Congenital urethrocutaneous fistula: a case report and literature review, with a nomenclature proposal

The authors report the case of a 4-year-old boy who had a congenital urethrocutaneous fistula (CUF) on the penile urethra. The previous reports of patients with fistula from the urethra to the skin are evaluated, and the spectrum of CUF is discussed.     

Delayed cerebrospinal fluid leakage after head and facial trauma resulting in meningitis: a case report

BACKGROUND: Several years ago, a successful surgical technique for treating depigmentation resulting from burn injuries was developed. OBJECTIVE: The purpose of this study was to investigate results of dermabrasion with melanocyte transplantation using new modifications of the technique in patients with vitiligo. METHODS: We performed 17 procedures on 12 patients with stable vitiligo. The epithelium of the vitiliginous areas was removed by dermabrasion. The dermabraded area was then reepithelialized with ultra-thin sheet grafts, which more recently were meshed and partially expanded. RESULTS: Good to excellent repigmentation was observed in 88% of the procedures. Scarring did not develop in the repigmented or donor site regions. The final color match has been good to excellent. CONCLUSIONS: This technique has proven beneficial in 88% of the procedures on our patients. Both our patients and we feel that this provides a valuable treatment option in patients who have failed medical management.     

Listeria infection after liver transplantation: report of a case and review of the literature

Listeria monocytogenes is a well-recognized cause of bacteremia and meningitis in immunocompromised individuals, including recipients of solid organ transplants, but has only rarely been reported following orthotopic liver transplantation (OLT). Most previously reported cases of listeriosis occurred months to years following liver transplantation; we describe a case of listeriosis that occurred within 1 wk of liver transplantation, shortly after discontinuation of trimethoprim-sulfamethoxazole prophylaxis, and review the English literature on Listeria infection after OLT. The patient developed abdominal pain and fever that suggested a bile leak, but was definitively diagnosed with Listeria infection by blood culture. The infection was successfully treated with 3 wk of intravenous ampicillin. We conclude that serious systemic infection with Listeria monocytogenes is uncommon following OLT, may occur early in the postoperative period, and responds well to treatment with high dose ampicillin.     

Fever, negative blood culture findings and absence of response to antibiotic therapy in a patient after a second aortic valve prosthesis

HISTORY AND CLINICAL FINDINGS: A 53-year-old patient had a prosthetic valve (St. Jude Medical 25) 9 years ago because of a Staphylococcus aureus endocarditis with severe aortic regurgitation. An initially mild, progressively more severe, aortic regurgitation then developed as a result of an empty paravalvular abscess cavity, requiring another valve replacement. Fever started on the 3rd postoperative day and persisted despite combined treatment with beta-lactam antibiotics and aminoglycoside. INVESTIGATIONS: At first no infectious focus could be identified radiologically or by echocardiography. But transoesophageal echocardiography revealed vegetations in the old abscess cavity. Several blood cultures were negative, while serological tests gave markedly raised antibody titers against Coxiella burnetii. DIAGNOSIS, TREATMENT AND COURSE: Assuming Coxiella burnetii endocarditis the patient was given doxycycline, 2 x 100 mg daily and cotrimoxazole, 1 x 960 mg daily. The fever subsided and the vegetations had disappeared after four weeks. Because of the high risk of recurrence the antibiotic treatment was to be continued for two years. CONCLUSION: Coxiella burnetii should be considered as a possible cause of fever of unknown origin, especially in patients with existing or operated cardiac valvar defects, when endocarditic vegetations have been demonstrated and several blood cultures have been negative.     

