Longitudinal Midline Incision Research Articles

Presence of mast cells in the rat pericranium – a tissue very sensitive to pain

ObjectiveTo evaluate mast cell presence in the pericranium of Wistar rats.MethodsFive male rats of the Wistar strain were used. The animals were housed under a 12 h light cycle with ad libitum access to food and water and allowed 10 days of acclimatization before tissue sampling. The five rats were anesthetized by intraperitoneal injection of ketamine/xylazine, 10/20 mg/kg. Following aseptic preparation of the head skin, a midline longitudinal incision was made to expose the pericranium. Two samples of the pericranium were taken, one from the right and one from the left. These samples were fixed in 10% buffered formaldehyde for 24 h. After fixation, tissue samples were paraffin-embedded and sectioned at 4 μm. Then, slides were deparaffinized, stained with a concentration of 0.1% toluidine blue for 1 min, and washed with distilled water. Last, slides were photomicrographed under 400x magnification to identify mast cells.ResultsMast cells were identified in the dura mater and the five rats' pericranium. In the dura mater, mast cells were also found in these rats. We found both granulated (intact) and degranulated mast cells.ConclusionWe suggest that future preclinical studies investigating the involvement of dural mast cells and other meningeal cell populations should also include pericranium samples to explore this structure's relevance in migraine pain and other headache disorders.

Abdominal multiorgan procurement from slaughterhouse pigs: a bespoke model in organ donation after circulatory death for ex vivo organ perfusion compliant with the 3 Rs (Reduction, Replacement & Refinement).

BackgroundAdvances in organ preservation, reconditioning and assessment have been driven by the increasing necessity to utilise organs from extended criteria donors, particularly donors after circulatory death. Research efforts in this area have aided translation of machine perfusion technology into clinical practice. Pigs are anatomically and physiologically similar to humans and are an excellent model. However, conducting large animal experimental research is challenging and typically limited by ethical and economic constraints. Here we describe a reproducible, cost-effective multi-organ abdominal procurement model of porcine organs from the slaughterhouse.MethodsDomestic pigs are electrically stunned and exsanguinated following the standard abattoir process. Via a longitudinal midline incision, the thoracoabdominal viscera are removed en bloc by incising along the anterior vertebral plane. The abdominal organs are isolated, perfused and separated preserving their respective vasculature, allowing individual organ use for specific experiments.ResultsThe warm ischaemic time is kept between 15–30 minutes. Using this highly protocolized procurement technique we have procured 12 livers, 162 kidneys and 12 pancreata for research, the majority of which have been utilized for ex situ perfusion experiments.ConclusionsWe have described a reliable and reproducible procedure for abdominal multi-organ procurement from slaughterhouse pigs.

Changes of Neuronal Plasticity in Postoperative Cognitive Dysfunction (POCD)

AbstractBackgroundPostoperative cognitive dysfunction (POCD) is defined as a prolonged cognitive function impairment that occurs within weeks to months of a surgical procedure. Clinically this is a well‐known risk of the surgical experience in the elderly, having been described as a consequence of anesthesia. The medial prefrontal cortex (mPFC) plays a critical role in remote, recent, and short‐term memories over a broad range of tasks. The effect of POCD on neuronal plasticity in mPFC remains controversial. The present study investigates the impact of laparotomy on cognition and synaptic functions.MethodMice were induced with 5% sevoflurane and maintained with 3 ‐ 4% sevoflurane continuously for 30 mins. Under sevoflurane anesthesia, a 2.5 cm longitudinal midline incision was made. Approximately 10 cm of intestine was exteriorized and vigorously rubbed for 2 min and stay outside the abdominal cavity for 1 min. Novel Object Recognition (NOR) test was performed 1hour and 24 hours for the short‐term and long‐term memory seven days after the surgery. Open field test (OFT) and The Elevated Plus Maze test, was performed to exclude motor dysfunction and anxiety. The miniature excitatory postsynaptic currents (mEPSC) and miniature inhibitory postsynaptic currents (mIPSC) were recorded on the 7 or 14 days after surgery.ResultIn the NOR test, mice with undergone laparotomy surgery had worse cognitive performance than the control group. There was no significance between the laparotomy group and the control group in the OFT test and Elevated Plus Maze test. There was no significance in the amplitude of the mEPSC between laparotomy and control group. However, the frequency increased significantly in the laparotomy group than the control group, which can last for 14 days. There was no significance of mIPSC in the amplitude and frequency between the laparotomy group and the control group.ConclusionThese findings demonstrated that laparotomy surgery under sevoflurane leads to learning and memory impairment in adolescent mice without altering motor dysfunction and anxiety. The increase in the presynapse release ability indicated the glutamatergic neuron abnormalities without altering the GABAergic neuron’s function. Our result suggested that postoperative cognitive dysfunctions may be related to surgical trauma and glutamate neurons abnormalities.

