Partial Aneurysmectomy of Venous Aneurysms in Arteriovenous Dialysis Fistulas.

Upper extremity native arteriovenous fistulas (AVFs) continue to be the standard of care for hemodialysis patient's access. Although autogenous fistulas are superior to catheters and synthetic grafts, they are not without their own complications. One complication is venous aneurysms that can lead to skin erosion, bleeding, and site loss. Although traditionally repaired with ligation, interposition grafts, or stent placement, in this article, we discuss our experience with aneurysmorrhaphy utilizing a thoracoabdominal (TA) stapler. Thirteen aneurysms were treated with the TA stapler at a single, nonuniversity hospital for all patients from 2012 to 2014. The average aneurysm diameter was 3.6 cm, and the average fistula age was 57.9 months. There were no bleeding complications or recurrences. The primary patency was 80% at 6 months, with a primary assisted patency of 90% during the same time frame. Aneurysmorrhaphy with the TA stapler appears to be a safe and viable option for the treatment of venous aneurysms associated with AVFs.

Retroperitoneoscopic left upper moiety heminephroureterectomy for dribbling incontinence.

A 7-year-old girl underwent a prone, retroperitoneoscopic left upper moiety heminephroureterectomy for a non-functioning upper moiety associated with a dilated, ectopic ureter. The dilated ureter was noted prenatally, but postnatal investigations failed to demonstrate the duplex system. The child remained asymptomatic until she represented at 6 years of age, with dribbling of urine. She went on to have an ultrasound scan, dimercaptosuccinic acid and magnetic resonance urogram, which identified a grossly-dilated fluid-filled structure in proximity of the left kidney, but failed to demonstrate the small non-functioning left upper moiety. A computed tomography urogram was more helpful in establishing the diagnosis. Retroperitoneoscopy via three 5-mm ports allowed clear visualisation of both the left duplex ureters, as well as the small non-functioning upper moiety, which had been challenging on the pre-operative imaging. The procedure is described in the accompanying video. The child was discharged home the following day and has been completely well and dry at 6 months' follow-up.

The first 5-year follow up of distal antegrade continence enema stomas.

AIM: We investigated 5-year results of distal sites for antegrade continence enemas (DACE). METHODS: Patients with DACE sites placed more than 5 years previously were identified. Details of procedures were obtained. Parents, and patients over 18, were telephoned and asked to answer a standardised questionnaire. RESULTS: 31 patients were identified. Median age at DACE placement was 7 years (range 3-20). Median follow up was 92 months (range 66-145). 22 tubes were placed endoscopically, 7 were placed at open surgery and 2 at laparoscopic surgery. 28 responses to the telephone questionnaire were obtained. Of these, 15 were still using their DACE and 13 had stopped. Of those who had ceased washouts: 7 reported resolution of symptoms, 4 had a colostomy, 1 an ileostomy and 1 patient had abandoned their DACE. In patients using their stoma, washouts took a median of 5 min, with a median time to result of 25 min. 10 patients reported no soiling, 4 monthly and 1 daily soiling. Median satisfaction score was 8/10 (range 1-10/10). 24 (85%) said that they would recommend a DACE. CONCLUSIONS: This is the first report of 5-year follow up of a series of patients performing DACE washouts. The results are encouraging.

Search for light dark matter in XENON10 data.

We report results of a search for light (≲10 GeV) particle dark matter with the XENON10 detector. The event trigger was sensitive to a single electron, with the analysis threshold of 5 electrons corresponding to 1.4 keV nuclear recoil energy. Considering spin-independent dark matter-nucleon scattering, we exclude cross sections σ(n)>7×10(-42) cm(2), for a dark matter particle mass m(χ)=7 GeV. We find that our data strongly constrain recent elastic dark matter interpretations of excess low-energy events observed by CoGeNT and CRESST-II, as well as the DAMA annual modulation signal.

Ritual circumcision: no longer a problem for health services in the British Isles.

