bluuebunny/crossref_metadata_2025 huggingface dataset:
Helicobacter pylori cagA, iceA and vacA status in Taiwanese patients with peptic ulcer and gastritis
Authors: PERNG CHIN‐LIN , LIN HWAI‐JENG ,   FACG, SUN I‐CHEN , TSENG GUAN‐YING
Published: October 2003

Background:  Helicobacter pylori causes chronic gastritis, peptic ulcer, gastric cancer and mucosa‐associated lymphoid tissue (MALT) lymphoma. Different genotypes of H. pylori are confirmed from diverse geographical areas. Its association with clinical diseases remains controversial. The aim of the present study was to investigate the H. pylori vacuolating cytotoxin (vacA) alleles, cytotoxin‐associated gene (cagA) and iceA, in patients with peptic ulcer and gastritis.

Methods:  We enrolled patients with peptic ulcer and chronic gastritis. Biopsy specimens were obtained from the antrum and lower body of the stomach. DNA extraction and polymerase chain reaction (PCR) were used to detect the presence or absence of cagA and to assess the polymorphism of vacA and iceA.

Results:  A total of 133 patients (57 gastric ulcer, 52 duodenal ulcer, 24 chronic gastritis) had positive PCR results from biopsy specimens. Concerning genotypes, we found cagA (79% in the antrum, 92% in the body) and iceA1 (73% in the antrum, 82.8% in the body) strains in the majority of patients. The dominant vacA subtype was s1a (74.4% in the antrum, 75% in the body), followed by s1c (51.1% in the antrum, 60.5% in the body). In the middle region, the m2 strain dominated (49.6% in the antrum, 41.4% in the body), followed by m1T (19.5% in the antrum, 9.5% in the body). Mixed infection occurred in 89 patients (67%). There was no statistical difference in genotypes among the three groups.

Conclusion:  In Taiwan, H. pylori with positive cagA and iceA1 was found in the majority of cases. H. pylori with vacA s1a strains was the most common vacA subtype, followed by s1c, while s1b was rare. In the middle region, the m2 subtype was predominant followed by m1T. There was no significant association between genotypes and clinical diseases.
Current clinical and pathogenetic understanding of β2‐m amyloidosis in long‐term haemodialysis patients
Authors: GEJYO Fumitake , NARITA Ichiei
Published: October 2003

SUMMARY:  As the number of patients undergoing long‐term haemodialysis continues to grow, β2‐microglubulin (β2‐m) amyloidosis is emerging as an increasingly common complication. The frequency of β2‐m amyloid‐related osteoarthropathy in haemodialysis patients rises steadily with length of survival. We confirmed that the prevalence of carpal tunnel syndrome increases with years of dialysis. Up to 50% of patients had developed this complication after 20 years were affected and the percentage was even higher after 25 years.

Although retention of β2‐m is a necessary requirement for onset of amyloidosis, it is probably not sufficient. Using an in vitro model of β2‐m‐related amyloid fibril (fAβ2‐m) extension, we demonstrated that various amyloid‐associated molecules, such as apolipoprotein (apo) E and proteoglycans, accelerate β2‐m amyloid fibril formation.

General categories of therapeutic approaches for amyloidosis include prevention of onset or progression, symptomatic therapy (conservative treatment, orthopedic procedures, and physiotherapy), and renal transplantation. In association of haemodialysis, β2‐m has been removed by high‐flux membranes or a β2‐m adsorption column. However, proof is lacking that amyloid deposits are decreased by long‐term use of dialysis techniques to eliminate β2‐m. More effective treatment procedures are needed.
Sclerosing encapsulating peritonitis as a complication of long‐term continuous ambulatory peritoneal dialysis in Korea
Authors: LEE Ho Yung , KIM Beom Seok , CHOI Hoon Young , PARK Hyeong Cheon , KANG Shin Wook , CHOI Kyu Hun , HA Sung Kyu , HAN Dae Suk
Published: October 2003

SUMMARY:  Sclerosing encapsulating peritonitis (SEP) is a rare yet serious complication in patients with continuous ambulatory peritoneal dialysis (CAPD). Incidence and prevalence of this syndrome have been defined in some large populations and a few single‐centre experiences, but there is no satisfactory estimate of the comparative incidence of dialysis related SEP. The pathogenesis of SEP still remains uncertain, but there could be various causative factors. The diagnosis of SEP remains based on clinical suspicion confirmed with radiologic and/or pathologic findings. The possible variable etiologies and probable distinct pathways leading to this syndrome may make a uniform therapeutic approach unlikely.

To determine the prevalence, etiologic factors, clinical features, effect of dialysis duration, and outcome of SEP in Korea, patients undergoing CAPD who developed SEP were retrospectively studied in five University Hospital dialysis centres with large numbers of CAPD patients in Korea. Out of a total 3888 CAPD studied patients between January 1981 to December 2002 in those five medical centres, 31 cases developed SEP with the overall prevalence 0.8%. There were 15 men and 16 women. The mean age of these patients was 44.0 ± 9.8 years old. The mean duration of CAPD before SEP was 70.3 ± 41.9 months (range 9–144 months) and 67.8% of patients (21/31) had been on CAPD more than 4 years. Peritonitis, including one fungal peritonitis, was the main cause of SEP in 25 cases (80.6%). Seventy percent of these cases used β‐blocker and the mean duration of the usage was 61.7 ± 47.6 months. Seven cases were surgically treated and others were treated conservatively with intermittent total parenteral nutrition. The mortality rate was 25.8%.

