Prehospital pathways of occipital stroke patients with mainly visual symptoms.

OBJECTIVES: Occipital ischemic strokes typically cause homonymous visual field defects, for which means of rehabilitation are limited. Intravenous thrombolysis is increasingly and successfully used for their acute treatment. However, recognition of strokes presenting with mainly visual field defects is challenging for both patients and healthcare professionals. We studied prehospital pathways of occipital stroke patients with mainly visual symptoms to define obstacles in their early recognition. MATERIALS & METHODS: This observational, retrospective, registry-based study comprises occipital stroke patients with isolated visual symptoms treated at the neurological emergency department of Helsinki University Central Hospital in 2010-2015. We analyzed their prehospital pathways, including time from symptom onset to admission at the neurological emergency department (ODT), the number of points of care, the percentage of patients with ODT≤4.5 hours, and factors associated with delay. RESULTS: Among 245 patients, only 20.8% arrived within 4.5 hours and 6.5% received IV thrombolysis. Delayed arrival was most often due to patients' late contact to health care. Of the patients, 27.3% arrived through at least two points of care, and differential diagnostics to ophthalmologic disorders proved particularly challenging. ODT≤4.5 hours was associated with EMS utilization, direct arrival, and atrial fibrillation; a visit at an ophthalmologist and initial misdiagnosis were associated with ODT>4.5 hours. After multivariable analysis, only direct arrival predicted ODT≤4.5 hours. CONCLUSIONS: Occipital stroke patients with visual symptoms contact health care late, are inadequately recognized, and present with complex prehospital pathways. Consequently, they are often ineligible for IV thrombolysis. This presents a missed opportunity for preventing permanent visual field defects.

Neurocognitive effects following an overnight call shift on faculty anesthesiologists.

BACKGROUND: The impact of sleep deprivation on neurocognitive performance is a significant concern to both the health of patients and to the physicians caring for them, as demonstrated by the Accreditation Council for Graduate Medical Education enforced resident work hours. This study examined the effects of an overnight call at a level 1 trauma hospital on neurocognitive performance of faculty anesthesiologists. METHODS: Eleven faculty anesthesiologists completed a series of computerized tests that were designed to evaluate different areas of neurocognition, such as working memory, verbal learning, and concentration. The anesthesiologists completed the tests following an overnight call in the morning at 6:30 and again following a normal night's rest at 6:30 on a different date. RESULTS: Within-subjects, repeated measures analysis of variance revealed a significant difference on post-call vs. control performance on measures of learning and memory (P = 0.04). However, there were no significant differences on performance on measures of working memory or sustained attention and vigilance. Pre-call vs. control performances were also evaluated, but no significant differences were detected. CONCLUSIONS: Following a night call shift, performance on learning and memory was significantly reduced. Other areas were not significantly affected, which may have been due to certain possibilities, such as practice effect or variability in the call shifts. The real-world relevance of the decline in performance on these measures remains unclear.

A visual migraine aura locus maps to 9q21-q22.

OBJECTIVE: To identify susceptibility loci for visual migraine aura in migraine families primarily affected with scintillating scotoma type of aura. METHODS: We included Finnish migraine families with at least 2 affected family members with scintillating scotoma as defined by the International Criteria for Headache Disorders-II. A total of 36 multigenerational families containing 351 individuals were included, 185 of whom have visual aura and 159 have scintillating scotoma. Parametric and nonparametric linkage analyses were performed with 378 microsatellite markers. The most promising linkage loci found were fine-mapped with additional microsatellite markers. RESULTS: A novel locus on chromosome 9q22-q31 for migraine aura was identified (HLOD = 4.7 at 104 cM). Fine-mapping identified a shared haplotype segment of 12 cM (9.8 Mb) on 9q21-q22 among the aura affected. Four other loci showed linkage to aura: a locus on 12p13 showed significant evidence of linkage, and suggestive evidence of linkage was detected to loci on chromosomes 5q13, 6q25, and 13q14. CONCLUSIONS: A novel visual migraine aura locus has been mapped to chromosome 9q21-q22. Interestingly, this region has previously been linked to occipitotemporal lobe epilepsy with prominent visual symptoms. Our finding further supports a shared genetic background in migraine and epilepsy and suggests that susceptibility variant(s) to visual aura for both of these traits are located in the 9q21-q22 locus.

