstruction is then carried out in a stepwise fashion aiming to restore active function first, followed by passive function, and finally addressing aesthetic reconstruction. Reconstructive techniques are applied in a hierarchy from simplest to most complex. Primary excision and closure of scars by reorientating the scar to the lines of relaxed skin tension can significantly improve appearance. The use of z-plasty, flap repair, and tissue expansion are also reviewed. Skin expansion, in particular, has become the standard management of postburn alopecia and, although associated with a relatively high rate of complication, has significantly improved the aesthetic appearance of such patients. The management of common problems affecting the face is discussed with particular reference to management of the eyelids, oral commissure, and lips. These areas need to be reconstructed as aesthetic units and each requires individualized management of donor tissue. The reconstruction of the burn patient is often a long process requiring multiple procedures. The approach presented here advocates a stepwise, prioritized approach aiming at both maximum function as well as optimal appearance.

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Resumen El manejo de la reconstrucción de lesiones por quemadura se hace más complejo debido a los frecuentes y múltiples requerimientos de reconstrucción en el paciente individual. El presente artículo presenta un enfoque simple y comprensivo de la reconstrucción después de la cicatrización de la quemadura. El propósito primario del cirujano es prevenir la deformación por la cicatrización de quemadura mediante el cierre precoz de la herida, la corrección de las deficiencias tisulares y une vigorosa utilización de férulas y de terapia de compresión. El paso inicial en el manejo de deformaciones secundarias es establecer las prioridades en cuanto a los requerimientos de reconstrucción; la reconstrucción es luego practicada en forma secuencial para lograr función activa, seguida de función pasiva, para finalmente realizar la reconstrucción estética. Las técnicas de reconstrucción son aplicadas en forma jerárquica desde las más simples a las más complejas. La resección primaria de cicatrices y el cierre mediante la reorientación de la cicatriz hacia las lineas de relajación de la tensión cutánea puede mejorar significativamente la apariencia del paciente. También se revisa el uso de plastias en Z, la reparación con colgajos y la expansión tisular. La expansión cutánea, en particular se ha convertido en el método estándar de tratamiento de la alopecia por quemadura y aunque se asocia con una tasa de complicaciones relativamente alta, ha mejorado significativamente la apariencia de tales pacientes. El manejo de los problemas comunes que afectan la cara es tratado con referencia particular a los párpados, la comisura oral y los labios. Estas áreas deben ser reconstruidas como unidades estéticas y cada cual requiere un manejo individualizado del tejido donante. La reconstrucción del paciente quemado con frecuencia es un proceso prolongado que presenta preconiza un enfoque secuencial y de prioridades con un propósito tanto de resultados funcionales, máximos y estéticos óptimos.

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Résumé La reconstruction après brûlure est souvent compliquée par le fait que plusieurs procédés de reconstruction sont nécessaires chez le même patient. Cet article présente une approche simple et globale de la refection des cicatrices dues aux brûlures. Le premier travail du chirurgien comporte la prévention des malformations secondaires aux brûlures par la fermeture rapide des plaies, la correction des pertes tissulaires et l'utilisation obligatoire des attelles et de moyens de contention. La première phase du traitement a pour but d'établir la priorité des besoins de reconstruction. La reconstruction est alors entreprise étape par étape dans le but, d'abord, de rétablir les fonctions actives, puis les fonctions passives et enfin d'améliorer l'aspect esthétique. Les techniques de reconstruction suivent une hiérarchie bien déterminée du plus simple en plus complexe. L'excision et la fermeture primitive des cicatrices orientant les cicatrices vers les lignes de relaxation maximale est un premier pas pour améliorer l'aspect morphologique. Les indications des lambeaux en Z, et de l'expansion tissulaire sont passées en revue. L'expansion cutanée est devenue une méthode standard pour le traitement de l'alopécie postbrûlure. Bien que le taux de complications soit relativement élevé, cette technique améliore grandement l'aspect physique des brúlés. La tactique opératoire des problèmes des brûlés du visage est envisagée avec une référence particulière à la reconstruction des paupières, des commissures de la bouche et des lèvres. Ces régions doivent être traitées comme des unités esthétiques et chacune d'entre elles nécessite un site donneur de tissu individualisé. La chirurgie reconstructive chez un brûlé est souvent longue et nécessite de multiples procédés. L'approche présentée ici vise une restauration maximale de la fonction et de l'aspect physique par un traitement progressif.

     

Relationship between Fat Oxidation and Lactate Threshold in Athletes and Obese Women and Men

The first aim of this study was to determine the exercise intensity that elicited the highest rate of fat oxidation in sedentary, obese subjects (OB; n=10 men, n=10 women) compared with endurance athletes (AT; n=10 men, n=10 women). The second aim was to investigate the relationship between VO₂ at the intensity eliciting the highest rate of fat oxidation and the corresponding VO₂ at the lactate threshold. Peak oxygen consumption (VO_2peak) was determined in 20 AT and 20 OB using an incremental exercise protocol on a cycle ergometer. Based on their VO_2peak values, subjects completed a protocol requiring them to exercise for 20 min at three different workloads (55, 65 and 75% VO_2peak), randomly assigned on two separate occasions. The oxidation rates of fat and carbohydrate were measured by indirect calorimetry. The highest rates of fat oxidation were at 75 % VO_2peak (AT), and at 65 % VO_2peak (OB). The rate of fat oxidation was significantly higher in AT (18.2 ± 6.1) compared with OB women (10.6 ± 4.5 kJ min^-1·kg^-1) (p < 0.01). There was no significant difference in the rate of fat oxidation for the men (AT 19.7 ± 8.1 vs. OB 17.6 ± 8.2 kJ min^-1·kg^-1). AT reached LT at a significantly (p < 0.01) higher exercise intensity expressed in VO_2peak than obese subjects (AT women 76.4 ± 0.1, men 77.3 ± 0.1 vs. OB women, 49.7 ± 0.1, men 49.5 ± 0.1% VO_2peak). A significant correlation was found between VO₂ at LT and VO₂ (L·min^-1) eliciting the maximal rate of fat oxidation in athletes (women; r = 0.67; p = 0.03; men: r = 0.75; p = 0.01) but not in the obese. In summary, we observed higher rates of fat oxidation at higher relative work rates in AT compared with OB. A significant correlation was found between LT and the exercise intensity eliciting a high rate of fat oxidation in AT (r=0.89; p < 0.01) but not in OB. Cardiorespiratory fitness, defined as VO_2peak, seems to be important in defining the relationship between a high rate of fat oxidation and LT.

