Utilization of the Iliac Artery as Inflow in the Morbidly Obese During Orthotopic Liver Transplantation: A Case Report.

Arterial conduits are a well-recognized technique used in liver transplantation to achieve allograft arterial inflow when conventional hepatic arterial inflow is compromised. Indications for ectopic inflow include native arterial disease at the time of initial transplantation, as well as reconstruction in the setting of thrombotic complications. Although supraceliac or infrarenal aortic reconstructions are preferred approaches, the right common iliac artery represents a viable alternative. We present the case of a morbidly obese patient with occlusive atheromatous plaque at the celiac origin not amenable to preoperative angioplasty who underwent reconstruction with a donor iliac artery conduit to the recipient right common iliac artery. His hepatic arterial inflow remained patent postoperatively with no thrombotic or hemorrhagic complications.

Prediction of medication non-adherence and associated outcomes in pediatric kidney transplant recipients.

Studies have continued to evaluate risk factors associated with post-transplant non-adherence in pediatric patients. However, many of these studies fail to evaluate how risk factors can be utilized to predict MNA. The aims of this study were to (i) determine salient risk factors associated with MNA to develop an adequate predictive risk model and (ii) assess transplant outcomes based on the presence of MNA in a large, diverse cohort of pediatric KTX recipients. One hundred and seventy-five solitary pediatric KTX recipients transplanted from 1999 to 2013 were included. AA, males, older patients, those who lived in urban environments, had legal issues, and lived shorter distances from the transplant center were more likely to have MNA. Using logistic regression, a parsimonious model applying nine risk factors together was developed for predicting MNA, demonstrating a PPV of 69% and a NPV of 81%. Patients with MNA had more than twice the risk of biopsy proven acute rejection, 1.6 times the risk of hospitalization, and 1.8 times the risk of graft loss. Utilization of a predictive model to determine risk of MNA after pediatric KTX may offer clinicians the ability to efficiently and effectively monitor MNA following transplant.

Clinical outcomes and costs associated with in-hospital biliary complications after liver transplantation: a cross-sectional analysis.

INTRODUCTION: In-hospital biliary complications (BCs) after liver transplantation (LT) are reported in up to 20 % of patients and contribute to poor outcomes and increased costs. Existing single-center outcome and cost analyses studies are limited in scope. METHODS: This is a cross-sectional analysis of national data involving 7,967 patients transplanted between 2011 and 2012 with the primary aim of determining the association between BCs and clinical outcomes and costs. Age, race, diagnosis, and severity of illness are associated with the development of BCs. RESULTS: BCs develop in 14.6 % of LT recipients and have substantial implications for perioperative outcomes, including length of hospital and ICU stay (27.9 vs 19.6 mean days, p < 0.001 and 12.0 vs 8.3 mean days, p < 0.001, respectively), in-hospital morbidity (39 vs 27 %, p < 0.001), 30-day readmissions (14.8 vs 11.2 %, p < 0.001), and in-hospital mortality (5.8 vs 4.0 %, p < 0.001). BCs contributed to a mean increase in in-hospital costs of $36,212 (p < 0.001), due to increases in accommodations ($9,539, p < 0.001), surgical services ($3,988, p < 0.001), and pharmacy services ($8,445, p < 0.001). DISCUSSION: BCs are a predominant etiology for in-hospital morbidity and mortality, while contributing significantly to the high cost of LT. Efforts should be focused on understanding salient and modifiable risk factors, while developing innovative strategies to reduce BCs.

Effects of an outdoor bicycle-based intervention in healthy rural Indian men with normal and low birth weight.

