C-reactive protein as a marker of complicated diverticulitis in patients on anti-inflammatory medications.

BACKGROUND: Diverticulitis is a common indication for surgical emergency room admission, often leading to abdominal computed tomography (CT) scanning for both diagnosis and staging. C-reactive protein (CRP) has been identified as a useful biomarker of inflammation. Aspirin and corticosteroids are known to down-regulate CRP production. In this study, we evaluated the usefulness of CRP as a biomarker for complicated diverticulitis and specifically in patients on anti-inflammatory medications: aspirin and corticosteroids. METHODS: We analyzed the medical records of patients diagnosed at one medical center during a two-year period, with left-sided diverticulitis, according to clinical data and CT scan. Disease severity was assessed by the Hinchey score using the radiological findings detected by CT. RESULTS: A total of 295 patients were included in the study. Two hundred and forty-three (82 %) were classified with uncomplicated (Hinchey 1a) and 52 (18 %) with complicated disease (Hinchey > 1a). Mean CRP levels were 133.5 and 63.5 mg/ml for those with complicated and uncomplicated disease, respectively (p < 0.001), and 139 and 60 mg/ml, respectively (p < 0.001) in the subgroup of patients taking aspirin (n = 61). For 14 patients on corticosteroid treatment, the difference in mean CRP levels for complicated and uncomplicated disease was not statistically significant. CRP > 90 mg/ml had 88 % sensitivity and 75 % specificity for complicated disease. CONCLUSIONS: The CRP level distinguished between complicated and uncomplicated disease among left-sided diverticulitis patients including those taking aspirin, but not among those on corticosteroid treatment.

Bioethics consultation practices and procedures: a survey of a large Canadian community of practice.

The literature fails to reflect general agreement over the nature of the services and procedures provided by bioethicists, and the training and core competencies this work requires. If bioethicists are to define their activities in a consistent way, it makes sense to look for common ground in shared communities of practice. We report results of a survey of the services and procedures among bioethicists affiliated with the University of Toronto Joint Centre for Bioethics (JCB). This is the largest group of bioethicists working in healthcare organizations in Canada. The results suggest there are many common services and procedures of JCB bioethicists. This survey can serve as a baseline for further exploration of the work of JCB bioethicists. Common practices exist with respect to the domains of practice, individual reporting relationships, service availability within business hours and the education and training of the bioethicist.

How young is too young to be a living donor?

Assessing people in adolescence and early adulthood who wish to become living organ donors (LDs) provides unique challenges. In several Canadian provinces, 16-year-old can legally consent to living organ donation. While the World Health Organization states that adolescence corresponds roughly to the ages of 10-19 years, parts of the brain associated with judgment continue to develop into the mid-20s. Therefore, it is legally possible for some young people to donate organs before their capacity to judge the benefits and risks of surgery has fully matured. Potential young living donors (YLDs) may be financially and/or psychologically dependent on their recipients (e.g. parents), which can make it difficult to determine if the YLD's donation is voluntary. This paper suggests ways to manage three ethical challenges in the use of young people as LDs: (1) determining the YLD's ability to appreciate the consequences of living organ donation, (2) determining whether the YLD's donation is voluntary and (3) evaluating the unique risks and benefits to the YLD. We conclude that there are compelling ethical reasons to offer the opportunity of living donation to selected young people. A thorough and fair evaluation process can address social, emotional and developmental issues associated with YLDs.

Eruptions arising from tidally controlled periodic openings of rifts on Enceladus.

In 2005, plumes were detected near the south polar region of Enceladus, a small icy satellite of Saturn. Observations of the south pole revealed large rifts in the crust, informally called 'tiger stripes', which exhibit higher temperatures than the surrounding terrain and are probably sources of the observed eruptions. Models of the ultimate interior source for the eruptions are under consideration. Other models of an expanding plume require eruptions from discrete sources, as well as less voluminous eruptions from a more extended source, to match the observations. No physical mechanism that matches the observations has been identified to control these eruptions. Here we report a mechanism in which temporal variations in tidal stress open and close the tiger-stripe rifts, governing the timing of eruptions. During each orbit, every portion of each tiger stripe rift spends about half the time in tension, which allows the rift to open, exposing volatiles, and allowing eruptions. In a complementary process, periodic shear stress along the rifts also generates heat along their lengths, which has the capacity to enhance eruptions. Plume activity is expected to vary periodically, affecting the injection of material into Saturn's E ring and its formation, evolution and structure. Moreover, the stresses controlling eruptions imply that Enceladus' icy shell behaves as a thin elastic layer, perhaps only a few tens of kilometres thick.

