Systematic review of the incidence, presentation and management of gastroduodenal artery pseudoaneurysm after pancreatic resection

Background

Gastroduodenal artery (GDA) pseudoaneurysm is a serious complication following pancreatic resection, associated with high morbidity and mortality rates. This review aimed to report the incidence of GDA pseudoaneurysm after pancreatic surgery, and describe clinical presentation and management.

Methods

MEDLINE and Embase were searched systematically for clinical studies evaluating postoperative GDA pseudoaneurysm. Incidence was calculated by dividing total number of GDA pseudoaneurysms by the total number of pancreatic operations. Additional qualitative data related to GDA pseudoaneurysm presentation and management following pancreatic resection were extracted and reviewed from individual reports.

Results

Nine studies were selected for systematic review involving 4227 pancreatic operations with 55 GDA pseudoaneurysms, with a reported incidence of 1·3 (range 0·2–8·3) per cent. Additional data were extracted from 39 individual examples of GDA pseudoaneurysm from 14 studies. The median time for haemorrhage after surgery was at 15 (range 4–210) days. A preceding complication in the postoperative period was documented in four of 21 patients (67 per cent), and sentinel bleeding was observed in 14 of 20 patients (70 per cent). Postoperative complications after pseudoaneurysm management occurred in two‐thirds of the patients (14 of 21). The overall survival rate was 85 per cent (33 of 39).

Conclusion

GDA pseudoaneurysm is a rare yet serious cause of haemorrhage after pancreatic surgery, with high mortality. The majority of the patients had a preceding complication. Sentinel bleeding was an important clinical indicator.

Profile of exhaled-breath volatile organic compounds to diagnose pancreatic cancer

Background

Pancreatic cancer has a very poor prognosis as most patients are diagnosed at an advanced stage when curative treatments are not possible. Breath volatile organic compounds (VOCs) have shown potential as novel biomarkers to detect cancer. The aim of the study was to quantify differences in exhaled breath VOCs of patients with pancreatic cancers compared with cohorts without cancer.

Methods

Patients were recruited to an initial development cohort and a second validation cohort. The cancer group included patients with localized and metastatic cancers, whereas the control group included patients with benign pancreatic disease or normal pancreas. The reference test for comparison was radiological imaging using abdominal CT, ultrasound imaging or endoscopic ultrasonography, confirmed by histopathological examination as appropriate. Breath was collected from the development cohort with steel bags, and from the validation cohort using the ReCIVA™ system. Analysis was performed using gas chromatography–mass spectrometry.

Results

A total of 68 patients were recruited to the development cohort (25 with cancer, 43 no cancer) and 64 to the validation cohort (32 with cancer, 32 no cancer). Of 66 VOCs identified, 12 were significantly different between groups in the development cohort on univariable analysis. Receiver operating characteristic (ROC) curve analysis using significant volatile compounds and the validation cohort produced an area under the curve of 0·736 (sensitivity 81 per cent, specificity 58 per cent) for differentiating cancer from no cancer, and 0·744 (sensitivity 70 per cent, specificity 74 per cent) for differentiating adenocarcinoma from no cancer.

Conclusion

Breath VOCs may distinguish patients with pancreatic cancer from those without cancer.

Enoxaparin and abciximab adjunctive pharmacotherapy during percutaneous coronary intervention

