Hybrid open-endovascular repair of a contained suprarenal mycotic aneurysm using femoral vein.

Mycotic aneurysms have a high mortality rate, predominantly driven by sepsis. We present a 61-year-old patient who was treated with a hybrid open-endovascular repair using autologous femoral vein as a single channel revascularization. This provided a practical and innovative approach to a high-risk situation.

Successful glue embolization of a late type 1A endoleak causing abdominal aortic aneurysm rupture.

We describe the successful treatment with n-butyl cyanoacrylate embolization of a ruptured infrarenal abdominal aortic aneurysm caused by a late type-1A endoleak 10 years after endovascular aneurysm repair (EVAR).

The effects of pharmacological blockade of the 5-HT(6) receptor on formalin-evoked nociceptive behaviour, locomotor activity and hypothalamo-pituitary-adrenal axis activity in rats.

5-hydroxytryptamine (5-HT) mediates behavioural and neuroendocrine responses to noxious or stressful stimuli. 5-HT(6) receptors are expressed in brain regions involved in nociceptive processing, however, their role in nociception is unknown. Here we demonstrate that acute, systemic administration of the 5-HT(6) receptor antagonist, 5-chloro-N-(4-methoxy-3-benzothio-phenesulfonamide (SB-271046), reduces formalin-evoked nociceptive behaviour and increases plasma corticosterone. SB-271046 dose-dependently reduced pre-formalin distance moved, rearing, grooming and defecation. These data provide the first evidence for 5-HT(6) receptor-mediated regulation of nociception and hypothalamo-pituitary-adrenal axis activity in a model of persistent pain although effects on locomotor activity demand that the putative antinociceptive effect of SB-271046 be interpreted with some caution.

Effect of lamotrigine on the activities of monoamine oxidases A and B in vitro and on monoamine disposition in vivo.

Recent clinical evidence indicates that the broad spectrum anticonvulsant drug lamotrigine is effective against the depressive phase of bipolar illness and the difficult to treat rapid cycling form of the disorder. However, the molecular mechanism underlying this therapeutic action remains uncertain. Given that inhibition of the A-type of monoamine oxidase (MAO) is a proven antidepressant mechanism, we investigated the effects of lamotrigine on MAO activities in vitro and on monoamine disposition in vivo. In vitro, lamotrigine inhibited rat brain MAO activities with Ki values (MAO-A, 15 microM; MAO-B, 18 microM) potentially within the therapeutic range for this drug. The effects of lamotrigine on the MAO-A activities of rat brain and human liver preparations were almost identical suggesting minimal species or tissue variation. In contrast, there was no (MAO-A) or minimal (MAO-B) reduction in brain MAO activities when assayed ex vivo following the administration of lamotrigine to rats. In vivo brain microdialysis failed to detect meaningful alterations in extracellular hippocampal or frontal cortex monoamine concentrations. Furthermore, lamotrigine did not modulate oral tyramine-induced hypertension in rats or 5-hydroxytryptophan-induced head shaking in mice, providing strong evidence that the drug does not perturb monoamine metabolism in vivo. The absence of observable effects of lamotrigine on monoamine disposition in vivo may be explained by the competitive and highly reversible nature of the interaction of lamotrigine with MAO isoforms. Thus, altered monoamine metabolism in vivo is unlikely to account for the antidepressant action of the drug in bipolar depression.

Randomized trial comparing Quixil surgical sealant with Kaltostat hemostatic dressing to control suture line bleeding after carotid endarterectomy with ePTFE patch reconstruction.

Following carotid endarterectomy (CEA), patch angioplasty provides a significant reduction in the risk of perioperative complications. The expanded polytetrafluoroethylene (ePTFE) patch is strong, is resistant to infection, and has low thrombogenicity; but it remains unpopular because of its tendency of prolonged bleeding at the suture line. We aimed to investigate whether the application of Quixil sealant to the suture line could improve the time to achieve hemostasis and reduce local blood loss when compared to a standard topical hemostat Kaltostat. A prospective, randomized trial of 20 patients undergoing CEA was undertaken. Patients were randomized to receive either Quixil sealant (treatment group) or topical Kaltostat (controls) as a hemostatic agent to the patch suture line. Hemostasis was defined as no bleeding at the suture line for 1 minute. Statistical analysis was performed using the Mann-Whitney test. The two groups had a similar age and sex distribution. The mean age was 71 years, and there were seven men and three women in each group. The time to achieve hemostasis was significantly lower in the Quixil group (median 2.5 minutes, range 1-4 minutes) compared to the controls (median 17 minutes, range 7-59 minutes) (p < 0.001). Blood loss after clamp release was also significantly reduced in the Quixil group; median 24.5 ml (range 5.5-105.0 ml) versus 203 ml (range 54.5-817.0 ml) (p < 0.001). This study has demonstrated that Quixil human surgical sealant is an effective sealant of ePTFE patch suture holes and does not compromise the patch repair. It could be used during other vascular procedures involving ePTFE.