Neonatal right mini thoracotomy for repair of critical pulmonary stenosis.

Over the last few decades, due to evolving surgical techniques and medical management, there has been a significant decrease in the rate of mortality and complications for neonates born with critical pulmonary valve stenosis. Median sternotomy is the standard approach; however, this longitudinal midline incision is invasive and leaves a significant scar. A right mini thoracotomy approach to this surgical repair decreases recovery time and the chance of possible future psychological distress from a visible median sternotomy scar. This is the first article to describe a right mini thoracotomy approach for critical pulmonary stenosis during the neonatal period.

Retrocalcaneal Spur Removal and Achilles Tendon Reattachment for the Treatment of Haglund Deformity

Insertional Achilles tendinopathy frequently involves intratendinous calcification of the Achilles tendon insertion and a prominent superolateral calcaneus tuberosity known as a Haglund’s deformity. The incidence of insertional Achilles tendinopathy is up to 30%, affecting both recreational and elite athletes. The indications for surgical treatment of insertional Achilles tendinopathy is appropriate when a patient’s symptoms are recalcitrant to nonoperative therapies. Advancements in surgical treatment include the utilization of the midline longitudinal incision, improved soft tissue handling, and minimizing the detachment of the Achilles tendon insertion during surgery. Surgical treatment includes removal of the Haglund’s deformity, debridement of the Achilles insertion, and bone to tendon repair utilizing a double-row suture anchor construct. The authors are presenting a unique surgical technique for Haglund’s deformity excision, Achilles debridement, and repair without flexor hallucis longus augmentation. Level of Evidence: Diagnostic Level V. See Instructions for Authors for a complete description of levels of evidence.

Postmortem changes in skin appendages-A histological study

Introduction: The importance of estimating time since death was discussed through centuries, even in the most unsophisticated social setups in different parts of the world. Hair, nails, sweat and sebaceous glands are known as the appendages of the skin .They are of epithelial origin and along with the skin, forms the integumentary system. The study aims at looking into the histological changes that occurs during the decomposition process as an attempt to calculate the time since death. Objectives: To observe various histological changes in skin and its appendages. To study time relation between these histological changes and postmortem interval. Materials and Methods: 30 skin samples from human cadavers are collected where actual time of death is known, from Yenepoya Medical college mortuary. Skin samples (1 x 2 cm) from the anterior chest were collected, parallel to the longitudinal midline incision. Tissues were fixed in 10% formalin, embedded in paraffin wax, and stained with hematoxylin-eosin (H and E) and sweat glands for periodic acid-Schiff (alcian-PAS). The skin samples were observed under light microscope for the changes in the following structures: sweat glands, sebaceous glands, and hair follicles. Result: Sebaceous glands and Hair follicle showed minimal changes that are difficult to correlate with PMI. Changes in sweat glands shared an intermediate status between the other two groups in this study which can be sought for in relation with the relation with dermis and epidermis for correlation. Sweat gland PAS staining proved to be of no definite value in this study. This study proves that histology of skin and its appendages is a powerful tool in determining time since death. Conclusion: This study will be helpful in determination of the time since death from the changes in skin appendages. Keywords: Postmortem Interval.

