The experience of a regional pediatric intestinal failure program: Successful outcomes from intestinal rehabilitation

Background

The aim of this study was to evaluate the clinical experience of a regional multidisciplinary intestinal failure program for children established in 2005.

Methods

Data were collected from a prospective internal database. Univariate analyses were performed to compare pre- and post-treatment outcomes. Median values are reported.

Results

Forty-nine children were referred at an age of 7 months. Remnant small bowel length was 29 cm. With follow-up of 14 months, overall patient survival was 88%. Thirteen bowel-lengthening procedures were performed, thereby increasing small bowel length from 83 to 132 cm (P < .05). Enteral autonomy was achieved in 22 patients (45%), and the caloric requirement for parenteral nutrition was decreased from 100% to 41% (P < .01). Conjugated bilirubin was reduced from 4.1 to 0 mg/dL (P < .05).

Conclusion

A multidisciplinary approach to pediatric intestinal failure that prioritizes intestinal rehabilitation can achieve successful enteral feeding advancement, improved liver function, and excellent survival in intermediate-range follow-up.     

Midterm follow-up study of high-type imperforate anus after laparoscopically assisted anorectoplasty

Purpose

The aim of this study was to evaluate postoperative anal function of high-type imperforate anus after laparoscopically assisted anorectoplasty (LAARP).

Methods

Between 2000 and 2002, LAARP was performed in 13 patients with high-type imperforate anus. Clinical data of the LAARP group were compared with the posterior sagittal anorectoplasty (PSARP) group (n = 7) operated before 2000. All patients were treated with initial colostomy in the newborn period. After anorectoplasty, daily glycerin enemas were given for postoperative bowel management. Anorectal function of these patients was evaluated using the Kelly score and manometry at the age of 3 to 5 years (LAARP) and 5 to 6 years (PSARP).

Results

Age at evaluation in the LAARP group was younger than that in the PSARP group (51 ± 10 vs 73 ± 12 months, P < .01). Kelly score was 3.8 ± 1.3 vs 3.4 ± 0.8, respectively. Resting pressure of internal sphincter was 31 ± 11 vs 33 ± 10 cm H₂O, respectively. Relaxation reflex of the internal anal sphincter was observed in 62% (8/13) and 29% (2/7), respectively.

Conclusions

Midterm follow-up study revealed that satisfactory fecal continence can be achieved in patients with high-type imperforate anus after LAARP. Laparoscopically assisted anorectoplasty may be a good alternative in this patient population. However, long-term follow-up is necessary to compare the benefits of LAARP against PSARP.     

Role of plasmapheresis as liver support for early graft dysfunction following adult living donor liver transplantation

Background

Severe early graft dysfunction has been occasionally encountered following adult living donor liver transplantation (LDLT). We have assessed the effectiveness of plasmapheresis (PP) as liver support for LDLT recipients with severe early graft dysfunction.

Methods

Of the 789 adult LDLTs performed between January 2007 and December 2009, 50 patients (6.3%) underwent PP as a supportive measure during the first month.

Results

The mean time from LDLT to start of plasmapheresis was 11.2 ± 6.8 days (range 2-28). The 50 patients underwent 517 sessions of PP, or a mean of 10.3 ± 6.8 sessions per patient, over a mean 21.6 ± 9.4 days. Thirty-four patients (68%) required concurrent hemodiafiltration. Mean serum total bilirubin concentration before PP was 16.2 ± 6.7 mg/dL, peaking at 20.3 ± 7.9 mg/dL during PP, and decreasing to 13.4 ± 5.4 mg/dL 1 week after completion of PP (P < .001 compared with before PP). Except for prothrombin time, no other biochemical parameter was significantly altered by PP. There were no serious complications related to PP. Of the 50 patients, 17 (34%) died soon or a few months after PP. The 6-month graft survival rate after completion of PP was 66%; the overall 1-year patient survival rate was 64.0%.

Conclusion

PP appeared to have beneficial effects for LDLT recipients with severe early graft dysfunction, namely total bilirubin concentrations greater than 10 mg/dL.     

Two-hit rat model of short bowel syndrome and sepsis: independent of total parenteral nutrition, short bowel syndrome is proinflammatory and injurious to the liver

Introduction

Infants with short bowel syndrome (SBS) are at a high risk for infectious complications and liver failure. We hypothesized that SBS, independent of total parenteral nutrition, is a proinflammatory state that is magnified by sepsis.

