Oral Losartan After Limited Mandibulectomy for Treatment of Desmoid-Type Fibromatosis

Desmoid-type fibromatosis (DF) is a rare soft tissue lesion with an annual incidence of 2 to 4 per million population and peak incidence occurring at approximately 4.5 years of age. While benign, the tumor has a locally aggressive infiltrative growth pattern and a high rate of recurrence. Given the functional and aesthetic implications of excision and reconstruction in the facial skeleton, novel medical treatment options are highly desirable. We describe the case of a 3-year-old boy who presented with an enlarging, asymptomatic mass involving the left mandible. Biopsy revealed an immunohistochemical profile consistent with DF. Despite the high likelihood of recurrence, conservative, mandible-sparing en bloc resection and limited mandibulectomy were performed. Pathological and immunohistochemical analysis of the resection specimen revealed DF with grossly positive margins and elevated expression of angiotensin II type 1 receptor. Postoperative medical treatment with the angiotensin receptor blocker losartan was initiated. The patient remains medically stable and disease progression-free on repeat imaging at 20 months post-resection. We describe for the first time the successful use of the angiotensin blocker losartan following conservative surgery for management of DF.

Choosing Wisely Canada - pediatric otolaryngology recommendations

The Choosing Wisely Canada campaign raises awareness amongst physicians and patients regarding unnecessary or inappropriate tests and treatments. Using an online survey, members of the Pediatric Otolaryngology Subspecialty Group within the Canadian Society of Otolaryngology – Head & Neck Surgery developed a list of nine evidence based recommendations to help physicians and patients make treatment decisions regarding common pediatric otolaryngology presentations: (1) Don’t routinely order a plain film x-ray in the evaluation of nasal fractures; (2) Don’t order imaging to distinguish acute bacterial sinusitis from an upper respiratory infection; (3) Don’t place tympanostomy tubes in most children for a single episode of otitis media with effusion of less than 3 months duration; (4) Don’t routinely prescribe intranasal/systemic steroids, antihistamines or decongestants for children with uncomplicated otitis media with effusion; (5) Don’t prescribe oral antibiotics for children with uncomplicated tympanostomy tube otorrhea or uncomplicated acute otitis externa; (6) Don’t prescribe codeine for post-tonsillectomy/adenoidectomy pain relief in children; (7) Don’t administer perioperative antibiotics for elective tonsillectomy in children; (8) Don’t perform tonsillectomy for children with uncomplicated recurrent throat infections if there have been fewer than 7 episodes in the past year, 5 episodes in each of the past 2 years, or 3 episodes in each of the last 3 years; and (9) Don’t perform endoscopic sinus surgery for uncomplicated pediatric chronic rhinosinusitis prior to failure of maximal medical therapy and adenoidectomy.

Systemic Bevacizumab for Treatment of Respiratory Papillomatosis: International Consensus Statement

OBJECTIVES/HYPOTHESIS

The purpose of this study is to develop consensus on key points that would support the use of systemic bevacizumab for the treatment of recurrent respiratory papillomatosis (RRP), and to provide preliminary guidance surrounding the use of this treatment modality.

STUDY DESIGN

Delphi method-based survey series.

METHODS

A multidisciplinary, multi-institutional panel of physicians with experience using systemic bevacizumab for the treatment of RRP was established. The Delphi method was used to identify and obtain consensus on characteristics associated with systemic bevacizumab use across five domains: 1) patient characteristics; 2) disease characteristics; 3) treating center characteristics; 4) prior treatment characteristics; and 5) prior work-up.

RESULTS

The international panel was composed of 70 experts from 12 countries, representing pediatric and adult otolaryngology, hematology/oncology, infectious diseases, pediatric surgery, family medicine, and epidemiology. A total of 189 items were identified, of which consensus was achieved on Patient Characteristics (9), Disease Characteristics (10), Treatment Center Characteristics (22), and Prior Workup Characteristics (18).

CONCLUSION

This consensus statement provides a useful starting point for clinicians and centers hoping to offer systemic bevacizumab for RRP and may serve as a framework to assess the components of practices and centers currently using this therapy. We hope to provide a strategy to offer the treatment and also to provide a springboard for bevacizumab's use in combination with other RRP treatment protocols. Standardized delivery systems may facilitate research efforts and provide dosing regimens to help shape best-practice applications of systemic bevacizumab for patients with early-onset or less-severe disease phenotypes.

LEVEL OF EVIDENCE

5 Laryngoscope, 131:E1941-E1949, 2021.

Competency-Based Assessment Tool for Pediatric Tracheotomy: International Modified Delphi Consensus

OBJECTIVES/HYPOTHESIS

Create a competency-based assessment tool for pediatric tracheotomy.

STUDY DESIGN

Blinded, modified, Delphi consensus process.

METHODS

Using the REDCap database, a list of 31 potential items was circulated to 65 expert surgeons who perform pediatric tracheotomy. In the first round, items were rated as "keep" or "remove," and comments were incorporated. In the second round, experts were asked to rate the importance of each item on a seven-point Likert scale. Consensus criteria were determined a priori with a goal of 7 to 25 final items.

RESULTS

The first round achieved a response rate of 39/65 (60.0%), and returned questionnaires were 99.5% complete. All items were rated as "keep," and 137 comments were incorporated. In the second round, 30 task-specific and seven previously validated global rating items were distributed, and the response rate was 44/65 (67.7%), with returned questionnaires being 99.3% complete. Of the Task-Specific Items, 13 reached consensus, 10 were near consensus, and 7 did not achieve consensus. For the 7 previously validated global rating items, 5 reached consensus and two were near consensus.

CONCLUSIONS

It is feasible to reach consensus on the important steps involved in pediatric tracheotomy using a modified Delphi consensus process. These items can now be considered to create a competency-based assessment tool for pediatric tracheotomy. Such a tool will hopefully allow trainees to focus on the important aspects of this procedure and help teaching programs standardize how they evaluate trainees during this procedure.

