Systematic review and meta-analysis of laparoscopic Nissen fundoplication with or without division of the short gastric vessels

BACKGROUND

The aim of this meta-analysis was to provide a pooled analysis of individual trials comparing clinical outcome following laparoscopic Nissen fundoplication with or without division of the short gastric vessels (SGVs).

METHODS

Primary outcome measures were the requirement for reoperation, and the presence of postoperative gastro-oesophageal reflux and postoperative dysphagia. Secondary outcome measures were duration of operation, length of hospital stay, postoperative complications (within 30 days of surgery), postoperative gas bloat syndrome, lower oesophageal sphincter resting pressure and DeMeester score. Pooled odds ratios were calculated for categorical outcomes, and weighted mean differences for secondary continuous outcomes, using random-effects models for meta-analysis.

RESULTS

Five randomized trials were included in the analysis. There was no statistically significant effect on the requirement for reoperation, or presence of postoperative dysphagia or reflux. SGV division was associated with a longer duration of operation and a reduced postoperative lower oesophageal sphincter pressure. There was no statistically significant difference in length of hospital stay, postoperative complications, postoperative gas bloat syndrome or DeMeester score.

CONCLUSION

This meta-analysis has demonstrated that clinical outcome following laparoscopic Nissen fundoplication appears to be similar regardless of whether the short gastric vessels are divided. However, it is not possible to exclude many potentially important clinical differences and further studies are needed.

Delayed transhiatal herniation of the small bowel after Ivor Lewis esophagectomy

Transhiatal intrathoracic herniation of the intestine after an Ivor Lewis esophagectomy is an unusual occurrence. This complication may present after any form of esophagectomy at varying intervals following primary surgery. Diagnosis is established on the basis of presenting symptoms and radiological features on computed tomography (CT scan). The authors herewith report this rare occurrence 42 months after an Ivor Lewis esophagectomy. The patient had herniation of the small bowel into the left pleural cavity , which was treated surgically through an entirely intra-abdominal approach and the defect in the diaphragm was bridged using a prosthetic polypropylene mesh.

Maternal obesity: a review of interventions

BACKGROUND

Obesity has become a serious global public health issue and has consequences for nearly all areas of medicine. Within obstetrics, obesity not only has direct implications for the health of a pregnancy but also impacts on the weight of the child in infancy and beyond. As such, maternal weight may influence the prevalence and severity of obesity in future generations. Pregnancy has been identified as a key time to target a weight control or weight loss strategy to help curb the rapidly growing obesity epidemic. In addition, if delivered sensitively, pregnancy may be a good time to target health behaviour changes by using the extra motivation women tend to have at this time to maximise the health of their child.

AIM

This study reviews the current evidence for interventions to promote weight control or weight loss in women around the time of pregnancy. A comprehensive review of medical research--PubMed, Embase, Ovid Medline and the Cochrane Clinical Trials register--showed that despite numerous reports of the prevalence and complications of maternal obesity, few intervention strategies have been suggested.

CONCLUSION

This study finds that there is a deficiency of appropriately designed interventions for maternal obesity and it concludes by highlighting areas for developing a more effective strategy.

STI management in Tanzanian private drugstores: practices and roles of drug sellers

OBJECTIVES

To describe the role and possible contribution of private drugstores in sexually transmitted infection (STI) management in rural Tanzania.

METHODS

A cross-sectional study that included drug sellers in private drugstores in eight districts of Tanzania. Data collected through interviews with drug sellers and the simulated client method presenting a male and female STI case. "QATI" scores (Questions, Advice, Treatment and drug Information) were developed to describe overall STI management.

RESULTS

Although 74% of drug sellers stated that there were no STI-related drugs in the store, medications were dispensed in 78% of male and 63% of female simulated client visits. The clients were dispensed drugs recommended in the Tanzanian guidelines for syndromic management of urethral or vaginal discharge in 80% of male and 90% of female cases. Drug sellers dispensed antibiotics during 76% of male and 35% of female simulated client visits. Dosage regimens were often incorrect and complete syndromic management rarely provided. Most drug sellers agreed that it is within their professional role to give information on STI treatment (89%) and prevention (95%). Drug-use information was almost always provided. Advice was however seldom given and questions occasionally asked. Overall STI management was better for men than for women.

