Hormonal differences between female kidney transplant recipients and healthy women with the same gynecologic conditions

Background

End-stage renal disease is associated with severe abnormalities in reproductive function. However, the abnormalities are reversed by successful kidney transplantation. The aim of the present study was to compare hormonal levels between recipients with successful kidney transplantations and healthy women with the same gynecologic conditions.

Methods

The study group consisted of 31 women of reproductive age with end-stage renal disease who underwent successful kidney transplantation. The ratio of the control group, composed of healthy woman, to the study group was 3:1 matched for age and symptoms.

Results

Abnormal bleeding (n = 14) and infertility were the most common gynecologic conditions in kidney transplant recipients. The levels of estrogen (E2) and follicle-stimulating hormone (FSH) in the study group were higher than in the control group, but the levels of progesterone (P4) and luteinizing hormone (LH) were lower in the study group than in the control group. There were no significant differences in prolactin and thyroid-stimulating hormone between the two groups. The incidence of infertility in patients who receive steroid was higher than those with no steroid use (P = .007).

Conclusions

Compared with healthy age- and symptom-matched women, female kidney transplant recipients have increased levels of E2 and FSH and decreased levels of P4 and LH. These differences in hormone profiles may predispose kidney transplant recipients to increased risk of gynecologic pathologies.     

Bipolar radiofrequency tonsillotomy compared with traditional cold dissection tonsillectomy in adults with recurrent tonsillitis

Objective

To compare short- and long-term results of radiofrequency tonsillotomy and traditional cold dissection tonsillectomy in adult patients with recurrent tonsillitis.

Study Design

A randomized clinical trial.

Setting

A tertiary referral university hospital.

Subjects and Methods

Of 62 adults with recurrent tonsillitis, 24 patients were treated with cold dissection tonsillectomy, while radiofrequency tonsillotomy (RF) by use of radiofrequency induced thermotherapy probes was performed in the remaining 38 patients. Duration of surgery, amount of intraoperative bleeding, recovery time, postsurgical pain (measured by use of visual analogue scale on days 1, 3, 5, and 10 after surgery), dysphagia, weight loss, and time of return to normal diet and activity were measured. All the patients were followed for 12 to 24 months for recurrence of tonsillitis episodes.

Results

Comparing the radiofrequency tonsillotomy group to the cold dissection tonsillectomy group, mean duration of surgery was 16.89 versus 45.04 minutes, recovery time was 14.32 minutes versus 17.08 minutes, and amount of intraoperative bleeding was 15 to 20 cc versus 250 to 300 cc, respectively (P < 0.005). There was no difference between the two groups in the recurrence of tonsillitis episodes after 24 months.

Conclusion

Tonsillotomy with radiofrequency is a simple, rapid, and effective method in adult patients with recurrent tonsillitis.     

Failure of immunosuppressive drug levels to predict T-cell reactivity in pediatric transplant patients

Purpose

In children, therapeutic management of immunosuppression relies on allograft function, drug levels, and clinical insight. Using a Food and Drug Administration-approved test for T-cell response, T-cell activation in vitro can be measured to monitor the immune response.

Methods

In a retrospective study, 92 posttransplant children who received either a liver and/or kidney transplant and were followed by routine screening had their T-cell response tested by the Cylex ImmuKnow assay (Columbia, MD). After phytohemagglutinin-L stimulation of T-cells, adenosine triphosphate (ATP) concentrations were measured. In this assay, light emission at λ = 562 nm is proportional to the ATP concentration (ng/mL). Immunosuppressive drug trough levels were also measured. Quantitative real-time polymerase chain reaction Epstein-Barr virus (EBV) viral titers were determined for 2 patients.

Results

Separating the results into younger than 12 years and 12-year or older populations, we found that for the younger than 12 years, 28% of patients were in the low immune function category, 47% in the moderate, and 25% in the high category. For the 12 years or older, 25% of patients were in the low immune function category, 47% in the moderate, and 28% in the high category. The immune function distribution was not different (P = not significant) between the younger than 12 years and 12-year or older groups. Tacrolimus trough levels were 6.3 ± 2.4 ng/mL for younger than 12 years and 5.6 ± 3.3 ng/mL for 12 years or older (P = not significant), and rapamycin was similar, but both showed no correlation to immune function. We observed increased ATP values with decreased EBV viral loads.

