Louisiana State University Medical Center Research Articles

A Conversation with Robert C. Elston

Robert C. Elston was born on February 4, 1932, in London, England. He went to Cambridge University to study natural science from 1952–1956 and obtained B.A., M.A. and Diploma in Agriculture (Dip Ag). He came to the US at age 24 to study animal breeding at Cornell University and received his Ph.D. in 1959. From 1959–1960, he was a post-doctoral fellow in biostatistics at University of North Carolina (UNC), Chapel Hill, where he studied mathematical statistics. He then rose through the academic ranks in the department of biostatistics at UNC, becoming a full professor in 1969. From 1979–1995, he was a professor and head of the Department of Biometry and Genetics at Louisiana State University Medical Center in New Orleans. In 1995, he moved to Case Western Reserve University where he is a professor of epidemiology and biostatistics and served as chairman from 2008 to 2014. Between 1966 and 2013, he directed 42 Ph.D. students and mentored over 40 post-doctoral fellows. If one regards him as a founder of a pedigree in research in genetic epidemiology, it was estimated in 2007 that there were more than 500 progeny. Among his many honors are a NIH Research Career Development Award (1966–1976), the Leadership Award from International Society of Human Genetics (1995), William Allan Award from American Society of Human Genetics (1996), NIH MERIT Award (1998) and the Marvin Zelen Leadership Award, Harvard University (2004). He is a Fellow of the American Statistical Association and the Institute of Mathematical Statistics as well as a Fellow of the Ohio Academy of Science. A leader in research in genetic epidemiology for over 40 years, he has published over 600 research articles in biostatistics, genetic epidemiology and applications. He has also coauthored and edited 9 books in biostatistics, population genetics and methods for the analysis of genetic data. The original conversation took place on August 4, 2009, during the Joint Statistical Meetings (JSM) in Washington, DC by GZ and ZL. NLG had dinner with RCE during the 2013 JSM in Montreal, Canada, and added supplementary material and edited the conversation. RCE updated and clarified certain points.

Outcomes of a novel minimalist approach for the treatment of cubital tunnel syndrome

We describe a minimalist approach to perform in situ decompression of the ulnar nerve. Our technique employs a unique small skin incision strategically placed to minimize postoperative scarring over the ulnar nerve and potentially decrease the risk of iatrogenic injury to the medial antebrachial cutaneous nerve. We retrospectively report the outcome of patients who have undergone this procedure at our institution, the Michael E. DeBakey Veterans Affairs Medical Center, from January 1 2007 through November 29 2010. All individuals underwent in situ decompression via the previously described minimalist approach. Outcome variables were Louisiana State University Medical Center (LSU) ulnar neuropathy grade, patient satisfaction, subjective improvement, complications and re-operation rate. A total of 44 procedures were performed in this cohort of 41 patients. Overall, patients’ postoperative LSU grades showed a statistically significant improvement (p=0.0019) compared to preoperative grades. Improvement of at least one grade in the LSU scale was observed in 50% of the procedures with a preoperative grade of four or less. Overall procedure satisfaction rate was 88% (39 of 44) with 70% (31 of 44) of the procedures resulting in improvement of symptoms. There were no intraoperative or postoperative complications. One patient required re-operation due to failure of neurological improvement. Our minimalistic approach to perform in situ decompression of the ulnar nerve at the cubital tunnel is both safe and effective. We observed a statistically significant improvement in LSU ulnar neuropathy grades and a success rate comparable to those reported for other more extensive surgical techniques while providing the benefit of a smaller incision, less scarring, decreased risk of iatrogenic nerve injury and minimal complications.

Introduction of Steven A. Nadler, Recipient of the Henry Baldwin Ward Medal for 2013

Introduction of Steven A. Nadler, Recipient of the Henry Baldwin Ward Medal for 2013

Auto-activation of c-JUN Gene by Amino Acid Deprivation of Hepatocellular Carcinoma Cells Reveals a Novel c-JUN-mediated Signaling Pathway

