Risk-Adapted Anastomosis for Partial Pancreaticoduodenectomy Reduces the Risk of Pancreatic Fistula: A Pilot Study

Background

Pancreatic fistula (PF) is the main cause of postoperative morbidity and mortality after pancreatectomy. Two reasons for PF are a “soft” pancreatic texture and a narrow pancreatic duct (high-risk gland). Pancreaticojejunostomy (PJ) may lead to a higher fistula rate in such glands. In the literature there are no data available on risk-adapted assignment of pancreatogastrostomy (PG) in a high-risk gland. Therefore, an observational pilot study was conducted to address this issue.

Methods

Since January 2007 the concept of a “risk-adapted pancreatic anastomosis” (RAP) was introduced (PG for high-risk glands). The PF rate, morbidity, and mortality during this period (January 2007 to December 2008, n = 74) were compared to those between January 2004 and December 2006 (n = 119, only PJ). PF was defined according to the International Study Group on Pancreatic Surgery.

Results

Through RAP the PF rate was reduced from 22 to 11% (P = 0.0503). Grade C PF rate was reduced from 6.7 to 1.4% (P = 0.1569) and grade A PF from 6 to 1.4% (P = 0.2537). The PF-associated mortality was reduced from 3.4 to 1.4%. PG revealed a PF rate of 7% and PJ accounted for 19% of PFs (P = 0.1765). There was no incidence of grade C PF following PG. The incidence of intraluminal hemorrhage (P = 0.0422) and delayed gastric emptying (P = 0.0572) was higher following PG.

Conclusions

The rate of PF could be significantly reduced with the use of RAP. One should be cautious about the indication for PG, since it is associated with a higher rate of intraluminal hemorrhage and delayed gastric emptying. There are no long-term results on PG with respect to its durability and function. A general recommendation for its use cannot currently be made.     

Upper extremity musculoskeletal pain during and after rehabilitation in wheelchair-using persons with a spinal cord injury

STUDY DESIGN: Prospective cohort study. OBJECTIVES: To study upper extremity musculoskeletal pain during and after rehabilitation in wheelchair-using subjects with a spinal cord injury (SCI) and its relation with lesion characteristics, muscle strength and functional outcome. SETTING: Eight rehabilitation centers with an SCI unit in the Netherlands. METHODS: Using a questionnaire, number, frequency and seriousness of musculoskeletal pain complaints of the upper extremity were measured. A pain score for the wrist, elbow and shoulder joints was calculated by multiplying the seriousness by the frequency of pain complaints. An overall score was obtained by adding the scores of the three joints of both upper extremities. Muscle strength was determined by manual muscle testing. The motor score of the functional independence measure provided a functional outcome. All outcomes were obtained at four test occasions during and 1 year after rehabilitation. RESULTS: Upper extremity pain and shoulder pain decreased over time (30%) during the latter part of in-patient rehabilitation (P<0.001). Subjects with tetraplegia (TP) showed more musculoskeletal pain than subjects with paraplegia (PP) (P<0.001). Upper extremity pain and shoulder pain were significantly inversely related to functional outcome (P<0.001). Muscle strength was significantly inversely related to shoulder pain (P<0.001). Musculoskeletal pain at the beginning of rehabilitation and BMI were strong predictors for pain 1 year after in-patient rehabilitation (P<0.001). CONCLUSIONS: Subjects with TP are at a higher risk for upper extremity musculoskeletal pain and for shoulder pain than subjects with PP. Higher muscle strength and higher functional outcome are related to fewer upper extremity complaints.     

Metabolic fate of fatty acids in type II cells isolated from adult rat lung

The present study is concerned with the metabolic fate of palmitate, oleate and linoleate in isolated rat lung type II cells. The cells readily oxidize the exogenously supplied fatty acids to CO₂ and incorporate them into lipids. The distribution between the pathways of oxidation and esterification is similar for saturated and unsaturated fatty acids. The majority of the fatty acids taken up by the cells is utilized for lipid synthesis. The fatty acids are incorporated preferentially into phospholipids, particularly into phosphatidylcholine. Addition of unsaturated fatty acids decreases the utilization of palmitate by type II cells. The distribution of palmitate between oxidation and esterification is not altered in the presence of unsaturated fatty acids. Addition of carnitine stimulates the fatty acid oxidation and decreases the esterification of fatty acids.     

