Treatment of anal fissure: a survey of surgical practice in Australia and New Zealand.

AIM: The aim was to determine whether or not the clinical management of anal fissure in Australia and New Zealand accords with published guidelines. METHODS: A comprehensive survey based on common clinical scenarios was distributed to 206 colorectal surgeons in Australia and New Zealand. RESULTS: The response rate was 44% (91 surgeons). For 19 topic areas, only seven (37%) reached consensus (defined as > 70% majority opinion). Of these, six (86%) agreed with guideline recommendations. Twelve (63%) topic areas demonstrated community equipoise (defined as less than or equal to 70% majority opinion), of which five (42%) agreed with guideline recommendations and seven (58%) disagreed with guidelines. Of the seven topics that disagreed with guidelines, three were based on moderate quality evidence (first line management of acute anal fissure in a young patient, fissure healing and faecal incontinence rates following anocutaneous flap) and four were based on low quality evidence (length of sphincter division during a lateral sphincterotomy in women, management of chronic low-pressure anal fissures postpartum, fissure healing rate following anoplasty with botulinum toxin or sphincterotomy and faecal incontinence rates following repeat sphincterotomy for recurrence). Consensus and/or agreement with guidelines were more prevalent in management when medical therapy failed. CONCLUSION: While areas of consensus mostly agreed with guideline recommendations, there remain many areas of community equipoise which warrant further research.

A systematic review of online resources to support patient decision-making for full-thickness rectal prolapse surgery.

BACKGROUND: The internet is becoming an increasingly popular resource to support patient decision-making outside of the clinical encounter. The quality of online health information is variable and largely unregulated. The aim of this study was to assess the quality of online resources to support patient decision-making for full-thickness rectal prolapse surgery. METHODS: This systematic review was registered on the PROSPERO database (CRD42017058319). Searches were performed on Google and specialist decision aid repositories using a pre-defined search strategy. Sources were analysed according to three measures: (1) their readability using the Flesch-Kincaid Reading Ease score, (2) DISCERN score and (3) International Patient Decision Aids Standards (IPDAS) minimum standards criteria score (IPDASi, v4.0). RESULTS: Overall, 95 sources were from Google and the specialist decision aid repositories. There were 53 duplicates removed, and 18 sources did not meet the pre-defined eligibility criteria, leaving 24 sources included in the full-text analysis. The mean Flesch-Kincaid Reading Ease score was higher than recommended for patient education materials (48.8 ± 15.6, range 25.2-85.3). Overall quality of sources supporting patient decision-making for full-thickness rectal prolapse surgery was poor (median DISCERN score 1/5 ± 1.18, range 1-5). No sources met minimum decision-making standards (median IPDASi score 5/12 ± 2.01, range 1-8). CONCLUSIONS: Currently, easily accessible online health information to support patient decision-making for rectal surgery is of poor quality, difficult to read and does not support shared decision-making. It is recommended that professional bodies and medical professionals seek to develop decision aids to support decision-making for full-thickness rectal prolapse surgery.

Marine dolomite of unusual isotopic composition.

A piston core taken off of the coast of Oregon in 358 meters of water contained an indurated calcareous layer composed partly of dolomite with a composition Ca(58.7)Mg(41.3). Dolomites of this chemical composition are typical of the supratidal environment. However, the dolomite has isotopic composition delta0(18) = 5.8 per mille, deltaC(13) = 35.1 per mille relative to the Chicago PDB-I standard. The unusual carbon isotope ratio is similar to that of calcites produced as a byproduct of bacterial breakdown of hydrocarbons.

Sewage sludge-based adsorbents: a review of their production, properties and use in water treatment applications.

