Nortriptyline versus fluoxetine in the treatment of depression and in short-term recovery after stroke: a placebo-controlled, double-blind study.

OBJECTIVE: This study compared nortriptyline and fluoxetine with placebo in the treatment of depression and in recovery from physical and cognitive impairments after stroke. METHOD: A total of 104 patients with acute stroke enrolled between 1991 and 1997 entered a double-blind randomized study comparing nortriptyline, fluoxetine, and placebo over 12 weeks of treatment. The majority of patients were recruited from a rehabilitation hospital in Des Moines, Iowa, but other enrollment sites were also used. Both depressed and nondepressed patients were enrolled to determine whether improved recovery could be mediated by mechanisms unrelated to depression. Nortriptyline in doses of 25 mg/day gradually increased to 100 mg/day or fluoxetine in doses of 10 mg/day gradually increased to 40 mg/day or identical placebo were given over 12 weeks. Response to treatment of depression for individual patients was defined as a greater-than-50% reduction in scores on the Hamilton Rating Scale for Depression and no longer fulfilling diagnostic criteria for major or minor depression. Improved recovery for a treatment group was defined as a significantly higher mean score from baseline to end of the treatment trial, compared with patients treated with placebo, on measures of impairment in activities of daily living and levels of cognitive and social functioning. RESULTS: Nortriptyline produced a significantly higher response rate than fluoxetine or placebo in treating poststroke depression, in improving anxiety symptoms, and in improving recovery of activities of daily living as measured by the Functional Independence Measure. There was no effect of nortriptyline or fluoxetine on recovery of cognitive or social functioning among depressed or nondepressed patients. Fluoxetine in increasing doses of 10-40 mg/day led to an average weight loss of 15. 1 pounds (8% of initial body weight) over 12 weeks of treatment that was not seen with nortriptyline or placebo. CONCLUSIONS: Given the doses of medication used in this study, nortriptyline was superior to fluoxetine in the treatment of poststroke depression. Demonstrating a benefit of antidepressant treatment in recovery from stroke may require the identification of specific subgroups of patients, alternative measurement scales, or the optimal time of treatment.

Standardization of surgeon-controlled variables: impact on outcome in patients with acute cholecystitis.

OBJECTIVE: To examine the effect of standardization of surgeon-controlled variables on patient outcome after cholecystectomy for two cohorts of patients with acute cholecystitis (AC). SUMMARY BACKGROUND DATA: Laparoscopic cholecystectomy (LC), when performed efficiently and safely, offers patients with AC a more rapid recovery and decreases the length of stay, thus reducing the health care utilization. Numerous studies have focused on the characteristics of patients with AC that may predict the conversion of LC to open cholecystectomy. However, analysis of these factors offers little insight for improving the outcome of patients with AC, because patient-controlled variables are difficult to influence. In the present study, treatment variables that were under the surgeon's control were standardized and the effects of these changes on the outcome of patients with AC were quantified. METHODS: Beginning in August 1997, a standardized treatment protocol was initiated for patients with suspected AC. LC was initiated as early as practical from the time of admission. All operations were performed in a specially equipped and staffed laparoscopic surgery suite, and all patients were supervised by one of two attending surgeons with a special interest in laparoscopic interventions. Two cohorts of patients with AC were retrospectively analyzed: 39 patients from the 12 months before initiation of this protocol (period 1) and 49 patients from the 12 months after its inception (period 2). Medical records were reviewed for demographic, perioperative, and outcome data. Surgical reports were reviewed to ascertain the reason for conversion and whether laparoscopic technical modifications were used. RESULTS: No significant difference was noted between the groups with regard to patient demographics, clinical presentation, or radiologic or laboratory parameters. After protocol initiation, patients received definitive treatment closer to the time of admission and had a greater percentage of laparoscopically completed cholecystectomies. Furthermore, the patients in period 2 had a significantly decreased postoperative length of stay and hospital charges than the earlier ones. Complications were infrequent and not significantly different between the groups. Two or more laparoscopic technical modifications were used in 95% of the successful LCs during period 2 versus 33.3% during period 1. CONCLUSIONS: By controlling when, where, and by whom LC for AC was performed, the authors have significantly improved the percentage of cholecystectomies that were completed laparoscopically. This has led to improved outcomes and lower hospital charges for patients with AC at this municipal hospital.

Preoperative abdominal ultrasound may be misleading in risk stratification for presence of common bile duct abnormalities.

