Silicone oil removal: results, risks and complications

Congenital or acquired dysfunction of the lower urinary tract may result in renal failure. In this group of patients urinary diversion or lower urinary tract reconstruction is mandatory prior to renal transplantation. Avoiding creation of an external stoma offers far more better quality of life to these unfortunate patients. We present three patients in end-stage renal disease. Two of them presented with dysfunction of the lower urinary tract and the third with absence of the bladder. Reconstruction or substitution of their bladders has been performed prior to kidney transplantation. In one patient an artificial urinary sphincter was implanted simultaneously in order to achieve continence, while all the patients have to empty their neobladders or augmented bladders by clean intermittent self-catheterization. In conclusion, dysfunction or absence of the lower urinary tract does not preclude renal transplantation and however abnormal the urinary tract, transplantation can still be performed if low-pressure, high-compliance reservoir can be achieved by means of augmentation or substitution cystoplasty.     

Iliac artery stenoses after percutaneous transluminal angioplasty: follow-up with duplex ultrasonography

PURPOSE: To assess iliac artery stenosis before and up to 1 year after percutaneous transluminal angioplasty (PTA) with duplex ultrasound (DUS) to determine the incidence of residual and recurrent stenoses and correlate these findings to clinical outcome. PATIENTS AND METHODS: Sixty-one patients with 70 iliac artery segments treated with PTA were examined. The peak systolic velocity (PSV) ratio (PSV ratio = PSV in stenosis divided by PSV proximal or distal to stenosis) was determined by DUS before PTA and 1 day, 3 months and 1 year after PTA. Three categories of results were identified by using PSV ratios at the site of the treated stenosis 1 day and 1 year after PTA (good result, residual stenosis, and recurrent stenosis). The DUS-determined anatomic result was correlated with the clinical outcome at 1 year. Clinical outcome was classified according to Society for Vascular Surgery/International Society for Cardiovascular Surgery (SVS/ISCVS) criteria. RESULTS: Good results with DUS (PSV ratio 1 day and 1 year after PTA > or = to 2.5) were found in 45 of 70 segments (64.3%), residual stenoses (PSV ratio > or .5 1 day after PTA) in 15 of 70 segments (21.4%), and recurrent stenosis (PSV ratio 1 day after PTA < 2.5 and 1 year after PTA > or = 2.5) in 10 of 70 segments (14.3%). PSV ratios of residual stenoses decreased significantly between 1 day and 1 year after PTA because some residual stenoses improved hemodynamically in time. Clinical results were significantly better in patients with a good result compared with other patients. However, the clinical outcome of patients with residual stenoses was not significantly different from the patients with good DUS results. CONCLUSION: Some residual stenoses improved sonographically after PTA. Clinical results at 1 year are highly variable within different groups. Clinical outcome of patients with residual stenoses did not differ from patients with good DUS results, whereas clinical outcome in patients with recurrent stenoses was worse than in the other groups.     

Iliac artery stenosis measurements: comparison of two-dimensional time-of-flight and three-dimensional dynamic gadolinium-enhanced MR angiography

OBJECTIVE: We compared our ability to make iliac artery measurements on two-dimensional (2D) time-of-flight (TOF) and three-dimensional dynamic gadolinium-enhanced MR angiography with conventional angiography. SUBJECTS AND METHODS: Fifteen patients with lower extremity vascular disease underwent pelvic MR angiography. Parameters of the cardiac-gated axial 2D TOF sequence included a TR/TE of 24/7 msec and a 50 degrees flip angle. Parameters for the three-dimensional MR angiography sequence, in which we obtained 32 coronal 3-mm slices with fat suppression, included a TR/TE of 32/5 msec and a 40 degrees flip angle during infusion of 40 ml of gadolinium-chelated contrast material. Patients then underwent conventional angiography of the iliac arteries. Maximum stenosis in the common iliac, external iliac, and common femoral arteries was then measured. Measurements of stenosis were compared by repeated measures of analysis of variance. Sensitivity and specificity were calculated for identification of greater than or equal to 50% stenosis and less than 50% stenosis. RESULTS: For all vessels studied, we found no significant difference in measurements obtained from the gadolinium-enhanced MR angiography technique and those obtained from conventional angiography (p > .05). However, significantly different stenotic measurements were obtained from the 2D TOF MR angiography sequence and conventional angiography. In the external iliac arteries, 2D TOF MR angiography exaggerated stenoses most substantially. Gadolinium-enhanced MR angiography achieved 100% sensitivity and specificity. CONCLUSION: Dynamic gadolinium-enhanced MR angiography was more accurate than 2D TOF MR angiography when measuring degree of stenosis in the iliac arteries.     

