Single-port laparoscopic appendectomy in children: single center experience in 50 patients.

BACKGROUND: Recent years evolution of minimal invasive laparoscopic procedures led to new techniques, like single-port laparoscopy (SPL), resulting in nearly-scarless procedures. The purpose of this study is to evaluate that SPL appendectomy is a safe and feasible procedure using a commercially available trocar (LESS: Laparo Endoscopic Single Site trocar; Olympus TriPort+) in pediatric patients. METHODS: From July 2011 to March 2014 all patients undergoing SPL appendectomy under 18 years were included in this retrospective study. Per- en postoperative data were collected in a prospective database. RESULTS: A total of 50 children (mean age 12 years) diagnosed as acute appendicitis underwent SPL appendectomy. SPL appendectomy was feasible and safe in all cases, both in non-perforated and perforated appendicitis. In one procedure (2%) an extra trocar was placed. Seven patients (14%) were readmitted to the hospital after initial uncomplicated postoperative course. One patient (2%) needed reoperation due to a wound abscess. Three patients (6%) were readmitted due to intra-abdominal abscesses for which antibiotics were given. CONCLUSIONS: SPL appendectomy is a safe and feasible procedure in children with acute appendicitis.

Abatement of an aircraft exhaust plume using aerodynamic baffles.

The exhaust jet from a departing commercial aircraft will eventually rise buoyantly away from the ground; given the high thrust/power (i.e., momentum/buoyancy) ratio of modern aero-engines, however, this is a slow process, perhaps requiring ∼ 1 min or more. Supported by theoretical and wind tunnel modeling, we have experimented with an array of aerodynamic baffles on the surface behind a set of turbofan engines of 124 kN thrust. Lidar and point sampler measurements show that, as long as the intervention takes place within the zone where the Coanda effect holds the jet to the surface (i.e., within about 70 m in this case), then quite modest surface-mounted baffles can rapidly lift the jet away from the ground. This is of potential benefit in abating both surface concentrations and jet blast downstream. There is also some modest acoustic benefit. By distributing the aerodynamic lift and drag across an array of baffles, each need only be a fraction of the height of a single blast fence.

Initial and long-term outcome after palliative surgical drainage of 269 patients with malignant biliary obstruction.

AIMS: This study aimed to analyse the current outcome after palliative surgical drainage of malignant biliary obstruction. METHOD: From 1992 to 2003, perioperative parameters and the incidence and indications of readmissions were analysed in 269 patients who underwent a palliative biliary bypass for periampullary carcinoma. RESULTS: Hospital mortality occurred in seven patients and median postoperative stay was 10 days. Anastomotic leakage occurred in three patients and intraabdominal haemorrhage in eight patients. Overall 75 patients experienced a complication. Nine patients underwent a relaparotomy during initial hospital admission. Overall, 142 patients were readmitted, 13 for indications related to the biliary bypass, 11 for surgery-related indications. Twenty-five patients were readmitted for radiochemotherapy, 112 for progressive disease and 23 for indications not related to the disease. Median survival was 7.5 months and the 3-year survival 3%. Survival was significantly lower in patients with metastases and in those who underwent elective bypass for gastric outlet obstruction. CONCLUSION: Current hospital mortality after palliative biliary bypass as well as readmission rates for complications related to the biliary bypass or surgical procedure are low. Surgical biliary bypass is a safe and effective palliative treatment for patients with malignant biliary obstruction.

Anterior lateral ankle ligament damage and anterior talocrural-joint laxity: an overview of the in vitro reports in literature.

