Treatment with botulinum toxin in children with chronic anal fissure.

INTRODUCTION: Chronic anal fissures with painful defecation and bloodstained stools can be seen in children of all ages. Constipation may precede or appear in connection with the symptoms. Adult patients with anal fissures have been treated successfully with the injection of botulinum toxin into both the internal and external sphincter. The effect of botulinum toxin is reversible and lasts for 3-4 months. This pilot study attempted to examine whether botulinum toxin is also effective in paediatric cases of anal fissure, a treatment which not yet has been reported in the literature. MATERIAL AND METHODS: Six boys and seven girls aged 1-10 years were treated with botulinum toxin (Botox ((R))) during 2002-2005 due to chronic anal fissure. Conventional treatment with laxatives and local anaesthetics had been unsuccessful in all cases. The treatment was given to five children under 2 years of age in a dosage of 1.25 Ux2. Eight children over 2 years of age were given 2.5 Ux2. The injections were given in the external sphincter on both sides of the fissure using EMG-stimulation for guidance and were performed under light anaesthetics (Diprivan ((R))). Follow-up was conducted at 1 and 3 months after treatment. RESULTS: Within one week, 11 of the children were free from pain and blood stained stools, according to their parent's observations. One 10-year old patient initially showed some improvement but soon experienced a recurrence. After another injection with a higher dosage 2 months later, the fissure healed. One 4-year old patient did not show any signs of improvement. The laxatives, which had been withdrawn after the injection treatment, were then reinstated. At the 3 month post-treatment examination the patient was finally symptom-free with no signs of a fissure. There were no negative side-effects detected in any of the cases. Seven recurrences were noted in 6 of the patients after 3-30 months, often in connection with an episode of constipation. Repeat injections were offered and accepted by four of these patients, once more producing good immediate results. CONCLUSION: Treatment with botulinum toxin in the external sphincter produces a quick and effective alleviation of pain with healing of chronic anal fissures in children. The treatment is not considered to carry any risks but requires light anaesthesia. Recurrences are common after the pharmacological effect has receded but can be cured with an additional injection.

Engineering and public health at CDC.

Engineering is the application of scientific and technical knowledge to solve human problems. Using imagination, judgment, and reasoning to apply science, technology, mathematics, and practical experience, engineers develop the design, production, and operation of useful objects or processes. During the 1940s, engineers dominated the ranks of CDC scientists. In fact, the first CDC director, Assistant Surgeon General Mark Hollis, was an engineer. CDC engineers were involved in malaria control through the elimination of standing water. Eventually the CDC mission expanded to include prevention and control of dengue, typhus, and other communicable diseases. The development of chlorination, water filtration, and sewage treatment were crucial to preventing waterborne illness. Beginning in the 1950s, CDC engineers began their work to improve public health while developing the fields of environmental health, industrial hygiene, and control of air pollution. Engineering disciplines represented at CDC today include biomedical, civil, chemical, electrical, industrial, mechanical, mining, and safety engineering. Most CDC engineers are located in the National Institute for Occupational Safety and Health (NIOSH) and the Agency for Toxic Substances and Disease Registry (ATSDR). Engineering research at CDC has a broad stakeholder base. With the cooperation of industry, labor, trade associations, and other stakeholders and partners, current work includes studies of air contaminants, mining, safety, physical agents, ergonomics, and environmental hazards. Engineering solutions remain a cornerstone of the traditional "hierarchy of controls" approach to reducing public health hazards.

The epidemiology of infantile hypertrophic pyloric stenosis in Sweden 1987-96.

AIMS: To find out whether the incidence of infantile hypertrophic pyloric stenosis (IHPS) has changed over the past decade, and if so, to investigate possible contributory factors. METHODS: All infants undergoing pyloromyotomy for IHPS in Sweden between 1987 and 1996 were studied. Using the national patient registers the yearly incidence was determined and evaluated in relation to sex, latitude, urbanisation, and type of surroundings by use of a Poisson model. RESULTS: There was a substantial decline from 2.7/1000 to 0.85/1000 over the time period. The incidence in the south was almost three times greater than in the north. CONCLUSION: The declining incidence and geographical difference suggest that environmental factors are of importance in this disorder.

