Rare, long-term complication after pancreatoduodenectomy-a case report of cecal volvulus

Complications after pancreatoduodenectomy are common, and range widely in timing of presentation, relation to pancreatobiliary pathology, and necessity of operative intervention. We present a case of a 74-year-old male with history of pancreatoduodenectomy for pancreatic adenocarcinoma who presented 11 months after index operation with cecal volvulus and required emergent right hemicolectomy. Prior history of pancreatoduodenectomy with mobilization of the right colon likely predisposed him to development of this surgical emergency. Patients have altered gastrointestinal anatomy after pancreatoduodenectomy and special care is necessary to protect the afferent biliopancreatic limb during intraoperative exploration, and particularly if right colectomy is necessary.

The Evolving Landscape of Medical Device Regulation in East, Central, and Southern Africa

Effective regulatory frameworks, harmonized to international standards, are critical to expanding access to quality medical devices in low- and middle-income countries. This review provides a summary of the state of medical device regulation in the 14 member countries of the College of Surgeons of East, Central, and Southern Africa (COSECSA) and South Africa. Countries were categorized according to level of regulatory establishment, which was found to be positively correlated to gross domestic product (GDP; rs=0.90) and years of freedom from colonization (rs=0.60), and less positively correlated to GDP per capita (rs=0.40). Although most countries mandate medical device regulation in national legislation, few employ all the guidelines set forth by the World Health Organization. A streamlined regulatory process across African nations would simplify this process for innovators seeking to bring medical devices to the African market, thereby increasing patient access to safe medical devices.

Abstract PR13: Surgical excision of the primary tumor in osteosarcoma model results in enhanced metastatic growth by modulating the lung immune microenvironment

Surgery has been shown to enhance metastasis in a number of cancers. To examine this in the context of osteosarcoma, we implanted syngeneic murine K7M2 cells into the tibia of BALB/c mice, which we had shown previously to result in immediate seeding of K7M2 cells into the lung. One week post-implantation, mice were assigned to either control or surgical groups and all mice were euthanized at week 4 post-implantation. Mice that underwent amputation of the primary tumor displayed an increase in the number of pulmonary surface nodules as compared to tumor-bearing control animals (17 vs. 9.5; p<0.05), showing that excision of the primary tumor indeed enhances metastasis in this model. As we previously showed that K7M2 metastasis without surgical intervention is strongly inhibited by re-educating tumor-associated macrophages (TAMs) with gefitinib, we also examined the effect of gefitinib on surgery-accelerated metastasis. We found that perioperative gefitinib abrogated the effects of primary tumor removal on the development of pulmonary metastases (17 vs. 6; p< 0.01), strongly suggesting that TAMs also mediate surgery-accelerated metastasis. To examine changes in the pulmonary immune milieu, we utilized the same model of surgery-accelerated metastasis. Lungs were homogenized and immune cell populations were analyzed using flow cytometric analysis at 48 hours and 3 weeks after surgery. We found that surgery caused a significant reduction in antitumor macrophages, identified by MHCII positivity (21.1% vs. 13.2%; p<0.01), and a significant increase in protumor macrophages, identified by CD206 positivity (33.0% vs. 42.4%; p<0.01), at 48 hours after surgical resection. There was no change in the proportion of CD4+ or CD8+ T cells at this time point. At 3 weeks post-surgery the proportion of macrophage populations became similar for both groups, but there was now a small but significant reduction in the CD4+ and CD8+ T cells in the surgical group (68.4% vs. 60.3%; p<0.05 and 25.0% vs. 19.3%; p<0.01). In conclusion, surgical removal of the primary tumor accelerated the growth of pulmonary metastases in a murine model of OS. Gefitinib was able to abrogate this effect, suggesting macrophages as key cellular mediators. Furthermore, surgery altered the macrophage phenotype within the lungs in the acute postoperative period toward a protumor state, subsequently reducing the CD4+ or CD8+ T-cell populations. Taken together these data suggest that surgery contributes to enhanced metastatic outgrowth by altering the immune microenvironment to an immunosuppressive and protumor state.

This abstract is also being presented as Poster B38.

Citation Format: Michelle P. Kallis, Caroline Maloney, Morris Edelman, Samuel Z. Soffer, Marc Symons, Bettie M. Steinberg. Surgical excision of the primary tumor in osteosarcoma model results in enhanced metastatic growth by modulating the lung immune microenvironment [abstract]. In: Proceedings of the AACR Special Conference on the Advances in Pediatric Cancer Research; 2019 Sep 17-20; Montreal, QC, Canada. Philadelphia (PA): AACR; Cancer Res 2020;80(14 Suppl):Abstract nr PR13.

