Health Status in Young Adults Two Decades After Pediatric Liver Transplantation

We conducted a cross‐sectional study of patients who underwent pediatric liver transplant (LT) between 1988 and 1992 to evaluate long‐term health status. Survivors completed socio‐demographic, medical and Health‐Related Quality of Life (HRQOL) surveys by mail including the SF‐36v2, PedsQL?4.0 Generic Core Scale, PedsQL? Cognitive Functioning Scale and PedsQL?3.0 Transplant Module. SF‐36 scores were converted to SF6D‐based utilities and risk factors for lower outcomes were assessed. Eighty‐five of 171 patients had survived. Fifty‐six were contacted with a response rate of 66%. Median age at LT was 0.86 years (IQR 0.58–3.0) and 64.3% had biliary atresia. Mean age at survey was 23.0 ± 4.4 years: 62% attended college, 68% lived with parents and 80% of those over 23 were employed. Patient health utilities were lower than norms (0.75 ± 0.12 vs. 0.82 ± 0.18, p < 0.01) and correlated with unemployment (p < 0.042), hospitalizations (p < 0.005) and lower education level (p < 0.016). Lower PedsQL?3.0 Transplant Module and PedsQL? 4.0 Generic Core Scale scores correlated with unemployment (p = 0.006, p = 0.009) and hospitalizations (p = 0.006, p = 0.02). Pediatric transplant recipients who survive to adulthood have lower physical HRQOL, measurable transplant‐related disability and lower health utility. Transplantation is life saving; however, physical and psychological sequelae continue to affect health status up to two decades later.     

Outcomes of liver transplantation for patients with Alagille syndrome: the studies of pediatric liver transplantation experience

Alagille syndrome (ALGS) is a multisystem disorder that manifests as childhood cholestasis. Reports of liver transplantation (LT) for patients with ALGS have come largely from single centers, which have reported survival rates of 57% to 79%. The aim of this study was to determine LT outcomes for patients with ALGS. We performed a retrospective analysis of the Studies of Pediatric Liver Transplantation database, which contains information about 3153 pediatric LT recipients. Data were available for 91 patients with ALGS and for 236 age-matched patients with biliary atresia (BA). The frequency of complex cardiac anomalies was lower in the LT group with ALGS versus published ALGS series (5% versus 13%). The pretransplant glomerular filtration rate (GFR) was <90 mL/minute/1.73 m(2) in 18% of the LT patients with ALGS and in 5% of the LT patients with BA (P < 0.001). The height deficit at listing was worse for the ALGS patients (66%) versus the BA patients (22%). The 1-year patient survival rates were 87% for the ALGS patients and 96% for the BA patients (P = 0.002). The deaths in the ALGS group mostly occurred within the first 30 days. No pretransplant factors associated with death were identified in the ALGS group. A survival analysis revealed that biliary (P = 0.02), vascular (P < 0.001), central nervous system (CNS; P < 0.001), and renal complications (P < 0.001) after LT were associated with death in the ALGS group. Renal insufficiency in the ALGS patients worsened after LT, and at 1 year, GFR was <90 mL/minute/1.73 m(2) in 22% of the LT patients with ALGS but in only 8% of the patients with BA (P = 0.0014). More LT pediatric patients with ALGS either were currently receiving special education (50% versus 30% for BA patients, P = 0.02) or had received special education in the past (60% versus 36%, P = 0.01). Vascular, CNS, and renal complications were increased in the ALGS patients after LT, and this reflected multisystem involvement. Although the 1-year survival rate was modestly lower for the ALGS patients versus the BA patients, the clustering of deaths within the first 30 days is notable and warrants increased vigilance and further investigation.     

The association between occupant restraint systems and risk of injury in frontal motor vehicle collisions

BACKGROUND: An evaluation of seat belt use and airbag deployment, either alone or in combination, on risk of injury to specific body regions has yet to be completed. METHODS: A retrospective cohort study of front seat occupants involved in police-reported, tow-away, frontal motor vehicle collisions using data from the 1995 through 2000 National Automotive Sampling System was conducted. Only vehicles with a change in velocity (delta-V) of >/= 15 km/h were included. Risk of injury (Abbreviated Injury Scale score >/= 2) to specific body regions was compared according to seat belt use and airbag deployment. RESULTS: Compared with completely unrestrained occupants, those using a seat belt alone or in combination with an airbag had a reduced overall risk of injury (relative risk, 0.42 and 0.71, respectively); no association was observed for those restrained with an airbag only (relative risk, 0.98). This pattern of results was similar for specific body regions with the exception of the lower extremity, wherein a significantly increased risk was observed for airbag deployment alone. CONCLUSION: Airbag deployment does not appear to significantly reduce the risk of injury either alone or in combination with seat belts. Airbag deployment without associated seat belt use may increase the risk of lower extremity injury.     

