RESUMEN
In this study, we present an in-depth characterization of a diamond-like carbon (DLC) film, using a range of techniques to understand the structure and chemistry of the film both in the interior and particularly at the DLC/air surface and DLC/liquid interface. The DLC film is found to be a combination of sp2 and sp3 carbon, with significant oxygen present at the surface. The oxygen seems to be present as OH groups, making the DLC somewhat hydrophilic. Quartz-Crystal Microbalance (QCM) isotherms and complementary neutron reflectivity data indicate significant adsorption of a model additive, bis(2-ethylhexyl) sulfosuccinate sodium salt (AOT) surfactant, onto the DLC from water solutions and indicate the adsorbed film is a bilayer. This initial study of the structure and composition of a model surfactant is intended to give a clearer insight into how DLC and additives function as antiwear systems.
RESUMEN
BACKGROUND: Bariatric surgery is an established treatment for severe obesity; however, fewer than 1 per cent of eligible patients undergo surgery. The perceived risk of surgery may contribute to the low uptake. The aim of this study was to determine perioperative mortality associated with bariatric surgery, comparing different operation types and data sources. METHODS: A literature search of Ovid MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials was conducted to identify studies published between 1 January 2014 and 31 July 2020. Inclusion criteria were studies of at least 1000 patients reporting short-term mortality after bariatric surgery. Data were collected on RCTs. Meta-analysis was performed to establish overall mortality rates across different study types. The primary outcome measure was perioperative mortality. Different operation types were compared, along with study type, in subgroup analyses. The study was registered at PROSPERO (2019: CRD 42019131632). RESULTS: Some 4356 articles were identified and 58 met the inclusion criteria. Data were available on over 3.6 million patients. There were 4707 deaths. Pooled analysis showed an overall mortality rate of 0.08 (95 per cent c.i. 0.06 to 0.10; 95 per cent prediction interval 0 to 0.21) per cent. In subgroup analysis, there was no statistically significant difference between overall, 30-day, 90-day or in-hospital mortality (P = 0.29). There was no significant difference in reported mortality for RCTs, large studies, national databases or registries (P = 0.60). The pooled mortality rates by procedure type in ascending order were: 0.03 per cent for gastric band, 0.05 per cent for sleeve gastrectomy, 0.09 per cent for one-anastomosis gastric bypass, 0.09 per cent for Roux-en-Y gastric bypass, and 0.41 per cent for duodenal switch (P < 0.001 between operations). CONCLUSION: Bariatric surgery is safe, with low reported perioperative mortality rates.
Weight loss surgery helps patients with severe obesity. This study looked at the risk of dying after weight loss surgery in over 3.6 million patients. The risk was less than 1 in 1000 (0.08 per cent). The risk was lowest for gastric band and sleeve gastrectomy, then for gastric bypasses and highest for the duodenal switch operation. This shows that weight loss surgery is safe, with a low risk of dying similar to that of other common operations.