Late postoperative quality of life following pancreatic head resections.

BACKGROUND/AIMS: To evaluate health-related quality of life (HRQoL) in patients that have undergone pancreatic resection and compare the results with representative population samples in early and late stage evaluations. Also, this study aims to observe possible associations with postoperative complications. METHODOLOGY: Twenty-seven single-institute patients operated on during a 3-year period due to a benign or malignant process of the periampullary region. HRQoL was measured by the 15D instrument. Data were compared with those obtained from representative Finnish general population samples. RESULTS: Twenty-five patients were interviewed in the early stage (24 months postoperatively). Fifteen had a benign and 12 a malignant disease. No differences were found in the postoperative HRQoL when the nature of the disease or the postoperative complications were considered. When compared with the general population in the early stage, HRQoL was lower in the study group in whole, and also when sleep, elimination (bladder or bowel function) and sexual activity were considered separately. In the late stage evaluation (110 months postoperatively) the study group consisted of 15 surviving patients. There were no differences in comparison to the general population. Also when comparing the same patients in 2 evaluation points (24 and 110 months), we did not find any difference in any of the 15D parameters. CONCLUSIONS: Postoperative HRQoL deteriorated in comparison to general population in the early stage but there were no differences in the late stage. This study encourages us to continue the use of the 15D at least as a part of HRQoL evaluation, because it allows comparisons between different diseases and the general population.

Detection of postoperative pancreatitis after pancreatic surgery by urine trypsinogen strip test.

BACKGROUND: The urine trypsinogen strip test has been used successfully in the diagnosis of pancreatitis of various aetiologies, but has not been studied in postoperative pancreatitis. The aim of this study was to evaluate this test for the diagnosis of postoperative pancreatitis after pancreatic resection. METHODS: Fifty patients undergoing pancreatic resection were included. The urine trypsinogen strip test was done daily during the first postoperative week, blood was analysed before and 4, 6 and 10 days after surgery, and amylase activity in the drainage fluid was measured on days 4 and 6. Patients underwent computed tomography (CT) before operation and on days 2 and 6 afterwards. RESULTS: Thirteen patients (26 per cent) developed CT-detected pancreatitis after operation. In 12 of these patients pancreatitis was detected on the second postoperative day. The urine trypsinogen test was positive in all 13 patients with postoperative pancreatitis, and was already positive on the first day after surgery in 12. The sensitivity, specificity, and positive and negative predictive values of the trypsinogen strip test in detection of postoperative pancreatitis were 100, 92, 81 and 100 per cent respectively. In receiver-operator characteristic analysis the area under the curve (AUC) was higher for the urine trypsinogen strip test (AUC 0.959) than for a serum amylase level more than two (AUC 0.731) or three times (AUC 0.654) above the upper normal range in the diagnosis of postoperative pancreatitis. Patients whose recovery was complicated by pancreatic fistula, detected by drain output measurements on day 6, more often had a positive urine trypsinogen test than patients without a fistula (11 of 12 versus five of 38; P < 0.001). CONCLUSION: This study suggests that the urine trypsinogen strip test might be a valuable method for diagnosis of pancreatitis after pancreatic surgery.

Duodenal diazepam-binding protein expression and plasma cholecystokinin after alcoholic pancreatitis.

OBJECTIVE: After the first acute alcohol-induced pancreatitis (AAIP) episode 46 % of patients will have a recurrent attack, but the pathophysiology is unclear. The hyperstimulation of the pancreas with cholecystokinin (CCK) induces acute pancreatitis. Alcohol induces temporary stimulation of the pancreas and CCK could be a mediator. CCK is regulated by releasing peptides - diazepam-binding protein (DBI) being a possible candidate. The aim of this study was to investigate the possible association between CCK plasma levels and DBI expression in patients with AAIP or its recurrence. MATERIAL AND METHODS: The study comprised 44 subjects (mean age 42 years): A) Patients with a first episode of AAIP (n = 9); B) patients with three or more episodes of AAIP (n = 11); C) patients with a heavy alcohol consumption, with no detected AAIP (n = 11) and D) healthy controls (n = 13). CCK levels were measured by radioimmunoassay (RIA). Duodenal biopsies were analyzed for DBI mRNA and histology. RESULTS: There was no significant difference in CCK plasma levels, DBI expression or CCK/DBI ratio between the groups. CONCLUSIONS: There were no changes in fasting CCK plasma levels or DBI expression. This may suggest that they do not play a major role as risk factors for alcohol-induced pancreatitis.