Key Points

• Within the tested intensities of 55, 65 and 75% VO_2peak athletes reached higher rates of fat oxidation at higher relative work rates compared with obese subjects.
• We found in obese women and men the intensity of the highest rate of fat oxidation at 65% VO_2peak.
• Between the lactate threshold and the intensity eliciting a high rate of fat oxidation a significant correlation was found in athletes but not in obese subjects.

Key words: Exercise intensity, substrate utilization, obesity, lactate threshold     

Cholecystectomy and drainage: Ultrasonographic and radioisotopic evaluation

Eighty patients undergoing cholecystectomy were either assigned deliberately (n=30) or randomized (n=50) to drainage (n=38) or nondrainage (n=42). Subhepatic collections were seen on ultrasonography (US) after 48 to 72 hours in 12 of 35 patients with drainage and 24 of 42 patients without drainage (p<0.05). Only two patients with subhepatic collections were symptomatic, and none required treatment. Postoperative infective complications were seen in 13 of 38 patients with drainage and 4 of 42 without drainage (p<0.01). Five of 12 patients with drainage and with a collection, and none of the 18 patients without drainage and without a collection had postoperative infective complications (p<0.05). Cholecystectomy was then performed in 100 patients without using a drain. BULIDA radioisotope scans revealed a bile leak in only 4 of 34 patients studied. Subhepatic collections were seen on US after 48 to 72 hours in 42 patients. The collection resolved in 22 patients and was smaller in 6 on repeat US. None of the patients with collection was symptomatic, and none required treatment. Postoperative infective complications were seen in 7 of 42 patients with a collection and 5 of 58 patients without a collection (not significant). We conclude that (1) cholecystectomy with drainage is associated with more infective complications than when a drain is not used; (2) cholecystectomy without drainage is safe; and (3) asymptomatic nonbilious subhepatic collections are common after cholecystectomy without drainage but do not require treatment, resolving spontaneously.

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Resumen Ochenta pacientes sometidos a colecistectomía fueron randomizados a drenaje (38) o no drenaje (42). Se observaron colecciones subhepáticas en ultrasonografía practicada a las 48–72 horas en 12/35 pacientes con drenaje y en 24/42 pacientes sin drenaje (p<0.05). Sólo 2 de tales colecciones fueron sintomáticas y ninguna requirió tratamiento. Complicaciones sépticas postoperatorias fueron registradas en 13/38 pacientes con drenaje y en 4/42 sin drenaje (p<0.01). Cinco de 12 con drenaje y con colección subhepática, y ninguno de 18 sin drenaje y sin colección presentaron complicaciones sépticas postoperatorias (p<0.05). Después de esta serie se practicaron 100 colecistectomías sin drenaje. La escanografía con radioisótopos, BULIDA, reveló escape biliar en sólo 4 de 34 pacientes estudiados; se visualizaron colecciones subhepáticas por US a las 48–72 horas en 42 pacientes. La colección se resolvió en 22 y apareció menor en 6 casos en que se repitió la US. Ninguna de estas colecciones fue sintomática y ninguna requirió tratamiento alguno. Se registraron complicaciones sépticas en 7/42 pacientes con colección y en 5/58 sin colección (ns). Nuestra conclusión es que la colecistectomía con drenaje se asocia con un numéro mayor de complicaciones sépticas. La colecistectomía libre de drenaje es un procedimiento seguro; las colecciones no biliares subhepáticas asintomáticas son frecuentes después de la colecistectomía sin drenaje pero no requieren tratamiento y se resuelven espontáneamente.

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Résumé Quatre-vingt patients (50 par randomisation) ont eu un drainage (n=38) ou non (n=42) après cholécystectomie traditionnelle. Une collection soushépatique a été mise en évidence par échographie dans les 48–72 heures postopératoires chez 12/35 patients avec drainage et chez 24/42 patients sans drainage (p< 0.05). Seulement deux de ces collections étaient symptomatiques et aucune n'a nécessité de geste thérapeutique. Des complications postopératoires infectieuses ont été observées chez 13/38 patients ayant eu un drainage comparées à 4/42 des patients sans drainage (p<0.01). Cinq des 12 patients ayant eu un drainage et une collection ont eu une infection postopératoire comparés à aucun des 18 patients sans drainage ni collection (p<0.05). On a ensuite réalisé 100 cholécystectomies sans drainage. Une scintigraphie au technétium a mis en évidence une fuite biliaire chez 4 des 34 patients étudiés. Une collection soushépatique a été mise en évidence par échographie chez 42 patients. Lors de la surveillance échographique, la collection s'est résorbée spontanément chez 22 patients et a diminué d'importance chez 6. Aucune de ces collections n'étaient symptomatiques et aucune n'a nécessité de geste thérapeutique. Des complications postopératoires ont été observés chez 7/42 patients avec une collection comparés à 5/58 patients sans collection (différence non significative). Nous concluons que: (1) il y a plus d'infection lorsque l'on draine l'abdomen après une cholécystectomie que lorsque l'intervention se termine sans drainage; (2) la cholécystectomie sans drainage est sans danger; et (3) des collections bilieuses asymptomatiques sont fréquentes après cholécystectomie sans drainage, mais elles se résorbent habituellement sans nécessiter d'intervention.

