Port-site hernia recurrence at previous 5-mm laparoscopic access: case report and review of literature.

Port-site hernia (PSH) of less than 10 mm is an exceptionally rare complication of minimally invasive surgery (MIS). To date, there have been no cases in the literature reporting recurrence of PSH from a 5 mm incision. We present the first case of PSH recurrence in a woman who underwent surgery for benign gynaecological pathology via a MIS approach. Her post-operative course was complicated by an episode of symptomatic hernia arising from a 5 mm accessory trocar which was surgically managed. A few months later she re-presented with the same symptoms and had a PSH recurrence of the same port-site. Two corrective surgeries employing different techniques were performed. The first episode was managed laparoscopically using interrupted stitches. On the other hand, the PSH recurrence was managed by placement of a mesh. Ultrasound played a crucial role in diagnostics, especially in the recurrent setting. Due to the complete absence of similar cases in the literature, the decision making around the management of a PSH recurrence from a 5 mm trocar site proved to be challenging. As MIS is the current standard of care, more cases are likely to occur, however despite the increasing number of surgical procedures performed via MIS, no established guidelines for managing such complications have been proposed. Trying to bridge this gap, we present the case report of the first case of PSH recurrence from a 5 mm accessory port and a review of the most significant literature available to date. We finally summarise the reported cases of PSH and the types of surgical repair conducted to highlight the absence of a standard of care.

Utility of routine preoperative laboratory testing for patients undergoing minor gynaecologic surgical procedures: interim analysis of their impact on intraoperative and postoperative complications.

Background: Despite discouragement from many scientific societies, routine preoperative testing remains a common practice. Minor gynaecological surgery, being widely performed in everyday practice, represents an opportunity for implementing cost-reduction policies by avoiding unnecessary diagnostic assessments. Objectives: To assess whether performing routine preoperative blood tests affects postoperative complications and cost-effectiveness in patients undergoing minor gynaecological surgery. Materials and Methods: An interim subgroup analysis of a retrospective study conducted by Fondazione Policlinico Gemelli (Rome) and Azienda Sanitaria Universitaria Friuli Centrale (Udine) was performed. Patients who underwent surgery under general anaesthesia were included. The studied population was divided based on the preoperative work up. Clinical data, surgical features and complications were collected. Main Outcome Measures: Intraoperative and postoperative complications, healthcare expenditure in two groups. Results: Subgroup analysis included 1191 patients in Centre A (Rome) who underwent routine complete preoperative tests and 500 patients in Centre B (Udine), who underwent exams only if indicated. Population characteristics were similar in two groups. Postoperative complications were observed in 1.2% and 1.4% of cases in Group A and Group B, respectively (p=0.70). Severe complications occurred in 0.3% of cases in Group A and 0.4% in Group B. Group B showed a cost saving of approximately 70 Euros per procedure (p < 0.001). Conclusions: Preliminary data indicate that routine perioperative assessment did not reduce complication rates, hospital readmissions or surgical reinterventions. Given the high number of procedures, performing specific preoperative tests only when indicated may result in significant cost reduction. What is new?: This study selectively highlights the potential benefits to overall public health expenditure that could be achieved through stricter adherence to guidelines on preoperative assessment in minor gynaecological surgery.

Simple hysterectomy versus radical hysterectomy in early-stage cervical cancer: A systematic review and meta-analysis.

BACKGROUND: This systematic review (SR) and meta-analysis aims to compare the surgery-related results and oncological outcomes between SH and RH in patients with early-stage cervical cancer. METHOD: We systematically searched databases including PubMed, Embase and Cochrane to collect studies that compared oncological and surgery-related outcomes between SH and RH groups in patients with stage IA2 and IB1 cervical cancer. A random-effect model calculated the weighted average difference of each primary outcome via Review Manager V.5.4. RESULT: Seven studies comprising 6977 patients were included into our study. For oncological outcomes, we found no statistical difference in recurrence rate [OR = 0.88; 95% CI (0.50, 1.57); P = 0.68] and Overall Survival (OS) [OR = 1.23; 95% CI (0.69, 2.19), P = 0.48]. No difference was detected in the prevalence of positive LVSI and lymph nodes metastasis between the two groups. Concerning surgery-related outcomes, the comprehensive effects revealed that the bladder injury [OR = 0.28; 95% CI (0.08, 0.94), P = 0.04] and bladder disfunction [OR = 0.10; 95% CI (0.02, 0.53), P = 0.007] of the RH group were higher compared to the SH group. CONCLUSION: This meta-analysis suggested there are no significant differences in terms of both recurrence rate and overall survival among patients with stage IA2-IB1 cervical cancer undergoing SH or RH, while the SH group has better surgery-related outcomes. These data confirm the need to narrow the indication for RH in early-stage cervical cancer.

