Ascites,pleural, and pericardial effusions in acute pancreatitis

Ascites and pleural and pericardial effusions can be observed during acute pancreatitis. The aims of this study were to evaluate their incidence, natural history, and prognostic role in patients with acute pancreatitis. One hundred patients consecutively admitted with a diagnosis of acute pancreatitis were prospectively submitted to abdominal, pleural, and cardiac ultrasonography at admission and during follow-up. Ascites was found in 18 patients, pleural effusion in 20, and pericardial effusion in 17. Twenty-four patients of this series had severe pancreatitis; three of them died. All effusions disappeared spontaneously in patients who survived pancreatitis up to two months after dismissal. At multivariate analysis ascites and pleural effusion were demonstrated to be accurate independent predictors of severity. The respective odds ratios were 5.9 [95% confidence interval (CI), 1.5–23.0%) and 8.6 (95% CI, 2.3–32.5%). Furthermore the presence of pleural effusion, ascites, and pericardial effusion were associated with an increased incidence of pseudocyst during follow-up. Ascites and pleural and pericardial effusions are frequent during acute pancreatitis. Pleural effusion and ascites are accurate predictors of severity in these patients.     

Effect of a high-carbohydrate, low-saturated-fat diet on apolipoprotein B and triglyceride metabolism in Pima Indians.

The mechanisms by which high-carbohydrate, low-saturated-fat diets lower LDL cholesterol (LDLC) concentrations are unknown. In this study, kinetics of VLDL, intermediate density lipoprotein (IDL), and LDL apoprotein B and VLDL triglyceride were determined in seven nondiabetic (ND) and seven non-insulin-dependent diabetic (NIDDM) Pima Indian subjects on high-fat and high-carbohydrate (HICHO) diets. Metabolic changes were similar in ND and NIDDM. On the HICHO diet, LDLC decreased (131 +/- 8 vs. 110 +/- 7 mg/dl, P less than 0.0001) in all subjects. Mean fasting and 24-h triglyceride (TG) concentrations were unchanged, as were mean production rates and fractional clearance rates (FCR) of VLDL apoB and VLDL TG. The mean VLDL apoB pool size (303 +/- 20 vs. 371 +/- 38 mg, P = 0.01) increased owing to a decrease in the mean transport rate (10.7 +/- 1.1 vs. 8.4 +/- 0.9 mg/kg fat-free mass (ffm) per day, P less than 0.0001) and the mean rate constant (2.3 +/- 0.2 vs. 1.5 +/- 0.2, P less than 0.001) for the VLDL apoB to IDL apoB conversion pathway. The mean transport rate of VLDL apoB to LDL apoB via IDL (10.2 +/- 0.9 vs. 8.0 +/- 0.8 mg/kg ffm per day, P less than 0.001) decreased. Mean LDL apoB concentrations decreased (70 +/- 5 vs. 61 +/- 5 mg/dl, P less than 0.001) on the HICHO diet. Means for total LDL apoB transport rate, LDL apoB FCR, and LDLC/apoB ratios were unchanged. In summary, the HICHO diet decreased the activity of mechanisms that convert VLDL to LDL, which contributed to the decrease in LDLC in all subjects. There was also evidence in some subjects for increased activity of LDL apoB clearance mechanisms, and a decrease in the LDLC to apoB ratio.     

Evolution of the minimally invasive treatment of esophageal achalasia

Thanks to the advent of laparoscopic techniques, the last decade and a half have witnessed a radical change in the treatment of esophageal achalasia. Because of the high success rate of the laparoscopic Heller myotomy, surgery has now become in many centers the first modality of treatment for achalasia. This shift in the treatment algorithm reflects the fact that laparoscopic Heller myotomy with partial fundoplication outperforms nonsurgical approaches, such as balloon dilatation and intrasphincteric botulinum toxin injection.     

Successful treatment of severe aplastic anemia by bone marrow transplantation from HLA nonidentical family members: preliminary results utilizing cyclophosphamide and 600 cGY fractionated total body irradiation

We have performed bone marrow transplants on four children with severe aplastic anemia who lacked an human leukocyte antigen (HLA)-identical sibling donor. Patients were prepared with cyclophosphamide and 600 cGy fractionated total body irradiation, and then received marrow from a parent donor mismatched for one (two patients), two (one patient), or three (one patient) HLA antigens. All four patients engrafted. One died early of acute graft-versus-host disease. The three others showed sustained complete hematopoietic reconstitution. Two are alive and hematologically normal 43-87 months after transplant. Both have had acute and chronic graft-versus-host disease (CGVHD), and one of the two remains on immunosuppressive drugs. The fourth died at 48 months after transplant of CGVHD. The previous experience with HLA-incompatible marrow transplants is reviewed, and the rationale for this preparative regimen is discussed. Cyclophosphamide and 600 cGy fractionated total body irradiation is an effective preparative regimen for children with severe aplastic anemia receiving transplants from HLA-nonidentical parental donors, allowing engraftment and full hematologic reconstitution.     