EFFECTS OF MUSIC AND STRESS ON HEALING OF INDUCED WOUND IN THE SKIN OF ADULT MALE ALBINO RATS

Background: Wound healing is a complex process involving intrinsic dermal and epidermal cells, and infiltrating macrophages and leukocytes.Noise and music exposure have long been used to investigate their effects on biological and biochemical responses. Objectives: Studyingthe possible acceleration effect of the process of wound healing after exposure to music, and the stressor effect after exposure to noise. Materials and Methods: Forty adult male albino rats of local strain were chosen as an animal model for this study. They were divided into four equal groups:Control group, wound group, stress-exposed group andmusic-exposed group. On the day of infection, superficial surgical wounds were produced on the shaved backs of anesthetized rats by making a longitudinal midline incision, 2.3 ± 0.2 cm in length and extending down to the panniculuscarnosus.At the end of the experiment (30 days), blood samples were obtained for estimation of WBC, neutrophils, lymphocytes and platelets count. Immediately after the animals were killed, 5-mm punch biopsy specimens of excised skin were taken, and immediately fixed in phosphate-buffered (pH 7.4) formalin (4%). Results: Stress- exposed group showed significant increase in both WBCs and neutrophils counts, and significant decrease in both lymphocytes and platelets counts. In music-exposed group, WBCs significantly increased and platelets significantly decreased. Histopathological examination revealed that the exposure to noise resulted in significantly slowed inflammatory process. This effect was demonstrated by increased infiltration of wounds with polymorphnuclear leucocytes (PMNL). The music exhibited significant acceleration of wound healing activity as compared to noise exposed group .The wound closure time was lesser, as well as the percentage of wound contraction was more. The epithelization of wound was found to be earlier as compared tonoise exposed group. Conclusion: Music has some antistressor effects and may accelerate wound healing.

Curative resection with minilaparotomy approach in the treatment of rectal cancer

To compare the surgical safety and short-term efficacy of minilaparotomy and laparoscopic approach for curative resection of rectal cancer. The retrospective cohort study was adopted. A review of patients scheduled to undergo a curative resection of rectal cancer via minilaparotomy or laparoscopic approach at Department of Colorectal Surgery of Changhai Hospital from June 2016 to May 2017 was carried out. All the patients were confirmed as rectal cancer by postoperative pathology. The following patients were excluded from the study: patients who had acute complete obstruction or perforation; patients underwent Miles or Hartmann procedure; patients who required an elongation of the skin incision in minilaparotomy or a conversion from laparoscopic to open surgery. Finally, 216 patients were enrolled in this study, of whom 143 were performed with minilaparotomy approach (minilaparotomy group) and 73 with laparoscopic approach (laparoscopic group) for curative resection of rectal cancer. For the minilaparotomy technique, a 7 cm longitudinal midline incision was made between the pubic symphysis and umbilicus; a wound retractor was applied to the edge of the wound; lymph node dissection around the inferior mesenteric and artery high ligation of inferior mesenteric artery were performed; by moving the minilaparotomy wound laterally and caudad or cephalad with the S-shaped hook, cautious mobilization of the relevant segment of the bowel loop was performed; bowel anastomosis was achieved by using the double-stapled technique; the gap of the pelvic floor peritoneum and mesentery were routinely closed by the absorbable surgical suture in cases with middle and low position rectal cancer. The surgical safety, the condition of resuming and the morbidity of postoperative complication were compared between the two groups. There were 145 men and 71 women. Age ranged from 26 to 87 years, with of mean age of 61 years. According to the TNM stage grouping, there were 61 patients with stage I(, 62 with stage II(, 85 with stage III(, and 8 with stage IIII( disease, respectively. These two groups did not differ significantly in terms of age, sex, body mass index, site of tumor, TNM stage(all P>0.05). All the patients completed the operation successfully. The median operation time of minilaparotomy group was significantly shorter than that of laparoscopic group [164(80-296) minutes vs. 230(90-665) minutes, Z=4.410, P=0.000]. The intraoperative medical consumable expense [11000(7000-22000) yuan vs. 23000(12000-47000) yuan, Z=11.759, P=0.000] and the total hospitalization expense [44000(22000-146000) yuan vs. 57000(45000-126000) yuan, Z=9.637, P=0.000] were significantly lower in the minilaparotomy group. There were no significant differences between the two groups in terms of operative blood loss, number of harvested lymph nodes, distance of distal resection margin, positive rate of circumferential resection margin (all P>0.05). The rate of postoperative complication in minilaparotomy group was 7.0%(10/143) and in laparoscopic group was 9.6%(7/73) without significant difference (χ2=0.449, P=0.503). There were 2 patients in each group who required readmission to the hospital within postoperative 30 days. The cause of readmission was ileus or acute hyponatremia in minilaparotomy group, and ileus or pevic infection in laparoscopic group. One patient died of brain death caused by acute pulmonary embolism during the perioperative period in minilaparotomy group. The minilaparotomy approach for curative resection of rectal cancer is safe and feasible. As compared with laparoscopic approach, it is advantageous to achieve minimal invasiveness and early recovery, but much cheaper and less time consuming.

