Are we meeting the standards set for endoscopy? Results of a large-scale prospective survey of endoscopic retrograde cholangio-pancreatograph practice

OBJECTIVE

To examine endoscopic retrograde cholangio-pancreatography (ERCP) services and training in the UK.

DESIGN

Prospective multicentre survey.

SETTING

Five regions of England.

PARTICIPANTS

Hospitals with an ERCP unit.

OUTCOME MEASURES

Adherence to published guidelines, technical success rates, complications and mortality.

RESULTS

Organisation questionnaires were returned by 76 of 81 (94%) units. Personal questionnaires were returned by 190 of 213 (89%) ERCP endoscopists and 74 of 91 (81%) ERCP trainees, of whom 45 (61%) reported participation in <50 ERCPs per annum. In all, 66 of 81 (81%) units collected prospective data on 5264 ERCPs, over a mean period of 195 days. Oximetry was used by all units, blood pressure monitoring by 47 of 66 (71%) and ECG monitoring by 37 of 66 (56%) units; 1484 of 4521 (33%) patients were given >5 mg of midalozam. Prothrombin time was recorded in 4539 of 5264 (86%) procedures. Antibiotics were given in 1021 of 1412 (72%) cases, where indicated. Patients' American Society of Anesthesiology (ASA) scores were 3-5 in 670 of 5264 (12.7%) ERCPs, and 4932 of 5264 (94%) ERCPs were scheduled with therapeutic intent. In total, 140 of 182 (77%) trained endoscopists demonstrated a cannulation rate >/=80%. The recorded cannulation rate among senior trainees (with an experience of >200 ERCPs) was 222/338 (66%). Completion of intended treatment was done in 3707 of 5264 (70.4%) ERCPs; 268 of 5264 (5.1%) procedures resulted in a complication. Procedure-related mortality was 21/5264 (0.4%). Mortality correlated with ASA score.

CONCLUSION

Most ERCPs in the UK are performed on low-risk patients with therapeutic intent. Complication rates compare favourably with those reported internationally. However, quality suffers because there are too many trainees in too many low-volume ERCP centres.

Cardiorespiratory requirements of the 6-min walk test in older patients with left ventricular systolic dysfunction and no major structural heart disease

The six-minute walk test (6-MWT) is widely used to assess functional status in patients with chronic heart failure (CHF). The aims of the present study were: (1) to compare metabolic gas exchange during the 6-MWT in older patients with left ventricular systolic dysfunction (LVSD) and in breathless patients with no major structural heart disease (MSHD); (2) to determine the exercise intensity of the 6-MWT relative to peak oxygen uptake; (3) to establish the accuracy and reproducibility of the Metamax 3B ergospirometer during an incremental workload. Twenty four older patients with LVSD (19 male; age 76 +/- 5 years; BMI 27 +/- 4), and 18 patients with no MSHD (12 male; age 75 +/- 8 years; BMI 27 +/- 4) attended on consecutive days at the same time. Patients completed a 6-MWT with metabolic gas exchange measurements using the Metamax 3B portable ergospirometer, and an incremental cycle ergometry test using both the Metamax 3B and Oxycon Pro metabolic cart. Patients returned and performed a second 6-MWT and an incremental treadmill test, metabolic gas exchange was measured with the Metamax 3B. In patients with LVSD, the 6-MWT was performed at a higher fraction of maximal exercise capacity (p = 0.02). The 6-MWT was performed below the anaerobic threshold in patients with LVSD (83 %) and in patients with no MSHD (61 %). The Metamax 3B showed satisfactory to high accuracy at 10 W and 20 W in patients with LVSD (r = 0.77 - 0.97, p < 0.05), and no MSHD (r = 0.76 - 0.94, p < 0.05). Metabolic gas exchange variables measured during the 6-MWT showed satisfactory to high day-to-day reproducibility in patients with LVSD (ICC = 0.75 - 0.98), but a higher variability was evident in participants with no MSHD (ICC = 0.62 - 0.97). The Metamax 3B portable ergospirometer is an accurate and reproducible device during submaximal, fixed rate exercise in older patients with LVSD and no MSHD. In elderly patients with LVSD and no MSHD, the 6-MWT should not be considered a maximal test of exercise capacity but rather a test of submaximal exercise performance. Our study demonstrates that the 6-MWT takes place at a higher proportion of peak oxygen uptake in patients with LVSD compared to those with no MSHD, and may be one reason why fatigue is a more prominent symptom in these patients.

