After laparoscopic Heller myotomy, do emergency department visits or readmissions predict poor long-term outcomes?

INTRODUCTION

Laparoscopic Heller myotomy is a first-line treatment for achalasia. To improve outcomes after myotomy and to determine if poor early results predict later outcomes, emergency department (ED) visits and readmissions within 60 days following laparoscopic Heller myotomy were studied.

MATERIALS AND METHODS

Since 1992, 352 patients have undergone laparoscopic Heller myotomy and are followed through a prospectively maintained registry. Causes of ED visits and readmissions within 60 days after myotomy were determined. Patients scored their symptoms of achalasia before myotomy and at last follow-up; scores were compared to determine if the reasons leading to ED visits and/or readmissions impacted long-term outcome after myotomy.

RESULTS

Fourteen (4%) patients had ED visits, and 18 (5%) patients had readmissions within 60 days following myotomy. Sixty-four percent of ED visits were for dysphagia/vomiting and 36% were for abdominal/chest pain, while 37% of readmissions were for dysphagia/vomiting. Pneumonia was complicated by empyema in four patients, all without leaks; two patients expired. Despite ED visits/readmissions, achalasia symptom (e.g., dysphagia, regurgitation, choking, heartburn, and chest pain) frequency and severity scores improved after myotomy (p < 0.05 for all).

CONCLUSIONS

ED visits and readmissions are infrequent following laparoscopic Heller myotomy. ED visits were generally due to complaints related to achalasia or edema after myotomy, while readmissions were generally related to complications of operative intervention or chronic ill health. Despite ED visits or readmissions early after myotomy, symptoms of achalasia are well palliated by myotomy long-term.

Online Planning Algorithms for POMDPs

Partially Observable Markov Decision Processes (POMDPs) provide a rich framework for sequential decision-making under uncertainty in stochastic domains. However, solving a POMDP is often intractable except for small problems due to their complexity. Here, we focus on online approaches that alleviate the computational complexity by computing good local policies at each decision step during the execution. Online algorithms generally consist of a lookahead search to find the best action to execute at each time step in an environment. Our objectives here are to survey the various existing online POMDP methods, analyze their properties and discuss their advantages and disadvantages; and to thoroughly evaluate these online approaches in different environments under various metrics (return, error bound reduction, lower bound improvement). Our experimental results indicate that state-of-the-art online heuristic search methods can handle large POMDP domains efficiently.

The risk of unexplained antepartum stillbirth in second pregnancies following caesarean section in the first pregnancy

OBJECTIVE

To determine if a previous caesarean section increases the risk of unexplained antepartum stillbirth in second pregnancies.

STUDY DESIGN

Retrospective cohort study.

SETTING

Large Canadian perinatal database.

POPULATION

158 502 second births.

METHODS

Data were obtained from a large perinatal database, which supplied data on demographics, pregnancy complications, maternal medical conditions, previous caesarean section and pregnancy outcomes.

MAIN OUTCOME MEASURES

Total and unexplained stillbirth.

RESULTS

The antepartum stillbirth rate was 3.0/1000 in the previous caesarean section group compared with 2.7/1000 in the previous vaginal delivery group (P= 0.46). Multivariate logistic regression modelling, including terms for maternal age (polynomial), weight >91 kg, smoking during pregnancy, pre-pregnancy hypertension and diabetes, did not document an association between previous caesarean section and unexplained antepartum stillbirth (OR 1.27, 95% CI 0.92-1.77).

CONCLUSION

Caesarean section in the first birth does not increase the risk of unexplained antepartum stillbirth in second pregnancies.

Gunshot injuries detected by post-mortem multislice computed tomography (MSCT): a feasibility study

Modern cross-sectional imaging techniques are being increasingly implemented in forensic pathology. These methods may serve as an adjuvant to classic forensic autopsies or even replace them altogether in the future. In order to assess the practicability of such a method, namely post-mortem multislice computed tomography (MSCT) in fatal gunshot injuries, 22 corpses underwent such an examination prior to forensic autopsy. The cardinal questions of the location of entrance and exit wounds, the detection of bullets and bullet fragments in the body, the bullet course, inflicted injuries and cause of death were addressed at MSCT and autopsy. The results of the two techniques revealed that post-mortem MSCT can answer these questions reliably and is therefore a useful tool in the assessment of such injuries.

