bluuebunny/crossref_metadata_2025 huggingface dataset:
Impact of a toxicology service on a metropolitan teaching hospital
Authors: Lee Victor , Kerr J Fergus , Braitberg George , Louis William J , O'Callaghan Chris J , Frauman Albert G , Mashford M Laurence
Published: March 2003

Objective:

To evaluate the impact of a toxicology service on a major metropolitan teaching hospital.

Method:

A descriptive comparative study of all patients presenting with poisoning or suspected poisoning 12 months before and after the commencement of a toxicology service. Data on length of stay in the emergency department, disposition, length of stay of admitted patients and substance(s) involved were examined.

Results:

A total of 1316 poisoned patients were studied. There was a statistically significant increase in self‐poisonings from 612 to 704 (P= 0.002) and in the number of admissions from 113 to 192 (P < 0.05). There was no significant change in emergency department length of stay. The average length of stay for patients admitted under the care of the toxicology service decreased, especially for complicated patients.

Conclusion:

In the first 12 months of operation the toxicology service treated more patients than the 12‐month period prior to commencement, achieving a decrease in average length of stay for those patients admitted to the service. The emergency department length of stay was not altered. We surmise that by decreasing average length of stay for the patients under the care of the toxicology service, the net increase in the general pool of unoccupied beds improves bed access for all emergency department patients.
Hyperpyrexia in the emergency department
Authors: McGugan Elizabeth A
Published: March 2003

The differential diagnosis of the hyperpyrexic patient in the emergency department is extensive. It includes sepsis, heat illness including heat stroke, neuroleptic malignant syndrome, malignant hyperthermia, serotonin syndrome and thyroid storm. Each of these possible diagnoses has distinguishing features that may help to differentiate one from another. However, establishing the correct diagnosis is a challenge in the setting of the obtunded emergency patient who gives no history and where there may be limited access to any past medical or drug history. This paper presents such a case and reviews the features of the differential diagnoses and management of the hyperpyrexic patient.
A study of triage of paediatric patients in Australia
Authors: Durojaiye Linda , O’Meara Matthew
Published: March 2003

Objectives:To describe the triage of children in a sample of mixed and paediatric emergency departments in Australia in 1999 and to measure the inter‐rater reliability of the National Triage Scale when used by triage nurses for the triage of paediatric patients.

Methods:A questionnaire was sent to 11 hospitals, including one paediatric and one mixed emergency department, in each state studied. Triage nurses were asked to assess 25 paediatric patient profiles and to assign appropriate triage categories to each profile. The number of responses within the modal triage category (concurrence), the percentage of responses with a concurrence of at least 50% and the number of responses within one triage category of the modal response (spread) of responses were measured. Triage data for 1999 from the same emergency departments were collected and numbers of children seen and admitted in each triage category were described. The patterns of distribution of triage categories for specific paediatric diagnoses (triage ‘footprints’) were also described. Data from mixed emergency departments were grouped and compared with data from paediatric emergency departments and any differences were described.

Results:Seventy‐eight nurses in 10 hospitals responded to the questionnaire. Sixty‐three per cent of all responses had a concurrence of greater than 50%. Ninety‐four per cent of patient profiles were triaged to within one triage category of their modal response. Nurses in paediatric emergency departments (concurrence greater than 50% for 79% of responses) were significantly more consistent in their use of the National Triage Scale compared with nurses in mixed emergency departments (concurrence greater than 50% for 50% of responses). Paediatric emergency department triage nurses were more likely to use the full range of the National Triage Scale and were fourfold as likely to allocate triage categories 4 and 5 to patient profiles. Paediatric hospitals allocated patients to triage categories 4 and 5 for an average of 71% of presentations compared with 47% for mixed emergency departments. Specific diagnoses had characteristic distributions of triage categories, with similar differences seen when comparisons were made between mixed and paediatric emergency departments.

Conclusion:Use of the National Triage Scale for the triage of paediatric patients by triage staff is not consistent and there are significant differences between the triage practices of paediatric and mixed emergency departments.
A review of the accuracy of references in the journal Emergency Medicine
Authors: O’Connor Alan E
Published: March 2003

Objective: To assess the accuracy of references in articles published in Emergency Medicine, and to categorize these errors.

Methods: All the references in Volume 12 of Emergency Medicine were listed and numbered consecutively. A sample of 100 references was then selected. Each reference was then checked, initially on an electronic database, with the original article being used as the gold standard.

Results: 1469 citations were included in the study. A random sample of 100 was taken and examined in detail. 35 papers were shown to have at least one error, and a total of 41 errors were found. The maximum number of errors in one paper was 3. These errors are analysed in detail.

Conclusion: Poor reference accuracy is a common problem in medical literature, and Emergency Medicine is not immune to these failings. Authors need to take more care to ensure that the accuracy of citations improves.
Nurse‐initiated intravenous morphine in the emergency department: Efficacy, rate of adverse events and impact on time to analgesia
Authors: Fry Margaret , Holdgate Anna
Published: March 2003

Objectives: The objectives of this study were: (i) to measure the analgesic efficacy and frequency of adverse events following autonomous nurse‐initiated intravenous morphine in patients presenting with acute pain, awaiting medical assessment; and (ii) to determine whether such a process would improve the time to analgesia.

Methods: A prospective convenience sample of patients presenting in acute pain received titrated intravenous morphine by experienced emergency nurses. Pain scores on a 10.0 cm visual analogue scale and predetermined adverse events defined by physiological parameters were measured at regular intervals over the following 60 min. Demographic, diagnostic and waiting time data were also recorded.

