Monteggia lesion in an Asian small-clawed otter (Aonyx cinerea).

A 10-yr-old female Asian small-clawed otter (Aonyx cinerea) presented with a history of right forelimb lameness. Antebrachial radiographs revealed a Monteggia lesion, classified by cranial radial head luxation and distal diaphyseal ulnar fracture. Open reduction with placement of an ulnar-radial positional screw was performed. The lateral collateral ligament was reconstructed using suture anchored by a condylar screw and bone tunnel in the radius. Reduction and proper implant placement was confirmed on postoperative radiographs. The ulnar-radial positional screw was removed 6 wk postoperatively to allow proper supination and pronation. Limb function was greatly improved at this time; however, a mild lameness was still observed. At 7 mo postoperatively, the otter was ambulating lameness-free. Radiographs documented proper joint reduction and stable condylar screw. At 32 mo postoperatively, the otter continued to exhibit normal ambulation.

Prevention of Rebleeding From Esophageal Varices in Patients With Cirrhosis Receiving Small-Diameter Stents Versus Hemodynamically Controlled Medical Therapy

BACKGROUND & AIMS Patients with cirrhosis and variceal hemorrhage have a high risk of rebleeding. We performed a prospective randomized trial to compare the prevention of rebleeding in patients given a small-diameter covered stent vs those given hepatic venous pressure gradient (HVPG)-based medical therapy prophylaxis. METHODS We performed an open-label study of patients with cirrhosis (92% Child class A or B, 70% alcoholic) treated at 10 medical centers in Germany. Patients were assigned randomly more than 5 days after variceal hemorrhage to groups given a small covered transjugular intrahepatic portosystemic stent-shunt (TIPS) (8 mm; n = 90), or medical reduction of portal pressure (propranolol and isosorbide-5-mononitrate; n = 95). HVPG was determined at the time patients were assigned to groups (baseline) and 2 weeks later. In the medical group, patients with an adequate reduction in HVPG (responders) remained on the drugs whereas nonresponders underwent only variceal band ligation. The study was closed 10 months after the last patient was assigned to a group. The primary end point was variceal rebleeding. Survival, safety (adverse events), and quality of life (based on the Short Form-36 health survey) were secondary outcome measures. RESULTS A significantly smaller proportion of patients in the TIPS group had rebleeding within 2 years (7%) than in the medical group (26%) (P = .002). A slightly higher proportion of patients in the TIPS group experienced adverse events, including encephalopathy (18% vs 8% for medical treatment; P = .05). Rebleeding occurred in 6 of 23 patients (26%) receiving medical treatment before hemodynamic control was possible. Per-protocol analysis showed that rebleeding occurred in a smaller proportion of the 32 responders (18%) than in nonresponders who received variceal band ligation (31%) (P = .06). Fifteen patients from the medical group (16%) underwent TIPS placement during follow-up evaluation, mainly for refractory ascites. Survival time and quality of life did not differ between both randomized groups. CONCLUSIONS Placement of a small-diameter, covered TIPS was straightforward and prevented variceal rebleeding in patients with Child A or B cirrhosis more effectively than drugs, which often required step-by-step therapy. However, TIPS did not increase survival time or quality of life and produced slightly more adverse events. Clinical Trial no: ISRCTN 16334693.

The role of the G20 in WTO governance

Report by Professor Sungjoon Cho, Associate Professor of Law, Chicago-Kent College of Law (Chair), and Charlotte Sieber-Gasser, Doctoral Research Fellow, World Trade Institute, University of Bern, Session 27, WTO Public Forum 2010: The Forces Shapping World Trade, pp.29-33. In the course of the financial crisis, the global geography of power has shifted from G8 to G20. The latter, although representing roughly two thirds of global trade, consists of relatively a small number of global players and is consequently excluding many others from decision-making at the international stage. Nevertheless, the G20 has been successful in its reaction to the financial crisis and became therewith an important new player within the international community. When highlighting how the G20 might interfere with the WTO, the panel voiced concerns over the political legitimacy of the G20, given the limited number of members and the global impact of its decisions. It agreed on the impression that although the G20 intends to extend its debates from the financial sector to world economy in general, it has so far little achieved in this direction, particularly when it comes to moving the Doha agenda forward. It remains, thus, open how the G20 will evolve in the coming few years, and what mandates it will shed or adopt. So far, the G20 has complemented the WTO and international financial institutions in handling the financial crisis. Yet, even if there is little evidence pointing towards a less cooperative role in the future, the desirability of a G20 commitment in WTO trade negotiations has yet to be debated. The panel concluded by providing ideas on how the potential of the G20 might be used to serve global interests even better in the future. In their concluding remarks, the panellists agreed that it remains to be seen whether or not the G20 will further broaden its agenda. Given the ebbing away of the financial crisis there is even the question whether the G20 will remain an important international forum for financial collaboration, or whether it has already served its cause and will eventually disappear from the international stage. The Chair concluded the well attended and lively panel with voicing the hope that the two international bodies – the G20 and the WTO – will work in a positive way together in the future and face the challenges and opportunities in their collaboration to the benefit of everyone.