Traumatic female urethral avulsion

Traumatic female urethral avulsion in the absence of a pelvic fracture is an exceedingly rare entity, with no consensus on its management. Here, we present a 35-year-old pregnant woman with severe anterior vaginal wall laceration and complete urethral avulsion secondary to straddle injury. Management consisted of primary urethral and vaginal repair.Complete circumferential rupture of the female urethra is extremely rare, and represents a challenging management situation.1 As the entire posterior length of the urethra is closely adherent to the anterior wall of the vagina; it is subsequently prone to simultaneous injury. Most reported cases were associated with pelvic bone fractures, but there is no current consensus on management.2 The diagnosis should be considered in cases of deep vaginal lacerations, with an inability to void with unsuccessful catheterization.3 Our objective in presenting this particular case is to highlight that early recognition and strict adherence to the principles of reconstructive surgery are necessary to maximize the results and prevent subsequent risks of morbidity.     

Thoracoscopic sympathectomy: endobronchial anesthesia vs endotracheal anesthesia with intrathoracic CO2 insufflation

Purpose. To compare clinical advantages and hemodynamic and respiratory changes during one lung-collapsed ventilation (OLCV) using a double-lumen tube (DLT) or a single-lumen tube (SLT) with intrathoracic CO₂ insufflation, in patients undergoing thoracic sympathectomy (TS) under general anesthesia. Methods. One hundred and twenty-five patients (94 men and 31 women) undergoing TS for the treatment of palmar hyperhidrosis (PH) were randomly allocated to two groups: group A (68 patients; age, 29 ± 6 years) in whom DLT was used, and group B (57 patients; age, 32 ± 3 years) in whom SLT with intrathoracic CO₂ insufflation at a rate of 0.5–1 l·min⁻¹ and sustained intrathoracic pressure at 6 mmHg insufflation were used. Anesthesia was maintained with 1 minimum alveolar concentration (MAC) isoflurane in 50% nitrous oxide in oxygen with incremental doses of sufentanil and atracurium when required. Arterial blood gases were measured in 10 patients in group B. Hemodynamic and respiratory parameters were obtained perioperatively. Results. There were no significant differences in hemodynamic and respiratory parameters between the two groups during the study phases, except for the arterial oxygen saturation (SpO₂). The times required for anesthesia and surgery were significantly shorter in the SLT group than in the DLT group. SpO₂ during OLCV was 95 ± 1% with DLT and 98 ± 1% with SLT, with a significant difference. Three patients had an SpO₂ of less than 90% in the recovery room, where the chest tube position was readjusted, with no further sequelae. Conclusion. General anesthesia with SLT and intrathoracic CO₂ insufflation provides optimal operating conditions, adequate oxygenation, and perfect hemodynamic stability during TS. Received: November 28, 2000 / Accepted: August 8, 2001     

Association of HLA Polymorphisms with Post‐transplant Lymphoproliferative Disorder in Solid‐Organ Transplant Recipients

The association between HLA polymorphisms and PTLD was investigated in a case–control study, comparing 110 predominantly adult solid‐organ transplant recipients who developed PTLD to 5601 who did not. Donor and recipient HLA were analyzed. We detected a significant association between recipient HLA‐A26 and the development of PTLD (OR 2.74; p = 0.0007). In Caucasian recipients, both recipient and donor HLA‐A26 were independently associated with development of PTLD (recipient A26 OR 2.99; p = 0.0004, donor A26 OR 2.81; p = 0.002). Analysis of HLA‐A and ‐B haplotypes revealed that recipient HLA‐A26, B38 haplotype was strongly correlated with a higher incidence of EBV‐positive PTLD (OR 3.99; p = 0.001). The common ancestral haplotype HLA‐A1, B8, DR3, when carried by the donor, was protective against PTLD (OR 0.41; p = 0.05). Several other HLA specificities demonstrated associations with clinical and pathological characteristics as well as survival. These findings demonstrate the importance of HLA polymorphisms in modulating the risk for PTLD, and may be useful in risk stratification and development of monitoring and prophylaxis strategies.     