Duplication of the male urethra

Duplication of the male urethra is an uncommon congenital malformation. The majority of cases are diagnosed during infancy, and are detected by observing two urethral meatus, or by the appearance of some form of complication, normally of an obstructive nature. Micturitional cystourethrography is an essential test, both in confirming diagnosis of this pathology, and in determining the type of urethral duplication. Excretory urography is also recommended due to its association with other possible urological and extra-urological congenital disorders. Treatment is based on the patient's clinical symptoms, with a waiting period considered advisable for asymptomatic cases. Here we present a case of incomplete urethral duplication, diagnosed from a bladder outlet obstruction, secondary to stenosis of the urethra, which was treated with an endoscopic urethrotomy and distal septotomy, obtaining excellent clinical results.     

Epidemiology of osteoporotic hip fractures in Spain

We conducted a multicentre study, divided into a retrospective and a prospective portion. The retrospective study evaluated osteoporotic hip fractures that occurred during 2002. The prospective study evaluated osteoporotic hip fractures that occurred during May 2003. The study was conducted in 77 hospitals in Spain and comprised patients 60 years of age and over. In the retrospective study we registered 13,195 hip fractures. Of the patients, 74% were women and 26% were men. The mean age was 80.7+/-8.4 years. The average incidence was 6.94+/-0.44 hip fractures per 1,000 inhabitants/year (95% CI, 6.07-7.82). In the prospective study, we registered 1,399 hip fractures. This represents a monthly incidence of 0.60+/-0.04 hip fractures per 1,000 inhabitants/year (95% CI, 0.51-0.69). Of the subjects, 74% were women and 26% were men. The mean age was 81.4+/-8.1 years. Using these data, we calculated the average annual prevalence in 2003 to be 7.20 fractures per 1,000 inhabitants. Thirty-three percent had previously suffered a hip fracture. Prior to the fracture, only 18% had received medical treatment for osteoporosis. After discharge from the hospital, only 26% were receiving pharmacological treatment for osteoporosis.     

Main traumatic events in Europe: PTSD in the European study of the epidemiology of mental disorders survey

A potentially traumatic event (PTE) contributes to trauma through its frequency, conditional probability of posttraumatic stress disorder (PTSD), and experience of other PTEs. A cross-sectional survey was conducted, enrolling 21,425 adults nationally representative of six European countries. Using the WHO-Composite International Diagnostic Interview, 8,797 were interviewed on 28 PTEs and PTSD. Prevalence of 12-month PTSD was 1.1%. When PTSD was present, the mean number of PTEs experienced was 3.2. In a multivariate analysis on PTEs and gender, six PTEs were found to be more traumatic, and to explain a large percentage of PTSD, as estimated by their attributable risk of PTSD: rape, undisclosed private event, having a child with serious illness, beaten by partner, stalked, beaten by caregiver.     

The inflammatory response to colloids and crystalloids used for pump priming during cardiopulmonary bypass

Background: Systemic inflammatory response frequently occurs after coronary artery bypass surgery and is strongly correlated with the risk of postoperative morbidity and mortality. This study tests the hypothesis that the priming of the extracorporeal circuit with colloid solutions results in less inflammation in patients undergoing cardiac surgery than priming with crystalloid solutions. Methods: A prospective, randomized study was designed. Forty‐four patients undergoing elective coronary artery bypass grafting were randomly allocated to one of two groups: 22 patients primed with Ringer's lactate (RL) solution and 22 patients primed with gelatin‐containing solution during the surgery. Plasma levels of interleukin (IL)‐6, IL‐8, tumor necrosis factor (TNF)‐α, C‐reactive protein (CRP) and, complement 4 were measured during the surgical intervention and over the following 48 postoperative hours. Cytokine levels were measured by enzyme‐linked assays from plasma samples obtained at specific time points pre‐ and post‐operatively. Results: In both groups the serum levels of the pro‐inflammatory cytokines (IL‐6, IL‐8, TNF‐α), CRP, complement 4, and leukocytes increased significantly over the baseline, although no significant differences were observed between the two groups. The operation time, blood loss, need for inotropic support, extubation time, and length of intensive care unit stay did not differ significantly between the two groups. Conclusion: Priming with gelatin vs. RL produces no significant differences in the inflammatory response in patients undergoing coronary artery bypass grafting with cardiopulmonary bypass.     

Donante vivo renal. experiencia de cirugía abierta y laparoscópica. hospital la paz

Laparoscopic live donor nephrectomy is a rare operation in our country because the complexity of the technique and the expansion of the cadaveric donor. We present our open and laparoscopic live donor nephrectomy from 1984.Material and MethodsFrom 1984 to 2007 we have done 84 live donor nephrectomies; 64 open, 20 laparoscopic surgeries. The transperitoneal approach is preferred in laparoscopy and lumbotomy for the open surgery.ResultsIn the open technique the operating time is 112min (70-155), ischaemia time 20 seconds (15-47) and postoperative hospital stay 4,8 days (3-9). Laparoscopic cases, the operating time is 146 min (90-210), ischaemia time 3 min 15 sec (2-3,25 min) and postoperative hospital stay 3,4 days (2-9).ConclusionsThe laparoscopic live donor nephrectomy is a difficult and demanding technique. It should be done by experienced team in laparoscopic renal surgery. The kidney from a live donor is a very good alternative for the cronic renal failure. It should be offered in our main hospitals.     

