bluuebunny/crossref_metadata_2025 huggingface dataset:
Glycaemic and nonglycaemic effects of pioglitazone in triple oral therapy of patients with type 2 diabetes
Authors: DORKHAN M. , MAGNUSSON M. , FRID A. , GRUBB A. , GROOP L. , JOVINGE S.
Published: June 2006

Objectives.  To examine pioglitazone as add‐on to metformin and insulin secretagogues in patients with type 2 diabetes and inadequate glycaemic control and its effect on glycaemic control, surrogate measures of insulin sensitivity (adiponectin) and β‐cell function (proinsulin/insulin) and fluid retention.

Design and setting.  Prospective open‐label study of 54 patients with type 2 diabetes and HbA1c≥6.5% admitted to outpatient unit at Malmö University Hospital. The patients received 30–45 mg pioglitazone daily during 26 weeks in addition to their existing antidiabetic medication. After 26 weeks, one‐third of patients were followed for 3 months without pioglitazone.

Results.  HbA1c decreased (7.8 ± 0.9–6.3 ± 0.9%, P < 0.001) with 61% of patients achieving levels <6.5%. However, in the group followed for another 3 months HbA1c increased (6.1 ± 0.73–7.1 ± 0.9, n = 18, P < 0.001) after pioglitazone withdrawal. Adiponectin increased (6.1 ± 2.8–13.2 ±5.8 μg mL−1, P < 0.001) and the proinsulin to insulin ratio decreased (0.89 ± 0.66–0.66 ± 0.53, P < 0.001). Nt‐proBNP increased from 487.3 ± 252.2 to 657.8 ± 392.1 pmol L−1 (P < 0.001).

Conclusions.  Pioglitazone is effective in achieving glycaemic targets and reducing risk factors involved in atherosclerosis and improving β‐cell function when used as part of triple oral therapy in patients with type 2 diabetes and secondary drug failure. Nt‐proBNP increase with concomitant decrease in haemoglobin suggests a subclinical sign of fluid retention.
Clinical and angiographic follow‐up after coronary drug‐eluting and bare metal stent implantation. Do drug‐eluting stents hold the promise?
Authors: JENSEN J. , LAGERQVIST B. , AASA M. , SÄREV T. , NILSSON T. , TORNVALL P.
Published: June 2006

Objectives.  To investigate the influence of drug‐eluting stent (DES) implantation on clinical and angiographic restenosis.

Design.  Registry study of data from the Swedish Coronary Angiography and Angioplasty Registry with a coronary angiographic substudy.

Setting.  Multi‐centre study.

Subjects.  During October 2002 to May 2004 a total of 23 590 percutaneous coronary intervention (PCI) procedures were performed at 25 hospitals. After selection, to achieve comparable groups, a total of 5068 patients of whom 4111 had a bare metal stent (BMS) implanted and 957 had a DES implanted, remained. End‐point in the registry follow‐up was >50% diameter restenosis at clinically driven reangiography within 12 months after index PCI. The primary end‐point in the angiographic substudy was late loss in patients’ DES at 6‐month angiographic follow‐up.

Results.  The rate of clinically driven restenosis, within 12 months, in patients receiving DES was less (3.9%) compared with those who received BMS (7.0%). In multivariate analysis the risk of clinical restenosis was one‐third for DES compared with BMS (HR 0.36, 95% CI 0.25–0.52). In the angiographic substudy late loss was 0.07 ± 0.53 mm (range −0.88 to 1.62). The amount of late loss was related to the presence of diabetes mellitus or not (0.19 ± 0.45 mm vs. −0.12 ± 0.58 mm), and lack of postdilatation of the stent or not (0.23 ± 0.51 mm vs. −0.09 ± 0.50 mm).

Conclusions.  The use of DES in the Swedish ‘real world’ is effective in reducing the clinically driven restenosis rate, when compared with patients with BMS treatment. In the angiographic follow‐up the average late loss was as low as observed in recent randomized multi‐centre trials.
Population‐attributable risk of coronary heart disease risk factors during long‐term follow‐up: the Malmö Preventive Project
Authors: NILSSON P. M. , NILSSON J.‐Å , BERGLUND G.
Published: June 2006

Aims.  To calculate the population‐attributable risk (PAR) of coronary events (CE) from 10 risk factors, during long‐term follow‐up.

Methods.  We used both case–cohort and case–control analyses for calculation of PAR in relation to 10 baseline risk factors. First CE (fatal or nonfatal, n = 3072) in 22 444 males and 10 902 females was recorded during a mean follow‐up of 20 years by use of national registers.

Results.  Using a Cox regression analysis in a case–cohort design, smoking (prevalence in men 49%, women 37%) was the strongest risk factor, RR 2.29 (95% CI 2.09–2.52; PAR 39%), followed by hypercholesterolaemia, RR 1.70 (95% CI 1.56–1.86; PAR 18%), and diabetes, RR 1.67 (95% CI 1.41–1.99; PAR 3%). For women the strongest risk factors were smoking, RR 3.16 (95% CI 2.50–3.98; PAR 44%), diabetes, RR 2.59 (95% CI 1.78–3.76; PAR 6%), and hypertension, RR 2.47 (95% CI 1.94–3.14; PAR 23%). In men, smoking was the strongest predictor both after 10 years [RR 2.69 (95% CI 2.23–3.24)] and 20 years [RR 2.45 (95% CI 2.15–2.79)], followed by hypercholesterolaemia (RR 2.16–1.63), hypertension (RR 2.04–1.51), and diabetes (RR 1.85 –1.47). The case–control design gave very similar results. Total PAR varied from 74% (fully adjusted Cox regression, case–control, in men) to 116% in women (case–cohort).

