Home nebulizer use among patients with cystic fibrosis.

OBJECTIVE: To describe current patterns of home nebulizer use among patients with cystic fibrosis. STUDY DESIGN: A population-based survey of home nebulizer practices among 227 patients with cystic fibrosis using nebulizers from 1993 to 1994 (Objective 1), and a prospective study of "typical" home use, including testing of performance and bacterial cultures in nebulizers after use, completed by 36 subjects (Objective 2). RESULTS: Objective 1: 85% of subjects reported using jet and 8% ultrasonic nebulizers (categories not mutually exclusive); 15% used unknown brands. Most jet nebulizers were disposable models, which were used for > 14 days by more than half the subjects. Mixing of medications in a single treatment (other than cromolyn and a bronchodilator) was reported by 28% of patients. Objective 2: no apparent deterioration in aerosol particle size or output rate of returned nebulizers compared with new units was observed. Staphylococcus aureus was cultured from 55% and Pseudomonas aeruginosa from 35% of returned nebulizers. Concordance between nebulizer and sputum cultures was poor. CONCLUSIONS: Although not generally tested for reusability, disposable nebulizers are generally used by patients for long periods. Medication mixing is common, although its effects on aerosol properties are unknown. Cystic fibrosis respiratory pathogens are frequently isolated from used nebulizers. Patient guidelines for home nebulizer use need to be established.

Management of choledocholithiasis encountered during laparoscopic cholecystectomy.

To evaluate the prevailing methods of management and assess the safety of laparoscopic treatment of choledocholithiasis, a retrospective review of all common bile duct explorations (CBDE) initiated during laparoscopic cholecystectomy at the Medical College of Georgia was performed. From December 1990 until December 1994, 604 laparoscopic cholecystectomies were performed. In 28 of these patients (26 female, 2 male) with an age range of 17 to 60 years, CBDE was initiated; 21 were performed laparoscopically, and 7 were converted to open CBDE. The procedure was successful in completely clearing the duct of stones in 24 of 28 cases (17 laparoscopic, 7 open). Postoperative endoscopic retrograde cholangiopancreatography was successfully employed in three of the cases of retained stones, and in the fourth, the stone was felt to be small enough to pass without further intervention. Biliary balloon catheters were successfully used to clear the duct in 8 of 17 laparoscopic CBDEs, and a laparoscopic choledochoscope introduced through the cystic duct was used in 7 cases; both were used in 2 cases. The open CBDEs were performed in standard fashion utilizing balloon catheters and choledochoscopy. The only operative complications were the four above-mentioned cases of retained stones. In summary, choledocholithiasis encountered during the course of laparoscopic cholecystectomy can frequently be managed with a laparoscopic CBDE.

Laparoscopic cholecystectomy in children with sickle cell disease.

Since 1991, laparoscopic cholecystectomy has been utilized in children with sickle cell disease, predominantly because of the decreased pain and shorter hospitalization. We believe that outpatient laparoscopic cholecystectomy or even a 24 hour hospitalization is not indicated in the patient with sickle cell disease. Perioperative complications include bleeding diathesis, vaso-occlusive phenomena, and delayed hemolytic transfusion reactions, although clotting parameters can be normal.

An experimental model for laparoscopic common bile duct exploration.

The development of an effective and reliable technique for laparoscopic common bile duct exploration has been limited by the technical difficulty of the procedure and the lack of a suitable animal model with a bile duct diameter large enough to accommodate the fiberoptic choledochoscope and other instruments used for stone extraction. Short-term bile duct ligation in the dog provides a simple and reproducible animal model that enables the surgeon to gain experience with laparoscopic common bile duct exploration in a laboratory setting. This model will enable the surgeon to develop the technical skills necessary to perform laparoscopic common bile duct exploration. In addition, the model may facilitate the development and refinement of new techniques and instruments that will facilitate laparoscopic common bile duct exploration in the clinical setting.

