Serum ionized magnesium and calcium levels in adult patients with seizures

Objective. Prior studies have been equivocal about whether or not serum levels of the divalent ions calcium and magnesium are altered during different types of seizures. Magnesium is a potential modulator of seizure activity because of its ability to antagonize the excitatory calcium influx through the N‐methyl‐D‐aspartate (NMDA) receptor. We hypothesize that serum ionized levels of calcium (Ca²⁺) and magnesium (Mg²⁺) would be altered significantly during certain types of seizures. Material and methods. A convenience sample of seizure patients presenting to an emergency department (ED) were enrolled in this prospective study. Novel ion‐selective electrodes were used to measure Ca²⁺ and Mg²⁺. Data were reported as mean values±standard deviations. Group comparisons were analyzed by ANOVA with post‐hoc testing using the Bonferroni, or the Fisher exact test, where appropriate, α = 0.05 (two‐tailed). Results. Forty‐nine patients with seizure and 32 healthy racially matched controls were included in the study. Seizure patients had a significantly (p<0.001) lower mean Mg²⁺, but not total serum Mg and a significantly (p<0.001) higher Ca²⁺/Mg²⁺ ratio than that in controls. Conclusions. We were able to show significantly lower Mg²⁺ and higher ionized Ca²⁺/Mg²⁺ ratios in seizure patients compared with a racially matched control group.     

High-dose cytosine arabinoside and daunorubicin as consolidation therapy for acute nonlymphocytic leukemia in first remission: a pilot study

High-dose (HD) cytosine arabinoside (ARA-C) is more effective treatment than conventional-dose ARA-C regimens for patients with relapsed acute nonlymphocytic leukemia (ANLL). We report here that HD ARA-C given during the first remission of ANLL has resulted in long remission durations and a high proportion of patients who survive more than three years free of disease. From August 1979 to September 1983, 36 adult patients with ANLL in first remission received one to three courses of HD ARA-C (3 g/m2 by one-hour infusion every 12 hours for 12 doses on days 1 through 6) alone or with daunorubicin (30 mg/m2 for two or three doses on days 7 through 9). Three patients died of sepsis or hemorrhage during consolidation, and 14 patients have relapsed from five to 48 months after diagnosis. The remaining 19 patients are in continued complete remission (CCR) from 11 to 62 months. Denoting all deaths in remission as relapse, the actuarial probability of CCR is 42% at 62 months, with an apparent plateau in the survival curve. Of the first 22 patients treated, ten remain in CCR from 37 to 62 months with no therapy for at least three years. Due to its heightened anti-leukemic activity, HD ARA-C allows brief but effective consolidation of ANLL in first remission, with long-term disease-free survival comparable to other approaches.     

Bench surgery with autotransplantation for bilateral synchronous Wilms' tumor: a report of three cases

The surgical management of bilateral synchronous nephroblastoma remains controversial. The authors describe three cases treated using ex vivo tumor dissection followed by autotransplantation in an attempt to preserve functioning renal tissue. Two children are alive and tumor free with adequate renal function at 30 months and 3 years, respectively. One died from tumor recurrence with metastases 9 months after surgery. This technique is an acceptable alternative to bilateral nephrectomy followed by transplantation.     

Anatomic renal artery branch microdissection to facilitate zero-ischemia partial nephrectomy

Background

Robot-assisted and laparoscopic partial nephrectomies (PNs) for medial tumors are technically challenging even with the hilum clamped and, until now, were impossible to perform with the hilum unclamped.

Objective

Evaluate whether targeted vascular microdissection (VMD) of renal artery branches allows zero-ischemia PN to be performed even for challenging medial tumors.

Design, setting, and participants

A prospective cohort evaluation of 44 patients with renal masses who underwent robot-assisted or laparoscopic zero-ischemia PN either with anatomic VMD (group 1; n = 22) or without anatomic VMD (group 2; n = 22) performed by a single surgeon from April 2010 to January 2011.

Intervention

Zero-ischemia PN with VMD incorporates four maneuvers: (1) preoperative computed tomographic reconstruction of renal arterial branch anatomy, (2) anatomic dissection of targeted, tumor-specific tertiary or higher-order renal arterial branches, (3) neurosurgical aneurysm microsurgical bulldog clamp(s) for superselective tumor devascularization, and (4) transient, controlled reduction of blood pressure, if necessary.

Measurements

Baseline, perioperative, and postoperative data were collected prospectively.

