Scoring Systems May be Effective in Predicting Mortality Associated with Palliative Emergency Gastrointestinal Surgery: A Retrospective Observational Study.

BACKGROUND: Palliative emergency gastrointestinal surgery is associated with significant morbidity and mortality and weighing up the benefits and harms during the decision-making may be challenging. There are very few studies on surgery in palliative patient population. The aim of this retrospective study was to evaluate morbidity and mortality after palliative emergency gastrointestinal surgery and the usability of scoring systems in predicting the outcome. METHODS: Consecutive adult patients undergoing palliative emergency surgery at a tertiary hospital during the period 2015 to 2016 were included. Pre- and post-operative functional status, morbidity and mortality of patients were assessed. The predictive value of the American Society of Anesthesiologists (ASA) classification, the American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator (ACS NSQIP SRC) and Palliative index (PI) in estimating morbidity and mortality were determined. RESULTS: A total of 93 patients (age 69 [28-92] years, 51% female) were included. Typical indications for surgery were bowel obstruction (52%) and securing food intake (30%). Pre-operatively two patients (2.2%) were totally dependent in daily activities, while post-operatively the respective share was 34% at discharge from hospital. The incidence of post-operative complications was 37% and 14% died during the hospital stay. One-, three-month and one-year mortality rates were 41%, 63% and 87%, respectively. While ASA score, PI score and ACS NSQIP did not predict post-operative morbidity, both ASA score and ACS NSQIP SRC predicted post-operative mortality. CONCLUSIONS: Palliative emergency laparotomy is associated with significant post-operative mortality and morbidity. Scorings, such as ASA score and ACS NSQIP SRC predict mortality in this patient population.

Thermal suit in preventing unintentional intraoperative hypothermia during general anaesthesia: a randomized controlled trial.

BACKGROUND: Unintentional perioperative hypothermia causes serious adverse effects to surgical patients. Thermal suit (T-Balance® ) is an option for passive warming perioperatively. We hypothesized that the thermal suit will not maintain normothermia more efficiently than conventional cotton clothes when also other preventive procedures against unintentional hypothermia are used. METHODS: One hundred patients were recruited to this prospective, randomized trial. They were allocated to the Thermal Suit group or a Control group wearing conventional hospital cotton clothes. All patients received our institution's standard treatment against unintentional hypothermia including a warming mattress, a forced-air upper body warming blanket and a warming device for intravenous fluids. Eardrum temperature was measured pre-operatively. In the operating room and post-anaesthesia care unit temperatures were measured from four locations: oesophagus, left axilla, dorsal surface of the left middle finger and dorsum of the left foot. The primary outcome measure was temperature change during robotic-assisted laparoscopic radical prostatectomy. RESULTS: The temperatures of 96 patients were analysed. There was no difference in mean core temperatures, axillary temperatures or skin temperatures on the finger between the groups. Only foot dorsum temperatures were significantly lower in the Thermal Suit group. Intraoperative temperature changes were similar in both groups. In the post-anaesthesia care unit temperature changes were minimal and they did not differ between the groups. CONCLUSION: Provided that standard preventive procedures in maintaining normothermia are effective the thermal suit does not provide any additional benefit over conventional cotton clothes during robotic-assisted laparoscopic radical prostatectomy.

Surgical pleth index in children younger than 24 months of age: a randomized double-blinded trial.

