Optimising delivery of care in coeliac disease - comparison of the benefits of repeat biopsy and serological follow-up.

BACKGROUND: The majority of deleterious health consequences of coeliac disease (CD) are most likely to be secondary to intestinal inflammation; hence, mucosal recovery is a desirable goal of therapy. Follow-up in CD is controversial and serological response is often used as a surrogate for histological recovery. AIMS: To inform the clinical management of CD using comparative serological and histological data from a biopsy-driven pathway of care. METHODS: A retrospective analysis of the Cambridge Coeliac Clinic database of 595 patients routinely followed up by biopsy and serology. RESULTS: Paired biopsy results were available for 391 patients (15% seronegative). Persisting villous atrophy (VA) occurred in 182 patients (47%). The sensitivity of anti-tissue transglutaminase (TTG) antibody for ongoing VA was only 43.6%. Information on dietetic management and further biopsy to assess response was available for 94 initially unresponsive patients, in whom targeted dietetic intervention by removal of identified gluten sources or avoidance of trace amounts of gluten led to resolution of persistent VA in 50%. The effects of institution of a formal care pathway are analysed in 298 patients. Discharge to primary care and clinical management was facilitated by the information derived from repeat biopsy. CONCLUSIONS: Serology appears to be a poor surrogate marker for mucosal recovery on a gluten-free diet; dietary assessment fails to identify a potential gluten source in many patients with ongoing villous atrophy. The benefits of re-biopsy on diet include stratification of patients with coeliac disease suitable for early discharge from secondary care or those requiring more intensive clinical management.

F14512, a polyamine-vectorized anti-cancer drug, currently in clinical trials exhibits a marked preclinical anti-leukemic activity.

Chemotherapy remains mainly used for the treatment of acute myeloid leukemia (AML). However, in the past 3 decades limited progress has been achieved in improving the long-term disease-free survival. Therefore the development of more effective drugs for AML represents a high level of priority. F14512 combines an epipodophyllotoxin core targeting topoisomerase II with a spermine moiety introduced as a cell delivery vector. The polyamine moiety facilitates F14512 selective uptake by tumour cells via the polyamine transport system, a machinery overactivated in cancer cells. F14512 has been characterized as a potent drug candidate and is currently in Phase I clinical trials. Here, we demonstrated marked survival benefit and therapeutic efficacy of F14512 treatments in a series of human AML models, established either from AML cell lines or from patient AML samples. Furthermore, we reported in vitro synergistic anti-leukemic effects of F14512 in combination with cytosine arabinoside (Ara-C), doxorubicin, gemcitabine, bortezomib or SAHA. In vivo combination of suboptimal doses of F14512 with Ara-C also resulted in enhanced anti-leukemic activity. We further showed that F14512 triggered both senescence and apoptosis in vivo in primary AML models, but not autophagy. Overall, these results support the clinical development in onco-hematology of this novel promising drug candidate.

What is a nurse? Is there an international consensus?

BACKGROUND: Historical experience and health service modernization partly account for the variation seen in definitions of what a 'nurse' is from country to country. It is unclear if international disparities in nursing provision, apparent in health data for developed countries, demonstrate real differences in staffing patterns or simply reflect the wide variations in understanding and use of terms for different categories of nurse. AIM: This paper is an opinion piece of international interest discussing the need for standardization in definitions of different categories of nurse internationally. DISCUSSION: The International Council for Nurses (ICN), the World Health Organization and the Organisation for Economic Cooperation and Development (OECD) all have different ways of defining a nurse. The wide variation in terms is particularly apparent from OECD countries however, where nursing density data present wide disparities, not readily accounted for by gross national product. Skill mix and clinical role developments may account for these better. CONCLUSION: Until proper consensus is reached on what a nurse is and does, any skill mix or clinical role developments will only have limited international relevance, especially in OECD countries. If nursing qualifications are to be valid even across the European Union, then recommended standards such as those of the ICN, must be specified in terms of what different categories of nurses actually can do, and their responsibilities and roles within that scope of practice. Standardization of definitions of categories of nurse internationally should reduce confusion and promote better understanding of patterns of nurse staffing and the effect these may have on patient outcomes.

