bluuebunny/crossref_metadata_2025 huggingface dataset:
One-Stage Repair of a Thoracoabdominal Aortic Aneurysm Associated with Infrarenal Aortic Occlusion and Visceral Artery Stenosis Using a Modification of the Standard Atriofemoral Bypass Technique
Authors: Sahgal Avisesh , Plestis Konstadinos A. , Sanchez Luis A. , Camacho Margarita , Gold Jeffery P. , Veith Frank J.
Published: June 2007

Thoracoabdominal aortic aneurysms (TAAA) are associated infrequently with visceral artery occlusive disease and rarely with aortoiliac occlusion. The presence of occlusion of the infrarenal abdominal aorta limits the options for visceral artery perfusion and spinal cord protection by means of distal aortic perfusion and, consequently, increases the risk for postoperative complications and mortality. Significant stenoses of the visceral arteries further add to the complexity of the repair. We describe a one-stage repair of a type I TAAA associated with infrarenal aortic occlusion and significant stenoses of all visceral arteries using a modified distal perfusion technique.
Multidisciplinary Treatment of Complicated Aortic Dissection: Combined Endovascular and Surgical Intervention
Authors: Leeser David B. , Kagan Steven A. , Ball David S.
Published: June 2007

Aortic dissection is the most common catastrophic pathologic process to affect the aorta and its branch vessels. The patient was diagnosed with an acute type III aortic dissection and symptomatic occlusion of the mesenteric, renal, and iliac arteries. The patient was treated with endovascular fenestration and stenting of the iliac and renal arteries followed by open fenestration of the superior mesenteric artery, bowel resection, and cholecystectomy. Duplex ultrasonagraphy demonstrated patency of the mesenteric and iliac vessels and normal size kidneys upon discharge. The combination of traditional surgical and modern endovascular techniques may improve survival of patients with complicated type III aortic dissections.
Defining the Learning Curve of the Endovascular In Situ Saphenous Vein Bypass: Operative Data from 115 Cases by Recently Trained Surgeons
Authors: Martin John D.
Published: June 2007

To record surgeons' results of endovascular in situ saphenous vein (EISV) bypasses during the learning curve phase, randomly selected patients were evaluated who were undergoing EISV bypass performed by surgeons who had been recently trained in the Side Branch Occlusion system. An independent observer recorded the technical details at each operation on a standardized data sheet that included: number of coils deployed, misdeployed coils, additional incisions required to occlude side branches, irrigation volume, vein preparation time, operative time, and technical complications. Operations were stratified into four subjective categories based on the technical aspects of the operation: (1) good results; (2) good results, minor technical issues; (3) good results, major technical issues; and (4) poor results. Sixty-four surgeons performed 115 EISV bypasses. Eighty-seven (76%) of the procedures were classified as either good results or minor technical problems. Major technical problems occurred in 10 patients, and 18 patients (15%) had poor results. Neither site of the distal anastomosis nor the saphenous vein length affected the technical success of the procedure. The average volume of irrigation was 3,000 mL and mean vein preparation time was 84 minutes (range 15-300 minutes). Coils were misdeployed in 59 (51%) cases, and 49 patients (42%) required additional incisions on the leg. EISV bypass offers significant theoretical advantages over open in situ vein bypass; however, it is challenging, and technical complications occurred in nearly 25% of cases during the learning phase. Aberrant venous anatomy poses the greatest challenge to the success of the EISV, and the ability of the surgeon to recognize and respond appropriately to these anomalies often dictates the success of the procedure. Further studies will be necessary to evaluate the clinical benefits of this new technique.
Unilateral Lower Extremity Inflow Procedures: Is There a Preferred Operation?
Authors: Dougherty Matthew J. , Calligaro Keith D. , DeLaurentis Dominic A.
Published: June 2007

There is no consensus on optimal surgical treatment of unilateral aortoiliac occlusive disease. The purpose of this study was to compare indications for and results of the various options. Patients undergoing primary, unilateral inflow procedures without adjunctive infrainguinal bypass over a 10-year period were analyzed. Groups were defined as Ax F for unilateral axillofemoral bypass (18); IF for aortounifemoral (two) or ipsilateral iliofemoral (29) bypass; and CF for contralateral iliac-to-femoral (six) or femorofemoral (10) bypass. Risk factors, level and severity of occlusive disease, morbidity, mortality, cumulative primary patency, and limb salvage were compared. Median age was 72 years, limb salvage was the surgical indication in 61% of patients. Infrainguinal occlusion was present in 76.6% of the whole group, while 27.7% had prior outflow procedures. Compared with the other groups, AxF patients were older with more comorbidity and had more contralateral iliofemoral occlusive disease (88.9% vs 48.4%, p < 0.01). IF patients more frequently had prior outflow operations (48.4% vs 11.1%, p < 0.01). Comorbidity and presence of contralateral iliac disease most strongly influenced operation choice. Overall, hospital mortality rate was 3.1% and morbidity rate was 21.5%, not significantly different between groups. Early occlusion occurred in three patients, two IF and one AxF. Life-table primary patency rate was 87.8% (SE ± 4.9%) at 2 years and was not significantly different among the groups. Three patients ultimately required contralateral inflow procedures, 2 AXF, 1 IF (p = NS). Unilateral inflow operations achieve reasonable patency and good limb salvage rates. Shorter length reconstructions were utilized preferentially when contralateral disease was not severe, but despite greater age, comorbidity, and occlusive disease, axillounifemoral bypass results were not inferior to more direct reconstructions.
Risk Factors Associated with Recurrent Carotid Artery Stenosis
Authors: Liapis Christos D. , Kakisis John D. , Papavassiliou Vassilios G. , Koumakis Konstantinos M. , Gogas John G.
Published: June 2007

