Synapse impairment associated with enhanced apoptosis in post-traumatic stress disorder.

Synapse impairment is associated with post-traumatic stress disorder (PTSD), which is characterized by enhanced apoptosis in the hippocampus, amygdala, and other brain regions. However, there are no detailed studies on the relationship between apoptosis and synaptic connectivity in PTSD. In this review, we discuss results from various studies describing the synaptic changes observed in the PTSD brain. A decreased number of dendrites/spines or increased number of immature spines in the hippocampus, medial prefrontal cortex, and other brain regions has been reported. Studies on axon guidance, myelination, and the cytoskeleton suggest that PTSD may involve axon overgrowth and overbranching. Apoptosis affects synapse formation; low levels of caspase maintain the balance between growth cone attraction and repulsion and inhibit axon elongation. PTSD enhances neuronal apoptosis through caspase activation, which disrupts the balance between growth cone attraction and repulsion and alters growth cone trajectory, leading to axon mistargeting. Meanwhile, caspase activation induces dendritic pruning and dendrite degeneration. These events contribute to the formation of fewer and aberrant synapses, which is associated with enhanced apoptosis in PTSD.

Esophageal rupture: Computed tomography with endoscopic correlation.

Boerhaave syndrome, or spontaneous rupture of the esophagus, is a complication of violent vomiting. Although the syndrome is rare, awareness of it is important because delayed or missed diagnosis can be fatal. Radiographic imaging, particularly computed tomography, is the mainstay of diagnosis, and endoscopy generally does not play a role. We present a case of Boerhaave syndrome diagnosed by computed tomography that was complemented by endoscopic direct visualization to optimize surgical management. True Boerhaave syndrome is extremely rare, and rarer still is an endoscopic view of a known full-thickness tear of the esophagus.

Proximal plantar fibroma as an etiology of recalcitrant plantar heel pain.

Prompted by repeated pathology reports of fibromas at the origin of the plantar fascia after fasciectomy for chronic plantar heel pain, this study examines the incidence of proximal plantar fibroma. A retrospective study of 101 pathology specimens from 97 patients with the preoperative diagnosis of recalcitrant plantar fasciitis was performed. Patients ranged in age from 36 to 82, and included 30 males and 67 females. The specimens consisted of medial and central bands of the fascia obtained from transverse plantar fasciectomies. The fasciectomies were performed between July 1994 and March 2008. One quarter of the cases studied had a histological appearance of plantar fibroma. This new finding has not been reported in any literature in connection with recalcitrant heel pain. Histologic findings of the specimens were placed into 3 groups: neoplastic involvement (25%, 21 female and 6 male), inflammation without neoplastic involvement (21%, 13 female and 6 male), and other, which consisted of having no inflammatory or neoplastic response (54%, 32 female and 19 male). All of the patients failed a 3- to 6-month conservative treatment regimen, which included anti-inflammatory medication, modification of activities, injection of corticosteroids, night splints, custom molded orthotics, and physical therapy. Only 4 patients underwent bilateral plantar fasciectomies. No patient required a revisional procedure. The authors conclude that 25% of recalcitrant heel pain is neoplastic in origin, and that patients presenting with these lesions require excision and not fasciotomy.

Proximal plantar fibroma as an etiology of recalcitrant plantar heel pain.

Prompted by repeated pathology reports of fibromas at the origin of the plantar fascia after fasciectomy for chronic plantar heel pain, this study examined the incidence of proximal plantar fibroma. A retrospective study of 100 pathology specimens from 97 patients with the preoperative diagnosis of recalcitrant plantar fasciitis was performed. Patients ranged in age from 36 to 82, and included 31 males and 66 females. The specimens consisted of medial and central bands of the fascia obtained from transverse plantar fasciectomies. The fasciectomies were performed by 4 surgeons between July 1994 and March 2008. One quarter of the cases studied had a histological appearance of plantar fibroma. This new finding has not been reported in any literature in connection with recalcitrant heel pain. Histologic findings of the specimens were placed into 3 groups: neoplastic involvement (25%, 21 female and 6 male), inflammation without neoplastic involvement (21%, 13 female and 6 male), and other, which consisted of having no inflammatory or neoplastic response (54%, 32 female and 19 male). All of the patients ailed a 3- to 6-month conservative treatment regimen, which included anti-inflammatory medication, modification of activities, injection of corticosteroids, night splints, custom molded orthotics, and physical therapy. Only 3 patients underwent bilateral plantar fasciectomies. No patient required a revisional procedure. The authors conclude that 25% of recalcitrant heel pain is neoplastic in origin, and that patients presenting with these lesions require excision and not fasciotomy.

Bilateral second metatarsal stress fractures after hallux valgus correction with the use of a tension wire and button fixation system.

The pathomechanics and treatments of hallux valgus vary widely by deformity and surgeon, and are extensively described in the orthopedic and podiatric literature. With each newly described treatment, new complications can be encountered. In this report, we describe the case of a 22-year-old woman who underwent bilateral hallux valgus repair with a tension wire and button fixation system, and developed bilateral second metatarsal stress fracture at the point of fixation application during the postoperative period. Although this fixation system has been useful in our practice, like other surgical implants, it conveys a certain amount of risk that should be considered by surgeons using the device.

