Managing pancreatoduodenal trauma.

Pancreatoduodenal injuries are an uncommon but important source of morbidity and mortality in the trauma patient. They require a multidisciplinary approach, with a pancreatic surgeon involved at the earliest opportunity. The investigation and management of these injuries are discussed along with the role of operative intervention.

Identification of mRNA for endocannabinoid biosynthetic enzymes within hippocampal pyramidal cells and CA1 stratum radiatum interneuron subtypes using quantitative real-time polymerase chain reaction.

The hippocampus is required for short-term memory and contains both excitatory pyramidal cells and inhibitory interneurons. These cells exhibit various forms of synaptic plasticity, the mechanism underlying learning and memory. More recently, endocannabinoids were identified to be involved in synaptic plasticity. Our goal was to describe the distribution of endocannabinoid biosynthetic enzymes within CA1 stratum radiatum interneurons and CA3/CA1 pyramidal cells. We extracted mRNA from single interneurons and pyramidal cells and used real-time quantitative polymerase chain reaction (RT-PCR) to detect the presence of 12-lipoxygenase, N-acyl-phosphatidylethanolamine-specific phospholipase D, diacylglycerol lipase α, and type I metabotropic glutamate receptors, all known to be involved in endocannabinoid production and plasticity. We observed that the expression of endocannabinoid biosynthetic enzyme mRNA does occur within interneurons and that it is coexpressed with type I metabotropic glutamate receptors, suggesting interneurons have the potential to produce endocannabinoids. We also identified that CA3 and CA1 pyramidal cells express endocannabinoid biosynthetic enzyme mRNA. Our data provide the first molecular biological evidence for putative endocannabinoid production in interneurons, suggesting their potential ability to regulate endocannabinoid-mediated processes, such as synaptic plasticity.

Pancreatic and peripancreatic somatostatinomas.

BACKGROUND: Somatostatinomas are rare neuroendocrine tumours with an annual incidence of 1 in 40 million. They arise in the pancreas or periampullary duodenum. Most are clinically non-secretory and do not cause the somatostatinoma syndrome. Many are metastatic at presentation and their management is typically multimodal. CASE HISTORIES: Four cases of somatostatinoma are described. Two patients with periampullary disease presented with biliary obstruction, one with frank jaundice and one with incidental bile duct obstruction on investigation of hepatitis B. Each patient had type 1 neurofibromatosis and resection of the somatostatinoma by means of a pylorus-preserving proximal pancreaticoduodenectomy has resulted in long-term survival. Another two patients with metastatic pancreatic somatostatinomas presented with abdominal pain. Contrasting management illustrates current treatment strategies that are dependent in part on the distribution of the disease. DISCUSSION: The pathophysiology, presentation, clinical associations and role of diagnostic imaging are discussed for periampullary and pancreatic neuroendocrine tumours. Operative treatment has an important role in both the curative and palliative settings in conjunction with appropriate medical treatments and these are described. Management options depend on the extent of the disease and the cases are used to illustrate the rationale of such strategies.

Evaluation of chemical controls and entomopathogenic nematodes for control of Phyllophaga white grubs in a Fraser fir production field.

The results of 2 yr of field trials evaluating various chemical and biological controls of Phyllophaga anxia (LeConte) white grubs in a Fraser fir [Abies fraseri (Pursh) Poir] Christmas tree production field are reported here. Chemical insecticides evaluated included bifenthrin, chlorantraniliprole, thiamethoxam, and time-released imidacloprid tablets (Coretect, Bayer CropScience, Research Triangle Park, NC). Entomopathogenic nematodes evaluated included Heterorhabditis bacteriophora (Poinar) and Steinernema carpocapsae (Weiser). Overall, the chemical controls provided the best root protection and grub control. Targeted treatments of an insecticide in the root zone may provide adequate tree protection and can be a way to reduce overall insecticide input compared with banded sprays. The nematode H. bacteriophora provided limited root protection and grub control, whereas S. carpocapsae did not provide effective control. Differences in efficacy and persistence of the two entomopathogenic nematode species can be attributed to the biology and environmental preferences of these organisms.

