Adult congenital bronchoesophageal fistula

Congenital bronchoesophageal fistula is a rare anomaly that requires surgical repair. A case of an incidental type II congenital bronchoesophageal fistula in a 58-year-old woman is reported. Barium swallow, esophagoduodenoscopy, bronchoscopy, and computed tomography of the chest demonstrated a bronchoesophageal fistula. Thoracotomy and resection of the fistula with reinforcement of the esophageal staple line achieved healing without postoperative complications.

Carotid endarterectomy in the elderly

BACKGROUND AND PURPOSE

Increasing life expectancy has resulted in an increasing number of elderly. As the elderly population grows, the incidence of stroke will increase. Many such strokes result from carotid stenosis (CS). In view of the benefits of carotid endarterectomy (CEA) shown in recent clinical trials, it would seem prudent that surgery for CS be considered for prevention of stroke in this population. Traditionally, members of the geriatric population have often been viewed, perhaps arbitrarily, as inappropriate candidates for CEA because of perceived greater operative risks. The purpose of this study was to assess the safety of performing CEA in geriatric patients.

PATIENTS AND METHODS

A total of 175 patients who underwent CEA between January 1994 and June 1996 were evaluated retrospectively. The patients were divided into the nongeriatric group (NGG <75 years of age) and the geriatric group (GG >75 years of age). There were 90 (51%) patients in the NGG and 85 (49%) in the GG. The two groups were compared for the following: rationale for surgery (symptomatic vs. asymptomatic), risk factor profile, preoperative imaging studies (noninvasive vs. invasive), and complications of surgery.

RESULTS

Both groups were generally comparable in terms of their risk factors, rationale for surgery, and preoperative cardiac risk. Noninvasive imaging alone was used in 56% of NGG and 60% of GG patients, whereas 44% of NGG and 40% of GG underwent invasive cerebral angiography in addition to other noninvasive studies. There were 4(4.4%) postoperative neurological complications, including two strokes and two transient ischemic attacks (TIAs), in the NGG and 1(1%) stroke in the GG. One patient died in the NGG from a stroke. Although one patient in the GG experienced a postoperative myocardial infarction, there was no mortality in this group.

CONCLUSION

CEA can be safely performed for both symptomatic and asymptomatic CS in appropriately selected patients irrespective of age.

Impact of laparoscopic adjustable gastric banding on obesity co-morbidities in the medium- and long-term

BACKGROUND

The authors evaluated the impact of laparoscopic adjustable gastric banding (LAGB) on obesity-associated diseases in a series at 3 to 8 years postoperatively, namely diabetes, pulmonary disease, hypertension and knee joint pain.

METHODS

145 morbidly obese patients underwent LAGB with mean age 38 years and preoperative BMI 48.5 kg/m2 (range 34-77). Changes in BMI and excess BMI loss (EBL) were evaluated.

RESULTS

138 of the 145 patients (95%) were available for full follow-up. At last follow-up, BMI had dropped to 34.0 +/- 6.4 SD kg/m2, and mean EBL was 61.9 +/- 26.1%. Prevalence of obesity-associated disease was significantly reduced: diabetes decreased from 10% to 4%, treatment-requiring pulmonary disease from 15% to 5%, hypertension from 43% to 27%, and knee pain from 47% to 38%.

CONCLUSION

Following gastric banding, >75% of patients suffering from obesity-related disease had significant decrease or resolution of their co-morbidities.

Comparison of two schedules (previous evening versus same morning) of bowel preparation for colonoscopy

BACKGROUND AND AIMS

Evening preparation for colonoscopy is often unsatisfactory and inconvenient. We performed this study to compare the efficacy of bowel preparation at two different timings: previous evening and same morning and to compare the loss of working hours and sleep between these groups.

PATIENTS AND METHODS

In this prospective, investigator blinded, randomized trial, 201 patients were enrolled from February to June 2005. Patients aged between 18 to 80 years needing colonoscopy were included. Patients with prior bowel surgery, suspected bowel obstruction or contraindications to phosphate preparation were excluded. Patients received a phosphate based preparation on the previous evening or morning of the procedure. The endoscopist and an observer scored bowel preparation using the Ottawa and Aronchick scales. Using the Ottawa scale right, middle and left colon were separately assessed. Loss of sleep and working hours were noted.

RESULTS

One hundred and two patients received morning preparation and 99 patients received preparation on the previous evening. There was no significant difference in bowel preparation in both the groups using the Ottawa ( P = 0.87) or Aronchick ( P = 0.22) scales. Bowel preparation for right colon was significantly better in the morning group ( P = 0.008). More working hours were lost in the evening group (7.99 vs 10.17, P< 0.001). Sleep was disturbed in 15 patients in morning group and in 42 patients in evening group ( P< 0.001).

CONCLUSION

Both preparations had similar efficacy. Right side preparation was significantly better in the morning group. Evening preparation was associated with loss of more working hours and sleep.

