Effect of population screening for type 2 diabetes on mortality: long-term follow-up of the Ely cohort.

AIMS/HYPOTHESIS: The aim of this study was to assess the impact of invitation to screening for type 2 diabetes and related cardiovascular risk factors on population mortality. METHODS: This was a parallel-group population-based cohort study including all men and women aged 40-65 years, free of known diabetes, registered with a single practice in Ely, UK (n = 4,936). In 1990-1992, approximately one-third (n = 1,705) were randomly selected to receive an invitation to screening for diabetes (with an OGTT) and related cardiovascular risk factors. In the remaining two-thirds of the population, 1,705 individuals were randomly selected for invitation to screening in 2000-2003 and 1,526 were not invited at any point during the follow-up period. All individuals were flagged for mortality until January 2008. RESULTS: There were 345 deaths between 1990 and 1999 (median 10 years follow-up). Compared with those not invited, individuals who were invited to the 1990-1992 screening round had a non-significant 21% lower all-cause mortality (HR 0.79 [95% CI 0.63-1.00], p = 0.05) after adjustment for age, sex and deprivation. There were 291 deaths between 2000 and 2008 (median 8 years follow-up), with no significant difference in mortality between invited and non-invited participants in 2000-2003. Compared with the non-invited group, participants who attended for screening at any time point had a significantly lower mortality and those who did not attend had a significantly higher mortality. CONCLUSIONS/INTERPRETATION: Invitation to screening was associated with a non-significant reduction in mortality in the Ely cohort between 1990 and 1999, but this was not replicated in the period 2000-2008. This study contributes to the evidence concerning the potential benefits of population screening for diabetes and related cardiovascular risk factors.

Current differences in referral patterns for pulmonary endarterectomy in the UK.

Pulmonary endarterectomy (PEA) surgery is the treatment of choice in surgically accessible chronic thromboembolic pulmonary hypertension and is potentially curative. The UK is served by seven specialist pulmonary hypertension centres and, consequently, there are regions which do not have a specialist unit. Since 2000, Papworth Hospital (Papworth Everard, UK) has been the sole PEA provider for the UK, offering the opportunity to study the national incidence of operable disease and give potential insight into factors that might affect geographical distribution within the UK. All 262 UK residents who underwent PEA surgery between April 2000 and May 2006 were included in the present study. The age-adjusted cumulative referral rates were compared between regions to test for uniformity. Overall, observed rates differed significantly from expected, with evidence of significant nonuniformity across the UK. The highest rates were observed in proximity to the nationally designated specialist centres and in particular in East Anglia and the West Midlands, nearest Papworth. These two regions differed by >2 x SD from the national mean rate. The present study demonstrates wide geographical variation in the number of patients referred for pulmonary endarterectomy surgery. This suggests that there may be patients who are not presently being offered this potentially curative option.

What happens to people diagnosed with tuberculosis? A population-based cohort.

We examined different patient outcomes following diagnosis of tuberculosis (TB). Incident cases were reported to the enhanced surveillance system in the East of England, between 2000 and 2003. For the 575 cases reported in 2001 and 2002, outcomes were assessed 1 year after initiating treatment. The crude clinical incidence rate of TB was 6.0 cases/100,000 person-years (pyr) [95% confidence interval (CI) 5.7-6.4], highest in the 25-29 years age group (14.9, 95% CI 12.9-17.1 cases/100,000 pyr) and among Black Africans (328.6, 95% CI 286.9-374.6 cases/100,000 pyr). Patients born abroad were 2.35 (95% CI 1.03-5.32) times more likely to be lost to follow-up than those born in the United Kingdom. Age at diagnosis (OR 1.05, 95% CI 1.04-1.07) and pulmonary disease (OR 2.73, 95% CI 1.21-6.15) were independently associated with mortality. Elderly patients and those with pulmonary TB appear to have worse outcomes despite treatment. Foreign-born patients may need closer follow-up to ensure favourable outcomes.

[Conservative treatment of a spontaneous splenic rupture in a patient with infectious mononucleosis]. / Conservatieve behandeling van een spontane miltruptuur bij een patiënt met de ziekte van Pfeiffer.

A 30-year-old man with flu-like symptoms for several weeks presented at the emergency room with pain in the left upper abdomen. There was no history of trauma. The patient had a spontaneous rupture of the spleen due to mononucleosis infectiosa. He was successfully treated with conservative management during a 7-day period of hospitalisation. Spontaneous splenic rupture is a rare but potentially lethal complication of infectious mononucleosis. Alarming symptoms are left upper abdominal pain, worsening during inspiration, and haemodynamic instability. Although splenectomy is the accepted treatment for haemodynamically unstable patients, some patients, may be adequately treated with conservative management. They should be observed during the critical phase and must comply to a period of restricted physical activity after they are discharged from the hospital. There is no consensus about the length or content of this restriction period.

Influence of abdominal-wound closure technique on complications after surgery: a randomised study.

