Inguinal herniation in two patients with continuous ambulatory peritoneal dialysis

We report two cases of subacute inguinal swelling in uremic patients on continuous ambulatory peritoneal dialysis (CAPD). Computed tomography, scintigraphy demonstrated a mass in the right groin. Surgical repair of an inguinal hernia resulted in complete resolution of the inguinal swelling. Both patients could restart continuous ambulatory peritoneal dialysis, without complication.     

Work hours reform: perceptions and desires of contemporary surgical residents

BACKGROUND: New Accreditation Council for Graduate Medical Education (ACGME) requirements on resident duty hours are scheduled to undergo nationwide implementation in July 2003. General surgery residents, because of their long duty hours, are likely to be among those most affected by changes imposed to comply with the ACGME requirements. There are few contemporary data on their attitudes toward work hours reform. STUDY DESIGN: The study entailed a region-wide survey of residents enrolled in general surgery residencies in New England to characterize the perceptions and desires of surgical residents on the issue of work hours reform. RESULTS: Respondents reported working a mean of 105 +/- 0.7 hours per week, considerably more than the 80-hour limit stipulated by the ACGME. Of the respondents, 81% reported that sleep deprivation had negatively affected their work. A strong majority of respondents believe that work hours reform would improve their quality of life but less than one half expect it to have a positive impact on patient care. A greater percentage of senior residents than junior residents (p < 0.05) have negative perceptions of work hour limitations, particularly with respect to consequences for patient care. Other findings suggest that residents who have actually experienced work hour restrictions are less positive about such restrictions than these residents who had not yet experienced them. CONCLUSIONS: Changes imposed by residency programs to comply with work hour requirements might have detrimental effects on senior residents and patient care. The impact of such changes should be carefully monitored as the ACGME requirements are implemented.     

A 16q22.2-q23.1 deletion identified in a male infant with West syndrome

In partial monosomy of the distal part of chromosome 16q, abnormal facial features, intellectual disability (ID), and feeding dysfunction are often reported. However, seizures are not typical and the majority of them were seizure-free. Here we present the case of a 16q22.2-q23.1 interstitial deletion identified in a male patient with severe ID, facial anomalies including forehead protrusions and flat nose bridge, patent ductus arteriosus, bilateral vocal cord atresia treated by tracheotomy, and West syndrome, which were developed 10 months after birth. Although phenobarbital, sodium valproate (VPA), and zonisamide were not effective as monotherapies or combination therapies, the patient's epileptic seizures and electroencephalogram anomalies disappeared following combined therapy with lamotrigine and VPA. Although WW Domain Containing Oxidoreductase (WWOX), which is known as a cause of autosomal recessive epileptic encephalopathy, was included within the 6.8-Mb deleted region which identified by targeted panel sequencing and validated by chromosomal microarray analysis, no pathogenic variants were detected in the other allele of WWOX. Therefore, it is possible that other genes within or outside of the long deleted region or their interactions may cause West syndrome in this patient.     

A longitudinal study from prepuberty to puberty of gingivitis

Abstract A longitudinal study of 24 subjects progressing normally from prepuberty to puberty was undertaken to evaluate the effects of sex hormone levels on clinical and microbiologic parameters and on serum antibodies. During elementary school, at the beginning of the longitudinal monitoring, 2 groups, 12 subjects with gingivitis and 12 gingivitis-free subjects, were selected and observed through puberty. Bone ages and self-assessment of secondary sex characteristics were used to confirm puberty. A statistically significant increase in the proportions of Prevotella intermedia including Prevotella nigrescens and serum antibody levels against P. intermedia was seen in gingivitis group throughout the longitudinal study. Serum levels of testosterone in boys and estradiol and progesterone in girls was positively correlated with levels of P. intermedia and P. nigrescens. In puberty, a slight but significant increase in GI scores over prepuberty has been shown; however, there was no significant change in PII from prepuberty to puberty. Our study confirmed that there was a statistically significant increase in gingival inflammation and in the proportion of P. intermedia and P. nigrescens in puberty relative to the baseline value, except in the gingivitis-free male group. Our findings suggest that these increases are correlated with elevation in systemic levels of the sex hormones.     

Possible mechanisms involved in gastric hypermotility caused by indomethacin in the rat

Pathogenesis of indomethacin-induced gastric lesions was investigated in the rat by measuring lesions, gastric motility, and terminal blood glucose levels and correlating them with each other. Subcutaneously administered indomethacin (3-25 mg/kg) dose-dependently produced lesions in the stomach with concomitant gastric hypermotility and reduction of blood glucose levels. When the lesion score and the motility were plotted against terminal glucose levels, a highly significant relationship was found among these three factors (P less than 0.01). Gastric lesions and hypermotility induced by indomethacin (25 mg/kg) were suppressed significantly by 16,16-dmPGE2 (10 micrograms/kg) with no effect on the glucose levels, while intravenous infusion of glucose (25% w/w, 1.4 ml/hr) prevented these responses and restored the reduced glucose levels above the basal values. In addition, both 16,16-dmPGE2 and glucose infusion afforded a significant protection against gastric lesions induced by indomethacin even in the acid-perfused stomach (150 mM HCl). These results confirmed gastric hypermotility as a key element in the pathogenesis of indomethacin-induced lesions and further suggested that indomethacin may sensitive gastric contractility through glycoprivic receptors by inducing hypoglycemia and PG deficiency.     

