Early oral feeding after elective abdominal surgery--what are the issues?

This review analyzes the literature and the historical concerns (restrictions, traditions, nasogastric tube) and pathophysiologic factors (postoperative ileus, risk of anastomotic dehiscence, nausea and vomiting, loss of appetite) invoked for not instituting early oral feeding after major abdominal procedures. It appears that several factors may promote postoperative oral feeding such as thoracic epidural analgesia, multimodal anti-emetic treatment, opioid-sparing analgesia, selective peripheral opioid antagonists, and enforced oral nutrition. Recent data from multimodal fast-track rehabilitation surgical programs in abdominal surgery provide a rational basis for future studies to investigate and facilitate enforced oral feeding after major abdominal procedures.     

Indolo[3,2-b]carbazole inhibits gap junctional intercellular communication in rat primary hepatocytes and acts as a potential tumor promoter

Indole-3-carbinol (I3C) is a naturally occurring substance that shows anti-carcinogenic properties in animal models. Besides its clear anti-carcinogenic effects, some studies indicate that I3C may sometimes act as a tumor promoter. Indolo[3,2-b]carbazole (ICZ), which is formed in the acidic environment of the stomach after intake of I3C, has a similar structure to, and shares biological effects with, the well-known tumor promoter 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD). Therefore, we hypothesized that ICZ could be responsible for the potential tumor-promoting activity of I3C. The aim of the present study was to investigate the effect of ICZ on gap junctional intercellular communication (GJIC) in primary cultured rat hepatocytes co-cultured with the rat liver epithelial cell line WB-F344. Indolo[3,2-b]carbazole inhibited GJIC in the rat hepatocytes in a dose- and time-dependent manner. Significant inhibition was observed after 8 and 12 h of treatment with 1 and 0.1 micro M ICZ, respectively. Maximum GJIC inhibition (cell-cell communication only 5% of control values) was observed after 24-48 h of ICZ treatment. Continued exposure to 1 micro M ICZ suppressed GJIC until approximately 120 h. Both ICZ and TCDD treatment reduced the Cx32 mRNA level as well as the plasma membrane Cx32 staining. Indolo[3,2-b]carbazole increased the Cyp1a1, Cyp1a2 and Cyp1b1 mRNA levels concurrently with an increase in 7-ethoxyresorufin O-deethylase (EROD) activities. Maximum EROD activity and Cyp1a1 mRNA levels were observed after approximately 12 h, whereas Cyp1a2 and Cyp1b1 mRNA levels peaked after 48 h. This study shows that ICZ may possess tumor promoter activity down-regulating GJIC by mechanisms, which seem to include activation of the Ah receptor and/or Cyp1 activity. Further studies are needed in order to clarify the anticarcinogenic/carcinogenic effects of I3C and ICZ before high doses of I3C may be recommended as a dietary supplement.     

Survival of severe congenital diaphragmatic hernia has morbid consequences

Background/Purpose

Fetal tracheal occlusion (TO) was developed in an attempt to enhance prenatal lung growth and improve survival in fetuses with severe congenital diaphragmatic hernia (CDH). We conducted a randomized, controlled clinical trial in 24 fetuses with severe left CDH (liver herniated into the thorax and low lung-to-head ratio) to compare survival after endoscopic fetal TO vs standard perinatal care (control) and prospectively followed up the 16 survivors (9 control, 7 TO) to compare neurodevelopmental, respiratory, surgical, growth, and nutritional outcomes.

Methods

At 1 and 2 years old, subjects underwent evaluation consisting of medical and neurological history and physical, developmental testing, nutritional assessment, oxygen saturation and pulmonary function testing, chest radiograph, and echocardiogram. Growth and developmental measures were corrected for prematurity. Data were analyzed by Mann-Whitney rank sum test, Fisher's Exact test, and logistic and linear regression.

