A SICE (Società Italiana di Chirurgia Endoscopica e Nuove Tecnologie) observational prospective multicenter study on anatomical variants of the superior mesenteric artery: intraoperative analysis during laparoscopic right hemicolectomy-CoDIG 2 database (ColonDx Italian Group)

Colorectal cancer, the third most common cancer worldwide, affects 40-45% of patients on the right side. Surgery, especially minimally invasive methods such as laparoscopic and robotic procedures, is the preferred treatment. However, these techniques present technical complications. The anatomical complexity and variations in vessel branching patterns pose challenges, particularly for less experienced surgeons. The CoDIG 2 is a nationwide observational study involving 76 specialized Italian general surgery departments focused on colorectal surgery. The centres were directed to maintain their standard surgical and clinical practices. The aim of this study was to analyse the intraoperative vascular anatomy of Italian patients who underwent laparoscopic right colectomy and explore the ligature techniques used by Italian surgeons. Surgeons reported information about vascularization of the right colon for 616 patients and about surgical anatomy of RCA for 368 patients. Fifty-three patients (10.8%) showed no RCA intraoperatively. The right colic artery (RCA) was categorized according to the Yada classification (types 1-4) during evaluation, and intraoperative assessments revealed that Yada type 1 was the most common type (55.2%), while radiologic evaluations revealed a higher prevalence of type 2. Furthermore, compared with the superior mesenteric vein (SMV), the RCA is more often located anteriorly according to intraoperative and contrast-enhanced CT examination; 59.9% were found in the anterior position during intraoperative examination, while 40.1% were found in the same position on preoperative contrast-enhanced CT. Vascularization of the right colon, including missing branches, additional branches, shared trunks, and retro-superior courses of the mesenteric vein, exhibited notable variations. To understand vascular variations, a preoperative radiological study is necessary; although there was no concordance between the intraoperative and radiological evaluations, this is a limitation of preinterventional radiological evaluation (PII) because it is always needed for oncological staging. This approach is especially critical for inexperienced surgeons to avoid potential complications, such as problematic bleeding.

Systematic review and meta-analysis of the anatomical variants of the left colic artery

AIM

To provide a comprehensive evidence-based assessment of the anatomical variations of the left colic artery (LCA).

METHOD

A thorough systematic search of the literature up until 1 April 2019 was conducted on the electronic databases PubMed, SCOPUS and Web of Science (WOS) to identify studies eligible for inclusion. Data were extracted and pooled into a meta-analysis using the Metafor package in R. The primary outcomes of interest were the absence of the LCA and the anatomical variants of its origin. The secondary outcomes were the distance (mean ± SD) between the origin of the inferior mesenteric artery (OIMA) and the origin of the left colic artery (OLCA).

RESULTS

A total of 19 studies (n = 2040 patients) were included. The pooled prevalence estimate (PPE) of LCA absence was 1.2% (95% CI 0.0-3.6%). Across participants with either a Type I or Type II LCA, the PPE of a Type I LCA was 49.0% (95% CI 40.2-57.8%). The PPE of a Type II LCA was therefore 51.0%. The pooled mean distance from the OIMA to the OLCA was 40.41 mm (95 CI% 38.69-42.12 mm). The pooled mean length of a Type I LCA was 39.12 mm (95% CI 36.70-41.53 mm) while the pooled mean length of a Type IIa and Type IIb LCA was 41.43 mm (95% CI 36.90-43.27 mm) and 39.64 mm (95% CI 37.68-41.59 mm), respectively.

CONCLUSION

Although the absence of the LCA is a rare occurrence (PPE 1.2%), it may be associated with an important risk of anastomotic leakage as a result of insufficient vascularization of the proximal colonic conduit. It is also necessary to distinguish variants I and II of Latarjet, the frequency of which is identical, with division of the LCA being technically more straightforward in variant I of Latarjet. Surgeons should be aware that technical difficulties are likely to be more common with variant II of Latarjet, as LCA ligation may be more difficult due to its close proximity to the inferior mesenteric vein (IMV).

Massard Prairie Restoration and Soil Microbiome Succession

We have initially sequenced soil microbial DNA from 4 restored and 3 virgin tallgrass prairie soil samples from Ben Geren Park and Massard Prairie (Fort Smith, AR), respectively. As expected, the soil microbiomes are distinct, with several lineages of nitrogen-fixing bacteria more common in virgin tallgrass prairie. However, we predict that as restoration of tallgrass prairie in Ben Geren Park progresses, the soil microbiome of restored prairie will more closely mirror those of the virgin prairie.

B-12 Cognitive Resilience in MS: Associations with Lesion Volume, Pain, and Smoking Status

Objective

Cognitive dysfunction is common in people with MS (pwMS), but relatively little is known about those with no objective or subjective impairment. We sought to further examine a previously characterized cognitively resilient group of pwMS (MS-RES)—individuals without cognitive impairment, without subjective cognitive complaints, and without informant-reported cognitive difficulties—and considered neuroimaging, pain-related, and smoking correlates in this group.

Method

We derived two groups of pwMS: cognitively resilient (MS-RES; N = 15) and other MS (N = 85). MS groups showed equivalent education, gender, symptom and diagnosis duration, MS subtype, EDSS rating, and reported hours of sleep, and endorsed no more than mild depression. Both MS groups were compared to age- and gender-matched healthy controls (N = 31) on appropriate variables, and MS groups were compared on lesion volume, pain, and smoking variables.

Results

Despite showing intact subjective and objective cognition, the MS-RES group had lesion volume comparable to other MS participants. The MS-RES group also reported less of an impact of pain on overall functioning, recreational activities, and life enjoyment compared to other MS participants (p < .05), and were comparable to healthy controls. There was a trend toward MS-RES participants being less likely to be current smokers than others with MS (p = .09), and MS-RES and healthy controls showed comparable smoking status.

Conclusions

We found that cognitively resilient pwMS have unique clinical features that differentiate them from others with MS despite similar lesion volumes. A more complete understanding of cognitively resilient pwMS may inform interventions that promote MS symptom management and general resilience.