In conclusion, SEP is a serious life threatening complication of CAPD, and most cases had long‐term peritoneal dialysis (PD) duration more than 4 years. To reduce the incidence of SEP, careful monitoring may be needed especially in patients with long‐term CAPD and peritonitis.
Development of bioartificial kidneys
Authors: SAITO Akira
Published: October 2003

SUMMARY:  Bioartificial kidneys, which consist of continuous haemofiltration and bioartificial tubules using tubular epithelial cells, have been studied since 1987. The bioartificial tubules consist of hollow fibre modules and tubular epithelial cells grown on the hollow fibre membranes after coating with extracellular matrices. The kinds of tubular epithelial cells, extracellular matrices and artificial membranes therefore have been investigated and then the most appropriate cell and materials have been selected on the basis of the development of bioartificial kidneys. Successful seeding to form confluent monolayers on the surfaces of hollow fibers is not easy, but this method has already been established. Renal assist devices using human renal proximal tubular epithelial cells have been used in the treatment of acute renal failure patients with endotoxemia by Humes et al., and successful treatment of acute renal failure patients with these devices was reported in 2001 and 2002, in which the improved mortality rate of those patients was shown. A bioartificial kidney, in which cDNA of multidrug resistance protein‐1 was transfected into tubular epithelial cells that were then grown on the outer surfaces of hollow fibers, was used in the experimental treatment of digoxin‐intoxicated dogs. Rapidly reduced digoxin levels were noted in the plasma of the dogs after treatment. Bioartificial kidneys, however, have never been used in the long‐term treatment of a maintenance dialysis patient, although patients need those kidneys. In order to establish long‐term treatment with a bioartificial kidney, each haemofilter has to function for more than one week without systemic anticoagulation and a bioartificial tubule must function for 3–4 weeks.
Skeletal resistance to parathyroid hormone as a background abnormality in uremia
Authors: FUKAGAWA Masafumi , IWASAKI Yoshiko , KAZAMA Junichiro J.
Published: October 2003

SUMMARY:  Skeletal resistance to parathyroid hormone (PTH) is a background abnormality underlying uremic bone disease. This abnormality exists even with high PTH. By the suppression of PTH, it has become uncovered, presenting as adynamic bone disease. Since patients with adynamic bone disease have higher risk of hypercalcemia or lumber fracture, mechanisms of this skeletal resistance to PTH need to be elucidated for the optimal management of bone turnover and parathyroid function in chronic dialysis patients.
C‐reactive protein as a cardiovascular risk factor and its therapeutic implications in end‐stage renal disease patients
Authors: PARK Jung Sik , KIM Soon Bae
Published: October 2003

SUMMARY:  We observed the association between a persistent elevation of C‐reactive protein (CRP) level and the presence of ischemic heart disease in 73 peritoneal dialysis (PD) patients. Twenty‐six patients showed an elevation of CRP for more than 6 months. Seventeen (65%) of the 26 patients had positive thallium single photon computed tomography (SPECT). Three of 9 patients who had a persistent elevation of CRP and negative thallium SPECT had a history of cerebral infarction or peripheral vascular disease. Therefore, 77% (20/26) of an elevated CRP level that lasted longer than 6 months can be explained by the presence of atherosclerotic vascular disease. There are as yet no valid recommendations on how chronic inflammation should be handled. We found that aspirin 200 mg daily for 8 weeks induce no significant changes of the CRP levels in PD patients (0.22 vs. 0.18 mg/dL, p > 0.05). However, 62 HD patients were randomly assigned to treatment group (simvastatin 20 mg/day) and control group. After 8 weeks medication, hs‐CRP levels significantly reduced from a median of 0.23 mg/dL to 0.12 mg/dL.
Management of secondary hyperparathyroidism of dialysis patients
Authors: AKIZAWA Tadao , KAMIMURA Motohiro , MIZOBUCHI Masahide , SHIIZAKI Kazuhiro , SUMIKADO Shinji , SAKAGUCHI Toshibumi , NEGI Shigeo , OGATA Hiroaki , KINUGASA Eriko
Published: October 2003

SUMMARY:  Hyperphosphatemia, vitamin D deficiency, and resulted hypocalcemia have been regarded as classical pathogeneses of secondary hyperparathyroidism. These factors have been treated by the administration of phosphorus binder and vitamin D derivatives. However, these therapies have not brought about a successful result for the prevention and treatment of secondary hyperparathyroidism. The reason could be mainly attributed to the hypercalcemia that results from the administration of calcium salts as a phosphorus binder and the calcemic action of vitamin D. To prevent hypercalcemia, non‐calcium containing phosphorus binder (sevelamer hydrochloride) and vitamin D analogues, which suppress PTH secretion with minimum calcemic action, have been developed. These new vitamin D analogues include 19‐nor‐1‐alpha, 25‐dihydroxyvitamin D2 (paricalcitol), 1‐alpha‐hydroxyvitamin D2 (doxercalciferol), 22oxa‐calcitriol (maxacalcitol) and F6‐calcitriol (falecalcitriol). Furthermore, calcimimetics that stimulate calcium‐sensing receptor of parathyroid cells as calcium and suppress PTH secretion are now under clinical trial. Percutaneous direct injection therapy of vitamin D, vitamin D analogue or calcimimetics into parathyroid gland has also been reported. The combination of these new strategies is expected to effectively and safely suppresses secondary hyperparathyroidism that has been resistant to conventional medical treatments.
Association of natural tooth loss with genetic variation at the SRC locus among elderly women in Japan
Authors: Hirano Hirohiko , Ezura Yoichi , Yoshida Hideo , Suzuki Takao , Hosoi Takayuki , Emi Mitsuru
Published: October 2003

Background:  Tooth loss is a major medical issue for the elderly population because it impairs masticatory function critical for oral intake of essential nutrition. Maintenance of sound natural tooth alignment is important for preserving masticatory potential in elderly individuals. Reduction in the number of natural teeth remaining intact (NTI) varies among individuals; thus, heterogeneity in NTI might reflect genetic variation within the population. One such candidate gene is the v‐src sarcoma viral oncogene homolog (SRC) gene, which plays an essential role in differentiation and maturation of the osteoclast.

