Outcome of 234 pregnancies in 140 renal transplant recipients from five middle eastern countries

OBJECTIVE: To study the pregnancy and offspring outcomes in postrenal transplant recipients. METHODS: This is a retrospective case-note review study investigating the outcome of 234 pregnancies in 140 renal transplant recipients from five different Middle Eastern countries. RESULTS: Of the overall pregnancies 74.4% were successful albeit with high prevalences of preterm and Caesarean deliveries (40.8% and 53%, respectively). The mean serum creatinine did not rise significantly during pregnancy in the group as a whole but did so in patients who had serum creatinine of or above 150 micromol/L at the beginning of their pregnancies. The mean birth weight was (2,458 g) with 41.3% of the newborns being of low birth weight (<2,500 g). The prevalences of stillbirths were 7.3% and of spontaneous abortion was 19.3%. Preeclampsia and gestational diabetes were observed in 26.1% and 2% of pregnancies, respectively. CONCLUSIONS: In the presence of good allograft function, the majority of pregnancies in renal transplant recipients have a good outcome but with increased incidence of preeclampsia, reduced gestational age, and low birth weights. Patients with baseline serum creatinine of above 150 micromol/L have an increased risk of allograft dysfunction resulting from the pregnancy.     

A critical review of modern and emerging absorbent dressings used to treat exuding wounds

Wound management has progressed significantly over the last five decades. This emanates from a greater understanding of wound healing, technological progression and improved clinical and scientific research. There are currently a plethora of absorbent dressings on the wound care market which claim to have the ability to manage exudates whilst encouraging healing. However, it is becoming clear, from analysing randomised controlled trials, that some of these absorbent dressings are not meeting their expectations when applied in a clinical setting. Many clinicians now feel that there should be more focus, not only on a dressing's ability to manage exudate efficiently, but on a dressing's ability to proactively encourage healing and thus exudate reduction will ensue. This paper proposes to critically review modern and emerging absorbent wound care dressings used to manage exuding wounds and discuses some advances in this area.     

Flexor tendon repair using shape memory alloy suture: a biomechanical evaluation

The purpose of the current study was to test in vitro a new shape memory alloy suture for flexor tendon repair. Forty fresh-frozen human anatomic flexor superficialis and profundus tendons were divided and repaired via the cruciate four-strand technique using one of two suture materials (the shape memory alloy suture and the 4-0 Ethibond suture). The forces required to cause a 1, 2, and 3 mm gap, ultimate load to failure, and repair stiffness were compared. Twenty specimens of each suture material also were tensile tested for load to failure, tensile strength, and elongation at failure. The shape memory alloy suture had a significantly higher mean resistance force to 1, 2, and 3 mm gap formation than the 4-0 Ethibond suture (47 N versus 31 N, 51 N versus 36 N, and 57 N versus 41 N, respectively). The shape memory alloy suture repair was 40% stronger than the 4-0 Ethibond suture (61.9 +/- 8.8 N versus 44.3 +/- 10.6 N). Repair with the shape memory alloy suture was significantly stiffer than repair with the 4-0 Ethibond suture (8.1 +/- 1.0 N/mm versus 6.1 +/- 0.9 N/mm). The load to failure and tensile strength of the shape memory alloy suture were significantly higher than that of the 4-0 Ethibond suture. The values of elongation for the two materials were not significantly different. The results of the current study suggest that the shape memory alloy suture may be superior to the 4-0 Ethibond suture in resisting gap formation in the range of forces generated in the early rehabilitation protocol and may be the future material of choice for tendon repairs.     

Optimal decentralized control of a wind turbine and diesel generator system

This article presents a decentralized optimal controller design technique for the frequency and power control of a coupled wind turbine and diesel generator. The decentralized controller consists of two proportional-integral (PI)-lead controllers which are designed and optimized simultaneously using a quasi-Newton based optimization technique, namely, Davidon–Fletcher–Powell algorithm. The optimal PI-lead controllers are designed in such a way that there are no communication links between them. Simulation results show the superior performance of the proposed controller with a lower order structure compared to the benchmark decentralized linear-quadratic Gaussian integral controllers of orders 4 and 11. It is also shown that the proposed controller demonstrates an effective performance in damping the disturbances from load and wind power, as well as a robust performance against the parameter changes of the power system.     