Buffy coat transfusions in neutropenic neonates with presumed sepsis: a prospective, randomized trial

Neonatal sepsis, accompanied by neutropenia, is associated with a high mortality. To determine whether granulocyte transfusions improve the survival of critically ill neutropenic infants, we prospectively randomized 25 infants to transfusion and nontransfusion groups, matching for birth weight (less than or equal to 1,500 g or greater than 1,500 g). Infants with necrotizing enterocolitis were randomized separately. Neutropenia was established by two successive absolute neutrophil counts less than or equal to 1,500 cells prior to randomization. The transfusion (n = 12) and nontransfusion (n = 13) groups did not differ with respect to clinical or hematologic characteristics. In 23 of 25, bone marrow aspirations were performed to determine the percentage of neutrophil storage pool. Granulocyte transfusions of buffy coats from single units of whole blood (0.1 to 0.9 X 10(9) polymorphonuclear leukocytes per kilogram) were given daily until the absolute neutrophil count increased to more than 1,500/microL. Only five infants, mostly those with necrotizing enterocolitis, required more than one transfusion. A circulating immature to total neutrophil ratio (I:T) greater than or equal to 0.80 was not predictive of an infant with a neutrophil storage pool less than or equal to 7%, and neither an I:T less than 0.80 nor a neutrophil storage pool greater than 7% were predictive of survival. Granulocyte transfusions did not improve survival when either comparing the whole group, those 17 infants with cultures positive for bacteria or viruses, the 19 infants with a circulating I:T greater than or equal to 0.80, or the nine infants with a neutrophil storage pool less than or equal to 7%.(ABSTRACT TRUNCATED AT 250 WORDS)     

Silicone gel breast implant rupture rates: research issues.

Documenting the rate of rupture of silicone breast implants appears to be deceptively easy. Largely because of the phenomenon of "silent rupture," it isn't. The authors explore the various technical biases (selection, misclassification, and confounding) and methodological problems that have plagued much of the research conducted to date. By means of a series of illustrations, they argue that explantation has limited utility. Noninvasive techniques have to be used to gather the proper type of data on the timing and frequency of these events. Only with the proper incidence data will researchers be able to identify better the different mechanisms underlying implant rupture and the relative importance of each. The authors recommend that better and standardized definitions of implant rupture be developed, that greater recognition be given to the technical biases and a greater effort be made to eliminate them from investigations of implant rupture, and that more research be conducted by multidisciplinary teams. Because of the growing awareness of the complexity of this issue, the authors also recommend that properly constituted advisory teams be used to provide comprehensive oversight of future research projects from beginning to end.     

Gastroesophageal reflux disease (GERD) and chest pain

Background

Laparoscopic fundoplication cures heart-burn and regurgitation in patients with gastroesophageal reflux disease (GERD) but its effect on the chest pain that is also experienced by some patients is less clear. Confusion stems from the fact that it is difficult to determine preoperatively whether the chest pain is actually caused by the reflux. Therefore, we designed a study in patients with GERD and chest pain that would assess the value of pH monitoring in establishing a correlation between the symptom and the disease, the predictive value of pH monitoring on the results of surgical treatment, and the outcome of laparoscopic fundoplication on chest pain in patients with GERD.

Methods

Of 487 patients who underwent laparoscopic fundoplication for GERD at our institution between October 1992 and July 2000, 165 (34%) complained of chest pain in addition to heartburn and regurgitation. Their symptoms had been present for an average of 118 months. The pH monitoring tracings were analyzed for a correlation between episodes of reflux and chest pain. The mean length of follow-up was 13 months.

Results

Among the 165 patients with chest pain, the relationship between pain and reflux during pH monitoring was as follows: 39 patients (group A) experienced no chest pain during the study; in 28 patients (group B), chest pain correlated with reflux in ≥40% of instances; in 98 patients (group C), chest pain correlated with reflux in ≥40% of instances. Chest pain improved post-operatively in 65% of group A patients, 79% of group B patients, and 96% of group C patients (group C vs A and B: p<0.05). Heartburn and regurgitation resolved or improved in 97% and 95% of patients, respectively.

Conclusions

These data show that pH monitoring helped to identify a relationship between chest pain and reflux; and when the two coincided, the chest pain was relieved by antireflux surgery.

     

Sublethal actions of copper in abalone (Haliotis rufescens) as characterized by in vivo 31P NMR

The sublethal biochemical actions of copper in live, intact red abalone (Haliotis rufescens) were characterized by in vivo 31P nuclear magnetic resonance spectroscopy (NMR). This non-invasive technique is ideal for examining cellular respiration since critical metabolite concentrations, including phosphoarginine ([PA]), inorganic phosphate ([P(i)]) and [ATP], and the arginine kinase (AK) rate constant, can be monitored in real time. Both metabolite concentrations and enzyme rate constants were measured in abalone during 8-h exposures to 66 microg l(-1) (1.04 microM) and 126 microg l(-1) (1.98 microM) copper (as CuCl2). Significant decreases in [PA] and corresponding increases in [P(i)] resulted, while [ATP] remained constant. In controls [PA], [P(i)] and [ATP] all remained unchanged. Furthermore, both copper concentrations induced a significant elevation in the forward AK rate constant over the basal value of 0.020 +/- 0.002 s(-1). Metabolite levels and enzyme rate constants were also measured during 8-h 66 microg l(-1) copper exposures both before and after a 2-week subchronic exposure to 36 microg l(-1) (0.57 microM) copper. Unlike before the subchronic exposure, no significant changes in [PA], [P(i)] or [ATP] were observed after the 36 microg l(-1) copper treatment, compared with controls. This induced tolerance was also evident from the forward AK rate constant data. Finally, copper accumulation was determined in gill, digestive gland and foot muscle samples. Whereas acute exposure only led to significant accumulation in the gill, copper levels in subchronically exposed abalone were significantly elevated in both the gill and digestive gland, and marginally so in foot muscle. Overall, the gill appears to be the primary site of copper accumulation and toxicity, while the foot and adductor muscles maybe secondarily impacted. The observed metabolic changes may result from insufficient oxygen delivery to the muscles, resulting from mucus accumulation or cytological damage at the gill. In conclusion, abalone acutely exposed to copper pollution may develop asphyxial hypoxia. Since their survival is dependent on adherence to rock surfaces, such a reduction of muscle function could ultimately prove fatal.