The aim of this open, perspective study was to determine the impact of risk factors, excluding the type of closure of the arteriotomy, in the development of recurrent carotid stenosis following carotid endarterectomy. One hundred and ninety-eight patients, who underwent a total of 221 carotid endarterectomies, were evaluated postoperatively with duplex scanning 1 month after the operation and every 6 months thereafter for a period of 6-120 months (mean duration of follow-up: 44 months). There were 149 (75.3%) men and 49 (24.7%) women with a mean age of 66.8 years (age range 38-92 years). Diabetes mellitus was present in 62 patients (31.3%), hypertension in 134 (67.7%), coronary artery disease in 130 (65.7%), hypercholesterolemia in 70 (35.4%), and smoking habit in 166 (83.8%). Indications for carotid endarterectomy were asymptomatic carotid stenosis > 70% in 20 (10.1%) patients and symptomatic stenosis > 50% in 178 (89.9%), 129 (65.2%) of whom had a history of transient ischemic attacks and 49 (24.7%) of previous stroke. General anesthesia was used in 197 (89.1%) operations and local anesthesia in 24 (10.9%). Deep endarterectomy with primary closure of the arteriotomy using 5/0 running suture was performed in this group of patients.

One patient (0.5%) died during the perioperative period. Five (2.5%) patients had a transient ischemic attack and three (1.5%) a nonfatal stroke in the immediate postoperative period, six (3.0%) a persistent cranial nerve injury, and two a hematoma, and three patients had delayed postoperative recovery. Twenty-six (13.1%) patients were transferred to the Intensive Care Unit postoperatively. Recurrent carotid stenosis > 50% was identified in eight patients (4.0%) and it was asymptomatic in all cases. Mean interval between endarterectomy and development of restenosis was 47.4 months (range 6-118 months). Factors such as clinical presentation, age, sex, diabetes mellitus, hypertension, coronary artery disease, hypercholesterolemia, and smoking habit were not found to be significantly associated with the development of restenosis (Chi-square). Smoking, coronary artery disease, and normal cholesterol levels were connected with a statistically nonsignificant tendency toward higher rates of restenosis. Recurrent carotid stenosis following carotid endarterectomy was not significantly associated with any of the risk factors studied in this series.
Low Absolute Neutrophil Counts in African Infants
Authors: Kourtis Athena P. , Bramson Brian , van der Horst Charles , Kazembe Peter , Ahmed Yusuf , Chasela Charles , Hosseinipour Mina , Knight Rodney , Lugalia Lebah , Tegha Gerald , Joaki George , Jafali Robert , Jamieson Denise J. ,   UNC Project BAN Study Team
Published: June 2007

Infants of African origin have a lower normal range of absolute neutrophil counts than white infants; this fact, however, remains under appreciated by clinical researchers in the United States. During the initial stages of a clinical trial in Malawi, the authors noted an unexpectedly high number of infants with absolute neutrophil counts that would be classifiable as neutropenic using the National Institutes of Health’s Division of AIDS toxicity tables. The authors argue that the relevant Division of AIDS table does not take into account the available evidence of low absolute neutrophil counts in African infants and that a systematic collection of data from many African settings might help establish the absolute neutrophil count cutpoints to be used for defining neutropenia in African populations.
Biofeedback Therapy After Perineal Rectosigmoidectomy or J Pouch Procedure
Authors: Hwang Yong Hee , Choi Jeong Seok , Nam Young Soo , Salum Mara R. , Weiss Eric G. , Nogueras Juan J. , Wexner Steven D.
Published: June 2007

The aim of this study was to determine the outcome and to identify possible predictors of success for biofeedback therapy after perineal rectosigmoidectomy (PRS) or coloanal or ileoanal J pouch. A retrospective chart review of all patients with electromyography-based biofeedback therapy due to fecal incontinence after PRS or a J pouch procedure was undertaken. Follow-up was obtained by telephone survey. Fourteen patients (4 men and 10 women) were included in this study. In the 9 patients after PRS, the frequency of daily bowel movements was 3.6 2.8 preoperatively, 4.1 3.2 prebiofeedback, and 2.2 - 1.3 postbiofeedback (P < .05). The frequency of daily incontinent episodes was reduced from 2.4 2.2 preoperatively and 2.0 + 1.9 prebiofeedback to 0.26 0.3 postbiofeedback (P< .05). The incontinence scores decreased from 17 3.1 preoperatively to 16 + 2.1 prebiofeedback and to 8.2 5 postbiofeedback (P < .001). At a follow-up of 15.8 7.1 months, 5 patients after the J pouch had decreased daily bowel frequency from 6.6 4.2 prebiofeedback to 3.3 2 postbiofeedback and 3.1 2 at follow-up (P < .05). The frequency of daily incontinent episodes was reduced from 1.9 1.3 prebiofeedback to 0.9 0.7 postbiofeedback to 0.7 0.8 at followup (P < .05). The incontinence scores decreased from 13.4 2.7 prebiofeedback to 8.8 5.1 postbiofeedback to 6.8 5.5 at follow-up (P < 0.05). In both groups, the postbiofeedback incontinence score correlated with the prebiofeedback incontinence score. Furthermore, there was no correlation between outcome and age, interval between surgery and biofeedback therapy, frequency of biofeedback sessions, or manometry results in either group. Biofeedback therapy is an effective option for patients with fecal incontinence after perineal rectosigmoidectomy or colonic or ileal J pouch.
Further Results of Incorporating Innovative Procedures in a Surgical Residency
Authors: Kehdy Farid J. , Allen Jeffrey W. , Vitale Gary C. , Polk Hiram C.
Published: June 2007

