J. N. Baxter

Although laparoscopic cholecystectomy has rapidly become routine practice in the UK, there has been no rigorous comparison of it with open cholecystectomy. In our trial, 302 patients were randomised to laparoscopic or minilaparotomy cholecystectomy. Recovery after surgery was assessed by length of hospital stay, outpatient review at 10 days and 4 weeks, and patient questionnaires 1, 4, and 12 weeks after surgery. The mean operation time was 14 min shorter for minilaparotomy, while median post-operative hospital stay was 2 days shorter after laparoscopic cholecystectomy. The hospital costs were about 400 pounds greater for the laparoscopic procedure. Laparoscopic patients returned to work in the home sooner; at 1 week, they had better physical and social functioning, were less limited by physical problems, and had less pain and depression. At 4 weeks, only physical functioning and depression scores were better in the laparoscopic group, and by 3 months there were no differences. Laparoscopic patients were more satisfied with the appearance of their scars. The incidence of complications after both procedures was 20%. Compared to minilaparotomy cholecystectomy, laparoscopic cholecystectomy results in shorter hospital stay, less postoperative dysfunction, and quicker return to normal activities, but is more costly.

Abstract The introduction of laparoscopic cholecystectomy has been associated with an increased incidence of bile duct injury. This review presents the incidence of bile duct injury in reported series and examines the role of the learning curve and other contributing factors. There is good evidence to suggest that, with adequate training and experience, the incidence of biliary injury can be reduced to a level comparable to that of open cholecystectomy. Continued audit is required to ensure that the low complication rates achieved in selected centres with wide experience are reproduced by the surgical community in general.

Obesity is associated with significant morbidity and mortality and is increasing in prevalence worldwide. Associated conditions include insulin resistance (IR), diabetes, hypertension and dyslipidaemia; a clustering of these has recently been termed as metabolic syndrome. Weight gain is a major predictor of the metabolic syndrome with waist circumference being a more sensitive indicator than body mass index as it reflects both abdominal subcutaneous adipose tissue and visceral adipose tissue (VAT). VAT has more metabolic activity and secretes a number of hormones and pro-inflammatory cytokines which are linked with the metabolic abnormalities listed above. Central obesity also increases the risk of obstructive sleep apnoea syndrome (OSAS), where the sleep disordered breathing may also independently lead to/or exacerbate IR, diabetes and cardiovascular risk. The contribution of OSAS to the metabolic syndrome has been under-recognized. The putative mechanisms by which OSAS causes or exacerbates these other abnormalities are discussed. We propose that activation of nuclear factor kappa B by stress hypoxia and/or by increased adipokines and free fatty acids released by excess adipose tissue is the final common inflammatory pathway linking obesity, OSAS and the metabolic syndrome both individually and, in many cases, synergistically.

Barrett's oesophagus patients accumulate chromosomal defects during the histological progression to cancer, one of the most prominent of which is the amplification of the whole of chromosome 4. We aimed to study the role that the transcription factor NF-kappaB, a candidate cancer- promoting gene, present on chromosome 4, plays in Barrett's oesophagus, using OE33 cells as a model. Specifically, we wanted to determine if NF-kappaB was activated by exposure to bile acid (deoxycholic acid) in oesophageal cells. We employed pathway specific cDNA microarrays and real-time PCR, to first identify bile acid induced genes and specifically to investigate the role of NF-kappaB. An NF-kappaB reporter system was used, as well as an inhibitor of NF-kappaB (pyrrolidine dithiocarbamate) to confirm the activation of NF-kappaB by bile. We show that physiological levels of DCA (100-300 microM) were capable of activating NF-kappaB in OE33 cells and inducing NF-kappaB target gene expression (particularly IkappaB and IL-8). Other gene expression abnormalities were also shown to be induced by DCA. Importantly, preliminary experiments showed that NF-kappaB activation by bile occurred at neutral pH, but not at acid pH. Acidic bile did however cause over-expression of the c-myc oncogene, as reported previously. Hence, we present data showing that NF-kappaB may be a key mediator of carcinogenesis in bile exposed Barrett's tissues. In addition, neutral bile acids appear to play a significant part in reflux induced gene expression changes. We postulate that the activation of the survival factor NF-kappaB by bile may be linked to the previous cytogenetic data from our laboratory showing the amplification of NF-kappaB's chromosome (chromosome 4), during Barrett's cancer progression. Hence chromosome 4 amplification may provide a survival mechanism for bile exposed oesophageal tissues via NF-kappaB.

The prediction of which patients with Barrett's metaplasia will develop cancer is difficult. Better genetic characterization of the condition may aid clinicians in devising more effective management and follow-up strategies.A review was undertaken of the accumulated genetic data relating to the progression of squamous epithelium to adenocarcinoma. The normal functions of a number of cancer-related genes are described and an explanation is given of how alterations in these genes interfere with normal cell processes and lead to cancer.The main genetic alterations accompanying the progression through dysplasia to adenocarcinoma were collated from 135 papers. The principal genetic changes implicated are the loss of p16 gene expression (by deletion or hypermethylation), the loss of p53 expression (by mutation and deletion), the increase in cyclin D1 expression, the induction of aneuploidy and the losses of the Rb, DCC and APC chromosomal loci.

Since previous reports have suggested that somatostatin may be of value in the control of acute variceal haemorrhage, we compared its efficacy with that of injection sclerotherapy in a randomised controlled clinical trial. Eighty consecutive patients with endoscopically-proven severe variceal bleeding were randomised to injection sclerotherapy (n = 41) or somatostatin (n = 39) given as a continuous infusion of 250 micrograms/h for 5 days plus daily bolus administration of 250 micrograms. The efficacy of injection sclerotherapy and somatostatin infusion in controlling haemorrhage and preventing rebleeding (censored at 5 days), mortality (censored at 28 days) and complications was compared. The aetiology of the portal hypertension and transfusion requirements was similar between the two groups, but there were more patients with severe liver disease (Child's C) in the somatostatin group. There was no significant difference between the two treatments in the initial (p = 1.0) or overall control of bleeding (p = 0.58). Furthermore, somatostatin was as effective as injection sclerotherapy in controlling bleeding in patients with severe liver disease or in those actively bleeding at the time of their endoscopy. The relative risk of rebleeding whilst receiving somatostatin compared to injection sclerotherapy was 1.39 [95% Confidence Interval (CI) 3.73; 0.52], but this was reduced to 0.98 (95% CI 0.37; 2.67) when readjusted for Child's grading, the only prognostic factor shown to be of significance. Mortality was not significantly different between the two groups of patients (p = 0.31). The relative risk of dying whilst receiving somatostatin compared to injection sclerotherapy was 1.6 (95% CI 3.93; 0.66) but was reduced to 1.03 (95% CI 0.47; 2.47) when adjusted for Child's grading, the only significant prognostic factor. Complications in the somatostatin group were minor and less frequent than after injection sclerotherapy. The results of this study indicate that somatostatin is a safe treatment, which is as effective an endoscopic injection sclerotherapy for acute variceal bleeding.

Bile acids are often refluxed into the lower oesophagus and are candidate carcinogens in the development of oesophageal adenocarcinoma. We show here that the secondary bile acid, deoxycholic acid (DCA), is the only one of the commonly refluxed bile acids tested here, to show genotoxicity, in terms of chromosome damage and mutation induction in the human p53 gene. This genotoxicity was apparent at both neutral and acidic pH, whilst there was a considerable increase in bile-induced toxicity at acidic pH. The higher levels of cell death and low cell survival rates at acidic pH may imply that acid bile exposure is toxic rather than carcinogenic, as dead cells do not seed cancer development. We also show that DCA (at neutral and acid pH) induced the release of reactive oxygen species (ROS) within the cytoplasm of exposed cells. We further demonstrate that the genotoxicity of DCA is ROS mediated, as micronucleus induction was significantly reduced when cells were treated with DCA + the anti-oxidant vitamin C. In conclusion, we show that DCA, is an effective genotoxin at both neutral and acidic pH. As bile acids like DCA can induce DNA damage at neutral pH, suppressing the acidity of the refluxate will not completely remove its carcinogenic potential. The genotoxicity of DCA is however, ROS dependent, hence anti-oxidant supplementation, in addition to acid suppression may block DCA driven carcinogenesis in Barrett's patients.

Abstract The effects of somatostatin (SRIF) and its long-acting analogue, SMS 201-995 on the prevention and treatment of acute pancreatitis were studied in rats. Acute pancreatitis was established by ligating the bile duct at the point of entry into the duodenum, thereby allowing reflux of bile into the pancreas. Administration of SRIF (4 μg kg−1 body wt IV followed by a 12 h infusion of 4 μg kg−1 body wt h−1) or SMS 201-995 (2 μgkg−1 body wt SC) at the time of bile duct ligation prevented the increase in the serum concentrations of amylase and lipase observed in control rats 12 h after bile duct ligation. Moreover, SRIF and SMS 201-995 administration prevented development of the histological changes consistent with acute pancreatitis observed in control animals. These results suggest that SRIF or SMS 201-995 may be of value in preventing acute pancreatitis following ERCP or after surgery on the pancreas. In rats with established pancreatitis, SRIF (IV bolus of 4μg kg−1 body wt followed by a 24h continuous infusion of 4μgkg−1 body wt h−1) or SMS 201-995 (2μgkg−1 body wt SC followed by a similar dose 12h later): (1) significantly improved survival; (2) produced histological changes in the pancreas consistent with organization and healing; (3) prevented the accumulation of ascitic fluid; (4) reduced the serum levels of amylase and lipase. These results suggest that SRIF and SMS 201-995 may prove valuable in the treatment of established acute pancreatitis in man.

OBJECTIVES: The assessment of cancer risk in patients with Barrett's esophagus (BE) is currently fraught with difficulty. The current gold standard method of assessing cancer risk is histological assessment, with the appearance of high-grade dysplasia (HGD) as the key event monitored. Sampling error during endoscopy limits the usefulness of this approach, and there has been much recent interest in supplementing histological assessment with molecular markers, which may aid in patient stratification. METHODS: No molecular marker has been yet validated to accurately correlate with esophageal histological progression. Here, we assessed the suitability of several membranous proteins as biomarkers by correlating their abundance with histological progression. In all, 107 patient samples, from 100 patients, were arranged on a tissue microarray (TMA) and represented the various stages of histological progression in BE. This TMA was probed with antibodies for eight receptor proteins (mostly membranous). RESULTS: Epidermal growth factor receptor (EGFR) staining was found to be the most promising biomarker identified with clear increases in staining accompanying histological progression. Further, immunohistochemistry was performed using the full-tissue sections from BE, HGD, and adenocarcinoma tissues, which confirmed the stepwise increase in EGFR abundance. Using a robustH-score analysis, EGFR abundance was shown to increase 13-fold in the adenocarcinoma tissues compared to the BE tissues. EGFR was “overexpressed” in 35% of HGD specimens and 80% of adenocarcinoma specimens when using theH-score of the BE patients (plus 3 s.d.) as the threshold to define overexpression. EGFR staining was also noted to be higher in BE tissues adjacent to HGD/adenocarcinoma. Western blotting, although showing more EGFR protein in the adenocarcinomas compared to the BE tissue, was highly variable. EGFR overexpression was accompanied by aneuploidy (gain) of chromosome 7, plus amplification of the EGFR locus. Finally, the bile acid deoxycholic acid (DCA) (at neutral and acidic pH) and acid alone was capable of upregulating EGFR mRNAin vitro, and in the case of neutral pH DCA, this was NF-κB dependent. CONCLUSIONS: EGFR is overexpressed during the histological progression in BE tissues and hence may be useful as a biomarker of histological progression. Furthermore, as EGFR is a membranous protein expressed on the luminal surface of the esophageal mucosa, it may also be a useful target for biopsy guidance during endoscopy.

