Living Donor in Renal Transplantation: Minimizing Risks.

In recent years, the broadening of indications for renal transplantation, together with the progressive reduction of donations following brain stem death, has led to living donation being considered in increasing numbers of cases for renal transplantation. To investigate this further, it is necessary to assess the impact it has on the postoperative outcomes in the intensive care unit (ICU). Our group conducted a retrospective, observational, single-center study from 2013 to 2016 to evaluate differences in outcomes between living and cadaveric kidney donation both during ICU admission and total hospitalization. We compared differences in characteristics between living and deceased graft recipients including demographics, comorbidities, analytical data, radioisotope imaging test results, complications, ICU and hospital ward length of stay, and mortality. In all, 387 patients were eligible for analysis, and 13% received living donor grafts. Our results demonstrate that this group had significantly fewer complications, shorter length of hospital stay, and reduced mortality in comparison with recipients of cadaveric donor grafts. The better postoperative outcomes from living donor grafts could result from careful selection of the donor and less inflammatory injury, minimizing risk in the postoperative period.

[Multiple sclerosis in Haute-Garonne: an important underestimation of case numbers]. / La SEP en Haute-Garonne : une sous-estimation importante du nombre de cas.

INTRODUCTION: In France, the prevalence of multiple sclerosis is estimated between 65 and 125 patients per 100,000 inhabitants with a South-West towards North-East gradient. Nevertheless, the epidemiology of multiple sclerosis remains still imperfectly known, the recent studies being realized, either in a region of France, or from a single data source and thus suscepted not to be exhaustive. OBJECTIVE: Assessing the prevalence of the multiple sclerosis in 2005 in Haute-Garonne by matching several data sources completed by a capture-recapture method; estimating the exhaustivity of each of the sources. METHODS: The data sources were hospital data (DRG for the hospitalization, data of consultation), data of public health insurance system (main health insurance, agricultural health insurance, social welfare for self employed), and data from the MIPSEP network. The linkage was based on name, maiden name, first name, date of birth and sex and allowed a first estimation of the number of cases. Models of loglinear regression allowed estimating the total number of case and the sensitivity of each source. RESULTS: The total number of cases obtained by matching several sources of information amounted to 1549. The use of several data sources increased by 25.6 % the maximum number of patients identified with a single source of information (national health insurance, any insurance). According to the model used, the method of capture-recapture estimated the number of cases up to 1722. Therefore, this study estimated a prevalence of multiple sclerosis between 110 and 149 cases per 100,000 inhabitants in Haute-Garonne. CONCLUSION: The prevalence of the multiple sclerosis is largely underestimated in Haute-Garonne and questions the magnitude over the so-called gradient. Matching several sources of information is indispensable to improve collection of the total number of cases.

Anaesthesia for phaeochromocytoma and sickle cell disease in pregnancy.

A 33-year-old woman (G(1)P(0)) presented to a maternity hospital at 36 weeks' gestation. She suffered from sickle cell disease with three acute crises in the previous five months of her pregnancy. She also had a phaeochromocytoma with inadequately controlled hypertension. This report describes the multi-disciplinary work-up and peri-operative management necessary to optimise her medical condition before caesarean section at 39 weeks' gestation and subsequent removal of a malignant phaeochromocytoma.

Locked-in syndrome: a catastrophic complication after surgery.

We describe the locked-in syndrome in a 31-yr-old patient after right upper lobectomy for suspected metastasis. After surgery, vertical eye movement was her only means of communication. She remained in a 'locked-in' state for 7 months before dying. Post-mortem examination showed extensive metastatic tumour deposition in the ventral pons. We discuss the clinical features of this syndrome and factors that may affect onset, diagnosis and management.

Desflurane, compared to halothane, augments phenylephrine-induced contraction in isolated rat aorta smooth muscle.

PURPOSE: The mechanism responsible for the mediation of hypertension in response to increased desflurane levels is unclear. This study compared the effect of desflurane and halothane on phenylephrine (PE)-induced contraction in rat aorta ring and the effect of desflurane in the presence and absence of nitric oxide (NO) synthase activity. METHODS: Endothelium-free rat aorta rings were exposed serially to 10(-7) M, 10(-6) M and 10(-5) M PE alone and subsequently in the presence of 2 MAC desflurane and halothane. Secondly, endothelium-free preparations were exposed to 10(-6) M PE serially in the presence of 0, 1, 2 and 3 MAC desflurane and halothane. Thirdly, using an endothelium-intact preparation, the effect of desflurane on PE-induced contraction was examined, in the presence or absence of NG-nitro-L-arginine (L-NNA), an inhibitor of constitutive and inducible NO synthase. RESULTS: Contraction amplitudes secondary to 10(-6) and 10(-5) M PE in endothelium-free preparations were increased by 74% and 36% respectively (P <0.05) in the presence of 2 MAC desflurane compared to controls. In endothelium-free preparations, contraction amplitudes secondary to 10(-6) M PE were increased in the presence of 1 and 2 MAC desflurane by 32% and 18% respectively (P <0.05) and reduced by 16% in the presence of 3 MAC halothane (P <0.05). In endothelium-intact preparations an expected absolute increase in contraction amplitude occurred in the presence of L-NNA but the desflurane effect was detectable both in the presence and absence of L-NNA. CONCLUSION: Our results suggest that desflurane may have a local vasoconstrictive effect independent of endothelium and NO synthase activity. The mechanism remains to be determined.