The instruction in precipitously advancing surgical technologies remains a real challenge to every surgery program. Our institution's ongoing experience with an identified center for student and resident education and clinical investigation provides an option for addressing these needs in a general surgery residency. Over the past 8 years, we have developed and described previously the Center for Advanced Surgical Technologies (CAST) in a joint undertaking of the Department of Surgery and the Norton Hospital, an affiliated hospital on our medical school campus. The idea behind this program has been to focus and develop high-quality skills in the hospital in many areas of advanced technology. CAST has subsequently provided a vehicle for excellent clinical research as well as the development of specially focused advanced surgical technologies, fellowships, and a large number of publications that have often focused on new, advanced methods for imaging surgical disease and minimal access treatment. This program has had a very positive impact on the general surgery residency as a whole and has permitted a steadily advancing agenda of new technologies, while relegating recently emerged but perfected technologies into the central aspect of our accredited general surgery residency.
In Vivo Robotic Laparoscopy
Authors: Oleynikov Dmitry , Rentschler Mark E. , Dumpert Jason , Platt Stephen R. , Farritor Shane M.
Published: June 2007

Laparoscopy reduces patient trauma but limits the surgeon's ability to view or touch the surgical environment directly. The surgeon's ability to visualize and manipulate target organs can be improved using currently available external robotic systems. However, tool tip orientation and optimal camera placement remain limited because the robot instruments and cameras are still constrained by the entry incisions. Placing a robot completely within the abdominal cavity would provide an unconstrained platform that could provide an enhanced field of view from arbitrary angles and dexterous manipulators not constrained by the abdominal wall fulcrum effect. Several in vivo robots have been developed and successfully tested in a porcine model. These in vivo robots have been used to observe trocar and tool insertions and placement, and to provide additional camera angles that improved surgical visualization. Equipped with a grasper, such robots will provide task assistance. These in vivo robots will be much less expensive than the current generation of large external robotic surgical systems and will ultimately allow a surgeon to be a remote first responder irrespective of the location of the patient.
Horseshoe Abscesses and Fistulas: How Are We Doing?
Authors: Rosen Seth A. , Colquhoun Patrick , Efron Jonathan , Vernava Anthony M. , Nogueras Juan J. , Wexner Steven D. , Weiss Eric G.
Published: June 2007

Background:Various surgical treatments exist for horseshoe abscesses and fistulae, including posterior midline sphincterotomy, catheter drainage, cutting and draining setons, and advancement flaps. The aim of this study was to evaluate the long-term results of patients treated for these complex anorectal problems.

Methods: A retrospective review was undertaken of patients with a diagnosis of horseshoe abscess, horseshoe fistula, postanal space abscess, or postanal space fistula from 1990 to 2001. Long-term follow-up was accomplished by telephone questionnaire.

Results: Thirty-one patients were identified, of whom 17 (54.8%) had a diagnosis of Crohn disease. The diagnosis at presentation included unilateral (ischiorectal) abscess (32.3%), bilateral horseshoe abscess (51.6%), bilateral horseshoe fistula (9.7%), and postanal space abscess (6.4%). Endoanal ultrasonography was used during the preoperative evaluation in 11 patients (35.5%). After referral to our institution, patients underwent a median of four operations (range, 1 to 9). At a mean follow-up of 49.3 months, 60.7% of patients had either healed perineal disease or were asymptomatic with controlled disease. Patients who had a posterior midline sphincterotomy were more likely to be asymptomatic (P = .047). Patients who had a diagnosis of Crohn disease required more operations than those without Crohn disease (3 vs 1.86, P= .02). Only patients who had a diagnosis of Crohn disease had a stoma at their last follow-up (4 of 17, 23.5% vs 0 of 11, 0%; P=.05).

Conclusions: Patients with horseshoe abscess or fistulae often require multiple operations for treatment but can expect reasonable rates of long-term success in controlling or curing their disease. Those who undergo posterior midline sphincterotomy seem to benefit with higher rates of improved symptoms. Patients with a diagnosis of Crohn disease may fare less well. The role of endoanal ultrasonography in directing therapy remains to be defined.
Unsedated Small-Caliber Upper Endoscopy: An Emerging Diagnostic and Therapeutic Technology
Authors: Kim Charles Y. , O’Rourke Robert W. , Chang Eugene Y. , Jobe Blair A.
Published: June 2007

