Retrospective comparison of outcomes of patients undergoing omental patch versus falciform patch repair of perforated peptic ulcers

BACKGROUND

The omental patch repair is the gold standard for the repair of perforated peptic ulcers. This can be performed open or laparoscopically. However, in the event of non-viable or inadequate omentum available at the time of surgery the falciform ligament has been reportedly used to as an alternative. Nonetheless, evidence for its safety is scant. This study aims to determine differences in patient outcomes when comparing the two repair techniques.

METHODS

Following ethics approval, patients who underwent surgical repair of perforated peptic ulcers using omental or falciform patch repair, between 1 January 2010 and 31 December 2017, across all three Western Australian tertiary hospital services and at least 18 years of age were included. Data were collected by reviewing medical records of included patients.

RESULTS

Three hundred twenty-nine patients who underwent either open or laparoscopic repairs were included. Thirty-seven patients had falciform repairs and were mostly ASA of 2 compared to 292 patients receiving omental patch repair who were mostly ASA 3. Falciform patch repairs were more commonly used in duodenal ulcer perforations. There were no statistically significant differences in patient outcomes between the omental patch and falciform ligament groups. This included post-operative intra-abdominal sepsis, return to theatre, post-operative ICU admission, inpatient mortality, 30-day readmission and ulcer healing on follow-up gastroscopy.

CONCLUSIONS

This study demonstrates safety, efficacy and similar outcomes for patients receiving the falciform ligament patch repair compared with omental patch repair.

Human Mesenchymal Stem Cell (hMSC) Donor Potency Selection for the "First in Cystic Fibrosis" Phase I Clinical Trial (CEASE-CF)

Human Mesenchymal Stem Cell (hMSC) immunotherapy has been shown to provide both anti-inflammatory and anti-microbial effectiveness in a variety of diseases. The clinical potency of hMSCs is based upon an initial direct hMSC effect on the pro-inflammatory and anti-microbial pathophysiology as well as sustained potency through orchestrating the host immunity to optimize the resolution of infection and tissue damage. Cystic fibrosis (CF) patients suffer from a lung disease characterized by excessive inflammation and chronic infection as well as a variety of other systemic anomalies associated with the consequences of abnormal cystic fibrosis transmembrane conductance regulator (CFTR) function. The application of hMSC immunotherapy to the CF clinical armamentarium is important even in the era of modulators when patients with an established disease still need anti-inflammatory and anti-microbial therapies. Additionally, people with CF mutations not addressed by current modulator resources need anti-inflammation and anti-infection management. Furthermore, hMSCs possess dynamic therapeutic properties, but the potency of their products is highly variable with respect to their anti-inflammatory and anti-microbial effects. Due to the variability of hMSC products, we utilized standardized in vitro and in vivo models to select hMSC donor preparations with the greatest potential for clinical efficacy. The models that were used recapitulate many of the pathophysiologic outcomes associated with CF. We applied this strategy in pursuit of identifying the optimal donor to utilize for the "First in CF" Phase I clinical trial of hMSCs as an immunotherapy and anti-microbial therapy for people with cystic fibrosis. The hMSCs screened in this study demonstrated significant diversity in antimicrobial and anti-inflammatory function using models which mimic some aspects of CF infection and inflammation. However, the variability in activity between in vitro potency and in vivo effectiveness continues to be refined. Future studies require and in-depth pursuit of hMSC molecular signatures that ultimately predict the capacity of hMSCs to function in the clinical setting.

Mesh versus non-mesh repair of groin hernias: a rapid review

BACKGROUND

Mesh is frequently utilized intraoperatively for the repair of groin hernias. However, patients may request non-mesh hernia repairs owing to adverse events reported in other mesh procedures. To inform surgical safety, this study aimed to compare postoperative complications between mesh and non-mesh groin hernia repairs and identify other operative and patient-related risk factors associated with poor postoperative outcomes.

METHODS

Ovid MEDLINE and grey literature were searched to 9 June 2021 for studies comparing mesh to non-mesh techniques for primary groin hernia repair. Outcomes of interest were postoperative complications, recurrence of hernia, pain and risk factors associated with poorer surgical outcomes. Methodological quality was appraised using the AMSTAR 2 tool.

RESULTS

The systematic search returned 4268 results, which included seven systematic reviews and five registry analyses. Mesh repair techniques resulted in lower hernia recurrence rates, with no difference in chronic pain, seroma, haematoma or wound infection, compared to non-mesh techniques. Risk factors associated with increased risk of hernia recurrence were increased body mass index (BMI), positive smoking status and direct hernia. These were independent of surgical technique. Patients under 40 years of age were at increased risk of postoperative pain.

CONCLUSIONS

Surgical repair of primary groin hernias using mesh achieves lower recurrence rates, with no difference in safety outcomes, compared with non-mesh repairs. Additional risk factors associated with increased recurrence include increased BMI, history of smoking and hernia subtype.

Enhancing Cystic Fibrosis Immune Regulation

In cystic fibrosis (CF), sustained infection and exuberant inflammation results in debilitating and often fatal lung disease. Advancement in CF therapeutics has provided successful treatment regimens for a variety of clinical consequences in CF; however effective means to treat the pulmonary infection and inflammation continues to be problematic. Even with the successful development of small molecule cystic fibrosis transmembrane conductance regulator (CFTR) correctors and potentiators, there is only a modest effect on established infection and inflammation in CF patients. In the pursuit of therapeutics to treat inflammation, the conundrum to address is how to overcome the inflammatory response without jeopardizing the required immunity to manage pathogens and prevent infection. The key therapeutic would have the capacity to dull the inflammatory response, while sustaining the ability to manage infections. Advances in cell-based therapy have opened up the avenue for dynamic and versatile immune interventions that may support this requirement. Cell based therapy has the capacity to augment the patient’s own ability to manage their inflammatory status while at the same time sustaining anti-pathogen immunity. The studies highlighted in this manuscript outline the potential use of cell-based therapy for CF. The data demonstrate that 1) total bone marrow aspirates containing Cftr sufficient hematopoietic and mesenchymal stem cells (hMSCs) provide Cftr deficient mice >50% improvement in survival and improved management of infection and inflammation; 2) myeloid cells can provide sufficient Cftr to provide pre-clinical anti-inflammatory and antimicrobial benefit; 3) hMSCs provide significant improvement in survival and management of infection and inflammation in CF; 4) the combined interaction between macrophages and hMSCs can potentially enhance anti-inflammatory and antimicrobial support through manipulating PPARγ. These data support the development of optimized cell-based therapeutics to enhance CF patient’s own immune repertoire and capacity to maintain the balance between inflammation and pathogen management.

Donor-defined mesenchymal stem cell antimicrobial potency against nontuberculous mycobacterium

Chronic nontuberculous mycobacterial infections with Mycobacterium avium and Mycobacterium intracellulare complicate bronchiectasis, chronic obstructive airway disease, and the health of aging individuals. These insidious intracellular pathogens cause considerable morbidity and eventual mortality in individuals colonized with these bacteria. Current treatment regimens with antibiotic macrolides are both toxic and often inefficient at providing infection resolution. In this article, we demonstrate that human marrow‐derived mesenchymal stem cells are antimicrobial and anti‐inflammatory in vitro and in the context of an in vivo sustained infection of either M. avium and/or M. intracellulare.

