Acute Mesenteric Ischemia: A Challenge for the Acute Care Surgeon.

Acute mesenteric ischemia is considered uncommon, but it appears to be more frequent cause of acute abdomen than appendicitis or ruptured abdominal aortic aneurysm in elderly patients. Surgical treatment without revascularization is associated with high overall mortality, up to 80%. The modern treatment of acute mesenteric ischemia requires collaboration of gastrointestinal surgeons, vascular surgeons, and interventional radiologists. Early revascularization may reduce the overall mortality associated with acute mesenteric ischemia by up to 50%. Clinical suspicion and contrast-enhanced computed tomography performed at early stage are keys to improve outcomes of acute mesenteric ischemia treatment. This review summarizes what the acute care surgeon needs to know about acute mesenteric ischemia with special emphasis on slowly progressing "acute on chronic" mesenteric ischemia.

Long-term mortality and causes of death in endoscopically verified upper gastrointestinal bleeding: comparison of bleeding patients and population controls.

OBJECTIVE: Upper gastrointestinal bleeding (UGIB) is a common emergency, with in-hospital mortality between 3 and 14%. However, the long-term mortality and causes of death are unknown. We investigated the long-term mortality and causes of death in UGIB patients in a retrospective single-centre case-control study design. METHODS: A total of 569 consecutive patients, aged ≥18 years, admitted to Kuopio University Hospital for their first endoscopically verified UGIB during the years 2009-2011 were identified from hospital records. For each UGIB patient, an age, sex and hospital district matched control patient was identified from the Statistics Finland database. Data on endoscopy procedures, laboratory values, comorbidities and medication were obtained from patient records. Data on deaths and causes of death were obtained from Statistics Finland. RESULTS: In-hospital mortality of UGIB patients was low at 3.3%. The long-term (mean follow-up 32 months) mortality of UGIB patients was significantly higher than controls (34.1 versus 12.1%, p < .001). During the 6 months following UGIB, the risk of death compared to controls was highest (HR 19.2, 95% CI 7.0-52.4, p < .001) and remained higher up to 3 years after the bleeding. Beyond 3 years' follow-up, there was no difference in mortality between the groups (HR 0.7, 95% CI 0.4-1.6, p = .436). During the first 3 months after the UGIB episode, mortality was related to gastrointestinal diseases; after 3 months, the causes of death were related to comorbidities and did not differ from causes of death in controls. CONCLUSIONS: UGIB patients have three times higher long-term mortality than population controls.

Surgical wound infections after vascular surgery: prospective multicenter observational study.

BACKGROUND AND AIMS: this multicenter prospective observational study defined the incidence and risk factors of surgical wound infections (SWI) after infrarenal aortic and lower limb vascular surgery procedures and evaluated the severity and costs of these infections. METHODS: the study cohort comprised of 184 consecutive patients. Postoperative complications were recorded. The additional costs attributable to SWI were calculated. RESULTS: Eighty-four (46%) patients had critical ischaemia, 81 (45%) patients underwent infrainguinal bypass surgery and 64 (35%) received vascular prosthesis or prosthetic patch. Forty-nine (27%) patients developed SWI. Staphylococcus aureus was the leading pathogen cultured from the wound. Forty-seven of the 49 infected wounds responded to and healed with the treatment. SWI was the cause of one major amputation. Independent predictors for SWI were infrainguinal surgery (OR 7.2, 95% Cl 2.92-17.65, p < 0.001), obesity (OR 6.1, 95% Cl 2.44-15.16, p < 0.001) and arteriography injection site within the operative area (OR 2.5, 95% Cl 1.13-5.48, p = 0.02). The average cost attributable to SWI was 3320 Ä. CONCLUSION: the incidence of SWI after vascular surgery is high. The risk factors for SWI are infrainguinal surgery, obesity and arteriography injection site within the operative area. SWI increases morbidity and costs of operative treatment.

Patient complaints in Finland 2000-2004: a retrospective register study.