Although conventional esophagogastroduodenoscopy has become widespread in its applications and availability, it is constrained by the requirement for patient sedation. This requirement contributes to morbidity, time lost from work, and additional resource utilization in personnel and facilities. Small-caliber endoscopy is an emerging technology that enables transnasal evaluation of the upper gastrointestinal tract in a unsedated patient. This procedure can be performed in a wider range of settings, including the clinic setting where a dedicated conscious sedation suite is not available and can be incorporated into the office visit. The applications of small-caliber endoscopy include general diagnostic upper endoscopy, screening and surveillance of Barrett esophagus, and intraoperative diagnostics or postoperative evaluation of the upper gastrointestinal tract. Therapeutic applications include the placement of nasoduodenal feeding tubes, esophageal pH catheters, and impedance catheters. When used in the sedated patient, small-caliber endoscopy can also facilitate esophageal stricture dilation and transnasal placement of a percutaneous endoscopic gastrostomy tube. This review discusses the techniques, equipment, and applications of small-caliber endoscopy of the upper gastrointestinal tract.
Radio Frequency Identification Systems Technology in the Surgical Setting
Authors: Nagy Paul , George Ivan , Bernstein Wendy , Caban Jesus , Klein Rosemary , Mezrich Reuben , Park Adrian
Published: June 2007

Radio frequency identification (RFID) is a technology that will have a profound impact on medicine and the operating room of the future. The purpose of this article is to provide an introduction to this exciting technology and a description of the problems in the perioperative environment that RFID might address to improve safety and increase productivity. Although RFID is still a nascent technology, applications are likely to become much more visible in patient care and treatment areas and will raise questions for practitioners. We also address both the current limitations and what appear to be reasonable near-future possibilities.
Colorectal Cancer Screening: Do We Practice What We Preach?
Authors: Colquhoun Patrick , Weiss Eric G. , Efron Jonathan , Nogueras Juan J. , Vernava Anthony M. , Wexner Steven D.
Published: June 2007

Objective: Compliance rates for colorectal cancer screening have been reported as low, and ignorance is the most common factor sighted to explain this. The aim of this study was to determine screening compliance among colorectal surgeons assumed to be educated of the risks of colorectal cancer. Methods: A postal survey was distributed to the members of the American Society of Colon and Rectal Surgeons. Results: A total of 1195 members were surveyed. All respondents indicated that they advocate screening. Colonoscopy every 10 years and annual fecal occult blood testing were the most common strategies advocated to individuals with baseline risk. Colonoscopy every 5 years and annual fecal occult blood testing were the most common strategies advocated to patients with a first-degree relative with polyps or cancer. Most of these colorectal surgeons initiated their screening before 50 years of age. Conclusion: Colorectal cancer screening compliance is high among members of the American Society of Colon and Rectal Surgeons. These rates may be the result of awareness of the risks of colorectal cancer.
Laparoscopic Distal Pancreatectomy With Splenic Preservation for Serous Cystadenoma: A Case Report and Literature Review
Authors: Aluka Kanayochukwu J. , Long Cynthia , Rickford Marc S. , Turner Patricia L. , McKenna Stephen J. , Fullum Terrence M.
Published: June 2007

A minimally invasive approach can be beneficial in a spleen-preserving distal pancreatectomy. This article reports a 71-year-old woman who presented to her internist with hypertension and persistent hypokalemia. A computed tomography scan to rule out a functional adrenal mass incidentally revealed a 4 cm × 3 cm × 2 cm serous cystadenoma of the distal pancreas and normal adrenal glands. The patient was referred to the general surgery service for resection of the distal pancreatic lesion. A laparoscopic spleen-preserving distal pancreatectomy was performed. The lesion was completely excised, and the pathology revealed serous cystadenoma with focal fibrosis and atrophic acini. The postoperative advantages of this approach were the early return of bowel function, minimal narcotic requirements, and early resumption of normal activities. This case illustrates the advantages of minimally invasive surgery in the performance of a spleen-preserving distal pancreatectomy.
Laparoscopic Resection of Clinically Suspected Gastric Stromal Tumors
Authors: Berindoague René , Targarona Eduard Mª , Feliu Xavier , Artigas Vicenç , Balagué Carmen , Aldeano Aurora , Lahoud Antonio , Navines Jordi , Fernandez-Sallent Enrique , Trias Manuel
Published: June 2007

