Treatment of severe acute lung allograft rejection with OKT3 and temporary extracorporeal membrane oxygenation bridging.

OBJECTIVES: The use of OKT3 for treatment of advanced high-grade acute rejection episodes eventually can result in cytokine release and consecutive pulmonary edema. Temporary extracorporeal membrane oxygenation (ECMO) bridging can be used to overcome this crucial period before the beneficial effects of OKT3 can be observed. METHODS: We summarize our experience with three patients, who underwent lung transplantation and presented with severe acute rejection episodes. OKT3 had to be initiated due to insufficient response to standard rejection therapy with corticosteroids. Upon initiation of OKT3 treatment, a massive life-threatening deterioration of lung function in spite of heavily invasive respirator treatment was seen and temporary ECMO support was imperative to support graft function. Results of this treatment were retrospectively reviewed. RESULTS: In all cases femoro-femoral veno-arterial ECMO was used for support of the impaired graft and after a period of 4-5 days led to a massive improvement of graft function. In the further course two patients could be discharged from hospital and are still alive 30 and 36 months, respectively, after the described incident. One patient died 4 months later due to liver failure. CONCLUSIONS: We conclude that the use of ECMO support in patients experiencing significant side effects from OKT3 therapy is a useful and effective therapeutic tool to overcome the initial critical period until the lung has sufficiently recovered.     

ESTS guidelines for intraoperative lymph node staging in non-small cell lung cancer.

The European Society of Thoracic Surgeons (ESTS) organized a workshop dealing with lymph node staging in non-small cell lung cancer. The objective of this workshop was to develop guidelines for definitions and the surgical procedures of intraoperative lymph node staging, and the pathologic evaluation of resected lymph nodes in patients with non-small cell lung cancer (NSCLC). Relevant peer-reviewed publications on the subjects, the experience of the participants, and the opinion of the ESTS members contributing on line, were used to reach a consensus. Systematic nodal dissection is recommended in all cases to ensure complete resection. Lobe-specific systematic nodal dissection is acceptable for peripheral squamous T1 tumors, if hilar and interlobar nodes are negative on frozen section studies; it implies removal of, at least, three hilar and interlobar nodes and three mediastinal nodes from three stations in which the subcarinal is always included. Selected lymph node biopsies and sampling are justified to prove nodal involvement when resection is not possible. Pathologic evaluation includes all lymph nodes resected separately and those remaining in the lung specimen. Sections are done at the site of gross abnormalities. If macroscopic inspection does not detect any abnormal site, 2-mm slices of the nodes in the longitudinal plane are recommended. Routine search for micrometastases or isolated tumor cells in hematoxylin-eosin negative nodes would be desirable. Randomized controlled trials to evaluate adjuvant therapies for patients with these conditions are recommended. The adherence to these guidelines will standardize the intraoperative lymph node staging and pathologic evaluation, and improve pathologic staging, which will help decide on the best adjuvant therapy.     

Case-control study of the alpha-synuclein interacting protein gene and Parkinson's disease.

We conducted a case-control study of the alpha-synuclein-interacting protein gene (SNCAIP, also known as synphilin-1) and Parkinson's disease (PD). A total of 319 PD cases and 195 controls were genotyped for four SNCAIP variants, including a microsatellite repeat in intron 4 and three restriction fragment length polymorphisms (RFLP) proximal to the 5' terminal of exons 1, 4, and 6. None of the variants were found associated with PD overall. Global score statistics were not significant for four, three, and two loci haplotypes. All four loci were in linkage disequilibrium for cases, controls, or both groups combined (P < 0.0001). Recursive partitioning showed no interactions between variants of the SNCAIP gene and variants of the alpha-synuclein gene (SNCA) or the parkin (PARK2) gene.     

The Workup for Bariatric Surgery Does Not Require a Routine Upper Gastrointestinal Series

Background: Morbid obesity is a serious disease that afflicts over five million Americans, threatening their health with such co-morbidities as diabetes, arthritis, pulmonary failure and stroke. Surgery is the only effective therapy, providing long-term control of weight, diabetes, pulmonary failure, and hypertension for as long as 14 years. Because the operation presents a major expense, this study examined whether X-ray examination of the gut could be omitted safely as a cost-saving measure. Methods: The records of 814 consecutive morbidly obese patients who underwent gastric bypass were reviewed to determine: (1) whether these individuals had undergone an upper gastro-intestinal (GI) series, and (2) if these studies influenced therapy or caused cancellation or postponement of surgery. Results: Of the 814 patients, 657 (80.7%) underwent a preoperative GI radiography. Of these examinations, 393 (59.8%) were normal, with the following abnormalities in the remaining 264: hiatal hernia, 164; esophageal reflux, 39; Schatzki's ring, 18; small bowel diverticula, four; renal stones, four; malrotation, three; gall stones, two; pyloric ulcer, one; possible pelvic mass, one; calcified leiomyoma, one; and dysphagial lusoria, one. None of these findings resulted in cancellation or a delay in surgery. Conclusions: The upper GI series can be safely omitted from the routine preoperative evaluation of patients undergoing gastric bypass. At a cost of $741.00 per examination, this change represents significant potential savings. Similar evaluations of other routine preoperative tests may well provide a better basis for the evaluation of these complex patients.     