Today, monitoring of patient complaints in healthcare services is being used as a tool for quality assurance systems and in the future development of services. This nationwide register study describes the number of all complaints processed, number of complaints between different state provinces, healthcare services and healthcare professionals, and outcomes of complaints in Finland during the period 2000-2004. All complaints processed at the State Provincial Offices and the National Authority for Medicolegal Affairs were analysed by statistical methods. Complaints about mental healthcare were explored in greater detail. The analysis showed that the number of patient complaints increased considerably during the study period. There were changes in the number of complaints between study years in different provinces. Out of different healthcare services, an especially marked increase was seen in private healthcare. Nearly all complaints were lodged against physicians, and over half of the complaints were made because of medical error. In mental health care, patients more often complained about unsatisfactory certificates and statements and the use of compulsory hospital care. An analysis of the outcomes revealed that in mental health care complaints more seldom led to consequences. The results need to be utilised when planning interventions for advanced supervision, prevention of adverse events and patient safety in healthcare, and especially in mental health care. From the patients' perspective, it is important to create a culture where most problem situations are handled where the treatment was provided, thus avoiding a complex complaints process.

Potentially hallucinogenic 5-hydroxytryptamine receptor ligands bufotenine and dimethyltryptamine in blood and tissues.

Bufotenine and N,N-dimethyltryptamine (DMT) are hallucinogenic dimethylated indolethylamines (DMIAs) formed from serotonin and tryptamine by the enzyme indolethylamine N-methyltransferase (INMT) ubiquitously present in non-neural tissues. In mammals, endogenous bufotenine and DMT have been identified only in human urine. The DMIAs bind effectively to 5HT receptors and their administration causes a variety of autonomic effects, which may reflect their actual physiological function. Endogenous levels of bufotenine and DMT in blood and a number of animal and human tissues were determined using highly sensitive and specific quantitative mass spectrometric techniques. A new finding was the detection of large amounts of bufotenine in stools, which may be an indication of its role in intestinal function. It is suggested that fecal and urinary bufotenine originate from epithelial cells of the intestine and the kidney, respectively, although the possibility of their synthesis by intestinal bacteria cannot be excluded. Only small amounts of the DMIAs were found in somatic or neural tissues and none in blood. This can be explained by rapid catabolism of the DMIAs by mitochondrial monoamino-oxidase or by the fact that the dimethylated products of serotonin and tryptamine are not formed in significant amounts in most mammalian tissues despite the widespread presence of INMT in tissues.

A high prevalence of hypovitaminosis D in Finnish medical in- and outpatients.

OBJECTIVE: To study the prevalence of hypovitaminosis D [serum 25(OH)D < or = 37 nmol L-1)] in Finnish medical in- and outpatients in a cross-sectional study. METHODS: The subjects were 106 consecutive medical inpatients (57 females, 49 males with mean ages of 65 and 58 years) from the Peijas Hospital, Vantaa, Finland, and 99 ambulatory patients (48 females, 51 males with mean ages of 42 and 46 years) contacting a private outpatient centre in Helsinki, Finland. Serum 25(OH)D, vitamin D binding protein (DBP), free vitamin D index (FDI), intact PTH (iPTH), and albumin-corrected calcium were measured. RESULTS: Serum 25-hydroxyvitamin D [25(OH)D] was 37 nmol L(-1) or less in 70% of female and in 61% of male inpatients and in 44% of female and in 37% of male outpatients. In the whole population, a statistically significant inverse association (P < 0.0001) was detected between iPTH and 25(OH)D levels; the iPTH concentration appeared to start increasing when 25(OH)D concentration was 50 nmol L(-1) or less. The association remained the same (P < 0.0001) when FDI was used instead of 25(OH)D in the calculations. When the sexes were analysed separately, the statistically significant association was found only in females (P < 0.0001 for iPTH versus 25(OH)D; P < 0.0001 for iPTH versus FDI) but not in males. CONCLUSION: Hypovitaminosis D is very common amongst Finnish in- and outpatients in both sexes, causing secondary hyperparathyroidism in females. More extensive studies are warranted to elucidate the vitamin D status of the Finnish population.

Determination of potentially hallucinogenic N-dimethylated indoleamines in human urine by HPLC/ESI-MS-MS.

A new method for the determination of N,N-dimethyl-5-hydroxytryptamine (bufotenine), N,N-dimethyltryptamine (DMT)*, 5-methoxy-N,N-dimethyltryptamine (5-MeODMT), and N-methyltryptamine (NMT) was developed using high-performance liquid chromatography-mass spectrometry (HPLC-MS). Identification of the analytes is based on liquid chromatographic retention times of analytes and two fragment ions produced by a triple quadrupole mass spectrometer. Quantification is based on electrospray ionization (ESI), and multiple reaction monitoring (MRM) was also utilized for getting better selectivity. The analytes and internal standard were separated from the urine matrix by solid-phase extraction (SPE). The method was applied for the determination of these compounds in urine samples of patients from surgical, medical and psychiatric wards. Of the dimethylated amines, only bufotenine was found in significant amounts (up to 34 microg/L). In keeping with our earlier results, the bufotenine excretion of psychiatric patients was found to be higher than that of the somatic patients. Method, procedure, considerations, statistical evaluations and urine sample spectra are presented.