INTRODUCTION: Primary care trust (PCT) funding of a ritual circumcision service has recently been withdrawn from our unit, raising concerns that this may result in greater morbidity from community circumcision. The aims of this study were to document our circumcision practice before and after the withdrawal of PCT funding and to determine its effect on the morbidity from circumcision. In addition, we wanted to survey all paediatric surgical centres in the British Isles to ascertain how many still offer a ritual circumcision service. PATIENTS AND METHODS: We retrospectively reviewed our circumcision practice for 1 year prior to the removal of UK Government funding, and then performed a prospective audit of our practice for the 12 months following funding withdrawal. An e-mail survey was also performed of all paediatric surgical units to determine the ritual circumcision service provision throughout the British Isles. RESULTS: A total of 213 boys underwent circumcision during the 12 months prior to the withdrawal of funding, of which 106 cases (50%) were ritual circumcisions. After funding withdrawal, 99 boys underwent circumcision, of which 98 cases (99%) were for medical reasons. A similar number of boys were re-admitted after a hospital circumcision during the two review periods (5 versus 4 patients), whereas the number admitted following a community circumcision rose after funding withdrawal (6 versus 11 patients). Only a third of British paediatric surgical centres offer a ritual circumcision service, and a significant pro- portion of these were either providing the service without PCT funding, or were reconsidering their decision to continue. CONCLUSIONS: PCT funding withdrawal for ritual circumcision had an impact on our unit's procedural case volume. This represented a cost saving to the trust, despite a higher rate of admissions for postoperative complications. There is an inequality in healthcare provision throughout the British Isles for ritual circumcision, and we feel it is vital to offer support and training to medical and non-medical practitioners who are being asked to perform a greater number of circumcisions in the community.

Limits on spin-dependent WIMP-nucleon cross sections from the XENON10 experiment.

XENON10 is an experiment to directly detect weakly interacting massive particles (WIMPs), which may comprise the bulk of the nonbaryonic dark matter in our Universe. We report new results for spin-dependent WIMP-nucleon interactions with 129Xe and 131Xe from 58.6 live days of operation at the Laboratori Nazionali del Gran Sasso. Based on the nonobservation of a WIMP signal in 5.4 kg of fiducial liquid xenon mass, we exclude previously unexplored regions in the theoretically allowed parameter space for neutralinos. We also exclude a heavy Majorana neutrino with a mass in the range of approximately 10 GeV/c2-2 TeV/c2 as a dark matter candidate under standard assumptions for its density and distribution in the galactic halo.

First results from the XENON10 dark matter experiment at the Gran Sasso National Laboratory.

The XENON10 experiment at the Gran Sasso National Laboratory uses a 15 kg xenon dual phase time projection chamber to search for dark matter weakly interacting massive particles (WIMPs). The detector measures simultaneously the scintillation and the ionization produced by radiation in pure liquid xenon to discriminate signal from background down to 4.5 keV nuclear-recoil energy. A blind analysis of 58.6 live days of data, acquired between October 6, 2006, and February 14, 2007, and using a fiducial mass of 5.4 kg, excludes previously unexplored parameter space, setting a new 90% C.L. upper limit for the WIMP-nucleon spin-independent cross section of 8.8x10(-44) cm2 for a WIMP mass of 100 GeV/c2, and 4.5x10(-44) cm2 for a WIMP mass of 30 GeV/c2. This result further constrains predictions of supersymmetric models.

On-pump vs. off-pump coronary artery bypass surgery at a non-academic community hospital: have biocompatibility improvements eliminated the superiority of off-pump surgery?

OBJECTIVES: Standard coronary artery bypass grafting (CABG) surgery involves cardiopulmonary bypass (CPB) but given concerns over neurological and inflammatory complications related to CPB, many patients receive so-called off-pump procedures (OPCABG). Our objective is to determine if the recent improvements in the biocompatibility of CPB circuitry have improved post-operative outcomes at the community hospital level, particularly in terms of hospital length of stay (LOS), stroke and post-operative infection. METHODS: We analyzed hospital LOS, incidence of stroke, infection, and mortality along with several clinical variables in 209 patients (38% underwent OPCABG) at a single, non academic community hospital. We constructed a series of forward, stepwise, multiple-variable regression models using mediastinal infection, hospital LOS, and stroke as dependant variables. RESULTS: OPCABG was associated with a shorter median hospital LOS (3 days vs. 4 days; p=0.0001) and a reduced occurrence of stroke (0% vs. 7.6%; p=0.03). However, mediastinal infections occurred more commonly in OPCABG cases (10% vs. 2.2%; p=0.02). CABG and pre-existing renal disease were predictors of increased hospital LOS (p< 0.0001) whereas CABG was the only factor associated with decreased risk of mediastinal infection (OR=0.21 (0.05-0.80); p=0.02). CONCLUSIONS: At the community level, OPCABG appears to be superior in terms of LOS and incidence of stroke. Paradoxically, CABG surgery demonstrates a reduced rate of mediastinal infection.

