Intercostal nerve cryoablation versus thoracic epidural analgesia for minimal invasive Nuss repair of pectus excavatum: a protocol for a randomised clinical trial (ICE trial)

INTRODUCTION

Epidural analgesia is currently considered the gold standard in postoperative pain management for the minimally invasive Nuss procedure for pectus excavatum. Alternative analgesic strategies (eg, patient-controlled analgesia and paravertebral nerve block) fail in accomplishing adequate prolonged pain management. Furthermore, the continuous use of opioids, often prescribed in addition to all pain management strategies, comes with side effects. Intercostal nerve cryoablation seems a promising novel technique. Hence, the primary objective of this study is to determine the impact of intercostal nerve cryoablation on postoperative length of hospital stay compared with standard pain management of young pectus excavatum patients treated with the minimally invasive Nuss procedure.

METHODS AND ANALYSIS

This study protocol is designed for a single centre, prospective, unblinded, randomised clinical trial. Intercostal nerve cryoablation will be compared with thoracic epidural analgesia in 50 young pectus excavatum patients (ie, 12-24 years of age) treated with the minimally invasive Nuss procedure. Block randomisation, including stratification based on age (12-16 years and 17-24 years) and sex, with an allocation ratio of 1:1 will be performed.Postoperative length of hospital stay will be recorded as the primary outcome. Secondary outcomes include (1) pain intensity, (2) operative time, (3) opioid usage, (4) complications, including neuropathic pain, (5) creatine kinase activity, (6) intensive care unit admissions, (7) readmissions, (8) postoperative mobility, (9) health-related quality of life, (10) days to return to work/school, (11) number of postoperative outpatient visits and (12) hospital costs.

ETHICS AND DISSEMINATION

This protocol has been approved by the local Medical Ethics Review Committee, METC Zuyderland and Zuyd University of Applied Sciences. Participation in this study will be voluntary and informed consent will be obtained. Regardless of the outcome, the results will be disseminated through a peer-reviewed international medical journal.

TRIAL REGISTRATION NUMBER

NCT05731973.

Pectus excavatum and carinatum: a narrative review of epidemiology, etiopathogenesis, clinical features, and classification

Background and Objective

A wide variety of congenital chest wall deformities that manifest in infants, children and adolescents exists, among which are pectus excavatum and pectus carinatum. Numerous studies have been conducted over the years aiming to better understand these deformities. This report provides a brief overview of what is currently known about the epidemiology, etiopathogenesis, clinical presentation, and classification of these deformities, and highlights the gaps in knowledge.

Methods

A search was conducted for all the above-described domains in the PubMed and Embase databases.

Key Content and Findings

A total of 147 articles were included in this narrative review. Estimation of the true incidence and prevalence of pectus excavatum and carinatum is challenging due to lacking consensus on a definition of both deformities. Nowadays, several theories for the development of pectus excavatum and carinatum have been suggested which focus on intrinsic or extrinsic pathogenic factors, with the leading hypothesis focusing on overgrowth or growth disturbance of costal cartilages. Furthermore, genetic predisposition to the deformities is likely to exist. Pectus excavatum is frequently associated with cardiopulmonary symptoms, while pectus carinatum patients mostly present with cosmetic complaints. Both deformities are classified based on the shape or severity of the deformity. However, each classification system has its limitations.

Conclusions

Substantial progress has been made in the past few decades in understanding the development and symptomatology of pectus excavatum and carinatum. Current hypotheses on the etiology of the deformities should be confirmed by biomedical and genetic studies. For clinical purposes, the establishment of a clear definition and classification system for both deformities based on objective morphologic features is eagerly anticipated.

Advancements in preoperative imaging of pectus excavatum: a comprehensive review

Pectus excavatum, the most common pectus deformity, varies in severity and has been associated with cardiopulmonary impairment and psychological distress. Since its initial documentation, a multitude of imaging techniques for preoperative evaluation (i.e., diagnosis, severity classification, functional assessment, and surgical planning) have been reported. Conventional imaging techniques encompass computed tomography (CT), chest radiography, magnetic resonance imaging (MRI), echocardiography and medical photography, while three dimensional (3D) optical surface imaging is a promising emerging technique in the preoperative assessment of pectus excavatum. This narrative review explores the current insights and advancements of these imaging modalities. CT imaging allows for the calculation of pectus indices and evaluation of cardiac compression and displacement. Recent developments focus on automated calculations, minimizing radiation exposure and improving surgical planning. Chest radiography offers a radiation-reducing alternative for pectus index measurement, but is unsuitable for disproportionally asymmetric chest deformations. MRI is a radiation-free imaging method, and allows for the calculation of pectus indices as well as the assessment of cardiac function. Real-time MRI provides dynamic insights, while exercise MRI shows promise for comprehensive evaluation of cardiac function but requires additional developments. Using echocardiography, structural cardiac changes can be identified, but its use in evaluating cardiac function in pectus excavatum patients is limited. Medical photography combined with caliper measurements complements other imaging methods for qualitative and quantitative documentation of pectus excavatum. Emerging as an innovative technique, 3D optical surface imaging offers a rapid, radiation-free assessment of the deformity which correlates with conventional pectus indices. Potential applications include quantifying other morphological features and predicting cardiac compression. However, standardization and validation are needed for its widespread use. This review provides an overview of preoperative imaging of pectus excavatum, highlighting the current developments in conventional methods and the potential of the emerging 3D optical surface imaging technique. These advancements hold promise for the future of the assessment and surgical planning of pectus excavatum.

