Para-aortic lymph node radiation in advanced cervical cancer

From 1970 until December, 1977, 36 patients with advanced carcinoma of the uterine cervix and with iliac or para-aortic nodes interpreted as un-equivocally positive on lymphangiography have received radiation therapy (4500–5000 rad) to the para-aortic area at the Department of Therapeutic Radiology at Tufts-New England Medical Center Hospital. Of 29 patients who received para-aortic area irradiation as part of their initial treatment, local control was achieved in 18 patients (62%). Of these, 11 patients are currently alive with no evidence of disease (NED); two died without evidence of tumor. The remaining 16 patients died of their tumor (11 with locally uncontrolled tumor and five with distant metastasis). Of seven patients in whom the para-aortic area was treated because of retroperitoneal nodal recurrence, only two are alive without disease and the rest succumbed to their tumor. Overall, four patients developed major complications requiring surgical intervention. Detailed results and our current pre-treatment evaluation policy including lymphangiography, percutaneous needle biopsy and selective extra-peritoneal lymph node biopsy will be discussed.     

Dynamic Measurements of Transverse Optical Trapping Force in Biological Applications

Optical tweezers present a technology for measurements of biological forces in the piconewton range. In such applications, one method of calibrating the transverse optical trapping force involves relating a known external force to the displacement of the trapped object from the trapping center. In this work we used Fourier analysis of the equation of motion to calculate the displacement of the trapped object from the trapping center under an external force induced by viscous drag. Triangular waveforms of different frequencies were used both in theoretical modeling and experiments to induce a force on a trapped object. We investigated the contribution of various factors including frequency of the external force, fluid viscosity, density, and dimensions of the trapped object, stiffness of the optical trap, and frequency response of the instruments used to control the motion of the viscous medium to the accuracy of the calibration. The developed model can be adopted for calibration of the transverse trapping force, analysis of the trapped object motion, and reconstruction of a force profile during measurements of dynamic biological forces.     

Opportunistic screening for diabetes in routine clinical practice

OBJECTIVE: Since 1997, the American Diabetes Association has recommended that nondiabetic individuals >/=45 years of age be screened for diabetes at least every 3 years. We sought to characterize the frequency, methods, and results of diabetes screening in routine clinical practice. RESEARCH DESIGN AND METHODS: We studied opportunistic screening in nondiabetic members of a health maintenance organization >/=45 years of age who were assigned to a large, integrated, academic health care delivery system. Screening was defined as the first glucose, HbA(1c), or oral glucose tolerance test (OGTT) performed between 1 January 1998 and 31 December 2000. Chart review was performed to determine the prevalence of diabetes risk factors and to describe follow-up. RESULTS: Of 8,286 nondiabetic patients >/=45 years of age, 69% (n = 5,752) were screened. The frequency of screening was greater in patients with one or more primary care visits and increased with age. Women were more likely to be screened than men, and patients with at least one diabetes risk factor were more likely to be screened than those without risk factors. Random plasma glucose was the most common screening test (95%). Four percent (n = 202) of those screened had abnormal results. Only 38% (n = 77) of those with abnormal results received appropriate follow-up, and 17% (n = 35) were diagnosed with diabetes within 6 months of screening. The yield of screening was very low (0.6%, 35 of 5,752). CONCLUSIONS: Despite frequent screening and appropriate targeting of high-risk patients, follow-up of patients with abnormal results is uncommon and the yield of screening is low. Interventions are needed to help physicians recognize and provide appropriate follow-up for patients with potentially abnormal random glucose levels.     

Thermal response of human skin epidermis to 595-nm laser irradiation at high incident dosages and long pulse durations in conjunction with cryogen spray cooling: an ex-vivo study

