219 vascular fellows' perception of the future of vascular surgery

In an attempt to identify the fellows' concerns about the future of the field of vascular surgery, we conducted a survey consisting of 22 questions at an annual national meeting in March from 2004 to 2007. In order to obtain accurate data, all surveys were kept anonymous. The fellows were asked (1) what type of practice they anticipated they would be in, (2) what the new training paradigm for fellows should be, (3) to assess their expectation of the needed manpower with respect to the demand for vascular surgeons, (4) what were major threats to the future of vascular surgery, (5) whether they had heard of and were in favor of the American Board of Vascular Surgery (ABVS), (6) who should be able to obtain vascular privileges, and (7) about their interest in an association for vascular surgical trainees. Of 273 attendees, 219 (80%) completed the survey. Males made up 87% of those surveyed, and 60% were between the ages of 31 and 35 years. Second-year fellows made up 82% of those surveyed. Those expecting to join a private, academic, or mixed practice made up 35%, 28%, and 20% of the respondents, respectively, with 71% anticipating entering a 100% vascular practice. Forty percent felt that 5 years of general surgery with 2 years of vascular surgery should be the training paradigm, while 45% suggested 3 and 3 years, respectively. A majority, 79%, felt that future demand would exceed the available manpower, while 17% suggested that manpower would meet demand. The major challenges to the future of vascular surgery were felt to be competition from cardiology (82%) or radiology (30%) and lack of an independent board (29%). Seventeen percent were not aware of the ABVS, and only 2% were against it; 71% suggested that vascular privileges be restricted to board-certified vascular surgeons. Seventy-six percent were interested in forming an association for vascular trainees to address the issues of the future job market (67%), endovascular training during fellowship (56%), increasing focus on the vascular fellows at national meetings (49%), and representation for the fellows on the national councils (37%). This survey suggests that several significant issues exist in the minds of vascular trainees that have not been addressed and may present opportunities for further dialogue.     

Effects of calcium supplementation on body weight reduction in overweight calcium stone formers

A randomized, placebo-controlled trial was conducted in overweight calcium stone-forming (CSF) patients, to evaluate the effect of calcium supplementation associated with a calorie-restricted diet on body weight (BW) and fat reduction and its potential changes upon serum and urinary parameters. Fifteen patients were placed on a hypocaloric diet for 3 months, supplemented with either calcium carbonate (CaCO₃, n = 8) or placebo (n = 7), 500 mg bid. Blood and 24-h urine samples were collected and body composition was assessed at baseline and after the intervention. At the end of the study, final BW was significantly lower vs baseline in both CaCO₃ (74 ± 14 vs. 80 ± 14 kg, P = 0.01) and placebo groups (80 ± 10 vs. 87 ± 9 kg, P = 0.02) but the mean percentage of loss of body weight and body fat did not differ between CaCO₃ and placebo (7.0 ± 2.0 vs. 8.0 ± 3.0%, P = 0.40 and 13.0 ± 7.0 vs. 13.0 ± 10.0%; P = 0.81, respectively). After CaCO₃ or placebo, no significant differences versus baseline were observed for urinary parameters in both CaCO₃ and placebo, except for a higher mean urinary citrate in placebo group. These data suggest that increasing calcium intake by calcium carbonate supplementation did not contribute to a further reduction of BW and fat in overweight CSF patients submitted to a hypocaloric diet nor altered urinary lithogenic parameters.     

Intragastric Balloon Followed by Biliopancreatic Diversion in a Liver Transplant Recipient: A Case Report

Liver transplantation is a life-saving procedure for end-stage liver disease. In liver transplant recipients, morbid obesity influences post-operative survival and graft function. In 1996, our patient underwent a successful liver transplantation because of a HCV-related liver failure (body mass index (BMI) 31). Follow-up showed a functional graft and the development of severe obesity up to a BMI of 61 in January 2006. In January 2007, he was submitted to intragastric balloon therapy for 6 months, reaching a BMI of 54. In September 2007, he underwent a biliopancreatic diversion. During follow-up to March 2008, he reached a BMI of 42 with ameliorations of comorbidities. In May 2008, during a hospital admission, he suddenly died of a heart attack. Post mortem study revealed a myocardial infarction. This is the first world case report for this approach. According to our opinion, patient’s death was not related to bariatric surgery.     