Pain management after pneumothorax surgery: intercostal nerve block or thoracic epidural analgesia

OBJECTIVES

In patients undergoing video-assisted thoracoscopic surgery for pneumothorax, the benefits and risks of single-shot intercostal nerve block as loco-regional analgesia are not well known. We retrospectively compared the effectiveness of intercostal nerve blocks as a viable alternative to thoracic epidural analgesia (TEA) regarding pain control and enhanced recovery.

METHODS

A retrospective multicentre analysis with single-centre propensity score matching was performed in patients undergoing video-assisted thoracoscopic surgery for pneumothorax receiving either TEA or intercostal nerve block. The primary outcome was a proportion of pain scores ≥4 (scale 0-10) until postoperative day (POD) 3. Secondary outcomes included variation in pain over time, additional opioid use, length of stay, mobility, complications and recurrence rate.

RESULTS

In 218 patients, TEA was compared to intercostal nerve block and showed no difference in the proportion of pain scores ≥4 {14.3% [interquartile range (IQR) 0.0-33.3] vs 11.1% (IQR 0.0-27.3) respectively, P = 0.24}, more frequently needed additional opioids on the day of surgery (18% vs 48%) and first POD (20% vs 42%), had a shorter length of stay (4.0 days [IQR 3.0-7.0] vs 3.0 days [IQR 2.8-4.0]) and were significantly more mobile until POD 3, while having similar recurrences. Intercostal nerve block had higher pain scores early in the course whereas TEA had higher late (rebound) pain scores.

CONCLUSIONS

In a multimodal analgesic setting with additional opioids, intercostal nerve block shows comparable moments of unacceptable pain from POD 0-3 compared to TEA and is linked to improved mobility. Results require randomized confirmation.

Treating Saddlebag Deformity after Massive Weight Loss: Vertical versus Lower Body Lift

SUMMARY

The saddlebag deformity remains a persistent and difficult-to-treat problem after body-contouring surgery. A new way to handle the saddlebag deformity is with the vertical lower body lift (VLBL). This retrospective cohort study evaluated the overall reconstruction outcome of the VLBL in 16 patients (32 saddlebags) and compared it to standard lower body lift (LBL). The BODY-Q and the Pittsburgh Rating Scale (PRS)-Saddlebag Scale were used in the evaluation process. Surgical outcomes regarding the saddlebag deformity were in favor of the VLBL technique in patients with marked saddlebag deformity. A 1.16 decrease in mean PRS saddlebag score (relative change of 61.7%) was observed for the VLBL group versus a mean decrease of 0.29 (relative change of 21.6%) in the LBL group. BODY-Q end point and change in scores did not differ between the VLBL and LBL groups at 3-month follow-up, but at 1-year follow-up, they were in favor of the VLBL group in the body appraisal domain. Patients were highly satisfied with the contour and appearance of their lateral thigh, despite the extra scarring caused by this novel technique. Therefore, the authors advise clinicians to consider performing a VLBL instead of the standard LBL in patients with notable saddlebag deformities after massive weight loss.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Modification of the Abramson procedure for minimally invasive repair of pectus carinatum: introduction of a pectus carinatum compression system

Pectus carinatum is characterized by a protruding sternum. This deformity can be surgically corrected through the minimally invasive Abramson technique. In this procedure, a presternal metal correctional bar, secured to rib-attached stabilizers, is implanted to redress the sternum to a neutral position. To anticipate the intended position of the sternum, manual compression is applied over the sternal deformity. We describe a modified version of the Abramson procedure, encompassing a table-mounted PectusAssist™ System which generates a constant mechanical compression over the protruding sternum. The PectusAssist™ System, most importantly, eliminates the necessity of manually applying repetitive pressure on the deformity, and therefore maintains a more stable sternal position. This will ensure accuracy of the template used to bend the bar into its desired configuration. The modification we propose also simplifies presternal tunnel creation as the two bilateral retromuscular tunnels, that need to be connected presternally, are potentially better aligned due to a more stable and reduced position of the sternum. The PectusAssist™ System makes the procedure less labor intensive and reduces variability without interfering with the safety of the procedure. Therefore, we advise standard use of the PectusAssist™ System during minimally invasive repair of pectus carinatum by the Abramson procedure.

Pectus Excavatum: Consensus and Controversies in Clinical Practice

BACKGROUND

Pectus excavatum is the most common congenital anterior chest wall deformity. Currently, a wide variety of diagnostic protocols and criteria for corrective surgery are being used. Their use is predominantly based on local preferences and experience. To date, no guideline is available, introducing heterogeneity of care as observed in current daily practice. The aim of this study was to evaluate consensus and controversies regarding the diagnostic protocol, indications for surgical correction, and postoperative evaluation of pectus excavatum.

METHODS

The study consisted of 3 consecutive survey rounds evaluating agreement on different statements regarding pectus excavatum care. Consensus was achieved if at least 70% of participants provided a concurring opinion.