Bone mineral status after pediatric spinal cord injury.

The impact of spinal cord injury (SCI) on later bone mineral status was studied in 35 adults who had sustained their injury in childhood. The median age of the patients was 31 years, the median age at injury 12.9 years and the median time period from injury was 19 years. The methods used in the study were clinical interview and examination, measurement of bone mineral density (BMD) of the lumbar spine and the proximal femur with dual energy X-ray absorptiometry (DEXA) and estimation of bone turnover with biochemical markers. The densitometric examination revealed that the BMD at the lumbar spine was within the normal range but grossly decreased in the femoral region. Moreover, there was a significant difference in BMD between patients with high (C2-T6) and low (below T6) lesions in the lumbar spine as well as in the femoral region. Patients with lower lesions had higher BMD values. The markers of bone turnover which were studied were serum and urinary calcium and phosphate serum alkaline phosphatase and its isoenzymes, osteocalcin, carboxyterminal propeptide of human type I procollagen (PICP), carboxyterminal telopeptide of type I collagen (ICTP) and urinary deoxypyridinoline. These markers of bone metabolism showed no signs of ongoing accelerated bone formation or resorption. The present study suggests that caution should be observed in weight bearing training or mobilisation of patients with pediatric SCI or perhaps with long standing SCI because of increased fracture risk. The prevention of dissociated osteoporosis should be investigated further in order to avoid fractures of weakened bones. The modes of prevention might be found in the use of modern pharmacotherapy of osteoporosis and from correctly dosage physical training.

Success in surgery for otosclerosis: hearing improvement and other indicators.

PURPOSE: This retrospective study investigates the general outcome and subjective impression of patients who have undergone surgery for otosclerosis. Postoperative complaints and complications, as well as hearing results, are also reported. MATERIALS AND METHODS: Questionnaire and audiomeric results of 246 stapes surgery patients (270 operations) were studied. RESULTS: Hearing results showed a mean improvement in pure-tone average of 26 dB and air-bone gap closure to within 10 dB in 214 cases (79%). No serious complications or profound sensorineural hearing loss occurred. Patients were generally pleased with surgery, and subjective evaluation of benefit corresponded with objective audiometric result. However, a variety of complaints, such as vertigo, tinnitus, loud noise intolerance, pain, chorda tympani symptoms, and sound distortion problems, were reported. Most of these symptoms correlated significantly with the patients' subjective opinion of the surgical outcome. CONCLUSION: Patients as well as surgeons consider hearing improvement as the main indicator of success in surgery for otosclerosis. However, postoperative symptoms and complaints can be expected in a certain percentage of patients. Because these can influence the general outcome of surgery, the ear surgeon should try to painstakingly refine his technique in an effort to minimize their sources. They should also be discussed in preoperative patient counseling.

Urinary excretion of bufotenin (N,N-dimethyl-5-hydroxytryptamine) is increased in suspicious violent offenders: a confirmatory study.

We previously reported that violent offenders with paranoid symptoms or whose violent actions had been directed against family members had higher urinary levels of bufotenin than other violent offenders. In the present study, patients were evaluated with the Karolinska Scales of Personality (KSP), and urinary levels of bufotenin were determined by mass spectrometry. In drug-free patients suspiciousness was positively correlated, and socialization was negatively correlated, with urinary bufotenin excretion. These two personality variables were strongly interdependent. In drug users, bufotenin excretion was correlated positively with social desirability and negatively with irritability, but not with suspiciousness. Bufotenin excretion was not found to be associated with violence toward family members in the present study. The results are in keeping with the earlier finding that violent offenders with paranoid personality traits have higher urinary levels of bufotenin than other violent offenders.

The nephropathy of type I tyrosinemia after liver transplantation.

