bluuebunny/crossref_metadata_2025 huggingface dataset:
Effect of peripapillary chorioretinal atrophy on GDx parameters in patients with degenerative myopia
Authors: Bozkurt Banu , Irkeç Murat , Gedik Sansal , Orhan Mehmet , Erdener Ugur , Tatlipinar Sinan , Karaagaoglu Ergun
Published: March 2003

Purpose: To determine the effect of peripapillary chorio­retinal atrophy in degenerative myopia on the retinal nerve fibre layer (RNFL) thickness measurements performed by scanning laser polarimetry.

Methods: Polarimetric RNFL analysis was done in 41 degenerative myopic eyes of 25 patients with spherical refractive errors between −7.50 and −22.00 D (mean −12.50 D; SD 3.5). Analysis was also performed on 46 eyes of 24 age‐matched healthy subjects with spherical refractive errors between −1.00 and +1.00 D (mean −0.25 D; SD 0.50) with GDx Nerve Fiber Analyzer (Version 1.0.12). All of the myopic patients had clinically evident peripapillary chorio­retinal atrophy in their fundus examination.

Results: In myopic patients most of the GDx parameters were statistically different from the control group (P < 0.05). Although average thickness, ellipse average, number, inferior maximum and inferior average were found to be higher than the healthy subjects, the modu­lation parameters and the ratio‐based parameters were significantly decreased in degenerative myopic patients (P < 0.05). The TSNIT (temporal, superior, nasal, inferior, temporal) graph showed irregular high spikes with loss of the regular double hump pattern, especially in quadrants with large chorioretinal atrophy and visible sclera.

Conclusion: Peripapillary chorioretinal atrophy increased retardation values, which might be explained by the high reflectivity of the bare sclera in these areas.
EARLY DUODENAL CARCINOMA SUCCESSFULLY TREATED BY ENDOSCOPIC MUCOSAL RESECTION
Authors: Kume Keiichiro , Okubo Yoshimitsu , Ejiri Yutaka , Abe Shintaro , Hakozki Hando , Murata Ikuo , Yoshikawa Ichiro , Otsuki Makoto
Published: March 2003

Two cases with duodenal carcinoma successfully treated by endoscopic mucosal resection are reported. Case 1 had a semipedunculate polyp, and case 2 had a flat elevated lesion with a central depression in the second portion of the duodenum. Histologic examination showed tubular adenocarcinoma in adenoma in case 1 and an intramucosal adenocarcinoma in case 2, indicating that complete endoscopic resection had been achieved in both cases. Endoscopic mucosal resection appears to be a safe and efficient method for management of early carcinoma of the duodenum as well as in other regions of the gastrointestinal tract.
Helicobacter Pylori and Precancerous Gastric Lesions
Authors: Cu Pham Quang , Huyen Nguyen Xuan , Luan Trinh Thi , Hung Nguyen Quang , Hop Tran Van
Published: March 2003

Background:
To determine the relationship between Helicobacter pylori (H. pylori) infection and the precancerous gastric lesions: atrophic gastritis (AG) and intestinal metaplasia (IM) and dysplasia.

Methods:
A total of 347 dyspeptic patients, including 141 H. pylori‐positive patients and 206 H. pylori‐negative patients, were studied alongside age‐ and sex‐matched controls. The patients underwent gastroscopy and endoscopic biopsy for detection of H. pylori, and histological examinations. Helicobacter pylori was detected by a urease test (CLO; Delta West; Bentley, Australia), by histology (H&E stain, Giemsa) and by serology (BioSig; BioMeditech, NJ, USA). Atrophic gastritis, IM and dysplasia were detected by histological examination (Giemsa, H&E stain).

Results:
There is a higher rate of atrophic gastritis in H. pylori‐positive than in H. pylori‐negative patients (46 vs 13.5%, odds ratio (OR) = 5.4; P < 0.01). Gastritis in H. pylori‐positive patients also has a higher rate of activity than in H. pylori‐negative patients. The rate of IM is higher in H. pylori‐positive patients than in H. pylori‐negative patients (35 vs 11%; OR = 4.3; P < 0.01). Metaplasia is more often diffuse in H. pylori‐positive than in H. pylori‐negative patients. Dysplasia is more common in H. pylori‐positive than in H. pylori‐negative patients (12 and 3.8%; OR = 3.3; P < 0.01).

Conclusions:
This study supports the suggestion of a relationship between H. pylori infection and precancerous gastric lesions. Wherever H. pylori is present, the precancerous lesions are more common and more severe.
CASE OF HEMORRHAGE FROM A DUODENAL DIVERTICULUM TREATED SUCCESSFULLY BY ENDOSCOPIC INJECTIONS OF EPINEPHRINE
Authors: Yoshikawa Masahide , Nakamoto Teruko , Nakatani Toshiya , Yamane Yoshiko , Iwasawa Shu , Nishimura Kimio , Watanabe Iwao , Shiroi Akira , Kojima Hideyuki , Kikuchi Eiryou , Matsumura Masahiko , Fukui Hiroshi
Published: March 2003

