bluuebunny/crossref_metadata_2025 huggingface dataset:
The Third Way in Health Care Reform: Does the Emperor have Any Clothes?
Authors: Ham Chris
Published: January 2017

The Labour government elected in the UK in May 1997 has described its approach to the National Health Service (NHS) as a third way in health care reform. This article seeks to analyse the defining features of the third way. It argues that the government has adopted an approach which combines central direction and local autonomy, sanctions and incentives, and planning and competition. The third way therefore entails a cocktail of different approaches and is both eclectic and pragmatic. In pursuing this policy, the government is seeking to deal with dilemmas that are as old as the NHS itself and is seeking a synthesis between approaches that in the past have been seen as exclusive. It can be argued that the search for a synthesis is unlikely to succeed and the government will have to decide whether it is really committed to a centralised health service in which the main emphasis is on planning and sanctions or whether it is willing genuinely to devolve power to a local level with reliance on incentives and elements of competition. The alternative interpretation is that by making use of a variety of instruments the government is increasing its chances of delivering its objectives. From this perspective, to insist on absolute consistency is to fail to recognise the complexity of the steering mechanisms required in modern public services. In the international context, the third way may find favour as a rhetorical device among politicians seeking to carve out a distinctive niche in the political market place, but its specific characteristics are likely to vary between systems.
Evolutionary Psychology and Health: Confronting an Evolving Paradigm
Authors: Higgs Paul , Jones Ian Rees
Published: January 2017

In much the same way that developments in genetics have opened up new areas of activity in health services, the ‘new genetics’ has also stimulated a renewal in approaches that try to explain the nature of health behaviours within the context of human biological development. Evolutionary psychology, as an umbrella term for these views, stresses the importance of the brain as an intermediary between genes and individual behaviour. From such a perspective, social context is less important than an understanding of why certain behaviours are ‘chosen’ by the evolutionary process and how they are predicated on reproductive success. Health policy is a key area where these ideas are likely to become important given evolutionary psychology's focus on the interplay between physiological and psychological factors in determining health behaviours. Health research provides a fertile environment because it is already seeking the hidden biological pathways connecting social status with specific diseases. The challenge represented by evolutionary psychology needs to be taken seriously because of the way in which such ideas mesh with the individualistic basis of much health promotion and health policy. In particular, it poses a challenge when it purports to explain how inequalities in health are not necessarily the result of the unequal distribution of income in society but are natural phenomena. It is also important to engage with such ideas because they increasingly seem likely to occupy the empty ideological space created by the disappearance of politics in policy and as such may have a greater impact than would otherwise be the case.
Practical Equations to Predict Claudication Pain Distances from a Graded Treadmill Test
Authors: Gardner Andrew W , Ricci Michael A , Case Terrence D , Pilcher David B
Published: January 2017

Treadmill testing is used to estimate the severity of claudication, but routine use is not practical or cost-effective in all settings. Thus, the purposes of this study were: (1) to develop and cross-validate prediction equations for treadmill claudication pain distances in a heterogeneous cohort of peripheral arterial occlusive disease patients, and (2) to determine if the regression equations were more accurate in assessing claudication distances than self-reported distances of patients. Medical history, vital signs, resting ankle/brachial systolic pressure index (ABI), and claudication distances during a graded treadmill test were obtained on a validation group of 178 claudicants and on a cross-validation group of 94 claudicants. The independent predictors of claudication pain distances of the validation group were ABI, body mass index, gender, and current smoking status, with multiple correlation coefficients of R=0.73 and R=0.82 for the distances to onset and to maximal pain, respectively. These equations were successfully cross-validated on an independent group of claudicants, as the predicted distances to onset of claudication pain (167.2± 102.6 m) and to maximal pain (354.6± 154.3 m) were similar ( p=0.99) to measured distances (169.1 ± 127.8 m and 356.6±181.0 m, respectively). However, the self-reported distances to onset (89.5± 126.3) and to maximal claudication pain (189.2±284.3) were 1–2 blocks less than either the measured or predicted distances ( p<0.01). It is concluded that claudication pain distances during an incremental treadmill test can be more accurately estimated from a composite of variables obtained during medical screening than by relying on the self-report of patients. Consequently, in clinical settings where treadmill testing is impractical, the functional severity of claudication can be assessed without exercise testing.
Heparin Administration via Nomogram versus a Standard Approach in Venous and Arterial Thromboembolic Disease
Authors: Jaff Michael R , Olin Jeffrey W , Piedmonte Marion , Pirzada Carol , Young Jess R
Published: January 2017

