A Novel, Dynamic Statistical Model for Predicting Patient Satisfaction with Fundoplication Based on Pre-Operative Symptom Patterns.

BACKGROUND: Fundoplication provides excellent control of gastro-oesophageal reflux disease (GORD), but there remain a number of unsatisfied patients who have proven difficult to identify pre-operatively. We hypothesised that pre-operative symptom patterns can predict of the risk of post-operative dissatisfaction. METHODS: Pre-operative symptoms and post-operative satisfaction were measured using standardised questionnaires along with routine investigations. These data were used to calculate our novel pre-operative risk of dissatisfaction (PROD) score. Potential pre-operative prognostic markers were tested against the post-operative satisfaction data, including the objective investigations and the PROD score. The prognostic utility of the PROD score and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) guideline was tested using receiver operating characteristic analysis to determine the area under the curve (AUC). RESULTS: An association was found between our PROD score and each of the satisfaction measures (n = 225, p < 0.001) which is likely to be of prognostic utility (AUC = 0.67-0.79). No such association was found between the routine investigations and post-operative satisfaction. The PROD score was found to be of greater prognostic utility than the SAGES guideline (n = 166, p < 0.001). CONCLUSIONS: The PROD score is a novel, easy-to-use test that can predict individual patient satisfaction with fundoplication.

Open Nissen fundoplication and highly selective vagotomy as a treatment for gastro-oesophageal reflux disease.

BACKGROUND: Open Nissen fundoplication has been the most common surgical treatment of gastro-oesophageal reflux disease (GORD). The present paper describes the symptomatic result, and quantifies the acid reduction achieved by open Nissen fundoplication combined with highly selective vagotomy (HSV) in a consecutive case series. METHODS: A study of 106 patients undergoing open Nissen fundoplication and HSV for GORD was performed between 1988 and 1996. A history consistent with reflux was obtained and the diagnosis confirmed with ambulatory oesophageal pH studies and endoscopy. Postoperative pH studies were performed, and peri-operative and late complications were recorded. A standard questionnaire was sent out to patients postoperatively to assess the efficacy of surgery. RESULTS: Pre-operative pH studies were performed on 104 (98%) patients, and on 97 (91.5%) following surgery. There was a highly significant improvement in all parameters of the pH study postoperatively. All symptoms, including bloating and dysphagia, improved significantly postoperatively, except flatulence, which was exacerbated. The majority of patients were very satisfied with their outcome, 82% rating the operation from 80 to 100% successful. Complications were rare and there was no mortality. CONCLUSIONS: Open Nissen fundoplication and HSV is an effective method of treating GORD, producing an improvement in symptoms and in ambulatory pH studies.

Pancreaticoduodenectomy of ampullary carcinoma.

Thirty-two consecutive patients with adenocarcinoma of the ampulla of Vater who had curative resection by pancreaticoduodenectomy were analyzed to determine the accuracy of preoperative investigations and factors that influenced survival. Obstructive jaundice was present in 31 patients, and most patients had pain and weight loss. Ultrasound was more useful than CT in identifying biliary obstruction, whereas CT was more accurate in demonstrating pancreatic duct dilatation and an ampullary mass. Endoscopic retrograde cholangiopancreatography with biopsy and brush cytology was the most accurate investigation and proved or was suspicious of carcinoma in all patients. Nineteen patients had postoperative complications, three of whom died (9.4%)-two of sepsis and one from aspiration following hematemesis. Actuarial 5-year survival was 46 per cent. Stage of disease was the strongest predictor of survival. All patients with T1 lesions are alive more than 5 years after resection. Patients with lymph node metastases had a significantly shorter survival than node-negative patients (P = 0.00087). Pancreaticoduodenectomy is advocated for ampullary carcinoma in good-risk patients, with the anticipation of prolonged survival in those with early (T1) lesions and node-negative disease.

Localization of a misplaced coronary artery stent by magnetic resonance imaging.

Coronary artery stents have been developed to overcome arterial abrupt closure and restenosis following balloon angioplasty. Complications of stent insertion include loss of the device from its delivery system into the peripheral circulation. Certain types of stents are almost radiolucent, making localization of the lost devices difficult. Nonferromagnetic metallic biomedical implants induce alteration of the local magnetic field and this leads to loss of signal from the surrounding tissues. We have used this property to localize a misplaced coronary artery stent in a 53-year-old man who underwent unsuccessful stent insertion. A 0.5 Tesla magnetic resonance scanner was used to acquire gradient-echo and spin-echo images. An in vitro experiment was first carried out on a stent similar to that used in our patient to establish that it was nonferromagnetic and to determine the optimum imaging technique. Gradient-echo images with a relatively long echo time (22 ms) gave the largest area of signal loss around the stent, and this sequence was used for localization of the stent found in the patient's left profunda femoris artery. This was subsequently confirmed by digital radiography. We have demonstrated the convenience and practicality of using magnetic resonance imaging for the localization of a misplaced coronary artery stent in a patient. The technique is safe, noninvasive, and uses no ionizing radiation.

Early exercise testing after treatment with thrombolytic drugs for acute myocardial infarction: importance of reciprocal ST segment depression.

