Does esomeprazole prevent post-operative nausea and vomiting?

BACKGROUND: Esomeprazole is a potent proton pump inhibitor (PPI), reducing acid production as well as gastric juice volume. This study evaluated the possible beneficial effect of esomeprazole on reducing post-operative nausea and vomiting (PONV). METHODS: Patients undergoing laparoscopic or open gynaecological surgery, or laparoscopic cholecystectomy were randomized to receive three peri-operative doses double blindly of either esomeprazole 40 mg or placebo, given intravenously or orally. All patients were given a standardized anaesthesia regimen including fentanyl and sevoflurane/nitrous oxide. RESULTS: The study population consisted of 284 patients. Demographic data and known PONV risk factors were similar for the two treatment groups. PONV was observed in 77% of patients on esomeprazole vs. 81% on placebo (NS) and rescue antiemetic medication was needed in 56% vs. 53%, respectively (NS). The proportion of patients that vomited during 0-24 h was lower on esomeprazole than placebo (38% vs. 49%; NS), and the mean amount of vomit was significantly lower (52 vs. 86 g; P < 0.05). The use of neostigmine, use of opioids and type of surgery were significant risk factors for PONV (P < 0.05). The 24-h incidence of PONV was 63% after laparoscopic gynaecology, 80% after laparoscopic cholecystectomy and 88% after open gynaecological laparotomy, whereas laparoscopic cholecystectomy had the lowest risk when corrected for other risk factors of PONV. CONCLUSION: Esomeprazole had no clinically relevant effect on the overall 24-h incidence of PONV. However, esomeprazole significantly reduced the total amount of vomit during 24-h post-operatively. This may be of value in patients with an increased risk of pulmonary aspiration.

Randomized trial of Lichtenstein versus Shouldice hernia repair in general surgical practice.

BACKGROUND: The aim of the present randomized trial was to compare the Shouldice procedure and the Lichtenstein hernia repair with respect to recurrence rate, technical difficulty, convalescence and chronic pain. A further aim was to determine to what extent general surgeons in routine surgical practice were able to reproduce the excellent results reported from specialist hernia centres. METHODS: Three hundred patients with primary inguinal hernia were randomized to either a Shouldice repair or to a tension-free Lichtenstein repair. In a pretrial training programme the five participating general surgeons were taught to perform the two techniques in a standard manner. Follow-up was performed after 8 weeks, 1 year and 3 years. The last examination was performed by an independent blinded assessor. RESULTS: There was a significant difference in operating time in favour of the Lichtenstein technique. After a follow-up of 36-77 months seven recurrences were found in the Shouldice group (95 per cent confidence interval (c.i.) 1.3 to 8.1) and one in the mesh group (95 per cent c.i. 0.0 to 2.0). Chronic groin pain was reported by 4.2 and 5.6 per cent in the Shouldice and Lichtenstein groups respectively. It was characterized as mild or moderate in all except two patients who had the Shouldice operation. CONCLUSION: Lichtenstein hernia repair was easier to learn, took less time and resulted in fewer recurrences. It was possible to achieve excellent results with this technique in a general surgical unit.

Distribution and diagenesis of organic and inorganic phosphorus in sediments of the Baltic proper.

Measurements of the distribution of organic and inorganic phosphorus in the sediment have been performed at 10 sites, in the central-northern Baltic proper. Variations in deposition environment and environmental properties, such as redox chemistry and bottom water dynamics, apparently affect the distribution by altering the supply and diagenesis of organic and inorganic phosphorus constituents. The C/P and the N/P ratios of the sediment are highly divergent (higher) from the average Redfield ratio for marine living organisms at all examined sites. This indicates preferential autolytic organic phosphorus degradation and/or (deeper down in the sediment) altered input of terrestrial organic matter. The redox condition seems to affect the degradation efficiency of the organic matter since higher concentrations of C(org) occur at anoxic conditions than at oxic. At two sites significant amounts of C(inorg) have been detected indicating authigenic precipitation of carbonates. Further, authigenic precipitation of phosphate minerals also seems to occur at certain environmental conditions.

Association between visual impairment and functional and morphological cerebral abnormalities in full-term children.

PURPOSE: To characterise the nature and degree of ocular disorders and cerebral morphological and functional abnormalities in a population-based group of visually impaired full-term pre-school children. METHODS: Forty-five children who were born at full-term between 1989 and 1995 in Värmland, Sweden, were reported as being visually impaired. An ophthalmological examination was performed and clinical data regarding mental development and neurological disease were obtained for all children. Cerebral imaging was performed in 35 children. RESULTS: Twenty-six per cent of the children were found to have ocular disorders only. Forty-two per cent had cerebral morphological abnormalities, verified by cerebral imaging, and 65% had signs of cerebral functional abnormalities. In total, 74% were found to have cerebral morphological and/or cerebral functional abnormalities. CONCLUSION: The majority of children with visual impairment, including children with ocular disorders, were found to have cerebral morphological and/or cerebral functional abnormalities. We suggest that any child with visual impairment should therefore undergo cerebral imaging and be examined by a paediatrician in order to establish the correct diagnosis.

