IMMUNE RESPONSE IN PATIENTS WITH PERSISTENT CANDIDURIA AND OCCULT CANDIDEMIA

PURPOSE: We evaluated the immunological response in patients with persistent candiduria with or without occult candidemia. MATERIALS AND METHODS: Levels of Thl (pro-inflammatory interleukin [IL]-1, IL-2 and tumor necrosis factor-alpha) and Th2 (anti-inflammatory IL-4 and IL-10) cytokines were measured in the sera of patients with persistent candiduria. Polymerase chain reaction assessment of the 158 base pair candidal actin gene was used to detect Candida albicans in blood to identify occult candidemia. RESULTS: During a 14-month period 66 hospitalized patients with a mean age of 63 years (range 44 to 80) with persistent candiduria were evaluated. Occult candidemia developed in 27 patients (41%) as evidenced by detection of candidal actin gene in the sera by polymerase chain reaction. Risk factors included antibiotics in 27 patients (100%), central venous catheter in 22 (81%), urinary catheter in 21 (78%), total parenteral nutrition in 18 (66%), diabetes mellitus in 16 (59%) and abdominal surgery in 14 (52%). A total of 17 age matched patients with a mean age of 59 years hospitalized for elective general or vascular surgical procedures with no clinical or laboratory evidence of urinary or hematogenous fungal or bacterial infection served as controls. Serum levels of Th2 cytokines were elevated in 18 of 39 patients with persistent candiduria alone, and in 22 of 27 patients with candiduria and occult candidemia compared to controls (p<0.002). Th1 cytokines were within normal limits or slightly decreased in all patients with persistent candiduria with or without candidemia. CONCLUSIONS: These observations indicate that an abnormal immune response develops in patients with persistent candiduria with or without candidemia.     

RE-OPERATIVE SURGERY FOR RECURRENT OR PERSISTENT PRIMARY HYPERPARATHYROIDISM

Background : While initial surgery for primary hyperparathyroidism, in experienced hands, will result in a cure in 98% of cases, re-operative surgery remains a significant challenge. Because attitudes as to who should perform initial exploration for hyperparathyroidism are significantly different around the world, the approach to re-operative surgery may also vary. The aim of the present study was to examine a local experience of re-operative surgery for recurrent or persistent primary hyperparathyroidism. Methods : Information on indications for surgery, the procedure performed, pathology and complications of all re-operative procedures for primary hyperparathyroidism in the period January 1962 to December 1996 were obtained from a prospective database. Results : Sixteen patients with persistent (n= 12) or recurrent (n= 4) primary hyperparathyroidism were treated in the unit over the study period. Eight patients had their initial operation within the unit at Royal North Shore Hospital and eight were referred from elsewhere for re-operation. Nine of the 12 patients with persistent hyperparathyroidism were cured by re-operation with failures due to spillage at first operation (n= 1) or failure to find any additional pathology (n= 2). All four patients with recurrent hyperparathyroidism were cured. All the failures occurred early in the learning phase of the unit, with a 100% cure rate for re-operative procedures performed in the last 15 years. The most common finding in patients referred from elsewhere with a failed initial operation was a missed inferior adenoma in association with the thymus. Localization studies had a variable sensitivity, with sestamibi scintigraphy, selective venous sampling and ultrasonography providing the most reliable information. Conclusions : Re-operative surgery for persistent or recurrent hyperparathyroidism is an uncommon procedure in Australia when compared to major centres in the USA. Successful surgery depends upon experience and an accurate knowledge of the embryology and anatomy of the parathyroid glands.     

LONG-TERM RESULTS OF COLPOCYSTOURETHROPEXY FOR PERSISTENT OR RECURRENT STRESS URINARY INCONTINENCE

PURPOSE: We review the long-term outcome of colpocystourethropexy for persistent or recurrent stress urinary incontinence after suspension procedure failure. MATERIALS AND METHODS: Medical records and preoperative studies were reviewed of 60 patients (mean age 60.8 years) who had undergone colpocystourethropexy after at least 1 suspension procedure (range 1 to 8, mean 2.7). Patient responses to a standardized questionnaire regarding overall health, degree of satisfaction with colpocystourethropexy, presence or absence of leakage, and pattern and degree of leakage were elicited by telephone or mail and compared with preoperative status. Results were graded according to the degree of satisfaction and number of pads used daily. Patients with persistent incontinence were reevaluated with video urodynamic studies. RESULTS: Mean interval since colpocystourethropexy was 6.9 years. Successful results (greater than 80% satisfaction and the use of 1 or no pad daily) were reported by 41 patients (69%), who were significantly younger at the time of surgery than those with unsatisfactory results. In the latter group significant urge incontinence was present in 61% before the repair and in 63% postoperatively, suggesting an additional nonanatomical cause, which was confirmed by postoperative video urodynamic studies. CONCLUSIONS: When colpocystourethropexy was used for persistent urinary incontinence after previous surgical repair two-thirds of the patients had excellent long-term results. In patients with less satisfactory results a nonanatomical cause of urinary incontinence was a major factor.     

