Laparoscopic colectomy is associated with decreased postoperative gastrointestinal dysfunction

Background  Major abdominal surgery is associated with early postoperative gastrointestinal dysfunction, which may lead to abdominal distention and vomiting, requiring nasogastric (NGT) tube insertion. This study aimed to compare the rates of early postoperative NGT insertion after open and laparoscopic colorectal surgery. Methods  A retrospective chart review was performed for patients who underwent colorectal surgery with removal of the NGT at completion of surgery. Patients who required reinsertion of the NGT in the early postoperative course were identified. The reinsertion rate for patients who underwent laparoscopic surgery was compared with that for the open group. Results  There were 103 patients in the open group and 227 in the laparoscopic group. In the laparoscopic group, 42 patients underwent conversion to open surgery. Reinsertion of the NGT was required for 18.4% of the patients in the open group, compared with 8.6% of the patients for whom the procedure was completed laparoscopically (p = 0.02). Conversion to open surgery resulted in a reinsertion rate of 17%. Conclusion  Laparoscopic colorectal surgery is associated with decreased postoperative gastrointestinal dysfunction, resulting in a significantly lower NGT reinsertion rate. Presented as a poster at the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons, (SAGES), Dallas, Texas, 26–29 April 2006, and at the annual meeting of the European Society for Endoscopic Surgeons (EAES), Berlin, Germany, 13–16 September 2006.     

The Role of Superoxide Dismutation in Malaria Parasites

Oxidant stress is associated with the generation of reactive oxygen species that are responsible for the damage of a variety of cellular components. The prevention of such biological damage can be achieved by dismutation of superoxide to H2O2 which in turn is removed by catalase and GSH peroxidase. However, redox-active iron released during the development of plasmodia in the erythrocyte can mediate the conversion of H2O2 to hydroxyl radical which is more reactive. The roles of SOD and the nitroxide SOD mimic 4-OH,2,2,6,6,tetramethyl piperidine-N-oxyl (Tempol) were examined in P. falciparum grown in vitro. Both compounds did not prevent the interference with growth inflicted by various inducers of oxidant stress. Moreover, Tempol inhibited parasite growth, in agreement with previous experiments depicting accelerated mortality in SOD overexpressing mouse model of malaria. Probably, effective defense against ROS requires balanced increments in antioxidant enzymes and is not necessarily improved by an increase in the activity of one enzyme.     

Atrial pacing and the exercise test in the evaluation of coronary disease. A comparative study

OBJECTIVE: to compare the relative value of Atrial Pacing and Exercise Electrocardiography in the diagnosis of Myocardial Ischaemia. DESIGN: prospective study in patients referred for coronary cineangiography. SETTING: Cineangiography and Ergonometry Departments of Cardiology Service. Santa Maria Hospital. PATIENTS: 16 patients (mean age 52.4 +/- 6.3), 13 males and 3 females. All were submitted to Atrial Pacing, Exercise Test and Coronariography. RESULTS: both tests were concordant in all cases but one, with negative Atrial Pacing, positive Exercise Test and negative Coronariography. CONCLUSIONS: Atrial Pacing compares favourably with Exercise Test in the diagnosis of Coronary Ischaemic Disease. It may constitute a valid alternative in patients unable to perform a conclusive Exercise Test.     

Skin reactivity and specific IgE levels in the evaluation of allergic sensitivity to common allergens for epidemiological purposes

An investigation was conducted to test the validity of the skin-prick test (SPT) with eleven common allergens (Lofarma series proposed by Italian National Research Council for epidemiological studies) as a method for predicting the presence of specific antibodies in serum. The relationship between SPT, evaluated by two different methods (MWD = mean weal diameter, AHWR = allergen histamine weal ratio), and specific IgE levels (RAST) has been investigated in 101 patients tested consecutively for suspected allergic disease. Sensitivity, specificity and overall efficiency were assessed for different criteria of SPT positivity (greater than or equal to 4 mm or greater than or equal to 5 mm using MWD; ++ or using AHWR). For pollens and moulds, a weal diameter greater than or equal to 5 mm gave better results than 4 mm, whereas for mites a MWD greater than or equal to 4 mm showed a better sensitivity and overall efficiency than 5 mm. Danders showed low sensitivity when either 5 or 4 mm criterion was considered. AHWR evaluation gave no better results, except for animal danders. Correlation coefficients between weal size and RAST class showed a good relationship for mites and pollens using both methods of SPT evaluation; a moderate relationship was observed with MWD criterion for moulds and with AHWR for danders. We conclude that a weal diameter greater than or equal to 5 mm can be assumed to to predict RAST positivity for pollens and moulds, and for mites, a weal greater than or equal to 4 mm can be a more accurate criterion.(ABSTRACT TRUNCATED AT 250 WORDS)     

