Renal clear cell carcinoma emerging in a transplanted kidney 3 years after return to dialysis. Case report and review of the literature

We present a female patient with end-stage renal disease who was referred to the emergency department with sudden, excruciating pain over the right lower abdomen and flank. Radiologic evaluation following admission revealed a mass, solid in nature, located at the upper pole of the transplanted kidney. The patient was treated with empiric antibiotics and analgesics, and her symptoms subsided over the course of the week. Based on the clinical course and radiological findings, a self-limiting, spontaneous haemorrhage was thought to be the cause of the patient's symptoms. Nevertheless, background malignancy could not be ruled out. Therefore, an interval, elective graft nephrectomy was scheduled. Pathology confirmed the diagnosis of renal clear cell carcinoma.

Does the recurrence of pregnancy-associated breast cancer during subsequent pregnancy 10 years after mastectomy support the unique hormonal milieu of pregnancy as a cause of tumorigenesis? A case and literature review

Abstract #3058

We report a case of pregnancy-associated chest wall recurrence of breast adenocarcinoma 10 years following mastectomy and reconstruction for initial pregnancy-associated breast cancer (PABC). This represents the first reported case in the literature of a pregnancy-associated recurrence of pregnancy-associated breast cancer. The patient had no episodes of recurrent breast cancer during the interim 10 years, and only experienced a recurrence with a rapidly growing left chest mass during the subsequent pregnancy. Thus, the possibility that the malignancy may have been triggered by the pregnancy cannot be ignored.
 Although prior studies following breast cancer patients and their subsequent pregnancy have not shown an increase risk of recurrence, these studies were performed in “all comers” with breast cancer, and would not have had the statistical power to distinguish a small subset of patients with an increased risk, such as PABC patients. As a result, these patients have been assumed to be at no greater risk for recurrence with pregnancy and have been advised as such.
 It is reasonable to assume that PABC patients may, in fact, represent a unique subset of breast cancer patients with the unique hormonal milieu of pregnancy playing a mechanistic role in the propagation and proliferation of the disease. In this case a patient with prior PABC had a rapidly growing progesterone receptor positive breast cancer during a subsequent pregnancy. Further, studies have indicated that there is a possibility that the hormone status of women during pregnancy may in fact lead to a change in tumor characteristics, and therefore their risks. This instance would support the concern and represent the sentinel report describing a new subset of breast cancer with a unique spectrum of risk factors.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 3058.

Internal hernias: clinical findings, management, and outcomes in 49 nonbariatric cases

Internal hernia, the protrusion of a viscus through a peritoneal or mesenteric aperture, is a rare cause of small bowel obstruction. We report the clinical presentation, surgical management, and outcomes of one of the largest series of nonbariatric internal hernias. Ten-year retrospective review of patients at our institution yielded 49 cases of internal hernias. Majority of patients presented with symptoms of acute (75%) or intermittent (22%) small bowel obstruction. While 16% of CT scans were suspicious for internal hernia, in no cases the preoperative diagnosis of internal hernia was made. The most frequent internal hernias were transmesenteric (57.0%) and 34 hernias (69%) were caused by previous surgery. All internal hernias were reduced and the defects were repaired. Compromised bowel was present in 22 cases and 11 patients underwent small bowel resection. The mean postoperative hospitalization was 10.9 days. The overall mortality rate from our series is 2%, and the morbidity rate is 12%. Transmesenteric hernias, as complications of previous surgeries, are the most prevalent internal hernias. Preoperative diagnosis of internal hernia is extremely difficult because of the nonspecific clinical presentation. However, if discovered promptly, internal hernias can be repaired with acceptable morbidity and mortality.

The management of 38 anastomotic leaks after 1,684 intestinal resections

PURPOSE

This study was designed to evaluate the management of anastomotic leaks and assess the impact of outpatient leak presentation on clinical outcome.

METHODS

Thirty-eight patients with clinical anastomotic leaks from 1,684 adult patients undergoing large and small intestinal anastomosis in a tertiary referral center between January 1, 2003 and September 1, 2005 were studied. All pediatric patients and adult patients with esophageal and gastric leaks were excluded. Charts were reviewed for information on anastomotic leak management, discharge status before leak presentation, length of stay, readmissions, and mortality.