LEVEL OF EVIDENCE

5 Laryngoscope, 130:2700-2707, 2020.

Evaluating short and long term outcomes following pediatric Myringoplasty with Gelfoam graft for tympanic membrane perforation following ventilation tube insertion

Background

Myringotomy with ventilation tube (VT) insertion to treat recurrent acute otitis media and chronic secretory otitis media has become one of the most common surgical procedures performed in children. Although contemporary literature has detailed the various patient and perioperative factors that affect successful pediatric myringoplasty, there is still limited evidence surrounding the increasing number of graft material options. In particular, gelfoam patching has arisen as a simple and efficient modality for perforation closure, but has a paucity of evidence particularly in pediatric cohorts. Our study aims to evaluate the clinical and audiometric outcomes following gelfoam myringoplasty for TMP following prolonged VT insertion in an urban pediatric population.

Methods

A retrospective review of pediatric patients who underwent myringoplasty between 2013 and 2018 following ventilation tube insertion. Patient demographics, comorbidities, and graft material were correlated with audiometric and clinical outcomes on follow up examination.

Results

One hundred twenty patients underwent myringoplasty, with 61 (50.8%) males with a mean age of 8.9 years old. 101 (84.2%) of patients eventually underwent successful tympanic membrane (TM) closure, with 93 (77.5%) demonstrating closure at initial follow up. In the gelfoam cohort, 77 (90.6%) of patients demonstrated successful TM closure at initial follow up. Overall mean time to closure was 5.6 (standard error (SE) 0.9) months. A multivariate Cox proportional hazards model demonstrated none of the covariates including graft material significantly affected TM closure. Mean change in air conduction threshold were comparable between graft materials.

Conclusions

Pediatric myringoplasty with gelfoam graft material is a safe and viable alternative with favorable short and long term clinical and audiometric outcomes.

Severe cryopyrin-associated periodic syndrome first characterized by early childhood-onset sensorineural hearing loss - Case report and literature review

Infant-onset bilateral sensorineural hearing loss is a key presenting symptom of the autoinflammatory cryopyrin-associated periodic syndrome. Other symptoms include periodic fever, cold-induced urticaria-like rash, chronic aseptic meningitis, polyarticular arthralgias, and renal AA amyloidosis. Early recognition and treatment with interleukin-1 blockade are critical for preventing disabling or fatal complications. We describe a patient with severe cryopyrin-associated periodic syndrome who presented at age 18 months with macrocephaly and moderate sensorineural hearing loss, later developing systemic sequelae. The pathogenic nature of the de novo NLRP3 gene variant identified was supported by a markedly elevated serum amyloid A level and sustained clinical response to anti-IL-1 therapy.

Secretory carcinoma: the eastern Canadian experience and literature review

Background

Secretory Carcinoma (SC) is a recently described malignancy affecting salivary glands of the head and neck, with a paucity of evidence regarding the natural history, morbidity, and mortality. This study aimed to investigate the current treatment options utilized for SC, as well as its presentation and outcomes.

Methods

This study is a retrospective case series and includes patients diagnosed with SC at four Maritime Canadian institutions. Literature review of patient outcomes following treatment of SC is also included.

Results

Thirteen patients were identified. Parotid was the most common subsite (69%), followed by minor salivary gland (23%) and submandibular gland (8%). All patients were S100 positive and had at least one additional positive confirmatory stain, including mammaglobin, CK7, or vimentin. Two patients had N2b disease. All patients were treated with primary surgery, and four were offered adjuvant radiotherapy. There was one instance of locoregional recurrence, and one of metastasis. Three patients displayed perineural invasion on pathology, and one patient displayed lymphovascular invasion.

Conclusion

Secretory Carcinoma remains understudied regarding its natural history, presentation, and treatment options. This study is the largest single case series in Canada, and highlights the young age and possible aggressiveness of SC. As well, we provide the most comprehensive literature review to date, with a focus on treatment and outcomes for this disease entity.

Electronic supplementary material

The online version of this article (10.1186/s40463-018-0315-6) contains supplementary material, which is available to authorized users.

Pseudosyndactyly and Musculoskeletal Contractures in Inherited Epidermolysis Bullosa: Experience of the National Epidermolysis Bullosa Registry, 1986–2002

Mitten deformities of the hands and feet occur in nearly every patient with the most severe subtype (Hallopeau-Siemens) of recessive dystrophic epidermolysis bullosa, and in at least 40–50% of all other recessive dystrophic epidermolysis bullosa patients. Smaller numbers of patients with dominant dystrophic, junctional, and simplex types of epidermolysis bullosa are also at risk of this complication. Surgical intervention is commonly performed to correct these deformities, but recurrence and the need for repeated surgery are common. Higher numbers of epidermolysis bullosa patients also develop musculoskeletal contractures in other anatomic sites, further impairing overall function. Lifetable analyses not only better project the cumulative risk of mitten deformities and other contractures but also emphasize the need for early surveillance and intervention, since both of these musculoskeletal complications may occur within the first year of life.

Informed Consent in Pediatric Otolaryngology

Objective

To evaluate parental recall of surgical risks and benefits in pediatric otolaryngology and to assess for factors that may influence recall.

Study Design

Prospective cohort study.

Setting

Academic pediatric otolaryngology clinic.

Subjects and Methods

Eighty-four parents of children <6 years of age who underwent consultation for adeno/tonsillectomy and/or tympanostomy tube insertion were prospectively enrolled. Consultation visits were video recorded and the benefits and risks of surgery documented. Two weeks following the consultation, parents were contacted for assessment of recall of information discussed during the consultation.

Results

Overall, parents recalled only one-third of the risks of surgery mentioned by the surgeons. Parents were significantly more likely to recall the benefits of surgery as opposed to the risks ( P < .001). Nine parents (10.7%) reported that no benefits were discussed during the consultation, and 10 (11.9%) reported no mention of any risks. Inconsistencies were present in which risks and benefits were mentioned by the providers. Parents who decided to proceed with surgery (58.3%) were significantly less likely to recall the surgical risks than those who did not ( P < .001). The specific surgeon involved, the number of caregivers present, parental education level, and prior surgical history did not influence recall.