OBJECTIVE: To provide a clear overview of the literature on the relationship between increased lateral ankle ligament damage and anterior talocrural-joint laxity. DESIGN: A systematic review of the literature. BACKGROUND: Diagnostic methods for inversion injuries of the ankle have remained controversial throughout the years. An instrumented test for anterior talocrural-joint laxity could be a diagnostic tool for evaluation of anterior lateral ankle ligament function. METHODS: An advanced electronic database search using MEDLINE and EMBASE was performed to find studies describing the correlation between lateral ankle ligament damage and talocrural-joint laxity. Two reviewers assessed the methodological quality for each study and agreement was noted. Two reviewers extracted all relevant data with respect to methodology, motion constraints and laxity measurement. RESULTS: The quality assessment resulted in 5 studies being scored as high quality and 5 as low quality. Different test devices were used to apply the load and measure the displacement. All in vitro tests applied a load to the calcaneus and subsequently measured the translation of the talus and/or calcaneus relative to the tibial dome. Rotation in the transversal and frontal plane was restricted in 8 tests. After analysis of the results presented by nine different studies, the mean value of anterior talocrural-joint laxity with intact ligaments is 4.2 mm. After sectioning of the anterior talofibular ligament, the mean anterior laxity value is 6.5 mm. The mean anterior laxity value after sectioning of the calcaneofibular ligament increases to 8.4 mm. The mean anterior laxity value with the foot in dorsal flexion (3.1 mm) is less than the mean value with the foot in neutral position (4.5 mm) or in plantar flexion (4.7 mm). The applied load and the anterior laxity values between the different studies vary greatly. CONCLUSIONS: Each ligament section results in significantly increased talocrural-joint laxity. Talocrural-joint laxity can be used as a measure for damage to the anterior talofibular ligament and/or the calcaneofibular ligament. From this review, it is neither possible to give universal recommendations about the optimal flexion angle for testing talocrural-joint laxity as a measure for lateral ankle ligament function, nor to recommend the ideal load for performing the test. RELEVANCE: The development of an instrumented test as a diagnostic tool for anterior talocrural-joint laxity in the clinical setting is near at hand and practicable.

Sentinel nodes outside lymph node basins in patients with melanoma.

BACKGROUND: Lymphoscintigraphy occasionally reveals hot spots outside lymph node basins in patients with melanoma. The aim of this study was to evaluate such abnormally located hot spots. METHODS: Sentinel node biopsy was studied prospectively in 379 patients with clinically localized cutaneous melanoma. One day after lymphoscintigraphy, sentinel node biopsy was performed guided by vital blue dye and a gamma ray detection probe. RESULTS: Persisting hot spots outside the regional node basins were seen in 25 patients (6.6 per cent). Several specific drainage patterns were discerned. In five patients, aberrant sentinel nodes were not explored. The hot spot represented a lymphangioma in two patients. Radioactive lymph nodes were identified in the remaining 18 patients (4.7 per cent). Four patients had metastasis in one of these aberrant lymph nodes. CONCLUSION: Sentinel nodes were found outside a lymph node basin in 5 per cent of patients. Particular drainage patterns exist. It is recommended to incorporate such sites in the late scintigraphy images and to pursue aberrant sentinel nodes, as they may be the only sites of metastasis.

Idiopathic aldosteronism in pregnancy.

This is the first reported case of the idiopathic type of primary aldosteronism in pregnancy. The severely hypertensive patient was unresponsive to treatment with high doses of four antihypertensive agents administered concurrently. A drastic improvement in blood pressure was noted within 24 hours of beginning enalapril maleate, although subsequent deterioration in fetal status led to delivery at 26 weeks' gestation. Alternatives to standard medical therapy may be necessary for this rare but potentially life-threatening disease during pregnancy.

Column-friendly reversed-phase high-performance liquid chromatography of peptides and proteins using formic acid with sodium chloride and dynamic column coating with crown ethers.

Reversed-phase high-performance liquid chromatography of proteins, traditionally carried out with strong acids like trifluoroacetic acid or phosphoric acid, which can damage reversed-phase columns, can be performed with excellent results using the far milder formic acid in the presence of salt. For certain separations, dynamic coating of the column with crown ethers can bring added resolution. Examples given are for peptides from a digest of methionine growth hormone, protein separations from whey proteins containing alpha-lactalbumin and the beta-lactoglobulins A and B, and bovine and porcine insulins. The separation of methionine-growth hormone from growth hormone is also described.

Value of electrophysiologic testing in patients with previous myocardial infarction and nonsustained ventricular tachycardia. Philadelphia Arrhythmia Group.

