The effect of the herbal medicines dai-kenchu-to and keishi-bukuryo-gan on bowel movement after colorectal surgery

BACKGROUND/AIMS: To evaluate the safety and efficacy of the herbal medicines Dai-ken-chu-to and Keish-bukuryo-gan in the patients undergoing colorectal resection. METHODOLOGY: Sixty-six patients undergoing colorectal resection were studied. Patients in the Study group began on 7.5g of Dai-ken-chu-to and 6.0g of Keish-bukuryo-gan on the first postoperative day. Control group did not take herbal medicine at all. All of the patients were monitored for vomiting, abdominal distention, length of ileus, tolerance of regular diet, duration of intravenous fluid administration, length of hospitalization, and complications. RESULTS: The time to flatus was 63.1 +/- 22.8 hours and 95.4 +/- 33.0 hours in the Study and Control group, respectively (p<0.05). And the time to tolerance of regular diet was 2.53 +/- 1.93 days and 6.25 +/- 1.50 days in the Study and Control group, respectively (p<0.05). In addition, length of postoperative hospitalization in the patients within the Study group was significantly shorter than those within the Control group (15.7 +/- 4.8 days vs. 20.8 +/- 4.8 days, p<0.05). The incidence of complications including nausea, vomiting, anastomotic leak and wound infection occurred equally in both groups. CONCLUSIONS: Administration of Dai-ken-chu-to and Keish-bukuryo-gan is safe, with no evidence of increased morbidity, and is also highly effective in improving postoperative bowel motility and in reducing hospital stay.     

Preventing prolonged post-operative ileus in gastric cancer patients undergoing gastrectomy and intra-peritoneal chemotherapy

AIM: To assess the efficacy of metoclopramide (Met) for prevention of prolonged post-operative ileus in advanced gastric cancer patients undergoing D2 gastrectomy and intra-peritoneal chemotherapy (IPC). METHODS: Thirty-two advanced gastric cancer patients undergoing D2 gastrectomy and IPC were allocated to two groups. Sixteen patients received Met immediately after operation (group A), and 16 did not (group B). Another 16 patients who underwent D2 gastrectomy without IPC were enrolled as the control group (group C). All patients had received epidural pain control. The primary endpoints were time to first post-operative flatus and time until oral feeding with a soft diet without discomfort. Secondary endpoints were early complications during hospitalization. RESULTS: Gender, the type of resection, operating time, blood loss, tumor status and amount of narcotics were comparable in the three groups. However, the group C patients were older than those in groups A and B (67.5±17.7 vs 56.8±13.2,57.5±11.7 years, P= 0.048). First bowel flatus occurred after 4.35±0.93 d in group A, 4.94±1.37 d in group B, and 4.71±1.22 d in group C (P>0.05). Oral feeding of a soft diet was tolerated 7.21±1.92 d after operation in group A, 10.15±2.17 d in group B, and 7.53±1.35 d in group C (groups A and C vs group B, P<0.05). There was no significant difference in respect to the first flatus among the three groups. However, the time of tolerating oral intake with soft food in groups A and C patients was significantly shorter than that in group B patients. Levels of C-reactive protein (CRP) were significantly lower in group C and there was a more prominent and prolonged response in CRP level in patients undergoing IPC. The incidence of post-operative complications was similar in the three groups except for prolonged post-operative ileus. There was no increased risk of anastomotic leakage in patients receiving Met. CONCLUSION: The results suggest that a combination of intravenous Met and epidural pain control may be required to achieve a considerable decrease in time to resumption of oral soft diet in advanced gastric cancer patients who underwent gastrectomy and IPC. Furthermore, the administration of Met did not increase anastomotic leakage. Met has a role in the prevention of prolonged post-operative ileus.     

