The effect of consultant outcome publication on surgeon behaviour: a systematic review and narrative synthesis.

Introduction Surgeon-specific outcome data, or consultant outcome publication, refers to public access to named surgeon procedural outcomes. Consultant outcome publication originates from cardiothoracic surgery, having been introduced to US and UK surgery in 1991 and 2005, respectively. It has been associated with an improvement in patient outcomes. However, there is concern that it may also have led to changes in surgeon behaviour. This review assesses the literature for evidence of risk-averse behaviour, upgrading of patient risk factors and cessation of low-volume or poorly performing surgeons. Materials and methods A systematic literature review of Embase and Medline databases was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Original studies including data on consultant outcome publication and its potential effect on surgeon behaviour were included. Results Twenty-five studies were identified from the literature search. Studies suggesting the presence of risk-averse behaviour and upgrading of risk factors tended to be survey based, with studies contrary to these findings using recognised regional and national databases. Discussion and conclusion Our review includes instances of consultant outcome publication leading to risk-averse behaviour, upgrading of risk factors and cessation of low-volume or poorly performing surgeons. As UK data on consultant outcome publication matures, further research is essential to ensure that high-risk patients are not inappropriately turned down for surgery.

MDCT of retractor-related hepatic injury following laparoscopic surgery: appearances, incidence, and follow-up.

AIMS: To investigate the postoperative computed tomography (CT) features resulting from the use of Nathanson retractors during laparoscopic upper gastro-intestinal surgery. MATERIALS AND METHODS: A 3-year retrospective study of 176 patients who had undergone laparoscopic upper gastro-intestinal surgery for bariatric or malignant disease was performed. Postoperative CT images [divided into early (≤ 30 days) and late (>30 days)] were assessed by a consultant radiologist and liver abnormalities recorded. RESULTS: The features of a retractor injury were a hypodense lesion, abutting the liver edge, usually triangular or linear in shape. Late postoperative features included focal subcapsular retraction and associated liver atrophy. Sixty-eight percent (52/77) of patients undergoing surgery for malignancy underwent postoperative CT, compared with 11% (11/99) of those undergoing bariatric surgery. Patients with malignancy were more likely to have retraction-related liver abnormalities (14/52, 27%) at postoperative CT than those in the bariatric group (2/11, 18%). CONCLUSION: Retractor-related liver injuries at MDCT are common following laparoscopic upper gastro-intestinal surgery. Recognition of the characteristic triad of features, a hypodense lesion abutting the liver edge with a triangular or linear shape, should allow confident diagnosis. CT follow-up reveals that over time these lesions may disappear, remain unchanged, or result in a focal subcapsular scar with associated atrophy.

Practical applications of digital tomosynthesis of the chest.

Digital tomosynthesis is a radiographic technique that generates a number of coronal raw images of a patient from a single pass of the x-ray tube. Tomosynthesis provides some of the tomographic benefits of computed tomography (CT), but at a much lower dose of radiation and cost when compared to CT. This review illustrates the range of practical applications of digital tomosynthesis of the chest.

Littoral cell angioma in a splenunculus: a case report.

Littoral cell angioma (LCA) is a rare primary splenic vascular tumour that arises from the littoral cells that line the red pulp sinuses. It is usually asymptomatic and is discovered incidentally on imaging for other pathologies. Radiologists should be aware of these lesions as they may be mistaken for malignant lesions and lead to unnecessary surgery. We present a case of LCA recurrence within a splenunculus that was discovered incidentally in a 60-year-old patient being investigated for right upper quadrant pain.

Imaging the pericardium: appearances on ECG-gated 64-detector row cardiac computed tomography.

Multidetector row computed tomography (MDCT) with its high spatial and temporal resolution has now become an established and complementary method for cardiac imaging. It can now be used reliably to exclude significant coronary artery disease and delineate complex coronary artery anomalies, and has become a valuable problem-solving tool. Our experience with MDCT imaging suggests that it is clinically useful for imaging the pericardium. It is important to be aware of the normal anatomy of the pericardium and not mistake normal variations for pathology. The pericardial recesses are visible in up to 44% of non-electrocardiogram (ECG)-gated MDCT images. Abnormalities of the pericardium can now be identified with increasing certainty on 64-detector row CT; they may be the key to diagnosis and therefore must not be overlooked. This educational review of the pericardium will cover different imaging techniques, with a significant emphasis on MDCT. We have a large research and clinical experience of ECG-gated cardiac CT and will demonstrate examples of pericardial recesses, their variations and a wide variety of pericardial abnormalities and systemic conditions affecting the pericardium. We give a brief relevant background of the conditions and reinforce the key imaging features. We aim to provide a pictorial demonstration of the wide variety of abnormalities of the pericardium and the pitfalls in the diagnosis of pericardial disease.

