Should a Living Donor Renal Graft be Removed Due To Prolonged Delayed Function? A Case Report.

BACKGROUND Delayed graft function (DGF) is defined as failure of the transplanted kidney to function in the early -post-transplant period. DGF is a rare complication after living donor kidney transplant and is most common after deceased donor kidney transplant, probably due to prolonged warm and cold ischemia times during retrieval. Most cases of DGF resolve spontaneously within days to weeks. There are very few reported cases in the literature of DGF lasting over 4 weeks. We present a case that resolved after 55 days. The recipient subsequently achieved normal renal function. CASE REPORT Our patient was a 52-year-old man with end-stage renal disease who underwent a second living donor renal transplant. The donor was his son, with whom he had 1 antigen mismatch. Postoperative day 1, the patient developed anuria and failed to improve with fluids and diuretics. Investigations ruled out common causes of renal dysfunction (rejection, ischemia), but failed to disclose the cause of this condition. After an extended period of watchful waiting, the graft function returned, reaching normal creatinine and urine output levels. CONCLUSIONS DGF after living donor kidney transplantation is rare, and few cases lasting more than a month have been reported. Before diagnosing DGF, other causes of renal dysfunction (rejection, ischemia, medication adverse effects) must be ruled out. In the absence of these, expectant management is appropriate and full graft recovery can be expected, even with anuria and hemodialysis.

Simethicone adjunct to polyethylene glycol improves small bowel capsule endoscopy imaging in non-Crohn's disease patients.

BACKGROUND: Currently, there is no standardized protocol for bowel preparation before small bowel capsule endoscopy (SBCE). This study aimed to investigate the effect of simethicone combined with polyethylene glycol (PEG) on the visualization quality (VQ) of the SBCE in patients with or without known or suspected Crohn's disease (CD). METHODS: This observational, prospective, single-center study included consecutive patients undergoing a SBCE between 2007 and 2008. Patients received either a standard bowel cleansing preparation of 2 L PEG and 80 mg simethicone orally 12 and 1 h before SBCE respectively (Group A) or only PEG (Group B). VQ, based on scores for luminal bubbles in frames taken from the small intestine, examination completeness, SBCE diagnostic yield, gastric and small bowel transit times were recorded. RESULTS: Of the 115 patients finally included (Group A, n=56 and Group B, n=59) the cecum was visualized in 103 (89.6%). Simethicone overall improved the VQ in the proximal [OR: 2.43 (95%CI: 1.08-5.45), P=0.032] but not in the distal bowel segment (P=0.064). Nevertheless, this effect was not observed in patients undergoing SBCE for either known or suspected CD. CONCLUSION: Simethicone as an adjunct to PEG for bowel preparation in patients undergoing SBCE significantly improved the VQ in non-CD patients.

Traumatic tricuspid valve rupture presenting as third-degree atrioventricular block.

BACKGROUND: Cardiac valve injury after blunt chest trauma is extremely rare, and the tricuspid valve is most commonly affected because of the anterior location of the right ventricle. Tricuspid valve insufficiency can range from a subclinical presentation to acute cardiac failure. OBJECTIVE: Diagnosis is difficult in trauma patients because hypotension is usually attributed to hemorrhage and anatomical cardiac injuries might be overlooked. CASE REPORT: This is a case of a 70-year-old patient with a history of rheumatic heart disease who suffered a complete rupture of her papillary muscles leading to tricuspid insufficiency after a motor vehicle collision. She presented with third-degree atrioventricular block. CONCLUSIONS: Consideration of screening for anatomical heart injuries in blunt trauma patients with new onset dysrhythmias is recommended to explain hypotension not attributable to hemorrhage.

Intralobar pulmonary sequestration: an uncommon case with triple arterial supply and systemic venous drainage.

Pulmonary sequestration is a rare congenital pulmonary malformation. We report a case of a 10-month-old infant with intralobar pulmonary sequestration diagnosed in utero. The lesion had an uncommon blood supply consisting of three large arteries deriving from the thoracic aorta and venous drainage into the inferior vena cava.

