Anjani Thakur

Comparison of loop versus end ileostomy for fecal diversion after restorative proctocolectomy for ulcerative colitis.

BACKGROUND The goal of this study was to compare the benefits versus complications of temporary loop ileostomies and end ileostomies in a consecutive series of patients undergoing colectomy and ileal pouch-anal anastomosis for ulcerative colitis. STUDY DESIGN A retrospective review was performed of all patients undergoing restorative proctocolectomy with diverting ileostomy for ulcerative colitis at the UCLA Medical Center during a 4-year period. An end ileostomy (EI) was used for 38 patients and a loop ileostomy (LI) for 39. All patients had a J pouch, with all EI patients having a hand-sewn ileoanal anastomosis, and 33 LI patients having a double-stapled anal anastomosis. EI closure was performed through a laparotomy, and LI closure was performed through a periileostomy incision. RESULTS The mean operative time for EI closure was 157 minutes, and for LI closure was 103 minutes. The wound infection rate after EI closure was 5.3% and after LI was 10.3%. For EI patients, 2 of 38 patients required reoperation, compared with 5 of 39 for LI. The mean hospital stay after EI closure was 6.7 days, and after LI closure was 7.1 days. Peristomal skin irritation was more severe, more prolonged, and occurred in more than twice as many LI as EI patients. Home ostomy nurse care was necessary for a mean of two visits for EI patients and five visits for LI patients. The cost ofostomy supplies and care was more than double for LI patients compared with those with EI. Patient satisfaction and ability to resume physical and social activities early after ileostomy construction were much more favorable for EI than LI patients. CONCLUSIONS The benefit of shorter operating time for LI closure compared with EI closure is often outweighed by the complications and costs of LI stomal care and patient dissatisfaction. EI should be considered more frequently for temporary ileal diversion after restorative proctocolectomy.

Scrotal abscess following appendectomy

Abstract. Postoperative infectious complications in children following perforated appendicitis present in diverse ways. We present two unusual complications of appendectomy for perforated appendicitis: an acute scrotum after open and laparoscopic appendectomy. A␣retrospective review of two cases of scrotal abscess following appendectomy at our hospital as well as a MEDLINE search was performed to review the clinical presentation, etiology, type of treatment, and outcome of these patients. Although scrotal inflammation occurring postoperatively in a patient with perforated appendicitis may be due to an incarcerated hernia, it is much more likely to be due to a scrotal abscess. Patients without a patent processus vaginalis or inguinal hernia at initial presentation of peritonitis must be carefully followed in the postoperative period and explored early if testicular or scrotal pain becomes manifest.

Subtotal hysterectomy for uterine rupture

Objective: The aim of this paper was to stratify patients with uterine rupture in extremis (with hypotension, change in vital organ function, and altered mental status) and evaluate outcome for patients undergoing subtotal hysterectomy (STH) vs. uterine repair (UR). Methods: Of 39 667 hospital deliveries between 1993 and 1998 at a university hospital, 367 presented with uterine rupture. Of these, 96 presented in extremis and had an irregularly torn uterus found at operation. Charts were retrospectively reviewed to stratify patient population with uterine rupture and their outcome. Results were analyzed using Fishers exact test. Results: Patients with uterine rupture were 31–35 years old, para≥3, had received no antenatal care, and presented with rupture in the lower uterine segment. Sixty‐one patients underwent STH while 35 underwent UR. The groups were similar with respect to patient age, parity, cause of rupture, and clinical condition at the time of evaluation (P=0.2). The operative time for STH was significantly less than UR, 35 min vs. 75 min (P<0.01). Maternal mortality was significantly higher in patients undergoing UR vs. STH, 46% vs. 20% (P=0.01). Maternal morbidity occurred in 30% of patients undergoing STH vs. 50% in patients undergoing UR (P=0.01). The time to discharge was significantly less in patients undergoing STH compared to UR, 14.5 days vs. 27 days (P<0.01). Conclusions: Patients with uterine rupture in extremis tend to be young, multiparous, receive no antenatal care, and have uterine rupture of the lower segment. STH significantly lowered operative time, morbidity, time to discharge, and mortality than UR in patients in extremis with uterine rupture.

Patient-satisfaction in an outpatient vein surgery office: A comparison of English- and Spanish-speaking patients

Background In spite of an increasing Latino population and accompanying rise in demand for health care, not much is known about patient-satisfaction in Spanish-speaking patients and how to improve patient-satisfaction when using interpreters. We sought to compare patient-satisfaction with vein surgery office visits between English-speaking and Spanish-speaking patients. Methods Directly before and after the office visit, 126 patients completed a socio-demographic survey, a five-point ordinal rating survey of physician and interpreter satisfaction with the encounter. Measures were satisfaction with the provider’s friendliness, respectfulness, concern, ability to make the patient comfortable, and time spent for the exam. Results When the provider was fluent in the language that the patient spoke, patients (M = 4.954, SD = 0.21) were significantly more satisfied with their visit at VVHC than patients who required an interpreter (M = 4.762, SD = 0.71), z = 2.230, p = 0.012. Spanish speaking patients were more likely to be satisfied with the visit when they felt their interpreter was friendly (n = 58, p = 0.049). There was no difference found with regard to the provider being thoughtful and comforting. Conclusion Spanish-speaking patients are less satisfied with the care provided in a vein surgery office. Patients who communicated through an interpreter were less satisfied with the patient–provider relationship. In light of the growing diversity of the US population and the fact that patient-satisfaction is increasingly tied to reimbursement, additional research might identify potential areas of improvement for the surgeon, interpreter, and patient perspectives.

Gene transfer to the embryo: Strategies for the delivery and expression of proteins at 48 to 56 hours post-fertilization

BACKGROUND/PURPOSE Although gene and protein transfer may potentiate the cure of genetic disease, current strategies involving fetal gene therapy remain nonfocal and confounded by the lack of imaging techniques and in vivo markers for precise gene transfer. METHODS Fourteen white Leghorn chick eggs were incubated for 48 to 56 hours postfertilization until they reached stages 11 to 16, about 3 mm in size. In 7 chick embryos, a glass needle was placed at the midbrain/hindbrain level and 1 x 10(7) pfu of an adenovirus containing the green fluorescent protein (GFP) reporter gene was injected into the lateral head. In another 7 chicken embryos, colored agarose beads coated with Sonic hedgehog (Shh) protein were implanted at the level of the hindbrain under direct microscopy. The eggs were then sealed, incubated at 37 degrees C for 24 hours, and reimaged using fluorescent microscopy and confocal laser microscopy. RESULTS At 24 hours postinjection, all embryos were alive and were imaged in vivo. Fluorescent microscopic imaging showed green fluorescence in the region of the injection site in all the embryos. In embryos that underwent bead placement, the beads were visualized under microscopy in the lateral hindbrain of all embryos, and the presence of the Shh protein was confirmed using fluorescein isothiocyanate (FITC)-conjugated secondary antibody. CONCLUSIONS This study shows that embryonic 3-mm chick embryos survive adenoviral transduction or agarose bead implantation in a focal manner in vivo and that this delivery results in production of imageable levels of protein. This may be used in mammalian systems, including humans, to introduce genes and proteins.