Granulomatous appendiceal disease in cystic fibrosis

Abdominal pain due to acute appendicitis in patients with cystic fibrosis is uncommon. A review of 572 patients with cystic fibrosis from the cystic fibrosis clinic of the Children's Hospital of Pittsburgh from 1959 to 1983 disclosed only 4 in whom the diagnosis of acute appendicitis lead to appendectomy. In 3 of these the diagnosis was confirmed at operation. In 1 child, laparotomy for a persistent asymptomatic abdominal mass disclosed a huge cecal fecaloma originating in the appendiceal lumen. Histological examination of the appendix established the diagnosis of cystic fibrosis. Large, symptomatic appendiceal granulomas were noted in 6 other children; these simulated abdominal tumors in 2. In 3 others there was smoldering infection and abscess with sepsis and in 1 a colocystic fistula. Such chronic granulomas, acute appendicitis, meconium ileus, and nonsurgical abdominal pain in cystic fibrosis can best be differentiated by careful clinical examination before and after treatment for meconium ileus equivalent. The granulomas involve not only the appendix but also the cecum and ascending colon. Contrast X-ray studies are of little value in diagnosis. The appendix in cystic fibrosis undergoes changes that are diagnostic even in the newborn; the granulomas described here appear to represent a progression of these changes.Offprint requests to: W. K. Sieber     

Effect of the somatostatin analogue lanreotide on meal-stimulated portal blood flow in patients with liver cirrhosis

BACKGROUND: Lanreotide, a new long-acting somatostatin analogue, has been shown to inhibit the meal-stimulated increase of splanchnic blood flow in healthy volunteers. To date, similar data in patients with liver cirrhosis have not been available. We have examined the effect of lanreotide compared with placebo on meal-stimulated portal blood flow in patients with liver cirrhosis using Doppler ultrasound. METHODS: 20 cirrhotic patients (placebo n = 12, lanreotide n = 8) with proven portal hypertension were studied after an overnight fast. Lanreotide, at a dose of 100 microg/h, was infused intravenously over 7 h after a 1-hour basal period. In parallel to the intravenous infusion, a liquid test meal (Ensure plus, 1.5 kcal/min) was perfused for 7 h through an intraduodenal tube at a rate of 3 ml/min. Blood pressure, heart rate and portal vein blood flow (PVF, ml/min, Doppler technique) were determined at regular intervals. RESULTS: Baseline PVF amounted to 725 +/- 182 ml/min in the placebo and to 917 +/- 252 ml/min in the lanreotide group (n.s.). The meal-stimulated increase in PVF was blunted by lanreotide (AUC, % x min): 62,709.6 +/- 6,817 (placebo) vs. 45,237 +/- 2,507 (lanreotide), p < 0.05. Lanreotide also blunted the postprandial increase in heart rate for the first 2 h of meal perfusion. CONCLUSIONS: Because of potent inhibition of postprandial splanchnic hyperemia in patients with liver cirrhosis, lanreotide may be useful in the treatment of complications of portal hypertension.     

Erythroid progenitors in mouse bone marrow detected by macroscopic colony formation in culture.

Methods for the cultivation of erythroid colonies in vitro are expected to allow selective assay of the earliest committed erythropoietic progenitors in the hemopoietic tissues of man and other species. In the present study, factors affecting erythroid colony formation were examined in methyl cellulose cultures of mouse bone marrow. Efficiency of colony formation observed after 2 days of culture was increased as much as 5-fold (to an average of 325 colonies/10-5 nucleated marrow cells) by the addition of thiol (either beta-mercaptoethanol or alphal-thioglycerol) at a final concentration of 10 minus 4 M. Optimum efficiency required 0.5 erythropoietin units/ml and was influenced by the purity of the preparation. When cultures contained thiol and high doses (3 units/ml) of purified erythropoietin, a second population of erythroid colonies became apparent after 5 days of culture, and increased in size to macroscopic dimensions by the tenth day, when they contained as many as 10-4 cells. Feeding was not required. These colonies, thought to be analogous to the "bursts" reported by Axelrad and coworkers in plasma clot cultures, were observed here at a 6-fold higher frequency (25/10-5 marrow cells) and were linearly related to the number of marrow cells plated, down to limiting numbers of colonies. On the basis of their impressive proliferative potential exhibited in culture, the cells originating these colonies are thought to represent a class of very early erythropoietin-responsive red cell progenitors.     