Effect of water-soluble contrast in colorectal surgery： A prospective randomized trial

AIM: Postoperative gastrointestinal-tract motility is normally delayed. Early feeding after colorectal surgery has been reported recently, but late feeding is common. Gastrografin not only enhances bowel peristalsis, but also decreases bowel-wall edema. Whether contrast medium allows early oral feeding and reduces the duration of hospitalization requires clarification. METHODS: Fifty patients underwent elective colorectal surgery In a regional medical center. Patients were prosp-ectively randomized into a Gastrografin group or control group (n=25 each). Patients in the Gastrografin group began their feeding schedule with 100 mL of 5% dextrose water with 100 mL of Gastrografin on postoperative d 3 and were advanced to a full liquid diet when the contrast reached the colon in 4 h. Patients in the control group began their feeding schedule with 200 mL of 5% dextrose water on postoperative d 3 and were advanced to a full liquid diet after the passage of flatus and stool. Nasogastric tubes were inserted for persistent postoperative vomiting. Fullness, nausea, vomiting, complications, time of anesthesia, time of operation, time of mobilization, time of oral feeding, and duration of hospital stay were recorded and analyzed with Student's t-test. RESULTS: In the Gastrografin group, one patient had aspiration pneumonia and one patient had anastomotic leakage resulting in sepsis and eventual death. This mortality was excluded from the subsequent statistical analysis. In the control group, two patients had wound infections. There was no significant difference between the two groups at the time of anesthesia, time of operation, or time of mobilization. There were significant differences between the two groups in the time of oral feeding (3.3±0.3 d in the Gastrografin group VS 4.8±0.4 d in the control group; P=odds ratio--, 95%CI [-0.5 to +0.7 d]) and in the length of hospital stay (7.6±1.1 d in the Gastrografin group VS 10.2±1.3 d in the control group; P=odds ratio--, 95% CI [-1.2 to +1.4 d]). CONCLUSION: Gastrografin not only allowed early oral feeding but also reduced the duration of hospitalization after elective colorectal surgery.     

Early closure of temporary stoma of the small bowel

AIM: Transient small bowel stoma is usually closed 9-12 weeks after initial operation (late closure). Since these stoma have a poor physiological and psychological impact with frequent social consequences, we wanted to estimate feasibility and results of early closure of small bowel stoma. PATIENTS AND METHOD: From January 1998 to December 2001, 39 patients (21 women and 18 men, mean age: 64 years) with a transient small bowel stoma were elected for early closure. Early closure was performed only if the patient was in good condition, and without developing wound or general sepsis. In the other patients, the stoma was closed in the usually recommended delay (> 8 weeks). Fifteen patients had an early closure of their stoma in a mean delay of 10.0 +/- 0.8 days after the initial procedure. Twenty-four patients had a late closure of their stoma in a mean delay of 11.4 +/- 3.7 weeks. RESULTS: There were no postoperative deaths and no intestinal fistula. Four (10%) wound abscesses occurred and were managed without any surgical procedure, 3 in the early closure group (20%) and 1 in the late closure group (4%) (P=0.85, NS). Time to recovered bowel activity and to resumed oral feeding were equivalent in the two groups. The mean length of hospital stay was longer in the delayed group (34.5 +/- 18.6 days) than in the early group (23.1 +/- 4.6 days) (P<0.01). CONCLUSION: Early closure of bowel stoma can be performed without major complications in elective patients. This procedure shortens hospital stay.     

Early switch from intravenous to oral antibiotics and early hospital discharge: a prospective observational study of 200 consecutive patients with community-acquired pneumonia

To determine the proportion of patients who can be treated with early switch to oral antibiotics and early discharge, to evaluate clinical outcome and patient satisfaction for patients treated with early switch and early discharge, and to define the factors that interfere with early discharge for some of the patients who underwent early switch to oral antibiotic therapy. Design: Prospective study. Participants: Two hundred consecutive hospitalized patients with community-acquired pneumonia. Main Outcome Measures: Number of days needed to switch to oral therapy and length of hospital stay. Clinical outcome and satisfaction with care were evaluated for those patients treated with early switch and early discharge. Results: Early switch to oral antibiotics (within the first 3 days of hospitalization) was performed in 133 patients (67%). Clinical failure was documented in 1 patient. Early switch and early discharge was performed in 88 patients (44%). The mean length of hospital stay for this group was 3.4 days. The most common reason for prolonged hospitalization after the switch to oral antibiotics was the need for diagnostic workup. More than 95% of patients were satisfied with the care they had received. Conclusions: Using simple clinical and laboratory criteria, a significant proportion of hospitalized patients with community-acquired pneumonia (44%) can be treated with early switch and early discharge. This model did not affect patient outcome, decreased the length of hospitalization, and was associated with a high level of patient satisfaction.     