To determine whether heparin administered by continuous intravenous infusion using a nomogram is superior to a random dosing scheme, we performed a prospective, randomized comparative trial in 161 patients. Patients were prospectively randomized to one of three groups. Group I received an intravenous bolus of 5000 IU of heparin followed by heparin administration according to a modification of a previously published nomogram. Group II patients received a 5000 IU intravenous bolus of heparin followed by continuous intravenous heparin infusion with dosage adjustment at the discretion of the treating physician. Group III patients received a continuous intravenous heparin infusion with dosage adjustments at the discretion of the treating physician without the prior administration of a bolus dose. Activated partial thromboplastin time (APTT) was obtained at baseline, 6 h after each heparin dose adjustment and every morning. The mean percent of each patient's APTTs in the subtherapeutic range (<50 sec) over the course of treatment was 9% for group I and 24% for groups II and III, p=0.0001. The three groups had a similar percentage of each patient's APTTs within the therapeutic range (50–80 sec). There was a larger percentage of APTTs >80 sec in group I (46%) compared to group II (31%) or group III (32%), p=0.01. There were no clinically recurrent deep venous thrombi or arterial thromboemboli in any of the groups. Two patients had documented pulmonary emboli during heparin therapy (one in group I; one in group II). There was no difference in the complication rates of heparin therapy or the need for blood transfusions among the three groups. Patients randomized to the heparin nomogram (group I) achieved an APTT >50 sec more frequently than patients in the other two groups. Overall, fewer patients in the nomogram group were subtherapeutic, and, when APTT levels fell in the subtherapeutic range, the nomogram restored APTTs to the therapeutic range faster than the standard methods. The heparin nomogram was clearly more effective as a method of heparin dosing than standard methods of anticoagulation dosing.
Hypothermia and Rewarming after Hypothermic Exposure Alter Venous Relaxation
Authors: Davies Mark G , Hopkin Mark A , Brockbank Kelvin GM , Hagen Per-Otto
Published: January 2017

Hypothermia has pathophysiological consequences on endothelial and smooth muscle cell function. This study investigates the impact on venous relaxation of hypothermia and rewarming following hypothermic exposure. In vitro isometric relaxation responses of norepinephrine precontracted rabbit external jugular veins to a panel of endothelium-dependent and -independent agonists were assessed in controls at 37°C, and in an experimental group after cooling to 20°C and after rewarming to 37°C. On cooling, the endothelium-dependent responses to acetylcholine became multiphasic with initial contraction at low concentrations followed by relaxation at higher concentrations, the maximum of which was significantly diminished compared to controls. Incubation with indomethacin did not affect this response. Rewarming re-established a monophasic dose-dependent acetylcholine induced relaxation response but the maximal response was significantly augmented. This augmentation in relaxation on rewarming could be prevented by preincubation with indomethacin. The maximal response to calcium ionophore was reduced at 20°C and augmented upon rewarming to 37°C. All veins relaxed in a dose-dependent manner to the nonendothelium-dependent agonists forskolin and sodium nitroprusside; the maximal responses were significantly reduced at 20°C and returned to normal upon rewarming. This study suggests that short-term exposure of venous tissue to hypothermia impairs the vessel's ability to produce endothelium-dependent relaxation. Rewarming does not re-establish normal endothelium-dependent relaxation but results in an enhanced, partially indomethacin-sensitive, response which appears to be independent of changes in nonendothelium-dependent mediated relaxation.
The Impact of Angiotensin Converting Enzyme Inhibitors on the Arterial Wall
Authors: Lee Alison FC , Struthers Allan D
Published: January 2017

There is recent interest in the possibility that angiotensin converting enzyme inhibitors (ACE inhibitors) may reduce the damage inflicted on the arterial wall by common cardiovascular risk factors such as hypertension, hyperlipidaemia and ageing. The efficacy of these drugs in blood pressure reduction is accepted, but whether there is an excess benefit on arterial structure and function, conferred by use of ACE inhibitors over more traditional antihypertensives, is still under debate. There is also evidence in animal models to suggest that ACE inhibition is effective in reduction of arterial damage due to experimental hyperlipidaemia.

ACE inhibitors not only reduce the conversion of angiotensin I and angiotensin II, which can interact with the sympathetic nervous system, but also prevent the degradation of bradykinin. This means that ACE inhibitors have several potential mechanisms through which they could suppress intimai hypertrophy and prevent endothelial dysfunction, which is believed to precede arteriosclerosis in man.

Although much further work is needed to clarify the mechanism underlying the beneficial effects on the arterial wall of this group of drugs, they do appear to have significant potential in the effort to reduce cardiovascular mortality and morbidity, especially in high risk groups.
Carotid Angioplasty
Authors: Gaines PA
Published: January 2017

Aspirin and carotid endarterectomy represent the current method of prophylaxis against stroke in patients with symptomatic high grade carotid stenoses. Whilst balloon dilatation and stent placement is an accepted form of recannalization, elsewhere in the arterial circulation the technique is in its infancy within the supra-aortic vessels. Carotid endarterectomy is expensive, requires a general anaesthetic and is associated with an acceptable complication rate as demonstrated by the ECST and NASCET studies. The author's experience in 55 patients with symptomatic high grade atherosclerotic disease is described with a disabling stroke rate at 30 days similar to the surgical series (5%). Long-term follow-up is awaited. Metallic intra-arterial stents provide the opportunity to reduce the immediate postintervention residual stenosis and possibly reduce the long-term restenosis rate. Modifications of the technique are in development and may reduce the cerebral embolization that occurs during the procedure.
The PACK Trial: Morbidity and Mortality Effects of Ketanserin
Authors: Verstraete Marc
Published: January 2017

A total of 3899 patients over 40 years old who had documented intermittent claudication for at least 2 months and in whom the ratio of systolic blood pressure in the ankle to that in the arm was <0.85 in both arteries of at least one foot were recruited in a double-blind, randomized, placebo-controlled trial after a single-blind run-in period of placebo treatment for 1 month. Trial drug was ketanserin 40 mg three times daily.

