RESUMEN
There are few published reports on outcomes of 5 or more years following laparoscopic fundoplication. Gastroesophageal reflux disease (GERD) specific quality of life questionnaires (QOLRAD), short form health surveys (SF12), and queries regarding current medication use and long-term satisfaction were mailed to all patients who underwent laparoscopic fundoplication at our institution. Results are reported as mean +/- SEM. Seventy-six patients underwent laparoscopic fundoplication (63 Nissen, 13 Toupet) between November 1992 and December 1997. Fifty-two patients completed questionnaires (68%). Mean follow-up was 5.1 +/- 0.2 years (range, 4-9 years). Mean QOLRAD scores were 5.8 +/- 0.2, (scale 0-7, a higher score reflecting improved QOL), which is comparable to the general population (6.0 mean). SF-12 mental and physical scores were 46.6 +/- 1.7 and 34.2 +/- 1.6, respectively, versus 50.7 and 51.2 for the general population. Forty-seven patients (92%) would have the procedure again. Eleven (21%) remained on antisecretory medications (15% proton pump inhibitor and 6% H2 receptor antagonists). None of the 11 patients underwent 24-hour pH testing to document persistent acid exposure. Furthermore, postoperative symptoms of heartburn, dysphagia, and abdominal bloating were rated as none to mild in the majority of patients. Laparoscopic fundoplication is an effective long-term treatment for GERD, resulting in high patient satisfaction, improved quality of life, and elimination of antisecretory medicines in the majority of patients.
Asunto(s)
Fundoplicación , Reflujo Gastroesofágico/cirugía , Laparoscopía , Adolescente , Adulto , Anciano , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Satisfacción del Paciente , Calidad de Vida , Encuestas y Cuestionarios , Resultado del TratamientoRESUMEN
BACKGROUND: The endoscopic delivery of temperature-controlled radiofrequency energy to the gastroesophageal junction (Stretta procedure) recently has been shown effective for patients with gastroesophageal reflux disease (GERD). However, its effectiveness has been assessed mainly over short periods (6-12 months). This study aimed to evaluate long-term results of the Stretta procedure. METHODS: All patients undergoing the Stretta procedure since August 2000 were prospectively evaluated under an institutional review board-approved protocol. All patients with a follow-up period longer than 18 months were recruited for a 24-h pH study and mailed a follow-up survey, which included the following: Short Form 12 (SF-12) health status questionnaire, GERD-specific quality-of-life questionnaire (QOLRAD), and queries regarding long-term satisfaction and medication use. RESULTS: The Stretta procedure was performed on 82 patients, and 41 patients with a follow-up period longer than 18 months qualified for the study. Follow-up surveys were completed by 36 patients (88%) during a mean follow-up period of 27.1 +/- 3.7 months. Of these 36 patients, 30 (83%) were highly satisfied with the procedure and would have it performed again. More than half of the Fifty Stretta patients (56%) had completely discontinued their use of proton pump inhibitors (PPIs), and an additional 31% had reduced their dose significantly. The mean PPI equivalent doses were 37.8 +/- 22.2 mg/day before the Stretta procedure and 11.6 +/- 14.6 mg/day at 27-month follow-up assessment (p = 0.001). According to the patient outcomes for daily PPI use (yes/no), the patients were divided into two groups: responders (n = 20) and nonresponders (n = 16). The responder group scored higher in QOLRAD score (p = 0.0001), SF-12 physical score (p = 0.038), and SF-12 mental score (p = 0.003). In the 24-hour pH study, the responder group demonstrated a significant decrease in distal esophageal acid exposure time (6.4% +/- 1.5% to 3.1% +/- 1.4%; p = 0.0001). CONCLUSION: The Stretta procedure results in a statistical significant long-term decrease in GERD symptoms and PPI use. The treatment effect is durable beyond 2 years, and 56% of patients had discontinued their user of all antisecretory drugs.
