Artificial neural networks: useful aid in diagnosing acute appendicitis.

BACKGROUND: [corrected] The purpose of the study was to assess the role of artificial neural networks (ANNs) in the diagnosis of appendicitis in patients presenting with acute right iliac fossa (RIF) pain and comparing its performance with the assessment made by experienced clinicians and the Alvarado score. METHODS: After training and testing an ANN, data from 60 patients presenting with suspected appendicitis over a 6-month period to a teaching hospital was collected prospectively. Accuracy of diagnosing appendicitis by the clinician, the Alvarado score, and the ANN was compared. RESULTS: The sensitivity, specificity, and positive and negative predictive values of the ANN were 100%, 97.2%, 96.0%, and 100% respectively. The ability of the ANN to exclude accurately the diagnosis of appendicitis in patients without true appendicitis was statistically significant compared to the clinical performance (p=0.031) and Alvarado score of >or=6 (p=0.004) and nearly significant compared to the Alvarado score of >or=7 (p=0.063). CONCLUSIONS: ANNs can be an effective tool for accurately diagnosing appendicitis and may reduce unnecessary appendectomies.

Long-term pharmacotherapy of obesity 2000: a review of efficacy and safety.

To clarify the efficacy of antiobesity drugs, this article reviews all long-term (> or =36 weeks), placebo-controlled trials of obesity pharmacotherapy published since 1960. Since fears of anorexiant-induced heart valve damage preclude many physicians and patients from even considering antiobesity drugs, this area is also reviewed in-depth. Electronic database and manual bibliography search was used to identify all relevant publications. While existing studies are too few and heterogeneous to warrant meta-analysis, their review does provide evidence highly relevant to the safety and efficacy of available anorexiants. Weight loss attributable to obesity pharmacotherapy (ie, in excess of placebo) in trials lasting 36 to 52 weeks was 8.1% or 7.9 kg for those receiving phentermine resin, 5.0 % or 4.3 kg for those receiving sibutramine hydrochloride, 3.4% or 3.4 kg for those receiving orlistat, and -1.5% or -1.5 kg for those receiving diethylpropion hydrochloride. Physiologic, pathologic, and epidemiological studies strongly support that anorexiant-induced valvulopathy is attributable to specific serotonergic properties of the fenfluramines that are not present with available weight loss drugs.

Neutrophil activation and hyperamylasaemia after endoscopic retrograde cholangiopancreatography: potential role for the leukocyte in the pathogenesis of acute pancreatitis.

BACKGROUND AND STUDY AIMS: Hyperamylasaemia occurs in up to 60% of patients following endoscopic retrograde cholangiopancreatography (ERCP), and in a small proportion of patients (1-5%) acute pancreatitis may develop. We evaluated the role of the neutrophil in post-ERCP hyperamylasaemia and acute pancreatitis by measuring circulating CD11b adhesion receptor expression--an indicator of leukocyte activation. PATIENTS AND METHODS: A total of 43 patients undergoing elective ERCP were studied. Peripheral blood measurements of amylase activity and neutrophil CD11b content (by flow cytometry) were made immediately before ERCP (baseline), and at 2 and 24 hours after the procedure. RESULTS: ERCP induced an increase in amylase level above baseline in 41 of 43 patients. The 2-hour and 24-hour post-ERCP amylase levels were directly related (R = 0.9, P < 0.01). Baseline CD11b receptor status was positively correlated with post-ERCP amylase activity (R = 0.4, P < 0.05), and this relationship was stronger when pancreatography had been performed (R = 0.67, P < 0.01). Three patients (7%) developed clinical acute pancreatitis, with post-ERCP amylase levels persistently elevated above 1000 IU/l. Multiple linear regression identified CD11b expression as the most significant explanatory variable for amylase level after ERCP (multiple R = 0.74, P < 0.01). CONCLUSIONS: The findings from this pilot study indicate an association between neutrophil activation and hyperamylasaemia following ERCP, and suggest a role for this leukocyte in the pathogenesis of pancreatitis. Further study of neutrophil characteristics may allow identification of individual susceptibility to ERCP-induced pancreatic injury.