RESULTS

All 3 rounds were completed by 57 participants (18% response rate). Consensus was achieved on 18 of 62 statements (29%). Regarding the diagnostic protocol, participants agreed to routinely include conventional photography. In the presence of cardiac impairment, electrocardiography and echocardiography were indicated. Upon suspicion of pulmonary impairment, spirometry was recommended. In addition, consensus was reached on the indications for corrective surgery, including symptomatic pectus excavatum and progression. Participants moreover agreed that a plain chest radiograph must be acquired directly after surgery, whereas conventional photography and physical examination should both be part of routine postoperative follow-up.

CONCLUSIONS

Through a multiround survey, international consensus was formed on multiple topics to aid standardization of pectus excavatum care.

Nuss bar removal without straightening is a safe technique: a single center experience

Background

A Nuss bar often placed to correct pectus excavatum is usually removed after a period of 2 to 3 years. Bar removal can result in potentially life-threatening complications. To minimize this risk, a recent systematic review recommends in-situ straightening of the bar before removal. Alternatively, the bar can be removed without straightening by extraction along the thoracic curvature. This study reports our single-center experience with this latter technique for bar removal, with focus on perioperative complications.

Methods

A single-center retrospective observational cohort study was conducted. Consecutive patients undergoing Nuss bar removal between 2011 and 2020 were eligible for inclusion. The primary outcome was the incidence of perioperative complications. Secondary outcomes included duration of operation, blood loss, and length of postoperative hospital stay.

Results

A total of 331 patients were included. Of these, 288 (87%) were male with a median age of 20 years [interquartile range (IQR), 19–26 years]. Perioperative complications occurred in a total of 4 patients (1%) following Nuss bar removal. Two patients (0.6%) experienced major complications (deep incisional surgical site infection and hemothorax respectively); there was no mortality. The median duration of surgery was 30 minutes (IQR, 20–40 minutes). Patients were discharged after a median postoperative stay of 1 day (IQR, 1–1 day).

Conclusions

Nuss bar removal without prior in-situ bar straightening appears to be a safe and effective technique. It is associated with a low complication rate of 1%.

Translation, cultural adaptation and linguistic validation of the pectus excavatum evaluation questionnaire

Background

Pectus excavatum often imposes significant burden on the patients’ quality of life. However, despite the known biopsychosocial effects, the deformity remains underappreciated. Patient reported outcome measures can be used to measure and appreciate results from a patient’s perspective. The pectus excavatum evaluation questionnaire (PEEQ) is the most employed disease specific instrument to measure patient-reported outcome measures (PROMs). A translation and linguistic validation of this questionnaire is presented for its use in the Dutch pediatric pectus excavatum population. By providing an insight in our translation process, we want to encourage other researchers to perform translations to other languages to make the questionnaire available to clinicians and researchers worldwide.

Methods

The 22-item PEEQ was translated and adapted according to the leading guidelines for the translation of patient reported outcome measures. Conceptual equivalence and cultural adaptation were emphasized.

Results

One forward translation was produced through reconciliation of two forward translations. Back translation resulted in 15 identical items, as well as 6 literal, and 1 conceptual discrepancy. The latter was expected as during the forward translation a more culturally appropriate translation was chosen. Ten patients were involved during the cognitive debriefing process, following which one item was revised and the final Dutch version was established.

Conclusions

We provide a culturally appropriate and linguistically validated Dutch version of the PEEQ.

Predicting Aesthetic Outcome of the Nuss Procedure in Patients with Pectus Excavatum

Patients suffering from pectus excavatum often experience psychosocial distress due to perceived anomalies in their physical appearance. The ability to visually inform patients about their expected aesthetic outcome after surgical correction is still lacking. This study aims to develop an automatic, patient-specific model to predict aesthetic outcome after the Nuss procedure. Patients prospectively received preoperative and postoperative 3-dimensional optical surface scanning of their chest during the Nuss procedure. A prediction model was composed based on nonlinear least squares data-fitting, regression methods and a 2-dimensional Gaussian function with adjustable amplitude, variance, rotation, skewness, and kurtosis components. Morphological features of pectus excavatum were extracted from preoperative images using a previously developed surface analysis tool to generate a patient-specific model. Prediction accuracy was evaluated through cross-validation, utilizing the mean root squared deviation and maximum positive and negative deviations as performance measures. The prediction model was evaluated on 30 (90% male) prospectively imaged patients. The model achieved an average root mean squared deviation of 6.3 ± 2.0 mm, with average maximum positive and negative deviations of 12.7 ± 6.1 and -10.2 ± 5.7 mm, respectively, between the predicted and actual postoperative aesthetic result. Our developed 2-dimensional Gaussian model based on 3-dimensional optical surface images is a clinically promising tool to predict postsurgical aesthetic outcome in patients with pectus excavatum. Prediction of the aesthetic outcome after the Nuss procedure potentially improves information provision and expectation management among patients. Further research should assess whether increasing the sample size may reduce deviations and improve performance.

