Predictors of psychosocial adaptation among people with spinal cord injury or disorder

OBJECTIVE: To examine the influence of disability-related medical and psychologic variables on psychosocial adaptation to spinal cord injury or disorder (SCI/D). DESIGN: A structural equation modeling design linking 3 sets of predictive variables to an outcome measure of adaptation. SETTING: Two outpatient SCI clinics (1 veteran, 1 civilian) in Texas. PARTICIPANTS: Veterans (n=181) and civilians (n=132) with SCI/D. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The adaptation outcome was measured by 2 subscales (acknowledgment, adjustment) of the Reactions to Impairment and Disability Inventory (RIDI) and by the Quality of Life Scale. The predictive variables were measured by a demographic questionnaire, 3 subscales (intrusion, re-experiencing, hyperarousal) of the Purdue Posttraumatic Stress Disorder-Revised scale, the McMordie-Templer Death Anxiety Scale, and 3 subscales (anxiety, depression, denial) of the RIDI. RESULTS: Goodness-of-fit indices suggested that a revised model of adaptation was a moderately good fit to the data. The revised model of adaptation indicated that there were medium total effects (direct plus indirect) on psychosocial adaptation by 2 latent variables (disability severity and impact, negative affectivity) and small total effects on psychosocial adaptation by disengagement coping. The latent factor of disengagement coping had the strongest direct effect on adaptation (although not statistically significant). Disability severity and impact had medium indirect effects and negative affectivity had small indirect effects on psychosocial adaptation. All of the aforementioned effects had a negative coefficient. CONCLUSIONS: Negative emotional responses (eg, depression, anxiety) to SCI/D, disengagement-type coping (eg, disability denial, avoidance), and the severity and impact of disability were related to lower levels of adaptation to SCI/D.     

Laparoscopic versus non-laparoscopic-assisted ventriculoperitoneal shunt placement in adults. A retrospective analysis

BACKGROUND: Ventriculoperitoneal shunts and distal shunt revisions bear a high risk of distal malfunction, especially in patients with previous abdominal pathologies as well as in obese patients. We performed laparoscopy-guided distal shunt placement or revision for patients with and without a positive abdominal history. We review the indications, techniques, complications, and long-term outcomes of these cases and compare the results to those of patients operated without laparoscopic guidance. METHODS: A total of 211 distal shunt procedures were performed in our institute between January 2001 and December 2005, 59 of which were laparoscopically guided, and 152 were not. Of the 211 procedures, 177 were placement of new shunt systems, and 34 were distal revisions. A total of 33 procedures were performed in 25 patients with a history of abdominal surgery or inflammatory bowel disease; 15 procedures were operated with laparoscopic guidance. RESULTS: The short-term complication and outcome rates were similar between the laparoscopy group and the other patients. Among the patients with new shunts, the long-term distal malfunction rate was lower in the laparoscopy group compared with the nonlaparoscopy group (4% vs 10.3%, respectively; P = .17). No patients in the laparoscopy group and 6 patients operated by other techniques had distal malfunction. There was 1 laparoscopy-related mortality and no morbidity. CONCLUSIONS: Laparoscopy is not routinely indicated in distal shunt placement or revision. However, a laparoscopy-guided procedure may lower the rate of distal malfunction in patients with previous abdominal surgeries.     

Laparoscopic adnexal transposition: novel surgical technique

Treatment of some cancers diagnosed at an early stage with expectation of prolonged survival has permitted the consideration of salvaging the reproductive and hormonal function of premenopausal female patients. When radiation to the pelvic area is part of treatment, this will almost always result in ovarian failure. To protect the ovaries, an oophoropexy may be performed, which involves moving the ovaries away from the radiation field. This procedure may be performed via laparoscopy. Some women undergoing laparoscopic radical hysterectomy may also be candidates for laparoscopic transposition. Because failure rates are still reported to be high, we developed a novel technique to mobilize the adnexa, which we present in this paper and attached movie.After separating the adnexa from the uterus and developing the infundibulopelvic (IP) ligament, a retroperitoneal tunnel is developed from the pelvis to the transposition opening laterally. The adnexa are moved through this tunnel, avoiding torsion of the vessels, and are brought through the opening back into the peritoneum. The adnexa are now fixed securely to the posterolateral abdominal wall with nonabsorbable sutures.Several issues permit better results using this technique. The IP ligament remains retroperitoneal and itself is outside the field of radiation. There is no kinking of the ovarian blood supply on the peritoneal fold. The location of the transposition is way above the field of radiation, preventing scatter injury. Even if one or both of the sutures fail, placement of the ovary will not change because of the peritoneum it has been brought through. This and the final location of the IP ligament retroperitoneally may enforce the ovary to it outside of the radiation field and prevent possible migration of the ovary back to the pelvis. This technique has advantages, which may offer the ovaries a better chance to resume hormonal function.     

Conception after early IVF pregnancy loss: should we wait?