BACKGROUND: The surgical pleth index (SPI) is a measurement of intraoperative nociception. Evidence of its usability in children is limited. Given that the autonomic nervous system is still developing during the first years of life, the performance of the SPI on small children cannot be concluded from studies carried out in older age groups. METHODS: Thirty children aged <2 yr, planned for elective open inguinal hernia repair or open correction of undescended testicle, were recruited. The children were randomized into two groups; the saline group received ultrasound-guided saline injection in the ilioinguinal and iliohypogastric nerve region before surgery and ropivacaine after surgery, whereas the block group received the injections in the opposite order. The SPI was recorded blinded and was analysed at the time points of intubation, incision, and when signs of inadequate anti-nociception were observed. RESULTS: There was a significant increase in the SPI after intubation (P=0.019) and after incision in the saline group (P=0.048), but not at the time of surgical incision in the block group (P=0.177). An increase in the SPI was also seen at times of clinically apparent inadequate anti-nociception (P=0.008). The between-patient variability of the SPI was large. CONCLUSIONS: The SPI is reactive in small children after intubation and after surgical stimuli, but the reactivity of the SPI is rather small, and there is marked inter-individual variability in reactions. The reactivity is blunted by the use of ilioinguinal and iliohypogastric nerve block. CLINICAL TRIAL REGISTRATION: NCT02045810.

Bedside diagnosis of persistent post-sternotomy pain.

BACKGROUND: The prevalence of persistent post-sternotomy pain (PPSP) varies largely and has been mainly studied using questionnaires. We decided to perform a systematic qualitative and quantitative sensory examination study on a power-calculated sample of patients who had undergone sternotomy for cardiac surgery. Pain was diagnosed as PPSP if the patient complained of sternal pain that had developed after surgery together with corresponding sensory disturbances. PATIENTS AND METHODS: One hundred elective patients undergoing coronary artery bypass via sternotomy were recruited for dynamic sensory mapping 4-6 months after surgery. Sensory testing was performed using thermal rollers, a cotton stick and pinprick. The intensity of sensation was registered as a score on a numeric rating scale. The area of sensory dysfunction on the chest wall was traced onto paper and calculated with the help of a computer-based program. The patient also answered a validated pain questionnaire. RESULTS: Altogether 90 patients took part in the examination. Thirteen (15.4%) of the patients had pain and formed the PPSP group, while the remaining patients formed the non-PPSP group. Both groups had sensory abnormalities over the chest wall (69% of all patients). Sensory disturbances were more common, more profound and extended over a larger skin area in the PPSP group. Furthermore, daily activity performance in the PPSP group was poorer compared to the non-PPSP group. CONCLUSION: PPSP is a clinical diagnosis easily achieved using simple diagnostic tools and a medical history. Severity and extent of sensory abnormalities were found to be greater in the PPSP group.

Postoperative hyperalgesia does not predict persistent post-sternotomy pain; observational study based on clinical examination.

BACKGROUND: Persistent post-sternotomy pain is a common problem, but the risk of developing it varies among patients. We sought to find out whether the risk of persistent post-sternotomy pain could be predicted by measuring the area of acute sensory dysfunction around the sternotomy wound. The secondary aim was to determine risk factors for persistent post-sternotomy pain. PATIENTS AND METHODS: Hundred patients who were scheduled to undergo elective coronary artery bypass surgery were recruited to the study. Patients were excluded if they had undergone previous cardiac surgery or if they lacked co-operation. Preoperative pain scores were determined and the patients filled in questionnaires about depression, anxiety, and pain. The area of sensory dysfunction around the sternotomy wound was assessed by pin prick on postoperative day 4. The presence of persistent post-sternotomy pain was determined at a follow-up evaluation at 4-6 months after surgery. RESULTS: The sizes of the area of hyperalgesia or overall sensory dysfunction were not associated with persistent post-sternotomy pain. Independent risk factors for persistent post-sternotomy pain were found to be smoking and high pain score on postoperative day 1. The prevalence of persistent post-sternotomy pain in our study population was 38% analyzed by only the questionnaire and 15% according to the clinical examination. CONCLUSION: Measuring the area of hyperalgesia in the acute phase does not give any additional information on the risk of developing a persistent post-sternotomy pain. We do thus not recommend measuring the area in this particular group of patients. Evaluation of pain by only a questionnaire risks to overestimate the presence of persistent post-sternotomy pain as compared to clinical examination.

The effects of propofol vs. sevoflurane on post-operative pain and need of opioid.