RESULTS

The overall leak rate was 2.3 percent. Eighty-seven percent of patients (n = 33) were managed operatively. Forty-two percent of patients (n = 16) were discharged after initial operation and presented as outpatients with anastomotic leak. The discharge and inpatient groups were comparable in respect to total length of stay (26.9 vs. 33.4 days) and number of readmissions (2 vs. 1.5). The overall mortality of 5 percent (n = 2) originated from the discharge group. A greater percentage of discharge patients required intensive care unit stays for more than two weeks (25 vs. 14 percent) and very long hospital admissions lasting more than two months (31 vs. 9 percent). A smaller percentage of the discharge group patients had their ostomies reversed (31 vs. 50 percent).

CONCLUSIONS

The primary management of clinical anastomotic leak remains intestinal diversion. Although length of stay was shorter in the discharge group, the number of patients who experienced significant intensive care unit stays and very long hospital stays was greater. Within the discharge group, mortality was higher and fewer patients had their ostomies reversed.

Mesenteric fibromatosis masquerading as an ovarian neoplasm twenty years after Chernobyl radiation exposure

BACKGROUND

Since their initial description in 1832, desmoid tumors have been reported to occur in virtually every part of the body. Intra-abdominal desmoid tumors, or mesenteric fibromatosis, are often associated with Familial Adenomatous Polyposis mutation in a syndrome known as Gardner's Syndrome. Although sporadic cases of desmoid tumors do occur, unlike Gardner's Syndrome, they predominantly occur extra-abdominally.

CASE

Case report of a 61-year-old female who presented with two months of abdominal pain, progressive lower abdominal distension and a 10-15 pound weight gain accompanied by one week of urinary hesitancy and frequency. Patient underwent a diagnostic workup for an ovarian neoplasm, but was found at surgery to have mesentric fibromatosis.

CONCLUSION

Although uncommon, mesentric fibromatosis must be considered in the differential diagnosis when evaluating a patient with an abdominal mass of unknown origin.

Modulatory effects on human sensorimotor cortex by whole-hand afferent electrical stimulation

OBJECTIVE

To investigate the effect of electrical stimulation of the nerve afferents of the hand on cortical activity elicited by whole-hand subthreshold stimulation for sensation in healthy human subjects.

METHODS

Ten healthy volunteers were studied using BOLD-fMRI with 1) a test motor-task with finger-to-thumb tapping of the left hand, 2) a whole-hand afferent electrical stimulation of the left hand below the sensory level for sensation for 30 minutes, 3) a second fMRI run with the same paradigm as in the test motor-task immediately after electrical stimulation, and 4) a final identical fMRI run 2 hours post-stimulation to test the cortical changes induced by electrical stimulation. Experiments were carried out on a 1.5 T MR scanner and for fMRI echoplanar sequences were used. Data analysis was performed with SPM99.

RESULTS

An increase of movement-related responses was seen within the primary motor and primary somatosensory areas of both hemispheres when comparing the test motor-task with the motor-task after electrical stimulation relative to the baseline or sham stimulation. Two hours post-stimulation the modulatory effects of mesh-glove stimulation diminished to baseline level except within the contralateral primary motor region.

CONCLUSIONS

The increased BOLD response spatially localized within the sensorimotor cortex reflects an increase in neuronal activity that may provide augmented neuronal excitability.

Neuropathic pain after femoropopliteal bypass surgery

OBJECTIVE

This retrospective study was performed to investigate prolonged postoperative pain in the area of the proximal or distal scar or the bypass tunnel after femoropopliteal bypass surgery to treat symptomatic peripheral arterial disease.

PATIENTS AND METHODS

Ninety-three patients with peripheral arterial disease who underwent femoropopliteal bypass surgery between January 2000 and December 2002 were included in the study. The short-form McGill Pain Questionnaire was used to score pain. Ultrasound examination of the soft tissue around the graft was performed to exclude other pathologic conditions responsible for pain, such as inflammatory processes, perigraft reactions, swollen lymph nodes, and hematomas.

