Fibrinogen in children undergoing cardiac surgery: is it effective?

There is speculation based on laboratory tests and biochemical data regarding the functional integrity of the fibrinogen in young children. Recent investigations in adults have demonstrated that their fibrinogen level correlates with the thromboelastogram maximum amplitude (MA) after modification with a glycoprotein IIb/IIIa receptor blocker that uncouples platelet-fibrinogen interactions. We postulate that if the fibrinogen of young children is functionally intact then their fibrinogen levels should also correlate with modified thromboelastogram MA values as they do in adults. We compared modified and unmodified thromboelastogram variables of 250 children <2 yr old undergoing cardiac surgery with their fibrinogen levels and platelet counts. Five age groups were distinguished to determine if and when correlations become significant (<1 mo, 1-3 mo, 3-6 mo, 6-12 mo, and 12-24 mo). Fibrinogen levels correlated with modified thromboelastogram MAs only in the 12-24 mo group. In this 12-24 mo age group other correlations between fibrinogen levels and thromboelastogram variables influenced by fibrinogen also became significant, as did correlations noted in adults between platelet counts and thromboelastogram variables. We conclude that the fibrinogen of children <12 mo old with congenital heart disease is qualitatively dysfunctional.     

Percutaneous nephrolithotomy in polycystic kidney disease: is it safe and effective?

Purpose

Nephrolithiasis is common in patients with autosomal dominant polycystic kidney disease (ADPKD). Percutaneous management of nephrolithiasis is challenging because of a large number of parenchymal cysts and distorted calyceal anatomy. These patients also have varying grades of chronic kidney disease and are at increased risk of bleeding, which further increases the challenge. The objective of the study is to study the efficacy and safety of PCNL in ADPKD.

Materials and methods

We retrospectively analyzed twenty-two patients of ADPKD with renal calculi managed by percutaneous nephrolithtomy (PCNL) from January 2000 to January 2010. Patients were divided into two groups: group I (serum creatinine ??1.5?mg%), group II (serum creatinine >1.5?mg%).

Results

PCNL was done in 25 renal units among 22 patients. Sixteen patients had chronic kidney disease, and the average stone burden was 2.4?cm?±?0.8?cm. The overall success rate (complete stone clearance/residual fragments <4?mm) was 88% (22/25). Two patients required relook PCNL for residual stone and one required ESWL for the incomplete clearance. Mean preoperative serum creatinine in group I was 0.9?±?0.1?mg% and in group II 3.1?±?1.2?mg%. There was improvement in serum creatinine in group II (1.4?±?0.5?mg%) postoperatively. Three patients required blood transfusion (13%) and four patients had fever postoperatively (18%). None of the patients required angioembolization.

Conclusion

Despite the distorted calyceal anatomy and associated chronic kidney disease, PCNL is safe and effective in managing nephrolithiasis in polycystic kidney disease.     

Inflammation in uremic patients: what is the link?

Uremic patients suffer to an extremely high degree from cardiovascular disease. Cardiovascular disease results mainly from atherosclerotic remodeling of the arterial system. Inflammation is considered to contribute significantly to development of atherosclerosis, and albeit many different factors may lead to inflammation, generation of enhanced oxidative stress is believed to be an important common feature of pro-inflammatory causes. Studies in the general population without renal disease could clearly show that markers of inflammation, in particular C-reactive protein, predict the cardiovascular risk. In this review article, we discuss the presence and the predictive value of inflammation in patients with end-stage renal disease, and analyze whether uremic patients are exposed to specific pro-inflammatory and pro-oxidative conditions. Particular emphasis is set on oxidative stress induced by oxidatively modified lipoproteins and angiotensin II. Based on pathophysiological considerations valid for uremic patients, we discuss therapeutical options that might help to reduce cardiovascular disease in uremic patients.     

Amnioexchange for fetuses with gastroschisis: is it effective?

Background/Purpose

Amniotic fluid of fetuses with gastroschisis (GS) contains inflammatory mediators, gastrointestinal, and urinary waste products. Dilution and removal of such harmful substances have been advocated to prevent damage to the herniated intestine. We evaluated the effectiveness of serial amnioexchange procedures in 8 consecutive fetuses with GS.

