Emergency hospitalization for acute, non-accidental abdominal pain. Prospective data of a surgical university clinic

During a 19-month period 549 patients (278 women, 271 men) suffering from abdominal pain unrelated to trauma (mean age 48.2 years) entered the emergency room of the Department of Surgery of the University Hospital Zürich. 43% presented during business hours, whereas 57% were admitted during nighttime and/or weekends. Clinical examination, abdominal roentgenograms (upright and supine) as well as sonography were the most commonly used diagnostic tools. 40% suffered from abdominal pain of unknown cause. The most common diagnosis on admission was appendicitis. Only half of these cases really proved to be an appendicitis. In 36% the diagnosis on admission corresponds both to the initial diagnosis made by a member of staff during his first visit, as well as to the final diagnosis. The initial diagnosis agrees in 57% with the final diagnosis. In 10% of the patients the cause of pain was not elucidated despite extensive diagnostic procedures. High technology and sophisticated diagnostics are less important than the clinical evaluation. The decision between operative or nonoperative treatment was mainly based on clinical findings.     

Endocannabinoid anandamide mediates hypoxic pulmonary vasoconstriction

Endocannabinoids are important regulators of organ homeostasis. Although their role in systemic vasculature has been extensively studied, their impact on pulmonary vessels remains less clear. Herein, we show that the endocannabinoid anandamide (AEA) is a key mediator of hypoxic pulmonary vasoconstriction (HPV) via fatty acid amide hydrolase (FAAH)-dependent metabolites. This is underscored by the prominent vasoconstrictive effect of AEA on pulmonary arteries and strongly reduced HPV in FAAH^−/− mice and wild-type mice upon pharmacological treatment with FAAH inhibitor URB597. In addition, mass spectrometry measurements revealed a clear increase of AEA and the FAAH-dependent metabolite arachidonic acid in hypoxic lungs of wild-type mice. We have identified pulmonary vascular smooth muscle cells as the source responsible for hypoxia-induced AEA generation. Moreover, either FAAH^−/− mice or wild-type mice treated with FAAH inhibitor URB597 are protected against hypoxia-induced pulmonary hypertension and the concomitant vascular remodeling in the lung. Thus, the AEA/FAAH pathway is an important mediator of HPV and is involved in the generation of pulmonary hypertension.Endocannabinoids have been shown to induce vasorelaxation in systemic vessels which is primarily mediated by the specific cannabinoid 1 and 2 (CB1/CB2) and also other G protein-coupled receptors (e.g., non-CB1/CB2 receptors) (1, 2). Based on these results, especially CB1 receptors have been proposed as promising therapeutic targets for the treatment of arterial hypertension (2). Endocannabinoids are also known to potentially act via their intracellular enzymatic metabolization by the fatty acid amide hydrolase (FAAH) or monoacylglycerol lipase (MAGL) to (vaso)active intermediates (3, 4), but these pathways are considered less important for the regulation of vascular tone in systemic vessels.Pulmonary arteries are unique because of their prominent vasoconstriction in response to hypoxia. Hypoxic vasoconstriction is responsible for adapting perfusion to ventilation in the lungs and therefore also plays an important role in pathophysiological situations characterized by a high ventilation/perfusion mismatch such as acute lung injury or liver cirrhosis (5, 6). In addition, this mechanism potentially contributes to the onset of pulmonary hypertension in response to hypoxia occurring in high altitude or in various respiratory diseases such as chronic obstructive pulmonary disease or fibrosis (7–9). Pulmonary arterial smooth muscle cells are suggested to play a major role in hypoxic vasoconstriction (10), but the precise mechanisms and the underlying signals are still not well understood. Earlier experimental evidence suggested that the endocannabinoid anandamide (AEA) can either enhance (11) or reduce (12) pulmonary arterial tone, and this prompted us to reexplore the role of endocannabinoids in basic physiological and pathophysiological responses of pulmonary arteries using experimental in vitro, ex vivo, and in vivo approaches.     

ACE Journal Watch From ACE (Alliance for Clinical Education) Review of Medical Education Articles in Family Medicine, 2008–2009

Background: We administered selected scales from the Cognitive Behavior Survey, Attitudes Toward Social Issues in Medicine survey, and Learning Environment Questionnaire. We gathered data from other medical schools to put our results into context.

Purpose: To present results on these scales from our own and other medical schools to identify the effects of "year in school" on the results.

