Airway fire with use of diathermy in conjunction with high-flow nasal oxygen.

Operating theatre fires are rare but can result in significant morbidity. A 76-year-old male with complex airway disease sustained superficial facial burns during an elective airway debulking procedure. His airway was being managed with high-flow nasal oxygen at 70 l.min-1 and FiO2 1.0 delivered by Optiflow™ (Fisher and Paykel Healthcare Limited, Auckland, New Zealand). When suction monopolar diathermy was used to excise hyperkeratotic tissue beside his epiglottis, an arc was created to the tip of the suspension laryngoscope, followed by a jet of flame as the Optiflow circuit ignited. This resulted in burns to the patient's face and shoulder. He required admission to the intensive care unit and had a complicated postoperative course that included the need for surgical tracheostomy to facilitate weaning from mechanical ventilation. This case highlights the dangers of using high-flow nasal oxygen alongside an ignition source.

Genetic parameter estimates for methane emission during lactation from breath and potential inaccuracies in reliabilities assuming a repeatability versus random regression model.

Methane (CH4) emissions will be added to many national ruminant breeding programs in the coming years. Little is known about the covariance structure of CH4 traits over a lactation, which is important for optimizing recording strategies and to establish optimal genetic evaluation models. Our aim was to study CH4 over a lactation using random regression (RR) models, and to compare the accuracy to a fixed regression repeatability model under different phenotyping strategies. Data were available from repeated measurements of CH4 concentrations (ppm), recorded in the feed bins of milking robots, on 52 commercial dairy farms in the Netherlands. In total, 36,370 averaged weekly records were available from 4,664 cows. Genetic parameters were estimated using a fixed regression model, and a RR model with 1st to 5th order Legendre polynomials for the additive genetic and within lactation permanent environmental effect. The mean heritability was 0.17 ± 0.04, and the mean within lactation repeatability was 0.56 ± 0.03. The genetic correlations between days in milk were high and ranged from 0.34 ± 0.36 to 1.00 ± < 0.01. Permanent environmental correlations showed large deviations and ranged from -0.73 ± 0.08 to 1.00 ± < 0.01. With a large number of full lactation daughter CH4 records per bull, the reliability was not sensitive to using the fixed versus RR model. However, when shorter periods were recorded at the start and end of the lactation, the fixed regression model resulted in a loss of reliability up to 28% for bulls. Assuming the fixed model when the true (co)variance structure is reflected by the RR model, more than twice as long recording from the start of lactation was required to achieve maximum reliability for a bull. Thus, a too simplistic model could result in implementing too little recording, and lower genetic gains than predicted from the reliability.

Heritability and genetic correlations between enteric methane production and concentration recorded by GreenFeed and sniffers on dairy cows.

To reduce methane (CH4) emissions of dairy cows by animal breeding, CH4 measurements have to be recorded on thousands of individual cows. Currently, several techniques are used to phenotype cows for CH4, differing in costs and applicability. However, there is uncertainty about the agreement between techniques. To judge the similarity and repeatability between measurements of different recording techniques, the repeatability, heritability, and genetic correlation are useful metrics. Therefore, our objective was to estimate (1) the repeatability and heritability for CH4 and carbon dioxide production recorded by GreenFeed (GF) and for CH4 and carbon dioxide concentration measured by cost-effective but less accurate sniffers, and (2) the genetic correlation between CH4 recorded with these 2 different on farm and high throughput techniques. Data were available from repeated measurements of CH4 production (grams/day) by GF units and of CH4 concentration (ppm) by sniffers, recorded on commercial dairy farms in the Netherlands. The final data comprised 24,284 GF daily means from 822 cows, 170,826 sniffer daily means from 1,800 cows, and 1,786 daily means from 75 cows by both GF and sniffer (in the same period). Additionally, CH4 records were averaged per week. For daily and weekly mean GF CH4 the heritabilities were 0.19 ± 0.02 and 0.33 ± 0.04, and for daily and weekly mean sniffer CH4 the heritabilities were similar and were 0.18 ± 0.01 and 0.32 ± 0.02, respectively. Phenotypic correlations between GF CH4 production and sniffer CH4 concentration were moderate (0.39 ± 0.03 for daily means and 0.37 ± 0.05 for weekly means). However, genetic correlations were high; 0.71 ± 0.13 for daily means and 0.76 ± 0.15 for weekly means. The high genetic correlation indicates that selection on low CH4 concentrations (ppm) recorded by the cost-effective sniffer method, will result in reduced CH4 production (grams/day) as recorded with GF.