Methods:  A possible association was investigated between the CA repeat polymorphism at the human SRC gene locus and the NTI in 455 elderly Japanese women. Genotypes were classified into 15 groups according to the number of CA repeats present, from A1 to A15.

Results:  The 44 women who possessed an A6 allele (197 bp, containing 23 repeats of CA) had significantly lower NTI than the participants (n = 411) who did not carry that allele (mean ± SD: 3.2 ± 6.25 vs 6.1 ± 8.25; P = 0.027, Mann–Whitney test). Although the tooth loss rate did not correlate with the A6 allele in an 8 year follow‐up study, significant difference of NTI was maintained during that 8 years.

Conclusion:  Genetic variation at the SRC gene locus is associated with tooth loss in elderly women, suggesting an existence of determinant genetic variation in this locus. The findings would be beneficial for development of a novel treatment and prevention of the periodontal diseases.
Study of Alzheimer's disease using transgenic mice: The mechanism of formation of brain Aβ amyloid and neurofibrillary tangles
Authors: Harigaya Yasuo
Published: October 2003

Background:  The purpose of the present paper was to clarify the role of brain amyloid β protein (Aβ) in Alzheimer's disease (AD) with the eventual aim of developing new treatments.

Methods:  Three kinds of transgenic mice (Tg) were examined: those overexpressing βAPP695ΔNL (APPsw mice), those expressing the R406W mutant form of human 4‐repeat tau (tauR406W mice), and those with both βAPP695ΔNL and R406W mutant tau (APPsw × tau R406 double Tg).

Results:  First, cored plaques, diffuse plaques and amyloid angiopathy were detected in the brains of APPsw mice. Loss of neurons and synapses was seen in the cored plaques, and accumulation of phosphorylated‐tau in dystrophic neurites around the cored plaques. However, Neurofibrillary tangles were not seen. These mice displayed memory impairment and decreased levels of acetylcholine in the cortex and hippocampus. Second, tau R406W mice were produced. These mice developed motor disturbances and memory impairment, accompanied by gliosis and marked tau accumulation in neurons of the frontotemporal cortex, hippocampus and amygdala. No Aβ was detected. Third, APPsw × tauR406W double Tg were produced. The pattern of Aβ deposition was similar in these double Tg and the APPsw mice. Gallyas silver‐staining showed greater levels of tauopathy in the hippocampus in these double Tg compared to the tauR406W mice.

Conclusion:  These findings suggest that deposition of brain Aβ is the initial event leading to subsequent disease such as accumulation of phosphorylated tau, neuronal loss and memory disturbance, and that the treatment of brain Aβ should be the first priority in finding a cure for AD.
Achievements of the Koganei Study
Authors: Shibata Hiroshi
Published: October 2003

The purpose of the present paper was to briefly review longitudinal interdisciplinary studies on aging and cross‐sectional studies for investigating problems in the aged society that were carried out in Koganei city, a suburb of Tokyo between 1976 and 1991. The signifi‐cance of the Koganei Study is emphasized from the viewpoint of pioneering gerontological reseach in Japan.
Elderly patient with short‐term recurrent pneumonia in the same lobe
Authors: Yamanari Hiroshi , Yamanari Shuichi , Tada Atsuhiko
Published: October 2003

After complaints of fever, cough and a right upper lateral chest pain, an 86‐year‐old man received medical examination in January 2001. A chest X‐ray showed right upper pulmonary infiltrates. He was empirically treated and the pulmonary infiltrates disappeared. He had a second episode of recurrent pneumonia in the same right upper lobe in April 2001, and then a third episode of recurrent pneumonia in October 2001. Chest computed tomography showed neither localized intraluminal bronchial obstruction nor localized extrinsic bronchial compression in the right upper pulmonary lobe. His immune system and pulmonary function tests were normal. Therefore, it appeared that these were the same lobar recurrent pneumonias, which are rare in the short term. He was tried on long‐term low‐dose erythromycin therapy after the third episode of recurrent pneumonia and he has had no recurrent pneumonia for 16 months.
Parathyroid hormone venous sampling prior to reoperation forprimary hyperparathyroidism
Authors: Estella E. , Leong M. S. Z. , Bennett I. , Hartley L. , Wetzig N. , Archibald C.A. , Harper J. S. , Cuneo R. C.
Published: October 2003

Background:  The surgical cure rate for primary hyperparathyroidismis greater than 95%. For those who have recurrent or persistentdisease, preoperative localization improves reoperation successrates. Selective parathyroid venous sampling (SPVS) for intact parathyroidhormone is particularly useful when non‐invasive localization techniquesare negative or inconclusive.

Methods:  We present all known cases (n = 13)between 1994 and 2002 who had venous sampling for localization atour institution prior to reoperation for recurrent or persistentprimary hyperparathyroidism. Comparison was made with non‐invasivelocalization procedures. Results of invasive and non‐invasive localizationwere correlated with surgical findings.