HNF4A and GATA6 Loss Reveals Therapeutically Actionable Subtypes in Pancreatic Cancer

Pancreatic ductal adenocarcinoma (PDAC) can be divided into transcriptomic subtypes with two broad lineages referred to as classical (pancreatic) and squamous. We find that these two subtypes are driven by distinct metabolic phenotypes. Loss of genes that drive endodermal lineage specification, HNF4A and GATA6, switch metabolic profiles from classical (pancreatic) to predominantly squamous, with glycogen synthase kinase 3 beta (GSK3β) a key regulator of glycolysis. Pharmacological inhibition of GSK3β results in selective sensitivity in the squamous subtype; however, a subset of these squamous patient-derived cell lines (PDCLs) acquires rapid drug tolerance. Using chromatin accessibility maps, we demonstrate that the squamous subtype can be further classified using chromatin accessibility to predict responsiveness and tolerance to GSK3β inhibitors. Our findings demonstrate that distinct patterns of chromatin accessibility can be used to identify patient subgroups that are indistinguishable by gene expression profiles, highlighting the utility of chromatin-based biomarkers for patient selection in the treatment of PDAC.

Five-year follow-up of a multicenter, double-blind randomized clinical trial of laparoscopic Nissen vs anterior 90 degrees partial fundoplication

HYPOTHESIS

Laparoscopic 90 degrees anterior partial fundoplication for gastroesophageal reflux disease achieves equivalent results to laparoscopic Nissen fundoplication.

DESIGN

A multicenter, prospective, double-blind randomized clinical trial with a minimum of 5 years' follow-up.

SETTING

Nine university teaching hospitals in 6 major cities throughout Australia and New Zealand.

PARTICIPANTS

One hundred twelve patients undergoing primary antireflux surgery were randomized to undergo either laparoscopic Nissen fundoplication (52 patients) or anterior 90 degrees partial fundoplication (60 patients).

INTERVENTIONS

Laparoscopic Nissen fundoplication with division of the short gastric vessels or laparoscopic anterior 90 degrees partial fundoplication.

MAIN OUTCOME MEASURES

Blinded assessment at 1 and 5 years' follow-up of clinical outcome for postoperative heartburn, dysphagia, gas-related symptoms, and satisfaction with the surgical outcome. Analog scales ranging from 0 to 10 were used to assess symptom severity.

RESULTS

Ninety-seven patients underwent follow-up at 5 years. Three others died during follow-up, 4 refused follow-up, and 8 were lost to follow-up; 89% remained at 5-years' follow-up. At 5 years' follow-up, mean analog scores for heartburn were 2.2 for anterior fundoplication vs 0.9 for Nissen fundoplication (P=.003). There were no significant differences between the groups for dysphagia scores. The mean score for outcome satisfaction was 7.1 after anterior fundoplication vs 8.1 after Nissen fundoplication (P=.18). Eighty-eight percent reported a good or excellent outcome following Nissen fundoplication vs 77% following anterior fundoplication.

CONCLUSIONS

Laparoscopic Nissen and anterior 90 degrees partial fundoplication achieve similar levels of patient satisfaction at 5 years' follow-up, with similar adverse effect profiles. However, at 5 years' follow-up, laparoscopic Nissen fundoplication achieves superior control of reflux symptoms.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Register Identifier: ACTRN12607000298415.

Incidence of bariatric surgery and postoperative outcomes: a population-based analysis in Western Australia

OBJECTIVE

To investigate the incidence of bariatric surgery and postoperative outcomes in a population-based cohort of patients in Western Australia over a 17-year period.

DESIGN AND SETTING

A population-based incidence study of all bariatric procedures (n=1403) performed in WA hospitals over the period 1988-2004, based on hospital morbidity and death data from the WA Data Linkage System.

MAIN OUTCOME MEASURES

Changes in incidence of bariatric procedures over time; mortality and complications within 30 days after surgery; survival rates after surgery relative to age-, sex-, and period-matched survival rates in the general population; factors predictive of re-admission to hospital.

RESULTS

The incidence of bariatric surgery increased from 1.2 procedures per 100,000 person-years in 1988 to 24.2 procedures per 100,000 person-years in 2004. Although some of this was ascribed to a rising prevalence of obesity generally, there was a 13-fold increase in the bariatric procedure rate within the obese population itself. At 5 years, the relative survival rate in bariatric patients was the same as the survival rate in the general population. Within the 30-day postoperative period, mortality was low (0.07%) and 9.6% of patients experienced complications. Those who had bypass-type procedures were more likely to be re-admitted within 30 days than those who had gastric reduction procedures (adjusted hazard ratio, 5.80 [95% CI, 3.42-9.84]).

CONCLUSION

The use of bariatric surgery increased 20-fold over the study period. Relative survival after surgery was in line with population norms. The observed low mortality rates and moderate level of complications are similar to findings in other studies in which the proportion of reduction procedures has been high.

Quality of life following laparoscopic anterior 90 degrees versus Nissen fundoplication: results from a multicenter randomized trial

BACKGROUND

The short-term clinical outcomes from a multicenter prospective randomized trial of laparoscopic Nissen versus anterior 90 degrees partial fundoplication have been reported previously. These demonstrated a high level of satisfaction with the overall outcome following anterior 90 degrees fundoplication. However, the results of postoperative objective tests and specific clinical symptoms are not always consistent with an individual patient's functional status and general well being following surgery, and quality of life (QOL) is also an important outcome to consider following surgery for reflux. Hence, QOL information was collected in this trial to investigate the hypothesis: improvements in QOL following laparoscopic antireflux surgery are greater after anterior 90 degrees partial fundoplication than after Nissen fundoplication.

METHODS

Patients undergoing a laparoscopic fundoplication for gastro-esophageal reflux at one of nine university teaching hospitals in six major cities in Australia and New Zealand were randomized to undergo either laparoscopic Nissen or anterior 90 degrees partial fundoplication. Quality of life before and after surgery was assessed using validated questionnaires - the Short Form 36 general health questionnaire (SF36) and an Illness Behavior Questionnaire (IBQ). Patients were asked to complete these questionnaires preoperatively and at 3, 6, 12 and 24 months postoperatively.

RESULTS

One hundred and twelve patients were randomized to undergo a Nissen fundoplication (52) or a 90 degrees anterior fundoplication (60). Patients who underwent anterior fundoplication reported significant improvements in eight of the nine SF36 scales compared to four of the nine following a Nissen fundoplication. The majority of these improvements occurred early in the postoperative period. With respect to the illness behavior data, there were no significant differences between the two procedures. Both groups had a significant improvement in disease conviction scores at all time points compared to their preoperative scores.

CONCLUSIONS

Patients undergoing laparoscopic anterior 90 degrees partial fundoplication reported more QOL improvements in the early postoperative period than patients undergoing a Nissen fundoplication. However, the QOL outcome for both procedures was similar at later follow-up.

Surgeon experience and trends in intraoperative complications in laparoscopic cholecystectomy

BACKGROUND

Intraoperative complications, particularly bile duct injuries (BDIs), have increased since the introduction of laparoscopic cholecystectomy (LC). This excess risk is expected to decline as surgeon experience in laparoscopic surgery increases.

