The effect of metoclopramide on gastric emptying in traumatic brain injury.

OBJECTIVE: Gastric paresis in traumatic brain injury (TBI) hinders the effectiveness of enteral support in this patient group. In this study we have investigated the effect of metoclopramide on gastric emptying in TBI patients. METHOD: In this prospective, randomized, controlled, double-blind study, 19 TBI patients with Glasgow Coma Scale scores of 3-11 were included. In all patients, enteral nutrition was commenced with a nasogastric feeding tube within 48 hours of trauma. Patients were randomized into two groups. In the metoclopramide (M) group, 10 mg metoclopramide was delivered intravenously three times daily for 5 days. In the control (C) group, an equal volume of saline was administered. Besides demographics, gastric emptying according to a paracetamol absorption test at days 0 and 5, time to reach target nutritional requirements, gastric residues, intolerance to feeding, nutritional complications, and clinical outcomes were recorded for each patient. RESULTS: The gastric residue rates were 2.7+/-7.4 mL and 8.1+/-17.7 mL per 100 patient days for groups C and M respectively (p=0.408). Similarly, feeding intolerance and complication rates did not significantly differ between groups C and M, (respectively p=0.543 and 0.930). Gastric emptying parameters also were similar between the study groups. CONCLUSION: We were unable to document any advantage to using metoclopramide in TBI patients. Simple intragastric enteral feeding with close monitoring of the possible complications seems to be sufficient with acceptable morbidity rates.     

Ginkgo biloba extract ameliorates ischemia reperfusion-induced renal injury in rats.

There is increasing evidence to suggest that reactive oxygen metabolites (ROMs) play a role in the pathogenesis of ischemia/reperfusion injury (I/R) in the kidney. This study was designed to determine the possible protective effect of Ginkgo biloba extract (EGb) on renal ischemia/reperfusion (I/R) injury. Wistar albino rats were unilaterally nephrectomized, and 15 days later they were subjected to 45 min of renal pedicle occlusion followed by 6 h of reperfusion. Ginkgo biloba extract (EGb) (50 mg kg(-1) day(-1)) or saline was administered twice, 15 min prior to ischemia and immediately before the reperfusion period. At the end of the treatment period, all rats were decapitated. Kidney samples were taken for histological examination or determination of the renal malondialdehyde (MDA) and glutathione (GSH) levels, myeloperoxidase (MPO) activity and collagen content. Production of reactive oxidants was monitored by chemiluminescence (CL) assay. Creatinine and urea concentrations in blood were measured for the evaluation of renal function. Tumor necrosis factor-alpha (TNF-alpha) and lactate dehydrogenase (LDH) were also assayed in serum samples. Ischemia/reperfusion caused a significant decrease in GSH level, which was accompanied with significant increases in MDA level, MPO activity and collagen content of kidney tissues. Similarly, serum BUN and creatinine levels, as well as LDH and TNF-alpha, were elevated in the I/R group as compared to control group. On the other hand, EGb treatment reversed all these biochemical indices, as well as histopathological alterations, which were induced by I/R. The findings imply that ROMs play a causal role in I/R-induced renal injury and EGb exerts renoprotective effects probably by the radical scavenging and antioxidant activities.     

Results of Surgery in General Surgical Patients Receiving Warfarin: Retrospective Analysis of 61 Patients

The aim of this study is to investigate postoperative complications, mortality rates, and to determine the factors affecting mortality on the patients receiving warfarin therapy preoperatively, as well as comparing the results obtained from emergency and elective surgeries. Surgical outcomes of 61 patients on long-term oral anticoagulation with warfarin who underwent surgery in our center were retrospectively reviewed over an 8-year period. Thirty-three (54.1%) patients were female, with a mean age of 53 years. Mitral valve replacement (62.3%) was the most frequent indication for chronic anticoagulation therapy. Twelve out of 61 (19.2%) patients underwent emergency surgery; 59 (96.7%) operations were classified as major surgery. We did not observe any thromboembolic events on patients receiving our bridging therapy protocol. Cardiopulmonary dysfunction (CPD; 19.7%) and hemorrhage (16.4%) were the most encountered postoperative complications. Presence of CPD, bleeding, endocarditis, and mortality were statistically significant for emergency surgeries when compared with the results obtained from elective surgeries. There were 5 (8.2%) deaths observed during follow-up. It was found that advanced age, prolonged duration of operations, and presence of CPD had a statistically significant effect on mortality (P < 0.05). The patients receiving oral anticoagulant had high postoperative complication and mortality rates. This case was more evident in emergency surgeries. It is recommendable that as mortality is more apparent in the patients who undergo emergency surgeries—being older, having long duration of operations as well as CPD. Therefore during the postoperative follow-up process, the patients should be closely monitored.Key words: Emergency, Postoperative complications, Morbidity, Mortality, WarfarinThromboembolism is a major global health concern contributing to more than 0.5 million deaths in Europe and up to 300,000 deaths in the United States each year.¹ Versatile arrays of anticoagulant and/or anti-aggregant agents are available. They are used to treat and prevent thrombosis occurring as a result of venous stasis, valvular heart disease, prosthetic valves, atrial fibrillation, or myocardial infarction. After using these medications, patients who require elective or emergency surgery represent a specific population; moreover, they are prone to developing either excessive bleeding or thrombosis.The annual incidence of major bleeding as a result of oral anticoagulant (OAC) use is reported between 2 and 5%.² Patients on OAC may require elective or sometimes emergency surgical or invasive procedures. There is no consensus on standard protocol to follow for those who require perioperative management.³In the current literature, there are limited numbers of studies regarding the discussions about the operations in general surgery patient population receiving warfarin treatments. In this retrospective study, our aim was to document the complications and outcomes of general surgical procedures implemented on patients receiving warfarin. Along with the comparison of the emergency and elective surgeries performed, we also aimed to determine the factors affecting mortality.     