Survival analysis after pancreatic resection for ampullary and pancreatic head carcinoma: an analysis of clinicopathological factors.

BACKGROUND AND OBJECTIVES: Surgery remains the only curative option for the treatment of pancreatic and ampullary carcinomas. To examine the survival differences between ampullary and pancreatic head carcinomas after pancreaticoduodenectomy. METHODS: A retrospective review of patients with ampullary or pancreatic head adenocarcinoma undergoing curative resection during a 6-year period prior to 2000. RESULTS: A total of 104 patients underwent pancreaticoduodenectomy for pancreatic head and ampullary carcinomas (n = 65 and n = 39, respectively). Histologically, pancreatic cancer was worse, with more lymph node involvement and more positive resection margins and vascular and perineural invasions than found in ampullary carcinoma. The median disease-free and overall survival rates were significantly better for ampullary cancer when compared with pancreatic cancer (17 vs. 9 months [P = 0.001] and 35 vs. 24 months [P = 0.006], respectively). The actuarial 5-year disease-free and overall survival rates were 4.4% and 10.5%, respectively, for pancreatic carcinoma and 27.9% and 31.8%, respectively, for ampullary carcinoma. Multivariate analysis showed that microscopic resection margin involvement (P = 0.02) and involvement of over three nodes (P < 0.001) were significant factors affecting the overall survival for pancreatic and ampullary carcinomas, respectively. CONCLUSIONS: In this study, patients with ampullary carcinoma have a better prognosis and survival than those with pancreatic carcinoma.

Potential management strategies for the linden borer (Coleoptera: Cerambycidae) in urban landscapes and nurseries.

The linden borer, Saperda vestita Say (Coleoptera: Cerambycidae), is a native insect species that is common throughout north central and northeastern North America. Over the past decade, increasing occurrence of damage associated with the linden borer has been reported on Tilia spp. in city street trees and nurseries throughout Wisconsin, probably because of increased use of these trees. Our objective was to gain a better understanding of the seasonal biology and potential management strategies for this important pest. We evaluated the effectiveness of three systemic insecticides, imidacloprid, thiamethoxam, and disulfoton, and a mechanical control method of chipping linden borer-infested wood as a means of reducing S. vestita larval survival, subsequent emergence, and oviposition. Autumn and spring soil injections of imidacloprid to linden borer-infested Tilia cordata'Greenspire' nursery stock (< 11.4 cm in diameter at breast height [dbh]) provided >90% control. Autumn soil injections of imidacloprid and thiamethoxam and a spring granular soil application treatment of disulfoton applied to larger (>22 cm dbh) Tilia spp. did not effectively control linden borer at the application rates tested. Chipping infested Tilia spp. effectively destroyed linden borer larvae, pupae, and adults. Arborists and landscape managers should consider chipping felled Tilia spp. trees infested with S. vestita to prevent adults from potentially attacking nearby susceptible trees.

Pancreas-sparing distal duodenectomy for infrapapillary neoplasms.

