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Biomedical subjects

John A Windsor

Publications and source records attributed to John A Windsor.

13 recordsLinked to original sources
PubMed2006

Quality of life following laparoscopic anterior 90 degrees versus Nissen fundoplication: results from a multicenter randomized trial.

BACKGROUND: The short-term clinical outcomes from a multicenter prospective randomized trial of laparoscopic Nissen versus anterior 90 degrees partial fundoplication have been reported previously. These demonstrated a high level of satisfaction with the overall outcome following anterior 90 degrees fundoplication. However, the results of postoperative objective tests and specific clinical symptoms are not always consistent with an individual patient's functional status and general well being following surgery, and quality of life (QOL) is also an important outcome to consider following surgery for reflux. Hence, QOL information was collected in this trial to investigate the hypothesis: improvements in QOL following laparoscopic antireflux surgery are greater after anterior 90 degrees partial fundoplication than after Nissen fundoplication. METHODS: Patients undergoing a laparoscopic fundoplication for gastro-esophageal reflux at one of nine university teaching hospitals in six major cities in Australia and New Zealand were randomized to undergo either laparoscopic Nissen or anterior 90 degrees partial fundoplication. Quality of life before and after surgery was assessed using validated questionnaires - the Short Form 36 general health questionnaire (SF36) and an Illness Behavior Questionnaire (IBQ). Patients were asked to complete these questionnaires preoperatively and at 3, 6, 12 and 24 months postoperatively. RESULTS: One hundred and twelve patients were randomized to undergo a Nissen fundoplication (52) or a 90 degrees anterior fundoplication (60). Patients who underwent anterior fundoplication reported significant improvements in eight of the nine SF36 scales compared to four of the nine following a Nissen fundoplication. The majority of these improvements occurred early in the postoperative period. With respect to the illness behavior data, there were no significant differences between the two procedures. Both groups had a significant improvement in disease conviction scores at all time points compared to their preoperative scores. CONCLUSIONS: Patients undergoing laparoscopic anterior 90 degrees partial fundoplication reported more QOL improvements in the early postoperative period than patients undergoing a Nissen fundoplication. However, the QOL outcome for both procedures was similar at later follow-up.

Australia↗
PubMed2004

Multicenter, prospective, double-blind, randomized trial of laparoscopic nissen vs anterior 90 degrees partial fundoplication.

HYPOTHESIS: Laparoscopic anterior 90 degrees partial fundoplication for gastroesophageal reflux is associated with a lower incidence of postoperative dysphagia and other adverse effects compared with laparoscopic Nissen fundoplication. DESIGN: A multicenter, prospective, double-blind, randomized controlled trial. SETTING: Nine university teaching hospitals in 6 major cities in Australia and New Zealand. PARTICIPANTS: One hundred twelve patients with proven gastroesophageal reflux disease presenting for laparoscopic fundoplication were randomized to undergo either a Nissen (52 patients) or an anterior 90 degrees partial procedure (60 patients). Patients with esophageal motility disorders, patients requiring a concurrent abdominal procedure, and patients who had undergone previous antireflux surgery were excluded from this study. INTERVENTIONS: Laparoscopic Nissen fundoplication with division of the short gastric vessels or laparoscopic anterior 90 degrees partial fundoplication. MAIN OUTCOME MEASURES: Independent assessment of dysphagia, heartburn, and overall satisfaction 1, 3, and 6 months after surgery using multiple clinical grading systems. Objective measurement of esophageal manometric parameters, esophageal acid exposure, and endoscopic assessment. RESULTS: Postoperative dysphagia, and wind-related adverse effects were less common after a laparoscopic anterior 90 degrees partial fundoplication. Relief of heartburn was better following laparoscopic Nissen fundoplication. Overall satisfaction was better after anterior 90 degrees partial fundoplication. Lower esophageal sphincter pressure, acid exposure, and endoscopy findings were similar for both procedures. CONCLUSIONS: At the 6-month follow-up, laparoscopic anterior 90 degrees culine partial fundoplication is followed by fewer adverse effects than laparoscopic Nissen fundoplication with full fundal mobilization, and it achieves a higher rate of satisfaction with the overall outcome. However, this is offset to some extent by a greater likelihood of recurrent gastroesophageal reflux symptoms.

Adult↗
PubMed2004

Early physiological response to intensive care as a clinically relevant approach to predicting the outcome in severe acute pancreatitis.