Alcoholic, but not biliary, pancreatitis varies seasonally in occurrence.

BACKGROUND: Alcohol is the most common cause of acute pancreatitis in Finland (70%). The amount of alcohol consumed has been shown to be associated with the prevalence of pancreatitis in the country, and also to be an important determinant of the severity of the first episode of acute alcoholic pancreatitis. We have a clinical suspicion that the use of alcohol and the incidence of pancreatitis are increased during holiday periods in summer, although no seasonal variations have been reported in a German population. METHODS: Between 1972 and 1992 a total of 1556 episodes with acute alcoholic pancreatitis were treated at Tampere University Hospital; 552 were first episodes and 1004 were recurrent. For comparison, we investigated 297 episodes of acute biliary pancreatitis treated in that same time period. We investigated the monthly prevalence of acute alcoholic (first and recurrent) pancreatitis and compared this with the monthly absolute alcohol consumption. RESULTS: Taking all alcoholic pancreatitis episodes into account, significant differences can be seen between prevalence and month of onset of the disease (P < 0.0001), whereas among biliary pancreatitis episodes there were no differences (P = 0.3). Prevalence of acute alcoholic pancreatitis was significantly higher than the expected prevalence in July and August, and the amount of alcohol consumption (100% alcohol, litres) was highest during these same months. Also during March, October and December the prevalence was higher than expected. CONCLUSION: Months with holiday seasons, Christmas, Easter, summer and autumn, are associated with the highest alcohol consumption and the highest prevalence of acute alcoholic pancreatitis.

Microfluidic technology for assisted reproduction.

The physical tools used in assisted reproduction have changed little over several decades. Microfluidics is an emerging technology that allows a fresh examination of the way assisted reproduction is performed. Here we review our work to develop microfluidic devices to perform the functions required in assisted reproduction. These functions include loading/unloading, culture, chemical manipulation, and mechanical manipulation of embryos and oocytes. Basic microfluidic theory and microfluidic device design and operation are discussed. Results are presented for mechanical removal of cumulus cells and for embryo culture. Results suggest that microfluidic systems will lead to improved efficiencies in assisted reproduction.

Resection of the head of the pancreas in Finland: effects of hospital and surgeon on short-term and long-term results.

BACKGROUND: To study the effect of hospital volume and surgeon volume on postoperative hospital mortality, morbidity and long-term survival after resection of the head of the pancreas in a nationwide study (case record study), taking into a consideration risk factors found important in series based on experience in one hospital. METHOD: The case record investigation of 374 patients identified from the National Hospital Discharge Database as having undergone resection of the head of the pancreas between 1990 and 1994 in Finland. RESULTS: The records of 350 patients were obtained for analysis. Operations were performed in 33 hospitals by 98 surgeons (average 2.1/year/hospital and 0.7/year/surgeon). Hospital mortality was 36/350 (10%), increasing from 4 and 7 to 13% with decreasing hospital volume from > 10 and 5-10 to < 5 respectively (P < 0.05) and increasing from 3 and 10 to 14% with decreasing surgeon volume from > 3 and 1-3 to < 1, respectively (P < 0.05). Most deaths were caused by surgical or technical complications (31/36 = 86%). Besides hospital mortality, postoperative complications, re-operations and hospital stay were also affected by surgeon volume. In the univariate analysis, also the age of the patient had an effect on the hospital mortality, and preoperative biliary stenting on the uncomplicated recovery, but in the multivariate analysis hospital mortality was independently affected by age (OR 0.94, P = 0.004) and surgeon volume (OR 1.3, P = 0.04), re-operations by surgeon volume (OR 1.10, P = 0.05) and hospital volume (OR 1.03, P = 0.05), postoperative complications by using the preoperative stent (OR 0.45, P = 0.02). Long-term survival was dependent on the histology of the specimen and by uncomplicated recovery, but not by hospital volume or surgeon volume. CONCLUSION: To decrease postoperative morbidity, mortality and hospital stay, pancreatic head surgery needs to be concentrated to only a few hospitals and to a few surgeons.

