Percutaneous vascular intervention after surgical shunting for portal hypertension

Twenty percutaneous transluminal angioplasty (PTA) procedures and 13 percutaneous venous embolization (PVE) procedures were performed in 23 patients who either had or were at risk for the development of recurrent bleeding, hepatic encephalopathy, or both after surgical shunt placement for portal hypertension. PTA, performed in 12 patients with significant shunt stenoses, resulted in reduction or elimination of gradients in all patients; rebleeding has occurred in only one patient. Complications consisted of one fatal rupture of a mesocaval interposition vein graft and one balloon rupture requiring surgical removal. PVE, performed in 11 patients, resulted in measurable improvement in four of seven encephalopathic patients and temporary control in the two patients with intractable bleeding. Three patients underwent PVE prophylactically. PTA of graft strictures is a valuable treatment modality. Embolization may be helpful in selected cases of hepatic encephalopathy.     

SUBTOTAL THYROIDECTOMY IN THE MANAGEMENT OF GRAVE'S DISEASE

Treatment options for Grave''s disease include radio-iodine ablation, which is the standard treatment in the USA, antithyroid drug therapy, which is popular in Japan, and surgery, which is commonly employed in Europe and India. There are very few reports about the outcome of surgery in Grave''s disease in the Indian setting. Surgery for Grave''s disease is an attractive option in under developed countries to cut short prolonged drug treatment, costly follow up and avoid the need for radio-isotope facilities for 1311 ablation. Aim of the present study was to assess the result of subtotal thyroidectomy in 32 cases of Grave''s Disease referred for surgery by the endocrinologist in a teaching hospital. Patients were prepared for surgery with Lugol''s iodine and propranalol. Subtotal thyroidectomy was performed by a standard technique, which included dissection and exposure of recurrent laryngeal nerves and parathyroid glands. Actual estimation of weight of the remnant gland was not part of the study. Duration of follow up ranged from 6 months to 4 years. 13 of 32 cases were males. Age ranged from 20 to 57 years. There was 1 death in the immediate post-operative period. There were no cases of permanent hypoparathyroidism or recurrent laryngeal nerve palsy. 1 patient developed temporary hypoparathyroidism. 1 patient developed recurrence of hyperthyroidism and 3 cases developed hypothyroidism all within 2 years of surgery. The study has demonstrated the safety and effectiveness of surgery for Grave''s Disease in comparison to the reported high incidence of hypothyroidism following radio-iodine therapy and high recurrence rate after anti thyroid drug therapy.Key Words: Grave''s Disease, Thyroidectomy     

Gastric tonometry as a prognostic index of mortality in sepsis

Background: Splanchnic hypoperfusion in sepsis leads to translocation of bacteria from gut and development of multi-organ dysfunction syndrome (MODS), with increased mortality in critically ill patients. Gastric tonometry can detect this hypoperfusion by measuring carbon dioxide tension (PgCO₂) and intramucosal pH (pHi) from gastric mucosa. Therapeutic intervention aimed at improving gut perfusion can improve the outcome and prognosticate the mortality in sepsis patients.     

Substrate utilization during the first weeks of life

It is assumed that substrate utilization changes markedly around birth, from mainly glucose utilization before, to glucose/fat utilization after birth. We studied substrate oxidation and turnover in preterm infants on the first day and during the first weeks of life. We found that only part of the glucose that is infused on the first day of life is oxidized, while glucose is also converted into fat at the same time. Almost half of the energy expenditure is provided by fat oxidation on day 7 and 28 of life. Fat oxidation is dependent on the type of fat oxidized; the rate of oxidation of medium chain triglycerides (MCT) is higher than that of long chain fatty acids. MCT can replace glucose as an energy source. Proteins contribute only to a small extent (approximately 7%) to the energy expenditure at all ages.     

Partial thickness supraspinatus tears: Diagnosis by magnetic resonance arthrography

Two patients, with clinical symptoms of advanced impingement syndrome, presented for radiologic evaluation. The magnetic resonance (MR) images of each patient were interpreted as representing a full thickness tear of the supraspinatus tendon. Magnetic resonance arthrography was performed on both patients to further determine the extent of the tear. Using this technique, both patients were diagnosed correctly as having partial thickness tears; one on the articular surface and the other on the bursal surface of the tendon. This information is useful in surgical planning and in patient outeome.     

