DAY-ONLY ADMISSION FOR VARICOSE VEIN SURGERY

Day-only admissions for surgery are strongly encouraged, in an effort to keep costs down. Varicose vein surgery has been considered too major for day-only management despite the fact that there have been studies from overseas showing that it can be done with a morbidity comparable to inpatient surgery. The morbidity of day-only surgery for varicose veins (both long and short saphenous procedures) was assessed and compared with the results of inpatient surgery. Patients were also asked whether they were satisfied with the surgery being done this way. There were 165 consecutive patients available for study, 64 day-only and 101 inpatient. All patients attending Shellharbour Hospital, Shellharbour, had surgery done as day-only (as it was a morning list and allowed adequate time for recovery). Patients attending Bulli Hospital, Bulli, had surgery done as an inpatient (afternoon list). All surgery was performed by one surgeon. There was no difference (Chi-squared) in the age distribution (mean 48 years for day-only, 51 years for inpatient) or sex proportion in either group (Chi-squared test of proportions with continuity correction). Assessment of the results was done by review of the surgeon's notes, as well as telephone interviews for day-only subjects. The complication rate in both groups was similar. Wound problems represented the main complication with an incidence of 10.5% in each group. There was one deep venous thrombosis (DVT) in each group (diagnosed by duplex scan). Response to the telephone interview suggested that most patients were happy to have the surgery done as a day-only procedure. Sixty-nine per cent responded that they would have it done this way again and 76% were satisfied with the result of the surgery. This study confirms the results of overseas studies, in that varicose vein surgery can be performed as day-only procedures with a complication rate similar to inpatient procedures and with a high degree of patient satisfaction. It is suggested that this should be used as the method of choice for the majority of patients requiring varicose vein surgery.     

Ueber den Einfluss der Kranzarterienerkrankungen auf das Herz und die chronische Myocarditis

Ohne Zusammenfassung     

Cardinal points and image–object magnification with an accommodative lens implant (1 CU)

A simple mathematical method for the determination of the cardinal points of pseudophakic eyes after implantation of an accommodative intraocular lens [posterior chamber intraocular lenses (PCIOL)] is presented. The purpose of this study was to explore the changes during pseudophakic accommodation (PAC) in (1). the positions of the cardinal points, (2). the distance of the object conjugate with the retina, and (3). the image-object magnification. These theoretical accommodation data are compared with clinical measurements. METHODS AND PATIENTS: Using biometrical measurements of the axial length, equivalent power of the cornea and the anterior chamber depth (ACD) in the non-accommodated state we used linear geometric optics for determination of the cardinal points and object distance as well as lateral magnification (the ratio of image to object size). With the measurement of ACD decrease (following pharmacological stimulation of the ciliary muscle with 2% pilocarpine eye drops) we determined the changes of the cardinal points and magnification to assess PAC amplitude from the shortening of the object distance. Calculated values of PAC amplitude were compared with the respective measured values derived from amplitude measures by accommodometer, defocusing and streak retinoscopy. We analysed the results of a prospective study on 35 eyes of 28 patients after cataract surgery (target refraction: -0.2 D) and accommodative PCIOL implantation (1 CU, Human Optics AG, Erlangen, Germany) 3 months after surgery. RESULTS: After pilocarpine eye drops, ACD (mean +/- S.D., range; median) decreased by 0.88 +/- 0.48 mm (0.51-1.91; 0.66). Distance of the in-focus object decreased from the non-accommodated state (-5.62 +/- 1.83 m, -25 to -1.1; -4.83 m) to the accommodated state (ACD decrease) (-0.81 +/- 0.21, -2.11 to -0.65; -0.79 m). For a theoretical ACD decrease of 1.0 mm (the intrinsic limitation of the PCIOL design) it was -0.59 +/- 0.28, -1.31 to -0.51; -0.63 m and resulted in an objective accommodative response of 1.49 +/- 0.16, 1.21-1.81; 1.46 D, depending on the actual geometry of the individual eye. On average, magnification as induced by PAC in contrast to that induced by adequate spectacle addition differed by only about 1%. Accommodation measured with defocusing and the accommodometer correlated significantly with the theoretical value based on IOLMaster measurement of ACD decrease (r = 0.752, p = 0.005 and r = 0.676, p = 0.02). Likewise, accommodation measured with streak retinoscopy correlated weakly with the theoretical value based on IOLMaster ACD decrease (r = 0.465, p = 0.05). CONCLUSIONS: Using geometrical optics, PAC can be derived from the biometric data of the eye and the measured ACD decrease. This approach may be an additional indicator for the accommodative response in pseudophakic patients and may allow a subdivision of the measured accommodation into true PAC and pseudoaccommodation, for example, because of increased depth of focus induced by pupillary constriction.     

Double-crowned valved stents for off-pump mitral valve replacement.

