Diagnostic double strike in the emergency room - two cases of complete pancreatic ruptures due to bicycle handlebar injuries on two consecutive days.

BACKGROUND: Pancreatic injuries are rare in cases of blunt abdominal trauma and therefore easily misdiagnosed at time of hospital admission. They are associated with a significantly elevated morbidity and lethality. Bicycle handlebar injuries are the most common cause of pancreatic trauma in children and adolescents. CASE PRESENTATION: We report two cases of a 23-year-old Caucasian woman and a 15-year-old Caucasian boy who presented to our clinic with a similar history of a bicycle accident on 2 consecutive days. Both suffered from a fall from a bicycle with bicycle handlebar injury 4 and 6 days prior to admission in our clinic. Emergency distal pancreatectomies were performed in both cases. CONCLUSIONS: Pancreatic injuries must be highly suspected in bicycle handlebar injuries, even if amylase/lipase levels or ultrasound findings seem unremarkable. The best initial strategies are early computed tomography and a quick referral to a level 1 trauma center. Distal pancreatectomy is the treatment of choice in cases of complete rupture of the pancreatic body.

Effects of intra-arterial octreotide on pancreatic texture: a randomized controlled trial.

BACKGROUND AND AIMS: Octreotide is suggested to harden the pancreas, thus facilitating the construction of a pancreatic anastomosis and lowering the risk of postoperative fistula. We tested the hypothesis that intra-arterial application of octreotide in the gastroduodenal artery during pancreatectomy may increase pancreatic hardness. MATERIAL AND METHODS: A single-center, prospective, double-blinded, randomized controlled trial with parallel assignment was conducted. Patients planned for a pancreatoduodenectomy or a total pancreatectomy, who had a palpatory and durometer proven (<40 Shore units) soft pancreas, were assigned to receive intraoperatively either 5 mL 500µg octreotide or 5 mL 0.9% saline solution as a bolus injection in the gastroduodenal artery. Pancreatic hardness was measured before, early, and late after intervention. The investigator performing the durometer measurements and pathologist were masked to group assignment. The primary outcome was increased pancreatic hardness. Analysis was by intention to treat. This trial is registered at http://www.clinicaltrials.gov (ID NCT01400100). RESULTS: A total of 12 patients received octreotide and 13 received saline solution. Pancreatic hardness marginally increased in the octreotide group: 0.67 ± 2.3 Shore units, whereas it decreased in the control group: -2.15 ± 2.7 Shore units. The difference was statistically significant, p = 0.029 (95% confidence interval = -4.87 to -0.77). Histology did not find any correlate for this clinically irrelevant hardening effect. CONCLUSIONS: A single bolus application of octreotide did not deliver a clinically relevant increase in pancreatic hardness. Future studies on the hardening effect of octreotide should employ repeated or continuous preoperative administration of this drug.

[Appendicitis in the elderly. CRP value as decision support for diagnostic laparoscopy]. / Altersappendizitis. CRP-Wert als Entscheidungshilfe für eine diagnostische Laparoskopie.

BACKGROUND: The diagnosis of acute appendicitis in the elderly bears many pitfalls due to a broad range of differential diagnoses and uncommon clinical presentation. This may result in late detection of appendicitis leading to poor outcome. The aim of this study was to examine the characteristics of appendicitis in elderly patients in order to facilitate early diagnosis. MATERIALS AND METHODS: All patients who underwent appendectomy in our institution were prospectively recorded over a 30 month period. Data on patient's age (>60 years versus < or =60 years), clinical findings, the inflammatory parameters leucocytes and C-reactive protein (CRP) and histological-findings (perforated versus non-perforated) were collected. Statistical analysis was carried out by ROC analysis, chi(2) and t-tests. RESULTS: In the examination period 403 patients underwent appendectomy and 11.2% (n=45) were older than 60 years. These patients were characterized by significantly more frequent perforations compared to those patients < or =60 years (35.6% versus 7.0%, p< or =0.05), peritonitis (42.2% versus 9.5%, p< or =0.05), conversion to open surgery (23% versus 5%, p< or =0.005), longer postoperative hospital stay (9.2 days versus 4.3 days, p< or =0.05) and a higher complication rate (28.9% versus 3.6%, p< or =0.005). CRP values in patients >60 years were on average 123.2 mg/l and significantly higher than in patients < or =60 years (35.5 mg/l, p< or =0.005). The ROC analysis resulted in a CRP cut-off value of 101.9 mg/l for patients >60 years for the existence of a perforation with a specificity of 72.4% and a sensitivity of 81.3% (AUC 0.811). CONCLUSIONS: The CRP value showed a strong correlation with respect to the grade of inflammation and perforation. In conclusion, elderly patients with symptoms of appendicitis and a CRP value higher than 102 mg/l should undergo early diagnostic laparoscopy.