Prokinetic effect of erythromycin after colorectal surgery

PURPOSE: Nausea and vomiting three to seven days after an elective operation on the colon and rectum remain a persistent clinical problem. Erythromycin, a safe, inexpensive drug that stimulates intestinal motilin receptors, has previously been shown to accelerate gastric emptying significantly after upper gastrointestinal surgery. We aimed to evaluate the effect of postoperative intravenous erythromycin on postoperative ileus in patients undergoing elective surgery for primary colorectal cancer. METHODS: Between May 1998 and April 1999, 150 patients undergoing primary resection of colon or rectal cancer were enrolled in this prospective, randomized, placebo-controlled trial. One hundred thirty-four patients completed the study. Patients were excluded if they had extensive metastatic disease, were taking medications known to interact with erythromycin, or if they required an ileostomy. Patients received either 200 mg of intravenous erythromycin or placebo every six hours. Clinical endpoints were recorded and continuous end-points are presented as mean +/- standard deviation. RESULTS: There were no significant complications related to erythromycin. The erythromycin (n = 65) and placebo (n = 69) groups were comparable regarding demographic and operative factors. The erythromycin group had a slightly shorter length of time to passage of flatus (4.1 +/- 1.3 vs. 4.4 +/- 1.1 days; P = 0.03). There was no significant difference between erythromycin and placebo in time to first solid food (5.6 +/- 1.9 vs. 5.4 +/- 1.8 days), time to first bowel movement (5.2 +/- 1.9 vs. 5.4 +/- 1.3 days), or time to discharge from hospital (7.5 +/- 2.0 vs. 7.6 +/- 2.8 days). There was no difference in the rate of clinically significant nausea (26 vs. 26 percent; P = 0.99), vomiting (17 vs. 16 percent; P = 0.88), or nasogastric tube placement (9 vs. 7 percent; P = 0.68). CONCLUSIONS: Erythromycin does not seem to alter clinically important outcomes related to postoperative ileus in patients undergoing resection for colorectal cancer.     

Timing of antibiotic prophylaxis in acute pancreatitis: a controlled randomized study with meropenem

OBJECTIVES: Antibiotic prophylaxis improves the outcome of acute pancreatitis. Since bacterial translocation from the gut occurs in the first h of disease, early therapy is likely to achieve the maximal effect. The study compares early antibiotic treatment with treatment started after the demonstration of pancreatic necrosis. METHODS: Two hundred fifteen patients with pancreatitis were randomized to either group A (N=108), who started antibiotic therapy (meropenem 500 mg t.i.d.) at admission, or group B (N=107), who received antibiotics after the demonstration of necrosis at computed tomography (CT). CT was performed in both groups after at least 48 hr of hospitalization. The clinical course of disease was compared in the two groups. RESULTS: Thirty patients in group A and 29 in B showed necrosis on CT. The two groups were similar in demographics and characteristics of disease. Antibiotic treatment was started after 4.56+/-1.2 days from hospitalization in group B and after 1.07+/-0.6 days in A. Pancreatic infection occurred in four patients in group A (13.3%) and in nine in B (31%) (p=0.1). Extrapancreatic infection occurred in 16.6% of patients in group A and in 44.8% in B (p<0.05). Need for surgery and length of hospitalization were also higher in group B. Mortality rates were similar in the two groups, but, 3 of 4 patients with infected necrosis in group A and only 2 of 9 in group B died. CONCLUSIONS: Early antibiotic treatment is associated with a significant improvement in the prognosis of necrotizing acute pancreatitis (AP), because of a reduction in the occurrence of septic complications.     

A simplified rehabilitation program for patients undergoing elective colonic surgery��randomized controlled clinical trial

Background

We have proposed a simplified perioperative rehabilitation program for elective colonic surgery that is focused on early oral nutrition and that could reduce hospital stay and postoperative ileus time without raising complications and readmission rates.

Patients and methods

Fifty-four patients admitted for elective colonic surgery were prospectively randomized into two groups: (1) an early feeding group (EFG)??on the first postoperative day, patients initially received a oral liquid diet and were advanced to a regular diet within the next 24?h as tolerated and at their discretion; (2) a traditional care group??patients were managed by nothing per orus until the elimination of the first flatus and then submitted to an oral liquid diet, followed by a regular diet within the next 24?h as described for the EFG. All patients followed a well-defined, simplified rehabilitation program.

