Surgical treatment of severe acute pancreatitis: timing of operation is crucial for survival.

BACKGROUND: In patients operated on for severe acute pancreatitis (SAP) the impact of the timing of operation on outcome is controversial. MATERIALS AND METHODS: In a retrospective analysis of a prospectively documented database, we studied 250 patients suffering from SAP, who were in need for surgical treatment during their course of disease. RESULTS: From 1982 to 1998, 250 patients with the diagnosis of SAP who required operative treatment were admitted to the intensive care unit (ICU) of a university hospital. The mean APACHE II score on the day of admission was 16.1 (8-35). One hundred eighty-five patients (74%) required reoperation, of whom 111 patients (60%) underwent reoperation on demand and 74 (40%) patients a pre-planned reoperation. Overall mortality was 38.8% (97 patients). In patients who were operated during the first three weeks after onset of disease, mortality was significantly higher than in patients who were operated after three weeks (46% vs. 25%, p < 0.01). Besides patient age (p < 0.05), APACHE II score at admission (p < 0.01), multiple organ dysfunction (p < 0.01), infection of pancreatic necrosis (p < 0.05), surgical control of pancreatic necrosis (p < 0.0001), and the time of surgical intervention (p < 0.05) determined survival significantly. CONCLUSION: Patients who were operated later than three weeks after onset of disease had a significantly better outcome. In patients suffering from SAP who required surgical treatment, the timing of operation is crucial for survival.

[Vaccine protection in the elderly: are Austrian seniors adequately protected by vaccinations?]. / Impfschutz im Alter: Sind österreichische Senioren durch Impfungen ausreichend geschützt?

OBJECTIVE: The aim of the study was to evaluate, if elderly persons are sufficiently protected against infectious diseases by vaccination. PROBANDS AND METHODS: 300 elderly (> 60 years) and 300 young (< 35 years) persons from five Austrian cities were recruited according to the criteria of a field study. Antibody concentrations against tetanus, diphtheria, tickborne encephalitis and influenza were assessed by ELISA or by haemagglutination inhibition test. Disease and vaccination histories were recorded. RESULTS: The results of the study demonstrate that protection against infectious diseases was frequently insufficient in the elderly. This was partly due to the fact that old persons were not vaccinated according to recommended strategies. However, low antibody concentration and a short duration of protective humoral immunity were also observed in many elderly persons in spite of regular vaccination. This was not only the case in frail, but also in healthy elderlies. CONCLUSION: The data demonstrate that vaccination has a relatively weak and short-lasting effect in old age. The results of the study should stimulate discussions about strategies how vaccinations can be made more effective in old age. Improved campaigns, shortened vaccination intervals as well as the design of novel vaccines tailored to fulfill the specific demands of the aging immune system are imaginable.

Release of toxic metals from button batteries retained in the stomach: An in vitro study.

BACKGROUND: Ingestion of button batteries by children is a rapidly growing problem, and opinions differ on how button batteries distal to the gastroesophageal junction should be managed. The authors therefore performed an experimental study to determine the cumulative load of various toxic elements released from retained button cells in simulated gastric juice. METHODS: Eight different groups of button cells were immersed in simulated gastric juice. Analyzed elements included Al, Ba, Cd, Cr, Cu, Fe, Hg, Li, Mg, Mn, Ni, Pb, Sb, Sn, Sr, Te, TI, V, W; and Zn. Inductively coupled plasma mass spectrometry (ICP-MS) was used to evaluate the residual amounts of elements after 4, 24, 72, and 120 hours. RESULTS: At 4 hours, leakage was seen with almost all batteries, with the levels increasing in a time-dependent manner. The highest detected levels at 4 hours were 1.20 microgram for Cd, 280.51 ng for Hg, and 2.63 microgram for Pb. Dissolution, holes, and defragmentation were seen within 24 to 72 hours. Battery weight loss varied between 22 and 104 mg over the course of the study. CONCLUSIONS: Toxic elements contained in button cells are released quickly in gastric juice. This finding might change the current policy of watchful waiting or conservative management of batteries lodged in the stomach.

Influence of controlled reaming on fat intravasation after femoral osteotomy in sheep.

This study assessed the influence of driving speed and revolution rate per minute of two reamers on femoral intramedullary pressure increases and fat intravasation. The AO and Howmedica reamers were tested in four groups with different combinations of driving speed and revolution rate per minute in both femurs in a sheep model. The 24 animals were exposed to hemorrhagic shock after midshaft osteotomy and were resuscitated before reaming of both femoral shafts. Controlled reaming was performed at 15 and 50 mm/second driving speed with 150 and 450 revolutions per minute. Fat intravasation and intramedullary pressure were measured by transesophageal echocardiography, Gurd test, and a piezoelectric gauge, respectively. Low driving speed and high revolutions per minute with the smaller cored reamer led to lower intramedullary pressure changes. The same reaming parameters led to greater pulmonary stress during surgery of the second side. Reaming with a smaller cored reamer and modified reaming parameters leads to a lower increase in intramedullary pressure and reduces the amount of fat intravasation. Primary reamed intramedullary nailing should be done after resuscitation at a low driving speed and high revolutions per minute with a smaller cored reamer to minimize the risk of pulmonary dysfunction.