Laparoscopic treatment of urinary incontinence

The optimal surgical management of stress incontinence in women remains a contentious issue. Retropubic urethropexies such as the Burch procedure are regarded as having excellent long-term success rates. The learning curve for transvaginal tape procedures is by far shorter and easier than for the laparoscopic Burch procedure. Data from the few randomized trials published thus far show that both procedures are associated with high success rates and patient satisfaction.     

Anatomic reconstruction for recurrent aortic obstruction in infants and children

Background

Patients undergoing operative repair of aortic obstruction are at a lifelong risk of recurrent obstruction, and there is controversy regarding the optimal surgical technique. We have used an alternative strategy for recurrent aortic obstruction, typically involving anatomic reconstruction by means of a median sternotomy, and describe our techniques and results.

Methods

Twenty-one patients presented with recurrent aortic arch obstruction. Mean age and weight were 7.8 ± 5.4 years (range, 0.21 to 15.2 years) and 30.6 ± 21.8 kg (range, 3.6 to 90 kg), respectively. Recurrence involved the aortic arch to some degree in each case, as the mean preoperative transverse aortic arch z score was −2.9 ± 1.6 (range, −7.0 to 0.1). Thoracotomy was possible in 2 patients, using re-resection with end-to-end anastomosis (n = 1) and patch aortoplasty (n = 1). The remaining 19 patients required median sternotomy, cardiopulmonary bypass, and deep hypothermic circulatory arrest for complete relief of obstruction by aortic arch advancement (n = 10), patch aortoplasty (n = 8), or interposition grafting (n = 1).

Results

There was 1 hospital death. Invasive blood pressure monitoring revealed no residual arm-to-leg gradient in 19 patients and a 20-mm Hg gradient in 2 patients. There have been no late deaths. No patients have undergone subsequent aortic intervention, and all are asymptomatic up to 85 months postoperatively. Two patients are currently followed with a 10-mm Hg arm-to-leg blood pressure gradient.

Conclusions

Anatomic reconstruction for recurrent aortic obstruction can be safely accomplished in the majority of patients. We favor median sternotomy because of the ability of establishing cardiopulmonary bypass, the facility of anatomic reconstruction techniques, and the ability to repair concomitant cardiovascular lesions.     

Surgical treatment for primary hyperparathyroidism in Hong Kong: changes in clinical pattern over 3 decades

HYPOTHESIS: With the introduction of the blood chemistry multichannel autoanalyzer, primary hyperparathyroidism (HPT) is increasingly diagnosed. The clinical pattern of primary HPT has undergone a significant evolution in Western countries. A similar change can be documented in a geographic region where this condition is considered to be relatively uncommon. DESIGN: Unselected case series. SETTING: A tertiary referral endocrine surgical unit. PATIENTS: All patients with primary HPT surgically treated over the past 30 years. MAIN OUTCOME MEASURES: The prevalence of patients per 100,000 hospital admissions, clinical presentation, biochemistry study results, pathologic status, and main outcome were compared over three 10-year spans according to the introduction of the multichannel autoanalyzer in 1982: 1973-1982 (n = 20), 1983-1992 (n = 31), and 1993-2002 (n = 190). RESULTS: A 7-fold increase in the prevalence of patients with primary HPT who were surgically treated per 100,000 hospital admissions was observed over the past 10 years. The clinical presentation of patients with primary HPT had evolved progressively with a higher proportion of older patients (P<.001) being asymptomatic. On presentation, the condition had decreased in severity with lower serum calcium (P =.04), parathyroid hormone (P<.001), and alkaline phosphatase levels (P<.001) as well as a smaller adenoma size (P<.001). There was no significant change in the underlying pathologic condition and surgical success. CONCLUSION: Similar to the West but in contrast to that observed in other Asian countries, an increase in the prevalence of patients surgically treated for primary HPT is documented and a change in disease presentation as well as its severity is observed in our population group.     

Indirect bronchial shunt flow measurements in AbioCor implantable replacement heart recipients

Bronchial shunt flows in the recipients of the electrohydraulic AbioCor implantable replacement heart have been measured indirectly. A built-in compliance chamber accommodates the differential flow output required of the two ventricles of the AbioCor. An occluder mechanism regulates the flow differential. For a thoracic unit, given a beat rate, an occluder setting, and the pressure differentials across the replacement heart ventricles, the atrial pressure difference depends only on the level of shunt flow present in the vasculature. For a replacement heart recipient, the bronchial shunt is the dominant shunt flow. For patients implanted with the AbioCor, the beat rates and the occluder settings are known and the pressure differentials across the ventricles are estimated. Atrial pressures were measured using catheters. The bronchial shunt flow was deduced from in vitro characterization data based on these parameters. Available data from five patients in the ongoing clinical trial of AbioCor showed 0-1.4 L/minute bronchial shunt flows. Maximum variation for any individual patient was 1.1 L/minute.     

Massive pulmonary embolism in a young patient on clozapine therapy

Clozapine-associated induction of venous thromboembolism has potentially catastrophic consequences. We report a case of sudden death caused by bilateral main pulmonary trunk thrombosis in a 31-year-old man receiving clozapine therapy. The patient presented with general weakness and exertional dyspnea. Bilateral main pulmonary trunk thrombosis was clearly demonstrated by helical chest computed tomography.     

2-(2-(dimethylaminomethyl)phenoxy)-5-iodophenylamine: an improved serotonin transporter imaging agent

Imaging serotonin transporters (SERT) is an emerging research tool potentially useful to cast light on the mechanisms of drug action as well as to monitor the treatment of depressed patients. We have prepared two new derivatives of 3, 2-(2-(dimethylaminomethyl)phenoxy)-5-iodophenylamine (4) and 2-(2-(dimethylaminomethyl)benzyl)-5-iodophenylamine (5) (K(i) for SERT = 0.37 and 48.6 nM, respectively). Both [(125)I]4 and [(125)I]5 displayed excellent brain uptakes in rats, and they showed a highest uptake in hypothalamus (between 60 and 240 min), a region populated with the highest density of SERT. The specific uptake of [(125)I]4 in the hypothalamus resulted in a target to nontarget ratio ([hypothalamus-cerebellum]/cerebellum) of 4.3 at 2 h. Autoradiography of rat brain sections (ex vivo at 2 h) of [(125)I]4 showed an excellent regional distribution pattern consistent with known SERT localization. These data suggest that [(123)I]4 may be useful for imaging SERT binding sites in the brain by single photon emission computed tomography (SPECT).     

Management of osteoporosis in Hong Kong

Osteoporosis is among the top 3 medical conditions that are associated with greatest morbidity and reduction of quality of life of Hong Kong elderly subjects. The genetic and environmental risk factors for osteoporosis in southern Chinese as well as the current approach towards managing this growing health problem in Hong Kong are presented.