Patient Discomfort in Relation to Thyroid Nodule Fine-Needle Aspiration (FNA) Performed with or without Parenteral and/or Topical Anesthetic

OBJECTIVE

There is much reported variation in the impact of local anesthesia on thyroid fine-needle aspiration (FNA) related discomfort. We compare patients undergoing thyroid FNA with subcutaneous injection or topical anesthetic to no anesthetic.

METHODS

We conducted a retrospective review of 585 sequential ultrasound guided thyroid FNA procedures in Mayo Clinic. Group 1 (n = 200), no anesthetic; Group 2 (n = 185), subcutaneous injection anesthetic; and Group 3 (n = 200), topical anesthetic. Patient demographics, number of FNA passes, needle gauge, and cytopathology were recorded plus a discomfort score (0 to 10) before and immediately post procedure in all 3 groups and peak discomfort during the FNA in Groups 1 and 2.

RESULTS

There were no differences among the 3 groups in age, sex, FNA sufficiency rate, cytopathology, and FNA passes number. There was no significant difference between Groups 1 and 2 in peak discomfort score during the FNA: 0 (45%, 42.2%), 1 to 2 (19%, 24.9%), 3 to 5 (23.5%, 20.5%), 6 to 8 (9.5%, 10.8%), 9 to 10 (3%, 1.6%), respectively. Discomfort score post procedure: 0 (78.5%, 77.8%, 53.5%), 1 to 2 (13%, 13%, 36.5%), 3 to 5 (7%, 7%, 9%), 6 to 8 (1.5%, 2.2%, 1%), 9 to 10 (0%, 0%, 0%) for groups 1, 2, and 3, respectively. There were no significant differences among the 3 groups for a discomfort score ≥3.

CONCLUSION

FNA associated patient discomfort was comparable during and after the procedure regardless of the use of anesthetic or the type utilized. Approximately 90% of patients experienced mild to moderate discomfort during the procedure. And 90% reported no more than a level 2 discomfort post procedure.

ABBREVIATIONS

End = endocrinology; FNA = fine-needle aspiration; MCF = Mayo Clinic Florida; MCR = Mayo Clinic Rochester.

Laparoscopy-assisted ureterostomy- technique

INTRODUCTION

Urinary tract anomalies in children at times pose challenges in which immediate urinary diversion is required before definitive reconstruction. Open cutaneous ureterostomy technique is a well-established approach for this scenario. We describe the laparoscopy-assisted alternative.

MATERIAL AND METHODS

Transperitoneal laparoscopy is performed with three ports. One trans-umbilical 5mm port for vision and two 3mm working instruments, one of which is through the proposed ureterostomy site minimising scarring. The position of the third port is carefully checked both externally and internally. Laparoscopic identification of the dilated ureter is quick and easy. The redundant ureter is mobilised and excess excised if needed. The ureteric loop is then exteriorised and the ureterostomy fashioned externally. Proximal and distal patency is checked both externally and laparoscopically.

RESULTS

Nineteen patients underwent the procedure for primary VUR (n=6), neuropathic bladder 7, posterior urethral valve 4, and vesico-ureteric obstruction 2. The mean operative time was 40 minutes. the patients received three doses of perioperative antibiotics and were discharged in 72 hours (mean). At three months, clinical and ultrasound review have shown satisfactory and stable upper tracts and no episodes of UTI.

DISCUSSION

The laparoscopic view gives the benefit of direct visualisation and identification with adequate dissection in order to bring the ureter to the surface in a tensionless manner. A redundant ureter can be easily addressed to correct tortuosity or redundancy appropriately. Bladder drainage can be ensured with careful dissection of the distal ureter and inspection at the end of the procedure.

CONCLUSION

Laparoscopy-Assisted ureterostomy formation is easy and quick to perform. It is feasible even in the smallest of babies, assures the shortest segment of ureter to the bladder providing prompt drainage in a refluxing ureterostomy setting. Our early experience is promising with potential benefits.

Laparoscopic posterior appendix Mitrofanoff using the modified Shanfield anastomosis

Laparoscopic transperitoneal technique for appendicovesicostomy was performed in a 5-year-old boy with a non-neurogenic neuropathic bladder using a transumbilical 5-mm port, two 3-mm working ports and a modified Shanfield anastomosis. Posterior extramucosal detrusorotomy and submucosal dissection was performed. The proximal appendix was spatulated and advanced into the bladder through a mucosal window using a U-stitch and fixed. The detrusor was then approximated creating an antirefluxing extramucosal tunnel. VQ plasty was fashioned for stoma formation. The procedure and postoperative period were uneventful. Clean intermittent catheterisation (CIC) was established subsequently and continued for the last 6 months. Our experience shows that appendix Mitrofanoff can be performed with minimal number and size of ports, resulting in a good cosmetic outcome. A simplified anastomosis makes it less cumbersome, and catheterisation is reliable as there is no mucosa-mucosa junction to negotiate.

