Day: 02/12/2011

Tumour cryoablation combined with palliative bypass surgery in the treatment of unresectable pancreatic cancer

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Although cryosurgery has been proved to be an effective treatment to extend the survival time of unresectable liver cancer patients and improve their quality of life, few surgeons actually treat unresectable pancreatic cancer with this method because of its safety risks. This study aims to evaluate the safety and efficacy of cryosurgical ablation in the treatment for unresectable pancreatic cancer.

Methods A retrospective study was conducted on 142 patients who underwent palliative bypass with cryoablation (PBC group: 68) or without cryoablation (PB group: 74) for unresectable pancreatic cancer from 1995 to 2002. The morbidity and 5 year survival rates of the two groups were compared. Carbohydrate antigen 19–9 (CA19-9) level and tumour size were evaluated in PBC group.

Results There was no significant difference in the rate of overall complications between the two groups (p=0.809), except for a higher delayed gastric emptying rate observed in the PBC group (36.8% vs 16.2%, p=0.005). In the PBC group, the median preoperative CA19-9 concentration decreased from 690 U/ml to 56 U/ml (p=0.000). CT scan results of 55 patients indicated that tumour mass shrinkage occurred in 36 of them, from 4.3 cm to 2.4 cm (pre-ablation to 3 months after ablation). Kaplan–Meier analysis showed no significant difference in 5 year survival rates between the two groups (p=0.124).

Conclusions Cryosurgery combined with palliative bypass surgery can be considered a safe and effective treatment for unresectable pancreatic cancer. Though this technique remains only palliative, it may be further employed to improve advanced stage pancreatic cancer.

source:BMJ

Spectrum of tardive syndromes: clinical recognition and management

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Tardive syndrome (TS) refers to a group of delayed onset disorders characterised by abnormal movements and caused by dopamine receptor blocking agents (DRBAs). Classical tardive dyskinesia is a specific type of oro-buccal-lingual dyskinesia. However, TS may exist in other forms—for example, stereotypy, dystonia, and akathisia—and frequently occur in combination. The onset typically is insidious and after reaching its maximum severity it often stabilises. Frequently reported risk factors are age, dose and duration of neuroleptic exposure, the use of conventional DRBAs, and co-existing mood disorders. This review highlights the broad spectrum of TS, not limited to classical tardive dyskinesia, as well as the clues for its recognition. Despite challenges in the treatment of TS, dictated by the different phenomenology, severity of TS and the need for ongoing neuroleptic treatment, the authors provide evidence based recommendations for patient management, which is not restricted to only withdrawal of the offending neuroleptics or the selection of an alternative medication, such as clozapine. In a minority of cases with significant functional disability, symptomatic or suppressive treatments should be considered. Recently, there has been a resurgence of stereotactic pallidal surgery for the treatment of TS. Although the efficacy of both pallidotomy and pallidal deep brain stimulation in dystonia has been encouraging, the evidence is still limited.

source: BMJ

Deep brain stimulation of the subthalamic nucleus improves temperature sensation in patients with Parkinson’s disease

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Patients with Parkinson’s disease (PD) reportedly show deficits in sensory processing in addition to motor symptoms. However, little is known about the effects of bilateral deep brain stimulation of the subthalamic nucleus (STN-DBS) on temperature sensation as measured by quantitative sensory testing (QST). This study was designed to quantitatively evaluate the effects of STN-DBS on temperature sensation and pain in PD patients. We conducted a QST study comparing the effects of STN-DBS on cold sense thresholds (CSTs) and warm sense thresholds (WSTs) as well as on cold-induced and heat-induced pain thresholds (CPT and HPT) in 17 PD patients and 14 healthy control subjects. The CSTs and WSTs of patients were significantly smaller during the DBS-on mode when compared with the DBS-off mode (P < .001), whereas the CSTs and WSTs of patients in the DBS-off mode were significantly greater than those of healthy control subjects (P < .02). The CPTs and HPTs in PD patients were significantly larger on the more affected side than on the less affected side (P < .02). Because elevations in thermal sense and pain thresholds of QST are reportedly almost compatible with decreases in sensation, our findings confirm that temperature sensations may be disturbed in PD patients when compared with healthy persons and that STN-DBS can be used to improve temperature sensation in these patients. The mechanisms underlying our findings are not well understood, but improvement in temperature sensation appears to be a sign of modulation of disease-related brain network abnormalities.