Characterization of a large Lebanese family segregating IgA nephropathy.

BACKGROUND: Familial aggregation of IgA nephropathy (IgAN) suggests that genetic factors contribute to the development of this trait. Because clinical manifestations in IgAN families are often limited to episodic haematuria, large kindreds tractable to linkage analysis have been difficult to identify. METHODS: We identified a large Lebanese-Druze kindred ascertained via an index case with biopsy-documented IgAN. We performed systematic screening of 38 family members and tested linkage to reported IgAN loci. RESULTS: Screening of this family identified 16 affected individuals, including 2 individuals with biopsy-documented IgAN and 14 with chronic renal failure or abnormal urinalyses on at least three separate occasions. This kindred spanned five generations and contained five consanguineous unions. Multigenerational inheritance suggested that autosomal dominant inheritance was most likely. Phenotypic manifestations among affected individuals varied from isolated haematuria to advanced renal failure necessitating transplantation; one instance of IgAN recurrence after transplantation was also documented. Older age was associated with greater severity of disease and higher incidence of renal failure. Parametric and non-parametric analyses with 33 microsatellite markers did not reveal any evidence of linkage to reported IgAN loci on chromosomes 6q22-23, 2q36 and 4q22-31. CONCLUSIONS: We describe one of the largest multigenerational IgAN kindreds reported to date. The high incidence of renal failure among older generations suggests a significant risk of progression to renal failure. We found no evidence of linkage to known loci, suggesting that familial IgAN encompasses multiple subtypes that will require distinction based on genetic or biomarker data.     

Laryngeal mask airway is associated with an increased incidence of adverse respiratory events in children with recent upper respiratory tract infections

BACKGROUND: The laryngeal mask airway (LMA) has been advocated as an alternative technique to tracheal intubation for airway management of children with recent upper respiratory tract infections (URIs). The authors determined the occurrence of adverse respiratory events and identified the associated risk factors to assess the safety of LMA in children. METHODS: During a period of 5 months, parents of children scheduled to undergo general anesthesia with an LMA were asked to fill out a questionnaire regarding their child's medical history and potential symptoms of URI. In addition, all episodes of adverse respiratory events in the perioperative period (laryngospasm, bronchospasm, coughing, airway obstruction, and oxygen desaturation) as well as details of anesthesia management were recorded. RESULTS: Among the 831 children included in the study, 27% presented with a history of a recent URI within the last 2 weeks before anesthesia. The presence of a recent URI doubled the incidence of laryngospasm (odds ratio, 2.6; 95% confidence interval, 1.3-5.0), coughing (odds ratio, 2.7; 95% confidence interval, 1.7-4.3), and oxygen desaturation (odds ratio, 1.9; 95% confidence interval, 1.2-2.8). This incidence was even higher in young children; in those undergoing ear, nose, and throat surgery; and when there were multiple attempts to insert the LMA. CONCLUSION: An LMA used in children with recent URIs was associated with a higher incidence of laryngospasm, cough, and oxygen desaturation compared with healthy children. However, the overall incidence of adverse respiratory events was low, suggesting that if anesthesiologists allow at least a 2-week interval after a URI, they can safely proceed with anesthesia using an LMA.     

The effects of surgicel and bone wax hemostatic agents on bone healing: An experimental study

Background:

The biological effects of hemostatic agends on the physiological healing process need to be tested. The aim of this study was to assess the effects of oxidized cellulose (surgicel) and bone wax on bone healing in goats’ feet.

Materials and Methods:

Three congruent circular bone defects were created on the lateral aspects of the right and left metacarpal bones of ten goats. One defect was left unfilled and acted as a control; the remaining two defects were filled with bone wax and surgicel respectively. The 10 animals were divided into two groups of 5 animals each, to be sacrificed at the 3^rd and 5^th week postoperatively. Histological analysis assessing quality of bone formed and micro-computed tomography (MCT) measuring the quantities of bone volume (BV) and bone density (BD) were performed. The results of MCT analysis pertaining to BV and BD were statistically analyzed using two-way analysis of variance (ANOVA) and posthoc least significant difference tests.