METHODS

This was a population-based study of trends in intraoperative injuries in 33 309 cholecystectomies carried out in Western Australia between 1988 and 1998, based on hospital discharge abstracts. Endpoints were identified from diagnostic and procedure codes in index or postoperative readmissions, or a register of endoscopic retrograde cholangiopancreatography procedures, and validated using hospital records. Multivariate analysis was used to estimate the risk of complications associated with potential risk factors.

RESULTS

Following the introduction of LC in 1991, the prevalence of all complications doubled by 1994 then stabilized, whereas that of BDI declined after 1994. The risk of complications increased with age, was higher in men, teaching and country hospitals, and was higher for LC and more complicated operations. It was lower when intraoperative cholangiography was performed and with increasing surgeon experience. Approximately 20 per cent of all complications and 30 per cent of BDIs were attributable to surgeons who had performed 200 or fewer cholecystectomies in the previous 5 years.

CONCLUSION

The risk of intraoperative complications declined with increasing surgical experience and use of intraoperative cholangiography.

The StarClose® vascular closure system: Interventional results from the CLIP study

BACKGROUND

The StarClose Vascular Closure System is a femoral access site closure technology that uses a flexible nitinol clip to complete a circumferential, extravascular arteriotomy close. The Clip CLosure In Percutaneous Procedures study was initiated to study the safety and efficacy of the StarClose device in subjects undergoing diagnostic and interventional catheterization procedures.

METHODS

A total of 17 U.S. sites enrolled 596 subjects, with 483 subjects randomized at a 2:1 ratio to receive StarClose or standard compression of the arteriotomy after the percutaneous procedure. The study included roll-in (n = 113), diagnostic (n = 208), and interventional (n = 275) arms with a primary safety endpoint of major vascular complications through 30 days and a primary efficacy endpoint of postprocedure time to hemostasis.

RESULTS

The results of the diagnostic StarClose cohort have been reported separately. Results for the interventional arm revealed major vascular complications occurring in 1.1% of StarClose subjects (2/184) and 1.1% in manual compression subjects (1/91; P = 1.00). No infections were seen in either cohort. Minor complications in the StarClose interventional group occurred at a rate of 4.3% (8/184) and with compression at 9.9% (9/91; P = 0.107). Pseudoaneurysm or arteriovenous fistula was not seen with StarClose. With StarClose, procedural success was 100% (136/136) for the diagnostic group and 98.9% (181/183) in the interventional group. Device success for the treatment group was 86.8%. In the interventional cohort, 87.3% (158/181) of StarClose subjects reported a pain scale of 0-3 compared with 93.3% (84/90) in the compression group, which was not statistically different.

CONCLUSIONS

The clinical results of this study demonstrate that the StarClose Vascular Closure System is noninferior to manual compression with respect to the primary safety endpoint of major vascular events in subjects who undergo percutaneous interventional procedures. StarClose significantly reduced time to hemostasis, ambulation, and dischargeability when compared with compression.

The safety and efficacy of the StarClose® vascular closure system: The ultrasound substudy of the CLIP study

BACKGROUND

The StarClose Vascular Closure System (Abbott Vascular, Redwood City, CA) features a nitinol clip that is designed to achieve closure of the femoral arteriotomy access site. The CLIP Study was performed to assess the safety and efficacy of StarClose when compared with standard manual compression following 5-6 French diagnostic or interventional percutaneous procedures. A substudy of this trial was designed to assess the utility of duplex ultrasonography to assess patency of the femoral artery and to determine access site complications (pseudoaneurysm, arteriovenous fistula, hematoma, deep vein thrombosis) in a multicenter prospective trial. This is the report of the duplex ultrasound (DUS) substudy of the CLIP trial.

METHODS

A total of 17 U.S. sites enrolled 596 subjects with 483 subjects randomized at a 2:1 ratio to receive StarClose or manual compression of the arteriotomy after a percutaneous procedure. The study included roll-in (n = 113), diagnostic (n = 208), and interventional (n = 275) arms with a primary safety endpoint of major vascular complications through 30 days and a primary efficacy endpoint of postprocedure time to hemostasis. A substudy of the CLIP interventional arm evaluated DUS images of the closure site at five study sites, targeting 100 subjects at day 30 following hemostasis. The DUS protocol was devised and implemented by an independent vascular ultrasound core laboratory with extensive experience in vascular device trials. DUS inguinal region from 6 cm proximal to 6 cm distal to the arteriotomy puncture was performed. A qualitative examination was performed to determine the presence of iatrogenic vascular injuries: hematoma, pseudoaneurysm (PSA), arteriovenous fistula (AVF), and arterial/venous thrombosis or stenosis using 2-dimensional gray scale, color, and focused Doppler images.

RESULTS

DUS of 96 subjects randomized to StarClose (n = 71) and compression (n = 25) were performed and evaluated. There was no evidence of hematoma, PSA, or AVF observed in the StarClose group. No StarClose subjects in the substudy had a PSA or AVF. All patients in the substudy demonstrated patency of the access site artery and vein without thrombosis or stenosis. Finally, in the entire study cohort, no clinically-driven DUS studies demonstrated iatrogenic vascular injury or vessel thrombosis in the StarClose treated patients.

CONCLUSION

DUS, a safe and reliable method for determining the safety and efficacy of access site closure devices, is a reliable, safe, inexpensive and accurate method of assessing vascular access site complications in multicenter trials. In this substudy of the CLIP study, DUS found no statistical difference in access site complications between the StarClose and manual compression groups. Both groups maintained vessel patency without stenosis, thrombosis, hematoma, pseudoaneurysm, or AV fistula.

Multicenter, prospective, double-blind, randomized trial of laparoscopic nissen vs anterior 90 degrees partial fundoplication

HYPOTHESIS

Laparoscopic anterior 90 degrees partial fundoplication for gastroesophageal reflux is associated with a lower incidence of postoperative dysphagia and other adverse effects compared with laparoscopic Nissen fundoplication.

DESIGN

A multicenter, prospective, double-blind, randomized controlled trial.

SETTING

Nine university teaching hospitals in 6 major cities in Australia and New Zealand.

PARTICIPANTS

One hundred twelve patients with proven gastroesophageal reflux disease presenting for laparoscopic fundoplication were randomized to undergo either a Nissen (52 patients) or an anterior 90 degrees partial procedure (60 patients). Patients with esophageal motility disorders, patients requiring a concurrent abdominal procedure, and patients who had undergone previous antireflux surgery were excluded from this study.

INTERVENTIONS

Laparoscopic Nissen fundoplication with division of the short gastric vessels or laparoscopic anterior 90 degrees partial fundoplication.

MAIN OUTCOME MEASURES

Independent assessment of dysphagia, heartburn, and overall satisfaction 1, 3, and 6 months after surgery using multiple clinical grading systems. Objective measurement of esophageal manometric parameters, esophageal acid exposure, and endoscopic assessment.

RESULTS

Postoperative dysphagia, and wind-related adverse effects were less common after a laparoscopic anterior 90 degrees partial fundoplication. Relief of heartburn was better following laparoscopic Nissen fundoplication. Overall satisfaction was better after anterior 90 degrees partial fundoplication. Lower esophageal sphincter pressure, acid exposure, and endoscopy findings were similar for both procedures.

CONCLUSIONS

At the 6-month follow-up, laparoscopic anterior 90 degrees culine partial fundoplication is followed by fewer adverse effects than laparoscopic Nissen fundoplication with full fundal mobilization, and it achieves a higher rate of satisfaction with the overall outcome. However, this is offset to some extent by a greater likelihood of recurrent gastroesophageal reflux symptoms.

