The Trend of Cefepime-Induced Neurotoxicity: A Systematic Review.

There has been increased use of cefepime due to concerns about the nephrotoxic effects of the combined use of vancomycin and Zosyn. However, cefepime is associated with neurotoxicity. We conducted a systematic review using online data to explore the trend of cefepime-induced neurotoxicity over the last 10 years. Forty-six articles met our inclusion criteria, including 73 cases of cefepime-induced neurotoxicity. We noticed a steady increase in the reports of cefepime-induced neurotoxicity, from one case in 2013 to 11 cases in 2022. Individuals aged 65 and older accounted for most cefepime-induced neurotoxicity cases (52%). The top three indications for cefepime administration included bone and joint infections (25%), urinary tract infections (22.7%), and pneumonia (22.7%). Most patients with renal impairment have never had a renal adjustment of their cefepime dosage (either 2 g 12 hours a day or 2 g eight hours a day). Most cases of cefepime-induced neurotoxicity occurred between days two and five (n=29, 71%), while most resolution occurred between days one and five (n=29, 85%). While cefepime continues to be a popularly used and effective antibiotic against gram-negative bacteria like Pseudomonas aeruginosa, its dosage needs to be adjusted in patients with renal impairment to avoid neurotoxicity.

Hepatic Artery Pseudoaneurysm Following Gunshot Injury With Early Rupture.

Pseudoaneurysms are a rare and potentially life-threatening complication that can be caused by trauma, infections, tumors, autoimmune diseases, organ transplants, or idiopathic causes. The management of liver trauma is based on the anatomy of the injury and the patient's physiology. Posttraumatic hepatic artery pseudoaneurysm (HAP) is a life-threatening complication that requires prompt recognition and a multidisciplinary approach in its management. We present a case of HAP rupture two weeks following a gunshot wound to the liver.

Prevalence of undiagnosed and inadequately treated type 2 diabetes mellitus, hypertension, and dyslipidemia in morbidly obese patients who present for bariatric surgery.

BACKGROUND: Pharmacotherapy is considered the primary treatment modality for diabetes mellitus (DM), hypertension (HTN), and dyslipidemia (DYS). We sought to investigate the status of DM, HTN, and DYS in patients who seek bariatric surgery. METHODS: Demographic and comorbidity history were prospectively collected on 1,508 patients referred for bariatric consultation at a single institution from February 2008 to March 2012. We utilized published consensus guidelines (GL) to benchmark the efficacy of standard pharmacotherapy for these metabolic diseases, and 881 patients met the study design criteria. RESULTS: Most patients exhibited at least one form of metabolic dysregulation (pre-DM or DM, 75.8%; pre-HTN or HTN, 91.1%; pre-DYS or DYS, 84.0%; metabolic syndrome, 76.0%). The majority of patients either did not meet GL treatment goals (DM, 45.7%; HTN, 39.5%; DYS, 22.3%) or were previously undiagnosed (DM, 15.8%; HTN, 13.7%; DYS, 41.7%). Non-GL pharmacotherapy was significantly less effective than GL pharmacotherapy at achieving treatment goals for DM (31.8 vs. 53.2%, p < 0.001) and HTN (43.6 vs. 63.2%, p = 0.007). Patients with concurrent DM, HTN, and DYS (35.5%) were less likely than patients with only one or two of these metabolic diseases to achieve GL treatment goals for HTN (38.1 vs. 72.6%, p < 0.001) and DYS (55.7 vs. 73.8%, p = 0.002). Only 8.0% of these patients achieved treatment goals for all three metabolic comorbidities. CONCLUSIONS: In this patient group, DM, HTN, and DYS were poorly compensated, even when pharmacotherapy was consistent with published GL. This may be due to disease burden in bariatric surgery candidates or to inadequate medical management prior to presentation.

Miscellaneous disorders and their management in gastric surgery: volvulus, carcinoid, lymphoma, gastric varices, and gastric outlet obstruction.

This article focuses on less common diseases that surgeons are called on for management options. Five topics-volvulus, carcinoid, lymphoma, gastric varices, and gastric outlet obstruction from peptic ulcer disease-are frequently used to evaluate surgical knowledge. Knowledge of these topics is useful for residents preparing for an in-training examination or board certification. Patients with these diseases require multidisciplinary management with oncologists and/or gastroenterologists, and mastery of these topics allows surgeons to effectively participate in the multidisciplinary care of these patients and advocate for surgical management when appropriate.

Application submission date reflects applicant quality.

PURPOSE: Applications for general surgery residency are submitted through the Electronic Residency Application Service (ERAS) beginning in early September. The purpose of this study was to determine whether the date of application submission could be used in the screening of an applicant for general surgery residency. METHODS: The 2007 ERAS data for an independent program that accepts 2 categorical residents per year was evaluated. International medical graduates were excluded because no international applicants were considered for interviews. Applicants for preliminary positions were also excluded. The remaining graduates from medical schools accredited by the Liaison Committee on Medical Education (LCME) who applied for categorical positions were evaluated based on United States Medical Licensing Examination (USMLE) scores and on medical school performance, as well as on the quality of their personal statements and letters of recommendation. Medical school performance was determined from dean's letters and transcript information, and each applicant was classified as outstanding, average, or poor. The date of application submission was compared with USMLE scores and medical school performance. The lag time to submit an application was also evaluated and compared with whether a student was offered an interview and the assessment of the quality of that interview. Results were evaluated using analysis of variance and the Pearson correlation test to evaluate for significance. RESULTS: A total of 155 applications from LCME-accredited schools for categorical positions were received. The mean lag time to application for students with an outstanding medical school performance was 15.2 +/- 15.5 days compared with 37.4 +/- 26.2 days for poorly performing students (p < 0.01). A negative correlation between USMLE score and the lag time to application was noted (p < 0.01 USMLE I and USMLE II). Applicants offered an interview demonstrated a lag time to submit their application of 19.2 days +/- 21.7 versus 34.0 days +/- 25.8 for applicants not selected to interview (p < 0.01). CONCLUSIONS: The results of our study suggest that the date of application submission can provide important screening information about an applicant for general surgery residency. If nearly all high-quality applications are received in September, programs could begin the interview process in early November, which gives students an opportunity to visit more programs and increase their exposure to a broader variety of training options.

