Endoscopic stapled diverticulotomy: a real advance in the treatment of hypopharyngeal diverticulum

Between November 1993 and May 1996, 51 patients with a hypopharyngeal diverticulum were treated by endoscopic stapled diverticulotomy. Normal swallowing was resumed within 36 h of surgery in 73%, and in 93% by 72 h. Two patients required nasogastric feeding for 5–7 days. There were no operative deaths or serious operative morbidity, and there have been no recorded cases of clinical recurrence of pouches to date (maximum follow-up 562 days: 46 cases over 12 months). The low morbidity, short hospital stay and early return to normal feeding, combined with a relative absence of complications or pouch recurrence, make endoscopic stapled diverticulotomy the treatment of choice for the majority of patients.     

Field and model investigations of external gamma dose rates along the Cumbrian coast, NW England.

A survey of the contribution to external dose from gamma rays originating from intertidal sediments in the vicinity of the British Nuclear Group Sellafield site showed that the major anthropogenic contributions were due to (137)Cs and (60)Co. At some sites, traces of other anthropogenic radionuclides were detected, namely (106)Ru, (125)Sb, and (154)Eu. The proportions of fine grained material (<63 microm) were used to improve model predictions of dose contribution due to external exposure to gamma rays, using the CUMBRIA77/DOSE77 model. Model dose predictions were compared to those directly measured in the field. Using the new proportions of fine grained material (1-17.5%) in conjunction with field gamma-ray spectra, model predictions were improved considerably for most sites. Exceptions were at Drigg Barn Scar and Whitehaven Coal Sands sites, which had their own unique characteristics. The highest (60)Co activity concentrations in this study were detected at Drigg Barn Scar. These relatively high activity concentrations of (60)Co were due to the presence of (60)Co in mussels and barnacles, hence upsetting the fine sediment relationships used in previous dose calculations. Whitehaven Coal Sands was unusual in that it contained higher levels of radionuclides than would be expected in sandy sediment. The mineralogy of these sediments was the controlling factor on (137)Cs binding, rather than the proportion of fine grained material. By adjusting the effective fine grained sediment proportions for calculations involving (60)Co and (137)Cs at Drigg Barn Scar and Whitehaven Coal Sands respectively, the CUMBRIA77/DOSE77 model predictions could be improved upon significantly for these sites. This work highlights the influence of particle size and sediment composition on external dose rate calculations, as well as the potential for external dose contributions from biota.     

9:30-9:45. Preliminary Evaluation of F-18 Fluorocholine (FCH) as a PET Tumor Imaging Agent

The purpose of this study was to develop and evaluate an F-18 labeled choline tumor imaging agent.FCH was synthesized through the intermediate F-18 fluorobromomethane that was used to alkylate dimethylethanolamine. The isolated FCH was evaluated in PC-3 human prostate cancer cells, PC-3 human prostate cancer xenograft studies, and human prostate and brain tumor patients.FCH was accumulated at a slightly lower rate than FDG in the cultures of PC-3 cells. Inhibition of choline transport and phosphorylation by hemicholinium-3 resulted in a 90% decrease in FCH uptake without altering FDG uptake. FCH had a similar biodistribution as C-14 choline in mice, with the liver and kidneys being the primary sites of uptake. Tumor uptake of FCH and FDG were comparable at 45-60 mins after injections. The tumor:blood ratio was higher for FCH (5.3 +/- 2.4) than for FDG (3.2 +/- 0.3). Brain uptake of FCH was 10% that of FDG. FCH-PET studies were compared to FDG-PET studies. In the prostate cancer patients, more lesions have been seen on the FCH studies than on the FDG studies, and the standardized uptake values (SUV) have been higher with the FCH. Decreases in FCH-PET SUV have been noted in patients treated by androgen deprivation. Patients with suspected recurrent brain tumors have had more clearly defined abnormal accumulation on the FCH-PET scans than on the FDG-PET scans. The FCH is not accumulated by normal cortex.FCH is a promising imaging agent for the evaluation of metastatic prostate cancer and recurrent brain tumor.     

Quality of Care for Acute Myocardial Infarction in Rural and Urban US Hospitals

CONTEXT: Acute myocardial infarction (AMI) is a common and important cause of admission to US rural hospitals, as transport of patients with AMI to urban settings can result in unacceptable delays in care. PURPOSE: To examine the quality of care for patients with AMI in rural hospitals with differing degrees of remoteness from urban centers. METHODS: This cohort study used data from the Cooperative Cardiovascular Project (CCP), including 4,085 acute care hospitals (408 remote small rural, 893 small rural, 619 large rural, and 2,165 urban) with 135,759 direct admissions of Medicare beneficiaries ages 65 and older for a confirmed AMI between February 1994 and July 1995. Outcomes included use of aspirin, reperfusion, heparin, and intravenous nitroglycerin during hospitalization; use of beta-blockers, aspirin, and angiotensin-converting enzyme (ACE) inhibitors at discharge; avoidance of calcium channel blockers at discharge; and 30-day mortality. FINDINGS: Substantial proportions of Medicare beneficiaries in both urban and rural hospitals did not receive the recommended treatments for AMI. Medicare patients in rural hospitals were less likely than urban hospitals' patients to receive aspirin, intravenous nitroglycerin, heparin, and either thrombolytics or percutaneous transluminal coronary angioplasty. Only ACE inhibitors at discharge was used more for patients in rural hospitals than urban hospitals. Medicare patients in rural hospitals had higher adjusted 30-day post-AMI death rates from all causes than those in urban hospitals (odds ratio for large rural 1.14 [1.10 to 1.18], small rural 1.24 [1.20 to 1.29], remote small rural 1.32 [1.23 to 1.41]). CONCLUSIONS: Efforts are needed to help hospital medical staffs in both rural and urban areas develop systems to ensure that patients receive recommended treatments for AMI.     