Efficacy of an intraperitoneal antibiotic to reduce the incidence of infection in the trauma patient: a prospective, randomized study

BACKGROUND: Antibiotic therapy in patients with blunt trauma remains an area of investigation. This study was undertaken in trauma patients evaluated with diagnostic peritoneal lavage to determine the effect of an intraperitoneal antibiotic on the following factors: infectious complications, length of hospital stay, and mortality. METHODS: A prospective, randomized double-blinded study compared using either 500 mg of intraperitoneal kanamycin or a saline control in 69 adult trauma patients requiring diagnostic peritoneal lavage was conducted over a 24-month period. Advanced trauma life support indications for performing diagnostic peritoneal lavage were used. Patients were randomized to receive 50 mL of solution intraperitoneally through a lavage catheter and were evaluated for all septic complications, length of hospital stay, and outcome. RESULTS: Over a 24-month period, 40 patients received kanamycin, and 29 patients received a placebo. Of patients receiving kanamycin, 27.5 percent experienced infectious complications compared to 65.5 percent of the control patients (p = 0.001, chi-square analysis). The average length of stay in the intensive care unit was 4.18 days in the kanamycin group and 6.96 days in the control group (p = 0.04, chi-square analysis). The average length of stay was 12.32 days for patients receiving kanamycin and 17.36 days for the control group (p = 0.03, chi-square analysis). The mortality rate for each group was 13 percent. CONCLUSIONS: Intraperitoneal kanamycin given to trauma patients requiring diagnostic peritoneal lavage within the first three hours following injury reduces the incidence of infectious complications and shortens intensive care unit and hospital stay.     

Combined thoracoscopic lung resection and laser ablation for lung cancer with pulmonary emphysema: report of a case

The incidence of clinically detectable parenchymal liver metastases in patients with recurrent ovarian carcinoma has been infrequently reported, but autopsy findings indicate that they are the second most common site of distant metastases in patients with epithelial ovarian carcinoma. The case of a 58-year-old patient who developed parenchymal liver metastases as the first site of recurrent ovarian carcinoma is presented. The different spreading routes of this malignancy, as well as a review of the incidence of liver metastases are discussed.     

A case report on surgery for chylothorax after anterior spinal fusion: usefulness and effectiveness of intraoperative milk administration and postoperative OK-432 administration]

After having reported preliminary results of soft system stabilization according to Graf in a series of 27 patients with degenerative disc disease of the lumbar spine in early 1995 the authors report long term clinical and radiological results of this patient series (n = 25). At a mean period of postoperative observation of 50 months excellent, good, satisfactory, moderate and poor results were obtained in 62, 9%, 11, 1% and 11, 1%, 7, 4% and 7, 4% of the patients, respectively. The well-known phenomenon of loss of disc height at the level of posterolateral fusion and instrumentation as well as overcharge of adjacent segments were not observed after soft system stabilization. Regional as well as global lumbar lordosis were maintained and, although statistically not significant, an increase of intervertebral distance was observed in adjacent segments in flexion of the lumbar spine. These phenomena might represent pressurization of instrumented as well as adjacent discs after the insertion of ligament prostheses. It is the impression of the authors, that the Graf technique leads to good surgical results in degenerative disc disease with destabilization of lumbar motion segment(s) if the following criteria are strictly respected: 1. No or only mild arthrotic changes of the facet joints 2. Preferably minor disc degeneration/only mild loss of intervertebral distance. 3. Well trained low back muscles and 4. A clear-cut, repeatedly demonstrated pain-relief on trial anaesthesia of the corresponding articular nerves and while wearing a probatory jacket.     

Complications with infection and foreign body reaction after silicon implant arthroplasty in the second metatarsophalangeal joint in an adolescent: a case report

