Growth impairment shows an age-dependent pattern in boys with chronic kidney disease

The impact of chronological age on longitudinal body growth from early childhood through adolescence using detailed anthropometric methods has not yet been studied in children with chronic kidney disease (CKD). We have evaluated growth failure by measuring four components of linear growth: body height (HT), sitting height (SHT), arm length (AL) and leg length (LL). Data were prospectively collected for up to 7 years on 190 boys (3–21 years old) with congenital or hereditary CKD (all had developed at least stage 2 CKD by the age of 10 years). Patients showed the most severe growth failure in early childhood, followed by an acceleration in growth in pre-puberty, a slowing-down of growth at puberty, as expected, and thereafter a late speeding-up of growth until early adulthood. This pattern was observed irrespective of the degree of CKD and different treatment modalities, such as conservative treatment, recombinant human growth hormone (rhGH) therapy or transplantation. LL showed the most dynamic growth changes of all the parameters evaluated and emerged as the best indicator of statural growth in children with CKD. A specific age-dependent pattern of physical growth was identified in pediatric male CKD patients. This growth pattern should be considered in the evaluation of individual growth and the assessment of treatment efficacy such as rhGH therapy.     

“Extended length” endoscopic harvest of the great saphenous vein for coronary artery bypass grafting

Introduction The endoscopically harvested vein from thigh usually falls short by half to one length in patients requiring multiple conduits. Increased risk of complications precludes routine endoscopic vein harvest from the leg and an extra incision for open technique is often required thereby nullifying the sole purpose of the former. We employed the endoscope to harvest this extra length of vein from the upper half of the leg with little or no extra risk. Methods From January 2006 to September 2006 we endoscopically harvested the vein in thigh as well as the leg using the same entry point incision over the medial epicondyle in 40 cases. The only exclusion criterion for the study was a superficial location and subcutaneous visibility of the vein in the leg. We made 3 incisions in each patient of average size 2.5 cm. Results Five patients required conversion to the open technique. The average harvest time was 59 minutes. Average length of the conduit was 48 cms. Complications included 1 minor wound infection, 1 case of superificial wound dehiscence, 1 haematoma requiring aspiration and minor erythema at the incision site in 2 patients. Most common complication observed was ecchymosis in 6 patients (5 high; 3 leg). None of the patient developed lymphoedema and none required re-hospitalization for vein harvest related wound complications. Conclusion “Extended endoscopic vein harvest” and avoidance of the open incision was possible in most patients with no additional risk and that the procedure could be routinely employed in patients requiring multiple conduits.     

Granulocyte Colony-stimulating Factor Supports Liver Regeneration in a Small-for-size Liver Remnant Mouse Model

Experimental partial hepatectomy of more than 80% of the liver weight bears an increased mortality in rodents, due to impaired hepatic regeneration in small-for-size liver remnants. Granulocyte colony-stimulating factor (G-CSF) promotes progenitor cell expansion and mobilization and also has immunomodulatory properties. The aim of this study was to determine the effect of systemically administered G-CSF on liver regeneration and animal survival in a small-for-size liver remnant mouse model. Mice were preconditioned daily for 5 days with subcutaneous injections of 5 μg G-CSF or aqua ad injectabile. Subsequently, 83% partial hepatectomy was performed by resecting the median, the left, the caudate, and the right inferior hepatic lobes in all animals. Daily sham or G-CSF injection was continued. Survival was significantly better in G-CSF-treated animals (P < 0.0001). At 36 and 48 h after microsurgical hepatic resection, markers of hepatic proliferation (Ki67, BrdU) were elevated in G-CSF-treated mice compared to sham injected control animals (P < 0.0001) and dry liver weight was increased (P < 0.05). G-CSF conditioning might prove to be useful in patients with small-for-size liver remnants after extended hepatic resections due to primary or secondary liver tumors or in the setting of split liver transplantation. Presented at the Forty-seventh Annual Meeting of The Society for Surgery of the Alimentary Tract, Los Angeles, CA, May 14–19, 2006 (poster presentation).     