Conclusion

Parental recall of benefits and risks associated with common pediatric otolaryngology procedures was poor. This information is important because a low rate of recall may influence parents’ perspectives of the procedure and could alter their decision-making processes or expectations. Methods to improve parental recall should be further studied.

Eating disorder professionals' perceptions of oral health knowledge

OBJECTIVE

The aim of this study was to assess the oral health knowledge among professionals who specialize in treating eating disorders, and identify to what extent their education, and training addresses oral health care delivery, and recommendations for individuals with eating disorders.

METHOD

Participants for this study were licensed behavioural and medical providers specializing in eating disorder treatment (n = 107), and recruited through professional eating disorder organizations. Participants completed an anonymous, online questionnaire (33 items) assessing level of oral health-related education, knowledge and treatment recommendations within the participant's respective eating disorder discipline.

RESULTS

The majority of respondents (85%) were formally trained in eating disorders, and of those trained, 64.4% were not satisfied with the level of oral health education during formal education, and 19.5% report no oral health education. Respondents consider their knowledge of risk of oral disease for their clients/patients as average or above (84%), and ranked tooth erosion as the greatest reason for oral care (63%) while dry mouth led in the rankings for least significant reason for oral care (33%). Referral for oral care was found to be more common after reports of complication (55%).

DISCUSSION

According to these findings, eating disorder professionals regard oral health care for their clients as significant, and may be unaware of associated oral risk factors, current oral care standards and long-term oral effects of disordered eating apart from enamel erosion.

Autotransplantation of solitary kidney with renal artery aneurysm treated with laparoscopic nephrectomy and ex vivo repair: a case report

INTRODUCTION

Renal artery aneurysms (RAA) are extremely rare clinical entities with associated morbidities including hypertension and rupture. Although most RAA can be treated with in vivo repair or endovascular techniques, these may not be possible in patients with complex RAA beyond the renal artery bifurcation. We report a case of RAA in a patient with a solitary kidney that we treated successfully by extracorporeal repair and autotransplantation and the 2-years follow-up.

CASE REPORT

A 64-year-old woman with a history of right nephrectomy for renal cell carcinoma presented with RAA found on routine computed tomography (CT). Preoperative workup demonstrated a 2.2 × 2.1 × 3-cm aneurysm in the distal left renal artery that was not amendable to in vivo or endovascular repair. The patient underwent a laparoscopic-assisted left nephrectomy, ex vivo renal artery aneurysm repair, and autotransplantation. She did well postoperatively and in clinic follow-up was found to have a creatinine of 1.2 mg/dL at the end of 2 years and stable blood pressure control.

DISCUSSION

This patient with RAA in her solitary kidney was successfully treated with laparoscopic-assisted nephrectomy, ex vivo repair, and autotransplantation. Her creatinine was stable postoperatively despite absence of a second kidney.

Liver transplantation in the United States, 1999-2008

Changes in organ allocation policy in 2002 reduced the number of adult patients on the liver transplant waiting list, changed the characteristics of transplant recipients and increased the number of patients receiving simultaneous liver-kidney transplantation (SLK). The number of liver transplants peaked in 2006 and declined marginally in 2007 and 2008. During this period, there was an increase in donor age, the Donor Risk Index, the number of candidates receiving MELD exception scores and the number of recipients with hepatocellular carcinoma. In contrast, there was a decrease in retransplantation rates, and the number of patients receiving grafts from either a living donor or from donation after cardiac death. The proportion of patients with severe obesity, diabetes and renal insufficiency increased during this period. Despite increases in donor and recipient risk factors, there was a trend towards better 1-year graft and patient survival between 1998 and 2007. Of major concern, however, were considerable regional variations in waiting time and posttransplant survival. The current status of liver transplantation in the United States between 1999 and 2008 was analyzed using SRTR data. In addition to a general summary, we have included a more detailed analysis of liver transplantation for hepatitis C, retransplantation and SLK transplantation.

Effect of time after transplantation on microbiology of urinary tract infections among renal transplant recipients

We evaluated the microbiology of renal transplant recipients hospitalized with urinary tract infections over a 10-year period. While gram-negative organisms were seen most frequently (73%), the median time to infection post transplantation was shorter in patients infected with gram-positive organisms (9.0 vs. 44.7 months).

Hepatocellular stem cells

The liver has enormous regenerative capacity. Restitution of the liver in response to different injuries involves proliferation of cells at different levels of liver lineage. Mature hepatocytes, which are normally dormant, could undergo rapid replication with a near infinite capacity to proliferate. When the replication of mature hepatocytes is inhibited, a reserve compartment of bipotential hepatic progenitor/stem cells is activated. The degree of activation appears to correlate with the degree of inflammation and stage of chronic liver disease. Deregulation of key regulatory signaling pathways such as transforming growth factor-beta, Wnt, hepatocyte growth factor, insulin-like growth factor, transforming growth factor-alpha and epidermal growth factor in this progenitor/stem cell population could give rise to HCC. Further understanding of these key signaling pathways and the molecular and genetic alterations associated with HCC could provide major advances in new therapeutic and diagnostic modalities.

Disruption of transforming growth factor-beta signaling through beta-spectrin ELF leads to hepatocellular cancer through cyclin D1 activation

Transforming growth factor-beta (TGF-beta) signaling members, TGF-beta receptor type II (TBRII), Smad2, Smad4 and Smad adaptor, embryonic liver fodrin (ELF), are prominent tumor suppressors in gastrointestinal cancers. Here, we show that 40% of elf(+/-) mice spontaneously develop hepatocellular cancer (HCC) with markedly increased cyclin D1, cyclin-dependent kinase 4 (Cdk4), c-Myc and MDM2 expression. Reduced ELF but not TBRII, or Smad4 was observed in 8 of 9 human HCCs (P<0.017). ELF and TBRII are also markedly decreased in human HCC cell lines SNU-398 and SNU-475. Restoration of ELF and TBRII in SNU-398 cells markedly decreases cyclin D1 as well as hyperphosphorylated-retinoblastoma (hyperphosphorylated-pRb). Thus, we show that TGF-beta signaling and Smad adaptor ELF suppress human hepatocarcinogenesis, potentially through cyclin D1 deregulation. Loss of ELF could serve as a primary event in progression toward a fully transformed phenotype and could hold promise for new therapeutic approaches in human HCCs.

