Incidence of hypoglycemia with tight glycemic control protocols: a comparative study.

BACKGROUND: Comparison of hypoglycemia incidence among tight glycemic control (TGC) protocols is a crucial aspect that has not been done in previous trials. This study compared the incidence of hypoglycemia using three TGC protocols in critically ill patients. METHODOLOGY: This was a prospective study of 420 patients over 18 months. Patients were divided into three groups by TGC protocol: A (modified Leuven protocol), B (Georgia Hospital Association protocol, target blood glucose [BG] 80-110 mg/dL), and C (modified Georgia Hospital Association protocol, target BG 90-140 mg/dL). End points included differences in the incidence of first-degree hypoglycemia (BG or= 180 mg/dL). RESULTS: A total of 34,497 BG samples were analyzed: group A, 11,202 (32.47%); group B, 9,627 (27.91%); and group C, 13,668 (39.62%). First-degree hypoglycemia was more frequent in group A (348 episodes [3.11%]) compared to group B (209 episodes [2.17%] [odds ratio (OR) 1.45, 95% confidence interval (CI) 1.25-1.172, P = 0.001]) and group C (266 episodes [1.95%] [OR 1.66, 95% CI 1.37-1.89, P = 0.001]). Second-degree hypoglycemia was more frequent in group A (131 episodes [1.17%]) compared to group B (62 episodes [0.64%] [OR 1.83, 95% CI 1.22-1.72, P = 0.001]) and group C (58 episodes [0.42%] [OR 2.77, 95% CI 2.04-3.79, P = 0.001]). No significant difference was found when groups B and C were compared (P = 0.10 and P = 0.06, respectively). Hyperglycemia was significantly more common in group A (2,175 episodes [19.42%]) compared to group B (1,333 episodes [13.83%] [OR 1.49, 95% CI 1.39-1.62, P = 0.001], but there was no significant difference compared to group C (2,560 episodes [18.73%] [P = 0.17]). CONCLUSIONS: TGC protocols vary in their risk of inducing hypoglycemia. Whether this translates into differences in clinical outcomes such as mortality and adverse effects is still to be determined by future studies.

Isolated gastrointestinal metastasis of breast carcinoma: a case report.

Purpose. Gastrointestinal tract is one of the rare locations for breast cancer metastasis. This paper shows such metastasis may occur even in the absence of breast metastasis in other more common locations. Case Report. A 64-year old female was admitted to the hospital with abdominal discomfort and diarrhea. She had breast carcinoma treated 7 years previously with normal follow-up since. Colonoscopy showed hepatic flexure thickening that was confirmed to be breast metastasis. Staging investigations showed upper and lower gastrointestinal tract metastasis with negative findings elsewhere. Conclusion. Although more common causes for gastrointestinal symptoms should be excluded, however, a high index of suspicion of metastatic breast cancer is needed when such patients develop gastrointestinal symptoms.

Perineum compression during EAUS enhances visualization of anterior anal sphincter defects.

OBJECTIVE: Endo-anal ultrasound (EAUS) can detect anal sphincter injuries. However, anterior external anal sphincter (EAS) defects can be difficult to define. We assessed different EAUS techniques to determine if any particular method improved defect identification. METHOD: Ninety females with faecal incontinence were prospectively studied. Wexner faecal incontinence scores were obtained. All patients underwent anorectal manometry and EAUS using three different techniques: standard, digit-assisted (gloved finger pressing on posterior vaginal wall) and balloon-assisted (standard balloon inflated into the vagina). The three techniques were assessed by comparing defect characteristics (detection, angle, edges and scar tissue), and perineal body thickness. All measurements were performed at the mid anal canal level. RESULTS: are expressed as medians (IQR). Results Standard EAUS (S-EAUS) identified a sphincter defect in 54 patients. Digit assisted EAUS (D-EAUS) and balloon-assisted EAUS (B-EAUS) ultrasound revealed a sphincter defect in additional 11 and 9 patients respectively compared to S-EAUS. Correlation of maximum squeeze pressure with EAUS findings improved on D-EAUS and B-EAUS. The defect angle was significantly wider with D-EAUS and B-EAUS [S-EAUS 90 degrees (63-97), D-EAUS 100 degrees (81-101.5), B-EAUS 100 degrees (80-105), P = 0.0005]. The perineal body was significantly thicker when measured with B-EAUS [D-EAUS 9 mm (7-10) vs B-EAUS 10 mm (8-11), P = 0.0005]. Inter-observer agreement was comparable [S-EAUS (K) = 0.677, D-EAUS (K) = 0.658, B-EAUS (K) = 0.601]. CONCLUSION: EAS anterior defect detection and definition on EAUS may be improved by the demarcation and gentle pressure on the posterior vaginal wall.