Pain management for unilateral orchidopexy in children: an effective regimen.

BACKGROUND: The reported high incidence of 30-60% postoperative pain after an elective day surgical orchidopexy is undesirable. We evaluated the efficacy of our analgesic regimen for unilateral orchidopexy in preschool children performed as a day surgical procedure. METHODS: Between January 2004 and December 2006, 247 children (mean age: 3.3 +/- 1.6 years) underwent a unilateral orchidopexy as a day surgical procedure. They were prospectively analyzed for postoperative pain during a period of 48 h by using the Visual Analogue Scale (VAS). After standardized general anesthesia, all children had a 0.25% levo-bupivacaine hydrochloride ilio-inguinal block and a rectal diclofenac sodium suppository. Orchidopexy was performed through transverse inguinal and scrotal incisions. The wounds were infiltrated with 0.25% levo-bupivacaine hydrochloride at the end of the operation. Postoperatively acetaminophen and ibuprofen were given orally at regular intervals for 48 h. RESULTS: On first assessment in the recovery room, 148 out of 247 (60%) patients were pain-free, and 99 of 247 (40%) patients had pain: VAS score ranged from 3 to 10. By 3 h, 27 (11%) had mild-to-moderate pain, with VAS scores between 3 and 7. All children were discharged home at 4 h with no pain. At home, 95% were pain-free at 10 h and 97% by 24 h, with a declining pain score. All children were pain-free at 32, 40, and 48 h. Pain scores were unrelated to the duration of surgery (r (s) = 0.54). CONCLUSION: Clinical effectiveness of our institution analgesic regime justifies the performance of unilateral orchidopexy as a day-case procedure.

Why do women have voiding dysfunction and de novo detrusor instability after colposuspension?

OBJECTIVE: To investigate the causes of voiding dysfunction and new detrusor instability after colposuspension. DESIGN: Prospective, observational study. SETTING: Urogynaecology unit, district general hospital. POPULATION: Seventy-seven women undergoing colposuspension for genuine stress incontinence. METHODS: The following factors were investigated: 1. bladder neck elevation by magnetic resonance imaging before and after surgery; 2. urethral compression by measuring bladder neck approximation to the pubis with magnetic resonance imaging after surgery (anterior compression) and the distance between the medial stitches during surgery (lateral compression); 3. clinical and urodynamic factors. MAIN OUTCOME MEASURES: 1. Post-operative voiding function (i.e. first day of voiding and day of catheter removal); 2. objective evidence of detrusor instability three months post-operatively. RESULTS: Pre-operative peak flow rate (P = 0.004), straining during voiding (P = 0.005), increasing age (P < 0.001), operative elevation (P < 0.001) and anterior urethral compression (P = 0.001) were associated with the number of days of post-operative catheterisation. Increasing age (P = 0.02), previous bladder neck surgery (P = 0.04), operative elevation (P = 0.049) and anterior urethral compression (P < 0.001) were associated with detrusor instability at three months. CONCLUSION: Surgical factors (bladder neck elevation and compression) are associated with voiding dysfunction and detrusor instability after colposuspension. These findings have implications for prevention.

Helicobacter pylori: from the benign to the malignant.

Half of the world's population is infected with Helicobacter pylori, making it a pathogen of potentially great significance. Although in the majority of cases, infection is harmless, many infected individuals develop peptic ulcer disease or gastric cancer. In developed countries, the prevalence of infection has decreased along with the incidences of duodenal and gastric ulcer and distal gastric cancer. In developing countries, H. pylori infection rates remain high, and, as life expectancy increases, the incidence of gastric cancer will increase. Recently, a working party of the World Health Organization designated H. pylori a class I carcinogen. This designation, along with the description of an H. pylori-infected animal model of gastric cancer, has strengthened the case for H. pylori eradication to prevent gastric cancer. However, concerns are growing that H. pylori eradication itself may cause harm. And, in developed countries, an increase in the rate of cancers arising near the gastroesophageal junction might be linked to the disappearance of H. pylori. Therefore, we are faced with a dilemma: Should we eradicate H. pylori to prevent cancer of the distal stomach, or should we leave it and hence avoid cancer of the proximal stomach or distal esophagus? The need for more reliable treatments further complicates the issue. So far, we cannot assume that current treatment regimens provide adequate eradication rates to justify widespread screening. Further research is needed to determine in whom, when, and how to eradicate H. pylori infection.