Adjunctive corticosteroids for <Emphasis Type="Italic">Pneumocystis jiroveci</Emphasis> pneumonia in patients with HIV infection: a meta-analysis of randomised controlled trials

Background  

The objective of this study was to review the effects of adjunctive corticosteroids on overall mortality and the need for mechanical ventilation in HIV-infected patients with Pneumocystis jiroveci pneumonia (PCP) and substantial hypoxemia (arterial oxygen partial pressure <70 mmHg or alveolar-arterial gradient >35 mmHg on room air).     

Acute Q fever and brachial neuritis: case report and literature review

Peripheral nervous system complications of Q fever are uncommon. A case of electrophysiologically documented brachial neuritis occurring during acute Coxiella burnetii infection is reported. The relevant literature is reviewed. Received: June 6, 2001 · Revision accepted: July 8, 2002 J. J. Post (corresponding author)     

How epidemiology contributes to the management of spinal disorders

Back pain constitutes a nearly universal experience, Point, one-year period and lifetime prevalence reach or exceed, in some European countries, 40%, 70% and 80%, respectively. No health care system is able to cope with the entire quantity and spectrum of cases. Clinically useful distinctions are urgently required. A basic classification distinguishes specific from non-specific cases. Non-specific back pain may then be graded on its actual severity in terms of pain intensity and disability. This already implies limited prognostic information. Staging assumes a more or less unidirectional course with definable phases and transition periods and definitely adds to prognosis (cf. the TNM-system in oncology). So far there seems to be no generally accepted staging system for chronic back pain, although some promising proposals can be presented. The disorder, once it has become chronic, has a rather unfavourable prognosis, although single episodes still have a high probability of completely resolving within a few weeks. An underestimated risk factor for a chronic-disabling course of current back pain is (besides its acute grade and stage) its previous history.     

Kriterien der Deutschen Gesellschaft für Kardiologie – Herz- und Kreislaufforschung für „Chest-Pain-Units“

The Chest Pain Unit (CPU) Task Force of the German Cardiac Society has elaborated prerequisites for a CPU certification program. To become a certified CPU, a facility must have 24-h cath lab capabilities, 24-h access to clinical chemistry, at least four intermediate care beds, and the capability for echocardiography, computed tomography (CT), magnetic resonance imaging (MRI) and abdominal ultrasound. The transfer time from the CPU to the cath lab should not exceed 15 minutes. The facility must demonstrate well-defined processes to evaluate moderate- and low-risk patients with chest pain that minimize unnecessary admissions and inappropriate discharges. This means that CPUs must have well-defined pathways when an acute coronary syndrome (ACS) patient arrives at their facility, including ST-segment elevation myocardial infarction (STEMI), non-STEMI (NSTEMI), unstable angina (UA) and low-risk patients. Nurses and doctors in the CPU should have education and training opportunities and undergo practice drills. Doctors should have a sound knowledge of echocardiography and intensive care medicine. The Chest Pain Unit must be headed by a cardiologist.     

The perfused rat lung as a model for studies on the formation of surfactant and the effect of Ambroxol on this process

The isolated perfused rat lung was used as a model to investigate the synthesis of surfactant phospholipids from various radioactive precursors and the effect of Ambroxol, a bronchial secretolyticum, on this process. Lungs were ventilated and perfused for periods up to 5 h without detectable development of pulmonary edema. The lungs remained metabolically stable during the entire period of perfusion. Both in whole lung tissue and in the surfactant fraction the radioactive substrates incorporated predominantly into phosphatidylcholine and phosphatidylglycerol. The degree of saturation of labelled phosphatidylcholines synthesized during perfusion with [Me-¹⁴C]choline, D [U-¹⁴C]glucose, [1(3)-³H]glycerol and [1-¹⁴C]palmitate was higher in surfactant than in whole lung tissue. A delayed incorporation into surfactant phospholipids was observed for all precursors. Under the conditions employed, glucose carbon was recovered mainly in the glycerol backbone of phosphatidylcholine and phosphatidylglycerol. Compared to glucose, glycerol appeared to be a minor substrate for lung lipid formation. If the lungs were perfused after pretreatment of the rats with Ambroxol on three consecutive days, the incorporation of labelled choline and glycerol into pulmonary phospholipids was found to be enhanced. This stimulation was more pronounced in the surfactant fraction than in whole lung tissue. The stimulatory effect on the formation of surfactant lipids was smaller after pretreatment of the animals with Ambroxol for one day. The results of the present study suggest that Ambroxol may specifically stimulate the synthesis of phospholipids in the alveolar type II cells and that the drug may not only affect the formation but also the secretion of surfactant lipids by these cells.