Results and limitations

Group 1 tumors were larger (4.3 vs 2.6 cm; p = 0.011), were more often hilar (41% vs 9%; p = 0.09), were medial (59% and 23%; p = 0.017), were closer to the hilum (1.46 vs 3.26 cm; p = 0.0002), and had a lower C index score (2.1 vs 3.9; p = 0.004) and higher RENAL nephrometry scores (7.7 vs 6.2; p = 0.013). Despite greater complexity, no group 1 tumor required hilar clamping, and perioperative outcomes were similar to those of group 2: operating room time (4.7 and 4.1 h), median blood loss (200 and 100 ml), surgical margins for cancer (all negative), major complications (0% and 9%), and minor complications (18% and 14%). The median serum creatinine level was similar 2 mo postoperatively (1.2 and 1.3 mg/dl). The study was limited by the relatively small sample size.

Conclusions

Anatomic targeted dissection and superselective control of tumor-specific renal arterial branches facilitate zero-ischemia PN. Even challenging medial and hilar tumors can be excised without hilar clamping. Global surgical renal ischemia has been eliminated for most patients undergoing PN at our institution.     

Intraoperative fluid administration volumes during pediatric liver transplantation and postoperative outcomes: A multicenter analysis

Introduction

Fluid administration is an important aspect of the management of children undergoing liver transplantation and may impact postoperative outcomes. Our aim was to evaluate the association between volume of intraoperative fluid administration and our primary outcome, the duration of postoperative mechanical ventilation following pediatric liver transplantation. Secondary outcomes included intensive care unit length of stay and hospital length of stay.

Methods

We conducted a multicenter, retrospective cohort study using electronic data from three major pediatric liver transplant centers. Intraoperative fluid administration was indexed to weight and duration of anesthesia. Univariate and stepwise linear regression analyses were conducted.

Results

Among 286 successful pediatric liver transplants, the median duration of postoperative mechanical ventilation was 10.8 h (IQR 0.0, 35.4), the median intensive care unit length of stay was 4.3 days (IQR 2.7, 6.8), and the median hospital length of stay was 13.6 days (9.8, 21.1). Univariate linear regression showed a weak correlation between intraoperative fluids and duration of ventilation (r² = .037, p = .001). Following stepwise linear regression, intraoperative fluid administration remained weakly correlated (r² = .161, p = .04) with duration of postoperative ventilation. The following variables were also independently correlated with duration of ventilation: center (Riley Children's Health versus Children's Health Dallas, p = .001), and open abdominal incision after transplant (p = .001).

Discussion

The amount of intraoperative fluid administration is correlated with duration of postoperative mechanical ventilation in children undergoing liver transplantation, however, it does not seem to be a strong factor.

Conclusions

Other modifiable factors should be sought which may lead to improved postoperative outcomes in this highly vulnerable patient population.     

Anatomic single- versus double-bundle ACL reconstruction: a meta-analysis

Purpose

To determine whether anatomic double-bundle anterior cruciate ligament (ACL) reconstruction compared to anatomic single-bundle ACL reconstruction more effectively restored antero–posterior (A–P) laxity, rotatory laxity and reduced frequency of graft rupture. Our hypothesis was that anatomic double-bundle ACL reconstruction results in superior rotational knee laxity and fewer graft ruptures due to its double-bundle tension pattern, compared with anatomic single-bundle ACL reconstruction.

Methods

An electronic search was performed using the PubMed, EMBASE and Cochrane Library databases. All therapeutic trials written in English reporting knee kinematic outcomes and graft rupture rates of primary anatomic double- versus single-bundle ACL reconstruction were included. Only clinical studies of levels I–II evidence were included. Data regarding kinematic tests were extracted and included pivot-shift test, Lachman test, anterior drawer test, KT-1000 measurements, A–P laxity measures using navigation and total internal–external (IRER) laxity measured using navigation, as well as graft failure frequency.

Results

A total of 7,154 studies were identified of which 15 papers (8 randomized controlled trials and 7 prospective cohort studies, n = 970 patients) met the eligibility criteria. Anatomic ACL double-bundle reconstruction demonstrated less anterior laxity using KT-1000 arthrometer with a standard mean difference (SMD) = 0.36 (95 % CI 0.214–0.513, p < 0.001) and less A–P laxity measured with navigation (SMD = 0.29 95 % CI 0.01–0.565, p = 0.042). Anatomic double-bundle ACL reconstruction did not lead to significant improvements in pivot-shift test, Lachman test, anterior drawer test, total IRER or graft failure rates compared to anatomic single-bundle ACL reconstruction.