复发性肝包虫病的诊治

目的 探讨肝包虫病局部复发的病因、诊断、治疗方法。方法 对105例复发性肝包虫病患者进行了回顾性分析。结果 肝包虫病复发的原因主为囊液外漏，或术中遗留有含子孙囊壁生发层的包虫囊壁。术后血清包虫相关抗体滴度下降缓慢。结论 复发性肝包虫病患者的诊断应主要依靠B超及CT，而不应依靠血清学检查。手术前后辅助性应用阿苯哒唑，采用囊肿完整切除及肝叶切除术，术中严密保护周围组织，是减少复发的主要措施。     

DISPLACEMENT OF HEMODIALYSIS CATHETER IN PERSISTENT LEFT SUPERIOR CAVAL VEIN

Objective: To test whether the administration of calcium chunnel antagonists, such as verapamil (V), on the day before, during, and for 24–36 h after an important abdominal intervention, can lower the onset of acute renal failure (ARF), mostly in renal-risk patients, such as the aged. Design: Randomized, nonblinded study. Setting: Three surgical care university departments and two intensive care units of the same hospital (S. Anna, Ferrara, Italy). Patients: Thirty-five elderly patients (61–83 years old) entered the study: 18 of them were given V; 17 were not treated and were considered as controls. The two study groups were overlapping as regards age, renal risk, and surgical challenge. The patients who underwent ARF (5 in the treated group, 7 among the controls) were rejected from the study. Interventions: V was given on the eve of surgery at a dose of 80 mg/8 h per os and then through slow infusion (5 mg/4–6 h) during the next intra- and postoperative 24–36 h. Abdominal surgery was performed owing to gastric cancer (8 cases), colorectal neoplasia (10 cases), gullstone disease (4 cases), subrenal aortic aneurysm (6 cases), and iliofemoral obstructive arteriopathy (7 cases). Measurements: Serum creatinine (s_Cr) was assessed to test renal function; 24-h urinary levels of brush-border enzymes (γ glutamyl transferase, or gGT), lysosomal enzymes (N-acetyl-β-D-glucosaminidase, or NAG), and β₂microglobulin (or β₂M) were determined at T_o (on the eve of surgery), T₁ (first and second day after), and T₂ (7th and 8th day after) to demonstrate possible tubule cell damage. Results: In the evaluated patients (13 treated with V and 10 untreated): (a) the 24-h urinary levels of gGt and NAG persisted unchanged throughout the study in the treated patients, whereas in the controls the same indices exhibited significant (p<0.01) increases at T₁ and T₂; (b) the 24-h urinary levels of β₂M showed significant (p<0.01) increases in both groups from T_o to T₁; however, at T₂ these values tended to return to normal ranges in the treated patients, whereas they continued to be elevated in the untreated group. As regards the patients who underwent postoperative ARF, in the treated group urine output was significantly larger (p<0.01 at T₁ and p<0.001 at T₂), s_Cr was significantly (p<0.05) lower, and the renal function recovered earlier (within 10 ± 3 vs. 22 ± 9 days) than in the controls. Conclusions: The administration of calcium channel antagonists to renal-risk patients during surgery and immediately before and after it has failed to prevent the onset of postoperative ARF. Nevertheless this procedure has been shown to somehow reduce surgery-mediated lesions of the tubule cells, as demonstrated by the finding of elevated urinary enzymes only in the untreated group.     

RECURRENT ADRENOCORTICAL CARCINOMA IN A 4 YEAR OLD GIRL

Adrenocortical tumours are rare in the paediatric age group. This is a report of a 4 year old girl with recurrent adrenocortical carcinoma emphasizing the role of surgery as the definitive form of therapy even in recurrent cases.     

RE-ANAESTHETIZING CASES OF TONSILLECTOMY AND ADENOIDECTOMY BECAUSE OF PERSISTENT POSTOPERATIVE HAEMORRHAGE

Five hundred and forty-six consecutive cases of tonsillectomyand adenoidectomy that had to be re-anaesthetized subsequentlyon account of postoperative haemorrhage were examined. Therewas one death. Some previously published case histories of deathand cardiac arrest associated with the procedure are summarized.The dangers inherent in the procedure are discussed and themeans whereby they may be avoided are outlined. The importanceis stressed of restoring the blood volume to normal, emptyingthe stomach, if at all possible, and removing all loose clotsfrom the pharynx and postnasal space before induction of anaesthesia,and of using, during anaesthesia, a high concentration of oxygen.A suggested technique of management, based upon personal experienceof forty cases is outlined.     

