Outcomes of laparoscopic antireflux procedures

BACKGROUND: Laparoscopy has increased the number of patients undergoing operative correction of gastroesophageal reflux disease (GERD). Symptom improvement has been most commonly reported as the means to assess operative outcome. We compared symptomatic outcome to postoperative pH testing at short-term follow-up to determine the accuracy of clinical assessment at predicting whether acid exposure would be normal or abnormal. METHODS: Of 640 patients who had antireflux surgery between 1993 and 1999, 228 (36%) agreed to repeat manometry and 24-hour pH monitoring 8 to 12 weeks postoperatively and are the subject of this study. Symptom resolution was assumed if the frequency was less than once per week. Normal acid exposure consisted of a distal esophageal pH below 4 less than 4% of the time and a DeMeester composite score less than 14.7. Accuracy of symptom scoring was calculated using acid exposure as the standard.RESULTS: The primary symptom was improved in 93% of the 228 patients. Acid exposure was reduced from a preoperative DeMeester score of 71 to 16 (P <0.05). Eighty percent of patients had normalization of acid exposure postoperatively. Heartburn was the only symptom to have a significant correlation with acid exposure in the postoperative period (P <0.05). Heartburn resolved in 181 patients, 168 of whom had normal acid exposure (true negative). Thirty-eight patients without symptoms had abnormal acid exposure (false negative). Nine patients had persistent heartburn with abnormal acid exposure (true positive) whereas 13 patients had persistent heartburn with normal acid exposure (false positive). Thus, the positive predictive value of heartburn was 43%, the negative predictive value was 82%, and the overall accuracy was 78%. CONCLUSIONS: Operative treatment improves both the symptoms of GERD and the degree of acid exposure as measured by pH monitoring. The most accurate symptom for predicting acid exposure in the postoperative period is heartburn. Although the absence of heartburn postopertively is fairly reliable at predicting normal acid exposure on pH testing, the presence of heartburn warrants postoperative pH monitoring, as more than half of these patients will have normal acid exposure.     

Clinical cerebral microdialysis: a methodological study

OBJECT: Clinical microdialysis enables monitoring of the cerebral extracellular chemistry of neurosurgical patients. Introduction of the technique into different hospitals' neurosurgical units has resulted in variations in the method of application. There are several variables to be considered, including length of the catheter membrane, type of perfusion fluid, flow rate of perfusion fluid, and on-line compared with delayed analysis of samples. The objects of this study were as follows: 1) to determine the effects of varying catheter characteristics on substance concentration; 2) to determine the relative recovery and true extracellular concentration by varying the flow rate and extrapolating to zero flow; and 3) to compare substance concentration obtained using a bedside enzyme analyzer with that of off-line high-performance liquid chromatography (HPLC). METHODS: A specially designed bolt was used to conduct two adjacent microdialysis catheters into the frontal cortex of patients with head injury or poor-grade subarachnoid hemorrhage who were receiving ventilation. One reference catheter (10-mm membrane, perfused with Ringer's solution at 0.3 microl/minute) was constant for all studies. The other catheter was varied in terms of membrane length (10 mm or 30 mm), perfusion fluid (Ringer's solution or normal saline), and flow rate (0.1-1.5 microl/minute). The effect of freezing the samples on substance concentration was established by on-line analysis and then repeated analysis after storage at -70 degrees C for 3 months. Samples assayed with the bedside enzyme analyzer were reassessed using HPLC for the determination of glutamate concentrations. CONCLUSIONS: Two adjacent microdialysis catheters that were identical in membrane length, perfusion fluid, and flow rate showed equivalent results. Variations in perfusion fluid and freezing and thawing of samples did not result in differences in substance concentration. Catheter length had a significant impact on substance recovery. Variations in flow rate enabled the relative recovery to be calculated using a modification of the extrapolation-to-zero-flow method. The recovery was approximately 70% at 0.3 microl/minute and 30% at 1 microl/minute (10-mm membrane) for all analytes. Glutamate results obtained with the enzyme analyzer showed good correlation with those from HPLC.     

Randomized phase III study of docetaxel compared with paclitaxel in metastatic breast cancer.

PURPOSE: This randomized, controlled, multicenter, open-label, phase III study compared docetaxel versus paclitaxel in patients with advanced breast cancer that had progressed after an anthracycline-containing chemotherapy regimen. PATIENTS AND METHODS: Patients (n = 449) were randomly assigned to receive either docetaxel 100 mg/m2 (n = 225) or paclitaxel 175 mg/m2 (n = 224) on day 1, every 21 days until tumor progression, unacceptable toxicity, or withdrawal of consent. RESULTS: In the intent-to-treat population, both the median overall survival (OS, 15.4 v 12.7 months; hazard ratio [HR], 1.41; 95% CI, 1.15 to 1.73; P = .03) and the median time to progression (TTP, 5.7 months v 3.6 months; HR, 1.64; 95% CI, 1.33 to 2.02; P < .0001) for docetaxel were significantly longer than for paclitaxel, and the overall response rate (ORR, 32% v 25%; P = .10) was higher for docetaxel. These results were confirmed by multivariate analyses. The incidence of treatment-related hematologic and nonhematologic toxicities was greater for docetaxel than for paclitaxel; however, quality-of-life scores were not statistically different between treatment groups over time. CONCLUSION: Docetaxel was superior to paclitaxel in terms of OS and TTP. ORR was higher for docetaxel. Hematologic and nonhematologic toxicities occurred more frequently in the docetaxel group. The global quality-of-life scores were similar for both agents over time.     