A molecular mechanism of integrin crosstalk: alphavbeta3 suppression of calcium/calmodulin-dependent protein kinase II regulates alpha5beta1 function.

Many cells express more than one integrin receptor for extracellular matrix, and in vivo these receptors may be simultaneously engaged. Ligation of one integrin may influence the behavior of others on the cell, a phenomenon we have called integrin crosstalk. Ligation of the integrin alphavbeta3 inhibits both phagocytosis and migration mediated by alpha5beta1 on the same cell, and the beta3 cytoplasmic tail is necessary and sufficient for this regulation of alpha5beta1. Ligation of alpha5beta1 activates the calcium- and calmodulin-dependent protein kinase II (CamKII). This activation is required for alpha5beta1-mediated phagocytosis and migration. Simultaneous ligation of alphavbeta3 or expression of a chimeric molecule with a free beta3 cytoplasmic tail prevents alpha5beta1-mediated activation of CamKII. Expression of a constitutively active CamKII restores alpha5beta1 functions blocked by alphavbeta3-initiated integrin crosstalk. Thus, alphavbeta3 inhibition of alpha5beta1 activation of CamKII is required for its role in integrin crosstalk. Structure-function analysis of the beta3 cytoplasmic tail demonstrates a requirement for Ser752 in beta3-mediated suppression of CamKII activation, while crosstalk is independent of Tyr747 and Tyr759, implicating Ser752, but not beta3 tyrosine phosphorylation in initiation of the alphavbeta3 signal for integrin crosstalk.

A placebo-controlled trial to assess the effects of 8 days of dosing with rabeprazole versus omeprazole on 24-h intragastric acidity and plasma gastrin concentrations in young healthy male subjects.

BACKGROUND: Rabeprazole (LY307640, E3810) is a new, potent, proton pump inhibitor. A single daily 20 mg dose significantly decreases 24-h intragastric acidity. There are no data currently available directly comparing the effect of rabeprazole on 24-h acidity with established proton pump inhibitors. AIM: To compare the effects of rabeprazole 20 mg o.m. and omeprazole 20 mg o.m. on 24-h intragastric acidity and plasma gastrin concentration in a randomized, double-blind, placebo-controlled trial, in healthy H. pylori-negative subjects. METHODS: Twenty-four healthy male volunteers, negative for H. pylori infection by serology and 13C-urea breath test, were studied on the 1st and 8th day of dosing with either placebo, rabeprazole 20 mg or omeprazole 20 mg, once each morning, in a crossover fashion. On days 1 and 8, hourly intragastric acidity was measured by gastric aspiration for 24 h from 08.00 hours. On day 8, plasma gastrin concentrations were also measured hourly from 08.00 to 24.00 hours, then every 2 h thereafter. RESULTS: A single dose of both rabeprazole and omeprazole significantly decreased 24-h intragastric acidity compared with placebo. The 24-h acidity on day 1 was significantly decreased for rabeprazole compared with omeprazole (331 vs. 640 mmol.h/L, P < 0.001), resulting in a significantly higher median 24-h intragastric pH and longer times at which intragastric pH was > 3 and > 4. On day 8 of dosing, the decrease in 24-h intragastric acidity was greater with rabeprazole than with omeprazole, but the difference was not statistically significant (160 vs. 218 mmol.h/L, P = 0.1). However, 24-h plasma gastrin concentration (1687 vs. 1085 pmol.h/L. P < 0.01) and percentage time that intragastric pH was > 3 (69 vs. 59%, P = 0.008) and > 4 (60 vs. 51%, P = 0.03) were significantly greater. CONCLUSIONS: Rabeprazole 20 mg once daily has a significantly faster onset of antisecretory activity than omeprazole 20 mg once daily. After 8 days the differences in intragastric pH > 3 and > 4 holding times persisted, but there was no significant difference in 24-h acidity.

A simple alternative technique of orchiopexy for high undescended testis.

Medial displacement of the testicular vessels constitutes an important principle for a successful operation for high undescended testis. Prentiss's manoeuvre involving division of the fascia transversalis attempts to achieve this objective but has not found favour with surgeons because it is more invasive. A simple alternative procedure of rerouting the testicular pedicle behind the fascia transversalis is described. The technique has been reported earlier and this paper aims to illustrate the steps with the help of intraoperative photographs. This method serves as a fixation procedure owing to the 'button-hole' effect of a small pathway and may be combined with other techniques of scrotal fixation such as formation of a dartos pouch and suturing.

