Minimally invasive surgery for achalasia: a 10-year experience

Minimally invasive esophagomyotomy for achalasia has become the preferred surgical treatment; the employment of a concomitant fundoplication with the myotomy is controversial. Here we report a retrospective analysis of 53 patients with achalasia treated with laparoscopic Heller myotomy; fundoplication was used in all patients except one, and 48 of the fundoplications were complete (floppy Nissen). There were no deaths or reoperations, and minor complications occurred in three patients. Good-to-excellent long-term results were obtained in 92% of the subjects (median follow-up 3 years). Two cases (4%) of persistent postoperative dysphagia were documented, one of which was treated with dilatation. Postoperative reflux occurred in five patients, four of whom did not receive a complete fundoplication; these patients were well controlled with medical therapy. We suggest that esophageal achalasia may be successfully treated with laparoscopic Heller myotomy and floppy Nissen fundoplication with an acceptable rate of postoperative dysphagia.

Evaluation of specialized laparoscopic suturing and tying devices

BACKGROUND

Laparoscopic suturing and tying constitute advanced minimally invasive surgery skills. Developing proficiency in the standard methods with needle drivers is often an arduous process. Recent advances in laparoscopic instrumentations has allowed for easier methods of suturing and tying. This study investigated the hypothesis that the use of a specialized suturing device and a specialized tying device allows inexperienced medical students to suture and tie laparoscopically.

METHODS

Preclinical medical students who had not received any training in open or laparoscopic surgery were included in this investigation. Each student was given a 5-minute demonstration of a specialized suturing device and a specialized tying device. The medical students were not allowed to deploy either device before actual use. After the demonstration, each student was given the device to use in a porcine model. Times were recorded and a subjective grade was given for each student.

RESULTS

Twenty medical students were involved in this study. All medical students were able to complete the task of suturing and tying. The average time to suture was 104.6 seconds and the average time to tying was 31.2 seconds. The average subjective performance grade was 90 (out of 100).

CONCLUSION

Specialized devices are easy to learn and use for laparoscopic suturing and tying with minimal instruction even for inexperienced medical students. Even surgeons who are not well versed in laparoscopic surgery should be able to suture and tie with certain laparoscopic instruments.

Laparoscopic wedge resection of gastric leiomyoma

Gastric leiomyoma is a relatively rare gastric neoplasm. Before the routine use of laparoscopy, various methods of treatment for gastric leiomyoma included open celiotomy with gastric wedge resection, partial gastrectomy, enucleation, and extended gastrectomy with en bloc resection of adjacent organs. Below, we describe a case of laparoscopic wedge resection and review the various laparoscopic techniques for the treatment of gastric leiomyoma.

Higher production of IL-8 in visceral vs. subcutaneous adipose tissue. Implication of nonadipose cells in adipose tissue

IL-8 is released from human adipose tissue. Circulating IL-8 is increased in obese compared with lean subjects and is associated with measures of insulin resistance, development of atherosclerosis, and cardiovascular disease. We studied 1) the production and release of IL-8 in vitro from paired samples of subcutaneous (SAT) and visceral (VAT) adipose tissue and 2) the production of IL-8 from whole adipose tissue, isolated adipocytes, and nonfat cells of adipose tissue. IL-8 release from VAT was fourfold higher than from SAT (P < 0.05), and IL-8 mRNA was twofold higher in VAT compared with SAT (P < 0.01). Dexamethasone (50 nM) attenuated IL-8 production by 50% (P < 0.05), and IL-1beta (2 microg/l) increased IL-8 production up to 15-fold (P < 0.001). IL-8 release from whole SAT explants correlated with body mass index (BMI; r = 0.78; P < 0.001), as did IL-8 release from nonfat cells (r = 0.79; P < 0.001). However, no correlation was found between IL-8 release from the fraction of isolated adipocytes and BMI (r = 0.01). In conclusion, we demonstrated an increased release of IL-8 from VAT compared with SAT. Furthermore, our data suggest that the observed elevation in circulating levels of IL-8 in obese subjects is due primarily to the release of IL-8 from nonfat cells from adipose tissue. The high levels of IL-8 release from human adipose tissue and accumulation of this tissue in obese subjects may account for some of the increase in circulating IL-8 observed in obesity.

Assessment of individual hand performance in box trainers compared to virtual reality trainers

Training residents in laparoscopic skills is ideally initiated in an inanimate laboratory with both box trainers and virtual reality trainers. Virtual reality trainers have the ability to score individual hand performance although they are expensive. Here we compared the ability to assess dominant and nondominant hand performance in box trainers with virtual reality trainers. Medical students without laparoscopic experience were utilized in this study (n = 16). Each student performed tasks on the LTS 2000, an inanimate box trainer (placing pegs with both hands and transferring pegs from one hand to another), as well as a task on the MIST-VR, a virtual reality trainer (grasping a virtual object and placing it in a virtual receptable with alternating hands). A surgeon scored students for the inanimate box trainer exercises (time and errors) while the MIST-VR scored students (time, economy of movements, and errors for each hand). Statistical analysis included Pearson correlations. Errors and time for the one-handed tasks on the box trainer did not correlate with errors, time, or economy measured for each hand by the MIST-VR (r = 0.01 to 0.30; P = NS). Total errors on the virtual reality trainer did correlate with errors on transferring pege (r = 0.61; P < 0.05). Economy and time of both dominant and nondominant hand from the MIST-VR correlated with time of transferring pegs in the box trainer (r = 0.53 to 0.77; P < 0.05). While individual hand assessment by the box trainer during 2-handed tasks was related to assessment by the virtual reality trainer, individual hand assessment during 1-handed tasks did not correlate with the virtual reality trainer. Virtual reality trainers, such as the MIST-VR, allow assessment of individual hand skills which may lead to improved laparoscopic skill acquisition. It is difficult to assess individual hand performance with box trainers alone.