Asunto(s)
Cirugía Bariátrica/mortalidad , Obesidad Mórbida/cirugía , Cirugía Bariátrica/métodos , Salud Global , Humanos , Laparoscopía/mortalidad , Obesidad Mórbida/mortalidad , Obesidad Mórbida/fisiopatología , Periodo Perioperatorio , Tasa de Supervivencia/tendencias , Pérdida de Peso/fisiologíaRESUMEN
There is an increased interest in the use of natural surfactant as replacements for synthetic surfactants due to their biosustainable and biocompatible properties. A category of natural surfactants which are attracting much current interest is the triterpenoid saponins; surface active components found extensively in a wide range of plant species. A wide range of different saponin structures exist, depending upon the plant species they are extracted from; but regardless of the variation in structural details they are all highly surface active glycosides. Greater exploitation and application requires a characterisation and understanding of their basic adsorption and self-assembly properties. HYPOTHESIS: Glycyrrhizic acid, extracted from Licorice root, is a monodesmosidic triterpenoid saponin. It is widely used in cosmetic and pharmaceutical applications due to its anti-inflammatory properties, and is an ingredient in foods as a sweetener additive. It has an additional attraction due to its gel forming properties at relatively low concentrations. Although it has attracted much recent attention, many of its basic surface active characteristics, adsorption and self-assembly, remain relatively unexplored. How the structure of the Glycyrrhizic acid saponin affects its surface active properties and the impact of gelation on these properties are important considerations, and to investigate these are the focus of the study. EXPERIMENTS: In this paper the adsorption properties at the air-water interface and the self-assembly in solution have been investigated using by neutron reflectivity and small angle neutron scattering; in non-gelling and gelling conditions. FINDINGS: The adsorption isotherm is determined in water and in the presence of gelling additives, and compared with the adsorption behaviour of other saponins. Gelation has minimal impact on the adsorption; apart from producing a rougher surface with a surface texture on a macroscopic length scale. Globular micelles are formed in aqueous solution with modest anisotropy, and are compared with the structure of other saponin micelles. The addition of gelling agents results in only minimal micelle growth, and the solutions remain isotropic under applied shear flow.
Asunto(s)
Ácido Glicirrínico , Tensoactivos , Adsorción , Micelas , Propiedades de SuperficieRESUMEN
We review two different presentations of non-parasitic splenic cysts, both of which are post-traumatic in aetiology. The first case was of slower onset and was managed electively. The second case was of acute onset and was managed as an emergency. Non-parasitic splenic cysts are uncommon and the optimal management strategy for them is not well defined. Historically, treatment has been with open splenectomy; however, infection rates following this surgery have been high, making it an unattractive management option. Both cases were managed successfully with laparoscopic fenestration with no recurrence at subsequent follow-up.
Asunto(s)
Quistes/cirugía , Laparoscopía/métodos , Bazo/cirugía , Enfermedades del Bazo/cirugía , Traumatismos Abdominales/complicaciones , Adolescente , Adulto , Quistes/diagnóstico , Quistes/etiología , Humanos , Masculino , Enfermedades del Bazo/diagnóstico , Enfermedades del Bazo/etiologíaRESUMEN
Saponins are highly surface active glycosides, derived from a wide range of plant species. Their ability to produce stable foams and emulsions has stimulated their applications in beverages, foods, and cosmetics. To explore a wider range of potential applications, their surface mixing properties with conventional surfactants have been investigated. The competitive adsorption of the triterpenoid saponin escin with an anionic surfactant sodium dodecyl sulfate, SDS, at the air-water interface has been studied by neutron reflectivity, NR, and surface tension. The NR measurements, at concentrations above the mixed critical micelle concentration, demonstrate the impact of the relative surface activities of the two components. The surface mixing is highly nonideal and can be described quantitatively by the pseudophase approximation with the inclusion of the quadratic and cubic terms in the excess free energy of mixing. Hence, the surface mixing is highly asymmetrical and reflects both the electrostatic and steric contributions to the intermolecular interactions. The relative importance of the steric contribution is reinforced by the observation that the micelle mixing is even more nonideal than the surface mixing. The mixing properties result in the surface adsorption being largely dominated by the SDS over the composition and concentration range explored. The results and their interpretation provide an important insight into the wider potential for mixing saponins with more conventional surfactants.
RESUMEN
Saponins are naturally occurring biosurfactants present in a wide range of plant species. They are highly surface active glycosides, and are used to stabilise foams and emulsions in foods, beverages and cosmetics. They have great potential for an even wider range of applications, especially when mixed with different synthetic surfactants. Understanding those mixing properties are key to the exploitation of saponins in that wider range of potential applications. The surface adsorption properties of the saponin, escin, with two conventional nonionic surfactants, polyethylene glycol surfactants, have been studied at the air-water interface using neutron reflectivity, NR, and surface tension, ST. Although the saponin and polyethylene glycol, CnEOm, surfactants are both nonionic the disparity in the relative surface activities and packing constraints result in non-ideal mixing. Comparison with the predictions of the pseudo phase approximation requires the inclusion of the quadratic, cubic and quartic terms in the expansion of the excess free energy of mixing to explain the variations in the surface composition. For escin/pentaethylene glycol monododecyl ether, C12EO5, the interaction is attractive and close to ideal. For escin/octaethylene glycol monododecyl ether, C12EO8, it is repulsive and close to the criteria for demixing. The differences in mixing behaviour are attributed to greater packing constraints imposed by the larger ethylene oxide headgroup of the C12EO8 compared to C12EO5.