[(section sign) 115 b SGB V threatens outpatient treatment for inguinal hernia. Analysis of outcome and economics]. / Das Aus für die minimal-invasive Leistenhernienversorgung durch (section sign) 115 b SGB V. Eine Analyse zu Patientenoutcome und Okonomie.

BACKGROUND: Current German legislation ( (section sign) 115 b SGB V) allows groin hernia inpatient treatment only under particular circumstances. That allows the operative technique of first choice for outpatient groin hernia repair to be determined by basic market principles. The aim of this paper was to study the feasibility of outpatient minimally invasive hernia surgery with regard to complication rates, patient satisfaction, and economic considerations. METHODS: For 1 year, a total of 571 patients with inguinal hernias (131 male, eight female, mean age 46 years, all ASA I) were treated at two surgical centers. Twenty-four percent (139/571) underwent outpatient total extraperitoneal repair (TEP). Complication rates were recorded. Patient satisfaction with the procedure was evaluated by a standard questionnaire. Cost calculations were compared with revenues according to the EBM2000plus. RESULTS: Of the patients, 96.4% were discharged on the day of operation without subsequent rehospitalization, 84% had no fears of complications at home, 54% went back to work in less than 14 days, and 88.7% were willing to undergo TEP a second time if necessary. Calculated average total cost of euro 709 exceeded the revenue of euro 565 by 20%. CONCLUSION: For a carefully selected group, outpatient TEP is patient-friendly and safe. Despite these advantages, it still remains economically unattractive to hospital management because of the 20% cover shortage. Improvements in the current legislation are urgently desired.

Safety and efficacy of Omniscan (gadodiamide injection) at 0.1 mmol/kg for MRI in infants younger than 6 months of age: phase III open multicenter study.

RATIONALE AND OBJECTIVES: To demonstrate that gadodiamide injection is a safe and efficient contrast agent for MRI in infants younger than 6 months of age. METHODS: The authors designed a phase III multicenter nonrandomized study using a control group. Gadodiamide injection at a dosage of 0.1 mmol/kg body weight was administered to 39 children; 20 received no contrast. The mean age was 10.6 weeks in the contrast group and 9.3 weeks in the control group. MR examinations, blood (serum creatinine, S-ASAT, S-ALAT, S-bilirubin, alkaline phosphatase) and urine (proteins, blood, others) sampling before sedation and after examination, heart rate (electrocardiography) and oxygen saturation (pulse oximetry) during examination, adverse events, and efficacy parameters were analyzed. RESULTS: In the contrast group, 18 (51.4%) children had 31 abnormal changes in one or more of the safety parameters and vital signs. In the control group there were 16 (80.0%) children with 19 abnormal changes. Gadodiamide injection had no negative influence on the safety parameters. No serious adverse events occurred, and only three clinically relevant adverse events (elevation of S-ALAT and S-ASAT, elevation of bilirubin) in two patients in the contrast group and one event (vomiting) in one patient in the control group were documented. The benefit of the contrast medium was clearly shown for all evaluated parameters. CONCLUSIONS: Gadodiamide injection is safe, well tolerated, and effective in infants younger than 6 months of age.

MRI temporal lobe volume measures and neuropsychologic function in Alzheimer's disease.

