Pneumoperitoneum after percutaneous endoscopic gastrostomy among adults in the intensive care unit: incidence, predictive factors, and clinical significance

The significance of post percutaneous endoscopic gastrostomy (PEG) pneumoperitoneum (PNP) is unclear. We studied patients in our intensive car unit who underwent PEG placement to better understand the significance of post PEG PNP at our institution. We identified all intensive care unit patients who underwent PEG placement between the years of 2000 and 2009. A review of 318 consecutive PEG procedures was performed. Radiographic imaging was reviewed for up to 14 days post PEG, noting the presence of PNP. The presence of common comorbidities and PEG-related complications were recorded. Of the 318 patients, radiologic imaging was not taken within 14 days in 37 patients. Forty-five patients were found to have PNP on imaging for an incidence of 16 per cent (45/281). Eight patients were found to require either surgical or endoscopic emergent intervention post PEG. Four of these had PNP on imaging. Post PEG PNP was associated with increased likelihood for complications requiring emergent surgical intervention (P = 0.0078) and 30-day mortality post PEG insertion (P = 0.0216). The presence of common comorbid conditions was not a significant determinant of post PEG PNP.     

Open Versus Robotic Radical Prostatectomy in Obese Men

Objectives

Robotic-assisted radical prostatectomy (RARP) has been shown to reduce blood loss, peri-operative complications and length of stay when compared to open radical prostatectomy (ORP). We sought to determine whether the reported benefits of RARP over ORP translate to obese patients.

Patients and Methods

We utilized the 2009–2010 Nationwide Inpatient Sample to identify all obese men with prostate cancer who underwent ORP and RARP. Our primary outcome was the presence of a peri-operative adverse event (i.e. blood transfusion, complication, prolonged length of stay). We fit multivariable logistic regression models to examine whether RARP in obese patients was independently associated with decreased odds of all three outcomes.

Results

We identified 9,108 obese patients who underwent radical prostatectomy. On multivariable analysis, the use of RARP in the obese population was not independently associated with decreased odds of developing a peri-operative complication (OR = 0.81, CI: 0.58–1.13, p = 0.209). RARP was, however, associated with decreased odds of blood transfusion (OR = 0.17, CI: 0.10–0.30, p < 0.001) and prolonged length of stay (OR = 0.28, CI: 0.20–0.40, p < 0.001).

Conclusion

Our findings suggest that in obese patients, the use of RARP may reduce length of stay and blood transfusions compared to ORP. Both approaches, however, are associated with similar odds of developing a complication.Key Words: Obesity, Prostatectomy, Prostate cancer, Robotic surgery     

Apneic oxygenation during prolonged laryngoscopy in obese patients: a randomized,controlled trial of nasal oxygen administration

Study ObjectiveTo evaluate the influence of nasal oxygen (O₂) administration on the duration of arterial oxygen saturation (SpO₂) ≥95% during simulated difficult laryngoscopy in obese patients.DesignProspective, randomized, controlled trial.SettingUniversity hospital.Patients30 obese men undergoing general anesthesia.InterventionsAfter thorough preoxygenation, and using total intravenous anesthesia, simulated difficult laryngoscopy was performed, with half the patients receiving additional nasal O₂ during apnea.MeasurementsDuration of SpO₂ ≥95% was measured up to a maximum of 6 minutes. Lowest SpO₂ values and time to regain 100% SpO₂ (resaturation time) also were recorded.Main ResultsNasal O₂ administration was associated with significant prolongation of SpO₂ ≥95% time (5.29 ± 1.02 vs. 3.49 ± 1.33 min, mean ± SD), a significant increase in patients with SpO₂ ≥95% apnea at 6 minutes (8 vs. one pt), and significantly higher minimum SpO₂ (94.3 ± 4.4% vs. 87.7 ± 9.3%). Resaturation times were no different between the groups.ConclusionsNasal O₂ administration is associated with significant increases in frequency and duration of SpO₂ ≥95%, and higher minimum SpO₂ during prolonged laryngoscopy in obese patients.     

Bleeding complications after dual antiplatelet therapy with ticagrelor versus dual antiplatelet therapy with clopidogrel—a propensity-matched comparative study of two antiplatelet regimes in off-pump coronary artery bypass grafting

PurposeTicagrelor combined with aspirin had shown better saphenous vein graft patency than aspirin with clopidogrel after off-pump coronary artery bypass grafting. However, the safety of this drug in regard to bleeding complications remains unknown. The aim of our study was to assess the bleeding complications of dual antiplatelet therapy with aspirin and ticagrelor compared with aspirin and clopidogrel within the first 3 months after off-pump surgery.MethodsThree hundred eighty-two consecutive patients who were prescribed aspirin with ticagrelor (ticagrelor group) were compared with 660 patients who received aspirin and clopidogrel (clopidogrel group). After propensity matching, 144 patients in each group were compared for bleeding events and major adverse cardiac and cerebral events. Major bleeding was defined as composite outcome of re-exploration for bleeding, any fatal bleeding, intracranial bleeding, and any bleeding requiring hospitalization.ResultsPatients in the ticagrelor group had more incidence of re-exploration for bleeding (p = 0.042), pericardial effusion requiring drainage (p = 0.007), readmissions (p < 0.01), gastrointestinal bleeding (p = 0.01), and major bleeding (5.8% vs. 2.1%, p < 0.01, OR 2.8 (1.43–5.58)). After propensity analysis, gastrointestinal bleed (p = 0.024), major bleeding (7.6% vs.1.4%, p < 0.001, OR 5.8 (1.28–26.97)), length of ICU stay (p = 0.039), and readmissions (p = 0.003, OR 11.83 (1.51–92.86)) were more in the ticagrelor group. Major adverse cardiac and cerebral events were similar between the groups.ConclusionDual antiplatelet therapy with aspirin and ticagrelor increased gastrointestinal bleeding events, major bleeding events, and readmission rates compared with aspirin and clopidogrel after off-pump coronary artery bypass grafting.     

