A rare case of adrenal extramedullary haematopoiesis in a Cypriot woman with ß-thalassaemia.

We report a rare case of adrenal extramedullary haematopoiesis (EMH) in a thalassaemia patient in Cyprus. A 40-year-old woman with ß-thalassaemia presented with a 2-day history of non-specific right-sided abdominal pain on routine follow-up for her thalassaemia treatment. Her laboratory tests were not dissimilar to her routine results and no palpable mass was detected. Computed tomography findings revealed a 5.8×4.2×4.6cm solid lesion in the right adrenal gland. Surgical excision was advised for this symptomatic large tumour with the possibility of malignancy in a young patient, and a laparoscopic adrenalectomy was performed. Postoperative follow-up was uneventful. A review of the literature in PubMed and MEDLINE revealed 14 case reports worldwide with adrenal EMH secondary to ß-thalassaemia. EMH tumours in patients with thalassaemia have been reported incidentally, which stresses the importance of considering this in the list of differentials of adrenal incidentalomas in this patient population.

2509 living donor nephrectomies, morbidity and mortality, including the UK introduction of laparoscopic donor surgery.

The worldwide expansion of laparoscopic, at the expense of open, donor nephrectomy (DN) has been driven on the basis of faster convalescence for the donor. However, concerns have been expressed over the safety of the laparoscopic procedure. The UK Transplant National Registry collecting mandatory information on all living kidney donations in the country was analyzed for donations between November 2000 (start of living donor follow-up data reporting) to June 2006 to assess the safety of living DN, after the recent introduction of the laparoscopic procedure in the United Kingdom. Twenty-four transplant units reported data on 2509 donors (601 laparoscopic, 1800 open and 108 [4.3%] unspecified); 46.5% male; mean donor age: 46 years. There was one death 3 months postdischarge and a further five deaths beyond 1 year postdischarge. The mean length of stay was 1.5 days less for the laparoscopic procedure (p < 0.001). The risk of major morbidity for all donors was 4.9% (laparoscopic = 4.5%, open = 5.1%, p = 0.549). The overall rate of any morbidity was 14.3% (laparoscopic = 10.3%, open = 15.7%, p = 0.001). Living donation has remained a safe procedure in the UK during the learning curve of introduction of the laparoscopic procedure. The latter offers measurable advantages to the donor in terms of reduced length of stay and morbidity.

External validity of a mortality prediction model in patients after open abdominal aortic aneurysm repair using multi-level methodology.

OBJECTIVES: Evaluation of the prognostic ability of the APACHE-AAA model in an independent group of post-operative (open) Abdominal Aortic Aneurysm (AAA) patients. METHODS: The model was applied to predict in-hospital mortality in 541 patients (325 elective and 216 emergencies; 489 from Oxford; 52 from Lewisham). Multi-level modelling was used to adjust for both the local structure and process of care and patient case-mix. Model performance was assessed using goodness-of-fit and subgroup analyses. RESULTS: The model's predictive ability to discriminate between dead and alive patients was very good (ROC area=0.84). The model achieved a good fit across all strata of risk (Hosmer-Lemeshow C-test (8, N=476)=7.777, p=0.456) and in all subgroups. The model was able to rank the ICUs according to their performance independently of the patient case-mix. CONCLUSION: The APACHE-AAA model accurately predicted in-hospital mortality in a population of patients independent of the one used to develop it, confirming its validity. The multi-level methodology employed has shown that patient outcome is not only a function of the patient case-mix but instead predictive models should also adjust for the individual hospital-related factors (structure and process of care).

Simultaneous pancreas--kidney transplantation: to anticoagulate or not? Is that a question?

Pancreas graft loss due to venous thrombosis is the leading non-immunological cause for graft failure following kidney-pancreas transplantation. Thromboelastography (TEG)-directed anticoagulation protocol has shown that approximately one-third of the patients undergoing pancreas transplantation require therapeutic anticoagulation to prevent the occurrence of graft thrombosis. This article presents the argument for individualised anticoagulation in these patients based on their TEG tracings and suggests the use of TEG in patients undergoing pancreas transplantation.

Novel applications of Dermabond (2-octyl -cyanoacrylate) in cardiothoracic surgery.