The imposition of more stringent legislation governing the disposal and utilisation of sewage sludge, coupled with the growth in its generation and the loss of traditionally accepted disposal routes, has prompted a drive for alternative uses for sewage sludge. One option that exhibits special promise, due to its potential to valorise the sludge, is the conversion of the sludge into adsorbents. This paper seeks to review the published research in this field: it covers the means of production, the characteristics and the potential applications of sewage sludge-based adsorbents (SBAs). The literature has indicated that chemical activation utilising alkali metal hydroxides is the most effective technique for producing high surface area SBAs. In addition, acid washing is highly effective at raising the BET surface area of SBAs, especially when coupled with physical activation. Due to their relatively low microporosity, the phenol uptake of SBAs produced by physical activation is low, but through a combination of their favourable surface chemistry and relatively high mesoporosity, the best of these adsorbents can attain high uptakes of organic dyes. The SBAs produced by carbonisation, through their high cation exchange capacity, generally exhibit a high metal cation capacity. For further research, the following investigations are recommended: the utilisation of alternative chemical activation reagents; the optimisation of the most effective chemical activation techniques; the combined utilisation of different activation and surface chemistry modification techniques to produce application-specific adsorbents.

Liverpool Ultrasound Pictorial Chart: the development of a new method of documenting anal sphincter injury diagnosed by endoanal ultrasound.

OBJECTIVE: To develop and validate a pictorial chart that documents ultrasound examination of the anal sphincter. DESIGN: A new pictorial chart (Liverpool Ultrasound Pictorial Chart [LUPIC]) depicting the normal anatomy of the anal sphincter was developed. METHODS: To validate LUPIC, two observers documented the findings of 296 endoanal scans. Reliability was assessed between observers using kappa agreement for presence and position of sphincter defects. To validate the use of LUPIC by different observers, a video of ten endoanal ultrasound scans was reviewed by our local expert (gold standard). Seven clinicians underwent test-retest analysis. Kappa agreement was calculated to assess intra-observer and gold standard versus observer agreement for the overall presence of sphincter defects and compared with the gold standard. Complete agreement for the position and level of sphincter defects was assessed for the five abnormal scans. MAIN OUTCOME MEASURES: Excellent agreement between the two observers was found for the presence (kappa 0.99), position and level of external anal sphincter defects documented using LUPIC. The intra-observer and gold standard versus observer kappa values of experienced clinicians (A-E) showed good agreement for the overall presence of sphincter defects. Complete agreement for the position and level of sphincter defects was found in 23 of 35 (66%) observations. CONCLUSIONS: LUPIC is designed and validated method of documenting anal sphincter injury diagnosed by endoanal ultrasound. Standardisation of endoanal ultrasound findings by using LUPIC may help correlate the degree of damage with patient symptoms.

Assessment of the risk of introduction of Anoplophora glabripennis (Coleoptera: Cerambycidae) in municipal solid waste from the quarantine area of New York City to landfills outside of the quarantine area: a pathway analysis of the risk of spread and establishment.

The risk associated with spread of Asian longhorned beetle, Anoplophora glabripennis (Motschulsky), from infested areas in New York City to the wide array of landfills across the eastern United States contracted by the city since 1997 was unknown, but of great concern. Landfills, some as far as South Carolina, Virginia, and Ohio, occupied forest types and climates at high risk of Asian longhorned beetle establishment. The city proposed a separate waste wood collection known as the "311 System;" this was estimated to cost federal and state agencies $6.1 to $9.1 million per year, including the cost of processing and disposal of the wood. Pathway analysis was used to quantify the probability that Asian longhorned beetle present in wood waste collected at curbside would survive transport, compaction, and burial to form a mated pair. The study found that in seven alternate management scenarios, risks with most pathways are very low, especially given existing mitigations. Mitigations included chemical control, removal of infested trees, and burial of wood waste in managed landfills that involved multiple-layering, compaction, and capping of dumped waste with a 15-cm soil cover at the end of each day. Although the risk of business-as-usual collection and disposal practices was virtually nil, any changes of policy or practice such as illegal dumping or disposal at a single landfill increased the risk many thousandfold. By rigorously maintaining and monitoring existing mitigations, it was estimated that taxpayers would save $75 to $122 million dollars over the next decade.

HIV/AIDS-related attitudes and practices of hospital-based health workers in Kampala, Uganda.

