Robotic resection of an ectopic goiter in the mediastinum

We report the first robotic resection of an ectopic mediastinal thyroid adenoma in a 72-year-old woman. This intervention was part of staged management for excessive bilateral cervical goiter with intrathoracic dispersion. The robotic resection was found to be feasible and safe. The robotic operating system offers better visual control and operative accuracy than does conventional thoracoscopy.     

Human galanin (GAL) and galanin 1 receptor (GALR1) variations are not involved in fat intake and early onset obesity

The neuropeptide galanin (GAL) is involved in food intake and in fat ingestion. Presumably, these effects are conveyed via the galanin 1 receptor (GALR1). We screened the coding region of GAL (including 444 bp of its promoter region) and GALR1 for mutations using single-strand conformation polymorphism analysis and denaturing HPLC in up to 191 obese children and adolescents and 106 healthy underweight young adults (students). In GAL, we identified 3 novel single nucleotide polymorphisms (SNPs; silent: g.-419T-->C, g.-244G-->A; missense: g.47C-->T: Ala16Val) and one infrequent missense variation (c.253A-->G: Asn85Asp), and in GALR1 2 novel SNPs (silent: c.150C-->T, missense: c.793A-->T: Ile265Phe). To test for an association with obesity, we genotyped 7 SNPs (GAL: g.-244G-->A, g.47C-->T, rs7101947, rs1042577, rs3136540; GALR1: c.150C-->T, c.793A-->T) in up to 322 obese children and adolescents compared with up to 277 healthy underweight and normal weight young adults. Furthermore, we analyzed these SNPs with respect to potential effects on the percentage of energy consumed as fat in obese children and adolescents. Allele and genotype frequencies did not differ among the groups tested. In addition, we performed a pedigree transmission disequilibrium test (PDT) for one SNP (GAL: g.-244G-->A) in 610 (518 independent) obesity-trios (obese child or adolescent and both of its parents). However, the PDT for SNP GAL g.-244G-->A revealed no transmission disequilibrium. We conclude that the analyzed SNPs in GAL and GALR1 do not play a major role in early onset obesity or dietary fat intake in the obese children and adolescents of our study groups.     

Medical decision-making for seriously ill non-elderly and elderly patients

OBJECTIVES: Age of patients by itself is no longer a contra-indication for most medical interventions. The increase of possible interventions for elderly patients has contributed to a sharp age-specific increase of health care costs. Our study aimed to increase the insight in medical decision-making about life-prolonging interventions for patients from non-elderly and elderly age groups. DESIGN: Case-control study. SETTING: Clinical practices in three settings: oncology, nursing home and cardiology. SUBJECTS: Eighty-one physicians, representing a response of 60%. METHODS: Face-to-face interviews using a structured questionnaire addressing decision-making about the application of taxoid treatment for breast cancer patients, the application of bypass surgery for patients with angina pectoris under or over 70 years of age, and referral to specialist treatment because of a suspected malignancy of nursing home patients under or over 75 years of age. RESULTS: The chance of having been treated was in all settings lower for patients with a relatively poor quality of life and for patients who had no (known) preference to be treated. No differences were found for chance of having been treated between non-elderly and elderly patients with similar patient characteristics. The only exception to this is the patient preference concerning treatment: elderly patients were more likely to have been treated against their will than non-elderly patients were. CONCLUSIONS: A relatively high frequency of non-treatment decisions for elderly patients may be predominantly explained by the fact that patient characteristics that determine non-treatment decision-making are more prevalent in elderly age groups, and not by the effect of age per se.     

Do online pharmacies fit European internal markets?

The aim of this article is to consider the suitability of online pharmacies into European internal market area. This required considering the models of present online pharmacies in respect to the existing legislation. Data on online pharmacy settings was collected by looking some online pharmacies, which were found by using Goggle search machine with term "online pharmacy" and by studying websites of some well-known online pharmacies. European legislation and policy were studied from European Union's official website. Online drug markets seem to be increasing in popularity for reasons related to their ready availability and cost benefits. Few online pharmacies are based in Europe, yet online markets are worldwide. Community legislation does not stipulate on the legality of online pharmacies on European internal markets. Instead Community legislation offers framework for electronic commerce that could also include online pharmacy practise. National legislation, however, may rule them out either directly or indirectly. Regardless of European internal markets online pharmacies' cross-border operations are particularly complicated. Preliminary ruling from the European Court of Justice concerning one European online pharmacy's cross-border practise is awaited 2003-2004 and will offer some aspects for future.     

Fluorescein-labeled sinistrin as marker of glomerular filtration rate

There is an obvious and growing medical need for an accurate and easy to handle determination of glomerular filtration rate (GFR) for a broad spectrum of indications. Newly synthesized fluorescein-isothiocyanate (FITC)-sinistrin (FS) with various degrees of labeling was selected by its physicochemical properties and good tolerability out of a number of dye-labeled compounds intended for use as GFR markers for characterization of its pharmacological profile. With respect to solubility FS is more convenient in handling compared to FITC-inulin (FI). Up to 100 mg ml(-1) of FS can be dissolved in aqueous solvents at room temperature, whereas FI can only be solubilized after warming up to 55 degrees C. This reveals a considerable advantage of FS over FI in preparation of galenical formulations for intended i.v. application. A fluorometric method was established to determine FS concentration in blood serum with a comparable accuracy to the established enzymatic method for polyfructosanes. Similar concentration time curves in blood serum of FS measured fluorometrically and enzymatically suggest no relevant change of pharmacokinetic behavior by dye labeling. This notion is supported by the rapid renal and missing of biliary excretion. On the basis of these results, FS is superior in handling to the available GFR markers and makes it highly interesting as a novel diagnostic drug.     

