15901
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Abstract
AIMS To describe paediatric experience, and to assess complications and therapeutic effectiveness of the use of endoluminal gastroplication in children with gastro-oesophageal reflux disease (GORD) refractory to, or dependent on, proton pump inhibitors. METHODS Seventeen (five male) consecutive children/adolescents (median (range) age 12.4 (6.1-15.9) years, median (range) weight 46.0 (16.5-87.5) kg) with GORD either dependent for more than 12 months on proton pump inhibitors or non-responsive to medical treatment underwent endoscopic gastroplication using a flexible endoscopic sewing device (EndoCinch). Three plications were placed in gastric tissue below the lower oesophageal sphincter. Drug dose requirement, pH measurements, daily symptom severity and frequency, and validated reflux (QOLRAD) and general gastrointestinal (GSRS) quality of life scores were compared before and after endoscopic gastroplication. RESULTS All patients showed post-treatment improvement in symptom severity, frequency, and quality of life scores (p<0.0001). Three patients with recurrent symptomatic GORD had a repeat procedure within six weeks and did well subsequently. At up to 33 months of follow up (median 23), 14/17 patients remained off all antireflux medications, and 14/17 had maintained their symptomatic improvement. All pH parameters improved and had returned to normal values in 14/16 patients post-treatment and in 6/9 after one year of follow-up: in particular the reflux index had decreased from a median of 16.6% (0.9-67%) to 2.5% (0.7-15.7%) (p<0.0001) six weeks and 4.3% (2.2-20.6) (p<0.02) 12 months post-procedure. The only complication observed was gastric bleeding in one patient due to previously undiagnosed coagulopathy, which spontaneously resolved. CONCLUSIONS Endoluminal gastroplication is an effective and safe procedure in children/adolescents with significant GORD refractory to, or dependent on, medical anti-GORD therapy.
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Affiliation(s)
- M Thomson
- Centre for Paediatric Gastroenterology, Sheffield Children's Hospital, Western Bank, Sheffield S10 2TH, UK.
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15902
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Abstract
AIMS To carry out a retrospective review of all postmortem reports during the period 1991 to 2000 at King's College Hospital, London, as an extension of a previous analysis performed for the period 1965 to 1990. METHODS The number of deaths resulting from necropsy confirmed fatal pulmonary embolism in hospitalised patients was determined, and a limited analysis of the clinical characteristics of those patients who died was performed. RESULTS During the 10 year period, 16 104 deaths occurred and 6833 (42.4%) necropsies were performed. The outcome measure, fatal pulmonary embolism, was recorded as cause of death in 265 cases (3.9% of all necropsies; 5.2% of adult cases). No deaths from pulmonary embolism occurred in patients under 18 years of age; 80.0% occurred in patients older than 60 years. Of the fatal emboli, 214 of 265 (80.8%) occurred in patients who had not undergone recent surgery. Of these patients, 110 (51.4%) had suffered an acute medical illness in the six weeks before death, most often an acute infectious episode (26 cases). CONCLUSIONS Thromboembolic events remain a relatively common cause of death in hospitalised patients and appear to occur more frequently in non-surgical than in surgical patients.
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Affiliation(s)
- R Alikhan
- Department of Medicine, Royal United Hospital, Combe Park, Bath BA1 3NG, UK
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15903
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Abstract
Teleoperated minimally invasive surgical robots can significantly enhance a surgeon's accuracy, dexterity and visualization. However, current commercially available systems do not include significant haptic (force and tactile) feedback to the operator. This paper describes experiments to characterize this problem, as well as several methods to provide haptic feedback in order to improve surgeon's performance. There exist a variety of sensing and control methods that enable haptic feedback, although a number of practical considerations, e.g. cost, complexity and biocompatibility, present significant challenges. The ability of teleoperated robot-assisted surgical systems to measure and display haptic information leads to a number of additional exciting clinical and scientific opportunities, such as active operator assistance through "virtual fixtures" and the automatic acquisition of tissue properties.
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Affiliation(s)
- A M Okamura
- is based in the Department of Mechanical Engineering, The Johns Hopkins University, Baltimore, Maryland, USA
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15904
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Abstract
Infective endocarditis (IE) is a life-threatening disease with substantial morbidity and mortality which affects individuals with underlying structural cardiac defects who develop bacteraemia, often as a result of dental, gastrointestinal, genitourinary, respiratory or cardiac invasive/surgical procedures. Prompt recognition of the clinical diagnosis by a wide variety of medical personnel, early involvement of specialist cardiologists, cardiac surgeon and a microbiologist, and prompt treatment with the most appropriate antimicrobial agents offer the greatest chance of improving the outcome for these patients. The guidance given here to clinicians involved in the management of patients with IE briefly covers diagnosis, antibiotic prophylaxis, medical treatment and the indications for surgery.
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15905
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Elsas PX, Neto HAP, Cheraim AB, Magalhães ESS, Accioly MTS, Carvalho VF, e Silva PMR, Vargaftig BB, Cunha FQ, Gaspar Elsas MIC. Induction of bone-marrow eosinophilia in mice submitted to surgery is dependent on stress-induced secretion of glucocorticoids. Br J Pharmacol 2004; 143:541-8. [PMID: 15381631 PMCID: PMC1575426 DOI: 10.1038/sj.bjp.0705943] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2004] [Revised: 06/23/2004] [Accepted: 07/08/2004] [Indexed: 12/21/2022] Open
Abstract
1 We examined bone-marrow in mice receiving subcutaneous implants of heat-coagulated egg white, which are known to present chronic eosinophilic inflammation at the implant site. Egg white implants (EWIs) induced marked bone-marrow eosinophilia, and increased bone-marrow cell responses to granulocyte-macrophage colony-stimulating factor and interleukin-5 in culture. These effects were observed as early as 24 h and lasted for, at least, 30 days in implant recipients. 2 We found, however, that increased eosinophil production was also observed in control mice which underwent surgery but received no EWI (sham-implanted mice), up to 15 days post-surgery. As this suggests an important contribution of nonspecific stress mechanisms to eosinopoiesis, we further evaluated the role of stress hormones produced by the adrenal glands in the bone-marrow eosinophilia of sham-implanted mice. 3 Bone-marrow eosinophilia in mice undergoing surgery was dissociated from increases in other haemopoietic lineages. Surgery by itself increased circulating corticosterone levels by 24 h, and the increase was prevented by inhibition of adrenal glucocorticoid production by metyrapone. The effect of surgery on bone-marrow eosinophilia was prevented by pretreatment with both the glucocorticoid receptor antagonist, mifepristone, and metyrapone, and by surgical adrenalectomy. 4 By contrast, cathecolamine receptor antagonists (propranolol, prazosin and yohimbine) were ineffective, indicating that cathecolamine release from the adrenal glands was not responsible for the effects on bone-marrow. 5 These results highlight a critical role for stress-induced glucocorticoid hormones in selectively upregulating bone-marrow eosinopoiesis in mice submitted to surgery.
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Affiliation(s)
- Pedro Xavier Elsas
- Departamento de Imunologia, Instituto de Microbiologia Prof. Paulo de Góes, UFRJ, Rio de Janeiro, Brazil.
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15906
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Jones GJ, Vanderpump MPJ, Easton M, Baker DM, Ball C, Leenane M, O'Brien H, Turner N, Else M, Reid WMN, Johnson M. Achieving compliance with the European Working Time Directive in a large teaching hospital: a strategic approach. Clin Med (Lond) 2004; 4:427-30. [PMID: 15536871 PMCID: PMC5351900 DOI: 10.7861/clinmedicine.4-5-427] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
This paper describes the strategy which achieved European Working Time Directive (EWTD) compliance at the Royal Free Hampstead NHS Trust in medicine and surgery. Compliance with EWTD regulations was assessed by diary card exercise, clinical care assessed through critical incident reports, electronic handover documents and nursing reports, training opportunities assessed by unit training directors, cost controls assessed by finance department analysis, and workload assessed by staff attendance on wards, in casualty and in theatres. There was a change in focus of care to a consultant-led, specialist registrar- (SpR-)driven service extending into evenings and on weekends, coupled with a move to a multi-skilled team for night cover, and to a move from traditional on-call shifts to a full shift system across both medicine and surgery. Compliance with the EWTD was achieved whilst maintaining good standards of clinical care, ensuring training opportunities for doctors in training, controlling payroll costs, removing the need for locums, and reducing workload for both junior doctors and consultants.