Osteosynthesis and allogeneic bone grafting in complex osteoporotic fractures.

Thirty patients with osteoporotic fractures were treated operatively. An allogeneic bone transplant was used in combination with a conventional osteosynthesis in each patient. The bone graft was pulverized in a bone mill and used as a substitute graft to fill the bone defect, add stability, and enhance bone union. Fractures healed without complications in 20 patients. The osteosynthesis failed in 4 patients. The fracture failed to unite in an additional 3 patients. One deep infection occurred. A biopsy taken from the allogeneic bone at plate removal after fracture union demonstrated mature bone and new bone formation. The use of pulverized allograft bone for large bone defects in patients with osteoporotic fractures yields acceptable results with no adverse effects.

Post-ERCP pancreatitis: reduction by routine antibiotics.

Cholangitis and pancreatitis are severe complications of endoscopic retrograde cholangiopancreatography (ERCP). Antibiotics have been considered important in preventing cholangitis, especially in those with jaundice. Some have suggested that bacteria may play a role in the induction of post-ERCP pancreatitis. It is not clear, however, whether the incidence of post-ERCP pancreatitis could be reduced by antibiotic prophylaxis, as is the case with septic complications. In this prospective study, a total of 321 consecutive patients were randomized to the following two groups: (1) a prophylaxis group (n = 161) that was given 2 g of cephtazidime intravenously 30 minutes before ERCP, and (2) a control group (n = 160) that received no antibiotics. All patients admitted to the hospital for ERCP who had not taken any antibiotics during the preceding week were included. Patients who were allergic to cephalosporins, patients with immune deficiency or any other condition requiring antibiotic prophylaxis, patients with clinical jaundice, and pregnant patients were excluded. In the final analysis six patients were excluded because of a diagnosis of bile duct obstruction but with unsuccessful biliary drainage that required immediate antibiotic treatment. The diagnosis of cholangitis was based on a rising fever, an increase in the C-reactive protein (CRP) level, and increases in leukocyte count and liver function values, which were associated with bacteremia in some. The diagnosis of acute pancreatitis was based on clinical findings, and increases in the serum amylase level (>900 IU/L), CRP level, and leukocyte count with no increase in liver chemical values. The control group had significantly more patients with post-ERCP pancreatitis (15 of 160 in the prophylaxis group vs. 4 of 155 in the control group; P = 0.009) and cholangitis (7 of 160 vs. 0 of 155; P = 0.009) compared to the prophylaxis group. Nine patients in the prophylaxis group (6%) and 15 patients in the control group (9%) had remarkably increased serum amylase levels (>900 IU/L) after ERCP, but clinical signs of acute pancreatitis with leukocytosis, CRP reaction, and pain developed in four of nine patients in the prophylaxis group compared to 15 of 15 patients with hyperamylasemia in the control group (P = 0.003). In a multivariate analysis, the lack of antibiotic prophylaxis (odds ratio 6.63, P = 0.03) and sphincterotomy (odds ratio 5.60, P = 0.05) were independent risk factors for the development of post-ERCP pancreatitis. We conclude that antibiotic prophylaxis effectively decreases the risk of pancreatitis, in addition to cholangitis after ERCP, and can thus be routinely recommended prior to ERCP. These results suggest that bacteria could play a role in the pathogenesis of post-ERCP pancreatitis

Cholecystokinin in acute alcoholic and biliary pancreatitis.

