Supraceliac aortic clamping during the anhepatic phase of experimental orthotopic liver transplantation.

BACKGROUND: The pig tolerates simultaneous clamping of the liver pedicle and inferior vena cava poorly, so venovenous bypass has to be used during the anhepatic phase of experimental orthotopic liver transplantation (OLT). The aim of this work is to assess whether clamping of the supracoeliac aorta during the anhepatic phase (AP) of experimental OLT in pigs allows transplantation in stable hemodynamic conditions. METHODS: Fourteen pigs (weight, 16 to 18 kg) received whole liver grafts from 14 age-matched donors and were subsequently divided into two groups: group I, OLT without venovenous bypass during the AP, group II, OLT with supracoeliac aortic clamping during the AP. Variables analyzed were cardiac output (CO) and related variables, mean systemic arterial pressure (MAP), mixed venous oxygen saturation (SvO2), hepatic artery and portal vein blood flow, systemic and hepatic O2 supply and uptake (SDO2, SVO2, HDO2, HVO2, respectively), liver enzymes, glucose, creatinine, and electrolytes. RESULTS: In group I, CO, MAP, and SvO2, decreased during the AP (anhepatic) in comparison with baseline (preanhepatic) values (CO, 3.60+/-0.74, preanhepatic, v. 1.21+/-0.25 L x min(-1), anhepatic; P<.05. MAP, 97+/-12, preanhepatic, v. 43+/-17 mm Hg, anhepatic; P<.05. SvO2, 91.6+/-5.6, preanhepatic v. 70.0+/-12.5%, anhepatic; P<.05), and SDO2/SVO2 increased by 16% (preanhepatic) to 33% (anhepatic; P<.05). In group II, CO decreased during the anhepatic phase by only 21% (3.82+/-0.81, preanhepatic, v. 3.07+/-0.99 L x min(-1), anhepatic; not significant), the MAP increased significantly (100+/-8, preanhepatic, v. 135+/-4 mm Hg, anhepatic; P<.05), and SVO2, SDO2, SVO2, and SDO2/SVO2 remained unchanged. After revascularization, none of these variables differed significantly between groups, and levels of liver enzymes, glucose, creatinine, urea, and electrolytes were similar in both groups, both before and aftertransplantation. CONCLUSIONS: Experimental OLT can be carried out in pigs without venovenous bypass, but it leads to severe hemodynamic disturbances. Clamping of the supraceliac artery during the AP is well tolerated and results in excellent hemodynamic stability, so it may prove to be a useful technique in liver transplantation in animals, such as dogs or pigs, that do not tolerate simultaneous clamping of the liver pedicle and inferior vena cava as well as human beings.     

Arterial oxygenation during one-lung ventilation: combined versus general anesthesia

The optimal anesthetic management of patients undergoing thoracotomy for pulmonary resection has not been definitely determined. We evaluated whether general i.v. anesthesia (propofol-fentanyl) provides superior PaO2 during one-lung ventilation (OLV) compared with thoracic epidural anesthesia (TEA) with supplemental local and general anesthetics. We studied 60 patients who had prolonged periods of OLV for elective thoracic surgery for lung cancer and who were prospectively randomized into two groups. In 30 patients (GA group), fentanyl/propofol/rocuronium anesthesia was used. Another 30 patients (TEA group) were anesthetized with propofol/rocuronium/epidural thoracic bupivacaine 0.5%. A double-lumen endotracheal tube was inserted, and mechanical ventilation with 100% oxygen was used during the entire study. Arterial and venous blood gases were recorded before surgery in a lateral position with two-lung ventilation, 15 and 30 min after OLV (OLV + 15 and OLV + 30, respectively) in all patients. We measured PaO2, venous central oxygen tension, arterial and central venous oxygen saturation, venous admixture percentage (Qs/Qt%), and arterial and central venous oxygen content. The mean values for PaO2 during OLV in the GA group after 15 min (175 mm Hg) and 30 min (182 mm Hg) were significantly (P < 0.05) higher compared with the TEA group (120 and 118 mm Hg, respectively). Furthermore, Qs/Qt% was significantly (P < 0.05) increased in the TEA group during OLV. There were no other significant differences. We conclude that using the TEA regimen is associated with a lower PaO2 and a larger intrapulmonary shunt during OLV than with total i.v. anesthesia alone. IMPLICATIONS: Sixty patients undergoing elective lung surgery during a prolonged period of intraoperative one-lung ventilation were studied and randomized to receive general i.v. anesthesia or general i.v. anesthesia combined with thoracic epidural anesthesia. The arterial oxygenation in the first group was better than that in the second group during one-lung ventilation.     