The effects of intracuff lidocaine on endotracheal-tube-induced emergence phenomena after general anesthesia.

UNLABELLED: Coughing during emergence from general anesthesia is a common clinical problem. We sought to determine whether inflating the endotracheal tube cuff with lidocaine would create a reservoir of local anesthetic, which might diffuse across the cuff membrane to anesthetize the mucosa, thus attenuating stimulation during extubation of the trachea. A total of 63 patients undergoing elective surgery were enrolled in a prospective, randomized, double-blinded study. After intubation of the trachea with an endotracheal tube, the cuff of the tube was inflated with either lidocaine 4%, saline, or air. After extubation, a blinded observer noted heart rate, blood pressure, oxygen saturation, end-tidal isoflurane concentration, and the incidence of coughing. Data were analyzed by using analysis of variance, Student's t-test, and the chi(2) test for multiple variables. The groups were demographically comparable. There was no difference in hemodynamic or oxygen saturation data between either group. The incidence of coughing was decreased in the lidocaine group for the time period of 4-8 min postextubation (P < 0.05). We conclude that inflation of the cuff of the endotracheal tube can reduce the incidence of coughing in the initial postextubation period, a finding that may benefit certain patient groups in which this is particularly desirable. IMPLICATIONS: Tracheal intubation with an endotracheal tube is often necessary during anesthesia. After intubation, inflating a cuff around the endotracheal tube maintains a seal. This can result in coughing during emergence from anesthesia. Our study shows that inflating the cuff of an endotracheal tube with lidocaine rather than air can reduce the incidence of postextubation coughing.

Intrathecal narcotics in cancer pain--a case report.

A 61 year old female patient presented with metastatic bone pain three years post mastectomy. Standard oral analgesics and epidural morphine were ineffective in achieving pain control. Her pain was eventually controlled with morphine sulphate 48 mg daily via a self administered intrathecal pump. These devices are being used with increasing frequency and this case report highlights some of the problems encountered in this patient's management.

Cataract surgery.

1. The eye is made up of three layers: the retina, uveal tract, and sclera, which is continuous with the cornea. 2. Drugs are used during surgery to achieve specific effects. Nonsteroidal anti-inflammatory drugs reduce irritation and maintain the dilation effect of cycloplegics and mydriatics. Viscoelastic substances protect the nonregenerative endothelial cells. 3. The risks involved with cataract surgery include hemorrhage in the anterior chamber, a tear in the posterior capsule, and damage to the endothelial cells and retina.

Diuretics after transurethral prostatectomy: a double-blind controlled trial comparing frusemide and mannitol.

Mannitol and frusemide were compared in a randomized, controlled, double-blind trial for their effects in promoting diuresis after prostatectomy and on indices of water intoxication. The drugs had comparable diuretic effects. Sodium loss was greater with frusemide, contributing to sodium depletion after operation. Administration of frusemide was associated with more frequent need for i.v. volume expansion after operation. Plasma osmolality was greater with mannitol (289 (SD 4.2 mosmol kg-1 at 1 h after operation and 285 (5.3) mosmol kg-1 at 4 h after operation) than with frusemide (282 (7.1) mosmol kg-1 and 279 (6.7) mosmol kg-1, respectively) (P less than 0.05). Plasma concentration of sodium was significantly greater with mannitol (136.9 (3.1) mmol litre-1) than with frusemide (134.4 (2.8) mmol litre-1) only on the morning after surgery (P less than 0.05). Mannitol is an effective alternative to frusemide in inducing diuresis after prostatectomy, and may protect against water intoxication.

Corticosteroids decrease airway hyperresponsiveness in the Basenji-Greyhound dog model of asthma.

Methacholine and citric acid responses were assessed before, during, and after 6 wk of oral treatment with either placebo or methylprednisolone (2 mg.kg-1.day-1) in 12 Basenji-Greyhound dogs. Bronchoalveolar lavage was performed in three dogs in each group before, during, and after pretreatment. Base-line airway resistance and dynamic compliance did not change with treatment in any of the groups. Placebo treatment had no demonstrable effect on methacholine and citric acid responsiveness. Methylprednisolone treatment abolished the constrictor response to citric acid during the 4th and 6th wk of treatment and significantly reduced methacholine responsiveness during the 3rd and 5th wk of treatment. Methylprednisolone treatment was associated with a marked reduction in the percent of eosinophils, but not mast cells, in the bronchoalveolar lavage fluid during the 7th wk. Blood eosinophil counts were also markedly reduced in the methylprednisolone-treated group compared with the placebo-treated group during the 7th wk. The decrease in numbers of eosinophils in blood and bronchoalveolar lavage fluid suggests interference with the inflammatory process as a possible mechanism for the observed reduction in airway hyperresponsiveness in the Basenji-Greyhound dog.

