Laparoscopic versus open total mesorectal excision: a case-control study

BACKGROUND AND AIMS

Because definitive long-term results are not yet available, the oncological safety of laparoscopic surgery for treatment of rectal cancer remains unproven. The aim of this prospective non-randomised study was to assess the feasibility and short-term outcome of laparoscopic total mesorectal excision (LTME) after 25--30 Gy preoperative radiotherapy and to compare the results with a matched-control group of open TME (OTME).

MATERIALS AND METHODS

A series of 41 patients with primary rectal cancer underwent LTME for rectal cancer and were matched with a historical control group of 41 patients who underwent OTME. Both groups received preoperative short-term radiotherapy.

RESULTS

There was no mortality in the LTME group and 2% mortality in the OTME group. The overall postoperative morbidity was 37% in the LTME group and 51% in the OTME group, including an anastomotic leakage of 9 and 14% in the LTME and OTME groups respectively. A positive circumferential margin was found in 7% of patients in the LTME group and in 12% of the patients in the OTME group.

CONCLUSION

This study shows that LTME is technically feasible and can be performed safely. We show at least a similar surgical completeness using a laparoscopic technique compared with open surgery.

Laparoscopic versus open total mesorectal excision for rectal cancer: An evaluation of the mesorectum’s macroscopic quality

BACKGROUND

Next to surgical margins, yield of lymph nodes, and length of bowel resected, macroscopic completeness of mesorectal excision may serve as another quality control of total mesorectal excision (TME). In this study, the macroscopic completeness of laparoscopic TME was evaluated.

METHODS

A series of 25 patients with rectal cancer were managed laparoscopically (LTME) and included in this study. The pathologic specimens of the LTME group were prospectively examined and matched with a historical group of resection specimens from patients who had undergone open TME (OTME). The two groups were matched for gender and type of resection (low anterior or abdominoperineal resection). Special care was given to the macroscopic judgment concerning the completeness of the mesorectum.

RESULTS

A three-grade scoring system showed no differences between the LTME and OTME groups.

CONCLUSION

The current study supports the hypothesis that oncologic resection using laparoscopic TME is feasible and adequate.

Applications of NIR spectroscopy to monitoring and analyzing the solid state during industrial crystallization processes

Fiber-optic near infrared (NIR) spectroscopy was used to investigate several key features of the polymorphic transitions observed during the crystallization and the filtration of SaC, an Active Pharmaceutical Ingredient (API) produced by Sanofi-Synthelabo. Using few samples, the spectroscopic data were calibrated to provide measurements of the polymorphic composition of the solid product which is likely to appear in two crystalline forms or in the amorphous state. Both qualitative and quantitative methods were successfully evaluated to characterize the API. The NIR spectroscopy measurement was then applied to investigate the kinetic behavior of the phase transition phenomena against various operating conditions. From the viewpoint of industrial process development several applications are presented. The effects of temperature and seed crystal habits on the rate of transition of filtration cakes are briefly investigated; and a study of the effect of residual water in the solvent on the transition occurring during filtration is more deeply analyzed. The experimental results demonstrate that highly valuable information can be provided by the NIR spectroscopy measurements, when one aims at understanding more deeply and optimizing the consequences of various and complex phenomena involved during the solid processing chain.

Pituitary deficiency following aneurysmal subarachnoid haemorrhage

OBJECTIVE

To investigate the incidence and severity of pituitary insufficiency after aneurysmal subarachnoid haemorrhage.

METHODS

Pituitary function was tested in a series of patients more than 12 months but less than 60 months after aneurysmal subarachnoid haemorrhage using a combined TRH-LHRH-arginine test and the insulin tolerance test, to elucidate possible deficits in the gonadotrophic, somatotrophic, thyreotrophic, and corticotrophic hormonal axes.

RESULTS

Of 21 patients screened, nine (43%) showed deficiencies of at least one pituitary hormone axis. Four patients had corticotrophin deficiency, one had partial growth hormone deficiency, two had severe growth hormone deficiency, and two had severe growth hormone deficiency plus corticotrophin deficiency.

