Simplified admission criterion for predicting severe complications of gallstone pancreatitis

HYPOTHESIS: Simple admission criteria (white blood cell count, > or =14. 5 x 10(9)/L; blood urea nitrogen level, > or =4.3 mmol/L [> or =12 mg/dL]; heart rate, > or =100 beats per minute; and serum glucose level, > or =8.3 mmol/L [> or =150 mg/dL]) are better predictors of severe complications of gallstone pancreatitis than an Acute Physiology and Chronic Health Evaluation II (APACHE II) score of 5 or greater, a modified Imrie (Glasgow) score of 3 or greater, and a biliary Ranson score of 3 or greater. DESIGN: A prospective consecutive case study. SETTING: A university-affiliated, urban, public hospital. PATIENTS: Ninety-two consecutive patients (77 women and 15 men, aged 18 to 76 years [mean age, 39 years]) with gallstone pancreatitis. Seventy-seven patients were Hispanic. MAIN OUTCOME MEASURES: Major local and systemic complications requiring intensive care unit care, and death. RESULTS: Fourteen patients (15%) had severe complications with a mortality of 2%. On univariate analysis, a white blood cell count of 14.5 x 10(9)/L or more (P =.03), a serum glucose level of 8. 3 mmol/L or more (> or =150 mg/dL) (P<.001), an APACHE II score of 5 or greater (P =.008), a modified Imrie score of 3 or greater (P<.001), and a biliary Ranson score of 3 or greater (P =.03) were statistically associated with the development of severe complications; whereas a blood urea nitrogen level of 4.3 mmol/L or more (> or =12 mg/dL) and a heart rate of 100 beats per minute or more were not. On multivariate analysis, only a serum glucose level of 8. 3 mmol/L or more (> or =150 mg/dL) was predictive of adverse events (P<. 001). CONCLUSIONS: Glucose level (> or =8.3 mmol/L [> or =150 mg/dL]) is the best single admission predictor of severe complications of gallstone pancreatitis and is superior to an APACHE II score of 5 or greater, a modified Imrie score of 3 or greater, and a biliary Ranson score of 3 or greater.     

Use of Fibrin Sealants in Cardiovascular Surgery: A Systematic Review

Background

Fibrin sealants are used for hemostasis and tissue adherence.

Aim of Study

This systematic review summarizes published clinical data for fibrin sealant use in cardiovascular surgery.

Methods

A literature search for the following terms was conducted using PubMed and EMBASE: (TISSEEL or Tissucol or Beriplast P or Evicel or Quixil or Crosseal or Reliseal or Fibringluraas or Bolheal or Tachosil or Vivostat or Vitagel or Artiss or “fibrin glue” or “fibrin sealant” or “fibrin tissue adhesive”) and (cardiac or cardiovascular or vascular or heart or coronary or surgery). Case reports and series were excluded; although reports of controlled trials were preferred, uncontrolled trial data were also considered.

Results

Clinical trials and chart review analyses of fibrin sealants were identified and summarized. Although clinical trial data were available for other agents, the majority of published studies examined TISSEEL. Overall, TISSEEL and other fibrin sealants showed improvements over standard of care or control groups for a variety of predefined endpoints. Safety findings are also summarized.

Conclusions

Data from these studies showed that fibrin sealants were well tolerated and provided effective hemostasis in a range of cardiac and aortic surgeries. doi: 10.1111/jocs.12099 (J Card Surg 2013;28:238–247)     

Reconstruction of the cervical esophagus using cutaneous or musculocutaneous flaps

Reconstruction of the cervical esophagus using cutaneous or musculocutaneous flaps is described. The delto-pectoral cutaneous flap, latissimus dorsi or pectoris major musculocutaneous flap, free forearm cutaneous flap, and free rectus abdominis musculocutaneous flap are generally used for reconstruction of the cervical esophagus. Although free jejunal transfer with microsurgery is now common for reconstruction of the cervical esophagus, cutaneous or musculocutaneous flaps remain useful in high-risk patients or patients in whom free jejunal transfer or gastrointestinal reconstruction would prove incompetency due to a history of abdominal surgery or other reasons. Cutaneous or musculocutaneous flaps are also used in patients with failure of free jejunal transfer or incurable fistula after reconstruction using the stomach or colon for thoracic esophageal cancer.     