BACKGROUND: Recent studies have shown that cholecystokinin (CCK) agonist, cerulein can induce acute pancreatitis in animals. The role of CCK in the induction of acute pancreatitis in humans is unclear. We investigated plasma CCK levels in alcoholic and biliary pancreatitis on admission and during the episode of acute pancreatitis. METHODS: Plasma CCK concentrations were determined by a specific and sensitive radioimmunoassay using CCK antiserum (Euro-Diagnostica, Malmö, Sweden) in 35 patients with acute alcoholic pancreatitis, in 27 patients with acute biliary pancreatitis, in 34 patients with nonpancreatic acute abdominal pain, and in 43 healthy subjects. The mean time from the first symptoms to the plasma sample was 31 (+/- 3.7) h in alcoholic pancreatitis patients and 25 (+/- 5.1) h in biliary pancreatitis patients. We also determined CCK levels in 20 patients during the episode of acute pancreatitis. Normal fasting level of CCK is < or = 1.12 pmol/L according to manufacturer. RESULTS: Basal plasma CCK concentrations were significantly lower both in alcoholic pancreatitis (mean +/- SEM, 0.04 +/- 0.03 pmol/L, p < 0.0001) and biliary pancreatitis patients (0.17 +/- 0.13 pmol/L, p < 0.0001) than in nonpancreatic acute abdominal pain patients (1.23 +/- 0.32 pmol/L) or healthy subjects (1.18 +/- 0.20 pmol/L). Plasma CCK levels also remained low until the patient was well-recovering and had started oral diet. CONCLUSION: Basal plasma CCK concentrations are significantly decreased in acute alcoholic and biliary pancreatitis after the first day from the beginning of the symptoms until the patient was well-recovering.

Cholecystokinin in the early course of acute post-ERCP pancreatitis.

BACKGROUND: A high dose of cholecystokinin (CCK) agonist cerulein can induce acute pancreatitis in animals. The role of CCK in the induction of acute pancreatitis in humans is unclear. We investigated basal plasma CCK levels before and after induction of post-ERCP pancreatitis to determine CCK levels in the early course of the disease. STUDY DESIGN: We determined plasma CCK concentrations in four groups of patients who underwent ERCP: (1) post-ERCP pancreatitis patients (n = 23); (2) patients with post-ERCP hyperamylasemia without pancreatitis (n = 5); (3) patients with post-ERCP abdominal pain without hyperamylasemia (n = 18); and (4) patients with an uneventful post-ERCP period (n = 43). Plasma samples were taken before ERCP, 4 to 8 hours, 10 to 16 hours, and 24 hours after ERCP. Plasma CCK concentrations were determined by a specific and sensitive radioimmunoassay using CCK antiserum (Euro-Diagnostica, Malmö, Sweden). RESULTS: Plasma CCK levels increased five-fold early in the course in post-ERCP pancreatitis patients, but not in post-ERCP hyperamylasemia patients or in uncomplicated ERCP patients, where CCK levels temporarily decreased after ERCP. In patients with abdominal pain, CCK levels did not change. After the early increase, plasma CCK levels declined to almost unmeasurable levels one day after the onset of symptoms in post-ERCP pancreatitis. In other groups CCK levels were close to the pre-ERCP level. CONCLUSIONS: It remains to be shown whether CCK is important in the pathogenesis of post-ERCP pancreatitis or merely a secondary phenomenon. There is a rationale to test CCK antagonists in preventing post-ERCP pancreatitis.

Effect of decreased glucose concentration on cerebrovascular tone in vitro.

We studied the effect of decreased glucose concentration on cerebrovascular tone in vitro. Segments of rat middle cerebral arteries (MCA) were isolated, cannulated at both ends with glass micropipettes, and pressurized to 85 mm Hg. Decreasing the glucose in the extraluminal bath and luminal perfusate from 5.5 mmol/L to 1.0 or 0.5 mmol/L for 1.5 hours each had no significant effect on the diameter of the arteries. When all the glucose was removed from the extraluminal bath and luminal perfusate for 1.5 hours, the MCA dilated by 23% [252 +/- 24 (SD) microns to 311 +/- 7 microns (P < .5, n = 7)]. This dilation was 80% of the maximum dilation produced by removal of Ca+2 from the bathing solutions. Neither removal of the endothelium nor inhibition of the ATP-sensitive K channels with 10(-5) mol/L glibenclamide altered the response of the isolated MCA to the removal of glucose. We conclude that rat MCA are relatively more resistant to substrate limitation compared to the brain as a whole.