OBJECTIVE: To investigate the clinical importance of reciprocal ST depression induced by exercise testing early after acute myocardial infarction in patients treated with thrombolysis. DESIGN: Prospective observational study. SETTING: District general hospital in London. SUBJECTS: 202 patients (170 men) aged 33-69 with acute myocardial infarction treated with thrombolysis. MAIN OUTCOME MEASURES: All patients underwent exercise testing and coronary arteriography. ST depression induced by exercise was classified as either reciprocal (associated with ST elevation) or isolated (occurring on its own). The relation between reciprocal ST depression and the following end points was studied: characteristics of the infarct, left ventricular ejection fraction, extent of coronary artery disease on arteriography, and presence of angina induced by exercise. RESULTS: Reciprocal ST depression occurred almost exclusively in Q wave infarctions and was associated with a lower overall ejection fraction than isolated ST depression. It tended to be associated with persistent occlusion of the coronary artery related to the infarct and did not indicate remote ischaemia due to multivessel coronary disease. Unlike isolated ST depression, reciprocal ST depression was not associated with angina induced by exercise. CONCLUSIONS: Reciprocal ST depression induced by exercise is usually associated with extensive Q wave infarctions and persistent occlusion of the artery related to the infarct. It does not seem to indicate reversible ischaemia and should not be used as a non-invasive marker of multivessel disease in the assessment of requirements for further investigation soon after acute myocardial infarction.

Bile leakage after laparoscopic cholecystectomy: biliary anatomy revisited.

Bile leakage from the gall-bladder bed following laparoscopic cholecystectomy is recognized as a potential cause of major morbidity. This problem is usually attributed to division of ducts draining a portion of liver directly into the gall-bladder. The authors' experience, however, and a review of the literature suggests that injury to a superficial duct draining into the major hepatic ducts rather than the gall-bladder is the principal cause of this problem. Three patients with bile leakage demonstrated on postoperative biliary tract imaging are presented with a discussion of the literature.

Comparing DuoDERM E with scarlet red in the treatment of split skin graft donor sites.

A prospective, randomised, controlled study compared DuoDERM E (DE) with scarlet red (SR) in the treatment of split skin graft donor areas in 60 patients. Healing and donor site comfort were significantly better in the DE group. There was no clinical infection in either group. The wound leakage rate was higher in the DE group, requiring an average of 0.8 replacement dressings per donor site as compared with an average of 0.04 for the SR group. An estimate of the cost per donor site for the first ten days of dressing is given.

A comparison of Zenoderm with DuoDERM E in the treatment of split skin graft donor sites.

A prospective, randomised, controlled study compared Zenoderm (ZM) with DuoDERM E (DE) in the treatment of split skin graft donor areas in 64 patients. The donor site comfort was similar in the two groups. DE usage resulted in significantly faster healing but also a higher leakage rate than ZM. Two patients in the ZM group developed infection in their donor sites. The cost is significantly less with ZM than DE.

Calcitonin gene-related peptide: a haemodynamic study of a novel vasodilator in patients with severe chronic heart failure.

The haemodynamic and neurohumeral response to a novel vasodilator calcitonin gene-related peptide was assessed in 11 patients with severe chronic heart failure. To assess tolerance, a continuous 48-h infusion (n = 6) was compared with a regimen of two successive 8-h infusions (n = 5). Haemodynamic response profiles were similar for both regimens, though the continuous infusion was poorly tolerated. Reductions in afterload reflected by changes in systemic vascular resistance and systemic blood pressure led to increases in cardiac index of at least 24%. Increments in heart rate accounted for much of the increase in cardiac output, there being no significant change in stroke volume index. The response was maintained over the 48-h study period with no tachyphylaxis. Renin and angiotensin levels increased significantly after 24 h. Calcitonin gene-related peptide exerts a favourable haemodynamic response in patients with severe heart failure. The dose used in this study, however, caused troublesome side-effects, particularly when given by continuous infusion. Further studies are required to establish the therapeutic range of this new peptide.

Lignocaine vs bupivacaine in prominent ear correction: a controlled trial.

Thirty patients were assigned to two equal groups to compare the effects of ear infiltration with bupivacaine versus lignocaine prior to correction of prominent ears. There was a statistically significant decrease in narcotic requirement in the first 4 h postoperatively in the bupivacaine group, associated with a decrease in the antiemetic requirement. The choice of local anaesthetic did not significantly affect the incidence of vomiting.

Open access exercise electrocardiography: a service to improve management of ischaemic heart disease by general practitioners.

