Histologic Findings One Year After Positive Crossmatch or ABO Blood Group Incompatible Living Donor Kidney Transplantation

Recent protocols have allowed successful positive crossmatch (+XM) and ABO incompatible (ABOI) kidney transplantation, although their long-term outcome is not clear. To begin to assess this issue we compared protocol biopsies performed 12 months posttransplant in 37 +XM, 24 ABOI and 198 conventional allografts. Although the majority in all three groups had only minimal histologic changes, transplant glomerulopathy (TG) was significantly increased in +XM (22% vs. 13% ABOI vs. 8% conventional, p = 0.015), and correlated with prior humoral rejection (HR) by multivariate analysis (odds ratio 17.5, p < or = 0.0001). Patients with a prior history of HR also had a significant increase in interstitial fibrosis (No HR 54% vs. HR 86%, p = 0.045). In the absence of HR no difference in histologic changes was seen between groups, although all three groups had a demonstrable mild increase in interstitial fibrosis from biopsies performed at the time of transplant. Thus, although HR is associated with an increase in TG, in its absence allograft histology is similar in +XM, ABOI and conventional allografts 1 year posttransplant.     

Interval laparoscopic appendectomy in children

BACKGROUND: Conservative management of advanced complicated appendicitis in children is becoming more common. Formation of an appendiceal mass or abscess may mitigate against urgent appendectomy during the acute stage, and conservative treatment followed by interval appendectomy has been advocated. We present our experience of interval laparoscopic appendectomy in our institution. MATERIALS AND METHODS: All children who were offered interval laparoscopic appendectomy between January 2000 and December 2004 were included. Retrospective case note analysis was performed and data collected included demographics, duration of symptoms, method of diagnosis, days of antibiotics, length of interval, operative time, length of hospital stay (conservative treatment and interval laparoscopic appendectomy), analgesia requirements, complications, and histology. RESULTS: Thirty-six children, median age 8 years (range, 1-15 years) diagnosed with appendiceal mass or abscess were offered interval laparoscopic appendectomy by two surgeons in our institution: one patient declined interval laparoscopic appendectomy. Median antibiotic treatment was 10 days (range, 3-23 days). Median length of stay for conservative treatment was 6 days (range, 1-27 days). Five children required percutaneous drainage. For the 35 children who had interval laparoscopic appendectomy, the median interval was 93 days (range, 34-156 days) and median operative time was 55 minutes (range, 25-120 minutes). Median length of stay for interval laparoscopic appendectomy was 1 day (range, 1-3 days). There were no complications following interval laparoscopic appendectomy. CONCLUSION: Interval laparoscopic appendectomy can be safely performed in children, is associated with a short hospital stay and minimal morbidity, analgesia, and scarring following conservative management of appendiceal mass or abscess. Interval laparoscopic appendectomy eliminates the risk of recurrent appendicitis and serves to excise undiagnosed carcinoid tumors. In future it may be possible to perform interval laparoscopic appendectomy as a day-case procedure in selected patients.     

Streptococcus milleri infections of the pleural space: operative management predominates

