Pyogenic liver abscess complicated by endogenous endophthalmitis

Background: Endogenous endophthalmitis is an inflammation of ocular tissues that can lead to deterioration of and loss of vision. Rarely, this can complicate the course of a patient with pyogenic liver abscess. Methods: Over an 18‐month period, 68 patients were treated for pyogenic liver abscesses. Three patients, all of whom were male and with diabetes, were diagnosed with a Klebsiella pneumoniae liver abscess complicated by endogenous endophthalmitis. Open surgical or percutaneous drainage of the liver abscess was undertaken and the symptomology and outcome of the endophthalmitis reviewed. Results: There was no mortality in our series. Two patients presented with simultaneous abdominal and ocular symptoms and one patient had ocular symptoms 3 days after surgical drainage of the liver abscess. Despite aggressive treatment, all patients had permanent deterioration of visual function with one patient becoming blind and requiring evisceration of the infected eye. Conclusion: Ocular symptoms in patients treated for pyogenic abscesses must be dealt with urgently with an ophthalmologic consultation. Increased awareness of this complication and a high index of suspicion are paramount for salvage of visual function.     

Ranula successfully treated by botulinum toxin type A: report of 3 cases.

The conventional treatment of ranula is surgical procedure. We report an innovative method for ranula by using botulinum toxin type A on 3 patients. All 3 cases of ranula resolved after this minimally invasive therapy. The treatment complication was minimal.     

Liver and lung resection for colorectal metastasis

Aim: To examine the survival benefit of liver and lung resection for colorectal metastasis and the potential prognostic factors that affect patient survival. Methods: All patients who had resection of lung or liver metastasis for colorectal metastasis in Queen Elizabeth Hospital, Hong Kong from 1995 to 2004 were retrospectively reviewed. The overall and disease‐free survival was analysed, in particularly between liver and lung metastasis. All factors that may have affected the survival were entered into Cox's proportional hazards regression model to identify significant variables associated with survival. Results: At 5 years, the overall survival of patients who had resection of lung and liver metastasis was 44% and 38%, respectively; the disease‐free survival was 26% and 24%, respectively. Overall and disease‐free survival of patients with resection of lung metastasis was comparable to those with resection of liver metastasis. The differentiations of primary tumour and time to metastasis were shown to be significant prognostic factors influencing overall survival. Those patients with systemic chemotherapy after resection of colorectal metastasis demonstrated a significantly higher probability of overall survival. Conclusion: Resection of lung and liver metastases from colorectal origin was safe and both procedures improved survival. The use of chemotherapy after resection of metastasis significantly improved the overall survival.     

Outcome assessment of bracing in adolescent idiopathic scoliosis by the use of the SRS-22 questionnaire

The SRS-22 questionnaire is specifically designed for the assessment of quality of life in spinal deformity patients. This study is the first to use it to assess the quality of life of adolescent idiopathic scoliosis patients under brace treatment and compares the results with an observational group matched by age and curve magnitude. Forty-six patients were enrolled into each group. Overall, it was found that patients under observation had a significantly better quality of life than braced patients. Specifically, the domains for function/activity and self-image were most affected. This effect was most apparent in those with a curve magnitude of under 20 degrees . The scores did not improve significantly with the duration of brace wear, suggesting little adaptation. This study has implications for treatment, and more attention will need to be given to those with mild but progressive curves to help improve patients' understanding of their treatment and hence their compliance and satisfaction.     

Surgical Operative Time Increases the Risk of Deep Venous Thrombosis and Pulmonary Embolism in Robotic Prostatectomy

Background and Objectives:

To evaluate the effect of operative time on the risk of symptomatic venous thromboembolic events (VTEs) in patients undergoing robot-assisted radical prostatectomy (RARP).

Methods:

We reviewed the records of all patients at our institution who underwent RARP by a single surgeon from January 2007 until April 2011. Clinical and pathologic information and VTE incidence were recorded for each patient and analyzed by use of logistic regression to evaluate for association with VTE risk. All patients had mechanical prophylaxis, and beginning in February 2008, a single dose of unfractionated heparin, 5000 U, was administered before surgery.

Results:

A total of 549 consecutive patients were identified, with a median follow-up period of 8 months. During the initial 30 days postoperatively, 10 patients (1.8%) had a VTE (deep venous thrombosis in 7 and pulmonary embolism in 3). The median operative time was 177 minutes (range, 121–360 minutes). An increase in operative time of 30 or 60 minutes was associated with 1.6 and 2.8 times increased VTE risks. A 5-point increase in body mass index and need for blood transfusion were also associated with increased risk of VTEs (odds ratios of 2.0 and 11.8, respectively). Heparin prophylaxis was not associated with a significant VTE risk reduction but also was not associated with a significant increase in estimated blood loss (P = .23) or transfusion rate (P = .37).

Conclusion:

A prolonged operative time increases the risk of symptomatic VTEs after RARP. Future studies are needed to evaluate the best VTE prophylactic approach in patients at risk.     

