A COMPARISON OF PRESCRIBED MEDICATION IN LEARNING DISABILITY PATIENTS BEFORE AND AFTER RESETTLEMENT FROM HOSPITAL INTO THE COMMUNITY

SUMMARY The use of prescribed medication was examined in 34 people with learning disability who underwent a planned resettlement from a hospital into the community. No significant differences were found in the number of subjects receiving antipsychotic, antimuscarinic, antidepressant, and anticonvulsant medication, lithium preparations, and non-psychoactive medication, just prior to discharge and 1 year after discharge. This study indicates that long-stay hospitalised adults with moderate, severe or profound mental retardation can successfully be relocated into the community — in spite of suffering from behavioural and major psychiatric disorders — with the aid of appropriate medication, psychiatric follow-up, and community resources.     

ORAL DISOPYRAMIDE IN THE TREATMENT OF RECURRENT NEUROCARDIOGENIC SYNCOPE

In neurocardiogenic syncope the normal compensatory response on assuming an upright posture is interrupted after several minutes and replaced by a paradoxical withdrawal of sympathetic activity and increased parasympathetic activity. The resulting reduction in blood pressure is severe, sympathetic activity is inhibited, plasma norepinephrine levels do not increase and the heart rate decreases. The defect is a paradoxical interruption of sympathetic excitation associated with parasympathetic excitation, causing profound vasodilatation and bradycardia. Disopyramide has been shown not only to treat the bradycardia but also to control the hypotension.     

The impact of laparoscopic anti-reflux surgery in patients with Barrett’s esophagus

Background

Barrett’s esophagus (BE) is a major risk factor for esophageal adenocarcinoma. It is believed that BE is caused by chronic gastro-esophageal reflux disease (GERD). Laparoscopic anti-reflux surgery (LARS) restores the competency of the cardia and may thereby change the natural course of BE. We studied the impact of LARS on the histological profile of BE and on the control of GERD.

Methods

We identified all patients with BE who underwent LARS from 1994 to 2007 and contacted them to assess post-operative GERD symptoms via questionnaire. Endoscopy findings, histology, 24 hour pH monitoring, and manometry were also collected using our prospectively maintained database. Histological regression was defined as either loss of dysplasia or disappearance of BE.

Results

Two hundred and fifteen patients met the initial inclusion criteria; in 82 of them histology from post-operative endoscopy was available for review. Endoscopy was performed a median of 8 years (range, 1–16 years) after surgery. Regression of BE occurred in 18 (22 %) patients while in 6 (7 %) BE progressed to dysplasia or cancer. Thirty-six (43 %) patients underwent pre- and post-operative manometry. The median lower esophageal sphincter pressure increased from 9 to 17 mmHg in these patients. Thirty-four (41 %) patients underwent pre- and post-operative pH studies. The median DeMeester score decreased from 54 to 9. Sixty-seven (82 %) of 82 patients completed the post-operative questionnaire; 86 % of these patients reported improvement in heartburn and regurgitation.

Conclusions

LARS was associated with both physiologic and symptomatic control of GERD in patients with BE. LARS resulted in regression of BE in 22 % of patients and progression in 7 %. Thus, continued surveillance of Barrett’s is needed after LARS.     

Prevalence of respiratory symptoms in patients with achalasia

Achalasia is a primary esophageal motor disorder that results in poor clearance of the esophagus. Although an esophagus filled with debris and undigested food should put these patients at risk for aspiration, the frequency with which the latter occurs has never been documented. In this study, we sought to determine the incidence of respiratory symptoms and complaints in patients with achalasia. A comprehensive symptom questionnaire was administered to 110 patients with achalasia presenting to the Swallowing Center at the University of Washington between 1994 and 2008 as part of their preoperative work‐up. Questionnaires were analyzed for the frequency of respiratory complaints in addition to the more typical symptoms of dysphagia, regurgitation, and chest pain. Twenty‐two achalasia patients with respiratory symptoms who had also undergone Heller myotomy and completed a post‐op follow‐up questionnaire were analyzed as a subset. Ninety‐five patients (86%) complained of at least daily dysphagia. Fifty‐one patients (40%) reported the occurrence of at least one respiratory symptom daily, including cough in 41 patients (37%), aspiration (the sensation of inhaling regurgitated esophagogastric material) in 34 patients (31%), hoarseness in 23 patients (21%), wheezing in 17 patients (15%), shortness of breath in 11 patients (10%), and sore throat in 13 patients (12%). Neither age nor gender differed between those with and those without respiratory symptoms. In the subset of patients with respiratory symptoms who had undergone Heller myotomy, respiratory symptoms improved in the majority after the procedure. Patients with achalasia experience respiratory symptoms with much greater frequency than the approximately 10% that was previously believed. Awareness of this association may be important in the workup and ultimate treatment of patients with this uncommon esophageal disorder.     

