Enteric conversion after pancreatic transplantation: resolution of symptoms and long-term results.

PURPOSE: Bladder drainage (BD) of pancreatic transplants is associated with a unique set of complications. We intended to analyze the incidence, indications, complications and long-term results of enteric conversion procedures (EC). METHODS: Using a prospective database, 32 EC patients out of 433 simultaneous pancreas-kidney-transplant (SPK) recipients were identified. Graft and patient survival rates were compared with those after primary enteric drainage (ED). RESULTS: The mean SPK-EC interval was 5.0 yr, and the mean patient follow-up was 13.8 yr. Indications for EC were genitourinary symptoms (62.5%), duodenal complications (15.6%), graft pancreatitis (12.5%), pyelonephritis (6.3%), and metabolic acidosis (3.1%). All patients reported significant long-term resolution of symptoms. Surgical complications, reoperations, early graft loss, and 30-d mortality occurred in 31.3%, 25.0%, 6.3%, and 3.1% of cases, respectively. Pancreatic graft and patient survival rates at 1, 5, and 10 yr after SPK were comparable between EC patients and ED patients at the same institution. CONCLUSION: For the treatment of symptoms associated with BD, EC results in excellent long-term graft function and significant resolution of symptoms even years after SPK. Postoperative morbidity after EC including early reoperation and graft loss, however, has to be considered.

The formal requirements of algorithms and their implications in clinical medicine and quality management.

PURPOSE: Clinical algorithms contribute to the problem- and priority-orientated management of patients and their disease in healthcare. Algorithms are of particular importance in all aspects of emergency medicine where the fast completion of a complex problem according to a hierarchy is required. The advantages and success of this priority- and problem-orientated concept led to its expansion to other subspecialties in medicine in recent years. However, in spite of algorithms being created based on defined norms, they are frequently violated in the literature, which renders the algorithm useless in a particular case. METHODS: The present debate addresses these issues and provides the formal criteria and their necessary modification for creating sufficient clinical algorithms. In this context, we also clarify the misunderstandings between step-by-step schemes, decision trees, and algorithms, which are often used synonymously, and discuss their implications in clinical medicine and quality management. RESULTS: A clinical algorithm can easily be created with the present derivation of the algorithm by its formal mathematical function using the corresponding norms describing specific symbols for a single criterion. Some symbol modifications as well as the usage of checklists to focus on the major criteria led to a rigorous reduction of the algorithm length and results in a clearer arrangement for routine clinical use. In clinical medicine, algorithms cannot only provide a fast access for solving complex problems but must also assure a transparent protocol and democratic treatment such that every patient receives the same quality of treatment. Thus, a treatment by chance can be excluded by standardization, which might impact the overall work needed to guide patients though diagnostics and therapy and may ultimately reduce cost. Algorithms are useful not only for quality in healthcare but also for undergraduate and continuous medical education. From a more philosophical point of view, we can raise the question of whether medical pathways and thereby the medical art should be disclosed to the general public by algorithms. Hippocrates form Kos held the view in the so-called Hippocratic Oath that medical art should only be revealed to medical scholars. CONCLUSIONS: The present derivation and nomination of the formal requirements may lead to a better understanding of algorithms themselves as well as their development and generation.

Teaching advanced wound closure techniques using cattle digits.

OBJECTIVES: To evaluate a model used to impart advanced wound closure skills because available models do not meet the necessary requirements to a substantial degree. MATERIALS AND METHODS: Seventy-one residents were asked to evaluate a 75-minute-long skills course using cadaveric cattle digits to learn Z-plasty, V-Y-plasty, and oval-shaped rotational flaps. A short film and the course instructor demonstrated each technique first. A Likert rating scale ranging from 1 to 6 was used for questions in the survey given to the residents. RESULTS: There was strong agreement among residents (1.65 ± 1.17 years of experience) that advanced wound closure training courses are necessary (5.73 ± 0.73), which corresponded to the residents' low level of knowledge and self-assessment of practical skills and present experience (2.84 ± 1.01). The course was evaluated with high acceptance, even though it was found to be demanding for the trainees (5.84 ± 0.40). This might also be related to the high rating of the model itself, which was found to be a suitable method for teaching advanced wound closure techniques (5.50 ± 0.71) that was easily comprehensible (5.73 ± 0.53). CONCLUSION: Skills training courses for young trainees are warranted to impart advanced wound closure techniques. The curriculum using cattle digits presented here is recommended. The authors have indicated no significant interest with commercial supporters.

Pulmonary sclerosing hemangioma in a 21-year-old male with metastatic hereditary non-polyposis colorectal cancer: report of a case.

