The Use of Bone Morphogenetic Protein in Spinal Transforaminal Lumbar Interbody Fusion: Our Experience.

OBJECTIVE: Since its introduction and FDA approval, rhBMP-2 has been adopted by spine surgeons as a substitute for ICBG in numerous spinal fusion techniques. As broad clinical use increased, reports on potential complications associated with rhBMP-2 also increased. We provide our experience with TLIF using rhBMP-2 or ICBG in an entirely Hispanic population. METHODS: This was a 2-year retrospective study of 67 patients, with 26 in the rhBMP-2 group and 41 in the ICBG group, who underwent TLIF. Pertinent information was obtained through review of the medical records documenting complications, intraoperative times, and EBL, among other things. RESULTS: There were 28 post-operative complications with 15 (53.6%) in the ICBG group and 13 (46.4%) in the rhBMP-2 group. The average EBL was 572.3 mL (SD: 411.8) in the ICBG group and 397.9 mL (SD: 312.2) in the rhBMP-2 group. The average intraoperative time was 243.1 minutes (SD: 79.5) in the ICBG group and 226.5 minutes (SD: 64.7) in the rhBMP-2 group. Fifty-two patients underwent open TLIF and 15 patients underwent MI TLIF. The average EBL was 571.2 mL (SD: 375.3) in the open TLIF group and 228.3 mL (SD: 299.3) in the MI-TLIF group. The average intraoperative time was 241.0 minutes (SD: 76.0) for patients in the open TLIF group and 218.8 minutes (SD: 65.0) for those in the MI-TLIF group. There were no new cancer events at any of the 2-year follow-up visits. RESULTS: Our results suggest that the safety profile of rhBMP-2 may be inferior to that of ICBG, rejecting the possibility of ICBG being replaced by rhBMP-2 as the gold standard for spinal fusion.

The aging brain: Movement speed and spatial control.

BACKGROUND/OBJECTIVES: With aging, people commonly develop motor slowing (bradykinesia). Although this slowness with aging may be entirely related to degradation of the cerebral networks important in motor programing, it is possible that, at least in part, it may be a learned procedure for enhancing the accuracy and/or precision of movements. The goal of this study is to test these contradictory hypotheses. METHODS: Twenty-four healthy adults, 12 younger than age 26 and 12 older than age 65 were asked to make alternative marks with a pen between a card centered in front of them and a series of circles distributed across a page. Performance was timed, and participants were instructed to complete the task as quickly as possible while not sacrificing accuracy for speed. The circle sizes and hand used varied by trial. RESULTS: The older adults performed the task more slowly for all target circle diameters. As the circles decreased in size, the younger adults performed the task more rapidly than did the older participants, but the younger participants also had a greater decline in accuracy. CONCLUSIONS: During this aiming task, healthy older adults were less likely than younger adults to sacrifice accuracy for speed. Thus, at least in part, their slowing may be a learned adaptive strategy.

Supramesocolic access to the left renal pedicle: anatomical and surgical description.

OBJECTIVE: To expose and remind the supamesocolic approach to the left renal pedicle, in addition to review its main indications. METHODS/RESULTS: We perform a detailed description of the surgical technique showing its indications, the position, the incision and retraction systems employed, detailing the steps followed during dissection. CONCLUSIONS: Adequate vascular control and complete resection of large renal and adrenal masses require an adequate exposition; the knowledge of surgical techniques such as supramesocolic approach to the left renal pedicle is very useful and may ease the course of retroperitoneal operations avoiding complications and giving comfort in a frequently difficult operation.

Isoflurane anesthesia alters complete blood count values in lilac-crowned parrots (Amazona finschi).

OBJECTIVE: To evaluate the effects of a chemical restraint with isoflurane compared to a physical restraint in hemogram values in psittacines. ANIMALS: 21 adult lilac-crowned parrots (Amazona finschi). METHODS: Subjects were physically restrained for blood sample collection, after this isoflurane anesthesia was administered for 30 minutes at which time a second blood sample was taken. Hemogram values were compared between both samples using a t test in variables with normal distribution and a Wilcoxon test in variables without normal distribution. Statistical significance was established at P < .05. RESULTS: When comparing the analytes of the respective CBCs, a decrease in PCV (P < .001), RBC count (P < .001), WBC count (P = .017), absolute lymphocytes (P = .024), and total proteins (P < .001) was observed in the samples taken under chemical restraint. No significant differences in MCV and absolute values of heterophils, monocytes, or eosinophils were observed. CLINICAL RELEVANCE: Isoflurane causes a decrease in some blood count values in lilac-crowned parrots under isoflurane anesthesia for 30 minutes. Although the magnitude of change could be variable between values, it is important to consider the blood collection method when interpreting the blood count in this species.

