Do Laparoscopy and Intraoperative Ultrasound Have a Role in the Assessment of Patients With End-Stage Liver Disease and Hepatocellular Carcinoma for Liver Transplantation?

BACKGROUND: Liver transplantation is the treatment of choice for patients with end-stage liver disease (ESLD) and early hepatocellular carcinoma (HCC), Routine laparoscopy with intraoperative ultrasound was employed in an attempt to improve patient selection for transplantation. Our aim was to assess whether laparoscopy improved the patient selection with ESLD and HCC being considered for transplantation. METHODS: We retrospectively reviewed the clinical notes and transplant database of all patients with ESLD complicated by HCC, being assessed for liver transplantation, from January 2000 to April 2005. RESULTS: Twenty-five patients with ESLD and HCC underwent assessment for liver transplantation. Eight were deemed untransplantable on cross-sectional imaging alone. Sixteen patients underwent laparoscopy and intraoperative ultrasound. One patient had undergone a previous segmental hepatectomy and laparoscopy was not technically feasible. At laparoscopy, all 16 patients were found to be free from extrahepatic disease and major vascular involvement. All 16 patients were listed for transplantation. At transplantation, one patient was found to have extrahepatic disease; the procedure was abandoned. One patient was found to have lesser curvature lymphadenopathy, Two patients had major vascular involvement noted in the explanted liver. All these findings were missed on pretransplant imaging and at laparoscopy. CONCLUSIONS: As an additional investigation, laparoscopy did not improve staging or alter the management of patients with HCC being assessed for liver transplantation. Since July 2005, we have ceased routine laparoscopic assessment of patients prior to listing. The decision use laparoscopy on patients is now being taken on a more selective basis.     

Donation after Cardiac Death Kidneys with Low Severity Pre-Arrest Acute Renal Failure

The widening gap between supply and demand for renal transplantation has prompted many centers to use donors after cardiac death. Some of these donors exhibit signs of acute renal failure (ARF) prior to cardiac arrest. Concern has been expressed about poor quality of graft function from such donors. In response to this perception, we reviewed 49 single renal transplant recipients from category III donors after cardiac death between 1998 and 2005, at our center. All kidneys but one had hypothermic machine perfusion and viability testing prior to transplantation. According to the RIFLE criteria, nine recipients had kidneys from donors with "low severity pre-arrest ARF". The remainder of the recipients were used as control group. There was no statistical significant difference in delayed graft function and rejection rates between these two groups. Recipients GFR at 12 months was 44.4 +/- 17.1 and 45.2 +/- 14.7 (mL/min/1.73m(2)) from donors with ARF and without ARF, respectively (p = 0.96). In conclusion, low severity ARF in kidneys from controlled after cardiac death donors can be a reversible condition after transplantation. Short-term results are comparable to the kidneys from same category donors without renal failure, providing that some form of viability assessment is implemented prior to transplantation.     

Staged Laparoscopic Sleeve Gastrectomy Followed by Roux-en-Y Gastric Bypass for Morbidly Obese Patients: A Risk Reduction Strategy

Background  In our centre laparoscopic Roux-en-Y gastric bypass (LRYGBP) is the most effective weight loss surgical procedure performed. However, LRYGBP may be associated with higher risk of peri- and postoperative complications in contrast to a purely restrictive procedure to justify this procedure on all comers. Laparoscopic sleeve gastrectomy (LSG) as a staged procedure may be an alternate risk reduction strategy. The aim of this study is to report on the short-term outcomes of LSG, the effect on operative risk reduction and resolution of comorbidities. Methods  A prospective review of 138 patients who underwent consecutive LSG from November 2004 to November 2006 was performed. Data were collected on all patients who attended the three to six monthly clinical follow-up and/or the patient questionnaire. Data collection included demographics, degree of weight reduction, postoperative complications, and changes in comorbidities. Results  Median BMI was 50.60 kg/m² (33–82). Of the patients, 46.38% had a BMI ≥50 kg/m². The overall median postoperative excess weight loss (EWL) was 43.26%, 31.08% at 6 months, 54.50% at 12 months, 51.47% at 18 months and 46.05% at 24 months. Of the patients, 39% had resolution of type 2 diabetes mellitus, 48% had resolution of dyslipidemia, 29% in hypertension, 52% in obstructive sleep apnea. Complication rate was 5.07% and four patients needed further surgical intervention. The mortality rate was zero. Conclusion  LSG does minimize postoperative complication rates significantly on high-risk patients and achieves effective short-term weight loss with resolutions in comorbidities. Additional studies are required to evaluate LSG as a stand-lone procedure.     

