Gordon H. Fick

Effect of cigarette smoking on recurrence of Crohn's disease.

The effect of cigarette smoking on recurrence (defined in this study as the need for repeat surgery) in patients who had previously required surgery for Crohns disease was assessed in a historical cohort of 174 patients. Mean follow-up was 10.8 yr. The 5- and 10-yr recurrence rates were 28% and 56%, respectively. Five- and 10-yr rates were significantly different for smokers (36%, 70%) and nonsmokers (20%, 41%). When patients were stratified by gender, the increased risk was more apparent in women (odds ratio 4.2, 95% confidence interval 2.0-4.2) than in men (odds ratio 1.5, 95% confidence interval 0.8-6.0). Evidence for a dose-response relationship could be identified in women but not men. Cigarette smoking may not only be a risk factor for development of Crohns disease but also may influence disease activity following surgery.

Diagnostic reasoning strategies and diagnostic success.

Purpose Cognitive psychology research supports the notion that experts use mental frameworks or ‘schemes’, both to organize knowledge in memory and to solve clinical problems. The central purpose of this study was to determine the relationship between problem‐solving strategies and the likelihood of diagnostic success.

The Effect of Elastic Bandages on Human Knee Proprioception in the Uninjured Population

Elastic bandages are often used to treat musculoskel etal disorders, even though there is little scientific evi dence currently to support this generalized practice. We tested the hypothesis that elastic bandages improve proprioception of the bandaged joint during their use, and that this benefit was more than temporary. The un injured human knee was used as a model. Fifty-four volunteers (54 knees), aged 22 to 40 years, were asked to identify a prior set joint angle as their knee was pas sively extended. Each knee was tested without the elas tic bandage, immediately after bandage application, after 1 hour of bandage wear, and finally after removal of the bandage. Results showed that elastic bandages significantly improved knee joint proprioception in the uninjured knee during the entire interval of their use (mean decrease in inaccuracy of 1.0°, equivalent to 25% improvement, P < 0.05), and that this benefit was lost when the bandage was removed. The magnitude of the improvement, or the potential beneficial effect of the bandage, was inversely related to the participants in herent knee proprioceptive ability, which was demon strated in the test group before the initial application of the bandage.

Serologic Response to Treatment of Infectious Syphilis

OBJECTIVE To evaluate the serologic response to treatment of patients with infectious syphilis. DESIGN Historical cohort study of all cases of infectious syphilis in Alberta from 1981 to 1987. PATIENTS A total of 1090 patients were entered; 857 with primary syphilis, 183 with secondary syphilis, and 50 with early latent disease. Two hundred and eight patients were excluded who either were pregnant, had negative serologic results before treatment, had clinical relapse, were treatment failures, or were lost to follow-up. INTERVENTIONS All 882 evaluable patients were treated with a recommended antibiotic regimen for infectious syphilis and returned for re-assessment including repeat serologic testing. MEASUREMENTS AND MAIN RESULTS Seventy-two percent (95% CI, 66% to 77%) and 56% (CI, 43% to 70%) of patients with initial episodes of primary or secondary syphilis had seroreverted according to rapid plasma reagin (RPR) test results by 36 months. A 2- and 3-tube decline was seen by 6 and 12 months in primary and secondary syphilis. Early latent syphilis resulted in only a 2-tube decrease at 12 months. Serologic response was not affected by sex, age, race, or sexual orientation. Patients with their first infection were more likely to experience RPR seroreversal than those with repeat infections. The RPR reversal rates also depended on the pretreatment titer and stage of disease. At 36 months, 24% (CI, 20% to 28%) of patients had nonreactive fluorescent treponemal antibody absorption tests (FTA-Abs), and 13% (CI, 11% to 15%) had nonreactive microhemoglutination tests for Treponema pallidum (MHA-TP). CONCLUSIONS Adequate therapeutic response for syphilis must be based on illness episode and the pretreatment RPR titer. Treponemal tests can demonstrate seroreversion after 36 months, and a negative treponemal test does not rule out a past history of syphilis.