Risk of Pneumothorax Requiring Pleural Drainage after Drainless VATS Pulmonary Wedge Resection: A Systematic Review and Meta-Analysis

OBJECTIVE

Omitting pleural drainage after video-assisted thoracic surgery (VATS) for pulmonary wedge resections has been shown to be a safe approach to enhance recovery. However, major concerns remain regarding the risk of postoperative pneumothoraces requiring surgical interventions. Therefore, our objective was to provide conclusive evidence whether chest tube omission after VATS wedge resection is safe and does not increase the risk of pneumothoraces requiring pleural drainage.

METHODS

Five scientific databases were searched. Studies comparing patients with (CT group) and without chest tube drainage (NCT group) after VATS wedge resection were evaluated. Outcomes included radiographically diagnosed pneumothoraces and pneumothoraces requiring pleural drainage, postoperative complications, hospitalization, and pain scores.

RESULTS

Overall, 9 studies (3 randomized controlled trials) were included (N = 928). Meta-analysis showed significantly more radiographically diagnosed pneumothoraces in the NCT group (risk ratio [RR] = 2.58, 95% confidence interval [CI]: 1.56 to 4.29, P < 0.001; I² = 0%). However, no significant differences were found in postoperative pneumothoraces requiring pleural drainage (RR = 1.72, 95% CI: 0.63 to 4.74, P = 0.29; I² = 0%) or complications (RR = 0.77, 95% CI: 0.39 to 1.52, P = 0.46; I² = 0%). Furthermore, the NCT group showed significantly shorter hospitalization (mean difference = -1.26, 95% CI: -1.56 to -0.95, P < 0.001) with high heterogeneity (I² = 58%, P = 0.02), and lower pain scores on postoperative day 1 (standard mean difference [SMD] = -0.98, 95% CI: -1.71 to -0.25, P = 0.009; I² = 92%) and postoperative day 2 (SMD = -1.28, 95% CI: -2.55 to -0.01, P = 0.05; I² = 96%) compared with the CT group.

CONCLUSIONS

VATS wedge resection without routine chest tube placement is suggested as a safe and less invasive approach in selected patients that does not increase the risk of a pneumothorax requiring pleural drainage.

Thoracic surgery in the Netherlands

The purpose of this article, part of the Thoracic Surgery Worldwide series, is to provide a descriptive review of how thoracic surgery is organized in the Netherlands. General information is provided on the Dutch healthcare system, as well as on how Dutch thoracic surgeons are organized and trained. Additionally, this study provides information on our national quality surveillance system, an overview of the most common thoracic surgeries performed in our country, and details of academic research conducted by Dutch medical specialists. Furthermore, we discuss current challenges and future perspectives. In the Netherlands general thoracic surgical procedures are performed by approximately 110 general thoracic surgeons and 25 of the 135 cardiothoracic surgeons. Dutch thoracic surgeons provide minimally invasive lung surgery, chest wall surgery, thymic and mediastinal surgery, and surgical diagnosis and treatment of pleural disorders. Some recently published data on hospital mortality and postoperative adverse events of thoracic surgeries are reported. Furthermore, the structure of the thoracic surgical education and training program is discussed, highlighting the particular structure of two educational programs for thoracic surgery via a general thoracic and cardiothoracic surgery program. To assure high-quality surgical care, the Netherlands has a well-structured national quality surveillance system, involving frequent site visits and mandatory participation in the national lung cancer surgery registry for all hospitals. In terms of academic research, the Netherlands ranked 14th worldwide on number of clinical trials conducted across all medical disciplines in 2021. Furthermore, several thoracic-related (inter-)national multicenter randomized trials which are currently performed and initiated by Dutch hospital research groups are mentioned. Finally, future challenges and advances of Dutch thoracic surgery are addressed, including the implementation of lung cancer screening, imbalanced labor market, and centralization of care.

Negative pressure wound therapy for massive subcutaneous emphysema: a systematic review and case series

Background

Massive subcutaneous emphysema can cause considerable morbidity with respiratory distress. To resolve this emphysema in short-term, negative pressure wound therapy could be applied as added treatment modality. However, its use is sparsely reported, and a variety of techniques are being described. This study provides a systematic review of the available literature on the effectiveness of negative pressure wound therapy as treatment for massive subcutaneous emphysema. In addition, our institutional experience is reported through a case-series.

Methods

The PubMed, Embase and Cochrane Library were systematically searched for publications on the use of negative pressure wound therapy for subcutaneous emphysema following thoracic surgery, trauma or spontaneous pneumothorax. Moreover, patients treated at our institution between 2019 and 2021 were retrospectively identified and analyzed.

Results

The systematic review provided 10 articles presenting 23 cases. Studies demonstrated considerable heterogeneity regarding the location of incision, creation of prepectoral pocket, and surgical safety margin. Also closed incision negative pressure wound therapy and PICO^© device were discussed. Despite the apparent heterogeneity, all techniques provided favorable outcomes. No complications, reinterventions or recurrences were documented. Furthermore, retrospective data of 11 patients treated at our clinic demonstrated an immediate response to negative pressure wound therapy and a full remission of the subcutaneous emphysema at the end of negative pressure wound therapy. No recurrence requiring intervention or complications were observed.

Conclusions

The findings of this study suggest that negative pressure wound therapy, despite the varying techniques employed, is associated with an immediate regression of subcutaneous emphysema and full remission at the end of therapy. Given the relatively low sample size, no technique of choice could be identified. However, in general, negative pressure wound therapy appears to provide fast regression of subcutaneous emphysema and release of symptoms in all cases.

