Laparoscopic appendicectomy — A successful operation in adults and children

Laparoscopic appendicectomy has been the subject of several encouraging reports, but has not as yet gained widespread acceptance. We present a series of 159 consecutive laparoscopic appendicectomies performed, over a 4 yr period, in both adults and children. We find the procedure as safe as its open counterpart, with patients fit to leave hospital within the same time period. Perforated appendices were amenable to this procedure, and the location of the appendix did not alter the outcome. Children responded as well as adults post-operatively. Obesity may be an indication for this form of treatment. Removal of displaced faecoliths associated with perforated appendicitis is a difficult technical problem in less than 5 per cent of patients.     

Mortality of cadmium-exposed workers. A five-year update

A cohort mortality study of cadmium-exposed workers initially followed to the end of 1979 has been updated for a further five years. The update has confirmed the findings of the original study with a significant excess risk from bronchitis related to intensity of exposure, although over the five-year period the excess mortality was no longer significant, a finding suggesting that the risk from bronchitis may now be declining in this cohort. In contrast, there is now a stronger indication of a excess risk from lung cancer related to intensity of exposure, significant for both the total and the five-year periods. There was again no increased risk from prostatic cancer, and from this and other studies it appears unlikely that cadmium, in the concentrations encountered in this and other recent studies, acts as a prostatic carcinogen. As in the initial study, there was no significant excess risk from hypertensive disease, nor any suggestion of an increased risk from cerebrovascular or renal disease.     

Paediatric dacryocystorhinostomy

Of 258 cases of dacryocystorhinostomy performed on children in the period September 1981 to September 1991, 130 were for simple, unresolved congenital nasolacrimal duct obstruction. Other indications for surgery included punctal agenesis, lacrimal fistula, post-traumatic and post-inflammatory canalicular obstruction. Of 177 children without canalicular pathology, 171 (96%) were relieved of symptoms with one operation, without canalicular intubation. Of 81 cases with canalicular disease, 55 of 70 (79%) who underwent DCR plus canalicular intubation, and 10 of 11 who underwent DCR plus Lester-Jones tube, were substantially improved with one operation. No child required peroperative or postoperative blood transfusion. Dacryocystorhinostomy in childhood, in experienced surgical hands, is a safe procedure, achieving relief of symptoms in most cases, particularly in the absence of canalicular disease.     

The identity and work of the ancient Egyptian surgeon.

That a well-developed and hierarchical medical profession existed in Pharaonic Egypt is without doubt. What is a matter of contention is the existence of a recognizable surgical profession, or even of the practice of surgery by medically qualified personnel. Palaeorchaeological specimens that demonstrate some form of surgical procedure are rare. Medical papyri and the treatises of the historians of antiquity provide a far more reliable source of information on surgical practice. They have indicated possible titles for surgeons, and the types of instruments used.     

Differential role of the vagus in diurnal gene expression rhythms in the small intestine