Requirement of integrin beta3 tyrosine 747 for beta3 tyrosine phosphorylation and regulation of alphavbeta3 avidity.

Leukocytes and platelets require stimulation for optimal beta3 integrin receptor function, whereas beta3 function is constitutive in many other cells. The molecular mechanisms that enhance integrin function in stimulated hematopoietic cells are poorly understood. Phosphorylation of the beta3 cytoplasmic tail is a recently described but prevalent phenomenon, with unknown effects on alphavbeta3 function. Here, we show that mutation of the beta3 cytoplasmic tail tyrosine 747 to phenylalanine (Y747F) prevents beta3 tyrosine phosphorylation in two cell lines. Whereas this mutation has no effect on alphavbeta3-mediated adhesion in a cell with constitutive beta3 function, it completely abolishes adhesion and clot retraction by a cell that requires stimulation for beta3 function. Ligand-induced conformational change as detected by LIBS-1 antibody occurs normally in Y747F mutant alphavbeta3. Thus, tyrosine 747 of beta3 is required for stimulation of alphavbeta3-mediated adhesion, probably due to its phosphorylation. Because the motif in beta3 required for tyrosine phosphorylation is shared by several integrin beta-chains, this may be a conserved mechanism for regulation of integrin-dependent adhesion.

Avascular necrosis of bone following an intensified chemotherapy regimen including high dose steroids.

We report the imaging findings and natural history of avascular necrosis of bone (AVN) that developed following a chemotherapy regimen including high dose steroid treatment. All patients had acute lymphoblastic (ALL) or non-Hodgkin's lymphoma (NHL). Symptoms followed the high dose steroid therapy and 28 joints in eight patients were involved, (11 knees, seven hips, five shoulders and five ankles). Plain radiographs at presentation were normal in most joints, whilst bone scintigraphy and magnetic resonance imaging (MRI) were positive. We believe that the development of AVN in these patients is most likely due to the high dose dexamethasone therapy as in all eight cases symptoms followed this stage of the regimen. Patients experiencing bone or joint pains while receiving high dose steroids as part of a chemotherapy regimen could be investigated by bone scintigraphy but MRI is preferable as it is more sensitive and specific for AVN. In this series of patients multiple joints were involved and all the male patients proceeded rapidly from bone infarction to joint collapse. If the MRI appearances are typical, an early diagnosis of AVN can be made enabling therapeutic interventions to prevent joint collapse and its associated morbidity.

The treatment of Helicobacter pylori infection.

Indications for eradication of Helicobacter pylori infection have widened since the National Institutes of Health consensus conference in 1994. It is argued that they should now include infected patients with non-ulcer dyspepsia, those concerned about the risk of gastric cancer, patients with gastric lymphoma, and those requiring long-term treatment with a proton pump inhibitor. Problems with existing clinical trials are discussed, and the results of different treatment regimens are discussed. It is proposed that future eradication trials should investigate H. pylori-infected subjects identified by serology, rather than ulcer patients, and that eradication is proved only by a pair of 13C-urea breath tests.

Inducible tyrosine phosphorylation of the beta3 integrin requires the alphaV integrin cytoplasmic tail.

We have found that the integrin beta3 chain can be phosphorylated on tyrosine residues in K562 cells transfected with alphavbeta3. Tyrosine phosphorylation of the beta3 cytoplasmic tail is induced by adhesion to alphavbeta3-specific ligand or antibody or by incubation in manganese-containing buffer. Under the same conditions, beta5 does not become tyrosine-phosphorylated in K562 transfected with alphavbeta5. Phosphorylation of the beta3 subunit requires the simultaneous presence of the alphav subunit cytoplasmic tail, because neither the alphaIIb subunit nor a truncated alphav subunit is sufficient to permit phosphorylation of beta3 when coexpressed as a heterodimer with beta3. Finally, tyrosine phosphorylation of the beta3 cytoplasmic tail occurs on both human and murine beta3 and is inducible in the ovarian carcinoma OV10 as well, independent of expression of integrin-associated protein (CD47). Tyrosine phosphorylation of the beta3 integrin subunit facilitates association of Grb-2, an adaptor protein leading to activation of the Ras signaling pathway, and may contribute to the unique functional and signaling capabilities of alphavbeta3.