Conclusion.  Smoking is the most important long‐term risk factor for CE in both genders, based on data from a population with a high proportion of smokers. Ten measured variables explained almost all variation in risk and could be used as a basis for intervention programmes.
Spinal tuberculosis: overlooked?
Authors: ABOU‐RAYA S. , ABOU‐RAYA A.
Published: June 2006

Objective.  The aim of the present study was to ascertain the degree of occurrence of tuberculous infection in patients presenting with low back pain (LBP).

Methods.  Forty consecutive patients seeking primary medical attention for the main symptom of LBP and presenting to the Rheumatology Outpatient Clinic of our institution from January 2004 to June 2005, were recruited in this cohort study. All patients were thoroughly interrogated (occupational, trauma, infection, diabetes mellitus and medication history), subjected to a rigorous clinical examination and a battery of investigations

Results.  Twelve of the 40 patients (33%) proved to have spinal TB as the cause of backache. Eight of these patients were above the age of 65. Five of the 12 patients with spinal TB also had concomitant osteoarthritic changes of the spine and two patients had concomitant disc prolapse. Eleven of the 12 patients with spinal TB had a completely normal chest X‐ray and in 10 of these patients the plain X‐ray of the lumbosacral region failed to show any significant lesion. In all 12 patients, sputum analysis failed to reveal acid‐fast bacilli.

Conclusions.  The findings of this study indicate that TB is a common cause of LBP that is liable to be overlooked in the differential diagnosis of LBP. Furthermore, evidence of concurrent active intrathoracic TB may be lacking and consequently a high level of suspicion is required. The need for prompt diagnosis and treatment of skeletal TB is of utmost importance to prevent serious bone and joint destruction and severe neurological sequelae. A reliable imaging modality for diagnosing spinal TB seems to be magnetic resonance imaging.
Intravenous immunoglobulin‐associated cranial pachymeningitis
Authors: MARIE I. , HERVÉ F. , LAHAXE L. , ROBADAY S. , GERARDIN E. , LEVESQUE H.
Published: June 2006

To date, intravenous immunoglobulin (IvIg) has more often been considered as a safe medication. However, with the wider use of IvIg, severe side effects have also been reported to occur in IvIg‐treated patients, notably aseptic meningitis. Other neurological complications have more rarely been described in patients receiving IvIg therapy, e.g. stroke or acute encephalopathy. We recently observed a case which is of particular interest, as the patient with steroid‐refractory polyarteritis nodosa developed cranial pachymeningitis related to IvIg therapy. To our knowledge, this is the first reported case of cranial pachymeningitis complicating IvIg therapy. Our findings emphasize the importance of recognizing IvIg‐related neurological complications in IvIg‐treated patients. As cranial pachymeningitis is a fibrosing process, both recognition and management at an early stage are required to prevent definite neurological impairment in patients.
Assessing cognition and psychomotor function under long‐term treatment with controlled release oxycodone in non‐cancer pain patients
Authors: Gaertner J , Radbruch L , Giesecke T , Gerbershagen H , Petzke F , Ostgathe C , Elsner F , Sabatowski R
Published: June 2006

Background:  The therapeutic use of opioids can be associated with altered cognition and impaired psychomotor function. Several studies have demonstrated the impact of opioid therapy on psychomotor performance and cognition, but no data exist about the effect of long‐term treatment with controlled release oxycodone (CRO) on driving ability.

Methods:  Thirty patients suffering from chronic non‐cancer pain who had been treated with stable doses of CRO where included in a prospective trial and compared with 90 healthy volunteers (matched pairs). A computerized test battery that was developed to assess the driving ability of traffic delinquents in Germany was employed. Attention reaction, visual orientation, motor coordination and vigilance were evaluated. The data from a total of 11 parameters were assessed and for each test a relevant score was defined. As the primary endpoint the sum score of the three relevant scores was determined. A weaker statistical means to assess the patients’ performance is to compare the test results with an age‐independent control group. Individuals performing worse than the 16th percentile of this control group are considered to be unable to drive according to German legislation.

Results:  Significant non‐inferiority could not be demonstrated for the primary endpoint. However, driving ability as defined as a result above the 16th percentile did not differ significantly between the patients receiving CRO and the age‐independent control group.

Conclusion:  The use of CRO does not prohibit driving, but individual assessment is necessary.
Acupuncture stimulation of ST‐36 (Zusanli) significantly mitigates acute lung injury in lipopolysaccharide‐stimulated rats
Authors: Huang C.‐L , Huang C.‐J , Tsai P.‐S , Yan L.‐P , Xu H.‐Z
Published: June 2006

Background:  We sought to investigate the potential therapeutic effects of acupuncture stimulation of ST‐36 (Zusanli) on endotoxemia‐induced acute lung injury in lipopolysaccharide (LPS)‐stimulated rats.

Methods:  Sixty rats were randomized into six groups (n= 10): (i) lipopolysaccharide (LPS) control group, (ii) normal saline (N/S) control group, (iii) LPS plus ST‐36 group, (iv) N/S plus ST‐36 group, (v) LPS plus sham point (Sham) group, and (vi) N/S plus Sham group. Manual acupuncture stimulation of ST‐36 (designated as ‘ST‐36’) or a ‘non‐acupoint’ (designated as ‘Sham’) was performed in lightly immobilized rats for 30 min. Then, LPS injection was employed to induce sepsis. Rats were killed at 6 h after LPS injection and lung injury, nitric oxide (NO) biosynthesis and inducible NO synthase (iNOS) expression were assayed.

