Donor and recipient pretransplant conditioning with nonlethal radiation and antilymphocyte serum improves the graft survival in a rat small bowel transplant model

BACKGROUND: Lymphoid tissue within the intestinal graft require immunomodulatory strategies to prevent graft versus host disease (GVHD) after transplant. Herein, we evaluate the potential advantage of donor-specific bone marrow infusions in donor and or recipient preconditioned with total body irradiation and or antilymphocyte serum (ALS) on the incidence of GVHD and rejection after small bowel transplantation. METHODS: Heterotopic SBTx was performed from DA to Lewis rats and distributed in nine groups: control group G0 (n=4) and G1 (n=6) without irradiation; recipients in G2 (n=4) were given 400 rd although in groups 3 (n=5), G4 (n=6), G6 (n=5), G7 (n=5), and G8 (n=6) with 250 rd. Donors in G5 (n=4) and G6 were given 250 rd of total body irradiation 2 hours before intestinal retrieval. Donors and recipients in G7 and donors in G8 additionally received ALS (day -5). G1, 2, 3, 5, 6, 7, and 8 were infused with UDBM and G4 with the same amount of TCDBM. Animals received tacrolimus for 15 days and accessed for rejection, GVHD and for chimerism analysis. RESULTS: High mortality due to GVHD was observed in G2, 3, and 4, and correlated with high levels of donor T cells in recipients blood. G0 and G1 showed early acute rejection with progression toward chronic rejection, in contrast to the preconditioned groups. High and low doses of total body irradiation resulted in allogeneic and in a mixed chimerism, respectively. Decrease in donor chimeric cells after 11 weeks in preconditioned groups was correlated with severe allograft rejection. CONCLUSION: Donor preconditioning with 250 rd and or ALS combined with recipient preconditioning and donor-specific bone marrow infusions prevented GVHD and resulted in a transient mixed chimerism with inhibition of allograft rejection after small bowel transplantation.     

Mathematical Modeling of Carbon Monoxide Exposures from Anesthetic Breakdown: Effect of Subject Size, Hematocrit, Fraction of Inspired Oxygen, and Quantity of Carbon Monoxide

Background: Carbon monoxide (CO) is produced by reaction of isoflurane, enflurane, and desflurane in desiccated carbon dioxide absorbents. The inspiratory CO concentration depends on the dryness and identity of the absorbent and anesthetic. The adaptation of existing mathematical models to a rebreathing circuit allows identification of patient factors that predispose to more severe exposures, as identified by carboxyhemoglobin concentration.

Methods: From our companion study, the authors used quantitative in vitro CO production data for 60 min at 7.5% desflurane or 1.5% isoflurane at 1 l/min fresh gas flow. The carboxyhemoglobin concentration was calculated by iteratively solving the Coburn Forster Kane equation modified for a rebreathing system that incorporates the removal of CO by patient absorption. Demonstrating good fit of predicted carboxyhemoglobin concentrations to published data from animal and human exposures validated the model. Carboxyhemoglobin concentrations were predicted for exposures of various severity, patients of different sizes, hematocrit, and fraction of inspired oxygen.

Results: The calculated carboxyhemoglobin concentrations closely predicted the experimental results of other investigators, thereby validating the model. These equations indicate the severity of CO poisoning is inversely related to the hemoglobin quantity of a subject. Fraction of inspired oxygen had the greatest effect in patients of small size with low hematocrit values, where equilibrium and not the rate of uptake determined carboxyhemoglobin concentrations.     