Surface-modified nanoparticles as a new, versatile, and mechanically robust nonadhesive coating: suppression of protein adsorption and bacterial adhesion.

The synthesis of surface-modified silica nanoparticles, chemically grafted with acrylate and poly(ethylene glycol) (PEG) groups, and the ability of the resulting crosslinked coatings to inhibit protein adsorption and bacterial adhesion are explored. Water contact angles, nanoindentation, and atomic force microscopy were used to characterize the cross-linked coatings. Coatings showed a high degree of hydrophilicity combined with a remarkable hardness and stiffness in the dry state. Adsorption of the small protein lysozyme from buffer solution on coated silica wafers decreased significantly with increasing grafting density of the PEG groups on the nanoparticles and was completely inhibited at 0.6 chains nm(-2). Coatings significantly reduced adhesion of Staphylococcus epidermidis HBH 276 in a parallel plate flow chamber with respect to bare glass (>90%), whereas adhesion of Pseudomonas aeruginosa AK1 was only marginally affected by the presence of the coating (<15%). Passage of an air-bubble resulted in almost complete detachment (>93%) of both strains from coated glass, indicating that the adhesion strength between both bacterial strains and the coated surface was significantly reduced by the grafted PEG groups. These coatings thus provide a new method to prepare mechanically robust films with nonadhesive properties that will be extremely useful for the design of biocompatible surfaces in biomedical applications.

Hepatic resection for benign non-cystic liver lesions.

BACKGROUND: Hepatic resection is indicated for a variety of benign conditions because of persistent symptoms, uncertainty regarding the diagnosis or the risk of malignant transformation. The aim of this study was to assess the indications for and outcome of hepatic resection for benign non-cystic liver lesions in a specialist hepatobiliary unit. PATIENTS AND METHODS: All patients who had undergone hepatic resection for benign non-cystic hepatic lesions between 1989 and 2001 were identified from a prospective database for analysis. RESULTS: A total of 49 patients (40 women, 9 men) with a mean age of 43 years (range 21-75 years) underwent resection of non-cystic benign lesions. Indications for operation included suspected liver cell adenoma (n=11), suspicion of malignancy (11), persistent symptoms attributable to the lesion (20) or chronic sepsis (7). The final diagnosis was focal nodular hyperplasia (n=12), haemangioma (12), adenoma (8), sclerosing cholangitis (5), inflammatory pseudotumour (4), intrahepatic cholelithiasis (3), chronic hepatic abscess (3), benign biliary fibrosis (I) and leiomyoma (I). Major anatomical hepatic resections were performed in 44 patients, and 5 patients underwent a segmentectomy or minor atypical resection. Median operating time was 215 min (range 45-450 min) and median blood loss was 875 ml (range 200-4000 ml). Ten patients (20%) required a median blood transfusion of 2 units (range 2-8 units). The median postoperative stay was 10 days (range 4-33 days). There were no deaths, but complications occurred in 15 patients (27%). CONCLUSIONS: Hepatic resection can be safely recommended for selected patients with a variety of benign non-cystic hepatic lesions. A small group of patients undergo resection as a result of inability to rule out a malignant process, but the large majority will be operated on because of either their malignant potential or related symptoms.

Clinical and cost-effectiveness of new and emerging technologies for early localised prostate cancer: a systematic review.