Physical inactivity and low birth weight (LBW) may lead to an increased risk for developing type 2 diabetes. The extent to which LBW individuals may benefit from physical exercise training when compared with those with normal birth weight (NBW) controls is uncertain. We assessed the impact of an outdoor exercise intervention on body composition, insulin secretion and action in young men born with LBW and NBW in rural India. A total of 61 LBW and 56 NBW healthy young men were recruited into the study. The individuals were instructed to perform outdoor bicycle exercise training for 45 min every day. Fasting blood samples, intravenous glucose tolerance tests and bioimpedance body composition assessment were carried out. Physical activity was measured using combined accelerometry and heart rate monitoring during the first and the last week of the intervention. Following the exercise intervention, the LBW group displayed an increase in physical fitness [55.0 ml (O2)/kg min (52.0-58.0)-57.5 ml (O2)/kg min (54.4-60.5)] level and total fat-free mass [10.9% (8.0-13.4)-11.4% (8.0-14.6)], as well as a corresponding decline in the ratio of total fat mass/fat-free mass. In contrast, an increase in total fat percentage as well as total fat mass was observed in the NBW group. After intervention, fasting plasma insulin levels, homoeostasis model assessments (HOMA) of insulin resistance (HOMA-IR) and insulin secretion (HOMA-IS), improved to the same extent in both the groups. In summary, young men born with LBW in rural India benefit metabolically from exercise training to an extent comparable with NBW controls.

Low-dose rapamycin treatment increases the ability of human regulatory T cells to inhibit transplant arteriosclerosis in vivo.

Regulatory T cells (T(reg)) are currently being tested in clinical trials as a potential therapy in cell and solid organ transplantation. The immunosuppressive drug rapamycin has been shown to preferentially promote T(reg) expansion. Here, we hypothesized that adjunctive rapamycin therapy might potentiate the ability of ex vivo expanded human T(reg) to inhibit vascular allograft rejection in a humanized mouse model of arterial transplantation. We studied the influence of combined treatment with low-dose rapamycin and subtherapeutic T(reg) numbers on the development of transplant arteriosclerosis (TA) in human arterial grafts transplanted into immunodeficient BALB/cRag2(-/-) Il2rg(-/-) mice reconstituted with allogeneic human peripheral blood mononuclear cell. In addition, we assessed the effects of the treatment on the proliferation and apoptosis of naïve/effector T cells. The combined therapy efficiently suppressed T-cell proliferation in vivo and in vitro. Neointima formation in the human arterial allografts was potently inhibited compared with each treatment alone. Interestingly, CD4(+) but not CD8(+) T lymphocytes were sensitive to T(reg) and rapamycin-induced apoptosis in vitro. Our data support the concept that rapamycin can be used as an adjunctive therapy to improve efficacy of T(reg)-based immunosuppressive protocols in clinical practice. By inhibiting TA, T(reg) and rapamycin may prevent chronic transplant dysfunction and improve long-term allograft survival.

A variant epidemic methicillin resistant Staphylococcus aureus-15 cavernous sinus thrombosis and meningitis: a rare occurrence with unusual presentation.

Septic cavernous sinus thrombosis (CST) is an uncommon clinical syndrome. Although Staphylococcus aureus (S aureus) is the most common bacterial pathogen causing CST, it is infrequent as a cause of meningitis. We report the first case of CST and meningitis from Bengaluru, Karnataka, caused by community-acquired epidemic methicillin resistant Staphylococcus aureus-15 (EMRSA-15), in a previously healthy individual without known risk factors; the patient recovered following treatment with vancomycin. The isolate was genotyped as belonging to staphylococcal cassette chromosome mec type IV and sequence type 22 and carried the panton-valentine leucocidin gene. It is the first Indian EMRSA-15 disease isolate from a case of meningitis. EMRSA-15 has been a major problem in hospitals in UK and it is a cause for great concern in Indian hospitals too.

Foreign body sensation in the throat due to displacement of the superior cornu of the thyroid cartilage: two cases and a literature review.

