Laparoendoscopic single site surgery (LESS) cholecystectomy requires a creative solution to retract the gallbladder. Transabdominal suture retraction is a commonly used technique to achieve adequate ...exposure of the critical structures within Calot's triangle. To avoid the multiple punctures of the gallbladder and abdominal wall required by such suture retraction, we developed a novel internal retractor specifically for use during LESS cholecystectomy. This retractor consists of a laparoscopic bulldog clamp fitted with a small metal hook, and was successfully used in a recent case of LESS cholecystectomy.
A number of studies have demonstrated both low nitric oxide (NO) and l-arginine (l-arg, the substrate for NO synthesis) levels during adult sickle cell vasoocclusive crisis (VOC). L-arg levels, while ...diminished, are 10-fold higher than the km (3 mM) of endothelial NO synthase (eNOS) and more than sufficient to saturate this enzyme (a state known as the arginine paradox). Diminished l-arg thus cannot directly explain lower NO levels. Two explanations, enhanced arginase activity (catalyzing the conversion of l-arg to ornithine), and inhibition of NOS by increased levels of asymmetric dimethylarginine (ADMA) have been proposed to explain this arginine paradox in VOC. We sought to investigate these mechanisms during adult VOC in the emergency department (ED). L-arg, ornithine, and citrulline (the end product of ADMA metabolism) were measured via ion exchange chromatography from blood obtained from adult ED VOC patients. Citrulline levels were used as an indirect indicator of ADMA and ornithine levels were used as an indicator of arginase activity. Samples from sickle patients in steady-state and from normal healthy volunteers were obtained for comparison. As expected, VOC subjects had significantly lower median l-arg levels (23.16 μM/l, 18.74–29.81 IQR, p<0.001 vs steady state, 38.56 μM/l, 5.88–20.26 IQR, and control, 73.01 μM/l, 27.42–37.2 IQR). There was no significant difference in citrulline levels. Ornithine, the end product of l-arg metabolism by arginase, was lower in VOC (median: 22.61 μM/l, 17.22–27.3 IQR, p<0.001 vs steady state median of 36.78 μM/l, 30.28–42.26 IQR). It has been suggested that the l-arg:ornithine ratio may be a better reflection of total arginase activity - in this study, the l-arg:ornithine ratio was significantly lower in adult VOC (1.02 vs 2.71) when compared to healthy controls, indicating enhanced total arginase activity. We conclude that the l-arg-arginase-ornithine pathway may play a significant role in the diminished NO seen in adult VOC patients via enhanced arginase activity. This enhanced arginase activity may alter available l-arg, resulting in decreased NO. ADMA does not appear to be an important contributor to the arginine paradox found in adult VOC.
We present the case of a 52-year-old female with recurrent symptomatic ascending colon diverticulitis who ultimately underwent elective laparoscopic right hemicolectomy. The following is a case ...report and literature review pertaining to right colonic diverticular disease.
hydrochlorothiazide (HCTZ) diuretics were correlated with an increased risk of non-melanoma skin cancer (NMSC) and melanoma in the general population. Information is a scarce regarding this effect in ...kidney transplant recipients who are at increased risk of skin malignancies under immunosuppression.
Single-center retrospective analysis of adult kidney transplant recipients between 1 January 2010 and 31 December 2015. The primary outcome of the study was the first diagnosis of skin cancer that was removed and pathologically analyzed. Exposure to thiazides was defined as HCTZ use daily for at least one year at a dose of 12.5 mg.
Among 520 kidney transplant recipients, 50 (9.4%) were treated with HCTZ. During a median follow-up of 9.8 years, 67 patients underwent surgical removal and pathological analysis of at least one skin cancer. Exposure to HCTZ during the 3 years following transplantation was associated with an increased risk of skin cancer (
= 0.004). In a multivariate model, there was a significant association between HCTZ exposure and NMSC (HR 2.54, 95%CI 1.26-5.15,
= 0.007). There was a higher rate of basal cell carcinoma with HCTZ exposure, according to both univariate and multivariate analyses (HR 2.61, 95%CI 1.06-6.43,
= 0.037) and (HR 3.03, 95%CI 1.22-7.55,
= 0.017, respectively). However, no significant association was observed between HCTZ exposure and squamous cell carcinoma.
These findings suggest a benefit of increased frequency of dermatologist inspection in kidney transplant recipients receiving HCTZ especially in increased ultraviolet exposure area.
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