Small hypervascular hepatocellular carcinoma revealed by double arterial phase CT performed with single breath-hold scanning and automatic bolus tracking

OBJECTIVE: The purpose of this study was to evaluate the usefulness of double arterial phase CT for the detection of small hypervascular hepatocellular carcinomas, using an automated bolus-tracking technique to initiate the hepatic arterial phase CT. MATERIALS AND METHODS: Double arterial and late phase contrast-enhanced helical CT scans were obtained on 287 consecutive patients suspected of having hepatocellular carcinoma. These included 56 patients with 90 small (< or 3 cm) hepatocellular carcinomas and 50 patients with no hepatocellular carcinomas. CT scans of these patients were interpreted by three reviewers. The first arterial phase scan was initiated automatically 10 sec after the bolus-tracking program detected the threshold enhancement of 50 H in the abdominal aorta. Three reviewers interpreted the late phase CT scans in combination with the first, second, or both hepatic arterial phases. Measures of the reviewers' detection of hepatocellular carcinoma included analysis of interobserver variation, sensitivity, specificity, and area under receiver operating characteristic curve (A(z)). RESULTS: The time elapsed from bolus initiation to threshold aortic enhancement ranged from 10 to 24 sec (mean, 13 sec), resulting in initiation of the first arterial phase CT scan from 20 to 34 sec (mean, 23 sec). The combination of late phase CT and both first and second arterial phase images showed significantly better performance than the combination of the late phase and either the first or second arterial phases, although the difference was most evident in comparison with the combination of second arterial and late phases. CONCLUSION: An automated bolus-tracking program can be used to optimize the timing of hepatic arterial phase CT. Multiphasic CT performed using this technique is useful in detection of small hepatocellular carcinoma.     

Bearing exchange in the management of pseudotumours

Introduction

Soft tissue reactions following metal-on-metal (MoM) arthroplasty of the hip have been under considerable discussion. These reactions are seen following both hip resurfacing and MoM total hip arthroplasty (THA). The phenomenon may arise owing to shedding of metal particles in high wear states, hypersensitivity with normal metal wear rates or a combination of the two.

Methods

Three patients were identified who had developed a soft tissue reaction (pseudotumour) following MoM hip resurfacing procedures. The prostheses were revised to ceramic-on-ceramic (CoC) THA with only minimal debridement of the pseudotumour. Pre and postoperative magnetic resonance imaging was performed to assess the size of the lesions.

Results

Progressive and satisfactory resolution of the associated pseudotumours was identified following revision of the prostheses to CoC THA.

Conclusions

In the early stages of pseudotumour formation following MoM hip resurfacing, this potentially devastating condition can be managed adequately with revision to a CoC bearing THA with minimal soft tissue excision.     

EAU Guidelines on Assessment and Nonsurgical Management of Urinary Incontinence

Context

The previous European Association of Urology (EAU) guidelines on urinary incontinence comprised a summary of sections of the 2009 International Consultation on Incontinence. A decision was made in 2010 to rewrite these guidelines based on an independent systematic review carried out by the EAU guidelines panel, using a sustainable methodology.

Objective

We present a short version of the full guidelines on assessment, diagnosis, and nonsurgical treatment of urinary incontinence, with the aim of increasing their dissemination.

Evidence acquisition

Evidence appraisal included a pragmatic review of existing systematic reviews and independent new literature searches, based on Population, Intervention, Comparator, Outcome questions. Appraisal of papers was carried out by an international panel of experts, who also collaborated on a series of consensus discussions, to develop concise structured evidence summaries and action-based recommendations using a modified Oxford system.

Evidence summary

The full version of the guidelines is available online (http://www.uroweb.org/guidelines/online-guidelines/). The guidelines include algorithms that refer the reader back to the supporting evidence, and they are more immediately useable in daily clinical practice.

Conclusions

These new guidelines present an up-to-date summary of the available evidence, together with clear clinical algorithms and action-based recommendations based on the best available evidence. Where such evidence does not exist, they present a consensus of expert opinion.     

Angiotensin II stimulates alpha3(IV) collagen production in mouse podocytes via TGF-beta and VEGF signalling: implications for diabetic glomerulopathy.