Gefitinib Inhibits Invasion and Metastasis of Osteosarcoma via Inhibition of Macrophage Receptor Interacting Serine-Threonine Kinase 2

Most patients with osteosarcoma have subclinical pulmonary micrometastases at diagnosis. Mounting evidence suggests that macrophages facilitate metastasis. As the EGFR has been implicated in carcinoma-macrophage cross-talk, in this study, we asked whether gefitinib, an EGFR inhibitor, reduces osteosarcoma invasion and metastatic outgrowth using the K7M2-Balb/c syngeneic murine model. Macrophages enhanced osteosarcoma invasion in vitro, which was suppressed by gefitinib. Oral gefitinib inhibited tumor extravasation in the lung and reduced the size of metastatic foci, resulting in reduced metastatic burden. Gefitinib also altered pulmonary macrophage phenotype, increasing MHCII and decreasing CD206 expression compared with controls. Surprisingly, these effects are mediated through inhibition of macrophage receptor interacting protein kinase 2 (RIPK2), rather than EGFR. Supporting this, lapatinib, a highly specific EGFR inhibitor that does not inhibit RIPK2, had no effect on macrophage-promoted invasion, and RIPK2^-/- macrophages failed to promote invasion. The selective RIPK2 inhibitor WEHI-345 blocked tumor cell invasion in vitro and reduced metastatic burden in vivo In conclusion, our results indicate that gefitinib blocks macrophage-promoted invasion and metastatic extravasation by reprogramming macrophages through inhibition of RIPK2.

Pharmacological prevention of surgery-accelerated metastasis in an animal model of osteosarcoma

BACKGROUND

Osteosarcoma is a highly metastatic primary bone tumor that predominantly affects adolescents and young adults. A mainstay of treatment in osteosarcoma is removal of the primary tumor. However, surgical excision itself has been implicated in promoting tumor growth and metastasis, an effect known as surgery-accelerated metastasis. The underlying mechanisms contributing to surgery-accelerated metastasis remain poorly understood, but pro-tumorigenic alterations in macrophage function have been implicated.

METHODS

The K7M2-BALB/c syngeneic murine model of osteosarcoma was used to study the effect of surgery on metastasis, macrophage phenotype, and overall survival. Pharmacological prevention of surgery-accelerated metastasis was examined utilizing gefitinib, a receptor interacting protein kinase 2 inhibitor previously shown to promote anti-tumor macrophage phenotype.

RESULTS

Surgical excision of the primary tumor resulted in increases in lung metastatic surface nodules, overall metastatic burden and number of micrometastatic foci. This post-surgical metastatic enhancement was associated with a shift in macrophage phenotype within the lung to a more pro-tumor state. Treatment with gefitinib prevented tumor-supportive alterations in macrophage phenotype and resulted in reduced metastasis. Removal of the primary tumor coupled with gefitinib treatment resulted in enhanced median and overall survival.

CONCLUSIONS

Surgery-accelerated metastasis is mediated in part through tumor supportive alterations in macrophage phenotype. Targeted pharmacologic therapies that prevent pro-tumor changes in macrophage phenotype could be utilized perioperatively to mitigate surgery-accelerated metastasis and improve the therapeutic benefits of surgery.

The incidence of Marfan syndrome and cardiac anomalies in patients presenting with pectus deformities

PURPOSE

The incidence of Marfan syndrome in the general population is 0.3%. Two-thirds of patients with Marfan syndrome have concurrent pectus deformity. However, incidence of Marfan syndrome and cardiac abnormalities in patients presenting with an isolated pectus deformity remains unknown. We sought to establish the degree of association between pectus deformities and these abnormalities, and whether referral of these patients for cardiac and genetic workup is warranted.

METHODS

Our pediatric surgery group refers patients with pectus deformities for genetic and cardiac evaluation. We examined 415 records from 2009 to 2016, and identified 241 patients with a chief complaint of a pectus deformity. Patient characteristics, echocardiogram results, Haller indices, and genetic results were analyzed.

RESULTS

The frequency of Marfan syndrome in our study was 5.3%. The incidence of Marfan was highest among patients with combined type pectus deformity (20%). Cardiac anomalies showed an overall incidence of 35%. Of those diagnosed with Marfan, 84% had cardiac abnormalities.

CONCLUSION

More than 5% of patients presenting with a chief complaint of pectus deformity will have a diagnosis of Marfan syndrome, compared to 0.3% in the general population. Approximately a third of this population will have cardiac abnormalities. Referral of patients with pectus deformities for evaluation for Marfan syndrome and cardiac abnormalities is appropriate.

LEVEL OF EVIDENCE

Level IV.

Repeated lipopolysaccharide exposure leads to placental endotoxin tolerance

PROBLEM

Placental infection induces increased levels of pro-inflammatory cytokines, which have been implicated in the pathogenesis of pre-term labor. Endotoxin tolerance is a phenomenon in which exposure to a dose of endotoxin makes tissue less responsive to subsequent exposures. The objective of our study was to determine whether repeated exposure to endotoxin will induce a tolerant phenotype in normal human second-trimester placental tissue.

