The unwritten price of cosmetic tourism: an observational study and cost analysis.

INTRODUCTION AND AIMS: Cosmetic tourism, driven by the promise of inexpensive operations abroad, is increasingly popular despite warnings from professional bodies regarding associated risks. Increasing numbers of individuals have presented to our department requesting NHS treatment of complications from such surgery. We set out to characterize these patients and evaluate costs incurred through their assessment and management. MATERIAL AND METHODS: An observational study was conducted from 2007 to 2009 on patients presenting to a tertiary referral Plastic Surgery practice with complications of cosmetic tourism surgery. Demographic characteristics, as well as those related to the operation, were recorded. Hospital patient flow pathways were constructed, cost analysis performed using Patient Level Costing, and expenditure and profitability calculated. KEY RESULTS: Nineteen patients presented within the study period. Most operations were performed in Europe or Asia, and were primarily breast augmentation procedures (n=13). The principal complications were wound infection or dehiscence, and poor cosmetic results. Eleven patients received NHS treatment, at a cost of £120,841. The mean cost for all patients' management was £6360 (range: £114-£57,968), rising to £10,878 for those accepted for treatment. For 8 of the 9 patients (89%) for whom full patient level costing was available, the hospital incurred a financial loss. CONCLUSION: The costs to the NHS of managing complications of cosmetic tourism are substantial, and underestimated by central funding agencies.

CpG oligodeoxynucleotides promote the host protective response against infection with Cryptococcus neoformans through induction of interferon-gamma production by CD4+ T cells.

In the present study, we elucidated the effect of synthetic CpG-containing oligodeoxynucleotides (ODN) on pulmonary and disseminated infection caused by Cryptococcus neoformans. CDF-1 mice were inoculated intratracheally with a highly virulent strain of this pathogen, which resulted in massive bacterial growth in the lung, dissemination to the brain and death. Administration of CpG-ODN promoted the clearance of C. neoformans in the lungs, decreased their dissemination to brain and prolonged the survival of infected mice. These effects correlated well with the enhanced production of interleukin (IL)-12 and interferon (IFN)-gamma and attenuated secretion of IL-4 in bronchoalveolar lavage fluids (BALF) and promoted development of Th1 cells, as indicated by the increased production of IFN-gamma by paratracheal lymph node cells upon restimulation with cryptococcal antigens. The IFN-gamma synthesis in BALF was inhibited by depletion of CD8(+) and CD4(+) T cells on days 7 and 14 after infection, respectively, but not by depletion of NK and gammadelta T cells. Consistent with these data, intracellular expression of IFN-gamma was detected predominantly in CD8(+) and CD4(+) T cells in the lung on days 7 and 14, respectively. The protective effect of CpG-ODN, as shown by the prolonged survival, was completely and partially inhibited by depletion of CD4(+) or CD8(+) T cells, respectively, but not by depletion of other cells. Finally, TNF-alpha was markedly induced by CpG-ODN, and the protective effect of this agent was strongly inhibited by neutralizing anti-TNF-alpha MoAb. Our results indicate that CpG-ODN alters the Th1-Th2 cytokine balance and promotes host resistance against infection with C. neoformans.

Huge IgD plasmacytoma in the abdomen presenting coagulation necrosis.

A 65-year-old Japanese woman was diagnosed in 1996 with a pathological fracture of the left femur caused by immunoglobulin D-type myeloma (IgD myeloma). She responded well to combination chemotherapy followed by irradiation. The patient experienced renal failure and became dependent on haemodialysis. In 1999, large plasmacytomas developed in the abdomen and left humerus. The abdominal tumour appeared to induce gastroduodenal ulcers and jejunal obstruction. We initiated irradiation therapy without chemotherapy to prevent further growth of the plasmacytoma, although treatment-resistant gastroduodenal ulcers developed. Continued blood loss from the gastroduodenal ulcers resulted in a deterioration in the patient's health, which prevented successful haemodialysis. An autopsy showed that the plasmacytoma had undergone coagulation necrosis. We conclude that the use of combination chemotherapy with topical irradiation was an acceptable treatment measure against IgD plasmacytoma; irradiation without chemotherapy was the most likely cause of the coagulation necrosis seen in the plasmacytoma at autopsy.

[Spinal cord protection during thoracoabdominal aortic aneurysm repair; efficacy of distal aortic perfusion and segmental aortic clamping].

