Randomized controlled trial to evaluate flush and reperfusion techniques in liver transplantation.

To determine the impact of different flush and reperfusion techniques on postreperfusion syndrome (PRS) and postoperative graft function, 100 transplants were randomly assigned into four groups as follows: group 1 (n=31), portal vein flush, no vena caval venting; group 2 (n=21), hepatic arterial flush, no vena caval venting; group 3 (n=29), portal vein flush with vena caval venting; and group 4 (n=19), hepatic artery flush with vena caval venting. Donor and recipient characteristics were similar. Extensive intraoperative and postoperative monitoring was performed and measurements were documented immediately before reperfusion and at 1, 5, 15, and 30 min after reperfusion. PRS was defined by three criteria: mean arterial pressure (MAP) <60 mmHg at 1 min after reperfusion, MAP <60 mmHg at 5 min after reperfusion, and a decrease of 30% or more for the MAP percent area under the curve during the initial 5 min after reperfusion (%AUC). Using these definitions, the overall incidence of PRS was 21%, 8%, and 43%, respectively. Group 1 was the most hemodynamically stable; the incidence of PRS in group 1 was 2/31 (7%) at 1 min and 8/31 (25%) using %AUC criteria compared with 7/21 (33%) at 1 min and 12/21 (57%) using %AUC criteria for group 2 (P<0.05). The patients in groups 3 and 4 (vena caval venting) demonstrated smaller percentage increases in serum potassium levels (as determined by %AUC; 4.3+/-6.8 and 0.3+/-5.4, vs. 15.1+/-8.1 for group 1 and 22.9+/-8.2 for group 2). The difference between group 4 and group 2 was statistically significant (P<0.05). The increases in serum potassium did not translate into increased cardiac or hemodynamic instability. Combining all data obtained over the first 30 min after reperfusion, there was no statistically significant difference in hemodynamic or biochemical changes noted among the four groups. Postoperative liver function was similar among the four groups. We conclude that portal vein flush without vena caval venting provided a lower incidence of PRS than any other technique. Vena caval venting decreased the release of potassium into the circulation. Postoperative graft function was not significantly affected by flush and reperfusion techniques.

Arden contrast sensitivity testing in glaucoma.

Two hundred sixteen eyes (164 patients) were studied with the Arden printed contrast gratings to test Arden's hypothesis that an abnormal score would distinguish between eyes with and without glaucoma. Ninety-five eyes were normal and 75 eyes were glaucomatous; 46 eyes suspected of being glaucomatous were also studied to determine whether such eyes would score differently than eyes with normal intraocular pressures. No age-dependent trend in scoring was found in the different diagnostic categories, except with the age group younger than 40 years, which had consistently better contrast sensitivity. The tests were demonstrated to be reproducible over time and showed little or no intertester variability. Decreased contrast sensitivity was found in the glaucomatous eyes compared with normal eyes. The scores of the eyes suspected of being glaucomatous fell between the scores of the glaucomatous and normal eyes. Overlapping distributions among the three groups, however, limit the diagnostic value of the test.

Liver transplantation in the morbidly obese.

STUDY OBJECTIVE: To test the hypothesis that morbid obesity implies increased difficulty of liver transplantation and increased risk of adverse outcome. DESIGN: Retrospective review of medical records of 40 morbidly obese patients using a control cohort of patients transplanted just before and after the obese patients. SETTING: University medical center. PATIENTS: All morbidly obese patients who underwent liver transplantation over a 52-month period were included. Forty adult patients met criterion for morbid obesity with body mass index greater than 30 kg/m2. Records for 61 time-matched controls were reviewed. MEASUREMENTS AND MAIN RESULTS: Demographic, intraoperative, and postoperative data were collected including preoperative diagnoses, laboratory and pulmonary function tests, intraoperative transfusion requirements and length of surgery postoperative complications, and survival. Data were analyzed using Student's t-tests, and Chi-square analyses as appropriate, with significance considered a p-value less than 0.05. Obese patients were more hypoxemic than controls prior to surgery (PaO2, 82.9 +/- 3.5 vs. 93.0 +/- 3.0 mmHg), were more likely to be diabetic, and had higher creatinine levels (3.0 +/- 0.6 vs. 1.7 +/- 0.2 mg/dl). Despite this evidence of multi organ dysfunction, intraoperative and postoperative pulmonary and cardiac complications did not differ between groups. Though more obese patients had prior cholecystectomy, length of surgery and intraoperative transfusion requirements were not different between groups. Obese patients did not have an increased incidence of reoperation for wound problems, and lengths of intensive care unit and hospital stays did not differ between groups. Graft and patient survival were similar in obese and nonobese liver transplant recipients. CONCLUSION: Morbid obesity alone does not predispose to increased complications or decreased survival after liver transplantation.

Smokeless tobacco use and oral pathology in a professional baseball organization.

