Return to work after general surgery: A comparative study

PURPOSES

There is scarce information on the time to return to work after general surgery. The aim of this study was to analyze time off work after elective cholecystectomy and to compare the results with those in patients undergoing other surgical interventions.

METHODS

Observational and comparative study. Inclusion criteria were: being of working age and undergoing elective laparoscopic cholecystectomy (group 1) or unilateral inguinal hernia or haemorrhoidectomy (group 2).

RESULTS

36 patients were included: 18 patients in each group. Overall, return to work occurred at a mean of 35.7 days, with no significant differences (p=0.656) between groups (group 1: 36.6 days vs. group 2: 35.44 days). The reasons for not returning to work earlier were fear of complications (37.5%), pain control (37.5%), surgeon recommendation (12.5%), and general practitioner recommendation (12.5%).

CONCLUSIONS

Time to recovery after laparoscopic cholecystectomy is prolonged. No statistically significant differences with less complex surgical procedures were detected.

Frailty prevalence and related factors in the older adult-FrailTURK Project

Frailty is one of the geriatric syndromes and has an important relationship with mortality and morbidity. The aim of this study is to present the characteristics, prevalence, and related factors of frailty in older adults in our country. The study included 1126 individuals over 65 years of age from 13 centers. Frailty was evaluated using the Fried Frailty criteria, and patients were grouped as "frail," "pre-frail," and "non-frail." Nutritional status was assessed with "Mini Nutritional Test," psychological status with the "Center for Epidemiological Studies Depression Scale-CES-D," and additional diseases with the "Charlson Comorbidity index." Approximately 66.5 % of the participants were between 65 and 74 years of age and 65.7 % were women. Some 39.2 and 43.3 % of the participants were rated as frail and pre-frail, respectively. The multinomial logistic regression analysis was used to determine the factors associated with frailty. It was observed that age, female gender, low education level, being a housewife, living with the family, being sedentary, presence of an additional disease, using 4 or more drugs/day, avoiding to go outside, at least one visit to any emergency department within the past year, hospitalization within the past year, non-functional ambulation, and malnutrition increased the risk of frailty (p < 0.05). Establishing the factors associated with frailty is highly important for both clinical practice and national economy. This is the first study on this subject in our country and will provide guidance in determining treatment strategies.

Comparison of the efficacy of the cardiac hypothermia and normothermia to myocardial damage in coronary artery bypass graft surgery with systemic normothermic cardiopulmonary bypass

AIM

The aim of our research is to investigate the cardiac damage formed by either local cardiac hypothermia or cardiac normothermia technique in patients who undergone isolated coronary artery bypass graft (CABG) surgery.

METHODS

The total of 40 patients who underwent isolated CABG operation under normothermic cardiopulmonary bypass (CPB) were studied. Patients were randomly divided into two groups as cardiac hypothermia and cardiac normothermia. Myocardial temperature was measured from the interventricular septum before aortic cross-clamp (ACC) (baseline), the ACC 20th minutes (ischemia) and after 20 minutes removal of the ACC (reperfusion). The coronary sinus blood samples were simultaneously obtained from the retrograde cardioplegia cannula while myocardial temperature was being measured. Complement component 3 (C3), complement component 4 (C4), troponin I and tumor necrosis factor-alpha (TNF-α) was measured from the coronary sinus blood samples.

RESULTS

Myocardial temperature was between 18-28 °C (deep hypothermia) during ACC in group 1. Myocardial temperature was over 34 °C (normothermia) during ACC in group 2. TNF-α values of group 1 for ischemia and reperfusion were higher than group 2, and it was found statistically significant (P<0.05).

CONCLUSION

Myocardial damage was less than in normothermia group according to hypothermia group. The results show that ice-cold blood cardioplegia and local ice treatment of the heart during CPB seems to harm the heart more than warm blood cardioplegia.

