Robert V. Wetz

Somatostatin and gabexate for post-endoscopic retrograde cholangiopancreatography pancreatitis prevention: Meta-analysis of randomized placebo-controlled trials

Background and Aim:  Prior studies have suggested the efficacy of somatostatin and gabexate in post‐endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis prevention. We examined this notion in our study.

Current concepts in triglyceride metabolism, pathophysiology, and treatment.

It is becoming more evident that age, gender, and race play a significant role in the metabolic profiles that are seen among individuals in a clinical setting. It is important to understand these variances in metabolic profiles; and with these variances in mind it is now possible to understand why a single diet might not decrease cardiovascular disease risk profiles uniformly for everyone. Much is now understood about triglyceride metabolism and its contribution to energy storage. In this review we will focus on triglycerides; their production, metabolism and influence on daily life, as well as the various methods for the treatment of hypertryglyceridemia and prevention of its sequelae.

Interferon and lamivudine vs. interferon for hepatitis B e antigen-positive hepatitis B treatment: meta-analysis of randomized controlled trials.

Aims: To compare interferon monotherapy with its combination with lamivudine for hepatitis B e antigen (HBeAg)‐positive hepatitis B treatment.

Association Between Coronary Artery Disease Diagnosed by Coronary Angiography and Breast Arterial Calcifications on Mammography: Meta-Analysis of the Data

BACKGROUND Previous studies evaluating breast arterial calcifications (BAC) as a risk marker for coronary artery disease (CAD) have been limited by sample size and have yielded mixed results. Our objective was to evaluate the association of BAC and CAD. METHODS Data sources included Medline (1970-2010), the Cochrane Controlled Trials Register electronic database (1970-2010), and CINAHL (1970-2010). The search strategy included the keywords, breast artery calcification, vascular calcification on mammogram, coronary angiography, and meta-analysis. Eligible studies included female patients who had undergone coronary angiography, the gold standard for diagnosing CAD, and had screening mammograms that revealed the presence or absence of BAC. Information on eligibility criteria, baseline characteristics, results, and methodologic quality was extracted by two reviewers. Disagreements were resolved by consensus. RESULTS A total of 927 patients were enrolled in the five studies. There was a 1.59 (95% confidence interval [CI] 1-21-2.09) increased odds of angiographically defined CAD in patients with BAC seen on mammography. CONCLUSIONS The presence of BAC on mammography appears to increase the risk of having obstructive CAD on coronary angiography; thus, BAC may not be a benign finding.

Using Six Sigma Methodology to Reduce Patient Transfer Times from Floor to Critical‐Care Beds

&NA; Introduction: In response to concerns regarding delays in transferring critically ill patients to intensive care units (ICU), a quality improvement project, using the Six Sigma process, was undertaken to correct issues leading to transfer delay. Objective: To test the efficacy of a Six Sigma intervention to reduce transfer time and establish a patient transfer process that would effectively enhance communication between hospital caregivers and improve the continuum of care for patients. Methods: The project was conducted at a 714‐bed tertiary care hospital in Staten Island, New York. A Six Sigma multidisciplinary team was assembled to assess areas that needed improvement, manage the intervention, and analyze the results. Results: The Six Sigma process identified eight key steps in the transfer of patients from general medical floors to critical care areas. Preintervention data and a root‐cause analysis helped to establish the goal transfer‐time limits of 3 h for any individual transfer and 90 min for the average of all transfers. Conclusions: The Six Sigma approach is a problem‐solving methodology that resulted in almost a 60% reduction in patienttransfer time from a general medical floor to a critical care area. The Six Sigma process is a feasible method for implementing healthcare related quality of care projects, especially those that are complex.

Serum lipoprotein levels in takotsubo cardiomyopathy vs. myocardial infarction.