Mid- to long-term outcomes of the 'anatomical approach' to congenital megaprepuce repair

INTRODUCTION

The understanding of the aetiopathogenesis and the long-term outcomes of correctional repair of congenital megaprepuce (CMP) remains unestablished. Different techniques have been described; however, optimum results have been difficult to achieve.

OBJECTIVE

The aim of our study was to review our experience of the 'anatomical approach' to the correction of CMP.

MATERIAL AND METHODS

This is a retrospective review of boys who underwent CMP repair between 2003 and 2014. All of them had the anatomical approach: A curved incision is made between the scrotal and penile skin. Circumferential dissection superficial to Buck's fascia frees the penis and allows the scrotum to assume a more caudal position. The dissection distally lifts the preputial sac that is opened ventrally. The redundant inner preputial skin is excised. After full degloving, the dorsal flap of skin is thinned. The base of the flap is anchored, and the rectangle of skin is wrapped around the shaft. The remaining diamond-shaped incision is closed in a vertical line. Postoperatively, foam dressings and urethral catheter are left in place. Symptomatology, hospital stay, postoperative complications, redosurgery, voiding and cosmesis were evaluated.

RESULTS

Sixty-one patients had surgery at 5-151 months (median 17 months). Median hospital stay was 24 h (12-168 h). Foam dressings and urethral catheter were used in 47 boys and removed in outpatient clinic after 3-7 days. There were two immediate postoperative complications requiring surgery. One due to severe oedema and constriction ring, and the other had wound infection with wound breakdown, both in patients with no dressings (P < 0.05). Follow-up was available for 58 patients, with a median of 22 months (3-79 months). Two required redosurgery (3.5%), one with poor cosmetic result and one recurrence. In all patients, a normal circumcised appearance had been achieved and in 47, cosmetic result was excellent (81%). Five patients have residual suprapubic fat, and four, excess ventral skin. One with residual suprapubic fat has reached puberty and it has resolved. All declared good stream. The same technique was used for six patients with poor cosmetic result after surgery elsewhere. The outcome is excellent for all, with median follow-up of 20.5 months (5-31 months).

CONCLUSION

The 'anatomical' repair provides the ability to create the appearance of a standard circumcision, which is generally accepted as normality. Apart from the penis itself, this technique facilitates correction of the penoscrotal transposition, giving the external genitalia the best appearance. It seems to provide good functional and cosmetic outcomes, and it holds true at mid- to long-term follow-up. Dressings and catheter can potentially prevent postoperative complications. However, a prospective study with standardised parameters is required to confirm these findings.

Abstract P5-07-05: Obesity, adipose inflammation, and race in patients with early stage breast cancer

Background: Elevated body mass index (BMI) is associated with increased risk of estrogen receptor-positive postmenopausal breast cancer. Mechanistically, most individuals with elevated BMI have breast white adipose tissue inflammation (WATi) which confers increased breast cancer risk, particularly in those with existing benign breast disease. Individuals with WATi have elevated in-breast expression of aromatase and several systemic changes that increase breast cancer risk, including hyperinsulinemia and higher levels of C-reactive protein. However, women with normal BMI but high levels of body fat are also likely to harbor WATi and are at increased risk of postmenopausal breast cancer. The accuracy of BMI for assessing adiposity and predicting obesity-related disorders, including cancer, varies across race and ethnicity. Whether the association between BMI and WATi varies by race is unknown. Here we aimed to characterize relationships among breast WATi and clinicopathologic features in a racially diverse cohort undergoing mastectomy for breast cancer treatment.

Methods: Non-tumorous breast tissue and fasting blood were collected from women undergoing mastectomy for breast cancer treatment or prevention at a single center serving a racially diverse patient population. Breast WATi was detected by the presence of crown-like structures in the breast (CLS-B), which are composed of a dead/dying adipocyte surrounded by CD68+ macrophages. Clinicopathologic data were abstracted from electronic medical records. Associations among categorical variables were examined using Fisher's exact test. Relationships between continuous variables were examined using the Spearman correlation.

Results: As of May 18, 2018 62 patients have been accrued; median age 55 (range 32 to 84). Self-reported race distribution was: 36 (58%) Asian, 5 African American (8%), 20 (32%) Caucasian, and 1 (2%) unknown. Breast tissue has been analyzed for WATi in 60 cases thus far. Clinicopathologic features stratified by the presence or absence of breast WATi are presented in. Breast WAT inflammation was associated with obesity (P=0.02) and a trend to association was observed with dyslipidemia (P&lt;0.09).

