The impact of percutaneous transluminal angioplasty on the management of peripheral vascular disease

Percutaneous transluminal angioplasty is a well established technique with wide application, but its place in the overall management of peripheral vascular disease is not well defined. This study compares similar groups of patients with peripheral vascular disease in 1981 and 1984, before and after the introduction of the technique to a district general hospital. More patients are now being investigated and treated and this is almost entirely due to the availability of angioplasty. The rates for surgery have not changed. Percutaneous transluminal angioplasty should therefore be seen as a new and separate form of treatment for peripheral vascular disease, not necessarily influencing or replacing surgery, and requiring its own allocation of resources in accordance with the increase in the level of care afforded by the technique.     

Primary squamous cell carcinoma of the thyroid gland: a case report and role of radiotherapy.

Primary squamous cell carcinoma is an extremely rare tumour of the thyroid gland. A case of an elderly lady who was diagnosed to have primary squamous cell carcinoma of the thyroid gland is presented and the role of radiotherapy is discussed.     

Endometrial carcinoma: Does the addition of intracavitary vault caesium to external beam therapy postoperatively result in improved control or increased morbidity?

A retrospective analysis of treatment for endometrial carcinoma is reported here. From 1987 to 1989, 138 patients were referred to the oncology department following total abdominal hysterectomy and bilateral salpingo-oophorectomy for endometrial cancer. Forty-seven patients were not prescribed postoperative radiotherapy; 31 had Stage I well differentiated adenocarcinoma with minimal myometrial invasion, while the remaining 16 patients were considered unfit for postoperative radiotherapy. There were no instances of local relapse amongst the 31 patients with minimal myometrial invasion.The remaining 91 patients all received external beam irradiation to the pelvis and, according to the preference of the individual therapist, 51 were prescribed additional intracavitary vault caesium-137. Patients receiving postoperative radiotherapy were analysed according to whether or not they received additional intracavitary vault caesium. The two groups were also analysed for incidence of vaginal vault recurrence and treatment related morbidity.In the group receiving additional intracavitary treatment more patients had Stage II or III disease (P<0.05), and had greater depth of myometrial invasion (P<0.05). Vaginal vault recurrence was not observed in patients receiving intracavitary therapy in addition to external beam therapy. Four patients (10%) receiving external beam therapy alone developed vaginal vault recurrence.The incidence of Kottmeier-Perez grade 2 or 3 bowel toxicity following treatment was significantly higher in those patients receiving combined treatment (18% vs. 2.5%; P<0.03). There was also a higher incidence of vaginal stenosis in the group receiving both external beam and intracavitary therapy (21% vs. 3%; P<0.05). There was only one instance of grade 2 bladder toxicity in the external beam and intracavitary treatment group and none in the external beam therapy alone group.In conclusion, postoperative radiotherapy for Stages I-III endometrial carcinoma was carried out in a non-randomized manner by two regimens; either external beam therapy alone or external beam therapy with additional intracavitary vaginal caesium. The combined therapy gave significantly better local control but resulted in significantly more late bowel and vaginal morbidity.     

Issues confronting the new health professionals.

New health practitioners (NHPs) is a generic term referring to mid-level health workers such as physician's assistants and nurse practitioners who perform tasks traditionally within the purview of physicians. In the little over ten years since the first program to train physician assistants was initiated at Duke University, 6,500 physician's assistants (PAs) have completed formal training programs. Similarly, programs to train nurses for extended roles have prepared more than 8,500 nurse practitioners over the same decade. This paper considers the comparative achievements of these two major new health professions during the last decade and identifies eight crucial issues which may influence new health professionals in the ten years which lie ahead: (1) How many NHPs are enough? (2) What impact are NHPs making on distribution? (3) Do we know what clinical difference NHPs make? (4) Are NHPs bringing about cost control in health care? (5) What is the status of the controversy between organized medicine and nursing with regard to NHPs? (6) Are there differences between nurse practitioners and physician's assistants? (7) How are NHPs certified? and (8) Finally, can a better name than "new health practitioners" be found?     

Glucocorticoids exacerbate insult-induced declines in metabolism in selectively vulnerable hippocampal cell fields

Glucocorticoids (GCs), the adrenal steroids released during stress, can compromise the ability of hippocampal neurons to survive necrotic neurological insults. This GC-induced endangerment has energetic facets, in that it can be attenuated with energy supplementation. In the present report, we studied the effects of GCs on the metabolic response of specific hippocampal cell fields to necrotic insults. We used silicon microphysiometry, which allows indirect measurement of metabolism in real time in tissue explants. Aglycemia caused a significant decline in metabolism in dentate gyrus explants, but not in CA1 or CA3 explants. When coupled with our prior report of cyanide disrupting metabolism only in CA1 explants, and the glutamatergic excitotoxin kainic acid disrupting metabolism only in CA3 explants, this demonstrates that microphysiometry can detect the selective regional vulnerability that characterizes the hippocampal response to these necrotic insults. We then examined the effects of GCs on the response to these insults, monitoring explants taken from rats that were adrenalectomized, intact, or treated with corticosterone (the GC of rats) that produced circulating levels equivalent to those of major stressors. Increased exposure to GCs worsened the decline in metabolism in dentate gyrus explants induced by hypoglycemia, and in CA1 explants induced by cyanide (after eliminating the effects of glial release of lactate for the support of neuronal metabolism). Thus, GCs worsen the metabolic consequences of necrotic insults in hippocampal explants.     

A decade of experience with the primary pull-through for hirschsprung disease in the newborn period: a multicenter analysis of outcomes

OBJECTIVE: To determine whether use of a primary pull-through would result in equivalent perioperative and long-term complications compared with the two-stage approach. SUMMARY BACKGROUND DATA: During the past decade, the authors have advanced the use of a primary pull-through for Hirschsprung disease in the newborn, and preliminary results have suggested excellent outcomes. METHODS: From May 1989 through September 1999, 78 infants underwent a primary endorectal pull-through (ERPT) procedure at four pediatric surgical sites. Data were collected from medical records and a parental telephone interview (if the child was older than 3 years) to assess stooling patterns. A similar group of patients treated in a two-stage fashion served as a historical control. RESULTS: Mean age at the time of ERPT was 17.8 days of life. Comparing primary ERPT with a two-stage approach showed a trend toward a higher incidence of enterocolitis in the primary ERPT group compared with those with a two-stage approach (42.0% vs. 22.0%). Other complications were either lower in the primary ERPT group or similar, including rate of soiling and development of a bowel obstruction. Median number of stools per day was two at a mean follow-up of 4.1 +/- 2.5 years, with 83% having three or fewer stools per day. CONCLUSIONS: Performance of a primary ERPT for Hirschsprung disease in the newborn is an excellent option. Results were comparable to those of the two-stage procedure. The greater incidence of enterocolitis appears to be due to a lower threshold in diagnosing enterocolitis in more recent years.