Is inguinal hernia mesh safe? A prospective study

BACKGROUND

Hernia repair surgery using synthetic mesh is the standard of care in modern surgery. Complications from uro-gynaecological mesh have been reported in the New Zealand media and there is public concern regarding the use of any mesh for any reason. This study reports long-term outcomes in inguinal hernia surgery in a large cohort of elective operations using mesh.

METHODS

A prospective database of patients having inguinal hernia mesh repairs was maintained in a private two surgeon practice from 2002 to 2016. Patient demographics, method of repair, the pre-operative and post-operative pain scores and complications following surgery were recorded.

RESULTS

A total of 1711 hernia in 1366 patients were repaired from 2002 to 2016. One thousand and forty-seven repairs were laparoscopic total extraperitoneal (LTEP), 333 were open. Post-operative pain scores were significantly lower than pre-operative scores in inguinal hernia repair by any method. Only 22% of patients described no pain pre-operatively and this rose to 76% post-operatively; conversely 7.9% described severe pain pre-operatively and this reduced to 1% post-operatively. The recurrence rate for open inguinal hernia was zero and for LTEP repair was 0.81%.

CONCLUSION

Inguinal hernia repair using mesh does not appear to produce significant rates of chronic pain long term. Overall, the complications from open or LTEP inguinal hernia repair with mesh are low.

Complete resection of colorectal cancer with ovarian metastases combined with chemotherapy is associated with improved survival

BACKGROUND

Ovarian metastases (OM) from colorectal cancer (CRC) are uncommon, and data about optimal management are lacking. The aim of this study was to examine the management and outcomes of patients with OM from CRC.

METHODS

A retrospective review of records of patients with a histopathological diagnosis of OM from CRC who were treated at Christchurch Hospital between 1 January 2000 and 31 December 2016. Data related to presentation, clinicopathological characteristics, treatment and outcomes were recorded. The primary outcomes were overall survival and disease-free survival.

RESULTS

Thirty-one patients were identified (median age 55 years, range 28-77), with a median follow-up of 23 months (range 3-84 months). Abdominal pain was the most common presenting symptom (22 patients). Synchronous OM occurred in 22 patients, 14 patients had bilateral ovarian involvement. Twenty-one patients received adjuvant chemotherapy. R0 resection was achieved in 14 patients. For all patients the 5-year disease-free and overall survival were 11% and 12%, respectively, while 5-year overall survival for R0 resections was 30%. Improved median survival was associated with negative colon resection margins (26.7 months versus 7.8 months, P = 0.03), R0 resection (30.5 months versus 23.5 months, P = 0.04), and use of adjuvant chemotherapy (28.8 months versus 8.2 months, P < 0.0001); however, on multivariate analysis adjuvant chemotherapy was the only independent factor associated with improved prognosis (P = 0.01).

CONCLUSIONS

OM from CRC are uncommon and carry a poor prognosis. Improved survival was associated with complete surgical resection of the primary tumour and metastatic disease in combination with systemic chemotherapy.

Elective surgical outcomes of patients in Christchurch, New Zealand

AIM

Most studies assessing mortality after surgery have been undertaken in major public hospitals or are procedure specific. The aim of this study was to determine mortality after elective surgery at a total community level with inclusion of all patients undergoing elective surgery.

METHOD

This was a prospective study of all patients that underwent elective surgery in Christchurch, New Zealand, within a calendar month. For each patient, we collected demographic data, American Society of Anaesthesiologists physical status classification (ASA), type of anaesthetic and surgical specialty. The primary outcome was 30-day mortality and the secondary outcome was 90-day mortality.

RESULTS

Four thousand seven hundred and fifteen patients were included in this study. Two thousand five hundred and seventy-eight (55%) were female and the median age was 56 years (range 0-99 years). Three thousand one hundred and forty-two (67%) patients had a general anaesthetic. By day 30, 11 (0.2%) patients had died and by day 90, 27 (0.6%) patients had died. Of the 27 deaths within 90 days after surgery, one was possibly anaesthesia-related (0.02%), while the majority were due to progression of disease (18).

