The Association of Coloproctology of Great Britain and Ireland consensus guidelines in surgery for inflammatory bowel disease.

AIM: There is a requirement of an expansive and up to date review of surgical management of inflammatory bowel disease (IBD) that can dovetail with the medical guidelines produced by the British Society of Gastroenterology. METHODS: Surgeons who are members of the ACPGBI with a recognised interest in IBD were invited to contribute various sections of the guidelines. They were directed to produce a procedure based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. An editorial board was convened to ensure consistency of style, presentation and quality. Each author was asked to provide a set of recommendations which were evidence based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after 2 votes were included in the guidelines. RESULTS: All aspects of surgical care for IBD have been included along with 157 recommendations for management. CONCLUSION: These guidelines provide an up to date and evidence based summary of the current surgical knowledge in the management of IBD and will serve as a useful practical text for clinicians performing this type of surgery.

Extracellular vesicles induce protective immunity against Trichuris muris.

Gastrointestinal nematodes, such as Trichuris trichiura (human whipworm), are a major source of morbidity in humans and their livestock. There is a paucity of commercially available vaccines against these parasites, and vaccine development for T. trichiura has been impeded by a lack of known host protective antigens. Experimental vaccinations with T. muris (murine whipworm) soluble Excretory/Secretory (ES) material have demonstrated that it is possible to induce protective immunity in mice; however, the potential for extracellular vesicles (EVs) as a source of antigenic material has remained relatively unexplored. Here, we demonstrate that EVs isolated from T. muris ES can induce protective immunity in mice when administered as a vaccine without adjuvant and show that the protective properties of these EVs are dependent on intact vesicles. We also identified several proteins within EV preparations that are targeted by the host antibodies following vaccination and subsequent infection with T. muris. Many of these proteins, including VWD and vitellogenin N and DUF1943-domain-containing protein, vacuolar protein sorting-associated protein 52 and TSP-1 domain-containing protein, were detected in both soluble ES and EV samples and have homologues in other parasites of medical and veterinary importance, and as such are possible protective antigens.

Establishing an external cephalic version clinic: outcome of the first year.

The effect of introducing an external cephalic version (ECV) clinic was evaluated after 12 months. The practical procedure of establishing the clinic, its protocol and the technique of ECV is described. All women had singleton pregnancies of at least 36 weeks gestation. There were 61 'primary' attempts at ECV, and one repeat attempt. The operator performing the majority of the ECVs had a 56% success rate, whilst the overall rate for the clinic was 53%. There was minimal fetal and maternal morbidity. Success according to placental site, parity, gestation and type of breech as well as the mode of delivery and neonatal outcome of all patients on whom ECV was attempted is presented. There was a significant decrease in the total number of breech deliveries, mainly through a 60% reduction in emergency caesarean section. The cost effectiveness of the clinic and the use of tocolytics is discussed.

Preliminary evaluation of an intelligent system for the management of labour.

Over the past 10-15 years, workers using conventional computing approaches have attempted to provide an accurate assessment of fetal condition during labour based on the cardiotocogram (CTG) alone. These have not proved successful perhaps because the correct interpretation of fetal condition also requires physiological knowledge, specific patient information, knowledge of events during labour and considerable practical experience. An intelligent system which considers all the relevant information and embodies expertise may better diagnose fetal condition and support decision making. This study reports the preliminary evaluation of such a system and investigates whether this approach can attain a performance comparable with experienced local clinicians. From a database of 200 high risk labour records, 30 cases were selected; the 9 cases which received clinical intervention for 'fetal-distress' and a further 21 cases selected randomly. The management specified by the system, 3 experienced clinicians (A, B and C) and the actual clinical management were compared in a retrospective blinded review. The experts were found to agree well with each other. Expert A reviewed the cases five months later and was found to be entirely consistent in the management of 28 of the 30 cases. The system's actions were indistinguishable from the experts' and in no case did the system recommend an action not also recommended by at least one experienced reviewer. This study demonstrates the potential of an intelligent system to assist in the management of labour.

A controlled trial of two forms of self-management education for adults with asthma.