Background. The use of minimal access surgery for repair of groin hernias is controversial. The aim of this study was to compare endoscopic tension-free hernia repair with open tesion-free hernia repair within a randomized clinical trial. Methods. One hundred twenty patients were randomized by four surgeons during a 1-year period. Early outcome measures were then analyzed by intention to treat. Results. Median postoperative pain scores (63 [interquartile range (IQR), 23 to 81] versus 35 [IQR, 17 to 62]; p =0.004) and analgesia requirements (2.5 [IQR, 2 to 4] doses versus 2.0 [IQR, 1 to 3] doses; p = 0.0008) were significantly less for patients undergoing endoscopic hernia repair. Hospital stay (1 [IQR, 0 to 1] day versus 2 [IQR, 1 to 2] days; p<0.0001) was also significantly reduced for the endoscopic group. Wound complications occurred significantly more frequently in the open group. No difference in pulmonary function or metabolic response to trauma (interleukin-6, C-reactive protein, glucose, albumin) was observed between the groups. Conclusions. This study shows significant short-term advantages for endoscopic tension-free repair over open tension-free repair. However, larger studies with a longer follow-up period are required to establish the relative merits of both procedures in the management of patients with groin hernias. Background. The use of minimal access surgery for repair of groin hernias is controversial. The aim of this study was to compare endoscopic tension-free hernia repair with open tesion-free hernia repair within a randomized clinical trial. Methods. One hundred twenty patients were randomized by four surgeons during a 1-year period. Early outcome measures were then analyzed by intention to treat. Results. Median postoperative pain scores (63 [interquartile range (IQR), 23 to 81] versus 35 [IQR, 17 to 62]; p =0.004) and analgesia requirements (2.5 [IQR, 2 to 4] doses versus 2.0 [IQR, 1 to 3] doses; p = 0.0008) were significantly less for patients undergoing endoscopic hernia repair. Hospital stay (1 [IQR, 0 to 1] day versus 2 [IQR, 1 to 2] days; p<0.0001) was also significantly reduced for the endoscopic group. Wound complications occurred significantly more frequently in the open group. No difference in pulmonary function or metabolic response to trauma (interleukin-6, C-reactive protein, glucose, albumin) was observed between the groups. Conclusions. This study shows significant short-term advantages for endoscopic tension-free repair over open tension-free repair. However, larger studies with a longer follow-up period are required to establish the relative merits of both procedures in the management of patients with groin hernias.

Despite the fact that repair of an inguinal hernia is one of the most common operations performed in general surgery, we have very little information on the natural history of the untreated hernia. The aim of this study was to evaluate the association between hernia symptoms and the duration the patients had their hernias before presentation to a surgical outpatient department for an elective or emergency operation.Data were gathered prospectively on a consecutive series of 699 patients admitted to two University Departments of Surgery for scheduled operations for an inguinal hernia.More than one third (267) of patients had their hernias for 1 year or longer, up to 65 years, before presentation. The most common symptom on presentation was pain or discomfort at the hernia site, which occurred in 457 (66%) patients. The cumulative probability of pain increased with time to almost 90% at 10 years. The hernia had become irreducible in 48 patients (6.9%). The cumulative probability of irreducibility increased from 6.5% (95% confidence interval 4% to 9%) at 12 months to 30% (95% confidence interval 18% to 42%) at 10 years. Leisure activities were affected in 29% of patients although only 13% of patients had to take time off work because of hernia-related symptoms. Only two patients (0.3%) required resection of infarcted bowel or omentum.Because many patients with an inguinal hernia are asymptomatic or mildly symptomatic, prospective clinical trials to assess the role of operations for such hernias are required.

The factors affecting cardiorespiratory changes and postoperative pain after laparoscopic cholecystectomy are poorly understood. The aim of this study was to assess these changes in patients undergoing laparoscopic cholecystectomy at an insufflation pressure of 7.5 or 15 mmHg.Forty patients with similar preoperative characteristics were randomized, 20 to each group.There were no significant differences in intraoperative heart rate or cardiac index although the latter fell significantly soon after insufflation in both groups. The fall in cardiac index lasted longer (7 versus 2 min) and coincided with a slower rise in mean arterial pressure in those having 15 mmHg insufflation. Changes in peak airway pressure, end-tidal carbon dioxide and arterial blood gases were similar. After operation the low-pressure group had significantly less pain, better preservation of pulmonary function and were discharged home sooner (P = 0.015).Insufflation pressure significantly affects the haemodynamic changes and postoperative pain associated with laparoscopic cholecystectomy.

Deoxycholic acid (DCA) is a secondary bile acid implicated in various cancers of the gastrointestinal (GI) tract. In oesophageal adenocarcinoma, DCA is believed to contribute to carcinogenesis during reflux where stomach contents enter the lower oesophagus. It is imperative that we understand the mechanisms whereby oesophageal carcinogens function in order that therapeutic options may be developed. We have previously shown that DCA can damage chromosomes and does so through its generation of reactive oxygen species (ROS). We show here, after detailed experiments, that DCA appears to have a non-linear dose response for DNA damage. DCA induces DNA damage (as measured by the micronucleus assay) at doses of 100 microM and higher in oesophageal OE33 cells, but fails to induce such DNA damage below this cut-off dose. We also show that in terms of NF-kappaB activation (as measured by up-regulation of two NF-kappaB target genes) by DCA, a similar dose response is observed. This dose-response data may be important clinically as DCA exposure to the oesophagus may be used as a way to identify the 10% of Barrett's oesophagus patients currently progressing to cancer from the 90% of patients who do not progress. Only quantitative studies measuring DCA concentrations in refluxates correlated with histological progression will answer this question. We further show here that ROS are behind DCAs ability to activate NF-kappaB as antioxidants (epigallocatechin gallate, resveratrol and vitamin C) abrogate DCAs ability to up-regulate NF-kappaB-controlled genes. In conclusion, low doses of DCA appear to be less biologically significant in vitro. If this were to be confirmed in vivo, it might suggest that reflux patients with low DCA concentrations may be at a lower risk of cancer progression compared to patients with high levels of DCA in their refluxate. Either way, antioxidant supplementation may possibly help prevent the deleterious effects of DCA in the whole GI tract.

Bariatric surgery is an effective treatment for morbid obesity. Obesity and type 2 diabetes are associated with chronic inflammation. There is lack of data examining the effects of sleeve gastrectomy (SG) on inflammatory biomarkers. Our aim was to study the effects of SG on specific cytokines associated with obesity including interleukin-6 (IL-6), interleukin-10 (IL-10), leptin, adiponectin, and C-reactive protein (CRP) preoperatively, 1 and 6 months after surgery.A nonrandomized prospective study comprising of 22 participants with impaired glucose homeostasis and type 2 diabetes undergoing SG (body mass index 50.1 kg/m(2), glycated hemoglobin [HbA1c] 53 mmol/mol). Serial measurements of IL-6, IL-10, leptin, adiponectin, and CRP were performed during oral glucose tolerance testing preoperatively, 1 and 6 months postoperatively.We observed significant improvements at 1 and 6 months in leptin (P≤.001) and CRP (P = .003) after SG. We also observed a significant reduction in IL-6 at 6 months (P = .001). No statistically significant differences were observed for adiponectin and IL-10.This study is the first to examine the detailed changes in the inflammatory cytokines after SG. Our study shows significant improvements in the inflammatory biomarkers after SG in patients with impaired glucose homeostasis and type 2 diabetes.

Abstract Background Parathyroid carcinoma is a rare malignancy affecting 0·5–5 per cent of all patients with primary hyperparathyroidism. This article reviews the literature on the pathogenesis, pathology, clinical features, diagnosis and management of parathyroid carcinoma. Methods A Medline search was performed and all relevant English language articles published between 1970 and 2005 were retrieved. The search words included ‘parathyroid carcinoma’, ‘pathology’, ‘genetics’, ‘management’ and ‘radiotherapy’. Secondary references were obtained from key articles. Results and conclusion The exact aetiology of parathyroid carcinoma remains obscure. Recently, the HRPT2 gene has been implicated in its pathogenesis and may prove to be a genetic target in future. Surgical resection is the accepted ‘gold standard’. There is now a growing consensus on the use of adjuvant radiotherapy as it has been shown to provide a survival benefit.

Abstract In a randomized controlled trial, 299 patients were sent a symptoms questionnaire 1 year after laparoscopic (n = 151) or minilaparotomy (n = 148) cholecystectomy for symptomatic cholelithiasis. The response rate to the questionnaire from contactable patients was 86 per cent. In both groups, at least 90 per cent of patients reported that their symptoms were improved, and at least 93 per cent rated the success of their operation as ‘excellent’, ‘good’, or ‘fair’. However, over half the patients reported abdominal pain, a quarter reported flatulence, and a quarter dyspepsia. The only difference between treatment groups was that a higher proportion of patients who underwent minilaparotomy reported heartburn (35 per cent versus 19 per cent, P = 0±005). Patients who reported a ‘poor’ outcome were more likely to have suffered a postoperative complication, had lower quality of life scores, and higher anxiety and depression scores. Both laparoscopic and minilaparotomy cholecystectomy result in symptomatic benefit in at least 90 per cent of patients with symptomatic cholelithiasis.

As part of a randomized trial, ventilatory and arterial blood gas changes were assessed during open (n = 30) and laparoscopic (n = 30) cholecystectomy. Measurements were made during anaesthesia before the start of surgery and at the time of removal of the gallbladder. Despite an increase in minute ventilation from a mean(s.d.) of 5.7(1.4) to 6.1(1.2) litres, mean(s.d.) arterial carbon dioxide tension (PaCO2) rose from 5.3(0.9) to 6.0(0.9) kPa during laparoscopic cholecystectomy. End-tidal carbon dioxide tension (PE'CO2) had poor precision in predicting PaCO2 (95 per cent interval of agreement -0.61 to 1.93 kPa). Mean(s.d.) peak airway pressure increased from 17(4) to 23(4) cmH2O. The mean PaCO2--PE'CO2 value did not change significantly, although there was significant within-patient variation. Arterial oxygen levels did not change significantly. By comparison, no clinically significant changes in ventilation or blood gas values occurred during open cholecystectomy. In conclusion, laparoscopic cholecystectomy requires a substantial but variable increase in minute ventilation to compensate for carbon dioxide absorption from the peritoneum.

Journal Article Preventing complications of laparoscopy Get access A J McMahon, A J McMahon University Department of Surgery, Western Infirmary, Glasgow G11 6NT, UK Search for other works by this author on: Oxford Academic Google Scholar J N Baxter, J N Baxter University Department of Surgery, Western Infirmary, Glasgow G11 6NT, UK Search for other works by this author on: Oxford Academic Google Scholar P J O'Dwyer P J O'Dwyer University Department of Surgery, Western Infirmary, Glasgow G11 6NT, UK Correspondence to: Mr P. J. O'Dwyer Search for other works by this author on: Oxford Academic Google Scholar British Journal of Surgery, Volume 80, Issue 12, December 1993, Pages 1593–1594, https://doi.org/10.1002/bjs.1800801233 Published: 06 December 2005 Article history Accepted: 13 March 1993 Published: 06 December 2005