[Laparoscopic surgery--evidence-based ?]. / Laparoskopisk kirurgi--hur evidensbaserad är den?

The literature has been searched for current results in laparoscopic cholecystectomy, hernia repair, appendectomy and fundoplication. This was performed as a systematic review. Laparoscopic cholecystectomy was judged to be safe and cost/effective, with good patient acceptability. However a need for further studies is indicated. Laparoscopic technique in hernia repair has a longer learning curve and is more expensive than open repair, with no major difference in recurrence rates. It is preferable in bilateral repairs. Laparoscopic appendectomy in the hands of experienced surgeons is cost/effective. Time to recovery is shorter and the rate of infectious complications is lower than in conventional procedures. There are still too few results reported from laparoscopic fundoplication to permit reliable conclusions.

Paradoxical embolism after cardiac catheterization.

Paradoxical embolism is seen in fewer than 2% of all arterial emboli. It occurs most often through a patent foramen ovale (PFO), which is present in up to one-third of patients with strokes of unknown etiology. We report a 69-year-old woman in whom a thrombus traveled from the lower extremity venous system to her right middle cerebral artery through an unsuspected atrial septal defect. Following right femoral artery catheterization for coronary angiography, she developed a femoral artery pseudoaneurysm and groin hematoma causing compression of the right femoral vein and venous thrombosis. Before she could undergo surgical evacuation and repair, she developed a right brain stroke with cognitive deficits, left field cut, left hemiparesis, and sensory loss. Transthoracic echocardiography with bubble contrast showed a small PFO with right-to-left interatrial shunting. A Greenfield filter was placed in the inferior vena cava, and the patient was anticoagulated before she underwent inpatient rehabilitation. This case illustrates the importance of considering paradoxical emboli in unexplained strokes. The literature is reviewed, and treatment and prevention of paradoxical emboli are discussed.

Cholescintigraphy and biochemical tests in cholecystitis--an evaluation with discriminant analysis.

The biochemical values of 76 patients with suspected cholecystitis were subjected to discriminant analysis. The final diagnoses, i.e. acute cholecystitis, chronic cholecystitis and non-biliary disease, were used as the grouping variable. Cholescintigraphy identified patients with acute cholecystitis. Routine preoperative biochemical tests were found to be of limited value. Only alkaline phosphatase was of help in predicting common-duct stones, especially in patients with acute cholecystitis. The conclusion is that many biochemical tests presently in common use could as well be dispensed with.

Acute cholecystitis in the elderly.

After a controlled randomized trial, the management of patients with acute cholecystitis was changed from delayed to early cholecystectomy. The results obtained in 125 consecutive patients some years before the trial and in 144 consecutive patients after the trial were compared. All patients were 70 years or older. The comparison confirmed that early cholecystectomy reduces morbidity and mortality. Early cholecystectomy for acute cholecystitis in the elderly is strongly recommended.

Cholescintigraphy versus infusion cholecystography in acute cholecystitis.

Patients with the clinical diagnosis of acute cholecystitis were studied with intravenous cholecystography and cholescintigraphy. The two examinations alternated in a random order. The final diagnosis was ascertained by surgery in most patients. Either cholecystography or cholescintigraphy could be used in the diagnostics of patients with suspected acute cholecystitis. The methods have about the same accuracy. However, cholescintigraphy is performed more easily and more rapidly than intravenous cholecystography.

Ultrasonic nonvisualization of the gallbladder in emphysematous cholecystitis. Case report.

In a patient with suspected acute cholecystitis, ultrasonography-although repeated-failed to visualize the gallbladder. Corresponding to the gallbladder fossa there was an area of high-density echoes casting a shadow posteriorly, but the examination was considered inconclusive because the gallbladder was not visualized. Plain abdominal radiographs established the diagnosis of acute emphysematous cholecystitis.

The kinetics of transport of lactate and pyruvate into rat hepatocytes. Evidence for the presence of a specific carrier similar to that in erythrocytes.