Readmission to the intensive care unit after liver transplantation.

OBJECTIVE: We undertook this study to understand the factors at our transplant center that contribute to patients' return to the ICU after their liver transplant and their initial discharge from that unit. Patients who, after liver transplantation, fail discharge from the Intensive Care Unit (ICU) and must be readmitted to that unit may well utilize many more resources than those patients who are well enough to stay out of the ICU. DESIGN: A retrospective review of a prospectively maintained liver transplant research database followed by a retrospective review of (a subgroup) patient charts and contemporaneous controls. SETTING: A large metropolitan tertiary care center and adult liver transplant center. PATIENTS: A total of 1,197 consecutive adult patients who underwent their initial liver transplantation from 1984 to 1996. INTERVENTION: Readmission to the intensive care unit after adult liver transplantation and discharge from that unit. MAIN RESULTS: Only recipient age, pretransplant synthetic function labs (protime and albumin), bilirubin levels, and intraoperative blood product requirements could be statistically linked to the group requiring ICU readmission. The primary etiology for ICU readmission was cardiopulmonary deterioration. Readmission was associated with significantly lower patient and graft survivals. A detailed review of 23 patients transplanted from October 1994 to June 1996 was made, with special emphasis on cardiopulmonary status (hemodynamics, respiratory variables, and chest radiograph findings). This subgroup was compared with 30 temporally matched controls who were not readmitted to the ICU. Intravascular fluid overload and lower inspiratory capacity were significant factors related to ICU readmission. Readmitted patients had a longer hospitalization with higher hospital charges than the control group. CONCLUSIONS: We conclude that the most important means of preventing ICU readmission in liver transplantation patients is to optimize cardiopulmonary function and status. Close monitoring of fluid balance to avoid hypervolemia is essential. Readmitted patients have a greater resource utilization and have lower survival rates.

Improving safety in the Alaskan commercial fishing industry.

OBJECTIVES: Over 90% of deaths in Alaska's commercial fishing industry were due to drowning, following vessel sinkings. In the early 1990's, the U.S. Commercial Fishing Industry Vessel Safety Act required the implementation of safety measures for all fishing vessels. The purpose of our study was to examine the effectiveness of these measures in reducing the high fatality rate of Alaska's commercial fishermen. STUDY DESIGN: Alaska Occupational Injury Surveillance System and AlaskaTrauma Registry data were used to examine fishing fatalities and injuries. Demographic, risk factor, and incident data were analyzed for trend. RESULTS: During 1991-1998, there was a significant (p<0.001) (decrease in Alaskan commercial fishing deaths. Significant progress has been made in saving lives of fishermen involved in vessel sinkings. During 1991-1997, 536 fishermen suffered severe injuries (437/100,000/year). These injuries resulted from being entangled, struck or crushed by equipment (60%) and from falls (25%). CONCLUSIONS: Vessel sinkings still continue to occur, placing fishermen at substantial risk. Efforts toward improving vessel stability and hull integrity and avoidance of harsh weather conditions must be made to further reduce the fatality rate. The nature of non-fatal injuries reflect that modern fishing vessels are complex industrial environments posing multiple hazards. Measures are needed to prevent falls and improve equipment handling and machinery guarding.

Alaska's model program for occupational injury prevention: applying surveillance for effective public health practice.