Previous studies of the value of electrophysiologic studies in patients with nonsustained ventricular tachycardia (VT) have been hampered by the inclusion of a small number of patients with various types of heart disease. This retrospective study was designed to assess the value of programmed stimulation in 205 asymptomatic patients who had had an acute myocardial infarction greater than 1 month before study. Inclusion was based on 24-hour Holter monitoring during which patients had to manifest greater than or equal to 3 consecutive ventricular beats at a rate greater than 135 beats/min. Forty-seven (23%) patients had normal, 70 (34%) mildly impaired and 88 (43%) severely impaired left ventricular function. Programmed stimulation, using up to 3 extrastimuli, was used in each. Seventy-five patients (36%) were noninducible, 59 (29%) had nonsustained VT (less than 30 seconds), 67 (33%) had sustained monomorphic VT and 4 (2%) had either polymorphic VT or ventricular fibrillation. Eighty-two patients were not treated with antiarrhythmic drugs, 57 others were placed on a program selected empirically and 66 had therapy guided by electrophysiologic testing. Satisfactory follow-up information was gathered in 187 of the 205 patients, with a mean follow-up of 18 months. One hundred forty-two patients are alive and well, 39 had sustained VT or sudden death and 6 others had a cardiac death. Only left ventricular function discriminated those who had a sustained arrhythmia or died from those who did not. Thus, programmed stimulation did not have independent predictive value in patients with nonsustained VT. However, definitive conclusions can be reached only with a large prospective study carried out in untreated patients.

Formic acid as a milder alternative to trifluoroacetic acid and phosphoric acid in two-dimensional peptide mapping.

In reversed-phase chromatography of peptides, formic acid has been shown to successfully replace the stronger traditional trifluoroacetic and phosphoric acids. Detection of non-aromatic peptide at lower wavelength is not impaired and being volatile the acid is easily removed, enabling further studies of the peptides. Also in ion-exchange chromatography (the first step of a two-dimensional approach) formic acid works well with a sulphonic acid ion-exchange resin.

A comparison of the treatment of hypertension with Chinese herbal and Western medication.

Forty-five patients with diastolic blood pressure (DBP) greater than or equal to 105 mmHg were randomly assigned to receive Western (group 1, n = 21) or a classical Chinese herbal preparation (group 2, n = 24) to treat their hypertension (HBP). All remained hypertensive after 4 days in the hospital without treatment. Except for baseline Na+ excretion (higher in group 1) and somewhat more evidence of end organ damage in group 1, the patient groups were comparable. Those in group 1 were given a thiazide diuretic and propranolol if needed, and those in group 2, a mixture of 12 herbs. Patients on active therapy in group 1 had a drop in blood pressure (BP) from 172.6 +/- 27.8/107.4 +/- 13.6 to 141.2 +/- 26.2/89.6 +/- 12.0 mmHg, whereas those in group 2 had no change in BP, 168.8 +/- 22.0/107.7 +/- 9.8 mmHg to 165.7 +/- 23.7/106.0 +/- 11.8 mmHg. Although 66% of patients in group 1 had a DBP under 90 mmHg by discharge, only 8% of those in group 2 did. Except for a fall in serum K+ in group 1, there were no significant biochemical or clinical problems in either group. We conclude that standard Western medication is more effective than a classical Chinese herbal preparation used to treat HBP.

Usefulness of programmed stimulation in idiopathic dilated cardiomyopathy.

The response to programmed electrical stimulation and the clinical outcome was determined in 47 patients with nonischemic dilated cardiomyopathy (DC). Thirteen patients (group 1) presented with sustained uniform ventricular tachycardia (VT), 14 (group 2) presented with cardiac arrest and 20 (group 3) presented with nonsustained VT. The mean ejection fraction of the study population was 28 +/- 9%. The response to programmed stimulation was related to arrhythmia presentation. In all patients in group 1 sustained, uniform VT was induced, compared with 1 patient in group 2 and 2 patients in group 3 (p less than 0.001). There were 14 sudden cardiac deaths and 1 cardiac arrest during a mean follow-up of 18 +/- 14 months. The only 4 patients who presented with sustained VT or a cardiac arrest in whom sustained arrhythmia induction was suppressed with antiarrhythmic therapy remain alive. Nine of the 23 patients (4 in group 2 and 5 in group 3) in whom no sustained ventricular arrhythmia was induced died suddenly, with 5 of the 9 receiving empiric antiarrhythmic therapy. Three other patients, who had a slower and hemodynamically tolerated VT at the time of arrhythmia induction, died suddenly. Thus, in patients with nonischemic DC, uniform, sustained VT is always and almost solely initiated in patients who present with this arrhythmia; although few patients presenting with sustained VT or cardiac arrest have inducibility of the arrhythmias suppressed with therapy, if it is suppressed the patient appears to have a good prognosis.(ABSTRACT TRUNCATED AT 250 WORDS)

Endocardial catheter mapping in patients in sinus rhythm: relationship to underlying heart disease and ventricular arrhythmias.

