Radial artery as conduit for distal renal artery reconstruction

Reconstruction of the renal artery with both saphenous vein and prosthetic material as bypass graft is durable in atherosclerotic disease. Extensive experience with saphenous vein grafts in pediatric patients and patients without atherosclerosis reveals a disturbing incidence of vein graft aneurysm degeneration. Distal renal artery reconstruction involving small branch vessels is generally not amenable to prosthetic reconstruction. We report a new approach to distal renal artery bypass grafting to avert these limitations. CASE: A 43-year-old man with previously normal blood pressure had malignant hypertension, which proved difficult to control despite use of a beta-blocker and an angiotensin II inhibitor. At renal angiography a fusiform aneurysm was revealed in a posterior branch of the right renal artery. The renal artery aneurysm was resected, and the left radial artery was harvested and used as a sequential aortorenal bypass graft to the two branch renal arteries. The postoperative course was uneventful, and the patient now has normal blood pressure with a calcium channel blocker for maintenance of the radial artery graft. Pathologic analysis revealed a pseudoaneurysm with dissection between the media and external lamella, consistent with fibromuscular dysplasia. CONCLUSION: Autologous artery is the preferred conduit for renal reconstruction in the pediatric population. On the basis of cardiac surgery experience, we used the radial artery and found it to be a technically satisfactory conduit for distal renal reconstruction in a patient without atherosclerosis.     

Tuberculose lymphonodale cervicale : prise en charge diagnostique et thérapeutique

ObjectivesThe purpose of this study was to evaluate the advantages of surgery for diagnosis and treatment of cervical lymph node tuberculosis.Material and methodsThis was a retrospective study from 1st January 1998 to 31st December 2007 including 30 patients with cervical lymph node tuberculosis. The population included 60% autochthones with a mean age of 47.1 years and a female predominance (73.33%).ResultsThe lymph nodes were most often supraclavicular, unilateral, firm, and a mean 3 cm at its largest span. Lymph nodes were excised for diagnosis in 22 patients, which demonstrated specific granulomatous and giant cell lesions with caseous necrosis in 21 patients out of 22. Five abscessed adenopathies required surgical drainage, and three cases required repeated lymph node cleaning after well-conducted medical treatment.ConclusionSurgery retains an important place in the diagnosis and treatment of cervical lymph node tuberculosis.     

Neonatal repair of cleft lip: a decision-making protocol

Purpose

Treatment of clefts lip during the neonatal period remains a controversial subject. Those who are in favor of delayed closure argue a higher-risk general anesthesia when it was performed in neonatal period. The purpose of this study was to evaluate the complications and the feasibility of this surgery during the neonatal period.

Methods

This was a retrospective study of 61 children with labial, labioalveolar, labio-alveolo-palatine, and labiopalatine clefts between May 2000 and November 2006. Each patient's medical file and particularly his or her anesthesia file was used to record the principal demographic data, the results of the malformation workup, and preoperative complications.

Results

Sixty-one newborns, 20 girls and 41 boys, aged 7.5 ± 6.7 days were operated on. The mean weight on the day of surgery was 3190 ± 454 g. Fifty-four children had a malformation workup (abdominal ultrasonography, spinal bone workup, transfontanelle ultrasonography, and cardiac ultrasonography). Thirteen associated malformations (21%) were thereby detected. There were no surgical complications. The anesthesiologists did not have any real intubation problems. In 4 cases, however, intubation was only possible after several laryngoscopies and changing the type of intubation shaft. There were no major complications. However, one child did present a preoperative complication. It was an episode of desaturation with bradycardia that was quickly resolved without further consequences in a child with a ventricular septal defect and an auricular septal defect.

Conclusions

We think that neonatal lip closure should continue to be performed. It is essential for the psychological status of the parents. We have not found any studies in the literature that reported an anesthesia risk that was greater in the neonatal period than at 3 months in patients without risk of complications.     

Seasonality of presentation of type I diabetes mellitus in children. Scottish Study Group for the Care of Young Diabetics.

Environmental influences are thought to have an aetiological role in onset of diabetes in children. Month of onset in over 2000 children in Scotland was established and there was an excess in colder/darker months than in warmer/lighter months. A meta-analysis of 21 previous studies with over 13,000 patients gave the same result at a much higher level of significance. A mechanism is postulated based on previous viral induced islet cell damage with ongoing progressive auto-immune destruction. There may be physiological seasonal changes with winter stress on carbohydrate and lipid metabolism. The raised winter levels of pituitary, adrenal and thyroid hormones fail to be antagonised by falling level of insulin. A role for seasonal variation in exercise and nutrition is considered.     

L-arginine attenuates trauma-hemorrhage-induced liver injury

OBJECTIVES: Liver injury is common after trauma-hemorrhage for which the underlying mechanism is not clear. Although administration of the essential amino acid L-arginine has been reported to restore the depressed cardiovascular functions and cell-mediated immune responses after trauma-hemorrhage, it remains unknown whether L-arginine protects against liver injury under those conditions. DESIGN: A prospective, controlled animal study. SETTING: A university research laboratory. SUBJECTS: Male Sprague-Dawley rats. INTERVENTIONS: Rats underwent sham operation or laparotomy and were bled to and maintained at a mean arterial blood pressure of 40 mm Hg until 40% of the maximum shed blood volume was returned in the form of lactated Ringer's solution. Hemorrhaged rats were then resuscitated with lactated Ringer's solution, four times the maximum shed blood volume over 1 hr. During resuscitation, animals received either 300 mg/kg of L-arginine or saline (vehicle) intravenously. At 3 and 5 hrs after resuscitation, rats were killed, blood was obtained, and the liver was fixed for histology (hematoxylin & eosin staining). Plasma glutathione S-transferase (a marker of liver damage), L-arginine, citrulline, and ornithine concentrations were assessed. MEASUREMENTS AND MAIN RESULTS: The increased concentrations of plasma glutathione S-transferase observed in vehicle-treated hemorrhage animals were normalized with L-arginine treatment at 5 hrs after resuscitation. Moreover, the histology indicated that L-arginine prevented liver edema and neutrophil infiltration after trauma-hemorrhage. Plasma L-arginine and citrulline were increased in L-arginine-treated rats. CONCLUSIONS: Because citrulline is a by-product of nitric oxide generation by nitric oxide synthase from L-arginine, this amino acid may be a useful adjunct for preventing hepatic injury after trauma-hemorrhage via endothelial derived nitric oxide production.     

Teaching with audiovisual recordings of consultations

The experience gained from two years' teaching with audiovisual recordings of consultations of both undergraduates and postgraduates is presented. Some basic teaching rules are suggested and further applications of the technique are discussed.