PURPOSE: Excess morbidity and mortality due to asthma, aggravated by demonstrably poor patient self-management practices, suggest the need for formal patient education programs. Individual and group asthma education programs were developed and evaluated to determine their cognitive, behavioral, and clinical effects. PATIENTS AND METHODS: We compared changes in asthma symptoms, utilization of medical services, knowledge about asthma, metered-dose inhaler (MDI) technique, and self-management behaviors for 323 adult Kaiser Permanente patients with moderate to severe asthma who were randomly assigned to small-group education, individual teaching, or 1 of 2 control conditions--an information (workbook) control or usual control (no formal asthma education). Data were collected from patients by questionnaire, diary, and physical examination at enrollment and at 5 months and 1 year after intervention. Medical record data on these patients were abstracted for a total 3-year period, from 1 year before to 2 years after enrollment. RESULTS: Compared with the usual control, the self-management education programs were associated with significant improvements in control of asthma symptoms (reduced "bother" due to asthma and increased symptom-free days), MDI technique, and environmental control practices. Small-group education also was associated with significant improvements in physician evaluation of the patients' asthma status and in patients' level of physical activity. For both group and individual education recipients, improvement in MDI technique was positively correlated with improved control of symptoms; however, the degree of improvement in symptoms was greater than that which could be accounted for on the basis of improvement in MDI technique alone. The time course over which changes occurred in the various outcome measures suggests the mechanism by which education resulted in improvement in the patient's status. Significant improvements in MDI technique and environmental control practices were manifest immediately following education (5-month follow-up) and at the 1-year follow-up. Significant improvements in symptom measures were not apparent until the 1-year follow-up. The rate of utilization of medical care for acute exacerbations decreased between baseline and the 2-year follow-up period, but this decrease did not differ significantly among treatment conditions. However, there was a trend toward greater reduction in patients receiving small-group education. An ad hoc finding of a significant difference favoring small-group education between the baseline and the second follow-up year acute visit rates was observed. This result must be regarded as tentative, since it is not clear that unambiguous statistical significance is attained in the light of multiplicity issues. However, this trend is consistent with the antecedent benefits of the small-group education, and appears to warrant further investigation. CONCLUSIONS: Carefully designed asthma education programs for adults can improve patients' understanding of their condition and its treatment and increase their motivation and confidence that the condition can be controlled, thereby increasing their adherence to the treatment regimen and management of symptoms, and, in turn, improving control of symptoms. Both small-group education and individual education were associated with significant benefits, but the group program was simpler to administer, better received by patients and educators, and more cost-effective. The results show promise for improving clinical outcomes, through well-designed educational programs, for patients with asthma and other chronic health problems.

Detectors for scanning video imagers.

Detectors for scanning video (10-MHz) imagers should be chosen for their high quantum efficiency and internal gain. Because of the high bandwidth both photomultiplier tubes and avalanche photodiodes are limited by photon noise, so that dark noise is not the determining quantity.

A case of affective disorder associated with the misuse of 'anabolic steroids'.

In the pursuit of gains in muscle size and strength, body-builders may mistakenly use illicit drugs believing them to be anabolic steroids. The case described illustrates the physical and psychological dangers of such behaviour.

Reflectometry with a scanning laser ophthalmoscope.

We describe noninvasive techniques to optimize reflectometry measurements, particularly retinal densitometry, which measures the photopigment density difference. With these techniques unwanted scattered light is greatly reduced, and the retina is visualized during measurements. Thus results may be compared for each retinal location, and visible artifacts are minimized. The density difference measurements of the cone photopigment depend on the optical configuration of the apparatus. The cone photopigment density difference is greatest near the fovea and for most observers decreases rapidly with eccentricity. A research version for reflectometry and psychophysics of the scanning laser ophthalmoscope is described.

Anterior segment fluorescein videoangiography with a scanning angiographic microscope.

The scanning laser ophthalmoscope can be modified to operate as a scanning laser biomicroscope for use in anterior segment fluorescein angiography. The substantial depth of focus, large field of view, co-axial illumination, low light levels, real-time television operation, and videorecording with immediate recall provide advantages not available with conventional photographic methods. Video techniques give a resolution slightly inferior to photography, but this is unlikely to be significant in clinical practice. A technique of traversing the entire anterior episcleral vasculature has been developed to give a comprehensive and reproducible angiographic record. Previous fluorescein studies suggesting the primary importance of retrograde (centrifugal) flow in the perforating anterior ciliary arteries were not supported; methodologic explanations are advanced. Several principles are proposed to improve techniques of anterior segment angiography.

An evaluation of approaches to asthma self-management education for adults: the AIR/Kaiser-Permanente Study.

