Persistent increases of BAL neutrophils as a predictor of mortality following lung transplant.

STUDY OBJECTIVES: To evaluate whether findings from surveillance bronchoscopy predict survival following lung transplantation. DESIGN: Retrospective review and analysis of 498 bronchoscopies with transbronchial biopsy (TBB) and BAL performed in 34 patients after lung transplantation. SETTING: University-based, tertiary referral medical center. PATIENTS: Thirty-four patients after lung transplantation. The mean age at transplantation was 49+/-9 years; 20 (59%) were female. Twenty-four (71%) underwent single and 10 (29%) underwent bilateral lung transplantation. The most common pretransplantation diagnostic groups were emphysema/COPD without concomitant alpha1-antiprotease deficiency (n = 13) and other obstructive disease processes (n = 10). INTERVENTIONS: Over follow-up, subjects underwent multiple bronchoscopies with TBB and BAL. The median number per subject was 15 (25 to 75% range 13 to 17). MEASUREMENTS AND RESULTS: We calculated the overall median BAL WBCs and median percent neutrophils (polymorphonuclear leukocytes [PMNs]) among all of the BALs performed for each subject. We then calculated the mean +/- SD of those median values. We used Cox proportionate hazards to assess mortality risk. The median overall follow-up observation period for the cohort was 560 days. There were 11 deaths during this period. Twenty-four subjects (71%) had acute rejection (AR) grades 2 to 4 (mild to severe), and nine (27%) had obliterative bronchiolitis (OB) diagnosed by TBB at any point. The mean value for BAL WBCs was 366+/-145 x 10(3) per milliliter; for percentage PMNs, the mean was 7+/-10%. Adjusting for age, gender, single vs bilateral lung transplantation, pretransplantation diagnostic group, presence of AR, presence of OB, BAL WBC concentration, and lymphocyte CD4/CD8 ratio, PMN percent was a significant predictor of mortality (p = 0.02). CONCLUSIONS: Ongoing inflammation manifested by an increased percentage PMNs over repeated bronchoscopies predicts mortality following lung transplantation. Biopsy data alone may be insufficient to identify posttransplantation patients at risk of poor outcome.

Experiences with the new inhalational agents in low-flow anesthesia and closed-circuit technique. Monitoring and technical equipment.

During recent years interest has focused on two completely fluorinated ethers, desflurane and sevoflurane, which promise a shorter induction of and emergence from anesthesia. Their physicochemical properties differ from isoflurane, enflurane and halothane, thus requiring new technical equipment and leading to a change in anesthesiological procedures. Low-flow anesthesia with desflurane can be performed, the technical equipment is available, especially vaporizers and gas analyzers. In contrast to anesthesia with isoflurane, enflurane and halothane, the initial high-flow wash-in period with desflurane can be shorter and the vaporizer setting can remain unchanged after fresh gas flow reduction. In order to administer desflurane and sevoflurane in closed circuit technique, new technical equipment is needed. Therefore, a computer controlled anesthesia machine was modified and the feedback mechanism to maintain the end-tidal anesthetic concentration was simulated. Isoflurane, desflurane or sevoflurane needed the same time for wash-in. Wash-out was slower with isoflurane; however, the technical equipment should be adapted to increase the elimination of the new agents. The consumption of desflurane and sevoflurane is effectively reduced by low-flow and closed circuit anesthesia.

Comparison of autoreinfusion and standard drainage systems in total joint arthroplasty patients.

The purpose of this study was to compare the costs and outcomes of the postoperative autoreinfusion device, the Constavac, with the standard suction device, the Hemovac, in which blood drainage is discarded, in patients undergoing total joint arthroplasty of the knee or hip. At the completion of the surgical procedure, a total of 91 subjects were randomly assigned to one of the two device groups. The findings of this study, which included a limited homogeneous sample, do not support the use of the Constavac device in patients undergoing total joint arthroplasty.

Pubic ramus fatigue fractures after total knee arthroplasty. A case report.

Fatigue fractures in the rheumatoid population are infrequent but well described clinical and radiographic entities, and rarely occur within the pelvis. These fractures often are difficult to diagnose. Pelvic fatigue fractures are much less commonly detected and reported after total joint arthroplasties. This article reports the sequential appearance of fatigue fractures of the superior portions of both pubic rami after total knee replacement arthroplasties which were not suspected on historical review, physical examination, nor well visualized on initial plain radiographs and technetium bone scanning.

Long-term results of tibiotalar arthrodesis.

One hundred and one tibiotalar arthrodeses were performed using a single surgical technique that has not been previously reported. The average follow-up was ten years (range, two to twenty-five years). The rate of pseudarthrosis was 5 per cent, four to five times less than in other recent large reports. Pseudarthrosis occurred only in patients with a sensory deficit. Secure fusion was radiographically documented in 95 per cent and the functional clinical result was good to excellent in 90 per cent. The ideal fusion position was found to be neutral or slight equinus angulation, and varus-valgus angulation equal to that of the contralateral side. More than 7 degrees of varus angulation of the heel was associated with symptomatic lateral metatarsalgia in all feet in which it occurred. Radiographic measurement documented an average 85 per cent (11-degree) increase in postoperative tarsal motion. Neither symptoms nor function correlated with the degree of tarsal hypermobility.

Fatigue fracture of the femoral neck after total knee arthroplasty a case report.

Prolonged immobility predisposes to a multitude of medical problems. In the rheumatoid patient, immobility contributes to a preexisting problem of osteoporosis. Our patient with longstanding rheumatoid arthritis underwent total knee arthroplasty and subsequently developed a fatigue fracture of the ipsilateral femoral neck. To our knowledge, this is the first such case to be reported in a patient with rheumatoid arthritis.

Rotational displacement of the distal tibial epiphysis without fibular fracture.

Rotational displacement of the distal tibial epiphysis, a rare injury, is reported in a 14-year-old girl. A high clinical index of suspicion and roentgenograms of the entire leg, including knee and ankle, are necessary for diagnosis. Long-term followup is indicated to determine if epiphyseal closure will eventuate as it did in our patient.

Avascular necrosis of the head of the talus without death of the body: report of an unusual case.

A case of fracture of the neck of the talus with dislocation of the subtalar joint is reported in which the head of the talus underwent avascular necrosis while the body remained alive.

Immobilization hypercalcemia crisis.

Profound hypercalcemia associated with immobilization is rare. Hypercalcemic crisis occurring as a result of immobilization in which there was not a coexisting, contributing medical condition has not, to our knowledge, been reported previously. Failure to consider hypercalcemia as the source of progressive anorexia, nausea, vomiting, and irritability resulted in a respiratory arrest and nearly fatal outcome in the case of a 13-year-old boy one month after a simple femoral fracture. Therapy consisting of the intravenous administration of fluids and corticosteroids was successful in lowering the serum calcium level until mobilization could be accomplished. Review of previously reported cases emphasizes the difficulty in recognition and diagnosis of this unusual condition. Surgeons treating patients with fractures should be aware of this complication and familiar with its appropriate therapy.