bluuebunny/crossref_metadata_2025 huggingface dataset:
Changes in body image satisfaction during pregnancy: A comparison of high exercising and low exercising women
Authors: Boscaglia Nadia , Skouteris Helen , Wertheim Eleanor H.
Published: March 2003

Objective: This study aimed to compare ratings of body image satisfaction (BIS) from 6 months prepregnancy to 23–30 weeks’ gestation for high exercising and low exercising pregnant women. The authors also aimed to assess and compare expectations of BIS for the post‐partum period in high and low exercising women.

Design: A partial prospective approach was implemented.

Sample: A total of 71 healthy pregnant women (40 high exercisers and 31 low exercisers) participated.

Methods: Participants completed a series of questionnaires at 15–22 weeks’ gestation and 23–30 weeks’ gestation.

Main outcome measures: There were two main outcome measures. At 15–22 weeks’ gestation there was an exercise inventory and two versions of the Body Cathexis Scale (BCS) (retrospective prepregnancy BIS and current BIS). At 23–30 weeks’ gestation there was an exercise inventory and two versions of the BCS (current BIS and projected post‐partum BIS).

Results:  At 15–22 weeks’ gestation, high exercisers demonstrated significantly higher levels of BIS compared to low exercisers. There were no other significant differences between groups. Within groups, high exercisers were significantly more satisfied with their bodies at 15–22 weeks’ gestation compared to 6 months prepregnancy, and expected to be less satisfied with their bodies at 6 weeks’ post‐partum than they were during pregnancy. Low exercisers demonstrated no significant changes over time.

Conclusions: The findings suggest that women are able to assimilate the bodily changes of pregnancy without a negative shift in BIS. However, women who exercise during pregnancy may respond more favourably to changes in their bodies at early pregnancy compared to women who remain sedentary.
Reduced transforming growth factor‐β1 production by mononuclear cells from patients with active chronic idiopathic thrombocytopenic purpura
Authors: Andersson Per‐Ola , Olsson Anna , Wadenvik Hans
Published: March 2003

Summary. Chronic idiopathic thrombocytopenic purpura (ITP) is an autoimmune disorder in which activated T‐helper (Th) cells and different Th‐cell cytokines might play an important role. We have recently reported that chronic ITP patients in remission had elevated plasma levels of the Th3 cytokine transforming growth factor‐β1 (TGF‐β1), possibly as a part of a bystander immune suppression. In the present study we found that, in ITP patients with active disease [platelet count (plc) < 50 × 109/l], mitogen‐stimulated peripheral blood mononuclear cells (PBMC) had a significantly reduced production of TGF‐β1 (444 ± 178 pg/ml; n = 6) compared with patients with plc 50–150 × 109/l (1293 ± 374 pg/ml; n = 9; P < 0·05), patients with plc > 150 × 109/l (1894 ± 244 pg/ml; n = 12; P < 0·005) and healthy controls (1698 ± 241 pg/ml; n = 10; P < 0·01). Nineteen per cent of ITP patients expressed a platelet‐induced PBMC proliferation. Surprisingly, 22% of the ITP patients had a PBMC proliferation below the normal range, i.e. a suppressed proliferation in the presence of platelets; five of these six patients had active disease. In summary, this study demonstrated that chronic ITP patients with active disease had reduced PBMC production of the Th3 cytokine TGF‐β1. This result gives further support to the theory that chronic ITP in active phase is associated with a downregulated Th3‐response.
Randomized, dose-finding phase III study of lithium gamolenate in patients with advanced pancreatic adenocarcinoma
Authors: Johnson C D , Puntis M , Davidson N , Todd S , Bryce R
Published: March 2003

Background

Chemotherapy for pancreatic cancer offers small survival benefits and considerable side-effects. Unsaturated fatty acids have an antitumour effect in experimental studies; in phase II studies few side-effects were seen.

Methods

In this group-sequential, open-label, randomized study, 278 patients with a diagnosis of inoperable pancreatic cancer were treated with either oral (700 mg daily for 15 days), low-dose (0·28 g/kg) or high-dose (0·84 g/kg) intravenous lithium gamolenate (LiGLA). The primary endpoint was survival time from randomization using Kaplan–Meier estimates.

Results

Median survival after oral and low-dose intravenous treatment was 129 and 121 days respectively. Median survival after high-dose intravenous treatment was 94 days. A good Karnofsky score and the absence of metastases were associated with increased survival. Haemolysis, a marker of rapid infusion, was associated with a median survival time of 249 days in the low-dose intravenous group.

Conclusion

Oral or low-dose intravenous LiGLA led to survival times similar to those of other treatments for pancreatic cancer although one subgroup (low-dose intravenous LiGLA with haemolysis) had longer survival. High-dose intravenous treatment appeared to have an adverse effect. Systemic treatment with LiGLA cannot be recommended for the treatment of pancreatic cancer.
Unique clinical characteristics of primary hyperparathyroidism in India
Authors: Mishra S K , Agarwal G , Kar D K , Gupta S K , Mithal A , Rastad J
Published: March 2003

Background

The features of primary hyperparathyroidism (PHPT) in developing countries have rarely been examined. This study explored the clinical characteristics of PHPT in India with the hypothesis that this may improve understanding of the pathogenesis of the disease worldwide.

