Laparoscopic ventral hernia repair (LVHR) in morbidly obese patients

OBJECTIVE

The aim of this study was to evaluate our experience with LVHR in morbidly obese patients (BMI >40) and to compare their outcomes to those of patients with lower BMI.

METHODS

Data on adult (>18 years old) patients who underwent LVHR with mesh over the last 13 years performed by four experienced surgeons were collected retrospectively and from a previously collected database. Of the 1,071 patients, 901 had completed LVHR and were available for follow-up. One hundred and thirty-four patients (group A) met BMI criteria for morbid obesity (>or=40, mean 46), 767 patients had BMI < 40, mean 30 (group B). The follow-up time ranged from 1 to 91 months. The Wilcoxon rank sum test was used for nonparametric data analysis. Outcomes were stratified on the follow up time and analyzed using Cochran-Mantel-Haenszel methodology.

RESULTS

The groups did not differ in terms of ASA score, previous surgery and conversion rate (p=0.22, 0.32 and 0.23). Morbidly obese patients were younger (48.3 vs. 54; p<0.01) and were more often female (p=0.02), but this did not correlate with outcome. Group A also had longer operative time (154 vs. 119 min, p<0.01) and hospital stay (3.6 vs. 2.4 days, p=0.03). Mesh size was significantly larger in group A (449 vs. 349 cm(2), p=002). During mean follow-up time of 19 months hernia recurrence was 8.3% in group A and 2.9% in group B (p=0.003), with an odds ratio of 4.3 (95% CI 1.9-9.9). However, there was no significant difference in the rate of complications (19.7 vs. 15.3%; p=0.46).

CONCLUSIONS

LVHR in the morbidly obese population is both safe and feasible, although there is a higher, but still acceptable recurrence rate. Despite the increased risk for recurrence, LVHR in morbidly obese patients minimizes the potential wound and mesh complications that frequently occur for open mesh repair in this group of patients.

Cognitive function and fatigue in cancer patients after chemotherapy: A longitudinal cohort study in patients with colorectal cancer (CRC)

9099

Background: There is growing evidence that fatigue and cognitive dysfunction can affect cancer survivors. Here we evaluated these symptoms in patients with CRC in a longitudinal prospective study. Methods: Patients with localized CRC were evaluated for cognitive function and fatigue at baseline (mean 8 weeks post-surgery or before neoadjuvant therapy), 6 & 12 months. Group A (Stage III/high risk II) received chemotherapy (CT) and group B (Stage I/II) received no CT. Pts had neuropsychological (NP) assessment with traditional tests and CANTAB, a computerized NP battery. They completed concurrent questionnaires for fatigue & QOL (FACT-F), anxiety/depression (GHQ), and perception of cognitive function (FACT-COG). Blood tests evaluated cytokine levels, blood clotting factors, sex hormones and apolipoprotein genotyping as potential causal factors. Primary endpoints were cognitive function (traditional NP tests) and fatigue. Associations between test results, demographic and disease-related factors were sought. Results: Baseline data are available for 182 pts: 127 group A, and 55 group B, with follow-up at 6 and 12 months for 71 and 39 pts. Mean age was 57 years and 62% were male. At baseline (pre CT): 30% had cognitive impairment on traditional NP tests & 20% on CANTAB; 25% reported moderate fatigue and 10% extreme fatigue. At 6 months there was no significant difference on objective NP testing between the groups or in perceived cognitive impairment (median FACT- COG 82 vs 88, p=0.34). CT pts had more fatigue (median FACT-F 75 vs 91, p<0.001). At 12 months CT pts tend to have more cognitive impairment on traditional NP tests (26% vs 0%, p=.09), more perceived cognitive impairment (13.5% vs 0%, p=.57) & greater fatigue (16% vs 0%). Cytokine levels were elevated in all groups at all time points compared to healthy volunteers. There was a trend to higher cytokine levels with greater fatigue and worse cognitive impairment. Fatigue, QOL and anxiety and depression were highly correlated. Conclusions: Cognitive impairment is present in some pts prior to CT and there is a trend for CT pts to have worse cognitive impairment at 12 but not at 6 months. Fatigue is associated with CT. Cytokine levels remained elevated in all groups compared to healthy volunteers.

No significant financial relationships to disclose.