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15907
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Forcione DG, Rosen MJ, Kisiel JB, Sands BE. Anti-Saccharomyces cerevisiae antibody (ASCA) positivity is associated with increased risk for early surgery in Crohn's disease. Gut 2004; 53:1117-22. [PMID: 15247177 PMCID: PMC1774147 DOI: 10.1136/gut.2003.030734] [Citation(s) in RCA: 100] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Revised: 01/15/2004] [Accepted: 01/17/2004] [Indexed: 12/17/2022]
Abstract
BACKGROUND Anti-Saccharomyces cerevisiae antibodies (ASCA) are a specific but only moderately sensitive diagnostic marker for Crohn's disease. We sought to explore the role of ASCA as a prognostic marker for aggressive disease phenotype in Crohn's disease. AIMS To determine the role of ASCA status as a risk factor for early surgery in Crohn's disease. SUBJECTS We performed a case control study in a cohort of patients, newly diagnosed with Crohn's disease, between 1991 and 1999. All patients were followed for at least three years. Case subjects (n = 35) included those who had major surgery for Crohn's disease within three years of diagnosis. Controls (n = 35) included patients matched to cases for age, sex, disease location, and smoking status, and who did not undergo major surgery for Crohn's disease within three years of diagnosis. METHODS Blinded assays were performed on serum for ASCA (immunoglobulin (Ig)A and IgG). A paired analysis of cases-controls was performed to test for the association between ASCA status and risk of early surgery. RESULTS ASCA IgA was strongly associated with early surgery (odds ratio (OR) 8.5 (95% confidence interval (CI) 2.0-75.9); p = 0.0013). ASCA IgG+ and ASCA IgG+/IgA+ patients were also at increased risk for early surgery (OR 5.5 (95% CI 1.2-51.1), p = 0.0265; and OR 5.0 (95% CI 1.1-46.9), p = 0.0433, respectively). The association between ASCA and early surgery was evident in patients requiring surgery for ileal or ileocolonic disease. CONCLUSIONS Patients with Crohn's disease who are positive for ASCA IgA, IgG, or both, may define a subset of patients with Crohn's disease at increased risk for early surgery.
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Affiliation(s)
- D G Forcione
- Gastrointestinal Unit and Center for the Study of Inflammatory Bowel Disease, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
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15908
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Sahin N, Atici T, Bilgen SM, Bilgen OF. Turf toe in a taekwandoo player: case report. J Sports Sci Med 2004; 3:96-100. [PMID: 24482585 PMCID: PMC3899538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2004] [Accepted: 03/19/2004] [Indexed: 06/03/2023]
Abstract
Metatarsophalengeal joint injuries of great toe termed as ''turf toe" can occur in many sportive activities. However, it has not been reported before in taekwondoo players. These injuries may result in significant morbidity. Turf toe injuries, which are mainly treated with conservative methods, occasionally require surgery. In this case report, we present a surgically treated turf toe in a taekwondoo player. Key PointsMTP joint injury may occur when the joint is forced into hyperextension repeatedly if the exercise is being performed bare foot on hard and artificial surfaces.Surgery should be taken into consideration as a choice of treatment of Turf Toe.
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Affiliation(s)
- Namik Sahin
- Clinics of Orthopedics and Traumatology, SSK Hospital , Bursa, Turkey
| | - Teoman Atici
- Clinics of Orthopedics and Traumatology, SSK Hospital , Bursa, Turkey
| | - Sadik M Bilgen
- Clinics of Orthopedics and Traumatology, Sarıyer State Hospital , Istanbul, Turkey
| | - Omer F Bilgen
- Department of Orthopedics and Traumatology, Uludag University , Bursa, Turkey
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15909
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Abstract
Aortoenteric fistula is one of the most challenging problems that confront the vascular surgeons. Controversy remains over the optimal treatment because of the continued publication of series with high mortality, amputation, and aortic disruption rates. A positive preoperative blood culture is the best predictor of mortality with increased amputation rates due to infection of the extra-anatomic bypass. Therefore, in selected cases with sepsis, a prudent management protocol is required. We report a 68-yr-old male presenting with a chronic primary aortoduodenal fistula extensively involving the duodenum and Gram-negative sepsis. We planned a staged operation. Initially, an emergency laparotomy and control of the aorta allowed stabilization of the patient, identification of the fistula, and direct in situ placement of the prosthetic graft followed by an en bloc resection of the aneurysm and the surrounding structures. After he recovered from sepsis and had been stabilized, a staged extra-anatomic bypass followed by transabdominal removal of the temporarily placed graft was done. This management plan will allow the highest success rate and may be a prudent management protocol for these difficult cases.
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Affiliation(s)
- Yong Pil Cho
- Department of Surgery, University of Ulsan College of Medicine, Gangneung Asan Hospital, Gangneung, Korea.
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15910
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Affiliation(s)
- R R Cima
- Division of Colon and Rectal Surgery, Mayo Clinic, St. Mary's Hospital, 200 First Street SW, Rochester, MN 55901, USA
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15911
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Affiliation(s)
- M A Kamm
- Department of Gastroenterology, St. Mark's Hospital, Watford Road, Harrow HA1 3UJ, UK.
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15912
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Penninckx F. Caring about the quality of surgical care in Belgium ? Why and how Opening lecture of the 5 th Belgian Surgical Week. Acta Chir Belg 2004; 104:243-245. [PMID: 28417713 DOI: 10.1080/00015458.2004.11681149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- F. Penninckx
- Department of Abdominal Surgery, University Clinic Gasthuisberg, Herestraat 49, 3000-Leuven. Belgium
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15913
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Agresta F, De Simone P, Bedin N. The laparoscopic approach in abdominal emergencies: a single-center 10-year experience. JSLS 2004; 8:25-30. [PMID: 14974658 PMCID: PMC3015501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
INTRODUCTION Laparoscopy has rapidly emerged as the preferred surgical approach to a number of different diseases because it allows for a correct diagnosis and proper treatment. In abdominal emergencies, both components of treatment--exploration and surgery--can be accomplished via laparoscopy. The aim of the present work is to illustrate retrospectively the results of a case-control experience with laparoscopic versus open surgery for abdominal emergencies performed at our institution. METHODS From January 1992 to January 2002, 935 patients (mean age, 42.3+/-17.2 years) underwent emergent or urgent surgery, or both. Of these, 602 (64.3%) were operated on laparoscopically (small bowel obstruction, 28; gastroduodenal ulcer disease, 25; biliary disease, 165; pelvic disease, 370 cases; colonic perforations, 14) based on the availability of a surgical team trained in laparoscopy. Patients with a history of malignancy, more than 2 previous major abdominal surgeries, or massive bowel distension were not treated laparoscopically. Peritonitis was not deemed a contraindication to laparoscopy. RESULTS The conversion rate was 5.8% and was mainly due to the presence of dense intraabdominal adhesions. Major complications ranged as high as 2.1% with a postoperative mortality of 0.6%. A definitive diagnosis was accomplished in 96.3% of cases, and 94.1% of these patients were treated successfully with laparoscopy. CONCLUSIONS Even if limited by its retrospective nature, the present experience shows that the laparoscopic approach to abdominal emergencies is as safe and effective as conventional surgery, has a higher diagnostic yield, and results in less trauma and a more rapid postoperative recovery. Such features make laparoscopy an attractive alternative to open surgery in the management algorithm for abdominal emergencies.
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Affiliation(s)
- Ferdinando Agresta
- Department of General Surgery, Presidio Ospedaliero di Vittorio Veneto, TV, Italy.
