The international exchange program: In the first person

This commentary presents personal reflections on the Social Work Leadership Enhancement Program in the Department of Social Work Services at the Mount Sinai Medical Center in New York. The value of the program, not only for the participants from other countries, but also the value of the exposure of social workers from other countries to the department staff is recognized. The international influence is unequalled. How if affects and nurtures global social work thinking, its impact on those taking part in the program, as well as the ever-expanding influence of the program on a growing network of social workers is noted.     

Gallbladder management during laparoscopic Roux-en-Y gastric bypass surgery: routine preoperative screening for gallstones and postoperative prophylactic medical treatment are not necessary

In the bariatric surgery literature, the optimum approach to the gallbladder is controversial. Recommendations range from concomitant cholecystectomy to selective screening and postoperative medical prophylaxis. At our institution, we have taken a highly selective approach where patients are not routinely screened for gallstones, nor are they medically treated postoperatively with bile salts. We have reviewed our experience with this approach. From January 2003 to January 2005, 407 laparoscopic Roux en Y gastric bypasses were performed at UCLA and postoperative outcomes were collected into a prospective database. Exclusion criteria included previous cholecystectomy, a follow-up period less than 6 months, or incomplete records. One hundred ninety-nine patients were included in the study. With a mean follow up period of 17.8 months, 12 (6%) patients required cholecystectomy for gallstone-induced pathology. Laparoscopic removal was performed in 11 (92%) patients. Indications for surgery included acute cholecystitis in five (2.5%) patients, gallstone pancreatitis in two (1%) patients, and biliary colic alone in another five (2.5%) patients. The incidence of symptomatic gallstones requiring cholecystectomy after laparoscopic Roux en Y gastric bypass is low. These results are similar to those from institutions where routine preoperative screening and prophylactic postoperative medical therapy is used. Routine preoperative screening or medical prophylaxis may not be necessary.     

No Abuse Potential of Silexan in Healthy Recreational Drug Users: A Randomized Controlled Trial

BackgroundSilexan is a lavender essential oil with established anxiolytic and calming efficacy. Here we asked whether there is a potential for abuse in human patients.MethodsWe carried out a phase I abuse liability single-center, double-blind, 5-way crossover study in healthy users of recreational central nervous system depressants. They received single oral doses of 80 mg (therapeutic dose) and 640 mg Silexan, 2 mg and 4 mg lorazepam (active control) and placebo in randomized order, with 4- to 14-day washout periods between treatments. Pharmacodynamic measures included validated visual analogue scales assessing positive, negative, and sedative drug effects and balance of effects; a short form of the Addiction Research Center Inventory; and a drug similarity assessment. The primary outcome measure was the individual maximum value on the drug liking visual analogue scale during 24 hours post-dose.ResultsForty participants were randomized and 34 were evaluable for pharmacodynamic outcomes. In intraindividual head-to-head comparisons of the drug liking visual analogue scale maximum value, both doses of Silexan were rated similar to placebo whereas differences were observed between Silexan and lorazepam and between placebo and lorazepam (P < .001). These data were supported by all secondary measures of positive drug effects and of balance of effects. Differences between placebo and both doses of Silexan were always negligible in magnitude. Moreover, Silexan showed no sedative effects and was not perceived to be similar to commonly used drugs that participants had used in the past.ConclusionsSilexan did not exhibit any abuse potential in a standard abuse potential detection screen study and is unlikely to be recreationally abused.     

Postoperative CPAP and BiPAP use can be safely omitted after laparoscopic Roux-en-Y gastric bypass

BACKGROUND: Obstructive sleep apnea (OSA) is prevalent in the morbidly obese population. The need for routine preoperative testing for OSA has been debated in bariatric surgery publications. Most investigators have advocated the use of continuous positive airway pressure (CPAP) or bi-level positive airway pressure (BiPAP) in the postoperative setting; however, others have reported pouch perforations or other gastrointestinal complications as a result of their use. From a review of our experience, we present an algorithm for the safe postoperative treatment of patients with OSA without the use of CPAP or BiPAP. METHODS: From January 2003 to December 2007, 1095 laparoscopic Roux-en-Y gastric bypasses were performed at our institution. Preoperative testing for OSA was not routinely performed. A prospective database was maintained. The data included patient demographics, co-morbidities (including OSA and CPAP/BiPAP use), perioperative events, complications, and follow-up information. Patients with known OSA were not given CPAP/BiPAP after surgery. They were observed in a monitored setting during their inpatient stay, ensuring continuous oxygen saturation of >92%. All patients used patient-controlled analgesia, were trained in the use of incentive spirometry, and ambulated within a few hours of surgery. The outcomes were compared between the OSA patients using preoperative CPAP/BiPAP versus those with OSA without preoperative CPAP/BiPAP versus patients with no history of OSA. RESULTS: A total of 811 patients were included in the study group with no known history of OSA. Of the 284 patients with a confirmed diagnosis of OSA, 144 were CPAP/BiPAP dependent. Statistically significant differences were present in age distribution and gender, with men having greater CPAP/BiPAP dependency. No significant differences were found in body mass index, length of stay, pulmonary complications, or deaths. One pulmonary complication occurred in the OSA, CPAP/BiPAP-dependent group, three in the OSA, non-CPAP group, and six in the no-known OSA group. No anastomotic leaks or deaths occurred in the series. CONCLUSION: Postoperative CPAP/BiPAP can be safely omitted in laparoscopic Roux-en-Y gastric bypass patients with known OSA, provided they are observed in a monitored setting and their pulmonary status is optimized by aggressive incentive spirometry and early ambulation.     