CONCLUSION

This study shows a lower mortality than what has previously been reported for elective surgical procedures when the denominator is the total community number of operations.

Improved survival for rectal cancer compared to colon cancer: the four cohort study

BACKGROUND

Colorectal cancer (CRC) is the third most common cancer worldwide. This study was undertaken to evaluate survival outcomes and changes of disease outcomes of CRC patients over the last decades.

METHODS

A retrospective analysis of CRC patients in Christchurch was performed in four patient cohorts at 5 yearly intervals; 1993-94, 1998-99, 2004-05 and 2009. Data on cancer location, stage, surgical and oncological treatment and survival were collected. Univariate, multivariate and Kaplan-Meier survival analysis were performed.

RESULTS

There were 1391 patients (355, 317, 419 and 300 per cohort), 1037 colon and 354 rectal cancers, respectively. For colon cancer, right-sided cancers appeared more common in later cohorts (P = 0.01). There was a significant decrease in the number of permanent stomas for colon cancer patients (P = 0.001). There was an analogous trend for rectal cancers (P = 0.075). More CRC patients with stage IV disease were treated surgically (P = 0.001) and colon cancer stages I and II tended to have increased survival if operated by a colorectal surgeon (P = 0.06). Oncology referrals have increased remarkably (P = 0.001). Overall 56% of patients were alive at 5 years however rectal cancer patients had significantly better 5-year survival than those with colon cancer (P < 0.05).

DISCUSSION

This four cohort study shows that modern CRC survival continues to improve and is comparable to international standards. Furthermore, rectal cancer patients have a better 5-year survival than colon cancer patients. The improved survival with early stage colon cancers operated on by specialist colorectal surgeons needs further exploration.

Cohort study of mesenteric panniculitis and its relationship to malignancy

Background

Mesenteric panniculitis (MP) is a rare condition that historically has been associated with the presence of malignancy. Paraneoplastic phenomena in general regress with cure and in most cases with treatment of the cancer. This study was undertaken to determine whether MP regressed with cancer treatment and cure.

Methods

This was a retrospective review of a database of all patients with MP confirmed on CT between 2003 and August 2015 at Christchurch Hospital. Patients were categorized as having malignant or non-malignant disease, and follow-up scans were assessed for remission of MP. Patients with malignancy were further categorized as having malignancy cured or not cured.

Results

A total of 308 patients were identified with possible MP; 135 were excluded as radiological appearances were not typical of MP (43 patients) or there was no follow-up CT (92). Of 173 patients (131 men) included, 75 (43·4 per cent) were diagnosed with malignancy. Follow-up imaging showed that 33 patients (19·1 per cent) had remission of MP, whereas 140 (80·9 per cent) had no remission. There was no difference in the rates of MP remission in the malignancy versus no malignancy groups (P = 1·000), or between groups in which malignancy was cured or not cured (P = 0·572). Nor was there any difference in the rates of MP remission in malignancy cured versus no malignancy groups (P = 0·524).

Conclusion

MP does not behave like a paraneoplastic phenomenon. The association with malignancy is most likely an epiphenomenon of the many CT images acquired for staging of cancer.

Management of malignant colorectal polyps in New Zealand

BACKGROUND

The management of colorectal polyps containing a focus of malignancy is problematic, and the risks of under- and over-treatment must be balanced. The primary aim of this study was to describe the management and outcomes of patients with malignant polyps in the New Zealand population; the secondary aim was to investigate prognostic factors.

METHODS

Retrospective review of relevant clinical records at five New Zealand District Health Boards.

