Progressive perioperative benefits of laparoscopy in combination with an ERAS (Enhanced Recovery After Surgery) protocol in radical cystectomy with ileal conduit. / Beneficios perioperatorios progresivos de la laparoscopia y su combinación con un programa Enhanced recovery after surgery (ERAS) en la cistectomía radical con derivación urinaria heterotópica.

INTRODUCTION: Although in the recent years, laparoscopy and Enhanced Recovery After Surgery (ERAS) protocols have improved postoperative recovery in radical cystectomy (RC), the clinical efficacy of their association remains unclear. Our objective is to analyze the possible benefits obtained from laparoscopic RC (LRC) and its subsequent combination with an ERAS (ERAS-LRC) protocol compared to open RC (ORC). MATERIAL AND METHODS: We analyzed 187 consecutive RCs with ileal conduit performed in our center, of which 139 met the inclusion criteria: 47 ORC, 39 LRC (both with conventional protocol) and 52 ERAS-LRCs. RESULTS: No significant differences were found regarding age, sex, BMI and ASA score between groups. ERAS-LRC obtained a shorter length of stay than LRC and ORC (median 8 [7-10]) vs. 13 [10-17] vs. 15 [13-19.5] days, respectively; P<.001). ERAS-LRC had a shorter stay in the ICU and less days of nasogastric tube (P<.001). Postoperative complications and readmission rates were similar among groups. Multivariate logistic regression showed that absence of complications, younger age and ERAS behaved as independent factors for shorter hospital stay, while ERAS was the only independent factor of lower readmission rate at 90 days. CONCLUSIONS: Although LRC presented perioperative benefits compared to ORC, the results were better after the implementation of an ERAS protocol. ERAS protocol had stronger impact on recovery than the surgical approach of the procedure.

Association of a single nucleotide polymorphism in the ubxn6 gene with long-term non-progression phenotype in HIV-positive individuals.

OBJECTIVES: The long-term non-progressors (LTNPs) are a heterogeneous group of HIV-positive individuals characterized by their ability to maintain high CD4+ T-cell counts and partially control viral replication for years in the absence of antiretroviral therapy. The present study aims to identify host single nucleotide polymorphisms (SNPs) associated with non-progression in a cohort of 352 individuals. METHODS: DNA microarrays and exome sequencing were used for genotyping about 240 000 functional polymorphisms throughout more than 20 000 human genes. The allele frequencies of 85 LTNPs were compared with a control population. SNPs associated with LTNPs were confirmed in a population of typical progressors. Functional analyses in the affected gene were carried out through knockdown experiments in HeLa-P4, macrophages and dendritic cells. RESULTS: Several SNPs located within the major histocompatibility complex region previously related to LTNPs were confirmed in this new cohort. The SNP rs1127888 (UBXN6) surpassed the statistical significance of these markers after Bonferroni correction (q = 2.11 × 10-6). An uncommon allelic frequency of rs1127888 among LTNPs was confirmed by comparison with typical progressors and other publicly available populations. UBXN6 knockdown experiments caused an increase in CAV1 expression and its accumulation in the plasma membrane. In vitro infection of different cell types with HIV-1 replication-competent recombinant viruses caused a reduction of the viral replication capacity compared with their corresponding wild-type cells expressing UBXN6. CONCLUSIONS: A higher prevalence of Ala31Thr in UBXN6 was found among LTNPs within its N-terminal region, which is crucial for UBXN6/VCP protein complex formation. UBXN6 knockdown affected CAV1 turnover and HIV-1 replication capacity.

Exsanguinating hemoptysis revealing the absence of left pulmonary artery in an adult.

Isolated absence of a pulmonary artery is an exceptional cause of massive hemoptysis. We report a 35-year-old woman with agenesis of the left pulmonary artery who presented with exsanguinating hemoptysis that prompted angiography with the aim to embolize the bleeding vessels selectively. The procedure could not be completed because of the presence of an anterior spinal artery branching from the aberrant systemic-to-pulmonary circulation. The patient successfully underwent an emergent pneumonectomy.

Rupture of the thoracic trachea with a Sengstaken-Blakemore tube.

Tracheal rupture from within is uncommon and always iatrogenic. We report a case of a tracheal rupture following the use of a Sengstaken-Blakemore tube to control a gastroesophageal hemorrhage. Emergency surgical repair was required. Although complications associated with balloon tamponade are well-documented, no major tracheal injury has ever been reported.

[Prolonged epidural analgesia following thoracotomy. Clinical study and serum levels over five days]. / Analgésie péridurale prolongée après thoracotomie. Etude clinique et taux sériques pendant cinq jours.

