Inconclusive benefit of adjuvant 90Yttrium hydroxyapatite to radiosynovectomy for diffuse-type tenosynovial giant-cell tumour of the knee.

Aims: Intra-articular 90Yttrium (90Y) is an adjunct to surgical treatment by synovectomy for patients with diffuse-type tenosynovial giant-cell tumour (dtTGCT) of the knee, with variable success rates. Clinical information is, however, sparse and its value remains unclear. We investigated the long-term outcome of patients who underwent synovectomy with and without adjuvant treatment with 90Yttrium. Patients and Methods: All patients with dtTGCT of the knee who underwent synovectomy between 1991 and 2014 were included in the study. Group A patients underwent synovectomy and an intra-articular injection of 90Yttrium between six and eight weeks after surgery. Group B patients underwent surgery alone. Results: There were 34 patients in group A and 22 in group B. Recurrence of dtTGCT was identified by MRI, which was undertaken in patients with further symptoms. At a mean follow-up of 7.3 years (2.5 to 25.4), there was residual disease in 15 patients in group A and 11 in group B (p < 0.363). The mean Musculoskeletal Tumor Society (MSTS) score at final follow-up was 85% and 83%, respectively (p < 0.91). Conclusion: There were no significant differences in outcome between patients treated surgically for dtTGCT of the knee with or without an adjuvant intra-articular injection of 90Yttrium. We were unable to provide conclusive evidence of any benefits derived from the adjuvant treatment. Cite this article: Bone Joint J 2018;100-B:984-8.

The distal pouch in esophageal atresia -- to dissect or not to dissect, that is the question.

Long-gap esophageal atresia remains a difficult problem for the pediatric surgeon and reconstruction using the native esophagus is considered to be superior to any interposition procedure. Because of esophageal segmental blood supply and vascular vulnerability of the distal esophageal pouch in the short term and its motility disorder in the long term, surgeons are reluctant to perform extensive esophageal dissection. However, ascending and descending branches of esophageal vessels converge along the anterolateral and posterolateral aspects of the esophagus. This arrangement allows for dissection and mobilization of the distal pouch without necessarily causing vascular impairment. Extensive dissection of the distal pouch was advocated by Robert Gross over fifty years ago. More recently, circular myotomy of the distal pouch has been performed. However, manometric studies showed that prior to surgical repair, peristalsis of the upper and lower esophageal pouch was synchronized, while after surgery this coordination was clearly defective. Furthermore, in the adriamycin-induced rat model, inherent abnormalities in the course and branching pattern of the vagus nerves in the lower esophagus have been demonstrated. Significant abnormalities of the intramural nervous components involving both the excitatory and inhibitory nerves, and elevated levels of S100 and galanin in the lower esophageal pouch could explain an inborn motility disorder. The selective injury of minor vagal branches in experimental animals also alters esophageal peristalsis. In conclusion, given that the native esophagus is still considered the best alternative for reconstruction of esophageal atresia, when indicated, gentle but extensive dissection of the lower esophageal pouch seems to be preferable, keeping in mind the possibility of vascular compromise and the inevitability of motility disfunction.

Military trauma life support: a comprehensive training program for military physicians.

The Israel Defense Forces Medical Corps prepares Israeli physicians for their field duty as providers of prehospital trauma care under combat conditions. Many physicians have no previous experience with emergency medicine. Military trauma education has been improving continuously to meet this challenge. In 1990, the Advanced Trauma Life Support program was launched in Israel. In 1998, a task-oriented approach to military trauma. Military Trauma Life Support, was introduced. This course is integrated in the 3-month training period of medical officers. Its objectives are to provide a comprehensive curriculum in prehospital military trauma, to simulate realistic combat scenarios and injury patterns, and to add practical skills and prehospital experience. The practical section includes definitive airway management in hospital operating rooms, emergency procedures training on cadavers, and prehospital experience on civilian emergency medical services ambulances.

Mortality epidemiology in low-intensity warfare: Israel Defense Forces' experience.