Results: Three hundred and forty nine patients were enrolled over a 12‐month period. The median initial pain score was 8.5 cm, with a reduction to 4.0 cm at 1 h. Respiratory rate, oxygen saturation, heart rate and blood pressure all showed small but statistically significant reductions over 60 min. There were 15 predefined adverse events, 10 episodes of hypotension and five episodes of oxygen desaturation. No intervention other than supplemental oxygen was required. There were no episodes of bradycardia, bradypnoea or reduced level of consciousness. The median time to narcotic was 18 min and the median time to be seen by a doctor was 52 min.

Conclusion: Experienced emergency nurses can initiate effective intravenous narcotic analgesia for patients in acute pain awaiting medical assessment, with minimal change in physiological parameters. This process can improve the time to analgesia for patients in acute pain.
The Canadian Triage and Acuity Scale: A Canadian perspective on emergency department triage
Authors: J Murray Michael
Published: March 2003

The Canadian Triage and Acuity Scale has received widespread acceptance in Canada as a reliable and valid tool for emergency department triage. The importance of accurate triage becomes more apparent as emergency department volumes increase, and resources shrink. The need to ensure that those patients requiring more urgent care receive care first is the basis for all triage scales. Through the Canadian Triage and Acuity Scale National Working Group, the scale became the recommended triage tool for Canadian emergency departments. Work has been done on the interrater reliability of Canadian Triage and Acuity Scale among health care providers. There is a need to further assess the validity of the scale. This scale has now been applied in the out of hospital setting by paramedics and is being used in measurements of emergency physician workload. The future may see an electronic triage tool develop for emergency department use to reduce variability in its application. The Canadian Triage and Acuity Scale has become an integral component of Canadian emergency departments.
The origins of surgery. 2: From barbers to surgeons*
Authors: Fu Louis Kuo Tai
Published: March 2003

The art, craft and science of surgery is a highly interpersonal skill, central to a variety of traditions and cultures throughout human history. The development of surgery parallels the evolution of the human race from prehistory to the present time. This review attempts to examine the changing concepts and practices in surgery from the earliest era, enshrouded in mysticism and magic, through a manual craft performed by barbers and artisans, to a dignified profession based on science and technology. The evolution of surgery in the previous millennia is reviewed against the culture and morals, the politics and religion, and the philosophy and science of its period; in so doing assessing its perspective on the threshold of a new millennium.
Evaluation of Hyphecan (1‐4,2‐acetamide‐deoxy‐B‐D‐glucan polymer) on wound healing in a rodent model
Authors: Ho Wai‐Sun , Ying Shun‐Yuen , Choi Paul Cheung‐Lung
Published: March 2003

Objective: To evaluate the effect of an artificial skin Hyphecan (1‐4,2‐acetamide‐deoxy‐B‐D‐glucan polymer) on wound healing in a rodent model.

Materials and Method: The prospective study was conducted at a basic science laboratory at a tertiary teaching hospital. Two 4 cm × 4 cm full‐thickness wounds were created on the dorsal surface of 10 Spraque–Dawley rats and covered with Hyphecan and Kaltostat, respectively. Wounds were examined and measured on days 4, 10, 21 and 28, and would continue after day 28 until healed up completely. Punch biopsies (3 mm) were taken on days 4, 10 and 28 for histological examination of the response of healing and repair.

Results: Despite the fact that the wound healing rate was similar for both groups on days 4, 10, 21 and 28, the average healing time for the Hyphecan group (29.1 ± 1.7 days) was significantly shorter statistically (P = 0.03) than the Kaltostat group (30.7 ± 2.8 days). Conversely, the marked healing response elicited by Hyphecan on day 4 persisted on days 10 and 28 in contrast to Kaltostat, which had only a mild degree of healing response on days 10 and 28. The study suggests that wounds treated by Hyphecan heal faster than Kaltostat.

Conclusion: The findings provide basic scientific evidence supporting the clinical use of Hyphecan in different wounds and might also reduce the cost of wound management as Hyphecan is cheaper than Kaltostat and requires a shorter treatment time.
Fire management in Tasmania’s Wilderness World Heritage Area: Ecosystem restoration using Indigenous‐style fire regimes?
Authors: Marsden‐Smedley Jon B. , Kirkpatrick Jamie B.
Published: March 2003

Summary In many natural areas, changes in fire regimes since European settlement have resulted in adverse impacts on elements of biological diversity that survived millennia of land management by Indigenous people. Some of the rainforest and alpine elements that depend on south‐west Tasmania’s World Heritage Area have been in decline since European settlement of Tasmania due to an increase in the incidence of landscape‐scale fires in the period 1850–1940. Some of the buttongrass moorland elements that also depend on the region are in decline or impending decline because of a decreased incidence and/or size of burns since 1940. Will an Indigenous‐style fire regime serve the interests of biological diversity? We examine this question in the context of the fire ecology and fire history of south‐west Tasmania. From this assessment we argue that a return to Indigenous‐ style burning, modified to address contemporary issues such as the prevention of unplanned ignition, suppression of wildfires and burning to favour rare and threatened species may help to reverse trends towards ecosystem degradation in this region.
Red Imported Fire Ants: A threat to eastern Australia's wildlife?
Authors: Moloney Shane , Vanderwoude Cas
Published: March 2003

The discovery of the Red Imported Fire ants (Solenopsis invicta) in Brisbane on 22 February 2001 sent shock waves through urban and rural communities alike. This article is an attempt to address the often repeated question ‘What will become of Australia's unique fauna if they spread along Australia's eastern seaboard?
Long‐term real‐time monitoring of adeno‐associated virus‐mediated gene expression in the rat retina
Authors: Rolling Fabienne , Shen Wei‐Yong , Barnett Nigel L , Tabarias Hyacinth , Kanagasingam Yogesan , Constable Ian , Rakoczy Piroska E
Published: March 2003

Purpose: Previous studies have demonstrated that adeno‐associated virus (AAV) efficiently transduced retinal pigmented epithelial (RPE) cells. The goal of this study was to further evaluate and characterize transgene expression within the RPE cells over time in vivo.

