Parainfluenza 3 Infections Early After Kidney or Simultaneous Pancreas-Kidney Transplantation.

Parainfluenza virus (PIV) can cause serious infections after hematopoietic stem cell or lung transplantation. Limited data exist about PIV infections after kidney transplantation. We describe an outbreak of PIV-3 in a transplant unit. During the outbreak, 45 patients were treated on the ward for postoperative care after kidney or simultaneous pancreas-kidney (SPK) transplantation. Overall, 29 patients were tested for respiratory viruses (12 patients with respiratory symptoms, 17 asymptomatic exposed patients) from nasopharyngeal swabs using polymerase chain reaction. PIV-3 infection was confirmed in 12 patients. One patient remained asymptomatic. In others, symptoms were mostly mild upper respiratory tract symptoms and subsided within a few days with symptomatic treatment. Two patients suffered from lower respiratory tract symptoms (dyspnea, hypoxemia, pulmonary infiltrates in chest computed tomography) and required supplemental oxygen. Four of six SPK patients and eight of 39 of kidney transplant patients were infected with PIV (p = 0.04). In patients with follow-up tests, PIV-3 shedding was still detected 11-16 days after diagnosis. Despite rapid isolation of symptomatic patients, PIV-3 findings were diagnosed within 24 days, and the outbreak ceased only after closing the transplant ward temporarily. In conclusion, PIV-3 infections early after kidney or SPK transplantation were mostly mild. PIV-3 easily infected immunosuppressed transplant recipients, with prolonged viral shedding.

Outbreak of Influenza A(H1N1) in a Kidney Transplant Unit-Protective Effect of Vaccination.

Seasonal influenza vaccination is recommended for patients with end-stage renal disease (ESRD), despite suggested inferior efficacy among these patients. We characterize an outbreak of influenza A(H1N1) in a kidney transplant unit. Altogether 23 patients were treated on the ward for postoperative care after kidney transplantation during the outbreak. After the first positive case, all patients were tested with nasopharyngeal swab tests and 7 patients were diagnosed with influenza A(H1N1). Altogether 17/23 patients had received adequate seasonal influenza vaccination, of whom 2/17 tested positive for influenza (one asymptomatic, one with mild cough). Five of six unvaccinated patients were diagnosed with influenza A(H1N1); 3/5 suffered from severe respiratory failure and were treated with ventilator support in the ICU, but all died due to acute respiratory distress syndrome, whereas 2/5 suffered from mild viral pneumonitis and recovered fully. The risk of influenza infection and mortality was significantly increased in unvaccinated patients (odds ratio 37.5 [95% CI 2.7-507.5, p = 0.01] and 6.7 [95% CI 2.3-18.9, p = 0.003], respectively). Influenza A(H1N1) had a high mortality in our cohort of nonvaccinated immunosuppressed patients early after kidney transplantation. None of the vaccinated patients developed serious disease, supporting the role of vaccination also for ESRD patients.

A single amino acid substitution in viral VP1 protein alters the lytic potential of clone-derived variants of echovirus 9 DM strain in human pancreatic islets.

In vitro studies with primary human pancreatic islets suggest that several enterovirus serotypes are able to infect and replicate in beta cells. Some enterovirus strains are highly cytolytic in vitro whereas others show virus replication with no apparent islet destruction. The capability to induce islet destruction is determined only partially by the virus serotype, since strain specific differences have been detected within some serotypes including echovirus 9 (E-9). In this study, the viral genetic factors determining the outcome of islet infection (i.e., destructive vs. benign) were investigated by constructing parallel infectious clones of lytic E-9-DM strain that was isolated from a small child at the clinical onset of type 1 diabetes. The capabilities of these clone-derived viruses to induce islet destruction were monitored and the lytic potential of clones was modified by site-directed mutagenesis. The lytic capabilities of these clone-derived viruses in human pancreatic islets were modified by a single amino acid substitution (T81A) in the capsid protein VP1. The data presented outline the importance of amino acid point mutations in the pathogenetic process leading to islet necrosis. However, although the amino acid substitution (T81A) modifies the lytic capabilities of E-9-DM strain-derived microvariant strains, it is likely that additional viral genetic determinants of pancreatic islet pathogenicity exist in other E-9 strains.