Deep venous thrombosis after arterial surgery: a literature review.

OBJECTIVE: To quantify the risk of DVT in arterial surgery, and to assess the need for prophylaxis. METHODS: A search was carried out through Medline, Embase and Cochrane databases to identify published studies on DVT in arterial surgery. To quantify the risk of DVT both randomised and prospective non-randomised studies were included for analysis. However, to assess the need for prophylaxis only randomised controlled trials were considered. RESULTS: Twenty three prospective studies that evaluated DVT in arterial surgery were identified. Ten reported data about DVT in aortic surgery, seven studies evaluated DVT in general vascular surgery, three studied DVT in infra-inguinal vascular surgery and three studied DVT incidence in patients after limb amputations. CONCLUSION: There is a wide variation in the reported incidence of DVT in arterial surgery (2%-24%). This is mostly due to the diversity of screening methods used and the inclusion or exclusion of below knee DVT. There is insufficient evidence to make a valid conclusion regarding the routine use of anticoagulants prophylaxis in arterial surgery. However, until such evidence becomes available, DVT prophylaxis in patients undergoing arterial surgery will continue to be guided by evidence gained from studies of general surgical patients.

Interventions for preventing venous thromboembolism following abdominal aortic surgery.

BACKGROUND: Deep vein thrombosis (DVT) is one of the most common, preventable complications of surgery. Although the relationship between surgery and DVT is well established in general surgical operations and most other subspecialties, the same cannot be said about arterial surgery. Deep vein thrombosis is believed to be less common in aortic surgery where its management is rather controversial with a reported incidence of DVT from 2% to 18%.Intra-operative heparin is believed to provide protection during the period when DVT is most likely to develop. However, the practice of using intra-operative heparin could increase the risk of haemorrhagic complications if further heparin is used during the recovery period. This can significantly limit the use of such prophylactic measures especially with the low perceived risk of venous thromboembolism (DVT or pulmonary embolism (PE)) following abdominal aortic surgery. However, vascular patients are usually older, with more co-morbidity and are subject to prolonged immobility, all of which increase the likelihood of developing venous thromboembolism. OBJECTIVES: To determine the efficacy of anticoagulant prophylaxis (with or without mechanical devices) in patients undergoing surgery for abdominal aortic aneurysm. SEARCH STRATEGY: The Cochrane Peripheral Vascular Diseases Group searched their trials register (last searched 8 August 2007) and the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, (last searched Issue 3, 2007). The authors searched for additional trials through reference lists of retrieved studies and conference proceedings. SELECTION CRITERIA: Randomised controlled trials comparing the use of anticoagulants (with or without mechanical devices) with control or no intervention in preventing DVT or PE after abdominal aortic operations. DATA COLLECTION AND ANALYSIS: Three authors independently selected potential trials and assessed trial quality. MAIN RESULTS: Two studies (n=147) were included. Both studies had methodological limitations. There were no data to indicate that post operative anticoagulation, with or without the use of mechanical devices, can safely reduce the incidence of DVT after aortic surgery. Neither study reported a significant effect of anticoagulants on the incidence of PE or related mortality. One study was terminated before recruiting sufficient participants due to a higher incidence of bleeding with the use of anticoagulants. The incidence of minor bleeding events was also slightly higher with anticoagulants. AUTHORS' CONCLUSIONS: There is not enough evidence to make a definitive conclusion about the use of anticoagulant drugs (with or without mechanical devices) for DVT prophylaxis in patients undergoing abdominal aortic surgery.

