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.     

Port-A-Cath insertions in acute leukemia: does thrombocytopenia affect morbidity?

Background

Unnecessary delay of insertion of Port-A-Cath indwelling venous catheters in thrombocytopenic patients may result from fear of potential morbidity. This study sought to compare the morbidity of Port-A-Cath insertions in acute leukemic patients with platelet counts below and above 50 × 10⁹/L.

Method

Incidence and profile of catheter-related bloodstream infections (CRBSIs) and other complications were determined in 80 consecutive Port-A-Cath insertions in pediatric patients with acute leukemia from January 2002 to December 2004. Subgroup analysis was performed for patients with platelet levels below and above the recommended safe level of 50 × 10⁹/L.

Results

Twenty-two (27.5%) patients had insertions performed at platelet levels below the recommended level (median, 35.3; range, 10-49 × 10⁹/L); postoperative counts were correspondingly higher (median, 66.0; range, 20-207 × 10⁹/L) with perioperative platelet transfusion. Catheter-related bloodstream infection incidence was similar in patients with platelets less than and greater than the recommended threshold (18.2% vs 17.2%, respectively), and likewise for CRBSIs encountered in the immediate 30 postoperative days (4.6% and 5.2%, respectively). Only 2 episodes of postoperative bleeding occurred, both in the group with platelet counts greater than 50 × 10⁹/L, with an equally low incidence of other local and mechanical complications in both subgroups. Patient demographics and other preoperative blood parameters did not differ significantly.

Conclusion

Preoperative thrombocytopenia was not associated with increased incidence of postoperative complications for Port-A-Cath insertions in acute leukemic children.     

Renal angiomyolipoma in Japanese tuberous sclerosis patients

Purpose

Renal angiomyolipoma (AML) is a benign neoplasm that may grow massive in tuberous sclerosis (TS) patients. The aim of this study was to document the characteristics of renal AML in Japanese TS patients.

Methods

Medical records of 29 TS patients followed up at the authors’ center were reviewed for the presence, size, symptom, and treatment of renal AML.

Results

Twenty-four patients screened for renal AML were subdivided into 4 groups: group 0 (n = 8), no mass; group 1 (n = 5), AML less than 1 cm in diameter; group 2 (n = 4), AML 1 to 4 cm in diameter; group 3 (n = 7), AML greater than 4 cm in diameter. When present, AML always affected both kidneys and were multiple. All patients in groups 1 and 2 were symptom free, and the tumors seemed stable in size. All tumors in group 3 grew progressively causing various symptoms. Total or partial nephrectomy or transarterial embolization was performed in 5 patients with limited success.

Conclusions

AML in TS patients can be stable or aggressive. Pediatric surgeons aware of this problem should be involved in a follow-up program.     

Size does matter-donor-to-recipient body mass index difference may affect renal graft outcome

Background

Obesity, in the either kidney donor or the recipient, has been related to worse graft function. The aim of this study was to compare long-term graft outcomes of living-related kidney recipients regarding the donor-to-recipient body mass index (BMI) ratio.

Methods

From November 2002 to November 2010, 62 consecutive living-related kidney transplantations were performed at our center. Donor and recipient BMIs were categorized by Taiwan's national standard using dividing values of 18.5, 24, and 27 kg/m² to divide subjects into donor-to-recipient BMI categories. These with the same BMI category as their donors were defined as the same-BMI group (group 0); recipients with a lower BMI category than their donors were defined as the large-to-small group (group 1); and those with a higher BMI category than their donors were defined as the small-to-large group (group 2). Baseline parameters and posttransplantation follow-up data were analyzed according to this grouping.

Results

Of the 57 recipients followed regularly at our hospital (mean follow-up 48.9 months), 21 (36.8.1%) were in group 0; 26 (45.6%) in group 1, and 10 (17.6%) in group 2. The baseline parameters were similar among these groups. The overall graft survival rates were 81.0% in group 0, 76.9% in group 1, and 90.0% in group 2. The rejection-free graft survival rates were 81.0%, 65.4%, and 90.0%, respectively. By Kaplan-Meier analysis, group 1 showed worse rejection-free graft survival than group 0 or group 2 (log-rank P = .046).

Conclusions

Living-related recipients of kidneys from donors with a higher BMI showed lower long-term graft survival, which might suggest that petite recipients may need time to compensate adequate blood flow for the relative large graft, thus carrying a higher chance of rejection and worse graft outcomes.     