A Case Report of Successful Kidney Donation After Brain Death Following Nicotine Intoxication.

Nicotine intoxication is a rare cause of death and can lead to brain death after respiratory arrest and hypoxic-ischemic encephalopathy. To our knowledge, no previous reports regarding organ donation after nicotine intoxication have been described. We present a successful case of kidney donation after brain death caused by subcutaneous nicotine overdose from liquid nicotine from an e-cigarette cartridge in an attempted suicide. Both kidneys were transplanted successfully with immediate graft function, and both recipients were discharged at postoperative day 9 with normal plasma creatinine levels. Graft function has remained excellent in follow-up. This case suggests that kidneys from a donor with fatal nicotine intoxication may be successfully used for kidney transplantation in the absence of other contraindications for donation.

Selective measurement of triacylglycerol lipase activities in pig post-heparin plasma.

Immunochemical methods for the selective measurement of pig post-heparin plasma lipoprotein lipase and hepatic lipase are described and validated. A simple two step purification method for porcine hepatic lipase from hepatic perfusate based on affinity chromatography and gel filtration is reported. The activity of the post-heparin plasma lipoprotein lipase and hepatic lipase in swine is reported. It is demonstrated that fasting decreases the activity of post-heparin plasma lipoprotein lipase activity more than two-fold while it does not affect the hepatic lipase activity significantly.

Clinical value of severity markers in acute pancreatitis.

Acute pancreatitis is a common digestive disease of which the severity may vary from mild, edematous to severe, necrotizing disease. An improved outcome in the severe form of the disease is based on early identification of disease severity and subsequent focused management of these high-risk patients. However, the ability of clinicians to predict, upon presentation, which patient will have mild or severe acute pancreatitis is not accurate. Prospective systems using clinical criteria have been used to determine severity in patients with acute pancreatitis, such as the Ranson's prognostic signs, Glasgow score, and the acute physiology and chronic health evaluation II score (APACHE II). Their application in clinical practise has been limited by the time delay of at least 48 h to judge all parameters in the former two and by being cumbersome and time-consuming in the latter. Contrast-enhanced computed tomography is presently the most accurate non-invasive single method to evaluate the severity of acute pancreatitis. It cannot, however, be performed to all patients with acute pancreatitis. Therefore, considerable interest has grown in the development of reliable biochemical markers that reflect the severity of acute pancreatitis. In this article we critically appraise current and new severity markers of acute pancreatitis in their ability to distinguish between mild and severe disease and their clinical utility.

Surgical complications following 1670 consecutive adult renal transplantations: A single center study.

BACKGROUND AND AIMS: The aim of the study was to clarify the frequency and the sequel of surgical complications occurring within 1 year after renal transplantation. PATIENTS AND METHODS: Surgical complications after 1670 consecutive adult kidney transplantations performed between 2000 and 2009 were retrospectively analyzed. In 2%, a living-related allograft was used, and 10% were retransplantations. An intravesical technique without stenting was used for the ureteric implantation. RESULTS: There were 282 surgical complications occurring in 259 (15.5%) transplantations. Ureteral obstruction occurred in 53 (3.1%), lymphoceles in 39 (1.5%), postoperative hemorrhage in 36 (2.1%), and renal vein thrombosis in 22 (1.3%) patients, respectively. Out of the 17 lung emboli, 4 were fatal. Male recipients had twice as much ureteral stenosis as female (2.4 vs 1.2%, p < 0.05), and the opposite was true of urinary leakage (1.8% vs 4.0%, p < 0.025). Five-year patient and graft survival was impaired in patients with complications compared with patients without complications. Five-year patient survival was 92% versus 88% and graft survival 87% versus 74%. CONCLUSION: Surgical complications impair patient and graft survival after kidney transplantation.