BACKGROUND: Following the advent of laparoscopic cholecystectomy (LC), the preoperative predictors of common bile duct (CBD) abnormalities became more important in perioperative decision making. Preoperative transabdominal ultrasound (US) is used to assess the preoperative risks associated with CBD abnormalities. This study attempts to determine the sensitivity and specificity of US in determining CBD abnormalities in patients prior to LC. METHODS: US measurements of the CBD diameter and presence of stones were ascertained from radiology reports in 100 patients who had LC with a routine intraoperative cholangiogram (IOC). The same information was obtained from the patients' IOC. A supraduodenal CBD diameter of >8 mm was considered dilated. RESULTS: US demonstrated a sensitivity of 25% and a specificity of 70% for the detection of CBD dilatation compared to IOC. The sensitivity of US for predicting CBD dilatation was 55% when the IOC-derived diameter was >10 mm and 100% when it was >15 mm. The overall sensitivity of US for detection of stones was 10%; it improved to 17% in patients with a dilated CBD on US. CONCLUSIONS: Preoperative ultrasound is neither sensitive nor specific for detecting CBD dilatation or presence of stones. A negative preoperative US report may be misleading in risk stratification for the presence of these CBD abnormalities. In order to avoid missing any CBD pathology, we recommend the routine use of intraoperative cholangiography.

Complete biliary avulsion from blunt compression injury.

The liver is the solid organ most commonly injured as a result of blunt abdominal trauma. Complete avulsion of the common hepatic duct is a rare and devastating type of hepatobiliary trauma. Here the authors report the case of a 7-year-old child who had complete biliary disruption as a result of an abdominal crush injury that was not diagnosed correctly preoperatively. The intraoperative diagnosis and treatment of this injury is discussed.

Cost-effective minimally invasive surgery: What procedures make sense?

Because laparoscopic surgery has emerged during a time of medical cost-consciousness, emphasis has been placed on the economic implications of this emerging field. The cost of these procedures, however, is just one component in determining their overall value to most of the stakeholders in the health care system. The value of a treatment is proportional to its appropriateness and quality per unit cost. Several confounding factors affect the variables in this equation and contribute to the difficulty in this type of assessment of an emerging technology. By understanding the mechanics of value assessment and certain caveats for specific procedures, the surgeon will be better able to determine what procedures makes sense (or are of value) in their practice and for their patients.

A combined laparoscopic and endoscopic approach to acute primary gastric volvulus.

We describe the combined use of laparoscopic and endoscopic techniques in a case of acute primary gastric volvulus. Once the diagnosis is confirmed with a water-soluble upper gastrointestinal series, prompt intervention is required. With an atraumatic bowel grasper the stomach is re-oriented with the greater curvature in its normal anatomic position. Two transabdominal wall sutures are placed along the greater curvature to fix it to anterior abdominal wall. Upper endoscopy is then performed. Once confident that the gastric mucosa is viable, a 20F "pull-type" gastrostomy tube is placed endoscopically, guided by the external illumination and probing by the laparoscope. The gastrostomy tube now acts as an anterior anchor for the stomach allowing repositioning of the gastropexy sutures if necessary. Endoscopy confirms the placement of a broad, properly aligned gastropexy. Classically, gastric volvulus has been treated by laparotomy. Both endoscopic and laparoscopic techniques have been individually reported in the treatment of acute and chronic gastric volvulus, however, each has as its limitations. By combining the procedures we were able to better assess both the intra-abdominal and the intraluminal status of the stomach and its position before, during, and after fixation to the anterior abdominal wall. The postoperative stay seen with the combined technique was less than has been reported in patients treated by open surgery or by either the endoscopic or laparoscopic methods alone. The combined laparoscopic and endoscopic approach to acute gastric volvulus provides the benefit of a minimally invasive approach, to a better anterior gastropexy. This procedure should be considered when confronted with patients with acute primary, gastric volvulus.

Outcome and comorbidity in first- compared with multiple-episode mania.

The aim of this study was to examine the outcome and comorbidity of patients with bipolar disorder presenting with first-episode as compared with multiple-episode mania. Based on studies from the prepharmacological era and the sensitization model of bipolar disorder, we hypothesized that compared with multiple-episode mania, first-episode mania would be associated with better outcome, milder severity, and less psychiatric comorbidity. Seventy-one hospitalized patients, age 12 years and older and meeting DSM-III-R criteria for bipolar disorder, were recruited over a 1-year period. Thirty-four (48%) first-episode and 37 (56%) multiple-episode patients were compared regarding demographics, phenomenology, comorbidity, family history, and short-term course. Compared with multiple-episode mania, first-episode mania was associated with significantly shorter hospitalization and a higher rate of comorbid impulse control disorders. These data provide indirect support for the sensitization model of bipolar disorder.