Methods

Sprague-Dawley rats were divided into 2 groups: sham laparotomy (SH, n = 10) or 75% small bowel resection (n = 10). After 14 days, each group underwent a second sham laparotomy (SH/SH and SBS/SH) or cecal ligation and puncture, followed 16 hours later by cecal excision and peritoneal washout (SH/sepsis and SBS/sepsis). Animals were killed 56 hours later.

Results

The SBS rats had higher serum levels of interleukin (IL) 6 vs SH (355 ± 99 vs 104 ± 71 pg/mL, P < .05). Liver injury scores were higher in SBS/sepsis compared with SBS/SH animals (3.7 ± 0.7 vs 1.9 ± 0.3, P < .05). Hepatic messenger RNA levels of IL-6 (12.8-fold change [FC]) and tumor necrosis factor α (5.65 FC) were elevated in SBS vs SH rats; and IL-6 (114 FC), tumor necrosis factor α  (3.87 FC), and Toll-like receptor 4 (7.65 FC) were increased in SBS/sepsis compared with SH/sepsis animals.

Conclusion

Our results suggest that SBS, independent of total parenteral nutrition, is a proinflammatory state and that sepsis induces an exaggerated proinflammatory cytokine response that may play an important role in liver damage and may be mediated by Toll-like receptor 4.     

Measurement of human erythrocyte C4d to erythrocyte complement receptor 1 ratio in cardiac transplant recipients with acute symptomatic allograft failure

Background

Complement activation has been recognized as a contributing factor to cardiac allograft dysfunction. Combined measurement of erythrocyte C4d (E-C4d) and complement receptor 1 (E-CR1) are potential biomarkers to monitor complement activity in patients with autoimmune diseases. We conducted a prospective study using CR1-2B11 monoclonal antibody to detect the E-C4d to E-CR1 ratio among our cardiac transplant recipients with acute symptomatic allograft failure.

Materials and methods

Eight recipients with acute cardiac allograft failure and 72 healthy controls were included in this study. Levels of E-C4d and E-CR1 were measured by indirect immunofluorescence and flow cytometry. The results were utilized to determine the association between patient C4d staining, histological features, and clinical outcomes.

Results

Eight patients with nine episodes of sudden onset of graft failure and suspected antibody-mediated rejection (AMR) were included in this study. One patient who received emergent mechanical circulatory support was treated with plasmapheresis for his unstable hemodynamic status. The mean pretreatment left ventricular ejection fraction was 30.3%. No histological study demonstrated cellular rejection or AMR in any patient. There were two patients with positive C4d immunostaining. Three patients had four episodes of acute rejection with sudden death at home. The mean E-C4d/E-CR1 ratio in the study group (n = 9) was 0.22 ± 0.07, and 0.12 ± 0.10 in the control group (n = 72). As comparing both groups, we found the ratios were significant higher in the study group (P = .0003).

Conclusions

Measurement of the E-C4d/E-CR1 ratio may be a noninvasive method for detecting acute rejection after cardiac transplantation.     

Nutrition assessment in children with short bowel syndrome weaned off parenteral nutrition: a long-term follow-up study

Purpose

The purpose of the study was to assess long-term growth and nutrition status of children with neonatal short bowel syndrome (SBS) after weaning off parenteral nutrition (PN).

Methods

Eight children with neonatal SBS weaned from PN therapy for more than 2 years were studied. Medical records were reviewed; anthropometric measurements and blood test (hemoglobin, albumin and prealbumin, immunoglobulin, electrolytes, trace elements, and fat-soluble vitamins) were assayed during follow-up.

Results

Anthropometric measurements, weight for age, and height for age were normal in all children; one child was found to be overweight according to weight for height z score. No children were found to have anemia, although one presented with macrocytosis and another had microcytosis. Low serum concentrations of zinc in 3 cases and iron in 1 case were detected. Immunoglobulin levels of all children were within the reference value. Low plasma levels of vitamin A in 2 cases, vitamin E in 4 cases, and β-carotene in 2 cases were found; one of them had obviously low levels of the 3 fat-soluble vitamins.

