Risk factors for impaired wound healing in sirolimus-treated renal transplant recipients

AIM

As sirolimus has been implicated in impaired wound healing, the aim of this study was to evaluate risk factors for wound complications after renal transplantation in patients treated with this drug de novo.

METHODS

This single center retrospective review of wound complications included 194 renal transplant recipients, all of whom received sirolimus immunosuppression in combination with reduced doses of cyclosporine (CsA) and corticosteroids de novo. A wound complication was defined as an infection, incisional hernia, or lymphocele.

RESULTS

The overall incidence of wound complications within the first year post-transplantation was 36% (n = 70) including infection in 12% (n = 23), lymphocele formation in 18% (n = 34), and incisional hernia in 18% (n = 34) of patients. Seventeen patients suffered more than one wound complication. A multivariate analysis showed that independent risk factors for the development of wound complications were recipients over the age of 40 yr (odds ratio 2.536, p = 0.011), subjects with body mass index (BMI) >26 (odds ratio 2.498, p = 0.027) and especially BMI >30 (odds ratio 3.738, p = 0.007), the use of thymoglobulin for induction immunosuppression (odds ratio 3.627, p = 0.002), and a cumulative dose of sirolimus of at least 35 mg by post-transplant day 4 (odds ratio 2.694, p = 0.023). African-American (odds ratio 0.139, p < 0.001) or Hispanic recipients (odds ratio 0.337, p = 0.014) were less likely to experience a wound problem than Caucasian recipients.

CONCLUSION

A number of potentially modifiable risk factors independently increase the incidence of wound complications among renal transplant recipients receiving sirolimus-based immunosuppression de novo.

Gastric leak after sleeve gastrectomy: analysis of its management

BACKGROUND

Bariatric surgery is increasingly being performed and sleeve gastrectomy (SG) has proved to be effective and safe. Among its complications, leaks are the most serious and life threatening.

METHODS

The focus of the study is nine patients who underwent a SG and developed a gastric leak after surgery. Our data were obtained from the clinical charts of the patients and through interviews with the surgeon who performed the index surgery.

RESULTS

Eight patients underwent SG at outside institutions while one was operated at Clinica Alemana. Three patients developed symptoms within 5 days after surgery, while the rest were diagnosed after 10 days from the surgery. A CT scan was the method used to confirm the diagnosis in all patients. The three patients who had a leak detected during the immediate postoperative period underwent laparoscopic reoperation. Among the rest of the patients, percutaneous drainage was employed in one patient as the primary procedure while the other underwent surgical drainage. An esophageal endoluminal stent was employed in four patients. The leak closed in all patients with the healing time ranging from 21 to 240 days.

CONCLUSIONS

Diagnosis of a leak after a SG required a greater index of suspicion in order to perform an early diagnosis. Sepsis control and nutritional support are the cornerstones of this treatment. Evolution is characterized by longer periods of time that are necessary in order to wait until the leak closes. Management must be tailored to each patient.

Prospective randomized study of T-tube versus biliary stent for common bile duct decompression after open choledocotomy

The T-tube has been the alternative of choice for decompression following common bile duct (CBD) exploration. The development of laparoscopic surgery has suggested using a biliary stent as an alternative to the T-tube following choledochotomy. The purpose of this prospective randomized study was to compare clinical results obtained from patients who underwent open CBD exploration using a biliary stent versus those from patients with a T-tube for decompression. Between September 2000 and June 2002 a total of 81 patients were randomly assigned to a biliary stent or a T-tube as the decompression method following choledochotomy. An open CBD exploration was performed when CBD stones were suspected, in both elective and emergency settings. The length of the postoperative hospital stay was 6.8 +/- 4.7 days for patients with the T-tube and of 5.2 +/- 3.3 days for, patients with the biliary stent (p = 0.19). Postoperative complications were observed in 13 patients (30%) with the T-tube and in 4 patients (11%) with the biliary stent (p = 0.03). One patient with a biliary stent was reoperated because of an intraabdominal abscess, and another patient was reoperated because of biliary peritonitis following T-tube removal. Three patients (7%) with a biliary stent and one patient (3%) with a T-tube were rehospitalized. There were no deaths. The T-tube and biliary stent were removed 27.1 +/- 10.8 days and 34.9 +/- 12.9 days after surgery, respectively (p = 0.24). The biliary stent is a safe alternative to the T-tube as a biliary decompression method following an open CBD exploration.

