Optimising physiotherapy for people with lateral elbow tendinopathy - Results of a mixed-methods pilot and feasibility randomised controlled trial (OPTimisE)

BACKGROUND

The OPTimisE intervention was developed to address uncertainty regarding the most effective physiotherapy treatment strategy for people with Lateral Elbow Tendinopathy (LET).

OBJECTIVES

To assess the feasibility of conducting a fully-powered randomised controlled trial (RCT) evaluating whether the OPTimisE intervention is superior to usual physiotherapy treatment for adults with LET.

DESIGN

A mixed-methods multi-centred, parallel pilot and feasibility RCT, conducted in three outpatient physiotherapy departments in the UK.

METHOD

Patients were independently randomised 1:1 in mixed blocks, stratified by site, to the OPTimisE intervention or usual care. Outcomes were assessed using pre-defined feasibility progression criteria.

RESULTS

50 patients were randomised (22 Female, 28 Male), mean age 48 years (range 27-75). Consent rate was 71% (50/70), fidelity to intervention 89% (16/18), attendance rate in the OPTimisE group 82% (55/67) vs 85% (56/66) in usual care, outcome measure completion 81% (39/48) at six-month follow-up. There were no related adverse events. Patients and physiotherapists reported that the OPTimisE intervention was acceptable but suggested improvements to the trial design. 49 patients were recruited from physiotherapy referrals vs one from primary care records. Outcome measure return rates were higher when completed online (74%) compared to postal questionnaire (50%). Exploratory analysis showed improvements in both groups over time.

CONCLUSIONS

It is methodologically feasible to conduct a fully powered RCT comparing the clinical and cost-effectiveness of the OPTimisE intervention versus usual physiotherapy treatment. Considering the similar improvements observed in both groups, careful consideration is needed regarding the priority research question to be addressed in future research.

Multiorgan MRI findings after hospitalisation with COVID-19 in the UK (C-MORE): a prospective, multicentre, observational cohort study

INTRODUCTION

The multiorgan impact of moderate to severe coronavirus infections in the post-acute phase is still poorly understood. We aimed to evaluate the excess burden of multiorgan abnormalities after hospitalisation with COVID-19, evaluate their determinants, and explore associations with patient-related outcome measures.

METHODS

In a prospective, UK-wide, multicentre MRI follow-up study (C-MORE), adults (aged ≥18 years) discharged from hospital following COVID-19 who were included in Tier 2 of the Post-hospitalisation COVID-19 study (PHOSP-COVID) and contemporary controls with no evidence of previous COVID-19 (SARS-CoV-2 nucleocapsid antibody negative) underwent multiorgan MRI (lungs, heart, brain, liver, and kidneys) with quantitative and qualitative assessment of images and clinical adjudication when relevant. Individuals with end-stage renal failure or contraindications to MRI were excluded. Participants also underwent detailed recording of symptoms, and physiological and biochemical tests. The primary outcome was the excess burden of multiorgan abnormalities (two or more organs) relative to controls, with further adjustments for potential confounders. The C-MORE study is ongoing and is registered with ClinicalTrials.gov, NCT04510025.