Zufriedenheit einweisender ?rzte als Qualit?tskriterium im Rettungsdienst

Background

Having published the outcome of his surgical work in 1914, Ernest Codman is seen as the founder of total quality management in medicine. Many publications on the quality of structure, process and outcome in emergency medical services followed at the turn of the millennium. In this work we examined the dimension of satisfaction of referring physicians as an instrument of quality assurance in emergency medical services.

Methods

A questionnaire was sent to referring physicians. Satisfaction about emergency call provider 144, time until arrival at the emergency scene, organization, treatment, expertise and interpersonal skills including cooperation with the referring physician were evaluated for three Swiss Emergency Medical Services.

Results

Detailed analysis brings strength and weaknesses to light. The overall satisfaction was high and reached a value of 88.0%.

Conclusions

Total quality management in medicine focused on effectiveness and efficiency in the past. Quality of structure, process and outcome will remain standard; however, it is time to broaden the concept with soft-skill factors.     

The role of distal third radius dual energy X-ray absorptiometry (DXA) and central DXA in evaluating for osteopenia and osteoporosis in men receiving androgen deprivation therapy for prostate cancer

The authors assessed the use of distal third radius dual energy X-ray absorptiometry (DXA) concomitantly with central (hip and lumbar spine) DXA to identify men with osteopenia or osteoporosis receiving androgen deprivation therapy (ADT) for prostate cancer. Initial classification with central DXA demonstrated 60 (17%) normal, 187 (55%) osteopenic, and 96 (28%) osteoporotic patients. Sixteen of 60 (27%) normal patients were reclassified as osteopenic (14) or osteoporotic (2), and 20 of 187 (11%) osteopenic patients were reclassified as osteoporotic with the combination of central DXA plus distal third radius DXA. The difference in reclassification was statistically significant. The addition of distal third radius to central DXA scanning in men with bone loss associated with ADT identifies a statistically significant number of men being reclassified as having osteopenia or osteoporosis. Combined central and distal third radius DXA scanning should be considered routine in the evaluation of all men suspected of bone loss associated with ADT. This has specific significant clinical relevance because of the large number of men with nonevaluable central DXA studies. Fracture risk prediction and treatment recommendations based on this reclassification will need to be determined by follow-up studies.     

Complications and mortality after percutaneous endoscopic gastrostomy in geriatrics: a prospective multicenter observational trial

BackgroundGenerally, the high short-term mortality after percutaneous endoscopic gastrostomy (PEG) in geriatric patients is attributed to the severity of their underlying diseases. However, the procedure-related mortality in this group is unknown.MethodsThis prospective multicenter observational study gathered information about 197 geriatric patients treated with PEG insertion, including the indication for PEG insertion and the prevalence of postprocedure complications and analyzed how these factors related to mortality.ResultsDysphagia (64%) and insufficient food intake (76%) were the most frequent indications for PEG insertion. Severe complications after PEG insertion occurred in 9.6% of patients. Mortality was 9.6% in hospital, as well as 18.4% at 1 month. Six months after PEG placement, with 81 patients lost to follow-up, mortality was 51.9%. Hospital mortality was significantly higher in patients with severe complications caused by PEG insertion (47.4% vs 5.6%; P < .001). A regression analysis that corrected for confounding factors revealed that severe complications in general (HR 6.9; 95% CI: 2.6–18.1; P < .001), peritonitis (HR 33.1; 95% CI: 3.7–293.2; P = .002), and severe wound infections (HR 6.9; 95% CI: 1.9–24.9; P = .003) were each independently associated with hospital mortality. Considering the prevalence of procedure-related complications and their association with early mortality after PEG insertion, the procedure-related mortality rate in geriatric patients was at least 2% in this study.ConclusionAlthough the prevalence of complications after PEG in this study of multimorbid geriatric patients is within the expected range, the procedure-related mortality is higher than expected.