The adult hip: an anatomic study. Part I: the bony landmarks

A comprehensive anatomic, pathologic and radiographic study of the adult hip was undertaken to define bony landmarks which, when altered, are reliable indicators of disease. Methodology included radiography of cadaveric specimens and analysis of over 300 anteroposterior (AP) radiographs of "normal" adult hips. This information was applied to clinical situations with the following conclusions: (a) The diagnosis of protrusio acetabuli is warranted if the acetabular line projects medial to the ilioischial line by 3 mm or more in men and by 6 mm or more in women. (b) In acetabular trauma, an AP and two oblique radiographs (30 degrees anterior oblique and 30--45 degrees posterior oblique) are required for complete evaluation. (c) Characteristic alterations in the joint space allow accurate diagnosis of disease.     

Clinical and radiographic "reankylosis" following hip surgery in ankylosing spondylitis.

Eleven patients with ankylosing spondylitis underwent reconstructive hip surgery (21 hips). In 10 of these hips multiple surgical procedures had been performed. The final procedure included total hip arthroplasties (16 hips), femoral cup arthroplasties (four hips) and an Austin-Moore prosthetic replacement (one hip). A clinical and radiographic evaluation in the postoperative period revealed a high incidence of decreased joint motion and heterotopic ossification. Clinically moderate to severe restriction of motion was noted in 12 hips, and in six of these "reankylosis" was present. Radiographically moderate to severe new bone formation was seen in 11 hips, and in nine of these "reankylosis" was suggested. An association of excessive ossification and multiple surgical procedures was evident. It would appear that when the prime indication for hip surgery in patients with ankylosing spondylitis is restricted motion, the operation may not be beneficial.     

Hormonal and synaptic influences of serotonin on adult neurogenesis

New neurons are incorporated into the adult brains of a variety of organisms, from humans and higher vertebrates, to non-vertebrates such as crustaceans. In virtually all of these systems serotonergic pathways appear to provide important regulatory influences over the machinery producing the new neurons. We have developed an in vitro preparation where adult neurogenesis can be maintained under highly controlled conditions, and are using this to test the influence of hormones on the production of neurons in the crustacean (Homarus americanus) brain. Serotonin levels have been manipulated in this in vitro preparation, and the resulting effects on the rate of neurogenesis have been documented. In addition we have compared in vitro influences of serotonin with results acquired from in vivo exposure of whole animals to serotonin. These experiments suggest that there are multiple mechanisms and pathways by which serotonin may regulate neurogenesis in the crustacean brain: (1) serotonin is effective in regulating neurogenesis at levels as low as 10⁻¹⁰ M, suggesting that circulating serotonin may have hormonal influences on neuronal precursor cells residing in a vascular niche or the proliferation zones; (2) contrasting effects of serotonin on neurogenesis (up- vs. down-regulation) at high concentrations (10⁻⁴ M), dependent upon whether eyestalk tissue is present or absent, indicate that serotonin elicits the release of substances from the sinus glands that are capable of suppressing neurogenesis; (3) previously demonstrated (Beltz, B.S., Benton, J.L., Sullivan, J.M., 2001. Transient uptake of serotonin by newborn olfactory projection neurons. Proc. Natl. Acad. Sci. USA 98, 12730-12735) serotonergic fibers from the dorsal giant neuron project directly into the proliferation zone in Cluster 10, suggest synaptic or local influences on neurogenesis in the proliferation zones where the final cell divisions and neuronal differentiation occur. Serotonin therefore regulates neurogenesis by multiple pathways, and the specific mode of influence is concentration-dependent.     

Multiparametric MR evaluation of uterine leiomyosarcoma and STUMP versus leiomyoma in symptomatic women planned for high frequency focussed ultrasound: accuracy of imaging parameters and interobserver agreement for identification of malignancy

Objective:To assess accuracy of and interobserver agreement on multiparametric MR findings to distinguish uterine leiomyoma (LM) from uterine leiomyosarcoma (LMS) and soft tissue tumour of unknown malignant potential.Methods:Inclusion criteria: All females over 18 years with least one uterine mass measuring 5 cm or more in at least one of the three standard orthogonal dimensions on MR with histopathological confirmation of LM, LMS, or soft tissue tumour of unknown malignant potential (STUMP) in the 3 months following MR. Patients with LMS were drawn from a larger cohort being assessed for MR-guided focussed ultrasound (MRgFUS) suitability. Image evaluation: Assessed variables were: lesion margin, margin definition, T2 signal homogeneity, >50% of lesion with T2 signal brighter than myometrium, haemorrhage, restricted diffusion, contrast enhancement (CE), CE pattern, local lymphadenopathy and ascites.Results:32 LM, 10 LMS and 1 STUMP were evaluated. Ill-defined (p-value = 0.0003–0.0004) or irregular (p = 0.003–0.004) lesion margin, T2 hyperintensity >50% (p = 0.001–0.004), and peripheral CE (p = 0.02–0.05) were significantly more common in LMS/STUMP than LM for both radiologists. 10/11 (Reader 2) and 11/11 (Reader 1) LMS/STUMP displayed restricted diffusion but so did 63–80% of LM. Agreement was greatest for margin characteristics (κ = 0.73–0.81).Conclusion:Irregular/ill-defined lesion margin best distinguished LMS/STUMP from LM with good interrater reliability.Advances in knowledge:Assessment of agreement regarding MR parameters distinguishing LM from LMS and STUMP has not previously been undertaken in a cohort including a large number of patients with LMS. This will help inform evaluation of females considering minimally invasive LM treatment.     