Qualitative analysis of sequence specific binding of flavones to DNA using restriction endonuclease activity assays

Flavones, found in nature as secondary plant metabolites, have shown efficacy as anti-cancer agents. We have examined the binding of two flavones, 5,7-dihydroxy-3,6,8-trimethoxy-2-phenyl-4H-chromen-4-one (5,7-dihydroxy-3,6,8-trimethoxy flavone; FlavA) and 3,5-dihydroxy-6,7,8-trimethoxy-2-phenyl-4H-chromen-4-one (3,5-dihydroxy-6,7,8-trimethoxy flavone; FlavB), to phiX174 RF DNA using restriction enzyme activity assays employing the restriction enzymes Alw44, AvaII, BssHII, DraI, MluI, NarI, NciI, NruI, PstI, and XhoI. These enzymes possess differing target and flanking sequences allowing for observation of sequence specificity analysis. Using restriction enzymes that cleave once with a mixture of supercoiled and relaxed DNA substrates provides for observation of topological effects on binding. FlavA and FlavB show differing sequence specificities in their respective binding to phiX. For example, with relaxed DNA, FlavA shows inhibition of cleavage with DraI (reaction site (5') TTTAAA) but not BssHII ((5') GCGCGC) while FlavB shows the opposite results. Evidence for tolological specificity is also observed, Molecular modeling and conformational analysis of the flavones suggests that the phenyl ring of FlavB is coplanar with the flavonoid ring while the phenyl ring of FlavA is at an angle relative to the flavonoid ring. This may account for aspects of the observed sequence and topological specificities in the effects on restriction enzyme activity.

In vitro effects of lidocaine hydrochloride on coronary artery bypass grafts

AIM

Coronary artery bypass grafting (CABG) is one of the most common procedures performed to improve blood supply to myocardium. The characteristics of grafts, mechanical stress and pharmacological agents have substantial influence on the short and long term graft patency. Lidocaine is among the most frequently used antiarrhythmic agents perioperatively. The aim of this study was to evaluate the in vitro effects of lidocaine on internal mammarian artery (IMA), radial artery (RA) and saphenous vein (SV) grafts.

METHODS

Using standard tissue bath techniques, responses to increasing concentrations of lidocaine hydrochloride were obtained, in segments of IMA, RA and SV grafts. Twenty patients were enrolled in the study with a total number of 48 grafts (16 for IMA, RA and SV grafts each). In vitro lidocaine concentrations between 10(-9)M and 10(-3.5)M were studied to represent therapeutic plasma concentration of 1.5-5 mcg/mL.

RESULTS

In IMA and RA grafts, lidocaine hydrochloride caused vasodilatation (40.5±1.9% and 39.1±2.6 % respectively) at concentrations between 10(-9) to 10(-7.5) M while causing a dose dependent vasoconstriction response at concentrations above 10(-7.5) M. In SV graft samples, lidocain hydrochloride caused vasodilatation (24.4±1.9 %) at concentrations between 10(-9) to 10(-7) M while causing dose dependent vasoconstriction at concentrations above 10(-7) M. For vasoconstriction effect, mean±SD values for E(max) were calculated as: 120.1±6.6% in IMA, 83.35±5.06% in RA, and 154.0±13.8% in SV. The vasoconstriction in the SV samples was higher than in the RA and IMA. The mean ±SD LogEC(50) values were -5.15±0.27, -5.76±0.11 and -5.56±0.19 for SV, IMA and RA grafts respectively.) There was a statiscally significant differences in the Log EC(50) values between SV, IMA and RA (P<0.005)

CONCLUSION

Based on the results of our study, we conclude that, increasing doses of lidocaine in the perioperative period may cause vasospasm in IMA, RA and SV grafts. Thus, avoiding high doses may have a role in improving perioperative and long term mortality.