BACKGROUND: Post-operative pain continues to be a major problem. Some previous studies have suggested that patients anaesthetised with propofol have less pain after surgery than those anesthetised with volatiles. However, the results of previous studies are conflicting. We designed a large-scale trial to study, whether propofol or sevoflurane is more analgesic than the other. We measured opioid consumption in the acute post-operative phase after laparoscopic hysterectomy. METHODS: In a randomised, prospective single-blind trial, we evaluated the consumption of oxycodone and pain intensity in 148 women for 20 h after laparoscopic hysterectomy under propofol or sevoflurane anaesthesia. The primary endpoint was the cumulative amount of oxycodone consumed. Secondary endpoints were pain scores [numeric rating scale (NRS)] at rest and with coughing, severity of nausea and state of sedation. RESULTS: The consumption of oxycodone and the NRS pain scores did not differ between the groups. The oxycodone consumed during first 20 h after surgery was 42.5 (95% confidence interval 38.3-46.6) mg and 42.8 (37.3-48.4) mg in propofol- and sevoflurane-anaesthetised patients, respectively (P = 0.919). NRS scores for nausea were higher in the patients receiving sevoflurane during the first 60 min in the post-anaesthesia care unit, leading to higher consumption of rescue antiemetics. Sedation scores differed in favour of sevoflurane only at 4 h time point after anaesthesia. Patient characteristics did not differ. CONCLUSIONS: In this study, comparing sevoflurane with propofol for maintenance of general anaesthesia, the choice of anaesthetic had no effect on the requirement of oxycodone or intensity of pain after surgery.

The impact of perinatal probiotic intervention on the development of overweight and obesity: follow-up study from birth to 10 years.

BACKGROUND: The achievements in combating the increasing trend of overweight and obesity have thus far been inadequate. The recently discovered instrumental role of the gut microbiota in host metabolism may offer a novel target in the prevention and management of obesity. OBJECTIVE: To evaluate the impact of perinatal probiotic intervention on childhood growth patterns and the development of overweight during a 10-year follow-up. PATIENTS AND METHODS: Altogether 159 women were randomized and double-blinded to receive probiotics (1 × 10(10) colony-forming units of Lactobacillus rhamnosus GG, ATCC 53103) or placebo 4 weeks before expected delivery; the intervention extending for 6 months postnatally. Anthropometric measurements of the children were taken at the ages of 3, 6, 12 and 24 months and at 4, 7 and 10 years in 113 (72%) children. RESULTS: The excessive weight gain was detected to be two-parted; the initial phase of excessive weight gain initiating during fetal period and continuing until 24-48 months of age and a second phase of excessive weight gain starting after the age of 24-48 months. The perinatal probiotic intervention appeared to moderate the initial phase of excessive weight gain, especially among children who later became overweight, but not the second phase of excessive weight gain, the impact being most pronounced at the age of 4 years (P=0.063, analysis of variance for repeated measures). The effect of intervention was also shown as a tendency to reduce the birth-weight-adjusted mean body mass index at the age of 4 years (P=0.080, analysis of covariance). CONCLUSIONS: Early gut microbiota modulation with probiotics may modify the growth pattern of the child by restraining excessive weight gain during the first years of life. This novel observation calls for further epidemiological and clinical trials, with precise data on early growth patterns and on confounding factors influencing weight development.

Granulocyte-monocyte adsorptive apheresis in pediatric inflammatory bowel disease: results, practical issues, safety, and future perspectives.

