Chylous ascites as a complication of left sided robot-assisted laparoscopic partial nephrectomy.

OBJECTIVE: The aim of the study was to present a case series of the sparsely reported complication of chylous ascites (CA) after left sided robot-assisted laparoscopic partial nephrectomy (RALPN), identify possible risk factors for the development of postoperative CA, and explore current recommendations for identification, management and prevention of CA. MATERIAL AND METHODS: A retrospective review of patients that were treated with a RALPN during a one year time period (August 2012 to August 2013) by one surgeon at our institution was conducted. A total of 12 patients were included in the study. Demographics, tumor characteristics, and perioperative outcomes were assessed. RESULTS: Three patients in the study experienced postoperative CA. All three patients had left sided surgery. The initial clinical suspicion for CA was raised due to complaints of abdominal pain with increased milky appearance of JP fluid. JP triglycerides were elevated in all three patients. The patients responded to conservative measures, with two patients treated with medium chain triglyceride diets and one patient treated with total parenteral nutrition (TPN). Among the patients treated with RALPN, the group that was diagnosed with postoperative CA (CA group) was found to have a statistically significant lower average body mass index (BMI) as compared to the group that did not have CA (non-CA group) (24.67 kg/m2 in the CA group versus 31.77 kg/m2 in the non-CA group; P = 0.026). Other demographic data, tumor characteristics, and perioperative outcomes were similar in both groups. CONCLUSIONS: CA as a result of RALPN is a newly reported and rare postoperative complication. As utilization of RALPN continues to increase, urologists should be aware of this possible complication and be adept at diagnosing and managing CA. We suggest that left sided retroperitoneal surgery and a lower BMI preoperatively be considered risk factors for developing this complication.

Neurologic outcome of minimal head injury patients managed with or without a routine repeat head computed tomography.

BACKGROUND: Previous studies proposed that routine repeat head computed tomography (RHCT) is of little value in patients with a minimal head injury (MHI) and normal neurologic examination (NE). As of 2003, routine RHCT in these MHI patients was ordered at the discretion of the attending physician. The goal of this study was to compare the neurologic outcomes of MHI patients with an intracranial bleed and a normal NE who were managed with or without a routine RHCT. METHODS: A retrospective chart review of adult patients with MHI presenting to a Level I trauma center from August 2003 to December 2008 was performed. Demographics, injury severity, and HCT findings were collected for patients managed with or without a routine RHCT. Outcome measures included delayed neurologic deterioration, neurosurgical interventions, Glasgow Outcome Scale, and hospital length of stay (LOS). RESULTS: A total of 321 MHI patients with an intracranial bleed had a normal NE 24 hours after presentation. There were no significant differences in demographics, arrival Glasgow Coma Scale score, or injury severity between the 142 (44%) patients managed with RHCT and the 179 (56%) managed without RHCT. No patient had a neurologic deterioration or required a neurosurgical intervention, regardless of initial management. There was no significant difference in the neurologic outcomes, mortality, or discharge dispositions between both groups. Patients managed without an RHCT had significantly shorter LOS (2.2 ± 2.3 days vs. 4.3 ± 6.0 days; p < 0.001) compared with those with RHCT. CONCLUSION: Our study is the first to compare early neurologic outcomes of MHI patients with or without a routine RHCT. Patients managed without an RHCT had similar neurologic outcomes and shorter hospital LOS. Our data suggest that initial HCT followed by serial NEs (not routine RHCT) should be the standard of care in this patient population.

Müller straight stem total hip arthroplasty for fractured neck of femur.

UNLABELLED: We present the results of a retrospective review of 50 Müller straight stem total hip replacements performed for femoral neck fracture over a 10-year period. PATIENTS AND METHODS: Between 1992 and 2002, 50 Müller straight stem total hip replacements were performed for femoral neck fracture in 42 female and 8 male patients with a mean age of 74 years. RESULTS: No hips have required revision surgery. Two patients have suffered early dislocations and there have been three major medical complications. The mean Merle D'Aubigne-Postel score was 15.1. Of the 25 radiographs available for review there were no cases of radiological loosening. DISCUSSION: This is further evidence that total hip replacement in the right hands provides good results for the treatment of displaced intracapsular femoral neck fractures. The Müller straight stem gives acceptable results in a select group of patients.

Reduction of caveolin-3 expression does not inhibit stretch-induced phosphorylation of ERK2 in skeletal muscle myotubes.

Mechanotransduction is critical to the maintenance and growth of skeletal muscle, but the mechanism by which cellular deformations are converted to biochemical signals remains unclear. Among the earliest and most ubiquitous responses to mechanical stimulation is the phosphorylation and activation of mitogen-activated protein kinases, in particular ERK2. Caveolin-3 (CAV-3) binds ERK2 and its upstream activators in inactive states on the caveolae of resting muscle. Caveolae are deformed by stretch, and it was hypothesized that this deformation might disrupt the CAV-3-dependent inhibition of ERK2 to affect stretch-induced activation. Stretch-induced phosphorylation of ERK2 in myotubes was both amplitude and velocity dependent, consistent with a viscoelastic mechanism, such as deformation of caveolae. Chemical disruption of caveolae by cholesterol depletion increased ERK2 activation by up to 176%. Small interfering RNA oligomers were then used to knock down expression of CAV-3 in cultured myotubes before mechanical stimulation, with the expectation that reducing CAV-3 expression would eliminate the stretch-induced activation of ERK2. Knockdown reduced CAV-3 protein content by 55% but did not significantly alter the stretch-induced increase in ERK2 phosphorylation, suggesting that CAV-3 is not an essential element of the mechanotransduction pathway, although the limited extent of knockdown limits the strength of this conclusion.

Delays in open fracture management: where do they occur?

We audited the delays in the management of 29 patients presenting to our department with 30 open fractures over a 1-year-period to ascertain where the most lengthy delays were occurring. Gold standard treatment is the surgical debridement and stabilisation of the fracture within 6h of injury. In our series only 14 patients achieved this standard. The lengthiest delays were in getting a patient to the operating theatre following orthopaedic assessment. We have introduced an "open fracture proforma" to highlight the time-critical nature of the injury in an effort to speed-up the process.