FINDINGS

Of 2710 participants in Tier 2 of PHOSP-COVID, 531 were recruited across 13 UK-wide C-MORE sites. After exclusions, 259 C-MORE patients (mean age 57 years [SD 12]; 158 [61%] male and 101 [39%] female) who were discharged from hospital with PCR-confirmed or clinically diagnosed COVID-19 between March 1, 2020, and Nov 1, 2021, and 52 non-COVID-19 controls from the community (mean age 49 years [SD 14]; 30 [58%] male and 22 [42%] female) were included in the analysis. Patients were assessed at a median of 5·0 months (IQR 4·2-6·3) after hospital discharge. Compared with non-COVID-19 controls, patients were older, living with more obesity, and had more comorbidities. Multiorgan abnormalities on MRI were more frequent in patients than in controls (157 [61%] of 259 vs 14 [27%] of 52; p<0·0001) and independently associated with COVID-19 status (odds ratio [OR] 2·9 [95% CI 1·5-5·8]; padjusted=0·0023) after adjusting for relevant confounders. Compared with controls, patients were more likely to have MRI evidence of lung abnormalities (p=0·0001; parenchymal abnormalities), brain abnormalities (p<0·0001; more white matter hyperintensities and regional brain volume reduction), and kidney abnormalities (p=0·014; lower medullary T1 and loss of corticomedullary differentiation), whereas cardiac and liver MRI abnormalities were similar between patients and controls. Patients with multiorgan abnormalities were older (difference in mean age 7 years [95% CI 4-10]; mean age of 59·8 years [SD 11·7] with multiorgan abnormalities vs mean age of 52·8 years [11·9] without multiorgan abnormalities; p<0·0001), more likely to have three or more comorbidities (OR 2·47 [1·32-4·82]; padjusted=0·0059), and more likely to have a more severe acute infection (acute CRP >5mg/L, OR 3·55 [1·23-11·88]; padjusted=0·025) than those without multiorgan abnormalities. Presence of lung MRI abnormalities was associated with a two-fold higher risk of chest tightness, and multiorgan MRI abnormalities were associated with severe and very severe persistent physical and mental health impairment (PHOSP-COVID symptom clusters) after hospitalisation.

INTERPRETATION

After hospitalisation for COVID-19, people are at risk of multiorgan abnormalities in the medium term. Our findings emphasise the need for proactive multidisciplinary care pathways, with the potential for imaging to guide surveillance frequency and therapeutic stratification.

FUNDING

UK Research and Innovation and National Institute for Health Research.

Guidance for the use and reporting of anaesthetic agents in BJP manuscripts involving work with animals

Scientists who plan to publish in the British Journal of Pharmacology (BJP) should read this article before undertaking studies utilising anaesthetics in mammalian animals. This editorial identifies certain gaps in the reporting of details on the use of anaesthetics in animal research studies published in the BJP. The editorial also provides guidance, based upon current best practices, for performing in vivo experiments that require anaesthesia. In addition, mechanisms of action and physiological impact of specific anaesthetic agents are discussed. Our goal is to identify best practices and to provide guidance on the information required for manuscripts submitted to the BJP that involve the use of anaesthetic agents in studies with experimental animals.

Clinical characteristics with inflammation profiling of long COVID and association with 1-year recovery following hospitalisation in the UK: a prospective observational study

BACKGROUND

No effective pharmacological or non-pharmacological interventions exist for patients with long COVID. We aimed to describe recovery 1 year after hospital discharge for COVID-19, identify factors associated with patient-perceived recovery, and identify potential therapeutic targets by describing the underlying inflammatory profiles of the previously described recovery clusters at 5 months after hospital discharge.

METHODS

The Post-hospitalisation COVID-19 study (PHOSP-COVID) is a prospective, longitudinal cohort study recruiting adults (aged ≥18 years) discharged from hospital with COVID-19 across the UK. Recovery was assessed using patient-reported outcome measures, physical performance, and organ function at 5 months and 1 year after hospital discharge, and stratified by both patient-perceived recovery and recovery cluster. Hierarchical logistic regression modelling was performed for patient-perceived recovery at 1 year. Cluster analysis was done using the clustering large applications k-medoids approach using clinical outcomes at 5 months. Inflammatory protein profiling was analysed from plasma at the 5-month visit. This study is registered on the ISRCTN Registry, ISRCTN10980107, and recruitment is ongoing.