Methods: Adeno‐associated virus‐mediated gene transfer was monitored and quantified by retinal photography following subretinal injection of a recombinant AAV encoding the green fluorescent protein gene (rAAVCMV‐gfp) into rat eyes. Retinal function of transduced rat eyes was measured by electroretinography.

Results: The maximum level of transgene expression was reached at 8 weeks postinjection followed by a gradual decrease throughout the experimental period. Interestingly, it was observed that while gfp expression was stable in some RPE cells, gfp fluorescence completely disappeared in other cells over the duration of the experiment. The expression of AAV‐mediated gfp in RPE cells did not alter the retinal function for over 1 year.

Conclusions: These results confirm the importance of this direct visualization system to study vector transgene expression in vivo and support the use of AAV for diseases treatable by targeting RPE cells.

Key words: adeno‐associated virus, gene transfer, green fluorescent protein, retinal photography, retinal pigmented epithelium.
Penetrating keratoplasty for silicone oil keratopathy
Authors: Lee Graham A , Shah Peter , Cooling Robert J , Dart John KG , Bunce Catey
Published: March 2003

Purpose: Penetrating keratoplasty for silicone oil keratopathy is associated with high risks and limited visual prognosis. This study examined the outcomes and factors influencing graft failure.

Methods: A retrospective, non‐comparative, interventional case series of patients attending Moorfields Eye Hospital, London.

Results: A total of 24 penetrating keratoplasties were performed in 17 patients (13 men and four women) from 1991 to 2000. The mean age of patients undergoing surgery was 43.6 years (range 17–84 years, SD ± 21.0). Silicone oil was removed before or during the time of initial penetrating keratoplasty in nine patients (52.9%) and left in situ in eight patients (47.1%). Ten out of 24 grafts survived (41.7%). The median duration of graft survival was 21 months (range 2 weeks–98 months) with median duration of follow up 33 months (range 2–100 months). At final follow up, the number of patients with a clear graft who had oil removed before or during the time of penetrating keratoplasty was seven out of 10 (70.0%). Risk factors for graft failure included hypotony, multiple keratoplasty, corneal neovascularization, rejection episode, silicone oil left in situ and postoperative glaucoma.

Conclusions: Management of these complex patients requires a combined approach from anterior segment and vitreoretinal subspecialties. The long‐term success of the graft can be improved if silicone oil is removed prior or during the time of penetrating keratoplasty.
Relationship between the concentration of copper and iron in the aqueous humour and intraocular pressure in rabbits treated with topical steroids
Authors: Lqbal Zafar , Muhammad Zia , Shah M Tahir , Bashir Shumaila , Khan Taous , Khan Muhammed Daud
Published: March 2003

Purpose: To evaluate the concentration of copper and iron in the aqueous humour of steroid‐treated eyes, particularly to study the concentration of these metals in relation to steroid‐induced increases in intraocular pressure (IOP).

Methods: Adult rabbits of both sexes were selected in order to study the effect of steroids on the concentrations of copper and iron in the aqueous humour and on IOP. The rabbits were acclimatised for 2 weeks prior to the instillation of various drugs into the eyes. Then a steroid (dexamethasone, betamethasone or fluoromethalone) was instilled in both eyes of the rabbits, for about 1 month. Intraocular pressure was measured twice a week. When IOP was significantly increased, the animals were killed. The aqueous humour was collected and analysed for copper and iron using atomic absorption spectrophotometry coupled with graphite furnace.

Results: After about 30 days of steroid
treatment the mean (± SD) IOP in dexamethasone,
betamethasone and fluoromethalone treated groups was 17.5 (± 4.81)
mmHg, 18.48 (± 4.5) mmHg and 21.8 (± 5.7)
mmHg, respectively. These values were significantly higher compared
to the control group where the mean IOP was 11.6 (± 2.2) mmHg.
The concentration of copper in the aqueous humour of steroid‐treated
rabbits was significantly lower (P < 0.001) compared to the control group. However, the concentration of iron was not significantly different between the control and steroid treated rabbits.

Conclusion: A greater increase in IOP was observed in the fluoromethalone‐treated group compared to the dexa­methasone and betamethasone‐treated groups, but the difference was not significant. The lower concentrations of copper in aqueous humour in steroid‐treated eyes may play an important role in the maintenance of IOP. The concentration of iron was not significantly different compared to the control group. These results may help to explain the role of these metals in the pathogenesis of open angle glaucoma.
WHICH MODALITY CAN BE STANDARDERIZED for ENDOSCOPIC SPHINCTEROTOMY in JAPAN?
Authors: Igarashi Yoshinori , Ukita Takeo , Inoue Hirokazu , Maetani Iruru , Sakai Yoshihiro
Published: March 2003