Efficacy of breast MRI in elderly women

608

Background: Breast MRI is useful in evaluating extent of disease and screening of high risk patients, especially younger patients with dense breasts. The utility of MRI in the elderly population is currently unknown. The purpose of this study was to review the use of breast MRI and MRI findings in elderly women. Methods: Retrospective review identified women over the age of 70 who underwent breast MRI at our institution between 11/2000 and 12/2005. Clinicopathologic features, MRI results and mammograms (MMG) were reviewed. Results: 228 patients were identified. The mean age was 73.5 years (range 70–91). Forty-three patients (19%) had no history of breast cancer, 99 (43%) had a history of breast cancer, and 86 (38%) had a current diagnosis of breast cancer at the time of MRI. Ninety-two patients (40%) underwent MRI for screening, 49 (21%) as further workup for an abnormal MMG or physical finding, and 78 (34%) for extent of disease assessment. MRI found 49 additional sites of abnormality and 15 additional cancers (14% false positive). Five cancers were detected in women with no current diagnosis of cancer. In patients with a diagnosis of cancer at the time of MRI, 10 additional cancers were found: 7 in the contralateral breast and 3 additional ipsilateral sites. Conclusions: MRI detected an additional 15 mammographically occult breast cancers in this population of women over the age of 70. MRI was efficacious in screening as well as evaluating extent of disease, with a relatively low false-positive rate of 14%. Breast MRI is a useful tool in the evaluation of elderly patients; further study in the use of MRI for screening in this population is needed.

[Table: see text]

No significant financial relationships to disclose.

Endovascular treatment of a pulmonary artery pseudoaneurysm with a stent graft: report of two cases

Two patients with hemoptysis secondary to pulmonary artery pseudoaneurysm were treated by endovascular placement of stent grafts. Aneurysms were effectively excluded and hemoptysis stopped. Stent grafts were occluded in both patients. However, endovascular treatment of the pulmonary artery pseudoaneurysm with a stent graft is a safe alternative to coil embolization or surgery.

Centralisation of a hypospadias repair service – The Warwickshire experience

An audit of the hypospadias repair service provided in the county of Warwickshire has shown that centralising all referrals to a single surgeon who uses limited, well-practiced techniques, greatly improves outcome. Comparison to previous audit of the service, when provided by a number of surgeons in the region, shows complication rates dropping - fistulae occurrence reducing from 35.8% to 6.7% and urethral stricture rates showing similar improvement from 4.4% to 0%. Overall productivity increased, and referral out of region dropped from 13% to 0%. This provides definitive evidence that restructuring of a service already in place has decreased morbidity and increased efficiency to give results comparable to published data.

Impact of Androgen Deprivation Therapy on Physical and Cognitive Function, as Well as Quality of Life of Patients With Nonmetastatic Prostate Cancer

PURPOSE

Many patients with prostate cancer receive androgen deprivation therapy for long periods. We compared physical and cognitive function, and quality of life in a cross-sectional study of 57 patients receiving androgen deprivation therapy for nonmetastatic prostate cancer and 51 healthy age matched controls.

MATERIALS AND METHODS

Physical and daily function were measured by the 6-minute walk test, grip strength, the timed up and go test, and activities of daily living measures. Cognitive function was evaluated by the High Sensitivity Cognitive Screen and by a self-report prototype Functional Assessment of Cancer Therapy cognitive function subscale. Quality of life was assessed by the Functional Assessment of Cancer Therapy-General with the subscale for fatigue and by the Patient-Oriented Prostate Utility Scale.

RESULTS

Androgen deprivation therapy was given for a median of 1.8 years (range 0.4 to 7.4). Patients had lower median hemoglobin than controls (134 vs 148 gm/l, p <0.0001). Performance on physical tests was similar in the 2 groups. Moderate or severe cognitive impairment by the High Sensitivity Cognitive Screen was similar for patients (23%) and controls (35%, p = 0.2). Self-reported cognitive dysfunction was also similar. Scores for the Functional Assessment of Cancer Therapy-General were similar but the Patient Oriented Prostate Utility Scale summary score was worse for patients (median 71 vs 86, p <0.001). More patients reported severe fatigue (Functional Assessment of Cancer Therapy-Fatigue score less than 35, p = 0.03). Low energy, poor bladder control and loss of sexual function were reported in 36%, 47% and 95% of patients, and in 16%, 34% and 33% of controls, respectively.

CONCLUSIONS

Patients treated with androgen deprivation therapy experience more symptoms and have worse fatigue than controls, but this study did not detect any effect on physical or cognitive function.

Further monitoring for Salmonella species and Escherichia coli O86 at a bird table in south-west Scotland

Pooled faeces collected from a garden bird table were screened for Salmonella species and Escherichia coli O86, two recognised causes of garden bird mortality. Dead birds found at the site were also screened for these organisms, and bird numbers and meteorological data were recorded. In the first year of the study, 48.5 per cent of the samples were positive for Salmonella Typhimurium DT56 (variant), decreasing to 38.9 per cent in the second year and 12.8 per cent in the third year. E. coli O86 was not recovered from any of the 288 samples of pooled faeces tested. S. Typhimurium DT56 (variant) was recovered from the carcases of eight birds found dead at the site, and E. coli O86 was isolated from three carcases. The degree of contamination of the bird table with S. Typhimurium DT56 (variant) was positively correlated with the number of house sparrows observed in the garden, but not with the number of blackbirds, chaffinches or greenfinches.