The purpose of the AIR/Kaiser-Permanente asthma project is to evaluate various approaches to the education of adults with asthma, identifying those types of patients for whom particular approaches are most cost effective. Critical self-management practices for adults with asthma were identified using the critical incident technique. An individualized and a group administered educational program are being developed to teach the identified critical skills, using the instructional models previously employed in AIR WISE and AIR POWER programs for children with asthma. Three hundred patients with moderate to severe asthma from Northern California Kaiser-Permanente Medical Group clinics will participate in a trial of these programs. Patients will be randomly assigned to one of four conditions: One of two educational programs, an information/attention control, or a data-only control condition. Data will be collected on all patients for 15 months; health care utilization data covering a two-year period will be available from medical records. Program effectiveness will be evaluated in terms of pre-post changes in the patients' knowledge, attitudes, self-management practices, medical condition, daily functioning, and utilization of services. Cost effectiveness will be evaluated, paying specific attention to the cost effectiveness of different educational approaches for different types of patients.

Confocal scanning laser ophthalmoscope.

A confocal scanning imager moves an illumination spot over the object and a (virtual) detector synchronously over the image. In the confocal scanning laser ophthalmoscope this is accomplished by reusing the source optics for detection. The common optical elements are all mirrors-either flat or spherical-and the scanners are positioned to compensate astigmatism due to mirror tilt. The source beam aperture at the horizontal scanner is small. Light returning from the eye is processed by the same elements, but now the polygon's facet is overfilled. A solid-state detector may be at either a pupillary or retinal conjugate plane in the descanned beam and still have proper throughput matching. Our 1-mm avalanche photodiode at a pupillary plane is preceded by interchangeable stops at an image (retinal) plane. Not only can we reject scattered light to a degree unusual for viewing the retina, but we choose selectively among direct and scattered components of the light returning from the eye. One (of many) consequences is that this ophthalmoscope gives crisp and complete retinal images in He-Ne light without dilation of the pupil.

Fundus tracking with the scanning laser ophthalmoscope.

A technique is described of using the video output of the scanning laser ophthalmoscope to monitor the positions of fundus features with respect to an input laser raster. The monitoring performance characteristics are discussed as well as tracking methods and possible applications in psychophysics and laser photocoagulation.

Self-management education of children with asthma: AIR WISE.

This study was conducted to test the efficacy of AIR WISE, an individually administered asthma self-management program. Subjects were paired and randomly assigned to either an experimental group (N = 7) or a control group (N = 7). The frequency of experimental group emergency visits, analyzed over a 12-month posttreatment period, was substantially less than those of the control group, supporting the hypothesis that AIR WISE is effective in high-utilizer children through improved self-management.

Rural versus urban parasuicide--referral and management.

The referral and management of parasuicide patients from urban and rural areas were compared in a retrospective study of hospital and general practice records. Whereas most urban patients were physically and psychiatrically managed in general hospitals, the majority of rural patients were managed at home or in cottage hospitals by general practitioners. The overall parasuicide rate of the rural population was found to be similar to that of the city. Although there were no clinical differences between the two groups of patients, relatively more middleaged rural patients were admitted to hospital. The results suggest that parasuicide is now as commonly seen in rural situations, but that the problem is managed outside district general hospitals by general practitioners.

Scanning laser ophthalmoscopy. Clinical applications.

The scanning laser ophthalmoscope (SLO) provides a high-quality television image of the retina using less than 1/1000 of the light required for conventional indirect ophthalmoscopy. The SLO employs a new ophthalmoscopic principle in which a dim laser beam scans across the fundus, and light is collected only from one retinal point at a time. Since the instrument is highly light efficient, illumination levels are comfortable for the patient, and fluorescein angiography can be performed with one tenth of the usual fluorescein dose. Since a continuous, large depth of field view is displayed on the SLO screen and stored on video tape, repeated dynamic inspection of the vitreous, retina and vitreoretinal interface is afforded. In addition, any graphical material that can be displayed on a microcomputer monitor (such as text of video games) can also be impressed on the retinal pattern formed by the sweeping laser beam. The graphical material is thus observed directly by the patient and on the patient's retina by the clinician. Since the exact retinal locus of each point in the graphical material is viewed directly, it is possible to perform perimetry directly on the retina, to measure acuity at arbitrary retinal loci, to study how patients with macular disease use residual functional retina for reading, and to perform distortometry with a retinal (Amsler-type) grid.

Retinal localization of scotomata by scanning laser ophthalmoscopy.

The scanning laser ophthalmoscope (SLO) system has been modified to permit direct retinal perimetry. A movable pinhole in a retinal conjugate plane furnishes a mapping stimulus whose retinal locus is directly observable on a video image of the fundus. Scotoma maps in patients with macular disease and physiologic scotomata associated with normal optic discs are presented. Clinical applications of the method are discussed.