Is it possible to identify the inguinal nerves during hernioplasty? A systematic review of the literature and meta-analysis of cadaveric and surgical studies

Purpose

Patients who undergo inguinal hernioplasty may suffer from persistent postoperative pain due to inguinal nerve injuries. The aim of this systematic review and meta-analysis was to provide comprehensive data on the prevalence (identification rates), anatomical characteristics, and ethnic variations of the ilioinguinal (IIN), the iliohypogastric (IHN) and the genital branch of the genitofemoral (GNF) nerves.

Methods

The systematic literature search was conducted using the PubMed, Scopus and Web of Science databases.

Results

A total of 26 articles (5265 half-body examinations) were included in this study. The identification rate of the IIN was 94.4% (95% CI 89.5–97.9) using a random-effects model. Unweighted multiple regression analysis showed that study sample size (β = − 0.74, p = .036) was the only statistically significant predictor of lower prevalence. The identification rates of the IHN and GNF was 86.7% (95% CI 78.3%–93.3%) and 69.1% (95% CI 53.1%–83.0%) using a random-effects model, respectively. For those outcomes, a visual analysis of funnel and Doi plots indicated irregularity and provided evidence that larger studies tended to have lower identification rates. In terms of the synthesis of anatomical reference points, there was a large and statistically significant amount of heterogeneity for most outcomes.

Conclusions

The identification rates of the inguinal nerves in our study were lower than reported in literature. The lowest was found for GNF, suggesting that this nerve was the most difficult to identify. Knowledge regarding the anatomy of the inguinal nerves can facilitate their proper identification and reduce the risk of iatrogenic injury and postoperative pain.

A systematic analysis of controlled clinical trials using the NiTi CAR™ compression ring in colorectal anastomoses

Anastomotic leak following colorectal surgery can be a devastating adverse event. The ideal stapling device should be capable of rapid creation of an anastomosis with serosal apposition without the persistence of a foreign body or a foreign body reaction which potentially contribute to early anastomotic dehiscence or late anastomotic stricture. A systematic review was performed examining available data on controlled randomized and non-randomized trials assessing the NiTi compression anastomosis ring-(NiTi CAR™) (NiTi Solutions, Netanyah Israel) in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) standards. A protocol for this meta-analysis has been registered on PROSPERO (CRD42016050934). The initial search yielded 45 potentially relevant articles. After screening titles and abstracts for relevance and assessment for eligibility, 39 of these articles were eventually excluded leaving 6 studies for analysis in the review. Regarding the primary outcome measure, the overall anastomotic leak rate was 2.2% (5/230) in the compression anastomosis group compared with 3% (10/335) in the conventional anastomosis group; this difference was not statistically significant (RR 0.75, 95% CI 0.25-2.24; participants = 565; studies = 6; I ² = 0%). There were no statistically significant differences between compression and conventional anastomoses in any of the secondary outcomes. This review was unable to demonstrate any statistically significant differences in favor of the compression anastomosis technique over conventional manual or stapled mechanical anastomoses.

Acute appendicitis can be treated with single-incision laparoscopy: a systematic review of randomized controlled trials

AIM

Single-incision laparoscopic surgery (SILS) has been proposed as the next step in minimally invasive surgery for appendicectomy. Previous reviews have summarized the results of low-evidence comparative studies, suggesting that the two approaches are comparable in terms of outcomes but showing the need for randomized controlled trials (RCTs). This review offers a meta-analyses of RCTs on this topic to evaluate the safety and efficacy of single-incision laparoscopic appendectomy (SILA).

METHOD

A comprehensive research of electronic databases was performed. Primary outcomes (overall and access-specific morbidity) were designated as safety issues. Secondary outcomes were pain, cosmesis, operative time, conversion rate and length of hospital stay.

RESULTS

After exclusions, five RCTs satisfied the inclusion criteria. They included a total of 761 patients [379 SILA and 382 conventional three-port laparoscopic appendectomies (CLA)]. No significant differences were found in overall morbidity, early wound morbidity or length of stay between SILA and CLA. Cosmesis and pain were not comparable due to different scales and time records. Conclusions on the incisional hernia rate were not reliable due to short follow-up periods.

CONCLUSION

SILA can be considered an acceptable alternative to CLA in the treatment of acute appendicitis, but an economic evaluation of the various techniques for single access must be performed before its widespread clinical introduction. Better-designed RCTs are necessary to define a population in which SILA could have major benefits.

Laparoscopic treatment of colovesical fistulas due to complicated colonic diverticular disease: a systematic review

Colovesical fistulas originating from complicated sigmoid diverticular disease are rare. The primary aim of this review was to evaluate the role of laparoscopic surgery in the treatment of this complication. The secondary aim was to determine the best surgical treatment for this disease. A systematic search was conducted for studies published between 1992 and 2012 in PubMed, the Cochrane Register of Controlled Clinical Trials, Scopus, and Publish or Perish. Studies enrolling adults undergoing fully laparoscopic, laparoscopic-assisted, or hand-assisted laparoscopic surgery for colovesical fistula secondary to complicated sigmoid diverticular disease were considered. Data extracted concerned the surgical technique, intraoperative outcomes, and postoperative outcomes based on the Cochrane Consumers and Communication Review Group's template. Descriptive statistics were reported according to the PRISMA statement. In all, 202 patients from 25 studies were included in this review. The standard treatment was laparoscopic colonic resection and primary anastomosis or temporary colostomy with or without resection of the bladder wall. Operative time ranged from 150 to 321 min. It was not possible to evaluate the conversion rate to open surgery because colovesical fistulas were not distinguished from other types of enteric fistulas in most of the studies. One anastomotic leak after bowel anastomosis was reported. There was zero mortality. Few studies conducted follow-up longer than 12 months. One patient required two reoperations. Laparoscopic treatment of colovesical fistulas secondary to sigmoid diverticular disease appears to be a feasible and safe approach. However, further studies are needed to establish whether laparoscopy is preferable to other surgical approaches.

Single incision laparoscopic right colectomy: a systematic review and meta-analysis

AIM

A meta-analysis was performed to compare the outcome of single incision laparoscopic right hemicolectomy with standard multiport laparoscopic right hemicolectomy.