VariableBreast WATi Absent (n=25)Breast WATi Present (n=35)Age, years  Median (range)51 (32 to 71)59 (36 to 80)BMI, kg/m2  Median (range)22.5 (18.1 to 35.3)28.0 (19.2 to 38.9)BMI Category  Underweight1 (4%)0 (0%)Normal16 (64%)10 (29%)Overweight5 (20%)18 (51%)Obese3 (12%)7 (20%)Race, n (%)  Asian15 (60%)19 (54%)African American2 (8%)3 (9%)Caucasian8 (32%)12 (34%)Unknown0 (0%)1 (3%)Menopausal Status, n (%)  Pre10 (40%)12 (34%)Post15 (60%)23 (66%)Hypertension, n (%)7 (28%)16 (46%)Diabetes mellitus, n (%)0 (0%)5 (14%)Dyslipidemia, n (%)1 (4%)11 (31%)

Conclusions: Breast adipose inflammation is associated with elevated BMI and possibly metabolic syndrome disorders in a racially diverse population. These findings are consistent with observations from predominantly Caucasian cohorts. Race-specific characteristics will also be examined. Study accrual is ongoing and updated results will be presented.

Citation Format: Iyengar NM, Siegel B, Malik M, Giri DD, Tsai J, Hughes M, Adam A, Williams S, Zhou XK, Rodgers W, Ginter P, Patel A, Yong F, Cherian A, August P, Dannenberg AJ. Obesity, adipose inflammation, and race in patients with early stage breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-07-05.

External stent in laparoscopic pyeloplasty: The K-wire technique

The majority of surgeons leave internal stents following laparoscopic pyeloplasty, which necessitates a second anaesthetic for removal. A novel technique of placing external nephro-ureteric stents, thus obviating a second procedure for retrieval, is shown in this video bank. As demonstrated in the video, a Kirschner wire (K-wire) is used to thread the stent in place. Although, there are few reports of using externalised stents in laparoscopic pyeloplasty, it is believed that this technique has not been previously described. So far this technique has been used in 22 patients without any stent-related complications. The technique is feasible, safe and reproducible. It obviates the need for a further anaesthetic and avoids potential risks of another procedure. Secondary benefits include avoiding another hospital admission.

Hydronephrotic kidney with multiple extra-renal calyces

Extra-renal calyces are a rare anomaly of the renal collecting system, characterised by the presence of calyces and pelvis outside the renal parenchyma. It may also be associated with other anomalies, such as renal ectopia, fusion and malrotation. We describe an unusual case of extra-renal calyces with six long calyces arising from a suspected multicystic dysplastic kidney that was successfully managed laparoscopically.

Global minimally invasive pyeloplasty study in children: Results from the Pediatric Urology Expert Group of the European Association of Urology Young Academic Urologists working party

INTRODUCTION

Minimally invasive pyeloplasty (MIP) for ureteropelvic junction (UPJ) obstruction in children has gained popularity over the past decade as an alternative to open surgery. The present study aimed to identify the factors affecting complication rates of MIP in children, and to compare the outcomes of laparoscopic (LP) and robotic-assisted laparoscopic pyeloplasty (RALP).

MATERIALS AND METHODS

The perioperative data of 783 pediatric patients (<18 years old) from 15 academic centers who underwent either LP or RALP with an Anderson Hynes dismembered pyeloplasty technique were retrospectively evaluated. Redo cases and patients with anatomic renal abnormalities were excluded. Demographics and operative data, including procedural factors, were collected. Complications were classified according to the Satava and modified Clavien systems. Failure was defined as any of the following: obstructive parameters on diuretic renal scintigraphy, decline in renal function, progressive hydronephrosis, or symptom relapse. Univariate and multivariate analysis were applied to identify factors affecting the complication rates. All parameters were compared between LP and RALP.

RESULTS

A total of 575 children met the inclusion criteria. Laparoscopy, increased operative time, prolonged hospital stay, ureteral stenting technique, and time required for stenting were factors influencing complication rates on univariate analysis. None of those factors remained significant on multivariate analysis. Mean follow-up was 12.8 ± 9.8 months for RALP and 45.2 ± 33.8 months for LP (P = 0.001). Hospital stay and time for stenting were shorter for robotic pyeloplasty (P < 0.05 for both). Success rates were similar between RALP and LP (99.5% vs 97.3%, P = 0.11). The intraoperative complication rate was comparable between RALP and LP (3.8% vs 7.4%, P = 0.06). However, the postoperative complication rate was significantly higher in the LP group (3.2% for RALP and 7.7% for LP, P = 0.02). All complications were of no greater severity than Satava Grade IIa and Clavien Grade IIIb.