BACKGROUND: Wound complications that occur after closure of midline laparotomy remain challenging. A new continuous double-loop closure (CDLC) technique was developed to avoid wound rupture through resistance to high intra-abdominal pressure and continued approximation of wound edges. We investigated the efficacy of this technique. METHODS: We randomly assigned 390 patients undergoing midline laparotomy-wound closure with the commonly used continuous running suture (CRS) technique (n=204) or with the CDLC technique (n=186). We assessed the influence of closure technique on the rate of wound and other complications, with emphasis on wound dehiscence, pulmonary complications, and death. FINDINGS: The rate of wound complications did not differ significantly between groups. Pulmonary complications were seen in 11 patients (5.4%) in the CRS group, and in 32 patients (17.2%) in the CDLC group (p=0.0002). In the CRS group, 17 (8.3%) patients died, compared with 39 (21.0%) patients in the CDLC group (p=0.0004). INTERPRETATION: The CDLC technique should not be used. The lessened compliance of the abdominal wall, which raises intra-abdominal pressure for long periods, may increase the risk of postoperative pulmonary complications and death. The ideal closure technique should combine strength to prevent wound rupture with elasticity to adapt to increased intra-abdominal pressure.

Continuous double loop closure: a new technique for repair of laparotomy wounds.

BACKGROUND: Wound dehiscence after midline laparotomy is a life threatening complication, most frequently caused by sutures cutting through the fascia. Increasing the strength of the sutured wound could prevent wound rupture. METHODS: In an experimental study in the rat, the simple continuous suture (SCS), loop suture (LS), interrupted double loop closure and continuous double loop closure (CDLC) techniques were evaluated. Dehiscence pressure and volume were measured after closing a standard laparotomy. RESULTS: Laparotomies closed with the newly developed CDLC technique could withstand by far the highest intra-abdominal pressure before dehiscence (P < 0.0002). Wounds closed with this technique remained well approximated regardless of the intra-abdominal pressure, unlike wounds closed with the frequently used SCS and LS methods. CONCLUSION: In all animals sutured with the CDLC technique the intact abdominal wall ruptured lateral to the wound at dehiscence pressure, indicating that the bursting strength of the sutured wound was higher than that of the intact abdominal wall.

Mechanical factors influencing the incidence of burst abdomen.

OBJECTIVE: To compare laparotomy closure with interrupted polyglactin 910 (Vicryl) and continuous polydioxanone (PDS II), and assess the mechanical and other factors that influenced the incidence of burst abdomen. DESIGN: Retrospective study. SETTING: University hospital, The Netherlands. SUBJECTS: A random sample of 346 patients who did not burst their abdomens, taken from the total of 3768 patients who underwent primary midline laparotomy from 1986-1990, together with the 45 (1%) from the total series who did burst their abdomens. MAIN OUTCOME MEASURES: Incidence of burst abdomen, and the association with mechanical and others risk factors. RESULTS: There were no differences in the incidence of burst abdomen between those sutured with interrupted polyglactin 910 and those sutured with continuous polydioxanone (p = 0.12). Layered closure resulted in significantly more burst abdomens than any other method of closure (p < 0.001 in each case). Postoperative wound infection (14/43, 33%, compared with 33/343 10%) and pulmonary complications (25/43, 58%, compared with 44/344, 13%) were also significantly associated with the development of burst abdomens (p < 0.001). CONCLUSIONS: A continuous, monofilament, absorbable suture should be used to close a laparotomy incision. Elastic suture material, loop sutures, an the continuous figure-of-eight technique should be investigated.

Knotting abilities of a new absorbable monofilament suture: poliglecaprone 25 (Monocryl).

OBJECTIVE: To study the mechanical knotting abilities of the new synthetic absorbable monofilament suture poliglecaprone 25 (Monocryl) compared with other absorbable suture materials. DESIGN: Experimental laboratory study. MATERIAL: Knotted loops (3/0 USP) of five synthetic absorbable sutures: Monocryl (poliglecaprone 25), PDS-2 (polydioxanone), Maxon (polyglyconate), Vicryl (polyglactin-910) and Dexon-Plus (polyglycolic acid). Three different knots were tested in a total of 150 experiments. MAIN OUTCOME MEASURES: Mean loop holding capacity (LHC) of 10 experiments, expressed in Newtons (N). RESULTS: Monofilament Maxon tied significantly more secure knots than the other sutures. Sliding knots of Monocryl (poliglecaprone 25) were similar to, and three-throw square knots were less secure than those tied with monofilament PDS-2. Braided Dexon-Plus was superior to Monocryl for sliding knots but comparable for square knots. Braided Vicryl did not differ significantly from Monocryl. CONCLUSION: The mechanical knot performance of Monocryl is identical to that of Vicryl, less than that of one other synthetic absorbable monofilament suture (Maxon) and comparable to or somewhat less than the other alternative (PDS-2). These findings, together with other characteristics such as degradation rate, should be used to define the application of Monocryl.