Removal of an entrapped large metallic dilator from the sigmoid neovagina in a male-to-female transsexual using a laparoscopic approach

INTRODUCTION

To describe the role of laparoscopy for removal of entrapped vaginal metallic dilator (20cm in length and 3.5cm in diameter) in a case of male-to-female transsexual.

PRESENTATION OF THE CASE

The patient was a 24-year old male-to-female transsexual, presented with entrapment and upward migration of the vaginal metallic dilator 1 week before admission. She underwent gender reassignment surgery with sigmoid vaginoplasty 8 month before admission. After 3-port transperitoneal laparoscopic abdominopelvic exploration, through an incision over the sigmoid vagina the dilator was extracted. The sigmoid vagina was repaired with free-hand intracorporeal laparoscopic suturing and knot-tying techniques in two layers and the dilator was removed by extending the site of umbilical port. The operative time was 70min.

DISCUSSION

Up to 60% of rectosigmoidal or vaginal foreign bodies can be extracted transanally or transvaginally with adequate sedation. When surgical exploration is indicated, a longitudinal laparatomy is performed to extract the foreign body. To reduce the associated morbidity of an open procedure in our patient, we performed a laparoscopic approach for complete abdominal exploration for possible presence of intestinal or sigmoidal injuries together with removal of this large metalic dilator.

CONCLUSION

Laparoscopic approaches in cases of neovaginal foreign body are useful when the endovaginal approaches have failed, especially in transsexual patients, to prevent another major open surgery.

The Multiple Forms of Leishmania major in BALB/C Mice Lung in Iran

Cutaneous leishmaniasis is one of the most important parasitic diseases, which are endemic in different parts of Iran. Leishmania major and L. tropica are the primary causative agents of this disease. The aim of the present study was to detect the multiple forms of L. major in lung. Ppromastigotes of L. major at stationary phase were injected to BALB/c mice. After 60 days, the different forms of Leishmania parasites were checked in lung tissue. Promastigote and amastigote forms of Leishmania parasites were detected.

Noninvasive diagnosis of bronchiolitis obliterans due to sulfur mustard exposure: could high-resolution computed tomography give us a clue?

PURPOSE

Previous pathological investigations have reported bronchiolitis obliterans (BO) as the major long-term sequela of exposure to sulfur mustard. In this study, we investigated whether high-resolution computed tomography (HRCT) could be used as a noninvasive imaging modality to differentiate between mustard lung (as a subtype of BO) and other respiratory disorders.

MATERIALS AND METHODS

Three groups of patients with sulfur-mustard-induced lung injury (BO), severe chronic asthma (resistant asthma) and smoking habit, respectively, were recruited. Also 30 nonsmoking participants were recruited randomly as the control group. Pulmonary function tests (PFT) and HRCT were performed. Images were viewed with a window level of -450 and window width of 1,400 HU. All images were evaluated by an expert radiologist who was blinded regarding the patients' diagnoses and clinical situations.

RESULTS

Airway involvement was higher and more frequent than parenchymal involvement in the groups with chemical-induced injury and asthma in comparison with smokers. On the other hand, parenchymal involvement was more frequent than airway involvement in the smokers' group in comparison with the other groups.

CONCLUSIONS

HRCT can be a very useful method for differentiating between mustard lung, resistant asthma and lung injuries due to cigarette smoking.

Assessment of diabetes mellitus (DM) as a risk factor for development of cisplatin-induced nephrotoxicity (CIN)

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Background: DM is the most common cause of kidney disease in the US, and it may increase the risk of CIN. In vivo studies however suggest that DM not only is not a risk factor for CIN, it may even be protective. This may be explained by dysfunction of organic cation transporter-2, the critical transporter for cisplatin uptake in proximal tubules, in diabetic kidneys. We conducted a case-control study to assess the relationship between DM and CIN. Methods: Records of all patients (pts) who received cisplatin between 1/1/00 and 12/31/06 at Oklahoma City VA Hospital were reviewed. DM was diagnosed if pt had (1) been taking anti-diabetic treatment, or (2) Hgb A1C ≥6.5%, or (3) ≥2 fasting outpatient serum glucose levels 126–199 mg/dl, or (4) ≥1 serum glucose level ≥200 mg/dl at any time, prior to receiving cisplatin. CIN was defined as increase in serum creatinine (SCr) by ≥50% above baseline and higher than upper limit of normal, after exclusion of other causes of elevated SCr, during or within 8 weeks of completion of treatment. Continuous variables are reported by means and ranges, and compared using 2-tailed student's t test. Odds ratio (OR) was calculated to compare risk of CIN between diabetics and non-diabetics. Results: Two hundred pts (2 females, 198 males) received cisplatin in the study period, 50 (25%) were diabetic. Distribution of age (years, diabetics: 62 [46–77]; non-diabetics: 60 [26–79], p = 0.18) and baseline SCr (mg/dl, diabetics: 1.0 [0.4–1.5]; non-diabetics: 1.0 [0.5–1.6], p = 0.86) were similar between the two groups. Overall 15% of pts (30 of 200) developed CIN. Risk of CIN was not different between diabetics (8 of 50 pts, 16%) and non-diabetics (22 of 150 pts, 14.7%); OR = 1.11 (95% CI = 0.46 to 2.67) (Table). Conclusions: DM was not shown to be a risk factor for development of CIN. This finding is consistent with in vivo data obtained through animal diabetic models.