PURPOSE: an analysis of the mortality epidemiology in low-intensity warfare. BASIC PROCEDURES: we retrospectively reviewed all cases of Israeli soldiers killed in small-scale warfare during 1996-1998, using field data, hospital charts and autopsy reports. Data on injury pattern, offending munitions and time of death were analyzed. MAIN FINDINGS: in the study period, 106 soldiers were killed. Penetrating trauma was the common injury mechanism (95%) most frequently due to claymore bombs and gunshot bullets. The percentage dying in the prehospital phase and in the first 30-min were 77 and 88%, respectively. The average injury severity score (ISS) was 42.5. Seriously injured body regions were thorax (38%), head (24%), abdomen and pelvis (13%) and neck (12%). CONCLUSIONS: there is no trimodal death distribution in military trauma. Most casualties of low-scale conflicts die very early after injury. Most fatal injuries involve the head and trunk regions. The distribution of injury depends on the type of assaulting munitions.

Preliminary experience with postmortem computed tomography in military penetrating trauma.

BACKGROUND: Postmortem examination serves as a tool for confirmation of clinical diagnosis, "quality" assurance, and education. In Israel, mostly because of religious reasons, most families withhold their permission to perform autopsies. To obtain objective information regarding the death of soldiers, the Israel Defense Forces Medical Corps started in September of 1997 to perform postmortem computed tomographic (PMCT) scans. The purpose of our study is to determine what information can be obtained from the PMCT scans. METHODS: In a period of 16 months, 27 soldiers were killed in low-intensity conflicts and PMCT was obtained in 22 cases. Medical data obtained from the field medical care providers were collected and compared with PMCT results. RESULTS: Several examples of patients whose death was determined at the scene either before any medical intervention or after initiation of resuscitative treatment are shown in our study and compared with the clinical impression of the treating physician. Two examples of autopsy results are compared with PMCT results. Gas was detected in various parts of the circulatory system in many cases. The significance of this finding, described in our study for the first time, needs further investigation. CONCLUSION: PMCT scanning has limits in detecting superficial injuries and injuries of the extremities and determining the exact route of fragments through body tissues in penetrating military trauma. It also cannot serve as a tool for examining ammunition or the protection provided by various armors. However, it can provide a substantial amount of evidence that, when reviewed with the clinical information obtained from the physician at the scene, can help in assessing the treatment given at the field and point toward the probable cause of death.

Perineal reconstruction for severe sequela of ecthyma gangrenosum: report of a case.

Ecthyma gangrenosum is a cutaneous gangrenous disorder which usually follows Pseudomona aeruginosa infection and is found mainly in immunosuppressed children. We describe a case of a five-year-old female with leukemia with a severe perineal ecthyma gangrenosum resulting in a cloaca-like deformity. One year later a perineoplasty with puborectalis interposition and overlapping external anal sphincteroplasty was successfully performed, achieving satisfactory continence.

Necrotizing enterocolitis: the impact of the establishment of a Department of Pediatric Surgery on the Beilinson Medical Campus.

Necrotizing enterocolitis (NEC) is the most commonly acquired gastrointestinal emergency in neonates. We retrospectively surveyed all cases of confirmed NEC treated at the Beilinson Medical Center (BMC) (now Rabin Medical Center, Beilinson Campus) during a 12 year period to determine whether the establishment of a department of pediatric surgery has influenced the treatment and outcome of NEC patients. Of the 48 patients, 23 were patients treated in the "early period", 1982-87, when surgery was performed in the Department of General Surgery by staff trained in pediatric surgery (group I), and 25 were treated in the "later period" 1988-93, in the same neonatal intensive care unit, with surgical supervision by the new Department of Pediatric Surgery (group II). We found that 32% of the group II patients were of extremely low birthweight (<1,000 g) compared with 13% of group I. They also had lower Apgar scores, and a higher percentage needed respiratory assistance (56 vs. 26%, P = 0.02). All those infants of group II who had been born in other hospitals and were transferred to BMC for treatment were in an advanced state of disease and all required surgery. Total mortality decreased from 22% in group I to 8% in group II. This decrease may be attributed to improved supportive treatment in the neonatal intensive care unit, earlier surgery for NEC based on relative rather than absolute indications, higher rates of primary resection, and better postoperative care. Our review indicates that the establishment of a Department of Pediatric Surgery at the BMC has contributed to the considerable improvement in NEC outcome in our center.