BACKGROUND: Pulmonary sclerosing hemangioma (SH) is a rare tumor of the lung predominantly affecting Asian women in their fifth decade of life. SH is thought to evolve from primitive respiratory epithelium and mostly shows benign biological behavior; however, cases of lymph node metastases, local recurrence and multiple lesions have been described. CASE PRESENTATION: We report the case of a 21-year-old Caucasian male with a history of locally advanced and metastatic rectal carcinoma (UICC IV; pT4, pN1, M1(hep)) that was eventually identified as having hereditary non-polyposis colorectal cancer (HNPCC, Lynch syndrome). After neoadjuvant chemotherapy followed by low anterior resection, adjuvant chemotherapy and metachronous partial hepatectomy, he was admitted for treatment of newly diagnosed bilateral pulmonary metastases. Thoracic computed tomography showed a homogenous, sharply marked nodule in the left lower lobe. We decided in favor of atypical resection followed by systematic lymphadenectomy. Histopathological analysis revealed the diagnosis of SH. CONCLUSIONS: Cases have been published with familial adenomatous polyposis (FAP) and simultaneous SH. FAP, Gardner syndrome and Li-Fraumeni syndrome, however, had been ruled out in the present case. To the best of our knowledge, this is the first report describing SH associated with Lynch syndrome.

Natural history, clinical pattern, and surgical considerations of pneumatosis intestinalis.

OBJECTIVE: Pneumatosis intestinalis has been increasingly detected in recent years with the more frequent use of computed tomography for abdominal imaging of the intestine. The underlying causes of the gas found during radiographic studies of the bowel wall can vary widely and different hypotheses regarding its pathophysiology have been postulated. Pneumatosis intestinalis often represents a benign condition and should not be considered an argument for surgery. However, it can also require life-threatening surgery in some cases, and this can be a difficult decision in some patients. METHODS: The spectrum of pneumatosis intestinalis is discussed here based on various computed tomographic and surgical findings in patients who presented at our University Medical Centre in 2003-2008. We have also systematically reviewed the literature to establish the current understanding of its aetiology and pathophysiology, and the possible clinical conditions associated with pneumatosis intestinalis and their management. RESULTS: Pneumatosis intestinalis is a primary radiographic finding. After its diagnosis, its specific pathogenesis should be ascertained because the appropriate therapy is related to the underlying cause of pneumatosis intestinalis, and this is sometimes difficult to define. Surgical treatment should be considered urgent in symptomatic patients presenting with an acute abdomen, signs of ischemia, or bowel obstruction. In asymptomatic patients with otherwise inconspicuous findings, the underlying disease should be treated first, rather than urgent exploratory surgery considered. Extensive and comprehensive information on the pathophysiology and clinical findings of pneumatosis intestinalis is provided here and is incorporated into a treatment algorithm. CONCLUSIONS: The information presented here allows a better understanding of the radiographic diagnosis and underlying aetiology of pneumatosis intestinalis, and may facilitate the decision-making process in this context, thus providing fast and adequate therapy to particular patients.

Aspiration and injection-based technique for incision and drainage of a sacrococcygeal pilonidal abscess.

The incision and drainage of a sacrococcygeal abscess is a common procedure in the Emergency Department (ED) both to decrease a patient's pain and to improve the local wound conditions for subsequent definitive surgical therapy. However, the local infiltration of anesthetics is often problematic due to the unacceptable and unavoidable pain resulting from the injection itself, as well as the inability to achieve a complete anesthetic response. Therefore, standard textbooks generally recommend the concomitant use of local and systemic analgesics in the treatment of sacrococcygeal abscesses. We describe herein an alternative technique to administer local analgesia after the aspiration of an abscess for incision and drainage of a sacrococcygeal abscess that is safe and rapid. The patient is placed in the prone position and the buttocks are separated from the midline with adhesive tape. The technique involves needle aspiration of the abscess with consecutive slow injections of the same amount of local anesthetic into the abscess cavity via the same needle, followed by abscess drainage by incision and gentle curettage. This method therefore eliminates multiple infiltrations of the abscess and the surrounding area and obviates the associated pain due to the low volume of anesthetic required. The described technique is well tolerated by the patient and reduces the frequently encountered difficulty with incision and drainage of coccygeal abscesses in the ED.

Histochemical assessment of early myocardial infarction using 2,3,5-triphenyltetrazolium chloride in blood-perfused porcine hearts.