Bowel Preparation Is Associated With Spillage of Bowel Contents in Colorectal Surgery

PURPOSE Infectious complications pose a significant cause of morbidity in colon and rectal surgery. This study was designed to assess the effect of bowel preparation on spillage of bowel contents into the peritoneal cavity during colorectal surgery, and its potential effect on the rate of postoperative infectious complications.METHODS The quality of bowel preparation and the incidence of spillage of bowel contents were prospectively assessed in patients undergoing elective colon and rectal resection. The patients were followed for 30 days for postoperative infectious and noninfectious complications.RESULTS A total of 333 patients were included in this study, of which 181 did not receive mechanical bowel preparation. Intraoperative spillage of bowel contents occurred in 48 patients (14 percent), whereas in 285 patients (86 percent), spillage did not occur. There was a trend toward a higher rate of overall surgical infectious and noninfectious complications in patients who had spillage of bowel contents compared with patients without spillage; however, this difference was not statistically significant (18.7 vs. 11 percent, and 29 vs. 19 percent, respectively). Preoperative mechanical bowel preparation and colocolonic or colorectal anastomosis was associated with a higher rate of bowel contents spillage, although this difference did not reach statistical significance. Liquid colonic contents caused significantly higher rates of spillage.CONCLUSIONS Spillage of bowel contents into the peritoneal cavity during colon and rectal surgery may increase the rate of postoperative infectious complications. In addition, inadequate mechanical bowel preparation, leading to liquid bowel contents, increases the rate of intraoperative spillage.Reprints are not available.     

Effect of Systemic Vasodilators on Internal Mammary Flow During Coronary Bypass Grafting

Background. The effect of vasodilators on acute flow in the internal mammary (IMA) is unclear. Topical vasodilators show no effect on acute flow when the distal segment of the IMA is resected. The purpose of this study was to evaluate the effect of systemic vasodilators when this segment is resected.

Methods. We studied 60 patients with proximal anterior descending coronary artery lesions in whom the left IMA was harvested for grafting to the left anterior descending coronary artery. The patients were divided into six groups (n = 10), based on which of the following agents were studied: normal saline solution, nitroglycerin, nitroprusside, dobutamine, dopexamine, and amrinone. After harvesting, the IMA was trimmed as proximally as possible (and at least 3 cm proximal to the bifurcation), and free flow was measured before any pharmacologic intervention (flow 1). Systemic infusion of one of the six agents commenced. A mean of 17 ± 3.4 minutes after infusion began, with a comparable cardiac index, a second measurement of IMA flow was taken (flow 2). Hemodynamic measurements for each flow, including blood pressure, heart rate, and cardiac output, were taken.

Results. A significant increase in IMA flow was noted for those patients receiving nitroglycerin (93.5 versus 106.8 mL/min; p = 0.025), and a significant decrease in flow was noted for those receiving nitroprusside (91.0 versus 78.2 mL/min; p = 0.042). The effects remained significant when corrected for cardiac index and compared with the normal saline solution group. No other systemic agents tested significantly affected the IMA flow (dobutamine, 83.8 versus 85.0 mL/min; dopexamine, 101.8 versus 91.4 mL/min; amrinone, 75.4 versus 79 mL/min; normal saline solution, 85.8 versus 84.6 mL/min).

Conclusions. Resection of the distal segment of the IMA and the use of intravenous nitroglycerin optimizes the flow in IMA grafts.     

Effect of nebulizer configuration on delivery of aerosolized tobramycin.