Results:  Significant lung injury, pulmonary iNOS expression and systemic and pulmonary NO biosynthesis were noted in the LPS groups. Rats in the LPS plus Sham group had lung injury, pulmonary iNOS expression, systemic and pulmonary NO biosynthesis similar to those observed in the LPS group. However, the degree of lung injury, pulmonary iNOS expression and pulmonary NO biosynthesis, but not systemic NO biosynthesis, were significantly attenuated in the LPS plus ST‐36 group as compared with those in both the LPS group and the LPS plus Sham group.

Conclusion:  Acupuncture stimulation of ST‐36 may be effective as a prophylaxis measure against sepsis. However, results from this study do not support the use of acupuncture for the treatment of sepsis.
GABAmimetic intravenous anaesthetics inhibit spontaneous Ca2+‐oscillations in cultured hippocampal neurons
Authors: Sinner B. , Friedrich O. , Zink W. , Fink R. H. A. , Graf B. M.
Published: June 2006

Background:  Spontaneous Ca2+‐oscillations are a possible mechanism of Ca2+‐mediated signal transduction in neurons. They develop by a periodical interplay of Ca2+, which enters the neuron from the extracellular medium and triggers Ca2+ release from the endoplasmic reticulum (ER). Ca2+‐oscillations are terminated by reuptake into the ER or plasmalemmal extrusion. Spontaneous Ca2+‐oscillations are glutamate dependent and appear to be responsible for neuronal plasticity and integration of information. Here, we examined the role of the gamma‐aminobutyric acid (GABAA) receptor on spontaneous Ca2+‐oscillations and studied the effects of the anaesthetics midazolam, thiopental and the non‐anesthetic barbituric acid on spontaneous Ca2+‐oscillations.

Methods:  Hippocampal neuronal cell cultures of 19‐day‐old embryonic Wistar rats 17–18 days in culture were loaded with the Ca2+‐sensitive dye Fura‐2AM. Experiments were performed using dual wave‐length excitation fluorescence microscopy and calibration constants were obtained from in situ calibration.

Results:  Spontaneous Ca2+‐oscillations are influenced by the GABAA receptor. The intravenous anaesthetics midazolam and thiopental suppressed the amplitude and frequency reversibly in a dose‐dependent manner with EC50 in clinically relevant concentrations. This effect was mediated via the GABAA receptor as it could be reversed by the GABAA receptor antagonist bicuculline. In contrast, the application of barbituric acid had no effects on the spontaneous Ca2+‐oscillations.

Conclusion:  Spontaneous Ca2+‐oscillations are influenced by the GABAA receptor. Spontaneous Ca2+‐oscillations might represent an interesting model system to study anaesthetic mechanisms on neuronal information processing.
Allocation of tasks between anesthesiologists and anesthesia nurses in Finland
Authors: Vakkuri A. , Niskanen M. , Meretoja O. A. , Alahuhta S.
Published: June 2006

Background:  The shortage of anesthesiologists in Finland is worsening. A survey was carried out in 2003 among head anesthesiologists and head nurses to clarify current practice and the potentials for reorganizing tasks between anesthesiologists and anesthesia nurses. A national working group analyzed the results.

Methods:  A questionnaire concerning doctor and nurse resources in anesthesiology, current allocation of tasks, and opinions on how these tasks could be reallocated was sent to 87 head anesthesiologists and 32 head nurses in 45 different hospitals. The answers from the doctors and nurses were compared.

Results:  The response rate of doctors and nurses was 87% and 100%, respectively. In the enrolled hospitals there were 64 unoccupied positions for specialists in anesthesiology. The ratio of anesthesiologists to operation rooms (OR) they attended varied between 0.3 and 1.5. Doctors and nurses reported the allocation of tasks quite similarly. The great majority of respondents considered spinal, epidural, and interscalene brachial plexus blocks, and the induction of general anesthesia to be tasks that should be performed by an anesthesiologist. Very few respondents of either profession were willing to reallocate tasks so that nurses could deliver general anesthesia, including endotracheal intubation, even in low‐risk patients.

Conclusion:  Nurses could be trained nationwide to perform procedures already performed by locally trained nurses in some hospitals. To cope with the shortage of anesthesiologists, other strategies must be adopted in addition to transferring part of their work load to nurses.
Multimodal cerebral monitoring and decompressive surgery for the treatment of severe bacterial meningitis with increased intracranial pressure
Authors: Baussart B. , Cheisson G. , Compain M. , Leblanc P. E. , Tadie M. , Benhamou D. , Duranteau J.
Published: June 2006

Bacterial meningitis is still associated with a high mortality, mainly because of cerebral herniation as a result of increased intracranial pressure. Published data stress the necessity of an early diagnosis and immediate start of antibiotic therapy. Nevertheless, there are only few reports in which therapeutic strategy was based on the monitoring and the reduction of intracranial pressure (ICP). We report one case of bacterial meningitis caused by Neisseria meningitidis with an initial ICP value of 60 mmHg, which was treated by large hemicraniectomy and ventriculostomy, leading to a favorable neurological long‐term result. The surgical decision was accelerated by an accurate ICP evaluation based on cerebral monitoring [transcranial Doppler ultrasonography (TCD) and intracranial ICP‐device]. In selected patients with bacterial meningitis and clinical and radiological evidence of elevated ICP, cerebral monitoring and aggressive reduction of ICP may be crucial to improve survival and neurological outcome. When maximal medical ICP treatment fails to reduce severe intracranial hypertension, decompressive craniectomy should be rapidly proposed.
Ultrasound guidance improves the success rate of a perivascular axillary plexus block
Authors: Sites B. D. , Beach M. L. , Spence B. C. , Wiley C. W. , Shiffrin J. , Hartman G. S. , Gallagher J. D.
Published: June 2006

Background:  Traditional approaches to performing brachial plexus blocks via the axillary approach have varying success rates. The main objective of this study was to evaluate if a specific technique of ultrasound guidance could improve the success of axillary blocks in comparison to a two injection transarterial technique.

