Day-case haemorrhoidectomy

BACKGROUND

Ligation excision haemorrhoidectomy is usually performed on an inpatient basis. This study was designed to assess the feasibility of day-case haemorrhoidectomy.

METHODS

Patients fulfilling criteria for day surgery underwent ligation excision haemorrhoidectomy with the intention of a same-day discharge from hospital. A standardized protocol for anaesthesia, perioperative analgesia and antiemesis was followed. Patients received daily home nursing visits until they felt both comfortable and confident. Staff recorded pain and nausea scores on a visual analogue scale (range 1-10) until the first bowel action. Patient satisfaction was assessed independently after operation.

RESULTS

Fifty-one patients underwent planned day-case haemorrhoidectomy. Forty-two (82 per cent) were discharged on the day of surgery. All patients were discharged within 26 h of surgery. Four patients required readmission, two with reactive bleeding, one with urinary retention and one for pain control. Pain and nausea were well controlled. Forty-four patients (86 per cent) were totally or very satisfied with their overall care.

CONCLUSION

Ligation excision haemorrhoidectomy can be performed successfully as a day-case procedure.

HIV envelope protein gp120 induces neuropeptide Y receptor-mediated proliferation of vascular smooth muscle cells: relevance to AIDS cardiovascular pathogenesis

Hyperplasia of vascular smooth muscle cells (VSMCs) occurs during HIV infection, part of a spectrum of HIV-mediated cardiovascular and microvascular pathologies. These changes are not due to direct viral infection but may involve the receptor-mediated action of viral proteins, such as the envelope protein gp120. We sought to identify gp120 receptors which might mediate the vascular smooth muscle cell hyperplasia present in HIV infection. A homology between neuropeptide Y (NPY) and the previously identified receptor-active V2-region of gp120 defined by an octapeptide sequence (Peptide T) related to VIP was noted. Since NPY is mitogenic for VSMCs we therefore determined whether gp120 shares this activity. Rat aortic VSMCs were treated for 24 h with human (h)NPY and gp120 in the presence of 0.5% serum to measure [3H]thymidine incorporation, an index of cell proliferation. NPY increased [3H]thymidine incorporation by 80% after a 24-h treatment in a bimodal fashion, with peak effects at 10(-10) M and 10(-8) M. Gp120 was an even more potent mitogen for VSMCs with peak activity occurring at 10(-12) M. Peptide T was equipotent with gp120, and slightly less efficacious, suggesting that this domain may mediate gp120 effects on VSMCs. When combined, gp120 and NPY acted to antagonize one another, lowering DNA synthesis to basal levels. The profile of pharmacologic inhibition supports a role for NPY receptors since antagonists of Y1 and Y2 subtypes substantially or completely inhibited gp120-mediated VSMC proliferation. This is the first demonstration of the proliferative effects of HIV viral protein gp120 on VSMCs. The effect appears to be mediated via gp120 sequences related to VIP, peptide T, and NPY. These ligands may be competitive inhibitors of binding or gp120 processing. Novel treatments may emerge based upon VIP and NPY receptor antagonists if further work substantiates a role for gp120 in the vascular abnormalities of AIDS.

Woman-to-woman support: lessons from an Australian case story

The purpose of this article is to demonstrate the use of storytelling to generate critical thinking about women's mental and emotional health care. The case story at the heart of the storytelling process describes a real, conflict situation in a remote, Australian women's health center. The themes generated lead to critical analysis of the concepts of care, independence, self-responsibility, ideology and woman-space, as they pertain to services designed to promote women's mental and emotional well-being. The conflict in the story arose between a lay worker providing woman-to-woman support and a professional counselor. Woman-to-woman support is a strategy developed in the women's health movement. It refers to the provision of time and space in women's health centers for women to work on their own needs with the support of women's health workers. Based on feminist principles, the aim is to empower women with knowledge, resources and skills. Woman-to-woman support builds on the care that women have traditionally provided for each other and is particularly useful for women living in regions where only limited, professional counseling services may be available.

Attention and driving performance in Alzheimer's disease

The present study examined the relationship between visual attention measures and driving performance in healthy older adults and individuals with very mild and mild dementia of the Alzheimer type (DAT). Subjects were administered an on-road driving assessment and three visual attention tasks (visual search, visual monitoring, and useful field of view). The results indicated that error rate and reaction time during visual search were the best predictors of driving performance. Furthermore, visual search performance was predictive of driving performance above and beyond simple dementia severity and several traditional psychometric tests. The results suggest that general cognitive status may be useful for identifying individuals "at risk" for unsafe driving. However, measures of selective attention may serve to better differentiate safe versus unsafe drivers, especially in the DAT population.