Nursing interventions revisited.

Medication administration is one of the most highly contested tasks delegated by registered nurses to others. Readers are encouraged to complete this brief survey asking about which nursing interventions must be performed by an RN versus those that can be safely delegated.

Elevated tumour marker CA19-9: clinical interpretation and influence of obstructive jaundice.

AIMS: The tumour marker CA19-9 has been promoted as a reliable test for the detection of pancreatobiliary malignancy, yet its diagnostic role remains poorly defined. In this study the clinical interpretation of a raised serum CA19-9 level has been evaluated, with particular reference to obstructive jaundice. METHODS: One hundred and sixty-four patients with a CA19-9 level above 33 U/ml were studied. Serum CA19-9 was compared with clinical diagnosis and correlated with serum bilirubin level. In a subgroup of jaundiced patients (16 benign and 15 malignant cases), follow-up CA19-9 levels were determined 2 weeks after biliary drainage. RESULTS: The median CA19-9 level was lower in benign cases (102 (IQR 50-264) U/ml) than those with pancreatobiliary tumours (910 (IQR 263-6170) U/ml; P<0.01), although the overlap was substantial. In benign jaundiced cases, a positive correlation was observed between bilirubin and CA19-9 elevation (R=0.41, P<0.01). Relief of jaundice was associated with a fall in CA19-9 level in all benign cases and in nine of the 15 with malignancy. CONCLUSION: Confident discrimination between benign and malignant disease could not be made on the basis of a solitary elevated CA19-9 measurement. Hyperbilirubinaemia was associated with a further deterioration in specificity and caution is warranted when interpreting the results in jaundiced patients. Overall, only one half of patients with an elevated CA19-9 level ultimately proved to harbour a malignancy.

A model for faculty mentoring in academic radiology.

RATIONALE AND OBJECTIVES: The purpose of this report is to describe the development and implementation of a faculty mentoring program in radiology designed to promote the career development of junior faculty and enhance communication in the department. MATERIALS AND METHODS: The mentoring program was implemented in five stages: organizational readiness, participant recruitment, mentor matching and orientation, implementation, and evaluation. Evaluations were based on Likert scale ratings and qualitative feedback. A retrospective analysis was also conducted of the annual performance reviews of junior faculty in the areas of research, teaching, patient care, and overall performance. RESULTS: An average of 83% (19 of 23) of the junior faculty participated in the pilot phase of the mentoring program. During five rounds of testing, the median rating (1 indicates not important; 10, extremely important) from responding junior faculty was 10 for overall value of individual mentoring meetings; the median rating for the mentors responding was 8.75. Research and academic development were identified as the areas of greatest importance to the faculty. Research and patient care were most improved as assessed by faculty peers during performance reviews. The schedule of semiannual formal mentoring meetings was reported to be optimal. CONCLUSION: The program was implemented to the satisfaction of junior faculty and mentors, and longitudinal performance suggests positive effects. Issues to be contended with include confidentiality and the time needed for mentoring beyond already saturated schedules. Overall, the authors propose that mentoring programs can be an asset to academic radiology departments and a key factor in maintaining their vitality.

Electronic publishing: the movement from print to digital publication.

This article provides an overview of electronic publishing, describes how information increasingly is being exchanged within the scientific community, and discusses the scholarly qualifications of electronic venues. The following content is included: a.definition of electronic publishing; b.uses and types of electronic publishing; c.uses of electronic journals in nursing and health care; d.advantages and disadvantages of electronic journals; e.advantages and disadvantages of print journals; and f.the authors' projections for the future. Hotlinks to a variety of Internet resources on electronic resources are integrated throughout the article.

Prerequisites and priorities for nursing research in Israel.

