Interval appendectomy after perforated appendicitis: what are the operative risks and luminal patency rates?

BackgroundThe need for interval appendectomy after nonoperative management of a perforated appendicitis is being questioned owing to recent studies that estimated recurrence rates as low as 5% because of obliteration of the appendiceal lumen. We review our experience with interval appendectomy in this subset of patients to determine the postoperative outcomes and luminal patency rates.MethodsA retrospective review was conducted of all children treated nonoperatively for a perforated appendicitis followed by elective interval appendectomy during the past 10 years. The data collected included initial hospitalization, convalescence period, perioperative course, and luminal patency rates.ResultsA total of 128 patients were identified, of whom 55% were male. Their mean ± SD age was 9.1 ± 4.2 years. The mean interval from the initial presentation to appendectomy was 65.9 ± 20.3 d. All but 2 of the patients underwent laparoscopic appendectomy with 3 conversions to open surgery. The mean operative time was 43.6 ± 19.2 min. The complication rate was 9%, including 1 postoperative abscess, 1 reoperation for bleeding, and 1 readmission for Clostridium difficile infection. Six patients had a superficial wound infection, and 2 patients underwent outpatient procedures for suture granuloma. No risk factors for complications were identified. Of the specimens, 16% had obliterated lumens.ConclusionsMajor postoperative morbidity for interval appendectomy after a perforated appendicitis is low and should not be a deterrent in offering interval appendectomy to this subset of patients.     

Functional quality of life following open valve surgery in high-risk octogenarians

Abstract Aim: The aim of this study was to determine the midterm functional quality of life in octogenarians after open valvular surgery. Methods: One hundred and eighty‐five consecutive patients above age 80 had valvular surgery with or without coronary artery bypass grafting (CABG). Using the Karnofsky Performance score and Barthel Index, patients were evaluated for functional autonomy, living disposition, and leisure activity by a single telephone interview. Subgroup analysis was performed on the 49 cases of isolated aortic valve replacement (AVR). Results: Mean age of octogenarians undergoing valvular surgery was 82.7 years (range 80 to 92 years). Actuarial survival at one and three years was 71% and 59%, respectively, for the entire group, compared to 84% and 71%, respectively, for isolated AVRs. After a mean follow‐up of 38 months there were 110 survivors (59.5%). Among survivors, 66% were autonomous, 26% semiautonomous, and 8% deemed dependent. Seventy‐two percent were living at home, 19% in a residence, and 9% in a supervised nursing facility. Over 90% of patients pursued leisure activities in the social, cognitive, and physical domains. Conclusions: Valvular surgery in high‐risk octogenarians, can be performed with acceptable mortality rates, and provide patients with functional autonomy and an excellent quality of life. (J Card Surg 2012;27:408‐414)     

Oral steroid regimens for idiopathic sudden sensorineural hearing loss.

OBJECTIVE: To determine hearing recovery in patients with idiopathic sudden hearing loss treated with varying amounts of oral steroids. STUDY DESIGN AND SETTING: A retrospective chart review (n = 75) in a tertiary care clinic examined sudden hearing loss patients treated with 1 60-mg prednisone taper, 1 course of steroid less than a 60-mg taper, or any 2 courses of oral steroid. RESULTS: Overall, 35% of the patients recovered a clinically significant amount of hearing. Recovery was associated with immediate treatment (within 2 weeks from onset), better hearing at the onset of treatment, and treatment with the higher dose of prednisone in patients with just 1 additional symptom (dizziness or tinnitus). Patients tended to continue to experience some recovery in hearing up to 4 months after treatment. CONCLUSION: Immediate treatment of patients with unilateral idiopathic sudden hearing loss and additional symptoms (dizziness or tinnitus) with a 14-day course of 60 mg prednisone (with taper) is recommended. EBM rating: B-3.     