Increased striatal dopamine release in Parkinsonian patients with pathological gambling: a [11C] raclopride PET study.

Pathological gambling is an impulse control disorder reported in association with dopamine agonists used to treat Parkinson's disease. Although impulse control disorders are conceptualized as lying within the spectrum of addictions, little neurobiological evidence exists to support this belief. Functional imaging studies have consistently demonstrated abnormalities of dopaminergic function in patients with drug addictions, but to date no study has specifically evaluated dopaminergic function in Parkinson's disease patients with impulse control disorders. We describe results of a [(11)C] raclopride positron emission tomography (PET) study comparing dopaminergic function during gambling in Parkinson's disease patients, with and without pathological gambling, following dopamine agonists. Patients with pathological gambling demonstrated greater decreases in binding potential in the ventral striatum during gambling (13.9%) than control patients (8.1%), likely reflecting greater dopaminergic release. Ventral striatal bindings at baseline during control task were also lower in patients with pathological gambling. Although prior imaging studies suggest that abnormality in dopaminergic binding and dopamine release may be markers of vulnerability to addiction, this study presents the first evidence of these phenomena in pathological gambling. The emergence of pathological gambling in a number of Parkinson's disease patients may provide a model into the pathophysiology of this disorder.

Dual-task training reduces impact of cognitive task on postural sway.

Postural sway increases when a cognitive task is performed concurrently with a postural task. The author examined the hypothesis that following dual-task training, a concurrent cognitive task would not amplify postural sway. Participants (N = 18) were assigned to no-training, single-task training, or dual-task training groups. Single-task training consisted of 3 sessions in which the postural task, quiet standing on a compliant surface, and the cognitive task, counting backward by 3s, were practiced separately. Dual-task training consisted of 3 sessions of concurrent practice of the cognitive and postural tasks. After training, performance of a concurrent cognitive task increased postural sway in the no-training and single-task training groups but not in the dual-task training group. Results suggest that dual-task practice improves dual-task performance.

Release of matrix proteins from mitochondria to cytosol during the prereplicative phase of liver regeneration.

70% partial hepatectomy (PH) in the rat causes a release, into the cytosolic fraction, of mitochondrial matrix proteins, namely the mitochondrial isoform of aspartate aminotransferase (mAAT) and malate dehydrogenase (MDH), during the first 24 h after PH, when no growth of the residual liver is observed. After this time interval, the weight of the liver starts to increase and the normal weight is reached at 96 h after PH. This proliferative phase is characterized by a progressive recovery of the normal levels of intramitochondrial activities of mAAT and MDH. Mitochondria isolated at 24 h after PH show a membrane permeabilization to sucrose accompanied by a release of matrix enzymes; both are blocked by cyclosporin A. These results suggest an alteration of mitochondrial membrane integrity, during the prereplicative phase of liver regeneration, with the occurrence of an increased permeability that allows the passage into the cytosol of matrix enzymes.

Mitochondrial oxidative alterations following partial hepatectomy.

Mitochondria, isolated from rat livers during the early phase of liver regeneration (7-24 h after partial hepatectomy), show: (i) decrease in the rate of ATP synthesis; (ii) increase of malondialdehyde and of oxidized protein production; (iii) decrease of the content of intramitochondrial glutathione and of protein thiols on mitochondrial proteins; (iv) increase of the glutathione bound to mitochondrial proteins by disulfide bonds. These observations suggest an increase of production of oxygen radicals in liver mitochondria, following partial hepatectomy, which can alter the function of the enzymes involved in the oxidative phosphorylation. Blue-native gel electrophoresis of rat liver mitochondria, isolated after partial hepatectomy, shows, during the early phase of liver regeneration (0-24 h after partial hepatectomy), a progressive decrease of the content of F0F1-ATP synthase complex. The amount of glutathione bound to the F0F1-ATP synthase, electroeluted from the blue-native gels, progressively increased during the early phase of liver regeneration. It is concluded that partial hepatectomy causes mitochondrial oxidative stress that, in turn, modifies proteins (such as F0F1-ATP synthase) involved in the mitochondrial oxidative phosphorylation.