Methods: We searched for articles that had cited the articles that originally presented the scales we used. We organized the results by type of curriculum and presented data from multiple points in each course.

Results: With a few exceptions, the data suggest that students' perceptions of their cognitive behaviors, their attitudes to social issues in medicine, and their impressions of the medical school learning environment deteriorate as they proceed through the course. In the case of PBL and hybrid curricula, this may represent a reversal of gains conferred by these curricula during the early phases of the course.

Conclusions: These data provide a starting point for further study of some of the influences on students' perceptions of medical curricula as they proceed through the course.     

Effects of creatine supplementation in cystic fibrosis: results of a pilot study

BACKGROUND: The CF transmembrane conductance regulator (CFTR), whose mutations cause cystic fibrosis (CF), depends on ATP for activation and transport function. Availability of ATP in the cell and even more in specific cellular microcompartments often depends on a functional creatine kinase system, which provides the 'energy buffer' phosphocreatine. Creatine supplementation has been shown to increase phosphocreatine levels, thus promoting muscle growth and strength in athletes and having protective effects in neuromuscular disorders. AIM: To test clinically, if creatine supplementation improves maximal isometric muscle strength (MIMS), lung function and CFTR channel activity in patients with CF, and to determine enzymatic activity of creatine kinase in respiratory epithelial cells. METHODS: In an open-label pilot study 18 CF patients (8-18-year-old) with pancreatic insufficiency and mild to moderate lung disease received daily creatine supplementation during 12 weeks. Patients were monitored during 24-36 weeks. Enzymatic activity of creatine kinase was measured in primary epithelial cell cultures. RESULTS: After creatine supplementation, there was no change in lung function and sweat electrolyte concentrations, possibly due to the very low creatine kinase activities detected in respiratory epithelia. However, the patients consistently showed significantly increased MIMS (18.4%; P < 0.0001), as well as improved general well-being, as assessed by a standardized questionnaire. Except for one patient with transient muscle pain, no side effects were reported. CONCLUSIONS: Our pilot study suggests, that creatine supplementation should be further evaluated as a possible clinically beneficial adjuvant therapy for patients with CF to increase muscle strength, body-weight and well-being.     

Combined regional thrombolysis and surgical thrombectomy for treatment of iliofemoral vein thrombosis

OBJECTIVE: In at least half of patients with iliofemoral deep vein thrombosis post-thrombotic syndrome develops when only anticoagulant therapy is given. We combined thrombolysis, applied under ischemic conditions,with surgical thrombectomy to restore patency and valve function. The technique and the short-term and long-term results in 2 patient series are reported. METHODS: A catheter was inserted into a foot vein of the thrombosed leg, and the limb was excluded from the circulation with a pneumatic cuff placed on the thigh with the patient under general anesthesia. Urokinase (0.5 million-3 million IU) and heparin were infused and allowed to act for 30 minutes while the pelvic axis was cleared with a Fogarty catheter through an inguinal venotomy. The external iliac vein was then clamped and the cuff removed. Thrombi that detached from the wall were flushed out with reactive hyperemia and squeezed out with manual leg compression. The blood was retrieved, washed, and transfused back into the patient. Various additional procedures were performed to secure outflow. Two patient series are reported: 1 with 12 consecutive patients and 1 with 21 patients who were successfully treated 6 to 10 years previously. Follow-up data were obtained for all patients after 1 year and for 18 of 21 patients after 6 to 10 years. Patency and valve function were assessed with duplex scanning or venography. Studies of blood coagulation and the kinetics of urokinase were performed in 5 additional patients. RESULTS: Vein patency and valve function were restored in all consecutive patients. At 1 year none of the 33 patients had had recurrence, and none showed clinical signs of post-thrombotic syndrome. At 6 to 10 years 3 of 18 patients had experienced another venous thromboembolism, but none in the treated leg. Sixteen legs were asymptomatic without compression therapy, and 2 had venous claudication. Coagulation studies showed a trace concentration of urokinase and a mild decrease in fibrinogen in the systemic circulation. The concentration of urokinase in blood collected from the treated leg was only 1% of that infused. CONCLUSION: Regional thrombolysis combined with surgical thrombectomy is relatively easy to perform and seems safe. Vein patency and valve function were restored, and post-thrombotic syndrome was prevented. Additional procedures to overcome pelvic vein obstructions were required in 11 of 33 patients (33%). The procedure should be tested against standard anticoagulation therapy in patients with acute iliofemoral thrombosis.