Assessment of Individual Hand Performance in Box Trainers Compared to Virtual Reality Trainers

Training residents in laparoscopic skills is ideally initiated in an inanimate laboratory with both box trainers and virtual reality trainers. Virtual reality trainers have the ability to score individual hand performance although they are expensive. Here we compared the ability to assess dominant and nondominant hand performance in box.trainers with virtual reality trainers. Medical students without laparoscopic experience were utilized in this study (n = 16). Each student performed tasks on the LTS 2000, an inanimate box trainer (placing pegs with both hands and transferring pegs from one hand to another), as well as a task on the MIST-VR, a virtual reality trainer (grasping a virtual object and placing it in a virtual receptable with alternating hands). A surgeon scored students for the inanimate box trainer exercises (time and errors) while the MIST-VR scored students (time, economy of movements, and errors for each hand). Statistical analysis included Pearson correlations. Errors and time for the one-handed tasks on the box trainer did not correlate with errors, time, or economy measured for each hand by the MIST-VR (r = 0.01 to 0.30; P = NS). Total errors on the virtual reality trainer did correlate with errors on transferring pege (r = 0.61; P < 0.05). Economy and time of both dominant and nondominant hand from the MIST-VR correlated with time of transferring pegs in the box trainer (r = 0.53 to 0.77; P < 0.05). While individual hand assessment by the box trainer during 2-handed tasks was related to assessment by the virtual reality trainer, individual hand assessment during 1-handed tasks did not correlate with the virtual reality trainer. Virtual reality trainers, such as the MIST-VR, allow assessment of individual hand skills which may lead to improved laparoscopic skill acquisition. It is difficult to assess individual hand performance with box trainers alone.

Expression of fibroblast growth factor-2 (FGF-2) in early stages (days 3-11) of the development of the avian lung, Gallus gallus variant domesticus: an immunocytochemical study

In the avian lung, the bronchial system forms from epithelial (endodermal) cells. The intrapulmonary primary bronchus is the focal point of airway development. It originates secondary bronchi (SB) along its proximal-distal extent and parabronchi (tertiary bronchi) arise from and connect the SB. From as early as day 3.5, fibroblast growth factor-2 (FGF-2) is diffusely expressed in the epithelial and mesenchymal cells. Up-regulation of FGF-2 in discrete areas of the developing lung seem to set the growth rate, trajectories followed, areas appropriated, three-dimensional symmetry and coupling of the airways. Expressed early in development and persisting into the incubation period, FGF-2 may be involved in the formation of the avian lung. Morphogenetic differences between the avian and the mammalian lungs may explain the existing structural contrarieties.

Physicians-in-training recommendations for prophylactic bilateral mastectomies

The decision to recommend bilateral prophylactic mastectomy (PBM), one treatment modality used to reduce the development of breast carcinoma, may be influenced by physician bias. This investigation tested the hypothesis that there are physician-in-training biases in recommendations of PBM. All second-year medical students, general surgical residents, and internal medicine residents at our institution participated in a survey in which they were asked at what percent risk of developing breast carcinoma the physicians-in-training would recommend PBM for 1) their patients, 2) themselves, and 3) their significant others, as applicable. A total of 198 physicians-in-training responded. Univariate analysis demonstrated an association between both the type of physician-in-training (p<0.03) and gender (p<0.004) with the percent risk for which respondents would recommend PBM. However, with multivariate analysis, only gender was associated with percent risk (p<0.05). Physicians-in-training also chose PBM at a lower risk for their significant others than for themselves (67.5% versus 57.2%; p<0.02). Respondents also chose PBM at a similar risk for themselves or significant others as for their patients (r=0.83, r=0.98; p<0.001). This investigation suggests that males (compared to females) are more likely to recommend PBM for the prevention of breast cancer.

Selective use of esophageal manometry and 24-Hour pH monitoring before laparoscopic fundoplication

BACKGROUND

Preoperative esophageal manometry and 24-hour pH monitoring commonly are used in preoperative evaluation of patients undergoing fundoplication. Here we review our experience with the selective preoperative workup of patients undergoing fundoplication to treat gastroesophageal reflux disease.

STUDY DESIGN

A series of 628 consecutive antireflux procedures was reviewed. History and physical examination, upper endoscopy, and upper gastrointestinal videofluoroscopy were obtained preoperatively on all patients; the first 30 patients also underwent esophageal manometry and pH monitoring (routine evaluation group). Thereafter, pH monitoring only was performed for atypical reflux symptoms, and manometry only was performed for a history of dysphagia, odynophagia, or for abnormal motility on videofluoroscopy (selective evaluation group). All patients underwent a laparoscopic floppy Nissen fundoplication, and then endoscopy and fluoroscopy at 3 months and 12 months postoperatively.

RESULTS

Eighty-five of the patients in the selective evaluation group (14%) required manometry, and 88 (15%) underwent pH monitoring. Eighteen of the 115 patients who underwent manometry (16%) had evidence of dysmotility. None of these 18 patients had increased dysphagia postoperatively; 8 of 18 reported improvement with swallowing. Five patients in the selective group (0.8%) had persistent postoperative dysphagia caused by technical error (four patients) or with no identifiable cause (one patient). The estimated charge or collection reduction with use of the selective evaluation was 1,253,100 US dollars or 395,000 US dollars, respectively.

CONCLUSIONS

Selective use of manometry and pH monitoring was cost effective and safe in this series. Although esophageal manometry and 24-hour pH monitoring might be necessary with abnormal findings on videofluoroscopy or atypical symptoms, in our experience, their routine use is not essential in preoperative evaluation of patients undergoing fundoplication for gastroesophageal reflux disease.

Effect of a short structured session on medical student breast cancer screening knowledge

Formalized instruction in breast cancer screening during medical school may help improve early breast cancer detection and survival. Physicians-in-training must be proficient in skills relating to breast cancer screening. This study investigates the baseline breast cancer screening knowledge of medical students, the benefit of a structured lecture session, and its effect on improving medical students' knowledge of cancer screening. A self-administrated questionnaire relating to breast cancer screening was given to third-year medical students. A 60-minute structured lecture session was given to the medical students regarding breast cancer screening. A postintervention survey was administered immediately following the session. A total of 27 medical students were evaluated. There was a statistically significant improvement following the formalized teaching session (84% to 93%; p < 0.0016). While few students (15%) reported having previous instruction in cancer screening, most students (96%) felt that a formal session should be offered during medical school. While medical student knowledge of breast cancer screening may be adequate, formalized instruction in breast cancer health practices can improve medical student knowledge. Most students had limited previous instruction in breast cancer prevention and welcomed the opportunity for structured training in breast cancer prevention, education, and detection. Until a formal course becomes a fundamental aspect of medical education, a short structured session should be instituted.

