[Membranous nephropathy in a Russian population]. / Membranoznaia nefropatiia v rossiiskoi populiatsii.

AIM: To analyze the clinical and morphological manifestations of membranous nephropathy (MN) and to evaluate the efficiency of its therapy. MATERIAL AND METHODS: MN cases in 2009 to 2016 were retrospectively detected with a subsequent analysis of patients with primary MN (PMN). The titer of IgG-autoantibodies to phospholipase A2 receptor (anti-PLA2R Ab) was determined by an indirect immunofluorescence assay. Treatment outcomes, such as the time course of changes in proteinuria, nephrotic syndrome (NS), and the development of complete and partial remissions (CR and PR), were assessed. RESULTS: MN was detected in 201 cases; the secondary etiology of the disease was established in 24.9%. The prevalence of MN among morphologically confirmed glomerulopathies was 14%; that of PMN was 10.4%. The median period to diagnosis PMN was 8 (5; 19) months. 150 patients with PMN (66.7% were men; age was 50±15 years) were distributed according to the following morphological stages: Stages I (23.9%), II (48.5%), III (26.1%), and IV (1.5%). Elevated anti-PLA2R Ab levels were found in 51.6% of cases; NS in the presence of proteinuria was detected in 85.6% of patients. An estimated glomerular filtration rate (eGFR) of <60 ml/min/1.73 m2 was seen in 25% of cases. Treatment outcomes were evaluated in 80 cases; the median follow-up period was 19 (8; 40) months. 68% of cases had CR (32%) or PR (36%) with a median follow-up of 26 (13; 44) months. Spontaneous CRs or PRs were observed in 7.5% of the patients. Multivariate analysis showed that the probability of CR or PR increased 3.2-fold in the use of cyclophosphamide and/or cyclosporine and decreased as eGFR dropped. CONCLUSION: In Russia, PMN is a common type of glomerulopathy, the specific features of which should include the low rates of spontaneous remissions and detection of anti-PLA2R Abs. For renal protection, the majority of patients with PMN require timely diagnosis and treatment; individualization of the choice of treatment and its enhanced efficiency call for further investigations.

Kinetic study of biodegradation of BTX compounds in mono- and multicomponent systems in reactor with immobilized biomass.

In this study, kinetic parameters were determined for the biodegradation of BTX compounds in a fixed-bed reactor with immobilized biomass, fed with mono- and multicomponent systems. The parameter estimation was achieved through an algorithm using the finite volume method. Different kinetic models were evaluated. The Monod model proved to be suitable to predict the experimental data for the biodegradation individual BTX compound. In multicomponent systems, it was found that the presence of more than one compound tends to cause competitive inhibition. To identify the models that best fit the experimental data, a statistical analysis using the F test was applied. For the two- and three-component systems the presence of more than one compound tends to cause competitive inhibition. In this study, it was possible to predict kinetic parameters in mono- and multicomponent systems as well as different operation conditions for a fixed-bed reactor with immobilized biomass.

Liver transplantation in children using non-heart-beating donors (NHBD).

Selected livers from controlled NHBD are accepted for OLT in adults. Recent evidence has shown good medium-term outcome. The purpose of this study was to report our experience of pediatric OLT with whole and partial grafts from NHBD, analyzing complications and outcome. Retrospective review of all the recipients who underwent primary OLT between December 2005 and December 2008, using livers from NHBD. Four children (one male child) mean age was 9.5 yr (0.2-17), mean weight was 26 kg (range 2.6-48), underwent OLT using NHBD. Mean donor age was 14.2 yr, and mean WIT (systolic BP<50 mmHg to cold perfusion) 12.2 min (range 10-15). Two children received reduced grafts and two full grafts. Mean cold ischemia time was 7.18 h (range 6-8). Liver function tests one wk and nine months post-OLT confirmed a good graft function. One child was treated for two episodes of acute rejection. Post-transplant complications included two cases of mild ischemic cholangiopathy treated conservatively. Graft and patient survival was 100% with a mean follow-up of 19 months (range 8.1-43.4). Short- to medium-term follow-up suggests that liver grafts from young NHBD with short warm and cold ischemia times can be safely utilized in pediatric transplantation.

Sea level variation as an indicator of Florida current volume transport: comparisons with direct measurements.

