Hepatitis C among drug users: consensus guidelines on management in general practice

Background  

Hepatitis C (HCV) is a common cause of morbidity among patients who attend general practitioners (GPs) in Ireland for methadone maintenance treatment.     

Weight gain after laparoscopic cholecystectomy

Introduction Laparoscopic cholecystectomy (LC) relieves symptomatic cholelithiasis (SC) but may facilitate postoperative gluttony. Aim To examine changes in body mass index (BMI) and general health of a cohort of patients three years after uncomplicated LC for SC. Methods Patients were studied three years after uncomplicated LC and compared to age- and gender-matched controls who had undergone non-biliary surgery.Results Forty-two patients and 42 controls were studied. The mean age of the patients was 55 years (range 29–82) versus 54 years (25–82) for controls. Patients undergoing LC increased their mean BMI by 1.8kg/m2. Females were particularly likely to gain weight (mean change in BMI=+2.1), with no significant difference being found between premenopausal and postmenopausal women. Of the 24 LC patients who claimed to continue their low fat diet, the mean BMI changed from 27.6 to 29.6kg/m2. The mean BMI of the 17 people who claimed regular exercise changed less markedly (+1.4) than those who admitted infrequent exercise (+2.1). Conclusion Selection for LC may identify patients at risk of continuing or resumed aetiological contributors to obesity. Follow-up long after the surgery may therefore be necessary to facilitate additional healthcare interventions.     

The cost of managing diabetic foot ulceration in an Irish hospital

Background Little is known about the economic impact of diabetic foot ulceration in the Irish healthcare setting. Aim Audit of diabetic foot ulcer admissions in St James’s Hospital between April 2001 and March 2002. Methods Hospital charts were reviewed and costs were calculated on the length of patients’ hospital stay and the cost of individual investigations performed. Results Thirty patients were admitted with diabetic foot ulceration as the primary complaint. Amputation was performed in eight patients, two patients with a non-healing ulcer died. The average duration of each hospital admission was 20.3±30.7 days. Net in-hospital expenditure was ∈704,689, an average of ∈23,489.63 per hospital admission. Conclusions The management of diabetic foot ulceration has a significant economic impact on the Irish healthcare budget. Treatment should therefore be focused on primary prevention through specialised foot clinics and a multidisciplinary team approach to reduce this economic burden.     

One-stage Fowler-Stephens orchidopexy for impalpable undescended testis

Background The Fowler-Stephens orchidopexy (FSO) is a well-described treatment for high maldescended testes where the limiting factor for successful placement in the scrotum is short testicular vessels. The operation involves division of these vessels. The testicular blood supply is then dependent on collaterals from the vasal artery. Aims To assess the long-term outcome of patients who underwent this procedure in our institution. Methods The medical records of 20 patients who underwent 22 FSO from 1978 to 1999 by one urologist (HB) were reviewed. Outcome was assessed in terms of testicular position and size. Results Age at operation ranged from 2 to 14 years (mean 5.8 years). All patients had a one-stage FSO and in two of them the procedure was bilateral. In five patients, FSO was preceded by a diagnostic laparoscopy. Mean follow up was 22 months (range 0–121 months). Overall, results were considered good in 18 of 22 testes (82%). Conclusion Our results for the one-stage FSO are comparable with other procedures for the management of high maldescended testis.     

Application of human leukocyte antigen matching in the allocation of kidneys from cadaveric organ donors in the Nordic countries

