Second report (1998-2006) of the International Registry of Hand and Composite Tissue Transplantation

Since May 2002 all groups performing hand transplantations have supplied detailed information to the International Registry on Hand and Composite Tissue Transplantation. This report provides a review of all hand transplants performed to date. From September 1998 to February 2006 eighteen male patients underwent 24 hand/forearm/digit transplantations (eleven unilateral and four bilateral hand transplantations, two bilateral forearm transplantations, one thumb transplantation). The level of amputation was mostly at the distal forearm or wrist. Patient average age was 32. Time since hand loss ranged from 2 months to 22 years. Immunosuppressive therapy included tacrolimus, mycophenolate mofetil, rapamycin and steroids; polyclonal or monoclonal antibodies were used for induction. Topical immunosuppression was administered in some patients. Follow-up period ranged from 34 to 85 months. Patient survival was 100%. Graft survival was 100% at 1 and 2 years. Two cases of graft failure at a later date occurred and were caused by severe inflammation and progressive rejection in a non-compliant patient. In addition, 6 hands were lost due to a rejection process as the Chinese recipients did not take their immunosuppressive treatment. These failures were communicated in January 2006. Acute rejection episodes occurred in 12 patients within the first year. Rejection was completely reversible in all compliant patients. Side-effects included opportunistic infections and metabolic complications. No life-threatening complications or malignancies were reported. As it would have been very difficult to analyse transplantation functional results in a standardized way, the Registry has performed a functional score system. All patients had achieved protective sensation and in 17 of them also discriminative sensation. Extrinsic and intrinsic muscle recovery enabled patients to perform most daily activities and 90% of the recipients returned to work, and improved manual skills allowed them not only to resume their previous jobs but also, in some cases, to find more suitable employment. Fifteen recipients reported an improvement of their quality of life and we evaluated as a very important point as patient satisfaction and well-being are mandatory goals of hand transplantation.     

Prevalence of lower urinary tract symptoms among female elementary school teachers in Taipei

The aim of this study was to estimate the prevalence of lower urinary tract symptoms (LUTS) among female elementary school teachers in Taipei. A total of 520 self-administered surveys were distributed to 26 elementary schools in Taipei City. Data analyses were based on 445 usable surveys. The prevalence rates for different types of LUTS ranged from 9.9 to 44.5%. The prevalence of urinary incontinence (UI; 26.7%) and nocturia (16.0%) fell within the prevalence estimates of these LUTS in North American and European women. Employed women in this study were more likely to experience LUTS than women in previous epidemiological or community studies. This study extended research on UI into other LUTS among employed women in Asia. Study results suggest that the working environment may affect LUTS in female elementary school teachers. This preliminary study is important for developing future behavioral interventions for female LUTS in the workplace.     

Prognosis and Results After Resection of Very Large (≥10 cm) Hepatocellular Carcinoma

Introduction Few potentially curative treatment options exist besides resection for patients with very large (≥10 cm) hepatocellular carcinoma (HCC). We sought to examine the outcomes and risk factors for recurrence after resection of ≥10 cm HCC. Methods Perioperative and long-term outcomes were examined for 189 consecutive patients from 1993 to 2004 who underwent potentially curative resection of HCC ≥10 cm (n = 24; 13%) vs. those with HCC <10 cm (n = 165; 87%). Disease-free survival (DFS) and overall survival (OS) were determined by Kaplan–Meier analysis and patient, tumor, and treatment characteristics were compared using univariate and multivariate analysis. Results Median follow-up was 34 months. Tumors ≥10 cm were more likely to be symptomatic, of poorer grade, and have vascular invasion (p < 0.05). Twelve patients (50%) underwent an extended resection of more than four hepatic segments or resection of adjacent organs for oncologic clearance (diaphragm-2, inferior vena cava (IVC)-2, median sternotomy-1). Postoperative complications were more common after resection of >10 cm HCC (12/24, 50% vs. 35/165, 21%; p = 0.04). Median DFS was significantly shorter in patients with large HCC (≥10 cm) group compared to patients with smaller HCC (8.4 vs. 38 months; p = 0.001), but overall survival was not different between the two groups (5-year survival 54% vs. 53%; p = 0.43). Seventeen patients (71%) with very large HCC developed recurrences (12 intrahepatic, five systemic); eight of these patients (47%) underwent additional therapy (resection-4, TACE-3, RFA-1). Pathological positive margins and vascular invasion were significant determinants of DFS in tumors ≥10 cm (p < 0.05), but only vascular invasion was an independent risk factor for recurrence after multivariate analysis (HR 0.17; 95% CI: 0.04–0.8). Median OS after recurrence was 24 months. Conclusion Surgical resection is the optimal therapy for very large (≥10 cm) HCC. Although recurrences are common after resection of these tumors, overall survival was not significantly different from patients after resection of smaller HCC in this series. Presented at the 2006 American Hepato-Pancreatico-Biliary Congress, Miami, FL, March 9–12, 2006.     

