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Are young surgeons competent to perform alimentary tract surgery?
BACKGROUND: Assessment of competency during residency training has received increased attention recently. There has been less attention given to the competency of residents after training. HYPOTHESIS: Patient outcomes for alimentary tract surgery (ATS) should be similar for surgeons who recently completed their residency training compared with more experienced surgeons, indicating that the younger surgeons had achieved clinical competency on completion of their residency training. DESIGN: Retrospective analysis of Illinois inpatient discharge data (January 1, 1996-December 31, 1999). SETTING: All 205 nonfederal acute care hospitals in Illinois. PATIENTS: The patients were 120 160 adult Illinois residents who underwent ATS in Illinois. MAIN OUTCOME MEASURES: Mortality rate, morbidity rate, and hospital length of stay. RESULTS: Regression analyses demonstrated that surgeon experience was a significant determinant of mortality and morbidity rates, with worse outcomes observed for patients of young surgeons undergoing high-complexity ATS (ie, procedures other than appendectomy and cholecystectomy). CONCLUSIONS: For high-complexity ATS, there was a significant disparity in outcomes between young and more experienced surgeons, whereas for low-complexity ATS, there was no disparity. Attention to competency during residency training is warranted, especially as it relates to high-complexity ATS. Furthermore, patient outcomes provide an opportunity to assess competency after training that can complement assessments during training and together identify educational strengths and weaknesses of residency training.
Tissue distribution of 2-3 and 2-6 sialyl Lewis A antigens and significance of the ratio of two antigens for the differential diagnosis of malignant and benign disorders of the digestive tract.
The authors investigated the tissue distribution of two kinds of sialylated derivatives of Lewis A (Le(a)) antigen in patients with cancers of the digestive system using specific monoclonal antibodies, and evaluated the significance of determining the 2-3 and 2-6 sialylated Le(a) antigen levels for the diagnosis of cancer. In most specimens from patients with cancers of the pancreas, biliary tract, stomach, and colon, the 2-3 sialylated Le(a) antigen was strongly expressed in cancer cells. However, 2-6 sialylated Le(a) antigen was less frequently expressed in cancer cells. The former is therefore more specific to cancer than the latter. Also, the serum level of the 2-3 sialylated Le(a) antigen was significantly higher than that of the 2-6 counterpart in patients with cancers of pancreas, biliary tract, stomach, and colon. The resulting ratio of serum 2-3/2-6 sialylated Le(a) antigens was frequently high in patients with malignancy and was low in patients with benign disorders of these digestive organs. Therefore, the 2-3/2-6 sialylated Le(a) antigen ratio is a useful for the differential diagnosis of malignant disorders in these organs. However, liver disorders were found to be exceptional in that both antigens were mostly absent in hepatocellular carcinoma (HCC) cells in immunohistologic examination, as well as in nonmalignant parenchymal liver cells. Only the epithelial cells of the intrahepatic bile ducts expressed the 2-6 sialylated Le(a) antigen strongly, and expressed the 2-3 sialylated Le(a) antigen moderately. The levels of both antigens were sometimes high in patients with liver disorders, but the ratio always remained low in patients with HCC as well as benign liver disorders such as cirrhosis or chronic hepatitis. The sialylated Le(a) antigens, which sometimes accumulate in the sera of patients with HCC, were concluded to originate from the epithelial cells of the proliferating small bile ducts, and those serum antigens cannot be considered as evidence for the presence of liver cancer cells.
Clinical and experimental studies of the limulus test after digestive surgery.
A chromogenic limulus test (Toxicolor test) revealed a transiently increased blood endotoxin level in some patients after digestive surgery. However, most showed no clinical signs of endotoxemia. The Endospecy test of these specimens, which reacts specifically with endotoxin, did not show a high value, while the Gluspecy test, which reacts specifically with (1-->3)-beta-D-glucan (glucan), did. These findings thus suggested that the gauze used for surgery contains a large amount of glucan. The intraperitoneal injection of this gauze-saline into rats results in a phenomenon similar to that observed in clinical studies. These findings suggested the involvement of substances other than endotoxin such as glucan in the postoperative positive-Toxicolor phenomenon. In addition, the Toxicolor test also showed a higher value in patients with liver cirrhosis than in those without. In an experimental study in rats, the liver cirrhosis group also showed a significantly high value. These results therefore suggest that the glucan clearance mechanism is impaired in the reticuloendothelial system in liver damage such as cirrhosis.
[Economic evaluation in a trial of medically controlled prescription of narcotics to dependent users (PROVE)].