Structural and functional analysis of the interaction between the agonistic monoclonal antibody Apomab and the proapoptotic receptor DR5

Activation of the proapoptotic receptor death receptor5 (DR5) in various cancer cells triggers programmed cell death through the extrinsic pathway. We have generated a fully human monoclonal antibody (Apomab) that induces tumor cell apoptosis through DR5 and investigated the structural features of its interaction with DR5. Biochemical studies showed that Apomab binds DR5 tightly and selectively. X-ray crystallographic analysis of the complex between the Apomab Fab fragment and the DR5 ectodomain revealed an interaction epitope that partially overlaps with both regions of the Apo2 ligand/tumor necrosis factor-related apoptosis-inducing ligand binding site. Apomab induced DR5 clustering at the cell surface and stimulated a death-inducing signaling complex containing the adaptor molecule Fas-associated death domain and the apoptosis-initiating protease caspase-8. Fc crosslinking further augmented Apomab's proapoptotic activity. In vitro, Apomab triggered apoptosis in cancer cells, while sparing normal hepatocytes even upon anti-Fc crosslinking. In vivo, Apomab exerted potent antitumor activity as a single agent or in combination with chemotherapy in xenograft models, including those based on colorectal, non-small cell lung and pancreatic cancer cell lines. These results provide structural and functional insight into the interaction of Apomab with DR5 and support further investigation of this antibody for cancer therapy.

Virtopsy: Fatal stab wounds to the skull – The relevance of ante-mortem and post-mortem radiological data in case reconstructions

Homicides with a survival of several days are not uncommon in forensic routine work. Reconstructions of these cases by autopsy alone are very difficult and may occasionally lead to unsatisfying results. For the medico-legal reconstruction of these cases, ante-mortem and post-mortem radiological imaging should always be included in the expertise. We report on a case of fatal penetrating stab wounds to the skull in which a case reconstruction was only possible by combining the radiological ante- and post-mortem data with the autopsy findings.

Neurotensin receptor type 1: Escherichia coli expression, purification, characterization and biophysical study

NT (neurotensin) is an endogenous tridecapeptide neurotransmitter found in the central nervous system and gastrointestinal tract. One receptor for NT, NTS1, belongs to the GPCR (G-protein-coupled receptor) superfamily, has seven putative transmembrane domains, and is being studied by a range of single-molecule, functional and structural approaches. To enable biophysical characterization, sufficient quantities of the receptor need to be expressed and purified in an active form. To this end, rat NTS1 has been expressed in Escherichia coli in an active ligand-binding form at the cell membrane and purified in sufficient amounts for structural biology studies either with or without fluorescent protein [YFP (yellow fluorescent protein) and CFP (cyan fluorescent protein)] fusions. Ligand binding has been demonstrated in a novel SPR (surface plasmon resonance) approach, as well as by conventional radioligand binding measurements. These improvements in production of NTS1 now open up the possibility of direct structural studies, such as solid-state NMR to interrogate the NT-binding site, EM (electron microscopy), and X-ray crystallography and NMR.

The Control of Hypertension In Pregnancy Study pilot trial

OBJECTIVE

To determine whether 'less tight' (versus 'tight') control of nonsevere hypertension results in a difference in diastolic blood pressure (dBP) between groups.

DESIGN

Randomised controlled trial (ISRCTN#57277508).

SETTING

Seventeen obstetric centres in Canada, Australia, New Zealand, and UK.

POPULATION

Inclusion: pregnant women, dBP 90-109 mmHg, pre-existing/gestational hypertension; live fetus(es); and 20-33(+6) weeks. Exclusion: systolic blood pressure > or = 170 mmHg and proteinuria, contraindication, or major fetal anomaly.

METHODS

Randomisation to less tight (target dBP, 100 mmHg) or tight (target dBP, 85 mmHg) blood pressure control.

MAIN OUTCOME MEASURES

Primary: mean dBP at 28, 32 and 36 weeks. Secondary: clinician compliance and women's satisfaction. Other: serious perinatal and maternal complications.

RESULTS

A total of 132 women were randomised to less tight (n = 66; seven had no study visit) or tight control (n= 66; one was lost to follow up; seven had no study visit). Mean dBP was significantly lower with tight control: -3.5 mmHg, 95% credible interval (-6.4, -0.6). Clinician compliance was 79% in both groups. Women were satisfied with their care. With less tight (versus tight) control, the rates of other treatments and outcomes were the following: post-randomisation antenatal antihypertensive medication use: 46 (69.7%) versus 58 (89.2%), severe hypertension: 38 (57.6%) versus 26 (40.0%), proteinuria: 16 (24.2%) versus 20 (30.8%), serious maternal complications: 3 (4.6%) versus 2 (3.1%), preterm birth: 24 (36.4%) versus 26 (40.0%), birthweight: 2675 +/- 858 versus 2501 +/- 855 g, neonatal intensive care unit (NICU) admission: 15 (22.7%) versus 22 (34.4%), and serious perinatal complications: 9 (13.6%) versus 14 (21.5%).

CONCLUSION

The CHIPS pilot trial confirms the feasibility and importance of a large definitive trial to determine the effects of less tight control on serious perinatal and maternal complications.