Gastrointestinal stromal tumors (GISTs) account for 5% of all gastric tumors. Preoperative diagnosis is relatively difficult because biopsy samples are rarely obtained during fibergastroscopy. Surgical radical resection is the gold standard treatment, allowing pathologic study for both diagnosis and prognosis. Laparoscopic resection has become an alternative to the open approach, but long-term results are not well known. The aim of this study is to report experience with laparoscopic resection, placing special emphasis on preoperative diagnosis and describing long-term results. A retrospective analysis was made of all patients undergoing a laparoscopic resection for clinically suspected gastrointestinal stromal tumors between November 1998 and August 2006 at 2 tertiary hospitals. The medical records of all participants were reviewed regarding surgical technique, clinicopathologic features, and postoperative long-term outcome. Laparoscopic gastric resection was attempted in 22 patients (13 women and 9 men) with a mean age of 66.7 years (range, 29-84 years). One patient had 2 gastric tumors. Tumor localization was upper gastric third in 6 patients, mid-gastric third in 7, and distal third in 10. Surgical techniques were transgastric submucosal excision (n = 1), wedge resection (n = 13), partial gastrectomy with Y-en-Roux reconstruction (n = 6), and total gastrectomy with Y-en-Roux reconstruction (n = 2). Two patients (9.1%) required conversion to the open procedure because of tumor size. Postoperative morbidity was delayed gastric emptying in 3 patients. Median postoperative stay was 6 days (range, 4-32 days). Pathologic and immunohistochemical study confirmed gastrointestinal stromal tumors in 18 cases. The other 4 cases were adenomyoma, hamartoma, plasmocytoma, and parasitic tumor (anisakis). Median tumor size was 5.6 cm (range, 2.5-12.5 cm) in cases of gastrointestinal stromal tumors. Malignant risk of gastrointestinal stromal tumors assessed according to mitotic index and size was low (n = 8), intermediate (n = 6), or high (n = 4). After a median follow-up of 32 months (range, 1-72 months), there was 1 case of recurrence of GIST. Definitive preoperative diagnosis of gastric submucosal tumors is frequently difficult. The laparoscopic approach to surgical treatment of these tumors seems safe and is associated with acceptable intermediate-term results, especially in cases of gastrointestinal stromal tumors.
A Randomized Controlled Trial of Laparoscopic Nissen Fundoplication Versus Proton Pump Inhibitors for Treatment of Patients With Chronic Gastroesophageal Reflux Disease: One-Year Follow-Up
Authors: Anvari Mehran , Allen Christopher , Marshall John , Armstrong David , Goeree Ron , Ungar Wendy , Goldsmith Charles
Published: June 2007

A randomized controlled trial conducted in patients with gastroesophageal reflux disease compared optimized medical therapy using proton pump inhibitor (n = 52) with laparoscopic Nissen fundoplication (n = 52). Patients were monitored for 1 year. The primary end point was frequency of gastroesophageal reflux dis-ease symptoms. Surgical patients had improved symptoms, pH control, and overall quality of life health index after surgery at 1 year compared with the medical group. The overall gastroesophageal reflux disease symptom score at 1 year was unchanged in the medical patients, but improved in the surgical patients. Fourteen patients in the medical arm experienced symptom relapse requiring titration of the proton pump inhibitor dose, but 6 had satisfactory symptom remission. No surgical patients required additional treatment for symptom control. Patients controlled on long-term proton pump inhibitor therapy for chronic gastroesophageal reflux disease are excellent surgical candidates and should experience improved symptom control after surgery at 1 year.
Abdominal Wall Reconstruction After Temporary Abdominal Closure: A Ten-Year Review
Authors: Joels Charles S. , Vanderveer Andrew S. , Newcomb William L. , Lincourt Amy E. , Polhill John L. , Jacobs David G. , Sing Ronald F. , Heniford B. Todd
Published: June 2007

Abdominal wall reconstruction (AWR) is often required for hernias created after temporary abdominal closure (TAC). Demographic and clinical data from patients undergoing TAC and AWR between January 1, 1992, and December 31, 2002, were collected and univariate analysis performed. Temporary abdominal closure and AWR were performed in 21 patients. Complications developed in 12 patients (57.1%) after TAC; associated risk factors were mesh placement ( P = .04) and skin grafting ( P = .04). Successful AWR included mesh (n = 6), component separation (n = 6), primary repair (n = 4), and 3 combination techniques. Six patients (28.6%) developed intraoperative complications, and 14 (66.7%) developed postoperative complications. Intraoperative complications were increased in patients with tissue expanders ( P = .01). Postoperative complications ( P = .04) were less likely with component separation. The complication rate with TAC and AWR is high. Tissue expanders are associated with an increased risk of intraoperative complications with AWR, whereas component separation is associated with a reduction in postoperative complications.
The Effect of Direct-From-Recovery Room Discharge of Laparoscopic Cholecystectomy Patients on Recovery Room Workload
Authors: Seim Andreas R. , Andersen Bjørn , Berger David L. , Sokal Suzanne M. , Sandberg Warren S.
Published: June 2007

Ambulatory laparoscopic cholecystectomy pathways move patients through the hospital without encountering delays caused by congested inpatient bed units. However, redirecting patients to a direct discharge pathway might not be beneficial if recovery capacity is further taxed by additional workload. In this study, we attempt to assess the operational impact on recovery room workload of directly discharging laparoscopic cholecystectomy patients to home. We conducted a retrospective case-control review of recovery room flow sheets to determine recovery room time and effort required for laparoscopic cholecystectomy patients. The study was restricted to patients of a single surgeon to minimize confounds from surgical technique. Fifty-seven case patients (May 1, 2004, through November 30, 2004), all managed with intent to directly discharge from the recovery room, were compared with control patients (n = 81) from the corresponding 6 months in the year before the direct-discharge plan. The times (mean; 95% confidence interval) to meet objective criteria for adequate pain control (3.5 minutes [2.1 to 5.9] versus 4.0 minutes [2.6 to 6.1]) and readiness for discharge from phase 1 recovery (8.1 minutes [4.8 to 13.6] versus 6.1 minutes [4.0 to 9.5]) were not different between the groups. The number and distribution of interventions documented in the recovery process were not different between groups, nor was there a difference in recovery room length of stay (158 minutes [138 to 182] versus 149 minutes [132 to 167]). In our study, recovery room records reveal little if any increased workload associated with the direct-to-home discharge of laparoscopic cholecystectomy patients.
Laparoscopic Transgastric Repair of a Gastrogastric Fistula After Gastric Bypass
Authors: Roberts Kurt E. , Duffy Andrew J. , Bell Robert L.
Published: June 2007