Methods

Consecutive patients with PHPT (24 women, five men) were examined prospectively before and after parathyroidectomy.

Results

All patients had osteitis fibrosa cystica with a median symptom duration of 2·5 (range 1–26) years. Single or multiple fragility fractures were present in 14 patients (eight were bedridden); 20 had brown tumours. Mean preoperative serum calcium was 3·1 mmol/l, while mean serum intact parathyroid hormone (iPTH) and total alkaline phosphatase (ALP) levels were 17-fold and 12-fold higher than normal respectively. Nine patients had overt renal damage, mainly nephrocalcinosis. Parathyroidectomy invariably resulted in severe hypocalcaemia, necessitating long-term vitamin D treatment. The mean parathyroid gland weight was 8·6 (range 2·0–36·6) g and features of carcinoma were found in four patients. Serum calcidiol level correlated inversely (P < 0·05) with serum iPTH and ALP, and parathyroid gland weight.

Conclusion

PHPT in Indians is a severe, symptomatic disorder with skeletal, muscular and renal manifestations at a young age. The presence of this severe variant of PHPT in vitamin D-sufficient Indians, and the lack of skeletal disease in other vitamin D-deficient populations, raises the possibility of additional pathogenetic factors.
Probability of axillary node involvement in patients with tubular carcinoma of the breast
Authors: Papadatos G , Rangan A M , Psarianos T , Ung O , Taylor R , Boyages J
Published: March 2003

Background

The aim of this study was to investigate the frequency of axillary metastasis in women with tubular carcinoma (TC) of the breast.

Methods

Women who underwent axillary dissection for TC in the Western Sydney area (1984–1995) were identified retrospectively through a search of computerized records. A centralized pathology review was performed and tumours were classified as pure tubular (22) or mixed tubular (nine), on the basis of the invasive component containing 90 per cent or more, or 75–90 per cent tubule formation respectively. A Medline search of the literature was undertaken to compile a collective series (20 studies with a total of 680 patients) to address the frequency of nodal involvement in TC. A quantitative meta-analysis was used to combine the results of these studies.

Results

The overall frequency of nodal metastasis was five of 31 (16 per cent); one of 22 pure tubular and four of nine mixed tumours (P = 0·019). None of the tumours with a diameter of 10 mm or less (n = 16) had nodal metastasis compared with five of 15 larger tumours (P = 0·018). The meta-analysis of 680 women showed an overall frequency of nodal metastasis in TC of 13·8 (95 per cent confidence interval 9·3–18·3) per cent. The frequency of nodal involvement was 6·6 (1·7–11·4) per cent in pure TC (n = 244) and 25·0 (12·5–37·6) per cent in mixed TC (n = 149).

Conclusion

A case may be made for observing the clinically negative axilla in women with a small TC (10 mm or less in diameter).
Risk factors for complications following resection of large gastric cancer
Authors: Yasuda K , Shiraishi N , Adachi Y , Inomata M , Sato K , Kitano S
Published: March 2003

Background

Although there is a low mortality rate after gastrectomy in Japan, most studies include many early gastric cancers. There have been few studies on the morbidity after gastrectomy for advanced gastric cancer. The aim of this study was to clarify the characteristics and risk factors for postoperative complications after resection of large gastric cancers based on three clinical factors: patient, operation and tumour.

Methods

A retrospective study was carried out on 97 patients with a gastric tumour measuring 10 cm or more in diameter. Postoperative complications were recorded and the patients were divided into two groups: 38 with complications and 59 without. Patient, operative and tumour findings were compared between the two groups.

Results

Overall morbidity and mortality rates were 39 and 7 per cent respectively. The most frequent complication was pleural effusion (17 per cent), followed by anastomotic leakage (14 per cent), abdominal abscess (12 per cent), wound infection (12 per cent), pancreatic leakage (8 per cent) and peritonitis (6 per cent). Risk factors associated with postoperative complications were operating time (400 versus 337 min, P < 0·01), blood loss (1338 versus 782 ml, P < 0·01), pancreatic invasion (26 versus 8 per cent, P < 0·05) and raised serum carcinoembryonic antigen (CEA) level (5 ng/ml or greater) (36 versus 17 per cent, P < 0·05), independent of patient age, nutritional status, type of gastrectomy, splenectomy or pancreatectomy, extent of lymph node dissection, tumour location, size and stage of disease.

Conclusion

Even in Japan, the morbidity of gastrectomy for large gastric cancer is high and associated with operating time, blood loss, pancreatic invasion and serum CEA level.
Clinicopathological factors predicting outcome after resection of mass-forming intrahepatic cholangiocarcinoma
Authors: Uenishi T , Hirohashi K , Kubo S , Yamamoto T , Yamazaki O , Kinoshita H
Published: March 2003

Background

The prognosis for patients with intrahepatic cholangiocarcinoma differs according to macroscopic type. The identification of clinical and pathological features that predict outcome in patients with mass-forming intrahepatic cholangiocarcinoma is required in order to determine optimal surgical strategies for patients with this type of tumour.

Methods

The details of 35 patients with resected mass-forming intrahepatic cholangiocarcinomas were analysed retrospectively. Univariate analysis of potential prognostic factors was performed.

