Hypertension in pediatric patients with childhood-onset chronic kidney disease: much to be learned, more to be done

Pediatric patients with chronic kidney disease are increasingly recognized as being at increased risk of developing cardiovascular disease as adults. Numerous risk factors contribute, hypertension being one of the most identifiable and potentially modifiable. Despite this, numerous studies have demonstrated that hypertension is common and is frequently underrecognized and/or undertreated in this population. Greater efforts are needed to identify and effectively treat hypertension in these vulnerable patients to reduce the future burden of adult cardiovascular disease.     

Too much vacuum-assisted closure

There has been an explosion in the use of the vacuum-assisted closure device since 1997. Selectively and judiciously used, it is a valuable tool. However, we are concerned by the expanding list of 'indications' for its use. Prolonged applications, frequently several weeks, at the expense of early surgical reconstruction, might compromise the outcome in selected cases. We report four cases that illustrate this problem and stress the importance of timely surgical reconstruction utilizing the range of reconstructive techniques available as well as vacuum-assisted closure dressing.     

Breast cancer multi-disciplinary teams in England: much achieved but still more to be done

OBJECTIVE: To look at the national coverage, composition and discussion of breast cancer multi-disciplinary teams (MDTs) in England. DESIGN AND DATA SOURCE: All breast units in England both symptomatic and screening were sent a questionnaire. MAIN OUTCOME MEASURES: Attendance of core members at MDT meetings; Percentage of patients discussed with a treatment plan; Private patients discussed; Reconstructive surgery. RESULTS: The majority of core members of the breast MDT attend weekly meetings to discuss the multidisciplinary management of patients with breast cancer, although attendance by medical oncologists and reconstructive breast surgeons is limited. Three MDTs never had a radiologist present and 3 never had a pathologist present at the MDT meeting. Most breast MDTs have a meeting coordinator to collect case-notes, radiographs and pathology reports to facilitate the meeting. Seventy-nine out of 134 teams discuss every cancer patient and 118 also discuss private patients. Twenty-seven teams record the outcome of the MDT meeting electronically, 32 teams book surgery, 16 radiotherapy and 15 book chemotherapy direct from the MDT meeting.     

Fluid therapy: Too much or too little

There is much debate regarding the amount of perioperative fluid administration in relation to patient outcome.Fluid shifting towards the interstitial space is of two types (physiologic and pathologic) across the vascular endothelial membrane. This membrane, of 1 μm thickness, is formed of an endothelial layer coated by glycocalyx, a small concentration of albumin, and a non-circulating part of plasma. It acts as a gateway to the interstitial space with a primary molecular filler function, generating an effective molecular filter function, generating an effective molecular gradient across its thickness.Since the early sixties, perioperative fluid requirements were calculated by considering pre-existing deficits, maintenance volumes, and third-spaces loss, depending on the type of surgery. Based on this, a goal-directed “liberal” fluid approach was modulated. On the other hand, a “restrictive” fluid approach was later suggested to achieve better patient outcome. Extremes of either approach were shown to induce hyper- or hypovolemia, respectively. However, there are no clear definitions to describe the volume status of patients.The literature is currently characterized by inconsistency and contradiction regarding patient outcome parallel to perioperative “too much” or “too little” fluid administration. There is no single fluid regimen which provides optimal fluid volumes to all surgical patients all the times. So, available literature is discussed in this article with an early evidence of a preferred “adequate” rather than a “liberal” or a “restrictive” fluid approach.Further systematic reviews of randomized controlled trials are recommended to predict the volumes and types of administered fluids, and its timing as important determinants of postoperative patient outcome. Special evidence is also needed for “liberal” versus “restrictive” hemoglobin therapy to determine the same goals.     

The lung transplantation has come to be done in Japan

After the establishment of transplantation law, the right pulmonary transplantation was done from the brain dead donor for the first time in Japan at the attached hospital of Institute of Development, Aging and Cancer, Tohoku University on March 29, 2000. The woman in 30's had been deteriorated from progressive lymphangiomyomatosis since 1984. She was waiting for the right lung transplantation in the related hospital of the Institute Hospital since May, 1999. A brain dead donor appeared in Tokyo. After receiving the information from Japan Organ Transplant Network, we immediately started for Tokyo in order to procure the lung. We carried the right lung by Shinkansen. The lung of the donor was transplanted to the patient under the partial extracorporeal circulation on March 29, 2000. The total operating time was 6 hours and 7 minutes: 5 hours and 20 minutes for total ischemic period of the lung and 2 hours and 7 minutes for using extracorporeal circulation. The total amount of bleeding during the operation was 3,695 ml. Postoperative course of the transplanted patient was fair except chylothorax in the operated side, which was successfully controlled by intrathoracic infusion with OK-432. The transplanted patient was discharged from the hospital after 75 days postoperatively.