Perioperative and long-term morbidity and mortality after above-knee and below-knee amputations in diabetics and nondiabetics

We performed a retrospective review of a vascular surgery quality assurance database to evaluate the perioperative and long-term morbidity and mortality of above-knee amputations (AKA, n = 234) and below-knee amputations (BKA, n = 720) and to examine the effect of diabetes mellitus (DM) (181 of AKA and 606 of BKA patients). All patients in the database who had AKA or BKA from 1990 to May 2001 were included in the study. Perioperative 30-day cardiac morbidity and mortality and 3-yr and 10-yr mortality after AKA or BKA were assessed. The effect of DM on 30-day cardiac outcome was assessed by multivariate logistic regression and the effect on long-term survival was assessed by Cox regression analysis. The perioperative cardiac event rate (cardiac death or nonfatal myocardial infarction) was at least 6.8% after AKA and at most 3.6% after BKA. Median survival was significantly less after AKA (20 mo) than BKA (52 mo) (P < 0.001). DM was not a significant predictor of perioperative 30-day mortality (odds ratio, 0.76 [0.39-1.49]; P = 0.43) or 3-yr survival (Hazard ratio, 1.03 [0.86-1.24]; P = 0.72) but predicted 10-yr mortality (Hazard ratio, 1.34 [1.04-1.73]; P = 0.026). Significant predictors of the 30-day perioperative mortality were the site of amputation (odds ratio, 4.35 [2.56-7.14]; P < 0.001) and history of renal insufficiency (odds ratio, 2.15 [1.13-4.08]; P = 0.019). AKA should be triaged as a high-risk surgery while BKA is an intermediate-risk surgery. Long-term survival after AKA or BKA is poor, regardless of the presence of DM.     

Quality-of-life changes and psychiatric and neurocognitive outcome after heart and liver transplantation.

A prospective study compared psychiatric, neurocognitive, and quality-of-life changes of heart and liver transplant patients. The 51 heart and 61 liver transplant candidates and recipients completed the Beck depression inventory (BDI), state-trait anxiety inventory (STAI), sickness impact profile (SIP), mini-mental state (MMS), California verbal learning test (CVLT), Wisconsin card sorting test (WCST), trailmaking test (TMT), and the impact message inventory (IMI). Data were gathered before transplant and at 3-month intervals for up to 1 year after transplant. Psychometric tests scores were correlated with electroencephalograms for the liver patients. Both groups showed significant improvements after transplant in neurocognitive functioning, depressive symptoms, and quality of life.     

Hypoxia and hypotension during endoscopy and colonoscopy

Sixty-three patients undergoing oesophagogastroduodenoscopy (OGD) (n = 24) or proctosigmoidocolonoscopy (PSC) (n = 39) had continuous monitoring of arterial oxygen saturation (SaO2), pulse and mean blood pressure (BP). The degree of patient distress, duration, dose of sedative and details of the endoscope and operator were recorded. Marked hypotensive (greater than 40% fall in BP) and hypoxic (greater than 8% fall in SaO2) changes occurred in 13% and 17% of the overall group, respectively. There were no significant differences in fall in BP, SaO2 or pulse between the OGD and PSC groups. The dose of sedative was significantly related to the fall in SaO2 (P less than 0.001) but not to the fall in BP. The falls in both SaO2 and BP were related to the duration of the procedure (P less than 0.001, P = 0.03, respectively). There were no correlations between the degree of hypoxia or hypotension and the patient's age or previous medical history. Hypotension and hypoxia occur in both colonoscopy and OGD and are neither predictable nor usually recognizable clinically. Pulse oximetric and BP monitoring throughout gastrointestinal endoscopy are recommended for maximal safety.     

