Oral metronidazole as antibiotic prophylaxis for patients with nonperforated appendicitis

Hassan Ravari1, Ali Jangjoo2, Jalal Motamedifar2, Kasra Moazzami31Vascular and Endovascular Surgery Research Center, Imam Reza Hospital, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, 2Department of General Surgery, Mashhad University of Medical Sciences, Imam Reza Hospital, Mashhad, 3Department of General Surgery, Tehran University of Medical Sciences, Sina Hospital, Tehran, IranBackground: The rate of wound infection after appendectomy without antibiotic prophylaxis is 10%–30%. The role of prophylactic antibiotic therapy in nonperforated appendicitis is still controversial. Metronidazole is against anaerobic organisms and its bioavailability after oral and parenteral administration has been shown to be similar. The objective of the present study is to compare the infective complications rate after open appendectomy for nonperforated appendicitis receiving either oral or intravenous metronidazole as prophylaxis. Methods and Materials: From June 2007 to July 2009 in a randomized controlled trial, 204 patients with nonperforated appendicitis underwent an open appendectomy; 122 male and 82 female with mean age of 25 years. Among these, 102 (case group) received oral metronidazole and in 102 (control group) metronidazole was administered intravenously before surgery. The rate of wound infection and duration of the postoperative hospital stay was studied in the two groups.Results: The rate of wound infection was not significantly different in the two groups. (6% and 4% in study and control group, respectively, P = 0.861). Also the hospital stay was equal in two groups (2.3 days and 2.7 days in study and control group, respectively, P = 0.293).Conclusion: Single dose of oral metronidazole prior to operation can provide a sufficient prophylaxis for nonperforated appendicitis; so, it can be substitute the parental route of antibiotic administration. Keywords: antibiotic prophylaxis, wound infection, appendectomy, complication

Minimalnie inwazyjna paratyroidektomia pod kontrolą obrazowania radioizotopowego — porównanie niskich i wysokich dawek Tc-99m-MIBI

Introduction: Surgery remains the most effective treatment for primary hyperparathyroidism (PHPT). Minimally invasive radioguided parathyroidectomy (MIRP) is a common technique for detecting and excising abnormal parathyroid glands. The aim of this study was to compare injections of low-dose and high-dose (99m) Tc methoxy isobutyl isonitrile (MIBI) for intraoperative localisation of parathyroid adenomas by means of a gamma probe in patients with primary hyperparathyroidism (PHPT). Material and methods: Thirty patients with PHPT and a preoperative diagnosis of parathyroid adenoma were enrolled between 2010 and 2012. They were considered as Group B and underwent MIRP using 5 mCi Tc-99m MIBI, and their perioperative data were compared with twenty patients treated with conventional 20 mCi Tc-99m MIBI previously (Group A). Results: Group A was made up of 20 patients (mean age, 41.55 years; 14 women and 6 men), and group B included 30 patients (mean age, 40.43 years; 19 women and 11 men). The mean serum parathyroid hormone (PTH) and calcium values were recorded pre- and postoperatively. The mean follow-up period for the patients in the two groups was 18.4 and 16.5 months, respectively. Pre-operative evaluation demonstrated that the groups were statistically similar. Intraoperative data and success rate of surgery showed no difference between the two groups. No significant complication was detected after surgeries and no recurrence happened in either of the two groups during the follow-up period. Conclusions: A new protocol of MIRP using low doses of Tc-99m-MIBI resulted in an excellent success rate. Comparing results of the study, we conclude that low-dose Tc-99m-MIBI may be preferred for identification of parathyroid adenomas intraoperatively by means of a gamma probe in PHPT patients because it appears to be as effective as high-dose Tc-99m-MIBI.Wstęp: Najbardziej skutecznym leczeniem pierwotnej nadczynności przytarczyc (PHPT, primary hyperparathyroidism) nadal pozostaje zabieg chirurgiczny. Minimalnie inwazyjna paratyroidektomia z lokalizacją radioizotopową (MIRP, minimally invasive radioguided parathyroidectomy) jest techniką często stosowaną do wykrywania i wycinania nieprawidłowych przytarczyc. Badanie przeprowadzono w celu porównania małej i dużej dawki (99m) Tc metoksy-izobutylu-izonitrylu (MIBI) podawanych w celu śródoperacyjnej lokalizacji gruczolaków przytarczyc za pomocą sondy gamma u chorych z pierwotną nadczynnością przytarczyc (PHPT, primary hyperparathyroidism). Materiał i metody: W latach 2010–2012 do badania włączono 30 chorych z PHPT i przedoperacyjnym rozpoznaniem gruczolaka przytarczyc. W tej grupie chorych określonej jako grupa B wykonano MIRP po podaniu 5 mCi Tc-99m MIBI, a dane okołooperacyjne tych chorych porównano z danymi 20 pacjentów, u których zastosowano konwencjonalną dawkę 20 mCi Tc-99m MIBI (grupa A). Wyniki: Grupa A składała się z 20 chorych (średnia wieku 41,55 r.; 14 kobiet i 6 mężczyzn), a grupę B tworzyło 30 chorych (średnia wieku 40,43 r.; 19 kobiet i 11 mężczyzn). Zmierzono przed- i pooperacyjne stężenia w surowicy parathormonu (PTH, pathyroid hormone) i wapnia. Średni okres obserwacji chorych w grupach A i B wynosił odpowiednio 18,4 i 16,5 miesiąca. Ocena przedoperacyjna wykazała, że grupy nie różniły się statystycznie między sobą. Również dane śródoperacyjne odsetek zabiegów zakończonych powodzeniem były podobne w obu grupach. W żadnej z grup nie stwierdzono istotnych powikłań pozabiegowych ani nawrotu w okresie obserwacji. Wnioski: Nowy protokół MIRP z użyciem małych dawek Tc-99m-MIBI wiązał się z bardzo wysokim odsetkiem pomyślnych zabiegów. Porównanie wyników uzyskanych w badaniu pozwala sformułować wniosek, że do śródoperacyjnego identyfikowania za pomocą sondy gamma gruczolaków nadnercza u chorych z PHPT mogą być preferowane małe dawki Tc-99m-MIBI, ponieważ są równie skuteczne jak duże dawki Tc-99m-MIBI