Conclusions

These results suggest that tacrolimus and/or rapamycin levels do not adequately determine the biologic effect of immunosuppression. We expect that future T-cell activation monitoring will allow us to diminish rejection and infection events posttransplantation and lead to a healthier pediatric transplant population.     

Intravenous landiolol, a novel β(1)-adrenergic blocker, reduces the minimum alveolar concentration of sevoflurane in women

Study Objective

To investigate the effect of intravenous (IV) landiolol, a novel β₁-adrenergic blocker, on the minimum alveolar concentration (MAC) of sevoflurane in adult women.

Design

Prospective, randomized study.

Setting

University hospital.

Patients

42 ASA physical status 1 and 2 women, aged 24-57 years, who were scheduled to undergo elective abdominal surgery.

Interventions

Anesthesia was induced in all patients by vital capacity rapid inhalation induction of sevoflurane. In the landiolol group, administration of landiolol began when patients took a vital-capacity breath: 0.125 mg/kg/min for one minute and then 0.04 mg/kg/min. Normal saline was administered in the control group.

Measurements

MAC was determined by a technique adapted from the conventional up-down method.

Main Results

The MAC of sevoflurane was 2.2% ± 0.2% in the control group and 1.7% ± 0.2% in the landiolol group, a statistically significant difference (P = 0.0005).

Conclusions

IV landiolol reduces the MAC of sevoflurane in women by approximately 20%.     

The frequency of apneas in premature infants after inguinal hernia repair: do they need overnight monitoring in the intensive care unit?

Background

Postoperative apneas are reported in up to 49% of premature infants undergoing anesthesia for inguinal hernia repair. Our current practice is to monitor all of these babies in the intensive care unit (ICU) overnight after surgery. In addition to the considerable expense to the health care system, these cases are cancelled if no ICU bed is available.

Methods

A retrospective chart review of all premature infants undergoing inguinal hernia repairs over the past 5 years was undertaken. All postoperative apneas were identified. Potential risk factors were evaluated.

Results

Five (4.7%) of 126 premature infants had apneas after inguinal hernia repair. All of these babies had a previous history of apneas. They also had lower weights both at birth (1.08 vs 1.73 kg) and at the time of surgery (3.37 vs 4.4 kg) as well as lower gestational ages (29 vs 32.3 weeks). They were much more likely to have a complicated past medical history. Markers for this included intraventricular hemorrhage, patent ductus arteriosus, bronchopulmonary dysplasia, and requirement for mechanical ventilation and supplemental oxygen after birth. The use of sevoflurane was the only anesthetic factor which had significance.

Conclusion

Postoperative apnea in premature infants after inguinal hernia repair using current anesthetic techniques is much less common than previously reported. Infants with prior history of apneas are at highest risk. Other risk factors appear to include gestational age, birth weight, weight at time of surgery, and a complicated neonatal course. Selective use of postoperative ICU monitoring for high-risk patients could result in significant resource and cost savings to the health care system.     

Adriamycin induces notochord hypertrophy with conservation of sonic hedgehog expression in abnormal ectopic notochord in the adriamycin rat model

Background/purpose

The Adriamycin rat model (ARM) is a well-established model of the Vertebral, Anorectal, Cardiac, Tracheoesophageal, Renal, Limb (VACTERL) association. The notochord, which expresses Sonic Hedgehog (Shh), has been found to be grossly malformed with ventral ectopic branches in the foregut region of embryos in the ARM. The authors designed this study to test the hypothesis that Shh-expressing ectopic notochord could contribute to an increased volume of notochord relative to total embryo volume, resulting in an increased concentration of Shh in the notochord of affected embryos.

Methods

Adriamycin was administered intraperitoneally to rats on days 7 (E7), E8, and E9 of gestation and saline to control animals. Embryos recovered at E12 and E14 were examined immunohistochemically for Shh expression. Quantitative morphology using the Cavalieri technique was performed to determine embryo and notochord volume.