     

Diagnosis and treatment of genitofemoral and ilioinguinal neuralgia

During the past 8 years, a total of 36 patients were diagnosed as having either ilioinguinal or genitofemoral neuralgia. A multidisciplinary approach (surgeon, neurologist, anesthesiologist) as well as local blocks of the ilioinguinal nerve or paravertebral blocks of L_1,2 were essential to determine which nerve was likely to be entrapped. Seventeen of the 19 patients having a diagnosis of ilioinguinal neuralgia after previous inguinal herniorraphy were completely free of pain after resection of the entrapped portion of the nerve. Seventeen patients were diagnosed as having genitofemoral neuralgia after previous inguinal herniorraphy, blunt abdominal trauma, or another operation. Neurectomy of the genitofemoral nerve proximal to the entrapment controlled the persistent pain in 12 of 17 of these patients. Ilioinguinal or genitofemoral nerve entrapment neuralgias are rare complications of operations in the inguinal region. When the diagnosis is made by a multidisciplinary approach, neurectomy is frequently successful in relieving severe pain and paresthesias without serious morbidity.

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Resumen En los últimos 8 años hemos tenido 36 pacientes en quienes se ha diagnosticado neuralgia ilioinguinal o genitofemoral. El enfoque multidisciplinario (cirujano, neurólogo, anestesiélogo), así como la realización de bloqueos locales del nervio ilioinguinal o de bloqueos paravertebrales de L_1,2 fueron esenciales para determinar cual o cuales eran los nervios posiblemente atrapados. Diecisiete de 19 pacientes con el diagnóstico de neuralgia ilioinguinal consecutiva a herniprrafia inguinal fueron totalmente liberados de su dolor después de la resección de la porción afectada por atrapamiento del nervio. En diecisiete pacientes se estableció el diagnóstico de neuralgia consecutiva a herniorrafia inguinal, a trauma abdominal cerrado, y a otras operaciones; la neurectomía del nervio genitofemoral proximal al sitio de atrapamiento logró controlar dolor persistente en 12 de estos 17 pacientes. Las neuralgias por atrapamiento de los nervios ilioinguinal y genitofemoral son complicaciones raras de operaciones sobre la región inguinal. Cuando el diagnóstico ha sido establecido mediante enfoque multidisciplinario, la neurectomía es generalmente exitosa en cuanto a controlar el dolor severo y las parestesias, sin estar asociada con morbidad seria.

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Résumé Au cours des 8 dernières années, on a fait le diagnostic de névralgie génitocrurale ou abdominogénitale chez 36 patients. Une approche multidisciplinaire (chirurgien, neurologue, et anesthésiste) et l'utilisation de blocs nerveux L_1,2, sont 2 facteurs essentiels dans la détermination du nerf le plus vraisemblablement intéressé. Dix-sept des 19 patients ayant une névralgie abdominogénitale après cure de hernie inguinale ont été soulagés par la résection du nerf piégé. Dix-sept patients avaient une névralgie génitocrurale à la suite d'une cure pariétale pour hernie inguinale, un traumatisme abdominal fermé, ou une autre intervention. La résection nerveuse du nerf génitocrural en amont de la zone intéressée n'a été suivie de succès que chez 12 des 17 patients. La névralgie abdominogénitale ou génitocrurale est une complication rare de la cure de hernie inguinale. Lorsque le diagnostic est fait par une équipe multidisciplinaire, la résection nerveuse est souvent suivie de soulagement de la douleur et de paresthésies sans morbidité excessive.

     

Incorporation and release of85Sr and14C-proline-hydroxyproline in mineral and collagen of bone and incisor teeth of growing rats

The extent to which exchange and reutilization processes of mineral tracers affect skeletal mineral accretion and resorption measurements was evaluated by comparing the rates of appearance and disappearance of⁸⁵Sr and¹⁴C-proline-hydroxyproline in bones and teeth in growing rats for 12 days following simultaneous parenteral injection of these tracers. Expressions for the relative rates of collagen synthesis and breakdown, which unlike mineral metabolism are considered not to be complicated by exchange phenomena, were based on¹⁴C-proline conversion to¹⁴C-hydroxyproline; the specific activity of the latter was determined. Both the mineral and the collagen specific activities reflected the rates and patterns of growth of the samples assayed; rapid growth and a short interval of time between formation and resorption of tissue in themetaphyseal bone which contains the cartilagineous growth plate, slow growth and an interval of time between formation and resorption of tissue indiaphyseal bone and incisor teeth which is longer than the 12 days of the experiment. However, in metaphyseal bone the specific activity collagen/mineral ratio dropped by one half during the 4–12 day interval in contrast to diaphyseal bone and incisor teeth in which no change in this ratio was observed during this period of time. The data indicate that collagen in the metaphyseal growth zone is removed by resorption before it has become fully mineralized, and that exchange is a relatively unimportant factor in the long term kinetics of bone mineral.

