Microalbuminuria and coronary heart disease in NIDDM: an incidence study.

In most survival studies in NIDDM, microalbuminuria (urinary albumin excretion rate 20-200 microg/min) predicts early mortality; in cross-sectional studies, it is associated with coronary heart disease (CHD) morbidity. It is unclear, however, whether microalbuminuria is a risk factor for the development of CHD or the result of it, and little is known of the factors that predispose to the development of microalbuminuria in NIDDM. We examined these issues in a 7-year prospective study of a hospital-based cohort comprising 146 white NIDDM patients without clinical albuminuria. Microalbuminuria was a significant risk factor for both all-cause mortality (relative risk 3.94, 95% CI 2.04-7.62) and CHD mortality (relative risk 7.40, 95% CI 2.94-18.7) when adjusted for age only. Its independent predictive power did not persist, however, in age-adjusted multivariable survival analysis that allowed for the other significant risk factors: male sex, preexisting CHD, high levels of glycated hemoglobin, and high serum cholesterol. Among men free of CHD at baseline, the independent risk factors for CHD morbidity and mortality were microalbuminuria, current smoking, high diastolic blood pressure, and high serum cholesterol (all P < 0.05). For the 100 NIDDM patients with normoalbuminuria at baseline, the incidence of microalbuminuria was 29% over the 7-year period. In that group, fasting plasma glucose, current smoking, preexisting CHD, and high initial urinary albumin excretion rate were risk factors for the development of microalbuminuria (all P < 0.05). When men and women were analyzed separately, preexisting CHD was a significant risk factor in men only. These results demonstrate that microalbuminuria predicts incident clinical CHD in men with NIDDM. Preexisting CHD is also a risk factor for incident microalbuminuria in men, however, suggesting that microalbuminuria and CHD are not causally related but rather reflect common determinants.

A stepwise approach to laparoscopic Nissen fundoplication: avoiding technical pitfalls.

Laparoscopic Nissen fundoplication is now widely used in the surgical management of gastroesophageal reflux disease. However, it is a complex operation that requires advanced laparoscopic skills. The learning curve is steep, and complications are directly related to the surgeon's experience level. Both experimental and clinical data demonstrate a decline in complications with increasing experience. We divided this complex procedure into logical and orderly components, to facilitate the learning process. We believe that this approach will not only reduce complications by highlighting potential problems at each stage but also make it easier to teach others.

Lipid peroxidation and malondialdehyde in the synovial fluid and plasma of patients with rheumatoid arthritis.

The concentration of lipid peroxides in the plasma and synovial fluid of 65 arthritic patients was determined using a new ion-pairing reverse phase HPLC technique. Patients with rheumatoid arthritis receiving only non-steroidal anti-inflammatory drugs, had a significantly higher mean concentration of lipid peroxides in synovial fluid samples (162 +/- 22.0 micrograms/l) than osteoarthritic patients (40.0 +/- 8.0 micrograms/l, p less than 0.0001). Mean concentrations in both groups correlated strongly with the level of beta-glucuronidase activity as a measure of lysosomal enzyme release (r = 0.71, p less than 0.0001). Contrary to previous reports by investigators using less specific methods, we were unable to demonstrate any increase in plasma levels of lipid peroxides in the rheumatoid patient. Treatment of rheumatoid arthritis with D-penicillamine was associated with a significant reduction of lipid peroxide levels (83.2 +/- 11.5 micrograms/ml, p less than 0.002), suggesting that this drug may function as an oxygen radical scavenger in the joint cavity. These results give further support to the concept of oxygen-free radicals playing an important role in the pathogenesis of chronic inflammatory disorders.

Predictors of outcome in 100 consecutive laparoscopic antireflux procedures.

BACKGROUND: Published success rates for surgical intervention in gastroesophageal reflux disease exceed 90%. The goal of this study was to determine if any preoperative factors could accurately predict postoperative symptom relief. METHODS: One hundred consecutive patients undergoing laparoscopic antireflux surgery completed a detailed preoperative questionnaire, and underwent endoscopy, manometry, and 24-hour esophageal pH monitoring. Two surgeons performed all procedures in a standardized fashion. At least 2 months following operative intervention, a single interviewer, blinded to all preoperative information and procedure performed, recorded Visick and Gastroesophageal Reflux Disease-Health-Related Quality of Life scores for all patients. All follow-up was performed within 3 years of antireflux procedure. RESULTS: The surgical success rate, as defined by Visick scores of 1-2, was 91%. Three variables were predictive of postoperative success: age <50, presence of typical symptoms at presentation, and complete resolution of symptoms with acid suppression therapy. CONCLUSION: The study shows that surgical strategies can reproducibly control gastroesophageal reflux disease symptoms in more than 90% of patients. The optimal surgical candidate is a patient under the age of 50 whose typical symptoms completely resolve with acid suppression therapy.

Computer-enhanced laparoscopic training system (CELTS): bridging the gap.