In the 1994-1996 trial of medically controlled prescription of narcotics to dependent users, 800 places were ascribed to heroin substitutes and another 200 for methadone and morphine substitutes. The trial was evaluated with the aid of an accompanying research. Among the results demonstrated in the evaluation was an improvement of the health of the participants. The economic assessment was drawn from observations of health effects within a sub-sample of 142 participants from four centers. In a retrospective statistical survey, for each acute illness which could be influenced through the trial, the number of diagnoses was recorded in the first and thirteenth month after study entry. Also, based on a number of representative cases for each of these acute illnesses, the resource use, i.e. the types and numbers of medical products and services rendered to the patients, was recorded. The results showed a clear decline in depressive episodes, skin diseases, digestive system disorders as well as epileptic attacks and intoxication. Treatment costs could be reduced from a total of CHF 94875.--to CHF 21,998.--/month or from CHF 22.27 to CHF 5.15/patient per day. The improvement of somatic and psychic health due to the medically controlled prescription of narcotics resulted in a benefit of CHF 17.11/person per day.
Smoking and the digestive system.
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Adverse reactions and interactions with H2-receptor antagonists.
Histamine H2-receptor antagonists have been used in the treatment of gastrointestinal diseases for more than a decade and during this period have become one of the most commonly prescribed groups of drugs in the world. The deserved popularity of the H2-receptor antagonists reflects, in part, their therapeutic efficacy, which has revolutionised the treatment of peptic ulcer disease. An equally, or more, important reason for the widespread use of H2-receptor antagonists is their remarkably low toxicity. We have attempted, in this review, to present a detailed account of the minor and more serious adverse reactions, while emphasising the low incidence of the former and the rarity of the latter. The toxicology of the H2-receptor antagonists is discussed under two main headings: adverse effects; and drug interactions. The latter category is potentially the more significant, since the frequent use of therapy with multiple drugs may give rise to drug interactions, some of which are serious and may even be lethal. These drug interactions occur especially in the gastrointestinal tract, the liver and the kidneys. Thus, the absorption of other drugs may be altered because the H2-receptor antagonists inhibit gastric secretion--an effect illustrated by ketoconazole, the absorption of which is reduced when given in combination with cimetidine. Very important drug interactions are caused by inhibition of the hepatic microsomal enzyme cytochrome P450 by some of the H2-receptor antagonists. This effect appears to be related to the chemical structure of the individual H2-receptor antagonists and is not attributable to histamine H2-receptor blockade. For example, cimetidine is a powerful inhibitor of cytochrome P450, while the interaction of ranitidine with this system is weaker. Consequently, cimetidine reduces the metabolism of many drugs which are normally degraded by phase I reactions, leading to potentially toxic plasma concentrations of therapeutic agents such as some oral anticoagulants, beta-blockers, anticonvulsants, benzodiazepines and xanthines. Some of the H2-receptor antagonists are actively secreted by the renal tubules and may thus compete with other drugs for cationic tubular transport mechanisms, resulting in reduced urinary excretion and hence potentially toxic plasma concentrations. This type of drug interaction has been reported after administration of both cimetidine and ranitidine with procainamide or quinidine.(ABSTRACT TRUNCATED AT 400 WORDS)
High-flow arterioportal fistula: treatment with detachable balloon occlusion.
Transarterial embolization is one of the treatment choices for symptomatic hepatic arterioportal fistula that has low mortality and morbidity. Proper selection of the technique and embolic material is very important for the success of the procedure. We present a case with high-flow arterioportal fistula treated with transarterial embolization using detachable balloons.
Reduced TNFalpha and IL-6 production in patients who mount a preoperative acute phase response.
BACKGROUND/AIMS: In some patients postoperative infective complications are related to a reduced resistance to the operative trauma and the perioperative microbiological challenge. To investigate preoperative alterations in the immune responses in patients who had mounted an acute-phase response before the operation, we measured the capacity of tumor necrosis factor alpha and interleukin-6 production in whole blood. PATIENTS/METHODS: Serum concentrations of C-reactive protein, alpha1-antitrypsin, albumin, and prealbumin were measured in 89 patients submitted for major abdominal surgery on their admission to hospital. RESULTS: In 23 patients (26%) we found concentrations of at least one, and in 16 patients (18%) of two or more of these variables beyond the reference range. Patients who mounted an acute-phase response released 37% less TNFalpha (1339 vs. 848 pg/ml) and 31% less IL-6 (24293 vs. 16900 pg/ml) when whole blood was stimulated with lipopolysaccharide 0.5 microg/ml. CONCLUSION: Patients who mount an acute-phase response before operation may thus have a downregulated immune response at the level of proinflammatory cytokines. This is likely to alter their resistance to invasive micro-organisms in the perioperative period.
Expression of pancreatic digestive enzymes in normal and pathologic epithelial cells of the human gastrointestinal system.