HYPOTHESIS: The physiological response to treatment is a better predictor of outcome in acute pancreatitis than are traditional static measures. DESIGN: Retrospective diagnostic test study. The criterion standard was Organ Failure Score (OFS) and Acute Physiology and Chronic Health Evaluation II (APACHE II) score at the time of hospital admission. SETTING: Intensive care unit of a tertiary referral center, Auckland City Hospital, Auckland, New Zealand. PATIENTS: Consecutive sample of 92 patients (60 male, 32 female; median age, 61 years; range, 24-79 years) with severe acute pancreatitis. Twenty patients were not included because of incomplete data. The cause of pancreatitis was gallstones (42%), alcohol use (27%), or other (31%). At hospital admission, the mean +/- SD OFS was 8.1 +/- 6.1, and the mean +/- SD APACHE II score was 19.9 +/- 8.2. INTERVENTIONS: All cases were managed according to a standardized protocol. There was no randomization or testing of any individual interventions. MAIN OUTCOME MEASURES: Survival and death. RESULTS: There were 32 deaths (pretest probability of dying was 35%). The physiological response to treatment was more accurate in predicting the outcome than was OFS or APACHE II score at hospital admission. For example, 17 patients had an initial OFS of 7-8 (posttest probability of dying was 58%); after 48 hours, 7 had responded to treatment (posttest probability of dying was 28%), and 10 did not respond (posttest probability of dying was 82%). The effect of the change in OFS and APACHE II score was graphically depicted by using a series of logistic regression equations. The resultant sigmoid curve suggests that there is a midrange of scores (the steep portion of the graph) within which the probability of death is most affected by the response to intensive care treatment. CONCLUSION: Measuring the initial severity of pancreatitis combined with the physiological response to intensive care treatment is a practical and clinically relevant approach to predicting death in patients with severe acute pancreatitis.

APACHE↗
PubMed2004

Diagnosis and management of isolated pancreatic tuberculosis: recent experience and literature review.

The increased reporting of tuberculosis of the pancreas is related to a worldwide increase in tuberculosis and an increase in emigration from countries where tuberculosis is endemic into countries where more sophisticated healthcare and radiological imaging are available. Three recent cases of pancreatic tuberculosis in Auckland, New Zealand, emphasize that tuberculosis should now be included in the differential diagnosis of a pancreatic mass. Diagnostic indicators include emigration from, or recent travel to, a country where tuberculosis is endemic, the association of a pancreatic mass with fever, the presence of abdominal pain and a cystic pancreatic mass in a younger male. Radiological appearances might be similar to a mucinous cystic neoplasm or could show a pancreatic mass with involvement of peripancreatic lymph nodes or a mass centred in a peripancreatic lymph node. When the diagnosis is suspected an human immunodeficiency virus test and a comprehensive screening for tuberculosis at other sites should be performed. If tuberculosis is unable to be diagnosed then pancreatic biopsy and culture is indicated. Endoscopic ultrasound with fine needle aspiration for cytology is likely to become the preferred technique. Most patients have an excellent clinical response to standard antituberculosis regimens.

Adult↗
PubMed2003

Elevated protein carbonyls as plasma markers of oxidative stress in acute pancreatitis.

BACKGROUND: Experimental studies have demonstrated that protein and lipid oxidation is a feature of acute pancreatitis and that antioxidant pretreatment can ameliorate the severity of the disease. Justification for a clinical trial of antioxidant therapy requires stronger evidence for oxidative stress in patients. AIMS: To determine if oxidative stress is evident in patients with acute pancreatitis on admission to hospital, if it increases after admission and if it is related to disease severity. METHODS: Measurement of plasma concentrations of protein carbonyls and malondialdehyde as markers of protein oxidation and lipid peroxidation, respectively, in a consecutive series of 85 patients with acute pancreatitis 0, 2 and 5 days after admission. RESULTS: Patients with acute pancreatitis had significantly increased concentrations of protein carbonyls in plasma on recruitment (median 27 h after the onset of symptoms) that persisted over 5 days. Protein carbonyls were higher in severe compared with mild disease (median 0.099 and 0.043 nmol/mg protein, respectively, p = 0.0016). They were higher at day 0 in patients recruited with more established pancreatitis than in those presenting early. No increases in malondialdehyde were seen. Receiver operator characteristic curve analysis demonstrated that protein carbonyls at day 0 were comparable with C-reactive protein at predicting pancreatitis severity. CONCLUSION: Our demonstration of substantial protein oxidation provides further evidence for oxidative stress in patients with severe pancreatitis. Our results suggest that there could be a window for early antioxidant intervention and that protein carbonyls could be a useful plasma marker of oxidative injury.

Acute Disease↗
PubMed2003

Management of gallstone pancreatitis in Auckland: progress and compliance.

