Outcomes of HIV-infected patients treated for recurrent tuberculosis with the standard retreatment regimen.

SETTING: The Groupe Haitien d'Etude du Sarcome de Kaposi et des Infections Opportunistes (the GHESKIO AIDS and TB Center) in Port-au-Prince, Haiti. OBJECTIVE: To measure the effectiveness of the standard TB retreatment regimen (2HRZES/1HRZE/5HRE) in human immunodeficiency virus (HIV) infected adults. DESIGN: Cohort study. RESULTS: Of 1318 HIV-infected patients with access to antiretroviral therapy following World Health Organization guidelines, 56 were diagnosed with recurrent pulmonary TB and retreated with the standard retreatment regimen: 10 patients (18%) died during retreatment, 3 (5%) defaulted, and 2 (4%) failed treatment. Forty-one patients (73%) achieved retreatment 'success' (cure, treatment completed). Of these, 8 (20%) died during follow-up, 5 (12%) were lost, and 5 (12%) had a second recurrence of TB. Only 26 (46%) of the 56 patients remained alive, in care, and TB-free after a median of 36 months of follow-up. CONCLUSION: HIV-infected patients treated for recurrent TB with the standard retreatment regimen have high mortality and poor long-term outcomes.

A prospective study comparing the complication rates between laparoscopic and open ventral hernia repairs.

BACKGROUND: Although ventral hernia repair is increasingly performed laparoscopically, complication rates with this procedure are not well characterized. For this reason, we performed a prospective study comparing early outcomes after laparoscopic and open ventral hernia repairs. METHODS: We identified all the patients undergoing ventral (including incisional) hernia repair at a single tertiary care center between September 1, 1999 and July 1, 2001 (overall n = 257). To increase the homogeneity of the sample, we excluded umbilical hernia repairs, parastomal hernia repairs, nonelective procedures, procedures not involving mesh, and repairs performed concurrently with another surgical procedure. Postoperative complications (in-hospital or within 30-days) were assessed prospectively according to standardized definitions by trained nurse clinicians. RESULTS: Of the 136 ventral hernia repairs that met the study criteria, 65 (48%) were laparoscopic repairs (including 3 conversions to open surgery) and 71 (52%) were open repairs. The patients in the laparoscopic group were more likely to have undergone a prior (failed) ventral hernia repair (40% vs 27%; p = 0.14), but other patient characteristics were similar between the two groups. Overall, fewer complications were experienced by patients undergoing laparoscopic repair (8% vs 21%; p = 0.03). The higher complication rate in the open ventral hernia repair group came from wound infections (8%) and postoperative ileus (4%), neither of which was observed in the patients who underwent laparoscopic repair. The laparoscopic group had longer operating room times (2.2 vs 1.7 h; p = 0.001), and there was a nonsignificant trend toward shorter hospital stays with laparoscopic repair (1.1 vs 1.5 days; p = 0.10). CONCLUSIONS: The patients undergoing laparoscopic repair had fewer postoperative complications than those receiving open repair. Wound infections and postoperative ileus accounted for the higher complication rates in the open ventral hernia repair group. Otherwise, these groups were very similar. Long-term studies assessing hernia recurrence rates will be required to help determine the optimal approach to ventral hernia repair.

Laparoscopy may be lowering the threshold to operate on patients with suspected appendicitis.

BACKGROUND: Although several randomized trials have compared postoperative outcomes in patients undergoing open and laparoscopic appendectomy, few have examined whether laparoscopy has affected preoperative decision making. We hypothesized that surgeon enthusiasm for laparoscopic appendectomy would lower the threshold to operate on patients with possible appendicitis. To examine this question we designed a retrospective cohort study in the setting of a tertiary care medical center. METHODS: We studied a consecutive series of 130 patients taken to the operating room with preoperative diagnoses of appendicitis between 1 January 1997 and 31 December 1999. We excluded pregnant patients, those under 18 or over 75, those admitted electively for chronic symptoms, and those undergoing appendectomy incidental to another procedure. Measures included the proportion of patients with normal appendices or acute appendicitis (perforated and nonperforated), as determined from the pathology report. Other clinical and demographic data were obtained by review of the medical records. RESULTS: During the study period, 87 patients (67%) underwent open appendectomy and 43 patients (33%) underwent laparoscopic appendectomy. Women were more likely to receive the laparoscopic approach than men (43% vs 24% p = 0.021). Preoperative use of advanced imaging tests (computed tomography or ultrasound) was more prevalent in the laparoscopic group (40% vs 30%, p = 0.271). Patients undergoing the laparoscopic procedure were considerably less likely to have acute appendicitis than those undergoing an open one (67% vs 92%, p <0.001). However, among patients with confirmed appendicitis, those undergoing laparoscopic surgery were less likely to be perforated than those who had an open procedure (4.6% vs 25% p = 0.004). CONCLUSION: At our hospital, the availability of the laparoscopic approach to appendectomy may have lowered the threshold to operate on patients with possible appendicitis, as reflected in higher negative exploration rates and lower rates of perforated appendicitis.