Management of symptomatic tracheal pouches

OBJECTIVE

Acquired tracheal pouches arise following tracheoesophageal fistula (TEF) repair, but are usually asymptomatic. Symptomatic tracheal pouches are rare, and the optimal management strategy debated. The evolution of our management to this challenging problem is presented.

DESIGN

A case series over a 5-year period.

SETTING

A tertiary care pediatric hospital.

PATIENTS

Children with a past history of TEF repair in whom severity of pouch-related respiratory symptomatology warranted surgical intervention.

MAIN OUTCOME MEASURES

Symptomatology, bronchoscopic findings, number and type of surgical interventions required, complications, and outcomes.

RESULTS

Eleven patients required surgical intervention for a symptomatic tracheal pouch. Symptoms were due to stasis of secretions with associated pulmonary soiling in three children, severe tracheomalacia in six children, and respiratory obstruction related to the tip of a tracheotomy tube or endotracheal tube being displaced intermittently into the pouch in six children. Surgical management of the pouch included one fulguration with the CO(2) laser, one with microlaryngeal instruments, Bugbee cautery in two, open resection in one, and transcervical division in another. The final five children had endoscopic pouch division with Clickline biopsy forceps. All children have had resolution of their pouch-related symptoms, although two remain tracheotomy-dependent.

CONCLUSIONS

Symptomatic tracheal pouches are rare. Surgical intervention to divide the common party wall between the trachea and the pouch may alleviate associated respiratory symptomatology. The Clickline biopsy forceps is a safe, rapid, and effective method of dividing a tracheal pouch.

Impact of initial antibiotic choice and delayed appropriate treatment on the outcome of Staphylococcus aureus bacteremia

The study presented here investigated the impact of initial antibiotic choice (beta-lactams vs vancomycin) on the outcome of 342 patients with Staphylococcus aureus bacteremia (50.9% with methicillin-resistant isolates) encountered between 1 January 2002 and 30 June 2003. Initial antibiotics were inappropriate (beta-lactams) in 60 (34.5%) methicillin-resistant cases and suboptimal (vancomycin) in 62 (36.9%) methicillin-susceptible cases. Time to effective antibiotic therapy was longer in methicillin-resistant cases (25.5+/-28.6 vs 9.6+/-16.6 h; p<0.0005). All-cause in-hospital mortality was higher with inappropriate therapy (35.0 vs 20.9%; p=0.02). Initial vancomycin treatment was associated with a higher incidence of delayed clearance (>or=3 days) of methicillin-susceptible bacteremia (56.3 vs 37.0%; p=0.03). The results indicate inappropriate initial therapy is associated with higher in-hospital mortality and initial vancomycin may delay clearance.

Impact of inherited epidermolysis bullosa on parental interpersonal relationships, marital status and family size

BACKGROUND

The presence in a family of a child or children with epidermolysis bullosa (EB) may have profound psychological implications for other family members.

OBJECTIVES

To assess the impact of the presence of EB in one or more children on the personal relationships between their parents.

METHODS

Standardized questionnaires were used.

RESULTS

In general, the presence of a child severely affected with EB had profound effects on many aspects of marriage. This included a lack of interest in participating in activities as couples [junctional EB (JEB), 45%; recessive dystrophic EB (RDEB), 25%], a lack of energy to invest in such pursuits (JEB, 82%; RDEB, 50%), limitations in opportunities for sharing nonintimate physical activities (reported by most parents having children with some type of generalized EB), and negatively altered parental sex life (JEB, 55%; RDEB, 39%). This is consistent with the fact that 10%, 64%, 25% and 36% of parents of an affected child with EB simplex (EBS), JEB, dominant dystrophic EB (DDEB) and RDEB, respectively, characterized their relationships as couples as revolving almost exclusively around the day-to-day care of their affected children. The severity of disease in an affected child clearly influenced parental decisions about having more children: 24% and 64% of parents of children with JEB and RDEB, respectively, chose not to have additional children, compared with 26% and 54% of parents with children having EBS or DDEB. This choice was most often pursued via tubal ligation; less often, alternative means of surgical sterilization were chosen. Divorce was common among parents of children with EB (range: 17% in EBS to 31% in JEB) and, with the exception of parents of children with EBS, was usually directly attributed by one or both parents to the profound impact that this disease had exerted on their marriage.

CONCLUSIONS

Physicians caring for children with EB need to give more consideration to the many psychological factors that may contribute to their patients' well being. They may need to assist these children's parents in seeking support and counselling to prevent destruction of the family unit.

Acquired Subglottic Cysts in Preterm Infants

OBJECTIVES

Acquired subglottic cysts (SGCs) are a recognized complication of intubation in preterm infants. A brief window of our experience is reviewed to determine the demographics and outcomes of therapy.

DESIGN

A retrospective review encompassing patients diagnosed and treated from 2001 to 2002 inclusively. SETTING/METHODS: A case series of 11 patients evaluated at a tertiary care pediatric institution over a 2-year period is presented.

RESULTS

Eleven patients evaluated for symptoms of severe airway distress were diagnosed with SGC by microlaryngoscopy and bronchoscopy. All had a history of prematurity with intubation in the perinatal period. All but one became symptomatic many months following intubation. Two patients presented for assessment with tracheotomies, whereas a third received a tracheotomy during therapy owing to a large obstructive bilateral SGC. Large unilateral SGCs were the most common finding on endoscopy. Treatment consisted of cyst marsupialization or direct excision on laryngotracheoplasty. Twenty-six procedures were performed. Four patients required single procedures for complete resolution of symptoms. Two patients had staged procedures with the use of endoscopic diathermy. An element of subglottic stenosis was present in 10 of the 11 patients; however, only 3 patients required laryngotracheoplasty for definitive treatment.

CONCLUSION

SGCs are associated with intubation in premature infants and may develop many months following extubation. The duration of intubation does not appear to be a predictive risk factor. Subglottic stenosis is commonly an underlying finding in patients with SGC. Staging procedures with endoscopic diathermy is a highly effective modality, minimizing the need for more invasive procedures.