BACKGROUND: Recent advances in the management of acute gallstone pancreatitis include the introduction of laparoscopic cholecystectomy,defining the role of endoscopic retrograde cholangiopancreatography(ERCP) and early cholecystectomy to prevent recurrent pancreatitis. The aim of the present study was to review the current management of gallstone pancreatitis in Auckland Hospital, compare findings with a similar study published a decade ago and to determine the extent to which the management is compliant with recently published consensus guidelines. METHODS: A retrospective review of consecutive patients admitted with acute pancreatitis during a 39-month study period was undertaken. Data were recorded regarding demographics, diagnosis, predicted and actual severity of gallstone pancreatitis (index and recurrent attacks), the role of ERCP and computed tomography scanning, the timing of cholecystectomy (open and laparoscopic), intraoperative cholangiography, duration of hospital stay, complications and mortality. RESULTS: : There were 216 patients admitted with acute pancreatitis,106 of whom had proven gallstones. An ERCP was performed in 62(59%) patients with gallstone pancreatitis but not more commonly in patients with severe pancreatitis, and common bile duct stones were identified in 26% of these patients. Of the 70 (66%)patients who had a cholecystectomy, 56 (80%) had it within 3 weeks of admission. Although the proportion of patients with gallstone pancreatitis who had a cholecystectomy is similar to the earlier study, there has been a significant increase in the proportion of patients having a cholecystectomy during the index admission (chi2 = 3.83; P = 0.05). This has resulted in a reduction in recurrent pancreatitis (P < 0.001). Although the overall mortality from gallstone pancreatitis has not significantly decreased, it has for patients with predicted severe gallstone pancreatitis (P = 0.02). CONCLUSION: : There has been reasonable compliance with published guidelines and some progress in the management of gallstone pancreatitis,particularly in relation to performing timely laparoscopic cholecystectomy with a reduction in the incidence of recurrent pancreatitis. Concerns remain regarding the overuse of diagnostic ERCP in patients with mild pancreatitis.

Acute Disease↗
PubMed2003

Laparoscopic staging of upper gastrointestinal malignancy.

BACKGROUND: Laparoscopic staging (LS) of upper gastrointestinal malignancy has decreased the number of non-curative laparotomies. However, as radiological techniques have improved the value of this invasive staging technique has decreased, with some units either being more selective or abandoning it altogether for certain tumour types. The aim of the present study is to prospectively evaluate the additional utility of LS of upper gastrointestinal malignancy after radiological staging with modern techniques. METHODS: One hundred and six consecutive patients assessed as having potentially curable upper gastrointestinal malignancy after radiological staging underwent LS between April 1999 and June 2001. Laparoscopic findings, outcome at laparotomy and complications were prospectively recorded. RESULTS: Laparoscopic staging detected incurable disease in 28 of the 106 patients (26%). The negative likelihood ratio was 0.36 (95% CI 0.24-0.53). Twenty-seven patients were considered incurable because of findings at laparoscopy and one on the findings of laparoscopic ultrasound. Ten patients underwent open palliative procedures and seven had non-therapeutic laparotomies giving a non-curative laparotomy rate of 16%. LS was most useful for primary liver and biliary tract tumours and was least useful for colorectal liver metastases. The most frequent findings denoting incurability were the presence of liver disease (12 cases) and peritoneal metastases (nine cases). Complications occurred in three patients with one death being attributable in part to the laparoscopy. CONCLUSIONS: Laparoscopy was useful in decreasing the number of non-therapeutic laparotomies, but laparoscopic ultrasound gave little additional benefit. The utility of LS was dependent on tumour type and in particular was of marginal benefit for colorectal liver metastases. LS remains a useful staging tool but should be applied selectively.

Adult↗
PubMed2002

Proteolysis in severe sepsis is related to oxidation of plasma protein.

OBJECTIVE: To test the hypothesis that the oxidation of proteins is part of the mechanism of proteolysis in catabolic states. DESIGN: Prospective, observational study. SETTING: Critical care unit at a university teaching hospital, New Zealand. PATIENTS: 13 patients (6 male, 7 female; median age 61, range 26-76 years) who were admitted to the Department of Critical Care Medicine at Auckland Hospital with a diagnosis of severe sepsis. The median APACHE II score during the first 24 hours after admission was 22 (range 15-34). Control values of protein carbonyl in plasma were established in 15 healthy volunteers. INTERVENTIONS: We made serial measurements of total body protein (by neutron activation analysis) and plasma protein carbonyl (by ELISA) concentrations over a period of 10 days. MAIN OUTCOME MEASURE: Plasma protein carbonyl concentration and total body protein. RESULTS: The total amount of body protein decreased significantly over the 10 days (p < 0.001). Plasma protein carbonyl concentrations were significantly higher in the septic patients than in the control group throughout the study period (p < 0.0001). There was a significant reduction in plasma protein carbonyl concentration over the study period (p < 0.008). The early increase in the concentration of protein carbonyl formation was followed by an ongoing loss of body protein. There was a significant positive correlation between total body protein and plasma protein carbonyl (p < 0.03). CONCLUSIONS: Severe sepsis results in oxidation of plasma proteins and this precedes and is related to the loss of body protein.

