Fingertip nail bed injuries in children: Comparison of suture repair versus glue (2-octylcyanoacrylate) with 1-year follow-up.

The main objective of this study was to compare the medium-term results of nail bed repair in children using glue (2-octylcyanoacrylate) versus absorbable sutures. The secondary objective was to compare the results of treatment in the emergency room versus the operating room. This retrospective review of 74 fingertip nail bed lacerations (68 children) evaluated the appearance and pain at the last follow-up visit (minimum of 1 year), and the operating time. Mean age was 3.3 years at time of injury (range 10 months-13 years), with a mean follow-up of 2.6 (1-7) years. Thirty-six nail beds were repaired with glue; 38 were sutured. The clinical outcomes in the two groups were similar. The rate of nail dystrophy was 14% (5% major) regardless of the technique. Nail bed repair time was significantly shorter in the glue group (10.2 vs. 20.3min, p<0.001). Forty-five repairs were performed in the operating room and 29 in the emergency room. The complication rate (early infections) was significantly higher in patients treated in the emergency room. Tissue adhesive (2-octylcyanoacrylate glue) is a reliable option for repairing nail bed lacerations, both in terms of outcomes and speed of repair. Treatment in the operating room is preferable.

Proximal femoral osteotomies in children.

The aim of proximal femoral osteotomies (PFO) in children is to restore normal anatomy and optimal joint congruency to prevent medium and long-terms degenerative deterioration of the hip. They play an important role in the treatment of neurological subluxations or dislocations of the hip. Advances in modern imaging and surgical techniques have improved understanding of the anatomical factors associated with a number of disorders of the growing hip and their sequelae. The indications for isolated PFO or associated with other intra- or extraarticular procedures have become more rational and better adapted to the various architectural defects and the femoroacetabular impingements. Two types of osteotomies are described: intertrochanteric osteotomies (varus and valgus correction, valgisation, flexion, extension), and osteotomies of the greater trochanter, either simple or double with lengthening of the femoral neck. Primary stability of the osteosynthesis is the major problem, as it is often affected by osteopenia. The development of new implants (LCP plate) avoids this inconvenience, resulting in geometrically precise osteotomies and a more stable fixation. Even when it is correctly performed, articular congruence is not always managed by PFO alone, it is sometimes necessary to associate acetabular procedures.

Migration of a distal shunt catheter into the heart and pulmonary artery: report of a case and review of the literature.

INTRODUCTION: A rare complication of ventriculoperitoneal shunt placement is the proximal migration of the distal catheter into the heart and pulmonary artery. There have been 12 reported cases regarding intracardiac migration. In five of the cases, the catheter traveled further into the pulmonary vasculature. CASE REPORT: The authors report another case regarding the latter situation where the catheter tip localized in a right upper lobe pulmonary arterial branch. Removal of the catheter was complicated by redundancy of the catheter and a knot along the catheter. Nevertheless, extraction was successful via endovascular retrieval using interventional radiology and loop snares. Catheter migration likely began where the right internal jugular vein was penetrated during the initial shunt placement. Subsequent venous flow and negative intrathoracic pressure coordinated the proximal migration of the catheter. The authors provide a literature review to provide information regarding management of this rare complication.

Life-threatening post-thrombectomy hypotension due to residual complications from a translumbar catheter.

Translumbar catheters offer an alternative life-saving option in patients without conventional dialysis access, though their use and complication rates are poorly understood. We report the first case in the medical literature of a translumbar catheter inducing a central venous stenosis. This occult sequela converted what is usually a subclinical complication from an arteriovenous graft thrombectomy into a life-threatening one. This unusual clinical presentation highlights the need for clinicians to recognize the potential serious implications of translumbar catheter-induced occult central venous stenosis.

Multidetector-row computed tomographic angiography findings of musculoskeletal tumors: retrospective analysis and correlation with surgical findings.