RESULTS

Out of the 414 patients identified, 51 patients were excluded because of the presence of other relevant colorectal pathology, leaving 363 patients for analysis. Of these, 182 had a polypectomy, and 181 had a bowel resection as definitive treatment. The overall 5-year survival was not altered with resection but was improved with re-excision of any form (repeat polypectomy or bowel resection). There were 110 rectal lesions and 253 colonic lesions. A total of 16% of patients who had resection after polypectomy were found to have residual cancer in the resected specimen. Ischaemic heart disease, chronic obstructive pulmonary disease and metastatic disease were found to negatively impact overall survival (P < 0.001). Resection was more likely to follow polypectomy if polypectomy margins were positive, fragmentation occurred for sessile lesions and for pedunculated lesions with a higher Haggitt level.

CONCLUSION

Polypectomy is oncologically safe in selected patients. Re-excision improves overall survival and should be considered in patients with low comorbidity (American Society of Anesthesiologists score 1 and 2) and where there is concern about margins (sessile lesions and positive polypectomy margins). In the majority of patients, however, no residual disease is found.

Malignancy and mesenteric panniculitis

AIM

Mesenteric panniculitis (MP) is a chronic inflammatory process of the small bowel mesentery that has been reported in conjunction with malignancy. The objectives of the present study were to identify the frequency and type of cancers that may coexist with MP and whether these can be seen on the initial diagnostic computerised tomography (CT).

METHOD

A prospective database was kept of patients diagnosed with MP in the Canterbury region of New Zealand between 1 January 2003 and 31 December 2014. CT scans were independently reviewed. Clinical records were reviewed and family doctors were contacted for additional information.

RESULTS

There were 302 patients with possible MP identified and 259 in whom it was confirmed on review. Seventy-eight patients had a diagnosis of malignancy, with 54 having a current cancer (59 total cancers), 33 a past cancer and nine both. Of the 59 current cancers the most common primary sites were colorectum (19), lymph nodes (17), kidney (six) and prostate (four). Fifty-four were at sites included on an abdominal CT scan. At all sites [except prostate (0/4)] there were high rates of detection on CT with 44/54 cancers visible including 20/23 gastrointestinal tract, 14/17 lymphomas and 9/9 non-prostate urogenital tract malignancies. Six people were subsequently diagnosed with cancer after the index CT.

CONCLUSION

When MP occurs in association with malignancy, the commonest primary sites are large bowel, the lymph nodes and the urogenital tract. In those with MP on imaging, any cancer except prostate can usually be seen on the index CT. Further extensive investigation in asymptomatic patients is therefore likely to be of low yield.

Does Bowel Preparation for Colonoscopy Affect Cognitive Function?

Colonoscopy is a common procedure used in the diagnosis and treatment of a range of bowel disorders. Prior preparation involving potent laxatives is a necessary stage to ensure adequate visualization of the bowel wall. It is known that the sedatives given to most patients during the colonoscopy cause a temporary impairment in cognitive function; however, the potential for bowel preparation to affect cognitive function has not previously been investigated. To assess the effect of bowel preparation for colonoscopy on cognitive function. This was a prospective, nonrandomized controlled study of cognitive function in patients who had bowel preparation for colonoscopy compared with those having gastroscopy and therefore no bowel preparation. Cognitive function was assessed using the Modified Mini Mental State Examination (MMMSE) and selected tests from the Cambridge Neuropsychological Test Automated Battery. Individual test scores and changes between initial and subsequent tests were compared between the groups. Age, gender, and weight were also compared. Forty-three colonoscopy and 25 gastroscopy patients were recruited. The 2 groups were similar for age and gender; however, patients having gastroscopy were heavier. MMMSE scores for colonoscopy and gastroscopy groups, respectively, were 28.6 and 29.5 (P = 0.24) at baseline, 28.7 and 29.8 (P = 0.32) at test 2, 28.1 and 28.5 (P = 0.76) at test 3. Motor screening scores for colonoscopy and gastroscopy groups, respectively, were 349.3 and 354.1 (P = 0.97) at baseline, 307.5 and 199.7 (P = 0.06) at test 2, 212.0 and 183.2 (P = 0.33) at test 3. Spatial working memory scores for colonoscopy and gastroscopy groups, respectively, were 14.4 and 6.7 (P = 0.29) at baseline, 9.7 and 4.3 (P = 0.27) at test 2, 10 and 4.5 (P = 0.33) at test 3. Digit Symbol Substitution Test scores for colonoscopy and gastroscopy groups, respectively, were 36.3 and 37.8 (P = 0.84) at baseline, 36.4 and 40.0 (P = 0.59) at test 2, 38.6 and 40.8 (P = 0.76) at test 3.This study did not find evidence of cognitive impairment resulting from administration of bowel preparation before colonoscopy.