BACKGROUND: Management of patients with thoracic empyema ranges from tube thoracostomy drainage, with or without fibrinolytics, to operative intervention, with the optimal intervention remaining uncertain. Streptococcus milleri, typically a benign bacterium colonizing the oropharynx, has recently been reported as a potential pathogen in pneumonia and pleural space disease. Our initial experience indicated this infection, when in the pleural space, was particularly tenacious and often required major operative intervention to eradicate. Therefore, we hypothesized that patients with S milleri pleural space infections often require operative intervention as definitive treatment. METHODS: We reviewed all patients from June 17, 1999 to April 15, 2005 with S milleri infections at our level I academic trauma/acute care surgery department at a safety-net hospital. S milleri infections were diagnosed by thoracentesis, bronchoalveolar lavage, tube thoracostomy fluid, or intraoperative culture. RESULTS: Over the 70-month period evaluated, of 697 patients with S milleri infections, 39 patients had S milleri infections of the pleural space; 26 (67%) patients underwent operative intervention. The majority (72%) were men with a mean age of 46 (range 22 to 63); the underlying etiology in those patients requiring operation was pneumonia (26 patients; 67%), trauma (9 patients; 23%), postoperative infection (2 patients), foreign body ingestion (1 patient), and malignancy (1 patient). The vast majority of patients in the operative group were treated preoperatively with tube thoracostomy (88%) and antibiotics (96%). The average duration of chest tube drainage prior to operation was 4.4 days (95% confidence interval [CI] 2.6 to 6.2) and antibiotic treatment was 6.0 days (95% CI 3.8 to 8.2). Thirteen patients (50%) underwent video-assisted thoracoscopic surgery (VATS) and 13 patients required thoracotomy. VATS was performed more often when operative intervention occurred early (average hospital day 6.2) compared to initial thoracotomy or conversion from VATS to thoracotomy (average hospital day 9.8). Hospital length of stay was less in the operative group (average 24 days; 95% CI 17 to 31) than in the nonoperative group (34 days; 95% CI 19 to 49), discharge to home was greater in the operative group (77% vs. 16%), and mortality was less in operative group (0% vs. 23%). CONCLUSIONS: Despite attempts at nonoperative management, the majority of patients with a S milleri pleural space infection require operative intervention for definitive therapy. Patients diagnosed with S milleri empyema should be considered for early operative intervention due to the unrelenting nature of their infection. Operative treatment is associated with a shorter hospital length of stay, increased discharge to home, and decreased mortality.     

Symptomatic Right-Sided Diaphragmatic Hernia in the Third Trimester of Pregnancy

Background:

Laparoscopic repair of incarcerated diaphragmatic hernias is widely recognized as both safe and effective. However, symptomatic diaphragmatic hernias encountered in the setting of pregnancy, while rare, present a significant surgical challenge. Furthermore, right-sided diaphragmatic hernias account for only 13% of cases. Here, we present a case in which a symptomatic, posterior right-sided diaphragmatic hernia, presenting in the later stages of pregnancy, was successfully repaired using a laparoscopic approach.

Methods:

Our patient is a 42-y-old gravid woman who, at 27 wk gestation, was admitted to the gynecology service with a 2-d history of right upper quadrant abdominal pain, right shoulder pain, abdominal distension, and obstipation.

Results:

Computed tomography of the chest demonstrated an incarcerated right diaphragmatic hernia. Surgical consultation was obtained, and the patient was taken to the operating room urgently for repair. Intraoperatively, the cecum was reduced and the diaphragm repaired primarily using a laparoscopic approach. The patient recovered well and was discharged home on postoperative day 8 with no complications to the patient or the pregnancy.

Conclusion:

Laparoscopic reduction and repair of symptomatic incarcerated diaphragmatic hernia can be safely performed in the third trimester of pregnancy.     

Hypercoagulability following blunt solid abdominal organ injury: when to initiate anticoagulation

Background

The optimal time to initiate venous thromboembolism pharmacoprophylaxis after blunt abdominal solid organ injury is unknown.

Methods

Postinjury coagulation status was characterized using thromboelastography (TEG) in trauma patients with blunt abdominal solid organ injuries; TEG was divided into 12-hour intervals up to 72 hours.

Results

Forty-two of 304 patients (13.8%) identified underwent multiple postinjury thromboelastographic studies. Age (P = .45), gender (P = .45), and solid organ injury grade (P = .71) were similar between TEG and non-TEG patients. TEG patients had higher Injury Severity Scores compared with non-TEG patients (33.2 vs 18.3, respectively, P < .01). Among the TEG patients, the shear elastic modulus strength and maximum amplitude values began in the normal range within the first 12-hour interval after injury, increased linearly, and crossed into the hypercoagulable range at 48 hours (15.1 ± 1.9 Kd/cs and 57.6 ± 1.6 mm, respectively; P < .01, analysis of variance).