Methods:  Fifty‐six ASA physical status I–III patients presenting for elective hand surgery were prospectively randomized to receive an axillary block performed by either a transarterial technique (Group TA) or an ultrasound‐guided perivascular approach (Group US). Both groups received a total of 30 ml of 1.5% lidocaine (225 mg) with 5 μg/ml epinephrine. Patients were then evaluated for block onset in specific nerve distributions and whether or not the block acted as a surgical anesthetic.

Results:  Group TA sustained more failures defined as conversion to general anesthesia or the inability to localize the artery [Group TA eight patients (29%) vs. Group US in which 0 patients required conversion to general anesthesia (0%) P < 0.01]. Group US demonstrated a reduction in performance times vs. Group TA (7.9 ± 3.9 min vs. 11.1 ± 5.7 min, P < 0.05). By 30 min post‐injection, there were no significant differences between groups TA and US in terms of the proportion of patients demonstrating a complete motor or sensory loss.

Conclusion:  Ultrasonographic guidance improves the overall success rate of axillary blocks in comparison to a transarterial technique.
Plasma concentrations following repeated rectal or intravenous administration of paracetamol after heart surgery
Authors: Holmér Pettersson P. , Jakobsson J. , ÖWall A.
Published: June 2006

Background:  Paracetamol is commonly used for post‐operative pain management in combination with more potent analgesics. The best route of paracetamol administration after major surgery, when oral intake may not be optimal, is not known. Our primary purpose was to study plasma concentrations after the 1st and 4th dose of 1 g of paracetamol given either rectally or intravenously (i.v.) after major surgery.

Methods:  In this prospective, randomized study, 48 patients undergoing heart surgery were randomized upon arrival to the intensive care unit (ICU) to receive paracetamol every 6th hour either as suppositories or intravenous injections. In half the patients (n= 24), blood samples for paracetamol concentration were obtained before and 20, 40 and 80 min after the first dose. In the other patients (n= 24), additional samples were taken prior to, and at 20, 40, 80 min and 4 and 6 h after, the 4th dose.

Results:  Plasma paracetamol concentration peaked (95 ± 36 μmol/l) within 40 min after initial i.v. administration but did not increase within 80 min after the 1st suppository. Plasma concentration before the 4th dose was 74 ± 51 and 50 ± 27 in the rectal and i.v. groups, respectively. Paracetamol concentration peaked 20 min after the 4th dose for the i.v. patients (210 ± 84 μmol/l) and declined to 99 ± 27 μmol/l at 80 min as compared with the rectal patients 69 ± 44 to 77 ± 48 μmol/l.

Conclusion:  Both time course and peak plasma concentrations of paracetamol given rectally differ from the one seen after intravenous administration. The clinical impact of these differences needs further investigation.
Etoricoxib pre‐medication for post‐operative pain after laparoscopic cholecystectomy
Authors: Puura A. , Puolakka P. , Rorarius M. , Salmelin R. , Lindgren L.
Published: June 2006

Background:  Etoricoxib alleviates and prevents acute pain. The hypothesis of our study was that the pre‐operative use of etoricoxib would reduce the post‐operative need for additional pain treatment.

Methods:  In this double‐blind, randomized and active placebo‐controlled study, 75 patients were pre‐medicated 1.5 h before elective laparoscopic cholecystectomy with 120 mg of etoricoxib (E120 group), the same dose of etoricoxib combined with 1 g of paracetamol (E + P group) or placebo (Pla group). To alleviate post‐operative pain, a patient‐controlled analgesia (PCA) device was programmed to deliver 50 μg of fentanyl intravenously (lockout time, 5 min). The pain intensity and nausea were assessed using a visual analogue scale (VAS). The number of patients with post‐operative nausea and vomiting was recorded. Blood loss was compared between the groups. Because the operations are almost blood‐less, the operation time was also recorded to compare the possible effect on bleeding time.

Results:  Pre‐medication with etoricoxib or etoricoxib plus paracetamol had a statistically significant fentanyl‐sparing effect 2–20 h post‐operatively compared with placebo (P= 0.001). No significant differences were demonstrated in fentanyl‐sparing effect between the E120 and E + P groups. No significant differences in pain intensity were found between the three study groups. No significant differences were observed between the groups with regard to nausea, blood loss, duration of anaesthesia or duration of surgery.

Conclusion:  Etoricoxib is suitable for pre‐medication before laparoscopic cholecystectomy as it reduces the need for post‐operative opioids. Opioid‐related side‐effects, however, were not reduced in the present study, despite the observed opioid‐sparing effect of etoricoxib and combined etoricoxib and paracetamol.
Continuous peripheral nerve block catheter tip adhesion in a rat model
Authors: Buckenmaier C. C. , Auton A. A. , Flournoy W. S.
Published: June 2006

Background:  Continuous peripheral nerve block (CPNB) has been used effectively in combat casualties from Iraq and Afghanistan to provide surgical anesthesia and extended duration analgesia during evacuation and convalescence. Little information is available concerning catheter tip tissue reaction with prolonged use.

Methods:  Forty‐eight male Sprague‐Dawley rats were assigned (12 per group) to one of four catheter tip designs provided by Arrow International: group A, 20‐gauge catheter with three side‐holes and a bullet‐shaped tip; group B, 19‐gauge StimuCath™ catheter with coiled omni‐port end with hemispherical distal tip; group C, 19‐gauge catheter with single end‐hole in conducting tip; group D, 19‐gauge catheter with closed conducting tip with four side‐holes. Following laparotomy, a randomly assigned catheter tip was sutured to the parietal peritoneal wall with the tip extending between experimental injuries created on the abdominal wall and cecum. After 7 days in situ, the catheter tips were removed from the adhesion mass using a force gauge, and the grams of force needed for removal were recorded.

