Abnormal renal vasodilation to an amino acid infusion in congestive heart failure: normalization by enalapril

In congestive heart failure (CHF), the neurohormonal mechanisms that cause renal vasoconstriction, particularly those depending on the renin-angiotensin system, could interfere with renal vasodilating mechanisms. To elucidate this issue, we studied the kidney response to an amino acid infusion (known to cause renal vasodilation in healthy individuals) in eight patients with CHF. We found that the amino acid infusion (0.7 mL/kg/h of a 10% solution) elicited no renal hemodynamic response, in marked contrast to healthy subjects. We next hypothesized that the renin-angiotensin system (known to be activated in heart failure) has a role in the lack of response to the amino acid infusion. To test this hypothesis, we repeated the study after two 5-mg doses of enalapril, an inhibitor of the angiotensin-converting enzyme, administered 12 hours apart. After enalapril treatment, the amino acid infusion caused a 45% increase in mean renal blood flow (RBF) from 383 +/- 55 to 557 +/- 51 mL/min at the fifth hour (P < 0.05). This normalization of the renal response to the amino acid infusion occurred without changes in cardiac output or in systemic vascular resistance. Hence, the renal fraction of the cardiac output increased during the amino acid infusion. The recovery of the renal vascular response was not accompanied by an increase in glomerular filtration rate (GFR; filtration fraction decreased), suggesting a predominant efferent arteriole dilatation. Our study shows that, in heart failure, the kidney loses its ability to increase RBF in response to an amino acid load. This lack of renal vascular response can be restored by inhibiting the renin-angiotensin system and is unrelated to changes in systemic hemodynamics.     

Polymorphic variation within the ADAMTS2, ADAMTS14, ADAMTS5, ADAM12 and TIMP2 genes and the risk of Achilles tendon pathology: A genetic association study

ObjectivesAchilles tendon pathology (ATP) is a multifactorial condition for which genetic risk factors have been identified. The ADAMTS, ADAM12 and TIMP2 genes encode enzymes that are important regulators of tendon homeostasis. ADAMTS2 and ADAMTS14 proteins are procollagen N-propeptidases for pro-collagen type I, type II, and type III. ADAMTS2, like COL5A1, has been linked to Ehlers–Danlos syndrome. Variants within ADAMTS5 and ADAM12 have been associated with osteoarthritis. TIMP2, a metalloprotease inhibitor, maintains homeostasis in the ECM by inhibiting ADAM, ADAMTS and MMP functions. We sought to determine whether single nucleotide polymorphisms (SNPs) within the ADAMTS2, ADAMTS5, ADAMTS14, ADAM12 and TIMP2 genes were associated with the risk of ATP in two independent populations.Design213 (115 ATP cases and 98 asymptomatic controls) South African Caucasian participants and 209 (60 ATP cases and 149 asymptomatic controls) Australian Caucasian participants were recruited for this case–control genetic association study.MethodsAll participants were genotyped using TaqMan technology for the ADAMTS2 rs1054480, ADAMTS5 rs226794, ADAMTS14 rs4747096, ADAM12 rs3740199, and TIMP2 rs4789932 SNPs.ResultsWe report for the first time a significant (p = 0.016) genotypic association between the TIMP2 rs4789932 variant and ATP in a combined Caucasian cohort. We also identify an interaction between the ADAMTS14 rs4747096 variant and age of onset of ATP (p = 0.024).ConclusionsOur data show that DNA sequence variation within the TIMP2 gene is a risk factor for ATP in Caucasians. Furthermore, carriage of the ADAMTS14 rs4747096 GG variant appears to delay onset of the injury in the ATP group.     

Laparoscopic Colorectal Surgery for Obese Patients: Decreased Conversions with the Hand-Assisted Technique

Background

Laparoscopic surgery benefits obese patients but technical difficulties associated with suboptimal exposure and access in these subjects may prompt conversion to open surgery. Hand-assisted laparoscopic surgery (HALS) confers advantages over standard laparoscopy (LAP) by facilitating tactile feedback, assisted dissection, and retraction. These benefits could be particularly valuable in obese patients, allowing completion of difficult laparoscopic procedures in this subgroup. Our aim was to compare intra-operative and post-operative outcomes of HALS and LAP approaches in obese patients undergoing colorectal resection at our institution.

Methods

A retrospective study of a prospectively maintained laparoscopic colorectal surgery database was performed. HALS and LAP cases performed in obese patients (body mass index (BMI)?>30) were identified and compared for the following outcomes: operative time, intra-operative complications, rate of conversion to open, blood loss, length of stay, post-operative morbidity, and mortality. Outcomes for the converted patients were included on an intention-to-treat basis for all primary analyses. A secondary analysis of nonconverted and converted cases was also performed.

Results

Over a 5-year period, 496 obese patients underwent laparoscopic colorectal resection; 86 HALS and 410 LAP cases. The two groups were comparable in terms of age, gender, BMI, and indications for surgery. Conversion to open surgery was less often necessary in HALS compared to LAP cases (3.5 % vs. 12.7 %, p?=?0.014). The LAP group had a significantly smaller incision length for specimen extraction (HALS (7.0?±?1.3 cm) vs. LAP (5.7?±?2.1 cm), p?<?0.001). Length of stay, operative time, morbidity, and mortality rates were comparable between the two groups.

Conclusion

In obese patients who require colectomy, the HALS approach increases the likelihood of a successful minimally invasive operation. At the cost of a clinically negligible increase in incision length, HALS may save a high-risk group conversion to formal laparotomy and the adverse outcomes related to this.     

