Reports analysis of psychotropic drugs related adverse reactions in Australia and Poland during the COVID 19 pandemic

BACKGROUND

The COVID-19 pandemic has caused significant changes to the global health care system AIMS: It is unknown whether the COVID-19 pandemic influenced the occurrence of adverse drug reactions (ADR) of antidepressive agents, benzodiazepines, and antipsychotics plus mood stabilizers (AaMS). The study was designed in order to compare the incidence of ADR during the COVID-19 pandemic with the period preceding the pandemic in Poland and Australia, different in terms of their COVID-19 prevention strategy.

METHOD

We analysed ADR from the three surveyed pharmacological groups of drugs observed in Poland and Australia in the period prior to, and during the COVID-19 pandemic RESULTS: In Poland, a noticeable increase in the reported ADR of the assessed drug groups was observed during the COVID-19 pandemic. The highest was for antidepressive agents, but the reporting of ADR for benzodiazepines and AaMS drugs also increased significantly. In the case of ADR in Australian patients, the increase in the number of reported ADR for antidepressive agents was modest compared to that seen in Poland, but still noticeable, and there was a significant increase in ADR for benzodiazepines CONCLUSIONS: This study showed that the COVID-19 pandemic has had an impact on the incidence of ADR reported among both Polish and Australian patients but the modality of this was different.

Understanding occipital pressure sores in UK military casualties: a pilot study in healthy military personnel

INTRODUCTION

The high prevalence of occipital ulcers in UK military casualties observed during the conflict in Afghanistan is a multifactorial phenomenon. However, the consensus is that ulceration is triggered by excessive pressure that is maintained for too long during the use of the general service military stretcher. Thresholds for capillary occlusion are accepted benchmarks to define excessive pressure, but similar thresholds for safe/excessive duration of pressure application do not exist. To address this gap in knowledge, we propose to use the time it takes for a healthy person to feel pain at the back of the head as an initial indication of safe exposure to pressure.

METHODS

Healthy military personnel (16 male/10 female) were asked to lie motionless on a typical general service stretcher until they felt pain. Time-to-pain and the location of pain were recorded. To support the interpretation of results, baseline sensitivity to pain and pressure distribution at the back of the head were also measured. Independent samples t-test was used to assess differences between genders.

RESULTS

Twenty participants felt pressure-induced soft-tissue pain at the back of the head. The remaining six participants terminated the test due to musculoskeletal pain caused by poor ergonomic positioning. On average, pain at the occiput developed after 31 min (±14 min). Female participants were significantly more sensitive to pain (t(24)=3.038,p=0.006), but time-to-pain did not differ significantly between genders (p>0.05).

CONCLUSIONS

When people lie motionless on a typical military stretcher, the back of the head is the first area of the body that becomes painful due to pressure. The fact that pain develops in ≈30 min can help healthcare providers decide how frequently to reposition their patients who are unable to do this on their own. More research is still needed to directly link time-to-pain with time-to-injury.

A comparison of CT lung voxel density analysis in a blast and non blast injured casualty

INTRODUCTION

Primary blast lung injury (PBLI) is a prominent feature in casualties following exposure to blast. PBLI carries high morbidity and mortality, but remains difficult to diagnose and quantify. Radiographic diagnosis of PBLI was historically made with the aid of plain radiographs; more recently, qualitative review of CT images has assisted diagnosis.

METHODS

We report a novel way of measuring post-traumatic acute lung injury using CT lung density analysis in two casualties. One casualty presented following blast exposure with confirmed blast lung injury and the other presented following extremity injury without blast exposure. Three-dimensional lung maps of each casualty were produced from their original trauma CT scan. Analysis of the lung maps allowed quantitative radiological comparison exposing areas of reduced aeration of the patient's lungs.

RESULTS

45% of the blast-exposed lungs were non-aerated compared with 10% in the non-blast-exposed lungs.

DISCUSSION

In these example cases quantitative CT lung density analysis allowed blast-injured lungs to be distinguished from non-blast-exposed lungs.

Primary blast lung injury simulator: a new computerised model

Mathematical modelling and computational simulation are becoming increasingly important tools in many fields of medicine where in vivo studies are expensive, difficult or impractical. This is particularly the case with primary blast lung injury, and in this paper, we give a brief overview of mathematical models before describing how we generated our blast lung injury simulator and describe some early results of its use.

Inflammasomes: a novel therapeutic target in pulmonary hypertension?

Pulmonary hypertension (PH) is a rare, progressive pulmonary vasculopathy characterized by increased mean pulmonary arterial pressure, pulmonary vascular remodelling and right ventricular failure. Current treatments are not curative, and new therapeutic strategies are urgently required. Clinical and preclinical evidence has established that inflammation plays a key role in PH pathogenesis, and recently, inflammasomes have been suggested to be central to this process. Inflammasomes are important regulators of inflammation, releasing the pro-inflammatory cytokines IL-1β and IL-18 in response to exogenous pathogen- and endogenous damage-associated molecular patterns. These cytokines are elevated in PH patients, but whether this is a consequence of inflammasome activation remains to be determined. This review will briefly summarize current PH therapies and their pitfalls, introduce inflammasomes and the mechanisms by which they promote inflammation and, finally, highlight the preclinical and clinical evidence for the potential involvement of inflammasomes in PH pathobiology and how they may be targeted therapeutically. LINKED ARTICLES: This article is part of a themed section on Immune Targets in Hypertension. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v176.12/issuetoc.

Prone position ventilation in the Role 2 Afloat environment

Prone position ventilation is a life-saving technique for the management of hypoxic respiratory failure in ventilated patients. It has particular application in the isolated Role 2 Afloat (R2A) environment where both human and material resources are limited. It can be achieved with minimal training. This article describes the rationale behind prone position ventilation and equips the reader with the knowledge base that will allow the technique to be instigated.

Establishing and maintaining a robust Role 2 Afloat organisation within the Royal Naval Medical Services

In 2009, the Royal Navy (RN) reconfigured the Role 2 maritime medical treatment capability, the Role 2 Afloat (R2A). This capability is now firmly established on a number of platforms in the fleet and was recently externally validated on RFA MOUNTS BAY prior to completion of an operational deployment supporting contingency operations in the Mediterranean. This article outlines the future challenges for R2A and offers suggestions on how to maintain a robust R2A organisation within the Royal Naval Medical Service (RNMS).

