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The first Autocapture generation worked well with all recommended leads. The newer Autocapture generation provides a more sensitive resolution for evoked response testing and its implementation in a dual-chamber device. The purpose of the study was to evaluate the performance of the Affinity SR/DR pacemaker with the new Autocapture algorithm in combination with the small surface area pacing lead MembraneEX in 129 patients. Autocapture ventricular threshold, sensing threshold, lead impedance, evoked response (ER) and polarization signals were determined at implantation and discharge, as well as after 1 and 3 months. Autocapture recommendation rate was based on the ER sensitivity test. The median pacing threshold was 0.38, 0.50, 0.75, 0.75 V at implant, discharge, 1 and 3 months post-implant, respectively. The respective data for median lead impedance were 744, 605, 649 and 691 ohms; median sensing threshold was 12.5 mV at all visits. The median ER amplitude was 9.0, 10.1, 9.9 and 10.1 mV and the median polarization signal 0.39 mV at all visits. The frequency of recommended Autocapture activation was 98.3%, 99.2%, 98.3% and 96.2% of all patients at implant, at discharge, 1 and 3 months post-implant respectively. In conclusion, the studied pulse generator enabled, in combination with this pacing lead, in >95% of all patients activation of Autocapture.

Background: This study estimates the number of laparoscopic cholecystectomies required until improvement ceases, assesses the magnitude of such improvement, and provides some insight into the mechanism by which it takes place. Methods: Data from 500 consecutive laparoscopic cholecystectomies were analyzed from a prospective data base for number of short and long operations and operative time. Results: There was a 40% decrease (P

Injury at the time of trocar placement with the Hasson approach is rare. The cone of the Hasson cannula is wedged into the skin for an air seal, and, using fascial sutures, fastened under tension to flanges of the cannula. The shorter the fascial securing suture, the greater the tension and the more secure the air seal. Flanges for securing the fascial suture were attached to the external cannula in early Hasson cannula models. With these, much of the trocar needs to be intra-abdominal in order to shorten the suture. For lean patients, with very little distance between the anterior and posterior abdominal walls, the force required to fasten the sutures to the flanges may allow an intra-abdominal trocar to damage intervening organs. Later versions of the cannula had the flanges attached to the cone, allowing for short suture without need for intra-abdominal cannula. These models avoid the possibility of such injury. An unusually lean patient underwent laparoscopic cholecystectomy using an older Hasson cannula with flanges for the fascial securing suture attached to the cannula. Postoperative changes in vital signs and hemoglobin led to a diagnosis of intra-abdominal bleeding, and laparotomy revealed a transsected branch of the middle colic artery. Earlier Hasson cannulas, where the flanges are attached to the cannula, should be replaced with those with flanges attached to the cone.

AIMS To compare the efficacy and safety of lanoteplase, a single-bolus thrombolytic drug derived from alteplase tissue plasminogen activator, with the established accelerated alteplase regimen in patients presenting within 6 h of onset of ST elevation acute myocardial infarction. METHODS AND RESULTS 15,078 patients were recruited from 855 hospitals worldwide and randomized in a 2:1 ratio to receive either lanoteplase 120 KU. kg(-1)as a single intravenous bolus, or up to 100 mg accelerated alteplase given over 90 min. The primary end-point was all-cause mortality at 30 days and the hypothesis was that the two treatments would be equivalent. By 30 days, 6.61% of alteplase-treated patients and 6.75% lanoteplase-treated patients had died (relative risk 1.02). Total stroke occurred in 1.53% alteplase- and 1.87% lanoteplase-treated patients (ns); haemorrhagic stroke rates were 0.64% alteplase and 1.12% lanoteplase (P=0.004). The net clinical deficit of 30-day death or non-fatal disabling stroke was 7.0% and 7.2%, respectively. By 6 months, 8.8% of alteplase-treated patients and 8.7% of lanoteplase-treated patients had died. CONCLUSION Single-bolus weight-adjusted lanoteplase is an effective thrombolytic agent, equivalent to alteplase in terms of its impact on survival and with a comparable risk-benefit profile. The single-bolus regimen should shorten symptoms to treatment times and be especially convenient for emergency department or out-of-hospital administration.