Research questionIs the interval length between an early pregnancy loss and the following treatment cycle a predictor for achieving clinical pregnancy among IVF patients?DesignThis retrospective cohort study of 257 women who reinitiated treatment after first-trimester IVF pregnancy loss was conducted at a tertiary, university-affiliated medical centre between 1 January 2014 to 1 January 2018. Women aged 18–40 years, with normal uterine cavity, who experienced first-trimester pregnancy loss at less than 14 weeks after IVF, were included. Miscarriages were classified as spontaneous, biochemical, medical or surgical.ResultsAmong 257 women, interval to subsequent IVF treatment was not associated with achieving pregnancy. Patients after biochemical pregnancy (72.7 ± 56.4, median 60 days) or spontaneous miscarriage (97.7 ± 93.1, median 66 days) had shorter intervals to next cycle, compared with medical (111.9 ± 103.2, median 65 days) or surgical (123.4 ± 111.1, median 84 days) (Kaplan–Meier, P = 0.03) miscarriages.Logistic regression analysis showed that the chance of subsequent pregnancy was affected by the number of embryos transferred (P = 0.009) and the type of miscarriage. Medical (P = 0.005) and surgical (P = 0.017) miscarriages were related to lower likelihood of pregnancy compared with biochemical pregnancy (reference group).When pregnancy was achieved in the first post-miscarriage cycle, the chance of live birth increased with shorter intervals (median 57.5 days), whereas second miscarriage was related to longer intervals (median 82.5 days) between miscarriage and subsequent IVF cycle (P = 0.03).ConclusionOn the basis of this cohort, IVF should not be postponed after pregnancy loss, as shorter intervals were associated with greater likelihood of live birth.     

A mutation in the peroxisome proliferator-activated receptor γ-binding site in the gene for the cytosolic form of phosphoenolpyruvate carboxykinase reduces adipose tissue size and fat content in mice

Regulation of the turnover of triglycerides in adipose tissue requires the continuous provision of 3-glycerophosphate, which may be supplied by the metabolism of glucose or by glyceroneogenesis, the de novo synthesis of 3-glycerophosphate from sources other than hexoses or glycerol. The importance of glyceroneogenesis in adipose tissue was assessed in mice by specifically eliminating the expression of the cytosolic form of phosphoenolpyruvate carboxykinase (PEPCK-C), an enzyme that plays a pivotal role in the pathway. To accomplish this, we mutated the binding site for the peroxisome proliferator-activated receptor gamma (PPAR gamma) called the peroxisome proliferator-activated receptor element (PPARE), in the 5' flanking region of the PEPCK-C gene in the mouse by homologous recombination. The mutation abolished expression of the gene in white adipose tissue and considerably reduced its expression in brown adipose tissue, whereas the level of PEPCK-C mRNA in liver and kidney remained normal. Epididymal white adipose tissue from these mice had a reduced triglyceride deposition, with 25% of the animals displaying lipodystrophy. There was also a greatly reduced level of lipid accumulation in brown adipose tissue. A strong correlation between the hepatic content of triglycerides and the size of the epididymal fat pad in PPARE(-/-) mice suggests that hepatic triglyceride synthesis predominantly utilizes free fatty acids derived from the adipose tissue. Unlike other models, PPARE(-/-) mice with lipodystrophy did not exhibit the lipodystrophy-associated features of diabetes and displayed only moderate hyperglycemia. These studies establish the importance of the PPARE site for PEPCK-C gene expression in adipose tissue and the role of PEPCK-C in the regulation of glyceroneogenesis, a pathway critical for maintaining the deposition of triglycerides in adipose tissue.     

Differing proliferative responses in proximal and distal colons of growing rats fed food eaten by adenoma patients

Animal dietary studies related to human colorectal carcinogenesis are usually based on AIN-76A diet, which is dissimilar to human food in source, preparation, and content. Our aim was to examine colonic epithelial proliferation in rats fed a diet based on the mean daily food intake of adenoma patients. Foods were prepared as reported by the adenoma patients and dehydrated; 64 Sprague-Dawley rats were fed either “human adenoma” or AIN-76A diet and every eight weeks, eight from each group were sacrificed. Both groups gained weight equally, had no colonic histological changes, but during the study showed progressive lengthening of colonic crypts (P<0.01) and decreased proliferation (P<0.05) in distal colons. Compared to controls, rats fed human adenoma diet had significantly longer crypts (P<0.01) and more labeled cells (P<0.05) at 32 weeks; overall they had increased proliferation (P<0.01), most significantly in the distal colon. Thus, food eaten by adenoma patients induced hyperproliferative changes in the rat colon during growth and maturity, especially the distal colon, as found in humans at risk for neoplasia.     

Management and outcomes of elderly women and men with acute coronary syndromes in 2000 and 2002

BACKGROUND: Previous studies have suggested that women with myocardial infarction are treated less aggressively and have worse outcomes compared with men. The objective of this study was to evaluate sex differences in the management and outcomes of elderly (age > or = 70 years) women and men with acute coronary syndromes (ACSs) in the new millennium. METHODS: This study includes 1331 consecutive elderly patients with ACSs admitted to all intensive coronary care units and cardiology departments in Israel from 2 prospective nationwide ACS surveys conducted in 2000 and 2002. RESULTS: The mean age of women vs men was comparable (79 vs 78 years). Comorbidities were more frequent in women, whereas previous coronary disease and typical anginal pain on admission were more frequent in men. Medical treatments and revascularization procedures during the index hospitalization were comparable in both groups. Crude and covariate-adjusted mortality rates were higher in women at 7 days (12% vs 7%; P = .007; adjusted odds ratio [OR], 1.83; 95% confidence interval [CI], 1.15-2.91) but not at 6 months (21% vs 19%; adjusted OR, 1.10; 95% CI, 0.79-1.52). This difference was attributed to ST elevation (STE)-ACS in women vs men (19% vs 12%; P = .007; adjusted OR, 1.97; 95% CI, 1.14-3.46). Seven-day mortality rates were highest in patients with STE-ACS denied coronary angiography, especially women (23% vs 15%; P = .06). CONCLUSIONS: In the 2000s, elderly women and men with ACSs are receiving similar medical and invasive management during the index hospitalization; however, women with STE-ACS have higher mortality rates at 7 days but not at 6 months. Mortality rates are highest in patients with STE-ACS denied coronary angiography. The benefit of invasive procedures on mortality rates in elderly patients with STE-ACS needs further investigation.