Although duodenal diverticula are found relatively frequently in adult gastrointestinal tracts, the majority are asymptomatic. We report a case of duodenal diverticulum complicated with hemorrhage. A 74‐year‐old woman developed hematemesis and tarry stools. An emergent upper gastrointestinal endoscopy revealed a diverticulum, about 3 cm in diameter, in the posteromedial aspect of the second duodenal segment, right oral to the papilla. The diverticulum was filled with blood clots. After removing them by gentle suction, a linear ulcer became visible and an actively oozing site was seen at one edge of the ulcer. Three injections of epinephrine in a 2.5% sodium chloride solution (epinephrine concentration 0.05 mg/mL), each 1.0 mL for a total volume of 3.0 mL, were made at the oozing site. The exuding ceased immediately after the third injection and bleeding did not reappear. In our patient, successful and complete hemostasis was obtained by this endoscopic injection of epinephrine, although most cases of duodenal diverticulum complicated with hemorrhage had been treated surgically. We think that endoscopic, instead of surgical treatment is considerably becoming another choice for treating patients with a bleeding duodenal diverticulum.
Endoscopically treated esophageal lipoma presenting with recurrent dysphagia after esophagectomy for esophageal carcinoma
Authors: Yoshida Tatsuya , Nagahama Takeshi , Kure Norihito , Baba Hiroyuki
Published: March 2003

We have reported a case of endoscopically treated lipoma of the cervical esophagus. The patient was referred to our hospital with a chief complaint of dysphagia and underwent an esophagectomy through right thoracotomy, followed by esophagogastrostomy for superficial esophageal cancer 31/2 months before. However, this benign lesion was not revealed by preoperative check‐up. He again complained of dysphagia after esophagectomy and lipoma of the cervical esophagus was confirmed. Esophageal lipomas are relatively rare in the digestive tract; however, lipoma of the cervical esophagus can cause upper airway obstruction in the case of regurgitation of the tumor. Therefore, this disease must be considered in the examination of the patient with dysphagia.
Development of magnifying video endoscopes with high resolution
Authors: Udagawa Tetsuo , Amano Minami , Okada Fujio
Published: March 2003

Background: The diagnostic capability of a video‐endoscope has been remarkably enhanced by using a high pixel count charge‐coupled device (CCD) and is getting closer to that of the stereomicroscope as its image quality is improved. From this standpoint, the authors have been developing high‐resolution magnifying video‐endoscopes.

Methods: There are two methods available to increase the resolution of a video‐endoscope: (i) use a CCD with large pixel number and (ii) optically magnify the image impinging on the CCD. Since the video‐endoscope using a 410 Kilo (K) pixel count CCD was introduced in 1993, the authors have been developing a video‐endoscope using a large pixel count number CCD in pursuit of obtaining better image quality and resolution. Also, the technological innovations in CCD manufacturing have allowed CCDs to become much smaller in size with higher pixel numbers. As the CCD size decreases, the distal part of a video‐endoscope can be made thinner. With respect to optical magnification, two methods are available, the fixed close‐focusing system and variable focus.

Results: With combined use of the variable focus magnification and the electronic magnification, a magnification more than × 100 can be achieved on a 14″ television monitor with higher resolution power and wider depth of field.

Conclusions: The images captured by the latest magnifying video‐endoscope prove that the image quality of video‐endoscopy is improving and is approaching the diagnostic capability of the stereomicroscope.
Endosonographic criteria for assessment of the depth of duodenal invasion in carcinoma of the papilla of Vater
Authors: Morozumi Atsuro , Fujino Masayuki A. , Sato Tadashi , Kojima Yuichiro , Nakamura Toshiya , Kubo Katsuhiro , Kitahara Fumiaki , Ikeda Masahiro
Published: March 2003

Background: Imaging criteria by endosonography for assessment of the depth of duodenal invasion of carcinoma of the papilla of Vater (papilla carcinoma) have not been established.

Methods: Twelve patients with papilla carcinoma were studied. The endosonographic findings were described in each case and depths were evaluated based on endosonographic images of the normal papilla and by comparison with endosonographic images of gastric carcinoma. The information was compared with the histopathological findings of the resected specimens.

Results: Imaging criteria were proposed as follows: In d0 or T1, the papilla swelled preserving the basic structure; in d1 or T2, the papilla presented as a tumor but the non‐thickened duodenal fourth (proper muscle) layer was traceable behind the tumor; in d2 or T2, the papilla presented as a tumor fused with the thickened duodenal fourth layer; in d3 or T3–4, the papilla presented as a tumor and the duodenal fourth layer was partially or entirely untraceable behind the tumor. Accuracy of endosonography was 75% by the Japanese classification and 83.3% by the TNM system.

Conclusions: Proposed endosonographic criteria are suitable for clinical application for assessing the depth of duodenal invasion of papilla carcinoma.
Early sigmoid colon carcinoma developed from a pedunculated polyp
Authors: NAKASHIMA HIROTAKA , NAGAHAMA RYUJI , YAMAKI GORO , SHIGA TOSHIAKI , NOMOTO KAZUO , OHKURA YASUO
Published: March 2003

A 60‐year‐old man underwent routine colonoscopy, and was noted to have a pedunculated polyp in the sigmoid colon. The pathologic diagnosis was adenoma, and due to patient’s personal circumstances, the lesion was left untreated. The colonoscopic examination was repeated 4 years and 11 months later, to find that the polyp had transformed into an elevated lesion with irregularly depressed surface. The patient was diagnosed as having early sigmoid cancer, and underwent sigmoidectomy. The histologic examination of the excised specimen revealed well‐differentiated adenocarcinoma with invasion into the submucosal layer. Through studying the natural course of colon cancer, it has become known that the advanced cancers commonly develop from polyps with short pedicles (sessile polyps). This case represents an early sigmoid cancer developed from a pedunculated polyp, which differs from the current mainstream concept of ‘polyp‐cancer sequence of colon cancer.’
Antral Red Streaking is a Negative Endoscopic Sign for Helicobacter Pylori Infection
Authors: Kawabe Takao , Maeda Shin , Ogura Keiji , Yamaji Yutaka , Okamoto Makoto , Yoshida Haruhiko , Shiratori Yasushi , Omata Masao
Published: March 2003

Background:  One of the most important endoscopic findings for the diagnosis of chronic gastritis is erythema. Erythema is classified into two groups: spotted or scattered erythema and linear erythema. We feel that red streaking has a tendency to be found on the apparently normal gastric mucosa without inflammation.

