Acute gastrointestinal haemorrhage in anticoagulated patients: diagnoses and response to endoscopic treatment.

The underlying diagnosis and clinical course of 52 patients who presented with severe acute gastrointestinal haemorrhage while taking the anticoagulant warfarin is reviewed. A bleeding site was identified in 83% of cases, only slightly fewer than the 92% found in a control of group of 710 patients not taking warfarin who presented in the same four year period. The degree or duration of anticoagulation was unrelated to the frequency of establishing a diagnosis. The commonest diagnosis was peptic ulcer (25 cases) and endoscopic treatment by injection or heater probe was attempted in 23 of these. The outcome in this subgroup was compared with that in 50 closely matched control subjects who had similar risk factors for rebleeding from peptic ulcer. Permanent haemostasis was achieved in (91%) of the anticoagulated and in 92% of the control patients. There were no complications related to endoscopy. Patients who present with acute gastrointestinal haemorrhage while taking warfarin usually bleed from mucosal disease. They should be endoscoped after resuscitation and those with major bleeding from a peptic ulcer should be offered endoscopic treatment.     

Segmental jejunal lipomatosis--a rare cause of intestinal obstruction

A rare case of a segmental small intestinal (jejunal) lipomatosis is described. A 33-year-old male was admitted with a clinical diagnosis of an acute intestinal obstruction. A plain erect abdominal x-ray showed multiple air-fluid levels. On an exploratory laparotomy, a jejunojejunal intussusception was found secondary to a segmental submucosal lipomatosis. This was treated by a segmental resection and anastomosis, which resulted in a complete cure. Here we present this case with a review of the relevant literature.     

Laparoscopic versus open appendectomy: a prospective randomized trial of 81 patients

Objective

To compare the efficacy of laparoscopic appendectomy (LA) and open appendectomy (OA) in the treatment of acute appendicitis.

Design

A prospective randomized trial.

Setting

A university teaching hospital.

Patients

Eighty-one patients with a diagnosis of acute appendicitis were prospectively randomized to undergo either LA or OA. The two groups were matched for age and sex.

Interventions

LA or OA.

Main Outcome Measures

Number of days in hospital and time to full recovery.

Results

The mean hospital stay for LA was 3.23 days compared with 3.03 days for OA (p < 0.001). The mean number of narcotic injections required for patients in the LA group was 4.05 compared with 5.58 for patients in the OA group (p < 0.001). The mean time to complete recovery for patients in the LA group was 9.0 days compared with 16.2 days for patients in the OA group (p < 0.001). The mean operative time for LA was 73.8 minutes compared with 45.0 minutes for OA (p < 0.001). Three patients in the LA group had intra-abdominal abscesses (p > 0.25). No significant difference in wound infection rates was demonstrated (p > 0.05). Similarly, pain scores at 7 and 28 days showed no significant difference (p > 0.05).

Conclusions

With LA significantly fewer narcotic injections are required and there is a more rapid return to normal activities. LA takes longer to perform and was associated with three intra-abdominal abscesses. In cases of simple acute appendicitis the hospital stay for LA is significantly shorter.     

Total knee arthroplasty in extra articular deformities: A series of 36 knees

Background:

The presence of extra articular deformities either in the femur or the tibia with arthritis of the knee makes total knee arthroplasty (TKA) technically demanding. The purpose of this study is to report outcomes with Total Knee Arthroplasty in patients with arthritis of the knee associated with extra articular deformity by intraarticular resection and soft tissue balancing.

Materials and Methods:

Thirty six knees (32 patients) who had arthritis of the knee associated with extra articular deformity, underwent total knee arthroplasty between 1999 and 2006 were included in this retrospective analysis. All patients had intraarticular resection with soft tissue balancing to correct the deformity. Full length weight bearing anteroposterior X-rays, Knee society scores, and Knee range of motion was recorded pre- and postoperatively.