Randomized clinical trial of enhanced recovery versus standard care after laparoscopic sleeve gastrectomy

Background:

Optimized perioperative care within an enhanced recovery after surgery (ERAS) protocol is designed to reduce morbidity after surgery, resulting in a shorter hospital stay. The present study evaluated this approach in the context of sleeve gastrectomy for patients with morbid obesity.

Methods:

Patients were allocated to perioperative care according to a bariatric ERAS protocol or a control group that received standard care. These groups were also compared with a historical group of patients who underwent laparoscopic sleeve gastrectomy at the same institution between 2006 and 2010, selected using matched propensity scores. The primary outcome was median length of hospital stay. Secondary outcomes included readmission rates, postoperative morbidity, postoperative fatigue and mean cost per patient.

Results:

Of 116 patients included in the analysis, 78 were allocated to the ERAS (40) or control (38) group and there were 38 in the historical group. There were no differences in baseline characteristics between groups. Median hospital stay was significantly shorter in the ERAS group (1 day) than in the control (2 days; P < 0·001) and historical (3 days; P < 0·001) groups. It was also shorter in the control group than in the historical group (P = 0·010). There was no difference in readmission rates, postoperative complications or postoperative fatigue. The mean cost per patient was significantly higher in the historical group than in the ERAS (P = 0·010) and control (P = 0·018) groups.

Conclusion:

The ERAS protocol in the setting of bariatric surgery shortened hospital stay and was cost‐effective. There was no increase in perioperative morbidity. Registration number: NCT01303809 ( http://www.clinicaltrials.gov ). Copyright © 2013 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.     

Management of Failed and Infected First Metatarsophalangeal Joint Implant Arthroplasty by Reconstruction with an Acellular Dermal Matrix: A Case Report

Management of failed first metatarsophalangeal joint implant arthroplasty, especially in the face of infection, is an area of debate without a clear consensus. The purpose of the present report was to explore a new option of reconstructing the joint with an acellular dermal matrix substance in a single case study during a 12-month follow-up period. A staged approach that began with removal of the failed 2-component great toe implant, Koenig^®, excisional debridement of the wound with resection of the necrotic bone (proximal phalanx and distal portion of the first metatarsal bones), and culture-specific antibiosis therapy. The final stage included incorporating the acellular dermal matrix, Graftjacket^® into the joint in an accordion-type fashion, and reconstruction of the joint capsule. Postoperative radiographs revealed a more rectus joint with some improvement in length. At 6 months postoperatively, magnetic resonance imaging revealed incorporation of the graft material into the joint. Finally, at the 1-year mark, the patient was pain free with satisfactory function at the first metatarsophalangeal joint during gait. This is the first reported case of salvaging failed and infected first metatarsophalangeal joint implant arthroplasty with incorporation of the acellular dermal matrix and provides a new option to consider in the future.     

Quantitation of seminal factor IX and factor IXa in fertile, nonfertile, and vasectomy subjects: a step closer toward identifying a functional clotting system in human semen

Coagulation factor (F) IX is a zymogen of the plasma serine proteases, one that plays an essential role in the regulation of normal blood coagulation. Congenital defects of FIX synthesis or function cause hemophilia B (originally called hemophilia C). Factor IX is activated by Tissue Factor (TF):FVII/FVIIa complex and FXIa. Subsequent to its activation, FIXa combines with FVIIIa on the platelet surface and activates FX to FXa. Human semen forms a semi-solid gelatinous coagulum, which then liquefies within 5-20 minutes in vitro. In spite of evidence demonstrating the importance of the seminal coagulation and liquefaction process in terms of global fertility and despite the fact that the seminal coagulum is composed of fibrin-like material, it has always been addressed from the perspective of High Molecular Weight Seminal Vesicle (HMW-SV) proteins (Semenogelin I and II) and their cleavage by prostate-specific antigen rather than the conventional hemostatic factors. In this study and as part of our continuing investigation of human seminal clotting factors, we report here on seminal FIX and FIXa in normal, subfertile, and vasectomized subjects. Factors IX and FIXa were studied in a total of 119 semen specimens obtained from subfertile (n=18), normally fertile (n=34), and fertile sperm donors (n=27) and vasectomy subjects (n=40). Seminal FIX and FIXa levels were also measured in a group defined by normality in several parameters derived from the World Health Organization fertility criteria and termed "pooled normal semen parameters." Both FIX and FIXa were quantifiable in human semen. There was a wide individual variation in FIX and FIXa levels within groups. Despite the group size, statistically significant associations with fertility-related parameters were infrequent. There is a positive correlation between FIX and its activation product, FIXa (n=36; r=0.51; P <.05). Factor IXa elevation in the high sperm-clump group was significant (P <.05), and days of abstention correlated with FIXa levels (n=63; r=0.3; P <.05). The key finding of the present study is that both FIX and FIXa are present in concentrations that are not dissimilar to plasma levels and that are apparently functional, as the activated form is also present. This fact, taken with other reports of coagulation factors in semen, raises the likelihood that a functional set of hemostatic coagulation proteins exists in semen, potentially to interact with the HMW-SV proteins and the prostate-specific antigen system.     

Laparoscopic Transverse Rectus Abdominus Flap Delay for Autogenous Breast Reconstruction

Laparoscopic ligation of the deep and superficial inferior epigastric vessels was done for ten mastectomized patients who elected to have autogenous reconstruction of their breast. All these patients had at least one indication for the delay which included obesity, smoking, or requirement of a large volume of tissue for their reconstruction. The procedure did not add any morbidity or mortality to our patients and was found to be comparable to the “open” delay in preventing partial tissue loss in all but two patients. We describe the use of a minimally invasive procedure to augment the deep superior epigastric pedicled blood supply for the future transverse rectus abdominus flap. We have found in laparoscopic delay a safe, short procedure that is useful in high risk patients who choose the option of autologous breast reconstruction.