Asunto(s)
Saponinas/química , Tensoactivos/química , Adsorción , Aire , Conformación Molecular , Tamaño de la Partícula , Propiedades de Superficie , Agua/químicaRESUMEN
OBJECTIVE: The objective of this study is to systematically assess the quality of existing patient-reported outcome measures developed and/or validated for Quality of Life measurement in bariatric surgery (BS) and body contouring surgery (BCS). METHODS: We conducted a systematic literature search in PubMed, EMBASE, PsycINFO, CINAHL, Cochrane Database Systematic Reviews and CENTRAL identifying studies on measurement properties of BS and BCS Quality of Life instruments. For all eligible studies, we evaluated the methodological quality of the studies by using the COnsensus-based Standards for the selection of health Measurement INstruments checklist and the quality of the measurement instruments by applying quality criteria. Four degrees of recommendation were assigned to validated instruments (A-D). RESULTS: Out of 4,354 articles, a total of 26 articles describing 24 instruments were included. No instrument met all requirements (category A). Seven instruments have the potential to be recommended depending on further validation studies (category B). Of these seven, the BODY-Q has the strongest evidence for content validity in BS and BCS. Two instruments had poor quality in at least one required quality criterion (category C). Fifteen instruments were minimally validated (category D). CONCLUSION: The BODY-Q, developed for BS and BCS, possessed the strongest evidence for quality of measurement properties and has the potential to be recommended in future clinical trials.
Asunto(s)
Cirugía Bariátrica/psicología , Contorneado Corporal/psicología , Obesidad/cirugía , Calidad de Vida/psicología , Humanos , Obesidad/psicología , Evaluación de Resultado en la Atención de Salud , Reproducibilidad de los ResultadosRESUMEN
The challenge of managing the epidemic of patients with severe and complex obesity disease in secondary care is largely unmet. In England, the National Institute of Health and Care Excellence and the National Health Service England have published guidance on the provision of specialist (non-surgical) weight management services. We have undertaken a systematic review of 'what evidence exists for what should happen in/commissioning of: primary or secondary care weight assessment and management clinics in patients needing specialist care for severe and complex obesity?' using an accredited methodology to produce a model for organization of multidisciplinary team clinics that could be developed in every healthcare system, as an update to a previous review. Additions to the previous guidance were multidisciplinary team pathways for children/adolescent patients and their transition to adult care, anaesthetic assessment and recommendations for ongoing shared care with general practitioners, as a chronic disease management pathway.