Coupling Charge and Topological Reconstructions at Polar Oxide Interfaces

In oxide heterostructures, different materials are integrated into a single artificial crystal, resulting in a breaking of inversion symmetry across the heterointerfaces. A notable example is the interface between polar and nonpolar materials, where valence discontinuities lead to otherwise inaccessible charge and spin states. This approach paved the way for the discovery of numerous unconventional properties absent in the bulk constituents. However, control of the geometric structure of the electronic wave functions in correlated oxides remains an open challenge. Here, we create heterostructures consisting of ultrathin SrRuO_{3}, an itinerant ferromagnet hosting momentum-space sources of Berry curvature, and LaAlO_{3}, a polar wide-band-gap insulator. Transmission electron microscopy reveals an atomically sharp LaO/RuO_{2}/SrO interface configuration, leading to excess charge being pinned near the LaAlO_{3}/SrRuO_{3} interface. We demonstrate through magneto-optical characterization, theoretical calculations and transport measurements that the real-space charge reconstruction drives a reorganization of the topological charges in the band structure, thereby modifying the momentum-space Berry curvature in SrRuO_{3}. Our results illustrate how the topological and magnetic features of oxides can be manipulated by engineering charge discontinuities at oxide interfaces.

Suture Anchor Repair of Pectoralis Major Muscle Dehiscence After Modified Ravitch

During repair of pectus excavatum by the modified Ravitch procedure, the major pectoral muscles are detached from their sternal insertion to obtain adequate surgical exposure. Following repair, the muscles are approximated in midline and reinserted through scarring. Dehiscence of the major pectoral muscles after the modified Ravitch procedure is a rare phenomenon, not previously reported in literature. We report on 2 cases and describe an effective treatment method using sternal suture anchors with good long-term results.

[A man with a bloated abdomen]

A 61-year-old intellectually disabled, otherwise healthy man presented himself at the emergency department with a painful, abdominal distension and constipation. Abdominal computed tomography showed an impressive, acute urinary retention with a volume of 8.5 liter, without signs of renal dysfunction. Drainage with a urinary catheter provided immediate relief of symptoms.

Psychosocial care in dementia in European higher education: Evidence from the SiDECar ("Skills in DEmentia Care") project

In dementia care, psychosocial interventions can increase people's quality of life with dementia and their caregivers. Despite their effectiveness, their translation into practice lacks the desirable systematicity. Systematic educational programs on psychosocial interventions in dementia will improve this translation, as it prepares professionals to face the complexity of dementia care. This study aimed to systematically map out the extent to which higher education programs in Europe include teaching activities about psychosocial care of dementia. We collected quantitative and qualitative data about 303 higher education teaching activities on psychosocial care in dementia across Europe. The analysis revealed that the number of teaching activities focusing on psychosocial care in dementia was relative. Although the results reflected UNESCO indications, the teaching activities on psychosocial care in dementia appeared less systematized than optimal. As world health agencies recommend, international higher education systems should consider more psychosocial care topics because they can prepare professionals to respond timely and effectively to dementia patients and caregivers' needs.

Chronic Abdominal Pain After Previous Bariatric Surgery: Consider the Abdominal Wall

BACKGROUND

Up to 30% of patients who undergo bariatric surgery experience recurrent abdominal pain within 3 years after the operation. Although some causes for persisting discomfort are well known, a small portion of patients may suffer from an abdominal wall pain associated with Anterior Cutaneous Nerve Entrapment Syndrome (ACNES). Aim of the present study is to discuss incidence, clinical presentation, and treatment outcome in patients with ACNES after bariatric surgery.

METHODS

This retrospective observational cohort study analyzed electronically stored data of patients with ACNES having a history of bariatric surgery. All were treated for ACNES between 2011 and 2017 in a Dutch center of excellence for abdominal wall and groin pain. Success after treatment was defined as a minimal 50% drop in pain level using a Numeric Rating Scale.

RESULTS

A total of 49 patients (female n = 44, median age 45 (25-63) years) were identified. Four (8%) experienced long-term pain relief after just one abdominal wall infiltration with lidocaine. Ten additional patients reported success after 2-5 injections. A total of 35 unresponsive patients chose to undergo a neurectomy that was successful in 27. Therefore, this step-up approach conferred an 84% success rate. Occurrence of ACNES after bariatric surgery was estimated at 1 in 100 patients.

CONCLUSION

ACNES should be considered in the differential diagnosis of ongoing pain following previous bariatric surgery. A treatment regimen including abdominal wall infiltrations using an anesthetic agent or a neurectomy is successful in a vast majority of these patients.

