Outcome of liver transplantation in septuagenarians: a single-center experience

HYPOTHESIS: We hypothesized that selected septuagenarians may do as well after transplantation as those of a younger group of older recipients. This work compares post-liver transplant survival in septuagenarians with that of patients aged 50 to 59 years. DESIGN: Review of a prospectively maintained database. SETTING: University transplant center. PATIENTS: First-time liver transplant recipients treated from January 1, 1988, to December 31, 2005. Group 1 consisted of liver transplant recipients aged 70 years or older at the time of transplant. Group 2 was a younger cohort of patients aged 50 to 59 years. INTERVENTIONS: Liver transplantation. MAIN OUTCOME MEASURES: Patient survival. Survival data were stratified, Kaplan-Meier survival was calculated, and a multivariate analysis was performed. RESULTS: Group 1 included 62 patients aged 70 years or older (average, 71.9 +/- 2.1 years). Group 2 included 864 patients aged 50 to 59 years (average, 54.3 +/- 2.9 years). Unadjusted patient survival of group 1 at 1, 3, 5, and 10 years was 73.3%, 65.8%, 47.1%, and 39.7%, respectively. Unadjusted patient survival of group 2 at 1, 3, 5, and 10 years was 79.4%, 71.5%, 65.3%, and 45.2%, respectively. The difference was not statistically significant (P = .14). Multivariate analysis for factors affecting survival demonstrated preoperative hospitalization, cold ischemia time, and hepatitis C/ethanol as risk factors for death. Age 70 years or more was not a strong risk factor (mortality ratio, 1.28; P = .27). CONCLUSIONS: When other risk factors for mortality are controlled in older recipients, risk of death due to age is reduced in well-selected recipients. Age by itself should not be used to limit liver transplantation.     

Subarachnoid lumbar drains: A case series of fractured catheters and a near miss

PURPOSE: Lumbar subarachnoid catheters for cerebrospinal fluid (CSF) drainage (lumbar drains) are indicated for several medical and surgical conditions. A number of complications can occur from the placement of this type of catheter, including catheter breakage from excessive traction or shearing over the Tuohy needle. CLINICAL FEATURES: Five cases of lumbar subarachnoid catheter breakage/shearing and catheter fragment retention, as well as one near miss, were identified over a one-year period at a single institution. All (n = 6) patients were undergoing neurosurgical procedures. Four patients required surgical retrieval of the catheter fragments. No patient experienced log-term neurological sequelae. DISCUSSION: From these experiences, the following risks factors for catheter rupture are identified: 1) intentional or accidental retraction of the catheter through the needle during placement; 2) faulty use of the guidewire; or 3) use of excessive force during removal of the catheter. Methods to prevent such complications are suggested, including minimal use, or complete avoidance of a guidewire.     

Neurointensive care; impaired cerebral autoregulation in infants and young children early after inflicted traumatic brain injury: a preliminary report

The objective of this report is to describe cerebral autoregulation after severe inflicted pediatric traumatic brain injury (iTBI). We examined cerebral autoregulation of both cerebral hemispheres (mean autoregulatory index; ARI) in children <5 years with Glasgow Coma Scale (GCS) score of <9 and no evidence of brain death within the first 48 h of pediatric intensive care unit (PICU) admission. Discharge and 6-month Glasgow Outcome Scale (GOS) scores were collected. GOS of <4 reflected poor outcome. All three iTBI and all seven noninflicted TBI (nTBI) patients had admission GCS score of <9. Eight of 10 patients had Autoregulatory Index (ARI) of <0.4 (impaired cerebral autoregulation) of at least one hemisphere. All children with iTBI had poor outcome, and none had intact cerebral autoregulation in both hemispheres. Children with nTBI had better overall outcome than those with iTBI. Two of the children with nTBI had intact autoregulation in both hemispheres and good outcome. Two of the three children with iTBI had differential effects on autoregulation between hemispheres despite bilateral injury. These are, to our knowledge, the first data on cerebral blood flow autoregulation in the unique setting of iTBI and provide a rationale for further study of their relationship to outcome and effects of therapy.     

Repeated botulinum toxin type A (Dysport®) injections for women with intractable detrusor overactivity: a prospective outcome study

Introduction and hypothesis

We present the cohort of 33 women who underwent botulinum toxin type A (BTX-A) injections examining the efficacy and safety of BTX-A in idiopathic detrusor overactivity (IDO). The aim of this report is to describe the outcomes of those who underwent repeated injections of BTX-A.