Isoflurane and desflurane uptake during liver resection and transplantation

When reducing fresh gas flows, the course of the vaporizer dial settings required to maintain a constant end-expired concentration of a potent inhaled anesthetic becomes more dependent on the uptake pattern of the inhaled anesthetic. However, the uptake pattern of potent inhaled anesthetics during prolonged procedures remains poorly quantified. Therefore, we determined isoflurane and desflurane uptake (V(iso) and V(des), respectively) during liver resection (LR, n = 17) and orthotopic liver transplantation (OLT, n = 18) using a liquid injection closed-circuit anesthesia technique maintaining the end-expired concentration at 0.8% and 4.5%, respectively. Individual and average uptake curves were fit to a series of mathematical functions and compared with the square root of time and four-compartment models. Cumulative doses of isoflurane and desflurane after 1 and 3 h in the LR group and after 1, 3, and 8 h in the OLT group were correlated with demographic variables and each patient's average cardiac output and cardiac index. Average uptake was best described by a biexponential fit: V(iso) (LR) = 1.5 x (1 - e(-t x 0.525)) + 16.4 x (1 - e(-t x 0.00506)) (R(2) = 0.9996); V(iso) (OLT) = 1.4 + 3.1 x (1 - e(-t x 0.472)) + 26.7 x (1 - e(-t x 0.00307)) (R(2) = 0.9994); V(des) (LR) = 2.7 x (1 - e(-t x 0.763)) + 28.7 x (1 - e(-t x 0.00568)) (R(2) = 0.9984); and V(des) (OLT) = 1.4 x (1 - e(-t x 0.472)) + 26.7 x (1 - e(-t x 0.00307)) (R(2) = 0.9994). Uptake showed significant interindividual variability, and correlations between uptake variables and patient characteristics were inconsistent. The rate of uptake decreased more slowly then predicted by the uptake models. Because neither existing models nor patient characteristics accurately predict uptake in the individual patient, anesthesia techniques involving the use of low fresh gas flows will continue to have to rely on drug monitoring. However, the slowly decreasing rate of uptake during prolonged procedures suggests that the number of vaporizer adjustments to keep the end-expired concentration constant should be limited.     

Ketamine and Sympathetic Mechanisms in Cardiac and Smooth Muscle

The effects of ketamine on the response of rat isolated cardiac and smooth muscle to electrical stimulation of intramural sympathetic nerves and to exogenous norepinephrine are reported. Low concentrations of ketamine (1 x 10(-5) to 5 x 10(-5) mol l-1) significantly potentiated, whilst high concentrations (2 x 10(-4) and 4 x 10(-4) mol l-1) significantly depressed the positive inotropic response of left atria to sympathetic nerve stimulation. Ketamine 5 x 10(-5) mol l-1 caused a leftward shift of the concentration-response curves of left atria to norepinephrine (threefold increase in potency) and isoproterenol (twofold increase in potency). Spontaneously beating right atria were slowed in a concentration-dependent manner by ketamine (5 x 10(-5) to 4 x 10(-4) mol l-1). Ketamine 1 x 10(-4) mol l-1 potentiated the positive chronotropic response of right atria to low frequency (2 and 5 Hz) sympathetic nerve stimulation, whilst ketamine 4 x 10(-4) mol l-1 depressed the response to all stimulation frequencies. Ketamine 3 x 10(-5) mol l-1 significantly potentiated the amplitude of the response of both hepatic portal vein and vas deferens to field stimulation of sympathetic nerves, and to exogenous norepinephrine. In the presence of reuptake blockade of norepinephrine by pancuronium 1 x 10(-4) mol l-1, ketamine caused no further potentiation of the response of the vas to nerve stimulation.     