Periprocedural complications by Child-Pugh class in patients undergoing transcatheter arterial embolization or chemoembolization to treat unresectable hepatocellular carcinoma at a VA medical center

Background

For patients with compensated cirrhosis, transcatheter arterial embolization with and without additive chemotherapy has been shown to improve survival. The aim of this study was to compare periprocedural complications in a population with hepatitis C virus-related hepatocellular carcinoma to evaluate for differences in complications by severity of liver disease.

Methods

Patients with unresectable hepatocellular carcinoma treated by transcatheter arterial embolization with or without additive chemotherapy procedures from 2003 to 2006 were retrospectively reviewed and compared by Child-Pugh (CP) class. A total of 141 embolizations were done in 76 patients.

Results

Complication rates were seen in 27% of CP class A and 17% of CP class B patients. There was no significant difference in the grade of complications between the 2 groups or between procedure types. Survival rate was dependent on the degree of liver dysfunction (3-year CP class A, 49%; CP class B, 13%; P = .0048).

Conclusion

Embolization procedures to treat hepatitis C virus-related hepatocellular carcinoma can be performed safely with low morbidity and mortality rates, even in patients with a compromised hepatic reserve.     

Primary sternal osteomyelitis: a case series and review of the literature

Purpose

Primary sternal osteomyelitis is rare in the pediatric population.

Methods

We present 4 recent cases that demonstrate a wide range in age, presenting features, and clinical course, and we performed a literature review.

Result

A combination of diagnostic aspiration with prolonged appropriate antibiotic therapy led to successful resolution in all cases. Surgical debridement should be reserved for cases that do not respond to medical therapy.

Conclusion

Sternal osteomyelitis is a rare condition in children that usually resolves with aspiration and prolonged antibiotic therapy.     

Correlation Between HLA and Posttransplantation Diabetes Mellitus in the Han Population in South China

Background

Posttransplantation diabetes mellitus (PTDM) is a common metabolic complication in renal transplant recipients. Some studies have revealed predisposing or protective HLA genes for PTDM.

Objective

To describe the characteristics of PTDM in patients in the south of China.

Methods

The present study included 195 living-donor kidney transplant recipients. Informed consent was obtained from all participants, and the study was approved by our Institutional Ethics Committee. Each donor-recipient pair was related. Twenty-two patients had PTDM, whereas 173 did not. The frequency of each HLA phenotype was compared between these 2 groups. The 195 patients were divided into 2 groups according to immunosuppression regimen, a cyclosporine group and a tacrolimus group, and the incidence of PTDM was compared between the groups. Patients were then subdivided into 2 groups according to age, an elderly group (age 40 years or older) and a younger group (age younger than 40 years), and the incidence of PTDM was calculated and compared between these 2 groups.

Results

HLA-A30 and HLA-DR7 seem to be predisposing genes for PTDM in patients in the south of China; Low dosages of calcineurin inhibitors were used in our center, There was no significant difference in the incidence of PTDM between the CsA and Tac groups; The incidence of PTDM in the elderly group was significantly higher than that in the younger group.

Conclusion

Patients receiving HLA-A30 and HLA-DR7 antigens, and elderly patients are at higher risk of developing PTDM. Tacrolimus does not significantly increase the incidence of PTDM.     

Comparative analysis of adverse events requiring suspension of mTOR inhibitors: everolimus versus sirolimus

Background

Inhibitors of mammalian target of rapamycin (mTORi) have been suggested as an alternative to calcineurin inhibitors (CNIs) to treat stable renal transplant recipients. However, their use has been significantly limited owing to a high incidence of side effects.

Objective

To compare the rate of dropout (mTORi elimination and CNI reintroduction) caused by side effects among renal transplant patients converted to everolimus (EVL) or sirolimus (SRL).

Methods

Between October 1999 and February 2010, 409 subjects were converted to an mTORi at least 3 months after transplantation, including 220 (53.8%) to EVL and 189 (46.2%) to SRL. Most patients were under CNI therapy. Patients were followed for a median of 35 months (interquartile range [IQR], 18-50 months).