Renal failure caused by plasma cell infiltration in multiple myeloma

We report on a case of severe renal failure in a 61-year-old female with multiple myeloma (MM). Two months prior to admission, the patient was diagnosed to have anemia and progressive renal failure associated with urinary Bence Jones protein and was referred to our hospital. A bone marrow biopsy revealed 40% plasma cells with κ light chain restriction. Thus, she was considered to have MM. A renal biopsy revealed neoplastic plasma cell infiltration within the kidney, moderate interstitial fibrosis, tubular atrophy, and punctate, electron-dense material along the peripheral capillary walls, tubular basement membrane, and in the interstitium of the kidney. This suggested that a combination of compression of the tubules and the microvasculature by the infiltrative process, and local light chain deposition-mediated tissue damage might be implicated in the development of renal failure in this patient. Despite a remission of bone marrow plasmacytosis with a bortezomib-based regimen, her renal function gradually deteriorated and a periodic hemodialysis program was finally required. Although the clinical impact of the direct kidney infiltration of neoplastic plasma cells on the longitudinal changes in renal function remains to be delineated, it is reasonable to consider that the infiltration of neoplastic plasma cells associated with local light chain depositions may result in irreversible renal injuries. Obviously, further studies and accumulation of additional experience with renal biopsy are required to better determine the precise and prognostic relationship between renal outcome and morphological alterations among MM patients with varying degrees of renal impairment.     

Periodic Duplex Ultrasonography Screening Together with Elective Percutaneous Transluminal Angioplasty in the Management of Graft Arteriovenous Fistulas for Hemodialysis

Purpose To evaluate the effectiveness of regular duplex ultrasonography in the management of graft arteriovenous fistulas for hemodialysis. Methods Between March 1997 and December 2004, we prospectively studied consecutive patients who underwent polytetrafluoroethylene graft arteriovenous (AV) fistulae in the upper extremity with a subsequent regular duplex ultrasound examination for the identification of stenosis. The main ultrasound-guided indication for percutaneous transluminal angioplasty (PTA) was the identification of 50% or more venous stenosis. The assisted primary and secondary patency rates of vascular access were calculated in these 36 patients and were then compared with those in 19 patients who had undergone graft AV fistula before the start of regular ultrasonographic screening. Results The mean follow-up lasted 25 months. PTA procedures were performed in 24 patients, of which 13 patients received multiple PTAs. The half survival time (secondary patency) of the graft was 49 ± 3.8 months in patients who had undergone ultrasound screening followed by elective PTA, which was significantly (P < 0.01) longer than the 22 ± 7.1 months observed in patients who had not undergone regular duplex ultrasound screening. Conclusion The prospective monitoring of AV fistula with ultrasound is a simple and reliable technique for detecting graft AV outflow stenosis. Elective PTA is therefore considered to be an effective therapy for the maintenance of hemodialysis access.     

Does repeated surgery improve the prognosis of colorectal liver metastases?

Hepatic resection for colorectal metastases was performed for 188 patients. Overall survival rates after the first hepatectomy are 41.4% and 32.7% for 5 and 10 years, respectively. The survival rate of 116 cases with unilobar hepatic metastases (H1) is significantly higher than those of 48 cases with two to four bilobar metastases (H2) and 24 cases with more than four (H3), respectively. However, the differences between the survival rates from H1 with multiple metastases, H2, and H3 are not significant, even though the H3 group has no 10-year survivors. The 5-year survival rates after the second hepatectomy (30 patients) and the resection of the lung (26 patients) are 30.3% and 35.2%, respectively, in this series. In those patients, the 5-year survival rates from the first metastasectomy are 43.4% and 50.3%, respectively. There are 14 5-year survivors with multiple metastases and 8 of those patients underwent multiple surgeries. There are 13 patients with three or more repeat resections of the liver and/or lung. The 5-year survival rates of the patients from the first and third metastasectomy are 53.9% and 22.5%, respectively. Repeat operations for the liver and the lung contribute to the improving prognosis. Presented at the Forty-Sixth Annual Meeting of The Society for Surgery of the Alimentary Tract, Chicago, Illinois, May 14–18, 2005 (poster presentation).     

Does anatomic resection improve the postoperative outcomes of solitary hepatocellular carcinomas located on the liver surface?

Background

It is unclear whether anatomic resection achieves better outcomes than nonanatomic resection in patients with hepatocellular carcinoma. This study aimed to compare the outcomes of anatomic resection and nonanatomic resection for hepatocellular carcinoma located on the liver surface via one-to-one propensity score-matching analysis.