Successful treatment of calcific uremic arteriolopathy with sodium thiosulfate in a renal transplant recipient

Abstract Calcific uremic arteriolopathy (CUA) is a rare but life-threatening disorder of arteriolar calcification. It frequently leads to severe ischemia, intense pain, and tissue necrosis with non-healing skin ulcerations. CUA usually occurs in patients with chronic kidney disease (CKD), especially those on dialysis, and its occurrence is rare in kidney transplant recipients. The treatment of this disorder is not clearly defined, and no randomized prospective trials are available. Treatment has focused on optimizing dialysis treatment, control of bone mineral parameters, wound care, experimental anticalcification therapies-using bisphosphonates, cinacalcet, parathyroidectomy, and hyperbaric oxygen. Such treatments are based on the pathophysiological considerations and evidences from case reports or series. Recently, several cases have reported about the emerging benefits of intravenous sodium thiosulfate (STS) in the treatment of CUA. STS has resulted in rapid pain relief, wound healing, and prevention of death. We report a case of CUA in a 63-year-old Caucasian man with a functioning renal allograft. In this patient, intravenous STS was administered for 8 months, which was the principal therapy, which resulted in complete resolution of the CUA and skin healing.     

Vascular catastrophes following pancreas transplantation: an evolution in strategy at a single center

Fridell JA, Johnson MS, Goggins WC, Beduschi T, Mujtaba MA, Goble ML, Powelson JA. Vascular catastrophes following pancreas transplantation: an evolution in strategy at a single center.
Clin Transplant 2012: 26: 164–172.
© 2011 John Wiley & Sons A/S. Abstract: Introduction: Complications of pancreas transplantation involving the arterial anastomosis are potentially life threatening. In this report, we review our experience with such vascular catastrophes. Methods: Pancreas transplants performed between January 2003 and December 2009 were reviewed. All cases of pseudoaneurysm (PA) or arterioenteric fistula (AEF) were included. Results: Of 346 pancreas transplants, 10 vascular catastrophes in nine recipients were identified. There were five PAs, one involving the pancreas allograft, one involving the donor iliac artery Y‐graft stump following allograft pancreatectomy, two involving the kidney allograft, and one involving the bifurcation of the Y‐graft. The latter was treated with coil embolization, but subsequently developed into an AEF. There were five AEFs including the recipient mentioned above. Four had a failed allograft and three had discontinued immunosuppression. The final case had a clamp injury to the proximal common iliac artery that fistulized to the donor duodenum. The management, course and outcome of all nine recipients are described in detail. Conclusion: Vascular catastrophes such as PA and AEF are potentially life‐threatening complications of pancreas transplantation. Immediate treatment at the time of bleeding is essential and covered stenting of the involved artery may provide immediate vascular control in these situations.     

Detrusor myectomy: Long‐term functional outcomes

Objectives: Detrusor myectomy is a recognized method of bladder augmentation for treating refractory detrusor overactivity. Herein we report the long‐term outcomes of this procedure at the University Hospital of Wales in Cardiff, UK. Methods: Detrusor myectomy was carried out in 33 patients (7 males, 26 females) with urodynamically proven detrusor overactivity between 1995 and 2002. The mean patient age was 33 years (range 5–62). A total of 18 patients had idiopathic detrusor overactivity, whereas 15 had neurogenic detrusor overactivity. Results: A total of 24 patients had a detrusor myectomy alone, whereas eight patients had a detrusor myectomy with implantation of artificial urinary sphincter. One patient had detrusor myectomy with transuretero‐ureterostomy. The mean follow up was 148 months (range 108–192). A total of 10 of the 18 patients with idiopathic detrusor overactivity (55.5%) and six of the 15 patients with neurogenic detrusor overactivity (40%) showed marked improvement in symptoms. Detrusor overactivity was completely abolished in 11 patients and significantly reduced in five. Postoperatively, mean cystometric capacity improved from 290 to 458 mL, whereas mean maximum amplitude of detrusor contraction was reduced from 44 cm/H₂O to 20 cm/H₂O. An overall success rate of 48.5% (16/33 patients) was achieved. Intermittent self catheterization was needed to achieve bladder emptying in 12 of the 16 (75%) patients. Of the remaining 17 patients who did not improve, six had CLAM enterocystoplasty carried out and two await the operation. An ileal conduit diversion and suprapubic catheter insertion was carried out in one patient each, whereas seven patients declined any further intervention. Conclusions: Detrusor myectomy offers a reasonable long‐term success rate to patients undergoing surgical treatment for refractory detrusor overactivity.     