Minimally invasive parathyroidectomy using the lateral focused mini-incision technique without intraoperative parathyroid hormone monitoring

BACKGROUND

Minimally invasive parathyroidectomy (MIP) involves scan-directed removal of a single adenoma through a 2.0-cm mini-incision without intraoperative monitoring. The aim of this study was to analyse the outcomes of MIP using such a simplified technique.

METHODS

The study group comprised 500 consecutive patients undergoing MIP via a lateral mini-incision from August 2000 to September 2005. Levels of parathyroid hormone (PTH) were measured after operation solely to aid informed discharge.

RESULTS

Some 97.4 per cent of patients were initially cured by MIP. Eight patients remained hypercalcaemic and a further five were normocalcaemic on the day after surgery but became hypercalcaemic again within 3 months of the procedure. Eleven of these patients were cured with subsequent re-exploration. Analysis of postoperative PTH data indicated that, at best, the use of intraoperative PTH measurement during surgery would have increased the cure rate by only a further 1 per cent. Three (0.6 per cent) of 500 patients had permanent recurrent laryngeal nerve palsy after MIP.

CONCLUSION

MIP performed by the lateral focused mini-incision technique, without the use of intraoperative PTH monitoring, is a safe and effective procedure that results in outcomes equal to those of bilateral neck exploration.

Risk assessments for forest trees: the performance of the ozone flux versus the AOT concepts

Published ozone exposure-response relationships from experimental studies with young trees performed at different sites across Europe were re-analysed in order to test the performance of ozone exposure indices based on AOTX (Accumulated exposure Over a Threshold of X nmol mol(-1)) and AF(st)Y (Accumulated Stomatal Flux above a threshold of Y nmol m(-2) s(-1)). AF(st)1.6 was superior, as compared to AOT40, for explaining biomass reductions, when ozone sensitive species with differing leaf morphology were included in the analysis, while this was not the case for less sensitive species. A re-analysis of data with young black cherry trees, subject to different irrigation regimes, indicated that leaf visible injuries were more strongly related to the estimated stomatal ozone uptake, as compared to the ozone concentration in the air. Experimental data with different clones of silver birch indicated that leaf thickness was also an important factor influencing the development of ozone induced leaf visible injury.

Inaccuracy of high-performance liquid chromatography estimation of haemoglobin F in the presence of increased haemoglobin A1c

Increasingly high-performance liquid chromatography is being used for identification and quantification of normal and variant haemoglobins. In many laboratories, the Beta Thal Short programme of the Bio-Rad Variant II instrument is used for this purpose. We noted that a factitious elevation of haemoglobin F was sometimes observed in diabetic patients and therefore carried out a systematic study of this phenomenon. We found discrepant results in 41% of samples from diabetic patients but in no normal volunteers. This factitious elevation could be predicted from a retention time for haemoglobin F of more than 1.15 min, the normal retention time being 1.08-1.15 min. Haemoglobinopathy laboratories need to be alert to the possibility of this erroneous result.