The Journal of Alternative and Complementary MedicineVol. 12, No. 7 PhotoessayIntegrating Ear and Scalp Acupuncture Techniques into the Care of Blast-Injured United States Military Service Members with Limb LossRichard C. Niemtzow, Jeffrey Gambel, Joseph Helms, Arnyce Pock, Stephen Burns, and John BaxterRichard C. NiemtzowSearch for more papers by this author, Jeffrey GambelSearch for more papers by this author, Joseph HelmsSearch for more papers by this author, Arnyce PockSearch for more papers by this author, Stephen BurnsSearch for more papers by this author, and John BaxterSearch for more papers by this authorPublished Online:13 Sep 2006https://doi.org/10.1089/acm.2006.12.596AboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail FiguresReferencesRelatedDetailsCited byOreille externe, récepteur multifonctionHegel, Vol. N° 2, No. 2Provider Perceptions of Battlefield Acupuncture in a Major Veterans Health Administration Facility Gail Castañeda, Sergio Romero, Stephen Mudra, Ted Gingrich, and Charles Levy19 April 2021 | Medical Acupuncture, Vol. 33, No. 2Fallberichte: Akupunktur in der Notfallmedizin – Teil 1: innere Medizin17 July 2020 | Deutsche Zeitschrift für Akupunktur, Vol. 63, No. 3Essentials of Disaster Anesthesia23 June 2020 | , Vol. 65Pain in DisastersAcupuncture for cancer pain: protocol for a pilot pragmatic randomised controlled trial9 July 2019 | BMJ Open, Vol. 9, No. 7Auricular Acupuncture for Chronic Pain and Insomnia: A Randomized Clinical Trial Betty K. Garner, Susan G. Hopkinson, Ann K. Ketz, Carol A. Landis, and Lori L. Trego15 October 2018 | Medical Acupuncture, Vol. 30, No. 5A Study on Research for Utilization Acupuncture Treatment in Military MedicineJournal of Korean Medicine Rehabilitation, Vol. 26, No. 3A Randomized Exploratory Study to Evaluate Two Acupuncture Methods for the Treatment of Headaches Associated with Traumatic Brain Injury Wayne B. Jonas, Dawn M. Bellanti, Charmagne F. Paat, Courtney C. Boyd, Alaine Duncan, Ashley Price, Weimin Zhang, Louis M. French, and Heechin Chae17 June 2016 | Medical Acupuncture, Vol. 28, No. 3The Effectiveness of Individualized Acupuncture Protocols in the Treatment of Gulf War Illness: A Pragmatic Randomized Clinical Trial31 March 2016 | PLOS ONE, Vol. 11, No. 3Acupuncture for Treatment of Uncontrolled Pain in Cancer Patients25 November 2013 | Integrative Cancer Therapies, Vol. 13, No. 2Electroacupuncture improves burn-induced impairment in gastric motility mediated via the vagal mechanism in rats12 July 2013 | Neurogastroenterology & MotilityDoD–NCCAM/NIH Workshop on Acupuncture for Treatment of Acute Pain Emmeline Edwards, Jean Louis Belard, John Glowa, Partap Khalsa, Wendy Weber, and Kristen Huntley20 March 2013 | The Journal of Alternative and Complementary Medicine, Vol. 19, No. 3The effectiveness of acupuncture in the treatment of Gulf War IllnessContemporary Clinical Trials, Vol. 33, No. 3Notfallbehandlung eines epileptischen Anfalls mit Yamamoto Neuer Schädelakupunktur (YNSA) und Körperakupunktur Falldarstellung zur Akupunktur in der NotfallmedizinForschende Komplementärmedizin / Research in Complementary Medicine, Vol. 19, No. 5Design and Rationale of a Comparative Effectiveness Study to Evaluate Two Acupuncture Methods for the Treatment of Headaches Associated with Traumatic Brain Injury Courtney Lee, Dawn Wallerstedt, Alaine Duncan, Alexandra York, Michael Hollifield, Richard C. Niemtzow, Stephen M. Burns, and Wayne B. Jonas20 December 2011 | Medical Acupuncture, Vol. 23, No. 4Acupuncture for the Trauma Spectrum Response: Scientific Foundations, Challenges to Implementation Wayne B. Jonas, Joan A.G. Walter, Matt Fritts, and Richard C. Niemtzow20 December 2011 | Medical Acupuncture, Vol. 23, No. 4Anwendung von Akupunktur in NotfallsituationenDeutsche Zeitschrift für Akupunktur, Vol. 54, No. 3Integration von Yamamoto Neuer Schädelakupunktur (YNSA) in die Notfallmedizin – Falldarstellung zur Analgesie mittels YNSADeutsche Zeitschrift für Akupunktur, Vol. 53, No. 4Utilidad de la YNSARevista Internacional de Acupuntura, Vol. 3, No. 4Was ist möglich mit YNSA?Deutsche Zeitschrift für Akupunktur, Vol. 52, No. 3Pain Management in the Traumatic AmputeeCritical Care Nursing Clinics of North America, Vol. 20, No. 1 Volume 12Issue 7Sep 2006 InformationCopyright 2006, Mary Ann Liebert, Inc.To cite this article:Richard C. Niemtzow, Jeffrey Gambel, Joseph Helms, Arnyce Pock, Stephen Burns, and John Baxter.Integrating Ear and Scalp Acupuncture Techniques into the Care of Blast-Injured United States Military Service Members with Limb Loss.The Journal of Alternative and Complementary Medicine.Sep 2006.596-599.http://doi.org/10.1089/acm.2006.12.596Published in Volume: 12 Issue 7: September 13, 2006PDF download

Background Bariatric surgery is an effective treatment for morbid obesity. Current literature reports significant improvements in glucose homeostasis after malabsorptive surgery. There is limited evidence on the effects of laparoscopic sleeve gastrectomy (SG) on glucose-insulin homeostasis and postoperative incretin hormone response. The objective of this study was to examine the metabolic effects of SG on temporal changes in insulin and glucose homeostasis, incretin hormones and hepatic insulin clearance in patients with impaired glucose tolerance (IGT) and type 2 diabetes (T2 DM). Methods A nonrandomized prospective study comprising 22 participants undergoing SG (body mass index [BMI] 50.1 kg/m2, glycated hemoglobin [HbA1c] 53 mmol/mol) and 15 participants undergoing biliopancreatic diversion (BPD) (BMI 62.1 kg/m2, HbA1c 58 mmol/mol). Serial measurements of glucose, insulin, C-peptide, glucagon like peptide-1 (GLP-1) and glucose-dependent insulinotropic hormone (GIP) were performed during oral glucose tolerance testing preoperatively and 1 and 6 months postoperatively. Areas under the curve (AUC) were examined at 30, 60, and 120 minutes. Results Within the SG group, significant improvements were observed respectively at 1 and 6 months in glucose control (HbA1c: −0.9%, −1.3%), measures of insulin sensitivity (fasting insulin: −4.8 mU/L, −8.5 mU/L; fasting C-peptide: −0.6 pmol/L, −1.1 pmol/L; Homeostasis Model Assessment [HOMA-IR]: −0.144, −0.174; HOMA %S:+29.6,+92.4), hepatic insulin clearance (+0.07,+0.13) and postprandial GLP-1 response (AUC0-30 pmol h L−1:+300,+331, AUC0-60:+300,+294, AUC0-120:+316,+295). These results were comparable to the BPD group. Conclusions SG is associated with significant early improvements in insulin sensitivity and incretin hormone response and results in significant improvements in IGT/T2 DM.

In this study, octreotide was not found to be of benefit in the treatment of acute pancreatitis.Somatostatin and its long-acting analog octreotide have both been proposed for the treatment of patients with acute pancreatitis, but neither agent has been adequately assessed in patients with severe attacks.Fifty-eight patients with moderate or severe acute pancreatitis who were admitted to hospitals within the west of Scotland over an 18-mo period were randomized to receive octreotide, 40 micrograms/h, by continuous i.v. infusion for 5 d, or placebo in addition to standard supportive therapy.There was no significant difference in the incidence of complications (54% octreotide group and 40% placebo group) or mortality (octreotide group 18%; placebo group 20%).

Endoscopic laser Doppler flowmetry was used to measure neoterminal ileal blood flow in 16 patients who had undergone ileocolonic resection for Crohn's disease and had since remained clinically and biochemically free of disease, and eight control patients who had undergone similar surgery for colonic carcinoma. Four patients with clinically active Crohn's disease of the terminal ileum were also studied. Neoterminal ileal recurrence in those with inactive Crohn's disease was graded endoscopically. The median and minimum of five local blood flow measurements performed in each patient were inversely correlated with the endoscopic recurrence grade (r = -0.52, p = 0.04 and r = -0.63, p = 0.01 respectively). Relative to the control group, median blood flow was non-significantly lower in the inactive Crohn's disease group as a whole (p > 0.05) but was significantly reduced in patients with active disease (p = 0.02). A progressive reduction in tissue perfusion may accompany recurrence of Crohn's disease while at a subclinical stage.

Intestinal-type gastric cancer is preceded by gastritis and intestinal metaplasia. There is uncertainty regarding the stage at which genetic alterations in the p53 gene occur. Reactive oxygen species (ROS) may participate in the production of mutations and the inactivation of p53 is due to infection by the bacterium Helicobacter pylori. We have investigated whether alterations of the p53 gene can be detected in gastritis and intestinal metaplasia using the restriction site mutation assay. We also assessed the potential contribution of ROS to p53 inactivation using electron spin resonance spectroscopy (ESR) and correlated with the presence of H. pylori. In all, 35% of the gastritis samples and 45% of the intestinal metaplasia samples were found to contain mutations in exons 5-8 of the p53 gene. Electron spin resonance spectroscopy analysis showed a significant increase in free radical levels in gastritis samples compared with normal, intestinal metaplasia and cancer samples, suggesting that free radicals present in gastritis may contribute to p53 mutations. There was no significant difference in free radical levels between the H. pylori-positive and -negative groups. However, a small subpopulation of the H. pylori-negative patients had much higher levels of free radicals. This suggests a more prominent role for other factors in ROS production.

Laparoscopic cholecystectomy with carbon dioxide pneumoperitoneum may result in hypercarbia and acidosis in patients with cardiorespiratory disease. The aim of the present study was to assess helium as an alternative to carbon dioxide for creating the pneumoperitoneum. Ventilation requirements and carbon dioxide levels were assessed at the beginning and end of laparoscopic cholecystectomy using helium (n = 30) and carbon dioxide (n = 30) pneumoperitoneum. Insufflation with helium did not result in an increase in ventilation requirement although, like carbon dioxide pneumoperitoneum, it was associated with a mean rise in peak airway pressure (of 7 cmH2O; P < 0.001). There was also a 3.2-kPa increase in the alveolar-arterial oxygen gradient with helium (P = 0.006). Carbon dioxide pneumoperitoneum was associated with a significant rise in arterial carbon dioxide levels, despite increasing ventilation. Four patients with helium pneumoperitoneum had surgical emphysema for 5 days. Helium may be a suitable alternative to carbon dioxide for creating pneumoperitoneum in patients with severe cardiorespiratory disease. However, because of its low water solubility helium has a lower safety margin than carbon dioxide in the rare event of gas embolism.

Background . Irritable bowel syndrome (IBS) is a chronic, difficult to treat condition. The efficacy of Aloe vera in treating IBS symptoms is not yet proven. The purpose of this study was to determine if Aloe vera is effective in improving quality of life. Methods . A multicentre, randomised, double-blind, cross-over placebo controlled study design. Patients were randomised to Aloe vera , wash-out, placebo or placebo, washout, Aloe vera . Each preparation (60 mL) was taken orally twice a day. Patient quality of life was measured using the Gastrointestinal Symptoms Rating Score, Irritable Bowel Syndrome Quality of Life, EuroQol and the Short-Form-12 at baseline and treatment periods 1 and 2. Results . A total of 110 patients were randomised, but only 47 completed all questionnaires and both study arms. Statistical analysis showed no difference between the placebo and Aloe vera treatment in quality of life. Discussion. This study was unable to show that Aloe vera was superior to placebo in improving quality of life. Drop outs and other confounding factors may have impacted on the power of the study to detect a clinically important difference. Conclusion . This study failed to find Aloe vera superior to placebo in improving quality of life proven Irritable Bowel Syndrome patients.