BACKGROUND AND OBJECTIVES: Improved laser treatment of cutaneous hypervascular lesions is expected by utilizing higher incident dosages, longer pulse durations and longer wavelengths than those currently used in clinical settings. However, simply increasing the incident dosage will also increase the risk of nonspecific thermal injury to the epidermis due to light absorption by melanin. In this study, we investigated the thermal response of human skin epidermis to 595-nm wavelength laser irradiation at high incident dosages (up to 20 J/cm(2)) and long pulse durations (up to 40 milliseconds) in conjunction with cryogen spray cooling (CSC) using ex-vivo human skin samples. STUDY DESIGN/MATERIALS AND METHODS: The Candela V-beam trade mark laser (595-nm wavelength) was used in the experiments. Ex-vivo human skin samples (Fitzpatrick types I-VI) were irradiated at the incident dosages D(0) = 4, 6, 10, 15, and 20 J/cm(2), laser pulse durations tau(laser) = 1.5, 10, and 40 milliseconds, without and with CSC (refrigerant-134A, spurt duration tau(CSC) = 100 milliseconds). Thermal injury to the epidermis was evaluated by histological observations. RESULTS: Under the same incident dosage, longer pulse durations led to reduced thermal injury to the epidermis. Without CSC, no demonstrable thermal injury to the epidermis was observed in skin types I-II irradiated at the incident dosage as high as 15 J/cm(2), and in skin types III-IV at 10 J/cm(2). When CSC was applied, no evidence of thermal injury to the epidermis was present in skin types I-II even when irradiated at the maximum available incident dosage of the laser system (20 J/cm(2)). In skin types III-IV, no demonstrable thermal injury to the epidermis was observed when using incident dosage as high as 15 J/cm(2) in conjunction with CSC. In skin type VI, thermal injury to the epidermis could not be avoided even at the setting D(0) = 4 J/cm(2), tau(laser) = 40 milliseconds in conjunction with CSC. CONCLUSIONS: For a given incident dosage, longer pulse durations help reduce thermal injury to the epidermis. When a 100-millisecond cryogen spurt is applied, thermal injury to the epidermis can be prevented in ex-vivo skin types I-IV when irradiated at higher incident dosages (15-20 J/cm(2)) than those currently used in clinical settings. Further studies on optimizing the CSC parameters in conjunction with the laser irradiation parameters are needed to protect skin types V-VI from thermal injury to the epidermis.     

Improving diabetes processes of care in managed care

OBJECTIVE: To evaluate the impact of systematic patient evaluation and patient and provider feedback on the processes and intermediate outcomes of diabetes care in Independent Practice Association model internal medicine practices. RESEARCH DESIGN AND METHODS: Nine practices providing care to managed care patients were randomly assigned as intervention or comparison sites. Intervention-site subjects had Annual Diabetes Assessment Program (ADAP) assessments (HbA(1c), blood pressure, lipids, smoking, retinal photos, urine microalbumin, and foot examination) at years 1 and 2. Comparison-site subjects had ADAP assessments at year 2. At Intervention sites, year 1 ADAP results were reviewed with subjects, mailed to providers, and incorporated into electronic medical records with guideline-generated suggestions for treatment and follow-up. Medical records were evaluated for both groups for the year before both the year 1 and year 2 ADAP assessments. Processes and intermediate outcomes were compared using linear and logistic mixed hierarchical models. RESULTS: Of 284 eligible subjects, 103 of 173 (60%) at the Intervention sites and 71 of 111 (64%) at the comparison sites participated; 83 of 103 (81%) of the intervention-site subjects returned for follow-up at year 2. Performance of the six recommended assessments improved in intervention-site subjects at year 2 compared with year 1 (5.8 vs. 4.3, P = 0.0001) and compared with comparison-site subjects at year 2 (4.2, P = 0.014). No significant changes were noted in intermediate outcomes. CONCLUSIONS: The ADAP significantly improved processes of care but not intermediate outcomes. Additional interventions are needed to improve intermediate outcomes.     

Contouring of the midtrunk in overweight patients

Classical abdominoplasty primarily addresses the anterior abdominal wall. It involves a low transverse incision, extensive undermining in the supra-aponeurotic plane, correction of the musculofascial flaccidity, and resection of excessive skin and fat. The introduction of suction lipectomy into the armamentarium of the plastic surgeon has allowed a more thorough, yet safer, contouring of the entire midtrunk. When used in conjunction with a modified W-type abdominoplasty, circumferential suction lipectomy has yielded excellent results in contouring the midtrunk of overweight patients. It is the purpose of this article to present our technique for this procedure.     