Randomized controlled trials of patients with non-ST segment elevation acute coronary syndromes have established the superiority of enoxaparin (versus unfractionated heparin) for reducing adverse ischemic outcomes. Furthermore, adjunctive abciximab therapy during percutaneous coronary intervention (PCI) is associated with improved clinical outcomes. Since algorithms for integrating these pharmacotherapies have not been determined, patients undergoing elective PCI were enrolled into 2 distinct and separate studies conducted by the National Investigators Collaborating on Enoxaparin (NICE) study groups (NICE 1 and NICE 4 studies). Patients in NICE 1 were administered enoxaparin 1.0 mg/kg intravenously (without abciximab) and those enrolled in NICE 4 were administered a reduced dose (0.75 mg/kg) of enoxaparin in combination with standard-dose abciximab intravenously during PCI. Bleeding events and ischemic outcomes assessed in-hospital and at 30-days post-PCI were infrequent with either pharmacologic regimen. In the dose regimens studied, enoxaparin with or without abciximab appears to provide safe and effective anticoagulation during PCI. The combination of reduced-dose enoxaparin and abciximab was associated with a low incidence of adverse outcomes (bleeding or ischemic events). Additional studies may be required to establish the relative safety and efficacy of this new adjunctive pharmacologic strategy when compared with the combination of low-dose, weight-adjusted unfractionated heparin and abciximab.

Combination enoxaparin and abciximab therapy during percutaneous coronary intervention: "NICE guys finish first"

Data from randomized clinical trials support the administration of both enoxaparin and platelet glycoprotein IIb/IIIa blockade to patients who present with non-ST segment evaluation acute coronary syndromes. Enoxaparin does not activate platelets, has a more predictable dose response that facilitates weight-adjusted dosing and may have enhanced antithrombotic (increased anti-Xa activity) and safety (reduced anti-IIa activity) properties when compared with unfractionated heparin. Abciximab administration during percutaneous coronary intervention reduces the incidence of ischemic adverse outcomes and may improve survival in long-term follow-up. The preliminary experience with combining abciximab and intravenous enoxaparin during percutaneous coronary intervention in the NICE-4 Trial demonstrates a low incidence of minor/major bleeding (TIMI definition) and transfusion and infrequent major cardiac events to 30 days follow-up. Future algorithms to facilitate the transition of patients from the clinical service who have received subcutaneous administration of enoxaparin to the cardiac catheterization laboratory prior to percutaneous coronary intervention are forthcoming and will provide seamless integration of "optimal" adjunctive pharmacology through the course of hospitalization for patients with non-ST elevation acute coronary syndromes.

Safety and cost-effectiveness of early discharge after primary angioplasty in low risk patients with acute myocardial infarction. PAMI-II Investigators. Primary Angioplasty in Myocardial Infarction

OBJECTIVES

The second Primary Angioplasty in Myocardial Infarction (PAMI-II) study evaluated the hypothesis that primary percutaneous transluminal coronary angioplasty (PTCA), with subsequent discharge from the hospital 3 days later, is safe and cost-effective in low risk patients.

BACKGROUND

In low risk patients with myocardial infarction (MI), few data exist regarding the need for intensive care and noninvasive testing or the appropriate length of hospital stay.

METHODS

Patients with acute MI underwent emergency catheterization with primary PTCA when appropriate. Low risk patients (age <70 years, left ventricular ejection fraction >45%, one- or two-vessel disease, successful PTCA, no persistent arrhythmias) were randomized to receive accelerated care (admission to a nonintensive care unit and day 3 hospital discharge without noninvasive testing [n = 237] or traditional care [n = 234]).

RESULTS

Patients who received accelerated care had similar in-hospital outcomes but were discharged 3 days earlier (4.2+/-2.3 vs. 7.1+/-4.7 days, p = 0.0001) and had lower hospital costs ($9,658+/-5,287 vs. $11,604+/-6,125 p = 0.002) than the patients who received traditional care. At 6 months, accelerated and traditional care groups had a similar rate of mortality (0.8% vs. 0.4%, p = 1.00), unstable ischemia (10.1% vs. 12.0%, p = 0.52), reinfarction (0.8% vs. 0.4%, p = 1.00), stroke (0.4% vs. 2.6%, p = 0.07), congestive heart failure (4.6% vs. 4.3%, p = 0.85) or their combined occurrence (15.2% vs. 17.5%, p = 0.49). The study was designed to detect a 10% difference in event rates; at 6 months, only a 2.3% difference was measured between groups, indicating an actual power of 0.19.