In the past 30 years, prevalence of obesity has almost trebled resulting in an increased incidence of type 2 diabetes mellitus and other co-morbidities. Visceral adipose tissue is believed to play a vital role, but underlying mechanisms remain unclear. Our aim was to investigate changes in markers of oxidative damage in human visceral adipose tissue to determine levels of oxidative burden that may be attributed to obesity and/or diabetes.Visceral adipose tissue samples from 61 subjects undergoing abdominal surgery grouped as lean, obese and obese with type 2 diabetes mellitus, were examined using 3 different markers of oxidative stress. Malondialdehyde (MDA) concentration was measured as a marker of lipid peroxidation, telomere length and Comet assay as markers of oxidative DNA damage.No significant difference in MDA concentration, telomere length and DNA damage was observed between groups, although longer telomere lengths were seen in the obese with diabetes group compared to the obese group (P<0.05). Lower MDA concentration and longer telomere length were seen in subjects with diabetes compared to those without (P<0.05). DNA damage, analysed via Comet assay, was significantly lower in subjects with diabetes compared to those without (P<0.05).A paradoxical decrease in oxidative stress and DNA damage was observed in samples from subjects with type 2 diabetes mellitus. Further work is required to investigate this further, however this phenomenon may be due to an up regulation of antioxidant defences in adipose tissue.

Bile acids have been demonstrated, through the use of animal models and clinical association studies, to play a role in neoplastic development in Barrett's metaplasia. How specific bile acids promote neoplasia is as yet unknown, as are the exact identities of the important bile acid subtypes. The combination of bile subtype with appropriate pH is critical, as pH alters bile acid activity enormously. Hence glycine-conjugated bile acids are involved in neoplastic development at acidic pH (pH ~4), and unconjugated bile acids are involved in neoplastic development at more neutral pH (~6). Bile acids (at the appropriate pH) are potent DNA-damaging agents, due to the induction of ROS (reactive oxygen species), which are mainly induced by bile-induced damage to mitochondrial membranes, allowing leakage of ROS into the cytosol. These ROS also induce pro-survival signalling pathways [e.g. via PKC (protein kinase C)-dependent NF-κB (nuclear factor κB) activity]. Interestingly, NOS (nitric oxide synthase), through induction of NO may exacerbate this NF-κB activity and form a positive-feedback loop to amplify the activation of NF-κB by deoxycholic acid in particular. This combination of induced DNA damage and cell survival by bile acids is of major importance in neoplasia. Antioxidants and the tertiary bile acid UDCA (ursodeoxycholic acid) can block bile-induced DNA damage and bile-induced NF-κB activity, and should be considered in chemopreventative strategies.

Background Obesity is associated with reduced heart rate variability (HRV), reflecting detrimental changes in cardiac regulation by the autonomic nervous system (ANS). Weight loss reverses this change and ANS dysfunction is thought to have a role in obesity-related cardiac pathology. Few studies have examined the influence of weight-reduction (bariatric) surgery on cardiac autonomic control. This study therefore sought to assess longitudinal changes in indices of cardiac autonomic control following two types of bariatric procedure, laparascopic gastric banding (LGB) and biliopancreatic diversion (BPD). Methods Eleven morbidly obese subjects aged 47.8±7.9 years (mean±SD) with BMI 48.2±6.9 kg·m-2 underwent weight-reduction surgery: five received BPD and six received LGB. Holter ECG was recorded and HRV was quantified together with a QT variability index (QTVI), a complexity index (SampEn), and a fractal (scaling) index (DFAα). Repeated measures ANOVA compared the indices for the two groups as a function of time (1, 6 and 12 months follow-up). Results BMI was reduced by up to 24% (p=0.008) post-surgery despite patients remaining obese at one-year follow-up. Several indices showed prompt and persistent improvement with progressive weight loss, QTVI being the most sensitive discriminator of recovery time (F3,216=16.86; p<0.0005; η2=0.190). Autonomic responsiveness was functionally normal throughout. The bariatric procedures induced similar changes in cardiac autonomic control, despite their differing mechanisms of action. Conclusions This pilot study suggests that the mechanism responsible for improving cardiac regulation following bariatric surgery might be the weight loss itself. Furthermore, post-surgery improvement in QTVI implies that weight loss reduces the risk of ventricular arrhythmic events.

Aim . We examined endocannabinoids (ECs) in relation to bariatric surgery and the association between plasma ECs and markers of insulin resistance. Methods . A study of 20 participants undergoing bariatric surgery. Fasting and 2-hour plasma glucose, lipids, insulin, and C-peptide were recorded preoperatively and 6 months postoperatively with plasma ECs (AEA, 2-AG) and endocannabinoid-related lipids (PEA, OEA). Results . Gender-specific analysis showed differences in AEA, OEA, and PEA preoperatively with reductions in AEA and PEA in females postoperatively. Preoperatively, AEA was correlated with 2-hour glucose (<mml:math xmlns:mml="http://www.w3.org/1998/Math/MathML" id="M1"><mml:mi>r</mml:mi><mml:mo>=</mml:mo><mml:mn>0.55</mml:mn></mml:math>,<mml:math xmlns:mml="http://www.w3.org/1998/Math/MathML" id="M2"><mml:mi>P</mml:mi><mml:mo>=</mml:mo><mml:mn>0.01</mml:mn></mml:math>), HOMA-IR (<mml:math xmlns:mml="http://www.w3.org/1998/Math/MathML" id="M3"><mml:mi>r</mml:mi><mml:mo>=</mml:mo><mml:mn>0.61</mml:mn></mml:math>,<mml:math xmlns:mml="http://www.w3.org/1998/Math/MathML" id="M4"><mml:mi>P</mml:mi><mml:mo>=</mml:mo><mml:mn>0.009</mml:mn></mml:math>), and HOMA %S (<mml:math xmlns:mml="http://www.w3.org/1998/Math/MathML" id="M5"><mml:mi>r</mml:mi><mml:mo>=</mml:mo><mml:mo>-</mml:mo><mml:mn>0.71</mml:mn></mml:math>,<mml:math xmlns:mml="http://www.w3.org/1998/Math/MathML" id="M6"><mml:mi>P</mml:mi><mml:mo>=</mml:mo><mml:mn>0.002</mml:mn></mml:math>). OEA was correlated with weight (<mml:math xmlns:mml="http://www.w3.org/1998/Math/MathML" id="M7"><mml:mi>r</mml:mi><mml:mo>=</mml:mo><mml:mn>0.49</mml:mn></mml:math>,<mml:math xmlns:mml="http://www.w3.org/1998/Math/MathML" id="M8"><mml:mi>P</mml:mi><mml:mo>=</mml:mo><mml:mn>0.03</mml:mn></mml:math>), waist circumference (<mml:math xmlns:mml="http://www.w3.org/1998/Math/MathML" id="M9"><mml:mi>r</mml:mi><mml:mo>=</mml:mo><mml:mn>0.52</mml:mn></mml:math>,<mml:math xmlns:mml="http://www.w3.org/1998/Math/MathML" id="M10"><mml:mi>P</mml:mi><mml:mo>=</mml:mo><mml:mn>0.02</mml:mn></mml:math>), fasting insulin (<mml:math xmlns:mml="http://www.w3.org/1998/Math/MathML" id="M11"><mml:mi>r</mml:mi><mml:mo>=</mml:mo><mml:mn>0.49</mml:mn></mml:math>,<mml:math xmlns:mml="http://www.w3.org/1998/Math/MathML" id="M12"><mml:mi>P</mml:mi><mml:mo>=</mml:mo><mml:mn>0.04</mml:mn></mml:math>), and HOMA-IR (<mml:math xmlns:mml="http://www.w3.org/1998/Math/MathML" id="M13"><mml:mi>r</mml:mi><mml:mo>=</mml:mo><mml:mn>0.48</mml:mn></mml:math>,<mml:math xmlns:mml="http://www.w3.org/1998/Math/MathML" id="M14"><mml:mi>P</mml:mi><mml:mo>=</mml:mo><mml:mn>0.05</mml:mn></mml:math>). PEA was correlated with fasting insulin (<mml:math xmlns:mml="http://www.w3.org/1998/Math/MathML" id="M15"><mml:mi>r</mml:mi><mml:mo>=</mml:mo><mml:mn>0.49</mml:mn></mml:math>,<mml:math xmlns:mml="http://www.w3.org/1998/Math/MathML" id="M16"><mml:mi>P</mml:mi><mml:mo>=</mml:mo><mml:mn>0.04</mml:mn></mml:math>). 2-AG had a negative correlation with fasting glucose (<mml:math xmlns:mml="http://www.w3.org/1998/Math/MathML" id="M17"><mml:mi>r</mml:mi><mml:mo>=</mml:mo><mml:mo>-</mml:mo><mml:mn>0.59</mml:mn></mml:math>,<mml:math xmlns:mml="http://www.w3.org/1998/Math/MathML" id="M18"><mml:mi>P</mml:mi><mml:mo>=</mml:mo><mml:mn>0.04</mml:mn></mml:math>). Conclusion . Gender differences exist in circulating ECs in obese subjects. Females show changes in AEA and PEA after bariatric surgery. Specific correlations exist between different ECs and markers of obesity and insulin and glucose homeostasis.

In the past 15 years considerable advances have been made in our understanding of the molecular pharmacology of the mechanisms whereby somatostatin and its analogs mediate their direct and indirect antineoplastic effects. However, some important issues remain to be resolved, in particular the functional roles of the individual somatostatin receptors (SSTR-1–5) in tumor tissue and up- or downregulation of the hSSTRs with prolonged administration of somatostatin analogs. Answers to these questions are essential before we can maximize the therapeutic efficacy of somatostatin analogs in cancer. For example, is continuous administration more or less effective than intermittent therapy? The role of somatostatin analogs in the management of acromegaly and to a lesser extent neuroendocrine tumors is firmly established. The development of depot preparations of all 3 somatostatin analogs currently available for clinical use will undoubtedly improve both patient compliance and quality of life in patients with these conditions. There are only likely to be minor differences in the therapeutic efficacy of octreotide, lanreotide and vapreotide since all three analogs exert the majority of their antineoplastic effects via hSSTR-2 and hSSTR-5 and at the end of the day, price may well dictate which of these drugs oncologists use to provide symptomatic palliation of acromegaly and neuroendocrine tumors. Apart from some notable exceptions, somatostatin analog therapy has proven to be very disappointing in the management of advanced malignancy. Improvements in the management of solid tumors are likely to come only from combination therapy of somatostatin analogs with cytotoxic agents or other hormones in both advanced malignancy and in the adjuvant setting. Clinical trials with clear-cut objective outcome measures and health-related quality of life assessment are needed to evaluate the therapeutic efficacy of combination treatment in advanced malignancy and as an adjuvant to surgery. Particular attention needs to be paid to possible adverse effects of somatostatin analog therapy on the immune response to cancer. Further studies are required to establish whether the adverse effects of somatostatin analog therapy alone or in combination with cytotoxics or other hormones can be reversed with appropriate immunomodulatory treatment. Targeted somatostatin analog radiotherapy and chemotherapy are currently being investigated and the results of these studies are awaited with interest. Novel approaches using combinations of somatostatin analogs with antiangiogenic drugs or gene therapy are of particular interest and may provide important advances in the management of cancer in the not too distant future.

p53 mutations and loss of heterozygosity have been commonly associated with oesophageal adenocarcinoma. In this investigation, the p53 status of a Welsh population of Barrett's-associated oesophageal adenocarcinomas were fully characterised at the gene sequence, chromosomal, mRNA and protein levels. In total, 31 tumours were examined for p53 gene sequence mutations using RFLP with sequencing, allelic loss of the gene was characterised by FISH, mRNA expression by p53 pathway signalling arrays and protein levels by p53 immunohistochemistry. In all, 9.6% of adenocarcinomas harboured p53 mutations, 24% displayed p53 allelic loss and 83% exhibited p53 protein accumulation. Point mutations and deletions of the gene did not coexist within the same samples. All samples containing p53 mutations also displayed positive immunostaining; however; in the majority of cases, p53 protein accumulation developed in the absence of mutations. The gene expression analysis demonstrated no differences in p53 and mdm-2 transcription levels between the p53 immunonegative and immunopositive samples, indicating other mechanisms underlie the proteins' overexpression. In conclusion, p53 mutations and deletions do not appear to be frequent events in oesophageal adenocarcinomas; however, abnormal accumulation of the protein is present in a vast majority of cases. P53 gene mutations are not the primary cause of protein overexpression--an alternative mechanism is responsible for the positive p53 immunohistochemistry detected.

