Movement of the endotracheal tube during laparoscopic hernia repair

BACKGROUND

Laparoscopic surgery is not without its problems, and one of the less known is cephalad displacement of the carina and relative movement of the endotracheal tube in the trachea. The aetiology of this is presumably a consequence of both pneumoperitoneum and the Trendelenburg position frequently adopted during laparoscopic surgery.

METHOD

We studied 30 patients undergoing laparoscopic hernia repair utilising 10 degrees of Trendelenburg position and an intra-abdominal inflation pressure of between 12 and 15 mm Hg (mean 13.6 mm Hg). We measured the distance between the tip of the endotracheal tube and the carina using a fibreoptic bronchoscope.

RESULT

This distance decreased only slightly, from a mean (SD) of 39.6 (13) mm after intubation, to 38.9 (12.6) mm after adoption of Trendelenburg tilt and pneumoperitoneum. This did not represent a statistically significant change (P=0.09).

CONCLUSION

We conclude that the endotracheal tube does not routinely migrate towards the carina when laparoscopic hernia repair is performed under these conditions.

Enhancement of survival of stored dopaminergic cells and promotion of graft survival by exposure of human fetal nigral tissue to glial cell line--derived neurotrophic factor in patients with Parkinson's disease. Report of two cases and technical considerations

The authors have studied the ability of glial cell line-derived neurotrophic factor (GDNF) to promote survival of human fetal dopaminergic tissue after a storage period of 6 days and subsequent implantation into the human putamen. The results indicate that GDNF promotes survival of stored dopaminergic cells. Cells stored without GDNF had a 30.1% decrease in survival time compared with those exposed to GDNF. Two patients with Parkinson's disease received bilateral putaminal implants of fetal dopaminergic cells exposed to GDNF for 6 days and showed enhancement of graft survival as assessed by positron emission tomography scanning. A mean increase of 107% in putaminal fluorodopa uptake from baseline values was observed 12 months postgrafting.

Capture of human Fab fragments by expanded bed adsorption with a mixed mode adsorbent

A novel group of mixed mode adsorbents has been developed for purification of monoclonal and polyclonal antibodies from a broad range of raw materials such as hybridoma cell culture, ascites fluid, animal sera, milk, whey and egg yolk. The aim of this study was to determine whether such mixed mode adsorbents were also useful for the recovery of recombinant proteins from microbial feedstocks. This paper describes the performance of one of these adsorbents for expanded bed capture of a human Fab fragment from recombinant E. Coli cell extracts. It is concluded that the mixed mode adsorbent binds the Fab fragment efficiently from crude extracts without any requirement for preconditioning the extract by for example de-salting or dilution. The capacity of the mixed mode adsorbent is approx. 12 mg Fab/ml matrix. The novel mixed mode adsorbent can be useful during production of highly purified Fab fragments as the first step in a purification scheme. In this respect the mixed mode adsorbent is advantageous over alternative commercially available ion-exchange materials which require pre-conditioning of cell extract for Fab' capture. Together with the concentration and clarification effect a significant enrichment of the Fab fragment is obtained in one single high yield operation.

Prevalence of mental illness in a rehabilitation unit for older adults

The prevalence of psychiatric disorders was studied in 78 elderly people in a rehabilitation unit for older adults. The patients were assessed using the Evans Liverpool depression rating scale, Hospital Anxiety and Depression scale and Mini-Mental State Examination. Twenty-eight (35.9%) patients were found to be depressed, 15 of these also had raised anxiety. Thirty-one (41.0%) patients had significant cognitive impairment and 14 of these had associated depression. Only 33 (42%) had no evidence of either cognitive impairment or mood disorder. On discharge, 20 (25.6%) patients were on antidepressant treatment but only 50% of those had this diagnosis recorded on the discharge summary. Our results showed higher prevalence of depression in this situation compared with the reported prevalence of 20-30% in the acute hospital setting. We recommend that all patients undergoing rehabilitation should be routinely screened for depression as it is common and treatment will improve the overall outcome.