Results

Embryos in both Adriamycin and control groups at E12 and E14 showed comparable levels of Shh expression in notochord at all locations. The percentage of notochord per embryo was significantly increased in Adriamycin embryos at E12 and E14 compared with equivalent controls.

Conclusions

These data suggest that Adriamycin induces notochord hypertrophy. With all regions of the notochord secreting Shh, this could result in a higher concentration gradient of Shh in close abnormal proximity to the foregut, possibly contributing to the malformations found in the VACTERL association.     

Benefit/risk profile of drotrecogin alfa (activated) in surgical patients with severe sepsis

Background

The Protein C Worldwide Evaluation in Severe Sepsis (PROWESS) trial examined the safety and efficacy of drotrecogin alfa (activated) (Xigris) in adult patients with severe sepsis. A clinical evaluation committee examined clinical data for each patient enrolled in PROWESS. However, there were no surgeons on the committee, and thus questions remained regarding the safety and efficacy of drotrecogin alfa (activated) in surgical patients.

Methods

Masked to treatment, a Surgical Evaluation Committee adjudicated the presence and type of operation, timing of surgery, infection, and adequacy of source control of surgical patients included in PROWESS.

Results

Twenty-eight percent of PROWESS cases were confirmed as surgical. The absolute risk reduction for mortality in all surgical patients was 3.2% and 9.1% for patients undergoing intraabdominal procedures. Serious bleeding during the infusion and 28-day period was similar between surgical and nonsurgical patients.

Conclusions

Consistent with the overall PROWESS results, drotrecogin alfa (activated) has a favorable benefit/risk profile in surgical patients.     

The role of estrogen in the formation of experimental abdominal aortic aneurysm

Objective

The current study sought to investigate the role of estrogen in the formation of experimental abdominal aortic aneurysm (AAA).

Methods

Elastase perfusion of infrarenal AAA animal model was performed in 20 female and 20 male Wistar rats that were randomly divided into an ovariectomized/sham-operated group and an estradiol (E2) experimental/saline control group, respectively. At day 14, E2 was detected, while the mRNA and protein expressions of matrix metalloproteinases 2 and 9 (MMP-2 and -9) in AAA tissue were detected by immunohistochemistry and polymerase chain reaction (PCR).

Results

The ovariectomized group showed lower estrogen levels and a higher aneurysm dilatation rate and significantly higher MMP-2 and -9 expression compared with the sham-operated group (P < .01), which was in accordance with MMP-2 and -9 mRNA expression. The E2 group showed higher estrogen levels and a lower aneurysm dilatation rate and significantly lower MMP-2 and -9 expression than did the saline control group (P < .01), which was in accordance with MMP-2 and -9 mRNA expression.

Conclusions

In the pathogenesis of AAA, estrogen may play an inhibitory role by decreasing expression of MMP-2 and MMP-9 synthesis.     

Radiofrequency energy delivery to the anal canal: is it a promising new approach to the treatment of fecal incontinence?

Background

The present study was conducted to assess the efficacy and safety of the delivery of radiofrequency energy to the anal canal (the SECCA procedure).

Methods

Eight patients with fecal incontinence underwent the SECCA procedure. The Fecal Incontinence Severity Index (FISI) score and the Fecal Incontinence-related Quality of Life (FIQL) scale were completed at baseline and after the procedure. Anorectal manometry and endoanal ultrasound also were conducted.

Results

Seven of the 8 patients were women, and the median age of the patients was 59 years (range, 28-73 y). The mean FISI score and all of the parameters in the FIQL scale with the exception of the embarrassment scale measured at 6 months after the procedure was not improved significantly. We observed no changes in the anal manometry and endoanal ultrasound parameters. Complications associated with the procedure developed in 7 of the 8 patients, including anal bleeding, anal pain, and anal mucosal discharge.

Conclusions

The FISI score and FIQL scale were not improved significantly after the SECCA procedure, and considerable complications were associated with the procedure.     

Prompt correction of endotracheal tube positioning after intubation prevents further inappropriate positions

Study Objective

To determine whether the timely correction of endotracheal tube (ETT) positioning prevents further inappropriate positions.

Design

Prospective crossover study.