Results:  The mean force ± standard deviation values were 1.09 ± 1.21 g for group A, 21.20 ± 30.15 g for group B, 0.88 ± 1.47 g for group C and 1.60 ± 2.50 g for group D. The variation of each catheter group mean force compared with that of group B was significant (P < 0.05). There was no significant difference in adhesion force between groups A, C and D.

Conclusions:  These results suggest that the manufactured design of a CPNB catheter tip can contribute to the adhesion of the tip in an intense inflammatory environment. This finding may have important clinical implications for CPNB catheters left in place for extended periods of time.
Influence of developmental environment on male‐ and female‐mediated sperm precedence in Drosophila melanogaster
Authors: AMITIN E. G. , PITNICK S.
Published: June 2006

Length of the sperm flagellum and of the female's primary sperm‐storage organ, the seminal receptacle (SR), exhibit a pattern of rapid correlated evolution in Drosophila and other lineages. Experimental evolution studies with Drosophila melanogaster indicate that these traits have coevolved through sexual selection, with length of the SR representing the proximal basis of female sire discrimination, biasing paternity according to sperm length. Here, we examine the impact of experimentally varying the developmental environment, including larval density and larval and adult nutrition, on sperm length, SR length and on the pattern of sperm precedence. Expression of SR length was far more sensitive to variation among developmental environments than was sperm length. Nevertheless, there was striking co‐variation in sperm and SR length. The developmental environment of both females and second males, but not first males, significantly contributed to variation in male competitive fertilization success.
Allozyme diversity and morphometrics of the endangered Melocactus glaucescens (Cactaceae), and investigation of the putative hybrid origin of Melocactus	× albicephalus (Melocactus ernestii × M. glaucescens) in north‐eastern Brazil
Authors: LAMBERT SABRINA M. , BORBA EDUARDO L. , MACHADO MARLON C.
Published: June 2006

Melocactus glaucescens (Cactaceae) is a critically endangered species endemic to north‐eastern Brazil. It grows in sympatry with other congeneric species and there is evidence for hybridization among them. We evaluated the levels of genetic and morphological variability and their substructuring between populations of M. glaucescens and sympatric species, and we tested for the occurrence of natural hybridization. Genetic variability was investigated using 12 allozyme loci, and morphological variability was investigated using multivariate morphometric analyses of 18 vegetative characters in nine natural populations of M. glaucescens, Melocactus ernestii, Melocactus concinnus and two distinct morphs of putative hybrids (Melocactus ×albicephalus). Genetic variability was low in all populations (P = 7.7–41.7, A = 0.3–1.7, He = 0.009–0.096), and all taxa displayed a deficit in heterozygotes. Low genetic structuring and moderate morphological structuring were found for M. glaucescens (FST = 0.045, AMRPP = 0.16) and M. concinnus (FST = 0.022, AMRPP = 0.11). The results obtained are inconclusive with respect to confirming the hypothesis of occurrence of hybridization because of an absence of diagnostic loci in the presumed parental species. The presence of several private alleles and the absence of linkage disequilibrium in the putative hybrids indicate that M. albicephalus should be treated as a distinct species, and not given hybrid status as recently stated by a number of authors. The large number of exclusive alleles and the levels of morphological structuring in the populations of M. glaucescens are important factors that need to be considered in the definition of strategies for the conservation of this species.
Life‐history monographs of Japanese plants. 6: Convallaria keiskei Miq. (Convallariaceae)
Authors: OHARA MASASHI , ARAKI KIWAKO , YAMADA ETSUKO , KAWANO SHOICHI
Published: June 2006

The life‐history characteristics of Convallaria keiskei Miq. (Convallariaceae), an Asian lily of the valley, are described. This is a perennial species of temperate broad‐leaved deciduous forests in the Japanese islands and adjacent Far East regions. Convallaria keiskei is a clonal plant and depends on two reproductive modes, sexual reproduction via seeds and clonal growth. New aerial shoots (sheath leaves) elongate and appear above ground in late April to May, and subsequent flowering takes place in late May to June On the forest floor, there are two distinct vegetative aerial shoots, shoots with a single leaf and those with two leaves, as well as two‐leaved shoots that bear an inflorescence. As found in two other Convallaria species, Convallaria montana of North America and Convallaria majaris of Europe, flowers of C. keiskei have a mild fragrance, and nectar‐glands are developed at the base of the corolla. The number of ovules per flower ranges from 3 to 17 with an average of 12. Convallaria keiskei is a typical insect‐pollinated outbreeder and, in general, pollinators belong to the orders Coleoptera and Diptera. In addition, the observed self‐incompatibility suggests that pollen from ramets of a genet have little importance in the reproduction of this species, and that sexual reproduction requires pollen from different genets. The fruits ripen in July to August, and are globose berries, approximately 6 mm in diameter, and red or reddish brown when matured. The number of seeds produced per fruit ranges from 1 to 14 (average 4), and the fruit‐setting and seed‐setting rates are 32% and 11%, respectively. Fruit sets are distinctly influenced by the numbers of neighboring compatible flowers.
RANDOMIZED CONTROLLED TRIAL COMPARING PROLENE HERNIA SYSTEM AND LICHTENSTEIN METHOD FOR INGUINAL HERNIA REPAIR
Authors: Sanjay Pandanaboyana , Harris Dean , Jones Philippa , Woodward Alan
Published: June 2006

Background:  There are no data regarding the long‐term outcomes of prolene hernia system (PHS) mesh in the published reports. The aim of the study was to compare the short‐term and long‐term outcomes of the PHS mesh with the Lichtenstein mesh technique.