Plasma L-arginine concentrations in premature infants with necrotizing enterocolitis

OBJECTIVE To determine whether L-arginine concentrations (the substrate for nitric oxide synthesis) are lower in premature infants in whom necrotizing enterocolitis (NEC) develops than in unaffected infants. METHODS We measured arginine and nutritional intake, plasma arginine, glutamine, total amino acids, and ammonia concentrations in 53 premature infants (mean gestational age +/- SD: 27 +/- 1.7 weeks) at risk of NEC. Measurements were done on days 3, 7, 14 and 21 and just before treatment in infants with NEC. RESULTS Necrotizing enterocolitis developed in 11 infants between postnatal days 1 and 26. On day 3, plasma arginine concentrations were decreased compared with normal published values (mean +/- SE, 41 mumol/L +/- 4). Arginine concentrations increased with day of life of measurement (p < 0.001) and arginine intake (p < 0.001). Plasma arginine concentrations were significantly lower at the time of diagnosis in infants with NEC compared with control subjects, even after adjusting for arginine intake and day of life (p = 0.032). Plasma glutamine and total amino acid concentrations were not significantly different in infants with NEC compared with control subjects. Plasma ammonia concentrations were elevated on day 3 (mean +/- SE, 72 +/- 3.3 mumol/L) and decreased with postnatal age (p < 0.001) and increasing plasma arginine concentrations (p < 0.001). CONCLUSION Plasma arginine concentrations are decreased at the time of diagnosis in premature infants with NEC. The potential benefit of arginine supplementation in the prevention of the disease deserves evaluation.

Association between physical illness and suicide among the elderly

Background Only a few small studies have explored the association between various physical illnesses and suicide in the elderly and they have produced inconsistent results. Thus, we undertook this larger study to more definitively assess the association between elderly suicide and physical illness. Methods This case-control study compared the proportion with physical illnesses among 822 cases who committed suicide with that among 944 controls who died due to motor vehicle accident at age 55 years or over in Alberta, Canada. Results Compared to the motor vehicle accident deaths, the elderly who committed suicide were more likely to have cancer, ischemic heart disease, chronic pulmonary disease, peptic ulcer, prostatic disorder, depression and other psychiatric illnesses. There was no significant difference in the proportion of cerebrovascular disease and diabetes mellitus between the case and control groups before adjustment of demographic and clinical characteristics. After adjustment of these variables, the elderly with any of the following illnesses were more likely to die by suicide than those without the illness: cancer (adjusted odds ratio [95 % confidence interval]: 1.73 [1.16–2.58]), prostatic disorder (excluding prostatic cancer, 1.70 [1.16–2.49]), chronic pulmonary disease among the married (1.86 [1.22–2.83]), depression (6.70 [4.72–9.50]) or other psychiatric illness (2.16 [1.68–2.76]). There was no evidence that ischemic heart disease, cerebrovascular disease, peptic ulcer and diabetes mellitus might be associated with suicide in the elderly. Conclusions Cancer, prostatic disorder, chronic pulmonary disease among the married and psychiatric illness appear to be associated with suicide among the elderly.

Drinking 300 mL of clear fluid two hours before surgery has no effect on gastric fluid volume and pH in fasting and non-fasting obese patients