Nicorandil-induced colonic ulceration: a new cause of colonic ulceration. Report of four cases.

PURPOSE: Nicorandil is a widely used third-line treatment for ischemic heart disease. It can be associated with the development of stomatitis and oro-anal ulceration. The current report suggests an association between nicorandil and the development of colonic ulceration, both in isolation and in combination with anal ulceration. METHODS: This is a case report of four patients with new onset lower gastrointestinal symptoms. All had a history of ischemic heart disease and angina. All were taking several cardiac medications, including nicorandil. RESULTS: Four patients (3 men) were investigated. Colonoscopy revealed both solitary and multiple colonic ulcers. Pathology showed acute nonspecific inflammation. Two patients also displayed concomitant anal ulceration. Nicorandil therapy was stopped in all patients. No other active treatment was offered. All patients became asymptomatic within six weeks of cessation of nicorandil therapy with resolution of the anal and colonic ulceration. CONCLUSION: Nicorandil may induce colonic ulceration and should be considered in the differential diagnosis of idiopathic colonic ulceration in appropriate patients.

Correlation between anal manometry and endosonography in females with faecal incontinence.

OBJECTIVE: Female faecal incontinence (FI) is largely because of sphincter injury at childbirth. Sphincter assessment aims to identify surgically correctable defects. We aimed to identify endoanal ultrasonography (EAUS) parameters that correlate with sphincter function. METHOD: One hundred females with FI and 28 healthy asymptomatic females were prospectively assessed. Wexner FI score was recorded and all subjects underwent anorectal manometry and EAUS. Multiple EAUS parameters were assessed and correlated with external (EAS) and internal (IAS) anal sphincter function, determined by maximum squeeze pressure (MSP) and maximum resting pressure (MRP) respectively. Parameters included sphincter quality (echogenicity), thickness, perineal body thickness (PBT) and defect characteristics (angle, length). Results are expressed as medians and interquartile range (IQR). RESULTS: Median Wexner score was 14 (12-17). Maximum EAS thickness significantly correlated with MSP (P = 0.019). EAS defects were detected in 84 patients and seven controls (P < 0.0001). Full-length EAS defects were only detected in FI group and had significantly lower MSP [MSP mmHg: full length 85 (65-103) vs partial length 119 (75-155), P = 0.006]. FI patients were more likely to have a mixed echogenicity of EAS compared with controls. EAS ring quality, PBT and defect angle were not significant. IAS quality was significantly associated with MRP [MRP mmHg: uniform 62 (43-82) vs mixed 47 (30.5-57.5), P = 0.002]. CONCLUSION: Certain EAUS parameters can be predictive of anal sphincter function. These include the presence of an EAS defect and its length, EAS maximum thickness, IAS ring quality. Integration of these parameters can give better EAUS correlation with manometry for FI evaluation.

Prospective study of the diagnostic evaluation of faecal incontinence and leakage in male patients.