Sea level measurements from tide gauges at Miami, Florida, and Cat Cay, Bahamas, and bottom pressure measurements from a water depth of 50 meters off Jupiter, Florida, and a water depth of 10 meters off Memory Rock, Bahamas, were correlated with 81 concurrent direct volume transport observations in the Straits of Florida. Daily-averaged sea level from either gauge on the Bahamian side of the Straits was poorly correlated with transport. Bottom pressure off Jupiter had a linear coefficient of determination ofr(2) = 0.93, and Miami sea level, when adjusted for weather effects, had r(2) = 0.74; the standard errors of estimating transports were +/- 1.2 x 10(6) and +/- 1.9 x 10(6) cubic meters per second, respectively. A linear multivariate regression, which combined bottom pressure, weather, and the submarine cable observations between Jupiter and the Bahamas, had r(2) = 0.94 with a standard error of estimating transport of +/- 1.1 x 10(6) cubic meters per second. These results suggest that a combination of easily obtained observations is sufficient to adequatelv monitor the daily volume transport fluctuations of the Florida Current.

Chronic rejection after combined liver and small bowel transplantation in a child with chronic intestinal pseudo-obstruction: a case report.

An 11-year-old boy with irreversible intestinal failure secondary to chronic intestinal pseudo-obstruction (CIPO) and intestinal failure-associated liver disease (IFALD) underwent a combined en bloc reduced liver and small bowel transplantation. He was discharged home after 9 weeks on full oral intake without requiring intravenous nutritional or fluid supplementation. The first episode of mild acute rejection, which occurred 18 months after transplantation, was successfully treated with steroids. An episode of rotavirus gastroenteritis led to severe exfoliative rejection of the bowel graft, which was resistant to steroid and Infliximab treatment but responded to OKT3. There was associated Epstein-Barr virus viremia with no evidence of posttransplant lymphoproliferative disease. Another episode of moderate to severe acute liver rejection occurred 5 months later. At the same time, multiple biliary strictures were diagnosed and treated. Persistent clinical symptoms of abdominal pain and increased stomal output as well as atrophy of the ileal mucosa on several biopsies, suggested the possibility of chronic rejection (CR). A second combined whole liver and small bowel transplant was performed. The diagnosis of CR was confirmed on histology of the explanted graft. The postoperative course was severely complicated and 71 days after the retransplantation, the boy died because of respiratory failure and multiorgan failure. In summary, intestinal transplantation can be successfully performed in children with CIPO, giving them the opportunity to be free from total parenteral nutrition. As survival following intestinal transplantation continues to improve, the problem of CR has become increasingly important and the only treatment available is retransplantation, which is associated with poor outcomes.

An Evaluation of Kinetic Models in the Biodesulfurization of Synthetic Oil by Rhodococcus erythropolis ATCC 4277.

Biodesulfurization is an eco-friendly technology applied in the removal of sulfur from fossil fuels. This technology is based on the use of microorganisms as biocatalysts to convert the recalcitrant sulfur compounds into others easily treatable, as sulfides. Despite it has been studied during the last decades, there are some unsolved questions, as per example the kinetic model which appropriately describes the biodesulfurization globally. In this work, different kinetic models were tested to a batch desulfurization process using dibenzothiophene (DBT) as a model compound, n-dodecane as organic solvent, and Rhodococcus erythropolis ATCC 4277 as biocatalyst. The models were solved by ODE45 function in the MATLAB. Monod model was capable to describe the biodesulfurization process predicting all experimental data with a very good fitting. The coefficients of determination achieved to organic phase concentrations of 20, 80, and 100 % (v/v) were 0.988, 0.995, and 0.990, respectively. R. erythropolis ATCC 4277 presented a good affinity with the substrate (DBT) since the coefficients of saturation obtained to reaction medium containing 20, 80, and 100 % (v/v) were 0.034, 0.07, and 0.116, respectively. This kinetic evaluation provides an improvement in the development of biodesulfurization technology because it showed that a simple model is capable to describe the throughout process.

Improved technique of portal vein reconstruction in pediatric liver transplant recipients with portal vein hypoplasia.

BACKGROUND: Children with small or hypoplastic portal veins represent a challenge for liver transplantation. Graft loss of up to 70% has been reported in these patients in the past. A variety of techniques has been used in both cadaveric and living related transplants in an effort to overcome this problem. Variability arises as to whether to use a vascular graft and where on the portal system to attach the graft. METHOD: We present our usage of a simple and straightforward interposition iliac vein allograft fashioned in a manner to achieve large anastomotic cross-sectional area on the confluence of the superior mesenteric/splenic veins. The procedure also overcomes problems of graft vein/portal vein size mismatch in the cases where liver and vein grafts are procured from much larger donors. RESULTS: A total of 14 children presented with hypoplastic portal vein (diameter<5 mm), of a total of 30 consecutive patients requiring cadaveric liver transplants, and benefited from this technique. Median recipient age was 10.5 months. Revascularization times ranged from 22 to 43 min with a mean of 33 min. All patients are alive and well at a mean follow-up of 329 days (10 months). All liver grafts are well and functioning. No portal vein problem was detected. CONCLUSION: Results from this technique are clearly encouraging. Because portal vein hypoplasia is a common problem in pediatric transplant candidates, we believe this alternative technique is of interest and should be added to the transplant surgeon's armamentarium.