BACKGROUND: NIOSH established its Alaska Field Station in Anchorage, Alaska, in 1991, after identifying Alaska as America's highest-risk state for traumatic worker fatalities. Since then, NIOSH established comprehensive occupational injury surveillance in Alaska, and formed and facilitated interagency working groups (of state and federal agencies) and industry, labor, and professional organizations to address major factors leading to occupational death and injury in the state. STUDY DESIGN: Descriptive epidemiologic study of registry surveillance data obtained via direct on-site investigation of incidents and data-sharing with jurisdictional agencies. METHODS: We established a surveillance system, obtaining information via data-sharing with jurisdictional agencies and from direct on-site investigation of incidents. Also, we collaborate with state and regional government agencies, industry, workers, and non-governmental organizations to develop interventions. RESULTS: During 1991-1999, Alaska experienced a 50-percent overall decline in work-related deaths, including a substantial decline in commercial fishing deaths, and a very sharp decline in helicopter logging-related deaths. These efforts have lead to major national and international government-industry collaborative efforts in improving the safety of helicopter lift operations, and a concomitant improvement in fishing industry mortality rates among workers fishing Alaskan seas. CONCLUSIONS: Using surveillance data as information for action, these collaborative efforts have contributed to reducing Alaska's high occupational fatality rate. This reduction has been most clearly demonstrated in the rapidly expanding helicopter logging industry. The application of surveillance data also has played an important supportive role in the substantial progress made in reducing the mortality rate in Alaska's commercial fishing industry--historically, Alaska's (and America's) most dangerous industry, and the worst killer of Alaskan workers. Results suggest that extending Alaska's approach to occupational injury surveillance and prevention to other parts of the country, and application of these strategies to the entire spectrum of occupational injury hazards, could have a broad impact on reducing occupational injuries.

Is it safe on deck? Fatal and non-fatal workplace injuries among Alaskan commercial fishermen.

BACKGROUND: Commercial fishing in Alaska accounts for an occupational fatality rate that is 28 times the rate for all U.S. workers. Most deaths are attributed to vessel sinking or capsizing. However, many deaths and most non-fatal injuries are not related to vessel loss. This paper describes injuries that occur on the dock or on the fishing vessel. METHODS: Data from fishing fatalities and non-fatal injuries between 1991-1998 were analyzed using the Alaska Occupational Injury Surveillance System and the Alaska Trauma Registry. RESULTS: There were 60 workplace deaths unrelated to vessel loss; most from falls overboard, others from trauma caused by equipment on deck. There were 574 hospitalized injuries, often from falls on deck, entanglement in machinery, or being struck by an object. SUMMARY: Fishing boats are hazardous working environments. Further efforts are required to prevent falls overboard and on deck, and to redesign or install safety features on fishing machinery and equipment.

Asthma-like symptoms in wood product plant workers exposed to methylene diphenyl diisocyanate.

BACKGROUND: Diisocyanates, a group of highly reactive chemicals, have frequently been associated with occupational asthma. We evaluated respiratory health in workers at a new wood products manufacturing plant that uses methylene diphenyl diisocyanate (MDI), and was designed and operated with a goal of minimizing worker exposures. METHODS: Health surveys using standardized respiratory questionnaires were done prior to the initial use of diisocyanates in the plant, and semiannually thereafter for a period of 2 years. Other testing included occupational and work practice histories, serial peak flow measurements, spirometry, methacholine challenge, and measurement of specific IgE antibodies to MDI-albumin conjugate. RESULTS: Of 214 plant employees who participated in at least one health survey, a follow-up survey was also available from 178 employees (83%). New-onset asthma-like symptoms (NAS) were reported by 15 of 56 workers (27%) in areas with the highest potential for exposures to liquid MDI monomer and prepolymer, vs 0 of 43 workers in the lowest potential exposure areas (p = 0.001). In the areas with high potential exposure, NAS developed in 47% of workers who had noted MDI skin staining, vs 19% without skin stains (p = 0.07). Working around and cleaning up liquid MDI represented a significant risk for asthma-like symptoms in both current smokers and nonsmokers; work with finished wood products did not. Asthma-like symptoms were associated with variable airflow limitation (odds ratio [OR], 5.0; confidence interval [CI], 1.4 to 18.7) and specific IgE to MDI-albumin (OR, 3.2; CI, 1.1 to 9.0), but not with skin prick tests to common aeroallergens (OR, 1.1; CI, 0.5 to 2.7). CONCLUSIONS: During the first 2 years of operation, in a plant designed and operated to control exposure to diisocyanates, the development of asthma-like symptoms was reported in a relatively high proportion of the employees who worked with liquid MDI. To prevent asthma symptoms among workers, careful control of respiratory tract exposures associated with liquid MDI is important, especially during cleanup activities. Strict limitation of skin contact with diisocyanates may also be necessary.

