A registry analysis of damage to the deceased donor pancreas during procurement.

Surgical injury to the pancreas is thought to occur commonly during procurement. The UK Transplant Registry was analyzed to determine the frequency of pancreatic injuries, identify factors associated with damage, and assess the impact of injuries on graft survival. Twelve hundred ninety-six pancreata were procured from donation after brain death donors, with 314 (19.5%) from donation after circulatory death donors. More than 50% of recovered pancreata had at least one injury, most commonly a short portal vein (21.5%). Liver donation, procurement team origin, hepatic artery (HA) arising from the superior mesenteric artery (SMA), and increasing donor BMI were associated with increased rates of pancreas damage on univariate analyses; on multivariate analysis only the presence of an HA from the SMA remained significant (p = 0.02). Six hundred forty solid organ pancreas transplants were performed; 238 had some form of damage. Overall, there was no difference in graft survival between damaged and undamaged organs (p = 0.28); however, graft loss was significantly more frequent in pancreata with arterial damage (p = 0.04) and in those with parenchymal damage (p = 0.05). Damage to the pancreas during organ recovery is more common than other organs, and meticulous surgical technique and awareness of damage risk factors are essential to reduce rates of procurement-related injuries.

Acute cytomegalovirus cholecystitis following renal transplantation.

Solid organ transplant recipients are at risk of infection from cytomegalovirus (CMV). A wide range of disease is associated with CMV infection and we report two cases of CMV cholecystitis in patients following renal transplantation. Both patients presented with severe hemorrhagic cholecystitis, which required immediate resuscitation and emergency cholecystectomy. The diagnosis of CMV infection was confirmed in both cases using CMV-specific staining of the gallbladder. The diagnosis of CMV cholecystitis must be considered in all patients with upper abdominal pain after renal transplantation.

The biomechanics of simple steatosis and steatohepatitis.

Magnetic resonance and ultrasound elastography techniques are now important tools for staging high-grade fibrosis in patients with chronic liver disease. However, uncertainty remains about the effects of simple accumulation of fat (steatosis) and inflammation (steatohepatitis) on the parameters that can be measured using different elastographic techniques. To address this, we examine the rheological models that are capable of capturing the dominant viscoelastic behaviors associated with fat and inflammation in the liver, and quantify the resulting changes in shear wave speed and viscoelastic parameters. Theoretical results are shown to match measurements in phantoms and animal studies reported in the literature. These results are useful for better design of elastographic studies of fatty liver disease and steatohepatitis, potentially leading to improved diagnosis of these conditions.

Analgesia in the elderly. Practical treatment recommendations.

Pain management in the elderly increasingly presents a challenge for general practitioners and pain specialists. A careful history and examination need to be performed so that any underlying cause of the pain can be established and treated appropriately. The nature of the pain must also be determined so that inflammatory or neuropathic components can be treated effectively. Special care should be taken when new drug treatments are initiated in the elderly because increased sensitivity, a prolonged drug half-life and drug interactions are more likely. Local therapies and nondrug treatments are often very effective in helping to alleviate pain and to increase function and independence. The use of all these techniques, combined with appropriate psychological strategies and setting realistic aims, will result in effective pain management in most patients.

Strategies to improve the effectiveness of abdominal aortic aneurysm screening programmes.

OBJECTIVE: Ruptured abdominal aortic aneurysms (rAAAs) occurring in patients with screen-detected aneurysms could be regarded as a failure of screening and reduce effectiveness of screening. To understand this issue, we studied the reasons why rAAAs occur in screened patients and estimated the cost-benefit ratio if these ruptures could be prevented. METHODS: All rAAAs occurring in the Huntingdon district in the UK during the study period (1991-2000) were traced via a combination of hospital admission, accident and emergency attendance, and intensive therapy unit admission records, operating theatre registers and post-mortem reports. Cross-referencing with the aneurysm-screening database identified those patients who had attended screening. Previously used cost-effectiveness models were used to estimate the cost benefits to screening. RESULTS: Ninety-three rAAAs occurred in men over the study period, of whom 23 (25%) had been invited for screening and 13 (14%) had accepted the invitation. All who had been screened (mean age 75 [65-82]) had abnormal aortic diameters (>30 mm) on their first scan. Of those invited, 10/23 (43%) did not attend their screening appointment, 4/23 (17%) were deemed not fit for open surgery, 4/23 (17%) ruptured whilst being assessed for aneurysm repair, 2/23 (9%) ruptured whilst under six-monthly surveillance, and 3/23 (13%) failed to attend scheduled six-monthly surveillance appointments. Reducing screened ruptures by one half could increase the cost-effectiveness of screening by 27%. CONCLUSION: There were no failures of the screening test. The benefits of aneurysm screening can be improved by increasing the uptake of screening, the compliance with surveillance, and by streamlining the work-up process before surgery.

Rehabilitation of chronic low back pain using continuous epidural analgesia.

