Pregnancy, puerperium and perinatal constipation - an observational hybrid survey on pregnant and postpartum women and their age-matched non-pregnant controls.

OBJECTIVE: To evaluate the prevalence of constipation during pregnancy and early puerperium. DESIGN: Observational survey. SETTING: Secondary and tertiary hospital in Finland. POPULATION: Pregnant (n = 474) and postpartum (n = 403) women and a control group of 200 non-pregnant women who did not give birth in the past year. METHODS: Women reported bowel function and other gastrointestinal symptoms on a structured questionnaire using an 11-point numerical rating scale (0 = no symptom, 10 = most severe symptom) and binominal yes/no questions during the second and third trimesters and few days and 1 month after childbirth. MAIN OUTCOME MEASURE: Prevalence of constipation based on the Rome IV criteria. RESULTS: The data consist of five cohorts of women: second trimester (n = 264), third trimester (n = 210), after vaginal delivery (n = 200) or caesarean section (n = 203), and a control group (n = 200). The prevalence of constipation was 40% in pregnant women and 52% (P < 0.001) in postpartum women, which was a higher prevalence than that in the control group, where 21% had constipation (P < 0.001). A few days after delivery, the prevalence of constipation was lower after vaginal delivery (47%) than caesarean section (57%, P < 0.039). One month postpartum, the prevalence of constipation was low: 9% after vaginal delivery (P = 0.002 compared with the control group) and 15% after caesarean section. Other gastrointestinal symptoms were common; pregnant women had the highest prevalence (34%) of nausea/vomiting. CONCLUSION: The prevalence of constipation was two- to three-fold higher in pregnant women and a few days after delivery than in non-pregnant women. During puerperium, bowel function returned to or below that reported in non-pregnant women. TWEETABLE ABSTRACT: Constipation is common in pregnancy and after delivery, but bowel function returns early in puerperium.

The usage of procalcitonin in Finland.

BACKGROUND: We have surveyed the use of procalcitonin (PCT) in Finland with a specific emphasis on intensive care unit (ICU) patients. METHODS: The PCT use was surveyed from all 11 laboratories providing services for all 15 secondary and all five tertiary care hospitals in Finland. The laboratories reported the PCT use of each hospital in 2014 and 2015. Four hospitals were analysed for the first 100 adult ICU patients with PCT measurements in 2015. The indication for PCT measurement and whether PCT values affected antibiotic treatment were collected from patient records. RESULTS: The overall national PCT use was similar between 2014 and 2015 with around 15 000 measurements annually. The PCT use varied greatly between hospitals and specialities; one tertiary care hospital used 5600 measurements annually, while another tertiary care hospital did not use PCT at all. Over half of the requests for PCT were in the ICU. There were significant differences in PCT use for ICU patients: in the most frequent user, PCT was mainly used for follow-up of antibiotic treatment, whereas in the other three hospitals, PCT was mainly used for differential diagnosis. The most frequent user also had the highest per patient rate of PCT measurements, with a mean of six PCT tests/patient compared to two PCT tests/patient in the three other hospitals. PCT had an effect on antibiotic treatment in every 5th case. CONCLUSION: The use of PCT in Finland varies significantly between hospitals, even though the national guideline proposes its use for septic patients.

Intravenous dexketoprofen induces less injection pain than racemic ketoprofen.