Prolonged continuous epidural analgesia allows perithecal infusion with fentanyl and bupivacaine for 5 postoperative days after thoracic surgery. This study included 27 thoracotomized patients randomised into two groups: group X consisted of 15 subjects, group Y consisted of 12 subjects. Each patient received 33 micrograms/hr or fentanyl for 48 hours, associated with 0.25% bupivacaine in group X, and 0.125% bupivacaine in group Y. Over the three last days, the infusion rate of both drugs was decreased in the two groups. No significant clinical difference appeared between X and Y. No clinical respiratory depression occurred. In group Y, mean plasma bupivacaine concentrations remained significantly lower (p less than 0.05). Mean fentanyl levels did not increase beyond 0.8 ng/ml. The use of 0.125% bupivacaine improved the margin of safety but did not impair clinical analgesia in the study. This method provides good analgesia for thoracotomized patients.

[Results of surgical treatment of persistent or recurrent pneumothorax]. / Résultats du traitement chirurgical des pneumothorax persistants ou récidivants.

From 1st January 1988 to 31st December 1991, 107 patients were operated on for spontaneous idiopathic (N = 69) or secondary pneumothorax (N = 38). Surgery was performed for recurrence (63.6%) or failure to respond to management by tube drainage (36.4%). Ninety seven patients underwent pleural abrasion, and 10 underwent parietal pleurectomy. Prolonged continuous epidural analgesia was performed in 57 cases. Postoperative complications occurred in 15 patients (14%). Overall morbidity was significantly higher in patients with chronic lung disease (26.3%) than in patients without chronic lung disease (7.2%) (p < or = 0.01). As far as postoperative hospital stay was concerned, the same significant difference was observed (16.8 days versus 12.7 days) (p < or = 0.005). In patients with idiopathic pneumothorax, postoperative hospital stay was significantly shorter in those with epidural pain relief (11.7 days) than in the others (13.6 days) (p < or = 0.025). No recurrence was observed with a mean follow-up of 27 months. We conclude that: 1) surgery is the most efficient treatment of persistent or recurrent pneumothorax; 2) operative morbidity is related to the underlying lung disease and not to the procedure itself; 3) epidural analgesia is beneficial in this surgery.

[Extrapancreatic hypoglycemic tumors. Apropos of a case of pleural fibrosarcoma]. / Tumeurs hypoglycémiantes extra-pancréatiques. Etude à propos d'un cas de fibrosarcome pleural.

The authors report a case of pleural fibrosarcoma associated with severe hypoglycaemia. Chromatography of the patient's serum and tumour fragments revealed a substance with a high molecular weight and an insulin-like activity. Professor Poffengarger's laboratory identified this substance as Non Suppressible Insulin-Like Protein or NSILAp which induces insulin-like effects on various tissues. A review of the literature is presented in the light of this case.

How to design magneto-based total analysis systems for biomedical applications.

This article reviews recent developments on magnetoresistive detection of magnetic beads or nanoparticles by nanoscale sized sensors. Sensors are analyzed from an experimental and a numerical point of view in respect to their capability to either localize the position of a single magnetic particle or to detect the number of particles in a certain range. Guidelines are shown up on how to extend single sensors to sensor arrays with very high spatial resolution and how to modify the sensor shape in order to provide long distance measurements. Further, sensors in biological lab-on-a-chip environments are discussed. The magnetic ratchet and a gravitation based microfluidic component are reviewed as important tools to position and, therefore, detect biological components in continuous-flow devices.

[Ureterotransversopyelostomy and unilateral nephrostomy as supravesical urinary diversion in vesico-vagino-rectal fistula and incurable bladder cancers]. / Ureterotransversopyelostomie und einseitige Nephrostomie als supravesikale Harnableitung bei Blasen-Scheiden-Rektum-Fistel und inkurablen Blasenkarzinomen.

The use of a transversal uretero-pyelostomy as an alternative to other forms of supravesical urinary diversion is described in a patient suffering from incurable bladder cancer and in another patient with combined bladder-vaginal-rectal fistula, colostomy and radiogenic contracted urinary bladder. The operation is less severe to the patient and a transperitoneal or a retroperitoneal approach is possible. This type of urinary diversion should be included in the operative armamentarium of the urologist in selected cases because of the quality of patient's life is improved markedly.

[A rare case of benign ureteral tumor]. / Seltener Fall eines benignen Harnleitertumors.