INTRODUCTION: For neoplasms that arise in the third and fourth parts of the duodenum (D(3), D(4)), a duodenectomy that preserves the pancreas can provide adequate tumour clearance while avoiding the additional dissection and risk of the common alternative, pancreatoduodenectomy. PATIENTS AND METHODS: Pancreas-sparing distal duodenectomy (PSDD) was performed in 14 patients with infrapapillary duodenal neoplasms between 1991-2002, and the clinical outcome is reviewed. The operation entails careful separation of the lower pancreatic head from D(3), complete mobilisation of the ligament of Treitz and end-to-end duodenojejunal anastomosis 1-3 cm below the major duodenal papilla. RESULTS: There were 9 men and 5 women of median age 56 years, who presented with iron-deficiency anaemia (n = 8), gastric outlet obstruction (n = 4), anaemia and gastric outlet obstruction (n = 1), epigastric pain or mass (1 each). There were 11 malignant neoplasms (adenocarcinoma 5, stromal tumour 4, recurrent seminoma 1, plasmacytoma 1), 2 benign neoplasms (villous adenoma, lipoma) and 1 patient with steroid-induced ulceration. In addition to D(3) and D(4), resection included the distal part of D(2) in 5 patients, while 4 required concomitant partial colectomy. Median operation time was 240 min and median blood loss 1197 ml, being greater for malignant than benign lesions (1500 ml versus 700 ml). There was one death from gangrenous cholecystitis, one early re-operation for anastomotic bleeding and one late re-operation for delayed gastric emptying secondary to anastomotic stricture, but no pancreatic complications. At a median follow-up of 47 months, three patients had died of recurrent disease while the other 10 were alive and well with no upper gastrointestinal symptoms. CONCLUSIONS: Provided there is a minimum 1-cm clearance at the papilla, PSDD is a useful alternative to formal pancreatoduodenectomy in patients with unusual neoplasms arising from the third and fourth parts of the duodenum. Although a major undertaking in its own right, it avoids the extra time of a pancreatic resection and the extra risk of a pancreatic anastomosis.

Psychological assessment of ICU survivors: a comparison between the Hospital Anxiety and Depression scale and the Depression, Anxiety and Stress scale.

Recovery from a critical illness can be delayed by persistent anxiety and depression. To identify such patients, a new self-report questionnaire (the Depression, Anxiety and Stress scale, DASS) was used alongside an established instrument (the Hospital Anxiety and Depression scale, HADS) in those who had spent a minimum of 3 days (median 9 days) in a general intensive care unit. Fifty-one patients were studied 3 months later, and 45 survivors were reviewed at 9 months. High Cronbach alpha values (0.92-0.95) for each subscale of DASS confirmed its internal consistency, and likewise for HADS (0.82-0.86). HADS and DASS correlated strongly at each time point both for anxiety (r = 0.88) and depression (r = 0.93), with few discrepant values on a Bland and Altman plot. DASS performs as consistently as HADS in screening for anxiety and depression, and its psychometric properties support its use in an intensive care setting.

Suitability of various turfgrass species and cultivars for development and survival of black cutworm (Lepidoptera: Noctuidae).

Black cutworm, Agrotis ipsilon (Hufnagel) (Lepidoptera: Noctuidae), feeding bioassays were conducted on young and mature turfgrass species to determine their potential resistance. Measures of resistance included larval weight, survival rate, instar development, pupal weight, duration of pupation, and days to pupation and adult emergence. Black cutworm reared on Poa pratensis 'Midnight', Poa arachnigera 'Tejas', and Poa pratensis X Poa arachnigera 'Reveille' exhibited slower development, lower weight, and higher overall mortality than those fed upon other turfgrasses tested. Larvae reared on Reveille did not survive to pupation and all died within 14 d. Black cutworm larvae reared on Midnight died within 17 d in trial 1 but attained pupation in trial 2. However, development of black cutworm larvae was slower on Poa pratensis Midnight compared with other susceptible turfgrass species such as Agrostis stolonifera 'Penncross', Poa annua ('DW194', 'Q98-4-6', and 'Q98-6-18'), Lolium perenne, and Poa supina 'Supranova'. Generally, larval performance on young plant tissues was better than on mature plant tissues. Larvae reared on P. pratensis 'Midnight' exhibited the most distinctive difference on young versus mature plant tissue. These results suggest that plant age may play an important role in turfgrass susceptibility and resistance.

Prolonged cognitive dysfunction in survivors of critical illness.