DISCUSSION

This was the largest multicenter series of LP and RALP in the pediatric population. Limitations of the study included the retrospective design and lack of surgical experience as a confounder.

CONCLUSIONS

Both minimally invasive approaches that were studied were safe and highly effective in treating UPJ obstruction in children in many centers globally. However, shorter hospitalization time and lower postoperative complication rates with RALP were noted. The aims of the study were met.

Single incision retro-peritoneoscopic paediatric nephrectomy: early experience

Single incision, single port, or single site surgery for retro-peritoneoscopic nephrectomy and nephro-ureterectomy in paediatric practice using an advanced access platform (GelPOINT Mini) is described in two patients. One patient had bilateral synchronous nephrectomy. The technique, advantages, and challenges are reported. Beyond the initial hurdles and learning curve, this technique is promising and has the potential to be extended to other procedures in paediatric urology.

Primary bladder exstrophy closure in neonates: challenging the traditions

PURPOSE

We describe a novel approach to neonatal bladder exstrophy closure that challenges the role of postoperative immobilization and pelvic osteotomy.

MATERIALS AND METHODS

We reviewed the primary management of bladder exstrophy at our institutions between 2007 and 2011. In particular we compared postoperative management in the surgical ward using epidural analgesia to muscle paralysis and ventilation in the intensive care unit. Clinical outcome measures were time to full feed, length of stay, postoperative complications and redo closure. Cost-effectiveness was also evaluated using hospital financial data. Data are expressed as median (range). Significance was explored by Fisher exact test and unpaired t-test.

RESULTS

A total of 74 patients underwent primary closure without osteotomy. Successful closure was achieved in 70 patients (95%). A total of 48 cases (65%) were managed on the ward (group A) and 26 (35%) were transferred to the intensive care unit (group B). The 2 groups were homogeneous for gestational age (median 39 weeks, range 27 to 41) and age at closure (3 days, 1 to 152). Complications requiring surgical treatment were noted in 4 patients (8.3%) in group A and 3 (11.5%) in group B (p = 0.609). Length of stay was significantly shorter for the group managed on the ward (11 vs 18 days, p <0.0001). Median costs were $42,732 for patients admitted to the intensive care unit and $16,214 for those admitted directly to the surgical ward (p <0.0001).

CONCLUSIONS

Primary closure of bladder exstrophy without lower limb immobilization and osteotomy is feasible. Postoperative care on the surgical ward using epidural analgesia results in shorter hospitalization.

A massive occult pericardial effusion in an athletic young male

We present a case of a 27-year-old Royal Marine with a massive pericardial effusion, presenting with minimal clinical findings, suggesting that high levels of physical fitness may effectively mask the normal symptoms of this potentially life-threatening condition.

Combined laparoscopic and cystoscopic injection sclerotherapy for bladder venous malformation: a novel technique

Treatment of vascular malformations of the urinary bladder can be challenging. We report a case of bladder venous malformation treated with sodium tetradecyl sulphate (STS 3%) sclerotherapy, using a combined cystoscopic and percutaneous transperitoneal laparoscopy guided approach. When cystoscopic views are poor, the laparoscopic approach is a useful adjunct to aid sclerotherapy of bladder venous malformation. This technique has not been previously described.

Ileal bladder augmentation and vitamin B12: levels decrease with time after surgery

OBJECTIVE

We investigated vitamin B12 deficiency following ileocystoplasty in children.

METHODS

Patients who underwent ileocystoplasty between December 1993 and September 2006 were included and B12 levels were retrospectively analysed. Patients with a serum B12 of less than 150 pg/ml were considered deficient. The distance of the ileal segment from the ileocaecal valve was recorded.

RESULTS

There were 105 patients in the series; 61 were male. Mean age at surgery was 7.7 years (SD = 3.9). The mean interval from surgery to most recent B12 level was 50 months (SD = 30). None of the patients were on B12 supplementation. Two patients were B12 deficient, both more than 7 years after surgery; 44% of patients with levels available 7 years after surgery had a B12 below 300 pg/ml. There was a significant negative correlation between B12 level and length of follow up (Spearman's rank, P < 0.01). Twenty patients with an ileal segment sparing 60 cm from the ileocaecal valve had a higher mean B12 (524 vs 419, SEM 60 vs 28). This was not statistically significant.

CONCLUSION

We demonstrate a reduction in serum B12 level with time following ileocystoplasty. These patients should have their B12 levels measured in the long term.