Results:  Of the nine reoperated cases, eight had positive correlationsbetween SPVS and operative findings and histopathology. SPVS didnot reveal the parathyroid hormone source in one case with negativenon‐invasive localization procedures. Comparisons between SPVS,computerized tomography (CT), and parathyroid scintigraphy (MIBI)as expressed in terms of true positive (TP), false positive (FP)and false negative (FN) were: SPVS − TP88.8%, FP 0%, FN 11.1%; CT − TP22.2%, FP 22.2%, FN 55.5%; and MIBI − TP33.3%, FP 0%, FN 66.6%. At least sevenof the nine operated cases have been cured; another remained normocalcaemic 2 weeksafter subtotal parathyroidectomy.

Conclusion:  In our institution SPVS has proven to be a valuabletool in cases with recurrent or persistent primary hyperpara­thyroidismand negative non‐invasive localization procedures.
Noise exposure in the orthopaedic operating theatre: a significant health hazard
Authors: Love Hamish
Published: October 2003

Background:  Surgeons working in orthopedic operating theatres are exposed to significant noise pollution due to the use of powered instruments. This may carry a risk of noise‐induced hearing loss. The present study was designed to quantify the noise exposure experienced by surgeons and establish whether this breaches occupational health guidelines for workplace noise exposure.

Methods:  A sound dosimeter was worn by the operating surgeon during three total hip replacements and two total knee replacements. A timed record of the procedures was kept concurrently. Noise levels experienced during each part of the procedure and total noise exposures were measured. Noise exposures were compared with occupational health guidelines.

Results:  Noise exposure in total hip replacement averaged 4.5% (1.52−6.45%) of the allowed daily dose (average duration 77.28 min). Total knee replacement exposure was 5.74% (4.09−7.39%) of allowed daily exposure (average duration: 69.76 min). Maximum sound levels approached but did not exceed recommended limits of 110 dBA (108.3 dBA in total hip replacement and 107.6 dBA in total knee replacement). Transient peak sound levels exceeded maximums of 140 dB on multiple occasions during surgery.

Conclusions:  Overall total noise dose during orthopaedic surgery was acceptable but orthopaedic surgeons experience brief periods of noise exposure in excess of legislated guidelines. This constitutes a noise hazard and carries a significant, but unquantified risk for noise‐induced hearing loss.
Minimally invasive parathyroidectomy for recurrent or persistent hyperparathyroidism using carbon track localization
Authors: Kennedy Robert J. , Roberts Anthony P. , Reece G John , Malycha Peter L.
Published: October 2003

Background:  The present study documents the use of carbon tracking to localize parathyroid adenomas in three patients with persistent or recurrent parathyroid disease.

Methods:  Three patients requiring second or third operations for hyperparathyroidism were operated upon after the parathyroid lesion had been localized preoperatively using a suspension of carbon particles in water. The enlarged parathyroid glands were identified by using one or more of the following: computed axial tomography, magnetic resonance imaging, ultrasound or Sestamibi nuclear scan. The lesion was then localized with ultrasound or computed axial tomography and a carbon track was inserted from the lesion to the skin, leaving a small skin tattoo as a marker for the surgeon. Each patient underwent a minimally invasive parathyroid operation.

Results:  For each of the three patients the recurrent or persistent parathyroid adenoma was successfully identified and removed via a small incision.

Conclusion:  Minimally invasive techniques for primary hyperparathyroidism are changing our approach to parathyroid surgery. However, a minimally invasive technique is less applicable when the disease is persistent or recurrent. Although, when the recurrent or persistent parathyroid adenoma can be identified, localization and carbon tracking have proved useful in allowing the surgeon to remove the lesion via a minimally invasive technique.
Parastomal hernia following minimally invasive stoma formation
Authors: Carne Peter W. G. , Frye John N. R. , Robertson Greg M. , Frizelle Frank A.
Published: October 2003

Background:  Minimally invasive intestinal stoma formation using a laparoscopic approach or through a trephine, is widely described in published literature. The incidence of parastomal hernia (PH) following a stoma formed without formal laparotomy is not well reported. The present review aims to assess the current data available on minimally invasive stoma formation, with particular reference to the incidence of PH.

Methods:  A literature search using the Pubmed Medline database was performed, locating English language articles on minimally invasive stoma formation from 1970 to 2002. The manuscripts were searched manually for further references.

Results:  The number of published studies describing laparoscopic stoma formation is small (263 stomas) and the follow‐up studied were short (none longer than 1 year). The incidence of PH was 0−6.7%. The incidence following a trephine stoma was 6.7−12%, and the number of patients was small (118) and the follow up short (up to 12 months).

Conclusions:  The incidence of PH following minimally invasive stoma formation using a trephine or a laparoscopic technique remains unclear. Studies published to date are generally small and the follow up is short. A prospective randomized trial comparing minimally invasive stoma formation with stoma formation with laparotomy, is required.
Will MAC be back?
Authors: Salerno Stephen , Terrill Patricia
Published: October 2003

Background:  Microcystic adnexal carcinoma (MAC) was first described as a specific entity in 1982 by Goldstein et al. MAC is a very aggressive tumour, displaying locally invasive tendencies with perineural invasion. For this reason previous studies have suggested that Mohs micrographic surgery is a superior technique in establishing clear margins of excision. However, there is no evidence to suggest that standard local excision is less effective in achieving tumour clearance or a more favourable outcome.