FINDINGS

2320 participants discharged from hospital between March 7, 2020, and April 18, 2021, were assessed at 5 months after discharge and 807 (32·7%) participants completed both the 5-month and 1-year visits. 279 (35·6%) of these 807 patients were women and 505 (64·4%) were men, with a mean age of 58·7 (SD 12·5) years, and 224 (27·8%) had received invasive mechanical ventilation (WHO class 7-9). The proportion of patients reporting full recovery was unchanged between 5 months (501 [25·5%] of 1965) and 1 year (232 [28·9%] of 804). Factors associated with being less likely to report full recovery at 1 year were female sex (odds ratio 0·68 [95% CI 0·46-0·99]), obesity (0·50 [0·34-0·74]) and invasive mechanical ventilation (0·42 [0·23-0·76]). Cluster analysis (n=1636) corroborated the previously reported four clusters: very severe, severe, moderate with cognitive impairment, and mild, relating to the severity of physical health, mental health, and cognitive impairment at 5 months. We found increased inflammatory mediators of tissue damage and repair in both the very severe and the moderate with cognitive impairment clusters compared with the mild cluster, including IL-6 concentration, which was increased in both comparisons (n=626 participants). We found a substantial deficit in median EQ-5D-5L utility index from before COVID-19 (retrospective assessment; 0·88 [IQR 0·74-1·00]), at 5 months (0·74 [0·64-0·88]) to 1 year (0·75 [0·62-0·88]), with minimal improvements across all outcome measures at 1 year after discharge in the whole cohort and within each of the four clusters.

INTERPRETATION

The sequelae of a hospital admission with COVID-19 were substantial 1 year after discharge across a range of health domains, with the minority in our cohort feeling fully recovered. Patient-perceived health-related quality of life was reduced at 1 year compared with before hospital admission. Systematic inflammation and obesity are potential treatable traits that warrant further investigation in clinical trials.

FUNDING

UK Research and Innovation and National Institute for Health Research.

Ophthalmology examination during well-child visits in primary care health centres: Knowledge and difficulties experienced by health workers

INTRODUCTION

The red reflex examination (RRE) and visual acuity testing (VA) is a mandatory part of the examination during the well-child visits (WCV) in primary health care centres of the public system of health in Chile. The eye examination is aimed at the early detection of severe eye diseases in children, such as retinoblastoma, congenital cataracts, and amblyopia. The knowledge and difficulties experienced by health workers in primary care health centres for evaluating the red reflex during WCV in Chile is unknown.

MATERIAL AND METHODS

A survey was performed in primary community health centres of XXX Santiago de Chile.

RESULTS

The WCV were mainly performed by physicians (45.2%) and nurses (35.8%). Only 34% of health workers performed the red reflex test, and 42.3% checked VA during the WCV. The main reasons for not doing it include the lack of direct ophthalmoscopes and VA charts (55.2% and 43.9%, respectively) at their centres, and not having the knowledge or skills (29.3% and 22%, respectively) to properly perform these clinical tests.

CONCLUSION

In this series, the eye examination of children attending WCV was unfrequently performed. A better implementation of the health centres and training of the health workers are needed in order to improve the access and quality of the paediatric eye examination in primary health care institutions in Chile.

The D1 family dopamine receptor, DopR, potentiates hind leg grooming behavior in Drosophila

Drosophila groom away debris and pathogens from the body using their legs in a stereotyped sequence of innate motor behaviors. Here, we investigated one aspect of the grooming repertoire by characterizing the D1 family dopamine receptor, DopR. Removal of DopR results in decreased hind leg grooming, as substantiated by quantitation of dye remaining on mutant and RNAi animals vs. controls and direct scoring of behavioral events. These data are also supported by pharmacological results that D1 receptor agonists fail to potentiate grooming behaviors in headless DopR flies. DopR protein is broadly expressed in the neuropil of the thoracic ganglion and overlaps with TH‐positive dopaminergic neurons. Broad neuronal expression of dopamine receptor in mutant animals restored normal grooming behaviors. These data provide evidence for the role of DopR in potentiating hind leg grooming behaviors in the thoracic ganglion of adult Drosophila. This is a remarkable juxtaposition to the considerable role of D1 family dopamine receptors in rodent grooming, and future investigations of evolutionary relationships of circuitry may be warranted.