RESULTS

Pain in at least one scar existed in 22 patients on average 13.9 +/- 9.8 months after surgery. In 10 patients pain existed simultaneously along the inguinal scar and the above-knee or below-knee scar. Pain along the bypass tunnel was experienced by seven patients. Most patients had mild to moderate pain. The mean numeric ranking score of pain severity in patients with pain was 4.2 +/- 2.3. The occurrence of prolonged postoperative pain was not associated with age, gender, diabetes, indication for surgery, material or type of bypass, number of preceding operations, or postoperative wound complications. Only follow-up time after femoropopliteal bypass surgery tended to be lower in patients with pain compared with those without pain.

CONCLUSION

Prolonged postoperative neuropathic pain along the distal and proximal incision or the bypass tunnel exists in one fourth of patients after femoropopliteal bypass surgery. Patients should be informed of this kind of complication before surgery. The results of our study justify further investigations of the origin and treatment of this pain, to find effective methods to reduce the incidence of prolonged postoperative pain after femoropopliteal bypass surgery.

Prospective randomized trial using laser acupuncture versus desmopressin in the treatment of nocturnal enuresis

OBJECTIVES

Several treatment modalities for children suffering from monosymptomatic nocturnal enuresis are available, but desmopressin is a well-established option. On the other hand, alternative nonpharmacological therapies such as laser acupuncture are more frequently requested by the parents. To our knowledge, there is no prospective randomized trial which evaluated the efficacy of such an alternative approach in comparison with the widespread use of desmopressin.

METHODS

Forty children aged over 5 years presenting with primary nocturnal enuresis underwent a previous evaluation of their voiding function to assure normal voiding patterns and a high nighttime urine production. Then the children were randomized into two groups: group A children were treated with desmopressin alone, and group B children underwent laser acupuncture. All children were investigated after a minimum follow-up period of 6 month to evaluate the duration of the response.

RESULTS

The children of both groups had an initial mean frequency of 5.5 wet nights per week. After a minimum follow-up period of 6 months reevaluation revealed a complete success rate of 75% in the desmopressin-treated group. Additional 10% of the children had a reduction of their wet nights of more than 50%. On the other hand, 6 months after laser acupuncture, 65% of the randomized children were completely dry. Another 10% had a reduction of the enuresis frequency of more than 50% per week. 20% of the children in the desmopressin-treated group did not respond at all as compared with 15% in the acupuncture-treated group. Statistical evaluation revealed no significant differences among the response rates in both groups.

CONCLUSION

Im comparison with pharmacological therapy using desmopressin, our study shows that laser acupuncture should be taken into account as an alternative, noninvasive, painless, cost-effective, and short-term therapy for children with primary nocturnal enuresis in case of a normal bladder function and high nighttime urine production. Success rates indicated no statistically significant differences between the well-established desmopressin therapy and the alternative laser acupuncture.

Low-power laser light in the healing of burns: a comparison between two different wavelengths (635 nm and 690 nm) and a placebo group

BACKGROUND AND OBJECTIVE

Studies on the influence of low-power laser light on wound healing have shown inconsistent results, or, as in the case of burns, are very scarce. We have studied the effects of two different low-power diode laser lights on the healing of burns in rats.

STUDY DESIGN/MATERIALS AND METHODS

Thirty rats were burned on both flanks and randomly allocated to one of three study groups. In group A, both wounds remained untreated; in groups B and C, one wound each was irradiated with 635 nm or 690 nm laser light (1.5 J/cm(2)), whereas the other wound remained untreated. Diameter, redness, and edema of the wounds were examined daily.

RESULTS

Between and within groups, diameter, redness, and edema of the wounds were similar throughout the entire observation period. Irradiation of the burns did not accelerate wound healing when compared with control wounds.

CONCLUSION

We conclude that neither 690 nm nor 635 nm low-power laser light produced any beneficial effects on the healing processes of burns in rats.