Squamous cell carcinoma of the urethral process in a horse with hemospermia and self-mutilation behavior

A 14-year-old Arabian stallion was examined because of acute hemospermia. The stallion was used in an artificial breeding program and had a 6-year history of low-grade hemospermia and a 4-year history of self-mutilation behavior. During previous examinations, minor irritation of the urethral process was identified as the source of the bleeding. Physical examination revealed a mucosal ulceration in the distal portion of the urethra. Histologic examination of a biopsy specimen from this area revealed low-grade squamous cell carcinoma. The urethral process was excised, and the hemospermia resolved. Frequency of self-mutilation behaviors also decreased after surgery, suggesting that there may have been a link between irritation of the urethral process and development of self-mutilation behavior.

Immunohistochemical evidence for mesothelial origin of paratesticular adenomatoid tumour

AIMS

To investigate the histogenesis of paratesticular adenomatoid tumour by use of immunohistochemical markers for a variety of carcinomas and mesothelioma.

METHODS AND RESULTS

Immunohistochemical staining of sections from 12 cases of paratesticular adenomatoid tumour was undertaken using primary antibodies to antigens expressed by benign epithelial cells and carcinoma (cytokeratin AE1/AE3, cytokeratin 34ssE12, epithelial membrane antigen, MOC-31, Ber-EP4, CEA, B72.3, LEA.135, Leu M1), stromal and vascular markers (vimentin, CD34, factor VIII), and mesothelioma-associated antigens (thrombomodulin, HBME-1, OC 125) and p53 protein. There was absence of immunohistochemical expression of epithelial/carcinoma markers MOC-31, Ber-EP4, CEA, B72.3, LEA.135, Leu M1 and to factor VIII and CD34. All tumours expressed cytokeratin AE1/AE3, epithelial membrane antigen and vimentin, with weak expression of cytokeratin 34ssE12 in 25% of tumours. Each tumour showed expression of thrombomodulin, HBME-1 and OC 125 in a membranous distribution. p53 protein expression was not detected.

CONCLUSIONS

The immunohistochemical profile of paratesticular adenomatoid tumour is strongly supportive of a mesothelial cell origin.

The diagnosis and management of insomnia in clinical practice: a practical evidence-based approach

Insomnia, or the dissatisfaction with the quantity, quality or timing of sleep, is a common complaint. Because the definition of "normal" sleep is not well established, the estimates of the prevalence and severity of insomnia vary widely. Insomnia is often secondary to underlying psychiatric and medical conditions, and these should be evaluated and treated as a first measure. Nonpharmacological interventions for insomnia including sleep hygiene manoeuvres and exercise are recommended, although the success of these interventions has not been well documented. Benzodiazepines have been the pharmacologic agents of choice for the treatment of insomnia, but there is reason to exercise caution with their use; their overall benefit compared with placebo appears to be minor, and they are often associated with adverse cognitive effects. Unfortunately, no other class of drugs has proven to be superior to the benzodiazepines in terms of benefit:risk ratio. Given the importance of sleep for health and normal daily functioning the diagnosis, prognosis and treatment of insomnia should be a research priority.

Meta-analysis of benzodiazepine use in the treatment of insomnia

OBJECTIVE

To systematically review the benefits and risks associated with the use of benzodiazepines to treat insomnia in adults.

DATA SOURCES

MEDLINE and the Cochrane Controlled Trials Registry were searched for English-language articles published from 1966 to December 1998 that described randomized controlled trials of benzodiazepines for the treatment of insomnia. Key words included "benzodiazepines" (exploded), "randomized controlled trial" and "insomnia." Bibliographies of relevant articles were reviewed for additional studies and manufacturers of benzodiazepines were asked to submit additional randomized controlled trial reports not in the literature.

STUDY SELECTION

Articles were considered for the meta-analysis if they were randomized controlled trials involving patients with insomnia and compared a benzodiazepine with placebo or another active agent. Of the 89 trials originally identified, 45 met our criteria, representing a total of 2672 patients.

DATA EXTRACTION

Data were extracted regarding the participants, the setting, details of the intervention, the outcomes (including adverse effects) and the methodologic quality of the studies.

DATA SYNTHESIS

The meta-analyses of sleep records indicated that, when compared with placebo, benzodiazepines decreased sleep latency by 4.2 minutes (non-significant; 95% confidence interval (CI -0.7 to 9.2) and significantly increased total sleep duration by 61.8 minutes (95% CI 37.4 to 86.2). Patient-reported outcomes were more optimistic for sleep latency; those randomized to benzodiazepine treatment estimated a sleep latency decrease of 14.3 minutes (95% CI 10.6 to 18.0). Although more patients receiving benzodiazepine treatment reported adverse effects, especially daytime drowsiness and dizziness or light-headedness (common odds ratio 1.8, 95% CI 1.4 to 2.4), dropout rates for the benzodiazepine and placebo groups were similar. Cognitive function decline including memory impairment was reported in several of the studies. Zopiclone was not found to be superior to benzodiazepines on any of the outcome measures examined.