Mammalian cells respond to protein or amino acid (AA) limitation by activating a number of signaling pathways, collectively referred to as the AA response (AAR), that modulate a range of cellular functions, including transcriptional induction of target genes. This study demonstrates that in hepatocellular carcinoma cells, expression of c-JUN, JUN-B, c-FOS, and FOS-B was induced by the AAR, whereas JUN-D, FRA-1, and FRA-2 were not. Of the four activated FOS/JUN members, c-JUN made the largest contribution to the induction of several known AAR target genes. For several human liver, prostate, and ovarian cell lines, the AAR-induced increase in c-JUN expression was greater in transformed cells compared with nontransformed counterparts, an effect independent of cell growth rate. Thus far, the best characterized AA-responsive genes are all transcriptionally activated by ATF4, but the AAR-dependent induction of c-JUN transcription was ATF4-independent. The increased expression of c-JUN was dependent on ATF2 and on activation of the MEK-ERK and JNK arms of the MAPK signaling pathways. Formation of c-JUN-ATF2-activated heterodimers was increased after AA limitation, and c-JUN or ATF2 knockdown suppressed the induction of c-JUN and other AAR target genes. AA deprivation triggers a feed-forward process that involves phosphorylation of existing c-JUN protein by JNK and subsequent auto-activation of the c-JUN gene by recruitment of c-JUN and ATF2 to two AP-1 sites within the proximal promoter. The results document the novel observation that AP-1 sequences within the c-JUN gene can function as transcriptional amino acid-response elements.

Neostigmine antagonism of morphine's effects on intestinal transit.

Journal Article Neostigmine antagonism of morphine's effects on intestinal transit Get access John J Stewart John J Stewart Department of Pharmacology and Therapeutics, Louisiana State University Medical Center, Shreveport, Louisiana 71130, U.S.A. Search for other works by this author on: Oxford Academic Google Scholar Journal of Pharmacy and Pharmacology, Volume 34, Issue 6, June 1982, Pages 405–407, https://doi.org/10.1111/j.2042-7158.1982.tb04743.x Published: 12 April 2011 Article history Received: 08 October 1981 Published: 12 April 2011

Sodium and potassium.

Sodium and Potassium Get access George R. Meneely, M.D., George R. Meneely, M.D. Professor and Head in the Department of Physiology and Biophysics, School of Medicine, Louisiana State University Medical Center, Shreveport, Louisiana 71130. Search for other works by this author on: Oxford Academic PubMed Google Scholar Harold D. Battarbee, Ph D Harold D. Battarbee, Ph D Assistant Professor in the Department of Physiology and Biophysics, School of Medicine, Louisiana State University Medical Center, Shreveport, Louisiana 71130. Search for other works by this author on: Oxford Academic PubMed Google Scholar Nutrition Reviews, Volume 34, Issue 8, August 1976, Pages 225–235, https://doi.org/10.1111/j.1753-4887.1976.tb05775.x Published: 01 August 1976

Pancoast tumor resection with preservation of brachial plexus and hand function

Pancoast tumors are aggressive bronchogenic lesions of the lung apex that are rapidly fatal if untreated. Modern treatment includes induction chemotherapy and radiotherapy prior to resection, but many authors also resect the T-1 nerve root (with or without the C-8 nerve root and the lower trunk of the brachial plexus) as part of the therapy, causing significant loss of hand function in many patients. The current authors determined whether a different approach allowing preservation of the brachial plexus and hand function could be adopted without compromising patient survival. An extensive historical review of Pancoast tumors is presented as a baseline for clinical comparison. Five patients harboring Pancoast tumors with brachial plexus involvement underwent surgery performed by both a neurosurgeon and thoracic surgeon. In all cases the tumor was resected from the brachial plexus using neurolysis while preserving the C-8 and T-1 nerve roots and lower trunk of the brachial plexus. One patient died 3 years posttreatment; the other four patients remain alive and well 2 to 5 years postoperatively. Hand function improved or remained normal in all four survivors, with postoperative intrinsic hand muscle function being Louisiana State University Medical Center Grade 5 in each patient. These results (2-year survival rate of 100%) compare favorably with the Southwest Oncology Group Data (overall 2-year survival rate of 55%; 70% in patients who had undergone complete resection). With a minimum 2-year follow-up, 80% of patients remained alive and well, with normal hand function. Although this patient series is small, the findings are extremely encouraging and suggest that the described treatment paradigm preserves survival as well as hand function in patients with Pancoast tumors.

