Application of the AAST EGS Grade for Adhesive Small Bowel Obstruction to a Multi-national Patient Population

Background

The American Association for the Surgery of Trauma (AAST) anatomic severity grading system for adhesive small bowel obstruction (ASBO) has demonstrated to be a valid tool in North American patient populations. Using a multi-national patient cohort, we retrospectively assessed the validity the AAST ASBO grading system and estimated disease severity in a global population in order to correlate with several key clinical outcomes.

Methods

Multicenter retrospective review during 2012–2016 from four centers, Minnesota USA, Bologna Italy, Pietermaritzburg South Africa, and Bucharest Romania, was performed. Adult patients (age?≥?18) with ASBO were identified. Baseline demographics, physiologic parameters, laboratory results, operative and imaging details, outcomes were collected. AAST ASBO grades were assigned by independent reviewers. Univariate and multivariable analyses with odds ratio (OR) and 95% confidence intervals (CIs) were performed.

Results

There were 789 patients with a median [IQR] age of 58 [40–75] years; 47% were female. The AAST ASBO grades were I (n?=?180, 23%), II (n?=?443, 56%), III (n?=?87, 11%), and IV (n?=?79, 10%). Successful non-operative management was 58%. Conversion rate from laparoscopy to laparotomy was 33%. Overall mortality and complication and temporary abdominal closure rates were 2, 46, and 4.7%, respectively. On regression, independent predictors for mortality included grade III (OR 4.4 95%CI 1.1–7.3), grade IV (OR 7.4 95%CI 1.7–9.4), pneumonia (OR 5.6 95%CI 1.4–11.3), and failing non-operative management (OR 2.4 95%CI 1.3–6.7).

Conclusion

The AAST EGS grade can be assigned with ease at any surgical facility using operative or imaging findings. The AAST ASBO severity grading system has predictive validity for important clinical outcomes and allows for standardization across institutions, providers, and future research. Disease severity and outcomes varied between countries.

Level of evidence III

Study type Retrospective multi-institutional cohort study.

     

Validation of AAST EGS Grade for Acute Pancreatitis

Background

The AAST recently developed an emergency general surgery (EGS) disease grading system to measure anatomic severity. We aimed to validate this grading system for acute pancreatitis and compare cross sectional imaging-based AAST EGS grade and compare with several clinical prediction models. We hypothesize that increased AAST EGS grade would be associated with important physiological and clinical outcomes and is comparable to other severity grading methods.

Methods

Single institution retrospective review of adult patients admitted with acute pancreatitis during 10/2014–1/2016 was performed. Patients without imaging were excluded. Imaging, operative, and pathological AAST grades were assigned by two reviewers. Summary and univariate analyses were performed. AUROC analysis was performed comparing AAST EGS grade with other severity scoring systems.

Results

There were 297 patients with a mean (±SD) age of 55?±?17 years; 60% were male. Gallstone pancreatitis was the most common etiology (28%). The overall complication, mortality, and ICU admission rates were 51, 1.3, and 25%, respectively. The AAST EGS imaging grade was comparable to other severity scoring systems that required multifactorial data for readmission, mortality, and length of stay.

Conclusions

The AAST EGS grade for acute pancreatitis demonstrates initial validity; patients with increasing AAST EGS grade demonstrated longer hospital and ICU stays, and increased rates of readmission. AAST EGS grades assigned using cross sectional imaging findings were comparable to other severity scoring systems. Further studies should determine the generalizability of the AAST system.Level of Evidence: IVStudy Type: Single institutional retrospective review

     

High readmission rates are associated with a significant economic burden and poor outcome in patients with grade III/IV acute GvHD

Graft‐versus‐host disease (GvHD) is a common complication following haematopoietic stem cell transplant but little is published about the impact of this condition on hospital readmission rates. We report a retrospective analysis of readmission rates and associated costs in 187 consecutive allogeneic transplant patients to assess the impact of GvHD. The overall readmission rate was higher in patients with GvHD (86% (101/118) vs. 59% (41/69), p < 0.001). The readmission rate was higher both in the first 100 d from transplant (p = 0.02) and in the first year following transplant (p < 0.001). 151/455 (33%) of all readmission episodes occurred within 100 d of transplant. The mean number of inpatient days was significantly higher in patients with grade III/IV acute GvHD (101 d) compared with those with grade I/II GvHD (70 d; p = 0.003). The mean cost of readmission was higher in patients with GvHD (£28 860) than in non‐GvHD patients (£13 405; p = 0.002) and in patients with grade III/IV GvHD (£40 012) compared with those patients with grade I/II GvHD (£24 560; p = 0.038). Survival was higher in those with grade I/II GvHD (55%) compared to grade III/IV GvHD (14%; p < 0.001). This study shows the high economic burden and poor overall survival associated with grade III/IV GvHD.     