Genetic parameters for repeatedly recorded enteric methane concentrations of dairy cows.

Animal breeding techniques offer potential to reduce enteric emissions of ruminants to lower the environmental impact of dairy farming. The aim of this study was to estimate the heritability and repeatability of methane (CH4) concentrations, using the largest data set from long-term repeatedly recorded CH4 on cows to date, and to evaluate (1) the accuracy of breeding values for different CH4 traits, including using visits or weekly means, and (2) recording strategies (with varying numbers of records and recorded daughters per sire). The data comprised of long-term recording of CH4 and carbon dioxide (CO2), from 1,746 Holstein Friesian cows, on 14 commercial dairy farms throughout the Netherlands. Emissions were recorded in 10- to 35-s intervals, between 64 and 436 d, depending on farms. From each robot visit, CH4 and CO2 concentrations were summarized into various traits, averaged per visit and per week: mean, median, mean log, and mean CH4/CO2 ratio. Genetic parameters were estimated with animal repeatability models, using a restricted maximum likelihood procedure, and a relationship matrix based on genotypes and pedigree. The heritability was equal for mean and median CH4 per visit (0.13) but lower for logCH4 and CH4/CO2 (0.07 and 0.01, respectively). Phenotypic and genetic correlations were high (≥0.78) between the CH4 traits, apart from the genetic correlations with the CH4/CO2 trait, which were negative. To achieve a minimum reliability of 50% for the estimated breeding value of a bull, 25 records on mean CH4, measured on 10 different daughters, were sufficient. Although the heritability and repeatability were higher for weekly (0.32 and 0.68, respectively) than for visit mean CH4 (0.13 and 0.30, respectively), the reliabilities of estimated breeding values from visit or weekly means were equal; thus, we found no advantage in averaging records to weekly means for genetic evaluations.

Selective breeding as a mitigation tool for methane emissions from dairy cattle.

The global livestock sector, particularly ruminants, contributes substantially to the total anthropogenic greenhouse gases. Management and dietary solutions to reduce enteric methane (CH4) emissions are extensively researched. Animal breeding that exploits natural variation in CH4 emissions is an additional mitigation solution that is cost-effective, permanent, and cumulative. We quantified the effect of including CH4 production in the Dutch breeding goal using selection index theory. The current Dutch national index contains 15 traits, related to milk yield, longevity, health, fertility, conformation and feed efficiency. From the literature, we obtained a heritability of 0.21 for enteric CH4 production, and genetic correlations of 0.4 with milk lactose, protein, fat and DM intake. Correlations between enteric CH4 production and other traits in the breeding goal were set to zero. When including CH4 production in the current breeding goal with a zero economic value, CH4 production increases each year by 1.5 g/d as a correlated response. When extrapolating this, the average daily CH4 production of 392 g/d in 2018 will increase to 442 g/d in 2050 (+13%). However, expressing the CH4 production as CH4 intensity in the same period shows a reduction of 13%. By putting economic weight on CH4 production in the breeding goal, selective breeding can reduce the CH4 intensity even by 24% in 2050. This shows that breeding is a valuable contribution to the whole set of mitigation strategies that could be applied in order to achieve the goals for 2050 set by the EU. If the decision is made to implement animal breeding strategies to reduce enteric CH4 production, and to achieve the expected breeding impact, there needs to be a sufficient reliability of prediction. The only way to achieve that is to have enough animals phenotyped and genotyped. The power calculations offer insights into the difficulties that will be faced in trying to record enough data. Recording CH4 data on 100 farms (with on average 150 cows each) for at least 2 years is required to achieve the desired reliability of 0.40 for the genomic prediction.