BACKGROUND: Although magnetic resonance imaging (MRI) is a valuable method in staging musculoskeletal tumors, it may not give enough information on the association between the tumor and the main vascular structures adjacent to the tumor. In this respect, computed tomographic angiography (CTA) may be a useful alternative imaging technique. PURPOSE: To evaluate the effectiveness of CTA in determining vascular invasion in patients with musculoskeletal tumors and suspected vascular invasion by MRI, and to correlate the CTA findings with the surgical findings. MATERIAL AND METHODS: Twenty patients who had musculoskeletal tumors and lacked a fat plane between the tumor and adjacent vessels by MRI were included in this study. All patients were evaluated with CTA, and the CTA findings were reviewed by two radiologists to determine the presence of vascular invasion. Statistical analysis was carried out by using surgical findings as the gold standard. RESULTS: There were nine women and 11 men (mean age 31 years) with either bone (n=9) or soft-tissue (n=11) tumors. Twelve patients without invasion according to the CTA examination were also surgically negative (true-negative cases). Of the eight patients with invasion shown by CTA, only three had adhesions and were considered surgically negative (false-positive cases). Five had invasions proven by surgery and were considered surgically positive (true-positive cases). Compared to the surgical findings, CTA had 100% sensitivity, 80% specificity, 62.5% positive predictive value, 100% negative predictive value, and 80% accuracy. CONCLUSION: CTA is a more accurate imaging technique than MRI in evaluating vascular invasion of musculoskeletal tumors, and provides valuable preoperative data.

Intraoperative extracorporeal irradiation and re-implantation of involved bone for the treatment of musculoskeletal tumors.

The purpose of this trial is to evaluate the results of musculoskeletal tumors which is treated with limb salvage surgery and extracorporeal radiotherapy. Patients were treated with en-bloc resection followed by 50 Gy single dose extracorporeal irradiation and re-implantation of involved bone segments. Nine of fifteen were female and 6 were male, median age was 19. Tumor originated from tibia in 7 patients, femur in 3, humerus in 3, calcaneus in 1 and scapula in 1. Preoperative chemotherapy was given to 12 patients, 3 of them had not been treated previously. Median follow-up time of the survivors was 22 months (range 2-47 months); local recurrence and lung metastases occurred in one patient (local recurrence was away from the re-implanted bone segment), and lung metastases were reported in another 3 patients. Wound healing problems occurred in 4 patients and delayed union in 2 patients. Amputation was performed in 2 patients due to uncontrolled infection, and infected bone was replaced by a fibula graft in another patient. Treatment was successful in 12 patients where functional results were good in 9, excellent in 2 and not evaluated in 1. Limb salvage using en-bloc resection followed by intraoperative extracorporeal irradiation and re-implantation of involved bone is a useful and cheap reconstruction method in appropriately selected patients.

Protective effect of natural honey against acetic acid-induced colitis in rats.

AIMS: The protective effects of natural honey against acetic acid-induced colitis were investigated in rats. METHODS: Honey and glucose, fructose, sucrose, maltose mixture were administered, orally and rectally, daily for a period of 4 days. Induction of colitis was done on the third day using 3% acetic acid. Animals were killed on day 4 two hours after administration of the dose and colonic biopsies were taken for macroscopic scoring, histopathological and biochemical studies. RESULTS: Honey dose-dependently afforded protection against acetic acid-induced colonic damage. There was almost 100% protection with the highest dose (5 g/kg) used while glucose, fructose, sucrose, maltose mixture produced no significant protective effect. Also, honey prevented the depletion of the antioxidant enzymes reduced glutathione and catalase and restored the lipid peroxide malondialdehyde towards normal levels. CONCLUSIONS: Further studies are required to explore the active ingredients responsible for the antioxidant effect of honey and its therapeutic potential in humans.

The role of 99mTc-MIBI scintigraphy in the assessment of MDR1 overexpression in patients with musculoskeletal sarcomas: comparison with therapy response.