CONCLUSIONS

Persistent pituitary dysfunction may be more common after aneurysmal subarachnoid haemorrhage than has so far been recognised and warrants further investigation, given the possibility that some health and neurobehavioural problems in these patients could result from hormone deficiency.

Allelic imbalance and fine mapping of the 17p13.3 subregion in sporadic breast carcinomas

Chromosome arm 17p is frequently altered in a variety of human cancers, especially in breast cancer, and allelic imbalances (AIs) in the region 17p13.1 do not always coincide with mutations in the TP53 gene. A second interval that frequently shows AIs at 17p is the chromosomal band 17p13.3. This region is suspected to harbor another tumor suppressor gene. In order to get more information concerning the pattern of AIs in 17p13.3, we performed analysis of AI of 49 breast carcinomas at 6 polymorphic loci in 17p13.3. Eighty-six percent of the tumors present AI at least at one marker in 17p13.3. Among all loci tested, the highest percentage of Al was observed at loci D17S5 (77%) and D17S1528 (72%). According to these results, a minimal region of deletion could be determined between the markers D17S28 and D17S5. Fine mapping of this region revealed that the size of the deleted region is about 100-150 kb. Furthermore, a subset of the patients shows two other areas with AI close to the markers D17S1574/D17S513 and D17S849, respectively.

Protection afforded by sickle-cell trait (Hb AS): what happens when malarial selection pressures are alleviated?

A study of reproductive outcome in Mobile, AL was conducted among a large maternal cohort with sickle-cell disease (Hb SS), sickle-cell trait (Hb AS), and no hemoglobinopathies (Hb AA). It was found that mean gravidity and live births among Hb AS women were significantly higher than among Hb AA women. These findings were surprising since it is generally held that once malarial pressure is alleviated, any reproductive advantage that might be conferred by Hb AS would disappear and fertility levels would reach levels similar to or slightly less than that of Hb AA women. A search of the literature was subsequently conducted and a large cohort study of an African-derived population was found in the United Kingdom. Results from this study also showed that parity was significantly higher among Hb AS women compared to Hb AA women. If survivorship is similar among Hb AS and Hb SS women, findings from these two studies raise doubts whether directional selection is occurring against the Rb S allele in nonmalarial environments. Balancing selection may still be occurring.

RAI1 is a novel polyglutamine encoding gene that is deleted in Smith-Magenis syndrome patients

The human chromosomal band 17p11.2 is a genetically unstable interval. It has been shown to be deleted in patients suffering from Smith-Magenis syndrome. Previous efforts of physical and transcriptional mapping in 17p11.2 and subsequent genomic sequencing of the candidate interval allowed the identification of new genes that might be responsible for the Smith-Magenis syndrome. In this report, one of these genes named RAI1, the human homologue of the mouse Rai1 gene, has been investigated for its contribution to the syndrome. Expression analysis on different human adult and fetal tissues has shown the existence of at least three splice variants. Moreover, the most interesting feature of the gene is the presence of a polymorphic CAG repeat coding for a polyglutamine stretch in the amino terminal domain of the protein.

A physical map of the human genome

The human genome is by far the largest genome to be sequenced, and its size and complexity present many challenges for sequence assembly. The International Human Genome Sequencing Consortium constructed a map of the whole genome to enable the selection of clones for sequencing and for the accurate assembly of the genome sequence. Here we report the construction of the whole-genome bacterial artificial chromosome (BAC) map and its integration with previous landmark maps and information from mapping efforts focused on specific chromosomal regions. We also describe the integration of sequence data with the map.

Differentially expressed endoderm and mesenchyme genes along the fetal rat intestine

Developmental studies have shown that morphological and functional regionalization occurring along the mammalian intestine is defined at early fetal stages and that some aspects of this patterning are dependent on epithelial-mesenchymal cell interactions. The molecular basis of these processes are largely unknown. In this study, a differential display approach was used to identify genes differentially expressed along the longitudinal axis in the intestinal endoderm and mesenchyme moieties of 14-day-old rat fetuses at a stage prior to morpho-functional differentiation of the gut. Fifty-eight genes were identified, 36 being identical or similar to known genes and 13 corresponding to ESTs or genome sequences with unknown function. Nine cDNAs could not be assigned to any previously described nucleotide sequence. The selected genes are involved in several aspects of cell physiology, including metabolic pathways, cytoskeleton organization, signal transduction, protein biosynthesis, and regulation of gene transcription.

