Conservative management of iatrogenic oesophageal perforations--a viable option.

OBJECTIVE: Iatrogenic Oesophageal perforations are a dreaded complication and there is no consensus as to their best management. The aim of our study was to assess the results of conservative management in these cases. METHODS: Twenty-six patients with iatrogenic perforations of the oesophagus treated over a 10-year period were reviewed retrospectively. They were managed conservatively by keeping them nil by mouth on intravenous fluids and intravenous antibiotics. Out of these 26, nine were patients of carcinoma of the oesophagus while the remaining 17 had benign pathologies. Twenty-two were diagnosed within 6h, while the remaining four were diagnosed over 24h after perforation. Twenty-three of the 26 were caused by oesophageal dilatations. RESULTS: Twenty-two (84.6%) of the 26 survived on this regimen. Out of the four that died, two had advanced carcinomas and died of chest complications, one died of a myocardial infarction and the fourth was an old debilitated man who died of renal failure. All four who died had extension of the leak into the pleural cavity. Early diagnosis and treatment is of critical importance and is only possible by maintaining a high index of suspicion. CONCLUSIONS: Conservative management when applied to cases of iatrogenic oesophageal perforations gives results comparable to or better that those reported in series where early surgical intervention was practised. Extension of the leak into the pleura carries a worse prognosis.     

Airway responsiveness to beta-adrenergic agonist (salbutamol) in asthma.

Despite the controversy of airway responsiveness to beta2-agonist drugs in asthma, in a previous study we showed increased responsiveness of asthmatic airways to isoprenaline. Therefore, in the present study of airway sensitivity to other beta2-agonists, salbutamol and its relationship to histamine responsiveness was reexamined. The threshold bronchodilator concentrations of inhaled salbutamol required for a 20% increase in forced expiratory flow in 1 sec (FEV1), (PC20) was measured in 20 normal and 19 asthmatic adults. Airway responsiveness to histamine, as the concentration that caused a 20% decrease in FEV1, was also measured in 11 normal and 12 asthmatic subjects; and the correlation between PC20 salbutamol and PC20 histamine was evaluated. Sensitivity to salbutamol was greater in asthmatics (PC20 = 7.24 mg/L) than in non-asthmatics (PC20 = 124.25 mg/L, p < 0.001). Airway responsiveness to histamine in asthmatics (PC20 = 0.18 g/L) was also significantly greater than in normal subjects (PC20 = 19.46 g/L, p < 0.001). There was a significant correlation between PC20 salbutamol and histamine (Rs = 0.6052, p < 0.005). Maximum response to both salbutamol and histamine and slope of concentration-response curves of both agents were significantly greater in patients with asthma than in normal subjects (p < 0.001 and p < 0.005 for maximum response and slope, respectively). The increased sensitivity of asthmatics to inhaled salbutamol suggests that they also may be more sensitive to their endogenous adrenaline, which may thus dilate and stabilize their airways.     

Bilateral Duane syndrome and bilateral aniridia.

Duane retraction syndrome has been reported in association with structural abnormalities of the eye, including epibulbar dermoid, keratoconus, iris dysplasia, heterochromia iridis, persistent fetal vasculature, cataract, choroidal coloboma, microphthalmia, and optic nerve dysplasia. A novel association, that of bilateral Duane syndrome with bilateral aniridia, is the subject of this report.     

Low back pain education and short term quality of life: a randomized trial

Background  

Different interventions can reduce the burden of the chronic low back pain. One example is the use of a 'Back School Programme'. This is a brief therapy that uses a health education method to empower participants through a procedure of assessment, education and skill development. This study aimed to evaluate to what extent the programme could improve quality of life in those who suffer from the condition.     

