A two-consultant approach is a safe and efficient strategy to adopt during the learning curve for laparoscopic Roux-en-Y gastric bypass: our results in the first 100 procedures.

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (LRYGBP) can be technically challenging. It is imperative that patient morbidity and mortality are minimized while teams are on the learning curve for this procedure. METHODS: This retrospective study evaluated the peri-operative risk of LRYGBP utilizing a two-consultant surgeon approach in a newly established bariatric service. 100 consecutive patients undergoing LRYGBP were included. Two consultants participated in each procedure. RESULTS: Median operative duration was 113 minutes (range 80-240) and fell with increasing experience [127 minutes (range 90-240) in cases 1-50 and 105 minutes (range 80-210) in cases 51-100; P=0.009]. Multivariate analysis found operation time correlated only with number of procedures performed (P<0.001). There were no conversions to laparotomy. Intra-operatively, 2 patients had hand-assisted completion of the jejuno-jejunostomy, and 2 underwent laparoscopic revision of the reconstruction. Postoperative complications were observed in 8 patients on the operative admission. Median stay was 4 days (range 3-7). 4 patients required readmission. There was no mortality. Percentage of excess BMI loss was 47%, 53% and 70% at 3, 6 and 12 months respectively. CONCLUSION: A learning curve for LRYGBP is evidenced in this series by reduction in operative time with increasing experience. Complication rates in line with large published series can be achieved by adopting a two-surgeon approach, which we propose as a safe method to adopt in the development of new bariatric services.

Steroids in Duchenne muscular dystrophy; pilot study of a new low-dosage schedule.

Prednisolone has been shown to improve strength in Duchenne dystrophy, the improvement starting within 10 days of treatment and reaching a maximum by 3 months, and then plateauing. Unfortunately this has been associated with an unacceptably high level of side effects. In an attempt to obtain the benefit of steroids without the side effects we devised an intermittent low dosage schedule, with 0.75 mg kg-1 day-1 for 10 days at the beginning of each calendar month. To date 32 boys with Duchenne dystrophy have been enrolled into an open randomized trial. Preliminary data show an influence on strength at 6 months but a slow decline at 12 and 18 months. The weight gain and other side effects have been much less than with continuous therapy.

Deficiency of the 50 kDa dystrophin-associated glycoprotein and abnormal expression of utrophin in two south Asian cousins with variable expression of severe childhood autosomal recessive muscular dystrophy.

Two male cousins with severe childhood, autosomal recessive, Duchenne-like, muscular dystrophy (SCARMD) have been identified with a deficiency of the 50 kDa dystrophin-associated glycoprotein but normal expression of dystrophin. Both boys were from consanguineous marriages and were Asian, having originated from Pakistan. This is in contrast to all previously reported cases from North Africa. Clinical severity varied and the patients were still able to walk at 13 and 12 yr, respectively. Neither had calf hypertrophy, a feature reported to be almost consistent in the North African patients. Abnormal expression of utrophin, the dystrophin-related protein, was observed on the surface of several non-regenerating muscle fibres, with less intense immunolabelling in the clinically more affected child. This family shows that SCARMD is not confined to North Africa and illustrates a hitherto unreported expression of utrophin in this condition.

Manifesting carriers of Xp21 muscular dystrophy; lack of correlation between dystrophin expression and clinical weakness.

Ten females presenting with muscle weakness and a raised serum creatine kinase revealed abnormalities in the expression of dystrophin in their muscle biopsies and were diagnosed as manifesting carriers of Xp21 Duchenne/Becker muscular dystrophy. Seven cases, aged 3-22 yr at the time of biopsy, had a variable proportion of dystrophin-deficient fibres and an abnormal expression on immunoblot. These were confidently diagnosed as manifesting carriers. Results in the remaining three cases, aged 8-10 yr, were less clear-cut. Dystrophin expression on immunoblots was slightly reduced and some unevenness and reduction of immunolabelling was seen on sections, but dystrophin-deficient fibres were not a feature of these cases. The weakness in the ten carriers ranged from minimal to severe and there was no correlation between the degree of weakness and the number of dystrophin-deficient fibres. Two minimally weak girls had a high proportion of dystrophin-deficient fibres. Our results show that analysis of dystrophin expression is useful for the differential diagnosis of carriers of Xp21 dystrophy and autosomal muscular dystrophy, but that dystrophin expression does not correlate directly with the degree of clinical weakness.

Detection of Corynebacterium equi-specific antibody in horses by enzyme-linked immunosorbent assay.

An enzyme-linked immunosorbant assay was developed to measure naturally occurring Corynebacterium equi specific antibody in horse serum. Antibody against C equi was demonstrated in normal adults and was passively transferred to foals. Adult levels of specific antibody were reached by 5 to 6 months of age in healthy foals. Decreased early antibody levels were demonstrated in a limited number of foals with confirmed C equi infection.