WHAT IS KNOWN AND OBJECTIVE: Ketoprofen has high analgesic efficacy against inflammatory and nociceptive pain. Additionally, when ketoprofen is administered in conjunction with an opioid during pain management, it prevents the development of opioid-induced hyperalgesia. The main limitation for racemic ketoprofen IV administration is venous irritation. Dexketoprofen is the active enantiomer of racemic ketoprofen and has a similar analgesic efficacy in a dose proportion of 1 : 2, but it causes fewer adverse effects than racemic ketoprofen. It has been claimed that dexketoprofen may cause less frequent and less severe injection pain than racemic ketoprofen. In this study, we compared the injection pain of IV administered racemic ketoprofen and dexketoprofen in elective surgical patients. METHODS: The ethics committee of our institution approved this randomized, double-blinded, two-treatment, two-period, crossover clinical comparison of ketoprofen and dexketoprofen. A total of 221 ASA I-III adult patients, aged 20-75 years, were initially IV administered either 0·5 mg/kg racemic ketoprofen followed 2 h later with 0·25 mg/kg dexketoprofen (group 1) or vice versa (group 2). Both compounds were diluted in 20 mL of normal saline and were injected over 6 min. Patients reported injection pain on an 11-point numerical rating scale (NRS) (0 = no pain, 10 = most pain). RESULTS AND DISCUSSION: Significantly less injection pain was reported after dexketoprofen administration. A total of 201 of 209 patients reported pain during racemic ketoprofen injection, and 157 of 210 patients reported pain during dexketoprofen injection, respectively. Moderate or severe pain was reported by 90 (41%) patients during racemic ketoprofen administration and by 43 (20%) during dexketoprofen injection (P = 0·001). The mean of injection pain during racemic ketoprofen injection was 4·2 (SD 2·5) and was 2·5 (2·4) during dexketoprofen injection (P = 0·001). No serious or unexpected adverse events were reported. WHAT IS NEW AND CONCLUSION: Dexketoprofen causes significantly less injection pain than racemic ketoprofen; therefore, it may be a more suitable IV non-steroidal anti-inflammatory than the racemate.

The influence of timing on the effectiveness of epidural blood patches in parturients.

BACKGROUND: Postdural puncture headache is common in parturients following lumbar puncture. If headache is severe and persistent, an epidural blood patch is recommended. In this paper we reviewed the efficacy of epidural blood patches over a 13-year period at two hospitals in Finland with a particular emphasis on its timing. METHODS: The hospitals' databases were searched to identify parturients who underwent an epidural blood patch from March 1998 to June 2011. Parturients' records were reviewed to establish the characteristics and associated symptoms of headache and the effectiveness of the epidural blood patch. RESULTS: A total of 129 parturients received 151 epidural blood patches. These followed spinal (n = 49), epidural (n = 47) or combined spinal-epidural blocks (n = 33). The success rate of the first procedure was 89%, with permanent relief in 76%. The first procedure provided permanent relief of postdural puncture headache for 86% of 78 patients having the procedure after 48 h, compared to 65% of 37 patients when it was performed between 24 and 48 h, and 50% of 14 patients with the procedure within the first 24 h after dural puncture (P = 0.003). A second procedure was performed for 22 parturients due to incomplete relief (n = 5) or recurrent symptoms (n = 17); all had complete resolution of symptoms. CONCLUSIONS: Epidural blood patch performed later than 48 h following lumbar puncture or accidental dural puncture is effective in parturients with postdural puncture symptoms. The recurrence rate of symptoms after an initially successful epidural blood patch is high, and therefore patients should be provided with counselling and contact information.

Prolonged-release oxycodone/naloxone in postoperative pain management: from a randomized clinical trial to usual clinical practice.

OBJECTIVE: These studies evaluated the feasibility of using oral prolonged-release oxycodone/naloxone (OXN PR) for the management of acute postoperative pain. METHODS: Three studies were undertaken: (i) the analgesic efficacy of OXN PR was compared with prolonged-release oxycodone (OXY PR) in patients with knee arthroplasty in an immediate postoperative period (IPOP) study; (ii) OXN PR treatment was compared with other opioids during rehabilitation after knee arthroplasty in a noninterventional study (NIS); and (iii) surgical patients on other opioids were switched to OXN PR postoperatively during a quality improvement programme (QIP). RESULTS: In the IPOP study, the pain intensity at rest score decreased by a similar amount in the OXN PR and OXY PR groups, indicating similar analgesic efficacies. In the NIS, patient assessments indicated enhanced efficacy and tolerability for OXN PR compared with other opioids. The QIP indicated significant improvements in bowel function and less difficulty passing urine at the end of OXN PR treatment compared with baseline. No safety concerns were raised. CONCLUSIONS: The analgesic efficacies of OXN PR and OXY PR were similar in postoperative pain settings. OXN PR reduced the degree of restriction in relation to patients carrying out physiotherapy compared with other opioids, and improved bowel and bladder function.

