Palliative Appropriateness Criteria: A Pragmatic Method to Evaluate the Suitability of Palliative Radiotherapy Fractionation

Purpose: To describe a novel metric to aid clinical decision making between shorter versus longer palliative radiotherapy (PRT) regimens using objective patient factors. Materials and Methods: Patients receiving PRT at a single institution between 2014 and 2018 were reviewed. The time between PRT start and finish was calculated and divided by overall survival (in days from start of PRT) to generate the percent of remaining life (PRL). This value was compared across various clinical factors using the Kruskal-Wallis test. Factors identified with a significance level p < 0.01 were included in a novel Palliative Appropriateness Criteria Score (PACS) and were included in an online risk assessment tool to assist clinicians in patient-specific fractionation decisions. Results: Totally 1027 courses of PRT were analyzed. Median age was 64 years; Eastern Cooperative Oncology Group (ECOG) performance status was 3-4 in 22%. Primary malignancies included were lung (38%), breast (13.8%), prostate (9.3%), and other (39%). The indication for PRT was pain (61%), neurological (21%), or other (18%). Palliative regimens included 199 (19.4%) receiving single fraction, 176 (17.1%) receiving 2-5 fractions, and 652 (63.5%) receiving 10 fractions. Median follow-up was 83 days overall and 437 days for patients alive at last follow-up. Factors significantly associated with increased PRL (and included in the PACS) were male gender, ECOG 3-4, lung or "other" primary diagnosis (vs. breast or prostate), PRT indication (neurological dysfunction vs. pain/other), inpatient status, and extraosseous sites treatment. Death within 30 days was significantly associated with high-risk PACS categorization, regardless of fractionation scheme (p < 0.001). Conclusions: The PACS is a novel metric for evaluating the utility of PRT regimens to improve clinical decision making. Single fraction is associated with low PRL. When considering multifraction PRT regimens, the PACS identifies patients who may benefit from shorter courses of PRT and alternatively, low-risk patients for whom a more protracted course is reasonable. Prospective external validation is warranted.

Discordance Between Oncology Clinician-Perceived and Radiologist-Intended Meaning of the Postradiotherapy Positron Emission Tomography/Computed Tomography Freeform Report for Head and Neck Cancer

Importance

Assessment of response after radiotherapy (RT) using 18F-fluorodeoxyglucose positron emission tomography (PET) with computed tomography (CT) is routine in managing head and neck squamous cell carcinoma (HNSCC). Freeform reporting may contribute to a clinician's misunderstanding of the nuclear medicine (NM) physician's image interpretation, with important clinical implications.

Objective

To assess clinician-perceived freeform report meaning and discordance with NM interpretation using the modified Deauville score (MDS).

Design, Setting, and Participants

In this retrospective cohort study that was conducted at an academic referral center and National Cancer Institute-designated Comprehensive Cancer Center and included patients with HNSCC treated with RT between January 2014 and December 2019 with a posttreatment PET/CT and 1 year or longer of follow-up, 4 masked clinicians independently reviewed freeform PET/CT reports and assigned perceived MDS responses. Interrater reliability was determined. Clinician consensus-perceived MDS was then compared with the criterion standard NM MDS response derived from image review. Data analysis was conducted between December 2021 and February 2022.

Exposures

Patients were treated with RT in either the definitive or adjuvant setting, with or without concurrent chemotherapy. They then underwent posttreatment PET/CT response assessment.

Main Outcomes and Measures

Clinician-perceived (based on the freeform PET/CT report) and NM-defined response categories were assigned according to MDS. Clinical outcomes included locoregional control, progression-free survival, and overall survival.

Results

A total of 171 patients were included (45 women [26.3%]; median [IQR] age, 61 [54-65] years), with 149 (87%) with stage III to IV disease. Of these patients, 52 (30%) received postoperative RT and 153 (89%) received concurrent chemotherapy. Interrater reliability was moderate (κ = 0.68) among oncology clinicians and minimal (κ = 0.36) between clinician consensus and NM. Exact agreement between clinician consensus and the NM was 64%. The NM-rated MDS was significantly associated with locoregional control, progression-free survival, and overall survival.

Conclusions and Relevance

The results of this cohort study suggest that considerable variation in perceived meaning exists among oncology clinicians reading freeform HNSCC post-RT PET/CT reports, with only minimal agreement between MDS derived from clinician perception and NM image interpretation. The NM use of a standardized reporting system, such as MDS, may improve clinician-NM communication and increase the value of HNSCC post-RT PET/CT reports.

Efficacy and Survival after Palliative Radiotherapy for Malignant Pulmonary Obstruction