Chylomicron-bound LPS selectively inhibits the hepatocellular response to proinflammatory cytokines.

BACKGROUND/AIMS: Pretreatment of rodent hepatocytes with chylomicron-bound lipopolysaccharide (CM-LPS) renders these cells unresponsive to subsequent stimulation by proinflammatory cytokines. We sought to test the selectivity of this response. METHODS: Cellular responses to hypoxia, oxidative stress, apoptosis, and heat-shock response, and thermotolerance induced in CM-LPS pretreated hepatocytes were compared with responses in non-pretreated cells. RESULTS: CM-LPS inhibited the hepatocellular response to proinflammatory cytokines without affecting the response to the other cellular stressors. It did not affect the response to oxidative stress, as measured by mitochondrial activity after hydrogen peroxide was added, or protein induction before or after stimulation with cobalt chloride. Also, induction of heat shock proteins did not differ between the CM-LPS pretreated cells and non-pretreated cells. CM-LPS did not interfere with the adoption of the thermotolerant phenotype, as shown by similar mitochondrial activity between pretreated and non-pretreated cells. Although stimulation with tumor necrosis factor-alpha and actinomycin D increased activity of the apoptotic enzymes, there were no differences between cells pretreated with CM-LPS and non-pretreated hepatocytes. CONCLUSION: When the response to proinflammatory cytokines is inhibited, hepatocellular responses to hypoxia, oxidative stress, heat shock, and apoptosis remain intact after pretreatment with CM-LPS. CM-LPS may have a specific anti-inflammatory effect on hepatocytes.

Role of calcitonin receptor-like receptor in colonic motility and inflammation.

Calcitonin gene-related peptide (CGRP) mediates neurogenic inflammation and modulates intestinal motility. The CGRP receptor is a heterodimer of calcitonin receptor-like receptor (CLR) and receptor-associated modifying protein 1. We used RNA interference to elucidate the specific role of CLR in colonic motility and inflammation. Intramural injection of double-stranded RNA (dsRNA) against CLR (dsCLR) into the colonic wall at two sites caused the spatial and temporal downregulation of CLR in the colon within 1 day of dsRNA injection. Knockdown of CLR persisted for 7-9 days, and the effect of knockdown spread to approximately 2 cm proximal and distal to the injection sites, whereas control dsRNA injection did not affect CLR expression. Measurement of isometric contractions of isolated colonic muscle segments revealed that in control dsRNA-injected rats, CGRP abrogated contractions entirely and decreased resting muscular tone, whereas in dsCLR-injected rats, CGRP decreased muscle tone but slow-wave contractions of varying amplitude persisted. In trinitrobenzene sulfonic acid-induced colitis, rats with knockdown of CLR displayed a significantly greater degree of edema and necrosis than saline- or control dsRNA-injected rats. Levels of the proinflammatory cytokines TNF-alpha and IL-6 were markedly upregulated by trinitrobenzene sulfonic acid treatment. TNF-alpha mRNA levels were further increased in CLR knockdown rats, whereas levels of IL-6 were unaltered. Thus this study demonstrates that CLR is a functional receptor for CGRP.

Bipolar pulse coagulation for resection of the cirrhotic liver.

BACKGROUND: The major technical challenge of liver surgery is controlling bleeding during transection of the parenchyma. The Gyrus hand piece (GHP) is a bipolar diathermy pulsation instrument that is similar in design to a large hemostat (Péan) clamp that divides tissue while the clamp remains closed. MATERIALS AND METHODS: We retrospectively analyzed the peri-operative data from 10 patients with early cirrhosis (stage 1-4) who underwent liver resection for hepatocellular cancer between February 2004 and July 2005. Five consecutive patients who underwent resection using the GHP were compared to five other patients who underwent resection using the traditional "crush clamp technique" (CCT). Six patients underwent minor hepatectomy (<3 segments) and four underwent major hepatectomy (>3 segments). RESULTS: When the GHP was used, the mean Pringle time was 13 +/- 5 min, mean blood loss was 520 mL +/- 118, and mean operative time was 252 +/- 15 min. When the CCT was used, the average Pringle time was 13 +/- 3 min, mean blood loss was 630 +/- 67 mL, and mean operative time was 312 +/- 29 min. There were 2 major complications in the GHP group and 3 in the CCT group. Major complications included transient hepatic failure (i.e., ascites/encephalopathy) and biloma formation. CONCLUSIONS: One patient from each group suffered a minor wound complication. The average hospital stay was 8 days (range, 6-9) for the GHP group, and 8 days (range, 7-10) for CCT group. The operative mortality rate was 0%. Our preliminary results demonstrate that GHP provides an excellent and safe alternative to CCT for dividing the liver parenchyma in cirrhotic patients.