Arterial lactate does not predict outcome better than existing risk scores in upper gastrointestinal bleeding

Objective: Upper gastrointestinal bleeding (UGIB) is a frequent medical emergency and several scoring systems are developed to help risk-stratify patients. We aimed to investigate if elevated arterial lactate (AL) was associated with 30-day mortality, need for hospital-based intervention, or rebleeding. Furthermore, we compared the performance of AL with existing scoring systems and examined if incorporation of AL could improve their predictive ability.

Materials and methods: Retrospective cohort study of 331 consecutive patients admitted with UGIB during a one-year period. Multivariate analyses were performed to evaluate the association between AL and outcomes. Receiver operating characteristic curves were used to compare AL with existing scoring systems and to test if incorporation of AL could significantly increase their performance.

Results: AL was significantly associated with mortality (p?=?.001), need for hospital-based intervention (p?=?.005), and rebleeding (p?=?.031). In predicting mortality and rebleeding, AL performed equally to existing scoring systems, however, inferior to all, in predicting need for intervention. Two of the scoring systems were marginally improved in predicting mortality if AL was included.

Conclusions: AL is associated with adverse outcomes in patients with UGIB, but has only similar or inferior ability to predict relevant clinical outcomes compared to existing scoring systems. Although AL could enhance performance of two scorings systems in predicting mortality, it does not have an apparent clinical significance. Thus, our data does not support routine measurement of AL in patients with UGIB.     

Cumulative arsenic exposure and lung cancer in smelter workers: a dose-response study

The cause-specific mortality was followed through 1981 in a cohort of 3,916 male Swedish smelter workers employed for at least 3 months from 1928 through 1967. Arsenic levels in the air of all workplaces within the smelter were estimated for three different time periods. Using this exposure matrix and detailed information of the work history, cumulative arsenic exposure could be computed for each worker. Standardized mortality ratios (SMRs) were calculated for several dose categories using age-specific mortality rates from the county where the smelter was situated. A positive dose-response relationship was found between cumulative arsenic exposure and lung cancer mortality with an overall SMR of 372 (304-450, 95% confidence interval). The lung cancer mortality was related to the estimated average intensity of exposure to arsenic but not to the duration. No positive dose-response relationship was found between arsenic and ischemic heart disease or cerebrovascular disease. There was also no evident dose-response relationship between estimated exposure to sulfur dioxide and lung cancer.     

Subtotal pancreatectomy with stapling the pancreatic remnant

Conclusions We suggest that subtotal pancreatectomy in pancreatic cancers may be performed with stapling the pancreas and leaving the pancreatic remnant in situ without establishing a pancretico-digestive anastomosis. However, though not associated with complications related to insufficiency of a pancreatico-digestive anastomosis, the technique is encumbered with other, though not as severe, complications, mainly a high frequency of delayed gastrointestinal recovery. The technique enhails, however, potentials for further technical developments in the future, and has thus the potential to become a competitive challenge to conventional surgery.     

Retrospective evaluation of single photon emission computed tomography of the liver

Retrospective analysis, including indications for examination, of 335 consecutive liver examinations of adults with single photon emission computed tomography performed at the Karolinska Hospital during the first eight months of 1981 has been carried out. 85.1% of the investigations were performed in tumour patients. This group underwent retrospective evaluation specifically regarding space occupying lesions of the liver with a minimum followup time of 3 years. An adequate follow-up of 87.4% was achieved. The study showed a sensitivity of 82.7% and a specificity of 93.9%. The positive and negative predictive values were 78.2% and 95.4%, respectively. 4.4% of the examinations were regarded as equivocal. Compared to previously reported values for planar liver scintigraphy derived from several different studies, the tomographic technique produced no increase of specificity or positive predictive value but a higher total accuracy, probably due to better clarification of the hepatic anatomy. The false positive, false negative and equivocal diagnoses were analysed and reported.     

Dietary habits, gingival status and occurrence of Streptococcus mutans and lactobacilli as predictors of caries in 3-year-olds in Sweden

The aim was to study whether dietary habits, oral hygiene expressed as gingival status, and presence/absence of S. mutans and lactobacilli, singly or in combinations, could be used as caries predictors. Sensitivity, specificity and predictive values for positive (PV+) and negative tests (PV-) were calculated. 133 children, 3 yr of age, were examined for caries and presence/absence of S. mutans and lactobacilli. Three levels of gingival status and dietary habits, respectively, were registered. Two groups in respect of dietary habits and oral hygiene were formed by stepwise pooling of the caries data for the nine possible combinations of oral hygiene and dietary habits, setting the most discriminating border (screening level) where sensitivity (0.86) and specificity (0.69) simultaneously reached their highest value. PV + was 0.58 and PV- 0.91. Higher predictive values were obtained when presence/absence of lactobacilli and of S. mutans were combined. Combinations of defined levels of dietary habits, gingival status and presence/absence of lactobacilli showed sensitivity 0.87, specificity 0.95, PV + 0.87 and PV- 0.95, presence/absence of S. mutans sensitivity 0.94, specificity 0.76, PV + 0.74 and PV- 0.95. A two-step prediction, with gingival status as the first predictor and presence/absence of lactobacilli or S. mutans as the second, was the most efficient when lactobacilli were involved.     