Intracranial hypertension with delayed puberty: a rare presentation of juvenile onset systemic lupus erythematosus

An adolescent boy presented with headache, bilateral papilloedema, growth retardation and absent secondary sexual characteristics. The diagnosis of intracranial hypertension was confirmed by increased intracranial pressure and normal neuroimaging of the brain except for partial empty sella and prominent perioptic cerebrospinal fluid (CSF) spaces. Evaluation showed an erythrocyte sedimentation rate of 150 mm/hr, positive antinuclear antibody, anti-dsDNA and antiribosomal P protein. Renal biopsy revealed diffuse segmental proliferative lupus nephritis (LN) class IV-S (A), which confirmed the diagnosis of systemic lupus erythematosus (SLE). Treatment of LN with intravenous pulse methylprednisolone and cyclophosphamide normalised the patient's CSF pressure and symptoms. In cases of intracranial hypertension, SLE must be considered. Growth retardation and absence of secondary sexual characteristics could coexist and may be presenting features of SLE. These manifestations point to advanced grades of LN, which could be asymptomatic and may be missed without a renal biopsy.

Motor cortical prediction of EMG: evidence that a kinetic brain-machine interface may be robust across altered movement dynamics

During typical movements, signals related to both the kinematics and kinetics of movement are mutually correlated, and each is correlated to some extent with the discharge of neurons in the primary motor cortex (M1). However, it is well known, if not always appreciated, that causality cannot be inferred from correlations. Although these mutual correlations persist, their nature changes with changing postural or dynamical conditions. Under changing conditions, only signals directly controlled by M1 can be expected to maintain a stable relationship with its discharge. If one were to rely on noncausal correlations for a brain-machine interface, its generalization across conditions would likely suffer. We examined this effect, using multielectrode recordings in M1 as input to linear decoders of both end point kinematics (position and velocity) and proximal limb myoelectric signals (EMG) during reaching. We tested these decoders across tasks that altered either the posture of the limb or the end point forces encountered during movement. Within any given task, the accuracy of the kinematic predictions tended to be somewhat better than the EMG predictions. However, when we used the decoders developed under one task condition to predict the signals recorded under different postural or dynamical conditions, only the EMG decoders consistently generalized well. Our results support the view that M1 discharge is more closely related to kinetic variables like EMG than it is to limb kinematics. These results suggest that brain-machine interface applications using M1 to control kinetic variables may prove to be more successful than the more standard kinematic approach.

Central nervous system tuberculosis

Central nervous system (CNS) involvement, one of the most devastating clinical manifestations of tuberculosis (TB) is noted in 5 to 10% of extrapulmonary TB cases, and accounts for approximately 1% of all TB cases. Definitive diagnosis of tuberculous meningitis (TBM) depends upon the detection of the tubercle bacilli in the CSF. Every patient with TBM should preferably be evaluated by imaging with contrast enhanced CT either before or within the first 48 hours of treatment. An extra-neural focus of tuberculosis should be sought clinically and radiologically in all patients with CNS TB as it may indicate safer and more accessible sites for diagnostic samplings. A minimum of 10 months treatment is warranted, prompted by the uncertain influences of disease severity, CNS drug penetration, undetected drug resistance and patient compliance. All patients with TB meningitis may receive adjunctive corticosteroids at presentation regardless of disease severity even for those with HIV infection. Drug resistance is strongly associated with previous treatment. The key principle of managing drug-resistant TB is never to add a single drug to a failing regimen. Early ventriculo-peritoneal shunting should be considered in those with hydrocephalus failing medical management. The single most important determinant of outcome is the stage of tuberculous meningitis at which treatment has been started.

Strong purified protein derivative responses are associated with poor mycobacterium inhibition in latent TB

The tuberculin skin test (TST) using purified protein derivative (PPD) of Mycobacterium tuberculosis is traditionally used to diagnose latent tuberculosis (TB) infection (LTBI). However, LTBI diagnosis by peripheral blood mononuclear cell (PBMC) interferon (IFN)-gamma responses to M. tuberculosis-specific antigens, early secreted antigenic target 6 kDa (ESAT-6) and culture filtrate protein (CFP)-10 has greater specificity. We investigated the difference in antimycobacterium cellular immunity in TB contacts who were strong TST reactors but nonresponsive to the ESAT-6/CFP-10 assay compared with those with concordant results. Healthy TB contacts were tested using the above two assays and mycobacterium survival was measured after co-culture of infected macrophages with their PBMCs. Whether PPD reactivity was tested by TST or by PBMC-specific IFN-gamma responses, strongly PPD-reactive TB contacts without ESAT-6/CFP-10 responsiveness showed significantly better mycobacterium inhibition activity than ESAT-6/CFP-10-responsive TB contacts with the same PPD reactivity. In the former group, stronger PPD reactivity was associated with improved mycobacterium killing, whereas ESAT-6/CFP-10 responders showed the opposite result. PPD-reactive ESAT-6/CFP-10-nonresponsive TB contacts in our population may have had protective immunity related to prior mycobacterium exposure. ESAT-6/CFP10-responsive TB contacts are more likely to have LTBI and, in this group, strong PPD reactivity may paradoxically be associated with poor mycobactericidal activity.