Cannabinoids modulate ultrasound-induced aversive responses in rats.

RATIONALE: Mechanisms and brain substrates mediating cannabinoid-induced modulation of behaviour towards aversive stimuli are poorly understood. OBJECTIVES: To investigate the effects of systemic and intra-dorsal periaqueductal grey (PAG) administration of the cannabinoid receptor agonist HU210 on behaviour and plasma corticosterone levels in rats exposed to ultrasound and determine the contribution of CB(1) receptors. METHODS: In experiment 1, rats received vehicle or CB(1) receptor antagonist SR141716A (3 mg/kg, IP) 30 min prior to a second injection of vehicle or HU210 (5, 20 or 80 microg/kg, IP). In experiment 2, rats received intra-dorsal PAG vehicle or SR141716A (30 microg/rat) 10 min prior to intra-dorsal PAG vehicle or HU210 (5 microg/rat). Following injections, rats were exposed to an aversive 20 kHz ultrasonic tone for 3 min. Behaviour, including hyperlocomotor activity and freezing, was monitored during and post-ultrasound. Plasma corticosterone levels 10 min post-ultrasound were measured. RESULTS: Ultrasound induced explosive running and freezing behaviour. Systemic administration of HU210 attenuated the expression of ultrasound-induced hyperlocomotor activity and increased freezing. The HU210-induced attenuation of hyperlocomotor activity was blocked by SR141716A. Intra-PAG administration of HU210 reduced the expression of ultrasound-induced hyperlocomotor activity, an effect not blocked by SR141716A. Systemic and intra-PAG administration of HU210 increased plasma corticosterone levels, an effect not blocked by SR141716A. CONCLUSIONS: The cannabinoid receptor agonist HU210 modulates behaviour towards an aversive ultrasound stimulus in rats, an effect accompanied by increased HPA axis activity. These effects may be mediated, at least in part, by the dorsal PAG but cannot be explained solely by an action at CB(1) receptors.

The role of the central nucleus of the amygdala in nociception and aversion.

The role of the central nucleus of the amygdala in nociception--conditioned and unconditioned aversion--was studied. Rats received microinjection of vehicle or the N-type Ca2+ channel blocker omega-conotoxin GVIA (0.2 microg/250 nl) into the central amygdaloid nucleus prior to intra-plantar injection of formalin, ultrasound exposure or immediately prior to the acquisition phase of an aversive conditioning trial. Intra-amygdala omega-conotoxin GVIA resulted in an earlier onset of nociceptive response to formalin and increased nociceptive behaviour during the first 5 min. Omega-conotoxin GVIA significantly reduced conditioned freezing behaviour with no effect on ultrasound-induced unconditioned aversive behaviour. These data indicate that N-type Ca2+ channels in the central amygdaloid nucleus play a role in mediating behavioural responses to nociceptive and conditioned aversive stimuli.

Surgery of popliteal artery aneurysms: a 12-year experience.

