A Reduction in Delayed Gastric Emptying by Classic Pancreaticoduodenectomy with an Antecolic Gastrojejunal Anastomosis and a Retrogastric Omental Patch

Background  Delayed gastric emptying (DGE) continues to be a major cause of morbidity following pancreaticoduodenectomy (PD). A change in the method of reconstruction following PD was instituted in an attempt to reduce the incidence DGE. Methods  Patients undergoing PD from January 2002 to December 2008 were reviewed and outcomes determined. Pylorus-preserving pancreaticoduodenectomy (PPPD) with a retrocolic duodenojejunal anastomosis (n = 79) or a classic PD with a retrocolic gastrojejunostomy (n = 36) was performed prior to January 2008. Thereafter, a classic PD with an antecolic gastrojejunal anastomosis and placement of a retrogastric vascular omental patch was undertaken (n = 36). Results  A statistically significant decrease in DGE was noted in the antecolic group compared to the entire retrocolic group (14% vs 40%; p = 0.004) and compared to patients treated by classic PD with a retrocolic anastomosis alone (14% vs 39%; p = 0.016). On multivariate analysis, the only modifiable factor associated with reduced DGE was the antecolic technique with an omental patch, odds ratio (OR) 0.3 (confidence interval (CI) 0.1–0.8) p = 0.022. Male gender was associated with an increased risk of DGE with OR 2.3 (CI 1.1–4.8) p = 0.026. Conclusion  A classic PD combined with an antecolic anastomosis and retrogastric vascular omental patch results in a significant reduction in DGE.     

Chronic epigallocatechin-gallate improves aortic reactivity of diabetic rats: Underlying mechanisms

Diabetes mellitus is associated with major cardiovascular risk factors which are responsible for excess morbidity and mortality. Green tea catechins including epigallocatechin-3-gallate (EGCG) could exert beneficial health effects to ameliorate cardiovascular and metabolic diseases. Thus, the effect of chronic administration of EGCG was studied on aortic reactivity of streptozotocin (STZ)-diabetic rats. Male diabetic rats received EGCG 25 mg/kg/day for 8 weeks 1 week after diabetes induction. Contractile responses to KCl and phenylephrine (PE) and relaxation responses to acetylcholine (ACh) and sodium nitroprusside (SNP) were obtained from aortic rings. Maximum contractile response of endothelium-intact rings to KCL and PE was significantly lower in EGCG-treated diabetic rats relative to untreated diabetic ones. Endothelium removal abolished the significant difference between EGCG-treated and untreated diabetic groups regarding contractile response to KCl and PE. Meanwhile, endothelium-dependent relaxation to ACh was significantly higher in EGCG-treated diabetic rats as compared to diabetic ones. Pretreatment of rings with N(omega)-L-arginine methyl ester (L-NAME) and indomethacin (INDO) significantly attenuated the observed responses. Meanwhile, two-month diabetes resulted in an elevation of malondialdehyde (MDA) and decreased superoxide dismutase (SOD) activity in aortic tissue and EGCG treatment attenuated the increased MDA content and reduced activity of SOD. Therefore, chronic treatment of diabetic rats with EGCG could prevent the abnormal functional changes in vascular reactivity in diabetic rats through nitric oxide- and prostaglandin-dependent pathways and via attenuation of aortic lipid peroxidation.     

Oral ascorbic acid in combination with beta-blockers is more effective than beta-blockers alone in the prevention of atrial fibrillation after coronary artery bypass grafting

Because adrenergic beta antagonists are not sufficient to prevent atrial fibrillation after coronary artery bypass grafting, this prospective, randomized trial was designed to evaluate the effects of ascorbic acid as an adjunct to beta-blockers. Fifty patients formed our ascorbic acid group, and another 50 patients formed our control group. All patients were older than 50 years, were scheduled to undergo coronary artery bypass grafting, and had been treated with beta-blockers for at least 1 week before surgery. The mean age of the population was 60.19+/-7.14 years; 67% of the patients were men. Patients in the ascorbic acid group received 2 g of ascorbic acid on the night before the surgery and 1 g twice daily for 5 days after surgery. Patients in the control group received no ascorbic acid. Patients in both groups continued to receive beta-blockers after surgery. Telemetry monitoring was performed in the intensive care unit, and Holter monitoring was performed for 4 days thereafter. The incidence of postoperative atrial fibrillation was 4% in the ascorbic acid group and 26% in the control group (odds ratio, 0.119; 95% confidence interval, 0.025-0.558, P = 0.002). We conclude that ascorbic acid is effective, in addition to being well-tolerated and relatively safe. Therefore, it can be prescribed as an adjunct to beta-blockers for the prophylaxis of post-bypass atrial fibrillation.     

