Does sodium hyaluronate- and carboxymethylcellulose-based bioresorbable membrane (Seprafilm) decrease operative time for loop ileostomy closure?

BACKGROUND: Adhesions can result in serious clinical complications and make ileostomy closure, which is relatively simple procedure into a complicated and prolonged one. The use of sodium hyaluronate and carboxymethyl cellulose membrane (Seprafilm) was proven to significantly reduce the postoperative adhesions at the site of application. The aim of this study was to assess the incidence and severity of adhesions around a loop ileostomy and to analyze the length of time and morbidity for mobilization at the time of ileostomy closure with and without the use of Seprafilm. METHODS: Twenty-nine surgeons from 15 institutions participated in this multicenter prospective randomized study. 191 patients with loop ileostomy construction were randomly assigned to either receive Seprafilm under the midline incision and around the stoma (Group I), only under the midline incision (Group II), or not to receive Seprafilm (Group III). At ileostomy closure, adhesions were quantified and graded; operative morbidity was also measured. RESULTS: All 3 groups were comparable relative to gender, mean age and number of patients with prior operations (26, 25 and 19, respectively). Group II patients were significantly more likely to have pre-existing adhesions than Group III patients (30.6% vs. 14.1%, p = 0.025). At stoma mobilization, significantly more patients in Group III than in Group I had adhesions around the stoma (95.2% vs. 82.3%, p = 0.021). Mean operative times were 27, 25, and 28 minutes, respectively (p = 0.38), with significant differences among sites. There was no significant difference in the number of patients needing myotomy or enterotomy (29, 27 and 24 patients, respectively), nor in the number of postoperative complications (7, 9 and 7 patients, respectively). CONCLUSIONS: When consistently applied, Seprafilm significantly decreased adhesion formation around the stoma but not operative times without any increase in the need for myotomy or enterotomy. These findings were not seen in the overall study population possibly due to the large number of surgeons using a variety of application techniques.

Treatment of hemorrhagic radiation proctitis with 4 percent formalin.

PURPOSE: The purpose of this study was to review our results in patients undergoing treatment with 4 percent formalin for radiation-induced injury to the rectum. METHODS: A retrospective review of office charts was performed, identifying all patients undergoing formalin treatment. Patient gender, initial malignancy, prior treatments, response to treatment with formalin, complications, and length of follow-up were reviewed. All patients had flexible endoscopy to assess for proximal sources of bleeding. The indication for treatment was a symptomatic patient with endoscopic evidence of radiation injury. A cotton pledget was used for direct application of 4 percent formalin to the affected area via a rigid proctoscope or anoscope. The treatment was repeated if blanching did not occur or if bleeding continued. Patients were followed up at three-week to four-week intervals and treatment was repeated based on the above indications. Treatments were continued until cessation of bleeding occurred or, when treatment failed, operative treatment was required. RESULTS: Thirty-six patients were identified. Three were lost to follow-up. Symptoms included bleeding in all but one patient, who presented with an ulcer. There were 33 (26 male) patients. Seventeen (51.5 percent) patients had prior treatment. The number of formalin treatments ranged from 1 to 13, with a mean of 3.4. The follow-up ranged from 1 to 60 months, with a mean of 18 months. Twenty-nine (88 percent) patients had improvement or cessation of symptoms. Four (12 percent) patients failed treatment. Two patients were noted to have full-thickness ulcers and both failed formalin treatment. No complications were noted related to formalin treatment. CONCLUSION: We conclude that formalin therapy is a safe and effective form of treatment that can be performed in the office with minimal discomfort and no complications. It can be performed multiple times until results are achieved. Formalin therapy may be useful as a first-line treatment for chronic radiation proctitis, however, a prospective controlled trial comparing modalities is required to prove this to be true.

Redesigning clinical office practices to improve performance levels in an individual practice association model HMO.

Independent Health, a large health maintenance organization in western New York, is participating in a national initiative to redesign the way healthcare is delivered in the clinical office setting. The Idealized Design of Clinical Office Practices (IDCOP) project aims to initiate profound change in the ways physicians deliver care and treatment in the office; the focus is on demonstrating improvements in access to care, patient care, patient and staff satisfaction, and financial performance. Two clinical prototype test sites have successfully implemented an "open access policy," which enables most patients to see their physician on the day an appointment is requested. The two test sites also found improved clinical indicators (for diabetes and coronary heart disease) that positively affected the health of patients; reduced waiting time, enriching the overall experience of the office visit; and improved patient and staff satisfaction with the operational and care delivery modifications. This article describes the findings of the IDCOP initiative at Independent Health.

Annular colon lipoma: a case report and review of the literature.

Colonic lipomas are generally mildly symptomatic or asymptomatic pedunculated or sessile polyps, although they have been reported to cause intussusception or significant bleeding. The difficulty in differentiation is primarily with adenomatous polyps. We describe the unique case of a symptomatic annular colon lipoma simulating an annular colon carcinoma.

Elevated superoxide dismutase in Bloom's syndrome: a genetic condition of oxidative stress.

We have found that Bloom's syndrome (BS) cells exhibit elevated levels of superoxide dismutase activity. Since SOD activity has been shown to reflect the intracellular superoxide (O2-) content, these results indicate that BS cells exhibit oxidative stress which ultimately results in DNA damage. Elevated sister chromatid exchange, the major cytological characteristic of BS, and superoxide dismutase induction were simulated in normal lymphoblastoid cells by treatment with compounds that increase the steady-state concentration of O2(-.). The sister chromatid exchange response of a BS lymphoid cell line was modulated through the control of the endogenous O2-. content. We therefore suggest that a major biochemical defect resulting from this genetic disorder is chronic over-production of the superoxide radical anion. The consequence of high O2-. levels concomitant with induced superoxide dismutase activity is the formation of enormous amounts of H2O2 which can apparently inactivate the enzymes responsible for its elimination. The inefficient removal of peroxide can result in high rates of sister chromatid exchange and chromosomal damage in BS cells and in normal cells treated with oxidation-reduction cycling compounds through the formation of highly reactive intermediary forms of active oxygen.

The interaction of hemispheric preference, laterality, and sex in the perception of emotional tone and verbal content.

Twenty male and 20 female subjects, divided into those who showed a right or left hemispheric preference, listened to auditory messages with conflicting verbal content and emotional tone. The messages were presented to each ear to determine whether the effect of hemisphere of input on the evaluation of the messages was modified by hemispheric preference. Except for left preference males, subjects responded on the basis of preference rather than laterality.