Current management of adolescent pilonidal disease

Background

Controversy persists regarding the optimal management for adolescent pilonidal disease. We reviewed the outcome of wide local excision (WLE) vs unroofing and marsupialization (UM) for pilonidal disease.

Methods

A retrospective review 2002 to 2007 of adolescents undergoing surgical treatment of pilonidal disease was performed. Data were analyzed using Student's t test.

Results

Twenty-six patients were treated for pilonidal disease during this period. Average age was 16.7 years (range, 14-19 years) with 50% males. Nine patients underwent WLE and 17 had UM. Before initial evaluation, 44% of patients in the WLE group had drainage of acute abscess compared to 59% in the UM group (P > .05). Postoperative complications in the WLE group (78%) were significantly higher compared to the UM group (0%). Median time for final healing was significantly higher in the WLE group (32 weeks) compared to the UM group (6 weeks). The reoperative rate was also significantly higher in the WLE group (56%) compared to the UM group (0%). No patient had recurrent disease after complete healing in either group.

Conclusion

Unroofing and marsupialization for primary pilonidal disease has a shorter time to heal and carries a lower complication and reoperative rate compared to WLE.     

Is wide local excision for pilonidal disease still justified?

There is an ongoing debate regarding the optimal operation for chronic pilonidal disease. The current study analyzes the outcome of wide local excision (WLE) compared with unroofing and marsupialization (UM) as primary intervention for chronic pilonidal disease. A retrospective review of a single institution experience over a 5-year period was performed. Sixty-eight patients were treated for pilonidal disease. Their mean age was 25 years. There were 42 males (62%) and 26 females (38%). Twenty-six patients underwent WLE and 42 had UM. The type of operation was based on surgeon preference, but individual surgeons were consistent with their choice. Mean time for final healing was significantly higher for WLE compared with UM (21 vs. 6 weeks, P < 0.01). Postoperative complications and reoperative rate were significantly higher in the WLE group (P < 0.01). Nine patients in the WLE group (35%) required one or more reoperations compared with only one (2%) in the UM group (P < 0.01). This study demonstrates that WLE carries a high complication and reoperative rate. UM should be considered as the initial operation for most patients with pilonidal disease.     

Disparities in late stage diagnosis, treatment, and breast cancer-related death by race, age, and rural residence among women in Georgia

The objectives of this study were to examine the outcomes of late stage breast cancer diagnosis, receiving first course treatment, and breast cancer-related death by race, age, and rural/urban residence in Georgia. The authors used cross-sectional and follow-up data (1992-2007) for Atlanta and Rural Georgia cancer registries that are part of the National Cancer Institute's Surveillance, Epidemiology, and End Results Program (N = 23,500 incident breast cancer cases in non-Hispanic whites or non-Hispanic African Americans). Multilevel modeling and Cox proportional hazard models revealed that compared to whites, African American women had significantly increased odds of late stage diagnosis (odds ratio [OR] = 2.08, p = 0.0001) and unknown tumor stage (OR = 1.27, p = 0.0001), decreased odds of receiving radiation (OR = 0.93, p = 0.041) or surgery (OR = 0.50, p = 0.0001), and increased risk of death following breast cancer diagnosis (hazard rate ratio [HR] = 1.50, p = 0.0001). Increased age was significantly associated with the odds of late/unknown stage at diagnosis, worse treatment, and survival. Women residing in rural areas had significantly decreased odds of receiving radiation and surgery with radiation (OR = 0.59, p = 0.0001), and for receiving breast-conserving surgery compared to mastectomy (OR = 0.73, p = 0.005). Factors affecting each level of the breast cancer continuum are distinct and should be examined separately. Efforts are needed to alleviate disparities in breast cancer outcomes in hard-to-reach populations.     

Non-viral DNA delivery from porous hyaluronic acid hydrogels in mice

The lack of vascularization within tissue-engineered constructs remains the primary cause of construct failure following implantation. Porous constructs have been successful in allowing for vessel infiltration without requiring extensive matrix degradation. We hypothesized that the rate and maturity of infiltrating vessels could be enhanced by complementing the open pore structure with the added delivery of DNA encoding for angiogenic growth factors. Both 100 and 60 μm porous and non-porous hyaluronic acid hydrogels loaded with pro-angiogenic (pVEGF) or reporter (pGFPluc) plasmid nanoparticles were used to study the effects of pore size and DNA delivery on angiogenesis in a mouse subcutaneous implant model. GFP-expressing transfected cells were found inside all control hydrogels over the course of the study, although transfection levels peaked by week 3 for 100 and 60 μm porous hydrogels. Transfection in non-porous hydrogels continued to increase over time corresponding with continued surface degradation. pVEGF transfection levels were not high enough to enhance angiogenesis by increasing vessel density, maturity, or size, although by 6 weeks for all pore size hydrogels more hydrogel implants were positive for vascularization when pVEGF polyplexes were incorporated compared to control hydrogels. Pore size was found to be the dominant factor in determining the angiogenic response with 60 μm porous hydrogels having more vessels/area present than 100 μm porous hydrogels at the initial onset of angiogenesis at 3 weeks. The results of this study show promise for the use of polyplex loaded porous hydrogels to transfect infiltrating cells in vivo and guide tissue regeneration and repair.