Results

mTORi treatment was prematurely eliminated due to adverse events in 112 patients. The median time between the initiation of mTORi and discontinuation was 5.7 months (IQR, 1.9-15.7 months; range, 0.2-48 months): 5.5 (IQR, 1.6-16.3) in the EVL group and 7.4 (IQR, 2.6-15.6) in the SRL group. In the EVL group, the drug was stopped in 69 patients (31.4%), and in the SRL group in 43 patients (22.8%; P = .051). The most important causes of discontinuation were severe infections (2.3% in EVL group and 4.8% in SRL group; P = .17), pneumonitis (6.8 % in EVL group and 4.8 in SRL group; P = .38), acute rejection episode (4.1% in EVL group and 1.6% in SRL group; P = .13), proteinuria (4.1% in EVL group and 1.6% in SRL group; P = .13), renal function deterioration (2.3% in EVL group and 2.1% in SRL group; P = .91), and severe dermal eruption (2.3% in EVL group and 0.5% in SRL group; P = .14).

Conclusions

Although the overall incidence discontinuations due to side effects was higher in the EVL group, there was no greater frequency of severe side effects, such as pneumonitis, proteinuria, acute rejection episodes, renal function deterioration, or dermal eruptions.     

Local control, survival, and operative morbidity and mortality after re-resection, and intraoperative radiation therapy for recurrent or persistent primary high-risk neuroblastoma

Background/Purpose

Patients with locally recurrent or persistent high-risk neuroblastoma are difficult to treat. We describe our experience using intraoperative radiation therapy (IORT) after re-resection in this high-risk population.

Methods

We retrospectively reviewed 44 consecutive patients who received IORT at our institution between April 2000 and September 2009 after gross total resection of recurrent/persistent tumor. Specifically, we evaluated local recurrence rates, complications, and overall survival.

Results

The median age at diagnosis was 41.5 months. Median follow-up after IORT was 10.5 months. Each patient received prior chemotherapy and surgery, while 94.5% had previous external beam radiation therapy. MYCN was amplified in 34% of patients. There were no operative or postoperative deaths, and 18 patients (40.9%) had postoperative complications. There was a 50.4% probability of local control. MYCN amplification did not affect local control (local recurrence rate of 53.9% vs 52.4%, P = .89). Median overall survival was 18.7 months (95% confidence interval, 11.7-25.6 months). Mean survival for MYCN-amplified patients was 13.0 vs 39.2 months for those without MYCN amplification (P = .035).

Conclusions

Intraoperative radiation therapy after re-resection of locally recurrent/persistent neuroblastoma results in a reasonable rate of local control with acceptable morbidity and survival. This approach should be considered in this high-risk population.     

Investigation of histopathologic changes in the ureter walls in vesicoureteral reflux

Purpose

This study aimed to determine the histopathologic changes in ureteral walls (UWs) in children with vesicoureteral reflux (VUR).

Methods

Twenty ureteral specimens taken from children were divided into 2 groups, refluxing (R) and control (C) groups, each containing 10 specimens. Wall thickness of the ureter, tunica muscularis of the ureter, mucosal thickness of the ureter (uroepithelium), collagen thickness of the ureter, mucosal change, and inflammation were evaluated in resected distal UWs in children with VUR.

Results

The mean wall thickness of the ureter, mean tunica muscularis of the ureter, and mean uroepithelium values of the UWs in the R group were not significantly lower compared to those in the C group. Collagen thickness values in the R group were significantly lower than those in the C group.

Conclusions

Our data suggest that wall thickness (tunica muscularis and uroepithelium) was not significantly decreased, but collagen thickness of the ureter was decreased in the UWs of children with VUR.     

Utility of elastography for differential diagnosis of benign and malignant thyroid nodules

Objective

1) To classify the appearance of thyroid nodules displayed on ultrasound elastography; 2) to explore the sensitivity and specificity of this examination for differentiating benign and malignant nodules, with histopathologic analysis as the reference standard; and 3) to evaluate its utility for avoiding unnecessary procedures.

Study Design

Diagnostic test assessment.

Setting

Community hospital.

Subjects and Methods

Forty-seven thyroid nodules in 44 consecutive patients were examined with ultrasound elastography. The images we obtained were classified into four patterns. In addition, the mean strain index of the thyroid nodule and that of the sternocleidomastoid muscle were measured, and the nodule-to-muscle strain ratio was calculated. As the reference findings, the presence or absence of calcification, irregular margins, and hypoechogenicity of the thyroid nodules were examined using B-mode ultrasound.