Rabbit Antithymocyte Globulin: A Postoperative Risk Factor for Sirolimus-Treated Renal Transplant Patients?

AIMS

Randomized controlled studies suggest an increased incidence of perioperative wound complications among sirolimus-treated renal transplant patients. The present study analyzed the effect of rabbit antithymocyte globulin (rATG) on these postoperative complications.

METHODS

Four hundred and twelve renal transplants were performed and managed postoperatively at two University-affiliated hospitals between January 1, 2001, and December 31, 2003. The patients received corticosteroids and Sirolimus, with delayed introduction of cyclosporine when the serum creatinine had decreased below 2.5 mg/dL. Two groups of patients were discriminated: group 1 received Basiliximab 20 mg on day 0 and day 4 (n = 283); group 2 recipients with a high panel of reactive antibody (PRA > 20%) and retransplant patients received rATG for induction (n = 129) for a maximum of 2 weeks postoperatively. The incidence of rejection was 14.5% for group 1 vs. 8.5% for group 2 patients. To avoid confounding variable associated with the rejection treatment, any patient with rejection was excluded for statistical analysis, as were patients with follow- up less than 30 days. The final study group for analysis included 350 patients: 235 with Basiliximab induction (group 1) and 115 rATG induction (group 2). The mean follow-up was 21.8 +/- 11 months. Differences in the incidences of postoperative hernia, wound infections, or lymphoceles requiring any form of drainage were analyzed for statistical significance using the chi-square test.

RESULTS

The percentage of patients with wound complications was 26.0% versus 39.1% (P < .025) for group 1 versus group 2, respectively. Incisional hernias occurred in 10.6% versus 18.3% patients (P < .05), wound infections in 11.1% versus 16.5% (P = NS), and lymphoceles in 10.6% versus 15.9% (P = NS) for the two groups, respectively.

CONCLUSIONS

rATG-induced renal transplants recipients treated with sirolimus, cyclosporine, and steroids show a significantly increased incidence of postoperative incisional hernias and a trend toward a greater number of lymphocele and wound infection complications.

Increasing accuracy and decreasing latency during clean intermittent self-catheterization procedures with young children

We examined the effects of simulation training on performance of clean intermittent self-catheterization procedures with 2 young girls. Simulation training was conducted, after which independent performance was assessed within a multiple baseline design. The training resulted in increased accuracy and decreased latency for both girls.

Complete Remission of Previously Intractable Peripheral Cutaneous T-Cell Lymphoma of the Lower Extremity Using Isolated Hyperthermic Limb Perfusion with Melphalan (1-Phenylalanine Mustard)

The patient is a 74-year-old woman first diagnosed with a peripheral cutaneous T-cell lymphoma (PCTCL) in April of 1994. Initially she presented with subcutaneous indurated areas in the right forearm, scapula, and submadibular region. After chemotherapy with CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisone), she went into remission for 2 years before relapse of her PCTCL localized to the right lower extremity. Persistent isolated disease in the extremity since then led to numerous chemotherapy regimens and localized radiation therapy. Due to dramatic limb threatening progression of the disease in 2001, she underwent isolated hyperthermic limb perfusion with melphalan (1-phenylalanine mustard). Although limb preservation could not be achieved, this treatment resulted in complete clinical and pathological regression of the lesions of the perfused extremity.

[Pancreatic VIPoma. Report of one case]

Neuroendocrine tumors are uncommon, including VIPoma that produces vasoactive intestinal polypeptide. We report a 45-year-old female presenting with a history of diarrhea lasting three months. An abdominal CAT scan showed a solid tumor in the body of the pancreas. A fine needle aspiration biopsy of the tumor was compatible with a neuroendocrine tumor. The patient was subjected to a partial pancreatectomy, excising a 4 cm diameter tumor. The pathological study was compatible with a neuroendocrine carcinoma. There was no regional lymph node involvement. During the postoperative period the results of serum vasoactive intestinal polypeptide were received. These were 815.9 pg/ml before surgery and normalized after the operation.