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15914
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de Vos tot Nederveen Cappel WH, Buskens E, van Duijvendijk P, Cats A, Menko FH, Griffioen G, Slors JF, Nagengast FM, Kleibeuker JH, Vasen HFA. Decision analysis in the surgical treatment of colorectal cancer due to a mismatch repair gene defect. Gut 2003; 52:1752-5. [PMID: 14633956 PMCID: PMC1773904 DOI: 10.1136/gut.52.12.1752] [Citation(s) in RCA: 103] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND In view of the high risk of developing a new primary colorectal carcinoma (CRC), subtotal colectomy rather than segmental resection or hemicolectomy is the preferred treatment in hereditary non-polyposis colorectal cancer (HNPCC) patients. Subtotal colectomy however implies a substantial decrease in quality of life. To date, colonoscopic surveillance has been shown to reduce CRC occurrence. AIMS To compare the potential health effects in terms of life expectancy (LE) for patients undergoing subtotal colectomy or hemicolectomy for CRC. METHODS A decision analysis (Markov) model was created. Information on the 10 year risk of CRC after subtotal colectomy (4%) and hemicolectomy (16%) and stages of CRCs detected within a two year surveillance interval (32% Dukes' A, 54% Dukes' B, and 14% Dukes' C) were derived from two cohort studies. Five year survival rates used for the different Dukes stages (A, B, and C) were 98%, 80%, and 60%, respectively. Remaining LE values were calculated for hypothetical cohorts with an age at CRC diagnosis of 27, 47, and 67 years, respectively. Remaining LE values were also calculated for patients with CRC of Dukes' stage A. RESULTS The overall LE gain of subtotal colectomy compared with hemicolectomy at ages 27, 47, and 67 was 2.3, 1, and 0.3 years, respectively. Specifically for Dukes' stage A, this would be 3.4, 1.5, and 0.4 years. CONCLUSIONS Unless surveillance results improve, subtotal colectomy still seems the preferred treatment for CRC in HNPCC in view of the difference in LE. For older patients, hemicolectomy may be an option as there is no appreciable difference in LE.
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15915
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Gunzburg R, Szpalski M. The conservative surgical treatment of lumbar spinal stenosis in the elderly. Eur Spine J 2003; 12 Suppl 2:S176-80. [PMID: 12961080 PMCID: PMC3591835 DOI: 10.1007/s00586-003-0611-2] [Citation(s) in RCA: 75] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2003] [Accepted: 07/31/2003] [Indexed: 12/01/2022]
Abstract
Canal stenosis is now the most common indication for lumbar spine surgery in elderly subjects. Degenerative disc disease is by far the most common cause of lumbar spinal stenosis. It is generally accepted that surgery is indicated if a well-conducted conservative management fails. A meta-analysis of the literature showed on average that 64% of surgically treated patients for lumbar spinal stenosis were reported to have good-to-excellent outcomes. In recent years, however, a growing tendency towards less invasive decompressive surgery has emerged. One such procedure, laminarthrectomy, refers to a surgical decompression involving a partial laminectomy of the vertebra above and below the stenotic level combined with a partial arthrectomy at that level. It can be performed through an approach which preserves a maximum of bony and ligamentous structures. Another principle of surgical treatment is interspinous process distraction This device is implanted between the spinous processes, thus reducing extension at the symptomatic level(s), yet allowing flexion and unrestricted axial rotation and lateral flexion. It limits the further narrowing of the canal in upright and extended position. In accordance with the current general tendency towards minimally invasive surgery, such techniques, which preserve much of the anatomy, and the biomechanical function of the lumbar spine may prove highly indicated in the surgical treatment of lumbar stenosis, especially in the elderly.
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Affiliation(s)
- Robert Gunzburg
- Department of Orthopaedics, Eeuwfeestkliniek, Harmoniestraat 68, 2018, Antwerp, Belgium.
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15916
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Mac-Thiong JM, Labelle H, Rooze M, Feipel V, Aubin CE. Evaluation of a transpedicular drill guide for pedicle screw placement in the thoracic spine. Eur Spine J 2003; 12:542-7. [PMID: 12783286 PMCID: PMC3468009 DOI: 10.1007/s00586-003-0549-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2002] [Revised: 02/05/2003] [Accepted: 02/14/2003] [Indexed: 10/26/2022]
Abstract
Insertion of pedicle screws in the thoracic spine is technically difficult and may lead to major complications. Although many computer-assisted systems have been developed to optimize pedicle screw insertion, these systems are expensive, not user-friendly and involve significant radiation from pre-operative computed tomographic (CT) scan imaging. This study describes and evaluates a transpedicular drill guide (TDG) designed to assist in the proper placement of pedicle screws in the thoracic spine. Pilot holes were made manually using the TDG in the thoracic spine (T1-T11) of three human cadavers before inserting 4.5-mm-diameter screws. CT scans followed by visual inspection of the spines were performed to evaluate the position of the screws. Five of 66 screws (7.6%) violated the pedicle wall: two (3.0%) medially and three (4.5%) laterally. The medial and lateral perforations were within 1 mm and 2 mm of the pedicle wall, respectively. The medial perforations were not at risk of causing neurological complications. No screw penetrated the superior or inferior pedicle wall. The TDG is easy to use and can decrease the incidence of misplaced thoracic pedicle screws. The TDG could be used as a complement to fluoroscopy in certain applications, especially for training surgeons.
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Affiliation(s)
- Jean-Marc Mac-Thiong
- Department of Surgery, Faculty of Medicine, University of Montreal, Quebec, Canada
- Research Center, Sainte-Justine Mother-Child University Hospital, 3175 Cote-Sainte-Catherine Rd, Montreal, Quebec H3T 1C5 Canada
| | - Hubert Labelle
- Department of Surgery, Faculty of Medicine, University of Montreal, Quebec, Canada
- Research Center, Sainte-Justine Mother-Child University Hospital, 3175 Cote-Sainte-Catherine Rd, Montreal, Quebec H3T 1C5 Canada
| | - Marcel Rooze
- Laboratory for Functional Anatomy and for Anatomy and Embryology, University of Brussels, Belgium
| | - Véronique Feipel
- Laboratory for Functional Anatomy and for Anatomy and Embryology, University of Brussels, Belgium
| | - Carl-Eric Aubin
- Research Center, Sainte-Justine Mother-Child University Hospital, 3175 Cote-Sainte-Catherine Rd, Montreal, Quebec H3T 1C5 Canada
- Department of Mechanical Engineering, Ecole Polytechnique, Montreal, Quebec Canada
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15917
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van Sandick JW, Boermeester MA, Gisbertz SS, ten Berge IJM, Out TA, van der Pouw Kraan TCTM, van Lanschot JJB. Lymphocyte subsets and T(h)1/T(h)2 immune responses in patients with adenocarcinoma of the oesophagus or oesophagogastric junction: relation to pTNM stage and clinical outcome. Cancer Immunol Immunother 2003; 52:617-24. [PMID: 12802519 PMCID: PMC11034314 DOI: 10.1007/s00262-003-0406-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2003] [Accepted: 04/04/2003] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Recent studies have indicated that the cytokines produced by CD4(+) T helper type 1 (T(h)1) and type 2 (T(h)2) cells are critically important in antitumour immunity and perhaps clinical outcome. From this perspective, we investigated the immunocompetence of patients with previously untreated cancer of the oesophagus or oesophagogastric junction (OGJ) in relation to stage of disease and postoperative survival. METHODS Blood samples were taken prior to surgery from 32 patients with adenocarcinoma of the oesophagus or OGJ. Ten healthy volunteers served as normal controls. T-cell and monocyte subpopulations were determined using flow cytometry. Monocyte as well as T(h)1- and T(h)2-lymphocyte cytokine levels were assessed in stimulated whole blood cultures. RESULTS Absolute T-cell and monocyte (subset) counts as well as monocyte cytokine levels were similar among patients and controls. Production of T(h)1-type cytokines was higher in patients than in controls (IFN-gamma, p=0.01; IL-2, p=0.05), whereas T(h)2-type cytokine levels were comparable (IL-4, p=0.5; IL-13, p=0.3). T-cell CD4(+)/CD8(+) ratios decreased as pTNM stage worsened (stage I/II vs stage III/IV, p=0.009). Of all measured immunological parameters, only IL-2 production significantly affected both overall survival ( p=0.015) and disease-free survival ( p=0.0062). High IL-2 levels corresponded with a favourable prognosis. CONCLUSIONS Patients awaiting surgery for adenocarcinoma of the oesophagus or oesophagogastric junction demonstrated a shift in the T(h)1/T(h)2 balance-in favour of T(h)1-compared with healthy volunteers. The ability of T cells to produce IL-2 was related to survival indicating a crucial role of T(h)1-type cells in antitumour immunosurveillance.