Reoperative lower extremity revascularization with cadaver vein for limb salvage

We evaluated our experience using cryopreserved cadaver vein allografts (CVGs) for infrageniculate revascularization in patients with a history of failed bypass or no suitable autogenous vein. Records of all patients who underwent lower extremity revascularization with CVG for critical limb ischemia were reviewed. Patient demographics, vessel treated, and postoperative course were analyzed. Patients who had a redo cadaver vein bypass were compared to those with a first-time cadaver vein bypass. Cumulative patency rates, limb salvage, mortality, and factors associated with outcomes were determined using the Kaplan-Meier method with Cox proportional hazards. Between January 2000 and December 2006, 66 CVGs were done in 56 patients out of 1,726 total bypasses. There were 36 men and 20 women, and the mean age was 71.67 +/- 10.50 years. Mean follow-up was 12.12 +/- 14.16 months. Seventy-eight percent of patients had previous bypasses, and 50% of all failed bypasses were failed expanded polytetrafluoroethylene bypasses. Operative indications were tissue loss (73%) and ischemic rest pain (27%). The mean preoperative ankle-brachial index was 0.43 +/- 0.16, and this increased to 0.89 +/- 0.18 at 30 days (p = 0.001). Procedure-related complications included graft infection (3, 4%), graft thrombosis (3, 4%), pseudoaneurysm (3, 4%), and bleeding (2, 3%). Cumulative 1-year primary, primary assisted, secondary patencies, limb salvage, and survival rates with confidence intervals were 0.19 (0.10-0.36), 0.29 (0.18-0.47), 0.42 (0.29-0.60), 0.73 (0.62-0.86), and 0.77 (0.65-0.90). Reoperative procedures fared the same as primary procedures. Multivariable analysis showed that predictors for increased risk of secondary patency loss were age >70 (hazard ratio [HR] = 3.13, p = 0.009) and patients with secondary revascularization (HR = 3.36, p = 0.015). Older patients (HR = 2.92, p = 0.042) and those with renal insufficiency (HR = 2.92, p = 0.019) were at increased risk of mortality. CVG remains an option for reoperative lower limb revascularization for limb salvage if there is no autogenous vein available. However, patency rates are poor, and patients older than 70 are more likely to have inferior outcomes.     

Kaposi’s sarcoma following living donor kidney transplantation: review of 7,939 recipients

Introduction  Kaposi’s sarcoma (KS) is one of the most common tumors to occur in kidney recipients, especially in the Middle East countries. Limited data with adequate sample size exist about the development of KS in living kidney recipients. Methods  Therefore, we made a plan for a multicenter study, accounting for up to 36% (n = 7,939) of all kidney transplantation in Iran, to determine the incidence of KS after kidney transplantation between 1984 and 2007. Results  Fifty-five (0.69%) recipients who developed KS after kidney transplantation were retrospectively evaluated with a median follow-up of 24 (1–180) months. KS occurred more often in older age when compared to patients without KS (49 ± 12 vs. 38 ± 15 years, P = 0.000). KS was frequently found during the first 2 years after transplantation (72.7%). Skin involvement was universal. Furthermore, overall mortality rate was 18%, and it was higher in patients with visceral involvement compared to those with mucocutaneous lesions (P = 0.01). However, KS had no adverse affect on patient and graft survival rates compared to those without KS. Forty-four patients with limited mucocutaneous disease and four with visceral disease responded to withdrawal or reduction of immunosuppression with or without other treatment modalities. Renal function was preserved when immunosuppression was reduced instead of withdrawn in patients with and without visceral involvement (P = 0.001 and 0.008, respectively). Conclusion  The high incidence of KS in this large population studied, as compared to that reported in other transplant patient groups, suggests that genetic predisposition may play a pathogenetic role.     

The effect of low-intensity pulsed ultrasound on callus maturation in tibial distraction osteogenesis

Callus distraction is currently the most popular method of bone lengthening. Prolonged treatment time is one of its major problems. In this study, we investigated the effect of low-intensity pulsed ultrasound on tibial distraction osteogenesis. We managed 20 patients with tibial defects ranging from 5 cm to 8 cm with distraction osteogenesis using the Ilizarov external fixator. After the completion of distraction, ten patients received daily 20 min of low-intensity pulsed ultrasound stimulation (30 mW/cm²) onto the bone lengthening site (group A) while rigid fixation was maintained in the remaining patients (group B). All patients were followed with weekly radiographs to determine the formation of an external cortex and an intramedullary canal, at which time the fixator was removed. The mean healing index in group A was 30 (27–36) days/cm while it was 48 (42–75) days/cm in group B. In group B, one patient failed to consolidate the regenerated bone. Low-intensity pulsed ultrasound stimulation is highly effective in achieving maturation of bone and reducing time of distraction osteogenesis.

