Bowel perforation in Crohn's Disease: correlation between CDAI and Clavien-Dindo scores.

BACKGROUND: Many studies have elaborated different kind of activity indices for Crohn's Disesase (CD) with the endpoint of univocally measure and evaluate the gravity of its lesions and symptoms. AIM: Purpose of this work is to study and define the correlation that runs between the preoperative score obtained at the Crohn's Disease Activity Index, the occurrence of postoperative complications that will require re-intervention and the severity of the postoperative lesions evaluated using the Clavien-Dindo score. PATIENTS AND METHODS: We have collected and analyzed data from 23 patients (12 males, 11 females) that in a period that spans from 2010 to 2016 had been recovered in our Operative Unit and then undergone surgical treatment for the perforative complications of the CD. RESULTS: The CDAI scores obtained for each patient and the data concerning their postoperative period have been analyzed using the ANOVA system. Results demonstrate the existence of a statistically signifying correlation (p = 0.0016) between the mean category's CDAI score and the Clavien-Dindo classification. CONCLUSIONS: Despite the small number of patients that had been recruited and analyzed in our study, it clearly shows a statistically signifying correlation between CDAI scores higher than 150 points and the risk of occurrence of severe postoperative complications in patients that had been subjected to surgical procedures for perforative or abscessual complications in Crohn's Disease.

Clinical observations of the anatomy and function of the marginal mandibular nerve.

The objective of this study was to assess the anatomical variation of the marginal mandibular nerve, and evaluate the risk of nerve malfunction after neck dissection. The method involved clinical assessment of the anatomy and function of the marginal mandibular nerve in 133 neck dissections. When the neck was extended the nerve was displaced in an anterior and downward direction with the lowest point 1.25+/-0.7 cm below the mandible between the posterior and anterior facial veins. The nerve was >1cm below the lower border of the mandible in 54% of dissections. When the intent was to preserve the nerve, dysfunction was observed in 16 of 101 dissections (16%). The incidence of marginal mandibular nerve dysfunction following neck dissection is comparable to that observed following submandibular gland excision for benign disease. Placement of incisions 2 cm below the lower border of the mandible will put the nerve at risk in a significant number of patients.

Interstitial MR lymphangiography for the detection of sentinel lymph nodes.

BACKGROUND AND OBJECTIVES: The challenge for implementation of sentinel lymph node biopsy is to develop a reliable minimally invasive technique that identifies all possible sentinel nodes with high temporal and spatial resolution. This study evaluated the use of a magnetic resonance imaging (MRI) contrast agent (USPIO) for preoperative sentinel node detection. METHODS: Anesthetized pigs received interstitial or intradermal injections of ultra small superparamagnetic of iron oxide (USPIO) (0.2 or 5 mg Fe) in the L/R posterior tongue and stifles (knee) respectively. MRI was done before, during injection and at 0.25, 0.5, 1, 2, 4, 6, 24, and 48 hr after which isosulfan blue sentinel node mapping was done. RESULTS: In the tongue, both doses of USPIO identified the sentinel node in the early images. No additional nodes were detected by MR at 24 or 48 hr. In the hind limb, sentinel nodes identified on the early MR images were also identified by the isosulfan blue. In both locations, the higher dose also identified secondary nodes some of which were also identified by the isosulfan blue. All sentinel nodes that were identified by USPIO on MRI were noted to be stained brown at the time of dissection. CONCLUSIONS: Interstitial MR lymphangiography is a useful technique for the detection of sentinel lymph nodes. This method provides excellent simultaneous temporal and spatial resolution, is minimally invasive, and can be performed preoperatively.

Radiographic assessment of cemented humeral components in shoulder arthroplasty.

Forty-three shoulder arthroplasties performed with the use of cemented Neer II humeral components and followed radiographically for a mean of 6.6 years (range, 2-20 years) were analyzed. A humeral component was considered radiographically "at risk" for clinical loosening when a radiolucent line 2 mm or greater in width was present in 3 or more zones or tilt or subsidence was identified on sequential radiographs by 2 or 3 of the 3 independent observers. None of the components was considered to have tilted or subsided. Radiolucent lines of any size were present in 16 shoulders and were wider than 2 mm in 9 shoulders. They were limited to 1 zone in 8 shoulders and to 2 zones in 7 shoulders. Only 1 component (2%) with a 2-mm radiolucent line in 3 zones was judged to be "at risk." The incidence, extent, and thickness of humeral radiolucent lines were significantly higher in total arthroplasties than in hemiarthroplasties (P <.05). Clinically important changes around cemented Neer II humeral components are uncommon. Humeral radiolucent lines develop more frequently in the presence of a glenoid component. Data from this study can be used as one benchmark to compare with alternate methods of humeral component fixation.