Barbed Versus Usual Suture for Closure of the Gastrojejunal Anastomosis in Laparoscopic Gastric Bypass: a Comparative Trial

Background

Laparoscopic Roux-en-Y gastric bypass is one of the main bariatric procedures that require safe and reproducible anastomosis. The objective of this study is to compare the risk of leaks and stenosis of a mechanical gastric pouch jejunal anastomosis between the usual interrupted sutures and a continuous barbed suture for gastrojejunotomy, in order to reduce procedure time and costs.

Methods

A comparative trial of 100 consecutive patients undergoing laparoscopic Roux-en-Y gastric bypass was performed between October 2010 and July 2011. The population was divided into two groups of 50 consecutive patients. In the first group, gastrojejunotomy was sutured with resorbable interrupted sutures and the second with continuous barbed suture. Diabetes, body mass index and the American Society of Anaesthesiology score were compared. The time required for suturing and the incidence of anastomotic leaks and stricture were also compared after 6 months.

Results

No fistulas or anastomotic stenoses had occurred at post-operative month 6 in either group. Gastrojejunotomy suture time was significantly shorter in the barbed suture group (11 versus 8.22 min; p?<?0.01). Total costs of material to complete the reconstruction were significantly lower in the barbed suture group (€26.69 versus €18.33; p?<?0.001).

Conclusions

The use of barbed suture is as safe as usual sutures and allows easier and faster suture in the closure of gastrojejunotomy. This suture could be incorporated in the standard laparoscopic Roux-en-Y gastric bypass technique.     

Laparoscopic gastrointestinal anastomoses using knotless barbed sutures are safe and reproducible: a single-center experience with 201 patients

Background

Intestinal anastomosis is a complex procedure during laparoscopy, mainly due to the difficulties knotting the sutures. Unidirectional barbed sutures have been proposed to simplify wall and mesentery closure, but the results for intestinal anastomosis are not clear. This study aimed to establish the feasibility and the safety of laparoscopic intestinal anastomosis using barbed suture.

Methods

Between June 2011 and May 2012, 15-cm-long unidirectional absorbable barbed sutures (V-Loc; Covidien, Mansfield, MA, USA) were used for all laparoscopic intestinal anastomoses: one suture for closure of intestinal openings after mechanical anastomoses and two sutures for hand-sewn anastomoses.

Results

Over a 1-year period, 201 consecutive patients required 220 laparoscopic anastomoses for gastrojejunostomy (n = 177; 172 during Roux-en-Y gastric bypass and 5 after gastrectomy), ileocolostomy (n = 15), colocolostomy (n = 1), esophagojejunostomy (n = 5), and jejunojejunostomy (n = 22; 4 after small bowel resection and 18 during gastric bypass or gastrectomy). Senior and training surgeons performed 209 closures of intestinal openings and 11 hand-sewn anastomoses. There was no conversion to usual sutures. One fistula occurred in an esophagojejunostomy and was managed conservatively. One self-limited anastomotic bleeding occurred, and no anastomotic stenosis occurred during 6 months of follow-up evaluation.

Conclusions

The use of knotless barbed suture for laparoscopic intestinal anastomosis is safe and reproducible.     

Differing Postneonatal Mortality Rates of African-American and White Infants in Chicago: An Ecologic Study

Objectives: This study sought to determine whether neighborhood impoverishment explains the racial disparity in urban postneonatal mortality rates. Methods: Stratified and multivariate logistic regression analyses were performed on the vital records of all African-Americans and whites born in Chicago by means of a linked 1992–1995 computerized birth–death file with appended 1990 U.S. census income and 1995 Chicago Department of Public Health data. Four community-level variables (low median family income, high rates of unemployment, homicide, and lead poisoning) were analyzed. Communities with one or more ecologic risk factors were classified as impoverished. Results: The postneonatal mortality rate of African-Americans (N = 104,656) was 7.5/1000 compared to 2.7/1000 for whites (N = 52,954); relative risk (95% confidence interval) equaled 2.8 (2.3–3.3). Seventy-nine percent of African-American infants compared to 9% of white infants resided in impoverished neighborhoods; p < 0.01. In impoverished neighborhoods, the adjusted odds ratio (controlling for infant and maternal individual-level risk factors) of postneonatal mortality for African-American infants equaled 1.5 (0.5–4.2). In nonimpoverished neighborhoods, the adjusted odds ratio of postneonatal mortality for African-American infants equaled 1.8 (1.1–2.9). Conclusions: We conclude that urban African-American infants who reside in nonimpoverished neighborhoods are at high risk for postneonatal mortality.