Experimental verification of principal losses in a regulatory particulate matter emissions sampling system for aircraft turbine engines.

A sampling system for measuring emissions of nonvolatile particulate matter (nvPM) from aircraft gas turbine engines has been developed to replace the use of smoke number and is used for international regulatory purposes. This sampling system can be up to 35 m in length. The sampling system length in addition to the volatile particle remover (VPR) and other sampling system components lead to substantial particle losses, which are a function of the particle size distribution, ranging from 50 to 90% for particle number concentrations and 10-50% for particle mass concentrations. The particle size distribution is dependent on engine technology, operating point, and fuel composition. Any nvPM emissions measurement bias caused by the sampling system will lead to unrepresentative emissions measurements which limit the method as a universal metric. Hence, a method to estimate size dependent sampling system losses using the system parameters and the measured mass and number concentrations was also developed (SAE 2017; SAE 2019). An assessment of the particle losses in two principal components used in ARP6481 (SAE 2019) was conducted during the VAriable Response In Aircraft nvPM Testing (VARIAnT) 2 campaign. Measurements were made on the 25-meter sample line portion of the system using multiple, well characterized particle sizing instruments to obtain the penetration efficiencies. An agreement of ± 15% was obtained between the measured and the ARP6481 method penetrations for the 25-meter sample line portion of the system. Measurements of VPR penetration efficiency were also made to verify its performance for aviation nvPM number. The research also demonstrated the difficulty of making system loss measurements and substantiates the E-31 decision to predict rather than measure system losses.

Paediatric Molecular Radiotherapy: Challenges and Opportunities.

The common contemporary indications for paediatric molecular radiotherapy (pMRT) are differentiated thyroid cancer and neuroblastoma. It may also have value in neuroendocrine cancers, and it is being investigated in clinical trials for other diseases. pMRT is the prototypical biomarker-driven, precision therapy, with a unique mode of delivery and mechanism of action. It is safe and well tolerated, compared with other treatments. However, its full potential has not yet been achieved, and its wider use faces a number of challenges and obstacles. Paradoxically, the success of radioactive iodine as a curative treatment for metastatic thyroid cancer has led to a 'one size fits all' approach and limited academic enquiry into optimisation of the conventional treatment regimen, until very recently. Second, the specialised requirements for the delivery of pMRT are available in only a very limited number of centres. This limited capacity and geographical coverage results in reduced accessibility. With few enthusiastic advocates for this treatment modality, investment in research to improve treatments and broaden indications from both industry and national and charitable research funders has historically been suboptimal. Nonetheless, there is now an increasing interest in the opportunities offered by pMRT. Increased research funding has been allocated, and technical developments that will permit innovative approaches in pMRT are available for exploration. A new portfolio of clinical trials is being assembled. These studies should help to move at least some paediatric treatments from simply palliative use into potentially curative protocols. Therapeutic strategies require modification and optimisation to achieve this. The delivery should be personalised and tailored appropriately, with a comprehensive evaluation of tumour and organ-at-risk dosimetry, in alignment with the external beam model of radiotherapy. This article gives an overview of the current status of pMRT, indicating the barriers to progress and identifying ways in which these may be overcome.

Logistic regression model to predict acute uncomplicated and complicated appendicitis.