OBJECTIVE: To assess HIV/AIDS-related attitudes and practices of hospital-based health workers in Kampala, Uganda. METHODS: A cross-sectional study was conducted in Mulago Hospital, the main national referral hospital in Uganda. A total of 155 physicians and nurses completed a brief questionnaire on HIV risk perception, attitudes and practices regarding AIDS prevention education, HIV counseling and testing and care of patients with HIV disease. RESULTS: Twenty-nine per cent of health workers reported never having discussed AIDS prevention with patients, 26% had never referred patients for HIV counseling and 31% had never advised patients suspected of HIV infection to be tested. Frequent explanations for not providing AIDS prevention education included time constraints and/or lack of related knowledge or skills. While 29% perceived recapping needles as involving no risk, activities involving casual contact with patients and condom use for protection against HIV infection were associated with a high perceived risk of HIV transmission, particularly among nurses. Physicians and nurses differed in their HIV/AIDS-related attitudes and practices. The physicians had a more positive attitude towards the care of patients with HIV disease. In addition, 80% of physicians compared to 59% of nurses referred patients for HIV counseling. A similar trend was found for advising patients to obtain HIV testing. CONCLUSIONS: Hospital-based health workers are missing important opportunities for AIDS prevention education with their patients. There are gaps in their knowledge about HIV and related infection control practices. Interventions should address their concerns and barriers to HIV prevention practices.

Acute flaccid neonatal paraplegia: a case report.

A 3-day-old neonate became acutely and irreversibly paraplegic below L1/L2 after umbilical artery catheterization. The paraplegia was attributed to infarction of the spinal cord because of thrombosis of the artery of Adamkievicz or injection of drugs through the catheter into the spinal cord circulation. Catheterization of a more peripheral artery or placement of the umbilical catheter tip at a lower level in the aorta may prevent similar complications.

Smoking cessation methods: recommendations for health professionals. Advisory Group of the European School of Oncology.

Smoking is the leading preventable cause of death. Approximately 40% of Europeans now smoke. Many smokers want to stop but do not make the attempt, and of those who try, most are unsuccessful. Primary care health providers can help their patients to stop by using brief behavioural and pharmacological interventions. Specialised smoking cessation clinics can support selected patients referred by primary care providers. This report reviews intervention techniques for health care providers, which, in combination with effective legislative and educational interventions, can significantly reduce the prevalence of smoking.

Relationship between blood pressure measured in the clinic and by ambulatory monitoring and left ventricular size as measured by electrocardiogram in elderly patients with isolated systolic hypertension.

OBJECTIVE: To assess the additional diagnostic precision conferred by ambulatory blood pressure monitoring on clinic blood pressure measurement in evaluating the severity of isolated systolic hypertension. METHODS: The association between left ventricular size as determined by ECG voltages [R-wave voltages in lead V5 (RV5) and S-wave voltages in lead V1 (SV1)] and blood pressure as assessed by clinic measurements and ambulatory blood pressure monitoring was studied in 97 elderly patients included in the placebo run-in phase of the Syst-Eur trial. The additional diagnostic precision conferred by ambulatory monitoring on clinic blood pressure measurements was assessed by relating the residual ambulatory blood pressure level to the ECG-left ventricular size. The residual ambulatory blood pressure level was calculated by subtracting the predicted ambulatory blood pressure level for each patient (using the linear regression equation relating both techniques for the group) from the observed ambulatory blood pressure. RESULTS: Clinic systolic blood pressure was on average 20 mmHg higher (P < 0.001) than daytime ambulatory blood pressure while diastolic blood pressure was similar with both techniques. The sum of SV1 + RV5 was significantly related to clinic systolic pressure (r = 0.25), and 24-h (systolic, r = 0.37; diastolic, r = 0.29), daytime (systolic, r = 0.30; diastolic, r = 0.19) and night-time (systolic, r = 0.33; diastolic, r = 0.28) ambulatory blood pressure levels. These findings were not affected by adjustment for gender, age and the body mass index. The sum of SV1 + RV5 was significantly related to the residual 24-h (systolic, r = 0.30; diastolic, r = 0.31), daytime systolic (r = 0.20) and night-time (systolic, r = 0.31; diastolic, r = 0.29) ambulatory blood pressure monitoring levels. CONCLUSION: Ambulatory blood pressure monitoring adds to the diagnostic precision of clinic blood pressure measurement in assessing the severity of hypertension in this population. The ongoing side project on ambulatory blood pressure monitoring in the Syst-Eur study should establish whether these findings hold true for morbidity and mortality.