CONCLUSIONS

The drug sellers, although aware of the prescription-only status of antibiotics, saw themselves as having a role in STI management and were ready to provide drugs. In this resource-limited setting, drug sellers could provide effective and safe STI management especially to male patients if given appropriate tools to improve practice. The consequences of this for official policy need to be discussed.

Are patients with hematuria appropriately referred to Urology? A multi-institutional questionnaire based survey

INTRODUCTION

Hematuria is a common finding that may be a sign of serious underlying urologic disease. Thus, the AUA guidelines (written in conjunction with the American Academy of Family Practice) recommend urologic evaluation for patients with both microscopic and gross hematuria. We sought to evaluate practice patterns of the evaluation of hematuria by primary care physicians (PCPs) in two locations in the United States.

METHODS

Anonymous questionnaires regarding use of urinalysis (UA) and evaluation of hematuria were mailed to 586 PCPs in Miami, Florida and 1,915 in Dallas, Texas. Surveys were mailed to physicians who identified themselves as practitioners of internal medicine, family practice, primary care, or obstetrics and gynecology.

RESULTS

Surveys were completed by 788 PCPs including 270 (46%) and 518 (26%) PCPs in Miami and Dallas, respectively. Screening UAs were obtained on all patients by 77% and 64%, of physicians in Miami and Dallas, respectively. In both Miami and Dallas, only 36% of PCPs reported referring patients with microscopic hematuria to an urologist. In patients with gross hematuria, referral rates were 77% and 69% in Miami and Dallas, respectively.

CONCLUSIONS

While many PCPs use UA in many of their patients routinely, few PCPs automatically refer their patients with microscopic hematuria to urology and not all patients with gross hematuria are referred. Further investigations regarding why and when patients are referred to urology is warranted. Increasing awareness of the complete and timely evaluation of hematuria may be beneficial in preventing a delay in bladder cancer.

May-Thurner syndrome in a pediatric renal transplant recipient--case report and literature review

Vascular complications post-renal transplantation are not very common and can be associated with increased risk of graft loss. We report an unusual case of a young, female teenager with asymmetrical leg swelling. After one month of transplantation, the patient developed a rise in serum creatinine with right leg swelling (ipsilateral to transplant) from compression of the iliac vein by a right renal transplant lymphocele, which resolved after lymphocele drainage. Subsequently, left leg swelling (contralateral to transplant) was noticed and the diagnosis of May-Thurner syndrome was made by MRV. The patient was successfully managed with oral Plavix, stockings and leg elevation. The allograft function remained stable at 18 months post-transplant.

Primary tumour resection and survival in the palliative management of metastatic colorectal cancer

AIM

To examine whether surgical resection of the primary tumour confers a survival benefit and to identify the predictive factors of outcome in patients presenting with asymptomatic metastatic colorectal cancer (CRC).

MATERIALS AND METHODS

A review of a hospital database in a tertiary institution over a 6-year period (1999-2005) revealed 70 patients with asymptomatic primary CRC and unresectable liver metastases treated initially by systemic chemotherapy. A multivariate regression analysis model was used to determine the relative influence of multiple tumours, single/multiple liver metastases, tumour site, differentiation, response of liver and primary tumour to chemotherapy, biochemical response to chemotherapy, age at presentation, performance status and surgical intervention for the CRC primary.

RESULTS

In 67 cases (3 lost to follow-up), 63 had multiple and 4 single surgically irresectable liver metastases. A total of 41 deaths were recorded. All patients received systemic chemotherapy and surgery was performed for bowel obstruction, bleeding or stable disease (n=32). Surgery (OR 0.26; p=0.00013) and clinical response of the primary tumour (OR 0.53; p=0.012) were independently associated with prolonged survival. Proximal tumours (OR 2.61; p=0.0075) and multiple primaries (OR 3.37; p=0.02) were associated with poor outcome.

CONCLUSIONS

Surgical resection and response of the primary tumour to chemotherapy may be associated with improved survival, but proximal or multiple cancers predict poor outcome in patients with asymptomatic CRC and unresectable metastatic disease.

Neutropenic enterocolitis

We report a case of neutropenic enterocolitis diagnosed on computerized tomography abdomen in a 56-year-old man having high-grade non-Hodgkin's lymphoma. After appropriate management, the patient recovered completely.

Investigating mosquito-net coverage in Nigeria. How useful are consumer marketing surveys?

