Does perfusion matter? Preoperative prediction of incisional hernia development.

PURPOSE: Incisional hernias complicate 12-15% of general surgery cases with higher rates reported after laparotomy for aortoiliac occlusive disease (10-17%) and aneurysmal disease (17-38%). We hypothesize that inadequate perfusion of the abdominal wall promotes future hernia development. METHODS: Thirty-eight patients undergoing midline laparotomy or thoracoabdominal approach for aortic disease with at least 2 years of follow-up were included in the study. Preoperative imaging was reviewed to assess vessel patency, contributing to the abdominal wall perfusion. Patency of the superior epigastric artery was determined at the T10 level, the inferior epigastric artery at the L4 level, and the deep circumflex iliac artery at the anterior superior iliac spine. Lumbar arteries were considered patent if they were seen branching from the aorta. Clinic notes and hospital medical records were reviewed to evaluate the hernia development post-procedure. RESULTS: Thirteen patients (34%) developed an incisional hernia. Absent flow from bilateral superior epigastric arteries or absent flow from ipsilateral superior and inferior epigastric arteries was found to be predictive of hernia development (P = 0.013, 0.011, respectively). There was no association identified with perfusion from the lumbar or deep circumflex iliac arteries. CONCLUSIONS: Absent patency of the abdominal wall vasculature is a novel risk factor for incisional hernia development in the setting of aortic disease. Preoperative assessment of perfusion may convey the risk of hernia development and may be a tool to guide measures such as prophylactic mesh placement to reduce the future risk of incisional hernia.

Memantine for cognitive impairment in multiple sclerosis: a randomized placebo-controlled trial.

BACKGROUND: Memantine, an NMDA antagonist, is effective for moderate to severe Alzheimer's disease. OBJECTIVE: Determine whether memantine improves cognitive performance (CP) among subjects with multiple sclerosis (MS) and cognitive impairment (CI). METHODS: This double-blind, randomized, placebo-controlled trial (Clinicaltrials.gov NCT00300716) compared memantine 10 mg twice a day (4 week titration followed by 12 weeks on the highest tolerated dose) with placebo. The primary outcome was the change from baseline to exit on the Paced Auditory Serial Addition Test (PASAT) and the California Verbal Learning Test-II (CVLT-II) Long Delay Free Recall (LDFR). Secondary outcomes included additional neuropsychological tests; self-report measures of quality of life, fatigue, and depression; and family/caregiver reports of subjects' CI and neuropsychiatric symptoms. RESULTS: The differences between the groups on the change on the PASAT (placebo-memantine = 0.0 correct responses, 95% CI 3.4, 3.4; p = 0.9) and on CVLT-II LDFR (placebo-memantine =-0.6 words, 95% CI -2.1, 0.8; p = 0.4) as well as on the other cognitive tests were not significant. Subjects on memantine had no serious adverse events (AEs) but had more fatigue and neurological AEs as well as, per family members' reports, less cognitive improvement and greater neuropsychiatric symptoms than subjects on placebo. CONCLUSION: Memantine 10 mg twice a day does not improve CP in subjects with MS, ages 18-65, without major depression, who have subjective cognitive complaints and perform worse than one SD below the mean on the PASAT or on the California Verbal Learning Test-II (total recall or delayed free recall).

Serum factor: the inhibition of phytohemagglutinin-induced blastogenesis of chronic lymphocytic leukemia lymphocytes.

A serum factor (SF), isolated from acidified sera of normal donors, inhibited phytohemagglutinin (PHA) stimulation of lymphocytes isolated from patients with chronic lymphocytic leukemia (CLL),but had no effect on those from healthy donors. An SF isolated by an identical procedure from the sera of patients with CLL had essentially no inhibitory effect on DNA synthesis in normal or leukemic lymphocytes. The SF was isolated from sera or plasma by ammonium sulfate precipitation, acidification to pH 1.5, and chromatography on DEAE-cellulose. The SF was heat labile and sensitive to digestion by trypsin. Maximum inhibition was obtained when the factor was added within 24 hours after the cells were stimulated with PHA.

Cyclic adenosine 3':5'-monophosphate levels and activities of related enzymes in normal and leukemic lymphocytes.