CONCLUSIONS

Early identification of low risk patients with MI allowed safe omission of the intensive care phase and noninvasive testing, and a day 3 hospital discharge strategy, resulting in substantial cost savings.

Baseline and 6-month costs of primary angioplasty therapy for acute myocardial infarction: results from the primary angioplasty registry

OBJECTIVES

This study sought to describe the economic outcomes from a prospective multicenter registry of primary coronary angioplasty.

BACKGROUND

Interest in coronary angioplasty without preceding thrombolytic therapy as a primary reperfusion strategy has increased as a result of three recent randomized trials showing outcomes equivalent to or better than standard thrombolytic therapy.

METHODS

The Primary Angioplasty Registry enrolled 270 patients with acute myocardial infarction at six private tertiary care medical centers. Baseline and follow-up medical costs and counts of resources consumed were collected from enrollment to the 6-month follow-up visit. Correlates and predictors of cost were identified with multivariable linear regression modeling.

RESULTS

Ninety-five percent of patients had a revascularization procedure during the baseline hospital period: 85% had coronary angioplasty only; 4% had coronary bypass surgery only; 6% had both procedures. The total mean baseline hospital cost (not charge) was $13,113, with mean physician fees of $5,694. During the follow-up period, repeat coronary angiography was performed in 21% of patients, whereas 13% had repeat angioplasty and 3% bypass surgery. Mean hospital follow-up costs were $3,174, with mean physician fees of $1,443. Independent correlates of higher baseline hospital costs included older age (p = 0.049), anterior infarction (p = 0.03), initial Killip class (p < 0.0001), more severe coronary disease (p = 0.0015), need for bypass surgery alone or in addition to angioplasty (p < 0.0001) and recurrent ischemia (p < 0.0001).

CONCLUSIONS

Costs of primary angioplasty for patients with acute myocardial infarction eligible for thrombolysis were strongly influenced by infarction- and procedure-related complications but only modestly influenced by patient selection factors.

Association between neutrophil functions and periparturient disorders in cows

Neutrophil functions were examined in healthy periparturient dairy cows (n = 46) and in cows with retained placenta and metritis complex (n = 20); metritis (n = 18); or mastitis (n = 13). Blood samples (50 ml) were collected from each cow via jugular vein twice weekly from 1.5 weeks before to 4 weeks after parturition. Neutrophil function was evaluated, using 6 tests: random migration, chemotaxis, ingestion, myeloperoxidase activity (iodination), superoxide production (cytochrome C reduction), and antibody-dependent cell-mediated cytotoxicity. Ability to ingest bacteria and random migration activity of neutrophils from clinically normal cows were high around parturition and increased immediately after parturition, whereas myeloperoxidase activity and antibody-dependent cell-mediated cytotoxicity ability of neutrophils from these cows decreased after parturition. Measurement of neutrophil function in 4 ovariectomized cows revealed significant (P < 0.0005) seasonal changes in results of all 6 functional assays. We observed various defects of neutrophil function in all cows with abnormal conditions after parturition. Before parturition, superoxide production activity by neutrophils from cows with metritis and chemotaxis by neutrophils from cows with mastitis were significantly (P < 0.001 and P < 0.05, respectively) lower, indicating that a defect of neutrophil function may be a predisposing factor in the development of these disorders. In conclusion, the host defense role of neutrophils in periparturient cows was impaired, principally because of a defect in killing capacity, which may increase susceptibility to infections. We also investigated the in vitro effects of arachidonic acid metabolites and recombinant human colony-stimulating factors (rhCSF) on functions of neutrophils from clinically normal and postparturient cows with abnormalities, including retained placenta, metritis, or mastitis (n = 5/group). Each abnormal cow was matched for postpartum period with a clinically normal cow. Neutrophils from individual cows were preincubated with arachidonic acid metabolites (prostaglandin F2 alpha, 10(-7) M; prostaglandin E2, 10(-6) M; leukotriene B4, 10(-8) M; and lipoxin B, 10(-8) M) and rhCSF (rh-granulocyte-CSF, 1,000 or 6,000 U/ml; rh-granulocyte-macrophage-CSF, 5 or 15 ng/ml) in a 37 C water bath for 30 minutes before submitting them to function assays. There was no response by neutrophils from either clinically normal or abnormal postparturient cows to treatment with either arachidonic acid metabolites or rhCSF in any of the 6 functional assays. However, preincubation of neutrophils alone in a 37 C water bath for 30 minutes resulted in some alteration of neutrophil function.(ABSTRACT TRUNCATED AT 400 WORDS)