METHOD

A systematic search of databases was carried out to extract comparative studies (randomized and non-randomized, prospective and retrospective). Data were analysed according to Cochrane Collaboration guidelines. A meta-analysis was performed when the data permitted this form of analysis.

RESULTS

Nine comparative studies were retrieved comprising 241 patients with single incision and standard laparoscopy. None of these was randomized. There was no significant difference between the two methods for the primary end-points of mortality, morbidity and cancer-specific parameters and for the secondary end-points of operation time, blood loss, ileus, hospital stay and conversion. It was not possible to analyse pain and cosmetics data owing to insufficient information.

CONCLUSION

Single incision laparoscopic right hemicolectomy is comparable with standard multiport laparoscopic right hemicolectomy in primary and secondary outcomes. Given current information it is justified to use single incision laparoscopic right hemicolectomy, but there is a need for a prospective randomized study.

A prospective, multi-center, randomised trial to evaluate the efficacy of a cryopneumatic device on total knee arthroplasty recovery

Pain, swelling and inflammation are expected during the recovery from total knee arthroplasty (TKA) surgery. The severity of these factors and how a patient copes with them may determine the ultimate outcome of a TKA. Cryotherapy and compression are frequently used modalities to mitigate these commonly experienced sequelae. However, their effect on range of motion, functional testing, and narcotic consumption has not been well-studied. A prospective, multi-center, randomised trial was conducted to evaluate the effect of a cryopneumatic device on post-operative TKA recovery. Patients were randomised to treatment with a cryopneumatic device or ice with static compression. A total of 280 patients were enrolled at 11 international sites. Both treatments were initiated within three hours post-operation and used at least four times per day for two weeks. The cryopneumatic device was titrated for cooling and pressure by the patient to their comfort level. Patients were evaluated by physical therapists blinded to the treatment arm. Range of motion (ROM), knee girth, six minute walk test (6MWT) and timed up and go test (TUG) were measured pre-operatively, two- and six-weeks post-operatively. A visual analog pain score and narcotic consumption was also measured post-operatively. At two weeks post-operatively, both the treatment and control groups had diminished ROM and function compared to pre-operatively. Both groups had increased knee girth compared to pre- operatively. There was no significant difference in ROM, 6MWT, TUG, or knee girth between the 2 groups. We did find a significantly lower amount of narcotic consumption (509 mg morphine equivalents) in the treatment group compared with the control group (680 mg morphine equivalents) at up to two weeks postop, when the cryopneumatic device was being used (p < 0.05). Between two and six weeks, there was no difference in the total amount of narcotics consumed between the two groups. At six weeks, there was a trend toward a greater distance walked in the 6MWT in the treatment group (29.4 meters versus 7.9 meters, p = 0.13). There was a significant difference in the satisfaction scores of patients with their cooling regimen, with greater satisfaction in the treatment group (p < 0.0001). There was no difference in ROM, TUG, VAS, or knee girth at six weeks. There was no difference in adverse events or compliance between the two groups. A cryopneumatic device used after TKA appeared to decrease the need for narcotic medication from hospital discharge to 2 weeks post-operatively. There was also a trend toward a greater distance walked in the 6MWT. Patient satisfaction with the cryopneumatic cooling regimen was significantly higher than with the control treatment.

Nuclear electric quadrupole moments of Rb from the hyperfine spectrum of RbF

The molecular beam electric resonance technique has been used to examine the hyperfine spectrum of RbF. The Rb nuclear electric quadrupole interaction, the spin-rotation interactions, and tensor and scalar spin-spin interactions have been measured for both Rb isotopes, including their dependence on vibrational and rotational states. Transition frequencies have been determined to a precision of better than 1 Hz in many cases. The magnetic interactions in the two isotopomers are consistent with what is expected from the known masses and magnetic dipole moments. In the case of the Rb nuclear electric quadrupole interaction, adjustments have been made for a small isotopomer shift, and for the ratio of the effective nuclear electric quadrupole moments, Q(87Rb)Q(85Rb) = 0.483 830 1+/-0.000 001 8. The effective quadrupole interaction includes a pseudoquadrupole interaction that may be significant at this level of precision, but cannot be distinguished experimentally.

An anomaly in the isotopomer shift of the hyperfine spectrum of LiI

A high-precision examination of the hyperfine spectrum of 6LiI in comparison with 7LiI shows a shift in the iodine nuclear electric quadrupole moment that cannot be accounted for by a model in which the electric field gradient at the iodine site is assumed to depend only upon the internuclear distance between Li and I. The other hyperfine interactions are consistent between the two isotopomers, including the previously reported electric hexadecapole interaction of the iodine nucleus.

Testosterone concentrations in women aged 25-50 years: associations with lifestyle, body composition, and ovarian status

While there is substantial evidence of the importance of endogenous and exogenous estrogen in reproductive health and chronic disease, there is little consideration of androgens in women's health. In the Michigan Bone Health Study (1992-1995), the authors examined the correlates of testosterone concentrations in pre- and perimenopausal women (i.e., age, menopausal status, body composition, and lifestyle behaviors) in a population-based longitudinal study including three annual examinations among 611 women aged 25-50 years identified through a census in a midwestern community. Current smokers had the highest testosterone concentrations with decreasing values in former and nonsmokers (p = 0.0001). Body composition measures (body mass index, body fat (%), weight (kg), lean body mass (kg), and fat mass (kg)) were significantly and positively associated with total testosterone concentrations in a dose-response manner. Hysterectomy with oophorectomy was associated with significantly lower testosterone concentrations. Alcohol consumption, physical activity, and dietary macronutrient intake were not associated with testosterone concentrations. This is one of the first studies to examine correlates of serum testosterone concentrations in anticipation of the growing interest in the role of androgens in women's health. The greater circulating levels of testosterone in obese women and smokers suggest that testosterone concentrations should be considered in the natural history of disease conditions where obesity and smoking are risk factors, including cardiovascular disease.