Abstract 2313: ER stress-mediated unfolded protein response inhibits angiogenesis and breast tumor growth

Normal vasculature is quiescent in healthy adults with each endothelial cell dividing once every 10 years. But, angiogenesis is crucial for the growth and metastasis of breast cancer, and has been targeted for developing therapeutics. The current treatments are effective in only a small percentage of the total patient population. In addition, they are expensive, and accompanied by a host of side effects detrimental to patient's quality of life. Our laboratory has recently established that tunicamycin (an antibiotic and a glucosamine-containing pyrimidine nucleoside) interferes with the dynamic process of asparagine-linked protein glycosylation inhibiting angiogenesis in vitro and in vivo Matrigel™ implants. It causes cell cycle arrest in G1 and induces endoplasmic reticulum (ER) stress-mediated unfolded protein response (upr), and apoptosis by down regulated expression of Bcl-2 and cyclin D1, and upregulated expression of GRP-78/Bip and caspases3, 9 and 12. High expression of ATF6 and PERK in capillary endothelial cells indicates transcriptional and translational attenuation. Irreversibility of cellular proliferation by either IGF-1 or VEGF or inhibition of cell growth by clonogenic assay supports that tunicamycin can stand tumor microenvironment. There is down-regulation of phosphotyrosine kinase activity as well as the phosphoVEGFR1 and VEGFR2 levels. Most importantly, tunicamycin reduces the progression of a double negative (ER−/PR−/EGFR+) grade III breast adenocarcinoma and a triple negative (ER−/PR−/EGFR−) breast tumor xenograft in nude mice. Histopathology indicates reduced microvascular density and low tumor mitotic index along with reduced K-67 and VEGF expression. A significant reduction of N-glycan expression on the vessel wall correlates with the vessels size, and a high expression of GRP-78/Bip in CD144 positive vessels supports vessel death due to ER stress-mediated upr. WGA staining of tumor epithelia indicates loss of structural integrity with a high GRP-78/Bip expression, and has raised a question if induction of ER stress in tumor epithelia is an indirect effect of nutrient deprivation due to reduced blood flow in the absence of angiogenesis or does tunicamycin directly induce ER stress in the tumor cells. To test this hypothesis we have used a triple negative MDA-MB-231 human breast cancer cell line and cultured them with tunicamycin in a custom made media. Our results show that tunicamycin inhibits cell proliferation in a dose- and time-dependent manner as well as the colony formation. Expression of cyclin D1, wild type p53, phopspho p53(ser 392), Bcl-2 and caspase-3 supports cell cycle arrest followed by induction of apoptosis. High expression of GRP-78 and PERK/phosphoPERK concludes that tunicamycin can induce ER stress-mediated upr in MDA-MB-231 breast cancer cells. Supported in part by grants from Susan G. Komen for the Cure (BCTR06582) and NIH/NCRR/RCMI G12-RR03035 (KB)

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 2313. doi:1538-7445.AM2012-2313

Abstract 2095: Tunicamycin inhibits triple negative breast cancer progression

Triple negative (ER−/PR−/EGFR−) breast cancer accounts for 15% of all breast cancers. A large percentage of them are African and African-American women who are premenopausal. Histologically, the cancers are poorly differentiated, and most fall into the basal subgroup of breast cancers. Because of the absence of specific treatment guidelines, these patients are managed with standard treatment which leaves them associated with a high rate of local and systemic relapse. Angiogenesis is crucial for breast tumor growth and progression. Our laboratory has recently established that Tunicamycin (TM; an antibiotic and a glucosamine-containing pyrimidine nucleoside) interferes with the dynamic relationship between asparagine-linked (N-linked) glycosylation and angiogenesis. As a result, the xenograft developed in athymic nude mice [Balb/c (nu/nu)] with human breast cancer cell line MDA-MB-231 is reduced ∼65% in one week when Tunicamycin was given orally (0.25 mg/Kg) twice per week. To understand if it is due to a direct effect of Tunicamycin on the tumor microvsculature or a nutritional deprivation of the tumor cells due to insufficient blood flow, we have studied the effect of Tunicamycin on MDA-MB-231 breast cancer cells. When titrated with Tunicamycin (0.1 µg/ml, 1.0 µg/ml and 10.0 µg/ml) for seven days, the cell growth was inhibited almost quantitatively at all concentrations and as a function of time. In addition, no colony was formed at 1 µg/ml of Tunicamycin, the concentration used in all our experiments. Protein expression by western blotting and the gene expression by qRT-PCR indicated down-regulation of cyclin D1, and up-regulation of wild type p53, phopspho p53(ser 392), Bcl-2 and caspase-3 with no changes in the cdk-4 expression. These results strongly supported cell cycle arrest in G1 followed by the induction of apoptosis. Our recent study has demonstrated that Tunicamycin induces ER stress and consequently the apoptosis by unfolded protein response (upr) in breast tumor microvasculature. When examined, the MDA-MB-231 cells expressed high levels of GRP-78 as well as phospho PERK, a translational attenuator. Thus, we conclude that the MDA-MB-231 breast cancer cells experienced upr-mediated apoptotic death in the presence of Tunicamycin and strongly supported Tunicamycin's potential for a glycotherapeutic for treating a triple negative breast cancer in the clinic. Supported in part by grants from Susan G. Komen for the Cure (BCTR06582) and NIH/NCRR/RCMI G12-RR03035 (KB).

