Patient recovery following cholecystectomy through a 6 cm or 15 cm transverse subcostal incision: a prospective randomized clinical trial

The effect of incision length on patient recovery following cholecystectomy has not been investigated previously. In this study, 30 patients with symptomatic gallstones were randomized to cholecystectomy through a 6 cm or 15 cm transverse subcostal incision. Postoperative hospital stay was significantly shorter in the 6 cm incision group (median 3 days vs 5 days; P = 0.0069 Mann-Whitney U-test). In the 6 cm group analgesic requirements were reduced (median 2.5 vs 4.5 intramuscular opiate injections per patient) and recovery of depressed postoperative pulmonary function (FVC and FEV1) was faster (3% difference between groups on day 1 and 7% on day 3), although these differences did not achieve statistical significance. These results suggest that the length of incision may influence patient recovery following elective cholecystectomy. This has important implications as surgery carried out through shorter and less traumatic incisions may offer a cost-effective alternative to laparoscopic cholecystectomy. Moreover, some surgeons may find mini-laparotomy cholecystectomy easier to adopt than laparoscopic techniques.

Coagulopathy associated with large sacrococcygeal teratomas

Twelve neonates with sacrococcygeal teratoma (SCT) have been treated at British Columbia Children's Hospital over the past 5 years. Clinically significant coagulopathy developed in four of these neonates and two died, one before surgical intervention could be undertaken. Disseminated intravascular coagulation (DIC) was found in one patient and thrombocytopenia in another on preoperative laboratory studies. Etiology of the coagulopathy is unclear, but appears to be multifactorial. Although several clinical reviews have noted mortalities due to exsanguinating hemorrhage, no study has focused solely on this issue. The diagnosis of SCT in the neonate at high risk for development of coagulopathy is usually made prenatally. Premature labor is often precipitated by associated polyhydramnios and large tumor size. Fetal distress, prematurity, and low birth weight are common. Presence of placentamegaly, hydrops fetalis, and congestive heart failure are ominous prognostic signs. Early identification of patients at increased risk for development of hemorrhagic complications may allow optimization of their management. Cesarean section should minimize trauma to the SCT during delivery. Expeditious resection of the lesion may improve survival.

Duodenal carcinoid tumour associated with gastric leiomyoblastoma

We describe the synchronous occurrence of carcinoid tumour of the duodenum and leiomyoblastoma of the stomach in a patient presenting with anaemia. This combination of primary tumours has not previously been described.

Predictors of risk in patients with unstable angina admitted to a district general hospital

OBJECTIVE

To observe the long-term prognosis of patients with unstable angina and select simple criteria to identify high and low risk subgroups.

DESIGN

A six month prospective survey with three year follow up.

SETTING

One eleven bed coronary care unit.

PATIENTS

All patients admitted with chest pain in whom no infarct was confirmed by subsequent electrocardiographic or enzyme changes and for whom no alternative cause of chest pain was found were studied. Unstable angina was also diagnosed if there was evidence of myocardial ischaemia in the form of previous effort angina, previous myocardial infarction, or if transient electrocardiographic changes accompanied the pain. When none of the above were present, chest pain without a known cause, was diagnosed.

INTERVENTIONS

No routine intervention. Angiography and revascularisation for persistent symptoms despite medical treatment.

OUTCOME MEASURES

Death or non-fatal infarction.

RESULTS

In the 141 patients with unstable angina there were eight deaths and five non-fatal infarctions during the first eight weeks. Symptoms of increasing angina before admission were similar in all three groups and did not help predict early complications. Recurrence of pain in hospital, a rise in cardiac enzymes to less than twice the upper limit of normal, and transient electrocardiographic changes were all associated with an increased risk of early events. The presence of either abnormal enzyme activity or more than five episodes of pain in hospital identified a group of 49 in whom 11 of the 13 early events occurred. After three years, 29 of the 141 patients had died and eight had had infarctions (overall event rate 26%). Seventeen had undergone revascularisation (12%) and 51 (36%) were on antianginal treatment. Thirty six (26%) were still alive, without new myocardial infarction, and were free of angina. In the 29 patients with chest pain without a known cause there were no early events and only one non-fatal infarction during the three year follow up.