Results

Patients' baseline characteristics were similar in the two groups. Hospital stay was significantly lower in the EFG (4.0 [±3.7] versus 7.6 [±8.1]?days; p?=?0.000). Diet tolerance and progression were similar between groups. Time to first flatus after surgery was significantly lower in the EFG (1.5 [±0.5] versus 2.0 [±0.7]?days; p?=?0.019). Complication and readmission rates were similar in both groups.

Conclusions

Early oral nutrition associated with a simplified perioperative rehabilitation program reduces postoperative length of hospital stay and ileus time after elective colonic resection without increasing rates of complications or readmissions.     

Early removing gastrointestinal decompression and early oral feeding improve patients＇ rehabilitation after colorectostomy

AIM: To evaluate the feasibility, safety, and tolerance of early removing gastrointestinal decompression and early oral feeding in the patients undergoing surgery for colorectal carcinoma. METHODS: Three hundred and sixteen patients submitted to operations associated with colorectostomy from January 2004 to September 2005 were randomized to two groups: In experimental group (n=161), the nasogastric tube was removed after the operation from 12 to 24 hours and was promised immediately oral feeding; In control group (n=155), the nasogastric tube was maintained until the passage of flatus per rectum. Variables assessed included the time to first passage of flatus, the time to first passage of stool, the time elapsed postoperative stay, and postoperative complications such as anastomotic leakage, acute dilation of stomach, wound infection and dehiscense, fever, pulmonary infection and pharyngolaryngitis. RESULTS: The median and average days to the first passage of flatus (3.0±0.9 vs 3.6±1.2, P<0.001), the first passage of stool (4.1±1.1 vs 4.8±1.4 P<0.001) and the length of postoperative stay (8.4±3.4 vs 9.6±5.0, P<0.05) were shorter in the experimental group than in the control group. The postoperative complications such as anastomotic leakage (1.24% vs 2.58%), acute dilation of stomach (1.86% vs 0.06%) and wound complications (2.48% vs 1.94%) were similar in the groups, but fever (3.73% vs 9.68%, P<0.05), pulmonary infection (0.62% vs 4.52%, P<0.05) and pharyngolaryngitis (3.11% vs 23.23%, P<0.001) were much more in the control group than in the experimental group. CONCLUSION: The present study shows that application of gastrointestinal decompression after colorectostomy can not effectively reduce postoperative complications. On the contrary, it may increase the incidence rate of fever, pharyngolaryngitis and pulmonary infection. These strategies of early removing gastrointestinal decompression and early oral feeding in the patients undergoing colorectostomy are feasible and safe and associated with reduced postoperative discomfort and can accelerate the return of bowel function and improve rehabilitation.     

Must early postoperative oral intake be limited to laparoscopy?

PURPOSE: This prospective, randomized study was designed to evaluate whether or not early postoperative feeding (claimed as a unique benefit of laparoscopic surgery) is possible after laparotomy and colorectal resection. METHODS: The trial was performed between July 1, 1992 and October 31, 1992 and included all 64 consecutive patients who underwent laparotomy with either a colonic or an ileal resection. In all cases the nasogastric tube was removed immediately after the operation. Group 1 consisted of 32 patients (age range, 15–81 years; mean, 52 years) who received a regular diet on the first postoperative morning. Group 2 consisted of 32 patients (age range, 15–87 years; mean, 52 years) who were fed in a traditional manner. Regular food was permitted after resolution of ileus as defined by resumption of bowel movements in the absence of abdominal distention, nausea, or vomiting. RESULTS: The rate of nasogastric tube reinsertion for distention with persistent vomiting was 18.7 percent (six patients) in Group 1 and 12.5 percent (four patients) in Group 2. Although vomiting was experienced more frequently by patients in Group 1 (44 percent vs. 25 percent, respectively), there was no difference between the two groups with regard to the duration of postoperative ileus (3.6 vs. 3.4 days, respectively). In the 26 patients from Group 1 who did not require nasogastric tube reinsertion, there was a trend toward shorter hospitalization (6.7 vs.8.0 days, respectively). CONCLUSION: Early oral intake is possible after laparotomy and colorectal resection. Thus, the laparoscopic surgeon's claim of early tolerated oral intake may not be unique to laparoscopy.     