The role of cyclic adenosine 3':5'-monophosphate (cyclic 3':5'-AMP) in the regulation of cell division in lymphocytes obtained from healthy donors and from patients with chronic lymphocytic leukemia (CLL) was investigated by determining the levels of cyclic 3':5'-AMP and glycogen and also the activities of several enzymes that are closely associated with the metabolism of these cellular components. Intracellular levels of cyclic 3':5'-AMP were measured in normal and CLL lymphocytes in nondividing, dividing, and quiescent [after phytohemagglutinin (PHA) addition]states. In normal lymphocytes the levels of cyclic 3':5'-AMP fluctuated throughout the cell cycle after PHA addition, whereas in CLL lymphocytes the levels were approximately 3-fold lower than in normal cells and remained relatively constant before, during, and after mitogenic stimulation. Normal cells contained approximately 3-fold lower levels of glycogen than CLL cells, whereas glycogen phosphorylase activities were increased 2- to 4-fold above those in nondividing cells in normal but not in CLL lymphocytes after stimulation with PHA. Furthermore, cyclic 3':5'-AMP phosphodiesterase activities were higher in CLL lymphocytes than in normal ones. Collectively, these studies demonstrated that (a) the intracellular levels of cyclic 3':5'-AMP differ in these two cell types; (b) the levels of cyclic 3':5'-AMP and glycogen qualitatively correlate with the activities of the enzymes that are related to these components; and (c) an inverse relationship between the levels of cyclic 3':5'-AMP and cell growth exists in mitogen-stimulated lymphocytes from healthy donors but not from patients with CLL. These biochemical differences are presumed to exist between normal and "leukemic" lymphocytes, but alternatively they may reflect normal populations of immunologically distinct lymphocytes.

Abnormal ultrastructural changes in sodium periodate-stimulated lymphocytes from patients with chronic lymphocytic leukemia.

Lymphocytoid and plasmacytoid blasts have been identified in both normal and chronic lymphocytic leukemia lymphocyte cultures exposed to NaIO4. However, the appearance of ultrastructurally abnormal blasts in chronic lymphocytic leukemia cultures suggests that NaIO4 also stimulates the transformation of an abnormal subpopulation of lymphocytes. Development of invaginated nuclei produced morphological features similar to nuclear blebs, a cellular abnormally described in blood cells from other cancers. Furthermore, the consistent localization of nuclear invagination only to portions of nuclei adjacent to developing cytoplasmic microtublar complexes suggests a role for microtubules in the transformation process. The absence of these unusual blasts in cultures stimulated with other mitogens may indicate that these NaIO4-sensitive cells are not responsive to the more commonly used plant lectins.

Sagittal plane analysis of head, neck, and trunk kinematics and electromyographic activity during locomotion.

STUDY DESIGN: Descriptive study examining kinematic and electromyographic (EMG) patterns of the upper body during walking. OBJECTIVE: To examine trunk, neck, and head movements to determine a mechanism for upper body stabilization during walking. BACKGROUND: Dynamic balance of the upper body during walking provides a stable base for function of sensory systems. Prior investigations of upper body motion during walking were limited to examination of isolated segments, or examination of the upper body as a single unit. In our study, the upper body is examined as 3 segments: the trunk, neck, and head. METHODS AND MEASURES: Sagittal plane walking patterns were examined in 8 unimpaired young adults. Markers placed on the trunk, neck, and head segments were recorded on videotape. Angles were calculated with respect to an external horizontal reference to determine segment position relative to space. EMG measures were obtained from erector spinae, rectus abdominus, semispinalis capitis, and sternocleidomastoid muscles. RESULTS: Results showed dynamic stability was accomplished through maintenance of a posture where the trunk was flexed, the neck was extended and the head was flexed. The trunk segment demonstrated greatest stability with the neck being the least stable of the 3 segments. Movements of upper body segments showed a tendency for the head and neck to move opposite to the trunk. EMG data demonstrated erector spinae muscle activity occurring near heel contact of each limb followed by trunk extension. The remaining muscles exhibited variable patterns of activity. CONCLUSIONS: These data indicate that movements of the upper body help to maintain a posture that promotes stability of these segments during walking. The trunk was the most stable of the three segments thereby, providing a stable platform for head and neck movement. Erector spinae muscle activity contributed to upper body movements by extending the trunk to maintain balance at heel contact. These results provide a basis for studying changes in dynamic stability that occur with age.