The role of a nurse case manager in implementing a critical pathway for infrainguinal bypass surgery

BACKGROUND

A previous study showed the effectiveness of a clinical pathway for infrainguinal bypass surgery in reducing postoperative length of stay (LOS) in an acute care setting. Most of the deviations from the pathway were due to patient factors (50%) and/or external disposition problems (30%), but 20% were related to physician or system problems that could potentially be modified. The current study examined those factors influencing LOS following infrainguinal bypass surgery and the impact of daily rounds by a nurse case manager--a vascular nurse specialist--on LOS and pathway deviations.

METHODS

Data were collected through detailed chart review and prospective tracking of pathway deviations. LOS was compared in 58 patients on the modified pathway (with the nurse case manager) to 69 patients on the original pathway and 67 prepathway controls. Multivariate analysis was used to identify factors influencing postoperative LOS and to compare LOS among the three groups.

RESULTS

Use of a nurse case manager significantly reduced physician-related deviations, from the pathway from 10% to 0% (p = .015), and reduced system-related deviations from 3% to 0%. Median postoperative LOS was 7 days before the pathway was begun, 6 days with the original pathway, and 5 days after the introduction of a vascular nurse specialist (p = .0001). There were no differences in rates of complications, rates of readmission, or mortality.

CONCLUSIONS

Intervention by a nurse case manager facilitated implementation of a critical pathway for patients undergoing infrainguinal bypass surgery, especially by preventing patient deviations due to intrainstitutional factors.

Ileal pouch salvage following failed ileal pouch- anal anastomosis

Attempts have been made to salvage failed ileal pouch-anal anastomoses (IPAA) performed for ulcerative colitis or familial polyposis coli. These can be categorized as total reconstruction of the IPAA, partial transabdominal approach, and partial transperineal approach. The aims of our study were to determine the overall success of pouch salvage; to examine the demographics, indications, and outcomes for each approach; and to assess anorectal physiology and patient satisfaction in those with successful salvage operations. We reviewed data, including results of anorectal manometry, from 29 patients undergoing salvage procedures for failed IPAA. Seventeen salvage attempts were successful, 11 attempts failed, and one patient was lost to follow-up. Success rates were 100% in the total reconstruction group, 25% in the partial transabdominal group, and 55% in the transperineal group. In those undergoing total reconstruction of the IPAA (n = 9), functional outcome, as measured by incontinence, improved with 50% reporting incontinence preoperatively compared to 0% postoperatively (P = 0.055). Mean 24-hour stool frequency and nighttime stool frequency declined. All patients reported satisfaction with their outcomes. Sixty percent of patients who underwent ileal pouch salvage following IPAA have been successful in avoiding permanent ileostomy. These results suggest that a continued effort to salvage failed IPAA, including the use of total reconstruction, is a viable alternative to permanent ileostomy.

A case-control assessment of risk factors for gallbladder carcinoma

Gallbladder carcinoma is an uncommon, but highly fatal disease. Its symptoms frequently mirror those of gallstone disease, and in most instances, diagnosis is an incidental finding at surgery. While risk factors have been suggested for this cancer, many may in reality simply be a consequence of the older age of the population. This study is one of the few to approach this question by using a case-control study design comparing gallbladder carcinoma patients with a gallstone population, coupled with multivariate analysis to determine age-independent risk factors. Univariate analyses showed gallbladder carcinoma patients to be older than gallstone patients and to have many age-associated diseases. Following multiple regression adjustment for age, this disease was associated with female gender and with a previous history of gallstone symptoms. Carcinoma patients were less likely to have cholesterol gallstones in their gallbladders at surgery. A previous history of smoking was a substantial risk but of borderline statistical significance. Previous studies report associations that may be due to the older age of the gallbladder carcinoma patient. Our results show that after adjusting for age with multivariate analysis, gallbladder cancer subjects were predominantly female, more likely to report previous gallstone symptomology, and to smoke. While gallstones were not universally isolated from carcinoma patients at cholecystectomy, when present, they were less frequently classified as cholesterol gallstones based on visual inspection. Further cohort studies which target these populations will allow us to gain a more solid consensus on the risk factors for this disease.

Impact of a critical pathway on postoperative length of stay and outcomes after infrainguinal bypass

PURPOSE

To determine the effect of a critical pathway on postoperative length of stay and outcomes after infrainguinal bypass.

METHODS

A critical pathway for care of patients after infrainguinal bypass was introduced in December 1995 to coordinate postoperative care at our institution. We compared care of 67 consecutively treated patients before institution of the pathway with care of 69 consecutively treated patients with the critical pathway in place. Data collection was done by means of chart review. Univariate analyses were used to identify differences between prepathway and postpathway patients and to identify factors influencing postoperative length of stay. Multivariate analysis was used to identify factors that influenced length of stay and to examine the effect of use of the pathway after adjusting for other factors.

RESULTS

Patients on the pathway were similar to prepathway controls with respect to comorbid illnesses, vascular risk factors, indications for surgical treatment, type of conduit, and type of operation. Factors associated with longer postoperative stays included distal anastomoses to tibial rather than popliteal vessels (p = 0.02), preexisting cardiac disease (p = 0.005), postoperative complications (p = 0.0003), lower preoperative hematocrit (p = 0.01), and elevated preoperative creatinine level (p = 0.006). Overall, pathway patients had somewhat shorter postoperative lengths of stay (median value 7 days; range 2 to 29 days) than prepathway patients (median value 6 days; range 2 to 35; p = 0.01), and the two groups had similar frequencies of postoperative complications, readmission, and 6-month mortality. However, patients on the pathway were more likely to be discharged to an intermediate-care facility rather than directly home. After 12 patients with extraordinarily prolonged postoperative stays were excluded, multivariate analysis indicated that pathway patients had significantly shorter postoperative stays (p = 0.001). However, the difference was not significant if patients with extraordinarily long postoperative stays were included in the analysis (p = 0.28).

CONCLUSION

Use of a critical pathway was associated with a modest decrease in postoperative length of stay for most patients. This was accomplished without an adverse effect on readmission, complication, or mortality rates. However, the decrease in stay may have been achieved primarily by discharging more patients to intermediate-care facilities. The pathway did not appear to have any effect when the subset of patients with extraordinarily long stays because of complex medical problems was included.

Early outcome of in situ femorotibial reconstruction among patients with diabetes alone versus diabetes and end-stage renal failure: analysis of 83 limbs

PURPOSE

Both end-stage renal disease and diabetes have been demonstrated to have a negative effect on the outcome of infrainguinal arterial reconstruction, primarily because of increased perioperative morbidity and wound complications. This study was undertaken to determine whether the combination of these comorbid factors affects the outcome of distal arterial reconstruction.