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Affiliation(s)
- Johanna W van Sandick
- Department of Surgery, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
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15918
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Marsh A, Edge G, Lehovsky J. Spinal fusion in patients with Duchenne's muscular dystrophy and a low forced vital capacity. Eur Spine J 2003; 12:507-12. [PMID: 12748897 PMCID: PMC3468015 DOI: 10.1007/s00586-003-0545-8] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/10/2001] [Revised: 01/27/2003] [Accepted: 02/07/2003] [Indexed: 10/26/2022]
Abstract
Traditionally, spinal fusion has been denied to patients with scoliosis secondary to Duchenne's muscular dystrophy (DMD) when their forced vital capacity (FVC) is less than 30-40% of predicted values (PFVC). The reasons for this decision are a theoretically increased risk of adverse events from a prolonged anaesthetic and extensive surgery. This paper presents a retrospective analysis of 30 patients with DMD scoliosis who underwent posterior spinal fusion at the Royal National Orthopaedic Hospital. Two subgroups of patients were compared: those with more than 30% PFVC (17 patients) and those with less than 30% PVFC (13 patients). One patient in each group required a temporary tracheotomy and there were nine complications in total. The post-operative stay for patients in each group was similar (24 days in the >30% group, 20 days in the <30% group) and the complication rate was comparable with other published series. We conclude that spinal fusion can be offered to patients with DMD even in the presence of a low FVC.
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Affiliation(s)
- A Marsh
- Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, Middlesex, UK.
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15919
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15920
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Abstract
OBJECTIVES To assess (1) the clinical issues addressed during the medical encounter; (2) the feasibility of the process of shared decision-making in clinical practice and (3) patients' desires concerning the question of 'who should take the decision in breast cancer treatments?' DESIGN Qualitative pilot study based on clinical encounters using decision boards and information booklets. SETTING Centre Léon Bérard, a comprehensive cancer centre in the Rhône-Alpes region of France. PARTICIPANTS One breast cancer surgeon and 22 breast cancer patients. MAIN OUTCOME MEASURES Analysis of patients' reactions to a shared decision-making process concerning surgery and chemotherapy, and analysis of its practical feasibility (i.e. duration of the consultations). RESULTS (1) Twenty-one patients participated in the decision regarding surgery; all chose conservative treatment; 15 patients had their own say about chemotherapy (nine chose no chemotherapy, six chose chemotherapy). (2) Participating in treatment choice generated anxiety for a majority of patients. Some were dissatisfied because they had to make a choice and consequently to give up the other option. Finally, some were uncertain about making the right choice. Nevertheless, most were satisfied with the information given and the possibility of participating to the treatment decision-making process. (3) The total duration of the entire process of shared decision-making is consistent with the time spent with patients with such a severe disease. DISCUSSION/CONCLUSION Most of the patients expressed their satisfaction regarding the possibility to participate in treatment decision-making, knowing that offering treatment choice is very unusual in France. From this pilot study it appears that shared decision-making is feasible in clinical practice. Nevertheless, a quantitative study based on a large sample of patients is necessary to: (1) confirm this hypothesis, (2) ensure that patients are willing to participate in their treatment decision-making, and (3) measure the potential benefits related to this participation.
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Affiliation(s)
- Nora Moumjid
- GRESAC UMR 5823 CNRS, Centre Léon Bérard, Lyon, France
| | | | | | - Alain Brémond
- GRESAC UMR 5823 CNRS, Centre Léon Bérard, Lyon, France
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15921
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Abstract
The formation of multidisciplinary breast teams across the UK is intended to concentrate the assessment and treatment of breast cancer into the hands of high volume specialists. We undertook a retrospective population-based study in order to determine the trends in surgeon breast cancer workload in Yorkshire, UK, and to investigate whether patients treated by low-workload surgeons had poorer survival. Of 11 329 female breast cancer patients diagnosed in 1989-1994 in Yorkshire, 6% were managed by surgeons with a mean annual workload of less than 10 new patients, while surgeons with workloads of 10-29, 30-49 and >50 treated 21, 21 and 52%, respectively. Over the study period, increasing number of patients were managed by surgeons with higher workloads. Patients treated by low-workload surgeons had poorer survival. Five-year survival was 60% in the lowest workload category compared to 68% in the highest category. The relative risk of death was increased by 15% (RR=1.15, 95% CI 1.03-1.28) and by 10% (RR=1.10, 95% CI 1.02-1.18) for patients managed by surgeons with workloads <10 and 10-29 cases per annum in comparison to patients managed by surgeons with workloads of >50. The results of this study suggest increasing site specialisation in breast cancer among general surgeons. It also provides further evidence that the management of patients by surgeons with low workloads decreases overall survival.
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Affiliation(s)
- J Stefoski Mikeljevic
- Cancer Medicine Research Unit, Cancer Research UK, St James's Hospital, Leeds LS9 7TF, UK.
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15922
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Bümming P, Andersson J, Meis-Kindblom JM, Klingenstierna H, Engström K, Stierner U, Wängberg B, Jansson S, Ahlman H, Kindblom LG, Nilsson B. Neoadjuvant, adjuvant and palliative treatment of gastrointestinal stromal tumours (GIST) with imatinib: a centre-based study of 17 patients. Br J Cancer 2003; 89:460-4. [PMID: 12888812 PMCID: PMC2394385 DOI: 10.1038/sj.bjc.6600965] [Citation(s) in RCA: 109] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Malignant gastrointestinal stromal tumours (GIST) have a poor prognosis. Since these tumours are resistant to conventional radiation and chemotherapy, surgery has been the mainstay of treatment. However, surgery is usually inadequate for the treatment of malignant GIST. Imatinib, a KIT tyrosine kinase inhibitor, has recently been found to have a dramatic antitumour effect on GIST. In this centre-based study of 17 consecutive patients with high-risk or overtly malignant GIST, imatinib was used in three different settings - palliatively, adjuvantly, and neoadjuvantly. The treatment was found to be safe and particularly effective in tumours with activating mutations of exon 11 of the KIT gene. Clinical response to imatinib treatment correlated morphologically to tumour necrosis, hyalinisation, and reduced proliferative activity. The value of neoadjuvant imatinib treatment was illustrated in one case.
