Treatment of genitofemoral neuralgia after laparoscopic inguinal herniorrhaphy with fluoroscopically guided tack injection.

OBJECTIVE: This report illustrates that genitofemoral neuralgia can result from laparoscopic inguinal herniorrhaphy and offers a management strategy for this pain syndrome. DESIGN: A patient experienced pain in the distribution of the genitofemoral nerve after laparoscopic herniorrhaphy. Under fluoroscopy, the point of maximal tenderness was elicited and was found to be at the site of a surgical tack placed during the hernia repair. A genitofemoral nerve block was performed at the site of the surgical tack. This resulted in complete resolution of pain symptoms. RESULTS: The patient's treatment and recovery are described. CONCLUSIONS: Recognition and proper diagnosis of genitofemoral neuralgia after laparoscopic herniorrhaphy may result in appropriate therapy and hasten recovery.

Cardiomyopathy and embolization: risks and benefits of anticoagulation in sinus rhythm.

Systemic embolic complications in patients with cardiomyopathy are associated with significant morbidity and mortality. Despite the lack of prospective, randomized control data, the literature supports the use of left ventricular ejection fraction as an important determinant of the need for systemic anticoagulation therapy in patients with systolic dysfunction. This review discusses the risks and benefits of systemic anticoagulation for patients with cardiomyopathy and proposes a treatment algorithm for its initiation.

Hepatitis C transmission and infection by orthotopic heart transplantation.

BACKGROUND: The transmission and clinical consequences of hepatitis C viral (HCV) infection acquired by orthotopic heart transplantation (OHT) from an HCV-infected donor to an HCV-naive recipient have not been well described. We report our experience in 5 HCV-naive patients who were transplanted with hearts from HCV-positive donors. All transplants occurred within a 1-year period. METHODS: After cardiac transplantation we retrospectively examined the recipients' clinical course, liver-associated enzymes, HCV-antibody serology, quantitative HCV RNA level, and HCV genotype. RESULTS: Five subjects with rapidly deteriorating heart failure and negative serum antibodies to HCV received an emergent OHT from a donor known to be infected with HCV. Liver-associated enzymes peaked at 2 to 6 weeks post-transplant: mean peak alanine aminotransferase was 180 U/L (normal, 9 to 52) and aspartate aminotransferase was 111 U/L (normal, 14 to 36). Liver enzymes had returned to normal limits by 6 and 12 months post-OHT. At a mean 15 months after transplantation, only 1 of 5 patients has developed antibodies to HCV, but 4 of 5 have evidence of infection, as shown by serum HCV RNA. No patient has developed evidence of liver failure. CONCLUSIONS: (1) Transmission of HCV from an HCV-positive donor to an HCV-naive recipient at the time of OHT is likely. (2) Antibodies to HCV post-OHT may remain negative for more than 1 year in these patients. (3) Hepatitis C viral RNA using polymerase chain reaction should be the test of choice for diagnosis of HCV infection post-OHT. (4) Hepatitis C viral donor hearts should be limited to critically ill patients in extremis until the long-term consequences of acquisition of HCV by an OHT recipient are known.

Management of postoperative arrhythmias.

Arrhythmias occur commonly in patients after cardiac surgery. Atrial fibrillation is the most common arrhythmia in the postoperative period; it accounts for significant morbidity to the patient and prolonged hospital stays, and it contributes significantly to the cost of hospitalization. It occurs more commonly in elderly men and in patients undergoing valvular procedures. Beta blockers are effective agents that keep patients from developing postoperative atrial fibrillation and help maintain ventricular rate control. Prophylaxis with antiarrhythmic agents such as amiodarone and sotalol and recently with atrial pacing have shown promise in recent randomized trials. Patients with atrial fibrillation that persists for longer than 48 hours appear to be at a greater risk for cerebroembolic events and should receive anticoagulation unless a contraindication exists. Although frequent premature ventricular contractions and nonsustained ventricular tachycardia (NSVT) occur frequently in patients after cardiac surgery, sustained ventricular tachycardia and ventricular fibrillation are rare and are associated with a poor prognosis. Polymorphic ventricular tachycardia may occur in the setting of myocardial ischemia, metabolic disturbances, and drug toxicities (including antiarrhythmic agents used to treat atrial fibrillation). Poor left ventricular function is a potent risk factor for sudden death in patients with NSVT. Patients with persistent NSVT and ischemic cardiomyopathy with left ventricular ejection fractions of less than 40% should undergo electrophysiologic testing. Conduction abnormalities that may be encountered in patients after cardiac surgery are rarely life threatening. Patients who have undergone valve replacement or repair are at higher risk of developing significant bradyarrhythmias that may require temporary pacing.

Detection of anti-HLA antibody by flow cytometry in patients with a left ventricular assist device is associated with early rejection following heart transplantation.

