Prediction of calculated future cardiovascular disease by monocyte count in an asymptomatic population.

Introduction: Although atherogenesis is clearly entwined with systemic inflammation, the risk-predictive relationship between preclinical and overt cardiovascular disease (CVD) and systemic white blood cell (WBC) subtypes remains unclear. Implication of an association would greatly facilitate cardiac risk prediction, assessment and monitoring.

Methods: 1383 asymptomatic individuals (795 men, 588 women) attending for executive health screening were examined clinically as well as with phlebotomy and exercise stress testing to determine their ten-year risk of developing overt cardiovascular disease (as estimated by both Framingham and SCORE calculations).

Influence of delays on perforation risk in adults with acute appendicitis.

Purpose: This study analyzed whether prehospital or in-hospital delay was the more significant influence on perforation rates for acute appendicitis and whether any clinical feature designated patients requiring higher surgical priority.

Methods: A retrospective analysis was conducted over one year at a tertiary referral hospital without a dedicated emergency surgical theater. Admission notes, theater logbook, and the Hospital Inpatient Enquiry system were reviewed to identify the characteristics and clinical course of patients aged greater than 16 years who were operated upon for histologically confirmed acute appendicitis.

Intraoperative frozen section assessment of sentinel lymph nodes in the operative management of women with symptomatic breast cancer.

Background: Maximisation of the potential of sentinel lymph node biopsy as a minimally invasive method of axillary staging requires sensitive intraoperative pathological analysis so that rates of re-operation for lymphatic metastases are minimised. The aim of this study was to describe the test parameters of the frozen section evaluation of sentinel node biopsy for breast cancer compared to the gold standard of standard permanent pathological evaluation at our institution.

Methods: The accuracy of intraoperative frozen section (FS) of sentinel nodes was determined in 94 consecutive women undergoing surgery for clinically node negative, invasive breast cancer (37:T1 disease; 43:T2; 14:T3).

Lymphatic mapping and sentinel node biopsy in the colonic mesentery by Natural Orifice Transluminal Endoscopic Surgery (NOTES).

Introduction: Although intraluminal and transluminal techniques can achieve localized resection of early-stage alimentary tumours, they do not designate the status of the filtering mesenteric lymph nodes. Natural orifice transluminal endoscopic surgery (NOTES) may however effect sentinel node biopsy from within the peritoneum.

Methods: A transgastric NOTES technique was utilized in six pigs.

Simple adaptation of current abdominal aortic aneurysm screening programs may address all-cause cardiovascular mortality: prospective observational cohort study.

Background: Population screening for abdominal aortic aneurysm (AAA) can be cost-justified by its impact on the incidence of emergency presentations with rupture. The objective of this prospective, cohort study was to determine whether the proposed framework can be further evolved to address all-cause cardiovascular mortality in the community by integrating full risk factor assessment.

Methods: Male volunteers aged >60 years attending for AAA screening by ultrasound also underwent full cardiovascular assessment via physician-administered health questionnaire, sphygmomanometry, anthromorphometry, and fasting phlebotomy for lipid and glucose profiling.

What a signature adds to the consent process.

Background: "Consent is a process by which a patient is informed and becomes a participant in decisions regarding their medical management." It is argued, however, that providing a signature to a form adds little to the quality of this process.

Methods: Views regarding the consent ritual of nonselected patients undergoing endoscopy (cystoscopy or sigmoidoscopy) were prospectively studied together with those of the attending staff.

What's wrong with sentinel node mapping in colon cancer?

Despite near-universal embrace of the concept and clinical relevance of lymphatic mapping for sentinel node identification and analysis for cancers of the breast and integument, the same technique has struggled to a find a role in gastrointestinal cancers in general and, perhaps, in colon cancer in particular. Despite many studies demonstrating its feasibility in malignancies of the large bowel, concern is continually aroused by the variable and often unacceptably low sensitivity rates. Additionally, many confess uncertainty as to what benefit it could ever confer to patients even if it were proven sufficiently accurate given that standard surgical resection incorporates mesenteric resection anyway.

Penetrating ectopic peptic ulcer in the absence of Meckel's diverticulum ultimately presenting as small bowel obstruction.

We report here how a heterotopic penetrating peptic ulcer progressed to cause small bowel obstruction in a patient with multiple previous negative investigations. The clinical presentation, radiographic features and pathological findings of this case are described, along with the salient lessons learnt. The added value of wireless capsule endoscopy (WCE) in such circumstances is debated.

Hematochezia in a patient with liver cirrhosis.

Although commonly detectable in patients with cirrhosis, rectal varices only infrequently cause significant hematochezia (0.5-3.6%).

Postoperative phlegmasia caerulea dolens: a case report and consideration of potential iatrogenic factors.