Dermabond (Ethicon Inc., Somerville, NJ, USA) is a cyanoacrylate adhesive normally indicated for skin wound closure. This study describes the emergency use of this adhesive to control bleeding close to coronary anastomoses in exceptional cases. Dermabond was used in 17 patients who underwent cardiac surgery during an eight-month period, where other haemostatic interventions were unsuitable. It was applied for haemorrhage in 15 patients and control air leaks in two of the patients. Haemostasis was successful with Dermabond alone in 11 patients; the remaining four required additional interventions. It effectively controlled haemorrhage from ventricular pacing wires, vascular sling holes, peri-anastomotic bleeding, and epicardial tears. The adhesive was not placed directly on any graft because of embolic risk. In the two patients with visible air leaks, it was successfully used. No patient events were recorded as a result of haemorrhage and no reported toxicity. Dermabond may be indicated in circumstances in which haemostasis with traditional methods has failed or is inappropriate. A need for further high-quality objective research exists on the effectiveness and long-term safety of 2-octyl cyanoacrylate in cardiac surgery.

Comparison of mortality prediction models after open abdominal aortic aneurysm repair.

OBJECTIVES: Comparison of the accuracy of prediction of contemporary mortality prediction models after open Abdominal Aortic Aneurysm (AAA) surgery. METHODS: Post-operative data were collected from AAA patients from 2 UK Intensive Care Units (ICU). POSSUM and VBHOM based models were compared to the APACHE-AAA model which was able to adjust for the hospital-related effect on outcome. Model performance was assessed using measures of calibration, discrimination and subgroup analysis. RESULTS: 541 patients were studied. The in-hospital mortality rate for elective AAA repair (325 patients) was: 6.2% (95% confidence interval (c.i.) 3.5 to 8.8) and for emergency repair (216 patients) was: 28.7% (95% c.i. 22.5-34.9). The APACHE-based model had the best overall fit to the whole population of AAA patients, and also separately in elective and emergency patients. The V-POSSUM physiology-only (p<0.001) and VBHOM (p=0.011) models had a poor fit in elective patients. The RAAA-POSSUM physiology-only (p<0.001) and VBHOM models (p=0.010) had a poor fit in emergency patients. CONCLUSIONS: The APACHE-AAA model with its ability to adjust for both the hospital-related "effect" as well as the patient case-mix, was a more accurate risk stratification model than other contemporary models, in the post-operative AAA patient managed in ICU.

Quantification of mortality risk after abdominal aortic aneurysm repair.

BACKGROUND: The study was designed to evaluate the Acute Physiology And Chronic Health Evaluation (APACHE) II risk scoring system in abdominal aortic aneurysm (AAA) surgery. The aim was to create an APACHE-based risk stratification model for postoperative death. METHODS: Prospective postoperative APACHE II data were collected from patients undergoing AAA repair over a 9-year interval from 24 intensive care units (ICUs) in the Thames region. A multilevel logistic regression model (APACHE-AAA) for in-hospital mortality was developed to adjust for both case mix and the variation in outcome between ICUs. RESULTS: A total of 1896 patients were studied. The in-hospital mortality rate among the 1289 patients who had elective AAA repair was 9.6 (95 per cent confidence interval (c.i.) 8.0 to 11.2) per cent and that among the 605 patients who had an emergency repair was 46.9 (95 per cent c.i. 43.0 to 50.9) per cent. Four independent predictors of death were identified: age (odds ratio (OR) 1.05 (95 per cent c.i. 1.03 to 1.07) per year increase), Acute Physiology Score (OR 1.14 (95 per cent c.i. 1.12 to 1.17) per unit increase), emergency operation (OR 4.86 (95 per cent c.i. 3.64 to 6.52)) and chronic health dysfunction (OR 1.43 (95 per cent c.i. 1.04 to 1.97)). The APACHE-AAA model was internally valid, as shown by calibration (Hosmer-Lemeshow C statistic: chi(2) = 6.14, 8 d.f., P = 0.632), discrimination properties (area under receiver-operator characteristic curve 0.845) and subgroup analysis. There was no significant variation in outcome between hospitals. CONCLUSION: APACHE-AAA was shown to be an accurate risk-stratification model that could be used to quantify the risk of death after AAA surgery. It might also be used to determine the relative impact of ICU over high-dependency unit care.

