Laparoscopic resection of Osler-Weber-Rendu lesion.

BACKGROUND AND OBJECTIVES: Osler-Weber-Rendu is a hereditary disease characterized by telangiectasias, arteriovenous malformations, and aneurysms involving the cutaneous, gastrointestinal, pulmonary, and central nervous systems. This report describes a combinatorial approach using laparoscopic and intraoperative endoscopy to perform a partial gastric resection of bleeding arteriovenous malformations. METHODS: A 70-year-old female with a history of bleeding from Osler-Weber-Rendu disease presented to the emergency department complaining of hematemesis. Her vital signs were unstable, and she was immediately resuscitated with intravenous fluids and transfusions. A combined laparoscopic and intraoperative endoscopic approach to a partial gastric resection was planned. Intraoperatively, a single lesion was identified along the posterior aspect of the greater curvature of the stomach by using endoscopy. The blood supply was taken down with a Ligasure and gastric resection with a 60-mm Echelon stapler. RESULTS: The pathology report confirmed the complete resection of the arteriovenous malformations. The patient recovered well and was discharged home several days later without any pain complaints. CONCLUSIONS: Little has been written about the medical treatment of Osler-Weber-Rendu arteriovenous malformations, let alone surgical treatment. A combinatorial laparoscopic and intraoperative endoscopic approach to gastric resection allows both minimization of the gastric resection and the complete identification and removal of the arteriovenous malformations.     

Mechanism of opioid-induced pupillary effects.

OBJECTIVE: This study tested the hypothesis that increased activity in the pupilloconstrictor nucleus by the addition of ambient light and by the administration of fentanyl, sufficient to block pupillary reflex dilation, constricts the pupil of anesthetized patients. METHODS: Pupil diameter was measured in 10 anesthetized patients during noxious stimulation above an epidural block level, in darkness and then with light directed into the left eye. Two measurements were taken from the right eye separated by 5 min. Following the second measurement, fentanyl (1 mcg/kg) was administered and the measures in light and dark were repeated. The effect of light and fentanyl on pupil size and pupillary reflex dilation were analyzed. RESULTS: An increase in light directed into the left eye constricted the pupil from 2.15+/-0.38 to 1.87+/-0.40 mm before fentanyl. Fentanyl did not constrict the pupil either in darkness or light but it did decrease pupillary reflex dilation by 49%. CONCLUSIONS: The miotic pupil during general anesthesia is not maximally constricted. Increased excitation of the pupilloconstrictor nucleus does not account for blockade of pupillary reflex dilation after fentanyl administration during desflurane anesthesia. SIGNIFICANCE: This study does not support the hypothesis that opioid effects on the human pupil are brought about by a direct excitatory action on the pupilloconstrictor nucleus.     

Anticholinergic drugs,bladder retraining and their combination for urge urinary incontinence: a pilot randomised trial

Bladder retraining and anticholinergic drugs in women with urge urinary incontinence need to be compared. Women with urge urinary incontinence were recruited by advertisements, from primary care and from a urogynaecology clinic. Women were randomised using a web page to bladder retraining, anticholinergic drugs or both and followed up at 3 and 12 months. No blinding was attempted. The primary outcomes were the trial process and the Overactive Bladder Questionnaire (OAB-q) quality-of-life measure. Recruitment was much slower than anticipated. There were no differences in the OAB-q at 12 months (87.9 SD 11.6 bladder retraining, 81.6 SD 19.3 drug therapy and 88.9 SD 9.9 combination) but dry mouth was more common in those taking drugs. It is feasible to run a pragmatic randomised trial with 12-month follow-up for women with urinary urge incontinence. This will require about 500 participants per arm. Trial registration  This trial was registered as ISRCTN 66713401.     

Diagnosis and management of anaphylaxis

ANAPHYLAXIS IS A SEVERE SYSTEMIC ALLERGIC reaction that is potentially fatal. It requires prompt recognition and immediate management. Anaphylaxis has a rapid onset with multiple organ–system involvement and is mostly caused by specific antigens in sensitized individuals. Reactions typically follow a uniphasic course, however, 20% will be biphasic in nature. The second phase usually occurs after an asymptomatic period of 1–8 hours, but there may be a 24-hour delay. Protracted anaphylaxis may persist beyond 24 hours. Concurrent β-blocker therapy may adversely affect the response to management. Epinephrine is the treatment of choice and should be administered immediately. Secondary measures include circulatory support, H₁ and H₂ antagonists, corticosteroids and, occasionally, bronchodilators. Post-treatment observation of these patients is necessary, and they should remain within ready access of emergency care for the following 48 hours.     

Implementation of national diabetes retinal screening programme is associated with a lower proportion of patients referred to ophthalmology.

AIMS: To examine the impact of a new national retinal screening programme on screening attendance, technical quality of images, and referrals to the ophthalmology clinic. METHODS: Results from the previous ad hoc retinal screening service were compared with data from the first year of the new Scottish Diabetes Retinal Screening Programme in Dundee, which was administered according to criteria recommended by the Health Technology Board Scotland. RESULTS: Of 5150 patients invited for screening, 10.3% of patients did not attend. Overall, 4574 patients underwent single-field digital retinal photography and 25.4% required mydriasis for an adequate image. After screening, 1.9 and 90.5% were recalled for repeat photography at 6 months and 1 year, respectively, whilst 4.6% were ungradable and 3.0% were referred to the ophthalmology clinic. Compared with the last 18 months of the previous scheme, with the new programme a smaller proportion of patients were referred to ophthalmology (3.0 vs. 5.9%; P < 0.001, difference 2.9%: 95% confidence interval 2.1-3.7%). Moreover, the attendance was higher (89 vs. 82%; P < 0.01) and there were fewer ungradable images (4.6 vs. 7.1%; P < 0.001). CONCLUSIONS: Introduction of a systematic retinal screening programme can reduce the proportion of patients referred to the ophthalmology clinic, and use ophthalmology services more efficiently.