MTA1和MTA3与ER在乳腺癌组织中的表达及相关性研究

目的:观察转移相关基因蛋白(MTA1、MTA3)与雌激素受体(ER)在乳腺癌组织中的表达,探讨其与乳腺癌的关系.方法:应用免疫组织化学方法检测正常乳腺组织、癌前病变组织及乳腺癌组织中MTA1、MTA3和ER的表达,分析三者与乳腺癌的相关性.结果:正常乳腺组织、癌前病变组织、乳腺癌组织中MTA1的表达率分别为11.1%(10/90)、31.1%(28/90)和72.2%(65/90);MTA3的表达率分别为78.9%(71/90)、66.7%(60/90)和51.1%(46/90);ER的表达率分别为78.9%(71/90),56.7%(51/90)和35.6%(32/90).MTA1在ER阴性组中的阳性表达率为86.2%(50/58),高于阳性组中的46.9%(15/32);MTA3在ER阳性组中的阳性表达率为93.8%(18/19),高于阴性组中的22.5%(16/71).MTA1与ER表达呈负相关,相关系数为-0.466;MTA3与ER表达呈正相关,相关系数为0.547.结论:随着肿瘤分化程度的降低,MTA1表达逐渐增强,MTA3和ER表达逐渐减弱,甚至丧失.MTA1和MTA3及ER可能成为指导乳腺癌治疗和评价预后的重要分子标志物.     

Acute and concomitant deterioration of hyponatremia and renal dysfunction associated with heart and liver failure

BACKGROUND: Although hyponatremia with concomitant renal dysfunction has been described anecdotally, little is known about how these two conditions are related, which type of renal dysfunction usually occurs, and which patients are at risk. METHODS: From 3029 measured serum sodium (S(Na)) concentrations in 3 months, patients with at least one S(Na) < or =125 mmol/l were selected, and divided in patients with at least 1 S(Creat) > or =125 micromol/l (study group, n=20), and patients whose S(Creat) remained normal (control group, n=50). RESULTS: During the first 5 days of hospitalization, S(Creat) almost doubled in the study group from 125 +/- 40 micromol/l to 207 +/- 72 micromol/l, while S(Na) decreased concurrently from 130 +/- 2 mmol/l to 122 +/- 3 mmol/l. The peak S(Creat) and S(Na) values coincided, and the average courses were highly correlated (r = 0.88, p < 0.001). The study group more often had heart failure (10/20 vs. 1/50, p < 0.001) and liver failure (7/20 vs. 4/50, p = 0.009), and received more often loop diuretics (13/20 vs. 12/50, p = 0.002), spironolactone (11/20 vs. 7/50, p = 0.001), and/or angiotensin-converting enzyme inhibitors (5/20 vs. 2/50, p = 0.02). Four patients were admitted to the intensive care (10 in control group, p = 1.0), and 5 patients died (10 in control group, p = 0.7). CONCLUSIONS: Renal dysfunction is common in severe hyponatremia and usually develops in an acute-on-chronic fashion with concomitant deterioration of both conditions. This concourse is associated with heart failure, liver failure, and/or a renal drug regimen. Given the recent results of clinical trials, this patient group may be especially suitable for treatment with vasopressin antagonists.     