Natural history of intraventricular meningiomas: systematic review

Review the data published on the subject to create a more comprehensive natural history of intraventricular meningiomas (IVMs). A Medline search up to March 2018 using “intraventricular meningioma” returned 98 papers. As a first selection step, we adopted the following inclusion criteria: series and case reports about IVMs, as well as papers written in other languages, but abstracts written in English were evaluated. Six hundred eighty-one tumors were evaluated from 98 papers. The majority of the tumors were located in the lateral ventricles (602–88.4%), fourth ventricle (59–8.7%), and third ventricle (20–2.9%). These tumors accounted for a mortality rate of 4.0% (25 deaths) and a recurrence rate of 5.3% (26 recurrences). The majority of the tumors were grade I (89.8%) and consisted of the following subtypes: fibrous, 39.7% (n = 171); transitional, 22.0% (n = 95); meningothelial, 18.6% (n = 80); angiomatosus, 3.2% (n = 14); psammomatous, 2.6% (n = 11); and others, 13.9% (n = 60). Forty-five patients (7.4%) presented with grade II (GII) tumors, and 17 patients (2.8%) presented with grade III (GIII) tumors. These tumors follow the histopathological distribution of meningiomas in general, with the exception of the higher prevalence of the fibrous subtype, possibly due to its embryonic origin. Recurrence and mortality were lower than in other localizations likely due to a complete surgical resection rate than in the convexity and skull base, which suggests that GTR is the gold standard for the management of IVMs.     

Evidence-based validation of the predictive value of the American Association for the Surgery of Trauma kidney injury scale

BACKGROUND: To evaluate the predictive value of the American Association for the Surgery of Trauma (AAST) kidney injury scale for the management of traumatic renal injuries. METHODS: From October 1995 through October 2004, 424 patients presented to our hospital with traumatic renal injury. RESULTS: Overall, 27.8% of patients had grade I injury, 26.4% had grade II injury, 19.3% had grade III injury, 18.2% had grade IV injury, and 8.3% had grade V injury. Patient age, Glasgow Coma Scale score, Revised Trauma Score, creatinine, blood urea nitrogen (BUN), white blood count, gender, substance abuse, shock, flank ecchymosis, abdominal pain, and mortality were not associated with AAST grade. Systolic blood pressure and hematocrit levels decreased with increasing AAST grades (p = 0.032 and p = 0.045, respectively). Volume transfused and length of hospitalization increased with AAST grades (p = 0.003 and p = 0.004, respectively). Patients with gunshot injury had higher AAST grades than those with blunt trauma (p < 0.001). Hypotension (14%), blood transfusion (47%), gross hematuria (65.9%), and flank pain (25%) were associated with higher AAST grades (p = 0.010, p < 0.001, p = 0.016, and p = 0.001, respectively). Ninety patients (21.2%) underwent renal exploration: 61% nephrectomies and 39% renorraphies. In multivariable analyses, type of injury, hematuria at presentation, and AAST scale predicted the risk of renal exploration (p < 0.001, p = 0.024, and p < 0.001, respectively), whereas type of injury and AAST scale were the sole predictors of nephrectomy (p < 0.001 and p < 0.001, respectively). CONCLUSIONS: We confirmed that the AAST injury severity scale is a powerful and valid tool for prediction of clinical outcome in patients with renal trauma.     