Ten-year review of gastrointestinal stromal tumours at a tertiary referral hospital in New Zealand

BACKGROUND

Gastrointestinal stromal tumours (GISTs) are the most common mesenchymal tumours of the gastrointestinal tract and make up 1-2% of all gastrointestinal malignancies. Traditionally, the treatment of choice for primary disease is surgical resection; however, no single surgeon or institution gets extensive exposure to these patients so appropriate decision-making is difficult, particularly since the introduction of the tyrosine kinase inhibitor imatinib, which has become an important additional management tool.

METHOD

All patients were diagnosed and treated for GISTs in Christchurch Hospital (Christchurch, New Zealand) between 1 January 2000 and 31 December 2010. We maintain a prospective database of all patients with GISTs. Data on clinical and histopathological variables, management and survival outcomes were recorded. These were then reviewed.

RESULTS

There were 93 patients in this study. Fifty were women. Median age was 69 (interquartile range (IQR) 59-76) years. Fifty-one tumours were located in the stomach, 27 in the small bowel, six in the colon, three in the oesophagus, one in the rectum and five were extra-gastrointestinal. In total, 22 patients received imatinib therapy; four patients with metastatic disease had imatinib as sole therapy. The median follow-up was 58 (IQR 30-90) months. The 5-year overall survival and disease-free survival (DFS) for the entire study population was 69% and 64%, respectively. The 5-year DFS was higher for all patients who have localized disease when compared with those who have metastatic disease (76% versus 28%, P-value 0.001).

CONCLUSION

Surgery aiming at an R0 resection remains the mainstay of treatment. We propose the most effective way to grow the knowledge base in New Zealand is the establishment of a national register, thereby allowing better clinical decision-making by interpretation of a larger data set.

Medipix-based Spectral Micro-CT

Since Hounsfield's Nobel Prize winning breakthrough decades ago, X-ray CT has been widely applied in the clinical and preclinical applications - producing a huge number of tomographic gray-scale images. However, these images are often insufficient to distinguish crucial differences needed for diagnosis. They have poor soft tissue contrast due to inherent photon-count issues, involving high radiation dose. By physics, the X-ray spectrum is polychromatic, and it is now feasible to obtain multi-energy, spectral, or true-color, CT images. Such spectral images promise powerful new diagnostic information. The emerging Medipix technology promises energy-sensitive, high-resolution, accurate and rapid X-ray detection. In this paper, we will review the recent progress of Medipix-based spectral micro-CT with the emphasis on the results obtained by our team. It includes the state- of-the-art Medipix detector, the system and method of a commercial MARS (Medipix All Resolution System) spectral micro-CT, and the design and color diffusion of a hybrid spectral micro-CT.

Survival outcome in New Zealand after resection of colorectal cancer lung metastases

BACKGROUND

Colorectal cancer is the second most common type of solid organ cancer in New Zealand behind prostate cancer. Even with treatment, distant disease may develop in the liver and lungs. Surgical resection of isolated liver and/or lung metastasis is now commonly considered, but survival outcomes from the latter are not well described. This study aims to review the 5-year survival and prognostic factors of patients who have resection for lung metastasis of colorectal origin.