Conclusion

Anatomic double-bundle ACL reconstruction is superior to anatomic single-bundle reconstruction in terms of restoration of knee kinematics, primarily A–P laxity. Whether these improvements of laxity result in long-term improvement of clinical meaningful outcomes remains uncertain.

Level of evidence

II.     

Age-related changes in sex steroid levels influence bone mineral density in healthy Indian men

Summary  Age-related changes in sex steroid levels and its contribution to variations in rate of bone loss among men is unclear. Although, Bio-T and Bio-E₂ levels declined with age and depicted an association with BMD in healthy Indian men, Bio-E₂ was found to be an independent predictor of BMD. Introduction  Ethnicity influences sex steroid levels, therefore, their role in pathogenesis of low bone mass needs to be established in various populations. We assessed the extent of changes in sex steroid levels with age and related these to bone mineral density (BMD) in healthy Indian men. Methods  Total testosterone (TT), estradiol (E₂), sex hormone-binding globulin (SHBG), PTH, osteocalcin (OC), and c-terminal telopeptide (CTX) were measured in 330 men aged 20–55 years and correlated with BMD measured by DXA. Results  Both Bio-T (1% per year) and Bio-E₂ (0.8% per year) levels decreased significantly in ageing men, whereas TT (0.4% per year) and E₂ (0.3% per year) levels decreased only marginally with age. In contrast, SHBG (1.4% per year) and PTH (1% per year) levels increased significantly with age. Serum TT (r = 0.19, p = 0.01) and Bio-T (r = 0.2, p = 0.01) levels were associated positively with BMD at spine, whereas E₂ and Bio-E₂ levels were associated with BMD at spine [E ₂ (r = 0.31, p < 0.0001); Bio-E₂ r = 0.37, p < 0.0001] and femur (E₂ r = 0.26, p = 0.001; Bio-E₂ r = 0.27, p = 0.001). Men in the lowest quartile of Bio-E₂ were associated with lower BMD and higher bone turnover. Conclusions  Age-related decrease in bioavailable sex steroid levels is associated with BMD in healthy Indian men. Bio-E₂ was found to be an independent predictor of BMD.     

Radiographic findings in tuberculosis of the calvarium

We reviewed the pattern of involvement of the calvarium by tuberculosis (TB) in five patients and the role of imaging in its management. Four patients presented with localised scalp swelling and one with generalized seizures. Radiographs revealed lucent lesions with minimal surrounding sclerosis in the frontal (2), parietal (2) and occipital (1) bones. CT showed lesions involving the entire thickness of the calvarium and accompanying contrast-enhancing soft tissue. The patient presenting with seizures had a ring-enhancing lesion in the parietal lobe in addition to the extra-axial lesions. Although radiographs in all cases demonstrated calvarial TB, CT showed the extent of the defect, involvement of adjacent soft tissues, and in one case an intra-axial lesion. Radiographs suffice for follow-up of these patients. Received: 23 July 1999 Accepted: 20 September 1999     

Control of the renal artery and vein with the nonabsorbable polymer ligating clip in hand-assisted laparoscopic donor nephrectomy

BACKGROUND: The large and variable size of the renal vein has prompted most surgeons to select linear stapling devices to secure the vein during laparoscopic donor nephrectomy. Although effective, these stapling devices have a potential for misfire. Use of the nonabsorbable polymer ligating (NPL) clip during laparoscopic donor nephrectomy provides increased graft vessel length compared with the stapling device, and the NPL clip has a locking mechanism which may increase security compared with standard titanium clips. The objective of this study was to evaluate the safety and efficacy of the NPL clip for control of the renal artery and vein during hand-assisted laparoscopic donor nephrectomy (HALDN). METHODS: A retrospective chart review of 50 consecutive HALDN patients was conducted where two parallel NPL clips were used to control both the renal artery and vein. Information collected included demographic data, operative and postoperative data, and complications. RESULTS: Mean donor age was 33.4 years and body mass index was 25.8 kg/m2. Mean operative time was 266.0 min, mean hospital stay was 3.2 days, and mean warm ischemia time was 123.3 seconds. There were no transfusions, open conversions, or complications related to use of the NPL clip. A US 16,300 dollars disposable cost savings was seen during this 1-year period alone. CONCLUSIONS: The NPL clip was 100% safe and effective in controlling the renal artery and vein during HALDN, allowed for additional vessel length, and resulted in a disposable cost savings of US 362 dollars per patient.