Effect of Plantago ovata (psyllium) husk and seeds on sterol metabolism: studies in normal and ileostomy subjects

The diet of six normal and five ileostomy subjects was supplemented with 10 g/d Plantago ovata psyllium husk for 3 wk while six normal and four ileostomy subjects received 10 g/d psyllium seed. Fecal and ileostomy output, sterol excretion, serum cholesterol, and triglycerides were measured before and after supplementation. The husk had no effect on cholesterol or triglyceride concentrations in either normal or ileostomy subjects. Total and high-density-lipoprotein-cholesterol concentrations were reduced on average by 6.4% and 9.3%, respectively, in the normal group after seed supplementation. No effect on fecal bile acid excretion in the normal subjects was found after both regimes. Ileostomy bile acids were increased (on average 25%) after seed supplementation, whereas no effect on cholesterol concentrations was found. These results suggest that psyllium seed might be more effective than the husk in reducing serum cholesterol, that this cholesterol-lowering effect is not mediated by increased fecal bile acid losses, and increased ileal losses of bile acids might be compensated for by enhanced reabsorption in the colon.

Baby's milk: a source of trust between mothers and nurses

The task of providing infants adequate amounts of nutritious milk, in spite of mothers' ability to produce breast milk, has never been easy. In America cow's milk became the food of choice when mothers ceased to breast-feed their infants. In the mid-1800s advances in bacteriology and chemistry led to a beginning understanding of the role of microbes in food and the development of commercial proprietary formulas. Many mothers discontinued breast-feeding at an early age and relied on these products for their children. With the growth of cities, dairy farms were pushed many miles from the consumers of milk. The distance the new uncooled milk had to be transported, especially during the hot summer months, increased the chances of milk-borne diseases infecting infants. To combat the high rates of infant gastroenteritis and death, welfare reformers and health professionals banded together to improve the milk supply through pasteurization, certification, and safe distribution; and to educate the public, especially mothers, on ways to feed and keep their infants healthy. Through their close contact with mothers in their homes, nurses taught these women how to prepare, store, and feed infants' milk. When their babies survived the summer, mothers developed a sense of trust in the nurse and the things she taught about ways to protect their infants and the entire family's health.

A commitment to care: the development of clinical specialization in nursing

The development of clinical specialists is traced from the beginning of the profession into the present. Nurse anesthetists were the first clinical specialists to appear in the 1880s. In the 1900s, public health nurses began to specialize as infant, school, industrial, and tuberculosis nurses and midwives. From the 1950s to the present, the growth of critical care specialists paralleled the extraordinary growth of medicine. Underlying all specialization has been nursing's commitment to provide needed care.

Cocaine use and HIV infection in intravenous drug users in San Francisco

We assessed risk factors for human immunodeficiency virus (HIV) infection in 633 heterosexual intravenous drug users. The HIV seroprevalence was 26% in blacks, 10% in Hispanics, and 6% in whites. Intravenous cocaine use significantly increased the risk of HIV infection, with a seroprevalence of 35% in daily cocaine users (odds ratio, 6.4; 95% confidence interval, 3.0 to 13.3). Black subjects were more likely to use cocaine regularly. Drug use in shooting galleries and sharing of drug injection equipment were also associated with HIV infection and were more common in cocaine users. By multivariate analysis, black race, daily cocaine injection by blacks and Hispanics, all other cocaine injection, heavy use prior to entry into methadone treatment by blacks, and use of drugs in shooting galleries were independent predictors of HIV infection. Methadone therapy was associated with substantial reductions in heroin use and some reduction in cocaine use, but 24% of cocaine users receiving methadone began or increased cocaine injection after entry into treatment.