External iliac and common iliac artery angioplasty and stenting in men and women

OBJECTIVE: The effect of anatomic location of stent placement on the outcome of iliac artery angioplasty and stenting is not defined. Analyses of patency rates of external iliac artery (EIA) and common iliac artery (CIA) stents have provided conflicting results and have not considered men and women independently. The purpose of this study was to estimate the influence of the anatomic location of stenting on the outcome of iliac angioplasty and stent placement in both men and women. METHODS: From 1995 to 1999, 247 iliac angioplasty and stent placement procedures (303 stents) were performed in 67 women and 122 men, and all were included in a retrospective cohort study. The criteria prepared by the Ad Hoc Committee on Reporting Standards (Society for Vascular Surgery/International Society for Cardiovascular Surgery) were followed. The TransAtlantic Inter-Society Consensus classification was used to characterize the type of iliac lesions. Both univariate (Kaplan-Meier [KM]) and multivariate analyses (Cox proportional hazards model) were used to determine the association among the variables, cumulative patency, limb salvage, and survival. RESULTS: Indications for iliac angioplasty with stenting were disabling claudication (65%), limb salvage (33%), and blue toe syndrome (2%). Primary stenting was performed in 103 procedures (42%). Stents were placed selectively after iliac angioplasty mainly for residual stenosis or pressure gradient (43%). Patients with EIA stents, as compared with those who had CIA stents, had more extensive lesions (TransAtlantic Inter-Society Consensus type C lesions), poorer runoff, smaller vessel size, and less frequency of hyperlipidemia (P <.05). Primary patency rates at 1, 3, and 5 years were 76%, 56%, and 56%, respectively, for patients with EIA stents and 92%, 85%, and 76%, respectively, for those with CIA stents. Although overall primary patency rates were significantly decreased in patients with EIA lesions (KM, log-rank test, P =.001), stratified analyses revealed that women with EIA stents had the poorest outcome, with 61%, 47%, and 23% primary patency rates at 1, 3, and 5 years, respectively, (KM, log-rank test, P <.001). Cox regression analysis identified EIA stenting (relative risk, 4.3; 95% CI, 2.3-7.9; P <.001) as an independent predictor of decreased primary patency in women but not in men. CONCLUSIONS: Women undergoing EIA angioplasty with stent placement have significantly reduced primary patency rates. Despite initial technical success, these patients are at increased risk of long-term failure and might require subsequent procedures to obtain clinical success. Conversely, men undergoing EIA stenting have a more favorable outcome than women.     

Switchability of neoral and equoral according to Food and Drug Administration rules and regulations

According to the US Food and Drug Administration (FDA), if a drug product contains a drug substance that is chemically identical and is delivered to the site of action at the same rate and extent as another drug product, then it is equivalent and can be substituted (switchable) for that drug product. Methods used to define bioequivalence as stated by the FDA rules (FDA 21 CFR 320, 24) are (1) pharmacokinetic (PK) studies in healthy volunteers, (2) comparative clinical trials, and (3) pharmacodynamic (PD) studies (bioactivity). We evaluated the switchability of Equoral (IVAX-USA) with Neoral (Novartis Switzerland using all FDA rules. In a single oral dose, we undertook a comparative bioavailability study of Equoral (IVAX, USA) Neoral (Novartis, USA), and Neoral (Novartis UK). The pharmacokinetics of Equoral and Neoral were determined with blood levels at 0, 0.25, 0.5, 0.75, 1, 1.25, 1.5, 1.75, 2, 2.5, 3, 3.5, 4, 5, 6, 8, 10, 12, 16, 24, 30, 36, 42, and 48 hours. The area under curve (AUC), AUC extrapolated to infinity (AUC0-inf), rate of absorption (Tmax), extent of absorption (Cmax), half time (t1/2) of Equoral and Neoral were all within the 90% confidence interval of 80% to 125% boundaries. A comparative multinational multicenter clinical trial in stable renal transplant patients included 70 patients (22 women and 48 men) of mean age of 33 years (range, 26 to 43) was performed in Turkey, Lebanon, and Pakistan. In this study the ratios of LSM and the 90% confidence intervals for the Nontransformed/Parameters (AUC0-t, AUCinf, Tmax, and Cmax) of Equoral and Neoral SGC were 98% and 95%, respectively, which are within the 80% to 125% FDA acceptance range. For immunosuppressive drugs, the site of action is the lymphocyte and the measurable response is the decrease in lymphocyte count caused by the relative concentration of the drug in the lymphocyte. In a controlled switch, fixed-dose study, both Equoral and Neoral achieved the same concentration in the lymphocytes and caused the same degree of lymphocyte count reduction. The results of the testing (bioavailability-bioequivalence, clinical studies, and pharmacodynamic-bioactivity) required by FDA for interchangeability ("switchability") of immunosuppressive agents suggests that Neoral and Equoral are switchable.     