NLR is predictive of upstaging at the time of radical cystectomy for patients with urothelial carcinoma of the bladder

ObjectiveTo evaluate the ability of preoperative neutrophil-lymphocyte ratio (NLR) to predict pathologic upstaging and nonorgan-confined (NOC) (≥pT3) disease.Methods and materialsAfter institutional review board approval, the records of consecutive patients undergoing radical cystectomy (RC) for urothelial carcinoma from 2002 to 2012 at the University of Wisconsin Hospital were reviewed. A total of 102 patients with NLR within 100 days of surgery were eligible for analysis. The primary outcome was difference in stage from preoperative assessment to time of RC. Differences in preoperative NLR between groups were evaluated with an unequal variance t test. A univariate analysis assessed whether NLR, preoperative stage, grade, associated lymphovascular invasion, preoperative hydronephrosis, gender, previous pelvic radiotherapy, previous intravesical bladder cancer treatments, or nodal stage were related to upstaging. Multivariate analyses were performed to evaluate the relationship of NLR to upstaging and relative organ-confined (≤pT2) and NOC disease.ResultsOf 390 consecutive patients undergoing RC, 102 patients met study criteria. Overall, 55 (53.9%) patients were upstaged, 25 (25.5%) were unchanged, and 21 (20.6%) were downstaged. Fifty-one patients (50%) were upstaged to more advanced disease (≥pT3). NLR and preoperative hydronephrosis were significantly related to pathologic tumor staging. NLR, preoperative hydronephrosis, and preoperative tumor stage were significantly related to upstaging to NOC disease. Patients who were upstaged to≥pT3 demonstrated statistically significant greater NLRs (4.33±0.87) compared with patients who remained at≤pT2 stage (2.66±0.29) (P<0.001).ConclusionsPreoperative NLR is a simple measurement that can be used to identify high-risk patients who may be upstaged at the time of RC and may benefit from neoadjuvant chemotherapy.     

Transcranial Magnetic Stimulation: Use of Motor Evoked Potentials in the Evaluation of Surgically Induced Spinal Cord Ischemia

Abstract

We evaluated transcranial magnetic stimulation producing motor evoked potentials (TMS MEP) as a method to detect spinal cord ischemia during surgery for thoracoabdominal aneurysms. Four groups of swine were subjected to different types of surgically-induced ischemia. TMS MEP and neurological function were assessed at baseline, immediately after the ischemic insult and after four hours of reperfusion/post-ligation. Cross-clamping of the aorta in groups A & B resulted in the disappearance and subsequent reappearance of TMS MEP with significantly prolonged latencies in most animals and variable neurological function. Ligation of intercostal arteries produced no changes in TMS MEP or neurological function (group C). However, after ligation of intercostal and lumbar arteries, group D demonstrated no reappearance of TMS MEP and severe neurological deficits. TMS MEP can provide rapid detection of global spinal cord ischemia and can also predict local devascularization injury. (J Spinal Cord Med 1997; 20:395-401)     

Addressing Geographic Disparities in Liver Transplantation Through Redistricting

Severe geographic disparities exist in liver transplantation; for patients with comparable disease severity, 90‐day transplant rates range from 18% to 86% and death rates range from 14% to 82% across donation service areas (DSAs). Broader sharing has been proposed to resolve geographic inequity; however, we hypothesized that the efficacy of broader sharing depends on the geographic partitions used. To determine the potential impact of redistricting on geographic disparity in disease severity at transplantation, we combined existing DSAs into novel regions using mathematical redistricting optimization. Optimized maps and current maps were evaluated using the Liver Simulated Allocation Model. Primary analysis was based on 6700 deceased donors, 28 063 liver transplant candidates, and 242 727 Model of End‐Stage Liver Disease (MELD) changes in 2010. Fully regional sharing within the current regional map would paradoxically worsen geographic disparity (variance in MELD at transplantation increases from 11.2 to 13.5, p = 0.021), although it would decrease waitlist deaths (from 1368 to 1329, p = 0.002). In contrast, regional sharing within an optimized map would significantly reduce geographic disparity (to 7.0, p = 0.002) while achieving a larger decrease in waitlist deaths (to 1307, p = 0.002). Redistricting optimization, but not broader sharing alone, would reduce geographic disparity in allocation of livers for transplant across the United States.     

Hypertension and survival in hemodialysis patients

Hypertension is clearly an independent risk factor for cardiovascular (CV) events and death in the general population, but the relationship between blood pressure (BP) and survival in dialysis patients is less clear. In dialysis populations at lower risk of CV events, BP is directly related to survival, while in those with high risk, it has been difficult to show such an effect. The effects of cardiac disease complicate the relationship between BP and outcome. Retrospective studies of large cohorts, with high prevalence of CV disease, have shown a U-shaped relationship between both systolic and diastolic BP and outcome. These findings probably reflect a high prevalence of cardiac failure and thus high mortality associated with low BP (i.e., a so-called reverse causation). Pulse pressure (high systolic BP and low diastolic BP) predicts outcome in hypertensive dialysis patients. Whether this reflects advanced vessel wall disease or is an independent etiologically significant risk factor is unclear. However, the current uncertainties as to the exact relationship between BP and outcome in dialysis patients do not warrant complacency regarding the prevention and treatment of hypertension.     

CT angiography of the arterial system

CTA has become an important diagnostic tool in the evaluation of vascular diseases in virtually all parts of the body. Whereas CTA is able to provide images depicting exquisite anatomic detail, careful scanning technique and selection of scan parameters are critical for high quality studies. The choices to be made when prescribing a scan can seem daunting at first, but if one applies the principles outlined previously, CTA can be a relatively easy, fast, and safe diagnostic technique that is effective in the majority of patients with vascular disease.