FEASIBILITY OF CONDUCTING CARDIOVASCULAR OUTCOME RESEARCH IN AUSTRALIAN GENERAL PRACTICE: RESULTS FROM THE ANBP2 PILOT STUDY

1. The present study aimed to determine the feasibility of conducting a 5 year cardiovascular outcome trial of the treatment of 6000 elderly hypertensive patients in Australian general practices. 2. General practitioners (GPs) were invited to participate by mail and personal follow-up. Patient records were reviewed to identify subjects for a blood pressure (BP) screening programme. Blood pressure was measured on three occasions and eligible subjects were included if the average BP was 160 mmHg systolic or 90 mmHg diastolic if systolic BP was 140 mmHg. 3. Seven hundred and forty-one GPs were approached and 89 were enrolled in the study (12% of mail invites and 75% of those receiving a personal contact). In 16 practices where screening was completed, 82 000 records were reviewed to identify 4% patients eligible for screening. Twenty-two per cent of eligible subjects attended screening. Of 1938 subjects screened, 180 (9%) had BP 5=160/90 mmHg. Forty-seven percent of subjects (n = 916) were receiving antihypertensive therapy and 184 (20%) were withdrawn from therapy. One hundred and sixteen (63%) of these subjects had BP return to study entry levels within 6 weeks. Fifty-seven newly diagnosed and 81 previously treated subjects were randomized (7% of the screened population). 4. Based on the high participation rate of GPs, the response rate of patients to attend a BP screening programme and the 7% randomization to screening ratio for entry into the study, the ANBP2 pilot study has demonstrated that it is feasible to recruit subjects from Australian general practices to a cardiovascular outcome trial.     

Utilization of carbohydrates and free fatty acids by the gastrocnemius of the dog during long lasting rhythmical exercise

Summary Utilization of carbohydrates and free fatty acids (FFA) has been investigated in gastrocnemii of dogs during long lasting isotonic rhythmical exercise induced by supramaximal stimulation of the sciatic nerve. Uptake or output of gases and substrates was determined according to the Fick principle. The first measurements were done at about 2 min after the beginning of work when blood flow has reached a steady state, and the latest at about 100 min after the beginning of exercise.During the first 7 min when the work performed exceeded 5 kg/100g×min and O₂ consumption exceeded 11 ml/100g×min, uptake of arterial glucose and FFA was low, accounting for less than 40% of the total O₂ consumption. Since the RQ values at the same time were about 1.0, glycogen must have been oxidized as the major aerobic energy source.About 13 min after the beginning of exercise, the work the muscles could perform declined to about half of the initial value and remained so for the following 90 min. During this time the oxygen extraction ratio of FFA was about 50% and of arterial glucose was 40–50%, while the RQ value was about 0.8.During initial strong exercise an output of lactic acid (LA) of about 10 mg/100 g×min was measured. With the decrease of work as a consequence of fatigue, LA output became negligible, and in many experiments small amounts of LA were taken up by the working gastrocnemii.It is concluded that glycogen is the major aerobic energy source for strong muscular exercise which cannot be substituted for by the oxidation of arterial glucose or FFA.Supported by the Deutsche Forschungsgemeinschaft.     

Changes in mitotic rate and cell cycle fractions caused by delayed fixation

The mitosis frequency and flow cytometric data of malignant neoplasms are important, both for diagnosis and for prognosis. It is unclear to what extent these factors are affected by a delay in the fixation of tumor biopsies. We have thus studied the mitotic activity and DNA content in human soft-tissue sarcoma xenotransplants, fixed for periods of 5 minutes and 3, 6, 9 and 12 hours after biopsy. On average, the mitoses counted by two observers were 13% and 10% below initial values after 3 hours, and decreased by 46% and 39% after 12 hours. The mitosis decrease was related to the degree of mitotic activity of individual tumors, and was minimal in the sarcomas with the lowest mitotic rate. These results were reproducible. However, numerous pyknotic mitotic figures were observed, so the decrease in counts is largely due to their reduced identifiability, and only partly attributable to a completion of the cell cycle. Well-preserved mitotic figures demonstrable after 12 hours appear to indicate that the proliferation activity only gradually decreases in unfixed biopsies. The flow cytometric data did not change substantially; only a slight increase in the G2 + M-phase fraction was observed. General conclusions from the results are limited by the fact that the investigated sarcomas had a higher mitotic activity than most carcinomas. Nevertheless, early fixation of biopsies is desirable to accurately measure mitosis counts for the grading of malignancy.     