Introduction: The purpose of this study was to determine the efficacy of palliative radiotherapy (PRT) for patients with pulmonary obstruction from advanced malignancy and identify factors associated with lung re-expansion and survival. Materials and Methods: We reviewed all patients treated with PRT for malignant pulmonary obstruction (n = 108) at our institution between 2010 and 2018. Radiographic evidence of lung re-expansion was determined through review of follow-up CT or chest X-ray. Cumulative incidence of re-expansion and overall survival (OS) were estimated using competing risk methodology. Clinical characteristics were evaluated for association with re-expansion, OS, and early mortality. Treatment time to remaining life ratio (TT:RL) was evaluated as a novel metric for palliative treatment. Results: Eighty-one percent of patients had collapse of an entire lung lobe, 46% had Eastern Cooperative Oncology Group (ECOG) performance status 3-4, and 64% were inpatient at consultation. Eighty-four patients had follow-up imaging available, and 25 (23%) of all patients had lung re-expansion at median time of 35 days. Rates of death without re-expansion were 38% and 65% at 30 and 90 days, respectively. Median OS was 56 days. Death within 30 days of PRT occurred in 38%. Inpatients and larger tumors trended toward lower rates of re-expansion. Notable factors associated with OS were re-expansion, nonlung histology, tumor size, and performance status. Median TT:RL was 0.11 and significantly higher for subgroups: ECOG 3-4 (0.19), inpatients (0.16), patients with larger tumors (0.14), those unfit for systemic therapy (0.17), and with 10-fraction PRT (0.14). Conclusion: One-fourth of patients experienced re-expansion after PRT for malignant pulmonary obstruction. Survival is poor and a significant proportion of remaining life may be spent on treatment. Careful consideration of these clinical factors is recommended when considering PRT fractionation.

Factors associated with time to palliative radiotherapy in an academic radiation oncology clinic

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Background: Palliative radiotherapy (PRT) is a common and effective modality for the relief of symptoms due to malignancy. Members of the supportive care team may be hesitant to refer for PRT due to concerns regarding timeliness of treatment and patient/caregiver time burden. The current structure of most radiation oncology clinics is not conducive to the delivery of timely PRT and few metrics aimed at quality improvement have been reported. Methods: We reviewed all courses of PRT delivered at our institution between January 2017 and December 2018. Hematologic/myeloma primary and postoperative cases were excluded. The dates of referral, consultation, PRT planning simulation, PRT start and end were recorded. An inherent delay was noted if PRT was purposefully delayed (workup, imaging). Time to PRT (TTPRT) was defined as the number of days between referral and start of PRT. A remaining life ratio (RLR) representing TTPRT as a proportion of survival from the time of referral, was developed as a practical metric to represent timeliness of PRT with respect to prognosis. Results: 338 courses of PRT were included from 67% outpatient and 33% inpatient referrals. Indications included pain (55%), neurologic deficits/brain metastases (23%), respiratory symptoms (10%), bleeding (6%) and other (7%). Median TTPRT was 13 d (IQR 4-19), comprised of: referral to consult (3 d), consult to simulation (4 d), and simulation to PRT (6 d). Factors associated with TTPRT included ECOG, PRT indication, site (non-spine bone, chest, or brain), outpatient referral and delay. TTPRT was not associated with age, gender, rural residence, distance to hospital, race, median household income, insurance or marital status. Of 229 patients who died, factors associated with increased RLR were outpatient referral (13% v. 5%), abdomen/pelvis treatment site (16% v. 9%) and delay (17% v. 8%). Conclusions: TTPRT is associated with patient, treatment, and systematic factors, some of which are associated with increased RLR, elucidating several opportunities for improvement. Based on these results, our group has established a dedicated Palliative Radiation Oncology Clinic focused on timely, quality PRT, the outcomes of which will be assessed prospectively.

Predictors of neurologic and nonneurologic death in patients with brain metastasis initially treated with upfront stereotactic radiosurgery without whole-brain radiation therapy

Background

In this study we attempted to discern the factors predictive of neurologic death in patients with brain metastasis treated with upfront stereotactic radiosurgery (SRS) without whole brain radiation therapy (WBRT) while accounting for the competing risk of nonneurologic death.

Methods

We performed a retrospective single-institution analysis of patients with brain metastasis treated with upfront SRS without WBRT. Competing risks analysis was performed to estimate the subdistribution hazard ratios (HRs) for neurologic and nonneurologic death for predictor variables of interest.

Results

Of 738 patients treated with upfront SRS alone, neurologic death occurred in 226 (30.6%), while nonneurologic death occurred in 309 (41.9%). Multivariate competing risks analysis identified an increased hazard of neurologic death associated with diagnosis-specific graded prognostic assessment (DS-GPA) ≤ 2 (P = .005), melanoma histology (P = .009), and increased number of brain metastases (P<.001), while there was a decreased hazard associated with higher SRS dose (P = .004). Targeted agents were associated with a decreased HR of neurologic death in the first 1.5 years (P = .04) but not afterwards. An increased hazard of nonneurologic death was seen with increasing age (P =.03), nonmelanoma histology (P<.001), presence of extracranial disease (P<.001), and progressive systemic disease (P =.004).

Conclusions

Melanoma, DS-GPA, number of brain metastases, and SRS dose are predictive of neurologic death, while age, nonmelanoma histology, and more advanced systemic disease are predictive of nonneurologic death. Targeted agents appear to delay neurologic death.

Impact of systemic targeted agents on the clinical outcomes of patients with brain metastases

BACKGROUND

To determine the clinical benefits of systemic targeted agents across multiple histologies after stereotactic radiosurgery (SRS) for brain metastases.

METHODS

Between 2000 and 2013, 737 patients underwent upfront SRS for brain metastases. Patients were stratified by whether or not they received targeted agents with SRS. 167 (23%) received targeted agents compared to 570 (77%) that received other available treatment options. Time to event data were summarized using Kaplan-Meier plots, and the log rank test was used to determine statistical differences between groups.