BACKGROUND: There is a large and growing gap between the need for better surgical training methodologies and the systems currently available for such training. In an effort to bridge this gap and overcome the disadvantages of the training simulators now in use, we developed the Computer-Enhanced Laparoscopic Training System (CELTS). METHODS: CELTS is a computer-based system capable of tracking the motion of laparoscopic instruments and providing feedback about performance in real time. CELTS consists of a mechanical interface, a customizable set of tasks, and an Internet-based software interface. The special cognitive and psychomotor skills a laparoscopic surgeon should master were explicitly defined and transformed into quantitative metrics based on kinematics analysis theory. A single global standardized and task-independent scoring system utilizing a z-score statistic was developed. Validation exercises were performed. RESULTS: The scoring system clearly revealed a gap between experts and trainees, irrespective of the task performed; none of the trainees obtained a score above the threshold that distinguishes the two groups. Moreover, CELTS provided educational feedback by identifying the key factors that contributed to the overall score. Among the defined metrics, depth perception, smoothness of motion, instrument orientation, and the outcome of the task are major indicators of performance and key parameters that distinguish experts from trainees. Time and path length alone, which are the most commonly used metrics in currently available systems, are not considered good indicators of performance. CONCLUSION: CELTS is a novel and standardized skills trainer that combines the advantages of computer simulation with the features of the traditional and popular training boxes. CELTS can easily be used with a wide array of tasks and ensures comparability across different training conditions. This report further shows that a set of appropriate and clinically relevant performance metrics can be defined and a standardized scoring system can be designed.

The long term effect of intra-aortic balloon counterpulsation on left ventricular performance.

A patient who had had two coronary artery bypass grafts and an aneurysmectomy required intra-aortic balloon pump (IABP) assistance to allow discontinuation of cardiopulmonary bypass (CPBP). An indwelling electromagnetic flow probe on the ascending aorta was used to monitor IABP over the following 8 days of assistance. Stroke volume (SV), Cardiac output (CO), stroke work (SW), and ventricular afterload (VA) were measured directly. Recovery was indicated as the discrepancy between CO and SV on and off IABP decreased. VA depended upon the degree of augmentation. SW bore an incostant relationship to IABP.

Cardiomyopathy in adult Holstein Friesian cattle in Britain.

The clinical signs, pathology and breeding data of two cases of cardiomyopathy of an unusual kind in adult Holstein Friesian cattle in Britain are reported and compared with those in similar entities in Switzerland, Japan and Canada. The principal and primary lesions affect the heart and these produce secondary changes, particularly in the liver, and result in fatal congestive heart failure. The cardiac lesions consist of extensive myocyte vacuolation, endomysial and perimysial fibrosis and focal cardiac myocyte degeneration, atrophy and hypertrophy resulting in an extended range of myocyte size. Lesions affected all four heart chambers but were most severe in the ventricles. Vascular lesions, particularly moderate medial hypertrophy and intimal thickening of arterioles and arteries, occurred in heart, lung, kidney and lymph nodes. The liver showed severe fibrosis, chronic congestion and hepatocyte loss. There was a chronic multifocal nephritis. The cause is unknown, but the affected animals were full brother and sister and have a common ancestor in the male and female line five generations earlier.

Measurement of arterial oxygen-haemoglobin saturation in newborn lambs by pulse oximetry.

Percentage arterial oxygen saturation (SpO2) was measured in 69 neonatal lambs at one, five and 10 minutes after birth using a pulse oximeter applied to the tail. The lambs were given a subjective vitality score from 1 to 4, with 1 being normal and 4 being stillborn. Of the 42 lambs born after a normal parturition, 19 were measured after one minute, 29 after five minutes and 24 after 10 minutes; the mean (sd) SpO2 values of these groups were 67 (15) per cent, 84 (9) per cent and 83 (9) per cent, respectively. Of the 27 lambs born after dystocia, 16 were measured after one minute, 18 after five minutes and 12 after 10 minutes; the mean (sd) SpO2 values of these groups were 61 (15) per cent, 69 (16) per cent and 69 (19) per cent, respectively. The values measured in the lambs born after dystocia were significantly lower than those in the lambs born normally at five and 10 minutes (P < 0.005 and P < 0.05, respectively). Of the lambs born with a vitality score of 1, 24 were measured after one minute, 33 after five minutes and 26 after 10 minutes; they had mean SpO2 values of 72 (11), 82 (10) and 81 (12) per cent, respectively. Of the lambs born with vitality scores of 2 or 3, 11 were measured after one minute, 14 after five minutes and 10 after 10 minutes; they had mean SpO2 values of 48 (6), 68 (17) and 72 (20) per cent, respectively. The SpO2 values of the lambs with vitality scores of 2 or 3 were significantly lower than those of the lambs with a vitality score of 1 at one and five minutes after birth (P < 0.0001 and P < 0.05, respectively).

Oesophageal injury associated with the administration of an anthelmintic bolus to calves.

Six of 18 calves from a suckler herd which were dosed with a sustained-release anthelmintic bolus, using appropriate equipment, developed clinical signs related to oesophageal perforation. Two died as a direct result of the injuries sustained, one required surgical removal of the paraoesophageal bolus and the remaining three were managed medically. The calves were in the approximate weight range advised by the manufacturers as suitable for dosing, but some were younger than the minimum recommended age. These animals were of a fractious nature having been relatively little handed.

Persistent vaginal haemorrhage in five mares caused by varicose veins of the vaginal wall.

Persistent bleeding from the vulva was the only presenting clinical sign in five non-pregnant pluriparous mares varying in age from eight to 20 years. These were two hunter types, one shire, one thoroughbred and one Arab pony. The haemorrhage originated from ulcerated varicose veins present on the dorsal wall of the vagina adjacent to the vestibulovaginal junction. All five mares were successfully treated, by submucosal resection (two), ligation of vessels (two) or diathermy (one). In four mares there was evidence of vulval incompetence caused by depression of the perineum. The importance of this and the role of impaired venous return during and after pregnancy are discussed.