The first primary event after randomization was the endpoint. Primary events were definite myocardial infarction, major stroke, amputation above the ankle, excision of ischaemic viscera, and death due to other vascular causes.

There were 136 study endpoints in the 1930 patients treated with ketanserin, who were followed up for 2063 patient-years, and 132 study endpoints in the 1969 patients treated with placebo, who were followed up for 2129 patient-years. A harmful interaction of ketanserin and potassium-losing diuretics resulted in an increase in the number of deaths. After patients taking potassium-losing diuretics or antiarrhythmic agents were excluded, a secondary analysis showed that there were 65 endpoints in 1514 patients taking ketanserin and 87 in 1577 patients taking placebo, a reduction of 23% in the number of study endpoints in those taking ketanserin.

The treadmill walking distance and ankle systolic pressure were measured in a predetermined subset of 594 patients. Complete datasets at the beginning and end of 1 year's treatment with ketanserin or placebo were available in 436 patients. There was no difference between the groups in the improvement in pain-free treadmill walking distance. The placebo effect on treadmill walking distance increased continuously for at least 1 year at the rate of about 15% every 6 months. There was no significant change in either group in the ankle systolic pressure at the end of the treatment period, but, in the group given ketanserin, brachial systolic pressure was decreased and the ankle/arm systolic pressure ratio therefore increased.
The STIMS Trial: The Ticlopidine Experience and its Clinical Applications
Authors: Janzon Lars
Published: January 2017

The mortality in patients with intermittent claudication can be reduced by treatment with ticlopidine. This is the clinically most significant result from STIMS, the Swedish Ticlopidine Multicenter Study. During an average treatment period of 5.6 years, 153 of the 687 patients died, 26.1% in the placebo group and 18.5% in the ticlopidine group (RR0.7, p=0.015). The incidence of fatal vascular events in the two groups was 12% and 6%. In terms of lives saved per years of treatment, STIMS showed that by treating 200 claudicants for 5 years one can save 13 from a cardiovascular death, not merely dying from something else as treatment was associated with a reduced total mortality as well. The interpretation of the on-treatment analysis is that for those who tolerate the drug the combined vascular morbidity and mortality rate is lowered from 24% to 14%. The disadvantage is that many patients do not tolerate ticlopidine. In STIMS, 22% (2.5 times as many as in the control group) had to stop medication because of gastrointestinal side-effects. Although ticlopidine is associated with an increased risk of leukopenia, the risk in absolute numbers is small: according to STIMS, 4% during 5.6 years. All events were reversible. The 1.4% incidence of thrombocytopenia did not seem to be associated with ticlopidine treatment.
Prostanoid Drug Therapy for Peripheral Arterial Occlusive Disease—The European Experience
Authors: Dormandy John A
Published: January 2017

The most serious threat to a claudicant is not the possible future need for a major amputation, but rather that the medium-term mortality is two to three times that of the general age-matched population. In patients with more severe disease in the legs, approximately 45% will have had a major amputation or be dead within a year of developing rest pain, ulcers or gangrene. These are the challenges for pharmacotherapy in peripheral arterial occlusive disease. In the short and medium term, pharmacotherapy can only have a significant effect by modifying the microcirculatory response to the low perfusion pressure caused by the arterial disease. The microcirculatory changes in the leg in severe leg ischaemia are ill understood, but theoretically a number of pharmacological effects could be beneficial. In practice, the only type of drugs widely tested clinically in severe leg ischaemia are prostacyclin and its analogues. In the last 12 years the results of properly controlled randomized trials involving patients with chronic limb ischaemia have been carried out in approximately 2000 patients in Europe. The largest number were entered into trials using the prostacyclin analogue iloprost. Some of these trials have shown a significant benefit compared to placebo in terms of major amputation or death during the 6 months following a 2–4-week course of intravenous iloprost. The possible future indications for this type of therapy, as well as the use for prostaglandins in claudicants, is discussed.
Thrombolysis or Operation for Peripheral Arterial Occlusion
Authors: Ouriel Kenneth
Published: January 2017

Patients with peripheral arterial occlusion may be treated with one of three distinct treatment strategies: observation and/or anticoagulation alone, operative intervention, or catheter-directed thrombolytic therapy. The severity of symptoms is the most important clinical parameter with which to formulate clinical strategies. Patients with non-lifestyle limiting claudication may be best managed without arteriographic investigation, managing symptoms conservatively with exercise, cessation of smoking, and occasionally the oral pharmacologic agent pentoxifylline. Patients with threatened limbs in the form of rest pain or tissue loss carry a high risk of limb loss without intervention. These patients should undergo arteriography with consideration of endovascular intervention for focal lesions and bypass grafting for more diffuse disease. Patients with more acute symptoms may be best treated with catheter-directed thrombolytic therapy, addressing unmasked lesions responsible for the occlusion with an operative or endovascular approach. In all cases, the appropriate therapy must be tailored to the clinical presentation, the anatomic distribution of disease, and the experience of the clinical team.
The roots of neo-liberal resilience: Explaining continuity and change in background ideas in Europe’s political economy
Authors: Schmidt Vivien A
Published: January 2017