Bipolar revision arthroplasty for failed threaded acetabular components: radiographic evaluation of cup migration

 We studied the radiographic results of bipolar revision hip arthroplasty in 25 patients (25 hips). These patients had suffered from osteoarthrosis of the hip due to acetabular dysplasia and had undergone total hip replacement using smooth threaded acetabular components. In the revision surgery, these components were replaced by bipolar cups; autografts were implanted in 23 patients and hydroxyapatite grains were added in 7. At the time of follow-up, the severity of migration was radiographically graded from I to IV: grade I, 5 mm or less; grade II, 6 to 10 mm; grade III, 11 to 15 mm; and grade IV, 16 mm or more. Five to 11 years (average, 7.0 years) after surgery, 9 patients were classified as grade I, 6 as grade II, 4 as grade III, and 6 as grade IV. Among the 6 individuals with grade IV migration, hydroxyapatite grains had been used in 5. There was a significant negative correlation between the distance of migration and the increase in size of the threaded acetabular components used in the primary total hip replacement and the bipolar cups in the revision surgery. Because of the tendency to migrate, we concluded that this procedure has a limited role in revision surgery. Received: November 9, 2001 / Accepted: March 15, 2002     

Validation of the American Association for the Surgery of Trauma organ injury severity scale for the kidney

BACKGROUND: We queried an observational database of renal trauma patients to validate the organ injury severity scale (kidney) of the American Association for the Surgery of Trauma (AAST). METHODS: In a retrospective review of our renal trauma database (2,467 patients) with 58 clinical and radiographic patient variables, statistical "classification trees" were used to determine factors predicting need for surgical repair. RESULTS: Scales correlated with the need for surgery (grade I = 0%, grade II = 15%, grade III = 76%, grade IV = 78%, and grade V = 93%) and for nephrectomy (grade I = 0%, grade II = 0%, grade III = 3%, grade IV = 9%, and grade V = 86%). Classification tree analysis (confirmed in 83 additional patients) identified the AAST organ injury severity scale as the most important variable predicting the need for renal repair. CONCLUSION: In a retrospective review of more than 2,500 patients, we determined that the AAST organ injury severity scale correlates with the need for kidney repair or removal. Classification tree analysis confirmed the scale as the prime variable predicting need for surgical repair.     

Protein Z and natural anticoagulants in children on peritoneal dialysis and hemodialysis

Hemostatic alterations due to abnormalities in the coagulation and fibrinolytic system may occur in dialysis patients. Protein Z (PZ) is a vitamin K-dependent coagulation protein promoting assembly of thrombin with phospholipid vesicles. The aim of this study was to investigate PZ and natural anticoagulants in children on hemodialysis (HD) and peritoneal dialysis (PD). Protein Z, protein C (PC), protein S (PS), antithrombin III (AT III), and fibrinogen levels were studied in 24 PD, 13 HD patients and 23 controls. Plasma PZ levels in patients on HD were significantly higher than those on PD and control group (p = 0.04, p = 0.03). We observed elevated PC, PS and AT III activities in children on PD when compared to controls (p = 0.011, p = 0.003, p < 0.001). In HD patients, only PS activity was increased compared to controls (p = 0.016). PC and PS activities did not differ between PD and HD patients whereas AT III activity was higher in PD patients compared to HD patients (p < 0.001). Normal/high levels of PC, PS and AT III suggest that children on PD or HD treatment do not seem to have an increased risk of thrombogenesis due to reduction of these proteins. Increased PZ levels, however, might contribute to the hemostatic alterations in children on HD treatment along with other well known abnormalities.     

Outcomes after resection versus non-resection management of penetrating grade III and IV pancreatic injury: A trauma quality improvement (TQIP) databank analysis

