A 'hot clinic' for cold limbs: the benefit of urgent clinics for patients with critical limb ischaemia.

INTRODUCTION: The national reconfiguration of vascular surgery means that arterial centres serve larger populations with increased demand on resources. Emergency general surgery ambulatory clinics facilitate timely review and intervention, avoiding admission; a critical limb ischaemia (CLI) 'hot clinic' (HC) was implemented to achieve similar for vascular patients. The aim of the study was to determine HC efficacy. METHODS: This was a prospective cohort study comparing HC patients with emergency admission (EA) patients between 1 May and 1 December 2017. Age, sex, comorbidities, CLI severity and smoking status were noted. HC patients were provided with satisfaction surveys. Primary outcome measures were freedom from reintervention and major amputation. Secondary outcome measures included time to procedure, length of stay, returns to theatre and 30-day readmission. RESULTS: A total of 147 patients (72 HC, 75 EA) were enrolled in the study. No statistical difference was found in age, sex, smoking status, severity of CLI or prevalence of comorbidities between the groups except that diabetes was more prevalent in EA patients (p=0.028). The median length of stay for the HC cohort was shorter (3 days vs 17 days, p<0.001), with no difference between time to procedure, return to theatre or 30-day readmission. HC patients were nearly 6 times more likely to experience freedom from reintervention (odds ratio: 5.824, p<0.001) and 2.5 times less likely to undergo amputation (odds ratio: 2.616, p=0.043). HC utilisation saved a total of 441 bed days. Over 90% of attendees responded with 100% positive feedback. CONCLUSIONS: A vascular HC facilitates urgent review and revascularisation. It provides comparable in-hospital outcomes and better long-term outcomes, with greater efficiency than hospital admission, demonstrating its value in treating CLI.

Outcomes of Heart Transplant Recipients With Preexisting Malignancies.

BACKGROUND: Ensuring careful selection of heart transplant recipients with pretransplant malignancies (PTM) has been suggested in several retrospective studies. However, cancer survival rates continue to increase and we still lack outcomes data on PTM patients who have undergone heart transplantation (HT) within the Asian region. Herein we report pretransplant characteristics and outcomes among PTM patients with HT. METHODS: A total of 354 patients underwent HT from January 2004 to January 2016. Eight of these patients had a history malignancy that was being treated before transplantation. Posttransplant outcomes and clinical characteristics were collected and possible prognostic factors analyzed. RESULTS: The median age of the patients with a preexisting malignancy was 60 years. The PTM group included 5 males and 3 females, with a median duration of follow-up of 43 months. In this group there were 2 patients with lymphoma after chemotherapy, 1 with colon cancer postoperatively, and 1 was on chemotherapy. In the other 4 patients, nasopharyngeal cancer, thyroid cancer, breast cancer, and endometrial cancer were identified, and each had undergone treatment. Only 1 premalignancy patient, with nasopharyngeal cancer, had disease recurrence. The 5-year overall survival of these patients was 50.0 ± 17.7%, but 5-year survival for those without PTM was 68.7 ± 2.0%. CONCLUSION: PTM was 2.3% in our cohort. PTM is associated with an increased risk of all-cause mortality. Thus, our findings suggest careful consideration when selecting PTM patients for HT.

Survival Outcomes of Oversized Cardiac Allografts in Pediatric Patients-A Single-Center Experience in Taiwan.

OBJECTIVES: An oversized cardiac allograft may have a negative impact on survival outcomes according to previous studies; however, due to the shortage of pediatric donor hearts, the use of oversized cardiac allografts is sometimes inevitable. In this study, we reported the survival outcomes of pediatric patients in relation with the donor-recipient weight ratio. METHODS: Twenty-eight children, aged 3 months to 17 years, with dilated cardiomyopathy underwent primary cardiac transplantation at the National Taiwan University Hospital between 1995 and 2012. We analyzed these patients according to the donor-recipient weight ratio: group 1 (n = 19) with donor-recipient weight ratio <2.5 (median 1.1, interquartile range 1.0-1.6), and group 2 (n = 9) with donor-recipient weight ratio ≥2.5 (median 3.0, inter-quartile range 2.87-3.5). RESULTS: The 30-day survival rate was 100% for both group 1 and group 2 (P = 1). The survival rates for group 1 and group 2 were 95% vs 100% at 1 year, 84% vs 89% at 5 years, and 73% vs 61% at 10 years. The median survival was 14.4 years vs 12.9 years (P = .6313). CONCLUSION: In this cohort, the use of oversized cardiac allograft in pediatric patients for dilated cardiomyopathy did not have a negative effect on short-term and long-term survival.

Changes in Renal Function After Heart Transplantation.

