The intra-gastric balloon for pre-operative weight loss in bariatric surgery: is it worthwhile?

BACKGROUND: Super-obese patients in NHS Lothian during 2009-2010 were offered the intragastric balloon to assist with weight loss prior to definitive bariatric surgery along with participation in a structured weight management programme. Those who declined balloon placement continued to receive weight management alone (WM). The aim of this study was to compare the effectiveness of the structured weight management programme with and without the addition of the intragastric balloon. METHODS: Patients referred to the NHS Lothian Bariatric Service in 2009 with BMI > 55 kg/m(2) or weight > 200 kg and assessed as otherwise eligible for bariatric surgery were offered structured weight management with or without placement of an intragastric balloon with the aim of achieving a target of 10 % excess weight loss (EWL) over 6 months. RESULTS: Twenty-eight patients were recruited. Fifteen opted for balloon placement and 13 declined. Three patients in the balloon group required early balloon removal due to intolerance and three dropped out of the WM group through non-attendance. Of those remaining, two in the balloon group and three in the WM group failed to achieve the 10 % EWL target. Overall, median %EWL was 17.1 % for the balloon group and 16.1 % for the WM group (p = 0.295, Mann-Witney U-test). CONCLUSIONS: The additional use of intragastric balloon conferred no benefit over structured weight management alone in achieving pre-operative weight loss in a super-obese patient population. In the context of limited resources within NHS Lothian, the continued use of intragastric balloon in this way cannot be justified.

Computed tomography after radical pancreaticoduodenectomy (Whipple's procedure).

Whipple's procedure (radical pancreaticoduodenectomy) is currently the only curative option for patients with periampullary malignancy. The surgery is highly complex and involves multiple anastomoses. Complications are common and can lead to significant postoperative morbidity. Early detection and treatment of complications is vital, and high-quality multidetector computed tomography (MDCT) is currently the best method of investigation. This review outlines the surgical technique and illustrates the range of normal postoperative appearances together with the common complications.

CEACAM6 is a determinant of pancreatic adenocarcinoma cellular invasiveness.

Pancreatic adenocarcinoma is among the most aggressively invasive malignancies. The immunoglobulin superfamily member carcinoembryonic antigen-related cell adhesion molecule 6 (CEACAM6) is emerging as an important determinant of the malignant phenotype in a range of cancers. We sought to define the role of CEACAM6 in pancreatic adenocarcinoma cellular invasiveness. CEACAM6 was stably overexpressed in Capan2 cells, which inherently express low levels of CEACAM6. Retrovirally mediated RNA interference was used to silence CEACAM6 expression in BxPC3 cells, which inherently overexpress CEACAM6. Cellular invasiveness was quantified using a modified Boyden chamber assay. Overexpression of CEACAM6 increased Capan2 cellular invasiveness, whereas CEACAM6 knockdown attenuated BxPC3 invasiveness. A role for the c-Src tyrosine kinase in mediating CEACAM6-dependent invasiveness was defined using constitutively active and dominant-negative c-Src expression constructs. c-Src-dependent modulation of matrix metalloproteinase-9 activity contributes significantly to the increased cellular invasiveness induced by CEACAM6 overexpression. Levels of CEACAM6 expression can modulate pancreatic adenocarcinoma cellular invasiveness in a c-Src-dependent manner. This pathway warrants further investigation as a target for therapy.

Focal adhesion kinase gene silencing promotes anoikis and suppresses metastasis of human pancreatic adenocarcinoma cells.

