Diagnosis and treatment of diverticular disease

Background: With the aim of resolving the current controversy over the diagnosis and treatment of diverticular disease, this consensus development conference set out to summarize the actual state of the art. Methods: A multidisciplinary panel of international experts (n= 16) was selected to take part in the consensus process. Prior to the conference, all experts were asked to answer a series of questions on diverticular disease. The consensus statement compiled out of these evaluations was modified during a joint meeting of the panel members, then presented for discussion in a public session, and finally revised by the expert panel. The finalized statement was mailed to all panel members for approval (Delphi method). Results: Asymptomatic diverticulosis, diverticular disease (with actual or recurrent symptoms), and complicated diverticular disease were defined separately. No agreement was reached on whether barium enema or colonoscopy is the better choice as an initial diagnostic tool in uncomplicated cases. In complicated cases, computed tomography is recommended for diagnosis. After two attacks of diverticular disease, elective resection should be considered. For patients in whom a concomitant carcinoma cannot be excluded and those with chronic complications (fistula, stenosis, or bleeding) surgery is also indicated. Laparoscopic sigmoid colectomy is recommended only for uncomplicated and, after percutaneous drainage of abscesses, Hinchey stage I and II cases. Conclusions: Laparoscopic surgery has already begun to influence the management of diverticular disease, but the randomized controlled trials needed to support therapy decisions are largely missing.     

Epidemiology and natural course of social fears and social phobia

OBJECTIVE: To summarize epidemiological studies providing data on prevalence, incidence, comorbidity, natural course, risk factors and consequences of social phobia (SP). METHOD: Data from cross-sectional studies and prospective longitudinal studies in particular are considered. RESULTS: These studies portray SP as a frequent mental disorder, which begins typically in early adolescence, and is highly comorbid with other anxiety disorders, as well as secondary depression and substance abuse disorders. Several possible risk factors have already been identified for the onset and unfavorable course of SP; some of them have been tested in prospective longitudinal studies. SP is a chronic disorder when compared with other mental disorders and when subclinical symptomatic levels are considered. Impairment caused by SP is considerable and increases over a patient's life span. The negative impact of SP is not only reflected in subjective well-being and reduced quality of life but also in social role functioning, and it impacts negatively on career progression. CONCLUSION: Prospective longitudinal studies in representative samples drawn from the general population provide information that allows the overall direct and indirect costs of the disorder (treatment costs, disability, social welfare) to be determined, and enables an improvement in long-term care strategies as well as preventive efforts to be established.     

Renal transplantations performed using non-heart-beating organ donors: going back to the future?

BACKGROUND: As more expanded-criteria organ donors are used to bridge the widening gap between organ supply and demand, non-heart-beating (NHB) donors will become increasingly important. The purpose of this study was to analyze renal transplant outcomes using this source of cadaveric (CAD) organs and compare the results with heart-beating organ sources. METHODS: Data from 98,698 adult CAD renal transplant recipients and 34,531 living donor renal transplant recipients registered in the U. S. Renal Data System database between January 1993 and June 2000 were analyzed. Kaplan-Meier survival curves were used to compare graft and patient survival rates between NHB, CAD, and living donor transplant recipients. Cox proportional hazards models were used to identify risk factors for NHB donor recipients, while adjusting for potential confounding variables. RESULTS: Recipients of NHB donor organs experienced nearly twice the incidence of delayed graft function (DGF) compared with heart-beating donors (42.4% vs. 23.3%, respectively). NHB donor transplants experienced comparable allograft survival when compared with CAD transplants at 6 years (73.2% vs. 72.5%, respectively; P=NS); patient survival was greater at 6 years for NHB compared with CAD renal transplant recipients (80.9% vs. 77.8%, respectively; P=NS). Significant factors for allograft loss for NHB donor organ recipients included the following: organ used for repeat transplants; DGF; donor age older than 35 years; and head trauma as a cause of initial injury (relative risk 2.74, 1.90, 1.78, and 1.41, respectively). CONCLUSIONS: Although exhibiting elevated DGF rates, allograft and patient survival rates of transplants from NHB donor sources are equivalent to those from conventional CAD sources. Donor age, recipient transplant number, female recipient, mechanism of injury, and DGF were the most pertinent variables leading to poor outcomes.     

The effects of renal transplantation on peripheral blood dendritic cells

Recent advances allow accurate quantification of peripheral blood (PB) myeloid and plasmacytoid dendritic cell (DC) populations (mDC and pDC, respectively), although the response to renal transplantation (RT) remains unknown. Using flow cytometry, PBDC levels were quantified in patients with end stage renal disease (ESRD) undergoing RT. PBDC levels were significantly reduced in ESRD patients pre-RT compared to healthy controls, with further reduction noted immediately following a hemodialysis session. RT resulted in a dramatic decrease in both subsets, with a greater reduction of pDC levels. Both subset levels were significantly lower than in control patients undergoing abdominal surgery without RT. Subgroup analysis revealed significantly greater mDC reduction in RT recipients receiving anti-lymphocyte therapy, with preferential binding of antibody preparation to this subset. Samples from later time points revealed a gradual return of PBDC levels back to pre-transplant values concurrent with overall reduction of immunosuppression (IS). Finally, PBDC levels were significantly reduced in patients with BK virus nephropathy compared to recipients with stable graft function, despite lower overall IS. Our findings suggest that PBDC levels reflect the degree of IS in renal allograft recipients. Furthermore, PBDC monitoring may represent a novel strategy to predict important outcomes such as acute rejection, long-term graft loss and infectious complications.     

Conscious sedation for endoscopic and non-endoscopic interventional gastrointestinal procedures: meeting patients' expectations, missing the standard

AIM: To assess the level of sedation, patient satisfaction and frequency of unplanned events with conscious sedation for interventional procedures. MATERIALS AND METHODS: One hundred and seventeen patients were assessed prospectively before, during and after procedures. Blood pressure, pulse, oxygen saturation and sedation level were monitored and patients followed up after 24 h. Sedation was scored after drugs were given in accordance with an established protocol. Doses were recorded, as were patients' weight, age and ASA grade and any unplanned events and their management. RESULTS: Seventy-six of the 117 patients (65%) had no unplanned event, 20 (17.1%) became agitated, 15 (12.8%) hypotensive, three (2.6%) hypoxic and three (2.6%) had more than one response. Twelve patients required active management. Fifty-two (44.4%) had a sedation level of 相似文献   

The consent process in interventional radiology: the role of specialist nurses

AIMS: To evaluate the impact of patient education by specialist nurses on patients' understanding of interventional procedures, their anxiety levels and satisfaction with the given information. MATERIALS AND METHODS: Sixty patients attending the radiology department for gastrointestinal interventional procedures were interviewed. Patients were assessed using a combination of categorical and visual analogue scales. Parameters were assessed on admission and after additional information had been given by specialist nurses. After the procedure patients were asked to rate the quality of information given and their overall satisfaction. RESULTS: Four of the 60 patients were excluded due to a Mini Mental Test score of <7. Only 35 (62.5%) claimed to have been given information by the referring consultant. Fifty-three patients received additional information before formally giving consent, 50 (96.2%) from the specialist nurses. Patient anxiety before and after information did not significantly change (p=0.52) but there was significant improvement in levels of satisfaction (p=0.001) and perceived understanding (p<0.001). Patients rated overall quality of information at an average of 9.2/10 and overall satisfaction was high (median=9.1/10). CONCLUSION: The use of specialist nurses to educate patients greatly increases patient understanding. The process of informed consent is improved and patient satisfaction is increased.