Results:

The mean period of followup was 85 months (range 42-120 months). The deformities amenable to correction by intraarticular resection in our series were Femur- Coronal plane 11°-18° (mean 16.2°) Saggital plane 0°-15° (mean 10.1°) Tibia - Coronal plane 12°-24° (mean 21°). There was an improvement in the range of motion from mean of 54° preoperatively to 114° postoperatively (P value < 0.05). The Knee Society- Knee Score improved from 37 points to 85 points postoperatively (P value < 0.05). The functional score improved from a mean value of 19 to a mean of 69.5 at followup (P < 0.01). The preoperative hip knee ankle angle in the coronal plane improved from a mean of 14° ± 2° varus (26° varus to 4° valgus) to a mean of 2° ± 0.6° varus (6° varus to 2° valgus).

Conclusion:

With a good preoperative planning and templating, intraarticular bone resection and good soft tissue balancing both in flexion and extension, correction would be possible in majority of extraarticular deformities.     

The benefits of redesigning Benin's vaccine supply chain

Introduction

New vaccine introductions have put strains on vaccine supply chains around the world. While increasing storage and transportation may be the most straightforward options, it is also important to consider what financial and operational benefits can be incurred. In 2012, suboptimal vaccine coverage and impending vaccine introductions prompted the Republic of Benin's Ministry of Health (MOH) to explore ways to improve their vaccine supply chain.

Methods

Working alongside the Beninese MOH, we utilized our computational model, HERMES, to explore the impact on cost and vaccine availability of three possible options: (1) consolidating the Commune level to a Health Zone level, (2) removing the Commune level completely, and (3) removing the Commune level and expanding to 12 Department Stores. We also analyzed the impact of adding shipping loops during delivery.

Results

At baseline, new vaccine introductions without any changes to the current system increased the logistics cost per dose ($0.23 to $0.26) and dropped the vaccine availability to 71%. While implementing the Commune level removal scenario had the same capital costs as implementing the Health Zone scenario, the Health Zone scenario had lower operating costs. This increased to an overall cost savings of $504,255 when implementing shipping loops.

Discussion

The best redesign option proved to be the synergistic approach of converting to the Health Zone design and using shipping loops (serving ten Health Posts/loop). While a transition to either redesign or only adding shipping loops was beneficial, implementing a redesign option and shipping loops can yield both lower capital expenditures and operating costs.     

Differential modulation of apoptosis-associated proteins by ethanol in rat cerebral cortex and cerebellum

Chronic ethanol treatment caused a differential modulation of apoptosis-associated proteins, cytochrome c release, concomitant with procaspase-9 and procaspase-3 activation leading to oligonucleosomal DNA fragmentation in rat cerebral cortex and cerebellum. Caspase-3 proform (32 kDa) showed decreased immunoreactivity in cortex and cerebellum, while the cleaved active fragment (17 kDa) increased significantly in cerebellum after ethanol treatment. Further, chronic ethanol treatment increased caspase-3 activity in cortex and to a higher extent in cerebellum, which was further confirmed by blocking experiments with caspase-3 specific inhibitor, N-acetyl-Asp-Glu-Val-Asp-aldehyde (Ac-DEVD-CHO). We tested whether activated caspase-3 cleaves downstream substrates such as poly (ADP-ribose) polymerase-1 and protein kinase C-delta (PKC-δ). Western blots showed poly (ADP-ribose) polymerase-1 cleavage to its signature fragment of 85 kDa and decreased levels of PKC-δ in cerebral cortex and cerebellum after ethanol treatment, suggestive of caspase-3 activation. Elevated caspase-3 activity in cerebellum than cortex correlating with cytochrome c, caspase-9, active caspase-3 (p17), poly (ADP-ribose) polymerase-1 and PKC-δ data, suggests a mechanism by which ethanol might be exerting pro-apoptotic events in brain and how selective brain regions such as cerebellum are vulnerable to ethanol neurotoxicity in terms of cell death.