BACKGROUND: Inadequate or inappropriate cell-substrate contact triggers a subset of apoptotic cell death, termed anoikis. Resistance to anoikis is a characteristic of malignant cells that is associated with increased tumorigenesis and metastasis. Focal adhesion kinase (FAK) is an important regulator of cell survival and migration and cell cycle progression. We tested the hypothesis that FAK gene silencing would promote anoikis and reverse acquired anoikis resistance in human pancreatic adenocarcinoma cells. METHODS: FAK expression was assessed by Northern and Western blot analysis. Anoikis was induced in PANC1, BxPC3, MiaPaCa2, and Mia(AR) (an anoikis-resistant derivative of MiaPaCa2) with the use of polyHEMA culture. FAK expression was suppressed by RNA interference. Anoikis was detected by YO-PRO-1/propidium iodide staining and flow cytometry. Fluorometric caspase profiling was performed. Metastasis was assayed in a nude mouse orthotopic xenograft model. RESULTS: The cell lines that were tested showed marked variation in their anoikis resistance, greater resistance being associated with higher levels of FAK expression. FAK gene silencing promoted anoikis in all cell lines and reversed acquired anoikis resistance in Mia(AR), which was associated with increased caspase activation. Suppression of FAK expression also inhibited metastasis in the nude mouse model. CONCLUSION: FAK gene silencing suppresses anoikis resistance in pancreatic adenocarcinoma cells. FAK represents a potential target for novel antimetastatic therapies.

A randomised trial of knife versus diathermy in pilonidal disease.

BACKGROUND: Pilonidal disease is a common debilitating condition. This prospective randomised study compared excision of pilonidal disease with a scalpel or diathermy with respect to operation time, postoperative pain, functional recovery and wound healing. PATIENTS AND METHODS: Patients undergoing surgery for pilonidal disease were randomised to excision by scalpel (group 1) or diathermy (group 2). Patients received regular peri-operative oral analgesia and a standardised general anaesthetic technique. Duration of operation was recorded. Following surgery, pain, analgesic requirements, sedation, nausea and vomiting scores and time to mobilise and time to complete healing were compared. RESULTS: Statistical significance between groups was obtained for five outcomes after 32 patients had been recruited; of these, 81% were admitted as emergencies with an abscess. The duration of surgery in group 2 was significantly less, postoperative pain scores and morphine requirements were lower and mobility was regained sooner. CONCLUSIONS: We advocate the use of diathermy needle rather than scalpel blade when undertaking excision of pilonidal disease in both acute and chronic patients.

Management of colorectal cancer: variations in practice in one hospital.

AIMS: The Royal College of Surgeons of England and the Association of Coloproctology of Great Britain and Ireland guidelines for the management of colorectal cancer were published in 1996. We audited our practice against these guidelines. METHODS: Data from 211 consecutive patients undergoing colorectal cancer surgery, between September 1999 and September 2000, have been prospectively collected. Preoperative large bowel and liver imaging, assessment by colorectal specialist nurses and median number of lymph nodes resected have been compared between specialist colorectal and non-colorectal surgeons for rectal and colonic cancers. The adequacy of resection and rates of abdomino-perineal resection have been compared for rectal cancers. Following presentation of our findings, we re-audited practice between January and June 2002. RESULTS: There was marked variation in practice within our hospital. Colorectal specialists were more likely to conform to best practice guidelines, performed fewer abdomino-perineal resections and tended to perform more extensive lymphadenectomy. Following presentation of these data, compliance with guidelines was markedly improved and the number of rectal procedures performed by non-colorectal surgeons decreased. CONCLUSIONS: The ability of audit to change practice has been demonstrated. We feel that completion of this audit cycle has improved the quality of service we provide for colorectal cancer patients in our hospital.

Does a glass of red wine improve endothelial function?

AIMS: To examine the acute effect of red wine and de-alcoholized red wine on endothelial function. METHODS AND RESULTS: High frequency ultrasound was used to measure blood flow and percentage brachial artery dilatation after reactive hyperaemia induced by forearm cuff occlusion in 12 healthy subjects, less than 40 years of age, without known cardiovascular risk factors. The subjects drank 250 ml of red wine with or without alcohol over 10 min according to a randomized procedure. Brachial artery dilatation was measured again 30 and 60 min after the subjects had finished drinking. The subjects were studied a second time within a week of the first study in a cross-over design. After the red wine with alcohol the resting brachial artery diameter, resting blood flow, heart rate and plasma-ethanol increased significantly. After the de-alcoholized red wine these parameters were unchanged. Flow-mediated dilatation of the brachial artery was significantly higher (P<0.05) after drinking de-alcoholized red wine (5.6+/-3.2%) than after drinking red wine with alcohol (3.6+/-2.2%) and before drinking (3.9+/-2.5%). CONCLUSION: After ingestion of red wine with alcohol the brachial artery dilated and the blood flow increased. These changes were not observed following the de-alcoholized red wine and were thus attributable to ethanol. These haemodynamic changes may have concealed an effect on flow-mediated brachial artery dilatation which did not increase after drinking red wine with alcohol. Flow-mediated dilatation of the brachial artery increased significantly after de-alcoholized red wine and this finding may support the hypothesis that antioxidant qualities of red wine, rather than ethanol in itself, may protect against cardiovascular disease.