Despite improvement in adjuncts for thoracoabdominal aortic aneurysms (TAAA) repairs, many devastating complications remains after the surgery. Our experience with these aneurysms has been reviewed in order to identify those methods at risk of major morbidity, as well as which further improvements required. During last 16 years, 53 consecutive patients were operated on TAAA. The mean age was 58 years. Twenty patients had dissecting aneurysms and 13 patients had had prior aortic surgery. A femoro-femoral bypass was used to maintain distal aortic perfusion in most patients. Reimplantation of intercostal or lumbar arteries under the multi-segmental aortic clamping is consistent in our technique. Motor evoked potentials (MEP) were measured to monitor spinal cord protection since 2000. The hospital mortality was 9.4% (5/53), 22.2% (2/9) for emergency operation and 15.4% (2/13) for patients with prior aortic surgery. The mortality for the first and elective operations was 3.2% (1/31). No any neurologic dysfunction was observed in all patients including the hospital deaths. In view of clinical results, our adjuncts and techniques are useful for prevention of spinal cord ischemia during the TAAA surgery.

Blood distribution to the anterior spinal artery from each segment of intercostal and lumbar arteries.

AIM: Prevention of paraplegia, a serious complication of surgery for thoracoabdominal aortic aneurysm, has been well documented. However no assured prophylaxis against this complication has yet been found. Spinal ischemia is believed to be the major cause of paraplegia. We conducted an experimental study to define the development of paraplegia with regard to the blood supply to the spinal cord. METHODS: A porcine model was used to evaluate blood distribution to the anterior spinal artery. Colored silastic agent was selectively injected into the intercostal and lumbar arteries, and distribution to the anterior spinal artery was evaluated on 50 animals. The intercostal and lumbar arteries were ligated in the segments where the blood supply to the anterior spinal artery would be interrupted. Whether or not paraplegia developed was checked 2 days later. RESULTS: Colored silastic agent arrived at the anterior spinal artery from all segments of the 8th intercostal to 4th lumbar arteries. Two of 9 pigs (22.2%) that underwent ligation of the segments from the 9th intercostal to 2(nd) lumbar artery suffered paraplegia. In 3 non-paraplegic pigs, colored silastic agent injected into the preserved arteries was found to have covered a wider range. CONCLUSION: All the intercostal and lumbar arteries supplied blood to the anterior spinal artery. When large segments of intercostal and lumbar arteries were ligated, the blood flow from the preserved segments acquired increased dominance. The possibility exists that any intercostal and lumbar artery can supply blood to the spinal cord and become collateral circulation to the anterior spinal artery.

[Impact of multi-segmental aortic clamping and distal aortic perfusion on the prevention of postoperative paraplegia during thoracoabdominal aortic graft replacement]. / Multisegmentale Aortenabklemmung und distale Aortenperfusion zur Verhinderung der postoperativen Paraplegie bei thorakoabdomineller Aortenprothesenimplantation.

OBJECTIVE: We present the impact of multisegmental aortic clamping under distal aortic perfusion and segmental artery reimplantation on the prevention of postoperative paraplegia during thoracoabdominal aortic graft replacement. PATIENTS: During the last 14 years in 47 patients (age range: 22 to 82 years; average: 57,9 +/- 13,2 years; 16 females and 31 males) with thoracoabdominal aortic aneurysm a graft replacement was performed with adjuncts of normothermic partial bypass and multisegmental aortic clamping. As many patent segmental arteries as possible were reimplanted. RESULTS: Five patients died during hospitalization, for an in-hospital mortality rate of 10,6 %. In the elective patients (n = 40), the hospital mortality rate was 7,5 %. The average number of segmental aortic clampings per patient was 2,83 +/- 1,19 times. In 39 patients (82,9 %), 117 segmental arteries were reimplanted or preserved by beveled anastomosis. Eighty-three out of 117 segmental arteries (70,9 %) were located between TH9 and L2. Postoperative paraplegia/paraparesis did not occur in any patient. CONCLUSION: In view of our results reimplantation of as many segmental arteries as possible under multisegmental aortic clamping with adequate distal aortic perfusion can be recommended for effective prevention of spinal cord ischemia in TAAA surgery.

Application of hypothermia to autologous stem cell purging.