Methods:  All patients with MAC were identified from the pathology database. All patients who had undergone local excision were reviewed and included in the study. Histopathology was reviewed by dermatopathologists.

Results:  We reviewed the outcome of 17 patients treated with local excision. Eleven were female and six were male with a mean age of 70 years, and a mean follow up of 30 months. Two patients in this series experienced recurrence after standard local excision. The mean lateral and depth margins were 7.69 mm (range 0.2−21) and 4.66 mm (range 1−14.5), respectively. Recurrence occurred in two out of three patients who had lateral clearance margins of less than 4 mm. These two patients had evidence of perineural invasion on histopathology.

Conclusion:  In the present study, standard local excision is shown to be effective in tumour clearance for MAC with no recurrences provided there are lateral margins of at least 4 mm. However, a longer period of follow up is required because of the very aggressive locally invasive nature of the tumour.
Trauma teams in Australia: a national survey
Authors: Wong Kenneth , Petchell Jeffrey
Published: October 2003

Background:  Trauma teams have been associated with improved trauma patient outcomes. The present study seeks to estimate the use of trauma teams in Australian hospitals and describe their medical composition, leadership and criteria for activation.

Methods:  Australian public hospitals with more than 100 beds, an emergency department and offering surgical services were identified. A survey assessing the presence, composition and means of activation of a trauma team was mailed to the ‘Director, Emergency Department’ of all identified hospitals. Three months later, all hospitals were contacted by telephone to complete and verify data collection.

Results:  Questionnaires were distributed to 130 hospitals. After exclusion of hospitals that did not receive patients with traumatic injuries, and dedicated paediatric tertiary referral centres, 111 hospitals remained for analysis. Of these, 56% had an established trauma team, while 71% of hospitals without a trauma team claimed to have insufficient doctors to form one team. Ninety‐five per cent of trauma teams were potentially activated by prehospital paramedic data (field triage). For 92% of trauma teams a combination of anatomical, physiological and mechanistic criteria were required for activation. The most common methods of mobilizing a trauma team were by dispatching a common call onto individual pagers (31%) or by paging trauma team members individually (31%). Fifty‐eight per cent of trauma team leaders were emergency medicine specialists/registrars, while 8% of trauma teams were led by surgeons/registrars. Consultant surgeons were members of 23% of trauma teams and 74% of trauma teams consisted of more junior members after hours. Some form of trauma audit was engaged in by 64% of hospitals.

Conclusions:  Trauma teams are yet to be utilized by many Australian hospitals that provide trauma care. Australian surgeons presently have limited leadership roles and membership in trauma teams. Trauma audit can be more widely adopted in Australian hospitals.
Sentinel node biopsy in breast cancer: validation study and comparison of blue dye alone with triple modality localization
Authors: Meyer‐Rochow Goswym Y. , Martin Richard C. W. , Harman C. Richard
Published: October 2003

Background:  Sentinel node biopsy (SNB) for breast cancer patients is a new technique with the potential to provide an accurate staging of the axillary nodal status while avoiding the morbidity of an axillary dissection. The objective of the present study is to validate the use of sentinel node biopsy in a New Zealand hospital and to compare the ability of patent blue dye (PB) alone with triple modality (TM) (preoperative lymphoscintigraphy, intraoperative gamma probe and intraoperative blue dye) to identify the sentinel node.

Methods:  A total of 104 patients who had a palpable breast lump that was confirmed to be malignant by radiology and cytology and a clinical diagnosis of stage I or stage II breast cancer, were enrolled for SNB and randomly assigned to triple modality or blue dye alone for the localization of the sentinel node. Axillary dissection was performed after the sentinel node(s) had been removed.

Results:  There were 63 patients in the PB group and 41 patients in the TM group. Both groups are comparable, with a similar mean age and primary tumour size. A sentinel node was identified in 57 (90%) of the PB group patients and 40 (98%) of the TM group patients. Of these 23 (37%) of the PB group and 23 (56%) in the TM group had axillary nodes positive for malignancy. There was one false negative SNB in the PB group and two false negative results in the TM group. Therefore, the PB group had an accuracy of 98% and a sensitivity of 96% compared to an accuracy of 95% and a sensitivity of 91% for the TM group.

Conclusion:  The results of the present study validate the use of SNB in suitable breast cancer patients. Identification and the accuracy of the sentinel node localization were similar between the two groups. Therefore, in hospital centres without adequate access to a nuclear medical facility, it would be feasible to conduct SNB using blue dye alone.
Sentinel node biopsy for breast cancer: using local results for estimation of risk to the patient
Authors: Wilkinson David S. , Wetzig Neil R. , Bennett Ian C.
Published: October 2003

Background:  Sentinel node biopsy (SNB) is being increasingly used but its place outside randomized trials has not yet been established.

Methods:  The first 114 sentinel node (SN) biopsies performed for breast cancer at the Princess Alexandra Hospital from March 1999 to June 2001 are presented. In 111 cases axillary dissection was also performed, allowing the accuracy of the technique to be assessed. A standard combination of preoperative lymphoscintigraphy, intraoperative gamma probe and injection of blue dye was used in most cases. Results are discussed in relation to the risk and potential consequences of understaging.

