Systematic review of congenital and acquired portal-systemic shunts in otherwise normal livers.

BACKGROUND: Portal-systemic shunts (PSSs) are rarely seen in healthy individuals or patients with non-cirrhotic liver disease. They may play an important role in hepatic metabolism as well as in the spread of gastrointestinal metastatic tumours to specific organs. Small spontaneous PSSs may be more common than generally thought. However, epidemiological data are scarce and inconclusive. This systematic review examined the prevalence of reported PSSs and the associated detection methods. METHODS: Literature up to 2011 was reviewed for adult patients with proven congenital or acquired PSSs. Only PSSs in normal livers were analysed for the methods of diagnosis. Eligible studies were identified by searching relevant databases, including PubMed, Embase, MEDLINE and the Cochrane Library. The selection of eligible articles was carried out using predefined inclusion criteria (adult, non-surgical PSS) and a set of search terms that were established before the articles were identified. RESULTS: Eighty studies were included describing 112 patients with congenital or acquired PSSs. The majority were diagnosed incidentally using Doppler ultrasound imaging and CT. CONCLUSION: Congenital and acquired PSSs are rare. They are usually clinically asymptomatic and discovered incidentally by radiological techniques. They may be clinically relevant owing to drug, tumour cell, metabolic and pathogen shunting.

Acute upper gastrointestinal haemorrhage resulting in transient hepatic failure following liver resection.

BACKGROUND: Both acute stress ulcer and liver failure are well-known complications of hepatic resection. This case study documents how an episode of postoperative gastrointestinal haemorrhage can provoke transient hepatic failure. CASE OUTLINE: A 66-year-old woman with no previous history of reflux oesophagitis or peptic ulcer disease underwent a right liver resection for a solitary metastasis. On the fifth postoperative day, with a small premonitory haematemesis, she was started on omeprazole intravenously. She subsequently required blood transfusion and endoscopy; a bleeding acute gastric ulcer was injected with adrenalin. She then progressed to acute liver failure with associated hepatic encephalopathy but made a full recovery. DISCUSSION: Adverse effects of prophylactic H(2) receptor antagonists have included liver failure and hepatitis, and animal studies have shown inhibition of liver regeneration after hepatectomy. Proton pump inhibitors (PPIs) have an acceptable profile of adverse events and their effect on liver regeneration appears to be favourable. Given the serious potential for liver failure in the event of significant bleeding, a PPI is advocated for routine prophylaxis against acute stress ulceration in all major liver resections.

A chest injury in an isolated geo-politically sensitive area: questions in management.

The reported case of a stab wound to the chest occurred in an isolated area with no specialized surgical care available. The need for transport and specifically by air, introduced particular questions in management. On a humanitarian basis and in line with its mandate, the Peace Monitoring Group, a United Nations endorsed entity in Bougainville, Papua New Guinea, provided transport to a facility with an appropriate standard of care. The questions of need for patient evacuation and chest drainage, with the timing of this maneuver are considered.

Mass gathering medicine: a predictive model for patient presentation and transport rates.

INTRODUCTION: This paper reports on research into the influence of environmental factors (including crowd size, temperature, humidity, and venue type) on the number of patients and the patient problems presenting to first-aid services at large, public events in Australia. Regression models were developed to predict rates of patient presentation and of transportation-to-a-hospital for future mass gatherings. OBJECTIVE: To develop a data set and predictive model that can be applied across venues and types of mass gathering events that is not venue or event specific. Data collected will allow informed event planning for future mass gatherings for which health care services are required. METHODS: Mass gatherings were defined as public events attended by in excess of 25,000 people. Over a period of 12 months, 201 mass gatherings attended by a combined audience in excess of 12 million people were surveyed throughout Australia. The survey was undertaken by St. John Ambulance Australia personnel. The researchers collected data on the incidence and type of patients presenting for treatment and on the environmental factors that may influence these presentations. A standard reporting format and definition of event geography was employed to overcome the event-specific nature of many previous surveys. RESULTS: There are 11,956 patients in the sample. The patient presentation rate across all event types was 0.992/1,000 attendees, and the transportation-to-hospital rate was 0.027/1,000 persons in attendance. The rates of patient presentations declined slightly as crowd sizes increased. The weather (particularly the relative humidity) was related positively to an increase in the rates of presentations. Other factors that influenced the number and type of patients presenting were the mobility of the crowd, the availability of alcohol, the event being enclosed by a boundary, and the number of patient-care personnel on duty. Three regression models were developed to predict presentation rates at future events. CONCLUSIONS: Several features of the event environment influence patient presentation rates, and that the prediction of patient load at these events is complex and multifactorial. The use of regression modeling and close attention to existing historical data for an event can improve planning and the provision of health care services at mass gatherings.

Using the ability to perform CPR as a standard of fitness: a consideration of the influence of aging on the physiological responses of a select group of first aiders performing cardiopulmonary resuscitation.