Oddi括约肌松弛与复发性胆管炎胆结石

目的 探讨Oddi括约肌松弛与返流性胆管炎和结石复发的关系。方法 回顾性研究经手术证实Oddi括约肌松弛,乳头通过1cm以上的胆管探子,术后仍反复胆管炎和/或复发结石52例的病理与治疗。结果 再次手术行横断胆总管的胆管空肠Y型吻合术（29例）或胃改道术（12例）等术式,基本消除或明显减轻胆管返流因素效果良好,单纯再次胆管探查取石T管引流和非手术治疗效果不良。结论 Oddi括约肌松弛可以导致复发性返流性胆管炎和/或结石复发,采用外科手术消除或减轻胆管返流因素后效果良好。     

CONGENITAL DUODENAL DIAPHRAGM IN AN ADULT: AN UNUSUAL CASE ASSOCIATED WITH COELIAC DISEASE AND RECURRENT PEPTIC ULCERATION

A case of congenital duodenal diaphragm In an adult is reported. A correct preoperative diagnosis of this rare condition was made. The duodenal diaphragm was associated with both coellac disease and recurrent peptic ulceration, resulting In a complicated clinical course.     

直肠癌术后复发的原因,诊断和治疗

过去２２年中我院收治直肠癌术后复发患者４８例，占同期直肠癌住院病例的７．１０％。术后复发原因：①癌肿已外侵；②侧路淋巴结未切除；③下切端癌肿残留；④血行转移。诊断依靠体检、Ｂ超、胸片、ＣＴ等。局部复发应积极采用手术治疗，术后合并化疗、放疗。如不能切除，采用放疗加化疗。血行转移除孤立性肺、肝转移采用手术切除外，其余采用化疗加中草药治疗。     

微创技术治疗青少年术后复发性骨囊肿

目的探讨微创技术治疗青少年术后复发性骨囊肿的疗效。方法1984年12月～2003年12月,对36例青少年术后复发性骨囊肿采用微创技术治疗,男19例,女17例;年龄9～21岁,平均15岁。囊肿大小2.5cm×6.0cm～3.5cm×13.0cm,平均3.0cm×8.0cm。位于肱骨近端18例,肱骨干10例,股骨粗隆及股骨颈部8例。既往手术次数:1次23例,2次10例,3次3例。复发距微创治疗时间5～13个月,平均6.5个月。治疗均在门诊进行,摄正侧位X线片定位,先将囊肿内积液吸出,然后注入醋酸氢化可的松乳剂,剂量根据囊肿大小而定。每隔3.5～4个月重复穿刺1次,直至痊愈。结果36例获随访3～18年,平均5年。穿刺次数3～11次,平均6次。疗效判定:痊愈,囊肿消失,由新生骨充填,26例;大部分愈合,囊肿大部分消失仅残留部分小于1cm的囊腔,经1年以上随访无扩大,6例;部分愈合,囊肿经多次治疗,囊腔明显缩小,但仍残留多个硬化的小囊肿腔,4例。无局部及全身并发症,无再手术病例。结论微创技术治疗青少年术后复发性骨囊肿,具有痛苦小、安全有效、医药费用少及勿需住院等优点。     

PERIURETHRAL FAT INJECTION IN THE TREATMENT OF RECURRENT GENUINE STRESS INCONTINENCE

Purpose

We evaluated the efficacy, safety and mechanism of periurethral fat injection in the treatment of recurrent genuine stress incontinence.

Materials and Methods

Periurethral fat injections were performed in 26 patients for the treatment of recurrent genuine stress incontinence. A complete urogynecological study, including a 1-hour pad test, urodynamic studies and chain urethrocystography were done in each case and were repeated at least 3 months after operation. Each patient was followed for at least 12 months.

Results

Of 26 patients 13 (50%) were dry after operation and 4 (15.4%) showed improvement and were satisfied with the results of the operation, giving a total success rate of 65.4%. There were 6 cases of immediate postoperative minor complications (23%). Average volume of injected fat was 14.8 +/− 4.8 cc, which did not affect the success rate. Preoperative and postoperative chain urethrocystographic values for bladder neck descent in reference to the pubosacral tip line showed no statistical difference between successfully and unsuccessfully treated groups. Urodynamic studies in all cases showed no differences relating to operation. However, minimal urethral resistance increased from 0.122 +/− 0.061 to 0.205 +/− 0.134 (p = 0.023) in the treatment success group. This change was not demonstrated in the treatment failure group.

Conclusions

Periurethral fat injection for the treatment of recurrent genuine stress incontinence is a simple technique that works by the increment of urethral resistance. It has an acceptable success rate without financial outlay for the injected material.