Tubulocystic renal carcinoma (low grade collecting duct carcinoma).

OBJECTIVE: To report a case of tubulocystic renal carcinoma diagnosed in an adult, after a work up study for hematuria. METHODS/RESULTS: 59-year-old male, CT scan was performed during a study for self-limited hematuria showing a 4.2 cm solid mass with areas suspicious of pseudocystic malignancy. Due to its debut with hematuria and renal sinus involvement laparoscopic radical nephrectomy was performed, establishing the diagnosis of tubulocystic carcinoma (low grade collecting duct carcinoma). CONCLUSION: Tubulocystic carcinoma presents histological characteristics and a natural history that makes it different from the classic type of Bellini duct carcinoma, the latter being a rapidly growing tumor with poor prognosis which is usually diagnosed in advanced stages.

Supernumerary testicle: case report and bibliographic review.

OBJECTIVE: We report a case of supernumerary testis, a rare anomaly with only around 100 cases reported in the literature. METHODS: We describe the case of a 26-year-old man who consulted for a left paratesticular tumor. Physical examination and ultrasound showed a 2-cm nodular lesion over the left epididymis. The lesion was confirmed as supernumerary testis by surgical examination and biopsy and was subsequently excised, given the malignancy potential. RESULTS: The supernumerary testis was evaluated using two standard classifications, one assessing function and embryological development, and the other assessing topography, anatomy, and reproductive potential. CONCLUSIONS: The differential diagnosis for an intrascrotal mass should include the possibility of a supernumerary testis; hence, surgical examination and biopsy are necessary. Supernumerary testes should be excised in the case of pain, dysplasia, or in situ carcinoma, or whenever the biopsy is inconclusive.

Neuroendocrine carcinoma of the urinary bladder. 15-year retrospective analysis.

OBJECTIVES: Neuroendocrine tumors (NET) are cancers found in the bronchopulmonary tract, where they were first described in 1926. The tumors are associated with poor prognosis due to their high metastatic potency even after radical treatments associated with other neo- or adjuvant therapies. NET of the urinary bladder is a rare tumor and accounts for 0.5% of bladder tumors. METHODS: The study was designed as an observational, descriptive and retrospective study of 13 patients diagnosed, treated, and followed for NET of the urinary bladder at the Hospital and University Complex of Albacete, Albacete, Spain between 1995 and 2010. RESULTS: The sample was composed of 11 men and 2 women. Mean patient age at the time of diagnosis was 71 (range, 57-88; SD, 6.98) years. T4 (6 patients) was the most common T tumor stage, followed by T2 (5 patients) and T3 (2 patients). In the case of N tumor stage, the most common was N2. In the remaining 3 patients, the degree of lymph node involvement could not be assessed. Six presented distant metastasis at the time of diagnosis. Eleven patients presented small-cell NET on histology. Seven underwent radical surgery (radical cystectomy). All other patients were treated by deep transurethral resection of bladder tumor, except for 1 patient treated by partial cystectomy. Adjuvant chemo-therapy (usually an association of carboplatin/cisplatin and etoposide) was administered to 4 patients. Of these 4 patients, 2 were also treated by pelvic radiotherapy. Two patients survived more than 5 years following diagnosis. In fact, at the time the study data was collected only 4 patients had survived and 2 presented tumor recurrence. Of the 9 deaths, 8 occurred within 6 months of diagnosis and 1 at 24 months. All of them were the result of the disease itself. CONCLUSIONS: Neuroendocrine tumor of the urinary bladder is a rare, aggressive tumor with high metastatic potential that should be considered in the differential diagnosis of urinary bladder neoplasms. Despite various multimodality treatments have been used prognosis is poor.