Liver and kidney transplantation for polycystic liver and kidney-renal function and outcome

BACKGROUND: Polycystic liver disease (PLD) is a rare disorder frequently associated with polycystic kidney disease (PKD). Transplantation is a treatment option for these patients. Because of preservation of hepatic function in these patients, liver transplantation is not routinely utilized. We report a large series of PLD patients and their outcomes following liver and kidney transplantation. METHODS: Fourteen patients underwent orthotopic liver transplantation (OLTx) for PLD between 1987 and 2003. Twelve patients had PKD combined with PLD. Nine patients received only liver transplantation. Five patients had combined liver and kidney transplantation. Thirteen patients (93%) survived for at least one year following liver transplantation. Two out of eight patients who received solitary liver transplantation later required kidney transplantation. RESULTS: Pretransplant glomerular filtration rate (GFR) in patients with PKD was 75.8+/-25.4 ml/min/1.73 m. One year later, GFR was 37.2+/-8.3 ml/min/1.73 m. Kaplan-Meier analysis showed that one- and two-year graft survival for combined liver and kidney transplantation was 80% (n=5), whereas graft survival for solitary liver transplantation was 100% (n=9). Mean survival of patients who had combined liver and kidney transplantation was 46.7+/-54.2 months (n=5), whereas the mean survival for solitary liver transplant patients was 80.4+/-68.6 months (n=9) (P=0.36). CONCLUSION: Transplantation is an excellent option for PLD with dramatic improvement in quality of life and acceptable morbidity. For combined liver and kidney transplantation one- and two-year patient survival rates were similar to combined transplantation for other indications. For patients with acceptable renal function at time of transplantation, solitary liver transplantation has an excellent outcome.     

Sports and recreation activity of varus and valgus ankle osteoarthritis before and after realignment surgery

BACKGROUND: Realignment-surgery to unload ankle osteoarthritis (OA) has been proposed as treatment alternative for varus and valgus ankle OA. Sports activity after this procedure has not been analyzed. Realignment-surgery increases sports activity. Sports activity correlates with ankle pain, function, and alignment, but does not influence revision rate. MATERIALS AND METHODS: Prospective case series of 35 consecutive patients with post-traumatic varus or valgus ankle OA limited to half tibiotalar joint surface were treated by OA unloading realignment-surgery. Distal tibia osteotomy was used in all cases; additional osteotomies, tendon, ligament procedures in 92% of cases. Main Outcome Measurements: Pain (visual-analogue-scale; VAS), ankle range-of-motion (ROM); function (American-Orthopaedic-Foot-and-Ankle-Society (AOFAS) ankle-score; Swiss-symptom-related-Ankle-Activity-Scale (SAAS); Sports-Frequency-Score (SFS), OA and tibiotalar-alignment-grade (Takakura-Score), and revision surgery. Mean followup was 5 years. RESULTS: Mean values from preoperative to followup: VAS decreased (p = 0.0001) 4 points; ankle ROM increased (p = 0.001) 5 degrees; AOFAS-Score increased (p = 0.0001) 46 points; SAAS increased (p = 0.0001) 42 points; SFS increased (p = 0.02) 0.5 grades; Takakura-score decreased (p = 0.0001) 1.0 grades. Revision surgery was performed in 10 cases (29%). Three of these were revised to ankle arthroplasty. At follow-up, SAAS correlated with VAS, AOFAS score, Takakura score, and not with ROM or SFS. SFS did not correlate with other variables. Patients needing revision surgery had a higher (p = 0.003) SFS than patients who needed no revision. CONCLUSION: Realignment-surgery increased sports activity of ankle OA patients. Improved ankle pain and function correlated with ability to perform activity without symptoms; however, sports frequency had no correlation to patients' symptoms but showed higher revision rate.     