[Liver transplantation--development and experiences]. / Levertransplantasjon--utvikling og erfaringer.

A liver transplant program was established in Norway in 1984, and until March 1999 200 liver transplantations have been carried out. Data for these 200 consecutive patients are briefly outlined with emphasis on survival. Relevant data are also given from the Nordic Liver Transplant Registry (NLTR), the European Liver Transplant Registry (ELTR) and from United Network for Organ Sharing (UNOS). Future trends and potential advances in liver transplantation are briefly discussed. One-year and three-year survival rates for Norwegian patients have increased markedly over the years and were 85% and 75% respectively for the 1995-98 period. The number of liver transplantations per million population per year was 3.4 in Norway, 7.8 in Sweden, 5.7 in Finland and 5.4 in Denmark (1990-98). The low number of liver transplantations in Norway warrants attention. It is possible that some patients with end stage liver disease have not been offered this treatment modality. Monitoring of results and active participation in international liver transplant registries like NLTR and ELTR is an important quality control instrument.

Alaska's model program for surveillance and prevention of occupational injury deaths.

The National Institute for Occupational Safety and Health (NIOSH) established its Alaska Field Station in Anchorage in 1991 after identifying Alaska as the highest-risk state for traumatic worker fatalities. Since then, the Field Station, working in collaboration with other agencies, organizations, and individuals, has established a program for occupational injury surveillance in Alaska and formed interagency working groups to address the risk factors leading to occupational death and injury in the state. Collaborative efforts have contributed to reducing crash rates and mortality in Alaska's rapidly expanding helicopter logging industry and have played an important supportive role in the substantial progress made in reducing the mortality rate in Alaska's commercial fishing industry (historically Alaska's and America's most dangerous industry). Alaska experienced a 46% overall decline in work-related acute traumatic injury deaths from 1991 to 1998, a 64% decline in commercial fishing deaths, and a very sharp decline in helicopter logging-related deaths. Extending this regional approach to other parts of the country and applying these strategies to the entire spectrum of occupational injury and disease hazards could have a broad effect on reducing occupational injuries.

Recurrent primary sclerosing cholangitis after orthotopic liver transplantation: is chronic rejection part of the disease process?

BACKGROUND: The possibility of primary sclerosing cholangitis (PSC) recurrence after liver transplantation has been debated. The aim of this study is to examine whether recurrent PSC and chronic rejection (CR) are different expressions of the same disease process. METHODS: One hundred consecutive patients receiving 118 grafts for the diagnosis of PSC were reviewed and placed into three groups: group A, recurrent disease, as evidenced by cholangiographic and pathologic findings with radiographic arterial flow to the liver (n=18; 15.7%); group B, those who developed CR (n=15; 13.0%); and group C, all others (n=82; 71.3%). Cholangiograms and histopathologic specimens were examined in a blinded fashion. RESULTS: Demographic factors were similar, except for age, with a significantly younger age and more episodes of rejection in groups A and B (P<0.03). Group A had a higher incidence of cytomegalovirus hepatitis (P=0.008). Five-year graft survivals for A, B, and C were 64.6%, 33.3%, and 76.1%, respectively (P=0.0001), 5-year patient survivals were 76.2%, 66.7%, and 89.1%, respectively (P=0.0001), and repeat transplantation rates were 27.8%, 46.7%, and 8.5%, respectively (P=0.005). Radiographically, 90% of cholangiograms in patients with recurrent disease showed at least multiple intrahepatic strictures. Histopathologically, patients with recurrent disease and CR shared many features. CONCLUSIONS: We have described a high incidence of recurrent PSC and CR in patients who received transplants for PSC. Histopathologic analysis suggests that CR and recurrent PSC could represent a spectrum of indistinguishable disease. However, the distinct difference in clinical outcome, as evidenced by an increased repeat transplantation rate and lower graft and patient survival in the CR group, clearly suggests that they are two distinct entities that require very different treatment strategies.