Platelet transfusions in adult patients with particular reference to patients undergoing surgery.

Descriptive information on platelet (PLT) recipients, particularly during surgery, is limited. A description of the current epidemiology of PLT-transfused patients is required to optimize platelet transfusion care and to follow trends in PLT use. In 2004 and 2005, information was combined from several computerized medical systems. Participating hospitals (9 hospital districts of 21) handled approximately 64% of annual Finnish hospital admissions. A total of 6321 adult patients were transfused with 37,761 PLT products. Most PLT products (43.1%) were transfused to patients suffering from haematological malignancies. Only 1.0% of all surgical patients received PLTs (53.8% of PLT recipients and 35.8% of transfused PLTs). The most common single operation connected with PLT transfusion was coronary artery bypass while 27.1% of surgery-related PLTs were given to patients having an operation involving the digestive system or spleen. Only 36.4% of all PLT-transfused (operated and conservatively treated) patients were discharged directly home; in-hospital mortality was 9.5%. PLTs were given 40 products per 1000 hospital admissions requiring an operation in 2004, and 38 products in 2005. Perioperative PLT use is slightly decreasing in adult patients. As a single-operation type, coronary artery bypass patients receive most of the PLT products and have experienced no decline in PLT use over the years. Overall, PLT recipients have high in-hospital mortality.

Development of permanent national register of blood component use utilizing electronic hospital information systems.

BACKGROUND AND OBJECTIVES: We wanted to establish a permanent national database system, which can be utilized to study transfusion recipients and blood use in Finland. MATERIALS AND METHODS: A regularly updated register for permanent use was developed. To study the usability of the database, years 2002 and 2003 were further analysed. Database included all transfused patients in major blood-transfusing hospitals from four university and five central hospital districts managing altogether 63% of Finnish inpatient hospital episodes. RESULTS: Audit of gathered data reveal 96.8% match in adult blood components with Finnish Red Cross, Blood Service sales figures. Model data set includes 59,535 transfused patients (44.3% men and 55.7% women) having received 529,104 blood components. Half of all blood units were transfused in connection with surgical operations. Most of the blood recipients were elderly (51.6% are over 64 years of age). Blood-component use and transfusion-related costs varied widely between hospitals. CONCLUSION: Hospital data managing systems can be useful for creating a population-based database system to monitor and compare transfusion practices. This record provides information about transfusion epidemiology for transfusion professionals, hospital management, and hospital administration.

The complete set of genes encoding major intrinsic proteins in Arabidopsis provides a framework for a new nomenclature for major intrinsic proteins in plants.

Major intrinsic proteins (MIPs) facilitate the passive transport of small polar molecules across membranes. MIPs constitute a very old family of proteins and different forms have been found in all kinds of living organisms, including bacteria, fungi, animals, and plants. In the genomic sequence of Arabidopsis, we have identified 35 different MIP-encoding genes. Based on sequence similarity, these 35 proteins are divided into four different subfamilies: plasma membrane intrinsic proteins, tonoplast intrinsic proteins, NOD26-like intrinsic proteins also called NOD26-like MIPs, and the recently discovered small basic intrinsic proteins. In Arabidopsis, there are 13 plasma membrane intrinsic proteins, 10 tonoplast intrinsic proteins, nine NOD26-like intrinsic proteins, and three small basic intrinsic proteins. The gene structure in general is conserved within each subfamily, although there is a tendency to lose introns. Based on phylogenetic comparisons of maize (Zea mays) and Arabidopsis MIPs (AtMIPs), it is argued that the general intron patterns in the subfamilies were formed before the split of monocotyledons and dicotyledons. Although the gene structure is unique for each subfamily, there is a common pattern in how transmembrane helices are encoded on the exons in three of the subfamilies. The nomenclature for plant MIPs varies widely between different species but also between subfamilies in the same species. Based on the phylogeny of all AtMIPs, a new and more consistent nomenclature is proposed. The complete set of AtMIPs, together with the new nomenclature, will facilitate the isolation, classification, and labeling of plant MIPs from other species.

