Laparoscopic approach to small bowel obstruction

Historically, laparotomy and open adhesiolysis have been the treatment of choice for patients requiring surgery with small bowel obstruction (SBO), although laparotomy itself is an independent risk factor for bowel obstruction. Laparoscopy is known to create fewer intra-abdominal adhesions than open laparotomy. The observation that many patients with SBO have isolated adhesive bands has led to the use of laparoscopy as primary treatment of SBO by some authors. Although the laparoscopic approach to SBO has been described, the outcomes and indications are not well established. We will review the available literature regarding the laparoscopic approach to SBO. Additionally, we will describe the technique and make recommendations regarding which patients may be best suited for a trial of laparoscopy for adhesiolysis.     

A processive versus a distributive mechanism of action correlates with differences in ability of normal and xeroderma pigmentosum group A endonucleases to incise damaged nucleosomal DNA

A DNA endonuclease, isolated from the nuclei of normal human and xeroderma pigmentosum complementation group A (XPA) cells, which recognizes predominately pyrimidine dimers, was examined for the mechanism by which it locates sites of damage on UVC-irradiated DNA. In reaction mixtures with low ionic strengths (i.e. lacking KCl), the normal and XPA endonuclease locate sites of UV damage on both naked and reconstituted nucleosomal DNA by different mechanisms. On both of these substrates, the normal endonuclease acts by a processive mechanism, meaning that it binds non-specifically to DNA and scans the DNA for sites of damage, whereas the XPA endonuclease acts by a distributive one, meaning that it randomly locates sites of damage on DNA. However, while both the normal and XPA endonucleases can incise UVC irradiated naked DNA, they differ in ability to incise damaged nucleosomal DNA. The normal endonuclease showed increased activity on UVC treated nucleosomal DNA compared with naked DNA, whereas the XPA endonuclease showed decreased activity on the damaged nucleosomal substrate. Since a processive mechanism of action is sensitive to the ionic strength of the micro-environment, the KCl concentration of the reaction was increased. At 70 mM KCI, the normal endonuclease switched to a distributive mechanism of action and its ability to incise damaged nucleosomal DNA also decreased. These studies show that there is a correlation between the ability of these endonucleases to act by a processive mechanism and their ability to incise damaged nucleosomal DNA; the normal endonuclease, which acts processively, can incise damaged nucleosomal DNA, whereas the XPA endonuclease, which acts distributively, is defective in ability to incise this substrate.      

A new amino acid mixture permits new approaches to the treatment of phenylketonuria

A new amino acid mixture for incorporation into medical foods for the treatment of hyperphenylalaninemia has been tested in a regular clinic. The mix is designed to be as unobtrusive as possible, consistent with good nutrition. After more than 1 year of trial as a beverage, we have shown that it is safe and well tolerated but that plasma phenylalanine is no better controlled than with some other products. The mix can be incorporated into a large number of different foods without affecting the taste. Occult monitoring of the quantity of medical foods purchased compared with the amounts reported to be consumed in diet histories provides an excellent way to monitor dietary compliance.     

Serological response to cholera revaccination in a semi-closed community in Calcutta

Serological response to cholera revaccination has been studied in a semi-closed community consisting of individuals mostly in the 2-20-years age-group. The subjects had been inoculated against cholera every year at the beginning of the local epidemic season. Pre- and post-vaccination sera were obtained from 29 subjects inoculated with cholera vaccine (test group) and 28 from subjects inoculated with TAB vaccine (control group). These sera were tested for vibriocidal and agglutination titres. The geometrical means of the vibriocidal and agglutination titres of the post-vaccination sera in the test group rose by 490% and 463% respectively. This booster effect was observed mostly in individuals in the 2-14-years age-group, who had low titres (vibriocidal ≤320 and agglutination ≤40) in their prevaccination samples. Revaccination, therefore, appears to be useful as a booster for individuals having low titres.     

Geographic variation in sentinel node adaptation by practicing surgeons in Oregon

BACKGROUND: The sentinel node biopsy (SNB) technique is an important tool in the diagnosis and treatment of breast cancer and melanoma. However, surgeons in Oregon have not universally adopted its use. METHODS: Mailed questionnaire. RESULTS: The response rate was 32%. Seventy-four (76%) of the surgical respondents perform routine SNB; 49% completed courses, and 32% learned the technique in residency. Sixty-one (89%) performed axillary dissection with their initial cases. It took 21 of 40 (52%) surgeons greater than a year to accrue 20 cases. Of 23 surgeons (24%) not performing SNB, 89% believed it was an important skill to obtain, and 70% thought they would benefit from proctoring opportunities. Six (26%) did not have technological support at their hospital. Surgeons at hospitals with less than 50 beds (P = .001) and at rural hospitals (P = .003) were less likely to perform SNB. CONCLUSION: The majority of urban general surgeons in Oregon use SNB in their practice. However, the incorporation of SNB for surgeons practicing in smaller hospitals and rural settings is less frequent than in the urban environment. As SNB becomes the standard of care, we need to overcome these barriers so that patients can have access to this procedure in their own communities.     

Healthcare ethics: a pedagogical goldmine

The author explores how a well designed and delivered course in healthcare ethics can meet multiple curricular goals in a health administration program. The basic philosophy, content, and methods of instruction are presented along with discussion of the effectiveness of using ethics as a platform for development of critical analysis and decision-making skills. The author illustrates how the course meets specific curricular criteria for program accreditation by the Commission on Accreditation of Healthcare Management Education (CAHME). Finally, a number of specific challenges related to the design and delivery of an effective course in healthcare ethics are addressed including course design, materials of instruction, and faculty.     

Bone marrow-derived myofibroblasts are present in adult human heart valves

BACKGROUND AND AIM OF THE STUDY: Endothelial, smooth muscle and cardiomyocyte chimerism has been shown to occur in the human heart. It is currently unknown whether the bone marrow contributes to cellular components of adult human heart valves. Here, it was determined whether bone marrow-derived smooth muscle-like cells (SMLC) are present in the heart valves of adult subjects. METHODS: By combining immunofluorescence staining and fluorescence in-situ hybridization (FISH) for X and Y chromosomes, the heart valves of gender-mismatched bone marrow transplant patients were examined for the presence of chimeric cells expressing calponin, a smooth muscle-specific protein. Concomitant staining for CD68 antigen was carried out to exclude cells of a monocytic lineage. RESULTS: The mean percentage of bone marrow-derived SMLC in valves was 0.28 +/- 0.03%, with the total proportion of chimeric cells estimated at 0.71 +/- 0.05%. The mean proportion of CD68+ cells was 0.33 +/- 0.05%. Not a single cell stained doubly for calponin and CD68 antigen. CONCLUSION: These data establish, for the first time, human bone marrow as a source of progenitor cells contributing to SMLC in adult human heart valves.