Ectopic hepatic tissue presented as a posterior mediastinal mass

We present a young patient with respiratory complaints that was found to have a mass in her right posterior mediastinum. The mass was diagnosed to be ectopic histologically unremarkable hepatic tissue. We have also reviewed several of the few intrathoracic ectopic liver cases in the literature, along with a brief discussion of the significance of such a finding.

Limits on neutrino emission from gamma-ray bursts with the 40 string IceCube detector

IceCube has become the first neutrino telescope with a sensitivity below the TeV neutrino flux predicted from gamma-ray bursts if gamma-ray bursts are responsible for the observed cosmic-ray flux above 10(18)  eV. Two separate analyses using the half-complete IceCube detector, one a dedicated search for neutrinos from pγ interactions in the prompt phase of the gamma-ray burst fireball and the other a generic search for any neutrino emission from these sources over a wide range of energies and emission times, produced no evidence for neutrino emission, excluding prevailing models at 90% confidence.

The effect of elinogrel on high platelet reactivity during dual antiplatelet therapy and the relation to CYP2C19*2 genotype: first experience in patients

To study the effect of a new direct acting reversible P2Y(12) inhibitor, elinogrel (PRT060128), and the relation to cytochrome P450 (CYP) polymorphisms in patients with high platelet reactivity (HPR) on standard dual antiplatelet therapy.

METHODS AND RESULTS

We studied the pharmacodynamic and pharmacokinetic effects of a single 60-mg oral dose of elinogrel in 20 of 45 previously stented stable patients with HPR. We also genotyped for CYP2C19*2,3,5,17 and CYP3A5*3. Platelet reactivity fell within 4 h of dosing, the earliest time point evaluated as measured by the following assays: maximum 5 and 10 microM ADP LTA (P < 0.001 for both vs. predosing); maximum 20 microM ADP LTA (P < 0.05); VerifyNow (P < 0.001); thrombelastography (P < 0.05); VASP phosphorylation (P < 0.01); and perfusion chamber assay (P < 0.05); this was reversible within 24 h in these same assays (P = ns vs. predosing for all assays). CYP2C19*2 was present in 44% of all patients but was more frequent in HPR patients (77% vs. 16%, P = 0.0004).

CONCLUSIONS

HPR is reversibly overcome by a single 60-mg oral dose of elinogrel, a drug now being investigated in a phase 2 trial. CYP2C19*2 was associated with HPR during conventional dual antiplatelet therapy.

Extending the search for neutrino point sources with IceCube above the horizon

Point source searches with the IceCube neutrino telescope have been restricted to one hemisphere, due to the exclusive selection of upward going events as a way of rejecting the atmospheric muon background. We show that the region above the horizon can be included by suppressing the background through energy-sensitive cuts. This improves the sensitivity above PeV energies, previously not accessible for declinations of more than a few degrees below the horizon due to the absorption of neutrinos in Earth. We present results based on data collected with 22 strings of IceCube, extending its field of view and energy reach for point source searches. No significant excess above the atmospheric background is observed in a sky scan and in tests of source candidates. Upper limits are reported, which for the first time cover point sources in the southern sky up to EeV energies.

Limits on a muon flux from neutralino annihilations in the sun with the IceCube 22-string detector

A search for muon neutrinos from neutralino annihilations in the Sun has been performed with the IceCube 22-string neutrino detector using data collected in 104.3 days of live time in 2007. No excess over the expected atmospheric background has been observed. Upper limits have been obtained on the annihilation rate of captured neutralinos in the Sun and converted to limits on the weakly interacting massive particle (WIMP) proton cross sections for WIMP masses in the range 250-5000 GeV. These results are the most stringent limits to date on neutralino annihilation in the Sun.