Analysis of percutaneous tension band wiring for patellar fractures

Aim: Patella fractures are more common and account for approximately 1% of all fractures1. The most common method of fixation is a modified tension band wiring by using 2 k wires through a midline longitudinal incision which has its own complications. We analyzed the outcome of percutaneous tension band wiring which has less complication rate than open tension band wiring. Materials and Methods: Our study was a prospective study conducted in Department of Orthopaedics, Coimbatore medical college during March 2015 to December-2016. We analyzed the clinical and radiological outcome of transverse patellar fractures in 20 patients treated with percutaneous tension band wiring. There were 14 men and 6 women aged 22 to 50 (mean 36 years) in our study. Pain, operating time, mobility, functional score, and complications were evaluated. Results: Operative time and blood loss in percutaneous tension band wiring is much less compared with open tension band wiring. This technique both clinically and radiologically showed rapid bony union. Lysholm knee score that was used in our study is more with percutaneous tension band wiring. Mean operating time was 30 (range 20 to 50) minutes. The mean follow up period was 8 months (range 6 to 12) months. At the latest follow-up, all patients had good results with painless knee motion, no quadriceps wasting and no subjective disability. Total range of motion was excellent at an average of 142.4 degrees of knee flexion. There were no complications like infection, limitation of knee motion, loss of reduction, implant breakage. All patients had radiological union at eight weeks. Conclusion: As the percutaneous tension band wiring is done without a wide skin incision, patient satisfaction is more. This technique provide stable fixation, allows early mobilization by minimizing injury to extensor mechanism and reduce cosmetic problem in scar. Hence we conclude percutaneous tension band wiring is a safe and alternative procedure to open tension band wiring

Treatment of acetabular fractures involving the anterior column through the paramedian approach

