Safety of laparoscopic splenectomy in elderly patients with idiopathic thrombocytopenic purpura.

Laparoscopic splenectomy (LS) for immune thrombocytopenic purpura (ITP) is very successful. However, the safety of LS in older patients who have less cardiac and pulmonary reserve has not been studied. Our objective was to compare results of LS in elderly and younger patients with ITP. LS performed for ITP between 1992 and 1999 were studied. Perioperative data were collected concurrently. Follow-up was obtained by chart review and phone interview. Groups were arbitrarily divided: Group A, age > or =70; group B, age <70. Main outcome measures were platelet response, duration of operation, hospitalization, blood loss, and complications were compared using t test and Chi-square analyses. Group A had more comorbid conditions (80% vs 28%, P = 0.04). Operative time (80 vs 119 minutes, P = 0.23), estimated blood loss (156 vs 189 cm3, P = 0.62), and hospitalization (3.6 vs 2.8 days, P = 0.23) were similar for both groups. Although group B had significantly more patients with an early platelet response (70% vs 97%, P = 0.02), there was no difference in platelet response at long-term follow-up (70% vs 84%, P = 0.22). Long-term follow-up was completed on 87 per cent of patients at an average of 43 months postoperatively. We conclude that LS is safe and effective in elderly patients with ITP.

Gastroesophageal disease and nausea: does fundoplication help or hurt?

HYPOTHESIS: Nausea associated with gastroesophageal reflux disease is cured by laparoscopic Nissen fundoplication (LNF). DESIGN: Prospective cohort study of unselected patients who underwent LNF from January 1, 1995, through March 31, 1999. Patients were followed up by a physician for 6 to 36 months. SETTING: A large community teaching hospital. PATIENTS: One hundred consecutive patients with gastroesophageal reflux disease who underwent LNF; all patients were followed up. Patients were grouped according to the presence (group A, n = 33) or absence (group B, n = 67) of preoperative nausea. Interventions were LNF, esophageal manometry, 24-hour pH monitoring, and nuclear gastric emptying studies. MAIN OUTCOME MEASURES: Resolution of symptoms after LNF. RESULTS: Nausea was the most common atypical symptom of gastroesophageal reflux disease, occurring in 33 patients (33%). There were no differences in esophageal manometry or 24-hour pH results between groups. There was a female preponderance in group A (55% vs 33%; P = .003). Patients in group A had a higher prevalence of preoperative dysphagia (P = .02). Patients with persistent postoperative nausea had a higher prevalence of cough (P = .003) and dysphagia (P = .009). The LNF was more effective in reducing heartburn (95% reduction) and regurgitation (95% reduction) than cough and dysphagia (60% reduction). There was a 79% reduction in the number of patients with nausea (33 to 7; P<.001). CONCLUSION: Laparoscopic Nissen fundoplication is effective in eliminating nausea associated with gastroesophageal reflux disease and is not contraindicated in these patients.

Effect of metoprolol on myocardial function and energetics in patients with nonischemic dilated cardiomyopathy: a randomized, double-blind, placebo-controlled study.

OBJECTIVES: This study examined the effects of metoprolol on left ventricular performance, efficiency, neurohormonal activation and myocardial respiratory quotient in patients with dilated cardiomyopathy. BACKGROUND: The mechanism by which beta-adrenergic blockade improves ejection fraction in patients with dilated cardiomyopathy remains an enigma. Thus, we undertook an extensive hemodynamic evaluation of this mechanism. In addition, because animal models have shown that catecholamine exposure may increase relative fatty acid utilization, we hypothesized that antagonism of sympathetic stimulation may result in increased carbohydrate utilization. METHODS: This was a randomized, double-blind, prospective trial in which 24 men with nonischemic dilated cardiomyopathy underwent cardiac catheterization before and after 3 months of therapy with metoprolol (n = 15) or placebo (n = 9) in addition to standard therapy. Pressure-volume relations were examined using a micromanometer catheter and digital ventriculography. RESULTS: At baseline, the placebo-treated patients had somewhat more advanced left ventricular dysfunction. Ejection fraction and left ventricular performance improved only in the metoprolol-treated patients. Stroke and minute work increased without an increase in myocardial oxygen consumption, suggesting increased myocardial efficiency. Further increases in ejection fraction were seen between 3 and 6 months in the metoprolol group. The placebo group had a significant increase in ejection fraction only after crossover to metoprolol. A significant relation between the change in coronary sinus norepinephrine and myocardial respiratory quotient was seen, suggesting a possible effect of adrenergic deactivation on substrate utilization. CONCLUSIONS: These data demonstrate that in patients with cardiomyopathy, metoprolol treatment improves myocardial performance and energetics, and favorably alters substrate utilization. Beta-adrenergic blocking agents, such as metoprolol, are hemodynamically and energetically beneficial in the treatment of myocardial failure.

Development assistance: ruined hopes and great expectations in Africa.

PIP: This paper highlights the difficulties and complexities of development assistance projects through an analysis of 2 Urban Functions in Rural Development projects conducted by the US Agency for International Development (AID) in Upper Volta and northern Cameroon in 1977-82. The general objectives of the Upper Volta project were to carry out urban function studies, develop a plan for strengthening the contributions of urban centers to rural development, develop a list of investment priorities for facilities and services, and increase the capacities of the Ministry in planning processes and methods. The 2-year project was hindered by a 1-year delay in initiating assistance due to difficulties in locating a contractor. In addition, the contractor and other team members felt there was little justification for studies of spatial organization in a country with so much evident need; rather, they focused on a small rural works program and establishment of effective local government, producing an inconsistency between team activities and the original project agreement. A request by the team to extend the project 1 year beyond its official completion date to compensate for early delays was rejected by USAID. Nonetheless, there was agreement that the project had a small positive impact in Upper Volta. Key lessons from Upper Volta were transferred to the Cameroon project. Although this project was judged to have achieved its objective of preparing a regional plan and of identifying programs for facilities, services, and small-scale enterprises, it was beset by problems of inexperience and technical underqualification of team members, poor communication, inconsistency of USAID guidelines, and methodological confusion. It is suggested that a central challenge for such programs is to create a body of qualified Americans who can work with their local counterparts in meeting the challenges of development. A measure of the success or failure of these projects should be the degree to which learning contributes to improved performance.^ieng