Global patterns of diversification in the history of modern amphibians

The fossil record of modern amphibians (frogs, salamanders, and caecilians) provides no evidence for major extinction or radiation episodes throughout most of the Mesozoic and early Tertiary. However, long-term gradual diversification is difficult to reconcile with the sensitivity of present-day amphibian faunas to rapid ecological changes and the incidence of similar environmental perturbations in the past that have been associated with high turnover rates in other land vertebrates. To provide a comprehensive overview of the history of amphibian diversification, we constructed a phylogenetic timetree based on a multigene data set of 3.75 kb for 171 species. Our analyses reveal several episodes of accelerated amphibian diversification, which do not fit models of gradual lineage accumulation. Global turning points in the phylogenetic and ecological diversification occurred after the end-Permian mass extinction and in the late Cretaceous. Fluctuations in amphibian diversification show strong temporal correlation with turnover rates in amniotes and the rise of angiosperm-dominated forests. Approximately 86% of modern frog species and >81% of salamander species descended from only five ancestral lineages that produced major radiations in the late Cretaceous and early Tertiary. This proportionally late accumulation of extant lineage diversity contrasts with the long evolutionary history of amphibians but is in line with the Tertiary increase in fossil abundance toward the present.

Isolation and characterization of Viviparous-1 genes in wheat cultivars with distinct ABA sensitivity and pre-harvest sprouting tolerance

Pre-harvest sprouting (PHS) of wheat reduces the quality and economic value of grain, and increasing PHS tolerance is one of the most important traits in wheat breeding. Two new Vp-1B alleles related to PHS tolerance were identified on the 3BL chromosome of bread wheat and were designated Vp-1Bb and Vp-1Bc. Sequence analysis showed that Vp-1Bb has a 193 bp insertion and Vp-1Bc has a 83 bp deletion located in the third intron region of the Vp-1B gene, and that they shared 95.43% and 97.89% similarity, respectively, with the sequence of AJ400713 (Vp-1Ba) at the nucleotide level. Their sequences were deposited in the GenBank under the accession numbers DQ517493 and DQ517494. Semi-quantitative RT-PCR analysis showed that alternatively spliced transcripts of the Vp-1A, Vp-1B, and Vp-1D homologues were present and there were no differences in the splicing patterns or abundances of Vp-1A and Vp-1D from embryos 35 d after pollination between PHS-tolerant and -susceptible cultivars. Although Vp-1Ba, Vp-1Bb, and Vp-1Bc could each produce a set of transcripts, only one was correctly spliced and had the capacity to encode the full-length VP1 protein and was more highly expressed with Vp-1Bb and Vp-1Bc than with Vp-1Ba. Comparison of the expression patterns of Vp-1Ba, Vp-1Bb, and Vp-1Bc on different days after pollination also revealed that the expression of these genes was developmentally regulated. Furthermore, genotypes with different levels of tolerance to PHS respond differently to ABA exposure and differences in transcript levels of Vp-1Ba, Vp-1Bb, and Vp-1Bc were observed after ABA treatment. The results indicated that insertion or deletion in the third intron region might affect the expression of the Vp-1B gene and its sensitivity to ABA, and thus resistance to PHS.

Methylphenidate regulates activity regulated cytoskeletal associated but not brain-derived neurotrophic factor gene expression in the developing rat striatum

Methylphenidate (MPH) is a psychostimulant drug used to treat attention deficit hyperactivity disorder in children. To explore the central effects of chronic MPH, we investigated the expression of an effector immediate early gene, activity regulated cytoskeletal associated (arc), and the neurotrophin, brain-derived neurotrophic factor (bdnf) in the brain of immature and adult rats following repeated MPH. Prepubertal (postnatal day (PD) 25-38) and adult (PD 53-66) male rats were injected once daily for: a) 14 days with saline or MPH (2 or 10 mg/kg; s.c.) or b) 13 days with saline followed by a single dose of MPH (2 or 10 mg/kg; s.c.). To determine possible long-term effects of MPH, prepubertal rats were allowed a drug-free period of 4 weeks following the 14 days of treatment, and then were given a challenge dose of MPH. We demonstrated, for the first time, that an acute injection of MPH increased levels of activity-regulated cytoskeletal protein (ARC) and arc mRNA in the prepubertal rat striatum and cingulate/frontal cortex. This response was significantly attenuated by chronic MPH. The desensitization in arc expression observed in prepubertal rats persisted in the adult striatum following a later MPH challenge. In contrast to these data we observed little effect of MPH on bdnf expression. We also developed an effective, non-stressful technique to treat freely moving immature rats with oral MPH. Consistent with the results described above, we observed that oral MPH (7.5 and 10 mg/kg) also increased arc expression in the prepubertal rat striatum. However, unlike the effects of injected MPH, repeated oral MPH (7.5 mg/kg) did not alter the normal arc response. This result raises the important possibility that oral doses of MPH that reproduce clinically relevant blood levels of MPH may not down-regulate gene expression, at least in the short term (14 days). We confirmed, using mass spectrometry, that the oral doses of MPH used in our experiments yielded blood levels within the clinical range observed in children. The novel oral administration paradigm that we describe thus provides a clinically relevant animal model to further explore the effects of chronic drug exposure on central gene expression in the developing rat brain.

