Terbutaline for acute tocolysis prior to emergency caesarean delivery for suspected foetal compromise.

INTRODUCTION: Terbutaline has been used as a foetal resuscitation measure to improve the intrapartum foetal heart rate abnormalities and neonatal outcome for suspected foetal compromise. Unfortunately, till date, the available data are limited to draw any recommendation. MATERIAL AND METHODS: This was a double-blind, placebocontrolled trial conducted among women planned for emergent caesarean delivery for suspected foetal compromise where 100 were randomised to receive subcutaneous terbutaline or placebo. The primary outcomes were the neonatal acid-base status, while the 5- minute Apgar score, admission to the intensive care unit and the maternal outcomes were recorded as secondary outcomes. RESULTS: Data from a total of 96 women were analysed and showed a lower incidence of neonatal acidemia (4.4% vs 10.4%) and fewer neonates born with umbilical artery pH of less than 7.20 (12.5% vs 27.1%) and 7.10 (4.2% vs 6.2%) after terbutaline injection. However, the difference in the incidence of neonatal acidaemia, mean cord pH and base excess, Apgar score or admission to the intensive care unit did not differ significantly. No difference was seen in the maternal mean arterial pressure, estimated blood loss or haematocrit after the surgery between the study groups. The only significant maternal effect was tachycardia which was more common after terbutaline injection (54.2% vs 25.0 %, p=0.003). CONCLUSION: The study shows that acute tocolysis with subcutaneous terbutaline prior to caesarean delivery has the potential to improve the neonatal outcome in suspected intrauterine foetal compromise and should be further investigated.

Induction of labour survey: A need for standardisation and/or change in practice.

Induction of labour is one of the most common antepartum intervention. There are numerous methods available but the most commonly used in Malaysian public hospital is the intravaginal dinoprostone. This survey highlighted the various practices of using dinoprostone for different group of pregnant women which are unfortunately, not supported by robust clinical evidence. As such, it calls for futher studies to allow future practice standardization. Alternatively, the use of misoprostol for induction of labour, which has better data profile, should also be considered.

[Diagnosis of periprosthetic joint infection : Development of an evidence-based algorithm by the work group of implant-associated infection of the AE-(German Society for Arthroplasty)]. / Diagnostik der periprothetischen Infektion : Entwicklung eines evidenzbasierten Algorithmus der Arbeitsgruppe implantatassoziierte Infektion der Arbeitsgemeinschaft Endoprothetik.

BACKGROUND: Prosthetic joint infections (PPI) will challenge orthopaedic surgeons and the health care system in the coming years. Evidence-based and reliable preoperative diagnostics are necessary for success in the field of revision arthroplasty. Especially the preoperative detection of PPI is important with respect to the treatment strategy. AIM: The aim of this study was to develop a detailed and structured standard operating procedure (SOP) to detect PPI preoperatively. METHODS: A systematic literature research was performed and relevant articles identified. After extracting the data, statistical calculations of sensitivity, specificity, positive/negative predictive value and positive/negative likelihood ratio were performed. The results were discussed and evaluated in four meetings analogously to standard Delphi rounds by the workgroup of implant-associated infections of the German AE (Arbeitsgemeinschaft Endoprothetik). An algorithm for the diagnostic approach according to ISO 5807 was made. RESULTS: The standardized algorithm combines a sequence of evidence-based procedures with detailed and structured main and additional criteria to every critical step in the diagnostic approach. CONCLUSION: The detection of PPI is of tremendous importance prior to revision arthroplasty and determines its success or failure. The diagnosis "prosthetic joint infection" requires a substantial change with respect to treatment concepts. The algorithm summarizes current literature and specialized expert opinions in a modern standardized format for a transparent diagnostic approach.

The gluteal sling: an anatomical study.