Collagen synthesis is not altered in women with stress urinary incontinence

AIMS: The objective of this study was to demonstrate that weakened pelvic floor support of the lower genitourinary tract in women with stress urinary incontinence (SUI) is due, in part, to decreased collagen synthesis and secretion and/or an altered ratio of collagen III/I synthesis by the fibroblasts of the endopelvic fascia and skin compared to that of women without evidence of pelvic floor weakening. METHODS: Endopelvic fascia and skin biopsies were obtained from women with SUI (n = 14) and women without evidence of SUI or genital prolapse (n = 12). Fibroblast cultures established from the biopsies were incubated with 3H-proline in medium containing ascorbic acid for 3 hr. Conditioned medium was collected and cells were harvested. The radiolabeled collagens were precipitated and digested with collagenase. The collagen synthesized (as a percent of total protein) was determined. Collagen alpha1(III) was separated from collagen alpha1(I) and alpha2(I) by interrupted SDS-PAGE and the amount of (3)H-proline in each band was determined. RESULTS: Collagen synthesis, expressed as percent of total protein synthesis, was not significantly different between fibroblasts obtained from women with or without SUI. The mean of collagen III/I synthesized in fibroblasts was not significantly different between fibroblasts obtained from women with or without SUI. CONCLUSIONS: These data suggest that the lower collagen content in the endopelvic fascia and skin of women with SUI is not due to reduced collagen synthesis or selective reduction in synthesis of either collagen I or collagen III, compared to women without pelvic floor weakening.     

Primary spinal extradural hydatid cyst causing spinal cord compression

Primary spinal hydatid disease is rare and represents an uncommon but significant manifestation of hydatid disease. We report a case of primary intraspinal extradural hydatid cyst of the thoracic region causing spinal cord compression. The presenting symptoms were mostly atypical and the diagnosis was established preoperatively on the basis of magnetic resonance imaging. The patient underwent surgery resulting in complete recovery and is recurrence-free after 24 months follow-up.     

Growth hormone response to L-Dopa in diabetes mellitus

Summary The effect of a single oral dose of 0.5 g L-Dopa on the serum levels of human growth hormone (HGH) was studied in 38 diabetics and 15 age and sex matched control subjects. The diabetics were divided into three clinical sub-groups:a) juvenile diabetics, 15;b) maturity onset diabetics, 15; andc) insulin dependent diabetics admitted in a state of ketoacidosis, 8. L-Dopa-induced HGH secretion in juvenile and maturity onset diabetics was studied before and after the control of diabetes mellitus. HGH was estimated by a homologous double antibody radioimmunoassay. The fasting serum HGH in maturity onset diabetics did not differ significantly from that of control subjects; it was significantly higher in juvenile diabetics and in ketotic diabetics during ketosis and after the control of diabetes. In juvenile diabetics the mean fasting serum HGH level decreased after the control of diabetes but was still significantly higher than in normal subjects. L-Dopa caused a significant rise in serum HGH in 14 control subjects. Among the diabetics the HGH response to L-Dopa was either absent or markedly attenuated in the uncontrolled state. After the control of diabetes a significant improvement in HGH response to L-Dopa was evident in juvenile diabetics but no improvement was seen in maturity onset diabetics. There is thus a considerable derangement in HGH secretion in diabetes mellitus. The various possibilities are discussed.     

Implant Retained Auricular Prosthesis with a Modified Hader Bar: A Case Report

Auricular prostheses for defects of external ear are retained either by mechanical means or implants. All implant retained prostheses are retained by various means such as bar and clip, magnetic attachments or a combination of bar, clip and magnets. The commonest problem encountered with the bar and clip system is loosening of the clip after 3–4 months. When magnets are used as retaining component they tend to corrode over a period of time. So various alternative retention methods which possess good retentive qualities, ease of reparability and patient friendly were tried. In the present case a newly modified Hader bar design which can act as an additional retentive feature apart from the clip is employed to increase retention. The major advantages in the modified Hader bar system were that only two implants were employed, the additional loops in the Hader bar prevented micro movements and the retentive acrylic locks were easy to repair if broken. The modified Hader bar has anti-rotational slots which prevents the sliding or rotation of the prosthesis which gave new confidence to the patient who was otherwise worried of inadvertent displacement of the ear prosthesis while playing.     

Serous macular detachment associated with dysplastic disc

The article describes a case of abnormal looking optic disc (dysplastic) associated with serous macular detachment similar to what is described in cases of optic pit. However clinically as well as on fluorescein angiography, no optic pit or coloboma could be identified. Gas injection, prone positioning and laser along the temporal border of the disc could correct the macular detachment.