Complete femoral artery transection from blunt trauma

Complete common femoral artery transection from blunt trauma without bony injury is a rare event. Below we report upon a young cyclist who sustained complete transection of the common femoral artery following blunt trauma. The patient was managed successfully by graft repair of the transected artery. This case report highlights the importance of prompt recognition and repair of this unusual injury as well as the relationship of the injury to a previously described pattern known as motor-scooter-handlebar syndrome.

The quality of information about laparoscopic bariatric surgery on the Internet

BACKGROUND

Although easy access to the Internet can provide much information for patients, the quality and accuracy of information are uncertain. This investigation evaluated information concerning laparoscopic bariatric surgery available via the Internet.

METHODS

Searches on the six most popular search engines and two metasearch engines were performed. The first 20 "hits" for each separate search were included in the study.

RESULTS

A total of 602 "hits" were found. Only 119 unique Web sites were found. Although 63 of the 119 sites discussed some procedure related to laparoscopic obesity surgery, 18 of the 63 had biased or misleading information, 30 did not discuss the details of the procedure, 37 did not discuss other procedures, 30 did not discuss complications, 37 did not discuss death as a risk, and 7 did not discuss laparoscopic procedure as an option. Only 89 of the original 602 "hits" led to Web sites that discussed laparoscopic obesity surgery, details of the procedure, and complications in an unbiased manner.

CONCLUSIONS

A large amount of information is available via the Internet. However, it is difficult for the patient to identify the unbiased information. The Internet is not a dependable source of information for patients.

Surgical cricothyroidotomy in trauma patients

BACKGROUND

Surgical airway intervention is occasionally necessary due to contraindicated or failed endotracheal intubation. In cricothyroidotomy patients, a choice exists between continued long-term ventilation via the cricothyroidotomy portal or conversion to tracheostomy. We examined whether conversion to tracheostomy reduces the risk of acute complications.

METHODS

We retrospectively identified 46 patients with cricothyroidotomies performed at our level I trauma center over a 63-month period. We reviewed the success rate, indications, etiology, and complications.

RESULTS

An airway was obtained in all cases. The most common indicator for surgical airway intervention was unsuccessful endotracheal intubation. The cause of death among nonsurvivors was not due to airway complications. Of the 15 surviving patients, 8 had conversions to tracheostomy and 7 patients did not have conversions but had decannulations. The converted group had a greater percentage of acute complications than the nonconverted group.

CONCLUSION

Rate of acute complications with prolonged ventilation via cricothyroidotomy portal is equal to, if not lower than, via converted tracheostomy. Cricothyroidotomy in trauma patients may be used long term without any increase in acute complications.

Synchronous Occurrence of Glioblastoma Multiforme and Esophageal Adenocarcinoma

Synchronous malignancies are rare occurrences for which there may be a genetic link between two cancers or which may be simply coincidental. Although glioblastoma multiforme and esophageal adenocarcinoma have few clinical similarities there are no known biochemical or genetic links between the two malignancies. This case discussion details the synchronous occurrences of these two lesions and highlights possible clinical, biochemical, and genetic commonalities.

Synchronous occurrence of glioblastoma multiforme and esophageal adenocarcinoma

Synchronous malignancies are rare occurrences for which there may be a genetic link between two cancers or which may be simply coincidental. Although glioblastoma multiforme and esophageal adenocarcinoma have few clinical similarities there are no known biochemical or genetic links between the two malignancies. This case discussion details the synchronous occurrences of these two lesions and highlights possible clinical, biochemical, and genetic commonalities.

Laparoscopic Repair of a Recurrent Chronic Traumatic Diaphragmatic Hernia

Traditionally the approach to a long-standing traumatic diaphragmatic hernia has been a closure of the diaphragmatic defect via a thoracotomy. The evolution of minimally invasive surgery has allowed surgeons to challenge many of the traditional approaches. Herein we describe the first reported case of laparoscopic repair of recurrent chronic traumatic diaphragmatic hernia as well as review the current literature on minimally invasive surgery for traumatic diaphragmatic hernia. With proper advanced laparoscopic skills and techniques laparoscopic diaphragmatic herniorrhaphy for a chronic and recurrent defect is a safe and viable option.

Laparoscopic repair of a recurrent chronic traumatic diaphragmatic hernia

Traditionally the approach to a long-standing traumatic diaphragmatic hernia has been a closure of the diaphragmatic defect via a thoracotomy. The evolution of minimally invasive surgery has allowed surgeons to challenge many of the traditional approaches. Herein we describe the first reported case of laparoscopic repair of recurrent chronic traumatic diaphragmatic hernia as well as review the current literature on minimally invasive surgery for traumatic diaphragmatic hernia. With proper advanced laparoscopic skills and techniques laparoscopic diaphragmatic herniorrhaphy for a chronic and recurrent defect is a safe and viable option.

Pneumomediastinum as a complication of preperitoneal laparoscopic herniorrhaphy

BACKGROUND

As new approaches to herniorrhaphy are popularized, new complications are being encountered. Pneumomediastinum is one such complication.

METHODS

We present a patient who developed pneumomediastinum after an elective bilateral preperitoneal laparoscopic hernia repair.

RESULTS

The patient was observed and discharged 24 hours later with no permanent sequelae.

CONCLUSION

Pneumomediastinum is a rare complication of laparoscopic hernia repair.

Predicting acyl-coenzyme A: cholesterol O-acyltransferase inhibitory activity: computational approach using topological descriptors

Relationship between the topological indices and acyl-coenzyme A:cholesterol O-acyltransferase (ACAT) inhibitory activity of (aminosulfonyl)ureas has been investigated. Three topological indices, Wiener's index--a distance-based topological descriptor, molecular connectivity index--an adjacency-based topological index, and eccentric connectivity index--an adjacency-cum-distance-based topological descriptor, were used for the present investigations. A data set comprising 41 analogues of substituted (aminosulfonyl)ureas was selected for the present studies. The values of wiener's index, eccentric connectivity index, and molecular connectivity index for each of the 41 compounds comprising the data set were computed using an in-house computer program. Resultant data were analyzed and suitable models were developed after identification of active ranges. Subsequently, a biological activity was assigned to each compound using these models, which was then compared with the reported in vitro ACAT inhibitory activity. Accuracy of prediction using these models was found to vary from a minimum of approximately 83% to a maximum of approximately 91%.