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 102nd Annual Meeting of the American Association for Cancer Research; 2011 Apr 2-6; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2011;71(8 Suppl):Abstract nr 2095. doi:10.1158/1538-7445.AM2011-2095

Evaluation of iloprost to prevent vasospasm in coronary artery bypass grafts

This study assessed the efficacy of iloprost in relieving vasospasm in coronary artery bypass grafts. Radial artery (RA), left internal thoracic artery (LITA) and saphenous vein (SV) grafts were taken from 20 patients (13 men and seven women, mean age 63.8 years [range 48-74 years]) scheduled to undergo coronary artery bypass grafting. Ten 3 mm vascular rings were cut from each graft and kept under tension for at least 60 min. They were kept alive with 37 degrees C oxygenated Krebs solution. Smooth muscle contraction was achieved with phenylephrine before iloprost was administered every 2 min, starting at a concentration of 10(-9) mol/l and increasing in logarithmic increments to a concentration of 10(-5) mol/l. The vasodilation response to iloprost started in all samples at a concentration of 10(-9) mol/l and increased with each incremental increase in iloprost concentration up to 10(-5) mol/l. These data suggest that local administration of iloprost has a role in relieving graft vasospasm during harvesting and preparation for coronary artery bypass grafting.

Histopathological comparison of vascular wall damage created by external cross-clamp and endoluminal balloon occlusion techniques

AIM

Almost all cross-clamps utilized in vascular surgery, even atraumatic clamps, have been shown to cause mechanical damage to the vascular wall. In recent years, surgical procedures using an endoluminal balloon technique have been reported as an alternative occlusion strategy. This study discusses the histopathological characteristics and comparison between vascular wall damage secondary to the two occlusion techniques in the early postoperative period.

METHODS

Twelve adult rabbits were divided into two experimental groups: the clamp group (N. = 6) and the balloon group (N. = 6). External cross-clamp occlusion was applied to the abdominal aorta for 30 minutes via laparotomy in the clamp group. In the balloon group, occlusion was applied for 30 minutes by inflating the catheter balloon, which was inserted through the iliac artery and advanced into the abdominal aorta. The appropriate aortic segments were subsequently extracted in both groups and tissue samples were examined by light and electron microscopy. Finally, the samples were scored for grade of tissue damage.

RESULTS

In both experimental groups, tissue damage was apparent. In the investigations carried out under light microscopy, it was observed that the damage caused by balloon occlusion was remarkably less than the damage caused by the cross-clamp technique. In the balloon group, eight tissue samples (66.7%) had grade 1 damage. On the other hand, five tissue samples had grade 3 damage, all of which were in the clamp group. Investigation by electron microscopy revealed that greater intimal, medial, and adventitial damage occurred in the vascular walls of the clamp group samples, and this also corresponded with an increase in immune response and intraluminal thrombosis.

CONCLUSION

External clamp and internal balloon occlusion techniques applied to the aorta were compared, and widespread intimal and medial damage were observed in both techniques. However, endoluminal occlusion of the aorta should be the technique of choice in properly selected cases, since it results in lower damage grades, and it should also be used if application of an external clamp is technically difficult.