Background: This study examines the contribution of increased laparoscopic skills to ambulatory management of perforated appendicitis. Methods: All 38 perforated appendicitides from 151 laparoscopic appendectomies done by one surgeon were studied and ambulatory management (discharge less than 24 hours after surgery) of the last 18 perforations reported. Results: Over 4 years, rate of attempted laparoscopic appendectomy rose from 67% to 100% for perforations. Conversion rate fell from 100% to 22%. Ileus and pain control were not problems for most laparoscopic perforations, so by the end of 1997, experience suggested these patients might be discharged within 24 hours. Ambulatory rate was 57% (conversions excluded). There were no readmissions for wound infections or postoperative abdominal abscesses. Conclusions: Increasing laparoscopic skills allows laparoscopic treatment of complicated appendicitis with a low conversion rate and no infectious complications. Over one half of these patients can be managed as outpatients without jeopardy to outcome.

This work seeks to assess the possible contribution of hospitalization to hip fractures sustained in an acute care hospital and to determine the need for hospital care for these patients at the time of the fracture. Between 1988 and 1997 there was an average of 399 falls and four in‐hospital hip fractures per year. For 14 percent, no predisposing factors for falling were noted, 38 percent of the fractures occurred within the first three days and 47 percent during the first week of hospitalization. Original admission did not seem warranted for 10 percent and 48 percent no longer required inpatient care at the time of the fracture. Most fractures occur early during hospitalization; some patients seem to have no predisposing factors for falling and about one‐half may not require hospitalization at the time, all implicating hospitalization as a causative factor.

To review the role of cost analysis in deciding whether to provide laparoscopic cholecystectomy in a remote community, cholecystectomies for Baffin Region residents were reviewed. Actual cost was calculated using known travel costs, per diem costs, and length of stay (LOS) data. Laparoscopic cost was estimated using LOS and conversion data from the literature. Between 1992 and 1995, 72 patients from the Baffin Region had a cholecystectomy, 61 in Iqaluit and 11 in Montreal. Fifty-seven and five, respectively, were suitable candidates for laparoscopic surgery. LOS was 5.6 days in Iqaluit and 3.5 in Montreal. Annual cost was $167,465 (Canadian). Comparable laparoscopic cholecystectomy cost is $45,411, an annual saving of $122,054. Even after equipment depreciation, laparoscopy provides a calculated saving of over $100,000 a year. However, even maximal decrease in bed utilization is less than 0.5 bed per day. Such small decreases do not allow staffing reduction and, thus, most of the projected savings cannot be realized in practice. Therefore, neither costs nor savings can play a supportive role in a decision to provide laparoscopic cholecystectomy in remote communities. This decision would have to be based on other considerations.

To determine the learning curve (number of operations required) to stabilize operating times and complication rates for a general surgeon doing laparoscopic inguinal hernia repair in a community practice.A prospective analysis.A 256-bed secondary-care community hospital.Ninety-eight consecutive patients booked for elective laparoscopic hernia repair on an outpatient basis.Using the transbdominal preperitoneal approach, 100 operations were carried out to repair 138 groins and a total of 164 separate hernial defects.The number of operations required to decrease operative times and complication rates to a steady level.There were no deaths. There were 5 conversions and 10 admissions, all occurring between the 1st and 46th operations. Two reoperations for reasons other than recurrence were required between the 45th and 55th operations. There were 24 other complications. Complications and surgical times began to level off after 50 operations. The 1 readmission was after the 42nd operation. There were 4 recurrences (2.9% recurrence rate), 2 in each group of 50 operations. Both groups of 2 recurrence occurred within the first 10 operations involving the use of a new stapler. Twenty-two other patients had open hernia repairs because laparoscopy was unsuitable for them.The learning curve for laparoscopic inguinal hernia repair in the hands of a general surgeon in community practice who is experienced in open herniorraphy and laparoscopic cholecystectomy is at least 50 operations.

This is a case series of 14 consecutive patients treated as outpatients for spontaneous pneumothorax (SP) (1 January 1992 to 31 December 1995) by one surgeon in a community hospital setting. The purpose of this study was to examine the appropriateness and financial implications of routine outpatient management of SP with closed tube thoracostomy and the Heimlich valve. All 14 patients reviewed were successfully managed as outpatients, although 3 required an overnight admission because of anxiety, pain, or vasovagal reaction. The routine outpatient treatment of all cases of SP not requiring definitive surgical intervention may have saved more than $16,000.00 for the hospital and an estimated $500,000.00 for the province of Ontario during the 1993-1994 fiscal year. Our findings suggest that the Heimlich valve is an appropriate alternative for the management of SP in a nonteaching community hospital setting, with benefits to the patient and to the health care system.