Peripartum estimated blood loss: Effects of perineal laceration

IRENE STAFFORD, GARY DILDY, STEVEN CLARK, MICHAEL BELFORT, Louisiana State University Medical Center at New Orleans, Obstetrics & Gynecology, New Orleans, Louisiana, St Mark’s Hospital, Maternal-Fetal Medicine, Salt Lake City, Utah OBJECTIVE: The purpose of our study is to examine trends in blood loss according to degree of perineal laceration, comparing visual estimated blood loss (vEBL) with calculated estimated blood loss (cEBL) in vaginal deliveries. STUDY DESIGN: Between January 1 and September 2 of 2005, there were 876 deliveries on the LSU obstetrical service at University Hospital. After excluding those with blood transfusions, 677 who had height/weight and preand post-delivery hematocrit (HCT) data were analyzed. Of the 446 women who underwent vaginal delivery, 290 had no lacerations (L0), 72 had first degree lacerations (L1), 78 had second degree lacerations (L2) and 6 had either a third or fourth degree lacerations (L3-4). vEBL was recorded in mL by the physician present at delivery. cEBL was derived by multiplying the calculated pregnancy blood volume (0.75 ! {[Maternal height in inches ! 50]+ [Maternal weight in pounds ! 25]}) by percent of blood volume lost ({pre-delivery HCT – post-delivery HCT}/pre-delivery HCT). Statistitical analysis was accomplished using the Wilcoxon signed-rank test and the Kruskal-Wallis test with a P-value of less than .05 considered significant RESULTS: The median vEBL for L0, L1, L2, L3-4 was 200, 250, 300 and 350 mL respectively. The median cEBL for these groups was 519, 604, 764 and 932 mL respectively. Box plots in the figure illustrate 10, 25, 50, 75, and 90th percentile for each group. The median difference between vEBL and cEBL for L0, L1, L2, L3-4 was 259, 343, 460 and 582 mL respectively.

Prematurity represents an independent risk factor for eclampsia in preeclamptic women being treated with MgSO4

PREECLAMPTIC WOMEN BEING TREATED WITH MGSO4. MICHAEL BELFORT, JOHN ANTHONY, GEORGE SAADE, STEVEN CLARK, GARY DILDY, JANALEE THOMPSON, University of Utah, Obstetrics and Gynecology, Salt Lake City, Utah, University of Cape Town, Obstetrics and Gynaecology, Cape Town, South Africa, University of Texas Medical Branch at Galveston, Obstetrics & Gynecology, Galveston, Texas, University of Utah, Salt Lake City, Utah, Louisiana State University Medical Center at New Orleans, Obstetrics & Gynecology, Salt Lake City, Utah, St. Mark’s Hospital, Hospital Corporation of America, Maternal-Fetal Medicine, Salt Lake City, Utah OBJECTIVE: Magnesium sulfate (MgSO4) has an approximately 1% seizure prophylaxis failure rate in preeclampsia. Currently, factors predictive of seizure in such patients are unclear. STUDY DESIGN: Prospective data from preeclamptic women randomized to MgSO4 therapy were analyzed with univariate and multiple logistic regression analysis to determine independent variables associated with intrapartum and postpartum seizures. Variables included maternal age, race, gestational age, gravidity, previous preeclampsia, diabetes, chronic hypertension, epigastric pain, scotomata, headache, systolic BP, diastolic BP, platelet count, AST, ALT, and serum creatinine. A p ! 0.05 was used to denote statistical significance. RESULTS: 2038 patients were enrolled in two separate studies, of which 921 patients were randomized to MgSO4. Nine women or 0.98%, (95 percent confidence limits = 0.45% to 1.85%) on MgSO4 experienced seizure prophylaxis failure (8 intrapartum and 1 postpartum). No eclamptic patient had intracranial hemorrhage or other significant long-term neuropathology diagnosed and all recovered completely. By univariate analysis, lower gestational age and lower platelet count were identified as predictors of MgSO4 prophylaxis failure. On the multivariate regression analysis, only gestational age remained significantly associated with eclampsia (p = 0.04). 89% of patients in the seizure group (8/9) were !37 weeks while 61% (559/912) were preterm in the non-seizure group. CONCLUSION: Preterm preeclamptic patients (8/559 = 1.43%) receiving MgSO4 eclampsia prophylaxis are more likely to convulse than term patients (1/362 = 0.27%).