The influence of children's self-report trait anxiety and depression on visual search for emotional faces

BACKGROUND: This study presents two experiments that investigated the relationship between 7- and 10-year-olds' levels of self-report trait anxiety and depression and their visual search for threatening (angry faces) and non-threatening (happy and neutral faces) stimuli. METHOD: In both experiments a visual search paradigm was used to measure participants' reaction times to detect the presence or absence of angry, happy or neutral schematic faces (Experiment 1) or cartoon drawings (Experiment 2). On target present trials, a target face was displayed alongside three, five or seven distractor items. On target absent trials all items were distractors. RESULTS: Both experiments demonstrated that on target absent (but not present) trials, increased levels of anxiety produced significantly faster search times in the angry face condition, but not in the neutral condition. In Experiment 2 there was some trend towards significance between anxiety and searches for happy faces in absent trials. There were no effects of depression on search times in any condition. CONCLUSION: The results support previous work highlighting a specific link between anxiety and attention to threat in childhood.     

Predicting stress in pre-registration midwifery students attending a university in Northern England

OBJECTIVE: to determine which variables predict stress (psychological distress) in pre-registration midwifery students. DESIGN: a cross-sectional survey, using a range of self-report measures bound together in a 'questionnaire pack'. SETTING: the study reported here is taken from a wider investigation into stress among nursing and midwifery students, undertaken in the nursing and midwifery department of a large university in Northern England. PARTICIPANTS: 120 pre-registration midwifery students pursuing one of three diploma programmes: 'standard', 'enhanced' and 'short'. MEASUREMENTS: multivariate logistic regression was used as the analytical technique. The variables used in the analyses undertaken were all derived from formal and study-specific, self-report measures included in the questionnaire pack. 'Stress' (whether a participant was psychologically distressed or not) was obtained via the General Health Questionnaire. Potential predictors of stress were collected from two formal measures (the Student Nurse Stress Index and the Coping Inventory for Stressful Situations) and from questions in the questionnaire pack designed to elicit demographic data and data of specific interest to nurse and midwife educators. FINDINGS: 102 questionnaire packs (85%) were returned. The prevalence of stress among participants was over 40%. A series of logistic regression analyses resulted in five competing regression models. Through a systematic selection process, two of these models were chosen for discussion. These models suggested that the key predictors of psychological distress in the population studied were self-report of stress levels, the type of midwifery programme being pursued, the use of 'task-oriented' coping and, possibly, whether or not a student smokes cigarettes. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: despite the prevalence rate of 40%, the prevalence of stress among midwifery students is generally no better or worse than that of other students or of qualified health-care professionals. Those involved in midwifery education need to know how to manage student stress effectively. This can be achieved by ensuring that personal teachers (continue to) play a key role in supporting students, especially when students self-report high levels of stress. Incorporating formal stress-management training into pre-registration midwifery programmes may also be useful. Sound knowledge of the issues associated with student stress during curriculum design, however, may ultimately prove to be the most effective way of managing student stress. In a discipline such as midwifery, these issues are as divergent as the politics of midwifery, the processes used in recruitment and selection, the role of women in society, and the nature, quality and quantity of the learning experiences and the assessment strategies used.     

Ascorbic Acid and the Premature Infant

Little information exists about the plasma target nutritional needs of the >15 million premature infants <37 weeks gestation. Investigating ascorbic acid’s (AscA) role in infant health, our study details the relationship of infant characteristics and maternal health on infant plasma AscA level (pAscA) during postnatal development. Furthermore, we determined pAscA influence during the first week of life (EpAscA) with later infant morbidities. We hypothesize that pAscA is influenced by gestational organ immaturity, as well as maternal factors, with EpAscA associated with greater morbidity risk. We conducted a prospective longitudinal observational study of pAscA, demographics and hospital course detailed in infants ≤34 weeks. Sixty-three subjects were included, with >200 urine and plasma data points analyzed. Maternal smoking, exposure to magnesium sulfate (MgSO4) and advancing gestational and postnatal age were associated with lower pAscA. Non-white infants and those ≤30 weeks that developed bronchopulmonary dysplasia or retinopathy of prematurity had lower pAscA. Prenatal smoking, MgSO4, birth gestational age and race negatively influence pAscA. These results show prenatal and postnatal developmental factors influencing initial pAscA and metabolism, potentially setting the stage for organ health and risk for disease. Assessment of dietary targets may need adjustment in this population.