PAROXYSMAL TACHYCARDIA IN INFANCY AND CHILDHOOD I. Paroxysmal Supraventricular Tachycardia

A 1 to 30 year follow-up study of 54 infants and children with paroxysmal supraventricular tachycardia is presented. In 28 cases the first attack occurred in infancy, and in 18 of these already in the first months of life. Nine patients had organic heart disease. The WPW syndrome was diagnosed in 30 cases. When first seen, most of the infants presented signs of incipient or manifest congestive heart failure, which was very unusual in the children, most of whom had only minor symptoms. Four children had experienced brief syncopes during attacks. Digitalis was effective against congestive heart failure and, when continued, may have prevented failure during subsequent attacks. Whether digitalis and other anti-arrhythmic agents facilitated conversion to sinus rhythm could not be established in this study. Vagal stimulation was only rarely effective. Preventive treatment with digitalis or other antiarrhythmic drugs seemed to have little if any effect on the frequency of recurrent attacks. Out of 23 infants who were followed for at least 5 years, 17 had been free from attacks during the last 3 years and 13 of these had had their last attack before the age of 6 months. Out of 23 children followed for 5 years or more, only 3 had been free from recurrences during the last 3 years. Patients with the WPW-syndrome had a somewhat higher incidence of recurrent attacks.     

Local radiotherapy for unresectable hepatocellular carcinoma patients who failed with transcatheter arterial chemoembolization

Purpose: The purpose of this study was to investigate the efficacy of local radiotherapy (RT) as a salvage treatment for unresectable hepatocellular carcinoma (HCC) patients who failed with transcatheter arterial chemoembolization (TACE).

Methods and Materials: Patients with unresectable HCC who had been treated with and eventually failed with TACE were eligible. The judgment of TACE failure was based on incomplete tumor filling of lipiodol-adriamycin mixture on either angiography or computed tomography (CT) scan. From January 1993 to December 1997, 27 patients were entered into this study. They had UICC Stage III (17) or IVA (10) disease, with a mean tumor size of 7.2 ± 2.9 cm. Local RT was done, with a mean tumor dose of 51.8 ± 7.9 Gy, in daily 1.8-Gy fractions using a 10- or 6-MV linear accelerator. Survival was calculated from both the diagnosis and the start of RT using the Kaplan-Meier method.

Results: An objective response was observed in 16 of 24 patients (66.7%) including 1 CR. Intrahepatic metastasis was noted outside the RT field in 10 patients (37.0%). Extrahepatic distant metastasis occurred in 4 patients. Survival rates at 1, 2, and 3 years were 85.2%, 58.1%, and 33.2%, respectively, from the diagnosis and 55.9%, 35.7%, and 21.4%, respectively, from the start of RT. The median survivals were 26 months from the diagnosis and 14 months from the start of RT. Acute toxicity involved alteration in liver function test (13 patients) and thrombocytopenia (2 patients). Subacute and chronic toxicity involved gastroduodenal ulcer (3 patients) and duodenitis (2 patients). There was no treatment-related death.

Conclusion: In unresectable HCC patients who failed with TACE, local RT induced a substantial tumor response of 66.7%, with a 3-year survival rate of 21.4% and a median survival time of 14 months. Toxicity was significant but manageable. Although we do not know if there is survival benefit through this treatment, local RT in these patients seems to be valuable as a salvage for TACE-failed HCC.     

Looped silk tie: surgical technique for management of the renal vein during laparoscopic live-donor nephrectomy

Laparoscopic live-donor nephrectomy has revolutionized the field of kidney transplantation and has been adopted in many tertiary centers as the method of choice in procuring kidneys. While standard techniques for laparoscopic live-donor nephrectomy have been well described in the literature, there continues to be ample discussion about renal-vein ligation. Endo-GIA and other commonly used vascular stapling devices can be costly and prone to mechanical failures and may not be applicable in certain anatomic situations. Vascular clips, although simple to use for arteries, are difficult to apply to large renal veins. To address these issues, we describe a simple, cost-effective method of control that can be used for both right and left renal veins, using a loop constructed from a 0 silk tie.     

