Is replacement of albumin in major abdominal surgery useful?

Study Objective

To evaluate retrospectively serum albumin concentrations as well as morbidity and mortalitiy of abdominal surgical patients who -if hypoalbuminemic- did not receive human albumin solutions versus those who did receive such solutions.

Design

Retrospective observational study.

Setting

Academic community hospital.

Measurements

The records of 76 consecutive patients who had undergone elective abdominal surgery were reviewed. Preoperative and postoperative serum albumin concentrations up to the seventh day after surgery were recorded. Morbidity and mortality were followed until the time of discharge from the hospital.

Results

38 patients who received albumin replacement if they were hypoalbuminemic versus 38 patients who did not receive albumin replacement showed no significant difference in cumulative (P < 0.52) or individual postoperative complications (infections P < 0.35, cardiovascular complications P < 1.0, organ failure P < 0.67, thromboembolic incidents P < 0.26), and mortality (P < 0.47).

Conclusions

Postoperative serum albumin concentration had no correlation with postoperative morbidity. There is no justification for perioperative albumin replacement in abdominal cancer surgical patients.     

Complications arising from splenic embolization after blunt splenic trauma

Background

Nonoperative management (NOM) of splenic trauma is now the standard in stable trauma patients. Splenic artery embolization (SAE) is an increasingly used adjunct to NOM. We examined complications arising from SAE.

Methods

Patients admitted to a level I trauma center with splenic trauma over a 26-month period were identified. Management method, operative or nonoperative, was noted. SAE patients were analyzed in detail.

Results

There were 284 splenic trauma admissions. Ninety-three patients underwent operative management, and 191 received NOM. Fifteen patients (7.8%) underwent SAE. Embolization was proximal in 10, distal in 1, and combined in 4 patients. No NOM failures occurred. Major complications (27%) included splenic bleeding, splenic infarction, splenic abscess, and contrast-induced renal insufficiency. Minor complications of fever, pleural effusions, and coil migration occurred in 53% of patients. No relationship between SAE location and the presence of complications was noted.

Conclusions

SAE is an effective and safe procedure. Both major and minor complications can arise after SAE.     

Autologous stem cell transplantation for systemic lupus erythematosus: report of efficacy and safety at 7 years of follow-up in 17 patients

Introduction

We observed the efficacy and toxicity of autologous stem cell transplantation (auto-SCT) for patients with systemic lupus erythematosus (SLE).

Methods

Seventeen patients with SLE were treated with auto-SCT. No prisoners were used in the study. Peripheral blood stem cells were mobilized with cyclophosphamide (Cy) and granulocyte colony-stimulating factor. After a conditioning regimen of Cy and antithymocyte globulin, we reinfused stem cells. The probabilities of overall survival (OS) and progression-free survival (PFS) were used to assess the efficacy and adverse experiences, to detect the toxicities of the treatment.

Results

The median follow-up time was 89 months (range 33-110). Probabilities of 7-year OS and PFS were 82.4% ± 9.2% and 64.7% ± 11.6%, respectively. The principal adverse events included allergy, infection, elevation of liver enzymes, bone pain, and heart failure. Two patients died due to severe pneumonia and heart failure at 33 and 64 months after transplantation, respectively.

Conclusions

Our 7-year follow-up results suggested that auto-SCT seemed beneficial for SLE patients.     

Introduction of fibrinogen in the treatment of hemostatic disorders during orthotopic liver transplantation: implications in the use of allogenic blood

Background

Orthotopic liver transplantation (OLT) requires a large amount of blood-derived resources. The indications for their availability in the surgery area is based on empirical protocols. The implementation of point-of-care apparatuses gives rise to the detection of hemostatic alterations due to functional deficits of fibrinogen.

Methods

To monitor coagulation disorders and other biochemical parameters, we used thromboelastometry (ROTEM®) and a MovlLab® unit, respectively. We evaluated the stability and firmness of the clot based on fibrin (FibTem test). The measurements were performed during all of the liver transplant stages: baseline, anhepatic, and reperfusion. Fibrinogen (hemocompletan) was administered to achieve maximum clot firmness, based on patient weight and the existence of surgical bleeding. This pilot cohort of 20 transplant patients (group B) compared outcomes with the 59 patients from the previous year (group A).

Results

Haemocompletan was administered to 45% of the 20 patients. The ratio of red blood cell components per patient diminished from 8.4 to 3.9 (53% reduction) and, fresh frozen plasma from 5.6 to 1.9 (65% reduction). Transfusions of platelet concentrates decreased by 50% with a ratio of 1.5-0.7 per patient. Likewise, 20% of transplant patients received no transfusions of blood products compared with 3.5% in the previous period.

Conclusion

The incorporation of fibrinogen into the treatment of hemostatic disorders in OLT leads to a reduced use of allogenic blood products. We observed reduced number of patients who received transfusions, while those who underwent transfusion did so to a lesser degree.     

The role of obesity in kidney transplantation outcome

Background

The number of obese kidney transplant candidates has been growing. However, there are conflicting results regarding to the effect of obesity on kidney transplantation outcome. The aim of this study was to investigate the association between the body mass index (BMI) and graft survival by using continuous versus categoric BMI values as an independent risk factor in renal transplantation.

Methods

We retrospectively reviewed 376 kidney transplant recipients to evaluate graft and patient survivals between normal-weight, overweight, and obese patients at the time of transplantation, considering BMI as a categoric variable.

Results

Obese patients were more likely to be male and older than normal-weight recipients (P = .021; P = .002; respectively). Graft loss was significantly higher among obese compared with nonobese recipients. Obese patients displayed significantly lower survival compared with nonobese subjects at 1 year (76.9% vs 35.3%; P = .024) and 3 years (46.2% vs 11.8%; P = .035).