Delayed hepatic artery thrombosis in adult orthotopic liver transplantation-a 12-year experience.

BACKGROUND: Although the clinical features of early hepatic artery thrombosis (HAT) are well defined, the features of delayed (more than 4 weeks after transplantation) hepatic artery thrombosis are less clearly defined. The aim of our study was to identify risk factors, clinical presentation, and outcome of management of delayed hepatic artery thrombosis (HAT) after liver transplant (LTx). METHODS: An analysis of prospectively collected data of all patients transplanted from 1986 to 1998 was performed. The importance of recipient (age, sex, primary indication for LTx, cytomegalovirus status, and intraabdominal sepsis) and donor factors (donor age, cold ischemia time, and donor cytomegalovirus status), modes of presentation, and outcome of treatment (biliary reconstruction/stenting, regraft, vascular reconstruction, observation) were analyzed. RESULTS: Delayed HAT was seen in 31/1097 adult LTx recipients (incidence 2.8%). No recipient or donor factors were identified as risk factors. A total of 16 patients were symptomatic at presentation (HAT diagnosed on abdominal ultrasound). Six patients had recurrent episodes of cholangitis, four had cholangitis with a stricture, four had cholangitis and intrahepatic abscesses, and two had bile leaks. Biliary reconstruction was done in six patients (all of whom subsequently required a regraft), vascular reconstruction was performed in two patients (one regrafted and one died shortly after), four patients with cholangitis and stricture on presentation had a biliary stent (all four were later regrafted). A total of 16 patients were regrafted, 9 are alive, 5 died within 6 months (septic at time of LTx), 1 died after 1 year, and 1 died after 2 years. Fifteen patients were asymptomatic and detected on routine screening. 5 have remained asymptomatic and are still alive, 1 developed a biliary stricture that was stented and is alive 105 months later, 4 had recurrence of the original disease, 3 developed progressive graft failure and were listed for transplant but died before regraft due to overwhelming sepsis and hepatic encephalopathy. Two patients died due to nonbiliary sepsis. CONCLUSIONS: Delayed HAT is a rare complication of LTx that may present with biliary sepsis, or remain asymptomatic. Biliary or vascular reconstructions do not increase graft survival. Of the patients who were clinically silent on presentation, 20% developed progressive graft failure requiring a second transplant. A total of 33% survived in the long-term without a second transplant. Ongoing severe sepsis at the time of regraft results in poor survival.

Carcinoma of the gastric cardia and hiatal hernia.

Carcinoma of the cardia of the stomach in patients with sliding hiatal hernia is a disease of poor prognosis, since symptoms nearly always occur late in its course at an already incurable stage. Eleven cases are reviewed from the records of The New York Hospital-Cornell Medical Center from 1932 to 1975. Resectability of tumor appeared related to shorter interval between onset of symptoms and diagnosis. Barium studies combined with esophagoscopy led to correct preoperative diagnosis of malignancy in all cases.

Pacemaker leads: a simple atraumatic method for replacing pacemaker electrodes.

Early dislodgment or malfunction of pacemaker leads can result in significant morbidity and therefore must be corrected promptly. We describe a method of changing pacemaker leads that is atraumatic, maintains central venous access, and eliminates the need for venipuncture. Our technique is simple, highly reproducible, and can be performed with standard operating room instruments.

Leiomyosarcoma of the pulmonary vein.

OBJECTIVE: We report a case of leiomyosarcoma (LMS) of the pulmonary vein and comment on the natural history and determinants for survival for this rare condition. EXPERIMENTAL DESIGN: Our retrospective review is only the fourth such case reported in the world's literature. SETTING: A teaching hospital with an active surgical residency program. PATIENT OR PARTICIPANT: A 61-year-old female who presented with a central pulmonary mass. INTERVENTIONS: Complete resection without pneumonectomy of cardiopulmonary bypass. Pathology showed low grade LMS. MEASURES: Determinants for survival include complete surgical resection and a low mitotic activity of the tumor. RESULTS: The patient remains no evidence of disease three years following initial treatment. CONCLUSIONS: One reported case of LMS of the pulmonary vein had favorable determinants for survival; complete surgical resection and low mitotic activity of the tumor. These factors may have contributed to the successful outcome. The natural history of LMS of the pulmonary vein appears similar to the more widely studied LMS of the inferior vena cava.

Balloon blunt-tip trocar for laparoscopic cholecystectomy: improvement over the traditional Hasson and Veress needle methods.