BackgroundHigh-grade traumatic pancreatic injuries are associated with significant morbidity and mortality. Non-resection management is associated with fewer complications in pediatric patients. The present study evaluates outcomes following resection versus non-resection management of severe pancreatic injury caused by penetrating trauma.MethodsA retrospective study of the Trauma Quality Improvement Program (TQIP) database was performed from 1/2010 to 12/2014. Patients with AAST Organ Injury Scale pancreatic grade III and IV injuries caused by penetrating trauma were included in the study. Demographics, vital signs on admission, Abbreviated Injury Scale per body region, Injury Severity Score, transfusion and therapeutic modality were obtained. Mortality, length of stay (LOS), pseudocyst, pancreatitis, sepsis, thromboembolism, renal failure, ARDS and unplanned ICU admission or re-operation were stratified according to injury grade and treatment modality. Patients were stratified into those who did/did not undergo pancreatic resection.ResultsA total of 4,098 patients had a pancreatic injury of which 15.9% (n = 653) had a grade III and 6.7% (n = 274) a grade IV pancreatic injury. There were no differences in patient demographics or overall injury severity between the resected and non-resected cohorts within each pancreatic injury grade. Forty-two percent of grade III and 38.0% of grade IV injuries underwent pancreatic resection. The total LOS was longer in the resection arm irrespective of pancreatic injury severity. There was no significant difference in morbidity between cohorts. Similarly, mortality was not significantly different between the two management approaches for grade III: 15.1% (95% CI 11.0–19.9) vs. 18.4% (95% CI 14.6–22.6), p = 0.32 and grade IV: 24.0% (95% CI: 16.2–33.4) vs. 27.1% (95% CI: 20.5–34.4), p = 0.68.ConclusionResection for treatment of grade III and IV pancreatic injury is not associated with a significant decrease in mortality but is associated with an increase in hospital LOS.     

The striate sign: peritumoural perfusion pattern of infiltrative primary and recurrent gliomas

MR perfusion depicts angiogenesis as a key factor for growth and malignancy in gliomas by means of increased regional cerebral blood volume (rCBV). The rCBV increase is not limited to the tumour area, but may also produce a stripe-like pattern of peritumoural rCBV increase that we defined as the “striate sign”. We evaluated if prior radiochemotherapy influences perfusion values and pattern in and adjacent to malignant gliomas comparing rCBV of treated recurrent gliomas with untreated gliomas. Ninety-three patients with primary or recurrent WHO grades II–IV glial tumours underwent T2*-weighted dynamic susceptibility-weighted contrast-enhanced (DSC)-MRI. Differences of normalised rCBV and rCBV_max were evaluated using Kruskal−Wallis analysis with post hoc tests. The number of cases showing a hot spot of rCBV (rCBV_max) and/or a peritumoural striate pattern of rCBV increase (striate sign) was assessed and evaluated by Fisher’s exact test. Significance level was determined as p < 0.05. Normalised rCBV, rCBV_max and number of cases with the striate sign were significantly lower in recurrent (rCBV = 3.24 ± 1.22, rCBV_max = 5.05 ± 2.27 and striate sign = 10/24) compared to primary WHO grade IV tumours (rCBV = 4.44 ± 1.39, rCBV_max = 7.31 ± 3.0 and striate sign = 17/21, respectively). There were fewer cases with a striate sign in treated recurrent WHO grade III tumours than in untreated malignant transformed WHO grade II tumours. The pattern and degree of rCBV increase in and around gliomas differ between untreated and previously treated tumours. These differences might be due to post-therapeutic changes of the tumour-associated microvasculature by radiochemotherapy. Spectroscopic and susceptibility-weighted MR imaging may provide further insights into the tumour biology.     

Long-term outcome and chronic pain in atraumatic fibrin glue versus staple fixation of extra light titanized meshes in laparoscopic inguinal hernia repair (TAPP): a single-center experience

Inguinal hernia repair belongs to the most frequently performed surgical procedures. Endoscopic techniques like TAPP and TEP have become standard of care together with the conventional open techniques. Especially in endoscopic techniques, there is a confusing amount of different meshes and fixation techniques with impact on perioperative and long-term outcome. We present the first single-center data on the use of titanized extra lightweight meshes and fibrin glue fixation compared to staple fixation regarding long-term outcome, especially chronic pain. A clinical trial with retrospective analysis of patient- and procedure-related data and questionnaire-based follow-up of TAPP procedures performed in 2012–2014 was conducted in a specialized hernia center. Standard TAPP technique was used with placement of TiMesh extra light (16 g/m2) and either fibrin glue or staple fixation. Procedure- and patient-related data are compared after propensity score matching regarding perioperative complications and long-term outcome. Of 612 TAPP procedures 372 procedures were included in analysis after propensity score matching. Fibrin glue was used in n = 279 and staple fixation in n = 93 cases. There were significant differences regarding duration of the surgical procedures (p = 0.001) and distribution of mesh size. No differences were noted regarding perioperative complications such as seroma or hematoma formation and need for re-laparoscopy. During a mean follow-up of 32.1 ± 20.6 month with a follow-up rate of 79%, there was no difference in long-term outcome, especially for rate of recurrence (p = 0.112) and development of chronic pain (p = 0.846). The overall rate of recurrence was 3.0% (n = 11), and in 2.4% (n = 9) patients complained of chronic pain. Inguinal hernia repair using extra lightweight titanized meshes and fibrin glue fixation is safe and feasible compared to staple fixation even in large and combined hernia defects, if mesh size is adjusted to size of hernia defect. The rate of chronic pain was extremely low at 2.4%.     