Methods:  To evaluate this association prospectively, we conducted the present study in 1513 consecutive patients undergoing endoscopy. Helicobacter pylori infection was assessed by rapid urease test, culture, pathological test, serological test and urea breath test using 13C.

Results:  Of these patients, red streaking was recognized in 94 patients (6.2%). All of the tests showed very low prevalence (0–3.5%) of H. pylori infection in patients with red streaking whereas positive results were obtained recognized in 42–49% of 94 age‐sex‐matched patients without red streaking. Additionally, no peptic‐ulcer diseases, such as gastric ulcer/ulcer scar and duodenal ulcer/ulcer scar, were found in the patients with red streaks. In conclusion, red streaking is a negative sign for H. pylori infection and peptic‐ulcer diseases.

Conclusions:  The understanding of these results might also improve the effort and cost‐effectiveness of endoscopic examinations by avoiding unnecessary further testing.
Extraction of uncovered biliary metallic stent using percutaneous transhepatic cholangioscopy
Authors: Itoi Takao , Nakamura Kazuto , Sofuni Atsushi , Itokawa Fumihide , Shinohara Yasushi , Takeda Kazuya , Tsuchida Akihiko , Aoki Tatsuya , Moriyasu Fuminori
Published: March 2003

In this study, we describe the successful removal of a biliary nitinol metallic stent during percutaneous transhepatic cholangioscopy (PTCS) after lithotripsy of stones caused by obstruction of a metallic stent placed to alleviate stenosis of the choledochoduodenal anastomotic site in a case of benign biliary disease. Using serrated‐edge forceps, one third of the metallic stent was removed in piecemeal sections and then the remaining portion of the stent was removed in one piece through the percutaneous transhepatic fistula. The endoscope was not damaged because all stent materials were removed through the PTCS fistula, not the channel of the endoscope. There were no procedural complications excluding minor bleeding seen endoscopically and no residual stent wires on cholangiograms. In conclusion, this technique is a useful method for metal stent removal from patients in whom it is to extract metallic stent by peroral endoscopic treatment.
ENDOSCOPE CONTAMINATION FROM HBV‐ AND HCV‐POSITIVE PATIENTS AND EVALUATION OF A CLEANING/DISINFECTING METHOD USING STRONGLY ACIDIC ELECTROLYZED WATER
Authors: Sakurai Yukihiro , Nakatsu Masami , Sato Yuko , Sato Kinuko
Published: March 2003

Background:  It is well known that strongly acidic electrolyzed water (SAEW) has a potent bactericidal effect. We examined residual viruses on endoscopes that were used in hepatitis B virus (HBV)‐positive and hepatitis C virus (HCV)‐positive patients and evaluated the effectiveness of SAEW in cleaning/disinfecting the endoscopes.

Methods:  A random sample of endoscopes used in 109 endoscopies on HBV‐positive patients and 107 endoscopies on HCV‐positive patients, who underwent upper gastrointestinal endoscopy for various reasons was taken to determine the degree of HBV and HCV contamination. Samples were taken using 10 mL of physiological saline injected through the forceps channel of each endoscope and collected at the distal end to be assayed using polymerase chain reaction (PCR). After examination, each endoscope was treated with air aspiration, then 200 mL of tap water that contained an enzyme detergent was absorbed, and SAEW was aspirated after cleaning with a brush. After each procedure, PCR was used for comparison and to identify any residual viruses.

Results:  In saline collected after air aspiration, viruses were detected in 39/109 endoscopes used in HBV patients and in 20/107 endoscopes used in HCV patients. In the saline aspirated with tap water containing an enzyme detergent, HBV was detected in 12/109 endoscopes and HCV was detected in 6/107 endoscopes. However, neither HBV nor HCV was detected after the endoscopes were cleaned manually with a brush and disinfected with SAEW.

Conclusion:  Endoscopes contaminated with HBV and HCV are effectively cleaned and disinfected by SAEW.
Fourier‐transform infrared spectrometric analysis for detecting colorectal carcinoma
Authors: Sheng Jianqiu , Shen Shijie , Li Shirong , Wu Xia , Gao Ge , Li Shiyong , Chen Zhimin
Published: March 2003

OBJECTIVE: To assess the value of Fourier‐transform infrared (FT‐IR) spectroscopic analysis in detecting colorectal carcinoma.

METHODS: Fifty pairs of specimens of exfoliated cells from patients with colorectal carcinoma, who had undergone colorectal resection, were analyzed by using FT‐IR spectrometry. Exfoliated cells were obtained by scraping off: (i) the foci of the colorectal carcinoma; and (ii) the normal mucosa more than 5 cm away from the foci. Cell specimens were fixed and smeared onto two slides: a gold‐coated slide for the infrared spectrometry and a conventional one for histopathological evaluation. The spectra from 28 pairs of specimens were analyzed by logistic regression with multiple factors to establish a statistical model for predicting the probability of colorectal cancers, and then the spectra of the remaining 22 pairs were judged according to the model. Their corresponding diagnostic accuracy was calculated.