Autotransfusion management during and after cardiopulmonary bypass alters fibrin degradation and transfusion requirements

The coagulation-fibrinolytic profile during cardiopulmonary bypass (CPB) has been widely documented. However, less information is available on the possible persistence of these alterations when autotransfusion is used in management of perioperative blood loss. This study was designed to explore the influence of autotransfusion management on intravascular fibrin degradation and postoperative transfusions. Thirty patients, undergoing elective primary isolated coronary bypass grafting, were randomly allocated either to a control group (group A; n=15) or an intervention group (group B; n=15) in which mediastinal and residual CPB blood was collected and processed by a continuous autotransfusion system before re-infusion. Intravascular fibrin degradation as indicated by D-dimer generation was measured at five specific intervals and corrected for hemodilution. In addition, chest tube drainage and need for homologous blood were monitored. D-dimer generation increased significantly during CPB in group A, from 312 to 633 vs. 291 to 356 ng/mL in group B (p = .001). The unprocessed residual blood (group A) revealed an unequivocal D-dimer elevation, 4131 +/- 1063 vs. 279 +/- 103 ng/mL for the processed residual in group B (p < .001). Consequently, in the first post-CPB period, the intravascular fibrin degradation was significantly elevated in group A compared with group B (p = .001). Twenty hours postoperatively, no significant difference in D-dimer levels was detected between both groups. However, a significant intra-group D-dimer elevation pre- vs. postoperative was noticed from 312 to 828 ng/mL in group A and from 291 to 588 ng/mL in group B (p < .01 for both). Postoperative chest tube drainage was higher in the patients from group A, which also had the highest postoperative D-dimer levels. Patients in group A perceived a higher need for transfusions of red cells suspensions postoperatively. These data clearly indicate that autotransfusion management during and after CPB suppresses early postoperative fibrin degradation. Keywords: cardiopulmonary bypass, cardiotomy suction, coronary surgery, autotransfusion, fibrin degradation.     

The characteristics of Hep-2 cell with multiple drug resistance induced by Taxol.

OBJECTIVE: To investigate the characteristics of Hep-2 cell with multidrug resistance (MDR) induced by Taxol. STUDY DESIGN: Hep-2 cells were exposed in stepwise escalating concentration of Taxol to develop the resistant cell line-Hep-2T. Cell cycle distribution, apoptosis, and rhodamine accumulation were studied through flow cytometry. The MDR1 and MRP1 genes were detected through real-time quantitative RT-PCR, and the corresponding proteins were detected through Western blotting. RESULTS: The drug resistance of Hep-2T cells to Taxol, doxorubicin, gemcitabine, 5-FU, and cisplatin all increased. The percentage of G0/G1 phase and the antiapoptosis ability increased significantly compared with Hep-2 cells. Both MDR1 and MRP1 also increased at gene and protein level, though MDR1 was more prominent. CONCLUSION: More emphasis should be laid on MDR1/Pgp, the non-Pgp substrate chemotherapeutic agents, and the changes of cell cycle distribution to prevent MDR induced by Taxol. SIGNIFICANCE: These findings may provide theoretical support for the reverse of MDR.     

Mutant mice provide new insight into the role of (mis-)glycation in IgA nephropathy and other glomerular diseases.

In the 24 October 2006 issue of PNAS, Alexander and colleagues[1] describe the results of a systematic search for thrombocytopenicmice generated by large-scale mutagenesis. Amongst 3523 mice,one pedigree indeed exhibited 50% reduction in platelet counts.Apart from thrombocytopenia, the only other notable featureof these mice was prominent renal disease (albuminuria/proteinuria,glomerulosclerosis and tubulointerstitial inflammatory infiltration)leading to uraemia and death at around 200 days after birth.This renal disease was not immune mediated, since it persistedin mutant mice crossed to     

Laparoscopic versus open appendicectomy in children: A UK District General Hospital experience

Aims

The aim of this study was to evaluate the potential role of laparoscopic appendicectomy in reducing morbidity and length of stay in children compared to open procedures in a UK District General Hospital setting.

Methods

A three-year retrospective review of children ≤ 15 years with histologically confirmed appendicitis who underwent laparoscopic (LA) and/or open (OA) appendicectomy was performed. Choice of operation was based on individual surgeon’s preference and on patient’s body size. Data collected included rate of histologically complicated appendicitis, post-operative length of stay (LOS), and collective and differential morbidity rates, i.e., wound infection, intra-abdominal collection, and ileus. Chi-square and Mann–Whitney tests were used for statistical analysis. P < 0.05 was regarded as significant.