The occurrence of multidrug resistance (MDR), which is in part due to the overexpression of P-glycoprotein (Pgp), is a major problem in neoadjuvant therapy of malignant musculoskeletal tumours. The aim of this study was to investigate the role of technetium-99m hexakis-2-methoxyisobutylisonitrile (99mTc-MIBI) scintigraphy for functional imaging of the MDR1 phenotype in patients with musculoskeletal sarcomas. We aimed to compare 99mTc-MIBI uptake and washout kinetics with the expression of Pgp and with chemotherapy response. Twenty-five patients (16 males and 9 females, aged between 8 and 65 years) with malignant musculoskeletal tumours were studied. After injection of 555-740 MBq 99mTc-MIBI, dynamic flow images of the involved area were obtained for 3 min, and planar images were acquired at 10 min and 1 h. From the dynamic images, a tumour perfusion index (TPI) was obtained using Patlak-Rutland analysis. Tumour to background (T/B) ratios of both early and delayed images and percent wash-out rate (WR%) of 99mTc-MIBI were calculated. Immunohistochemical analysis of Pgp was performed on biopsy specimens and the degree of expression was graded according to a semiquantitative scoring system, from 0 to 6. After neoadjuvant therapy, tumour response was assessed by examining the ratio of viable cells and by detecting percent necrosis. Scintigraphic results were compared with Pgp status and therapy response. Irrespective of the Pgp status, all patients showed significant perfusion and 99mTc-MIBI uptake in early images. There was not a significant correlation between T/B ratios of early and delayed images and Pgp expression. We observed a positive correlation between WR% and Pgp status (r=0.61, P<0.01), and the wash-out rate of 99mTc-MIBI was significantly higher in patients with high Pgp expression than in those with a low Pgp score (33% +/- 9% vs 17% +/- 9%). Therapy response was determined in 21 of 25 patients, and in only 5 of 21 cases was the percent necrosis more than 90%. Neither Pgp expression rate nor WR% was found to show a significant correlation with percent necrosis in the bulk tumour specimens. In conclusion, the initial uptake of 99mTc-MIBI in bone and soft tissue sarcomas did not correlate with Pgp expression. A relationship was found between the wash-out rate of 99mTc-MIBI and the Pgp score, with a significant difference in WR% being observed between patients with high and patients with low Pgp expression.

A severely disabling disorder: fibrodysplasia ossificans progressiva.

Fibrodysplasia ossificans progressiva (FOP) is an extremely rare hereditary disorder characterised by progressive heterotopic ossification of the soft tissues. The resulting progressive immobilisation of the limbs, jaw and chest wall generally leads to severe disability. We present an 18-year-old girl with advanced FOP. She had three operative interventions to excise her ectopic bones but all resulted in failure. Treatment strategies for this disorder should include the avoidance of exacerbating factors.

Correlation of 99mTc-sestamibi uptake with blood-pool and osseous phase 99mTc-MDP uptake in malignant bone and soft-tissue tumours.

Technetium-99m-sestamibi (99mTc-MIBI) imaging is a well-established modality in oncologic investigations. The current study aimed to investigate whether any relationship could be found between 99mTc-MIBI uptake and local perfusion in malignant bone and soft-tissue tumours. It also aimed to compare 99mTc-MIBI images with those of technetium-99m-methylene diphosphonate (99mTc-MDP) bone scintigraphy with regard to the activity distribution pattern, intensity and lesion extension. The study group included 24 patients with various bone and soft-tissue tumours. Three-phase bone scintigraphy and 99mTc-MIBI studies were performed within the same week before any surgical and therapeutic intervention. Images were evaluated visually and quantitatively using regions of interest (ROIs) over the lesion and adjacent normal tissue. The 99mTc-MIBI study was positive with varying degrees of uptake (range, 1.4-5.3). The mean 99mTc-MIBI uptake and 99mTc-MDP blood-pool and osseous phase activity ratios were 2.5 +/- 0.5, 2.8 +/- 1.0 and 5.5 +/- 4.0, respectively. The correlation between the 99mTc-MIBI uptake and blood-pool ratios was 0.70 (P<0.05). While activity distribution patterns were in agreement in 99mTc-MIBI and blood-pool images in the majority of cases, 99mTc-MIBI better delineated tumour viability and extension in five cases. In conclusion, 99mTc-MIBI accumulation shows a reasonable correlation with blood-pool uptake assuming the presence of multifactorial mechanisms in addition to local hyperaemia. Better delineation of tumour outlines and cellular activity seems to be an advantage of 99mTc-MIBI scintigraphy which may be helpful in the evaluation of musculoskeletal tumours.