METHODS

Eighty-three distal lower extremity arterial bypasses originating from the femoral artery and terminating at the peroneal, anterior, or posterior tibial artery were performed on 76 patients over a 5-year period at a tertiary care medical center. Autogenous greater saphenous vein was used as the bypass conduit in all instances. Combined inflow and composite vein procedures were excluded.

RESULTS

There was one perioperative death, for a mortality rate of 1.2%. The diabetes mellitus (DM) plus end-stage renal disease (DM+ESRD) cohort displayed a significantly lower 1-year primary patency rate compared with the diabetes mellitus cohort, 53% versus 82% (p < 0.02). However, the limb salvage rate for the DM+ESRD and DM cohorts during the same time interval were not significantly different, 63% versus 84% (p < 0.06). The 52% 1-year survival rate for the DM+ESRD cohort was strikingly lower than the 90% 1-year survival rate for the DM cohort (p < 0.002).

CONCLUSION

Despite the use of the optimal autogenous conduit, the combination of diabetes and end-stage renal disease can be expected to significantly decrease primary graft patency without affecting limb salvage. The greatest effect of these comorbid factors is on patient survival.

Is splenectomy more dangerous for massive spleens?

BACKGROUND

Reports vary about whether risks are greater for removal of massive (> or = 1500 g) spleens than for smaller (< 1500 g) spleens. We sought to determine the hazards of splenectomy.

METHODS

We reviewed 223 consecutive adults with elective splenectomies for hematologic diseases. Morbidity and mortality rates were combined with published data to create a meta-analysis.

RESULTS

Patients with massive spleens are more likely to have postoperative complications (relative risk [RR] 2.1, 95% confidence interval [CI] 1.3 to 3.4; P = 0.003) and death (RR 4.7, 95% CI, 1.5 to 15.1; P = 0.01). However, when the investigation is restricted to comparable diagnoses, patients with massive spleens do not differ from those with smaller spleens regarding complications (RR 1.4, 95% CI, 0.8 to 2.7; P = 0.3) or mortality (RR 2.1, 95% CI, 0.5 to 9.7; P = 0.4). These observations are confirmed by metaanalysis. Furthermore, multivariate analysis indicts age as a critical risk of complications and death.

CONCLUSIONS

Increased age and underlying illness are the predominant factors associated with morbidity and mortality following splenectomy for hematologic disease. Adjusting for age and diagnosis, spleen size is not a hazard.

Durability of early prosthetic dialysis graft cannulation: results of a prospective, nonrandomized clinical trial

PURPOSE

Initiation of hemodialysis frequently requires temporary central venous catheterization, which leads to subsequent venous stenosis in 50% of patients. These lesions severely limit upper extremity dialysis fistula creation. The present study was undertaken to determine whether early cannulation (EC) allowed omission of temporary venous catheterization without affecting perioperative morbidity and long-term graft patency.

METHODS

Seventy-nine prosthetic grafts for hemodialysis were placed in 76 patients over a 40-month period. Patients who required hemodialysis between 24 and 72 hours after surgery were assigned to EC. The remaining grafts underwent late cannulation (LC) after postoperative day 14. All grafts were constructed with a 6 mm stretch-expanded polytetrafluoroethylene conduit in the brachial artery-to-axillary vein position. Statistical analysis of cumulative primary patency estimates and patient survival data were determined by Kaplan-Meier analysis and log-rank test, patient variables were compared using chi 2 and Fisher's exact test, and multivariate analysis was performed using Cox's proportional hazard model.

RESULTS

Forty-eight patients underwent EC and 31 underwent LC. There were no significant differences regarding age (mean, 61.5 years), history of diabetes, congestive heart failure, hematocrit level (mean, 30%), or presence of peripheral vascular disease. Thrombosis occurred before cannulation in one of 48 ECs (2.0%) and one of 31 LCs (3.2%). There were no episodes of cannulation hemorrhage or wound infection in either group. Cumulative primary patency estimates for EC were 0.89, 0.82, and 0.70 at 3, 6, and 12 months, respectively. These were not significantly different from the LC estimates of 0.86, 0.78, and 0.74 at 3, 6, and 12 months, respectively. Overall, patients who had a history of peripheral vascular disease had a significantly decreased 12-month patency rate (60% vs 74%; p = 0.05). Central venous catheters were omitted in 47 of 48 EC patients.

CONCLUSION

EC of prosthetic dialysis grafts does not increase perioperative morbidity rates or decrease 12-month cumulative primary patency rates.

Relationship of cardiovascular risk factors to racial differences in femoral bypass surgery and abdominal aortic aneurysmectomy in Massachusetts

Atherosclerosis is more severe in blacks than in whites, but abdominal aortic aneurysms, which have traditionally been thought to have an atherosclerotic etiology, appear to be less common in blacks. Because of this incongruity, we compared risk factor profiles in patients undergoing abdominal aortic aneurysm repair and patients undergoing femoral bypass for atherosclerotic occlusive disease. A dual case-control study was conducted, first, comparing patients who had undergone aneurysmectomy to a control group of patients who had undergone appendectomy; and then comparing patients who had undergone femoral bypass surgery to the same appendectomy controls. We initially used hospital discharge data for the entire state of Massachusetts and, in a second phase, data obtained from a review of medical records from Boston University Medical Center Hospital and Boston City Hospital. The statewide database indicated that rates of femoral bypass surgery were higher in blacks than in whites, but after adjusting for differences in hypertension, diabetes, and low socioeconomic status, the black/white odds ratio for femoral bypass fell to 1.44 (95% confidence interval: 1.08, 1.92). A similar analysis based on the hospital chart review, provided better control of confounding and indicated that there was no racial difference in rates of femoral bypass after correcting for other risk factors (odds ratio = 0.94; 95% confidence interval: 0.40, 2.22; p = 0.90). In contrast, the statewide database found higher rates of abdominal aortic aneurysm surgery in whites, and particularly in white males. Smoking and hypertension were strong risk factors for aneurysmectomy, but diabetes mellitus and socioeconomic status were not. After adjusting for other variables, the black/white odds ratio for aneurysmectomy was 0.29 (95% confidence interval: 0.07, 1.23; p = 0.09).