Asunto(s)
Ablación por Catéter/métodos , Reflujo Gastroesofágico/cirugía , Procedimientos Quirúrgicos del Sistema Digestivo/métodos , Esofagoscopía , Femenino , Estudios de Seguimiento , Gastroscopía , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Factores de TiempoRESUMEN
BACKGROUND: The surgical treatment of patients with chronic abdominal pain resulting from intraabdominal adhesions is controversial. We report our experience with treatment of this challenging patient population using laparoscopic lysis of adhesions (LOA) and placement of Seprafilm (Genzyme, Cambridge, MA, USA). METHODS: The participants in this study were 19 consecutive patients (2 men and 17 women) who underwent laparoscopic LOA and placement of Seprafilm between July 1998 and July 2001. Patients with abdominal pain resulting from irritable bowel syndrome, hernias, or endometriosis were excluded. The patients had undergone a mean of 6.4 previous abdominal procedures (range, 1-14) and 2.3 previous LOAs (range, 0-10). They had experienced chronic, intractable abdominal pain for at least 4 months (range, 4-180). Eight patients had preoperative obstructive symptoms. RESULTS: A completely laparoscopic procedure was used to treat 16 patients, whereas the procedure for 3 patients was converted to open surgery because of dense adhesions. Perioperative complications included two patients in whom enterocutaneous fistulae developed and one patient with intraabdominal hematoma. At follow-up (mean, 9.6 months; range, 1-32 months), 14 patients (73.7%) had completely discontinued all pain medications. At this writing, 12 of these patients are completely symptom free. Two patients are taking nonsteroidal antiinflammatory drugs (NSAIDs) as needed, and three patients require round-the-clock narcotics. Three patients were readmitted with small bowel obstruction, which was managed nonoperatively. One patient had diagnostic laparoscopy for recurrent pain 6 months postoperatively, but had no adhesions. CONCLUSION: Chronic intractable abdominal pain is relieved in most patients via this approach. Repeat laparoscopy in two patients showed no intraabdominal adhesions. Laparoscopic LOA and placement of Seprafilm is an excellent approach to this challenging patient population with symptoms caused by intraabdominal adhesions.
Asunto(s)
Pared Abdominal/cirugía , Materiales Biocompatibles/administración & dosificación , Membranas Artificiales , Dolor Intratable/prevención & control , Adherencias Tisulares/terapia , Adulto , Anciano , Femenino , Estudios de Seguimiento , Humanos , Ácido Hialurónico , Laparoscopía , Masculino , Persona de Mediana Edad , Dolor Intratable/etiología , Recurrencia , Reoperación , Adherencias Tisulares/complicacionesRESUMEN
A microsomal cytochrome b5 cDNA from the house fly, Musca domestica, was cloned and sequenced. The deduced amino acid sequence of the full-length house fly cytochrome b5 (134 residues) is 48% identical to that of rat microsomal cytochrome b5. The house fly cytochrome b5 protein was overexpressed in Escherichia coli, purified, and characterized. Absorption and EPR spectroscopy reveal properties very similar to cytochromes b5 from vertebrates. NMR spectra indicate that the orientation of the heme in the protein relative to its alpha,gamma meso axis is about 1:1. A redox potential of -26 mV versus standard hydrogen electrode was measured by cyclic voltammetry on a modified gold electrode in the presence of hexamminechromium(III) chloride. The cytochrome b5 is reduced by house fly cytochrome P450 reductase in a reconstituted system at a high rate (5.5 s-1), and it stimulates heptachlor epoxidation when reconstituted with house fly cytochrome P450 reductase, cytochrome P450 6A1, phospholipid, and detergent. Cytochrome b5 decreases the apparent Km for P450 reductase and increases the Vmax for heptachlor epoxidation at constant cytochrome P450 6A1 concentrations. The results indicate that cytochrome b5 stimulates a step following the first electron transfer during cytochrome P450 6A1 turnover.
