Combined proper hepatic artery and common hepatic duct injury in open cholecystectomy: Case report and review of the literature

A 24-y-old male patient underwent elective open cholecystectomy at another center. On the third postoperative day, he developed fever and jaundice, for which he underwent reoperation at the same center on the seventh postoperative day. During the second surgery, massive bleeding was encountered, suture ligations were applied, and T-tube drainage was performed. After the surgery was completed, the patient developed hepatic microabscess, and sepsis ensued. The patient presented at this hospital for further evaluation. To rule out vascular injury, which was suspected in this patient, celiac angiography was performed; it showed that the hepatic artery was occluded near the eminence of the gastroduodenal artery, and the liver was supplied by many collaterals. After the patient’s condition had stabilized and the sepsis had resolved, Roux-N-Y hepati-cojejunostomy was performed on the 59th d after admission.     

The practice of platelet transfusion in the intensive care unit

The practice of platelet transfusion in the intensive care unit varies, and liberal use may not be associated with improved outcome. This study reviewed the medical records of 117 patients with moderate-to-severe thrombocytopenia and without active bleeding who were admitted to intensive care unit beds during a 6-month period. The primary outcome measures were new bleeding episodes and platelet transfusion complications. Ninety (77%) received a platelet transfusion. Significant new bleeding developed in 1 patient who received a transfusion. Six patients (8%) developed transfusion complications: 2 transfusion-related acute lung injury, 2 allergic, and 2 febrile reactions. Patients who did not receive platelet transfusion had a higher severity of illness than transfused patients. Predictors of platelet transfusion were platelet count and postoperative status, but not invasive procedure. The practice of platelet transfusion in critically ill patients with thrombocytopenia varies. Prospective studies evaluating restrictive versus liberal platelet transfusion strategies are warranted.     

Relationship of demographic, dietary, and clinical factors to the hydration status of patients on peritoneal dialysis.

OBJECTIVES: To establish which clinical factors are associated with an increased proportion of extracellular fluid (ECF) in peritoneal dialysis (PD) patients. DESIGN: A single-center, cross-sectional analysis of 68 stable PD patients. METHOD: Bioelectrical impedance measurements (RJL, single frequency; RJL Systems, Clinton, Michigan, USA) of resistance and reactance were used to determine the proportion of ECF comprising total body water (TBW) in 68 stable PD patients attending for routine clearance and membrane studies. All patients underwent detailed dietetic, adequacy, and membrane function tests. Blood pressure and antihypertensive requirements were also documented. RESULTS: Significant gender differences in body composition were observed, such that women had lower absolute TBW and fat-free mass per kilogram body weight, but proportionately more ECF for a given TBW, mean ECF:TBW 0.5 +/- 0.03 versus 0.44 +/- 0.05, p < 0.005. In view of this, patients were split into two groups, defined as "over-" or "normally" hydrated, either by using the single discriminator (median ECF:TBW = 0.47) for the whole population, which resulted in groups distorted by gender, or by using different discriminators according to gender (women: 0.49, men 0.45). In both analyses, overhydrated patients were older, had significantly lower plasma albumin, less total fluid removal per kilogram body weight, and higher peritoneal solute transport. When split by a single discriminator, the overhydrated patients had lower sodium removal and significantly less intracellular fluid volume due to an excess of women in this group who also had less residual function and had been on dialysis longer. Using gender-specific discrimination, overhydrated patients were heavier due to expansion of the ECF volume: 20 +/- 4.1 L versus 16 +/- 3.3 L, p < 0.001. Stepwise multivariate analysis found age (p = 0.001), albumin (p = 0.009), and fluid losses per kilogram body weight (p = 0.025) to be independent predictors of gender-adjusted hydration status. Sodium intake did not vary according to hydration status. CONCLUSION: Gender influences the assessment of hydration status of PD patients when employing bioimpedance, such that women tend to have more ECF. Taking this into account, age, albumin, and achieved fluid removal appear to be independently associated with hydration status, whereas peritoneal solute transport is not. Advice on dietary sodium should take account of hydration status and achievable losses.     