CONCLUSION

When patients are admitted to the coronary care unit with chest pain not due to myocardial infarction, the history, electrocardiography and measurement of cardiac enzymes are sufficient to identify high and low risk subgroups.

Eosinophilia-myalgia syndrome in L-tryptophan-exposed patients

OBJECTIVES

To study the incidence of eosinophilia-myalgia syndrome, the risk factors associated with the syndrome, and the clinical spectrum of illness associated with L-tryptophan use in an exposed population.

DESIGN

Retrospective cohort and nested case-control studies of risk factors for eosinophilia-myalgia syndrome using inpatient and outpatient chart reviews, telephone interviews, and in-person patient interviews. Descriptive study of clinical course of L-tryptophan users.

SETTING

Office practice of one psychiatrist based in a small city (population 43,467) in South Carolina.

PATIENTS

Eligible subjects were all patients from the practice who used L-tryptophan during the 1989 study interval. Of these, 418 (87%) were interviewed.

MAIN OUTCOME MEASURES

Clinical spectrum of illness associated with L-tryptophan use, including definite and possible cases of eosinophilia-myalgia syndrome.

RESULTS

Among the 418 interviewed L-tryptophan users, we identified 47 definite cases (11%) and 68 possible cases (16%) of eosinophilia-myalgia syndrome, most of which involved patients who were using one retail brand of L-tryptophan (brand A). Among the 157 brand A users, we identified 45 definite cases (29%) and 36 possible cases (23%) of eosinophilia-myalgia syndrome, and the risk for the syndrome increased as the brand A dose increased. Fifty percent (19 of 38) of those using more than 4000 mg/day developed definite eosinophilia-myalgia syndrome, and 84% (32 of 38) developed either definite or possible eosinophilia-myalgia syndrome. On multivariate analysis, risk for definite eosinophilia-myalgia syndrome was associated with brand A dose and age of the patient; however, gender, race, and use of other medications were not associated with the syndrome.

CONCLUSIONS

These results suggest that many people exposed to the agent causing eosinophilia-myalgia syndrome may develop illness, and dose of presumably contaminated L-tryptophan is the single most important predictor of eosinophilia-myalgia syndrome. The broad range of signs and symptoms reported by patients using L-tryptophan illustrates that a strict case definition may identify only about half of those affected.

Eosinophilic gastroenteritis presenting as ascites. Case report

A 46 year old man presented with a four week history of ascites and loss of weight. The diagnosis of eosinophilic gastroenteritis was made only after histological examination of a biopsy specimen taken at laparotomy. All other investigations had been unhelpful. He made a good recovery and was given no treatment.

Delayed presentation of traumatic splenic arterio-venous fistula

We report a patient who presented with dyspnoea and was found on examination to have a machinery murmur in the left upper quadrant of the abdomen. The patient had sustained blunt abdominal trauma one year prior to presentation. A diagnosis of splenic arteriovenous fistula was made. The diagnosis and management of delayed presentation of traumatic splenic arteriovenous fistula are discussed.

Laparoscopic truncal vagotomy without drainage for the treatment of chronic duodenal ulcer

Four patients with chronic duodenal ulceration refractory to long term medical treatment were submitted to laparoscopic truncal vagotomy without drainage. No patient developed symptoms of gastric stasis or ulcer recurrence. The technique is described.

Nightie solution is ill fitting

It was with some disappointment that I read D D MacGregor's letter (Nursing Standard August 20) regarding nightwear for patients.

Familial juvenile polyposis coli and colorectal cancer

A 40-year-old mother and her 7-year-old son underwent colectomy for polyposis coli. Both colectomy specimens contained predominantly juvenile polyps. The mother's specimen also had numerous tubular adenomas and one 5-cm severely dysplastic villous adenoma without invasive carcinoma. Foci of adenomatous change in juvenile polyps were present in the son's specimen. The histologic features of both cases suggest a sequence of change from juvenile polyps to adenomatous polyps to cancer.