RESULTS

Patients who received SRS with targeted agents vs those that did not had improved overall survival (65% vs. 30% at 12 months, p < 0.0001), improved freedom from local failure (94% vs 90% at 12 months, p = 0.06), improved distant failure-free survival (32% vs. 18% at 12 months, p = 0.0001) and improved freedom from whole brain radiation (88% vs. 77% at 12 months, p = 0.03). Improvement in freedom from local failure was driven by improvements seen in breast cancer (100% vs 92% at 12 months, p < 0.01), and renal cell cancer (100% vs 88%, p = 0.04). Multivariate analysis revealed that use of targeted agents improved all cause mortality (HR = 0.6, p < 0.0001).

CONCLUSIONS

Targeted agent use with SRS appears to improve survival and intracranial outcomes.

Either main or accessory olfactory system signaling can mediate the rewarding effects of estrous female chemosignals in sexually naive male mice

A long-held view has been that interest of male mice in female body odors reflects an activation of reward circuits in the male brain following their detection by the vomeronasal organ (VNO) and processing via the accessory olfactory system. We found that adult, sexually naive male mice acquired a conditioned place preference (CPP) after repeatedly receiving estrous female urine on the nose and being placed in an initially nonpreferred chamber with soiled estrous bedding on the floor. CPP was not acquired in control mice that received saline on the nose before being placed in a nonpreferred chamber with clean bedding. Robust acquisition of a CPP using estrous female odors as the reward persisted in separate groups of mice in which VNO-accessory olfactory function was disrupted by bilateral lesioning of the accessory olfactory bulb (AOB) or in which main olfactory function was disrupted by zinc sulfate lesions of the main olfactory epithelium (MOE). By contrast, no CPP was acquired for estrous odors in males that received combined AOB and MOE lesions. Either the main or the accessory olfactory system suffices to mediate the rewarding effects of estrous female odors in the male mouse, even in the absence of prior mating experience. The main olfactory system is part of the circuitry that responds to chemosignals involved in motivated behavior, a role that may be particularly important for humans who lack a functional accessory olfactory system.

Biochemical polymorphism of starry flounder, Platichthys stellatus, from the northwestern and northeastern Pacific Ocean

Three enzyme systems, MDH, PGM and AGPDH, were investigated in starry flounder collected from off northwestern Hokkaido Island, Japan; western Kamchatka; USSR; Puget Sound, Washington, USA; and Yaquina Bay, Oregon, USA. Significant differences in MDH allele distribution were found between the Asian-Puget Sound and Yaquina Bay-Puget Sound samples suggesting that this system may be useful to separate different population units. The allele frequencies of MDH and PGM did not show significant variation with body length and handedness in starry flounder collected from Puget Sound, Washington, and did not support the hypothesis of differential viability between dextral and sinistrial forms of starry flounder.

Electrophoretic variation in intertidal and subtidal organisms in Puget Sound, Washington

This paper presents information on the biochemical properties (via starch gel electrophoresis) of 26 marine species (15 fish and 11 invertebrates). Evidence is presented on 48 polymorphisms found in the 26 species. Estimates of the proportion of the genome heterozygous per individual per species were calculated and ranged from 0.000 to 0.176 for the invertebrates and from 0.000 to 0.074 for the fish species. Estimates of the percentage of loci polymorphic per species for invertebrates were 0 to 54%; for the fish species, the range was 0 to 20%.

Poly A:U-induced secretion of T-lymphocyte helper factors

In vitro exposure of mouse thymocytes to complexes of polyadenylic:polyuridylic acid (poly A:U) effected, within 6 h, the release of soluble factor(s) capable of nonspecifically enhancing IgM and IgG plaque-forming cells (PFCs) in in vitro primary and secondary spleen cell responses to burro erythrocytes. Poly A:U stimulation was, most likely, polyclonal, since production of soluble factor(s) occurred in the absence of antigen and in serum-free culture media. Poly A:U-induced soluble factor(s) were not capable of substituting for T cells but were dependent on T cells for the expression of PFC enhancement. These data support the hypothesis that the mechanism of poly A:U's adjuvant action is polyclonal stimulation of T cells, causing early induction and release of nonspecific, soluble PFC-enhancing factor(s).

One-dimensional models of the human biliary system

This paper studies two one-dimensional models to estimate the pressure drop in the normal human biliary system for Reynolds number up to 20. Excessive pressure drop during bile emptying and refilling may result in incomplete bile emptying, leading to stasis and subsequent formation of gallbladder stones. The models were developed following the group's previous work on the cystic duct using numerical simulations. Using these models, the effects of the biliary system geometry, elastic property of the cystic duct, and bile viscosity on the pressure drop can be studied more efficiently than with full numerical approaches. It was found that the maximum pressure drop occurs during bile emptying immediately after a meal, and is greatly influenced by the viscosity of the bile and the geometric configuration of the cystic duct, i.e., patients with more viscous bile or with a cystic duct containing more baffles or a longer length, have the greatest pressure drop. It is found that the most significant parameter is the diameter of the cystic duct; a 1% decrease in the diameter increases the pressure drop by up to 4.3%. The effects of the baffle height ratio and number of baffles on the pressure drop are reflected in the fact that these effectively change the equivalent diameter and length of the cystic duct. The effect of the Young's modulus on the pressure drop is important only if it is lower than 400 Pa; above this value, a rigid-walled model gives a good estimate of the pressure drop in the system for the parameters studied.

Investigation of the functional three-dimensional anatomy of the human cystic duct: a single helix?