Somatostatin was first suggested for the treatment of acute pancreatitis more than 15 years ago but despite many studies, its role in the management of this condition remains unclear. The experimental and clinical studies are reviewed and the physiological actions of somatostatin, which may influence the course of acute pancreatitis are examined. It is concluded that although some reports suggest a trend towards improved survival and lessened complication rate with somatostatin treatment, insufficient evidence of benefit exists to support the use of somatostatin or its analogue in the treatment or prophylaxis against acute pancreatitis in routine clinical practice.

Objectives Barrett's oesophagus is a pre-neoplastic lesion, which develops as a complication of chronic gastro-oesophageal reflux disease and predisposes the patient to oesophageal adenocarcinoma. Our aim was to characterize karyotypic changes that may occur during the progression of Barrett's metaplasia through low-grade dysplasia and high-grade dysplasia to adenocarcinoma. Methods The technique of comparative genomic hybridization was used to characterize genome-wide changes in biopsies from patients with low-grade dysplasia, low-grade dysplasia plus high-grade dysplasia, high-grade dysplasia or adenocarcinoma. Both fresh and archival material was examined. Results Comparative genomic hybridization revealed a large amount of widespread chromosome instability at the high-grade dysplasia stage. No significant chromosome changes were detectable by comparative genomic hybridization in patients with low-grade dysplasia. Karyotypic changes in the adenocarcinoma patients were more specific than those found in the high-grade dysplasia patients. Chromosome 4 was amplified most often in high-grade dysplasia and chromosome 8q was amplified most frequently in the adenocarcinomas. Conclusions These data demonstrate that high-grade dysplasia is the stage exhibiting widespread chromosome instability, which is detectable by comparative genomic hybridization. This instability is undetectable in low-grade dysplasia. The chromosome variation seen at high-grade dysplasia may be the source of more specific karyotypes that progress to adenocarcinoma. Importantly, we have identified chromosome 4 amplification as being heavily involved in the initiation of Barrett's progression. Specific chromosome changes (4 and 8q) may represent important regions on which to focus attention in future studies, with a view to identifying diagnostic markers.

Abstract Serum levels of parathyroid hormone (PTH), calcium and albumin were measured daily for 5 days in 41 selected patients with moderate to severe acute pancreatitis. The PTH level was measured by means of a two-site immunoradiometric assay specific for the intact polypeptide. A rise in PTH level was observed more commonly in patients with a complicated or fatal outcome than in those with an uncomplicated course (14 of 16 versus six of 25 patients, P &amp;lt; 0.001). Although PTH levels were variable in the presence of hypocalcaemia, raised concentrations were found more frequently in patients with complications (seven of eight versus two of seven without complications, P = 0.035). This study confirms that an appropriate rise in PTH level occurs in response to the hypocalcaemic stimulus in patients with acute pancreatitis.

Barrett's oesophagus is a premalignant condition whose incidence is rising dramatically. Molecular markers are urgently needed to identify Barrett's patients at the highest risk of cancer progression. To this end, we have used a rapid molecular technique, restriction site mutation (RSM), to detect low-frequency mutations in the p53 tumour suppressor gene in premalignant Barrett's tissues of cancer-free patients. In total, 38 endoscopically diagnosed Barrett's patients with a range of histological stages of Barrett's progression, plus four control patients without Barrett's oesophagus, were analysed for early p53 mutations. Tissue samples taken from these patients (93 samples in total) were analysed for the presence of low-frequency p53 mutations at hotspot codons: 175, 213, 248, 249, 282. In total, 13 of the 38 Barrett's patients were shown to possess a p53 mutation in at least one sample (no mutations in the four control patients). Although no statistically significant associations were found, p53 mutations reflected histological progression in Barrett's patients with p53 mutations found in 30% of metaplasia patients (P=0.4) and low-grade dysplasia patients (P=0.33) and 45% of high-grade dysplasia patients (P=0.15). Detected p53 mutations were mainly GC to AT transitions at CpG sites.

It has become increasingly recognized over the past decade that, apart from causing gastro‐oesophageal varices, portal hypertension has effects on the remainder of the gastrointestinal tract, in particular, the gastric mucosa. There have been numerous reports suggesting that ‘hypertensive’ gastric mucosa is a frequent cause of haemorrhage in patients with portal hypertension; the condition has been variously described as haemorrhagic gastritis, erosive gastritis, portal hypertensive gastritis, congestive gastropathy, gastric mucosal red spots, gastric mucosal vasculopathy or portal hypertensive gastropathy (PHG). The feature in common with all these descriptions is the observation of a gastric mucosal lesion which has a propensity to bleed.

Cytomegalovirus (CMV) infection is associated with significant morbidity and mortality in immunocompromised patients. In immunocompetent individuals, the infection is usually subclinical but it can sometimes be life threatening. We describe a case of fatal CMV proctitis in a 71-year-old man following an Ivor–Lewis esophagectomy. After surgery he developed renal failure, methicillin-resistant Staphylococcus aureus pneumonia, and acute respiratory distress syndrome. He recovered but developed melena and massive fresh rectal bleeding. Sigmoidoscopy revealed severe proctitis and a biopsy was consistent with ischemia. Despite undergoing a proctectomy he continued to bleed and died despite every effort. The final histological examination of the rectum revealed a CMV infection.

Administration of a long active analogue of somatostatin, SMS 201-995 (2 micrograms subcutaneously twice a day) for 3 weeks after intraportal administration of Walker cells significantly inhibited their growth and development in the liver. This was not due to a direct cytotoxic effect of the analogue on Walker cells whose growth was stimulated in vitro. Furthermore, SMS 201-995 had no effect on the growth of Walker cells implanted into the thigh of rats suggesting that the inhibitory action of the analogue could be confined to tumour cells growing in the liver. Further studies suggested that the inhibitory effect of SMS 201-995 on the growth of Walker cells in the liver could be related to a marked stimulation of the hepatic reticuloendothelial system, by a reduction in portal venous flow in the early stages of treatment or by a combination of these effects. Further studies are required to delineate more precisely the mechanism whereby SMS 201-995 inhibits the growth of hepatic tumour derived from intraportal administration of Walker cells.

G astro-oesophageal reflux disease (GORD) is a signifi- cant health concern, usually being managed medically and often needing life-long treatment.In adults, 30% experience reflux once a month and at least 10% experience significant reflux once every day.Only a small number eventually seek surgical advice.Patients who benefit from surgery are those who are young and well controlled on proton pump inhibitors who do not want long-term acid

Obesity is associated with abnormal cardiac regulation by the autonomic nervous system (ANS), this being reversed by weight loss. Bariatric (weight-reduction) surgery can induce substantial long-term weight reductions. This study compares the acute influence on ANS control of two different types of bariatric surgery involving laparascopic and open procedures. To distinguish between the cardiac influences of surgery and obesity, we perform the same analysis for laparascopic surgery in non-obese patients. Eight morbidly obese and five non-obese patients underwent surgery. Obese patients received either laparoscopic procedures (group A: n = 5, BMI = 44.3 +/- 2.7 kg m(2)) or open procedures (group B: n = 3, BMI = 55.2 +/- 4.5 kg m(2)) and non-obese patients received a laparoscopic procedure (group C: n = 5, BMI = 30.8 +/- 5.8 kg m(-2)). Holter ECG was recorded and heart rate variability (HRV) was quantified together with measures of complexity (sample entropy) and structure (Hurst coefficient, scaling coefficient) of the heart rate data. Multifractal characteristics of heart rate data, not previously reported for obese patients, are also quantified and interpreted. Mixed model ANOVA was used to assess the magnitudes of each quantified variable, with surgical group and perioperative time as main factors. HRV measures were influenced only during anaesthesia (LFn increase: p = 0.009; HFn decrease: p = 0.033) and did not discriminate between patient groups. Multifractality was the only characteristic of heart rate data that discriminated between patient groups, being significantly (p < 0.001) greater in non-obese (group C) compared with obese patients (groups A and B, who had similar multifractal properties). Multifractality was also enhanced during anaesthesia (p = 0.028) but did not differ for other stages. We conclude that obesity per se rather than response to surgery is the cause of reduced multifractality. Reduced multifractality in obesity might reflect a diminished 'scaling' or 'collective response' across the multiple autonomic modulators of heart rate. The multifractal method appears to be a more sensitive measure of integrated cardiac autonomic function than linear methods for these patients.

We have analysed five mutation hotspots within the p53 gene (codons 175, 213, 248, 249, and 282) for mutations induced by hydrogen peroxide (H2O2), employing the restriction site mutation (RSM) assay. In addition, four other restriction sites covering non-hotspot codons of exons 5–9 of the p53 gene (codons 126, 153/54, 189 and the 3′ splice site of exon 9) were analysed by the RSM assay for H2O2-induced mutations. Two cell types were concurrently analysed in this study, i.e. primary fibroblast cells and a gastric cancer cell line. Using the RSM assay, H2O2-induced mutations were only detected in exon 7 of the p53 gene. This was true for both cell types. These mutations were mainly induced in the Msp I restriction site (codon 247/248) and were predominantly GC to AT transitions (71%). Hence these GC to AT mutations were presumably due to H2O2 exposure, possibly implicating the 5OHdC adduct, which is known to induce C to T mutations upon misreplication. Importantly, this study demonstrates that the RSM methodology is capable of detecting rare oxidative mutations within the hotspot codons of the p53 tumour suppressor gene. Hence, this methodology may allow the detection of early p53 mutations in pre-malignant tissues.

Intestinal type gastric cancer is a significant cause of mortality, therefore a better understanding of its molecular basis is required. We assessed if either aneuploidy or activity of the oncogenic transcription factor nuclear factor kappa B (NF-κB), increased incrementally during pre-malignant gastric histological progression and also if they correlated with each other in patient samples, as they are both induced by oxygen free radicals. In a prospective study of 54 (aneuploidy) and 59 (NF-κB) consecutive patients, aneuploidy was assessed by interphase fluorescent in situ hybridisation (FISH) for chromosome 1. NF-κB was assessed by expression of interleukin-8 (IL-8), and in a subset, by immunohistochemistry (IHC) for active p65. Aneuploidy levels increased incrementally across the histological series. 2.76% of cells with normal histology (95% CI, 2.14–3.38%) showed background levels of aneuploidy, this increased to averages of 3.78% (95% CI, 3.21–4.35%), 5.89% (95% CI, 3.72–8.06%) and 7.29% (95% CI, 4.73–9.85%) of cells from patients with gastritis, Helicobacter pylori positive gastritis and atrophy/intestinal metaplasia (IM) respectively. IL-8 expression was only increased in patients with current H. pylori infection. NF-κB analysis showed some increased p65 activity in inflamed tissues. IL-8 expression and aneuploidy level were not linked in individual patients. Aneuploidy levels increased incrementally during histological progression; were significantly elevated at very early stages of neoplastic progression and could well be linked to cancer development and used to assess cancer risk. Reactive oxygen species (ROS) induced in early gastric cancer are presumably responsible for the stepwise accumulation of this particular mutation, i.e. aneuploidy. Hence, aneuploidy measured by fluorescent in situ hybridisation (FISH) coupled to brush cytology, would be worthy of consideration as a predictive marker in gastric cancer and could be clinically useful in pre-malignant disease to stratify patients by their cancer risk.

The development of Barrett's esophagus and its progression to adenocarcinoma are clearly linked to reflux of acid and bile. Our objective in this study was to develop an optimized ex vivo biopsy culture technique to study the molecular signaling events induced after insult with individual refluxate constituents. We illustrate the utility of this method by showing results for NF-kB centered cell signaling, and compare the results with those obtained from esophageal cell lines. We show that upregulation of the two NF-kB target genes show differences in pH preference, with IL-8 being preferentially upregulated by DCA at neutral pH, and IkB being upregulated by neutral DCA, acidic DCA, and acid alone. This was found to be true in both cell lines and biopsy cultures. The maximum responses were noted in both models when mixed reflux (DCA at pH 6) was utilized, perhaps reflecting the pH preference of DCA (pKa 6.2). Both the optimized ex vivo models, and the in vitro cell lines show that bile and acid are capable of inducing NF-kB dependent gene expression, with some interesting differences in preferred transcriptional target. In conclusion, in both cells and cultured biopsies, similar reflux driven gene expression changes were noted, with maximum effects noted with DCA exposures at pH 6.