Methods

All 33 women had 3 or more injections with an initial dose of 500 units of Dysport® with subsequent injections between 500 and 750 U, administered by the classic trigone-sparing flexible/rigid cystoscopic technique. An informed consent was obtained in all cases. Efficacy was measured using voiding diaries and quality of life (QOL) assessed with the International Consultation on Incontinence Questionnaire-Short Form (ICIQ -SF). This project was approved by the Clinical Effectiveness Department and the Drugs and Therapeutics Committee (DTC). Therefore, ethical approval was not required.

Results

This study included 33 women who have been successfully treated with repeated intradetrusor injections of BTX-A (Dysport®). Mean duration between the first and second injections was 15.2?±?7.2 months, whereas between the second and third was 19.2?±?10 months (P?=?0.025). Two women developed urinary tract infection and required clean intermittent self-catheterization. Three women required dose escalation to 750 units. Longer duration of subjective QOL improvement was noted between the second and third botulinum toxin injections compared to duration between the first and second injections.

Conclusions

BTX-A appears to be effective and safe after repeated administration in women with IDO. The duration of the injection tends to get prolonged after the second injection.     

Hyperbaric oxygen for the treatment of nonhealing arterial insufficiency ulcers

There is limited data regarding hyperbaric oxygen's effectiveness in the treatment of nonhealing arterial insufficiency ulcers. This study was designed to analyze healing rates and amputation rates in patients who underwent adjunctive hyperbaric oxygen for a nonhealing arterial insufficiency ulcer. A retrospective chart review was completed on patients who underwent hyperbaric oxygen for arterial insufficiency ulcers that failed to heal despite standard treatment. Information collected included complete ulcer healing, amputation, and patient characteristics. There were 82 patients identified. A majority did not have diabetes (84.1%). The overall rate of healing was 43.9%. The overall major amputation rate was 17.1%. The amputation rate among those who healed was 0% compared to 42.4% among those not healed (p < 0.0001). Dialysis was predictive of major amputation (p = 0.03). Our findings suggest hyperbaric oxygen can play a role in management of arterial insufficiency ulcers that have failed standard treatment. The overwhelming majority of these patients did not have diabetes, which allows this study to be translated to patients with a primary arterial insufficiency ulcer. These results support the use of hyperbaric oxygen for select nonhealing arterial insufficiency ulcers that have failed standard therapy and the need for a prospective pilot study.     

Laparoscopic Bariatric Surgery Can Be Performed Through a Single Incision: A Comparative Study

Background

The application of single-incision laparoscopic surgery (SILS) in bariatric patients has been limited to less complex procedures. We evaluated the short-term outcomes of SILS sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB), compared to a group of well-established minimally invasive techniques.

Methods

Twenty-eight morbidly obese patients who underwent SILS SG (n?=?14) and RYGB (n?=?14) were compared to a matched control group composed of 28 cases of conventional laparoscopic surgery (CLS). A single vertical 2.5–3-cm intra-umbilical incision, three-ports placed trans-fascially, and a liver suspension technique were used to perform SILS.

Results

Both groups were comparable in terms of age (p?=?0.96), gender (p?=?1.0), type of procedure (p?=?1.0), and number of comorbidities (p?=?0.63). Two (7 %) SILS patients required placement of one additional port, and no conversions to CLS or open surgery were needed. The estimated blood loss (p?=?0.48), operative time (p?=?0.33), length of hospital stay (p?=?0.79), overall 90-day perioperative complication rate (p?=?1.0), and short-term weight loss (p?=?0.53) were comparable between the two groups. In terms of pain control, the frequency of patient-controlled analgesia use in both groups was similar. However, the pain score (assessed by visual analog scale) was significantly less for SILS patients on postoperative days 1 (5.0?±?2.1 vs. 6.5?±?1.8; p?=?0.007) and 2 (4.0?±?2.0 vs. 5.1?±?2.4; p?=?0.49). Cosmetic satisfaction with the scar was high in the SILS group. No patients required reoperation or readmission during the 90 days after surgery.

Conclusion

SILS is feasible in carefully selected bariatric patients and results in short-term outcomes comparable to those observed after CLS. Improved pain and cosmesis are potential benefits of SILS.     

Sacral examination in spinal cord injury: Is it really needed?

Objective: To determine if a self-report measure of S4-5 motor and sensory function in patients with chronic SCI accurately predicts sacral examination results.

Design: Prospective, single-blinded self-report survey compared with sacral exam.

Setting: Outpatient SCI clinic.

Participants: 116 patients aged 18+ with chronic SCI > 6 months who have undergone sacral exam.