Clinically significant ureteral obstruction caused by inflammatory complications of severe pancreatitis.

Clinically significant ureteral obstruction caused by the inflammatory complications of severe pancreatitis is rare with only eight previously reported cases. We present two additional cases and review the world literature. Clinically significant ureteral obstruction can affect either or both ureters and present simultaneously with an episode of pancreatitis or months later. If symptomatic ureteral obstruction is present, prompt urologic drainage is recommended. Definitive correction of the obstruction is frequently required and depends on the obstructive mechanism.

Histopathological determinants of survival in resected cases of pancreas cancer.

We have examined the histopathological factors affecting the degree of local spread, regional lymph node (RLN) metastases, and overall survival (O.S.) in a group of 39 cases of resected carcinoma of the exocrine pancreas. Although the mean O.S. for the group was 14.3 months, resected patients without RLN involvement had a mean survival of 24 months. In contrast the mean O.S. rate was 8 months for patients with RLNs involved. Size, tumor location, and histological grade were compared to RLN involvement and O.S. The mean size of primary tumor did not differ significantly between patients with or without RLN's (r.1 versus 4.6 cms). However, 7 or 8 T1 tumors were < 4 cm and 35% of tumors < 4 cm were T1 lesions. In contrast, only 1 of 17 tumors (6%) > 4 cm was T1. Histological grade was correlated with nodal status and O.S. There was a significant difference between histological grade and the presence of metastatic lymph nodes (G1, 37% positive, G2-4.50% positive). Patients with well differentiated tumors had a mean survival of 21 months compared to a mean survival of 10 months for less differentiated tumors (p < 0.05). This difference was even more significant when stratified for nodal status. The patients with well differentiated tumors and no RLN involvement had a mean survival of 32.5 months compared to 8.6 months for well differentiated tumors with RLN involvement. In summary, we have shown that size, histological grade, and local spread predict for nodal status. However, specific patient subsets (G1, node negative) may exhibit an excellent survival when curative pancreas resection is successful.

Esophageal tuberculosis: a rare presentation with hematemesis.

Esophageal tuberculosis is rare, with only 26 cases previously reported in the literature. Patients usually present with progressive dysphagia or odynophagia. We report a patient with hematemesis that was later attributed to the erosion of tuberculous subcarinal lymph nodes into the esophagus. This presentation has been described in only two other patients, both of whom died of exsanguinating hemorrhage. The successful outcome in the present case rested on the availability of rapid diagnostic modalities and timely surgical intervention.

Watercress and amphipods Potential chemical defense in a spring stream macrophyte.

We investigated the potential role of defensive chemicals in the avoidance of watercress (Nasturtium officinale) by the cooccurring amphipod,Gammarus pseudolimnaeus at two spring brooks: Carp Creek, Michigan and Squabble Brook, Connecticut. We conducted observations and laboratory experiments on the consumption of watercress, the toxicity of damaged (frozen) watercress, and the toxicity of damage-released secondary chemicals. Field-collected yellowed watercress typically lacked the bite and odor characteristic of green watercress and was consumed byG. pseudolimnaeus. G. pseudolimnaeus strongly preferred yellowed watercress to green watercress despite the higher nitrogen content of the latter (2.7 vs 5.4%), and usually consumed five times more yellowed watercress (>50% of yellowed leaf area vs. <8% of green leaf area presented). Fresh green watercress contained seven times more phenylethyl glucosinolate than yellowed watercress (8.9 mg/g wet vs. 1.2 mg/g). Cell-damaged (frozen) watercress was toxic toG. pseudolimnaeus (48-hr LC50s: ca. 1 g wet/liter), and the primary volatile secondary chemicals released by damage were highly toxic. The predominant glucosinolate hydrolysis product, 2-phenylethyl isothiocyanate had 48-hr LC50s between 0.96 and 3.62 mg/liter, whereas 3-phenylpropionitrile was less toxic, with 48-hr LC50s between 130 and 211 mg/liter. These results suggest that live watercress is chemically defended against consumption. The glucosinolate-myrosinase system, recognized as the principle deterrent system of terrestrial crucifers, is also possessed byN. officinale and may contribute to defense from herbivory by aquatic crustaceans. This system may be just one of many examples of the use of defensive chemicals by stream and lake macrophytes.