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Affiliation(s)
- P Bümming
- Department of Surgery, Lundberg Laboratory for Cancer Research, Sahlgrenska University Hospital, S-413 45 Göteborg, Sweden
| | - J Andersson
- Department of Pathology, Lundberg Laboratory for Cancer Research, Sahlgrenska University Hospital, S-413 45 Göteborg, Sweden
| | - J M Meis-Kindblom
- Department of Pathology, Lundberg Laboratory for Cancer Research, Sahlgrenska University Hospital, S-413 45 Göteborg, Sweden
| | - H Klingenstierna
- Department of Radiology, Lundberg Laboratory for Cancer Research, Sahlgrenska University Hospital, S-413 45 Göteborg, Sweden
| | - K Engström
- Department of Oncology, Lundberg Laboratory for Cancer Research, Sahlgrenska University Hospital, S-413 45 Göteborg, Sweden
| | - U Stierner
- Department of Oncology, Lundberg Laboratory for Cancer Research, Sahlgrenska University Hospital, S-413 45 Göteborg, Sweden
| | - B Wängberg
- Department of Surgery, Lundberg Laboratory for Cancer Research, Sahlgrenska University Hospital, S-413 45 Göteborg, Sweden
| | - S Jansson
- Department of Surgery, Lundberg Laboratory for Cancer Research, Sahlgrenska University Hospital, S-413 45 Göteborg, Sweden
| | - H Ahlman
- Department of Surgery, Lundberg Laboratory for Cancer Research, Sahlgrenska University Hospital, S-413 45 Göteborg, Sweden
| | - L-G Kindblom
- Department of Pathology, Lundberg Laboratory for Cancer Research, Sahlgrenska University Hospital, S-413 45 Göteborg, Sweden
| | - B Nilsson
- Department of Surgery, Lundberg Laboratory for Cancer Research, Sahlgrenska University Hospital, S-413 45 Göteborg, Sweden
- Department of Surgery, Lundberg Laboratory for Cancer Research, Sahlgrenska University Hospital, S-413 45 Göteborg, Sweden. E-mail:
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15923
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Abstract
OBJECTIVES To determine the prevalence and time course of pericardial effusion after open heart surgery for congenital heart diseases and to identify predisposing risk factors. DESIGN AND PATIENTS Prospective assessment of development of pericardial effusion in 336 patients (163 males) undergoing open heart surgery for congenital heart disease by serial echocardiography on days 5, 7, 14, 21, and 28 postoperatively. SETTING Tertiary paediatric cardiac centre. RESULTS The prevalence of pericardial effusion was 23% (77 of 336). Of the 77 patients who developed effusion, 43 (56%) had moderate to large effusions and 18 (23%) were symptomatic. Patients who had a large amount of effusion were more likely to be symptomatic than those with only a small to moderate amount (47.4% v 15.5%, p = 0.01). The mean (SD) onset of pericardial effusion was 11 (7) days after surgery, with 97% (75 of 77) of cases being diagnosed on or before day 28 after surgery. The prevalence of effusion after Fontan-type procedures (60%, 6 of 10) was significantly higher than that after other types of cardiac surgery: repair of left to right shunts (22.1%, 43 of 195), repair of lesions with right ventricular outflow tract obstruction (22.6%, 19 of 84), arterial switch operation (6.7%, 1 of 15), and miscellaneous procedures (25%, 8 of 32) (p = 0.037). Univariate analyses showed that female patients (p = 0.009) and those receiving warfarin (p = 0.002) had increased risk of postoperative pericardial effusion. A greater pericardial drain output in the first four hours after surgery also tended to be significant (p = 0.056). Multivariate logistic regression similarly identified warfarin treatment (beta = 1.73, p = 0.009) and female sex (beta for male = -0.63, p = 0.037) as significant determinants. CONCLUSIONS Pericardial effusion occurs commonly after open heart surgery for congenital heart disease. Serial echocardiographic monitoring up to 28 days postoperatively is indicated in selected high risk patients such as those with symptoms of postpericardiotomy syndrome and those given warfarin.
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Affiliation(s)
- E W Y Cheung
- Division of Paediatric Cardiology, Grantham Hospital, The University of Hong Kong, Hong Kong, People's Republic of China.
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15924
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Abstract
AIM To review surgical results of the Armenian Eye Care Project's (AECP) efforts in paediatric glaucoma and to identify additional morbidity associated with its initial itinerant nature. METHODS A non-randomised, retrospective historical cohort study of complicated paediatric glaucoma surgeries was performed by the AECP at the Republican Eye Hospital. 38 eyes of 34 paediatric patients underwent mitomycin C trabeculectomies (MMCT) (n = 20) or Ahmed glaucoma valve (AGV) placements (n = 18) for complicated paediatric glaucomas. The median age was 12.5 years with a range of 6-17 years. Three clinical groups were represented: congenital glaucoma, Frank Kamenetsky syndrome (a glaucoma associated with uveitis), and Rieger's syndrome. RESULTS Preoperative and postoperative intraocular pressures were similar for the two groups (MMCT v AGV = 30 v 32 mm Hg and 13.5 v 14.8 mm Hg, respectively; p>0.05, t test). The AGV group was twice as likely to use medications postoperatively (44% v 23%; p<0.05, t test). The MMCT group was more likely to have a three line drop in visual acuity than the AGV group (28% v 12%; p<0.05, t test). The decreased visual acuity found postoperatively was most commonly secondary to cataract formation. CONCLUSION Total success rates were similar in the two surgical treatment groups. These compared favourably with success rates reported for non-itinerant surgery. Postoperative complications worsened by the itinerant nature of the project were few and represented 5% of the total surgical interventions. Ultimately, the installation of fellowship trained specialists is the most effective approach to minimising this problem and is recommended by the AECP as a strategy for developing and recovering countries.
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Affiliation(s)
- R Hill
- Department of Ophthalmology, University of California, Irvine, CA 92697-4375, USA.
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15925
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Affiliation(s)
- G Neale
- Clinical Skills Centre, University College, Rockefeller Building, 21 University St, London WC1E 6JJ, UK;
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15926
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Olenchock SA, Reed JF, Brown A, Garzia FM. Improved postoperative outcomes with stentless aortic valve: a community hospital experience. Heart 2003; 89:551-2. [PMID: 12695464 PMCID: PMC1767639 DOI: 10.1136/heart.89.5.551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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15927
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Jack RH, Gulliford MC, Ferguson J, Møller H. Geographical inequalities in lung cancer management and survival in South East England: evidence of variation in access to oncology services? Br J Cancer 2003; 88:1025-31. [PMID: 12671698 PMCID: PMC2376363 DOI: 10.1038/sj.bjc.6600831] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
This study aimed to determine whether the management and survival of patients with lung cancer varied among 26 health authorities in South East England. The Thames Cancer Registry identified patients diagnosed with lung cancer (ICD-10 codes C33-C34) between 1995 and 1999. After excluding death certificate only patients, 32,818 (81%) patients were analysed. The proportions of patients receiving active treatment varied among health authorities between 5 and 17% for non-investigative surgery, 4 and 17% for any chemotherapy, 8 and 30% for any radiotherapy and 15 and 42% for any active treatment. One-year patient survival ranged from 11 to 34%. There was evidence of health authority level variation even after adjusting for case mix. Patients whose first hospital attendance was at a radiotherapy centre were more likely to receive active treatment (OR 1.72, 95% CI 1.21-2.46), chemotherapy (1.38, 1.06-1.79) or radiotherapy (1.86, 1.28-2.71). There was some evidence that patients whose first hospital attendance was at a radiotherapy centre survived longer. This study shows there is geographical inequality in the treatment given to lung cancer patients and patient survival in South East England. There was some evidence to suggest that these inequalities might be explained by variations in access to oncology services. Future studies should investigate the pathways and barriers to specialist care in this condition.
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Affiliation(s)
- R H Jack
- Department of Public Health Sciences, King's College London, UK.
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15928
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Abstract
Evidence is growing that patients with congenital heart disease who undergo surgery may be at increased risk of neurodevelopmental dysfunctions, particular paediatric survivors. However, paediatric studies involve different challenges from those conducted on adults.
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15929
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15930
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Zhao J, Li J, Wei X, Zhao B, Sun W. Tricuspid valve detachment in closure of congenital ventricular septal defect. Tex Heart Inst J 2003; 30:38-41. [PMID: 12638669 PMCID: PMC152833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
From January 1991 through December 2001, 600 patients underwent closure of a perimembranous ventricular septal defect through a right atrial approach at our institution. In 122 of these patients, the operation included temporary detachment of a tricuspid valve septal leaflet from the annulus to allow complete visualization of a perimembranous ventricular septal defect The mean age of the patients at surgery was 4.6 years in those who underwent leaflet detachment and 4.7 years in the 478 patients who did not (P > 0.05). Preoperatively, all patients were in sinus rhythm. Echocardiography showed trivial tricuspid regurgitation in 21 of the patients undergoing detachment and in 39 of the non-detachment patients. There was no difference in bypass time or aortic cross-clamp time between the 2 groups. Postoperatively, 3 patients in the non-detachment group had heart block; all other patients were in sinus rhythm. Echocardiograms on the 7th postoperative day showed small residual ventricular septal defects in none of the patients who underwent valve detachment and in 10 of the non-detachment patients; mild tricuspid regurgitation was present in 12 non-detachment patients only; and trivial tricuspid regurgitation was present in 19 patients who underwent valve detachment and in 29 who did not. There was no hospital death in either group. Long-term follow-up showed no progression of tricuspid regurgitation or tricuspid stenosis. All patients remained in sinus rhythm. This study suggests that tricuspid valve detachment is a safe, effective technique that improves exposure for ventricular septal defect repair and does not adversely affect valve competence.
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Affiliation(s)
- Jinping Zhao
- Department of Cardiothoracic Surgery, Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, 430030 Wuhan, People's Republic of China.