Background Obesity surgery is associated with improvement in type 2 diabetes mellitus. Our aim was to examine the effects of biliopancreatic diversion (BPD) and laparoscopic adjustable gastric banding (LAGB) on the body mass index, fasting insulin level, glucose level, and insulin resistance in morbidly obese subjects with type 2 diabetes mellitus. The setting was the Department of Surgery, Morriston Hospital (Swansea, Wales, United Kingdom). Methods A total of 13 morbidly obese patients (7 BPD, 6 LAGB) underwent serial measurements of fasting glucose and insulin at baseline, immediately after surgery (days 1–7), and 1, 6, and 12 months postoperatively. The homeostasis model of assessment–insulin resistance was calculated. Results In the BPD group, the glucose levels had normalized by day 3 (5.6 ± 1 mmol/L) and the difference was statistically significant at 6 and 12 months postoperatively (5 ± .7 and 4.4 ± .5 mmol/L, respectively). The insulin levels had improved from day 1, and the difference was statistically significant at days 2, 5, 6, and 7 (19 ± 9, 14.2 ± 7, 15.2 ± 8, and 17.4 ± 8 mU/L, respectively). All diabetes medications were stopped on the fourth postoperative day. In the LAGB group, no statistically significant changes were seen in the glucose levels. Statistically significant changes in insulin were seen on days 1 and 2 (19 ± 13 and 13 ± 6.5 mU/L, respectively). The homeostatic model of assessment–insulin resistance had improved in both groups (BPD, 1.6 ± 1.2, P < .01; and LAGB, 4.3 ± 1.4, P < .05). Conclusion BPD causes immediate remission of type 2 diabetes mellitus. Leptin might play an important role in the early improvement of insulin resistance in fasting states after BPD. In the LAGB group, glucose homeostasis improved, but the patients still required diabetes medications, although the dosages were reduced.

Molecular approaches are increasingly being employed to dissect the genetic changes accompanying tumour formation. These methods can often be confusing to the non-specialist as they include complex molecular steps. This can reduce the usefulness of such molecular data to clinicians. The authors aim to aid interpretation of molecular studies in general by presenting a comprehensive review of one molecular approach, i.e. the use of restriction enzymes in molecular studies of tumour development.A review was made of the molecular studies that have employed restriction enzymes in gastrointestinal cancer research. These studies have used restriction enzymes to analyse point mutation induction, gene methylation status and the deletion of chromosomal loci. In addition, emphasis is placed on some of the important considerations for the molecular analysis of tumours that can affect the molecular data obtained.Restriction enzyme digestion has played, and continues to play, a major role in analysing the genetic changes in cancer. Many adaptations of basic restriction enzyme methodologies have enhanced the application of this approach in cancer genetics.The availability of 200 different restriction enzymes, each recognizing different sequences in DNA, has been invaluable in studying cancer genetics. It is hoped that current advances in protein engineering will facilitate the creation of novel restriction enzymes with tailor-made sequence specificities. This will further improve the applicability of restriction enzymes in cancer genetics.

Despite the wide range of probes commercially available for interphase fluorescence in situ hybridisation (FISH), the supply of locus-specific probes is limited to genes or chromosomal regions commonly altered in genetic diseases or during carcinogenesis. Generation of these probes is therefore desirable to accommodate individual research requirements. Hence, we detail the methodology required to design and produce custom locus-specific interphase FISH probes for any human genomic region of interest and their application was illustrated in cytogenetic investigations of Barrett's tumourigenesis. Previously utilising FISH, we observed that Barrett's tissues demonstrated chromosome 4 hyperploidy [Gut 52 (2003) 623], but as centromeric probes were used in this analysis, it was not known if the whole chromosome was amplified. We consequently generated single-copy sequence probes for the 4p16.3 and 4q35.1 subtelomeric loci. Multicolour FISH was subsequently performed on interphase preparations originating from patients with Barrett's esophagus at varying histological grades, thus demonstrating the whole region of chromosome 4 was amplified within the tissues. Additionally, probes for the DNA methyltransferase genes were produced to determine if gene dosage alterations were responsible for increasing methylation activity during Barrett's neoplastic progression. No significant alterations at the DNMT1 and DNMT3a loci were detected. An increased copy number of these genes is therefore not the basis for the hypermethylation commonly observed in this premalignant lesion.

Summary A 35‐year‐old woman with morbid obesity and amenorrhoea underwent a bilo‐pancreatic diversion (BPD). Surgery was successful with good weight loss, restoration of menstruation and almost immediately she conceived for the first time. She was commenced on routine vitamin supplements after surgery but failed to attend follow‐up clinic. Five years later, she presented with limb girdle pains, lethargy, night blindness, skin pigmentation, amenorrhoea and dizziness. She had stopped taking supplements prescribed after the surgery. Investigations showed severe vitamin A and D deficiency along with iron and calcium deficiency. Her cholesterol was low at 3.5 mmol L −1 . Despite aggressive vitamin replacement, she continued to complain of lethargy and dizziness. Subsequently, three short adrenocorticotropic hormone‐stimulation tests were suboptimal (basal cortisol: 196, 185 and 223 nmol L −1 ; 30 min cortisol: 421, 453 and 435 nmol L −1 ). She was subsequently commenced on adrenal replacement and her symptoms resolved and she conceived. We describe for the first time in the literature the unexpected finding of adrenal insufficiency following a BPD.

We write with reference to the recently published article by Mancini et al [ [1] Mancini A. Leone E. Festa R. Grande G. Di Donna V. De Marinis L. et al. Evaluation of antioxidant systems (coenzyme Q10 and total antioxidant capacity) in morbid obesity before and after biliopancreatic diversion. Metabo Clin Exp. 2008; : 1384-1389 Abstract Full Text Full Text PDF Scopus (24) Google Scholar ]. They observed a marked reduction in levels of the lipophilic antioxidant CoQ10 after biliopancreatic diversion surgery in a sample of 11 morbidly obese patients, despite there being no parallel decrease in total antioxidant capacity. Levels of CoQ10 significantly decreased 3 to 6 months postsurgery (0.66 ± 0.09 and 0.34 ± 0.16 μg/mL), whereas no significant difference was noted in lag time for total antioxidant capacity before and after surgery (66 ± 5.3 and 57.5 ± 5.3 seconds). The authors gave no explanation for this phenomenon. They also described the diabetes status of the sample, although the mean presurgery fasting glucose was 146.91 ± 22.61 mg/dL (8.2 mmol/L). Reply: Total antioxidant capacity after malabsorptive bariatric surgeryMetabolism - Clinical and ExperimentalVol. 58Issue 9PreviewThe letter of Dr Prior et al gives us the opportunity to add some considerations to the data reported in our article published in Metabolism in November 2008 [1]. Full-Text PDF

ABSTRACT Structural and functional changes of the gastric mucosa were studied in rats made portal hypertensive by partially ligating the portal vein. Studies were carried out at either 3 or 12 days after ligation or sham operation. At 3 days, structural changes were greater than at 12 days, the major effects being vascular congestion in the lamina propria, muscularis mucosa, submucosa, and submucosal oedema. Transmission electron microscopy showed only a mild hyperplasia in the muscularis mucosa. Gastric blood flow appeared to decrease at 3 days post‐ligation compared to sham‐operated control rats, but was significantly increased by 12 days after ligation ( P &lt; 0.01). Cardiac output also appeared to increase in the portal hypertensive rats by 12 days post‐ligation but this was not statistically significant; Portal venous inflow was significantly increased by 12 days ( P &lt; 0.05) but after correction for collateral circulation liver blood flow had returned to normal values by 12 days post‐ligation.

Sixteen patients with persistent (n = 11) or recurrent (n = 5) variceal bleeding after injection sclerotherapy and balloon tamponade were treated with an intravenous infusion of somatostatin 250 micrograms/h. Somatostatin infusion successfully controlled the bleeding in 15 of the 16 patients but one rebled after 72 h of treatment. In one patient with poor liver function (Child's C) bleeding was not controlled by somatostatin, further injection sclerotherapy or balloon tamponade of the oesophagus. The results of this study, although uncontrolled and with a small number of patients, suggest that somatostatin is a very effective treatment for the control of post-injection sclerotherapy variceal bleeding.

Background: The mortality rate of bleeding from oesophageal varices (30-40%) makes it one of the most serious emergencies today. Since in 30-40% of patients varices are actively bleeding, urgent control is mandatory for preventing the patient from dying of hypovolaemic shock. Analysis of the different methods: Various reports have shown the efficacy of injection sclerotherapy, one session controlling bleeding in 75-80% of patients, and a second increasing the success rate to 90-95%. However, the facilities for 24-h endoscopy and the expertise are not always available in the hospital. Therefore, there is a need for an effective stop-gap therapy for controlling variceal bleeding until definitive therapy can be carried out. Comparisons of various drugs have provided conflicting results. It is not clear whether combined vasopressin and nitroglycerin is superior to injection sclerotherapy in the acute control of variceal haemorrhage. A randomized controlled trial has showed somatostatin to be as effective as injection therapy in the control of acute variceal bleeding and incidence of recurrent bleeding in the first 5 days after initiation of therapy. Conclusion: Somatostatin is a safe and effective treatment for the control of acute variceal haemorrhage and for preventing early rebleeding.

Summary A patient with subacute thyroiditis developed a thyroid abscess after drainage of a pilonidal abscess. An infective focus in a patient with subacute thyroiditis on steroids should be treated aggressively with adequate antibiotic cover .

The excellent Clinical update on obesity surgery by Michael Korenkov and Stefan Sauerland (Dec 15, p 1988)1Korenkov M Sauerland S Clinical update: bariatric surgery.Lancet. 2007; 370: 1988-1990Summary Full Text Full Text PDF PubMed Scopus (33) Google Scholar is very timely. I would particularly like to emphasise that this treatment is cost effective and saves lives. However, one aspect this review did not cover was how to deliver such a treatment in a socialised health-care system such as the UK's National Health Service (NHS).Currently, obesity surgery is being offered to around 1–3% of eligible patients in the UK. The country's National Institute for Health and Clinical Excellence (NICE) in 2002 independently assessed obesity surgery and updated its guidance in 2006.2National Institute for Health and Clinical ExcellenceObesity: guidance on the prevention, identification, assessment and management of overweight and obesity in adults and children. NICE, London2007http://www.nice.org.uk/nicemedia/pdf/CG43NICEGuideline.pdfGoogle Scholar NICE made it clear that this was a cost-effective treatment and suggested that it should be available on the NHS. Indeed, obesity surgery is much more cost effective than many other services available today on the NHS.The UK government has looked for any excuse to delay establishing obesity surgical centres: initially there were not enough surgeons, but now there are plenty clamouring to offer this treatment but are unable to do so because of ignorance and prejudice on the commissioners' part. UK bariatric services are patchy and very much a postcode exercise, with some areas not having any significant service and others struggling to cope. Most commissioners of obesity surgery services have arbitrarily raised the threshold beyond NICE guidelines in order to ration the service. This has had the effect of driving much of service into private practice (around 50% of all procedures done last year) and also encouraging patients to go overseas where prices are cheaper (but follow-up is often a problem).It is high time the UK government came off the fence and admitted to the voting public that the NHS cannot and will never cope with the demand for obesity surgery, and that other ways of funding it must be found (eg, part private funding).I declare that I have no conflict of interest. The excellent Clinical update on obesity surgery by Michael Korenkov and Stefan Sauerland (Dec 15, p 1988)1Korenkov M Sauerland S Clinical update: bariatric surgery.Lancet. 2007; 370: 1988-1990Summary Full Text Full Text PDF PubMed Scopus (33) Google Scholar is very timely. I would particularly like to emphasise that this treatment is cost effective and saves lives. However, one aspect this review did not cover was how to deliver such a treatment in a socialised health-care system such as the UK's National Health Service (NHS). Currently, obesity surgery is being offered to around 1–3% of eligible patients in the UK. The country's National Institute for Health and Clinical Excellence (NICE) in 2002 independently assessed obesity surgery and updated its guidance in 2006.2National Institute for Health and Clinical ExcellenceObesity: guidance on the prevention, identification, assessment and management of overweight and obesity in adults and children. NICE, London2007http://www.nice.org.uk/nicemedia/pdf/CG43NICEGuideline.pdfGoogle Scholar NICE made it clear that this was a cost-effective treatment and suggested that it should be available on the NHS. Indeed, obesity surgery is much more cost effective than many other services available today on the NHS. The UK government has looked for any excuse to delay establishing obesity surgical centres: initially there were not enough surgeons, but now there are plenty clamouring to offer this treatment but are unable to do so because of ignorance and prejudice on the commissioners' part. UK bariatric services are patchy and very much a postcode exercise, with some areas not having any significant service and others struggling to cope. Most commissioners of obesity surgery services have arbitrarily raised the threshold beyond NICE guidelines in order to ration the service. This has had the effect of driving much of service into private practice (around 50% of all procedures done last year) and also encouraging patients to go overseas where prices are cheaper (but follow-up is often a problem). It is high time the UK government came off the fence and admitted to the voting public that the NHS cannot and will never cope with the demand for obesity surgery, and that other ways of funding it must be found (eg, part private funding). I declare that I have no conflict of interest.