Education of medical students in clinical breast examination during surgical clerkship

BACKGROUND

Medical student training in clinical breast examination is deficient at most medical schools. The use of silicone breast models may allow the education of abnormal and normal findings. This study examines the efficacy of silicone breast models to educate medical students in clinical breast examinations during their third-year surgical rotation.

METHODS

Medical students were randomly selected to participate in formalized training sessions in clinical breast examination or as a control group. Presession and postsession testing with silicone breast models were performed. True positives (masses that were present and documented by the student) and false positives (masses that were not present but were documented by the student) were recorded.

RESULTS

Medical students undergoing the training sessions demonstrated improved true positive scores (2.2 to 2.8; P <0.05) as well as improved false positive scores (3.0 to 2.0; P = 0.30) and total scores (-0.8 to 0.8; P = 0.07). Students who documented an increase in the number of breast examinations during their rotations had statistically lower false positive scores.

CONCLUSIONS

Students after formalized clinical breast examination sessions do improve their ability to detect breast masses, although they continue to detect masses that are not present. Experience of actual breast examinations during their surgical rotations may refine their clinical skills.

Gastric emptying time, not enterogastric reflux, is related to symptoms after upper gastrointestinal/biliary surgery

BACKGROUND

It has been suggested that symptoms from bile reflux gastritis are related to the frequency and degree of enterogastric reflux (EGR).

METHODS

Patients with history of upper gastrointestinal surgery or cholecystectomy as well as control patients were studied. Presence of EGR, degree of EGR, and gastric bile emptying time were assessed and quantified via 99mTC scintillation imaging and then compared between symptomatic and asymptomatic patients.

RESULTS

Patients with vagotomy and pyloroplasty, Billroth I, Billroth II, and cholecystectomy demonstrated statistically higher degrees of EGR compared with controls. Although asymptomatic and symptomatic patients with a history of upper gastrointestinal or biliary surgery demonstrated no statistically significant differences between incidence of EGR and degree of EGR, there was a statistically significant difference in gastric emptying time.

CONCLUSIONS

Delayed gastric emptying time, not frequency or extent of EGR, was associated with the symptoms of bile reflux in patients who had previous upper gastrointestinal or biliary operations.

Gastrointestinal metastasis to the breast

BACKGROUND

Although primary breast cancer is common, metastatic disease to the breast, especially primary gastrointestinal cancer, is rare. Routine pathologic examination may be helpful in determining the true diagnosis, but can be misleading.

METHODS

To determine whether a signet ring carcinoma was a primary malignancy of the gastrointestinal tract metastatic to the breast or vice versa, histochemical analysis was performed for Her-2/NEU, gross cystic disease fluid protein-15, estrogen receptor, progesterone, carcinoembryonic antigen, cytokeratin 7, and cytokeratin 20.

RESULTS

Positive staining for carcinoembryonic antigen and cytokeratin 20 (and negative staining for the breast cancer antigens), and the clinical criteria favors the diagnosis of gastrointestinal carcinoma metastatic to the mammary gland.

CONCLUSIONS

Because the prognosis of therapy for metastatic cancer to the breast differs from that of primary breast cancer, it is imperative that the correct diagnosis be established. Immunohistochemistry for carcinoembryonic antigen and cytokeratin 20 are particularly useful. Metastatic gastrointestinal carcinoma to the breast is a rare lesion but needs to be at least included in the differential diagnosis of breast masses, especially in patients with a history of gastrointestinal cancer.

Self-reported differences in daily raw vegetable intake by ethnicity in a breast screening program

PURPOSE

While the literature has no conclusive causal relationship between nutrition and breast cancer, diet is believed to play a role in the development of breast cancer. This investigation focuses on differences of dietary practice between Caucasians and African Americans in a cohort of women presenting for breast cancer screening.

METHODS

Over a one-year period, 675 women presenting to the Breast Health Center at Tulane University Medical Center for an initial visit were given a self-reported health behavior questionnaire. Included in this survey were questions concerning the frequency of raw vegetable consumption and fat/oil intake.

MAIN FINDINGS

The overall proportion of women who presented for breast cancer screening that reported daily raw vegetable consumption in the study group was 40%. There were statistically significant differences between proportions of Caucasian women's and African American women's consumption of daily raw vegetable (51% versus 29%, respectively; P < 0.0001). These differences were not seen in daily fat/oil intake. No differences were seen in socioeconomic measures.

CONCLUSIONS

There is a substantial difference in the consumption of potentially protective foods among major ethnic groups. These dietary differences should be taken into account when investigating the ethnic differences in women with breast cancer, as well as the relationship between breast cancer and nutrition.

Laparoscopic omental-cerebellar pedicled graft harvest

The minimally invasive technique has altered our approach to many surgical diseases. Laparoscopic surgery is performed on a variety of abdominal organs. One such organ, the omentum, traditionally has been harvested via a laparotomy. The omental harvest now has been attempted successfully laparoscopically, although usually for reconstructive efforts. Here we describe the first case of a laparoscopic omental-cerebellar pedicled graft harvest.

Dialysis Access-Induced Superior Vena Cava Syndrome

Vascular thrombosis is a complication of dialysis access and thrombosis of the superior vena cava by indwelling dialysis catheters access can cause superior vena cava syndrome. We describe a case of superior vena cava syndrome resulting from a dialysis access catheter placed in the internal jugular vein. Although surgical intervention is often needed to treat dialysis access-related superior vena cava syndrome this patient required only conservative measures for resolution of the syndrome. In this paper we describe the presentation, diagnosis, and management of this case. A review of dialysis access thrombosis complications and treatment options is also presented.

Dialysis access-induced superior vena cava syndrome

Vascular thrombosis is a complication of dialysis access and thrombosis of the superior vena cava by indwelling dialysis catheters access can cause superior vena cava syndrome. We describe a case of superior vena cava syndrome resulting from a dialysis access catheter placed in the internal jugular vein. Although surgical intervention is often needed to treat dialysis access-related superior vena cava syndrome this patient required only conservative measures for resolution of the syndrome. In this paper we describe the presentation, diagnosis, and management of this case. A review of dialysis access thrombosis complications and treatment options is also presented.