A prospective study using neuropsychological testing explored cognitive performance, and specifically executive function, in survivors of critical illness during the first year of recovery. Fifty-one patients who had survived 3 days or more in the intensive care unit were studied approximately 3 months after discharge; 45 of them were studied again 6 months later. General health was assessed using the Short-Form 36. Cognitive and executive functions were measured using Raven's Progressive Matrices, the Hayling Sentence completion test and the Six-Element Test. Three months after discharge from intensive care, all eight domains of Short-Form 36 were impaired among survivors; by 9 months, four of the eight domains showed significant improvement. At 3 months, 35% of patients scored at or below a level equivalent to the lowest performing 5% of a normal population (i.e. the fifth percentile) on two or more tests of cognitive function; by 9 months only 4% of patients were impaired to this extent. Although cognitive performance improved with time, it remained below normal.

Comparison of sticky wing and cone pheromone traps for monitoring seasonal abundance of black cutworm adults and larvae on golf courses.

Black cutworm, Agrotis ipsilon (Hufnagel) (Lepidoptera: Noctuidae), flight activity was monitored on three golf courses in Wisconsin by using two types of pheromone traps: the Texas cone trap and sticky wing trap. The Texas cone trap caught significantly more black cutworm males compared with the sticky wing trap, capturing almost 12-fold more males. Black cutworm males were most abundant during mid-July in 2001 and 2002, between 700 and 800 cumulative degree-days. Flight activity also was detected in early May and mid-August, but these peaks were not as pronounced as in mid-July. No definitive relationship between black cutworm flight activity and subsequent larval infestations on golf course putting greens occurred.

Preoperative staging and evaluation of resectability in pancreatic ductal adenocarcinoma.

BACKGROUND: Cancer of the pancreas is a common disease, but the large majority of patients have tumours that are irresectable at the time of diagnosis. Moreover, patients whose tumours are clearly beyond surgical cure are best treated non-operatively, if possible, by relief of biliary obstruction and percutaneous biopsy to confirm the diagnosis and then consideration of oncological treatment, notably chemotherapy. These facts underline the importance of a standard protocol for the preoperative determination of operability (is it worth operating?) and resectability (is there a chance that the tumour can be removed?). Recent years have seen the advent of many new techniques, both radiological and endoscopic, for the diagnosis and staging of pancreatic cancer. It would be impracticable in time and cost to submit every patient to every test. This review will evaluate the available techniques and offer a possible algorithm for use in routine clinical practice. DISCUSSION: In deciding whether to operate with a view to resecting a pancreatic cancer, the surgeon must take into account factors related to the patient, the tumour and the institution and team entrusted with the patient's care. Patient-related factors include age, general health, pain and the presence or absence of malnutrition and an acute phase inflammatory response. Tumour-related factors include tumour size and evidence of spread, whether to adjacent organs (notably major blood vessels) or further afield. Hospital-related factors chiefly concern the volume of pancreatic cancer treated and thus the experience of the whole team. Determination of resectability is heavily dependent upon detailed imaging. Nowadays conventional ultrasonography can be supplemented by endoscopic, laparoscopic and intra-operative techniques. Computed tomography (CT) remains the single most useful staging modality, but MRI continues to improve. PET scanning may demonstrate unsuspected metastases and likewise laparoscopy. Diagnostic cholangiography can be performed more easily by MR techniques than by endoscopy, but ERCP is still valuable for preoperative biliary decompression in appropriate patients. The role of angiography has declined. Percutaneous biopsy and peritoneal cytology are not usually required in patients with an apparently resectable tumour. The prognostic value of tumour marker levels and bone marrow biopsy is yet to be established. Preoperative chemotherapy or chemoradiation may have a role in down-staging an irresectable tumour sufficiently to render it resectable. Selective use of diagnostic laparoscopy staging is potentially helpful in determination of resectability. Laparotomy remains the definitive method for determining the resectability of pancreatic cancer, with or without portal vein resection, and should be undertaken in suitable patients without clear-cut evidence of irresectability.

Decline in admission rates for acute appendicitis in England.