Perioperative chemotherapy in locally advanced gastric cancer in Chile: from evidence to daily practice

Gastric cancer (GC) is a leading cause of cancer death in Chile. Although recommended in international guidelines since 2006, perioperative chemotherapy was not available to patients in the public health system in Chile until 2016. We conducted an observational study to assess the feasibility of this strategy in public hospitals in Chile (Observational Study of Perioperative Chemotherapy in Locally Advanced Gastric Cancer – PRECISO). Patients with locally advanced, operable GC were offered to receive preoperative chemotherapy with Epirubicin + Cisplatin + Capecitabine (ECX) for three cycles followed by curative surgery. Staging included abdominal CT scan and laparoscopy if peritoneal carcinomatosis was suspected. Postoperative ECX for three cycles was recommended. Between August 2010 and March 2013, 110 patients were screened and 61 enrolled. Median age was 62 years (23–76 years) and most patients had good performance status at baseline (Eastern Cooperative Oncology Group performance status score (ECOG) 0: 42, ECOG 1: 19). Tumour site was proximal in 32 (52%) and medial and distal in 29 (48%) patients. All but four patients (n = 57, 93%) completed three cycles of preoperative chemotherapy. Fifty-six patients were operated and 54 (89%) had a curative resection. Thirty-three patients (54%) had pT0-2, and 18 (30%) had pN0 tumours, with two patients achieving a complete response. As of 20 December 2020, 39 patients died, 32 due to GC, one within 30 days of surgery, two due to intestinal obstruction at 5 and 3 months after surgery and four due to other causes. Five-year survival rate was 38%. We conclude that perioperative chemotherapy is feasible in public hospitals in Chile and should be offered to patients with locally advanced GC.

Test de estimulación intraarterial selectiva con calcio en el diagnóstico de localización de insulinomas: Casos clínicos

Insulinoma is the most common neuroendocrine tumor. Its clinical manifestations are frequently confounded with neuropsychiatric symptoms, and definitive diagnosis can be delayed for a long time. These tumors are usually small, of less than 2 cm. Thus, their preoperative localization is difficult. We report two patients with a clinical diagnosis of insulinoma, in whom the preoperative imaging study was negative. Both fulfilled diagnostic criteria, with high serum insulin levels in the presence of a blood glucose of less than 45 mg/dl. The imaging study, including abdominal computed tomography and pancreatic endoscopic ultrasonogrphy did not disclose the location of the tumor. A pancreatic angiography with selective stimulation with intra arterial calcium and venous sampling for insulin measurements, was performed in both patients. This test allowed the exact localization of the tumors and their successful excision. A review of other localization diagnostic tests is done.

[Active labour management in primiparas. Prospective study]

The objective of our study was prospectively compare the effect in the rate of cesarean section of active labor management and of traditional labor management in primiparas with physiological term pregnancy. From september 1, 1993 to may 31, 1994, 145 primiparas with physiological term pregnancy were randomly assigned to one group of active labor management (study group, n = 75) and to one group of traditional labor management (control group, n = 70). Cesarean section rate was 9.3% in the study group and 20% in the control group (p < 0.05). There was no increase in fetal morbidity or mortality. Active labor management can reduce cesarean section rate in primiparas with physiological term pregnancy.

Nurse practitioner students in Nicaragua

Despite the growing interest in enhancing the cultural awareness for nurse practitioner (NP) students who work with patients from the developing world, there is a dearth of reports on such experiences. This report describes the clinical experiences of NP students from George Mason University (Fairfax, VA) during an intensive 2 weeks in Nicaragua in their final semester, accompanied by an NP faculty member. The program was planned and implemented in collaboration with the Universidad Politecnica de Nicaragua School of Nursing (Managua, Nicaragua). The students' clinical experiences included working in a Health Post and an impoverished community. Students learned to manage clinical problems using minimal resources and acquired an appreciation for the cultural, political, and economic situations from which many of their patients in the United States originate. Recommendations for establishing this type of experience are included.