Asunto(s)
Peso Corporal , Manejo de la Enfermedad , Obesidad Mórbida/terapia , Obesidad Infantil/terapia , Adulto , Cirugía Bariátrica , Niño , Atención a la Salud/normas , Dieta , Inglaterra , Guías como Asunto , Humanos , Metaanálisis como Asunto , Programas Nacionales de Salud/normas , Ensayos Clínicos Controlados Aleatorios como AsuntoRESUMEN
BACKGROUND: Recruitment into surgical RCTs can be threatened if new interventions available outside the trial compete with those being evaluated. Adapting the trial to include the new intervention may overcome this issue, yet this is not often done in surgery. This paper describes the challenges, rationale and methods for adapting an RCT to include a new intervention. METHODS: The By-Band study was designed in the UK in 2009-2010 to compare the effectiveness of laparoscopic adjustable gastric band and Roux-en-Y gastric bypass for severe obesity. It contained a pilot phase to establish whether recruitment was possible, and the grant proposal specified that an adaptation to include sleeve gastrectomy would be considered if practice changed and recruitment was successful. Information on changing obesity surgery practice, updated evidence and expert opinion about trial design were used to inform the adaptation. RESULTS: The pilot phase recruited over 13 months in 2013-2014 and randomized 80 patients (79 anticipated). During this time, major changes in obesity practice in the UK were observed, with gastric band reducing from 32·6 to 15·8 per cent and sleeve gastrectomy increasing from 9·0 to 28·1 per cent. The evidence base had not changed markedly. The British Obesity and Metabolic Surgery Society and study oversight committees supported an adaptation to include sleeve gastrectomy, and a proposal to do so was approved by the funder. CONCLUSION: Adaptation of a two-group surgical RCT can allow evaluation of a third procedure and maintain relevance of the RCT to practice. It also optimizes the use of existing trial infrastructure to answer an additional important research question. Registration number: ISRCTN00786323 (http://www.isrctn.com/).
Asunto(s)
Derivación Gástrica/métodos , Gastroplastia/métodos , Obesidad Mórbida/cirugía , Ensayos Clínicos Controlados Aleatorios como Asunto/métodos , Atención a la Salud/métodos , Derivación Gástrica/estadística & datos numéricos , Gastroplastia/estadística & datos numéricos , Humanos , Selección de Paciente , Proyectos Piloto , Pautas de la Práctica en Medicina/tendenciasRESUMEN
BACKGROUND: Randomized controlled trials (RCTs) involving surgical procedures are challenging for recruitment and infrequent in the specialty of bariatrics. The pilot phase of the By-Band-Sleeve study (gastric bypass versus gastric band versus sleeve gastrectomy) provided the opportunity for an investigation of recruitment using a qualitative research integrated in trials (QuinteT) recruitment intervention (QRI). PATIENTS/METHODS: The QRI investigated recruitment in two centers in the pilot phase comparing bypass and banding, through the analysis of 12 in-depth staff interviews, 84 audio recordings of patient consultations, 19 non-participant observations of consultations and patient screening data. QRI findings were developed into a plan of action and fed back to centers to improve information provision and recruitment organization. RESULTS: Recruitment proved to be extremely difficult with only two patients recruited during the first 2 months. The pivotal issue in Center A was that an effective and established clinical service could not easily adapt to the needs of the RCT. There was little scope to present RCT details or ensure efficient eligibility assessment, and recruiters struggled to convey equipoise. Following presentation of QRI findings, recruitment in Center A increased from 9% in the first 2 months (2/22) to 40% (26/65) in the 4 months thereafter. Center B, commencing recruitment 3 months after Center A, learnt from the emerging issues in Center A and set up a special clinic for trial recruitment. The trial successfully completed pilot recruitment and progressed to the main phase across 11 centers. CONCLUSIONS: The QRI identified key issues that enabled the integration of the trial into the clinical setting. This contributed to successful recruitment in the By-Band-Sleeve trial-currently the largest in bariatric practice-and offers opportunities to optimize recruitment in other trials in bariatrics.
Asunto(s)
Derivación Gástrica , Gastroplastia , Obesidad Mórbida/cirugía , Selección de Paciente , Ensayos Clínicos Controlados Aleatorios como Asunto/métodos , Humanos , Proyectos Piloto , Investigación CualitativaRESUMEN
BACKGROUND: Bariatric surgery is an accepted treatment option for severe obesity. Previous analysis of the independently collected Hospital Episode Statistics (HES) data for outcomes after bariatric surgery demonstrated a 30-day postoperative mortality rate of 0·3 per cent in the English National Health Service (NHS). However, there have been no published mortality data for bariatric procedures performed since 2008. This study aimed to assess mortality related to bariatric surgery in England from 2009. METHODS: HES data were used to identify all patients who had primary bariatric surgery from 2009 to 2016. Clinical codes were used selectively to identify all primary bariatric procedures but exclude revision or conversion procedures and operations for malignant or other benign disease. The primary outcome measures were HES in-hospital and Office for National Statistics (ONS) 30-day mortality after discharge. RESULTS: A total of 41 241 primary bariatric procedures were carried out in the NHS between 2009 and 2016, with 29 in-hospital deaths (0·07 per cent). The 30-day mortality rate after discharge was 0·08 per cent (32 of 41 241). Both the in-hospital and 30-day mortality rates after discharge demonstrated a downward trend over the study period. CONCLUSION: Overall in-hospital and 30-day mortality rates remain very low after primary bariatric surgery. An increased uptake of bariatric surgery within the English NHS has been safe.