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Zusammenfassung Das Ausmaß, bis zu welchem Austausch- und Wiederverwendungsprozesse der mineralen Tracer die Messungen des mineralen Skelett-Auf- und Abbaues beeinflussen können, wurde ausgewertet; zu diesem Zweck wurde die Geschwindigkeit des Auftretens und Verschwindens von⁸⁵Sr und von¹⁴C-Prolin-Hydroxyprolin in Knochen und Zähnen von wachsenden Ratten während der 12 auf die simultane parenterale Injektion dieser Tracer folgenden Tage verglichen.Der Ausdruck für die relative Geschwindigkeit des Kollagen-Auf- und Abbaues, bei welchem im Gegensatz zum Mineralmetabolismus kein Mitwirken des Austauschphänomens vermutet wird, basiert auf der Umwandlung von¹⁴C-Prolin zu¹⁴C-Hydroxyprolin; die spezifische Aktivität des letzteren wurde bestimmt.Aus der spezifischen Aktivität des Minerals sowie jener des Kollagens konnten die Geschwindigkeit und die Art des Wachstums der untersuchten Proben ersehen werden, d.h.schnelles Wachstum und ein kurzes Zeitintervall zwischen Bildung und Resorption des Gewebes imKnochen der Metaphyse, die auch die knorpelige Wachstumsplatte enthält, und andererseitslangsames Wachstum und längeres Zeitintervall (länger als die 12 Tage des Experimentes) zwischen Bildung und Resorption des Gewebes imKnochen der Diaphyse und in den Schneidezähnen. Immerhin fiel die spezifische Aktivität des Kollagen/Mineral-Anteils im Knochen der Metaphyse während dem 4–12tägigen Zeitintervall auf die Hälfte, im Gegensatz zum Knochen der Diaphyse und der Schneidezähne, bei welchen während dieser Zeitspanne kein Unterschied in diesem Verhältnis beobachtet wurde.Diese Ergebnisse zeigen, daß Kollagen in der Wachstumszone der Metaphyse durch Resorption verschwindet, bevor es ganz mineralisiert ist, und daß der Austausch ein relativ unwichtiger Faktor in der Kinetik auf lange Sicht des Knochenminerals ist.

     

Presenteeism and Absenteeism Before and After Total Hip and Knee Arthroplasty

BackgroundAbsenteeism is costly, yet evidence suggests that presenteeism—illness-related reduced productivity at work—is costlier. We quantified employed patients’ presenteeism and absenteeism before and after total joint arthroplasty (TJA).MethodsWe measured presenteeism (0-100 scale, 100 full performance) and absenteeism using the World Health Organization’s Health and Work Performance Questionnaire before and after TJA among a convenience sample of employed patients. We captured detailed information about employment and job characteristics and evaluated how and among whom presenteeism and absenteeism improved.ResultsIn total, 636 primary, unilateral TJA patients responded to an enrollment email, confirmed employment, and completed a preoperative survey (mean age: 62.1 years, 55.3% women). Full at-work performance was reported by 19.7%. Among 520 (81.8%) who responded to a 1-year follow-up, 473 (91.0%) were still employed, and 461 (88.7%) had resumed working. Among patients reporting at baseline and 1 year, average at-work performance improved from 80.7 to 89.4. A Wilcoxon signed-rank test indicated that postoperative performance was significantly higher than preoperative performance (P < .0001). The percentage of patients who reported full at-work performance increased from 20.9% to 36.8% (delta = 15.9%, 95% confidence interval = [10.0%, 21.9%], P < .0001). Presenteeism gains were concentrated among patients who reported declining work performance leading up to surgery. Average changes in absences were relatively small. Combined, the average monthly value lost by employers to presenteeism declined from 15.3% to 8.3% and to absenteeism from 16.9% to 15.5% (ie, mitigated loss of 8.4% of monthly value).ConclusionAmong employed patients before TJA, presenteeism and absenteeism were similarly costly. After, employed patients reported increased performance, concentrated among those with declining performance leading up to surgery.     

经椎间孔减压椎间融合术治疗胸腰椎骨折脱位的临床及影像学结果分析

目的:评价经椎间孔减压椎间融合治疗胸腰椎骨折脱位的临床及影像学结果。方法:回顾性分析2010年6月至2017年6月采用后路经椎间孔减压、椎间植骨融合联合后方椎弓根螺钉治疗21例胸腰椎骨折脱位患者的临床资料,其中男15例,女6例;年龄25～58岁,平均45岁。术前ASIA神经功能损伤分级,A级3例,B级7级,C级6例,D级4例,E级1例。记录手术时间、术中出血量及相关并发症。评价术前及术后的VAS评分、ODI及Cobb角。分析末次随访的神经功能改善情况。通过CT三维重建评价椎间植骨融合情况。结果:手术时间150～240(192±47)min;术中出血量380～750(603±120)ml。术中发现3例由外伤导致的硬膜囊撕裂及脑脊液瘘,均给予缝合修补;1例术后浅表伤口感染,经换药后愈合。术后随访24～45(37.0±9.5)个月。患者的VAS评分由术前的8.9±0.4降低至术后即刻的4.2±1.3(P0.05)。至末次随访时,VAS评分进一步降低至3.6±0.8。ODI由术前的(95.30±3.52)%降低至末次随访时的(32.51±6.30)%(P0.05)。Cobb角由术前的(21.2±8.8)°矫正至术后即刻的(2.3±3.1)°(P0.05)。至末次随访时,Cobb角为(3.2±2.5)°,与术后即刻相比差异无统计学意义。至末次随访时,ASIA神经功能分级为A级3例,B级3例,C级5例,D级6例及E级4例。21例患者均获得良好的椎间植骨融合,融合时间为8～13(10.3±2.5)个月。结论:对于主要累及椎间盘及终板平面的胸腰椎骨折脱位,采用后路经椎间孔减压椎间融合术治疗不仅手术创伤小,而且能够有效的重建三柱结构及获得良好的生物力学稳定性,此外术后神经功能恢复良好。     