Reduction of atherosclerosis in cholesterol-fed rabbits and decrease of expressions of intracellular adhesion molecule-1 and vascular endothelial growth factor in foam cells by a water-soluble fraction of Polygonum multiflorum

Polygonum multiflorum stilbeneglycoside （PMS） is a water-soluble fraction of Polygonum multiflorum Thunb. , one of the most famous tonic traditional Chinese medicines, that has protective effects on the cardiovascular system. The purpose of the present study is to elucidate the effects of PMS on macrophage-derived foam cell functions and the reduction of severity of atherosclerosis in hypercholesterolemic New Zealand White （NZW） rabbits. NZW rabbits were fed for 12 weeks with a normal diet, a high cholesterol diet, or a high cholesterol diet associated with irrigation with different doses of PMS （25, 50, or 100 mg/kg）. Treatment of NZW rabbits fed with high cholesterol diet with 100 mg/kg PMS attenuated the increase in plasma cholesterol, low-density lipoprotein cholesterol, very low-density lipoprotein cholesterol, and plasma triglyceride. Treatment with 50 and 100 mg/kg PMS caused 43% and 60% decrease in atherosclerotic lesioned area ratio to total surface area, respectively. In U937 foam cells, PMS could decrease the high expression of intercellular adhesion molecule （ICAM）-1 protein and the vascular endothelial growth factor （VEGF） protein levels in the medium induced by oxidized lipoprotein when analyzed by flow cytometry. The results proved that PMS is a powerful agent against atherosclerosis and that PMS action could possibly be through the inhibition of the expression of ICAM-1 and VEGF in foam cells.     

Surgical management of primary aortoesophageal fistula secondary to thoracic aneurysm

Aortoesophageal fistula, secondary to thoracic aortic aneurysm, is an uncommon cause of gastrointestinal bleeding that is uniformly fatal without surgical intervention. These may be primary fistulas, in cases of thoracic aortic aneurysm without previous repair, or secondary fistulas occurring after surgical repair of thoracic aortic aneurysm. Surgical treatment has been successful in a small number of cases of primary aortoesophageal fistula, secondary to thoracic aortic aneurysm, but techniques used have varied. We report a successful repair of primary aortoesophageal fistula, secondary to descending thoracic aortic aneurysm, and review the evolution of management since the three previously reported successful repairs at our institution.     

Professionalism and professional values in orthopaedics

During a consensus conference in Fall, 1998, the Academic Orthopaedic Society identified the values and qualities of professionalism as defined by its members. One hundred eighty-six respondents rated 20 characteristics and values describing professionalism, based on the extent to which they believed each item was appropriate. The five items receiving highest average ratings were: integrity, trustworthiness, responsibility, reliability, and accountability. Principal components analysis yielded five factors that captured 62% of the total variability. These factors were labeled respect and relationships, altruism, accountability and reliability, integrity, and excellence. The authors anticipate that the Academic Orthopaedic Society will find these data useful, and incorporate this information into their decisions concerning evaluation of current residents and applicants to their programs. An additional challenge will be to develop a values curriculum (formal curriculum) and a learning environment (informal curriculum) that will encourage residents and faculty to aspire to the highest in professional values and professional conduct.     

The virtuous orthopaedist has fewer malpractice suits

It generally is believed that physicians who have poor relationships with their patients are more likely to be sued. We studied certain physician characteristics and related them to their number of malpractice suits and the amount paid to settle those claims. Physicians with better rapport with their patients, who took more time to explain, and who were available had fewer malpractice suits. The most significant correlation was found in time spent with the patient. As the time spent increased, the number of suits decreased.     

Patient preference for chronic obstructive pulmonary disease (COPD) treatment inhalers: a discrete choice experiment in France

Objectives: Understanding inhaler preferences may contribute to improving adherence in COPD patients and improving long-term outcomes. This study aims to identify and quantify preferences for convenience-related inhaler attributes in French moderate-to-severe COPD patients, with discrete choice experiment (DCE) methodology.

Methods: Attributes were defined from a literature search, clinician and patient interviews: shape, dose insertion, dose preparation, dose release, dose confirmation, dose counter and reusability. An online DCE was conducted in respondents with self-reported COPD stage 2–4 recruited through a panel. The study questionnaire included twelve choice scenarios per respondent and questions on patient characteristics, treatment and disease severity. Statistical analyses used a mixed logit regression model with random effects. Utility scores were estimated for four types of inhalers: Inhaler A – soft mist inhaler; Inhaler B – reusable soft mist inhaler; Inhaler C – multi-dose dry powder inhaler; and Inhaler D – single dose dry powder inhaler.

Results: The study was completed by 153 patients (50 females); respondents were 50.4?years old on average; 13 different inhaler devices were reported. The most preferred inhaler is L-shaped, has dose preparation with capsule insertion and a dose counter, and is reusable. Inhaler profiles A and B had the highest utilities (mean of 1.2533 and 0.9578 respectively) compared to inhaler C (0.6315) and D (0.2200).

Conclusions: This study showed statistically significant results that the strongest drivers of preference in French users of inhalation devices for COPD are shape, dose counter and reusability. Convenience-related characteristics are important to patients and should be taken into account by clinicians prescribing these devices.