Neurologic and ischemic complications of upper extremity vascular access for dialysis

Effects of x-irradiation on the urinary bladder of male New Zealand rabbits were studied by means of light microscopy 100 weeks after exposure. The absorbed dose was 33, 36 or 39 Gy given in 5 daily fractions administered to the whole, the cranial or the caudal part of the bladder. The changes in the epithelium and in the muscular tissue were dose-dependent while the changes in the submucosa and in the extramuscular layer were not. The transitional epithelium was generally either atrophic or hyperplastic. If dysplastic or neoplastic changes were seen, the involved areas were mostly surrounded by an apparently normally differentiated epithelium and the highly specialized superficial cells lining the bladder cavity were always present. The submucosal and muscular tissues showed fibrosis and changes in blood vessels and, sometimes also in lymph vessels.     

Renal artery stent placement for the management of ischemic nephropathy

The aim of this work was to determine the oesophageal transit time (OTT) of a bolus using the biomagnetic technique and compare the results to those obtained by means of scintigraphy. For the biomagnetic evaluation, a test meal (yoghurt) uniformly labelled with 5 g of powder ferrite was swallowed in a single gulp by 19 normal volunteers in the upright position. One sensor (first order gradiometer) was placed at the furcula and a second one at the xiphoid process to detect the passage of the test meal and the magnetic signal output was recorded in a computer. The OTT was determined by plotting the voltage signal against time. The scintigraphic technique was used in the same volunteers: the test meal was labelled with less than 350 MBq of 99mTc-phytate and swallowed in the same way. The bolus transit was recorded at 4 frames s(-1) (100-120 frames acquisition) and the OTT was determined by drawing two regions of interest in the same areas as the sensors. The results were determined by plotting counts against time. The averages for OTTs were 3.8 +/- 0.8 s for the scintigraphic technique and 4.6 +/- 0.9 s for the biomagnetic technique. Although scintigraphic OTT was significantly shorter than magnetic OTT, there was a significant correlation between them. We conclude that the biomagnetic study may be used to evaluate OTT.     

Chronobiologic aspects of ischemic coronary artery disease

Convincing evidence is now available suggesting that several unfavorable cardiovascular events respect a well-defined diurnal pattern in their occurrence. In particular, ischemic heart disease has been widely investigated, and many data indicate a constellation of underlying risk factors whose temporal coincidence might act as triggering factors in the occurrence of acute events. In this paper, the recent knowledge concerning both epidemiology of ischemic heart disease and potentially favoring factors are reviewed from a chronobiological point of view.     

Crash risks of older drivers: a panel data analysis

Considerable progress has been made on understanding older drivers' safety issues. None the less, findings from previous research have been rather inconclusive. Differences in data and research methodology have been suggested as factors that contribute to the discrepancies in previous findings. One of the methodological limitations is the lack of considering temporal order between events (i.e. the time between onset of medical condition, symptom and crash). Without time-series data, a 'snap-shot' of medical conditions and driving patterns were often linked to more than 1 year--of crash data, hoping to accumulate enough data on crashes. The interpretation of the results from these studies is difficult in that one cannot explicitly attribute the increase in highway crash rates to medical conditions and/or physical limitations. This paper uses a panel data analysis to identify factors that place older drivers at greater crash risk. Our results show that factors that place female drivers at greater crash risk are different from those influencing male drivers. More risk factors were found to be significant in affecting older men's involvement in crashes than older women. When the analysis controlled for the amount of driving, women who live alone or who experience back pain were found to have a higher crash risk. Similarly, men who are employed, score low on word-recall tests, have a history of glaucoma, or use antidepressant drugs were found to have a higher crash risk. The most influential risk factors in men were the number of miles driven, and use of antidepressants.     

Evaluation of non-cerebral complications in light of ischemic stroke severity

Extracerebral complications which were observed in great number of ischemic stroke patients increased the risk of death and disability. Pneumonia, myocardial infarction, pulmonary embolisms and urinary tract infections are most often. We considered the influences of extracerebral complications on anterior circulation territory disturbances. A cohort of 1697 patients with first-ever ischemic stroke within anterior circulation region was evaluated. Patients were divided into three groups: A, B, C according to the heaviness of stroke. We understood the heaviness of stroke as a degree of cerebral disfunction occurring within the first 24 hours of the onset and assessed it using Clinical Groups of the Whole Body Activity (CG WBM). CG WBM is an original classification, a three-degree one, prepared by Department of Neurology University School of Medicine Sciences in Bydgoszcz. The rate of complications was statistically significantly lower in group A with the mild course of ischemic stroke than in group B with moderate or in group C with the severe course of ischemic stroke. Pneumonia, myocardial infarction and pulmonary embolism were recognized more often in patients with fatal outcome. The amount of extracerebral complications raised with the severity of the ischemic stroke.     