A 21-year-old otherwise healthy male was referred to our clinic due to severe pain, deformation, development of fistules, and swelling of the second metatarsophalangeal joint of the right foot. He presented a history of two previous operations. At the age of 13, a 2-cm. resection of the distal part of the proximal phalanx was performed due to severe hammertoe deformity. At the age of 19, a partial phalanx resection and implantation of a silicon elastomer ball-shaped joint spacer was performed due to second metatarsophalangeal joint instability. After this operation, the patient suffered from fistules that appeared in the second metatarsophalangeal region. Following referral to our clinic, the patient was operated on. The proximal phalanx was removed along with the prosthesis which had slipped from the metatarsophalangeal joint into the proximal phalanx with the ends of the prosthesis perforating the skin. Debridement of infected tissue and implantation of gentamicin containing beads were performed. Bacterial specimens revealed growth of coagulase-negative staphylococci. Microscopic examination of the debrided tissue showed signs of acute and chronic inflammation. Postoperatively, the patient was treated with antibiotics and healing was uneventful. This case advocates the need for proper selection criteria and strict indications in patients with joint disease needing an arthroplasty.     

Residual neuromuscular block is a risk factor for postoperative pulmonary complications. A prospective, randomised, and blinded study of postoperative pulmonary complications after atracurium, vecuronium and pancuronium

BACKGROUND: After anaesthesia involving pancuronium a high incidence of both residual neuromuscular block and postoperative pulmonary complications (POPC) has been reported. The aim of this study was to compare the incidence of POPC following the use of pancuronium, atracurium, and vecuronium, and to examine the effect of residual neuromuscular block on the incidence of POPC. METHODS: A total of 691 adult patients undergoing abdominal, gynaecological, or orthopaedic surgery under general anaesthesia were randomised to receive either pancuronium, atracurium, or vecuronium. Perioperatively, the response to train-of-four (TOF) nerve stimulation was evaluated manually. Postoperatively, the TOF ratios were measured mechanomyographically, and through a 6-day follow-up the patients were examined for pulmonary complications. RESULTS: The incidence of residual block, defined as a TOF ratio < 0.7, was significantly higher in the pancuronium group (59/226: 26%) than in the atracurium/vecuronium groups (24/450: 5.3%). In the pancuronium group, significantly more patients with residual block developed POPC (10/59: 16.9%) as compared to patients without residual block (8/167: 4.8%). In the atracurium/vecuronium groups, the incidence of POPC was not significantly different in patients with (1/24: 4.2%) or without (23/426: 5.4%) residual block. Multiple regression analysis indicated that abdominal surgery, age, long-lasting surgery, and a TOF ratio < 0.7 following the use of pancuronium were potential risk factors for the development of POPC. CONCLUSION: Postoperative residual block caused by pancuronium is a significant risk factor for development of POPC.     

Unusual fibro-osseous lesion of the spinal cord with positive staining for glial fibrillary acidic protein and radiological progression: a case report

A rare intradural lesion of the lumbar spine producing leg pain and minimal neurological deficits is described in a 48-year-old man. Previous reports of similar lesions have been described under the designation "fibro-osseous lesions" and "calcifying pseudoneoplasms." This is the first report of an unusual fibro-osseous lesion with an intradural spinal location as well as the first to show immunohistochemical positivity for glial fibrillary acidic protein (GFAP) within cellular components of this process and crystal formation suggestive of calcium pyrophosphate. This case also shows radiographic progression suggesting the possibility that this entity may be a form of low grade neoplasm.     

Combined pretemporal and endovascular approach to the cavernous sinus for the treatment of carotid-cavernous dural fistulae: technical case report