[Table: see text]

No significant financial relationships to disclose.

Neoadjuvant therapy with celecoxib to women with early stage breast cancer

Cyclooxygenase-2 (COX-2) is preferentially expressed in breast cancer cells compared to normal breast tissue. COX-2 inhibitors are, therefore, potential therapeutic options for patients with breast cancer. Women newly diagnosed with non metastatic breast cancer were enrolled into the study after undergoing a diagnostic core needle biopsy. Patients received celecoxib treatment at 400 mg orally twice a day for 14 days, and then underwent surgical excision of their tumor. Core biopsies obtained at the time of initial diagnostic procedure and surgical excision specimens were stained for Ki-67, as well as COX-2 and cleaved poly (ADP-ribose) polymerase (PARP) expression (as an apoptosis marker). Appropriate negative and positive controls were included. We assessed the difference in Ki-67, COX-2 and cleaved PARP expression levels, before and after treatment using the Wilcoxon's matched-pair ranks test and the McNemar's test with continuity correction. Sixteen patients were enrolled. The median age was 54 years. ER and/or PR expression was present in 81% of tumors; Her-2 neu overexpression was present in 25%. No significant change in COX-2 or cleaved PARP expression was noticed in the post intervention specimen compared to the core biopsies. Surprisingly, there was a significant increase in the Ki-67 expression (p < 0.009). This short term prospective study was conducted to assess the effects of celecoxib, on the proliferative and apoptotic indexes in patients with early stage breast cancer. We have found an increase in the Ki-67 activity, with no significant down regulation of COX-2 or increase in cleaved PARP expression with 14 days of therapy. This could be partly due to the small sample size.

Effect of celecoxib, a specific cyclooxygenase 2 inhibitor, on the apoptotic and mitotic indexes of breast cancer in patients with early stage disease

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Background: To assess whether the administration of celecoxib, a specific cyclooxegenease-2 (COX-2) inhibitor, to patients with breast cancer alters the proliferative and apoptotic indexes of their tumors. Methods: Women newly diagnosed with non metastatic breast cancer were enrolled into the study after undergoing a diagnostic core needle biopsy. Patients received celecoxib treatment at 400 mg orally twice a day for 14 days, and then underwent surgical excision of their tumor. Core biopsies obtained at the time of initial diagnostic procedure and surgical excision specimens were stained for Ki-67, as well as COX-2 and cleaved poly (ADP-ribose) polymerase (PARP) expression (as an apoptosis marker). Appropriate negative and positive controls were included. We assessed the difference in Ki- 67, COX-2 and cleaved PARP expression levels, before and after treatment using the Wilcoxon’s matched-pair ranks test and the McNemar’s test. Results: 16 patients were enrolled. The median age was 54.6 years. ER and/or PR expression was present in 81% of tumors; Her-2 neu overexpression was present in 25%. No significant change in COX-2 or cleaved PARP expression was noticed in the post intervention specimen compared to the core biopsies. Surprisingly, there was a significant increase in the Ki-67 expression (p < 0.009). Conclusions: we have conducted a short term prospective study to assess the effects of celecoxib, on the proliferative and apoptotic indexes in patients with early stage breast cancer. We have found an increase in the Ki-67 activity, with no significant down regulation of COX-2 or increase in cleaved PARP expression with 14 days of therapy. This could be partly due to the small sample size.

