Continuation of treatment of drug misusers between primary and secondary care in the South West

Focal points

[News in emergency medicine 2009]

The field of Emergency Care Medicine is a very dynamic part of the Medical Science. That is why there is a huge amount of publications on this topic every year. This article is my personal selection of recently published scientific work on pulmonary embolism, classification of circulatory shock, betablockers in acute decompensated heart failure, advanced cardiac life support, subarachnoid hemorrhage, inhalation therapy with ipratropium-bromide, community acquired pneumonia, diverticulosis, gout and pancreatitis. Last but not least there is a choice of prophylactic interventions, you might not yet be aware of. Some of the discussed publications may help you manage the next patient you'll encounter, when you're on call next time.

[News in emergency medicine 2007]

During the year 2007 one could read plenty of interesting publications in the field of Emergency Care Medicine. I made a personal choice out of this recent literature for a workshop at the 6th Zentralschweizer Internistenwoche to discuss new aspects of Emergency Care patients that you could encounter tomorrow in your unit.

Serum vascular endothelial growth factor in breast cancer: its relation with cancer type and estrogen receptor status

PURPOSE

Angiogenesis is essential for tumor growth. Vascular endothelial growth factor (VEGF) is one of the most potent angiogenic cytokines. In breast cancer, tumor VEGF has been shown to have a good correlation with relapse-free survival. The aim of this study was to determine the relation of serum VEGF levels to the various indices of breast cancer and known tumor markers carcinoembryonic antigen and CA15.3.

EXPERIMENTAL DESIGN

Preoperative serum VEGF levels were determined in 200 women with breast cancer and compared with serum VEGF levels in 88 healthy female controls.

RESULTS

The serum VEGF levels of the cancer patients as a group were significantly elevated compared with those of the controls (P < 0.0005). VEGF levels were elevated in patients with invasive cancer of ductal/no specific type, ductal carcinoma in situ, and estrogen receptor (ER)-positive tumors. Patients with lobular carcinoma and ER-negative tumors had serum VEGF levels comparable with those in the controls. VEGF was more sensitive than CA15.3 and carcinoembryonic antigen in detecting breast cancer.

CONCLUSIONS

Preoperative serum VEGF detects breast cancer with a sensitivity of 62.1%. The relationship to cancer type and ER status may have future therapeutic implications. Additional long-term studies are required to determine the prognostic significance of serum VEGF.

Iatrogenic thoracic migration of the stomach complicating laparoscopic nissen fundoplication

BACKGROUND

Intrathoracic gastric herniation after laparoscopic Nissen fundoplication is an uncommon but potentially life-threatening complication that may present in the early or late postoperative period.

METHODS

A retrospective analysis was performed on all patients undergoing antireflux surgery from December 1991 to June 1999.

RESULTS

Nine cases of gastric herniation occurred after 511 operations (0.17%). Patients presented with the condition 4 days to 29 months after surgery. Eight of these nine patients (89%) had reported vomiting in the immediate postoperative period. Seven patients (78%) reported persistent odynophagia. A factor common to all patients was that posterior crural repair had not been performed.

CONCLUSIONS

Measures should be undertaken to prevent postoperative vomiting after laparoscopic Nissen fundoplication. Posterior crural repair is essential after surgery in all cases.

Laparoscopic ultrasound for the detection of hepatic metastases during laparoscopic colorectal cancer surgery

PURPOSE

The search for liver metastases before surgery forms an accepted part of colorectal cancer surgical practice. Intraoperative ultrasound and manual palpation of liver together form the criterion standard as far as screening for metastases is concerned. However, extracorporeal imaging, such as ultrasound and magnetic resonance imaging, are also widely used. The purpose of this study was to demonstrate the efficacy of laparoscopic ultrasound scan in detection of liver metastases during laparoscopic colorectal cancer surgery by comparison with conventional imaging modalities.

METHODS

A prospective, controlled study was undertaken. A total of 76 consecutive patients undergoing laparoscopic colorectal resections for malignancy were recruited. Patients underwent preoperative liver ultrasound scan and intraoperative blinded laparoscopic ultrasound scan examination performed by a single surgeon. Contrast-enhanced magnetic resonance imaging was performed within 30 days of surgery.

RESULTS

Conventional ultrasound scan was negative in all cases. Metastases were identified during simple laparoscopic inspection of the liver in one case. Two cases shown by laparoscopic ultrasound scan to have definite metastases were confirmed by magnetic resonance imaging. In seven further instances laparoscopic ultrasound scan identified suspicious liver masses. In three cases these were confirmed to be metastases at magnetic resonance imaging; one was confirmed as a cyst, and the remaining three suspicious lesions were confirmed at serial magnetic resonance imaging scans to be benign and of no significance.