Sciatic Benign and Malignant Non-nerve and Nerve Sheath Tumors: A Series of 50 Louisiana State University Medical Center Patients

Neurosurgery: August 2006 - Volume 59 - Issue 2 - p 461-462 doi: 10.1227/01.NEU.0000309875.71005.B3

Sciatic Benign and Malignant Non-nerve and Nerve Sheath Tumors: A Series of 50 Louisiana State University Medical Center Patients

Sciatic Benign and Malignant Non-nerve and Nerve Sheath Tumors: A Series of 50 Louisiana State University Medical Center Patients

Reflections on Hurricanes Katrina and Rita

Back to table of contents Previous article Next article From the PresidentFull AccessReflections on Hurricanes Katrina and RitaPedro Ruiz, M.D.Pedro RuizSearch for more papers by this author, M.D.Published Online:7 Jul 2006https://doi.org/10.1176/pn.41.13.0003 Almost a year has passed since hurricanes katrina and Rita crippled New Orleans and nearby areas along the Gulf Coast, but the impact of these natural disasters is still fresh on our minds.Several other natural and manmade disasters have affected this country in the past—for instance, the hurricane that devastated Galveston County in 1900 and the terrorist attacks in New york City and Washington, D.C., on September 11, 2001—but the sociopolitical and historic impact of a disaster on the scale of these hurricanes has never been observed before in the United States.Recently, I had the opportunity to visit New Orleans to attend APA's Area 5 Council meeting. While there, I toured parts of the city affected by katrina, including the area where Louisiana State University Medical Center and Tulane University Medical Center are located. I saw a children's clinic building totally decimated and a psychotherapy clinic building near Canal Street almost destroyed; I saw houses and other buildings that had been ruined or leveled. Incredibly, people were still living in this almost uninhabitable part of New Orleans. Most of them were African American and probably did not have many assets to fall back on. Frustration, despair, and even anger bubbled inside of me as I watched them. How could the federal government have turned its back on this struggling community?What is the problem with being African American in this country? How can an African-American community in the strongest nation on earth be treated so inhumanely? I have never understood the intense discrimination that African Americans are still enduring in the world's most advanced and prosperous country. I grew up in rural Cuba among descendents of slaves brought to Cuba from West Africa, and I attended medical school in Paris with many African peers. Over the years, I have worked and developed strong friendships with many African-American colleagues, as well as with African Americans in many other walks of life. While I have brown skin, I have never been treated this way, and African Americans deserve the same treatment given me and my Caucasian friends and coworkers.As I reflect on the disgraceful way in which the U.S. government has responded to the needs of katrina and Rita victims, I feel shame for the policymakers who could and should have done so much more for these poor and disadvantaged American citizens but instead ignored them. I am positive that New Orleans will come back, but the African-American influence that gave the city its unique character will never be the same.While our federal government failed miserably in its responsibilities to the people of New Orleans, American psychiatry did not. My respect and sincere thanks go to the many psychiatrists who volunteered their time and expertise to address the psychosocial and psychopharmacological needs of hurricane victims. This group included not only local psychiatrists—many of whom were hurricane victims themselves—but also psychiatrists from throughout the United States. APA's district branches in the regions impacted by the hurricanes also rose to the occasion: Louisiana Psychiatric Medical Association, Mississippi Psychiatric Association, Texas Society of Psychiatric Physicians, Alabama Psychiatric Society, and Florida Psychiatric Society. At the national level, APA's Office of International Activities and the Committee on Psychiatric Dimensions of Disasters provided excellent leadership and designed a series of very effective interventions to address victims' mental health needs. Psychiatry residents and medical students from Louisiana State University and Tulane University also assisted.What happened—or more accurately didn't happen—in the wake of hurricanes katrina and Rita is a reminder to Americans, and the rest of the world as well, that the U.S. government at times shows two faces: one for the rich and wealthy and another for the poor and disadvantaged, most of whom belong to the ethnic minority groups who reside in this country. ▪ ISSUES NewArchived

Oral Post‐Surgical Complications Following the Administration of Bisphosphonates Given for Osteopenia Related to Malignancy