Kissing naevus of the penis.

Divided or 'kissing' naevus was first described on the eyelids in 1908. Other types of divided naevus reported include naevus spilus on the eyelids, mast cell naevus and epidermal naevus in a divided form on the fingers. Six cases of kissing naevus of the penis appear in the literature. In this paper, we discuss a seventh case.

Incarcerated inguinal hernia in premature babies--a report of two cases.

UNLABELLED: We highlight the morbidity of incarcerated inguinal hernia in very low birthweight (VLBW) infants by presenting a report of two cases. Our aim is to raise the question of the optimal timing of surgery when this common problem presents on the neonatal unit. In each of our cases the hernia was diagnosed but surgery was delayed, as per normal policy on the unit, pending growth of the baby and improvement in respiratory status. Both babies suffered significant morbidity when the hernias subsequently became acutely incarcerated. CONCLUSION: In conclusion, we question whether the widespread practice of delayed surgery for inguinal hernia in VLBW infants should be reconsidered.

Analysis of broadband x-ray spectra of highly charged krypton from a microcalorimeter detector of an electron-beam ion trap.

Spectra of highly charged Kr ions, produced in an electron-beam ion trap (EBIT), have been recorded in a broad x-ray energy band (0.3 keV to 4 keV) with a microcalorimeter detector. Most of the spectral lines have been identified as transitions of B- to Al-like Kr. The transition energies have been determined with 0.2% uncertainty. A semi-empirical EBIT plasma model has been created to calculate a synthetic spectrum of highly charged Kr and to determine a charge state distribution of Kr ions inside the EBIT.

Simple incision: a safe and definitive procedure for congenital duodenal diaphragm.

BACKGROUND: Duodenal diaphragms generally are treated by either a duodeno-duodenostomy or excision. The former is a bypass procedure that involves a major anastomosis with its inherent postoperative problems, whereas the latter may result in inadvertent damage to the biliary and pancreatic ducts. To circumvent these problems, the authors used the technique of incision of the diaphragm on its lateral aspect. METHODS: Medical records of five children who underwent surgery for a perforate duodenal diaphragm during the period of 1992 through 1994 were reviewed retrospectively. All patients underwent a similar procedure. A longitudinal duodenotomy was made and the diaphragm incised on its anterolateral aspect. The cut edges of the diaphragm were oversewn, and the duodenotomy closed in "Heineke-Mikulicz" fashion. RESULTS: At a follow-up ranging from 1 to 3 years, all patients are growing normally and remain free of any obstructive symptoms. CONCLUSIONS: This simplified approach is a safe and physiological way of restoring the duodenal continuity and is associated with a highly satisfactory outcome.

A wandering nasal prong-a thing of risks and problems.

We describe an unusual complication of nasal continuous positive airway pressure (nCPAP) ventilation in a preterm low birth weight neonate being weaned from respiratory support. The tube used to administer nasal CPAP became dislodged from its metal connector whilst in the nasopharynx and slipped into the stomach. After waiting eight days the tube showed no signs of passing spontaneously through the gastrointestinal tract and retrieval was then successfully achieved by means of a 3.5 mm paediatric fibreoptic bronchoscope without complication.

Is delayed surgery really better for congenital diaphragmatic hernia?: a prospective randomized clinical trial.

Delayed surgery has become widely accepted in the management of congenital diaphragmatic hernia after comparing outcomes only with historical retrospective controls. It was the aim of this study to compare early and delayed hernia repair in a randomized prospective clinical trial. Fifty-four infants were randomized to receive either early repair (within 4 hours of admission) or delayed repair (more than 24 hours after birth). The survival rate was higher for the delayed group (57% v 46%), but the difference was not significant (difference: -11; 95% confidence limits: -37.5, 15.5). There were no significant differences between the two groups with respect to length of hospital stay, ventilator dependency, or survival time. Recorded preoperative risk factors were similar for the two groups. Eight infants in the delayed repair group died without having undergone surgery. The optimum time for surgery still needs clarification.

