A novel means of securing a laparoscopic port in the obese patient

Advanced interventional laparoscopy has necessitated the development of a vast array of new equipment, but inevitably some of this equipment has had to be adapted to specific patient needs. Standard laparoscopic ports may be too short for use in obese patients. We describe a technique using a Portex endotracheal tube as an over-tube, which will overcome this problem.     

Detection of site of air entry in venous air embolism: role of Valsalva maneuver

Venous air embolism in posterior fossa surgery is a well-documented complication. Various highly sensitive devices help in early detection of air embolism. In management of air embolism, sealing the site of air entry is an important step in preventing further episodes. Here we discuss the importance of inspiratory hold after lung inflation (Valsalva maneuver) in helping to localize the site of air entry and its role in the management of venous air embolism observed in two cases of posterior fossa mass, operated in sitting position.     

Panniculectomy: a useful technique for the obese patient undergoing gynecological surgery

BACKGROUND: The inner medullary collecting duct (IMCD) is composed of at least two functionally and morphologically distinct segments, the initial (IMCDi) and the terminal (IMCDt) portions. However, most studies of receptor signaling have been performed on cells obtained from the entire inner medulla. The purpose of this study was to determine whether the patterns of receptor-activated cAMP accumulation were different between these segments. METHODS: We measured cAMP accumulation stimulated by vasopressin and isoproterenol, and the effect of epinephrine in freshly dissected IMCDi and IMCDt segments cultured and IMCDi and IMCDt cells in primary culture. RESULTS: The maximum response to vasopressin was twofold higher in fresh IMCDt verus IMCDi (P < 0.05), however, it increased in cultured IMCDi by 40% verus fresh cells with no change in the response in fresh verus cultured IMCDt. The maximum response to isoproterenol was small in fresh cells but increased by five- and sixfold, respectively, in cultured IMCDi and IMCDt cells. alpha 2-Adrenoceptor stimulation almost completely inhibited both vasopressin and isoproterenol-stimulated cAMP accumulations in fresh IMCDi and IMCDt cells, but only partially inhibited either accumulation by 34 to 49% in cultured cells. CONCLUSIONS: (1) IMCDi and IMCDt cells are both subject to vasopressin and alpha 2- and beta-adrenergic regulation of adenylyl cyclase activity; (2) the relative influence of beta-adrenergic, alpha 2-adrenergic and V2 receptors to affect cAMP accumulation is altered in primary culture versus freshly dissected IMCD segments, suggesting that caution must be exercised in the extrapolation of data from cultured IMCD cells to in vivo models.     

Immediate TRAM flap breast reconstruction in an obese patient with relapsing benign phyllodes tumor: report of a case

The authors present a case of relapsing benign phyllodes cystosarcoma of the breast in an obese female treated with a simple mastectomy and an immediate reconstruction using a bipedicled transverse rectus abdominis musculocutaneous (TRAM) flap. After a brief review of treatment options for phyllodes tumors, they discuss the advantages of TRAM flap breast reconstruction, suggesting that it may also be applied in obese patients.     

Random-priming in vitro recombination: an effective tool for directed evolution

A simple and efficient method for in vitro mutagenesis and recombination of polynucleotide sequences is reported. The method involves priming template polynucleotide(s) with random-sequence primers and extending to generate a pool of short DNA fragments which contain a controllable level of point mutations. The fragments are reassembled during cycles of denaturation, annealing and further enzyme-catalyzed DNA polymerization to produce a library of full-length sequences. Screening or selecting the expressed gene products leads to new variants with improved functions, as demonstrated by the recombination of genes encoding different thermostable subtilisins in order to obtain enzymes more stable than either parent.     

Clinical differentiation of the patient in pain: an introductory guideline for CRNAs

The practical application of colour-coded duplex sonography shows that physico-technical artifacts of colour Doppler imaging may not be obvious in all cases and can lead to misinterpretation. Slice-thickness artifacts are due to restricted transversal resolution, as in the B-mode, and may cause false negative results in vascular occlusions. Specific problems in creating and processing the colour flow image interfere with lateral resolution and lead to errors in the quantification of stenoses from the colour Doppler image. Mirror image artifacts produce phantom pictures that can be easily identified as such in some cases, but may resemble recesses in the arterial wall in other cases. Phenomena of sound shadowing resulting from the same reasons as in B-mode may lead to assume vascular occlusions in cases of long-range stenoses. Artifacts of the sonication angle in case of blood vessel tortuosity may lead to misdiagnosis of a non-existent retrograde flow. The artifacts mentioned do restrict the capacity of colour coded duplex sonography for localising flow in the ultrasound image. Users of the method should therefore be familiar with these artifacts.     

Two-port laparoscopic cholecystectomy: an innovative new method for gallbladder removal

This study was directed at defining the optimal in vitro screening methodology for the selection of new anti-myelogenous leukemia agents. Using thousands of samples of synthetic compounds from the Eastman Pharmaceutical, Inc. and Sterling Research Corporation (Eastman/Sterling) inventory, a number of sequential combinations of 8 cell lines were employed to optimize the model. The cells in these lines were of either murine (L1210 lymphocytic leukemia, C1498 myelogenous leukemia, and colony-forming unit-granulocyte macrophage [CFU-GM]) or human (HL-60, K-562, HEL, and THP-1 myelogenous leukemias, and CFU-GM) origin. The focus of the study was to find the most efficient and cost-effective manner in which to test compounds for both cytotoxicity against the tumor cells and for differential cytotoxicity against tumor as compared with normal cells.     

Neonatal bladder rupture: an unusual complication of umbilical catheterization

Bladder injury in the neonatal period is an exceedingly rare phenomenon that is usually iatrogenic. Bladder rupture as a complication of umbilical catheterization in a newborn with urinary ascites, respiratory distress and hematuria is presented and discussed.     