METHODS OF STUDY

Human second-trimester placental explants from elective termination of pregnancy were cultured and exposed to endotoxin (LPS). After 24 hours, the media was collected for analysis, and the explants were re-exposed to LPS after adding fresh media for another 24 hours. This process was repeated for a total of 4 LPS doses. The media was collected from each day and analyzed for cytokine levels.

RESULTS

The first LPS treatment stimulated the secretion of the pro-inflammatory cytokines IL-1β and TNF-α. However, their production was significantly diminished with repeated LPS doses. Production of the anti-inflammatory cytokines, IL-1ra and IL-10, was also stimulated by the first LPS treatment, but secretion was more gradually and moderately decreased with repeated LPS doses compared to the pro-inflammatory cytokines. The ratios of the anti-inflammatory/pro-inflammatory mediators (IL-1ra/IL-1β and IL-10/TNF-α) indicate a progressively more anti-inflammatory milieu with repeated LPS doses.

CONCLUSION

Repeated LPS exposure of human second-trimester placental tissues induced endotoxin tolerance. We speculate that endotoxin tolerance at the maternal-fetal interface will protect the fetus from exaggerated inflammatory responses after repeated infectious exposure.

Intratibial Injection Causes Direct Pulmonary Seeding of Osteosarcoma Cells and Is Not a Spontaneous Model of Metastasis: A Mouse Osteosarcoma Model

BACKGROUND

Although metastasis is the major cause of mortality in patients with osteosarcoma, little is known about how micrometastases progress to gross metastatic disease. Clinically relevant animal models are necessary to facilitate development of new therapies to target indolent pulmonary metastases. Intratibial injection of human and murine osteosarcoma cell lines have been described as orthotopic models that develop spontaneous pulmonary metastasis over time. However, there is variability in reported injection techniques and metastatic efficiency.

QUESTIONS/PURPOSES

We aimed to characterize a widely used murine model of metastatic osteosarcoma, determine whether it is appropriate to study spontaneous pulmonary metastasis by establishing a reliable volume for intratibial injection, determine the incidence of primary tumor and metastatic formation, determine the kinetics of pulmonary metastatic seeding and outgrowth, and the contribution of the primary tumor to subsequent development of metastasis.

METHODS

The metastatic mouse osteosarcoma cell line K7M2 was injected into the tibia of mice. The maximum volume that could be injected without leakage was determined using Evan's blue dye (n = 8 mice). Primary tumor formation and metastatic efficiency were determined by measuring the incidence of primary tumor and metastatic formation 4 weeks after intratibial injection (n = 30). The kinetics of metastatic development were determined by performing serial euthanasia at 1, 2, 3, and 4 weeks after injection (n = 24; five to six mice per group). Number of metastatic foci/histologic lung section and metastatic burden/lung section (average surface area of metastatic lesions divided by the total surface area of the lung) was calculated in a blinded fashion. To test the contribution of the primary tumor to subsequent metastases, amputations were performed 30 minutes, 4 hours, or 24 hours after injection (n = 21; five to six mice per group). Mice were euthanized after 4 weeks and metastatic burden calculated as described previously, comparing mice that had undergone amputation with control, nonamputated mice. Differences between groups were calculated using Kruskal-Wallis and one-way analysis of variance.

RESULTS

The maximum volume of cell suspension that could be injected without leakage was 10 μL. Intratibial injection of tumor cells led to intramedullary tumor formation in 93% of mice by 4 weeks and resulted in detectable pulmonary metastases in 100% of these mice as early as 1 week post-injection. Metastatic burden increased over time (0.88% ± 0.58, week 1; 6.6% ± 5.3, week 2; 16.1% ± 12.5, week 3; and 40.3% ± 14.83, week 4) with a mean difference from week 1 to week 4 of -39.38 (p < 0.001; 95% confidence interval [CI], -57.39 to -21.37), showing pulmonary metastatic growth over time. In contrast, the mean number of metastatic foci did not increase from week 1 to week 4 (36.4 ± 33.6 versus 49.3 ± 26.3, p = 0.18). Amputation of the injected limb at 30 minutes, 4 hours, and 24 hours after injection did not affect pulmonary metastatic burden at 4 weeks, with amputation as early as 30 minutes post-injection resulting in a metastatic burden equivalent to tumor-bearing controls (48.9% ± 6.1% versus 40.9% ± 15.3%, mean difference 7.96, p = 0.819; 95% CI, -33.9 to 18.0).

CONCLUSIONS

There is immediate seeding of the metastatic site after intratibial injection of the K7M2 osteosarcoma cell line, independent of a primary tumor. This is therefore not a model of spontaneous metastasis.