Impact of laparoscopic cholecystectomy on hospital utilization

OBJECTIVE

The objective of the present study was to assess the impact of laparoscopic cholecystectomy (LC) and associated endoscopic retrograde pancreatography (ERCP) on hospital utilization.

BACKGROUND

Laparoscopic cholecystectomy (LC) has resulted in marked reductions in average length of hospital stay; but population-based studies of hospital utilization have generally not taken into account increased cholecystectomy rates or associated increases in pre and postoperative admissions.

METHODS

We conducted a population-based study of all residents of Western Australia who underwent cholecystectomy in the period 1980-2000. Record linkage was used to identify pre and postoperative admissions, and to estimate aggregate length of stay per case based on all relevant admissions. We estimated trends in cholecystectomy rates, proportions of cases with related pre and postoperative hospital admissions, average aggregate length of stay per case and total bed utilization per unit of population.

RESULTS

The introduction of LC was associated with a sustained increase in rates of cholecystectomy of 25%. Similar increases occurred in the percentage of cases with related preoperative and postoperative admissions. Average length of stay for index admissions declined by nearly 60% compared with 50% for all related admissions. Per capita hospital utilization for index admissions decreased by 45% compared with 38% for index and associated admissions combined, and 32% for all admissions for biliary disease.

CONCLUSIONS

Reduced hospital utilization associated with LC was partly offset by increases in pre and postoperative admissions and a sustained increase in cholecystectomy rates. Record linkage is required to assess the true impact of new technologies on hospital utilization.

Preoperative assessment of pancreatic malignancy using endoscopic ultrasound

BACKGROUND

Endoscopic ultrasound (EUS) has been regarded as the most accurate modality for locoregional staging of pancreatic malignancy. However, several recent studies have questioned this. The current study assessed the accuracy of EUS in determining preoperative resectability of pancreatic neoplasia.

METHODS

A retrospective review was performed of patients with pancreatic malignancy who had preoperative EUS and underwent surgery. EUS-predicted resectability was compared with surgical resectability. Where available, accuracies of vascular and nodal staging were also assessed.

RESULTS

Forty-five patients were identified (mean age 60 years, age range = 36-79 years). All patients underwent surgical exploration; vascular staging was available in 32 cases and 17 cases underwent surgical resection. The sensitivity, specificity, and accuracy of EUS in determining unresectability were 66%, 100%, and 78% respectively. Overall EUS stage concurred with surgical stage in 56%, greater than surgical stage in 4%, and less than surgical stage in 40%. Vascular staging on EUS had a sensitivity of 69% and a specificity of 100%. Accuracy of nodal staging was 71%.

CONCLUSION

EUS had a high specificity for assessing unresectable pancreatic malignancy. This technique should be used to avoid unnecessary surgical exploration of incurable lesions. However, EUS had only a moderate sensitivity, and a proportion of patients staged preoperatively as having resectable disease will not be surgically resectable.

Analysis of the Albumin Cobalt Binding (ACB) test as an adjunct to cardiac troponin I for the early detection of acute myocardial infarction

Human albumin has the ability to bind cobalt at the N-terminus. The exposure of circulating albumin to ischemic tissue alters the ability of albumin to bind cobalt, probably through a mechanism involving free-radical production. The Albumin Cobalt Binding (ACB) test measures the alteration in albumin metal binding, and elevation of the ACB test is thought to be an early indicator of myocardial ischemia. In a previous multicenter study of chest pain patients presenting to the emergency department (ED), this test demonstrated high negative predictive value and sensitivity in the sample collected at presentation for predicting cardiac troponin I (cTnI)-negative or cTnI-positive results 6-24 h later. Since the completion of that report, the European Society of Cardiology (ESC) and the American College of Cardiology (ACC) have redefined the criteria for the diagnosis of acute myocardial infarction (AMI). The data from the multicenter ACB study were re-examined using the new diagnostic criteria for AMI to determine if combining the ACB test with troponin improved the sensitivity of either assay used alone for early diagnosis of AMI. Assay values were compared to either the final discharge diagnosis made at each site or to a diagnosis of AMI using the strict application of the ESC/ACC guidelines. Using the criterion of physician's discharge diagnosis and using blood collected at ED presentation, the cTnI test alone had a sensitivity of 23.9%, and the ACB test alone had a sensitivity of 39.1%, but the sensitivity significantly increased to 55.9% (p < 0.001 over cTnI alone) when both tests were used in combination. The sensitivity of the combination of ACB and cTnI tests at the 1- to 6-h time-point was 86.7% and at the >6- to 12-h time-point was 93.5%, but they were not significantly improved over the cTnI test alone. In conclusion, using the new ESC/ACC criteria, the combination also resulted in a statistically significant higher diagnostic sensitivity on blood collected at presentation. These data indicate a possible role of the ACB test in the early triage of patients with chest pain.

Changing methods of imaging the common bile duct in the laparoscopic cholecystectomy era in Western Australia: implications for surgical practice

OBJECTIVE

To assess changes in the use of endoscopic retrograde cholangiopancreatography (ERCP), intraoperative cholangiography (IOC), and surgical exploration of the common bile duct (CBD) associated with the introduction of laparoscopic cholecystectomy (LC).

SUMMARY BACKGROUND DATA

The optimal strategy for dealing with potential stones of the CBD during LC remains controversial.

METHODS

The authors conducted a population-based study of all cases of cholecystectomy (20,084) in Western Australia in the periods before, during, and after the introduction of LC (1988-1994). Index admissions were linked to previous or subsequent admissions for ERCP. Factors associated with ERCP were analyzed by multivariate regression models.

RESULTS

Between 1988 and 1994, admissions for ERCP almost doubled, whereas the use of IOC decreased from 71% to 51%. Different trends were found for open and laparoscopic procedures. Exploration of the CBD declined because of the infrequent use of this procedure in LC. Preoperative ERCP was significantly more common in older patients and men; the reverse was found for IOC. There was an adjusted 3.5-fold increase in preoperative ERCP both during and after the introduction of LC. The adjusted odds ratios for IOC were 0.48 and 0.52 for these periods.

CONCLUSIONS

The introduction of LC was associated with increasing reliance on ERCP to image the CBD and a decrease in the use of IOC. These changes were observed in both LC and open cholecystectomy. They suggest that the use of ERCP before cholecystectomy has partly replaced IOC for visualization of the CBD for suspected stones. Although more than 40% of patients undergoing LC had IOC, surgeons appear to be reluctant to perform surgical exploration of the CBD when stones are present. Savings in terms of both complications and cost can be expected if preoperative ERCPs performed for suspicion of uncomplicated CBD stones are replaced by IOC.

Appendicectomy in Western Australia: profile and trends, 1981-1997

OBJECTIVE

To measure and describe changes in the incidence of appendicectomy in the population of Western Australia (WA) for 1981-1997.

DESIGN

Population-based incidence study using hospital discharge data.

SETTING

All hospitals in WA (1981-1997).

PATIENTS

All patients who underwent an appendicectomy in WA hospitals.

MAIN OUTCOME MEASURES

Changes in the incidence of appendicectomy procedures over time; age-standardised rates and age-sex profiles of four appendicectomy subgroups: (1) acute emergency admission, (2) other emergency admission, (3) incidental appendicectomy and (4) other appendicectomy.