Low-flow anaesthesia at a fixed flow rate

AIMS AND OBJECTIVES

This study attempts to assess the safety of low-flow anaesthesia (LFA) at fixed flow rates with particular reference to the incidence of a decline in FiO(2) below safe levels of 0.3 and to determine whether LFA can be used safely in the absence of an FiO(2) monitor.

METHODS

A total of 100 patients undergoing procedures under general anaesthesia at fresh gas flows of 300 ml/min of O(2) and 300 ml/min of N(2)O were monitored while maintaining the dial setting of isoflurane at 1.5% for 2 h. The changes in gas composition were analysed and even a single recording of FiO(2) of <0.3 was considered sufficient to render the technique unsafe in the absence of gas monitors.

RESULTS

The lowest recorded value of FiO(2) was 31% (v/v%). There was no incidence of adverse events necessitating the conversion from low flows to conventional flows.

CONCLUSIONS

We conclude that low flows of 300 ml/min of N(2)O and 300 ml/min of oxygen can be used safely for a period of 2 h without the use of monitors for gas analysis of oxygen and agent in adult patients weighing between 40 and 75 kgs.

Splenogonadal fusion: a rare cause of testicular enlargement

Splenogonadal fusion is a rare congenital abnormality found in boys and girls. There is fusion of the developing splenic anlage and the gonadal mesoderm at approximately week 5 of intrauterine life. It commonly presents as a testicular mass treated with an unnecessary orchidectomy. We report two cases of the discontinuous type presenting with testicular swelling and review the literature.

Thoracoscopic repair of diaphragmatic eventration

We report a 6-month-old child who presented with recurrent chest infections associated with a right diaphragmatic eventration. Failure in conservative management lead to thoracoscopic plication at 17 months of age and discharge on the third postoperative day. At one year followup he is completely free from all symptoms, and his chest x-ray demonstrates a marked improvement in the position of the diaphragm. We recommend thoracoscopy as a viable approach in treating this condition in children.

Small bowel volvulus due to giant mesenteric lipoma

We report on a 14-year-old girl with acute intestinal obstruction due to volvulus of the small bowel caused by a giant mesenteric lipoma. To the best of our knowledge, this presentation of a mesenteric lipoma is unknown in the previous paediatric literature.

Maternal depression and low maternal intelligence as risk factors for malnutrition in children: a community based case-control study from South India

AIMS

To determine whether current and postpartum maternal depression and low maternal intelligence are risk factors for malnutrition in children.

METHODS

In rural South India 72 children with malnutrition were identified from a central register; 72 controls were matched for age, gender, and residence.

RESULTS

Major depression in the postpartum period (OR 5.0, 95% CI 1.0 to 24.0), current major depression (OR 3.2, 95% CI 1.1 to 9.5), and low maternal intelligence (OR 3.8, 95% CI 1.3 to 11.1) were associated with malnutrition in the child. Low birth weight (OR 2.9, 95% CI 1.2 to 6.8) was also significantly associated with infant malnutrition. Conditional logistic regression adjusting for all other determinants yielded the following results: major depression during the postpartum period (OR 7.8; 95% CI 1.6 to 38.51), current major depression (OR 3.1; 95% CI 0.9 to 9.7), low maternal intelligence (OR 4.6; 95% CI 1.5 to 14.1), and low birth weight (OR 2.7; 95% CI 2.5 to 6.8). The interactions between current maternal depression and low birth weight and between postpartum depression and low maternal intelligence were statistically significant. The level of maternal intelligence was associated with nutritional status. The severity of malnutrition was also significantly associated with major depression during the postpartum period and low maternal intelligence.

CONCLUSION

There is evidence for an association between postpartum maternal depression, low maternal intelligence, and low birth weight with malnutrition in children aged 6-12 months.

Histamine-induced vasodilatation in the perfused mesenteric arterial bed of diabetic rats