Clinical research into the formation of gallstones has indicated that the anatomy of the cystic duct is one of a number of factors contributing to the formation of gallstones. The cystic duct allows low-viscosity hepatic bile to enter the gallbladder under low pressure and the expulsion of a more viscous gallbladder bile, but little is known about this transport mechanism and the effect of anatomical variations in structure. This article describes the variation in geometry of the cystic duct, obtained from acrylic resin casts of the neck and first part of the cystic duct in gallbladders removed for gallstone disease and obtained from patients undergoing partial hepatectomy for metastatic disease. The data obtained allowed us to formulate a number of standard terms for describing cystic duct morphology and demonstrate that the term "spiral valve" is only partially correct when describing the duct anatomy. In over half of the casts, spiraling was not the dominant feature of the cystic duct. Additionally, the term valve implies active resistance to flow in one direction, whereas the internal baffles of the cystic duct would serve to regulate bile flow in both directions. These data are useful for realistic 3D modeling of fluid-structure interactions of the flow of bile in the human cystic duct.

A randomized, double-blind, placebo-controlled, parallel-group study to assess the efficacy and safety of dual ACE/NEP inhibitor GW660511X in mild-to-moderate hypertensive patients

This multicentre, double-blind, placebo-controlled, parallel-group study determined the efficacy and safety of GW660511 200 mg, a dual inhibitor of angiotensin-converting enzyme (ACE) and neutral endopeptidase (NEP), in mild-to-moderate hypertensive patients (diastolic blood pressure (DBP), > or =90 and < or =109 mm Hg; systolic blood pressure (SBP), > or =150 and < or =180 mm Hg). After a single-blind 2- to 4-week placebo run-in period, 123 patients (aged 18-65 years) were randomized to either placebo (n=62) or to active treatment (n=61) consisting of two consecutive 3-day dose titration periods of GW660511X 50 mg once daily and 100 mg once daily followed by GW660511X 200 mg once daily for 14 days. GW660511X 200 mg significantly lowered (baseline and placebo-corrected) both trough mean cuff SBP (-8.00 mm Hg, P=0.002) and DBP (-5.38 mm Hg, P=0.003). GW660511X 200 mg significantly reduced placebo-corrected mean 24-h and daytime but not night-time ambulatory SBP and DBP. Over the 0-24 h time period following GW660511X 200 mg, there were significant (P<0.001) reductions in serum ACE activity and significant (P<0.001) increases in plasma ANP concentration compared with placebo in terms of both peak and trough effects. In addition, treatment with GW660511X 200 mg significantly (P=0.003) increased (placebo-corrected, 1.52-fold) urinary excretion of cGMP over the 0-24 h interval. Treatment-related adverse events were experienced by 43% of the patients administered GW660511X 200 mg and 44% of those dosed with placebo with headache the most commonly reported. In conclusion, GW660511X 200 mg is an effective antihypertensive in mild-to-moderate hypertensive patients with potent effects on biological markers of ACE and NEP inhibition.

Choledochoduodenostom a reappraisal of its indications based on a study of 64 patients

The indications for choledochoduodenostomy in 64 patients are discussed and compared with those in other series from the literature. The essential indications are the presence of a dilated common bileduct with calculous disease or associated pathology at the lower end of the common bile-duct, particularly in the elderly and poor-risk patients. It is a safe procedure with few complications provided that a stoma of 2.5 cm. or more is made.

The flow of bile in the human cystic duct

Clinical studies suggest that the flow of bile in the biliary system may be a contributing factor in the pathogenesis of cholelithiasis, but little is known about its transport mechanism. This paper reports a numerical study of steady flow in human cystic duct models. In order to obtain parametric data on the effects of various anatomical features in the cystic duct, idealised models were constructed, first with staggered baffles in a channel to represent the valves of Heister and lumen. The qualitative consistency of these findings are validated by modelling two of the real cystic ducts obtained from operative cholangiograms. Three-dimensional (3D) models were also constructed to further verify the two-dimensional (2D) results. It was found that the most significant geometric parameter affecting resistance is the baffle clearance (lumen size), followed by the number of baffles (number of folds in the valves of Heister), whilst the least significant ones are the curvature of the cystic duct and the angle between the neck and the gallbladder. The study presented here forms part of a larger project to understand the functions of the human cystic duct, especially the influence of its various anatomical structures on the resistance to bile flow, so that it may aid the assessment of the risk of stone formation in the gallbladder.

Bethanechol provocation testing does not predict symptom relief after cholecystectomy for acalculous biliary pain

BACKGROUND

The currently accepted hypothesis to explain acalculous gallbladder pain is the lack of contractile co-ordination between the body and neck. We have previously shown that bethanechol, a muscarinic stimulant causes differential stimulation of these two regions.

AIM

To evaluate the reliability of bethanechol-induced gallbladder contraction in predicting symptom relief after cholecystectomy in patients with acalculous gallbladder disease.

METHODS

Fifty-one patients underwent a bethanechol provocation test together with serial ultrasound to determine gallbladder emptying. McGill pain questionnaires were completed, and patients positive for pain (bethanechol provocation test +ve) were offered cholecystectomy, and patients negative for pain (bethanechol provocation test -ve) were reassessed at 6 months and offered cholecystectomy if symptoms persisted. All patients answered pain questionnaires either 6 months after surgery or as follow-up.

RESULTS

There was no difference in the percentage of gallbladder emptying between the bethanechol provocation test +ve and bethanechol provocation test -ve groups. Fifty-three percent of bethanechol provocation test +ve patients and 54% of bethanechol provocation test -ve patients still remained symptomatic 6 months after surgery. Conclusion. Gallbladder pain provoked by bethanechol does not predict symptom relief after cholecystectomy.