Psychometric properties of the Spanish version of the Eating Behaviours and Body Image Test for Preadolescent Girls (EBBIT)

The purpose of the current study was to explore the psychometric properties of the Spanish adaptation of the Eating Behaviours and Body Image Test for Preadolescent Girls (EBBIT), as well as its factor structure and internal consistency. A further objective was to determinate the convergent validity between measures of body mass index (BMI) and scores on the Body Dissatisfaction (BD) subscale, taking into account a wider questionnaire, known as the Eating Disorders Inventory (EDI-2). Once the original scale was translated, 525 girls (age range 7-12 years) were assessed by the EBBIT, and the BD subscale. Students were weighed and measured, using calibrated electronic instruments to calculate BMI scores. Factor analysis suggested two primary factors which represent body image dissatisfaction/ restrictive eating (BIDRE) and binge eating behaviours (BEB). The internal consistency of the EBBIT was 0.904. A multiple regression analysis was performed using BMI, age and BD subscale data (independent variables). Results suggest that scores on the EBBIT factors are related to body size satisfaction. Higher BMI and higher BD scores were associated with higher scores on the BIDRE, and BD scores were associated with higher scores on the BEB factor.

The role of inflammation in atrial fibrillation following open heart surgery

This study investigated the role of systemic inflammation in the development of atrial fibrillation (AF) after coronary artery bypass grafting (CABG). CABG was performed using cardiopulmonary bypass in 77 patients. Pre-operative AF was present in six patients (7.8%) and postoperative AF developed in 13 (18.3%) of the 71 patients with pre-operative sinus rhythm. Post-operative mediastinal drainage was significantly increased in patients with post-operative AF compared with those with sinus rhythm. Plasma E-selectin, P-selectin and vascular cell adhesion molecule levels were not significantly different between patients with pre- and post-operative sinus rhythm, those with pre-operative sinus rhythm and post-operative AF, and those with pre- and post-operative AF. There were significant differences between pre- and post-operative C-reactive protein, interleukin (IL)-6 and IL-10 levels within all three groups, but no differences in these parameters between the groups. Thus, in all groups there were significant alterations in mediators indicative of systemic inflammation following CABG, but comparisons between the groups revealed no differences predictive of AF.

The use of esmolol and magnesium to prevent haemodynamic responses to extubation after coronary artery grafting

BACKGROUND AND OBJECTIVE

The haemodynamic responses during extubation can cause complications after open-heart surgery. In this study, we aimed to examine the effect of esmolol and magnesium before extubation on these haemodynamic responses.

METHODS

Following the approval of local Ethics Committee, 120 patients having coronary artery bypass grafting with extubation in the intensive care unit were included in the study. Patients were allocated to receive esmolol 1 mg kg-1 (group I, n = 40), magnesium 30 mg kg-1 (Group II, n = 40) or normal saline (Group III, n = 40). Study medication was administered as a 20-min infusion in a volume of 20 mL. Patients were extubated just after termination of the infusion. Heart rate, blood pressure and central venous pressure were recorded prior to drug administration, before extubation, during extubation and 1 min after extubation.

RESULTS

Heart rate was lower in Group I than in Groups II (P < 0.05) and III (P < 0.001) and lower in Group II than in Group III (P < 0.05) during extubation. It was also lower in Group I than in Group III (P < 0.05) after extubation. Systolic blood pressure was lower in Group I than in Groups II and III (P < 0.001) during extubation. Diastolic blood pressure was higher in Group III than in Groups I and II during extubation (P < 0.001) and after extubation (P < 0.05). Mean arterial pressure was lower in Group I than in Groups II and III (P < 0.001) during extubation, lower in Group II than in Group III (P < 0.05) during extubation and lower in Group I than in Group III (P < 0.05) after extubation.

CONCLUSION

We found that using esmolol before extubation following coronary artery bypass graft surgery prevents undesirable haemodynamic responses while magnesium reduces undesirable haemodynamic responses but does not prevent them.