CONCLUSIONS

Substantial differences are found in the risk factor profiles for aneurysmal disease and femoral atherosclerotic occlusive disease. Diabetes is a particularly strong risk factor for femoral disease, but not for aneurysmal disease. In addition, blacks had higher rates of femoral bypass surgery in Massachusetts, but the apparent racial difference appeared to be due to a greater prevalence of hypertension, smoking, and diabetes in blacks. In contrast, abdominal aortic aneurysms occurred predominantly in white males, and adjustment for other risk factors further accentuated the greater risk in whites.

Risks of synchronous gastrointestinal or biliary surgery with splenectomy for hematologic disease

BACKGROUND

The addition of splenectomy to a gastrointestinal (GI) operation may have an adverse effect on mortality, morbidity, and even survival.

OBJECTIVE

To determine the risks of the converse: synchronous GI surgery appended to splenectomy for hematologic diseases.

DESIGN

Retrospective cohort.

SETTING

Multiple hospitals comprising an affiliated surgical training program.

PATIENTS

Consecutive sample of 207 adults (mean age, 49 years) with splenectomies for hematologic diseases.

INTERVENTION

Splenectomy and concomitant GI or biliary surgery (group 1, n=19) and splenectomy alone (group 2, n=188).

MAIN OUTCOME MEASURES

Length of hospital or intensive care unit stay, later operations, postoperative infections, postoperative abdominal abscess, major complications, and death.

RESULTS

Preoperative and intraoperative factors were similar in both groups. Operative mortality was 3 of 19 in group 1 and 8 of 188 in group 2 (p=.07). The mean number of major complications tended to be higher in group 1 (1.5 vs 0.5, P=07). Despite no difference between the incidences of overall postoperative infections, patients in group 1 were much more likely to develop an abdominal abscess (4 of 19 vs 3 of 188, P=.002). Logistic regression established that patients undergoing splenectomy and synchronous GI or biliary surgery were 25 times more likely to develop an intra-abdominal abscess than were patients with splenectomy alone, even controlling for confounding factors (odds ratio, 24.7; 95% confidence interval, 3.1 to 196; P=.002).

CONCLUSIONS

Synchronous GI or biliary surgery with splenectomy for hematologic disease increases the risk of intra-abdominal abscess and should be avoided. Complication and mortality rates may also be increased.

Risk factors for chronic venous insufficiency: a dual case-control study

PURPOSE

Most epidemiologic studies on chronic venous insufficiency (CVI) are cross-sectional surveys that suggest potential risk factors by describing their population. However, these relationships could be due to the CVI population's older age. We performed a dual case-control study with multivariate analysis to address this issue.

METHODS

Ninety-three patients with venous ulcers, 129 patients with varicose veins (VV), and 113 general population control patients from two hospitals were interviewed by use of a standardized questionnaire covering medical history, patient demographics, medications, and lifestyle questions. Univariate and multivariate analyses were used to compare the groups.

RESULTS

Univariate analyses showed CVI to be characterized by several factors, many of which were found to be age related after multivariate analysis. Age-adjusted relationships for CVI include male sex and obesity. Histories of serious leg injury or phlebitis were important associations resulting in a 2.4-fold and 25.7-fold increase in risk for CVI, respectively. After adjusting for age, subjects with VV tend to be younger and female, to more frequently have a history of phlebitis, and to report a family history of VV more frequently than control subjects.

CONCLUSIONS

Many of the previously suggested associations found with CVI are in reality due to this population's greater age. Patients with CVI are older, male, obese, have a history of phlebitis, and have a history of serious leg injury. These results suggest that a prior deep vein thrombosis, either clinical or subclinical, may be a predisposing factor for CVI.

Racial differences in the incidence of femoral bypass and abdominal aortic aneurysmectomy in Massachusetts: relationship to cardiovascular risk factors

PURPOSE

Atherosclerotic disease appears to be more severe in black patients than in white patients, but abdominal aortic aneurysms, which have traditionally been believed to have an atherosclerotic cause, are reported to be less common in black patients than in white patients. Our goals were to compare and contrast factors associated with the development of abdominal aortic aneurysms and clinically significant atherosclerotic occlusive disease (1) to determine whether these diseases share a common cause and (2) to explore their association with race.

METHODS

Dual case-control studies were conducted with multivariate analysis to compare cases (patients undergoing aneurysmectomy or patients undergoing femoral bypass) with a comparison group consisting of patients who had undergone appendectomy. Two data sources were used: (1) hospital discharge data for Massachusetts from 1984 through 1988 and (2) medical records at University Hospital of Boston and Boston City Hospital. For both the Massachusetts database and the hospital chart review, records were obtained for all patients discharged between January 1984 and December 1988 with an International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) procedure code for abdominal aortic aneurysm resection (38.44) or aneurysmorrhaphy (38.34) or with a procedure code for femoral artery bypass/reconstruction (39.29). To conduct a nested case-control study, records were also obtained for a control group consisting of patients between the ages of 50 and 84 years who had undergone appendectomy during the same 5-year period.

RESULTS

Black patients had higher rates of femoral bypass than did white patients after adjustment for age and sex (odds ratio = 1.97; 95% confidence interval: 1.49, 2.61; p < 0.0001). However, femoral bypass was also associated with hypertension, diabetes, and low household income. After adjusting for these additional factors in the statewide data set, the black/white odds ratio for femoral bypass was only 1.44 (95% confidence interval: 1.08, 1.92). The parallel case-control study at University Hospital and Boston City Hospital, which provided information about smoking status and more accurate ascertainment of coexisting hypertension and diabetes, indicated that there was no racial difference in rates of femoral bypass after correcting for these additional risk factors (odds ratio = 0.94; 95% confidence interval: 0.40, 2.22; p = 0.90). In contrast, abdominal aortic aneurysmectomy occurred predominantly in white men. Aneurysmectomy was also associated with smoking and hypertension, but aneurysmectomy was not significantly associated with diabetes mellitus or family income. The black/white odds ratio for aneurysm was 0.29; (95% confidence interval: 0.07, 1.23; p = 0.09 after adjustment for other variables).

CONCLUSIONS

Hypertension, smoking, and male sex are risk factors for the development of femoral atherosclerosis and abdominal aortic aneurysm formation. However, abdominal aortic aneurysms occur predominantly in white men and do not appear to be associated with diabetes mellitus or income. In contrast, the higher rate of femoral artery bypass in black patients is probably the result of greater prevalence among black patients of hypertension, diabetes, smoking, and perhaps by other ill-defined factors associated with socioeconomic status.