Duodenogastric reflux of lysolecithin in the pathogenesis of experimental porcine stress ulceration.

The role of duodenogastric reflux of lysolecithin, a normal constituent of duodenal juice, in the pathogenesis of gastric stress ulcerations was investigated with a swine shock-ulcer model. Twenty-seven piglets, weighing 8 to 12 kilograms, were used. In an intact animal, the average concentration of intragastric lysolecithin before shock was 138 mug per milliliter (median, N = 6). At the end of the shock period, the average concentration of lysolecithin was 540 mug per milliliter and the over-all amount in the gastric juice was 14.3 mg. (median, N = 6). Following hemorrhagic shock (3 hours duration; mean arterial pressure, 40 mm. Hg), all six control animals with normal gastroduodenal continuity got gastric ulcerations. Interruption of duodenogastric reflux by duodenal exclusion and gastrojejunostomy completely abolished the development of these ulcerations in six test animals. When the interrupted duodenogastric reflux was replaced artificially by intragastric instillation of lysolecithin (500 mug per milliliter; 25 ml.), all six animals developed lesions. Intragastric lysolecithin without shock had no effect. The results provide further support to the concept that regurgitation of duodenal juice into the stomach is an essential factor in the pathogenesis of gastric stress ulceration. The results also suggest that, in this respect, one of the active components in duodenal juice is lysolecithin.

Pseudocysts in chronic pancreatitis. Surgical results in 102 consecutive patients.

Preoperative symptoms, diagnoses, and postoperative outcomes in 102 consecutive patients with pancreatic pseudocysts were analyzed. Upper epigastric pain, loss of weight, obstructive jaundice, and sudden arterial bleeding from the pseudocyst were the most common preoperative symptoms. Ultrasonography, computed tomography, and endoscopic retrograde cholangiopancreatography were the most useful diagnostic tools in the evaluation of the presence, size, location, and possible pancreatic ductal communications of the pseudocyst. In a single thick-walled pseudocyst, the best long-term results were achieved by internal drainage. Pancreatic resection is justified if the patient already has diabetes or multiple pseudocysts or if the pseudocyst is not amenable to internal drainage. The most fatal preoperative complication was a sudden arterial bleeding from a pseudocyst. In treating this complication, hemostasis with transcystic arterial ligation and external drainage of the pseudocyst gave the best results.

Analysis of 58 patients surviving more than ten years after operative treatment of gastric cancer.

We evaluated 58 patients who were still alive more than ten years after operative treatment of gastric cancer. We reexamined their histologic specimens and compared them with those of matched paired controls of the same sex and age who had died of gastric cancer. Forty-two patients consented to a follow-up study. The age of the patients did not affect survival. For patients with gastric cancer, those with distal cancer or an ulcer simulating cancer had had a better prognosis. Forty percent of the patients had had an early gastric cancer. Only two patients had had lymph node metastases in regional lymph nodes, and macroscopic tumor growth through the serosa had been recorded in only four cases. In 23 cases, a distal resection had proved successful. No significant correlation between intestinal or diffuse types of cancer and prognosis was observed. One recurrence after ten years was found; in one case, there was a new cancer in the gastric remnant. In addition, biopsy specimens from two patients showed grave dysplasia. We suggest that throughout their lives annual follow-up examinations be performed in patients who have undergone radical operations for gastric cancer.

Ganglioside pattern and neuraminic acid content of human gastric and colonic carcinoma.

Twenty-five human gastric and 11 human colonic adenocarcinomas were analysed for their ganglioside pattern and for their content of lipid-bound and protein-bound neuraminic acid. In most carcinomas the content of both lipid-bound and protein-bound neuraminic acid was increased by an average of four- and two-fold, respectively. The ganglioside pattern of all the carcinomas resembled that of normal tissue. In six gastric carcinomas the content of lipid-bound neuraminic acid and the ratio of lipid-bound neuraminic acid to protein-bound neuraminic acid (L/P ratio) were lower than those of normal gastric mucosa. These carcinomas were significantly larger than the rest of the tumours.