Assessment of mobility, activities and pain in different subtypes of epidermolysis bullosa

A standardized questionnaire was used to assess mobility, activity and pain in 140 randomly chosen children, who were representative of all major types and subtypes of inherited epidermolysis bullosa (EB). Pain status in these children was compared with 374 randomly selected adults with EB. The level of independence for each of six activities of daily living (ADL) (toileting; feeding; bathing; dressing; grooming; walking) was assessed in these EB children using conventional criteria for scoring. Whereas more than 90% of all EB simplex (EBS) and dominant dystrophic EB (DDEB) children were totally independent for each function (excluding walking), the frequency of similarly totally independent patients with junctional EB (JEB) and recessive dystrophic EB (RDEB) ranged from only 39% to 73%. No DDEB children and only 2% of EBS patients were totally dependent in their individual ADL, in comparison to 8-27% of JEB and 2-27% of RDEB children. Totally independent walking was reported in only 31%, 31%, 67%, and 24% of EBS, JEB, DDEB, and RDEB children, respectively. A daily level of EB-related pain was assessed in children by their parents using a linear scale of 0 (no pain) to 10 (unbearable pain). Whereas 14-19% of all children with EBS, JEB, and DDEB were graded with pain levels of more than 5, 32% of all RDEB children reportedly suffered this much pain. Increased frequencies of pain with scores more than 5 were most often noted in those patients having more clinically extensive or severe EB subtypes. These included JEB-Herlitz (20% vs. 14% in JEB-non-Herlitz) and RDEB-Hallopeau-Siemens (47% vs. 20% in all other RDEB subtypes). Only 5% of all RDEB children reportedly were pain-free, compared to 12-14% of those with EBS, JEB, and DDEB. Collectively, these data provide the first report of the specific impact different forms of EB have on daily living and coping with this genodermatosis.

Complications of adenotonsillectomy

OBJECTIVE

To review the immediate, short-term, and long-term complications of adenotonsillectomy.

STUDY DESIGN

Review.

METHODS

Complications of adenotonsillectomy and methods for preventing and treating them were reviewed.

RESULTS

The most common complications of adenotonsillectomy, such as bleeding, generally occur in the immediate perioperative period but can develop up to 2 weeks postoperatively. Long-term complications, such as nasopharyngeal stenosis, may appear months to years after surgery. These more unusual sequelae result from scar contracture and maturation.

CONCLUSION

Although rare, complications associated with adenotonsillectomy can be taxing for patients and health care resources. The most common complications, namely, anesthesia risks, pain, otalgia, and bleeding, should be discussed with patients' caregivers.

Pharmacokinetics and biochemical effects of hepapoietin in patients with chronic liver disease

BACKGROUND

Hepapoietin is a naturally occurring cytokine that promotes hepatocyte growth. Animal studies have suggested that hepapoietin and hepatocyte growth factor have a potential role in the prevention and management of liver diseases. However, human studies have been lacking.

AIM

To evaluate the safety and pharmacokinetics of single escalating doses of hepapoietin in patients with chronic liver disease.

METHODS

An open-label, single escalating dose trial with five different doses of hepapoietin (1, 3, 10, 30 and 100 mg) was performed. Adults with chronic, compensated, non-viral liver disease were included. Liver function tests were obtained before dosing, 24 h after hepapoietin administration and on days 4, 7, 30 and 45. All patients were followed for 45 days.

RESULTS

Twenty-five subjects received hepapoietin, with five subjects each at 1, 3, 10, 30 and 100 mg of hepapoietin. Significant decreases occurred in total bilirubin, ammonia, partial thromboplastin time and cholesterol levels overall, and both high-density and low-density lipoprotein cholesterol showed a downward trend. An increase in albumin was observed at the 30 mg dose level. Slight decreases in haemoglobin and red blood cell levels were observed at day 4, but returned to normal levels immediately thereafter. Child-Pugh scores from day 0 to day 7 were improved in 24%, stable in 64% and worse in 12% of patients. Hepatic encephalopathy displayed changes from day 0 to day 45 with improvement in 16%, no change in 80% and worsening in 4%.

CONCLUSIONS

Hepapoietin in doses up to 100 mg is safe for use in humans. Potential benefits are suggested by significant decreases in bilirubin, ammonia, partial thromboplastin time and cholesterol levels and an increase in albumin. Further studies with multiple dosing regimens are needed to identify the clinical utility of hepapoietin in the management of chronic liver disease.

Molecular analysis of coagulase-negative Staphylococcus isolates from blood cultures: prevalence of genotypic variation and polyclonal bacteremia

Fifty-seven coagulase-negative Staphylococcus isolates from 22 inpatients who had > or =2 blood cultures that were positive for Staphylococcus within 24 hours were analyzed to determine the frequency of polyclonal bacteremia. Patients were considered to have bacteremia (14 patients) or contamination of sample (8 patients) on the basis of clinical criteria. Nine colonies were randomly selected from each blood culture and genotyped by means of SmaI digestion/pulsed-field gel electrophoresis. Relatedness was determined by calculation of the Dice coefficient of banding-pattern similarity (S(AB)). Analysis of bacteremic isolates demonstrated the presence of a single species in 35 of 41 blood cultures, 1 related variant in 5 blood cultures (87%-92% S(AB)), and an unrelated strain in 1 blood culture (79% S(AB)). Analysis of contaminated samples demonstrated the presence of a single strain in 10 of 16 blood cultures and 1-3 variants (28%-97% S(AB)) in the remainder. Genotype diversity was significantly more common in the contaminated samples (P=.036). Almost all coagulase-negative Staphylococcus bacteremias were monoclonal.