Association between Thyroid Hormones and Non-alcoholic Fatty Liver Disease and Non-alcoholic Steatohepatitis in Obese Individuals Undergoing Bariatric Surgery

Background: Non-alcoholic fatty liver disease (NAFLD), non-alcoholic steatohepatitis (NASH), and hepatic fibrosis have emerged as one of the leading causes of chronic liver disease. The prevalence of the NAFLD spectrum has increased, which can be attributed to the rise in obesity. As NAFLD can ultimately lead to liver cirrhosis, it is imperative to identify modifiable risk factors associated with its onset and progression to provide timely intervention to prevent potentially disastrous consequences. Considering the pivotal role of the endocrine axis in several metabolic pathways such as obesity and insulin resistance, thyroid hormones are crucial in the pathophysiology of NAFLD. The study is focused on the identification of an association between thyroid function and radiographic and histological parameters of NAFLD in patients with severe obesity. Methods: Ninety patients were recruited for this study and underwent initial assessments, including demographic profiles, anthropometric measurements, hepatic biopsy, and basic laboratory tests. Liver stiffness was evaluated using two-dimensional shear wave elastography (2D-SWE) at least 2 weeks before liver biopsy. Results: Among the 90 participants, 80% were women. The mean age was 38.5 ± 11.1 years, and the mean body mass index (BMI) was 45.46 ± 6.26 kg/m2. The mean levels of serum T3 and free T4 in patients with positive histology were not statistically significant compared with patients with negative histology. Furthermore, there was no statistical significance in the mean T3 and free T4 levels between patients diagnosed with hepatic steatosis or fibrosis (on ultrasonography and elastography) and those with negative hepatic imaging. Serum levels of thyroid-stimulating hormone (TSH) were negatively correlated with ultrasonography (P = 0.007). Binary logistic regression analysis revealed that none of the thyroid hormones was a predictive factor for liver histology in both adjusted and crude models. Conclusion: The results from our analysis did not suggest an association between thyroid hormones and NAFLD, which is in line with several previously published studies. However, the authors note that there are published data that do propose a link between the two entities. Therefore, well-designed large-scale clinical studies are required to clarify this discrepancy

Added value of blue dye injection in sentinel node biopsy of breast cancer patients: Do all patients need blue dye?