OBJECTIVE AND IMPORTANCE: The endovascular treatment of carotid-cavernous dural fistulae is becoming the prominent treatment modality for these lesions. The intractability of these lesions and their tendency to recur, especially after previous endovascular treatment sessions, exhausts the available routes and tends to present a difficulty in accessing the cavernous sinus. To avoid the risks associated with a direct surgical approach, an alternative, less invasive route to the cavernous sinus using a pretemporal extradural approach is combined with a direct endovascular approach. CLINICAL PRESENTATION: A 38-year-old woman presented with a history of right visual and ocular symptoms related to a Type D cavernous carotid dural fistula, which was fed by internal carotid and external carotid branches. The fistula was initially treated with embolization of the external carotid arterial supply. After a transient improvement, the patient's visual acuity worsened. A follow-up angiogram showed the major supply from the intracavernous internal carotid branches and draining through the inferior ophthalmic vein. The transvenous route was not accessible. An attempt to cannulate the intracavernous branches was not successful. The combined pretemporal and endovascular approach was then used. INTERVENTION: The pretemporal extradural region of the superior orbital fissure was exposed. Using microsurgical techniques and Doppler flow guidance, the anterior cavernous sinus was cannulated through the orbital venous drainage channels. Using intraoperative angiography, thrombogenic coils were deployed at the level of the fistula. Intraoperative angiography confirmed complete obliteration of the fistula. CONCLUSION: The combined pretemporal (extradural) and endovascular approach to the cavernous sinus is a less invasive alternative for the treatment of intractable carotid-cavernous dural fistulae.     

People living with HIV infection who attend and do not attend support groups: a pilot study of needs, characteristics and experiences

People living with Human Immunodeficiency Virus (HIV) confront a myriad of stressors over the course of their infection. Social support groups offer a means of addressing the support needs of people living with HIV. In the present study, 34 persons who had attended HIV support groups and 29 who had not attended groups completed measures of distress, coping, and social connectedness, and participated in open-ended interviews concerning their support group experiences. Results showed that those who attended support groups knew they were HIV-seropositive for a longer time, reported less emotional distress, and had more social contact than did non-attenders. However, non-attenders endorsed avoidant coping strategies to a greater extent. Analyses showed that time since testing positive accounted for differences between groups in social connectedness but not differences in anxiety, depression, or avoidance coping. Thus, HIV-seropositive persons become socially reconnected with time, but individuals with avoidant coping styles experience greater emotional distress and are unlikely to seek support groups. A sizeable proportion of people with HIV may therefore need supportive interventions, particularly nearer to the time that they test HIV-seropositive.     

Diagnostic value of compression ultrasonography and fibrinogen-related parameters for the detection of postoperative deep vein thrombosis following elective hip replacement: a pilot study

To determine their ability to diagnose postoperative deep vein thrombosis (DVT) D-dimer - by three methods -, fibrinogen degradation products (FgDP) and fibrinogen levels were measured in 68 consecutive patients before elective surgery for hip replacement and on postoperative day 1, 3, 6, and 10. All patients received prophylaxis and underwent compression real-time B-mode ultrasonography (C-US) on postoperative day 5 and 9, and bilateral ascending venography on day 10. Twenty-two out of 68 patients developed asymptomatic postoperative DVT, which was limited to the calf veins in 14 and involved the proximal veins in 8 patients. C-US was negative in all patients on day 5. On day 9, C-US sensitivity and specificity for proximal DVT were 63% (95% confidence interval: 26%-90% and 98% (89%-100%) respectively. Postoperative changes in the laboratory parameters evaluated were not different in patients with or without DVT until day 10. On day 10, mean D-dimer, FgDP and fibrinogen levels were significantly higher in patients with DVT than in those without DVT (p values between 0.006 and 0.032), but only D-dimer was higher with DVT involving two or more venous segments than with thrombosis involving one venous segment only (p < 0.05). Stepwise logistic regression analysis identified D-dimer and fibrinogen on day 10 as predictors of postoperative DVT. In a receiver operator curve and after weighing for the coefficients generated by logistic regression analysis, the combination of a latex photometric immuno-assay and of PT-derived fibrinogen yielded-at a cut-off value of 7.0 a sensitivity of 100% (73%-100%) and a specificity of 58% (39%-75%) for DVT, with a negative predictive value of 100% (78%-100%), a positive predictive value of 52% (32%-71%) and an overall accuracy of 71% (55%-83%). These results suggest that two simple, fast and reproducible tests may permit the identification of patients at low risk of having postoperative DVT and that a combination of sensitive laboratory assays and of the highly specific C-US may select patients requiring anticoagulant treatment. Efficacy and cost-effectiveness of this approach should be evaluated in large clinical management studies.     