OBJECTIVES: To evaluate the clinical and cost-effectiveness of new and emerging technologies for early, localised prostate cancer. DATA SOURCES: Electronic databases, reference lists of relevant articles and various health services research-related resources. REVIEW METHODS: A list of new and emerging technologies was identified and agreed. A systematic review was undertaken and selected studies were reviewed against a set of criteria. An economic model was developed and used to compare the specified newer treatments with the traditional approaches. RESULTS: For neoadjuvant hormonal therapy, no evidence of benefit was seen in terms of biochemical disease-free survival. For adjuvant hormonal therapy, there was no evidence of benefit in terms of survival, but some conflicting evidence that higher risk patients may benefit. The largest number of studies reported results for brachytherapy, where some evidence suggested that it may be more effective than standard treatments for lower risk patients, although less effective for intermediate- and high-risk patients, in terms of biochemical disease-free survival. Lower quality evidence reported fewer complications than for standard treatments. Higher quality evidence suggested that disease-specific quality of life (QoL) for brachytherapy patients was lower than for patients receiving standard treatments. The review of three-dimensional conformal radiotherapy (3D-CRT) considered treatment-related morbidity, where significantly fewer gastrointestinal complications occurred than with standard radiotherapy. It was suggested that higher radiation doses achieved better disease control, although patient characteristics were often reported as independent indicators of control. The review of intensity-modulated conformal radiotherapy suggested that late gastrointestinal toxicity may be reduced compared with 3D-CRT. For cryotherapy, high rates of impotence were reported. Owing to the paucity and poor quality of evidence identified for other interventions, conclusions regarding their clinical effectiveness cannot be drawn. Cost-effectiveness estimates were based on the impact of adverse events on quality-adjusted life-years and the assessment was restricted to brachytherapy, 3D-CRT and cryotherapy compared with standard treatments. Of the new treatments included, only cryotherapy appeared not to be potentially cost-effective compared with traditional treatments, owing to the associated high incidence of impotence. CONCLUSIONS: The results of the clinical effectiveness review should be viewed in the context of the quality of the available evidence. Very few randomised controlled trials (RCTs) were identified, with the majority of included studies being descriptive case series, open to patient selection bias and measuring surrogate end-points with short-term follow-up. It is difficult therefore to draw conclusions on the relative benefits or otherwise of the newer technologies owing to the lack of substantive evidence of any quality and the lack of comparisons between the newer technologies and with standard treatments. Given the lack of high-quality clinical evidence with long-term follow-up and the uncertainty surrounding the assumptions in the economic analysis, the following areas are recommended for further research: RCTs with sufficient follow-up to measure benefits in terms of overall survival to include QoL measurement to establish trade-offs between potential adverse events and benefits of treatment; the identification of prognostic risk factors among men diagnosed with early prostate cancer; QoL studies to compare the utility of health states among patients on active monitoring, patients receiving treatment and the comparable healthy population; the relationship between surrogate end-points and survival; and the adoption of standard definitions for adverse events.

Postchemoembolisation syndrome--tumour necrosis or hepatocyte injury?

Transarterial chemoembolisation of liver tumours is typically followed by elevated body temperature and liver transaminase enzymes. This has often been considered to indicate successful embolisation. The present study questions whether this syndrome reflects damage to tumour cells or to the normal hepatic tissue. The responses to 256 embolisations undertaken in 145 patients subdivided into those with hepatocyte-derived (primary hepatocellular carcinoma) and nonhepatocyte-derived tumours (secondary metastases) were analysed to assess the relative effects of tumour necrosis and damage to normal hepatocytes in each group. Cytolysis, measured by elevated alanine aminotransferase, was detected in 85% of patients, and there was no difference in the abnormalities in liver function tests measured between the two groups. Furthermore, cytolysis was associated with a higher rate of postprocedure symptoms and side effects, and elevated temperature was associated with a worse survival on univariate analysis. Multivariate analysis demonstrated that there was no benefit in terms of survival from having elevated temperature or cytolysis following embolisation. Cytolysis after chemoembolisation is probably due to damage to normal hepatocytes. Temperature changes may reflect tumour necrosis or necrosis of the healthy tissue. There is no evidence that either a postchemoembolisation fever or cytolysis is associated with an enhanced tumour response or improved long-term survival in patients with primary or secondary liver cancer.

The management of inhibitors in haemophilia A: introduction and systematic review of current practice.