CONCLUSION

Laparoscopic ultrasound scan with a flexible-tipped probe permits satisfactory hepatic examination. It is superior to conventional ultrasound scan and seems to be as effective as magnetic resonance imaging, although the latter modality is still required to delineate identified lesions.

[Heparin and insulin in the treatment of acute hypertriglyceridemia-induced pancreatitis]

Hypertriglyceridaemia is thought to be the aetiology in 3% of patients with acute pancreatitis, often associated with poorly controlled diabetes mellitus or chronic alcohol abuse. However, in patients with non-biliary pancreatitis, chylomicronaemia is an underrated cause of acute pancreatitis. The activity of lipoprotein lipase (LPL) is crucial in removing triglycerides from the plasma; LPL gene mutations combined with secondary alterations in plasma lipoproteins, such as occur in pregnancy, diabetes mellitus, and alcohol abuse can cause severe hypertriglyceridaemia and pancreatitis. Heparin and insulin stimulate LPL activity. During a 12 months' period we consecutively screened all patients with the diagnosis of acute non-biliary pancreatitis for hypertriglyceridaemia, to evaluate the prevalence of hypertriglyceridaemia-induced pancreatitis and to assess the outcome under standardised treatment with intravenous heparin and insulin. Hypertriglyceridaemia-induced pancreatitis was diagnosed in 5 out of 46 patients (11%) with acute pancreatitis. In 2 patients hypertriglyceridaemia was associated with diabetes mellitus, in one patient with pregnancy and in another with chronic alcohol abuse. Four patients had to be referred to the intensive care unit. Plasma concentrations of triglycerides were (median +/- range) 43 mmol/l (14.7 to 80.4); pancreas amylase was 574 U/l (155 to 1606), and lipase was 1003 U/l (330 to 3010). All patients had oedematous pancreatitis demonstrated by CT scan. Treatment with i.v. heparin and i.v. insulin decreased trigylceride levels to less than 10 mmol/l within 2.8 days (1 to 6), the amylase and lipase levels returned to normal after 3 and 4 days respectively, and the abdominal pain was resolved. Hypertriglyceridaemia is a common and under-diagnosed etiology of acute non-biliary pancreatitis. Intravenous heparin and insulin is safe and effective in the treatment of hypertriglyceridaemia-induced pancreatitis. Low fat diet, supplements of (n-3) fatty acids ("fish oil") and fibrates are recommended for long-term maintenance therapy.

Revival of tetracyclines--in the treatment of visceral leishmaniasis?

A 37-year-old immigrant from Kosovo who had been in Switzerland for 2 years developed fever, cough, weight loss and malaise. Serology (complement binding reaction) was positive for leptospirosis. The symptoms resolved very rapidly under vibramycin 2 x 100 mg/day for 3 weeks. However, a flare-up occurred after cessation of medication. Reexposure to tetracyclines improved the symptoms though they did not subside completely. Bone marrow analysis demonstrated intracellular leishmania (amastigotes). Analysis of frozen serum preserved since the first hospitalisation and samples from the second admission were positive for leishmania (indirect fluorescence antibody test) and confirmed the diagnosis of visceral leishmaniasis. Reevaluation of the serology for leptospirosis was negative using the specific microagglutination method. Treatment with antimony for 28 days resolved all symptoms. The parasites of visceral leishmaniasis grow intracellularly and eradication may be impossible in patients with an impaired cellular immune response. Flare-ups thus recur in 60-100% of patients with organ transplants or AIDS, despite regular treatment. Our finding raises the question whether relapses are suppressed in immunocompromised patients by tetracyclines, drugs known to be well tolerated even under long-term exposure. Randomised studies are required in this setting.

Optimal education techniques for basic surgical trainees: lessons from education theory

"Calmanisation" of surgical training and the introduction of the "New Deal" on doctor's hours has led to a reduction in "in service" training and a proliferation of training courses. Little research has been done into the optimum design of these courses. Education theory has shown that individuals have optimal learning styles and that these styles tend to be generalised across professional groups. It was decided, therefore, to investigate the optimal learning styles of basic surgical trainees. A learning style inventory was used to assess the preferred learning style of 52 basic surgical trainees. The predominant learning styles (86.5%) were convergent (n = 31) or accommodative (n = 14) whilst only 5 (9.6%) assimilative and 2 (3.9%) divergent styles were detected. Convergent and accommodative learners rely principally on hands on experience and problem solving as their optimal learning technique. Given the shorter hours and duration of Basic Surgical Training, in service practical training and surgical courses should be structured accordingly.