Validity of unplanned admission to an intensive care unit as a measure of patient safety in surgical patients

BACKGROUND: An unplanned admission to the intensive care unit within 24 h of a procedure (UIA) is a recommended clinical indicator in surgical patients. Often regarded as a surrogate marker of adverse events, it has potential as a direct measure of patient safety. Its true validity for such use is currently unknown. METHODS: The authors validated UIA as an indicator of safety in surgical patients in a prospective cohort study of 44,130 patients admitted to their hospital. They assessed the association of UIA with intraoperative incidents and near misses, increased hospital length of stay, and 30-day mortality as three constructs of patient safety. RESULTS: The authors identified 201 patients with a UIA; 104 (52.2%) had at least one incident or near miss. After adjusting for confounders, these incidents were significantly associated with UIA in all categories of surgical procedures analyzed; odds ratios were 12.21 (95% confidence interval [CI], 6.33-23.58), 4.06 (95% CI, 2.74-6.03), and 2.13 (95% CI, 1.02-4.42), respectively. The 30-day mortality for patients with UIA was 10.9%, compared with 1.1% in non-UIA patients. After risk adjustment, UIA was associated with excess mortality in several types of surgical procedures (odds ratio, 3.89; 95% CI, 2.14-7.04). The median length of stay was increased if UIA occurred: 16 days (interquartile range, 10-31) versus 2 days (interquartile range, 0.5-9) (P < 0.001). For patients with a UIA, the likelihood of discharge from hospital was significantly decreased in most surgical categories analyzed, with adjusted hazard ratios of 0.41 (95% CI, 0.23-0.77) to 0.58 (95% CI, 0.37-0.93). CONCLUSIONS: These findings provide strong support for the construct validity of UIA as a measure of patient safety.     

Synthetic colloids attenuate leukocyte-endothelial interactions by inhibition of integrin function

BACKGROUND: It has been suspected that synthetic colloids may interfere with leukocyte adhesion by down-regulation of endothelial cell adhesion molecules. Although inhibition of endothelial inflammation might reduce leukocyte-related tissue injury, the same mechanism may be detrimental for host defense during severe infection. Regarding the widespread use of colloids, the authors performed a laboratory investigation to determine the mechanisms by which synthetic colloids interfere with leukocyte-endothelial interactions. METHODS: Adhesion molecule expression on native and cytokine-activated endothelium from umbilical veins was measured after pretreatment with gelatin and various preparations of dextran or hydroxyethyl starch. Inhibition of neutrophil adhesion to activated endothelium was examined in a flow chamber by perfusion of untreated and colloid-treated neutrophils over colloid-pretreated endothelium at 2 dyn/cm. Comparisons were made between untreated controls, colloid-pretreated endothelium, and colloid-cotreated neutrophils. RESULTS: Intercellular adhesion molecule 1, vascular cell adhesion molecule 1, E-selectin, and P-selectin were not attenuated by any colloid. Accordingly, colloid pretreatment of endothelium alone did not reduce neutrophil adhesion. In contrast, when neutrophils were cotreated by addition of colloids to the perfusate immediately before perfusion, adhesion decreased by 31-51% (P < 0.05) regardless of the colloid type. As indicated by the twofold increased rolling fractions, this reduction was due to an inhibition of neutrophil integrins. CONCLUSIONS: This study shows that synthetic colloids inhibit neutrophil adhesion by a neutrophil-dependent mechanism rather than interfering with endothelial cell activation. This suggests that inhibition of leukocyte sequestration by volume support is a common and transient phenomenon depending on the colloid concentration in plasma.     

Bayesian prediction bounds and comparisons of operating room times even for procedures with few or no historic data

BACKGROUND: Lower prediction bounds (e.g., for fasting), upper prediction bounds (e.g., to schedule delays between sequential surgeons), comparisons of operating room (OR) times (e.g., when sequencing cases among ORs), and quantification of case uncertainty (e.g., for sequencing a surgeon's list of cases) can be done accurately for combinations of surgeon and scheduled procedure(s) by using historic OR times. The authors propose that when there are few or no historic data, the predictive distribution of the OR time of a future case be centered at the scheduled OR time, and its proportional uncertainty be based on that of other surgeons and procedures. When there are a moderate or large number of historic data, the historic data alone are used in the prediction. When there are a small number of historic data, a weighted combination is used. METHODS: This Bayesian method was tested with all 65,661 cases from a hospital. RESULTS: Bayesian prediction bounds were accurate to within 2% (e.g., the 5% lower bounds exceeded 4.9% of the actual OR times). The predicted probability of one case taking longer than another was estimated to within 0.7%. When sequencing a surgeon's list of cases to reduce patient waiting past scheduled start times, both the scheduled OR time and the variability in historic OR times should be used together when assessing which cases should be done first. CONCLUSIONS: The authors validated a practical way to calculate prediction bounds and compare the OR times of all cases, even those with few or no historic data for the surgeon and the scheduled procedure(s).