Elongation behavior of calcaneofibular and cervical ligaments during inversion loads applied in an open kinetic chain.

The cervical ligament plays a significant role in lateral stability of the subtalar joint but has received little attention compared with other ankle and subtalar joint ligaments. The purpose of this research was twofold. First, the elongation behavior of the cervical ligament was assessed with the calcaneofibular ligament intact and cut during two different types of inversion loads (manual and mechanical). Second, inversion range of motion was determined concomitantly with inversion loading and the difference in inversion range of motion between the calcaneofibular ligament intact to cut state was compared. The mean elongation of the cervical ligament with the calcaneofibular intact was 0.58 mm (+/- 0.33 mm) and 0.46 mm (+/- 0.23 mm) for manual and mechanical methods, respectively, and 0.88 mm (+/- 0.37 mm) and 0.78 mm (+/- 0.37 mm), respectively, for the same methods in the absence of the calcaneofibular ligament. This difference was statistically significant (P < 0.05 manually and P < 0.02 mechanically). An average increase in the inversion range of motion was noted with both methods [7.5 degrees manually (+/- 2.75 degrees) and 7.7 degrees mechanically (+/- 2.95 degrees)] after lesioning of the calcaneofibular ligament. This difference was statistically significant (P < 0.001) for both manual and mechanical range of motion testing. The results of this study indicate that there is a significant increase in elongation of the cervical ligament in the absence of the calcaneofibular ligament during manual and mechanically applied inversion loads in a open kinetic chain. Clinical and theoretical implications of this data are discussed.

Talonavicular coalition. Objective gait analysis.

Talonavicular coalitions, a rarely reported fusion between the talus and navicular, are often an incidental radiographic finding that may be asymptomatic or associated with peroneal spasm. The authors present a review of literature and case report based on clinical evaluation and instrumented gait analysis. Specifically, a patient presenting with a bilateral talonavicular coalition was objectively evaluated with kinetic, kinematic, muscle dynamometry, and pedobarographic testing to understand the biomechanical limitations related to this pathology. An excessive passive component of ankle torque, a high first metatarsophangeal joint plantar pressure, and a diminished time in the midstance portion of stance phase were measured and compared to those of healthy individuals.

Fitness and Exercise in Advertising: Mining a National Mania.

Advertisers are using images of fitness to promote just about every product from cosmetics to candy bars. But these campaigns may increase public acceptance of products that do little to promote health-or that may even harm it.

Is Fitness Reaching Only the Wealthy?

Poor Americans bear a disproportionately large burden of chronic disease, which researchers blame on health habits that wealthier Americans have abandoned. Many researchers are looking for ways to bring the health movement to those who now need it most.

Perceived Exertion: An Old Exercise Tool Finds New Applications.

Rating scales of perceived exertion, which rely on an individual's subjective perceptions to determine energy output, may have uses beyond the clinic and laboratory-maybe even in everyday life.

Family Exercise Means Relative Fitness.

Family members have a lot of power over each other. With a little planning and a commitment to succeed, they can use that power to promote each other's fitness.

Wheelchair Athletes Need Special Treatment-But Only for Injuries.

Disabled athletes are coming into their own, and they now compete in a wide variety of sports. But the medical community hasn't caught up, especially in research.

Boardsailing: The Spills Don't Dampen the Thrills.

Boardsailors may not get bored, but they do get hurt. However, serious injury is unlikely, and participants can obtain modest fitness benefits.

Physical Therapy Joins the Fitness Boom.

Moving physical therapy out of hospitals and into fitness centers seems to make economic sense. But while patients seem pleased and entrepreneurs are enthusiastic, many medical professionals remain skeptical. For both physicians and their patients, the final judgment will be based on results.

Should Women Go Easy on Exercise?

Women who have been reading the lay press in recent months may get the idea that exercise is bad for them. But it ain't necessarily so.

From Activity to Eternity.

Your chances of living to a ripe old age may be improved with regular exercise-no, make that activity.

HMOs: Directing the Future of Sports Medicine?

Health maintenance organizations may be the best thing to happen to sports medicine since the fitness boom. Or they may hinder patient care and frustrate physicians. It depends on who is asked.

Exercise and Depression: Swapping Sweat for Serenity?

Many physicians now prescribe exercise as a safe and effective treatment for depression-though researchers are hard-pressed to explain why it seems to help.