Management of acute cholecystitis in UK hospitals: time for a change

Early cholecystectomy for patients with acute cholecystitis is safe, cost effective, and leads to less time off work compared with delayed surgery. This study was designed to assess current practice in the management of acute cholecystitis in the UK. A postal questionnaire was sent to 440 consultant general surgeons to ascertain their current management of patients with acute cholecystitis. Replies were received from 308 consultants who were involved in treating patients with acute cholecystitis of whom 18 transferred these patients on to another team for further management the day after admission. Thirty two consultants (11%) routinely treated patients by early cholecystectomy, with limiting factors stated to be the availability of surgical staff, theatre space, and radiological investigations. The remaining consultants (n = 258) routinely manage their patients conservatively with intravenous antibiotics and allow the inflammation to resolve before undertaking cholecystectomy at a later date. Indications for undertaking early cholecystectomy during the first admission by this latter group included the presence of spreading peritonitis due to bile leak, empyema, and unexpected space on theatre list. The commonest method for both elective and early cholecystectomy is laparoscopic, but the percentage of consultants using an open method rises from 8% in the elective situation to 47% for urgent early cholecystectomy. Despite evidence which strongly advocates early cholecystectomy, this practice is routinely carried out by only 11% of consultants in the UK at present.

Active relaxation of human gallbladder muscle is mediated by ATP-sensitive potassium channels

BACKGROUND

Active and significant relaxation of the human gallbladder must be one of the facets of its motility during both the filling and emptying cycle. Conflicting reports about the presence or significance of nitric oxide have been reported in the literature. The aim of this study was to investigate the role of nitric oxide and K(ATP) channels in human gallbladder muscle using isolated strips from human gallbladder.

METHODS

Full thickness strips were obtained from 56 human gallbladders and suspended under isometric tension in organ baths. The effect of nitric oxide donors and inhibitors on cholecystokinin octapeptide- and carbachol-induced contraction was examined. In separate experiments the effect of the K(ATP) channel activator, cromakalim, and the inhibitor, glibenclamide, were determined.

RESULTS

Cromakalim induced a significant relaxation of agonist-induced contraction in human gallbladder in vitro, an effect which was abolished by the K(ATP) channel inhibitor glibenclamide. No evidence of significant nitric oxide involvement in relaxation was observed.

CONCLUSIONS

This study has demonstrated the presence of K(ATP) channels in human gallbladder for the first time. These are capable of causing significant relaxation in the presence of hormonal and muscarinic agonists and may represent a major pathway for gallbladder relaxation.

Determinants of migration values and expectations in rural Thailand

"Based on the argument that values and expectations underlie behavioral motives, this study explores the determinants of migration-related values and expectations, and whether they are intervening factors in explaining intentions to move among residents of rural northeast Thailand. Data from the 1992 National Migration Survey of Thailand identify four migration-related value-expectancy dimensions: income, affiliation, stimulation, and comfort. Logistic regression analysis shows that landownership and being married are associated with higher expectations, while a diversified village economy, a village economy development program, and a younger and extended household structure are associated with lower expectations of attaining valued goals in the local rural village. The analysis also shows that value-expectancy concepts are only partial intervening explanations for intentions to move or stay."

Acute cholecystitis--room for improvement?

AIMS

A recent survey of UK general surgeons showed that almost 90% prefer to manage patients with acute cholecystitis by initial conservative management and delayed cholecystectomy (DC). The aim of this study was to assess the effectiveness of this management policy in a large university hospital.

PATIENTS AND METHODS

All patients admitted with acute cholecystitis between January 1997 and June 1999 who went on to have a cholecystectomy were identified. Patients were required to have right upper quadrant pain for > 12 h, a raised white cell count and findings consistent with acute cholecystitis on ultrasound to be included in the study.

RESULTS

109 patients were admitted with acute cholecystitis (76 female, 33 male) with a median age of 62 years (range, 22-88 years). Conservative management failed in 16 patients (14.7%) who underwent emergency cholecystectomy due to continuing symptoms (9), empyema (4) and peritonitis (3). Symptoms settled in 93 patients and delayed cholecystectomy was performed without further problems in 66 (60.6%). 27 patients were re-admitted with further symptoms before their elective surgery and, of these, 3 were admitted for a third time before surgical intervention. Ten of the 30 re-admission episodes (33%) occurred within 3 weeks of discharge but 15 (56%) occurred more than 2 months after discharge. Elective surgery was undertaken at a median of 10 weeks post-discharge with 67% of operations occurring within 3 months. Mean total hospital stay (days) +/- SEM, for the three groups were: emergency surgery group, 10.21 +/- 0.85; uncomplicated DC group, 12.48 +/- 0.37; re-admitted group, 14.75 +/- 0.71.

CONCLUSIONS

The policy of conservative management and DC was successful in 60.6% of cases but 14.7% of patients required emergency surgery and 24.8% were re-admitted prior to elective surgery with a resultant increase in total hospital stay. Performing elective surgery within 2 months of discharge in all cases would have reduced the re-admission rate by 56% and this along with the increased use of early cholecystectomy during the first admission are areas where the treatment of acute cholecystitis could be significantly improved.