Risk factors affecting survival after brain metastases from non-small cell lung carcinoma: a follow-up study of 70 patients.

OBJECT: The authors present their experience with the treatment of brain metastases from non-small cell lung carcinoma (NSCLC). METHODS: A retrospective review was conducted in which records from 74 patients treated at the authors' institution between 1994 and 1999 were assessed. Survival and functional outcome were reviewed relative to individual patient variables. The median survival time was 12.9 months, with 1-, 2-, and 5-year survival milestones reached by 52.2%, 30.7%. and 18.1% of patients, respectively. Patients were stratified into groups composed of those with synchronous brain metastases (tumors diagnosed within 3 months of NSCLC) and metachronous brain metastases (tumors diagnosed 3 months after NSCLC). The median survival time and 5-year survival rate were 18 months and 28.9% for metachronous, compared with 9.9 months and 0% for synchronous brain metastases. In univariate analyses, the stage of brain metastases, an initial Karnofsky Performance Scale (KPS) score of 90 or less, and conservative therapy for NSCLC were associated with worse outcomes (p < 0.05). In analyses in which tumors were stratified by synchronous compared with metachronous brain metastases, a preoperative KPS score of 90 or less and radiation therapy (RT) alone for brain metastases were associated with worse outcomes in patients with metachronous brain metastases but not with synchronous tumors (p < 0.05). When stratified by preoperative KPS score, the synchronous brain metastases stage or treatment of brain metastases with RT alone were associated with worse outcome in patients with KPS scores of 100, but had no discernible effect on patients with KPS scores of 90 or less (p < 0.05). CONCLUSIONS: The tumor stage and preoperative KPS score were significantly associated with survival. Craniotomy plus RT significantly improved the prognosis in patients with metachronous brain metastases or those with a preoperative KPS score of 100.

[Shoulder hemi-arthroplasty in proximal humeral fractures]. / Schulterhemiarthroplastik bei proximalen Humerusfrakturen.

Most fractures of the proximal humerus with significant displacement are best treated surgically. The range of surgical treatment varies from closed reduction and pinning to hemiarthroplasty depending on the degree of displacement, age of the patient, and bone quality. Determining whether or not the individual fractured bone segments are displaced to a significant degree requires high quality x-rays which can be difficult to obtain from acutely injured patients. Indications for replacement of the humeral head in acute fractures include: head splitting fractures in elderly patients, Neer 4-part fracture dislocations, selected 3 part fractures and fracture dislocations in elderly patients with poor bone quality and a very small head fragment, selected severe impression fractures in elderly patients that involve more than 40% to 50% of the articular surface and selected anatomical neck fractures in which internal fixation is not possible. If a prosthetic replacement of the humeral head is chosen, secure repair of the tuberosities is essential to avoid tuberosity migration and malunion. The clinical results of prosthetic replacement of the proximal humerus for acute fractures are superior to those for late arthroplasty. This treatment modality has been proven to relieve pain. However, even for patients treated with primary arthroplasty, a restricted range of motion has to be expected postoperatively. Furthermore, several studies indicate that a significant number of complications can occur following early and late prosthetic replacement. Humeral head replacement as a salvage procedure after malunions or failed open reduction and internal fixation is technically demanding with a relatively high rate of complications. Newer implant designs and instruments may improve the clinical results.

Magnetization transfer imaging and proton MR spectroscopy in the evaluation of axonal injury: correlation with clinical outcome after traumatic brain injury.