RESUMEN
A detailed comparison of the adsorption behavior of long straight chain saturated and unsaturated fatty acids at the iron oxide/oil interface has been considered using a combination of surface study techniques. Both depletion isotherms and polarized neutron reflectometry (PNR) show that the extent of adsorption decreases as the number of double bonds in the alkyl chains increases. Sum frequency generation spectroscopic measurements demonstrate that there is also an increase in chain disorder within the adsorbed layer as the unsaturation increases. However, for the unsaturated analogues, a decrease in peak intensity is seen for the double bond peak upon heating, which is thought to arise from isomerization in the surface-bound layer. The PNR study of oleic acid adsorption indicates chemisorbed monolayer adsorption, with a further diffuse reversible adsorbed layer formed at higher concentrations.
Asunto(s)
Alcanos/química , Compuestos Férricos/química , Ácido Linoleico/química , Ácido Oléico/química , Ácidos Esteáricos/química , Adsorción , Cinética , Propiedades de Superficie , TermodinámicaRESUMEN
Outcome reporting in bariatric surgery needs a core outcome set (COS), an agreed minimum set of outcomes reported in all studies of a particular condition. The aim of this study was to summarize outcome reporting in bariatric surgery to inform the development of a COS. Outcomes reported in randomized controlled trials (RCTs) and large non-randomized studies identified by a systematic review were listed verbatim and categorized into domains, scrutinizing the frequency of outcome reporting and uniformity of definitions. Ninety studies (39 RCTs) identified 1,088 separate outcomes, grouped into nine domains with most (n = 920, 85%) reported only once. The largest outcome domain was 'surgical complications', and overall, 42% of outcomes corresponded to a theme of 'adverse events'. Only a quarter of outcomes were defined, and where provided definitions, which were often contradictory. Percentage of excess weight loss was the main study outcome in 49 studies, but nearly 40% of weight loss outcomes were heterogeneous, thus not comparable. Outcomes of diverse bariatric operations focus largely on adverse events. Reporting is inconsistent and ill-defined, limiting interpretation and comparison of published studies. Thus, we propose and are developing a COS for the surgical treatment of severe and complex obesity.
Asunto(s)
Cirugía Bariátrica , Obesidad Mórbida/cirugía , Pérdida de Peso , Humanos , Evaluación del Resultado de la Atención al Paciente , Ensayos Clínicos Controlados Aleatorios como Asunto , Resultado del TratamientoRESUMEN
Bariatric surgery is increasingly being used to treat severe obesity, but little is known about its impact on patient-reported outcomes (PROs). For PRO data to influence practice, well-designed and reported studies are required. A systematic review identified prospective bariatric surgery studies that used validated PRO measures. Risk of bias in randomized controlled trials (RCTs) was assessed, and papers were examined for reporting of (i) who completed PRO measures; (ii) missing PRO data and (iii) clinical interpretation of PRO data. Studies meeting all criteria were classified as robust. Eighty-six studies were identified. Of the eight RCTs, risk of bias was high in one and unclear in seven. Sixty-eight different PRO measures were identified, with the Short Form (SF)-36 questionnaire most commonly used. Forty-one (48%) studies explicitly stated measures were completed by patients, 63 (73%) documented missing PRO data and 50 (58%) interpreted PRO data clinically. Twenty-six (30%) met all criteria. Although many bariatric surgery studies assess PROs, study design and reporting is often poor, limiting data interpretation and synthesis. Well-designed studies that include agreed PRO measures are needed with reporting to include integration with clinical outcomes to inform practice.