Serum phospholipase A2 and pulmonary changes in acute fulminant pancreatitis.

Twenty-three patients with acute fulminant pancreatitis were studied. The diagnosis was confirmed at laparotomy in every case. Blood samples for the assay of phospholipase A2 were collected for 14 days, and the pulmonary status of the patients was followed by monitoring the blood gases and the inspired oxygen fraction and studying a derived variable, the alveolar to arterial oxygen tension difference--the arterial oxygen tension ratio (A--aDo2/PaO2). The serum phospholipase A2 activities correlated with the changes in pulmonary function and with the outcome of the disease. Eight patients succumbed and they showed higher phospholipase A2 activities and A--aDo2/PaO2 ratios than the five patients who survived after major complications and the ten patients who survived without major complications. The results suggest that in acute fulminant pancreatitis serum phospholipase A2 activity correlates with the severity of the pulmonary changes. Furthermore, it seems to reflect the prognosis.

Total and near-total gastrectomy for gastric cancer in patients over 70 years of age.

A total or near-total gastrectomy was performed in 52 patients over 70 years of age in our hospital from 1975 through 1982. The hospital mortality rate was 9.6 percent. The operation was palliative in nine patients. In these patients, the operation was performed because of an obstructing cancer. At last follow-up, 11 patients had survived more than 5 years and 6 patients were alive and free of disease more than 3 years after the operation. Total and near-total gastrectomies seem to be justified in elderly patients in good overall physical condition.

Total gastrectomy with esophagojejunostomy. Analysis of 100 consecutive patients.

One hundred consecutive patients treated for gastric cancer by total gastrectomy from 1977 to 1982 at the second department of surgery of the Helsinki University Central Hospital were analyzed. The mean age of the patients was 61.5 years. Gastroscopy proved to be diagnostically superior to roentgenographic examination, particularly in cases of proximally located cancer. The mean length of postoperative hospital stay was 19.7 days, and the hospital mortality was 8 percent. Respiratory complications accounted for nearly half of the complications, and postoperative intraabdominal complications were recorded in 15 patients. Reoperation was performed on eight patients during the initial hospital stay due to complications. The results suggest that total gastrectomy is a safe procedure with an acceptable mortality rate, and it can be recommended both as a curative and a palliative operation in patients with gastric cancer.

Surgical treatment of gastric carcinoma.

To investigate changes in the results of treatment of gastric carcinoma, two 10-year periods between 1963 and 1982 with 641 and 630 patients, respectively, were compared. In the two groups, 94 percent and 92 percent of patients were operated on. The operation was considered curative in 200 and 265 patients in Groups 1 and 2, respectively. There was a shift towards more radical operations, with 215 total or subtotal gastrectomies in Group 2 compared with 76 in Group 1, when distal gastric resection was considered radical enough. Despite the increasing number of curative operations and more radical surgery in Group 2, no progress in the 5-year survival rate was noted. Distal and subtotal gastrectomies gave slightly better results than total gastrectomies, but the most important single factor contributing to the long-term survival was cancerous invasion of the serosa. It is concluded that in the past 20 years, the results of surgical treatment of gastric carcinoma have not improved, despite the more advanced diagnostic methods and more radical surgery.

Near-total gastrectomy for gastric cancer.