Conclusion

Children with SBS are still at risk for different nutrient malabsorption even after weaning off PN for a long time. Therefore, they need long-term, regular monitoring and intensive nutritional care to prevent various nutrient deficiencies.     

Evaluation of changes in quality of life among Turkish patients undergoing ventricular assist device implantation

Background

Ventricular assist device (VAD) application has become an increasingly common method to treatment end-stage heart failure. In this study we evaluated the effect of VAD implantation upon the quality of life among Turkish patients with end-stage heart failure.

Methods

Twenty-eight VAD implantation patients included 3 (10.7%) with biventricular support using the Berlin Heart Excor; 15 (53.6%), left ventricular support with the Berlin Heart Excor; and 10 (35.7%), Heartware implantation for left ventricular support. The Minnesota Living with Heart Failure Questionnaire (MLHFQ) and Short Form 36 (SF-36) Health Questionnaire were used to assess changes in the quality of life (QOL).

Results

Of the 28 patients, 2 were females (7.1%) and 26 were males (92.9%) of overall mean age of 44.6 ± 15.3 years (range, 8-66). Preoperative mean score of MLHFQ was significantly improved at 200.4 ± 147.4 days follow-up (72.8 ± 11.5 vs 13.7 ± 10.5; P < .05). SF-36 physical scores and mental scores were improved postoperatively (physical scores, 20.0 ± 24.4 vs 70.2 ± 19.9; mental scores, 38.4 ± 18.8 vs 73.9 ± 15.7; P < .05). No significant relation was observed between the postoperative scores of questionnaires and type of surgery. More improvement in postoperative MLHFQ scores was seen in patients younger than 45 years of age (P = .027). The severity of chronic heart failure (CHF) regressed from New York Heart Association (NYHA) class IV to NYHA class II in 26 and to NYHA class III in 2 patients (P = .000).

Conclusion

The QOL among patients with end-stage heart failure improved dramatically soon after VAD implantation.     

Fascia iliaca compartment block reduces emergence agitation by providing effective analgesic properties in children

Study Objective

To determine whether fascia iliaca compartment block (FICB) reduces emergence agitation.

Design

Prospective, randomized, blinded clinical trial.

Setting

Operating room and Postanesthesia Care Unit (PACU) of a university hospital.

Patients

64 ASA physical status 1 and 2 pediatric patients aged three to 7 years, scheduled for orthopedic surgery involving the anterior or lateral thigh.

Interventions

Patients enrolled in the FICB group received FICB immediately after the operation, while control group patients received intravenous (IV) patient/parent-controlled analgesia (PCA) with fentanyl.

Measurements

Severity of agitation and pain were evaluated using the Pediatric Agitation and Emergence Delirium (PAED) scale and the Children's Hospital of Eastern Ontario Pain Scale (CHEOPS). Data were collected at 10-minute intervals in the PACU. The results were analyzed using the t-test.

Main Results

PAED scores in the FICB group were significantly lower than those of the control group on arrival at the PACU (7.3 ± 2.9 vs 10.4 ± 3.2, P < 0.001). The FICB group also had significantly lower CHEOPS pain scores than the control group, both on arrival at the PACU and 10 minutes after arrival (6.4 ± 1.5 vs 10.4 ± 1.8, P < 0.001 and 6.7 ± 1.6 vs 8.0 ± 1.4, P = 0.009, respectively).

Conclusion

In children having surgery on the thigh, FICB effectively reduced the severity of emergence agitation and postoperative pain during the immediate postoperative period.     

The adolescent child with short bowel syndrome: new onset of failure to thrive and need for increased nutritional supplementation

Background

Proper nutrition for children with short bowel syndrome (SBS) is challenging. An underappreciated SBS cohort is the group of adolescents in which nutritional demand is markedly increased. We identified several children that previously had weaned off parenteral nutrition but needed re-initiation of parenteral nutrition or increased enteral nutritional supplementation (NS) during adolescence. This study aims to identify characteristics of adolescent SBS patients to better understand their nutritional status.

Methods

A single institution, retrospective review of SBS patients over 10 years was done. Patients were analyzed for NS need, remaining bowel length, height, weight, and essential nutrient levels.