BACKGROUND: The purpose of the study was to collect data on granulocyte-monocyte adsorptive apheresis (GMA) for the treatment of corticosteroid-dependent (SD) or corticosteroid-resistant (SR) inflammatory bowel disease (IBD) in children from 3 Nordic countries to evaluate its efficacy and safety and to assess practical issues. METHODS: Retrospective data on 37 children treated with GMA were collected. In all, 22 children had ulcerative colitis (UC), 13 Crohn's disease (CD), and 2 had indeterminate colitis (IC). Their mean age was 13.2 years, range 5-17 years, and mean duration of disease was 2.4 years, range 1 month to 6 years. Indication for treatment in the UC group was SD in 11 cases, SR in 6 cases, and other reasons in 5 cases. The corresponding numbers in the CD group were SD in 8 cases, SR in 2 cases, and other reasons in 3 cases. In the IC group, 1 had SD and 1 was refractory to steroids, azathioprine, and infliximab. Efficacy was evaluated by severity indices: the Pediatric Ulcerative Colitis Activity Index (PUCAI) and the Pediatric Crohn's Disease Activity Index (PCDAI) and tapering of corticosteroids. RESULTS: PUCAI and PCDAI decreased significantly in both groups after 3 months (P = 0.0007, P = 0.025). The dosage of corticosteroid was significantly reduced in the UC group by the end of GMA (P = 0.004) and this response continued after 3 months. Relapse was seen in 2 patients with UC and 3 patients with CD after 3 months follow-up. CONCLUSIONS: GMA seems to be an effective and safe treatment in 81% of the SD or SR pediatric IBD patients, especially in those with UC.

Persistent pain after groin hernia surgery: a qualitative analysis of pain and its consequences for quality of life.

BACKGROUND: Despite a high prevalence of persistent groin pain after hernia repair, the specific nature of the pain and its clinical manifestation are poorly known. The aim of this study was to determine the type of post-herniorrhaphy pain and its influence on daily life. METHODS: In order to assess long-term pain qualitatively and to explore how it affects quality of life, 100 individuals with persisting pain, identified in a cohort study of patients operated for groin hernia, were neurologically examined, along with 100 pain-free controls matched for age, gender and type of operation. The patients were asked to answer the SF-36 questionnaire, the hospital anxiety and depression scale, the Swedish Scales of Personality (SSP) and a standardised questionnaire for assessing everyday life coping. The patients were approached approximately 4.9 years after surgery. RESULTS: Twenty-two patients from the pain group had become pain free by the time of examination, whereas 76 patients still had pain, of whom 47 (68%) suffered from neuropathic pain and 11 from nociceptive pain. The remaining patients suffered from mixed pain, neuropathic and nociceptive, or were found to have another reason for pain. All dimensions of SF-36 were poorer for the pain group than the control group. CONCLUSION: Persistent post-herniorrhaphy pain is mainly neuropathic and has a substantial impact on health-related quality of life.

Modulation of the maturing gut barrier and microbiota: a novel target in allergic disease.

The underlying denominators and treatment targets in atopic disease may be outlined as aberrant barrier functions of the skin epithelium and gut mucosa, and dysregulation of the immune response to ubiquitous environmental antigens. The route of sensitization varies with age, dietary antigens predominating in infancy. The immaturity of the immune system and the gastrointestinal barrier may explain the peak prevalence of food allergies at an early age. Dietary methods to control symptoms and reduce the risk of allergic disease have hitherto focused on elimination diets, alone or in combination with other environmental measures. The results have not been satisfactory regarding long-term prevention, primary or secondary. In view of the increasing burden of the abnormalities, new approaches are urgently needed for the management of allergic diseases and their prevention in at-risk infants. Novel methods here may include probiotics to counteract the immunological and gut mucosal barrier dysfunction associated with allergic disease, and thereby to strengthen endogenous defence mechanisms. Notwithstanding the demonstrations of important immunoregulatory potential of the well-balanced gut microbiota, the major objective health benefits of specific strains in allergic infants have only recently been clinically proven. Advances here have prompted enthusiasm in the scientific community and food industry and have fuelled research activities currently focusing firstly on identification of specific strains with anti-allergenic potential, and secondly on the question how food matrix and dietary content interact with the most efficacious probiotic strains.

Food allergy in irritable bowel syndrome: new facts and old fallacies.