Korean hand acupressure reduces postoperative vomiting in children after strabismus surgery

A double-blind, randomized, placebo-controlled study was conducted to investigate the effectiveness of Korean hand acupuncture in preventing postoperative vomiting in children scheduled for strabismus surgery. In one group, acupressure was performed 30 min before induction of anaesthesia by applying an acupressure disc onto the Korean hand acupuncture point K-K9; the disc remained in situ for at least 24 h. The second group functioned as placebo group. The treatment groups did not differ with regard to patient characteristics, surgical procedure and anaesthetic administered. In the acupressure group, the incidence of vomiting was significantly lower (20%) than in the placebo group (68%). We conclude that Korean hand acupressure of the acupuncture point K-K9 is an effective method for reducing postoperative vomiting in children after strabismus repair.

Exogenous neopterin causes cardiac contractile dysfunction in the isolated perfused rat heart

Neopterin is known in humans as a sensitive marker for diseases associated with increased activity of the cellular immune system. Recent studies report neopterin also to exhibit distinct effects: neopterin induces inducible nitric oxide synthase expression in rat vascular smooth muscle cells and activates translocation of nuclear factor- kappa B. Neopterin may also induce oxidative stress causing apoptotic cell death, or superinduce tumor necrosis factor- alpha -mediated apoptosis. Observing these effects in cell cultures, we were interested in possible consequences of neopterin on cardiac function in the isolated perfused rat heart. The influence of neopterin in three different concentrations (10 micromol/l, 50 micromol/l, 100 micromol/l) on cardiac contractility parameters and coronary vascular resistance were studied in 67 male Sprague-Dawley rats using the temperature-controlled and pressure-constant Langendorff apparatus with retrograde perfusion of the aorta with a Krebs-Henseleit buffer. Treatment with 100 micromol/l neopterin resulted in a significant decrease in coronary flow and cardiac contractility. Coronary flow decreased from 15.2 to 9.5 ml/min (P=0.002), left ventricular pressure from 80 to 52 mmHg (P=0. 002), rate of pressure fall from 1605 to 923 mmHg/s (P=0.001) and rate of pressure rise from 2862 to 1709 mmHg/s (P=0.001). Concentrations lower than 100 micromol/l neopterin had no significant effect on cardiac function. Our study demonstrates a considerable influence of exogenous neopterin on cardiac performance in the Langendorff model of isolated perfused rat hearts. This has to be considered a potential pathogenic factor of cardiac disturbances in diseases in which high concentrations of neopterin are released due to immune activation. At present the exact mechanism remains unclear.

Oxygen application by a nasal probe prevents hypoxia but not rebreathing of carbon dioxide in patients undergoing eye surgery under local anaesthesia

BACKGROUND/AIM

Hypoxia and carbon dioxide rebreathing are potential problems during eye surgery in spontaneously breathing patients. The aim of the present study was to determine effectiveness of nasal application of oxygen to prevent hypoxia and carbon dioxide accumulation in spontaneously breathing patients undergoing cataract surgery.

METHODS

Oxygenation and carbon dioxide rebreathing were examined in 40 elderly patients using two different methods of oxygen supply-nasal v ambient air-with a constant flow of 2 l/min. Partial pressure of carbon dioxide under ophthalmic drapes, transcutaneous pressure of carbon dioxide, and the respiratory rate were measured during 25 minutes while oxygen was supplied via a nasal cannula or into the ambient air under the drapes.

RESULTS

In both groups carbon dioxide accumulation under the drapes, carbon dioxide rebreathing, tachypnoea, and an increase in peripheral oxygen saturation occurred. No significant differences were found between the two methods.

CONCLUSION

Nasal application of oxygen prevented hypoxia but did not prevent carbon dioxide accumulation in patients undergoing eye surgery under retrobulbar anaesthesia. Additionally, as a side effect when using nasal probes, irritation of the nose was described in half of the patients investigated.