Results

Eighty children (70% male) were identified at median age 11 (3–15) years. They could be divided into complicated (n = 18, 22%) and simple appendicitis (n = 62, 78%). Appendicectomy was performed in all as an OPEN (n = 53, 66%) or LAPAROSCOPIC (n = 27, 34%) procedure. Both groups were comparable in gender distribution (P = 0.11) and rate of complicated appendicitis (30% vs. 19%, respectively; P = 0.27). Median age was significantly lower in the OPEN group [10 (3–15) vs. 12 (7–15) years; P < 0.004]. Laparoscopic appendicectomy had a significantly lower rate of collective morbidity (3.8% vs. 25.9%; P < 0.003), including lower rate of intra-abdominal collection (1.9% vs. 14.8%; P < 0.01). Median LOS was not significantly different (1 day vs. 2 days; P = 0.14).

Conclusion

Laparoscopic appendicectomy in children in a UK District General Hospital is safe and was associated with significantly less post-operative morbidity than the open technique.     

Inpatient survival after gastrectomy for gastric cancer in the 21st century

Background

Surgical treatment for gastric cancer has evolved substantially. To understand how changes in patient- and hospital-level factors are associated with outcomes over the last decade, we examined a nationally representative sample.

Methods

Retrospective cross-sectional discharge data from the 2001–2010 Nationwide Inpatient Sample were analyzed using cross tabulation and multivariable regression modeling. Patients with a primary diagnosis of gastric cancer undergoing gastrectomy as primary procedure were included. We examined relationships between patient- and hospital-level factors, surgery type, and outcomes including in-hospital mortality and length of stay (LOS).

Results

A total of 67,327 patients with gastric cancer undergoing gastrectomy nationwide with complete information were included. Compared with patients treated in 2001, patients in 2010 were younger, more likely admitted electively, treated in a teaching hospital, or at an urban center. There was no difference in the type of procedure performed over time. Factors associated with an increased risk of in-hospital mortality included older age, male gender, and nonelective admission (P < 0.05). In multivariable analysis, patients undergoing gastrectomy in 2010 demonstrated 40% lower odds of in-hospital mortality (odds ratio, 0.60; P = 0.008). Overall mean LOS was 13.9 d (standard error, 0.1) without change over time. Factors associated with longer LOS included procedure type, hospital location, nonelective admission, and comorbid disease (all P < 0.05).

Conclusions

The adjusted odds of in-hospital mortality among surgically treated patients with gastric cancer decreased >40% between 2001 and 2010. Further research is warranted to determine if these findings are due to better patient selection, regionalization of care, or improvement of in-hospital quality of care.     

Delayed Complications after Anterior Craniofacial Resection of Malignant Skull Base Tumors

Objective To report complications occurring at least 6 months after completion of treatment for patients with anterior skull base malignancy undergoing anterior craniofacial resection (CFR). Design Retrospective review of medical records of all patients undergoing traditional CFR for treatment of anterior skull base malignancy from 2002 through 2011. Setting Massachusetts General Hospital/Massachusetts Eye and Ear Infirmary Cranial Base Center. Participants Thirty-one consecutive patients who had at least 18 months of follow-up for analysis were reviewed. All patients underwent traditional CFR. A total of 28 patients received postoperative proton beam radiation therapy. Eleven patients received adjuvant chemotherapy. Main Outcome Measures A delayed complication was any complication occurring at least 6 months after the completion of treatment. Results Seventeen patients had delayed complications. Orbital complications were the most common type (13 patients) followed by issues with wound healing (6 patients). The most common orbital complication was epiphora (7 patients). The most common wound complication was a nasocutaneous fistula (5 patients). Conclusions Patients with anterior skull malignancy can develop complications months to years after the completion of treatment. Therefore, it is important to continue to follow and report complications for several years when deciding on the optimal approach for treatment of these patients.     

Percutaneous reduction and flexible intramedullary nailing for monteggia fracture in a skeletally mature patient

INTRODUCTION

Monteggia lesions are defined as a fracture of the proximal ulna with an associated radial head dislocation. Management of these injuries varies depending upon the patient population, ranging from non-operative treatment with closed reduction and immobilization to surgical fixation. Percutaneous techniques of radial head reduction are often reserved for skeletally immature patients.

PRESENTATION OF CASE

In this case report, a 14-year-old female presented with left elbow pain three days after a fall. Radiographs and CT images from an outside hospital revealed a displaced left radial head fracture and a non-displaced proximal olecranon fracture, consistent with a Monteggia equivalent fracture. The patient underwent percutaneous reduction and internal fixation of the radial head with a flexible intramedullary nail (Metaizeau technique), and open reduction and internal fixation of the olecranon. She developed a 25 degree left elbow flexion contracture and, five months after her index procedure, underwent arthroscopic release and removal of hardware. The radial head reduction was near anatomic and she regained full extension.

DISCUSSION

This report demonstrates that percutaneous reduction with intramedullary nailing and fixation techniques can be performed successfully in skeletally mature patients.

CONCLUSION

Given their less invasive nature, we recommend attempting percutaneous interventions in some skeletally mature individuals for fracture reduction and fixation.