AbstractBackgroundIn the current study, we evaluated the incremental value of blue dye injection in sentinel node mapping of early breast cancer patients. We specially considered the experience of the surgeons and lymphoscintigraphy results in this regard.Methods605 patients with early stage breast cancer were retrospectively evaluated in the study. Patients underwent sentinel node mapping using combined radiotracer and blue dye techniques. Lymphoscintiraphy was also performed for 590 patients. Blue dye, radioisotope, and overall success rates in identifying the sentinel lymph node were evaluated in different patient groups. The benefit of blue dye and radioisotope in identifying the sentinel lymph nodes was also evaluated.ResultsMarginal benefits of both blue dye and isotope for overall sentinel node detection as well as pathologically involved sentinel nodes were statistically higher in inexperienced surgeons and in patients with sentinel node visualization failure. In the patients with sentinel node visualization on lymphoscintigraphy, 6 sentinel nodes were detected by blue dye only. All these six nodes were harvested by inexperienced surgeons. On the other hand 8 sentinel nodes were detected by dye only in the patients with sentinel node non-visualization. All these nodes were harvested by experienced surgeons.ConclusionsThe use of blue dye should be reserved for inexperienced surgeons during their learning phase and for those patients in whom lymphoscintigraphy failed to show any uptake in the axilla

Mapowanie węzłów wartowniczych w raku brodawkowatym tarczycy z zastosowaniem radioznacznika i niebieskiego barwnika

Introduction: In the current study, we evaluated the accuracy of sentinel node mapping in thyroid cancer patients using both radiotracer and blue dye.Material and methods: 30 patients with a diagnosis of papillary thyroid carcinoma (PTC) were included in the study; 2–3 hours before surgery, 0.5 mCi 99m-Tc-Antimony Sulfide Colloid was injected intra-tumourally. 15 minutes post-injection, lymphoscintigraphy images of the neck were obtained. Immediately after anaesthesia induction, 0.5 mL patent blue V was also injected in the same fashion. Sentinel lymph nodes were detected intraoperatively using gamma probe and blue dye. Total thyroidectomy was performed for all patients with dissection of central neck lymph nodes as well as sampling of the lateral neck lymph nodes.Results: At least one sentinel node could be identified during surgery in 19 patients (63.3%). The median number of sentinel nodes per patient was 1. Sentinel nodes in 12 patients were pathologically involved. No false negative case was noted. Upstaging occurred in six patients (20%).Conclusions: Sentinel node mapping in papillary thyroid carcinoma is a feasible technique with high accuracy for the detection of lymph node involvement. This technique can guide surgeons to perform central lymph node dissection only in patients with pathologically involved sentinel nodes. Although SLN detection in the lateral neck lymph nodes increases the extension of lymphadenectomy, SLN mapping can result in upstaging in older patients (> 45 years of age) or treatment plan change in younger patients (< 45 years of age) by the detection of lateral lymph node involvement. (Endokrynol Pol 2014; 65 (4): 281–286)Wstęp: W badaniu oceniono dokładność mapowania węzłów wartowniczych u chorych na raka tarczycy w przypadku jednoczesnego zastosowania radioznacznika i niebieskiego barwnika.Materiał i metody: Do badania włączono 30 chorych z rozpoznaniem raka brodawkowego tarczycy (PTC, papillary thyroid carcinoma). Dwie do trzech godzin przed zabiegiem do guza wstrzykiwano koloid siarczanu antymonu znakowany 99m-Tc (0,5 mCi). Po upływie 15 minut od wstrzyknięcia radioznacznika wykonywano badanie limfoscyntygraficzne szyi. Bezpośrednio po znieczuleniu w ten sam sposób wstrzykiwano 0,5 ml błękitu patentowego V. Węzły wartownicze wykrywano śródoperacyjnie, używając sondy promieniowania gamma i błękitnego barwnika. U wszystkich pacjentów wykonano totalną tyroidektomię z wycięciem węzłów chłonnych szyjnych środkowego przedziału oraz pobraniem wycinków węzłów szyjnych bocznych.Wyniki: U 19 chorych (63,3%) udało się zidentyfikować w trakcie zabiegu co najmniej jeden węzeł wartowniczy. Mediana liczby węzłów wartowniczych na pacjenta wynosiła 1. U 12 chorych w węzłach wartowniczych wykryto zmiany patologiczne. Nie stwierdzono ani jednego przypadku uzyskania fałszywie ujemnego wyniku. U 6 (20%) chorych zmieniono stopień zaawansowania nowotworu na wyższy.Wnioski: Mapowanie węzłów wartowniczych w raku brodawkowatym tarczycy jest dostępną metodą cechującą się dużą dokładnością w wykrywaniu zajętych węzłów chłonnych. Ta metoda może stanowić wskazówkę dla chirurgów, aby usuwać węzły chłonne szyjne środkowego przedziału tylko u pacjentów ze zmianami w węzłach wartowniczych. Mimo że wykrycie węzłów wartowniczych w obrębie węzłów szyjnych bocznych zwiększa zakres limfadenektomii, mapowanie węzłów wartowniczych może spowodować zmianę oceny stopnia zaawansowanie nowotworu u starszych pacjentów (> 45 lat) lub zmianę planu leczenia u młodszych pacjentów (< 45 lat) w związku z wykryciem zmian w węzłach bocznych szyi. (Endokrynol Pol 2014; 65 (4): 281–286