Gbrowse Moby: a Web-based browser for BioMoby Services

Background

The BioMoby project aims to identify and deploy standards and conventions that aid in the discovery, execution, and pipelining of distributed bioinformatics Web Services. As of August, 2006, approximately 680 bioinformatics resources were available through the BioMoby interoperability platform. There are a variety of clients that can interact with BioMoby-style services. Here we describe a Web-based browser-style client – Gbrowse Moby – that allows users to discover and "surf" from one bioinformatics service to the next using a semantically-aided browsing interface.

Results

Gbrowse Moby is a low-throughput, exploratory tool specifically aimed at non-informaticians. It provides a straightforward, minimal interface that enables a researcher to query the BioMoby Central web service registry for data retrieval or analytical tools of interest, and then select and execute their chosen tool with a single mouse-click. The data is preserved at each step, thus allowing the researcher to manually "click" the data from one service to the next, with the Gbrowse Moby application managing all data formatting and interface interpretation on their behalf. The path of manual exploration is preserved and can be downloaded for import into automated, high-throughput tools such as Taverna. Gbrowse Moby also includes a robust data rendering system to ensure that all new data-types that appear in the BioMoby registry can be properly displayed in the Web interface.

Conclusion

Gbrowse Moby is a robust, yet facile entry point for both newcomers to the BioMoby interoperability project who wish to manually explore what is known about their data of interest, as well as experienced users who wish to observe the functionality of their analytical workflows prior to running them in a high-throughput environment.

The relationship between the lactate turnpoint and the time at VO2max during a constant velocity run to exhaustion

The present investigation examined the relationship between the running velocity at the lactate turnpoint (vLTP) and the time at which VO2max can be sustained (TVO2max) during a continuous run to exhaustion at the minimal running velocity that elicits VO2max (vVO2max). Seven moderately-trained endurance runners undertook three tests on a treadmill. The first test was to determine vVO2max; the second to determine the time to exhaustion during a constant velocity run at vVO2max (Tlim vVO2max) and TVO2max; and the third to determine the vLTP. Pearson's correlation coefficient was used to determine the association between the vLTP (%vVO2max; i.e. the relative vLTP) and TVO2max, and between other selected physiological variables. Correlations between the relative vLTP and TVO2max, expressed as a percentage of T(lim vVO2max (the relative TVO2max; r=0.82), and between TVO2max and Tlim vVO2max (r=0.89), were significant at the p<0.05 level. All other correlations between selected measured physiological variables were found to be statistically insignificant. The main finding of this present study is that the relative vLTP demonstrated a significant positive correlation with the relative TVO2max. The physiological mechanism by which the lactate turnpoint may influence the relative TVO2max has not been elucidated, but may be due to a combination of decreasing the time to attain VO2max and increasing Tlim vVO2max. The present investigation has demonstrated that the lactate turnpoint may influence the relative time at which VO2max can be sustained during a continuous run to exhaustion at vVO2max, although further research is required to substantiate these findings.