Intraoperative diagnosis of choledochal cyst in preparation for laparoscopic cholecystectomy.

The initial description of abnormalities of the biliary tree was reported by Vater in 1723. However, it was not until 1959 that Alonzo-Lej and colleagues reported on the full description and classification of choledochal cysts. This report describes a Hispanic female who presented with classic findings consistent with biliary colic. A preoperative ultrasound revealed multiple gallstones and mild dilatation of the common bile duct. At the time of laparoscopy, she was found to have a dilated common bile duct, cystic duct, and gallbladder. Further dissection was discontinued, a cholecystectomy made, and a percutaneous transabdominal cholangiogram through the gallbladder performed, which revealed a type I choledochal cyst (cystic dilatation of the extrahepatic bile ducts). The patient then underwent resection of the extrahepatic biliary tree with a Roux-en-Y hepaticojejunostomy. Her subsequent postoperative course was uneventful. This case illustrates the role of cholangiography using the gallbladder as a conduit in the diagnosis of complex biliary tree anomalies during laparoscopy when the biliary tree cannot be safely accessed.

Comparison of adhesion formation in transperitoneal laparoscopic herniorrhaphy techniques.

Two techniques of transperitoneal laparoscopic inguinal hernia repair were studied to evaluate the incidence of short term adhesion formation. Two methods were evaluated in thirty pigs with induced bilateral inguinal hernia defects. Half of the defects were repaired by incising the peritoneum, placing the mesh over the muscle defect, securing the mesh with staples, and reapproximating the peritoneum over the defect with staples. The other hernias were repaired by positioning the mesh over the defect and securing the mesh with staples, with no reapproximation of the peritoneum. The animals were allowed to recover and were killed at the end of two weeks. At autopsy, the animals were examined for the presence of adhesions to bowel. A statistically greater number of adhesions were formed with peritoneal reapproximation, 43 per cent (13/30), compared with 10 per cent (3/30) when the peritoneum was not reapproximated. The simpler method of repair, with no reapproximation, resulted in a statistically lower incidence of adhesions.

Percutaneous transhepatic drainage of the nondilated biliary system.

PURPOSE: The authors sought to develop a safe, efficacious technique for percutaneous transhepatic drainage of nondilated biliary systems. PATIENTS AND METHODS: Twenty-three drainage procedures were performed on 14 consecutive patients with nondilated ducts. Fourteen procedures were carried out for primary placement of a transhepatic biliary drain, eight for placement of a second drain, and one for placement of a third drain. Drainage catheter access into the biliary tree was gained via direct puncture of a peripheral duct (fourth order or smaller branch) in four procedures. In the remaining 19 procedures, peripheral duct punctures were facilitated by retrograde passage of a 5-F catheter from a previous, remote percutaneous access site into the fourth-order duct to be punctured. Nine of these 19 duct punctures were facilitated by the use of a nitinol Goose Neck snare passed through the intraductal catheter. RESULTS: Of the access methods used, the nitinol snare technique was the fastest. Successful peripheral access was achieved in all patients without bleeding complications. One patient developed symptoms of bacteremia, which resolved within 12 hours with antibiotic therapy and external biliary drainage. CONCLUSION: Percutaneous peripheral access can be achieved safely in the nondilated biliary tree and can obviate surgery for some patients and facilitate future interventions.

Laparoscopic anatomy of the biliary tree.

A thorough knowledge of the anatomy of the extrahepatic biliary tree and its frequent anatomic variations is essential for performance of a safe laparoscopic cholecystectomy. The surgeon should have an appreciation for the distortions in the anatomy as a result of retraction on the gallbladder and how the direction of retraction alters the spatial relationships between the cystic duct and common bile duct. The steps in the operative procedure have been outlined to provide good exposure and optimize the identification of structures. Good exposure will enable the surgeon to identify anatomic variants; however, a thorough knowledge of these variants is necessary for safe performance of the operation.

