How to approach major surgery where patients refuse blood transfusion (including Jehovah's Witnesses)

Jehovah's Witnesses do not permit the use of allogeneic blood products. An increasing number of patients are refusing blood transfusion for non-religious reasons. In addition, blood stores are decreasing, and costs are increasing. Transfusion avoidance strategies are, therefore, desirable. Bloodless surgery refers to the co-ordinated peri-operative care of patients aiming to avoid blood transfusion, and improve patient outcomes. These principles are likely to gain popularity, and become standard practice for all patients. This review offers a practical approach to the surgical management of Jehovah's Witnesses, and an introduction to the principles of bloodless surgery that can be applied to the management of all patients.     

Immunization of mice with Neisseria meningitidis serogroup B genomic expression libraries elicits functional antibodies and reduces the level of bacteremia in an infant rat infection model

The feasibility of expression library immunization against the pathogenic bacterium Neisseria meningitidis was studied. A genomic library of N. meningitidis serogroup B strain CU385, containing 6000 individual clones, was constructed and divided into 10 sublibraries. Immunization of BALB/c mice with plasmid DNA from six sublibraries induced a humoral response, with recognition of several meningococcal proteins by Western blot. Three of these sublibraries elicited bactericidal antibodies against the homologous strain, and sera from mice immunized with one of these sublibraries reduced significantly the number of viable bacteria in blood of infant rats challenged with N. meningitidis. In addition, after DNA immunization, mice were boosted intraperitoneally with 5 x 10(2) colony forming units of strain CU385. Mice immunized with nine of the 10 libraries developed bactericidal antibodies 1 week after the boost and controls did not, demonstrating the priming capacity and specificity of our immunization strategy. Our study demonstrates, for the first time, that genomic immunization offers a novel approach for screening possible vaccine candidates against N. meningitidis.     

characterization of acute-phase humoral immunity to monkeypox: use of immunoglobulin M enzyme-linked immunosorbent assay for detection of monkeypox infection during the 2003 North American outbreak

A monkeypox outbreak occurred in the United States in 2003. Patient's sera were sent to the Centers for Disease Control and Prevention as a part of outbreak response measures. Clinical and epidemiologic information was abstracted from the case investigation forms. Serum samples from patients were tested by using an immunoglobulin M (IgM)-capture and an IgG enzyme-linked immunosorbent assay ELISA against Orthopoxvirus antigen. The detection of antiviral IgG and IgM antibodies and the kinetics of the antiviral IgG and IgM antibody responses were evaluated. Patients were classified as confirmed, probable, or suspect cases or were excluded as cases based on laboratory test results and epidemiologic and clinical criteria. A total of 37 confirmed case patients with monkeypox were identified, and 116 patients were excluded as case patients based on molecular testing or insufficient epidemiology and clinical data to warrant classification as a suspect or probable case. Of 37 confirmed case patients, 36 had a known history (presence or absence) of smallpox vaccination. Of those, 29 of the 36 either had or developed an IgG response, while 34 of the 36 developed an IgM response, regardless of vaccination status. Serum collected > or =5 days for IgM detection or serum collected > or =8 days after rash onset for IgG detection was most efficient for the detection of monkeypox virus infection. IgM ELISA detects recent infection with orthopoxviruses and, in this case, recent infection with monkeypox virus. In addition, analysis of paired sera for IgG and IgM detected seroconversion, another indicator of recent infection. The ELISA results correlated with the virologic PCR and viral culture results, indicating its diagnostic capabilities for monkeypox and potentially other orthopoxvirus infections due to zoonotic transmission or bioterrorism events.     

Lymphoepithelial cyst of the pancreas. A case report

Lymphoepithelial cyst of the pancreas is a benign and rare pathology. Its histogenesis is still unknown. The diagnosis is difficult to establish before surgery. We report a new case of a 20-year-old woman admitted for abdominal pain and vomiting. Radiologic investigations described a multilocular cystic tumor of the tail of the pancreas. The patient underwent a left pancreatectomy with splenectomy. Histologic investigations revealed pancreatic cysts lined by squamous epithelium surrounded by dense lymphoid tissue. The diagnosis of lymphoepithelial cyst of the pancreas was done.     

Preoperative bowel preparation--is it useful?

Mechanical cleansing of the colon prior to elective colorectal surgery is a dogmatically established belief in surgery. Polyethylene glycol was extensively used in the 1980's and 1990's but has been largely replaced by other laxative solutions such as sodium phosphate which are better tolerated by the patient. Evidence-based data in the surgical literature question the dogma of routine mechanical bowel cleansing (8 randomized controlled studies and 4 meta-analyses). These data show with a good level of evidence that mechanical bowel preparation is unnecessary and perhaps harmful.     