Renal function after heart transplantation (HTx) typically follows a biphasic pattern and an initial decay within 1 to 2 years. Trajectory of renal function after HTx is less reported, especially in Asia. The aims of this cohort study were to describe the changes in HTx recipients' serum creatinine and estimated glomerular filtration rate (eGFR) levels 5 years following HTx in Taiwan. METHODS: We retrospectively reviewed 5 years of 440 consecutive adult patients (≥ 18 years) who underwent first HTx from June 1987 to December 2014 at the National Taiwan University Hospital. RESULTS: Among 422 participants, they received induction therapy consisting of intravenous rabbit antithymocyte globulin. Here, we illustrated the trends over the years by dividing the subjects into 2 groups based on their immunosuppressive regimen of transplantation (1987-2002 and 2003-2014) The pretransplantation median serum creatinine concentration level was 1.2 mg/dL, rose to 1.4 mg/dL at 3 months after surgery, and remained steady over 5 years after HTx. Pretransplant median eGFR was 67 mL/min/1.73 m2.The median serum creatinine concentration level and eGFR at baseline were all significantly difference than pretransplantation (P > .05). This result has showed that an initial steep decline within 3 months after transplant remained stable 5 years after HTx. CONCLUSION: As renal function deteriorates after HTx, we observed a steep decline in serum creatinine level and glomerular filtration rate within the 3 months after HTx, followed by a slow rate of deterioration over the following months. We found a time-related progressive deterioration in renal function during the 5 years after HTx.

Pancarpal dissociation with palmar Capitate fracture-dislocation: Case report.

Capitate fractures are rare and dislocations are even more uncommon. To our knowledge, there has been no report of a Capitate fracture with complete dislocation in the literature. Here, we present the first case of a Capitate fracture-dislocation, sustained after a motorcycle accident.

Demonstration of reserved anterior pituitary function among patients with amenorrhea after postpartum hemorrhage.

To demonstrate the residual pituitary function of patients with Sheehan's syndrome years after the obstetric complication, 14 patients with postpartum hemorrhage followed by secondary amenorrhea and agalactia were included in this review. Due to their unfamiliarity with the clinical symptoms, these patients did not receive pretreatment hormonal therapy. The mean age at their last delivery was 29 years (range 21-38 years). The mean duration between postpartum hemorrhage and the subsequent clinical manifestations leading to the endocrine investigation was 18 years (range 1-33 years). Eight patients presented with symptoms of severe hyponatremia (serum sodium less than 125 mmol/l) more than 16 years (mean 23 +/- 10) after the occurrence of postpartum hemorrhage. The electrolyte abnormality was primarily due to adrenal dysfunction. Seven out of 14 patients had normal basal luteinizing hormone (LH) levels and adequate LH responses to gonadotropin releasing hormone stimulation. Administration of thyrotropin releasing hormone provoked thyrotropin release and/or prolactin secretion in four cases. The manifestation of clinical hypopituitarism and the degree of empty sella on computed tomography scanning did not accurately indicate the secreting ability of the pituitary in patients with Sheehan's syndrome. Although all the patients had amenorrhea, the gonadotropic functions of the pituitary still remain in some patients. Various degrees of other pituitary functions can also been demonstrated even several decades after the occurrence of obstetric complications. Our data suggest that the amenorrhea of Sheehan's patients is not simply due to a dysfunction of the pituitary gonadotrophs.

Herpesvirus in localized juvenile periodontitis.

Herpesvirus genomic sequences can be detected in gingival crevicular fluid of adult periodontitis lesions. Herpesviruses are immunosuppressive and may facilitate establishment of subgingival pathogens. Electron microscopic studies have identified nuclear and cytoplasmic virus-like inclusions in gingival inflammatory cells from localized juvenile periodontitis (LJP). The present study aimed to determine if herpesviruses occur in LJP lesions and if human cytomegalovirus (HCMV) activation is associated with elevated levels of subgingival Actinobacillus actinomycetemcomitans, the putative bacterial pathogen of LJP. Eleven systemically healthy patients exhibiting LJP (10-23 yr) were studied. In each patient, subgingival samples were pooled from 3 periodontitis lesions around first molar and incisor teeth (5-11 mm periodontal pocket depth) and from 3 gingivitis/healthy sites around canines (2-3 mm periodontal pocket depth). Polymerase chain reaction (PCR) was used to detect herpesvirus DNA and HCMV cDNA of major capsid protein transcripts, indicative of viral activation. Selective culture and 16S rRNA PCR were used to identify A. actinomycetemcomitans. Of 11 deep periodontal samples, 8 showed HCMV, 7 showed Epstein-Barr virus type 1 (EBV-1), 1 showed EBV type 2, 6 showed herpes simplex virus (HSV) and 8 showed viral co-infection. Of 11 shallow periodontal samples, 2 showed HCMV, 2 showed EBV-1, 1 showed HSV and 2 showed viral co-infection. The difference in occurrence of HCMV and viral co-infection between deep and shallow periodontal sites was statistically significant (p =0.031). HCMV activation was detected in deep pockets of all 5 virally positive patients with early LJP (aged 10-14 years) but only in 1 of 3 virally positive LJP patients older than 14 years, and not in any shallow pocket tested. HCMV activation appeared related to absence of radiographic crestal alveolar lamina dura, a possible indication of periodontal disease progression. A. actinomycetemcomitans tended to be more prevalent in samples showing active than latent HCMV infection. The present findings are consistent with the notion that periodontal herpesvirus infection and possibly HCMV activation constitute important features of the etiopathogenesis of LJP.