Use of the blood transfusion service in total knee replacement arthroplasty. The cost implications.

In view of the rising costs of blood transfusion and reports of inappropriate transfusions an audit of the local practice was organised. The aim was to investigate whether blood transfusion in primary unilateral Total Knee replacement Arthroplasty (TKA) operations was being used inappropriately locally, the resultant cost implications and suggest ways of reducing these. A 1-year retrospective survey of blood transfusion practice was conducted for all consecutive elective, primary, unilateral TKA operations at a District-General Hospital. 169 operations were performed and 58 (34%) patients were transfused. A retrospective Haemoglobin concentration (Hb) analysis was performed for all the transfused patients to identify the number of transfusions that satisfied the suggested transfusion criteria of a threshold Hb of 8 g/dl and when indicated, a minimum transfusion of 2 units. Complete transfusion data was available on 49/58 (84%) patients transfused. When applying the above criteria to this sample, the potential annual saving for the department was estimated at approximately 8000 pounds Sterling; only 9 of these patients were deemed to be appropriately transfused.

A preventable cause of acute abdomen.

Haemoperitoneum is an extremely rare presentation of hepatocellular carcinoma in the industrialised world. We present the first reported case in the UK. In contrast, up to 10% of hepatocellular carcinomas in Africa present in this way, the median time between presentation and death being just six weeks. Hepatitis B infection at birth and during childhood is the major cause of hepatocellular carcinoma in the developing world. The World Health Organisation, UNICEF and the World Bank have all advocated routine hepatitis B vaccination of children. This can reduce the burden of disease in these communities, among people in their productive years of life.

Transfusion practice in primary unilateral total knee replacement arthroplasty; the need for guidelines.

BACKGROUND AND AIMS: There are no universally accepted guidelines for blood transfusion in primary, unilateral Total Knee Replacement Arthroplasty (TKA). Transfusion is associated with post-operative infection, fluid overload and prolonged duration of hospitalisation. Due to this morbidity and reports of "inappropriate" transfusion practice, an audit of the local practice was organised, with the aim of assessing compliance to existing evidence. METHODS: A 1-year retrospective survey of blood transfusion practice was conducted for all consecutive elective, primary, unilateral TKA operations. RESULTS: 169 operations were performed; 96% for osteoarthritis; mean patient age was 69 years; 66% were females; 34% of the patients were transfused, 60% intra-operatively. There was no threshold of pre-operative Hb predictive of a transfusion and no significant difference in the pre-operative Hb between transfused and non-transfused groups. Only 26% of the cross-matched blood was eventually transfused. Intra-operative blood loss was negligible and only 10% of transfused patients had shown cardiovascular instability. The post-operative Hb drop was maximal at around day-4. CONCLUSIONS: The lack of guidelines has led to inconsistent local transfusion practice, often with no scientific evidence to support it. In the absence of a randomised controlled trial addressing the issue, certain transfusion guidelines are suggested, based on existing indirect scientific evidence.

A comparison between different formats of educational feedback to junior doctors: a prospective pilot intervention study.

OBJECTIVES: Audit feedback is conventionally given in the format of an average performance of the department relative to established guidelines. The impersonality of this feedback format may compromise audit outcome. The aim of the study was to compare personal, peer-comparison feedback, an effective method of changing physician practice, to the 'conventional' departmental one. METHODS: Eleven SHOs working at a central London A&E department were audited in terms of the adequacy of their documentation process. The study comprised patients presenting with closed head injury, acute asthma and chest pain of possible cardiac origin. Personal peer-comparison feedback and average departmental feedback was given for the first two groups, respectively. No feedback was given for the chest pain group, acting as a temporal control. The outcome measure was documentation of the minimum variables, as specified by departmental guidelines. RESULTS: The peer-comparison feedback group showed a significant improvement (p-value<0.0001) in two out of three target variables audited, in contrast to the departmental feedback group and the control group which did not show a significant improvement in any of the variables. CONCLUSIONS: Personal, confidential peer-comparison feedback was more effective than departmental feedback, in an audit of process of junior doctors. This pilot study should form the basis of a larger study (more SHOs, wider range of conditions) to establish unequivocally the best format for educational feedback.