Non‐HLA‐matched 3rd party vascular allograft in renal transplant may lead to sensitization against donor HLA

3rd party donor vessels are often used for vascular reconstruction in organ transplantation. While current practice ensures that 3rd party vessels are blood group matched, HLA matching to the non‐intended recipient is not performed. This practice potentially sensitizes the recipient and may reduce their future chance of renal transplant from a larger pool of donors. We examined our cohort of renal transplant recipients who received non‐HLA‐matched 3rd party vessels for the de‐novo development of donor‐specific HLA antibodies. Our institution's Human Tissue Authority (HTA) blood vessel registers were examined to identify stored donor vessels and their non‐intended recipients. Donor vessel HLA status was cross‐referenced with the recipient HLA status. Between 2004 and 2014, five patients were identified that received 3rd party non‐HLA‐matched vessels for vascular reconstruction during renal transplantation. Three patients (60%) subsequently developed donor‐specific HLA antibodies. These data provide evidence that use of non‐HLA‐matched stored 3rd party vascular grafts may lead to sensitization in the recipient. Where time permits, HLA matching should be performed to avoid this allogeneic response. Laboratories monitoring DSA should be aware of any patient receiving a non‐HLA‐matched 3rd party vascular graft, and recipients may benefit from increased post‐transplant immunological vigilance.     

Hypotension does not increase mortality in brain-injured patients more than it does in non-brain-injured Patients

OBJECTIVES: Hypotension increases mortality after all types of injuries. Prior studies comparing mortality of hypotensive traumatic brain injury (TBI) patients to normotensive TBI patients have implied that hypotension is particularly detrimental after TBI. It is unknown whether hypotension affects TBI patients more severely than it affects other types of patients. We hypothesized that hypotension does not increase mortality in TBI patients more than it does in non-TBI patients. METHODS: National Trauma Data Bank (1994-2002) patients aged 18 to 45 years with blunt mechanisms of injury treated at Level I and Level II centers were included. Deaths occurring before 24 hours were excluded. Logistic regression was used to measure the association between hypotension (< or =90 mm Hg) and death after adjusting for confounding variables of age, gender, comorbidities, complications, Glasgow Coma Scale score, and severity of associated injuries. Odds ratios (95% confidence interval) indicate the risk of death in hypotensive patients in each group compared with normotensive patients in the same group. RESULTS: The study population consisted of 79,478 patients (TBI, 30,742; no TBI, 48,736). Hypotension independently quadrupled the risk of death after adjusting for confounding variables (odds ratio [OR], 4.8; 95% confidence interval [CI], 4.1-5.6). However, increase in this risk associated with hypotension was the same in TBI (OR, 4.1; 95% CI, 3.5-4.9) and non-TBI patients (OR, 4.6; 95% CI, 3.4-6.0). Furthermore, the relationship between hypotension and TBI did not change with increasing head Abbreviated Injury Scale score severity. CONCLUSION: Hypotension is an independent risk factor for mortality. However, it does not increase mortality in TBI patients more than it does for non-TBI patients.     

Thyroid-stimulating hormone, thyroid hormones, and bone loss

It has become accepted by virtue of rich anecdotal experience and clinical research that thyrotoxicosis is associated with high-turnover osteoporosis. The bone loss, primarily due to accelerated resorption that is not compensated by a coupled increase in bone formation, has been attributed solely to elevated thyroid hormone levels. Evidence using mice lacking the thyroid hormone receptors α and β establishes a role for thyroid hormones in regulating bone remodeling but does not exclude an independent action of thyroid-stimulating hormone (TSH), levels of which are low in hyperthyroid states, even when thyroid hormones are normal, as after thyroxine supplementation and in subclinical hyperthyroidism. We show that TSH directly suppresses bone remodeling and that TSH receptor null mice have profound bone loss, suggesting that reduced TSH signaling contributes to hyperthyroid osteoporosis. TSH and its receptor could become valuable drug targets in treating bone loss.