Gastrogastric fistulas are an uncommon complication following laparoscopic Roux-Y gastric bypass surgery (LRYGB) and may be caused by staple-line dehiscence or leak. Described here is a novel technique to treat these fistulae via a laparoscopic transgastric approach and closure of the fistulous tract with an Endo Stitch™ device. The 33-year-old patient, post LRYGB in 2002, with documented gastrogastric fistula, had failed non-operative management. A transoral endoscope was passed into the cephalad portion of the gastrogastric fistula; a glidewire was passed from the gastric pouch into the gastric remnant. Laparoscopically, 2 gastrotomies were made and a “pneumogastrium” created with carbon dioxide. Under direct, transgastric visualization, the distal portion of the gastrogastric fistula was closed using an Endo Stitch™ device. This technique is safe and reproducible when performed by an experienced laparoscopic surgeon and could be modified for other scenarios requiring alternate access to the stomach.
Regional Variation in Surgery for Gastroesophageal Reflux Disease in Ontario
Authors: Lopushinsky Steven R. , Austin Peter C. , Rabeneck Linda , Kulkarni Girish S. , Urbach David R.
Published: June 2007

The optimal treatment for gastroesophageal reflux disease (GERD) is unclear, and the degree of variation in the rate of antireflux surgery in different regions is unknown. Large variation has significant implications for health care spending and may represent uncertainty among health care providers. The objective of this study was to identify population-based utilization and measure area rate variations in the use of GERD surgery; 11 685 primary antireflux procedures in the provincial administrative health databases were studied. Small-area variation was quantified using 4 measures. The crude rate of antireflux procedures was 11.6/100 000 adults. Patients between the ages of 45 and 64 had the highest rates of surgery. More women than men underwent antireflux surgery (13.6 vs. 9.4 per 100 000). Between counties, adjusted surgical rates ranged from 5.0 to 28.7 per 100 000 persons. Significant regional variation exists for antireflux surgery across Ontario, suggesting that its appropriate role in the management of GERD remains ill-defined.
Dietary Factors in Reducing Risk of Cardiovascular Diseases
Authors: Melanson Kathleen J.
Published: June 2007

Diet influences many modifiable risk factors for cardiovascular diseases (CVDs). Considering this, moderation of total dietary fat, particularly trans and saturated fats, as well as cholesterol is recommended. Dietary fats should come mainly from plants and fatty fish, providing monounsaturated and polyunsaturated (including omega-3) fatty acids. Carbohydrate sources to emphasize include whole grains, legumes, vegetables, fruits, and other fiber-rich sources, rather than sugars. Although vitamins such as E, C, and some B vitamins are associated with reduced CVD risk, data do not support the use of supplements, but foods rich in these nutrients are advocated. Dietary minerals such as potassium, magnesium, and calcium may be beneficial to heart health, while reduction of dietary sodium decreases risk of hypertension. A large variety of phytonutrients are also associated with reduced CVD risk. Other dietary factors receiving research attention regarding CVD risk. Other dietary factors receiving research attention regarding CVD risk include caffeine, alcobol, and meal frequency, although more work is needed in these areas. In contrast, data are quite robust to support the importance of healthy body weight management in cardiovascular health. In general, diets based on a variety of less processed foods, mainly of plant origin, in the context of an active lifestyle, are conducive to heart health.
Anglicans and Islam in Nigeria: Anglicans Encountering Difference
Authors: Idowu-Fearon Josiah
Published: June 2007

Nigeria is the most populous nation in Africa. It is also divided on religious grounds with a predominantly Muslim north and a mainly Christian south. Christians make up the majority of the population (52.6 per cent) compared with Muslims (41 per cent). The 17 million Anglicans are the second largest Christian group. With its large and religiously divided population Nigeria is one of the main countries in Africa, and the world, where large numbers of Muslims and Christians live and interact together. In today's world where the ‘Christian’ West and the Islamic world are becoming increasingly polarized, the history of Anglican/Muslim relations in Nigeria provides a key case study with important implications for Anglicans all over the world.
Imperial Nexus and National Anglican Identity: The Australian 1911–12 Legal Nexus Opinions Revisited
Authors: Withycombe Robert S.M.
Published: June 2007

The legal Opinion of eminent English Counsel on the legal nexus of the Australian Anglican colonial dioceses to their Mother Church in England was delivered on 20 June 1911. It provoked a decade of debate in diocesan, provincial and national synods that revealed how leading Australian Anglicans identified themselves before and after World War One. Great diversity appears among the responses of bishops, clergy and laity. Both enthusiasm for change and wariness of it were confined to no one region or diocese. Lay understandings and participation in these debates, along with churchmanship anxieties and long traditions of colonial diocesan independence, were among important factors that governed the Australian Anglicans' long march towards constitutional autonomy in 1962. Lambeth archives, printed Synod Reports, Australian secular and religious press reports are quarried to reconstruct these images of a diverse and uncertain pre-1921 Australian Anglican identity.
The Church in Wales and the State: A Juridical Perspective
Authors: Doe Norman
Published: June 2007