Effects of L-arginine supplementation on endothelial function after stent implantation

BACKGROUND: In-stent restenosis after percutaneous coronary intervention (PCI) is due to the proliferation of intima. Supplementation with L-arginine has been shown to improve endothelial function and decrease neointima proliferation in experimental animal model of restenosis. AIM: To assess the effects of L-arginine supplementation on neointima proliferation and endothelial markers as well as growth factor levels in patients after stent implantation. METHODS: In this prospective, randomised, double-blind, placebo-controlled study 60 patients undergoing stent implantation received placebo or L-arginine (200 mg/kg infused intravenously over 4 hours, 12 and 3 hours before PCI, and 500 mg over 10 minutes prior to stent implantation, followed by oral supplementation of 6 g/day for 14 days after PCI). Quantitative coronary angiography (QCA) and intracoronary ultrasonography (ICUS) were performed at baseline and after a seven-month follow-up period. Serum concentration of L-arginine was measured at baseline, before PCI, 24 hours after PCI, and 7 as well as 14 days after PCI. The transforming growth factor-beta (TGF-beta), vascular endothelial growth factor (VEGF) and endothelin levels were assessed before PCI, and 24 hours as well as 14 days after the procedure. RESULTS: No significant differences in the QCA or ICUS parameters were found between patients receiving L-arginine or placebo. 24 hours after stent implantation patients who received placebo had significantly a higher increase in the endothelin serum concentration and a lower rise in the VEGF level than the patients who received L-arginine (92.6+/-49 pg/ml vs 76.1+/-27 pg/ml, p<0.05, and 10 pg/ml vs 17.6+/-12 pg/ml, p<0.05, respectively). The TGF-beta level, assessed 14 days after PCI, was significantly higher in the placebo group than in the L-arginine group (14.8+/-10 ng/ml vs 11.2+/-6.1 ng/ml, p<0.05). CONCLUSIONS: In spite of favourable changes in the vascular endothelial biochemical marker profile, supplementation with L-arginine did not decrease the in-stent reocclusion rate.     

Timing of oral anticoagulation therapy in the treatment of angiographically proven acute pulmonary embolism

The optimal time to begin oral anticoagulation therapy with warfarin sodium in the treatment of acute pulmonary embolism has not been defined. To evaluate the relative cost, efficacy, and safety of early initiation of warfarin therapy, we reviewed the medical records of 38 patients with angiographically proven pulmonary embolism. Patients were divided into two groups: those who received warfarin early (less than or equal to 3 days after initial heparin sodium bolus, n = 17) and those who were treated late (greater than 3 days after initial heparin bolus, n = 21). After three months of follow-up, there was a similar incidence of mortality, recurrent pulmonary embolism, and bleeding complications in both treatment groups. Length of hospitalization was substantially less in the early group (9.6 +/- 2.0 vs 11.8 +/- 2.1 days). Early warfarin therapy in the treatment of acute pulmonary embolism appears to be both cost-effective and safe. A prospective multicenter controlled trial should be performed.     

Motility across esophageal anastomoses after esophagectomy or gastrectomy

The esophageal motility of 23 patients who underwent esophagectomy or gastrectomy for carcinoma of the esophagus or gastroesophageal junction was recorded daily during the immediate post-operative period for high-pressure transients or other motility disturbances. Patients were divided into three subgroups according to the level of the esophageal anastomosis: group 1, neck (n = 4); group 2, thoracic (n = 14); group 3, diaphragmatic hiatus (n = 5). Peristalsis was absent in all patients studied during ventilation and sedation in the intensive care unit (five patients). Early post-operative esophageal motility after esophageal anastomosis varied somewhat with the length of residual esophagus. With short lengths of residual esophagus, no consistent motility pattern emerged. With longer lengths, early peristaltic activity was evident, but diminished over the first few post-operative days. Esophageal resection and anastomosis is associated with loss of peristalsis in the initial post-operative period, consistent with the concept of an esophageal ileus.     