Phase I study of preoperative oral uracil and tegafur plus leucovorin and radiation therapy in rectal cancer

PURPOSE

Preoperative combined-modality therapy for rectal cancer may allow for sphincter preservation, while decreasing recurrence rates and improving the overall prognosis. Oral chemotherapy with uracil and tegafur (UFT) plus leucovorin (LV) may reduce costs and complications associated with protracted infusions of fluorouracil. Our goal was to evaluate the safety of UFT plus LV combined with preoperative radiation and determine the maximum-tolerated dose (MTD) and dose-limiting toxicity (DLT) of UFT plus LV in this setting.

PATIENTS AND METHODS

Patients with tumor-node-metastasis stage II or III rectal cancer received escalating doses of UFT (starting at 250mg/m(2)/d, with 50-mg/m(2)/d increments between consecutive cohorts) and fixed doses of LV (90 mg/d). The UFT and LV combination was given 5 days per week concurrently with a 5-week course of preoperative radiation totaling 45 Gy (1.8 Gy/fraction). Surgery was performed 4 to 6 weeks after radiation and was followed by four 35-day cycles of fixed doses of UFT and LV (28 days of therapy each cycle).

RESULTS

Fifteen patients were treated, and 13 received the full preoperative chemotherapy. All planned radiation was delivered successfully. The MTD of UFT with radiation was 350 mg/m(2)/d with 90 mg/d of LV. Diarrhea was the DLT. Sphincter-preserving surgery was performed in 12 of 14 patients. One patient had progressive disease before surgery. Pathologic evaluation of 14 resected specimens showed a complete response in three cases.

CONCLUSION

Preoperative chemoradiation with oral UFT plus LV is feasible and well tolerated and should be further investigated.

FORUM: The Relationship of Ecosystem Management to NEPA and Its Goals

/ The National Environmental Policy Act of 1969 (NEPA) was intended to promote a systematic, comprehensive, interdisciplinary approach to planning and decisionmaking, including the integration of the natural and social sciences and the design arts. NEPA critics have cited three key shortcomings in its implementation: (1) a lack of engagement with the NEPA process early in the planning process through interdisciplinary collaboration; (2) a lack of rigorous science and the incorporation of ecological principles and techniques; and (3) a lack of emphasis on the Act's substantive goals and objectives. In recent years and independent of NEPA, a policy of ecosystem management has been developed, which represents a fundamental change from a fragmented, incremental planning and management approach to a holistic, comprehensive, interdisciplinary land and resource management effort. We postulate that by incorporating ecosystem management principles in their planning and decisionmaking, federal agencies can address the shortcomings in NEPA implementation and move closer to NEPA's intent. A case analysis of EISs prepared by the USDA Forest Service before and after adopting an ecosystem management approach supports our hypothesis.

Physician, nurse, and social worker collaboration in primary care for chronically ill seniors

OBJECTIVES

To examine the impact of an interdisciplinary, collaborative practice intervention involving a primary care physician, a nurse, and a social worker for community-dwelling seniors with chronic illnesses.

METHODS

A concurrent, controlled cohort study of 543 patients in 18 private office practices of primary care physicians was conducted. The intervention group received care from their primary care physician working with a registered nurse and a social worker, while the control group received care as usual from their primary care physician. The outcome measures included changes in number of hospital admissions, readmissions, office visits, emergency department visits, skilled nursing facility admissions, home care visits, and changes in patient self-rated physical, emotional, and social functioning.

RESULTS

From 1992 (baseline year) to 1993, the two groups did not differ in service use or in self-reported health status. From 1993 to 1994, the hospitalization rate of the control group increased from 0.34 to 0.52, while the rate in the intervention group stayed at baseline (P= .03). The proportion of intervention patients with readmissions decreased from 6% to 4%, while the rate in the control group increased from 4% to 9% (P=.03). In the intervention group, mean office visits to all physicians fell by 1.5 visits compared with a 0.5-visit increase for the control group (P=.003). The patients in the intervention group reported an increase in social activities compared with the control group's decrease (P=.04). With fewer hospital admissions, average per-patient savings for 1994 were estimated at $90, inclusive of the intervention's cost but exclusive of savings from fewer office visits.

CONCLUSIONS

This model of primary care collaborative practice shows potential for reducing utilization and maintaining health status for seniors with chronic illnesses. Future work should explore the specific benefit accruing from physician involvement in the collaborative practice team.

Follicle-stimulating hormone is secreted more irregularly than luteinizing hormone in both humans and sheep

Recently introduced statistical tools capable of discerning differences between the pattern of luteinizing hormone (LH) secretion and that of follicle-stimulating hormone (FSH) could be valuable in understanding ovulation and menopause, and ultimately in making diagnostic decisions and treating infertility and polycystic ovary syndrome. We assessed the validity and scope of the hypothesis that FSH is secreted more irregularly than LH in ewes and fertile women. We compared secretory irregularity of LH to that of FSH in both ovariectomized ewes (n = 7) and women of proven fertility (n = 5) during the follicular and luteal phases of their reproductive cycles. In each sheep, time series from both hypophyseal portal blood (HPB) and peripheral blood were evaluated in 72 samples obtained every 5 min; in each human, both luteal and follicular periods were studied in 192 samples obtained every 7.5 min. To quantify serial irregularity, we used approximate entropy (ApEn), a scale- and model-independent statistic. FSH secretion was consistently more irregular than that of LH in each subject. For sheep HPB, ApEn(FSH) = 1.415+/-0.097 was larger than ApEn(LH) = 0. 822+/-0.213, P < 0.0001 (mean+/-SD, paired t test). This difference persisted peripherally: ApEn(FSHper) = 1.431+/-0.101 > ApEn(LHper) = 1.252+/-0.086, P = 0.024. In women, ApEn(FSH) = 1.467+/-0.217 > ApEn(LH) = 0.923+/- 0.305, P < 0.0001. ApEn(FSH) > ApEn(LH) in 100% of women (peripheral) and sheep HPB. Secretion during the follicular phase was more irregular than during the luteal phase for both FSH and LH (P < 0.01). LH mean level secretion showed a wake/sleep difference in women, P < 0.005, with higher values awake. The consistency and statistical significance of these findings suggest that this LH/FSH difference may be broadly based within higher mammals. Ranges of normative and abnormal regularity values of LH, FSH, and their difference can be used in a number of settings, both (currently) research and (potentially ultimately) clinical milieus.

