An institutional experience with epidural analgesia in children and young adults undergoing cardiac surgery

Background: Allowing spontaneous respiration after cardiac surgery eliminates complications related to mechanical ventilation and optimizes cardiopulmonary interaction. Epidural analgesia has been proposed to promote early extubation after cardiac surgery. Objective: To identify the characteristics of patients with epidural analgesia and safety profiles with respect to the timing of extubation following cardiac surgery. Design and method: A retrospective chart review of patients who underwent cardiac surgery during a 5‐year period. Demographic, procedural, and perioperative variables were analyzed to investigate factors that affect the timing of extubation. Results: A total of 750 records were reviewed. The patients’ median age was 12 months, and 52% were infants (<1 year). Seventy‐five percent of the patients utilized cardiopulmonary bypass. The study population was classified into three groups according to the timing of extubation: 66% were extubated in the operating room or upon arrival at the PICU (Immediate), 15% were extubated within 24 h (mean, 10.8 h; 95% CI, 9.0–12.6) (Early), and 19% were extubated after 24 h (Delayed). For the Immediate and Early groups, multivariate logistic regression identified young age, increased cross‐clamp time, and inotrope score as independent risk factors for the need for mechanical ventilation. Postextubation respiratory acidosis (mean P_aCO₂, 50 mmHg; 95% CI, 49–51) was well tolerated by all patients. There were no neurologic complications related to the epidural technique. Conclusion: Epidural analgesia in children undergoing cardiac surgery provides stable analgesia without complications in our experience.     

Stones in anomalous kidneys: Results of treatment by shock wave lithotripsy in 150 patients

OBJECTIVE: To determine the efficacy of shock wave lithotripsy (SWL) in anomalous kidneys. METHODS: From October 1990 to October 2002, 150 patients (93 men and 57 women) with anomalous urinary tracts, including 45 horseshoe kidneys, 57 duplex kidneys, 30 malrotated kidneys, 14 pelvic and four crossed ectopic kidneys were treated with SWL for urolithiasis at the Gazi University Faculty of Medicine. Shock wave lithotripsy was performed with Siemens Lithostar plus (Siemans, Erlanger, Germany) device and all procedures were carried under fluoroscopic control. Results: The mean shock wave number and intensity received by the patients was 3770 (range, 1380-4100) shocks and 18.4 (range, 16.1-19) kV per session, respectively. The minimum success rate was obtained in patients with lower calyceal (50%) followed by middle calyceal (60%) calculi. The stone-free rate decreased and the number of sessions per patient increased with increasing stone diameter (dm). In patients with a stone dm > 30 mm, only 34% could be stone-free, compared to a rate of 92% for calculi dm < 10 mm. The overall stone free rate at the third month was 68%. The best stone-free rates were obtained in patients with ureteral duplication (80.7%). The stone-free rates in horseshoe, malrotated, pelvic and crossed ectopic kidneys were found to be 66.7%, 56.7%, 57.2% and 25%, respectively. CONCLUSION: Shock wave lithotripsy might be an effective and minimally invasive treatment alternative in stone-bearing anomalous kidneys. The type of anomaly, stone burden and localization seem to be the main parameters effecting the treatment success.     

Fournier's gangrene: Report of thirty-three cases and a review of the literature

Background: Fournier’s gangrene (FG) is an extensive fulminant infection of the genitals, perineum or the abdominal wall. The aim of this study is to share our experience with the management of this difficult infectious disease. Methods: Thirty‐three male patients were admitted to our clinic with the diagnosis of FG between February 1988 and December 2003. The patient’s age, etiology and predisposing factors, microbiological findings, duration of hospital stay, treatment, and outcome were analyzed. The patients were divided into two groups. The first 21 patients (Group I) were treated with broad‐spectrum triple antimicrobial therapy, broad debridement, exhaustive cleaning, and then they underwent split‐thickness skin grafts or delayed closure as needed. The other 12 patients (Group II) were treated with unprocessed honey (20–50 mL daily) and broad‐spectrum triple antimicrobial therapy without debridement. Their wounds were cleaned with saline and then dressed with topical unprocessed honey. The wounds were inspected daily and the honey was reapplied after cleaning with normal saline. Then, the patients’ scrotum and penis were covered with their own new scrotal skin. Results: The mean age of the patients was 53.9 ± 9.56 years (range = 23–71). The source of the gangrene was urinary in 23 patients, cutaneous in seven patients, and perirectal in three patients. The predisposing factors included diabetes mellitus for 11 patients, alcoholism for 10 patients, malnutrition for nine patients, and medical immunosuppression (chemotherapy, steroids, malignancy) for three patients. The mean duration of hospital stay was 41 ± 10.459 (range = 14–54) days. Two patients in Group I died from severe sepsis. The clinical and cosmetic results were better in Group II than Group I. Conclusions: Necrotizing fasciitis of the perineum and genitalia is a severe condition with a high morbidity and mortality. Traditionally, good management is based on aggressive debridement, broad‐spectrum antibiotics, and intensive supportive care but unprocessed honey might revolutionize the treatment of this dreadful disease by reducing its cost, morbidity, and mortality.     