Enucleations, Eviscerations, and Exenterations at a Supratertiary-care Hospital in Puerto Rico: A Retrospective Study.

OBJECTIVE: To provide a descriptive analysis of the indications and the intraoperative and postoperative complications of eye enucleations and eviscerations, and orbital exenterations performed at the only academic institution in Puerto Rico providing supratertiary care. METHODS: A retrospective medical record review of patients who underwent enucleations, eviscerations, and exenterations from January 2015 through June 2020 was conducted. The data were analyzed to generate a descriptive profile of the demographic characteristics of the patients, their clinical indications and surgical complications, and a histopathological diagnosis per type of eye-removal procedure. RESULTS: A total of 118 eyes were removed via enucleation, evisceration, or exenteration over the 66-month study period. The average patient age was 64 (±17.5) years and 63.8% of the patients were male. The most frequently performed eye-removal procedure was enucleation (73.7%), followed by evisceration (18.6%) and exenteration (7.6%). The main clinical indications for enucleations and eviscerations were infectious processes, namely panophthalmitis, endophthalmitis, and/or perforated corneal ulcers, that failed medical management. In our sample, squamous cell carcinoma was the most common diagnosis (both clinically and histopathologically) leading to exenteration. Postoperative complications in our patient cohort were minimal. CONCLUSION: At our institution, enucleations predominate over eviscerations. Retrospective reviews published in recent years indicate that the rate of eviscerations at our institution is comparatively low. The results of this study, the first of its kind at our institution, may encourage a re-evaluation of the indications for evisceration versus enucleation in our patient population.

Implant Removal Due to Infection After Open Reduction and Internal Fixation: Trends and Predictors.

Background: Implant removal due to infection is one of the major causes failure following open reduction and internal fixation (ORIF). The aim of this study was to determine trends and predictors of infection-related implant removal following ORIF of extremities using a nationally representative database. Methods: Nationwide Inpatient Sample data from 2006 to 2017 was used to identify cases of ORIF following upper and lower extremity fractures, as well as cases that underwent infection-related implant removal following ORIF. Multivariate analysis was performed to identify independent predictors of infection-related implant removal, controlling for patient demographics and comorbidities, hospital characteristics, site of fracture, and year. Results: For all ORIF procedures, the highest rate of implant removal due to infection was the phalanges/hand (5.61%), phalanges/foot (5.08%), and the radius/ulna (4.85%). Implant removal rates due to infection decreased in all fractures except radial/ulnar fractures. Tarsal/metatarsal fractures (odds ratio (OR)=1.45, 95% confidence interval (CI): 1.02-2.05), and tibial fractures (OR=1.82, 95% CI: 1.45-2.28) were identified as independent predictors of infection-related implant removal. Male gender (OR=1.67, 95% CI: 1.49-1.87), Obesity (OR=1.85, 95% CI: 1.34-2.54), diabetes mellitus with chronic complications (OR=1.69, 95% CI: 1.13-2.54, P<0.05), deficiency anemia (OR=1.59, 95% CI: 1.14-2.22) were patient factors that were associated with increased infection-related removals. Removal of implant due to infection had a higher total charge associated with the episode of care (mean: $166,041) than non-infection related implant removal (mean: $133,110). Conclusion: Implant removal rates due to infection decreased in all fractures except radial/ulnar fractures. Diabetes, liver disease, and rheumatoid arthritis were important predictors of infection-related implant removal. The study identified some risk factors for implant related infection following ORIF, such as diabetes, obesity, and anemia, that should be studied further to implement strategies to reduce rate of infection following ORIF.

Endovascular management of malperfusion in acute type B aortic dissections.