Role of calciotrophic hormones in calcium mobilization of lactation

The postpartum period can be a time when profound changes in calcium metabolism and bone mineral density (BMD) occur, particularly in association with lactation. We investigated the hypothesis that calciotrophic hormones [1,25-dihydroxyvitamin D, 25-hydroxyvitamin D, and parathyroid hormone (PTH)] are different by lactation practice or hormone status [PTH-related peptide (PTHrP), estradiol, and prolactin] and have a potential role in the bone loss and recovery associated with lactation. 1,25-Dihydroxyvitamin D, 25-hydroxyvitamin D, PTH, femoral BMD, PTHrP, prolactin, estradiol, and bone turnover markers were measured at 2 wk and at 2, 4, 6, 12, and 18 mo postparturition in 115 postpartum women aged 20-40 y (parity: 0-1). Lumbar spine BMD was measured at 2 wk and at 6, 12, and 18 mo during the postpartum period. PTH, 1,25-dihydroxyvitamin D, and 25-hydroxyvitamin D concentrations were nonlinear across the 18-mo postpartum period. Between baseline and 18 mo postparturition, PTH and 1,25-dihydroxyvitamin D concentrations did not decline, while there was a substantial decline in 25-hydroxyvitamin D concentrations. PTH, 1,25-dihydroxyvitamin D, and 25-hydroxyvitamin D concentrations did not differ by lactation practice or by PTHrP, estradiol, or prolactin status. These classic calciotrophic hormones were not associated with concentrations of bone turnover markers or changes in BMD in lactating women. In summary, patterns of change in calciotrophic hormones (PTH, 1,25-dihydroxyvitamin D, and 25-hydroxyvitamin D) in the 18-mo postpartum period appeared to be independent of PTHrP, estradiol, prolactin, or lactation status and were not associated with bone turnover markers. These data do not support the hypothesis that these three calciotrophic hormones are a central part of the calcium mobilization associated with the bone loss of lactation.

Unexplained infertility: evaluation of the luteal phase; results of the National Center for Infertility Research at Michigan

OBJECTIVE

To evaluate the luteal phase in women with rigorously defined unexplained infertility.

DESIGN

Prospective study.

SETTING

National Center for Infertility Research at Michigan.

PATIENT(S)

Evaluation of 1,885 women with infertility identified 12 women who met the rigorously defined criteria for unexplained infertility: [1] infertility of > or = 24 months duration, with no male factor, anatomic-functional disorders of the reproductive tract, or immunologic infertility; [2] normal body mass index (BMI); [3] ovulatory cycles ranging from 26 to 32 days; [4] normal luteal phase determined by endometrial biopsy; and [5] normal baseline hormonal profile. Controls (n = 12) were healthy, parous women with normal ovulatory cycles, normal hormonal screen, and were matched for age and BMI to patients.

MAIN OUTCOME MEASURE(S)

Pattern of follicular growth rate and luteal phase hormonal profile.

RESULT(S)

Women with unexplained infertility did not differ in menstrual cycle characteristics, follicular growth rate or mean preovulatory follicle diameter, or endometrial biopsy dating. The mean levels of P tended to be lower in the unexplained infertility group throughout the luteal phase, but only the midluteal interval reached statistical significance. Luteal phase mean integrated P or urinary PDG levels of unexplained infertility women did not differ from those of fertile controls. The ratio of integrated E2:P also was significantly greater in women with unexplained infertility than in fertile controls.

CONCLUSION(S)

Women with rigorously defined unexplained infertility have subtle hormonal anomalies during the luteal phase when compared with fertile controls.

Elevated parathyroid hormone-related peptide associated with lactation and bone density loss

OBJECTIVE

To investigate the hypothesis that parathyroid hormone-related peptide (PRHrP) may be involved with bone loss and recovery as a means of providing adequate calcium and phosphate to infants.

DESIGN

An 18-month prospective cohort study.

SETTING

General community setting with recruitment occurring at birthing education classes.

PARTICIPANTS

Volunteer sample of 115 postpartum healthy women aged 20 to 40 years, and 0 or 1 parity prior to parturition with no intent to breast-feed or intent to breast-feed at least 6 months.

MAIN OUTCOME MEASURES

Parathyroid hormone-related peptide, prolactin, estradiol, 1,25-dihydroxyvitamin D, 24-hydroxyvitamin D, femoral bone mineral density, and bone turnover markers were measured in 115 postpartum women at 2 weeks, 2 months, 4 months, 6 months, 12 months, and 18 months postpartum. Lumbar bone mineral density was measured at 2 weeks, 6 months, 12 months, and 18 months postpartum.

RESULTS

Elevated PTHrP values were significantly associated (P<.001) with breast-feeding status, elevated prolactin levels, and lower serum estradiol levels, conditions occurring during lactation. Furthermore, elevated PTHrP levels were negatively and significantly associated (P<.01) over time with bone mineral density change at both the spine and the femoral neck, even after accounting for prolactin levels, breast-feeding status, return of menstruation, estradiol levels, PTH levels, 1,25-dihydroxyvitamin D levels, dietary calcium intake, physical activity, and body size.

CONCLUSION

These data clearly support the hypothesis that PTHrP is an alternative mechanism associated with bone loss and recovery during and subsequent to lactation.