Endurance training damages small airway epithelium in mice

RATIONALE: In athletes, airway inflammatory cells were found to be increased in induced sputum or bronchial biopsies. Most data were obtained after exposure to cold and dry air at rest or during exercise. Whether training affects epithelial and inflammatory cells in small airways is unknown. OBJECTIVES: To test whether endurance training under standard environmental conditions causes epithelial damage and inflammation in the small airways of mice. METHODS AND MEASUREMENTS: Formalin-fixed, paraffin-embedded lung sections were obtained in sedentary (n = 14) and endurance-trained (n = 16) Swiss mice at baseline and after 15, 30, and 45 days of training. The following variables were assessed (morphometry and immunohistochemistry) in small airways (basement membrane length < 1 mm): (1) integrity, proliferation, and apoptosis of bronchiolar epithelium; and (2) infiltration, activation, and apoptosis of inflammatory cells. MAIN RESULTS: Compared with sedentary mice, bronchiolar epithelium of trained mice showed progressive loss of ciliated cells, slightly increased thickness, unchanged goblet cell number and appearance, and increased apoptosis and proliferation (proliferating cell nuclear antigen) (p < 0.001 for all variables). Leukocytes (CD45(+) cells) infiltrated airway walls (p < 0.0001) and accumulated within the lumen (p < 0.001); however, apoptosis of CD45(+) cells did not differ between trained and sedentary mice. Nuclear factor-kappaB translocation and inhibitor-alpha of NF-kappaB (IkappaBalpha) phosphorylation were not increased in trained compared with sedentary mice. CONCLUSIONS: Bronchiolar epithelium showed damage and repair associated with endurance training. Training increased inflammatory cells in small airways, but inflammatory activation was not increased. These changes may represent an adaptive response to increased ventilation during exercise.     

Mesenteric adipose tissue alterations resulting from experimental reactivated colitis

BACKGROUND: Adipose tissue secretes a large number of hormones that act either locally or at distant sites, modulating immune responses, inflammation, and many endocrine and metabolic functions. Abnormalities of fat in the mesentery have been long recognized in surgical specimens as characteristic features of Crohn's disease; however, the importance of this in chronic inflammatory disease is unknown. Additionally, adipocytes in depots that enclose lymph nodes or other dense masses of lymphoid tissue have many site-specific physiological properties. METHODS: In this study, the alterations of mesenteric and perinodal mesenteric adipose tissue during experimental colitis, induced by repeated intracolonic trinitrobenzene sulfonic acid instillations, were evaluated, focusing on morphological and activity alterations and the adipocytokine production profile. RESULTS: After a 35-day protocol, the colitis animals presented greater mesenteric fat masses despite their lower body weights. Another adipose tissue depot, epididymal adipose tissue, was also evaluated and no change in mass was observed. The mesenteric adipocyte from colitis animals had a reduced diameter, normal PPAR-gamma-2 expression, and higher basal lipolysis and TNF-alpha production when compared to normal rats. Perinodal mesenteric adipocytes present normal diameters, downregulated levels of PPAR-gamma-2, higher basal lipolysis and TNF-alpha, and leptin and adiponectin production. CONCLUSIONS: The findings suggest that mesenteric adipose tissue has a site-specific response during experimental inflammation, where perinodal adipose tissue retains the ability to produce different adipocytokines. These substances may interfere in many lymph node aspects, while mesenteric adipose tissue produces substances that could contribute directly to aggravate the inflammatory process.     

Resting energy expenditure and body composition in bedridden institutionalized elderly women with advanced-stage pressure sores

BACKGROUND: Our study investigated nutritional status, body composition, and resting energy expenditure (REE) in elderly patients with advanced-stage pressure sores (PS), in addition to researching any hypermetabolic condition and its relationship with PS size. METHODS: The study involved 52 institutionalized bedridden elderly women (aged 83.7 +/- 6.3 years), divided into two groups: 23 with advanced-stage (stage 3 and 4) PS and 29 without PS. Albumin, prealbumin, and retinol-binding protein were measured in all patients, and fat-free mass (FFM) and fat mass (FM) were obtained by dual-energy x-ray absorptiometry (DEXA). REE was measured by indirect calorimetry and predicted with the Harris-Benedict formula. PS area and volume were also measured. RESULTS: The elderly women with and without PS were comparable in age, FFM, and FM. Mean albumin, prealbumin, and retinol-binding protein values were lower in cases with PS. Unadjusted mean REE was significantly higher in patients with PS (1212.3 +/- 236.7 vs 1085.5 +/- 161.3 kcal/d; p <.05), even after adjusting for FFM or expressed per kilogram of body weight (25.8 +/- 6.7 vs 21.1 +/- 4.0 kcal/d/kg; p <.01). Hypermetabolism, i.e., a measured REE > 110% of the predicted REE, was seen in 74% of patients with PS and 38% of controls. The difference between measured and predicted REE (DeltaREE) correlated with PS volume (r = 0.58; p <.01), but not with area. CONCLUSION: Advanced-stage PS in elderly women are associated with a hypermetabolic state that is influenced by the volume of the PS.     

Low specificity of the Murex fourth-generation HIV enzyme immunoassay in Tanzanian adolescents

Objective To determine the specificity of the Abbott Murex HIV antigen/antibody combination enzyme immunoassay (EIA) for the diagnosis of HIV infection in Tanzania. Methods A cross‐sectional survey of 7333 Tanzanian adolescents and young adults was carried out. Sera testing positive by the Murex assay were further evaluated using a battery of other EIA which detect either antibody to HIV‐1 or p24 antigen, and by PCR using pol primers. Results Of the 674 sera testing positive by the Murex assay, only 53 (7.9%) were confirmed. The specificity of the Murex assay was 91.5%. Conclusions Serological tests for HIV may perform differently in different populations. New diagnostic tests should not be introduced into populations in which they have not been evaluated.