Vascular endothelial growth factor in premenopausal women--indicator of the best time for breast cancer surgery?

Timing of surgery in premenopausal patients with breast cancer remains controversial. Angiogenesis is essential for tumour growth and vascular endothelial growth factor (VEGF) is one of the most potent angiogenic cytokines. We aimed to determine whether the study of VEGF in relation to the menstrual cycle could help further the understanding of this issue of surgical intervention. Fourteen premenopausal women were recruited, along with three post-menopausal women, a woman on an oral contraceptive pill and a single male subject. Between eight and 11 samples were taken per person, over one menstrual cycle (over 1 month in the five controls) and analysed for sex hormones and VEGF165. Serum VEGF was significantly lower in the luteal phase and showed a significant negative correlation with progesterone in all 14 premenopausal women. No inter-sample variations of VEGF were noted in the controls. Serum from both phases of the cycle from one subject was added to MCF-7 breast cancer cells; VEGF expression in the supernatant was lower in the cells to which the luteal phase serum was added. The lowering of a potent angiogenic cytokine in the luteal phase suggests a possible decreased potential for micrometastasis establishment in that phase. This fall in VEGF may be an effect of progesterone and should be the focus of future studies.

Preoperative serum vascular endothelial growth factor can predict stage in colorectal cancer

Neovascularization has been shown to be essential for the growth of solid tumors. Vascular endothelial growth factor (VEGF) is one of the most important mediators of angiogenesis. This study was conducted to determine the significance of this cytokine as a tumor marker for staging colorectal cancer. Preoperative serum VEGF was measured in 108 colorectal cancer patients and in 136 normal healthy controls. The results of this study showed a significant difference between the four T classes, Union International Contre Cancer (UICC) stages, and Dukes' stages. In comparison to serum levels in controls (median, 173.8 pg/ml), VEGF levels were significantly elevated in T2 (P = 0.003), T3, and T4 (P < 0.0005); UICC I (P = 0.001), UICC II, UICC III, and UICC IV (P < 0.0005); and Dukes' A (P = 0.001), Dukes' B, and Dukes' C (P < 0.0005). Serum VEGF showed a significant elevation over control in node-negative (P < 0.0005) and in node-positive colorectal cancer (P < 0.0005) patients. Node-positive cancer had a significant elevation of serum VEGF compared to node-negative cancer (P = 0.008). This study reveals that preoperative serum VEGF can detect all but very early colorectal cancer i.e., T1 (P = 0.06).

Antihypertensive efficacy and well-being during monotherapy and combination therapy with ketanserin

The effects of ketanserin on blood pressure and well-being were investigated in 188 patients, aged 41-82 years, with mild to moderate essential hypertension. At entry, 107 were untreated, 42 were taking the diuretic combination hydrochlorothiazide (50 mg/day) plus amiloride (5 mg/day) and another 39 were taking the beta-blocker atenolol (100 mg/day). A single-blind, 4-week placebo run-in period was followed by 12 weeks' oral ketanserin treatment at 20 or 40 mg twice a day. This regimen significantly reduced systolic and diastolic blood pressures in each group. Response rates were greater in patients aged over 60 years. Compared with placebo, sleep disturbances, daytime fatigue and overall weakness decreased during ketanserin treatment (P less than 0.05 for all), but the incidence of dry mouth and stuffy nose increased. In patients older than 60 years there was a greater reduction of complaints than in younger patients. Ketanserin proved effective and well tolerated, improving peripheral circulatory symptomatology, particularly in older patients and those with a good blood pressure response.

Echocardiographic features of eosinophilic endomyocardial disease

Nine patients with eosinophilic endomyocardial disease who had undergone angiocardiography with histological staging of their disease, were studied by M-mode and two dimensional echocardiography to determine the extent to which specific features of the disease could be evaluated by these non-invasive methods. In seven patients, amplitude processed two dimensional echocardiography showed regions where the relative intensity of endomyocardial echoes was greater than normal, and their distribution corresponded to known areas of fibrosis. Standard two dimensional echocardiography was normal in all but three patients. In eight patients M-mode echocardiography showed only non-specific abnormalities, but appeared to be useful in assessing the functional consequences of myocardial or mitral valve disease. After digitisation a reduction in the duration and an increase in the peak rate of dimension increase during filling was prolonged. It was concluded that amplitude processed two dimensional echocardiography might be useful in diagnosing the extent and severity of endomyocardial disease in patients with hyperosinophilia. These noninvasive techniques may thus provide a means for the early diagnosis of endomyocardial fibrosis and could be useful in assessing in progression or response to treatment.