Phase I and pharmacokinetic study of etoposide phosphate

Etoposide phosphate (EP) is a water-soluble derivative of etoposide (VP-16), a semisynthetic podophyllotoxin which is useful in the treatment of a wide variety of hematological malignancies and solid tumors. Because etoposide is poorly water soluble, it must be dissolved in a variety of organic solvents and given in relatively large volumes of saline. EP is rapidly converted to the parent drug in vivo and has been shown to be active in animal studies. We performed a phase I pharmacokinetic study in 27 patients. Three patients each received an etoposide-equivalent dose of 50 or 75 mg/m2 each day by i.v. bolus (5 min) daily for 5 days and 21 patients received a dose equivalent to 100 mg/m2 of etoposide each day for 5 days. Non-compartmental pharmacokinetic data were obtained for 22 of the patients. As with previous studies, EP behaves as a prodrug of etoposide. The Cmax (25.3-42.5 micrograms/ml) increased linearly, while AUCinf (75.8-156 h micrograms/ml) of etoposide increased proportionately with dose (50-100 mg/m2 of etoposide equivalents). Time to achieve Cmax corresponded to the end of the 5 min injection, indicating a rapid formation of etoposide from EP. Mean etoposide phosphate/etoposide Cmax and AUCinf ratios were 0.08 or less and 0.003, respectively, indicating that the major circulating moiety in plasma was etoposide. Parameters such as MRT, T1/2, CL/F, CLR, VSS/F and %UR were dose independent. The toxicities of EP were virtually identical to those seen with etoposide, with dose-related myelosuppression, alopecia and stomatitis. Severe neutropenia was the dose-limiting toxicity. No significant problems with hypotension or allergic reactions were observed. No problems, difficulties or complications were observed as a result of bolus (5 min) administration. On the basis of phase I toxicity data, we recommend an etoposide equivalent starting dose of 100 mg/m2/day for 5 days in previously untreated patients who have an excellent performance status. In patients who have had one or more prior chemotherapy regimens, extensive prior radiation therapy or moderately impaired performance status, we recommend an etoposide phosphate starting dose of 75 mg/m2/day for 5 days with courses repeated at 3 week intervals.

Phase II randomized study of cisplatin plus etoposide phosphate or etoposide in the treatment of small-cell lung cancer

PURPOSE

This randomized phase II study evaluated the efficacy and toxicity of etoposide phosphate when used in combination with cisplatin in the treatment of small-cell lung cancer.

PATIENTS AND METHODS

Patients with previously untreated small-cell lung cancer were randomized to receive cisplatin in combination with either etoposide or etoposide phosphate. Molar-equivalent doses of etoposide and etoposide phosphate were used. Response rate, time to progression, survival, and toxicity were compared.

RESULTS

Major response rates with etoposide phosphate and etoposide were 61% (95% confidence interval, 55% to 67%) and 58% (95% confidence interval, 52% to 64%), respectively (P = .85). No significant differences in median time to progression or survival were observed in patients who received etoposide phosphate versus etoposide. Grade 3 and 4 leukopenia occurred in 63% of patients who received etoposide phosphate compared with 77% who received etoposide (P = .16).

CONCLUSION

The combination of etoposide phosphate and cisplatin is effective in the treatment of small-cell lung cancer, and can be administered with acceptable toxicity. Although this study was not designed to be a formal comparative trial, the efficacy and toxicity observed with this regimen were found to be similar to a standard etoposide/cisplatin regimen, using molar-equivalent etoposide doses. Because of its greater ease of administration, etoposide phosphate is preferable to etoposide for routine clinical use.

A proposed classification of vaginal anomalies and their surgical correction

A classification of vaginal anomalies has been derived, which permits logical operative decisions. This tool allows the assignment of increasingly involved reconstructive operations to progressively more complex vaginal anatomies. The outcome of this approach in 49 vaginal reconstructions performed in 36 patients over a 25-year period has been analyzed. The cause was found to be congenital adrenal hyperplasia in 21 patients, gonadal dysgenesis in four, and cloaca in two; nine children had other causes. Based on the following anatomic classification and the authors' clinical experience, the following approaches to reconstruction can be recommended. Eight infants with labial fusion (type I) underwent simple introitoplasty. Fourteen patients with distal urogenital sinus (type II) underwent flap vaginoplasty using labioscrotal tissue and/or a posteriorly based flap. Pull-through vaginoplasty was used in 10 children with distal vaginal atresia and proximal urethrovaginal fistula (type III). Four patients with absence of the vagina (type IV) required segmental colon vaginoplasty. Thirteen revisions have been required in nine patients thus far. The follow-up period is 1 to 17 years, and despite the need for reoperation, all but two patients have excellent or satisfactory results based on anatomic and functional considerations. The choice for and timing of vaginal reconstruction rests on precise anatomic evaluation. The complexity of vaginal reconstruction in the growing child and the essentiality of psychosocial adjustment to appropriate sexual identity and function mandate long-term comprehensive follow-up. Optimal care for each patient requires experience and continuity to take the child through diagnosis, surgical reconstruction, stressful adolescence, and into adulthood with full attention to anatomic, physiological, and psychological support.

A prospective study of bone density and pregnancy after an extended period of lactation with bone loss

OBJECTIVES

To determine if pregnancy after an extended period of lactation curtails the recovery of maternal bone mineral density.

METHODS

Twenty-five women who fully breast-fed their infants for at least 6 months and had a subsequent pregnancy within 18 months of initiating lactation were studied longitudinally. Twenty controls breast-fed similarly, but had no subsequent pregnancy. The women were healthy, well-nourished, and between 20-40 years old. Bone mineral density was measured by dual x-ray energy absorptiometry at the spine and hip.

RESULTS

Both cases and controls lost bone mineral density with extended lactation. The case group had a bone mineral density recovery comparable to the controls.

CONCLUSION

Women with the dual calcium demands of extended lactation and a subsequent pregnancy are not at risk for failure of bone recovery to pre-lactation levels.