Results

The cumulative survival rate at 1, 3 and 5 years after operation was 58, 33 and 33 per cent respectively. Patients with stage II tumours had a better outcome than those with advanced stage tumours. By univariate analysis, lymphatic invasion, lymph node metastasis, intrahepatic satellite lesions and microscopic resection margin involvement were found to be highly significant variables and were identified as possible risk factors for a poor outcome after operation.

Conclusion

When frozen-section examination of lymph nodes reveals negative nodal metastasis, extensive anatomical hepatic resection is indicated for mass-forming intrahepatic cholangiocarcinomas. Intraoperative frozen-section examination of the resection margin to confirm the absence of cancer cells is recommended.
Tumour location and the effects of preoperative radiotherapy in the treatment of rectal cancer
Authors: Holm T , Johansson H , Rutqvist L E , Cedermark B
Published: March 2003

Background

Preoperative radiotherapy improves local control and survival in rectal cancer, but may also increase postoperative morbidity and mortality rates. Establishing selection criteria for preoperative radiotherapy is crucial. The tumour level above the anus may be one such criterion. The effect of preoperative radiotherapy in relation to the distance between the tumour and the anus was therefore assessed.

Methods

In 457 patients operated for cure included in the Stockholm II Trial the local recurrence rate in irradiated and non-irradiated patients was analysed in relation to the tumour location (low, mid or upper rectum).

Results

Radiotherapy reduced the local recurrence rate from 30 to 20 per cent in low rectal cancer, from 25 to 11 per cent in mid rectal cancer and from 21 to 5 per cent for tumours in the upper rectum.

Conclusion

With conventional surgical techniques preoperative radiotherapy plays an important role in rectal cancer irrespective of the location of the tumour. To irradiate only patients with tumours in the lower rectum and to omit this treatment for patients with tumours in the mid and upper rectum cannot be recommended. Whether this statement is valid with standardized total mesorectal excision (TME) surgery is not known. Until this knowledge is available the current indications for preoperative radiotherapy should probably also be used with TME surgery.
Totally extraperitoneal endoscopic repair of recurrent inguinal hernia
Authors: van der Hem J A , Hamming J F , Meeuwis J D , Oostvogel H J M
Published: March 2003

Background

Conventional repair of recurrent inguinal hernia is associated with a re-recurrence rate as high as 35 per cent. Endoscopic mesh repair has promising results regarding both recurrence and complication rates.

Methods

In a retrospective review, the results of endoscopic totally extraperitoneal repair were evaluated in 104 patients with 108 recurrent hernias. Follow-up was at least 1 year. Type of recurrence, time of occurrence after previous repair, duration of surgery, complications, duration of hospital stay and number of re-recurrences were evaluated.

Results

Follow-up ranged from 12 to 29 (mean 16) months. Forty-three recurrences were direct, 41 indirect and 15 combined; one was a femoral hernia. Median time to previous operation was 36 months (range 8 days to 42 years). Median duration of surgery was 63 (range 25–160) min. While there were no complications during operation, 12 patients (12 per cent) had a postoperative complication. Two direct re-recurrences (2 per cent) occurred as a result of inadequate positioning of the prosthetic mesh.

Conclusion

The endoscopic totally extraperitoneal technique is safe and effective for the repair of recurrent inguinal hernia.
Recombinant soluble P-selectin glycoprotein ligand 1 moderates local and remote injuries following experimental lower-torso ischaemia
Authors: Kyriakides C , Favuzza J , Wang Y , Austen W G , Moore F D , Hechtman H B
Published: March 2003

Background

A central role for the polymorphonuclear leucocyte (PMN) in skeletal muscle ischaemia–reperfusion has been demonstrated by the observation that PMN depletion reduced local and remote pulmonary vascular permeability. This study investigated the role of recombinant soluble P-selectin glycoprotein ligand–immunoglobulin fusion protein (rPSGL-Ig), a P- and E-selectin antagonist, in moderating injury.

Methods

Mice underwent 2 h of hindlimb ischaemia and 3 h of reperfusion. Muscle and lung vascular permeability index (PI) was assessed by extravasation of 125I-radiolabelled albumin. Lung myelo peroxidase (MPO) activity was also measured.

Results

In mice treated with rPSGL-Ig 1 mg/kg before reperfusion (n = 12) muscle PI was reduced by 40 per cent, whereas it was moderated by 20 per cent in animals treated 30 min after reperfusion (n = 15). Lung PI in mice treated with rPSGL-Ig before (n = 12) and 30 min after (n = 15) reperfusion was reduced by over 99 and 98 per cent respectively. Lung MPO activity in mice treated with rPSGL-Ig before (n = 10) and 30 min after (n = 12) reperfusion was reduced by 68 and 58 per cent respectively. Treatment with rPSGL-Ig 1 h after reperfusion, or with m20ek.Fc 1 mg/kg (n = 9; negative control for rPSGL-Ig which is inactive for selectin binding) before reperfusion failed significantly to moderate local or remote organ injury.

Conclusion

Selectin blockade moderated local skeletal muscle and remote lung injury following hindlimb ischaemia–reperfusion. Significantly, delayed antiselectin therapy also decreased injury.
Endotoxin, cytokines and lipid peroxides in children with intussusception
Authors: Willetts I E , Kite P , Barclay G R , Banks R E , Rumley A , Allgar V , Stringer M D
Published: March 2003

Background

Intussusception is a relatively common paediatric surgical emergency. The aim of this study was to investigate selected inflammatory mediators in children with acute intussusception and to identify potentially useful plasma markers of clinical outcome.