A marketing company conducting a consumer omnibus survey (COS) in April 2000 was paid to include questions about household ownership of mosquito nets. At the time of the survey, which involved 5018 respondents, most and perhaps all of the nets owned by the respondents would have been untreated, as a product for net treatment was then virtually unavailable. Sampling was conducted in all 36 states and the Federal Capital Territory, Abuja. Core questions were asked about socio-demographic and socio-economic characteristics, and commissioned questions were asked about household net ownership, the source of the household's newest net, if any, and the price paid for that net. The data were analysed using bivariate and multivariate methods. Socio-economic status was measured using an asset index. The estimated number of nets was adjusted using information on asset ownership from the national Demographic and Health Survey of 1999. After this adjustment for sampling bias, net coverage and the total number of nets in Nigerian households were estimated to be approximately 9% and 3 million, respectively. The single most important association with net ownership was access to a flit-gun. It appears that COS are a potentially useful source of information for assessing mosquito-net coverage at household level and monitoring changes over time. They have the advantage of being administered frequently, and they are relatively low cost. The present results were comparable with those from other studies conducted at a similar time. The main disadvantage of COS is sampling bias but, as shown here, it is often possible to adjust for this.

Nuclear spin relaxation of sodium cations in bacteriophage Pf1 solutions

The nuclear magnetic resonance (NMR) spectra for the I=3/2 23Na cation dissolved into filamentous bacteriophage Pf1 solutions display line splittings and relaxation times consistent with an interaction between the 23Na nuclear quadrupole moment and the electric field gradient produced by the negatively charged Pf1 particles. The 23Na NMR line splittings and relaxation rates corresponding to magnetization recovery and single, double, and triple quantum coherence decays are measured in Pf1 solutions and compared to theoretical values. The deviation of the observed dc spectral density J0 from the equal first harmonic J(omega0) and second harmonic J(2omega0) values as J(omega0)=J(2omega0) not equal to J0 in these solutions suggests that ion migration in the electric field gradient of the Pf1 particles produces an anisotropic relaxation mechanism. Correlation functions and thus spectral densities for this process are calculated from solutions to the Fokker-Planck equation for radial motion in an electric potential and used to estimate measured relaxation rates. Appropriate electric potentials are generated from the solutions to the Poisson-Boltzmann equation for a charged Pf1 particle in aqueous phase, functions that lead to theoretical estimates of NMR line splittings consistent with experimental observations.

Low sale of antibiotics without prescription: a cross-sectional study in Zimbabwean private pharmacies

OBJECTIVES

To assess the quality of private pharmacy practice with a focus on the extent of antibiotic sales without prescription in private pharmacies in four Zimbabwean cities in relation to two tracer infectious conditions-sexually transmitted infections (STIs) among females and males, and diarrhoea in a child.

METHODS

A cross-sectional study including pharmacies in Harare and three other towns. Information about each pharmacy was collected through structured interviews. Staff were interviewed using a different structured interview guide and simulated clients were used to assess staff performance. Data were analysed statistically, and step models to evaluate pharmacist performance were developed.

RESULTS

A majority (69%) stated that they would never sell an antibiotic without a prescription and very few actually did in spite of a high patient demand. Few respondents however performed acceptably regarding provision of information and advice in relation to guidelines: 8% for the STI male, 33% for the STI female and 22% for the diarrhoea scenario.

CONCLUSIONS

The study revealed low sales of antibiotics without prescription, showing good adherence to the letter of the law. However, few respondents performed acceptably in relation to guidelines when considering information and advice for the tracer conditions.

A Pelvic Drain Can Often Be Avoided After Radical Retropubic Prostatectomy—An Update in 552 Cases

OBJECTIVES

The routine placement of a pelvic drain following radical retropubic prostatectomy (RRP) may not be required. We describe our experience in 552 consecutive RRPs to emphasise the safety of this approach and explain our rationale for avoiding a drain when possible.

METHODS

RRP was performed in 552 consecutive patients with clinically localised adenocarcinoma of the prostate between January 2002 and June 2005. Clinical and pathologic information was documented for each patient. After the prostate was removed and the anastomotic sutures tied, the bladder was gently filled with approximately 50 ml of saline through the urethral catheter. If there was no leak, a drain was not placed.

RESULTS

A drain was not placed in 419 (76%) of the 552 patients. We compared the postoperative complication rates in those with (D+) and without (D-) a drain. There were 27 (5%) immediate postoperative complications and no significant difference between the two groups (D+, 6%; D-, 5%; p=0.629): three (1%) patients who did not have a drain had a urinoma, one (1%) who had a drain had a lymphocele, and two (2%) who had a drain had a small pelvic haematoma.