INTRODUCTION: While patients with acute uncomplicated appendicitis may be treated conservatively, those who suffer from complicated appendicitis require surgery. We describe a logistic regression equation to calculate the likelihood of acute uncomplicated appendicitis and complicated appendicitis in patients presenting to the emergency department with suspected acute appendicitis. MATERIALS AND METHODS: A cohort of 895 patients who underwent appendicectomy were analysed retrospectively. Depending on the final histology, patients were divided into three groups; normal appendix, acute uncomplicated appendicitis and complicated appendicitis. Normal appendix was considered the reference category, while acute uncomplicated appendicitis and complicated appendicitis were the nominal categories. Multivariate and univariate regression models were undertaken to detect independent variables with significant odds ratio that can predict acute uncomplicated appendicitis and complicated appendicitis. Subsequently, a logistic regression equation was generated to produce the likelihood acute uncomplicated appendicitis and complicated appendicitis. RESULTS: Pathological diagnosis of normal appendix, acute uncomplicated appendicitis and complicated appendicitis was identified in 188 (21%), 525 (59%) and 182 patients (20%), respectively. The odds ratio from a univariate analysis to predict complicated appendicitis for age, female gender, log2 white cell count, log2 C-reactive protein and log2 bilirubin were 1.02 (95% confidence interval, CI, 1.01, 1.04), 2.37 (95% CI 1.51, 3.70), 9.74 (95% CI 5.41, 17.5), 1.57 (95% CI 1.40, 1.74), 2.08 (95% CI 1.56, 2.76), respectively. For the same variable, similar odds ratios were demonstrated in a multivariate analysis to predict complicated appendicitis and univariate and multivariate analysis to predict acute uncomplicated appendicitis. CONCLUSIONS: The likelihood of acute uncomplicated appendicitis and complicated appendicitis can be calculated by using the reported predictive equations integrated into a web application at www.appendistat.com. This will enable clinicians to determine the probability of appendicitis and the need for urgent surgery in case of complicated appendicitis.

Efficient and accurate computation of base generation allele frequencies.

Allele frequencies are used for several aspects of genomic prediction, with the assumption that these are equal to the allele frequency in the base generation of the pedigree. The current standard method, however, calculates allele frequencies from the current genotyped population. We compared the current standard method with BLUP and general least squares (GLS) methods explicitly targeting the base population to determine whether there is a more accurate and still efficient method of calculating allele frequencies that better represents the base generation. A data set based on a typical dairy population was simulated for 325,266 animals; the last 100,078 animals in generations 9 to 12 of the population were genotyped, with 1,670 SNP markers. For the BLUP method, several SNP genotypes were analyzed with a multitrait model by assuming a heritability of 0.99 and no genetic correlation among them. This method was limited by the time required for each BLUP to converge (approximately 6 min per BLUP run of 15 SNP). The GLS method had 2 implementations. The first implementation, using imputation on the fly and multiplication of sparse matrices, was very efficient and required just 49 s and 1.3 GB of random access memory. The second implementation, using a dense full A22-1 matrix, was very inefficient and required more than 1 d of wall clock time and more than 118.2 GB of random access memory. When no selection was considered in the simulations, all methods predicted equally well. When selection was introduced, higher correlations between the estimated allele frequency and known base generation allele frequency were observed for BLUP (0.96 ± 0.01) and GLS (0.97 ± 0.01) compared with the current standard method (0.87 ± 0.01). The GLS method decreased in accuracy when introducing incomplete pedigree, with 25% of sires in the first 5 generations randomly replaced as unknown to erroneously identify founder animals (0.93 ± 0.01) and a further decrease for 8 generations (0.91 ± 0.01). There was no change in accuracy when introducing 5% genotyping errors (0.97 ± 0.01), 5% missing genotypes (0.97 ± 0.01), or both 5% genotyping errors and missing genotypes (0.97 ± 0.01). The GLS method provided the most accurate estimates of base generation allele frequency and was only slightly slower compared with the current method. The efficient implementation of the GLS method, therefore, is very well suited for practical application and is recommended for implementation.

Radiation exposure to comforters and carers during paediatric molecular radiotherapy.