Catheter mapping during sinus rhythm was performed in 132 patients with coronary artery disease and 26 patients with congestive noncoronary cardiomyopathy. Each of the patients had a clinical history of one of the following: no ventricular arrhythmia, nonsustained ventricular tachycardia, cardiac arrest, or sustained ventricular tachycardia. The characteristics of the endocardial electrogram and other measured indexes of slow endocardial conduction were compared between patients with different types of disease and in different arrhythmia groups to determine if differences existed. The cardiomyopathic group had a higher percent of normal endocardial electrograms than the coronary artery disease group, with no evidence of slow endocardial conduction. The sustained ventricular tachycardia group exhibited a greater percent of abnormal endocardial electrograms and more evidence of slow endocardial conduction, distinguishing this group from the three other arrhythmia groups. We conclude the following: The underlying electrophysiologic substrate varies in patients with different ventricular arrhythmias. It is therefore inappropriate to analyze all patients with ventricular arrhythmias as a single group. Patients with congestive noncoronary cardiomyopathy, regardless of the type of their arrhythmia, have a relatively normal endocardium. Those patients with serious ventricular arrhythmias should not be considered candidates for surgery directed at removing abnormal endocardium.

A comparison of the care of hypertension in Hunan and Connecticut.

The demographic, clinical, and social characteristics of 300 hypertensive patients (150 seen in the Hypertension Clinic at Yale University and 150 seen in a newly opened clinic at the First Affiliated Hospital of the Hunan Medical College) were compared at their initial visit to the clinic. The mean blood pressure of both treated and untreated patients and the frequency of mild hypertension and rarity of secondary causes of hypertension were similar. Americans drank more alcohol and were more likely to be heavy smokers, and the Chinese were older, had more end organ damage, and had many more symptoms. The majority of patients in China (77%) were being treated most often with combination pills containing multiple agents. We feel that hypertensive patients are similar in the United States and China, though the Chinese patients appeared to have been seen at a later stage of their disease.

Abnormal signal-averaged electrocardiograms in patients with nonischemic congestive cardiomyopathy: relationship to sustained ventricular tachyarrhythmias.

We assessed whether signal-averaged electrocardiography could identify patients with sustained ventricular arrhythmias in 41 patients with non-ischemic cardiomyopathy. Twelve of these patients presented with sustained ventricular arrhythmia and 29 patients had no history of sustained ventricular arrhythmias. The mean ejection fractions in the groups were 30 +/- 9% and 24 +/- 9%, respectively. Results were compared with signal-averaged electrocardiograms in 55 normal individuals. The filtered QRS duration was longest in patients with sustained ventricular arrhythmias (130.2 +/- 19.5 vs 105.0 +/- 13.1 msec in the group without sustained ventricular arrhythmia, p less than .001 and 95.9 +/- 9.1 in the normal group, p less than .001). The voltage in the last 40 msec of the filtered QRS was lower in the sustained ventricular arrhythmia group (11.3 +/- 9.3 microV) than the group without sustained ventricular arrhythmia (53.5 +/- 28.3 microV; p less than .001) or the normal group (53.7 +/- 25.2 microV; p less than .001). Eighty-three percent of patients in the sustained ventricular arrhythmia group had an abnormal signal-averaged electrocardiogram characterized by both a long filtered QRS duration and a late potential of low voltage level; only 2% of normal subjects and 14% of patients without sustained ventricular arrhythmias had an abnormal signal-averaged electrocardiogram. The signal-averaged electrocardiogram can identify patients with nonischemic congestive cardiomyopathy and sustained ventricular arrhythmias.

Sustained ventricular tachycardia in patients with idiopathic dilated cardiomyopathy: electrophysiologic testing and lack of response to antiarrhythmic drug therapy.