Is there a role for second-look capsule endoscopy in patients with obscure GI bleeding after a nondiagnostic first test?

BACKGROUND: Long-term follow-up data on patients with obscure GI bleeding subjected to capsule endoscopy (CE) are missing. OBJECTIVE: Our purpose was to follow up patients with a nondiagnostic test and determine whether a second-look CE would be beneficial. PATIENTS: We enrolled 293 subjects. CE studies were classified as diagnostic (positive findings) or nondiagnostic (findings of uncertain significance/no findings). Patients were followed up for a mean (SD) 24.8 (5.2) months. Outcome was defined as continued or complete resolution of bleeding. INTERVENTIONS: Patients with a nondiagnostic test were subjected to a repeat CE if they manifested a new bleeding episode or a drop in hemoglobin >or=2 g/dL. RESULTS: Positive findings, findings of uncertain significance, and no findings were identified in 41.6%, 16.0%, and 42.3% of our patients, respectively. Therapeutic intervention was possible in 72.1% of those with positive findings and in 30% of those with findings of uncertain significance. Complete resolution of bleeding occurred more often in patients with a diagnostic test (65.2%) compared with those with a nondiagnostic test (35.4%, P < .001). Second-look CE was performed in a subgroup of our patients (n = 76) and was diagnostic in those whose presentation changed from occult to overt or those whose hemoglobin dropped >or=4 g/dL. CONCLUSIONS: In patients with obscure GI bleeding, a diagnostic CE leads to therapeutic interventions and a favorable outcome. Patients with a nondiagnostic test would definitely benefit from a second-look CE if the bleeding presentation changes from occult to overt or if the hemoglobin value drops >or=4 g/dL.

A pilot study comparing hydrocortisone premedication to concomitant azathioprine treatment in preventing loss of response to infliximab.

OBJECTIVES: Antibodies to infliximab may lead to loss of response to infliximab (IFX) in Crohn's disease. Azathioprine (AZA) coadministration prevents the formation, whereas hydrocortisone (HC) premedication reduces the levels of antibodies to IFX. This pilot study aims at assessing the efficacy of these strategies to prevent loss of response to IFX. METHODS: Eligible patients had active steroid-dependent luminal Crohn's disease and received IFX (5 mg/kg at weeks 0, 2, and 6 for induction and then scheduled q8 week for remission maintenance). Patients were stratified in a 1 : 1 ratio to oral AZA (2-2.5 mg/kg/day, stratum A) or HC premedication (250 mg intravenously, stratum B). Stratum A included only patients naive to AZA; stratum B included both AZA naive and intolerant patients. Steroids were tapered within 6-8 weeks. Patients were followed up with monthly clinical assessments, laboratory tests, Crohn's Disease Activity Index calculations, adverse-events check up, and adherence to treatment. RESULTS: Overall, 23 patients received IFX/HC and 23 IFX/AZA. There were no differences at baseline in any patient-related or disease-related parameters. Seventeen (74%) patients on IFX/AZA completed the study; six patients were withdrawn for primary nonresponse (one patient), lost response to IFX (two patients), or AZA-related adverse events. Eighteen (78%) patients on IFX/HC completed the study; five patients were withdrawn for primary nonresponse (one patient), loss of response (two patients), or infusion reactions to IFX. No significant differences emerged between strata in clinical remission rates or lost response to IFX. CONCLUSION: This prospective 2-year pilot study has not confirmed superiority of any available strategy to maintain the efficacy of IFX.

Earlier eradication of intra-anal warts with argon plasma coagulator combined with imiquimod cream compared with argon plasma coagulator alone: a prospective, randomized trial.