BACKGROUND AND PURPOSE: Current imaging does not permit quantification of neural injury after traumatic brain injury (TBI) and therefore limits both the development of new treatments and the appropriate counseling of patients concerning prognosis. We evaluated the utility of magnetization transfer ratio (MTR) and proton MR spectroscopy in identifying patients with neuronal injury after TBI. METHODS: Thirty patients with TBI (21-77 years old; mean age, 42 years; admission Glasgow Coma Scale (GOS) scores 3-15; mean score, 11) were studied on a 1.5-T system with magnetization transfer imaging and MR spectroscopy of the splenium. Magnetization transfer imaging was also performed in the brain stem in all patients, and other areas of the brain were sampled in one patient. The splenium of the corpus callosum and brain stem were studied because these are often affected by diffuse axonal injury. Scans were obtained 2 to 1129 days after injury (median, 41 days). MTR was considered abnormal if it was more than 2 SD below normal. Proton MR spectroscopy was used to calculate the N-acetylaspartate (NAA)/creatine (Cr) ratio. GOS was determined at least 3 months after injury. RESULTS: In 10 patients with a GOS of 1 to 4, the mean NAA/Cr was 1.24 +/- 0.28; two of these patients had abnormal MTR in normal-appearing white matter (NAWM). In 20 patients with a GOS of 5, the mean NAA/Cr was 1.53 +/- 0.37 (P < .05); four of these patients had abnormal MTR in NAWM. MTR abnormalities in NAWM were identified in six patients, but these changes did not correlate with GOS or MR spectroscopy changes. CONCLUSION: MTR and MR spectroscopy can quantify damage after TBI, and NAA levels may be a sensitive indicator of the neuronal damage that results in a worse clinical outcome.

Perioperative blood transfusion and albumin administration are independent risk factors for the development of postoperative infections after colorectal surgery.

OBJECTIVES: To determine whether transfused colorectal surgery patients were at increased risk for postoperative infections in a tertiary care teaching hospital and whether transfusion alone was the only significant risk factor. DESIGN: A retrospective study. SETTING: A single tertiary care teaching hospital. PATIENTS: All patients admitted to St. Boniface General Hospital, Winnipeg, for colorectal surgery during the period Apr. 1, 1995, through Mar. 31, 1996, were studied (N = 154). RESULTS: The overall infection rate was 17%: nontransfused patients, 13%, and transfused patients, 28% (p < 0.038). Patients who received albumin perioperatively had a significantly higher infection rate (38%) than those who did not (13%) (p < 0.001). Stepwise logistic regression analysis identified transfusion and albumin administration as the only independent risk factors for postoperative infection. CONCLUSION: Perioperative transfusion or albumin administration significantly increases the risk of postoperative infection in colorectal surgery patients.

A synthetic peptide initiates Gerstmann-Sträussler-Scheinker (GSS) disease in transgenic mice.

The molecular basis of the infectious, inherited and sporadic forms of prion diseases is best explained by a conformationally dimorphic protein that can exist in distinct normal and disease-causing isoforms. We identified a 55-residue peptide of a mutant prion protein that can be refolded into at least two distinct conformations. When inoculated intracerebrally into the appropriate transgenic mouse host, 20 of 20 mice receiving the beta-form of this peptide developed signs of central nervous system dysfunction at approximately 360 days, with neurohistologic changes that are pathognomonic of Gerstmann-Sträussler-Scheinker disease. By contrast, eight of eight mice receiving a non-beta-form of the peptide failed to develop any neuropathologic changes more than 600 days after the peptide injections. We conclude that a chemically synthesized peptide refolded into the appropriate conformation can accelerate or possibly initiate prion disease.

Radiographic assessment of ingrowth total shoulder arthroplasty.

Sixty-two primary ingrowth total shoulder arthroplasties, performed between 1989 and 1992 and with a minimum radiographic and clinical follow-up of 2 years or until the time of revision surgery (mean, 4.6 years), were reviewed. To combine data on both the distribution and the thickness of periprosthetic lucency and change in component position, criteria were used to determine whether a component was radiographically "at risk" for clinical component loosening. A glenoid component was "at risk" when a complete lucent line was present, some part of it being 1.5 mm or greater in width, or when 2 of 3 or 3 of 3 independent observers identified migration or tilt of the component. A humeral component was "at risk" when a lucent line 2 mm or greater in width was present in 3 or more of 8 zones or when at least 2 of 3 independent observers identified tilt or subsidence of the component. Four (6.5%) of the 62 glenoid components and 6 (9.7%) of the 62 humeral components were judged to be "at risk." There were no identifiable patient, disease, or surgical characteristics associated with the development of an "at risk" glenoid or humeral component. Currently, despite this very favorable radiographic assessment, we reserve the use of a tissue ingrowth glenoid component for those patients with bone loss precluding bone cement fixation with a keel type of implant. Because advantages exist for use of a tissue ingrowth humeral component, a press-fitted component with ingrowth surfaces is currently used unless bone deficiencies prevent secure fixation without cement.