Early switch to oral antibiotics and early discharge guidelines in the management of community-acquired pneumonia

BACKGROUND AND OBJECTIVE: The major cost of managing community-acquired pneumonia (CAP) relates to the duration i.v. antibiotic use and length of hospital stay (LOS). Guidelines on early switch to oral antibiotics and early discharge from hospital may help to achieve a unified approach to managing CAP. The aim of this study was to assess the benefits and safety of these guidelines in an Australian respiratory medicine unit. METHODS: This prospective study included consecutive patients admitted with a diagnosis of CAP over a 6-month period. Early switch to oral antibiotics and early discharge guidelines were implemented one month prior to the evaluation period. Comparison was made to a retrospective control group admitted before the guidelines were implemented. Data collection included patient demographics, clinical and outcome parameters, duration of i.v. antibiotics and LOS. Thirty-day outcomes on patient safety and satisfaction were collected from the prospective group. RESULTS: One hundred and twenty-five patients in the prospective group were compared to 100 patients in the controls. Baseline characteristics were similar between the comparison groups. Both the mean duration of i.v. antibiotics used (3.38 +/- 0.22 vs. 3.99 +/- 0.28 days, P = 0.03) and LOS (7.62 +/- 0.60 vs. 8.36 +/- 0.55 days, P = 0.04) were significantly shorter in the prospective group. Thirty-day readmission rate was 6% and patient self-reported overall satisfaction was 93.9% in those who were followed up. CONCLUSIONS: The use of early switch and early discharge guidelines for CAP reduced the duration of i.v. antibiotics and LOS while maintaining high levels of safety and patient satisfaction.     

Readmissions to hospital within 30 days of discharge from the internal medicine wards in southern Israel

INTRODUCTION: Hospital readmission within a short time of discharge is a common phenomenon in internal medicine. Although there are a few reports of intensive care and surgical readmission rates there is almost no information available on the readmission rates of internal medicine patients. AIMS: To explore the medical patient readmission rate within 30 days of discharge from a medical center in southern Israel, and determine how it may be related to age, gender, diagnoses and other factors. METHODS: Chart review of all 2469 patients admitted to the departments of internal medicine of Barzilai Health Center between May 1st and July 15th 2002. A randomized control group of 87 patients was gathered from patients admitted to hospital during the study period but who were not readmitted within 30 days of discharge. RESULTS: 124 patients (5%) were readmitted. They were significantly older than controls (mean age 68.7+/-14.8 vs. 59.3+/-16.3 years), (p<0.0003), 21% being over 80 years of age (compared with 9% of controls, p<0.05) and had a lower average Functional Independence Measure (FIM). The index hospitalization of readmitted patients was significantly longer than the hospitalization of control patients (6.1+/-5.5 vs. 4.1+/-3.8 days), (p<0.04). Most patients (85%) were readmitted for the same medical reason that prompted the original hospitalization. The 15% readmitted for other reasons were older (74.9+/-12.4 vs. 67.6+/-15.0 years) (p<0.001) and had a lower Functional Independence Measure (mean FIM 4.6+/-2.2 vs. 5.7+/-1.9), (p<0.05). New immigrants (mean age 71.1+/- 12.9 years) had significantly lower readmission rate compared to the general population (3.2% vs. 4.98%), (p<0.05). Veteran Israelis, on the other hand, had a higher readmission rate than the general population (6.8% vs. 4.98%) (p<0.001). CONCLUSION: Only 5% of patients required readmission. The original hospitalization period of readmitted patients was significantly longer than controls and most readmissions were for the original medical problem for which they were readmitted originally or because of a low functional status. Hospitalized new immigrants although being older in age are less likely to require readmission, while veteran Israelis are more likely to be readmitted.     

Prospective randomized study comparing ultrasound-guided thrombin injection to compression in the treatment of femoral pseudoaneurysms.