CLINICAL RELEVANCE

This model should not be used to study the early components of the metastatic cascade, but rather used as an experimental model of metastasis. Improved understanding of this commonly used model will allow for proper interpretation of existing data and inform the design of future studies exploring the biology of metastasis in osteosarcoma.

Ultrasound-guided bilateral rectus sheath block vs. conventional local analgesia in single port laparoscopic appendectomy for children with nonperforated appendicitis

INTRODUCTION

Despite its minimally invasive approach, laparoscopic surgery can cause considerable pain. Regional analgesic techniques such as the rectus sheath block (RSB) offer improved pain management following elective umbilical hernia repair in the pediatric population. This effect has not been examined in laparoscopic single-incision surgery in children. We sought to compare the efficacy of bilateral ultrasound-guided RSB versus local anesthetic infiltration (LAI) in providing postoperative pain relief in pediatric single-incision transumbilical laparoscopic assisted appendectomy (TULA) with same-day discharge.

METHODS

We retrospectively reviewed 275 children, ages 4 to 17 years old, who underwent TULA for uncomplicated appendicitis in a single institution from August 2014 to July 2015. We compared those that received preincision bilateral RSB (n=136) with those who received LAI (n=139). The primary outcome was narcotic administration. Secondary outcomes included initial and mean scores, time from anesthesia induction to release, operative time, time to rescue dose of analgesic in the PACU and time to PACU discharge.

RESULTS

Total narcotic administration was significantly reduced in patients that underwent preincision RSB compared to those that received conventional LAI, with a mean of 0.112 mg/kg of morphine versus 0.290 mg/kg morphine (p<0.0001). Patients undergoing RSB reported lower initial (0.38 vs. 2.38; p<0.0001) and mean pain scores (1.26 vs. 1.77; p<0.015). Time to rescue analgesia was prolonged in patients undergoing RSB compared to LAI (58.93min vs. 41.56min; p=0.047).

CONCLUSION

Preincision RSB for TULA in uncomplicated appendicitis in children is associated with decreased opioid consumption and lower pain scores compared with LAI. As the addition of this procedure only added 6.67min to time under anesthesia, we feel that it is a viable option for postoperative pain control in pediatric single-incision laparoscopic surgery.

RETROSPECTIVE COMPARATIVE STUDY

LEVEL III EVIDENCE.

The Macrophage Inhibitor CNI-1493 Blocks Metastasis in a Mouse Model of Ewing Sarcoma through Inhibition of Extravasation

Metastatic Ewing Sarcoma carries a poor prognosis, and novel therapeutics to prevent and treat metastatic disease are greatly needed. Recent evidence demonstrates that tumor-associated macrophages in Ewing Sarcoma are associated with more advanced disease. While some macrophage phenotypes (M1) exhibit anti-tumor activity, distinct phenotypes (M2) may contribute to malignant progression and metastasis. In this study, we show that M2 macrophages promote Ewing Sarcoma invasion and extravasation, pointing to a potential target of anti-metastatic therapy. CNI-1493 is a selective inhibitor of macrophage function and has shown to be safe in clinical trials as an anti-inflammatory agent. In a xenograft mouse model of metastatic Ewing Sarcoma, CNI-1493 treatment dramatically reduces metastatic tumor burden. Furthermore, metastases in treated animals have a less invasive morphology. We show in vitro that CNI-1493 decreases M2-stimulated Ewing Sarcoma tumor cell invasion and extravasation, offering a functional mechanism through which CNI-1493 attenuates metastasis. These data indicate that CNI-1493 may be a safe and effective adjuvant agent for the prevention and treatment of metastatic Ewing Sarcoma.

An analysis of pancreas transplantation outcomes based on age groupings--an update of the UNOS database

INTRODUCTION

Previously, increasing age has been a part of the exclusion criteria used when determining eligibility for a pancreas transplant. However, the analysis of pancreas transplantation outcomes based on age groupings has largely been based on single-center reports.

METHODS

A UNOS database review of all adult pancreas and kidney-pancreas transplants between 1996 and 2012 was performed. Patients were divided into groups based on age categories: 18-29 (n = 1823), 30-39 (n = 7624), 40-49 (n = 7967), 50-59 (n = 3160), and ≥60 (n = 280). We compared survival outcomes and demographic variables between each age grouping.

RESULTS

Of the 20 854 pancreas transplants, 3440 of the recipients were 50 yr of age or above. Graft survival was consistently the greatest in adults 40-49 yr of age. Graft survival was least in adults age 18-29 at one-, three-, and five-yr intervals. At 10- and 15-yr intervals, graft survival was the poorest in adults >60 yr old. Patient survival and age were found to be inversely proportional; as the patient population's age increased, survival decreased.