Setting

University-affiliated hospital.

Patients

44 adult, ASA physical status 1, 2, and 3 patients undergoing open or laparoscopic abdominal procedures.

Interventions

ETT positioning was verified by both auscultation and fiberoptic bronchoscopy (FOB), after intubation, and before extubation. In laparoscopic procedures, two additional measurements were performed: after maximal abdominal gas insufflation and with head-down position. An ETT in the bronchus or at the carina was considered an inappropriate placement. An ETT ≤ one cm from the carina was considered a critical placement.

Measurements

The frequency of inappropriate and critical ETT positioning with both auscultation and FOB and the number of ETTs that remained in an incorrect position despite repositioning.

Main Results

FOB detected 5 inappropriately positioned ETTs, 4 of which were also detected by chest auscultation (P = 0.99). Critical positioning was detected by FOB in 6 patients, three of which were also detected by auscultation (P = 0.24). There were 15 other "out-of-desired range” positions (out of the 3-5 cm range) - one placed too high and 14 placed too low, while 18 were placed within the range of positions. All patients with inappropriate ETT positioning were women (P = 0.005). Age, body mass index, Mallampati grade > 3, thyromental distance < 6 cm, or laryngoscopy grade ≥ 2 were not associated with either inappropriate or critical placement. No episodes of inappropriate or critical positioning were detected by FOB or auscultation at the end of surgery.

Conclusions

Early detection and prompt correction of inappropriate ETT positioning after intubation prevented further ETT migration into undesired positions.     

Early Postoperative Care of Liver Transplantation for Infants With Biliary Atresia During Pediatric Intensive Care Unit Stay

Subject

The aim of this study was to present our institutional experience with the pediatric intensive care unit (PICU) stays of liver recipients to understand prevention of complications.

Methods

This retrospective review included 22 infants who weighed 8.8 kg or less and underwent 23 transplantations. No grafts were from executed prisoners. We summarized the diagnosis, evaluation, medicine usage, and therapeutic intervention associated with subjects experiencing complications of rejection episodes, surgery, or infection during their ICU stay.

Results

There was one perioperative death from primary graft nonfunction. The most common postoperative complications were infections, gastrointestinal bleeding, and vascular complications. Rejection episodes occurred among 25% of patients. The most common isolated pathogenic bacteria was Staphylococcus epidermidis. Median initial ICU stay was 10 days. Mean requirement for artificial ventilation was 37.6 hour. Mean times of use of dobutamine, prostaglandin E1, and dopamine was 3.3, 7.5, and 8.8 days, respectively. Parenteral nutrition was started at a mean of 12 hours and oral food intake at a mean of 72 hours.

Conclusions

Although challenging, orthotopic liver transplantation (OLT) in small infants can be successfully performed with meticulous surgical technique and keen postoperative surveillance.     

Caecal volvulus

Background

Caecal volvulus accounts for 30% of all cases of volvulus of the colon.

Methods

We recorded clinical data and accurate images of volvulus of the cecum.

Results

A detorsion with resection and primary anastomosis was performed. We reviewed the management and surgical strategies for cecal volvulus.

Conclusions

Caecal volvulus is an uncommon entity with potentially severe outcomes and requires surgical management.     

Tricalcium phosphate bone substitute in corrective osteotomy of the distal radius

Aim

To evaluate the outcome of using tricalcium phosphate (TCP) as void filler and structural support in corrective opening-wedge osteotomy of the distal radius.

Methods

A consecutive series of 17 patients with malunited dorsally angulated distal radius fracture underwent corrective osteotomy using plates, screws and TCP blocks. Results were evaluated postoperatively with DASH at 6 months with radiography at 8-12 weeks and 0.5-3.5 years.

Results

Mean DASH score improved from 52 (S.D. 22) preoperatively to 30 (S.D. 22) postoperatively. There was one non-union. There was also a mean loss of radial length of 1.1 mm (S.D. 1.0 mm) between the first postoperative radiograph and final follow-up. Radiolucent zones were observed around the TCP grafts after 6-8 weeks in 10/14 cases, but could not be statistically correlated with the slight loss of reduction.

