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Between 1954 and 1975, 80 pancreaticojejunostomies were performed on 77 patients for intractable pain of chronic pancreatitis. All patients had a history of chronic alcoholism. Drainage operations done primarily for pseudocysts were excluded. Operative procedures included seven caudal pancreaticojejunostomies, 42 longitudinal pancreaticojejunostomies with splenectomy and implantation of the pancreas into the jejunum, and 31 side-to-side pancreaticojejunostomies. Eighty-one percent of the patients noted substantial improvement or complete resolution of their abdominal pain on follow-up that ranged up to 21 years. The operative mortality was 5%. Thirty-two patients died during the period of the follow-up. Continued alcohol abuse, carcinoma, and cardiovascular disease were the leading causes of mortality. Data from this review confirm the effectiveness of pancreaticojejunostomy in relieving the pain of chronic relapsing pancreatitis.
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PMID:Pancreaticojejunostomy for chronic pancreatitis. Two- to 21-year follow-up. 7 68

Despite the recent publicity given to studies pointing out the negative side effects associated with the use of oral contraceptives, the pill is still the most common form of contraceptive used in Great Britain and constitutes the form of contraception for many women. Some of the negative effects currently receiving wide publicity, no longer represent a serious threat for the pill user; many of these effects have been negated or ameliorated by modifying the composition of the pills. In combined pills the estrogen content has been reduced from 150ug to 20-35ug. In the 2 major studies linking oral contraceptives with the development of cardiovascular disease most of the women in the studied population had taken pills containing 50-100ug of estrogen. Given the wide choice of pills currently available, many of the negative effects, such as nausea and pain, cna be ameliorated by choosing a more appropriate oral contraceptive for the specific patient. Other side effects such as headaches and poor cycle control can be treated by regimen modification. Although there is a relationship between pill use and hypertension, pills containing levonorgestrel in combination with 30ug of ethinyloestradiol have only a slight effect on blood pressure. Lactation is not reduced for women who take progestogen only pills. Fertility is successfully restored in almost all women shortly after they stop using the pill. Drug interaction failures can be avoided in many cases by prescribing pills containing 50ug of estrogen for women taking other drugs. In order to obtain immediate effectiveness, the combined pill can be started on the 1st day of the period instead of waiting until the 5th day.
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PMID:Oral contraception. 57 14

1500 men (aged 30-55 years) volunteered in a trial of early recognition of cardiovascular disease. History and clinical as well as biochemical data were obtained and compared with results of exercise ECGs. In the group as a whole abnormal ECGs were obtained in 6.2%, in a subgroup of those without exercise-dependent pain in the thorax, without hypertension and noraml resting ECG it was 3.8%, while in the presence of one or several of these risk factors it was as high as 17.8%. It is concluded that in any screening programme it is not reasonable to perform exercise ECGs in asymptomatic persons without risk factors, because in this group there is likely to be only a small percentage of abnormal findings and the number of false-positive ones is higher than that or correct positive ones. In connection with the known risk factors and risk indicators it would be best to define the risk group and, using selective indications, to go step-by-step from exercise ECG to additional invasive diagnostic measures such as coronary angiography.
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PMID:[Exercise ECG as a screening test in the early diagnosis of coronary heart disease. Result of a trial study (author's transl)]. 63 17