BACKGROUND: To show whether the incidental radiation exposure received by comforters and carers of children undergoing molecular radiotherapy was kept as low as reasonably achievable and was within English national dose constraints. PROCEDURE: The radiation exposure of adult comforters and carers was routinely monitored with a whole body personal dose meter while the child was in hospital. Data were collected on iodine-131 meta-iodobenzylguanidine (131 I-mIBG), lutetium-177 DOTATATE (177 Lu-DOTATATE), and iodine-131 sodium iodide (131 I-NaI) treatments. RESULTS: Data were available for 50 treatments with high-administered activity double-infusion 131 I-mIBG and 12 single administrations; 15 177 Lu-DOTATATE treatments and 28 131 I-NaI administrations. The median age was 7 years (1-18). The median administered activity of: 131 I-mIBG was 16.2 GBq (6.8-59 GBq) for double infusion patients and 8.1 GBq (5.26-16.25 GBq) for single administrations; 177 Lu-DOTATATE was 7.2 GBq (2.5-7.5 GBq); and 131 I-NaI was 3 GBq for thyroid remnant ablation and 5.5 GBq for cancer therapy. The median number of comforters and carers for all administrations was 2 (range 1-9). The median exposure values for comforters and carers for high-administered activity 131 I-mIBG administrations was 302 µSv (0-5282 µSv); for single fraction 131 I-mIBG 163 µSv (3-3104 µSv); 177 Lu-DOTATATE 6 µSv (1-79 µSv); and 131 I-NaI 37 µSv (0-274 µSv). Only one of the comforters and carers exceeded the dose constraint of 5 mSv. CONCLUSIONS: Doses to comforters and carers were in all but one case within the dose constraint nationally recommended by the Health Protection Agency, now part of Public Health England. New evidence is presented which show that comforter and carer radiation exposure levels from paediatric molecular radiotherapy in routine clinical practice are acceptably low. Pediatr Blood Cancer 2015;62:235-239. © 2014 Wiley Periodicals, Inc.

Addressing non-adherence to antipsychotic medication: a harm-reduction approach.

This paper discusses the evidence base for interventions addressing non-adherence to prescribed antipsychotics. A case study approach is used, and the extent to which adherence improvement interventions might be used in collaboration with a specific patient is considered. The principles and application of harm-reduction philosophy in mental health are presented in a planned non-adherence harm-reduction intervention. This intervention aims to acknowledge the patient's ability to choose and learn from experience and to reduce the potential harm of antipsychotic withdrawal. The intervention evaluation method is outlined.

Evaluation of a low-dose/slow-rotating SPECT-CT system.

The 4-slice CT that forms part of the GE Infinia Hawkeye-4 SPECT-CT scanner (Hawkeye) is evaluated against the diagnostic 16-slice CT that is incorporated in the GE Discovery ST PET-CT system (DST). The x-ray tube of the slow-rotating Hawkeye system (23 s/rotation) operates at approximately a third of the dose of diagnostic systems as used for conventional diagnostic imaging. Image reconstruction is optimized for low noise. High-contrast spatial resolution significantly falls behind diagnostic figures: the average of MTF(50) and MTF(10) (resolution where the MTF has fallen to 50% and 10%) is 2.8 +/- 0.1 cm(-1) for Hawkeye and 5.3 +/- 0.1 cm(-1) for the DST (standard reconstruction filters). Resolution in the direction of the couch movement (z coordinate) is governed by the fixed Hawkeye slice width of 5 mm. Reconstruction accuracy is found to be increased by reducing the default z increment from 4.4 mm to 2.2 mm. Low-contrast object detectability is superior compared with diagnostic systems operating in the Hawkeye dose range. In the diagnostic dose regime, however, small low-contrast details remain visible in DST that are not detectable with Hawkeye. Although not of diagnostic quality, the low-dose Hawkeye provides appropriate data for SPECT attenuation correction and anatomical localization capability.

Top tips for RIGIDfix femoral fixation.

The use of pin fixation for grafts in the femoral tunnel in anterior cruciate ligament (ACL) reconstruction is becoming more popular. The transtibial stiff femoral guides are necessary to ensure that the pins fix the graft. However, the cross pins can sometimes miss the femoral tunnel. As a result of some technical problems that we encountered, we introduced an extra step in the technique of the Mitek RIGIDfix ACL Graft Fixation System (Mitek Products, Ethicon, Edinburgh, UK). This article suggests some tips for fixing problems that arise in cases in which the graft is accidentally missed with the cross pins.

