Post-Pancreatoduodenectomy Outcomes and Epidural Analgesia: A 5-Year Single Institution Experience

Introduction Optimal pain control post-pancreatoduodenectomy is a challenge. Epidural analgesia (EDA) is increasingly utilized despite inherent risks and unclear effects on outcomes. Methods All pancreatoduodenectomies (PD) performed from 1/2013-12/2017 were included. Clinical parameters were obtained from retrospective review of a prospective clinical database, the ACS NSQIP prospective institutional database and medical record review. Chi-Square/Fisher’s Exact and Independent-Samples t-Tests were used for univariable analyses; multivariable regression (MVR) was performed. Results 671 consecutive PD from a single institution were included (429 EDA, 242 non-EDA). On univariable analysis, EDA patients experienced significantly less wound disruption (0.2% vs. 2.1%), unplanned intubation (3.0% vs. 7.9%), pulmonary embolism (0.5% vs. 2.5%), mechanical-ventilation >48hrs (2.1% vs. 7.9%), septic shock (2.6% vs. 5.8%), and lower pain scores. On MVR accounting for baseline group differences (gender, hypertension, pre-operative transfusion, labs, approach, pancreatic duct size), EDA was associated with less superficial wound infections (OR 0.34; CI 0.14-0.83; P=0.017), unplanned intubations (OR 0.36; CI 0.14-0.88; P=0.024), mechanical ventilation >48 hrs (OR 0.22; CI 0.08-0.62; P=0.004), and septic shock (OR 0.39; CI 0.15-1.00; P=0.050). EDA improved pain scores post-PD days 1-3 (P<0.001). No differences were seen in cardiac or renal complications; pancreatic fistula (B+C) or delayed gastric emptying; 30/90-day mortality; length of stay, readmission, discharge destination, or unplanned reoperation. Conclusion Based on the largest single institution series published to date, our data support the use of EDA for optimization of pain control. More importantly, our data document that EDA significantly improved infectious and pulmonary complications

Less Is Not More: Evidence of Mere Proximity in \u3ci\u3eState v. Gurske\u3c/i\u3e Does Not Render the Defendant Armed under Washington\u27s Deadly Weapon Special Verdict Statute

In State v. Gurske, Division III of the Washington State Court of Appeals affirmed the application of Washington State\u27s Deadly Weapon Special Verdict statute to Samuel Gurske\u27s conviction for possession of methamphetamine. The Deadly Weapon Special Verdict statute enhances the sentence of a defendant who commits a crime while armed with a deadly weapon. In Gurske, the parties stipulated that a backpack holding Gurske\u27s pistol and drugs lay within arm\u27s reach of the driver\u27s position. From this fact, the trial judge determined that Gurske was armed while he was in possession of methamphetamine. Under Washington State Supreme Court precedent, however, a court must apply two tests in constructive possession cases like Gurske to determine whether the defendant is armed. First, the weapon must be easily accessible and readily available for use (the easily accessible test). Second, there must be a nexus between the weapon and the defendant (weapon-defendant nexus) and between the weapon and the crime (weapon-crime nexus). The Gurske court determined that Gurske\u27s proximity to the weapon satisfied the easily accessible test. Again relying on the proximity between the defendant, the weapon, and the drugs, the Gurske court determined that proximity also satisfied the nexus test. Although proximity may satisfy the easily accessible test and the weapon-defendant nexus, a plurality of the Washington State Supreme Court in State v. Schelin explicitly required more than proximity to satisfy the weapon-crime nexus. According to Schelin, courts should consider three factors: the nature of the crime, the type of weapon, and the circumstances under which police discovered the weapon. These three factors identify evidence that may permit an inference that a defendant used a weapon in furtherance of the commission of a crime. Assuming that the State also presented evidence satisfying the easily accessible test and the weapon-defendant nexus, the addition of this inference establishes a defendant as armed. In light of the three Schelin factors, the Gurske evidence does not support the inference that Gurske used the weapon in furtherance of his drug crime. The trial judge, therefore, mistakenly found a weapon-crime nexus, and Division III erroneously affirmed the trial judge\u27s application of the sentence enhancement. On appeal, the Washington State Supreme Court should reverse the application of the Deadly Weapon Special Verdict statute to Gurske\u27s conviction for possession of methamphetamine

Effect of diet on aerobic performance

The purpose of this investigation will beto examine the effect of diet on aerobic performance in adult male runners. On their assigned diets the subjects will be tested twice for the maximal distance covered while running 30 minutes on two non-consecutive days

Effect of Diet on Aerobic Performance

Aerobic performance is affected by a number of physiological, psychological, sociological and environmental factors (Astrand, 1977). Among the many physiological factors nutrition plays an important part. However, when considering what constitutes a balanced diet, nutritionists express varying opinions as to what percentage of protein, fat and carbohydrate should be included for the general populace and the athlete. Mayer and Bullen (1960) in their review of literature on nutrition and athletic performance concluded a balanced diet is adequate for the athlete