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Résumé La distraction du cal est la méthode dallongement de los la plus populaire actuellement. La longueur du traitement est un de ses problèmes majeurs. Nous avons étudié leffet des ultrasons pulsés de basse intensité sur lostéogenèse dans la distraction tibiale.Nous avons traité 20 malades présentant un défaut tibial de 5 à 8 centimètres avec ostéogenèse de distraction utilisant un fixateur externe dIlizarov. Après lachèvement de la distraction 10 malades ont reçu quotidiennement une stimulation par ultrasons (30 mW/cm²) sur lemplacement de lallongement osseux pendant 20 minutes (groupe A), pendant que la fixation rigide était maintenue pour le restant des malades (groupe B). Tous les malades ont été suivis avec des radiographies hebdomadaires pour déterminer la formation dun cortex périphérique et dun canal intramédullaire au moment ou le fixateur a été enlevé. Lindex de consolidation moyen dans le groupe A était 30 (27–36) jours/cm pendant quil était 48 (42–75) jours/cm dans le groupe B. Dans le groupe B un malade na pas consolidé los régénéré. La stimulation par ultrasons pulsés de basse intensité est très efficace pour favoriser la maturation osseuse et réduire le temps dostéogenèse dans la distraction.

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None of the authors received financial support for this study.     

Unusual cause of lower extremity wounds: Cobb syndrome

Cobb syndrome (Cutaneomeningospinal Angiomatosis) is a rare segmental neurocutaneous syndrome associated with metameric cutaneous and spinal cord arteriovenous malformations (AVMs). In this syndrome, capillary malformation or angiokeratoma‐like lesions are formed in a dermatomal distribution, with an AVM in the corresponding segment of the spinal cord. The spinal cord lesions can cause neurological disorder and paraplegia, which typically develop during young adulthood. We report a 32‐year‐old male with the Cobb syndrome associated with lower extremity painful wounds and acute‐onset paraplegia due to metameric vascular malformations.     

Maximizing Weight Loss After Roux-en-Y Gastric Bypass May Decrease Risk of Incident Organ Cancer

Background

Recent studies have suggested that metabolic surgery reduces cancer risk. This study aims to determine if incident cancer is associated with the extent of weight loss after Roux-en-Y gastric bypass (RYGB).

Methods

Patients at a large tertiary bariatric surgery center were retrospectively reviewed to identify patients with no history of cancer at the time of RYGB. Diagnoses in the electronic health record, a tumor registry, and chart review were used to identify postoperative incident solid organ cancer. The overall incidence of organ cancer was estimated using Kaplan-Meier analysis. The percent total body weight loss (%TWL) in the 48 months after surgery but prior to cancer was compared between those that developed organ cancer versus those that did not using repeated measures linear regression.

Results

The 2943 patients had a mean age of 45.6 years (SD?=?11.1), 81 % were female, and a mean baseline body mass index (BMI) of 47.2 kg/m² (SD?=?7.9). Median follow-up after surgery was 3.8 years (range?=?[<1, 12]). Incident organ cancer developed and was verified in 54 of the 2943 patients (1.8 %). Kaplan-Meier estimates for cancer at 3, 5, and 10 years postsurgery were 1.3, 2.5, and 4.2 %. After adjusting for age, BMI, sex, diabetes, hypertension, and dyslipidemia, patients that developed organ cancer achieved less weight loss (?1.5 % TWL, 95 % CI?=?[?2.9 %, ?0.1 %], p?=?0.034).

Conclusions

Greater weight loss after metabolic surgery may be associated with lower organ cancer risk.

     

Photodynamic therapy of head and neck basal cell carcinoma according to different clinicopathologic features

BACKGROUND AND OBJECTIVES: We aimed to treat different pathologic types of basal cell carcinomas (BCCs) using photodynamic therapy (PDT). STUDY DESIGN/MATERIALS AND METHODS: Thirty lesions in six patients underwent PDT. The photosensitizer used was Photoheme, a hematoporphyrin derivative IX. It was injected intravenously at the dose of 2-3.25 mg/kg. After 24 hours, the lesions were illuminated by laser light (lambda = 632 nm, light exposure dose = 100-200 J/cm2). Lesions were evaluated pre and post-operatively and at follow-up sessions (of up to 6 months). RESULTS: After a single session of PDT, the average response rate in different histopathologic kinds of basal cell carcinoma (e.g., ulcerative, superficial, nodular, and pigmented forms) were 100%, 62%, 90%, and 14%, respectively. In patients who responded completely, the cosmetic results were excellent and there were no recurrence at 6th month of follow-up. CONCLUSION: Although PDT seems to be an effective treatment modality for superficial, ulcerative, and nodular BCCs, it is not recommended for pigmented lesions.