This case report seeks to illustrate the clinical consequences of the administration of bisphosphonate therapy to prevent osteopenia secondary to malignancy in one patient. A 69-year-old white female with a history of breast cancer with metastasis presented with pain in the upper left quadrant and periodontal pocketing of at least 6 mm in each of the four quadrants of the oral cavity. One week following surgery on the lower right region, lingual bone exposure was noted, and several attempts at achieving healing over the course of 15 months proved unsuccessful. Upon referral to a surgeon at the Louisiana State University Medical Center, New Orleans, Louisiana, a potential causative factor was finally identified. The drug zoledronic acid, a bisphosphonate given for prevention of osteoclastic activity of bone metastasis, secondary to breast cancer, was identified as the possible cause of inhibition of healing, most likely from regional vascular insufficiency. The drug was immediately discontinued. The patient is healing very slowly with the aid of hyperbaric therapy; she has been unable to achieve smoking cessation, which is deterring thorough healing of the exposed bony area on the lower right lingual side. Physicians and dentists alike must become increasingly aware of impaired oral healing following the use of bisphosphonates given for malignancy-related osteopenia. A dental exam should be performed before bisphosphonate therapy, as recommended for radiation therapy related to malignancy.

Randomized, Prospective Study Comparing Ulnar Neurolysis In Situ with Submuscular Transposition

To help clarify the optimal surgical strategy for idiopathic, symptomatic ulnar nerve compression at the elbow in terms of overall outcome and morbidity by using objective criteria. Forty-four surgical candidates were recruited prospectively and were randomized into the neurolysis (n = 23) or transposition (n = 21) arm of the study. Preoperative and postoperative outcomes were assessed symptomatically and by performance on McGowen and Louisiana State University Medical Center grading systems at 1 month, 6 months, and 1 year. Both procedures were equally effective in producing objective neurological improvement (61% in the neurolysis group, 67% in the transposition group). Wound complications, however, were more significant in the transposition group. Three of 21 in the transposition group compared with 0 of 23 in the neurolysis group experienced a deep wound infection. Idiopathic symptomatic ulnar nerve compression at the elbow is adequately treated by both neurolysis in situ and submuscular transposition. Submuscular transposition was associated with a higher incidence of complications. The authors therefore suggest the simpler procedure of neurolysis in situ as the treatment of choice. Submuscular transposition remains appropriate in certain circumstances.

The Roentgenographic Diagnosis of Renal Mass Lesions. By Erich K. Lang, M.D., Professor and Chairman, Department of Radiology, Louisiana State University Medical Center. Pp. 182 + viii. Illustrated. 1971. St. Louis: Warren H. Green, Inc. $11.50

Journal Article The Roentgenographic Diagnosis of Renal Mass Lesions. By Erich K. Lang, M.D., Professor and Chairman, Department of Radiology, Louisiana State University Medical Center. Pp. 182 + viii. Illustrated. 1971. St. Louis: Warren H. Green, Inc. $11.50 Get access The Roentgenographic Diagnosis of Renal Mass Lesions. By Erich KLang, M.D., Professor and Chairman, Department of Radiology, Louisiana State University Medical Center. Pp. 182 + viii. Illustrated. 1971. St. Louis: Warren H. Green, Inc. $11.50. British Journal of Surgery, Volume 58, Issue 9, September 1971, Page 716, https://doi.org/10.1002/bjs.1800580944 Published: 07 December 2005

Histone Deacetylase Inhibitors Suppress the Induction of c-Jun and Its Target Genes Including COX-2

Cyclooxygenase-2 (COX-2) is considered to be a target for anticancer therapy. Histone deacetylase (HDAC) inhibitors exhibit antitumor activity, but the mechanisms of action are incompletely understood. We investigated whether HDAC inhibitors blocked AP-1-mediated activation of COX-2 transcription. Trichostatin A and suberoylanilide hydroxamic acid, two structurally related inhibitors of HDAC activity, blocked AP-1-mediated induction of COX-2 expression and prostaglandin E2 biosynthesis. Chromatin immunoprecipitation assays indicated that HDAC inhibitors suppressed c-Jun binding to the COX-2 promoter and thereby blocked transcription. The observed reduction in binding reflected reduced levels of c-Jun. HDAC inhibitors suppressed the induction of c-jun transcription by blocking the recruitment of the preinitiation complex (RNA polymerase II and TFIIB) to the c-jun promoter. HDAC3 but not HDAC1 or HDAC2 was required for AP-1-mediated stimulation of c-jun expression. Because HDAC inhibitors suppressed the induction of c-jun gene expression, resulting in reduced COX-2 transcription, it was important to determine whether other known AP-1 target genes were also modulated. Cyclin D1 and collagenase-1 are AP-1-dependent genes that have been implicated in carcinogenesis. HDAC inhibitors suppressed the induction of both cyclin D1 and collagenase-1 transcription by inhibiting the binding of c-Jun to the respective promoters. Taken together, these results suggest that HDAC inhibitors block the induction of c-jun transcription by inhibiting the recruitment of the preinitiation complex to the c-jun promoter. This led, in turn, to reduced expression of several activator protein-1-dependent genes (COX-2, cyclin D1, collagenase-1). These findings provide new insights into the mechanisms underlying the antitumor activity of HDAC inhibitors.