Economics of surgery

The time has come to subject surgery to the same rigours of economic assessment that other health-care sectors are already receiving--namely, the comparative assessment of costs and benefits. The surgical management of gallstones provides a good example of the role of economics in surgery. Gallstone disease is common and patients are usually referred to a surgeon, but the threshold for intervention is not agreed and varies widely, with considerable implications for resources. Gallstone removal has been subject to much innovation over the past 10 years, yet economic assessment of laparoscopic and "mini" cholecystectomy and of gallstone lithotripsy is rare, despite the fact that operation rates have increased by up to 50% in some countries. For surgery to compete with other interventions, economic assessment of new surgical techniques will be increasingly important. This assessment should be based on well-conducted clinical trials in which interventions are provided in a routine service setting, and in which benefits are assessed among other things on the basis of the patient's perceived quality of life. Economic assessment often needs data beyond those collected in a clinical trial, however pragmatic the trial design, so modelling will often be required, incorporating a range of sources of evidence. Finally, evidence alone will not be enough to promote cost-effective practices. The take-up of surgical techniques will always be affected by the way hospitals and surgeons are remunerated. Affecting practice requires a realistic system of reimbursement that reflects evidence on cost effectiveness.

Mismatch between general surgical trainees' sub-specialist interests and advertised jobs: a cause for concern?

The main aim of this study was to establish the primary sub-specialist interest of a group of senior general surgical trainees and compare these results with the required sub-specialist interests in consultant vacancies advertised in the British Medical Journal between 3.1.98 and 25.12.99. Colorectal surgery was the most popular sub-specialty amongst trainees (29.4%) followed by upper gastrointestinal/hepato-pancreato-biliary (UGI/HPB) (27.2%) and vascular surgery (24.3%). The least popular sub-specialties were breast/endocrine (11.4%) and transplant (2.9%). A total of 324 consultant jobs were advertised, with the sub-specialist interest required as follows: Colorectal (25.6%), breast/endocrine (23.5%), vascular (20.4%), UGI/HPB (12%) and transplant (5.6%). Although this study only covers a two-year period, there are obvious discrepancies between trainees' sub-specialist interests and consultant vacancies. Whilst the jobs to trainees ratios are well matched in colorectal and vascular surgery, it appears that there are not enough transplant or breast trainees and too many UGI/HPB trainees for the number of jobs available. This problem needs urgent attention to avoid service shortfalls in unpopular sub-specialties and to avoid training people for jobs that do not exist.

Blood pressure is linked to salt intake and modulated by the angiotensinogen gene in normotensive and hypertensive elderly subjects

OBJECTIVES

To evaluate salt sensitivity in elderly subjects with different forms of hypertension and controls and to investigate any modulation by genotype

DESIGN

Randomized, double-blinded, placebo-controlled latin-square

SETTING

Tertiary referral hospital

PARTICIPANTS

Community subjects (n = 46) aged > or = 60 years classified as isolated systolic hypertension [ISH; systolic blood pressure (SBP) > or = 160, diastolic blood pressure (DBP) < 90 mmHg, n = 19], diastolic +/- systolic hypertension (SDH; DBP > or = 90 mmHg, n = 10) and normotension (SBP < 160, DBP < 90 mmHg, n = 17).

INTERVENTION

Four 14 day treatments, 50, 100, 200 and 300 mmol/day of sodium chloride supplementation interspersed with 14 day washout periods on a salt-restricted diet.

MAIN OUTCOME MEASURES

The 24 h blood pressure, heart rate, weight, urinary sodium and creatinine clearance measured during baseline, treatment and washout periods and angiotensinogen (AGT) and angiotensin converting enzyme (ACE) genotypes.

RESULTS

For the entire cohort, the mean +/- standard error (SE) of change from baseline in SBP for 50, 100, 200 and 300 mmol/day salt was 7.7+/-2.4, 12.1+/-2.4, 16.6+/-3.0, 18.5+/-2.6 mmHg, respectively. For DBP, the respective changes were: -0.1+/-1.5, 2.4+/-1.6, 3.0+/-1.5, 5.8+/-1.7 mmHg. The increase in SBP among ISH subjects was significantly higher than among subjects in the SDH and normotensive groups (P < 0.05). AGT genotype influenced the effect of salt dose on the change in DBP (P = 0.006) but not SBP (P = 0.7).

CONCLUSIONS

In healthy, older subjects, a linear increase in BP occurred with increasing salt dose, it appeared most pronounced in ISH subjects and could be modulated by AGT genotype.

Photodynamic therapy for dysplastic Barrett's oesophagus: a prospective, double blind, randomised, placebo controlled trial

BACKGROUND AND AIMS

Photodynamic therapy (PDT) is a treatment in which cell damage is achieved by the action of light on a photosensitizing agent. We have assessed the potential use of PDT in the ablation of Barrett's oesophagus.

METHODS

Thirty six patients with dysplastic Barrett's oesophagus receiving acid suppression medication with omeprazole were randomised to receive oral 5-aminolaevulinic acid (ALA) 30 mg/kg or placebo, followed four hours later by laser endoscopy. Follow up endoscopy was performed at one, six, 12, and 24 months.

RESULTS

Of 18 patients in the ALA group, a response was seen in 16 (median decrease in area in the treated region 30%; range 0-60%). In the placebo group, a decrease in area of 10% was observed in two patients with no change in 16 (median 0%; range 0-10%; treatment v placebo, p<0.001). No dysplasia was seen in the columnar epithelium within the treatment area of any patient in the PDT group. However, in the placebo group, persistent low grade dysplasia was found in 12 patients (p<0.001). There were no short or long term major side effects. The effects of treatment were maintained for up to 24 months.