Relaxation training for psychiatric inpatients.

In Exp. 1 the effects of progressive and imaginal relaxation training were examined for 51 psychiatric inpatients. Relaxation Inventory scores indicated significant changes in the direction of greater relaxation for each training procedure; there were no significant differences in responses to the two types of training. Significant relaxation effects were found for each of three training sessions, but the effects were not cumulative. Only one patient was withdrawn because reaction to training was overtly negative. Exp. 2 was an analysis of Exp. 1 data in combination with data from a prior study. Patients and college students responded much alike but students reached greater relaxation within sessions. Further experimentation on relaxation training with psychiatric inpatients appears justified.

Complications of laparoscopic surgery.

The potential complications of a laparoscopic procedure include those related to laparoscopy and those related to the specific operative procedure. The majority of these complications occur during the early learning phase for laparoscopy. They also may occur, however, during procedures performed by surgeons who have considerable laparoscopic experience. As new applications for laparoscopy continue to emerge, it is important for the surgeon to be familiar with the possible complications associated with the various laparoscopic procedures. Only through an appreciation of the potential complications of a procedure can their overall incidence be reduced to a minimum.

A "fair" comparison of progressive and imaginal relaxation.

Progressive and imaginal relaxation-training procedures are difficult to compare because the latter takes many forms. In this study, an imaginal procedure was used that closely followed progressive operations except that muscle tension was imagined rather than experienced. The dependent variable was the total score on the Relaxation Inventory. College students were placed in groups (ns = 50) high and low on suggestibility based on scores on the Creative Imagination Scale, assigned in equal numbers to the imaginal and progressive relaxation conditions and given four sessions of relaxation training. The pre- and posttrials effects were significant within each of the four training sessions. There were no significant differences in reports of relaxation by the progressive and imaginal treatments. The expected cumulative effect of relaxation training across the four sessions was not found; in fact, the imaginal condition showed a significant decrease. The only significant suggestibility effect was an interaction between suggestibility and trials in which highly suggestible subjects reported less pre-session relaxation. These results are consistent with reports of no differences between progressive and imaginal relaxation training.

Anthropometric, metabolic, and immunological effects of recombinant human growth hormone in AIDS and AIDS-related complex.

Metabolic and anthropometric changes induced by "pharmacological" versus "physiological" doses (5.0 vs. 2.5 mg, every other day) of recombinant human growth hormone (rhGH) were compared in 10 human immunodeficiency virus-positive patients with AIDS or AIDS-related complex. Five patients were randomly assigned to each treatment schedule in a 3-month prospective, double-blind clinical trial. Three of the 10 patients, none taking zidovudine and all with low initial CD4 counts, were withdrawn during the study due to acute opportunistic infections. During treatment, insulin-like growth factor-1 (IGF-1) levels increased significantly (p < 0.05) in the pharmacological hGH treatment group, whereas no significant change was observed in IGF-1 in the physiological dose rhGH group. In the pharmacological hGH treatment group, weight loss preceding the study was reversed (p < 0.05) in each of the four patients who completed the study. This weight gain was associated with increases (p < 0.05) in lean body mass and total body water, with concomitant decreases in fat mass (p < 0.05) and urinary nitrogen excretion. Muscle power and endurance, as assessed by standardized omnikinetic dynamometry, also improved. All four patients lost weight again (p < 0.05) 6 weeks after completion of the study and termination of rhGH treatment. Minor positive changes in body composition were also observed in the physiologic-dose hGH group. The pharmacological dose of hGH was associated with minor increments (p < 0.05) in fasting plasma glucose, insulin, and C-peptide concentrations, which were of negligible clinical significance.(ABSTRACT TRUNCATED AT 250 WORDS)

The current status of the Whipple operation for periampullary carcinoma.