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15931
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Affiliation(s)
- Catherine M Otto
- Division of Cardiology Box 356422, University of Washington, Seattle, WA 98195, USA.
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15932
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Oliver JM, Gallego P, Gonzalez A, Dominguez FJ, Aroca A, Mesa JM. Sinus venosus syndrome: atrial septal defect or anomalous venous connection? A multiplane transoesophageal approach. Heart 2002; 88:634-8. [PMID: 12433899 PMCID: PMC1767459 DOI: 10.1136/heart.88.6.634] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVE To discuss the anatomical features of sinus venosus atrial defect on the basis of a comprehensive transoesophageal echocardiography (TOE) examination and its relation to surgical data. METHODS 24 patients (13 men, 11 women, mean (SD) age 37 (17) years, range 17-73 years) with a posterior interatrial communication closely related to the entrance of the superior (SVC) or inferior vena cava (IVC) who underwent TOE before surgical repair. Records of these patients were retrospectively reviewed and compared with surgical assessments. RESULTS In 13 patients, TOE showed a deficiency in the extraseptal wall that normally separates the left atrium and right upper pulmonary vein from the SVC and right atrium. This deficiency unroofed the right upper pulmonary vein, compelling it to drain into the SVC, which overrode the intact atrial septum. In three patients, TOE examination showed a defect in the wall of the IVC, which continued directly into the posterior border of the left atrium. Thus, the intact muscular border of the atrial septum was overridden by the mouth of the IVC, which presented a biatrial connection. In the remaining eight patients, the defect was located in the muscular posterior border of the fossa ovalis. A residuum of atrial septum was visualised in the superior margin of the defect. Neither caval vein overriding nor anomalous pulmonary vein drainage was present. CONCLUSIONS Sinus venosus syndrome should be regarded as an anomalous venous connection with an interatrial communication outside the confines of the atrial septum, in the unfolding wall that normally separates the left atrium from either caval vein. It results in overriding of the caval veins across the intact atrial septum and partial pulmonary vein anomalous drainage. It should be differentiated from posterior atrial septal defect without overriding or anomalous venous connections.
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Affiliation(s)
- J M Oliver
- Adult Congenital Heart Disease Unit, La Paz Hospital, Madrid, Spain
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15933
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McNaught CE, Woodcock NP, MacFie J, Mitchell CJ. A prospective randomised study of the probiotic Lactobacillus plantarum 299V on indices of gut barrier function in elective surgical patients. Gut 2002; 51:827-31. [PMID: 12427785 PMCID: PMC1773461 DOI: 10.1136/gut.51.6.827] [Citation(s) in RCA: 109] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Bacterial translocation occurs in surgical patients and may predispose to postoperative septic morbidity. Many factors are thought to influence the prevalence of bacterial translocation, one of which is the composition of the gut microflora. The aim of this prospective and randomised study was to assess the effect of the probiotic Lactobacillus plantarum 299v on the incidence of bacterial translocation, gastric colonisation, and septic complications in elective surgical patients. METHODS Patients undergoing elective major abdominal surgery were randomised to either a treatment or control group. The treatment group received an oral preparation containing Lactobacillus plantarum 299v (Proviva) for at least one week preoperatively and also in the postoperative period. Bacterial translocation was determined by culture of a mesenteric lymph node and serosal scraping obtained at laparotomy. Gastric colonisation was assessed by microbiological culture of nasogastric aspirates. All postoperative septic complications were recorded. RESULTS A total of 129 patients completed the study (probiotic group n=64). There was no significant difference between the two groups in terms of bacterial translocation (12% v 12%; p=0.82), gastric colonisation with enteric organisms (11% v 17%; p=0.42), or septic morbidity (13% v 15%; p=0.74). CONCLUSIONS Administration of Lactobacillus plantarum 299v in elective surgical patients does not influence the rate of bacterial translocation, gastric colonisation, or incidence of postoperative septic morbidity.
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Affiliation(s)
- C E McNaught
- Combined Gastroenterology Unit, Scarborough Hospital, Scarborough, North Yorkshire, UK
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15934
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Abstract
AIMS To assess the punctal apposition syndrome (PAS) and its response to lateral canthal tendon (LCT) repair. METHODS In this retrospective, interventional case series, five patients (seven symptomatic eyes) with PAS were managed. Lateral canthal tendon repair was performed in all seven eyes. The main outcome measure was correction of watery eye symptomatology. RESULTS All five patients achieved symptomatic resolution. Conjunctivochalasis and functional nasolacrimal duct obstruction were associated with the PAS. CONCLUSION This new surgical approach to the PAS, using a LCT repair, was successful in all patients. Two patients (three eyes) required conjunctivochalasis excision.
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Affiliation(s)
- I C Francis
- Ocular Plastics Unit, Prince of Wales Hospital and the University of NSW, Sydney, New South Wales 2031, Australia.
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15935
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Abstract
BACKGROUND The management of patients with end stage ocular surface disease sometimes requires extensive surgical treatment that can only be provided by specialised ophthalmology. The authors discuss the costs and gains of such complex techniques based on a case of bilateral corneal blindness secondary to Stevens-Johnson syndrome. METHODS AND RESULTS Despite multiple lid surgery for trichiasis and repeated corneal grafting for perforations a white female patient became bilaterally blind at the age of 29 years. She also suffered from disabling discomfort in the right dry eye. At the age of 52 a two stage osteo-odonto-keratoprosthesis achieved visual rehabilitation in the left eye and microvascular transplantation of an autologous, submandibular gland resulted in sufficient lubrication to alleviate her severe discomfort in the right eye. As a result of these procedures she was able to take up a regular job again. The total costs of rehabilitation were pound 13 661 which compare with annual gains and regains for society of pound 13 497. An additional pound 4625 was saved annually in guide dog costs. CONCLUSION This estimate shows that despite the expense of these complex techniques gains are made well within the second year after rehabilitation. In view of the benefit in quality of life for the patient and monetary savings for society these procedures should be funded by national health services at specialist centres.
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Affiliation(s)
- G Geerling
- Medizinische Universität Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany.
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15936
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Abstract
AIMS To describe the aetiology, demography, surgical management, and outcome of a cohort of paediatric ptosis patients in a large tertiary referral oculoplastic centre. METHODS A case note review of all patients undergoing ptosis surgery below the age of 16 years in a tertiary referral oculoplastic unit documenting the laterality, aetiology, severity of ptosis, indications for and type of surgery undertaken, the proportion of good, suboptimal, and poor surgical outcomes, re-operations, and level of patient satisfaction. RESULTS 340 patients (82% (280/340) unilateral, 18% (60/340) bilateral ptosis) with myogenic (79%, 269/340), aponeurotic (5%, 16/340), neurogenic (11%, 37/340), mechanical (2%, 6/340), apparent (1%, 2/340), and syndrome related (3%, 10/340) ptosis underwent anterior (41%, 141/340) and posterior (26%, 90/340) levator resection, frontalis suspension with mersilene (9%, 29/340) and autogenous fascia lata (17%, 59/340), levator transposition (5%, 15/340) and other surgery (1%, 6/340) for visual (43%, 141/333) and cosmetic (57%, 189/333) indications. 77% (260/340) of patients achieved a good outcome, 10% (35/340) a suboptimal outcome, and 13% (45/340) a poor outcome requiring re-operation. There was no statistically significant difference in surgical outcome between patients with mild, moderate, or severe ptosis and with good, moderate, or poor levator function. The level of recorded patient satisfaction with the surgical outcome was 90% (206/229). CONCLUSIONS Results suggest that most groups of paediatric ptosis patients, including those with poor levator function and severe ptosis, achieve satisfactory results with the appropriate ptosis surgery.
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Affiliation(s)
- V Lee
- Oculoplastic Service, Moorfields Eye Hospital, London, UK.