Results:

Histological analysis at 3 weeks showed granulation tissue with new bone formation in the control defects, active bone formation only at the borders for surgicel filled defects and fibrous encapsulation with foreign body reaction in the bone wax filled defects. At 5 weeks, the control and surgicel filled defects showed greater bone formation; however the control defects had the greatest amount of new bone. Bone wax filled defects showed very little bone formation. The two-way ANOVA for MCT results showed significant differences for BV and BD between the different hemostatic agents during the two examination periods.

Conclusion:

Surgicel has superiority over bone wax in terms of osseous healing. Bone wax significantly hinders osteogenesis and induces inflammation.     

Malignant fibrous histiocytoma presenting with complete opacification of the hemithorax: A case report

BACKGROUND

Malignant fibrous histiocytoma, a subtype of primary lung sarcoma is a very rare disease. It usually presents as a lung nodules and the final diagnosis is made by immunohistochemical studies.

METHODS

A 45-year-old patient presented with progressive dyspnea, dry cough and right shoulder pain. Chest X-ray revealed complete opacification of the right hemithorax. Chest computed tomography confirmed the presence of a heterogeneous lesion occupying the whole right hemithorax causing a mass effect on the trachea. Ultrasound guided biopsy was done and final pathology was suggestive of malignant fibrous histiocytoma.

CONCLUSION

Progressive dyspnea in young otherwise healthy patients should be investigated early on. In our case the presence of right shoulder pain indicates advance disease illustrated by the singular imaging findings.     

Subureteral polydimethylsiloxane injection versus extravesical reimplantation for primary low grade vesicoureteral reflux in children: a comparative study

PURPOSE: We compare the outcome of extravesical ureteral reimplantation to endoscopic polydimethylsiloxane (Macroplastique, Uroplasty, Inc., Minneapolis, Minnesota) subureteral injection for primary low grade vesicoureteral reflux in children. MATERIALS AND METHODS: Between 1997 and 2000, 180 patients underwent polydimethylsiloxane injection (74, 108 ureters) or extravesical ureteral reimplantation (106, 166 ureters) for low grade vesicoureteral reflux. Low grade reflux was defined as grades I to III. Outcome analysis included success rates, de novo hydronephrosis, voiding efficiency, urinary tract infections and complications. RESULTS: Mean patient age at surgery for the injection and surgery groups was 60 and 77 months, and mean followup was 12 and 15 months, respectively. Of the patients who underwent single injection 80.6% were cured of reflux at 3 months and 91.6% were cured at last followup. Success rate after reimplantation was 95.8% at 3 months which improved to 98.8% 1 year later. The success rate was significantly different between the injection and reimplantation groups at 3 and 12 months (p <0.01). Postoperative complications in the reimplantation group included transient urinary retention after bilateral surgery in 2 patients (3.3%), suprapubic fluid collections in 2 and wound seroma in 1. No complications occurred in the polydimethylsiloxane group. CONCLUSIONS: Extravesical ureteral reimplantation has near perfect success with a low but definite complication rate. Polydimethylsiloxane offers high success rates for reflux in an ambulatory setting with no short-term complications. Currently, endoscopic polydimethylsiloxane injection is our preferred mode of therapy for low grade vesicoureteral reflux in children when surgical correction is indicated.     

Anomalous course of the right coronary artery in the right atrial wall: a word of caution

We report a case of anomalous course of the right coronary artery in the wall of right atrium which was encountered during coronary artery bypass surgery. As the stenotic lesion in the vessel was proximal, the large posterior descending branch of the right coronary was grafted. Such an anomalous course of the right coronary artery has not been previously described in the literature and lack of knowledge of such an abnormal course may result in inadvertant damage during cannulation of the inferior vena cava or coronary sinus.