Obesity surgery is the most cost-effective form of treatment for morbid obesity. Unfortunately the NHS has failed to provide widespread comprehensive assessment and obesity surgical services. As a result we are lagging behind many developed countries to the detriment of our patients.

Morbid obesity is a major public health risk, and obesity-related diseases cost the United Kingdom National Health Service (NHS) £500 million a year, equivalent to 1.5% of its total expenditures. It is well documented that surgery is more effective than conservative treatment for morbidly obese patients and that it is also likely to be cost-effective [ 1 Maggard M.A. Shugarman L.R. Suttorp M. Maglione M. Sugerman H.J. Livingston E.H. et al. Meta-analysis: surgical treatment of obesity. Ann Intern Med. Apr 5 2005; 142: 547-559 Crossref PubMed Scopus (1188) Google Scholar , 2 Sjostrom L. Lindroos A.K. Peltonen M. Torgerson J. Bouchard C. Carlsson B. et al. Swedish obese subjects study scientific group. lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery. N Engl J Med. Dec 23 2004; 351: 2683-2693 Crossref PubMed Scopus (3196) Google Scholar ]. Despite this evidence, bariatric surgery in the UK lags behind than in most other western countries, the reasons for which are unclear. Some doctors doubt the value of bariatric surgery and such prejudices may result in obese patients being denied valuable and potentially life-saving treatment.

Background and Aims: Studies describe adverse pulmonary effects in those who responded to the World Trade Center (WTC) disaster in New York City,with mention of aerodigestive symptoms (sx) described as GERD.Little is known about the mechanism of gastrointestinal sx in the WTC-exposed populations.The WTC Environmental Health Center (WTCEHC) was established to respond to health issues related to the attack on 9/11/01 and serves those exposed to WTC dust or fumes, including local residents, workers, and clean-up workers.We now report biopsy findings of post 9/11 refractory GERD-like sx.Methods: Participants were self-referred for medical sx and WTC exposure within the year after 9/11/2001.A standardized questionnaire was administered, including questions assessing the presence of heartburn and/or "acid indigestion."Patients with sx were treated with proton pump inhibitors (PPIs); those with refractory sx were referred to a single gastroenterologist.Endoscopic results from patients evaluated between 1/11/07 and 10/23/08 are analyzed.Results: 160 patients were referred for endoscopy for refractory GERD-like symptoms.33 patients whose sx resolved before their appointment were not endoscoped.18 patients did not attend their appointment.109 patients underwent endoscopy (mean age of 49.8, 48.6% male).41.3% were white, 11.0% black, 8.3% Asian, 0.9% Native American, and 40% were undeclared.64.2% of patients were Hispanic.Many patients (58.7%) had an income <15K.Visible abnormalities were seen on endoscopic evaluation in most patients (94.5%).On biopsy, 49.5% had reflux esophagitis, 44% had chronic inactive gastritis (CIG) and 43.1% had chronic active gastritis (CAG).40% had evidence of infection with Helicobacter pylori (HP).CIG and CAG were associated with HP (P<0.0001) and Asian race (p=0.02).In patients who were HP negative, many had CIG (63.5%),CAG (19.1%), and reflux esophagitis (21.7%).Conclusions: GERD-like sx in a WTC exposed population were associated with gastritis as well as reflux esophagitis.Although we identified a high frequency of HP in our population, in patients without HP, gastritis remained common.The high frequency of HP in our population is most likely due to the country of origin of our patients.Further studies are ongoing to characterize the esophageal disease through pH testing and manometry.Biopsy and EGD results S1938

McMAHON, ANDREW J.; RUSSELL, IAN T.; RAMSAY, GRAHAM; SUNDERLAND, GRAHAM; BAXTER, JOHN N.; ANDERSON, JOHN R.; GALLOWAY, DAVID; O'DWYER, PATRICK J. Author Information

ABSTRACT A simply designed entropion patch provided effective temporary preoperative relief of the symptoms of lid malposition in lower lid involutional entropion in six patients. The patch is easily fashioned and used after appropriate instruction, with its design taking into account lid mechanics and the pathophysiology of involutional entropion.

The development of laparoscopic interventional surgery has brought about a revolution in general surgery over the past 5 years. Laparoscopic cholecystectomy has now become the treatment of choice for symptomatic cholelithiasis because of a reduction in access trauma, resulting in less postoperative pain and a faster recovery. Laparoscopic fundoplication for gastroeosophageal reflux also looks to be a promising procedure which will probably become generally accepted. Laparoscopic hernia repair, although widely practised, has raised question marks because of doubt about recurrence rates and major complications such as intestinal obstruction. Laparoscopic colectomy has similarly raised concerns about complication rates and tumour recurrence rates. Laparoscopic appendicectomy offers marginal benefits over open appendicectomy. Virtually every other intra-abdominal procedure has been performed laparoscopically, but most require further evaluation.

University Department of Surgery, Western Infirmary and Royal Infirmary, and University Department of Anesthesia, Royal Infirmary, Glasgow, United Kingdom

Reductions in plasma endocannabinoids following bariatric surgery in morbidly obese females with impaired glucose homeostasis: A non-randomized prospective study • Endocannabinoids (ECs) are bioactive lipid mediators − N-arachidonyl ethanolamine (AEA) − N-palmitoyl ethanolamine (PEA) − N-oleoyl ethanolamine (OEA) − related N-acylethanolamine (NAE) derivatives − 2-arachidonyl glycerol (2-AG) • Endocannabinoid system (ECS) plays a critical role in regulation of body weight and may have a role in aetiopathogenesis of Type 2 Diabetes (T2DM) • Elevated circulating levels of AEA and 2-AG in obese people compared to non-obese controls of both genders • Little information available on the effects of extreme weight loss associated with bariatric surgery in relation to the ECS.

CAMBRIDGE.?D. H. Barron has been appointed University lecturer in the Department of Anatomy.

LondonRoyal Society, February 25.JULIA BELL and J. B. S. HALDANE: The linkage between the genes for colour-blindness and haemophilia in man. Colour-blindness and hsemophilia are known to be sex-linked. The genes responsible for them should therefore be carried in the same chromosome, and exhibit partial linkage with one another. Six pedigrees are described in which both conditions are found. In three of these, the genes are located in the same chromosome, and are associated throughout the pedigree, all hsemophilics investigated being also colour-blind, and none of their non-hsemophilic brothers being colour-blind. In two pedigrees, the opposite condition holds, whilst one is doubtful, including two colour-blind brothers only one of whom is heemophilic. This fact is attributed to crossing-over. A function P (x, p) of the frequency x of crossing-over, and the frequency p of colour-blindness in the male population, is calculated, which represents the probability of the observed association. The probability that the association attributed to linkage is due to sampling is less than 4 x 10˜6. The frequency of crossing-over is as likely to be above as below 5 per cent. Further confirmation has been obtained for the view that haemophilia originates by mutation.

Gastric emptying was measured in 12 patients with chronic duodenal ulceration and compared with the results from 10 healthy volunteers. The test meal of 300 ml 15% dextrose, labelled with 99mTc-DTPA, was ingested in increments over 6 min. Gamma camera imaging proceeded over 30 min, with a 1-min frame time. A direct correction was applied for the fraction emptying into the small bowel during the ingestion period. Gastric emptying at 6 min was significantly greater in the group with duodenal ulcer (14.4 +/- 2.7% vs. 4.2 +/- 0.9%: mean +/- SEM, p less than 0.01). From this time onwards there were no significant differences in the rates of gastric emptying. These results suggest that chronic duodenal ulcer is associated with an abnormal pattern of gastric emptying of liquid, characterised by an initial rapid phase.

Background/Aims; Helicobacter pylori is a high risk factor for the development of gastric adenocarcinoma.Previous studies have shown that H. pylori activates Wnt/β-catenin signaling pathway.In addition, this pathway related protein kinase CK2 is potentially a highly plausible target for cancer therapy.ERK1/2, which is activated by H. pylori associated EGFR signaling, directly phosphorylates CK2α and the activated CK2α phosphorylates α-catenin at S641.This Helicobacter pylori -associated CK2 activation induces disruption of β-catenin/α-catenin complex and the results can raise nuclear translocation of β-catenin.The aim of this study was to evaluate the role of CK2α in Wnt/β-catenin signaling pathway through α-catenin phosphorylation in H. pylori stimulated gastric epithelial cells.Methods; VacA+, CagA+ wildtype H. pylori strain (ATCC 49503, Rockville, MD,USA) was grown on blood agar plate supplemented with 5% sheep blood for 48 hours at 37°C in microaerobic system jar (Difco, Sparks, MD, USA); CO2 and N2 gas were generated by Campy Pak Plus (BBL, Sparks, MD, USA).Human gastric epithelial cells (AGS, MKN28 and MKN74) were cultured in RPMI-1640 (Gibco, Grand Island, CA, USA), containing 10% FBS (Gibco).The cells were incubated at 37°C in humidified atmosphere with 5% CO2.Gastric epithelial cells were pre-treated with CK2 inhibitor and infected with H. pylori for different periods of time.The effects of CK2 inhibitor on H. pylori-stimulated gastric cancer cells were evaluated by using western blotting, Immunofluorescence, In Vitro kinase assay and Immunoprecipitation. Results; western blotting revealed that phosphorelated form of α-catenin (at S641) was increased in H. pylori stimulated gastric epithelial cells and these increased expression of phospho α-catenin molecules decreased when H. pylori stimulated gastric epithelial cells pre-treated with CK2 inhibitor.CK2 siRNA can also reduce the increased phospho α-catenin in H. pylori stimulated gastric epithelial cells.Conclusion; This data suggests that H. pylori activates Wnt/β-catenin signal pathways through the protein kinase CK2 by α-catenin phosphorylation.Regulation of CK2 activity may serve as novel therapeutic targets in H. pylori-induced gastroduodenal diseases.

Obesity surgery causes resolution/improvement of type 2 diabetes mellitus (T2DM). Our aim was to examine the effects of biliopancreatic diversion (BPD) and gastric banding (GB) on BMI, fasting insulin, glucose & leptin in morbidly obese diabetic subjects with T2DM.