RESULTS: Substantial differences were found in the spectral properties of cancer and non‐cancer cells, which were evident in the frequency region of 1000–1350/cm. A shift of the phosphodiester groups of nucleic acids was noted: compared with the spectral features of non‐cancerous cells, the distance between VsPO2– and VasPO2– was shorter in cancerous cells. The C–O stretching bonds of cell proteins were significantly changed in the frequency region of 1140–1180/cm. In non‐cancerous cells, the peak intensity of 1155/cm was stronger than that of 1174/cm, whereas in cancerous cells the peak intensity of 1155/cm was weaker than that of 1174/cm; the peak intensity ratio of 1174/cm : 1155/cm was increased in cancerous cells. The spectral characteristics of the spectrometric data from the 22 pairs of specimens were consistent with those of the base‐model data. The other 22 pairs of specimens were analyzed according to the model, indicating that Fourier‐transform infrared spectrometry can be used to discriminate cancerous cells from non‐cancerous cells with a sensitivity of 90.91%, a specificity of 86.36%, a positive prediction value of 86.96% and a negative predictive value of 90.48%.

CONCLUSIONS: Fourier‐transform infrared spectrometry is of value in detecting colorectal cancer cells and it could be used as a rapid method for the clinical screening of malignant cells.
Senile cardiac amyloidosis
Authors: Ako Junya , Sagawa Kayo , Iijima Katsuya , Ohike Yumiko , Watanabe Tokumitsu , Kozaki Koichi , Yoshizumi Masao , Ouchi Yasuyoshi
Published: March 2003

A case of senile cardiac amyloidosis with recurrent episodes of congestive heart failure is reported here. An 83‐year‐old woman with a history of hypertension was admitted for the treatment of worsening dyspnea. The echocardiography revealed diffuse mild hypokinesis of the left ventricle with an ejection fraction of 46%. An elevated E wave and shortened deceleration time in the left ventricular inflow waveform was demonstrated with Doppler echocardiography, which suggested that the nature of the heart failure was restrictive. The patient required hospitalization for the treatment of congestive heart failure four times in 2 years. An autopsy revealed deposition of prealbumin‐positive amyloid substance in the atrial myocardium and the intramyocardial arterioles of the left ventricle. Recurrent congestive heart failure was presumed to be a result of diastolic dysfunction due to senile cardiac amyloidosis.
New reliable and valid motor assessment scale for stroke patients: Hemiplegic motor behavior tests
Authors: Ohtsuru Izumi , Eto Fumio , Wada Naoki , Saotome Ikuko , Furuichi Teruhito
Published: March 2003

Background:

Various motor function tests have been reported and applied for the assessment of impairment and disability in stroke patients with hemiplegia. However, those staging criteria are ambiguous and show little evidence of reliability and validity. New criteria have therefore been designed that allow practical use of staging; namely, a well‐defined set of hemiplegic motor behavior tests (HMBT) based on simplified staging criteria. The purpose of the present paper was to assess the reliability and validity of this method as applied to hemiplegic stroke patients.

Methods:

The MBT were divided into three areas (upper extremities; hand and fingers; and lower extremities) on a six‐point ordinal grading scale (stages 1–6). Two raters evaluated the patients independently within 24 h, and the same raters assessed patients twice within 24 h. Intrarater and interrater reliability was evaluated using weighted kappa statistics on each item. The internal consistency of the scale was evaluated using Cronbach’s alpha. The study included 110 patients with hemiplegia. The HMBT scores were compared with the Barthel Index (BI) score and Modified Rankin Scale (MRS) score in 88 stroke patients. Correlations were calculated by Spearman rank correlation coefficients.

Results:

Intrarater and interrater agreements were high; weighted kappa values for different items ranged from 0.985 to 0.998 and from 0.975 to 0.983, respectively. The internal consistency was excellent (Cronbach’s alpha ≥ 0.863). Correlation coefficients of the HMBT with the BI for the different items ranged from 0.565 to 0.810; with the MRS these values ranged from –0.700 to –0.828, respectively.

Conclusion:

The HMBT, with clarified and simplified staging criteria, were confirmed to be highly reliable and valid.
Effect of joint flexibility on walking economy in middle‐aged and older people
Authors: Katamoto Shizuo
Published: March 2003

Purpose: The purpose of the present study was to clarify the effect of joint flexibility on walking economy.

Methods: Forty‐one healthy people (20–79 years) were divided into old (n =
13, 67 ± 5 years), middle (n = 11, 54 ± 3 years) and young groups
(n = 17, 23 ± 3 years). Each group was asked to measure maximal walking speed, flexibility (trunk, ankle and hip joint), oxygen uptake during treadmill walking (60, 80 and 100 m/min) with and without stretching.

Results: All variables measured (except flexibility of ankle joint) in older groups (n
= 24) were significantly lower than those in the young (P < 0.05–0.001).
However, there was no difference in mean values between the two older groups. Although
stretching improved flexibility in all groups (P < 0.01–0.001),
oxygen uptake during walking decreased only in the older groups (P < 0.05–0.01).
Maximal walking speed in the older groups positively correlated only with flexibility
of hip joint (r = 0.52; P < 0.01) and negatively with oxygen uptake
during walking (r = –0.37 to –0.41 (P < 0.05)). The
only flexibility that showed significant correlations with oxygen uptake during walking
was that of the hip joint in the older groups (older: r = –0.44 to
–0.55; P < 0.05–0.01; young: r = –0.11 to 0.08).