Kinetics of prion protein accumulation in the CNS of mice with experimental scrapie.

The kinetics of PrP(Sc) and insoluble PrP accumulation in the spleens and brains of CD-1 mice were studied. The mice were inoculated intracerebrally with RML prions and euthanized at various times between inoculation and the onset of illness at approximately 130 days. Protease-resistant PrP(Sc), PrP 27-30, was first detected in brain by histoblotting 49 days after inoculation and by Western immunoblotting at 70 days. In spleen, PrP 27-30 was first detected by Western immunoblotting at 28 days after inoculation. Like PrP 27-30, substantial increases in detergent-insoluble PrP were first detected at 70 days after inoculation in brain and 28 days in spleen. In addition, a progressive increase in detergent-soluble PrP was detected beginning 70 days after inoculation. Further characterization of detergent soluble and insoluble PrP with respect to protease-sensitive PrP(Sc) and prion infectivity will be of considerable interest.

Clinical consultations using store-and-forward telemedicine technology.

OBJECTIVE: To investigate the potential role of a store-and-forward (SAF) telemedicine system in specialty consultations initiated by primary care physicians. MATERIALS AND METHODS: In this pilot telemedicine study, patients needing consultations in cardiology, dermatology, endocrinology, and orthopedics had both standard face-to-face (FTF) consultations and SAF consultations. RESULTS: Fifteen patients had both FTF and SAF consultations, 4 had echocardiograms transmitted for an SAF consultation only, and 1 had an SAF consultation but no FTF appointment. Of 19 diagnoses made, all were essentially the same in both types of consultations; 14 of 15 FTF consultations and 15 of 19 SAF consultations resulted in additional treatment recommendations. CONCLUSIONS: While it was possible to develop a desktop system for SAF consultations, the equipment was not adequately integrated. Without total digital input, including electronic patient medical records, packaging of information is laborious and impractical. Seamlessly adapting to existing clinical practice is vital. Issues such as increasing work for the physicians or office staff, gathering adequate patient information, and designing a referral process were more difficult than we had anticipated. Patient acceptance was high, but the clinical pilot had very small numbers.

A mouse prion protein transgene rescues mice deficient for the prion protein gene from purkinje cell degeneration and demyelination.

Disruption of both alleles of the prion protein gene, Prnp, renders mice resistant to prions; in a Prnp o/o line reported by some of us, mice progressively developed ataxia and Purkinje cell loss. Here we report torpedo-like axonal swellings associated with residual Purkinje cells in Prnp o/o mice, and we demonstrate abnormal myelination in the spinal cord and peripheral nerves in mice from two independently established Prnp o/o lines. Mice were successfully rescued from both demyelination and Purkinje cell degeneration by introduction of a transgene encoding wild-type mouse cellular prion protein. These findings suggest that cellular prion protein expression may be necessary to maintain the integrity of the nervous system.

Prion protein of 106 residues creates an artifical transmission barrier for prion replication in transgenic mice.

A redacted prion protein (PrP) of 106 amino acids with two large deletions was expressed in transgenic (Tg) mice deficient for wild-type (wt) PrP (Prnp0/0) and supported prion propagation. RML prions containing full-length PrP(Sc)produced disease in Tg(PrP106)Prnp0/0 mice after approximately 300 days, while transmission of RML106 prions containing PrP(Sc)106 created disease in Tg(PrP106) Prnp0/0 mice after only approximately 66 days on repeated passage. This artificial transmission barrier for the passage of RML prions was diminished by the coexpression of wt MoPrPc in Tg(PrP106)Prnp+/0 mice that developed scrapie in approximately 165 days, suggesting that wt MoPrP acts in trans to accelerate replication of RML106 prions. Purified PrP(Sc)106 was protease resistant, formed filaments, and was insoluble in nondenaturing detergents. The unique features of RML106 prions offer insights into the mechanism of prion replication, and the small size of PrP(Sc)106 should facilitate structural analysis.

The spiral compression plate for proximal humeral shaft nonunion: a case report and description of a new technique.

