Hepatic lobe torsion: A rare disease necessitating surgical management.

BACKGROUND: Accessory liver lobes and other congenital liver abnormalities are rare and most often asymptomatic. However, these abnormalities can result in liver torsion, requiring surgical resection. CASE REPORT: We report a case of a 72-year-old woman with hepatic lobe torsion. She presented with an acute onset of chest pain and was discovered to have hypoperfusion of the left lobe of the liver on contrast-enhanced abdominal computed tomography (CT) scan. An exploratory laparotomy revealed left hepatic lobe torsion with irreversible ischemic changes requiring left hepatic lobe resection. CONCLUSION: Even though hepatic torsion is rare, it should be considered in the differential diagnosis for abdominal pain and appropriately imaged so that surgical teams can prepare for the complex surgical procedure.

Assessment of the Nova StatSensor whole blood point-of-care creatinine analyzer for the measurement of kidney function in screening for chronic kidney disease.

BACKGROUND: Point-of-care testing for creatinine using a fingerprick sample and resultant estimated glomerular filtration rate has potential for screening for chronic kidney disease in community settings. This study assessed the applicability of the Nova StatSensor creatinine analyzer for this purpose. METHODS: Fingerprick samples from 100 patients (63 renal, 37 healthy volunteers; range 46-962 micromol/L) were assayed using two StatSensor analyzers. Lithium heparin venous plasma samples collected simultaneously were assayed in duplicate using the isotope dilution mass spectrometry-aligned Roche Creatinine Plus enzymatic assay on a Hitachi Modular P unit. Method comparison statistics and the ability of the StatSensor to correctly categorise estimated glomerular filtration rate above or below 60 mL/min were calculated pre- and post-alignment with the laboratory method. RESULTS: StatSensor 1 creatinine results (y) were much lower than the laboratory (y=0.75x+10.2, average bias -47.3, 95% limits of agreement -208 to +113 micromol/L). For estimated glomerular filtration rates above or below 60 mL/min, 100% and 87% of results respectively agreed with the laboratory estimated glomerular filtration rate (79% and 96% post-alignment). StatSensor 2 statistics were similar. The 95% limits of agreement between StatSensor creatinine results were -35 to +34 micromol/L. CONCLUSIONS: Isotope dilution mass spectrometry alignment of the StatSensor will identify most patients with estimated glomerular filtration rate <60 mL/min, but there will be many falsely low estimated glomerular filtration rate results that require laboratory validation. Creatinine results need improvement.

Screening for chronic kidney disease in Australia: a pilot study in the community and workplace.

The pilot program Kidney Evaluation for You (KEY) was conducted in Australia to screen for chronic kidney disease (CKD). Targeting people at high risk (those with diabetes, hypertension, a first-degree relative with kidney failure, or age >50 years), KEY aimed to establish community-based screening protocols, assess efficacy in promoting changes in risk-factor management, and explore participant CKD awareness. KEY offered free cardiovascular and kidney checks using point-of-care testing for on-site pathology measurements (estimated glomerular filtration rate, hemoglobin A1c, cholesterol, hemoglobin, albuminuria), lifestyle assessment, and exit interviews. Participants were telephoned at 3 months to ascertain whether KEY advice had been followed. Community and health professional support was strong; 99% of participants rated involvement as beneficial. Of 402 high-risk individuals recruited, findings were suggestive of CKD in 20.4%. Of these, 69% had hypertension, 30% diabetes, and 40% elevated total cholesterol. All participants with CKD stage 3b or higher were aged >61 years. Overall, 58% of participants were referred to their primary care providers for further action; of these, 82% saw their doctors in the next 3 months and 94% discussed KEY results. Follow-up telephone contact was successful for 82% of participants. A change in management occurred for 67%. Thus, the KEY approach to early detection of CKD and selected referral of participants was largely successful.

Review article: Early detection of chronic kidney disease in Australia: which way to go?

Early detection of chronic kidney disease (CKD) followed by appropriate clinical management appears the only means by which the increasing burden on the health-care system and affected individuals will be reduced. The asymptomatic nature of CKD means that early detection can only occur through testing of individuals. The World Health Organization principles of screening for chronic disease can now be largely fulfilled for CKD. The risk groups to be targeted, the expected yield and the tests to be performed are reviewed. For a screening programme to be sustainable it must carry a greater benefit than risk of harm for the participant and be shown to be cost-effective from the community point of view. Whole population screening for CKD is impractical and is not cost-effective. Screening of those at increased risk of CKD could occur either through special events run in the community, workplace or in selected locations such as pharmacies or through opportunistic screening of high-risk people in general practice. Community screening programmes targeted at known diabetics, hypertensives and those over 55 years have been described to detect 93% of all CKD in the community. The yield of CKD stages 3-5 from community screening has been found to vary from 10% to 20%. The limitations of screening programmes including the cost and recruitment bias are discussed. The most sustainable and likely the most cost-efficient model appears to be opportunistic general practice screening. The changing structure of general practice in Australia lends itself well to the requirements for early detection of CKD.

Safety of 96-hour incision-site continuous infusion of ropivacaine for postoperative analgesia after bowel cancer resection.

The aim of this study was to examine the safety of ropivacaine given to patients as a continuous infusion [0.2% (2 mg/mL), 5 mL/h for 96 hours] into a right lateral transverse incision using a portable elastomeric infusion pump after colon cancer resection. Blood samples were collected throughout the infusion and up to 12 hours after infusion and were analyzed by high-performance liquid chromatography (HPLC) for total and unbound ropivacaine concentrations in plasma. Alpha1 acid glycoprotein (AAG) concentrations were measured at 0 and 48 hours to assess possible changes in ropivacaine protein binding after surgery. Postoperative pain control was assessed using 12 hour visual analog scale (VAS) scores. Patient-controlled analgesia (PCA) using fentanyl was freely available in parallel for breakthrough pain, with usage and consumption compared with a historical cohort. The mean +/- SD Cmax total plasma ropivacaine concentration (n = 5) from 12 hours to the end of the infusion was 4.5 +/- 2.6 mg/L, comparable with the previously published threshold for CNS toxicity in the most sensitive patient studied (3.4 mg/L). However, the corresponding maximum unbound ropivacaine concentration (ie, the pharmacologically active moiety) of 0.07 +/- 0.01 mg/L ranged from four- to sevenfold below the reported toxicity threshold (0.34 mg/L). The apparently greater safety margin seen with unbound ropivacaine may have resulted from a significant increase (mean 63%, P < 0.05) in AAG concentrations measured at 48 hours after surgery. This reduction resulted from the known AAG reaction after surgical intervention, resulting in a reducing unbound ropivacaine fraction throughout the 96 hour infusion in all patients. Mean subjective 12 hour pain scale scores at rest and on movement showed large variability between patients. No signs or symptoms of ropivacaine toxicity were observed or reported on questioning. In this limited sample, extending the infusion period from the presently approved 48 hours to 96 hours seems to be a safe alternative and/or adjunct to standard opiate analgesia after colorectal surgery using a right lateral transverse incision, hence reducing the incidence of opiate adverse effects and enhancing recovery. Unbound ropivacaine concentrations suggest there is scope for testing elevated doses to enhance efficacy further.