Is there a role for laparoscopic appendectomy in pediatric surgery?

Although laparoscopic procedures are currently in vogue in general surgery, the role of this approach in children has not been prospectively evaluated in the United States using the new instrumentation now available to us. To assess the value of laparoscopic appendectomy (LA) in childhood, we prospectively compared 14 LAs with 50 open appendectomies (OA) over 6 months in a single children's hospital. Antibiotic usage was at the discretion of the surgeon regardless of the procedure performed and was not different between groups. LA was performed under the direction of a single laparoscopy-trained surgeon and patient selection was based on parental consent. A three-puncture LA technique was used; children from this group were allowed to return to full activities as soon as they were comfortable. There were no significant differences between groups for severity of disease, age, weight, hospital cost, or complications. The types of complications that developed were comparable in both groups. The percent of complicated appendicitis (gangrene or perforation) was 32% in the OA group and 36% in the LA group. Patients in the LA group spent significantly fewer days in the hospital and returned to unrestricted activities (school, athletics, etc) faster than patients in the OA group. LA is approximately $1,000 more expensive than OA, the differences being easily explainable by the cost of the disposable supplies necessary for the procedure (laser fibers, trocars, etc), but because of the shorter hospital stay in the LA group the mean total cost for each group was comparable. These data suggest that although there appears to be no cost advantage, LA shortens the hospital stay and allows children to return to unrestricted activity sooner than OA.(ABSTRACT TRUNCATED AT 250 WORDS)     

Evaluation of COBAS AMPLICOR (Roche): accuracy in detection of Chlamydia trachomatis and Neisseria gonorrhoeae by coamplification of endocervical specimens

We evaluated further the accuracy of the COBAS AMPLICOR (Roche) (CA) PCR-based system in detection of Chlamydia trachomatis and Neisseria gonorrhoeae in endocervical specimens. Endocervical specimens collected for any indication for testing for C. trachomatis and N. gonorrhoeae among a university hospital health system population were included. Testing for C. trachomatis was done by two PCR methods, CA and manual microwell AMPLICOR (Roche) (MWA), and by culture; testing for N. gonorrhoeae was done by CA and culture. Discrepancy resolution was performed. Reproducibility testing and hands-on labor time measurements for CA were done. Among 654 C. trachomatis samples, the prevalence of true positivity was 9.2%, and among the 618 N. gonorrhoeae samples, the prevalence of true positivity was 4.4%. For detection of C. trachomatis, the sensitivity, specificity, and negative and positive predictive values were, respectively, as follows for each test: CA, 93.3, 99.7, 99.3, and 96.4%; MWA, 91.7, 99.7, 99.2, and 96.5%; and culture, 65.0, 100, 96.6, and 100%. For detection of N. gonorrhoeae those values were as follows: CA, 96.3, 100, 99.8, and 100%; and culture, 92.6, 100, 99.7, and 100%. Hands-on labor time for each clinical result was estimated to be at 7.5 min. The prevalence of inhibitory specimens was 3.5%, including two positive C. trachomatis samples which would have been missed otherwise. The direct cost of each clinical result with CA was estimated to be $9.09. Our methods include a diverse range of indications for testing among women, using endocervical swabbing samples, 2 M sucrose phosphate transport medium, and discrepancy resolution for comparison. Under our test conditions, the CA system is an accurate, rapid, and cost- and labor-efficient method for detection of C. trachomatis and N. gonorrhoeae.     

Characterization of the purine-reactive site of the rat testis cytosolic adenylate cyclase

Naturally soluble rat germ cell adenylate cyclase was inhibited by adenosine and the adenosine analogs, 9-beta-D-arabinofuranosyl adenine (AFA) and 2',5'-dideoxyadenosine (DDA), all of which inhibited hormone-sensitive adenylate cyclases at the "P" site. The IC50 values for adenosine and DDA were approximately 0.1 and for AFA, 4.0 mM. The onset of adenosine inhibition was very rapid whether adenosine was added to the enzyme reactant mixture at time zero concomitantly with the addition of substrate or after the enzyme had been activated by the addition of substrate. The adenosine analogs, N6-methyladenosine (MeA) and N6-phenylisopropyl adenosine (PIA), which interact with plasma membrane receptors ("R" receptors) for hormone-sensitive adenylate cyclase, had little effect on the activity of the cytosolic adenylate cyclase. Additionally, aminophylline, which has been shown to competitively antagonize adenosine interactions with the plasma membrane "R" receptors but not "P" site interactions, had no effect upon substrate activation of the soluble enzyme and did not prevent adenosine from inhibiting the activity of the enzyme. These data provide evidence for an adenosine regulatory site on the cytosolic enzyme which resembles the "P" site described for membrane bound-adenylate cyclase.     