踝足部组织缺损的显微外科修复

目的研究踝足部组织缺损显微外科修复的效果。方法回顾性分析应用带血管蒂(肌)皮瓣、骨瓣等组织瓣移植修复踝足部组织缺损的临床资料。结果本组共78例,其中吻合血管(肌)皮瓣移植术21例,带血管蒂(肌)皮瓣移位术53例,吻合血管骨瓣移植术4例。组织瓣全部成活,随访3月～1年,骨愈合时间8～10周,踝足部大部分恢复保护性感觉,行走正常。结论踝足部组织缺损应用带血管蒂(肌)皮瓣、骨瓣移植、移位术修复效果好。     

Pathology of the pituitary, parathyroid, thyroid and adrenal glands

The clinical presentation of pathology of these endocrine organs is usually of hyper- or hyposecretion of hormones, and/or nodules found either clinically or radiologically. Hyperfunction usually results from hyperplasia or functioning neoplasms. Hypofunction usually represents destruction of the gland. Neoplasms may be functional or non-functional, and benign or malignant, the latter may also present as distant metastases. Many cases benefit from multidisciplinary team discussion, pre- or postoperatively, or both. Most hyperplasia/neoplasia is sporadic, but a significant minority occurs in familial settings, for example multiple endocrine neoplasia (MEN) syndromes type 1 and type 2. Any of these endocrine organs can also be involved by non-endocrine primary malignancy, either by direct infiltration or blood-borne metastasis.     

Long-term survival in carcinoma of the biliary tract. Analysis of prognostic factors in 146 resections

In 146 consecutive patients undergoing resection for carcinoma of the biliary tract, various tumor characteristics that affected long-term survival of the patients were studied. Patients with gallbladder carcinoma whose tumors had no serosal infiltration or vessel invasion were grossly papillary, or were papillary or well-differentiated adenocarcinoma histologically survived longer than those without these tumor characteristics. In upper-third lesions, patients whose tumors showed no serosal infiltration or vessel invasion, were grossly papillary, were papillary or well-differentiated adenocarcinoma histologically, or were treated with hepatic lobectomy had a higher chance of long-term survival. Patients with the middle-third lesions, whose tumors were grossly papillary or nodular or whose margins were tumor-free, were apt to survive longer. Long-term survival for patients with lower-third lesions was obtained most often in patients without lymph node metastasis or vessel invasion.     

甲状旁腺素通过磷脂酶C非依赖途径激活蛋白激酶C

目的利用基于荧光共振能量转移(Fluorescence resonance energy transfer,FRET)技术的检测PKC激活或PKC-delta激活的报告分子来确定PTH是否可以通过PLC非依赖途径激活PKC和PKC-delta。方法将表达PKC激活报告分子(CKAR)的质粒和表达PKC-delta激活报告分子的质粒转染HEK293细胞,培养72h后通过共聚焦显微镜检测FRET的改变,并以此判断佛波酯(TPA)是否激活PKC和PKC-delta。将表达甲状旁腺素1型受体(PTHR1)的质粒与CKAR质粒或PKC-delta质粒共转染HEK293细胞,培养72h后通过共聚焦显微镜检测FRET的改变,并判断PTH(1-34)、G1R19(1-34)和0.1%的三氟乙酸(TFA)对PKC和PKC-delta的作用。结果在转染CKAR质粒或PKC-delta质粒的HEK293细胞,TPA均使青色荧光与黄色荧光的强度之比(C/Y)增加。在共转染PTH1R质粒与CKAR质粒或PKC-delta质粒的HEK293细胞,PTH(1-34)和G1R19(1-34)均增加了C/Y的值,而0.1%TFA未引起C/Y的改变。结论 PTH与PTHR1结合后通过PLC非依赖途径激活PKC/PKC-delta。     

