Laparoscopically supervised PEG at time of Nissen fundoplication: a safe option

BACKGROUND/PURPOSE: Children with gastroesophageal reflux disease (GERD) often have associated feeding difficulties that warrant the insertion of a feeding gastrostomy at the time of the antireflux procedure. Options for gastrostomy tube insertion at the time of laparoscopic Nissen fundoplication (LNF) include laparoscopic gastrostomy, percutaneous endoscopic gastrostomy (PEG), and classic open gastrostomy. The complication rate of PEG may be decreased if it is placed under laparoscopic supervision. The purpose of this paper is to describe our experience with laparoscopically supervised PEG tube placement at the time of antireflux procedure. METHODS: A retrospective chart review was conducted on all children undergoing a PEG tube placement at the time of the LNF. Perioperative complications were recorded. RESULTS: Forty-four patients had attempted PEG tube placement at the time of the LNF. In 3 (7%) cases, laparoscopic supervision was crucial in the prevention of a complication. No major PEG-related complications were recorded. In 43% of patients, minor PEG tube problems arose in the postoperative period: all were transient and/or easily correctable. Management of all these problems was in an outpatient setting. Follow-up ranged from 11 to 41 months. CONCLUSIONS: PEG tube placement at the time of a LNF is safe and effective. A combined laparoscopic and endoscopic approach minimizes complications. This method also allows for an intra- and extraluminal evaluation of the fundoplication at its completion.     

The molecular mechanisms of the thrombotic complications of atherosclerosis

Our evolving knowledge of the cellular and molecular mechanisms underlying atherosclerosis has helped uncover the underlying causes behind thrombotic complications of this disease. Most fatal coronary thrombosis result from fibrous cap rupture or superficial erosion. Recent research has established a role for matrix metalloproteinases in the regulation of aspects of plaque structure related to propensity to disrupt and provoke thrombosis. Inflammatory pathways impinge on proteinase activity and aspects of oxidative stress that may favour plaque disruption. Novel molecular imaging strategies may permit visualization of proteinase activity in vivo , providing a new functional window on pathophysiology.     

Cancer incidence,survival and mortality: Explaining the concepts

Cancer incidence, survival and mortality are essential population‐based indicators for public health and cancer control. Confusion and misunderstanding still surround the estimation and interpretation of these indicators. Recurring controversies over the use and misuse of population‐based cancer statistics in health policy suggests the need for further clarification. In our article, we describe the concepts that underlie the measures of incidence, survival and mortality, and illustrate the synergy between these measures of the cancer burden. We demonstrate the relationships between trends in incidence, survival and mortality, using real data for cancers of the lung and breast from England and Sweden. Finally, we discuss the importance of using all three measures in combination when interpreting overall progress in cancer control, and we offer some recommendations for their use.     

Advances in Imaging of Cardiac Allograft Rejection

Endomyocardial biopsy with its inherent invasiveness and morbidity calls for the development of noninvasive imaging methods to evaluate heart transplant recipients. While conventional imaging technologies report on anatomical and metabolic changes in heart grafts, macrophage-targeted imaging could allow disease detection before gross anatomical and functional changes have occurred. One important approach in magnetic resonance–based molecular imaging exploits an increased T2/T2* relaxation effect, occurring when phagocytic cells localized in the heart graft take up iron-oxide nanoparticles. This methodology of nanoparticle reporting on immune cell accumulation in the graft combined with precise functional and morphological information of cardiac MRI has potential to supplant endomyocardial biopsy. The use of multifunctional nanoparticles fit for multiple imaging modalities (magnetic, optical, and nuclear) will help improve methods of ex vivo and in vitro imaging of allograft rejection and also further our knowledge of allograft rejection by providing a tool for nondestructive serial in vivo assessment.     

In vitro evaluation of antibiotic prophylaxis in the prevention of biliary stent blockage

BACKGROUND: Bacterial adherence and biofilm formation are important factors in the blockage of biliary stents. Clinical studies with oral antibiotic prophylaxis to prevent stent blockage have produced conflicting results. The aim of this study was to evaluate the in vitro effect of single antibiotic (ciprofloxacin, ceftazidime, or ampicillin) treatment on adherence of Escherichia coli and Enterococcus to plastic stents. METHODS: Selected clinical isolates of E coli and Enterococcus were perfused through a modified Robbins device containing segments of polyethylene stents. The stents were removed daily and the number of bacteria attached was measured. The effect of antibiotic treatment on bacterial adherence was tested by the perfusion of individual antibiotics into separate modified Robbins devices using a side-arm adaptor and the results were compared with saline controls. RESULTS: Compared with the saline controls, ciprofloxacin and ceftazidime caused a 10- to 100-fold reduction in the number of E coli attached to the stents, whereas ampicillin had no effect on adherence of E coli. Ampicillin caused a 5- to 10-fold reduction in Enterococcus adherence but there was no change with ceftazidime. Sustained reduction in E coli adherence was observed with prolonged ciprofloxacin perfusion. CONCLUSION: Timely treatment with appropriate antibiotics reduced bacterial adherence in vitro and may be potentially beneficial in the prevention of stent blockage.     

Substitution in a Medicaid mental health carve-out: services and costs

The objective is to empirically test the incentives associated with a Medicaid capitated mental health carve-out contract, whether outpatient services (less expensive, inside the contract) and residential treatment center care (costly care, outside of the contract) were substituted for inpatient psychiatric hospitalization used by children and adolescents. Data sources include Medicaid fee-for-service (FFS) claims for the non-capitated comparison sites and for residential treatment center use, and "shadow billing" encounter data for the experimental capitated managed care sites that provided public mental health services for children and adolescents with Medicaid insurance statewide in Colorado from September 1994 to June 1997. Two part least squares regression models are used to decompose services. Managed care sites are compared to sites that remained under FFS financing, before and in two post-periods after the carve-out. Principal findings show that children and adolescents who received mental health services from a capitated managed care provider were significantly less likely to receive inpatient care, and significantly more likely to receive residential treatment center care. In addition, insurance contract design contains financial incentives that affect the amount and mix of clinical care provided to clients by risk-bearing provider agencies. Findings provide evidence of cost substitution from inpatient care both inside the specialty system and outside the carve-out to other child-serving systems.     

Death rate variation in US subpopulations

OBJECTIVE: To account for variations in death rates in population subgroups of the USA. METHODS: Factors associated with age-adjusted death rates in 366 metropolitan and non- metropolitan areas of the United States were examined for 1990-92. The rates ranged from 690 to 1108 per 100 000 population (mean = 885 +/- 78 per 100 000). FINDINGS: Least squares regression analysis explained 71% of this variance. Factors with the strongest independent positive association were ethnicity (African-American), less than a high school education, high Medicare expenditures, and location in western or southern regions. Factors with the strongest independent negative associations were employment in agriculture and forestry, ethnicity (Hispanic) and per capita income. CONCLUSION: Additional research at the individual level is needed to determine if these associations are causal, since some of the factors with the strongest associations, such as education, have long latency periods.