The notion of food allergy in irritable bowel syndrome (IBS) is not new. However, recent evidence suggests significant reduction in IBS symptom severity in patients on elimination diets, provided that dietary elimination is based on foods against which the individual had raised IgG antibodies. These findings should encourage studies dissecting the mechanisms responsible for IgG production against dietary antigens and their putative role in IBS

Neuropeptide FF, but not prolactin-releasing peptide, mRNA is differentially regulated in the hypothalamic and medullary neurons after salt loading.

Hypothalamic paraventricular and supraoptic nuclei are involved in the body fluid homeostasis. Especially vasopressin peptide and mRNA levels are regulated by hypo- and hyperosmolar stimuli. Other neuropeptides such as dynorphin, galanin and neuropeptide FF are coregulated with vasopressin. In this study neuropeptide FF and another RF-amide peptide, the prolactin-releasing peptide mRNA levels were studied by quantitative in situ hybridization after chronic salt loading, a laboratory model of chronic dehydration. The neuropeptide FF mRNA expressing cells virtually disappeared from the hypothalamic supraoptic and paraventricular nuclei after salt loading, suggesting that hyperosmolar stress downregulated the NPFF gene transcription. The neuropeptide FF mRNA signal levels were returned to control levels after the rehydration period of 7 days. No changes were observed in those medullary nuclei that express neuropeptide FF mRNA. No significant changes were observed in the hypothalamic or medullary prolactin-releasing peptide mRNA levels. Neuropeptide FF mRNA is drastically downregulated in the hypothalamic magnocellular neurons after salt loading. Other neuropeptides studied in this model are concomitantly coregulated with vasopressin: i.e. their peptide levels are downregulated and mRNA levels are upregulated which is in contrast to neuropeptide FF regulation. It can thus be concluded that neuropeptide FF is not regulated through the vasopressin regulatory system but via an independent pathway. The detailed mechanisms underlying the downregulation of neuropeptide FF mRNA in neurons remain to be clarified.

Pandemic of atopic diseases--a lack of microbial exposure in early infancy?

Improved hygienic conditions in Western societies have reduced early microbial exposure, which has been proposed as a reason for the continuously rising prevalence of atopy and subsequent atopic diseases: atopic eczema, allergic rhinitis and asthma (The Hygiene Hypothesis of Allergy). This hypothesis is supported by immunological data showing that the immune response to microbial antigens, both pathogenic and non-pathogenic ones, is accompanied by preferential expression of cytokines that counterbalance the T-helper 2-polarized cytokine production of neonates, the continuity of which might lead to enhanced IgE production, atopy, and atopic disease. Experimental, epidemiological and clinical studies, conducted over the last decade, indicate that non-pathogenic microbes in the gut might be a major factor essential for the maturation of the human immune system to a nonatopic mode. A recent randomised, placebo-controlled trial demonstrated that perinatal administration of probiotics, cultures of potentially beneficial bacteria of the healthy gut microflora, halved the later development of atopic eczema during the first two years of life. Some putative mechanisms of action of gut commensals in host-microbe interactions have been described. Two structural components of bacteria, the lipopolysaccharide portion of Gram-negative bacteria and specified CpG motif in bacterial DNA, activate immunomodulatory genes via Toll-like receptors present e.g. on intestinal epithelial cells thus controlling physiological cytokine milieu in the gut. Probiotics have also been shown to reverse increased intestinal permeability and to reduce antigen load in the gut by degrading and modifying macromolecules. The actual preventive role of natural and genetically constructed supplementary microbes in the development of immunological diseases, like allergy, remains to be elucidated.

Polyunsaturated fatty acids in maternal diet, breast milk, and serum lipid fatty acids of infants in relation to atopy.