Objective To explore the surgical techniques and clinical efficacy of the paramedian approach in the treatment of acetabular fractures involving the anterior column. Methods From August 2013 to December 2014, 56 patients with acetabular fracture were treated through the paramedian approach. They were 34 men and 22 women, aged from 29 to 58 years (average, 38 years) . According to Letournel-Judet classification, 12 cases were anterior column fracture, 18 cases fracture of anterior column plus posterior hemitransverse, 9 cases transverse fracture, 6 cases T-shape fracture, and 11 cases both column fracture. All patients were treated by open reduction and internal fixation through the paramedian approach after general anesthesia. After an abdominal midline longitudinal incision was made, the rectus abdominis anterior sheath was cut longitudinally 2-3 cm para-linea alba. After the rectus abdominis was retracted to the lesion side, the rectus abdominis posterior sheath was cut to expose the deep pelvic fracture. In the 12 patients who had been complicated with iliac wing fracture, an additional iliac fossa approach was used. Results The mean surgical time was 105 min (range, from 96 to 188 min) ; the mean blood lose was 400 mL (range, from 200 to 800 mL) ; red cell transfusion was 2.4 units (range, from 0 to 4 units) . The 56 patients were followed up for an average of 16 months (range, from 6 to 22 months) . According to the Matta's fracture reduction assessment, 38 cases were excellent, 11 good, 4 fair, and 3 poor, giving a good-to-excellent rate of 87.5%. All factures healed within 3 months. According to the modified Merle d'Aubigne & Postel scoring at the end of follow-up, the hip joint function was rated as excellent in 34 cases, good in 12, fair in 6 and poor in 4, giving a good-to-excellent rate of 82.1%. No abdominal wall hernias, wound infection or injury to major nerves or vessels was observed during follow-up. Conclusions In the treatment of acetabular fractures involving the anterior column, the paramedian approach can fully reveal anterior wall, anterior column and posterior column of the acetabulum. It is easy to handle and unlikely to injure major vessels and nerves. It also leads to less blood loss. This approach can be used for the majority of acetabular fractures involving the anterior column. Key words: Acetabulum; Fractures, bone; Fracture fixation, internal; Paramedian approach

Prevention of abdominal adhesions and healing skin after peritoniectomy using low level laser

Adhesions commonly occur after abdominal surgery and can cause bowel obstruction, chronic abdominal pain, and infertility. Their prevention remains a challenge. To evaluate the effects of the application of low-level lasers on the prevention of adhesions and scarring of the skin after peritoniectomia. Twenty-four New Zealand breed male rabbits, approximately 2 months of age, were randomly divided into 3 groups (n = 8): GC-control group not subjected to laser, GL1-group with laser application at a dose of 0.2 J, and GL2-group with laser application at a dose of 3.6 J. All animals received a longitudinal midline incision and a bilateral resection of the peritoneal fragment, measuring 3 × 1 cm(2) . The animals received a laser treatment of one application every 24 hours, beginning at the time of surgery and lasting for a period of 4 days. After 14 days post-surgery, the animals were killed and adhesion formation was evaluated qualitatively and quantitatively by means of a laparotomy shaped inverted "U", which allowed for the verification of the broad wall of the abdominal cavity and organs. Differences were considered significant at P < 0.05. The adhesion formation was observed in 100% of the rabbits from groups GC and GL1, as compared to 37.5% of the rabbits from group GL2 (P < 0.01). The evaluation of the vascularization and tenacity of adhesions among the groups showed no significant difference. In groups CG and GL1, 72% and 83% of adhesions were verified between visceras, respectively whereas in GL2 occurred among abdominal wall. The tensile strength of the skin between the groups was not significant (P = 0.3106). The resistance of abdominal wall segments without skin he resistance of skin segments between groups GL2 and GC were higher than in GL1 (P = 0.01). Low-level LASER is effective in preventing intra-abdominal adhesions in rabbits without compromising strength and healing of the abdominal wall.

Cannulation of the internal carotid artery in mice: A novel technique for intra-arterial delivery of therapeutics

We have developed a novel minimally invasive technique for the intra-arterial delivery of therapeutics to the mouse brain. CD-1 mice were anesthetized and placed in a lateral decubitus position. A 10mm midline longitudinal incision was made over the thyroid bone. The omohyoid and sternomastoid muscles were retracted to expose the common carotid artery and external carotid artery (ECA). To maximize delivery of administered agents, the superior thyroid artery was ligated or coagulated, and the occipital artery and the pterygopalatine artery (PPA) were temporarily occluded with 6-0 prolene suture. The ECA was carefully dissected and a permanent ligature was placed on its distal segment while a temporary 6-0 prolene ligature was placed on the proximal segment in order to obtain a flow-free segment of vessel. A sterilized 169μm outer diameter polyimide microcatheter was introduced into the ECA and advanced in retrograde fashion toward the carotid bifurcation. The catheter was then secured and manually rotated so that the microcatheter tip was oriented cephalad in the internal carotid artery (ICA). We were able to achieve reproducible results for selective ipsilateral hemispheric carotid injections of mannitol mediated therapeutics and/or gadolinium-based MRI contrast agent. Survival rates were dependent on the administered agent and ranged from 78 to 90%. This technique allows for reproducible delivery of agents to the ipsilateral cerebral hemisphere by utilizing anterograde catheter placement and temporary ligation of the PPA. This method is cost-effective and associated with a low rate of morbimortality.