Transsacral usage of a pure island TRAM flap for a large sacral defect: a case report.

A pedicled transverse rectus abdominis musculocutaneous (TRAM) flap was used to reconstruct a large sacral defect retroperitoneally. Muscle and superiorly located skin were elevated on the deep inferior epigastric pedicle. The flap was transposed retroperitoneally from the abdominal wall to the sacral region of the patient. The selection criteria for this particular flap are discussed and compared with other reconstructive choices.

Assessment of chemotherapy-induced changes in bone sarcomas: clinical experience with 99Tcm-MDP three-phase dynamic bone scintigraphy.

The aim of this study was to evaluate the value of three-phase dynamic bone scintigraphy (TPBS) in the assessment of the response of bone sarcomas to pre-operative chemotherapy and to correlate serial scintigraphic changes with histological findings. The study group comprised 27 patients (osteogenic sarcoma, n = 20; Ewing's sarcoma, n = 5; malignant fibrous histiocytoma, n = 2) with a mean age of 19.2 years. All patients received 99Tcm-methylene diphosphonate TPBS before and after pre-operative chemotherapy. Each phase of the imaging procedure was interpreted qualitatively and quantitatively. The percentage of tumour necrosis was analysed on resection materials following surgery. Histologically, 12 patients were non-responsive (tumour necrosis less than 90%) and 15 patients were responsive (tumour necrosis more than 90%). A decrease in the tumour blood flow ratio and extension were the most notable findings in the responders. The mean change in the tumour blood flow ratio following therapy was 58.7 +/- 8.3% and 19.9 +/- 26.6% (P < 0.005) in responders and non-responders respectively. The accuracy of three-phase imaging and static bone scintigraphy was 88% and 74% respectively. Since bone scintigraphy is a valuable technique owing to its ability to detect distant metastases in clinically early disease, TPBS should be helpful in monitoring therapy effects without any additional cost or radiation dose.

Liposarcoma of soft tissue: MRI findings with pathologic correlation.

OBJECTIVE: To evaluate the MRI findings of liposarcomas of different histologic types and correlate these with the histopathologic features. DESIGN: The MR images of seven liposarcomas were reviewed retrospectively to assess the tumor size, location, margination, signal characteristics and enhancement patterns in different histologic types. PATIENTS: Seven liposarcomas comprising three well-differentiated, two myxoid and two pleomorphic types were evaluated. RESULTS AND CONCLUSION: All tumors showed well-defined and mostly lobulated margins. The well-differentiated liposarcomas were composed mainly of fat with septations or nodules, were hyperintense on T2-weighted images, and demonstrated faint enhancement or no enhancement following intravenous contrast. Myxoid liposarcomas were homogeneous or mildly heterogeneous and a pseudocapsule was present in one case. Pleomorphic types showed a markedly heterogeneous internal structure. Both myxoid and pleomorphic lesions-showed moderate or marked heterogeneous enhancement after contrast administration. Well-differentiated liposarcomas may be differentiated from other types of the tumor by their largely lipomatous appearance. The malignancy grade increases in parallel with tumor heterogeneity and contrast enhancement.

[The crisis of internal medicine]. / La crisis de la medicina interna.