Ultrastructural and histological changes in tibial remnant of ruptured anterior cruciate ligament stumps: a transmission electron microscopy and immunochemistry-based observational study

Anterior cruciate ligament (ACL) rupture is a common injury and has a non-union rate of 40–100%. Important cellular events, such as fibroblast proliferation, angiogenesis and change in collagen fibril thickness in the ACL remnant, as described in other dense connective tissue, might have an implication in graft recovery following ACL reconstruction. Thus we conducted a study with an aim to characterize the ultrastructural and histological features of ruptured ACL tibial stump and correlate the same with the duration of injury. This was a prospective observational study in which 60 ruptured human ACLs were evaluated for collagen fibril thickness, blood vessel density (per mm2) and fibroblast density (per mm2) with the help of transmission electron microscopy, immunohistochemistry via CD34 antibody staining and light microscopy (H&E staining). The findings were correlated with duration of injury. Fifty-four male and six female patients with a mean duration of the injury of 23.01 weeks (SD = 26.09; range 2–108 weeks) were included for the study and were divided on the basis of duration of injury as follows: Group I (≤ 6 weeks; N = 16), Group II (7–12 weeks; N = 18), Group III (13–20 weeks; N = 7), Group IV (21–50 weeks; N = 12), Group V (> 50 weeks; N = 7). A significant correlation was seen with blood vessel density (r = 0.303, p = 0.01) and fibroblast density (r = − 0.503, p = 0.001). Thickness of collagen fibril did not correlate with the duration of injury (r = 0.15, p = 0.23). The thickness of the collagen reached its peak after 50 weeks following injury, whereas highest density of blood vessel and fibroblast was seen at 12–20 weeks. Matched pair analysis revealed a significant decrease in collagen fibril thickness and an increase in fibroblast density at 7–12 weeks. Following injury to ACL, the ruptured tibial stump undergoes a series of changes at the cellular level vis-à-vis changes in collagen fibril thickness, vascular density and fibroblast density that possibly suggest an intrinsic healing response. This further may have implications on the functional outcome following ACL reconstruction with remnant preservation. III     

Who Benefits from Gastric Banding?

Background In the present study, criteria were investigated to predict major benefit after laparoscopic adjustable gastric banding (LAGB). Materials and Methods 85 morbidly obese patients were operated with LAGB between 1999 and 2005. Seventy-one of these patients were analyzed according to several possible predictive characteristics for success as the primary endpoint. Success was defined as excess body weight loss (EBWL) >50% and no band removal. Median follow-up was 27 months (range 8–90 months). Results In total, median EBWL was 43% (−41 to 171.5%) with a decrease in BMI of 8.0 kg/m² (−9 to 35 kg/m²). Success rate was 37% (n = 26). These patients were compared to all other patients (n = 45). Significant success predictors were baseline absolute BW, EBW, BMI (p < 0.01), BMI with a threshold value of 50 kg/m² (p = 0.02), and female sex (p = 0.02) as well as postoperative vomiting (p = 0.02), eating behavior and physical activity after LAGB (p < 0.01). Baseline EBW and change in eating behavior after surgery were identified as independent predictors in multivariate analysis. Conclusion Patients with a lower excess body weight who improve especially their eating behavior after surgery have the highest chance of success after LAGB.     