Asunto(s)
Cirugía Bariátrica , Obesidad Mórbida/cirugía , Evaluación de Resultado en la Atención de Salud/estadística & datos numéricos , Autoinforme/normas , Cirugía Bariátrica/estadística & datos numéricos , Humanos , Estudios Prospectivos , Ensayos Clínicos Controlados Aleatorios como Asunto , Resultado del TratamientoRESUMEN
BACKGROUND: The American Diabetes Association recently defined remission of type II diabetes as a return to normal measures of glucose metabolism (haemoglobin (Hb) A1c below 6 per cent, fasting glucose less than 5·6 mmol/l) at least 1 year after bariatric surgery without hypoglycaemic medication. A previously used common definition was: being off diabetes medication with normal fasting blood glucose level or HbA1c below 6 per cent. This study evaluated the proportion of patients achieving complete remission of type II diabetes following bariatric surgery according to these definitions. METHODS: This was a retrospective review of data collected prospectively in three bariatric centres on patients undergoing gastric bypass, sleeve gastrectomy and gastric banding. RESULTS: Some 1006 patients underwent surgery, of whom 209 had type II diabetes. Median follow-up was 23 (range 12-75) months. HbA1c was reduced after operation in all three surgical groups (P < 0·001). A total of 72 (34·4 per cent) of 209 patients had complete remission of diabetes, according to the new definition; the remission rates were 40·6 per cent (65 of 160) after gastric bypass, 26 per cent (5 of 19) after sleeve gastrectomy and 7 per cent (2 of 30) after gastric banding (P < 0·001 between groups). The remission rate for gastric bypass was significantly lower with the new definition than with the previously used definition (40·6 versus 57·5 per cent; P = 0·003). CONCLUSION: Expectations of patients and clinicians may have to be adjusted as regards remission of type II diabetes after bariatric surgery. Focusing on improved glycaemic control rather than remission may better reflect the benefit of this type of surgery and facilitate improved glycaemic control after surgery.
Asunto(s)
Glucemia/metabolismo , Diabetes Mellitus Tipo 2/sangre , Diabetes Mellitus Tipo 2/diagnóstico , Gastrectomía , Derivación Gástrica , Gastroplastia , Hemoglobina Glucada/metabolismo , Adulto , Anciano , Biomarcadores/sangre , Diabetes Mellitus Tipo 2/tratamiento farmacológico , Diabetes Mellitus Tipo 2/epidemiología , Femenino , Gastrectomía/métodos , Derivación Gástrica/métodos , Gastroplastia/métodos , Humanos , Hipoglucemiantes/administración & dosificación , Insulina/sangre , Masculino , Persona de Mediana Edad , Noruega/epidemiología , Estudios Prospectivos , Estudios Retrospectivos , Factores de Tiempo , Resultado del Tratamiento , Reino Unido/epidemiologíaRESUMEN
BACKGROUND: Bile acids can act as signalling molecules via various receptors including the nuclear farnesoid X receptor (FXR) and pregnane X receptor (PXR), and the cell surface G-protein-coupled receptor TGR5. The signalling has been implicated in the release of peptide YY (PYY) and glucagon-like peptide 1 (GLP-1), which improves glycaemic control and energy expenditure. We investigated whether morbidly obese subjects have altered postprandial bile acid responses in comparison to normal weight subjects. METHOD: Blood samples were taken every 30 min from 0 to 180 min following a 400 kcal test meal. Samples were taken from 12 normal weight subjects with a body mass index (BMI) of 23.2 (2.8) kg/m(2) (median [interquartile range (IQR)]) and seven obese patients with a BMI of 47.2 (7.2) kg/m(2). Fractionated bile acids were measured on these samples using high-performance liquid chromatography tandem mass spectrometry. RESULTS: The obese subjects showed a lower postprandial response in total bile acids compared with the normal weight subjects. An increase of 6.4 (5.0) and 2.6 (3.3) micromol/L (median [IQR]) in normal weight and obese subjects was observed, respectively (P = 0.02). The difference was predominantly due to the glycine-conjugated fraction (P = 0.03). There was no difference in the increase of the unconjugated or taurine-conjugated fractions. CONCLUSIONS: The decreased postprandial bile acid response in obese subjects compared with normal weight subjects may partly explain the suboptimal GLP-1 and PYY responses and could affect appetite, glycaemic control and energy expenditure.