Time courses of L-lactate and pyruvate uptake into isolated rat hepatocytes were measured in a citrate-based medium to generate a pH gradient (alkaline inside), by using the silicone-oil-filtration technique at 0 degrees C to minimize metabolism. At low concentrations of lactate and pyruvate (0.5 mM), transport was inhibited by over 95% by 5 mM-alpha-cyano-4-hydroxycinnamate, whereas at higher concentrations (greater than 10 mM) a significant proportion of transport could not be inhibited. The rate of this non-inhibitable transport was linearly related to the substrate concentration, was less with pyruvate than with L-lactate, and appeared to be due to diffusion of undissociated acid. Uptake of D-lactate was not inhibited by alpha-cyano-4-hydroxycinnamate and occurred only by diffusion. Kinetic parameters for the carrier-mediated transport process were obtained after correction of the initial rates of uptake of lactate and pyruvate in the absence of 5 mM-alpha-cyano-4-hydroxycinnamate by that in the presence of inhibitor. Under the conditions used, the Km values for L-lactate and pyruvate were 2.4 and 0.6 mM respectively and the Ki for alpha-cyano-4-hydroxycinnamate as a competitive inhibitor was 0.11 mM. Km values for the transport of L-lactate and pyruvate into rat erythrocytes under similar conditions were 3.0 and 0.96 mM. The Vmax. of lactate and pyruvate transport into hepatocytes at 0 degrees C was 3 nmol/min per mg of protein. Carrier-mediated transport of 0.5 mM-L-lactate was inhibited by 0.2 mM-p-chloromercuribenzenesulphonate (greater than 90%), 0.5 mM-quercetin (80%), 0.6 mM-isobutylcarbonyl-lactyl anhydride (70%) and 0.5 mM-4,4'-di-isothiocyanostilbene-2,2'-disulphonate (50%). A similar pattern of inhibition of lactate transport is seen in erythrocytes. It is suggested that the same or a similar carrier protein exists in both tissues. The results also show that L-lactate transport into rat hepatocytes is very rapid at physiological temperatures and is unlikely to restrict the rate of its metabolism. Differences between our results and those of Fafournoux, Demigne & Remesy [(1985) J. Biol. Chem. 260, 292-299] are discussed.

Acute cholecystitis and thiazides.

Drugs purchased by a random sample (17 000) of the population of Jämtland county, Sweden, are continuously monitored. Patients who had been admitted to the county's only hospital with acute cholecystitis and who were part of this sample were studied, and controls matched for age and sex were drawn from the sample. The purchase of thiazides and other drugs prescribed to the patients with acute cholecystitis was compared with that of the controls. The estimated relative risk of developing acute cholecystitis in patients who had purchased thiazides in the year before admission to hospital, as compared with those who had not, was 2.1 (95% confidence limit 1.1-3.9). As it has been reliably reported that the use of thiazides is not itself associated with cholelithiasis, the association found between thiazides and cholecystitis suggests that thiazides may increase the risk of acute cholecystitis developing in a patient with gall stones.

Function of liver, gallbladder and sphincter of Oddi after major surgery studied by computer-assisted cholescintigraphy and real-time ultrasonography.

Patients with normal gallbladders were subjected to computer-assisted Tc-HIDA cholescintigraphy at fixed intervals after major surgery. Hepatic time--activity curves showed that hepatic excretion of the material was first reduced and later a reduction of hepatic uptake followed. The gallbladder responded first by dilatation and reduction of motility and later by delay in or even absence of visualization. Postoperative dilatation was confirmed with real-time ultrasonography. No tracer passed into the duodenum in the early postoperative stage indicating spasm of the sphincter of Oddi. Healthy volunteers were studied with and without morphine and with and without a 24 h fast. The sphincter of Oddi closed after morphine but not after fasting. Transient non-visualization of the gallbladder after surgery makes the diagnosis of postoperative cholecystitis more difficult.

Jaundice in acute cholecystitis without common duct stones.

Patients with acute cholecystitis without common duct stones were studied pre- and postoperatively with 99mTc-HIDA scintigraphy. The resulting hepatic time-activity curves were analyzed. Preoperative serum bilirubin levels were closely correlated with hepatic discharge but not with hepatic uptake of the radiopharmaceutical. Cholecystectomy resulted in prompt improvement of hepatic discharge but did not affect uptake. In acute as well as in chronic cholecystitis cholangiograms taken before removal of the gallbladder were compared with those taken after. In acute cholecystitis the former view frequently showed medial displacement of the biliary tract and incomplete filling of its proximal part. Displacement of the duct was also apparent in comparisons of pre- and postoperative scintigrams. Jaundice in acute cholecystitis is due to reduced excretion which may be caused by pressure on the ducts by the distended gallbladder.

Transient nonvisualization of the gallbladder by Tc-99m HIDA cholescintigraphy in acute pancreatitis: concise communication.

In five of seven patients with acute pancreatitis, Tc-99m HIDA scintigraphy failed to visualize the gallbladder. In all five patients the gallbladder was later found to be normal and in three of them normal filling was obtained at a repeat examination performed after the attack had subsided. Transient nonvisualization of the gallbladder in acute pancreatitis is probably due to disturbed motility of the biliary tree.