INTRODUCTION: Sciatic nerve palsy is a devastating complication which may be seen after acetabular exposure in total hip resurfacing via a posterior approach. An anatomical structure termed as the "gluteal sling" was suggested to play a role in sciatic nerve palsies during this operation. "Gluteal sling" is formed by the attachment of the deep fibers of the inferior part of the gluteus maximus on the gluteal tuberosity of the femur and the lateral intermuscular septum. It is suggested to be released to avoid such compressive injuries. The purpose of this study is to demonstrate how much of the gluteal sling should be released to decrease the tension on sciatic nerve during posterior hip arthroplasties. We also aimed to study the anatomical structures at risk during releasing procedure. MATERIALS AND METHODS: The gluteal sling was examined in 17 sides of 9 adult cadavers. Its relation with the sciatic nerve, first perforating artery, the tip of greater trochanter and the ischial tuberosity were evaluated. RESULTS: The closest distance between the gluteal sling and the sciatic nerve was measured as 1.9 ± 0.6 cm. This point was corresponding to the distal 2/3 part of the gluteal sling. The distance of the proximal edge of the gluteal sling to the first perforating artery was 3.7 ± 0.9 cm, while its ascending branch was closer, being 1.8 ± 0.8 cm. CONCLUSIONS: Theoretically, it is enough to release the proximal 2/3 of the gluteal sling to avoid its compression on the sciatic nerve. However, further clinical studies would need to be undertaken to properly determine the effects of this procedure.

Molecular Protein and Expression Profile in the Primary Tumors of Clear Cell Renal Carcinoma and Metastases.

Metastasis involves the spread of cancer cells from the primary tumor to surrounding tissues and distant organs and is the primary cause of cancer morbidity and mortality. The aim of the study was the determination of change in molecular factors expression in primary kidney cancers (ccRCC) and metastatic sites. In total, 62 patients with RCC were enrolled in the study. The mRNA levels of molecular markers were studied by real-time PCR, and the content of the studied parameters was determined by Western blotting and ELISA. The features in the intracellular signal metabolites in the series of normal renal parenchyma, tumor tissue of localized, disseminated kidney cancer and metastatic tissue were studied. A decrease in some indicators in the tissue of the metastatic lesion was noted. Protein products of transcription factors HIF-1, CAIX, PTEN and activated AKT kinase, as well as expression of the VEGFR2 receptor and m-TOR protein kinase were revealed to be reduced in the metastatic sites. In addition, some indicators increased in metastasis: the protein levels of NF-κB p 50, NF-κB p 65, HIF-2, VEGF, VEGFR2, m-TOR and mRNA of HIF-1, CAIX, PTEN and PDK. There were indicators with multidirectional changes. HIF-1, CAIX, PTEN, VEGFR2 and m-TOR mRNA: VEGFR2, m-TOR, HIF-1, CAIX, PTEN and PDK had an opposite change in protein content and mRNA level. PTEN loss resulted in the downstream activation of AKT/mTOR signaling in secondary cancer lesions and determined the overall ccRCC patient's survival. The AKT/mTOR signaling cascade activation was found in the primary kidney tumors. The PTEN content and mRNA level were correlated with total AKT, GSK-3ß, the 70S 6 kinases and AKT expression.

[Targeting of the AKT/m-TOR Pathway: Biomarkers of Resistance to Cancer Therapy--
AKT/m-TOR Pathway and Resistance to Cancer Therapy].

Resistance to cancer therapy continues to be a major limitation for the successful treatment of cancer. There are many published studies on therapy resistance in breast and prostate cancers; however, there are currently no data on molecular markers associated with resistance. The conflicting data were reported regarding the AKT/m-TOR signaling pathway components as markers predicting resistance. The AKT/m-TOR signaling pathway is involved in the development of many human cancers; its activation is related to cell proliferation, angiogenesis, apoptosis, as well as to therapy resistance. Molecular alterations in the AKT/m-TOR signaling pathway provide a platform to identify universal markers associated with the development of resistance to cancer therapy.

Prenatal Diagnosis of Thoracoschisis and Review of Literature.