We present a case of humeral nonunion managed with a dynamic compression plate (DCP) contoured in a spiral fashion to preserve the deltoid muscle insertion. A forty-one-year-old woman sustained a closed proximal third humeral shaft fracture with an associated supraclavicular brachial plexus injury. She presented five months later with an atrophic nonunion of the proximal humeral shaft, inferior subluxation of the humeral head, and a resolving brachial plexopathy. Autogenous cancellous bone grafting and open reduction and internal fixation with a narrow DCP was performed. The deltoid muscle insertion was preserved by contouring the plate to fix the proximal humerus laterally over the greater tuberosity and anteriorly over the mid-humeral shaft. During the postoperative period, the humeral head reduced spontaneously. Five months after surgery, the fracture healed, and an excellent clinical result was achieved. We recommend the use of the spiral DCP for proximal shaft fractures and nonunions when preservation of the deltoid insertion is desirable.

The effect of thymic inoculation to induce tolerance of allogeneic thyroid grafts in the outbred rabbit.

Many studies have demonstrated that allograft tolerance can be achieved in inbred rats and mice following intrathymic injection of donor cells or antigen and treatment with antilymphocyte serum (ALS). In outbred dogs, xenografts, and inbred rat strains with major MHC antigen difference, tolerance has not similarly been induced. The focus of this study was to determine whether allogeneic thyroid graft tolerance could be achieved in outbred rabbits. In the experimental group (n = 5), recipients received an intrathymic injection of donor lymphocytes and a single treatment of ALS. Controls (n = 5) received intrathymic cell culture medium and ALS treatment. Donor-recipient allogenicity was monitored with mixed lymphocyte culture (MLC) over 18 weeks. Donor thyroid tissue was placed into recipient gluteal muscle fibres one week following the last MLC measurement. A third group of rabbits (n = 4) received thyroid autografts without any other treatment. There were no differences in MLC stimulation indices (SI) between the control and experimental group nor did MLC (SI) change within groups. All thyroid autografts survived the two week monitoring period and demonstrated normal appearing thyroid follicles on histologic examination. All thyroid allografts showed severe acute rejection reactions on biopsy within one week. Further studies using outbred animals to examine the role of thymic inoculation are required to determine whether similar techniques might be successful in the human.

Eight prion strains have PrP(Sc) molecules with different conformations.

Variations in prions, which cause different incubation times and deposition patterns of the prion protein isoform called PrP(Sc), are often referred to as 'strains'. We report here a highly sensitive, conformation-dependent immunoassay that discriminates PrP(Sc) molecules among eight different prion strains propagated in Syrian hamsters. This immunoassay quantifies PrP isoforms by simultaneously following antibody binding to the denatured and native forms of a protein. In a plot of the ratio of antibody binding to denatured/native PrP graphed as a function of the concentration of PrP(Sc), each strain occupies a unique position, indicative of a particular PrP(Sc) conformation. This conclusion is supported by a unique pattern of equilibrium unfolding of PrP(Sc) found with each strain. Our findings indicate that each of the eight prion strains has a PrP(Sc) molecule with a unique conformation and, in accordance with earlier results, indicate the biological properties of prion strains are 'enciphered' in the conformation of PrP(Sc) and that the variation in incubation times is related to the relative protease sensitivity of PrP(Sc) in each strain.

Doxycycline control of prion protein transgene expression modulates prion disease in mice.

Conversion of the cellular prion protein (PrPC) into the pathogenic isoform (PrPSc) is the fundamental event underlying transmission and pathogenesis of prion diseases. To control the expression of PrPC in transgenic (Tg) mice, we used a tetracycline controlled transactivator (tTA) driven by the PrP gene control elements and a tTA-responsive promoter linked to a PrP gene [Gossen, M. and Bujard, H. (1992) Proc. Natl. Acad. Sci. USA 89, 5547-5551]. Adult Tg mice showed no deleterious effects upon repression of PrPC expression (>90%) by oral doxycycline, but the mice developed progressive ataxia at approximately 50 days after inoculation with prions unless maintained on doxycycline. Although Tg mice on doxycycline accumulated low levels of PrPSc, they showed no neurologic dysfunction, indicating that low levels of PrPSc can be tolerated. Use of the tTA system to control PrP expression allowed production of Tg mice with high levels of PrP that otherwise cause many embryonic and neonatal deaths. Measurement of PrPSc clearance in Tg mice should be possible, facilitating the development of pharmacotherapeutics.