Transobturator tape procedure outcome: a clinical and quality of life analysis of a 1-year follow-up

To report the results obtained with the transobturator sub-urethral tape (TOT) for the surgical treatment of stress urinary incontinence (SUI) after 1 year follow-up. Ninety-three patients diagnosed with SUI or mixed urinary incontinence (MUI) underwent a TOT procedure associated to prolapse surgery, if necessary. Pre-operative quality of life (QoL) was assessed with the Urogenital Distress Inventory Short Form (UDI-6)/Incontinence Impact Questionnaire Short Form (IIQ-7) questionnaires. Surgical and early complications were monitored. A stress test and an urodynamic test if urge incontinence de novo appeared were performed at 1 year follow-up. UDI-6/IIQ-7 questionnaires and SUI symptoms were recorded. Patients’ characteristics, pre-operative quality of life and urodynamic evaluation were similar in the TOT and in the pelvic floor surgery group. From the sample, 15% had post-operative retention and 10% had vaginal erosion. The global rate of objective cure was 97% in both groups. The scores of the QoL questionnaires were worse by 9% and 10% with the procedure, respectively. Patients with urodynamic (MUI) or persistence of SUI symptoms (10%) did not reach a significant improvement, although patients with urge incontinence de novo (10%) did. The TOT procedure is safe and effective. Results showed that the association to pelvic floor surgical techniques did not diminish 1 year later. The stress test outcome assessment can overestimate the results, compared to the QoL assessment. In our report, the MUI did not improve with this surgical approach. Our results highlight the necessary employment of both the objective testing and the patient’s opinion of her symptoms during daily life.     

Hypertension and albuminuria in chronic kidney disease mapped to a mouse chromosome 11 locus

Chronic kidney disease (CKD) is a key cause of hypertension and a potent independent risk for cardiovascular disease. Epidemiological studies suggest a strong genetic component determining susceptibility for renal disease and, by inference, the associated cardiovascular risk. With a subtotal nephrectomy model of kidney disease, we found the 129S6 mouse strain to be very susceptible to the development of hypertension, albuminuria, and kidney injury, whereas the C57BL/6 strain is relatively resistant. Accordingly, we set out to map quantitative trait loci conferring susceptibility to hypertension and albuminuria using this model with F2 mice. We found significant linkage of the blood pressure trait to two loci. At D11Mit143, mice homozygous for the 129S6 allele had significantly higher systolic blood pressure than mice heterozygous or homozygous for the C57BL/6 allele. Similarly, at D1Mit308, there was an excellent correlation between genotype and the blood pressure phenotype. The effect of the chromosome 11 locus was verified with a separate cohort of F2 mice. For the albuminuria trait, a significant locus was found at D11Mit143, which overlaps the blood pressure trait locus. Our studies have identified a region spanning approximately 8 cM on mouse chromosome 11 that is associated with susceptibility to hypertension and albuminuria in CKD.     

Paresthesia in various spinal anesthesia techniques for cesarean section

OBJECTIVE: To determine the incidence of paresthesia with different spinal puncture techniques using a 27-gauge Whitacre needle. MATERIAL AND METHODS: Spinal puncture was performed in 224 elective cesarean sections using different techniques in this single-blind, prospective trial. Patients were randomized to 4 groups: group 1, combined epidural and subarachnoid puncture using an introducer needle; group 2, combined epidural and subarachnoid puncture without an introducer; group 3, subarachnoid puncture with an introducer; and group 4, subarachnoid puncture with an introducer to within a few millimeters of the dural sac, at which point the introducer was withdrawn. RESULTS: Paresthesia developed in 23, 11, 16 and 5 patients in groups 1, 2, 3 and 4, respectively. Various nerve roots were affected. In 2 and 11 cases the fourth and fifth lumbar nerve roots were affected; in 29 and 13 cases, the first and second sacral nerve roots were involved. In comparison with group 4, the risk of paresthesia was 7, 2.5 and 4 times greater in groups 1, 2 and 3, respectively. CONCLUSIONS: Combined epidural-subarachnoid puncture leads to a higher incidence of paresthesia in comparison with simple spinal puncture, probably because the lumbar puncture is performed on a dural sac that has been previously deformed due to the "tent effect" caused by the epidural needle. Fewer cases of paresthesia occur when the subarachnoid puncture is slow and steady and the introducer needle is withdrawn millimeters before it reaches the dural sac.     