Surveillance for nonfatal work-related injuries in Alaska, 1991-1995.

Historically, Alaska has had an occupational fatality rate five times greater than that for the United States. This article reports recent surveillance results for hospitalized nonfatal work-related injuries in Alaska, using the population-based Alaska Trauma Registry (ATR) from 1991 through 1995. The fishing, construction, and logging industries led with the highest number of reported cases in the ATR. Workers in the logging, water transportation, and wood product manufacturing industries had the highest injury rates. Cause, severity, type, and body region of injury were examined for each target industry. For industries with the highest numbers and rates of injuries, in most cases, falls were identified as a common cause of injuries. A fractured bone was the most common type of injury, and the extremities were the most common body region affected. The ATR has proved to be a reliable tool for work-related injury surveillance and will be helpful in planning research priorities and targeting injury prevention efforts.

Colon carcinoma in patients undergoing liver transplantation.

BACKGROUND: Organ recipients are at risk for certain neoplasms. Ulcerative colitis (UC) is itself a strong risk factor for the development of colon carcinoma (CCa). Transplant patients with UC might be at higher risk for CCa. We analyzed these patients to compare the incidence and pattern of CCa development in these and non-UC patients following liver transplantation (OLTX). PATIENTS AND METHODS: Retrospective study of 1,085 OLTX patients. RESULTS: In 1,022 patients without UC, 1 patient (< 0.1%) developed adenocarcinoma in a colonic polyp 46 months after OLTX. Sixty-three of 108 (60%) patients undergoing OLTX simultaneously had UC. Five OLTX patients (8%) with UC developed colon adenocarcinoma 22 to 66 (mean 48) months after OLTX. Two have died. CONCLUSIONS: Coexistent UC in patients requiring OLTX constitutes a potentially high risk for the development of colonic cancer, a late-appearing event. These patients require close observation and frequent colonoscopic/histologic screening of the colon.

Does intraoperative hepatic artery flow predict arterial complications after liver transplantation?

BACKGROUND: Little is known about the value of intraoperative hepatic artery (HA) flow measurement on the development of HA complications in orthotopic liver transplantation (OLT). We undertook this study to see whether assessing HA flow at the OLT helps predict posttransplant HA complications (HA thrombosis or stenosis). METHODS: Four hundred and eleven consecutive OLT in 367 adult patients who received grafts between November 1992 and August 1995 were reviewed. Of these, 259 grafts in 255 patients with at least 1 year of follow-up and with complete data were studied. HA flow, portal vein flow, percentage of cardiac index going to HA (HA/CI), HA flow per 100 g of liver tissue, mean arterial pressure, central venous pressure, and CI were analyzed. Preservation injury was assessed by posttransplant alanine aminotransferase and aspartate aminotransferase levels. RESULTS: Thirty-four patients with 35 grafts developed HA thrombosis or stenosis during a median follow-up time of 29 months. HA complications occurring within the first 100 days of OLT were classified as early complications. HA flow at the time of surgery and percentage of CI going to the liver were found to be significant variables in early HA complications. Hepatic hemodynamics were not different in the late HA complication group compared to the control. Systemic hemodynamics and posttransplant alanine amino-transferase and aspartate aminotransferase levels were similar in all three groups. Logistic regression analysis showed that patients with HA flows less than 400 ml/min were more than 5 times as likely to develop HA complications (risk ratio 5.1). CONCLUSIONS: HA flow measurement should be obtained at the time of OLT and may help to predict early but not late posttransplant HA complications. Patients with HA flows less than 400 ml/min or HA/CI values of less than 7% may carry a higher risk for HA stenosis or thrombosis and may need close surveillance to detect such problems.