Oral bisphosphonate use in the elderly is not associated with acute kidney injury

Intravenous bisphosphonates can cause acute kidney injury; however, this risk was not found with oral bisphosphonates in randomized clinical trials with restrictive eligibility criteria. In order to provide complementary safety data, we studied the risk of acute kidney injury in a population-based cohort of 122,727 patients aged 66 years and older discharged from hospital following a new fragility fracture and no history of bisphosphonate use in the prior year. Bisphosphonate treatment was identified within 120 days after discharge and event rates were measured from 90 days of therapy initiation. The primary outcome was hospitalization with acute kidney injury with secondary outcomes of new nephrology consultation and, in a subset of patients with laboratory values, acute kidney injury was defined as an increase in serum creatinine. We identified 18,286 bisphosphonate users and 104,441 non-users with a mean age of 81 years. Of 5772 patients with laboratory values, 40% had chronic kidney disease (eGFR <60?ml/min per 1.73?m(2)). Overall, there was no statistically significant difference in the risk of acute kidney injury among bisphosphonate users compared to non-users (adjusted odds ratio 1.03), and no significant differences in other outcomes or in subgroups of patients with baseline chronic kidney disease. Thus, in this older population-based cohort, oral bisphosphonate use was not associated with acute kidney injury.     

Changing Pattern of Intestinal Obstruction in Northern Jordan

Background  

Obstructed abdominal wall hernias have been reported to be the leading cause of mechanical intestinal obstruction (MIO) among adults in developing countries. In the developed countries, postoperative adhesions are the commonest cause. With the worldwide improvements in health services and education, especially in developing countries, we aimed to determine the effects of these improvements on the patterns and outcomes of management of MIO in Jordan     

Lateralized response of dynorphin a peptide levels after traumatic brain injury

Traumatic brain injury (TBI) induces a cascade of primary and secondary events resulting in impairment of neuronal networks that eventually determines clinical outcome. The dynorphins, endogenous opioid peptides, have been implicated in secondary injury and neurodegeneration in rodent and human brain. To gain insight into the role of dynorphins in the brain's response to trauma, we analyzed short-term (1-day) and long-term (7-day) changes in dynorphin A (Dyn A) levels in the frontal cortex, hippocampus, and striatum, induced by unilateral left-side or right-side cortical TBI in mice. The effects of TBI were significantly different from those of sham surgery (Sham), while the sham surgery also produced noticeable effects. Both sham and TBI induced short-term changes and long-term changes in all three regions. Two types of responses were generally observed. In the hippocampus, Dyn A levels were predominantly altered ipsilateral to the injury. In the striatum and frontal cortex, injury to the right (R) hemisphere affected Dyn A levels to a greater extent than that seen in the left (L) hemisphere. The R-TBI but not L-TBI produced Dyn A changes in the striatum and frontal cortex at 7 days after injury. Effects of the R-side injury were similar in the two hemispheres. In naive animals, Dyn A was symmetrically distributed between the two hemispheres. Thus, trauma may reveal a lateralization in the mechanism mediating the response of Dyn A-expressing neuronal networks in the brain. These networks may differentially mediate effects of left and right brain injury on lateralized brain functions.     