In 1536 Wales (Cymru) and England were formally united by an Act of Union of the English Parliament. At the English Reformation, the established Church of England possessed four dioceses in Wales, part of the Canterbury Province. In 1920 Parliament disestablished the Church of England in Wales. The Welsh Church Act 1914 terminated the royal supremacy and appointment of bishops, the coercive jurisdiction of the church courts, and pre-1920 ecclesiastical law, applicable to the Church of England, ceased to exist as part of public law in Wales. The statute freed the Church in Wales (Yr Eglwys yng Nghymru) to establish its own domestic system of government and law, the latter located in its Constitution, pre-1920 ecclesiastical law (which still applies to the church unless altered by it), elements of the 1603 Canons Ecclesiastical and even pre-Reformation Roman canon law. The Church in Wales is also subject to State law, including that of the National Assembly for Wales. Indeed, civil laws on marriage and burial apply to the church, surviving as vestiges of establishment. Under civil law, the domestic law of the church, a voluntary association, binds its members as a matter of contract enforceable, in prescribed circumstances, in State courts.
A trial of asthma self-management in Beijing schools
Authors: Clark Noreen M. , Gong Molly , Kaciroti Niko , Yu Jimmy , Guixian Wu  , Zhechun Zeng  , Zhaosu Wu
Published: June 2007

Objectives: This study examined the effectiveness in children in China of an asthma education programme adapted from a model developed in the USA.

Methods: Six hundred and thirty-nine children in 21 elementary schools in one agricultural and one industrial area participated in a randomized, controlled trial. Data were collected at baseline and 1 year subsequently. The self-regulation-based programme addressed topics including preventing and managing symptoms, using medicines, and identifying and controlling triggers.

Results: Positive effects on treatment children v. control children were noted in school performance (0.21 v. -0.06, p=0.04), absences (-0.55 v . -0.32, p=0.02), and home environment (1.78 v. 4.75, p=0.009). Industrial-area children additionally benefited from fewer hospitalizations (odds ratio=1.96, p=0.05) and asthma-related concerns of parents (-0.63 v. -0.34, p=0.001). Agricultural-area parents showed greater improvement in asthma management (0.93 v. 0.26, p=0.0001), and expressed more negative feelings about asthma (-0.13 v. -0.58, p=0.04) and asthma concerns (-0.31 v. -0.63, p=0.0001).

Discussion: The programme provided overall benefits related to school performance, absences, and home environment. In the agricultural area, where fewer resources were available, benefits were fewer and concerns greater. In the industrial area, where education and income were higher, additional benefits related to healthcare use and parents' quality of life were realized.
Women's and doctors' accounts of their experiences of depression in primary care: the influence of social and moral reasoning on patients' and doctors' decisions
Authors: Maxwell Margaret
Published: June 2007

Background: Little is known about how general practitioners (GPs) manage depression within everyday clinical practice, particularly in relation to the issue of `problem definition'. In addition, there has been relatively little research on the patients' perspective of depression and its management in primary care.

Methods: Qualitative interviews explored women's and GPs' experiences of recognizing depression and their experiences of the management of depression. Thirty-seven women and 20 GPs were recruited from practices in four National Health Service Board areas of Scotland. Each participant was interviewed at the start of the study, and 30 women and 19 GPs were revisited approximately 9—12 months later so that the process of care could be reviewed.

Results: The findings demonstrate the social and moral reasoning that lies behind women's decisions to seek help and to subsequently accept their GPs' explanation and advice, and that the acceptance of antidepressants created a moral dilemma for the women. For GPs, the diagnosis and management of depression led to contemplating the boundaries of their professional role, and social and moral reasoning was also evident in their decision-making processes.

Discussion: The implication is that, for the majority of women, a chronic-disease model for the management for depression in primary care would be likely to increase rather than reduce the moral dilemma. In addition, the management of depression is not solely based on clinical decisions, so the applicability of a chronic-disease model to primary care requires further consideration.
Pastoral relationships and holding work in primary care: affect, subjectivity and chronicity
Authors: Cocksedge Simon , May Carl
Published: June 2007

Objectives: To understand family doctors' constructs of long-term therapeutic relationships with patients in primary care.

Methods: Semi-structured interviews were administered to general practitioners with >5 years of experience ( n=28) working in an English semi-rural district, and the results were subjected to constant comparative qualitative analysis.

Results: Participants identified pastoral relationships as long-standing patterns of doctor—patient interaction aimed at providing reliable supportive care indirectly concerned with clinical medicine. Holding work was identified as a technique for structuring and delivering care within pastoral relationships. Pastoral relationships and holding work were seen as valuable in the affective management of people with long-standing chronic illness, especially mild-to-moderate depression and anxiety.