The authors performed quantitation of the temporal lobes using magnetic resonance imaging in 20 patients with mild-to-moderate Alzheimer's disease, 20 age-matched aged control subjects, and 26 healthy young volunteers. Compared to young subjects, aged controls showed volume reductions in amygdala (17%, p = 0.02), hippocampus (15%, p = 0.0001) and temporal lobe (22%, p = 0.0001). Compared to aged controls, Alzheimer's subjects showed further volume reductions in amygdala (33%, p = 0.0001) and hippocampus (20%, p = 0.006) but not temporal lobe (7%, p = 0.15). In Alzheimer's subjects, left temporal lobe volume correlated strongly with the Mini Mental State (MMSE) score (adjusted r2 = 0.46, p = 0.0006) whereas right amygdala volume correlated inversely with the noncognitive ADAS score (adjusted r2 = 0.46, p = 0.0006). The authors conclude that significant volume changes occur in the temporal lobe in aging and in Alzheimer's disease, with the greatest percentage reductions in the amygdala in Alzheimer's disease. Temporal neocortical atrophy and temporal limbic atrophy might be associated with different patterns of performance and behavior in Alzheimer's patients.

Short-term oral 3-hydroxypyridin-4-one dosing increases aluminum excretion and partially reverses aluminum-induced toxicity in the rabbit independent of chelator lipophilicity.

The objectives of the present study were to determine the efficacy and toxicity of repeated oral administration of 3-hydroxypyridin-4-one (HP) chelators in a rabbit model of aluminum (Al) accumulation and toxicity, and the influence of chelator lipophilicity on these effects. Efficacy was assessed as chelator-induced Al mobilization and excretion and reversal of Al accumulation and Al-induced toxicity. Chelator-induced toxicity was assessed by multiple measures. Six HPs were given orally 12 times over 1 month to Al-loaded rabbits, which had significant elevation of Al in most tissues and evidence of Al-induced nephrotoxicity, osteomalacia, and anemia. Intravenous desferrioxamine (DFO), the current chelator of choice for the treatment of Al-overload and toxicity, was included as a positive control. All six HPs and DFO demonstrated efficacy evidenced by significantly greater urinary and biliary Al elimination after the twelfth dose than seen in saline-treated controls. All of the HPs were more effective than DFO. Chelator-induced urinary Al excretion accounted for 58-98% of total (urinary plus biliary) Al excretion. Chelator-facilitated Al excretion was nearly complete within 12 hr, demonstrating a fairly short duration of action in rabbits with intact renal function. HP treatments did not consistently affect tissue concentrations of Al or other metals. However, there was a trend toward chelator-induced reduction of Al-induced nephrotoxicity. The influence of HP lipophilicity was limited to a positive correlation between HP x Al lipophilicity and biliary Al output and a negative correlation between HP and HP x Al lipophilicity and reduction of Kupffer cell Al. Little toxicity was evident after repeated oral HP dosing. Adrenal weight increased after treatment with several HPs. There was a decrease in testes weight after several HPs, which is consistent with an antiproliferative effect. More frequent dosing and/or a longer duration of HP treatment might produce greater reversal of the Al-induced toxicity and perhaps reveal more adverse effects than seen in this study. There was a lack of profound toxicity during this short-term study. The 1,2-dimethyl (CP20) and 1,2-diethyl (CP94) HPs, which have been the most extensively studied HPs, were the least effective of the HPs examined. These results encourage the further investigation of other HPs as oral alternatives to DFO for the treatment of Al accumulation and toxicity.

The 3-hydroxypyridin-4-ones more effectively chelate aluminum in a rabbit model of aluminum intoxication than does desferrioxamine.