Liver and kidney transplantation for polycystic disease.

BACKGROUND: With the poor results of resective and fenestration procedures for polycystic liver disease (PCLD), we present the first series of patients receiving orthotopic liver transplantation for this condition. METHODS: Five of our six patients with PCLD had polycystic kidney disease also. Three of these five received combined organ transplants, while the other two required subsequent kidney transplants. RESULTS: Forty-eight and 52 months after orthotopic liver transplantation, all surviving patients had relief of their pain, distention, and anorexia. Two patients had succumbed to infectious complications and died at 15 and 24 months after transplant. CONCLUSIONS: We conclude that patients with PCLD can be transplanted safely for the relief of their distention and anorexia, with good results. Those patients with both PCLD and polycystic kidney disease who are not dialysis dependent can be managed for several years with isolated liver transplantation and then receive kidney transplantation if needed. Those who are dialysis dependent should receive combined liver-kidney transplantation. Unfortunately, patients with polycystic disease seem to be very susceptible to infectious complications after organ transplantation.

Protection by cyclosporine A against normothermic liver ischemia-reperfusion in pigs.

BACKGROUND: Cyclosporine A (CYA) is primarily utilized as an immunosuppressant, but its mechanisms of action (including decreased neutrophilic free radical production and stabilization of mitochondrial and lysosomal membranes) may have beneficial effects in ischemia and reperfusion (IR) injury. This study was undertaken to examine the effect of CYA pretreatment on porcine liver histopathologic changes and enzymatic release caused by ischemia and reperfusion. MATERIALS AND METHODS: CYA was administered orally for 4 days prior to surgery in two doses (10 or 20 mg/kg) while controls received only the control vehicle. Pigs were then exposed to 4 h of hepatic ischemia followed by 2 h of reperfusion. RESULTS: Significant decreases in AST levels compared to controls were seen in high dose CYA pigs at the end of ischemia and at 30-min intervals during the reperfusion period. Controls exhibited necrotic hepatocytes and severe inflammatory cell infiltration, while high dose CYA animals demonstrated mild inflammatory cell infiltrates. Controls had decreased survival--20% did not survive reperfusion. CONCLUSIONS: This study indicates that CYA may be useful in decreasing initial damage resulting from warm hepatic IR injury.

Liver transplantation in hyponatremic patients with emphasis on central pontine myelinolysis.

Patients awaiting liver transplantation may suffer from severe hyponatremia. It has been suggested that hyponatremia or its treatment might be associated with central pontine myelinolysis (CPM), a serious complication that can be seen after orthotopic liver transplantation (OLT). We undertook this study to assess the outcome of hyponatremic patients after OLT and to evaluate the risk factors in the development of CPM. A total of 379 adult OLT performed in 347 patients between March 1993 and December 1995 was studied using a prospectively-collected data base and retrospective chart review. The following risk factors for the development of CPM were analyzed: primary liver disease, nutritional status, alcoholism, diuretic use, hepatic encephalopathy, United Network for Organ Sharing (UNOS) status, preoperative serum sodium, magnesium and cholesterol levels, increase in serum sodium concentration during surgery, and immunosuppressive treatment. Overall 12 patients (3.5%) underwent OLT in a hyponatremic state (serum sodium < or = 127 meq/L). At a median follow-up of 14 months, 8 patients were alive without any neurological sequel. Six of the 12 patients developed neurological complications in the early post-operative period including CPM in 3, confusion in 2, and seizure in 1. The 3 patients who developed CPM expired within 3 months of OLT. The changes in serum sodium concentration during OLT in patients with and without CPM were 20.7 +/- 8.1 and 7.0 +/- 5.1 meq/L, respectively (p = 0.005). No other risk factor could be identified in the development of CPM. It is concluded that prognosis of hyponatremic patients after OLT is poor if they develop CPM. Slow correction of hyponatremia perioperatively may be critical in preventing this devastating complication.