Methods

Amnioexchange was performed bimonthly during the third trimester. Amniotic fluid collected before each procedure was tested for pH, osmolarity, urea, creatinine, cystatin-C, proteins, albumin, bilirubin, biliary salts, pancreatic amylase, serum amyloid A, C-reactive protein, alanine transaminase (ALT), alcaline phosphatase (ALP), gamma-glutamyl transpetidase (γGT), tumor necrosis factor α, interleukin 2, interleukin 6, epidermal growth factor, transforming growth factor β, and myeloperoxidase.

Results

A total of 25 samples (median, 3 per fetus) were examined. Biochemical or inflammatory markers did not correlate with gestational age, nor was any trend observed in values from individual patients during the course of amnioexchange treatment. There was no correlation between biochemical or inflammatory markers and clinical outcome, including time to full enteral feeding.

Conclusions

Serial amnioexchanges did not modify the biochemical or inflammatory status of amniotic fluid nor appeared to prevent injury to the herniated gut. Because repeated amnioexchanges may carry some risks, their use in fetuses with GS is not recommended outside the setting of a prospective randomized trial.     

Laparoscopic contralateral groin exploration: is it cost effective?

Background

Transinguinal laparoscopy offers a safe and effective method for evaluating the contralateral groin during unilateral inguinal hernia repair (UIHR). The purpose of this study is to determine whether laparoscopic contralateral groin exploration (LCGE) is cost effective.

Methods

A retrospective review of all children who underwent UIHR and LCGE from 2006 to 2007 by a single surgeon was performed. Cost analysis comparing the time to perform the LCGE and time to repair the contralateral patent processus vaginalis (CPPV) to the cost saved by preventing future operation for a contralateral inguinal hernia repair was calculated based on Medicare reimbursement.

Results

Eighty-one patients underwent UIHR with planned LCGE; 78 (96.3%) had successful LCGE; 8 (10.3%) had a CPPV and underwent contralateral open repair. The total cost for the additional time to perform LCGE and repair of the 8 CPPV was $13 080. The total cost for returning for a second operation to repair the contralateral inguinal hernia was $20 440.

Conclusion

Laparoscopic contralateral groin exploration at the time of unilateral inguinal hernia repair was cost effective.     

Baclofen neurotoxicity in uremic patients: is continuous ambulatory peritoneal dialysis less effective than intermittent hemodialysis?

OBJECTIVES: To compare the efficacy between continuous ambulatory peritoneal dialysis (CAPD) and intermittent hemodialysis in the treatment of baclofen-associated neurotoxicity. METHODS: Three uremic patients suffering baclofen-associated neurotoxicity were treated by CAPD at our hospital. We obtain 12 cases with detailed clinical course of baclofen-associated neurotoxicity treated by hemodialysis from a literature review using the Medline and Science Citation Index, six of these patients were treated by early hemodialysis which was defined as hemodialysis intervention within 48 h of the onset of clinical toxicity. RESULTS: Our cases regain full consciousness within 2-3 days after the onset of neurotoxicity. Clinical characteristics of our cases including age, dialysis time, preexisting central nervous system (CNS) lesion, concomitant use of CNS depressant, total baclofen dose, onset of neurotoxicity, and duration of neurotoxicity are not significantly different from reported cases that treated by either early or routine hemodialysis. CONCLUSIONS: Baclofen should be avoided in uremic patients. When consciousness disturbance occurs in uremic patients, baclofen-associated neurotoxicity should be included in the list of differential diagnosis. According to experiences of our patients, we conclude that neither early nor routine hemodialysis is more effective than CAPD in shortening the recovery time of baclofen-associated neurotoxicity.     

Heller myotomy for failed pneumatic dilation in achalasia: how effective is it?