This study was conducted to assess the influence of lipophilicity on the in vivo aluminum (Al) chelation activity of 3-hydroxypyridin-4-ones (HPs). Chelation activity was evidenced as increased Al elimination in an animal model of Al accumulation and toxicity. The subjects were Al-loaded rabbits. A non-Al-loaded group was included to characterize the rabbit model of Al intoxication. Eight HPs and desferrioxamine (DFO), the drug currently used to treat Al intoxication, were studied. Chelation activity was determined from quantitative biliary and urinary Al excretion and serum Al determinations conducted for 24 hr after DFO or HP intravenous administration, compared with saline. Toxicity was evaluated by observation, blood biochemistry assays, hematological evaluation, gross necropsy, and histopathological assessment of the liver. Al loading produced nephrotoxicity, hepatotoxicity, and anemia. Each of the chelators mobilized Al into serum. The efficiency of Al chelation, calculated from 24-hr biliary plus urinary Al output, ranged from 2.8 to 11.7% for the HPs, compared with 2.1% for DFO. Urinary Al excretion accounted for 78-98% of total Al excretion. Nearly all of the chelator-facilitated Al excretion occurred within 8 hr of dosing. Al chelation efficacy did not correlate with HP or HP Al lipophilicity; however, increasing HP lipophilicity increased the biliary fraction of the excreted Al. There was no evidence for toxicity after HP dosing, other than the previously shown ability of one of the HPs to produce seizures. The greater chelation efficacy of the HPs than DFO provides advantages over DFO. The lack of toxicity after a single dose of all but the most lipophilic HP encourages their further evaluation as orally effective chelators.

HPLC quantitation of a very hydrophilic 3-hydroxypyridin-4-one chelator using a simple separation procedure and the baseline file subtraction method.

The lack of a method to isolate very hydrophilic 3-hydroxypyridin-4-ones (HPs) from blood has prevented determination of their pharmacokinetics. The objective of this study is to develop method to quantitate these compounds. A simple sample preparation method coupled with high-performance liquid chromatography is used to quantitate 1-[ethan-1-ol]-2-methyl-3- hydroxypyridin-4-one, a very hydrophilic HP, in plasma. Plasma proteins are precipitated by trichloroacetic acid. The baseline file subtraction method is used to improve the resolution of this HP in the presence of interfering chromatographic peaks that could not be resolved from the HP by the methods investigated. The method is used to determine the pharmacokinetics of this HP in rabbits. The precision of the pharmacokinetic results is comparable or better than the results obtained from seven more lipophilic HPs that were separated by a published method. The new method is slightly modified and used in a study of the pharmacokinetics of this HP in the rat, and precision is comparable with results obtained with two more lipophilic HPs determined by the published method. Baseline file subtraction is useful when other methods cannot be used to adequately resolve a hydrophilic analyte from coeluting interfering substances.

Effect of diabetes mellitus during the luteal phase of the oestrous cycle on preovulatory follicular function, ovulation and gonadotrophins in gilts.

Development of preovulatory follicles was studied during the oestrous cycle in two experiments designed to examine the effects of short-term lack of insulin on preovulatory follicular function and (Expt 2 only) ovulation. In Expt 1, on day 12 of the third postpubertal oestrous cycle, insulin treatment was discontinued in streptozocin-induced diabetic gilts (n = 4), and on day 18, ovaries were removed from the diabetic gilts and from four normal untreated gilts. Diabetic gilts had a higher percentage of macroscopically atretic follicles (29.4 versus 6.8%; SEM = 5.9, P < 0.03) than did normal gilts. Binding of 125I-labelled hCG by freshly collected granulosa cells from non-atretic follicles was similar in diabetic and normal gilts. Diabetic gilts had more LH peaks in 3 h on days 12-17 of the oestrous cycle than did normal gilts (2.3 versus 1.6; SEM = 0.12; P < 0.01). Serum oestradiol and progesterone concentrations were not affected by treatment, but serum testosterone was increased (P < 0.01) in diabetic gilts. In Expt 2, insulin treatment was withdrawn from nine diabetic gilts on day 12 of the oestrous cycle and ten normal gilts served as controls. On day 18, ovaries were removed from six diabetic and six normal gilts; four normal and three diabetic gilts were ovariectomized 25 days after oestrus. Follicular diameter of diabetic gilts tended to be smaller than that of control (control: 3.95 versus diabetic: 3.01 mm; SEM = 0.4, P < 0.08) and the proportion of follicles with histologic evidence of atresia was higher in diabetic gilts (control: 29 versus diabetic: 47%; SEM = 5; P < 0.05) on day 18. In both experiments, the insulin-like growth factor I (IGF-I) and oestradiol concentrations of follicular fluid of diabetic gilts untreated with insulin from day 12 to day 18 was lower than in nondiabetic gilts. After day 18 in Expt 2, normal gilts exhibited oestrus (duration of cycle was 20 +/- 0.5 days) accompanied by preovulatory surges in oestradiol and LH, whereas diabetic gilts did not exhibit oestrus or ovulate. In diabetic gilts, oestradiol concentrations were lower compared with those of normal gilts, and LH patterns were characterized by two (two gilts) or three (one gilt) increases of more than 2 ng ml-1 between day 18 and day 25. Thus, impaired follicular function in diabetic gilts is not explained by decreased function of the hypothalamo-pituitary axis, since LH was not decreased.(ABSTRACT TRUNCATED AT 400 WORDS)