Morbidity and Mortality Assessment of Cytoreductive Surgery and Perioperative Intraperitoneal Chemotherapy for Diffuse Malignant Peritoneal Mesothelioma—A Prospective Study of 70 Consecutive Cases

Background Although many reports regarding morbidity and mortality of cytoreductive surgery plus perioperative intraperitoneal chemotherapy are available, there are no prospective data on morbidity and mortality limited to patients with diffuse malignant peritoneal mesothelioma (DMPM). Methods This prospective morbidity and mortality assessment was performed on 70 consecutive cytoreductive procedures with perioperative intraperitoneal chemotherapy for DMPM. Forty-seven adverse events by eight categories were rated from grades I to IV with increasing severity. Grade I morbidity was self-limiting; grade II required medical treatments; grade III required an invasive intervention; grade IV required returning to the operating room or intensive care management. Risk factors for grades III and IV morbidity were determined. Results The perioperative mortality rate was 3%. The grades III and IV morbidity rates were 27 and 14%, respectively. Primary colonic anastomosis (P = 0.028), more than four peritonectomy procedures (P = 0.015), duration of the operation of more than 7 h (P = 0.027) were the risk factors for grade IV morbidity. Survival analysis of these 70 patients was provided. Conclusions The morbidity and mortality results for cytoreductive surgery and perioperative intraperitoneal chemotherapy for patients with DMPM were within the acceptable range for major gastrointestinal surgery. Grade IV morbidity was associated with more extensive cytoreduction.     

Preoperative change of modified Glasgow prognostic score after stenting predicts the long-term outcomes of obstructive colorectal cancer

Inflammation-based markers predict the long-term outcomes of various malignancies. We investigated the relationship between the modified Glasgow prognostic score (mGPS) and the long-term outcomes of obstructive colorectal cancer in patients who underwent self-expandable metallic colonic stent placement and subsequently received curative surgery. We retrospectively analyzed 63 consecutive patients with pathological stage II and III obstructive colorectal cancer from 2013 to 2018. The mGPS was calculated before stenting and surgery, and the difference of the scores was defined as the d-mGPS. All d-mGPS = 2 patients were > 70 years of age (p = 0.01). Postoperative complications were more common in the preoperative mGPS = 2 group (p = 0.02). The postoperative hospital stay was significantly longer in the mGPS = 2 group (p = 0.007). Multivariate analyses revealed that d-mGPS was an independent prognostic factor for overall survival (OS) (hazard ratio [HR] = 9.18, p = 0.004) and cancer-specific survival (HR = 9.98, p = 0.01). Preoperative mGPS = 2 was significantly associated with poor OS (HR = 5.53, p = 0.04). The results indicated that mGPS might serve as a valuable indicator of the immunonutritional status of preoperative patients, and a preoperative change of the status might affect the long-term outcomes of patients with obstructive colorectal cancer.     

Laparoscopic Approach to Colorectal Procedures in the Obese Patient: Risk Factor or Benefit?

Background Obesity is a modern-day phenomenon that is increasing throughout the world. The aim of the present study was to provide data to establish whether the laparoscopic approach to colorectal surgery in the obese patient represents a risk or, rather, a benefit for the patient. Method The data presented in this paper were obtained within the framework of a prospective multicenter study initiated by the “Laparoscopic Colorectal Surgery Study Group (LCSSG)” and performed on 5,853 recruited patients. The perioperative course was compared between the three groups: nonobese, obesity grade I, and obesity grade II/III. Results Increasing body mass index correlated with a highly significant increase in the duration of the operation (nonobese 167 min, grade I 182 min, grade II/III 191 min; p < 0.001) and in the conversion rate (nonobese 5.5%, obesity grade I 7.9%, obesity grade II/III 13.1%; p < 0.001). The intraoperative complication rate also showed a tendency to increase (nonobese 5.0%, grade I 6.2%, grade II/III 7.1%; p = 0.219). In contrast, no significant differences were found between the groups with regard to the postoperative complication rate (nonobese 20.7%, grade I 21.0%, grade II/III 20.2%), the reoperation rate (nonobese 4.1%, grade I 3.9%, grade II/III 3.6%), and the postoperative mortality rate (nonobese 1.1%, grade I 1.9%, grade II/III 1.8%). Conclusion Laparoscopic colorectal surgery is clearly more technically demanding in the obese patient. Apart from this, however, it is not associated with any increased risk of postoperative complications, and thus demonstrates that the pathologically overweight patient can benefit to a particular degree from the laparoscopic modality.     