Medial meniscus interposition in proximal tibial epiphyseal fracture: a case report and review of the literature.

Proximal tibial fractures are rare in children, and most are treated conservatively. We report a case of a minimally displaced proximal tibial epiphyseal injury (Salter-Harris type III) in an 11-year-old child. We initially thought to treat this fracture conservatively, but the presence of massive haemarthrosis and considerable pain made us choose arthroscopy under general anaesthetic. During examination under anesthesia no instability could be detected, but the knee was locked in 5 degrees of flexion. On screening the fracture was not reducible anatomically. At arthroscopy the medial meniscus was not visualised as it was displaced into the fracture site. A small medial arthrotomy showed the meniscus trapped in the fracture site without any avulsion in the anterior or posterior horns. The fracture easily reduced once the meniscus was levered out. The importance of this injury is the fact that it could have been easily missed and would have led to serious functional deficit of the knee joint. We present radiographs and intra-operative pictures of this interesting injury.

Pancreatic acinar cell carcinoma presenting as acute pancreatitis.

BACKGROUND: Acinar cell carcinoma (ACC) is a rare pancreatic neoplasm, and its presentation with acute pancreatitis has not been reported previously. CASE OUTLINE: A 70-year-old man presented with acute pancreatitis, and a spiral CT scan showed a 5-cm tumour in the body of the pancreas. Distal pancreatectomy was performed, and histological examination showed an ACC. DISCUSSION: This is a newly reported mode of presentation for a rare pancreatic tumour.

Colesevelam hydrochloride: a novel bile acid-binding resin.

OBJECTIVE: To review the pharmacology, pharmacokinetics, efficacy, and adverse effects of colesevelam hydrochloride, a bile acid-binding resin. METHODS: MEDLINE searches (1966-June 2000) and manufacturer prescribing literature were employed to find articles on colesevelam. Additional studies and abstracts were identified from the bibliographies of reviewed literature. STUDY SELECTION AND DATA EXTRACTION: All articles identified from data sources were evaluated, and all information deemed relevant was included in this review. Priority was given to randomized, double-blind, placebo-controlled studies. FINDINGS: Colesevelam HCl is a nonabsorbed hydrogel with bile acid sequestrant properties. Monotherapy using colesevelam in once-daily or two divided daily doses of 1.5-4.5 g has produced significant reductions in total cholesterol and low-density lipoprotein (LDL) cholesterol. Mean LDL cholesterol decreases to 20% have been noted when the patient is on 3.75-4.5 g/d. Increases in high-density lipoprotein (HDL) cholesterol have been observed (up to 9%), whereas triglycerides (TG) have increased significantly to 25% in some studies. In unpublished studies, combined use of colesevelam plus hydroxymethylglutaryl coenzyme A (HMG-CoA) reductase inhibitor have produced greater reductions in LDL cholesterol than either the statin or colesevelam administered alone. The efficacy of colesevelam monotherapy is slightly less than or similar to cholestyramine or colestipol in decreasing LDL cholesterol, although colesevelam is more potent on a gram-to-gram basis. Adverse effects have been minimal with colesevelam in published studies; this suggests an advantage over cholestyramine or colestipol therapy. Colesevelam appears to be more cost-effective than the packet dosage form of the brand formulation of the older bile acid resins. Care in selection of an appropriate agent should be exercised when considering the issues of adverse effects and palatability. CONCLUSIONS: Colesevelam alone or combined with an HMG-CoA reductase inhibitor is effective in the reduction of total and LDL cholesterol. Since colesevelam is formulated as a tablet, problems with palatability such as with the powder formulation of the bile acid-binding resins are likely to be eliminated.

The relationship between low-density lipoprotein cholesterol goal attainment and prevention of coronary heart disease--related events.