Predicting anticonvulsant activity of benzamides/benzylamines: computational approach using topological descriptors

The relationship of Wiener's index (a distance-based topological descriptor), Zagreb group parameter (an adjacency-based topological descriptor) and eccentric connectivity index (an adjacency-cum-distance-based topological descriptor) with the anticonvulsant activity of a series of substituted benazamides/benzylamines has been investigated. A training set comprising 41 analogues of substituted benazamides/benzylamines was selected for the present investigations. The values of the Wiener's index, Zagreb group parameter and eccentric connectivity index and of each of 41 analogues comprising the data set were computed and active ranges were identified. Subsequently, a biological activity was assigned to each analogue involved in the data set which was then compared with the reported anticonvulsant activity. An exceptionally high accuracy of predictions ranging from a minimum of approximately 88% for the Zagreb group parameter to a maximum of approximately 97% for Wiener's index were obtained.

A prospective, randomized trial of laparoscopic polytetrafluoroethylene (PTFE) patch repair vs simple cruroplasty for large hiatal hernia

HYPOTHESIS

Large hiatal hernias are prone to disruption, resulting in reherniation, when repaired with simple cruroplasty. The use of mesh may decrease the rate of reherniation in the laparoscopic repair of large hiatal hernias.

DESIGN

Prospective, randomized controlled trial.

SETTING

University-affiliated private hospital.

PATIENTS

Seventy-two individuals undergoing laparoscopic Nissen fundoplication with a hernia defect greater or equal to 8 cm in diameter.

INTERVENTION

Nissen fundoplication with posterior cruroplasty (n = 36) vs Nissen fundoplication with posterior cruroplasty and onlay of polytetrafluoroethylene (PTFE) mesh (n = 36).

MAIN OUTCOME MEASURES

Recurrences, complications, hospital stay, operative time, and cost.

RESULTS

Patients in both groups had similar hospital stays, but the PTFE group had a longer operative time. The cost of the repair was $960 +/- $70 more in the group with the prosthesis. Complications were minor and similar in both groups. There were 8 hernia recurrences (22%) in the primary repair group and none in the PTFE group (P<.006).

CONCLUSION

The use of prosthetic reinforcement of cruroplasty in large hiatal hernias may prevent hernia recurrences.

Expression of PH-20 in normal and neoplastic breast tissue

BACKGROUND

Tumor metastasis involves a sequence of interrelated steps, of which penetration beyond the basement membrane is an essential component. Hyaluronic acid (HA) is a major structural component of the complex proteoglycans found in extracellular matrices and basement membranes. Hyaluronidase (PH-20) degrades HA, resulting in the disruption of basement membrane integrity and possible tumor dissemination.

MATERIALS AND METHODS

Total RNA was extracted from samples (n = 51) of normal breast tissue (n = 12), ductal carcinoma in situ (DCIS) (n = 12), infiltrating ductal breast adenocarcinoma (n = 13), and metastatic breast cancer to lymph nodes (n = 14). RT-PCR was used to determine the relative level of PH-20 in each specimen.

RESULTS

PH-20 was detected in 41/51 (80.4%) of the specimens evaluated. PH-20 was present in 12/12 (100%) normal breast tissues; 8/12 (66.7%) DCIS; 13/13 (100%) invasive breast cancers; and 8/14 (57.1%) metastases. Of those specimens in which PH-20 was detected, there were increased levels of PH-20 in metastatic breast cancer to lymph nodes compared to DCIS and invasive breast cancer. Stratification of specimen by race revealed that African American women had higher levels of PH-20 with invasive and metastatic beast cancer.

CONCLUSIONS

Increased levels of PH-20 are noted in invasive and metastatic breast cancer compared to DCIS. Tumors from African American women with invasive and metastatic breast cancer demonstrated higher levels of PH-20 than Caucasians. Varying levels of PH-20 in mammary tissue may contribute to early invasion and metastasis of breast cancer.

How early is early laparoscopic treatment of acute cholecystitis?

BACKGROUND

Despite the well-accepted success of laparoscopic cholecystectomy in elective treatment of symptomatic cholelithiasis, the efficacy and timing of this technique has been subject to some debate in the setting of acute cholecystitis. This study was undertaken to evaluate our institution's experience with early cholecystectomy as a safe, effective treatment of acute cholecystitis.

METHODS

Charts of all patients who had undergone laparoscopic cholecystectomy for the diagnosis of acute cholecystitis were reviewed. Patients were divided into two groups based on the length of time from onset of symptoms to surgical intervention: less than 48 hours in the early group (n = 14) and more than 48 hours in the late group (n = 31).

RESULTS

Comparing the two groups, the conversion rate to an open procedure was significantly less (0 versus 29%, P <0.04) in the early treated patients. Furthermore, the operative time (73 versus 96 minutes, P <0.004), postoperative hospitalization (1.2 versus 3.9 days, P <0.001), and total hospital stay (2.1 versus 5.4 days, P <0.004) were significantly reduced in patients undergoing early laparoscopic cholecystectomy.

CONCLUSIONS

Laparoscopic cholecystectomy performed by experienced surgeons is a safe, effective technique for treatment of acute cholecystitis. Patients treated within 48 hours of onset of symptoms experience a lower conversion rate to an open procedure, shorter operative time and reduced hospitalization.

Barrier precautions in trauma: is knowledge enough?

OBJECTIVES

The risk of blood and body fluid exposure and, therefore, risk of blood-borne disease transmission is increased during trauma resuscitations. Use of barrier precautions (BPs) to protect health care workers (HCWs) from exposure and infection has been codified in hospital rules and in national trauma education policy. Despite these requirements, reported rates of BP compliance vary widely. The reasons for noncompliance are not known. This study assesses self-reported rates of BP usage during resuscitations among trauma professionals, explores reasons for noncompliance, and compares self-reported compliance rates with actual observed compliance rates.

METHODS

A survey regarding BPs was distributed to all HCWs involved in trauma resuscitations at our Level I trauma center. All surgical and emergency medicine residents as well as attending faculty from both disciplines and nursing staff were included in this study. A total of 161 surveys were distributed and 123 were returned.