CONCLUSIONS

This is the first randomised controlled trial of PDT for Barrett's oesophagus. It demonstrates that ALA induced PDT can provide safe and effective ablation of low grade dysplastic epithelium.

The serotonin transporter gene and Parkinson's disease

Dysfunction in the serotonin (5-hydroxytryptamine) system and reduced serotonin concentrations have been reported in patients with Parkinson's disease (PD). Serotonin concentrations in neural tissue are controlled by a presynaptic serotonin transporter protein that is encoded by a single gene. Therefore, we investigated whether a polymorphic region in the serotonin transporter gene is associated with PD. Three variable-number tandem repeat (VNTR) elements of the serotonin transporter gene were detected by polymerase chain reaction, those with 9, 10, 11 and 12 copies of the repeat element. The 10-copy VNTR element was significantly less common in patients with PD than controls in the univariate analysis (p < 0.05). Logistic regression analysis revealed no significant differences between patients (n = 198) and controls (n = 200) in the distribution frequencies of 9- and 12-copy alleles and combined genotypes (odds ratio = 1.20; p = 1.71). A positive family history of PD was a strong predictor of disease risk (odds ratio = 2.98; 95% confidence interval 1.51-5.87; p = 0.001). Although slight differences were observed between patient and control groups, these data suggest that defects in serotonin concentrations in patients with PD are unlikely to be due to polymorphisms in the serotonin transporter gene in this large Australian cohort; however, the inverse association observed with the 10-copy allele warrants further investigation.

Laparoscopic cholecystectomy: a good buy? A cost comparison with small-incision (mini) cholecystectomy

OBJECTIVES

To compare inpatient costs for laparoscopic and small-incision cholecystectomy.

DESIGN

Retrospective analysis using results of a single blind prospective randomised trial.

SETTING

Teaching hospital, UK.

SUBJECTS

200 patients having elective cholecystectomy.

INTERVENTIONS

Standard laparoscopic cholecystectomy with conversion to open cholecystectomy if necessary. Small-incision cholecystectomy using high right transverse epigastric incision, enlarged if necessary for safe exposure.

MAIN OUTCOME MEASURES

Providers inpatient costs.

RESULTS

Small-incision cholecystectomy cost Pound Sterling 995 and was 29% less expensive than the laparoscopic procedure which cost Pound Sterling 1397. Costs of equipment and operations themselves accounted for most of the difference. Results also suggest that costs to patients and society from time lost away from work may be lower for mini-cholecystectomy.

CONCLUSIONS

The national health service could be spending over Pound Sterling 10m a year by encouraging laparoscopic rather than small-incision operations for cholecystectomy. Commissioners of health care should question whether the benefits of laparoscopic surgery justify the additional costs.

The ACE deletion polymorphism is not associated with Parkinson's disease

The deletion allele (D allele) polymorphism in the angiotensin converting enzyme (ACE) gene is associated with increased levels of the neuropeptide substance P in the basal ganglia and substantia nigra. A reduction of substance P levels in the brain occurs in Parkinson's disease (PD) and has been implicated in the pathogenesis of the disease. We investigated the hypothesis that the D allele may be protective towards PD by examining the frequency of the ACE (I/D) polymorphism in 178 PD cases (male:female ratio = 1.4) and 192 controls (male:female ratio = 1.5). ACE (I/D) genotype was determined using polymerase chain reaction and 3% agarose gel electrophoresis. Unadjusted chi-square analysis revealed no significant difference between genotype frequencies (chi2 = 3.30, p > 0.10) or allele frequencies (chi2 = 2.52, p > 0.10) between patient and control groups, although PD patients were less likely to be homozygous (OR = 0.80, 95% CI = 0.49-1.29) or heterozygous (OR = 0.80, 95% CI = 0.59-1.06) for the D allele. A stepwise logistic regression analysis of the ACE deletion and risk factor data confirmed that there was no significant association between the ACE deletion (D allele) polymorphism and PD (OR = 0.62, 95% CI = 0.35-1. 10, p = 0.10). This study does not support the hypothesis that the D allele of the ACE gene confers a protective effect with respect to PD.

Giant hydronephrosis--a diagnostic dilemma

We report a complex case in which the left kidney had undergone giant hydronephrotic change after chronic obstruction at the vesicoureteric junction. Minor blunt abdominal trauma caused rupture of the parenchyma of this expanded and dilated kidney, with bleeding into its collecting system. The mixture of blood and urine remained contained within the kidney's structural layers, so producing a tense, cystic, fluid-filled mass arising from the left hypochondrium. Pathogenesis, differential diagnosis and investigation of giant hydronephrosis and its rupture are discussed. The observation is made that gross distortion of the renal parenchyma by rupture or hydronephrosis impairs arterial inflow to the kidney.

The epidemiology of Parkinson's disease in an Australian population

A prevalence study of Parkinson's disease (PD) was conducted in the rural town of Nambour, Australia. There were 5 cases of PD in a study population of 1207, yielding a crude prevalence ratio of 414 per 100,000 (95% confidence interval; 53-775). We performed a separate case-control study involving 224 patients with PD and 310 controls from South East Queensland and Central West New South Wales, to determine which factors increase the risk for PD in Australia. A positive family history of PD was the strongest risk factor for the development of the disease (odds ratio = 3.4; p < 0.001). In addition, rural residency was a significant risk factor for PD (odds ratio = 1.8, p < 0.001). Hypertension, stroke and well water ingestion were inversely correlated with the development of PD. There was no significant difference between patients and controls for exposure to herbicides and pesticides, head injury, smoking or depression. The high prevalence of PD in Nambour may be explained by rural residency. However, the most significant risk factor for PD was a positive family hisotry. This demonstrates the need for improved understanding of the genetic nature of the disease.