Methods

Clinical, radiographic, operative and pathological details were recorded prospectively of all children presenting to a single institution with a confirmed diagnosis of acute intussusception during 1 year. Paired acute and convalescent venous blood samples were collected in a standard manner for blinded analysis of the following: malondialdehyde, C-reactive protein (CRP), interleukin (IL) 6, neopterin, tumour necrosis factor α, endotoxin, and immunoglobulin (Ig) G and IgM antiendotoxin core antibody (EndoCAb).

Results

Thirty-two consecutive children (23 boys, nine girls) with a median age of 4 months were studied. Acute ileocolic intussusception was managed by air enema reduction (n = 19), operative reduction (n = 8) or surgical resection (n = 5). Peripheral blood cultures were sterile. Acute levels of plasma IL-6, neopterin and CRP were significantly raised in comparison to both normal laboratory ranges and convalescent samples (P < 0·001). Using stepwise discriminant analysis, CRP was identified as the best variable at distinguishing between the three treatment groups (P < 0·001). IgM EndoCAb concentrations were significantly greater in the convalescent sera of all the patients (P < 0·001).

Conclusion

Acute ileocolic intussusception in childhood is associated with endotoxinaemia and significantly raised levels of circulating inflammatory cytokines. Plasma CRP at diagnosis showed a statistically significant positive correlation with disease severity.
Clinical and economic evaluation of surgical treatments for faecal incontinence
Authors: Malouf A J , Chambers M G , Kamm M A
Published: March 2003

Background

Faecal incontinence affects 1–2 per cent of the adult population. While many patients can be managed successfully with conservative therapy, a small proportion require surgery. Improved imaging techniques and technological advances have led to the availability of a wide range of surgical treatments. Decision-makers increasingly require clinical and cost-effectiveness studies of surgical treatments for faecal incontinence. This review examines the practical aspects of undertaking such studies.

Methods

The practical issues related to different aetiologies, different types of treatment, defining outcomes, the hidden costs of the condition and its treatment, the rapid changes in technology and issues of patient choice were all considered. A Medline search was undertaken to identify relevant publications, and the reference lists of identified papers were scanned manually.

Results

There are few randomized controlled studies and those that have been performed have been limited in their scope. There has also been very limited health economic analysis undertaken. Strategies for conducting such studies, and the criteria they use, have been outlined.

Conclusion

Randomized trials have a limited role in this setting because of variations in aetiology, difficulty in standardizing procedures, continuing evolution of devices, small patient numbers, concerns for patient choice and the need for long-term follow-up. Issues to be addressed when evaluating interventions for faecal incontinence include choosing appropriate measures of surgical outcome, using new continence scoring systems and tools for quality-of-life assessment, and choosing appropriate cost perspectives and time horizons for economic evaluation.
Performance indicators from routine hospital data: death following aortic surgery as a potential measure of quality of care
Authors: Rigby K A , Palfreyman S , Michaels J A
Published: March 2003

Background

There is increasing pressure to monitor surgical performance. In the UK, the Department of Health has produced clinical indicators based on routine data to monitor performance. This study analysed whether such data could measure performance in aortic surgery.

Methods

Routine hospital data on postoperative mortality were collected for 1995–1997 in the Trent region. Procedural and diagnostic codes, modes of admission, districts of residence, treatment and specialty data were compared with audit data and the Operating Theatre Information System.

Results:  

Inaccuracies in the Health Resource Group (HRG) codes meant that 21·4 per cent of elective aortic cases (HRG Q02) were probably emergencies and 26 per cent of probable ruptured aneurysms were not coded as a vascular emergency. Case mix and patient selection introduced a bias, apparent between tertiary and district general hospitals. For patients aged over 80 years, two district hospitals undertook no elective aortic surgery; the rate for emergency aortic surgery varied between 16 and 25 per cent in the district hospitals, and was 77 per cent in the tertiary centre.

Conclusion

Crude mortality rates used as an indicator of performance are subject to bias and distortion owing to the collection of incorrect information, variation in patient selection between hospitals and case-mix differences. There was a considerable variation in selection and outcomes of patients undergoing aortic surgery in this study.
Prospective randomized trial of polypropylene mesh compared with nylon darn in inguinal hernia repair
Authors: Koukourou A , Lyon W , Rice J , Wattchow D A
Published: March 2003

Background

The main aim of this study was to evaluate outcome in patients undergoing open inguinal hernia repair with either polypropylene mesh or nylon darn.

Methods

This was a randomized prospective trial of patients who underwent the procedure with follow-up at 1 week, 6 weeks and 1 year.

Results

One hundred men underwent 105 repairs by consultant surgeons and registrars; there were 54 mesh and 51 nylon repairs. Demographics in both groups were similar at the start of the trial, as were the types of hernia. The pain scores at 24, 48 and 72 h were similar, as was the duration of analgesia requirement. There were no differences in early or late complications. Return to normal activity in each group was also similar, with a mean time of 5 weeks. The recurrence rate in both groups was comparable: 4 per cent after mesh repair and 4 per cent after darn repair at 1-year review.