Autologous stem cell transplantation is used widely after high-dose chemotherapy for treating hematological and other malignancies. Bone marrow harvested for autologous bone marrow transplantation may contain residual malignant cells even when the cancer is judged to be in remission. Attempts to purge marrow of its putative residual malignant cells may delay hemopoietic reconstitution and are of uncertain efficacy. In this report, we demonstrate the possibility of applying hypothermia to autologous stem cell purging. Using clonogenic assay, we compared the surviving fraction of human leukemia (HL60, K562) and human small cell lung cancer (H69) cell lines with that of normal human bone marrow CFU-GM and BFU-E cells after incubation at 4 +/- 0.1 degrees C for 24 and 48 h. Hypothermia decreased the surviving fraction of HL60, H69, and K562 cells. In contrast, the surviving fractions of stem cells were not affected by the temperature shift. The surviving fraction of HL60 cells at 4 degrees C cooling was significantly lower than that at 22 degrees C cooling. These findings suggest that in vitro hypothermia may selectively purge residual malignant cells in stored remission bone marrow and may be applicable before autologous bone marrow transplantation. In addition, the method is very simple and cost effective.

One-stage operation for descending thoracic aortic aneurysm and left lung cancer: a case report.

We performed concomitant graft replacement for descending thoracic aortic aneurysm and pulmonary resection for squamous cell carcinoma of the left upper lobe in a 79-year-old man. The tumor reached the parietal pleura. No distance metastasis was found, and the tumor was diagnosed preoperatively as a stage IIB (N0, M0, T3) tumor. The descending thoracic aortic aneurysm was saccular, with greatest diameter being 55 mm, and extending from TH5 to TH8. A left upper lobectomy was performed, and after irrigation with a large volume of saline diluted with povidone iodine, graft replacement for the aortic aneurysm was performed under femoro-femoral partial bypass. To prevent postoperative graft infection, the greater omentum was dissected and placed over the resected pulmonary hilum and the graft. The patient's postoperative course was uneventful. There was no sign of infection, and the patient was discharged 1 month after surgery. Artificial graft wrapping with the greater omentum was useful for the prevention of the postoperative graft infection in this case of surgical treatment of lung cancer and descending thoracic aortic aneurysm.

Successful living donor liver transplantation for polycystic liver in a patient with autosomal-dominant polycystic kidney disease.

Orthotopic liver transplantation has been recommended for patients with disabling polycystic liver disease (PCLD). Because of the shortage of cadaveric donors, living donor liver transplantation (LDLT) has been developed as an alternative. We describe the case of a woman with PCLD as an extrarenal manifestation of autosomal-dominant polycystic kidney disease (ADPKD) who was successfully palliated by LDLT. The patient was a 48-year-old woman with abdominal distention. Computed tomography showed a massively enlarged liver containing innumerable cysts, as well as bilateral kidney cysts. Hepatic and renal functions were well preserved. Genetic analysis of the family did not exclude linkage to the PKD1 locus. Two and a half years after the first examination, the patient reported severely disabling symptoms caused by the PCLD. Living donor liver transplantation was performed using a right-lobe graft. The recipient and donor were both well 8 months after the transplantation. The excised liver weighed 7.4 kg, and the histopathology revealed multiple cysts and von Meyenburg complexes in the portal areas.

Basaloid-squamous cell carcinoma of the esophagus: diagnosis based on immunohistochemical analysis.

Basaloid-squamous cell carcinoma of the esophagus (BSCC) is an extremely rare tumor. Histologically, this tumor should be differentiated from adenoid cystic carcinoma (ACC) and small cell undifferentiated carcinoma (SCUC). Biologically, this tumor is very aggressive, with a propensity for distant metastasis. We report a 64-year-old male with esophageal BSCC. The patient complained of dysphagia and was found to have a torous lesion in the esophagus on radiological examination. Upper gastrointestinal fiberscopy showed a localized ulcerative type tumor, which was diagnosed as squamous cell carcinoma (SCC) on biopsy. Surgery resulted in curative resection. A histological examination of the resected tumor showed features of BSCC. Immunohistochemical examination demonstrated AE3/1- and CAM 5.2-positive tumor cells, and laminin-positive cells in the periphery of the nests. These data were useful in differentiating this tumor from ACC and SCUC. Six months after surgery, the patient developed hepatic metastases, which were successfully treated by regional chemotherapy via the hepatic artery by using fluorouracil. The patient is currently being followed up at the outpatient clinic and shows no signs of any recurrence.

Effect of ACE gene polymorphism on age at renal death in polycystic kidney disease in Japan.