In situ hybridization of luteinizing hormone/human chorionic gonadotropin receptor messenger ribonucleic acid during hormone-induced down-regulation and the subsequent recovery in rat corpus luteum

Previous studies have shown that injection of a pharmacological dose of hCG to rats primed with PMSG/hCG results in a loss of hCG binding in the luteinized ovary, which is closely coupled with the loss of LH/hCG receptor (LH/hCG-R) messenger RNA (mRNA). The time course of down-regulation of the receptor mRNA reveals that mRNA totally disappears 24 h after the hormone injection, but fully recovers by 72 h. The purpose of this study was to determine by in situ hybridization whether the recovery of the receptor mRNA occurs in preexisting or newly formed corpora lutea. Twenty-one-day-old female rats were treated with 50 IU PMSG, followed 56 h later by a single injection of hCG. On day 5 after the hCG injection, one group of rats was treated with a desensitizing dose of hCG, and a control group received saline. The ovaries were collected 6, 12, 24, 48, 72, and 96 h after the treatments and were processed for in situ hybridization using 35S antisense RNA synthesized from a 750-mer LH/hCG-R complementary DNA. In control ovaries, heavily labeled LH/hCG-R mRNA-containing cells were observed in the numerous corpora lutea. Ribonuclease pretreatment of the sections eliminated the signal, and no specific hybridization was observed when sense strand probe was used. No hybridization to the granulosa cells was seen. Some hybridization occurred to the theca interna, but the intensity was lower than that in the corpora lutea. Time-course studies showed a marked decline in the hCG-R mRNA signals in corpora lutea as early as 6 h after hCG injection, with a maximum loss of receptor mRNA by 24 h. After 48 h, hCG-R mRNA reappeared in preexisting corpora lutea, with the intensity of the hybridization signal equaling that in corpora lutea of controls. New corpora lutea could not be identified at any time after injection of the down-regulating dose of hCG. As down-regulated receptor mRNA recovered in preexisting, not new, corpora lutea, hormone-induced loss of luteal cell receptors would appear to be reversible.

Clinical and pharmacokinetic overview of parenteral etoposide phosphate

Etoposide phosphate (Etopophos, BMY-40481) is a water-soluble derivative of the widely used podophyllotoxin etoposide (VP-16). The phosphate ester renders the compound water-soluble, eliminating the need for formulation in polysorbate (Tween) 80, ethanol, and polyethylene glycol. As a result the compound can be given at high concentrations and as a bolus. In animals and in vitro, etoposide phosphate (EP) is rapidly and completely converted to VP-16. Clinical development of the i.v. formulation has focused on the identification of the maximum tolerated dose (MTD) and pharmacokinetic characteristics of the drug using a 5 daily dose schedule and a days 1, 3, and 5 schedule, with the drug being given over 30 or 5 (bolus) min. Myelosuppression was dose-limiting. Data from these trials show the rapid and complete conversion of EP to VP-16, a pharmacokinetic/pharmacodynamic relationship for myelosuppression and exposure to VP-16, and an MTD of 100 and 150 mg/m2 (molar equivalent to VP-16) when EP is given daily for 5 days and on days 1, 3, and 5, respectively. A formal randomized trial has been conducted to show the pharmacokinetic comparability of EP and VP-16. In this trial, exposure to VP-16 was the same after the parenteral administration of equimolar doses of EP or VP-16. The feasibility of bolus dosing and treatment at high concentrations has been demonstrated, with no effects on the cardiovascular system being noted. Parenteral EP is pharmacokinetically and biologically equivalent to VP-16 and has the advantages of the elimination of potentially toxic excipients; more convenient administration; and ability to be given as a bolus, at high concentrations, and as a continuous infusion.

Heterotopic ossification in children with burns: two case reports

Heterotopic ossification is the formation of ectopic bone in soft tissue, and has been reported as a rare complication in pediatric burn patients. At our hospital, two 86% body surface area burn patients developed heterotopic ossification in the shoulder, elbows, distal femur, proximal tibia, fibula, and ribs approximately four months after the burn injury. These two rare and unusual cases are presented documenting the clinical involvement, radiological studies, laboratory data, as well as treatment of their heterotopic ossification. Discussion will focus on the incidence, diagnosis, pathophysiology, and treatment of heterotopic ossification in burn patients and how this information relates to the specific diagnosis and management of the complication of heterotopic ossification in the burn child.

A strategy for resection of Wilms' tumor with vena cava or atrial extension

Resection of a Wilms' tumor that extends into the vena cava or right atrium results in excellent survival when combined with adjuvant therapy. Preoperative identification of the presence of intravascular tumor thrombus and the level of vascular involvement is essential. It facilitates safe surgical resection, with cardiopulmonary bypass immediately available for retrohepatic and atrial tumors. Six patients with intracaval or intracardiac tumor thrombus were treated over a 5-year period with no perioperative deaths. Preoperative chemotherapy was useful in two patients with extensive tumors and pulmonary metastases. Our results using an integrated management plan suggest that an aggressive surgical approach is justified for this extensive variant of Wilms' tumor.

The surgical management of infants and children with ambiguous genitalia. Lessons learned from 25 years

Over a 25-year period, 91 children with ambiguous genitalia have received surgical management. Female sex assignment was made for 79. Of these, 60 patients underwent extensive clitoral reconstruction consonant with the female assignment. Forty-two patients had vaginal reconstruction. Factors relating to success include: (1) prompt and appropriate sex assignment; (2) early and accurate diagnosis; (3) conservative reconstruction of the clitoris at an early age (less than 1 year); and (4) choice of vaginal reconstruction based on the severity of the malformation. Long-term follow-up demonstrates satisfactory anatomic and functional results when clitoral surgery alone was required. Functional results for patients with extensive vaginal reconstruction have been compromised. Physicians caring for children with congenital intersexual anomalies can expect to encounter a wide spectrum of anatomic and physiologic derangements. Cosmetic appearance alone is an inadequate measure of success because endocrinologic, social, psychological, and sexual factors must be blended into comprehensive evaluation of these patients. The management plan must be flexible and individualized, incorporating long-term follow-up to adulthood.

Functional results in young women having clitoral reconstruction as infants

Nine young women who had clitoral recession for clitoromegaly as infants have been evaluated for anatomical appearance, psychosocial adjustment, and sexual function. Highly satisfactory anatomic results were obtained, although two patients required subsequent revision. The tested psychological parameters were essentially normal. Virtually all patients were sexually active and all but one have achieved regular painless orgasm. Surgical reconstruction has been accomplished by recessing the entire disfigured clitoris, thereby conserving all erectile tissue and preserving sensation. In addition to assessment of anatomical appearance, long-term follow-up of children with ambiguous genitalia requires regular evaluation of social, psychological, and sexual parameters.

Oxygen free radicals and pelvic adhesion formation: I. Blocking oxygen free radical toxicity to prevent adhesion formation in an endometriosis model

Intraperitoneal superoxide dismutase (SOD) and catalase were used to block the toxic effects of superoxide anion (O2) and hydrogen peroxide (H2O2), associated with the production of endometriosis and inflammation in a rabbit model. In a two-part animal study, the combined instillation of SOD and catalase significantly reduced the formation of intraperitoneal adhesions at endometriosis sites.