On the mechanism of post-splenectomy leukocytosis in mice

BACKGROUND: Increased number of peripheral white blood cells (PWBCs) has been noted after removal of the spleen. DESIGN: To clarify the possible mechanisms by which splenectomy affects the PWBC number, the percentage of apoptotic PWBCs, the number and migration rate of peritoneal cells, as well as the 3H-TdR incorporation into PWBCs, were examined in splenectomized, sham-operated and control mice. In addition, the effect of control plasma injected to splenectomized animals on the number of PWBCs was examined. RESULTS: One and two months after splenectomy the PWBC counts significantly increased, whereas the percentage of apoptotic PWBCs and the number of cells in the peritoneal cavity decreased in comparison with that of the control and sham-operated mice. Seventeen days after injection of carboxy-fluorescein diacetate succinimidyl ester (CFSE)-labelled peritoneal cells into the peritoneal cavity of the animals, their number was significantly higher in the peripheral blood and lower in the peritoneal cavity of the splenectomized animals in comparison with that of the control and sham-operated mice. Injection of control plasma into the splenectomized mice prevented the development of postsplenectomy leukocytosis. Finally, 3H-TdR incorporation into nonstimulated and Con A stimulated PBMCs from the splenectomized mice was higher as compared with cells from the control and sham-operated mice. CONCLUSIONS: The results of the study present several mechanisms that may clarify the cause of postsplenectomy leukocytosis.     

Phagocytic capacity and apoptosis of peripheral blood cells from patients with iron deficiency anemia.

Following clinical observations that patients with iron deficiency anemia (IDA) are more susceptible to infections than non-anemic individuals, the phagocytic capacity and number of apoptotic peripheral white blood cells (PWBC) from patients with IDA were examined. PWBC from 15 patients with IDA and from 18 healthy donors were incubated with various doses of iron. Phagocytosis was examined using latex particles and apoptosis was evaluated by a flow cytometric assay using propidium iodide staining. The percentage of phagocyting polymorphonuclear cells was lower in IDA patients compared to that of the controls. However, there was no difference in the percentage of phagocyting monocytes from individuals of both groups. The number of latex beads engulfed by each polymorphonuclear or monocyte was lower in IDA patients. Incubation with 100 microg% of iron did not affect the phagocytic ability of both cell types in IDA patients, but increased that of control cells. Incubation with 300 microg% of iron caused an increase in the phagocytic capacity of patients' cells and a decrease in that function in cells from controls. Higher dose (500 microg%) induced suppression of phagocytosis in cells from both groups. There was no difference in the number of apoptotic cells from individuals of both groups. Apoptosis of polymorphonuclears, but not mononuclear cells from both controls and IDA patients showed a linear dependency on the iron concentration in the medium. It is possible that the impaired phagocytic capacity of the PBWC found in patients with IDA contribute to the increased susceptibility to infections observed in these individuals.     

Effectiveness of using high-fidelity simulation to teach the management of general anesthesia for Cesarean delivery

Purpose

The objective of this study was to assess the influence of a teaching plan consisting of didactic teaching and repeated simulations on the performance of anesthesia residents in the management of general anesthesia (GA) for emergency Cesarean delivery (CD).

Methods

Twenty-one postgraduate year 2 (PGY2) and 3 (PGY3) anesthesia residents from the University of Toronto were recruited in this prospective cohort study. All participants received didactic teaching in the management of GA for emergency CD, which was followed one week later by assessment of performance in the same scenario using a high-fidelity simulator. Another simulation assessment was repeated two months later in the same scenario. All simulation video recordings were assessed by two blinded experts using a validated checklist and an Anaesthetists’ Non-Technical Skills (ANTS) scale in order to rate their technical and non-technical skills, respectively. The participants’ performance (based on the above scales) in the two simulation sessions were then compared.

Results

Nineteen residents completed both simulation sessions. There was an improvement in the mean (SD) weighted checklist score from 64.5% (7.1%) in session 1 to 76.7% (6.7%) in session 2 (P < 0.001). The mean (SD) ANTS scores also increased from 2.8 (0.5) in session 1 to 3.3 (0.4) in session 2 (P = 0.001). No difference in the checklist or ANTS scores was seen between PGY2 and PGY3 residents in any of the simulation sessions. Several common performance errors were identified, but these improved in the second session. The correlation between checklist and ANTS scores was moderately high (correlation coefficient [r] = 0.7; P < 0.001). The inter-rater reliability among the experts was also high (intraclass correlation coefficient [ICC] for the checklist = 0.72; 95% confidence interval [CI] 0.62 to 0.81; ICC for the ANTS = 0.74; 95% CI 0.49 to 0.89).

Conclusion

Didactic teaching followed by simulation sessions enhances not only the technical skills but also the non-technical skills of residents, most likely due to the feedback received after the first simulation session. Repeated simulation sessions may help prepare residents to deal more effectively with similar critical situations in clinical practice with minimum errors.