Cytokine levels in patients (pts) with localized colorectal cancer (CRC) after surgery and their relationship to fatigue and cognitive function

3623

Background: Cytokines have been associated with fatigue and cognitive dysfunction. Here we evaluate cytokine levels in pts with CRC as part of a longitudinal study evaluating these symptoms. Methods: Serum levels of 12 cytokines were measured using a LiquiChip assay on pts with localized CRC at baseline (mean 7 weeks post-surgery or before neoadjuvant therapy), 6 and 12 months. Group A (Stage III/high risk II) received chemotherapy (CT) and group B (Stage I/II) received no CT. Pts completed concurrent questionnaires for fatigue & QOL (FACT-F), anxiety/depression (GHQ), and perception of cognitive function (FACT-COG); they had neuropsychological (NP) assessment with traditional tests and CANTAB, a computerized NP battery. Associations between cytokine levels, test results, demographic and disease-related factors were sought. Results: Baseline data are available for 82 pts: 65 group A and 17 group B, with follow-up at 6 and 12 months for 32 and 15 pts. Mean age was 58 years and 68% were male. Cytokine levels were elevated in all groups with larger ranges after surgery (selected data in table ); in healthy people they are generally undetectable. There was cognitive impairment at baseline in 28% on traditional NP tests. At 6 months CT pts had more fatigue (median FACT-F 43 vs 47), perceived more cognitive impairment (median FACT-COG 127 vs 138), and had more cognitive impairment on CANTAB (42% vs 17%), but not on traditional NP tests (32% vs 33%). At 6 months, elevated cytokines (IL-1,-6,-8,-12, TNF, IFN) were associated with greater deficit on CANTAB (p<0.06); there was no association of cytokines with time from surgery, traditional NP test score, FACT-COG, fatigue, QOL or anxiety & depression. Conclusions: Cytokine levels were elevated in most pts. Cognitive impairment is present in some pts prior to chemotherapy and CT pts have worse impairment on computerized NP tests than non-CT pts. Elevated cytokines may be associated with worse cognitive function.

[Table: see text]

No significant financial relationships to disclose.

[Myositis of the sternocleidomastoid muscle as a result of arthritis of the sternoclavicular joint]

This article describes a rare case of a myositis of the sternocleidomastoid muscle due to an acute septic arthritis of the sternoclavicular joint. A 51-year-old male in reduced condition was admitted to the Department of Otorhinolaryngology with a one-week history of a painless swelling of the sternocleidomastoid muscle associated with recurrent fever. Physical examination was otherwise unremarkable. An intravenous antibiotic therapy was initiated without improvement of the process, accordingly a specific infection or a malignancy was ruled out by biopsy. The positron emission tomography and magnetic resonance imaging finally revealed the diagnosis of a septic arthritis of the sternoclavicular joint as the causal focus of the infection. After an extensive surgical debridement and under continued antibiotic therapy the patient made an uneventful recovery. The acute septic arthritis of the sternoclavicular joint is an uncommon infection with an insidious onset and is often unrecognized until it spreads to adjacent structures leading to serious complications. This case emphasizes that a myositis of sternocleidomastoid muscle can be caused by an ascending infection due to an acute septic arthritis of the sternoclavicular joint. Clinical course, diagnosis and treatment of this uncommon disease are reviewed in this article.

APOE related alterations in cerebral activation even at college age

BACKGROUND

Associations between the APOE genotype and various medical conditions have been documented at a very young age. The association between the APOE genotype and cognitive performance varies at different ages. APOE related changes in brain activation have been recently reported for middle aged and elderly subjects.

OBJECTIVE

To explore APOE related alterations during cognitive activation in a population of young adults.

METHODS

Using H2(15)O positron emission tomography (PET), imaging was carried out in 20 healthy young adults (age 19 to 28 years; four epsilon4 carriers and 16 non-epsilon4 carriers) during a non-verbal memory task. Voxel-wise multiple regression analyses were undertaken, with the activation difference PET counts as the dependent variable and the APOE genotype as the independent variable.

RESULTS

Brain regions were identified where epsilon4 carriers showed significantly lower or higher activation than non-carriers.

CONCLUSIONS

The results suggest that APOE dependent modulation of cerebral flow may be present even at a young age. This may reflect an APOE related physiological heterogeneity which may or may not predispose to brain disease in the ensuing decades or, less likely, the effect of very early Alzheimer's disease related pathological changes.