INTERPRETATION

The use of benzodiazepines in the treatment of insomnia is associated with an increase in sleep duration, but this is countered by a number of adverse effects. Additional studies evaluating the efficacy of nonpharmacological interventions would be valuable.

Novel size-independent modeling of the dilute solution conformation of the immunoglobulin IgG Fab' domain using SOLPRO and ELLIPS

The proliferation of hydrodynamic modeling strategies to represent the shape of quasirigid macromolecules in solution has been hampered by ambiguities caused by size. Universal shape parameters, independent of size, developed originally for ellipsoid modeling, are now available for modeling using the bead-shell approximation via the algorithm SOLPRO. This paper validates such a "size-independent" bead-shell approach by comparison with the exact hydrodynamics of 1) an ellipsoid of revolution and 2) a general triaxial ellipsoid (semiaxial ratios a/b, b/c) based on a fit using the routine ELLIPSE (. J. Mol. Graph. 1:30-38) to the chimeric (human/mouse) IgG Fab' B72.3; a similar fit is obtained for other Fabs. Size-independent application of the bead-shell approximation yields errors of only approximately 1% in frictional ratio based shape functions and approximately 3% in the radius of gyration. With the viscosity increment, errors have been reduced to approximately 3%, representing a significant improvement on earlier procedures. Combination of the Perrin frictional ratio function with the experimentally measured sedimentation coefficient for the same Fab' from B72.3 yields an estimate for the molecular hydration of the Fab' fragment of approximately (0.43 +/- 0.07) g/g. This value is compared to values obtained in a similar way for deoxyhemoglobin (0.44) and ribonuclease (0.27). The application of SOLPRO to the shape analysis of more complex macromolecules is indicated, and we encourage such size-independent strategies. The utility of modern sedimentation data analysis software such as SVEDBERG, DCDT, LAMM, and MSTAR is also clearly demonstrated.

Public opinion and rationing in the United Kingdom

In the United Kingdom and as in all other countries, health care professionals ration access to diagnosis and treatment. Throughout its history there has been a reluctance to acknowledge the existence, let alone the nature of rationing processes and public opinion about them. Several health policy reforms are discussed with reference to their approach to dealing with the scarcity of health care resources. Data taken form the 1998 Eurobarometer Survey are analysed to examine public opinion regarding rationing issues, such as funding for health care, the need to set limits in health coverage, the role of stakeholders in setting priorities, and the use of age, and other factors, as a criteria for setting priorities.

Evaluating the performance of academic medical education administrators

Educators have devoted little attention to formal evaluation of educational administrative personnel. The authors surveyed the educational administrators working in McMaster University's Department of Medicine residency program and found they felt they were receiving little useful feedback. The authors also surveyed the colleagues, residents, and administrative staff with whom the administrators worked and found they felt they had inadequate input into the administrators' evaluation. In response to these results, a measurement instrument was developed based on existing job descriptions and feedback was obtained on administrators' performance from relevant individuals. After three yearly evaluations, administrators and evaluators acknowledged much broader input into evaluation but saw little evaluation-related improvement in performance. Of the administrators, 85% felt the process should continue as did 91% of the evaluators. An evaluation process may not alter perceived performance when it is already good but there may be other benefits to rigorous evaluation.

An emergency department tackles bed management and home-based care

Ipswich Hospital Emergency Department played a vital role in the Post Acute Treatment in the Home Program (PATH) of West Moreton District Health Service. PATH used two strategies to reduce the district reliance on acute hospital beds: a short-stay unit for rapid assessment, treatment and early discharge of patients with simple conditions; and a hospital-in-the-home program utilising community health services to treat acute conditions. The program enhanced existing services to create a new treatment stream for acute patients and to promote a cultural shift from fragmented care to district responsibility for total episode of patient care.