The influence of genotype on warfarin maintenance dose predictions produced using a Bayesian dose individualization tool

Background A previously established Bayesian dosing tool for warfarin was found to produce biased maintenance dose predictions. In the following study, we aimed to (1) determine if the biased warfarin dose predictions previously observed could be replicated in a new cohort of patients from two different clinical settings, (2) explore the influence of CYP2C9 and VKORC1 genotype on the predictive performance of the Bayesian dosing tool, and (3) determine if the prior population used to develop the kinetic-pharmacodynamic (KPD) model underpinning the Bayesian dosing tool was sufficiently different from the test (posterior) population to account for the biased dose predictions. Methods The warfarin maintenance doses for 140 patients were predicted using the dosing tool and compared to the observed maintenance dose. The impact of genotype was assessed by predicting maintenance doses with prior parameter values known to be altered by genetic variability (e.g., EC50 for VKORC1 genotype). The prior population was evaluated by fitting the published kinetic-pharmacodynamic model, which underpins the Bayesian tool, to the observed data using NONMEM and comparing the model parameter estimates to published values. Results The Bayesian tool produced positively biased dose predictions in the new cohort of patients (mean prediction error [95% CI]; 0.32 mg/day [0.14, 0.5]). The bias was only observed in patients requiring ≥7 mg/day. The direction and magnitude of the observed bias was not influenced by genotype. The prior model provided a good fit to our data, suggesting that the bias was not caused by different prior and posterior populations. Conclusions Maintenance doses for patients requiring ≥7 mg/day were overpredicted. The bias was not due to the influence of genotype nor was it related to differences between the prior and posterior populations. There is a need for a more mechanistic model that captures warfarin dose–response relationship at higher warfarin dose

Accumulation of p53 protein in normal, dysplastic, and neoplastic Barrett's oesophagus

Accumulation of p53 protein was determined by immunohistochemisty in archival material of biopsy specimens from 102 patients with Barrett's oesophagus with different grades of dysplasia, in 24 oesophageal adenocarcinomas associated with Barrett's oesophagus, and in 23 cases of metaplatic epithelium adjacent to these carcinomas. Immunostaining for the p53 protein was found in 23/102 (23 per cent) cases of the Barrett's oesophagus biopsies and in 12/23 (52 per cent) cases of Barrett's oesophagus adjacent to adenocarcinoma. Significant correlations were found between the grade of dysplasia and p53 immunoreactivity in both Barrett's biopsies without adenocarcinoma (P<0.001) and Barrett's oesophagus adjacent to adenocarcinoma (P<0.05). In the adenocarcinomas, intense nuclear immunohistochemical staining for p53 was diffusely or focally present in 20/24 (83 per cent) of the specimens. In Barrett's oesophagus, p53 is a progression marker with high expression in high-grade dysplasia (89 per cent) and adenocarcinoma (83 per cent)

H. A. Fennerty, O. T. Harrington to Mississippi Alpha Phi Delta Theta Fraternity, 25 September 1962

Fraternity members in Louisiana urge the Mississipi chapter to rush James Meredith. They cite several reasons and feel [he] will be compatible with members of Mississippi Alpha whom [they] have met.https://egrove.olemiss.edu/west_union_um/1059/thumbnail.jp

Rapid Development of Intestinal Type Gastric Adenocarcinoma

Intestinal type gastric adenocarcinoma is felt to develop over a protracted time period through a series of defined steps. Several potential risk factors for the development of gastric cancer have been identified, including a family history of gastric cancer and Helicobacter pylori infection. We present the case of a patient with neither risk factor who progressed in a 14 month time frame from histologically normal gastric mucosa to early stage intestinal type gastric adenocarcinoma in the setting of diffuse gastric intestinal metaplasia and atrophic gastritis. This patient's presentation conflicts with our current understanding of the development of intestinal type gastric adenocarcinoma

Tissue Staining (Chromoscopy) of the Gastrointestinal Tract

Tissue staining, or chomoscopy, is used as an adjunctive technique during gastrointestinal endoscopy. Chemical agents are applied to the gastrointestinal mucosal surface to identify specific epithelia or to enhance the mucosal surface characteristics of the gastrointestinal epithelium. This aids in the recognition of subtle lesions (ie, polyps) or allows directed targeting of biopsies (ie, sprue or Barrett’s esophagus) to increase the yield of endoscopic diagnostic accuracy. The four endoscopic tissue-staining techniques in use are vital staining, contrast staining (chromoscopy), reactive staining and tattooing. Some of the agents used for endoscopic tissue staining and the uses of chromoscopy in identifying pathology of the esophagus, stomach, small bowel and colon during endoscopy are discussed