Radiologically controlled balloon dilatation of rectal strictures

Rectal stricture is a well recognized complication following anterior resection. It is traditionally managed with metal dilators or resection. This paper describes the use of balloon dilatation for benign anastomotic rectal strictures. Eight patients were included in the trial. Only one dilatation was necessary in four patients while the remaining four patients required further dilatation for relief of symptoms. The mean diameter of the stricture increased from 7.2 mm to 17.0 mm post-dilatation. There were no complications associated with the procedure. Balloon dilatation is a safe and effective method of treating benign anastomotic rectal strictures.

Duodenocaval fistula in peptic ulceration

Duodenocaval fistula is usually caused by abdominal trauma. We report a patient in whom it was associated with peptic ulcer.

Evidence for protein kinase C--independent pathways mediating phorbol ester induced plasmacytoid differentiation of B chronic lymphocytic leukemia cells

The effects of phorbol esters on many cell types are known to be mediated through activation of the protein kinase C (PKC) signal transduction pathway. By using the specific inhibitor of this enzyme 1-(5-isoquinolinylsulfonyl)-2-methyl-piperazine dihydrochloride (H7) we have assessed the role of PKC activation in phorbol ester (phorbol 12-myristate 13-acetate, PMA)-induced plasmacytoid differentiation of B chronic lymphocytic leukemia cells (B-CLL) as a model of terminal differentiation of human B lymphocytes. H7 affected a dose-dependent inhibition of PMA-induced thymidine and uridine uptake with ID50 values of 41 microM and 32 microM, respectively. A comparable ID50 value (34 microM) was obtained for H7 inhibition of B-CLL PKC activity in a cell-free system. PMA-induced changes in cell morphology, expression of CD20, CD37 and FMC7 surface antigens together with increased secretion of immunoglobulin were variably abrogated by H7 suggesting that PKC activation is more important in B cell activation/DNA synthesis than in the differentiative response. Consistent with this, expression of a sizable proportion of PMA-inducible genes was not significantly affected by H7. These data are consistent with the existence of a PMA-activated, PKC-independent signal transduction pathway which may be important, though by itself apparently insufficient, for eliciting full terminal differentiation in B lymphocytes.

A comparison of same day and separate day injection protocols for myocardial perfusion SPECT using 99Tcm-MIBI

Three dose administration protocols for 99Tcm-MIBI were applied to groups of 15 patients with known or suspected ischaemic heart disease. Firstly, injections were given on consecutive days, with 300 MBq at rest and 500 MBq 24 h later at exercise. Secondly, both injections on the same day with 200 MBq at rest followed 1.5 h later by 1000 MBq during exercise. Finally, both injections on the same day with 200 MBq at rest followed 1.5 h later by 600 MBq during exercise. The diagnostic accuracy was significantly better when the administrations were on separate days than when given on the same day. There was no difference in diagnostic accuracy between the two same day protocols. The same day protocols gave a significantly higher false negative reporting rate than the separate day protocol.

Cell-type-specific early response gene expression during plasmacytoid differentiation of human B lymphocytic leukemia cells

Monoclonal B lymphocytes from B cell chronic lymphocytic leukemia (B-CLL) can be induced to undergo plasmacytoid differentiation in vitro by the phorbol ester, phorbol 12-myristate 13-acetate (PMA). By differential screening of a cDNA library derived from cells treated with phorbol ester we have isolated and characterised a set of early response genes (ERGs) displaying rapid transient up-regulation of expression in response to PMA. Cross-hybridisation studies showed that PMA probably induces the expression of over one hundred distinct genes, implying an ERG complexity comparable to that activated by mitogenic stimulation of fibroblasts and normal T lymphocytes. Of 13 genes analysed in detail, most were induced by PMA without a requirement for de novo protein synthesis, whilst nuclear run-on analysis showed that at least some of the more abundant classes of ERG were up-regulated through transcriptional mechanisms. In a proliferating variant B-CLL population, few differences in ERG expression were seen, suggesting that these genes are part of a gene regulatory pathway coupled to the differentiative rather than the proliferative response of B-CLL cells. However, studies in a range of cell types revealed a surprisingly diverse pattern of PMA-induced expression where most ERGs were relatively B-CLL-specific. This implies an extreme diversity of gene regulatory pathways activated in the primary response by phorbol ester generally and suggests that the onset of PMA-induced plasmacytoid differentiation of B-CLL cells is preceded by activation of a complex gene regulatory program that is largely unique to this maturation-arrested B cell.