Effect of duodenal osmolality on gastrin and secretin release and on gastric and pancreatic secretion

We have measured the osmolality of duodenal contents in 9 dogs after a hypertonic meal, given either by mouth or directly into the stomach or perfused into the duodenum. A test meal of 2,475 mosm/kg, given by mouth, raised the intraduodenal osmolality to 700–1,500 mosm/kg over a 1-hour period. Hypertonic glucose solutions (2,000 and 3,400 mosm/kg), given into the stomach, were found to be diluted to about 700 and 1,100 mosm/kg, respectively, at the level of the mid-duodenum 30 minutes later. Hypertonic saline solutions (1,800 and 2,700 mosm/kg), perfused into the duodenum, created a stable intraluminal osmolality of 800 and 1,200 mosm/kg, respectively, (about 45% that of the perfusate) after 30 minutes. In 6 Heidenhain pouch dogs, gastric secretion and gastrin release stimulated by food were significantly diminished by administration of hypertonic sodium chloride solution (1,800 mosm/kg) into the duodenum. This hyperosmolality caused greater suppression of acid secretion (52%) than of gastrin release (28%). Stimulation of pancreatic water and bicarbonate secretion and of release of radioimmunoassayable secretin by intraduodenal HCl (pH 1.3) were significantly suppressed when the osmolality of the HCl solution was raised to 2,700 mosm/kg. Pancreatic protein secretion remained unchanged with hypertonic solutions. We have confirmed that stimulation of intraduodenal osmoreceptors inhibits gastric acid secretion in dogs, and we suggest that this is due, at least in part, to a suppression of gastrin release. We further suggest that duodenal osmolar inhibition of pancreatic secretion involves suppression of secretin but does not appear to involve cholecystokinin.

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Résumé Nous avons mesuré l'osmolalité du contenu duodénal chez 9 chiens après un repas hypertonique administré soit per os, soit directement dans l'estomac, soit par perfusion dans le duodénum. Un repas à 2,475 mosm/kg, administré per os, élève l'osmolalité duodénale à 700–1,500 mosm/kg pendant une heure. Des solutions de glucose hypertonique à 2,000 et 3,400 mosm/kg, introduites directement dans l'estomac, sont, 30 minutes plus tard, diluées à 700 et 1,100 mosm/kg au niveau de la partie moyenne du duodénum. Des solutions salines hypertoniques à 1,800 et 2,700 mosm/kg, en perfusion intraduodénale, donnent, après 30 minutes, une osmolalité duodénale de 800 et 1,200 mosm/kg (±45% de la solution perfusée).Chez 6 chiens à poche de Heidenhain, la sécrétion gastrique et la libération de gastrine provoquées par un repas sont réduites de façon significative par la perfusion intraduodénale de chlorure de sodium en solution hypertonique (1,800 mosm/ kg). Cette hyperosmolalité réduit plus la sécrétion d'acide (52%) que la libération de gastrine (28%). La perfusion dans le duodénum d'une solution d'HCl (pH 1.3), dont l'osmolalité est portée à 2,700 mosm/kg, diminue la stimulation des sécrétions d'eau et de bicarbonate pancéatiques et la libération de sécrétine mesurable par radio-immunoessai. La sécrétion pancréatique de protéines n'est pas modifiée par les solutions hypertoniques. Nous avons done confirmé l'inhibition de la sécrétion gastrique d'acide chez le chien par stimulation des osmorécepteurs duodénaux; nous pensons que cette inhibition est due, en partie en tous cas, à la suppression de la libération de gastrine. Nous estimons de plus que l'inhibition de la sécrétion pancréatique par l'hyperosmolalité duodénale résulte d'une suppression de la libération de sécrétine, mais est sans effet sur la libération de cholécystokinine.

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Supported by grants from the National Institutes of Health (AM 15241) and the John A. Hartford Foundation, Inc.

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An abstracted preliminary report of a portion of this work has appeared (Physiologist 20:93, 1977).

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Recipient of a grant from the Deutsche Forschungsgemeinschaft (Te 79/1).     

Glenoid and scapulohumeral characteristics and their influence on preoperative range of motion and patient-determined outcomes