Transplantation of hepatitis C-positive livers in hepatitis C-positive patients is equivalent to transplanting hepatitis C-negative livers

A significant number of patients with end-stage liver disease secondary to hepatitis C die of disease-related complications. Liver transplantation offers the only effective alternative. Unfortunately, organ demand exceeds supply. Consequently, some transplant centers have used hepatitis C virus-positive (HCV(+)) donor livers for HCV(+) recipients. This study reviews the clinical outcome of a large series of HCV(+) recipients of HCV(+) liver allografts and compares their course with that of HCV(+) recipients of HCV-negative (HCV(-)) allografts. The United Network for Organ Sharing Scientific Registry was reviewed for the period from April 1, 1994, to June 30, 1997. All HCV(+) transplant recipients were analyzed. Two groups were identified: a group of HCV(+) recipients of HCV(+) donor livers (n = 96), and a group of HCV(+) recipients of HCV(-) donor livers (n = 2,827). A multivariate logistic regression model was used to determine the odds of graft failure and patient mortality, and unadjusted graft and patient survival were determined using the Kaplan-Meier method. There were no differences in demographic criteria between the groups. A greater percentage of patients with hepatocellular carcinoma received an HCV(+) allograft (8.3% v 3.1%; P =.01). Patient survival showed a significant difference for the HCV(+) group compared with the HCV(-) group (90% v 77%; P =.01). Blood type group A, group B, group O incompatibility was significant, with 4.2% incompatibility in the HCV(+) group and only 1.3% in the HCV(-) group (P =.04). Donor hepatitis C status does not impact on graft or patient survival after liver transplantation for HCV(+) recipients. Their survival was equivalent, if not better, compared with the control group. Using HCV(+) donor livers for transplantation in HCV(+) recipients safely and effectively expands the organ donor pool.

Candida fasciitis following renal transplantation

BACKGROUND

We describe a rare case of necrotizing fasciitis involving Candida albicans, an organism that has been reported to have a minimal potential for invasive soft tissue infection. In this case, immunosuppression, chronic renal failure, and a history of diabetes mellitus were predisposing factors.

METHODS

The medical record and histopathologic material were examined. The clinical literature was reviewed for previous cases of C albicans necrotizing fasciitis.

RESULTS

A review of the literature showed that in solid organ transplant recipients, localized fungal soft tissue infection is infrequent, with only 35 cases reported between 1974 and 1992. Necrotizing fasciitis caused by C albicans is extremely rare in the modern era of solid organ transplantation.

CONCLUSIONS

The management of transplant patients at risk for invasive fungal infection warrants a high index of suspicion for fungal necrotizing fasciitis in the setting of wound infection and merits a thorough investigation for atypical pathogens.

Outcome of extra-anatomic vascular reconstruction in orthotopic liver transplantation

BACKGROUND

Portal venous and hepatic arterial reconstruction are critical to successful outcomes in orthotopic liver transplantation (OLT). With portal vein thrombosis or inadequate hepatic arterial inflow, extra-anatomic vascular reconstruction is required. However, the clinical outcomes following extra-anatomic vascular reconstruction are largely unknown.

METHODS

To determine the outcomes associated with extra-anatomic vascular reconstruction, we performed a retrospective review of 205 OLT recipients transplanted between 1995 and 2000.

RESULTS

Extra-anatomic portal venous inflow was based upon the recipient superior mesenteric vein using donor iliac vein graft in a retrogastric position (n = 12). Extra-anatomic arterial inflow was based on recipient infrarenal aorta using donor iliac artery graft through the transverse mesocolon (n = 25). OLT with routine anatomic vascular construction served as control (n = 168). Extra-anatomic vascular reconstruction was not associated with increased morbidity, mortality, operating room time, length of stay, or thrombosis.

CONCLUSION

We conclude that extra-anatomic vascular conduits are associated with excellent long-term outcomes and provide acceptable alternatives for vascular reconstruction in OLT.

Diastereoselective synthesis of substituted tetrahydroquinoline-4-carboxylic esters by a tandem reduction-reductive amination reaction

A diastereoselective synthesis of 1-methyl-2-alkyl- and 2-alkyl-1,2,3,4-tetrahydroquinoline-4-carboxylic esters has been developed from methyl (2-nitrophenyl)acetate (1). The method involves alkylation of 1 with an allylic halide, ozonolysis of the double bond, and catalytic hydrogenation. The final hydrogenation initiates a tandem sequence involving (1) reduction of the aromatic nitro group, (2) condensation of the aniline or hydroxylamine(8) nitrogen with the side chain carbonyl, (3) reduction of the resulting nitrogen intermediate, and (4) reductive amination of the tetrahydroquinoline with formaldehyde produced in the ozonolysis to give a methyl (+/-)-1-methyl-2-alkyl-1,2,3,4-tetrahydroquinoline-4-carboxylate. Removal of the formaldehyde prior to hydrogenation gives the simple (+/-)-2-alkyl derivatives. The products are isolated in high yield as single diastereomers having the C-2 alkyl group cis to the C-4 carboxylic ester. The reaction has been extended to the synthesis of tricyclic structures with similar high diastereoselection.

Hyperacusis in Williams syndrome

OBJECTIVE

To define hyperacusis in audiologic parameters and to further elucidate central and peripheral auditory pathways.

DESIGN AND SETTING

Theories surrounding hyperacusis have always been highly debated. A group of children with Williams syndrome universally complain of hyperacusis. They have highly reproducible behavioural responses to noise and are thus hampered in their social interactions. Loss of inhibitory modulation to efferent sensory input to the cochlea is thought to be a possible mechanism.

METHODS

Nine patients with Williams syndrome received a complete audiologic work-up, including audiogram, speech reception thresholds, acoustic reflexes, impedance, and transient evoked otoacoustic emissions (TEOAEs).

MAIN OUTCOME MEASURES

Assessment of the efferent system is done by measuring changes in TEOAEs following stimulation of the contralateral ear.

RESULTS

Three patients had high-frequency sensorineural hearing loss (SNHL) and thus, as expected, absent TEOAEs, indicating cochlear damage. Two had normal hearing and normal TEOAEs. However, four patients had normal hearing with absent TEOAEs.

CONCLUSIONS

These findings are suggestive of cochlear disease and may, in fact, support the hypothesis of outer hair cell modulation by the ipsilateral medial olivocochlear system. Behavioural aspects of the syndrome make audiologic testing difficult. Thus, the diagnosis of SNHL may be hampered if it truly exists. The data show a preponderance of SNHL in the older age groups of our study population. This either reflects previously missed diagnoses or underlying cochlear disease, which may manifest later in life. Thus, this finding blurs the boundary between loudness recruitment and hyperacusis.