Reconstruction of Lower Eyelid Defects Using a Cross Upper Eyelid Flap Composited with Ear Cartilage

BACKGROUND: Basal cell carcinomas (BCC) most frequently involve the lower eyelid and are treated with total excision. Various techniques have been proposed for reconstruction of the excised eyelid. OBJECTIVE: Because most flaps used in such techniques are bulky, thinner, and aesthetically more favorable, flaps have been sought recently. METHODS: Defects of the lower lid have been closed with a combination of cross-flaps and choncal cartilage prepared from the upper eyelid. RESULTS: Eleven lower lids from 10 patients operated for BCC were reconstructed. All flaps survived. The duration of follow-up was 10 months, and no complications such as relapse, ectropion, or lagophthalmus occurred. CONCLUSIONS: The upper eyelid flap was found to be an appropriate cover for both the skin and the conjunctiva due to its hairless and smooth structure. The outcome in patients followed up for a mean of 10 months was successful, cosmetically and functionally.     

Improved dextran preparation of human leucocytes for chemiluminescence analysis of the oxidative burst of polymorphonuclear cells

Anti-thymocyte globulin (ATG) is extensively used for both prophylaxis and treatment of rejection episodes in renal transplantation, but it is expensive and potentially hazardous. We report the utility of therapeutic monitoring by the readily available total lymphocyte count, compared with the more complex and expensive assay of CD3 counts by flow cytometry in eight renal transplant patients receiving ATG. Aiming for an absolute CD3 count of 0.2–0.5×10⁹/l, it was possible to reduce the mean daily dose of ATG from the recommended 2.5 mg/kg/d to a mean of 1.6 mg/kg/d. Analysis of simultaneously taken total lymphocyte counts showed that the same dose reductions could have been made if the target for therapeutic effect had been a total lymphocyte count of <0.3×10⁹/l. Anti-rejection therapy was successful in all cases, with satisfactory graft function at 6–9 months post-therapy. Lower than recommended doses of ATG proved effective prophylaxis and treatment of renal allograft rejection, with considerable cost savings. A simple protocol may be followed titrating dose against total lymphocyte count, provided it remains below 0.3×10⁹/l. CD3 estimation can be reserved for those times when the total lymphocyte count rises to 0.3×10⁹/l or above.     

STRAIN RELATEDNESS IN PERSISTENT AND RECURRENT CANDIDURIA

Purpose

We assessed the value of determining strain relatedness in differentiating persistent from recurrent candiduria.

Materials and Methods

Prospective monitoring of patients with candiduria (10⁴ or greater colony forming units per ml.) during a 5-month period. All patients with persistent or recurrent infection after documented clearance were selected. Pair isolates were typed using restriction endonuclease analysis of genomic deoxyribonucleic acid with SfiI. Isolates were considered related if all deoxyribonucleic acid bands matched.

Results

We encountered 22 and 5 patients with persistent and recurrent infection, respectively. The isolates were recovered 1 to 140 days apart (21.56 +/− 28.97). Most patients were women (85.2%) with a mean age of 66.41 +/− 18.11 years. Risk factors included antibiotics (100%), indwelling catheter (88.9%) and diabetes mellitus (40.7%). Of 15 individuals who received antifungal therapy candiduria persisted in 10 and resolved but recurred within 4 to 26 days (13.00 +/− 9.08) after treatment in 5. Candida albicans accounted for 34 of 58 isolates (58.6%), and it was mixed with other species in 4 cultures. Paired strains were genetically identical in 26 of 27 patients. Strain persistence was documented in 21 of 22 cases with persistent infection and in all 5 patients with recurrent disease.

Conclusions

These findings show that strain persistence is exceedingly frequent in candiduria. These results imply that determining strain relatedness of Candida urinary isolates may not be reliable in differentiating persistent from recurrent infection.