PURPOSE: To examine the feasibility, efficacy, and midterm results of endovascular stent-graft management of acute type B aortic dissection complicated by renal, visceral, or lower limb malperfusion. METHODS: A retrospective review was conducted to identify all patients with acute type B dissection treated endovascularly at a single center between 1998 and 2009. Of the 85 patients identified, 23 (27%) consecutive patients (20 men; mean age 60.9 ± 11.6 years) presented with clinical and imaging evidence of end-organ malperfusion: 7 (30%) renal, 6 (26%) lower limb, 4 (17%) renal and lower limb, 3 (13%) visceral, and single cases of renal/visceral, renal/lower limb/spinal cord, and renal/visceral/spinal cord/lower limb. RESULTS: All patients had stent-graft coverage of the proximal entry tear; 5 (22%) patients required additional branch vessel stenting, and 2 (9%) had femorofemoral bypass graft. Successful correction of malperfusion was achieved in 21 (91%) patients. In 1 patient, ischemia in the lower limb was resolved but not in the left kidney; the other patient had an ischemic but viable lower limb and did not require any additional intervention. Thirty-day mortality was 9% (2/23 patients). The incidences of postoperative stroke and paraplegia were 17% (4/23) and 9% (2/23), respectively. The 21 survivors were followed for 17.2 ± 15 months; during this period, 1 patient died, 1 was lost to follow-up, and 5 patients underwent additional open or endovascular procedures. CONCLUSION: Endovascular coverage of the proximal entry tear in acute type B dissections complicated by end-organ malperfusion resulted in correction of malperfusion in the majority of patients. It is a reasonable first line of treatment, but its superiority must be assessed in comparison with other techniques, such as fenestration.

Vaginal metastasis of a clear renal cell carcinoma.

OBJECTIVE: Remember that kidney cancer is a disease whose incidence is increasing due to increased use of additional imaging tests, which is changing the way of diagnosis, making the classic clinical syndrome synonymous with advanced illness. METHODS: We report the case of a patient with a right renal tumor with renal vein involvement that in the natural course of the disease showed a vaginal metastasis of clear renal cell carcinoma, which was treated with surgical excision. RESULTS: This case is a clear example of how unpredictable is the clinical evolution of this disease and how little we know about the way of dissemination. CONCLUSIONS: Local excision, with or without radiotherapy, or radiotherapy alone are recommended in cases of unique metastasis after nephrectomy.

Blockade of beta adrenergic receptors protects the blood brain barrier and reduces systemic pathology caused by HIV-1 Nef protein.

Combination antiretroviral therapy (cART) targets viral replication, but early viral protein production by astrocytes may still occur and contribute to the progression of HIV-1 associated neurocognitive disorders and secondary complications seen in patients receiving cART. In prior work with our model, astrocytic HIV-1 Nef expression exhibits neurotoxic effects leading to neurological damage, learning impairment, and immune upregulation that induces inflammation in the lungs and small intestine (SI). In this follow-up study, we focus on the sympathetic nervous system (SNS) as the important branch for peripheral inflammation resulting from astrocytic Nef expression. Male and female Sprague Dawley rats were infused with transfected astrocytes to produce Nef. The rats were divided in four groups: Nef, Nef + propranolol, propranolol and naïve. The beta-adrenergic blocker, propranolol, was administered for 3 consecutive days, starting one day prior to surgery. Two days after the surgery, the rats were sacrificed, and then blood, brain, small intestine (SI), and lung tissues were collected. Levels of IL-1ß were higher in both male and female rats, and treatment with propranolol restored IL-1ß to basal levels. We observed that Nef expression decreased staining of the tight junction protein claudin-5 in brain tissue while animals co-treated with propranolol restored claudin-5 expression. Lungs and SI of rats in the Nef group showed histological signs of damage including larger Peyer's Patches, increased tissue thickness, and infiltration of immune cells; these findings were abrogated by propranolol co-treatment. Results suggest that interruption of the beta adrenergic signaling reduces the peripheral organ inflammation caused after Nef expression in astrocytes of the brain.

Historical Spatial Distribution of Zoonotic Diseases in Domestic, Synanthropic, and Wild Animals in the Mexican Territory of the Yucatan Peninsula.

The Mexican territory of the Yucatan Peninsula has a tropical climate and harbors a wide variety of domestic, synanthropic, and wild animals, as well as disease vectors. To determine the distribution of recorded zoonotic diseases in the Yucatan Peninsula, scientific publications referring to these diseases in animals and containing geographic coordinates of disease occurrence, were studied. The epidemiological bulletins of the national government were also consulted to obtain information on zoonotic diseases reported in humans in the territory. The territory harbors a wide variety of tropical zoonotic pathogens, including Trypanosoma cruzi, Leptospira interrogans, Toxoplasma gondii, Leishmania mexicana, Dirofilaria immitis, and Rickettsia felis. A variety of domestic, synanthropic, and wild animals act as hosts or reservoirs in the transmission cycle of the zoonotic diseases in the Yucatan Peninsula, and some spillover into human populations has also been recorded. There are still zoonotic diseases that have rarely or never been reported in humans, but it is not clear whether this is because these diseases in humans are not common, there is a lack of viable transmission cycle or there is a lack of appropriate diagnosis. It is necessary to continue monitoring vectors, animal hosts, and humans to identify risk factors for zoonotic diseases in the Yucatan Peninsula.