Cuterebra cutaneous myiasis, New Hampshire, 2004

We describe a cluster of patients in New Hampshire with Cuterebra cutaneous myiasis.     

Effects of sequential changes from conventional ventilation to high-frequency oscillatory ventilation at increasing mean airway pressures in an ovine model of combined lung and head injury

BACKGROUND: The objective of this study was to determine the intracranial, cardiovascular and respiratory changes induced by conversion to high-frequency oscillator ventilation from conventional mechanical ventilation at increasing airway pressures. METHODS: In this study, 11 anaesthetized sheep had invasive cardiovascular and intracranial monitors placed. Lung injury was induced by saline lavage and head injury was induced by inflation of an intracranial balloon catheter. All animals were sequentially converted from conventional mechanical ventilation to high-frequency oscillator ventilation at target mean airway pressures of 16, 22, 28, 34 and 40 cm H(2)O. The mean airway pressure was achieved by adjusting positive end expiratory pressure while on conventional mechanical ventilation, and continuous distending pressures while on high-frequency oscillator ventilation. Cerebral lactate production, oxygen consumption and venous oximetry were measured and analysed in relation to changes in transcranial Doppler flow velocity. Transcranial Doppler profiles together with other physiological parameters were measured at each airway pressure. RESULTS: Cerebral perfusion pressure was significantly lower during high-frequency oscillator ventilation than during conventional mechanical ventilation (CMV: 45, 34, 22, 6, 9 mmHg vs. HFOV: 33, 20, 19, 5, 5 mmHg at airway pressures mentioned above, P = 0.02). Intracranial pressure and cerebrovascular resistance increased with increasing intrathoracic pressures (P = 0.001). Cerebral metabolic indices demonstrated an initial increase in anaerobic metabolism followed by a decrease in cerebral oxygen consumption progressing to cerebral infarction as intrathoracic pressures were further increased in a stepwise fashion. Arterial PaCO(2) increased significantly after converting from conventional mechanical ventilation to high-frequency oscillator ventilation (P = 0.001). However, no difference was observed between conventional mechanical ventilation and high-frequency oscillator ventilation when intracranial pressure, metabolic and transcranial Doppler indices were compared at equivalent mean airway pressures. CONCLUSIONS: The use of high positive end expiratory pressure with conventional mechanical ventilation or high continuous distending pressure with high-frequency oscillator ventilation increased intracranial pressure and adversely affected cerebral metabolic indices in this ovine model. Transcranial Doppler is a useful adjunct to intracranial pressure and intracranial venous saturation monitoring when major changes in ventilation strategy are adopted.     

Cost Minimisation Using Clinic-Based Treatment for Common Hand Conditions – A Prospective Economic Analysis

INTRODUCTION

The purpose of this study was to compare the cost of treatment of Dupuytren''s disease, ganglia and trigger digits in the out-patient department with the operating theatre.

PATIENTS AND METHODS

All patients seen in a new patient hand clinic with a diagnosis of Dupuytren''s disease, trigger digit or ganglion of the wrist or hand requiring treatment were prospectively identified over a 6-month period. The numbers undergoing a procedure in the out-patient clinic or theatre were recorded. Costings of theatre time and out-patient time, as well as national tariff income, were obtained from the hospital management.

RESULTS

Over the 6-month period, 80, 26, and 52 patients were treated with regard to Dupuytren''s disease, ganglia and trigger digits, respectively. Of these, 37, 23, and 44 were treated by an out-patient procedure, and 43, 3 and 8 underwent a formal operation. The total cost of the out-patient procedures was calculated at £1560 over 6 months. To perform these as formal operations would have cost £64,896. The cost savings were, therefore, £63,336, or £126,672 per annum.

CONCLUSIONS

Out-patient interventions for Dupuytren''s disease, ganglia and trigger digits result in significant cost savings over formal surgical treatment.     

A method for patient set-up guidance in radiotherapy using augmented reality

A system for patient set-up in external beam radiotherapy was developed using Augmented Reality (AR). Live images of the linac treatment couch and patient were obtained with video cameras and displayed on a nearby monitor. A 3D model of the patient’s external contour was obtained from planning CT data, and AR tracking software was used to superimpose the model onto the video images in the correct position for treatment. Throughout set-up and treatment, the user can view the monitor and visually confirm that the patient is positioned correctly. To ensure that the virtual contour was displayed in the correct position, a process was devised to register the coordinates of the linac with the camera images. A cube with AR tracking markers attached to its faces was constructed for alignment with the isocentre using room lasers or conebeam CT. The performance of the system was investigated in a clinical environment by using it to position an anthropomorphic phantom without the aid of additional set-up methods. The positioning errors were determined by means of CBCT and image registration. The translational set-up errors were found to be less than 2.4 mm and the rotational errors less than 0.3°. This proof-of-principle study has demonstrated the feasibility of using AR for patient position and pose guidance.     