BackgroundIt is not clear if glenoid and scapulohumeral characteristics influence preoperative range of motion (ROM) and patient-determined outcomes. It is important to understand these interactions when planning and performing total shoulder arthroplasty in efforts of improving patient satisfaction and implant longevity.MethodsA retrospective review of patients that had three-dimensional computed tomography imaging for total shoulder arthroplasty was performed. Patients were separated into 2 groups determined by the presence (rotator cuff tear arthropathy [RCTA]) or absence (osteoarthritis [OA]) of an irreparable rotator cuff tear. Using the computed tomography measurements, shoulders were stratified by glenoid version (anteverted, normal, and retroverted), glenoid inclination (inferior, normal, and superior), and scapulohumeral subluxation (anterior, centered, and posterior) based on criteria determined from a review of the orthopedic literature. The Western Ontario Osteoarthritis Scale and the American Shoulder and Elbow Surgeons scores and ROM were determined preoperatively.ResultsIn OA patients (n = 154), version was associated with scapulohumeral subluxation (P < .0001). Retroverted glenoids had less flexion (96° vs. 108°; P = .049) and external rotation (15° vs. 21°; P = .04) compared with normal version. Inferiorly inclined glenoids had greater posterior subluxation (77%) than those with normal (67%; P = .001) and superior inclination (68%; P = .01). There were no relationships between excessive inclination or subluxation on ROM. In RCTA patients (n = 115), retroverted glenoids had greater superior inclination compared with normal glenoids (12.1° vs. 8.4°; P = .049). Version was associated with scapulohumeral subluxation (anteverted = mean 34% subluxation; normal version = 56.4% subluxation; retroverted = 71.2% subluxation; P < .0001). Retroverted glenoids had less flexion compared with normal version (70° vs. 90°; P = .048), less abduction (62°) than normal glenoids (88°; P = .03) and anteverted glenoids (115°; P = .03), and less abduction/internal rotation (7°) than normal (22°; P = .03) and anteverted glenoids (36°; P = .04). Superiorly inclined glenoids have more posterior subluxation than normally inclined glenoids (64% vs. 56.6%; P = .02). There was no relationship between inclination and ROM. Patients with posterior subluxation had less external rotation compared with those with a centered humeral head (10° vs. 22°; P = .009) and less abduction/internal rotation compared with anterior subluxation (12° vs. 35°; P = .02). There was no relationship between version, inclination, or subluxation with preoperative Western Ontario Osteoarthritis Scale or American Shoulder and Elbow Surgeons in patients with OA (P > .17) or RCTA (P > .31).ConclusionsAn interaction between version, inclination, and scapulohumeral subluxation in patients with OA and RCTA was found. Retroverted glenoids had decreased ROM measurements. RCTA shoulders with posterior scapulohumeral subluxation had decreased ROM. There was no relationship between glenoid and scapulohumeral morphology and patient-determined outcome scores.Level of evidenceLevel III; Retrospective Case-Control Prognosis Study     

Tibial and Fibular Mid-Shaft Bone Traits in Young and Older Sprinters and Non-Athletic Men

High impact loading is known to prevent some of the age-related bone loss but its effects on the density distribution of cortical bone are relatively unknown. This study examined the effects of age and habitual sprinting on tibial and fibular mid-shaft bone traits (structural, cortical radial and polar bone mineral density distributions). Data from 67 habitual male sprinters aged 19–39 and 65–84 years, and 60 non-athletic men (referents) aged 21–39 and 65–80 years are reported. Tibial and fibular mid-shaft bone traits (strength strain index SSI, cortical density CoD, and polar and radial cortical density distributions) were assessed with peripheral quantitative computed tomography. Analysis of covariance (ANCOVA) adjusted for height and body mass indicated that the sprinters had 21 % greater tibial SSI (P < 0.001) compared to the referents, with no group × age-group interaction (P = 0.54). At the fibula no group difference or group × age-group interaction was identified (P = 0.12–0.81). For tibial radial density distribution ANCOVA indicated no group × radial division (P = 0.50) or group × age-group × division interaction (P = 0.63), whereas an age × radial division interaction was observed (P < 0.001). For polar density distribution, no age-group × polar sector (P = 0.21), group × polar sector (P = 0.46), or group × age-group × polar sector interactions were detected (P = 0.15). Habitual sprint training appears to maintain tibial bone strength, but not radial cortical density distribution into older age. Fibular bone strength appeared unaffected by habitual sprinting.     

Effects of phytate and pyrophosphate on brushite and hydroxyapatite crystallization

This is a comparative study of the effects of phytate and pyrophosphate and other polyphosphates on the crystallization of hydroxyapatite and brushite, the most frequent calcium phosphates involved in calcium oxalate urolithiasis. Brushite and hydroxyapatite crystal formation was studied in synthetic urine, through kinetic-turbidimetric measurements that allowed evaluation of the inhibitory effects on crystallization of insoluble salts. The effectiveness in preventing brushite crystallization decreases in the sequence phytate > polyphosphate > EDTPO > etidronate > pyrophosphate > triphosphate > medronate; whereas the order of effectiveness in preventing hydroxyapatite crystallization was EDTPO > etidronate=pyrophosphate > triphosphate > medronate > polyphosphate > phytate. Phytate, a natural inhibitor in urine, most effectively blocked brushite precipitation (1.21·10⁻⁵ M prevented crystallization during time periods of at least 1 h), and pyrophosphate was the natural inhibitor that most effectively blocked hydroxyapatite precipitation (2.87·10⁻⁶ M prevented crystallization during time periods of at least 1 h). This demonstrates that low excretion of these substances would pose a risk of renal lithiasis. Received: 15 July 1999 / Accepted: 28 October 1999     

Effect of menopause and aging on serum total and ionized calcium and protein concentrations

Summary The effects of menopause and aging on serum total and ionized calcium concentrations were evaluated in 402 healthy women (aged 18–71 years), of whom 83 were premenopausal and 319 postmenopausal. Serum albumin and globulin concentrations and serum pH were also measured in most of these women. Serum total but not ionized calcium concentration increased significantly at menopause. This increase in the protein-bound component of total calcium in postmenopausal women was associated with increases in mean serum globulin concentration (P=0.03) and in serum pH (P=0.03). Serum total calcium declined with age within the pre- and postmenopausal groups (r=−0.225,P=0.04 and r=−0.121,P=0.03, respectively). This was associated with an age-related decrease in serum albumin concentration in all women (r=−0.47,P<0.0001). Neither serum globulin concentration or pH varied with age. Thus, menopause and aging affect serum total, but not ionized calcium concentration.     

