A novel reference coordinate system to locate the inferomedial point of the transverse-sigmoid sinus junction

Background

A coordinate system was previously developed to identify landmarks on the skull surface to help locate the transverse-sigmoid sinus junction in order to reduce surgical morbidity in retrosigmoid craniotomy; however, in practice we found that this system has important flaws.

Objective

To develop and evaluate a novel reference coordinate system to precisely locate the inferomedial point of the transverse-sigmoid sinus junction (IMTS) and evaluate the effect of gender and skull side (left or right).

Methods

Forty-two adult skulls (84 sides) were obtained for analyses. The X-axis was defined by point A (where the upper edge of the zygomatic arch joins with the frontal process of the zygomatic bone) and point B (where the upper edge of the zygomatic arch blends posterosuperiorly into the supramastoid crest). The Y-axis was defined by the line perpendicular to the X-axis and extending across the tip of the mastoid. The x and y coordinates of IMTS (IMTS-x and IMTS-y) were measured in this coordinate system.

Results

There were 20 male skulls and 22 female skulls. The mean IMTS-x measurements were significantly higher on the right side compared with the left side in both males and females. For the left skull side, the mean IMTS-y measurements were significantly lower in females compared with males.

Conclusion

This novel reference coordinate system may be a reliable and practical method for identifying the IMTS during retrosigmoid craniotomy. There are significant differences in location of the axes with regard to gender and skull side.     

How early should VATS be performed for retained haemothorax in blunt chest trauma?

Background

Blunt chest injury is not uncommon in trauma patients. Haemothorax and pneumothorax may occur in these patients, and some of them will develop retained pleural collections. Video-assisted thoracoscopic surgery (VATS) has become an appropriate method for treating these complications, but the optimal timing for performing the surgery and its effects on outcome are not clearly understood.

Materials and methods

In this study, a total of 136 patients who received VATS for the management of retained haemothorax from January 2003 to December 2011 were retrospectively enrolled. All patients had blunt chest injuries and 90% had associated injuries in more than two sites. The time from trauma to operation was recorded and the patients were divided into three groups: 2–3 days (Group 1), 4–6 days (Group 2), and 7 or more days (Group 3). Clinical outcomes such as the length of stay (LOS) at the hospital and intensive care unit (ICU), and duration of ventilator and chest tube use were all recorded and compared between groups.

Results

The mean duration from trauma to operation was 5.9 days. All demographic characteristics showed no statistical differences between groups. Compared with other groups, Group 3 had higher rates of positive microbial cultures in pleural collections and sputum, longer duration of chest tube insertion and ventilator use. Lengths of hospital and ICU stay in Groups 1 and 2 showed no statistical difference, but were longer in Group 3. The frequency of repeated VATS was lower in Group 1 but without statistically significant difference.

Discussion

This study indicated that an early VATS intervention would decrease chest infection. It also reduced the duration of ventilator dependency. The clinical outcomes were significantly better for patients receiving VATS within 3 days under intensive care. In this study, we suggested that VATS might be delayed by associated injuries, but should not exceed 6 days after trauma.     

Gasless laparoscopic assisted surgery for abdominal trauma

Background

Numerous studies have described the effectiveness of laparoscopy for trauma patients. In gas-filling laparoscopic surgery, most of the disadvantages are related to a positive pressure pneumoperitoneum that compromises the cardiopulmonary function. The main advantage of gasless laparoscopic assisted surgery (GLA) is that it does not affect the haemodynamic status, which is particularly critical for trauma patients. The purpose of this study was to investigate the feasibility and safety of GLA for abdominal trauma.

Materials and methods

This was a retrospective, 1:2 matched case–control study of all trauma gasless assisted laparoscopies performed from January 2010 until January 2013 in a Level I trauma centre. In total, 965 patients with abdominal trauma were admitted. According to the abdominal trauma protocol, a total of 93 hemodynamically stable patients required the operation; we selected fifteen patients to undergo GLA and matched 30 other patients to undergo laparotomy. Demographic information, perioperative findings, injury severity score, and postoperative recovery were recorded and analyzed.

Results

A total of fifteen patients (ten men, five women) with a mean age of 44.4, standard deviation (SD) 13.2 years underwent GLA for abdominal trauma. Eight patients had penetrating injuries, while seven had blunt injuries. Overall, 73% patients had multiple injuries. The mean time to the identified lesion was 23.1, SD 10.9 min, and the mean operative time was 109.7, SD 33.5 min. Most of the lesions were repaired concurrently by GLA. One conversion to laparotomy was done. The mean length of hospital stay (HLOS) was 9.1, SD 4.5 days. No mortality occurred in this series. The mean follow-up was 22.0, SD 7.9 months, and there were no significant events during this period. The mean operative times were comparable in the GLA and open surgery group (109.7, SD 33.5 vs. 131.2, SD 43.6 min; p = 0.076). Compared with the open surgery group, the HLOS was significantly shorter in the GLA group (9.1, SD 4.5 vs.16.3, SD 6.4 days; p = 0.030).

Conclusion

GLA offers both therapeutic and diagnostic advantages for patients with abdominal trauma. GLA shares the advantages of laparoscopy and prevents the cardiopulmonary function from being compromised due to pneumoperitoneum, which is especially critical for trauma patients.     

Long-term outcomes of extracorporeal shockwave therapy for chronic foot ulcers

Background

Recent studies showed that extracorporeal shockwave therapy (ESWT) is effective in the treatment of chronic foot ulcers in short term. However, the long-term effects of ESWT in chronic foot ulcers are unknown. The purpose of this study was to evaluate the long-term outcomes of ESWT in chronic foot ulcers with 5-y follow-up.