OBJECTIVES: This long-term prospective study describes the effect of myotomy in patients who fail to respond to repeated pneumatic dilations and compares their clinical course with that of patients responding to dilation therapy. METHODS: Nineteen consecutive patients who had never reached a clinical remission after repeated pneumatic dilation underwent myotomy. Their clinical course was compared with that of patients who had reached a clinical remission after a single (n = 34) or multiple (n = 14) pneumatic dilation(s). Symptoms were graded with a previously described symptom score ranging from 0 to 12. Remission was defined as a score of 3 or less persisting for at least 6 months. Duration of remission was summarized using Kaplan Meier survival curves. Association between baseline factors and the need for surgery was evaluated using logistic regression. RESULTS: Complete follow-up was obtained for 98.5% of the patients. The median duration of follow-up was similar in patients treated by myotomy (10.0 years), in patients reaching a clinical remission after a single dilation (10.6 years), but differed in patients undergoing repeated dilations (6.9 years). The 10-year remission rate was 77% (95% CI 53-100%) in patients undergoing myotomy, 72% (95% CI: 56-87%) in patients "successfully" treated with a single pneumatic dilation and 45% (95% CI: 16-73%) in patients undergoing several dilations. Among all baseline factors investigated, young age was associated with an increased need of surgery. CONCLUSIONS: Myotomy is an effective treatment modality in patients with achalasia who have failed to respond to pneumatic dilation. Young patients may benefit from primary surgical therapy.     

Fistula-in-ano in infants: is nonoperative management effective?

PURPOSE: Recently, a number of studies have reported positive results from the nonoperative management of fistula-in-ano in infancy, although it has not been of use in all patients. The purpose of this study was to discern the effective treatment methods of fistula-in-ano in infants. METHODS: A retrospective review was done of 310 children who required operative management for fistula-in-ano or perianal abscess between January 1991 and July 2000. Eighteen patients displayed an onset of symptoms at less than 1 year of age and a duration of symptoms longer than 12 months. The authors analyzed these patients' medical records. RESULTS: All patients were boys. The mean duration of the symptoms was 26.6 +/- 27.5 months. Fourteen patients had shown an onset of symptoms at less than 6 months of age. The longest duration was 10 years. The patients showed conservative periods of over 12 months because their parents did not want them to undergo surgery. The disease in these patients followed 2 patterns. One (6 patients) was an onset of symptoms followed by a silent fistula-in-ano state. The other (12 patients) was an onset of symptoms followed by an intermittent relapse of inflammation. All patients underwent fistulotomy, and none of them had recurrent fistula during the follow-up period. CONCLUSIONS: Although the advantages of a nonoperative management of fistula-in-ano in infants include the avoidance of general anesthesia and surgical intervention, the lesions cannot be cured by a period of conservation. Surgical management is more effective in respect to the time factor.     

Nonsurgical management of blunt splenic injury: is it cost effective?

Background

This study analyzed outcomes and cost of splenic embolization compared with surgery for the management of blunt splenic injury.

Methods

We performed a retrospective chart review of all patients admitted with isolated, blunt splenic injury. An intent-to-treat analysis was initially conducted. Outcomes and cost/charges were compared in patients treated with embolization and surgical treatment.

Results

Of 236 patients admitted with isolated, blunt splenic injury, 190 patients were ultimately managed by observation, 31 by splenic embolization, and 15 by surgical management. Comparing outcomes and cost data for splenic embolization versus surgical management, there was no significant difference in intensive care unit use, hospital stay, complications, or re-admission. Surgical management patients required more blood transfusions and incurred higher procedure charges. Conversely, splenic embolization patients underwent more radiologic evaluations and charges. Total procedure-related charges were higher for surgical management when compared with splenic embolization ($28,709 vs $19,062; P = .016), but total hospital cost and total hospital charges were not significantly different.

Conclusions

Nonsurgical treatment of blunt splenic injury is safe and cost effective. Angioembolization was statistically similar to surgical therapy regarding cost.     

Cryosurgery: is it an effective option for patients failing radiation?

Cryotherapy of the prostate represents a potential treatment for localized recurrent prostate cancer after radiation therapy. Current salvage cryotherapy of the prostate can result in undetectable serum PSA levels with low morbidity. Further refinements in technique and equipment may enhance cryosurgical results.     

Cervical spondylolysis in children: is it posttraumatic?

Cervical spondylolysis is a rare defect of unknown etiology. Five cases of cervical spondylolysis as well as two cases of fractures of the pedicles of C2 in infants are presented. Comparison of the cases suggests that a fracture at birth or in infancy may be the cause of some cases of cervical spondylolysis.     

Sedation in neurocritical patients: is it useful?

Anesthetics are widely used in the management of neurocritical patients, although has never been proved that the use of these drugs can contribute to positive outcome. The aim of this review was to evaluate the expected benefit of anesthetics use in relation to the altered physiology of the damaged brain while considering possible related complications.