When choosing injectable penicillin for the treatment of group A beta-hemolytic streptococcal pharyngitis, there is a less painful choice

OBJECTIVE

To determine whether injection of patients with Bicillin CR is less painful than injection with Bicillin LA. To discover if Bicillin CR with the addition of procaine, which doubles the volume, causes the injection to be less painful.

DESIGN

An experimental, double-blinded crossover design was used for this study.

SETTING

University children's and women's tertiary care emergency Department (ED) with an annual pediatric census of 22,000.

PARTICIPANTS

A convenience sample was enrolled from the student body of a large university and house staff, and employees of a 152 bed children's and women's hospital in southern Alabama. The sample size was limited to 50 participants, all of whom completed the study.

METHODS

Each participant received two penicillin injections, one Bicillin CR and one Bicillin LA, and rated the pain of the injection immediately after the injection, 1 hour after the injection and 12 hours after the injection. A visual analogue scale was the tool used for measuring the pain. The penicillin injections were randomized using a random number generator.

RESULTS

For each of the three periods, comparisons of pain were made between the Bicillin CR versus Bicillin LA injections. Bicillin LA pain score values were consistently higher for all but the 12-hour comparison. These differences were statistically significant (P < 0.008-0.002).

CONCLUSIONS

Injection of Bicillin CR with the addition of procaine to the benzathine penicillin G is statistically significantly less painful than the injection of Bicillin LA without the addition of procaine to the benzathine penicillin G, even though the Bicillin LA is one-half the volume of the Bicillin CR due to the addition of procaine to the Bicillin CR.

Physical and transcriptional mapping of the 17p13.3 region that is frequently deleted in human cancer

Studies of chromosomal losses at 17p13 have suggested the presence of at least two distinct regions for tumor suppressor genes, the TP53 region at 17p13.1 and a more distal region at 17p13.3. Within the latter region, Hypermethylated in Cancer 1 (HIC1) is located, a likely candidate for a tumor suppressor gene that has also been suggested to play a role in the pathogenesis of Miller-Diecker syndrome (MDS). However, single-gene isolation efforts have retrieved additional genes from 17p13.3 that could play a role in tumorigenesis. This indicates that the full potential of this chromosomal region with respect to disease-related genes has not yet been exhausted and that there may exist still unknown genes that contribute to tumorigenesis or to the complex MDS phenotype. To provide a basis for the systematic isolation and evaluation of such genes, we established a physical map over 1.5 Mb of 17p13.3 and assigned 29 transcriptional units within this region.

Estrogen replacement therapy is underutilized among postmenopausal women at high risk for coronary heart disease

Observational studies have found that estrogen replacement therapy (ERT) reduces the risk of coronary heart disease (CHD) in postmenopausal women. To determine the frequency of current use of ERT in an economically and racially diverse group of women at high risk for CHD, we examined the medical records of 393 women older than 40 who were admitted to the University of South Alabama Medical Center with symptoms suggestive of angina. Women in the study group were classified as African American or European American and data were examined for significant differences. Use of ERT was lower in African American women (11 of 111, 9.9%) than in European American women (26 of 152, 17.1%, odds ratio 1.9). Compared with the reported utilization of ERT in middle-class European American women, ERT is underutilized in this economically diverse group of women at high risk for coronary heart disease. In our population, European American women were twice as likely to be receiving ERT as African American women.

Improved branching ratio measurement for the decay K(0)(L) --> &mgr;(+)&mgr;(-)

We report results from Experiment 871, performed at the BNL AGS, of a measurement of the branching ratio K(0)(L)-->&mgr;(+)&mgr;(-) with respect to the CP-violating mode K(0)(L)-->pi(+)pi(-). This experiment detected over 6200 candidate &mgr;(+)&mgr;(-) events, a factor of 6 more than that seen in all previous measurements combined. The resulting branching ratio gamma(K(0)(L)-->&mgr;(+)&mgr;(-))/gamma(K(0)(L)-->pi(+)pi(-)) = (3. 474+/-0.057)x10(-6) leads to a branching fraction B(K(0)(L)-->&mgr;(+)&mgr;(-)) = (7.18+/-0.17)x10(-9), which is consistent with the current world average, and reduces the uncertainty in this decay mode by a factor of 3.