Perioperative blood transfusion in cancer patients undergoing laparoscopic colorectal resection: risk factors and impact on survival.

BACKGROUND: Perioperative blood transfusion has been associated with a poor prognosis in patients undergoing surgery for colorectal cancer. The aim of this study was to evaluate risk factors for blood transfusion and its impact on long-term outcome exclusively in patients undergoing laparoscopic surgery for curable colorectal cancer. METHODS: Data were retrieved from a prospectively collected database of patients who underwent laparoscopic surgery for curable colorectal cancer over a 6-year period. Long-term data were collected from our outpatient clinic and personal contact when necessary. RESULTS: Two hundred and one patients underwent laparoscopic surgery for curable colorectal cancer (stage I-III). Sixty-eight (33.8 %) received blood transfusions during or after surgery. These patients were typically older, had lower preoperative hemoglobin levels, had a more advanced cancer, had a higher Charlson score, had a higher rate of complications and had a higher conversion rate. Kaplan-Meier overall survival analysis was significantly worse in patients who received blood transfusions (P = 0.004). Decreased disease-free survival was also observed in transfused patients; however, this did not reach statistical significance (P = 0.21). A multivariate analysis revealed that transfusion was not an independent risk factor for decreased overall and disease-free survival. The Charlson score was the only independent risk factor for overall survival (OR = 2.1, P = 0.002). Independent factors affecting disease-free survival were stage of disease, Charlson score and, to a lesser degree, age and body mass index. CONCLUSIONS: Perioperative blood transfusion is associated with decreased long-term survival in patients undergoing laparoscopic resection for colorectal cancer. However, this association apparently reflects the poorer medical condition of patients requiring surgery and not a causative relationship.

Five-year follow-up of Doppler-guided hemorrhoidal artery ligation.

BACKGROUND: Doppler-guided hemorrhoidal artery ligation (DGHAL) was described as lower risk and a less painful alternative to hemorrhoidectomy. We report our experience and 5-year follow-up with this procedure. METHODS: Between May 2003 and December 2004, 100 patients with symptomatic Grade II or III hemorrhoids underwent ultrasound identification and ligation of 6-8 terminal branches of the superior rectal artery above the dentate line by a single surgeon using local, regional, or general anesthesia. There were 42 men and 58 women (mean age 42 years, median duration of symptoms 6/3 years). A 10-point visual analog scale was used for postoperative pain scoring. Surgical and functional outcome was assessed at 6 weeks and 3 and 12 months after surgery, with long-term follow-up by a telephone questionnaire at 5 years after the procedure. RESULTS: The mean operative time was 19 min. Local anal block combined with intravenous sedation (n = 93) or general or spinal (n = 7) anesthesia was used. Only 5 patients were hospitalized overnight. There was no urinary retention, bleeding, or mortality in the immediate postoperative period. The mean pain score decreased from 2.1 at 2 h postoperatively to 1.3 on the first postoperative day. All patients had complete functional recovery by the third postoperative day. Ninety-six patients completed 12 months of follow-up. Eighty-five of these patients (89%) remained asymptomatic at 12 months, though this number dropped to 67/92 (73%) at 5 years. CONCLUSIONS: Long-term follow-up confirms the effectiveness of the DGHAL procedure for treatment for Grade II hemorrhoids. The DGHAL procedure alone seems less effective for Grade III hemorrhoids.

Is Doppler ultrasonography essential for hemorrhoidal artery ligation?

BACKGROUND: Doppler ultrasonography enables accurate identification of the terminal branches of the superior rectal artery prior to hemorrhoidal artery ligation (HAL). However, since the positions of these branches have been found to be relatively constant, the question arises as to the necessity of ultrasonography for their identification. The aim of the current study was to examine the positions of all arteries identified and ligated during the HAL procedure. METHODS: We recorded the position of all arteries located and ligated in 135 consecutive patients who underwent the HAL procedure during the years 2003 to 2006. RESULTS: In all patients, 6-8 terminal arterial branches were located above the dentate line. In 102 (76 %) patients, terminal branches were located in all 6 of the odd-numbered clock positions around the anus (1, 3, 5, 7, 9, and 11 o'clock in the lithotomy position). If we had ligated arteries only at these odd-numbered clock positions, without using Doppler ultrasonography, we would have located all the arteries in 96 (71 %) of our patients. CONCLUSIONS: The number and location of arterial branches of the superior rectal artery are relatively constant. Nevertheless, if, Doppler ultrasonography had not been performed and, ligation in the HAL procedure had been at the odd-numbered clock positions only, then at least one artery would have been missed in 29 % of our patients.