BACKGROUND: According to the National Cholesterol Education Program (NCEP) treatment guidelines, patients with preexisting coronary heart disease (CHD) or other atherosclerotic vascular disease should lower low-density lipoprotein (LDL) cholesterol to < or = 100 mg/dL. Recent statin trials document the benefit of cholesterol lowering on CHD events but do not address the optimal goal of LDL cholesterol. METHODS: The pravastatin to simvastatin conversion-lipid optimization program (PSCOP) at the VA San Diego Healthcare System (VASDHS) was a formulary-conversion program designed to increase the percentage of patients who meet their recommended NCEP LDL cholesterol goal. We compared the incidence of clinical outcome and mortality between CHD patients from the original PSCOP cohort with postconversion LDL cholesterol greater than and < or = 100 mg/dL. A total of 524 patients were stratified by postconversion LDL cholesterol levels (greater than [N=183]) or < or = 100 mg/dL [N=341]) and observed for a mean duration of 27.7 months. Patients' VASDHS records were reviewed for postconversion mortality from any cause and CHD-related events. Patients were mailed a questionnaire to capture similar events that may have occurred outside of VASDHS, which might not be present in the patient's VASDHS record. RESULTS: Lipid-lowering therapy < or = 100 mg/dL was associated with a significantly lower percentage of total deaths and CHD-related events (40% vs 61%, P=0.008). In patients with LDL cholesterol >100 mg/dL, the relative risk of unstable angina (relative risk, 2.2; 95% confidence interval, 1.3 to 3.8; P=0.004) and stroke (relative risk, 3.0; 95% confidence interval, 1.04 to 8.6; P=0.04) were significantly greater compared to patients meeting their LDL cholesterol goal. CONCLUSIONS: Our study results support reducing LDL cholesterol to at least 100 mg/dL in the patient with CHD.

Fenofibrate and warfarin interaction.

A 79-year-old man with atrial fibrillation and coronary heart disease who was taking warfarin (Coumadin) was converted to fenofibrate from gemfibrozil therapy for persistently elevated triglyceride levels. The patient took fenofibrate for 1 month and subsequently experienced rectal bleeding that required a visit to the emergency room. Before starting fenofibrate therapy, his coagulation values were within therapeutic range, but when measured in the emergency room the international normalized ratio (INR) was grossly elevated. The patient denied any changes in diet, alcohol ingestion, compliance with therapy, or use of other new drugs except for fenofibrate. His drug therapy profile consisted of digoxin, fosinopril, and furosemide for chronic heart failure, allopurinol for gout, and potassium supplementation. To minimize the risk of supratherapeutic INR values and/or hemorrhagic events, clinicians should perform serial monitoring of INR when initiating fenofibrate therapy in a patient previously stabilized on a coumarin anticoagulant.

Arterial reconstruction for radial artery occlusion.

This study was designed to detail the history and symptoms of symptomatic radial artery vaso-occlusive disease and to evaluate the results of radial artery reconstruction. Thirteen patients with symptomatic vaso-occlusive disease of the radial artery unresponsive to management by nonoperative modalities were managed with arterial reconstruction. All cases were treated with reversed interpositional vein grafting from the radial artery in the forearm (end-to-side) to the deep arch distally (end-to-end). Patients completed preoperative and postoperative assessments of symptoms and function, cold sensitivity (cold intolerance), and digital microvascular perfusion (isolated cold stress test evaluation with laser Doppler fluxmetry). At the follow-up examination all vascular grafts were patent, as determined by Allen's testing and Doppler ultrasound. The patients reported symptoms and functional status that demonstrated significant improvement following reconstruction. Microvascular evaluations demonstrated a significant improvement in digital microvascular perfusion as assessed by laser Doppler fluxmetry and digital temperature recordings with a resultant resolution of ischemic pain, numbness, and ulceration.

Islet cell tumours: surgical treatment.

The majority of neuroendocrine tumours of the pancreas are malignant and surgical resection is the mainstay of treatment. The tumours are often small and intraoperative tumour localization is an important part of the operation. The type of tumour will dictate specific treatment.