Conclusions

Obesity may represent an independent risk factor for graft loss and patient death. Careful patient selection with pretransplantation weight reduction is mandatory to reduce the rate of early posttransplantation complications and to improve long-term outcomes.     

Is excisional biopsy indicated for patients with lobular neoplasia diagnosed on percutaneous core needle biopsy of the breast?

Background

The value of excisional biopsy for patients with lobular neoplasia diagnosed by core needle breast biopsy is controversial.

Methods

A retrospective analysis of all patients with lobular carcinoma in situ or atypical lobular hyperplasia on core needle biopsy.

Results

Twenty-five patients were identified. Twelve (48%) underwent excisional biopsy. None of the patients who had excisional biopsy were found to have ductal carcinoma in situ (DCIS) or invasive cancer. The mean follow-up was 66 months. Five patients (20%) developed DCIS or invasive cancer during follow-up. The rate of subsequent carcinoma among those undergoing excisional biopsy was 25%, and among those not undergoing excisional biopsy it was 15% (P = .57). Among patients who did not undergo excisional biopsy, none developed carcinoma within the same quadrant of the breast.

Conclusions

Excisional biopsy for lobular neoplasia did not identify understaged carcinoma or alter the rate of subsequent carcinoma. The subsequent carcinoma risk is diffuse and bilateral; it does not correlate with the site at which lobular neoplasia was diagnosed.     

Prolongation of Islet Graft Survival Using Concomitant Transplantation of Islets and Vascular Endothelial Cells in Diabetic Rats

Background

The transplantation of isolated islets of Langerhans is nearing acceptance as treatment of type 1 diabetes mellitus. Because the arterial and venous connections of the pancreas are disrupted during islet isolation, islets must be revascularized after transplantation.

Objective

To observe whether increased numbers of vascular endothelial cells in islets can affect the angiogenesis and function of the grafts.

Materials and Methods

Rats with streptozocin-induced diabetes were divided into 3 groups. The rats in group 1 received islet grafts under the capsule of the left kidney; rats in group 2 received combined vascular endothelial cell and islet transplants; and rats in group 3 served as controls. After the transplantation procedure, blood glucose and insulin concentrations were evaluated daily. Hematoxylin-eosin and immunohistochemical staining was used to detect expression of vascular endothelial growth factor antibodies in the diabetic rat kidneys. The mean microvascular density was also calculated.

Results

At 3 days posttransplantation, blood glucose and insulin concentrations returned to normal in group 2, however, they declined only slightly in group 1, and moderate hyperglycemia was present. There was a significant difference in blood glucose and insulin concentrations between the 2 groups after 3 days (P < .05). The mean (SD) microvascular density in group 2 was markedly higher than that in group 1 (12.58 [1.81] vs 10.38 [0.97] P = .04).

Conclusion

This study suggests that concomitant transplantation of isolated islets with endothelial cells can prolong islet graft survival in diabetic rats.     

Cold Ischemia Time Influences Spermatogenesis in a Testicular Ischemia/Reperfusion Injury Model

Objective

To evaluate the influence of cold ischemia time on spermatogenesis in a rabbit model of testicular ischemia-reperfusion (I/R) injury.

Material and Methods

The testicular I/R model was established in 24 male white rabbits. The left testes were preserved using HC-A solution at 0°C to 4°C. Cold ischemia time was 1, 2, 4, and 6 hours. The right testes without vascular occlusion were used as autologous controls. Twenty-four hours after reperfusion, the animals were sacrificed, and samples were obtained at bilateral orchiectomy. Another 8 normal testes were used as normal controls. Testicular tissue Johnsen score, malondialdehyde concentration, and apoptosis index were used to evaluate spermatogenesis.

Results

The Johnsen score decreased and the apoptosis index increased with the duration of cold ischemia time in the I/R groups. The malondialdehyde concentration in the I/R groups was significantly higher than the sham and normal groups, and was highest at 4 hours of cold ischemia time.

Conclusion

Testicular I/R injury is highly related to cold ischemia time. In rabbit models, testis transplantation is best performed within 4 hours of cold ischemia with traditional hypothermic protection.     

Prognostic significance of biochemical heterogeneity of catecholaminergic clones in neuroblastoma

Background/Purpose

Genetic heterogeneity of neuroblastic tumors leads to biochemical changes that manifest themselves in different symptoms and clinical courses, which may vary from spontaneous regression and remission to progression with fatal outcome.

Methods

To test the hypothesis that ratios of dopamine (DA) to noradrenaline and of DA to vanillylmandelic acid reflect the composition of adrenergic clones and tumor heterogeneity, we determined urinary DA/noradrenaline and DA/vanillylmandelic acid ratios that presumably reflect DA-β-hydroxylase (DBH) activity and the prognostic values thereof.

Results

Based on catecholamine metabolism, 4 model situations were defined: (a) complete block of DBH in all cells; (b) block of DBH in some cells; (c) a different enzymatic block; and (d) normal DBH activity in the population of tumor-forming cells. Normal DBH activity was encountered most frequently in children younger than 2 years and in tumors representing favorable prognostic stages (I, II, and IVS). Surviving children with stage IV neuroblastoma presented with tumors composed primarily of cells without the DBH block. Further stratification of 2 prognostically poor groups (stages IV and III + IV) was possible with respect to DBH activity.

Conclusions

Differential production of neurotransmitters in a population of tumor cells may be explained in terms of tumor heterogeneity.