Complexed PSA performance for prostate cancer detection in an African-American population

Objectives Complexed prostate-specific antigen (cPSA) has been shown to improve the differentiation of benign and malignant disease compared with total PSA (tPSA) in studies evaluating predominantly white populations of men. We sought to evaluate the diagnostic performance of cPSA relative to tPSA in a population of African-American men. Methods Consecutive African-American men scheduled for prostate biopsy were enrolled prospectively at the Louisiana State University Medical Center, New Orleans. Serum was collected before the biopsy procedure and tested with the Immuno 1 tPSA and cPSA methods. Receiver operating characteristic curve analysis was performed and the area under the curve was calculated for tPSA and cPSA. Results A total of 156 patients were evaluated, 51 (32.7%) of whom were diagnosed with prostate cancer. The median PSA value for men with prostate cancer was 4.96 ng/mL and for those with benign disease was 3.93 ng/mL. The receiver operating characteristic analysis indicated that the area under the curve for cPSA (0.679) was statistically greater than that achieved for tPSA (0.642, P = 0.004). Using cutoff values for cPSA of 2.3 ng/mL and for tPSA of 2.85 ng/mL provided a specificity of 31.4% and 26.7%, respectively, at a sensitivity for prostate cancer detection of 95%. This was not statistically significant ( P = 0.18). Conclusions cPSA offers modest improvement in prostate cancer detection compared with tPSA in African-American men, but not at the clinically relevant 95% sensitivity level. Additional work is needed to improve prostate cancer detection in this high-risk cohort of patients.

Operative Management of Brachial Plexus Injuries and Tumors

The objective of this review is to contribute information that improves surgical outcomes and to provide management guidelines for various lesions of the brachial plexus. This review was based on the analysis of 1,019 cases of brachial plexus injuries, entrapment, and tumors that were surgically treated at Louisiana State University Medical Center between 1968 and 1998. We describe surgical outcomes of 859 cases, excluding 160 thoracic outlet syndrome cases. Mechanisms of injury included 509 stretch injuries, 118 gunshot wounds (GSWs), 71 lacerations, and 161 neural sheath tumors. Functional outcomes after surgical repair are encouraging. A functional recovery of grade 3 or better was seen in 87% of the stretch injury cases having lesions in continuity, 71% of those repaired with sutures, and 53% of those that underwent graft repairs. In the GSW group, 129 of 202 of the injured plexus elements that had suffered complete loss recovered to grade 3 or better levels. In comparison, 85 of the 91 lesions with incomplete loss of function eventually recovered. Of the lacerating injuries that were repaired, more than 65% of the elements recovered to a grade 3 or better level. Of the 161 neural sheath tumors arising from brachial plexus, most schwannomas and solitary neurofibromas were resected without significant deficits. These surgical results suggest that surgical exploration and repair of brachial plexus lesions are technically feasible and may obtain favorable outcomes if patients are selected appropriately. This review provides management guidelines that may enhance functional outcomes of brachial plexus surgery.