A multicenter study of the pharmacokinetics of lisinopril in pediatric patients with hypertension

The pharmacokinetic (PK) parameters of lisinopril were obtained in 46 children aged 6 months to 15 years. A lisinopril suspension (0.15 mg/kg per day) was administered to patients <6 years of age; the remaining children received lisinopril tablets, the daily dose being adjusted according to body weight, i.e., 2.5 mg if <25 kg, 5 mg if 25–45 kg, and 10 mg if >45 kg. Blood was drawn predose and on eight occasions postdose in children aged 4–15 years, and on five occasions in those aged <4 years. PK data are reported for the 46 children in terms of age groups: Group I (n = 9), aged 6–23 months; Group II (n = 8), aged 2–5 years; Group III (n = 12), aged 6–11 years; Group IV (n = 17), aged 12–15 years. The dose of lisinopril ranged from 3.07 mg/m² per day in Group I to 4.78 mg/m² per day in Group IV. C_max of lisinopril, which occurred 5–6 h postdose, varied from 22 ng/ml in Groups I and II to 44 ng/ml in Groups III and IV; AUC_{0–24 h} ranged from 301–311 ng·h/ml in Groups I and II to 550–570 ng·h/ml in Groups III and IV. No serious adverse events related to lisinopril were reported.     

Relationship between Classification of Fabellae and the Severity of Knee Osteoarthritis: A Relevant Study in the Chinese Population

ObjectiveTo classify the fabellae and discuss the relationship between the classification of fabellae and the severity of knee osteoarthritis (KOA) in Chinese.MethodsFrom February 2019 to February 2020, 136 patients were measured and classified using three‐dimensional computed tomography (CT) reconstruction. According to the CT imaging characteristics, the fabellae were divided into five types: type I, a fabella on the lateral femoral condyle; type II, a fabella on the medial femoral condyle; type III, a fabella on the lateral femoral condyle and a fabella on the medial femoral condyle; type IV, two fabellae on the medial femoral condyle; and type V, two fabellae on the lateral femoral condyle. The severity of KOA was assessed on the Recht grade by magnetic resonance imaging (MRI). The data were analyzed with SPSS 24.0.ResultsThe classification of fabellae were correlated with KOA grades (χ² = 35.026, P < 0.05). In terms of KOA grades, grade I and grade II were occupied most by fabellar type II (32, 72.8%); type II and other types showed significant statistical difference (P < 0.05). Grade I and grade II were also mainly fabellar type IV (four, 100%). Fabellar type V''s biggest component was grade III and grade IV (six, 75%). Type IV and type V showed significant statistical difference (P < 0.05).ConclusionThe classification of fabellae were correlated with KOA grades. The type II may mean the lower KOA grades while type V may mean the higher KOA grades.     

Routine Liver Biopsy to Screen for Nonalcoholic Fatty Liver Disease (NAFLD) during Cholecystectomy for Gallstone Disease: Is it Justified?

Background  Nonalcoholic fatty liver disease (NAFLD) and gallstone disease (GD) share common risk factors. There are no firm recommendations regarding screening of NAFLD in patients at risk. Our aim was to assess the prevalence of and factors associated with NAFLD in a cohort of patients operated for symptomatic GD and evaluate the usefulness of routine liver biopsy. Methods  Ninety-five consecutive patients underwent a liver biopsy at the end of a standard laparoscopic cholecystectomy for symptomatic GD. Clinical, biochemical, demographic, and anthropometric variables were obtained prospectively. Results  Fifty-two patients (55%) had biopsies compatible with NAFLD. These patients were classified according to the system proposed by Brunt et al. as follows: grade I, n = 27 (52%); grade II, n = 15 (29%); grade III, n = 10 (19%). Two grade III patients had zone III focal perisinusoidal fibrosis and three had overt cirrhosis. Only 13% of subjects had a suspected diagnosis of NAFLD preoperatively. In multivariate logistic regression, only obesity was significantly associated with NAFLD. There were no complications or mortality. Discussion  Fifty-five percent of patients with GD have associated NAFLD. Awareness of this association may result in an earlier diagnosis. The high prevalence of NAFLD in patients with GD may justify routine liver biopsy during cholecystectomy to establish the diagnosis, stage, and possible direct therapy. This work was presented at the Plenary Session of the 2008 Society of Surgery of the Alimentary Tract meeting in San Diego, CA, USA.