Surgical management of osteoarthritis, aseptic necrosis and rheumatoid arthritis has been revolutionized by the introduction of acrylic cement-stabilized joint surface replacement. Although single joint surface replacements have been employed extensively for more than half a century, total surface replacement operations with a wear-resistant high-density polyethylene and noncorrosive stainless steel stabilized by acrylic cement were introduced only a little more than 12 years ago. This evolved with Charnley's discovery of the high level of bone tolerance for acrylic cement. Acrylic cement made it possible mechanically to bond artificial joint surfaces to the bone ends and produce an insensitive Charcot-like functioning joint. A barium sulfate additive makes the cement radiopaque for visualizing the bone-cement interface. Barium sulfate additive also lowers the polymerization temperature and opens the polymer for influx of interstitial fluids. Antibiotics have also been added to the cement for prevention and treatment of infection of the surrounding tissues. In aged individuals with cardiovascular disease, the absorption of the acrylic monomer depresses cardiac output and produces hypotension for 2-5 minutes after impaction of acrylic cement into spongy bone. The hypotension has been minimized by cautious fluid replacement and maintenance of adequate blood volume before, during and after the operation. Approximately 30,000 total hip arthroplasties are performed in the United States annually in patients older than 50 years of age with fractured femoral head replacements, bilateral rheumatoid arthritis, old neglected congenital dislocations of the hip or osteonecrosis with and without osteoarthritis. The pain relief is more complete and the functional improvement more predictable than in any other previously recommended surgical operation for the purpose. For this reason, total hip arthroplasty has almost completely supplanted mold-arthroplasty, osteotomy, capsulotomy (hanging hip) and resection of the femoral head. Hemiarthroplasty in the form of femoral head replacement still is the procedure of choice in patients with fractures of the neck of the femur and a normal acetabular articular cartilage, irrespective of age. As a countermeasure against loosening of the prosthesis in patients with osteoporosis and a hollow proximal end of the femur, the stem can be stabilized with acrylic cement. A standard replaceable femoral head for subsequent conversion of femoral head replacement to total hip arthroplasty is an important consideration and presently is under investigation in several medical centers.(ABSTRACT TRUNCATED AT 400 WORDS)
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PMID:Acrylic cement stabilized joint replacements. 80 82

Vascular and neuropathic complications of diabetes are a significant cause of morbidity and mortality. Symmetric polyneuropathy is the most common diabetic neuropathy. Treatment of the mononeuropathies consists of pain control and physical therapy to maintain muscle tone. Prognosis for recovery is excellent. Renal and retinal microangiopathy produce most of the clinically significant mortality and morbidity in diabetes. Recent advances in chronic hemodialysis and renal transplantation have improved the outlook for diabetics with end-stage nephropathy. The poor prognosis for retention of vision in diabetic malignant retinopathy has led to exploration of various forms of palliative therapy, including pituitary ablation, xenon arc coagulation, and laser treatment. Cardiovascular disease is more prevalent among diabetics than among the general population, according to a recent study, and mortality from this cause is three times higher. Animal studies linking aortic wall metabolism and atherosclerotic changes with hyperglycemia suggest that poor control of diabetes may play a role in the development of vascular lesions.
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PMID:Neuropathic and vascular complications occurring in diabetes. 124 35

A 16 year old teenager with chest pain came to the emergency room at Children's Hospital in Charleston, South Carolina. Her sharp, constant midsternal pain and breathing difficulties began the morning of admission. 1 week before admission, she experienced a similar but less intense pain which resolved spontaneously. She was taking low-dose, triphasic oral contraceptives (OCs) as treatment for severe dysmenorrhea and dysfunctional uterine bleeding. She had no family history of elevated lipids, blood or clotting disorders, and cardiovascular disease. She did not smoke. She was obese (137.3 kg). She had elevated blood pressure (147/33 mm Hg), a high low-density lipoprotein count (140 mg/dL), and a high total cholesterol count (237 mg/dL). Her tender right calf was larger than the left calf. She had decreased perfusion of the entire left lung and right lower lobe. A pulmonary angiogram revealed emboli, and ultrasound of the legs revealed a thrombus behind the right knee. The physicians discontinued the OCs. They administered 2 anticoagulants--intravenous heparin followed by oral sodium warfarin for 6 months. Her respiratory distress ended within several days. Her right calf was no longer tender after 1 week. The physicians discharged her on a low-cholesterol, low-fat diet. They suggested she reduce her weight and exercise more often. She did not experience another venous thrombosis or pulmonary embolus. It appeared that the OCs contributed to her thromboembolism; yet, she did lead a sedentary lifestyle and was considerably overweight. Even though thromboembolism is rare in adolescents with no underlying predisposition for cardiovascular disease and who do not smoke, physicians should watch for sizeable changes in blood pressure, lipids, and cholesterol level as well as symptoms of deep venous thrombosis and cardiovascular disease.
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PMID:Pulmonary embolus in an adolescent on oral contraceptives. 129 Jul 74