Results

Elastography patterns 3 and 4 were predictive of malignancy, with 73 percent sensitivity (95% confidence interval [CI]: 39%-94%) and 64 percent specificity (95% CI: 46%-79%). Additionally, all nodules without calcification and those that presented with patterns 1 or 2 were benign. A strain ratio greater than 1.5 was set as the predictor of thyroid malignancy. This criterion showed 90 percent sensitivity (95% CI: 59%-100%) and 50 percent specificity (95% CI: 33%-67%).

Conclusion

Although elastography can assist in the differential diagnosis of thyroid nodules, its diagnostic performance is not ideal at present. Further improvements in the technique and the diagnostic criteria are necessary for this examination to provide a useful contribution to diagnosis.     

Safety and efficacy of a quinolone-based regimen for treatment of tuberculosis in renal transplant recipients

Background

Rifampin (RFP) is a first-line antituberculosis drug, but it increases the risk of acute rejection (AR) in transplant recipients. This study evaluated whether quinolone (QNL) can replace RFP in renal transplant recipients with tuberculosis.

Methods

One hundred nine patients with active tuberculosis were included. Patients consisted of RFP (n = 91) and QNL (n = 18) groups based on the initial treatment regimen. Patients with RFP-associated adverse effects were subdivided into RFP-maintenance (RFP-M; n = 18) and QNL-conversion (QNL-C; n = 8) groups. Clinical outcomes were compared between groups.

Results

The incidence of AR was higher in the RFP group than in the QNL group (24.2% vs 5.6%). The QNL group showed significantly higher 10-year graft survival rates than the RFP group (88.1% vs 66.5%; P = .022). The QNL-C group showed significantly higher 10-year graft survival rates than the RFP-M group (87.5% vs 27.8%; P = .011). The rate of complete functional recovery after AR was higher in the QNL-C group than in the RFP-M group (50% vs 22.2%).

Conclusions

A QNL-based regimen may be safe and effective for treatment of tuberculosis and may lower the risk of graft failure in renal transplant recipients.     

Effect of splenic artery embolization for splenic artery steal syndrome in liver transplant recipients: estimation at computed tomography based on changes in caliber of related arteries

Purpose

To estimate the effect of splenic artery embolization (SAE) on blood flow in orthotopic liver transplantation (OLT) recipients with splenic artery steal syndrome (SASS) based on changes in caliber of related arteries upon serial computed tomography (CT) scans.

Methods

Between 2004 and 2007, nine OLT recipients with SASS underwent SAE. They had CT scans before and after SAE: short-, mid-, and long-term, ie, approximately 1 week, 1 month, and 1 year, respectively. The diameters of the celiac axis (CA), common hepatic artery (CHA), and splenic artery (SA) were measured with arterial phase of each CT scan and the ratios of SA to CHA diameter (SA/CHA) calculated to analyze their changes during the follow-up period.

Results

The diameters of celiac axis, CHA, and SA and SA/CHA changed most rapidly during the short-term period. The CHA diameter significantly increased short-term post-SAE by CT and slightly decreased thereafter. However, the mid-term and long-term post-SAE CT values were still significantly greater than those on the pre-SAE CT. The SA diameter steadily decreased throughout the follow-up. The SA/CHA decreased until the mid-term. The SA diameter and SA/CHA were significantly smaller upon mid-term and long-term post-SAE CT compared with those at pre-SAE CT.

Conclusions

The effect of SAE to improve hepatic arterial flow in OLT recipients with SASS might be expected for at least approximately one year. The effect maximally occurred during the short-term after SAE on the basis of changes in the caliber of related arteries upon CT.     

Serum levels of interleukin-9 during acute rejection in liver transplantation

Introduction

Interleukin-9 (IL-9) has been cast as a player in autoimmunity, but its role in liver transplantation remains to be clarified. The aim of our study was to investigate the time course of IL-9 serum levels during hepatic allograft rejection.

Methods

IL-9 serum levels were determined in 34 healthy subjects and 50 hepatic transplant recipients. The patients were divided into two groups: group I was composed of 15 patients with acute rejection episodes, and group II, 35 patients free of this problem. Samples were collected on days 1 and 7 after liver transplantation and on the day of liver biopsy.

Results

The concentrations of IL-9 were similar in the rejection and nonrejection groups over the entire postoperative period. The whole transplant group, including those with stable graft function, showed higher IL-9 serum levels than the controls at all times after liver transplantation.

Conclusions

These preliminary results suggest a lack of participation of IL-9 in human liver allograft rejection.     

