Zero mortality after 152 consecutive pancreaticoduodenectomies with pancreaticogastrostomy

BACKGROUND: Since 1968, there have been three published reports in the United States literature of 41, 118, and 145 consecutive patients undergoing pancreaticoduodenectomy without mortality. In all of these series, the pancreatic remnant was anastomosed to the jejunum. STUDY DESIGN: This study was designed to review 152 consecutive patients who underwent pancreaticoduodenectomy in whom the pancreatic remnant was anastomosed to the stomach (pancreaticogastrostomy). RESULTS: A total of 152 patients underwent pancreaticoduodenectomy with pancreaticogastrostomy between July 1992 and May 2002. There were 85 men and 67 women with a mean age of 65.7 years (range 31 to 90 years). Of the patients, 87 were less than 69 years of age and 65 were more than 69 years. A total of 114 patients had a malignant neoplasm and the remaining 38 had either cystic neoplasms or benign disease. When the two groups were compared, the patients who were more than 69 years of age had a significantly high incidence of hypertension, previous cancer, atrial fibrillation, and coronary artery disease. In addition, patients more than 69 years of age had a significantly high incidence of jaundice and placement of preoperative stents. Patients more than 69 years of age had significantly less operative time but there was no between-group difference in estimated blood loss, transfusion, number of units transfused, and postoperative length of stay. There was no postoperative mortality [corrected] in this series. Pancreatic leak and fistulae were the most common complications, followed by intraabdominal abscess, wound infection, and delayed gastric emptying. CONCLUSIONS: In this study, 152 consecutive patients underwent pancreaticoduodenectomy with pancreaticogastrostomy without postoperative mortality. Morbidity was mostly because of pancreatic leaks and fistulae, which were successfully treated nonoperatively. With proper selection, careful preoperative preparation, and proper intraoperative conduct of operation, the Whipple procedure can be performed without postoperative mortality.     

Liposuction: a less invasive surgical method of debulking plexiform neurofibromas

BACKGROUND: Neurofibromatosis type 1 (NF1) is a common autosomal dominant disorder in humans. The hallmark of NF1 is development of neural tumors. Plexiform neurofibromas are a major source of morbidity associated with NF1. Surgical removal of these particular tumors is associated with a high risk of damage of surrounding vital structures as well as a risk of significant hemorrhage. Surgical debulking of tumors also sometimes leads to extensive scarring, which may be very disfiguring. OBJECTIVE AND METHODS: We report a novel approach to the surgical therapy of plexiform neurofibromas using liposuction in two patients. RESULTS: Debulking of plexiform neurofibromas with liposuction was successful in both patients. Postoperative follow-up 6 months later showed no evidence of tumor regrowth in either case. CONCLUSION: Liposuction may be a preferable surgical method for debulking of superficial plexiform neurofibromas in patients with NF1. This method is less invasive than conventional surgical tumor debulking.     

Effects of treating depression and low perceived social support on clinical events after myocardial infarction: the Enhancing Recovery in Coronary Heart Disease Patients (ENRICHD) Randomized Trial

Context  Depression and low perceived social support (LPSS) after myocardial infarction (MI) are associated with higher morbidity and mortality, but little is known about whether this excess risk can be reduced through treatment. Objective  To determine whether mortality and recurrent infarction are reduced by treatment of depression and LPSS with cognitive behavior therapy (CBT), supplemented with a selective serotonin reuptake inhibitor (SSRI) antidepressant when indicated, in patients enrolled within 28 days after MI. Design, Setting, and Patients  Randomized clinical trial conducted from October 1996 to April 2001 in 2481 MI patients (1084 women, 1397 men) enrolled from 8 clinical centers. Major or minor depression was diagnosed by modified Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria and severity by the 17-item Hamilton Rating Scale for Depression (HRSD); LPSS was determined by the Enhancing Recovery in Coronary Heart Disease Patients (ENRICHD) Social Support Instrument (ESSI). Random allocation was to usual medical care or CBT-based psychosocial intervention. Intervention  Cognitive behavior therapy was initiated at a median of 17 days after the index MI for a median of 11 individual sessions throughout 6 months, plus group therapy when feasible, with SSRIs for patients scoring higher than 24 on the HRSD or having a less than 50% reduction in Beck Depression Inventory scores after 5 weeks. Main Outcome Measures  Composite primary end point of death or recurrent MI; secondary outcomes included change in HRSD (for depression) or ESSI scores (for LPSS) at 6 months. Results  Improvement in psychosocial outcomes at 6 months favored treatment: mean (SD) change in HRSD score, -10.1 (7.8) in the depression and psychosocial intervention group vs -8.4 (7.7) in the depression and usual care group (P<.001); mean (SD) change in ESSI score, 5.1 (5.9) in the LPSS and psychosocial intervention group vs 3.4 (6.0) in the LPSS and usual care group (P<.001). After an average follow-up of 29 months, there was no significant difference in event-free survival between usual care (75.9%) and psychosocial intervention (75.8%). There were also no differences in survival between the psychosocial intervention and usual care arms in any of the 3 psychosocial risk groups (depression, LPSS, and depression and LPSS patients). Conclusions  The intervention did not increase event-free survival. The intervention improved depression and social isolation, although the relative improvement in the psychosocial intervention group compared with the usual care group was less than expected due to substantial improvement in usual care patients.      