BACKGROUND: Management of asymptomatic popliteal aneurysm is controversial, and the prognosis for acutely thrombosed aneurysm is notoriously poor. We evaluated the management and outcome for popliteal aneurysm. PATIENTS AND METHODS: A retrospective review of all patients with popliteal aneurysm between 1988 and 2000 was carried out. Fifty-two limbs were operated on in 41 patients. Data collected included findings at presentation, operative details, graft patency, limb salvage, complications, and 30-day mortality. RESULTS: Initial findings included acute ischemia (n = 14), no symptoms (n = 29), acute rupture (n = 2), chronic ischemia (n = 5), and symptoms of nerve or vein compressive (n = 2). All patients with symptomatic aneurysms and 22 patients with asymptomatic aneurysms (21 larger than 2 cm in diameter, 1 with thrombus at duplex ultrasound scanning) underwent surgery as first-line treatment. Of the 7 patients with asymptomatic aneurysm managed with surveillance with duplex ultrasound scanning, acute ischemia developed in three, 1 aneurysm ruptured, compressive symptoms developed in 1, and 2 remained asymptomatic but required surgery because of aneurysm enlargement (>2 cm). Of the 17 patients with acute ischemia, 13 had neurologic signs and underwent immediate thromboembolectomy (trifurcation alone in 8, ankle-level arteriotomy in 4) and bypass grafting (n = 12) or inlay grafting (n = 1), and the other 4 underwent intra-arterial thrombolysis initially. Of these 4 procedures, 2 were successful and had elective surgery; the other 2 required urgent surgery because of secondary distal embolism and failure of recanalization. Thirteen of the 17 grafts were to the crural vessels. Bypass grafting (medial approach) was used in 16 of the 17 patients with acute ischemia, all 5 patients with chronic ischemia, and the 8 patients with no symptoms. An inlay technique (posterior approach) was used in 16 patients with no symptoms, the 3 patients with symptoms of nerve or vein compression, and 1 patient with acute ischemia. The distal anastomoses were to the below-knee popliteal artery in 35 patients and the crural arteries in 15 patients, using autologous vein. Two of the patients with rupture underwent ligation alone, the other undergoing bypass grafting in addition. The overall 5-year primary patency rate was 69%, secondary patency rate was 87%, and limb salvage rate was 87%. Limb salvage was achieved in 14 of the 17 patients with acute ischemia. Patients with asymptomatic aneurysms had better secondary graft patency (100%) compared with symptomatic aneurysms (74%; P <.01). Acute ischemia, technique used, and crural artery grafts were not predictors of graft failure with either univariate or multivariate analysis. Symptomatic aneurysms were associated with more postoperative complications and greater 30-day mortality (4 of 28 vs 0 of 24). CONCLUSION: Thromboembolectomy followed by crural bypass grafting is an effective treatment for popliteal aneurysm with severe acute limb ischemia. Outcome is better with surgical management of asymptomatic popliteal aneurysm compared with symptomatic aneurysm.

Composite sequential grafts for femorocrural bypass reconstruction: experience with a modified technique.

BACKGROUND: To evaluate the efficacy of a modification of the composite sequential femorocrural bypass graft that we adopted in 1985, a retrospective case-note study was undertaken. The grafts combined a prosthetic femoropopliteal section with a popliteal to crural section with autologous vein, linked via a common intermediate anastomosis sited on the above-knee popliteal artery. PATIENTS AND METHODS: Between 1985 and 2000, 68 grafts of this type were constructed in 65 patients with critical ischemia of the lower limb and insufficient autologous vein for construction of an all venous bypass. Reasons for insufficient long saphenous vein included previous lower limb bypass in 33 cases, phlebitis in 16 cases, venous hypoplasia in eight cases, and previous varicose vein surgery in seven cases. Distal anastomoses were carried out to the peroneal artery in 26 cases, the anterior tibial artery in 17 cases, the posterior tibial artery in 17 cases, and the pedal arteries in eight cases. Sources of vein included the long saphenous vein in 26 cases, the arm vein in 38 cases, and the short saphenous vein in two cases. In 22 limbs (32%), angiography had shown an occluded segment of above-knee popliteal artery, and in these cases, local popliteal disobliteration was performed to receive the composite anastomosis and to provide additional outflow. RESULTS: The 2-year cumulative primary patency, secondary patency, and limb salvage rates were 68%, 73%, and 75%, respectively. Localized popliteal disobliteration did not compromise graft patency (P =.07, with log-rank test). CONCLUSION: In the absence of sufficient autologous vein, patients needing bypass to crural arteries can be offered reconstruction with composite sequential grafting with satisfactory results. Furthermore, an occluded above-knee popliteal segment is not a contraindication for composite sequential bypass reconstruction.

Long-term changes in social interaction and reward following repeated MDMA administration to adolescent rats without accompanying serotonergic neurotoxicity.