APACHE↗
PubMed2002

Lexipafant and acute pancreatitis: a critical appraisal of the clinical trials.

The recent clinical trials of lexipafant in the treatment of acute pancreatitis were undertaken with considerable optimism. It was expected that this single agent anticytokine would reduce the morbidity and mortality of this disease. Published clinical trials of lexipafant (BB-882) in acute pancreatitis were retrieved by MEDLINE, EM Base, and Science Citation Index. The critical appraisal included the question asked, design of the study, group and selection of patients, results, and statistical analysis. The historical sequence of the trials and the impact of commerce on their performance were highlighted. Lexipafant did not reduce mortality in severe acute pancreatitis. Comparison between the trials is difficult because of changes in study groups and dose. The clinical trials were designed without the benefit of open discussion of the preliminary pharmacological studies. The results of the trials have not been communicated in an open, timely, and systematic manner, probably because of commercial constraints.

Acute Disease↗
PubMed2002

Ethnic disparity of pancreatic cancer in New Zealand.

BACKGROUND: The etiology of pancreatic cancer remains elusive. Identification of high-risk groups may enable targeted study to identify new markers and risk factors. AIM: To review the epidemiology of pancreatic cancer in New Zealand and identify any differences between ethnic groups. METHODS: All cases notified with pancreatic cancer between 1988 and 1997 were identified from the New Zealand Cancer Registry. Age-specific and age-standardized incidence rates (ASR) of pancreatic cancer were calculated for the total sample and the ethnic subgroups (Maori, Pacific, and Other, which was predominantly European). Data on the site, morphology, stage of tumors, and survival times were also reviewed. RESULTS: There were 3004 cases over the 10-yr period. Ethnic ASR comparisons demonstrated higher rates in Maori (7.3/100,000) compared with Pacific (6.4/100,000) and the Other (5.6/100,000) ethnic group. Males had higher incidence rates than females in Pacific and Other, but not in Maori because of the unusually high rate among Maori women (7.2/100,000). The most commonly identified site, morphological type, and stage at presentation were the head of the pancreas (80.9% of site-specified cases), adenocarcinoma (44.3% of histologically confirmed cases), and diffuse +/- metastases (69.2% of staged cases), respectively. The median survival time was 92 d, and this did not differ significantly for the Maori and Other ethnic groups. CONCLUSION: The Maori have higher rates of pancreatic cancer than other ethnic groups in New Zealand, and do not show the expected male predominance. Maori women currently have one of the highest reported female rates in the world, and are a population that should be further investigated for disease markers and modifiable risk factors.

Adult↗
PubMedDate not supplied

The impact of parenteral nutrition on the body composition of patients with acute pancreatitis.

BACKGROUND: Nutrition support by the enteral route is now the preferred modality in patients with severe acute pancreatitis. Parenteral nutrition is now required to supplement enteral nutrition when the latter is not able to provide the full nutritional requirement. We report the changes in body composition, plasma proteins, and resting energy expenditure (REE) during 14 days of parenteral nutrition (PN) in patients with acute pancreatitis. METHODS: Total body protein (TBP), total body water (TBW), and total body fat (TBF) were measured by neutron activation analysis and tritium dilution before and after PN. Fat-free mass (FFM) was derived as the difference between body weight and TBF. REE was measured by indirect calorimetry. Protein index (PI) was the ratio of measured TBP to TBP, calculated from healthy volunteers. RESULTS: Fifteen patients with acute pancreatitis (11 men, 4 women; median age 56, range 30-80 years) were studied. Thirteen patients had severe acute pancreatitis (Atlanta criteria), and 1 patient died. The gains in body weight (1.05 +/- 0.77 kg), TBW (0.49 +/- 0.87 kg), TBP (0.20 +/- 0.22 kg), FFM (0.73 +/- 0.92 kg), TBF (0.32 +/- 0.95 kg), and REE (146 +/- 90 kcal/d) after 14 days of PN were not significant. Plasma prealbumin increased by 46.5% (p = .020). When patients (n = 6) with intercurrent sepsis and recent surgery were excluded, there were significant increases in TBP (0.65 +/- 0.17 kg, p = .005) and PI (0.060 +/- 0.011, p = .0006). CONCLUSIONS: Body composition is preserved in acute pancreatitis during 14 days of PN. In patients without sepsis or recent surgery, PN is able to significantly increase body protein stores.

Acute Disease↗