Cost and quality effects of treating erosive oesophagitis. A re-evaluation

The objective of this study was to re-evaluate the clinical and economic effects of common therapies for erosive oesophagitis in the light of a newly approved treatment regimen. A previously constructed 7-month community practice decision analytical model was revised to include the latest published data on efficacy and symptomatic outcomes. The original results of phase I therapy (antacids plus dietary, sleeping and lifestyle changes) alone or combined with ranitidine 150mg bid or omeprazole 20mg od were reassessed by adding new clinical data on the efficacy of and symptomatic response to ranitidine 150mg qid. The same payment data used in the first analysis were applied here as well, with the addition of the US price of ranitidine 150mg qid. The study perspective was that of the payer or insurer. Omeprazole-based therapy remained a dominant strategy for symptomatic care during the 7-month model. It was 14% less costly per patient, led to 23% fewer symptomatic months, and had 21% lower cost per symptom-free month than ranitidine 150mg qid, the next best alternative. Evolving treatment strategies necessitate rapid assessment and reassessment so that clinical practice can remain current, patients can be assured of the best quality, and insurers can be aware of treatment cost and budgetary impact given limited resources in all countries. Only by consistent and continuous re-evaluation of new or changing medical interventions can clinicians and insurers adapt patient management to new scientifically derived results. This is the best manner by which to meet patients' care needs and the clinical needs of practitioners, as well as the financial needs of payers.     

The splay angle: A new measure for assessing neuromuscular dysfunction in rats

This report describes a new method, the splay angle measures, to determine neuromuscular dysfunction. Splay angles are measured from a standard splay test and define hind limb orientation quantified, in degrees, by the paw strike of the hind limbs. We used mutant rats, presenting with a chronic central nervous system demyelinating disease, characterized by tremor, ataxia, immobility, epilepsy, and paralysis (taiep). Significant differences between taiep (n = 12) and normal control rats (n = 10) were found for Linear Splay, AngleLeft, AngleRight, and AngleBoth. These results suggest that the splay angles are a sensitive measure of hind limb orientation and may reflect an underlying pathology.     

Recent progress in the curative surgical treatment of stomach cancer

Surgical resection is currently the only potentially curative treatment for gastric cancer. Nodal extension, present in 3/4 of the patients, is related to topography and penetration of the tumor and is progressive, beginning by the perigastric proximal lymph nodes N1 to the perivascular distal nodes N2. A subtotal gastrectomy is possible for distal cancers and total gastrectomy is necessary for cancers of the middle and upper portions. D1 lymphadenectomy is the resection of the N1 perigastric nodes (> 15) and D2 lymphadenectomy is the resection fo the N2 perivascular nodes (> 25). In Japan, 5 year survival after D2 resection is very high, around 60%, but all the series are retrospective with a high proportion of superficial cancers. In several recent European controlled studies, D2 resection is responsible for a high mortality rate (> 10%) and the reported 45% survival is not statistically different from the D1 resection. In Western patients an "in-between" lymphadenectomy without spleno-pancreatectomy can be recommended with analysis of at least 15 nodes, and with a mortality lower than 5%. Pathological analysis of the operative specimen allows to use the new TNM classification where the number of positive lymph nodes is the main independent prognostic factor.     

Genitourinary surgery and Arthur Jacobs: father of urology in Glasgow

Arthur Jacobs (1899-1974) was the father of urology in Glasgow. His extensive experience with genitourinary tuberculosis, ureterosigmoidostomy, and bladder augmentation were far ahead of his time. He became an expert in retropubic prostatectomy and was a pioneer in early imaging techniques.     

Hypertension control through the design of targeted delivery models

If we discard some of the assumptions upon which curatively oriented medical care is based, we can design models to deliver more effective services for those with chronic diseases. Assumptions to be discarded are--that disease processes can be cured through the delivery of a "magic bullet" rather than controlled through continuous surveillance, -that the physician must be an active decision maker and thus act as gatekeeper and monitor for all disease victims, and -that care for a family of consumers must be provided together. Models for the delivery of services can then be designed to provide continuity of care for those with a specific chronic disease, and paraprofessionals can be used as gatekeepers and monitors, in combination with physicians, rather than physicians alone, to give services. Models can be targeted to reach specific high-risk groups within the population at the workplace, the school, unemployment office, or wherever groups routinely congregate for purposes other than health care. Building targeted models requires extensive knowledge of the specific geographic area and its population as well as knowledge of the natural history of the disease and its treatment. For hypertension programs, goals can be set in terms of numbers of persons whose disease is controlled and the number of new programs initiated as the result of the control efforts.     

Pharmacological treatment following experimental cerebral infarction: implications for understanding psychological symptoms of human stroke

Middle cerebral artery ligation in the rat produces decreases in catecholamine concentrations at brain sites uninjured by ischemic damage and a transient increase in spontaneous horizontal activity. Development of this hyperactivity can be blocked by postoperative treatment with the antidepressant, desmethylimipramine, or by preoperative destruction of norepinephrine terminals with 6-hydroxydopamine. These results suggest that ischemic damage to the cerebral cortex which injures some axonal branches of elaborately arborizing catecholamine-containing neurons may alter the biochemical and functional state of the entire system in its intact collateral axons. Thus the concept of stroke as a local injury producing symptoms by local structure-function relationships is conceptually inadequate, and poststroke symptoms must be evaluated with these "whole brain" concepts in mind. We suggest that the poststroke symptoms of apathy and depression may represent emotional changes which result from pathophysiological processes in catecholamine neurons far from the site of the stroke.     

Left pancreatectomy with preservation of the spleen without its pedicle. Apropos of 13 cases]

Overwhelming post splenectomy infections in childhood were first described by King and Shumaker in 1952. This septic risk, although a matter of controversy, also exists in adults. Thus, splenic conservation must become a surgical concern in left pancreas resections for benign or traumatic diseases. The authors report their experience with a simplified procedure in which the splenic pedicle is resected "en bloc" with the left pancreas. This technique has been employed in thirteen patients, in whom spleen could be preserved in twelve, without operative mortality and a low morbidity rate.     

Pancreatic apudomas

Pancreatic apudomas are not common but are frequently curable. Thus, it is important for every clinician to be fully aware of the varied clinical syndromes that suggest their presence. The availability of specific radioimmunoassays has made confirmation of the diagnosis relatively simple. Advances in the techniques for staining the different cell types have led to the recognition that many of these tumors are mixed, and that the general term pancreatic apudoma is appropriate. Pancreatic endocrine tumors, as examples of nature's experiments, have yielded considerable insight into the possible physiologic effects of the various peptides they produce. It is to be hoped that further study of tumors such as the somatostatinoma and PPoma may yield further information about these enigmatic compounds.

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Résumé Les apudomes pancréatiques sont rares. Ils sont fréquemment curables. Il est donc important de connaître les divers syndromes cliniques qui peuvent en faire soupçonner l'existence. Le diagnostic peut être facilement confirmé par dosage radioimmunologique. L'amélioration des techniques de coloration des divers types cellulaires a montré que bon nombre de ces tumeurs sont des tumeurs mixtes, qui méritent donc l'appellation générale d'apudomes. Les tumeurs pancréatiques endocrines sont de bons exemples d'expérimentation naturelle: elles ont largement contribué à une meilleure connaissance des effets physiologiques des divers peptides qu'elles secrètent. Il faut espérer que l'exploration future de certaines tumeurs, comme le somatostatinome ou le PPome, apportera de nouvelles informations sur ces substances encore énigmatiques.