[Various dynamics of Tc-99m-tetrofosmin and Tc-99m-MIBI in a parathyroid adenoma]

Case report of a patient with hypercalcemia and suspected parathyroid adenoma. Because of a previous strumectomy a precise preoperative localization of the suspected parathyroid adenoma was demanded. Tc-99m-tetrofosmin scintigraphy in double phase technique failed to detect a parathyroid adenoma by failing to show a region of increased focal uptake with delayed washout in relation to the thyroid gland. Only comparison of the Tc-99m-tetrofosmin images with a Tc-99m-pertechnetate scan revealed a right caudal parathyroid adenoma. A double phase Tc-99m-MIBI study of the same patient was able to localize this parathyroid adenoma without the need of a corresponding Tc-99m-pertechnetate scintigraphy due to a differential washout with persistent focal uptake in the parathyroid adenoma and a progressively decreasing uptake in the thyroid tissue. This case indicates that Tc-99m-tetrofosmin is a suitable agent for parathyroid imaging only if used together with Tc-99m-pertechnetate but it seems to lack the differential washout characteritics of Tc-99m-MIBI according parathyroid gland and thyroid gland.

Pneumonia as a complication of pregnancy

OBJECTIVE

To identify risk factors for the development of antepartum pneumonia and to describe maternal and perinatal outcome in pregnant women with pneumonia.

METHODS

The study group consisted of 59 women with antepartum pneumonia. Pneumonia was defined by the presence of lower respiratory tract symptoms, radiographic findings, no other source of infection, and at least two of the following: oral temperature > or =38 degrees C, white blood cell count > or =15,000/ml, auscultatory findings, and/or positive sputum cultures. For comparison, a control group (n = 118) of pregnant women was formed by selecting the first mother who delivered immediately before and after an index study subject.

RESULTS

Mothers in the study group were significantly more likely than women in the control group to have either a history of asthma (P = 0.022) or an admission hematocrit < or =30% (P < 0.001). Women with pneumonia were also more likely to receive a tocolytic agent (P < 0.001) and/or beta-methasone to enhance fetal lung maturity (P < 0.001). In addition, study subjects delivered at an earlier mean gestational age (P = 0.002) and had infants who weighed significantly less (P = 0.003) than mothers in the control group. Multivariate analysis indicated that women with asthma or anemia had more than a five-fold increase in the risk of developing pneumonia during pregnancy (P = 0.013), and mothers with pneumonia were significantly more likely to deliver before 34 weeks gestation (P = 0.04).

CONCLUSIONS

Pneumonia during pregnancy was associated with maternal anemia and asthma. In addition, preterm labor with tocolysis and/or beta-methasone was more common in women with pneumonia, and these women were more likely to deliver preterm and have low birthweight infants compared to women without pneumonia.

Pregnancy, HLA allogeneic challenge, and implications for AIDS etiology

Because of the large HLA genetic polymorphism, a human fetus usually has several paternal HLA antigens allogeneic to its mother. The maternal gamma-immunoglobulin (IgG) antibody response to fetal HLA alloantigens is noncytotoxic and associated with local suppression of maternal cell-mediated immunity (CMI) at the maternal-fetal interface. When mother and fetus are syngeneic for most HLA antigens, an increased risk exists for a maternal anti-placental cytotoxic CMI responses, compromising fetal survival. Local suppression of maternal CMI by an anti-HLA IgG response may have evolved to protect the fetoplacental unit from a maternal CMI cytotoxic reaction against expressed developmental neoantigens. A negative aspect of this adaptive response is that infectious organisms bearing HLA-homologous alloantigens (e.g. human immunodeficiency virus type 1, HIV-1) may generate a systemic IgG response suppressing CMI. Findings are reviewed suggesting this is an etiologic factor in the acquired immune deficiency syndrome (AIDS).