Acute idiopathic thenar and hypothenar compartment syndrome

Compartment syndrome (CS) is a condition associated with intra-compartment pressures exceeding the perfusion pressure of the tissue. This condition can occur in any body compartment surrounded by fascia, however CS of some regions like the thenar and hypothenar is extremely rare. Acute CS is often caused by major trauma and idiopathic acute CS is sparsely reported in literature. We present a case report of a 39-year-old male, with a medical history of rheumatoid arthritis (RA) for which he uses adalimumab and low-dose prednisone, with idiopathic acute CS of thenar and hypothenar compartments. Unexplained tremendous pain, paresthesia and swelling of his hand were the only symptoms observed. Due to direct recognition of the condition there was no delay in time to treatment. Treatment involved a fasciotomy of the thenar and hypothenar compartments as well as a release of the carpal tunnel. This direct surgical approach resulted in retaining excellent function and appearance of the hand. We hypothesized several causes for the etiology of the condition (e.g. rhabdomyolysis, rheumatologic disease-related condition, other systemic diseases, trauma, infection), but all could be rejected based on laboratory or clinical findings. Remarkable is that the patient experienced a comparable episode in his other hand two years earlier. Although the acute CS is of unknown origin in the presented case, the development of acute CS in both hands over time suggests a predisposing factor in idiopathic acute CS that is far from being elucidated.

Confirmation of High Cytokine Clearance by Hemofiltration with a Cellulose Triacetate Membrane with Large Pores: An in vivo Study

Objective

To confirm in vivo the hypothesis that hemofiltration with a large pore membrane can achieve significant cytokine clearance.

Method

We used a well-known animal model of endotoxinic shock (0.5 mg/kg of lipopolysaccharide from Escherichia Coli over a period of 30 mins). Six pigs were hemofiltrated for 3 hours with a large pore membrane (78 Å pore, 80 kDa cut off) (Sureflux FH 70, Nipro, Osaka, Japan). The ultrafiltration rate was 45 ml/kg/min. Samples were taken from arterial, venous line and in the ultrafiltrate at T120 and T240. We measured concentrations of interleukin 6, interleukin 10 and albumin.

Results

At T120 and T240, the IL-6 clearances were 22 ± 7 and 15 ± 3 ml/min, respectively. The IL-6 sieving coefficients were 0.97 and 0.7 at T120 and T240, respectively. At T120 and T240, the IL-10 clearances were 14 ± 4 and 10 ± 7 ml/min, respectively. The sieving coefficients were 0.63 and 0.45 at T120 and T240, respectively. The concentrations of IL-6 and IL-10 were the same at T0 and T240. At T60 and T240, the plasmatic albumin concentrations were 24 ± 4 g/L and 23 ± 4 g/L, respectively (p = 0.13).

Conclusions

In this animal model of endotoxinic shock, we confirm the high cytokine clearance observed when hemofiltration is applied to a large pore membrane. The loss of albumin seems negligible. The impact of such clearances on hemodynamic stability and survival remains to be proved.

A comparison between four techniques to measure cardiac output

Cardiac output is an important variable when monitoring hemodynamic status. In particular, changes in cardiac output represent the goal of several circulatory management therapies. Unfortunately, cardiac output is very difficult to estimate, either in experimental or clinical settings. The goal of this work is to compare four techniques to measure cardiac output: pressure-volume catheter, aortic flow probe, thermodilution, and the PiCCO monitor. These four techniques were simultaneously used during experiments of fluid and endotoxin administration on 7 pigs. Findings show that, first, each individual technique is precise, with a relative coefficient of repeatability lower than 7 %. Second, 1 cardiac output estimate provided by any technique relates poorly to the estimates from the other 3, even if there is only small bias between the techniques. Third, changes in cardiac output detected by one technique are only detected by the others in 62 to 100 % of cases. This study confirms the difficulty of obtaining a reliable clinical cardiac output measurement. Therefore, several measurements using different techniques should be performed, if possible, and all such should be treated with caution.

CHD7 mutations and CHARGE syndrome: the clinical implications of an expanding phenotype

BACKGROUND

CHARGE syndrome is a highly variable, multiple congenital anomaly syndrome, of which the complete phenotypic spectrum was only revealed after identification of the causative gene in 2004. CHARGE is an acronym for ocular coloboma, congenital heart defects, choanal atresia, retardation of growth and development, genital hypoplasia, and ear anomalies associated with deafness. This typical combination of clinical features is caused by autosomal dominant mutations in the CHD7 gene.

OBJECTIVE

To explore the emerging phenotypic spectrum of CHD7 mutations, with a special focus on the mild end of the spectrum.

METHODS

We evaluated the clinical characteristics in our own cohort of 280 CHD7 positive patients and in previously reported patients with CHD7 mutations and compared these with previously reported patients with CHARGE syndrome but an unknown CHD7 status. We then further explored the mild end of the phenotypic spectrum of CHD7 mutations.

RESULTS

We discuss that CHARGE syndrome is primarily a clinical diagnosis. In addition, we propose guidelines for CHD7 analysis and indicate when evaluation of the semicircular canals is helpful in the diagnostic process. Finally, we give updated recommendations for clinical surveillance of patients with a CHD7 mutation, based on our exploration of the phenotypic spectrum and on our experience in a multidisciplinary outpatient clinic for CHARGE syndrome.

CONCLUSION

CHARGE syndrome is an extremely variable clinical syndrome. CHD7 analysis can be helpful in the diagnostic process, but the phenotype cannot be predicted from the genotype.

Successful paediatric HIV treatment in rural primary care in Africa

OBJECTIVE

Clinical outcomes of HIV-infected children on antiretroviral treatment (ART) in a decentralised, nurse/counsellor-led programme.

DESIGN

Clinical cohort.

