Prospective randomised multi-centre trial comparing the clinical efficacy, safety and patient acceptability of circular stapled anopexy with closed diathermy haemorrhoidectomy.

OBJECTIVE: Unlike excisional haemorrhoidectomy, stapled anopexy (SA), which does not involve radical excision, has theoretical advantages, thus offering potential patient benefits. We compared the clinical efficacy, safety and patient acceptability of SA, with closed haemorrhoidectomy (CH). PATIENTS AND METHODS: 182 patients with symptomatic haemorrhoids (grades II, III, IV) were randomly assigned to receive SA or CH and were followed for up to 1 year (6, 12, 24, 48 weeks) after operation. Postoperative pain, symptom control, complications, re-treatment rates, patient satisfaction, and quality of life were compared on an intention-to-treat basis. RESULTS: Postoperative pain in the SA group (n = 91) was significantly lower (p = 0.004, Mann-Whitney U test). At 1 year there were no significant differences in the symptom load, symptom severity or the disease severity between the two groups. Overall complication rates were similar but faecal urgency was reported more frequently following SA (p = 0.093, Fisher's exact test). Despite a similar rate of residual symptoms, prolapse control was better with CH (p = 0.087, Fisher's exact test), and more patients in the SA group required re-treatment for residual prolapse at 1 year (p = 0.037, Fisher's exact test). However, more patients rated SA as an excellent operation at 6 and 12 weeks (p = 0.008 and 0.033, binary logistic regression) and were willing to undergo a repeat procedure if required (p = 0.018, Fisher's exact test). CONCLUSION: Stapled anopexy offers a significantly less painful alternative to excisional haemorrhoidectomy and achieves a higher patient acceptability. Although the overall symptom control and safety are similar in the majority of the patients, the re-treatment rate for recurrent prolapse at 1 year is higher following SA when compared to CH.

Long-term comparative outcome between laparoscopic total Nissen and Toupet fundoplication: Symptomatic relief, patient satisfaction and quality of life.

BACKGROUND: Laparoscopic antireflux surgery has become an established method of treatment of gastroesophageal reflux disease. This study compares the long-term outcome of total (Nissen) and partial (Toupet) fundoplication, performed in a single institution, by evaluating symptoms and quality of life. METHODS: 266 patients who underwent laparoscopic Nissen or Toupet fundoplication completed a preoperative reflux symptom questionnaire. Postsurgery symptom evaluation, patient satisfaction and quality of life in reflux and dyspepsia (QOLRAD) questionnaires were sent to these patients in December 2004. The two groups were compared for each item nonparametrically. RESULTS: Completed questionnaires were received from 161 patients (61%) of whom 99 had a laparoscopic Nissen fundoplication and 62 laparoscopic Toupet fundoplication. Both procedures were equivalent in improving reflux symptom scores in the long term, 79/99 (80%) and 56/62 (90%) were either symptom free or had obtained significant symptomatic relief. Both groups had equivalent QoL scores on the QOLRAD questionnaire. An equivalent number of patients (86% and 83.9% after Nissen and Toupet, respectively) were sufficiently satisfied to recommend antireflux surgery to a friend or relative complaining of reflux symptoms. CONCLUSION: In conclusion, in patients who have returned the questionnaire, long-term satisfaction, general symptom scores, and quality of life are equivalent after laparoscopic Nissen (complete) or Toupet (partial) fundoplication. There is however, a significant increased prevalence of persistent heartburn after laparoscopic Toupet fundoplication.

Postdefaecation pain syndrome after circular stapled anopexy is abolished by oral nifedipine.

BACKGROUND: Controversy has surrounded the technique of circular stapled anopexy since an isolated report of a high incidence of persistent postdefaecation pain following the procedure. The characteristics, clinical course and management of this complication have not been described. METHODS: Within an ongoing multicentre randomized clinical trial comparing circular stapled anopexy with closed haemorrhoidectomy, 77 patients underwent circular stapled anopexy. Follow-up was at 6, 12, 24 and 48 weeks. Patients underwent transanal ultrasonography, anal electrosensitivity testing and manometry. RESULTS: Of the 77 patients who had circular stapled anopexy, three men reported new-onset postdefaecation pain that compromised lifestyle, including ability to return to work. All three had sphincter hypertonicity on digital and manometric examination but were refractory to topical 0.2 per cent glyceryl trinitrate ointment. The addition of oral nifedipine 20 mg twice daily did not alter anal sphincter pressures but rapidly abolished symptoms and restored quality of life. CONCLUSION: Postdefaecation pain is a specific complication of circular stapled anopexy, affecting a small percentage of patients. Men with a high anal sphincter pressure appear to be at risk. Although the exact aetiology remains unclear, it is likely that rectal rather than anal sphincter muscle is affected. Oral nifedipine represents an effective therapy.

Cardiac sodium channel Markov model with temperature dependence and recovery from inactivation.

A Markov model of the cardiac sodium channel is presented. The model is similar to the CA1 hippocampal neuron sodium channel model developed by Kuo and Bean (1994. Neuron. 12:819-829) with the following modifications: 1) an additional open state is added; 2) open-inactivated transitions are made voltage-dependent; and 3) channel rate constants are exponential functions of enthalpy, entropy, and voltage and have explicit temperature dependence. Model parameters are determined using a simulated annealing algorithm to minimize the error between model responses and various experimental data sets. The model reproduces a wide range of experimental data including ionic currents, gating currents, tail currents, steady-state inactivation, recovery from inactivation, and open time distributions over a temperature range of 10 degrees C to 25 degrees C. The model also predicts measures of single channel activity such as first latency, probability of a null sweep, and probability of reopening.

The microbiological composition of airliner cabin air.

Hundreds of millions of passengers travel on U.S. airliners annually. These large numbers, together with the close proximity required onboard, raise a concern about microbiologic disease transmission in cabin air. Previous air quality surveys generally concentrated on environmental tobacco smoke and particulate matter. They largely ignored the microorganisms also present. We sampled the microbiologic climate of 45 domestic and international flights. We also sampled common locations in a major southwestern city. The concentration of microorganisms in airline cabin air is much lower than in ordinary city locations. We conclude that the small number of microorganisms found in U.S. airliner cabin environments does not contribute to the risk of disease transmission among passengers.