Partial cholecystectomy as a safe and viable option in the emergency treatment of complex acute cholecystitis: a case series and review of the literature

Partial cholecystectomy (PC) is an alternative choice to standard cholecystectomy in situations with increased risk of Calot's components injury. We reported our experience with the patients treated with PC and reviewed the literature. Fifty-four patients with complex acute cholecystitis underwent PC, including conventional partial cholecystectomy (CPC; n = 48) and laparoscopic partial cholecystectomy (LPC; n = 6). The clinical diagnosis was verified by ultrasonography. In addition, we reviewed 1190 published cases (1972-2005) who underwent a "nonconventional" surgery for severe cholecystitis, including cholecystostomy, CPC, or LPC. Review of the literature, including our cases, showed a male:female ratio of 1.3:1. The major operative indication was severe acute cholecystitis. Procedures included cholecystostomy (65.8%) and PC (34.2%). In the follow-up (n = 1190), biliary leak (4.8%), retained stones (4.6%), recurrent symptoms (2.3%), wound infections (1.9%), persistent biliary fistula (0.9%), and prolonged biliary drainage (0.2%) were found, with an overall mortality rate of 9.4 per cent. In 133 patients, because of postoperative complications (e.g., recurrent symptoms, remaining common bile duct stones, or persistence of bile fistula), reoperation was necessary, including 121 cases (90.1%) of cholecystectomy, whereas the other 11 patients underwent other procedures such as common bile duct exploration or closure of the fistula. The surgical trend for complex acute cholecystitis treatment has been changed from only cholecystostomy to a spectrum of cholecystostomy, CPC, and LPC with the progressive increase of PC. The proportion of the LPC compared with CPC has also increased during recent years. It seems that PC is a safe procedure for treating complicated acute cholecystitis. Whether the indication and need for alternative techniques to standard cholecystectomy is changing should be evaluated in future studies.     

Psychosociophysical Factors of Low Back Pain： What Role do They Play for Iranian Nurses？

Objective To examine the effect of psychosocial and physical factors, and demographic variables on low back pain in nurses. The roles of physical and psychosocial factors to low back pain investigated separately, however psychosociophysical model for it require further research especially among nurses. Methods Participants included 261 males and 162 females randomly selected from Namazi, Shahid Faghihi, Shahid Beheshty, and Shahid Chamran hospitals in Shiraz, Iran. A demographic questionnaire, the Low Back Pain Scale, Psychosocial Factor Scale and Physical Factor Scale were used in the study. Results The resulting data showed that in this particular sample psychosocial and physical factors relatively explain low back pain for total sample and both genders, when using a multiple regression model. The MANOVA indicated that gender, marital status, age, education, ethnicity, hospital and ward, type of working shift, type of responsibility in hospital, level of education, professional experience, and aged-group demographical variables are effective in low back pain, and physical and psychosocial factors related to LBP for nurses. Conclusions Significant findings were explained within a psychosociophysical framework for low back pain prevention among nurses and further research trends.     

Carbon dioxide absorber as a cause of high airway pressures

We investigate an incident in which a carbon dioxide absorber caused difficulty with ventilation. The problem as it developed throughout the anesthetic, and clues that led to the determination that the carbon dioxide canister was the problem, is discussed.     

Impact of baseline platelet count in patients undergoing primary percutaneous coronary intervention in acute myocardial infarction (from the CADILLAC trial)

Despite the well-recognized role of platelets in the pathogenesis of acute myocardial infarction (AMI) and in the vascular responses to angioplasty, the relation between platelet count and outcomes after primary percutaneous coronary intervention (PCI) in AMI is unknown. We therefore determined the effect of baseline platelet count on clinical and angiographic outcomes of patients with AMI undergoing primary PCI. In the prospective, randomized CADILLAC trial, platelet count on admission was available in 2,021 of 2,082 patients (97.0%). Angiographic results and outcomes at 30 days and 1 year were stratified by quartiles of platelet count. Median platelet count was 231 x 10(9)/L (range 38 to 709). Primary PCI angiographic success rates were independent of platelet count. The 30-day incidence of target vessel thrombosis or reocclusion increased steadily across the higher quartiles of baseline platelet count (0.2%, 0.6%, 1.0%, and 2.0%, p = 0.027). At 1 year, patients with a baseline platelet count >or=234 versus <234 x 10(9)/L had higher rates of death or reinfarction (8.9% vs 4.5%, p <0.0001), death (5.8% vs 3.1%, p = 0.002), and reinfarction (3.4% vs 1.6%, p = 0.008). By multivariable analysis, a higher baseline platelet count was the strongest predictor of 1-year death or reinfarction (hazard ratio [HR] per 10,000 increase in platelet count 1.02, 95% confidence interval [CI] 1.02 to 1.07, p <0.0001) and independently predicted reinfarction (HR 1.06, 95% CI 1.02 to 1.09, p = 0.002) and cardiac mortality (HR 1.03, 95% CI 1.00 to 1.06, p = 0.055) at 1 year. In conclusion, a higher baseline platelet count in patients with AMI is a powerful independent predictor of death and reinfarction within the first year after primary PCI.