Asunto(s)
Ácidos y Sales Biliares/sangre , Peso Corporal , Obesidad/sangre , Obesidad/fisiopatología , Periodo Posprandial , Ácidos y Sales Biliares/metabolismo , Estudios de Casos y Controles , Femenino , Humanos , Masculino , Persona de Mediana Edad , Obesidad/metabolismo , Adulto JovenRESUMEN
OBJECTIVE: We established a fast-track flexible sigmoidoscopy service to meet the two-week target for colorectal cancer, and have performed a prospective observational study over three years to assess its impact on the proportion of patients with colorectal cancer presenting as an emergency. METHODS: The fast-track system was established on 1 November 1999 using six screening criteria to select high-risk patients. Data on all high-risk patients referred through the fast-track system and all patients diagnosed with colorectal cancer were recorded prospectively in two time periods: six months before fast-track (1 November 1998 to 30 April 1999, Period 1) and three years following fast-track (1 November 1999 to 31 October 2002, Period 2). RESULTS: In Period 2, 2294 fast-track referrals were received. A total of 635 cases (321 male, 314 female) of colorectal cancer were diagnosed in Period 2 vs. 84 cases (43 male, 41 female) in Period 1. In Period 1, 30 patients with colorectal cancer (35.7% of the total) presented as an emergency vs. 165 patients (25.9%) in Period 2 (P = 0.059, chi(2)test). CONCLUSION: Introduction of a fast-track service to meet the two-week target has resulted in a trend towards fewer emergency presentations with colorectal cancer.
Asunto(s)
Citas y Horarios , Neoplasias Colorrectales/diagnóstico , Sigmoidoscopía/métodos , Urgencias Médicas , Femenino , Hospitales Generales/estadística & datos numéricos , Humanos , Masculino , Admisión del Paciente/estadística & datos numéricos , Estudios Prospectivos , Derivación y Consulta/estadística & datos numéricos , Factores de Tiempo , Reino Unido/epidemiologíaRESUMEN
OBJECTIVE: This prospective study assesses the introduction of a fast-track referral system for patients with suspected colorectal cancer. PATIENTS AND METHODS: The referral system was initiated in Yeovil District Hospital and Taunton and Somerset Hospital using six screening criteria to select high-risk patients. Data on all high-risk patients from 1 November 1999 to 30 April 2000 was recorded prospectively. Patients with proven colorectal cancer diagnosed between 1 November 1998 and 30 April 1999 have been identified for comparison. RESULTS: There were 158 new cases of colorectal cancer in total (111 elective, 47 emergency). 59 cases of colorectal cancer were diagnosed from 433 fast-track referrals (53% of total elective cases). Median time from referral to diagnosis in the fast-track group was 11 days vs. 32.5 days for nonfast-track elective patients (P < 0.001). Median time from referral to diagnosis for all elective cases was 17 days vs. 38.5 days for patients presenting one year earlier (P < 0.001). 75% of fast-track patients were diagnosed with colorectal cancer within two weeks, compared with 17% of nonfast-track elective patients (P < 0.001). The proportion of emergency admissions was reduced from 40% to 30% (P=0.07) following the introduction of this system. CONCLUSION: Data from the first six months reveal that over half of the elective cases of colorectal cancer were diagnosed within the fast-track system. The median time from referral to diagnosis in these patients was within two weeks and there has been a significant reduction in the time to diagnosis associated with the introduction of this service.