The Nordic organ exchange organization Scandiatransplant was founded in 1969. It covers a population of 24.41 million inhabitants in five countries: Denmark (5.45 million), Finland (5.19 million), Iceland (0.29 million), Norway (4.54 million), and Sweden (8.94 million). Initially, the purpose of Scandiatransplant was to establish and maintain a common waiting list for all Nordic patients with end-stage renal failure waiting for a cadaveric kidney transplant. The basis of maintaining a common Nordic waiting list was the recognition of the wide polymorphism of the human leukocyte antigen system, which demands a substantial pool of waiting patients to provide optimal histocompatibility matching between organ donor and recipient. Thus, one of the major tasks of the organization was and still is to specify rules for the exchange of kidneys between the participating transplant centers. Scandiatransplant includes the cooperation of all 10 Nordic kidney transplant centers in addition to eight immunology laboratories. Denmark has four transplant centers located in Copenhagen, Herlev, Odense, and Aarhus. Finland has one center in Helsinki. Norway has one center located in Oslo. Sweden has four kidney transplantation centers located in each of the university hospitals in G?teborg, Malm?, Stockholm, and Uppsala. The fifth Nordic country, Iceland, is participating fully in organ donation but has no individual transplant center. Organ transplantation in Icelandic patients is performed in other Nordic countries.     

Continued symptomatic improvement three to five years after transmyocardial revascularization with CO(2) laser: a late clinical follow-up of the Norwegian Randomized trial with transmyocardial revascularization

OBJECTIVES: The goals of this study were to assess late clinical outcome and left ventricular ejection fraction (LVEF) after transmyocardial revascularization with CO(2) laser (TMR). BACKGROUND: During the 1990s TMR emerged as a treatment option for patients with refractory angina not eligible for conventional revascularization. Few reports exist on clinical effects and LVEF >3 years after TMR. METHODS: One hundred patients with refractory angina not eligible for conventional revascularization were block-randomized 1:1 to receive continued medical treatment or medical treatment combined with TMR. The patients were evaluated at baseline and after 3, 12 and 43 (range: 32 to 60) months with end points to angina, hospitalizations due to acute myocardial infarctions or unstable angina, heart failure and LVEF. Mortality was registered and MOS 36 Short-Form Health Survey answered at baseline and after 3, 6 and 12 months. RESULTS: Forty-three months after TMR, angina symptoms were still significantly improved, and unstable angina hospitalizations reduced by 55% (p < 0.001). Heart failure treatment (p < 0.01) increased, whereas the number of acute myocardial infarctions, LVEF and mortality was not affected. Quality of life was improved 3, 6 and 12 months after TMR. CONCLUSIONS: Forty-three months after TMR, angina symptoms and hospitalizations due to unstable angina were significantly reduced, heart failure treatment increased and LVEF and mortality were seemingly unaffected.     

Analysis of acute myelogenous leukemia: preparation of samples for genomic and proteomic analyses

During the last decade, several large clinical studies have demonstrated that analysis of chromosomal abnormalities is an essential basis for therapeutic decisions in patients with acute myelogenous leukemia (AML), and cytogenetic studies should now be regarded as mandatory both for routine treatment and as a part of clinical investigations in AML. However, new techniques for detailed genetic characterization and analysis of gene expression as well as protein modulation will become important in the further classification of AML subsets and the development of risk-adapted therapeutic strategies. In this context, we emphasize the importance of population-based clinical studies as a basis for future therapeutic guidelines. Such studies will then require the inclusion of patients at small clinical centers without specialized hematological research laboratories. To document a high and uniform quality of the laboratory investigations, it will be necessary to collect material for later analysis in selected laboratories. In this article, we describe current methods for collection of biological samples that can be used for later preparation of DNA, RNA, and proteins. With the use of gradient-separated AML cells, it should be possible to establish the necessary techniques for collection and handling of biological samples even at smaller centers, and complete collections from all included patients should then be possible even in population-based clinical studies.     

Psychiatric comorbidity and hostility in patients with psychogenic nonepileptic seizures compared with somatoform disorders and healthy controls

