Trocar introduction performed during laparoscopy of the obese patient

Obesity, especially morbid obesity, is reported to be a relative contraindication to laparoscopy. A technique for trocar introduction and laparoscopy of the obese patient to eliminate this contraindication is described. The technique presented herein differs from the traditional method by: 1, primary trocar entry at a 90 degree angle to the horizontal plane, and 2, confirmation for intraperitoneal position of the instruments before creating the pneumoperitoneum. A retrospective study was done to compare demographic, medical and surgical data of obese and non-obese patients. No important differences were found and it was also found that obesity was not a relative contraindication to laparoscopy. Obesity was defined by a ponderal index of less than 11.7. No operative complications were found for the 344 obese patients studied and all laparoscopy procedures were completed as intended. These differences in technique can avoid the pitfalls commonly reported concerning laparoscopy of the obese patient.     

Exaggerated signet-ring cell change in stromal nodule of prostate: a pseudoneoplastic proliferation

A stromal nodule of the prostate was incidentally identified in a simple prostatectomy specimen from a 66-year-old man with benign prostatic hyperplasia. Microscopically, the nodule consisted of short spindly cells with bland nuclear features. Many of the cells in the nodule, however, contained a large, clear cytoplasmic vacuole that displaced and indented the nucleus, generating signet-ring cell morphology. Immunohistochemically, these cells were strongly positive for vimentin and weakly positive for desmin, suggesting a myofibroblastic nature. Further immunostains demonstrated the cells to be negative for cytokeratins and prostate-specific antigen, excluding the possibility of signet-ring cell carcinoma. The cytoplasmic vacuoles also stained negative for mucin production. Electron microscopy revealed no intracytoplasmic lumina. Notably, thermal effect or other signs of cellular injury, frequently associated with signet-ring cell change seen in prostate specimens obtained by transurethral resection and needle biopsy, were not appreciated in this stromal nodule. This case demonstrates that signet-ring cell change may occur in benign, hyperplastic, prostatic stromal cells in the absence of cellular damage.     

A novel model of acetaminophen-induced acute hepatic failure in rabbits

BACKGROUND: Few reliable and reproducible animal models of acute hepatic failure exist or conform to the criteria proposed by Terblanche and Hickman (Dig. Dis. Sci. 36: 770, 1991). In this prospective randomized study we describe the selective induction of CYP450 enzymes, depletion of glutathione, and hepatotoxic insult using acetaminophen in the development and characterization of a novel rabbit model of acute hepatic failure. MATERIALS AND METHODS: Male New Zealand white rabbits weighing 3-5 kg were used. After preliminary dose ranging experiments, two groups of New Zealand white (n = 8 in each group) rabbits had CYP450 induction with phenobarbitone (40 mg/kg ip for 5 days) or with 20-methylcholanthrene (80 mg/kg ip). The glutathione synthetase inhibitor buthionine sulfoxime (2 mmol/kg iv) was then administered prior to acetaminophen administration (500 mg/kg sc). Clinical observations were recorded and arterial blood was sampled over 72 h. RESULTS: Grade I-III encephalopathy occurred at 5-12, 12-25, and 28-56 h, respectively, in animals pretreated with 20-methylcholanthrene, but not in the phenobarbitone pretreated group. Mortality was 75% in the 20-methylcholanthrene group compared to 0% in the phenobarbitone group. Blood lactate (P < 0.05), prothrombin time (P < 0.005), aspartate transaminase (P < 0.005), and creatinine (P < 0.05) were higher in the 20-methylcholanthrene group compared to the phenobarbitone group. Histological changes were marked in the 20-methylcholanthrene group with massive coagulative hepatic necrosis compared to minimal histological damage in the phenobarbitone group. CONCLUSION: The induction with 20-methylcholanthrene, glutathione depletion with buthionine sulfoxime, and subcutaneous administration of acetaminophen have led to the development of an animal model that parallels clinical, biochemical, and histological features of human hepatic failure.     

How and why the health insurance system will collapse

The advocates of defined-contribution health plans extol the virtues of consumer-driven health care, consumer choice, and empowered consumers as solutions to the problems--particularly the rapidly growing costs--of employer-sponsored health benefits. This paper argues that the widespread use of defined-contribution plans, with more consumer choice and more knowledgeable consumers, will lead to the erosion of the social contract on which health insurance must be based, with healthier employees subsidizing the care of older and sicker ones, and a death spiral of adverse selection. If unchecked by government intervention, these trends will lead to the collapse of employer-sponsored health insurance.     

Risk factors for salmonella food poisoning in the domestic kitchen--a case control study

Domestic kitchen food handling risk factors for sporadic salmonella food poisoning are largely unknown. We compared food consumption and food handling practices, opportunities for cross contamination and refrigerator temperature control, in 99 households in South East Wales in 1997/8 with a case of salmonella food poisoning, and control households matched for electoral ward. On univariate analyses, cases were significantly more likely than control respondents to have purchased free-range eggs in the preceding week, and more likely than control households to have handled frozen whole chicken in the previous week, and to handle raw chicken portions at least weekly. In multivariate analysis, only consumption of raw eggs and handling free-range eggs were significant risk factors, independent of the age structure of the family and of the season.