Treatment of Schatzker Type V and VI Tibial Plateau Fractures Using a Midline Longitudinal Incision and Dual Plating

PurposeThe purpose of this study was to evaluate the results of the treatment of Schatzker type V and VI tibial plateau fractures using a midline longitudinal incision and dual-plate fixation.Materials and MethodsTen patients with Schatzker type V and VI tibial plateau fractures treated with a midline longitudinal incision and dual plating were analyzed. The patients were followed for a minimum of one year. Clinical outcomes were evaluated using range of motion, visual analogue scale (VAS) and Knee Society Score. Radiological outcomes were evaluated using the bony union time, medial proximal tibial angle (MPTA) and posterior proximal tibial angle (PPTA).ResultsThe mean VAS score was 2.2 points, and the mean Knee Society function score was 85 points at the final follow-up. The mean flexion contracture was 2.5° and the mean further flexion was 125°. It took an average of 4 months until bony union occurred. The mean MPTA and PPTA were 90.5° and 4.4°, respectively. There was one case of delayed wound healing, but no other complications were observed.ConclusionsThe treatment of Schatzker type V and VI tibial plateau fractures with a midline longitudinal incision and dual-plate fixation resulted in satisfactory clinical and radiological outcomes. This can be an option when treating Schatzker type V and VI tibial plateau fractures.

Tubularized incised plate urethroplasty with dorsal inlay graft prevents meatal/neourethral stenosis: a single surgeon's experience

Background/Purpose Snodgrass tubularized incised plate urethroplasty (SUP) is versatile and has good cosmesis. However, postoperative meatal/neourethral stenosis (M/N-S) is common enough for some surgeons to add a dorsal inlay graft (DIG) harvested from the inner prepuce and sutured to cover the longitudinal midline incision of the urethral plate. This is the first formal assessment of the effectiveness of DIG for preventing M/N-S. Methods We reviewed the medical records of 100 consecutive SUP cases performed by a single surgeon between 2003 and 2010 comparing SUP + DIG (S + D group, n = 50) with SUP − DIG (S − D group, n = 50). Mean follow-up was 3.6 years. Data were analyzed statistically using the χ 2, 2-way ANOVA, and Mann-Whitney tests, with P < .05 considered significant. Results Severity of hypospadias and type of SUP were similar. Mean age at SUP was 3.3 years in S + D and 3.6 years in S-D ( P = NS). There were 4 complications in the S + D group: urethrocutaneous fistula (n = 3) and neourethral stenosis without diverticulum (n = 1). There were 15 complications in the S-D group : meatal stenosis (n = 2), neourethral stenosis with or without diverticulum (n = 6), urethrocutaneous fistula (n = 7) ( P < .01). M/N-S was significantly less in the S + D group (1 vs 8; P < .05). Conclusions We strongly recommend that DIG be performed routinely during SUP.