Intramuscular dexmedetomidine as premedication for general anesthesia. A comparative multicenter study.

BACKGROUND: Dexmedetomidine is a new potent and selective alpha 2-agonist that might prove useful as a preanesthetic agent. METHODS: A randomized, double-blind study design was used in 192 ASA physical status 1 and 2 patients scheduled for elective abdominal hysterectomy, cholecystectomy, or intraocular surgery under general anesthesia. Intramuscular injection of 2.5 micrograms/kg dexmedetomidine administered 60 min before and intravenous saline placebo 2 min before induction of anesthesia (DEXPLA group, n = 64) was compared with a combination of 0.08 mg/kg intramuscular midazolam 60 min and 1.5 micrograms/kg intravenous fentanyl 2 min before induction (MIDFENT group, n = 64), or a combination of intramuscular dexmedetomidine and intravenous fentanyl (DEXFENT group, n = 64). After thiopental induction, anesthesia was maintained with 70% N2O/O2, and fentanyl was administered according to clinical and cardiovascular criteria. Patients undergoing cholecystectomy received additional enflurane. RESULTS: Dexmedetomidine and midazolam induced comparable preoperative sedation and anxiolysis. The DEXFENT combination blunted the increases in blood pressure and heart rate induced by tracheal intubation more efficiently when compared with the DEXPLA and MIDFENT groups, in which approximately 25 mmHg and 15 beats/min greater increases were observed. The intraoperative fentanyl requirements were greater in MIDFENT patients when compared with both dexmedetomidine groups, in which 56% (DEXFENT group) and 31% (DEXPLA group) less fentanyl, respectively, was needed. Intraoperatively, fluids or vasopressors for hypotension and glycopyrrolate for bradycardia were administered more often to patients receiving dexmedetomidine than to those who did not. Postoperatively, there were no differences in oxygen saturation, analgesic, or antiemetic requirements, but dexmedetomidine-induced blood pressure and heart rate reductions were still evident at the end of the 3-h follow-up period. Bradycardia as an adverse event was reported more frequently in dexmedetomidine patients (20% in the DEXPLA and 33% in the DEXFENT groups) than in MIDFENT patients (8%). CONCLUSIONS: The results suggest that pretreatment with a single intramuscular injection of 2.5 micrograms/kg dexmedetomidine is efficacious, but significantly increases the incidence of intraoperative hypotension and bradycardia in ASA physical status 1 or 2 patients.

Mitomycin C and lipiodol do not improve the effect of intermittent hepatic artery occlusion on liver tumour growth. An experimental study in the rat.

The effect of Mitomycin C (MMC 2.0 mg/kg bw), lipiodol (0.2 ml/kg bw) and intermittent hepatic artery occlusion on liver tumour growth, as well as their possible interrelation, were studied in 29 rats. An adenocarcinoma was inoculated in the left liver lobe. After one week, the tumour size was measured and the rats then divided into five different groups of treatment. Intermittent hepatic artery occlusion was performed during five days for 1 hour daily alone, of initially in combination with MMC and lipiodol. One group was treated with MMC and lipiodol in combination and one group with lipiodol only. The tumour growth six days later was compared between the groups and with control rats. It was found that intermittent arterial occlusion significantly reduced the tumour growth (P = 0.01). However, the retarding effect of intermittent arterial occlusion on tumour growth was not significantly improved with additional treatment of MMC and lipiodol.

Metabolic responses to intermittent hepatic dearterialization in the rat.

Hepatic dearterialization is a palliative treatment for irresectable liver tumours. In the current study, the metabolic consequences of hepatic dearterialization were examined in the rat. Liver glycogen content was reduced to an average of 84% following 60 min dearterialization and was further reduced to an average of 16% following 60 min reperfusion. Plasma concentration of beta-hydroxybutyric acid was elevated by an average of 65% following 60 min hepatic dearterialization. In contrast, hepatic dearterialization did not alter cholesterol and triglyceride plasma levels. In addition, the hepatic activity of hepatic lipase was reduced by 29% after 60 min of hepatic dearterialization, a reduction which remained after 60 min of reperfusion. Clearance of intravenously administered antipyrine, which reflects the activity of liver microsomal enzymes, was reduced by 37% after 60 min of hepatic dearterialization. In conclusion hepatic dearterialization is accompanied by marked activity in the processes related to carbohydrate, lipid and xenobiotic metabolism. These effects should be taken into account when treating patients with hepatic dearterialization.