The Predictive Role of Parathyroid Hormone for Nonalcoholic Fatty Liver Disease following Bariatric Surgery

Background. Morbid obesity is frequently complicated by chronic liver diseases, including nonalcoholic fatty liver disease (NAFLD), nonalcoholic steatohepatitis (NASH), and fibrosis. Parathyroid hormone (PTH) is found to be elevated in morbid obesity due to the defective hepatic metabolism of vitamin D. Bariatric surgery is performed to help patients with BMI>40 kg/m2 to effectively lose weight, particularly in patients with obesity who are afflicted with complications such as NAFLD/NASH. Objective. This study aimed to evaluate the PTH level as a predictor of hepatic function in individuals with morbid obesity who have undergone bariatric surgery. Methods. Ninety subjects with morbid obesity referred for Roux en-Y gastric bypass surgery were recruited. After IRB approval, demographic profiles, anthropometric factors, liver biopsy, and laboratory tests were obtained. The two-dimensional shear wave elastography (2D-SWE) technique was applied to assess hepatic stiffness. Results. A significant reduction occurred six months after bariatric surgery in the anthropometric indices p<0.001, hepatic elasticity p=0.002, alanine aminotransferase p<0.001, serum alkaline phosphatase p<0.001, gamma-glutamyl transpeptidase (GGT) p<0.001, and nonalcoholic fatty liver disease fibrosis score (NFS) p<0.001. Serum PTH concentration was not predictive of postsurgical liver fibrosis and steatosis at six months but could predict weight loss success rate. No significant alteration in serum PTH levels was observed between presurgical vs. postsurgical time points. Conclusion. A significant reduction was observed in the anthropometric parameters, liver enzymes, and hepatic elasticity after bariatric surgery. No significant effect was found on PTH levels

Evaluation of the diagnostic value of Sentinel Lymph Node in patients with gastric adenocarcinoma

Objective(s):  Sentinel lymph node biopsy (SLNB) has been proven as a safe and efficient procedure in some cancers like breast cancer and melanoma with a reduction of complications and side effects of unnecessary lymphadenectomy in many patients. However, the diagnostic value of SLNB in gastric cancer is a point of debate. This study evaluated the diagnostic value of SLNB using radiotracer and isosulphan blue dye injection in patients with Gastric Adenocarcinomas (GA).Methods: This descriptive study was performed at Imam-Reza HOSPITAL on 39 patients diagnosed with GA with no lymphatic metastasis using two methods: the combination of radionuclide with isosulphan together (R&I) method compared with the isosulphan alone method. Lymphatic dissection was performed in all patients. The pathological results were compared between the sentinel lymph nodes (SLN) and other lymph nodes and their accordance rate was calculated.Results: In the T1 group, the sentinel lymph node biopsy detection rate was 100% for the combination of the R&I method and 60% for the isosulphan method and the false negative rate was zero. These values respectively were 88.8% and 88.8% in the T2 group with a false negative rate of 75%. In the T3 group, the values were 100% for the combination of the R&I method and 93.7% for the isosulphan method with a false negative rate of 40%. In the combination of the R&I method, the sensitivity, specificity, and positive and negative predictive values were 57.9, 100, 100, and 69.2 percent respectively.Conclusion: Based on the false negative rate (47.4%), SLNB by injection of isosulphan blue dye alone is not a diagnostic enough value for predicting lymph node metastasis in GA. Although, SLNB by combination of the R&I had better accuracy compared to the isosulphan alone, more studies with larger samples are needed to prove this result