Does the supine sleeping position have any adverse effects on the child? I. Health in the first six months. The ALSPAC Study Team

OBJECTIVE

To assess whether the recommendations that infants sleep supine could have adverse health consequences.

DESIGN

A prospective study of infants, delivered before, during, and after the Back to Sleep Campaign in the United Kingdom (UK), followed to 6 months of age. The children were part of the Avon Longitudinal Study of Pregnancy and Childhood (ALSPAC). Subjects. Singletons born to mothers resident in the three former Bristol-based health districts of Avon in the period June 1991 to December 1992, and for whom questionnaires were completed on sleeping position at 4 to 6 weeks of age (n = 9777); for these infants 8524 questionnaires were also completed at 6 to 8 months of age.

MAIN OUTCOME MEASURES

Subjective measures of health, the presence of specific signs and symptoms, duration of sleep at night, and calling the family doctor to the home.

RESULTS

Of 43 outcomes considered, after adjustment for 12 factors using logistic regression only 2 were associated with raised risk among infants put to sleep on their back (diaper rash and cradle cap). Infants put to sleep prone had increased risk of a number of health outcomes, including cough and possibly pyrexia.

CONCLUSIONS

There is no evidence that putting infants to sleep in the supine position results in increased morbidity, although changes in prevalence of rare disorders would not have been identified.

The role of selective attention in driving and dementia of the Alzheimer type

This paper examines the relationship between cognitive processes and driving in aging and dementia of the Alzheimer type. Several studies that have explored the relationship between neuropsychological test performance and various indicators of driving safety are reviewed. It is argued that deficits in selective attention are specific to impaired driving performance in dementia of the Alzheimer type. Results from a recent study supporting this notion are presented. It is suggested that screening measures that emphasize the ability to selectively attend to relevant information and inhibit irrelevant information should be used to identify mildly demented individuals who are at risk for unsafe driving.

The impact of T-cell depletion on the effects of HLA DR beta 1 and DQ beta allele matching in HLA serologically identical unrelated donor bone marrow transplantation

Unrelated donor bone marrow transplants have been associated with relatively high rates of acute graft-vs.-host disease and treatment-related mortality. These complications reflect histo-incompatibility between donor and recipient. Molecular technology has recently been applied to HLA typing to identify alleles not distinguishable with serologic typing techniques. We report results in 92 unrelated marrow transplant recipients who were HLA seroidentical with donor HLA-A, -B, and -DR antigens and assess the effect of DR beta 1 and DQ beta compatibility using sequence specific oligonucleotide primers. Forty-eight patients received T-cell depleted marrow grafts, and 44 received unmodified grafts. Among recipients of unmodified marrow grafts, matching for both DR beta 1 and DQ beta reduced the rate of grade 3-4 acute graft-vs.-host disease to 38 +/- 20% vs. 73 +/- 20% among recipients mismatched for either allele (p = 0.02). This difference was not observed in recipients of T-cell depleted marrow grafts. Multivariate analysis confirmed matching for both DR beta 1 and DQ beta loci (p = 0.015), and receiving a T-cell depleted graft (p = 0.008) independently predicted for reduced risk of grade 3-4 acute graft-vs.-host disease. In conclusion, both DR beta 1 and DQ beta appear biologically important for development of acute graft-vs.-host disease in patients receiving unmanipulated marrow grafts for unrelated donor transplant.

The effects of housing on the health of preterm infants

Using a prospective study based on cases and controls selected from a geographical population, we have investigated the effects of housing on the health of very preterm infants (< or = 32 weeks' gestation) during the first year of life. Information on health morbidity of the 117 preterm and 226 term babies was collected using a parent-held record, and housing data by a validated self-completion questionnaire. The most common health problems in the first year-upper (UR) and lower (LR) respiratory tract infection, otitis media (OM) and diarrhoea and vomiting (DV)-were all more frequent in the preterm group, There were no significant differences in the housing conditions to which preterm and control infants were exposed. Relative risks (RR) and 95% confidence intervals (CI) associated with each housing factor were calculated for preterm and control infants separately. Significant (P < 0.05) interaction effects were found for overcrowding and gas cooking. Overcrowding was associated with an increased incidence of LR [RR = 1.53; CI 0.96-2.42] and DV [RR = 1.57; CI 0.92-2.67] in the preterm, but with a decreased incidence of LR [RR = 0.28; CI 0.04-1.86] and DV [RR = 0.85; CI 0.30-2.38] in the term controls. The use of gas ovens was found to be associated in preterm infants with an increase in LR [RR = 1.48; CI 0.96-2.28] and DV [RR = 2.24; CI 1.28-3.93] but the controls did not show this effect for LR [RR = 0.67; CI 0.40-1.09] or DV [RR = 0.93; CI 0.56-1.56]. These associations are robust-even after allowing for confounding social factors-but causality has not been proved. This work suggests that preterm infants may be vulnerable to specific adverse housing factors, and further studies are now indicated to clarify potential mechanisms and interactive effects behind these associations.