Groin hernia and surgical truth.

BACKGROUND: Surgeons have used many methods to repair groin hernia since 1889. In that year, both Halsted and Bassini described the first effective operation. All operative solutions to groin hernia since then have used a suture repair. The differences have been related to the anatomic structures that are joined by the sutures. Recently, laparoscopy has forced most surgeons to question their approach to groin hernia. Common questions are: Is laparoscopy superior? When should mesh be used? Which of the many available techniques give superior results? DATA SOURCES: This review presents an opinion-based review of the classical and recent literature. In addition, this review considers the manner in which surgeons search for answers to such questions. CONCLUSION: The result of this search, for the author, is an acceptance of the mesh plug repair as superior to all others currently available.

Outcomes evaluation for operative and nonoperative management of the abnormal mammogram.

BACKGROUND: This study reviewed the outcome of women with an abnormal mammogram and no mass (n = 194). METHODS: Patients were immediately biopsied (34%) or followed up mammographically (66%). Information was collected prospectively over a 13-year period. RESULTS: Eight of those initially biopsied (12%) proved to be cancer. Of the remaining 129 patients, 20 were lost to follow-up, leaving 109 for further review. Thirty of these patients ultimately came to biopsy, with 5 (17%) proving to be cancer. Of those followed up mammographically and not biopsied, the majority (92%) of lesions either remained unchanged or resolved. The average follow-up time is 53 months. Biopsy was avoided in 51%. Of the 179 patients with follow-up information, 40 (23%) developed new lesions. Fourteen of these lesions have been biopsied, and 36% were cancer. CONCLUSIONS: Most mammographic lesions resolve or remain unchanged. Women who have a lesion on mammography are at increased risk for further mammographic abnormalities.

External-feedback effects in high-gain scattering media.

We report on experimental studies of external-feedback effects on high-gain scattering media. We explain experimental results for the pump energy required for laser action as a function of the separation between a mirror and the media by use of Monte Carlo simulations and integration of the laser equations.

Speckle-mirror laser.

We report on a new laser feedback mechanism that uses speckle-pattern phenomena to create highly dispersive feedback. This speckle mirror is capable of creating laser emission as narrow as that from laser cavities using a number of dispersive elements such as gratings and prisms. Contributions from the peaks of intensity of the speckle patterns and a limited pumping-beam diameter are the basic conditions for the observation of this effect.

Alteration of gastric surface cell pH regulation by sodium taurocholate.

Gastric mucosal cells from guinea pigs were grown in cell culture. Acridine orange fluorescence at 624 nm was used as an qualitative indicator of intracellular pH. The cultured cells were exposed to Hank's solution at pH 7.4, 6.0, 5.0, 4.0, 3.0, and 1.8 for 30 min. After removal of the acid, the cells were loaded with acridine orange for qualitative pH assessment. The cells developed alkaline shifts in the cytoplasmic pH in direct proportion to the acid load. This alkaline overcorrection after exposure to acid was blocked by amiloride and blunted by taurocholic acid in a dose-dependent fashion. These results suggest that gastric surface cells may regulate their cytoplasmic pH with a sodium-hydrogen antiporter. These results also suggest that this antiport system may be adversely affected by bile salts.

Selective nonoperative management of patients referred with abnormal mammograms.

Screening mammography provides a means of detecting clinically occult breast carcinoma, but the question of whether all abnormal mammograms require biopsy remains unanswered. We retrospectively reviewed records of 214 women referred over an 8-year period for abnormal mammograms. They were selectively assigned to biopsy or mammographic follow-up based on specific mammographic criteria. Of 114 women initially observed mammographically, 2 were later found by biopsy to have carcinoma. Initial assignment to mammographic observation delayed the recommendation for biopsy 3 and 12 months, respectively, in these patients, but no effect on outcome was documented. Because they have benign lesions by clinical and mammographic criteria, 102 women (53%) have been spared biopsy; they continue to be monitored closely. We believe these data support the use of a selective approach to biopsy based on specific mammographic criteria.

Ultrastructural changes in gastric epithelium caused by bile salt.