Polycystic kidney disease (PKD) is one of the most common genetic disorders and a major cause of renal death or end-stage renal disease (ESRD) requiring regular hemodialysis. The responsible genes recently have been cloned; however, genetic factors influencing the rate of progression to ESRD in patients with PKD have yet to be defined. Several studies have shown increased activity of the renin-angiotensin system (RAS) in patients with PKD. In addition, genetic polymorphisms of the RAS have been associated with the development of cardiovascular diseases. Therefore, these polymorphisms are good candidates for disease-modifying genetic factors or markers in PKD. In two previous reports of white subjects with a cumulative survival analysis, it was suggested that patients with P:KD1 homozygous for the deletion allele of the angiotensin-converting enzyme (ACE) gene are at increased risk for early renal death. To confirm this hypothesis in Japanese subjects, 103 individuals with PKD were genotyped for several components of the RAS, ie, ACE insertion/deletion (I/D) polymorphism, angiotensinogen (AGT) M235T, and angiotensin II type 1 receptor (AT1) A1166C. Seventy-six of the 103 patients (73.8%) reached ESRD at an average age of 52.1 +/- 11.3 years. The frequencies of each genotype of the genes were similar to those expected from Hardy-Weinberg equilibrium. There was a tendency to an excess of patients homozygous for the D allele in patients with ESRD (DD in patients with ESRD, 11.8%; DD in patients without ESRD, 3.7%; chi-square, 1.505; P: = 0.22). Cumulative renal survival was significantly less in those with the DD genotype compared with ID/II genotypes. Estimated mean renal survival was 46.4 years (95% confidence interval, 39.5 to 53.3) in subjects with the DD genotype and 57.2 years (95% confidence interval, 54.2 to 60.2) in ID/II genotypes (chi-square, 7.76; P: = 0.0053). There was no association between age at onset of ESRD and either M235T or A1166C polymorphism. These findings suggest that Japanese patients with PKD homozygous for the D allele of the ACE gene are at increased risk for developing ESRD at an early age.

Management of the heart rate during coronary artery bypass grafting on the beating heart: newly devised methods of decreasing heart rate--a preliminary report-.

BACKGROUND: To develop new methods for achieving bradycardia, we studied the feasibility of producing transient, reversible bradycardia with atrial stimulation and cooling of the sinoatrial node. METHODS: In an animal study, the atrium was stimulated electrically during the refractory period of the atrioventricular node. Alternatively, an area of the sinoatrial node was cooled regionally. The two methods were also performed in combination. In a clinical study, atrial stimulation was applied in seven consecutive patients who underwent coronary artery bypass grafting (CABG). RESULTS: In the animal study, atrial stimulation was effective only when 2 mg/kg of diltiazem was administered. Such atrial stimulation decreased heart rate (beats/minute) from 95.8+/-16.9 to 64.2+/-20.0 (the average reduction from the control value 66.1+/-10.3%). Cooling the sinoatrial node decreased heart rate, and was effective with or without administration of diltiazem. Heart rate was decreased from 156.6 31.7 to 110.7+/-21.7 (average reduction from control value 71.3+/-9.2%) before using diltiazem and from 102.0+/-11.9 to 63.5+/-13.9 (average reduction from control value 62.0+/-10.4%) after administration of diltiazem. By combining the two methods, heart rate was decreased from 102.0+/-12.3 to 44.6+/-9.1 (average reduction from control value 43.5+/-6.3%). In our clinical study, the atrial stimulation method was effective. CONCLUSION: Atrial stimulation or regional cooling of the sinoatrial node slowed the heart rate. By combining the two methods, the heart rate was slowed to 40. Clinically, atrial stimulation was effective in CABG patients.

Brain metastasis of epithelioid sarcoma--case report.

A 20-year-old-female first presented with an epithelioid sarcoma of the right thumb, and the right thumb was amputated. Five years later, a metastasis was found in the right lower lung and a partial lobectomy was performed. Three years later, computed tomography showed a metastatic brain tumor in the left frontal lobe, which was removed surgically. Adjuvant radiotherapy and chemotherapy were given after all operations. Histological examination showed all resected tumors were epithelioid sarcoma. She has maintained a good activity of daily living level as an outpatient for 2 years, although subcutaneous metastases and bronchial lymph node metastases have been observed. Such intensive treatment of slowly growing tumors often prolongs survival time, even in patients with multiple metastases.

Cytotoxic effect through fas/APO-1 expression due to vitamin K in human glioma cells.