PurposeTo determine whether, in obese [body mass index (BMI) > 30 kg·m2] patients, oral intake of 300 mL clear liquid two hours before elective surgery affects the volume and pH of gastric contents at induction of anesthesia.MethodsA single-blind, randomized study of 126 adult patients, age ≥18 yr, ASA physical status I or II, BMI > 30 kg·m2 who were scheduled for elective surgery under general anesthesia. Patients were excluded if they had diabetes mellitus, symptoms of gastroesophageal reflux, or had taken medication within 24 hr that affects gastric secretion, gastric fluid pH or gastric emptying. All patients fasted from midnight and were randomly assigned to fasting or fluid group. Two hours before their scheduled time of surgery, all patients drank 10 mL of water containing phenol red 50 mg. Those in the fluid group followed with 300 mL clear liquid of their choice. Immediately following induction of general anesthesia and tracheal intubation, gastric contents were aspirated through a multiorifice Salem sump tube. The fluid volume, pH and phenol red concentration were recorded.ResultsMedian (range) values in fasting vs fluid groups were: gastric fluid volume 26 (3–107) mL vs 30 (3–187) mL, pH 1.78 (1.31–7.08) vs 1.77 (1.27–7.34) and phenol red retrieval 0.1 (0–30)% vs 0.2 (0–15)%. Differences between groups were not statistically significant.ConclusionObese patients without comorbid conditions should follow the same fasting guidelines as non-obese patients and be allowed to drink clear liquid until two hours before elective surgery, inasmuch as obesity per se is not considered a risk factor for pulmonary aspiration.RésuméObjectifDéterminer si, chez des patients obèses [indice de masse corporelle (IMC) > 30 kg·m2], la prise orale de 300 mL de liquide clair deux heures avant de subir une opération réglée a un effet sur le volume et le pH du contenu gastrique lors de l’induction anesthésique.MéthodeUne étude randomisée, à simple insu, a été menée auprès de 126 patients adultes, ≥18 ans, d’état physique ASA I ou II, d’IMC > 30 kg·m2, devant subir une intervention chirurgicale réglée sous anesthésie générale. La présence de diabète, ou de symptômes de reflux gastro-œsophagien ou la prise de médicaments, dans les 24 h avant l’opération, pouvant affecter la sécrétion gastrique, le pH du liquide gastrique ou l’évacuation gastrique entraînaient l’exclusion du patient. Tous les patients, à jeun depuis minuit, ont été répartis en deux groupes :jeûne ou liquide. Deux heures avant l’heure prévue de l’opération, tous les patients ont bu 10 mL d’eau contenant 50 mg de rouge de phénol. Les patients du groupe «liquide» ont pris ensuite 300 mL d’un liquide clair de leur choix. Immédiatement après l’induction de l’anesthésie et l’intubation endotrachéale, le contenu gastrique a été aspiré au moyen d’une sonde multiorifice Salem. Le volume de liquide, le pH et les concentrations de rouge de phénol ont été notés.RésultatsLes valeurs moyennes (étendue) du groupe de jeûne vs le groupe «liquide» ont été : volume de liquide gastrique 26 (3–107) mL vs 30 (3–187) mL, pH 1,78 (1,31–7,08) vs 1,77 (1,27–7,34) et repérage du rouge de phénol 0,1 (0–30) % vs 0,2 (0–15) %. Il n’y avait pas de différence intergroupe significative.ConclusionLes patients obèses, sans symptômes comorbides, devraient suivre les mêmes directives de jeûne que les patients non obèses. Ils peuvent boire un liquide clair jusqu’à deux heures avant une opération réglée, étant donné que l’obésité en elle-même n’est pas considérée comme un facteur de risque d’aspiration pulmonaire.

The LMA-ProSeal is an effective alternative to tracheal intubation for laparoscopic cholecystectomy.