It is reported on an extremely rare case of a benign ureteral fibroepithelioma. If the diagnosis is correct, in these tumors a conservative surgical approach is indicated, in contrast to malignant urothelial tumors which require a radical nephroureterectomy including removal of a bladder cuff.

[Changes in the kidney and upper urinary tract in the normal course of pregnancy. Results of a sonographic study]. / Veränderungen der Nieren und des oberen Harntraktes bei normal verlaufender Schwangerschaft. Ergebnisse einer sonographischen Studie.

In 232 women with a normal course of pregnancy the kidneys and the upper urinary tract were studied by means of ultrasonography. In 73% of the patients a dilation of the renal collecting system was found. Frequency and grade of the dilation have been increased from the first to the third trimenon, with a significant preference of the right side. A marked dilation with a sagittal diameter of the pyelon of more than 15 mm was found in only 12% of the pregnant women. In a single case during uncomplicated pregnancy also monstrous dilation could be demonstrated.

[Changes in the kidney and upper urinary tract in pathologic pregnancy follow-up. Results of an ultrasonic study]. / Veränderungen der Nieren und des oberen Harntraktes bei pathologisch verlaufender Schwangerschaft. Ergebnisse einer sonographischen Studie.

In 201 women with pathologic course of pregnancy (161 women suffering from urinary tract infection, pyelonephritis and colic, 40 women with gestosis) the kidneys and the upper urinary tract were studied by means of ultrasonography. In 86% of the 161 women with colic, urinary tract infection and septic complications a dilation of the renal collecting system was found, in 39.4% of them a marked dilation (sagittal diameter of more than 15 mm). Frequency and grade of dilation have been uncreased from the first to the third trimenon, with a significant preference of the right side. In patients suffering from gestosis a lower frequency and grade of dilation was found. Pregnant women with a sagittal diameter of the pyelon of more than 15 mm should controlled more intensively prae and post partum, but the grade of dilation is not the only criterion of therapeutic strategies.

Measurement of lower oesophageal pH during induction of anaesthesia: use of oesophageal probe.

Gastric contents regurgitation into the oesophagus during induction of anaesthesia may easily fail to be recognized. The incidence of this complication was investigated in 59 consecutive patients. They were scheduled for elective thoracic surgery. Anaesthesia was induced with thiopentone (6 mg.kg-1), fentanyl (3 micrograms.kg-1), and either atracurium (0.4 mg.kg-1), vecuronium (0.1 mg.kg-1) or suxamethonium (1.5 mg.kg-1). Oesophageal pH was monitored with an oesophageal pH probe, connected to a portable computer. The pH probe had a virtually instantaneous response time and was positioned in the lower oesophagus. Acid reflux was defined as a decrease in pH to less than 4.0. During the course of induction, three patients (5%) presented an episode of acid reflux. No patient presented any clinical or radiological signs of pulmonary aspiration. This study suggests that monitoring oesophageal pH is a simple method of detecting gastric reflux during the period of induction.

Pharmacokinetics and tissue penetration of a single dose of ceftriaxone (1,000 milligrams intravenously) for antibiotic prophylaxis in thoracic surgery.

The pharmacokinetics and tissue penetration of ceftriaxone after a single intravenous injection of 1,000 mg to 17 patients for antibiotic prophylaxis in thoracic surgery were studied. The patients were scheduled for elective noncardiac thoracic surgery. Adequate levels in serum (higher than or equal to the MIC for 90% of isolates of Staphylococcus aureus, Streptococcus spp., Escherichia coli, Haemophilus influenzae, and Klebsiella pneumoniae) were found for all patients throughout the surgical procedures. Mean maximal (5-min) and final (24-h) ceftriaxone levels in serum were 157 +/- 42 and 8.6 +/- 4.5 mg/liter, respectively. The beta-phase elimination half-life was 8.6 +/- 3 h, the plasma clearance was 18.4 +/- 6.25 ml/min, and the apparent volume of distribution at steady state was 0.21 +/- 0.07 liters/kg. At the time of the thoracotomy, the ceftriaxone concentrations were 13.5 +/- 7.8 micrograms/g in thoracic wall fat and 27 +/- 9 micrograms/g in lung tissue. At the time of closure, the ceftriaxone concentration was 15 +/- 9 micrograms/g in thoracic wall fat. During the different steps of the surgical procedures, 100% of patients had adequate levels in tissue (higher than or equal to the MIC for 90% of isolates of Streptococcus spp., E. coli, H. influenzae, and K. pneumoniae). For S. aureus, 90 to 100% of patients had adequate tissue ceftriaxone levels.