[Table: see text]

Immunomodulation by 1,25-dihydroxyvitamin D3: therapeutic implications in hemodialysis and renal transplantation

The active metabolite of vitamin D3, 1,25-dihydroxyvitamin D3, is a secosteroid hormone that regulates calcium and bone metabolism, controls cell proliferation and differentiation, and plays an important role as an immunomodulator. Recent advances in understanding the mechanisms underlying 1,25(OH)2D3 immune actions expand the range of the therapeutic implications of 1,25(OH)2D3 and its analogs. This review will cover the current knowledge on vitamin D-mediated immunotolerance and recent advances in vitamin D-based therapies for the treatment of autoimmune disease and the prevention of graft rejection in renal transplantation. Initiation of vitamin D-based therapies at earlier stages of chronic kidney disease may impact the immune status of patients who progress to require dialysis or transplantation.

[Early postoperative hyperamylasemia after parathyroidectomy for primary hyperparathyroidism]

AIM

The postoperative pancreatitis was a classical complication in the historical series of primary hyperparathyroidism (HPT), but the causal association was never demonstrated and even recent studies denied it. The aim of this study was to determine the augmentation of postoperative amylasemia, and its possible clinical traduction in patients operated for primary HPT.

MATERIAL AND METHODS

Fifty consecutive patients operated for cure of a primary HPT were included in this study. Total amylase, as well as isoenzyme fractions P (pancreatic) and S (salivary), calcium, phosphorus and intact PTH serum concentrations were determined on the days prior and after parathyroidectomy. Fifteen normocalcemic patients operated for secondary HPT constituted the control group.

RESULTS

The study deals with 42 female and eight male patients, their mean age was 58.5 years (range 19-89 years). All patients underwent parathyroidectomy for adenoma or hyperplasia. No patient had pancreatitis before parathyroidectomy. Postoperative amylasemia developed in four patients (8%), one with increased total amylase and P fraction, one with only increased total amylase, and two with increased total amylase and S fraction. No patients exhibited abdominal symptoms suggesting acute pancreatitis in the postoperative period. There was no correlation between pre- and post-operative calcium serum levels and pre- and post-operative amylasemia. In the secondary HPT group no significant diminution of the total amylasemia or of P and S fractions were observed.

CONCLUSIONS

These results indicate that acute pancreatitis is an exceptional postoperative complication of primary HPT nowadays. The 8% incidence reported in the present study matches the incidence of hyperamylasemia reported postoperatively in non-abdominal or non-parathyroid surgery.

[Prospective study of early predictive factors of permanent hypocalcemia after bilateral thyroidectomy]

AIM OF THE STUDY

The aim of this prospective cohort study was to identify the early criteria potentially predictive for outcome of permanent hypocalcemia after thyroidectomy.

PATIENTS AND METHODS

Serum calcium (Ca) et phosphorus (Ph) were measured daily until discharge in 2035 consecutive patients undergoing bilateral thyroidectomy. In all patients experiencing postoperative hypocalcemia, defined as a Ca < 8.0 mg/dl on two consecutive days, parathyroid hormone was measured prior initiation of calcium therapy et discharge (early PTH), et blood sample was also obtained 7 to 14 days after discharge for Ca et Ph measurements (delayed Ca et Ph). These patients were then followed up until complete resolution of hypocalcemia or at least one year. Those still needing substitutive therapy to maintain normocalcemia one year after surgery were considered to have permanent hypocalcemia. Correlation of outcome with clinical characteristics, postoperative Ca et Ph levels, early PTH, et delayed Ca et Ph were examined with univariate analysis et multivariate logistic regression.

RESULTS

Postoperative hypocalcemia occurred in 153 patients (7.5%) and spontaneously recovered in all but 7 patients (0.3%). Delayed Ca, and delayed Ph were found to be predictive for outcome of hypocalcemia by univariate analysis (p < 0.01). Relative risk to develop permanent hypocalcemia was 15 for patients with early PTH < 12 pg/ml, 52 when delayed Ph was > 4.0 mg/dl, and 121 when delayed Ca was < 8.0 mg/dl. None of the 113 patients with delayed Ca > or = 8.0 mg/dl and delayed Ph < or = 4.0 mg/dl developed permanent hypocalcemia, in contrast to 1 out of 31 patients (3%) with delayed Ca > 8.0 mg/dl or delayed Ph > 4.0 mg/dl, and 6 out of 9 patients (66%) with delayed Ca < 8.0 mg/dl and delayed Ph > 4.0 mg/dl. Both delayed Ca and delayed Ph appeared as independent factors predicting outcome of hypocalcemia at one year with multivariate logistic regression analysis.

CONCLUSION

Delayed serum calcium and phosphorus levels, when measured one week after starting calcium therapy but prior to administration of any vitamin D analogs, accurately predict outcome of hypocalcemia after thyroidectomy. Patients with delayed Ca under 8.0 mg/dl and/or delayed Ph above 4.0 mg/dl are at high risk to develop permanent hypocalcemia.