Insertion/deletion polymorphism of the angiotensin-converting enzyme predicts left ventricular hypertrophy after renal transplantation

Background

Kidney transplant recipients show a higher risk for cardiovascular complications, such as left ventricular hypertrophy and heart failure, leading to the premature death in many cases.

Methods

We investigated the contribution of angiotensin-converting enzyme (ACE) insertion/deletion (I/D) polymorphism to the development of left ventricular hypertrophy (LVH), an indicator of heart disease progression among kidney transplant recipients.

Results

We observed a significant correlation between graft function and left ventricular mass index. The occurrence of LVH or severe LVH was significantly greater among patients with at least one D-allele (ID or DD).

Conclusion

The use of ACE inhibitors or angiotensin receptor blockers seemed to be advantageous for patients with the ID and especially, the DD genotype.     

Effective use of laparoscopy for long-term peritoneal dialysis access

Background

Laparoscopy is an underused modality for peritoneal dialysis access procedures. The strengths of laparoscopy are that it can both prevent and resolve the common mechanical problems that adversely effect dialysis catheter outcomes.

Method

Laparoscopically enabled catheter implantation and rescue procedures included rectus sheath catheter tunneling, omentopexy, adhesiolysis, resection of epiploic appendices, colopexy, salpingectomy, and appendectomy. Using these techniques, the outcomes of 428 laparoscopically implanted catheters were studied.

Results

During a mean follow-up of 21.6 months, mechanical obstruction complicated 3.7% of implantation procedures. The incidence of pericatheter leak was 2.6%. There were no occurrences of pericatheter hernia or subcutaneous cuff extrusion. Laparoscopic salvage procedures limited losses from mechanical catheter problems to .9%. Cumulative revision-free and assisted catheter survival probabilities for loss from mechanical complications at 5 years were .96 and .99, respectively.

Comments

Because it is enabled by techniques not available to other catheter-placement methods, laparoscopy produces superior outcomes.     

Sentinel lymph node biopsy in patients with multicentric/multifocal breast cancer: low false-negative rate and lack of axillary recurrence

Background

Accuracy of sentinel lymph node biopsy (SLNB) and rate of axillary recurrence in multicentric/multifocal (MC/MF) breast cancer are reported.

Methods

From 1999 to 2006, 93 patients with MC/MF breast cancer underwent SLNB; 41 underwent axillary lymph node dissection regardless of SLN pathology (group 1), and 52 underwent axillary lymph node dissection only if an SLN was positive (group 2). Patient demographics, SLN techniques, and pathology were recorded.

Results

There were no differences between the 2 groups with respect to patient age; tumor size, grade, stage, and histology; or method of SLN detection. The incidence of axillary metastasis was greater in group 1 patients (68%) compared with group 2 patients (12%) (P < .01). In group 1, the sensitivity and specificity of SLNB were 93% and 100%, respectively, with a false-negative rate of 7%. None of the 52 patients in group 2 experienced axillary recurrence (median follow-up 4.8 years).

Conclusions

The accuracy of SLNB in MC/MF breast cancer is comparable with that observed in unifocal breast cancer. Despite a lower rate of SLN positivity in patients undergoing SLNB only, axillary recurrence was not observed.     

A comparison of circumumbilical and transverse abdominal incisions for neonatal abdominal surgery

Purpose

Although neonatal bowel surgery traditionally involves a transverse abdominal incision, several authors have reported that the circumumbilical incision is effective and cosmetically appealing. We report the first study comparing the circumumbilical incision to the transverse abdominal incision for a variety of neonatal abdominal operations.

Methods

Retrospective cohort analysis comparing the circumumbilical incision to the transverse abdominal incision for neonates who underwent surgical repair of malrotation, duodenal atresia/web, or intestinal atresia/web was performed between 1999 and 2009.

Results

One hundred thirty-two patients underwent a laparotomy through a transverse abdominal incision (n = 106) or a circumumbilical incision (n = 26). Baseline characteristics between groups were similar. No differences were found when comparing operative time, postoperative days on a ventilator, narcotic infusion, time to full feeds, length of hospital stay, incidence of surgical site infection, and bowel obstruction. Although more incisional hernias occurred in the circumumbilical incision group (38%) than the transverse abdominal incision group (6%), all hernias in the circumumbilical group resolved without intervention, whereas 33% required surgical repair in the transverse abdominal group.

Conclusions

Because of its cosmetic advantages and similar outcomes to the transverse abdominal incision, the circumumbilical incision should be considered as an alternative to the transverse abdominal approach in neonatal surgery.