Background In the setting of myocardial infarction (MI) or acute coronary syndrome (ACS), current guidelines recommend early and aggressive lipid lowering therapy with statins, irrespective of the baseline lipoprotein levels. Takotsubo cardiomyopathy (TCM) patients have a clinical presentation similar to myocardial infarction and thus receive early and aggressive statin therapy during their initial hospitalization. However, the pathology of TCM is not atherosclerotic coronary artery disease and hence we assumed the lipid profiles in TCM would be healthier than coronary artery disease patients. Methods In this retrospective study, we assessed fasting serum lipoprotein levels of ten TCM patients and compared them with forty, age and sex-matched myocardial infarction (MI) patients. Results Comparing serum lipoprotein levels of TCM with MI group, there was no significant difference in mean total cholesterol between the two groups (174.5 mg/dL vs. 197.6 mg/dL, p = 0.12). However, in the TCM group, mean HDL-C was significantly higher (66.87 mg/dL vs. 36.5 mg/dL, p = 0.008), the mean LDL-C was significantly lower (89.7 mg/dL vs. 128.9 mg/dL, p = 0.0002), and mean triglycerides was also significantly lower (65.2 mg/dL vs. 166.8 mg/dL, p < 0.0001). Conclusions In this study, TCM patients in comparison to MI patients had significantly higher levels of HDL-C, lower levels of LDL-C levels and triglycerides. The lipid profiles in TCM were consistent with the underlying pathology of non-atherosclerotic, non-obstructive coronary artery disease. As lipoproteins in most TCM patients were within the optimal range, we recommend an individual assessment of lipid profiles along with their coronary heart disease risk factors for considering long term lipid-lowering therapy. A finding of hyperalphalipoproteinemia or hypotriglyceridemia in 40% of TCM patients is novel but this association needs to be confirmed in future studies with larger sample sizes. These findings may provide clues in understanding the pathogenesis of takotsubo cardiomyopathy.

A STEMI Code Protocol Improves Door-to-Balloon Time on Weekdays and Weekends

Abstract: Primary percutaneous coronary intervention (PCI) has emerged as the standard of care for the management of ST‐elevation myocardial infarctions (STEMI). Only 32% of patients with STEMI receive this procedure within the recommended 90 min for door‐to‐balloon time (DTB). We reviewed all STEMI cases that presented to our institution before and after the implementation of a STEMI Code protocol. Before the STEMI Code protocol, 27.1% of weekday cases and 6.3% of weekend cases were performed within 90 min. After the STEMI Code protocol, there was a threefold increase in the number of patients who received PCI within 90 min (p<.0001). A STEMI Code protocol dramatically improves DTB and equalizes disparities between weekday and weekend care.

Smoke trails of a dying gut: portal and mesenteric vein gas

DESCRIPTION A 49-year-old male, status postresection of melanoma 2 years ago, presented with constipation, abdominal pain and abdominal distension for the last 1 week. CT abdomen with contrast showed small bowel obstruction and a transition point was identified in the central abdomen (figure 1). Also noted were innumerable hepatic and splenic metastases (figure 2), and innumerable abdominal lymph nodes, largest one measuring 6.9 cm. After 3 h, a repeat CT abdomen was performed to look for delayed passage of contrast beyond the transition point. In this interim, the patient developed small bowel pneumatosis, with new mesenteric and portal venous gas (figures 3 and 4). An emergency laparotomy was performed. The entire mid small bowel was covered with fibrinous exudate with evidence of ischaemia and perforation. Ischaemia and obstruction was from strangulation of the small bowel due to lymph node adhesions and external compression by massively enlarged lymph nodes. A wide mesenteric resection was carried out incorporating all the large lymph nodes in the area of perforation. A primary anastomosis was performed between the ileum and the mid jejunum. Postsurgery, the patient remained mechanically ventilated with pressure support, but the family decided to withdraw all the supportive measures and the patient expired in 2 days. This rare radiological sign was first described by Wolfe and Evans 1 in neonates secondary to necrotising enterocolitis. It is believed that air leaks through the obstructed gut into capillary veins due to perforation of ischaemic intestinal wall. The treatment and prognosis of portal venous gas depends on the underlying cause. 2 In adults, it is mostly seen secondary to bowel ischaemia, hence requires emergency laparotomy and carries a high mortality. 3 This sign is also reported in some benign conditions requiring only conservative management. 4