Thoracoschisis is a rare congenital malformation characterized by herniation of the abdominal content through a defect in the thorax. There are previously 12 reported cases, most discussing the postnatal findings and management. Here we describe a case of left thoracoschisis with associated upper limb abnormality which was diagnosed antenatally with the aid of 3D ultrasound.

Effect of Targeted Therapy With Pazopanib on Expression Levels of Transcription, Growth Factors and Components of AKT/m-TOR Signaling Pathway in Patients with Renal Cell Carcinoma

Background: The effect of the targeted therapy on cancer molecular markers remains currently unknown. The aim of the study was to investigate the expression and content of transcription, growth factors and components of the AKT/m-TOR signaling pathway in kidney cancer patients before and after targeted therapy with pazopanib. Methods: A total of 157 patients with renal cell carcinoma were enrolled into the study. The level of mRNA expression was investigated by real-time PCR, and the contents of transcription and growth factors, as well as the levels of AKT/m- TOR signaling pathway components were determined by ELISA and Western blotting. Results: Targeted therapy with pazopanib resulted in a 3.1-fold decrease in HIF-2α expression that was accompanied by a reduction in the levels of NF-κB p65 and p50, HIF-1α and CAIX. The levels of GSK-3ß and AKT mRNA were increased; however, the levels of corresponding proteins remained low. The targeted therapy with pazopanib did not influence the level of PTEN phosphatase. A 1.9-fold increase in the level of p70 S6 (S371) was observed after therapy. Conclusion: The efficacy of tyrosine kinase inhibitors is associated with the changes in the angiogenic factors. Molecular characteristics of cancer could determine markers of disease progression as well as potential targets for anticancer therapies

[Addition of antibiotics to bone cement for septic prosthesis exchange]. / Antibiotikazumischung zum Knochenzement beim septischen Prothesenwechsel.

OBJECTIVE: Decontamination of periprosthetic infections by local antibiotic therapy with maximum dosing. Commercially available bone cement is used as the carrier material. Bone cement containing antibiotics is an established procedure in orthopedics for the fixation of cemented implants in artificial joint replacement. It is part of the primary and revision endoprosthetic treatment together with systemic administration of antibiotics for routine local antibiotic prophylaxis. INDICATIONS: Bone cement containing antibiotics is used in the treatment of periprosthetic infections for two-stage septic exchange operations as a spacer in the prosthesis-free interval and for reimplantation in the second operation. In one-stage septic exchange operations it is an essential means of achieving a locally sufficient antibiotic concentration, which allows direct reimplantation following radical débridement of the infected tissue. The high antibiotic concentration prevents recolonization and formation of a biofilm on the surface of the new implant. CONTRAINDICATIONS: Periprosthetic infections with pathogens which are known to be resistant to the antibiotics used in the mixture. Unsuitability of patients for surgery under anesthesia. Known allergies of patients to substances mixed with or contained in the cement. OPERATION TECHNIQUE: Homogenization of the powdered antibiotic. Mixing of the antibiotic with the powder phase of the bone cement. Homogenization of the antibiotic-cement mixture by stirring. Addition of the liquid monomer and the usual mixing procedure. Application of the cement in the routine manner.

[Lesions of the distal radio-ulnar joint associated with isolated fractures of the radial shaft]. / Les lésions de l'articulation radio-cubitale distale associées aux fractures isolées de la diaphyse du radius.

The authors have performed a retrospective study of 49 Galeazzi fractures treated between 1990 and 1998. This lesion is considered rare because it is often misdiagnosed as an isolated fracture of the radius. The mean age of the patients was 31 years. There was a male predominance with a sex ratio of 4/1. Road traffic accidents were the main etiology (45%). Galeazzi fracture type III in Mansat's classification represented 53%, followed by type II (33%), type I (8%) and equivalents of Galeazzi fracture (6%). The treatment was surgical in all cases. The radial fracture was internally fixed with a plate. Reduction of the distal radio-ulnar instability, achieved by manipulation, was maintained with radio-ulnar pin fixation in 53% and with plaster cast immobilization 45%. The results, evaluated according to Mikic's criteria were excellent in 87%. The prognosis of Galeazzi's fracture depends mainly on the initial treatment of the lesions of the distal radio-ulnar joint, which require for their diagnosis a meticulous clinical evaluation and a good radiological analysis.