Use of aerosolized inhaled epoprostenol in the treatment of portopulmonary hypertension

BACKGROUND

Portopulmonary hypertension is a known complication in the liver transplant candidate. Intravenous epoprostenol has been demonstrated to decrease pulmonary artery pressures and possibly remodel right ventricle geometry.

METHODS

In this report, we document the efficacy of inhaled aerosolized epoprostenol in a patient with portopulmonary hypertension. The effect was of rapid onset and offset.

RESULTS

After 10 min of delivery, mean pulmonary artery pressure decreased 26%; cardiac output increased by 22%; pulmonary vascular resistance decreased by 42%; and the transpulmonary gradient decreased by 29%. There were no untoward side effects.

CONCLUSION

The inhaled route of delivery of epoprostenol is potential alternative for the acute therapy of portpulmonary hypertension.

The virulence factor AvrXa7 of Xanthomonas oryzae pv. oryzae is a type III secretion pathway-dependent nuclear-localized double-stranded DNA-binding protein

AvrXa7 is a member of the avrBs3 avirulence gene family, which encodes proteins targeted to plant cells by a type III secretion apparatus. AvrXa7, the product of avrXa7, is also a virulence factor in strain PXO86 of Xanthomonas oryzae pv. oryzae. Avirulence and virulence specificities are associated with the central repeat domain, which, in avrXa7, consists of 25.5 direct repeat units. Mutations in three C-terminal nuclear localization signal motifs eliminated avirulence and virulence activities in rice and severely reduced nuclear localization in a yeast assay system. Both pathogenicity functions and nuclear localization were restored on the addition of the sequence for the nuclear localization signal motif from SV40 T-antigen. The loss of avirulence activity because of mutations in the acidic transcriptional activation domain was restored by addition of the activation domain from the herpes simplex viral protein VP16. The activation domain was also required for virulence activity. However, the VP16 domain could not substitute for the endogenous domain in virulence assays. In gel shift assays, AvrXa7 bound double-stranded DNA with a preference for dA/dT rich sequences. The results indicate that products of the avrBs3-related genes are virulence factors targeted to host cell nuclei and have the potential to interact with the host DNA and transcriptional machinery as part of their mode of action. The results also suggest that the host defensive recognition mechanisms are targeted to the virulence factor site of action.

Prospects for understanding avirulence gene function

Avirulence genes are originally defined by their negative impact on the ability of a pathogen to infect their host plant. Many avirulence genes are now known to represent a subset of virulence factors involved in the mediation of the host-pathogen interaction. Characterization of avirulence genes has revealed that they encode an amazing assortment of proteins and belong to several gene families. Although the biochemical functions of the avirulence gene products are unknown, studies are beginning to reveal the features and interesting relationships between the avirulence and virulence activities of the proteins. Identification of critical virulence factors and elucidation of their functions promises to provide insight into plant defense mechanisms, and new and improved strategies for the control of plant disease.

Laparoscopic donor nephrectomy increases the supply of living donor kidneys: a center-specific microeconomic analysis

BACKGROUND

A tenet of microeconomics is that new technology will shift the supply curve to the right. Laparoscopic donor nephrectomy (LDN) is a new technique for removal of living donor kidneys. Centers performing this procedure have noted an increased number of patients presenting for donor evaluation. This has not been previously studied.

METHODS

The records of all LDN performed from May 1998 to February 1999 were reviewed. The following variables were examined: sex, age, related vs. unrelated donation, estimated blood loss, i.v. analgesia, length of stay, and time out of work. Donors undergoing traditional open donor nephrectomy during January 1997 to May 1998 served as the control group. A composite cost index was constructed.

RESULTS

LDN significantly decreased length of stay, pain, and time out of work; the supply function shifted to the right. Telephone interviews revealed that 47% donated solely because of the LDN procedure.

CONCLUSIONS

LDN increases the supply of living donor kidneys.

Laparoscopic donor nephrectomy with a 23-hour stay: a new standard for transplantation surgery

OBJECTIVE

To determine the outcomes associated with laparoscopic donor nephrectomy (LDN) performed as a 23-hour day surgery protocol.

SUMMARY BACKGROUND DATA

Living donor renal transplantation is associated with immediate graft function and prolonged graft survival. The recent application of laparoscopic technology to living renal donation has refocused attention on the advantages of this donor source. LDN is associated with decreased donor pain, length of stay, time out of work, and opportunity costs. The authors hypothesized that LDN would be a viable 23-hour stay procedure.

METHODS

All living donation procedures since May 1998 have been performed with LDN. The 23-hour protocol was initiated in January 1999. LDNs performed from May 1998 to December 1998 and traditional open donor nephrectomy procedures from May 1996 to May 1998 served as historical controls. The following variables were examined: donor sex, related versus nonrelated donation, operative time, blood loss, length of stay, time out of work, recipient and donor serum creatinine levels, hospital charges, and complications.

RESULTS

The 23-hour LDN protocol was associated with high degrees of donor satisfaction. Thirty-six of the 41 donors were discharged within 23 hours; 1 was readmitted. Time out of work was equivalent to that of the control group; graft function was identical among all three comparison groups. Hospital charges were equivalent between the control group and the open nephrectomy group and were significantly decreased in the 23-hour group.

CONCLUSIONS

Laparoscopic donor nephrectomy can be performed as a 23-hour stay procedure without incurring additional complications or donor dissatisfaction. By further decreasing opportunity costs and disincentives for donation, LDN may increase the number of potential donors appearing for evaluation.

Outcome in recipients of dual kidney transplants: an analysis of the dual registry patients

BACKGROUND

A novel but controversial method to increase the utilization of aged donor kidneys is the transplantation of both kidneys as a dual transplant. Initial single-center reports demonstrated outcomes similar to single kidneys from younger donors. In this report, we compare outcome in recipients of kidneys from donors > or =54 years of age who received a single kidney transplant reported to the United Network for Organ Sharing Scientific Registry versus a dual kidney transplant reported to the Dual Kidney Registry.