Multiple systems failure and circulatory support

As our knowledge of and capabilities in surgery improve, the problems that we encounter change. We have learned to better support the circulation and the heart, the kidneys, the lungs and other organs in patients after trauma or after operation and failure of any one of these organs alone has been less of a problem. In the early 1970's, there was a simultaneous or sequential development of problems or failure of several organs. We called this syndrome multiple, progressive or sequential systems or organ failure (MOF). It is truly a syndrome related to surgical progress. By defining the problem and developing an understanding of it, we can better prevent its occurrence and increase the survival and well-being of those under our care. Common factors in patients who develop this syndrome include some or all of following: A) A multiple systems injury or extensive soft tissue injury and/or a major or extensive operation. These can lead to MOF, even in a previously normal patient. In patients with limited systems such as with prior vascular disease or emphysema, the problem is intensified. B) A period of shock accompanying the injury or operation and/or later circulatory instability with a marginal cardiac output. C) Requirement for multiple and perhaps continuous blood transfusions. D) Renal injury or an alteration in renal blood flow that may not be evident initially. E) Marginal ventilatory function with atelectasis, aspiration, fat embolism or other problems. F) Early problems such as continued or recurrent bleeding requiring reoperation, large hematomas, tissue necrosis, peritoneal contamination, pulmonary injury or head injury. G) Catabolism with all of its attendant problems. H) Failure of rapid return of gastrointestinal function and discontinuation of intravenous infusions to enable oral intake and spontaneous adequate ventilation for extubation. I) There are often clinical or technical errors or problems such as a leaking anastomosis or wound separation. J) Depressed host resistance leading to invasive sepsis or abscesses. As this occurs, ventilatory failure ensues or there is a worsening of previously abnormal ventilation, right heart failure secondary to increased pulmonary vascular resistance or myocardial depression with increased venous pressure, progressive evidence of hepatic failure with a rising bilirubin, renal failure and problems with an altered sensorium, coagulation and stress ulceration. The key factor in most reports on this problem has been infection. Attention to the problems of cell injury and a better definition of changes in host resistance, the relationship fsepsisto to pulmonary, renal and hepatic failure and other organ relationships should help to prevent this problem. The injured or surgically-treated patient who has experienced a severe metabolic insult may have multiple systems or organ failure. Careful evaluation, a well-planned operative procedure, and excellent supportive postoperative care with elimination of clinical or technical errors and prevention of sepsis should result in survival of most of these patients.     

组织移植受区可供吻合血管的解决方法

目的 探讨吻合血管游离组织哉组合组织移植受区无可供吻合血管或可供吻合血管数量不足的解决方法：方法 在显微解剖研究的基础上,选择组织供区供血血管具有较粗大分支、终末支的组织单位参与移植,利用其自身血管分支桥接移植组织及伤肢远端,或者采用Ｙ型静脉倒置、顺置搭桥的方法,桥接组织及伤肢远端。结果 采用上述二种方法进行吻合血管的单一组织移植２０例,组合组织移植６６例,参与移植组织全部成活且具有良好的血液循环     

Ankle arthroscopy in the lateral decubitus position

Ankle or subtalar arthroscopy is a commonly performed procedure. It is often desirable to perform a diagnostic or therapeutic ankle arthroscopy followed by an open lateral ankle or hindfoot surgery. Standard positioning for ankle or subtalar arthroscopy is supine with or without the use of noninvasive distractor. In order to save operative time and avoid repositioning and redraping the patient intraoperatively, the authors have developed a positioning technique for performing ankle or subtalar arthroscopy, as well as anterior or medial procedures, followed by sequential procedures of the lateral ankle or hindfoot.     

