Abstract Background : Cytomegalovirus (CMV) following orthotopic liver transplantation can result in significant morbidity and mortality. Prophylaxis with oral aciclovir (ACV) or ganciclovir (GCV) for all transplant recipients (universal prophylaxis) may be beneficial, but which agent is more cost‐effective is unknown. Methods : A single centre, retrospective study of all patients who had OLT at the Western Australian Liver Transplantation Service was performed. Patients received ACV from 1992 to 1998, and GCV from 1999 to 2001. A comparative cost‐effectiveness analysis for the two groups was performed based on the mean total cost of the number of cases of CMV infection and disease as the clinical end‐point. Results : The ACV group comprised of 55 patients and there were 24 in the GCV group. The incidence of CMV disease was 7% and 4% for the ACV and GCV groups, respectively ( P > 0.05). For CMV infection it was 16% and 8%, respectively ( P > 0.05). GCV prevented more cases of CMV infection and disease than ACV but at an incremental cost of $A20 000 ($US10 172) per case prevented. Overall, ACV was more cost‐effective than GCV by $A2200 ($US1119) per person. The cost benefit of ACV was derived principally through a reduced pharmaceutical cost. Both agents were well tolerated without development of antiviral resistance. Conclusions : Universal prophylaxis of CMV infection following liver transplantation with aciclovir is more cost‐effective than with ganciclovir. (Intern Med J 2004; 34: 410−415)
Introduction The Gyrus PlasmaKinetic bipolar coagulation device has been described for use in most types of abdominal surgery. However, its use in liver resection has, to date, not been described. This study has been conducted to evaluate the safety and efficacy of the Gyrus PlasmaKinetic bipolar coagulation device during the parenchymal transection phase of both open and laparoscopic liver resections. Materials and Methods A retrospective review was undertaken of 30 consecutive liver resections using the Gyrus Plasmakinetic pulsed bipolar coagulation device. The study period was from July 20, 2005 to November 1, 2006. Post‐operative morbidity, mortality, and need for blood transfusion were measured. Results There were 18 males and 12 females. The average age was 54.8 +/− 13.8 yrs, with a range of 29 to 87 yrs. There were 27 open procedures and 3 laparoscopic procedures. Of these, there were 13 major resections (greater or equal to 3 segments) and 17 minor resections (<3 segments). Six patients had histopathological confirmation of cirrhosis in the adjacent liver. Average operation time was 263.1 +/−117.2 min. Length of stay had a median of 9 days. 16 patients (53.3%) did not require any blood transfusion. There was no difference in the proportion of patients receiving a blood transfusion between the cirrhotic and non‐cirrhotic groups (p = 0.46). There were no post‐operative deaths. 6 patients (20 %) had significant post‐operative complications. Conclusion The Gyrus PlasmaKinetic system is safe and efficacious for use in hepatic parenchymal transection when used together with Argon beam coagulation and other more traditional haemostatic strategies in both cirrhotic and non‐cirrhotic livers.
Abstract Background A major shift in treatment of appendicitis occurred early in the SARS-CoV-2 pandemic with non-operative management used commonly outside research protocols and in units with limited previous experience. This study aims to compare real-world outcomes of surgery versus non-operative management of uncomplicated appendicitis in children with 1-year follow-up. Method A prospective multicentre observational study of children treated for uncomplicated appendicitis at 74 hospitals in the UK and Ireland from 1 April to 31 July 2020 was performed. Propensity-score matched analysis was conducted using age, sex, C-reactive protein at diagnosis and duration of symptoms as covariates. Primary outcomes were success of non-operative management defined as achieving 1-year follow-up without undergoing appendicectomy due to recurrent appendicitis or ongoing symptoms, and occurrence of any predefined complication (intra-abdominal collection, wound infection, bowel obstruction or reintervention). Results Of 1464 children with presumed uncomplicated appendicitis, 1027 (70.2 per cent) underwent surgery and 437 (29.9 per cent) underwent non-operative management. Ninety-four children (21.5 per cent) treated by initial non-operative management required appendicectomy during the index hospital admission while recurrent appendicitis after discharge occurred in 25 (10.4 per cent) children within 1 year. The overall success rate of non-operative management at 1 year was 63.1 per cent (95 per cent c.i. 58.0 to 68.3 per cent). For propensity-score matched analyses, 688 children undergoing surgery and 307 undergoing non-operative management were included. Any predefined complication occurred in 50 (7.3 per cent) children undergoing surgery and in four (1.3 per cent) children undergoing non-operative management (OR 5.9 (95 per cent c.i. 2.1 to 16.6)) in the propensity-score matched cohort. There was no mortality or stoma formation. Conclusion Non-operative management is a safe and valid alternative to appendicectomy in children with uncomplicated appendicitis.