OBJECTIVE: An animal model has been designed to assess the feasibility of off-pump mitral valve replacement using valved stents. METHODS: Glutaraldehyde-preserved homograft was sutured inside a prosthetic tube (Dacron). Then, two self-expandable nitinol Z-stents were sutured on the external surface of the prosthesis in such a way to create two self-expanding crowns for fixation. In adult pigs and under general anesthesia, the left atrium was exposed through a left thoracotomy and atrio-ventricular roadmapping was performed with intravascular ultrasound (IVUS) and fluoroscopy. The double-crowned valved stents were loaded into a delivery sheath. The sheath was then introduced into the left atrium and the valved stents was deployed in mitral position in such a way that the part in between the two stents was at the level of the mitral annulus. Intracardiac Unltrasound (ICUS) was used to assess the valve function. Hemodynamic parameters were gathered as well. Animal survived for no more than 3h after the valve deployment and gross anatomy examination of the left heart was carried out. RESULTS: The mean height of the valved stents was 29.4+/-0.2 mm, with an internal diameter of 20.4+/-1.0mm, and an external diameter of 25.5+/-0.8 mm. The procedure was successfully carried out in eight animals. In vivo evaluation showed a native mitral annulus diameter of 24.9+/-0.6 mm, and a mean mitral valve area of 421.4+/-17.5 mm2. ICUS showed a mild mitral regurgitation in three out of eight animals. Mean pressure gradient across the valved stents was 2.6+/-3.1 mmHg. Mean pressure gradient across the left ventricular outflow tract (LVOT) was 6.6+/-5.2 mmHg. The mean survival time was 97.5+/-56.3 min (survival time range was 40-180 min). One animal died due to the occlusion of the LVOT because of valved stents displacement. Postmortem evaluation confirmed correct positioning of the valved stent in the mitral position in seven out of eight animals. No atrial or ventricular lesions due to the valved stents were found. CONCLUSIONS: Off-pump implantation of a self-expandable valved stent in the mitral position is technically feasible. Further studies will assess if this procedure is also feasible in humans.     

Evaluation of postsurgical crestal bone levels adjacent to non‐submerged dental implants

In most of the studies on long-term radiographic evaluations of crestal bone levels adjacent to dental implants, no baseline radiographs taken immediately post-surgically had been obtained.The aim of this study was to test the reproducibility of a simple radiographic method for linear measurements of changes in bone levels and to evaluate changes in crestal bone levels adjacent co non-submerged ITI® implants 1 year following the surgical procedure. From 128 patients enrolled in a clinical and radiographic longitudinal study 40 patients also had radiographs taken immediately postsurgically. They were, however, not obtained as “identical” images. The radiographs were mounted onto slides and projected on a screen. Mesially and distally from 57 implants triplicate linear measurements of the distance implant shoulder to bone crest were taken, using known dimensions of the implants as internal reference distances. The median difference of 213 (out of 228 possible) duplicate measurements was 0.00 mm (ranging from ?1.72 mm to +1.47 mm when comparing the second co the third reading). Some 81% of the double measurements were within ±0.5 mm and the precision was 0.30 mm. In the immediate postoperative radiographs the median mesial bone level was located at 2.07 mm (distally 2.19 mm) from the implant shoulder. A statistically significant amount of bone loss in the first year was observed mesially (median=?0.78 mm) and distally (0.85 mm)(Wilcoxon matched pairs signed rank test ±0.001). No statistically significant influence of the implant location, the implant length, type of the implant (screw; cylinder) was observed (Kruskal-Wallis P>0.05).The age of the patients was not correlated significantly to the amount of bone loss observed. In conclusion, methodological limitations existed when evaluating linear bone changes in non-identical radiographs using reference dimensions of the implants. The amount of postsurgical bone loss estimated in other studies was confirmed when using an immediate postoperative radiograph as a baseline.     

Hepatic resections for metastases]

Between January 1981 and December 1990, 79 liver resections were performed for hepatic metastases in 73 patients. Eight of these patients had a repeat resection (2 patients had their first resection performed before 1981). This figure represented 35% of 228 liver resections performed during this period. Mean age was 56.5 years (23 to 81 years). There were 38 men and 35 women. Fifty-four resections were performed for colorectal metastases and 25 resections for secondaries of other origins. There were 45 major hepatectomies (57%), defined by the resection of at least 3 Couinaud segments, and 34 minor resections (less than three segments). In 12 patients, liver resection was associated with excision of the primary tumor. Complications were observed in 25 patients (32%), pulmonary complications being the most frequent. Five re-explorations were necessary: 3 for postoperative bleeding, one for an abdominal abscess and one for intestinal obstruction. Mean postoperative stay was 18 days. There was no mortality for the first liver resections in 71 patients. One death was encountered among the second resections in 8 patients, with a global mortality of 1.3%. Follow-up was obtained for all patients but one (lost to follow-up at 5 years). Actuarial survival for the 50 patients operated on for colorectal secondaries was 98% at 6 months, 83% at 1 year, 46% at 2 years, 24% at 3 years and 15% at 5 years. In non-colorectal secondaries, the survival depended on the nature of the primary tumor but was very different from one patient to another.(ABSTRACT TRUNCATED AT 250 WORDS)     

Enhancement of antigen-presenting ability of B lymphoma cells by partial inhibition of protein synthesis through inducing B7-1 expression.

During the investigation of the role of protein synthesis in antigen-presenting cell (APC) function of A20-HL B lymphoma cells, we found that partial inhibition of protein synthesis enhanced their APC function. The treatment of A20-HL cells with 0.313-2.5 microM emetine, an irreversible inhibitor of protein synthesis, decreased protein synthesis by 60-70%, and enhanced their APC function to stimulate I-Ad/OVA323-339-specific T cells to produce interleukin-2 in response to ovalbumin (OVA). The emetine-treated and paraformaldehyde-fixed A20-HL cells required only 20 nM OVA323-339 peptide to stimulate the T cells, whereas those untreated and fixed required 200 nM peptide. This enhancement of APC function was mostly because of the induction of B7-1 expression on A20-HL cells by the emetine treatment, since B7-1 molecules were detected on the emetine-treated A20-HL cells, but only negligibly, if at all, on the untreated cells, and an anti-B7-1 monoclonal antibody, 1G10, inhibited the enhanced APC function of the emetine-treated A20-HL cells. The emetine-treatment also increased B7-1 mRNA expression in A20-HL cells, suggesting that the induction of B7-1 expression was due to the increase in the accumulation of mRNA and the translation with residual ability to synthesize protein. Thus, partial inhibition of protein synthesis in A20-HL cells increases B7-1 mRNA accumulation and its expression on the cell surface, which results in the enhancement of their APC function.