Eleven consecutive patients with idiopathic dilated cardiomyopathy and spontaneous, sustained ventricular tachycardia (VT) of uniform morphology underwent programmed ventricular stimulation and serial antiarrhythmic drug testing. The mean ejection fraction was 30 +/- 6.4%. Sustained VT was induced by programmed electrical stimulation in all 11 patients. A mean of 3.7 +/- 2.4 antiarrhythmic drugs were evaluated by programmed stimulation, including at least one experimental agent in eight patients. In nine of 11 patients VT remained inducible on all drug therapy. During a mean follow-up period of 21 +/- 14 months there were four sudden deaths and two patients with recurrences of VT. In all six patients with sudden death or recurrence of VT, the arrhythmia remained inducible on drug therapy. Three patients who died suddenly had a hemodynamically stable, induced tachycardia on antiarrhythmic therapy. Of eight patients treated with amiodarone, only two were successfully treated. We conclude that in patients with sustained VT and idiopathic dilated cardiomyopathy, VT can be induced by programmed electrical stimulation. VT will usually remain inducible on antiarrhythmic therapy, and sudden death can occur despite slowing and improved tolerance of the induced arrhythmia. Amiodarone may have limited efficacy, and more aggressive therapy, such as surgery or implantation of an automatic internal defibrillator, should be considered in this patient population.

Surgical therapy of variant angina associated with nonobstructive coronary disease.

Patients with variant angina refractory to medical therapy pose a difficult management problem. We report two patients with variant angina who had focal spasm in coronary arteries with fixed obstructions of less than 20% of the luminal diameter. Ischemic episodes were accompanied by malignant ventricular arrhythmias and third degree atrioventricular block. Symptoms were refractory to intensive medical management with nitrates and calcium blocking agents in one patient and with nitrates in the other who was treated before calcium blockers were available. Surgery was done; a bypass graft was placed distal to the area of focal spasm and the native artery was ligated proximally. Both patients are asymptomatic 24 and 66 months after surgery and neither takes anginal medication regularly. The surgical procedure outlined should be considered only if therapy to control life threatening ischemic symptoms with nitrates and calcium blocking agents fails.

Acute cardiac failure and hepatic ischemia induced by disopyramide phosphate.

Two patients abruptly developed congestive heart failure and elevation in serum transaminase levels when given disopyramide phosphate; enzyme abnormalities and hemodynamic status corrected upon withdrawal of the drug. Both patients had underlying ischemic cardiomyopathy. Myocardial infarction, pulmonary embolism, and viral hepatitis were ruled out in both patients. One patient had a liver biopsy documenting central hepatic necrosis with congestion, consistent with hepatic ischemia and not toxic hepatitis. In the other patient, cardiac decompensation and hepatocellular enzyme elevation were reproduced on rechallenge with the drug. Disopyramide should be used with caution in patients with heart failure.

Liver microsomal beta-glucuronidase and UDP-glucuronyltransferase.

Both UDP-glucuronyltransferase (GT) and beta-glucuronidase (betaG) were assayed in untreated liver microsomes. Optimum assay conditions were established with rat liver microsomes using p-nitrophenol (pNP) and its glucuronide (pNPGA) at the pH optima of GT (7.5) and betaG (4.5). The activities of the two enzymes were compared using microsomes from rats, mice, pigs, cattle and horses, with pNP, pNPGA, and phenolphthalein as substrate, in the presence of various cofactors and inhibitors at pH 7.5 and 4.5. These data disclose pronounced differences with respect to species, substrate and other experimental conditions, thereby precluding the establishment of general optimum conditions. The two enzymes were also assayed under strictly identical conditions using pNP and pNPGA and rat liver microsomes at pH 7.5 in the presence and absence of UDP-glucuronate disodium (UDPGA), activators (ATP;UDP-N-acetylglucosamine) and inhibitors. When provided with a functional level of UDPGA, both enzymes proved active under those conditions, and a conjugation-deconjugation interplay was indicated. The two processes could be selectively and totally inhibited by Zn2+ and saccharolactone. The results suggest that conjugation-deconjugation-reconjugation cycles may be operative in the metabolism of drugs in vivo, taking place already at the level of the liver endoplasmic reticulum.