In an address delivered before the Boston Surgical Society in 1942, Whipple made the following statement: The radical operation for these tumors of the ampullary region and pancreas, based on the principle of wide, en bloc removal of the tumors, as required in modern cancer surgery, is evidently in an evolutionary stage. Many more cases, with five-year survivals, will be required before valid claims can be made for the operations as done at present. In the nearly 50 years since this address, the Whipple operation has undergone numerous modifications and technical refinements. A number of recent clinical studies clearly demonstrate that this procedure now can be performed with acceptable morbidity and mortality, and that long-term survival is possible even for patients with adenocarcinoma of the head of the pancreas. The decline in operative morbidity and mortality has been achieved largely through advances in surgical technique. Further improvements in survival for patients with periampullary tumors are likely to occur through the development of more effective adjuvant therapy and improved understanding of the biologic behavior of these tumors.

Supplemental growth hormone alters body composition, muscle protein metabolism and serum lipids in fit adults: characterization of dose-dependent and response-recovery effects.

Using double-blind, placebo-controlled procedures, the effects of low and high therapeutic dosages of methionyl-human growth hormone (met-hGH) on body composition, muscle protein metabolism and serum lipids were studied in 7 fit adults without growth hormone (GH) deficiency. Dose-dependent changes in body composition were observed that in part appeared to be influenced by a response-recovery effect, as measured by responses factored according to the duration of washout between exposure to the low and high dosages of met-hGH (6 weeks vs. 12 weeks vs. 18 weeks). Increases in fat-free weight were accompanied by an increase in skeletal muscle protein metabolism. Basal levels of cholesterol were inversely related to peak levels of GH in response to exercise stimulation and IGF-I, while GH supplementation lowered levels of total cholesterol and high- and low-density lipoproteins. A dose-dependent effect occurred for total cholesterol, and the percent change in cholesterol was related to the percent change in insulin-like growth factor I (IGF-I). Endogenous levels of GH were attenuated in response to stimulation and IGF-I levels were increased after treatment with GH, but no dose-dependent changes were observed. We conclude that met-hGH alters body composition and muscle protein metabolism, and decreases stored and circulating lipids in fit adults with a pre-existing supranormal body composition. The physiological profile of the person was not as important as the treatment conditions in determining the somatic and physiological response outcomes.

Exogenous human growth hormone reduces body fat in obese women.

The effects of biosynthetic methionyl human growth hormone (met-hGH) on body composition and endogenous secretion of insulin-like growth factor I (IGF-I) were studied in obese women ranging between 138 and 226% of ideal body weight. Following double-blind procedures, 12 subjects were assigned at random to either treatment with met-hGH (n = 6, 0.08 mg/kg desirable body weight) or placebo (n = 6, bacteriostatic water diluent). Treatments were delivered intramuscularly three times per week for a period of 27-28 days. Subjects were instructed to follow a weight-maintaining diet and their pre- and posttreatment kilocaloric intake was monitored for verification. The baseline peak serum GH response to L-dopa/arginine stimulation for the study population as a whole, was in the hyposecretory range (9.6 +/- 1.9 ng/ml), accompanied by a low level of circulating IGF-I (0.56 +/- 0.09 U/ml). Hydrodensitometry revealed that the met-hGH-treated subjects had a significant reduction in body fat, while an observed mean increase in fat-free mass (FFM) approached significance. The percent change in body fat was unrelated to pretreatment levels of body fat, total body weight, or initial endogenous GH status. Changes in circulating IGF-I were similar to those for FFM, with increases approaching significance. There were no significant changes in body composition or IGF-I in the placebo-treated subjects. No significant differences were observed in the self-reported dietary intake of kilocalories during the experimental period between the two groups. We conclude that exogenous GH reduces body fat in obese women in the apparent absence of significant kilocaloric restriction. The effect appears to be unrelated to endogenous GH secretion or body composition.

Factors influencing survival after pancreaticoduodenectomy for pancreatic cancer.