Artesunate suppositories: an effective treatment for severe falciparum malaria in rural areas

Artesunate is a potent antimalarial agent available in oral, parenteral and rectal formulations. Artesunate suppositories rapidly reduce and quickly clear parasitaemias. The rapidity of effect, availability and convenient dosage regimen make artesunate in suppository form a promising treatment for severe falciparum malaria, particularly in rural areas where parenteral formulations are unavailable.     

Atorvastatin: an effective lipid-modifying agent in familial hypercholesterolemia

Hydroxymethylglutaryl coenzyme A (HMG-CoA) reductase inhibitors are the drugs of choice in heterozygous familial hypercholesterolemia (FH), which has a high risk of ischemic heart disease. An open-label study was conducted to test the efficacy and safety of atorvastatin, a new synthetic HMG-CoA reductase inhibitor in proven FH. After a 4-week placebo phase, 22 subjects were randomized to either 80 mg atorvastatin at night (n = 11) or 40 mg twice a day for 6 weeks. The two dosage groups were well matched and had no difference in lipoprotein responses. After 6 weeks, the LDL cholesterol concentration was reduced by 57%, from 8.16 +/- 1.15 to 3.53 +/- 0.99 mmol/L (P < .001). The total cholesterol concentration decreased from 9.90 +/- 1.32 to 5.43 mmol/L (P < .001). HDL cholesterol concentration increased from 1.19 +/- 0.31 to 1.49 +/- 0.43 mmol/L (P < .001). Triglyceride concentrations decreased from 1.34 +/- 0.66 to 0.88 +/- 0.36 mmol/L (P < .01). Three subjects had single, transient increases of serum transaminase of up to twice the upper limit of normal. Apolipoprotein B concentration decreased significantly by 42%. Changes in apolipoproteins AI and (a) were not statistically significant. Nondenaturing gradient gel electrophoresis revealed increases in the size of smaller LDL particles in four subjects. Plasma fibrinogen concentration increased by 44%. The drug was well tolerated. One subject withdrew for personal reasons. Atorvastatin is a powerful and safe lipid-modifying agent for LDL cholesterol; it also modifies HDL cholesterol and triglyceride concentrations, and may suffice as a single agent for many subjects with heterozygous FH.     

Successful eradication of H. pylori in an elderly patient with gastric cancer after effective UFT-E therapy

The patient was a 83-year-old female with 2' T2-type gastric cancer associated with positive H. pylori in the lesser curvature of the stomach. The patient was treated with oral UFT-E alone in a daily dose of 400 mg. The tumor exhibited an O' IIa + IIc-like appearance 4 weeks after the start of administration and became scarred 8 weeks later, revealing marked tumor reduction in a short period of time. At 8 weeks, biopsy showed marked polymorphonuclear cells infiltration of gastric mucosa with no evidence of malignancy. In an attempt to eradicate H. pylori, 30 mg of lansoprazole, 400 mg of clarithromycin, and 2.0 g of ecabet-Na (3.0 g of Gastrom) were administered for 2 weeks. H. pylori was found to have been successfully eradicated, and the inflammatory lesions were no longer visible histologically. UFT-E was highly effective in this patient, and the eradication of H. pylori may contribute to the prevention of cancer recurrence.     

Management of late-onset tibia vara in the obese patient by using circular external fixation

Previously published series of surgery for late-onset tibia vara reported a significant number of complications and fair or poor results. Obesity in many of these patients makes surgical intervention an even more daunting prospect. Circular external fixation is applicable to almost any limb size and allows weight bearing as tolerated, with gradual adjustment of alignment. Twenty-five tibiae in 17 patients who exceeded their ideal body weight by > or =50% underwent correction of late-onset tibia vara with the Ilizarov technique. Average age at surgery was 11 years 7 months (range, 7 years 8 months to 15 years 11 months). Mean varus deformity was 27 degrees (range, 10-55 degrees). Treatment time averaged 12 weeks in patients without lengthening and 16.9 weeks in those requiring lengthening (mean, 3.5 cm). All patients achieved alignment within 5 degrees of normal. Complications included one delayed union, premature consolidation in one, and two residual limb-length inequalities. There were no cases of osteomyelitis, compartment syndrome, or nerve palsy. These results are a significant improvement over reports of traditional methods in these difficult patients.     

Cerebral and pulmonary miliary tuberculosis in an immunocompetent patient: aggravation in an adequately treated patient

BACKGROUND: Extrapulmonary localizations are observed in 20% of tuberculosis cases, mainly in immunosuppressed patients. Prognosis is poor in case of relatively uncommon cerebral localizations and miliary dissemination, especially if treatment is initiated in late stages. We report a case of disseminated tuberculosis associated with cerebral and pulmonary localizations in an immunocompetent patient. THe disease progressed despite adapted treatment. CASE REPORT: A young immunocompetent man with an uneventful history developed miliary tuberculosis with pulmonary localizations visualized on the computed tomography (CT) of the thorax. Brain CT was normal, but magnetic resonance imaging revealed several intracranial lesions. The disease course was marked by development of neurological symptoms and progression of the cerebral lesions after one month of treatment. No evidence of therapeutic failure (insufficient dosing, non-compliance, primary resistance) could be identified. DISCUSSION: Magnetic resonance imaging provides a more precise evaluation of tuberculosis lesions in the brain. Early antituberculosis therapy associated with corticosteroids can improve prognosis. Clinicians should be aware that cerebral lesions may continue to progress despite appropriate treatment, a course which is not satisfactorily explained by any current pathogenic hypothesis.