Results:  Where both probe and dye were used, the SN was identified in 90% of patients. A significant number of patients were treated in two stages and the technique was no less effective in patients who had SNB performed at a second operation after the primary tumour had already been removed. The interval from radioisotope injection to operation was very wide (between 2 and 22 h) and did not affect the outcome. Nodal metastases were present in 42 patients in whom an SN was found, and in 40 of these the SN was positive, giving a false negative rate of 4.8% (2/42), with the overall percentage of patients understaged being 2%. For this particular group as a whole, the increased risk of death due to systemic therapy being withheld as a consequence of understaging (if SNB alone had been employed) is estimated at less than 1/500. The risk for individuals will vary depending on other features of the particular primary tumour.

Conclusion:  For patients who elect to have the axilla staged using SNB alone, the risk and consequences of understaging need to be discussed. These risks can be estimated by allowing for the specific surgeon's false negative rate for the technique, and considering the likelihood of nodal metastases for a given tumour. There appears to be no disadvantage with performing SNB at a second operation after the primary tumour has already been removed. Clearly, for a large number of patients, SNB alone will be safe, but ideally participation in randomized trials should continue to be encouraged.
Audit and the birth of the abdomino‐perineal excision for carcinoma of the rectum
Authors: Wiley Malcolm J. , Rieger Nicholas
Published: October 2003

Sir Ernest Miles first performed his radical abdomino‐perineal excision for carcinoma of the rectum in 1907. This event was the culmination of almost a decade of audit in which he carefully studied the outcomes of patients with rectal carcinoma. Miles's interpretation of his audit led, in a stepwise manner, to gradual changes in his operative technique and the eventual development of the radical abdomino‐perineal operation; the operation that bears his name. The Miles operation and the principles upon which it is based, would lead to an improved outcome for patients with rectal carcinoma.
Laparoscopic staging of upper gastrointestinal malignancy
Authors: Rodgers Michael S. , Windsor John A. , Koea Jonathan B. , McCall John L.
Published: October 2003

Background:  Laparoscopic staging (LS) of upper gastrointestinal malignancy has decreased the number of non‐curative laparotomies. However, as radiological techniques have improved the value of this invasive staging technique has decreased, with some units either being more selective or abandoning it altogether for certain tumour types.

The aim of the present study is to prospectively evaluate the additional utility of LS of upper gastrointestinal malignancy after radiological staging with modern techniques.

Methods:  One hundred and six consecutive patients assessed as having potentially curable upper gastrointestinal malignancy after radiological staging underwent LS between April 1999 and June 2001. Laparoscopic findings, outcome at laparotomy and complications were prospectively recorded.

Results:  Laparoscopic staging detected incurable disease in 28 of the 106 patients (26%). The negative likelihood ratio was 0.36 (95% CI 0.24−0.53). Twenty‐seven patients were considered incurable because of findings at laparoscopy and one on the findings of laparoscopic ultrasound. Ten patients underwent open palliative procedures and seven had non‐therapeutic laparotomies giving a non‐curative laparotomy rate of 16%. LS was most useful for primary liver and biliary tract tumours and was least useful for colorectal liver metastases. The most frequent findings denoting incurability were the presence of liver disease (12 cases) and peritoneal metastases (nine cases). Complications occurred in three patients with one death being attributable in part to the laparoscopy.

Conclusions:  Laparoscopy was useful in decreasing the number of non‐therapeutic laparotomies, but laparoscopic ultrasound gave little additional benefit. The utility of LS was dependent on tumour type and in particular was of marginal benefit for colorectal liver metastases. LS remains a useful staging tool but should be applied selectively.
Is there an association between chronic lung disease and abdominal aortic aneurysm expansion?
Authors: Spencer Carole , Jamrozik Konrad , Kelly Shane , Bremner Peter , Norman Paul
Published: October 2003

Background:  Although there is evidence demonstrating an association between chronic obstructive pulmonary disease (COPD) and abdominal aortic aneurysm (AAA), it is not clear whether COPD predicts greater rates of expansion of established aneurysms. We sought such an association in a cohort of men with aneurysms detected in a population‐based study of screening for aneurysms.

Methods:  In addition to regular aortic ultrasound scans, 179 men with AAA underwent full lung function testing in order to identify the presence of COPD and its subgroups, emphysema and other obstructive ventilatory defects (OVD). The rate of expansion of each aneurysm was calculated and the men were divided into ‘rapid expanders’ (3 mm or more per year) and ‘slow expanders’ (less than 3 mm per year). Any association with the presence of COPD or smoking was tested using a multivariate model.

Results:  Over a median follow‐up period of 36 months the mean rate of aortic expansion for the cohort of 179 men was 2.1 mm/year. There was no significant difference in prevalence of COPD (68% overall) or having ever been a smoker (87% overall) between the rapid expanders and the slow expanders.

Conclusions:  Although there was a high prevalence of COPD among men with an AAA, there was no association between the rate of expansion of AAA and the presence of any form of this disease.
Clinical categorization for elective surgery in Victoria
Authors: Russell Colin , Roberts Maree , Williamson Timothy G. , McKercher Jane , Jolly Simon E. , McNeil John
Published: October 2003

Aim:  The aim of the present paper was to assess trends in clinician's utilization of urgency categories for elective surgery.

Methods:  The present paper reviews the additions to the Victorian elective surgery waiting list for hip replacement and prostatectomy as recorded by the Elective Surgery Information System database. Review of general trends in utilization over two separate 12 month periods were undertaken.

Results:  There is inconsistency in categorization of patients referred to the waiting list for hip joint replacement and prostatectomy. An increasing trend to categorize patients as semi‐urgent (category 2) in preference to non‐urgent (category 3) emerged over this period (category creep). Semi‐urgent cases might be competing for access within the category 2 band with less urgent cases.