Early postoperative transtibial articular fistula formation after anterior cruciate ligament reconstruction: a review of three cases

Introduction

This is a retrospective case report of three cases with an early postoperative transtibial fistula after anterior cruciate ligament reconstruction (ACL).

Materials and methods

The patients had undergone ACL reconstruction and complained of fluid drainage through the not-healed wound or swelling localized on the anteromedial aspect of the ipsilateral proximal tibia during the early postoperative. Magnetic resonance imaging showed a multilocular fluid-filled cyst arising from the distal hole of the tibial bone tunnel. Open resection of the fistula and the cyst was performed in all cases and communication between the tibial tunnel and the joint space was confirmed. During revision surgery the distal hole of the tibial tunnel was covered with a fascio-periosteal flap.

Results

All wounds healed without complications. There was no recurrence of drainage or cyst formation. At 2 years follow-up the knee function was normal and was not affected by the complication in any of the patients. Early postoperative transtibial fistulae after ACL reconstruction are rare complications that clinically present either as anterior tibial cysts or persistent wound drainage. Surgical treatment is required, and some delay in the rehabilitation routine is required, but the final outcome is not affected.     

Estudio de coste-beneficio comparando la reparación de la hernia ventral abierta y laparoscópica

Objective

Laparoscopic surgery is a successful treatment option offering significant advantages to patients compared with open ventral hernia repair. A cost-benefit analysis was performed to compare the clinical results and economic costs of the open and laparoscopic techniques for anterior abdominal wall hernia repair, in order to determine the more efficient procedure.

Material and methods

We performed a prospective study of 140 patients with primary and incisional hernia, and analyzed clinical data, morbidity, costs of surgery and hospital stay costs.

Results

The cost of disposable surgical supplies was higher with laparoscopic repair but reduced the average length of stay (P < .001) and patient morbidity (P < .001). The total cost of the laparoscopic procedure was, therefore, less than initially estimated, yielding a savings of 1,260 € per patient (2,865 € vs. 4,125 €).

Conclusions

Laparoscopic ventral hernia repair is associated with a reduced complication rate, a lower average length of stay and with lower total costs. Laparoscopic repair can save 1.260 € for each patient, and so this procedure should be considered a cost-effective approach.     

Whole-body (67)Ga scintigraphy in a patient with thymus carcinoma

We report a case of a 50 year old man referred to our department with a history of mild cough, dyspnea and dysphagia. The thoracic CT scan showed a large solid mass in the anterior mediastinum, corresponding to the findings in the chest radiographs.A 67Ga scintigraphy was performed and showed high pathological accumulation in the anterior mediastinum. A subsequent fine needle aspiration biopsy (FNAB) showed the presence of malignant cells, suggesting thymic carcinoma. Although this type of tumour is uncommon, it should be taken into account in order to establish the differential diagnosis of gallium-avid mediastinal masses.     

Treatment of 125 sinonasal tumors: Prognostic factors, outcome, and follow-up

We reviewed our experience with sinonasal cancer patients to assess the prognostic factors. Between 1974 and 1995, we enrolled 125 patients (58 + 16 years [mean age + SD]; 94 males and 31 females). Tumor stage distribution was: T1, 64 patients; T2, 36 patients; and T3, 25 patients. Surgery as a primary treatment was selected for 106 patients (55 cases of surgery alone, 40 cases of surgery plus radiotherapy, and 11 cases of surgery plus chemotherapy with/without radiotherapy). The 1-, 5-, and 10-year overall survival was 75.0%, 37.2%, and 24.7%, respectively. The parameters with statistical prognostic significance were nodal stage, locoregional failure, and tumor stage. Histological type and primary site had no prognostic value. There were no significant survival differences between surgery alone and surgery plus radiotherapy. Sinonasal tumors have a poor survival, despite early diagnosis, radical surgical resection, and strict follow-up. Radiotherapy seems not to be clearly necessary in stage T1.