Practical and technical considerations in establishing an intraoperative radiation therapy program in the community practice

The Radiation Oncology Center in Sacramento, California, has developed a procedure for establishing an intraoperative radiation therapy facility in a community practice. The logistics pertaining to personnel, equipment, physical measurements, and quality assurance are presented. Particular emphasis is given to the most effective means of acquiring the large quantity of data needed to ensure a program of acceptable quality.     

Suitability of various control sera for use in testing the accuracy of cholesterol determination with enzymic kits

We used 20 different commercial enzymic kits to measure cholesterol in 19 commercial control sera and in a pooled specimen of human serum and compared the relative biases, with the Abell -Kendall procedure as reference. Our purpose was to select those sera in various enzymic kits showing behavior similar to that of human serum and which thus can be used to measure the accuracy of these kits. The overall mean relative biases obtained with each of the 20 kits for the pooled human serum on the one hand and for a given control serum on the other generally correlated significantly. On the basis of the correlation coefficients and regression equations, we could select the control sera best suited for measurement of accuracy. They were all human-serum based, with cholesterol concentrations greater than 5 mmol/L. Animal sera with above-normal lipid values produced by feeding special diets appeared to be less reliable control sera in this respect.     

Laboratory standardizatin in an international study: the Kaunas--Rotterdam intervention study (KRIS).

Laboratory results obtained in different laboratories over lengthy periods of time usually are difficult to compare. In cooperative long-term studies where such results must be pooled, thorough standardization of methods is vital. We describe a program in which comparable plasma cholesterol and glucose analyses have been obtained, by simple methods. In the Netherlands and the Soviet Union in close collaboration with the Center for Disease Control, Atlanta, Ga., U.S.A. The two laboratories produced glucose values (direct o-toluidine reaction) within 2% of the target reference values and cholesterol results (direct Liebermann-Burchard reaction) with a consistent 6-8% positive bias over the reference method values. Intralaboratory precision was subject to preset acceptance limits. The use of common control materials, exchange of patient samples, and on-site comparison of all details of laboratory procedures are vital tools in standardization efforts. A laboratory protocol that included quality requirements and rejection criteria was developed and proved to be indispensable. The experience gained should be useful in standardizing inter-laboratory results in similar studies.     

What is important in evaluating health care quality? An international comparison of user views

Background  

Quality of care from the perspective of users is increasingly used in evaluating health care performance. Going beyond satisfaction studies, quality of care from the users' perspective is conceptualised in two dimensions: the importance users attach to aspects of care and their actual experience with these aspects. It is well established that health care systems differ in performance. The question in this article is whether there are also differences in what people in different health care systems view as important aspects of health care quality. The aim is to describe and explain international differences in the importance that health care users attach to different aspects of health care.     

Gallstone disease. Management of common bile-duct stones and associated gallbladder stones: Surgical aspects

For many years, open exploration of the common bile duct has been the treatment of choice for patients with common bile-duct stones. During recent decades endoscopic sphincterotomy has gained wide acceptance as an effective and less invasive alternative. After sphincterotomy, subsequent (laparoscopic) cholecystectomy is warranted in patients with gallbladder stones. This chapter will discuss whether sphincterotomy should be performed prior to, during or after cholecystectomy, and will also address the question of whether single-stage treatment by laparoscopic cholecystectomy and laparoscopic bile-duct exploration is in fact preferable. The rate of recurrent choledocholithiasis after endoscopic biliary sphincterotomy can reach more than 20%. This review focuses on the risk factors--delayed bile-duct clearance and bactobilia--that may lead to recurrent primary bile-duct stone formation. Underlying altered bile composition (relative phospholipid deficiency) should be recognised in a subgroup of patients. Identification of these risk factors may significantly affect treatment policy.     

Management of common bile-duct stones and associated gallbladder stones: surgical aspects