To determine what proportion of patients booked for elective cholecystectomy can be treated on an outpatient basis and what criteria will predict the need for hospital admission.A prospective analysis.A 306-bed, nonteaching, acute-care community hospital on the outskirts of a major urban centre.One hundred consecutive patients in private referral practice scheduled for outpatient laparoscopic surgery between November 1992 and January 1994.Laparoscopic cholecystectomy.The proportion of patients who successfully avoided hospital admission, the degree of discomfort, complications and the objective criteria that assist in predicting the need for initial or eventual hospital admission.Outpatient cholecystectomy was successful in 87% of the patients, and patient acceptance of the procedure was good. Advanced age, major associated health problems, acute cholecystitis and longer operations were the criteria most likely to lead to hospital admission, although none of these factors, alone or in combination, was a contraindication to outpatient cholecystectomy.Outpatient laparoscopic cholecystectomy can be performed successfully in most patients. There are four criteria that increase the likelihood of hospital admission after this procedure.

One hundred consecutive outpatient cholecystectomies were reviewed to determine hospital utilization. Operative time was 43 minutes and total hospital time eight hours. Fifty patients required parenteral analgesia in the recovery room and five in day surgery. Eight patients were admitted postoperatively for an average hospital stay of 2.5 days. There was one readmission, no major complications and high patient satisfaction. Outpatient cholecystectomy may be possible for 90 percent of all elective patients.

85% enterectomy or jejunal biopsy was randomly carried out on 80 male Sprague-Dawley rats, 300-350 gm. After recovery, rats in each group were randomly fed either elemental diet (ED) or rat chow. All rats were sacrificed 8 weeks postoperatively. Biopsied rats gained more weight with ED than chow (22% vs. 18%; p less than .01). Resection produced greater weight loss than biopsy (p less than .01) and slower gain (p less than .01). The failure to gain was most marked in ED rats, significantly less than in the chow group (p less than .05) by week two. A fall in hemoglobin, protein and albumin was seen: neither the fall nor difference between the groups was significant (p greater than .05). Enterectomized chow rats ate 22% more than their controls (p greater than .05). Increase in bowel length after resection, equally divided between jejunum and ileum, was 21% with ED and 26% with chow. Gut diameter after resection increased 104% and 98% with chow and ED, respectively. Villus height increased 65% in the jejunum of both enterectomized groups and 85% and 78% with chow and ED, respectively, in the ileum. Changes in gut length, diameter and villus height are significant in each group (p less than .01) but not between groups (p greater than .05).

Abdominoperineal resection to cure adenocarcinoma of the rectum was performed in 62 patients between 1965 and 1969 at the Winnipeg General Hospital. Mean age was 64, ranging from 41 to 83; 40 patients were male and 22 female. Distribution by Dukes' staging was: A, 11; B, 28; C, 23. Complications occurred in 22 patients (35%). Average hospital stay was 29 days, 27 days in uncomplicated patients and 36 days in those with complications. There were two deaths, a 3.2% operative mortality rate. Sixty of the 62 patients were available for 5-year followup. Crude survival rate was 52%: A, 91%; B, 59%; C, 25%. Two patients died of an operation that permanently cured three patients in whom disease had spread beyond local confines. Abdominoperineal resection offered a 52% 5-year survival rate, increased the rate of cures in the unstaged patient by at least 5% over that afforded by local therapy, gave a 14% chance of cure in stage C disease compared with 0% with local therapy, and, compared with local therapy, was at least 67% more likely to offer cure than to kill in the event of disease spread to regional lymph nodes.

A combination of oral and intravenous phenoxybenzamine block has been used at the University of Manitoba since 1958 in all elective operations on sympathetic amine-secreting tumors. A review of the last decade's (1965 to 1974, inclusive) experience reveals operations on 10 such patients. A preoperative diagnosis was made in eight cases, and the use of phenoxybenzamine in these eight cases is reviewed. Major fluctuations in hemodynamics during operative manipulation of tumor or following tumor removal were not observed in individuals receiving phenoxybenzamine in a dose of 1–3 mg/kg given 12 to 18 hr before operation. In those patients with high levels of catecholamine secretion, plasma volume expansion was sometimes required to sustain stable blood pressure during induction of the adrenergic blockade. However, no increased intraoperative requirements for transfusion occurred and no significant arrhythmias were detected on continuous monitoring.