High friction from a stiff polymer using microfiber arrays

High dry friction requires intimate contact between two surfaces and is generally obtained using soft materials with an elastic modulus less than 10 MPa. We demonstrate that high-friction properties similar to rubberlike materials can also be obtained using microfiber arrays constructed from a stiff thermoplastic (polypropylene, 1 GPa). The fiber arrays have a smaller true area of contact than a rubberlike material, but polypropylene's higher interfacial shear strength provides an effective friction coefficient of greater than 5 at normal loads of 8 kPa. At the pressures tested, the fiber arrays showed more than an order of magnitude increase in shear resistance compared to the bulk material. Unlike softer materials, vertical fiber arrays of stiff polymer demonstrate no measurable adhesion on smooth surfaces due to high tensile stiffness.

Photopatch testing of 1155 patients: results of the U.K. multicentre photopatch study group

BACKGROUND

Photoallergic contact dermatitis can be difficult to diagnose if not appropriately investigated. Currently, the most common U.K. photoallergens appear to be sunscreen chemicals. The investigation of choice is photopatch testing (PPT), which is probably underused. In part, this is due to differences in methodology and results interpretation.

OBJECTIVES

To conduct PPT using a group of sunscreen chemicals, defined indications and a standardized methodology including interpretation and relevance of reactions in patients attending for investigation at 17 centres across the U.K., Ireland and the Netherlands.

METHODS

Patients (n = 1155) who fulfilled the inclusion criteria were investigated with PPT using sunscreen chemicals in addition to suspected topical products. Readings were taken at 24, 48 and 72 h following standardized ultraviolet A irradiation (5 J cm(-2)). The clinical relevance of any reaction was recorded.

RESULTS

Of the 1155, 130 had allergic reactions (11.3%). Of these, 51 had photoallergy (PA) (4.4%), 64 had contact allergy (CA) (5.5%), and 15 patients had combined PA and CA (1.3%). Multiple PA was seen in some. The most common photoallergen was benzophenone-3 (27 reactions; 21%). Most reactions (60%) were clinically relevant. The most common indication for testing in patients found to have PA was a history of reacting to a sunscreen (41%). The other 59% had an exposed-site dermatitis/skin problem or a photodermatosis. Some centres (n = 8) performed readings after the standard 48-h reading, and an extra 32 PA and 22 CA reactions were detected, which were not evident at 48 h. A new photoallergen (octyl triazone) was detected in two patients.

CONCLUSIONS

Sunscreen PA and CA are probably equally uncommon. Most reactions, of both reaction types, were relevant clinically. A large proportion of patients (59%) found to have PA was unaware of reacting to a sunscreen chemical, suggesting that PA should be considered as an explanation in any exposed-site dermatitis. Although this study focused on reactions at 48 h postirradiation, readings performed up to 96 h, while inconvenient, add value by detecting additional relevant responses. A previously unknown photoallergen was found, highlighting the need for awareness of novel photoallergens in the marketplace. A standardized PPT method not only encourages more use of this investigation, but also facilitates comparison of results between centres and so will improve our understanding of PA.

A phase II study of weekly gemcitabine and docetaxel in first and second line metastatic breast cancer