source: science direct

The menacing phantom: What pulls the trigger? the phantom pain syndrome

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Phantom phenomena are frequent following amputation, but how this often painful experience is modified or triggered by spontaneous events or sensations often puzzles amputees and clinicians alike. We explored triggers of phantom phenomena in a heterogeneous sample of 264 upper and lower limb adult amputees with phantom sensations. Participants completed a structured questionnaire to determine the prevalence and nature of the triggers of phantom phenomena. The four categories of triggers identified include: (a) a quarter of participants experiencing psychological, emotional or autonomic triggers; (b) half experiencing behavioral triggers, “forgetting” the limb’s absence and attempting to use the phantom; (c) one-fifth experiencing weather-induced triggers; and (d) one-third experiencing sensations referred from parts of the body. Upper limb amputees; and were more likely to experience weather-induced phantom phenomena than lower limb amputees; and upper and lower limb amputees were equally likely to experience referred sensations from the genitals, contradicting the homuncular remapping hypothesis. Traumatic amputees were more likely to report emotional triggers. Further, while those with emotional triggers exhibited poorer acceptance of the limitations of amputation, they were more likely to employ adaptive coping mechanisms. Finally, habitual “forgetting” behaviors were most common soon after amputation, whereas other more adaptive schemata (e.g., self-defense) were equally likely to be performed at any time following amputation. Various likely inter-related mechanisms are discussed in relation to phantom triggers. Ultimately, optimizing stump and neuroma management, as well as restoring function of central networks for pain, limb movement, and amputation-related memories, should help manage spontaneously triggered phantom phenomena.

source: science direct

Capnography for Monitoring Patients Outside of the Operating Room

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Over the past two decades, continuous monitoring of end tidal carbon dioxide (etCO2) using capnography has become the American Society of Anesthesiologists (ASA) standard of care for continuous ventilation monitoring in patients undergoing general anesthesia in hospital operating rooms. In this setting, a review of a closed claims database concluded that capnography along with pulse oximetry monitoring could have prevented 93% of adverse respiratory events.1

Conventional capnography technology is associated with a number of drawbacks that have traditionally limited its use to the operating room. The development of innovative technology has made bedside capnography possible, and it is now rapidly becoming the standard of care for ventilation monitoring of non-intubated patients. Outside of the operating room, capnography addresses the specific needs of patients who are not intubated, who may alternate mouth/nose breathing, and who may be receiving supplemental oxygen. Growth in the use of capnography outside of the operating room can be attributed to increased attention to respiratory risk associated with opioid pain control therapy, as well as a growing recognition of the safety advantages of capnography for ventilation monitoring of patients receiving deep or moderate sedation.2

Capnography provides continuous, real-time, non-invasive measurement of etCO2, producing a waveform, or capnogram, that indicates changes in CO2 concentration throughout respiration. This enables measurement of the quality of breathing and exchange of O2 and CO2 during the respiratory cycle, beyond what is provided by pulse oximetry.

Accumulating evidence demonstrates that capnography is more accurate than traditional methods – pulse oximetry and visual inspection – for detecting alveolar hypoventilation and preventing hypoxemia during procedural sedation and patient-controlled analgesia (PCA).8,10,17,18,21,22

The best measure of adequate ventilation is the carbon dioxide tension of an arterial blood sample, which would not be practical due to the invasive nature of arterial blood sampling and the need for frequent sampling. However, the tension of carbon dioxide in expired gas, particularly at the end of a tidal expiration, closely approximates the tension in arterial blood. While normal PaCO2 is ~40 mm Hg, normal etCO2 is ~35–38 mm Hg.

source: smart capnography

Is Diet Soda Linked to Heart, Stroke Risk?

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Study Suggests Connection Between Drinking Diet Soda and Risk of Heart Attack and Stroke
soda being poured into glass

Feb. 9, 2011 (Los Angeles) — You may feel less guilty if you opt for diet sodas over sugary beverages, but drinking them regularly may raise your risk of heart attack and stroke, a study suggests.

In a nine-year study of more than 2,500 people, those who drank diet soda daily were 48% more likely to have a heart attack or stroke or die from those events, compared with those who rarely or never drank soda.

There was no increased risk of cardiovascular disorders among daily drinkers of regular soda, says study researcher Hannah Gardener, ScD, an epidemiologist at the University of Miami Miller School of Medicine.

The analysis, presented at the American Stroke Association International Stroke Conference (ISC), took into account a host of cardiovascular risk factors including age, sex, smoking, physical activity, alcohol and calorie consumption, metabolic syndrome, and pre-existing heart disease.

Still, the study doesn’t prove cause and effect. And even though the researchers tried to account for risk factors that that could skew the results, they couldn’t tease out everything, doctors caution.

“You try to control for everything, but you can’t,” says Steven Greenberg, MD, PhD, vice chair of the ISC meeting committee and professor of neurology at Harvard Medical School.

People who drink a lot of diet soda may share some characteristic that explains the association, he explains.

