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.

[(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.

Antihypertensive effects of captopril and saralasin in essential and renal hypertension.

The antihypertensive effect of captopril and its mechanism of action were studied in patients with essential and renal hypertension. In mild essential hypertension (n = 12), during monotherapy with captopril (50 to 450 mg, 4 to 12 weeks) blood pressure was normalized in seven, improved in two and remained unchanged in three patients, plasma levels of active and acid-activatable inactive renin significantly increased and angiotensin II decreased, whereas no consistent changes in urinary kallikrein excretion occurred. In severe renal (n = 14) and essential (n = 9) hypertension, blood pressure was normalized in eight (seven with renal hypertension), improved in seven and unchanged in eight patients, when captopril (50 to 450 mg, 3 to 15 months) was added to the antihypertensive medication. In one patient with stenosis in a transplanted renal artery reversible renal failure occurred during captopril therapy possibly because of a steep initial decrease in blood pressure, although a toxic effect of the drug cannot be excluded. In another series of 12 renal and 8 essential hypertensive patients, a significant correlation between the acute effect of captopril (within 90 minutes) an saralasin on blood pressure was demonstrated (r=0.71, p less than 0.001). The change in blood pressure after either drug was significantly related to the initial plasma renin concentration. In conclusion, captopril seems to be an effective antihypertensive agent in essential and renal hypertension. Renal function should be monitored during captopril therapy. Our studies suggest that captopril decreases blood pressure by inhibiting the vasopressor action of the renin-angiotensin system.

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.

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.

Some evidence for aldosterone action on 2,3-diphosphoglycerate level in human red cells.

In healthy male subjects aldosterone excretion and plasma renin activity were reduced by a 4-6 hr head-out immersion in thermoindifferent water baths (35.5 +/- 0.1 degrees C). The red cell 2,3-diphosphoglycerate (DPG) concentration before and throughout immersion period was positively correlated both with aldosterone excretion in 2 hr pooled urine (r = +0.69; 2 p less than 0.001) and with renin activity (r = + 0.54; 2p less than 0.001) despite a concomitant increase of cubital venous pH and inorganic phosphate concentration. These findings furnish evidence for a regulatory role of aldosterone in DPG metabolism, possibily by a direct influence on red cell glycolysis.

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.

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.

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.

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.