Long-term Outcomes of Patients Undergoing War-related Amputations of the Foot and Ankle

Long-term clinical and functional outcomes for patients undergoing foot and ankle amputations are not well documented. We attempted to document long-term outcomes for patients who required lower extremity amputations as a result of wounds suffered during wartime. For this study, 27 Iranian soldiers who had wounds requiring amputation of the foot and ankle were selected for follow-up. The participants' wartime medical records were reviewed, a clinical examination was performed, and each participant completed a questionnaire. Postamputation follow-up averaged 17.5 years. The most prevalent (66.6%) cause of injury was a land mine. The prevalences of different clinical symptoms reported by the amputees at the time of the last follow-up were as follows: 11 (40.7%) with phantom sensation, 6 (22.2%) with phantom pain, 12 (44.4%) with stump pain, 12 (44.4%) with back pain, 9 (33.3%) with contralateral knee pain, and 4 (14.8%) with ipsilateral knee pain; 20 (74%) reported treatment for psychological conditions. In regard to social conditions, 13 (48.1) were currently employed, or had been employed, for a number of years after the amputation; 26 (96%) had children, and all of the patients were married. The results of this observational study indicate that individuals have significant long-term pain and discomfort after war-related lower extremity amputation. Although all 27 (100%) of the amputees were able to maintain satisfactory family functioning, only 13 (48.1%) of the study participants were able to remain productively employed after undergoing amputation, and 20 (74%) reported long-term psychological problems in addition to their physical pain.     

The program for phenotyping of genetically modified animals at AstraZeneca

Genetically modified mice offer a wide range of possibilities in preclinical drug discovery, e.g. for use in target identification, target validation and disease model generation. However, genomic modification and alteration in gene expression may cause unpredicted phenotypic alterations in the organism other than the intended ones. The aim of this study was to determine the importance of establishing the phenotype of transgenic and knockout mice models for use in pharmaceutical research.

A total number of 51 mouse models (transgenic and knockout) produced at AstraZeneca during a 4 year period were subjected to a thorough phenotyping package covering clinical as well as morphological aspects. Phenotype abnormalities were recorded in 36 (70.6%) of the mouse models. The majority of findings were considered to be minor in magnitude. Histopathological changes related to the genotype of the animals were observed in 33% of the mouse models, underlining the importance of pathology in the phenotyping program.     

Model of reentrant ventricular tachycardia based on infarct border zone geometry predicts reentrant circuit features as determined by activation mapping

BACKGROUND: Infarct border zone (IBZ) geometry likely affects inducibility and characteristics of postinfarction reentrant ventricular tachycardia, but the connection has not been established. OBJECTIVE: The purpose of this study was to determine characteristics of postinfarction ventricular tachycardia in the IBZ. METHODS: A geometric model describing the relationship between IBZ geometry and wavefront propagation in reentrant circuits was developed. Based on the formulation, slow conduction and block were expected to coincide with areas where IBZ thickness (T) is minimal and the local spatial gradient in thickness (DeltaT) is maximal, so that the degree of wavefront curvature rho proportional, variant DeltaT/T is maximal. Regions of fastest conduction velocity were predicted to coincide with areas of minimum DeltaT. In seven arrhythmogenic postinfarction canine heart experiments, tachycardia was induced by programmed stimulation, and activation maps were constructed from multichannel recordings. IBZ thickness was measured in excised hearts from histologic analysis or magnetic resonance imaging. Reentrant circuit properties were predicted from IBZ geometry and compared with ventricular activation maps after tachycardia induction. RESULTS: Mean IBZ thickness was 231 +/- 140 microm at the reentry isthmus and 1440 +/- 770 microm in the outer pathway (P <0.001). Mean curvature rho was 1.63 +/- 0.45 mm(-1) at functional block line locations, 0.71 +/- 0.18 mm(-1) at isthmus entrance-exit points, and 0.33 +/- 0.13 mm(-1) in the outer reentrant circuit pathway. The mean conduction velocity about the circuit during reentrant tachycardia was 0.32 +/- 0.04 mm/ms at entrance-exit points, 0.42 +/- 0.13 mm/ms for the entire outer pathway, and 0.64 +/- 0.16 mm/ms at outer pathway regions with minimum DeltaT. Model sensitivity and specificity to detect isthmus location was 75.0% and 97.2%. CONCLUSIONS: Reentrant circuit features as determined by activation mapping can be predicted on the basis of IBZ geometrical relationships.     