Conclusions

Patients sustaining blunt abdominal solid organ injuries transition to a hypercoagulable state approximately 48 hours after injury. In the absence of contraindications, pharmacoprophylaxis should be considered before this time for effective venous thromboembolism prevention.     

The role of head and neck cancer advocacy organizations during the COVID‐19 pandemic

The COVID‐19 pandemic has had a significant impact on many aspects of head and neck cancer (HNC) care. The uncertainty and stress resulting from these changes has led many patients and caregivers to turn to HNC advocacy groups for guidance and support. Here we outline some of the issues being faced by patients with HNC during the current crisis and provide examples of programs being developed by advocacy groups to address them. We also highlight the increased utilization of these organizations that has been observed as well as some of the challenges being faced by these not‐for‐profit groups as they work to serve the head and neck community.     

Uterine activity during sleep

REM-related increases in uterine activity were found in 10 healthy young adult volunteer subjects. Contraction baseline pressures were elevated compared with NREM sleep, stage 2 sleep, stages 3 and 4 slow wave sleep (SWS), and stage 0. Contraction amplitudes during REM sleep were greater than those during SWS and stage 0, while contraction rates differed only between REM sleep and SWS. The results strongly indicated a cycle of genital activity in women that parallels the penile erection cycle in men. The implications of this finding and suggestions for future research are discussed.     

Immunohistochemical detection of ras oncogene p21 product in benign and malignant mammary tissue in man.

The monoclonal antibody RAP-5 generated against a synthetic peptide corresponding to amino acid positions 10-17 of the ras p21 protein was used in an immunohistochemical study of the expression of ras in normal, benign, and malignant breast epithelium in man. The staining intensity and intracellular distribution of RAP-5 was similar in the three epithelial populations and extended to other tissue elements including myoepithelial cells, smooth muscle, myelin, capillary endothelium, and stromal fibroblasts, as well as sebaceous glands and sweat glands overlying the breast. These results suggest that RAP-5 recognises a normal cellular component, the expression of which is not more enhanced in hyperplastic or neoplastic conditions. The detection of mutant forms of p21 exclusively expressed in malignant tumours requires that alternative reagents be developed.     

Neutrophil activation in thermal injury as assessed by increased expression of complement receptors

We studied neutrophil activation in patients with burns by serial immunofluorescent measurement of neutrophil expression of the complement opsonin receptors CR1 and CR3. CR1-dependent fluorescence was initially (days 0 through 5 after the burn) elevated (mean +/- SEM, 294 +/- 42 vs. 63 +/- 6 in the controls; P less than 0.001) and gradually returned to normal (days 6 through 8, 270 +/- 62, P less than 0.001; days 9 through 13, 185 +/- 38, P less than 0.001; days 14 through 19, 143 +/- 27, P less than 0.001; and days 20 through 50, 93 +/- 5, P less than 0.04). CR3-dependent fluorescence paralleled that of CR1. Neutrophil chemotaxis in response to zymosan-activated serum, a source of C5a, was depressed (days 0 through 5, 77 +/- 4 percent of control, P less than 0.001; days 6 through 8, 70 +/- 4 percent, P less than 0.001; days 9 through 13, 74 +/- 3 percent, P less than 0.001; days 14 through 19, 90 +/- 4 percent, P less than 0.01; and days 20 through 50, 97 +/- 3 percent, P not significant) and inversely correlated with CR1- and CR3-dependent fluorescence (r = -0.559, P less than 0.001; and r = -0.709, P less than 0.001, respectively). Plasma C3a desArg levels were above normal (100 +/- 5 ng per milliliter) throughout (days 0 through 5, 305 +/- 42; days 6 through 8, 546 +/- 69; days 9 through 13, 490 +/- 72; days 14 through 19, 409 +/- 54; and days 20 through 50, 260 +/- 36; all P less than 0.005). Thus, neutrophils in burned patients were activated as indicated by increased expression of complement receptors. The correlation between this increase and the depression of chemotaxis in response to zymosan-activated serum suggests that C5a is responsible for systemic neutrophil activation, which may contribute to the increased susceptibility to infection of patients with burns.