Defines and elucidates the concept of ‘background ideas’; Defines and elucidates neo-liberalism and its relationship to background ideas; Uses discursive institutionalism as framework for analysis of background ideas and neo-liberalism; Explores different levels of neo-liberal ideas in terms of philosophy, program, and policy; Considers how different levels of ideas may be transformed over time through revolutionary or evolutionary change; Examines different forms of ideas, especially as philosophies, ideologies, and discourse, and different types of ideas, both cognitive and normative; Considers the different ways in which ideas are constructed and communicated by policy or political entrepreneurs and/or act in discursive policy communities; Discusses political entrepreneurs as ideological, pragmatic, or opportunistic.

Neo-liberalism has come to constitute the core background idea of European political economies, as the unquestioned set of beliefs, understandings, or core philosophy exercising a seemingly incontrovertible hold since the 1980s in Europe. Using a discursive institutionalist framework, this article defines background ideas; describes their different forms, levels, and types; theorizes about the nature of continuity and change in such ideas; and considers the agents and discursive processes through which such ideas are constructed and disseminated. It illustrates throughout with examples of neo-liberalism, from the philosophical origins through its many different permutations in different institutional contexts over time. This article concludes that although ‘background ideas’ as a concept remains somewhat elusive, it is nonetheless useful as a way of understanding how neo-liberalism has managed to infuse people’s deepest assumptions about the possible and thereby to set the limits of the imaginable with regard to political economic action.
Building Resilient Finance? Uncertainty, complexity, and resistance
Authors: Brassett James , Holmes Christopher
Published: January 2017

Research Highlights and Abstract

The article develops a critical analysis of the politics of financial resilience as an increasingly prevalent discourse of economic policy and practice. Against existing critiques of resilience which focus on the neoliberal rationalities and subjectivities that it (apparently) perpetuates, we argue that resilience per se does not—of necessity—infer any particular form of governance or subjectivity. Instead, resilience can be thought of as a sphere of political engagement. An emphasis on system, structure, and the relations between actors over time gives financial resilience a productive ambiguity: neither structure nor subject is ever fully defined and thus remains open. To this end, we engage the Bank of England’s recent turn to complexity modeling and its correlative, somewhat metaphorical, ethos of ‘clear thinking’ in ‘complex times’. This idea of complexity foregrounds the ‘unknown’ through positing the unpredictability of system-wide events; however, ensuing attempts to ‘model complexity’ entail a closure, rendering uncertainty ‘known’ in particular (and limited) ways. Indeed, we identify a general disconnect between the radical rhetoric of resilience agendas that emphasize complexity and the relative banality of resulting policy advice: self-regulation, capital ratios, and so on. We then explore how a focus on the ‘unknown’ can also give financial resilience an open quality, emphasizing the role of imagination and the diversity of agency. Put simply, if financial governance must be imagined, then it can be imagined differently. We therefore examine a set of everyday attempts to use the openness of resilience/complexity, in order to imagine finance in more democratic or communitarian terms. In particular, market formations such as local banking, peer lending, and wider attempts to politicize financial regulation through documentaries like Bank of Dave play on the productive ambiguities of financial resilience in critical ways. Such agendas do not exhaust or solve the dilemmas identified, but do represent a creative set of attempts to engage the politics of finance in inclusive, participatory, and reciprocal terms.
Quality of Life and Pain in Patients with Acute Cholecystitis
Authors: Vetrhus M. , Søreide O. , Eide G. E. , Nesvik I. , Søndenaa K.
Published: January 2017

Background:

Acute cholecystitis carries a higher risk of subsequent gallstone related events than symptomatic, non-complicated disease. However, it is largely unknown to what extent non-operative treatment will affect the patient's well-being as no trial has studied the possible consequences on pain and quality of life. Our aim was to study in a randomized trial how observational treatment (watchful waiting) compared to cholecystectomy.

Methods:

Sixty-four patients with acute cholecystitis were randomized to observation or cholecystectomy. All gallstone related events were registered and patients answered questionnaires on quality of life (PGWB and NHP) and pain (Pain score and VAPS) at randomization and at 6, 12 and 60 months later.

Results:

Patients were followed-up for a median of 67 months. Ten of 33 patients (30 %, 95 % CI 15 %−46 %) patients randomized to observation and 27 of 31 (87 %, 95 % CI 75 %−99 %) of patients randomized to operation had a cholecystectomy. Twelve of 33 (36 %, 95 % CI 20 %−53 %) patients in the observation group had a gallstone related event compared to 6 of 31 (19 %, 95 % CI 5%−33 %) patients in the operation group, but the difference was not significant. When patients were grouped according to randomization or actual operative outcome (+/− cholecystectomy), we did not find any significant differences in pain or quality of life measurements.