Methods

The study cohort consisted of 67 patients with 72 ulcers including 38 patients with 40 ulcers in the diabetes mellitus (DM) group and 29 patients with 32 ulcers in the non–diabetes mellitus (non-DM) group. Each patient received ESWT to the affected foot twice per week for 3 wk for a total of six treatments. The evaluations included clinical assessment for the ulcer status, local blood flow perfusion, and analysis of mortality and morbidity.

Results

The results showed completely healed ulcers in 55.6% and 57.4% of total series, 48% and 43% of DM group, and 66% and 71% of non-DM group at 1 and 5 y (P = 0.022 and P = 0.027), respectively. The mortality rate was 15% in total series, 24% in DM group, and 3% in non-DM group (P = 0.035). The rate of amputation was 11% in total series, 17% in DM group, and 3.6% in non-DM group (P = 0.194). The blood flow perfusion rate significantly increased after ESWT for up to 1 yr but decreased from 1–5 y in both groups. However, the non-DM group showed significantly better blood flow perfusion than the DM group at 5 y (P = 0.04).

Conclusions

ESWT appears effective in chronic diabetic and nondiabetic foot ulcers. However, the effects decreased from 1–5 y after treatment.     

Association of inflammaging (inflammation + aging) with higher prevalence of OAB in elderly population

Introduction

Although epidemiology studies consistently report increased prevalence of overactive bladder (OAB) with age, an accurate deciphering of causative links between the two entities remains elusive. Studies on aged rodent bladder have so far yielded contradictory results on age-associated changes in muscarinic receptors, which highlight the challenge posed by species differences in understanding OAB pathology. We hypothesized that age-related biochemical changes in bladder leading to altered bladder function will be reflected in altered urinary proteome of elderly OAB patients.

Methods

Single time point urine specimens were obtained from 140 OAB patients in the age range of 25–90 years of either sex coming routinely to the urology clinics. Eight chemokines in urine were measured by MILLIPLEX MAP human cytokine/chemokine multiplex immunoassay and ELISA. Multivariate and univariate statistical analyses were done to determine association of age with urinary chemokines in OAB patients.

Results

In agreement with age-dependent higher prevalence of OAB, the logistic regression of the data also revealed the significant association of OAB symptoms with age [odds ratio (OR) 1.12; 95 % CI, (1.072, 1.187), p = 0.0001]. Univariate analysis of 8 urinary proteins revealed an age-associated elevation of NGF (nerve growth factor) in 137 out of 140 OAB patients [Pearson r = 0.274; 95 %CI (0.112–0.422); p = 0.001]. Modest correlation with age was also noted for MCP-1 (monocyte chemoattractant protein-1), which was detected in 115 OAB patients, and the remaining chemokines were undetectable in nearly two-third of OAB patients included in our cohort.

Conclusions

Based on our findings, we postulate that age-associated biochemical changes may accentuate the inflammation associated with OAB. Urinary NGF elevation in elderly OAB patients may be a homeostatic response to counter the senescence of bladder nerves and arrest the progression of OAB into detrusor hyperactivity with impaired contractility. Likewise, elevation of MCP-1 may be related to decreased muscle mass and increased content of adipose tissue in bladder of elderly OAB patients. Urinary NGF and MCP-1 can serve as surrogate markers for monitoring age-associated biochemical changes and the effect of therapeutic interventions in OAB patients.     

Pilot Study of Liposome-encapsulated OnabotulinumtoxinA for Patients with Overactive Bladder: A Single-center Study

Background

Intradetrusor onabotulinumtoxinA (BoNT-A) injection benefits overactive bladder (OAB) patients, but increased postvoid residual (PVR) urine volume and urinary tract infection (UTI) remain risks. Intravesical instillation of liposomal BoNT-A instead of injection could prevent such adverse events.

Objective

To evaluate instillation of liquid liposomal BoNT-A (Lipotoxin) for the treatment of OAB and to determine its mechanism of action.

Design, setting, and participants

A double-blind randomized parallel controlled pilot trial in 24 OAB patients at a single tertiary center.

Intervention

Patients were randomly assigned to intravesical instillation of Lipotoxin containing 80 mg liposomes and 200 U BoNT-A or normal saline (N/S). Patients were retreated with Lipotoxin 1 mo later if they failed the first treatment.

Outcome measurement and statistical analysis

Voiding diaries, OAB symptom scores, urodynamic studies, and adverse events were monitored. The primary end point was change of total urinary frequency per 3 d at 1 mo after treatment. Immunohistochemistry and Western blotting for synaptic vesicle glycoprotein 2A (SV2A) and synaptosomal-associated protein, 25 kDa (SNAP25) were performed at baseline and 3 mo after treatment. The Wilcoxon rank sum test and Wilcoxon signed rank test were used for statistical analysis.

Results and limitations

At 1 mo after treatment, the change of urinary frequency per 3 d significantly improved in the Lipotoxin group (n = 12; median: −6.50; interquartile range [IQR]: −18.3 to −0.25; p = 0.008) but not in the N/S group. (n = 12.0; IQR: −7.75 to 8.0; p = 0.792). Urgency episodes also showed a significant decrease in the Lipotoxin group (−12.0; IQR: −20.3 to −2.75; p = 0.012) but not in the N/S group (−1.0; IQR: −11.0 to 2.5; p = 0.196). SV2A and SNAP25 were expressed in urothelial cells and suburothelial tissues. However, the protein expression did not significantly differ between responders and nonresponders at 3 mo after treatment.

Conclusions

Intravesical Lipotoxin instillation effectively reduced frequency episodes 1 mo after treatment in OAB patients without any increase in PVR or risk of UTI.

Patient summary

We demonstrated that intravesical Lipotoxin instillation reduced frequency episodes at 1 mo in overactive bladder patients. This procedure is safe, without an increase in postvoid residual or the risk of urinary tract infection.