Liver Transplantation for Hepatocellular Carcinoma: Results of a Multicenter Study With Common Priorization Criteria

Objective

To evaluate the results of liver transplantation (OLT) performed for hepatocellular carcinoma (HCC) among a multicenter cohort of patients with predefined common inclusion and priorization criteria.

Patients and Methods

Over a 5-year period (January 2002-December 2006), 199 HCC patients underwent OLT in four centers in Andalusia. The morphological (Milan) inclusion criteria were priorized in two consecutive periods, according to the Model for End-stage Liver Disease score: group I, 53 patients (HCC < 2 cm = 24 points; ≥ 2 cm or multinodular = 29 points) and group II, 146 cases (HCC < 3 cm without priorization; HCC ≥ 3 cm or multinodular = 18 points).

Results

Among the 199 HCCs, 186 (93.5%) subjects were transplanted and 13 (6.5%) were excluded. There were 18 cases (9.7%) where the diagnosis was incidental and 168 were known HCC cases; 144 (85.7%) complied with the Milan criteria (Milan+); 24 (14.3%) exceeded there criteria (Milan−). According to preoperative imaging, the number of nodules and tumor mean sizes among the excluded—Milan+ and Milan− groups—were 1.8/5.3 cm, 1.4/3.5 cm, and 2.3/6.7 cm, respectively (P < .001). Percutaneous treatment during listing was delivered to 55% of the excluded cases: 49% of Milan+ and 96% of Milan−. The median time on the list was 88 days for known HCC (53 days for group I, and 97 days for group II), and 172 days for the incidental HCCs. Staging (pTNM) was correct in 64% of cases: 23% were understaged and 13% were overstaged. Overall mortality within the first 90 days was 9%, and transplant patient survival at 5 years was 61%. No differences were observed in survival rates between both study periods, although there were differences between the Milan+ (65%) and Milan− (23%) groups (P < .04). In addition, the difference in the recurrence rates was also significant between the Milan+ (7%), Milan− (24%), and the incidental (25%) groups (P < .02).

Conclusions

A common priorization policy of HCC for OLT based on morphological criteria results in a low exclusion rate on the waiting lists (6.5%). The Milan criteria are still a good cutoff to stratify the risk of recurrence, despite preoperative tumor staging being correct in only two-thirds of cases.     

Clinical and Pathological Factors Related to 18F-FDG-PET Positivity in the Diagnosis of Recurrence and/or Metastasis in Patients with Differentiated Thyroid Cancer

Background  Objectives were to analyze the relationship between a positive ¹⁸F-fluorodeoxyglucose (FDG)-positron emission tomography (PET) result and clinical and tumor factors in patients treated for differentiated thyroid cancer (DTC) and under suspicion of recurrence or metastasis, and to determine the diagnostic validity of PET in DTC patients with elevated serum thyroglobulin (Tg) and negative ¹³¹I whole-body scan (¹³¹I-WBS). Methods  We studied 50 DTC patients with elevated serum Tg and negative WBS treated with total thyroidectomy and ¹³¹I ablation. Thyroxin treatment was withdrawn and patients were on iodine-free diet before WBS. Tg, anti-Tg antibodies, and thyroid-stimulating hormone (TSH) were determined. Patients with negative WBS and elevated Tg underwent PET study 1 week later. PET findings were verified by pathology findings or other imaging techniques [computed tomography (CT), magnetic resonance imaging (MRI), ultrasound (US)] and/or 12-month follow-up. The relationship between PET findings and tumor (histological type, size, multifocality, thyroid capsular invasion, lymph-node and/or metastatic involvement) and clinical (age at diagnosis, sex, Tg, accumulated iodine dose, and recurrence time) variables was analyzed. Results  PET was positive in 32/39 patients with confirmed disease (82% sensitivity) and negative in 7/11 of disease-free cases (64% specificity), a positive predictive value (PPV) of 89%. Tumor size (P < 0.05) and thyroid capsular invasion (P < 0.05) were significantly associated with positive PET study. The relationship of PET findings with Tg levels and age at diagnosis was close to significance. Conclusion   ¹⁸F-FDG-PET study offers a high sensitivity and positive predictive value (PPV) in patients with negative WBS and Tg positive. The use of FDG-PET is strongly recommended in DTC patients with large tumors, thyroid capsule invasion or poor-prognosis variants.