Bone strength and its determinants in pre- and early pubertal boys and girls

Higher fracture rates in women than men may be related to a sex difference in bone strength that is thought to emerge during growth. However, sexual dimorphism in bone strength and the determinants of bone strength in boys and girls are not well understood. Thus, our objectives were to (1) compare tibial bone strength and its components (geometry and density) between pre- and early pubertal boys and girls and (2) identify the contribution of muscle cross-sectional area and other modulating factors to bone outcomes. We used pQCT to assess the distal tibia (8%) and tibial midshaft (50%) in 424 Asian and Caucasian pre- and early pubertal boys and girls. Our primary outcomes were bone strength index (BSI, mg2/mm(4)) at the distal tibia and strength strain index (SSI, mm3) at the midshaft. We also assessed components of bone strength including bone geometry [total (ToA) and cortical (CoA) cross-sectional areas, mm2] and total (ToD, mg/cm3) and cortical (CoD, mg/cm3) density. We used ANCOVA to compare bone outcomes between boys and girls in each maturity group (PRE or EARLY pubertal by Tanner stage) and multiple regression to evaluate the contribution of muscle cross-sectional area (MCSA, mm2 by pQCT), maturity, ethnicity, physical activity, dietary calcium, and vertical jump height to bone outcomes. After adjusting for tibial length and MCSA, bone strength indices were 6-15% (P < 0.05) greater in PRE and EARLY boys compared with PRE and EARLY girls. The sex difference in bone strength was due largely to greater bone areas (4-6%) in boys. At the distal tibia ToD was significantly greater in PRE boys (6%, P < 0.001) compared with PRE girls and at the midshaft CoD was slightly greater in both PRE and EARLY girls (1%, P = 0.01). After adjusting for tibial length, MCSA was the primary explanatory variable of tibial bone geometry and strength in both sexes accounting for 10-16% of the variance. The influence of maturity, ethnicity, physical activity, and dietary calcium on pQCT bone outcomes was small and was both site- and sex-specific. Sexual dimorphism in tibial bone strength is evident in prepuberty. Our results are consistent with a functional model of bone development in which bone adapts its geometry and strength to withstand challenges from muscle forces during growth.     

Pharmacokinetics and pharmacokinetic-dynamic modelling of rocuronium in infants and children

We have determined the pharmacokinetics and pharmacokinetic- pharmacodynamic relationship of rocuronium in infants and children. We studied infants (n = 5, 0.1-0.8 yr) and children (n = 5, 2.3-8 yr), ASA II, in the ICU while undergoing artificial ventilation under i.v. anaesthesia with an arterial cannula in situ and the EMG of the adductor pollicis muscle was monitored. Rocuronium 0.06 (infants) and 0.09 (children) mg kg-1 min-1 was given i.v. over +/- 5 min until 85% neuromuscular block was obtained. Arterial blood samples were obtained over 240 min. Plasma concentrations were measured by HPLC. Pharmacokinetic-dynamic variables were calculated using the Sheiner model and the Hill equation. Statistical analysis was performed using the Mann-Whitney U test (P < 0.05). The mean administered dose was 0.32 (SD 0.08) mg kg-1 and 0.4 (0.1) mg kg-1 for infants and children, respectively. Infants differed from children in plasma clearance (4.2 (0.4) vs 6.7 (1.1) ml min-1 kg-1), distribution volume at steady state (231 (32) vs 165 (44) ml kg-1), mean residence time (56 (10) vs 26 (9) min), concentration in the effect compartment at 50% block (1.2 (0.4) vs 1.7 (0.4) mg litre-1) and the slope of the concentration-effect relationship (5.7 (1.3) vs 3.9 (0.5)). Calculated mean ED90 values were 0.26 and 0.34 mg kg-1 for infants and children, respectively. The time course of neuromuscular block after equipotent doses did not differ.      