OBJECTIVE: Male faecal incontinence (FI) has received little attention. No consistent pathophysiological abnormality has been identified in those studies that have specifically assessed male patients with FI or faecal leakage (FL). This study was designed to re-examine the different theories relating to the pathophysiology of male incontinence and to assess if manometric and ultrasound assessment yields clinically relevant information that directs patient care. METHOD: This was a prospective study of all men referred to a Coloproctology clinic with incontinence. The Wexner Incontinence score was used to assess severity of symptoms. Specific investigations included anal manometry, rectal sensation and endo-anal ultrasound (EAUS). Results were compared with a group of 20 normal male controls. RESULTS: A total of 59 symptomatic male patients were investigated (36 FI, 23 FL). FL and control groups had similar maximum resting (MRP) and maximum squeeze pressure (MSP). The incontinence group had a significantly lower MRP & MSP compared with controls [MRP: FI 58 (42-75.5) vs control 85 (72-104)] (P < 0.0001), [MSP: FI 167 (125-215) vs control 248 (192-302)] (P < 0.0001). There was no significant difference in rectal sensation between the groups and the defecation index was also similar. EAUS detected only one external anal sphincter defect amongst the 23 male patients with FL. One external sphincter defect and three internal sphincter defects were identified amongst the 36 patients with incontinence. Of these five patients with sphincter defects, four had previously undergone anorectal surgery. [Results expressed as median (interquartile range): manometry expressed as mmHg]. CONCLUSION: Male patients presenting with faecal incontinence frequently show impaired sphincter function which may be associated with sphincter defects. In contrast, those presenting predominantly with FL have no morphological or physiological changes that might account for their symptoms. Investigating such patients with anorectal physiology and EAUS is usually unhelpful and can be omitted.

Quality of life and alteration in comorbidity following laparoscopic adjustable gastric banding.

OBJECTIVES: Obesity is an increasing problem in the UK and bariatric surgery is likely to increase in volume in the future. While substantial weight loss is the primary outcome following bariatric surgery, the effect on obesity-related morbidity, mortality and quality of life (QOL) is equally important. This study reports on weight loss, QOL, and health outcomes following laparoscopic adjustable gastric banding (LAGB) in a low volume bariatric centre (<20 cases/year) and presents the first assessment of factors relating to the QOL which has been produced from a UK based surgical practice. STUDY DESIGN: Questionnaire based study of patients who had LAGB. Each patients' initial body mass index (BMI), QOL, and comorbidities were recorded. Change in these parameters was measured including excess weight loss, and output from both the Moorehead-Ardelt QOL questionnaire, and the Bariatric Analysis and Reporting Outcome System (BAROS). RESULTS: Eighty-one patients (14 males, 67 females) answered the questionnaire. More than 50% excess weight loss was recorded in 52/81 patients (64%). Sixty-four patients (79%) reported improvement in their QOL including self-esteem, physical activity, social involvement, and ability to work. Seventy-one patients had initial obesity related comorbidity. In 61 of these patients (86%) their comorbidities resolved or improved. Minor port site related complications were recorded in nine patients while two patients had removal of the band because of infection. CONCLUSION: LAGB is a safe method of bariatric surgery. It can achieve satisfactory weight loss with significant improvement in QOL and comorbidity.

Comparison of carotid Doppler ultrasound and computerised tomographic angiography in the evaluation of carotid artery stenosis.

PURPOSE: To compare results of carotid Doppler ultrasound (CDUS) and spiral computerised tomographic angiography (CTA) in patients with suspected carotid artery stenosis and to evaluate their combined effect on decision making for carotid endarterectomy (CEA). METHODS: A total of 107 patients were studied. All of the patients had CDUS followed by CTA as a standard method of investigation. Data included the indications for investigation, stenosis degree measured in both modalities, in addition to difficulties and limitations faced while doing them. RESULTS: Out of the 214 carotid scans performed, 187 scans were included in the comparison, while 27 scans were excluded due to inadequate data or imaging difficulties. The overall concordance between both CDUS and CTA was 79.1% (148/187) (95% CI 0.72-0.83). CDUS under-estimated and over-estimated the degree of stenosis in 26/187 (14%, 95% CI 0.09-0.19) and 13/187 (7%, 95% CI 0.04-0.12), respectively. When CTA was considered in conjunction with CDUS, the decision regarding operative treatment was changed in 29/187 cases (16%) (95% CI 0.11-0.21). CONCLUSIONS: CDUS remains the first line non-invasive imaging for carotid artery stenosis. However, in cases where it is inconclusive, CTA is an excellent, reliable, minimally invasive, and outpatient alternative for patient selection for CEA.