Sliding free transverse rectus abdominis myocutaneous flap for closure of a massive abdominal wall defect: A case report

Despite considerable advances in reconstructive surgery, massive abdominal wall defects continue to pose a significant surgical challenge. We report the case of a 72‐year‐old morbidly obese female patient with Clostridium septicum‐related gas gangrene of the abdominal wall. After multidisciplinary treatment and multiple extensive debridements, a massive full‐thickness defect (40 cm × 35 cm) of the right abdominal wall was present. The abdominal contents were covered with a resorbable mesh to prevent evisceration. Finally, the composite defect was successfully reconstructed through a contralateral extended free transverse rectus abdominis myocutaneus (TRAM) flap (50 cm × 38 cm). An arterio‐venous loop to the superficial femoral vessels using the great saphenous vein was necessary to allow the flap to reach the defect. Postoperatively, a minor wound healing disorder of the flap was successfully treated with split skin grafting. Six month after surgery, the patient presented with a completely healed flap coverage area and a small abdominal hernia without the need of further surgical revision. This case illustrates the use of a sliding free TRAM flap for closure of a massive abdominal wall defect.     

The Value of Routinely Performed Ultrasonography in Patients with Crohn Disease

Background: In active Crohn disease (CD), abdominal ultrasound can demonstrate morphological changes in the bowel wall. By contrast, the role of ultrasonography in periods with no disease activity has never been evaluated. In this prospective study we investigated the outcome of routinely performed abdominal ultrasonography in CD patients irrespective of symptoms and disease activity. Methods: 255 consecutive patients with chronic CD (117 M, 138 F, mean age ( ± s ) 38 ± 14) were evaluated by high-resolution ultrasonography of the bowel wall and abdomen. The findings were graded with respect to further diagnostic and/or therapeutic implications. In addition, the CD activity index (CDAI) was determined. In patients with pathological sonographic findings, complementary procedures (e.g. endoscopy, computed tomography, biopsy or operation) were performed to validate the suspected diagnosis. Results: In 46/255 (18%) patients with CD, the diagnosis of a transmural inflammatory reaction (TMR) with or without fistula was made by ultrasonography. In respect of CDAI, 29/46 (63%) of these patients were graded as active disease (CDAI >150) and 17/46 (37%) as inactive disease (CDAI &#104 150). Of the 17 patients with a TMR and CDAI &#104 150, 4 patients revealed interenteric fistula, 7 patients mesenteric or perirectal fistula, whereas 6 patients presented with a transmural mesenteric inflammatory reaction without fistula. All fistulae were confirmed by radiography. Ultrasonography of the remaining abdominal organs revealed pathological findings with further diagnostic implications in 25/255 (10%) patients and with therapeutic implications in 9/255 (4%) patients. Conclusion: Routinely performed ultrasonography of the abdomen reveals pathological findings with therapeutic implications not only in symptomatic but also in asymptomatic patients with CD. It can therefore be recommended as a screening tool for this group of patients.     

Health care providers on the World Wide Web: quality of presentations of surgical departments in Germany

It is becoming increasingly common for health care providers to present information on the World Wide Web (WWW). Patients, as well as health care professionals, do not really know what they can expect today. Many quality criteria are proposed for the assessment of medical Internet sites focusing mainly on structure and content management. The objective of this study was to assess the quality of presentations by health care providers on the WWW and to detect strengths and weaknesses with regard to potential target groups, patients, colleagues, and students. A sample of 171 presentations was randomly selected in March 2000 from a collection of 469 surgical departments in Germany. Medical doctors undergoing a full-time training in medical informatics rated the presentations. A previously evaluated questionnaire was used to assess the presentations with regard to 12 criteria about content and technical features. For each criterion the categories 'very good', 'sufficient', and 'insufficient' could be used. Twenty medical doctors assessed 168 presentations with one to seven valuations per presentation. Three presentations could not be accessed at the time of evaluation. Sixty-eight per cent of the median values of each criterion were rated as insufficient. The only criteria rated sufficient or better in at least 50% were: employees/map, survey of offered medical services, navigation, and layout. University hospitals and heart centres achieved significantly better results than regional hospitals. In conclusion, the quality of provider information on the W WW is unsatisfactory. Most surgical departments do not provide information that could help patients to choose their physicians. The criteria set developed here could be a useful tool for a target-group-oriented self-assessment of provider presentations on the World Wide Web.