CONCLUSIONS

If the bladder neck is preserved or meticulously reconstructed, there may be little extravasation and, thus, routine drainage is unnecessary. Our 4-year experience indicates that morbidity is not increased by omitting a drain from the pelvic cavity after RRP in properly selected cases.

Concurrent radical retropubic prostatectomy and Lichtenstein inguinal hernia repair through a single modified Pfannenstiel incision: a 3-year experience

OBJECTIVE

To present the results of a 3-year experience of radical retropubic prostatectomy (RRP) through a modified Pfannenstiel incision and concomitant repair of an inguinal hernia at the time of RRP, using a tension-free technique with a mesh, as described by Lichtenstein, with no additional incision(s), as 5-10% of patients with clinically localized prostate cancer have a detectable inguinal hernia.

PATIENTS AND METHODS

Patients who had RRP between October 2002 and July 2005 were included; we used a standard open RRP, in all cases using a modified Pfannenstiel incision. If the patient had an inguinal hernia, we approached the inguinal canal through the same incision and performed a Lichtenstein mesh repair, through the inguinal canal and avoiding placing mesh within the pelvis. Patients were followed at 1 and 6 weeks, 3-monthly for 1 year and 6-monthly thereafter. All clinical variables were entered into a database and analysed.

RESULTS

In all, 450 men underwent RRP; 44 (10%) had inguinal hernia and in all, 56 hernias were repaired (32 unilateral and 12 bilateral; 16 indirect, 22 direct, six both) The mean (sd) age of the patients was 60 (7) years. Most patients were discharged within 36 h. The mean (sd) follow-up was 9 (8) months. Two patients had a superficial inguinal haematoma and one had a scrotal haematoma. They were treated conservatively with no sequelae. There were no wound infections. One patient developed a recurrent inguinal hernia. None had any clinical evidence of testicular atrophy or chronic pain.

CONCLUSION

Concurrent formal mesh repair of the inguinal hernia and RRP through a single modified Pfannenstiel incision is safe and effective. The complications were minimal and recurrence rates were low. This procedure eliminates the risks involved with the preperitoneal mesh repair and avoids multiple incisions.

Management of miscarriage: expectant, medical, or surgical? Results of randomised controlled trial (miscarriage treatment (MIST) trial)

OBJECTIVE

To ascertain whether a clinically important difference exists in the incidence of gynaecological infection between surgical management and expectant or medical management of miscarriage.

DESIGN

Randomised controlled trial comparing medical and expectant management with surgical management of first trimester miscarriage.

SETTING

Early pregnancy assessment units of seven hospitals in the United Kingdom.

PARTICIPANTS

Women of less than 13 weeks' gestation, with a diagnosis of early fetal demise or incomplete miscarriage.

INTERVENTIONS

Expectant management (no specific intervention); medical management (vaginal dose of misoprostol preceded, for women with early fetal demise, by oral mifepristone 24-48 hours earlier); surgical management (surgical evacuation).

MAIN OUTCOME MEASURES

Confirmed gynaecological infection at 14 days and eight weeks; need for unplanned admission or surgical intervention.

RESULTS

1200 women were recruited: 399 to expectant management, 398 to medical management, and 403 to surgical management. No differences were found in the incidence of confirmed infection within 14 days between the expectant group (3%) and the surgical group (3%) (risk difference 0.2%, 95% confidence interval - 2.2% to 2.7%) or between the medical group (2%) and the surgical group (0.7%, - 1.6% to 3.1%). Compared with the surgical group, the number of unplanned hospital admissions was significantly higher in both the expectant group (risk difference - 41%, - 47% to - 36%) and the medical group (- 10%, - 15% to - 6%). Similarly, when compared with the surgical group, the number of women who had an unplanned surgical curettage was significantly higher in the expectant group (risk difference - 39%, - 44% to - 34%) and the medical group (- 30%, - 35% to - 25%).

CONCLUSIONS

The incidence of gynaecological infection after surgical, expectant, and medical management of first trimester miscarriage is low (2-3%), and no evidence exists of a difference by the method of management. However, significantly more unplanned admissions and unplanned surgical curettage occurred after expectant management and medical management than after surgical management. TRIAL REGISTRATION NATIONAL RESEARCH REGISTER: N0467011677/N0467073587.