We assessed the influence of bile salt in neutral solution on the morphology and function of the Ussing-chambered stomach mucosa. Guinea pig gastric mucosa was exposed to 5, 10, and 20 mM taurocholic acid in balanced salt solution with glucose. Control tissues were exposed to salt solution without taurocholic acid. During exposure to the bile salt, the pH of the bathing solutions was maintained at 7.0-7.4 with 0.1 M sodium hydroxide. Potential difference, short-circuit current, and resistance of the tissues were recorded every 15 min. The morphologic effects of the bile salt were determined with light and electron microscopy. The 10 and 20 mM concentrations caused significant deterioration of the electrophysiologic measurements and major morphologic alteration on both light and electron microscopic evaluations. The 5 mM concentration of taurocholic acid did not affect the electrophysiologic measurements or the light microscopic appearance of the surface cells. Electron microscopy, however, revealed morphologic changes in over 50% of the specimens examined. These findings demonstrate that in vitro, mammalian gastric mucosa shows significant ultrastructural changes when exposed to physiological concentrations of bile salt in a neutral solution. These changes appear to be subtle in that they are evident on transmission electron microscopy even before significant change can be demonstrated by light microscopy or by standard electrophysiologic measurements.

Effect of delayed operation for bleeding esophageal varices on Child's class and indices of liver function.

The charts of 38 patients managed with a period of intensive medical treatment (mean 7 days) prior to portosystemic shunting were examined. We found that the operative delay did not improve the Child's class or the indices of liver function. The operative mortality rates in these patients were 0 in Child's A patients, 13 percent in Child's B patients, and 50 percent in Child's C patients. Based on these findings, we began to operate on patients with bleeding esophageal varices as soon as they stabilized. The charts of 10 consecutive Child's C patients operated on without a period of intensive medical management (mean 3 days) were reviewed and compared with the charts of 8 Child's C patients with delayed operation. The two groups of patients were similar. We recommend that patients who need a shunt should be operated on as soon as possible after bleeding has ceased.

Screening mammography: a surgeon's strategy for dealing with abnormal mammographic findings.

Screening mammography is a valuable tool in the detection of breast cancer at an early stage. Large numbers of patients are being referred to surgeons for biopsies on the basis of mammographic abnormalities alone. As mammograms are complex studies and the findings often subtle, variation in terms of interpretation and recommendations for biopsy can leave the surgeon in a difficult position. We have reported a systematic method for evaluating patients and mammograms. Eighty-eight patients were referred to a single surgeon solely for an abnormal mammographic finding. Physical examination was repeated and the mammogram reviewed with a single consulting radiologist using specific criteria to define a mammographic abnormality. Through this evaluation, biopsy was avoided in 42 of 88 patients, with follow-up mammograms and physical examinations finding no suspicion of malignancy. By becoming educated in regard to mammographic abnormalities, establishing specific criteria with a consistent radiologist, and following patients carefully who are not biopsied, the surgeon can deal effectively with screening mammography.

Detailed comparison of regional and general anesthesia for carotid endarterectomy.

Forty-one variables were examined in 75 patients who underwent carotid endarterectomy to determine if significant differences were present between 45 patients who had general anesthesia and 30 patients who had regional anesthesia. The two groups were similar in terms of age, existing medical illnesses, neurologic presentation, and angiographic severity of the carotid lesions. There were no differences between the two groups for operative time, anesthesia time, blood loss, maximum or minimum blood pressures, postoperative hemodynamic data, or the requirement for or duration of intravenous pressor or antihypertensive medications. One patient in the regional group had a postoperative neurologic deficit which resolved in 1 month. Three patients in the general group had cardiovascular complications. Postoperative hospital stay was significantly longer in the general anesthesia group (5.6 to 3.2 days, p = 0.003). Regional and general anesthesia produce similar perioperative hemodynamic and surgical outcomes, but regional anesthesia results in a shorter hospital stay and less cardiovascular morbidity in this high risk population.

Rational preoperative evaluation.

Clinical data from two hundred consecutive patients undergoing surgical procedures at the Salt Lake City VA Hospital form the basis of this study. Results of nine commonly ordered preoperative tests (blood count, differential, electrolytes, chemistry panel, urinalysis, prothrombin time, partial thromboplastin time, electrocardiogram, and chest X-ray) were matched with the preoperative history and physical examination and the outcome of surgery in each patient. Each test was examined by the frequency with which it was ordered, the frequency with which it was abnormal, and the frequency with which the abnormal result affected preoperative care. A prevalence of medical illness was found in this population, with 47.5% having a major cardiovascular diagnosis, 35.5% a metabolic or endocrine disease, and 28% a major pulmonary diagnosis. A total of 1271 tests were performed, with 477 (35.5%) showing some abnormality. However, only 76 (5.9%) changed the patient's management before surgery. All but five of these abnormalities were predictable from the clinical evaluation and these five were minor. The overall postoperative complication rate was 9%. No complication was attributed to the omission of a preoperative test. No surgical cases were cancelled during the study period based solely on a preoperative test. We conclude that many preoperative tests can be safely eliminated by ordering only those based on a specific abnormality in the history or physical examination, resulting in more cost-effective surgical care.