Conclusion:

Although conservative treatment of AC carried a certain but not significantly increased risk of subsequent gallstone related events, this did not influence the symptomatic outcome as assessed by quality of life and pain measurements. Thus, we argue that conservative (non-operative) treatment and observation of AC is an acceptable option and should at least be considered in elderly and frail patients.
Fate of the Rectum after Colectomy with Ileorectal Anastomosis in Ulcerative Colitis
Authors: Lepistö A. , Järvinen H. J.
Published: January 2017

Objective:

Aim of the study was to evaluate the cumulative success of colectomy and ileorectal anastomosis in 20 patients with ulcerative colitis.

Patients and Methods:

Data were collected from patient histories and cumulative success was calculated by the Kaplan-Meier method.

Results:

Seven of 20 (35 %) ileorectal anastomoses were lost. Cumulative success rate was 84 % at 5 years, 69 % at 10 years and 56 % at 20 years. Most common indication for proctectomy was disabling proctitis. Other reasons for failure were postoperative ileal necrosis and persisting presacral infection. Patients with advanced colonic cancer managed relatively well with ileorectal anastomosis until death. No cases of rectal cancer were detected during postoperative follow-up but one moderate dysplasia was treated locally.

Conclusion:

Ileorectal anastomosis can be chosen for patients who are not suitable for ileoanal operation. Rectal endoscopies are mandatory postoperatively.
Surgery for Pilonidal Disease
Authors: Hølmebakk T. , Nesbakken A.
Published: January 2017

Background and Aims:

Surgery for pilonidal disease carries a considerable risk of complications, recurrence, and cosmetic sequelae. The present study evaluates the four procedures performed in our institution.

Material and Methods:

Operations from 1999 through 2002 were retrospectively assessed. Cosmetic result and overall satisfaction were reported on visual analogue scales.

Results:

Seventy-three procedures were performed in 71 patients: excision with open granulation in nine; excision and primary suture in 25; rhomboid plasty in 23; and lay-open in 16 patients. Infections were as frequent after rhomboid plasty (40 %) as after excision and primary suture (43 %). Nineteen recurrences (26 %) were observed during a median follow-up of 20 months, and the estimated five-year actuarial recurrence rate was 44 %. Recurrence occurred in 1/9 (11 %) after excision with granulation, in 4/23 (17 %) after excision and suture, in 5/25 (20 %) after rhomboid plasty, and in 9/16 patients (56 %) after lay-open. The cosmetic result was satisfactory only in 22/53 (42 %) patients; the result was poor in 16/53 (30 %) patients.

Conclusion:

Results after surgery for pilonidal disease are modest and should be compared to conservative management in a randomised trial.
The Profile of Leg Symptoms, Clinical Disability and Reflux in Legs with Previously Operated Varicose Disease
Authors: Saarinen J. , Suominen V. , Heikkinen M. , Saaristo R. , Zeitlin R. , Vainio J. , Nordback I. , Salenius J-P.
Published: January 2017

Purpose:

It is difficult to assess the severity and location of venous insufficiency in legs with recurrent varicose disease. This present purpose was to evaluate the distribution of reflux and the diagnostic role of current classifications in a consecutive series of legs with previously operated varicose disease.

Methods:

A total of 90 legs in a cohort of 66 patients were included. The examination comprised CEAP clinical class, clinical disability score (CDS) and leg symptoms. Colour-flow duplex imaging (CFDI) was used to observe reflux in deep and superficial veins. Details of prior surgery were assessed.

Results:

The site of superficial reflux was at the groin in 58 % (recurrent or residive vein trunk or unoperated great saphenous vein), and the rate in the popliteal fossa was 11 % (unoperated short saphenous vein). In 58 % of the legs presenting superficial reflux at groin level, previous surgery at the saphenofemoral junction was noted. A sensation of pain was observed in 74 % of the legs, sensation of oedema in 64 %, itching in 26 %, and night cramps in 8%, respectively. Only itching was significantly infrequent in uncomplicated (CEAP C 2–3) legs, and in legs with local reflux was restricted to vein tributaries. Higher CDS (classes 2–3) were significantly more frequent among complicated legs (CEAP clinical class C2–3: 22% versus CEAP clinical class C4–6: 77%; p < 0.005). A similar situation was noted when legs with only local reflux were compared to those with more severe reflux (local reflux: 7 % versus severe reflux: 48 %; p < 0.005).

Conclusions:

Superficial reflux is frequently detected at groin level despite prior surgery. Unstructured evaluation of leg symptoms is not beneficial. Clinical disability scores associate well with the severity of the venous disease.
Comparison between Flutter Valve Drainage Bag and Underwater Seal Device for Pleural Drainage after Lung Surgery
Authors: Vuorisalo S. , Aarnio P. , Hannukainen J.
Published: January 2017

Aim of the study:

The purpose of the present study was to compare the use of a conventional underwater seal device with suction and a flutter valve drainage bag for pleural drainage after lung surgery.

Patients and Methods:

Altogether 59 patients undergoing elective lung surgery except pneumonectomy between February 2001 and April 2002 were prospectively randomized to receive postoperative pleural drainage by 28F chest tube(s) attached to underwater seal device placed on negative pressure of 15 cm of water or flutter valve drainage bag. Following withdrawal of four patients from the study, 55 patients were evaluated (31 patients in the underwater seal device group and 24 patients in the flutter valve drainage bag group).