METHODS

A retrospective audit of surgical resection for lung metastasis performed by thoracic departments of several tertiary referral centres within New Zealand was performed. The study period was between 1997 and 2011. Patients were identified through operative logs, audit databases, clinical case mix codes and pathology databases. Patient demographics, preoperative and post-operative variables were recorded. All patients were followed up for survival analysis. Mann-Whitney and chi-square tests were performed for data analysis. A P-value of less than 0.05 was significant.

RESULTS

There were 106 (59 male) patients. Median age was 64 (inter-quartile range (IQR) 57-73) years. Median follow-up period was 30 (IQR 16-46) months. The 5-year overall and cancer-specific survival was 40% and 43%, respectively. The only good prognostic factor for survival after lung resection was a long disease-free interval (P = 0.04) between surgery for the colorectal primary and lung metastasis.

CONCLUSION

Lung resection for isolated colorectal metastases provides a reasonable 5-year survival. Outcomes from lung resection for colorectal metastases in New Zealand are comparable to that from international series.

Patterns of recurrence in patients with acute diverticulitis

Background

The natural history of acute diverticulitis remains unclear, with the role of prophylactic surgery following conservatively managed diverticulitis increasingly controversial. This study investigated recurrence rates, patterns and complications after conservatively managed diverticulitis.

Methods

This was a retrospective chart review of all patients admitted with diverticulitis between June 1997 and June 2002. Demographic data, management, recurrence rates, complications and subsequent surgery were recorded.

Results

Some 502 patients were identified, 337 with uncomplicated and 165 with complicated diverticulitis. Median follow-up was 101 (range 60–124) months. Of 320 patients with uncomplicated diverticulitis managed conservatively, 60 (18·8 per cent) had one episode of recurrence, whereas 15 (4·7 per cent) had two or more episodes. After an initial attack of uncomplicated diverticulitis, only 5·0 per cent developed complicated disease. Complicated disease recurred in 24 per cent, compared with a recurrence rate of 23·4 per cent in those with uncomplicated diverticulitis (P = 0·622). When recurrence occurred, it usually did so within 12 months of the initial episode.

Conclusion

Acute diverticulitis has a low recurrence rate and rarely progresses to complications. Any recurrence is usually early, in a pattern more consistent with failure of the index episode to settle. Subsequent elective surgery to prevent recurrence and the development of complications should be used sparingly.

Immunomodulation does not alter histology in resected Crohn's disease

BACKGROUND

The use of immunomodulators (Azathioprine, 6-Mercaptopurine and Methotrexate) and biological agents (Infliximab and adalimumab) for the treatment of Crohn's disease (CD) has increased in the recent years with the aim of treating the inflammatory component of the disease and hoping to change the natural history of the disease. The aim of this study was to determine if the use of immunomodulators or biological agents in the 2 years prior to resection affects the histopathological characteristics of the patient's disease.

METHODS

A retrospective review was conducted over a 10-year period (1996-2005) of patients who underwent resection for CD. Clinical case notes and histology specimens were reviewed. Patients treated with Azathioprine, 6-Mercaptopurine, Methotrexate or Infliximab for more than 3 months within the 2 years preceding surgery were deemed to have been immunomodulated. The results were also analysed by Montreal phenotype.

RESULTS

A total of 165 patients were identified. 52 patients had been treated with either immunomodulator or biological agent. Of 20 histological features examined, only muscular hypertrophy approached significance (P = 0.05), Montreal A and Montreal L phenotypes were the same regardless on immunomodulators, however, there was a significant difference (P = 0.03) with regard to Montreal B in patients with stricturing disease being more likely to have received an immunomodulator.

CONCLUSIONS

In this cohort of patients requiring resection for CD, those with stricturing disease were more likely to receive immunomodulators or biologics than those without stricturing disease. However, there were no significant histological differences in the resected specimens between those who did and those who did not receive these drugs.