INTRODUCTION: Although the chemical mechanism of the triphenyltetrazolium (TTC) reaction, for macroscopic detection of myocardial infarction, has been described previously, literature reports on correct tissue preparation and the use of this technique in intact large animals are lacking. METHODS: We investigated the special requirements for TTC staining in blood-perfused porcine hearts, validated the various handling steps and provided detailed information for precise and easy use of this histochemical method. The left anterior descending coronary artery was occluded for 45 min followed by 6 h of reperfusion in an open chest preparation using anesthetised domestic pigs. The hearts were excised and the organ-handling steps and TTC-staining procedure validated. RESULTS: The protocol includes (i) intracoronary saline perfusion, (ii) pressure-controlled determination of the non-ischemic region by Evans blue dye, (iii) a freeze-thaw cycle, (iv) a triphenyltetrazolium incubation period, and (v) a bleach cycle with 4% paraformaldehyde. The TTC-staining results were confirmed by histology of transitional regions of the infarct area, area-at-risk and non-risk-region. DISCUSSION: If some special features associated with blood-perfused porcine hearts are considered carefully, reliable results for subsequent infarct size calculations can be obtained and large potential errors excluded.

Validation and application of a high-performance liquid chromatographic-based assay for determination of the inosine 5'-monophosphate dehydrogenase activity in erythrocytes.

Thiopurine drug monitoring has become an important issue in treating children with acute lymphoblastic leukaemia (ALL). In this population, a genetic polymorphism causes wide differences in the activity of thiopurine S-methyletransferase (TPMT)--the rate-limiting enzyme of the thiopurine degradation metabolism--leading to the necessity of drug dose adjustments. It is not yet known if similar differences exist in the inosine 5'-monophosphate dehydrogenase (IMPDH; EC 1.1.1.205), the rate-limiting enzyme of the thiopurine synthesis. To test this, we established and validated a high-performance liquid chromatographic (HPLC)-based assay to determine the IMPDH enzyme activity in erythrocytes. The remarkable features of this assay are its simple erythrocyte separation/haemolysis and assay conditions and a distinct segregation of xanthosine 5'-monophosphate (XMP) from the clear supernatant after precipitation. The probes were processed without a time-consuming extraction and heating procedure and the assay demonstrated a good intra- and interday stability as well as a recovery rate of approximately 100%. The IMPDH enzyme activity was measured in erythrocytes of 75 children with diagnosis of ALL before starting antileukaemic therapy and their activity compared to those of 35 healthy adult controls. The measured enzyme activity was wide ranging in both groups. The individual enzyme activity differences observed in children with ALL might led to differences in the thionucleotide levels in those undergoing the standard thiopurine dose regimen.

The critical role of aprotinin in controlling haemostasis in conjunction with non-pharmacological blood-saving strategies during routine coronary artery bypass surgery.

OBJECTIVE: Aprotinin, a non-specific serine protease inhibitor, has been confirmed to be safe and effective in reducing intra- and postoperative blood drainage, transfusion requirements, and perioperative morbidity and mortality during coronary artery bypass surgery. It is the only one of the currently available haemo-static agents that is approved by the U.S. Food and Drug Administration (FDA) for use in cardiac surgery. However, one major weakness of currently available trials is the lack of information regarding the concomitant usage of aprotinin with blood-saving strategies that have been used more frequently in recent years. METHODS: Patients undergoing elective first-time coronary artery bypass grafting (n = 172) who were given systemic high-dose aprotinin (n = 85), combined systemic high-dose aprotinin and topical aprotinin (n = 27), or no aprotinin (n = 60) were reviewed retrospectively. The use of all blood-saving procedures was systematically taken in account. RESULTS: Postoperative blood drainage was significantly less in patients treated with aprotinin than controls (P < 0.0001). Concomitant use of topical aprotinin was accompanied by a postoperative blood loss reduction of 35% compared to systemic aprotinin use alone (P < 0.003). The intra- and postoperative donor blood requirements were dramatically reduced in both aprotinin-treated groups compared to controls, although patients received different blood saving strategies as appropriate (P < 0.0001). A trend of up to 20% lower postoperative blood drainage was noted in patients in whom intraoperative haemodilution and autologuos blood transfusions were used (P > 0.05). CONCLUSIONS: The present analysis demonstrates that the local and systemic administration of aprotinin is safe and effective in reducing intra- and postoperative blood drainage and transfusion requirements. In elective CABG procedures, aprotinin should still be used even if blood-saving strategies are employed.

Calpain inhibition reduces infarct size and improves global hemodynamics and left ventricular contractility in a porcine myocardial ischemia/reperfusion model.