An initial study of the use of open access exercise electrocardiography by general practitioners (GPs) in South East Kent showed that patient selection and interpretation of test results was frequently incorrect. After issuing guidelines, modifying the request form and instituting registrar review of all requests, significant improvements in both referral pattern, result interpretation and patient management have resulted. Forty-nine GPs requested 110 exercise tests during 1988/89. Twelve per cent were not undertaken after discussion with the referring practitioner. Eighty-four per cent of those tested would have been referred to the district general hospital cardiology outpatient department in the absence of open access exercise electrocardiography service. Six per cent of patients were referred directly for invasive investigation. Thirty-five per cent were referred to the district general hospital cardiology outpatient department, whilst 42% were spared hospital referral based on the result of the investigation. Better use of the modified service was suggested by: referral of fewer patients with non-cardiac chest pains (P = 0.002); more patients with a moderate pre-test probability of ischaemic heart disease (P less than 0.05); fewer inappropriate requests (P less than 0.01); and fewer inappropriately undertaken tests (P less than 0.001) than in the previous study. All patients with strongly positive test results were appropriately managed. Open access exercise electrocardiography in the format investigated is potentially a cost-effective and useful tool to improve diagnosis and management of heart disease by GPs.

Sensitivity of endoscopic detection of malignancy in resectable gastric carcinoma.

In 50 consecutive cases of resected gastric carcinoma the absolute sensitivity in making an unequivocal pre-operative diagnosis was 54% for endoscopic inspection, 76% for biopsy and 48% for cytology. Inspection and biopsy in combination yielded 90% and adding cytology achieved 92% absolute sensitivity. The relative sensitivity (which included equivocal reports) was far higher for each individual test, and 100% for the combination of all three, but did not reflect the clinical value of these investigations as clinicians did not react appropriately to equivocal reports. Thus for the endoscopic detection of gastric carcinoma in routine clinical practice, inspection was insensitive, biopsy mandatory, cytology of little additional value and endoscopic followup of apparently benign lesions appeared important.

The voltage-sensitive sodium channel from rabbit skeletal muscle. Chemical characterization of subunits.

The alpha and beta subunits of the rabbit skeletal muscle sodium channel have been separated and isolated preparatively under denaturing conditions. In this sodium channel, the beta subunit is not linked covalently to the alpha subunit. The isolated subunits have been subjected to amino acid and carbohydrate analysis. Both subunits are heavily glycosylated (alpha = 26.5%, beta = 29.7% carbohydrate by weight) with N-acetylneuraminic acid and N-acetylhexosamines representing the predominant monosaccharides in each. Enzymatic deglycosylation with neuraminidase and endoglycosidase F yielded single core peptides of approximately 209 kDa for the alpha subunit and 26.5 kDa for the beta subunit. Based on the known carbohydrate composition, the molecular masses for the glycosylated subunits are, therefore, 285 and 37.5 kDa for alpha and beta, respectively. Using the isolated subunits, we calibrated our protein-labeling system on sodium dodecyl sulfate-polyacrylamide gel electrophoresis and determined the subunit stoichiometry for the rabbit skeletal muscle channel; in the native preparation, the molar ratio of alpha:beta is 1 : 1.

Voltage-sensitive sodium channels: an evolving molecular view.

Sodium channel proteins have now been isolated from a number of nerve and muscle preparations. All are characterized by the presence of a very large glycoprotein subunit of approximately 260 kilodaltons which may contain the structural features required for voltage-dependent channel gating and cation selectivity. These purified proteins have been reconstituted into vesicle systems and planar bilayers and demonstrate the ensemble and single-channel behavior characteristic of the native sodium channel. Although the sodium channel from eel appears to consist of only the 260-kilodalton protein, the channels from rat brain and rat or rabbit skeletal muscle contain one or more smaller subunits of 37-39 kilodaltons. In skeletal muscle, a 38-kilodalton subunit is present in both conventionally purified channel and channel isolated with immunoaffinity techniques. The stoichiometry of the large (alpha) and the small (beta) subunits appears to be 1:1 in skeletal muscle but 1:2 in rat brain. The role of the small subunits in the normal functioning of the sodium channel remains to be defined.

Evaluation of cyfluthrin as a ULV cold aerosol against caged mosquitoes.

Cyfluthrin was evaluated against caged mosquitoes using a truck-mounted Leco HD model ULV cold aerosol generator and the results were compared to the effectiveness of malathion. Calculated effective dosages (ED) for 90% and 95% control with cyfluthrin against Aedes taenorhynchus were 0.2 and 0.3 g AI/ha and against Anopheles quadrimaculatus were 0.09 and 0.1 g AI/ha. Cyfluthrin was about 106X more effective against An. quadrimaculatus and about 69X more effective against Ae. taeniorhynchus at the ED-95 level than malathion.

Laboratory evaluation of four organophosphate compounds as larvicides against field collected salt marsh Culicoides spp. (Diptera: Ceratopogonidae).

The relative effectiveness of 4 organophosphate compounds was tested in the laboratory against Culicoides spp. larvae obtained from salt marsh areas on the Gulf coast of Florida. Larvae were exposed to the insecticide either in estuarine water or in a combination of estuarine water and dried substrate from the salt marsh habitat. The relative potency of the 4 chemicals varied greatly, with chlorpyrifos being the most toxic. Nine times as much temephos, 22 times as much fenthion, and 176 times as much malathion were required to achieve the 50% mortality level compared to chloryprifos (LC50, 0.5 ppb) in water. Addition of habitat soil did not change the order of effectiveness, but 9 times as much chlorpyrifos, 2.3 times as much temephos, and 1.3 times as much fenthion or malathion were required to cause the same mortality as in estuarine water alone.