PURPOSE: To investigate the prevalence of psychiatric comorbidity and level of anxiety, depression, and aggression in patients with psychogenic nonepileptic seizures compared with those in patients with somatoform disorders and healthy controls. METHODS: Twenty-three patients with psychogenic nonepileptic seizures (PNESs) and 23 age- and sex-matched patients with somatoform disorders (SDs) underwent a clinical and a semistructured psychiatric interview (MINI) and filled in the Hospital Anxiety and Depression scale (HAD) and the Aggression Questionnaire (AQ). Twenty-three sex- and age-matched controls without psychopathology also underwent a clinical interview and completed the HAD and AQ. RESULTS: PNES reported more minor head injuries in the past than did the two comparison groups, and more unspecific EEG dysrhythmias were observed on EEG. Twenty-one PNES patients and 18 with SDs had comorbid psychiatric diagnoses. However, the mean number of comorbid psychiatric diagnoses was higher in the PNES group (1.9 +/- 0.3 compared with 1.5 +/- 0.5 in the SD group; p = 0.003). Ten PNES patients additionally had a somatoform pain disorder, and seven had an undifferentiated somatoform disorder. Both patient groups reported significantly higher levels of anxiety, depression, and anger than did the healthy controls, but the PNES patients had significantly higher level of hostility than both comparison groups. CONCLUSIONS: Increased psychiatric comorbidity is known to be associated with poorer response to regular interventions, and hostility is associated with more hostile coping patterns, often interfering with treatment compliance. Thus the increased prevalence of soft neurologic signs and comorbid psychiatric disorders and increased hostility as well in the PNES group, emphasizes that assessment and treatment of patients with PNES referred to a tertiary center requires an integrated approach involving both neurologic and psychiatric resources.     

Exercise tolerance in carnitine palmitoyltransferase II deficiency with IV and oral glucose

BACKGROUND: Patients with carnitine palmitoyltransferase II (CPT II) deficiency often experience muscle pain and myoglobinuria during prolonged exercise because of impaired oxidation of long-chain fatty acids. OBJECTIVE: To investigate whether IV or oral glucose can improve exercise tolerance in CPT II deficiency. METHODS: Five patients with CPT II deficiency and healthy matched volunteers were investigated on a cycle ergometer at a constant workload of 60% of VO(2max). Perceived exertion, heart rate, and venous plasma glucose and insulin levels were monitored. The study was randomized, placebo controlled, single blind, and crossover. Glucose and placebo were administered both orally and IV in patients and IV in healthy subjects. RESULTS: In patients with CPT II, exercise duration was prolonged by 28 +/- 8% (p = 0.02), and perceived exertion (p = 0.05) and heart rate (p = 0.09) were lowered by glucose infusion. In contrast, IV glucose resulted in higher heart rate during exercise in healthy subjects. Oral glucose and placebo resulted in the same exercise duration, perceived exertion, and heart rate in patients. Plasma glucose and insulin were consistently elevated during exercise by oral and IV glucose vs placebo, but plasma glucose was higher and insulin lower in IV vs oral glucose studies in patients (p = 0.02). CONCLUSION: Exercise tolerance is markedly improved by a glucose infusion in patients with CPT II deficiency, but because of lower glucose availability and higher insulin levels that inhibit muscle glycogenolysis, the patients cannot achieve this effect themselves by oral glucose ingestion.     

Comparison of three triple regimens with omeprazole or ranitidine bismuth citrate for Helicobacter pylori eradication

BACKGROUND: Regimens with ranitidine bismuth citrate (RBC) or omeprazole (O) are effective in eradicating Helicobacter pylori. This randomized, open, multicentre trial compares three different regimens with these drugs. METHODS: Consecutive H. pylori +ve outpatients were included. The alternative regimens were: 1) O 20 mg, clarithromycin (C) 250 mg and metronidazole (M) 500 mg (O.C.M), 2) RBC 400 mg, C 250 mg and M 500 mg (RBC.C.M), 3) RBC 400 mg, tetracycline (T) 1000 mg and M 500 mg [RBC.T.M]. All drugs were given twice daily for 7 days. H. pylori infection was assessed with H. pylori urea breath tests. RESULTS: 426 H. pylori +ve patients were included (mean age 58 years [range 18-88], male/female: 244/182). The eradication rates (intention to treat) in the O.C.M, RBC.C.M and RBC.T.M groups were 117/137 (85%), 141/146 (97%) and 117/143 (82%), respectively (P < 0.001, overall assessment). There were no significant differences in side effects between the alternatives. CONCLUSION: In this trial, RBC.C.M was the most effective one, it was well tolerated and compliance was satisfactory. RBC.T.M is an alternative to regimens with clarithromycin.