10668

Background: Combination chemotherapy for metastatic breast cancer has generally been demonstrated to be associated with a higher response rate than single agent therapy, however such therapy is often accompanied by increased toxicity. Thus there is a need to develop well-tolerated combination chemotherapy regimens. Gemcitabine and docetaxel are both active agents in the treatment of this disease, and are effective and well tolerated when administered on a weekly basis. The purpose of this study was to evaluate the therapeutic efficacy and toxicity of weekly gemcitabine and docetaxel as first or second line treatment of metastatic breast cancer (MBC). Methods: Patients with measurable MBC who had received no more than 1 prior chemotherapy regimen in the metastatic setting were treated with gemcitabine 800 mg/m2 and docetaxel 30 mg/m2 on days 1 and 8 every 21 days without growth factor support. Results: Thirty-one patients were enrolled. Twenty-nine patients were evaluable for toxicity and 25 for efficacy. Median age was 55 (range 30 to 79). Visceral disease was the dominant site in 74% of patients. Doxorubicin and paclitaxel were previously administered in 74% and 48% of patients respectively. The overall response rate was 56% (complete response in 1 patient and partial responses in 13 patients). Stable disease was evident in 10 additional patients (38.4%). The progression free survival was 35 weeks (range 9 to 101 weeks) and the median overall survival was 17 months. Treatment was well tolerated with the majority of toxicities being grade 1 or 2 (85%). The only grade 3 (G3) or 4 (G4) toxicities observed were neutropenia in 14 participants (G3 41%; G4 7%), anemia in 4 (13%), G3 elevated transaminases in 3 (10%), G3 thrombocytopenia in 1 (3%), G3 flu-like symptoms in 2 (7%) and G3 edema in 1 (3%). Conclusions: The regimen of gemcitabine 800 mg/m2 and docetaxel 30 mg/m2 given two weeks out of three for MBC showed excellent overall response of 56% with very good tolerability. The findings from our trial compare well to the response rates of 36% to 79% seen in prior phase II trials utilizing higher doses of this combination chemotherapy.

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Criteria and other methodological considerations in the evaluation of time at V.O2max

AIM

Many previous studies have examined the time limit at which an individual can maintain VO(2max) (T(lim) VO(2max)) during high-intensity continuous and intermittent runs to exhaustion. The main purpose of the present study was to examine the effects of employing different criteria used in previous investigations during T(lim) VO(2max) evaluation.

METHODS

Seven moderately trained competitive runners completed 2 running tests to exhaustion, during which metabolic data was obtained from breath-by-breath gas analysis. The 1(st) test was an incremental test to evaluate VO(2max) and the minimal running velocity at which VO(2max) was elicited (v VO(2max)). The 2(nd) test was a continuous single velocity test at v VO(2max) from which the time to attain VO(2max) (TA VO(2max)) and T(lim) VO(2max) were subsequently evaluated. Time at VO(2max) was evaluated employing 6 specific criteria. Intra-individual differences in T(lim) VO(2max) values due to applying the different criteria were analysed using a one-way ANOVA, with significant differences between pairs identified using Tukey's HSD posthoc test. Significance was set at p<0.05.

RESULTS

A one-way ANOVA demonstrated that significant differences (F=4.03, p=0.005) existed between T(lim) VO(2max) values generated by employing the six different criteria.

CONCLUSIONS

The present study provides support that employing different criteria in the evaluation of T(lim) VO(2max), such as those used in previous investigations, leads to significantly different T(lim) VO(2max) values. However, the practical implications of these measurement differences require further investigation.

Organ doses from prostate radiotherapy and associated concomitant exposures

In addition to the therapeutic exposure, a course of radiotherapy will involve the additional (concomitant) irradiation of the patient using CT, simulator or portal imaging systems, for localization of the target volume and subsequent verification of treatment delivery. The number of concomitant exposures is likely to increase as the developing technical capabilities for conformal, image-guided radiotherapy make target and critical organ definition an increasingly important aspect of radiotherapy. Estimation of doses and risks to critical organs in the body from all sources is thus necessary to provide the basis for adequate justification of the exposures as required by ICRP. In this paper, doses to selected organs and tissues for which ICRP have identified fatal cancer probabilities have been measured using a realistic anthropomorphic phantom loaded with thermoluminescent dosemeters and irradiated using a treatment protocol for radical radiotherapy of the prostate. Independently, doses to the same organs and tissues have been measured from concomitant CT and portal imaging exposures given for localization and verification purposes. Although negligible in comparison with the target dose, realistic numbers of concomitant exposures give a small but significant contribution to the total dose to most organs and tissues outside the target volume. Generally, this is in the range 5-10% of the total organ dose, but can be as high as 20% for bone surfaces. These data may be used to estimate concomitant doses from any combination of CT and portal imaging and may help in the justification process, especially when additional verification exposures may be required during treatment.