Comparative Histological and Functional Controlled Analysis of Tubularized Incised Plate Urethroplasty With and Without Dorsal Inlay Graft: A Preliminary Experimental Study in Rabbits

We analyzed the histological and functional characteristics of the tubularized incised plate vs dorsal inlay graft urethroplasty in an experimental rabbit model. A total of 24 New Zealand male rabbits were randomly allocated into 4 groups, including sham operation, urethroplasty, tubularized incised plate urethroplasty and dorsal inlay graft urethroplasty. In the urethroplasty group the anterior urethral wall was half excised and the dorsal aspect was tubularized. In the tubularized incised plate group the same steps were followed but tubularization followed a longitudinal midline incision in the dorsal wall. In the dorsal inlay graft group the defect created by the dorsal incision was covered with an inner preputial graft. The animals were sacrificed at 4 and 8 weeks, respectively. The penis was immediately harvested for standardized passive flowmetry and subsequently fixed for histological staining. The grafts took in all animals. The tubularized incised plate defect was bridged by urothelium while in the dorsal inlay graft group the preputial graft kept its original histological characteristics. There was a significant decrease in average flow in the urethroplasty group (1.6 ml per second) compared to that in the sham operated group (3.4 ml per second) and to the other groups (p <0.05). However, no significant difference in average flow was found for the tubularized incised plate and dorsal inlay graft groups (2.4 and 2.2 ml per second, respectively, p = 0.7). In this short-term rabbit model dorsal inlay graft urethroplasty was feasible with good graft take and integration. Simple tubularization of a reduced urethral plate led to significantly decreased flow. Incision of the reduced plate with or without grafting improved the average flow. Findings in this experimental model do not support the superiority of dorsal inlay graft urethroplasty over tubularized incised plate urethroplasty in terms of urethral flow dynamics.

Reflexes from pulmonary arterial baroreceptors in dogs: interaction with carotid sinus baroreceptors

In contrast to the reflex vasodilatation occurring in response to stimulation of baroreceptors in the aortic arch, carotid sinuses and coronary arteries, stimulation of receptors in the wall of pulmonary arteries results in reflex systemic vasoconstriction. It is rare for interventions to activate only one reflexogenic region, therefore we investigated how these two types of reflexes interact. In anaesthetized dogs connected to cardiopulmonary bypass, reflexogenic areas of the carotid sinuses, aortic arch and coronary arteries and the pulmonary artery were subjected to independently controlled pressures. Systemic perfusion pressure (SPP) measured in the descending aorta (constant flow) provided an index of systemic vascular resistance. In other experiments, sympathetic efferent neural activity was recorded in fibres dissected from the renal nerve (RSNA). Physiological increases in pulmonary arterial pressure (PAP) induced significant increases in SPP (+39.1 ± 10.4 mmHg) and RSNA (+17.6 ± 2.2 impulses s(−1)) whereas increases in carotid sinus pressure (CSP) induced significant decreases in SPP (−42.6 ± 10.8 mmHg) and RSNA (−42.8 ± 18.2 impulses s(−1)) (P < 0.05 for each comparison; paired t test). To examine possible interactions, PAP was changed at different levels of CSP in both studies. With CSP controlled at 124 ± 2 mmHg, the threshold, 'set point' and saturation pressures of the PAP–SPP relationship were higher than those with CSP at 60 ± 1 mmHg; this rightward shift was associated with a significant decrease in the reflex gain. Similarly, increasing CSP produced a rightward shift of the PAP–RSNA relationship, although the effect on reflex gain was inconsistent. Furthermore, the responses to changes in CSP were influenced by setting PAP at different levels; increasing the level of PAP from 5 ± 1 to 33 ± 3 mmHg significantly increased the set point and threshold pressures of the CSP–SPP relationship; the reflex gain was not affected. These results indicate the existence of interaction between pulmonary arterial and carotid sinus baroreceptor reflexes; physiological and pathological states that alter the stimulus to one may alter the reflex responses from the other.