Conclusion

Open inguinal hernia repair with a nylon darn was equivalent to polypropylene mesh with respect to early measures of postoperative outcome and recurrence at 1 year.
Gender differences in long-term survival of patients with colorectal cancer
Authors: Wichmann M W , Müller C , Hornung H M , Lau-Werner U , Schildberg F W
Published: March 2003

Background

Significant differences exist in the immunological response to surgery. This raises the possibility that gender differences exist concerning the outcome after curative colorectal cancer resection.

Methods

To study this hypothesis, a database of patients with colorectal cancer was analysed prospectively.

Results

Some 894 patients were included, 500 (55·9 per cent) were men and 394 (44·1 per cent) were women. Median follow-up was 54·5 months for the entire group and 63·3 months for survivors. The mean(s.e.m.) patient age was 65·3(0·4) years (women 66·1(0·6), men 64·7(0·5) years; P < 0·05). Women lived significantly longer after cancer resection than men (57·8(1·5) versus 52·0(1·3) months; P < 0·05, log rank 0·009). Disease-free survival was significantly longer in women than in men (51·6(1·7) versus 46·0(1·4) months; P < 0·05). Subgroup analysis revealed significant gender differences in Union Internacional Contra la Cancrum (UICC) stages I (n = 195, log rank 0·01) and UICC IV (n = 38, log rank 0·021). Survival analysis after rectal cancer resection revealed significant advantages for women (log rank 0·02), while no gender differences were detected when comparing patients after resection for colonic cancer. Moreover, patients older than 50 years (n = 635) showed significant gender-related survival differences (log rank 0·015).

Conclusion

Significant gender differences following curative rectal cancer resection were observed. In women disease-free and overall survival were significantly longer. Whether or not these gender differences are related to gender-specific immune functions or to other gender-related local or systemic factors remains to be determined.
Portsmouth POSSUM models for abdominal aortic aneurysm surgery
Authors: Prytherch D R , Sutton G L , Boyle J R
Published: March 2003

Background

The Portsmouth Physiological and Operative Severity Score for enUmeration of Mortality and morbidity (P-POSSUM) equation permits comparative audit that allows for differences in case mix. The methodology has previously been shown accurately to model general surgical and vascular surgical patients. Patients with a ruptured abdominal aortic aneurysm (AAA) are, however, very different from elective patients and it may be hypothesized that they require their own specific risk model.

Methods

POSSUM data on 444 (213 emergency, 231 elective) admissions for AAA surgery between August 1993 and July 2000 were analysed using the P-POSSUM equation for general surgery and the P-POSSUM equations developed for vascular surgery.

Results

All equations successfully modelled the elective aneurysms but failed to fit the emergency aneurysms, and the elective and emergency aneurysms combined. This suggested that admission method (not a POSSUM data item) is an important factor for patients with AAA. However, with these data it was not possible to generate a model, including admission method, that successfully modelled the combined elective and emergency data. The 213 emergency aneurysm repairs were divided into two groups by operation date. The first 106 (training set) were used to form logistic regression models following the P-POSSUM methodology. These models were found successfully to fit the remaining 107 records (test set) on prospective application (χ2 = 4·50, 4 d.f., P = 0·345).

Conclusion

Ruptured AAAs appear to be different from elective AAAs and other vascular cases and require their own risk model.
Resection rate and effect of postoperative chemotherapy on survival after surgery for colorectal liver metastases
Authors: Figueras J , Valls C , Rafecas A , Fabregat J , Ramos E , Jaurrieta E
Published: March 2003

Background

The purpose of this study was to investigate whether adjuvant therapy can improve survival after curative resection of colorectal liver metastases.

Methods

Some 235 patients had 256 liver resections for metastatic colorectal cancer. There were no predefined criteria for resectability with regard either to the number or size of the tumours or to locoregional invasion, except that resection had potentially to be complete and macroscopically curative. All patients who had curative hepatic resection were advised to start postoperative adjuvant chemotherapy.

Results

The resectability rate in screened patients was 91 per cent (235 of 259 patients); the postoperative mortality rate was 4 per cent. In 35 patients resection of the primary tumour was performed simultaneously with partial liver resection. Forty-four patients (19 per cent) developed intra-abdominal recurrence; 14 (6 per cent) underwent reoperation and the recurrent tumour was resected. Adjuvant chemotherapy was given to 99 patients (55 per cent), most treatments being based on 5-fluorouracil with folinic acid. The overall actuarial survival rates at 1, 3 and 5 years were 87, 60 and 36 per cent respectively. In a multivariate analysis, four or more metastases, preoperative carcinoembryonic antigen level higher than 5 ng/ml and a positive resection margin were independent predictors of poor outcome. Adjuvant chemotherapy improved the 5-year survival rate to 53 per cent.

Conclusion

This study provides some evidence that postoperative chemotherapy is beneficial; however, prospective randomized studies are necessary to define its exact role.
Road traffic fatalities in Victoria, Australia and changes to the trauma care system
Authors: McDermott F T , Cordner S M , Tremayne A B
Published: March 2003

Background

The aim was to identify organizational and clinical errors in the management of road traffic fatalities and to use this information to improve Victoria's trauma care system.