[Femoral neck fracture in osteopoikilosis]. / Fracture du col de fémur sur ostéopoecilie.

Osteopoikilosis was discovered in a 53-year-old patient who suffered a fracture of the right femoral neck. Plain X-rays demonstrated symmetrical bilateral stippling of variable size. No images were seen in the skull and spine. The fracture of the femoral neck was treated by total hip replacement. At surgery, the joint cartilage of the femoral head and the acetabulum had a normal aspect. Pathology examination of the femoral head demonstrated regular thick dense lamellae. Functional outcome at ten months was good (Postel-Merle-d'Aubigné score). Osteopoikilosis is an uncommon clinically latent condensing bone disease which can be revealed by bone fracture.

[Results of primary median nerve repair at the wrist: report of 24 cases]. / Résultats de la réparation primaire des plaies du nerf médian au niveau du poignet: à propos de 24 cas.

INTRODUCTION: Nerve injuries of the upper limb can cause serious damage: primary repair has improved the results but the prognosis for recovery remains uncertain. We present the results of primary repair of 24 median nerve injuries at the level of the wrist. MATERIALS AND METHODS: Between 1990-1998, we repaired 57 median nerve injuries at the wrist. Only 24 patients were included in this retrospective study. The average age of the patients was 25 years (range: 18-60 years). Seventeen patients were men and seven were women. All the patients were operated within 12 h after the accident. In all the cases, epiperineural suture was performed followed by immobilisation in a cast for 3 weeks. No specific rehabilitation programme was employed. RESULTS: At review with a mean follow-up of 3 years, 46% of the patients obtained good or very good results according to Chanson's scoring system. The sensory recovery was between S4-S2 with the Weber test in 75% of patients. Fifty-eight percent of patients recovered a motor function between M3-M2. DISCUSSION: In most papers, very good and good results averaged 60%. The results in our series did not achieve this level. We believe that this is due to two factors: firstly, the age distribution of our patients and secondly the lack of a specific program of sensory rehabilitation.

One-stage exchange: it all began here.

Based on the first implementation of mixing antibiotics into bone cement in the 1970s, the Endo-Klinik has used one stage exchange for prosthetic joint infection (PJI) in over 85% of cases. Looking carefully at current literature and guidelines for PJI treatment, there is no clear evidence that a two stage procedure has a higher success rate than a one-stage approach. A cemented one-stage exchange potentially offers certain advantages, mainly based on the need for only one operative procedure, reduced antibiotics and hospitalisation time. In order to fulfill a one-stage approach, there are obligatory pre-, peri- and post-operative details that need to be meticulously respected, and are described in detail. Essential pre-operative diagnostic testing is based on the joint aspiration with an exact identification of any bacteria. The presence of a positive bacterial culture and respective antibiogram are essential, to specify the antibiotics to be loaded to the bone cement, which allows a high local antibiotic elution directly at the surgical side. A specific antibiotic treatment plan is generated by a microbiologist. The surgical success relies on the complete removal of all pre-existing hardware, including cement and restrictors and an aggressive and complete debridement of any infected soft tissues and bone material. Post-operative systemic antibiotic administration is usually completed after only ten to 14 days.

Dislocation after total hip arthroplasty.

Dislocation remains one of the most common complications after total hip arthroplasty, regardless of the surgical approach. While multiple reasons as laxity, implant position, improper implant choice, and impingement etc. might be leading factors for dislocation, an exact identification of the exact reason is of major importance, to plan for a proper surgical or nonsurgical correction. This article describes in detail the definition, etiology, reduction, and possible treatment options for dislocation after primary and revision total hip arthroplasty that are currently used at the Endo Klinik in Hamburg. It furthermore includes a distinct overview of possible surgical treatment options, based on the main pathology leading to dislocation.