The sensation of a foreign body in the throat when swallowing is a common and very discomforting symptom for those who experience it. Common causes are gastroesophageal reflux disease and possibly upper oesophageal dysmotility. This complaint may be dismissed as psychogenic when a cause for the problem is not readily apparent. We present two cases in which the patient had a foreign body sensation in the throat, associated with a dry swallow. The most helpful diagnostic procedure was careful examination of the hypopharynx and neck and flexible fibre-optic rhinolaryngoscopy. One case was treated with surgery of the neck and larynx to trim the medially projecting superior cornu of the thyroid cartilage. Surgery was successful in eliminating the symptoms. Although an uncommon finding, our experience is that symptoms due to a medially displaced thyroid cornu should be considered in the differential diagnosis as an important and surgically correctable cause of persistent foreign body sensation at the hyoid level in the neck.

A blinded in-vitro study to compare the efficacy of five topical ear drops in clearing grommets blocked with thick middle ear effusion fluid.

OBJECTIVE: To compare the efficacy of 5% NaHCO3, 3% H2O2, Sofradex (dexamethasone sodium metasulphobenzoate 0.05%, framycetin sulphate 0.5%, gramicidin 0.005%), 0.33% acetic acid and 0.9% NaCl eardrops in clearing grommets blocked with harvested thick middle ear effusion fluid. STUDY DESIGN: A blinded in-vitro study. SETTING: District general hospital. PARTICIPANTS: A total of 473 grommets were blocked with freshly harvested unpooled thick middle ear effusion fluid obtained from 68 patients. MAIN OUTCOME MEASURES: Patency of the grommets before and 7 days after intervention was ascertained by tympanometry and close visual inspection. RESULTS: Instillation of eardrops leads to a statistically significant increase in the clearance of grommets as compared with not using any drops (chi2 = 14.3, d.f. = 5, P = 0.006). The numbers needed to treat were 2.8 for NaHCO3, 3.2 for 0.9% NaCl, 3.9 for 0.33% acetic Acid, 4.4 for Sofradex and 9.5 for H2O2 eardrops. Pair-wise comparison was only significant for comparison between 5% NaHCO3 and 3% H2O2 eardrops (Bonferroni corrected P = 0.01, odds ratio = 4.3, CI = 1.9-9.9). CONCLUSIONS: Use of eardrops leads to a clinically and statistically significant increase in the clearance of blocked grommets. Of the five drops used, 5% NaHCO3 was the most efficacious and 3% H2O2 the least efficacious. Limitations of this in-vitro study are recognized and a prospective in-vivo double blind randomized controlled trial is planned.

Why do we have a uvula?: literature review and a new theory.

From ancient times up to the present day many different functions and conditions have been attributed to the uvula, many speculative and some with a more scientific basis. The uvula has been shown to have the ability to produce and secrete large quantities of thin saliva. A common complication of surgery involving removal of the uvula is pharyngeal dryness. We have observed that on phonation and swallowing the uvula swings back and forth in the oropharynx. We present a review of the literature on the uvula and propose a theory that the uvula bastes the throat and thereby helps keep it moist and well lubricated.

A blinded in vitro comparison of five sets of bipolar diathermy forceps.

The objective of this blinded randomized trial was to compare five sets of bipolar forceps, both single use and reusable, and discuss their potential role in postoperative complications. An animal tissue experiment was set up with standardized parameters. Results indicate larger tips give larger burns. We also found that some forceps gave suboptimal burns.

A cost-effectiveness analysis of conventional and nurse-led telephone follow-up after nasal septal surgery.

BACKGROUND: The need to bring down costs while maintaining a high standard of care has led to the expansion in the role of nurses in recent years. METHODS: We present results of cost-effectiveness analysis of conventional and nurse-led telephone follow-up after nasal septal surgery. RESULTS AND CONCLUSIONS: Our results indicate that the substitution of nurse-led telephone follow-up for conventional out-patient follow-up has the potential for substantial cost reduction and decreased out-patient access times in the NHS.

Benign inflammatory pseudotumour of the parotid gland: a case report and literature review.

We describe a rare case of benign inflammatory pseudotumour of the parotid gland. The literature concerning this condition is discussed.