Persistent pulmonary abnormalities after 18 months of SARS-CoV-2 pneumonia

OBJECTIVE

To describe persistent pulmonary abnormalities detected on HRCT after 18 months of SARS-CoV-2 pneumonia, and to determine their extension and correlation with pulmonary function.

PATIENTS AND METHODS

A prospective cross-sectional study with an initial cohort of 90 patients in follow-up due to persisting lung abnormalities on imaging, functional respiratory impairment and/or respiratory symptoms. Of these, 31 (34%) were selected for analysis due to the persistence of their lung abnormalities on HRCT at 18 months after infection. A double reading was performed for each HRCT (62 observations).

RESULTS

Of the 31 patients included: 20 (65%) were men; mean age was 67 years; 17 (55%) were smokers/ex-smokers. The mean hospitalisation time was 38 days. Eighteen (58%) patients were admitted to intensive care units. Five patients (16%) suffered an acute pulmonary thromboembolism and three (9.7%) had a pneumothorax. The mean time between the onset of pneumonia and the follow-up HRCT was 20.34 months. Nineteen percent of patients suffered from total lung function abnormalities; and ground-glass opacities and reticulation were present in 12% and 4.5% respectively. The findings of the 62 readings were: ground-glass opacities (100%), reticulation (83%), subpleural curvilinear lines (62%), parenchymal bands (34%), traction bronchiectasis (69%), displacement of vessels/fissures (46%) and honeycombing (4.9%). Pulmonary function 18 months after the acute episode revealed a mean FVC of 92% of predicted value, with an FVC < 80% of predicted value in 11 patients (35.4%). Mean DLCO was 71% of predicted value, with a DLCO < 80% in 22 patients (70%). We observed a statistically significant relationship between total lung function abnormalities on HRCT and FVC (P < 0.05), and a trend towards statistical significance with DLCO (P = 0.051); there was a statistically significant relationship between the presence of ground-glass opacities and FEV1/FVC (P < 0.01). The relationships between reticulation and FVC, FVC%, FEV1, FEV1% and DLCO% were also considered statistically significant (P < 0.05).

CONCLUSION

Persistent interstitial lung abnormalities are seen on HRCT for a subset of patients infected with SARS-CoV-2 pneumonia. Seventy percent of these patients suffered a slight decrease in DLCO.

Impacto en la mortalidad de un tratamiento conjugado, en pacientes intoxicados no ocupacionalmente, con paraquat en el Hospital Universitario San Vicente de Paúl de Medellín, entre agosto de 2002 y agosto de 2003

En Colombia se utiliza frecuentemente el Paraquat, herbicida que al ser ingerido en cualquier cantidad produce toxicidad grave y alta mortalidad, sin haberse encontrado un tratamiento eficaz para la recuperación de los intoxicados. El objetivo de este estudio fue establecer si un tratamiento conjugado con N-acetilcisteína, vitamina A, C, E, propranolol, colchicina y furosemida, disminuye la mortalidad en pacientes, basados en la probabilidad de supervivencia, los niveles plasmáticos y el seguimiento clínico. RESULTADOS De diez pacientes con intoxicaciones no ocupacionales que ingresaron al Hospital Universitario San Vicente de Paúl de Medellín, seis severamente intoxicados fallecieron, tres por falla orgánica multisistémica y tres por insuficiencia respiratoria aguda. Se obtuvieron resultados con significancia estadística, que muestran que la probabilidad de muerte se correlaciona directamente con los niveles sanguíneos de paraquat y con la severidad según la clasificación clínica. Todos los pacientes con compromiso grave murieron y este desenlace fue independiente de sus niveles séricos de paraquat. Con los resultados obtenidos se puede afirmar que este tratamiento es adecuado para pacientes intoxicados en forma leve y moderada; que no hay correlación entre la clínica y los niveles plasmáticos de Paraquat y que la clínica es un indicador confiable para el pronóstico de esta intoxicación. Sin embargo, se requiere de una muestra mayor para aumentar la confiabilidad estadística.