The wire‐guided type has been a papillotome of first choice since 1991 when it was developed. This type of papillotome has an advantage in that if an endoscopic retrograde cholangiopancreatography (ERCP) cannula can be passed into the bile duct, then the papillotome can be inserted without fail over the guide‐wire. Furthermore, if an insulated guide‐wire is used, an electric current can be passed through the retained guide‐wire during endoscopic sphincterotomy (ES). Clever Cut (Olympus Optical Co.) has been designed so that half the length of the cutting‐wire is coated with insulation, so an incision can be made without the cutting‐wire penetrating too deep into the bile duct by using the coated portion as a guide. Three‐lumen Clever Cut3 (Flow Cut; Olympus Optical Co. ) has an incorporated stabilizer so that the cutting‐wire is forcibly made to change its course in the direction of 11–12 o’clock. The endoscopic high‐frequency surgical apparatus (ICC200, Erbe Co., Germany) has an Endocut system that performs an incision and coagulation in automatic mode; the ICC200 controls the cutting speed automatically. Because the endoscopist can adjust the length of the incision, the ES can be performed safely without adjusting the depth of pedal depression. As a conclusion, the modality employing Clever Cut3 and a high‐frequency surgical apparatus equipped with an insulated guide‐wire and the Endocut system may be considered standard ES in Japan.
EVALUATION OF THE COLOR‐EMPHASIS SYSTEM AS AN ENDOSCOPIC DIAGNOSTIC METHOD: IS THE ADOPTED TYPE HEMOGLOBIN INDEX COLOR EMPHASIS USEFUL FOR THE DIAGNOSIS OF SUPERFICIAL TYPE COLON TUMORS?
Authors: Tamura Satoru , Ookawauchi Kohji , Tadokoro Takehisa , Higashidani Yoshifumi , Yokoyama Yuichi , Onishi Saburo
Published: March 2003

The difficulty in an endoscopic diagnosis of colorectal tumors depends mainly on their gross configuration. As the superficial flat type and depressed type tumors are usually detected endoscopically by a faint redness on their surface, we evaluated the usefulness of an adopted type hemoglobin index color emphasis system in the lesion of a non‐granular (NG) type laterally spreading tumor (LST). The NG‐type LST was composed of only a flat surface without any nodules. The frequency of Tis was 20.2% and that of T1/T2 was 15.7% in the lesion of the NG‐type LST. Results showed that the adopted type hemoglobin index color emphasis system can emphasize the color level, as the redness and whiteness intensified in this system. The degree of redness and whiteness depended on the emphasis level, and the clarity of colors became clearer in level 5 than level 3 in a lesion of the NG‐type LST. This system may thus contribute to the endoscopic diagnosis of flat and depressed type colorectal lesions.
A case of gastric cancer with high pepsinogen II levels in both serum and ascites
Authors: Muto Manabu , Saito Yasutoshi , Koike Tomoyuki , Miki Kazumasa
Published: March 2003

The first case of gastric cancer in which pepsinogen (PG) II levels were found to be extremely high not only in the serum but also in the ascites, with values of 603 ng/mL and 1910 ng/mL, respectively, is reported. Pepsinogen I and PG II are normally secreted into the gastric lumen and only 1% of the amount secreted enters the circulation. Although gastric cancer cells are found to produce PG II more often than PG I, elevated PG values in serum are extremely rare, and only one case has ever been reported. That patient had extremely high serum levels of PG I and PG II at the time of gastric cancer relapse. Pepsinogen has never been reported in the ascites, and thus nothing is known about the mechanism of entry into the ascites. In this case report, we postulate two mechanisms to explain the increased PG II in the ascites: (i) a high level of serum PG II infiltrated the ascites and caused elevation of PG II in the ascites; or (ii) disseminated cancer cells directly produced PG II and it elevated PG II levels in the ascites.
Vanishing Tumor of the Stomach: Sequential Endoscopic and Endosonographic Features
Authors: Sabet Eman A , Motoo Yoshiharu , Okai Takashi , Yamaguchi Yasushi , Watanabe Hiroyuki , Nagao Shin , Sawabu Norio
Published: March 2003

A 50‐year‐old man developed epigastralgia 1 day later, after eating a raw squid meal. A submucosal tumor‐like lesion at the gastric fornix was demonstrated on gastroscopic examination. Manifestations of acute gastritis were also seen. In 5 days (the period between the first and second examinations), the tumor disappeared and a large ulcer was seen endoscopically at the same site. Biopsy specimens revealed eosinophilic infiltration at the site of the lesion. Mild leucocytosis, significant eosinophilia and high serum anti‐Anisakis antibodies were also revealed. The patient was closely followed up by endoscopy, endosonography, barium studies and laboratory investigations until the ulcer was completely healed. The lesion was probably caused by gastric anisakiasis and could be categorized as a so‐called ‘vanishing tumor of the stomach’.
TRENDS IN THE CAUSES AND OUTCOME OF LIVER CIRRHOSIS DIAGNOSED BY LAPAROSCOPY IN OSAKA, JAPAN DURING THE PAST THREE DECADES
Authors: Habu Daiki , Shiomi Susumu , Lee Chulyoo , Kadoya Hirokazu , Morikawa Hiroyasu , Enomoto Masaru , Tamori Akihiro , Sakaguchi Hiroki , Seki Shuichi , Kuroki Tetsuo
Published: March 2003

Background: Although various factors are assumed to have substantially altered the demographic characteristics of liver cirrhosis, few studies of patients with endoscopically confirmed cirrhosis have been done in Japan. We analyzed trends in causes and outcome of liver cirrhosis in Osaka, Japan during the past three decades.

Method: The study group comprised 466 patients with cirrhosis of the liver who underwent laparoscopy at any time between 1969 and 1998. To analyze trends in the causes and outcome of cirrhosis, the study period was divided into three 10‐year intervals, variables included hepatitis B surface antigen (HBsAg), hepatitis C virus (HCV) antibody, alcohol intake, causes of death and outcome.