RESULTS

From 1981 to 1997, there were 59,749 appendicectomies in WA hospitals. The age-standardised rate of appendicectomy declined by 63% in metropolitan females, by 44% in non-metropolitan females, by 41% in metropolitan males and by 21% in non-metropolitan males. The rate of decline was significantly greater in females and in metropolitan patients. From 1988 to 1997, acute emergency admission for appendicectomy was the most common admission status and was more common in males than females (122 v 103 per 100,000 person-years) and in non-metropolitan areas. The rate of incidental appendicectomy was higher among females than males (20 v 7 per 100,000 person-years). From 1988 to 1997, recorded diagnosis coding for appendicitis became more specific, with a marked reduction in the use of the "unspecified" appendicitis code.

CONCLUSIONS

The overall incidence of appendicectomy has declined markedly in WA and includes a decline in the practice of incidental appendicectomy. The trend was greatest in the metropolitan hospitals.

Gallstones. Modern management

BACKGROUND

Management of gallstones has changed as a result of new technologies, such as ultrasound, endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic surgery.

OBJECTIVE

This paper describes the clinical situations in which gallstones occur and their natural history. This is then related to the advantages and disadvantages of ERCP, laparoscopic cholecystectomy and open cholecystectomy.

DISCUSSION

Laparoscopic cholecystectomy has become the treatment of choice, but does have risk of serious complications of which the patient should be informed. Incidental gallstones should generally be left untreated. Patients presenting with biliary pain are certain to develop recurrence and require elective cholecystectomy. Those with acute cholecystitis should be managed early, with laparoscopic or open operation depending on the experience of the surgeon. Patients with obstructive jaundice can undergo laparoscopic duct exploration or have an ERCP/sphincterotomy. Those with gallstone pancreatitis should have laparoscopic cholecystectomy within the same hospital admission.

Finding bile duct injuries using record linkage: a validated study of complications following cholecystectomy

Laparoscopic cholecystectomy was introduced to Western Australia in 1991 and has become the method of choice for this procedure, although there are concerns about complications, particularly bile duct injuries. Previous studies have investigated this problem but have not confirmed the accuracy of coded information. We used Record Linkage to link operative admissions to subsequent admissions for all people who underwent cholecystectomy between 1988 and 1994. Using ICD9-CM discharge codes, we identified patients with an associated complication. We validated these patients' medical notes to obtain the proportion of complications in the period encompassing the introduction of laparoscopic cholecystectomy. We found 48 bile duct injuries in 413 patients. Of these 43% were found using complication codes on the operative admission, 79% using linked records of subsequent admissions, and 90% by adding lists of complicated cases from the three teaching hospitals. Any epidemiological research that uses surgical complication codes from operative admissions, particularly in the absence of a specific ICD9-CM code, will lead to significantly underestimating the prevalence of complications. By using record linkage, and validating medical records, we captured a significant proportion of complications.

Ex-Offenders and the Labour Market: A Review of the Discourse of Social Exclusion and Consequences for Crime and the New Deal

The growth of mass unemployment and concerns about crime in industrialised countries have been paralleled by an increasing preoccupation of policymakers with social exclusion. A key feature of the social exclusion discourse has been its emphasis on paid work as a mechanism of integration. The author outlines how ex-offenders are excluded from the labour market. The consequences for crime and implications for policy focused on the New Deal are also discussed. The key findings are that exclusion is as much a social and political phenomenon as an economic one. Consequently, the focus of the New Deal on reinforcing immediate labour-market attachment by enhancing individual employability is unlikely to succeed in reintegrating ex-offenders through work. The central challenge for policy remains the tackling of inequality in the labour market.

Complications of cholecystectomy: risks of the laparoscopic approach and protective effects of operative cholangiography: a population-based study

BACKGROUND

Previous studies suggest that laparoscopic cholecystectomy (LC) is associated with an increased risk of intraoperative injury involving the bile ducts, bowel, and vascular structures compared with open cholecystectomy (OC). Population-based studies are required to estimate the magnitude of the increased risk, to determine whether this is changing over time, and to identify ways by which this might be reduced.

METHODS

Suspected cases of intraoperative injury associated with cholecystectomy in Western Australia in the period 1988 to 1994 were identified from routinely collected hospital statistical records and lists of persons undergoing postoperative endoscopic retrograde cholangiopancreatography. The case records of suspect cases were reviewed to confirm the nature and site of injury. Ordinal logistic regression was used to estimate the risk of injury associated with LC compared with OC after adjusting for confounding factors.

RESULTS

After the introduction of LC in 1991, the proportion of all cholecystectomy cases with intraoperative injury increased from 0.67% in 1988-90 to 1.33% in 1993-94. Similar relative increases were observed in bile duct injuries, major bile leaks, and other injuries to bowel or vascular structures. Increases in intraoperative injury were observed in both LC and OC. After adjustment for age, gender, hospital type, severity of disease, intraoperative cholangiography, and calendar period, the odds ratio for intraoperative injury in LC compared with OC was 1.79. Operative cholangiography significantly reduced the risk of injury.

CONCLUSION

Operative cholangiography has a protective effect for complications of cholecystectomy. Compared with OC, LC carries a nearly twofold higher risk of major bile, vascular, and bowel complications. Further study is required to determine the extent to which potentially preventable factors contribute to this risk.

Distal colonic neoplasms predict proximal neoplasia in average-risk, asymptomatic subjects

Flexible sigmoidoscopy has been recommended as a screening method to reduce the incidence of colorectal cancer in asymptomatic, average-risk subjects through the early detection and removal of polyps. However, the association between distal and proximal colonic neoplasia and, hence, the requirement for colonoscopic follow up of screen-detected distal neoplasms is unclear. Our aims were: (i) to evaluate the risk of having proximal neoplasms in those with distal colonic neoplasms; and (ii) to determine whether the risk was dependent on the number, size, histology or morphology of the distal lesions. We prospectively evaluated asymptomatic subjects in a flexible sigmoidoscopy based screening programme. Those with rectosigmoid neoplasia underwent colonoscopy. The number, size, histology and morphology of the polyps were recorded. Advanced lesions were defined as adenomas > 1 cm or with a villous component or severe dysplasia, carcinoma in situ or cancer. Adenomatous polyps were found in 17% (135) of screening flexible sigmoidoscopies. At colonoscopy, up to 30% of subjects with distal colonic neoplasms had synchronous proximal lesions at colonoscopy and up to 20% had advanced proximal lesions. The risk of proximal colonic neoplasia was increased in those with distal sessile colonic neoplasms but appeared independent of distal lesion size, number or morphology. In conclusion, distal colonic neoplasia predicts proximal neoplasia in up to 30% of subjects and these were advanced lesions in up to 20%. We recommend that all subjects with biopsy proven distal colonic neoplasia undergo colonoscopy.

