Gastro-oesophageal reflux disease: Medical or surgical treatment? Report of an interactive workshop

Gastroesophageal reflux disease (GERD) is the most common disease of the upper gastrointestinal tract. With the introduction of proton pump inhibitors medical treatment of GERD has been significantly improved. However, the development of laparoscopic antireflux surgery resulted in an increasing interest of surgeons in this disease. An interactive meeting was organized in order to develop an agreement between gastoenterologists and surgeons regarding therapeutic decisions and this is the main topic of this paper.     

Transformation: are nurse leaders in critical care ready?

Aim The aim was to determine whether nursing leaders met the criteria for transformational and/or transactional leadership. Background Many changes have occurred in South Africa and are reflected in the health-care systems. As a result, it has become crucial to source leaders who are able to manage the change process effectively so as to ensure the success and survival of our health-care organizations. Methods The 45-item Multifactor Leadership Questionnaire (Rater) was completed by 41 respondents out of a population of 121. A proportional stratified simple random sampling technique was used to select the raters of seven leaders. Results Most nursing leaders role-modelled the culture of the organisation but did not stimulate their followers intellectually and did not demonstrate innovative motivation or individual consideration. Consequently, their followers may exhibit a lack of commitment to collective goals, with detrimental effects on the health-care organisation as a whole. Conclusions and implications for nursing managers Nursing leaders should be trained to become transformational leaders so as to encourage their followers to become innovative and motivated to render high quality nursing care.     

Infected Endocardial Pacemaker Electrodes: Successful Open Intracardiac Removal

The long-term results after open intracardiac removal of infected pacing electrodes are presented. Methods: between 1985 and 1990 open intracardiac removal of 19 infected pacing electrodes was performed in seven patients (six male and one femalel, with a mean age of 56 years. The indications were; persisting bacteremia in three; generator pocket infection in four; endocarditis in one; and ventricular tachycardia caused by retracted electrodes in one. All electrodes were fixed in the right heart and extraction by closed methods failed. Percutaneous catheter techniques were not applied in these seven patients. In five patients two ventricular electrodes had to be removed, and in two patients a single one. A total of seven atrial electrodes were removed in six patients (one electrode each in five patients; two electrodes in one patient). All atrial and two ventricular electrodes could be removed through a pursestring suture without use of a pump oxygenator. For the removal of ten ventricular electrodes in six patients (two electrodes each in four patients; 1 electrode each in two patients) a right-sided atriotomy was necessary with cardiopulmonary bypass (CPB). Simultaneously, five new pacing systems were implanted. Results; there were no early or late mortalities. In January 1991, all seven patients are alive and in a mean New York Heart Association Class 1,3 of heart failure after a mean interval of 33 months. In all cases the infection could be controlled with a simultaneous antimicrobial chemotherapy and the postoperative period was free of major complications. Conclusion; open intracardiac removal of retained pacing electrodes with or without use of CPB is a safe procedure without major complications. It is mandatory for all infected pacing electrodes that cannot be extracted by closed methods.     

In Vivo Depletion of Chicken T-Cell Subsets

In the chicken three types of T-cell receptors can be defined by monoclonal antibodies TCR1, TCR2 and TCR3, which recognize γδ T cells, and Vβ1- and Vβ2-expressing αβ T cells, respectively. In the present report we have analysed means of selectively depleting the γδ T cells and the Vβ1 ⁺αβ T cells. γδ cells, which represent up to 66% of all T cells in blood of a 6-month-old chicken, can be effectively depleted by neonatal thymectomy (Tx) to levels as low as 1%. Immunohistology demonstrates a similar depletion in lymphoid organs while intestinal epithelium-associated γδ T cells are affected by Tx to a lesser extent. Vβ1-bearing αβ T cells, which comprise about 80% of the αβ T cells, were depleted by embryonic and neonatal injection of the TCR2 antibody. In the thymus such treatment depleted only the Vβ1 ⁺αβ T cells with high density expression of T-cell receptor. Therefore, we thymectomized TCR2-treated animals in order to prevent development of mature Vβ1⁺αβ T cells from the low density immature thymocytes. Treatment of chickens with a total of 22 mg of TCR2 antibody plus Tx reduced Vβ⁺αβ T cells from an average of 65% to 10% of all T cells. In these TCR2 antibody-treated animals the Vβ2-expressing αβ T cells become the predominant type of T cell (average 85%).     