Coupling of early response gene expression to distinct regulatory pathways during alpha-interferon and phorbol ester-induced plasmacytoid differentiation of B chronic lymphocytic leukaemia cells

Phorbol esters (phorbol 12-myristate 13-acetate; PMA) and alpha-interferon (alpha-IFN) act through divergent signal transduction pathways to induce B chronic lymphocytic leukaemia cells (B-CLL) to undergo plasmacytoid differentiation in vitro. By using a panel of PMA-inducible early response gene probes we show that these two different effectors are coupled to second messenger pathways that do not converge on a common gene regulatory programme in differentiation of B-CLL cells. Moreover, using the calcium ionophore, A23187, four distinct regulatory classes of early response gene could be defined implying that multiple regulatory pathways may mediate the process of terminal differentiation in B lymphocytes.

Sepsis associated with transfusion of red cells contaminated with Yersinia enterocolitica

Between April 1987 and May 1989, the Centers for Disease Control investigated seven cases of transfusion-associated Yersinia enterocolitica sepsis; four were caused by organisms of serotype O:3, and one each was caused by organisms of serotype O:1,2,3; O:5,27; and O:20. All seven recipients developed septic shock after receiving units of red cells (RBCs) contaminated with Y. enterocolitica; five recipients died. The cases occurred in seven states and were unrelated. There was no evidence for contamination of the RBC units during processing. Six of the seven donors had serologic evidence of recent Y. enterocolitica infection, and it is hypothesized that these donors had asymptomatic bacteremia when they donated the implicated blood. Four of the seven donors reported gastrointestinal illness in the 4 weeks before blood donation, and one donor became ill on the day he donated blood. Y. enterocolitica grows well at 4 degrees C and in the presence of dextrose and iron. If blood is contaminated at the time of collection, storage of the RBCs at 4 degrees C provides an ideal environment for bacterial growth and endotoxin production. These cases demonstrate the need for careful evaluation of patients with transfusion reactions for possible sepsis and suggest a need to screen prospective blood donors for mild gastrointestinal illness, including those illnesses not requiring physician evaluation or medication.

Patterns of nuclear proto-oncogene expression during induced differentiation and proliferation of human B chronic lymphocytic leukaemia cells

Phorbol ester-induced differentiation of human B-chronic lymphocytic leukaemic cells was found to be preceded by a rapid transient induction in expression of the c-jun proto-oncogene, which paralleled that of c-fos. Induced expression of c-myc but not of c-fos/c-jun proto-oncogenes was markedly higher in a proliferating variant leukaemic cell population compared with that seen in typical lymphocytic leukaemia cells. These data suggest that the c-fos/c-jun nuclear oncogenes play a role in induced differentiation, whilst c-myc is more important in the proliferative response of B lymphocytes.

Findings at necropsy in the heart of a patient with anticardiolipin syndrome

A 40 year old man with a history of myocardial infarction and hypertension presented with transient cerebral ischaemic attacks, aortic regurgitation, a raised erythrocyte sedimentation rate, and thrombocytopenia. The anticardiolipin syndrome was diagnosed and he was treated with prednisolone and warfarin. He died two years later after the development of acute heart failure. At necropsy his heart showed widespread arteriolar thrombosis without vasculitis, recanalised large vessel occlusion, and a "post-inflammatory" valvulitis of the aortic valve.