Biomedical subjects
Publications and source records attributed to H Krishnan.
We report a case of axillary lymphadenopathy thirty years after a decorative tattoo clinically mimicking metastatic melanoma. The importance of relying on histological confirmation of metastatic disease before altering extent of surgery is discussed. The importance of recording presence of decorative tattoos is stressed.
Choledochocholedochostomy (CCD) with a 7 fr/8 fr Cotton Leung internal biliary stent removed at endoscopic retrograde cholangiography (ERC) 3 months following orthotopic liver transplantation (OLT) was the technique used on our unit for biliary reconstruction. From June 1995 to July 1996, we randomised 37 OLT patients with CCDs to receive either an internal stent (group I, nd = 18) or no stent (group II, n = 19). Patients in group I had an ERC at 3 months for stent removal whereas patients in group II had an ERC if indicated. The mean follow up was 19 (13-26) months. Biliary complications occurred in 9 out of 18 patients in group 1 compared to 1 out of 19 patients in group II (P = 0.007). In group I, ERC was required for complications in 8 patients and early surgery in 2, compared to 1 ERC for abnormal liver function tests in group II. Five of the early complications in group I were stent related. Late biliary stenosis occurred in 1 patient at 9 months. There was one stent-related death. The use of stents contributes to biliary complications and CCD without stenting is safe after OLT.
University of Wisconsin solution (UW) is now used widely for the preservation of livers for transplantation. However, the use of commercial solutions has added considerably to the cost. We were able to produce a local version of organ perfusion fluid (NOPF) incorporating all the constituents of UW except for the hydroxyethyl starch and adenosine. We compared graft outcome using NOPF with imported grafts perfused with commercial UW solution. The two recipient groups (15 patients each) were similar with respect to age and sex distribution, urgency of transplantation, regraft status and patient and graft survival. Postoperative duration of ventilation, dialysis requirements, peak bilirubin, peak ALT and lowest unsupported prothrombin time were also similar in both groups. In conclusion, local perfusion fluids based on UW can be produced without detriment to graft outcome with considerable financial savings. At our institution, this represents a reduction of 33% in the cost of perfusion fluids.
Painful defaecation is a common and distressing problem in children. A retrospective study has been made of 27 such children who underwent examination under anaesthetic and anal dilatation as part of their overall management. At operation, fifteen were found to have perianal skin inflammation and fissuring. Follow-up was continued where possible until symptoms resolved. The length of follow-up ranged from 1 to 18 months (mean 7 months). At discharge, 21 of the children were cured or substantially better. The author concludes that anal dilatation may help in the management of these children but only as part of an overall strategy of medical care.
OBJECTIVE: To assess the outcome of parathyroidectomy for renal failure-related hyperparathyroidism. DESIGN: A retrospective analysis with a mean follow-up of 4.34 years of a case series of 67 consecutive patients with renal failure-associated hyperarathyroidism. SETTING: All patients were operated on at the University Hospital of Wales and Cardiff Royal Infirmary between October 1981 and December 1991. PATIENTS: Of the 67 consecutive patients, 35 were receiving hemodialysis and 32 had received a renal transplant. INTERVENTION: Total parathyroidectomy with autotransplantation was performed in 52 patients and subtotal parathyroidectomy was performed in 15. MAIN OUTCOME MEASURES: Symptomatic improvement after parathyroidectomy, the normalization of biochemical parameters, and the rate of recurrent hyperparathyroidism after parathyroidectomy. RESULTS: Symptomatic improvement after parathyroidectomy occurred in 81% of hemodialysis patients and in 72% of transplant patients. The best predictor for successful relief of skeletal pain after parathyroidectomy was an elevated preoperative alkaline phosphatase level. Recurrent hyperparathyroidism developed in four of 38 patients after total parathyroidectomy with autotransplantation and in one of 14 surviving patients after subtotal parathyroidectomy. All five patients with recurrent disease were hemodialysis patients (22%). CONCLUSIONS: Transplant patients usually present with less severe disease, have better normalization of biochemical parameters after parathyroidectomy, and rarely develop recurrent hyperparathyroidism compared with hemodialysis patients. Both total parathyroidectomy with autotransplantation and subtotal parathyroidectomy result in good control of renal hyperparathyroidism with excellent improvement of symptoms.
Seventeen pancreatic transplantations were performed in 17 patients with diabetic renal failure over a 6-year period. Ten patients received a simultaneous kidney transplant, the other seven having undergone previous successful renal transplantation. The actuarial pancreatic survival rate at 12 months was 63 per cent and the patient survival rate 92 per cent. The kidney transplant 12-month survival rate (86 per cent) did not differ significantly from that in a group of 22 diabetic patients receiving kidney transplants alone during the same period. Patients with a successful pancreatic transplantation had an increase in quality of life but most developed one or more complications; sometimes these required prolonged hospitalization. Pancreatic transplantation should be restricted to patients with diabetic renal failure who are particularly unstable or exhibit progressive diabetic complications. A small programme can be successful in directing what is an expensive procedure towards patients who are most likely to benefit.