Calpains, a family of Ca2+-dependent cysteine proteases, are activated during myocardial ischemia and reperfusion. This study investigates the cardioprotective effects of calpain inhibition on infarct size and global hemodynamics in an ischemia/reperfusion model in pigs, using the calpain inhibitor A-705253. The left anterior descending coronary artery was occluded for 45 min and reperfused for 6 h. A bolus of 1.0 mg/kg A-705253 or distilled water was given intravenously 15 min prior to induction of ischemia and a constant plasma level of A-705253 was maintained by continuous infusion of 1.0 mg/kg A-705253 during reperfusion. Infarct size was assessed histochemically using triphenyltetrazolium chloride staining. Macromorphometric findings were verified by light microscopy on hematoxylin-eosin- and Tunel-stained serial sections. Global hemodynamics, including the first derivate of the left ventricular pressure (dP / dtmax), were measured continuously throughout the experiment. A-705253 reduced the infarct size by 35% compared to controls (P < 0.05). Hemodynamic alterations, including heart rate, aortic blood pressure, central venous pressure and left atrial pressure, were attenuated mainly during ischemia and the first 2 h during reperfusion by A-705253. Cardiac function improved, as determined by dP / dtmax, after 6 h of reperfusion (P < 0.003). Our results demonstrate that myocardial protection can be achieved by calpain inhibition, which decreases infarct size and improves left ventricular contractility and global hemodynamic function. Hence, the calpain-calpastatin system might play an important pathophysiological role in porcine myocardial ischemia and reperfusion damage and A-705253 could be a promising cardioprotective agent.

Interference free and simplyfied liquid chromatography-based determination of thiopurine S-methyltransferase activity in erythrocytes.

The determination of the thiopurine S-methyltransferase activity (TPMT; EC 2.1.1.67) has become an important issue during thiopurine therapy due to its known genetic polymorphism resulting in a wide range of TPMT activity. Therefore, the standard thiopurine drug regimen is associated with increased hematopoetic toxicity in patients with low or absent TPMT activity, whereas patients with high activity may be insufficiently treated. However, presently available methods are labour intensive and time consuming and tend towards too high or too low enzyme activity due to their methodological approach. The use of instable substrate solutions (6-MP or 6-TG), organic solvents like dimethyl sulfoxide and too high substrate and co-substrate saturation concentrations contribute to this phenomenon. We therefore, established an optimized and fast isocratic HPLC linked TPMT assay based on the enzymatic methylation of mercaptopurine or thioguanine in RBC lysates with S-adenosyl-l-methionine as methyl donor. Unspecific non-enzymatic methylation was not detectable. The recovery of 6-methyl-mercaptopurine was 97-102%, the intra- and interday variation between 1.0 and 5.0%, respectively. The assay dispenses with a time consuming extraction procedure with organic solvents, a heating step, and a gradient elution and is therefore, favourable for clinical routine application. The TPMT activity was measured in 62 untreated children with acute lymphoblastic leucemia at the time of diagnosis (activity = 34.0+/-10.6 nmol/g Hb/h, range: 11.5-55.4 nmol/g Hb/h) and in 12 adult healthy volunteers (62.8+/-7.7 nmol/g Hb/h, range: 48-82 nmol/g Hb/h) reflecting the wide measurable TPMT activity found in erythrocytes.

Blunt Cardiac Injury in the Severely Injured - A Retrospective Multicentre Study.

BACKGROUND: Blunt cardiac injury is a rare trauma entity. Here, we sought to evaluate the relevance and prognostic significance of blunt cardiac injury in severely injured patients. METHODS: In a retrospective multicentre study, using data collected from 47,580 patients enrolled to TraumaRegister DGU (1993-2009), characteristics of trauma, prehospital / hospital trauma management, and outcome analysis were correlated to the severity of blunt cardiac injury. The severity of cardiac injury was assessed according to the abbreviated injury score (AIS score 1-6), the revised injury severity score (RISC) allowed comparison of expected outcome with injury severity-dependent outcome. N = 1.090 had blunt cardiac trauma (AIS 1-6) (2.3% of patients). RESULTS: Predictors of blunt cardiac injury could be identified. Sternal fractures indicate a high risk of the presence of blunt cardiac injury (AIS 0 [control]: 3.0%; AIS 1: 19.3%; AIS 2-6: 19.1%). The overall mortality rate was 13.9%, minor cardiac injury (AIS 1) and severe cardiac injury (AIS 2-6) are associated with higher rates. Severe blunt cardiac injury (AIS 4 and AIS 5-6) is associated with a higher mortality (OR 2.79 and 4.89, respectively) as compared to the predicted average mortality (OR 2.49) of the study collective. CONCLUSION: Multiple injured patients with blunt cardiac trauma are at high risk to be underestimated. Careful evaluation of trauma patients is able to predict the presence of blunt cardiac injury. The severity of blunt cardiac injury needs to be stratified according to the AIS score, as the patients' outcome is dependent on the severity of cardiac injury.