All abdominoperineal resections for carcinoma of the rectum carried out 1963-1972 in two small community hospitals are reviewed. Seventy-six patients were found: males slightly outnumbered females; the average age was 61. There were 67 adenocarcinomas, 7 squamous cell carcinomas and one each of villous adenoma and carcinoid. Distribution of Dukes' classification was: A-20, B-26, C-21, D-9. In an average case the operative time was 3 hours, 25 minutes, 4 units of blood were used, and postoperative hospital stay was 30 days. Postoperative complications were recorded in over 50% of the patients with reoperation needed in 26% of all patients and delayed complications occurred in 41%. The operative mortality was 1.3%. Five year followup was possible in 40 of 43 patients; survival according to Dukes' classification was A-80%, B-53%, C-9% and D-25% with overall survival 45%.

An elemental diet was used during the adaptive phase of the short gut syndrome in 8 patients. The diet was well tolerated by the patients, and positive nitrogen balance was achieved. There was an average weight gain of 3.3 kg per month for the group. Adaptation in 4 patients was sufficient to tolerate normal food. One patient underwent major surgery which he withstood well, and eventually had intestinal continuity restored. Three patients died—2 from their disease and 1 from aspiration. The latter patient demonstrates the importance of radiographic verification of nasogastric tube position prior to diet infusion. Provided that care is taken with tube position, no serious complications with this technique are encountered. Elemental diet is a useful addition to the nutritional armamentarium in the treatment of short gut syndrome, if sufficient absorptive surface is left. In extremely short bowels, even a predigested elemental diet may not be absorbable initially, but adaptation may provide sufficient absorptive surface to allow eventual chronic use of elemental diet in preference to permanent intravenous hyperalimentation.

An elemental diet was used as the sole source of nutrition in six patients with complicated pancreatitis. The patients, unable to tolerate normal food and unsuitable for intravenous hyperalimentation, tolerated the elemental diet well with complete recovery in all but one case. Positive nitrogen balance, increase in red blood cell mass, weight gain, resolution of sepsis and ascites, and spontaneous closure of pancreatic fistulas were documented.

ObjectivesWe evaluated the relative contributions of the loading and maintenance doses of prasugrel on events in a TRITON–TIMI 38 (TRial to Assess Improvement in Therapeutic Outcomes by Optimizing Platelet InhibitioN with Prasugrel–Thrombolysis In Myocardial Infarction) analysis.BackgroundPrasugrel is superior to clopidogrel in preventing ischemic events in patients with an acute coronary syndrome who are undergoing percutaneous coronary intervention, but it is associated with an increased risk of major bleeding.MethodsLandmark analyses for efficacy, safety, and net clinical benefit were performed from randomization to day 3 and from day 3 to the end of the trial.ResultsSignificant reductions in ischemic events, including myocardial infarction, stent thrombosis, and urgent target vessel revascularization, were observed with the use of prasugrel both during the first 3 days and from 3 days to the end of the trial. Thrombolysis In Myocardial Infarction major non–coronary artery bypass graft bleeding was similar to clopidogrel during the first 3 days but was significantly greater with the use of prasugrel from 3 days to the end of the study. Net clinical benefit significantly favored prasugrel both early and late in the trial.ConclusionsBoth the loading dose and maintenance dose of prasugrel were superior to clopidogrel for the reduction of ischemic events. This result emphasizes the importance of maintaining high levels of inhibition of platelet aggregation via P2Y12 receptor inhibition, not only for the prevention of periprocedural ischemic events but also during long-term follow-up. The excess major bleeding observed with the use of prasugrel occurred predominantly during the maintenance phase. Approaches to reduce the relative excess of bleeding with prasugrel should focus on the maintenance dose (e.g., reduction in maintenance dose in previously reported high-risk subgroups, such as the elderly and those patients with low body weight). (A Comparison of CS-747 and Clopidogrel in Acute Coronary Syndrome Subjects Who Are to Undergo Percutaneous Coronary Intervention; NCT00097591)

The frequency of cholecystectomies has given the surgeon familiarity and confidence when dealing with biliary anomalies. Internal anomalies are not equally recognized, for they play little role in cholecystectomy. Recognition of internal anomalies is of prime importance, however, when the biliary tree is drained through the gallbladder. Radiographic confirmation of a patent drainage system, avoiding spillage of contrast material, should be routinely employed in these situations to obviate potentially lethal complications due to technical error.

The authors report on three patients who had a perforated sigmoid diverticulum after unrelated surgery. If the preceding operation is remote in time from the perforation, detection is relatively easy, but if the perforation occurs shortly after major abdominal surgery, its presentation may be totally masked by the postoperative state. Awareness of this possibility may help alert the clinician to the presence of perforation of a sigmoid diverticulum in unexplained postoperative collapse. Although discovery of these three cases suggests that diverticular perforation is not uncommon after surgery, a causal relationship is not known, and the authors could not find any previous reports of such a relationship.