Ambulatory oesophageal manometry and pH monitoring for investigation of chest pain: a New Zealand experience

AIMS

Patients with chest pain of uncertain origin are often referred to gastroenterology to assess for possible oesophageal causes. Oesophageal spasm is difficult to ascertain with stationary manometry, as pain seldom occurs during this brief study. Twenty-four-hour ambulatory manometry and oesophageal pH recording (AMP) offers the opportunity to correlate pain symptoms with abnormal motility or acid reflux for more definitive diagnosis. AMP has been available at Christchurch Hospital since 2000 and we describe our experience.

METHODS

Thirty-seven patients (23 female, 14 male) underwent AMP between January 2000 and January 2004. Tracings were analysed by automated software and manually by an experienced scientist and gastroenterologist. Case-notes were reviewed for history and drug data.

RESULTS

Thirty-three patients (89%) experienced typical pain and/or dysphagia symptoms during AMP. Twenty-one had no correlation between symptoms and pH or manometric abnormalities, excluding reflux disease or an oesophageal hypercontractile disorder as a cause of symptoms. Only one patient had oesophageal spasm proven. One patient's pain correlated strongly with acid reflux. Seven others had reflux episodes during AMP with less consistent pain correlation. At least six patients required treatment for ischaemic heart disease after a negative AMP result.

CONCLUSIONS

AMP has been a useful additional investigation for chest pain and was able to exclude oesophageal causes of pain in most patients studied. Oesophageal spasm appears to be a rare cause of chest pain in Christchurch. When a diagnosis was made on AMP, it was most often gastro-oesophageal reflux disease.

Liver injury in children: causes, patterns and outcomes

AIM

To compare the causes, patterns and outcomes of hepatic trauma in children with those in adults.

METHODS

A retrospective audit was conducted of a five-year period from 1996 of adults and children admitted to Christchurch Hospital with liver injuries. Details of age, mechanism of injury, injury severity score (ISS), radiological grade of liver injury, operations and mortality were recorded and analysed.

RESULTS

There were 93 liver injuries over the five-year period: 22 in children and 71 in adults. The median age of each group was 7 and 29 years respectively. The most common causes of injury in children were bicycle (7/22) and motor vehicle accidents (MVAs) (7/22). The majority (37/71) of adult injuries were caused by MVAs. The median length of hospital stay was significantly shorter in the paediatric group: 4 days (range 1-12) in children vs 9 days (range 0-52) in adults.

CONCLUSIONS

Liver trauma in children has a different spectrum of causes, and results in more severe liver injury than in adults. However, children are more likely to have an isolated liver injury that results in a shorter length of stay in hospital. A nationwide paediatric-injury surveillance system might allow better identification of preventable causes of injury.

Postdischarge clean wound infections: incidence underestimated and risk factors overemphasized

BACKGROUND

Wound infections are a leading cause of postoperative morbidity and a cost to both the individual and community. The surgeon now has a reduced appreciation of wound-infection rates because of shorter hospital stays and an increasing reliance on the primary care physicians. The incidence of wound infections which occurred following clean surgical procedures, as well as whether they could have been predicted by the known risk factors, were analysed in the present prospective study.

METHODS

A prospective audit of the first 30 postoperative days following clean general surgical wounds was undergone, with inpatient assessment by a research nurse, and subsequent outpatient followup by patient telephone interview.

RESULTS

Of 1964 clean wounds over a 30-month period, 98.5% were traced. The overall clean-wound infection rate was 12.6% (inpatient:4.5%; outpatient: 8.1%). Inpatient infection rates(but not postdischarge wound-infection rates) were significantly correlated (P < 0.05)to the American Society of Anesthesiologists' rating, operation duration, preoperative day stay, and age. Infection rates varied with operation type: vascular (18.3%), breast (16.0%),abdominal (10.3%), hernia (8.0%), head and neck (7.1%).