Material sensitivity study on lumbar motion segment (L2-L3) under sagittal plane loadings using probabilistic method

OBJECTIVE: In this study, the probabilistic responses of a three-dimensional finite element L2-L3 motion segment, with and without posterior elements, tested under sagittal plane loadings, are presented. Understanding the effect of biologic uncertainties and variations on the biomechanical response provides an insight into spinal behavior under normal and degenerated conditions. METHODS: The biologic variability of 19 spinal components (nucleus, annulus, ligament, cortical/cancellous bone, endplate, and ligaments) in the motion segment was incorporated using statistical distributions into the model. A total of 2000 runs were performed using Monte Carlo probabilistic algorithms to compute the probabilistic response. RESULTS: This study establishes the relative importance of the spinal components in resisting the loading modes. The results show that for an intact motion segment, posterior ligaments are more dominant than intervertebral disc in resisting flexion moment. In extension, the capsular ligaments were found to be the most influential parameter. The intervertebral disc (ie, nucleus and annulus) affects the angular response of the disc body segment more than the hard tissues (ie, cortical and cancellous bone). CONCLUSIONS: The application of the probabilistic analysis provides a new approach whereby the influences of inherent uncertainties and variations in biologic structures can be studied and the biomechanical response assessed.     

Simultaneous bilateral retrograde intrarenal surgery for bilateral complex upper tract stone disease

Recent advances in retrograde endoscopy have greatly expanded the role of minimally invasive surgery in addressing upper tract stone disease. In an attempt to decrease patient morbidity further, we present our initial experience with simultaneous bilateral retrograde intrarenal surgery in a patient with complex bilateral upper tract stones.     

Inpatient admissions for interventional radiology: philosophy of patient management

As an alternative to performing interventional radiology on inpatients under the care of internists and surgeons, the authors have established a cardiovascular radiology admitting service for well-screened, elective patients. The patients are admitted under the care of a cardiovascular radiology fellow and a staff physician. From April 1982 to December 1983, 133 patients were admitted to the service. Patients are cared for in a surgical ward or in an intermediate unit, as determined by the clinical situation. Advantages of this approach include a broader patient referral base, improved rapport with clinical colleagues and patients, improved follow-up data, and rapid evaluation and treatment, resulting in short hospital stays. The major disadvantages involve the commitment of time and staff necessary to provide quality care. The concept of the interventional radiologist in the role of admitting physician has important implications in terms of negotiations for additional financial compensation, commensurate with the skill and time required for performing these procedures and caring for the patient.     

Long-term clinical and histological outcomes in patients with spontaneous hepatitis B surface antigen seroclearance

BACKGROUND/AIMS: During the natural course of hepatitis B virus (HBV) infection, the long-term clinical and histological outcomes following spontaneous hepatitis B surface antigen (HBsAg) seroclearance remain unclear. METHODS: Between 1984 and 2003, 49 (9.5%) out of 432 inactive HBsAg carriers had no detectable level of circulating HBsAg. Fifteen of 49 patients had undergone paired peritoneoscopic liver biopsies. RESULTS: During a mean follow-up period of 19.6 months after HBsAg seroclearance, 5 of 49 (10.2%) patients were noted to have HCC. Liver cirrhosis (P=0.040), a history of perinatal infection (P=0.005) and long-standing duration (at least 30 years) of HBsAg positivity (P=0.002) were associated with a significantly higher risk of developing HCC. Despite HBsAg seroclearance, HBV DNA was detected in the liver tissues from all 15 patients who underwent paired liver biopsies. Necroinflammation was significantly ameliorated (P<0.0001). On the other hand, amelioration of the fibrosis score did not reach a statistically significant level (P=0.072). Interestingly, aggravation of liver fibrosis was evident in 2 patients (13.3%) including one who had rapidly progressed to overt cirrhosis. CONCLUSIONS: In patients with spontaneous HBsAg seroclearance, necroinflammation was markedly improved and liver fibrosis was unchanged or regressed despite occult HBV infection. However, HCC developed in a minority of cases.     

Factors associated with postoperative delirium after major head and neck surgery

Postoperative delirium (POD) is an acute change in cognitive status characterized by fluctuating consciousness and is associated with high incidences of morbidity, high complication rates, and long hospitalizations. This study was performed to determine the incidence of POD and the perioperative risk factors in order to predict which patients have an increased risk and thus to prevent POD after major head and neck surgery. The authors retrospectively evaluated 341 patients who underwent laryngectomy or the Commando (combined operation of mouth, mandible, and neck dissection) procedure at Pusan National University Hospital from January 1986 through July 2001. Postoperative delirium developed in 13.8% of the patients who underwent laryngectomy (42 of 304) and 13.5% of the patients who underwent the Commando procedure (5 of 37). A multivariate analysis showed that older age, hypertension, low postoperative O2 saturation, and decreased postoperative hemoglobin levels were risk factors for POD (p < .05). Postoperative delirium is preventable, and its incidence can be decreased by predicting these risk factors during the preoperative and postoperative periods.