Methods

A multidisciplinary committee evaluated the complete ambulance, hospital and autopsy records of 559 consecutive road traffic fatalities, who were alive on arrival of ambulance services, in five substantial time periods between 1992 and 1998. Patients who survived more than 30 days were excluded. Errors or inadequacies in each phase of management, including those contributing to death, were identified and an assessment was made of the potential preventability of death.

Results

Findings between 1992 and 1998 were similar. In 1998, 1672 problems were identified in 110 deaths with 1024 (61 per cent) contributing to death. Eight hundred and forty-two (50 per cent) of the total problems occurred in the emergency department. There were frequent problems in initial patient reception and medical consultation, resuscitation, investigation and assessment (especially of the abdomen and head), and in transfer to the operating theatre or to a higher-level hospital. Victoria's combined preventable and potentially preventable death rate has been unchanged between 1992 and 1998 (34–38 per cent).

Conclusion

The problems identified led to a Ministerial Taskforce on Trauma and Emergency Services in Victoria as a consequence of which a new trauma system is now being implemented.
Effect of multimodality therapy on circulating vascular endothelial growth factor levels in patients with oesophageal cancer
Authors: McDonnell C O , Harmey J H , Bouchier-Hayes D J , Walsh T N
Published: March 2003

Background

Angiogenesis is critical for tumour growth and metastasis. The switch to the angiogenic phenotype depends on the net balance between positive and negative angiogenic factors released by the tumour. It was hypothesized that patients with oesophageal cancer would express raised serum levels of vascular endothelial growth factor (VEGF) which would return to normal values with neoadjuvant chemoradiotherapy.

Methods

Forty-four patients with oesophageal cancer who were selected for treatment with neoadjuvant chemoradiotherapy had blood samples taken before treatment, during chemoradiotherapy, before operation, on days 1, 3 and 5 after surgery, and 3 months after resection. Serum levels of VEGF were measured. Values were correlated with response to treatment. Controls were patients who were undergoing surgery for non-malignant conditions.

Results

Serum VEGF levels were raised in patients with oesophageal cancer compared with age-matched controls (mean 247 versus 1157 pg/ml; P < 0·01). VEGF levels were unaffected by neoadjuvant treatment but fell significantly on the first day after operation (652 versus 1057 pg/ml before operation; P < 0·05). No decrease occurred in control patients. VEGF levels had returned to preoperative levels by day 5. A similar postoperative rise in VEGF levels was seen in the control subjects (1194 pg/ml on day 5 versus 71 pg/ml before operation; P = 0·001). There was no correlation between VEGF level and response to treatment or tumour stage. VEGF levels had decreased significantly at 3 months following tumour resection (594 versus 1558 pg/ml on day 5; P = 0·03).

Conclusion

VEGF levels are raised in patients with oesophageal cancer and are unaltered by neoadjuvant treatment, suggesting an additional source other than tumour cells for this proangiogenic agent.
Intragastric balloon in the treatment of patients with morbid obesity
Authors: Evans J D , Scott M H
Published: March 2003

Background

Morbid obesity is a major health problem. This study evaluated the effectiveness and safety of an intragastric balloon (IGB) for the treatment of morbid obesity.

Methods

Sixty-nine IGBs were inserted endoscopically over a 3-year period in 63 consecutive patients (59 women; median age 41 (range 24–67) years). Median weight and body mass index were 124·5 (range 89·0–177·8) kg and 46·3 (range 36·2–72·4) kg/m2 respectively. Significant coexistent disease was present in 34 patients. Median American Society of Anesthesiologists score was 3 (range 1–4). Data were recorded following retrospective review of patient case notes.

Results

Mean operating time was 22 (range 15–30) min and median inpatient stay was 1 (range 1–6) day. Vomiting was the commonest early complication following 31 procedures and necessitated early removal of four IGBs. Of 58 patients with long-term follow-up, 18 suffered displacement of the IGB after at least 6 months in situ and three required a laparotomy for intestinal obstruction. Fifty patients (86 per cent) lost weight; median weight loss was 15·0 kg (P < 0·001). Median excess weight loss was 16·4 (range − 49·0 to +4·8) and 18·7 (range −51·5 to 12·6) per cent by 4 and 7 months after IGB insertion respectively.

Conclusion

The IGB represents a useful device for the treatment of morbid obesity, particularly in preparation for definitive antiobesity procedures. Early IGB replacement is essential to minimize complications.
Expression of inducible nitric oxide synthase contributes to the development of pancreatitis following pancreatic ischaemia and reperfusion
Authors: Ayub K , Serracino-Inglott F , Williamson R C N , Mathie R T
Published: March 2003

Background

Inducible nitric oxide synthase (iNOS) activity is increased in experimentally induced acute pancreatitis. Increased expression of this isoform of nitric oxide synthase has been demonstrated in several organs subjected to ischaemia–reperfusion injury. The present experiment investigated the expression of iNOS and the effect of selective iNOS inhibition in pancreatic ischaemia–reperfusion.

Methods

Wistar rats (n = 40) were randomly and equally assigned to four groups. Groups 2 and 4 underwent 60 min of total pancreatic ischaemia followed by 6 h of reperfusion (I–R). Groups 1 and 3 underwent sham operation. The selective iNOS inhibitor l-N6-(1-iminoethyl)-lysine (l-NIL) was administered to groups 3 and 4. Expression of iNOS was examined by immunohistochemistry. Other investigations included measurement of serum amylase activity and pancreatic wet: dry weight ratio, and histopathological examination.