Conclusions:  There seems to be an increasing imbalance between demand for and availability of elective surgery for lower urgency elective surgical procedures. This imbalance, characterized by lengthening waiting times, means that not all patients will receive treatment within the clinically recommended waiting times. The variable approach to categorization of urgency suggests that the process lacks objectivity and consensus. Simple clinical tools to assist prioritization are currently being evaluated in Victoria (Australia) and other countries.
Vocal cord paralysis, synkinesis and vocal fold motion impairment
Authors: Benjamin Bruce
Published: October 2003

Felix Semon's ‘laws’ of vocal cord paralysis were conceived over a century ago, based on the simple concept that abductor function of the recurrent laryngeal nerve was more vulnerable than adductor function. It is now clear that the neuromuscular pathology of laryngeal innervation is much more complex. Whether the nerve has been cut, crushed, stretched, cauterized or otherwise injured, it is seldom completely transected. There might be no detectable vocal cord movement at laryngoscopy, yet, electromyography usually shows at least some activity because of incomplete denervation and/or developing synkinesis. Electrical silence hardly ever persists forever. Disordered vocal fold movement following nerve injury appears to depend on laryngeal synkinesis with disorganized neuromuscular function caused by misdirected regeneration and aberrant reinnervation, sometimes by adjacent nerves. The severity of the injury, abnormal random reinnervation, scar tissue formation and nerve growth‐stimulating and inhibiting factors influence the final position of the vocal fold. For a better understanding of neurolaryngological disorders it is no longer sufficient to think merely in terms of ‘vocal cord paralysis’.
General anaesthesia for lobectomy in an 8‐year‐old child with Kartagener's syndrome
Authors: Sahajananda H. , Sanjay O.P. , Thomas Johny , Daniel Bobby
Published: October 2003

Kartagener's syndrome (KGS) is an autosomal recessive disorder characterized by the clinical triad of bronchiectasis, sinusitis and dextrocardia (situs inversus ). Reports of general anaesthesia in a child with KGS are rare in medical literature. We describe the case of a young boy who underwent lobectomy under general anaesthesia using a single lumen tube. Anaesthetic implications of this syndrome are mentioned. Key points in the management of anaesthesia in KGS are discussed.
Remifentanil infusion for cleft palate surgery in young infants
Authors: Roulleau P. , Gall O. , Desjeux L. , Dagher C. , Murat I.
Published: October 2003

Background:  The residual depressant effect of opioid is a major concern in infants scheduled for cleft palate repair. Remifentanil is associated with a fast and predictable recovery, independent of age.

Methods:  About 40 infants in the 2–12 month age range were prospectively enrolled in this open study, to receive either remifentanil (infusion starting at 0.25 μg·kg−1·min−1) or sufentanil as part of a balanced anaesthesia regimen. Isoflurane was maintained at an endtidal concentration of 1.2% in oxygen and nitrous oxide and the opioid dosing was titrated to autonomic responses. Postoperative pain relief was provided by morphine infusion. Morphine administration started intraoperatively in the remifentanil group.

Results:  Consistent haemodynamic stability was achieved throughout surgery in both groups. Infants of the remifentanil group required, on average, lower concentrations of isoflurane than children of the sufentanil group (1.2 ± 0.2% vs 1.7 ± 0.3%, P < 0.001). The median time from last suture to tracheal extubation was 12.5 min (5–25 min) in the remifentanil group and 15.0 min (10–30 min) in the sufentanil group. There was no evidence of hyperalgesia or enhanced morphine consumption in the remifentanil group compared with the sufentanil group. Postoperative pain scores were even lower in the remifentanil group, compared with the sufentanil group, soon after arrival in the postanaesthesia care unit.

Conclusions:  Remifentanil‐based anaesthesia appeared well suited for primary cleft palate repair in young infants.
Latex allergy in children with oesophageal atresia
Authors: Gentili A. , Ricci G. , Di Lorenzo F.P. , Pigna A. , Masi M. , Baroncini S.
Published: October 2003

Background:Latex allergy is frequently found in children and patients with spina bifida and urogenital abnormalities and have been considered at risk for latex sensitization. The aim of the study was to evaluate the incidence of latex sensitization in patients with oesophageal atresia and undergoing three or more surgical procedures and to identify possible risk factors in the process of latex sensitization.

Methods:A total of 20 patients were analysed: 19 boys and one girl. The oesophageal atresias were as follows: type I in three children, type II in two and type III in 15 children. Surgical and anaesthetic procedures, intensive care management, age, type of oesophageal atresia, associated congenital malformations, Waterston and Montreal prognostic classifications were considered as risk factors that may be implicated in the process of sensitization.

Results:Five patients (25%) were considered sensitized to latex (group 1) and 15 (75%) nonsensitized (group 2). Among the five sensitized patients, three reported clinical reactions to latex, while the other two presented only specific IgE sensitization. The number of operations, the total hours of surgery, the number of drainages, the total days of drainage, the total days of central venous catheter were significantly greater in group 1 than in group 2. Both of the highest risk oesophageal atresia classes (Waterston C and Montreal II) were related to latex allergy.

Conclusions:Oesophageal atresia, especially in cases of prolonged management, must be considered as a risk for the development of latex allergy.
Oral high‐dose midazolam premedication for infants and children undergoing cardiovascular surgery
Authors: Masue Tatsuhiko , Shimonaka Hiroyuki , Fukao Izumi , Kasuya Shugo , Kasuya Yukiko , Dohi Shuji
Published: October 2003

Background:  The purpose of this study was to determine whether oral midazolam 1.5 mg·kg−1 is a safe and effective alternative to standard‐dose midazolam (0.5–1.0 mg·kg−1) premedication for infants and children with congenital heart disease.

