Breast implant research: where we have been, where we are, where we need to go

This article summarizes the current state and future needs of research into saline-filled and silicone gel breast implants. The authors describe recent investigations into possible causes and potential risk factors for silicone gel and saline implant failure. Also discussed are local complications of breast implantation and the need for revisional operations in augmentation and reconstruction patients. In addition, the effects that surgical, implant, and patient variables have on the aesthetic outcome of surgery are addressed. The last portion of the article lays out future research needs, such as determining the incidence rate of implant failure, reducing the frequency of revisional surgery, and the difficulty of designing better breast implants in the current strict regulatory climate.     

Newborn screening and renal disease: where we have been; where we are now; where we are going

Newborn screening (NBS) has rapidly changed since its origins in the 1960s. Beginning with a single condition, then a handful in the 1990 s, NBS has expanded in the past decade to allow the detection of many disorders of amino-acid, organic-acid, and fatty-acid metabolism. These conditions often present with recurrent acute attacks of metabolic acidosis, hypoglycemia, liver failure, and hyperammonemia that may be prevented with initiation of early treatment. Renal disease is an important component of these disorders and is a frequent source of morbidity. Hemodialysis is often required for hyperammonemia in the organic acidemias and urea-cycle disorders. Rhabdomyolysis with renal failure is a frequent complication in fatty-acid oxidation disorders. Newer screening methods are under investigation to detect lysosomal storage diseases, primary immunodeficiencies, and primary renal disorders. These advances will present many challenges to nephrologists and pediatricians with respect to closely monitoring and caring for children with such disorders.     

Lans lecture. Lamellar refractive surgery: where have we been and where are we going?

In summary, the greatest challenge for lamellar refractive surgery is in the treatment of myopia. There are and always will be patients who are satisfied with a partial correction of myopia. Many of these patients can be served quite adequately by currently available refractive techniques, but a technique in which level of accuracy is adequate for the treatment of myopia in general is not yet available. Lamellar refractive surgery--where have we been and where are we going? We have seen the evolution of the epikeratoplasty procedure for almost a decade and continue to see procedural changes which may increase the accuracy and stability of the procedure, such as alternative modalities for tissue preservation and alternative methods for surgical attachment. It remains potentially useful in several areas of refractive surgery, but its inaccuracy in the treatment of myopia remains a significant problem. Will the epithelial healing problems and postoperative care be too cumbersome for the general ophthalmologist? Will the excimer laser fill the needs of myopic refractive surgery? Personally, I do not feel that any biological lens, be it a cornea which has had incisions as with radial keratotomy, or a cornea which is remolded in one way or another as with the excimer laser, will produce predictable refractive results to the extent that is required to satisfy the general needs of the myopic population. Hydrogel keratophakia is in its infancy, but it holds the potential of being a far more accurate procedure because of the ability to interchange lenses to further refine the refractive result. Refractive surgery will in the next decade achieve a level of sophistication far greater than what we have seen to date. Lans could not have dreamed of the remarkable evolution in refractive surgical innovation in the past century. It is hoped that we will not have to wait that long to create a readily available solution to the problem of refractive surgery for myopia.     

Early intervention for trauma: Where are we and where do we need to go? A commentary

In this commentary, the author underscores the importance of early intervention for trauma and describes the challenges that lie ahead for researchers, decision makers, and care providers. The author also provides a review of where things stand, briefly reviews psychological first aid strategies, and underscores where we need to go from here. Although the field has advanced considerably in the last decade or so, and there are compelling trials underway, there is much work that needs to be done, especially in terms of effectiveness and the task of integrating early intervention into various work cultures, such as the military.     

Sentinel node biopsy for melanoma: Where have we been and where are we going?

The sentinel node (SN) concept is not new, but its potential surgical application was not fully appreciated until the landmark report by Morton and Cochran et al. in 1992. It has since been confirmed that SN status in melanoma patients accurately reflects the status of the entire regional node field, and is a critically important prognostic indicator. However, randomized trials have yet to determine whether the SN biopsy technique is of any therapeutic value. With extended follow-up times, false-negative SN rates of up to 15% are being reported and presumably represent failures of nuclear medicine and/or surgery and/or histopathology. Innovative methods of increasing the accuracy of SN identification and of checking this retrospectively are being assessed. The next great challenge is to develop methods of SN assessment that are noninvasive yet are even more accurate than present methods. Techniques such as in vivo proton magnetic resonance spectroscopy hold great promise and suggest that this goal might be achievable.     

