Inpatient Burden and Mortality of Methanol Intoxication in the United States

BackgroundThis study aimed to assess inpatient prevalence, characteristics, outcomes, and resource utilization of hospitalization for methanol intoxication in the United States.Materials and MethodsA total of 603 hospitalized patients with a primary diagnosis of methanol intoxication from 2003 to 2014 were identified in the National Inpatient Sample database. The inpatient prevalence, clinical characteristics, treatments, outcomes, resource utilization, were investigated. Multivariable logistic regression was performed to identify factors independently associated with in-hospital mortality.ResultsThe overall inpatient prevalence of methanol intoxication among hospitalized patients was 6.4 cases per 1,000,000 admissions in the United States. The mean age was 38±18 (range 0–86) years. 44% used methanol for suicidal attempts. 20% of admissions required mechanical ventilation, and 40% required renal replacement therapy. The three most common complications were metabolic acidosis (44%), hypokalemia (18%), and visual impairment or optic neuritis (8%). The three most common end-organ failures were renal failure (22%), respiratory failure (21%), and neurological failure (17%). 6.5% died in the hospital. Factors associated with increased in-hospital mortality included alcohol drinking, hypernatremia, renal failure, respiratory failure, circulatory failure, and neurological failure. The mean length of hospital stay was 4.0 days. The mean hospitalization cost per patient was $43,222ConclusionThe inpatient prevalence of methanol intoxication in the United States was 6.4 cases per 1,000,000 admissions. The risk of in-hospital mortality mainly depended on the number of end-organ failures.     

Renal magnesium wasting and tubular dysfunction in leptospirosis.

BACKGROUND: Tubulo-interstitial nephritis is the main cause of acute renal injury in leptospirosis. The aim of this study was to evaluate renal tubular function and excretion of solutes in leptospirosis patients during a recent outbreak of leptospirosis in Nan province, Thailand. METHODS: Clinical manifestations were recorded and routine laboratory tests were performed upon admission. Renal tubular functions including tubular reabsorption of phosphate (TRP), fractional excretion of magnesium (FE(Mg)), urinary calcium to creatinine ratio (Uca/cr), urine N-acetyl-beta-D glucosaminidase (NAG) and urine beta(2)-microglobulin were serially monitored during 2 weeks after admission. RESULTS: A total of 20 leptospirosis patients were recruited. Nine (45%) patients had acute renal failure (ARF). Increased urine NAG and beta(2)-microglobulin, which indicate proximal tubular dysfunction, were demonstrated in all 20 (100%) patients. Fifteen (75%) patients had hypermagnesuria, whereas 10 (50%) patients had decreased TRP. Renal magnesium (Mg) and phosphate (P) wasting caused hypomagnesaemia and hypophosphataemia in nine and three patients with ARF, respectively. These abnormal findings significantly improved within 2 weeks after admission. CONCLUSIONS: We conclude that renal Mg and P wasting commonly occur in patients with leptospirosis. The measurement of Mg and P levels in both serum and urine of leptospirosis patients, especially those with ARF, is therefore highly recommended.     

Preoperative bariatric screening and treatment of Helicobacter pylori

Background

A preoperative screening and treatment program for pre-existing H. pylori infections was hypothesized to reduce postoperative bariatric complications and associated morbidity as the role of H. pylori in gastrointestinal symptomatology and peptic ulcer disease is well established.

Methods

A single-institution, single-surgeon, IRB-approved, retrospective chart review was performed. It included 183 consecutive patients who underwent an initial laparoscopic gastric bypass over a 40-month period from December 2003 to April 2006. The patients were divided into a H. pylori untested group (125 patients) and a tested and treated if indicated group (58 patients). Patient demographics and incidence of hospital re-admissions, GI ulceration and bleeding, perforated viscus, esophagogastroduodenoscopy (EGD), and foregut symptoms were documented at routine follow-up and emergency room visits. Results were subjected to analysis with Fisher’s exact test.

Results

Seven patients (12%) in the tested group were positive for H. pylori and treated. The number of GI ulcers and bleeding, EGDs, ER visits, and hospital re-admissions were not statistically different between groups; however, in the untested group, six patients (5%) presented with viscus perforation compared with none in the tested and treated group (p = 0.09). Demographics for both groups were similar and both had a large number of nonspecific foregut symptoms.

Conclusion

Preoperative H. pylori screening should continue, especially in geographically high-prevalence areas, as data suggest that the incidence of viscus perforation may be reduced with preoperative treatment if indicated.     