Methods:  Sixty‐four patients with inguinal hernia were randomized to undergo either a PHS or a Lichtenstein repair under local anaesthesia as a day case. Early outcome measures were duration of surgery, pain scores, analgesic requirements, time to return to work, driving and full activity. Long‐term outcome measures were chronic groin pain and recurrence.

Results:  Mean duration of surgery in the PHS group was 36 min (SD ± 11) versus 34 min in the Lichtenstein group (SD ± 8; P = 0.3). There was no significant difference in analgesic requirements (P = 0.65). Overall mean pain score was 3.5/10 versus 2.5/10 (P = 0.1). Mean time to return to work was 42 versus 30 days (P = 0.3), returning to driving was 20 versus 14 days (P = 0.2) and full activity was 21 versus 22 days (P = 0.8). Chronic groin pain developed in four patients in the PHS group (12.9%) and in five patients in the Lichtenstein group (15.1%; P > 0.05). One patient developed recurrent herniation in the PHS group. The median follow up was 4.2 years (range, 4–4.6 years). Patient satisfaction was very high with both the techniques.

Conclusion:  There is no significant difference in the early and long‐term outcomes between PHS and Lichtenstein hernia repairs. The PHS technique involving preperitoneal dissection is well tolerated and easy to carry out under local anaesthesia.
QUESTIONNAIRE TO AID PRIORITY AND OUTCOMES ASSESSMENT IN GALLSTONE DISEASE
Authors: Chen Tina Y. T. , Landmann Michael G. , Potter Jonathan C. , Van Rij Andre M.
Published: June 2006

Background:  Limited health resources necessitate prioritization for access to elective cholecystectomy in New Zealand. We aimed to develop and validate a patient questionnaire for determining the effect of gallstone disease on quality of life (QOL) and evaluate its potential role in appraising prioritization and outcomes from surgery.

Methods:  The Otago gallstones condition‐specific questionnaire (CSQ) was designed based on review of published reports, structural equation modelling, input from experts and patient feedback. Fifty‐four patients with symptomatic gallstone disease completed the CSQ including a single question asking about global condition impact, along with other QOL measures: the Gallstone Impact Checklist and the Short Form‐36 Health Survey. Validity and reliability of the CSQ were assessed using standard psychometric criteria and patient acceptance was explored in a semistructured interview. Patients’ priority status for surgery was determined by two participating surgeons and resulting scores were correlated with the QOL measures.

Results:  Average CSQ completion time was 2.7 (range 1–5) min and patients found its content concise and comprehensive. Validity was supported through high correlations with the Gallstone Impact Checklist (r = 0.74), the global condition impact (r = 0.69) and related dimensions of the Short Form‐36 Health Survey. CSQ questions showed satisfactory internal consistency (Cronbach’s α = 0.94) and reproducibility (ICC = 0.93, where ICC is intraclass coefficient). Of all the QOL measures, the CSQ was the most clinically relevant, showing the strongest relationship with surgeon‐rated priority (r = 0.62).

Conclusions:  Evidence is provided to support the validity of the CSQ for assessing the effect of gallstone disease on QOL. The CSQ could be particularly valuable in aiding priority decisions surgeons make and may be useful in tracking subsequent outcomes.
ANASTOMOTIC LEAKAGE AFTER LOWER GASTROINTESTINAL ANASTOMOSIS: MEN ARE AT A HIGHER RISK
Authors: Lipska Magdalena A. , Bissett Ian P. , Parry Bryan R. , Merrie Arend E. H.
Published: June 2006

Background:  Anastomotic leakage is the most important complication specific to intestinal surgery. The aim of this study was to review the anastomotic leakage rates in a single Colorectal Unit and to evaluate the risk factors for anastomotic leakage after lower gastrointestinal anastomosis.

Methods:  A total of 541 consecutive operations involving anastomoses of the colon and rectum that were carried out between 1999 and 2004 at a single colorectal unit were reviewed. Data concerning 35 variables, relating to patient, tumour and surgical factors, were recorded. Outcomes with respect to anastomotic leakage and mortality were recorded. Data were analysed using univariate and multivariate analyses and odds ratios (OR) calculated.

Results:  The overall rate of anastomotic leakage was 6.5% (35 of 541). The most frequently carried out operations were right hemicolectomy and anterior resection of the rectum, with leak rates of 2.2 and 7.4%, respectively. Univariate analysis showed that male gender (OR = 3.5), previous abdominal surgery (OR = 2.4), Crohn’s disease (OR = 3.3), rectal cancer ≤12 cm from the anal verge (OR = 5.4) and prolonged operating time (OR = 2.8) were factors significantly associated with anastomotic leakage. Male gender, a history of previous abdominal surgery and the presence of a low cancer remained significant after multivariate analysis. The risk of anastomotic leakage increased when two or more risk factors were present (P < 0.01). The overall mortality was 3.7% and was higher in patients with anastomotic leakage (14.3%; P = 0.01).

Conclusions:  Male gender, previous abdominal surgery and low rectal cancer are associated with increased anastomotic leakage rates. These have important implications during preoperative patient counselling and decision‐making regarding defunctioning stoma formation.
TRAINING IN PAEDIATRIC TRAUMA: THE PROBLEM OF SAFER SOCIETIES
Authors: Hamill James , Beasley Spencer W.
Published: June 2006

Background:  Trauma remains the most common cause of child death worldwide but the incidence of major trauma is declining in many developed countries: this has implications for training. A survey of paediatric surgeons and paediatric surgical trainees was undertaken to evaluate perceptions of the relative importance of various forms of trauma training.