Metastasis to the tunica vaginalis testis from a primary mucinous tumor of the cecum.

OBJECTIVES: We review the literature about secondary testicular tumors. METHODS: We present the case of a patient with a metastatic mucus-secreting testicular tumor who presented in the emergency room with symptoms of acute scrotum 10 months after surgery for a mixed tumor of the cecum. This type of tumor is rare, and the treatment of choice is orchiectomy; nevertheless, the prognosis of such metastasis remains poor. RESULTS: Because mucinous tumors can present late dissemination, long-term follow-up with assessment of the most common sites of metastasis is necessary. Our patient died 21 months after the initial diagnosis CONCLUSIONS: Testicular metastases and mucus-secreting intestinal tumor metastases are rare. These tumors occur in patients older than 60 years of age and young men. As in the case of primary tumors, the treatment is orchiectomy.

Primary retroperitoneal tumors: review of our 10-year case series.

OBJECTIVES: To investigate our case series of patients with primary retroperitoneal tumors over the past 10 years, analyzing clinical symptoms, diagnostic tests, tumor pathology, surgical data, concomitant cancer treatments, recurrence and survival rates. METHODS: Retrospective analysis of 37 patients with primary retroperitoneal tumors diagnosed at our hospital over the past 10 years. RESULTS: Computed tomography (CT) was the imaging technique used most often and the most accurate. Tumors were malignant in 83% of patients and benign in 17%. Complete tumor resection was performed in 73% of cases; the most common approach was midline laparotomy. Neighboring organs were also removed in 51.8% of cases in which radical resection was performed. The recurrence rate was 45% in patients who underwent surgery. Median time to onset of recurrence following open surgery was 23 months. Repeat resection was performed in 66% of cases with recurrence. Five-year survival following total resection of malignant tumors was 44%. The mean patient survival after repeat resection was 9.8 months. CONCLUSIONS: Primary retroperitoneal tumors are rare and usually malignant. Surgery is the treatment of choice and complete tumor resection is the main factor that determines prognosis.

Melatonin added to freezing diluent improves canine (Bulldog) sperm cryosurvival.

Cryopreservation compromises the capacity of sperm fertilizing due to a series of alterations in the structure and physiology of the sperm. The use of antioxidants, such as melatonin, added to freezing media, may help to reduce sperm cryoinjury. To test the effect of melatonin on Bulldog (Canis lupus familiaris) sperm cryosurvival, spermatozoa were diluted in a standard freezing medium and cooled to 5°C. Then, more freezing medium was added to obtain 200 × 106 cells/mL, and 5% glycerol. Diluted spermatozoa were treated with melatonin (0.0, 0.0005, 0.002, and 0.0035 mol/L), and packaged in 0.25 mL straws, which were further cooled to -5°C before freezing in liquid nitrogen. Thawing was carried out at 70°C for 5 s, and the progressive motility, viability, plasma membrane integrity, acrosome integrity, capacitation status, and plasma membrane fluidity of the spermatozoa (at 37°C) were assessed. Data were analyzed using ANOVA to detect differences between the melatonin doses. There were statistical differences (P < 0.05) in the percentage of sperm having hyper-fluid membranes, intact acrosome, capacitated acrosome-intact, and acrosome-reacted. The values for the high melatonin doses (0.002 and 0.0035 mol/L) were better than for the low melatonin doses (0.0 and 0.0005 mol/L). In conclusion, 0.002 and 0.0035 mol/L of melatonin improved the cryosurvival of sperm from male bulldogs. LAY SUMMARY: Preservation of sperm by freezing enables breeding of individuals geographically separated; protocols for the dog may be used to preserve the semen from threatened wild canids. To improve fertility of female dogs that become pregnant with frozen and then defrosted sperm, these cells must survive that process which can be damaging whilst keeping their ability to fertilize. Antioxidants are substances capable of retarding or preventing the oxidation of any oxidizing substrate such as lipids, proteins, and DNA, which are structural compounds of the sperm. The use of antioxidants, added to freezing media, may provide the sperm the capacity to neutralize oxidative compounds, such as reactive oxygen species, produced during the freezing and thawing process. In this work we tested different levels of melatonin, a natural antioxidant, on dog (English Bulldog) sperm survival and quality after freezing. We found that adding melatonin to the freezing media improved sperm quality after thawing.