Gender and Racial Differences in Focal and Global Acetabular Version

The purpose of this study was to compare the acetabular version between male and female pelvises. We hypothesized that female acetabula would demonstrate more retroversion because Pincer-type femoroacetabular impingement (FAI) is associated with acetabular retroversion, which is more commonly observed in females. 120 bony pelvic specimens were randomly collected. The version was measured at three different axial sections of each acetabulum: cranial, central, and caudal. Males demonstrated significantly less anteversion than females in every section. The global version (the average of all three measurements) was also significantly different between males and females (16° ± 7° and 19° ± 8° respectively, P < 0.001). Of the 240 examined acetabuli, 21 demonstrated cranial retroversion (16 males & 5 females). The data showed no significant difference (P = 0.353) between global version of African Americans (18° ± 9°) and Caucasians (17° ± 7°). The results of this study suggest that symptomatic FAI in the female population likely reflects a complex interplay of femoral and acetabular dysmorphology and cannot be explained by differences in acetabular version alone.     

Pre-operative and post-operative radiotherapy and rectal cancer

The appropriate role for additional radiotherapy in patients with resectable rectal cancer is not yet settled. Irradiation has been considered by surgeons and radiotherapists as superfluous since no effect on survival has been shown. However, numerous trials have demonstrated that perioperative radiotherapy decreases an often high local recurrence rate while others believe it has a definite place in routine management. Several surgeons have, on the contrary, claimed that a skilled surgeon compared to a less skilled surgeon, will get the same acceptably low local recurrence rates. Since we will probably never have a randomized trial comparing good and bad surgeons, this argument cannot be settled. A further obstacle arises in the difficulty of persuading surgeons to organize their routine work so that it is performed in an optimal way by those specializing in this field. The question also arises whether radiotherapy should be delivered pre-operatively, postoperatively or as a sandwich technique, i.e., both pre-operatively and postoperatively. According to radio-biological considerations and results from reported trials, the best effect on local tumor control has been achieved using pre-operative radiotherapy.

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Resumen Aún no se ha defindo la indicación apropriada para radioterapia adicional en pacientes con cáncer rectal. La irradiación ha sido considerada como superflua por cirujanos y radioterapeutas, puesto que no se ha demostrado efecto sobre la sobrevida. Sin embargo, numerosos ensayos clínicos han demostrado que la radioterapia perioperatoria disminuye la que con frecuencia es una elevada tasa de recurrencía local, mientras ostros creen que tiene un lugar definido en el manejo rutinario. Por el contrario, varios cirujanos han planteado que un cirujano hábil comparado con uno menos hábil, logra las mismas aceptables tasas de recurrencia, alg que jamás se ha decidido, puesto que nunca habremos de realizar ensayos comparando buenos cirujanos con malos cirujanos. Un obstáculo adicional surge de la dificultad en cuanto a persuadir a los cirujanos de organizar su trabajo rutinario de tal manera que sea realizado en forma óptima por aquellos que se especializan en este campo. También ha surgido el interrogante sobre si la radioterapia debe ser administrada preoperatoriamente, postoperatoriamente o como técnica de sandwich, o sea tanto pre como postoperatoriamente. Según consideraciones radio-biológicas y los resultados de los ensayos clínicos, el mejor efecto sobre el control local del tumor ha sido logrado mediante el uso de radioterapia preoperatoria.

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Résumé La place de la radiothérapie adjuvante chez les patients ayant un cancer du rectum reste discutée. La radiothérapie est estimée superflue par certains chirurgiens et radiothérapeutes car aucun bénéfice n'a eté clairement démontré en ce qui concerne la survie. De nombreux essais cliniques ont indiqué, cependant, que la radiothérapie périopératoire diminuait le taux habituellement élevé des récldives locales, et certains estiment que la radiothérapie a toujours une place dans le schéma thérapeutique. D'autres, au contraire, croient que la quialité et l'expérience de l'opérateur influencent directement le taux de récidives, et équivalent l'efficacité de la radiothérapie. Puisqu'il est peu probable qu'on réalise une étude randomisée entre les bons et les mauvais chirurgiens, on ne peut régler cette querelle. Un autre obstacle incontournable semble être de persuader les chirurgiens d'organiser leur travail de façon à ce que cette chirurgie soit faite par des spécialistes. Le meilleur moment pour réaliser la radiothérapie (préopératoire, postopératoire, ou les deux) reste à déterminer. Selon les données radiobiologiques et les résultats des essais contrôlés, il semble que le meilleur contôle sur les récidives locales soit obtenu par la radiothérapie préopératoire.

     

The relationship between body composition and the urinary excretion of deoxypyridinoline and galactosyl-hydroxylysine in children and adolescents

The study intends to investigate the relationship of body composition (%fat, percent body fat; FM, fat mass; FFM, fat free mass; FA and MA cross-sectional fat and muscle area) to the urinary excretion of deoxypyridinoline (DPD) and galactosyl-hydroxylysine (Gal-Hyl). 231 healthy children and adolescents (age 5–19 years; 112 males) of the DONALD study were analyzed for FM and FFM by measuring 4 skinfold thicknesses, for DPD and Gal-Hyl in urine samples and for bone parameters, FA and MA at the forearm by peripheral quantitative computed tomography. In contrast to adrenarchal females, adrenarchal males with low %fat had low levels of DPD and Gal-Hyl. %fat was correlated with DPD in pre-adrenarchal males (r = 0.290) and females (r = 0.298). Cortical bone mineral density (BMDcort) was correlated with DPD (r = −0.351) in adrenarchal males. Controlled for BMDcort, FM was correlated with DPD in pre-adrenarchal males (r = 0.348), and FA was correlated with DPD in pre-adrenarchal females (r = 0.294). FFM was negatively correlated with Gal-Hyl in adrenarchal males (r = −0.436) and females (r = −0.338). Less than 40% of variance of excreted DPD and Gal-Hyl was explained by regression models based on parameters of body composition. The effect of body composition explains the minor part of variance of the urinary excretion of DPD and Gal-Hyl. The association of body composition to excreted DPD and Gal-Hyl was not explained by the effect of adipose tissue on bone formation and bone resorption.     