RESULTS

Most HCWs (114 of 123 [93%]) reported at least one exposure (usually intact skin contact) to blood or other body fluids. A considerable variation in the type of BP used was reported for those HCWs who reported use of BPs "all of the time." Of the HCWs who reported universal use of BPs, reported usage rates were as follows: gloves, 105 of 123 (85%); eyewear (no side protectors), 58 of 123 (47%); eyewear (side protectors), 20 of 123 (16%); gowns, 22 of 123 (18%); and masks, 5 of 123 (4%). The two most common reasons for noncompliance were "time factors" (61%) and "BPs are too cumbersome" (29%). Observed compliance rates were statistically significantly lower than self-reported rates in all BPs except gloves (p < 0.02).

CONCLUSION

The wide variation in BP use and the gap between perceived and actual usage that we have observed suggest that the effectiveness of current educational approaches to ensure BP use is inadequate.

Magnification Views of Mammography Decrease Biopsy Rates

Mammography is a valuable tool for screening and has increased early detection of breast cancer. Magnification views are commonly used to further elucidate suspicious changes seen on routine mammograms. The effect of magnification views and their utility have not been studied regarding the influence on treatment strategies. All patients who had magnification views performed along with their mammogram at Tulane University Medical Center over a one-year period were included. Patient charts were reviewed for mammogram readings, recommendations, and any biopsy results. The original mammograms without the magnification views were given to a physician who was blinded to the final results of the magnification views for a recommendation of whether or not to biopsy the lesion. These recommendations were compared with the results with actual recommendations. Magnification views were performed on 127 patients. After the additional magnification views were taken 27 per cent (34 of 127) of patients had biopsies performed. Biopsy results revealed benign findings in 71 per cent and nonbenign findings (lobular carcinoma in situ, ductal carcinoma in situ, or carcinoma) in 29 per cent. On the basis of the recommendations without magnification views 64 per cent of patients would have had biopsies performed. Magnification views decreased the biopsy rates by 58 per cent ( P < 0.001; χ2 tests). Magnification views can help decrease the number of biopsies performed for suspicious small areas on mammograms. Their judicious use can help decrease unnecessary procedures, patient anxiety, and cost. Magnification views are useful to help surgeons and radiologists best screen for breast cancer.

Esophageal carcinosarcoma

Carcinosarcoma is an uncommon malignancy of the esophagus that presents as a bulky intraluminal polypoid lesion of the esophagus. Histologically, both carcinomatous and sarcomatous components are seen. Because of accelerated intraluminal growth, esophageal carcinosarcoma often presents relatively early. This report describes a 64-year-old man with carcinosarcoma who was successfully treated with an esophagectomy. As in typical squamous cell carcinoma, early detection and treatment by surgical resection are needed to produce significant long-term survival.

Predicting anti-HIV activity: computational approach using a novel topological descriptor

The discriminating power of a novel topological descriptor termed as eccentric adjacency index in the estimation of anti-HIV activity, for a data set of 107 1-[(2-hydroxyethoxy)methyl]-6-(phenylthio)thymine (HEPT) derivatives was investigated in the present study. The value of eccentric adjacency index of each derivative was computed and active range was identified using moving average analysis. Subsequently, each derivative was assigned a biological activity which was then compared with the reported anti-HIV activity. The accuracy of prediction was found to be more than ninety percent in the active range using eccentric adjacency index. The proposed index offers a vast potential for structure-activity/property studies.

Magnification views of mammography decrease biopsy rates

Mammography is a valuable tool for screening and has increased early detection of breast cancer. Magnification views are commonly used to further elucidate suspicious changes seen on routine mammograms. The effect of magnification views and their utility have not been studied regarding the influence on treatment strategies. All patients who had magnification views performed along with their mammogram at Tulane University Medical Center over a one-year period were included. Patient charts were reviewed for mammogram readings, recommendations, and any biopsy results. The original mammograms without the magnification views were given to a physician who was blinded to the final results of the magnification views for a recommendation of whether or not to biopsy the lesion. These recommendations were compared with the results with actual recommendations. Magnification views were performed on 127 patients. After the additional magnification views were taken 27 per cent (34 of 127) of patients had biopsies performed. Biopsy results revealed benign findings in 71 per cent and nonbenign findings (lobular carcinoma in situ, ductal carcinoma in situ, or carcinoma) in 29 per cent. On the basis of the recommendations without magnification views 64 per cent of patients would have had biopsies performed. Magnification views decreased the biopsy rates by 58 per cent (P < 0.001; chi2 tests). Magnification views can help decrease the number of biopsies performed for suspicious small areas on mammograms. Their judicious use can help decrease unnecessary procedures, patient anxiety, and cost. Magnification views are useful to help surgeons and radiologists best screen for breast cancer.

Extrapancreatic pseudoaneurysm after pancreas transplantation

Pseudoaneurysms after pancreatic transplantation are an infrequent event. Repair usually involves removal of the transplant. We describe a patient with a pseudoaneurysm associated with pancreatic transplantation. The pseudoaneurysm originated from the external iliac artery distal to the donor Y-graft anastomosis. Diagnosis was made by duplex ultrasound. Surgical repair was effected through a retroperitoneal incision enabling vascular control. The patient has done well postoperatively, and with 1-year follow-up, continues to have normal renal and pancreatic allograft function.

Noncompliance of health care workers with universal precautions during trauma resuscitations

BACKGROUND

Universal precautions during resuscitations are mandated by hospital regulations. We documented adherence to universal precautions during trauma resuscitations at our level I trauma center.

METHODS

During trauma resuscitations, a medical student using an elevated viewing platform observed health care workers (HCWs) for the use of barrier precautions (BPs): gloves, masks, gowns, and eyewear. Only HCWs having direct patient contact were included. The purpose of the observation was not disclosed to those being observed.

RESULTS

In 12 resuscitations involving 104 HCWs, none had 100% compliance with BPs. Compliance rates for individual BPs were gloves, 98%; eyewear (any type), 52%; gowns, 38%; masks, 10%; and eyewear (with side protectors), 9%. Resuscitations in which bleeding was observed involved 59 HCWs with 38% compliance; only 2 used full BPs. No difference in compliance rates occurred during the study period.