Traction injury to the liver during laparoscopic cholecystectomy

We describe an intraoperative complication of laparoscopic cholecystectomy and make recommendations to avoid its occurrence. We describe a case in which the liver was lacerated during a routine laparoscopic cholecystectomy. The laceration occurred when the gallbladder was retracted into the suprahepatic space, causing a traction injury of the quadrate lobe, 2 cm lateral to the falciform ligament. The placement of the epigastric trocar through the falciform ligament fixed the liver to the abdominal wall, facilitating the injury. When placing the epigastric trocar, care should be taken to avoid placement through the falciform ligament. If this is not possible, retraction of the gallbladder into the suprahepatic space should be accomplished while observing the liver edge. If the liver edge seems to be under tension, division of the falciform ligament to allow for easy retraction of the liver is recommended.

Functional outcomes in limb salvage vascular surgery

BACKGROUND

The crisis in health care brings a new focus to defining successful outcomes of medical treatments. The surgical literature has been criticized for not assessing functional outcomes in addition to technical success.

METHODS

We evaluated the functional outcomes of limb salvage surgery over 3 years in 38 patients 65 years of age and older with limb-threatening ischemia. The RAND-36-Item Health Survey 1.0 was used as a health assessment tool.

RESULTS

In spite of an 80% limb salvage rate, only 58% of patients survived 3 years and only 25% survived with the index limb and were able to walk. The RAND scores of patients whose limbs were amputated did not significantly differ from those of patients whose surgery was successful.

CONCLUSION

Functional outcome goals need to be better defined for patients who need limb salvage vascular operations to enhance the quality of care given these patients and to be in concert with emerging health policy.

Increased dietary fat content accelerates cholesterol gallstone formation in the cholesterol-fed prairie dog

Epidemiological studies have provided conflicting information about the relationship between fat consumption and gallstone formation. We studied cholesterol gallstone formation in prairie dogs after 1 wk of the following diets: (group A) a control diet with no added cholesterol and 5% of calories from corn oil, (group B) 1.2% cholesterol with 5% of calories from corn oil or (group C) 1.2% cholesterol with 40% of calories from corn oil. In controls serum cholesterol was 58.9 +/- 4.5 mg/dl, gallbladder bile was unsaturated with cholesterol (cholesterol saturation index = 0.7 +/- 0.1; cholesterol = 3.8 mmol/L) and none of 12 animals formed cholesterol crystals or stones. The low-fat diet supplemented with cholesterol (group B) increased serum and biliary cholesterol concentrations to 292 +/- 76 mg/dl and 7.5 +/- 1.1 mmol/L, respectively (p < 0.05), but cholesterol saturation index was only modestly increased (1.1 +/- 0.1) and in only one of eight animals did cholesterol monohydrate crystals develop. Group C, animals, which received cholesterol plus high levels of corn oil, had higher serum cholesterol levels (457 +/- 66 mg/dl), higher biliary cholesterol concentrations (16.6 +/- 1.3 mmol/L), higher cholesterol saturation indexes (1.7 +/- 0.1) and increased incidence of cholesterol gallstones (5 of 11). The two cholesterol-supplemented diets increased biliary phospholipid concentrations, decreased the ratio of cholic/chenodeoxycholic acid and increased the proportion of biliary lecithins containing linoleic acid, but these abnormalities were greatest in group C, which was given large amounts of corn oil. These findings suggest that cholesterol gallstone formation in the prairie dog is accelerated by increased dietary omega-6 polyunsaturated triglycerides.

Postlaparoscopic small bowel obstruction

Laparoscopic surgery continues to grow in popularity as a technique for approaching a variety of clinical problems. With an increase in the number of these procedures performed, unique complications, both early and late, will be identified. Optimal management of complications may differ significantly from the conventional approach. We describe the course of a patient who develops a high-grade partial small bowel obstruction 2 days after an uneventful laparoscopic cholecystectomy for acute cholecystitis. The patient had a history of laparoscopic pelvic surgery 7 years previously. Findings at exploration included a Richter's hernia through a midline fascial defect unrelated to our procedure. This defect, approximately 5 cm below the umbilicus, was most likely secondary to her previous laparoscopic procedure. This finding supports routine fascial closure of 10-mm or greater trochar sites and early, aggressive investigation and intervention in postlaparoscopic bowel obstructions.

Finding locations in the environment: the map as mediator

When an observer (O) uses a map (M) whose orientation does not correspond to the orientation of the environment (E) in which performance occurs, substantial errors occur: these are called map alignment effects. Much of the prior research on map/environment (M/E) alignment has involved maps of simple paths, although alignment effects have also been demonstrated for you-are-here (YAH) maps. A study is reported in which simple YAH maps were used to test the hypothesis that errors with misaligned maps would fall into categories predictable from the application of inappropriate cognitive operations to the misaligned maps, as demonstrated earlier by Rossano and Warren. Further, performance under conditions of M/E misalignment was compared with performance under map/observer (M/O) misalignment, the situation in which the map is sideways or upside-down with respect to the observer. The major hypothesis was supported: predictable errors occurred under conditions of M/E misalignment. Errors under conditions of M/O misalignment were significantly smaller. Furthermore, when given the choice of using M/E or M/O alignment, each at the expense of the other, the overwhelming choice was to retain M/E rather than M/O alignment. This pattern of results occurred even when environmental features were represented by words rather than by lines and shapes on the map. The results underscore the robustness of map alignment effects.

Intravenous glutamine fails to improve gut morphology after radiation injury

Male Sprague-Dawley rats housed in individual metabolic cages received total parenteral nutrients via chronic indwelling internal jugular catheters to determine whether supplementing parenteral nutrition with glutamine would accelerate recovery of small-bowel morphology after abdominal radiation. After recovering from catheter insertion for 3 days they received either 1000 cGy gamma radiation to the abdomen only or no radiation and immediately thereafter received isonitrogenous and isocaloric intravenous solutions containing either 0% or 2% glutamine at 1.58 mL/h for the next 5 days. Intestinal segments were then assayed for whole-bowel deoxyribose nucleic acid content and villus height. Irradiation caused a 40% decrement in these parameters, which were not restored by glutamine supplementation. Therefore, intravenous glutamine supplementation failed to accelerate recovery of small-bowel morphology in this model of combined surgical and radiation injury.