Evaluation of invasive and non-invasive methods for the diagnosis of Helicobacter pylori infection in symptomatic children and adolescents

CONTEXT: Multiple diagnostic methods are available for the detection of Helicobacter pylori infection, but at present no single one can be used as the gold standard. OBJECTIVE: The aim of this study was to evaluate the diagnostic accuracy of 3 invasive and 2 non-invasive methods for detection of Helicobacter pylori infection in symptomatic children and adolescents. DESIGN: Prospective cohort study SETTING: Peptic Disease outpatients service, Discipline of Pediatric Gastroenterology, Universidade Federal de São Paulo (UNIFESP) / Escola Paulista de Medicina. PATIENTS: Forty-seven patients who underwent endoscopy because of dyspeptic symptoms. DIAGNOSTIC METHODS: Endoscopy with gastric biopsies for 3 invasive (rapid urease test, histology and culture) and 2 non-invasive methods (a commercial ELISA serology and 13carbon urea breath test - isotope ratio mass spectrometry) for detection of Helicobacter pylori infection. MAIN MEASUREMENTS: Sensitivity, specificity, positive and negative predictive values of each method and agreement and disagreement rates between the methods. RESULTS: Forty-seven patients [mean age, 11y9mo (SD 2y10mo), 27 female and 20 male]; 62% of them were Helicobacter pylori-positive. All methods agreed in 61%, and were negative in 21% and positive in 40%. The greatest concordance between 2 methods occurred between the invasive methods: histology and rapid urease test (89.6%) and histology and culture (87.5%). The greatest sensitivity, considering Helicobacter pylori-positive cases, for any combination of 3 or more tests, was achieved by the rapid urease test (S=100%), followed by histology, serology and 13carbon-urea breath test (S=93.1%) and lastly by culture (S=79.3%). The highest specificity was obtained by histology (100%) and culture (100%), followed by the rapid urease test (84.2%), serology (78.9%) and 13carbon-urea breath test (78.9%). CONCLUSIONS: Our results suggest that among invasive methods, an association between the rapid urease test and histology constituted the best choice for the detection of Helicobacter pylori infection. If results of histology and the rapid urease test are different, serology may be recommended.CONTEXTO: Vários métodos diagnósticos estão disponíveis para a detecção da infecção por Helicobacter pylori (Hp), porém, até o presente momento, não há um teste que possa ser utilizado isoladamente como padrão-ouro. OBJETIVO: Avaliar a acurácia de três métodos invasivos e dois não-invasivos na detecção da infecção por Hp em crianças e adolescentes sintomáticos. TIPO DE ESTUDO: Estudo coorte prospectivo. LOCAL: Ambulatório de Doença Péptica, Disciplina de Gastroenterologia Pediátrica, Universidade Federal de São Paulo (UNIFESP) / Escola Paulista de Medicina. PACIENTES: 47 pacientes sintomáticos que realizaram exame endoscópico devido a sintomas dispépticos. MÉTODOS DIAGNÓSTICOS: Exame endoscópico com biopsias gástricas para três métodos invasivos (teste rápido da urease, histologia e cultura) e dois métodos não-invasivos (teste sorológico ELISA industrializado e teste respiratório com uréia marcada com Carbono13). VARIÁVEIS ESTUDADAS: Sensibilidade, especificidade, valor preditivo positivo e negativo de cada método e taxas de concordância e discordância entre os métodos. RESULTADOS: 47 pacientes [idade média de 11a9m (DP 2a10m), 27 do sexo feminino e 20 do masculino], 62% deles com infecção por Hp. Todos os 5 métodos concordaram em 61%, sendo negativo em 21% e positivo em 40%. As maiores concordâncias entre dois métodos ocorreram entre os métodos invasivos: histologia e teste rápido da urease (89,6%) e entre a histologia e cultura (87,5%). A maior sensibilidade, considerando como Hp positivo, qualquer combinação de 3 ou mais testes, foi encontrada no teste rápido da urease (S=100%), seguido pela histologia, sorologia e o teste respiratório com uréia marcada com Carbono13 (S=93,1%) e por fim a cultura (S=79,3%). A maior especificidade foi obtida pela histologia e cultura (100%), seguidos pelo teste rápido da urease (84,2%), sorologia (78,9%) e teste respiratório com uréia marcada com Carbono13 (78,9%). CONCLUSÕES: Nossos resultados sugerem que, entre os métodos invasivos, a associação do teste rápido da urease e histologia constituem a melhor escolha para a detecção da infecção por Hp. Se os resultados da histologia e do teste rápido da urease forem discordantes é recomendada a sorologia.Universidade Federal de São Paulo (UNIFESP) Escola Paulista de Medicina Pediatric DepartmentUNIFESP, EPM, Pediatric DepartmentSciEL