Endometrial stromal nodule: a case report

The endometrial stromal nodule is the rarest of the endometrial stromal tumours. It is a benign tumour composed of well-differentiated endometrial stromal cells arranged as a well-circumscribed nodule with smooth, non invasive margins. We describe a case of uterine stromal nodule occurring in a 45-year-old woman with history of menometrorrhagia in which case ultrasonography conclude to a leiomyoma. Epidemiology, pathologic aspects, differential diagnosis, treatment and prognosis are reviewed.     

Carcinoid tumors of the appendix. A report of 46 cases

Carcino?d tumors of the appendix are rare. The appendix constitutes the most frequent localization of these tumors. We studied of a retrospective way all cases that had an appendectomy in the service of general surgery of Sfax on a period of 7 years going from 1995 to 2001. During this period, 9584 patients had an appendectomy in our service. Among which, 46 cases (0.48%) of carcinoid tumor of the appendix have been diagnosed. In more than 95% of cases, patients were admitted due to acute appendicitis; but none of them had the signs of the carcinoid syndrome. The treatment was a simple appendectomy in 44 cases (95%). The right hemicolectomy was necessary in two cases, because of an invasion of the appendicular base in a case and a tumor greater than 2 cm in the other case. There is no reported case of lymph node or systemic metastasis. The authors discuss data in the literature and analyse the features of the clinical picture, diagnosis, and try to define a convenient attitude of treatment of these tumors.     

Esophageal involvement in Behcet's disease

Esophageal involvement in Behcet's disease is very rare, and normally is observed as aphtosis and esophagitis, but serious complications such as erosions, perforations, and stenosis may occur. We carried out this prospective study to evaluate the prevalence of esophageal involvement in Behcet's disease and to establish if routine endoscopy and/or manometry are necessary. Twenty-three patients who fulfilled the diagnostic criteria of the international study group for Behcet's disease were enrolled. None were taking drugs or had disease that might produce esophageal abnormalities or alter any existing changes due to the Behcet's disease itself. Twenty- three patients underwent esophagogastroduodenoscopy by a single observer. Esophageal biopsies were performed in thirteen patients and esophageal manometry in twenty. At the beginning of the study, the disease activity was defined by the presence of more than one symptom related to Behcet's disease, and upon the classification of Behcet's disease. Of the twenty three patients enrolled two were excluded from final analysis because of the presence of hiatus hernia. Thus, 13 men and 8 women, ranging in age from 20 to 63 years with a mean age of 36.2 years were included. Ten patients (47.6%) had active disease and four (19%) complained of upper gastrointestinal symptoms at the time of the study. Fourteen patients had endoscopic, manometric and/or microscopic abnormalities. Esophageal manometry was performed in twenty patients and was abnormal in 7 cases (35%). Esophageal biopsies were done in 13 patients and revealed histopathological abnormalities in 5 cases. Microscopic findings showed vasculities in one case, and non-specific inflammatory infiltration mainly consisting of neutrophils in 4 cases. Our results suggest that the prevalence of esophageal involvement in Behcet's disease is rather high and occur even in asymptomatic patients, but that this usually does not result in specific abnormalities.     

Medicine should be evidence-based,surgery too

SURGERY TOO: The concept of evidence-based medicine, in vogue for several years, must also apply to surgery, even if the latter has specific characteristics. ADVANTAGES OF EVIDENCE-BASED SURGERY: The advantages are related to the expansion of surgeons' critical eye and their questioning of the scientifically unfounded dogmas. CONSTRAINTS OF EVIDENCE-BASED SURGERY: The constraints are not only basically material with the need to have access to data banks, which often costs money, but also methodological with the need to assess the scientific quality of the articles found in the literature. LIMITS OF EVIDENCE-BASED SURGERY: These are related to the rarity of randomized trials and meta-analyses in the surgical literature and therefore, regarding surgery as opposed to other medical domains, to the reduced level of evidence. Hence,to develop good quality, so-called "pragmatic" and prospective trials is needed. DANGERS OF EVIDENCE-BASED SURGERY: The greatest danger is the fact that the evidence-based approach is either misunderstood or misconstrued, particularly since it integrates in the scientific data the surgeons' decision, the clinical context or even the patients' preference. CONCLUSION: Evidence-based surgery is not a fleeting fancy. Today, it is a well-established fact, the aim of which is to treat the patients according to the most fitting scientific data.