CONCLUSION

Pancreas transplants performed in patients of increasing age demonstrate decreased patient and graft survival when compared to pancreas transplants in patients <50 yr of age.

The use of venous jump grafts in pancreatic transplantation - no difference in patient or allograft outcomes - an update of the UNOS database

Venous jump grafts are used in pancreas transplantation to salvage a pancreas with a short portal vein or to facilitate an easier anastomosis. There have been no large studies evaluating the safety of venous jump grafts in pancreas transplantation. We analyzed the UNOS database to determine whether venous jump grafts are associated with graft loss or patient death. Data from UNOS on all adult pancreas transplant recipients 1996-2012 were analyzed. Venous extension grafts were used in 2657 cases; they were not in 18 124. Kaplan-Meier/product-limit estimates analysis demonstrated similar patient survival (p < 0.641) and death-censored graft survival (p < 0.351) at one, three, five,10, and 15 yr between subjects with and without venous jump grafts. There was a statistically significant difference in one-yr unadjusted patient survival between the venous extension graft (94.9%) and the no-venous extension graft (95.8%) groups (p < 0.045) and a borderline difference in one-yr graft survival between the venous extension graft (84.1%) and the no-venous extension graft (82.6%) groups (p < 0.055). There was no significant difference in patient survival or allograft survival at the three-, five-, 10-, and 15-yr intervals. The use of venous jump grafts is not associated with increased graft loss or mortality.

Haemophilus segnis: a rare cause of endocarditis

This report presents a case of endocarditis due to Haemophilus segnis, which represents a speciation difficulty for the routine laboratory. In this study, a molecular approach provided speciation, which was confirmed phenotypically by a reference laboratory. The use of molecular genotypic analysis is an additional strategy in the investigation of endocarditis. It has applications not only in isolate identification but also in primary detection of infection, particularly in patients whose blood is culture negative by conventional methodologies.

Pulmonary function testing in spinal cord injury: effects of abdominal muscle stimulation

The purpose of this study was to assess the effects of applying transcutaneous electrical stimulation to paralyzed abdominal muscles during pulmonary function testing (PFT) of individuals with spinal cord injury (SCI). Ten male subjects with anatomical level of SCI between C5-T7 were studied. Subjects performed PFTs with and without electrical stimulation delivered to the abdominal muscles. Subjects with the lowest percentage of predicted expiratory volumes and flows demonstrated the greatest improvement when electrical stimulation was delivered during forced expiration. The overall increases seen in percent of predicted for the study sample were 23 percent for forced vital capacity (FVC), 16 percent for forced expiratory flow in 1 s (FEV1), and 22 percent for peak expiratory flow rate (PEF). Contractions of paralyzed expiratory muscles in response to electrical stimulation during the performance of PFT maneuvers can significantly improve FVC, FEV1, and PEF in some individuals with SCI.

Implementation of a nursing home urinary incontinence management program with and without tolterodine

OBJECTIVE

To evaluate the implementation of a nursing home urinary incontinence management program.

DESIGN

A prospective field trial of the program incorporating practice guidelines and principles of continuous quality improvement.

SETTING

Five nursing homes in New York, Virginia, and Georgia

PARTICIPANTS

One hundred fifty-one residents identified as being incontinent of urine and who met inclusion criteria for ongoing participation in the program.

INTERVENTION

Key multidisciplinary staff from the five nursing homes were trained in the program and assumed responsibility for implementing it in their facilities. The program consisted of a clinical assessment, toileting protocols, and the addition of the antimuscarinic drug tolterodine in selected residents who did not respond well to toileting alone. Data on dryness rates during the 60-day toileting protocols, collected by nursing home staff, were analyzed on a weekly basis by an overall project coordinator who sent data back to the nursing homes in an easy-to-read graphical format.

MEASURES

(1) The dryness rate, defined as the number of times the resident was dry divided by the number of times the resident was checked (every 2 hours from 7 a.m. to 7 p.m.); and (2) adverse events (eg, dry mouth, increased confusion, need for dosage reduction).

RESULTS

Of 645 residents in the 5 nursing homes, 377 (58%) were identified as incontinent of urine, of whom 151 (40%) were placed on an ongoing toileting program. Of these 151 residents, 48 (32%) were prescribed tolterodine, and 117 (78%) completed the 60-day trial. The initial dryness rate was 57%, and for the group as a whole remained essentially unchanged (increase in dryness 1%, P = 0.50). Among 50 clinically stable residents on a toileting program alone, the increase in the dryness rate was 16% (P = 0.001), and for 31 clinically stable residents prescribed tolterodine, the increase in the dryness rate was 29% (P = 0.012). Two residents had their dosage of tolterodine reduced because of dry mouth and nausea,one resident was taken off the drug because of increased pain in the back and legs and increased confusion.