Direct assay of vitamins B1, B2, and B6 in hospitalized patients: relationship to level of intake.

High-performance liquid chromatography assays for vitamins B1 by erythrocyte thiamine pyrophosphate, B2 by plasma and urinary riboflavin, and B6 by plasma pyridoxal phosphate and urinary pyridoxic acid were used to evaluate the B vitamin status of hospitalized patients. Over an intake range of up to 3.4 mg of thiamine per day and up to 4.1 mg of riboflavin per day, erythrocyte thiamine pyrophosphate and urine and plasma riboflavin increased proportionately with intake. There was no relationship between B6 intake and blood levels. Rather, a constant blood level was maintained with an intake range of 0.5 to 4 mg/d, and urinary pyridoxic acid showed a linear increase proportionate to intake. There were extremely variable blood and urine concentrations of B vitamins noted in our patient population.

Erythropoietin response to anemia as a function of age.

The erythropoietin (EPO) response to anemia was assessed for 244 subjects aged 1-64 years (mean 45.2 years) and 121 subjects aged 65-94 years (mean 68.3 years). Subjects included non-anemic individuals as well as those with anemia of various etiologies, excluding renal disease and pregnancy. Significant inverse correlations between serum immunoreactive EPO and hematocrit were noted for both groups. Regression lines failed to show a significantly lower slope or y-intercept for older compared to younger subjects. EPO levels were not significantly lower for older compared to younger subjects when controlled for hematocrit level. These results suggest that the EPO response to anemia in older subjects is similar to that of younger subjects.

Decreased follicular steroids and insulin-like growth factor-I and increased atresia in diabetic gilts during follicular growth stimulated with PMSG.

Four streptozotocin-diabetic gilts (maintained on exogenous insulin for 3 months) and 4 normoglycaemic gilts were treated with 600 i.u. PMSG. Diabetic gilts had insulin therapy removed at the time of PMSG administration. Plasma glucose averaged 463 +/- 5 mg/100 ml for diabetic gilts and 82 +/- 4 mg/100 ml for control gilts over the 72-h sampling period. Serum insulin was lower in diabetic than in normoglycaemic gilts (glycaemic state by time interaction; P less than 0.0001). At ovary removal 75 h after PMSG, numbers and percentages of large (greater than or equal to 7 mm) and medium (3-6 mm) non-atretic follicles were similar for diabetic and control gilts (31 vs 68%; s.e.m. = 7; P less than 0.05). Diabetic gilts had a greater percentage of atretic follicles over all size classes (50 vs 21%; s.e.m. = 7; P less than 0.03). After PMSG, LH was suppressed within 12 h in control gilts and remained similar to values in diabetic gilts until 72 h, when LH was elevated in 2 diabetic gilts (glycaemic state by time interaction; P less than 0.001). Pulsatile LH patterns during 52-55 h after PMSG were not affected by glycaemic state. Serum concentrations of IGF-I tended (P less than 0.1) to be lower in diabetic gilts. Concentrations of oestradiol and FSH in serum were similar in diabetic and control gilts. Follicular fluid concentrations of oestradiol in follicles greater than or equal to 7 mm were lower in diabetic than normoglycaemic gilts (341 vs 873 ng/ml; s.e.m. = 86; P less than 0.05). Testosterone was higher in follicles 3-6 mm in diameter in diabetic than in normoglycaemic gilts (142 vs 80 ng/ml; s.e.m. = 26; P less than 0.05). Progesterone concentrations in follicular fluid were not affected by glycaemic state. Concentrations of IGF-I in follicles greater than or equal to 7 mm were lower in diabetic than control gilts (150 vs 200 ng/ml; s.e.m. = 13; P less than 0.05). We conclude that follicles of diabetic gilts respond to external gonadotrophic stimulation with decreased hormone production and increased ovarian follicular atresia, despite an absence of effects on circulating gonadotrophin and oestradiol concentrations.