In this study, we have examined the contribution of endothelium-derived nitric oxide (EDNO) and endothelium-derived hyperpolarizing factor (EDHF) to histamine-induced endothelium-dependent relaxation in the perfused mesenteric arterial bed of rats treated with streptozotocin (STZ) to induce diabetes. Histamine (10(-10) to 5 x 10(-6) mol) produced dose-dependent vasodilator response in the perfused mesenteric arterial bed of both control and diabetic animals. In order to isolate the EDHF component of histamine-induced vasodilator response, NG-nitro-L-arginine-methyl ester hydrochloride (L-NAME) (10(-4) M) and indomethacin (10(-6) M) were added to the Krebs solution throughout the experiment. Histamine induced vasodilatation in the perfused mesenteric bed in preparations from both control and diabetic rats. The vasodilator response to histamine was slightly potentiated in the diabetic rat preparations. Sodium nitroprusside (SNP)-induced relaxation was similar in diabetic and control rats. The role of EDNO in histamine-induced vasodilatation was also examined. Vascular preparations were perfused with 20 mM K(+)-Krebs solution to inhibit the EDHF contribution to histamine-induced vasodilatation. Under this condition, histamine induced a vasodilator response in preparations from both control and diabetic rats. However, relative to nondiabetic control animals, histamine-induced maximal response was significantly reduced in preparations from diabetic animals. Pretreatment with L-NAME (10(-4) M) attenuated histamine-induced vasodilatation in both preparations, indicating an NO-mediated vasodilator response. There was a significant attenuation in histamine-induced vasodilatation in the vascular preparations from diabetic rats. The vasodilator effect of calcium ionophore A23187 was investigated in preparations from control and diabetic rats to investigate receptor dysfunction associated with diabetes. A23187 (10(-11) to 10(-7) mol)-induced vasodilator response was not significantly different in the preparations from control and diabetic animals. In conclusion, our results indicated that histamine-induced vasodilation in the perfused mesenteric arterial bed of the STZ-induced diabetic rats is mediated by two vasodilator components, namely EDHF and EDNO. Under diabetic conditions, the EDHF component was potentiated, while histamine-induced vasodilation mediated by the EDNO component was attenuated.

Electro convulsive therapy in a pre-pubertal child with severe depression

Electro Convulsive Therapy (ECT) in pre-pubertal children is a controversial and underreported treatment. Even though the effectiveness and side effects of ECT in adolescents are comparable with those in adults, there is a pervasive reluctance to use ECT in children and adolescents. We report the case of a pre-pubertal child in an episode of severe depression with catatonic features, where a protracted course of ECT proved life-saving in spite of prolonged duration of seizures and delayed response to treatment. The case illustrates the safety and efficacy of ECT in children. Relevant literature is also reviewed along with the case report.

Endothelium-dependent relaxation in isolated renal arteries of diabetic rabbits

1 In this study, we have investigated the vasodilator response to acetylcholine under diabetes conditions in isolated renal arteries of rabbits. We have also examined the contribution of endothelium-derived nitric oxide (EDNO) and endothelium-derived hyperpolarizing factor (EDHF) to the endothelium-dependent relaxation caused by acetylcholine in the renal arteries of alloxan-induced diabetic rabbits. 2 Acetylcholine (10(-10) - 10(-4) M) produced cumulative concentration-response curve in the renal arteries of both control and diabetic rabbits. The EC50 values and maximal responses to acetylcholine were not significantly different relative to diabetic conditions. In order to isolate the EDHF component of acetylcholine-induced vasodilator response, L-nitro-methyl arginine ester (L-NAME, 10(-4) M) and indomethacin (10(-6) M) were added to the Krebs' solution throughout the experiment. Under these conditions, acetylcholine induced vasodilatation in the isolated renal arteries from both control and diabetic rabbits. The vasodilator response to acetylcholine was not affected under diabetic conditions. 3 Sodium nitroprusside (SNP)-induced relaxation was increased in the diabetic rabbits compared with the control animals. 4 Tetrabutyl ammonium (TBA, 0.5 mM) produced a significant reduction in acetylcholine-induced vasodilatation in both preparations from control and diabetic animals, consistent with involvement of K+ channels in mediating this response. Glibenclamide (1 microM) attenuated acetylcholine-induced vasodilatation in preparations from control animals only, while iberiotoxin (0.05 microM) significantly reduced the vasodilator response to acetylcholine in preparations from both control and diabetic animals. 5 The role of EDNO in mediating acetylcholine-induced vasodilatation was examined. The vascular preparations were incubated with 20 mM K(+)-Krebs' solution to inhibit the EDHF contribution to acetylcholine-induced vasodilatation. Under this condition, acetylcholine induced a vasodilator response in both preparations from control and diabetic rats. Pretreatment with L-NAME (10(-4) M) attenuated acetylcholine-induced vasodilatation in both preparations, indicating an nitric oxide-mediated vasodilator response. 6 Our results indicated that acetylcholine-induced vasodilatation in the isolated renal arteries of alloxan-induced diabetic rabbits was not affected under diabetic conditions. Acetylcholine-induced vasodilatation is mediated by two vasodilator components; namely, EDHF and EDNO. The contribution of EDHF and EDNO to acetylcholine-induced vasodilatation was not affected under diabetic conditions and there was no indication of endothelial dysfunction associated with diabetes. EDHF component was found to act mainly through high conductance Ca(2+)-activated K+ channels under normal and diabetic conditions, while the adenosine triphosphate-dependent K+ channels were involved in mediating acetylcholine vasodilator response in the control preparations only.