Hypersomatotropism and insulin-resistant diabetes mellitus in a cat

In this report, we described the clinical, radiographic, and echocardiographic findings in a cat with hypersomatotropism and insulin-resistant diabetes mellitus. Growth hormone determinations were made because of persistent hyperglycemia despite insulin requirements exceeding 2.2 U/kg of body weight, and the acromegalic features of the cat. Also, the results of a therapeutic trial in which a long-acting analogue of somatostatin was used are discussed.

Evidence for inhibition of growth related to compromised DNA synthesis in the interaction of daunorubicin with H-35 rat hepatoma

The H-35 rat hepatoma is relatively insensitive to the anthracycline antibiotic, daunorubicin (DNR), requiring 0.25 microM daunorubicin for inhibition of cell proliferation by 50%. Studies were undertaken to investigate the basis for the apparent intrinsic resistance in this cell line. The relative insensitivity of the H-35 cells to DNR is not a function of metabolic inactivation of DNR to deoxyaglycone derivatives; after a 2-h incubation, less than 10% of drug is metabolized, exclusively by conversion to daunorubicinol. The limited toxicity of DNR to the rat hepatoma may be explained, in part, by the absence of DNA strand breaks at daunorubicin concentrations up to 1 microM while higher (supraclinical) DNR concentrations (5 and 10 microM) produce direct, "non-protein-associated" DNA strand breaks. Limited daunorubicin toxicity in this tumor cell line may also be related to the apparent absence of free radical-mediated cellular damage as the free radical scavengers dimethyl sulfoxide, catalase, methanol, and mannitol fail to reverse the inhibitory effect of 1 microM DNR on cell proliferation. Daunorubicin does not induce leakage of the cytoplasmic enzyme, glutamic oxaloacetate transaminase, or diminish mitochondrial enzyme function. Conversely, while drug effects on RNA synthesis are small, and protein synthesis is minimally diminished, inhibition of cell proliferation corresponds closely with inhibition of DNA synthesis.

A comparison of thermal injury, healing patterns, and postoperative adhesion formation following CO2 laser and electromicrosurgery

To further define the role of CO2 laser in infertility surgery, the authors compared the immediate tissue damage and the subsequent healing patterns that followed the randomized use of CO2 laser and electrocautery on opposite sides of the reproductive tracts of 20 mature, female rabbits. Blind histopathologic evaluations were performed on the ovarian and uterine tissues immediately to compare the extent of the acute thermal damage, and 4 weeks postoperatively to compare the healing patterns. There were no differences in the depth of thermal damage, extent of collagen deposition, or in postoperative adhesion formation between CO2 laser and electrocautery. However, the mean depth of the acute thermal damage was significantly less on the ovary than on the uterus, and the area of fibrosis was significantly less when the incised uterine surfaces were approximated.

Current indications for decortication in the treatment of empyema in children

Although most children with empyema respond to antibiotics and pleural drainage, a recognizable number fail to improve. This study reviews experience with ten children over the past 7 years who have been selected for lung decortication for refractory empyema. Decortication was performed because of lack of clinical improvement despite drainage and multiple antibiotics during an average 20-day preoperative hospitalization. Responsible organisms included beta-hemolytic Streptococcus, Streptococcus pneumoniae, and Hemophilus influenzae. A computerized tomographic (CT) scan of the chest was performed in the last eight patients and showed at least a 50% limitation of lung expansion by the products of the empyema in each case. Following decortication, chest tubes were removed, antibiotics stopped, and temperature and white blood cell count returned promptly to normal. The advantages of early decortication in selected patients with empyema who do not respond to antibiotics and drainage include low morbidity, shorter hospitalization, and excellent long-term results.

Subclinical autoimmune disease and recurrent spontaneous abortion

We describe a patient with no clinical complaints except 5 unexplained spontaneous abortions in whom investigations revealed a positive antinuclear factor, antibodies to native double-stranded DNA, LE cells, a positive Coombs' test, a positive lupus anticoagulant test, and anticardiolipin antibodies. Despite preeclampsia our patient successfully completed her 6th pregnancy after treatment with corticosteroids, subcutaneous heparin, and low dose aspirin throughout the pregnancy. Serial measurements of anticardiolipin antibody showed suppression of anticardiolipin antibody levels with corticosteroids. The response of the lupus anticoagulant was less obvious. No anticardiolipin antibodies were detected in the baby.

Enhancing psychosocial adaptation to gastric partitioning for morbid obesity

Gastric partitioning, a surgical treatment for morbid obesity, challenges patients to drastically change their eating habits and self-image. Preoperative psychiatric assessment should not be aimed simply at selecting patients in whom there are no psychiatric contraindications. Many patients have some degree of risk for postoperative problems. If the risk factors can be identified before surgery, appropriate pre- and postoperative psychologic intervention may help minimize maladaptation.

Long-term morbidity and mortality in morbidly obese adolescents after jejunoileal bypass

To evaluate the long-term results of jejunoileal bypass in the treatment of morbidly obese adolescents, we studied 11 patients who underwent surgery between 1972 and 1974. More than 10 years after surgery, 45% of the patients had extremely satisfactory results (correction of morbid obesity). Three patients died within the year after surgery, two of them under extenuating clinical circumstances. There have been no subsequent deaths. All eight survivors were found to have metabolic abnormalities to various degrees. Two patients had a total of five pregnancies; each had one healthy infant, and three pregnancies ended in abortion (one spontaneous). Two patients had significant medical problems related to the procedure but basically remained in good health, whereas three patients had severe symptoms requiring reanastomosis. Of the five patients who continue with the bypass, none has become significantly obese. They have all maintained a weight loss of between 45 and 90 kg, and as adults express strong feelings in favor of the procedure. This series demonstrates that, although significant weight loss was maintained, and improvement in the quality of life for half of our patients was dramatic, side effects and complications continue to develop, mandating careful follow-up for an indefinite time.