Long term response to gallstone treatment--problems and surprises

OBJECTIVE

To re-evaluate after 5 years the results of a randomised trial of cholecystectomy and lithotripsy for the treatment of symptomatic gallstones.

DESIGN

Late follow-up of a randomised controlled trial.

SETTING

Teaching hospital, UK.

SUBJECTS

144 of the 179 patients originally randomised.

INTERVENTIONS

Either elective open cholecystectomy under general anaesthesia or a maximum of 4 sessions of lithotripsy (up to 3000 shocks/session) on consecutive days with no anaesthesia or analgesia.

RESULTS

Of the original 87 patients randomised to be treated by lithotripsy, 39 (45%) subsequently underwent cholecystectomy, most of them within 32 months of treatment ("crossover" group). Patients in both main groups had a pronounced reduction in the number of episodes of pain at 5 years and significant reductions in the mean severity scores both on VAS and the McGill rating. Those in the crossover group had the worst scores. Gastrointestinal symptoms improved in the two main groups, but again the crossover group did least well. Quality of life improved significantly over baseline in the two main groups, but was much poorer in the crossover group.

CONCLUSIONS

Patients who had primary cholecystectomy were more likely to be free of pain than those treated by lithotripsy. Lithotripsy gave good symptomatic results in 55% of patients, and this was not dependent on clearance of stones. Patients who had a cholecystectomy after lithotripsy had the worst symptomatic results. It is difficult to identify patients who will not benefit from lithotripsy, but the presence of many coexisting symptoms may be an important predictor.

In vitro responses of gallbladder muscle from patients with acalculous biliary pain

BACKGROUND

Diagnosis and identification of patients with acalculous biliary pain, who would benefit from surgery, remains a significant clinical problem. The cholecystokinin (CCK) provocation test helps diagnosis, but lack of consistency limits its usefulness.

AIM

To characterize the response of gallbladder muscle strips, from patients with acalculous biliary pain, to hormonal and muscarinic stimulation and to compare these with strips from gallstone patients and normal controls.

PATIENTS

Eleven patients with acalculous biliary pain were studied, 5 had a positive CCK test. Eight gallbladders from gallstone patients and 6 from partial hepatectomies were used for comparison.

METHODS

Muscle strips from the body and neck of the gallbladder were suspended in organ baths and dose-response curves were constructed for CCK-8 and carbachol.

RESULTS

In the acalculous group the strips from the body were less sensitive to carbachol than those of the neck.

CONCLUSION

Since we found no differences in the CCK responses for the groups, it casts doubt over the effectiveness of the CCK test to diagnose acalculous biliary pain. Since carbachol sensitivity was different, it might be that a similar test using muscarinic stimulation would help in the diagnosis of this difficult group of patients.

The 460Trp polymorphism of the human alpha-adducin gene is not associated with isolated systolic hypertension in elderly Australian Caucasians

The study was undertaken to determine whether polymorphic variants of the alpha-adducin gene are associated with isolated systolic hypertension (ISH) in elderly Australian Caucasians. Participants were classified with ISH (n = 87, systolic blood pressure (SBP) > or =160 mm Hg and diastolic blood pressure (DBP) < or =90 mm Hg) or normotension (n = 124, SBP <140 mm Hg and DBP <90 mm Hg with no family history of hypertension). To collect demographic data, a structured questionnaire was used. DNA was extracted using standard techniques from 211 subjects (age range 61-89, mean age 73 +/- 6.6 years, male: female ratio 1.1:1). Genotypes (gly/gly, trp/gly and trp/trp) were assigned in triplicate by polymerase chain reaction (PCR) followed by electrophoresis, using a laser scanning electrophoresis unit. The validity of the method was confirmed by sequencing. Frequencies of allele distribution in ISH or control groups were determined by Chi-square tests and a stepwise logistic regression model, which controlled for potential confounders, was used to examine any independent association between alpha-adducin genotypes or alleles with ISH and normotensive controls. Mean BP (+/- s.d.) was: 170/79.8 +/- 14.9/8.3 mm Hg and 122.1/ 73.4 +/- 8. 8/7.6 mm Hg in the ISH and normotension groups respectively. The unadjusted allele and genotypes frequencies were not significantly different in the ISH patients groups compared with normotensive controls (chi2 = 1.59, P = 0.45 and chi2 = 1.23, P = 0.28 respectively). In this elderly cohort, after adjustment for potential confounders, no statistically significant association was found between alpha-adducin genotype and SBP (P = 0.65 for homozygotes, P = 0.59, for heterozygotes), DBP (P = 0.49 homozygotes, for heterozygotes P = 0.45) pulse pressure (P = 0.87 homozygotes, for heterozygotes P = 0.95) diagnosis of ISH (P = 0.72 for homozygotes, P = 0.68 for heterozygotes). However age and renal disease predicted the diagnosis of ISH (P = 0.001, P = 0.459, respectively), a large pulse pressure (P < 0.0001, P = 0.033, respectively) and a higher SBP (P < 0.0001, P = 0.025, respectively) in this large cohort of elderly Australian Caucasian volunteers. Journal of Human Hypertension (2000) 14, 199-203.