Progression to 100% off-pump coronary artery bypass with the Octopus 1 dual holder

BACKGROUND

Can off-pump coronary artery bypass grafting become the routine standard in all elective primary coronary artery bypass grafting (CABG) operations? This paper shows how this aim has been achieved during one year in 130 off-pump cases performed through a sternotomy. This strategy allows for full revascularization (up to six grafts) without the disadvantage of cardiopulmonary bypass. The study introduces a variant of the Octopus stabilizer, a single Octopus 1 arm (Medtronic, Inc., Minneapolis, MN) with a dual holder.

MATERIALS AND METHODS

From November 1998 through February 2000, 130 patients underwent coronary artery bypass grafting through a sternotomy off-pump utilizing a stabilizer and CO2 blower. The stabilizer most frequently used to achieve this was a single Octopus 1 arm equipped with a dual holder to accommodate two straight suction pods. The holder allowed increased flexibility and manipulation of the suction pods with an equivalent of seven degrees' freedom of motion at the dual holder junction. Techniques for carrying out total revascularization are discussed. The progress of proportion of elective primary CABG revascularization performed off-pump is shown and results are compared with published reviews of the literature for off-pump coronary revascularization.

RESULTS

Patient demographics included: age range 32 to 87, mean 61.3; female sex: 17%; ejection fraction < 50%: 54%; presence of left main stem disease: 17%. Overall Parsonnet risk score ranged 0-31, with a mean of 8.8. Graft numbers carried out were: 34 x 2, 34 x 3, 32 x 4, 25 x 5 and 5 x 6 anastomoses respectively. The mean number of distal anastomoses was 3.6 +/- 1.0. There was extensive coverage of the lateral aspect of the heart (153 circumflex territory grafts, 33%). Radial artery, left internal mammary artery or saphenous vein sequential (jump) grafts were used in 26 cases (20%). Apart from general experience, the use of the dual holder and wide opening of the right pleura were the two important factors allowing freedom for multi-vessel lateral and posterior wall grafting. Thirteen Genzyme (Genzyme Surgical Products, Inc., Cambridge, MA) and ten Octopus 2 (or 2+) stabilizers were used, mostly for two or three grafts. The remainder were carried out using the Octopus 1 (dual holder: 83). In the first three-month period, 31% of cases were off-pump compared to the last three-month period, when 96% were off-pump. In the last two months we performed 100% of all 27 cases referred off-pump. There were no deaths, strokes or myocardial infarctions. Ventricular arrhythmia occurred in two cases. Conversions to bypass were undertaken twice. Two unexpected renal failures occurred, neither of which were from the 13 patients with preoperative incipient renal failure, of whom none suffered a rise in postoperative creatinine of greater than 30%. The results compare favorably with published results despite having a large mean number of grafts of 3.6.

CONCLUSION

Off-pump surgery with full revascularization has now become feasible for all primary elective coronary artery graft operations.

Encapsulated fat necrosis: a case of 'thigh mouse'

Encapsulated fat necrosis is a rare condition with clinical features that closely resemble a lipoma. The aetiology and pathogenesis are not fully understood but the condition has a distinctive histological appearance. We describe a case of encapsulated fat necrosis that exhibited unusual mobility. The literature is also reviewed.

Use of a pulsatile beating heart model for training surgeons in beating heart surgery

BACKGROUND

Coronary artery bypass on the beating heart has undergone resurgence with the introduction of minimally invasive techniques and new stabilizing devices. It is important to develop a method for training surgeons to perform accurate anastomoses despite cardiac motion and to develop the skills needed for consistent results in this demanding field.

METHODS

A prosthetic model of the beating heart was created by Limbs and Things, Ltd. (Bristol, UK) and used in our center to simulate clinical situations of beating heart surgery. Anastomotic quality was evaluated using a pre-established set of criteria on patency and suturing with each anastomosis graded on a 12-point scale.

RESULTS

The average scores for trainees using the Pulsatile Beating Heart Model were 8.5 while that of the expert surgeon with MIDCAB experience was 11. Defects seen included cross-wall suturing and significant narrowing of the toe of the anastomosis. Scores improved with increasing practice during each session. Operators with more clinical experience scored higher. All surgeons felt the model duplicated the exposure and feel of the tissue characteristic of clinical cases.

CONCLUSIONS

The beating heart simulator provides excellent training for new as well as experienced surgeons, provides visual feedback of anastomotic errors, and instills increasing confidence in the participants in their ability to construct accurate anastomoses on the beating heart.