BACKGROUND: The incidence of acute appendicitis declined in western countries between the 1930s and the early 1990s. The aim of this study was to determine time trends in hospital admissions for acute appendicitis in England between 1989-1990 and 1999-2000, and in population mortality rates for appendicitis from 1979 to 1999. METHODS: : Hospital Episode Statistics for admissions were obtained from the Department of Health and mortality data from the Office for National Statistics. RESULTS: Between 1989-1990 and 1999-2000, age-standardized hospital admission rates for acute appendicitis decreased by 12.5 per cent in male patients and by 18.8 per cent in female patients. The proportions of admissions that resulted in operation remained stable. Admission rates for non-specific mesenteric lymphadenitis fell. Admission rates for abdominal pain increased between 1989-1990 and 1995-1996, at which time the International Classification of Diseases codes changed. Between 1995-1996 and 1999-2000, admission rates for abdominal pain declined. Analysis of age-specific admission rates for acute appendicitis and abdominal pain from 1989-1990 to 1995-1996 showed that the decline in acute appendicitis could not be accounted for by a change in diagnostic practice. Mortality rates for acute appendicitis remained stable over the study period. CONCLUSION: Admission rates for acute appendicitis declined over the study period. This decline cannot be explained by reclassification.

Gallstones--an increasing problem: a study of hospital admissions in England between 1989/1990 and 1999/2000.

BACKGROUND: The number of operations for cholelithiasis increased from the 1950s to the 1990s. AIMS: To determine the time trends in cholelithiasis for hospital admissions, operations and in-hospital case fatalities in England between 1989/1990 and 1999/2000, and population mortality rates between 1979 and 1999. METHODS: Hospital Episode Statistics for admissions were obtained from the Department of Health and mortality data were obtained from the Office for National Statistics. RESULTS: Between 1989/1990 and 1999/2000, age-standardized hospital admission rates for cholelithiasis increased by 30% for males and 64% for females. The proportions of admissions undergoing an operation declined progressively over the study period. In 1999/2000, the frequency of operation was approximately 50-60% for most age groups, but decreased progressively with advancing age at > or = 65 years. The proportions of admissions undergoing therapeutic endoscopy increased several-fold, especially amongst older individuals. Case fatality rates declined. Mortality rates declined from 1979 to 1988, but showed no further change from 1989 to 1999. CONCLUSIONS: There has been a steady increase in admission rates for cholelithiasis over the study period. Whilst the frequency of operation has declined, the proportion of patients undergoing therapeutic endoscopy has increased.

Resection of renal metastases to the pancreas: a surgical challenge.

BACKGROUND: Metastasis to the pancreas from renal cell carcinoma (RCC) is distinctly uncommon. Most cases are detected at an advanced stage of the disease and are thus unsuitable for resection. A solitary RCC metastasis to the head of pancreas is rarely encountered and, although it is potentially amenable to surgical resection, surgeons may be hesitant to perform pancreatoduodenectomy. CASES OUTLINES: Two patients with a solitary RCC metastasis to the head of pancreas were treated by pancreatoduodenectomy, while a third with multiple RCC metastases declined any treatment. Two of the patients were asymptomatic, and one presented with anaemia and mild abdominal pain. Computed tomography (CT) and angiography were used to exclude other metastases and to assess resectability of the pancreatic tumour. All three patients are still alive, those with resectable disease at 2 years and 9 years and the one with irresectable disease at 4 years. DISCUSSION: Isolated RCC metastasis to the pancreas is a rare event. Patients present either on follow-up imaging or with symptoms such as mild abdominal pain, weight loss, jaundice, anaemia or gastrointestinal bleeding (whether occult or overt). Dynamic spiral CT can visualise the tumour and exclude distant metastasis. Angiography often reveals a highly vascularised tumour and will help to assess resectability. In the absence of widespread disease, pancreatic resection can provide long-term survival in metastatic RCC, although few cases have been reported with lengthy follow-up. The prognosis is better than for pancreatic adenocarcinoma.