CONCLUSIONS

The overall wound-infection rate is higher than previously described with two thirds of infections occurring after discharge. While inpatient wound-infection rates fit known risk factors, postdischarge wound-infection rates do not. Certain clean-wound operations have a higher incidence of infection than others. Consideration needs to be given to the identification of risk factors for postdischarge wound infections,and to further trials of prophylactic antibiotics in clean surgery.

The use of 3-[2-(N,N-diethyl-N-methylammonium)ethyl]-7-methoxy-4-methylcoumarin (AMMC) as a specific CYP2D6 probe in human liver microsomes

Recently, a novel nonfluorescent probe 3-[2-(N,N-diethyl-N-methylammonium)-ethyl]-7-methoxy-4-methylcoumarin (AMMC), which produces a fluorescent metabolite AMHC (3-[2-(N,N-diethyl-N-methylammonium)ethyl]-7-hydroxy-4-methylcoumarin) was used with microsomes containing recombinant enzymes (rCYP) to monitor CYP2D6 inhibition in a microtiter plate assay. This article describes the studies that were performed in human liver microsomes (HLM) to establish the selectivity of AMMC toward CYP2D6. Metabolism studies in HLM showed that AMMC was converted to one metabolite identified by mass spectrometry as AMHC. Kinetic studies indicated an apparent K(m) of 3 microM with a V(max) of 20 pmol/min. mg of protein for the O-demethylation reaction. The O-demethylation of AMMC in HLM was inhibited significantly in the presence of a CYP2D6 inhibitory antibody. Using a panel of various HLM preparations (n = 12), a good correlation (r(2) = 0.95) was obtained between AMMC O-demethylation and bufuralol metabolism, a known CYP2D6 substrate, but not with probes for the other major xenobiotic metabolizing CYPs. Finally, only rCYP2D6 showed detectable metabolism in experiments conducted with rCYPs using AMMC at a concentration of 1.5 microM (near K(m)). However, at a concentration of 25 microM AMMC, rCYP1A also contributed significantly to the formation of AMHC. Knowing the experimental conditions under which AMMC was selective for CYP2D6, a microtiter assay was developed to study the inhibition of various compounds in HLM using the fluorescence of AMHC as an indication of CYP2D6 activity. The inhibition potential of various chemicals was found to be comparable to those determined using the standard CYP2D6 probe, bufuralol, which requires high-performance liquid chromatography separation for the analysis of its CYP2D6-mediated 1'-hydoxylated metabolite.

Dehydroepiandrosterone and cardiac allograft vasculopathy

BACKGROUND

Tissue culture, animal model, and epidemiologic studies suggest that dehydroepiandrosterone may inhibit atherosclerosis through its potent antiproliferative effects. Because cardiac allograft vasculopathy is predominantly a proliferative abnormality of intimal and medial smooth muscle cells, plasma levels of dehydroepiandrosterone may play an important role in the development of this disease.

METHODS

Sixty-one cardiac allograft recipients who survived for 1 year or more and had at least one annual follow-up cardiac catheterization were included in the study. Plasma levels of dehydroepiandrosterone, dehydroepiandrosterone sulfate, and free dehydroepiandrosterone (dehydroepiandrosterone not bound to sex hormone-binding globulin) were measured in all 61 subjects and compared with the presence or absence of cardiac allograft vasculopathy as defined by angiography.

RESULTS

Plasma levels of total and free dehydroepiandrosterone were lower in subjects in whom cardiac allograft vasculopathy developed (p = 0.005 and 0.003, respectively). Furthermore, the time to development of cardiac allograft vasculopathy was shorter in subjects with low levels of total and free dehydroepiandrosterone (p = 0.062 and 0.046, respectively). This relationship was maintained after adjusting for age, gender, cholesterol, prednisone use, and blood pressure.

CONCLUSIONS

Low plasma levels of dehydroepiandrosterone may facilitate and high levels may retard the development of cardiac allograft vasculopathy.