Gallstones in a community free of obesity but prone to slow intestinal transit

OBJECTIVES

To verify anecdotal reports that gallstones were frequent in a remote community where obesity is rare and to look for possible explanations of their occurrence, including slow intestinal transit.

DESIGN

Population survey of gallbladder status and stool form.

SETTING

Two villages in Ladakh, a mountainous region of northern India; for comparison, a stratified random sample from general practitioners' lists in East Bristol.

SUBJECTS

Women aged 25-59 years, 437 in Ladakh and 974 in Bristol.

MAIN OUTCOME MEASURES

Presence of gallstones on ultrasonography and response to questionnaires about parity, the intake of dried legume seeds (pulses) and bowel function including the form or appearance of the stools on a seven-point, transit-sensitive scale. Weight, height and waist circumference were also recorded.

RESULTS

Gallstone disease was at least as frequent in Ladakh as in Bristol although Ladakhi women were uniformly slim and their weight, waist size and body mass index failed to rise with age. After adjustment for age, gallstone disease was associated with higher body mass index and waist size in Bristol but not in Ladakh. It was associated with increased parity in Bristol, but not significantly so after adjusting for age and not at all in Ladakh. Gallstone disease was not directly associated with bowel function but Ladakhis often reported their stools to be lumpy (42.4 vs. 26.5% of Bristol women) and seldom as soft or loose (6.4 vs. 42.5%), implying that their intestinal transit tends to be slow.

CONCLUSION

Gallstones can be common in a population free of obesity but prone to intestinal stasis.

Attentional deficits in stroke patients: a visual dual task experiment

OBJECTIVE

(1) To compare the performance of subjects who have suffered a single lateralized cortical, ischemic stroke versus controls on measures of attention including a computerized dual visual attentional task to determine if this task is more sensitive for detecting the presence of subtle hemi-inattention compared to traditional attention tasks; (2) to determine if there is evidence of hemi-inattention in persons who completed spontaneous neurological recovery after a cortical, ischemic stroke compared to controls.

SUBJECTS

Thirty-six patients (N = 20 Right Hemisphere and N = 16 Left Hemisphere) who had previously undergone stroke rehabilitation and who were at least 1 year poststroke. All patients were currently living in the community. A control group of 20 subjects was recruited from the community.

RESULTS

There was no difference in performance between the three groups on gross clinical testing for hemi-inattention, or on the traditional letter-cancellation tasks. All subjects also participated in two computer generated tasks: (1) tracking a moving stimulus and (2) detecting briefly appearing targets. On the single task performance the control group performed significantly better than both cerebrovascular accident (CVA) groups (p < .004), but with no trend for hemi-inattention in any individual group. When the two computer tasks were combined, there was a significant difference in performance between the control group and all stroke subjects (p < .02) for target detection. A fatiguing effect over time was also found in the right CVA group on the dual task. Stroke subjects driving at the time of data collection performed better on the dual attentional task compared to stroke subjects not driving (p = .05).

CONCLUSIONS

On single and dual dynamic computerized visual attentional tasks, individuals who have suffered a cortical stroke more than 1 year before testing have significantly impaired attention compared to controls.

Streptococcal necrotizing fasciitis of the eyelids and orbit

Streptococcal necrotizing fasciitis in previously healthy persons can develop quickly and may be difficult to diagnose. In a number of cases, this potentially fatal condition has been seen originally in the eyelid and orbit. Intensive antibiotic therapy and prompt debridement are the usual course of treatment.

Ocular lyme disease

Lyme disease is reported from all over the United States. Transmitted by deer ticks, mosquitoes, and deer flies, it affects numerous organ systems. All age groups are vulnerable to this disease and must be educated about early signs and symptoms to speed diagnosis and appropriate treatment.

Ocular toxocariasis

Toxocara canis is a preventable cause of intraocular inflammation and visual loss ... caused by the larvae of toxocara canis usually occurring in children and young adults following accidental ingestion of the larvae from infected dogs. Treatment of ocular toxocariasis can include a combination of cryopexy and photocoagulation, with vitrectomy surgery utilized in the more serious cases.