Endoluminal fundoplication – the Hill procedure

Endoluminal operations for reflux are currently limited by the inability to visualise and manipulate structures outside the wall of the gut. This may be possible using endoscopic ultrasound (EUS). The aim of this study was to define EUS‐anatomy of structures outside the gut which influence reflux; to place stitches in the median arcuate ligament (MAL); to perform posterior gastropexy (Hill procedure) and test the feasibility of crural repair under EUS control in pigs. In survival experiments in 14 pigs, using linear array echo‐endoscopes the MAL and part of the right crus were identified and punctured with a needle, which served as a carrier for a tag and thread. These were anchored into the muscle. An endoscopic sewing device was used allowing stitches to be placed through a 2.8?mm accessory channel to any predetermined depth. New methods allowed knot‐tying and thread‐cutting through the 2.8?mm channel of the echo‐endoscope. Stitches were placed through the gastric wall into the MAL and one just beyond the wall of the lower esophageal sphincter (LES). They were tied together and locked against the gastric wall. Preoperative manometry showed a median LES pressure of 11mm/Hg and 21?mm/Hg after stitch placement (p = 0.0028). The length of the LES increased from median 2.8?cm pre‐procedure to 3.5?cm post‐procedure. At post mortem, the force to pull the tags out of the MAL was 2.8?kg median. This study shows that transgastric gastro‐esophageal reflux surgery using stitching under EUS control can significantly increase the lower oesophageal sphincter pressure in pigs.     

Testosterone and cardiovascular disease – the controversy and the facts

Since November 2013, there has been a flurry of articles written in the media touting the risk of cardiovascular (CV) disease in men treated with testosterone, based on two recent reports. Since first synthesized in 1935, testosterone therapy has demonstrated substantial benefits for men with testosterone deficiency (also called hypogonadism). Testosterone has an acceptable safety profile and literature spanning more than 30 years, suggesting a decreased CV risk with low levels of testosterone and benefits associated with testosterone therapy. However, nonmedical media outlets have seized on reports of increased CV risk, and published scathing editorials impugning testosterone therapy as a dangerous and overprescribed treatment. Here, we review these recent studies, and find no scientific basis for assertions of increased CV risk. This article is intended to provide the clinician with the facts needed for an informed discussion with men who suffer from testosterone deficiency and who desire treatment for their symptoms.     

Testing the water – problem-based learning and the cultural dimension

This study reports the findings of a small case study using problem-based learning (PBL) as a teaching and learning strategy in a cultural awareness module, which forms part of a pre-registration diploma in nursing course.The study was carried out using a qualitative research methodology. It aimed to describe and explore 20 diplomat student nurses and their lecturers’ experience of undertaking PBL. The categories that emerged from the analysis were: knowledge development and PBL process. A selection of these categories and their sub-categories are described and discussed in relation to the literature on problem-based learning.The study concluded that undergoing PBL as a teaching and learning strategy had positive outcomes for the students. Prior knowledge was utilised in knowledge development in relation to the problem and was seen as beneficial. Students reported that they felt more confident and used the knowledge gained to care for patients’ cultural needs in practice. Students also identified lack of knowledge amongst staff in the clinical area in relation to cultural awareness. There were however some challenges in the transition to a PBL strategy from the perspective of the students and lecturers. Issues that were found to be difficult include the change to a different teaching and learning strategy, the implications of self-direction for the student and the role of the facilitator as a non-directive guide. The study recommends that the findings may be of use for other nurse educators implementing PBL as a teaching and learning strategy.