PURPOSE: Physical rehabilitation is one of the major forms of treatment of chronic low back pain. The ability of some patients to cooperate is limited by pain. Since 1992 continuous epidural analgesia has been combined with a physical rehabilitation programme for patients with chronic low back pain who have been unable to make progress with conventional physical rehabilitation due to severity of pain. METHOD: This study reports a series of 46 consecutive patients with chronic back pain admitted over a 6 month period to a 5-day inpatient rehabilitation programme. A lumbar epidural catheter was inserted and bupivacaine 0.125% was infused at a rate that produced analgesia without sensory or motor deficit over a period of 5 days. An intensive mobilizing physiotherapy programme was instituted. Physical and psychological parameters were measured on day 1, after 1 week, after 1 month and after 1 year. RESULTS: Time to complete a 50 m walk, time from sitting to standing, and spinal flexion were improved at 1 week and 1 month, but only time to complete the walk remained improved at 1 year. In Goldberg's General Health Questionnaire 28 scores were improved for social dysfunction, somatic symptoms, anxiety and insomnia, and depression, at 1 week and 1 month but only social dysfunction remained improved at 1 year. Using a Visual Analogue Scale pain ratings were unaltered after 1 year. CONCLUSION: Continuous 5 day epidural analgesia combined with intensive physiotherapy may offer a means of initial rehabilitation of chronic low back pain. The initial benefit was most marked at 1 week, with benefit still evident after 1 month. However, the benefit decreased with time. This technique may be of value as part of a more comprehensive programme of physical and psychological rehabilitation.

A case report of massive vaginal variceal hemorrhage in a patient with cirrhosis secondary to nonalcoholic steatohepatitis unresolved even after successful liver transplantation.

Massive hemorrhage from vaginal varices in patients with cirrhosis and a previous hysterectomy can be life-threatening. In the few previous reports, the treatments have all included an initial local tamponade followed by interventional radiology procedures, transvenous intrahepatic portosystemic shunts, surgical shunt, or liver transplantation. A patient with cirrhosis secondary to nonalcoholic steatohepatitis developed massive vaginal variceal hemorrhage. Control of the bleeding was achieved initially with local tamponade. Upon admission to the intensive care unit, the patient was upgraded to urgent status on the liver transplant waiting list, which was performed on day 7. Due to a portal vein thrombosis, an interpositional vein graft to the superior mesenteric vein was required. Postoperatively despite a functional graft and normalization of coagulation system, the vaginal bleeding continued as the left-sided portal hypertension had not been decompressed by the liver transplantation. During a subsequent laparotomy, splenectomy and ligation of the inferior mesenteric vein were required to definitively control the vaginal variceal hemorrhage. The degree and anatomy of the portal hypertension play a crucial role in determining the proper course of management and treatment of vaginal varices in a cirrhotic patient.

Cutting edge: interactions through the IL-10 receptor regulate autoimmune diabetes.

BDC2.5/nonobese diabetic (NOD) transgenic mice express a TCR from a diabetogenic T cell clone yet do not spontaneously develop diabetes at high incidence. Evidence exists showing that in the absence of endogenous TCR alpha-chain rearrangements this transgenic mouse spontaneously develops diabetes and that CTLA-4 negatively regulates diabetes onset. This strongly suggests that onset of diabetes in BDC2.5/NOD mice is governed by T cell regulation. We addressed the mechanism of immune regulation in BDC2.5/NOD mice. We find that activated spleen cells from young, but not old, BDC2.5/NOD mice are able to transfer diabetes to NOD-scid recipients. We have used anti-IL-10R to show that the failure of splenocytes from older mice to transfer diabetes is due to dominant regulation. We furthermore found that diabetes developed following anti-IL-10R treatment of 6-wk old BDC2.5/NOD mice indicating that endogenous IL-10 plays a key role in the regulation of diabetes onset in this transgenic mouse.

Jaw thrusting as a clinical test to assess the adequate depth of anaesthesia for insertion of the laryngeal mask.

We have studied the efficacy of the loss of response to jaw thrust as a clinical test to assess adequate depth of anaesthesia for insertion of the laryngeal mask in 60 patients. After induction of anaesthesia with propofol (infused using a syringe driver), the patients were randomly allocated to one of two groups. In one group, insertion of the laryngeal mask was attempted immediately after the loss of verbal contact and in the other group, after the loss of motor response to a jaw thrust. Conditions for insertion of the laryngeal mask were assessed. The mean dose of propofol required to obtain loss of verbal contact was 1.94 mg.kg-1 (SD 0.39, 95% confidence intervals (CI) 1.79-2.08 mg.kg-1) and that for the loss of response to jaw thrust was 2.55 mg.kg-1 (SD 0.46, 95% CI 2.38-2.72 mg.kg-1). When depth of anaesthesia was assessed using jaw thrusting, it was always possible to insert the mask and the conditions were optimal in 87% (95% CI 72-95%) of patients. Neither coughing nor gagging occurred. In contrast, conditions were almost always less than optimal when insertion was attempted after the loss of verbal contact. Conditions were significantly better when jaw thrust was used as a clinical test compared with loss of verbal contact (p < < 0.001). No marked haemodynamic depression occurred in any patient. Thus, jaw thrust is a reliable clinical test to assess the adequate depth of anaesthesia for uncomplicated insertion of the laryngeal mask after induction of anaesthesia with propofol.