Pancreatic digestive enzymes have rarely been reported in human nonpancreatic organs. We examined their expression in the epithelial cells of the nonpancreatic gastrointestinal organs, looking for pancreatic alpha-amylase, trypsin, chymotrypsin and pancreatic lipase. Western blotting, enzyme assay and pancreatic alpha-amylase mRNA were also used in selected specimens. In normal tissues, immunoreactivity of one or more of these enzymes was frequently noted in cells of the salivary glands, stomach, duodenum, large pancreatic ducts, extrahepatic bile ducts and gall bladder. The epithelium of the normal oesophagus, small intestine and colon were consistently negative for these enzymes. In pathologic tissues, immunoreactivity for one or more enzymes was present in epithelial cells of pleomorphic adenomas of the salivary glands, oesophageal squamous cell carcinoma, gastric adenoma and adenocarcinoma, pancreatic adenocarcinoma, cholecystitis, adenocarcinoma of the gall bladder and extrahepatic bile duct, and colon adenoma and adenocarcinoma. Western blotting showed a specific band of each enzyme in some specimens of normal stomach. In situ hybridization for pancreatic alpha-amylase mRNA showed specific signals in the normal stomach, but not in the normal colon. Reverse transcriptase polymerase chain reaction analysis for pancreatic alpha-amylase mRNA revealed specific signals in the normal stomach. Enzyme assay revealed that the stomach and gall bladder showed these activities. The data suggest that pancreatic digestive enzymes are produced by several epithelial cell types of the nonpancreatic gastrointestinal organs, that the organs positive for pancreatic enzyme have a common cell lineage, and that neoplasms continue to express or neoexpress these enzymes after neoplastic transformation.
The specialization of gastroenterology in America.
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Pickles, peptide hormones and pregnancy: a hypothesis.
In western societies a high frequency of heartburn, nausea and vomiting occur during pregnancy. The causes and mechanisms of these clinical symptoms remain poorly understood. Evidence suggests steroid hormones modulate gastrointestinal transit time and plasma peptide hormones, while peptide hormone modulated food intake and preferences. Since diurnal and episodic release of steroid and peptide hormones occur, it is postulated that heartburn and other digestive dysfunction during pregnancy are associated with elevated steroid and peptide (beta-endorphin, NPY) hormone interaction with innate biological rhythms controlling the gastrointestinal tract.
Protease inhibitor activity in human skeletal muscle.
Myofibrillar protease activity and activity of inhibitors toward trypsin, chymotrypsin, elastase, and the myofibrillar protease were determined in human skeletal muscle. The protease activity was found to increase in patients with acute and chronic inflammation as well as in patients with metastatic and nonmetastatic tumors. The inhibitory activity directed against trypsin and chymotrypsin was not affected by acute inflammation, while the inhibition of elastase and the myofibrillar protease was increased. Chronic inflammation did not affect the ability of the muscle cytosol to inhibit trypsin and elastase, but increased the inhibition of chymotrypsin and the myofibrillar protease. Nonmetastatic tumors produced an increase in the activity of inhibitors toward trypsin, chymotrypsin, and elastase, while patients bearing metastatic tumors had a high level of cytosolic inhibitors of all the tested proteolytic activities. These results indicate that the myofibrillar protease and the cytosolic protease inhibitors in human skeletal muscle are differentially affected by catabolic conditions.
Minimally invasive abdominal surgery: lux et veritas past, present, and future.
BACKGROUND: Laparoscopic surgery has developed out of multiple technology innovations and the desire to see beyond the confines of the human body. As the instrumentation became more advanced, the application of this technique followed. By revisiting the historical developments that now define laparoscopic surgery, we can possibly foresee its future. DATA SOURCES: A Medline search was performed of all the English-language literature. Further references were obtained through cross-referencing the bibliography cited in each work and using books from the authors' collection. CONCLUSION: Minimally invasive surgery is becoming important in almost every facet of abdominal surgery. Optical improvements, miniaturization, and robotic technology continue to define the frontier of minimally invasive surgery. Endoluminal resection surgery, image-guided surgical navigation, and remotely controlled robotics are not far from becoming reality. These and advances yet to be described will change laparoscopic surgery just as the electric light bulb did over 100 years ago.
[Indications of laparoscopic general and digestive surgery. Evidence based guidelines of the French society of digestive surgery].
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Feedlot health and management.
Health programs based solely on vaccination and treatment regimens are often short-lived and unrewarding. The basis of any successful ongoing health program is a working health management system. The key to the success of the system is a functioning record system that generates information meaningful to management. The basic information generated should include morbidity and mortality data categorized by cause, the number of repeat treatments, and the number of chronic animals or railers. Goals should be set for each major category so that a database can be established for a feedlot operation to assess problems and progress. The most common reason for expectations not being achieved is factors that are largely beyond the control of the feed yard. Although attempts to address these factors should be periodically reviewed, attention to the health program and potential modifications are among the factors that we can control and modify as appropriate. BRD is the most important economic disease in the feedlot. Prearrival management is extremely important in assessing the risk category of incoming calves and in applying a preventive health strategy. Good husbandry, proper nutrition, proper pen maintenance, and selective immunization help to ensure that the cattle adapt quickly to the feed yard environment. Careful observation, timely effective therapy, and excellent hospital management increase the opportunity to produce cost-competitive, safe, and wholesome beef in a humane fashion with limited effects of the environment.
Feedlot diseases.
This article includes a brief discussion of common diseases, listed by body systems, affecting feedlot cattle. Each disease is approached from a practitioner's point of view. This includes interactions with other management factors, differential list, and practical diagnostic procedures. Also included are guidelines for initiating case management before a definitive diagnosis is made.
Functional disorders of the gastrointestinal tract. Preface.
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