Eukaryotic initiation factor 6 selectively regulates Wnt signaling and beta-catenin protein synthesis

Eukaryotic initiation factor 6 (eIF6), an essential protein important in ribosome biosynthesis and assembly, was identified as an interacting partner of the beta-catenin C terminus in the yeast two-hybrid assay. Independent studies identified Drosophila eIF6 (DeIF6) in a genetic screen designed to detect new genes involved in the regulation of the Wnt/Wg (wingless) pathway. Ectopic expression of DeIF6 in wing discs results in a Wg phenotype. Expression of eIF6 in adenomatous polyposis coli (APC)-mutant colon cancer cells, which express high levels of active beta-catenin, showed that eIF6 selectively inhibits the Wnt pathway at the level of beta-catenin protein independently of proteasomal degradation. Incorporation of radiolabeled amino acids into beta-catenin was selectively decreased in cells that overexpressed eIF6. A similar inverse relationship of the two proteins was observed in the APC(min/+) mouse intestine, in which beta-catenin levels are very high. Taken together these data reveal a link between eIF6 and Wnt signaling, perhaps at the level of ribosome recycling on beta-catenin mRNA.

Immunotransplantation for multiple myeloma using allogeneic peripheral blood stem cell transplantation

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Background: Despite the improvement seen in patients with multiple myeloma (MM) treated with autologous hematopoietic cell transplantation (auto-HCT), most of the patients relapse or die of their disease. The objective of the study was to decrease toxicity of allogeneic HCT for MM patients while allowing the benefit of graft-versus-myeloma effect by using a non-myeloablative HCT (NM- HCT) approach. Methods: Newly diagnosed or previously treated myeloma patients of any stage were enrolled. All patients but one received VAD regimen prior to conditioning regimen which consisted of Fludarabine at 30 mg/m2/day on days -5, -4, -3 and Melphalan at 80 mg/m2 x 2 on days -2 and -1. Graft-versus-host disease (GVHD) prophylaxis included cyclosporine 3 mg/kg intravenously on day -2 and methotrexate at 10 mg/m2 intravenously on days 3, 6, and 11. Results: A total of 8 MM patients (4 IgG, 1 IgA, 1 light chain restriction, 2 non-secretory MM) with a median age of 46 years old (range, 35 to 57 years) have been enrolled. Only one patient received 3 regimens prior to NM-HCT. The initial responses to therapy prior to NM-HCT were: 2 CR, 1 nCR, and 5 PR. All patients received identical 6/6 HLA sibling donor stem cells. All patients but one attained CR (88%) after NM-HCT. The median time for ANC engraftment (≥ 500/mm3) was 12.5 days (range, 10–22 days). Four patients developed acute GVHD grade I-II (3 skin, 1 gastrointestinal); all of them responded well to methylprednisolone treatment. Four patients developed chronic GVHD (grade I-II). The 100-day mortality rate was 12% (1 patient died at day + 96 without evidence of MM). Post-transplant, all patients have reported a Karnofsky’s scale performance status between 80%-100%. Two patients relapsed after 31 months post-transplantation. After a median follow-up of 46 months, median survival has not been reached. Only 1 patient who relapsed has received treatment including auto-HCT. Conclusions: NM-HCT is a feasible treatment option in MM patients with a manageable toxicity profile and acceptable treatment-related mortality. Longer follow-up is needed to evaluate for graft-vs- myeloma effect using this approach.

No significant financial relationships to disclose.

Results of BFM 90 protocol at a single institute in a developing country: Three years experience

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Background: In a developing country the affordability status of a patient is the main factor in deciding the type of treatment a patient will receive. Majority of patients [>95%] at our institute have received MCP 841 protocol for acute lymphoblastic lymphoma .We have reviewed the treatment results of patients who had received chemotherapy as per the BFM 90 protocol over last 3 years. Methods: 18 patients (15 males and 3 females) with ALL who had received BFM 90 protocol as therapy during the period between January 2003 to January 2006 were analysed. 15 were of the pediatric age group (2–13 years) and 3 were adult patients (31 & 42 years). Median follow up period was 1 year 9 months. 5 patients were considered as high risk, 4 medium risk and the rest as standard risk. All patients were ph chromosome negative. Results: All paediatric patients are in CR. One patient had CNS relapse but he responded well to reinduction and is in CR. Three patients developed grade 4 toxicity after high dose methotrexate. The rest tolerated it well, however, leucoverin rescue had to be given empirically as methotrxeate level measurement was not available at that time. Two patients turned HCV positive during the course of treatment and had altered liver enzymes due to which maintenance treatment was interrupted. There were three instances of catheter removal and one port had to be removed due to infection. Both the adult patients had bone marrow relapse during treatment [one during maintenance and the other during reinduction] and could not be salvaged. Conclusions: BFM 90 protocol is a viable alternative to MCP 841 in developing countries where high dose methotrexate is given with empirical leucoverin rescue. High rates of catheter infection is of concern. Better patient education and improved techniques will probably improve the situation.

No significant financial relationships to disclose.