SETTING

KwaZulu-Natal, South Africa.

PATIENTS

HIV-infected children aged

MAIN OUTCOME MEASURES

Survival according to baseline characteristics including age, WHO clinical stage, haemoglobin and CD4%, was assessed in Kaplan-Meier analyses. Hazard ratios for mortality were estimated using Cox proportional hazards regression and changes in laboratory parameters and weight-for-age z scores after 6-12 months' treatment were calculated.

RESULTS

477 HIV-infected children began ART at a median age of 74 months (range 4-180), median CD4 count (CD4%) of 433 cells/mm(3) (17%) and median HIV viral load of log 4.2 copies/ml; 105 (22%) were on treatment for tuberculosis and 317 (76.6%) were WHO stage 3/4. There were significant increases after ART initiation in CD4% (17% vs 22%; p<0.001), haemoglobin (9.9 vs 11.7 g/l; p60 months (adjusted HR 3.2; 95% CI 1.2 to 9.1).

CONCLUSIONS

Good clinical outcomes in HIV-infected children on ART are possible in a rural, decentralised service. Few young children are on ART, highlighting the urgent need to identify HIV-exposed infants.

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MESH Headings

• Adolescent
• Anti-HIV Agents/therapeutic use
• Antiretroviral Therapy, Highly Active
• CD4 Lymphocyte Count
• Child
• Child, Preschool
• Epidemiologic Methods
• Female
• HIV Infections/drug therapy
• HIV Infections/immunology
• HIV Infections/virology
• HIV-1/isolation & purification
• Humans
• Infant
• Male
• Primary Health Care/organization & administration
• Program Evaluation
• Rural Health Services/organization & administration
• South Africa
• Treatment Outcome
• Viral Load

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Grants

• Wellcome Trust
• 050534 Wellcome Trust

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The structure and optical properties of ZnO nanocrystals embedded in SiO2 fabricated by radio-frequency sputtering

Zinc oxide (ZnO) nanocrystals (NCs) with high crystalline quality were prepared via radio-frequency magnetron sputtering as a SiO(2)/ZnO/SiO(2) trilayer on Si(100) and Al(2)O(3)(0001) substrates with an intermediate in situ annealing step. Transmission electron microscopy reveals a uniform dispersion of ZnO NCs in the amorphous SiO(2) matrix with typical sizes up to 16 nm with a larger fraction of smaller crystals. The size distribution analysis yields a mean grain size of 5 nm for small particles. Individual ZnO NCs show a well-defined hexagonal close packed wurtzite structure and lattice parameters close to those of bulk ZnO, confirming their high crystalline quality. Mapping of the Zn distribution by means of energy-filtered transmission electron microscopy reveals a strongly non-uniform distribution of Zn within the SiO(2) matrix, corroborating the chemical separation of ZnO NCs from surrounding SiO(2). Optical transmittance measurements confirm the findings of the electron microscopy analysis. The fabrication technique described opens up new possibilities in the preparation of ZnO NCs with high crystalline quality, including growth in monolithic optical cavities without intermediate ex situ fabrication steps.

Effect of vegetation type on throughfall deposition and seepage flux

This paper compares different vegetation types (coniferous and deciduous forest, grassed and pure heathland) in terms of input (throughfall deposition) and output (seepage flux) in a region with intermediate nitrogen load (+/-20kg Nha(-1)y(-1) via bulk precipitation) in comparable conditions in north Belgium. Coniferous forest (two plots Pinus sylvestris and two plots Pinus nigra) received significantly higher nitrogen and sulphur throughfall deposition than deciduous forest and heathland. Grassed and pure heathland had significantly highest throughfall quantities of Ca(2+) and Mg(2+), respectively. The observed differences in throughfall deposition between the different vegetation types were not univocally reflected in the ion seepage flux. Considerable seepage fluxes of NO(3)(-), SO(4)(2-), Ca(2+) and Al(III) were only found under the P. nigra plots. We discuss our hypothesis that the P. nigra forests already evolved to a situation of N saturation, while the other vegetation types did not.

[Coronary dissection and non-penetrating chest trauma]

The occurrence of an acute myocardial infarction after non-penetrating chest trauma is an extremely rare complication. We report a case of dissection of the left anterior descending artery in a 43 year old man after being punched in the chest. Using data from a literature search relish revealed 76 cases; we review the characteristics of the pathology and its incidence. We also characterize its etiology, anatomy and path physiology. We then consider the diagnostic and therapeutic implications.

[Idiopathic retroperitoneal fibrosis: unusual cause of abdominal pain. A case report]

Retroperitoneal fibrosis is an uncommon inflammatory disease which is characterized by the development of a fibrous process that surrounds the major vessels and organs located within the retroperitoneum. Isolated as an idiopathic expression or associated with several other diseases in its secondary form, retroperitoneal fibrosis remains relatively of rare occurrence and as a result, is devoid of either diagnostic or therapeutic definitive recommendations. We report the observation of one case admitted in the emergency room for abdominal pain induced by left hydronephrosis. Radiographic exploration with contrast-enhanced studies evidenced retroperitoneal fibrosis causing left ureteric obstruction. Therapeutic approach was based on corticosteroids and ureteral drainage which prevented recurrence while fibrosis was almost reversed six months later.