A history of total mercury in edible muscle of fish from lakes in northern Canada

Subsistence fishing has been an important source of food for Native People in northern Canada since prehistoric time. Measurements of the levels of mercury in edible muscle of northern fish have been undertaken for over three decades in efforts to evaluate the risks of consuming northern fish. This report summarizes the data obtained from 7974 fish of 25 species from sites distributed from the Yukon to Labrador. The most abundant species were lake trout, lake whitefish, arctic char, walleye, northern pike and burbot. The question being asked was essentially "Are the fish safe to eat?" The results were used to support decisions on fishing and consumption of fish. They were sorted in several ways, into concentration ranges corresponding to human consumption guidelines, into political jurisdictions and into types of bedrock geology. Overall walleye, northern pike and lake trout, usually exceeded the subsistence consumption guideline of 0.2 microg g-1 total mercury and often exceeded the higher guideline of 0.5 microg g-1 total mercury for commercial sales of fish. Mercury in burbot, another facultative predator, was often lower but several still exceeding a guideline. Arctic char collections were mostly from anadromous populations and these had very low levels of mercury, presumably reflecting marine food sources. Lake whitefish were among the cleanest fish examined with 69 of 81 collections falling in the lowest range. Most collections were from sites in sedimentary rock. However a few sites were in metamorphic, intrusive or volcanic rocks and these, taken together, tended to have a higher proportion of sites in the higher ranges of mercury. These results indicate a widespread problem with mercury in subsistence fisheries for predator species of fish with the problem being most problematic for Nunavut.

Elevated mercury concentrations in fish in lakes in the Mackenzie River Basin: the role of physical, chemical, and biological factors

During the mid-1990s and through the early 2000s, researchers determined that elevated mercury concentrations were a common occurrence in predatory fish in many lakes in the Mackenzie River Basin (MRB), located in northern Canada. Here we present the results of studies investigating factors contributing to higher mercury concentrations in fish in many of these lakes. Twenty-two percent of lake trout, 33% of northern pike, and 50% of walleye populations had mean mercury concentrations >0.5 microg/g, the guideline for the commercial sale of fish. Higher mercury concentrations were strongly associated with the relatively old age of MRB predatory fish; mean age ranged from 7.6 to 24.9 years for the three species. In contrast, none of the lake trout sampled in eight lakes further south in northern Saskatchewan and Alberta had mean mercury concentrations >0.5 microg/g; fish also were younger (mean age 6 years for the 8 lakes). Mercury concentrations in MRB fish generally increased with fish length, age, and trophic feeding although the nature of these relationships varied with the lake. Mean length was a good predictor of mean mercury concentrations in walleye populations across the study lakes but not for whitefish, lake trout, and pike; age was a good predictor for lake trout and walleye. Mercury concentrations in water and invertebrates were similar to those observed in more southerly regions where fish do not have elevated mercury concentrations. Mercury concentrations tended to be higher in fish in smaller vs. larger lakes and as a probable consequence of higher summer epilimnion temperatures, which favour a higher net methylation rate, and higher mercury and methyl mercury concentrations in water which enter these lakes from the watershed. Increasing fishing pressures on MRB lakes may be a means of reducing mean fish age, improving growth rates, and decreasing mercury body burdens. Increased global warming may result in higher mercury concentrations in fish through increased water temperatures, a longer ice free season, and increased release of stored mercury from the watershed into these lakes.

Healthcare users and computerised resources

This paper concerns users' views on computerised resources. The focus concerns a software tool that could be used to allow safety conscious user manipulation of the combination of these computerised resources. It is of concern to the authors that computerised resources used in healthcare should reflect users' working practices rather than working practices being changed to reflect computerised resources.

Appetitive and consummatory sexual behaviors of female rats in bilevel chambers. II. Patterns of estrus termination following vaginocervical stimulation