Results

Eight of ten rats in group 2 (I–R only) expressed iNOS but none of the ten animals in group 1 (sham laparotomy) did so. Group 4 (I-R + l-NIL) animals had significantly lower serum amylase levels and wet: dry weight ratios than those in group 2 (I–R only). Microscopic evidence of pancreatic injury was present only in rats in group 2 (I–R only).

Conclusion

Expression of iNOS during reperfusion following pancreatic ischaemia contributes significantly to the development of acute pancreatitis.
Comparison of cardiac troponin I and creatine kinase ratios in the detection of myocardial injury after aortic surgery
Authors: Haggart P C , Adam D J , Ludman P F , Bradbury A W
Published: March 2003

Background

Perioperative myocardial infarction may not be diagnosed correctly because World Health Organization criteria are often not met and creatinine kinase myocardial fraction (creatinine kinase/creatinine kinase MB isoenzyme; CK/CK-MB) ratios can be difficult to interpret. Cardiac troponin (cTn) I and cTnT are the most sensitive and specific markers of myocardial cell necrosis currently available but are not widely used in surgical practice. The aim was to compare cTnI and CK/CK-MB ratios in the detection of myocardial injury following aortic surgery.

Methods

This was a prospective study of 59 patients undergoing elective (n = 28) or ruptured (n = 24) abdominal aortic aneurysm repair or elective aortofemoral bypass (n = 7). cTnI level was measured before operation and at 6, 24 and 48 h after surgery. The CK/CK-MB ratio was measured where cTnI was detectable.

Results

Some 14 of 24 emergency and ten of 35 elective patients had detectable cTnI (greater than 0·5 ng/ml) at one or more time-points. The CK/CK-MB ratio was greater than 5 per cent in only four of 24 patients having an emergency operation and in none of the elective patients with detectable cTnI.

Conclusion

Over half of patients undergoing emergency operation and more than a quarter of those having elective aortic surgery suffered myocardial necrosis as determined by detectable cTnI levels. This was accompanied by a raised CK/CK-MB ratio in less than one-fifth of patients.
Confidentiality and healthcare
Authors: McEwen J
Published: March 2003

This is the seventh in a series of articles on ethics, professional governance and the law that BJS will run through the remainder of 2001.
Population-based study of factors influencing occurrence and prognosis of local recurrence after surgery for rectal cancer
Authors: Manfredi S , Benhamiche A M , Meny B , Cheynel N , Rat P , Faivre J
Published: March 2003

Background

Few data are available from population-based statistics on the risk of local recurrence after surgery for rectal cancer. The aims of this study were to determine factors influencing local control and to analyse treatment and prognosis of recurrences in a well defined population.

Methods

Data were obtained from the cancer registry of the Côte d'Or (France). From 1976 to 1995, 682 patients resected for cure for a rectal carcinoma were included. Recurrence rates and survival rates were calculated using actuarial methods. A relative survival analysis and Cox multivariate analysis were performed.

Results

During the study 135 local recurrences were registered. The 5-year cumulative local recurrence rate was 22·7 per cent. In multivariate analysis the two variables significantly associated with local recurrence risk were stage at diagnosis and the macroscopic type of growth. There was a non-significant decrease in local recurrence rate in patients treated by preoperative radiotherapy compared with that in patients treated by surgery alone. The proportion of patients re-resected for cure was 25·2 per cent, and increased from 13·0 per cent in 1976–1985 to 37·9 per cent in 1986–1995 (P = 0·001). The 5-year relative survival rate was 13·6 per cent overall and 40·6 per cent after resection for cure (P < 0·001).

Conclusion

Local recurrence of rectal cancer following resection remains a substantial problem. Improvement can be expected from better care and earlier diagnosis.
Randomized clinical trial comparing totally extraperitoneal inguinal hernia repair with the Shouldice technique
Authors: Fleming W R , Elliott T B , Jones R McL , Hardy K J
Published: March 2003

Background

The optimal technique for inguinal hernia repair remains contentious. This study compared the Shouldice repair with the totally extraperitoneal endoscopic (TEP) method in a randomized clinical trial, with quality of life (QoL) and cost analysis.

Methods

Two hundred patients were randomized to Shouldice or TEP repair. Patients were assessed after operation by questionnaire to determine operative outcomes, complications, QoL, and return to work and normal lifestyle.

Results

There were 117 TEP and 115 Shouldice repairs. Median operating time was longer for TEP repair (70 versus 56 min; P = 0·0001), but patients were discharged earlier (68 versus 48 per cent within 1 day; P = 0·0065), and had a quicker return to work (14 versus 30 days; P = 0·0001) and normal lifestyle (21 versus 35 days; P = 0·0001). Open repair was nearly 40 per cent cheaper. Late follow-up in 171 patients (86 per cent) at a median of 1·3 years found that TEP repair led to fewer complications at 1 year (9 versus 21 per cent; P = 0·05) and was associated with significant improvement for the QoL components of work performance and satisfaction, physical symptoms and sense of well-being.

Conclusion

TEP repair results in fewer complications and an earlier return to work and normal lifestyle, but is more expensive and takes longer to perform.
Small bowel obstruction after appendicectomy
Authors: Andersson R E B
Published: March 2003

Background

This study analysed the risk of surgically treated small bowel obstruction after open appendicectomy.