Haemophilia is the commonest bleeding disorder in the UK, affecting approximately 5400 people, almost all of them male. In haemophiliacs, reduced levels, or absence, of factor VIII (FVIII) cause bleeding episodes, typically into joint spaces or muscles. Haemophilia is generally treated with exogenous FVIII. However, in some haemophiliacs, therapeutically administered FVIII comes to be recognized as a foreign protein, stimulating the production of antibodies (inhibitors), which react with FVIII to render it ineffective. Alternative treatment strategies then have to be used to manage bleeding episodes. In addition, strategies have been developed to attempt to abolish inhibitor production through the induction of immune tolerance. A systematic review was undertaken of current international practice for the clinical management of haemophilia A patients with inhibitors to FVIII, concentrating on literature published from 1995 onwards. Although it can be difficult to determine what constitutes current practice, current guidelines indicate that immune tolerance induction is seen as desirable, with the choice of regimen dependent on patient characteristics, familiarity with regimens and cost. Various approaches, based on similar factors, are used to control bleeding episodes.

Tethered polymer chains: surface chemistry and their impact on colloidal and surface properties.

In this review the grafting of polymer chains to solid supports or interfaces and the subsequent impact on colloidal properties is examined. We start by examining theoretical models for densely grafted polymers (brushes), experimental techniques for their preparation and the properties of the ensuing structures. Our aim is to present a broad overview of the state of the art in this field, rather than an in-depth study. In the second section the interactions of surfaces with tethered polymers with the surrounding environment and the impact on colloidal properties are considered. Various theoretical models for such interactions are discussed. We then review the properties of colloids with tethered polymer chains, interactions between planar brushes and nanocolloids, interactions between brushes and biocolloids and the impact of grafted polymers on wetting properties of surfaces, using the ideas presented in the first section. The review closes with an outlook to possible new directions of research.

The incidence of flushing on induction of anaesthesia in patients who blush easily.

Flushing (reddening and blotching of the skin) is seen frequently at induction of anaesthesia, is associated with anaesthetic agents such as thiopental and muscle relaxants, and is attributed to histamine release. The changes are generally confined to the neck and upper chest (the blush area). In conscious subjects, the mechanisms responsible for blushing in the same skin distribution are well defined and neurally mediated. We investigated the relationship between a history of blushing easily and flushing after intravenous induction o f anaesthesia. We interviewed 898 patients about to undergo general anaesthesia and asked them if they blushed easily. Anaesthesia was induced with thiopental followed by suxamethonium and/or alcuronium. We noted skin colour and the presence of a flush every 5 min for 20 min. Women reported blushing more than men (47% of women, compared with 33% of men, p < 0.001), and blushing was more common in young people (p < 0.001). In those women with a history of blushing, 32% flushed on induction of anaesthesia, compared with 6% of those who did not blush. In men, a flush was seen in 22% of those who blushed, and in 0.2% of those who did not. These differences in the frequency of flushing were significant (p < 0.001). In conclusion, flushing after induction of anaesthesia appears to be related to individual predisposition and may be neurally mediated.

Incidence of benign pathology in patients undergoing hepatic resection for suspected malignancy.

BACKGROUND: Confirming the presence of hepatic or proximal bile duct malignancy pre-operatively remains difficult and some patients may undergo surgical resection for suspected malignant lesions which subsequently turn out to be benign. The aim of this study was to establish whether improvements in pre-operative staging might better identify this patient population. METHODS: Analysis of a prospectively collected database, which has been maintained in our unit since 1988. RESULTS: Of 250 consecutive patients undergoing hepatic resection for presumed malignancy, 18 (7.2%) were shown to have benign pathology. These "false positive" rates were 4 out of 160 (2.5%) resections for colorectal metastases, 4 out of 49 (8.2%) resections for other solid hepatobiliary tumours and 10 out of 41 (24.4%) resections for hilar cholangiocarcinoma. Four of the 18 patients (22%) developed post-operative complications but there was no postoperative mortality. CONCLUSION: Although hepatic resection remains a potentially curative procedure for patients with tumours involving the liver parenchyma or proximal bile ducts, pre-operative confirmation of malignancy remains difficult. Despite appropriate investigation a subset of patients with benign disease will still be subjected to major hepatic resection which should be undertaken in a specialist unit.

Treatment of hepatic metastases of neuroendocrine malignancies: a 10-year experience.