CONCLUSIONS

Experienced trauma care HCWs are cavalier regarding blood-borne disease exposure risks. Measures to encourage (or force) compliance are needed.

Ageism in medical students' treatment recommendations: the example of breast-conserving procedures

PURPOSE

Age bias may play a role in physicians' discussions of equivalent therapeutic options with patients, especially in respect to breast-conservation therapy. This study investigated bias based on age (ageism) among physicians-in-training in their treatment recommendations for breast-conserving procedures.

METHOD

Second-year medical students responded to a questionnaire concerning recommendations they would make for breast conservation or mastectomies with or without breast reconstruction for eight patients with similar-stage breast cancer. The patients differed by age (older were > or =59 years, younger < or =31 years), race, and marital status. A total of 116 students made 1,146 recommendations. Percentages of the students' recommendations for breast-conservation therapy (BCT) were calculated for the two patient age groups and for the recommendations for breast reconstruction after the patient had already chosen modified radical mastectomy (MRM). Chi-square tests were used for statistical analysis.

RESULTS

The students recommended BCT for a significantly higher percentage of younger patients than older patients (86% versus 66%; p<.001). They recommended MRM to 34% of older patients versus 14% of younger patients (p<.001). Furthermore, the students recommended breast reconstruction after MRM to a significantly higher percentage of younger patients than older patients (95% versus 65%; p<.001).

CONCLUSIONS

Medical students' recommendations of breast conservation and breast reconstruction showed age bias. Educational efforts should be instituted during the medical school to decrease ageism in students' treatment recommendations.

Age bias: a cause of underutilization of breast conservation treatment

BACKGROUND

Breast conservation therapy (BCT) has been shown to result i about the same disease control and survival as modified radical mastectomy (MRM) for stage I and II breast cancers. Barriers to using BCT in patients with invasive breast cancer include "physician preference." This study was undertaken to investigate the bias of residents with respect to breast-conserving procedures.

METHODS

Internal medicine and surgery residents were instructed about the efficacy of BCT. Subsequently, their opinions were assessed using a questionnaire concerning recommendations for BCT versus MRM as well as breast reconstruction after MRM in similar patients. Chi square tests were used for statistical analysis.

RESULTS

Seventy-nine residents (54 medical, 25 surgical) participated. MRM was recommended for 38% of older (> 59 years old) versus 11% of younger patients (< 31 years old), p < 0.01. Furthermore, breast reconstruction was recommended for 96% of younger versus only 70% of older patients (p < 0.01).

CONCLUSIONS

Residents are biased against older women in their recommendations for breast conservation and breast reconstruction. Educational efforts to decrease this age bias should be instituted during residency.

Meckel's diverticulum causing cecal volvulus

Meckel's diverticulum is present in 2 per cent of the population with bowel obstruction as its most common complication. This case report describes an extremely rare complication of a Meckel's diverticulum, a cecal volvulus. The diagnosis of cecal volvulus was made preoperatively on abdominal X-rays; the diagnosis of a Meckel's diverticulum was made intraoperatively. The cecum was found to be twisted around a vitelline band on a broad-based Meckel's diverticulum extending to the umbilicus. The diverticulum was resected. The patient did well postoperatively and was discharged without any difficulty.

Axillary lymph node status of T1 primary breast cancer in a diverse population

The utility of level I and II axillary lymph node dissection in women with primary tumors less than 1 cm in diameter has recently received extensive evaluation. Numerous patients undergo axillary lymph node dissection ultimately to discover no pathological involvement. This study investigates the lymph node status in T1 primary breast adenocarcinoma in our diverse patient population. A retrospective evaluation of patients treated at the Medical Center of Louisiana at New Orleans and the Tulane University Medical Center with breast adenocarcinoma less than or equal to 2 cm was performed. Demographic data and pathological reports were reviewed to obtain breast lesion size and lymph node status. One hundred sixteen patients were found to have T1 lesions. Ethnic distribution was African American 66 per cent; Caucasians 30 per cent; Hispanic 2 per cent; and Asian 3 per cent. Whereas no patients with T1a lesions had positive lymph nodes, 11 per cent of patients with T1b lesions and 36 per cent of patients with T1c lesions had positive lymph nodes. However, in our patient population no patients with tumors less than 1.0 cm. in diameter had positive lymph nodes. Although this may be due to our relatively small sample size axillary lymph node dissection may be unnecessary in this select patient population. For patients with lesions 1.0 cm and greater an axillary lymph node dissection seems to add necessary information for correct treatment in a small percentage of patients. The use of lymphatic mapping with sentinel axillary lymph node biopsy may reduce the number of unnecessary axillary dissections in early breast cancer.

Meckel's Diverticulum Causing Cecal Volvulus

Meckel's diverticulum is present in 2 per cent of the population with bowel obstruction as its most common complication. This case report describes an extremely rare complication of a Meckel's diverticulum, a cecal volvulus. The diagnosis of cecal volvulus was made preoperatively on abdominal X-rays; the diagnosis of a Meckel's diverticulum was made intraoperatively. The cecum was found to be twisted around a vitelline band on a broad-based Meckel's diverticulum extending to the umbilicus. The diverticulum was resected. The patient did well postoperatively and was discharged without any difficulty.

Axillary Lymph Node Status of T1 Primary Breast Cancer in a Diverse Population

The utility of level I and II axillary lymph node dissection in women with primary tumors less than 1 cm in diameter has recently received extensive evaluation. Numerous patients undergo axillary lymph node dissection ultimately to discover no pathological involvement. This study investigates the lymph node status in T1 primary breast adenocarcinoma in our diverse patient population. A retrospective evaluation of patients treated at the Medical Center of Louisiana at New Orleans and the Tulane University Medical Center with breast adenocarcinoma less than or equal to 2 cm was performed. Demographic data and pathological reports were reviewed to obtain breast lesion size and lymph node status. One hundred sixteen patients were found to have T1 lesions. Ethnic distribution was African American 66 per cent; Caucasians 30 per cent; Hispanic 2 per cent; and Asian 3 per cent. Whereas no patients with T1a lesions had positive lymph nodes, 11 per cent of patients with T1b lesions and 36 per cent of patients with T1c lesions had positive lymph nodes. However, in our patient population no patients with tumors less than 1.0 cm. in diameter had positive lymph nodes. Although this may be due to our relatively small sample size axillary lymph node dissection may be unnecessary in this select patient population. For patients with lesions 1.0 cm and greater an axillary lymph node dissection seems to add necessary information for correct treatment in a small percentage of patients. The use of lymphatic mapping with sentinel axillary lymph node biopsy may reduce the number of unnecessary axillary dissections in early breast cancer.