CONCLUSIONS

Overall, this program resulted in significant increases in dryness rates for clinically stable incontinent nursing home residents. These residents represented 22% of the total number of residents identified as incontinent in the five participating nursing homes. Tolterodine was prescribed for approximately one-third of incontinent residents as a supplement to a toileting program, and was well tolerated. Nursing homes should be encouraged to implement similar urinary incontinence programs, target toileting protocols to the most responsive residents, and maintain the program using principles of continuous quality improvement.

Breathing pattern retraining and exercise in persons with chronic obstructive pulmonary disease

Breathing pattern retaining, in the form of pursed-lip breathing, has been used as one method in pulmonary rehabilitation to help alleviate the symptoms of dyspnea endured by people who suffer from airflow obstruction secondary to chronic obstructive pulmonary disease (COPD). Other techniques such as biofeedback also have been successfully used. This article describes the altered breathing patterns used by patients with COPD at rest and during physical activity. The literature is reviewed regarding techniques of breathing pattern retraining that have been developed to improve the capacity of persons with COPD to perform activities of daily living, a primarily rehabilitative outcome.

Effect of local conjugated estrogens on vaginal pH in elderly women

OBJECTIVE

The decline in estrogens during and after menopause is associated with an increase in vaginal pH and an increased susceptibility to urinary tract infections (UTIs). Decreased vaginal pH following short-term treatment with topical estrogens may reduce the incidence of such infections. This study was undertaken to evaluate the effect of low-dose, topical conjugated estrogens vaginal cream (CEVC) on vaginal pH in older, postmenopausal women.

DESIGN

We conducted a retrospective analysis of initial and follow-up evaluations of older, postmenopausal women residing in 19 long-term care facilities who were referred to Seton Health System's Incontinence Treatment Center between January 2, 1997, and June 13, 1998. Patients were untreated or were administered conjugated estrogens intravaginally (0.5 g/d, 3 days per week).

SETTING

Incontinence Treatment Center, Seton Health System.

PARTICIPANTS

Two hundred fifty-eight postmenopausal women (mean age 83 years), residents of skilled nursing facilities, who were diagnosed with urinary incontinence, were included in the study.

MEASUREMENTS

Measurements included age, CEVC treatment, vaginal pH, and history of UTIs or hysterectomy.

RESULTS

In the CEVC-treated women, vaginal pH was reduced from a mean of 7.41 +/- 0.71 to 6.80 +/- 0.70 after 6 weeks (n = 213; P = 0.0001). No differences in vaginal pH were observed in untreated women (n = 45). Continuation of CEVC treatment for an additional 6 weeks (n = 93) resulted in further decreases in vaginal pH (P = 0.017). Women who discontinued treatment after 6 weeks maintained a lower vaginal pH for 6 weeks (P = 0.0004), and there was no significant difference between groups at Week 12.

CONCLUSIONS

Low-dose CEVC for 6 and 12 weeks reduces vaginal pH in older women residing in long-term care facilities. The decreased vaginal pH following short-term treatment with topical estrogens may reduce the incidence of recurrent UTIs.

Risks of morbidity and mortality in dialysis patients undergoing coronary artery bypass surgery. Northern New England Cardiovascular Disease Study Group

BACKGROUND

Although dialysis patients are undergoing CABG with increasing frequency, large studies specifically comparing patient characteristics and procedure-related risks in this population have not been performed.

METHODS AND RESULTS

We conducted a regional prospective cohort study of 15,500 consecutive patients undergoing CABG in northern New England from 1992 to 1997. We used multiple logistic regression analysis to examine associations between preoperative dialysis-dependent renal failure and postoperative events and to adjust for potentially confounding variables. The 279 dialysis-dependent renal failure patients (1.8%) were 4.4 times more likely to experience in-hospital mortality than were other CABG patients (12.2% versus 3.0%, respectively; P:<0.001). Dialysis-dependent renal failure patients were older and had more comorbidities and more severe cardiac disease than did other CABG patients. After adjusting for these factors in multivariate analysis, however, dialysis-dependent renal failure patients remained 3.1 times more likely to die after CABG (adjusted odds ratio [OR] 3.1, 95% CI 2.1 to 4.7; P:<0.001). Dialysis-dependent renal failure patients compared with other CABG patients also had a substantially increased risk of postoperative mediastinitis (3.6% versus 1.2%, respectively; adjusted OR 2.4, 95% CI 1.2 to 4.7; P:=0.011) and postoperative stroke (4.3% versus 1.7%, respectively; adjusted OR 2. 1, 95% CI 1.1 to 3.9; P:=0.016), even after controlling for potentially confounding variables. Risks of reexploration for bleeding were similar for patients with and without dialysis-dependent renal failure.

CONCLUSIONS

Preoperative dialysis-dependent renal failure is a strong independent risk factor for in-hospital mortality and mediastinitis after CABG.