Optical performance comparison of deflectable laparoscopes for laparoendoscopic single-site surgery

Abstract Background and Purpose: Flexible working angles and fine optical visualization are major requisite factors in performing laparoendoscopic single-site (LESS) urologic procedures. Multiple mechanical design approaches have been used to develop deflectable laparoscopes for LESS procedures. We compared the optical characteristics of three such devices using a bench top approach to simulate LESS in straight and deflected positions. Materials and Methods: A 10-mm fixed-rod rotating lens device (Storz EndoCameleon) and two 5-mm articulating devices (Olympus EndoEye and Stryker IdealEye) were compared using standard industry testing protocols for image resolution (United States Air Force-1951 test target), distortion (multifrequency grid distortion target), and color reproducibility (Gretag Macbeth color checker). Results: The 10-mm fixed-rod rotating lens system demonstrated the highest image resolution (5.04 line pairs/mm), but also the highest distortion (22.8%). Among the 5-mm flexible articulating laparoscopes, resolution was superior with the Olympus EndoEye (4.00 line pairs/mm) compared with the Stryker IdealEye (3.17 line pairs/mm). Distortion (7.0%) and color reproduction (1.18) were superior with the IdealEye vs the EndoEye (18.8 %, 1.27). Laparoscope deflection resulted in attenuation of resolution by 11% with both articulating models, but not with the fixed rod system. Conclusions: Definition of these optical characteristics may inform further development and selection of laparoscopic systems optimized for LESS surgery. A narrow but flexible camera can be crucial in the limited working space available during these procedures. Further investigation is warranted to determine if these objective findings translate into improved surgeon performance.     

Using transcutaneous carbon dioxide monitor (TOSCA 500) to detect respiratory failure in patients with amyotrophic lateral sclerosis: A validation study

Amyotrophic lateral sclerosis (ALS) is a fatal neurodegenerative condition, respiratory failure being the commonest cause of death. Quality of life and survival can be improved by supporting respiratory function with non-invasive ventilation. Transcutaneous carbon dioxide monitoring is a non-invasive method of measuring arterial carbon dioxide levels enabling simple and efficient screening for respiratory failure. The aim of this study was to validate the accuracy of carbon dioxide level recorded transcutaneously with a TOSCA 500 monitor. It is a prospective, observational study of 40 consecutive patients with ALS, recruited from a specialist ALS clinic. The partial pressure of carbon dioxide (PCO(2)) in each patient was determined by both transcutaneous monitoring and by an arterialized ear lobe capillary blood sample. The carbon dioxide (CO(2)) levels obtained with these two methods were compared by Bland-Altman analysis. The results showed that the mean difference between arterialized and transcutaneous readings was - 0.083 kPa (SD 0.318). The Bland-Altman limits of agreement ranged from 0.553 to - 0.719 kPa. The difference was ?0.5 kPa, with a maximum recorded difference of 0.95 kPa. In conclusion, non-invasive carbon dioxide monitoring using a TOSCA monitor is a useful clinical tool in neurology practice. Users should be aware of the possibility of occasional inaccurate readings. A clinically unexpected or incompatible reading should be verified with a blood gas analysis, especially when a decision to provide ventilatory support is required.     

Sigmoid volvulus in pregnancy and puerperium: a surgical and obstetric catastrophe. Report of a case and review of the world literature

ABSTRACT: Sigmoid volvulus is a rare surgical complication occurring in pregnancy and puerperium. Only 84 cases of sigmoid volvulus in pregnancy have been reported in the English literature so far. We have reviewed the available literature on this subject and present another case recently managed at our institution. The available literature suggests that over the years, there has been an improvement in the maternal and fetal outcome for this critical condition, but delay in presentation and a further delay in diagnosis remain a challenge for the treating physicians. Our patient was a 30-week pregnant lady, who presented late with 6?days history of abdominal pain, distension and absolute constipation. She had evidence of multi-organ dysfunction at presentation due to complicated sigmoid volvulus. She was resuscitated and surgical exploration revealed gangrenous large bowel. Bowel resection with diverting ileostomy was performed, but she succumbed to the septic shock due to late presentation. Acute surgical pathology may be overlooked in pregnant patients due to reluctance in radiological workup and a high index of suspicion is essential for enhanced outcome. There is a need to increase the awareness amongst the obstetricians and general practitioners. Early diagnosis and referral and timely surgical intervention could significantly improve the outcome of this surgical and obstetric catastrophe.