Conclusion: These data suggest that the increase of flexibility, especially flexibility of the hip joint, induces improvement of walking economy in older adults, but not in young adults, and that increasing the flexibility of the hip joint could contribute a beneficial effect to maintaining and improving walking ability in middle‐aged and older adults.
Plasma insulin and glucose levels in elderly female subjects with Alzheimer’s disease
Authors: Umegaki Hiroyuki , Ushida Chika , Ikari Hiroyuki , Ogawa Osamu , Nakamura Akira , Suzuki Yusuke , Endo Hidetoshi , Akatsu Hiroyasu , Yamamoto Takayuki , Iguchi Akihisa
Published: March 2003

Background:  The function of insulin in the central nervous system has been intensively investigated recently. Epidemiological studies have shown that hyperinsulinemia or diabetes mellitus is a risk factor for Alzheimer’s disease. Several studies have reported plasma levels of insulin and glucose in subjects with Alzheimer’s disease, however, the results were conflicting. A recent study suggested that fasting plasma insulin levels in subjects with Alzheimer’s disease depend on apolipoprotein E genotype, specifically, subjects with Alzheimer’s disease who were not apolipoprotein‐E4‐homozygotes had higher plasma insulin levels. The purpose of this study was to clarify plasma levels of insulin and glucose in subjects with Alzheimer’s disease.

Methods:  We performed a 75 g oral glucose tolerance test (OGTT) in elderly female subjects with Alzheimer’s disease (AD) and age‐matched female non‐demented subjects (mean age of the subjects involved was 82.9 ± 8.1 years). All subjects were non‐apolipoprotein E4‐homozygotes, and scores for mini‐mental state examination of all AD subjects were less than 16.

Results:  When fasting plasma levels of insulin and glucose in all recruited subjects were compared, those of glucose and insulin were significantly lower in AD subjects, possibly due to their lower body mass index (BMI). When only subjects with normal glucose metabolism in OGTT were included, BMI was comparable. Although plasma levels of fasting glucose and insulin were still lower in AD subjects, the difference lacked statistical significance.

Conclusion:  We failed to show that subjects with AD who were not apolipoprotein‐E4‐homozygotes had higher fasting plasma insulin levels compared with non‐demented subjects.
Clinical evaluation of long‐term use of a portable oxygen concentrator capable of operating under car battery power
Authors: Fuse Daisuke , Nakamoto Takaaki , Harasawa Hiroshi , Machida Suguru , Amano Hirohisa , Yoshida Takeshi , Mathuda Toshiya , Nakajima Takahide , Kuga Hideyo , Machida Suguru , Suzuki Hidehiko , Akiba Hirobumi , Kaneko Noboru
Published: March 2003

An oxygen concentrator that can be powered by a car battery was clinically evaluated. The oxygen concentrator was used on a 67‐year‐old man with sequelae of pulmonary tuberculosis who was receiving long‐term home oxygen therapy (HOT) after long‐term use of 4.7 years. His work required automobile trips over long distances. The equipment used was an adsorption‐type oxygen concentrator capable of operating on a DC 12 V power supply, which could be powered from a residential power outlet (AC 100 V) using a dedicated voltage converter. Using this equipment, he was capable of driving himself in comfort for 2 hours or longer, over a period of 4 years. Furthermore, it was possible to stay in a hotel during a trip, inhaling oxygen generated by the equipment. Hereafter, this equipment should enable or facilitate long‐distance driving, travel and lodging for HOT patients.
Association of amino acid variation (Trp64Arg) in the beta3‐adrenergic receptor gene with bone mineral density
Authors: Ogawa Sumito , Emi Mitsuru , Shiraki Masataka , Hosoi Takayuki , Orimo Hajime , Ouchi Yasuyoshi , Inoue Satoshi
Published: March 2003

Background:  Recent studies have revealed that a mis‐sense mutation replacing tryptophan with arginine at codon 64 (Trp64Arg) of the beta3‐adrenergic receptor (β3‐AR) gene was associated with insulin resistance in non‐diabetic subjects and to earlier onset of non‐insulin dependent diabetes mellitus. To analyze a possible involvement of β3‐AR in bone metabolism, we investigated the association between bone mineral density (BMD) and the Trp64Arg polymorphism.

Methods:  A large cohort of Japanese postmenopausal women comprised the study population. The genotypic frequencies in this cohort were Trp/Trp, 61.8%; Trp/Arg, 33.2%; and Arg/Arg, 5.0%.

Results:  When the subjects were separated into two groups, one bearing at least one Trp allele at codon 64 (Trp/Trp and Trp/Arg) and the other with none (Arg/Arg), the former subjects had significantly higher Z scores for total‐body BMD (mean ± SD, 0.432 ± 0.93 versus −0.135 ± 0.93; P = 0.033).

Conclusions:  These data suggested an association between this single‐nucleotide polymorphism (SNP) in the β3‐AR gene and BMD, and therefore a possible involvement of the Arg allele (or the absence of Trp64) in postmenopausal osteoporosis among Japanese women.
Cost of surgical site infections following coronary artery bypass surgery
Authors: Jenney Adam W. J. , Harrington Glenys A. , Russo Philip L. , Spelman Denis W.
Published: March 2003

Background:  Little information is available on the financial impact of surgical site infections (SSI) after major surgery. In order to calculate the cost of SSI following coronary artery bypass graft surgery (CABGs), a 2‐year retrospective case‐control study was undertaken at Alfred Hospital, a university‐affiliated tertiary referral centre.

Methods:  One hundred and eight patients with SSI (cases) after CABGs and 108 patients without SSI (controls) were matched for gender, age, risk index (Centers of Disease Control and Prevention, National Nosocomial Infection Surveillance (NNIS) System) and number of principal comorbidities. The patient’s postoperative length of stay (LOS), in both the intensive care unit (ICU) and the non‐ICU (general) ward, was obtained from the medical records and the cost of a day in each was provided by the hospital’s finance department. The cost of antibiotics prescribed for SSI was provided by the hospital’s pharmacy department.