Ethnic differences in drinking outcomes following a brief alcohol intervention in the trauma care setting

Background Evidence suggests that brief interventions in the trauma care setting reduce drinking, subsequent injury and driving under the influence (DUI) arrest. However, evidence on the effectiveness of these interventions in ethnic minority groups is lacking. The current study evaluates the efficacy of brief intervention among whites, blacks and Hispanics in the United States. Methods We conducted a two‐group parallel randomized trial comparing brief motivational intervention (BMI) and treatment as usual with assessment (TAU+) to evaluate treatment differences in drinking patterns by ethnicity. Patients were recruited from a level 1 urban trauma center over a 2‐year period. The study included 1493 trauma patients, including 668 whites, 288 blacks and 537 Hispanics. Hierarchical linear modeling was used to evaluate ethnic differences in drinking outcomes including volume per week, maximum amount consumed in 1 day, percentage days abstinent and percentage days heavy drinking at 6‐ and 12‐month follow‐up. Analyses controlled for age, gender, employment status, marital status, prior alcohol treatment, type of injury and injury severity. Special emphasis was given to potential ethnic differences by testing the interaction between ethnicity and BMI. Results At 6‐ and 12‐month follow‐up, BMI significantly reduced maximum amount consumed in 1 day (P < 0.001; P < 0.001, respectively) and percentage days heavy drinking (P < 0.05; P < 0.05, respectively) among Hispanics. Hispanics in the BMI group also reduced average volume per week at 12‐month follow‐up (χ² = 6.8, df = 1, P < 0.01). In addition, Hispanics in TAU+ reduced maximum amount consumed at 6‐ and 12‐month follow‐up (P < 0.001; P < 0.001) and volume per week at 12‐month follow‐up (P < 0.001). Whites and blacks in both BMI and TAU+ reduced volume per week and percentage days heavy drinking at 12‐month follow‐up (P < 0.001; P < 0.01, respectively) and decreased maximum amount at 6‐ (P < 0.001) and 12‐month follow‐up (P < 0.001). All three ethnic groups In both BMI and TAU+ reduced volume per week at 6‐month follow‐up (P < 0.001) and percentage days abstinent at 6‐ (P < 0.001) and 12‐month follow‐up (P < 0.001). Conclusions All three ethnic groups evidenced reductions in drinking at 6‐ and 12‐month follow‐up independent of treatment assignment. Among Hispanics, BMI reduced alcohol intake significantly as measured by average volume per week, percentage days heavy drinking and maximum amount consumed in 1 day.     

Physiology of the small bowel: a new approach using MRI and proposal for a new metric of function

Background

The mechanics of small bowel motility are extremely complex. Routine clinical access to small bowel has been restricted to radiological enteric contrast studies which have not contributed significantly to the understanding of small bowel physiology. Small bowel mechanics are understood within a framework of individual visible or measurable elements such as peristaltic wave formation, intra-luminal pressure gradients and transit times. There are no global measures of small bowel function that can be readily obtained in vivo in humans. Magnetic resonance imaging (MRI) is playing an increasingly important role in radiological diagnosis of small bowel disease and dynamic MRI offers the possibility of capturing small bowel movement in three-dimensional cinematic datasets. The metrics that are used to describe small bowel mechanics, typically anatomical measures in isolated segments, are not suited to analysing these large dynamic datasets. The proposal in this paper is to leave behind all previously described anatomical metrics and to describe anew the mechanics of small bowel movement in mathematical terms derived from changes in pixel intensity within dynamic MRI datasets so that global small bowel activity might be summarised in a single novel metric.

Hypothesis

The hypothesis of this paper is that global small bowel activity can be quantified by a new dynamic MR based metric.

Evaluation

A proposed strategy for evaluation includes a progression through feasibility, optimisation, reliability and validation studies. Thereafter normal volunteers would be required in order to define normal ranges for the new metric. These ranges would describe small bowel activity during fasting or after ingestion of fluids and standard meals. Mathematical modelling of the data could follow a two stage approach. The first stage could be to study segmentation or extraction techniques by which the small bowel activity could be isolated from MRI signal generated by the rest of the abdomen. The second stage would be to apply a number of data mining techniques that would identify significant features within the datasets.

Conclusion

If this approach proves to be a useful model for studying small bowel physiology in humans, it would afford significant new avenues of research and treatment particularly in areas such as enteric drug delivery, the ageing gut, and nutrition.