Bone Density,Microstructure and Strength in Obese and Normal Weight Men and Women in Younger and Older Adulthood

Obesity is associated with greater areal BMD (aBMD) and is considered protective against hip and vertebral fracture. Despite this, there is a higher prevalence of lower leg and proximal humerus fracture in obesity. We aimed to determine if there are site‐specific differences in BMD, bone structure, or bone strength between obese and normal‐weight adults. We studied 100 individually‐matched pairs of normal (body mass index [BMI] 18.5 to 24.9 kg/m²) and obese (BMI >30 kg/m²) men and women, aged 25 to 40 years or 55 to 75 years. We assessed aBMD at the whole body (WB), hip (TH), and lumbar spine (LS) with dual‐energy X‐ray absorptiometry (DXA), LS trabecular volumetric BMD (Tb.vBMD) by quantitative computed tomography (QCT), and vBMD and microarchitecture and strength at the distal radius and tibia with high‐resolution peripheral QCT (HR‐pQCT) and micro–finite element analysis. Serum type 1 procollagen N‐terminal peptide (P1NP) and collagen type 1 C‐telopeptide (CTX) were measured by automated electrochemiluminescent immunoassay (ECLIA). Obese adults had greater WB, LS, and TH aBMD than normal adults. The effect of obesity on LS and WB aBMD was greater in older than younger adults (p < 0.01). Obese adults had greater vBMD than normal adults at the tibia (p < 0.001 both ages) and radius (p < 0.001 older group), thicker cortices, higher cortical BMD and tissue mineral density, lower cortical porosity, higher trabecular BMD, and higher trabecular number than normal adults. There was no difference in bone size between obese and normal adults. Obese adults had greater estimated failure load at the radius (p < 0.05) and tibia (p < 0.01). Differences in HR‐pQCT measurements between obese and normal adults were seen more consistently in the older than the younger group. Bone turnover markers were lower in obese than in normal adults. Greater BMD in obesity is not an artifact of DXA measurement. Obese adults have higher BMD, thicker and denser cortices, and higher trabecular number than normal adults. Greater differences between obese and normal adults in the older group suggest that obesity may protect against age‐related bone loss and may increase peak bone mass. © 2014 American Society for Bone and Mineral Research.     

Association between age and epididymal and accessory sex gland function and their relation to sperm motility

Increased male age has been associated with significant reduction in pregnancy rates. This study investigated the association between age, the function of epididymal and accessory sex glands, and their relation to sperm motility. Ejaculates from 498 men assessed for infertility were analysed according to WHO [1999] guidelines. Seminal markers of epididymal (neutral alpha-glucosidase (NAG)), prostatic (prostate-specific antigen (PSA) and zinc), and seminal vesicle function (fructose) were measured. Four groups according to age were defined: G(21-30) (21-30 years), G(31-40) (31-40 years), G(41-50) (41-50 years), and G(>50) (51-66 years). Percentage progressive motility was significantly lower in G(>50) compared with G(21-30). NAG, PSA, zinc, and fructose were significantly lower in G(>50) compared with G(21-30). In a multiple regression analysis model, NAG and PSA showed positive significant association with percentage progressive motility. The opposite trend was found regarding zinc. No association between fructose and percentage progressive motility was shown. In this cross-sectional study, declined sperm motility observed in men over 50 years of age might be due to age-dependent changes in epididymal and accessory sex gland function.     

Nausea and vomiting after anesthesia and minor surgery

The antiemetic effects of droperidol, diphenidol, and placebo were compared in 210 patients subjected to minor gynecologic or urologic procedures. Atropine (0.6 mg), meperidine (1 mg/kg) body mass, and either droperidol (5 mg), diphenidol (40 mg), or 2 ml of 0.9% saline were administered IM, 1 hour before general anesthesia. Trial drugs were presented in coded ampules so that the study was conducted double-blind. Droperidol appeared superior to both diphenidol (p less than 0.01) and placebo (p less than 0.001) in the prevention of vomiting, and reduced the incidence of nausea when compared to saline (p less than 0.05). Forty-four patients experienced side effects, which occurred with similar frequency in the 3 groups studied.     