Results:  Postoperatively the cases were in ICU for a total of 313 days whereas the controls spent 165 days in ICU, a mean of 2.89 versus 1.53 days, respectively (P = 0.035). In general wards, cases were inpatients for a total of 1651 days and controls for 589 days. This is a mean of 10.8 days for cases and 4.7 days for controls (P = 0.0001). The extra LOS for 108 cases (compared to the controls) was costed at $1 299 082, a mean cost of $12 028 per patient. The total cost of antibiotics prescribed for these SSI was $42 270 (a cost per case of $391). The total excess cost related to increased LOS and antibiotic treatment was $12 419 per patient. In the subgroup analysis for deep sternal site infections the mean excess cost was $31 597 per patient.

Conclusions:  Postoperative SSI result in significant patient morbidity and consume considerable resources. In the present study, patients with SSI following CABGs had significant prolongation of hospitalization (both in ICU and general wards). The present study illustrates the potential cost savings of introducing interventions to reduce SSI rates. This is the first time such a study has been undertaken in Australia.
Effectiveness of intra‐operative wound infiltration with long‐acting local anaesthetic
Authors: Kuan Yew‐Ming , Smith Steve , Miles Campbell , Grigg Michael
Published: March 2003

Background: Postoperative pain relief is of importance to both patients and surgeons. One of the simpler techniques is infiltration of the surgical incision with long acting local anaesthetic. The literature is confusing, with numerous reports attesting to the value of this approach and a similar number disputing the demonstrable benefits.

Methods: A prospective, ‘blinded’, randomized trial was undertaken involving 18 females undergoing uncomplicated bilateral sapheno‐femoral ligation. They received intraoperative bupivacaine infiltration into one or the other of their groin incisions. Postoperatively these patients were asked to assess a number of variables relating to their postoperative pain, each patient thereby acting as their own control.

Results: There was no significant difference in the postoperative pain experience between groins infiltrated with bupivacaine and those not infiltrated. Two patients developed wound infections and both of these occurred on the sides which had been infiltrated with bupivacaine, however this was not statistically significant. There was no difference found in pain experience with respect to pre‐ versus post‐incision infiltration.

Conclusion: Intraoperative wound infiltration with bupivacaine is widely employed as a method of minimizing postoperative pain. This study was unable to demonstrate a benefit of employing the technique in terms of a reduction in the patient’s perception of pain. By having each patient act as their own control, we have avoided one of the major deficiencies of previous studies, namely, interpatient variability in assessment and perception of pain.
POSSUM: A re‐evaluation in patients undergoing surgery for rectal cancer
Authors: Isbister William H. , Al Sanea Nasser
Published: March 2003

Background:  The problem of directly comparing morbidity and mortality rates between institutions without some sort of adjustment for case mix is well documented. Scoring systems have been developed to allow comparisons to be made. The Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) is one such system. It was designed to predict operative mortality and morbidity in differing settings and to be independent of case mix. The present study examines the use of POSSUM in colorectal practice in Saudi Arabia.

Methods:  Patients referred to King Faisal Specialist Hospital between 1990 and 1998 for primary management of an histologically proven rectal cancer were identified. POSSUM mortality and morbidity scores and Portsmouth‐Physiological and Operative Severity Score (P‐POSSUM) mortality scores were calculated separately for each patient, and predicted rates were compared with observed rates in the patients studied.

Results: There were 70 men (mean age: 55.6 years; range: 25−87) and 75 women (mean age: 52.8 years; range: 26−84). One hundred and six patients underwent ‘curative’ surgery. Abdominoperineal resection was the most frequently performed procedure. Major anastomotic leakage following anterior resection occurred in two of fifty patients. One patient developed a pulmonary embolism but no patient developed postoperative myocardial infarction. Two patients died. The median and mean physiological and operative severity scores were 13 (range: 12−37) and 17 (range: 8−37) and 14.68 and 18.36, respectively. The overall POSSUM‐predicted (using median scores) morbidity and mortality rates were 35.4% and 6.7%. The P‐POSSUM‐predicted (using mean scores) mortality rate was 3.5%. Observed morbidity and mortality rates were 54.5% and 1.4%.

Conclusion:  POSSUM failed to predict outcomes accurately in patients undergoing surgery for rectal cancer in Saudi Arabia. P‐POSSUM also overpredicted mortality but to a lesser extent. Patient's ‘wellness’ and the previously identified inability of POSSUM to accurately predict death in low‐risk populations may explain these findings. Care must be exercised in using the POSSUM formulae for risk adjustment in different settings.
Preoperative prediction of long‐term outcome following laparoscopic fundoplication
Authors: O'Boyle Colm J. , Watson David I. , DeBeaux Andrew C. , Jamieson Glyn G.
Published: March 2003

Background:  Although long‐term outcomes following laparoscopic fundoplication for gastro‐oesophageal disease have now been reported as very satisfactory, a small, but important, minority of patients are unhappy with the outcome, often due to recurrent reflux symptoms or new‐onset dysphagia. In this study, we sought to establish whether various parameters that can be determined before surgery, can predict the long‐term outcome of surgery.

Methods:  Data collected prospectively were evaluated to determine factors that were associated with outcome at 5 years following laparoscopic fundoplication. Inclusion criteria were complete preoperative assessment data and 5‐year follow‐up data. Data examined included information on preoperative age, sex, weight, home address, health insurance status, duration of reflux symptoms, previous surgery, operating surgeon, endoscopy and 24‐h pH monitoring. In addition, lower oesophageal sphincter resting and residual relaxation pressures were evaluated before and after surgery. The postoperative symptoms of heartburn and dysphagia, as well as overall satisfaction 5 years following surgery was determined using a 0−10 visual analogue scale. The association of the pre‐ and perioperative factors and outcome at 5 years was determined by univariate and linear regression analysis.