Citizens and rationing: analysis of a European survey

While many studies have reviewed the issues involved in rationing and priority setting within health care services, few studies have comprehensively analysed the views and attitudes of a significant stakeholder in the debate - the public. The aims of this paper are to discuss the issues involved in involving the public in rationing and priority setting decision-making; and to analyse data pertaining to citizen's attitudes towards rationing and priority setting. The data analysed were taken from the 1998 Eurobarometer Survey, with specific questions pertaining to rationing and priority setting asked in six countries within the European Union: Germany; France; Italy; the Netherlands; Britain and Sweden. The review of previous studies and the analysis of the Eurobarometer data, focus on issues relating to funding for health care; the need to set limits in health coverage; the role of stakeholders in setting priorities; and the use of age, and other factors, as a criteria for setting priorities.

Autocorrelation measurement of femtosecond laser pulses by use of a ZnSe two-photon detector array

We demonstrate autocorrelation measurements of 85-fs Ti:sapphire laser pulses, using a 32-pixel ZnSe detector array in a single-shot geometry. The two-photon photoconductor is fabricated by deposition of an array of interdigitated gold fingers on a single-crystal ZnSe substrate.

Development of a disease specific questionnaire to measure health related quality of life in patients with chronic liver disease

BACKGROUND AND AIMS

To develop and assess a disease specific instrument for measuring health related quality of life (HRQL) in patients with chronic liver disease (CLD).

METHODS

Based on responses from 60 patients with chronic liver disease, from 20 liver experts, and from a Medline search of the literature, items potentially affecting the HRQL of these patients were identified. A separate sample of 75 patients identified which items they found problematic and rated their importance. Results were explored using factor analysis; domains were chosen and items placed within domains. Redundant questions were eliminated and the final questionnaire was pretested in 10 patients. Using this instrument, HRQL was assessed in a further 133 patients with various types and stages of liver disease.

RESULTS

Patients, experts, and the literature search identified 156 items of potential importance. Of these, 35 proved important to over 50% of 75 respondents in the item reduction sample. The factor analysis suggested six domains. After eliminating redundancies, the Chronic Liver Disease Questionnaire (CLDQ) included 29 items in the following domains: fatigue, activity, emotional function, abdominal symptoms, systemic symptoms, and worry. In pretesting, patients found the CLDQ clear and easy to complete in 10 minutes. In another 133 patients, the CLDQ showed a gradient between patients without cirrhosis, Child's A cirrhosis, and those with Child's B or C cirrhosis. CLDQ has evidence for moderate reliability at six months and seems to be responsive.

CONCLUSION

The CLDQ is short, easy to administer, produces both a summary score and domain scores, and correlates with the severity of liver disease.

An 'inherent' biodegradability test for oil products: description and results of an international ring test. CONCAWE Biodegradation Task Force

Current test guidelines for assessing 'inherent' (potential) biodegradability were designed for water-soluble, organic compounds of low volatility and are unsuitable for most oil products. It was against this background, that CONCAWE (the oil companies' European organisation for environment, health and safety) formed a task force to develop a standard test protocol for assessing the 'inherent' biodegradability of oil products.

Funduscopy: a forgotten art?

Funduscopy is an integral part of the physical examination, especially in older patients in whom visual problems and systemic diseases affecting the fundi (e.g., diabetes mellitus) are more common. We have assessed the views of hospital doctors to funduscopy via a questionnaire survey, reviewed the case notes to see whether or not funduscopy is carried out on older patients, and assessed the views of older patients on vision via a questionnaire survey. Review of the case notes showed only three of 100 patients had had funduscopy. Most patients reported a visual problem on specific enquiry. Whilst most hospital doctors believed funduscopy was important, many felt they had insufficient training in this procedure and felt their skills could be improved. We conclude that older patients are missing out on routine funduscopy. Hospital doctors should be aware that not all patients complain of visual problems and specific enquiry should be made. The issue of training and encouragement to perform funduscopy needs to be addressed before funduscopy becomes a forgotten art.