LEPROMATOUS LEPROSY WITH EXTENSIVE TRUNCAL SEBORRHEIC KERATOSES AND ACRAL VERRUCA VULGARIS

A 37-year-old man came to us with asymptomatic dark colored warty iesions of 3V2 years' duration. The lesions started on the dorsa of the feet and hands and progressively increased in size and number to cover more than 60% of these areas. Later, they spread to other parts of the body. There was no history of sudden loss of weight or appetite, change in bowel habits, or of major illness in the past. The patient had not taken any medication. A general and systemic examination of the patient revealed no abnormality. On dermatological examination, hyperpigmented well-defined, verrucous papules and plaques of varying sizes were seen on the extremities, almost covering the dorsa of the hands and feet (Figs. 1–3). Small flattopped hyperpigmented papules with a smooth surface and “stuck-on” appearance were present on the trunk (Fig. 4). The rest of the body had scattered hyperpigmented papules and plaques, up to 2 × 2 cm in size with a minimally verrucous surface. The patient also had a shiny appearance of the face, infiltration of the ear lobes, with mild ichthyosis of the limbs. Examination of the peripheral nerves revealed bilateral thickening without tenderness or sensory loss. Slit smears for acid-fast bacilli from the earlobe and normal skin showed a bacteriological index of 5+ and 2+, respectively. A diagnosis of lepromatous leprosy with extensive verruca vulgaris and seborrheic keratoses was made. Biopsies of the normal-looking skin, the flat truncal lesions, and the verrucous lesions on the extremities were taken. Histopathologic examination of the trunk lesions showed hyperkeratosis and acanthosis with interwoven tracts of basaloid cells and horn cysts, indicative of the acanthotic type of seborrheic keratosis (Fig. 5). Below the epidermis there was a clear zone of dermis. A foamy macrophage granuloma was seen in the deeper dermis; M. leprae with Fite-Faraco staining was demonstrated. On histopathologic examination the acral lesions showed hyperkeratosis, acanthosis, and papillomatosis. The rete ridges were elongated and bent inwards and typical vacuolated cells were seen in some areas, indicative of verruca vulgaris (Fig. 6). The biopsy from a lesion on the arm revealed seborrheic keratosis and verruca vulgaris in continuity along the epidermis with a foamy macrophage granuloma in the lower dermis (Fig. 7). Mycobacterium leprae were demonstrable in all the sections. Thus, the histopathology of the lesions confirmed a diagnosis of lepromatous leprosy with acral verruca vulgaris and truncal seborrheic keratosis. The patient was further investigated and baseline parameters including urine and stool examination, hemogram, blood sugar, and renal and hepatic function tests revealed no abnormality. Keeping in mind the sign of Leser-Trelat, the patient was also investigated for any focus of malignancy. Gastroscopy, x-ray of the chest, and other tests were normal. The Mantoux and blood serology for H(v were negative. The patient was started on antileprosy treatment according to the WHO Multidrug Regimen and was also given a course of levamisole. Minimal response was noted. Eighteen months later the patient returned to the hospital and a 50% regression of the acral lesions was seen. A few lesions were also cauterized by electrocautery and the response was good.     

Zum Vorkommen von Chrysosporium keratinophilum (Frey) Carmichael und einer thermophilen Variante im Erdboden und bei Tieren*)

Zwischen Dermatophyten und Chrysosporium-Arten bestehen enge Beziehungen. Wegen seiner Stoffwechselphysiologie und Griseofulvinsensibilität verdient insbesondere Chrysosporium keratinophilum verstärkte Beachtung. Aus 346 Erdproben des Leipziger Stadtgebietes züchteten wir 11mal (= 3,2%) Chrysosporium keratinophilum. Die Erdproben wiesen einen pH-Wert zwischen 6,4 und 7,6 auf. Eine Abhängigkeit des Pilzvorkommens vom Humusgehalt oder der Höhe wasserlöslicher NO₃-, P- oder K-Verbindungen war nicht festzustellen. Bei der Untersuchung von insgesamt 514 tierischen Materialien (Bürstenabstriche von Tieren des Zoologischen Gartens in Leipzig) isolierten wir weitere 28 (= 5,5%) Chrysosporium keratinophilum-Stämme; darunter befanden sich 2 atypische Varianten. Im Gegensatz zu alien anderen Chrysosporium keratinophilum-Stämmen zeigten diese Pilze gutes Wachstum bei 37° C und hohe Griseofulvinresistenz. Die Größe der Aleuriosporen lag zwischen den für Chrysosporium keratinophilum und Chrysosporium tropicum angegebenen Werten. Möglicherweise handelt es sich um den gleichen Pilz, den GARG (1966 a) aus Bodenproben in Indien isolierte und zu Chrysosporium tropicum stellte. In Deutschland sind Funde von Chrysosporium tropicum bisher nicht bekannt geworden. Für fleißige technische Mitarbeit danke ich Fräulein Ulrike Kunze     

Antiplatelet effects of clopidogrel and bleeding in patients undergoing coronary stent placement

Summary. Background: In patients undergoing percutaneous coronary intervention (PCI), a link between bleeding and excess mortality has been demonstrated. A potential association of platelet response to clopidogrel and bleeding has not been well established yet. Objectives: The aim of the present study was to assess the impact of clopidogrel responsiveness on the risk of bleeding in clopidogrel‐treated patients undergoing PCI. Methods: Patients (n = 2533) undergoing PCI after pretreatment with 600 mg of clopidogrel were enrolled in this study. Blood was obtained directly before PCI. Adenosine‐diphosphate (ADP)‐induced platelet aggregation was assessed on a Multiplate analyzer. The primary endpoint was the incidence of in‐hospital Thrombolysis in Myocardial Infarction (TIMI) major bleeding and the secondary endpoint was in‐hospital TIMI minor bleeding. Receiver‐operator curve (ROC) analysis was used to derive the optimal platelet aggregation value defining enhanced clopidogrel responders for the association of measurements with major bleeding. Results: Thirty‐four (1.3%) major bleeding events and 137 (5.4%) minor bleeding events were observed. The risk of a major bleeding was significantly higher in patients (n = 975) with an enhanced response to clopidogrel as compared with the remaining patients (n = 1558) (2.2 vs. 0.8%, unadjusted odds ratio (OR) 2.6, 95% confidence interval (CI) 1.3–5.2, P = 0.005; adjusted OR 3.5, 95% CI 1.6–7.3, P = 0.001). No significant differences between both groups were observed for the occurrence of minor bleeding events (P = 0.68). Conclusions: Enhanced clopidogrel responsiveness is associated with a higher risk of major bleeding. Whether guidance of antiplatelet treatment based on platelet function testing proves useful for avoiding bleeding events warrants further investigation.