Results:  Two hundred and sixty‐two patients from an overall experience of over 1000 laparoscopic anti‐reflux procedures met the entry criteria. There was no association between patient address, age, weight, duration of symptoms, the presence of endoscopically proven oesophagitis, operating surgeon, the necessity for conversion to an open procedure, change in lower oesophageal sphincter residual relaxation pressure and the outcome parameters. Using univariate analysis, a higher heartburn score was associated with previous abdominal surgery, female sex, no private health insurance, and a normal preoperative 24‐h pH study. A higher dysphagia score was associated with a normal preoperative pH study, a postoperative increase in lower oesophageal sphincter resting pressure of more than 6 mmHg, and previous abdominal surgery. Overall satisfaction with the outcome at 5 years was higher among male patients, private patients, patients who had a hiatus hernia, and patients who had an abnormal preoperative pH study. Linear regression analysis confirmed that private insurance, male sex, and the absence of previous abdominal surgery, were the strongest predictors of an improved heartburn score, whereas male sex and private health insurance were the strongest predictors of greater satisfaction with the overall outcome.

Conclusions:  There are parameters that can be assessed before or during laparoscopic Nissen fundoplication that correlate with late outcome parameters. In particular, male patients and those from higher socioeconomic groups appear to have a better long‐term outcome.
Study of serum calcium and trace elements in chronic cholelithiasis
Authors: Verma Ganga R. , Pandey Ajay K. , Bose Shashank M. , Prasad Rajendra
Published: March 2003

Background:  High biliary calcium and trace elements (copper, zinc and iron) in patients with chronic cholelithiasis can be associated with gallstones.

Methods:  Estimations of calcium, copper, zinc and iron were done in the serum, gall bladder bile and gallstones of 48 patients with chronic cholelithiasis and in 20 age‐ and sex‐matched controls. Biliary levels of calcium and trace elements and bile/serum ratio of calcium and trace elements were compared in the two groups.

Results:  Serum calcium was significantly less (P= 0.009) than controls, but biliary calcium was higher in the patients with chronic cholecystitis. All trace elements were found to be significantly higher (P≤ 0.036) in the bile of patients with chronic cholelithiasis. The bile/serum ratio of calcium, copper and zinc was significantly greater (P≤ 0.03) in patients of chronic cholelithiasis. Gall bladder bile in patients with chronic cholelithiasis was slightly more alkaline. Pigment stones contained significantly more calcium, copper and iron than cholesterol stones (P≤ 0.001).

Conclusion:  Higher biliary calcium and trace elements as well as a defective pH of gall bladder bile in patients with chronic cholelithiasis could be the underlying factor in the pathogenesis of gallstones.
Hepatic artery thrombosis and intraoperative hepatic artery flow rates in adult orthotopic liver transplantation
Authors: Lin Martin , Crawford Michael , Fisher Jodi , Hitos Kerry , Verran Deborah
Published: March 2003

Introduction: Thrombosis of the hepatic artery following orthotopic liver transplantation (OLT) can be a devastating com­plication impacting on recipient outcome. The utility of routine intraoperative flow measurements of the hepatic artery in predicting subsequent hepatic artery thrombosis (HAT) is presented in this study.

Methods: Data on all adult OLT recipients between July 1995 and May 2000 were analysed. This included the routine intra­operative flow measurements of both the hepatic artery and portal vein using a Doppler flow meter.

Results: Thirteen out of 198 (6.6%) instances of OLT were complicated by HAT. The mean and median flow rates of the hepatic artery in the OLT with HAT were 262 mL/min and 220 mL/min, respectively. These were significantly lower than the respective values of 436 mL/min and 400 mL/min in the OLT without HAT (P = 0.0036). This was independent of recipient age, sex, weight and intraoperative portal flow rates. However there was extensive overlap for the intraoperative hepatic artery flow rates obtained between the HAT and non‐HAT groups. The risk of HAT was increased by a factor of 6 if the intraoperative hepatic artery flow rate was less than 200 mL/min. The average allograft survival was significantly lower in the HAT group at 373 daysvsthe non‐HAT group at 763 days (P = 0.026).

Conclusion: The routine use of intraoperative flow measurements of the hepatic artery may be a useful adjunct in identifying the hepatic artery reconstruction, which is at risk of subsequent HAT.
Minimal access thyroid surgery: Is it feasible, is it appropriate?
Authors: Sackett Wendy R. , Barraclough Bruce H. , Sidhu Stan , Reeve Tom S. , Delbridge Leigh W.
Published: March 2003

Background:  Reports of minimal access thyroid surgery (MATS) using various techniques have recently appeared. This study examined the feasibility of MATS using either a lateral ‘focused’ or endoscopically assisted approach.

Methods:  The study group comprised all patients undergoing minimally invasive parathyroidectomy (MIP) during the period May 1998 to April 2002 in whom a concomitant thyroid procedure was undertaken. All procedures were performed either through a 2‐cm lateral cervical incision (n = 19) or endoscopically (n = 7).

Results:  Twenty‐six patients underwent thyroid surgery, consisting of either local excision of a thyroid nodule (n = 25) or hemi­thyroidectomy (n = 1). In 13 patients the nodule was incidentally discovered, in four patients removal of the parathyroid necessitated partial thyroidectomy, and in nine patients the lesion identified by preoperative parathyroid localization proved to be a thyroid nodule. There were no permanent complications in the study group. Two patients required drainage of a haematoma. The final pathology of all 26 cases revealed benign nodular thyroid disease.