It is customary for patients undergoing kidney transplantation to receive their first dose of cyclosporin either just before or during the transplant operation. This ensures the early establishment of good levels of immunosuppression but might depress early graft function and contribute towards the development of acute tubular necrosis. In a controlled clinical trial, we have studied the effects of withholding cyclosporin for 12 h in patients undergoing cadaveric renal transplantation. Consecutive adult recipients of a cadaveric renal transplant were randomised to receive their first dose of cyclosporin (10 mg/kg p.o.) 6 h prior to transplant surgery or 12 h afterwards. All patients received azathioprine (1.5 mg/kg i.v.) and methylprednisolone (0.5 g i.v.) in addition during surgery. From the 2nd day onwards both groups were treated with an identical triple immunosuppressive regimen. The 27 patients who received their first dose of cyclosporin post-operatively had significantly better immediate and subsequent function than did the 26 patients who received their cyclosporin at the time of surgery. The delayed dosing was associated with improved graft survival and no increase in the frequency of rejection episodes. This regimen is recommended for all patients receiving triple therapy.
Renal transplant rejection is frequently difficult to differentiate from other causes of renal dysfunction. This study examined the use of duplex Doppler ultrasound and intrarenal manometry in a consecutive series of 73 patients who underwent renal transplantation. Altogether 327 duplex scans were analyzed and, for each, a resistive index (RI) was calculated. A raised RI predicted rejection in patients with grafts that functioned immediately, but not in those that had delayed function. A rise in intrarenal pressure ( greater than or equal to 40 mmHg) indicated the presence of rejection in both groups. However, neither test had a sensitivity of more than 71% and this was not improved by combining the results of the two tests for each patient. Although both tests have a place in transplantation, renal biopsies may still be required to confirm rejection.
An adrenal-specific protein reacting with autoantibodies in the sera of patients with adult onset Addison's disease has been purified from human adrenal glands. The protein, mol.wt. 55K, has the biochemical characteristics of steroid 21-hydroxylase and reacts on Western blots with rabbit antibodies to recombinant 21-hydroxylase. Absorption of the native human 55K adrenal protein with human adrenal autoantibodies prevented the subsequent reaction of the 55K protein with rabbit antibodies to 21-hydroxylase in Western blot analysis. In addition, human adrenal autoantibodies reacted with recombinant 21-hydroxylase expressed in yeast. These data indicate that the adrenal specific enzyme steroid 21-hydroxylase is a major autoantigen involved in adult onset autoimmune Addison's disease.
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Seventy-one patients with allograft dysfunction had concomitant Doppler sonography and percutaneous biopsy. Forty-one had biopsy proven acute cellular rejection and eight had acute cellular rejection in combination with acute tubular necrosis. Real time ultrasonic appearance and various parameters of Doppler waveform were studied and compared with 30 controls who had a long period of stable function with no previous episodes of rejection or acute tubular necrosis (ATN). Morphological appearances were unhelpful in diagnosing rejection. A resistive index greater than 0.8 in the study group was highly specific for dysfunction but could not differentiate between acute rejection and ATN. However, two patients in the control group of normal transplants had a resistive index of 0.83. An early to mid diastolic notch was highly specific for acute rejection but of low sensitivity. It may be the only Doppler indication of cellular rejection and may be present when the resistive index is in the normal range.
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Ketamine produced a significant reduction in synaptosomal Na+-K+ ATPase activity both in vivo as well as in vitro. The in vitro inhibition was non-competitive. The observed inhibition of this enzyme may play a significant role in the neurotransmitter events at synapses.
The effect of feeding low protein diet, and the low protein irradiated diet on the deposition of myelin in the brains of rats over two generations showed that malnourishment lowered the CNP enzyme activity when compared to the normal (high protein) diet fed control rats during early postnatal period. Irradiated low protein diet, when fed within 21 days of irradiaton (15 Krads Gamma radiation, 60Co rays), produced still lower CNP enzyme activity. This also enhanced other effects of retarding the brain development, by lowering the protein and lipid contents of the brain during a period from the 4th to 25th day of postnatal development. This suggests the possibility that feeding irradiated low protein food to malnourished developing mammals could cause serious problems like mental retardation.
Problems with breathing immediately after extubation following thyroidectomy are rare, but can usually be attributed to a surgical error such as damage to one or both recurrent laryngeal nerves. Tracheomalacia may also cause respiratory distress following extubation. We present an unusual cause of failure to resume spontaneous respiration after thyroidectomy.