The isolated internal iliac artery aneurysm--a review.

BACKGROUND: The isolated internal iliac artery aneurysm (IIIAA) is rare but rupture has a high mortality rate. This paper reviews the available literature regarding the epidemiology, aetiology, natural history, diagnosis and management with a focus on aneurysms of atherosclerotic origin. METHODS: A literature search was performed using internet databases PubMed, Medline and Medscape followed by manual cross referencing of relevant articles. Data were retrieved from the papers, tabulated and analysed to form a review of atherosclerotic IIIAA. RESULTS: Three hundred and seventy-two papers were found relating to internal iliac artery aneurysms in general and 82 were directly relevant to this paper, reporting 94 cases of atherosclerotic IIIAA. For atherosclerotic aneurysms, the median (range) age was 71.9 (47-89) years and 95% were male. The natural history is unclear but is probably one of increasing size, with corresponding increased risk of rupture. Presentation was with rupture in 40%, leading to rapid death if untreated. The death rate in the group as a whole was 31%. The median (range) size of aneurysms at diagnosis was 7.7 (2-13) cm and death was significantly associated with rupture (Spearman correlation coefficient r=0.327, p=0.007). Symptoms included abdominal pain (31.7%), urological symptoms (28.3%), neurological symptoms (18.3%), groin pain (11.7%), hip or buttock pain (8.3%) and gastrointestinal symptoms (8.3%). Diagnosis may also be coincidental as a result of investigation for other conditions. Of particular use in diagnosis and assessment are ultrasound, computerised tomography and magnetic resonance angiography. Surgical treatment is difficult but can be achieved by ligation, excision or endoanneurysmorrhaphy. More recently, radiological treatments include coil embolisation and endoluminal stenting (often in combination) with the established advantages of endovascular repair have yielded promising short term results, although long term follow-up is required to assess complications and the durability of the devices. CONCLUSIONS: Atherosclerotic IIIAA is a rare condition and if undiagnosed is often fatal. Early diagnosis and treatment may reduce morbidity and mortality particularly with the advent of endovascular techniques.

A critical look at ocular allergy drugs.

Topical ocular allergy drugs are indicated for the treatment of allergic conjunctivitis after more conservative measures have been employed. Antihistamines, vasoconstrictors, nonsteroidal anti-inflammatory drugs, mast cell stabilizers and corticosteroids are available. Levocabastine and ketorolac tromethamine are new drugs for the treatment of allergic conjunctivitis. Lodoxamide is currently indicated only for the treatment of vernal keratoconjunctivitis, although treatment efficacy has been demonstrated in patients with giant papillary conjunctivitis and atopic keratoconjunctivitis. As a general rule, topical ocular allergy drugs are well tolerated by most patients except for transient stinging and burning on instillation. Ocular steroids should be reserved for severe cases and should be prescribed by an ophthalmologist, who can monitor the patient for possible ocular side effects.

[Porokeratosis of Mibelli in two monozygotic twins (author's transl)]. / Porkératose de Mibelli chez deux jumeaux monozygotes.

Two monozygots twins had porokeratosis Mibelli and a deep mental retardation. The exploration of this nervous components is negative. The porokeratosis in one twin had in several sites the aspect of a skin's horn. The demonstration of the monozygotis was made by the same repartition of 16 characters (HLA, blood groups). The boys had the same aspect and the same skin disease. The twin method is discussed. The existence of the porokeratosis of Mibelli in two monozygotic twins is an argument for the genetic mechanism of the disease. The familial cases of porokeratose Mibelli reported by Bataillard, Civatte, Vigne, Bloom, have consistent features for an dominant autosomic transmission with variations in the penetrance and the expressivity of the skin disease.