LaPorta great toe implant. Long-term study of its efficacy. Student Research Group

The purpose of this study was to evaluate the long-term function of the LaPorta design great toe implant. Eight cases were evaluated preoperatively and on a short-term (mean = 3.6 months) and a long-term basis (mean = 20.5 months) postoperatively. Findings of clinical importance included decreased hallux dorsiflexion and radiographic evidence of hyperostosis formation at the implant hinge. However, all of the patients studied were satisfied with their results.

African American adolescents: adaptational processes and socioeconomic diversity in behavioural outcomes

The study was concerned with determining the relationship of economic diversity to stress reactivity. Parental ratings of competence and behavioural problems were obtained for very young adolescents following a long-term and highly acute stress: the Atlanta youth murders. Intellectual and identity-formation data obtained both before and after the crisis were analyzed with the parental ratings of youth competence and behavioural problems. Consistent socioeconomic status (SES) links between the manifestation of behavioural problems and the display of competencies were obtained; lower income (LI) youths manifested more problems and fewer competencies. The findings were more pronounced for LI males. Personal identity was a significant predictor of school competence. School self-esteem was a predictor of academic performance. The manifestation of behavioural problems was significantly predicted by cognitive performance variables. The findings are discussed in terms of variations in adaptational strategies mediated by socioeconomic status and psychological factors.

A double-blind crossover study comparing two doses of Duranest (etidocaine) 1% with a fixed dose of Sensorcaine (bupivacaine) 0.5% utilizing infiltration regional blocks of the fifth ray

Two local anesthetics, Duranest 1% (etidocaine HCl) and Sensorcaine 0.5% (bupivacaine HCl), were tested against each other in dose-related blocks of the fifth ray. This study was conducted under double-blind cross-over conditions using 24 healthy volunteers. It was found that 4 ml. of either agent was sufficient to anesthetize the fifth ray area in all but 4.2% of the injections and 8 ml. of etidocaine always accomplished complete fifth ray anesthesia. Also, 4 ml. of etidocaine was found to have a more rapid onset and longer duration than the same volume of bupivacaine, 6.3 vs. 8.3 min. onset, and 487 vs. 449 min. duration, respectively. Pain and burning upon injection of either bupivacaine or etidocaine was encountered in 70% of the subjects tested. Residual pain was noted in some of the subjects given etidocaine after complete resolution of sensory anesthesia. Residual pain was not noted in any of the subjects given bupivacaine. Etidocaine was found to have a more rapid onset and a longer duration than bupivacaine or a lidocaine-bupivacaine mixture, and was thus found to be a superior agent in the subjects tested.

Epidemiological Study of Psychiatric Disorder in Adolescent Girls: Preliminary Communication

A two-stage general population study of affective disorder and problems of eating control in 15–19-year-old girls is in progress, the sample being identified by the use of general practitioners' age-sex registers. So far, 244 girls and their mothers have been interviewed and have independently completed questionnaires relating to mood and appetite control. The girls completed questionnaires both on themselves and on their mothers, and their mothers on themselves and on their daughters. Significant correlations between self-rating and rating of the other person were obtained in all cases, with agreement on the daughters' mood being higher in non-manual couples.

High perfusion pressure damages the sieving ability of sinusoidal endothelium in rat livers

Fenestrated endothelium lining liver sinusoids forms an ultrastructural sieve between blood and hepatocytes which at physiological perfusion pressures has previously been shown to shield hepatocytes from large triglyceride-rich chylomicrons. In the study reported in this paper, enlargement of endothelial fenestrae at high perfusion pressures has been confirmed and a concurrent increase in trapping of large chylomicrons by the liver noted. These findings suggest the importance of employing physiological perfusion pressures in studies designed to examine hepatic lipoprotein metabolism and also suggest a possible mechanism in the pathogenesis of fatty change seen in the "nutmeg" liver of chronic venous congestion.