Early Prophylactic Gastrectomy for the Management of Gastric Adenomatous Proximal Polyposis Syndrome (GAPPS).

Background: Gastric adenomatous proximal polyposis syndrome (GAPPS) is a recently described, rare, autosomal dominant condition characterized by the extensive involvement of the proximal stomach with hundreds of heterogeneous fundic gland polyps with antral and duodenal sparing. GAPPS is caused by a point mutation of the APC gene promoter 1B and is associated with a risk of malignant transformation, distant metastasis, and death. There are no surveillance, screening, or treatment guidelines for managing GAPPS. The few reported cases have been variably managed with endoscopic surveillance or prophylactic gastrectomy. However, there is no consensus on the optimal management approach. Summary: In this case series, we review the relevant literature on GAPPS and present two siblings who underwent early prophylactic total gastrectomies with good outcomes. Conclusion: Due to the poor correlation between the endoscopic findings on sampled polyps and the risk of harboring invasive gastric cancer, patients with GAPPS should be strongly considered for early prophylactic total gastrectomies in the absence of prohibitive comorbidities.

What drives variation in the corticosterone stress response between subspecies? A common garden experiment of swamp sparrows (Melospiza georgiana).

Although differences in the corticosterone stress response have frequently been reported between populations or closely related subspecies, their origin remains unclear. These differences may appear because individuals adjust their corticosterone stress response to the environmental conditions they are experiencing. However, they may also result from selection that has favoured individuals with specific corticosterone stress response or from environmental factors that have affected the development of the corticosterone stress response during early life. We investigated these hypotheses by studying the corticosterone stress response of two closely related subspecies of swamp sparrows (Melospiza sp.). We showed for the first time that two closely related subspecies can differ in their corticosterone stress response when raised at the laboratory and held in similar conditions for a year. Thus, we demonstrated that selection, developmental processes or a conjunction of both of these processes can account for variation in the stress response between closely related subspecies.

Outcome of repeated stapler haemorrhoidopexy for recurrent prolapsing haemorrhoids.

AIM: Stapled haemorrhoidopexy (SH) is associated with minor postoperative pain and high overall satisfaction rates. Some patients will have persistent or recurrent symptoms requiring re-intervention. METHOD: All patients who underwent SH for grade III internal haemorrhoids and required a second SH (2005-2008) were studied. Grade IV patients were excluded. Data on surgical technique, postoperative pain, complications, time to first bowel movement, functional recovery and suspected reason for first SH failure were retrieved from medical records. Similar data were collected for the second procedure at four postoperative follow-up visits. RESULTS: Twelve patients were enrolled. The mean time to recurrent symptoms was 15 months. The indications for repeated surgery were bleeding, prolapse, and pruritus w/wo discharge. Recurrence was attributed to a too high staple line in the first procedure (n = 4) and an incomplete resected ring (n = 1). The median operative time of the second procedure was 24 min (17-29) and the median follow up was 20 ± 4.3 months (15-30). Repeat SH was associated with higher pain scores, more analgesic requirements, and longer recovery period compared to the first procedure. There were no early or late postoperative complications. Histological examination of the 12 tissue doughnuts resected during the second SH showed no smooth muscle fibres in any of the patients. After 12 months of follow up, 10 patients with repeated SH remained asymptomatic, while 2 had recurrent bleeding. CONCLUSION: Repeat SH can be performed safely and reliably without risk of complications, but the second SH is associated with more pain and longer recovery time.

Outcome of stapled hemorrhoidopexy versus doppler-guided hemorrhoidal artery ligation for grade III hemorrhoids.

PURPOSE: To evaluate the long-term results, early and late complication rates, and overall satisfaction of patients with grade III hemorrhoids treated by stapled hemorrhoidopexy (SH) or Doppler-guided hemorrhoidal artery ligation (DGHAL). METHODS: Operative and follow-up patients' data were prospectively collected for patients undergoing either SH or DGHAL by a single surgeon during a 2-year period. A retrospective comparison between patients' outcome operated by one of the two methods was made based on this data. Clinical data on postoperative pain, analgesic requirements, time to first bowel movement and functional recovery were collected at five postoperative follow-up visits (1 and 6 weeks, 6, 12, and 18 months). Data on patient satisfaction, recurrence of hemorrhoidal symptoms and further treatments were obtained by a standardized questionnaire that was conducted during the last visit 18 months postoperatively. RESULTS: A total of 63 patients underwent SH (aged 52 ± 3.2 years) and 51 patients underwent DGHAL (aged 50 ± 7.3 years). DGHAL patients experienced less postoperative pain as scored by pain during bowel movement (2.1 ± 1.4 vs. 5.5 ± 1.9 for SH), and required fewer analgesics postoperatively. Hospital stay, time to first bowel movement, and complete functional recovery were also significantly shorter for the DGHAL patients. Nine DGHAL patients (18%) suffered from persistent bleeding or prolapses and required additional treatment compared with 2 (3%) patients in the SH group. SH patients reported greater satisfaction compared with DGHAL patients at 1 year postoperatively. CONCLUSION: Both SH and DGHAL are safe procedures and have similar effectiveness for treating grade III hemorrhoids. DGHAL is less painful and provides earlier functional recovery, but is associated with higher recurrence rates and lower satisfaction rates compared with SH.