Results:

In the conventional underwater seal device group the mean drainage time was 2.6 (SD ± 2.0) days and in the flutter valve drainage bag group the mean drainage time was 3.3 days (SD ± 4.0); difference −0.8, 95% confidence interval (CI) −2.4 to 0.9. The mean length of hospitalization in the surgical ward was 3.6 (SD ± 2.7) and 4.1 (SD ± 4.4) days respectively (difference −0.5, 95% CI −2.5 to 1.4).

Conclusions:

The results of this study suggest that flutter valve drainage system is a safe and feasible alternative in managing postoperative air leaks and haemorrhage after lung surgery other than pneumonectomy if air leaks are not extremely massive.
Four or Twelve Months' Follow-Up in the Evaluation of Functional Outcome after Hip Fracture Surgery?
Authors: Heikkinen T. , Jalovaara P.
Published: January 2017

Background and Aims:

As a rule, follow-up for at least one year is recommended for fracture studies. This is considered the shortest reliable interval. Still, in the case of hip fractures of the elderly, shorter follow-up might be more practical, since the life expectancy of these patients is often short. The aim of this study was to see if a short four months follow-up period would be acceptable in hip fracture surveys.

Material and Methods:

Information on 196 consecutive non-pathological hip fracture patients aged 50 years or over (mean 79 years) was collected using a standardised hip fracture audit concentrating on functional measurements at admission and at four and twelve months' follow-ups.

Results:

167 patients were alive at four months and 152 and at one year. The patients who died between four and twelve months had poorer functional capacity in the four-month evaluation than those who survived one year. The analysis of repeated measures, including only the patients alive at the last follow-up, showed that residential status, use of walking aids and 6 out of 10 and ADL variables (bathing, toileting, shopping, household activities, doing laundry, banking) did not change significantly. Walking ability and the rest 4 ADL variables (dressing, eating, food preparation, use of transportation) improved and pain decreased.

Conclusions:

Due to high mortality and age-related deterioration of functioning, no steady state i.e. “final result” is ever reached after hip fracture in the elderly. Four-month follow-up is justified as the shortest possible period, because the socioeconomically most important variable, i.e. place of living, and most of the ADL functions do not change significantly after that.
Gamma Irradiation and Ethylene Oxide in the Sterilization of Native Reindeer Bone Morphogenetic Protein Extract
Authors: Pekkarinen T. , Hietala O. , Jämsä T. , Jalovaara P.
Published: January 2017

Background and Aims:

For human use, it is necessary to sterilize bone morphogenetic proteins (BMPs), in order to reduce the risk of infections and associated complications. We compared the effects of ethylene oxide and gamma irradiation in the sterilization of native reindeer BMP extract with regard to bone induction in the Balb/C mouse thigh muscle pouch model.

Materials and Methods:

BMP extract, sterilized with ethylene oxide gas (Steri-Vac 4XL' temperature 29°C, exposure time 4 h, ethylene oxide concentration 860 mg/l), or gamma irradiation at doses of 3.15 MRad was administered in implants containing 5 or 10 mg of BMP extract with collagen carrier. Non-sterilized collagen implants served as controls. New bone formation was evaluated based on the incorporation of Ca45 and radiographically three weeks after implantation.

Results:

The collagen was not able to induce new bone visible in radiographs. The mean Ca45 incorporation in the gamma sterilized group containing 5 mg of BMP extract was 30 % (p = 0.04) and that containing 10 mg of BMP extract was 60 % (p = 0.02) higher than seen in the corresponding ethylene oxide sterilized groups. The mean new bone areas were 45 % higher in the gamma sterilized groups than in the corresponding ethylene oxide sterilized groups, but the differences were not significant. The mean optical density of new bone in the gamma sterilized group containing 5 mg of BMP extract was 75 % (p = 0.00) and in that containing 10 mg of BMP extract was 70 % (p = 0.00) higher than seen in the corresponding ethylene oxide sterilized groups.

Conclusion:

Native reindeer BMP extract is more sensitive to the effects of ethylene oxide gas sterilization than gamma irradiation. These results suggest that gamma irradiation is recommendable for the sterilization of BMP extracts.
Molecular Basis for Action of Bioactive Glasses as Bone Graft Substitute
Authors: Välimäki V.-V. , Aro H. T.
Published: January 2017

Bone grafting procedures are undergoing a major shift from autologous and allogeneic bone grafts to synthetic bone graft substitutes. Bioactive glasses are a group of synthetic silica-based bioactive materials with bone bonding properties first discovered by Larry Hench. They have several unique properties compared with other synthetic bioresorbable bioactive ceramics, such as calcium phosphates, hydroxyapatite (HA) and tricalcium phosphate (TCP). Bioactive glasses have different rates of bioactivity and resorption rates depending on their chemical compositions. The critical feature for the rate of bioactivity is a SiO2 content <60% in weight. In vivo, the material is highly osteoconductive and it seems to promote the growth of new bone on its surface. In a recent study, the activity of the material was found even to overshadow the effect of BMP-2 gene therapy. In vivo, there is a dynamic balance between intramedullary bone formation and bioactive glass resorption. Recent studies of molecular biology have shown that bioactive glass induces a high local turnover of bone formation and resorption. Many osteoporotic fracture patients are candidates for concurrent treatment with bisphosphonates and bioceramic bone graft substitutes. Since osteopromotive silica-based bioactive glasses induce accelerated local bone turnover, adjunct antiresorptive agents may affect the process. However, a recent study showed that an adjunct antiresorptive therapy (zoledronic acid) is even beneficial for bone incorporation of bioactive glass. Based on these observations, bioactive glasses are a promising group of unique biomaterials to act as bone graft substitutes.
Carcinoid Tumours in the Gastrointestinal Tract — A Population-Based Study from Western Norway
Authors: Helland S. K. , Prøsch A. M. , Viste A.
Published: January 2017

Objective:

To analyze population-based incidence, anatomic distribution and patient characteristics of gastrointestinal carcinoid tumours.