Gastric Tonometry as a Prognostic Index of Mortality in Sepsis

Background

Splanchnic hypoperfusion in sepsis leads to translocation of bacteria from gut and development of multi-organ dysfunction syndrome (MODS), with increased mortality in critically ill patients. Gastric tonometry can detect this hypoperfusion by measuring carbon dioxide tension (PgCO₂) and intramucosal pH (pHi) from gastric mucosa. Therapeutic intervention aimed at improving gut perfusion can improve the outcome and prognosticate the mortality in sepsis patients.

Methods

100 patients with clinical diagnosis of sepsis were included and divided into two groups of 50 each. Group A patients were managed traditionally without gastric tonometry and in Group B gastric tonometry was used for therapeutic intervention. The intramucosal PCO₂, pHi, end tidal carbon dioxide tension (EtCO₂) and (PgCO₂-EtCO₂) differences were monitored at 0, 12 and 24 hours interval.

Result

Overall mortality in Group A was 64 % and 54 % in Group B. In Group B 45% patients developed MODS and 54 % died with low pHi. As an index of mortality low pHi had a sensitivity of 70% and specificity of 65%.

Conclusion

There is a good correlation between mortality prediction on the basis of pHi and PgCO₂-EtCO₂ difference and actual mortality in critically ill patients. The gastric tonometer should be used to predict mortality and guide resuscitation in septicemia.Key Words: Sepsis, Splanchnic hypoperfusion, Multi-organ dysfunction syndrome, Gastric tonometry     

Biochemical markers of bone metabolism and bone tissue losses after allotransplantation of the cadaveric kidney: a cross-sectional

The biochemical markers of bone metabolism (osteocalcin (OC), C- and N-terminal procollagen I propeptides (PICP) and PINP), bone alkaline phosphatase (BALP), deoxypyridinoline (DPD), beta-crosslaps (beta-CL), bone acid phosphatase (BAP), osteoprotegerin (OPG), insulin-like growth factor I (IGF-I), and parathyroid hormone (PTH)), daily urinary calcium excretion (DUCE) (intestinal calcium absorption), and lumbar and hip bone mineral density (BMD) were determined in 195 patients (78 females and 74 males with normal function of the grafted kidney and 11 females and 31 males with chronic renal failure (CRF) 40 +/- 33 months after renal transplantation (RT). All RT recipients received triple immunosuppressive therapy (cyclosporin, prednisolone, and azathioprine). All groups showed a significant increase in resorption markers and a moderate increase in bone formation markers (except BALP), which suggested bone remodeling dissociation, as well as elevated levels of PTH and OPG and decreased DUCE and BMD in the vertebral column and hip. Increased bone metabolism and decreased intestinal calcium absorption were largely pronounced in CRF. In the majority of recipients, the BMD reduction in the vertebral column and hip was moderate (osteopenia) and only in male recipients with CRF, axial osteopenia was concurrent with peripheral osteoporosis. The main predictor of accelerated bone metabolism and BMD losses following RT was hyperparathyroidism mainly caused by decreased renal graft function. Decreased IGF-I may be a cause of bone remodeling dissociation after RT/ and the increase in OPG seems to be compensatory, which suppresses bone resorption and reduces bone losses.     

The dynamics of biochemical markers of remodelling of bone tissue after liver transplantation

The sample of 45 recipients (30 females and 15 males) after orthotopic transplantation of liver was examined thrice in dynamics. Three groups were formed according the resulted values of T-criterion of bone mineral density in the area of lumbar vertebrae. The bone mineral density of group A was considered as osteoporosis, of group B as osteopenia and of group C as physiologic norm. In early period (1-4 months) after orthotopic transplantation of liver gross disorders of bone metabolism were established in all recipients independently of the degree of bone mass loss. In distant period (up to 32 months) after orthotopic transplantation of liver the bone losses decreased entailing full normalization of bone metabolism in 37% of recipients with osteoporosis, 82% with osteopenia and 91% with normal bone mineral density.