Results

Infants with TO were significantly more premature at birth (control vs TO, 37.4 ± 1.0 vs 31.1 ± 1.7 weeks; P < .01). Growth failure (z score for weight <2 SDs below mean) was severe in both groups at 1 year of age (control vs TO, 56% vs 86%; P = .31). There was considerable catch-up growth by age 2 years (growth failure: control vs TO, 22% vs 33%; P = .19). There were no differences in other growth parameters. There were also no differences in neurodevelopmental outcome at 1 and 2 years. Supplemental oxygen at hospital discharge was a significant predictor of worse neurodevelopmental outcome at 1 and 2 years old (P = .05 and P = .02, respectively). Hearing loss requiring amplification has been diagnosed in 44% of the group (control vs TO, 44% vs 43%; P = 1.0).

Conclusions

In this group of infants with severe CDH, there were no differences in outcome at 2 years old despite significant prematurity in the TO group. Oxygen supplementation at hospital discharge identified the most vulnerable group with respect to neurodevelopmental outcome, but all infants had significant growth failure, and hearing impairment is a substantial problem in this population. Severe CDH carries significant risk of chronic morbidity.     

Decision making in general practice: the availability and use of a specific laboratory analysis

OBJECTIVES: The aim of this investigation was to study the effect of general practitioners' (GP's) characteristics on two decisions: whether to have the Helicobacter pylori rapid test (HPRT) in the office laboratory and whether to use this test or a similar hospital-based serological test in a typical clinical situation described in a vignette. METHODS: Discrete choice analysis with binary logit models were used to predict the probability that a general practice has the HPRT, as well as the GP's probability of using the HPRT or a similar test in this clinical situation. RESULTS: We found that the number of consultations per week has a positive effect on the probability of having the HPRT, indicating that the size of the practice affects the decision to have such a test in the repertoire. Furthermore, four variables significantly increased the probability of using one of the lab tests: more if located in urban practices, more by solo practitioners, more when the GP stated a high probability for H. pylori associated disease, and more when the GP had the rapid test available in the practice. In our analysis, the remuneration system is endogenous and does not have a significant effect on the two decisions. CONCLUSIONS: Our study demonstrates that characteristics of the GP affect the availability and use of a specific laboratory analysis.     

Cold air challenge and specific airway resistance in preschool children

Important asthma outcomes such as lung function and bronchial hyperresponsiveness are probably determined in early childhood. Early and longitudinal objective assessment of lung function and bronchial hyperresponsiveness is necessary to enable early diagnosis, monitor intervention and improve prognosis in preschool children. Cold air challenge and plethysmographic measurement of specific airway resistance (sRaw) are feasible candidate methods for diagnosis, clinical monitoring and research during this critical period of lung growth and development. Methodology and practical aspects of cold air challenge and assessment of sRaw in preschool children are reviewed. Reference values are provided for sRaw and have allowed discrimination between health and respiratory disease, both in cross-sectional and longitudinal studies. Bronchial hyperresponsiveness can be determined with acceptable repeatability and provides good discrimination between asthmatics and healthy. The effects of classic anti-asthmatic therapies have also been documented with these techniques. The need for further standardisation and improvement of these methods and future perspectives are outlined.     

Cesarean section: is pretransfusion testing for red cell alloantibodies necessary?

BACKGROUND: Routine pretransfusion testing for red cell alloantibodies (RBCab) in cesarean patients is standard practice in many obstetric centers. The objective of the present study was to evaluate the usefulness of this test. METHOD: A retrospective study was conducted using computerized registers to extract data on blood transfusions and the occurrence of RBCab in cesarean patients. RESULTS: A total of 4434 admissions for cesarean section were identified. Only 10 patients (0.23%) had clinically significant RBCab, which had not been previously detected. Blood transfusions were required in relation to 147 cesarean sections (3.3%). A number of preoperative conditions, traditionally believed to be risk factors for preoperative and postpartum hemorrhage, occurred more frequently in transfused patients than in nontransfused. The probability of a cesarean patient having a previously undetected clinically significant RBCab and receiving a blood transfusion during admission for delivery was estimated to be 9.0 x 10(-5) (1 in 11 050 cesarean sections). Analyses of the time relationships between cesarean sections and initiation of blood transfusions indicated that most often there would be enough time for postoperative antibody screening and/or cross matching if the routine pretransfusion testing was omitted. CONCLUSION: These findings suggest that routine pretransfusion testing in cesarean patients can be omitted.