Effect of exercise on perceived quality of life of individuals with Parkinson's disease

The purpose of this study was to determine if individuals with Parkinson's disease (PD) who completed an 8-week, supervised PoleStriding exercise program would undergo significant improvements in cognitive skills, activities of daily living, motor function, and quality of life. The Unified Parkinson's Disease Rating Scale (UPDRS) and the Parkinson's Disease Questionnaire (PDQ-39) were used to measure functional independence. Six male volunteers (72.7+/-3.7 years of age) performed PoleStriding exercise three times per week for 37+/-3 minutes. Differences in the participants' pre- and post-training scores on the UPDRS and PDQ-39 were analyzed using the Wilcoxin Signed Ranks Test. A statistically significant improvement occurred in the UPDRS (P<0.026) and PDQ-39 (P<0.028) scores following the moderate-intensity exercise intervention. The results of this nonrandomized clinical trial indicate that an 8-week individualized PoleStriding exercise program increases perceived functional independence and quality of life in individuals with PD.

Implementing an incontinence program in long-term care settings. A multidisciplinary approach

Urinary incontinence is a prevalent and costly problem in long-term care settings. Impaired bladder function can cause many physical and social problems, such as impaired skin integrity, falls, and altered psychological well-being. Fortunately, there are several low-risk interventions that can cure or improve continence status in many individuals, regardless of cognitive status. Basic assessment of medical and environmental status, as outlined in this article, can assist staff in determining transient conditions which often alter bladder control. Because many interventions are dependent on mobility, dexterity, and diet, an interdisciplinary approach is ideal.

Urinary incontinence. Noninvasive treatment options

One in six women older than 45 experiences incontinence, but 31% of them never discuss their condition with anyone. A proactive approach on the part of all health care providers is needed to break this silence, particularly among clinicians who care for women. Urinary incontinence is classified as stress, urge, mixed, overflow or functional incontinence. Differential diagnosis of incontinence is essential to choosing appropriate treatment options. This article outlines noninvasive treatment options that are specific to diagnosis.

Estrogen in urinary incontinence treatment: an anatomic and physiologic approach

Most women and health care providers are knowledgeable about the benefits that estrogen replacement therapy has on the prevention of cardiovascular disease and osteoporosis. What is commonly unknown and under research is the role estrogen plays in maintaining continence. The lower urinary tract shares a common embryologic origin with the female genital organs and is hormonally sensitive. Menopause, either surgical or natural, results in decreased or diminished circulating estrogens that can affect the genitourinary system, causing atrophic symptoms. A comprehensive urinary incontinence workup should include assessment of the vaginal mucosa and treatment of hormone deficiency symptoms such as atrophic vaginitis and urethritis. Risk assessment should be done before hormone replacement therapy is considered.

Inhibition of poly(ADP-ribose) polymerase preserves surfactant synthesis after hydrogen peroxide exposure

Exposure to hydrogen peroxide (H2O2) decreases phosphatidylcholine (PC) synthesis in rabbit type II pneumocytes. Activation of poly(ADP-ribose) polymerase (PARP) may play a role in this process. Exposure of type II pneumocytes to H2O2 resulted in a 53% decrease in the rate of incorporation of [3H]choline into PC (P < 0.001). Cell NAD and ATP levels were decreased by 52% (P < 0.001) and 39% (P < 0.01), respectively, without significant changes in cell viability. Exposure to H2O2 also resulted in a 52% (P < 0.05) increase in the activity of PARP. Preincubation of type II cells with inhibitors of PARP (nicotinamide; 3-aminobenzamide) before H2O2 exposure prevented the increase in PARP activity, and blocked the decreases in ATP, NAD, and rate of PC synthesis. These results suggest that the energy depletion associated with activation of PARP contributes to the effects of oxidant stress on type II cell metabolic function and may be ameliorated by pharmacological agents in vitro.

Evaluation and treatment of urinary incontinence: a primary care approach

Of the approximate 10 million Americans affected by urinary incontinence, it is estimated that, when diagnosed and evaluated appropriately, 80% will respond to treatment. Primary care providers are in ideal positions to initially screen their patients for symptoms of urinary incontinence. In many situations, the primary care provider can also diagnose and successfully treat urinary incontinence as part of routine health care.