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15937
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Costin M, Rampersad A, Solomon RA, Connolly ES, Heyer EJ. Cerebral injury predicted by transcranial Doppler ultrasonography but not electroencephalography during carotid endarterectomy. J Neurosurg Anesthesiol 2002; 14:287-92. [PMID: 12357085 PMCID: PMC2435244 DOI: 10.1097/00008506-200210000-00003] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
When shunts are selectively used during carotid endarterectomy, the adequacy of collateral cerebral blood flow (CBF) after the carotid artery is clamped is determined by monitors based on different physiologic measurements. In this series of three patients, we used electroencephalography (EEG) to measure neuronal electrical activity and transcranial Doppler ultrasonography (TCD) to measure CBF velocity. In each of our cases, the EEG was unchanged from preclamp values, while TCD CBF velocity was dramatically reduced. All three patients had transient neuropsychometric or neurologic changes after surgery, which resolved.
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Affiliation(s)
- Mihaela Costin
- Department of Anesthesiology, Columbia University, New York, New York 10032, USA
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15938
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Adebamowo CA, Ezeome ER, Ajuwon JA, Ogundiran TO. Survey of the knowledge, attitude and practice of Nigerian surgery trainees to HIV-infected persons and AIDS patients. BMC Surg 2002; 2:7. [PMID: 12201903 PMCID: PMC126215 DOI: 10.1186/1471-2482-2-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2002] [Accepted: 08/30/2002] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND The incidence of HIV infection and AIDS is rising in Nigeria. Surgeons are at risk of occupationally acquired infection as a result of intimate contact with the blood and body fluids of patients. This study set out to determine the knowledge, attitude and risk perception of Nigerian surgery residents to HIV infection and AIDS. METHODS A self-administered postal questionnaire was sent to all surgery trainees in Nigeria in 1997. RESULTS Parenteral exposure to patients' blood was reported as occurring 92.5% times, and most respondents assessed their risk of becoming infected with HIV as being moderate at 1-5%. The majority of the respondents were not aware of the CDC guidelines on universal precautions against blood-borne pathogens. Most support a policy of routinely testing all surgical patients for HIV infection but 76.8% work in centers where there is no policy on parenteral exposure to patients' blood and body fluids. Most (85.6%) do not routinely use all the protective measures advocated for the reduction of transmission of blood borne pathogens during surgery, with the majority ascribing this to non-availability. Most want surgeons to be the primary formulators of policy on HIV and surgery while not completely excluding other stakeholders. CONCLUSIONS The study demonstrates the level of knowledge, attitude and practice of Nigerian surgery trainees in 1997 and the need for policy guidelines to manage all aspects of the healthcare worker (HCW), patients, and HIV/AIDS interaction.
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Affiliation(s)
- Clement A Adebamowo
- Division of Oncology, Department of Surgery, University College Hospital, Ibadan, Oyo State, Nigeria
- Department of Nutrition, Harvard School of Public Health, 665 Huntington Ave., Boston MA 02115
| | - Emma R Ezeome
- Division of Oncology, Department of Surgery, University College Hospital, Ibadan, Oyo State, Nigeria
- Current address: Department of Surgery, University of Nigeria, Nsukka
| | - Johnson A Ajuwon
- Department of Preventive and Social Medicine, University College Hospital, Ibadan, Oyo State, Nigeria
| | - Temidayo O Ogundiran
- Division of Oncology, Department of Surgery, University College Hospital, Ibadan, Oyo State, Nigeria
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15939
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Abstract
Several studies indicate that organ failure is the leading cause of death in surgical patients. An excessive inflammatory response followed by a dramatic paralysis of cell-mediated immunity following major surgery appears to be responsible for the increased susceptibility to subsequent sepsis. In view of this, most of the scientific and medical research has been directed towards measuring the progression and inter-relationship of mediators following major surgery. Furthermore, the effect of those mediators on cell-mediated immune responses has been studied. This article will focus on the effect of blood loss and surgical injury on cell-mediated immune responses in experimental studies utilizing models of trauma and hemorrhagic shock, which have defined effects on the immunoinflammatory response. Subsequently these findings will be correlated with data generated from surgical patients. The results of these studies may generate new approaches for the treatment of immunodepression following major surgery, thus reducing the susceptibility to infection and increasing the survival rate of the critical ill surgical patient.
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Affiliation(s)
- Martin K Angele
- Department of Surgery, Klinikum Grosshadern, Ludwig-Maximilians University, Munich, Germany
| | - Eugen Faist
- Department of Surgery, Klinikum Grosshadern, Ludwig-Maximilians University, Munich, Germany
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15940
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Abstract
While often considered to be cured, patients with repaired coarctation of the aorta frequently have premature morbidity and even mortality.
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15941
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Abstract
AIM To describe cataract surgical services in 1998 in 12 eastern European countries and to identify their needs to reduce cataract blindness. METHODS All inpatient eye departments in the 12 countries received a standardised questionnaire; the data obtained were further processed at the coordinating centre in Prague. RESULTS All 458 eye departments in the region were involved. The response rate was 100%, except for Bulgaria (93%) and Romania (93%). The total number of cataract surgeries per one million inhabitants in 1998 was calculated: Belarus (800), Federation of Bosnia and Herzegovina (1275), Bulgaria (1730), the Czech Republic (4210), Estonia (2530), Hungary (3530), Latvia (1860), Lithuania (1550), Trans-Dniester Moldova (1300), Poland (1475), Romania (1260), and Slovakia (2430). Cataracts were mostly operated on by the extracapsular technique. Intracapsular extractions were frequently performed in Federation of Bosnia and Herzegovina (47%), Belarus (46%), Bulgaria (18%), and Romania (14.3%). Phacoemulsification was uncommonly used in 1998, except for the Czech Republic (86%), Estonia (50%), Slovakia (38%), and Hungary (16%). An IOL was implanted in more than 90% of patients in the Czech Republic, Estonia, Hungary, Latvia, Lithuania, and Slovakia. CONCLUSIONS Conditions for cataract surgery in the eastern European region differ. The main barriers to cataract surgery were state budget limitations, insufficient supply of consumables, underutilisation of operating theatres, and poor detection of patients requiring surgery.
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Affiliation(s)
- I Kocur
- Charles University Eye Clinic, Charles University, Prague, Czech Republic.
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15942
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Affiliation(s)
- A C J Windsor
- Department of Surgery, St Mark's Hospital, North London Hospitals NHS Trust, Harrow, Middlesex HA1 3UJ, UK.
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15943
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Affiliation(s)
- M J G Farthing
- Faculty of Medicine, University of Glasgow, 12 Southpark Terrace, Glasgow GL12 8LG, UK.
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15944
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Tennvall J, Lundell G, Wahlberg P, Bergenfelz A, Grimelius L, Akerman M, Hjelm Skog AL, Wallin G. Anaplastic thyroid carcinoma: three protocols combining doxorubicin, hyperfractionated radiotherapy and surgery. Br J Cancer 2002; 86:1848-53. [PMID: 12085174 PMCID: PMC2375444 DOI: 10.1038/sj.bjc.6600361] [Citation(s) in RCA: 187] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2001] [Revised: 03/27/2002] [Accepted: 04/12/2002] [Indexed: 11/30/2022] Open
Abstract
Patients with anaplastic thyroid carcinoma can rarely be cured, but every effort should be made to prevent death due to suffocation. Between 1984 and 1999, 55 consecutive patients with anaplastic thyroid carcinoma were prospectively treated according to a combined regimen consisting of hyperfractionated radiotherapy, doxorubicin, and when feasible surgery. Radiotherapy was carried out for 5 days a week. The daily fraction until 1988 was 1.0 Gyx2 (A) and 1989-92 1.3 Gyx2 (B). Thereafter 1.6 Gyx2 (C) was administered. Radiotherapy was administered to a total target dose of 46 Gy; of which 30 Gy was administered preoperatively in the first two protocols (A and B), while the whole dose was given preoperatively in the third protocol (C). The therapy was otherwise identical. Twenty mg doxorubicin was administered intravenously weekly. Surgery was possible in 40 patients. No patient failed to complete the protocol due to toxicity. In only 13 cases (24%) was death attributed to local failure. Five patients (9%) 'had a survival' exceeding 2 years. No signs of local recurrence were seen in 33 patients (60%); 5 out of 16 patients in Protocol A, 11 out of 17 patients in Protocol B, 17 out of 22 patients in Protocol C (P=0.017). In the 40 patients undergoing additional surgery, no signs of local recurrence were seen in 5 out of 9 patients, 11 out of 14 patients and 17 out of 17 patients, respectively (P=0.005).