Aortic dissection: percutaneous management of ischemic complications with endovascular stents and balloon fenestration

PURPOSE: The purpose of this study was to evaluate endovascular stenting (EVS) and balloon fenestration (BF) of intimal flaps for the management of lower extremity, renal, and visceral ischemia in acute or chronic aortic dissection. METHODS: Twenty-two patients (16 male, 6 female) with a median age of 53 years (range 35 to 77 years) underwent percutaneous treatment for peripheral ischemic complications of 12 type A (five acute, seven chronic) and 10 type B (nine acute, one chronic) aortic dissections. RESULTS: Ten patients had leg ischemia, 13 had renal ischemia, and 6 had visceral ischemia. Sixteen patients were treated with EVS including 11 with renal, 6 with lower extremity, 2 with superior mesenteric artery, and 2 with aortic stents. Three patients had BF of the intimal flap, and three had BF in combination with EVS. Revascularization with clinical success was achieved in all 22 patients. Two patients died 3 days and 13.4 months after the procedure was performed, respectively. Of the remaining 20 patients, 1 is lost to follow-up, and 19 have persistent relief of clinical symptoms. Mean follow-up time is 13.7 months (range 1.1 to 46.5 months). One case was complicated by guidewire-induced perinephric hematoma. CONCLUSION: EVS and BF provide a safe and effective percutaneous method for managing peripheral ischemic complications of aortic dissection.     

Coronary-to-pulmonary artery shunts via the bronchial artery: analysis of cineangiographic studies

Coronary-to-pulmonary artery shunts via the bronchial artery (CA-BA-PA shunts) were observed in 16 of 2,922 consecutive patients who underwent selective coronary cineangiography. Underlying diseases included Takayasu arteritis (n = 8), chronic pulmonary inflammatory diseases (n = 4), pulmonary thromboembolism (n = 2), pulmonary artery tumor (n = 1), and tetralogy of Fallot with pulmonary atresia (n = 1). Ventilation-perfusion scans were available in 15 of the 16 patients. Mismatched defects were identified in 11 patients, and matched defects were identified in four. Bronchial-to-pulmonary artery shunts were detected on selective bronchial angiograms and/or thoracic aortograms in 13 patients. Feeding arteries of the CA-BA-PA shunts included left atrial branches (n = 13), right sinus node branches (n = 7), left sinus node branches (n = 2), right conal branch (n = 1), left conal branch (n = 1), and posterolateral branches (n = 2). These coronary branches seemed to serve as collateral vessels from a coronary arterial system with a higher pressure to a pulmonary arterial system with a lower pressure in conditions of decreased pulmonary flow or in cases of chronic pulmonary inflammatory disease. The importance of the coronary artery along with other superior thoracic collateral networks in contributing to the development of shunts to the pulmonary artery is underscored.     

Esophagogastrectomy: reoperation for complications

We investigated various factors related to secondary hyperparathyroidism among hemodialysis patients. Subjects were 26 patients (20 men and 6 women) ranging in age from 24 to 75, treated at an ordinary hemodialysis center throughout the year 1991. The serum inorganic phosphate level and serum intact PTH level varied greatly from 2.5 to 12.5 mg/dl and from 10 to 1,102 pg/ml (normal range, 10-60 pg/ml), respectively. All patients were classified according to the serum intact PTH level into two groups: those with less than 120 pg/ml (Group I) and those with 120 pg/ml or more (Group II). The patients in Group I responded well to hemodialysis and drug therapy, but those in Group II were likely to have secondary hyperparathyroidism. In all patients in Group II, the PTH level increased markedly in the summer. This may be attributed to insufficient ingestion of calcium, vitamins, and other nutrients due to loss of appetite.     