In most countries, endoscopic sphincterotomy is the first-choice treatment for common bile-duct stones. In patients with residual gallbladder stones, laparoscopic cholecystectomy is the next step. The optimal timing of laparoscopic cholecystectomy after endoscopic sphincterotomy remains to be determined. An alternative approach of combined cholecystocholedocholithiasis consists of laparoscopic cholecystectomy together with laparoscopic stone removal. The advantage of this ‘single-stage’ therapy appears to be limited to patients with stones that can be removed transcystically. This approach is successful in about half of the patients. Laparoscopic common bile-duct exploration is technically more demanding, more time-consuming, and associated with increased postoperative morbidity. If transcystic removal is not possible, a postoperative ERCP with endoscopic sphincterotomy is a good option. Intraoperative ERCP and endoscopic sphincterotomy are also feasible, but require specific organisational efforts.Recurrence of choledocholithiasis after ES is reported in a considerable number of patients (6–21%), resulting from de novo primary stone formation or recurrent secondary migration from the gallbladder. Primary choledocholithiasis is associated with bactobilia and delayed bile-duct clearance, indicated by CBD dilation. Endoscopic reintervention is safe and usually easy to perform. Surgery should be reserved for intractable cases. In selected patients, an underlying lithogenic bile composition (low-phospholipid-associated cholelithiasis) should be identified, and preventive medical treatment with UDCA could be considered.

• in patients with combined cholecystocholedocholithiasis, endoscopic sphincterotomy should be followed by elective laparoscopic cholecystectomy, even in the elderly; however, a ‘wait-and-see’ policy does not lead to higher mortality, and therefore expectant management can be advocated in case of significant contraindications to surgery

• laparoscopic cholecystectomy combined with laparoscopic stone removal offers a one-stage treatment of patients with combined cholecystocholedocholithiasis. Laparoscopic transcystic duct clearance is associated with low morbidity and short hospital stay. In contrast, laparoscopic common bile-duct exploration remains a procedure with increased risk of biliary complications and prolonged hospital stay. In case of stones that cannot be removed transcystically, it may be wise to perform an intraoperative or early postoperative ERCP

• performing an endoscopic sphincterotomy during laparoscopic cholecystectomy using a ‘rendezvous’ procedure may be beneficial in selected patients (especially in case of earlier failed ERCP)

• laparoscopic cholecystectomy after endoscopic sphincterotomy is associated with increased conversion rates to open procedure compared to laparoscopic cholecystectomy for uncomplicated gallstones; laparoscopic cholecystectomy planned early after endoscopic sphincterotomy may reduce this risk

• morphological or functional bile-duct defects, indicated by a dilated CBD, may lead to bactobilia and biliary stasis, thus promoting primary stone formation

• in a subgroup of patients with recurrent bile-duct stones, an MDR3 gene mutation must be considered, resulting in low-phospholipid-associated cholelithiasis. These patients are characterised by early onset of symptoms, recurrence after cholecystectomy, hyperechogenic foci in the liver, and often a history of intrahepatic cholestasis of pregnancy. Ursodeoxycholic acid is beneficial in these patients

• the optimal timing or ERCP in patients scheduled for laparoscopic cholecystectomy (before, during, or after the operation) still needs to be defined.

• further data are needed to determine potentially increased incidence of conversion and postoperative complications for laparoscopic cholecystectomy after endoscopic sphincterotomy compared to laparoscopic cholecystectomy for uncomplicated gallstones

Intravenous glucose intake independently related to intensive care unit and hospital mortality: an argument for glucose toxicity in critically ill patients

OBJECTIVE: It is assumed that the toxic effects of glucose play a role in the outcome of critically ill patients. We studied the impact of the amount of infused glucose as a determinant of mortality. DESIGN: A retrospective cohort study design was used as blood glucose levels in critically ill patients are nowadays tightly controlled. PATIENTS: Long-stay critically ill patients (7-30 days). MEASUREMENTS: The association between the mean amount of glucose infusion and both intensive care unit (ICU) and hospital mortality was determined. We corrected for the mean glucose serum concentration, the mean dosage of insulin and for severity of illness, using the acute physiology and chronic health evaluation (APACHE II) score. RESULTS: Of the 2,042 admitted patients, 273 met the inclusion criteria. The mean length of stay was 14.4 days [interquartile range (IQR) 9-18]. Hospital mortality was significantly lower for patients with a mean glucose level below 8 mmol/l (30/79; 38%) compared to patients with a level above 8 mmol/l (104/194; 54%, P=0.023). Logistic stepwise multivariate regression analysis for both ICU and hospital mortality as dependent variables showed that APACHE II score and the mean daily amount of infused glucose were associated with mortality. CONCLUSION: In long-stay ICU patients without blood glucose level control, the ICU and hospital mortality was independently related to the mean amount of infused glucose. In addition, mortality in patients with a mean glucose level above 8.0 mmol/l was higher. Both these determinants of mortality can exert their effects by insulin-independent uptake of glucose with subsequent toxic intracellular effects.