Experience of anesthesia for transthoracic endoscopic sympathectomy in palmar hyperhidrosis--110 cases.

Transthoracic endoscopic sympathectomy (TES) is an effective treatment for palmar hyperhidrosis. We review our experience and discuss the anesthetic technique and perioperative complications encountered in 110 patients undergoing TES for palmar hyperhidrosis. All patients were monitored with EKG, NIBP and pulse oximetry (SPO2) during the operation. The trachea was intubated with a single lumen endotracheal tube and ventilation was controlled manually. 100% inspired oxygen was necessary during TES to avoid hypoxia. One patient developed sudden cardiac arrest during electrocauterization of the left sympathetic chain and two patients required underwater drainage for hemothorax. Minimal pneumothorax was diagnosed in 4 patients and all cases resolved spontaneously without active treatment.

[The study of anatomic factors in difficult intubations].

Endotracheal intubation is a common procedure in anesthesia which can usually be accomplished easily. However if the attempt is unexpectedly difficult the patient may be seriously at risk. If all difficult airways can be predicted confidently in the pre-operative period, anesthesiologists can plan the safest and most effective way of managing tracheal intubation. The purpose of this study was to analyze not only the incidence, anatomic factors, immediate complications and management of difficult intubation cases but also the view obtained at laryngoscope which was graded according to the Cormack's and Lehane's description. Patients who received general anesthesia with endotracheal tube within 1 year's period from November 1, 1991 to October 31, 1992 in Show Chwan Memorial Hospital were collected. All difficult intubations were performed by senior anesthesiologists. 3925 patients were intubated, 92 cases were noted to have difficult intubations and their overall incidence were 2.3%. Among the 92 patients, those with 2 anatomic factors (41 patients, 44.6%) represented the majority for patients with difficult intubations. On the other hand, the four most common anatomic factors and their incidences in order of frequency included short neck (48.9%), protruding teeth (38.0%), receding mandible (27.2%) and limited opening mouth (26.1%). According to Cormack's and Lehane's laryngoscopic grading, the results were shown respectively as follow: 4 cases (4.4%) for grade 1;2 cases (2.2%) for grade 2;82 case (89%) for grade 3 and 4 cases (4.4%) for grade 4. We also found that tachycardia/hypertension (70.7%), bleeding (37.0%) and esophageal intubation (33.7%) were the three most frequent immediate complications during difficult intubations.(ABSTRACT TRUNCATED AT 250 WORDS)

Association of the eosinophilia-myalgia syndrome with the ingestion of tryptophan.

We report on a series of three patients with an unusual syndrome of eosinophilia and myalgia associated with the oral ingestion of tryptophan that was recognized in New Mexico in October 1989. All three patients, who were women 37 to 44 years of age, had severe muscle pain, muscle weakness, mouth ulcers, and striking eosinophilia (more than 8 X 10(9) cells per liter). Other manifestations included fever, abdominal pain, dyspnea, skin rash, and elevated serum concentrations of aminotransferase and aldolase. The women had been taking tryptophan in doses of 1.2 to 2.4 g a day for three weeks to 2 1/2 years. The discontinuation of tryptophan and the initiation of glucocorticoid treatment resulted in improvement, but all three women were still symptomatic three to five months later. Tests for trichinosis and other parasites and for allergic and connective-tissues disorders were negative, and serum immunoglobulin concentrations and erythrocyte sedimentation rates were normal. A muscle biopsy in one patient and biopsies of the vagina, liver, and other abdominal organs in another revealed eosinophilic infiltration, as well as the extracellular deposition of eosinophil-granule major basic protein. All three patients had elevated serum and urinary levels of this protein and eosinophil-derived neurotoxin, indicative of eosinophil degranulation. The syndrome of eosinophilia and myalgia in association with the ingestion of tryptophan that was seen in these three patients is a newly recognized adverse effect of tryptophan ingestion. Our identification of this association in these patients led to the discovery of an epidemic of what is now called the eosinophilia-myalgia syndrome.