Congenital diaphragmatic hernia: a modern day approach

Centralization of all complicated congenital diaphragmatic hernias (CDH) was organized in Germany from 1998, collecting 325 consecutive patients with striking increasing survival rates. This series report 244 patients from 2002 to 2007. Today, large defects are detected early in pregnancy by ultrasound and magnetic resonance imaging (MRI). In extracorporeal membrane oxygenation (ECMO) patients, prenatal lung head ratio (LHR) was 1.2 (median) at the 34th week of gestation or less than 25 ml lung tissue in MRI. This means that all patients below LHR of 1.4 should be transferred prenatally in a tertiary center. High risk group for survival was defined as LHR below 0.9, ie, 10 ml in MRI planimetry. Inborn patients show better results than outborns. In algorithm therapy, gentle ventilation plays an important role in preventing damage to the lung tissue and avoiding long term ventilation. When PaCO(2) was more than 75 mmHg, ventilation was changed to high frequency oscillatory ventilation (HFOV). Indication for ECMO was seen in preductal PaO(2) less than 50 mmHg over 2-4 h or less than 40 mmHg over 2 h. ECMO related risks included intracerebral bleeding (9%), intrapulmonary bleeding (14%), and convulsions (16%). Surgically, a longitudinal midline incision for exposure of the defect, the duodenal kinking, and probably for abdominal patching was perfect. A cone formed goretex patch provided more abdominal space and reduced abundant intrathoracical cavity. No drain was used. Postoperative complications were described. Overall survival in 244 consecutive patients was 86.5% for all patients born alive. All those who needed ECMO survived in 71%, underlining ECMO as a treatment of last choice. Follow-up for quality of life after CDH is described.

Emergency cricothyrotomy

Emergency cricothyrotomy

Observations on the Fibrous Retinacula of the Heel Pad

The original purpose of the study was to clarify whether or not there is continuity of the Achilles tendon and the plantar fascia. Those findings have been previously published. In the course of that study, observations of the anatomy of the retinacular tethers of the heel pad were made. These observations included the discovery of the medial calcaneal retinaculum. Ten adult cadaver feet were dissected. A longitudinal midline incision was made along the Achilles tendon and on the plantar surface of the foot. The heel pad was incised and the skin and heel pad were reflected side-to-side to reveal the calcaneal tuberosity. In this way the retinacular tethers of the heel pad could be seen. Two types of retinacular fibers were observed. Abundant small retinacula were seen coming off the plantar fascia and calcaneal tuberosity. Less abundant larger retinacula originated from the calcaneus only. Both types anchored the heel pad by branching into the fibrous stroma of the heel pad. In nine of 10 feet, a much larger retinacular structure was the principle tether of the heel pad to the medial process of the calcaneal tuberosity. We named this the medial calcaneal retinaculum. The heel pad is anchored by retinacula that vary in number, location, and size. The most consistent and significant tether of the heel pad appears to be the medial calcaneal retinaculum. Dislocation of the fat pad of the heel is a relatively rare but potentially devastating injury. An understanding of the anatomical anchoring of the heel pad and its mechanical function can lead to a surgical procedure to restore stability to the heel pad.

Hepatocyte Growth Factor/Scatter Factor and MET Are Involved in Arterial Repair and Atherogenesis

Several studies have shown that in the arterial wall hepatocyte growth factor/scatter factor (HGF/SF) is expressed by smooth muscle cells (SMCs) but acts on endothelial cells, not SMCs. Other studies, however, have indicated that SMCs can respond to HGF/SF. We have reinvestigated expression and activity of HGF/SF and its receptor MET in arterial SMC and endothelial cell cultures and in whole arteries after superficial or deep injury or atherogenesis. High-density cultures of SMCs produced HGF/SF but did not express MET, whereas SMCs, at the leading edge of injured cultures, expressed both ligand and receptor and showed a dramatic motility and growth response to HGF/SF. In line with these results, HGF/SF and MET expression was undetectable in the media of uninjured carotid arteries but was induced after deep arterial injury in areas of SMC migration in the neointima. Strong MET expression was also observed in the SMCs of the atherosclerotic lesions of homozygous apoE(-/-) mice, whereas HGF/SF was expressed by macrophage-derived foam cells. These results demonstrate that MET is induced in migrating and proliferating SMCs and that HGF/SF and MET are key mediators of the SMC response in atherogenesis.