Hepatic dearterialisation induces glucose intolerance and inhibits insulin secretion in patients with liver malignancy.

Intermittent hepatic dearterialisation is used in palliation of liver malignancy. In rats hepatic dearterialisation is accompanied by glucose intolerance and impaired insulin secretion, but it is not known if similar effects occur in man. Six patients with nonresectable liver malignancy were subjected to an intravenous glucose (50 g) challenge before dearterialisation (control challenge), during a 1-hour dearterialisation period, and in the immediate reperfusion phase after the end of 1-hour dearterialisation. Insulin secretion, as judged by the plasma levels of both insulin and C peptide, was inhibited during the 1-hour dearterialisation, while the glucose elimination rate was delayed (both p less than 0.03). Contrastingly, in the immediate reperfusion phase both insulin secretion and glucose elimination did not differ from values after the control challenge. We therefore conclude that hepatic dearterialisation in patients with liver malignancy is accompanied by inhibited insulin secretion and glucose intolerance, both readily reversible.

Intermittent hepatic arterial or portal occlusion reduces liver tumor growth.

The effect of repeated, intermittent hepatic vascular occlusion on liver tumor growth was studied in 32 rats. An adenocarcinoma was inoculated in the left liver lobe. After 8 days, the tumor size was measured and then, in three groups, the hepatic artery was occluded intermittently during 5 days for 15 min, 1 hr, or 2 hr daily, respectively. The tumor growth after 6 days in these groups was compared with that in a group where instead the portal vein was occluded intermittently during 5 days for 15 min, and with that in a group of sham-operated control rats. In the control rats, the tumor volume (mean +/- SEM) increased from 0.16 +/- 0.03 to 1.34 +/- 0.15 cm3 during the 6 days of experiment. It was found that repeated, intermittent occlusion of the hepatic artery or the portal vein, retarded the liver tumor growth to 30-60% of the growth rate in sham-operated controls (P less than or equal to 0.015). The 15-min daily hepatic artery or portal vein occlusion was found to reduce the tumor growth rate as much as daily hepatic artery occlusion for 2 hr. It is suggested that short, daily, intermittent hepatic vascular occlusions might be efficient in the palliative treatment of liver malignancy.

Effect of hepatic artery or portal vein occlusion on liver tumour blood flow.

To study the blood flow in normal liver tissue and in liver malignancies after occlusion of the hepatic artery or the portal vein, an adenocarcinoma was inoculated in the left liver lobe of 10 rats. Eight days postoperatively, blood flow in normal hepatic tissue and tumour was estimated by laser Doppler flowmetry (LDF). In both normal tissue and tumour, occlusion of the hepatic artery reduced LDF values by approximately 30%, whereas occlusion of the portal vein reduced LDF values by approximately 70%. These findings indicate that changes of hepatic blood flow can be monitored by LDF, and that the portal blood flow is dominating also in liver metastasis.

Intermittent hepatic dearterialization induces glucose intolerance: an experimental study in the rat.

Intermittent hepatic dearterialization is used in the palliative treatment of liver malignancy. However, its metabolic consequences are not established. Therefore the influences of the procedure on the plasma insulin, glucagon and glucose responses were studied in healthy rats and in rats with a tumour inoculated subcapsularly into the liver. To study the influence on stimulated islet hormone secretion we infused arginine intravenously (7 mg/min) for 30 min, because arginine is known to stimulate the secretion of both insulin and glucagon. During hepatic dearterialization, hyperglycaemia developed; mean(s.e.m.) blood glucose levels after 60 min of dearterialization were 20.2(1.3) mM versus 14.7(1.5)mM in controls (P less than 0.001). Concomitantly, compensatory hyperinsulinaemia and hypoglucagonaemia occurred. Furthermore, during both dearterialization and in the immediate reperfusion phase, the arginine-induced increase in plasma insulin levels was impaired (P less than 0.001), whereas the arginine-induced increase in plasma glucagon levels was not significantly affected. These changes were qualitatively the same in tumour-free and tumour-bearing rats. We conclude that glucose intolerance develops during selective hepatic dearterialization, which is evident both from basal hyperglycaemia and impaired insulin secretion.