BACKGROUND: Smokeless tobacco has been implicated as a risk factor for numerous oral conditions. Since baseball players are known to have a high incidence of smokeless tobacco use, they are an excellent group in which to study the effects of smokeless tobacco on the oral cavity. We report our findings in 206 of 220 eligible men during spring training of a professional baseball organization. Major and minor league ballplayers, coaches, and management personnel were included. METHODS: Participants completed a 2-page, 23-item questionnaire on smokeless tobacco use. This was followed by a detailed examination for oral leukoplakia, periodontal disease, and dental caries performed by a physician who was blinded to the results of the questionnaire. Oral leukoplakia was graded I, II, or III according to severity. RESULTS: Eighty-eight of 206 participants (42.7%) reported current use of smokeless tobacco; 62 of these men used smokeless tobacco year round, while 26 used smokeless tobacco only during the baseball season. The 88 smokeless tobacco users often used more than one form of tobacco. Moist snuff was the most common form (73.9% of users) followed by loose leaf tobacco (53.4%) and plug tobacco (9.1%). Oral leukoplakia was found in 25 of 88 current users (28.4%). Only the year-round users, however, had an incidence rate (37.1%) that was significantly different from all others (odds ratio = 9.35, 95% CI = 3.46 to 26.21). Year-round users were also more likely to have a higher grade of oral leukoplakia. Periodontal disease and dental caries were no more prevalent among smokeless tobacco users than nonusers. CONCLUSIONS: We conclude that the use of smokeless tobacco products is a significant risk factor for the development of oral leukoplakia, and that this risk is greatest in those individuals who use smokeless tobacco continuously throughout the year.

The head-up tilt test -- a cause of myocardial infarction.

INFARCTION: A 74-year-old man with no known ischaemic heart disease presented to the Cardiology Department with a history of multiple episodes of pre-syncope. During a head-up tilt test to investigate a neurocardiogenic cause, after glyceryl trinitrate provocation he became profoundly hypotensive and unwell. Subsequent ECGs and Troponin-T levels confirmed a Non ST-Elevation Myocardial Infarction. Angiography confirmed coronary artery disease. This case highlights a rare complication of tilt testing and emphasises that the test is not without risk.

Early tracheal extubation after liver transplantation.

OBJECTIVE: To assess the value and safety of tracheal extubation in the operating room at the end of liver transplantation. DESIGN: Retrospective chart review. SETTING: University Medical Center. PARTICIPANTS: Eighteen adult patients extubated in the operating room at the end of liver transplantation (study patients) compared with 17 patients who were not extubated and had < or = 3 U of blood transfused during liver transplantation (control patients). INTERVENTIONS: Data collected include severity of preoperative liver disease, anesthetic technique, use of venovenous bypass, surgical time, intraoperative blood replacement, core temperature and arterial blood gases on admission to the intensive care unit (ICU), times to discharge from ICU and the hospital. MEASUREMENTS AND MAIN RESULTS: Except for age (43.9 +/- 2.7 in study patients v 52.4 +/- 2.5 years; p = 0.03), patients were similar with regard to preoperative Child's-Pugh class and liver function tests. Study patients received more crystalloid in the OR (5,306 +/- 561 v 3,771 +/- 454 mL; p = 0.04), were warmer (36.6 degrees C +/- 0.2 degree C v 35.6 degrees C +/- 0.3 degree C; p = 0.01), had a lower arterial pH (7.29 +/- 0.01 v 7.36 +/- 0.02; p = 0.003) and higher arterial carbon dioxide tension (45 +/- 1 v 35 +/- 2 mmHg; p < 0.001) on admission to ICU than controls. There were no significant differences between groups with regard to discharge times from the ICU (50.6 +/- 2.7 hours in the study group v 61.2 +/- 4.7 in control group; p = 0.06), or discharge from the hospital (14.8 +/- 1.6 in the study group v 21.3 +/- 3 days in control group; p = 0.06). CONCLUSIONS: Tracheal extubation of selected patients at the end of liver transplant surgery in the operating room is safe but did not result in decreased ICU or hospital stay.

Don't forget prostatic carcinoma in abdominal carcinomatosis.

An incarcerated hernia containing peritoneal secondaries from carcinoma of the prostate is presented. Abdominal carcinomatosis may be due to a prostatic primary and will benefit from hormonal treatment.

Initial clinical experience with an implantable human atrial defibrillator.

Low energy biatrial shock is an effective means of restoring sinus rhythm in patients with atrial fibrillation (AF). Ventricular proarrhythmia is avoided provided that shocks are well synchronized to R waves that are not at closely coupled intervals or preceded by long-short cycles. Based on these principles, an implantable atrial defibrillator has been developed and was implanted in three patients with drug refractory paroxysmal AF. The device detects AF via an actively fixed right atrial and a self-retaining coronary sinus defibrillating leads, and delivers 3/3 ms biphasic shocks up to 300 V synchronized to the R wave. The mean implant threshold (ED50) was 195 V (1.8 J). and minimum voltage at conversion during follow-up assessments at 1, 3, and 6 months were 260 V, 2.5 J. 250 V, 2.3 J, and 300 V, 3.0 J respectively. Detection of AF was 100% specific and shocks were 100% synchronized, although only a proportion of synchronized R waves were considered suitable for shock delivery primarily because of closely coupled cycles. Three patients had 9 spontaneous AF episodes, 8/9 (89%) successfully defibrillated by shocks of 260-300 V. Sedation was not used in 4 out of 9 (45%) episodes. Backup ventricular pacing was initiated by the device in 6 out of (67%) episodes. One patient had more frequent AF after lead placement, which subsided after a change of medication. There was no ventricular proarrhythmia. It is concluded that an implantable atrial defibrillator is a viable therapy for selected patients with paroxysmal AF. The device is capable of accurate AF detection, R wave synchronization and ventricular support pacing after successful defibrillation of AF.