Healing of burns after treatment with 670-nanometer low-power laser light

Recent investigations have reported contradictory results on the influence of low-power laser light on wound healing. Low-power laser with a power output of 250 mW and an emitted laser light of 670 nm have been insufficiently investigated to date. The effect of a 250-mW/670-nm laser light on the healing of burning wounds in rats was investigated. Thirty rats were burned on both flanks. One wound was irradiated with 670-nm laser light (2 J/cm2), whereas the other side remained untreated. Macroscopic evaluation of the wounds was performed daily; 10, 20, and 30 days after burning, 10 rats were killed and the wounds histologically evaluated. Neither macroscopic nor histologic examination of the irradiated wound showed accelerated wound healing when compared with control wounds. In the present study, irradiation of burns with a 250-mW/670-nm laser light produced no beneficial effects on wound-healing processes.

Rectally administered dimenhydrinate reduces postoperative vomiting in children after strabismus surgery

We have investigated the effectiveness of rectally administered dimenhydrinate on postoperative vomiting in children undergoing strabismus surgery, in a double-blind, randomized, placebo-controlled study. In one group, dimenhydrinate 50 mg was administered rectally 30 min before starting anaesthesia, whereas in the control group, placebo suppositories were given. Children who received dimenhydrinate showed a significantly (P < 0.001) lower incidence of vomiting (15%) than those in the control group (75%). We conclude that rectal administration of dimenhydrinate is an effective means of reducing postoperative vomiting in children undergoing strabismus surgery.

Effect of fluvoxamine on sufentanil antinociception and tolerance under chronic intravenous infusion in rats

Fluvoxamine, a selective serotonin reuptake inhibitor (SSRI), significantly potentiates analgesia when administered in animals together with opioids. The aim of the present study was to investigate the effects of fluvoxamine on sufentanil antinociception and tolerance. Following animal care committee approval, the effects of continuous infusions of fluvoxamine and sufentanil were studied in behavioural tests (hot-plate test, tail-flick test, catalepsy test) in Sprague-Dawley rats with a jugular vein catheter. Saline was administered as a control. The time-effect curves for continuous intravenous sufentanil indicate dose-related antinociception and rapid development of tolerance in the hot-plate and tail-flick tests. Co-administration of fluvoxamine with continuous sufentanil enhances antinociception and attenuates development of tolerance, most clearly seen in the tail-flick test. Fluvoxamine alone and saline were not effective. No animal showed catalepsy. As a side effect we observed a marked loss of body weight. The IC50 values of sufentanil binding with and without fluvoxamine addition are 0.56+/-0.17 nM and 0.3+/-0.15 nM, respectively, indicating no direct effect on the occupancy of sufentanil on the mu-receptor by this serotonin reuptake inhibitor. In conclusion, we were able to show that the combination of an opioid with an SSRI at low doses improves analgesia and decreases development of tolerance in nociceptive tests in rats. The clinical implications of these promising results in an animal model, however, await further investigation.

Heat trapped under paper and plastic ophthalmic drapes during eye surgery using local anesthesia

PURPOSE

To assess whether heat trapped under ophthalmic drapes is responsible for patient reports of being hot during cataract surgery using local anesthesia.

SETTING

Departments of Anaesthesia and Intensive Care Medicine and of Ophthalmology and Optometry, Innsbruck University Hospital, Innsbruck, Austria.

METHODS

In a prospective, randomized, single-blind study, the temperature in the ambient air under 2 types of paper drapes (Group A: Barrier Ophthalmology Drape, Johnson & Johnson; Group B: Steri Drape 1062, 3M) and a plastic drape (Group C: cotton drape + Steri Drape 1024, 3M) was measured for 25 minutes in 60 patients having cataract surgery under local anesthesia.

RESULTS

Three minutes after the patient's head was draped, the mean temperature under the drape began to increase significantly: Group A, 25.7 degrees C +/- 0.3 degree C (SD) to 29.17 degrees C +/- 0.9 degree C (P < or = .001); Group B, 25.87 degrees C +/- 0.4 degree C to 29.41 degrees C +/- 0.9 degree C (P < or = .001); Group C, 25.8 degrees C +/- 0.35 degree C to 29.4 degrees C +/- 0.6 degree C (P < or = .001). It continued to increase in all groups as the operation continued. No significant differences in temperature were observed among the 3 drape types studied. Subjective thermal discomfort was reported by 35% to 40% of patients.