Fecal impaction

Fecal impaction is a common disorder with variable presentation and many potential complications. Its pathophysiology is complex, and the treatment is often difficult and frustrating. Preventive measures are likely to be cost effective in populations at high risk, such as institutionalized or debilitated elderly people, mentally ill patients, those with chronic renal failure or cancer, and those who are neurologically impaired.     

Differences in perceptions of hospital marketing orientation between administrators and marketing officers

Hospital administrators have been struggling for more than a decade to determine the role and proper position for marketing and marketers within their organizations. Results of a study now confirm the expected--administrators and their chief marketing officers do not see the same marketing actions being conducted for their hospitals. The consequence of such perceptual differences in marketing orientation for the role of marketers within the hospital are significant and are discussed in this article. Of particular importance is the finding that the marketing behaviors of the organization as identified by line managers correlate strongly with both revenues (r = .6r for inpatient revenue) and occupancy levels (r = .44). Additionally, it was found that as little as a 10 percent improvement in a hospital's marketing orientation is associated with a $25 million increase in total net patient revenues and an 8 percentage point increase in occupancy rate.     

College management of student death: A survey

Abstract

A national survey of Association for Death Education and Counseling members who coded themselves as employed in higher education in the 1989–1990 membership directory was conducted during that school year. Of the 141 members solicited,53 (38 %) of the sample responded with answers to questions about how their school managed student death and what they found to be helpful on a case by case basis. Results indicated that most schools did not have a written policy of operation, there was very little training of personnel in death matters, and the functionaries that were called into play were determined in large part by school size or mission. The main obstacle to carrying out successful efforts in managing death on campus related to the timely relay of facts and information from police and other officials. There were a number of helpful practices listed and gleaned from the cases presented.     

Aminophylline therapy for acute bronchospastic disease in the emergency room

OBJECTIVE: To assess the role of aminophylline in the treatment of acute exacerbations of bronchospastic disease when used in addition to inhaled beta-agonists and intravenous corticosteroids. DESIGN: Randomized, double-blind, placebo-controlled intervention study. PATIENTS: One hundred thirty-three adult patients with either asthma or chronic obstructive pulmonary disease who presented to the emergency department with asthma or wheezing. INTERVENTIONS: All patients received therapy with both aerosolized metaproterenol and intravenous methyl-prednisolone. Patients were randomly assigned to receive either a loading dose of aminophylline followed by a routine infusion (n = 65) or an equal volume of placebo as a loading dose and infusion (n = 68). MEASUREMENTS AND MAIN RESULTS: At discharge from the emergency department, the median serum theophylline concentration for the aminophylline group was 54 mumol/L (9.7 mg/L). The two groups showed no differences (P greater than 0.2) in measurements of forced expiratory volume at 1 second (FEV1), forced vital capacity (FVC), or peak expiratory flow rate (PEFR) at baseline or at 60 or 120 minutes after aminophylline administration. Neither patient satisfaction nor physician assessment of response to therapy differed between the two groups. There was no difference (P greater than 0.2) in the frequency of side effects, except for a trend toward a higher frequency of nausea (P = 0.13) in the aminophylline group. There was, however, a threefold decrease in the hospital admission rate for patients treated with aminophylline (6%) compared with placebo recipients (21%) (P = 0.016). CONCLUSION: Aminophylline, in doses producing levels just below the commonly accepted therapeutic range, appears to decrease hospital admissions in patients with acute exacerbation of asthma or chronic obstructive pulmonary disease. This finding, if confirmed in larger studies, may represent a substantial cost savings.     

Neutrophil extracellular traps and thrombosis in COVID-19

Journal of Thrombosis and Thrombolysis - Studies of patients with COVID-19 have demonstrated markedly dysregulated coagulation and a high risk of morbid arterial and venous thrombotic events....