Patients with primary hyperparathyroidism are often elderly with cardiovascular disease and in some an operation might be hazardous owing to anaesthetic complications. A technique for operation for primary hyperparathyroidism under local anaesthesia is described. The method uses a unilateral approach. Seventeen consecutive patients operated on under local anaesthesia were compared with a group of 15 patients undergoing surgery under general anaesthesia. Normocalcaemia was achieved in 14 patients in each group. There was no difference in the extent of pain or the overall well-being between the two groups as determined by a visual analogue scale. Patients receiving local anaesthesia, however, experienced significantly less nausea after operation (P < 0.01). There was more fluctuation in blood pressure and heart rate in the general anaesthesia group compared with the other group. Surgery for primary hyperparathyroidism can be performed safely under local anaesthesia, and could be offered to patients if general anaesthesia were not suitable or involved an increased perioperative risk. It should not be recommended for routine use in patients who are fit for general anaesthesia.
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PMID:Surgery for primary hyperparathyroidism performed under local anaesthesia. 142 61

The association between medical risk factors and the outcome of foot ulcers was evaluated in 208 consecutive diabetic patients with severe peripheral vascular disease (systolic toe blood pressure < or = 45 mm Hg). All patients were treated and followed by the same foot care team. Eighty patients healed primarily, 83 healed after a minor or major amputation, and 45 died. The systolic toe blood pressure was higher among primary healed (30 +/- 13 mm Hg) compared with amputated (22 +/- 15 mm Hg; p < 0.001) and deceased patients (20 +/- 14 mm Hg; p < 0.001). The patients were comparable regarding age, sex, and diabetes and wound duration. Only 41 (19%) patients had intermitten claudication, whereas 153 (77%) lacked palapble pedal pulses, 36% of whom healed primarily. Rest pain occurred in 72 (33%) patients, 38 (47%) of whom had an amputation and 18 (25%) who healed primarily (p < 0.01). Peripheral edema and proteinuria were more common among patients who healed after amputation compared with those who healed primarily (p < 0.001 and p < 0.01, respectively). Signs of sensory neuropathy were found in 158 (77%) patients. There were no differences concerning cardiovascular disease, smoking habits, or short-term metabolic control between patients who healed primarily or after an amputation. In conclusion, diabetic patients with foot ulcers and severe peripheral vascular disease with low systolic toe blood pressure were not excluded from the possibility of primary healing. The most important risk factors for amputation were a systolic toe pressure of less than 30 mm Hg, peripheral edema, rest pain, and proteinuria.
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PMID:Medical risk factors in diabetic patients with foot ulcers and severe peripheral vascular disease and their influence on outcome. 147 42

Opioids (narcotic analgesics) are widely used in the practice of anesthesia for preanesthetic medication, systemic and spinal analgesia, supplementation of general anesthetic agents, and as primary anesthetics. The last use is particularly widespread for major surgical operations, especially those involving patients with cardiovascular disease. The use of opioids in anesthetic doses is based on the absence of cardiac depression by the opioids. As with all anesthetic drugs, the opioids have limitations and side effects, but for the most part, these are easily managed on the basis of knowledge of their pharmacology. The key to their efficient use is careful titration of dose according to the individual patient's responses to the drug as well as to noxious stimulation. Although there is a very wide margin of safety, allowing administration of enormous doses intraoperatively when the patient's ventilation is supported mechanically, the disadvantage of using doses far in excess of the individual patient's need is a prolonged recovery from anesthesia with the risk of postoperative ventilatory depression. Titration of the dose can be facilitated by computer-controlled infusion pumps with the benefit that the recovery time from anesthetic doses can be appropriate for the individual patient and surgical procedure, and postoperative analgesia can be continued by patient-controlled analgesia, which is another example of computer-controlled opioid infusion. Although specific opioid antagonists are available, their use to antagonize residual anesthetic effects is potentially hazardous.
J Pain Symptom Manage 1992 Aug
PMID:Opioids: clinical use as anesthetic agents. 151 51

The use of peritoneal dialysis on an acute basis is increasing each year. Peritoneal dialysis pulls waste products and excess water out of the blood stream and into dialysate solution in the peritoneal cavity. When patients are unstable hemodynamically, have severe cardiovascular disease, already require peritoneal dialysis, or are small children, peritoneal dialysis is the preferred treatment. Patients may be dialyzed using either a cycler or manual peritoneal dialysis. Patients should be monitored carefully for volume status, bowel status, and infection. Potential complications include problems with access, infection, pain, respiratory status, fluid imbalance, and potassium imbalance. Special consideration should be given to nutritional status because critically ill patients often need increased intake. Drug therapy needs modification because excretion of drugs by the kidney is delayed. Patient and family support is important because of decreased ability to understand, anxiety, loss of control, and change in body image. Treatment termination also may be an issue.
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PMID:Peritoneal dialysis in the critically ill patient. 152 28


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