Eighty-nine patients with carcinoma of the head of the pancreas underwent pancreaticoduodenectomies. The actuarial 5-year survival for all 89 patients was 19%, with a median survival of 11.9 months. The 81 hospital survivors were analyzed in an effort to determine factors influencing long-term survival. Negative lymph nodes and the absence of blood vessel invasion both favored long-term survival. The strongest predictive factor was negative lymph node status with a median survival of 55.8 months, compared with 11 months with lymph nodes involved with tumor (p less than 0.05). Blood transfusions were also predictive, with patients receiving two or fewer units having a median survival of 24.7 months, compared with 10.2 months for those receiving three or more units (p less than 0.05). The most important determinant of long-term survival after pancreaticoduodenectomy for pancreatic cancer is biology of the tumor (lymph node status, blood vessel invasion). However, performance of the resection (units of blood transfused) also appears to be an important factor influencing survival.

Supplemental growth hormone increases the tumor cytotoxic activity of natural killer cells in healthy adults with normal growth hormone secretion.

Using double-blind, placebo-controlled procedures, the effects of methionyl-human growth hormone (met-hGH) on the tumor cytotoxic activity of natural killer (NK) cells were studied in seven healthy adults using a repeated measures experiment. Subjects were assigned at random to either a placebo (bacteriostatic water) treatment condition or a met-hGH (16.0 mg/wk of Protropin) treatment condition, then crossed-over to the alternative treatment. Treatments were delivered on alternate days (3 d/wk) for 6 weeks. Without bias from the met-hGH treatment, there was no evidence for GH hyposecretion as measured by the peak circulating GH response to exercise stimulation (14.1 +/- 3.1 ng/mL) or insulin-like growth factor (IGF-I) levels (0.82 +/- 0.09 U/mL). When compared with placebo, met-hGH induced a significant overall increase in the percent specific lysis (%SL) of K562 tumor target cells (placebo 22.2 +/- 1.7 v met-hGH 28.5 +/- 2.1 %SL; P = .008). NK activity was increased within the first week of treatment and this level was maintained throughout the remaining period of supplementation. There was a trend (P = .057) for the met-hGH-induced percent change in NK activity (NK%) to be inversely related to placebo IGF-I levels (r = -.761), while there were significant positive correlations between NK% and the met-hGH-induced percent changes in IGF-I (r = .727; P = .035), the fat-free mass (FFM)/fat mass (FM) ratio derived by hydrodensitometry (r = .792; P = .012), and the endogenous GH response to exercise (r = .469; P = .034).(ABSTRACT TRUNCATED AT 250 WORDS)

Diet and insulinlike growth factor I in relation to body composition in women with exercise-induced hypothalamic amenorrhea.

To assess the potential influence of diet and endogenous peptide anabolic hormone secretion on exercise-related differences in body composition, we compared levels of macronutrient intake, insulinlike growth factor I (IGF-I), and fat-free mass (FFM) and fat mass (FM) in matched groups of exercising women with and without secondary hypothalamic amenorrhea. Women were tightly matched according to somatotype and grouped into those with exercise amenorrhea (EXam, n = 6), exercise eumennorhea (EXeu, n = 5), and sedentary eumennorheic controls (SED, n = 5). Although no between-group difference was observed in FFM, the EXeu subjects had a significantly lower fat fraction and a significantly elevated FFM/FM ratio. Kilocaloric and protein intakes did not differ between groups, but dietary fat intake was lowest and carbohydrate intake highest in the EXam subjects. Dietary macronutrients were not correlated with the FFM/FM ratio. However, levels of insulinlike growth factor I were significantly correlated to the FFM/FM ratio and there was a clear trend for the hormone to be highest in the EXeu subjects. We conclude that differences in body composition between exercising women with and without exercise-induced hypothalamic-pituitary dysfunction were related to an alteration in IGF-I secretion, although differences in macronutrient intake might also be a factor. Further studies are warranted to elaborate upon the dietary and hormonal factors regulating the body composition response to exercise.