While the haemorrhagic consequences of anti-coagulants are well and frequently described in the surgical literature, the paradoxical prothrombotic tendencies of these drugs tend to be under-recognised due, perhaps, to their clinical infrequency. However, when these effects pertain, their consequences can be devastating. Here, we present a postoperative oncology patient who suffered a massive recrudescence of his lower limb venous thrombosis immediately after discontinuation of his heparin infusion, despite seemingly being adequately anticoagulated by warfarin therapy (INR > 2.

The immunomodulatory effects of laparoscopic surgery.

Laparoscopic alternatives to conventional surgical procedures confer many advantages to patients including reduced postoperative pain, shortened convalescence and, perhaps, improved disease-related outcomes. The diminished degree of immune dysfunction apparent with these techniques may underpin these beneficial aspects. However, minimal access is accompanied by various ancillary anesthetic and mechanical associations (including the induction of a carbon dioxide pneumoperitoneum), which must be considered in addition to reduced tissue trauma when attempting to correlate cause with effect.

Primary endourologic realignment of complete posterior urethral disruption.

The management of posterior urethral disruption is controversial. Debate continues on whether primary realignment at results in a higher incidence of incontinence and impotence compared to delayed reconstruction. We report on our experience using early endoscopic realignment.

Infantile hypophosphatasia: transplantation therapy trial using bone fragments and cultured osteoblasts.

Background: Hypophosphatasia (HPP) is a rare, heritable, metabolic bone disease due to deficient activity of the tissue-nonspecific isoenzyme of alkaline phosphatase. The infantile form features severe rickets often causing death in the first year of life from respiratory complications. There is no established medical treatment.

Preoperative selection of symptomatic breast cancer patients appropriate for lymphatic mapping and sentinel node biopsy.

Background: This study examines whether preoperative ultrasound-assessed tumour diameter and diagnostic core biopsy-determined grade can be used to select those most likely to benefit from SLNB (i.e. those that are "node negative") before their definitive operation.

Contemporary management of drug-packers.

Experience with management of drug-packers (mules) is variable among different centres. However, despite a recorded increase in drug trafficking in general, as yet, no unified, clear guidelines exist to guide the medical management of those who only occasionally encounter these individuals. We describe our recent experience with this growing problem and discuss the most salient points concerning the contemporary management of body packers.

Evaluation of postoperative peritoneal adhesion formation following perioperative nicotine administration.

Purpose: The primary step in postoperative peritoneal adhesion formation involves the exudation of fibrin through permeable mesenteric capillaries. Nicotine, the most potent constituent of cigarette smoke, augments the release of vascular endothelial growth factor (VEGF), which increases vascular permeability. The objective of this study was to evaluate the effect of nicotine on postlaparotomy abdominal adhesions.

Considerations on the learning curve for laparoscopic colorectal surgery: a view from the bottom.

Introduction: Those who have surmounted the learning curve for laparoscopic colorectal resection state that considerable numbers of highly selected cases should comprise a department's early experience to ensure reliability of technique before routine implementation. The objective of this study was to determine how this advice may interrupt case flow.

Methods: Details on all colorectal operations performed in a single institution over a 4-year period were gleaned from a prospectively maintained database.

Enteric bacteria and their antigens may stimulate postoperative peritoneal adhesion formation.

Background: Intraabdominal sepsis causes exuberant inflammation, which results in dense adhesions. Translocation of enteric bacteria and/or their antigens after laparotomy may therefore also affect peritoneal healing by promoting local release of proinflammatory cytokines. Our hypothesis was that targeted counter therapy could be beneficial if such contamination was to augment postoperative adhesion formation.

The impact of the establishment of a surgical high dependency unit on management of abdominal aortic aneurysm.

Background: Our ability to maintain satisfactory levels of outcome after elective abdominal aortic aneurysm (AAA) surgery is increasingly strained by rising levels of co-morbidity in the presenting population. In this study we present a comparative outcome analysis of patients undergoing elective AAA surgery 18 months before and after the establishment of a surgical high dependency unit (HDU).

Methods: The preoperative status (ASA and POSSUM scores), operative factors and postoperative outcomes as well as duration of stay were calculated for 104 patients undergoing elective AAA repair (57 prior to the HDU opening and 47 patients afterwards).

Radiation enteropathy.

Radiation enteritis is a functional disorder of the intestine that occurs during or after a course of radiotherapy to the abdomen, pelvis or rectum. It presents in both an acute and chronic form and has sequelae that can be life threatening. As radiotherapy is now being used more than ever before in the treatment of solid organ malignancies in the abdomen and pelvis, the incidence of radiation enteropathy is likely to increase in the future.