Ethnic differences in seclusion and restraint.

Data on seclusions or restraints were analyzed by ethnic group for 587 patients in 19 New York State psychiatric hospitals for a 4-week period. No differences among White, Black, or Hispanic patients were found for sex; type of ward where episode occurred; frequency of, length of, or reason for confinement; or the administration of medication as needed. The groups did differ in age, diagnosis, and target of their assaults. When analyzed by age groups, minority patients were not overrepresented in the secluded/restrained sample. Age was the most important variable to account for ethnic differences in confinement.

Visual evoked potentials and changes in serum glycine concentration during transurethral resection of the prostate.

Visual evoked potentials were recorded in 10 patients undergoing transurethral prostatectomy under subarachnoid anaesthesia. They were compared with those obtained in a control group (n = 5) having other operative procedures also under spinal anaesthesia. Serum concentrations of glycine, ammonia, glucose and sodium, and osmolality, were determined during the perioperative period. The prostatectomy group demonstrated a significant prolongation of visual evoked potential P2 latency in the postoperative period when compared with preoperative values (P less than 0.01). No significant changes in latency occurred in the control group when measured at similar times. The prostatectomy group demonstrated a significant increase in serum glycine concentration (P less than 0.01); changes in serum ammonia and sodium concentrations and osmolality were not significant. There was no correlation between visual evoked potential latency and changes in serum glycine concentration. Changes in visual evoked potential during transurethral prostatectomy may be the result of an accumulation of a metabolite of glycine.

Variations in seclusion and restraint practices by hospital location.

Data from a survey of seclusion and restraint practices in New York state hospitals were analyzed to determine if they differed by hospital location. The study included 19 hospitals--five in New York City, four in New York City suburbs, three in large towns, and seven in small towns. Overall, New York City and large-town hospitals had the highest rates of seclusion and restraint, but analysis by age group showed that New York City had the lowest rate for patients under age 35, who constituted the majority of patients who were secluded or restrained, and large towns had the highest rate. Compared with suburban and small-town hospitals, city and large-town hospitals used seclusion more often than restraint and had a higher ward census and a lower-staff patient ratio. In all groups males and blacks were overrepresented compared with the hospital population. The authors believe clarification of regional variations in assaultive behavior is important for treatment and system planning.

Aspiration pneumonia and coma--an unusual presentation of dystrophic myotonia.

A 30-year-old female patient presented in a comatose state with clinical and radiographic signs of aspiration pneumonia 16 hours following elective surgery. Subsequent clinical assessment and investigations revealed the characteristic facies, proximal muscle weakness, lenticular opacities, pulmonary function defects, arterial desaturation and abnormal breathing during rapid eye movement (REM) sleep often associated with myotonia dystrophica. Although these characteristic features were evident on clinical examination postoperatively they were not noted in the preoperative assessment. The aspiration pneumonia and coma were unusual presenting features of this disease. Unsuspected myotonia dystrophica should be considered in the differential diagnosis of unexplained respiratory depression, aspiration or comatose state following surgery. Recognition of the disorder during the preoperative assessment is the key to avoiding complications during the perioperative management of such patients.

Isoflurane in paediatric anaesthesia. Induction and recovery from anaesthesia.

The characteristics of induction with and recovery from isoflurane anaesthesia were studied in 248 children. The mean time to loss of consciousness was 1.5 min (SD 0.5). Tracheal intubation, without interruption of spontaneous ventilation, was accomplished in a mean time of 4.2 min (SD 54 seconds). Movement and excitement, of 20-30 seconds duration, occurred in 23.9% children and 22 patients coughed during induction; 15 (12.6%) during the first 124 inductions; 7 (5.6%) subsequently. The mean half-times of reduction of alveolar isoflurane concentrations in 28 children whose lungs were ventilated with isoflurane and in 13 children who breathed isoflurane spontaneously during anaesthesia were: 45 sec after exposure for one hour, 70 sec after exposure of 2-3 hours and 110 seconds following exposures of 4-8 hours. The mean recovery times of the three groups were 6.5, 9.5 and 11.5 min respectively. In two further groups of nine children the mean half times of elimination of halothane and isoflurane were 220 seconds and 54 seconds respectively; recovery from isoflurane was markedly faster. Isoflurane is well accepted by children; induction is more rapid than with halothane, and the marked flexibility in the control of its effects are due to its relative insolubility. It has wide application in paediatric anaesthesia.