Yesterday, today, and tomorrow's pediatric world

The paper covers the historical evolution of children's health care beginning in antiquity and proceeding into the present. Various themes emerge including the indifference of society to children and the overt acts of infanticide and child abuse. By the 18th century new information in the field of medicine and chemistry led to improvements in the physical care of children. A spirit of humanism and the rise of the health professions joined forces in the late 19th century to institute important changes in the health status of children. Finally, several current national trends are discussed in light of their potential impact on child health care.

Prevalence of Trypanosoma theileri in cows and fetuses at slaughter

Blood from 171 pregnant and 65 nonpregnant cows was taken at slaughter for culture and examined during the culturing period for Trypanosoma theileri once a week for 5 weeks. Of the 171 fetuses from the pregnant cows, 119 (69.6%) were greater than or equal to 4 months gestation; blood samples from these fetuses were also taken for culture. Of 236 cows (81 of 171 [47.4%] pregnant and 20 of 65 [30.8%] nonpregnant cows), 101 (42.8%) were culture positive. More of the pregnant than nonpregnant cows were culture positive (P less than 0.05). More beef cows (48.0%) than dairy cows (34.1%) were culture positive (P less than 0.025). Two of the 119 (1.7%) fetus samples were found culture positive. The percentages of positive cultures from Brucella-reactor cows, 18 of 40 (45.0%), and from non-Brucella-reactor cows, 83 of 196 (42.3%), were similar. However, both of the culture-positive fetuses were from Brucella-reactor cows.

Improved method for selenium determination in biological samples by gas chromatography

A gas chromatographic assay employing electron-capture detection for the determination of selenium in biological samples is reported. A calibration curve of 4-nitro-o-phenylene-diamine derivative of selenium as a function of peak area was linear from 5-1000 pg. The limit of detection for the electron-capture detector was approximately 0.5 pg. Recoveries of selenium added to various biological materials ranged from 95-105%. This procedure reduces the number of transfers thereby reducing errors associated with losses or contamination. One advantage of the present method is that interfering compounds occurring in previously employed chromatographic methods are eliminated. This procedure can be used for routine microanalysis of selenium. Samples containing less than 2 ng selenium in 200 microliter of biological fluid can be routinely analyzed using this method.

Echocardiographic and hemodynamic relationships of ejection sounds

The physiologic correlates of ejection sounds have been studied by simultaneous phonocardiograms, echocardiograms and high fidelity pressure tracings. Ejection sounds associated with semilunar valve stenosis or hypertension of the systemic or pulmonary circulation occur at the moment of complete opening of the aortic or pulmonary valve recorded echocardiographically. The start of opening of these valves occurs at the onset of the pressure rise in the corresponding great vessel and completion of valve opening always occurs on the pressure upstroke. The ejection sound in the presence of stenotic valves occurs with checking of the opening motion of the thickened valve cusps. Although the hypertensive ejection sounds also occur at the precise moment of full opening of the valve it remains to be seen whether this relationship is causal or coincidental.

THE POLYMERIZATION OF ACETALDEHYDE

The polymerization of acetaldehyde to paraldehyde at 15 °C. using phosphoric acid is a reaction which at low concentrations of catalyst is of the third order At higher concentrations of catalyst the velocity tends to increase with time due to factors which may include changed ionic conditions. The velocity of the reaction is directly proportional to the quantity of added catalyst.The method of studying this reaction was the observation of the change of volume dilatometrically with time, under conditions which would not favor the production of metaldehyde.