Picture of the Month

A 2?year-old boy had the onset of pain and swelling of his penis during the past 3 days. The swelling and pain increased significantly within the past 24 hours. The child's penis is shown in the Figure. DENOUEMENT AND DISCUSSION PARAPHIMOSIS Paraphimosis is an urologic emergency that results when the foreskin is retracted away from the glans penis and cannot be reduced to its former position. The opening in the prepuce, when forcibly retracted beyond the coronal sulcus, becomes a constricting ring that cannot be reduced. The constricting ring created causes a tension greater than the lymphatic pressure and results in edema of the prepuce, the penile shaft, and the glans penis distal to the incarcerated foreskin.1,2As lymphatic drainage is impaired and tissue swelling increases, reduction of the foreskin becomes more difficult. Pain occurs as a result of swelling, and, eventually, as a result of vascular compromise. If.     

Fußkorrekturen beim Apert-Syndrom

Zusammenfassung Operationsziel Schmerzfrei belastungsf?hige Fü?e. Indikationen Gehen und Stehen schmerzhaft. Unbefriedigende Einlagen- und Schuhversorgung. Unbefriedigende ?sthetik. Kontraindikationen Schlechte Hautverh?ltnisse. Operationstechnik Dorsaler Zugang beiderseits. Resektion von intermetatarsalen Knochenbrücken. Korrekturosteotomien fehlstehender Mittelfu?knochen. Beseitigung des Hallux varus durch Reposition der Gro?zehe im Grundgelenk und tempor?re Kirschner-Drahtfixation des Gro?zehenstrahls und der Mittelfu?fragmente. Ergebnisse Zw?lf Jahre nach den Eingriffen an beiden Fü?en lag ein ?sthetisch und funktionell sehr gutes Resultat vor. Die Patientin trug normale Kaufschuhe und belastete beide Fü?e tadellos. Die Fü?e konnten allerdings wegen ausgedehnter angeborener Synostosen der Fu?wurzel- und Tarsometatarsalgelenke nicht befriedigend abgerollt werden.     

Immunization of Adolescents: Recommendations of the Advisory Committee on Immunization Practices, the Amerii Academy of Pediatrics, the American Academy of Family Physicians, and the American Medical Association

SUMMARY: This report concerning the immunization of adolescents (ie, persons 11–21 years of age, as defined by the American Medical Association [AMA] and the American Academy of Pediatrics [AAP]) is a supplement to previous publications (ie, MMWR 1994;43[No. RR-1] 1–38; the AAP 1994 Red Book: Report of the Committee on Infectious Diseases; Summary of Policy Recommendations for Periodic Health Examination, August 1996 from the American Academy of Family Physicians [AAFP]; and AMA Guidelines for Adolescent Preventive Services [GAPS]: Recommendations and Rationale). This report presents a new strategy to improve the delivery of vaccination services to adolescents and to integrate recommendations for vaccination with other preventive services provided to adolescents. This new strategy emphasizes vaccination of adolescents 11–12 years of age by establishing a routine visit to their health-care providers. Specifically, the purposes of this visit are to a) vaccinate adolescents who have not been previously vaccinated with varicella virus vaccine, hepatitis B vaccine, or the second dose of the measles, mumps, and rubella (MMR) vaccine; b) provide a booster dose of tetanus and diphtheria toxoids; c) administer other vaccines that may be recommended for certain adolescents; and d) provide other recommended preventive services. The recommendations for vaccination of adolescents are based on new or current information for each vaccine. The most recent recommendations from AC1P, AAP, AAFP, and AMA concerning specific vaccines and delivery of preventive services should be consulted for details.     

Pathomechanical aspects of intra-articular calcaneus fractures. Typing, grading and surgical therapy]

The forces to produce fractures of the os calcis are combined compression and shear under a cranio-caudal impulse of 10-40 kN and a short time of stroke about 10-40 ms. The main patterns in biomechanics of calcaneal fractures are the time of stroke and the geometrical position of the foot in the moment of impact. Furthermore individual structural changes of the calcaneal cancellous bone, age, diseases as Diabetes mellitus and vascular obliterations are to be respected. Operative treatment of these fractures needs an understanding of the pathomechanism of the intracalcaneal shear-tension-forces. With plantarflexion of the foot combined with vertical forces within 40 ms to the anterior talocalcanear facette impact-fractures of the anterior part can be expected. These forces develop a posterior directed shear tension parallel to the axis of the os calcis, dividing the bone horizontally in two parts (Typ A, 44-56%), well-known as tongue-type fracture. Compression of the posterior talo-calcaneal joint leads to an impact of this structure producing the joint depression type within about 30 ms in dorsoflexion of the foot (Type B, 42%) together with sagittal shear fractures. High-energy forces are supposed to produce the so-called primary fractures of the sustentacular process in about 10 ms in a supinated position of the foot (Type C, 2-10%); these fractures represent in cases of dislocation an indication for open reduction and internal fixation. In our own experience with 45 cases in 35 patients using the lateral or/and medial approach no infection happened. Palmer's lateral approach was preferred.