The decrease in serum IL-18 levels after bariatric surgery in morbidly obese women is a time-dependent event

Background We have evaluated the impact of the reproductive status of morbidly obese women, and of the time elapsed since surgery, on the response of the proinflammatory serum cardiovascular risk marker interleukin-18 (IL-18) to the sustained and marked weight loss achieved after bariatric surgery. Methods Serum IL-18 levels were measured in 33 morbidly obese women before bariatric surgery and after losing at least 15% of the initial weight, irrespective of the time needed to achieve this goal (5 to 33 months). Results Patients lost 30.7 ± 7.8% of the initial weight, with a concomitant reduction of serum IL-18 concentrations (P < 0.001). A stepwise multiple regression analysis showed that the percentual decrease in serum IL-18 levels was determined by the interaction between the time elapsed since surgery and the percentual reduction of waist circumference (R² = 0.333, F = 15.500, β = 0.577, P < 0.001), but not by the individual effects of the time elapsed since surgery, percentual body weight loss, percentual reduction of waist circumference, menopausal status or type of surgical procedure, or by the interaction between the time elapsed since surgery with the percentual body weight loss or with menopausal status. Conclusion Serum IL-18 levels decrease after bariatric surgery in a time-dependent manner, in relation to the reduction in waist circumference. The fact that the amelioration of the obesity-associated inflammatory process requires time and not only weight loss, might contribute to explain early non-surgical cardiovascular complications of bariatric surgery.     

Familial steroid-sensitive nephrotic syndrome in Southern Israel: clinical and genetic observations

Reports on genetically informative steroid-responsive (sensitive) idiopathic nephrotic syndrome (SSNS) families are lacking. We studied an extended SSNS Bedouin (B) family with a high rate of consanguinity. The clinical presentation and steroid response of its 11 affected individuals were similar to those of sporadic SSNS (spontaneous remission towards puberty and minimal change disease by kidney biopsy). Genome-wide linkage analysis, using a 382 microsatellite-markers mapping set and additional markers adjacent to 80 candidate genes of the index family, did not support linkage to any chromosomal locus. Retrospective analysis of all additional children with SSNS treated by our institution in the past 20 years (n = 96, 50% of them of Jewish origin) revealed another five non-related B families with 2–3 first-degree cousins affected with SSNS in each. The overall familial SSNS rate among the B population (excluding the index family) was 28%, compared with 4% among Jews (Js) (OR 1.8–64, P < 0.005). There were more Bs with simple SSNS than there were Js (71% and 40%, respectively; OR 3.58, 95% CI 1.41–9.23, P < 0.01). In summary, SSNS in this index family was not linked to any of the presently known chromosomal loci nor predicted to be caused by mutation in any one of a list of genes associated with nephrotic syndrome (NS). The presence of other B families affected by SSNS supports the role for susceptibility genes enrichment, exposing highly consanguineous populations to an increased incidence of SSNS. An erratum to this article can be found at     

Pregnancy after TVT-O: case report and literature review

A 37-year-old woman previously treated with TVT-O developed recurrent symptoms of stress urinary incontinence during pregnancy. Symptoms started to develop later in the second trimester and progressed gradually to affect her quality of life at the end of pregnancy. In the event she had a very quick spontaneous vaginal delivery at 40 weeks’ gestation. Postnatal physiotherapy successfully controlled the incontinence symptoms and urodynamic studies demonstrated no incontinence with a stable bladder and a normal flow rate. The patient remains well 2 years following delivery with no further treatment.     

Radiotherapy for nonfunctioning pituitary adenomas: from conventional to modern stereotactic radiation techniques

The initial management of nonfunctioning pituitary macroadenomas (NFAs) is usually surgery; however, a significant proportion of NFAs may require further treatment. Radiotherapy is currently used in patients with residual tumour and achieves excellent long-term control, but there are concerns about potential late toxicity. Stereotactic radiotherapy, both in the form of radiosurgery or fractionated stereotactic radiotherapy, has been developed as a more accurate technique of irradiation with more precise tumour localization and consequently a reduction in the volume of normal tissue, particularly the brain, irradiated to high radiation doses. A review of the literature suggests that new radiation techniques offer safe and effective treatment for recurrent or residual pituitary adenomas; however longer follow-up is necessary to confirm the excellent tumour control and the potential reduction of long-term radiation toxicity. Currently, radiotherapy has an important role in patients with residual or progressive disease after surgery. Patients with small or no residual tumours after surgery may generally continue on a policy of surveillance without immediate irradiation, in order to avoid the potential toxicity of treatment.     