Anaesthesia and juvenile hyaline fibromatosis.

Juvenile hyaline fibromatosis is a rare autosomal recessive disease characterized by large cutaneous nodules, especially around the head and neck and often involving the lips. The effects become increasingly severe with age and also include joint contractures, gingival hypertrophy and osteolytic lesions. We describe the anaesthetic management of two sisters with this disease. Safe maintenance of a patent airway is the principal anaesthetic challenge.

Oronasopharyngeal teratomas.

Oronasopharyngeal teratomas are rare tumours that usually present in the neonatal period with airway obstruction. Management should include prompt establishment of the airway and early excision. Complete excision is recommended, which may require more than one operation, but multilating surgery should be avoided as the malignant potential of these tumours is extremely low. We describe our experience with three patients along with a literature review.

Mild dilatation of the fetal kidney: a follow-up study.

OBJECTIVE: To assess morbidity in children with mild prenatally detected pelvicalyceal dilatation and to document the natural history of this ultrasound finding in post-natal life. PATIENTS AND METHODS: A retrospective (on-going) study was carried out in 29 children (39 kidneys) with mild dilatation confined to the pelvis and/or calices confirmed on initial post-natal ultrasound scan. Re-evaluation was carried out at a mean age of 4.2 years (range 1.5-7.8). Clinically, each patient's history, height, weight and blood pressure were recorded. On ultrasound examination the renal length, collecting system appearances and dimensions were recorded. RESULTS: Vesico-ureteric reflux was demonstrated in 1 of 14 infants who underwent neonatal micturating cystourethrography. During cumulative follow-up totaling 122 years, there were only two documented episodes of urological morbidity, i.e. one episode of unexplained haematuria and one of urinary tract infection. By a mean age of 4.2 years the ultrasound appearances had reverted to normal in 69% of kidneys. In 31% dilatation persisted and was unchanged or diminished in severity. No case of increasing dilatation was seen. Renal growth was normal in 97% of kidneys. CONCLUSIONS: Mild dilatation of the fetal urinary tract is a common prenatal ultrasound finding. When confined to the renal pelvis and/or calices it is of doubtful clinical significance and is associated with a low level of morbidity in infancy and early childhood. Invasive investigation in post-natal life is not justified.

Systemic reactions to immunotherapy.

Systemic anaphylactic reactions occur in a small percentage of patients receiving allergen immunotherapy. A 1 year study was performed in a large health maintenance organization to determine the incidence of systemic reactions (SR) to allergen immunotherapy. We measured the number of SR that occurred during a 12 months period. A SR data sheet was completed for each reaction, documenting the time of onset, symptoms, treatment, history of asthma or previous reaction, and concentration and type of extract. Twenty-seven thousand eight hundred six injection visits resulted in 143 SR (0.51%). Forty-five percent of the patients (pts) with SR had a history of prior SR, 50% had a history of asthma, and 36% developed reactions in season. Seventy-two percent of SR started within 30 minutes, although 8% appeared after 2 hours. Fifty-seven percent of SR occurred at concentrations of 1,000-10,000 PNU/cc, 25% at 10-100 PNU/cc, and 17% when both concentrations were given at the same visit. Eighty-three percent of SR were judged to be mild, nonlife threatening reactions, requiring no treatment or antihistamine therapy only. Seventeen percent were judged to be more severe, requiring treatment with epinephrine, with or without other agents. SR are a small but definite risk of immunotherapy. Most SR are mild, but some may be life threatening. The majority of reactions occur within 30 minutes, but significant reactions may occur after 2 hours. A large percentage of SR occurred in patients with a history of asthma, previous SR, or both.

Catheterization of posterior tibial artery leading to limb amputation.

A cannula inserted into the posterior tibial artery of a preterm infant resulted in irreversible ischaemia of the foot with proximal extension to involve the lower leg. No predisposition to thrombosis was found and a below-knee amputation was ultimately required.