BACKGROUND AND PURPOSE: Laparoscopic cholecystectomy (LC) is a routine procedure for most general surgeons, yet the technical aspects of gaining access to the peritoneal cavity continue to be quite diverse. We describe a prospective review of 180 LCs using three access techniques: open balloon blunt-tip trocar (BBTT), open Hasson (HA), and closed Veress needle (VN). We favor the BBTT because it is designed to avoid all sharp instrumentation and offers superior seal and mobility, as well as expeditious and easy abdominal access. PATIENTS AND METHODS: The techniques and devices were evaluated prospectively with regard to simplicity of access, leakage of carbon dioxide, access time, and complications. All patients underwent LC by one of two Board-certified surgeons. RESULTS: The mean time to insertion of the laparoscope for the BBTT (3.5 +/- 0.99 minutes) was significantly less than the insertion time for the VN technique (5.2 +/- 0.9 minutes, P < 0.05). The insertion time for the BBTT was also less than for the standard HA approach (4.25 +/- 1.0 minutes; P < 0.05). There were no visceral or vascular injuries noted, but CO2 leakage and subcutaneous insufflation of gas experienced in the standard HA and VN groups resulted in lengthened operative times. One patient in the BBTT group experienced a postoperative port-site herniation, which was repaired primarily without consequence. CONCLUSION: The BBTT is an established, safe alternative to blind access for LC. Our technique is simple and rapid and avoids most of the technical difficulties encountered by other open access devices. We believe this method provides surgeons with an option that is efficient and easier to perform than most other conventional open-access laparoscopic techniques.

Case study: gluteal abscess due to Crohn's disease.

Spontaneous retroperitoneal abscess as a result of Crohn's disease does not always terminate at the psoas or iliac spaces. The abscess may continue downward breaching the obturator fascia. Passage through the sciatic foramina can result in a buttock or posterior upper thigh abscess. This possibility is illustrated in the case presented by a 40 year old female with toxemia and a fluctuant mass in the right gluteal area. Surgical drainage and control of the sepsis was followed by enterocutaneous fistula formation. Small bowel barium series demonstrated communication of the tracking abscess with the caput cecum. Surgical management consisted of formal ileocolectomy. The pathology report revealed Crohn's disease of the terminal ileum and right colon.

Use of bioelectrical impedance analysis to assess liver steatosis.

BACKGROUND: The shortage of donor livers has led to increased utilization of steatotic marginal livers. Bioelectrical impedance analysis (BIA) uses the principles of electric current flows through tissue, with less resistance offered if the water content is high and the opposite in the presence of fat. Our hypothesis was that liver steatosis would result in an increased resistance to current flow, and correlate with the degree of liver steatosis. METHODS: Before studying cadaveric donor livers for transplantation, this study was performed in patients undergoing liver resection. A total of 37 patients undergoing liver resection for cancer were analysed with BIA, using a handheld, specially calibrated Maltron BIA analyser (BioScan 915) with modified tertrapolar electrodes. These electrodes were applied to the liver surface and resistance was recorded. To validate the results of BIA, a liver biopsy was performed. Histopathology was graded quantitatively as no steatosis, mild, moderate, or severe steatosis according the percentage of fat as well as qualitatively by type of fat (micro and macrovesicular). RESULTS: Bioelectric resistance showed a correlation with macroveiscular steatosis (P = .03). CONCLUSION: BIA is a simple, noninvasive technique and its use should be explored in donor livers to assess steatosis.

Techniques for and outcome of liver transplantation in neonates and infants weighing up to 5 kilograms.

BACKGROUND: Neonates and small infants represent less than 5% of paediatric candidates for liver replacement. Most cases present under urgent conditions and receive grafts from large donors. Surgical techniques must be adapted for adequate graft preparation, vascular reconstruction, and abdominal closure. METHODS: Technical aspects and outcome of 15 liver transplantations in infants weighing less than 5 kg performed at our unit were analysed retrospectively. RESULTS: Liver transplantation was performed under urgent or highly urgent condition in 13 cases. Reduced or split liver grafts were used in all cases (median donor to recipient weight ratio, 9), including a monosegmental graft in 2 cases. In 10 cases, vascular reconstruction was done using a vascular conduit (5, 4, and 1 for artery, portal, and hepatic veins, respectively) and a delayed closure of the abdomen was necessary in 7 children. Postoperative complications were as follows: thrombosis of hepatic artery (n = 1) or portal vein (n = 1), gastrointestinal haemorrhage (n = 2), intraperitoneal bleeding (n = 1), biliary stricture (n = 2), septicaemia (n = 1). Two infants died of brain damage with a functioning graft. One child underwent retransplant for chronic rejection. CONCLUSIONS: Overall, survival rate is 60% (median follow-up, 34 months), which compares favourably with older patient groups when case mix is comparable.