Randomized clinical trial of suction versus standard clearance of the diathermy plume

BACKGROUND: Diathermy smoke contains complex hydrocarbons and organic material, and may contain viable tumour cells or viral particles. These particles measure from 0.05 to more than 25 microm, and long-term exposure to such particles may have adverse effects on health. This study investigated whether a suction clearance device reduces the amount of smoke reaching the surgeon's mask. METHODS: This was a randomized clinical trial in which subjects were randomized to standard diathermy equipment (group 1) or a diathermy smoke extraction system (group 2). All patients underwent thyroid or parathyroid surgery with standard anterior cervical collar incision and division of the strap muscles. The difference in the amount of smoke reaching the level of the operator's mask was measured by means of an aerosol monitor. RESULTS: Fifteen patients were randomized to each group. The mean amount of smoke detected at the level of the operator's mask was 0.137 mg/m(3) in group 1 and 0.012 mg/m(3) in group 2 (P < 0.001). The maximum amount detected was 2.411 and 0.255 mg/m(3) respectively (P < 0.001). There were no significant differences between the groups in terms of incision time or background particles measured before and after surgery. There was no correlation between gland weight and incision time or amount of smoke detected. CONCLUSION: Suction clearance of the diathermy plume resulted in a significant reduction in the amount of smoke reaching the level of the operator's mask. Although the risk of diathermy smoke inhalation is currently unknown, use of such a system appears advisable.     

Adenosine A(2A) receptors play a role in the pathogenesis of hepatic cirrhosis

1. Adenosine is a potent endogenous regulator of inflammation and tissue repair. Adenosine, which is released from injured and hypoxic tissue or in response to toxins and medications, may induce pulmonary fibrosis in mice, presumably via interaction with a specific adenosine receptor. We therefore determined whether adenosine and its receptors contribute to the pathogenesis of hepatic fibrosis. 2. As in other tissues and cell types, adenosine is released in vitro in response to the fibrogenic stimuli ethanol (40 mg dl(-1)) and methotrexate (100 nM). 3. Adenosine A(2A) receptors are expressed on rat and human hepatic stellate cell lines and adenosine A(2A) receptor occupancy promotes collagen production by these cells. Liver sections from mice treated with the hepatotoxins carbon tetrachloride (CCl(4)) (0.05 ml in oil, 50 : 50 v : v, subcutaneously) and thioacetamide (100 mg kg(-1) in PBS, intraperitoneally) released more adenosine than those from untreated mice when cultured ex vivo. 4. Adenosine A(2A) receptor-deficient, but not wild-type or A(3) receptor-deficient, mice are protected from development of hepatic fibrosis following CCl(4) or thioacetamide exposure. 5. Similarly, caffeine (50 mg kg(-1) day(-1), po), a nonselective adenosine receptor antagonist, and ZM241385 (25 mg kg(-1) bid), a more selective antagonist of the adenosine A(2A) receptor, diminished hepatic fibrosis in wild-type mice exposed to either CCl(4) or thioacetamide. 6. These results demonstrate that hepatic adenosine A(2A) receptors play an active role in the pathogenesis of hepatic fibrosis, and suggest a novel therapeutic target in the treatment and prevention of hepatic cirrhosis.     

Laparoscopic adrenalectomy: a 6-year experience of 59 cases

Background: The aims of this paper were to review our experience with laparoscopic transperitoneal adrenalectomy, report on outcomes in comparison with the published literature, and demonstrate any learning curve with the technique. Methods: A review of our database and patient records was carried out for the period April 1995 to December 2000. Patient demographics, tumour characteristics, operating times, outcomes and lengths of stay were studied. Diagnostic tools, including a comparison between tumour size on computed tomography scanning and on pathological section were reviewed. A comprehensive literature review was conducted using MEDLINE. Results: Indications for surgery included 33 patients with primary hyperaldosteronism (29 adenomas, 4 hyperplasias), 12 phaeochromo­cytomas, 7 cortisol‐secreting adenomas, 4 non‐secreting adenomas, 1 medullary cyst, 1 metastasis and 1 ganglioneuroma. The tumours ranged in size from 7 to 110 mm. All tumours were localized and lateralized preoperatively using standard techniques. Throughout the review period, six open procedures were undertaken electively, for various reasons. Three cases were converted to open procedures (5.1%). Thirty‐eight left and 21 right procedures were undertaken. For all laparoscopic procedures, the average time in the operating theatre was 175.1 min. Men took 188.3 min compared with 165.7 min for women. Left‐sided lesions took 178.72 min compared with 167.63 min for right‐sided lesions. The average length of stay was 3.8 days. There was one wound infection, one blood transfusion and two readmissions: one for pain control in a patient with difficult home circumstances, and one patient suffered transient hypoadrenalism. Conclusion: The results achieved in our initial experience with this technique are comparable with the published literature. The results confirm that laparoscopic adrenalectomy is the method of choice for resection of benign adrenal pathology. The procedure has a learning curve and should be performed by a surgeon experienced in both open and laparoscopic adrenal surgery.     