PURPOSE: Despite the increasing incidence of condylomata acuminate, optimal treatment of anal warts is still undecided. This prospective, randomized study was designed to compare the efficacy of combined argon plasma coagulation and imiquimod cream vs. argon plasma coagulation alone in the management of intra-anal warts. METHODS: From October 2002 to March 2005, 49 patients with intra-anal warts were randomly assigned to argon plasma coagulation plus imiquimod cream (n = 24) vs. argon plasma coagulation alone (n = 25). Therapeutic sessions were repeated until the elimination of the warts. Efficacy of therapy was defined as the time needed for eradication. All patients were followed up for a mean period of 12 months for signs of recurrence. RESULTS: Elimination of warts was achieved earlier in patients receiving combination therapy compared with those receiving monotherapy with argon plasma coagulation (62.5 +/- 5.4 days vs. 91.2 +/- 6.4 days; P = 0.0016). A subgroup analysis performed in HIV-positive patients showed similar results (combination therapy 95 +/- 22.6 days; monotherapy 124.3 +/- 20.7 days; P = 0.033); however, in HIV-positive patients warts were eradicated later compared with HIV-negative patients (110.8 +/- 25.7 days vs. 65 +/- 25.4 days; P < 0.0001). No major complications were observed in our study population. After the follow-up period, recurrence of warts was evident in 22.7 percent of patients in the combination group compared with 34.7 percent of patients in the monotherapy group (P = 0.51). Recurrence was significantly higher in HIV-positive patients compared with HIV-negative patients (P = 0.0039). CONCLUSIONS: Combination therapy with argon plasma coagulator plus imiquimod cream results in earlier clearance of intra-anal warts in both immunocompetent and immunocompromised patients; however, it does not affect the rate of recurrence.

Impact of capsule endoscopy in obscure small-bowel bleeding: defining strict diagnostic criteria for a favorable outcome.

BACKGROUND: The most frequent indication for capsule endoscopy is to diagnose the cause of obscure GI bleeding. The objective of the study was to determine the impact of capsule endoscopy on the outcome of patients with GI bleeding of obscure origin. METHODS: Ninety-six patients (53 men, 43 women; mean [standard deviation] age, 60.84 years [16.55 years]) were enrolled in the study. All patients have been subjected to gastroscopy, colonoscopy, small-bowel barium follow-through or enteroclysis, and push enteroscopy; no bleeding site had been identified. Capsule endoscopy was performed with the Given M2A video capsule system. By using strict criteria, studies were classified as having positive findings, findings of uncertain significance, and no findings. Outcome was defined as continued or complete resolution of bleeding. RESULTS: Positive findings, findings of uncertain significance, and no findings were identified in 41.7%, 20.8%, and 37.5% of our study population, respectively. The most common lesions seen were angiodysplasias of the small intestine. Therapeutic intervention was possible in 82.5% of patients with positive findings and in 35.0% of patients with findings of uncertain significance. Complete resolution of bleeding, after a median (interquartile range) follow-up period of 14 months (9-17 months), occurred significantly more often in patients with positive findings (68.4%) compared with patients with findings of uncertain significance and no findings (40.8%, p = 0.009). CONCLUSIONS: Capsule endoscopy increases the diagnostic yield in the workup of patients with obscure small-bowel bleeding. Strictly defined positive findings are associated with a favorable outcome.

Physicians and complementary and alternative medicine cancer therapies in Greece: a survey.

OBJECTIVES: To assess the prevalence of complementary and alternative medicine (CAM) cancer therapies and attitudes toward them in a nonrandom sample of physicians in Greece. SUBJECTS: Four hundred and ninety-four (494) physicians from private practices and hospitals in the Athens area were approached to complete a questionnaire on perceived cancer etiology, self-reported knowledge, and attitudes about CAM therapies used by cancer patients. Two hundred and thirty-six (236) (47.8%) questionnaires were returned. RESULTS: Greek physicians are most familiar with homoeopathy (58.5%), diets (58.1%), antioxidants (vitamin C) (55.9%), and acupuncture (47.9%). Perceived rates of patients using CAM are low. Predominantly, physicians shared concepts of carcinogenesis accepted by conventional biomedicine. Only physicians who considered disorders of cellular metabolism or in the flow of body energy to be relevant believed that homoeopathy could be an adequate CAM therapy. CONCLUSIONS: Greek physicians in our sample displayed little interest in CAM. However, media and Internet coverage may generate a greater demand for these methods in the future in Greece and physicians will thus need to be better informed.