Extra-anatomic bypass grafting for aortoesophageal fistula: a logical operation

Aortoesophageal fistula (AEF) is an uncommon cause of upper gastrointestinal hemorrhage. Usually, but not always, patients present with a small sentinel bleed followed by a variable interval of apparent resolution, and then they experience a massive exsanguinating hemorrhage. The variable interval of time after the sentinel bleed is the period in which most AEFs resulting from thoracic aortic aneurysm have been successfully treated. Although only a few successful cases have been reported in the literature, most describe an in situ repair. We describe treatment of a late-presenting AEF due to a thoracic aneurysm with an extra-anatomic bypass graft for the aortic repair.

Insulin-like growth factor I receptor antagonism augments response to chemoradiation therapy in colon cancer cells

BACKGROUND

Colorectal cancer remains one of the most prevalent malignancies in the United States. Improvement in local disease control is seen when 5-fluorouracil (5-FU) is used in combination with pelvic irradiation for rectal adenocarcinoma. The frequent overexpression of insulin-like growth factor I receptor (IGF-I-R) in rectal adenocarcinoma suggests that inhibition of the signal transduction pathway may be a novel approach to enhance tumor response. This investigation seeks to define the role of IGF-I-R antagonism, using monoclonal antibody alpha-IR3, in augmenting cytotoxicity to adjuvant chemoradiation therapy for adenocarcinoma of the rectum.

MATERIALS AND METHODS

SW 480 colon cancer cells were cultured to semiconfluent conditions with dose titrations performed for 5-FU to determine that the IC(50) (inhibitory concentration of 50% of the cells) was 0.5 microg/ml. The IC(50) for 5-FU was reassessed in the presence of IGF-I. Experimental groups included colon cancer cells combined with 5-FU; 6-MeV external beam radiation (100-500 cGy); and alpha-IR-3.

RESULTS

The addition of 100 ng/ml IGF-I 1 h prior to 5-FU or radiation significantly blunted the expected cytotoxicity, resulting in a 10-fold increase in the IC(50) (from 0.5 to 5 microg/ml). Receptor antagonism using the monoclonal antibody alpha-IR-3 (100-400 ng/ml) produced a dose-dependent increase in cytotoxicity compared with 5-FU alone. The addition of radiation produced synergistic amplification of this response.

CONCLUSIONS

IGF-I-R activation blocks the expected cytotoxic effects of 5-FU and external beam radiation. Receptor antagonism increased the cytotoxic response of chemoradiation therapy. These data suggest the utility of inhibiting IGF-I-R signal transduction in the treatment of rectal adenocarcinoma.

Higher risk of HIV transmission during trauma resuscitations

Despite an appreciation of the potential for blood borne pathogen exposure, compliance of universal precautions is low. While reports of HIV positive rates in trauma patients have varied from 0.15% to 7.8%, the estimated prevalence of HIV in Louisiana is 0.32%. We made use of two unique, complimentary data sources: the Trauma Registry and the HIV/AIDS Reporting System database of known HIV positive patients to estimate the relative prevalence of HIV which may indicate an increase risk of blood borne pathogen transmission to health care workers during trauma resuscitations. In one year, 1031/1159 patients were evaluated from the Trauma Registry Database and 22 similar patients (2.13%) were found in both the Trauma Registry and the HIV/AIDS Reporting System Database. Our prevalence is an indicator of the minimum risk since it is based on only reported cases of HIV and justifies intensification of education and enforcement of the practice of universal precautions.

Treatment of antibody-mediated accelerated rejection using plasmapheresis

Accelerated antibody-mediated rejection is believed to be due to an anamnestic response of an allograft recipient to donor antigens. Few reports have demonstrated successful reversal of this type of rejection, and no consensus exists for either diagnosis or treatment. Accelerated antibody-mediated rejection was suspected on the basis of clinical findings and confirmed by cytotoxic and flow crossmatches, and leukocyte antibody screens. Serial crossmatches and antibody screens were performed through post-transplant day 112. Plasmapheresis was performed on post-transplant days 1, 2, 4, 6, 12, 14, 20, and 28. The duration of treatment was determined by the cytotoxic crossmatch results. We present a case of successfully treated accelerated antibody-mediated rejection using plasmapheresis and aggressive immunosuppression. Serial crossmatch and leukocyte antibody screen results are presented that confirm the production of anti-donor antibody and demonstrate the effectiveness of the treatment protocol in eliminating detectable levels of the anti-donor antibody. At 6 months post-transplant, the patient has a serum creatinine of 1.1 and has not had any additional rejection episodes or infectious complications. The protocol suggested in this paper allows for rapid diagnosis, institution of treatment, and monitoring the efficacy of treatment, providing the basis for follow-up clinical trials.

Socioeconomic Factors, not Ethnicity, Predict Breast Self-Examination

The American Cancer Society has recommended monthly breast self-examinations (BSEs) to aid in the early detection of breast cancer. Compliance with BSE recommendations has been shown to be decreased in certain ethnic groups. This investigation evaluates relevant variables involved in BSE compliance in an urban breast cancer screening center. A survey over a 1-year period (June 1996-June 1997) was given to all patients on their initial visit to the Breast Health Center at Tulane University Medical Center. Demographic and socioeconomic factors associated with the compliance of BSE were explored. The overall rate of BSE was relatively high at 80%. There was no difference between ethnic groups in rates of BSE (Caucasians 21% versus African Americans 20%). Statistically significant variables associated with BSE noncompliance were high school education (did not complete high school 16% versus completed high school 33%; p < 0.0004), employment status (employed 16% versus unemployed 31%; p < 0.0004), and marital status (married 15% versus single/divorced 22%; p < 0.05). While the majority of women in our study practiced BSE and ethnicity did not predict BSE, several socioeconomic factors were predictive of BSE compliance. Efforts to increase community outreach to lower socioeconomic patients as well as efforts to ensure proficient BSE techniques by patients may help detect early breast cancer.