PURPOSE: To compare in a randomized prospective study the treatment of femoral pseudoaneurysms with ultrasound-guided thrombin injection versus ultrasound-guided compression. METHODS: Thirty consecutive patients (22 men; mean age 67+/-8 years, range 53-82) with iatrogenic femoral pseudoaneurysms were randomized to treatment with either ultrasound-guided compression (n=15) or injection of bovine thrombin (n=15). The primary outcome measure was thrombosis of the pseudoaneurysm within 24 hours. Secondary outcome measures were complications and hospitalization time (LOS). RESULTS: Thrombosis within 24 hours was achieved in 15 (100%) patients given thrombin versus 2 (13%) in the compression group (p<0.001). Of 13 pseudoaneurysms failing the initial compression treatment, 7 were retreated, 4 successfully. Thus, only 6 (40%) lesions were thrombosed within 48 hours after 1 or 2 compression sessions. The other 9 cases were successfully treated with thrombin injection. LOS was 2.8+/-1.5 days and 3.5+/-2.4 days in the thrombin and compression groups, respectively (p>0.05). No complications were noted in either group. CONCLUSIONS: Ultrasound-guided thrombin injection induces a fast, effective, and safe thrombosis of postcatheterization pseudoaneurysms. The technique is clearly superior to compression treatment and is recommended as the therapy of choice.     

Time course of left ventricular remodeling after myocardial infarction: a two-dimensional echocardiographic study

In order to forecast the clinical course of acute myocardial infarction (MI), the time course of the functional changes of the left ventricular myocardium that result in remodeling was evaluated with two-dimensional echocardiography (2DE). The study group comprised 45 patients with anterior MI treated with successful percutaneous transluminal coronary angioplasty. 2DE studies were performed on days 1, 3, 7 and 14; months 1 and 3 and 1 year after MI, and the following parameters were recorded: (1) infarcted wall thickness, (2) traced length of the endocardium and of the epicardium on end-diastolic apical long axis images, and (3) wall motion score (total of asynergy scores of 16 segments of left ventricle (LV); normal: 0, hypokinesis: 1, akinesis: 2, dyskinesis: 3). According to the peak creatine kinase (CK) level, patients were classified into L group (CK > or =8000 U/L, n=16), M group (8000> CK > or =4000, n=13) and S group (CK <4000, n=16). The following results were obtained. (1) There was progressive thinning of the infarcted myocardium up to 1 month after (1 day: 9.3+/-1.7, 14 days: 6.3+/-1.7 vs 1 month: 5.9+/-1.8 mm, p<0.05; vs 1 year: 5.9+/-1.9 mm, NS). (2) Dilatation of the LV cavity occurred shortly after MI and continued up to 14 days (endocardium at 14 days: 176.8+/-13.6 vs 1 day: 164.1+/-11.4 mm, p<0.01; vs 1 year: 176.3+/-12.7 mm, NS). (3) The wall motion score improved rapidly by 14 days, and continued to improve gradually to 1 year (1 day: 12.2+/-3.4, 14 days: 6.8+/-4.0, 1 year: 4.6+/-3.1). (4) The expansion ratio (endocardial length at 14 days/1 day) was significantly greater in the L group than in the S group (p<0.05). Comparing the groups, the LV cavity of the L group remained dilated up to 14 days, whereas that of the S and M groups was dilated up to 7 days (L group 14 days: 179.3+/-11.9 vs 1 day: 156.9+/-9.2mm, p<0.01; vs 1 year: 180.0+/-14.1 mm, NS) (S group 7 days: 171.7+/-13.6 vs 1 day: 161.5+/-7.2 mm, p<0.01; vs 1 year: 172.7+/-14.4 mm, NS) (M group 7 days: 170.5+/-10.5 vs 1 day: 157.7+/-14.5 mm, p<0.05; vs 1 year: 177.08+/-9.6 mm, NS). Serial 2DE on days 1 and 14 after MI were useful for evaluating the course of LV remodeling and to forecast cardiac function in the chronic phase of MI. Determining the length of hospital stay on the basis of infarction size is justified.     