A prospective single-blind randomized-controlled trial comparing two surgical techniques for the treatment of snoring: laser palatoplasty versus uvulectomy with punctate palatal diathermy.

The aim of this study was to compare laser palatoplasty with uvulectomy with punctate palatal diathermy as treatment modalities for snoring. The study design was a prospective, single-blind, randomized-controlled trial. Eighty-three patients entered the trial. After a mean follow-up period of more than 18 months there was no statistically significant difference between the two groups regarding the patient perception of benefit from surgery or the subjective improvement in snoring. However, there was a statistically significant difference in the degree of pain in the immediate postoperative period (mean difference = 22.14, 95% CI = 7.98-36.31, P = 0.003), with the pain being worse in the laser palatoplasty group. Relative risk of complications for laser palatoplasty was 1.42 (95% CI = 0.93-2.17). The snoring scores and Glasgow Benefit Inventory scores decreased with time in both the groups but there was no statistically significant difference between the two groups.

Patient satisfaction with conventional and nurse-led telephone follow-up after nasal septal surgery.

The need to bring down costs while maintaining a high standard of care has led to the expansion in the role of nurses in recent years. We present results of an audit of patient satisfaction with conventional and nurse-led telephone follow-up after nasal septal surgery. Our results indicate that patient satisfaction with nurse-led telephone follow-up is significantly higher than conventional follow-up (p=0.001, two-tailed). More patients in the conventional follow-up group felt that a follow-up appointment with an ENT doctor was essential compared with the patients in the nurse-led telephone follow-up group (p<0.001, two-tailed). We conclude that nurse-led telephone follow-up avoids unnecessary outpatient appointments, while identifying patients who require further care. It makes more appointment slots available for patients with pressing clinical problems and has the potential to reduce outpatient access times in the NHS.

Synovial sarcoma in the retropharyngeal space.

Synovial sarcoma is an aggressive mesenchymal tumour, rarely occurring in the head and neck. Management guidelines are by extrapolation of management of sarcomas in the extremities. We present a case involving the retropharyngeal space in a 20-year-old male. Analysis of more data on head and neck synovial sarcoma is necessary to make meaningful management recommendations.

Small cell carcinoma of the prostate: an underrecognized entity.

Adenocarcinoma is by far the most commonly diagnosed histologic subtype among prostate malignancies. Historically, there has been little awareness of the rare but lethal small cell carcinoma (SCC) in association with prostate cancer. Within the last decade, however, several reports have documented the existence of a neuroendocrine-like tumor arising from cells in the prostate. There is evidence that the development of poorly-differentiated neuroendocrine cells (similar to those found in oat cell carcinomas of the lung) can be seen in the progression of an initially pure adenocarcinoma, possibly due to the totipotential nature of the basal or reserve cells normally present in the prostatic acini. Although pure SCC is rare, admixtures of adenocarcinoma and small cell components may be more prevalent than previously believed. Since effective treatment of a prostatic tumor, or part of a tumor, with an SCC etiology differs from that of pure adenocarcinoma, early recognition of any histologic or clinical changes in the patient with prostate cancer may alter the course of the disease.

Effect of Hepatogard--an indigenous formulation on dexamethasone induced antihealing effects in male albino rats.

Hepatogard, is a multi-ingredient phytopharmaceutical product containing crude powders of eleven plants. Its effect on the different parameters of wound healing was assessed alone and in the presence of dexamethasone. The parameters chosen for the study were the breaking strength of incised wound, breaking strength of granulation tissue and hydroxyproline content. The result showed that Hepatogard increased the breaking strength of granulation tissue but not of incised wound. It reversed the dexamethasone induced decrease in breaking strength in both incised wound and granulation tissue. Even though it had no effect of its own on hydroxyproline concentration, it reversed the dexamethasone induced decrease in the hydroxyproline content of granulation tissue. Thus, Hepatogard has the potential for antagonizing the antihealing effect of steroids in patients receiving steroid therapy.