Asunto(s)
Citocromos b5/genética , Dípteros/enzimología , Secuencia de Aminoácidos , Animales , Clonación Molecular , Sistema Enzimático del Citocromo P-450/metabolismo , Citocromos b5/química , Citocromos b5/metabolismo , ADN Complementario , Escherichia coli/genética , Cinética , Datos de Secuencia Molecular , Oxidación-Reducción , Proteínas Recombinantes/química , Proteínas Recombinantes/genética , Proteínas Recombinantes/metabolismo , Homología de Secuencia de Aminoácido , Análisis EspectralRESUMEN
With increasing numbers of general practitioners wishing to provide child health surveillance during the 1980s and the expected further increase with the 1990 General Practice Contract, a course in child health surveillance was developed. The content of the course was determined by a needs assessment of Welsh general practitioners in combination with the expectations of paediatricians already involved in educating doctors in community child health. A multicentre course with prepared materials was developed. Teaching methods reflected adult learning needs, included practical clinical competencies and was centred in small groups each led by local tutors. The course was held annually on three occasions, with 220 participants in total. The materials and teaching methods were highly acceptable to the participants, and evaluation demonstrated a significant increase in knowledge and confidence. All participants reached the required clinical competence, six after further teaching. The content, teaching methods, and evaluation methods were altered in the light of feedback, resulting in a 'stand alone' course with built-in evaluation, which is now being provided by local tutors. This study has demonstrated the feasibility of providing a course for large numbers of doctors, using predominantly small-group teaching and discussion with local tutors. We are grateful to all the participants and especially the tutors.
Asunto(s)
Protección a la Infancia , Educación Médica Continua/métodos , Medicina Familiar y Comunitaria/educación , Vigilancia de la Población/métodos , Niño , Curriculum , Estudios de Evaluación como Asunto , Humanos , GalesRESUMEN
The educational needs of general practitioners and other doctors wishing to provide child health surveillance are unknown. This study determines the needs of doctors prior to attending a course in child health surveillance by testing their knowledge of childhood immunization, and by self assessment of their skills and knowledge in different aspects of surveillance. A child health surveillance course must cover a core content to enable participants to reach a required standard. Assessment of educational needs allows greater emphasis and time to be given to certain aspects, thus making the course of greater educational value and more relevant to the participant.
Asunto(s)
Educación Médica Continua/normas , Medicina Familiar y Comunitaria/educación , Pediatría/educación , Medicina Preventiva/educación , Humanos , Inmunización/normas , Encuestas y Cuestionarios , GalesRESUMEN
The importance of the developmental surveillance of children is generally accepted. One method which could be used in general practice is opportunistic surveillance, where the doctor makes use of contacts with children in the surgery to assess their development, and offer advice and health education to parents where appropriate. This study describes an audit of opportunistic developmental surveillance in one general practice. It was found that 95% of a cohort of 78 children had been assessed at least once by the time they were one year old. In addition, at two points in the study, after one and two years, it was found that 81% of children aged two years or less in the practice had had a recent assessment. This level of surveillance compares favourably with reported attendance rates in clinics.
Asunto(s)
Desarrollo Infantil , Medicina Familiar y Comunitaria , Vigilancia de la Población/métodos , Adolescente , Niño , Preescolar , Estudios de Cohortes , Humanos , Lactante , Recién NacidoRESUMEN
The authors postulate that effective developmental surveillance of children, both in terms of detection of abnormalities and in maternal counselling, can be carried out by taking advantage of opportunities during ordinary consultation to identify problems and to offer advice. The results presented in this paper are part of a more detailed study in progress to compare such an opportunistic method of health surveillance with the traditional method of regular age-linked examinations provided by clinical medical officers. From a retrospective analysis of the medical records of 58 children who had reached their first birthday and who had been registered with the study practice since their birth, the authors suggest that, based upon attendance rates, opportunistic assessment of development by a general practitioner or a health visitor is more likely to encompass those children most at risk than assessment at clinics.