Vaccination as infection control: A pilot study to determine the impact of Staphylococcus aureus vaccination on nasal carriage

Background

There is a critical need for an effective Staphylococcus aureus vaccine for the prevention of staphylococcal disease. In this study, we investigated the impact of S. aureus conjugate vaccine comprised of capsular polysaccharides 5 and 8 (CP5, CP8) on nasal colonization with S. aureus.

Methods

Healthy adults recruited from one academic medical center to participate in a lot consistency trial of StaphVAX^® (S. aureus capsular polysaccharide 5 and 8 conjugate vaccine) were assessed for S. aureus nasal colonization at two weekly points prior to vaccination and again at six weeks post-vaccination. Serum anti-capsular antibody titers to CP5 and CP8 were obtained prior to vaccination and 42 days post-vaccination and measured by ELISA.

Results

Thirty of 88 enrolled subjects (34%) had S. aureus isolated from at least one of the pre-immunization cultures. Of these, 20 were termed persistent carriers due to two positive cultures one week apart; 19 of the 20 were evaluable at Day 42. Baseline anti-CP8 concentrations were higher in persistent carriers of CP8+ S. aureus; however, baseline anti-CP5 levels were not significantly higher in individuals persistently colonized with CP5+ S. aureus. Statistically significant rises in antibody concentrations were noted after vaccination. At Day 42, 14 of 19 persistent carriers remained colonized; 5 subjects did not have evidence of S. aureus colonization. Ten additional subjects were positive for S. aureus at Day 42 who were not persistently colonized at baseline. Serum antibody concentrations were not statistically different between those with persistent carriage vs. those that lost carriage or those with newly acquired carriage.

Conclusions

Immune responses to vaccine were brisk and comparable in subjects with or without persistent colonization. Despite a substantial rise in anti-CP5 and anti-CP8 antibody concentrations post-vaccination, S. aureus nasal colonization rates did not significantly change.     

A mutation in the small heat-shock protein HSPB1 leading to distal hereditary motor neuronopathy disrupts neurofilament assembly and the axonal transport of specific cellular cargoes

Distal hereditary motor neuronopathies (dHMNs) are a clinically and genetically heterogeneous group of disorders in which motor neurons selectively undergo age-dependant degeneration. Mutations in the small heat-shock protein HSPB1 (HSP27) are responsible for one form of dHMN. In this study, we have analysed the effect of expressing a form of mutant HSPB1 in primary neuronal cells in culture. Mutant (P182L) but not wild-type HSPB1 led to the formation of insoluble intracellular aggregates and to the sequestration in the cytoplasm of selective cellular components, including neurofilament middle chain subunit (NF-M) and p150 dynactin. These findings suggest a possible pathogenic mechanism for HSPB1 whereby the mutation may lead to preferential motor neuron loss by disrupting selective components essential for axonal structure and transport.     

Granulocyte-macrophage colony-stimulating-factor increases interferon-tau protein secretion in bovine trophectoderm cells

PROBLEM: Uterine-derived factors are required for optimal conceptus development and secretion of the maternal recognition of pregnancy factor, interferon-tau (IFN-tau). Identifying these factors may lead to the development of schemes for increasing pregnancy success in cattle. METHOD OF STUDY: The objectives were to examine the effects of granulocyte-macrophage colony-stimulating-factor (GM-CSF) on trophectoderm proliferation rates and IFN-tau production, and verify the appropriateness of using an in vitro model of bovine trophectoderm (CT-1 cell). RESULTS: Rate of [(3)H]-thymidine incorporation into DNA was increased by supplementation of CT-1 medium with 10 or 100 ng/mL porcine (po) GM-CSF. GM-CSF supplementation to CT-1 medium also increased IFN-tau secretion. When results were normalized to account for number of CT-1 cells, 10 and 100 ng/mL poGM-CSF increased antiviral activity and IFN-tau concentrations (using an IFN-tau-specific enzyme-linked immunosorbent assay) in CT-1 conditioned medium compared with controls. CONCLUSIONS: These findings indicate that GM-CSF increases proliferation and IFN-tau production in bovine trophectoderm.