Results: Hepatitis C virus has remained the major cause of liver cirrhosis during the past 30 years. Hepatitis B virus has remained the cause of liver cirrhosis in about 20–25% in all three decades. Alcohol played a part in the development of liver cirrhosis in more than 30% of the study group, alone or with hepatitis viruses. Therefore, alcohol remains an important factor in the pathogenesis of cirrhosis. The outcome of cirrhosis has improved gradually during the past decade owing to more effective means of treatment for complications of cirrhosis.

Conclusion: Hepatitis C virus has remained the major cause of liver cirrhosis for the past three decades. Improvement of outcome in patients with cirrhosis caused by HCV infection should be an important task in the next decade.
GASTRIC SUBMUCOSAL HETEROTOPIA OF THE IMMATURE GASTRIC GLANDS WITH ENDOSCOPIC FEATURE MIMICKING CARCINOID TUMOR
Authors: Mizuta Yohei , Yamakawa Masaki , Isomoto Hajime , Takeshima Fuminao , Murase Kunihiko , Abe Kuniko , Kawai Kioko , Murata Ikuo , Kohno Shigeru
Published: March 2003

We describe a rare case of gastric submucosal heterotopia of the immature gastric glands mimicking carcinoid tumor shown by endoscopic examination, which was successfully treated by endoscopic tumor resection. A 66‐year‐old woman was admitted to our hospital for further examination of the gastric abnormality. Endoscopic examination of the upper gastrointestinal tract revealed a flat, rounded elevated lesion with a central erosion in the anterior wall of the upper gastric body. Endoscopic ultrasonography revealed a poorly demarcated, slightly hypoechoic lesion located in the third layer of the gastric wall. Based on these findings, a submucosal tumor, particularly a carcinoid tumor, was suspected. Endoscopic tumor resection, which provides a significant benefit for accurate final diagnosis and eradication of submucosal lesion, was performed. Histological study showed the gastric gland heterotopia of immature type in the submucosa.
PANCREATIC PLEURAL EFFUSION SUCCESSFULLY TREATED BY ENDOSCOPIC PANCREATIC DUCT DRAINAGE COMBINED WITH EXTRACORPOREAL SHOCK‐WAVE LITHOTRIPSY: REPORT OF A CASE
Authors: Kin Hideyuki , Kiriya Kei‐ichi , Mori Shigeo , Suzuki Naoyuki , Mukai Shin‐ichi , Yamaguchi Kyoichi , Mochizuki Tsutomu , Asano Takeshi , Kojima Hiroyoshi , Ito Kazuki , Kojima Koichi , Kubota Yoshitsugu , Inoue Kyoichi
Published: March 2003

A 52‐year‐old man was admitted with complaints of dyspnea. Physical examination revealed that the breath sounds were reduced at the left lung. The results of the abdominal examination were normal. Chest radiography showed massive left‐sided pleural effusion. His white blood cell count was 4600/mm3, serum amylase 666 IU/L, serum C‐reactive protein (CRP) 3.7 mg/dL. Thoracentesis yielded bloody fluid with a protein level of 3.7 g/dL and amylase level of 6250 IU/L. Computed tomography showed dilatation of the pancreatic duct with calcifications of the pancreas, mediastinal pancreatic pseudocysts and bilateral pleural effusion. Magnetic resonance cholangiopancreatography demonstrated dilated pancreatic duct with pancreatic calculi and pancreaticopleural fistula. Initial endoscopic retrograde cholangiopancreatography showed obstructing pancreatic calculi of the main pancreatic duct at the head; however, insertion of a naso‐pancreatic drain was unsuccessful. A naso‐pancreatic drain could be placed beyond the site of obstruction following three extracorporeal shock‐wave lithotripsy (ESWL) sessions. Pleural effusion was resolved and the chest tube was removed 5 days following placement of the drain. The naso‐pancreatic drain was replaced with a pancreatic stent 20 days later. Endoscopic retrograde cholangiopancreatography after a total of nine ESWL sessions showed a significant reduction of pancreatic calculi at the head. The pancreatic stent was removed 70 days following stent placement and there has been no recurrence during a follow‐up period of 2 years. We suggest that endoscopic treatment combined with ESWL is a first‐line treatment for pancreatic pleural effusion resulting from obstructing pancreatic calculi, and operation should be reserved as a second‐line treatment.
Evaluation of new plastic stents for malignant biliary obstruction
Authors: Uno Koji , Yasuda Kenjiro , Tanaka Kiyohito , Hayakumo Takanobu , Nakajima Masatsugu
Published: March 2003

Background: A new plastic stent was designed for endoscopic biliary stenting to achieve a long and effective drainage period.

Method: The Double layer stent is composed of Teflon as the inner layer and nylon as the outer layer divided with metallic mesh. This structure gives the stent several side‐flaps without side‐holes. Double layer stents were applied in 24 patients with inoperable malignant biliary obstruction.

Results: The Double layer stents were successfully placed in all cases, and the effective drainage rate of these stents was 96%. The mean patency period evaluated by the Kaplan–Meier method without ineffective cases was 207 days, which was longer than the ordinary plastic stent of the same diameter. Concerning the complications related to inserting, we experienced dislocation was experienced in three patients.