Impact of major co-morbidities on mortality and complications after gastric bypass

BACKGROUND: We hypothesized that major co-morbidities affect survival and complications after gastric bypass. METHODS: A total of 1465 patients undergoing laparoscopic and open gastric bypass between 1995 and 2002 were studied. Patients with a body mass index >or= 35 kg/m(2) and major co-morbidities (group 1, n = 1045) were compared with patients with a body mass index >or= 40 kg/m(2) with minor/no co-morbidities (group 2, n = 420). RESULTS: Group 1 patients were older (43 versus 36 years, P < 0.001) and had a greater BMI (53 versus 50 kg/m(2), P < 0.001). Early postoperative complications were greater in group 1 than in group 2 and included leaks (4.1% versus 1.2%, P < 0.0032) and wound infections (3.9% versus 1.4%, P < 0.0133). Procedure-related mortality in the series was 1.7%. Mortality was 10-fold greater in group 1 (2.3% versus 0.2%, P < 0.0032). The incidence of small bowel obstruction, incisional hernia, and pulmonary embolism was similar in the two groups. Excess weight loss was significantly greater in group 2 (68% versus 62%, P < 0.001) at 1 year. Resolution of group 1 co-morbidities was great, including hypertension in 62%, diabetes in 75%, venous stasis disease in 96%, and pseudotumor cerebri in 98%. CONCLUSION: Outcomes analysis of obesity surgery requires risk stratification. The very low mortality rates in published studies are likely explained by surgical treatment of low-risk patients with minor co-morbidities, such as those seen in group 2. However, despite the increased perioperative risk, the group 1 patients (with major co-morbidities) demonstrated dramatic resolution of their co-morbid conditions, justifying the decision to go forward with surgery. The data support a radical change in treatment philosophy in which morbidly obese individuals should be offered bariatric surgery before major co-morbid conditions develop as a strategy to decrease the operative risk.     

Cystic echinococcosis in Central Saudi Arabia: A 5-year experience.

Background/aims: In this series of patients we aim to describe aspects of presentation, diagnosis and management of patients suffering from Echinococcosis in an endemic region. Methods: This is an observational study done at Riyadh Medical Complex, Saudi Arabia from 1999 to 2004. All adult patients admitted with the primary or incidental diagnosis of echinococcosis were included. These patients were followed up for 6 months. Data relating to patients' demographic characteristics, mode and duration of presentation, investigations, complications and treatment offered was collected. This data was then analyzed using SPSS 11.0. Result: 117 patients with a mean age of 40.9+/-20.7 years were admitted, male to female ratio being 1.7:1. 114 (97.4%) originated from Middle East which is an endemic area. Pain right upper quadrant (RUQ), followed by cough were the commonest symptoms. Nine patients presented with jaundice +/- choleangitis: 3 patients had intrabiliary rupture of the hydatid cyst, while 6 had extrinsic compression. Six patients had infected cyst. Fourteen patients had intrabronchial rupture diagnosed on bronchoscopy. Twenty five (21.4%) patients presented with recurrent disease. The Haemagglutination Inhibition test gave a sensitivity of 78.6. All cysts were visualized using USG, CXR and CT scan. Endocystectomy was the most frequent procedure. Post op 8 patients had biliary leakage and 3 had bronchopleural fistula a majority of whom settled conservatively while two required ERCP and one patient with bronchopleural fistula required surgery. Fifteen patients had infection related complications. During our follow up period no recurrences were recorded. All patients undergoing surgery also received medical treatment. Twenty five patients (21.4%) were unable to undergo operative treatment due to multiple reasons. They were medically treated. Conclusion: Cystic Echinococcosis is a disease of the middle aged. Ultrasonogram combined with a serological assay is the best diagnostic tool available for abdominal echinococcosis allowing diagnosis and staging, while chest X ray is the best screen for the pulmonary disease. The recommended treatment is endocystectomy with antihelmenthic therapy. But the problem of early detection of echinococcosis in endemic areas needs attention by workers as this approach can potentially prevent the devastating complications due to this disease.     

Finite element analysis of the effects of thermal obturation in maxillary canine teeth.

OBJECTIVE: The purpose of the present study was to determine the distribution and level of temperature, in a model of a maxillary canine, the surrounding periodontal tissues, and the bones, during a System B heat obturation technique simulation. STUDY DESIGN: The temperature distribution was determined by using a three-dimensional finite element analysis. The tooth was assumed to have undergone an endodontic treatment before the application. Heat applications of 200 degrees C and 100 degrees C were considered. RESULTS: By using the virtual model and the simulation technique, the maximum temperature in the periodontal ligament was found to be 43.5 degrees C. CONCLUSIONS: Within the assumptions and the limitations of the study, it was determined that the simulation of System B technique created no potentially harmful levels of temperature throughout the maxillary canine model.