The efficacy of oral vitamin A supplementation for measles and respiratory syncytial virus (RSV) infection

Recently, the efficacy of oral vitamin A supplementation for measles and respiratory syncytial (RSV) infection has been evaluated in developing countries. However, in developed countries where vitamin A deficiency is little worth consideration, few studies have been conducted on the effect of vitamin A supplementation. The effect of oral vitamin A (100,000 IU) supplementation was evaluated in 105 children with measles (age 5 months to 4 years) and in 96 children with RSV infection (ages a month to 2.5 years) in Fukushima, Japan. Comparisons were made of clinical signs, duration of hospitalization and complications between treated groups and non-treated groups. Treated group (measles n = 47, RSV n = 54) and non-treated groups (measles n = 58, RSV n = 42) had similar baseline characteristics. Patients with measles given a vitamin A supplementation had a shorter duration of cough (7.2 +/- 1.6 vs 9.2 +/- 1.8 days, p < 0.05) and patients with severe RSV infection given a vitamin A supplementation had a shorter duration of retraction (3.6 +/- 1.4 vs 5.3 +/- 0.8 days, p < 0.05) and wheezing (4.4 +/- 1.7 vs 6.3 +/- 1.5 days, p < 0.05). Toxicities, including excess vomiting and bulging fontanel were not observed. Our findings may suggest the efficacy of oral vitamin A supplementation for measles and severe RSV infection, in children who have no malnutrition.     

阿普唑仑可降低射频导管消融手术患者的住院费用

目的观察术前加用阿普唑仑对射频导管消融手术患者的心理状况及住院费用的影响。方法前瞻性、随机、双盲、安慰剂对照研究142例因阵发性室上性心动过速而择期行首次心内电生理检查或射频导管消融手术的患者,随机纳入安慰剂组（对照组,70例）或阿普唑仑组（治疗组,72例）。所有患者均于入组当晚开始每晚睡前服用阿普唑仑0．4mg或外形、性状类似于治疗药的安慰剂,至少3天后行射频导管消融治疗。所有患者均于术前24h内行中国版90项症状量表评价。结果二组之间年龄、性别、体重、烟酒嗜好、职业、文化程度、婚姻状况、家庭关系和医疗费用的支付方式（即是否有医疗保险）等方面以及二组间合并高血压和糖尿病的患者数差异均无统计学意义。与对照组相比,治疗组射频导管消融术前的患者躯体化（1．38±0．40比1．65±0．56,P〈0．01）、焦虑（1．50±0．39比1．69±0.50,P〈0．05）、恐怖（1．24±0.36比1．47±0.57,P〈0．01）、精神病性（1．24±0．34比1．35±0．30,P〈0．05）和总均分（1．36±0．35比1．49±0．37,P〈0．05）等项目评分均有明显下降,治疗组住院费用（32498±1170）元,明显低于对照组（32947±1096）元,P〈0．05。结论术前服用阿普唑仑可改善射频导管消融手术患者的心理状况并降低其住院费用。     

Does the time of resternotomy for bleeding have any influence on the incidence of sternal infections, septic courses or further complications?

BACKGROUND: Former studies on sternal wound infections indicate predisposing factors like diabetes, obesity, use of bilateral internal mammary grafts, impaired renal function and reoperation. We wanted to evaluate whether the time of resternotomy for postoperative bleeding has any influence on the development of a sternal wound infection and other complications. METHODS: In our department, 12,315 patients underwent median sternotomy for cardiac surgery between 1987 and 1998. We analyzed the clinical data of all patients which were reoperated on for postoperative bleeding, especially patients with subsequent operations caused by sternal wound infections. All data were compared by T-test respectively chi2-test, and p<0.05 was regarded as significant. RESULTS: 406 of the 12,315 patients were re-explored because of postoperative bleeding (3.3%). 57 (14%) of these patients died in the postoperative period of non-infectious complications. The remaining patients were divided into two groups: Group A (286 patients) (70.4%) did not suffer from any sternal wound complications, where as group B patients (n = 63) (15.6%) needed subsequent surgery due to sternal infection. There were no significant differences in either concerning age, clinical data and first operation. All patients had an average blood loss of 223 ml/hr. The time before re-operation for bleeding was 5.3+/-1.7 hours in group A compared to 11.1+/-4.2 hours in group B (p<0.05). A significant delay of reoperation for bleeding could also be found for patients with postoperative septic complications (?: 5.2+/-1.9 hours, +: 12.9+/-5.2 hours), renal failure, mechanical ventilation >48 hours and a stay in hospital >20 days. CONCLUSIONS: Early reoperation for postoperative bleeding decreases the number of subsequent complications, e.g. sternal wound infections, septic complications and prolonged mechanical ventilation.