RESUMEN
Endocrine surgery includes excision of diseased or sometimes normal endocrine glands and occasionally the transplantation of endocrine tissues. Male castration was performed for social reasons in prehistoric times, and thyroid operations were described during the twelfth century. Until the end of the nineteenth century most operations were undertaken to relieve the local effects of pathologic enlargement of the thyroid, ovaries, pituitary, and adrenals; and with the development of anesthesia, antisepsis, and effective hemostasis, thyroidectomy for benign, nontoxic goiter was perfected. Thyroid deficiency followed total thyroidectomy, and thyroid replacement therapy was developed. Toxic goiter was sometimes relieved by partial thyroidectomy. After the discovery of hormones early this century, knowledge of endocrinology increased, and many syndromes of hormonal excess were described. Surgeons began to operate to relieve them. Results improved with mastery of surgical technique, especially for operations on the thyroid, parathyroids, and pituitary; with the development of methods for diagnosis of syndromes and the localization of lesions; with teamwork; and with the use of hormones, drugs, and radiotherapy as alternative or additional forms of therapy before, during, and after operation. Notable advances followed adequate resection of thyroid tissue and the use of iodine and antithyroid drugs before operation for toxic goiter. The use of cortisone rendered adrenalectomy safe for the relief of cancer of the breast and prostate and of Cushing's syndrome. For about 40 years increasing numbers of surgeons have specialized in endocrine surgery as a discipline within general surgery, and results of treatment have improved greatly.
Asunto(s)
Endocrinología/historia , Cirugía General/historia , Europa (Continente) , Femenino , Historia del Siglo XVIII , Historia del Siglo XIX , Historia del Siglo XX , Humanos , Masculino , Estados UnidosRESUMEN
BACKGROUND: Acid aspiration leads to lung polymorphonuclear neutrophil (PMN) sequestration and an associated increase in permeability. Although it is known that the neutrophil adhesion receptor (CD18) plays no role in determining PMN accumulations in the region aspirated, we postulated that this PMN adhesion receptor and its endothelial ligand, intercellular adhesion molecule-1 (ICAM-1), mediate remote neutrophil sequestration. METHODS: Anesthetized rabbits underwent localized aspiration of either 0.1N HCl 0.1 ml/kg (n = 18) or saline solution (n = 18). RESULTS: After 30 minutes leukopenia was noted, 2290 +/- 200 white blood cells/mm3 (p < 0.05). At 3 hours diapedesis occurred in the aspirated segment with accumulations in bronchoalveolar lavage fluid (X10(4)) of 87 +/- 6 PMN/ml versus control of 6 +/- 1 PMN/ml (p < 0.05). Histologic evidence of generalized lung leukosequestration occurred. The wet to dry weight ratio of the nonaspirated lung rose to 5.7 +/- 0.2 versus control of 3.9 +/- 0.1 (p < 0.05). Treatment (n = 18) with the CD18 monoclonal antibody (mAb) (R15.7, 1 mg/kg) had no effect on neutrophil accumulations in the aspirated segment. However, the mAb attenuated the remote inflammatory response: early leukopenia (5790 +/- 400 white blood cells/mm3); lung leukosequestration (24 +/- 4 PMN/10 high-power fields); protein leak in bronchoalveolar lavage fluid (570 +/- 50 micrograms/ml); and edema, wet to dry weight ratio (4.9 +/- 0.1) (all p < 0.05). Treatment with the ICAM-1 mAb (RR1/1, 1 mg/kg) (n = 9) did not reduce neutrophil accumulations in the aspirated segment but limited the remote inflammatory response. CONCLUSIONS: Acid aspiration leads to neutrophil adhesion and edema in regions remote from those aspirated via neutrophil CD18 and endothelial ICAM-1.