TIVA,TCI, and pediatrics: where are we and where are we going?

The current role of TIVA in children is limited because of hardware limitations, and pharmacokinetic and monitoring issues. Nonetheless, the role of TIVA in children has been increasing in the past decade, in part because of surgical and medical indications. If TIVA is to become more widely used, it must be easy and simple to set up, without serious drawbacks and without added risks. Currently, many drugs destined for use with TIVA in children are off‐label, and their pharmacology is poorly understood. Such off‐label designations must be resolved if TIVA is to become more widely used. At the same time, many institutions have a limited number of infusion pumps, which creates a serious bottleneck and restriction on the use of TIVA.. If a true TIVA technique is used, i.v. access must be established before induction of anesthesia, which will require a means to establish i.v. access painlessly, e.g., using a topical local anesthetic. This is not a common practice in a number of jurisdictions but must be introduced if TIVA is to expand in its scope in children. Currently, I believe that we deliver a ‘partial’ TIVA technique in which TIVA occasionally follows an inhalational induction but in the future when the current obstacles have been resolved, I believe that we will be able practice a true TIVA technique ubiquitously in children.     

Prostate specific antigen: a decade of discovery--what we have learned and where we are going.

PURPOSE: Many advances have occurred during the last decade in the clinical use of prostate specific antigen (PSA) for detecting, staging and monitoring prostate cancer. We review the clinical usefulness and limitations of serum PSA as a tumor marker of prostate cancer. MATERIALS AND METHODS: The English language literature was reviewed with respect to the major contributions and limitations of PSA in present clinical practice. RESULTS: Although controversial, age specific PSA reference ranges can improve the sensitivity for prostate cancer detection in young men and the specificity in older men. Percent free PSA improves the specificity for prostate cancer detection in men with PSA values between 4 and 10 ng./ml., and a PSA density of greater than 0.15 may better distinguish benign prostatic hyperplasia from prostate cancer. PSA velocity can improve the ability to detect prostate cancer when 3 serial PSA values are measured during a 2-year period. For prostate cancer staging PSA is most useful combined with clinical stage and Gleason score in multivariate analysis. Percent free PSA may prove useful for staging prostate cancer but further clinical trials are needed to determine its clinical usefulness. PSA is the most clinically useful means to monitor disease recurrence after treatment of prostate cancer. With ultrasensitive PSA assays it is now possible to increase the lead time for detection of disease recurrence by several months. CONCLUSIONS: During the last decade much of the focus has been on improving the ability of this tumor marker to detect prostate cancer. PSA remains the best and most widely used tumor marker in urology today.     

American Hepato-Pancreato-Biliary Association: Who are we and where are we going?

The American Hepato-Pancreato-Biliary Association (AHPBA) was initiated in 1994 following the first World Congress of the International Hepato-Pancreato-Biliary Association (IHPBA), which was held in Boston. Presently, the AHPBA has more than 500 dues-paying members whose median age is in the mid-40s. More than 90% of members reside in North America. Approximately 80% of members have completed a fellowship in transplantation, hepato-pancreato-biliary surgery and/or research, surgical oncology, gastroenterology, or laparoscopy. Approximately 90% have a faculty appointment with 80% of these being full-time faculty. More than half of the average AHPBA member’s time is spent in patient care, but approximately 45% of time is divided equally among research, teaching, and administration. Approximately 85% of members perform biliary, 75% hepatic, and 45% pancreatic surgery, whereas 25% perform liver and pancreatic transplantation. Nearly 90% are members of the American College of Surgeons, two thirds The Society for Surgery of the Alimentary Tract, 60% the Association for Academic Surgery, and 40% the IHPBA. The AHPBA’s vision is to be the leading American association devoted to hepato-pancreato-biliary education, research, surgical training, and patient care and to serve as the American chapter of the IHPBA. The AHPBA mission is as follows: (1) to disseminate knowledge of hepatopancreato-biliary disease, techniques, and research; (2) to facilitate clinical trials in hepato-pancreato-biliary disease; (3) to coordinate advanced training in hepato-pancreato-biliary surgery; and (4) to foster excellence in the care of patients with hepato-pancreato-biliary disease. The AHPBA has strategic initiatives to increase membership, bring value to a journal affiliation, and enhance its education, research, and training missions through multiple collaborations and better communication. Presented at the Third Americas Hepato-Pancreato-Biliary Congress, Miami, Fla., February 23, 2001.