Clinical decision analysis as a means of technology assessment. The effectiveness of intraoperative cholangiography

Three strategies for timely detection of common duct stones are examined by decision analysis: the use of intraoperative cholangiography (IOC) in ALL, NONE, or in SOME of the cases that are selected by the estimated probability of a common duct stone. Selective use of IOC is the most cost-effective option and offers a slightly lower mortality risk.

Inhibition of prostaglandin synthesis fails to prevent gallbladder mucin hypersecretion in the cholesterol-fed prairie dog

Gallstone formation in the cholesterol-fed prairie dog is preceded by an increase in mucin secretion by the gallbladder epithelium, and mucin hypersecretion is believed to promote cholesterol gallstone formation by accelerating the nucleation of cholesterol monohydrate crystals. Some studies have suggested that gallbladder mucin hypersecretion is mediated by increases in gallbladder prostaglandin synthesis, but other observations are difficult to reconcile with this view. An organ culture technique was used to measure mucin secretion in normal prairie dog gallbladder in response to exogenous prostaglandins and agents that increased or decreased endogenous prostaglandin production. Incubation with indomethacin produced a concentration-dependent inhibition of endogenous prostaglandin synthesis with virtually complete inhibition at 10(-5) mol/L indomethacin. However, indomethacin had no effect on gallbladder mucin secretion at concentrations as high as 10(-5) mol/L, and significant inhibition of mucin secretion was only found at 10(-4) mol/L indomethacin, a concentration that also produced a significant increase in lactate dehydrogenase release from cultured explants. Incubation of gallbladder explants with the calcium ionophore A23187 significantly stimulated endogenous prostaglandin synthesis in a concentration-dependent manner, increasing synthesis of prostaglandins E and F to as much as 278% +/- 20% and 335% +/- 21% of basal values, respectively; however, the same concentrations of A23187 did not stimulate mucin secretion. Incubation of gallbladder explants in the presence of exogenous prostaglandin E2 or prostaglandin F2a in concentrations as high as 10(-6) mol/L also did not stimulate mucin secretion. Prairie dogs fed a lithogenic 1.2% cholesterol diet showed a significant increase in gallbladder mucin secretion after 1 week (117.5 +/- 10.2% of control, P less than 0.05), and 4 of 5 had formed cholesterol monohydrate crystals after 3 weeks. Long-term treatment with indomethacin, 1.2 mg.kg-1.day-1, failed to inhibit gallbladder mucin hypersecretion (129.2 +/- 10.7% of control after 1 week) or cholesterol monohydrate crystal formation (3/5) in cholesterol-fed prairie dogs. Furthermore, incubation of explants with 10(-5) mol/L indomethacin failed to prevent in vitro mucin hypersecretion in cholesterol-fed animals. These findings suggest that prostaglandins do not regulate gallbladder mucin secretion in the prairie dog, and it is unlikely that increases in gallbladder prostaglandin synthesis are responsible for mediating gallbladder mucin hypersecretion during cholelithiasis in the prairie dog.

Effects of dietary fish oil on biliary phospholipids and prostaglandin synthesis in the cholesterol-fed prairie dog

Cholesterol gallstone formation in the prairie dog is accompanied by an increase in the percentage of biliary phospholipids containing arachidonic acid, and an increase in gallbladder prostaglandin (PG) synthesis, but the pathogenetic significance of these changes is unclear. Dietary supplementation with eicosapentaenoic acid (EPA), an omega-3 fatty acid which is commonly found in fish oil, decreases prostaglandin synthesis in some tissues by replacing arachidonic acid, and by competitively inhibiting prostaglandin synthesis. We studied the effect of dietary fish oil on gallbladder PG synthesis, and the relative abundance of various molecular species of phosphatidylcholines and phosphatidylethanolamines in bile and gallbladder epithelium in the cholesterol-fed prairie dog. Prairie dogs were maintained for 4 weeks on one of four diets: i) control, ii) cholesterol-supplemented (0.34%), iii) menhaden oil (50 g/kg chow), or iv) cholesterol plus menhaden oil. Supplementation with menhaden oil resulted in a replacement of arachidonic and linoleic acids with EPA and docosahexaenoic acids in the phospholipids of bile and gallbladder mucosa. In cholesterol-fed animals, supplementation with menhaden oil prevented increased gallbladder PG synthesis. Menhaden oil also reduced the incidence of cholesterol monohydrate crystals among cholesterol-fed animals (9/20 with cholesterol plus menhaden oil vs 21/22 with cholesterol alone), but the improvement could not clearly be attributed to decreased PG synthesis since supplementation with menhaden oil also increased the total phospholipid concentration in bile, and decreased the degree of cholesterol saturation. These results demonstrate that dietary supplementation with omega-3 fatty acids significantly influences biliary phospholipids, and decreases the incidence of cholesterol monohydrate crystal formation in this animal model.

Effect of dietary cholesterol on phosphatidylcholines and phosphatidylethanolamines in bile and gallbladder mucosa in the prairie dog

Humans with cholesterol gallstones have been reported to have alterations in the molecular species of phospholipids in bile. Both decreases in phospholipids with linoleic acid and increases in those with arachidonic acid have been found. The purpose of this study was to investigate the effect of a lithogenic diet (0.34% cholesterol) on the relative abundance of individual molecular species of phospholipids in the biliary tract of the prairie dog. In hepatic bile, cholesterol feeding resulted in increases in phospholipid species containing arachidonate and decreases in the major species containing its precursor, linoleate. In gallbladder bile of both control and cholesterol-fed animals, phospholipid species containing linoleate were significantly less abundant than in hepatic bile, suggesting that linoleoyl species were selectively absorbed by the gallbladder epithelium. This apparent uptake was significantly increased by cholesterol feeding. Phosphatidylcholines and phosphatidylethanolamines containing arachidonate were also significantly increased in the gallbladder mucosa of the cholesterol-fed animals. These increases in arachidonate-containing phospholipids in the gallbladder mucosa may contribute to the increase in gallbladder prostaglandin synthesis that precedes gallstone formation in this animal model.