Results

Sixteen adolescent SBS patients were identified for analysis. Of these, ten did not require increased NS upon reaching adolescence (group A), and six required increased NS during adolescence (group B). Group B patients required a mean increase in NS of 29.6 kcal/kg per day. Group B patients had significantly shorter remaining bowel length. NS resulted in minimal height increase, but more substantial gains in weight and pubertal development.

Conclusions

Adolescents with SBS may require NS beyond what can be provided enterally. These patients are at risk for nutritional deficiencies, and an aggressive approach to monitoring and supplementing these deficiencies is warranted, especially during this critical period of growth.     

Colonic manometry via appendicostomy shows reduced frequency, amplitude, and length of propagating sequences in children with slow-transit constipation

Background/Purpose

We wish to define colonic motor function in children with slow-transit constipation (STC) using manometry catheters introduced through appendiceal stomas, previously sited for controlling fecal retention by colonic irrigation.

Methods

We undertook 24-hour pancolonic manometry of 6 children (5 boys; mean, 11.5 years; SD, 3.0) using a multilumen silastic catheter. Results were compared to nasocolonic motility studies obtained in healthy young adults.

Results

Antegrade propagating sequences (APSs) originated less frequently in the cecum compared to controls. There were fewer APS (mean ± SEM: STC, 13 ± 6 per 24 hours; controls, 52 ± 6 per 24 hours; P < .01) and high-amplitude propagating contractions (HAPCs: STC, 5 ± 2 per 24 hours; controls, 9.9 ± 1.4 per 24 hours; P < .05). The amplitude of APS and HAPC was less in STC (APS, 39 ± 9 mm Hg; controls, 54 ± 3 per 24 hours; P < .05) (HAPC: STC, 94 ± 10 mm Hg; control, 117 ± 3 mm Hg; P < .01), whereas the amplitude of retrograde propagating sequences was greater in STC (43 ± 6 mm Hg; control, 27 ± 1 mm Hg; P < .01). The distances propagated by HAPC were significantly less in STC (36 ± 4.5 vs 47 ± 2.3 cm, controls; P < .05), and there was no evidence of a region-specific difference in propagation velocity of APS. Neither meal ingestion nor waking significantly increased colonic motor activity in patients with STC.

Conclusions

Despite the small numbers available to be studied, we found that children with STC in whom an appendicostomy had been placed show significant abnormalities in pancolonic motor function.     

Incidental thyroid nodule: patterns of diagnosis and rate of malignancy

Background

The clinical significance of thyroid incidentalomas is controversial.

Methods

The rate of malignancy was determined for patients with an incidentally discovered thyroid nodule, and results were stratified according to imaging modality as well as presence and type of pre-existing malignancy.

Results

One hundred fifty patients were identified, of which 88 with a known malignancy were screened for metastases. Twenty-three (15%) patients were diagnosed with thyroid malignancy. Incidental nodules identified on positron emission tomography scan were malignant in 33% of the patients compared with 11% for those identified on computed axial tomography (P = .016). The rate of thyroid malignancy in patients with pre-existing nonthyroid malignancy (18%) was not significantly different from patients without a history of malignancy (13%, P = .36).

Comments

Thyroid incidentalomas are associated with a high rate of malignancy. The rate of malignancy is highest for nodules discovered on positron emission tomography scan and is no different in patients with or without pre-existing malignancy.     

Risk Factors for Septic Complications in Kidney Transplant Recipients

Introduction

Septic complications following kidney transplantation are a leading cause of therapeutic failure. An early diagnosis may protect the recipient from the severe consequences of sepsis. We sought to determine the risk factors influencing the occurrence of septic complications among kidney transplant recipients.

Materials and methods

The 146 potential donors included in the study were evaluated for brain stem death criteria. Supportive management included mechanical ventilation to normocapnia, rewarming, as well as fluid and electrolyte replacement. Dopamine infusions and desaminovasopressin were titrated to predetermined mean arterial pressure (MAP). Central venous pressure (CVP) was maintained at 8 to 11 mm Hg. Hemodynamic data were acquired by the thermodilution method prior to organ procurement: MAP, CVP, pulmonary capillary wedge pressure (PCWP), and systemic vascular resistance index (SVRI). Recipient data included age, gender, period of prior hemodialysis, panel reactive antibodies, cold ischemia time, and cause of renal insufficiency. The 232 kidney recipients were examined for occurrence of septic complications including septicemia, pneumonia, peritonitis, or graft infection.