Copulation with intromission or manual vaginocervical stimulation (VCS) shortens the duration that intact female rats maintain lordosis responding during estrus. The present study examined whether VCS could shorten the duration of both appetitive and consummatory measures of female sexual behavior, and whether these effects occur differentially in time and across different hormone priming intervals. Ovariectomized, sexually experienced female rats were administered subcutaneous injections of estradiol benzoate 48 h and progesterone 4 h, before receiving 50 manual VCSs with a lubricated glass rod distributed over 1 h. Control females received sham VCSs distributed over the same time. The females were then tested for sexual behavior in bilevel chambers with two sexually vigorous males (to one ejaculatory series or 10 min with each male, separated by 5 min) 12, 16, and 20 h after VCS. Prior to the final hormone treatment, different groups of females had been given the same hormone treatment either 28, 14, 7, or 4 days before. In females tested at 28- and 14-day hormone intervals, VCS induced both active and passive rejection responses at 12, 16, and 20 h. In contrast, females that received sham VCS displayed relatively normal sexual behavior at 12 h, although by 16 and 20 h these females displayed active and passive rejection. Females tested at 7- or 4-day intervals displayed normal levels of lordosis at all testing times, regardless of VCS treatment. These data indicate that VCS facilitates rejection responses that precede the decrease in lordosis responsiveness. However, the effects of VCS are dependent on the frequency of hormone priming, suggesting that hormone treatment may block some of the long-term inhibitory effects of VCS on female sexual behavior.

Federated healthcare record server--the Synapses paradigm

The delivery of healthcare relies on the sharing of patient information between those who are providing for the care of the patient and this information is increasingly being expressed in terms of a 'record'. Further, it is desirable that these records are available in electronic form as Electronic HealthCare Records. As it is likely that patient records or parts of records will be stored in many different information systems and in the form of disparate record architectures, uniform access to patient records would be problematic. This paper presents an overview of the Synapses computing environment in which a Federated Healthcare Record Server provides uniform access to patient information stored in connected heterogeneous autonomous information systems and other Synapses servers. The Synapses record architecture is based on the architecture proposed by the Technical Committee 251 of the European Committee for Standardisation and the interfaces to the Synapses server are specified in the ISO standard Interface Definition Language. Synapses is a pan-European project involving a number of hospitals, software companies, universities and research institutes and is partly funded by the EU Health Telematics Programme. The overview is described in terms of the Open Distributed Processing Reference Model.

A CORBA-based integration of distributed electronic healthcare records using the synapses approach

The ability to exchange in a meaningful, secure, and simple fashion relevant healthcare data about patients is seen as vital in the context of efficient and cost-effective shared or team-based care. The electronic healthcare record (EHCR) lies at the heart of this information exchange, and it follows that there is an urgent need to address the ability to share EHCR's or parts of records between carers and across distributed health information systems. This paper presents the Synapses approach to sharing based on a standardized shared record, the Federated Healthcare Record, which is implemented in an open and flexible manner using the Common Object Request Broker Architecture (CORBA). The architecture of the Federated Healthcare Record is based on the architecture proposed by the Technical Committee 251 of the European Committee for Standardization.

A sequence within the cytoplasmic tail of GpIIb independently activates platelet aggregation and thromboxane synthesis

All integrin alpha subunits contain a highly conserved KXGFFKR motif in their cytoplasmic domains that plays a crucial role in the regulation of integrin affinity for their ligands. We show that a lipid-modified peptide corresponding to the cytoplasmic region, 989-995, of the platelet integrin subunit glycoprotein GpIIb (alphaIIb), palmitoyl-KVGFFKR (Ppep; 10 microM), but not a similarly modified scrambled peptide (palmitoyl-FKFVRGK), can specifically induce platelet activation and aggregation equivalent to that of strong agonists such as thrombin. Ppep-induced aggregation is also associated with indices of platelet activation including thromboxane A2 (TXA2) synthesis (EC50 = 45 +/- 5 microM), secretion of alpha-granules detected as enhanced surface expression of P-selectin (EC50 = 52 +/- 8 microM), and conformational changes in GpIIb/IIIa measured by the monoclonal antibody, PAC-1 (EC50 = 3.7 +/- 1 microM). The TXA2 receptor antagonist, SQ29548, PGE1, and the ADP scavenger, apyrase, differentially inhibit the aggregation response and TXA2 synthesis in response to Ppep. Similarly, GpIIb/IIIa antagonists (RO-449883 and integrelin), which inhibit aggregation by greater than 90%, have little effect on peptide-induced TXA2 synthesis, suggesting that this event is independent of fibrinogen binding to GpIIb/IIIa. Alanine-stepping of the Ppep sequence identifies GFFK(991-994) as the critical residues in all peptide-mediated events. We conclude that this peptide can imitate the cytoplasmic domain of GpIIb and initiate parallel but independent signaling pathways, one leading to ligand binding and platelet aggregation and the other to intracellular signaling events such as TXA2 synthesis and secretion.