Haemosuccus pancreaticus: treatment by arterial embolization.

AIM: Haemosuccus pancreaticus is bleeding into the pancreatic duct from a peripancreatic artery. This condition most commonly follows pseudoaneurysm formation secondary to acute or chronic pancreatitis. It is a rare disorder, challenging in both diagnosis and therapy. We present an eight-year experience of managing these patients using endovascular embolization as the primary therapy. MATERIALS AND METHODS: We retrospectively reviewed the imaging, laboratory results and clinical notes of the five patients who presented to this institution between 1991-1999 with gastrointestinal bleeding subsequently found to be haemosuccus pancreaticus. RESULTS: There were four men and one women aged 38-75 years. All had a history of gastrointestinal haemorrhage and had acute (n=1) or chronic pancreatitis with a complicating pseudoaneurysm. All underwent embolization as the primary therapy for the pseudoaneurysm. There was immediate technical success in all cases without major complication. No patient required operative surgery for the pseudoaneurysm. Follow-up ranged from 18 months to 7 years. One patient died four years after embolization due to hepatic failure but the other four remain well without further gastrointestinal bleeding. CONCLUSION: Endovascular embolization is an effective and safe treatment for haemosuccus pancreaticus.

Acute and chronic pancreatitis--diseases on the rise: a study of hospital admissions in England 1989/90-1999/2000.

BACKGROUND: The number of hospital admissions for acute and chronic pancreatitis increased in Britain from the 1960s to the 1980s. AIMS: To determine time trends in acute and chronic pancreatitis for hospital admissions from 1989/90 to 1999/2000, mortality from 1979 to 1999, and various indices of alcohol consumption. METHODS: Hospital Episode Statistics for admissions were obtained from the Department of Health and mortality data from the Office for National Statistics. Alcohol consumption data were obtained from the General Household Survey. RESULTS: Between 1989/90 and 1999/2000, age-standardized hospital admission rates for acute pancreatitis increased by 43%, whilst those for chronic pancreatitis rose by 100%. The proportions of admissions requiring surgical operations increased for acute pancreatitis, but declined for chronic pancreatitis. Case fatality rates for acute pancreatitis declined, but mortality statistics showed no significant change. The proportion of women who drank more than 14 units of alcohol a week also increased. CONCLUSIONS: There has been a steady increase in admission rates for both acute and chronic pancreatitis over the study period, and these conditions will become an increasingly important part of the workload of the gastroenterologist.

Expression of inducible nitric oxide synthase contributes to the development of pancreatitis following pancreatic ischaemia and reperfusion.

BACKGROUND: Inducible nitric oxide synthase (iNOS) activity is increased in experimentally induced acute pancreatitis. Increased expression of this isoform of nitric oxide synthase has been demonstrated in several organs subjected to ischaemia-reperfusion injury. The present experiment investigated the expression of iNOS and the effect of selective iNOS inhibition in pancreatic ischaemia-reperfusion. METHODS: Wistar rats (n = 40) were randomly and equally assigned to four groups. Groups 2 and 4 underwent 60 min of total pancreatic ischaemia followed by 6 h of reperfusion (I-R). Groups 1 and 3 underwent sham operation. The selective iNOS inhibitor L-N(6)-(1-iminoethyl)-lysine (L-NIL) was administered to groups 3 and 4. Expression of iNOS was examined by immunohistochemistry. Other investigations included measurement of serum amylase activity and pancreatic wet : dry weight ratio, and histopathological examination. RESULTS: Eight of ten rats in group 2 (I-R only) expressed iNOS but none of the ten animals in group 1 (sham laparotomy) did so. Group 4 (I-R + L-NIL) animals had significantly lower serum amylase levels and wet : dry weight ratios than those in group 2 (I-R only). Microscopic evidence of pancreatic injury was present only in rats in group 2 (I-R only). CONCLUSION: Expression of iNOS during reperfusion following pancreatic ischaemia contributes significantly to the development of acute pancreatitis.