The rapid technological progress in medicine has lead to a better physiopathologic and etiological knowledge of adult diseases, producing a fragmentation of internal medicine and a great development of its subspecialties. Furthermore, specialization grants a professional, scientific and academic status. Contrarywise technological enrichment has impoverished the human relationship of clinical practice. The training at the Medical School has a great responsibility towards General Internal Medicine, and the technical capacity of teachers should be revised. The practical tutorial teaching at the hospital should be accomplished by Internists with a general clinical orientation. Outpatient clinics should be incorporated as places where a more clinical and less technological medicine could be taught. Internship should be a period in which General Internal Medicine should be valorized, continuing in post-graduate training and continuous teaching. General Internal Medicine is going through a crisis; Medical Schools and the Medical society have the responsibility to overcome it.

Effect of desferrioxamine on cisplatin-induced nephrotoxicity in normal rats.

Biochemical and histological evaluations of the effects of the iron chelator desferrioxamine on the nephrotoxicity induced by cisplatin in normal rats were carried out. A single dose of cisplatin (7.5 mg/kg, intravenously) caused nephrotoxicity that manifested biochemically as an elevation of blood urea nitrogen, serum creatinine and an increase in the kidney weight as a percent of body weight. Moreover, severe decreases in serum calcium and albumin were observed. Histopathological examination of kidney tissue revealed tubular necrosis with sloughing of tubular epithelium. Desferrioxamine treatment (250 mg/kg, intraperitoneally) 30 min before cisplatin administration does not protect the kidney from the damaging effects of cisplatin. A greater increase in blood urea nitrogen, serum creatinine and kidney weight was observed with significant tubular necrosis and a mild lymphocytic infiltrate. Desferrioxamine pretreatment decreased the lipid peroxidation induced by cisplatin but at the same time increased nonprotein sulfhydryl (-SH) concentrations in the kidney tissue. The findings of this study suggest that lipid peroxidation is not the main cause of cisplatin-induced nephrotoxicity and that desferrioxamine which was useful for prevention of cardiac and hematological damage induced by doxorubicin, aggrevated the cisplatin-induced nephrotoxicity. More investigations are needed to establish a definite assessment of its selectivity.

Hepatic manifestations of Wilson's disease: frequency and pattern in Saudi patients.

Seven symptomatic patients with Wilson's disease have so far been diagnosed at King Khalid University Hospital (KKUH), Riyadh, over the last six years. On family screening, another three asymptomatic patients were found to be affected. Five of the symptomatic patients had clinical features of liver disease on initial presentation and was preceded by renal dysfunction in another patient. The remaining patient presented with neurological features. Six patients had Kayser-Fleisher ring. Abnormal liver function tests were found in half of the patients. Ceruloplasmin was reduced in 7 of 10 patients. Serum copper and urinary copper estimations were most useful diagnostic laboratory tests. Morphological alteration was found in all 9 patients who had a percutaneous liver biopsy. All patients were treated initially with D-penicillamine and clinical response was noted in seven, of whom one developed neurological manifestations while receiving the treatment. D-penicillamine was replaced by zinc sulfate in 3 patients who developed thrombocytopenia. The data suggest that Wilson's disease may not be rare in Saudi Arabia. For early detection and prompt treatment, the disease should be suspected under appropriate clinical circumstances especially in young patients with liver diseases. Close relatives of such index patients should be routinely screened.

Histological changes following high-dose methotrexate and cisplatinum administration and the influence of dosage scheduling.

Histological changes were studied in experimental animals following the intraperitoneal administration of high-dose cisplatin with or without high-dose methotrexate and citrovorum factor. There were pronounced renal toxicities with high-dose (10 mg/kg) cisplatin, particularly involving distal tubules with glomerular congestion. However, lower toxicities were noted with reduced dosage of cisplatin (5 mg/kg) and especially if given once as a single bolus injection instead of a 5-day regimen. Renal and hepatic toxicities were marked with concomitant methotrexate administration leading to hemorrhagic diathesis and shorter survival. However, toxicities were relatively reduced when cisplatin was given as a single bolus injection instead of a 5-day divided course. Such information may prove helpful in future planning of combination chemotherapy in patients with malignancies using these two agents.