Interventions: The survey included demographic/clinical and sacral function information such as light tough (LT), pinprick sensation (PP), deep anal pressure (DAP) and voluntary anal contraction (VAC). Survey results and sacral exam were compared and stratified by the patient’s American Spinal Cord Injury Association Impairment Scale (AIS) category.

Outcome Measures: Sacral self-report survey, AIS examination.

Results: Mean age was 41.3?±?14.4 years with majority male (69%) and Caucasian (71.6%). Overall, Positive Predictive Value (PPV) ranged between 48% (VAC) to 73% (DAP) and Negative Predictive Value (NPV) between 92% (VAC) to 100% (LT). AIS-A had NPV of 100% across all categories, and AIS-D had PPV of 100% across all categories.

Conclusion: Patient report of sacral sparing can predict negative sensation in patients with AIS-A and predict positive sensation in persons with AIS-D. Overall, the self-report of sacral sparing of motor and sensory function is not predictive enough to rely on for accurate classification.     

Sodium removal and sodium concentration during peritoneal dialysis: effects of three methods of sodium measurement.

BACKGROUND: Sodium removal (NaR) may have a major impact on the survival of peritoneal dialysis patients. The dialysate/plasma sodium concentration ratio (D/P(Na)) is an indirect index of transcellular water transport by aquaporin channels, and thus of ultrafiltration. Sodium concentration can be assessed by means of flame photometry (F), and direct (D-ISE) or indirect ion-selective electrodes (I-ISE), but these methods have different properties. I-ISE is being used increasingly in clinical laboratories. The aim of this study was to evaluate NaR and D/P(Na) using the three different measurement methods. METHODS: We performed peritoneal equilibration tests (PETs) in 44 peritoneal dialysis patients and calculated the NaR. We also calculated D/P(Na) during the test; plasma and dialysate sodium concentrations were measured by F, D-ISE and I-ISE. RESULTS: NaR was lower (P<0.001) with D-ISE (69+/-29 mmol) than with F (81+/-29 mmol) or I-ISE (79+/-28 mmol). D/P(Na) was also lower at baseline (0.92+/-0.02 vs 0.95+/-0.02 and 0.95+/-0.02; P<0.001), after 60 min (0.87+/-0.03 vs 0.90+/-0.03 and 0.90+/-0.03; P<0.001) and at the end of PET (0.88+/-0.04 vs 0.92+/-0.04 and 0.92+/-0.04; P<0.001) when measured by D-ISE in comparison with F and I-ISE, respectively. CONCLUSIONS: NaR and D/P(Na) were lower when measured by the D-ISE method compared with the F and I-ISE methods. NaR and D/P(Na) were similar when measured by F or I-ISE. I-ISE can be used reliably in the evaluation of NaR and D/P(Na) in everyday clinical practice of peritoneal dialysis.     

Isotopic renal function studies in severe hypothyroidism and after thyroid hormone replacement therapy

AIM: To investigate the possible changes in the renal tubular function in severe short-term hypothyroidism using (99m)Tc-MAG(3) renography. METHODS: 27 consecutive thyroidectomized patients (7 males and 20 females) aged 19-79 (mean 53) years were included in the present study. (99m)Tc-MAG(3) renography was performed in all patients before and after thyroid hormone replacement therapy. In addition, (51)Cr-EDTA clearance and serum creatinine concentrations were determined. RESULTS: The serum creatinine concentrations were significantly increased in hypothyroidism as compared with the concentrations after thyroxine substitution (1.30 +/- 0.44 vs. 1.04 +/- 0.32 mg/dl, p < 0.05). According to the (51)Cr-EDTA clearance, the glomerular filtration rate was significantly lower in hypothyroidism than after treatment (61 +/- 18 vs. 75 +/- 23 ml/min). In contrast, we did not find any significant change in the renographic parameters for (99m)Tc-MAG(3) before and after treatment (total excreted activity 20 min after administration 51 +/- 12 vs. 54 +/- 14%; T(max) left:right 4.2 +/- 1.77 : 3.91 +/- 1.06 min vs. 4.1 +/- 1.66 : 4.4 +/- 1.96 min). CONCLUSIONS: We did not find any influence of thyroid hormones on the outcome of (99m )Tc-MAG(3) renography. As (99m)Tc-MAG(3) reflects the tubular function, it seems that the renal hemodynamic changes in severe hypothyroidism mainly affect the glomerular function. In general, the glomerular filtration rate reduction seems to be reversible after hormone substitution therapy; however, care has to be taken in patients with renal insufficiency.