     

Diminished Bone Strength Is Observed in Adult Women and Men Who Sustained a Mild Trauma Distal Forearm Fracture During Childhood

Children and adolescents who sustain a distal forearm fracture (DFF) owing to mild, but not moderate, trauma have reduced bone strength and cortical thinning at the distal radius and tibia. Whether these skeletal deficits track into adulthood is unknown. Therefore, we studied 75 women and 75 men (age range, 20 to 40 years) with a childhood (age <18 years) DFF and 150 sex‐matched controls with no history of fracture using high‐resolution peripheral quantitative computed tomography (HRpQCT) to examine bone strength (ie, failure load) by micro–finite element (µFE) analysis, as well as cortical and trabecular bone parameters at the distal radius and tibia. Level of trauma (mild versus moderate) was assigned using a validated classification scheme, blind to imaging results. When compared to sex‐matched, nonfracture controls, women and men with a mild trauma childhood DFF (eg, fall from standing height) had significant reductions in failure load (p < 0.05) of the distal radius, whereas women and men with a moderate trauma childhood DFF (eg, fall while riding a bicycle) had values similar to controls. Consistent findings were observed at the distal tibia. Furthermore, women and men with a mild trauma childhood DFF had significant deficits in distal radius cortical area (p < 0.05), and significantly lower dual‐energy X‐ray absorptiometry (DXA)‐derived bone density at the radius, hip, and total body regions compared to controls (all p < 0.05). By contrast, women and men with a moderate trauma childhood DFF had bone density, structure, and strength that did not differ significantly from controls. These findings in young adults are consistent with our observations in children/adolescents with DFF, and they suggest that a mild trauma childhood DFF may presage suboptimal peak bone density, structure, and strength in young adulthood. Children and adolescents who suffer mild trauma DFFs may need to be targeted for lifestyle interventions to help achieve improved skeletal health. © 2014 American Society for Bone and Mineral Research.     

Stress response and well-being after open,laparoscopic, and NOTES transgastric uterine horn resection in a randomized porcine model

Background

NOTES is believed to induce less surgical trauma than open and laparoscopic surgery. The degree of surgical trauma can be assessed by measuring serum levels of acute-phase proteins such as CRP and TNF-α. We conducted a prospective randomized survival trial in which the inflammatory responses after laparoscopic, open, and NOTES transgastric uterine horn resection were compared. The aim of this study was to investigate whether NOTES procedures induce less inflammatory response.

Methods

Thirty pigs were randomized into three groups to undergo open, laparoscopic, or transgastric uterine horn resection. Weight, body temperature, and postoperative recovery were recorded and venous blood samples were taken for analysis of CRP and TNF-α at different time points. Analyses of CRP and TNF-α were performed using pig-specific ELISA assays.

Results

Procedure time was significantly longer for NOTES [median = 121 min (range = 94–155)] compared with that for open surgery [median = 22 min (14–27)] and laparoscopy [median = 37 min (20–45)] (p < 0.0001). There was a nonsignificant tendency for shorter recovery time for the NOTES animals. Twenty-seven animals survived for 4 weeks. One animal in each group was euthanized prior to 4 weeks. All animals gained weight during the 4-week period with no significant differences. Only animals in the NOTES group showed a significant weight gain during the first postoperative week (p = 0.007). On postoperative day (POD) 1, CRP was significantly lower in the NOTES group compared with the open and laparoscopic groups (mean = 0.72 ± 0.22, 0.98 ± 0.26, and 0.97 ± 0.20, respectively; p = 0.048). The CRP levels were normalized on day 14. Throughout the study there were no significant changes in TNF-α levels in the laparoscopic and NOTES groups. At POD 3 the open surgery group showed significantly higher TNF-α levels than the other groups (p = 0.036).

Conclusions

Despite the longer operating time, the transgastric NOTES approach seems to be less traumatic than open or laparoscopic uterine horn resection in this porcine model.     

Pharmacy education instruction: Preference and practices,Saudi students’ perception

Aim/Background

The methods of instruction in pharmacy education are crucial and meant to suit the professional development and encompass the advanced variety of services and functions provided by the pharmacists to serve individual patients. The aim of this study was to determine the students’ opinions on the adopted and preferred methods of instruction in pharmacy colleges in Kingdom of Saudi Arabia.

Methods

Opinions of Saudi pharmacy students regarding the adopted methods of learning were measured using a pretested questionnaire combined with Likert-type scales.

Results

Three hundred pharmacy students were interviewed. Direct type of lecturing was dominant (53.7%). The most frequently used language of instruction was combined English and Arabic (48.8%), that was mostly preferred by 52.5% of the students. Handouts were the most adopted post-lecture learning method (48.3%), while only 5.9% used student’s self-written notes. A cocktail of traditional and electronic aids was used as admitted by 68.7% and 59.3% of the students who preferred this lecture delivery method. Almost half (49.3%) of the students agreed of having a routine fair guidance and support when referring to their lecturers.

Conclusion

The study outcomes had revealed a practical guidance to be considered for instituting preferred modes of instruction to upgrading students’ capacities for better understanding and acquiring academic and professional skills.