Heterochromatin-like regions as ecological niches for avirulence genes in the Leptosphaeria maculans genome: map-based cloning of AvrLm6

Map-based cloning of avirulence genes of the AvrLml-2-6 cluster was recently undertaken in Leptosphaeria maculans and led to the identification of AvrLm1. The ensuing chromosome walk toward AvrLm6 resulted in the delineation of a 562-kb bacterial artificial chromosome (BAC) clone contig in an avirulent isolate. Following sequencing of the contig and sequence comparison with a virulent isolate, four AvrLm6 candidate genes were identified. Complementation of the virulent isolate with the four candidates was performed and one gene was found to fully restore the avirulent phenotype on Rlm6 oilseed rape genotypes. AvrLm6 was found to be located in the same genome context as AvrLml, because it is a solo gene surrounded by 85 and 48 kb of degenerated repeats on its 5' and 3' sides, respectively. AvrLm6 is an orphan gene encoding a small, potentially secreted, cysteine-rich protein. Comparison of AvrLm1 and AvrLm6 expressions by quantitative reverse-transcription polymerase chain reaction revealed that both genes are highly overexpressed during primary leaf infection. Using RNA interference, decreasing expression of AvrLm6 was shown to result in virulence toward Rlm6 genotypes whenever the expression was reduced by more than 60% compared with the wild-type isolate.

D-dimer level is associated with the extent of pulmonary embolism

OBJECTIVES

Our aim was to study the association between the level of D-dimer and the severity of pulmonary embolism (PE) as determined by various biochemical and radiological prognostic markers in order to investigate the potential value of D-dimer as a prognostic marker for the severity of PE.

PATIENTS AND METHODS

PE was diagnosed in 100 consecutive out-patients by multi-detector computerized tomography. One patient was excluded and the final cohort consisted of 99 patients. Pulmonary Artery Obstruction Index (PAOI) and Right Ventricular/Left Ventricular (RV/LV) ratio were assessed.

RESULTS

The median value for D-dimer was 5.0 mg/L (inter-quartile range: 1.8, 12.2). There was a significant association between log D-dimer, and between log RV/LV (r=0.45), log PAOI (r=0.5), and PaO(2) (r=0.40). The multivariate analysis showed an increased association between log D-dimer and between log RV/LV ratio (r=0.54) and log PAOI (r=0.52) after adjusting for age, gender and for the duration of symptoms. Significant association was found between the level of D-dimer and the most proximal level of PE (p<0.0005). There was a significant dose-response relationship between the level D-dimer and between Troponin-T and the frequency of thrombolysis (p<0.0005). In the subgroup of patients with D-Dimer over the upper quartile (>12.2), 12 (67%) patients had elevated Troponin-T and 8 (32%) patients received thrombolysis, compared to 1 (5%) patient with elevated Troponin-T and none treated with thrombolysis in the subgroup of patients with D-dimer<lower quartile.

CONCLUSIONS

We have shown that the level of D-dimer is related to the severity of PE assessed by various radiological, biochemical and clinical markers and might have a potential value as prognostic marker for the severity of PE.

Patient compliance in hypertension: role of illness perceptions and treatment beliefs

Despite many years of study, questions remain about why patients do or do not take medicines and what can be done to change their behaviour. Hypertension is poorly controlled in the UK and poor compliance is one possible reason for this. Recent questionnaires based on the self-regulatory model have been successfully used to assess illness perceptions and beliefs about medicines. This study was designed to describe hypertensive patients' beliefs about their illness and medication using the self-regulatory model and investigate whether these beliefs influence compliance with antihypertensive medication. We recruited 514 patients from our secondary care population. These patients were asked to complete a questionnaire that included the Beliefs about Medicines and Illness Perception Questionnaires. A case note review was also undertaken. Analysis shows that patients who believe in the necessity of medication are more likely to be compliant (odds ratio (OR)) 3.06 (95% CI 1.74-5.38), P<0.001). Other important predictive factors in this population are age (OR 4.82 (2.85-8.15), P<0.001), emotional response to illness (OR 0.65 (0.47-0.90), P=0.01) and belief in personal ability to control illness (OR 0.59 (0.40-0.89), P=0.01). Beliefs about illness and about medicines are interconnected; aspects that are not directly related to compliance influence it indirectly. The self-regulatory model is useful in assessing patients health beliefs. Beliefs about specific medications and about hypertension are predictive of compliance. Information about health beliefs is important in achieving concordance and may be a target for intervention to improve compliance.

Conceptions and uses of public health ideas by New Zealand government policymakers: report on a five-agency survey

OBJECTIVES

This article describes New Zealand government policymakers' awareness of, attitudes toward and self-reported use of ideas about the determinants of health. Some comparison with an earlier Canadian study is provided.

METHODS

Employees with policymaking and advisory responsibilities in government departments of health, social development, housing, education and finance were surveyed.

RESULTS

More than half of the respondents (58%) were familiar with ideas about health determinants. Eighty percent felt that health determinants should be considered in all government policy, but that more practical information on effective policy interventions is needed. Commitment to the idea that the economy should take precedence over reducing health inequalities was low.

CONCLUSIONS

There is a demand for literature on health determinants that is sector specific and which provides practical and proven information about effective interventions that influence health.