Ambulatory blood pressure monitoring in elderly patients with isolated systolic hypertension.

OBJECTIVES: This study compared clinic and ambulatory blood pressure measurement and the reproducibility of these measurements in older patients with isolated systolic hypertension (ISH). PATIENTS: Eighty-seven patients aged greater than or equal to 60 years with ISH on clinic measurement were followed in the placebo run-in phase of the Syst-Eur trial. METHODS: Clinic blood pressure was defined as the mean of two blood pressure readings on each of three clinic visits (six readings in total). Ambulatory blood pressure was measured over 24 h using non-invasive ambulatory blood pressure monitors. RESULTS: Daytime ambulatory systolic pressure was, on average, 21 mmHg lower than the clinic blood pressure, whereas diastolic pressure was, on average, similar with both techniques of measurement. In the 42 patients who had repeat measurements, clinic blood pressure levels nad the amplitude of the diurnal blood pressure profile (fitted by Fourier analysis) were equally reproducible. However, both were less reproducible than ambulatory blood pressure levels. The repeatability coefficients, expressed as per cent of near maximum variation (four times the standard deviation of a given measurement), were 52% and 45% for the clinic systolic and diastolic pressures, 56% and 42% for the amplitude of the diurnal profile, and 29% and 26% for mean 24-h pressures. CONCLUSIONS: In older patients with ISH, clinic and ambulatory systolic blood pressure measurements may differ largely: the prognostic significance of this difference remains to be elucidated. Furthermore, in these patients the level of pressure is more reproducible by daytime ambulatory blood pressure measurement than by clinic measurement.

Bench and ambulatory field evaluation of the A & D TM-2420 automated sphygmomanometer.

Adequate evaluation of automated sphygmomanometers, in terms of safety, accuracy, mechanical reliability, patient acceptability and ability to record ambulatory blood pressure is essential before these devices are used in clinical practice and in clinical trials. We have evaluated the accuracy and performance of the A & D TM-2420 automated sphygmomanometer, an auscultatory device designed for ambulatory blood pressure recording. Four devices were tested for accuracy by simultaneous comparison against two experienced observers using standard mercury column sphygmomanometers. Two of these devices developed faults that precluded complete evaluation. One of the remaining devices met and one failed to meet the somewhat liberal criteria for accuracy recommended by the American Association for the Advancement of Medical Instrumentation, the current standard for evaluation (mean difference of less than or equal to 5 mmHg and standard deviation of differences less than or equal to 8 mmHg). The mean differences (standard deviation of differences) between observers for simultaneous triplicate observations of systolic/diastolic pressure in 50 subjects, including 35 hypertensives, were 0.8 (3.0)/-0.6 (2.4) mmHg. In comparison, the differences between each device and each observer were: device 11, observer 1, -6.4 (5.4)/-6.3 (9.9); device 11, observer 2, -5.6 (4.7)/-7.0 (10.4); device 12, observer 1, -4.9 (5.2)/-4.0 (7.5); device 12, observer 2, -4.1 (4.9)/- -4.5 (7.7) mmHg. Ambulatory trials were carried out with a further 10 devices. Of these, seven developed faults requiring their return to the supplier. Numerous additional problems were encountered with microphones, cuffs, leads and connections, the processing unit, error algorithms and data-handling software. The device was not capable of making truly ambulatory recordings. We do not confirm the previously favourable, but limited, evaluation of this device. We stress the vital importance of subjecting a number of devices to benchtesting for accuracy, and the need to undertake extensive 'field' testing before any devices can be considered suitable for ambulatory recording. Exercise testing under laboratory conditions is not an adequate substitue for true ambulatory evaluation.