Brachial Plexus Injury: A Survey of 100 Consecutive Cases from a Single Service

We analyzed the epidemiology, preoperative management, operative findings, operative treatment, and postoperative results in a group of 99 patients who sustained 100 injuries to the brachial plexus. The charts of 100 consecutive surgical patients with brachial plexus injuries were reviewed. The patient group comprised 80 males and 19 females ranging from 5 to 70 years of age. One male patient had bilateral brachial plexus palsy. Causes of injury were largely sudden displacement of head, neck, and shoulder and included 27 motorcycle accidents. There were 23 open wounds, including 8 gunshot wounds, 6 other penetrating wounds, and 9 wounds caused by operative or iatrogenic trauma. Loss was exhibited at C5-C6 in 19 patients, at C5-C7 in 15 patients, and at C5-T1 in 39 patients, and 8 patients had another spinal root pattern of injury. Nineteen patients had injury at the cord or the cord to nerve level. Associated major trauma was present in 59 patients. Emergency surgery for vessel or nerve repair was necessary in 18 patients. Myelography (n = 57) or magnetic resonance imaging (n = 7) revealed at least one root abnormality in 52 patients. The median interval from trauma to operation was 7 months. Operative exposures used included anterior supraclavicular, infraclavicular, combined supra- and infraclavicular, or a posterior approach in 5, 14, 77, and 4 patients, respectively. The surgical procedures performed included neurolysis alone in 12 patients and nerve grafting, end-to-end anastomosis, and/or neurotization in 81, 5, and 47 patients, respectively. Postoperative follow-up of at least 36 months was conducted in 78% of the patients. Grade 3 recovery according to Louisiana State University Medical Center criteria means contraction of proximal muscles against some resistance and of distal muscles against at least gravity. Among the 18 patients with open wounds, 14 (78%) recovered to a Grade 3 or better level, as did 35 (58%) of 60 patients with stretch injuries. In all cases of C5-C6 stretch injuries repaired by nerve grafting (n = 10), the patients recovered useful arm function. Brachial plexus injury represents a severe, difficult-to-handle traumatic event. The incidence of such injuries and the indications for surgery have increased during recent years. Graft repair and neurotization procedures play an important role in the treatment of patients with such injuries.

Mirizzi's Syndrome: Experience from a Multi-Institutional Review

P.L. Mirizzi described in 1948 a partial or spastic obstruction of the common hepatic duct secondary to an impacted gallstone in the cystic duct or infundibulum of the gallbladder. The modern definition of Mirizzi's syndrome is thought to include four components: anatomic arrangement of the cystic duct at the gallbladder neck such that it runs parallel to the common hepatic duct; impaction of a stone in the cystic duct or neck of the gallbladder; mechanical obstruction of the common hepatic duct by the stone itself or by secondary inflammation; and intermittent or constant jaundice causing possible recurrent cholangitis and, if longstanding, secondary biliary cirrhosis. Intermittent symptomatology may make Mirizzi's syndrome difficult to diagnose preoperatively or intraoperatively. Bilio-biliary fistulas may or may not be present. Diagnosis and choice of operative repair may be best accomplished by open operative technique. Over a 24-year period two faculty members from Louisiana State University (LSU) Medical Center-Shreveport at Monroe and LSU Baton Rouge treated 4180 cases of cholelithiasis at six Louisiana university and private hospitals. Eleven cases of Mirizzi's syndrome were diagnosed on the basis of operative and preoperative notes with detailed description of size and extent of biliobiliary fistulas when they were present. These 11 cases were reviewed and followed from one to 20 years. Presentation, workup, operative findings, choice of operative repair, choice of operative approach, and complications were evaluated by retrospective chart review. Review of the pertinent literature for informative and comparative purposes was also completed. These 11 cases ranged from Csendes Type I to III. There were no Type IV cases. They were ultimately diagnosed and managed by classical open technique. Four laparoscopic procedures were converted to open technique following initial inspection. All four were converted to open as a result of inability to delineate structures in and adjacent to the triangle of Calot due to marked scarring in the subhepatic space. No iatrogenic injuries or major complications occurred. Mirizzi's syndrome occurs in fewer than 0.5 per cent of patients with cholelithiasis. Removal of stones with partial cholecystectomy and use of gallbladder or cystic duct remnant to oversew or repair Mirizzi fistulas should be considered. Roux-en-y hepaticojejunostomy becomes the procedure of choice when the vascularity or viability of the hepatic duct or tissues available for duct repair is questionable. Review of the literature reveals the increase in complications with laparoscopic versus open technique in Mirizzi's syndrome. Although very little direct evidence exists we believe that when this syndrome is diagnosed or strongly suspected open biliary operation is the procedure of choice because the increased potential for major complications with the use of laparoscopic technique far outweighs the potential slight increase in morbidity of an open procedure.