Congeners of vitamin K have been found to inhibit growth in various rodent and human tumor cells, but the mechanisms of the inhibitory action are still not well understood. To investigate the modes of actions of vitamin K, we used several vitamin K analogs and examined their cytotoxic effect for human glioma cell lines RBR17T and U251. The analogs included vitamin K1 (VK1), vitamin K2 (VK2), vitamin K3 (VK3), and geranylgeraniol (GGO) which form an unsaturated side chain of VK2. Cell viability was estimated by MTT assay. DNA fragmentation was demonstrated by gel electrophoresis and flow cytometry. In order to study the mechanism of apoptosis, we measured the changes of intracellular reactive oxygen intermediates (ROI) and Fas/APO-1 expression by flow cytometry. The results showed: (1) VK2, VK3, and GGO inhibited cell growth; (2) VK3 had a more potent cytotoxic effect than VK2, and VK3 enhanced the cytotoxic effect of antitumor agents (ACNU and IFN-beta) in RBR17T cells; (3) VK2, VK3, and GGO induce apoptosis: (4) VK3 increased the expression of Fas/APO-1 although VK2 and GGO did not increase its expression in glioma cells; (5) VK3 increased the production of intracellular ROI. Catalase and reduced glutathione (GSH) inhibited production of intracellular ROI and antagonized inhibition of cell-growth induced by VK3, but failed to antagonize that of VK2 and GGO. We hypothesize that VK3 induces apoptosis by promoting the generation of intracellular ROI and Fas/APO-1 expression. On the other hand, VK2 and GGO induce apoptosis but most likely by some other unknown pathway.

[Relapse of small cell carcinoma of the lung with metastasis to iris].

We reported a case of small cell carcinoma of the lung with metastasis to the iris during a stage of complete remission obtained with chemotherapy and radiation therapy. The patient was a 55-year-old man hospitalized for hoarseness and abnormal chest radiographs in August 1996. Small cell carcinoma of the lung had been diagnosed, and the stage was limited disease. Treatment consisted of 3 cycles of chemotherapy with cisplatin and etoposide, together with radiation therapy. The patient achieved complete remission and was discharged. In mid-December, he visited an eye clinic with the complaints of blurred vision and congestion in the right eye. Metastatic tumor of the iris was diagnosed. At that time, neither local recurrence of the lung cancer nor metastasis to other organs were observed. The patient was treated with cisplatin and etoposide again, resulting in a reduction of the iris tumor's size. After chemotherapy, the right eye was treated with electron irradiation, and the iris tumor and other clinical signs almost entirely disappeared. The patient retained normal vision during the clinical course.

Reversible peritoneal calcification in a patient treated by CAPD.

The patient, a female, aged 65 years, developed diffuse peritoneal calcification nine years after commencing CAPD therapy. No abdominal symptoms or evidence of peritonitis were discovered during this period. Before peritoneal calcification was detected, a dialysate with a high glucose concentration (3.86%) had been used once daily for 16 months. In the case of this patient, it was not possible to discover any of the previous indicated etiologies of peritoneal calcification such as significantly elevated values for the product Ca x P, overt secondary hyperparathyroidism, or relapsing peritonitis. It was realized that the use of a high-glucose dialysate in a patient on long-term CAPD treatment had been one causative factor. After peritoneal calcification had been confirmed, the calcium concentration of the dialysate changed from 3.5 mEq/l to 2.5 mEq/l and the patient was put on a regime of 2.0 g alumigel (aluminum-containing phosphate binders) a day. Eight months later, a CT scan was taken. The peritoneal calcification has clearly been mitigated. At present, CAPD therapy is being continued in the absence of any abdominal symptoms.

A patient with improvement in short-term memory disturbance brought about by radiation therapy for germinoma involving Papez circuit.

A 27-year-old male presented with memory loss. With magnetic resonance imaging (MRI), enhanced masses on the right side of hypothalamus, right side of anterior basal ganglia, and left side of hypothalamus were found. Histological analysis of the tumor by stereotactic biopsy proved it to be a germinoma. When related to the map of the thalamic nuclei, the tumor involved anterior column of the fornix and anterior nuclei of the thalamus. Neuropsychological tests prior to radiation therapy disclosed only short-term memory disturbance. The patient received radiation therapy to a total dose of 55 Gy to the primary lesion. After the completion of radiation therapy, the enhanced effect disappeared on gadolinium enhanced T1-weighted MRI. Single photon emission computed tomography indicated improvement in blood flow in the anterior portion of the bilateral thalami. Neuropsychological tests after radiation therapy showed improvement in short-term memory compared with baseline. Test results have remained stable for two and half years. This case indicates the possibility of improvement in memory function by treatment for tumor when it involves part of Papez circuit. Nevertheless, a decrease in intellectual ability by irradiation remains the major problem. Better approaches not only for cure but also to reduce the late effects should be undertaken when radiation therapy is the treatment of choice.