Nail incorporation kinetics of terbinafine in onychomycosis patients

Patients with toe-nail onychomycosis were treated with terbinafine (250 mg daily, n= 20) for either 6 or 12 weeks in a randomized double-blind study. Plasma and distal nail clippings were taken before initiation of therapy and 1, 6, 12, 18, 24, 36 and 48 weeks thereafter. Analytical data of terbinafine extracted from nail clippings or plasma were obtained by high-performance liquid chromatography (HPLC). Nail extracts and isolated HPLC terbinafine peaks were analysed using a combined gas chromatography - mass spectroscopy system (GC-MS) for unequivocal identification of the drug. Terbinafine could be detected in the distal nail in the majority of the patients within 1 week of starling therapy. Maximum terbinafine levels of 0·52 and 1·01 μg;g were measured after 18 weeks in the 6- and 12-week treatment groups, respectively. While plasma levels decreased rapidly after termination of therapy terbinaiine was detected in the nails as long as 36 weeks (6 weeks treatment) and 36 weeks (12 weeks treatment) after termination of therapy at a range of 0·–0·19 μg/g. The drug concentrations measured at all time points are well above the minimum inhibitory concentration (MIC) tor dermatophytes and other fungi, These data suggest that the drug readies the nail plate rapidly and persists there for several months after cessation of active treatment.     

Protective effect of aqueous garlic extract against naphthalene-induced oxidative stress in mice

The aim of this study was to investigate the possible protective effects of aqueous garlic extract (AGE) against naphthalene-induced oxidative changes in liver, kidney, lung and brain of mice. Balb/c mice (25-30 g) of either sex were divided into five groups each comprising 10 animals. Mice received for 30 days: 0.9% NaCl, i.p. (control); corn oil, i.p; AGE in a dose of 125 mg kg-1, i.p.; naphthalene in a dose of 100 mg kg-1, i.p. (dissolved in corn oil); and AGE (in a dose of 125 mg kg-1, i.p.) plus naphthalene (in a dose of 100 mg kg-1, i.p.). After decapitation, liver, kidney, lung and brain tissues were excised. Malondialdehyde (MDA) and glutathione (GSH) levels and myeloperoxidase activity (MPO) were determined in the tissues, while oxidant-induced tissue fibrosis was determined by collagen content. Tissues were also examined microscopically. Serum aspartate aminotransferase, alanine aminotransferase levels and blood urea nitrogen and creatinine concentrations were measured for the evaluation of hepatic and renal function, respectively. MDA and GSH levels were also assayed in serum samples. In the naphthalene-treated group, GSH levels decreased significantly, while MDA levels, MPO activity and collagen content increased in the tissues (P<0.01-0.001), suggesting oxidative organ damage, which was also verified histologically. In the AGE-treated naphthalene group, all of these oxidant responses were reversed significantly (P<0.05-0.01). Hepatic and renal function test parameters, which increased significantly (P<0.001) following naphthalene administration, decreased (P<0.05-0.001) after AGE treatment. The results demonstrate the role of oxidative mechanisms in naphthalene-induced tissue damage. The antioxidant properties of AGE ameliorated oxidative organ injury due to naphthalene toxicity.     

Simple two-part tool for screening of malnutrition

OBJECTIVE: Malnutrition in hospitalized patients is a major problem that is underdiagnosed. Early recognition of malnutrition is important for nutritional support to be effective. Our aims were to determine the malnutrition rate at our center and to devise an effective screening tool for identifying patients at risk for malnutrition. METHODS: This prospective study included 2211 patients. Each subject was assessed for malnutrition by the Subjective Global Assessment (SGA), and combination criteria (CC), which included anthropometric measurements and laboratory testing. Findings based on these methods were compared with findings in a series of malnutrition screening tests (malnutrition screening tool, self-assessment portion of a mini-nutritional assessment, a question about unintentional weight loss, evaluation of loss of subcutaneous fat, and various combinations of these). RESULTS: The SGA and CC methods identified 242 (11.0%) and 345 (15.6%) patients as malnourished, respectively. Of the screening methods that were tested, the combination of unintentional weight loss and loss of subcutaneous fat proved to be the most valuable, with 93% accuracy for predicting malnutrition according to the SGA, and 82.9% accuracy for predicting malnutrition according to CC. The corresponding negative predictive values were 95.5% and 87.3%. CONCLUSIONS: The results show that this simple two-part nutritional screening tool (unintentional weight loss and loss of subcutaneous fat) is valuable for identifying malnutrition according to the SGA and CC at our institution; however, its validity must be confirmed at other centers.     

HOW TO EVALUATE CLINICAL PARAMETERS AT A GLANCE

Schiøtz, P.O., Beck, B. and Pedersen, M. (Paediatric Department TG, Rigshospitalet, Copenhagen, Denmark). How to evaluate clinical parameters at a glance. Acta Paediatr Scand 1982; suppl 301: 121-124. — A brief introduction is given to the practical approach in cystic fibrosis patient care, which is used at the Danish Cystic Fibrosis centre employing Dr. Flensborg's flowsheets.     

Giant adrenal hemangioma: a case report

Although adrenal masses are relatively common, hemangiomas occurring in adrenal glands are rare. This entity creates problems in the differential diagnosis. We report a patient with a giant cavernous hemangioma with a diameter of 13 cm, which was pre-operatively diagnosed as an adenoma or a malignant tumour. Clues to the correct diagnosis and therapeutic alternatives are discussed in the context of the available literature.