Fifty-nine consecutive patients (95 percent) with gastric cancer of the distal portion of the stomach were operated on with 95 percent subtotal gastrectomy between 1975 and 1980. The operations were for cure in all cases. Twenty-five patients were alive after 5 years, for a crude 5 year survival rate of 42 percent. The operative mortality rate was 5 percent (three patients). Twenty-four patients (41 percent) had complications, which consisted of postoperative respiratory infection in 11 patients (19 percent), postoperative ileus in 4 patients (7 percent), and subphrenic abscess in 2 patients (3.4 percent). In addition, there was one wound dehiscence and one liver rupture (with fatal outcome), one deep venous thrombosis, one urinary infection, and one wound infection. Only one patient (1.7 percent) had an anastomotic leak at the gastrojejunostomy site. Seven relaparotomies (12 percent) had to be performed for complications. We have concluded that, in patients with distal gastric cancer, 95 percent subtotal gastrectomy can result in a 5 year survival rate that is comparable to that reported in the literature for total gastrectomy, and it has the advantage of a very low rate of anastomotic leakage between the minute gastric remnant and the jejunum. Therefore, 95 percent subtotal gastrectomy is recommended over total gastrectomy in the treatment of distal gastric cancer.

Gastric blood flow, tissue gas tension and microvascular changes during hemorrhage-induced stress ulceration in the pig.

Various features of blood supply to the gastric mucosa were studied in the piglet stomach during stress ulceration induced by hemorrhagic shock. Gastric blood flow, as measured by the radioactive microsphere technique, significantly decreased during shock, but no major change occurred in the gastric function of total cardiac output. There was no difference in the magnitude of the decrease of mucosal blood flow between the nonulcerating antral mucosa and the more readily ulcerating corpus or fundic mucosa. At the same time, a significant decrease in tissue partial pressure of oxygen and increase in tissue partial pressure of carbon dioxide occurred, but again no difference was observed between the antrum and the corpus. Microangiographic studies demonstrated a clearly diminished filling of the arterial and capillary bed of the gastric mucosa during shock, suggesting intense vasoconstriction, thrombosis of the mucosal blood vessels, or both. These changes were more prominent in the corpus portion of the stomach than in the antrum. At the site of mucosal lesions, the filling defects persisted even after the shock, suggesting permanent thrombosis of the blood vessels.

Results of hepatic lobectomy for primary epithelial cancer in 31 adults.

Hepatic lobectomy for primary epithelial cancer was performed in 31 adults from 1964 through 1977 in the surgical departments of six Scandinavian hospitals. Twenty-three patients were discharged and had a 2 year survival rate of 62 per cent and a 5 year survival rate of 16 per cent. Alternatives to surgery have not yet emerged. Further progress requires centralization.

Microangiography of the pancreas in experimental hemorrhagic pancreatitis.

In experimental hemorrhagic pancreatitis induced with sodium-taurocholate-trypsin, contrast enhancement of the pancreas in computed tomography (CT) has been shown to be decreased in spite of normal pancreatic blood flow. The contrast enhancement in CT depends on blood flow to the organ, capillary permeability and the amount of extracellular fluid in the organ. For further evaluation of the role of microcirculatory changes in our model of hemorrhagic pancreatitis, microangiography was performed in five normal piglets and in ten piglets with acute hemorrhagic pancreatitis. In this experimental model histological studies showed focal necroses, hemorrhages and leucocyte accumulation. In the affected areas microangiography revealed unfilled capillaries and extravasation of contrast medium. Arteries and arterioles were well filled, as in the normal control animals. These severe disturbances in the capillary circulation of the pancreas may explain the decreased contrast enhancement of the pancreas in CT during acute hemorrhagic pancreatitis.

Significance of extrapancreatic findings in computed tomography (CT) of acute pancreatitis.

Computed tomography (CT) has proven reliable in the early detection of acute haemorrhagic pancreatitis. In the present study the extrapancreatic changes at CT were studied in 60 patients with acute pancreatitis. The CT findings were correlated to the early "prognostic signs" by Ranson and the clinical course of the disease. All the patients with minor extrapancreatic changes recovered without complications. When moderate to severe extrapancreatic changes were seen the incidence of haemorrhagic pancreatitis and the risk of development of pseudocyst or abscess was high. In these patients a dynamic contrast enhanced CT should be done in order to select the patients with haemorrhagic pancreatitis.