Missing Variables

Maureen Storey, PhD, senior vice president of science policy for the American Beverage Association, says that the researchers failed to control for two important variables — family history of stroke and weight gain — that affect stroke risk.

Even Gardener says it’s too early to tell people to skip soda based on this study alone. “But if confirmed, diet drinks may not be an optimal substitute for sugar-sweetened beverages.”

The new study involved 2,564 people in the Northern Manhattan Study, with an average age of 69. About two-thirds of the participants were women, 21% were white, 24% African-American, and 53% Hispanic.

At the start of the study, people were asked to fill out a questionnaire that asked what foods and beverages they consumed and how often they consumed them.

They were also asked about their exercise routine, as well as whether they smoked or drank alcohol. The participants also had physical checkups.

Of the total, 901 said they never drank soda or drank it less than once a month, 282 said they drank at least one regular soda daily, and 116 reported they drank at least one diet soda daily.

Over the next nine years, 212 of them had strokes, 149 had a heart attack, and 338 died from vascular disease.

Study Drawbacks

One drawback of the study is that participants were only asked about their soda habits at one time point; they could have changed over the study period, Gardener says. Also, there was no information on the types of soft drinks drunk, she says, pointing out that variations among brands, coloring, and sweeteners could have affected the results.

Philip B. Gorelick, MD, MPH, head of neurology and stoke research at the University of Illinois in Chicago, says the food questionnaire used in the study isn’t a good way to gauge people’s overall dietary patterns.

“You have to look at what people eat in totality,” he tells WebMD. “People who are reducing calories by drinking diet soda may have an unhealthy dietary pattern, consuming a lot of fat and salt, for example. And that won’t be picked up using a questionnaire like the one used here.”

Storey says there is no diet soda-heart and stroke connection. “There is no scientific evidence to support the idea that diet soda uniquely causes increased risk of vascular events or stroke,” she says in a written statement. “The body of scientific evidence does show that diet soft drinks can be a useful weight management tool, a position supported by the American Dietetic Association. Thus, to suggest that they are harmful with no credible evidence does a disservice to those trying to lose weight or maintain a healthy weight.”

As for why diet soda might be bad for our hearts and brains, Gardener says that’s still a big question mark.

Previous research linking regular and diet soda to diabetes and metabolic syndrome, both of which are risk factors for stroke and heart attacks, may offer a clue, she says.

source: web MD

Tests for Wilson Disease in Asymptomatic Children

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Measuring serum ceruloplasmin concentration was confirmed as an adequate initial diagnostic test.

Wilson disease (WD) is a rare autosomal recessive disorder of copper metabolism that can lead to liver disease and adverse effects on kidneys, bones, and the nervous system. Early diagnosis and treatment can prevent substantial morbidity but can be challenging, particularly in children.

To evaluate the performance of conventional tests and a recently proposed scoring system for diagnosing WD (Liver Int 2003; 23:139), researchers in Italy studied asymptomatic children with WD — confirmed by an abnormal liver copper concentration plus the identification of two disease-causing mutations or homozygosity for a single disease-causing mutation (the gold standard for diagnosing WD). The diagnostic tests that were assessed measured serum ceruloplasmin level, basal 24-hour urinary copper level, and 24-hour urinary copper level after the penicillamine challenge test (PCT). The WD scoring system measured serum ceruloplasmin level, liver copper level (Rhodanine stain if copper level test was not performed), and 24-hour urinary copper level. Receiver operating characteristic (ROC) analysis measured the sensitivity and specificity of each test at different cutoff values.

Researchers enrolled 40 patients with WD (median age, 6.1 years; 26 males and 14 females) and 58 sex- and age-matched controls with liver disease other than WD. For the serum ceruloplasmin test, a cutoff value of 20 mg/dL achieved sensitivity of 95.0% and specificity of 84.5%. For the basal urinary copper test, a cutoff value of 40 µg/24 hours achieved sensitivity of 78.9% and specificity of 87.9%. The 24-hour urinary copper test after PCT demonstrated poor performance. The WD scoring system had positive and negative predictive values of 93.0% and 91.6%, respectively.

Comment: These findings confirm that serum ceruloplasmin level (<20 mg/dL) is adequate as an initial diagnostic test for WD in children with asymptomatic disease. The 24-hour urine copper test is not as good, and the 24-hour urinary copper test after PCT is poor. The WD scoring system has excellent diagnostic characteristics but requires a liver biopsy. Therefore, clinicians should be confident about using serum ceruloplasmin level as the initial test. If the level is normal, then no further work-up is required. However, if the level is low, clinicians should proceed with a liver biopsy and employ the WD scoring system.

— Atif Zaman, MD, MPH

Published in Journal Watch Gastroenterology February 11, 2011