Results

Kidney transplants from donors with MAP < 70 mm Hg and SVRI < 1200 dyne × s/cm⁵ × m² showed a significantly higher occurrence of septic complications in recipients (P < .05) where mortality rate was also significantly greater (P < .01).

Conclusions

MAP < 70 mm Hg and SVRI < 1200 dyne × s/cm⁵ × m² among organ donors predicted greater occurrence of septic complications and increased mortality among kidney transplant recipients.     

Steroid-Free Immunosuppression After Liver Transplantation Does Not Increase the Risk of Graft Fibrosis

Background

Steroid-free immunosuppression after liver transplantation (OLT) is effective and safe in the short and mid terms. However, research has shown a higher risk for late fibrosis among pediatric liver transplant recipients who have steroids withdrawn. Our aim was to test this hypothesis in the adult population.

Patients and Methods

The study involved 27 adults, 14 of whom were on a regimen of cyclosporine, azathioprine, and steroid (group A) and 13 cyclosporine and azathioprine steroid-free immunosuppression (group B). The main end point of the study was liver graft histology in the late stage after OLT, with emphasis on the evolution of fibrosis, which was scored according to Ishak. The secondary end points were patient and graft survivals, liver and kidney functions, rejection rates, infections, and tumors, as well as the incidences of cardiovascular and metabolic complications.

Results

After a mean follow-up of 89.3 ± 21 months, the mean fibrosis scores did not differ between the 2 groups (2.2 ± 1.5 vs 1.9 ± 1.2; P = NS). One group A patient developed a severe acute rejection episode. The 7-year patient and graft survivals, as well as liver and kidney functions, incidence of infections, and cardiovascular and metabolic complications were comparable. Patients receiving steroids showed a trend toward an higher rate of de novo malignancies.

Conclusion

Steroid-free immunosuppression did not increase the risk of graft fibrosis in the long term.     

Impact of omphalocele size on associated conditions

Purpose

Omphalocele is often associated with the presence of other congenital anomalies. Case reports have demonstrated nonclassical associations occurring in smaller omphaloceles. The aim of this study was to determine if omphalocele defect size correlates with the type of anomalies found.

Methods

Patient records at a pediatric hospital were retrospectively reviewed for an 8-year period. Data were collected on patient demographics, omphalocele size, and congenital anomalies identified. Size of the abdominal wall defect was determined by either physical examination or operative record of repair. Patient cohorts were designated as those with small (4 cm and less) or large (greater than 4 cm) omphaloceles.

Results

Fifty-three cases of omphalocele were observed. Twenty-seven cases were classified as small, with 26 classified as large. A predominance of males was noted in the small omphalocele group (78% vs 42%; P = .01). Intestinal anomalies, including Meckel's diverticulum and intestinal atresia, were only seen in patients with small omphaloceles. Most cardiac anomalies were associated with large omphaloceles (34.6% vs 3.7%; P = .01).

Conclusion

Small omphalocele size correlates with an increased prevalence of associated gastrointestinal anomalies, a lower prevalence of cardiac anomalies, and a higher predominance of male sex.     

Prophylaxis of cytomegalovirus disease in mismatched patients after heart transplantation using combined antiviral and immunoglobulin therapy

Background

Cytomegalovirus (CMV) is a common cause of infection and morbidity after heart transplantation. Seronegative recipients (R−) of seropositive donor hearts (D+) are at high risk for CMV disease. We compared three different CMV prophylaxis regimens using combined antiviral and immunoglobulin therapy.

Methods

In 99 patients who survived more than 30 days after heart transplant, all received induction with antilymphocytic therapy and triple-drug therapy. In group A, D+R− patients received one dose of intravenous immunoglobulin (IVIG) followed by one dose of CMV-specific immunoglobulin (CMV-IVIG), and intravenous ganciclovir (GCV) for 4 weeks followed by 11 months of oral acyclovir (ACV). In group B, D+R− patients received one dose IVIG followed by five doses of CMV-IVIG and intravenous GCV for 14 weeks followed by 9 months of oral ACV. In group C, D+R− patients were treated with the same regimen as for group B, except oral ACV was replaced with oral GCV.