OBJECTIVE: Previous research has suggested that the physical demands of performing cardiopulmonary resuscitation (CPR) are relatively low. However, the subjects studied have generally been of a young age. The aim of this study was to test the hypothesis, in null form, that the physiological responses to the performance of single operator CPR for 10 min are independent of age. Confirmation of the hypothesis would allow the use of a period of time performing CPR as a socially non-discriminatory means of testing ability across a wide spectrum of age. DESIGN: 33 St. John Operations Branch members (a sample of convenience), aged between 18 and 65 years, were examined whilst performing 10 min of single operator CPR on a manikin at St. John Ambulance Headquarters, Adelaide, South Australia. Heart rate and cardiac rhythm were monitored continuously. Blood pressure was recorded at baseline and the end of the 3rd, 6th and 9th min of CPR. Subjects also rated their perceived level of activity using the 15-point Borg rating scale every 3 min and at the end of the test. RESULTS: The calculated rate-pressure product did not vary significantly with age, either at rest or in response to performing CPR. The rate-pressure product increased significantly (P < 0.05) whilst performing CPR. There was no effect of age on the perceived level of exertion, which also increased significantly during CPR as compared with rest. CONCLUSION: There was no significant effect of age on the physiological responses to the performance of 10 min of single operator CPR in this select group.

The safety and efficacy of laparoscopic live donor nephrectomy: a systematic review.

BACKGROUND: The aim of this systematic review was to compare the safety and efficacy of laparoscopic live donor nephrectomy with the "gold" standard of open live donor nephrectomy. SEARCH STRATEGY: Three search strategies were devised to enable literature retrieval from the Medline, Current Contents, Embase, and Cochrane Library databases up until, and including, February 2000. STUDY SELECTION: Inclusion of a report was determined on the basis of a predetermined protocol, independent assessment by two reviewers, and a final consensus decision. English language reports were selected and acceptable study designs included randomized-controlled trials, controlled clinical trials, case series, or case reports. Each report was required to provide information on at least one of several safety and efficacy outcomes as detailed in the protocol. DATA COLLECTION AND ANALYSIS: Twenty-five reports met the inclusion criteria. They were tabulated and critically appraised in terms of the methodology and design, sample size, outcomes, and the possible influence of bias, confounding, and chance. RESULTS: High level evidence comparing the safety and efficacy of laparoscopic live donor nephrectomy with open donor nephrectomy was not available at the time of this review. Limited low level evidence suggested that the laparoscopic approach might be advantageous regarding the donor's hospital stay, convalescence, pain, and resumption of employment. CONCLUSIONS: The ASERNIP-S Review Group concluded that the evidence-base for laparoscopic live donor nephrectomy was inadequate to make a safety and efficacy recommendation. Clinical and research recommendations were developed regarding the introduction and current practice of this procedure in Australia.

Rationale and intended use for the Veress needle: a translation of the original descriptive article.

The technical development of equipment in the last decade has resulted in a rapid expansion in the range of procedures capable of being performed safely by a laparoscopic technique. For many procedures, the first step is induction of a pneumoperitoneum. This has inherent danger, and there is disagreement on the preferred technique. The Veress needle is an instrument developed in the 1930s that has continued to be used into the 1990s. In view of the controversy about its present role, the authors reviewed the article that provided the original description of the needle. This review demonstrates that the designer had a clear intention for its use and an understanding of the hazards involved. In his hands, the complications were few. A translation of the article from German into English is provided.

The effect of the Angelchik prosthesis on esophageal and gastric function.

The effects of the Angelchik prosthesis on esophageal and gastric function were investigated in 17 patients (11 men and six women; median age, 57 years; age range, 36 to 88 years) who underwent surgery for treatment of gastroesophageal reflux disease. All patients demonstrated unequivocal reflux, either at endoscopy or 24-hour pH testing. There was a significant increase in lower esophageal sphincter pressure after surgery, and no patient demonstrated abnormal reflux on pH testing. Gastric emptying of liquids and solids was not altered by surgery. Six months after surgery, all symptoms except dysphagia had significantly improved. Thirty-three months after surgery, six patients described symptoms as severe as or worse than those before surgery. Four patients had the prosthesis removed, two because of dysphagia alone, one because of reflux and dysphagia, and one because of flatulence and bloating. The patients who required removal of the prosthesis because of dysphagia had gross delay of esophageal emptying. We conclude that the Angelchik prosthesis is an effective antireflux device, but it interferes with esophageal function in some patients, requiring removal of the prosthesis. We think the rate of removal of the prosthesis is too high for its routine use in the treatment of gastroesophageal reflux disease.

Laparoscopy in the diagnosis of acute lower abdominal pain.

Laparoscopy was performed on twenty-seven hospital inpatients presenting with acute lower abdominal pain. Nineteen of the twenty-seven were admitted with a provisional diagnosis of appendicitis. Following laparoscopy, nine patients underwent appendicectomy, and a further three underwent laparotomy. Fifteen patients had a laparoscopy as the sole procedure, and all were discharged from hospital without need for further surgery. Of those patients in the operative group, five had their proposed incisions modified as the result of the laparoscopic findings. The only complications attributable to laparoscopy was one small wound haematoma.

Traumatic renal arteriovenous fistula.

A case of a 29-year-old man who developed a renal arteriovenous fistula after a gunshot injury is reported. The patient presented with renovascular hypertension associated with high putput cardiac failure, both of which were reversed by surgery.