Cognitive activity shifts the attractors of bimanual rhythmic coordination.

The attractors of bimanual rhythmic coordination are given as the solutions of a motion equation in relative phase. How are those attractors affected by cognitive activity? In 3 experiments, participants (N = 10 in Experiments 1 and 2; N = 5 in Experiment 3) were required to produce in-phase or antiphase coordination while they either did or did not perform an information-reduction task. The average absolute deviation from in-phase (0 degrees ) and antiphase (180 degrees ) satisfying a particular parameterization of the motion equation was amplified by cognitive activity. That amplification of absolute phase shift was the same for both in-phase and antiphase coordination. Furthermore, the amplification (in degrees) increased linearly with the magnitude of cognitive activity (in bits). Cognitive activity had limited influence on the variability of relative phase and did not affect its average signed deviation. Collectively, the results suggest that cognitive activity produces a shift in the attractors of bimanual coordination dynamics that is directionally nonspecific and is independent of movement speed, detuning, and the in-phase-antiphase distinction.

Lumbar traction: a review of the literature.

Lumbar traction is commonly used to treat patients with back pain. Typically, clinicians rely on expert opinion in making decisions about when and how to implement lumbar traction. The purpose of this paper was to review current knowledge of lumbar traction and to identify what, if any, empirical evidence supports the expert opinions. This review found that whereas the mechanical effects of lumbar traction are well substantiated, the results of studies examining clinical effectiveness are conflicting. The failure to conclusively demonstrate the clinical benefit of lumbar traction may be related to the varied diagnostic categories and treatment techniques employed in the studies. Of the 10 types of lumbar traction described in the literature, static and intermittent mechanical traction are the two most commonly used. Indications, contraindications, and treatment techniques for these two types of traction are discussed. Based on the findings of this review, further study is needed to determine optimal treatment duration, frequency, and mode of administering lumbar traction. Also, classification systems to identify patients most likely to benefit from traction need to be developed and validated.

Intertester reliability of the cyriax evaluation in assessing patients with shoulder pain.

James Cyriax's approach to diagnosis and treatment of soft tissue disorders is frequently used by orthopaedic and sport physical therapists. The reliability of using Cyriax's system to determine diagnostic categories, however, has not been established. The purpose of this study was to examine the intertherapist reliability of assessments made using Cyriax's shoulder evaluation. Twenty-one cases of painful shoulder were evaluated independently by two experienced physical therapists. Therapists used a checklist to indicate their assessment of each case by selecting a specific shoulder lesion or by indicating that the case did not fit the Cyriax model. Cohen's kappa statistic was used to measure intertherapist agreement. Therapists classified 19 of the 21 cases into the same diagnostic category for a percent agreement of 90.5%. The kappa value was .875, indicating "almost perfect" agreement. Both therapists classified the same four cases of painful shoulder as not fitting the Cyriax model of soft tissue examination. The results of this study show that the Cyriax evaluation can be a highly reliable schema for assessing patients with shoulder pain.

Differential diagnosis in physical therapy evaluation of thigh pain in an adolescent boy.

Slipped capital femoral epiphysis (SCFE) is a condition of the adolescent hip in which the femoral head displaces relative to the femoral neck. This disorder is characterized by a synovitis of the hip joint or a mechanical limitation of motion with pain referred to the thigh or knee. The case described in this report is typical of an adolescent with SCFE. A brief review of epidemiology, etiology, clinical presentation, and treatment is presented to facilitate the physical therapist's knowledge of this condition and its proper management. Delay in diagnosis and treatment of SCFE may result in progression of the slip and chronic disability from osteoarthritis. It is imperative, therefore, that a patient suspected of having this condition be promptly referred to an orthopaedic surgeon for radiographic evaluation.

Assessing lumbar stabilization from point-light and normal video displays of manual lifting.