Intra-operative parathyroid identification using methylene blue in parathyroid surgery.

The objective of this study was to determine the value of intra-operative methylene blue (MB) during parathyroid surgery. We did a retrospective study of 473 patients after initial exploration for previously untreated symptomatic primary hyperparathyroidism. Procedural and post procedural data were collected on four groups of patients: minimally invasive parathyroidectomy with MB (n = 147), and without MB (n = 205), bilateral parathyroid exploration with intra-operative parathormone assay with MB (n = 56), and without MB (n = 65). Length of surgery was shorter for patients explored with MB (P = 0.026). For the minimally invasive parathyroidectomy group, the difference between the MB and non-MB groups was seven minutes. Twelve minutes was the difference between the MB and non-MB intra-operative parathormone assay groups. Length of stay, local complications, and correction of hypercalcemia after parathyroidectomy were not significantly affected by the use of MB. Systemic complications were lower in the MB groups. Aside from a statistically significant, but quantitatively minimal decrease in the length of surgery, no consistent benefit was identified with the use of MB for intra-operative parathyroid identification.

Success rate of retrograde double-balloon enteroscopy.

BACKGROUND: Retrograde double-balloon enteroscopy (rDBE) is technically a different procedure from its antegrade counterpart. Its unique indications, success rate, and learning curve have not been specifically reported. OBJECTIVE: To examine technical issues specific to the rDBE approach. DESIGN: Retrospective review. SETTING: Single tertiary-care center. PATIENTS: All patients referred for rDBE. MAIN OUTCOME MEASUREMENTS: Procedure duration, technical success, learning curve, and complications related to rDBE. RESULTS: A total of 59 rDBEs were performed on 56 patients for obscure GI bleeding (46.4%), metastatic carcinoids (23.2%), Crohn's disease (14.3%), and other indications. rDBE enabled a diagnosis in 47.5% of procedures and had a 38% diagnostic rate in finding primary small-bowel lesions that were responsible for metastatic carcinoids. The mean (standard deviation) total procedure time was 111.3 +/- 39.9 minutes. Procedure failure occurred in 12 cases (21%), which is significantly more than reported with antegrade procedures (2%). Failure was more common among patients with a prior abdominal or pelvic surgery (P = .001), and the time to achieve a stable ileal intubation was prolonged in these patients (13.9 vs 38.1 minutes; P = .0006). A trend was noted toward successful small-bowel access and increased lengths of small bowel examined after 20 procedures were performed. LIMITATIONS: Small retrospective study. CONCLUSIONS: rDBE is effective for the evaluation and the treatment of lower small-intestinal lesions; however, maintaining access through the ileocecal valve may be difficult. Prior surgery may be an important factor associated with failure. A minimum of 20 rDBE procedures was needed to minimize procedure failure, examine a substantial segment of the small-bowel, and shorten procedure duration.

Induction chemoradiation for rectal cancer.

OBJECTIVE: To review the application, outcome, and recent developments of neoadjuvant chemoradiation therapy with respect to rectal cancer. DATA SOURCES AND STUDY SELECTION: Articles written in English after 1980 selected from MEDLINE and PubMed from the National Library of Medicine. Case reports were excluded. There were no other criteria for exclusion of published information pertaining to this topic. DATA EXTRACTION AND SYNTHESIS: Articles were obtained and organized from MEDLINE and PubMed as well as the reference lists of pertinent literature. CONCLUSIONS: Published reports have demonstrated that neoadjuvant chemoradiation improves survival and decreases local recurrence in patients with stage II and III rectal cancers. It is anticipated that advances and technical developments in both chemotherapy and radiation therapy will lead to improved oncologic results with decreased toxic side effects.

Topical alpha-tocotrienol supplementation inhibits lipid peroxidation but fails to mitigate increased transepidermal water loss after benzoyl peroxide treatment of human skin.

Benzoyl peroxide (BPO) is a commonly used drug in the treatment of acne vulgaris, but it induces unwanted side effects related to stratum corneum (SC) function. Since it has been recently shown to oxidize SC antioxidants, it was hypothesized that antioxidant supplementation may mitigate the BPO-induced SC changes. To test this, 11 subjects were selected to be topically supplemented with alpha-tocotrienol (5% w/vol) for 7 d on defined regions of the upper back, while the contralateral region was used for vehicle-only controls. Starting on day 8, all test sites were also treated with BPO (10%) for 7 d; the alpha-tocotrienol supplementation was continued throughout the study. A single dose of BPO depleted 93.2% of the total vitamin E. While continuing the BPO exposure for 7 d further depleted vitamin E in both vehicle-only and alpha-tocotrienol-treated sites, significantly more vitamin E remained in the alpha-tocotrienol-treated areas. Seven BPO applications increased lipid peroxidation. Alpha-tocotrienol supplementation significantly mitigated the BPO-induced lipid peroxidation. The transepidermal water loss was increased 1.9-fold by seven BPO applications, while there was no difference between alpha-tocotrienol treatment and controls. The data suggest that alpha-tocotrienol supplementation counteracts the lipid peroxidation but not the barrier perturbation in the SC induced by 10% BPO.