Laparoscopy as the initial approach for epiphrenic diverticula

Background  

Most epiphrenic diverticula traditionally have been approached through a left thoracotomy. Because laparoscopy provides excellent exposure to the distal esophagus and decreases the morbidity of thoracoscopy or thoracotomy, we have used it preferentially since 1997 and routinely since 2001. This study describes our experience with this approach.     

Laparoscopic repair of congenital bilateral Morgagni hernia

Morgagni hernia is a rare type of congenital diaphragmatic hernia found in the anterior aspect of the diaphragm. It typically presents in the pediatric population and rarely is diagnosed in adults. Only 3% of diaphragmatic hernias are the Morgagni type, and only 4% of these are found to present bilaterally. Surgical repair of Morgagni hernia has been performed through various approaches including open, laparoscopic, thoracotomy, and video-assisted thoracoscopic surgery (VATS), all with and without mesh. The optimal method of surgical repair is not known due to the rarity of this condition and the limitations of setting up a prospective, randomized trial to evaluate the different methods. Laparoscopic repair with mesh has been described with good short-term results. Few case reports exist in the world literature describing laparoscopic repair of a bilateral Morgagni hernia with mesh. At the University of Washington, the authors present a video showing their technique for laparoscopic repair of a congenital, bilateral Morgagni type hernia with mesh.     

The International Headache Society classification of chronic daily and near-daily headaches: a critique of the criticism

The classification of the International Headache Society (IHS) published in 1988 has been positively received throughout the world. However, the classification of headaches occurring daily or almost daily has been criticized repeatedly. This criticism is discussed in the present review. It is possible to classify virtually all chronic headache patients using the IHS Classification and there seems to be more need for emphasizing a correct application of the classification than for a revision in this regard. The entity of transformed migraine is disputed and so is the existence of hemicrania continua. Neither of these syndromes has been adequately defined nor studied. Chronic daily headache of sudden onset (new persistent daily headache) is not adequately classified at present and should be included as a separate entity in the next edition of the IHS Classification. In a future revision it should also be possible to classify drug-related headache simply on the basis of drug consumption and without mandatory demands for withdrawal. Better longitudinal studies of patients with chronic daily headache are necessary to evaluate finally whether a revision of the classification of these headache syndromes is necessary. Eventually the ongoing discovery of migraine genes is likely to change radically the classification of migraine.     

Compared effects of ruthenium red and cis [Ru(NH3)4Cl2]Cl on the isolated ischaemic-reperfused rat heart

Summary— The sequence ischaemia-reperfusion is characterized by reperfusion damage. The calcium overload occurring at the beginning of reperfusion is one of the main mechanisms responsible for reperfusion damage. Ruthenium red, a blocker of the mitochondrial calcium uniport system, could prevent this damage by preserving the ATP synthesis in the mitochondria. We tested ruthenium red and another ruthenium compound, cis-tetrammine dichlororuthenium (III) chloride in our experimental model of ischaemic-reperfused rat hearts. After a 15 minute-stabilization period, the hearts were submitted to a 30 minute global ischaemia period and then reperfused for 45 minutes with the standard perfusion solution or with ruthenium red or cis-tetrammine dichlororuthenium (III) chloride at 1, 3 or 9 μM. Ruthenium red at 3 μM exerted a protective effect in our experimental conditions by showing a significant improvement of the contractility recovery at the end of reperfusion and a significant decrease of the malondialdehyde production, which reflects free radical production. The cis-tetrammine dichlororuthenium (III) chloride (containing 1 Ru ion per molecule) at 9 μM was slighty less efficient than ruthenium red at 3 μM (containing 3 Ru ions per molecule). The heart ruthenium binding was better for the ruthenium red than for the cis-tetrammine dichlororuthenium (III) chloride, suggesting a role of the ruthenium ion complexation in the crossing of the membrane, whereas the cardiac effect seemed to be linked to the ruthenium ion heart concentration, which was similar for the ruthenium red at 3 μM and for the cis-tetrammine dichlororuthenium (III) chloride at 9 μM. One can hope that ruthenium compounds would limit reperfusion damage and infarct size after ischaemia in in vivo models.