Metastatic lymph node ratio (LNR) as a prognostic variable in colorectal cancer patients undergoing laparoscopic resection.

BACKGROUND: Lymph node ratio (LNR: the ratio of metastatic to total retrieved nodes) has shown prognostic significance in several tumors. Its role in patients with colorectal cancer submitted to laparoscopic resection is still not clearly defined. The aim of this study was to evaluate the impact of LNR on long-term outcome in patients undergoing curative laparoscopic resection. METHODS: Patients' data were retrieved from our prospective in-hospital collected data of patients that underwent laparoscopic surgery for curable colorectal cancer over a 6-year period. Long-term data were collected from our outpatient's clinic data and personal contact when necessary. RESULTS: Two hundred and five patients underwent laparoscopic resection for curable colorectal cancer in the study period. Sixty-five patients were node positive. Receiver operating characteristic (ROC) analysis selected 0.13 as the best LNR cutoff value in this group. Kaplan-Meier 5-year survival analysis revealed a significant decrease in overall and disease-free survival in patients with an LNR above 0.13. Long-term outcome of patients with an LNR below 0.13 was similar to node-negative stage II patients. CONCLUSIONS: The lymph node ratio is a valuable prognostic factor in node-positive colon cancer patients undergoing laparoscopic resection. Patients with an LNR below 0.13 have the same long-term outcome as stage II node-negative patients. The laparoscopic approach presents the same trends in terms of overall survival and disease-free survival as conventional open access when LNR is considered.

Spinal and visceral ischemia after endovascular aortic repair.

With the evolution of endovascular therapy, there is a broader application of this technology for the treatment of aortic disease. The span of treatment is no longer limited to the descending thoracic aorta and the infrarenal abdominal aorta. The development of branched aortic endograft therapies has allowed stent graft treatment of more extensive thoracoabdominal aortic aneurysms and more complex aortic pathologies. With this rapidly expanding experience it is possible to better assess the complications that arise with this surgery. Two devastating complications that can occur with conventional aortic surgery are spinal cord and visceral ischemia. The incidence of these complications is low, and is often related to periods of visceral or cord malperfusion during periods of hypotension or aortic cross-clamping. Unfortunately, however, these complications continue to occur despite the use of endovascular technology. As the volume of endovascular aortic procedures increases, it is possible to more accurately assess the incidence of these dreaded complications. In addition, it appears that the pathophysiology associated with their development may occasionally differ from that observed in open surgery. Enhancing our understanding of spinal and visceral ischemia development during aortic endovascular surgery will allow us to more effectively prevent and treat their occurrences. This article will review our current understanding of the incidence, pathophysiology, preventive and treatment options for spinal cord and visceral ischemia associated with endograft surgery of the aorta.

Hybrid procedures for the treatment of aortic arch aneurysms.

Aortic arch aneurysms present a significant clinical challenge. Historically, open repair has been the mainstay of therapy, but it is associated with significant morbidity and mortality. In particular, the risk of stroke is not insignificant. The development of endovascular therapies has allowed for the less invasive treatment of thoracic aortic aneurysms using endograft therapy. This treatment is limited by the need for "healthy" aorta proximal and distal to the aneurysm in order to get an appropriate seal. This limits use of endografts in the aortic arch as treatment of aneurysms in this location would necessitate coverage of critical brachiocephalic vessels including the innominate and left carotid arteries. To overcome these limitations, hybrid approaches to arch aneurysm repair have been developed. These include partial arch reconstruction through a median sternotomy, or extra-anatomic arch vessel bypass depending on the location of the aneurysm and the patients overall medical condition. These are accompanied by the placement of a thoracic stent-graft at the same setting (either antegrade or retrograde) or at a subsequent procedure. Outcomes evaluating these procedures are just beginning to become available in significant numbers. The outcomes, however, demonstrate these are durable procedures that may provide a viable alternative to conventional aortic arch surgery. As experience with these procedures grows, our understanding of the factors affecting outcomes will be clearer, and the use of these procedures will become associated with even lower morbidities and mortality. The further evolution of aortic endograft technology, however, will ultimately allow for complete endovascular treatment of the entire aortic arch.