Bipedicle Orbicularis Oculi Flap in the Reconstruction of the Lower Eyelid Ectropion

Background Lower eyelid ectropion is conventionally reconstructed with a local flap or full-thickness skin graft. However, scar contracture and recurrence of ectropion often occur. This article describes an effective surgical technique for lower eyelid ectropion repair using a bipedicle orbicularis oculi muscle or myocutaneous flap from the upper eyelid. Methods This study prospectively analyzed collected data on the bipedicle orbicularis oculi muscle or myocutaneous flap from the upper eyelid in reconstruction of lower eyelid ectropion between 1995 and 2004. The flap was used in 12 eyelid procedures for the correction of lower eyelid ectropion, in 10 cases with traumatic ectropion, and in 1 case with bilateral congenital ectropion. In these cases, a strip of orbicularis oculi muscle or a myocutaneous flap from the upper eyelid with two pedicles attached in the medial and lateral canthus was advanced to the lower eyelid to suspend the eyelid and repair the skin defect. Results No problem of flap viability was encountered in any of the patients, and all healed well. Deformities were corrected, and evaluation showed satisfactory function and appearance during 0.5 to 6 years (average, 2 years) of follow-up evaluation. Eyelid malposition and bulkiness of the lower eyelid occurred in the early stages, but disappeared gradually about 3 months after the operation. There was no flap contraction, recurrent deformity, or significant donor site morbidity in the follow-up period. The incision scars were almost invisible. Conclusions The application of bipedicle orbicularis oculi muscle or a myocutaneous flap from the upper eyelid in reconstruction of lower eyelid ectropion is effective and reduces postoperative morbidity.     

Resolution of Diabetes Mellitus and Metabolic Syndrome following Roux-en-Y Gastric Bypass and a Variant of Biliopancreatic Diversion in Patients with Morbid Obesity

Background Obesity is associated with increased prevalence of type 2 diabetes mellitus (DM2) and metabolic syndrome and increased morbidity and mortality. Bariatric surgery results in significant and long-term weight loss. Two of the most effective and popular bariatric procedures are Roux-en-Y gastric bypass (RYGBP) and biliopancreatic diversion (BPD). The objective of this study was to investigate the effects of RYGBP and BPD-RYGBP, a variant of BPD with a lower rate of metabolic deficiencies than BPD, on DM2 and the major components of metabolic syndrome in patients with morbid obesity and DM2. Methods The prospective database of our unit, from June 1994 until May 2006, was analyzed and 137 patients with DM2 were found. 26 underwent RYGBP (BMI 46.1±2.9 kg/m²) and 111 BPD-RYGBP (BMI 59.7±10.6 kg/m²). 7 of the patients were on insulin (4.90%) and 37 on oral hypoglycemic agents (25.87%). Pre- and postoperative medications, and clinical and biochemical parameters were considered in the analysis. The mean follow-up was 26.39±21.17 months. Results Excess weight loss was ∼70% after either procedure. DM2 resolved in 89% and 99% of the cases following RYGBP and BPD-RYGBP, respectively. 2 years after BPD-RYGBP all the patients had blood glucose <110 mg/dl, 95% had normal cholesterol, 92% normal triglycerides and 82% normal blood pressure. The respective values following RYGBP were 66%, 33%, 78% and 44%. Uric acid decreased significantly only after BPD-RYGBP. Liver enzymes improved in both groups. Conclusions RYGBP and BPD-RYGBP are safe and lead to normalization of blood glucose, lipids, uric acid, liver enzymes and arterial pressure in the majority of patients, although this variant of BPD was more effective than RYGBP.We suggest that further studies should also investigate its usefulness in patients with milder degrees of obesity, DM2 and metabolic syndrome.     

Prevalence and Severity of Sleep Apnea in a Group of Morbidly Obese Patients

Background Obesity is the most important risk factor for obstructive sleep apnea. It is estimated that 70% of sleep apnea patients are obese. In the morbidly obese, the prevalence may reach 80% in men and 50% in women. The aim of this study was to determine the prevalence and severity of sleep apnea in a group of morbidly obese patients, leading to bariatric surgery. Methods In a cross-sectional study developed in Bahia, northeastern Brazil. 108 patients (78 women and 30 men) from the Obesity Treatment and Surgery Center - “Núcleo de Tratamento e Cirurgia da Obesidade” underwent standard polysomnography. Patients with an apnea-hypopnea index (AHI) ≥ 5 events/hour were considered apneic. Results Mean ± SD for age and BMI were 37.1 ± 10.2 years and 45.2 ± 5.4 kg/m2, respectively. The calculated AHI ranged widely from 2.5 to 128.9 events/hour. Sleep apnea was detected in 93.6% of the sample, wherein 35.2% had mild, 30.6% moderate and 27.8% severe apnea. Oxyhemoglobin desaturation was directly related to the AHI and was more severe in men. Conclusion There was a high frequency of sleep apnea in this group of morbidly obese patients, for whom it was very important to request polysomnography, thus enabling therapeutic management and prognostication.