Gamma-glutamyl transpeptidase, an ecto-enzyme regulator of intracellular redox potential, is a component of TM4 signal transduction complexes

CD21 (C3dg/EBV receptor) is physically associated on B cells with a complex of proteins that includes CD19 and the widely distributed tetraspan 4 (TM4) family protein CD81 as well as other TM4 proteins (CD53, CD37 and CD82). Monoclonal antibodies (mAb) were generated that blocked homotypic adhesion induced by CD21 ligands in the human B cell line Balm-1. One inhibitory mAb (3A8) was found to recognize the ecto-enzyme gamma-glutamyl transpeptidase (GGT), a membrane protein involved in recycling extracellular glutathione and regulating intracellular redox potential. Molecular associations between GGT and TM4 proteins CD81, CD53 and CD82, in addition to CD21 and CD19, were detected by co-precipitation and co-capping analysis. GGT is expressed on several B and T cell lines independently of CD21 expression. These results demonstrate that GGT is a component of widely distributed TM4 complexes, and that on B cells the GGT-containing TM4 complexes also contain CD19 and CD21.

One hundred liver resections including comparison to non-resected liver-mobilized patients

BACKGROUND

Factors of liver resection associated with postoperative recovery and survival, the modalities that affect survival with resected colorectal carcinoma liver metastases, the comparison of liver function of liver-resected to liver-mobilized but not resected patients, and observation of early liver regeneration volume over time have not been studied prospectively. This study aimed to prospectively analyse these factors.

METHODS

Data were collected prospectively on 100 consecutive liver resections, and 10 liver-mobilized but not resected patients by the Hepatobiliary Unit, University of Melbourne, Austin Campus. Follow-up of patients was 100%.

RESULTS

The factors associated with blood loss were the type of liver resection (P = 0.0001), the length of the operation (P = 0.0001) and a central venous pressure greater than 5 cm of water (P = 0.0008). An inverse correlation existed between blood loss and long-term survival (P = 0.003). The only predictor for a postoperative complication was the length of the operation (P = 0.03): a correlation of moderate significance existed between blood loss and a complication (P = 0.052; confidence interval 0.19-1.17). The 5-year cumulative survival for hepatic resection for colorectal carcinoma Dukes A + B was 55%; there was a significantly better survival of Dukes A + B compared to Dukes C (P = 0.03) and also for those 50 years or older, but this did not depend on whether there were one or more lesions present. Resected patients had a significantly higher alanine transaminase (ALT), total bilirubin and international normalized ratio than non-resected patients, but not albumin, total protein, alkaline phosphatase or aspartate aminotransferase. The serum albumin fall was similar in both groups, which indicated that loss of liver tissue was not the cause. The re-resection rate was 8% without mortality and with low morbidity. Liver volume was restored by 64% (510 +/- 170 cc) by 7 days postoperatively.

CONCLUSIONS

Major hepatic resection can be performed with low mortality, morbidity and short hospital stay, with a 5-year survival for colorectal carcinoma better than 50%. Resection needs to be considered more frequently for curative management. Serum albumin fall is not caused by loss of liver tissue and blood loss can be controlled by central venous pressure manipulation and vascular isolation. Re-resection is a safe and rewarding treatment and needs to be planned at the first resection.

The Effectiveness of Active Labour-Market Policies: Latest Evidence from the National Development Programme

The persistence and pervasiveness of long-term unemployment across Europe has led to a renewed interest in active labour-market policies by policymakers. In the United Kingdom the new government has recently announced its proposals for the ‘New Deal’ aimed at getting young people (aged 18–24 years) and the long-term unemployed into work. This has stimulated a growing debate about the effectiveness of such policies. The author contributes to that debate by discussing the findings of a recent evaluation of the National Development Programme undertaken for the Employment Service.

The Quality of Surgical Care Project: a model to evaluate surgical outcomes in Western Australia using population-based record linkage

BACKGROUND

The aim of this study is to establish a model to evaluate surgical outcomes and, where indicated, recommend changes to improve the quality of surgical care in Western Australia (WA). Open resection for aneurysm of the abdominal aorta was the first procedure evaluated and the results are reported in an accompanying paper.

METHODS

The Quality of Surgical Care Project (QSCP) is conducted under the aegis of the Royal Australasian College of Surgeons (RACS) in WA, and brings together a multidisciplinary team of surgeons, public health researchers and health service administrators. The Western Australia Health Services Research Linked Database (the WA Linked Database) is used to provide linked chains of patients records residing in the state health department from the following sources: hospital morbidity data system, birth and death records, mental health services data, cancer registrations and midwives' notifications. This links 16 years of population-based patient records from 1980, including all public and private hospital admissions and re-admissions. The Quality of Surgical Care Project was established to use and to correlate the data from the WA Linked Database.

RESULTS

The result is a powerful database for a contained population that is available for scientific analysis by a multidisciplinary team of clinical epidemiologists, surgeons and health service managers. Users will have the ability to establish benchmark standards for the outcomes of surgical procedures in WA for use in quality improvement programmes run by the College and will facilitate self-directed performance auditing activities as a commitment to greater community accountability.

CONCLUSIONS

The Quality of Surgical Care Project provides a potential model of benefits to be realized by both the medical profession and the community through multidisciplinary collaboration supported by adequate information. Although migration from WA is relatively low, future linkage to the state electoral roll will allow correction for any population change.

Colorectal cancer screening by general practitioners: comparison with national guidelines

OBJECTIVE

To determine whether general practitioners (GPs) had received Australian guidelines on early detection, screening and surveillance for colorectal cancer or rectal bleeding, and whether their reported practice conformed with these guidelines.

DESIGN

Cross-sectional postal survey of self-reported practice.

PARTICIPANTS AND SETTING

213 GPs in practice in the southern metropolitan area of Perth, Western Australia, were randomly selected from the Fremantle Regional Division of General Practice database and surveyed in March 1997.

RESULTS

Replies were received from 155 (73%) of the GPs, and 110 reported receiving guidelines (from the Australian Gastroenterology Institute [AGI], 44; Gut Foundation of Australia [GFA], 40; others, 6; and not specified, 20). GPs who reported receiving guidelines were significantly more likely to screen for colorectal cancer (99/110; 90%) than those who reported not receiving guidelines (33/45; 73%) (P = 0.008). The commonest method to investigate people with identifiable risk factors for colorectal cancer was colonoscopy. Reported screening frequencies in asymptomatic patients with above-average risk (family history of colorectal cancer or past history of adenomatous polyps or colorectal cancer) were significantly higher than recommended by AGI and GFA guidelines (P < 0.05). Up to 24% of GPs investigated altered bowel habit or bleeding per rectum with faecal occult blood testing.

CONCLUSIONS

Most GPs report having received guidelines. Reported screening frequency was higher than recommended for most above-average-risk patients, which will result in excessive consumption of resources without benefits for cancer prevention.

Peptic disease: can we afford current management?

BACKGROUND

While surgery has the potential to cure peptic disease (ulceration and reflux), the development in the 1970s of H2 receptor antagonists saw them replace surgery in the management of peptic symptoms, controlling disease while the medication was taken. Medical cure at least in the case of a duodenal ulcer is now also possible by the use of anti-Helicobacter therapy.

METHODS

Australian Pharmaceutical Benefits Scheme (PBS) and Medicare data on the treatment of peptic disease were reviewed.

RESULTS

The data showed that medical cure of duodenal ulcer is rarely attempted. While elective surgical treatment for duodenal ulcer, highly selective vagotomy, has decreased 10-fold in 10 years, prescriptions for antisecretory agents (H2 and proton pump) are doubling every 2 years (increasing from 6.7 to 7.8% of PBS budget). Meanwhile upper gastrointestinal endoscopy rates are doubling every 5 years. By comparison, the most appropriate treatment, anti-Helicobacter therapy, is prescribed at 1/50th the rate of antisecretory agents and over 2 years decreased to 1/80th. Antisecretory treatment has not been effective in reducing mortality from duodenal ulcer, at least not in New South Wales.