Altered regulation of IL-6 production with normal aging. Possible linkage to the age-associated decline in dehydroepiandrosterone and its sulfated derivative

Normal aging in humans has been recently shown to be accompanied by reduced control over production of the multifunctional cytokine IL-6. This cytokine was reported to be quantitatively elevated in most serum samples obtained from "normal" elderly humans. In the present investigation, we report that IL-6 levels are elevated in serum samples obtained from aged mice, and its spontaneous production could also be easily detected in culture supernatants of unstimulated lymphoid cells obtained from aged, but not mature, adult donors. Spontaneous production of IL-6 was consistently observed in culture supernatants of lymphoid cells from both the spleen and mesenteric lymph nodes from aged donors, but was absent from supernatants derived from their peripheral lymph nodes. In aged mice, the reduced regulation of IL-6 production could be effectively prevented and/or reversed by supplementing aging animals with dehydroepiandrosterone sulfate, a steroid hormone whose endogenous production is known to decline with advancing age in all species tested. It was also established that serum obtained from old dehydroepiandrosterone sulfate-treated mice contained lower (normal) levels of serum amyloid P substance (an acute phase reactant), reduced levels of serum Ig (all classes and isotypes) and lower titers of tissue-specific autoantibodies than untreated aged controls. Therefore, a number of well described, age-related conditions, some of which could be contributing to the pathologic phenotype of old age, may actually represent secondary effects to this age-associated change in IL-6 production.

Altered regulation of IL-6 production with normal aging. Possible linkage to the age-associated decline in dehydroepiandrosterone and its sulfated derivative

Normal aging in humans has been recently shown to be accompanied by reduced control over production of the multifunctional cytokine IL-6. This cytokine was reported to be quantitatively elevated in most serum samples obtained from "normal" elderly humans. In the present investigation, we report that IL-6 levels are elevated in serum samples obtained from aged mice, and its spontaneous production could also be easily detected in culture supernatants of unstimulated lymphoid cells obtained from aged, but not mature, adult donors. Spontaneous production of IL-6 was consistently observed in culture supernatants of lymphoid cells from both the spleen and mesenteric lymph nodes from aged donors, but was absent from supernatants derived from their peripheral lymph nodes. In aged mice, the reduced regulation of IL-6 production could be effectively prevented and/or reversed by supplementing aging animals with dehydroepiandrosterone sulfate, a steroid hormone whose endogenous production is known to decline with advancing age in all species tested. It was also established that serum obtained from old dehydroepiandrosterone sulfate-treated mice contained lower (normal) levels of serum amyloid P substance (an acute phase reactant), reduced levels of serum Ig (all classes and isotypes) and lower titers of tissue-specific autoantibodies than untreated aged controls. Therefore, a number of well described, age-related conditions, some of which could be contributing to the pathologic phenotype of old age, may actually represent secondary effects to this age-associated change in IL-6 production.

Bone metabolism in children with asthma treated with inhaled beclomethasone dipropionate

Previous studies have shown that inhaled corticosteroids can affect bone metabolism in adults. A study to assess the effect of inhaled beclomethasone, 300 to 800 micrograms/day for at least 6 months (mean 25 months), was therefore undertaken in children. In part 1 of the study, 18 children with asthma, aged 4 to 17 years (mean 10.1 years), were compared with an age- and sex-matched group of children with asthma not treated with corticosteroids. In part 2, eight more pairs were compared. Comparisons were also made with 61 healthy children. Bone mineral density measured by radiographic absorptiometry, and bone mineral content measured by single-photon absorptiometry and by dual-energy x-ray absorptiometry, showed no significant differences. Serum levels of calcium, magnesium, zinc, total alkaline phosphatase, bone specific alkaline phosphatase, parathyroid hormone, 25-hydroxyvitamin D, and 1,25-dihydroxyvitamin D also showed no differences. The activity of tartrate-resistant acid phosphatase, a marker of bone resorption, was significantly lower in the beclomethasone group than in both the asthma control and the normal control groups, but urine calcium excretion did not differ. Patients with asthma had lower serum osteocalcin and higher serum copper levels than control subjects without asthma, but treatment with beclomethasone did not affect these values. We conclude that inhaled beclomethasone (up to 800 micrograms/day) does not reduce bone mineralization or increase bone resorption. Effects on bone formation were difficult to assess because asthma per se caused a significant reduction in osteocalcin, a sensitive marker of bone formation.

Acute management of the self-cutter

'Self-cutting' is a specific type of emergency presenting to accident and emergency departments. All cases presenting in Sheffield in a 6-month period were studied. The self-cutter is most often a young, unemployed man: this is the group most likely to cut repeatedly. At least 45% of all cutters had a past psychiatric history, and a quarter of them were judged a high suicidal risk. The seriousness of the physical injury and the suicidal risk cannot be simply correlated. The crucial part of acute management is the decision about psychiatric referral. As with a complex physical injury, formal assessment must be performed and specialist referral made on that basis.

Near-infrared dye having a large ultrafast third-order susceptibility

Efficient degenerate four-wave mixing of 160-psec infrared light pulses at lambda = 1.064 microm in solutions of a new dye that absorbs between 1.0 and 1.6 microm is reported. A Kerr-like third-order susceptibility of X((3))(xyyx) = 8 +/- 3) x 10(-12) esu with a decay time of less than 50 psec is observed in various solvents.