Risk factors and prevention of early infection after implantation or revision of transjugular intrahepatic portosystemic shunts: results of a randomized study

The aim of this study was to evaluate the efficacy of a single dose of a second-generation cephalosporine to prevent postinterventional infection and to identify risk factors for postinterventional infection in patients receiving implantation or revision of a transjugular intrahepatic portosystemic shunt (TIPS). Eighty-four patients (105 transjugular interventions) were randomized receiving no antibiotic treatment (46 interventions) or 2 g cefotiam (56 interventions) given at the beginning of the procedure. Patients with overt infection or those receiving antibiotic treatment in the preceding two weeks were excluded. Groups were comparable with respect to biographic and medical data. Postinterventional infection was defined as an increase in WBC count (> or =15,000/microl), fever (> or =38.5 degrees C), or a positive blood culture. Infection occurred in 17% of the patients. Patients not receiving cefotiam had a slightly higher incidence of infection (20%) than patients treated with cefotiam (14%, NS). Multivariate analysis demonstrated prognostic relevance for multiple stenting and periprocedural use of a central venous line. The clinical outcome of the patients was unaffected by cefotiam treatment. In conclusion, a single dose of intrainterventional cefotiam does not prevent postinterventional infection. This may be due to the antimicrobial spectrum and short half-time of cefotiam. Strict adherence to aseptic conditions during intervention and early removal of central venous lines may reduce the rate of post interventional infection considerably. Antibiotic prophylaxis with cefotiam does not seem to be useful since it will not influence outcome and costs.     

The prediction of risk of recurrence and time to recurrence of hepatocellular carcinoma after orthotopic liver transplantation: a pilot study

Orthotopic liver transplantation (OLTx) in the presence of hepatocellular carcinoma (HCC) has been complicated by high recurrence rates. The ability to determine the risk and timing of HCC recurrence on an individual basis would greatly aid in the candidate selection process resulting in a more efficient use of donated organs and allow the individualization and better evaluation of adjuvant chemotherapy. The 214 patients who underwent OLTx in the presence of HCC were analyzed. From the 178 patients who survived more than 150 days, 71 (40%) have suffered HCC recurrence. Based on five risk factors, that is, gender, tumor number, lobar tumor distribution, tumor size, grade of vascular invasion, artificial neural network models predicting the likelihood of HCC recurrence within 1, 2, and 3 consecutive years after transplantation were developed. Based on model predictions, those combinations of risk factors that should/should not lead to recurrence were generated, allowing stratification of patients into the following three groups: 1) patients who should not suffer HCC recurrence and who should not need adjuvant therapy, 2) patients who will suffer recurrence and for whom postoperative chemotherapy significantly prolonged survival (but did not prevent recurrence), and 3) patients who may or may not suffer HCC recurrence and whose recurrence may be prevented by adjuvant chemotherapy. The outcome of OLTx for patients with HCC can be prognosticated based on a number of clinical variables. If verified through multicenter trials, these models could be made available to transplantation programs performing OLTx in the presence of HCC.     

Reoperation for mitral regurgitation 13 years after aortic valve replacement and manouguian's anulus enlargement: report of a case

The patient was 22-year-old female. She had undergone aortic valve replacement and Manouguian's anulus enlargement with low porosity woven Dacron patch for congenital aortic stenosis 13 years ago, and developed mitral regurgitation 9 years after that operation. Two regurgitant flow were observed. One was originated from the orifice due to mitral prolapse. The other was from a tear in the anterior leaflet. It was around the tip of the prosthetic patch, approximately 7 mm in size, and was repaired easily. But the mitral valve itself was found to be malformed and prolapsed, requiring mitral valve replacement. Her postoperative course was uneventful.     