Leukemias and lymphomas: Treatment and prophylaxis of the central nervous system

Opinion statement Central nervous system (CNS)-directed therapy is required for many acute leukemia patients and for nearly all aggressive or high-grade non-Hodgkin’s lymphoma patients as part of an overall chemotherapy plan for disease eradication. The CNS therapy decisions differ for overt disease treatment versus prophylactic treatment and take into consideration the type of leukemia or lymphoma, the age of the patient, and other prognostic factors. A variety of CNS-directed therapies are used for prevention or treatment of CNS disease in acute leukemias or aggressive lymphomas: intrathecal medications (cytosine arabinoside, methotrexate, or both in combination with hydrocortisone) with or without cranial or craniospinal irradiation, intrathecal medication only with intensive systemic chemotherapy, or high-dose chemotherapy specifically chosen for CNS penetrance. Any type of CNS-directed therapy, whether intrathecal chemotherapy, high-dose systemic chemotherapy, or irradiation, may cause acute or delayed (late) toxicity. Ongoing clinical trial research aims to reduce the risk of toxicity from CNS-directed therapy while preserving or improving treatment efficacy.     

Intraoperative consultation for the liver, biliary system, pancreas, duodenum, and spleen

The urologist, when operating transabdominally, may unexpectedly encounter a cystic or solid mass in the liver, a dilated gallbladder or a gallbladder containing stones, or a mass in the pancreas, or may inadvertently injure the duodenum or spleen when mobilizing these organs for a nephrectomy or adrenalectomy. Discussed are some of these common liver, biliary, and pancreatic problems and their management, and the methods of management of duodenal and splenic injuries.     

"Syndrome in syndrome": Wernicke syndrome due to afferent loop syndrome. Case report and review of the literature

Wernicke syndrome is a rare neurological pathology due to a deficit in vitamin B1. The syndrome is common among alcohol abusers, patients with malignant tumor or gastrointestinal diseases, those who undergo hemodialysis or long-term peritoneal dialysis, pregnant women with hyperemesis, women who breast-feed, patients with hyperthyroidism or anorexia nervosa or gastric or jejunal-ileal bypass surgery for obesity, patients submitted to gastric surgery or prolonged total parenteral nutrition or prolonged intravenous therapy. We report a case of Wernicke syndrome due to afferent loop syndrome characterized by incoercible vomiting.     

Peroneal nerve repair. Surgical results

Eleven patients had either repair (two) or nerve graft reconstruction (nine) of the common peroneal nerve or its superficial or deep divisions about the knee. The average follow-up period was 29.1 months. A good or excellent result was achieved in six (54.5%) patients. The results appeared best when direct nerve repair was possible or when a defect of 6 cm or less required grafting. Peroneal nerve exploration and repair or reconstruction as required seem indicated for known nerve disruption or unknown nerve continuity if there is no suggestion of continuing recovery by three to six months after the injury.     

Pathophysiology of paraprotein production

Paraproteins or monoclonal proteins are the result of clonal B-cell or plasma cell proliferation of a malignant, premalignant or non-malignant nature. Monoclonal proteins may consist of intact immunoglobulin molecules or of heavy or light chains only. Depending on their rate of production and/or secretion they may accumulate in the serum and/or urine of patients. Their presence in the circulation may remain silent, as in monoclonal gammopathy of undetermined significance (MGUS), or may lead to clinical syndromes such as Hyperviscosity, Acrocyanosis, Cold hemagglutination, hemolysis and hemorrhagic manifestations. Their tissue deposition may be localized, with the kidney being the most frequent target as in Mveloma Cast Nephropathy or systemic, as in AL amyloidosis where heart, liver, nerves, tongue are usual targets, in addition to the kidneys.     

Pharmacological modification of cardiac function and blood vessel calibre

Drugs that modify the function of the cardiovascular system are in widespread use as long-term therapy in patients with cardiovascular disease or for acute cardiovascular management in anaesthesia and intensive care. Cardiac function and blood vessel calibre can be pharmacologically manipulated with drugs acting via the sympathetic nervous system (sympathomimetic drugs, e.g. catecholamines, or sympatholytic drugs, e.g. α- or β-blockers). Sympathomimetic drugs are endogenous or synthetic and act via adrenergic or non-adrenergic mechanisms. Alternatively, drugs with direct or indirect actions on the heart or vascular smooth muscle can be used. Such drugs may act via ion channels, receptors and second-messenger systems or via neurohumeral mechanisms (e.g. angiotensin-converting enzyme inhibitors or angiotensin receptor blockers). In general, drugs acting directly on blood vessels or via neurohumeral mechanisms cause vasodilatation and are used in the treatment of hypertension, angina, cardiac failure or as hypotensive agents. This article aims to provide a classification and overview of the drugs currently available and their uses.     