Conclusions: The authors regard this new device as an useful stent, which users can expect long patency period, easy exchange management, and reduced cost for the patients with inoperable obstruction in the biliary tract.
Economic analysis of recombinant interferon α 2b in the treatment of chronic hepatitis B and C
Authors: Guangbi Yao , Baoen Wang
Published: March 2003

OBJECTIVE: To evaluate the long‐term economic impact and benefits of interferon α 2b (IFNα 2b) treatment in patients with chronic hepatitis B and C.

METHODS: Data from 6500 patients with chronic hepatitis B and C from 12 teaching hospitals in different areas of China were collected and analyzed. Cohorts of these patients with either chronic hepatitis B (2198 cases) or chronic hepatitis C (756 cases) that were treated with IFNα 2b were compared with a non‐IFN‐ treated cohort (B, 2642 cases; C, 904 cases). Data from MEDLINE and Chinese Bio‐Medical Database (CBMD) searches regarding the natural course of the disease, progression, efficacy and cost of IFN therapy were also included. Using a decision analysis software program, Markov computer simulation was used to estimate the progression of the disease and perform economic analyses.

RESULTS: The 30‐year disease progression to compensated and uncompensated cirrhosis and hepatocellular carcinoma in both chronic hepatitis B and C in the IFN‐treated cohort was significantly decreased in comparison with the non‐IFN‐treated cohort. The results suggest that IFN treatment could increase life expectancy by 5.32 years in chronic hepatitis B and 4.06 years in chronic hepatitis C. In the IFN‐treated group, life expectancy would increase by 5.41 and 4.27 quality‐adjusted life‐years (QALY), respectively. The cost to increase life expectancy by 1 QALY could be reduced by 5180 or 9066 yuan RMB in chronic hepatitis B or C patients treated with IFNα 2b, respectively. Over a 30‐year period, the total direct medical costs would be reduced by 42 820 and 65 440 yuan RMB in chronic hepatitis B and C patients treated with IFNα 2b, respectively.

CONCLUSION: Interferon α 2b therapy can prolong life expectancy, improve quality of life and lower the medical costs for patients with chronic hepatitis B and C.
Effect of epidermal growth factor on pathological changes of the gastric mucosa in rats with chronic atrophic gastritis
Authors: Wu Jiaguo , Si Jianmin , Cao Qian , Lu Wen , Wang Jian , Lu Bingjian , Dai Ning
Published: March 2003

OBJECTIVE: To study the effect of epidermal growth factor (EGF) on pathological changes of the gastric mucosa in rats with chronic atrophic gastritis (CAG).

METHODS: The established CAG rat models were divided into groups A and B. The rats in group A received 10 μg/kg EGF subcutaneously. In group B, rats were subcutaneously injected with the same quantity of normal saline. Twelve weeks later, all rats were killed by cervical dislocation and their gastric mucosa were examined microscopically.

RESULTS: The grading of the inflammatory cell infiltration in group A was lower than that in group B (P < 0.01). The thickness of the gastric mucosal gland layer was 215.0 ± 20.7 μm in group A and 139.2 ± 13.8 μm in group B (P < 0.01). The ratio of the thickness of the gastric mucosal glands to that of the muscularis mucosa (L1/L2) was 2.70 ± 0.34 in group A and 1.27 ± 0.27 in group B (P < 0.01). The number of gastric glands in a 1‐mm length of mucosal layer was 26.20 ± 1.27 in group A and 19.90 ± 1.78 in group B (P < 0.01). In group A, the gastric glands were rearranged, without signs of malignant proliferation. The width of gastric mucosa expressing proliferating cell nuclear antigen (PCNA) was larger in group A than in group B (77.70 ± 4.16 μm vs 54.40 ± 4.54 μm; P < 0.01).

CONCLUSIONS: Epidermal growth factor plays a therapeutic role in reversing gastric mucosal atrophy in rats with CAG. It promotes the expression of PCNA, which induces a protective proliferation in gastric mucosal lesions in rats with CAG.
Vitality Index as a useful tool to assess elderly with dementia
Authors: Toba Kenji , Nakai Ryuhei , Akishita Masahiro , Iijima Setsu , Nishinaga Masanori , Mizoguchi Tamaki , Yamada Shizuru , Yumita Kiyoshi , Ouchi Yasuyoshi
Published: March 2003

Background: The aim of the present paper was to establish a new objective scale to measure vitality related to activities of daily living in elderly patients with dementia.

Methods: Cross‐sectional and longitudinal observational studies were carried out on patients and residents in long‐term care facilities. Reliability of the scale was examined by determining test–retest reliability, interrater reliability and internal consistency. Validity of the scale was evaluated with respect to criterion validity and predictive validity. Clinical usefulness of the scale was tested by measuring the time taken to perform scoring and evaluating the changes in the score before and after behavioral therapy for functional urinary incontinence.

Results: The test–retest correlation coefficient was 0.98. Mean kappa coefficient
of Vitality Index was 0.63. Interrater coefficient of variation was 0.14. Cronbach
α of the Index was 0.88. Vitality Index was negatively correlated with Geriatric
Depression Scale (GDS) (P < 0.01). A low score was an independent risk
factor for survival. Behavioral therapy for functional urinary incontinence increased
Activities of Daily Living (ADL) (P < 0.05) and Vitality Index (P < 0.05).