This article describes prerequisites and priorities for nursing research in Israel. The historical development of nursing research in Israel details shifts in types of research by decade from the 1960s through 1990s. The four phases of development and evaluation of nursing research are explored. Prerequisites for the development and growth of nursing research in Israel, as is true worldwide, include individual, professional, institutional and federal commitments. Priorities for Israeli nursing research include the development of a master plan which reflects its unique culture and geography.

Surgical intervention in acute pancreatitis: indications, techniques and complications.

Acute pancreatitis is a disease with a significant morbidity and mortality. It has been reported as the principal diagnosis in 2% of hospital admissions with abdominal pain in the UK. The incidence is in the range of 200 to 300 cases per million population per year, but it is probably increasing. The overall mortality rate is 10 to 12%. The management of the disease and its complications requires close co-operation between surgeon, radiologist and gastroenterologist. There have been a number of improvements in the management of acute pancreatitis in the last decade.

Lung herniation through a postthoracoscopy chest wall defect: demonstration with spiral CT.

The incidence of complications following thoracoscopy is approximately 10%, the most prevalent being prolonged air leak and chest pain. We report two cases of lung herniation through the chest wall defect created by thoracoscopy. Use of the Valsalva maneuver during CT scanning is recommended as a diagnostic imaging method in cases with suspected lung herniation.

Perforated colonic carcinoma presenting as epididymo-orchitis and Fournier's gangrene.

Epididymo-orchitis is a relatively common diagnosis in elderly men, often related to prostatic outflow obstruction. A 70-year-old man presented with a 4-day history of swelling and pain in the scrotum, fevers, dysuria and frequency. He had severe symptoms of prostatic hypertrophy. Physical examination and urine microscopy confirmed the diagnosis of left epididymo-orchitis and antimicrobial therapy was commenced. Subsequently, however, he developed severe necrotizing fasciitis (Fournier's gangrene) of the scrotum requiring surgical debridement, and at laparotomy, a perforated carcinoma of the sigmoid colon was found at the level of the left deep inguinal ring. Despite further radical surgery the gangrene extended, his condition deteriorated and he died. There has been no other similar case reported in the literature, and thus, although rare, intra-peritoneal causes of infection should be considered in patients with Fournier's gangrene.

Fatal haemorrhage following liver biopsy in patients with HIV infection.

A retrospective review of all 248 liver biopsies performed in patients with HIV infection at two referral centres in London over a 12 year period revealed five cases of major bleeding following biopsy, with four deaths. The risk of major bleeding was 2.0%, and mortality was 1.6% following liver biopsy. The risk of bleeding as much higher than in published series of biopsies done in patients without HIV infection, owing in part to the high prevalence of thrombocytopaenia and clotting abnormalities in patients with HIV infection. HIV infection per se may also increase the risk of bleeding following liver biopsy.

Preoperative staging of non-small-cell carcinoma of the lung: imaging methods.

Preoperative tumor staging in patients with non-small-cell lung cancer is important for selecting those patients with localized disease who are likely to benefit from surgical resection. The TNM staging system of the American Joint Committee on Cancer is the most widely accepted and used classification system for preoperative and postoperative staging [1] (Table 1). Small-cell carcinoma has a very different biologic behavior and is classified and treated differently; it will not be discussed in this imaging review. Chest radiography is the preferred initial imaging technique for patients with known or suspected lung cancer because of its availability, low cost, low radiation dose, and sensitivity [2]. CT and MR imaging of the chest and abdomen are often used to stage a known or suspected lung carcinoma. Various nuclear medicine procedures may be used to aid in the staging process and to assess the patient's medical status for surgery, including cardiac and pulmonary function. This article reviews the major imaging techniques that are currently used to stage primary non-small-cell carcinoma of the lung. Although evaluation of distant metastatic disease is highly important in these patients, discussion of the imaging methods used for this purpose is beyond the scope of this article.

Scintigraphic evaluation of clinically silent adrenal masses.