Acquired left ventricular to right atrial intracardiac shunt after myocardial infarction: a case report and review of the literature

A patient without a history of heart disease was seen in our institution after 3-week history of progressive weakness, dyspnea, and orthopnea. Transthoracic echocardiography demonstrated inferoposterobasal akinesis and a left ventricular to right atrial shunt through the coronary sinus, which was confirmed on cardiac catheterization. This is only the second case reported in the English-language literature documenting this rare shunt after a myocardial infarction.     

Reconstruction and rehabilitation of short-range, high-velocity gunshot injury to the lower face: a case report

BACKGROUND: Germ cell tumors (GCTs) and their metastases may be found in numerous sites that are accessible to cytologic sampling, and many are responsive to chemotherapy. METHODS: The authors reviewed 20 examples of GCT cytology from 16 males and 3 females ranging in age from 1.5 to 61 years (median, 34 years). With two exceptions, one benign cystic ovarian teratoma in which intraoperative cytology was used to diagnose an associated adult-type carcinoma and one undescended testis in which seminoma presented as an abdominal mass, the material reviewed included no examples of primary gonadal GCT. RESULTS: The authors studied 7 primary and 13 metastatic GCTs; these studies were based on 13 in vivo aspirations, 4 intraoperative preparations, and 3 samples of body cavity fluids. All samples were correctly interpreted as malignant, and only one was incorrectly classified as a non-GCT malignancy. CONCLUSIONS: Clinical and cytologic findings are useful in the diagnosis of GCTs and their metastases. Incorrect interpretation of these neoplasms as poorly differentiated malignancies of other types may deprive the patient of effective chemotherapy. Air-dried, Romanowsky-stained smear material and cell block sections may contribute to the resolution of diagnostic dilemmas.     

Efficacy of ondansetron and prochlorperazine for the prevention of postoperative nausea and vomiting after total hip replacement or total knee replacement procedures: a randomized, double-blind, comparative trial

BACKGROUND: Limited data are available on the efficacy of ondansetron hydrochloride compared with prochlorperazine maleate for the treatment of postoperative nausea and vomiting (PONV). OBJECTIVE: To evaluate the comparative efficacy of ondansetron and prochlorperazine for the prophylaxis of PONV in patients undergoing total hip replacement or total knee replacement procedures. METHODS: A randomized, double-blind, comparative trial was conducted at a tertiary care, university hospital. Seventy-eight patients undergoing elective total hip or total knee replacement procedures received a single dose of ondansetron hydrochloride (n = 37), 4 mg intravenously, or prochlorperazine maleate (n = 41), 10 mg intramuscularly, at the end of the surgical procedure. Rescue therapy was administered every 4 hours as needed during the initial 48 hours. Primary outcome measures were the incidences and severity of PONV. Secondary outcome measures included the number of rescue antiemetic doses required, number of physical therapy cancellations because of PONV, length of hospital stay, and cost of antiemetic agents administered. RESULTS: The incidence of nausea was significantly greater in the ondansetron group compared with the prochlorperazine group (81% vs 56%; odds ratio, 3.4; 95% confidence interval, 1.2-9.4) as was the severity of nausea (P = .04). Multivariate analysis identified administration of ondansetron, history of PONV, obesity, and female sex as risk factors for a nausea event. The incidence of vomiting tended to be greater in the ondansetron group (49% vs 32%; odds ratio, 2.0; 95% confidence interval, 0.8-5.0). The need for rescue antiemetic therapy was also greater in the ondansetron group (46% vs 27%; odds ratio, 2.3; 95% confidence interval, 0.9-6.0). The mean antiemetic drug cost per patient was significantly greater for the ondansetron group ($47.56 vs $2.47; P<.001). However, the proportion of patients who were unable to participate in physical therapy because of PONV and the median length of hospital stay were similar in both groups. CONCLUSION: Prochlorperazine is associated with superior efficacy and significant cost savings compared with ondansetron for the prevention of PONV in patients undergoing total hip and total knee replacement procedures.