Drugs acting on the heart: antiarrhythmics

Arrhythmias are abnormalities of cardiac rate or rhythm occurring for a variety of reasons. They are common in the perioperative period and in intensive care. Causes may reflect an underlying heritable predisposition, the presence of new pathology either of the heart or conducting system, or as a result of systemic illness. Targets for antiarrhythmics include myocardial ion channels, muscarinic or nicotinic acetylcholine receptors, adrenergic or adenosine receptors. Arrhythmias may cause cardiac arrest and haemodynamic compromise, requiring rapid identification and corrective treatment either of rate or rhythm. Even where stable, arrhythmias present an increased risk of thromboembolic events requiring the use of anticoagulation. Treatment may be directed at controlling heart rate or rhythm to restore the circulation and tissue perfusion. Strategies may include prevention or correction of precipitating factors (such as electrolyte abnormalities or sepsis) and sometimes non-pharmacological treatments (cardioversion, surgical ablation or pacing). Antiarrhythmic drugs are often required. The targets, mechanisms and clinical guidelines are reviewed for common antiarrhythmic agents.     

Ovarian Cysts in Childhood1

This is a review of cases of ovarian cyst encountered in childhood in the Manchester children's hospitals. The patients presented with acute or recurrent abdominal pain or an abdominal or pelvic mass. The commonest cyst found was a teratoma, which was discovered because of its size or because of a complication. All but one of the girls with teratomas had not reached puberty. After puberty the cysts were follicular or luteal in type, although there was one case of cystadenoma. Complications in the form of torsion, rupture with hamoperitoneum or haemorrhage into the cyst were common. Treatment consisted of ovarian cystectomy, oophorectomy or salpingo-oophorectomy, and the results were satisfactory.     

Immediate amputation stump coverage with forearm free flaps from the same limb

When the traumatic amputation level or the degree of damage to the arm or forearm does not justify reimplantation of the severed part there may be sufficient undamaged skin to be used as a free flap to resurface the arm or the stump. Stump length or the elbow joint may thus be preserved and more durable skin cover for the fitting of a prosthesis may be obtained. A "spare-parts" forearm free flap may be raised on the radial or ulnar vessels or both. Three cases are reported.     

"开窗技术"治疗退行性腰椎管狭窄症融合指征

目的 探讨初次"开窗技术"治疗退行性腰椎管狭窄症融合的指征.方法 对1999年12月至2005年12月收治的145例退行性腰椎管狭窄症患者进行回顾性研究.按术前腰椎条件及手术方法分三组:A组39例,术前合并腰椎失稳运动、退变性滑脱或侧弯,行融合术;B组31例,术前合并腰椎失稳运动、退变性滑脱或侧弯,行非融合术;c组75例,术前无腰椎失稳运动、退变性滑脱或侧 弯,行非融合术.对患者住院天数、手术时间、估计出血量复发、再手术及并发症情况等进行统计分析;采用Oswestry 功能障碍指数(ODI)和疼痛视觉模拟评分(VAS)及满意率等进行疗效评估,并进行统计学分析.结果 所有患者随访时间均在3年以上.C组的住院时间少于A组和B组(P<0.05);A组的手术时间和估计出血量均大于B组和c组,差异均有统计学意义(P<0.05);A、C组长 期疗效优于B组(P<0.05),而A、c两组间差异无统计学意义;三组间的复发或残余症状恶化、再手术及并发症等方面差异没有统计学意义.结论 对于术前合并腰椎失稳、滑脱或侧凸的退变性腰椎管狭窄症患者,即使初次行"开窗技术"减压,也应融合;单纯狭窄患者初次手术则无需融合.