Conclusion:  Thyroid surgery can safely be performed as a minimally invasive procedure. Minimal access thyroid surgery is therefore a feasible option for selected patients. The question remains to be answered as to whether this surgical approach is appropriate treatment for nodular thyroid disease.
Extra‐nodal lymphoma presenting as a mimic of soft‐tissue sarcoma
Authors: Knowles Brett , Serpell Jonathan W.
Published: March 2003

Background:  A variety of soft‐tissue tumours result in soft‐tissue masses, which are all differential diagnoses of soft‐tissue sar­comas. A rare cause is extra‐nodal lymphoma which, unlike a soft‐tissue sarcoma which it mimics, should not be excised, but rather treated by chemotherapy and/or radiotherapy. The aim of the present study was to identify clinical, radiological, biopsy and management features of lymphoma when presenting as a soft‐tissue mass.

Methods:  A review of 17 cases of soft‐tissue lymphoma presenting as a soft‐tissue mass from a total database of 295 soft‐tissue tumours was undertaken. Lymphomas arising in cervical, axillary and inguinal nodes were excluded.

Results:  All patients presented with a soft‐tissue mass but none had the symptoms of lymphoma. Computed tomography scanning identified seven (54%) of 13 with regional lymphadenopathy, six (46%) of 13 with encasement of major vascular structures and three with invasion across major soft‐tissue boundaries. Core biopsy established a diagnosis in 13 patients (sensitivity 93%). All patients were treated with either chemotherapy and/or radiotherapy and all are alive with a mean follow up of 19 months. None underwent major resectional surgery.

Conclusion:  The present series highlights a rare subgroup of patients with extra‐nodal soft‐tissue lymphoma mimicking soft‐tissue sarcoma. Core biopsy is accurate in their diagnosis. Computed tomography scanning may show features suggesting the diagnosis.
Thoracoscopic talc pleurodesis for malignant pleural effusion
Authors: Love David , White Dean , Kiroff George
Published: March 2003

Background:  Malignant pleural effusion (MPE) is a common and distressing condition at the end of life for many patients with disseminated cancer. The challenge for the surgeon lies in managing this problem in order to deliver the most effective palliation with the least impact on the limited time available to these patients.

Methods:  Herein is reported a retrospective review of outcomes for a consecutive series of 66 MPE (61 patients) treated over a 5‐year period from 1995 to 2000. A standard operative technique involving a single‐lung anaesthetic and two‐port thoracoscopy was employed. Outcomes were determined by contacting the referring practitioner or the patients themselves. Principal outcome measures included time to recurrence of the effusion and survival.

Results:  Complete follow up was achieved for 60 MPE (55 patients; five of whom were treated for metachronous, bilateral ­disease). The three most common primary sites were breast, lung and mesothelial tissue. The planned procedure was not completed in two cases due to encasement of the underlying lung by tumour. Primary failure (immediate recurrence of the effusion) occurred in six cases. Delayed recurrence of the effusion occurred in a further 23 MPE resulting in complete control in 31 cases (52%) until death. Overall median survival was 220 days and the 30‐day mortality was 0.

Conclusions:  Complete and permanent control of a malignant effusion is difficult to achieve. Management based on thoracoscopy and talc insufflation produces satisfactory results with an acceptable morbidity and no early mortality. The ability to inspect the pleural space, break down adhesions and completely drain pockets of fluid to achieve complete lung expansion probably contributes to this.
Optimizing glycoprotein IIb/IIIa inhibition: lessons from recent randomized controlled trials
Authors: Chew D. P. , Bhatt D. L.
Published: March 2003

Recent randomized clinical trials with intravenous glycoprotein IIb/IIIa inhibition have provided unanticipated results, thereby questioning their role as empirical medical management for acute coronary syndromes. The lack of benefit with abciximab observed in Global Utilization of Strategies to Open Occluded Coronary Arteries IV is somewhat inconsistent with the benefits seen with this agent in coronary intervention, and the benefits of an early invasive approach incorporating tirofiban seen within Treat Angina with Aggrastat and determine Cost of Therapy with an Invasive or Conservative Strategy Thrombolysis in Myocardial Infraction 18. Additionally, a direct ‘head‐to‐head’ comparative study of abciximab and tirofiban within the setting of percutaneous coronary intervention demonstrates clinically relevant superiority with abciximab with respect to 30‐day outcomes.

These findings indicate that the interaction between glycoprotein IIb/IIIa inhibition and clinical outcome in the setting of coronary instability and mechanical plaque disruption is more complex than initially perceived. Hence, although an abundance of evidence details the efficacy of these agents, their optimal clinical application remains somewhat challenging in light of these recent data. However, within the context of previous trial experience, the current evidence highlights several key aspects of glycoprotein IIb/IIIa inhibitor therapy that may be associated with improved patient outcomes. In particular, these trials indicate: (i) the importance of selecting high‐risk patients in whom substantial clinical benefit is evident, (ii) the incorporation of these agents into an early invasive strategy, thereby matching the timing of vascular injury with maximal platelet inhibition and (iii) optimal dosing to achieve the high levels of platelet inhibition that appear to be required for efficacy with these agents. (Intern Med J 2002; 32: 338−345)
DESCRIPTION OF SHORT FATIGUE CRACK GROWTH IN A SHOT=PEENED MEDIUM CARBON STEEL
Authors: Koca D , Koca S , Tomaszek H
Published: March 2003

A probabilistic and simplified approach to the description of short crack growth in shot‐peened, medium carbon steel specimens is presented. In order to model the dynamics of short crack growth, a difference equation has been formulated with coefficients originating from a two‐parameter Weibull distribution of crack advance. The Fokker–Planck partial differential equation is the source of a solution based on the form of a probability density function of crack length. The resolved function allows one to calculate the expected crack length, crack growth rate and standard deviation of crack length. The viability of the probabilistic method has been verified using experimental data gained for shot‐peened specimens fatigued under reversed torsion.