Methods:  A questionnaire was emailed to Australasian paediatric surgeons and trainees to determine trauma courses they had undertaken, operative and non‐operative paediatric trauma experience and attitudes towards trauma training.

Results:  The overall response rate was 49% (40 of 83 consultants and 11 of 22 trainees). The Early Management of Severe Trauma course had been undertaken by 82% of consultants and all trainees. The Definitive Surgical Trauma Care course had been undertaken by 22% of consultants and one trainee. The number of trauma laparotomies carried out in the previous year was in the one to five range for 71% of responders. Greater emphasis was placed on the value of adult trauma experience by consultants who had a general surgical fellowship.

Conclusion:  In societies where major trauma in children is relatively rare (fortunately) and the opportunities for training are limited, it is important to ensure that advanced trainees in paediatric surgery gain sufficient skills from a variety of sources to enable them to treat competently the severely injured child with multiple injuries.
MARGINS AND OUTCOME OF SCREEN‐DETECTED BREAST CANCER WITH EXTENSIVE IN SITU COMPONENT
Authors: Kitchen Paul R. B. , Cawson Jennifer N. , Moore Suzanne E. , Hill Prue A. , Barbetti Toni M. , Wilkins Pamela A. , Power Ann‐Marie , Henderson Michael A.
Published: June 2006

Background:  In situ disease surrounding invasive tumours is an important consideration in the management of patients with early breast cancer. This study of screen‐detected breast cancers assessed the influence of in situ disease including an extensive in situ component (defined as ductal carcinoma in situ involving more than 25% of the area within the invasive tumour) on surgical management, local recurrence and survival of a group of patients.

Methods:  A total of 595 cases of invasive breast cancer detected at St Vincent’s BreastScreen were retrospectively reviewed to determine presence and extent of in situ disease, the surgical procedure and adequacy of excision. Outcome was examined in a cohort of 126 cases.

Results:  A total of 438 (74%) patients had in situ foci in or around the invasive tumour and 107 (18%) were defined as extensive in situ component (EIC)‐positive. The initial procedure was mastectomy in 20% of the cases and breast‐conserving surgery in 80% including 18% who underwent further surgery. Re‐excision (P = 0.02) or mastectomy (P = 0.01) was more often required in patients with EIC. After definitive local excision, margins were close or involved with invasive disease in 3% but the patients with EIC were more likely to have margins close or involved with in situ disease (16 vs 2%; P = 0.001). There were seven deaths and one local invasive recurrence in the follow‐up group and none of the deaths were in patients who were EIC‐positive.

Conclusions:  EIC predicts for a higher rate of re‐excision and/or mastectomy. For patients with EIC, there is an acceptably low risk of local recurrence if margins are clear.
LAPAROSCOPIC CARDIOMYOTOMY FOR ACHALASIA: LONG‐TERM OUTCOMES
Authors: Bessell Justin R. , Lally Carolyn J. , Schloithe Anne , Jamieson Glyn G. , Devitt Peter G. , Watson David I.
Published: June 2006

Background:  Although the laparoscopic approach to oesophageal myotomy for achalasia is associated with reduced early postoperative morbidity compared with the open approach, most published reports describe relatively short‐term follow up. For this reason, in a prospective cohort study, we determined the longer‐term outcome for patients with uncomplicated achalasia who underwent a laparoscopic myotomy. In addition, we sought to identify preoperative factors predicting a good postoperative outcome.

Methods:  The outcome for 167 patients who underwent a laparoscopic cardiomyotomy and anterior partial fundoplication at one of two teaching hospitals was determined. All patients underwent preoperative assessment with a contrast swallow radiology, gastroscopy and oesophageal manometry. Patients also underwent objective symptom evaluation before and after surgery using various outcome scales to determine dysphagia, reflux symptoms, side‐effects and overall satisfaction with the clinical outcomes. Patients were followed prospectively at yearly time points and data were managed on a computerized database. Postoperative objective investigations were undertaken if clinically indicated.

Results:  Median operating time was 78 min (range, 30–210 min). Most patients left the hospital within 72 h of surgery. Surgery was associated with a 5% complication rate and a 4% rate of conversion to open surgery. Five per cent of patients required a subsequent intervention during follow up. Over longer‐term follow up (5 years or longer), 77% of patients had either no or minimal symptoms. At 1, 3 and 5 years, 96, 93 and 97% of patients indicated that they thought that they had made the correct decision to undergo surgery, although men consistently fared worse on their reported dysphagia outcome across a range of measures.

Conclusion:  Laparoscopic myotomy with anterior partial fundoplication achieves a good outcome for patients undergoing treatment of achalasia. Male patients do not perceive their outcome to be optimal in comparison with females but in the long term, they do not regret proceeding.
SURGICAL MANAGEMENT OF EXTRACRANIAL INTERNAL CAROTID ANEURYSMS BY CERVICAL APPROACH
Authors: Bakoyiannis Chris N. , Georgopoulos Sotirios E. , Tsekouras Nikolaos S. , Klonaris Chris N. , Skrapari Ioanna C. , Papalambros Efstathios L. , Bastounis Elias A.
Published: June 2006

Background:  Extracranial internal carotid artery aneurysms (EICAA) are rare vascular problems with a great potential for lethal thromboembolic episodes.

Methods:  From 1994 to 2004, nine patients with EICAA, seven men and two women, were surgically treated for 10 aneurysms in our department. Aneurysm led to hemispheric symptoms in six cases (two hemispheric strokes and four hemispheric transient ischaemic attacks). The cause was fibrodysplasia in two cases, atherosclerosis in four cases, trauma in two cases and spontaneous dissection in two cases. All aneurysms were treated surgically by the cervical approach using shunting. Extended cervical approach was necessary in four patients with high‐lying aneurysms. Nine aneurysms were totally resected and successful revascularization was carried out. Open aneurysmorrhaphy with vein patch angioplasty was carried out in one case of a saccular aneurysm.