Splenic and gastro-duodenal vein occlusion--influence on the pancreatic gland and on the outcome of experimental pancreatitis.

The observation that splenic vein thrombosis results in pancreatic changes similar to haemorrhagic pancreatitis initiated the present investigation. The influence of splenic and/or gastroduodenal vein occlusion on the pancreatic gland was evaluated and compared to that obtained after induction of experimental pancreatitis (EP). The influence of splenic vein occlusion on EP was also investigated. An approximately 4-fold increase in serum amylase activity was obtained after simultaneous ligation of the splenic and gastroduodenal veins. This increase was comparable to that obtained after EP. On the other hand, amylase activity in ascites was considerably lower after vein occlusion than after EP. Splenic vein occlusion in rats with EP more moderately increased the amylase activity but did not influence mortality rate 24 h postoperatively. Venous thromboses were observed in all groups with occluded veins but not in rats with EP. Vein occlusion alone did not result in fat necroses. Although occlusion of the splenic and gastroduodenal veins results in macromorphologic and biochemical changes resembling those in EP, the microscopic findings of the two conditions differ. Thus, the results do not support the hypothesis that pancreatic vein thromboses are of etiologic significance for the development of acute haemorrhagic pancreatitis.

Effects of the specific cholecystokinin antagonist L 364,718 in experimental acute pancreatitis in the rat.

Cholecystokinin (CCK) has been suggested to be involved in the pathogenesis of acute pancreatitis. To test this hypothesis, we administered the highly selective and specific CCK receptor antagonist L 364,718 to rats in which acute experimental pancreatitis had been induced by the use of transduodenal pancreatic duct injection of taurocholate. It was, however, found that despite the use of L 364,718 at a high dose level (1 mg/kg body weight given three times), and also given prior to induction of pancreatitis, the mortality rate, the serum or ascites amylase activity, the pancreatic concentrations of lysosomal enzymes or the morphology of the pancreas were not affected. This suggests that the CCK receptors are not involved in the pathogenesis of acute pancreatitis in this experimental model, and, consequently, that CCK receptor antagonists have no place in the therapy of this condition.

6 alpha-glucuronidation of hyodeoxycholic acid by human liver, kidney and small bowel microsomes.

Kinetic constants for the glucuronidation of hyodeoxycholic acid in man were determined using microsomal preparations of liver, kidney and small bowel. The affinity of hyodeoxycholic acid for the microsomal hepatic and extrahepatic enzymes was in the same range as previously observed for the monohydroxy bile acid lithocholic acid and about 3-14-times the affinity for the dihydroxy bile acids chenodeoxycholic, deoxycholic and ursodeoxycholic acids. The Vmax values for glucuronidation of hyodeoxycholic acid with hepatic microsomes were 10-30-times higher and with kidney microsomes 50-110-times higher than for the bile acids lacking a 6 alpha-hydroxy group. The site of glucuronidation was determined by gas chromatographic-mass spectrometric analysis of derivatives of products formed after periodate and chromic acid oxidation. Hyodeoxycholic acid glucuronides synthesized with microsomal preparations from the three organs were all found to be conjugated at the 6 alpha position. This has previously been shown to be the site of glucuronidation of endogenous hyodeoxycholic acid glucuronide excreted in urine.

Double tumours of the appendix: a rare entity. A case report.

A 73-year-old man was admitted with the suspicion of appendiceal abscess. Emergency appendectomy was done. Histology revealed two tumours, an adenocarcinoma and a carcinoid. Tumours of the appendix are seldom diagnosed preoperatively and often first at microscopic examination. All specimens should therefore be histologically examined.