BACKGROUND: Liver metastases from neuroendocrine tumours may give rise to symptoms due to hormone production or mass effect. Accepted management options include administration of somatostatin-analogues, selective chemoembolisation or hepatic resection. The aim of this study was to review the management of hepatic neuroendocrine metastases in our unit. METHODS: Patients with neuroendocrine tumours presenting between 1989 and 1999 were identified from pathology, radiology and surgical databases. Case notes were retrospectively reviewed for demographic data, treatment modality and outcome. Response to treatment was based on biochemistry, radiology or symptoms, and response rates were defined accordingly. RESULTS: Thirty patients with a mean age of 55 years presented with, or later developed liver metastases. The most frequent presenting symptoms were abdominal pain (63%), diarrhoea (40%), weight loss (33%) and flushing (13%). Five patients underwent liver resection with complete symptomatic response, nine underwent chemoembolisation with a 75% response rate (either biochemically, radiologically or symptomatic) and fifteen were treated with a somatostatin-analogue, with a response rate of 86%. Median survival from detection of metastases was 45 months. CONCLUSIONS: Liver resection provides good symptomatic relief, but it is only indicated in a small proportion of patients with metastatic neuroendocrine tumours. Both chemoembolisation and somatostatin-analogues offer useful symptomatic control for these patients with good survival prospects.

Virtual hepatic resection using three-dimensional reconstruction of helical computed tomography angioportograms.

OBJECTIVE: To establish the accuracy of virtual hepatic resection using three-dimensional (3D) models constructed from computed tomography angioportography (CTAP) images in determining the liver volume (LV) resected during resectional liver surgery. SUMMARY BACKGROUND DATA: The ability to measure LV before surgery could be useful in determining the extent and nature of hepatic resection. Accurate assessment of LV and an estimate of liver function may also allow prediction of postoperative liver failure in patients undergoing resection, assist in volume-enhancing embolization procedures, help with the planning of staged hepatic resection for bilobar disease, and aid in selection of living-related liver donors. METHODS: A retrospective study was conducted involving 27 patients scheduled for liver resection. Using mapping technology, 3D models were constructed from helical CTAP images. From these 3D models, tumor volume, total LV, and functional LV were calculated and were compared with body weight. The 3D liver models were subjected to a virtual hepatectomy along established anatomical planes, and the resected LV was calculated. The resected volume predicted by radiologists (unaware of the actual weight) was compared with the specimen weight measured after actual surgical resection. RESULTS: A significant correlation was found between body weight and functional LV but not total LV. The computer prediction of resected LV after virtual hepatectomy of 3D models compared well with resected liver weight. CONCLUSION: Virtual hepatectomy of 3D CTAP reconstructed images provides an accurate prediction of liver mass removed during subsequent hepatic resection. The authors intend to combine this technology with an assessment of liver function to attempt to predict patients at risk for liver failure after hepatic resection.

Sociologic perspectives on juvenile violence.

In sum, there are four sets of social factors that help us understand why juvenile violence appears when, and where, it does, and why some communities and entire societies are persistently wracked by youth violence whereas others are largely spared its worst expressions. When it comes to the first three factors in particular--deprivation, disorganization, and brutalization--the evidence for these links is as strong as anything in social science, and that evidence is supported by a variety of sources and a variety of methods of investigation. Such investigation includes the knowledge we gain through social intervention. Some of the most effective violence prevention programs are successful precisely because they confront and deflect the social forces that otherwise often lead to violence. Consider, for example, the home-visiting programs that work with poor parents in disorganized communities to lower the risks of child abuse; and some of the more "holistic" or "multisystemic" efforts to work with violent juvenile offenders. The best of these programs work by tackling the problems of social isolation and lack of supports in the community, as well as immediate issues of economic survival for vulnerable families and children. More generally, we know that the availability of steady and rewarding work in the future, of the kind that can reliably sustain a family, is one of the most important factors allowing some youths to "desist" from violence as they mature. These conclusions give us much to be encouraged about, and much to be alarmed about. On the one hand, understanding that youth violence often is rooted in a set of adverse social conditions that are identifiable, and potentially modifiable, is a fundamentally optimistic message. It reminds us that the level of juvenile violence we suffer in America today is neither fated nor inevitable. Other societies that are in many respects much like us suffer far less of it; so could we, and we increasingly understand some of the ways in which we could make that happen. We know that some programs designed to increase opportunities and supports for high-risk youth and families do work, and we know that there are broader social and economic policies--policies that are not abstract visions, but have actually been put into place in societies much like our own--that can significantly diminish the pressures toward violence that are bred by poverty and social insecurity among the young. But knowing what to do is one thing, and actually doing it is another. In this there is much reason for concern. The 7-year economic boom that began in the early 1990s has had salutary effects on youth violence, mainly by providing improved economic opportunities for low-income youth and, accordingly, diminishing the appeal of illegal activities. Despite that extraordinary burst of sustained prosperity, however, too many of America's youth remain impoverished, sometimes desperately so: the boom has had only limited effect on our disturbingly high rates of family poverty, which continue to tower above those of comparable industrial societies. And if the boom should come to an end, and we enter again into a period of rising joblessness for youth and young adults, then much, or all, of the recent gains could be quickly lost. The positive economic trends that have helped take the edge off serious juvenile violence in the past few years, in short, are both partial and fragile. Worse, some of our recent social and economic policies, at both state and federal levels, are working in the opposite direction. Some variants of welfare reform, for example, have tossed many vulnerable families off of public assistance without offering solid economic opportunities in its place. Many more families face this future as federal time limits on public welfare increasingly come into play. Given what we know about the links between deprivation and youth violence, this is not a development we can celebrate. (ABSTRACT TRUNCATED)