The role of protein kinase C in the inactivation of hepatic glycogen synthase by calcium-mobilizing agonists.

The regulation of glycogen synthase by Ca2+-mobilizing hormones was studied by using rat liver parenchymal cells in primary culture. Long-term exposure of hepatocytes to 4 beta-phorbol 12-myristate 13-acetate (TPA) resulted in a decrease in vasopressin or ATP inhibition of glycogen synthesis and glycogen synthase activity, without any change in the activation of glycogen phosphorylase. In contrast, treatment with TPA did not diminish the effects of glucagon, isoprenaline or A23187 on glycogen synthase or phosphorylase. TPA treatment for 18 h did not change specific [3H]vasopressin binding, but abolished protein kinase C activity in a concentration-dependent manner. The effects of TPA to decrease protein kinase C activity and to reverse the inactivation of glycogen synthase by vasopressin were well correlated and were mimicked by mezerein, but not by 4 alpha-phorbol. However, 1 microM-TPA totally inhibited protein kinase C activity, but reversed only 60% of the vasopressin effect on glycogen synthase. It is therefore concluded that Ca2+-mobilizing hormones inhibit glycogen synthase partly, but not wholly, through a mechanism involving protein kinase C.

[Renal and adrenal function following acute administration of urapidil in hypertensive patients with normal and impaired renal function]. / Nieren- und Nebennierenfunktion nach akuter Gabe von Urapidil bei hypertensiven Patienten mit normaler und eingeschränkter Nierenfunktion.

The effects of i.v. injection of urapidil (Ebrantil) (25 mg) on arterial blood pressure, renal function and renin-aldosterone system were studied in a group of patients with hypertension and normal renal function, in patients with hypertension and chronic renal failure and in normotensive controls. The pharmacokinetics of urapidil were evaluated simultaneously by measuring blood levels of the compound and its main metabolite. In the controls and in patients with hypertension, systolic and diastolic blood pressure were lowered few minutes after injection. Minimal blood pressure values were reached after 15-20 min. Hypotensive action was more pronounced in hypertensive patients as compared to controls. In contrast, increment in heart rate was greater in the controls. Despite the fall in blood pressure, renal plasma flow and glomerular filtration rate remained unchanged. Following the injection of urapidil, plasma renin activity increased with no change in plasma aldosterone levels. Plasma half-life of urapidil averaged 1.96 +/- 0.17 h in controls, 3.31 +/- 0.75 h in patients with hypertension and normal renal function and 2.52 +/- 0.46 h in patients with hypertension and chronic renal failure. Urapidil effectively lowers arterial blood pressure in patients with normal and impaired renal function with no deterioration in renal function.

Comparative trial of lisinopril and nifedipine in mild to severe essential hypertension.

A total of 136 patients with mild to severe uncomplicated essential hypertension were evaluated in a multicenter, randomized, double-blind, double-placebo, parallel study to compare the effect of lisinopril, a new angiotensin-converting enzyme inhibitor, with that of nifedipine. Following a 2-week placebo control period the patients were treated with either 20-80 mg/day of lisinopril (n = 89) or with 40-80 mg/day of nifedipine (n = 47). Blood pressure was significantly reduced in both groups after 4, 8, and 12 weeks of treatment. There was no difference in the effect of lisinopril compared to nifedipine. No serious clinical or laboratory adverse experiences were observed during the study. The incidence of clinical side effects was significantly lower in the lisinopril group than in the nifedipine group (21.3 vs. 48.9%, p less than or equal to 0.01). There were no significant changes in laboratory data in either group. The results indicate that lisinopril is as effective as nifedipine in the treatment of uncomplicated essential hypertension and that lisinopril is well tolerated and has an acceptable safety profile.