[The significance of elbow dysplasia (ED) for breeding in Bernese Mountain Dogs in Germany]

Results from the elbow dysplasia screening program in Bernese Mountain Dogs of Germany were analysed in respect to its relevance for genetic evaluation and breeding. In total 2677 gradings were used. The grading was performed radiographically according to the recommendations of the International Elbow Working Group (IEWG). 75.8% of the dogs were free from visible dysplastic signs, 10.8%, 6.8% and 5.5% were classified to be of Grade 1, 2 and 3, respectively. 1.1% were classified as a borderline case between ED-free and Grade 1. A slight reduction of ED could be observed over years. Males had a 3.1 higher rate of dysplasia than females. Treating ED as a numerical trait, coded proportional to the severity of clinical relevant signs, gave a heritability estimation of 0.188 and a maternal effect of 0.07. From different mating combinations it was found, that ED average was higher in the progeny if one mate was affected but there was no increase in the prevalence with increasing grade of ED in the affected mates. About 10% more affected dogs could be observed, if one mate is affected. Heritability for dichotomic coding the trait was found to be 0.20. From these results can be suggested, that the differentiation in various grades of ED to describe the clinical relevance for the specific dog is helpfull, however, from a breeders point of view, dogs with ED should be treated equally for genetic evaluation.

Fatigue as a predictor of sickness absence: results from the Maastricht cohort study on fatigue at work

OBJECTIVES

To investigate whether there is a relationship between fatigue and sickness absence. Two additional hypotheses were based on the theoretical distinction between involuntary, health related absence and voluntary, attitudinal absence. In the literature, the former term is usually used to describe long term sickness absence, the latter relates to short term sickness absence. In line with this, the first additional hypothesis was that higher fatigue would correspond with a higher risk of long term, primarily health related absence. The second additional hypothesis was that higher fatigue would correspond with a higher risk of short term, primarily motivational absence.

METHODS

A multidimensional fatigue measure, as well as potential sociodemographic and work related confounders were assessed in the baseline questionnaire of the Maastricht cohort study on fatigue at work. Sickness absence was objectively assessed on the basis of organisational absence records and measured over the six months immediately following the baseline questionnaire. In the first, general hypothesis the effect of fatigue on time-to-onset of first sickness absence spell during follow up was investigated. For this purpose, a survival analysis was performed. The effect of fatigue on long term sickness absence was tested by a logistic regression analysis. The effect of fatigue on short term sickness absence was investigated by performing a survival analysis with time-to-onset of first short absence spell as an outcome.

RESULTS

It was found that higher fatigue decreased the time-to-onset of the first sickness absence spell. Additional analyses showed that fatigue was related to long term as well as to short term sickness absence. The effect of fatigue on the first mentioned outcome was stronger than the effect on the latter outcome. Potential confounders only weakened the effect of fatigue on long term absence.

CONCLUSIONS

Fatigue was associated with short term but particularly with long term sickness absence. The relation between fatigue and future sickness absence holds when controlling for work related and sociodemographic confounders. Fatigue as measured with the Checklist Individual Strength can be used as a screening instrument to assess the likelihood of sickness absence in the short term.

The Demand-Control-Support model as a predictor of return to work

The present study investigated work-related determinants of return to work. Our hypothesis was based on the strain hypothesis of the Demand-Control-Support model, which postulates a relation between job demands, job control and support at work on the one hand, and the aetiology of health complaints on the other hand. High demands were hypothesized to obstruct return to work, whereas high control and high support were thought to have a positive effect on return to work. This hypothesis was tested in a population of employees who were sick-listed for 6-8 weeks. Return to work, as operationalized by the categories (i) not working; (ii) return to work with adjustments; and (iii) full return to work, was determined 4 months after the onset of the sick leave. The hypothesis was tested by logistic regression analyses. High job demands were the least predictive of full return to work. However, the likelihood of employees with high job demands returning to work with adjustments was higher than the likelihood of them not working. Therefore, job demands might also work as a pressure to return to work (compare this with Smulders and Nijhuis, 1999). Furthermore, high skill discretion in combination with high job demands predicted working with adjustments in comparison with not working. Finally, high supervisor support was the most predictive of return to work without adjustments, and the least predictive of not working.

Motor vehicle exhaust and chronic respiratory symptoms in children living near freeways

To examine whether motor vehicle exhaust from freeways has an effect on respiratory health of children, a cross-sectional study was conducted. Children attending schools situated less than 1000 m from major freeways in the Province of South Holland were asked to participate. The selected freeways carry between 80,000 and 150,000 vehicles per day. Separate counts for truck traffic indicated a range from 8000 to 17,500 trucks per day. At a total of 13 schools, 1498 children were asked to participate. From these children, 1068 usable questionnaires were obtained. Chronic respiratory symptoms reported in the questionnaire were analyzed with logistic regression. Distance from the freeway and (truck) traffic intensity were used as exposure variables. Cough, wheeze, runny nose, and doctor-diagnosed asthma were significantly more often reported for children living within 100 m from the freeway. Truck traffic intensity and the concentration of black smoke measured in schools were found to be significantly associated with chronic respiratory symptoms. These relationships were more pronounced in girls than in boys.