Difference in microbes contaminating pancreatic necrosis in biliary and alcoholic pancreatitis.

CONCLUSION: There are differences in the microbiology of infected pancreatic necrosis in alcoholic and biliary pancreatitis. One possible explanation may be different routes of contamination. BACKGROUND: Infection is a severe complication in acute pancreatitis. Bacteria are found in 40-70% of all patients suffering from necrotizing pancreatitis. We investigated whether there were any differences in microbes isolated from pancreatic necrosis in biliary and alcoholic pancreatitis. METHODS: Microbiological tests were conducted on necrosis taken at the operation for pancreatitis with the etiology of (group A) alcoholic pancreatitis (n = 47) and (group B) biliary pancreatitis (n = 23). Patients with simultaneous cholecystitis were excluded. The time from the first symptoms to the operation or the extent of necrosis did not differ between the groups. RESULTS: Microbes were isolated more often in the cultures from group B than group A (17/23 = 74% vs 15/47 = 32%, p = 0.001). The most common were Gram-positive bacteria in group A and Gram-negative bacteria in group B. From the first week, from the onset of symptoms to the operation. Gram-negative bacteria were isolated significantly more often in the cultures from group B patients than from group A patients (8/10 = 80% vs 1/5 = 20%, p = 0.04). In multivariate analysis, we found that biliary pancreatitis was an independent risk factor (adds ratio 5.5, 95% confidence interval [CI] 0.59-52.10) of contamination of necrosis with Gram-negative bacteria.

The presence of the gallbladder is associated with the severity of acute biliary pancreatitis.

CONCLUSION: The presence of the gallbladder at the onset of acute biliary pancreatitis is associated with increased severity of the disease. One possible explanation is that gallbladder contraction might induce bile reflux into the pancreatic duct during the transfer of a gallstone through the ampulla. BACKGROUND: In clinical practice there is an impression that the presence of the gallbladder in patients with biliary pancreatitis may be associated with increased severity of the disease, compared to patients who have undergone cholecystectomy. METHODS: To test this hypothesis, we studied 266 cases with biliary pancreatitis. Patients were divided into two groups: (A) those who had a gallbladder in situ at the onset of biliary pancreatitis (n = 234, 88%) and (B) those who had undergone previous cholecystectomy (n = 32, 12%). RESULTS: Pancreatitis was more severe in group A than in group B, according to Glasgow criteria (> or = 3 positive, 66/210 = 31% vs 4/29 = 14%, p = 0.04); development of complications (77/234 = 33% vs 4/32 = 13%, p = 0.01); and mortality (40/234 = 17% vs 1/32 = 3%, p = 0.03). Furthermore, serum C-reactive protein levels on admission were over 150 mg/L twice as often in group A as in group B.

Intraoperative jugular desaturation during surgery for traumatic intracranial hematomas.

Traumatic intracranial hematomas which are present on hospital admission or which develop during the hospital course are associated with a worse neurological outcome than diffuse injuries. The purpose of this study was to monitor jugular venous oxygen saturation (Sjvo2) during surgery for evacuation of traumatic intracranial mass lesions, to determine the incidence and the causes of jugular venous desaturation, and to assess the usefulness of Sjvo2 monitoring in this setting. Twenty-five severely head injured patients were monitored during 27 surgical procedures. At the start of the surgical procedure, the median Sjvo2 was 47% (range 25%-89%). Seventeen (63%) of the patients had a Sjvo2 less than 50%. Five patients had extremely low Sjvo2 values (< or = 30%). Upon evacuation of the intracranial hematoma, there was a significant (P < 0.001) increase in the median Sjvo2 to 65% (range 50%-88%). Intracranial hypertension was the primary cause of the low Sjvo2, as confirmed by the response to surgical evacuation. Hypotension (mean arterial pressure < 80 mm Hg) was a contributing factor in seven of the cases of jugular desaturation. The definitive treatment of a traumatic intracranial hematoma is surgical evacuation. However, during the period prior to evacuation of the hematoma, jugular venous desaturation was common, suggesting that monitoring Sjvo2 might provide useful information about the adequacy of cerebral perfusion.