Intestinal ischemia is a rarely reported complication following laparoscopic cholecystectomy. We describe a case of massive small intestinal necrosis 3 days following this procedure. An autopsy determined the cause to be splanchnic hypoperfusion, likely due to the physiologic changes induced by the pneumoperitoneum necessary to conduct the surgery. We sought to determine whether all reported cases of intestinal ischemia following laparoscopic cholecystectomy (LC) shared the same etiology, and if faulty operative technique could be invoked.A review of all known published cases of intestinal ischemia following LC was conducted to determine the underlying etiology of ischemia, and whether adequate operative technique had been observed.Multiple causes of intestinal ischemia following LC have been described: splanchnic hypoperfusion, thrombosis of the superior mesenteric artery, and thrombosis of the inferior mesenteric vein. All occurred despite correct operative technique.Intestinal ischemia following LC has diverse causes. Patient factors rather than faulty operative technique would appear to underlie the development of this rare complication.
What is already known about this subject • Although renal excretion is one important route of excretion of moxifloxacin and its metabolites, moxifloxacin pharmacokinetics are similar in patients with varying degrees of renal impairment (but not on dialysis) and in healthy subjects. What this study adds • This study showed that moxifloxacin pharmacokinetics are comparable in patients with severe renal failure requiring haemodialysis and in healthy subjects and patients with impaired renal function not on dialysis. • No dose adjustments are required for haemodialysis patients on oral moxifloxacin therapy. Aim We investigated single dose and steady‐state pharmacokinetics of moxifloxacin in eight venovenous haemodialysis patients. Methods Plasma, dialysate and urine pharmacokinetic parameters for moxifloxacin and its main metabolites were calculated after single and multiple (7 days) dosing with 400 mg day −1 . Results Moxifloxacin pharmacokinetics after a single dose and at steady state (multidose day 7) were comparable in patients with impaired renal function and healthy subjects (geometric mean/%CV AUC mg l −1 h single dose 37.0/24.3 in haemodialysis patients vs. 29.8/22.6 in healthy subjects, 95% CI for ratio of haemodialysis patients to healthy subjects 99.34%, 154.60%; steady state 40.4/29.1 haemodialysis patients vs. 33.9/20.1 in healthy subjects, 95% CI for ratio of haemodialysis patients to healthy subjects 90/39%, 156.93%). In haemodialysis patients plasma concentrations of moxifloxacin at steady‐state were elevated compared with those after a single 400 mg dose (AUC mg l −1 h, geometric mean/%CV, 40.4/29.1) compared with 37.0/24.3; 95% CI for ratio of steady‐state to single dose 87.29%, 136.52%, as were concentrations of metabolite M1 3.21/34.6 compared with 2.02/45.3, 95% CI for ratio of steady state to single dose 14.21%, 175.07%. Haemodialysis cleared about 9% of the dose as unchanged moxifloxacin. Conclusions No dose adjustments are required for venovenous haemodialysis patients on oral moxifloxacin therapy.
We present a rare case of iron deficiency anaemia due to metastatic malignant melanoma of small bowel that occured 9 years after curative resection of melanoma from right foot. A 48 yr old white lady presented with IDA, and abdominal pain for 4 weeks. A malignant melanoma was removed from her right foot in 1995 and a local recurrence was excised 2 yrs later. she was discharged from surveillance follow up 5 years later. On examination she looked pale but systemic exam was otherwise normal. Laboratory results showed Hb 9.9 g/dL with MCV 67 fl. CRP was 67.6 mg/L. Liver and renal profiles, EMA and tumour markers were normal. Stool tests (x 3) were negative for occult blood. Upper endoscopy and colonoscopy were normal. Abdominal and pelvic ultrasound exam was normal. Two weeks later her Hb dropped to 5.7g/dL with CRP rising to 170 mg/L. As the stool tests were negative for occult blood we requested a CT scan rather than small bowel enema. CT scan showed a large (16mm) jejunal mass (Figure 2) and liver lesions suggestive of metastasis deposits. A small bowel enema confirmed a large mass in mid-jejunum. The jejunal tumour was excised. Liver lesions were biopsied. The resected jejunal mass and liver biopsies confirmed metastatic melanoma (Figure 1). Patient is currently undergoing chemotherapy 6 months post surgery. Metastatatic melanoma to GI tract is a relatively uncommon cause of iron deficiency anaemia. Metastasis of melanoma to GI tract is particularly rare after nearly a decade of curative resection. It is important for clinicians to bear in mind the importance of past history of melanoma, however remote it may be. [figure 1][figure 2]Figure 1Figure 2
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