Conclusions

TCP seems to be an alternative to iliac crest bone grafting in corrective osteotomies of the distal radius. The shortening observed over time may be attributable to inflammation induced by the TCP.     

Complications of mechanical suturing in pediatric patients

Background/purpose

Although it is widely accepted that staplers are effective in reducing operating time, potential complications related to their use in the pediatric population are not well defined yet. The aim of this study is to evaluate the safety of mechanical suturing.

Methods

Between 1996 and 2001, 174 procedures were performed using circular staplers in gastrointestinal anastomosis, whereas linear staplers were used in gastrointestinal and lung resection. Intraoperative and early complications of each intervention were recorded.

Results

Overall, 12 complications occurred (6.9%). Two were caused by technical problems: In one case the stapler broke, in the other the anvil detached from the instrument shaft. Ten (5.7%) were major complications: 2 cases of leakage and 3 of bleeding in gastrointestinal procedures, and one case of bronchopleural fistula and 4 cases of bleeding during lung surgery. There was a significant correlation (P < .05) between type of stapler used and development of complications, suggesting a safer use of endoscopic staplers compared with conventional linear ones.

Conclusions

Mechanical suturing in children is not used frequently, but some procedures could be used more widely because they are fast and safe.     

High diagnostic yield of gastrointestinal endoscopy in children with intestinal failure

Purpose

Children with intestinal failure (IF) often have gastrointestinal (GI) symptoms, including bleeding, increased stool output, and feeding intolerance. The use of endoscopic assessment of these symptoms has not been previously reported. This report evaluates the diagnostic yield of GI endoscopy in the setting of IF.

Methods

After institutional review board approval, we reviewed the medical records (including endoscopy, pathology and microbiology data) of patients with IF who underwent GI endoscopies between September 1999 and March 2007.

Results

Twenty-seven patients underwent 61 GI endoscopies: 34 esophagogastroduodenoscopies, 17 colonoscopies, 7 flexible sigmoidoscopies, and 3 ileoscopies. Indications for endoscopy, which were not mutually exclusive, included chronic diarrhea (39%, n = 24), GI bleeding (36%, n = 22), suspected bacterial overgrowth (36%, n = 22), and suspected peptic disease (15%, n = 9). Based on gross endoscopic appearance, histopathology, or microbiology, 43 (70%) procedures yielded abnormalities. These included infectious (20%, n = 12), anatomical (18%, n = 11), peptic (15%, n = 9), allergic (15%, n = 9), and other (2%, n = 1) findings. Eleven (73%) of 15 duodenal cultures grew a spectrum of 17 bacterial species. Overall, 24 (89%) of 27 patients had gross endoscopic, histopathologic, or microbiologic abnormalities.

Conclusions

In pediatric patients with IF, diagnostic upper and lower GI endoscopies yield high rates of abnormalities and can help guide clinical management.     

A double blind, randomised trial to compare the analgesic effect of oral premedication with paracetamol, diclofenac, or diclofenac and paracetamol, on postoperative pain following surgical suction termination of pregnancy

Objectives:

The aim of this study was to determine whether a combination of paracetamol and diclofenac provided a more effective analgesic premedication than paracetamol, or diclofenac alone for the treatment of postoperative pain following surgical suction termination of early pregnancy.

Methods:

A double blind, prospective trial, involving 60 patients randomized to receive either paracetamol (1 g) and placebo, diclofenac (50 mg) and placebo, or diclofenac (50 mg) and paracetamol (1 g) orally, prior to surgical termination of pregnancy. Intraoperative management was standardized. Peak pain was the primary end point. Pain scores were recorded immediately postoperatively, and at 2 and 4 h. Secondary end points were nausea, sedation, intraoperative blood loss, supplementary postoperative analgesic use, and delayed hospital discharge.

Results:

There was no statistically significant difference in peak pain between the three groups (P = 0.6).

Discussion:

The co-administration of prophylactic oral analgesic premedication with diclofenac and paracetamol did not result in a reduction in pain scores when compared to either diclofenac or paracetamol administered alone.     

Clinicopathologic characteristics and prognosis of young patients with breast cancer

Background

The aim was to describe the clinicopathological features and prognosis of young patients with breast cancer.