Background:

Neuroendocrine carcinomas (NE, carcinoid tumours) arise from neuroendocrine cells and are most commonly found in gastrointestinal tract and lungs. Previous studies on carcinoids report varying incidence rates, location of tumours and patient survival rates.

Methods:

Retrospective study.88 patients were diagnosed with carcinoids located in the gastrointestinal tract in the period 1983–2003 in the Norwegian counties Hordaland and Sogn og Fjordane. Patient and tumour characteristics, treatment and survival were analyzed in a sub-group of 51 patients treated at Haukeland University Hospital.

Results:

Incidence of carcinoids was 0.8 when analyzed from the counties Hordaland and Sogn og Fjordane as well as when analyzed from Haukeland University Hospital. There were 26 men and 25 women. Median age at surgery was 61 years (range 17–87 years). The tumours were located in the small bowel in 53%, appendix 18%, colon 4%, rectum 4%, stomach 8% and duodenum 10%. Five-year survival rate was 50% in stomach, 80% in duodenum, 43% in the small bowel, 100% for tumours in appendix, 40% in colon and 100% in rectum.

Conclusion:

Carcinoid tumours are relatively uncommon neoplasms and most of them are found in the small bowel. Carcinoids in the ileum tend to be more aggressive and carry a poorer prognosis than carcinoids at other locations. Tumours in the appendix are found at lower age and in an early stage. They rarely metastasize and have an excellent prognosis.
Diagnostic Laparoscopy and Ultrasonography for Colorectal Liver Metastases
Authors: Mortensen F. V. , Zogovic S. , Nabipour M. , Nielsen D. Tønner , Pahle E. , Rokkjaer M. , Jensen L.
Published: January 2017

Background and Aims:

To evaluate diagnostic laparoscopy (DL) and laparoscopic ultrasonography (LuS) in the diagnostic workout of patients with colorectal liver metastases, who were considered to have resectable disease after multi detector computed tomography (MDCT).

Material and Methods:

The medical records of 45 patients, 22M/23F, mean age 62.0 (± 10.6), who were considered to have resectable liver metastases after CT-scan, were analysed.

Results:

DL and LuS could not be performed in 7 patients (16%) because of adhesions. unresectable disease was detected by DL in 3 patients (7%), in all cases due to carcinosis. Additional lesions in the liver were detected by DL in 2 cases (4%), none of these making the patient unresectable. LuS showed additional lesions in 3 patients (7%), which in one case (2%) made the patient unresectable. None of the patients in the present study experienced adverse effects to DL or LUS.

Conclusion:

DL and LUS, due to the low efficacy with regard to avoid unnecessary laparotomies and the relative high failure rate because of adhesions, should not be a routine part of the diagnostic work out in patients with colo-rectal liver metastases.
Pulmonary Sequestration — A Review of 8 Cases Treated with Lobectomy
Authors: Pikwer A. , Gyllstedt E. , Lillo-Gil R. , Jönsson P. , Gudbjartsson T.
Published: January 2017

Background and Aims:

Pulmonary sequestration (PS) is a rare congenital malformation where non-functioning lung tissue is separated from the bronchial tree and vascularised with an aberrant artery from the systemic circulation. The aim of this report was to study all patients who were treated for PS at Lund University Hospital between 1994 and 2004, with emphasis on clinical presentation of the disease and evaluate the results of surgical treatment.

Material and Methods:

8 cases were identified, 7 females and one male, with a mean age of 7.3 years (range 25 days — 17 years) at the time of diagnosis.

Results:

Out of 8 patients, seven presented with respiratory symptoms and two with congestive heart failure. Five patients had other congenitial malformations; including scimitar syndrome and congenital heart disease. All the patients underwent a successful lobectomy. There were no major postoperative complications. At a medium follow-up of 77 months all of the fully treated children were doing well.

Conclusion:

Respiratory and cardiovascular symptoms are the most common symptoms related to PS. The wide range of clinical symptoms may cause diagnostic problems, especially in children and young adults with concomitant congenital heart disease. Therefore PS should be considered as a differential diagnosis in children with unexplained respiratory symptoms or with signs of congestive heart failure. In patients with PS, lobectomy seems to be a good therapeutic option.
Predictive Value of Parathyroid Scintigraphy in the Preoperative Evaluation of Patients with Primary Hyperparathyroidism
Authors: Rasmussen K. , Larsen L. P. , Arveschoug A. , Nielsen J. Theil , Vestergaard P. , Rønning H. , Mosekilde L. , Christiansen P.
Published: January 2017

Background and Aims:

The surgical gold standard in primary hyperparathyroidism was until recently exploration of all four parathyroid glands. Today more patients undergo minimal invasive procedures demanding more accurate preoperative localization studies. The aim of the study was to determine the positive predictive value (PPV) of parathyroid scintigraphy (PS) and to some extent ultrasonography (US), defined as the probability of finding one single adenoma on the affected side at surgery when the scans had shown one single focus.