CONCLUSIONS

If the principle of treatment is to decrease cost and prevent complications by curing duodenal ulcer, then current practice is a failure. A management algorithm for peptic symptoms which has the potential to relieve symptoms, cure ulcer when present, minimize surgery and reduce complications and cost is proposed for the purpose of debate.

Flexible sigmoidoscopy screening for colorectal cancer in average-risk subjects: a community-based pilot project

OBJECTIVE

To test a pilot screening program for colorectal cancer.

DESIGN

Subjects, chosen at random and recruited by mail, were examined by flexible sigmoidoscopy.

PARTICIPANTS AND SETTING

Normal-risk, asymptomatic men and women aged 55-59 years recruited from the community, July to December, 1995.

MAIN OUTCOME MEASURES

Number of polyps detected and cancers diagnosed, and compliance with screening.

RESULTS

Letters of invitation were sent to 3500 subjects; of these, 2881 were eligible for inclusion in the study and 342 (12%) consented to participate. A further 3.5% of non-compliant subjects attended the screening program after a telephone survey assessing reasons for non-attendance. Common reasons for non-attendance were a lack of interest (30%) or a lack of time, mainly due to work commitments (28%). A third of subjects had polyps and 46% of these were adenomas. Three subjects were found to have adenocarcinoma: in two the cancer was confined to a polyp and treated with polypectomy, and one subject underwent anterior resection (overall prevalence of cancer, 0.9%). The median depth of insertion achieved with flexible sigmoidoscopy was 55 cm (range, 25-100 cm). Median pain level (on a scale of 0 = no pain to 10 = worst pain imaginable) was 2 (range, 0-8.5), and 99% of the subjects would have the test again if required.

CONCLUSIONS

Flexible sigmoidoscopy was well tolerated and had an acceptable detection rate of adenomatous polyps and early cancer. Subject compliance emerged as a major issue which requires further evaluation to maximise participation in future programs.

Hepatic pathology resulting from mouse hepatitis virus S infection in severe combined immunodeficiency mice

Mouse hepatitis virus (MHV) is a pervasive pathogen that causes morbidity and mortality in mouse colonies worldwide. Although it is not a major cause of mortality in immunocompetent mice, infections from MHV strains of lower virulence can be fatal to athymic nude mice. The histopathologic features and alterations of serum biochemical parameters resulting from infection with a low-virulence MHV strain in severe combined immunodeficiency (scid) mice has not been well described. Thus we recently studied the disease caused by MHV-S in scid mice after intranasal inoculation. Mouse hepatitis virus infection in scid mice, which have severe defects of B and T cells, may be highly lethal, resulting in immediate mortality. However, our results indicate that scid mice survived for an average of 12 to 14 days after infection with doses of MHV up to 10(7) PFU/mouse. The virus caused a significant increase in serum enzyme activities and bilirubin concentration associated with histologically demonstrable hepatocellular injury at postinoculation days 3, 4, and 8. Furthermore, virus was detected in mouse liver homogenates and nasal and bronchial lavage specimens. These results provide valuable information regarding the histopathologic and biochemical consequences of MHV-S infection in scid mice.

Laparoscopic cholecystectomy: what national benefits have been achieved and at what cost?

Changes in the practice of surgery following the introduction of laparoscopic cholecystectomy (removing asymptomatic gallstones, duplicating procedures for diagnosing and managing common bile duct stones, and deferring laparoscopic management of complicated gallstones) as well as the increased rate of complications (particularly duct injury), have eroded the economic benefits to health care funders of shorter hospital stays. However, these benefits may be achieved if laparoscopic procedures are performed only by experienced surgeons and if the procedure is offered to all patients with gallstones, including complicated cases. Benefits to the community remain in terms of productivity savings as a result of an earlier return to work for patients.

Biliary tract complications of laparoscopic cholecystectomy are detected more frequently with routine intraoperative cholangiography

Controversy over whether intraoperative cholangiography (IOC) should be done routinely has intensified since the advent of laparoscopic cholecystectomy (LC). As yet, no study has demonstrated a clear benefit to its use, although their have been suggestions in the literature that routine use may confer an advantage to detection of injuries. One-hundred seventy-seven biliary tract complications occurring secondary to LC were identified from the combined data of seven institutions. The goal of this retrospective study was to examine the impact of IOC on the occurrence, recognition, and correction of such complications. The complications identified include 39 cystic duct leaks, 69 major ductal leaks or strictures, and 69 major ductal transection or excision injuries. Whether IOC was performed was known in 157 (88%) patients with 53 patients definitely having and 104 not having an IOC. Data concerning IOC were unavailable in 20 cases. More injuries were detected intraoperatively in the group having IOC (P < 0.001). Conversion of the LC to a laparotomy, often for repair of the injury, occurred more commonly in the group having a correctly interpreted IOC (P < 0.001). Conversion resulted in detection of injuries sooner, resulting in fewer operative procedures to correct the injury (P < 0.001). A transecting injury was prevented in at least seven patients when no visualization of the proximal biliary tree was documented by IOC. These partial ductal incisions were treated by t-tube placement. Incorrect interpretation of the IOC occurred in at least eight patients, with no identification of the proximal biliary tree in six.(ABSTRACT TRUNCATED AT 250 WORDS)

Intracellular neutralization of influenza virus by immunoglobulin A anti-hemagglutinin monoclonal antibodies

Traditionally, immunoglobulin A (IgA) was thought to neutralize virus by forming complexes with viral attachment proteins, blocking attachment of virions to host epithelial cells. Recently we have proposed an intracellular action for dimeric IgA, which is actively transported through epithelial cells by the polymeric immunoglobulin receptor (pIgR), in that it may be able to bind to newly synthesized viral proteins within the cell, preventing viral assembly. To this effect, we have previously demonstrated that IgA monoclonal antibodies against Sendai virus, a parainfluenza virus, colocalize with the viral hemagglutinin-neuraminidase protein within infected epithelial cells and reduce intracellular viral titers. Here we determine whether IgA can interact with influenza virus hemagglutinin (HA) protein within epithelial cells. Polarized monolayers of Madin-Darby canine kidney epithelial cells expressing the pIgR were infected on their apical surfaces with influenza virus A/Puerto Rico/8-Mount Sinai. Polymeric IgA anti-HA, but not IgG anti-HA, delivered to the basolateral surface colocalized with HA protein within the cell by immunofluorescence. Compared with those of controls, viral titers were reduced in the supernatants and cell lysates from monolayers treated with anti-HA IgA but not with anti-HA IgG. Furthermore, the addition of anti-IgA antibodies to supernatants did not interfere with the neutralizing activity of IgA placed in the basal chamber, indicating that IgA was acting within the cell and not in the extracellular medium to interrupt viral replication. Thus, these studies provide additional support for the concept that IgA can inhibit replication of microbial pathogens intracellularly.