HLA-DQw alloantigens and pulmonary dysfunction in rheumatoid arthritis

HLA-DR4 and keratoconjunctivitis sicca (secondary Sjögren's syndrome) are associated with abnormal pulmonary function in patients with rheumatoid arthritis. Since recent investigations have found that much of the genomic polymorphism of the HLA-DR4 haplotype comes from the closely linked DQw allele, we reanalyzed this set of data to evaluate the relationship between the DQw allotypes and pulmonary function in rheumatoid arthritis. Using a step-wise regression analysis, we found that the presence of DQw1 was a stronger predictor of an abnormal forced vital capacity (FVC), forced expiratory volume in one second (FEV1), and carbon monoxide diffusing capacity (D) than the presence of DR4, keratoconjunctivitis sicca, smoking status, or any other clinical parameter. DQw1-positive patients had a mean (+/- SD) percent of predicted FEV1, FVC, and D of 84.2 (+/- 19.8), 88.0 (+/- 17.9) and 85.6 (+/- 20.9) percent, respectively, all significantly lower than DQw-1 negative patients (p = 0.02, 0.02, and 0.03). Smokers with the heterozygous phenotype, DQw1/DQw3, tended to have obstructive disease of the airways, with a mean (+/- SD) FEV1 of 80.1 +/- 24.4 percent of predicted, compared to 95.7 +/- 12.1 percent of predicted in DQw1/DQw3-negative individuals (p = 0.03). Patients who had a DQw2 allele were more likely to have normal pulmonary function. We conclude that the HLA-DQw1 allotype is a strong predictor of abnormal pulmonary function and that it may identify smoking subjects with rheumatoid arthritis subjects who are prone to develop obstruction of airflow.

Intracranial and paranasal sinus infection due to Drechslera

Drechslera, a common soil fungus, has rarely been reported as a human pathogen. We have reported a case of Drechslera paranasal sinus and intracranial infection successfully treated with surgical resection, amphotericin B, and ketoconazole.

Systemic sclerosis (scleroderma): clinical, genetic, and serologic subsets

Immunogenetic markers, autoantibodies, and clinical features were studied in 47 patients, 35 Caucasian and 12 black, with systemic sclerosis. Twenty-two had generalized scleroderma, while 25 had limited skin involvement. HLA-DR1 (RR = 2.1, p = 0.08) and DR5 (RR = 2.1, p = 0.08) were increased in Caucasian patients vs controls as was the supertypic specificity HLA-DRw52 (RR = 2.8, p = 0.02, pc = 0.04). HLA-DR6.1 was increased in black patients vs controls (RR = 15.4, p = 0.008, pc = 0.088). There were no significant increases in any of the complement allotypes in either racial group. Anticentromere antibody was noted in 10 patients, all Caucasian; 7 had limited disease. Anti-Scl-70 was noted in 4 patients; all had generalized disease (p = 0.036). HLA-DR2 was present in all anti-Scl-70 positive patients (RR = 22.5, p = 0.006). Our results suggest that clinical subsets of systemic sclerosis can be defined by genetic and serological markers.

HLA-DR4 and pulmonary dysfunction in rheumatoid arthritis

Rheumatoid arthritis is associated with an increased frequency of the B cell alloantigen HLA-DR4, and preliminary work has suggested an association between HLA-DR4 and obstructive lung disease in subjects with rheumatoid arthritis. To prospectively evaluate the influence of HLA-DR4 on pulmonary involvement in patients with rheumatoid arthritis, pulmonary function was measured in four groups of subjects with rheumatoid arthritis in whom HLA-DR4 and smoking status was known: 16 DR4-positive smokers (six current and 10 exsmokers), 16 DR4-negative smokers (six current and 10 exsmokers), eight DR4-positive nonsmokers, and eight DR4-negative nonsmokers. Significant reductions in one-second forced expiratory volume and forced vital capacity were observed in DR4-positive subjects compared with DR4-negative subjects irrespective of cigarette smoking status. In addition, patients with keratoconjunctivitis sicca (secondary Sjögren's syndrome) demonstrated significant reductions in one-second forced expiratory volume, forced vital capacity, and ratio of one-second forced expiratory volume to forced vital capacity compared with those patients without evidence of secondary Sjögren's syndrome. It is concluded that the presence of the HLA-DR4 antigen and secondary Sjögren's syndrome are associated with abnormal pulmonary function in patients with rheumatoid arthritis.

Nicardipine in the treatment of Raynaud's phenomenon. Dissociation of platelet activation from vasospasm

A new calcium channel blocker, nicardipine, was studied for treatment of Raynaud's phenomenon in a double-blind, placebo-controlled, crossover trial during the winter months. Clinical response was assessed by a patient-kept diary of symptoms and finger systolic pressure that was measured at room temperature and during cold challenge. In vivo platelet activation was determined by measuring plasma levels of the platelet-specific proteins, beta-thromboglobulin and platelet factor 4. When treatment with placebo was compared with treatment with nicardipine, no significant differences were found in the number of Raynaud's attacks per day, the severity of attacks, change in character in Raynaud's phenomenon, use of hands in winter months, patient assessment of medication or objective measurements of finger systolic pressure, and critical closing temperature. There was a reduction of plasma levels of beta-thromboglobulin and platelet factor 4 in the overall study group while taking nicardipine compared with that during the placebo period (mean change 5.0 +/- 2.4 ng/ml, P = 0.054, and 1.4 +/- 0.6 ng/ml, P less than 0.01, respectively). These results demonstrate that while nicardipine was not effective in reducing the episodes of Raynaud's phenomenon, it did inhibit in vivo platelet activation. These findings suggest that platelet activation is not the primary event in the pathogenesis of acute vasospasm in Raynaud's phenomenon, since reduction of platelet activation by the drug did not change the severity of vasospasm.

Gallbladder prostaglandins and lysophospholipids as mediators of mucin secretion during cholelithiasis

Mucin hypersecretion from the gallbladder epithelium contributes to cholesterol gallstone formation by accelerating the nucleation of cholesterol-supersaturated bile. Prostaglandins (PGs) and lysophosphatidylcholine (LPC) have both been implicated as potential mediators of mucin hypersecretion, but their roles are unclear. We fed prairie dogs a lithogenic diet (0.34% cholesterol), and after 1, 2, 4, or 6 wk of cholesterol feeding, we measured glycoprotein and LPC concentrations in bile and PG synthesis in gallbladder and liver slices. Hypercholesterolemia and cholesterol supersaturation of bile occurred after 1 wk of cholesterol feeding, but marked crystal formation was delayed until 4 wk, when glycoprotein concentrations became markedly elevated. Glycoprotein hypersecretion was preceded by increased synthesis of PGF2 alpha (P less than 0.002), PGE2 (P less than 0.001), prostacyclin (P less than 0.05), and thromboxane (P = 0.07) in the gallbladder after only 2 wk of cholesterol feeding, but PG synthesis in the liver remained unchanged (P greater than 0.14). LPC concentrations in gallbladder bile also increased at 2 wk (P less than 0.02), but LPC in hepatic bile was unchanged (P = 0.35). In organ culture studies, LPC caused a dose-dependent stimulation of [3H]glycoprotein release from guinea pig gallbladder mucosa that could not be explained solely by LPC's detergent properties. We conclude that gallbladder PG synthesis and LPC production are increased at an early stage of cholesterol gallstone formation in the prairie dog model. These changes probably play a significant role in gallstone pathogenesis, since they mediate hypersecretion of gallbladder mucin and thus favor the nucleation of cholesterol-supersaturated bile.