Guanylyl Cyclase C as a tumor marker for detection of circulating tumor cells in the peripheral blood of colorectal cancer patients

Purpose: Guanylyl cyclase C (GCC) is one of the most frequent tumor markers to detect the circulating tumor cells (CTCs) in peripheral blood of colorectal cancer (CRC) patients. It has been proposed as a new marker for the molecular staging of CRC. The level of GCC mRNA expression in peripheral blood of CRC patients was evaluated to explore its probable correlations with the clinicopathological features.Methods: Relative quantitative expression analysis of GCC mRNA was performed on 80 blood samples (40 patients and 40 normal) using the Real-time RT-PCR.Results: GCC mRNA expression was detected in 70% of the CRC blood samples. The level of GCC mRNA expression in peripheral blood of patients was significantly higher than that in the normal cases (p = 0.031). Moreover, there was a significant correlation between the GCC copy number and advanced stages of tumor (p = 0.041). Furthermore, we have observed a significant correlation between tumor sizes and GCC copy numbers (p = 0.050).Conclusion: GCC can be a useful marker not only for detection of CTCs in CRC blood samples, but also for the molecular staging of colorectal cancer.

The role of prophylactic cefazolin in the prevention of infection after various types of abdominal wall hernia repair with mesh

There are controversies about the benefits of prophylactic antibiotics in the prevention of postoperative surgical site infection (SSI) in mesh herniorrhaphy for a long time. This study aimed to evaluate the effectiveness and efficacy of systemic prophylactic cefazolin in prevention of wound infection in various types of hernia repair with mesh materials. This is a prospective randomized control study. We evaluated wound infection rates in 395 patients with various kinds of hernia who underwent elective mesh repair using polypropylene mesh from 2007 to 2011. A total of 237 (60.0%) patients received prophylactic cefazolin (study group) and the remaining 158 (40.0%) patients did not receive any prophylactic antibiotics (control group). Patients were followed for infection at the following periods after the operation by an independent surgeon: 10 days, 30 days, 12 months, and then annually for at least 2 years. Eight (2.03%) patients had infection in the site of surgery [2 (1.27%) in the control group and 6 (2.53%) in the study group]. The distribution of infection was not significantly different between the two groups (p = 0.364). The superficial infections were managed by drainage and irrigation. One patient from the study group developed deep SSI and was readmitted and subsequently received antibiotic therapy, drainage, and debridement. Preoperative administration of single-dose cefazolin for prosthetic hernia repairs did not markedly decrease the risk of wound infection. Our results do not support the use of cefazolin as a prophylactic antibiotic for various kinds of abdominal wall hernia repair with mesh

The Frequency of Job Burnout among Dentists of Kerman City

Background: Dentistry is a demanding profession with high physical and mental tiredness, which can result in job burnout. The aim of this study was to find the frequency of job burnout in dentists of Kerman Methods: This cross- sectional study was carried out on 145 dentists working in private offices and health care centers of Kerman. Data were collected using Maslach job burnout questionnaire and analyzed through SPSS18 software and using regression analysis. Results: Among these dentists, 51.7% were male and 48.3% were female. Mean age of participants was 35 ± 7.18 years. In whole, 14.1% had a high level of depersonalization, 30.46% showed high emotional exhaustion, and 71.76% reported high personal accomplishment failure. Demographic variables such as age, sex, occupational status and year of graduation showed no significant relationship with job burnout. But, depersonalization showed a significant relationship with occupational status and marital status. Conclusion: There is a high frequency of job burnout among Kerman dentists. Intervention policies for evaluation and to find the related factors and preventive measures are recommended. Keywords: Job Burnout, Dentists, Kerma