Improving outcomes from acute kidney injury (AKI): Report on an initiative

Acute Kidney Injury (AKI) is a complex disorder for which currently there is no accepted definition. We describe an initiative to develop uniform standards for defining and classifying AKI and establish a forum for multidisciplinary interaction to improve care for patients with, or at risk for AKI. Members representing key societies in critical care and nephrology along with additional experts in adult and pediatric AKI participated in a 2-day conference in Amsterdam in September 2005 to draft consensus recommendations for diagnosing and staging AKI. This report describes the proposed diagnostic and staging criteria for AKI and the formation of a multidisciplinary collaborative network.

[Appendicitis necessitatis: appendicitis perforating the abdominal wall]

Perforation of the appendix through the anterior abdominal wall is a rare complication of a frequent disorder. We report on a 37-year old patient presenting with purulent secretion from the right lower abdomen. The CT scan of the abdomen revealed a perityphlitic abscess with perforation of the anterior abdominal wall. The patient underwent laparotomy with appendectomy and subsequent revision of the abdominal wall. Appendicocutaneous fistula due to perforation through the abdominal wall is a rarity. In analogy to empyema necessitatis, which would require the pleural empyema to penetrate the thoracic wall, the entity was denoted appendicitis necessitatis.

Robotic assisted laparoscopic radical prostatectomy: a review of the current state of affairs

Open retropubic radical prostatectomy is the gold standard treatment for localised prostate cancer. However, the procedure has inherent morbidity associated to it. Therefore, less invasive surgical techniques have been sought, one such alternative is robotic-assisted laparoscopic radical prostatectomy. The advantages provided by robotic technology have the potential to minimise patient morbidity while improving both functional and oncological outcomes. Although it is a recent technological advancement, robotic surgery has shown an increasing rate of adoption worldwide. Currently more than 30,000 patients have undergone this procedure worldwide. We present a review of the available literature on robotic-assisted laparoscopic radical prostatectomy.

Rationale for the administration of acellular pertussis vaccine to parents of infants in the neonatal intensive care unit

Pertussis infections in the United States are increasing as a consequence of waning immunity and increased surveillance. Those most at-risk of mortality include infants less than 6 months of age and premature infants. The 2006 immunization schedule emphasizes an adolescent pertussis booster at 12 years of age. However, of concern is the current generation of parents and grandparents who will still be un-immunized and therefore, available vectors of pertussis to vulnerable neonates. Given the proximity of parents to medical care in the Neonatal Intensive Care Unit (NICU), and the potential for severe disease in their children, NICU personnel should consider administration of acellular pertussis vaccine to parents of hospitalized infants.

Haemoglobin and albumin as markers of HIV disease progression in the highly active antiretrovial therapy era: relationships with gender

OBJECTIVES

The aims of the study were to describe gender differences in haemoglobin and albumin and to investigate the prognostic value of these measurements in relation to highly active antiretroviral therapy (HAART).

METHODS

Anaemia was defined as haemoglobin <13.5 g/dL for men and <11.5 g/dL for women. Albumin <35 g/L was defined as hypoalbuminaemia. Proportional hazards models were used to describe relationships between these markers and HIV progression and death.

RESULTS

A total of 291 patients had pre-HAART and 1-year measurements. Mean haemoglobin and albumin levels pre-HAART were lower in women than in men (haemoglobin: 11.2 vs 13.2 g/dL, respectively, P<0.0001; albumin: 37.4 vs 40.2 g/L, respectively, P<0.0001), and a higher proportion of women were anaemic and hypoalbuminaemic compared with men. Despite a rise in both markers in the first year on HAART, mean haemoglobin levels remained lower by 2.08 g/dL (P<0.0001) and albumin by 2.88 g/L (P<0.0001) in women. In the 495 patients included in this analysis, haemoglobin and albumin levels were both significantly related to short-term risk of AIDS and death independently of CD4 count [hazards ratio (HR)=0.73/g/dL higher haemoglobin, 95% confidence interval (CI) 0.55-0.82, P<0.0001 and HR=0.87/g/L higher albumin, 95% CI 0.83-0.91, P<0.0001]. The prognostic value did not differ by gender.

CONCLUSIONS

Women were more likely to be anaemic and/or hypoalbuminaemic pre-HAART, but post-HAART increases were similar to those in men. Both haemoglobin and albumin were strong independent prognostic factors for risk of AIDS and death, regardless of gender.

Hepatic veno-occlusive disease due to tacrolimus in a single-lung transplant patient

Hepatic veno-occlusive disease is defined as nonthrombotic fibrous obliterative endophlebitis of small centrilobular hepatic venules. Clinically, patients present with elevated liver enzymes and a triad of jaundice, hepatomegaly and ascites. Although reported as a complication of other solid organ and stem cell transplantation, there have been no reported cases to date of veno-occlusive disease following lung transplantation. The present authors report a case of veno-occlusive disease following single-lung transplantation in a patient on a triple-drug immunosuppressive regimen composed of tacrolimus, mycophenolate mofetil and prednisone. The diagnosis was established by transjugular liver biopsy and by discontinuing tacrolimus; there was clinical regression of symptoms and serological return to baseline.