Neural analysis of visual information during locomotion.

For most vertebrate species, vision is critical during locomotion. In this review, we survey what is known about neural mechanisms that might be involved in this visual analysis. Problems that such mechanisms are likely to solve include: (1) determination of heading (the discrepancy between an observer's direction of motion and direction of gaze); (2) detection of course changes; (3) setting of courses using goals and landmarks; (4) obstacle avoidance; (5) accurate foot placement. To understand how the visual system handles these tasks, we must first consider what neurons 'see' during locomotion: this is determined both by an observer's motion and by his gaze. We then review response properties of neurons in the cortical 'motion pathways' of the monkey and cat as they relate to problems encountered during locomotion. The most studied areas are the medial superior temporal area in the monkey, which has been linked to heading determination, and the lateral suprasylvian area in the cat, where many cells are sensitive to motion in depth, and some are selective for optic flow patterns generated during locomotion. A few subcortical populations have also been linked to visual analysis during locomotion. Most notable are cells in the pigeon's nucleus rotundus: these respond selectively to looming stimuli, some firing at a specific time before the stimulus collides with the bird. Another intriguing population is in the cat's visual pontine nucleus, where cells respond to large displays suggestive of optic flow during locomotion.

Omeprazole may exert both a bacteriostatic and a bacteriocidal effect on the growth of Helicobacter pylori (NCTC 11637) in vitro by inhibiting bacterial urease activity.

AIMS: To assess the potential antibacterial effect of omeprazole, a benzimidazole proton pump inhibitor, on the growth of Helicobacter pylori in vitro and to evaluate the effect of this compound on bacterial urease activity. METHODS: The growth of H pylori was observed in liquid culture in the presence and absence of omeprazole (0.8 mg/ml). Urease activity was evaluated in aliquots removed from two hour cultures by monitoring the initial change in absorbency at 560 nm in the presence of 0.02% phenol red. RESULTS: The minimum inhibitory concentration of omeprazole against H pylori was 0.8 mg/ml. The concentration of omeprazole required to inhibit growth was dependent on inoculum density: omeprazole (0.8 mg/ml) prevented growth from a 1 x 10(6) cfu/ml inoculum, but not from the higher inocula of 10(7) or 10(8) cfu/ml. This is the first study to demonstrate that omeprazole exerts a bacteriocidal effect against low bacterial densities and a bacteriostatic effect when bacterial density is high. When used at the onset of growth, this concentration of omeprazole has a bacteriocidal effect after four hours, although it exerts a bacteriostatic effect when added to cultures after the exponential phase. Bacterial urease activity is competitively inhibited by omeprazole in a dose dependent manner. CONCLUSION: The results suggest that omeprazole exerts both a bacteriocidal and a bacteriostatic effect against H pylori and competitively inhibits bacterial extracellular urease activity.

Prolonged survival of axons terminating within lesions of cat visual cortex.

It is well known that brain lesions made by the injection of ibotenic acid destroy neuronal cell bodies but do not kill passing axons. We have found that axons terminating within such lesions in visual cortex also survive for at least 2 months, despite the absence of available synaptic sites. We made tracer injections in area 17, and observed dense patches of anterograde label within lesions in other visual cortical areas. Furthermore, because the retinotopic site of the tracer injection was known, we could conclude that the retinotopic site was encompassed within the lesion.

Coronary event and case fatality rates in an English population: results of the Oxford myocardial infarction incidence study. The Oxford Myocardial Infarction Incidence Study Group.