Genomic prediction of bone strength in laying hens using different sources of information

Bone damage in laying hens remains a significant welfare concern in the egg industry. Breeding companies rely on selective cross-breeding of purebred birds to produce commercial hybrids, which farmers raise for table-egg production. Genomic prediction is a potential tool to improve bone quality in laying hens. Because commercial layers are crossbred and kept in different environments than pure lines, the question arises whether to use within-line purebred selection or whether to use crossbred data. While selection based on pure line data is common, achieving optimal bone strength in hybrids may require incorporating hybrid data to account for heterosis and housing-specific effects. This study aims to evaluate how combining pure line and hybrid data could affect the accuracy of breeding values for bone strength. Genotypes and phenotypes were available from two types of white hybrids (Bovans White and Lohmann Selected Leghorn Classic) housed in two housing systems (furnished cages and floor housing). This resulted in four hybrid-housing combinations (n ∼ 220 for each). Tibia strength and genotypes for pure breeding lines of White Leghorn (WL, n = 947) and Rhode Island Red (RIR, n = 924) were also included. Each of the hybrid-housing combinations and pure lines was fitted separately into (1) single-trait Genomic Best Linear Unbiased Prediction (GBLUP), then simultaneously via multitrait GBLUP, (2) within hybrids across housing, (3) across hybrids within housing, (4) across hybrids and housing, (5) the latter in combination with WL and/or RIR data. Including hybrid data slightly increased the accuracy of the genomic estimated breeding value (GEBV) of other hybrids, but not that of pure lines. Pure line data increased the GEBV accuracy of hybrids over and above that of combining hybrid information. Combining data from two pure lines improved the GEBV accuracy of both. In comparison to the combination of data across lines and/or houses, combining tibia strength and BW within-lines increased tibia strength GEBV accuracy. The maximum GEBV accuracy obtained for tibia strength ranged from 0.42 to 0.65 for hybrids and from 0.63 to 0.78 for pure lines. Further study is required to test whether modelling the interactions of genotype by environment could help to breed hybrids for specific housing systems.

Perioperative chemotherapy in locally advanced gastric cancer in Chile: From evidence to daily practice

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Background: Gastric cancer is the leading cause of cancer death in Chile, with mortality rate of 26.7/100.000 in men, placing the country among the highest mortality rates worldwide. For locally advanced gastric cancer, a multimodality treatment is recommended, but in Chile, the treatment covered by the public health insurance, which assists more than 70% of the patients, is surgery alone. We conducted an observational study to assess efficacy and toxicity of perioperative chemotherapy (CT) in public hospitals in Chile (NCT01633203). Methods: Patients with locally advanced, operable gastric carcinoma, defined as presence of invasion of serosa or beyond (cT > 3 AJCC 2002) and/or lymph node metastasis (cN+) without distant metastasis (M0), were offered to receive preoperative CT with Epirubicin+Cisplatin+Capecitabine (ECX) regimen for 3 cycles followed by curative surgery with D2 lymphadenectomy. Staging abdominal CT scan was mandatory, laparoscopy was recommended. Patients with gastric retention, severe dysphagia or contraindications for CT were excluded. All patients signed the IRB approved informed consent form prior to enrolment. Data were collected using the OpenClinica platform. Results: Between August 2010 and March 2013, 110 patients were screened and 61 enrolled. Median age was 62 years (23-76 years) and most patients had good performance status at baseline (ECOG 0: 42, ECOG 1: 19). Tumor site was proximal in 24 (39%), medial in 16 (26%) and distal in 10 patients (16%). All but 4 patients (n = 57, 93%) completed three cycles of preoperative CT as planned. Fifty-five patients were operated and 54 (89%) had curative R0 resection. Of these, 36 (67%) had pT0-2, and 15 (28%) had pN0 tumors. A complete pathological response was found in 2 patients. Two patients were not operated for other reasons (one patient refused surgery and one patient presented a cerebrovascular accident during preoperative CT and died), and 5 patients (8%) progressed. As of September 1, 2015, 32 patients died. Three-year survival rate was 49%. Conclusions: Perioperative CT is feasible in public hospitals in Chile and should be offered as an alternative to primary surgery for patients with locally advanced gastric cancer.