Gingival and bacterial plaque response to instrumentation, oral hygiene instruction and nutritional therapy

Thirty-three male subjects participated in a study to examine the effect of supplements of multiple vitamins and minerals, local therapy (periodontal instrumentation and oral hygiene instruction) and a combination of both on gingival inflammation and bacterial plaque formation. Subjects were given either multivitamin and mineral supplements or placebos on a double-blind basis for 21 days. On Day 7, the mandibular incisors were instrumented, and each subject was instructed in brushing and flossing. Observations were taken at Days 0, 7 and 21. There was a significant (P = 0.004) effect from micronutrient supplementation at Day 7 on the gingival index but no significant effect on the plaque index. On Day 21 there was no statistical superiority noted for the supplemented group in respect to either the gingival or plaque index, although the gingival index approached significance (P = 0.062).

Increases in gallbladder prostaglandin synthesis before the formation of cholesterol gallstones

Increased synthesis of prostaglandins in the wall of the gallbladder may play a role in the pathogenesis of cholesterol gallstones by mediating mucus hypersecretion and thereby accelerating nucleation and the precipitation of cholesterol-supersaturated bile. We induced gallstones in prairie dogs and guinea pigs by feeding a cholesterol-supplemented diet for periods as long as 6 weeks. Gallbladder prostaglandin synthesis was quantitated by specific radioimmunoassays that measured the amount of various prostanoids released from the gallbladder during in vitro incubation. The gallbladders of cholesterol-fed prairie dogs showed increased synthesis of prostaglandin E2, prostaglandin F2a, and thromboxane and increased concentrations of glycoprotein in gallbladder bile. These changes were evident as early as 2 weeks after institution of the cholesterol diet, although cholesterol gallstones did not form until 4 or more weeks. In contrast, cholesterol feeding of the guinea pig did not induce cholesterol supersaturation. In this species pigment gallstones formed, probably as a result of a cholesterol-induced hemolytic anemia, and gallbladder mucus hypersecretion did not occur. Pigment gallstone formation in the guinea pig was associated with an increase in prostacyclin synthesis, but the synthesis of prostaglandin F2a and thromboxane was decreased. Increased prostaglandin synthesis may contribute to the formation of cholesterol gallstones but does not appear to participate in pigment gallstone formation.

Pigment gallstone formation in the cholesterol-fed guinea pig

Female Hartley guinea pigs fed a 0.5% cholesterol-supplemented diet were found to form pigmented gallstones after 6 weeks (17/23) and 12 weeks (11/11), while only 2 of 44 animals fed a trace cholesterol diet formed gallstones over a comparable period. The light brown stones consisted primarily of aggregates of fine granular crystals, morphologically similar to calcium bilirubinate crystals. The stones were soluble in 0.1 N sodium hydroxide and were found to contain a substance which co-migrated with unconjugated bilirubin during thin-layer chromatography. Despite hypercholesterolemia (202 +/- 34 vs. 59 +/- 22 mg per dl in controls, p less than 0.05) and fatty infiltration of the liver, cholesterol-fed animals had a lithogenic index of only 0.22 +/- 0.04 in gallbladder bile as compared to a lithogenic index of 0.02 +/- 0.01 in animals fed the trace cholesterol diet. Accordingly, no cholesterol monohydrate crystals were found in any animals. Hematocrits among cholesterol-fed animals (47.6 +/- 1.2%) were lower than those of controls (54.8 +/- 1.3%, p less than 0.05) probably as a result of the cholesterol-induced hemolytic anemia which has been reported by others in this species. Fasting gallbladder volume was greater in cholesterol-fed animals (2.4 +/- 0.18 ml) than in controls (1.7 +/- 0.11, p less than 0.0025), and a comparable increase in gallbladder dry tissue mass was found. There was no evidence of biliary obstruction, however, and the gallbladder contractile response to octapeptide cholecystokinin was comparable in both groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Intestinal consumption of intravenously administered fuels

Total parenteral nutrition has been extensively used to feed patients with a variety of gastrointestinal diseases, but little attention has focused on the nutritional requirements of the gut. To investigate intestinal consumption of intravenously administered nutrients, uptake of three principal fuels determined from in vitro studies was quantitated in seven awake, unrestrained dogs. Portal blood flow was measured by a dye dilution technique and, simultaneously, substrate samples were obtained from chronic indwelling arterial and portal venous catheters. Studies were performed during a postabsorptive basal period and during separate infusions of glutamine (0.10 mmol/kg X min), glucose (0.10 mmol/kg X min), and beta-hydroxybutyrate, (0.40 mmol/kg X min). During the basal period there was a significant arterial-portal vein gradient for glucose (144 +/- 26 mumol/liter) and glutamine (49 +/- 11 mumol/liter). These substances were taken up by the gut at rates of 4.11 +/- 1.23 and 1.43 +/- 0.19 mumol/kg X min, respectively. No significant uptake of beta-hydroxybutyrate was determined in the basal studies (0.27 +/- 0.10 mumol/kg X min). During substrate infusion, gut glucose uptake was unchanged (2.68 +/- 1.67 mumol/kg X min, NS), but consumption of glutamine (4.60 +/- 0.66 mumol/kg X min, p less than 0.001) and beta-hydroxybutyrate (4.33 +/- 0.71 mumol/kg X min, p less than 0.001) increased significantly. During parenteral feedings in patients with gastrointestinal disorders, circulating levels of beta-hydroxybutyrate and glutamine are often low, and glutamine is absent from standard amino acid solutions. Current parenteral formulation may not provide appropriate fuels for the gastrointestinal tract.

Management of traumatic carotid cavernous fistula using the Fogarty catheter technique

Two patients with traumatic carotid cavernous fistula are described, in whom operative introduction of a Fogarty catheter through the internal carotid artery at the cervical level was followed by complete and partial relief of neurologic symptoms and no recurrence of fistulas. This technique offers simplicity, lower morbidity, and no known mortality.