OBJECTIVES: To determine coronary event and case fatality rates in an English population aged less than 80 years in Oxfordshire, and to compare these rates with those reported by the UK monitoring trends and determinants of cardiovascular disease (MONICA) centres in Scotland and Northern Ireland and those ascertained in Oxfordshire in 1966-67. DESIGN: A population wide surveillance study conducted in 1994-95 using prospective and retrospective case ascertainment. SETTING: A resident population in Oxfordshire of 568,800. SUBJECTS: Patients with suspected myocardial infarction or coronary death. OUTCOME MEASURES: A diagnosis of definite or possible myocardial infarction or coronary death using WHO MONICA diagnostic criteria based on symptoms, electrocardiograms, cardiac enzymes, necropsy findings, and past medical history. RESULTS: The annual rate for a first or recurrent coronary event per 100,000 population aged less than 65 years in 1994-95 was 273 for men and 66 for women after age adjustment to a standard world population. Rates in the age group 65-79 years were 1350 for men and 677 for women. Between 1966-67 and 1994-95, the age standardised event rate in the age group 30-69 years decreased significantly by 33% (95% confidence interval (CI) 44 to 21) in men, and there was a non-significant reduction of 8% (95% CI -33 to 17) in women. The age standardised 28 day case fatality rates also decreased significantly by 28% (95% CI 41 to 15) in men and by 32% (95% CI 55 to 9) in women. CONCLUSIONS: The coronary event rate in Oxfordshire was much lower than rates reported by MONICA centres in Glasgow and Belfast, and similar to rates reported by MONICA centres in France and northern Italy. The substantially lower event rate accounts for lower coronary heart disease mortality in Oxfordshire than in Scotland and Northern Ireland. The reduced coronary mortality in this region is attributable to declines in coronary event and case fatality rates.

Predictors of successful smoking cessation following advice from nurses in general practice.

At follow-up of 751 subjects receiving a brief nurse-administered anti-smoking intervention in general practice, 135 subjects (18%) reported stopping smoking, of whom 44 (6%) reported sustained cessation for one year. The demographic, social and attitudinal characteristics of these subjects were compared with 616 subjects who continued to smoke. The most important predictors of cessation were intention to stop (OR 5.1, 95% CI 2.1-12.0), personal rating of likelihood of cessation (OR 4.9, 95% CI 2.8-8.5), nurse rating of likelihood of cessation (OR 4.0, 95% CI 2.2-7.4), and smoking habit of partner (1.9, 95% CI 1.3-2.9). As practice nurses are able to distinguish likely quitters from those who are not motivated and less likely to succeed, it is important to decide whether it is more cost effective to target support at the motivated or to spend more time encouraging less motivated. The most challenging, but possibly the most rewarding, task is to try to reduce the high proportion of new ex-smokers who relapse. Although 41.1% (95% CI 28.1, 58.0) of those expressing a definite intention to stop smoking gave up, only 17.9% (95% CI 8.9, 30.4) achieved sustained cessation. However, as sustained cessation is strongly predicted by social variables, such as marital status and time spent in the company of smokers, preventing relapse may not be easy to achieve through medical intervention alone.

Differences between amlodipine and lisinopril in control of clinic and twenty-four hour ambulatory blood pressures.

The anti-hypertensive efficacy of once-daily amlodipine (up to 10 mg) and lisinopril (up to 20 mg) were compared in terms of clinic and ambulatory blood pressure (BP) control, in an observer-blind, two-period crossover study. Following a 4-week placebo run-in period, patients underwent two active treatment phases each lasting 12 weeks and separated by a 4-week washout period. Sixty patients with a supine diastolic BP between 90 and 120 mm Hg were included, irrespective of whether or not they had received previous anti-hypertensive medication. Amlodipine reduced supine systolic and diastolic clinic BP significantly more than lisinopril (-20+/-2/-14+/-1 vs -11 3/-7+/-1 mm Hg; P=0.02/ P=0.001) 24 h post-dose. Clinic standing diastolic BP was also significantly reduced with amlodipine compared with lisinopril (P=0.05). Both drugs produced control of mean ambulatory BP relative to baseline over 24 h. Amlodipine showed more consistent control of BP over the 24-h period in contrast to lisinopril which exerted its greatest effect during the daytime.