Jan K. Horn

Prospective Randomized Trial of LC+LCBDE vs ERCP/S+LC for Common Bile Duct Stone Disease

OBJECTIVE To compare outcome parameters for good-risk patients with classic signs, symptoms, and laboratory and abdominal imaging features of cholecystolithiasis and choledocholithiasis randomized to either laparoscopic cholecystectomy plus laparoscopic common bile duct exploration (LC+LCBDE) or endoscopic retrograde cholangiopancreatography sphincterotomy plus laparoscopic cholecystectomy (ERCP/S+LC). DESIGN Our study was a prospective trial conducted following written informed consent, with randomization by the serially numbered, opaque envelope technique. SETTING Our institution is an academic teaching hospital and the central receiving and trauma center for the City and County of San Francisco, California. PATIENTS We randomized 122 patients (American Society of Anesthesiologists grade 1 or 2) meeting entry criteria. Ten of these patients, excluded from outcome analysis, were protocol violators having signed out of the hospital against medical advice before 1 or both procedures were completed. INTERVENTIONS Treatment was preoperative ERCP/S followed by LC, or LC+LCBDE. MAIN OUTCOME MEASURES The primary outcome measure was efficacy of stone clearance from the common bile duct. Secondary end points were length of hospital stay, cost of index hospitalization, professional fees, hospital charges, morbidity and mortality, and patient acceptance and quality of life scores. RESULTS The baseline characteristics of the 2 randomized groups were similar. Efficacy of stone clearance was likewise equivalent for both groups. The time from first procedure to discharge was significantly shorter for LC+LCBDE (mean [SD], 55 [45] hours vs 98 [83] hours; P < .001). Hospital service and total charges for index hospitalization were likewise lower for LC+LCBDE, but the differences were not statistically significant. The professional fee charges for LC+LCBDE were significantly lower than those for ERCP/S+LC (median [SD],

Evidence of complement catabolism in acute pancreatitis.

4820 [1637] vs

Modulation of the endotoxin receptor (CD14) in septic patients.

6139 [1583]; P < .001). Patient acceptance and quality of life scores were equivalent for both groups. CONCLUSIONS Both ERCP/S+LC and LC+LCBDE were highly effective in detecting and removing common bile duct stones and were equivalent in overall cost and patient acceptance. However, the overall duration of hospitalization was shorter and physician fees lower for LC+LCBDE. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00807729.

Complement and endotoxin-induced lung injury in sheep

Active proteolytic enzymes are released into the gland parenchyma and surrounding tissues during episodes of acute pancreatitis. Since complement components are potential substrates for active proteases and may be the source of biologically active peptides capable of mediating tissue injury, we have examined sera obtained from 12 patients during 13 episodes of acute pancreatitis for evidence of complement catabolism. In 8 of 13 acute phase sera, there were decreased levels of CH50, C3, C4, or some combination thereof as well as degradation products of C3 (revealed by crossed immunoelectrophoresis). In convalescent sera, levels of complement components were normal or elevated. Measurements of alpha1-antitrypsin, alpha2-macroglobulin, and trypsin inhibitory capacity failed to reveal evidence of protease-antiprotease imbalance. These findings provide evidence of complement catabolism in acute pancreatitis and suggest the possibility that activated complement components may play a role in the pathogenesis of some systemic pathologic changes which occur in this disease.

Pain control in outpatient surgery1

The monocyte is a pivotal cell in septic patients that responds to endotoxin with release of inflammatory cytokines. Monocytes display on their surface a receptor (CD14) for complexes formed by endotoxin (lipopolysaccharide, LPS) and a plasma LPS-binding protein (LBP). We compared monocytes obtained from normal controls with those obtained from septic patients for expression of CD14 by flow cytometric analysis of immunofluorescent-stained cells. In normal individuals and patients, 75%-95% of monocytes are CD14 positive (CD14+). Mean fluorescence exhibited by the CD14+ population was measured after maintaining cells at 37 degrees C for 15 minutes and compared with baseline cells held at 4 degrees C (mean fluorescence ratio). All cells increased their CD14 mean fluorescence ratio with warming; however, the level achieved by monocytes obtained from septic patients was on average 78% +/- 8% of control levels (p = 0.014). To further clarify CD14 expression, we examined the effect of Escherichia coli LPS on normal monocytes by comparing monocytes treated in serum-free buffer (no LBP) with monocytes treated in whole blood (containing LBP). The LPS (1.0 ng/mL) incubated with whole blood for 120 minutes generated an increase in CD14+ mean fluorescence compared with buffer. In contrast, phorbol myristate acetate lowered CD14+ mean fluorescence levels. These data indicate that normal monocytes incubated in the presence of ligand (LBP-LPS complexes) increase their expression of CD14, whereas CD14 expression in septic patients is diminished. We conclude that monocytes from septic patients were responsive to other stimuli aside from LPS and that decreased expression of CD14 may indicate a poor prognosis.

