The formation of cocaethylene and clinical presentation of ED patients testing positive for the use of cocaine and ethanol

The purpose of this investigation was to document the clinical presentation of emergency department (ED) patients who tested positive for concurrent cocaine (COC) and ethanol (EtOH) use and the incidence of cocaethylene (CE) formation in this study population. Four study groups were evaluated: (1) drug-free, (2) EtOH-only, (3) COC-only, and (4) COC plus EtOH. CE was detected in plasma or urine specimens in 88% of the COC/EtOH-positive patients, and correlated directly with plasma COC and its metabolite benzoylecognine. Blood pressure and body temperature did not vary across study groups. COC/EtOH-positive patients displayed a significantly higher mean respiratory rate while the EtOH-only study group had an elevated mean heart rate. No significant differences were detected with respect to cardiac and neurological complaints between study groups. Trauma complaints in the drug-positive groups were more frequent than the incidence reported in the drug-free population. COC/EtOH-positive patients had the greatest percentage of trauma complaints (34.6%). Nearly half of the patients who tested positive for CE cited trauma as the primary reason for reporting to the ED. We conclude that ED patients who have concurrently used COC and EtOH are more closely associated with presentations related to traumatic injury than to those related to toxicologic complications.     

Analysis of Differential BRAFV600E Mutational Status in High Aggressive Papillary Thyroid Microcarcinoma

Papillary thyroid cancers often occur as microcarcinoma. Some papillary thyroid microcarcinoma (PTMC) have been considered to be high aggressive according to advanced disease stages, extrathyroidal extension, and severe cervical lymph node metastasis. Although several factors are thought to predict the occurrence of aggressiveness from PTMCs, the origin of aggressiveness has been rarely studied. To answer this question, the correlation between BRAF^V600E mutation and high aggressive PTMCs was investigated. The clinicopathological characteristic of totally 64 cases of PTMCs was investigated and the BRAF^V600E mutational status of them was identified. BRAF^V600E mutation was exclusively detected in PTMCs (37.5%). The data provided no correlation between the occurrence of BRAF^V600E mutations and clinicopathological parameters, such as sex, age, and tumor-like lesions combination. The prevalence of BRAF^V600E mutation of PTMCs with high aggressiveness (advanced disease stages, extrathyroidal extension, and nodal metastasis) was significantly higher (p < 0.05) than that of PTMCs without aggressive behavior. The BRAF^V600E mutated PTMCs exhibited signs of higher aggressiveness than PTMCs without the mutation. BRAF^V600E mutation may be a marker of high aggressiveness in PTMCs.     

Cost Effectiveness of Routine Laparoscopic Ultrasound for Assessment of Resectability of Gallbladder Cancer

Background

In addition to a diagnostic laparoscopy (DL), a routine laparoscopic ultrasound (LUS) has been proposed to identify undetected hepatic metastases and/or anatomically advanced disease in patients with T2 or higher gall bladder cancer (GBC) patients planned for surgical resection. It was hypothesized that a routine LUS is not a cost-effective strategy for these patients.

Methods

Decision tree modeling was undertaken to compare DL-LUS vs. DL at the time of definitive resection of GBC (with no prior cholecystectomy). Costs in US dollars (payer’s perspective), quality-adjusted life weeks (QALWs), and incremental cost-effectiveness ratios (ICER) were calculated (horizon: 6 weeks, willingness-to-pay: $1,000/QALW or $50,000/QALY).

Results

DL-LUS was cost effective at the base case scenario (costs: $30,838 for DL vs. $30,791 for DL-LUS and effectiveness 3.81 QALWs DL vs. 3.82 QALW DL-LUS), resulting in a cost reduction of $9,220 per quality-adjusted life week gained (or $479,469 per QALY). DL-LUS became less cost effective as the cost of ultrasound increased or the probability of exclusion from resection decreased.

Conclusions

Routine LUS with DL for the assessment of resectability and exclusion of metastases is cost effective for patients with GBC. Until improvements in preoperative imaging occur to decrease the probability of exclusion, this appears to be a feasible strategy.     

Is Hepatic Resection for Large or Multinodular Hepatocellular Carcinoma Justified? Results From a Multi-Institutional Database

Background The role of surgical resection in patients with large or multinodular hepatocellular carcinoma (HCC) remains unclear. This study evaluated the long-term outcome of patients with hepatic resection for large (>5 cm in diameter) or multinodular (more than three nodules) HCC by using a multi-institutional database.Methods The perioperative and long-term outcomes of 404 patients with small HCC (<5 cm in diameter; group 1) were compared with those of 380 patients with large or multinodular HCC (group 2). The prognostic factors in the latter group were analyzed.Results The postoperative complication rate (27% vs. 23%; P = .16) and hospital mortality rate (2.4% vs. 2.7%; P = .82) were similar between groups. The overall survival rates were significantly higher in group 1 than group 2 (1 year, 88% vs. 74%; 3 years, 76% vs. 50%; 5 years, 58% vs. 39%; P < .001). Among patients in group 2, five independent prognostic factors were identified to be associated with a worse overall survival: namely, symptomatic disease, presence of cirrhosis, multinodular tumor, microvascular tumor invasion, and positive histological margin.Conclusions Hepatic resection can be safely performed in patients with large or multinodular HCC, with an overall 5-year survival rate of 39%. Symptomatic disease, the presence of cirrhosis, a multinodular tumor, microvascular invasion, and a positive histological margin are independently associated with a less favorable survival outcome.     

Coronary endarterectomy on beating heart: Our experience

Introduction Coronary artery bypass grafting (CABG) associated with Endarterectomy is a high risk procedure. After the first report of coronary endarterectomy by Bailey et al in 1951, the preference for this surgical procedure was decreased due to increased morbidity and mortality In patients with total or subtotal large coronary artery obstructions in which there is no possibility to receive a conduit as graft for myocardial revascularisation, endarterectomy remains the procedure of choice. This study was designed to study early and midterm results of off pump coronary artery endarterectomy. Methods Of 172 Consecutive Off Pump CABG done at our institution from Jan 2003 to July 2005, 22 patients underwent supplementary coronary endarterectomy. 16 patients had chronic stable angina 4 had unstable angina two required emergency CABG with endarterectomy following perioperative infarction. The mean ejection fraction was 29.2±4.3 and all of the patients were in New York Heart Association (NYHA) III or IV. All patients were planned for complete total arterial revascularisation using Left Internal Mammary Artery (LIMA). Right Internal Mammary Artery (RIMA), Radial composite “Y” graft, Two patients operated for periop infarct received vein graft. In 16 patients closed endarterectomy was done in five patients double endarterectomy in single vessel was done to chase the plaque distally, in one patient open left anterior descending (LAD) endarterectomy with vein patch reconstruction was performed. Results There were no deaths. None of the procedures were converted to on pump operation. All endarterectomies and bypasses were performed on Beating Heart, all patients were completely revascularised. Peri operative cardiac enzymes studied showed no significant rise in the Creatinine Phoshpokinase (CPK)-Creatinine Phosphokinase myocardial Band (CPK-MB). The mean postoperative Ejection Fraction (EF) was 36.7%±7.2% which was significantly higher than the Preoperative one (p<.05). At the end of four months to one and half year 22 patients were in NYHA class I to II and all were angina free in canadian cardiovascular society class.f Conclusions Coronary End Arterectomy without cardiopulmonary bypass can be performed in patients who are expected to benefit from complete revascularisation. It can be performed with closed as well as open method. However to achieve complete endarterectomy by closed technique in some patients it is essential to chase the plaque. Early and mid term results are encouraging.