Methods:  A total of 193 infants and children (4 months to 2 years) undergoing cardiovascular surgery were studied. Each patient received 0.5, 1.0, or 1.5 mg·kg−1 of oral midazolam. The level of sedation was assessed with a 5‐point scale and vital signs were measured including blood pressure (BP), heart rate (HR) and oxyhaemoglobin saturation (SpO2) before and after the medication.

Results:  Infants and children premedicated with oral midazolam 1.5 mg·kg−1 were better sedated than those with standard‐dose midazolam: 4% of infants and children given 1.5 mg·kg−1 of midazolam became agitated compared with 14% given 1.0 mg·kg−1 and 26% in those given 0.5 mg·kg−1. Ninety percentage of infants and children given 1.5 mg·kg−1 of midazolam achieved satisfactory sedation (calm, drowsy, or asleep) in 30 min, whereas 68% in those given 1.0 mg·kg−1 and 35% in those given 0.5 mg·kg−1. Midazolam 1.5 mg·kg−1 did not cause any statistically significant decrease in BP, HR, or SpO2, although eight infants and children showed ≥20% drop in systolic BP and six infants and children showed >5% drop in SpO2. No ‘spelling attacks’, seizure‐like activity, apnoea, nor laryngospasm were observed in any infants and children during and after the medication.

Conclusions:  Oral midazolam 1.5 mg·kg−1 is excellent for preanaesthetic medication for infants and children undergoing cardiovascular surgery.
Intraoperative transoesophageal echocardiography in a low birth weight neonate with atrioventricular septal defect
Authors: Kawahito Shinji , Kitahata Hiroshi , Tanaka Katsuya , Nozaki Junpei , Oshita Shuzo
Published: October 2003

An 18‐day‐old male neonate (45 cm, 1.8 kg) with a history of cyanosis and congestive heart failure from an atrioventricular septal defect (AVSD) with a large left‐to‐right shunt was scheduled for surgical repair of the AVSD. After routine induction of anaesthesia with fentanyl and vecuronium, a 4.5‐mm diameter transoesophageal echocardiography (TOE) probe was inserted into the oesophagus, and systematic echocardiographic evaluation was performed during surgery. After cardiopulmonary bypass was stopped, intraoperative TOE revealed mild residual mitral valve regurgitation. Because good left ventricular wall motion was confirmed and haemodynamic parameters were stable, cardiopulmonary bypass was not reinitiated. The patient's cardiac output was low in the postoperative intensive care unit. TOE was performed the next day to detect the source of this problem, revealed severe regurgitation compared with that observed intraoperatively. TOE was useful for evaluation of the residual mitral valve regurgitation, and we reconfirmed the importance of continuous monitoring even in a low birthweight neonate undergoing repair of a complete AVSD.
Systemic embolism in an infant following haemangioma embolization: a two‐step process
Authors: Firth Paul G. , Ahmed Mohammed I.
Published: October 2003

Summary A case is presented of therapeutic embolization of a hypervascular hamartoma of the liver, in a term baby. During the procedure signs of pulmonary embolism occurred and the baby subsequently died from myocardial ischaemia. Potential intrathoracic shunts of the newborn together with changes associated with the vascular tumour are thought to have allowed systemic embolization of the embolic material.
Anaesthetic management in children with metachromatic leukodystrophy
Authors: Hernández‐Palazón Joaquín
Published: October 2003

We present a case of metachromatic leukodystrophy in a child who required surgery for gastro‐oesophageal reflux. In spite of his demyelinating disease, we used a lumbar epidural technique with general anaesthesia; the epidural catheter allowed us to continue the analgesia postoperatively and to avoid opioids in this high risk patient.
Laryngeal mask insertion in children: a rational approach
Authors: Kundra Pankaj , Deepak R. , Ravishankar M.
Published: October 2003

Background: Various techniques of laryngeal mask airway (LMATM) insertion have been described in adults but only limited clinical trials have been conducted in children despite a varying range in success rate by the recommended method.

Method: The study was conducted in 62 ASA 1 and 2 children who were randomly allocated for the evaluation of LMA insertion by the midline approach with the cuff completely deflated (group MD, control group, n = 31) or laterally with the cuff partially inflated (group LP, study group, n = 31). Propofol was used as the sole induction agent in all children. Ease of insertion, position of the LMA with fibreoptic laryngoscope and incidence of stomach insufflation were assessed.

Results: Fewer attempts and a significant reduction in the time for insertion was noted in group LP (14.4 ± 4.2 s) compared with group MD (23.1 ± 2.1 s), P < 0.05. Despite a good seal around the cuff and satisfactory ventilation a significantly higher incidence of malposition of the LMA was recorded by intraluminal fibreoptic endoscopy in group MD (13% to nil), P < 0.05. Similarly gastric insufflation was significantly greater in group MD (42% compared with 10%). In children with grade 3 fibreoptic view significantly higher endtidal carbon dioxide values were recorded throughout the study period after LMA insertion until its removal. LMA was stained with blood in 13% children in group MD compared with 3% in group LP at the time of removal.

Conclusion: A partially inflated cuff inserted by the lateral route is a better method of insertion in children and grade 3 fibreoptic views can be associated with a significant build up of carbon dioxide in children breathing spontaneously.