Metabolism in single rat brain slices measured by magnetic resonance spectroscopy

Nuclear magnetic resonance spectroscopy (MRS) has been used to study brain biochemistry in superfused brain slice preparations for over a decade. However, unlike techniques that monitor electrical activity, ion fluxes, or the release of radio-labeled compounds in single brain slices, MRS studies have required samples composed of several slices and inherently poor anatomical specificity in order to achieve adequate signal-to-noise levels, spectral resolution, or, in the case of 1H MRS, a high degree of artifact-free water signal suppression. We report that gradient-enhanced 1H MRS techniques combined with a simple slice positioning and perfusion technique yield high-quality spectra from single 400 microns rat forebrain or neocortical-hippocampal slices within 15 min of data acquisition time. Spectra of comparable quality were obtained from samples with three neocortical or three hippocampal slices within the same time frame. The assessment of anaerobic energy metabolism in single slices by 1H MRS is also demonstrated. In addition to greater anatomical resolution in studies on brain slice biochemistry, single slice MRS also presents the possibility of correlating, within the same slice, 1H MRS-detectable metabolite levels with other physiological measurements commonly performed on single brain slices.

Meta-analysis of benzodiazepine use in the treatment of acute alcohol withdrawal

OBJECTIVE

To analyse the evidence for the efficacy and potential harmful effects of benzodiazepines compared with other therapies in the treatment of acute alcohol withdrawal.

DATA SOURCES

MEDLINE and the Cochrane Controlled Trials Registry were searched for English-language articles published from 1966 to December 1997 that described randomized controlled trials (RCTs) of benzodiazepines in the treatment of acute alcohol withdrawal. Key words included "benzodiazepines" (exploded) and "randomized controlled trial." Bibliographies of relevant articles were reviewed for additional RCTs, and manufacturers of benzodiazepines were asked to submit additional RCT reports not in the literature.

STUDY SELECTION

Articles were considered for the meta-analysis if they were RCTs involving patients experiencing acute alcohol withdrawal and comparing a benzodiazepine available in Canada with placebo or an active control drug. Of the original 23 trials identified, 11 met these criteria, representing a total of 1286 patients.

DATA EXTRACTION

Data were extracted regarding the participants, the setting, details of the intervention, the outcomes (including adverse effects) and the methodologic quality of the studies.

DATA SYNTHESIS

The meta-analysis of benefit (therapeutic success within 2 days) showed that benzodiazepines were superior to placebo (common odds ratio [OR] 3.28, 95% confidence interval [CI] 1.30-8.28). Data on comparisons between benzodiazepines and other drugs, including beta-blockers, carbamazepine and clonidine, could not be pooled, but none of the alternative drugs was found to be clearly more beneficial than the benzodiazepines. The meta-analysis of harm revealed no significant difference between benzodiazepines and alternative drugs in terms of adverse events (common OR 0.67, 95% CI 0.34-1.32) or dropout rates (common OR 0.68, 95% CI 0.47-0.97).

INTERPRETATION

Benzodiazepines should remain the drugs of choice for the treatment of acute alcohol withdrawal.

Diagnosis and management of acute alcohol withdrawal

Alcohol abuse produces a considerable burden of illness in the Canadian population. The diagnosis of alcohol dependence and withdrawal can be difficult, particularly in the setting of covert intake or comorbidity. Two validated scales, the CAGE questionnaire to screen for alcohol abuse and dependence and the Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) scale to assess the severity of withdrawal, are valuable tools for clinicians to use on a regular basis. For the treatment of alcohol withdrawal, compelling anecdotal evidence supports the routine administration of thiamine, but not necessarily other vitamins. Phenytoin has not been shown to be superior to placebo for uncomplicated withdrawal seizures. Neuroleptics are not recommended for routine use. Sedation with benzodiazepines guided by the CIWA-Ar results is recommended. There is good evidence that the management of alcohol withdrawal can be improved with the routine use of the CIWA-Ar scale to assess severity, treatment with adequate doses of benzodiazepines and follow-up monitoring of patients in alcohol withdrawal.

An analysis of the geographic variation in cancer incidence and its determinants in Ontario

Cancer incidence data for the Ontario Public Health Units in 1980-91 were examined to investigate regional patterns and the existence of outlier values after adjustment for known risk factors. Candidate risk factors were derived from the Ontario Health Survey and the census. Weighted regressions were fit to the data, and the spatial pattern of the residuals was analyzed. The number of outlier data points with significant elevations or reductions in risk was close to that expected by chance. They were dispersed geographically, and occurred in a variety of cancer types. We conclude that, in general, most of the geographic variation in cancer risk can be associated with variation in known risk factors, and that there appear to be no broad regional effects remaining after adjustment for these factors. A few cancer sites provide limited evidence of regional effects that may warrant further investigation.