BACKGROUND: Patients with a left ventricular assist device (LVAD) as a bridge to heart transplantation (HT) often have elevated levels of panel reactive antibodies (PRA). The clinical significance of anti-human histocompatibility leukocyte antigen (HLA) antibodies detected by flow cytometry in PRA negative patients remains unclear. METHODS: Eighteen patients who underwent LVAD placement as a successful bridge to HT had standard anti-human globulin complement-dependent cytotoxicity and retrospective flow cytometry assays performed to detect class I anti-HLA antibodies. A positive flow result was defined as a fluorescent ratio of 23:1 versus a negative control. RESULTS: Six patients had anti-HLA antibodies detected by flow cytometry. Univariate analysis demonstrated more moderate-severe rejection episodes (ISHLT > or = IIIA) at 2 months (0.83+/-0.75 vs. 0; P=0.04) and a trend toward decreased time to first rejection (61+/-17 vs. 225+/-62 days; P=0.06) in these patients. No differences were observed in donor-recipient HLA mismatch or 1 year Kaplan-Meier survival between patients with or without anti-HLA antibodies. CONCLUSION: Despite a negative PRA, LVAD patients with class I anti-HLA antibodies detected by flow cytometry have a greater incidence of moderate-severe rejection in the first 2 months after HT. Flow cytometry may be a useful clinical tool in screening PRA negative LVAD patients before transplantation. Patients with positive anti-HLA antibody screening by flow cytometry may require more intensive immunosuppression in the early post-HT period.

Pulmonary damage by Vibrio vulnificus cytolysin.

Vibrio vulnificus is an estuarine bacterium that causes septicemia and serious wound infection. Cytolysin produced by V. vulnificus has been incriminated as one of the important virulence determinants of bacterial infection. Cytolysin (8 hemolytic units) given intravenously to mice via their tail veins caused severe hemoconcentration and lethality. Cytolysin treatment greatly increased pulmonary wet weight and vascular permeability as measured by (125)I-labeled albumin leakage without affecting those factors of other organs significantly. Blood neutrophils were markedly decreased in number after cytolysin injection, with a concomitant increase in the level of pulmonary myeloperoxidase activity, indicating that cytolysin-induced neutropenia might be due to pulmonary sequestration of neutrophils. By microscopic examination, severe perivascular edema and neutrophil infiltration were evident in lung tissues. These results suggest that increased vascular permeability and neutrophil sequestration in the lungs are important factors in lethal activity by cytolysin.

Miliary tuberculosis in a patient with Epstein-Barr virus-associated angioimmunoblastic lymphadenopathy.

A 74-year-old woman developed angioimmunoblastic lymphadenopathy (AILD) with involvement of intra-abdominal and retroperitoneal lymph nodes. Southern blot analysis showed germline configuration of the JH genes and an oligoclonal pattern of the TcR beta genes. The immunoblasts were of B-cell phenotype and often expressed the CD30 antigen and the latent membrane protein 1 (LMP1) oncogene. Six nonsilent point mutations were identified near the 3' end of the LMP1 gene, leading to a cluster of six amino acid changes within a protein domain needed for maximal NF-kappa B stimulation. After a clinical remission of 8 months the patient relapsed with generalized lymphadenopathy and died secondary to tuberculosis. The oligoclonal rearrangements of the TcR beta genes may reflect an unsuccessful cellular immune response to Mycobacterium tuberculosis or an HLA-restricted T-cell response to B-immunoblasts expressing mutated viral antigens. A positive percutaneous tuberculin test observed 6 months prior to the onset of AILD is in favor of the first possibility.

Plasma Markers of Procoagulant Activity Among Individuals with Coronary Artery Disease.

Background: There is compelling evidence that coronary atherosclerosis represents a chronic active process characterized by inflammation, impaired fibrinolysis, intermittent plaque rupture, and luminal thrombosis. Identifying readily measurable plasma markers of procoagulant activity may have an important role in both tracking and understanding the natural history, as well as in defining the ideal treatment, of patients with coronary artery disease. Methods/Results: A total of 30 men and women with suspected coronary artery disease who underwent outpatient cardiac catheterization were sampled for evidence of thrombin generation and fibrin formation in plasma. Compared with healthy controls, patients had significantly increased concentrations of fibrinopeptide A (18.8 +/- 10.8 ng/ml vs. 2.5 +/- 2.3, p < 0.001), thrombin-antithrombin complexes (8.13 +/- 4.56 ng/ml vs. 3.4 +/- 3.0, p < 0.001), and prothrombin activation fragment 1.2 (0.15 +/- 0.09 ng/ml vs. 0.12 +/- 0.19, p = 0.01). There was a statistically insignificant trend toward increased thrombin-antithrombin complex concentrations in patients with hypercholesterolemia (p = 0.10). Patients with angiographically defined coronary artery disease involving two or more vessels were found to have heightened thrombin generation and fibrin formation compared with those with single vessel disease. Conclusions: Patients with atherosclerotic coronary artery disease exhibit evidence of heightened procoagulant activity, including thrombin generation and fibrin formation. This observation, coupled with those derived from other recent studies, support the hypothesis that coronary atherosclerosis represents a chronic active process typified by vessel wall inflammation and recurrent thrombosis. Future efforts in disease prevention and treatment must consider these fundamental pathobiologic properties.

Pregnancy after cardiac transplantation.

A patient who had undergone cardiac transplantation for familial hypertrophic cardiomyopathy 4 years previously underwent a successful normal spontaneous vaginal delivery. Her immunosuppressive therapy consisted of cyclosporine, prednisone, and azathioprine. She showed some evidence of renal insufficiency and had pregnancy-induced hypertension.