Is there autonomic impairment in congestive (dilated) cardiomyopathy?

Autonomic function was investigated in patients with congestive (dilated) cardiomyopathy and compared with that in controls. Heart-rate and blood-pressure were recorded during physiological and pharmacological interventions and plasma noradrenaline concentration was measured at rest and when the physiological interventions produced a peak response. The results indicate that even at an early (pre-failure) stage of the disease parasympathetic function is impaired but no significant increase in sympathetic activity occurs at this stage.

[Papillomatosis coronae glandis. Frequency of occurrence and clinical picture]

The clinical picture of pearly penile papules (PPP) is described on the basis of the literature and the authors' own investigations. Although symptomless and without functional significance, PPP may lead to damaging therapeutic measures if not recognized as such by physician and patient. The incidence of PPP has been investigated in 642 19-year-old Swiss men originating from the same geographical region. PPP were found in 33%, in 9.2% as the major variant and in 23.8% as the minor variant.

[Falciparum malaria in Switzerland: a problem of intensive care?]

In the period 1972-1976, 5 of 17 patients admitted to the Cantonal Hospital, Basel, for falciparum malaria had to be treated in the intensive care unit. Two patients died. None had performed regular chemoprophylaxis and in all of them several days had elapsed between onset of symptoms and diagnosis. The importance of information on malaria to tourists and physicians is stressed.

Experimental carcinogenesis in the resected colon of the rat

Until now, carcinoma of the large intestine resected previously for benign disease has not been published. However an increasing number of patients resected for Crohn's disease, diverticulitis or trauma may reach nowadays a high lifespan. On the other hand, it is known that the gastroenteral anastomosis is predisposed to cancer development. In this study, the question of whether the large intestine following colotomy or ileotransversostomy is sensitive to carcinogenesis is examined. Male Wistar rats, subjected to colotomy or resection and ileotransversostomy, were treated weekly by subcutaneous injection of 1,2-dimethylhydrazine (12 mg/kg body weight) for seven weeks. The animals were killed 54 weeks after the first injection. At autopsy, 21 out of 29 operated rats had developed adenocarcinomas of the remaining colon. Intact control animals had the same incidence of malignant degeneration of the large bowel. When the anastomosis is chronically irritated by inflammation or by formation of a diverticulum, development, of carcinoma near the stoma was observed. This was the case in three rats of 28 animals. The results demonstrate that the resected colon of the rat is not more sensitive to experimental carcinogenesis than the intact one.

[Hyperparathyroidism. Quantitative determination of specific skeletal changes in the radiography of the hand]

1. The extent to which skeletal involvement in hyperparathyroidism can be detected by X-ray remains an unsolved issue. The present investigation, aimed at resolving this problem, was carried out in 44 patients with primary (PHPT) and 57 subjects with secondary hyperparathyroidism (SHPT) due to terminal renal insufficiency. For comparison, 49 age-matched controls were included in this series. Subperiostal resorption of the phalanges of the hand was considered pathognomonic and graded according to a semiquantitative system using a magnifying lens. The data were compared with the serum calcium and alkaline phosphatase values. 2. Pathological subperiostal resorption was detected in 38.5% of the PHPT and in 56% of the SHPT patients while the controls showed 4% (false) positive results. A highly significant correlation between the extent of bone resorption and alkaline phosphatase was found (PHPT: r=0.80, SHPT: r=0.71, p less than 0.001). No correlation of the X-ray findings to the serum calcium could be detected. Compared to the degree of skeletal involvement demonstrated by X-ray, the alkaline phosphatase was significantly lower in SHPT than in PHPT. In PHPT on the other hand, subperiostal resorption was prominent among female patients aged over 40 years, while no prevalence for sex and age was found in the SHPT group. 3. These results demonstrate that a clinically relevant degree of bone involvement in hyperparathyroidism may be easily and reliability assessed by evaluating X-rays of the hands by means of a magnifying lens. Increased bone resorption in hyperparathyroidism appears to be paralleled by an increase of osteoblastic activity as assessed by elevation of alkaline phosphatase. In SHPT due to chronic renal failure, however, a relative osteoblastic insufficiency seems to exist. In PHPT, the prevalence of subperiostal bone resorption in women aged over 40 years may be compatible with a skeletal protecting effect of intact ovarian function (estrogens).