Methods

This was a historical cohort study of 245 400 patients who underwent open appendicectomy and population-based matched controls, identified by linkage of computer registries. Analyses were made with the life-table technique, Kaplan–Meier plots and Cox proportional hazards regression analysis.

Results

The cumulated risk of surgically treated small bowel obstruction after appendicectomy was 0·41 per cent after 4 weeks, 0·63 per cent after 1 year and 1·30 per cent after 30 years of follow-up, compared with 0·003 per cent at 1 year and 0·21 per cent after 30 years of follow-up among the non-operated controls. The highest risk was found after operation for other diagnoses (adjusted hazard ratio 5·2 (95 per cent confidence interval 4·6–5·8)), followed by operation for perforated appendicitis (adjusted hazard ratio 3·5 (3·1–3·8)), non-specific abdominal pain (adjusted hazard ratio 2·6 (2·3–3·0)) and mesenteric lymphadenitis (adjusted hazard ratio 2·4 (2·0–2·8)) compared with operation for non-perforated appendicitis. The relation with age was J shaped, with the lowest risk at 20–39 years. Women had a slightly lower risk than men.

Conclusion

The risk of postoperative small bowel obstruction needing surgical treatment after open appendicectomy is lower than previously thought. Perforated appendicitis, negative appendicectomy and high age are the risk factors.
Randomized clinical trial of intravenous fluid replacement during bowel preparation for surgery
Authors: Sanders G , Mercer S J , Saeb-Parsey K , Akhavani M A , Hosie K B , Lambert A W
Published: March 2003

Background

Bowel preparation using purgatives has previously been shown significantly to increase haemoglobin concentration and decrease weight. This prospective randomized study assessed the effects of administering intravenous fluid during bowel preparation.

Methods

Patients having bowel preparation with Picolax® for colonic procedures were randomized prospectively to receive no intravenous fluid (group 1) or calculated intravenous crystalloid based on body-weight (group 2) during preparation. Physiological, haematological and biochemical variables were measured before and after bowel preparation.

Results

Forty-one patients were recruited with a median age of 69 (range 29–86) years, 22 in group 1 and 19 in group 2. There was no difference between groups in any of the variables measured before bowel preparation. On completion, there was a significant difference between groups in mean weight loss (P = 0·01), postural change in systolic pressure (P = 0·015) and serum creatinine concentration (P = 0·008). In addition there was a significant fall in erect blood pressure after bowel preparation in group 1 (P = 0·02). The mean urine output in group 1 was 982 ml and in group 2 was 1808 ml (P = 0·004). The faeces weight between groups was not significantly different.

Conclusion

Picolax® bowel preparation has a significant dehydrating effect, which can be minimized by administering a simultaneous volume of intravenous fluid (mean 2 litres in this study).
Outcome of surgical treatment for carotid body paraganglioma
Authors: Plukker J T M , Brongers E P , Vermey A , Krikke A , van den Dungen J J A M
Published: March 2003

Background

The present study reviewed a 30-year experience of managing carotid body paraganglioma (CBP) and analysed clinical findings associated with perioperative morbidity.

Methods

Clinical records, radiological findings and pathological reports of all patients who presented with CBP between 1966 and 1997 were reviewed. There were 39 consecutive patients with 45 tumours and median follow-up was 10 years. The Shamblin classification was used to define complication rates and long-term surgical results.

Results

Preoperative information derived from magnetic resonance angiography (MRA) and colour Doppler imaging (CDI) was comparable to that from standard four-vessel arteriography. Forty-one CBPs were resected in 35 patients. Six patients had bilateral tumours and seven had multicentric tumours. The median duration of operation and blood loss were substantially higher for Shamblin type III tumours. All major vascular complications (four of 39 patients) and permanent neurological complications (three of 39) were observed in type III tumours.

Conclusion

Surgical planning and prediction of perioperative complications can be obtained by staging derived from MRA and CDI. Severe complications occur predominantly in type III CBPs.
Value of lymph node dissection during resection of intrahepatic cholangiocarcinoma
Authors: Shimada M , Yamashita Y , Aishima S , Shirabe K , Takenaka K , Sugimachi K
Published: March 2003

Background

Hepatectomy with extensive lymph node dissection is the standard operation for intrahepatic cholangiocarcinoma (IHCC). However, lymph node dissection may not always be effective at reducing tumour recurrence.

Methods

Forty-nine patients with IHCC who underwent hepatectomy were investigated to determine patterns of tumour recurrence and to estimate the value of lymph node dissection during resection.

Results

At hepatectomy most metastatic lymph nodes were identified at least to the level of group 2 lymph nodes. Among 23 patients who developed recurrence, 17 had liver metastases and the other six had recurrence at other sites, mainly in the peritoneum. Poorly differentiated histology was related to the development of liver metastases. No patient with the intraductal growth type of IHCC had tumour recurrence. Lymph node dissection did not appear to improve patient survival. Histological findings of lymph node metastases and intrahepatic metastases were independent indicators of poor prognosis.

Conclusion

Lymph node metastases were seldom limited to the regional lymph nodes; most tumour recurrence occurred in the liver. Lymph node dissection did not appear to improve patient survival. Lymph node dissection alone is not likely to improve the prognosis without further control of liver metastases.