New results with the Zenith graft in the treatment of aortic aneurysms.

Aneurysmal disease of the arterial vasculature has been reported since ancient times. Regarding aneurysms of the aorta, a steady progress has been made ranging from making such pathology amenable to surgical treatment to making the procedure much less invasive. There have been a number of stent grafts, introduced by different companies, used to exclude different segments of the aneurysmal aorta and the Zenith devices are one of them. The safety and efficacy of these devices to exclude infrarenal and descending thoracic aortic aneurysms has been well documented. The early and late complications associated with these procedures and the methods used to manage such complications have also been elucidated in different publications. In dealing with pararenal and thoracoabdominal aneurysms, the need to ensure patency of the visceral vessels while still repairing the aorta to healthy tissue must be considered. Strategies involving fenestrations and side-arm branches have evolved extending the ability to treat the entire aorta with an endovascular approach. Challenges exist including the inherent tortuosity and mobility of the aortic arch, close approximation of the supra-aortic vessels, small or multiple renal vessels, the commonly noted arcuate ligament compression of the celiac artery, but great strides have been made and virtually all pathologies have been addressed. The desire for smaller delivery systems has spurred interest in low-profile devices. This manuscript is intended to address the latest developments and clinical results for endovascular grafting of the aorta.

Number of retrieved lymph nodes and survival in node-negative patients undergoing laparoscopic colorectal surgery for cancer.

BACKGROUND: The number of retrieved lymph nodes in colorectal cancer resection may have an impact on staging and survival. Examination of at least 12 nodes has become a quality measure for adequate surgical practice. To evaluate the impact of the number of retrieved lymph nodes in laparoscopic colorectal surgery for cancer on node-negative patients' survival. METHODS: Evaluation of our prospective in-hospital collected data of patients that underwent laparoscopic surgery for curable colorectal cancer over a 5-year period. Long-term data were collected from our outpatient's clinic data and personal contact when necessary. RESULTS: During a 5-year period since September 2003,173 patients were operated laparoscopically for curable colorectal cancer. Of the 117 patients who were node negative, 85 node-negative patients (72%) had 12 or more evaluated lymph nodes (mean, 18.3 + 2.4), while 32 node-negative patients had less than 12 (mean, 8.3 + 6.2). Patients with fewer than 12 nodes evaluated had significantly more left-sided tumors, while patients with 12 nodes or more had more right-sided tumors. A comparison of 5-year disease free and overall Kaplan-Meier survival curves revealed no statistically significant difference between the two groups. CONCLUSIONS: Evaluation of less than 12 nodes may not necessarily impact patients' survival in node-negative patients undergoing laparoscopic resection for curable colorectal cancer. A lower number of nodes may be sufficient.

Comparative safety profile of chloral hydrate versus other sedatives for procedural sedation in hospitalized infants.

BACKGROUND: Given the limited available evidence on chloral hydrate safety in neonatal populations and the discrepancy in chloral hydrate acceptance between the US and other countries, we sought to clarify the safety profile of chloral hydrate compared to other sedatives in hospitalized infants. METHODS: We included all infants <120 days of life who underwent a minor procedure and were administered chloral hydrate, clonidine, clonazepam, dexmedetomidine, diazepam, ketamine, lorazepam, midazolam, propofol, or pentobarbital on the day of the procedure. We characterized the distribution of infant characteristics and evaluated the relationship between drug administration and any adverse event. We performed propensity score matching, regression adjustment (RA), and inverse probability weighting (IPW) to ensure comparison of similar infants and to account for confounding by indication and residual bias. Results were assessed for robustness to analytical technique by reanalyzing the main outcomes with multivariate logistic regression, a doubly robust IPW with RA model, and a doubly robust augmented IPW model with bias-correction. RESULTS: Of 650 infants, 497 (76%) received chloral hydrate, 79 (12%) received midazolam, 54 (8%) received lorazepam, and 15 (2%) received pentobarbital. Adverse events occurred in 41 (6%) infants. Using propensity score matching, chloral hydrate was associated with a decreased risk of an adverse event compared to other sedatives, risk difference (95% confidence interval) of -12.79 (-18.61, -6.98), p <  0.001. All other statistical methods resulted in similar findings. CONCLUSION: Administration of chloral hydrate to hospitalized infants undergoing minor procedures is associated with a lower risk for adverse events compared to other sedatives.