Cognitively impaired older adults: risk profiles for institutionalization

BACKGROUND: This study focused on the identification of risk profiles for institutionalization among older adults diagnosed with cognitive impairment-not dementia or dementia in 1991/92 and subsequent institutionalization in the following 5-year period. METHODS: Data were from a sample of 123 individuals aged 65+ and their unpaid caregivers in Manitoba, Canada. Cluster analysis was conducted using baseline characteristics of age, cognition, disruptive behaviors, ADLs/IADLs, use of formal in-home services, and level of caregiver burden. RESULTS: Three distinct groups emerged (high risk [n = 12], medium risk [n = 40], and low risk [n = 71]). The high-risk group had the poorest cognitive scores, were the most likely to exhibit disruptive behaviors, were the most likely to need assistance with ADLs and IADLs, and had the highest level of burden among their caregivers. Follow-up of the groups validated the risk profiles; 75% of the high-risk group were institutionalized within the next 5 years, compared to 45% of the medium-risk group and 21% of the low-risk group. DISCUSSION: The risk profiles highlight the diversity among individuals with cognitive impairment and the opportunity for differential targeting of services for the distinct needs of each group.     

Perceived coercion at hospital admission and adherence to mental health treatment after discharge

The authors investigated whether mental health inpatients' perceptions of coercion were associated with later treatment adherence. Psychiatric inpatients receiving acute care at three sites were interviewed during their hospitalization and up to five times after discharge. Patients' perceptions of coercion were measured at admission. Adherence to medication and clinical treatment was measured every ten weeks for one year after discharge. Among the 825 patients who had a perceived coercion score and ten-week follow-up data and who reported that outpatient treatment was prescribed, perceived coercion scores were not associated with treatment adherence. The authors concluded that perceived coercion neither increases nor decreases psychiatric inpatients' medication adherence or use of treatment services after discharge.     

Concealment of psychopathology in forensic evaluations: a pilot study of intentional and uninsightful dissimulators

Dissimulation is the concealment of genuine psychiatric symptoms in an attempt to present a picture of psychiatric health. In this pilot study, the authors set out to demonstrate that defendants may conceal psychiatric illness even in forensic settings, contrary to their apparent self-interest. They reviewed their records for forensic assessments of dissimulators and malingerers and classified dissimulators as "intentional" or "uninsightful" depending on whether their concealment of symptoms appeared to be a volitional act or driven by a lack of insight. Although there were obvious diagnostic differences, the only other significant difference between malingerers and dissimulators was that malingerers were more likely to be facing charges related to financial crimes. Uninsightful dissimulators were significantly older than were intentional dissimulators. Uninsightful dissimulators were also more likely to be psychotic, particularly delusional and schizophrenic, than were intentional dissimulators. While forensic psychiatrists are vigilant in attempts to detect malingering, these data suggest that they should be equally vigilant regarding the possibility of dissimulation. Although further study is indicated, it appears that dissimulators are a heterogeneous group.     

Differential involvement of amygdaloid CRH system(s) in the salience and valence of the stimuli

Anxiety is a heterogeneous term encompassing not only state or trait characteristics but also a wide range of pathologies such as generalized anxiety disorders, phobias, panic and obsessive–compulsive disorders, acute stress disorder, and posttraumatic stress disorder. Given that diverse forms of anxiety exist, numerous animal models have been developed, which are considered to be useful in identifying mechanisms underlying anxiety states. Examples of such animal models include paradigms that assess the behavioral response to neurogenic (or painful stimuli) or psychogenic stressors or to cues that had previously been associated with painful stimuli. The present report presents data regarding the impact of stressors on corticotropin-releasing hormone (CRH), and relates these to changes in anxiety-like states. Specifically, we demonstrate that (1) psychogenic stressors influence the in vivo release of CRH at the central nucleus of the amygdala (CeA); (2) although CRH changes within the CeA are exquisitely sensitive to stressors, they are also elicited by positive stimuli; and (3) while treatment with diazepam attenuates behavioral signs of anxiety, the CRH release associated with a stressor is unaffected by the treatment. The position is offered that although release of CRH within the CeA is increased under stressful conditions, it is not a necessary condition for the consequent behavioral expression of anxiety-like reactions, at least not in minimally threatening situations. We suggest that the CRH responses at the CeA may be involved in a preparatory capacity and, as such, may accompany a range of emotionally significant stimuli, be they appetitive or aversive.     

Use of intracardiac echocardiography in guiding radiofrequency catheter ablation of atrial tachycardia in a patient after the senning operation

A patient with D-transposition of the great arteries developed drug refractory atrial tachycardia 12 years after a Senning operation. Electrophysiological study confirmed the presence of atrial baffle-tricuspid valve isthmus dependent reentrant intraatrial tachycardia. Intracardiac echocardiography facilitated initial identification of structures, catheter positioning, and identification of the atrial baffle-tricuspid valve isthmus.