CONCLUSION

Paper drapes did not cause less heat from being trapped than the plastic drape. Trapped heat may impair the comfort of patients having eye surgery under local anesthesia.

New support for ophthalmic drapes

A new flexible support for ophthalmic drapes with the possibility of continuous oxygen supplementation was designed for use in patients undergoing eye surgery under local anesthesia. This new equipment is easy to handle and prevents contact between the patient's face and the ophthalmic drape. To prevent hypoxia of spontaneously breathing patients, the ambient air under the drapes can be supplemented with oxygen using this new equipment and no other devices. The equipment described here is advantageous for practical use in patients undergoing eye surgery under retrobulbar anesthesia.

New equipment to prevent carbon dioxide rebreathing during eye surgery under retrobulbar anaesthesia

BACKGROUND

Carbon dioxide concentration under ophthalmic drapes increases during eye surgery under local anaesthesia. A new prototype has been designed which combines continuous suction of carbon dioxide enriched air and continuous oxygen insufflation under ophthalmic drapes to prevent carbon dioxide accumulation in spontaneously breathing patients undergoing cataract surgery.

METHODS

In a prospective randomised single blind study the effectiveness of this new prototype was examined in 50 unpremedicated elderly patients. In 25 patients suction was applied under ophthalmic drapes, whereas in the other 25 patients no suction was used. In all cases oxygen was insufflated under the drapes at a constant flow of 2 l/min. Carbon dioxide concentration in the ambient air surrounding the patient's head under ophthalmic drapes, transcutaneous partial pressure of carbon dioxide, respiratory rate, and oxygen saturation were measured.

RESULTS

Carbon dioxide concentration under the drapes, transcutaneous partial pressure of carbon dioxide, and respiratory rate remained unchanged in the suction group, whereas in the non-suction group these values increased significantly. Oxygen saturation rose significantly in both groups without differences between the groups.

CONCLUSION

Application of this new prototype for continuous aspiration of carbon dioxide enriched air prevents carbon dioxide rebreathing and subsequent hypercapnia associated with an elevated respiratory rate. This new equipment may therefore be useful in patients undergoing ophthalmic surgery under retrobulbar anaesthesia.

Accumulation of carbon dioxide under ophthalmic drapes during eye surgery: a comparison of three different drapes

Carbon dioxide accumulation under ophthalmic drapes is caused by their impaired permeability to exhaled carbon dioxide in spontaneously breathing patients. Three different ophthalmic drapes were examined under clinical conditions. Sixty unpremedicated patients of each gender, aged over 60 years and with an ASA status of I-III undergoing cataract surgery under retrobulbar anaesthesia were included in the study. Patients with known pulmonary diseases were excluded. The patients were divided into three groups of 20 patients each. In all groups, oxygen was insufflated under the drapes at a constant flow of 21.min-1. Carbon dioxide concentration in the inspired air, transcutaneous carbon dioxide pressures, respiratory rate and oxygen saturation by pulse oximetry were measured. Accumulation of carbon dioxide under the drapes, increase of partial pressure of transcutaneous carbon dioxide and hyperventilation were observed in all three groups. An oxygen supply of 21.min-1 prevented hypoxaemia but not hypercapnia. Therefore, producers of ophthalmic drapes are encouraged to look for further ways to increase the carbon dioxide permeability of their drapes with the aim of reducing carbon dioxide accumulation and hyperventilation in spontaneously breathing patients undergoing eye surgery.

[Acupuncture in prevention of postoperative nausea and vomiting]

In this review the effectiveness of the acupuncture point Pericard 6 (P 6) on postoperative nausea and vomiting (PONV) is described. Use of the acupuncture, acupressure as well as the laser stimulation of P 6 proved as efficient prophylaxis of PONV in numerous studies. These methods are free of side effects and represent therefore a good alternative to the pharmacological prophylaxis and treatment of PONV.