PurposeTo compare LMA-ProSeal™ (LMA-PS) with endotracheal tube (ETT) with respect to pulmonary ventilation and gastric distension during laparoscopic cholecystectomy.MethodsWe randomized 109 ASA I–III adults to LMA-PS or ETT after stratifying them as non-obese or obese (body mass index > 30 kg·m−2). After preoxygenation, anesthesia was induced with propofol, fentanyl and rocuronium. An LMA-PS (women #4, men #5) or ETT (women 7 mm, men 8 mm) was inserted and the cuff inflated. A # 14 gastric tube was passed into the stomach in every patient and connected to continuous suction. Anesthesia was maintained with nitrous oxide, oxygen and isoflurane. Ventilation was set at 10 mL·kg−1 and 10 breaths·min−1. The surgeon, blinded to the airway device, scored stomach size on an ordinal scale of 0–10 at insertion of the laparoscope and upon decompression of the pneumoperitoneum.ResultsThere were no statistically significant differences in SpO2 or PETCO2 between the two groups before or during peritoneal insufflation in either non-obese or obese patients. Median (range) airway pressure at which oropharyngeal leak occurred during a leak test with LMA-PS was 34 (18–45) cm water. Change in gastric distension during surgery was similar in both groups. Four of 16 obese LMA-PS patients crossed over to ETT because of respiratory obstruction or airway leak.ConclusionsA correctly seated LMA-PS or ETT provided equally effective pulmonary ventilation without clinically significant gastric distension in all non-obese patients. Further studies are required to determine the acceptability of the LMA-PS for laparoscopic cholecystectomy in obese patients.RésuméObjectifComparer le LMA-ProSeal™ (LMA-PS) et le tube endotrachéal (TET) quant à la ventilation pulmonaire et à la distension gastrique pendant la cholécystectomie laparoscopique.MéthodeLe tirage au sort de 109 adultes d’état physique ASA I–III, répartis en deux groupes, LMA-PS ou ETT, a été stratifié sur les facteurs non obèses ou obèses (indice de masse corporelle > 30 kg·m−2). Après la préoxygénation, l’anesthésie a été induite avec du propofol, du fentanyl et du rocuronium. Un LMA-PS (no 4: femmes et no 5: hommes) ou un TET (7 mm: femmes et 8 mm: hommes) a été inséré, et le ballonnet gonflé. Un tube gastrique no 14 a été poussé dans l’estomac et relié à une aspiration continue. L’anesthésie a été maintenue avec du protoxyde d’azote, de l’oxygène et de l’isoflurane. La ventilation a été instaurée à 10 mL·kg−1 et 10 respirations·min−1. Le chirurgien a coté, sans connaître le dispositif d’intubation utilisé, la taille de l’estomac selon une échelle ordinale de 0–10 au moment de l’insertion du laparoscope et lors de la décompression du pneumopéritoine.RésultatsLes SpO2 et PETCO2 n’ont pas présenté de différence intergroupe statistiquement significative avant ou pendant l’insufflation péritonéale chez les patients obèses ou non. La pression médiane des voies aériennes (limites) à laquelle une fuite oropharyngienne est survenue pendant une épreuve d’étanchéité avec le LMA-PS a été de 34 (18–45) cm d’eau. La variation de distension gastrique peropératoire a été comparable entre les groupes. Quatre des 16 patients obèses porteurs du LMA-PS ont été intégrés au groupe TET à cause d’obstruction respiratoire ou d’une fuite du masque laryngé.ConclusionUn LMA-PS ou un TET bien installé permet une ventilation également efficace sans distension gastrique significative chez tous les patients non obèses. D’autres études devront déterminer l’acceptabilité du LMA-PS pour la cholécystectomie laparoscopique chez les obèses.

LMA-Classic™ and LMA-ProSeal™ are effective alternatives to endotracheal intubation for gynecologic laparoscopy