Routinely, physical therapists use visual observation to assess qualitatively a patient's performance. The literature, however, indicates that assessments of gait and lumbar stabilization from visual observation are at best only moderately reliable. Point-light video displays have been used to study the visual perception of human motion. The present purpose was to examine the reliability of assessments made by a physical therapist when viewing point light and normal video displays of subjects performing a lifting task. Three physical therapists assessed lumbar stabilization by viewing normal and point-light displays of 25 subjects who lifted an 8-lb. milkcrate from floor to waist height. Greater agreement of the therapists' ratings of lumbar stabilization was achieved on assessments made from point-light displays than on those made from normal displays. This finding suggests that the use of point-light displays may improve the reliability of qualitative assessments of performance on motor tasks.

Drug-induced deactivation of inhibitory networks predicts pathological gambling in PD.

OBJECTIVE: Some patients with Parkinson disease (PD) develop pathological gambling when treated with dopamine agonists (DAs). However, little is known about DA-induced changes in neuronal networks that may underpin this drug-induced change in behavior in vulnerable individuals. In this case-control study, we aimed to investigate DA-induced changes in brain activity that may differentiate patients with PD with DA-induced pathological gambling (gamblers) from patients with PD without such a history (controls). METHODS: Following overnight withdrawal of antiparkinsonian medication, patients were studied with H2(15)O PET before and after administration of DA (3 mg apomorphine) to measure changes in regional cerebral blood flow as an index of regional brain activity during a card selection game with probabilistic feedback. RESULTS: We observed that the direction of DA-related activity change in brain areas that are implicated in impulse control and response inhibition (lateral orbitofrontal cortex, rostral cingulate zone, amygdala, external pallidum) distinguished gamblers from controls. DA significantly increased activity in these areas in controls, while gamblers showed a significant DA-induced reduction of activity. CONCLUSIONS: We propose that in vulnerable patients with PD, DAs produce an abnormal neuronal pattern that resembles those found in nonparkinsonian pathological gambling and drug addiction. DA-induced disruption of inhibitory key functions--outcome monitoring (rostral cingulate zone), acquisition and retention of negative action-outcome associations (amygdala and lateral orbitofrontal cortex)--together with restricted access of those areas to executive control (external pallidum)--may well explain loss of impulse control and response inhibition in vulnerable patients with PD, thereby fostering the development of pathological gambling.

Active lateral neck flexion range of motion measurements obtained with a modified goniometer: reliability and estimates of normal.

OBJECTIVE: To describe a new method for measuring lateral neck flexion range of motion (ROM), document the reliability of the method and present estimates of normal. SUBJECTS: One hundred thirty-five subjects ranging in age from 14-95 yr. Two physical therapists with 13 and 2 yr of experience, respectively, served as testers. INTERVENTION: Measurement of active lateral neck flexion ROM using a universal goniometer modified by the placement of a portion of a small paper clip through the axis. The goniometer arms were aligned with the subject's nose, and the free-swinging paper clip (pendulum) was used as a marker. The more experienced therapist measured lateral flexion of 100 subjects to establish intratester reliability and estimates of normal. Both therapists measured 35 subjects to determine intertester reliability. MAIN OUTCOME MEASURE: Degrees of lateral neck flexion. RESULTS: Intraclass correlation coefficients for intratester reliability exceeded 0.90. Coefficients for intertester reliability were 0.86 and 0.65. ROM decreased with increasing age. CONCLUSION: The modified goniometer is inexpensive, easy to use and can yield high intratester reliability and satisfactory intertester reliability. The estimates of normal provide preliminary values with which a patient's lateral neck flexion ROM can be compared.

Membrane protein degradation by AAA proteases in mitochondria: extraction of substrates from either membrane surface.

Two AAA proteases, each with its catalytic site at the opposite membrane surface, mediate the ATP-dependent degradation of mitochondrial inner membrane proteins. We demonstrate here that a model substrate polypeptide containing hydrophilic domains at both sides of the membrane can be completely degraded by either of the AAA proteases, if solvent-exposed domains are in an unfolded state. A short protein tail protruding from the membrane surface is sufficient to allow the proteolytic attack of an AAA protease that facilitates domain unfolding at the opposite side. Our results provide a rationale for the membrane arrangement of AAA proteases in mitochondria and demonstrate that degradation of membrane proteins by AAA proteases involves an active extraction of transmembrane segments and transport of solvent-exposed domains across the membrane.