Material and Methods:

Eighty-eight surgically treated patients (76 women and 12 men, 8 with multiglandular disease) were included. The PS consisted of 99mTc-sestamibi scan with dual-phase technique, both planar and SPECT imaging, followed by 99mTc-pertechnetate scan. A positive scan was defined as a single focus accumulating sestamibi. Focal lesions on US were defined as hypoechoic nodules.

Results:

PS was positive in 80 patients. Seventy-nine had only one focus, of which 64 were correctly localized adenomas (PPV 81%). Forty-seven of 77 US examinations were positive. In 44 there was only one focus of which 38 were correctly localized (PPV 86%). PPV was 97% when both examinations were positive.

Conclusions:

Both PS and US have acceptably high PPVs defined as the ability to predict whether or not one single focus represents a parathyroid adenoma. Concordant positive results were accompanied by a PPV close to 100%.
The Essentials of Locoregional Control in the Treatment of Gastric Cancer
Authors: den Dulk M. , Verheij M. , Cats A. , Jansen E. P. M. , Hartgrink H. H. , van de Velde C. J. H.
Published: January 2017

Gastric cancer is the fourth most frequent cancer in the world. For curative treatment and local control of gastric cancer, surgery is essential. The extent of the lymph node dissection is still under debate. Only one available trial showed significantly increased overall survival, whereas in all other randomised trials no significant difference could be found.

As surgery alone often is not sufficient in the curative treatment in gastric cancer, different (neo)adjuvant treatment strategies have extensively been studied. The recently published MAGIC trial showed downstaging, downsizing and an improved overall survival for patients treated with perioperative chemotherapy, compared to surgery alone (difference 13%, p = 0.009). The INT 0116 trial on the other hand, demonstrated the benefit of postoperative chemoradiotherapy compared to surgery alone for patients with a curative resection of gastric cancer. However, the quality of resections in this trial was poor, illustrating the importance of standardisation by quality control. This could be done by the Maruyama index, which quantifies the likelihood of unresected disease.

In the Netherlands, the CRITICS trial has recently been launched, which will be a quality controlled trial comparing postoperative chemoradiotherapy and chemotherapy on survival and/or locoregional control in patients who receive neoadjuvant chemotherapy followed by a D1+ gastric resection.
Early Gastric Cancer: Diagnosis and Less Invasive Treatments
Authors: Sano T. , Hollowood A.
Published: January 2017

The prognosis of early gastric cancer (EGC) is excellent worldwide. Incidence of EGC shows considerable geographic variation, and in high prevalence areas where diagnostic skills are adept, EGCs are not frequently overlooked. In these countries, less invasive, function-preserving treatments such as endoscopic mucosal resection and pylorus-preserving gastrectomy have become standard options. The criteria to apply conservative treatments are being expanded along with the technological improvement. Though its natural history is relatively long, EGC could be a fatal disease and should be carefully treated. Lymph node metastasis is the most important prognostic factor that should be considered in treatment selection and follow-up planning of EGC.
Adenocarcinoma of the Esophago-Gastric Junction
Authors: Siewert J. R. , Stein H. J. , Feith M.
Published: January 2017

Background:

The border between the esophagus and stomach gives rise to many discrepancies in the current literature regarding the etiology, classification and surgical treatment of adenocarcinoma arising at the esophago-gastric junction. We have consequently used the AEG-criteria (adenocarcinoma of the esophago-gastric junction) for classification and have based the selection of the surgical approach on the anatomic topographic subclassification.

Methods:

In the following we report an analysis of a large and homogeneously classified population of 1602 consecutive patients with adenocarcinoma of the esophago-gastric junction, with an emphasis on the surgical approach, the pattern of lymphatic spread, the outcome after surgical treatment and the prognostic factors. Demographic data, morphologic and histopathologic tumor characteristics, and long-term survival rates were compared among the three tumor subclassifiations.

Results:

The study confirms the marked differences in sex distribution, associated specialized intestinal metaplasia in the esophagus, tumor grading, tumor growth pattern, lymphatic spread, and stage between the three tumor entities. The degree of resection and lymph node status were the dominating independent prognostic factors by multivariate analysis. The data show no significant differences of long-term survival after abdomino-thoracic esophagectomy and extended total gastrectomy in these patients.

Conclusion:

The classification of adenocarcinomas of the esophago-gastric junction in three types, AEG type I, type II and type III shows marked differences between the tumor entities and is recommended for selection of a proper surgical approach. Complete tumor resection and adequate lymphadenectomy are associated with good long-term prognosis. Better surgical management and standardized procedures will improve the outcome also of patients who need to undergo more radical surgery, i.e. abdomino-thoracic esophagectomy.