Results

The actuarial freedom from CMV disease for D+R− patients at 1 month, 1 year, and 2 years after transplantation in group A was 100%, 25% ± 15%, and 25% ± 15%, respectively; group B was 100%, 67% ± 27%, and 67% ± 27%; group C was 100%, 83% ± 15%, and 83% ± 15% (P < .01, groups B and C vs group A). By comparison, the actuarial freedom from CMV disease for seropositive recipients (D−R+ or D+R+) at 1 month, 1 year, and 2 years in group A was 100%, 87% ± 7%, and 82% ± 8%, respectively; group B was 100%, 88% ± 8%, and 75% ± 11%; group C was 100%, 72% ± 9%, and 72% ± 9% (P = NS among groups). Rejection rates did not differ among the three groups.

Conclusions

A longer course of intravenous GCV with multiple doses of CMV-IVIG was a more effective prophylaxis regimen against CMV disease for the high-risk group of seronegative recipients of seropositive donor hearts.     

A pilot study of the use of epidermal growth factor in pediatric short bowel syndrome

Background

This study examined the effects of enterally administered epidermal growth factor (EGF) on nutrient absorption and tolerance of enteral feeds in pediatric patients with short bowel syndrome (SBS).

Methods

Patients identified with severe SBS (<25% bowel length predicted for age) were prospectively enrolled in treatment using human recombinant EGF (1-53); 100 μg/kg per day given mixed with enteral feeds and patients were treated for 6 weeks. End points followed were patient weight, tolerance of enteral feeds, nutrient absorption, and intestinal permeability as determined using carbohydrate probes and hematologic values for liver function parameters.

Results

Five patients were treated with EGF; all showed a significant improvement in carbohydrate absorption (3-0 methylglucose): absorption 24.7% ± 9.7% pretreatment vs 34.1% ± 13.8% posttreatment and improved tolerance of enteral feeds (enteral energy as % of total energy, 25% ± 28% pretreatment vs 36% ± 24% posttreatment; mean ± SD; P < .05 by Wilcoxon's signed rank test). Epidermal growth factor treatment was not associated with significant changes in intestinal permeability, the rate of weight gain, or liver function tests. During the treatment phase, no patients developed episodes of sepsis; however, within 2 weeks of discontinuation of EGF treatment, 3 patients developed septic episodes. No adverse effects of EGF administration were noted.

Conclusions

These results suggest that enteral treatment with EGF in pediatric SBS improves nutrient absorption, increases tolerance with enteral feeds, and may improve the infection rate. Further studies exploring treatment strategies including the timing and duration of EGF administration are indicated.     

Direct measurement of hepatic blood flow during living donor liver transplantation in children

Background

The changes in liver blood flow associated with living donor liver transplantation (LDLT) in children have not yet been studied. The aim of the present study was to investigate changes in hepatic hemodynamics before and after pediatric partial liver transplantation.

Methods

In 7 pediatric recipients with congenital cholestasis and native liver Child-Pugh classes B and C, portal vein flow (PVF) and hepatic arterial flow (HAF) were measured using an ultrasonic transit time flow meter before removal of the native liver and after transplantation and compared with donor left PVF and donor left HAF.

Results

The mean portal contribution to total hepatic blood flow was markedly decreased in the recipient native liver compared with that in the donor (69% ± 15% vs 32% ± 15%; P = .0003) and after reperfusion changed to almost the same ratio as that in the donor liver (73% ± 18%; P < .0001).

Conclusion

The extreme imbalance between PVF and HAF that is common in implanted partial liver in adult LDLT recipients was not observed in pediatric LDLT. After transplantation of an appropriately sized liver graft, the portal contribution to total liver blood flow normalized to the value for normal liver.     

Platelet dysfunction in acute type A aortic dissection evaluated by the laser light-scattering method

Objectives

Platelet dysfunction contributes to bleeding tendency in acute type A aortic dissection. Particle counting by new laser light-scattering methods more accurately quantifies changes in the number of different-sized platelet aggregates than do conventional optical density methods. We studied platelet aggregation kinetics and patterns of aggregation deficiency in acute-phase aortic dissection with laser light scattering.