APOE-dependent PET patterns of brain activation in Alzheimer disease

Using H2(15)O PET, the authors imaged 13 patients with Alzheimer disease (AD) while performing a serial nonverbal recognition memory task. Patterns of brain activation differed as a function of APOE genotype: epsilon4 carriers exhibited lower activation in the left lingual gyrus and higher activation in left cuneus, precuneus, parahippocampal, and right precentral gyrus. The APOE genotype seems to play a role in cerebral physiologic activity even after onset of clinical manifestations of AD.

Advances in coupling a commercial total organic carbon analyser with an isotope ratio mass spectrometer to determine the isotopic signal of the total dissolved nitrogen pool

A new method has been developed to analyse 15N of the total dissolved nitrogen (TDN) pool. The method operates on a commercial total organic carbon (TOC) analyser coupled to an elemental analyser/isotope ratio mass spectrometer (EA-IRMS). Nitrogen compounds are combusted to nitric oxide (NO) and nitrogen dioxide (NO2) by high-temperature catalytic oxidation (HTCO), after which the NOx gas is transferred to an EA-IRMS for isotopic nitrogen analysis. The system is described, including five modifications of the system in order to overcome analytical problems. First, flow paths were modified to run both systems on helium as carrier gas, while complete sample oxidation was maintained. Secondly, the catalyst structure was adapted to allow high injection volumes at the given backpressures delivered by the EA system. Thirdly, we installed a Permapure dehumidification system as the standard Peltier element did not satisfy dehumidification requirements. Finally, we prevented the inflow of atmospheric nitrogen into the system. In a final stage, we are planning to automate the coupled system in order to run a continuous batch of up to 60 samples. We have obtained satisfactory results on the accuracy and precision of 180+/-1 per thousand potassium nitrate samples (IAEA, USGS-32). Running a batch of five samples resulted in a mean isotopic value of 178.8 per thousand with a standard deviation of 2.8 per thousand. Some important issues could not yet be addressed here, and will have to be evaluated once the system is running on a continuous base. However, the results appear promising and this system has the potential to become a method for TD15N analysis. An appropriate TD15N analysis method might open new challenges in aquatic and terrestrial ecosystem nitrogen studies, including a more comprehensive study of the dissolved organic nitrogen pool.

Evaluating the introduction of a pilot client attachment scheme in mental health nursing education

Client attachment (CA) allows student nurses to gain clinical experience through forming therapeutic attachments with individual clients, rather than through a series of location-based placements. This paper describes a pilot project that evaluated CA with pre-registration student mental health nurses. Using semi-structured interviews, the researchers identified the students', their supervisor's, and their clients' experiences of CA. Most participants agreed that students were able to learn relevant and appropriate clinical skills, and to consolidate experience-increasing motivation, autonomy, organizational skills, and confidence.

Live broadcast of laparoscopic surgery to handheld computers

BACKGROUND

Thanks to advances in computer power and miniaturization technology, portable electronic devices are now being used to assist physicians with various applications that extend far beyond Web browsing or sending e-mail. Handheld computers are used for electronic medical records, billing, coding, and to enable convenient access to electronic journals for reference purposes. The results of diagnostic investigations, such as laboratory results, study reports, and still radiographic pictures, can also be downloaded into portable devices for later view. Handheld computer technology, combined with wireless protocols and streaming video technology, has the added potential to become a powerful educational tool for medical students and residents. The purpose of this study was to assess the feasibility of transferring multimedia data in real time to a handheld computer via a wireless network and displaying them on the computer screens of clients at remote locations.

METHODS

A live laparoscopic splenectomy was transmitted live to eight handheld computers simultaneously through our institution's wireless network.

RESULTS

All eight viewers were able to view the procedure and to hear the surgeon's comments throughout the entire duration of the operation.

CONCLUSION

Handheld computer technology can play a key role in surgical education by delivering information to surgical residents or students when they are geographically distant from the actual event. Validation of this new technology by conducting clinical research is still needed to determine whether resident physicians or medical students can benefit from the use of handheld computers.

A technique for real-time digital measurements in laparoscopic surgery

BACKGROUND

The current techniques for the measurement of intracorporeal targets in laparoscopic surgery are relatively cumbersome and imprecise.

METHODS

A structured light technique was used to obtain the length and width of two defects and an object in a laparoscopic training box. These measurements were compared against two current and standard laparoscopic techniques of intracorporeal measurement: the introduction of a plastic ruler and the use of an opened end of a laparoscopic instrument to approximate 2 cm. The time needed to measure the defects and object was recorded.

RESULTS

Structured light-derived measurements were closest to the criterion standard, followed by plastic ruler measurements, then by instrument-end measurements. Digital measurements were quickest, followed by the instrument-end method, then by the plastic ruler.

CONCLUSIONS

This report describes a novel structured light technique for laparoscopic measurement of intracorporeal targets capable of producing results superior to those of current techniques.