The role of N-acetylcysteine in lower extremity ischemia/reperfusions

AIM

To evaluate the efficacy of N-acetyl cysteine (NAC) in lower extremity ischemia/reperfusion.

METHODS

A total of 23 patients who underwent surgical intervention due to acute femoral artery occlusion were assigned into 2 groups: control group (group 1, n=12); and NAC group (group 2, n=11). Patients in NAC group received NAC before reperfusion, and 8 and 16 h after reperfusion (3x300 mg), while patients in control group received only NaCl 0.9% (3x100 mL). Catalase, malondialdehyde (MDA) and thiol concentrations were determined in femoral vein samples collected at 6 different time points: before reperfusion (t1), and 30 min (t2), 2 h (t3), 6 h (t4), 12 h (t5) and 24 h (t6) after reperfusion. Alveolar-arterial oxygen gradient (A-aO2) was calculated in radial artery blood samples simultaneously collected at the same time points.

RESULTS

No significant differences between the two groups with regard to age (control group 61+/-13 and NAC group 64+/-11 years), gender (control group M/F: 7/5, NAC 6/5) and the average time from onset of symptoms (control group 9.6+/-3.5 h, and NAC group 10.2+/-3.1 h) were present. Catalase enzyme activity increased with reperfusion in both groups and there were no differences between the two groups. MDA levels did not change significantly with reperfusion in NAC group, whereas they were significantly higher in control group at t2 and t3 compared to NAC group (P<0.05). Thiol concentrations decreased with reperfusion in control group, and in NAC group increases that started with reperfusion returned back to baseline levels after 24 hours. Although the A-aO2 gradient increased in both groups with the beginning of reperfusion, the most prominent increase occurred in control group (P<0.05).

CONCLUSIONS

In control group, the significant increase in MDA levels and A-aO2 gradient in reperfusion phase were considered a sign of local and end organ injury. We did not observe these changes in NAC performed group thus showing the efficacy of NAC.

Reduction in the prevalence and intensity of infection in Onchocerca volvulus microfilariae according to ethnicity and community after 8 years of ivermectin treatment on the island of Bioko, Equatorial Guinea

Bioko is the only island known in the world with endemic onchocerciasis. The island's rural communities consist of villages and cocoa plantations inhabited by Bubi and Fang ethnic groups. The aim of this study was to evaluate the impact of 8 years of vertical ivermectin distribution on the prevalence and intensity of Onchocerca volvulus infection in the rural population by means of pre- (1989) and post-long term treatment (1998) epidemiological surveys. In both surveys, the entire population of 12 randomly selected communities (1723 and 1082 individuals) was examined. The mean ivermectin therapeutic coverage for the 8 years was 53.2%. Iliac crest skin snips were used for differential diagnosis between O. volvulus and Mansonella streptocerca. The crude O. volvulus infection prevalence before ivermectin intervention was 74.5% (1284/1723); after the intervention it was 38.4% (415/1082). The Community Microfilarial Load (CMFL) before and after ivermectin intervention was 28.29 microfilariae/snip vs. 2.32 microfilariae/snip. The reduction in prevalence and CMFL after eight annual rounds of ivermectin treatment corroborates the drug microfilaricidal activity and good tolerability. In the pre-treatment survey, the prevalence was higher in the Bubi group (77.1%, 1126/1461); post-treatment it was higher among the Fang (51.1%, 92/180). The reduction in prevalence and intensity of O. volvulus infection differed between ethnic groups and communities.

Late manifestation of a pseudoaneurysm in the descending thoracic aorta

Rupture of the descending aorta following deceleration trauma is a catastrophic event because it has a high mortality. Prompt surgical treatment is generally considered to be mandatory. However, a few injured patients may leave the hospital with an undiagnosed aortic rupture which may give rise to a chronic pseudoaneurysm. In this report, a 28-year-old man is presented in whom a pseudoaneurysm of the descending thoracic aortic was diagnosed six months after a car accident.