BACKGROUND: The increased consumption of n-6 polyunsaturated fatty acids (PUFA) has been shown to coincide with the increased prevalence of atopic diseases. We aimed to investigate whether maternal diet and atopic status influence the PUFA composition of breast milk and the serum lipid fatty acids of infants. METHODS: Maternal diet was assessed by a food questionnaire. The PUFA composition of breast milk obtained at 3 months from 20 allergic and 20 healthy mothers and of their infants' (10 atopic and 10 nonatopic/group of mothers) serum lipids was analyzed. RESULTS: Although no differences in maternal PUFA intake were observed, the breast milk of allergic mothers contained less gamma-linolenic acid (18:3 n-6) than that of healthy mothers. Similarly, atopic infants had less gamma-linolenic acid in phospholipids than healthy infants, although n-6 PUFA were elevated in other serum lipid fractions in atopic infants. The serum lipid fatty acids in atopic infants did not correlate with those in maternal breast milk. CONCLUSION: Our results suggest that dietary n-6 PUFA are not as readily transferred into breast milk or incorporated into serum phospholipids, but may be utilized for other purposes, such as eicosanoid precursors, in allergic/atopic individuals. Subsequently, high dietary proportions of n-6 PUFA, or reduced proportions of regulatory PUFA, such as gamma-linolenic acid and n-3 PUFA, may be a risk factor for the development of atopic disease.

Probiotics in primary prevention of atopic disease: a randomised placebo-controlled trial.

BACKGROUND: Reversal of the progressive increase in frequency of atopic disease would be an important breakthrough for health care and wellbeing in western societies. In the hygiene hypothesis this increase is attributed to reduced microbial exposure in early life. Probiotics are cultures of potentially beneficial bacteria of the healthy gut microflora. We assessed the effect on atopic disease of Lactobacillus GG (which is safe at an early age and effective in treatment of allergic inflammation and food allergy). METHODS: In a double-blind, randomised placebo-controlled trial we gave Lactobacillus GG prenatally to mothers who had at least one first-degree relative (or partner) with atopic eczema, allergic rhinitis, or asthma, and postnatally for 6 months to their infants. Chronic recurring atopic eczema, which is the main sign of atopic disease in the first years of life, was the primary endpoint. FINDINGS: Atopic eczema was diagnosed in 46 of 132 (35%) children aged 2 years. Asthma was diagnosed in six of these children and allergic rhinitis in one. The frequency of atopic eczema in the probiotic group was half that of the placebo group (15/64 [23%] vs 31/68 [46%]; relative risk 0.51 [95% CI 0.32-0.84]). The number needed to treat was 4.5 (95% CI 2.6-15.6). INTERPRETATIONS: Lactobacillus GG was effective in prevention of early atopic disease in children at high risk. Thus, gut microflora might be a hitherto unexplored source of natural immunomodulators and probiotics, for prevention of atopic disease.

Breast milk--immunomodulatory signals against allergic diseases.

Breastfeeding holds a key position with regard to the increasing burden of allergic diseases in the industrialized countries. Not only does it provide the infant with nutrients for growth and development, it also confers immunological protection during a critical period in life, when the infant's own defense mechanisms are immature. A delicate balance of stimulatory, even inflammatory, maturational signals, together with a myriad of anti-inflammatory compounds, is transferred from mother to infant via breastfeeding. Breastfeeding mothers, however, do not constitute a uniform group. The composition of breast milk shows marked individual variation and so, consequently, does the success of breastfeeding in reducing the risk of disease. Recent clinical studies indicate that the potential of breastfeeding to counteract allergic disease may be promoted by dietary means. While uncoordinated elimination diets result in a risk of general nutritional inadequacy or deficiency of essential single nutrients, a balanced diet following current dietary recommendations, specifically containing fresh fruits and vegetables (antioxidants) and fat of predominantly vegetable origin, may be associated with a lower incidence of atopy in the infant. As early nutrition appears to program the subsequent health of the child, the importance of the maternal dietary composition during breastfeeding should be emphasized. In future, an improved understanding of the mechanisms of this programming may offer specific therapeutic modalities for the prevention of allergic disease.