PurposeTo compare the laryngeal mask airways (LMA), LMA-Classic™ (LMA-C) and LMA-ProSeal™ (PLMA) with the endotracheal tube (ETT) with respect to pulmonary ventilation and gastric distension during gynecologic laparoscopy.MethodsWe stratified 209 women, aged ≥ 18 yr, ASA physical status I–III, by body mass index as non-obese (≤ 30 kg·m−2) or obese (> 30 kg·m−2) and randomized them to LMA-C/PLMA or ETT groups for airway management. Anesthesia was induced with propofol, fentanyl and succinylcholine or rocuronium. In the LMA-C/PLMA group we used a size 4 LMA-C in non-obese patients and size 4 or 5 PLMA in obese patients. In the ETT group we used a cuffed 7.0 mm ETT in all patients. Anesthesia was maintained with isoflurane in nitrous oxide and 30–50% oxygen, fentanyl and neuromuscular blockade with mechanical ventilation (tidal volume 10 mL·kg−1). The staff surgeon, blinded to the type of airway, scored stomach size on an ordinal scale 0–10 at initial insertion of the laparoscope and immediately before the conclusion of the surgical procedure.ResultsThere were no crossovers and no statistically significant differences between LMA-C/PLMA and ETT groups for SpO2, PETCO2or airway pressure before or during peritoneal insufflation in short (≤ 15 min) or long (> 15 min) periods of peritoneal inflation. Differences between groups with respect to stomach size changes during surgery were not statistically significant.ConclusionA correctly placed LMA-C or PLMA is as effective as an ETT for positive pressure ventilation without clinically important gastric distension in non-obese and obese patients.RésuméObjectifComparer les masques laryngés (ML), ML Classique™ (MLC) et le ML ProSeal™ (MLP), au tube endotrachéal (TET) quant à la ventilation pulmonaire et à la distension gastrique pendant la laparoscopie gynécologique.MéthodeNous avons réparti 209 femmes, ≥ 18 ans, d’état physique ASA I–III, selon l’indice de masse corporelle, comme non obèses (≤ 30 kg·m−2) ou obèses (> 30 kg·m−2) et leur avons assigné au hasard le MLC/MLP ou le TET pour maintenir la perméabilité des voies aériennes. L’anesthésie a été induite avec du propofol, du fentanyl et de la succinylcholine ou du rocuronium. Dans le groupe MLC/MLP, un MLC de taille 4 a été utilisé chez les patientes non obèses et un MLP de taille 4 ou 5 chez les patientes obèses. Dans le groupe TET, un TET de 7,0 mm à ballonnet a été inséré chez toutes les patientes. L’anesthésie a été entretenue avec de l’isoflurane dans du protoxyde d’azote et de l’oxygène à 30–50 %, du fentanyl et un blocage neuromusculaire associé à une ventilation mécanique (volume courant de 10 mL·kg−1). Le chirurgien en service, qui ne connaissait pas le type d’appareil utilisé pour les voies aériennes, a évalué la taille de l’estomac sur une échelle ordinale de 0–10 lors de l’insertion initiale du laparoscope et immédiatement avant la fin de l’intervention chirurgicale.RésultatsIl n’y a pas eu d’abandon de technique respiratoire et aucune différence significative au plan statistique entre les groupes MLC/MLP et TET, concernant la SpO2, la PETCO2 ou la pression des voies aériennes, avant ou pendant l’insufflation péritonéale, qu’il s’agisse d’insufflation courte (≤ 15 min) ou longue (> 15 min). Les différences intergroupes quant aux changements de la taille de l’estomac pendant l’opération n’ont pas été statistiquement significatives.ConclusionUn MLC ou un MLP bien mis en place sont aussi efficaces qu’un TET pour la ventilation à pression positive sans distension gastrique significativement importante chez des patientes obèses ou non.

Neurovascular decoupling is associated with severity of cerebral amyloid angiopathy

Objectives: We used functional MRI (fMRI), transcranial Doppler ultrasound, and visual evoked potentials (VEPs) to determine the nature of blood flow responses to functional brain activity and carbon dioxide (CO2) inhalation in patients with cerebral amyloid angiopathy (CAA), and their association with markers of CAA severity. Methods: In a cross-sectional prospective cohort study, fMRI, transcranial Doppler ultrasound CO2 reactivity, and VEP data were compared between 18 patients with probable CAA (by Boston criteria) and 18 healthy controls, matched by sex and age. Functional MRI consisted of a visual task (viewing an alternating checkerboard pattern) and a motor task (tapping the fingers of the dominant hand). Results: Patients with CAA had lower amplitude of the fMRI response in visual cortex compared with controls (p = 0.01), but not in motor cortex (p = 0.22). In patients with CAA, lower visual cortex fMRI amplitude correlated with higher white matter lesion volume (r = −0.66, p = 0.003) and more microbleeds (r = −0.78, p < 0.001). VEP P100 amplitudes, however, did not differ between CAA and controls (p = 0.45). There were trends toward reduced CO2 reactivity in the middle cerebral artery (p = 0.10) and posterior cerebral artery (p = 0.08). Conclusions: Impaired blood flow responses in CAA are more evident using a task to activate the occipital lobe than the frontal lobe, consistent with the gradient of increasing vascular amyloid severity from frontal to occipital lobe seen in pathologic studies. Reduced fMRI responses in CAA are caused, at least partly, by impaired vascular reactivity, and are strongly correlated with other neuroimaging markers of CAA severity.