Methods

Blood from 20 acute type A aortic dissection patients undergoing surgery was sampled during acute (9.1 ± 6.8 hours from onset) and chronic (postoperative day 20, control) phases of aortic dissection. Platelet count and aggregability were assessed by optical density and laser light-scattering methods after aggregation was induced (addition of 2.0 μg/mL collagen to samples).

Results

Optical density showed significant reduction in acute-phase platelet aggregation (acute vs chronic: 65 ± 27% vs 77 ± 17%, P < .03). Laser light scattering showed significant reduction in medium (25-50 μm) and large (50-70 μm) but not small aggregate (9-25 μm) generation (acute vs chronic: small, 1.2 ± 0.6 × 10⁷ vs 1.5 ± 1.0 × 10⁷, NS; medium, 0.6 ± 0.3 × 10⁷ vs 1.1 ± 0.5 × 10⁷, P < .001; large, 1.4 ± 1.2 × 10⁷ vs 2.6 ± 1.7 × 10⁷, P < .001). Acute- versus chronic-phase platelet counts were significantly decreased (1.7 ± 0.1 × 10⁵/μL vs 3.6 ± 0.3 × 10⁵/μL, P < .001).

Conclusions

Platelet aggregation is suppressed in acute-phase aortic dissection. This suppression does not occur in the initial phase of small aggregate formation; rather, it occurs during the conglomeration of small aggregates into larger aggregates.     

Laparoscopic vs open surgical approach for intussusception requiring operative intervention

Purpose

Laparoscopy has recently been used to treat intussusception that cannot be reduced radiologically. The effectiveness and practical nature of this approach has been questioned.

Methods

This study retrospectively analyzed the authors' experience with this laparoscopic approach and compared this to the conventional open laparotomy procedure.

Results

Sixteen patients were treated via laparoscopy, with 2 of these requiring conversions to an open procedure (12.5%). Twenty-five patients underwent an open reduction. Operative time was not significantly different (P = .698) between the laparoscopic (49.56 ± 26.40 minutes) and open groups (45.00 ± 24.74). Length of stay, however, was significantly reduced (P = .005) in the laparoscopic group (3.00 ± 1.31 days) compared to the open group (4.52 ± 1.98). Total hospital charges were lower in the laparoscopic group ($8171 ± 2595) compared to the open group ($11,672 ± 5466); this difference was not significant (P = .088). There were no significant differences in intra- or postoperative complication rates (P = .637) between the 2 approaches.

Conclusions

Although there remains a group who will require a conversion to an open procedure, the laparoscopic approach should be considered a safe and effective option for all children who do not respond to a radiological reduction.     

Tacrolimus dose and blood concentration variability in kidney transplant recipients undergoing conversion from twice daily to once daily modified release tacrolimus

Introduction

Maintenance of the target blood levels of immunosuppressive drugs is one of the main factors determining transplant function. The aim of this study was to assess the effect of the conversion of tacrolimus from twice daily (Tc) to the prolonged release form administered once daily (Tc-pr) including the variability of blood concentrations and glomerular filtration rates in kidney transplantation patients.

Materials and Methods

This retrospective analysis evaluated 52 patients including 23 females, and 29 males with established grafts who underwent a scheduled change of treatment from Tc to Tc-pr. We examined data from six consecutive visits before and six visits after conversion.

Results

The average daily dose of Tc was 3.8 ± 2.6 mg/24 h, whereas mean coefficient of variation (CoV) calculated from the visits before conversion was 68%. After the conversion, the mean total daily dose of Tc-pr was not significantly lower (3.2 ± 1.8 mg), as was the mean CoV at six subsequent visits 57% (P = ns). Blood concentrations in both analyzed periods remained in the target range (Tc-pr 6.7 ± 2.9 ng/mL versus Tc-pr 5.0 ± 1.11) with a lower CoV in the case of Tc-pr compared to Tc (22% versus 44%; P < .001). There was no difference in graft function in the analyzed periods. After conversion, lower blood glucose levels were observed: 103.4 ± 28.3 mg/dL versus 95 ± 25.9 mg/dL (P < .03).

Conclusions

The slow-release form of tacrolimus provided greater stability of drug blood concentrations compared with the standard form administered twice daily. The change of the tacrolimus treatment from Tc to Tc-pr dosing did not effect organ function but seemed to improve glycemic control.