Patients and Methods

We reviewed the records of 1478 consecutive patients aged ≤50 years with first diagnosis of invasive breast cancer referred to surgery from January 1999 to March 2005. A total of 174 patients were aged <35 years (group I) and 1304 were aged 35-50 years (group II).

Results

Compared with patients of group II, patients of group I had a higher percentage of tumors classified as estrogen receptors (ER) negative, progesterone receptors (PR) negative, with a Ki-67 labeling index ≥20% of the cells. The 5-year survival of group I was 78.3% as compared with 84.2% for group II (P = 0.006).

Conclusion

Compared with patients aged between 35 and 50 years, patients aged <35 years have a greater chance of having an endocrine-unresponsive tumor and a significantly poor prognosis.     

Risk of late bleeding following hemorrhoidal banding in patients on antithrombotic prophylaxis

Background

The risk of bleeding following rubber band ligation of internal hemorrhoids is 1%-2%. This risk may be increased in patients taking antithrombotic therapy. The goal of the current study was to find a safer approach to banding without increasing the risk of bleeding.

Methods

This retrospective review identified patients undergoing banding while on antithrombotic therapy. These medications were held for 7-10 days following the procedure. The number of bands placed while on antithrombotic therapy and their post band complications were recorded.

Results

There were 605 bands placed on 364 patients taking antithrombotic medications. There were 23 complications involving bleeding, a value that was not statistically different from those not taking antithrombotic therapy. Patients on clopidogrel experienced 50% of the significant bleeding episodes and 18% of the insignificant bleeding episodes.

Conclusions

Holding antithrombotic medication following banding appears to equalize the risk of bleeding to that of patients not taking antithrombotic medications. Patients taking clopidogrel may be at higher risk for bleeding complications.     

Portoenterostomy for biliary atresia: Long-term survival and prognosis after esophageal variceal bleeding

Background/purpose

Portoenterostomy is the procedure of choice in patients with biliary atresia. The authors analyzed the long-term survival rate and complications of the procedure in children operated on at The University of Hong Kong Medical Centre between 1979 and 2000.

Methods

Seventy-seven consecutive patients were analyzed by retrospective chart review. The patients were divided into groups according to postoperative bile flow, decade of operation, and age at operation. The data were analyzed statistically.

Results

The overall actuarial transplant-free survival rate was 68% at 10 years after operation. For patients with poor, partial, and good postoperative bile flow, transplant-free survival rate was 0%, 22%, and 96%, respectively (P < .001). Age and decade of operation were not significant risk factors. Esophageal variceal bleeding occurred in 13 patients and was a prognostic indicator for end-stage liver failure (P = .044); the poor prognosis of patients with variceal bleeding, however, was related to poor or partial initial bile drainage.

Conclusions

The postoperative serum bilirubin level is the most important predictor of long-term survival in patients with portoenterostomy for biliary atresia. Esophageal hemorrhage is not an absolute indication for urgent liver transplantation in patients with good bile drainage.     

The influence of Down's syndrome on the management and outcome of children with Hirschsprung's disease

Background

Children with Down’s syndrome (DS) have a reportedly poorer outcome after treatment of Hirschsprung’s disease (HD) compared with control children. Because of overall improvements in their management, the authors hypothesized that the diagnosis of DS would not influence outcome after the management of HD.

Methods

Consecutive children with HD (1995 through 2002) were collected prospectively then divided retrospectively into those with DS and controls (C). Patients who underwent surgery at another institution and those with total colonic aganglionosis were excluded.

Results

Of 66 patients, 9 had DS. Mean age at diagnosis, gender, racial distribution, gestational age, and proximity to our center were similar between groups. Presenting symptoms, location of the transition zone, and type of initial operation were similar. Patients with DS had significantly more comorbidities than controls, which generated significantly greater treatment costs and a higher mortality rate. However, with an average of 22 months of follow-up, the overall outcome including postoperative complications, enterocolitis, and constipation was similar.

Conclusions

These data suggest that in contrast to earlier reports, DS has minimal influence on surgical outcome of patients with HD. Although the overall cost of treating patients with DS is greater, this mainly reflects the impact of managing comorbidities.