Results:  There were no perioperative deaths or transient ischaemic attacks or strokes. Four patients developed cranial nerve deficits: one had hoarsness, two had partial facial paralysis (patients with extended cervical approach) and one had tongue deviation. These neurological symptoms were observed in large aneurysms (>4.5 cm) and disappeared within 14 months. No neurological complication was observed in a follow up that ranged from 6 months to 10 years.

Conclusions:  Surgical repair of EICAA, especially with total resection and arterial reconstruction, is strongly recommended. Extended cervical approach has many technical difficulties but can allow treatment of high‐lying aneurysms.
LOCALIZATION OF SMALL PULMONARY NODULES FOR VIDEOTHORACOSCOPIC SURGERY
Authors: Hu Jian , Zhang Chong , Sun Li
Published: June 2006

The aim of this study is to discuss and summarize the localization of small pulmonary nodules for videothoracoscopic surgery. Thirty‐eight patients were selected, 22 men and 16 women, and they underwent video‐assisted thoracoscopic surgery resection for small pulmonary nodules: 28 patients for small solitary pulmonary nodules and 10 patients for multiple small pulmonary nodules. In all cases, resection of the nodules was successful. Localization methods included: (i) computed tomography (CT)‐guided methylene blue labelling for preoperative localization; (ii) a high‐quality chest CT scan for preoperative localization; (iii) visual exploration, digital palpation and ‘instrumental’ palpation to locate the nodule; and (iv) endosonographic inspections of intraoperative localization. Using a combination of CT scan, digital palpation, methylene blue labelling and endosonographic inspections, all nodules were successfully localized and resected without significant complications. Video‐assisted thoracoscopic surgery is an effective approach but the small lung nodules (especially those less than 1.0 cm in diameter) localized at thoracoscopic resection must be treated carefully. Combined imaging and thoracoscopic techniques may help identify small nodules.
POTENTIAL EFFECTS OF HYPERBARIC OXYGEN THERAPY IN ACUTE PANCREATITIS
Authors: Cuthbertson Christine M. , Christophi Christopher
Published: June 2006

Background:  To extract from the biomedical published reports, the effects of hyperbaric oxygen (HBO) on inflammatory disease, in particular acute pancreatitis. This review will explain these effects and evaluate potential mechanisms of action of HBO in acute pancreatitis.

Methods:  A Medline/PubMed search (January 1966 to July 2004) with manual cross‐referencing was conducted, including all relevant articles investigating the molecular and systemic effects of HBO on inflammatory diseases, particularly focusing on the studies of acute pancreatitis. All publication types, languages and subsets were searched.

Results:  Original and review articles and short communications were extracted. The selected original articles covered the molecular and systemic effects of HBO and the effects in inflammatory disease states. The major findings are that HBO can act as an anti‐inflammatory agent and as an antimicrobial agent. Many of the effects of HBO would be beneficial in the treatment of acute severe pancreatitis. Work carried out to date in animal models of acute pancreatitis shows promising improvements in severity but studies are limited to date.

Conclusion:  Acute pancreatitis impairs the pancreatic and systemic microcirculation and causes acute inflammation. These processes are potentially improved by HBO therapy.
HEPATOCELLULAR CARCINOMA PRESENTING WITH OBSTRUCTIVE JAUNDICE
Authors: Lai Eric C. H. , Yee Lau Wan
Published: June 2006

Background:  Jaundice occurs in 5–44% of patients with hepatocellular carcinoma (HCC). It is an important clinical presentation as the different aetiological causes of jaundice in HCC determine the therapeutic approach and the prognosis. This article aims to review the classification, management and prognosis of patients with jaundice associated with HCC.

Methods:  A Medline search was undertaken to identify articles using the key words ‘hepatocellular carcinoma’, ‘jaundice’ and ‘tumour thrombus’. Additional articles were identified by a manual search of the references from the key articles.

Results:  Patients with jaundice due to hepatic parenchymal insufficiency (hepatocellular type) have a very dismal prognosis. For patients with biliary obstruction due to HCC (icteric type), the reported 1‐, 3‐ and 5‐year survival rates after curative resection were 57.1–100%, 20–47% and 6.7–45%, respectively. The mean survival after palliative biliary drainage alone was less than 6 months but when biliary drainage was combined with other palliative treatment, the mean survival could be up to 1 year.

Conclusions:  It is important to differentiate the hepatocellular type from the icteric type of HCC. For patients with the icteric type of HCC, curative liver resection can achieve a survival comparable to that in patients without jaundice. For patients with unresectable icteric type of HCC, treatment can provide improvement in patient’s quality of life and survival.
TERRORISM AND BLAST EXPLOSIONS: LESSONS FOR THE AUSTRALIAN SURGICAL COMMUNITY
Authors: Neuhaus Susan J. , Sharwood Peter F. , Rosenfeld Jeffrey V.
Published: June 2006

The prospect of a terrorist attack against Australian interests is currently being debated across our society. The explosive blast attack is most favoured by terrorists. Blast injuries create unique patterns of multisystem injury with contaminated wounds and extensive devitalized tissue. Australian civilian surgeons are increasingly likely to be involved in the management of these injuries, either in response to a terrorist incident in Australia or as part of delayed management of Australian nationals injured overseas. An appreciation of the unique complexities of blast injuries is equally important to both military and civilian surgeons. This paper covers the mechanisms and pathophysiology of blast injuries and discusses issues of surgical management as they would apply to an Australian civilian setting.