Risk factors for serious nonsteroidal-induced gastrointestinal complications: regression analysis of the MUCOSA trial

Gene rearrangements involving MLL (also known as ALL1, HRX, or Htrx) are among the most common molecular abnormalities associated with acute leukemia. These leukemias generally have one allele involved in a rearrangement, while the remaining allele is uninvolved and demonstrates a germline MLL configuration. In this study, we describe a leukemic cell line that does not have a germline MLL allele and thus cannot produce a normal MLL gene product. We show that the ML-1 cell line, derived from a patient with acute myeloid leukemia, has one allele involved in a t(6;11)(q27;q23), while the remaining MLL allele is deleted. Cloning of the genomic breakpoints on the derivative(6) and der(11) chromosomes demonstrated a balanced translocation between MLL on chromosome band 11q23 and AF6 on chromosome band 6q27. Sequence analysis of the derivative chromosomes revealed that a 186-bp segment of MLL intron 6, downstream of the breakpoint, had been duplicated, inverted, and inserted between MLL and AF6 on the der(11) chromosome. In light of the fact that ML-1 cells can be induced to differentiate along the granulocyte and macrophage lineages, the finding that ML-1 lacks a germline MLL allele demonstrates that a normal MLL gene is not required for survival, proliferation, or differentiation of this cell line.     

Cardiac complications in adult diphtheria: analysis of 212 cases

In a series of 212 cases of diphtheria toxica in adults 90 (42%) suffered from cardiac complications. While early clinical signs were lacking or unspecific, the diagnosis could be suspected based on changes in the ECG. The earliest signs were sinus bradycardia, AV dissociation, AV escape rhythmus, prolongation of QT interval and large U wave (U > T, T + U wave). In cases where the differential diagnosis of myocarditis and other heart diseases in adults is difficult, attention should focus in the sickle-like depression ('sagging') of the ST interval, which is a typical sign for diphtheric myocarditis. It occurs even in the presence of pre-existing left-ventricular hypertrophy or bundle branch block. The severest forms of diphtheric myocarditis are complicated by AV and intraventricular conduction disturbances and malignant ventricular tachyarrhythmias.     

Hospital readmission after trauma: an analysis of outpatient complications

BACKGROUND: Outpatient complications leading to hospital readmission after hospitalization for trauma have not been examined. METHODS: A retrospective chart review of all trauma victims admitted to a Level 1 trauma center from January of 1990 to January of 1995 was performed to characterize patients who required readmission after hospitalization for trauma. Risk factors for readmission were determined by stepwise regression analysis. RESULTS: Of 15,463 trauma admissions, 209 patients (1.4%) required readmission, 84% within 30 days, 71% within 14 days. Reasons for readmission included wound (29%), abdominal (29%), pulmonary (18%), and thromboembolic (19%) complications. Fifty of the patients (24%) readmitted with a complication required an operation. Risk factors for readmission included: operation during first hospitalization (p < 0.0001), penetrating injury (p = 0.0001), and advanced age (p = 0.0001). Injury Severity Score, length of hospitalization, and gender were not independent predictors of readmission. CONCLUSIONS: Outpatient complications leading to readmission after hospitalization for trauma are not common; however, many are serious and require operative intervention. Because most complications were identified by the second week after discharge, outpatient follow-up visits should be scheduled within 7 to 14 days. Based on our findings, we recommend protocols be established to ensure follow-up for trauma patients, especially those who have had an operation, were victims of penetrating injury, or those > 65 years of age.     

Acute ischemic syndromes following coronary artery bypass graft surgery

METHODS: In 146 eyes/patients who underwent Nd:YAG laser iridotomy after glaucomatous attack or after prophylactic iridotomy, we evaluated whether the frequency of posterior synechiae depends on (1) glaucomatous attack, (2) preoperative miotic therapy, (3) postoperative antiglaucomatous therapy or (4) mode of intraoperative laser therapy. Out of 616 eyes with YAG iridotomy between 1983 and 1987, 146 eyes/patients fulfilled the inclusion criteria: observation time of minimum 3 months after iridotomy, preoperative examination without signs of preexisting synechiae, postoperative examination at discharge and a later control examination in mydriasis to exclude posterior synechiae. RESULTS: Eyes with and without glaucomatous attack and eyes with an without pre-operative long-term miotic therapy showed no significant difference in frequency of posterior synechiae. Eyes with postoperative long-term therapy with miotics or beta-blockers showed posterior synechiae significantly more often than eyes without post-operative miotic or beta-blocker therapy. Eyes that received DPE in the early post-operative period developed posterior synechiae significantly less often. The number of laser pulses and the mean total energy used were significantly higher in eyes which later developed posterior synechiae. In the group of patients with glaucomatous attack women outnumbered men by four to one, but there was no significant difference in refraction between women and men. CONCLUSIONS: Patients with glaucomatous attack are not at a higher risk of developing posterior synechiae than those without glaucomatous attack. Post-operative antiglaucomatous therapy, the number of laser pulses and the total energy alter the frequency of postoperatively developed posterior synechiae.     