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Affiliation(s)
- J Tennvall
- Department of Oncology, Lund University Hospital, SE-221 85 Lund, Sweden.
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15945
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Affiliation(s)
- A Cuschieri
- Department of Surgery and Molecular Oncology, Ninewells Hospital and Medical School, Dundee DD1 9SY, UK.
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15946
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Abstract
AIM Investigation of the natural history of trachomatous trichiasis in the Gambia and of the outcome of self epilation and surgery for the condition. METHODS A 1 year longitudinal study of 190 subjects with trichiasis was performed. Major trichiasis cases (five lashes or more) were referred for surgery and minor trichiasis cases were advised to epilate. Outcome measures included progression of trichiasis and corneal scarring; attendance for and results of surgery. RESULTS 34 of 148 (23%, 95% CI 16 to 31) subjects with major trichiasis attended for surgery over the year. Progression from minor to major trichiasis occurred in 18 of 55 subjects (33%, 95% CI 21 to 47). Progression of corneal scarring occurred in 60 of 167 patients (36%, 95% CI 29 to 44). Clinically active trachoma and conjunctival bacterial isolation predicted progression of corneal opacity. Surgery was successful in 39 of 54 (72%) eyes. CONCLUSIONS Despite the overall decline in trachoma in the Gambia, patients with both minor and major trichiasis remain at risk of developing corneal opacity. Active trachomatous inflammation and additional infection with bacteria may accelerate this process. Antibiotic treatment for trichiasis patients (in addition to surgery) should be investigated. Surgery for minor trichiasis may be indicated. Regular audit of surgical results is necessary with retraining where needed.
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Affiliation(s)
- R J C Bowman
- International Centre for Eye Health, 11-43 Bath Street, London EC1V 9EL, UK.
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15947
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Wakiyama H, Cowan DB, Toyoda Y, Federman M, Levitsky S, McCully JD. Selective opening of mitochondrial ATP-sensitive potassium channels during surgically induced myocardial ischemia decreases necrosis and apoptosis. Eur J Cardiothorac Surg 2002; 21:424-33. [PMID: 11888758 PMCID: PMC3711118 DOI: 10.1016/s1010-7940(01)01156-3] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE Mitochondrial ATP-sensitive potassium channels have been proposed to be myoprotective. The relevance and specificity of this mechanism in cardiac surgery was unknown. The purpose of this study was to examine the effects of the mitochondrial potassium ATP-sensitive channel opener diazoxide on regional and global myocardial protection using a model of acute myocardial infarction. METHODS Pigs (n=19) were placed on total cardiopulmonary bypass and then subjected to 30 min normothermic regional ischemia by snaring the left anterior descending coronary artery (LAD). The aorta was then crossclamped and cold blood Deaconess Surgical Associates cardioplegia (DSA; n=6) or DSA containing 50 microM diazoxide (DZX; n=6) was delivered via the aortic root and the hearts subjected to 30 min hypothermic global ischemia. The crossclamp and snare were removed and the hearts reperfused for 120 min. RESULTS No significant differences in preload recruitable stroke work relationship, Tau, proximal, distal or proximal/distal coronary flow, regional or global segmental shortening, systolic bulging or post-systolic shortening were observed within or between DSA and DZX hearts during reperfusion. Infarct was present only in the region of LAD occlusion in both DSA and DZX hearts. Infarct size (% of area at risk) was 33.6+/-2.9% in DSA and was 16.8+/-2.4% in DZX hearts (P<0.01 versus DSA). Apoptosis as estimated by TUNEL positive nuclei was 120.3+/-48.8 in DSA and was significantly decreased to 21.4+/-5.3 in DZX hearts. Myocardial infarct was located centrally within the area at risk in both DSA and DZX hearts but was significantly increased at borderline zones within the area at risk in DSA hearts. CONCLUSIONS The addition of diazoxide to cardioplegia significantly decreases regional myocardial cell necrosis and apoptosis in a model of acute myocardial infarction and represents an additional modality for achieving myocardial protection.
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Affiliation(s)
| | | | | | | | | | - James D. McCully
- Corresponding author. Tel.: +1-617-667-0725; fax: +1-617-975-5245. (J.D. McCully)
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15948
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Dmochowski R. Interventions for detrusor overactivity: the case for multimodal therapy. Rev Urol 2002; 4 Suppl 4:S19-27. [PMID: 16986017 PMCID: PMC1476017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
Viable therapeutic alternatives for the management of overactive bladder (OAB) have recently evolved that provide satisfactory symptomatic control for the majority of patients. However, the presupposition that interventions exist as stand-alone entities is not representative of experience in unique populations with the therapeutic benefit of combination therapy, using components drawn from behavioral, physiotherapeutic, neuromodulatory, and, if necessary, surgical alternatives. Even in populations relatively refractory to therapy, the use of multimodal therapy yields additive benefits for patients with OAB symptoms. Herein is detailed the evidence supporting the concept that multimodal therapy provides optimal benefit to patients suffering from this symptom complex.
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15949
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Abstract
The surgical management of epithelial ovarian cancer in the South West of England was studied in the two years 1997-1998 in order to determine the factors that influence the outcome of surgery and to provide a baseline from which to assess the effect of centralisation of cancer services. All hospitals in the South West region of England participating in the Regional Cancer Organisation's longitudinal study of outcomes in gynaecological malignancies are included. Six hundred and eighty-two patients with epithelial ovarian cancer were registered with the RCO in the two-year study period. Five hundred and ninety-five women were offered primary cytoreductive surgery of which 438 were said to be optimally cytoreduced. Applying multivariate models to analyse the outcome of surgery, older patients (OR = 0.82 per 5-year increase in age, P = 0.0003), patients treated in hospitals managing fewer than ten cases of ovarian cancer per year (OR = 1.92, P = 0.02) and patients with FIGO stage 3 (OR = 0.02, P < 0.0001) or 4 (OR = 0.002, P < 0.0001) disease were less likely to be optimally cytoreduced. Gynaecological oncologists were 2.06 times more likely to attain optimal cytoreduction when compared to general gynaecologists and this was statistically significant (P = 0.01). The results from this study support the argument that limiting surgery for ovarian malignancy to specialised surgeons improves the extent of cytoreductive surgery.
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Affiliation(s)
- A Olaitan
- Department of Gynaecological Oncology, St Michael's Hospital, Southwell Street, Bristol, BS2 8EG, UK
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15950
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Abstract
Advances in technology continue at a rapid pace and affect all aspects of life, including surgery. We have reviewed some of these advances and the impact they are having on the investigation and management of colorectal cancer. Modern endoscopes, with magnifying, variable stiffness and localisation capabilities are making the primary investigation of colonic cancer easier and more acceptable for patients. Imaging investigations looking at primary, metastatic and recurrent disease are shifting to digital data sets, which can be stored, reviewed remotely, potentially fused with other modalities and reconstructed as 3 dimensional (3D) images for the purposes of advanced diagnostic interpretation and computer assisted surgery. They include virtual colonoscopy, trans-rectal ultrasound, magnetic resonance imaging, positron emission tomography and radioimmunoscintigraphy. Once a colorectal carcinoma is diagnosed, the treatment options available are expanding. Colonic stents are being used to relieve large bowel obstruction, either as a palliative measure or to improve the patient’s overall condition before definitive surgery. Transanal endoscopic microsurgery and minimally invasive techniques are being used with similar outcomes and a lower mortality, morbidity and hospital stay than open trans-abdominal surgery. Transanal endoscopic microsurgery allows precise excision of both benign and early malignant lesions in the mid and upper rectum. Survival of patients with inoperable hepatic metastases following radiofrequency ablation is encouraging. Robotics and telemedicine are taking surgery well into the 21st century. Artificial neural networks are being developed to enable us to predict the outcome for individual patients. New technology has a major impact on the way we practice surgery for colorectal cancer.
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Affiliation(s)
- G B Makin
- University of Hull Academic Surgical Unit, Castle Hill Hospital, Castle Road, Cottingham HU16 5JQ, United Kingdom
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