The carcinogenic risks of alcoholic beverages: implications for cancer education

The proper analysis of the data generated by studies of carcinogenic risks of drinking alcoholic beverages would be the application of models from the relatively new approach of meta-analysis. In this study, 441 articles were generated by a 1992 MEDLINE search of the key words "alcohol drinking" and "cancer." Of these, only 29 met the criteria for a formal meta-analysis. For these 29 research reports, the 95% confidence limits for the odds ratio were 1.28 and 1.15, suggesting a weak association between drinking and cancer. This conclusion was rendered even less decisive by the following problems in the studies analyzed: 1) absence of comparable measures of either dosages or drinking patterns; 2) absence of comparable methods of data analysis; 3) absence of comparable measures of other population characteristics; and 4) widely varying results from study to study. For example, the 95% confidence limits for the odds radio of the 16 European studies were 1.14 and 0.98, indicating not even a reliable directional difference between drinking and nondrinking populations. Although the World Health Organization International Agency for Research on Cancer concluded in 1987 that alcoholic beverages are carcinogenic, the scientific literature extant in 1992 provides only very weak support for that finding. There is a need for multiple nonexperimental investigations using methods that will produce results sufficiently comparable to justify the application of the statistical models being generated for the meta-analysis of important questions not subject to direct experimentation.(ABSTRACT TRUNCATED AT 250 WORDS)

Laparoscopic adrenalectomy

Minimal access surgery continues to expand its applications now including laparoscopic adrenalectomy. Two differing intraperitoneal techniques are described in six patients, three with Conn's Syndrome, one with a Cushing's tumour, one with a phaeochromocytoma and one with a large non-functioning cortical adenoma. This initial Australasian experience with the procedure followed careful preparation in the cadaver and pig.

The role of the kidney in the clearance of calcitonin gene related peptide (CGRP)

Calcitonin gene-related peptide (CGRP) is a 37 amino-acid peptide, undetectable in the plasma in health but elevated in certain disease states such as medullary thyroid cancer, and potentially causes symptoms. The kidney is a major site of and influence on the clearance of exogenously infused CGRP. As CGRP might cause symptoms in renal dysfunction, this study was performed to determine the clearance of CGRP in humans and animals with altered renal function. In chronic renal failure patients, CGRP was not detected in plasma either before or after haemodialysis. In sheep, before and after bilateral nephrectomy, there was an approximate halving of plasma clearance and doubling of the circulating half-life of infused CGRP. This reduction in clearance was greater than that which could be accounted for by the reduction in degradation by renal substance alone. This renal influence on extra-renal CGRP metabolism was not due to the renal production of a circulating peptidase as evidenced by the absence of such peptidase in the plasma of normal and anephric sheep. Further, severity of uraemia had no influence on the extra-renal metabolism. The mechanism by which the kidney influences the extra-renal metabolism of CGRP remains obscure.

Changes in the practice of biliary surgery and ERCP during the introduction of laparoscopic cholecystectomy to Australia: their possible significance

Two and a half years after the introduction of laparoscopic cholecystectomy to Australia in February 1990, estimates from Medicare statistics suggest that by July 1992, 69% of cholecystectomies were being performed laparoscopically. There was a smaller decline in the numbers of open cholecystectomies performed, suggesting a 28% rise in the rate of cholecystectomy. This has been associated with a 66% decline in the use of intra-operative cholangiography. Whereas 87% of cholecystectomies had an operative cholangiogram performed, now only 23% of all cholecystectomies do. It is suggested that in approximately half the patients, no attempt is made to exclude common duct stones. With those patients in whom an attempt is made, most surgeons rely on endoscopic retrograde cholangiopancreatography, as evidenced by a 43% increase in its use, or, more recently, a small proportion of surgeons have been using intravenous cholangiography, as evidenced by a 26% increase in its use. Once diagnosed, these stones are no longer being treated by open exploration of the bile duct, indicated by a 46% decrease in this procedure, but are being treated by endoscopic sphincterotomy, which has shown a 242% increase in its use. From the published results of the outcome of these treatments, the added risk, nationally, of these additional procedures in managing uncomplicated bile duct stones is predicted to increase mortality 1-3-fold and morbidity 10-15-fold. This risk can be reduced by the use of laparoscopic bile duct exploration. These techniques are already well established and can be learnt quickly if practice is achieved by performing routine intra-operative cholangiography.(ABSTRACT TRUNCATED AT 250 WORDS)

An evaluation of laparoscopic versus open cholecystectomy

OBJECTIVE

To compare open cholecystectomy (OC) with laparoscopic cholecystectomy (LC) in terms of clinical aspects and a limited review of costs.

SETTING

The Austin Hospital, Melbourne, a university teaching hospital.

DESIGN

Prospective LC patients were compared with a retrospective group of OC patients whose surgery had been performed by the same surgeons.

METHODS

Consecutive patients undergoing LC were interviewed, their medical records were analysed and the cost of their hospitalisation was assessed. Similar data, collected previously from patients undergoing OC, were used for comparison.

RESULTS

There were 108 patients in each group, 93.5% treated electively. All had gallstones. No deaths or common bile duct injury occurred. The mean operating room time was 131 +/- 3.7 minutes for OC and 164 +/- 4.7 minutes for LC. Operative cholangiography was attempted in 80% in each group, being successful when attempted in all OCs and in 95% of LCs. The conversion rate of LCs to OCs was 4.5%. Minor complications were more frequent with OCs. The mean duration of hospital stay was 6.5 +/- 0.3 days for OCs and 2.0 +/- 0.2 days for LCs. The amount and period of analgesia were significantly less in the LC group. Patients recovered significantly faster after LC (P < 0.01) during the first eight weeks after surgery. There was no difference by 12 weeks. The overall cost for each LC was $838 less than OC for the entire hospital stay.

CONCLUSION

These results support the view that LC is a safe and justified replacement for OC in the elective situation, with benefits to the patient, hospital and general community. The hospital cost for LC was less than for OC.

The morbidity of surgical access: a study of open versus laparoscopic cholecystectomy

A prospective non-randomized study of 37 adult patients undergoing open cholecystectomy and 40 patients undergoing laparoscopic cholecystectomy was undertaken to test the hypothesis that surgical access alone has a significant impact on postoperative morbidity. Specifically the study examined the deterioration of pulmonary function, development of pulmonary complications, postoperative narcotic requirement and total bed stay as markers of postoperative morbidity. The results showed that significantly less deterioration of pulmonary function occurred in patients treated using the laparoscopic approach. In this group there was also significantly less requirement for postoperative narcotics, less consequent development of pulmonary complications and a shorter bed stay in hospital. The study documents the substantial impact of surgical access on postoperative morbidity and highlights the benefits of the laparoscopic 'minimal access' approach.

The effect of incisional infiltration of bupivacaine upon pain and respiratory function following open cholecystectomy

A controlled, prospective, double-blind trial of wound infiltration with bupivacaine in elective open cholecystectomy was performed to determine if this was an effective method of pain relief and reduced respiratory complications. Additionally, dextran was added to the bupivacaine in an attempt to prolong the effect. The solutions used were, bupivacaine alone 0.25% (n = 14), bupivacaine 0.25% with dextran 70 (n = 16) and saline (n = 16) as a control. To determine the effect of each solution, the subjects were assessed for pain perception and respiratory function before and after surgery. Pain was assessed using a visual analogue scale and narcotic usage, and respiratory function was assessed by spirometry, chest X-rays and arterial blood gases. The study did not demonstrate any objective improvement in either pain relief or respiratory function. This may reflect inadequate infiltration by the surgeons in the study or that infiltration should have been performed prior to incision.