Conclusion: Vitality Index could be a new tool to assess patients with dementia.
Roles of oxidized low‐density lipoprotein and its receptors in the pathogenesis of atherosclerotic diseases
Authors: Kume Noriaki , Kita Toru
Published: March 2003

In elderly populations, atherosclerotic diseases, including ischemic heart disease and stroke, frequently impair quality of life and affect mortality. Hypercholesterolemia, especially increased plasma low‐density lipoprotein (LDL), is one of the strongest risk factors for atheroscletorotic diseases. Oxidative modification of LDL appears to convert LDL particles to more atherogenic forms. Scavenger receptor class A (SR‐A) and CD36 have been identified and well‐characerized as receptors for Ox‐LDL in macrophages. In addition to these molecules, lectin‐like oxidized LDL receptor (LOX)‐1 and scavenger receptor for phosphatidylserine and oxidized lipoprotein (SR‐PSOX) are type II and I membrane glycoproteins, respectively, both of which can act as cell‐surface endocytosis receptors for atherogenic oxidized LDL (Ox‐LDL). LOX‐1 expression can dynamically be induced by pro‐inflammatory stimuli, and is detectable in cultured macrophages and activated vascular smooth muscle cells (VSMC), in addition to endothelial cells. LOX‐1‐dependent uptake of Ox‐LDL induces apoptosis of cultured VSMC. In vivo, endothelial cells that cover early atherosclerotic lesions, and intimal macrophages and VSMC in advanced atherosclerotic plaques dominantly express LOX‐1. LOX‐1 expressed on the cell‐surface can be cleaved in part and released as soluble molecules, suggesting the diagnostic value of soluble LOX‐1. SR‐PSOX is a newly identified receptor for Ox‐LDL, which appears to be identical to CXCL16, a novel membrane‐anchored chemokine directed to CXCR6‐positive lymphocytes. In contrast to LOX‐1, which is expressed by a variety of cell types, SR‐PSOX expression appeared relatively confined to macrophages in atherogenesis. Taken together, oxidized LDL receptors, including LOX‐1 and SR‐PSOX, may play important roles in atherogenesis and atherosclerotic plaque rupture.
Improvement of respiratory symptoms following laparoscopic Nissen fundoplication
Authors: Brouwer Richard , Kiroff George K.
Published: March 2003

Background:  Laparoscopic fundoplication has become the standard of care for the management of symptomatic gastro‐­oesophageal reflux disease (GORD). Although atypical and respiratory symptoms are frequently described in standard texts in association with reflux, the response of respiratory symptoms to management of GORD has not been extensively studied.

Methods:  Herein is reported a prospective series of 29 patients who presented with predominantly respiratory symptoms. Typical and respiratory symptoms were graded according to a standard scale. All patients had preoperative investigations confirming GORD. These patients were treated by a laparoscopic Nissen fundoplication and followed up for a minimum of 14 months (range: 14−48 months). Patients were contacted and interviewed by an independent observer.

Results:  Conversion to open surgery was necessary in three patients. There were four significant complications. Ultimately control of typical reflux symptoms was achieved in 88%. Cough was completely relieved in 81% and improved in a further 13%. Wheeze and nocturnal bronchospasm was completely relieved in 50% and improved in the balance. Dysphagia remains a significant problem, with only 42% of patients completely free of trouble.

Conclusions:  Overall the respiratory symptoms were improved in the majority of patients, with cough responding somewhat better than wheeze. Appropriate patient selection remains the greatest challenge when a patient with cough or wheeze that is considered to be due to GORD is referred for surgery.
Management of acute superior mesenteric artery occlusion
Authors: Barakate Michael S. , Cappe Ian , Curtin Austin , Engel Karen D. , Li‐Kim‐Moy Jean , Poon Michael S. F. , Sandeman Matthew D.
Published: March 2003

Background: This review examines the surgical management of acute superior mesenteric artery (SMA) occlusion and the impact of interventional radiology techniques.

Methods: Eight consecutive patients with SMA occlusion were treated at the Lismore Base Hospital, Lismore, NSW, Australia, from 1996 through to 2001 and of these, one patient was managed successfully with catheter‐directed lytic therapy. The study group included five male and three female patients with a mean age of 71.3 (range 57–88) years. The records of these patients were reviewed to determine demographic characteristics, clinical features, predisposing factors and the duration of symptoms before intervention, management details and final outcome.

Results: Embolic phenomena due to atrial fibrillation were the most frequently identifiable cause of acute SMA occlusion, present in six of eight patients. Seven patients were managed with open surgery in the first instance and of these, four died. Three patients remain alive and well at a mean 2.8 years follow‐up. Patient number eight developed acute SMA occlusion from embolism secondary to atrial fibrillation and was managed initially with SMA urokinase thrombolysis. This patient’s pain was relieved 1 h after initiation of the procedure. Delayed films after 18 h from initiation of thrombolysis demonstrated re‐opening of all the ileo‐colic branches and at 6 weeks’ follow‐up the patient remains well with normal bowel function.

Conclusions: There is a role for selective SMA cannulation and urokinase thrombolysis in the management of patients with acute SMA thrombosis.
Recurrent torsion after previous testicular fixation
Authors: Sells Henry , Moretti Kim L. , Burfield Geoffrey D.
Published: March 2003

Background: Occasionally patients present with acute testicular pain having undergone a previous testicular fixation for torsion. The aim of this article is to review the literature and determine whether recurrent torsion of the testis is possible and whether the technique used at initial fixation is relevant.

Methods: A literature search was performed using MEDLINE, Pre‐MEDLINE, EMBASE and CIANHL databases using the terms ‘spermatic cord torsion’ and ‘testicular torsion’ in combination with ‘treatment failure’, ‘re‐operation’ or ‘recurrence’.

Results: Twenty cases of recurrent testicular torsion after fixation are described. Fifteen of the 17 that specified the type of suture used at initial fixation had used absorbable suture. Animal models suggest that to produce dense adhesions at testicular fixation, the tunica vaginalis must be everted behind the testis with or without fixation, before the testis is returned to the scrotum. Without this eversion, the adhesions around the testis are fine and only located at the site of fixation suture. The use of non‐absorbable suture led to abscess formation in 30% of testes in animal models.