Type I tyrosinemia (HTI) is an autosomally recessively inherited disease caused by deficiency of fumarylacetoacetate hydrolase. The disease manifests with liver failure, renal tubular defects, and neurologic crises. Currently orthotopic liver transplantation (OLT) enables patients to survive. However, renal fumarylacetoacetate hydrolase deficiency is not corrected by OLT, and the long-term prognosis of the nephropathy is not known. We investigated tyrosine metabolism, GFR, renal tubular function, and histopathology before and 18-36 mo after OLT in eight patients with HTI. Progressive renal dysfunction was not documented despite continuing, although diminished, urinary succinylacetone excretion in all patients. The mean GFR was 82 mL/min/1.73 m2 before and 102 mL at 18 mo and 93 mL at 36 mo after OLT. All patients showed tubular dysfunction before OLT. At 18 mo, glucosuria occurred in one, amino aciduria and phosphaturia in three, and hypercalciuria in six patients. Only hypercalciuria was seen at 36 mo. Renal biopsies showed mild nonspecific changes caused either by minimal progression of the renal disease or by mild cyclosporine nephrotoxicity. In conclusion, patients with HTI had normal GFR, but showed signs of tubular dysfunction 18-36 mo after OLT. Renal function and histopathology should be monitored after OLT for HTI.

Nialamide, an MAO inhibitor, increases urinary excretion of endogenously produced bufotenin in man.

Nialamide, an MAO inhibitor, was given per os (PO) to a normal man who volunteered in two separate trials (total intake 300 mg and 1000 mg, respectively), and his bufotenin excretion was followed by consecutive urine samples. In both experiments the excretion rose well above the values measured from the same test subject when not taking nialamide (median 0.089 nmol/mmol creatinine, range 0.002-1.78). At its highest, the excretion was 16.5 nmol/mmol creatinine, and the maximum urinary output was 495 nmoles (56 micrograms) in 24 hr. The levels of bufotenin in plasma required for the excretion of the latter amounts are not far from those that produce psychic symptoms in man.

Lynestrenol induced therapeutic amenorrhea: effects of dose reduction on serum sex-hormones and lipids.

The effect of reducing the dose of peroral lynestrenol by half on serum sex-hormone, lipid and lipoprotein status was studied in 21 mentally retarded women with therapeutic amenorrhea (TA). They had previously received 5 or 10 mg peroral lynestrenol daily for periods ranging from 32 to 196 months. Dose halving of lynestrenol resulted in an increase in serum total testosterone (T) by 16% (p less than 0.05), sex-hormone binding globulin (SHBG) by 39% (p less than 0.01) and high-density lipoprotein cholesterol (HDL-C) by 28% (p less than 0.001). Both the mean serum total and free concentrations of norethisterone (NET and fNET) decreased by 60% (p less than 0.001). The serum concentrations of 17-beta-estradiol (E2), its free fractions (fE2) and free T (fT) were not significantly altered. Significant correlations were observed between the change in HDL-C and the change in T (r = 0.45, p less than 0.05), between the change in SHBG and the change in T (r = 0.62, p less than 0.01), fT (r = 0.43, p less than 0.05) and E2 (r = 0.51, p less than 0.05). The elevation of HDL-C was probably caused by the reduced serum NET concentrations. This also resulted in an increase in serum SHBG concentration, which is regarded as an indicator of the overall estrogen/androgen ratio.

Comparison of mass spectrometry and radioimmunoassay to measure medroxyprogesterone acetate in patients with endometrial cancer.

Serum medroxyprogesterone acetate (MPA) was measured by radioimmunoassay (RIA) and gas chromatography-mass spectrometry (GC-MS) in patients with endometrial cancer. Samples were obtained 3, 6 and 24 h after the oral administration of 100 or 200 mg MPA once a day. The levels obtained by GC-MS were lower (median 16-29%) than those obtained by RIA, which is probably attributable to the presence of metabolites interfering with the RIA. Two commercial MPA formulations gave different MPA serum levels by both RIA and GC-MS. The levels obtained by GC-MS were so low that frequently only partial saturation of the endometrial progesterone receptor may be achieved which may explain why high oral doses are needed to produce optimum therapeutic response.

Plasma endogenous opioids and dexamethasone suppression test in depression.