Discussion: At a time when primary care is undergoing significant structural change, respondents in this study laid emphasis on personal and continuing relationships with patients who had diffuse needs connected with the experience of complex and chronic problems, and their accounts intimately connected life events with health status. Importantly, these accounts suggest that such relationships are hard to define and therefore hard to measure, but have important therapeutic purposes.
Review Paper: The impact of social deprivation on chronic back pain outcomes
Authors: Carr Jane L. , Klaber Moffett Jennifer A.
Published: June 2007

Chronic low back pain is the commonest cause of disability for adults of working age. It is a complex problem frequently encapsulated as a bio-psychosocial issue, yet the social element has received less attention than it deserves, particularly for low-income and socially deprived patients. Rehabilitation programmes are often based on increasing function through cognitive and behavioural techniques, which, for many reasons, may be less effective for the socially disadvantaged. In this paper we discuss the potential barriers to successful rehabilitation in socially deprived groups and we look at possible factors that may need to be considered when designing interventions.
Harnessing the potential of the Internet to promote chronic illness self-management: diabetes as an example of how well we are doing
Authors: Bull Sheana S. , Gaglio Bridget , Mckay H. Garth , Glasgow Russell E.
Published: June 2007

Objectives: Given the potential for the Internet to be used as a dynamic, interactive medium for providing information, changing attitudes and behaviour and enhancing social support, it is important to consider whether what is currently available online for chronic illness self-management adequately harnesses this potential. The objective of this paper was to review the content of diabetes self-management websites and to identify strengths and limitations of online diabetes self-management.

Methods: We reviewed and coded features of 87 publicly available diabetes websites hosted by governmental, health plan, commercial, pharmaceutical, and not-for-profit organizations. We assessed whether each website was using online opportunities in the areas of interactivity, theory-based interventions, social support, and evidence-based care.

Results: The majority of sites provided information, essentially using an electronic newspaper or pamphlet format. Few sites offered interactive assessments, social support or problem-solving assistance, although there were some significant differences in these characteristics across the types of site.

Discussion: Current diabetes websites fall short of their potential to help consumers. Suggestions are made for ways to improve the helpfulness and interactivity of these resources.
Recruiting older people into a large, community-based study of heart failure
Authors: Barnes Sarah , Gott Merryn , Payne Sheila , Parker Chris , Seamark David , Gariballa Salah , Small Neil
Published: June 2007

This paper highlights some of the challenges encountered when recruiting older people with heart failure into longitudinal, community-based research. It draws on the experience gained in a study to provide insights into the palliative care needs of older people with heart failure and the timing and need for service interventions. Five hundred and forty-two people with heart failure (New York Heart Association (NYHA) stages II—IV) and 213 of their informal carers were recruited from primary care practices in four areas of the UK. Ethical issues arising around gate-keeping, terminology and participant burden are discussed along with challenges faced during the recruitment process. Strategies to increase general practitioner and patient recruitment are provided. The paper concludes that prospective longitudinal studies are of particular relevance to chronic illness, and the complexity of setting up such research must be acknowledged and appropriately resourced.
A naturalistic study of ambulatory asthma severity and reported avoidant coping styles
Authors: Nazarian Deborah , Smyth Joshua M. , Sliwinski Martin J.
Published: June 2007

Objective: To examine how the use of dispositional avoidant coping traits prospectively predicts ambulatory asthma severity in daily life.

Methods: An ecological momentary assessment (EMA) design enabled examination of stable coping styles across dynamic daily changes of ambulatory peak expiratory flow rate (PEFR), asthma symptoms and stress in the natural environment of patients with asthma. A community sample of 61 adults with asthma reported their typical use of avoidant coping styles and carried palmtop computers that alerted them to record their stress and symptoms five times per day for 1 week.

Results: Some aspects of dispositional avoidant coping predicted more asthma symptoms and worse PEFR. Denial and behavioural disengagement as typical coping styles predicted more symptoms and worse PEFR. Mental disengagement was unrelated to symptoms and PEFR.

Discussion: These data suggest that individuals with asthma who report typically utilizing avoidant coping may have worse health parameters in momentary reports when examined in their natural environments. Differences between avoidant coping styles emerged, suggesting the existence of moderating factors of coping effectiveness.
Bridging the knowledge—action gap in diabetes: information technologies, physician incentives and consumer incentives converge
Authors: Nobel Jeremy
Published: June 2007

The gap between current medical knowledge and its application in chronic disease management is especially apparent in diabetes care. Although research over the last decade has shown that adherence to standards of care can prevent or delay the onset of devastating diabetic complications, little more than one-third of patients achieve adequate glycaemic control. Obstacles to better care include `system' factors such as inadequate record-keeping and reimbursement policies that reimburse amply for illness but poorly for diabetes education and interventions via telephone and computer. Disparities in healthcare compound the difficulty among vulnerable populations in urban and rural areas. Emerging healthcare delivery systems that encourage payers, providers and consumers to improve diabetes care with the use of information technology and financial incentives are described in different health management settings.
`Walking like John Wayne': open-format diaries of people with knee pain and disability
Authors: Bie Nio Ong  , Jinks Clare
Published: June 2007

Objective: To describe older people's everyday experience and context of living with knee pain and disability, and to explore the potential of open-format diaries in accessing these experiences.

Methods: This was a diary study, embedded in a larger mixed-method study. Ten people who participated in a qualitative interview study volunteered to keep an open-format diary over a period of 1 week.

Results: Diaries provided current and historical details about people's lives and their health. The diaries set these experiences within the context of daily life, and combined description with reflection. Themes covered included: causes of pain, symptoms and treatments, consultations, and co-morbidity.

Discussion: Open-format diaries allow insights into the complex and contextual experience of pain and disability, and because of the contemporaneous detail, can be helpful to clinicians' holistic understanding of the impact of knee pain on people's quality of life. This method provides descriptive material that complements survey and qualitative interview data.