Symptomatic seroma after open abdominal aortic aneurysm repair.

Seroma following open abdominal aortic aneurysm repair has rarely been described. The majority of cases in the literature have been associated with use of polytetrafluoroethylene grafts. Here, we present a patient with a very large, symptomatic periaortic graft seroma 10 years after conventional (open) repair. The etiology of such seromas is of significant interest in endovascular aortic repair.

[Renal hematomas after extracorporeal shock-wave lithotripsy (ESWL)]. / Hematomas renales tras litotricia extracorpórea por ondas de choque (LEOCH).

INTRODUCTION: The use of fragmentation due to shock- waves as a treatment of urinary stone was one of the most important therapeutics findings in the history of urology. It's the first election treatment for most of the calculus at renal and urethral location due to the fact that it is a low invasive treatment and it has a few number of complications, but this method also has a few negative side effects, it can caused a more or less important traumatic lesion at the organs which crosses the shock-waves, including the kidney where it can caused a small contusion or renal hematoma with different resolution and treatment. MATERIAL AND METHOD: We reviewed 4815 extracorporeal shock-wave lithotripsy that we performed in our department in which we found six cases with subcapsular and perirenal hematoma which we followed up and treated. RESULTS: After the urological complications (pain, obstruction and infection) the renal and perirenal hematic collections are the most frequent adverse effects of shock-waves used in lithotripsy, these are related to the power of energy used and patient age. CONCLUSIONS: Between the years 1992-2007 we performed 4.815 extracorporeal shock-wave lithotripsy finding seven cases of severe hematoma, less then 1%. Treatment of these complications is usually not aggressive though sometimes it is necessary to perform surgical drainage and even nephrectomy.

Total knee arthroplasty in patients with multiple hereditary exostoses.

We present a case report of a patient with severe valgus deformity of the right knee due to multiple hereditary exostoses (MHEs) treated with total knee arthroplasty (TKA). The surgical management of MHE affecting the knee encompasses exostoses resection, joint deformity rectification, and limb-length discrepancy alignment. On rare occasions, distraction osteogenesis and TKA have been used to correct valgus deformities of the knee. TKA in MHE patients with knee involvement has only been described in 6 cases. Several considerations, such as extensive knowledge of frequently occurring skeletal aberrations, are required to successfully correct the deformities associated with MHE via TKA. This report describes a case of severe valgus knee deformity with a rotational component in MHE managed with TKA, the surgical technique, and future recommendations.

Background distraction during vertical solid and character line bisections.

Background-objectives: When vertical lines are positioned above or below the center of the page, line bisection deviates toward the center of the page, suggesting that the edges of the page distract the allocation of attention to the line. A letter-character line (LCL) bisection requires both global and focal attention, to identify the target letter closest to the line's center. If more focal and less global attention is allocated to a LCL, more global attentional resources may be available and inadvertently allocated to the page. Alternatively, if the allocation of focal attention to a LCL inhibits global attentional processing, there may be less distraction by the page. METHOD: Twenty-four healthy adults (12 older) bisected vertical solid and character lines centered, or positioned closer to the top or bottom of the page. RESULTS: There was no difference between bisection of solid and character lines centered on the page. Page-related deviations were greater with character lines than solid line bisections, and greater for lines positioned toward the top than the bottom of the page. With lines positioned toward the top, the older participants' attempted bisections were higher than those of the younger participants. CONCLUSIONS: These results suggest that the allocation of focal attention increases global attentional distractibility and that global-background attentional distraction is greater when the vertical lines are placed in the upper part of the page. Older participants appeared to be less distracted when lines were placed toward the top of the page, but the reason for this age difference requires further research.