Distribution of colorectal liver metastases in patients referred for hepatic resection.

BACKGROUND: There is a perception that streamline flow of blood in the portal vein may influence the anatomic distribution of liver metastases, depending on the site of the primary tumor. It has previously been reported that cancers arising in the right colon are distributed to the right lobe of the liver 10 times more commonly than to the left lobe, whereas liver metastases from tumors arising from the left colon and rectum are believed to be distributed homogenously. METHODS: Data were collected prospectively on the anatomic site of hepatic metastases in 207 patients with colorectal metastases referred for consideration for surgery. Anatomic site was established by a combination of computed tomography scanning and either laparoscopic or intraoperative ultrasonography. The site of the primary tumor was known in all cases. RESULTS: A total of 708 metastases were identified, of which 67% were in the right hemiliver and 33% were in the left. The ratio of involvement of the right and left hemilivers by metastases arising from right colon tumors was 2. 02:1 and for left colon tumors 2.1:1. When patients with unilobar disease only were considered, the ratio of involvement of the right and left hemilivers increased to 2.9:1, but again no difference was evident that depended on the site of the primary tumor. CONCLUSIONS: This study could not find any evidence to support a differential pattern of metastasis within the liver dependent on the location of the primary colorectal carcinoma.

Evaluation of an antiseptic triple-lumen catheter in an intensive care unit.

OBJECTIVE: To evaluate a decrease in catheter-related bloodstream infection rate in patients with antiseptic triple-lumen catheters in an intensive care unit. DATA SOURCES: Retrospective review of surveillance records, patient medical records, laboratory and microbiological reports, and antibiotic administration records. STUDY SELECTION: Patients admitted to the intensive care unit with triple-lumen catheters. DATA EXTRACTION: A subset of one entry per patient was extracted from 2 yrs of primary bloodstream infection surveillance data. Data collection included risk factors, laboratory and microbiological data, and insertion sites and dates of all intravascular catheters present during triple-lumen catheterization. DATA SYNTHESIS: The catheter-related bloodstream infection rate was 5.4 and 11.3 per 1000 catheter days in antiseptic and nonantiseptic triple-lumen catheter groups, respectively (p = .06). By multivariate analysis using a Cox Proportional Hazards Model, the antiseptic triple-lumen catheters were associated with a significant reduction in catheter-related bloodstream infection (p = .03). Model expansion to include intrajugular site was significant by a likelihood ratio test [2(log likelihood diff) = 4.26 P<.05 chi2(1)] CONCLUSIONS: The use of antiseptic triple-lumen catheters may substantially reduce catheter-related bloodstream infections in an intensive care population and may be subsequently associated with a decrease in length of stay.

Does the subspecialty of the surgeon performing primary colonic resection influence the outcome of patients with hepatic metastases referred for resection?