METHODS

A retrospective analysis was performed, comparing four donor and nine recipient and outcome variables between recipients of a single versus a dual transplant between March 1993 and March 1999.

RESULTS

Dual versus single transplants from donors > or =54 years of age have a significantly decreased incidence of delayed graft function, and lower serum creatinines up to 2 years after transplant despite having kidneys from significantly older donors with poorer HLA matching.

CONCLUSIONS

Dual kidney transplants improve graft performance and outcome in recipients of kidneys from donors > or =54 years of age.

Outcomes of laparoscopic donor nephrectomy in obese patients

The applicability of laparoscopic donor nephrectomy (LDN) has not been assessed in the obese donor. We hypothesized that obesity is not a technical contraindication to LDN. From May 1998 to February 1999, 40 patients underwent LDN at the Georgetown Transplant Institute with the transperitoneal technique. Prophylaxis against deep venous thrombosis consisted of venous compression stockings, low-molecular weight heparin in obese patients, and early ambulation. The following variables were examined: donor sex, age, weight, height, related versus nonrelated donation, body mass index (BMI; wt/ht2), operating room time, estimated blood loss, length of stay, time out of work, and complications. BMI>31 indicates morbid obesity, BMI>27 indicates >20% over ideal body weight, and normal BMI is 25. The patients were divided into nonobese (BMI< or =31) and obese groups (BMI>31). The two groups do not differ in outcome after LDN. Our data indicate that obesity is not associated with increased morbidity or mortality after LDN.

Retroperitoneal compartment syndrome after renal transplantation

We report the case of a 21-year-old man with end-stage renal disease secondary to systemic lupus erythematosus who underwent living related renal transplantation and developed an extraperitoneal compartment syndrome postoperatively.

Transverse hepatectomy for symptomatic polycystic liver disease

Polycystic liver disease can result in massive enlargement of the liver with resultant debilitating symptoms of abdominal pain, chronic fatigue, and severely compromised functional status. Fenestration of hepatic cysts has been advocated as a treatment for polycystic disease. However, in patients with predominant small cyst replacement, fenestration alone often results in limited hepatic volume reduction without improvement in patient functional status. Liver transplantation has also been previously advocated for polycystic liver disease with predominant small cyst replacement, but, with the severe shortage of donor organs, alternative treatment should be considered. In this report we present a case of massive enlargement of the liver with severe clinical debilitation due to polycystic liver disease. Transverse hepatectomy provided a safe and effective alternative to fenestration or liver transplantation.

The C terminus of AvrXa10 can be replaced by the transcriptional activation domain of VP16 from the herpes simplex virus

The avirulence gene avrXa10 of Xanthomonas oryzae pv oryzae directs the elicitation of resistance in a gene-for-gene manner in rice lines carrying the resistance gene Xa10. We have localized a transcriptional activator domain in the C terminus of AvrXa10 by using amino acid replacement mutagenesis. One mutant, with replacements at three hydrophobic amino acid residues in the C-terminal domain, was defective for transcriptional activation in yeast and avirulence activity in rice. The activation domain from the herpes virus protein VP16 restored the ability of the bacteria expressing the hybrid protein to elicit a resistance reaction. Elicitation was specific for Xa10, and the reaction had the hallmarks of the response to AvrXa10. The results indicate that a domain with the properties of a transcriptional activator plays a critical role in AvrXa10 function. The results also indicate that the protein has the potential to interact with the plant transcriptional program, although a role for the domain in the stability or conformation of the protein in the plant cannot be excluded. In a broader sense, the transcriptional activation domain of avrXa10 may represent a prokaryotic version of the acidic transcriptional activation domain, which heretofore has been found exclusively in eukaryotes.

Laparoscopic versus open donor nephrectomy: comparing ureteral complications in the recipients and improving the laparoscopic technique

BACKGROUND

Laparoscopic live donor nephrectomy (LDN) is a recently developed procedure, the performance of which needs to be studied. Given the reported advantages in the donors, this study looks at graft outcome and ureteral complications in recipients of kidneys procured by open donor nephrectomy (ODN) versus LDN.

METHODS

The LDN recipients consisted of 193 patients since 3/27/96. A total of 168 ODN recipients from 1991 to 1998 served as controls. Immunosuppression protocols were similar for both groups.

RESULTS

Two-year graft survival for LDN and ODN was 98% and 96%, respectively. Two-year patient survival for LDN and ODN was 98% and 97%, respectively. The incidence of delayed graft function and mean serum creatinine at 3 and 12 months was similar in both groups. However, the number of ureteral complications that required operative repair was significantly higher for LDN recipients compared to ODN recipients, 7.7% (n=15) vs. 0.6% (n=1) respectively (P=0.03). Ureteral stenting was required in an additional 3.1% (n=6) of LDN and 2.4% (n=4) of ODN (P=NS). There was, however, a learning curve with time. For the first 130 LDN patients, a total of 20 ureteral complications were recorded, whereas only one occurred in the more recent 63 patients (P=0.03).

CONCLUSIONS

The higher ureteral complication rate in LDN recipients has improved over time as technical causes have been identified. We have noted significant improvement in ureteral viability by using the endogastrointestinal anastomosis instrument on the ureter and peri-ureteral tissue. LDN is therefore an excellent alternative to ODN. Identification of hazards unique to this technique is critical before its broader application.

Portopulmonary hypertension and the liver transplant candidate

The management of the liver transplant (OLT) candidate with portopulmonary hypertension (PPHTN) has dramatically changed in the past 3 years. Careful preoperative evaluation with functional characterization of right ventricular function plays a critical role. The pulmonary vascular response to epoprostenol infusion serves as a deciding factor for OLT candidacy. Careful perioperative attention to avoid right ventricular failure from acutely elevated pulmonary artery pressures or sudden increases in right ventricular preload is a key physiologic tenet of management. With increased surgical expertise, anesthetic sophistication, and availability of epoprostenol, PPHTN is no longer considered an absolute contraindication for OLT.