Conclusions: The higher incidence of recurrent torsion after fixation using absorbable rather than non‐absorbable sutures in the literature may be caused by a greater number of fixations being carried out using absorbable suture. Use of non‐absorbable suture is limited by the high rate of abscess formation. The most important factor for adhesion formation would appear to be the eversion of the tunica vaginalis and it is recommended that this is carried out at all testicular fixations.
Colonoscopy training: The need for patience (patients)
Authors: Church James , Oakley John , Milsom Jeff , Strong Scott , Hull Tracy
Published: March 2003

Background: The insertion of a colonoscope to the caecum is a difficult technique to teach and to learn. The most commonly used criterion for proficiency is completion rate and early experience is often discouraging. In order to document the learning curve and better define normal progress for the early learning experience, the performance of trainees during their first 100–125 cases was recorded.

Methods: The completion rate and time for office colonoscopy were recorded prospectively over a 5‐year period for each of 18 trainees. Trainees’ experience was analysed in groups of 25 cases, numbered chronologically. Completion rate was defined as the number of examinations completed to the caecum by the trainee expressed as a percentage of the number completed by the staff.

Results: The mean overall completion rate for trainees was 56.4% (range 27.8–83.9%). For the first five groups of 25 cases, the percentage completion rates (in order from first 25 cases to fifth 25 cases) were 43.1, 52.6, 49.3, 61.8 and 75.1%, respectively. There was a wide variation in completion rates between trainees, but no difference in time taken. (Time for trainees to complete the procedure, in order from the first 25 cases to fifth 25 cases: 18.7, 19.1, 19.4, 17.6 and 17.1 min, respectively.)

Conclusions: Early experience in colonoscopy can be discouraging. At least 100 cases are needed to attain a level of proficiency that enables completion in two‐thirds of cases, whereas 125 cases lead to an average completion rate of 75%.
Selective use of preoperative endoscopic retrograde cholangiopancreatography in the era of laparoscopic cholecystectomy
Authors: Nataly Yogesh , Merrie Arend E. , Stewart Ian D.
Published: March 2003

Background: The use of endoscopic retrograde cholangiopancreatography (ERCP) in the management of suspected common bile duct (CBD) stones prior to laparoscopic cholecystectomy is common. The associated morbidity can be significant. The present study determines significant predictors of CBD stones and improves the selection of patients for preoperative ERCP.

Methods: All preoperative ERCP for suspected CBD stones in the year 1998 were studied retrospectively. Univariate and multivariate analyses of a number of clinical, biochemical and radiological variables were carried out to determine the best predictors of CBD stones.

Results: A total of 112 patients had successful preoperative ERCP. Sixty‐one
per cent of these were negative for stones and the morbidity was 9%. Univariate
analysis revealed the following variables as predictors: cholangitis (P =
0.006), abnormal serum bilirubin ≥ 3 days (P = 0.002), serum alkaline phosphatase
≥ 130 U/L (P = 0.002), deranged liver function tests (P = < 0.001)
and CBD diameter ≥ 8 mm (P = 0.009) with positive predictive values of
80%, 68%, 49%, 38% and 52%, respectively.
Multivariate analysis revealed the model with the best ability to discriminate for
CBD stones (P = 0.0005) was cholangitis, abnormal serum bilirubin for ≥ 3 days and CBD diameter ≥ 8 mm. The best predictors from this study had a sensitivity of 80% and a specificity of 27%.

Conclusions: The predictors of CBD stones are imprecise. Until laparoscopic exploration of CBD becomes widely available, ERCP prior to cholecystectomy will remain popular. The use of stricter selection criteria can reduce the number of negative preoperative ERCP.
Combination of a new composite biocampatible skin graft on the neodermis of artificial skin in an animal model
Authors: Lam Ping K. , Chan Eric S. Y. , Liew Choong T. , Lau Chi H. , Yen S. C. , King Walter W. K.
Published: March 2003

Introduction: There have been very limited and inconsistent attempts at combining the cultured epidermal autograft (CEA) with the neodermis of artificial skin (Integra). The reasons for this remain unknown. The basement membrane proteins of conventional CEA sheets are easily damaged by the dispase treatment during the harvesting of the CEA from the culture flask. The damage of the basement membrane proteins may affect the anchorage of CEA onto the neodermis of Integra. A new Composite Biocompatible Skin Graft (CBSG) was recently developed.

Methods: Composite biocompatible skin graft consists of autologous keratinocytes cultivated on a pliable hyaluronate‐derived membrane (Laserskin) which has been pre‐seeded with allogenic dermal fibroblasts. Basement membrane proteins of CBSG are protected from the dispase treatment because the keratinocytes are directly seeded onto Laserskin. The engraftment of CBSG was evaluated on 20 wounds of 10 rats. Integra was grafted on two freshly excised full‐thickness wounds (3 cm in diameter) in the dorsum of each animal. A polypropylene ring was applied to each wound to prevent the migration of epithelium from the edges. Composite Biocompatible Skin Graft was used to cover the neodermis of Integra after the silicone membrane was removed 14−21 days postgrafting.

Results: Fourteen (70%) of 20 skin biopsies taken at day 21 from the centre of the grafted wounds revealed regenerated epithelium.

Conclusion: A feasible delivery system of cultured keratinocytes onto the neodermis of Integra is demonstrated in this animal ­experiment.