Case Managers in Mass Casualty Incidents

Intravenous infusions of endotoxin in sheep cause lung injury characterized by edema due to increased microvascular permeability. Similar increases in pulmonary microvascular permeability are seen in septic patients with the adult respiratory distress syndrome. Since endotoxin-induced lung injury may be mediated by interactions between products of complement activation and polymorphonuclear leukocytes, plasma and lung lymph from six unanesthetized sheep infused with Escherichia coli endotoxin (1.0 micrograms/kg over 30 min) were examined for complement-derived chemotactic activity. By 2-3 hr following infusion of endotoxin, all animals had the increased lung lymph fluid and protein flows characteristic of permeability edema. Preinfusion samples of plasma and lung lymph did not contain chemotactic activity for polymorphonuclear leukocytes. Following infusion of endotoxin, however, significant chemotactic activity was detected in plasma at 0.5-3.5 hr (P less than 0.05) and in lymph at 1.5-6.5 hr (P less than 0.025). The chemotactic activity was heat stable (56 degrees C for 30 min) but was abolished by treatment with antibodies to C5. These data indicate that infusions of endotoxin lead to the generation in plasma, and the appearance in lung lymph, of C5-derived peptides with chemotactic activity for polymorphonuclear leukocytes. C5-derived peptides may account for the pulmonary microvascular leukostasis and endothelial injury that lead to increased permeability edema after infusions of endotoxin.

The additional use of end-tidal alveolar dead space fraction following D-dimer test to improve diagnostic accuracy for pulmonary embolism in the emergency department

Excellence in perioperative pain management can result in reduced time in the recovery room, more rapid rehabilitation and return to work, and increased patient satisfaction. Recently, the assessment of pain, the “fifth vital sign,” has been recognized as an essential component of patient care. Unfortunately, many surgeons neither evaluate nor treat perioperative pain in an organized fashion based on well-controlled clinical studies. Pharmaceutical companies purchase prescription records from pharmacies to learn about physician prescription patterns and collectively spend

Congenital cleft spleen with CT scan appearance of high-grade splenic laceration after blunt abdominal trauma.

12 billion per year to influence these patterns. So the use of a particular analgesic drug may be unduly influenced by commercial considerations, unless surgeons understand the pharmacology of pain management. Pain management in outpatient surgery is also a shared responsibility involving the surgeon, the anesthesiologist, and the perioperative nurse. Many factors in addition to the postoperative pain regimen can influence the quality of perioperative pain control, including preoperative interview, reception in the outpatient surgery suite, premedication, anesthetic technique, and the magnitude and conduct of the operation. An organized collaboration between the surgeon, anesthesiologist, and nurse will optimize the results of the outpatient surgery pain management program. This article will review the objective assessment of pain, the pharmacology of analgesic and local anesthetic drugs, and the use of preemptive analgesia to diminish postoperative pain after outpatient surgery.

Hypercalcemia: A Possible Cause for Elevated Serum Lysozyme Levels

Objective:To examine whether case managers affect patient evaluation/treatment/outcome and staffing requirements during Multiple Casualty Incidents (MCIs). Summary Background Data:Multiple patient relocations during MCIs may contribute to chaos. One hospital changed its MCI patient relocation policy during a wave of MCIs; rather than transfer patients from one medical team to another in each location, patients were assigned case-managers ± teams who accompanied them throughout the diagnostic/treatment cascade until definitive placement. Methods:MCI data (n = 17, 2001–2006) were taken from the hospital database which is updated by registrars in real-time. ISSs were calculated retrospectively. Matched events before (n = 5)/after (n = 3) the change yielded data on staff utilization. Semi-structured interviews were conducted with 26 experienced staff members regarding the effect of the change on patient care. Results:Twelve events occurred before (n = 379 casualties) and 5 occurred after (n = 152 casualties) the change. Event extent/severity, manpower demands and patient mortality remained similar before/after the change. Reductions were observed in: the number of x-rays/patient/1st 24-hour (P < 0.001), time to performance of first chest x-ray (P = 0.015), time from first chest x-ray to arrival at the next diagnostic/treatment location (P = 0.016), time from ED arrival to surgery (P = 0.022) and hospital lengths of stay for critically injured casualties (37.1 ± 24.7 versus 12 ± 4.4 days, P = 0.016 for ISS ≥ 25). Most interviewees (62%, n = 16) noted improved patient care, communication and documentation. Conclusions:During an MCI, case managers increase surge capacity by improving efficacy (workup/treatment times and use of resources) and may improve patient care via increased personal accountability, continuity of care, and involvement in treatment decisions.

Laparoscopic adrenalectomy for pheochromocytoma.

Purpose To determine the diagnostic performance of bedside assessment of end-tidal alveolar dead space fraction (ADSF) for pulmonary embolism (PE) and whether the use of additional ADSF assessment following D-dimer assay can improve the diagnostic accuracy in suspected PE patients in the emergency department. Methods A prospective observational study of 112 consecutive adult patients suspected of PE of whom 102 were eligible for analysis. ADSF was calculated using arterial carbon dioxide and end-tidal carbon dioxide. An ADSF less than 0.2 was considered normal. Results PE was confirmed in 11 (10.8%) of 102 patients. D-dimer assay alone as a reference standard test for PE had a sensitivity of 100%, specificity of 38.5% and false negativity of 0%. Area under the receiver-operator characteristic curve for the diagnosis of PE using ADSF values alone was 0.894, Sensitivity, specificity and false negativity for the combined results of a positive D-dimer test and abnormal ADSF were 100%, 78.0% and 0% for the presence of PE, respectively. Of 65 patients with a low or intermediate clinical probability and a positive D-dimer assay, 36 (55.4%) patients displayed normal ADSF and had no PE. Conclusions By itself ADSF assessment performed well in diagnosis of PE. The combined result of a positive D-dimer and abnormal ADSF increased the specificity for diagnosing PE compared with the D-dimer test alone. The use of additional bedside ADSF assessment following a positive D-dimer test may reduce the need for further imaging studies to detect PE in patients with a low or intermediate clinical probability.