Plasma levels of beta-endorphin plus beta-lipotropin were determined in 35 hospital patients with depression and in 23 controls before and after administration of 1 mg of dexamethasone (dxm). Dxm suppressed opioid secretion in both groups. The opioid levels of the patients were significantly higher than those of the controls both before and after dxm. All the controls were cortisol suppressors. Among the patients the post-dxm opioid levels of cortisol nonsuppressors (n = 14) were higher than those of cortisol suppressors (n = 21). A significant correlation between the opioid and cortisol levels was found in the patients. There was a significant association between the use of neuroleptics and high opioid levels, but the difference between the patients and the controls was not explained by the effect of any single class of drugs. The results support the concept of hypersecretion of corticotropin-releasing factor in depression.

Clinical and lipid metabolic effects of unopposed oestrogen and two oestrogen-progestogen regimens in post-menopausal women.

No differences in the clinical effects on climacteric complaints of an unopposed oestrogen and two oestrogen-progestogen regimens were observed in a double-blind cross-over study. Only 4 out of 18 women with an intact uterus had withdrawal bleeding during oestradiol valerate (2 mg/day) treatment alone, but 14 out of 18 had regular bleeding during the two oestrogen-progestogen regimens (oestradiol/medroxyprogesterone acetate and oestradiol/levonorgestrel (LNG], each of which prevented the development of endometrial hyperplasia. High-density-lipoprotein cholesterol (HDL-CH) concentration remained 6% above the initial level and the atherogenic index (low-density-lipoprotein (LDL) cholesterol to HDL-CH ratio) improved significantly during the oestradiol/medroxyprogesterone acetate regimen, while the HDL-CH concentration fell by 20% in relation to the initial level and there was a deterioration in the atherogenic index during the oestradiol/LNG regimen. The data suggest that both of these oestradiol/progestogen combinations are clinically as effective and well-tolerated as oestradiol alone, but that combined oestradiol/medroxyprogesterone acetate causes fewer adverse lipid metabolic effects than the oestradiol/LNG combination.

Hormone treatment of meningiomas: lack of response to medroxyprogesterone acetate (MPA). A pilot study of five cases.

Medroxyprogesterone acetate (MPA) has been used in high doses as hormone treatment for metastatic breast cancer. We treated five intracranial meningiomas with MPA expecting that MPA would reduce the volume or decrease the growth rate. All five patients were postmenopausal women, aged 47 to 73 years. Before treatment, the growth rate of each tumour was assessed by two consecutive CT scans (CT 1 and CT 2). Tumours 1 to 4, histologically benign meningiomas, grew slowly as the tumour volumes were not found to increase in 21 to 45 months between CT 1 and CT 2. Tumour 5 was an anaplastic meningioma the rapid growth of which was evident in 8 weeks between CT 1 and CT 2. After CT 2, MPA was given 1,000 mg intramusculary once weekly for 17 to 29 weeks until CT 3 which showed the response. Tumours 1 to 4 had neither reduced in volume nor developed necroses, and tumour 5 continued its fast growth at the same rate as before.

Prostacyclin and thromboxane in breast cancer: relationship between steroid receptor status and medroxyprogesterone acetate.

To study the production and significance of prostacyclin (PGI2) and thromboxane A2 (TxA2) in breast cancer, tissue fragments of breast cancer (n=23) and mastopathy (n=10) were superfused in vitro and the release of 6-keto-PGF1 alpha (a metabolite of PG12) and TxB2 (a metabolite of TxA2) measured by radioimmunoassay. Breast cancer formed more 6-keto-PGF1 alpha (4.5 +/- 0.9 ng min-1 g-1 of tissue dry weight, mean +/- s.e.) and TxB2 (2.5 +/- 0.6 ng min-1 g-1) (P less than 0.01) than did mastopathic breast (1.4 +/- 0.5 and 0.4 +/- 0.1 ng min-1 g-1, respectively). These productions were similar in steroid receptor positive and negative tumours. Breast cancer metastasized in 15 patients during the follow-up time of 3.7 +/- 0.7 years, but the initial prostanoid productions in these patients were not different from those in nonmetastatic patients. Two patients died from metastases, but their initial mammary production of prostanoids was not profoundly different from those in the survivors. In 8 patients (4 with steroid receptor positive and 4 with negative tumour), the cancer tissue was superfused in the presence or absence of medroxyprogesterone acetate (100-5000 ng ml-1), which is commonly used for treatment of breast cancer. This hormone had no effect on mammary PGI2 and TxA2 production. We thus conclude that the PGI2 and TxA2 productions are increased in mammary cancer but that this may not be of primary significance for metastastic spread.