The anaesthetic management of a woman with a 31-week abdominal pregnancy.

An 18-year-old primigravida was admitted to hospital complaining of abdominal pain and vomiting. An ultrasound examination suggested the diagnosis of advanced abdominal pregnancy and this was confirmed using magnetic resonance imaging. Two days later she underwent operative delivery of a live fetus. The placenta was left in situ as it was attached to a large number of pelvic structures. Such surgery can result in maternal death due to massive haemorrhage as there is no mechanism to stem blood loss from the placental bed. Death can also occur in the post-partum period from septic complications if the placenta is left in situ. The management of such patients requires personnel and equipment to deal with massive and rapid haemorrhage; aortic cross clamping may be required to control bleeding. In this case, surgery and recovery were uneventful.

An unusual presentation of meningitis as a consequence of inadvertent dural puncture.

Bacterial meningitis and aseptic meningitis have been reported as a consequence of spinal anaesthesia. The case we report is of an unusual presentation of meningitis, for which no cause was found, in a patient who received epidural anaesthesia, complicated by dural puncture.

Intravenous immunoglobulin in juvenile dermatomyositis--four year review of nine cases.

Juvenile dermatomyositis is difficult to treat, compounded by complications of the disease itself as well as side effects of treatment. The mainstay of pharmacological management is corticosteroids, to which the disease is usually very responsive, but steroids have well established short and long term side effects. Refractory cases may be resistant to steroids or patients may become dependent on high doses, with relapse in clinical disease precipitated by reduction. Overtreatment with steroids and too rapid a reduction are common errors. Various second line agents have been used with success in complex or refractory cases, including cyclophosphamide, methotrexate, and cyclosporin. Intravenous immunoglobulin has been tried in the management of autoimmune diseases, either as an alternative to cytotoxic treatment or as a steroid sparing agent. The reported benefit in a number of childhood illnesses, including juvenile dermatomyositis, prompted this clinical trial in some of our more refractory cases. Over the past four years, nine children attending a dermatomyositis clinic have been treated with intravenous immunoglobulin. The two main indications were failure of conventional treatment and severe side effects from previous treatment, principally corticosteroids. All nine were still on treatment with various permutations of prednisolone, azathioprine, and cyclosporin. All nine showed clinical improvement at some point in their treatment with intravenous immunoglobulin. Of eight children on concurrent prednisolone, the dose could be reduced in six and kept the same in two.

Acute infective airway obstruction associated with subglottic stenosis.

Pre-existing subglottic stenosis in a 22-month-old child with laryngotracheobronchitis resulted in failure to intubate the trachea on the intensive therapy unit. Tracheostomy was necessary in the operating theatre to secure the airway. The implications for safe management are discussed.

A modified expiratory valve for teaching.

The shrouding of anaesthetic expiratory valves prevents the anaesthetist from either seeing valve disc movement or hearing clearly the escape of gas during expiration. A modification to one type of valve (Medishield II) is described which replaces this lost information by providing a direct indication of valve opening.

A new dual function nerve stimulator.

The Duostim model TV02 is a new peripheral nerve stimulator designed both for nerve identification in the performance of regional anaesthesia and for monitoring neuromuscular blockade. The output pulses are unipolar and of adjustable constant current. The provision of single twitch (1 Hz and 1/15 Hz) train-of-four and tetanic stimuli, together with indication of the current delivered and the small size of the unit, facilitate its clinical use. Performance was assessed and found to be according to specification.

The recruitment and training crisis in community paediatrics: what do registrars think?

OBJECTIVE: There is currently a crisis in the recruitment of trainees into community paediatrics. Focus groups were conducted to explore the views of paediatric specialist registrars about this crisis. DESIGN: A total of 18 registrars participated in two focus groups. Data were analysed qualitatively by content analysis. RESULTS: The overriding theme was the poor status and image of community compared with acute paediatrics. This existed at five levels, which could be arranged from a 'macro' structural level down to a 'micro' individual level. These were: the hospital/community divide, issues related to training, practical experience, the influence of role models, and personal factors. CONCLUSIONS: We identified several specific implications for community paediatric training. However, the deep divide between acute and community paediatrics, as perceived by registrars, is unlikely to change unless training programmes are designed to produce paediatricians suited to the needs of future child health services rather than existing models of acute and community paediatricians.

Multiple-choice examinations: adopting an evidence-based approach to exam technique.

Negatively marked multiple-choice questions (MCQs) are part of the assessment process in both the Primary and Final examinations for the fellowship of the Royal College of Anaesthetists. It is said that candidates who guess will lose marks in the MCQ paper. We studied candidates attending a pre-examination revision course and have shown that an evaluation of examination technique is an important part of an individual's preparation. All candidates benefited substantially from backing their educated guesses while only 3 out of 27 lost marks from backing their wild guesses. Failure to appreciate the relationship between knowledge and technique may significantly affect a candidate's performance in the examination.