Targeting of the AKT/m-TOR Pathway: Biomarkers of Resistance to Cancer Therapy-- AKT/m-TOR Pathway and Resistance to Cancer Therapy / 中国肺癌杂志

Resistance to cancer therapy continues to be a major limitation for the successful treatment of cancer. There are many published studies on therapy resistance in breast and prostate cancers; however, there are currently no data on molecular markers associated with resistance. The conflicting data were reported regarding the AKT/m-TOR signaling pathway components as markers predicting resistance. The AKT/m-TOR signaling pathway is involved in the development of many human cancers; its activation is related to cell proliferation, angiogenesis, apoptosis, as well as to therapy resistance. Molecular alterations in the AKT/m-TOR signaling pathway provide a platform to identify universal markers associated with the development of resistance to cancer therapy.

Review of the ecology of malaria vectors in the WHO Eastern Mediterranean Region.

On the basis of published records and unpublished reports to WHO, the author reviews the information available on the ecology of 15 anopheline malaria vectors occurring in areas of the WHO Eastern Mediterranean Region where attack measures are being applied. The information, which is still incomplete, relates chiefly to the period since 1956, the year when the malaria eradication programme in the Region was launched. An attempt is made to evaluate the control measures undertaken so far, and to provide data on the sensitivity to insecticides, behaviour, and mortality of vector populations.

Vector control operations in the African context.

In order to define the scope of vector control as a component of malaria control in the WHO African Region, examples of recent experiences with different vector control methods in this region are reviewed. Residual house spraying applied alone or in combination with mass drug administration has failed to interrupt malaria transmission in savanna areas for several technical and administrative reasons. Nevertheless, there is evidence that residual house spraying has led to an improvement in general health. However, the existence of DDT and dieldrin/HCH and lately malathion resistance in the Sudan in Anopheles gambiae s.l. would militate against the use of residual house spraying as a main tool for long-term malaria control. It should therefore be used only to reduce malaria prevalence to an acceptable level until integrated control methods can be developed and become operational.Experience with larval control, space spraying, and biological control of vectors is also reviewed, and the value of self-help methods of reducing man-vector contact under African conditions is examined. All these methods need to be more thoroughly assessed. Several proposals are made for applied field research.

The practical implications of resistance of malaria vectors to insecticides.

Insecticide resistance is an inherent characteristic dependent on relatively simple genetic mechanisms. This seems to be especially true of dieldrin resistance in anopheline mosquitos, though less obvious in DDT resistance among these species; little is known as yet about the inheritance of organophosphate and carbamate resistance as it occurs in Anopheles albimanus. The speed of selection of resistance depends on the original frequency of the gene or genes involved, the nature of the resistance imparted, and the selection pressure of the insecticide. This in turn depends on the inherent toxicity of the chemical, the efficiency with which it is applied, the proportion of the mosquito population coming under its influence, and the behaviour of the mosquito. In the past, too much reliance has been placed on the determination of the LD(50) in assessing the presence or absence of insecticide resistance. Quite high incidences of resistant individuals can result in such small changes in the LD(50) that resistance may be overlooked. The use of single discriminating dosages is advocated, based on concentrations of insecticides that normally kill all susceptible individuals. The authors discuss such dosages in respect of dieldrin and DDT, and put forward newly-established tentative discriminating dosages for organophosphorus and carbamate insecticides, which await field confirmation.From a practical standpoint, an insecticide should not be abandoned or replaced by another as soon as resistance is confirmed. This may not be necessary where the degree of resistance is not high and the vector is not highly efficient. Certain procedures are proposed in order to assess the epidemiological and entomological implications of resistance before the insecticide concerned is abandoned.