The relative potencies of dendrotoxins as blockers of the cloned voltage-gated K+ channel, mKv1.1 (MK-1), when stably expressed in Chinese hamster ovary cells

1. The mKv1.1 voltage-gated K+ channel has been expressed stably in Chinese hamster ovary cells and whole-cell currents recorded by the patch-clamp method. 2. A range of structurally related peptide toxins (dendrotoxins) from the venom of green mamba (Dendroaspis angusticeps) and black mamba (Dendroaspis polylepis polylepis) snakes were tested for mKv1.1 channel blocking activity. Their potencies were compared based on EC50s derived from their respective concentration-inhibition relationships. 3. The rank order of potency, thus determined was: Toxin K > 7-dendrotoxin(7-Dtx) > delta-Dtx > Toxin I = alpha-Dtx > beta-Dtx. 4. Block was independent of voltage and no effects of the toxins on the kinetics of activation were observed. These results are consistent with a mechanism involving the block of closed channels. 5. A wide range of activity was observed even between toxins with an extremely high degree of sequence homology. Toxin K, in particular was an exquisitely potent blocker of the mKv1.1 channel, having an EC50 of 30 pM compared with 1.8 nM for delta-Dtx in spite of 95% sequence identity.

OpenLabs advanced instrument workstation services

The advanced instrument workstation (AIW) is one of a number of system modules developed in the OpenLabs project, offering advanced services that complement the basic services available from laboratory information systems (LIS) in general. The AIW services relate to instrument interfacing, user interfacing, quality control, calibration verification, patient result validation, local and remote fault diagnosis and maintenance, and external quality assessment (EQA) by external organisations.

Delayed gastric emptying after gastric surgery

BACKGROUND

The reported incidence of delayed gastric emptying (DGE) after gastric surgery is 5% to 25% and usually is based on operations for peptic ulcer disease. Ongoing improvements in perioperative care, nutritional support, and new prokinetic drugs may have had a beneficial effect on the frequency and course of postoperative DGE.

METHODS

We therefore studied our recent experience with DGE in 416 patients who had gastric surgery for ulcer disease (283), cancer (92), or trauma and other indications (41) between January 1985 and December 1993. DGE was defined as inability to eat a regular diet by postoperative day 10.

RESULTS

DGE occurred in 99 of 416 patients (24%). In 75 of these 99 patients, a postoperative contributing factor for DGE was identified. These factors were sepsis (32), anastomotic edema and leaks (23), obstruction (4), pancreatitis (3), multiple system organ failure (5), and miscellaneous conditions (8). In 24 patients there was no obvious cause for DGE; these patients recovered with nutritional support and time. Re-operation specifically for gastric stasis was not performed. Among the 99 patients with DGE, 67% were eating by day 21, 92% by 6 weeks, and 100% by 10 weeks. Significant risk factors for DGE were diabetes (55%), malnutrition (44%), and operations for malignancy (38%). The Whipple procedure had the highest incidence of DGE (70%), highly selective vagotomy the lowest (0%), while truncal vagotomy had no significant effect. The response to metoclopramide was 20% and unpredictable.

CONCLUSION

DGE continues to affect a considerable number of our patients (24%) after gastric surgery and is particularly common in patients with diabetes, malnutrition, and gastric or pancreatic cancer. However, gastric motility does return in 3 to 6 weeks in most patients and the need for re-operation for gastric stasis is rare.