Zonal analysis of electrolytes in epiphyseal cartilage and bone of normal and rachitic chickens and pigs

Electrolytes were analyzed in serum, and in mineralizing tissues at varying stages of calcification, in normal and vitamin D-deficient chickens and pigs. Moisture, ash, and organic matter were also measured.Results revealed that in addition to Ca, other serum electrolytes were altered in rickets. Mg and inorganic P were diversely affected by the vitamin deficiency. Larger changes in mineral level were seen in the tissues in the early stages of calcification than were seen at corresponding times in the serum, suggesting a direct effect of the vitamin deficiency on the calcifying tissue itself. Relative to the serum level, Ca was deposited in the tissues of rachitic animals to a greater extent than in normal animals. This was not true for Mg or inorganic P, indicating a preferential affinity for Ca in the rachitic tissue. Gravimetric analyses of organic and dry matter in epiphyseal zones revealed that the amounts of proliferating and hypertrophic cartilage were increased, and calcified cartilage decreased, in rickets, in accord with previous histological observations. Unexpectedly, the proportion of resting cartilage was also increased.

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Zusammenfassung Die Elektrolyte im Serum und in mineralisierenden Geweben wurden zu verschiedenen Zeitpunkten der Verkalkung bei normalen Hühnern und Schweinen und bei solchen mit Vitamin D-Mangel analysiert. Wassergehalt, Asche, trockene und organische Substanz wurden ebenfalls gemessen.Die Ergebnisse zeigten, daß außer Ca auch andere Elektrolyte bei Rachitis verändert wurden. Mg und anorganischer P wurden durch den Vitaminmangel bei den beiden Gattungen verschiedenartig beeinflußt. In den Geweben wurde in den frühen Phasen der Verkalkung eine größere Änderung des Mineral-Spiegels gefunden, als dies zu übereinstimmenden Zeiten im Serum der Fall war, was auf eine direkte Wirkung des Vitaminmangels auf das verkalkende Gewebe schließen läßt. Im Verhältnis zum Serumspiegel wurde Ca in den Geweben der rachitischen Tiere zu einem größeren Grade als normal abgeschieden. Dies war nicht der Fall bei Mg oder anorganischem P, was einen Vorzug für Ca in den rachitischen Geweben anzeigt.Gravimetrische Analysen von organischer und trockener Substanz in epiphysischen Schichten zeigten, daß die Menge des proliferierenden und hypertrophischen Knorpels zunahm und daß verkalkter Knorpel bei Rachitis abnahm, gemäß klassischen histologischen Beobachtungen. achtungen. Ganz unerwartet war bei Rachitis eine verhältnismäßige Zunahme des ruhenden Knorpels festzustellen.

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Résumé Les électrolytes ont été analysés dans le sérum et dans les tissues en voie de minéralisation, à des stades variables de calcification, chez des poulets et des pores normaux et rachitiques. L'humidité, les cendres et les matières organiques et déssèchées ont été analysées.Il apparait que d'autres électrolytes sériques, en plus du Ca, sont modifiés au cours du rachitisme. Le Mg et le P inorganique sont modifiés de façon variable au cours de l'avitaminose D. Des changements plus importants en contenu minéral des tissus sont observés dans les stades précoces de calcification que ceux que l'on a pu constater dans le sérum à des stades similaires, ce qui suggère un effet direct de l'avitaminose sur le tissu en voie de calcification. Quant au contenu du sérum, le dépôt de Ca est plus élevé dans les tissus d'animaux rachitiques par rapport aux témoins. Ceci n'est pourtant pas le cas du Mg ou du P inorganique, indiquant une affinité préférentielle du Ca pour le tissue rachitique.L'analyse gravimétrique de matières organiques et déssèchées des zones épiphysaires montre que les quantités de cartilage hypertrophique et en voie de dévelopment augmentent dans le cas de rachitisme, alors que le cartilage calcifié diminue, confirmant les observations histologiques antérieures. De manière inattendue, la proportion de cartilage au repos augmente au cours du rachitisme.

     

Hemodynamic and pulmonary changes during and after laparoscopic cholecystectomy

Background: The cardiopulmonary changes experienced by patients who undergo laparoscopic cholecystectomy (LC) and the prognostic value of patient characteristics are not well understood. Methods: Cardiorespiratory changes were investigated in 120 patients undergoing LC or open cholecystectomy (OC). The results and their relation to patient variables were statistically evaluated. Results: The most significant cardiorespiratory changes were (A-a)PO₂ increase during OC; decrease of pH and compliance and increase of peak airway pressure during LC; impairment of arterial blood gas mean values and respiratory muscle strength; atelectasis and pneumonia (five cases) after OC; and lamellar atelectasis (two cases) after LC. Significant adverse prognostic factors related to intra- and postoperative LC cardiorespiratory changes were ASA class greater than I, FEF_75–85% < 900 ml, and PaO₂ < 10.4 kPa (PPV, 71.4% and 46.6%, respectively). Conclusions: LC carries no significant cardiorespiratory changes provided that intraoperative monitoring of hemodynamics and respiratory parameters is done for the study of blood gas values in all patients at risk.