OBJECTIVE: To compare resection rates and outcome of patients subsequently referred with hepatic metastases whose initial colon cancers were resected by surgeons with different specialty interests. SUMMARY BACKGROUND DATA: Variation in practice among noncolorectal specialist surgeons has led to recommendations that colorectal cancers should be treated by surgeons trained in colorectal surgery or surgical oncology. METHODS: The resectability of metastases, the frequency and pattern of recurrence after resection, and the length of survival were compared in patients referred to a single center for resection of colorectal hepatic metastases. The patients were divided into those whose colorectal resection had been performed by general surgeons (GS) with other subspecialty interests (n = 108) or by colorectal specialists (CS; n = 122). RESULTS No differences were observed with respect to age, sex, tumor stage, site of primary tumor, or frequency of synchronous metastases. Comparing the GS group with the CS group, resectable disease was identified in 26% versus 66%, with tumor recurrence after a median follow-up of 19 months in 75% versus 44%, respectively. Recurrences involving bowel or lymph nodes accounted for 55% versus 24% of all recurrences, with respective median survivals of 14 months versus 26 months. CONCLUSION: Fewer patients referred by general surgeons had resectable liver disease. After surgery, recurrent tumor was more likely to develop in the GS group; their overall outcome was worse than that of the CS group. This observation is partly explained by a lower local recurrence rate in the CS group.

Tailoring the management of nonparasitic liver cysts.

OBJECTIVE: To determine the optimal management of symptomatic non-parasitic liver cysts. SUMMARY BACKGROUND DATA: Management options for symptomatic nonparasitic liver cysts lack substantiation through comparative studies with respect to safety and long-term effectiveness. METHODS: A retrospective review of the surgical management of patients with hepatic cysts between October 1988 and August 1997 was undertaken to determine morbidity rates and to assess long-term recurrence. RESULTS: Thirty-eight patients (35 women, 3 men) underwent 48 operations for symptomatic hepatic cysts of mean diameter 12 cm, with a mean follow-up of 41 months. Twenty-three patients had simple cysts, and 15 patients had polycystic liver disease (PCLD). The symptomatic recurrence rates after laparoscopic or open deroofing for simple cysts were 8% and 29%, and for PCLD 71% and 20%, respectively. There were no symptomatic recurrences after 14 hepatic resections. There were no perisurgical deaths; however, morbidity rates were significant after laparoscopic deroofing, open deroofing, and hepatic resection (25%, 36%, and 50%, respectively). CONCLUSIONS: Selection of patients with truly symptomatic hepatic cysts is crucial before considering interventional techniques. For simple cysts, radical laparoscopic deroofing is usually curative; open deroofing should be reserved for cysts inaccessible by laparoscopy. The latter technique is well tolerated; however, long-term symptom control is unpredictable in patients with PCLD. Hepatic resection for PCLD provides satisfactory long-term symptom control but has an appreciable morbidity rate. Although laparoscopic and open deroofing procedures are less reliable in the long term for solitary cysts, they might be useful steps before embarking on this major procedure.

Medication patterns of recurrent headache sufferers: a community study.

This community-based telephone survey determined medication patterns of 274 frequent headache sufferers who reported 12 or more headaches a year. Headaches were classified using the International Headache Society's (IHS) criteria. Participants reported on 465 types of headaches: 129 tension headaches, 158 migraine headaches, 8 chronic tension headaches, and 148 headaches which were unclassifiable using IHS criteria. Females (n = 133) reported an average of 1.9 types of headache and males (n = 141) reported 1.5 headache types. Fifty-six percent of respondents used acetaminophen for tension-type and 60% used acetaminophen for migraine. One percent used prescription medication for tension headache and 12% used prescriptions for migraine. The perceived effectiveness of over-the-counter medication was approximately 7 on a scale of 0-10 for tension headaches and 6 for migraine. Both tension-headache and migraine-headache sufferers waited about 1 h before taking any medication. Tension-headache sufferers waited until the headache was above 5 on a 0 to 10 scale (4.6 for migraine). It is possible that more aggressive use of medication might improve headache management.