Head nurse leadership style with staff nurse burnout and job satisfaction in neonatal intensive care units.

Leadership style has been defined as a two-factor construct composed of "consideration" and "initiating structure." Research has suggested that these factors affect the behavior and attitude of subordinates. This study's purpose was to quantify the relationships of head nurse leadership style with self-reported staff nurse burnout and job satisfaction in Neonatal Intensive Care Units (NICUs). Three instruments--the Minnesota Satisfaction Questionnaire, the Tedium Scale, and the Leadership Opinion Questionnaire--were voluntarily completed by 283 registered nurses employed by 14 level-III NICUs in the United States. The leadership dimensions of consideration and structure were distinct (r = -.10). Staff nurse satisfaction and burnout were related (r = -.41). Head nurse consideration was clearly related to staff nurse satisfaction (r = -.55) and to a lesser extent to burnout (r = -.29). Initiating structure alone was not related to satisfaction or burnout. Aggregate perceptions of head nurse leadership were ranked across NICUs in order to classify the head nurses on consideration and structure. The 14 head nurses were separated into four groups: high consideration-high structure, high consideration-low structure, low consideration-high structure, and low consideration-low structure. Satisfaction and burnout of staff nurses in each of the leadership-style groups were then compared. Analysis of variance for satisfaction (F(3,279) = 3.10, p = .03) and burnout (F(3,279) = 3.90, p = .01) were both significant. For both satisfaction and burnout, the head nurse leadership classification of low consideration-high structure was most deviant.(ABSTRACT TRUNCATED AT 250 WORDS)

Measurement of the nurse organizational climate of neonatal intensive care units.

The concept of organizational climate is important for the study and understanding of work organizations. Researchers have not yet studied the organizational climate of hospital intensive care units, so it is not clear that the dimensions useful in description of other work settings will be appropriate for conceptualizing neonatal intensive care units (NICU's). This study investigated nurse perceptions of the organizational climate of NICU's in a sample of 18 hospitals. The Organizational Climate Description Questionnaire was modified for use in the NICU setting. A set of homogeneous climate scales was developed from the revised instrument. The six scales of the resulting instrument, the Nursing Organizational Climate Description Questionnaire, Form B (NOCDQ-B), demonstrated median internal-consistency reliability of .69 on cross-validation. Analysis of variance indicated that each of the six NOCDQ-B dimensions served to differentiate the NICU's in the study. Further, significant relationships were found at the unit mean level between three of the six NOCDQ-B scales and nurse satisfaction, as measured by the Minnesota Satisfaction Questionnaire.

Staff nurse turnover in neonatal intensive care units.

The turnover rate and patterns in Neonatal Intensive Care Units (NICUs) were assessed and compared with adult Intensive Care Units (ICUs) and General Infant Care Units at the same hospitals for the year 1976. Thirty-five hospitals with NICUs participated in the study. The findings of this study disagree with the previous literature in three major ways: 1 The turnover rate of staff nurses was less than half that estimated by The National Commission on Nursing for 1970. 2 The turnover rates in ICUs and NICUs were not significantly higher than that for staff nurses in Non-Intensive Care Units. In addition, the pattern of turnover among leavers is identical for all three major types of unit. The variability pattern for neonatal units, however, is statistically significant; this is not so with the other units studied. 3 There is no evidence for a stabilization of turnover following the usual 'induction crisis period' (the first 3 to 6 months).