BACKGROUND: The podocyte is bathed in an angiotensin II (AngII)-rich ultrafiltrate, but the impact of AngII on podocyte pathobiology is not well known. Because podocytes play a direct role in the glomerular basement membrane (GBM) thickening of diabetes, the alpha3(IV) collagen chain was examined. Podocyte expression of alpha3(IV) collagen may involve the transforming growth factor-beta (TGF-beta) and vascular endothelial growth factor (VEGF) systems. METHODS: Cultured mouse podocytes were treated with various doses of AngII for selected periods of time, with or without inhibitors of TGF-beta and VEGF signalling, SB-431542 and SU5416, respectively. TGF-beta1 and VEGF were assayed by enzyme-linked immunosorbent assay (ELISA); alpha3(IV) collagen, TGF-beta type II receptor and phospho-Smad2 were assayed by immunoblotting. RESULTS: AngII >or=10(-10) M was found to stimulate the production of alpha3(IV) collagen significantly in as short a time as 3 h. The expression of alpha3(IV) collagen was influenced by the TGF-beta system, but AngII did not increase the podocyte's production of TGF-beta1 ligand; rather, it increased the expression of the TGF-beta type II receptor and activated the TGF-beta signalling system through Smad2. Despite the TGF-beta receptor upregulation, synergy between AngII and TGF-beta1 to boost alpha3(IV) collagen production was not observed. However, blockade of TGF-beta signalling with SB-431542 prevented AngII from stimulating alpha3(IV) collagen production. Podocyte expression of alpha3(IV) collagen was also increased by the autocrine activity of VEGF. Podocytes were stimulated to secrete VEGF by 10(-10) M or higher AngII after 48 h. Blockade of the endogenous VEGF activity by SU5416 prevented AngII-stimulated alpha3(IV) collagen production. CONCLUSIONS: AngII stimulates the podocyte to produce alpha3(IV) collagen protein via mechanisms involving TGF-beta and VEGF signalling. Alterations in alpha3(IV) collagen production may contribute to GBM thickening and perhaps proteinuria in diabetes.     

Percutaneous dilatational tracheostomy (PDT) in trauma patients: a safe procedure

Purpose

Percutaneous dilatational tracheostomy (PDT) is a standard procedure routinely performed on intensive care units. While complication rates and long-term outcomes have been studied in different patient populations, there are few studies known to these authors involving PDT in trauma patients and the complications which may result.

Methods

Between March 2007 and August 2013, all instances and peri-procedural complications during PDT occurring on the trauma intensive care unit, a unit specialized in the care of injured patients and especially polytrauma patients, were documented. PDTs were performed by a surgeon with the assistance and supervision of another, using bronchoscopic guidance performed by the respiratory medicine department.

Results

289 patients were included in the study, 225 men and 64 women with a mean age of 49 ± 21 years. Complications occurred in 37.4 % of cases. The most common complication, bleeding, occurred in 26.3 % of patients ranging from little to severe bleeding. Fracture of tracheal cartilage occurred in 6 % of PDT cases. Additional complications such as dislocation of the guidewire, hypotension, and oxygen desaturation were observed. Most complications did not require treatment. The second tracheal intercartilaginous space was successfully intubated in 82 % of cases.

Conclusions

PDT is a safe procedure in trauma patients. When considering the severity of complications such as major blood loss, pneumothorax, or death, this evidence suggests that PDT is safer in trauma patients compared to other patient cohorts.

     

Quercetin ameliorates polychlorinated biphenyls‐induced testicular DNA damage in rats

Polychlorinated biphenyls (PCBs) are a group of environmental contaminants widely reported to cause gonadal toxicity in both humans and animals. This study investigated the amelioratory role of quercetin in PCBs‐induced DNA damage in male Wistar rats. Polychlorinated biphenyls were administered intraperitoneally at a dose of 2 mg kg^?1 alone or in combination with quercetin (orally) at 50 mg kg^?1 for 25 days. Quercetin modulation of PCBs‐induced gonadal toxicity was evaluated using selected oxidative stress indices, comet assay, measurement of DNA concentration and histology of the testes. Administration of PCBs alone caused a significant (P < 0.05) depletion in the total thiol level in testes of treated rats. Conversely, the levels of reactive oxygen species (ROS) and thiobarbituric acid reactive substances (TBARS) production were markedly elevated in testes of PCBs‐treated rats compared with control. Further, PCBs exposure produced statistically significant increases in DNA tail migration, degraded double‐stranded DNA (dsDNA) concentration and histological alterations of testes of the treated rats compared to control. Quercetin cotreatment significantly improved the testicular antioxidant status, decreased DNA fragmentation and restored the testicular histology, thus demonstrating the protective effect of quercetin in PCBs‐treated rats.