The objective of this study was to examine the function of vagal innervation in maintaining diurnal rhythmicity in the expression of intestinal absorptive genes. Rats underwent truncal vagotomy and were maintained for 7 days on nighttime scheduled feeding (12-h light/12-h dark cycle). Vagotomized rats (V; n = 9) were pair-fed with sham-operated controls (S; n = 4). Unoperated normal rats (N; n = 6) were also included as controls. Half the rats were killed 3 h after lights on (ZT3; Zeitgeber Time, with lights-on considered ZT0) and the other half at ZT9, the time interval over which we have previously shown that sucrase and sugar transporter expression exhibits a significant anticipatory increase. RNA and protein extracted from mucosa of proximal jejunums were subjected to Northern and Western blot analyses to assess the increase in gene expression. Sham operation did not alter the normal diurnal rhythmicity of intestinal gene expression. Control rats (S plus N) exhibited the expected increase in RNA levels at ZT9 versus ZT3 for SGLT1 (4.5-fold), GLUT2 (5.3-fold), GLUT5 (4.1-fold), and sucrase (2.9-fold; P > 0.001 in all cases). In contrast, the induction in V rats was markedly blunted for GLUT2 (1.3-fold) and sucrase (1.5-fold) but not for SGLT1 (5.0-fold) or GLUT5 (4.2-fold). The mRNA levels for GLUT2 and sucrase at ZT9 were significantly lower in V rats versus controls (P < 0.001). GLUT2 and SGLT1 protein levels exhibited a parallel pattern: SGLT1 induction was 4.3-fold in control rats (P < 0.01) and 3.8-fold in V rats (P <0.01), whereas GLUT2 induction was 3.3-fold in control rats (P < 0.01) but only 1.4-fold in V rats (NS). Our results indicate that signaling through the vagus nerve is necessary to maintain the anticipatory induction pattern of GLUT2 and sucrase. The persistent rhythm in both SGLT1 and GLUT5 indicates that (1) diurnal induction of these genes is independent of vagal innervation and (2) the procedure did not cause an overall loss of intestinal function. Thus, entrainment of anticipatory diurnal gene expression in the intestine occurs via two separate pathways that are differentially dependent on vagal input.     

Organisational factors in relation to control of blood pressure: an observational study

BACKGROUND: Studies show that 60-75% of treated patients with hypertension in general practice, still do not reach the recommended blood pressure targets of <150/90 mmHg. AIM: To investigate aspects of hypertension management in relation to sociodemographic variables, antihypertensive drug treatment, and organisational factors in primary care. DESIGN OF STUDY: Observational study over 3 years. SETTING: Eight general practices in Tayside, UK. METHOD: Participants were 560 randomly selected patients aged 40-79 years receiving treatment for hypertension. The outcome measurement was blood pressure control, expressed in binary form based on the British Hypertension Society audit standard of <150/90 mmHg. RESULTS: Of 536 eligible patients, 261 (49%) were defined as having inadequate blood pressure control at the end of the study period. No significant associations were discovered with sex, age, deprivation score and comorbidity. In those patients with inadequate control, 30% had no modifications to their drug treatment during the study period. Blood pressure control at the end of the study period was not associated with number of antihypertensive drugs taken or number of antihypertensive drug modifications. The mean number of clinician contacts was 11 (standard deviation = 8), and mean continuity in primary care was high, although this was not associated with improved blood pressure control. A higher proportion of hypertension-related consultations were associated with increased odds of having inadequate blood pressure control. CONCLUSION: Achieving adequate blood pressure control continues to represent a substantial health problem in a significant proportion of the hypertensive population. Patient, physician and organisational elements play a role in ensuring effective delivery of hypertension care in the community.     

Country-specific cost-effectiveness of early intervention with budesonide in mild asthma.

Early intervention with budesonide is an effective strategy for mild persistent asthma, which has been shown to provide additional clinical benefits at a low incremental cost using USA cost data. The present authors analysed whether this strategy would be cost-effective using cost data for other countries. Based on the 3-yr prospective, randomised, double-blind inhaled Steroid Treatment As Regular Therapy (START) in early asthma study (comparing budesonide and placebo combined with usual asthma therapy), the cost-effectiveness was estimated separately for eight different countries, from both healthcare payer and societal perspectives, of adding budesonide to usual asthma therapy. Local unit costs were applied to data for the total trial population. Incremental cost-effectiveness ratios (ICER) were estimated as cost per symptom-free day (SFD) gained. Budesonide increased SFDs by an average of 14.1 days annually. From a healthcare payer perspective, budesonide would reduce the total cost of asthma care in Australia. In Sweden, Canada, France, Spain, UK, China and the USA, the ICER ranged from US$2.4-11.3 per SFD. From a societal perspective, budesonide would be cost-saving in Australia, Canada and Sweden. In conclusion, for countries where costs with budesonide are higher, the policy implication has to be determined by that health system's willingness to pay for an additional symptom-free day. However, where budesonide therapy increases symptom-free days and reduces total costs, the policy conclusion clearly favours early intervention.