Fundoplication improves disordered esophageal motility

Patients with gastroesophageal reflux disease (GERD) and disordered esophageal motility are at risk for postoperative dysphagia, and are often treated with partial (270-degree) fundoplication as a strategy to minimize postoperative swallowing difficulties. Complete (360-degree) fundoplication, however, may provide more effective and durable reflux protection over time. Recently we reported that postfundoplication dysphagia is uncommon, regardless of preoperative manometric status and type of fundoplication. To determine whether esophageal function improves after fundoplication, we measured postoperative motility in patients in whom disordered esophageal motility had been documented before fundoplication. Forty-eight of 262 patients who underwent laparoscopic fundoplication between 1995 and 2000 satisfied preoperative manometric criteria for disordered esophageal motility (distal esophageal peristaltic amplitude ≤30 mm Hg and/or peristaltic frequency ≤80%). Of these, 19 had preoperative manometric assessment at our facility and consented to repeat study. Fifteen (79%) of these patients had a complete fun-doplication and four (21%) had a partial fundoplication. Each patient underwent repeat four-channel esophageal manometry 29.5 ± 18.4 months (mean ± SD) after fundoplication. Distal esophageal peristaltic amplitude and peristaltic frequency were compared to preoperative data by paired t test. After fun-doplication, mean peristaltic amplitude in the distal esophagus increased by 47% (56.8 ± 30.9 mm Hg to 83.5 ± 36.5 mm Hg; P < 0.001) and peristaltic frequency improved by 33% (66.4 ± 28.7% to 87.6 ± 16.3%; P< 0.01). Normal esophageal motor function was present in 14 patients (74%) after fundoplication, whereas in five patients the esophageal motor function remained abnormal (2 improved, 1 worsened, and 2 remained unchanged). Three patients with preoperative peristaltic frequencies of 0%, 10%, and 20% improved to 84%, 88%, and 50%, respectively, after fundoplication. In most GERD patients with esophageal dysmotility, fundoplication improves the amplitude and frequency of esophageal peristalsis, suggesting refluxate has an etiologic role in motor dysfunction. These data, along with prior data showing that postoperative dysphagia is not common, imply that surgeons should apply complete fun-doplication liberally in patients with disordered preoperative esophageal motility. Presented at the Forty-Third Annual Meeting of The Society for Surgery of the Alimentary Tract, San Francisco, California, May 19–22, 2002 (poster presentation).     

Bovine pericardium buttress limits recanalization of the uncut roux-en-Y in a porcine model

In contrast to the traditional Roux-en-Y reconstruction, an uncut Roux-en-Y provides biliopancreatic diversion and may preserve myoelectric continuity. Previous iterations of the uncut Roux have been plagued by recanalization of the uncut staple line in the afferent small bowel. Our aim was to determine if bovine pericardium buttress prevents recanalization of the stapled smallbowel partition in a porcine model. Sixteen female pigs (-30 kg) underwent a side-to-side stapled jejunojejunostomy, 20 cm distal to the ligament of Treitz, with placement of a nondivided stapled partition with a single row of 2.5 mm width staples in the intervening jejunal loop. Nine animals in the experimental group had a bovine pericardium buttressed staple line (5 permanent, 4 absorbable), whereas seven animals in the control group had a nonbuttressed staple line. At 6 or 12 weeks, necropsy was performed and the primary outcome, staple line recanalization, was assessed grossly and histologically. Statistical analysis was performed by means of the chi-square test. There were no major complications and all animals gained weight. Overall, eight of nine bovine pericardium buttressed staple lines were grossly and histologically intact at necropsy, whereas all nonbuttressed uncut staple lines had recanalized completely (P < 0.05). At 6 weeks, both permanent (N = 4) and absorbable (N = 3) buttress preparations prevented recanalization. At 12 weeks the permanent buttress remained closed (N = 1), but the absorbable buttress had allowed partial recanalization (N _ 1). The use of bovine pericardium buttress will prevent small bowel recanalization of uncut small bowel staple lines at early follow-up. Pilot data at intermediate follow-up suggest permanent buttress is more durable than absorbable buttress. These results warrant investigation of bovine pericardium for intestinal applications in humans. Presented at the Forty-Third Annual Meeting of The Society for Surgery of the Alimentary Tract, San Francisco, California, May 19–22, 2002 (poster presentation). Supported in part by a grant from Bio-Vascular, Inc.     

Gallbladder function before and after fundoplication

No study has reported an association between gastroesophageal reflux disease (GERD) or its therapies and gallbladder function. We compared pre- and postoperative gallbladder function in patients undergoing fundoplication to determine the following: (1) whether patients with chronic GERD have preexisting gallbladder motor dysfunction; (2) whether medical or surgical therapy alters gallbladder function; and (3) whether division of the hepatic branch of the anterior vagus nerve is detrimental to gallbladder motility. Nineteen patients with documented GERD consented to a preoperative cholecystokinin-stimulated technetium hepatobiliary (CCK-HIDA) scan to quantify the gallbladder ejection fraction (GBEF). All patients underwent laparoscopic Nissen fundoplication. One month after fundoplication, 12 patients completed a repeat CCK-HIDA scan for determination of GBEF, with comparison to the preoperative GBEF. Among patients with preoperative GERD, 11 (58%) of 19 met the scintigraphic criteria for gallbladder dysfunction (GBEF <35%), which is a ratio comparable to that in patients undergoing a CCK-HIDA scan for presumed biliary dyskinesia during the same time period (31 [60%] of 53;P=NS, chi square test) and exceeds the rate of abnormal GBEF reported in healthy volunteers (3%). Six of seven patients with a low preoperative GBEF who underwent repeat evaluation postoperatively had normalization of the GBEF (P=0.05, paired t-test). In the 12 patients who underwent postoperative CCK-HIDA scanning, there was no association between preservation or division of the hepatic branch of the anterior vagus nerve and postoperative gallbladder dysfunction (P=NS, chi-square test). Unexpectedly, 58% of patients with GERD demonstrated gallbladder motor dysfunction prior to fundoplication, with improvement to normal occurring in most of those studied postoperatively. These data support controlled trials to determine the effect of chronic GERD and antisecretory therapy on gallbladder and global gastrointestinal smooth muscle function. Preservation of the hepatic branch of the anterior vagus nerve during fundoplication offered no clear benefit with regard to early postoperative gallbladder function. Presented at The Forty-Third Annual Meeting of The Society for Surgery of the Alimentary Tract, San Francisco, California, May 19–22, 2002 (oral presentation).