A questionnaire on the necessity and ethics of a randomized trial to compare laparoscopic cholecystectomy and open cholecystectomy was sent to 200 randomly selected surgeons in the British Isles, of whom 117 replied. Of these, 58% thought that a trial was needed to compare laparoscopic cholecystectomy with open cholecystectomy by either minilaparotomy or the conventional approach. Nearly half (45%) expressed interest in participating in such a trial. A hypothetical protocol for a trial was sent to 40 ethical committees; 25 gave approval and only 3 considered that a trial was unethical (12 refused to comment). This survey shows wide support for a trial comparing laparoscopic cholecystectomy with open cholecystectomy.

Portal systemic shunting (PSS) and portal pressure were measured in control rats and in animals with portal hypertension induced by partial portal vein ligation (PPVL). The portal pressure in rats with partial portal vein ligation (13.4 ± 0.5 mm.Hg.) was significantly higher (p &lt; 0.005) than in the control group (9.6 ± 0.6 mm.Hg.). Portal systemic shunting measured by consecutive injections of radiolabelled methylene diphosphonate (MDP), a non-diffusable marker and albumin microspheres directly into the splenic pulp was significantly increased (P &lt; 0.005) in the portal hypertensive animals (30.8 ± 2.5%) compared to sham operated rats (2.6 ± 1.5%). Similarly, in portal hypertensive rats portal systemic shunting measured by intrasplenic injections of radiolabelled cobalt microspheres (37.1 ± 3.9%) was significantly greater (p &lt; 0.005) than in control animals. There was a good correlation and agreement (r = 00.97) between the two methods of measuring portal systemic shunting. However because the 99 Tc m -albumin microspheres are biodegradable the method allows portal systemic shunting to be measured in man. Furthermore since the computer adjusts the baseline to zero after each determination of portal systemic shunting the methodology allows repeated measurements to be made.

Morbidly obese patients have moderately reduced lung volumes. Obesity is also closely linked to obstructive sleep apnea (OSA). Bariatric surgery results in improvement/resolution of OSA by increasing the cross-sectional area of the upper airway and preventing collapsibility. One of the main factors in preventing the collapse of the upper airway is the increased lung volume. Bariatric surgery increases the lung volume (forced vital capacity [FVC]) by reducing abdominal obesity. Our aim was to compare the effects of biliopancreatic diversion (BPD) and laparoscopic gastric banding (LGB) on the apnea hypopnea index, and FVC.

Abstract The Annual Scientific Meeting of the Association of Upper Gastrointestinal Surgeons for Great Britain and Ireland was held in Liverpool in 25th and 26th September 2008, under the presidency of Mr Myrddin Rees. To view all abstracts and posters from this meeting, please click the pdf link on this page.

Australian and New Zealand Journal of SurgeryVolume 59, Issue 3 p. 261-262 ABSTRACTS FROM THE ANNUAL MEETING OF THE SURGICAL RESEARCH SOCIETY OF AUSTRALASIA, HELD IN WESTMEAD, SYDNEY, NSW, 15–17 SEPTEMBER 1988 A prospective randomized controlled clinical trial comparing somatostatin and injection sclerotherapy in the control of acute variceal haemorrhage: A preliminary report J. N. Baxter, J. N. Baxter University Department of Surgery, Royal Liverpool Hospital, Liverpool, EnglandSearch for more papers by this authorS. A. Jenkins, S. A. Jenkins University Department of Surgery, Royal Liverpool Hospital, Liverpool, EnglandSearch for more papers by this authorS. Ellenbogen, S. Ellenbogen University Department of Surgery, Royal Liverpool Hospital, Liverpool, EnglandSearch for more papers by this authorR. Shields, R. Shields University Department of Surgery, Royal Liverpool Hospital, Liverpool, EnglandSearch for more papers by this author J. N. Baxter, J. N. Baxter University Department of Surgery, Royal Liverpool Hospital, Liverpool, EnglandSearch for more papers by this authorS. A. Jenkins, S. A. Jenkins University Department of Surgery, Royal Liverpool Hospital, Liverpool, EnglandSearch for more papers by this authorS. Ellenbogen, S. Ellenbogen University Department of Surgery, Royal Liverpool Hospital, Liverpool, EnglandSearch for more papers by this authorR. Shields, R. Shields University Department of Surgery, Royal Liverpool Hospital, Liverpool, EnglandSearch for more papers by this author First published: March 1989 https://doi.org/10.1111/j.1445-2197.1989.tb01514.xAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article. Volume59, Issue3March 1989Pages 261-262 RelatedInformation

Cronin, J.; Jenkins, G. J. S.; Alhamdani, A.; Doak, S. H.; Griffiths, A. P.; Parry, J. M.; Baxter, J. N. Author Information

Aims: Pancreatogenic diabetes associated with total pancreatectomy is described as unstable and 'brittle' with control labile and a high risk of hypoglycaemia.This has not been the experience of our patients and we sought to establish the nature and lability of diabetic control, and complications of diabetes in this group.Methods: Patients that had undergone a total pancreatectomy in our unit were identified from the departmental database (1989)(1990)(1991)(1992)(1993)(1994)(1995)(1996)(1997)(1998)(1999)(2000)(2001)(2002)(2003).Case notes provided basic data with further information obtained by liaison with the patient's GP.Data regarding postoperative diabetic control was augmented by a telephone interview where possible.Pancreatectomy for necrotising pancreatitis was excluded.Results: Forty-six patients underwent total pancreatectomy with an average age of 56 years.Twenty-nine patients were alive with 23 available for telephone assessment.Mean follow up was 28 months.Thirty-five were primary operations with 11 as completion procedures; 32 were for malignancy (15 dead) and 14 for benign conditions (one dead).There were nine perioperative deaths.Diabetic control was reported by the patients as excellent (8), good (12), fair (8) and poor (4).We were unable to document control in 14 patients.From initial treatment insulin dose was increased in 17, decreased in seven and unchanged in six patients.Eleven patients reported minor episodes of hypoor hyperglycaemia and a 'settling' period.The mean settling time was 13 (range, 1•5-81) months.Two patients needed inpatient treatment for complications.Conclusions: Our patients report better glycaemic control than expected.Fluctuations were common but inpatient treatment was rare.Unstable diabetes is not necessarily the outcome of total pancreatectomy.

The ileal conduit of Bricker is still widely used for urinary diversion after radical cystectomy for bladder carcinoma. We have modified the standard technique with the aim of reducing the complication rate and facilitating treatment.We leave the conduit in its natural isoperistaltic anterior position, the ureters are anastomosed in an anterior position on their own side, using a short ileum segment. The incision of the peritoneum is made in a particular manner to allow on its closure to extraperitonealize the anastomoses and the bottom of the conduit and to support and fasten the loop.A total of 100 consecutive patients after radical cystectomy for bladder cancer had anterior ileal conduit. The complication rates were 5% temporary ureteroileal leakage, 1% reoperation rate, 5% long-term stenoses and 3% renal function deterioration. The surgical revision and the treatment of ureteroileal stenoses with anterograde percutaneous ureteral stenting were not complicated procedures. A comparison with conventional Bricker series shows a significant decrease in the complication rate.The anterior ileal conduit reduces the technique complication rate and facilitates the treatment of complications, and it is a recommended operation for these reasons.

Background: For tension pneumothorax, the UK recommendation is to use a 14 g, 5 cm cannula to decompress the chest. Advice around site selection differs between using the second intercostal space (ICS) mid-clavicular line or the fifth ICS near the mid-axillary line. The aim of this literature review is to determine the best approach for needle decompression using a standard 14 g, 5 cm cannula. Methods: A systematic search of multiple databases was conducted, using inclusion and exclusion criteria. Outcomes were tabulated to identify any trends between various criteria including success with a 5 cm cannula. Results: Thirty-one studies were found, of which four were included. Mean chest wall thickness was 35.8 mm at the anterior site and 39.7 mm at the lateral site. Overall success rates with a 5 cm catheter were on average 79.7% at the anterior and 80% at the lateral position. Conclusion: There is no significant difference in success between using the anterior or the lateral approach for needle decompression.

Background People living with dementia have frequent encounters with ambulance services and have a high risk of mortality when admitted to hospital. The Mental Capacity Act and the National Institute for Health and Care Excellence (NICE) guidance provide a framework for all healthcare practitioners to support the person living with dementia into making their own healthcare decisions and encourages participation regardless of capacity status. The purpose of this study was to understand if people living with dementia are afforded these opportunities to participate in healthcare decisions during interactions with paramedics and what key themes affect participation. Methods Electronic database search of literature, based on keywords, of EBSCO (searching MEDLINE and CINAHL), hand-sifting, and grey literature. Articles were searched for pre-hospital care, Paramedic, EMS, EMT but yielded few results and the terms Doctor, Nurse, Healthcare Professional were added to search matrix. Included articles focused on decision making, participation, were under 10 years old and UK based. 1 exception was made for a Norwegian study focusing on participation. Articles were reviewed multiple times in a meta-synthesis to find themes within each article. Data was grouped, coded and categorised based on themes. Results The findings illustrate that people living with dementia wish to retain autonomy and should be afforded the opportunity to participate in their own decision making regardless of capacity. Good and bad practice occurs, but many people living with dementia are marginalised, manipulated or have decisions taken from them. Conclusion Paramedics need to engage with people living with dementia during all encounters regardless of the severity of the person’s dementia or capacity status. They need to take time to give the person every opportunity to participate, not be influenced by someone who is not the patient and aim to be more inclusive of the patient. Further primary research is required to fully understand the quality of interactions between paramedics and people with dementia.

A 34 year old woman presented with a 10 week history of paroxysmal attacks of headache associated with vomiting, sweating,and palpitations. Her blood pressure always remained normal during these episodes. A 24 hour urine collection showed a mildly elevated level of adrenaline at 180 nmol/24hr (normal < 140nmol/24hr) with normal levels of noradrenaline and dopamine. Abdominal computed tomography (CT) showed the following abnormality (see figure). Abdominal computed tomography scan showing a cystic lesion arising from the right adrenal gland impinging on the liver capsule and the inferior vena cava 1. What abnormality is seen on the scan? 2. What is the likely diagnosis? 1. A cystic adrenal tumour. 2. Adrenal phaeochromocytoma. Phaeochromocytoma is an uncommon tumour with an incidence estimated at 0.8 per 100 000 person years. It is associated with a variety of symptoms …

Jenkins, Spencer A.; Baxter, John N.; Critchley, Mair; Kingsnorth, Andrew N.; Makin, Carol A.; Ellenbogen, Simon; Grime, J. Steven; Love, Janet G.; Sutton, Robert

Abstract Applied Surgical Anatomy – A Guide for the Surgical Trainee M. A. Glasby, W. J. Owen and F. Kristmundsdottir (eds) 252 × 192 mm. Pp. 299. Illustrated. 1998. Oxford: Butterworth-Heinemann. £49.50. A Guide to Laparoscopic Surgery A. Najmaldin and P. Guillou 233 × 154 mm. Pp. 169. Illustrated. 1998. Oxford: Blackwell Science. £24.95.

Poetics breathes new life into the study of Aristotle's aesthetics by allowing the English-speaking student to experience the dynamic quality characteristic of Aristotle's arguments in the original Greek.Aristotle's Poetics combines a complete translation of the Poetics with a running commentary, printed on facing pages, that keeps the reader in continuous contact with the linguistic and critical subtleties of the original while highlighting crucial issues for students of literature and literary theory.Whalley's unconventional interpretation emphasizes Aristotle's treatment of art as dynamic process rather than finished product.The volume includes two essays by Whalley in which he outlines his method and purpose.He identifies a deep congruence between Aristotle's understanding of mimesis and Samuel Taylor Coleridge's view of imagination.This new translation makes a major contribution to the study of not only the Poetics and tragedy but all literature and aesthetics.

peak plasma insulin value was reached 15 minutes after glucose injection.These findings lead us to conclude that intra- venous administration of hypertonic solutions such as glucose 40%, but probably also radio- graphic contrast media, may cause a fall of blood pressure in the elderly, probably through direct vasodilatation.Secondly, the endogenous insulin response to glucose 40% given intravenously elicited no effect on blood pressure in the elderly.