UNLABELLED: We studied 229 patients with abnormal adrenal anatomy depicted by CT who were without biochemical evidence of endocrine dysfunction using the presence of 131I-6 beta-iodomethyl-nor-cholesterol (NP-59) adrenal gland uptake as an index of differential adrenal function in the evaluation of the clinically "silent" adrenal mass lesion. METHODS: NP-59 (1 mCi) was injected intravenously with posterior and lateral abdominal images obtained 5-7 days postinjection. RESULTS: One-hundred and fifty-nine of 185 patients with unilateral adrenal enlargement on CT had scintigraphic evidence that the mass represented a functioning (NP-59 avid) but not hypersecretory, (biochemically normal) adrenal cortical adenoma (concordant imaging pattern). Forty-one of 44 patients with intra-adrenal neoplasms were depicted on scintigraphy as decreased or absent NP-59 accumulation on the side of the adrenal mass (discordant imaging pattern). In this study, sensitivity was 71% (41 of 58 patients; 95% confidence interval (CI), 58% to 88%); specificity was 100% (171 of 171 patients; 95% CI, 95% to 100%) and accuracy was 93% (212 of 229 patients; 95% CI, 88% to 96%). CONCLUSIONS: These data confirm our earlier observations that the functional information depicted by scintigraphy complements the morphological evaluation by CT and in the absence of hormonal dysfunction, the presence of concordant CT and 131I-NP-59 scans are characteristic of functioning, but not hypersecretory, benign adrenocortical adenomas. Conversely, discordant CT and 131I-NP-59 scans are suggestive of nonfunctioning, space-occupying, adrenal lesions.

Multicentre audit of death from acute pancreatitis.

A prospective audit of acute pancreatitis involving nine hospitals in the North-West Thames Region recruited 631 patients over 54 months. There were 57 deaths (9 per cent); a diagnosis had been reached in 50 patients (88 per cent) before death and in seven (12 per cent) at autopsy. Eighteen patients (32 per cent) died within the first week, usually as a result of multisystem organ failure (15 patients). Thirty-nine patients (68 per cent) died after the first week from complications related to infection (26 patients) co-morbid conditions (nine) or non-infective complications (four). Twenty-one patients (42 per cent) had been inadequately evaluated by Ranson's criteria, and only 22 (44 per cent) of 50 with a premortem diagnosis of pancreatitis had undergone computed tomography (CT). Fifteen of 26 patients who died from infection-related complications had CT and only nine underwent necrosectomy or surgical drainage. These data suggest that improved diagnosis, investigation and management of patients with acute pancreatitis is possible, and may result in improved clinical outcome.

Resource implications of head injuries on an acute surgical unit.

Head injuries are expensive and demanding in terms of resources. In the UK, most are cared for outside neurosurgical centres. In the absence of specialist rehabilitation services, patients with on-going disability add to those admitted for observation and treatment on acute surgical wards. We audited the workload pattern and financial implications related to head injuries on a general surgical unit in a central London teaching hospital. Data collected prospectively at the time of admission and derived from departmental computerized information systems included clinical outcome, hospital stay and its relationship to severity of injury and other factors. Ward, departmental (accident and emergency (A & E), intensive therapy unit (ITU), radiology, and theatre) and neurosurgical referral costs were derived. Long-term social and rehabilitation costs were not calculated. Over a 6 month period 899 patients with head injuries were treated in the A & E department, of whom 156 were admitted. Of the admitted patients 68% were classified as minor; 22% as moderate; and 10% as severe head injuries. Fifty-one per cent of adult admissions were intoxicated by alcohol. Prolonged hospital stay was related to age, severity of head injury, mechanism of injury, associated injuries and preexisting neuropsychiatric conditions (including alcoholism). Six patients died. The direct cost of these head injuries patients was estimated at 173,500 pounds, during which time they occupied 7.6% of our unit's adult inpatient capacity. Twenty-four hour observation of 76 patients with minor head injuries contributed 9700 pounds (5.6%) to this figure. Associated extracranial injuries cost a further 46,500 pounds.(ABSTRACT TRUNCATED AT 250 WORDS)