High vagal tone is associated with more efficient regulation of homeostasis in low-risk human fetuses

Homeostasis is maintained primarily by the parasympathetic nervous system and is thought to provide a physiological substrate for the development of complex behaviors. This investigation was undertaken to test the hypothesis that infants with high parasympathetic tone are more efficient regulators of homeostasis than infants with low parasympathetic tone. Respiratory sinus arrhythmia (RSA) was used as a measure of parasympathetic tone, and the efficiency of homeostatic control was quantified, for each infant, by the slope (SRSA) and correlation coefficient (RRSA) of the regression line relating fluctuations in heart period and fluctuations in RSA. To test our hypothesis, we examined the relationship between RSA and both SRSA and RRSA in 34 low-risk human fetuses between 36 and 40 weeks gestation. We found that fetuses who were parasympathetic-dominated had larger SRSA and RRSA values, and hence were more efficient regulators of homeostasis, than fetuses who were sympathetic-dominated. The results of our analyses are important because they establish, very early in development, a physiological basis for the relationship between vagal tone and the development of complex behaviors.

Hospital readmission for postpartum endometritis

This study identified risk factors associated with readmission for postpartum endometritis. The study group consisted of 109 mothers (Group I) who were discharged after delivery and readmitted with endometritis. Control groups consisted of women who had endometritis immediately after delivery but who did not require readmission (Group II, n = 109), and women who had no intrapartum or puerperal infection and also were not readmitted (Group III, n = 109). Subjects in Groups II and III were matched to an index study subject for date of delivery and maternal age, race, and parity; and women in Groups I and III were also matched for route of delivery. Groups were compared in terms of demographic characteristics, intrapartum course, and clinical presentation. The data were analyzed with the t-test, chi2, and multiple logistic regression analyses, and a P value < .05 was considered significant. Women in Groups I and III delivered vaginally more often than mothers in Group II. In addition, mothers in Groups I and III had similar postpartum courses, no evidence of infection on discharge after delivery, and a similar period from delivery until postpartum discharge. Although women in Group I were more likely to have spontaneous rupture of membranes, a shorter latent period, and have fewer bilateral tubal ligations than mothers in Group II, multivariate analysis identified route of delivery as the only significant maternal variable associated with postpartum endometritis requiring readmission. Women who were readmitted for endometritis usually delivered vaginally, and the occurrence of late-onset postpartum endometritis was unrelated to the length of stay following delivery.

Methods used to diagnose premature rupture of membranes: a national survey of 812 obstetric nurses

OBJECTIVE

To identify methods used to diagnose premature rupture of membranes (PROM).

METHODS

A 14-item questionnaire was mailed to 1992 registered nurses certified in inpatient obstetrics to determine information on practice facility, obstetric services, procedures used to obtain vaginal fluids for testing, and methods used to diagnose PROM.

RESULTS

A total of 812 (40.8%) surveys were available for analysis. Of tests used to confirm PROM, observation of pooling fluid in the posterior fornix and fern tests were much more likely to be used in teaching and military hospitals and in facilities with tertiary obstetric services than in private hospitals (all P values < .001). To obtain vaginal fluids for fern and nitrazine testing, the dry glove method (ie, insertion of a gloved hand or nitrazine strip into the vagina) was used significantly more often in private hospitals than in teaching or military facilities (P < .001). In addition, the dry glove method was used significantly more often (P < .001) and the speculum examination was used less often (P < .001) to collect vaginal fluids for testing when private physicians performed more than 75% of deliveries at a particular hospital. In contrast, vaginal fluid was obtained during a sterile speculum examination more often in facilities in which more than 75% of deliveries were performed by residents (P < .001), and/or when more than 75% of speculum examinations were performed by nursing personnel (P < .001). Multiple linear regression analyses indicated that observation of pooling fluid and use of the fern test were significantly associated with hospital type, percentage of deliveries by private physicians, and percentage of speculum examinations performed by nursing personnel (all P values < .001).

CONCLUSION

A sterile speculum examination is used more often to obtain vaginal fluids for testing and to diagnose ruptured membranes in teaching or military facilities and when nursing personnel have been trained in speculum examinations.