Clinical risk factors for ischemic complications after percutaneous coronary interventions: results from the EPIC trial. The EPIC Investigators

BACKGROUND: Most analyses of complications after percutaneous coronary intervention have been limited to angiographic predictors of abrupt closure. We sought to determine the relation between baseline clinical and angiographic characteristics and clinical ischemic events and whether treatment with the platelet glycoprotein IIb/IIIa receptor antagonist c7E3 reduced ischemic events differentially in patients with distinct lesion morphologic characteristics. In the EPIC trial, a bolus and infusion of c7E3 decreased the 30-day incidence of death, myocardial infarction, and need for revascularization by 35% in 2099 high-risk patients. METHODS: We used logistic regression modeling to determine the relations between these patients' baseline clinical and angiographic characteristics and the composite primary end point. We also constructed multivariable models with interaction terms to assess treatment effect on prespecified, core laboratory-assessed, coronary morphologic characteristics. RESULTS: The most important predictors of a poor outcome were low weight (chi-square = 10.5, P =.001) and preprocedural percent stenosis (chi-square = 15.0, P <.001). History of hypertension, nonwhite race, and peripheral vascular disease were also associated with an increased risk, as were all measures of lesion complexity except calcification and presence of a side branch. The treatment benefit with abciximab was significantly greater with less complex than with more complex lesion morphologic characteristics. CONCLUSIONS: Future risk models should include these baseline characteristics to define the risk for ischemic complications in individual patients, and treatment with abciximab should not be predicated on lesion morphologic findings alone.     

Malaria at Christmas: risks of prophylaxis versus risks of malaria

A large increase in the number of falciparum malaria cases imported into the UK was reported to the malaria reference laboratory in the first quarter of 1998. Contributory factors were unusually heavy rains in east Africa and a reduction in the use of the most effective antimalarial drug, mefloquine. There was also an increase in the number of cases of severe malaria in the UK. During December 1997 and January 1998, the Hospital for Tropical Diseases, London, treated 5 patients for severe malaria and gave advice on 20 more patients with malaria who had been admitted to intensive care units throughout England. 4 of the severe cases treated at the hospital are reported. In 3 of those 4 cases, incorrect, misleading, or inadequate advice was given by health care professionals. Media coverage of the adverse effects of antimalarial drugs has contributed to confusion about prophylactic regimens among both health care professionals and the public. The incidence of falciparum malaria among travellers who do not take prophylactic drugs is about 0.6% in east Africa and 3.5% in west Africa over a 2-week travel period. Travellers need to take measures to avoid being bitten by mosquitoes and should be taught to promptly seek medical help if they develop a fever while abroad or after they return. Moreover, using any one of the recommended prophylactic regimens is better than not using a potent regimen or no prophylaxis at all. Mefloquine is 90% protective against malaria in sub-Saharan Africa. While the efficacy of proguanil and chloroquine in 1987 was about 70% in west Africa and 50% in east Africa, those levels are now probably lower. The side effects of antimalarial drugs are discussed.     

Thoracic epidural anaesthesia for coronary artery bypass graft surgery. Effects on postoperative complications

We have performed a retrospective analysis of the peri-operative course of 218 consecutive patients who underwent routine coronary artery bypass graft surgery in this institution. All patients received a standardised general anaesthetic using target-controlled infusions of alfentanil and propofol. One hundred patients also received thoracic epidural anaesthesia with bupivacaine and clonidine, started before surgery and continued for 5 days after surgery. The remaining 118 patients received target-controlled infusion of alfentanil for analgesia for the first 24 h after surgery, followed by intravenous patient-controlled morphine analgesia for a further 48 h. Using computerised patient medical records, we analysed the frequency of respiratory, neurological, renal, gastrointestinal, haematological and cardiovascular complications in these two groups. New arrhythmias requiring treatment occurred in 18% of the thoracic epidural anaesthesia group of patients compared with 32% of the general anaesthesia group (p = 0.02). There was also a trend towards a reduced incidence of respiratory complications in the thoracic epidural anaesthesia group. The time to tracheal extubation was decreased in the epidural group, with the tracheas of 21% of the patients being extubated immediately after surgery compared with 2% in the general anaesthesia group (p < 0.001). There were no serious neurological problems resulting from the use of thoracic epidural analgesia.