Mass-independent fractionation of oxygen isotopes during thermal decomposition of carbonates

Nearly all chemical processes fractionate 17O and 18O in a mass-dependent way relative to 16O, a major exception being the formation of ozone from diatomic oxygen in the presence of UV radiation or electrical discharge. Investigation of oxygen three-isotope behavior during thermal decomposition of naturally occurring carbonates of calcium and magnesium in vacuo has revealed that, surprisingly, anomalous isotopic compositions are also generated during this process. High-precision measurements of the attendant three-isotope fractionation line, and consequently the magnitude of the isotopic anomaly (delta17O), demonstrate that the slope of the line is independent of the nature of the carbonate but is controlled by empirical factors relating to the decomposition procedure. For a slope identical to that describing terrestrial silicates and waters (0.5247 +/- 0.0007 at the 95% confidence level), solid oxides formed during carbonate pyrolysis fit a parallel line offset by -0.241 +/- 0.042 per thousand. The corresponding CO2 is characterized by a positive offset of half this magnitude, confirming the mass-independent nature of the fractionation. Slow, protracted thermolysis produces a fractionation line of shallower slope (0.5198 +/- 0.0007). These findings of a 17O anomaly being generated from a solid, and solely by thermal means, provide a further challenge to current understanding of the nature of mass-independent isotopic fractionation.     

Update on the management of hyperuricemia and gout

Gout is the most common inflammatory arthritis in the United States, with more than three million sufferers. Management of gout has changed relatively little in the past 50 years, despite the fact that many gout patients have contraindications to one or more currently available gout therapies. However, recent insights into gout pathophysiology suggest that time is ripe for a change. This article reviews recent updates in the management of gout, including new insights into dietary management that may permit better control of hyuperuricemia. Also reviewed are the biological and clinical data behind newly-developed drugs for gout that are likely to receive serious consideration for FDA approval, and clinical use, in the foreseeable future.     

Novel developments in the treatment of acute bacterial skin and skin structure infections

ABSTRACT

Introduction: Acute bacterial skin and skin structure infection (ABSSSI) represents a major burden for healthcare systems. The increased prevalence of Methicillin-resistant Staphylococcus aureus, combined with the limited availability of microbiologic data when treating ABSSSI, has led to a need for more convenient, less toxic anti-MRSA agents. Recent approvals have added several agents to the antibiotic armamentarium that provide an expanded spectrum of activity and ease of administration compared to older agents.

Areas covered: In this review, the authors discuss updated approaches to the management of ABSSSI. They also provide a review of recent FDA approved antibiotics and emerging investigational agents for treatment of ABSSSI.

Expert opinion: Several new antibiotic agents have received FDA approval through the revised guidance on ABSSSI clinical trials with advantages of activity against MRSA and ease of administration. In theory, this may translate to reducing the utilization of healthcare resources by allowing for earlier discharge and reducing the need for outpatient parenteral therapy. While the approval of new agents offers the opportunity to improve and simplify treatment of ABSSSI, it is more important now than ever to use these agents in a responsible manner.     

Drugs causing muscle disease

Many drugs can cause myopathies, and such myopathies may range widely from asymptomatic elevations in the serum creatine phosphokinase levels to severe myalgias, cramps, exercise intolerance, muscle weakness, and even rhabdomyolysis. In this article, some of the commonly used drugs that may induce myopathies, as well as the clinical phenotypes, diagnosis, and management of these syndromes are reviewed.     

Narrative review: the pathophysiology of fibromyalgia

Primary fibromyalgia is a common yet poorly understood syndrome characterized by diffuse chronic pain accompanied by other somatic symptoms, including poor sleep, fatigue, and stiffness, in the absence of disease. Fibromyalgia does not have a distinct cause or pathology. Nevertheless, in the past decade, the study of chronic pain has yielded new insights into the pathophysiology of fibromyalgia and related chronic pain disorders. Accruing evidence shows that patients with fibromyalgia experience pain differently from the general population because of dysfunctional pain processing in the central nervous system. Aberrant pain processing, which can result in chronic pain and associated symptoms, may be the result of several interplaying mechanisms, including central sensitization, blunting of inhibitory pain pathways, alterations in neurotransmitters, and psychiatric comorbid conditions. This review provides an overview of the mechanisms currently thought to be partly responsible for the chronic diffuse pain typical of fibromyalgia.