RATIONALE: MDMA is a popular drug of abuse in adolescents which causes serotonergic neurotoxicity in adult but not young rodents. However, few studies have examined the long-term behavioural consequence of MDMA and it is unclear whether such changes occur in the absence of neurotoxicity. OBJECTIVES: The present study examined whether treatment of young rats with MDMA produced long-term behavioural alterations without accompanying serotonergic neurotoxicity. METHOD: Male Lister hooded rats ( n=36, postnatal day (PND) 39) received MDMA (7.5 mg/kg i.p., twice daily for 3 days) or saline (l ml/kg i.p.) and the acute effect on open field behaviour and body temperature was monitored. Following drug withdrawal, social interaction in pre-treatment- and weight-matched rat pairs, cortical [(3)H]paroxetine binding and hippocampal and frontal cortical serotonin and dopamine levels (PND 53, n=12) and conditioned place preference (PND 70, n=24) to cocaine (5 mg/kg IP) were analysed. RESULTS: MDMA elicited the expected immediate serotonin syndrome with significant hyperlocomotion, decreased rearing and hypothermia. Twelve to 29 days after the last MDMA injection social interaction was significantly attenuated (by 41%) and the sub-threshold conditioned place preference to cocaine was significantly enhanced compared with that in saline controls, although no significant side preference to cocaine occurred in the latter. MDMA pre-treatment did not alter 5-HT levels or cortical [(3)H]paroxetine binding. CONCLUSION: MDMA administration to adolescent rats reduced social interaction and enhanced the sub-threshold rewarding effect of cocaine at adulthood, despite an absence of accompanying serotonergic and dopaminergic neurotoxicity.

Open clavicle fractures: a case report.

Open fractures of the clavicle are rare, whereas closed fractures are quite common. Presented here is a case report of a grade IIIA open clavicle fracture. After reviewing the literature, there appears to be little information on the treatment or outcome of these fractures. One can only surmise that the outcome and complications are similar to those of other open fractures.

Pseudo-dislocation of the sternoclavicular joint.

Fractures of the medial third of the clavicle are the rarest of all clavicle fractures. We present two cases of medial clavicle fracture nonunions that were initially thought to be chronic anterior sternoclavicular dislocations and describe the entity of pseudo-dislocation of the sternoclavicular joint. Computed tomography should be performed on all patients with suspected or established injuries of the sternoclavicular region to ensure differentiation between fracture and dislocation.

Use of Ilizarov external fixation for a periprosthetic supracondylar femur fracture.

Supracondylar femur fractures above a total knee replacement are rare injuries that may be challenging to treat. We present a case of an elderly woman whose supracondylar femur fracture was not deemed amenable to conventional treatment. This patient underwent fixation of her femur fracture above a total knee replacement using an Ilizarov external fixator. The fixator was removed at 10 weeks, at which time the fracture was solidly healed. At the most recent follow-up, the patient is 19 months postinjury. She is fully weight bearing without walking aids and has a knee range of motion of 0 degree to 110 degrees.

Management priorities in patients with polytrauma.

BACKGROUND: The basic principles for the treatment of the polytraumatized patient is early resuscitation, followed by a physical examination and diagnostic studies. These are performed to establish the priorities for life-saving management and further treatment. DISCUSSION: Trauma management regarding musculoskeletal injuries is discussed in four different distinguished periods: (1) acute or resuscitation period (0-3 h); (2) primary or stabilization period (3-72 h); (3) secondary or regeneration period (days 3-8); and (4) tertiary or rehabilitation period (beyond day 8). For management during the acute period, a trauma algorithm is described, which consists of four different steps: (1) first look; (2) shock treatment; (3) check up; and (4) control and diagnosis. During the acute period, decompression of organ cavities (tension pneumothorax, cardiac tamponade) is performed along with life-saving operations for hemorrhage control of thoracic, abdominal, pelvic or external bleeding. The primary period (3-72 h) of treatment starts when the vital functions have been stabilized. During this period, so-called 'day-one' surgery is performed. During the secondary period (days 3-8), a phase of regeneration, a secondary deterioration of organ function must be prevented. During the tertiary phase (beyond day 8), in most cases, recovery usually continues and final reconstructive operations can be performed.

Mesenchymal chondrosarcoma of the cervical spine in a child.

Mesenchymal chondrosarcoma is a rare small-cell neoplasm of bone and soft tissue. After reviewing the literature, we believe that the patient in this report is the youngest in whom mesenchymal chondrosarcoma originating in a cervical vertebra has been diagnosed.

An unusual presentation of telangiectatic osteosarcoma.

Telangiectatic osteosarcoma (TOS) is a rare subtype of osteosarcoma that accounts for approximately 2% of all osteosarcomas. Presented is a case of a sacral mass that was originally thought to be a chordoma and was treated surgically but on pathologic examination was diagnosed as a TOS. A review of the literature on other sacral lesions is provided. The intention for presenting this case is twofold: to make physicians aware of the differential diagnoses of sacral lesions and to report an unusual presentation of this rare tumor.