Differences in the reported efficacy of aerosolized aminoglycosides may be due, in part, to differences in aerosol delivery. Optimization of delivery systems of bench testing of nebulizers in a manner that simulates clinical conditions can lead to enhanced lung deposition in subsequent clinical studies. In the present study, we assessed the effects of varying nebulizer configuration on the performance of ultrasonic and jet nebulizers. Tobramycin was mixed with a radiotracer (99mTc) to facilitate measurement of nebulizer output and particle size. A piston ventilator provided a simulated breathing pattern, and the dose delivered to a filter corresponded to what would have been inhaled by a patient (percentage of nebulizer charge inhaled). Particle size was measured using a cascade impactor, sampling at 1 L/min. An ultrasonic nebulizer (Ultra-Neb; DeVilbiss, Somerset, PA), ventilated at 20 breaths per minute, charged with 600 mg of tobramycin (in 30-mL volume) and fitted with its standard tubing, was tested with and without the addition of one-way valves to the inspiratory and expiratory ports of the mouthpiece. In order to assess the degree of environmental contamination associated with jet nebulizer therapy, a filter was placed at the expiratory port of all jet nebulizer experiments. The addition of the valves reduced the percentage of charge inhaled from a mean +/- standard deviation (SD) of 29.2% +/- 1.4% to 7.6% +/- 2.3% and reduced mass median aerodynamic diameter [MMAD (sigma g) from 4.3 microns (2.1) to 1.45 microns (1.65)]. A Circulaire (Westmed, Tucson, AZ) jet nebulizer (7 L/min flow, 50 pounds per square inch gauge (psig), 20 breaths per minute, containing 160 mg of tobramycin in a 4-mL volume) was tested in two configurations: using a plain T-piece and using a valved inflatable aerosol chamber. The use of the holding chamber resulted in an almost twofold reduction in MMAD [MMAD (sigma g) = 2.45 microns (2.0); T-piece; 1.25 microns (2.0), holding chamber]. A slight reduction in the percentage of nebulizer charge inhaled using the holding chamber, compared to the plain T-piece, was not statistically significant (mean +/- SD of percentage inhaled with holding chamber = 20.8% +/- 1.6%; with T-piece = 23.6% +/- 0.5%). With both the jet and ultrasonic nebulizers, breathing frequency influenced percentage inhaled, with a higher percentage inhaled at 20 breaths per minute compared to 15 breaths per minute. The use of the plain T-piece at 20 breaths per minute was associated with more environmental contamination than the use of the holding chamber with the same breathing pattern (26.7% +/- 1.0%, T-piece; 4.5% +/- 0.3%, holding chamber, P < 0.0001). We conclude that nebulizer configuration can potentially affect both the amount of aerosol inhaled and the particle size, and needs to be specified precisely in treatment protocols.     

Retrospective analysis of the use of inferior vena cava filters in routine hospital practice

Introduction

Characteristics and outcomes of patients undergoing inferior vena cava (IVC) filter insertion are not well reported. Particularly, the role of long term anticoagulation in these patients is unclear.

Aims

(1) To describe in a cohort of patients undergoing IVC filter insertion, underlying diseases, indications for filter insertion, complications, and survival. (2) To determine the effect of long term anticoagulant treatment on thromboembolism and patient survival.

Study design

A retrospective analysis of 109 consecutive patients undergoing IVC filter insertion in two university hospitals.

Results

Average age was 67.4 years. Median duration of follow up was two years. Indications for IVC filter insertion were: contraindication to anticoagulation (n = 61, 56%), prophylactic insertion (n = 29, 27%), thromboembolism while receiving adequate anticoagulation (n = 17, 15%), and non‐compliance with anticoagulation (n = 2, 2%). Insertion related complications were groin haematoma in four patients (3.5%) and localised infection at the puncture site in one patient (0.9%). Fifty six patients (51.4%) died during the study period. Of these, 22 received long term anticoagulants and 34 did not. Overall and thrombosis free survival was greater in the anticoagulant treated group (median survival not reached) than in the untreated group (median survival = 12 months). Patients not receiving long term anticoagulation after IVC filter insertion were nearly 2.5‐fold more likely to die or experience venous thromboembolism.

Conclusion

IVC filter insertion was a safe procedure and was performed for appropriate indications in the patients studied. In patients surviving for longer than 30 days, prolonged administration of oral anticoagulants was associated with improved survival with no significant increase in haemorrhagic complications.