Olsalazine Versus Sulphasalazine for Relapse Prevention in Ulcerative Colitis: A Multicenter Study

Objective : To compare the relapse-preventing effect and the frequency of adverse events of olsalazine and sulphasalazine in sulphasalazine-tolerant patients with ulcerative colitis. Methods : Patients in remission, with at least two episodes of active disease during the last 5 yr, were randomized to 2 g of sulphasalazine or 1 g of olsalazine daily and were followed for 6–18 months. Relapse rates in the two groups were compared using frequency and life-table analysis. Sixty-nine patients with proctitis, 140 with left-sided colitis, and 113 with subtotal or total colitis were evaluated. Results : In the intention-to-treat analysis, the failure rate (relapses plus withdrawals) was 54.7% in the olsalazine and 47.2% in the sulphasalazine group. In the per-protocol analysis excluding withdrawals, 44.7% relapsed in the olsalazine and 39.3% in the sulphasalazine group. Remission curves did not differ significantly, although at all time intervals the frequency of remission was slightly higher in the sulphasalazine group ( p = 0.19 in the intention-to-treat analysis and p = 0.42 in the per-protocol analysis estimated by the log-rank test). Twelve patients (of whom five had diarrhea) in the olsalazine group versus eight patients in the sulphasalazine group discontinued the study because of side effects. Conclusion : The relapse-preventing effect of olsalazine and sulphasalazine in sulphasalazine-tolerant patients did not differ. Furthermore, the tolerability of olsalazine, particularly concerning diarrhea, appears to be better than previously reported.     

Improvement of the effects of intrasplenic transplantation of hepatocytes after 90% hepatectomy in the rat by cotransplantation with pancreatic islets

Acute liver failure is associated with high mortality. Whether support with transplanted hepatocytes improves the outcome is not established. We studied the potential beneficial effects of intrasplenic transplantation of hepatocytes in conjunction with islets of Langerhans on 90% hepatectomy-induced acute liver failure in rats. We found that all control rats died within 48 hr following 90% hepatectomy. In contrast, the mortality decreased significantly in rats transplanted with 10(7) hepatocytes into the spleen parenchyma at 1-3 days prior to 90% subtotal hepatectomy, whereas no significant reduction in mortality was seen in rats transplanted with hepatocytes immediately after the operation. However, cotransplantation of hepatocytes and 400 isolated pancreatic islets into the spleen reduced mortality when performed immediately after the 90% hepatectomy. Therefore, hepatocyte transplantation reduces mortality after 90% hepatectomy only if performed prior to the hepatectomy. However, transplantation of hepatocytes in conjunction with pancreatic islets reduces mortality when performed at the same time as 90% hepatectomy. Hence, the combined transplantation of hepatocytes and islets might offer support after liver failure.     

Metabolic responses to intermittent hepatic dearterialization in the rat

Hepatic dearterialization is a palliative treatment for irresectable liver tumours. In the current study, the metabolic consequences of hepatic dearterialization were examined in the rat. Liver glycogen content was reduced to an average of 84% following 60 min dearterialization and was further reduced to an average of 16% following 60 min reperfusion. Plasma concentration of beta-hydroxybutyric acid was elevated by an average of 65% following 60 min hepatic dearterialization. In contrast, hepatic dearterialization did not alter cholesterol and triglyceride plasma levels. In addition, the hepatic activity of hepatic lipase was reduced by 29% after 60 min of hepatic dearterialization, a reduction which remained after 60 min of reperfusion. Clearance of intravenously administered antipyrine, which reflects the activity of liver microsomal enzymes, was reduced by 37% after 60 min of hepatic dearterialization. In conclusion hepatic dearterialization is accompanied by marked activity in the processes related to carbohydrate, lipid and xenobiotic metabolism. These effects should be taken into account when treating patients with hepatic dearterialization.     

Physical Restraints in Geriatric Care

The aim of the present study was to investigate the use of physical restraints in institutional elder care and staff knowledge about and attitudes toward the use of these restraints. Poor knowledge and negative attitudes toward the use of restraints were found among staff. Significant differences between various staff categories were found concerning knowledge about the use of restraints; nurse aids had the lowest and physicians the highest scores on the knowledge test. Nurse aids demonstrated the least negative attitudes (were most prone to use restraints) and physicians the most negative. Furthermore, there was a significant relation between attitudes and knowledge, i.e. staff with poor knowledge also demonstrated the least negative attitudes toward the use of restraints. Despite these negative attitudes among staff, we found a large proportion of restrained patients in the institutions investigated. Twenty-nine percent of the patients at the investigated clinics were physically restrained. The most common reason given was that restraints were used to prevent falls. No documentation of the observed use of restraints was found in any of the restrained patients' hospital records.