Alcohol consumption patterns and predictors of use following liver transplantation for alcoholic liver disease.

For patients who receive a liver transplant (LTX) for alcoholic liver disease (ALD), investigators are focusing beyond survival to determine specific alcohol use outcomes. Studies suggest the use of alcohol ranges from 8 to 22% for the first post-transplant year with cumulative rates reaching 30 to 40% by 5 years following transplantation. Yet while investigators are interested in determining specific rates of alcohol use and predictors of use, only three studies since 1990 have been prospective. In 1998, we began a prospective study of post-LTX alcohol consumption in ALD recipients using multiple repeated measures of alcohol use. After 5 years of follow-up, we found that 22% had used any alcohol by the first year and 42% had a drink by 5 years. By 5 years, 26% drank at a heavier use (binge) pattern and 20% drank in a frequent pattern. In a univariate model, predictors of alcohol use included pre-transplant length of sobriety, a diagnosis of alcohol dependence, a history of other substance use, and prior alcohol rehabilitation.     

LONG‐TERM FOLLOW UP OF PATIENTS WITH SMALL GASTROINTESTINAL STROMAL TUMORS IN THE STOMACH USING ENDOSCOPIC ULTRASONOGRAPHY‐GUIDED FINE‐NEEDLE ASPIRATION BIOPSY

Background: Gastrointestinal stromal tumors (GIST) are one of the most common mesenchymal tumors of the gastrointestinal tract. GIST are defined by positive immunohistochemical staining for KIT or CD34 and thus are generally diagnosed after surgery. Because small GIST are rarely diagnosed before surgery, the clinical course of these small tumors is not clear. The aim of the present study was to follow changes in size and configuration of small GIST that were pathologically confirmed using endoscopic ultrasonography‐guided fine‐needle aspiration biopsy (EUS‐FNAB). Methods: Between July 1997 and December 2003, 16 tumors in 16 patients (10 men and 6 women) with an immunohistochemical diagnosis of GIST were regularly followed in our hospital. The median patient age when EUS‐FNAB was performed was 62 years (range 26–82 years) and the median follow‐up period was 4.9 years (range 0.5–9.6 years). Results: Fourteen tumors showed no remarkable changes in size and shape during follow up compared with the initial diagnosis. Two tumors enlarged: one tumor approximately doubled its diameter in 8 years and the other tumor increased from 1.8 cm at diagnosis to up to 10 cm after only 2 years. Doubling time of the latter tumor was calculated as 3.1 months. Conclusions: We conclude that EUS‐FNAB might be a good modality for final diagnosis of GIST without surgery, and that GIST without rapid growth on follow up can be endoscopically followed.     

Chimeric cytotoxin IL2-PE40 inhibits relapsing experimental allergic encephalomyelitis.

IL2-PE40 is a chimeric protein composed of human interleukin-2 (IL2) genetically fused to a modified form of Pseudomonas exotoxin lacking the cell recognition domain. IL2-PE40 is cytotoxic for IL2 receptor-bearing lymphocytes in culture and can inhibit activation of T cells in vivo. IL2-PE40 can significantly diminish antigen-stimulated proliferation of lymphocytes sensitized to myelin basic protein. Intraperitoneal administration of IL2-PE40 not only markedly inhibits the clinical manifestations of adoptively transferred relapsing experimental allergic encephalomyelitis but also dramatically reduces both inflammation and demyelination characteristic of the disease.     

Undergraduate surgical training: variations in program objectives and curriculum implementation across Canada.

BACKGROUND: Although nationally recognized learning objectives for undergraduate surgical education exist, the extent to which Canadian medical schools follow these guidelines has never been established. METHODS: We distributed a survey to all program directors and clinical-teaching-unit coordinators for undergraduate surgery at Canada's 16 medical schools, and subsequently assessed the perceived emphasis placed on learning objectives and student performance, and the impact of instructional tools and teaching locations. RESULTS: Program directors in 15 medical schools responded to the survey. We identified a wide variation in the emphasis placed on basic learning objectives as well as specialty specific learning objectives. The length of rotations, methods of instruction and tools used to grade student performance also varied widely. CONCLUSIONS: Our findings suggest significant variation in the design and implementation of undergraduate surgical education in Canada. This study may serve as a basis for reassessing learning objectives in Canadian undergraduate surgical education.     

Changing patterns of hip fracture care before and after implementation of the prospective payment system

We tested the hypothesis that since the implementation of the prospective payment system (PPS), elderly patients hospitalized for hip fractures receive shorter, less care-intensive hospitalizations and are more frequently institutionalized. In blinded fashion, we reviewed the charts of elderly patients with hip fractures admitted to a municipal hospital from 1981 through 1985. Demographic and clinical characteristics of patients treated before implementation of the PPS were similar to patients treated thereafter. After implementation of the PPS, the mean length of hospitalization fell from 16.6 to 10.3 days, and the mean number of physical therapy sessions received decreased from 9.7 to 4.9. Concomitantly, the proportion of patients discharged to a nursing home increased (21% to 48%), as did the proportion receiving nursing home care at six months after discharge (13% to 39%). This increase in long-term nursing home placement suggests that the quality of care for elderly patients with hip fractures may have deteriorated.     

Incorrect positioning of nasogastric feeding tubes and the development of pneumothorax.

The authors describe 12 patients in whom feeding tubes were inadvertently placed in the bronchial tree a total of 14 times. All but four of the misplacements were complicated by pneumothorax. No deaths were directly attributable to the misplacements, although one cardiac arrest occurred as a late complication of intrapleural feeding. Careful, controlled insertion of feeding tubes and radiographic confirmation of their placement are essential to reduce morbidity and mortality.