Trends and Outcomes in Simultaneous Liver and Kidney Transplantation in Australia and New Zealand

AimRates of simultaneous liver and kidney transplantation (SLKT) have increased, but indications for SLKT remain poorly defined. Additional data are needed to determine which patients benefit from SLKT to best direct use of scarce donor kidneys.MethodsData were extracted from the Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) database for all SLKT performed until the end of 2017. Patients were divided by pretransplant dialysis status into no dialysis before SLKT (preemptive kidney transplant) and any dialysis before SLKT (nonpreemptive). Baseline characteristics and outcomes were compared.ResultsBetween 1989 and 2017, inclusive, 84 SLKT procedures were performed in Australia, of which 24% were preemptive. Preemptive and nonpreemptive SLKT recipients did not significantly differ in age (P = .267), sex (P = .526), or ethnicity (P = .870). Over a median follow-up time of 4.5 years, preemptively transplanted patients had a statistically equivalent risk of kidney graft failure (hazard ratio (HR) 1.83, 95% confidence interval [CI]: 0.36-12.86, P = .474) and all-cause mortality (HR 1.69, 95% CI: 0.51-5.6, P = .226) compared to nonpreemptive patients. Overall, 1- and 5-year survival rates for all SLKTs were 92% (95% CI: 86-96) and 60% (95% CI: 45-75), respectively.ConclusionKidney graft and overall patient survival were similar between patients with preemptive kidney transplant and those who were dialysis dependent.     

Hemodialysis catheter survival and complications in children and adolescents

. Venous catheters have become an indispensable form of hemodialysis access. We evaluated catheter performance as temporary and long-term access in children with end-stage renal disease (ESRD). We assessed the survival rates and causes of catheter failure in 78 catheters used for hemodialysis access in 23 pediatric patients (aged 10 months to 22 years) with ESRD over a 5-year period. Median survival was 31 days for 56 uncuffed catheters. One- and 2-month actuarial survival was 69% and 48%, respectively. Reasons for removal were: elective (39%), kinking (36%), trauma (11%), infection (7%), and other (5%). Smaller catheters (7 or 9 French) were more likely to be removed for kinking (P = 0.003). One-year actuarial survival for 22 cuffed catheters was 27%. Cuffed catheters were removed due to: infection (36%), kinking (14%), elective (9%), trauma (9%) and other (9%). Twelve catheters were removed for infection. Infection rates leading to removal were 0.58 and 0.71 per patient-year for uncuffed and cuffed catheters, respectively. Staphylococcus species were cultured most commonly. We conclude that uncuffed catheters function well for short-term hemodialysis access of up to 2 months’ duration and cuffed catheters are successful for long-term access in children and adolescents with ESRD. Received April 1, 1996; received in revised form and accepted August 1, 1996     

Uptake and elimination of isoflurane and halothane by children and adults

The rate of increase of alveolar concentrations (FA/FI) of isoflurane and halothane was studied in children and adults during general anaesthesia and controlled ventilation. After 30 min of body equilibrium, elimination curves of the volatile anaesthetics were determined by measurement of alveolar (FA/FA0; infrared technique) and venous concentrations (gas chromatography). The distribution and elimination half-times (t1/2 alpha, t1/2 beta), clearance (Cl), volume of central and peripheral compartment (V1, Vz) and the volume of distribution at steady state (Vss) were calculated from the intercepts and slopes of a two-compartment model. During the uptake of anaesthetic concentrations of isoflurane and halothane, the FA/FI ratio of each gas was found to rise significantly faster in children than in adults. The reason for the more rapid approach to equilibrium in children seems to be related to physiological differences. Irrespective of age, uptake of isoflurane was more rapid than that of halothane, as it is less soluble. Similarly, isoflurane was eliminated from the lung or blood faster than halothane. Moreover, anaesthetic wash-out in children differed from that in adults. In the paediatric age group t1/2 beta under isoflurane was shorter than in adults, whereas halothane excretion took longer in children. This could be accounted for by the larger volumes of distribution Vz and Vss in the young, due to higher organ affinity of halothane. From our data we conclude that age significantly affects uptake and elimination of volatile anaesthetics and the control of anaesthesia is easiest with isoflurane in paediatric patients.