Training of a Minimally Invasive Bariatric Surgeon: Are Laparoscopic Fellowships the Answer?

Background: Fellowships in advanced laparoscopy with emphasis in laparoscopic gastric bypass (LGBP) are available for obtaining experience in performing LGBP. The following is the first report in the literature prospectively documenting a single surgeon's experience with LGBP outcomes following completion of an advanced laparoscopic surgical fellowship. Methods: Outcomes measured prospectively included length of stay, length of operation, complications, reduction in obesity-related co-morbidities, and percentage excess weight loss. Outcomes were analyzed by quartile to see if there was a difference over time. Complications were also compared to outcomes in the literature. Results: 175 patients (147 female, 28 male) underwent LGBP. The mean BMI was 49.2. Mean operative time was 123 minutes, and mean length of stay was 2.2 days. The percentage excess weight loss at 1 year was 73% (n = 79). One patient developed an internal hernia (0.6%) and 1 patient developed an anastomotic leak (0.6%). Postoperative transfusion rate was 4.6%. There were no deep venous thromboses or pulmonary emboli detected. There were no conversions to open, and there was no mortality. Upon quartile analysis, there was no difference in complication rates. Complication rates were comparable to published outcomes in the literature. Conclusion: Fellowships in advanced laparoscopy with emphasis on LGBP provide the optimal training environment for acquisition of skills necessary to safely and effectively perform LGBP. With fellowship training, complication rates were comparable to published outcomes in the literature without a period of higher complications (the learning curve).     

Anterior glenohumeral force/translation behavior with and without rotator cuff contraction during clinical stability testing

OBJECTIVE: Measure stiffness of the glenohumeral joint during clinical laxity testing with and without muscular contraction of the Internal rotators. DESIGN: Cross-sectional study of normal shoulders. BACKGROUND: Clinical examination for shoulder instability is based on subjective impression, and is only performed passively. Our study presents a method for quantitative clinical examination of the shoulder under both passive and active muscle contraction conditions. We hypothesized that in a normal shoulder, contraction of the internal rotators will increase the stiffness of the glenohumeral joint, effectively constraining the head of the humerus against anterior directed forces. METHODS: Ten subjects were instrumented with electromagnetic sensors to record glenohumeral linear displacements. A mini-force transducer recorded forces applied to subjects during anterior drawer testing (forced anterior glenohumeral displacement), which was performed passively, and during isometric contraction of internal rotators. RESULTS: Only mild contraction of the internal rotators is needed to significantly increase the stiffness to anterior directed forces. Greater muscular activation does not result in further increased stiffness. CONCLUSION: Objective measurement of glenohumeral stiffness during passive and active muscular contraction may be useful for evaluating the capacity of rotator cuff muscles to stabilize the shoulder. The concept of more strength is better, for rotator cuff strengthen programs is questioned.     

High-fat diet induced adiposity in mice with targeted disruption of the dopamine-3 receptor gene

Dopamine (DA) signaling has been implicated in the control of energy balance and ingestive behavior. In the present study, we sought to characterize body weight, body fat and food intake regulation in a mouse with a targeted disruption of the dopamine-3 receptor gene (Drd3). In the first set of experiments male and female wild-type and mutant (Drd3-/-) mice were given access to two different diets varying in fat content. Body weight, food intake, carcass analysis and plasma levels of leptin and insulin were measured. Male Drd3-/- mice have increased body weight and body fat when given access to high fat (HF) diet but not standard rodent chow. The female Drd3-/- mice did not demonstrate increased body weight when given access to either diet, but did have increased body fat on both diets. Plasma leptin and insulin levels reflected the increased adiposity demonstrated in each genotype and gender. These findings suggest the D3-R signaling is involved in the regulation of body weight and body fat when mice are given access to diets differing in palatability and fat content.     

Fertility Enhancing Hysteroscopic Surgery: Our Experience

690 hysteroscopies done over a period of four and a half years for infertility were evaluated. 85 therapeutic hysteroscopic procedures like hysterscopic metroplasty, lysis of intrauterine adhesions, electroresection of fibroids, removal of foreign bodies and cornual cannulation were carried out. These minimally invasive procedures were associated with satisfying results, least morbidity, shorter hospital stay and high patient satisfaction.Key Words: Cornual cannulation, Electroresection, Hysteroscopy, Intrauterine adhesions, Metroplasty, Submucus fibroids     

Clinical diagnosis of presenile Alzheimer's disease: A novel approach

A national retrospective survey of hospital records was used to select those patients with presenile dementia who had undergone neuropathological examination. The National Institute of Neurological and Communicative Disorders and the Alzheimer's Disease and Related Disorders Association (NINCDS–ADRDA) clinical criteria for probable Alzheimer's disease and a Hachinski score were applied to each record before the neuropathological diagnosis was known. A discriminant analysis, which entered the criteria as variables, was performed. The diagnostic accuracy of the clinical criteria was compared before and after discriminant analysis. One thousand six hundred and seventy-one records were scrutinised of which 61 patients had undergone neuropathological examination. NINCDS–ADRDA criteria had a diagnostic accuracy of 72% (specificity 88%, sensitivity 61%) compared to 77% (specificity 80%, sensitivity 75%) after analysis. NINCDS–ADRDA criteria together with the Hachinski score had an accuracy of 72% (specificity 61%, sensitivity 88%) compared to 83.6% (specificity 76%, sensitivity 89%) after analysis. Variables of highest discriminating value were the Hachinski score, presence of coexistent neurological disease and presence of coexistent systemic disease. The results highlight limitations of current clinical criteria used to diagnose Alzheimer's disease and suggest that substantial improvements are possible.     

Clinical review of patients with fixed bridges (2). A study of deviations between observers

The authors have made a study of observer deviations in the re-examination of patients with fixed bridges. The material consisted of eighteen patients who have had their bridges for about 2 years. The total number of bridge-elements was 126, including eighty-three abutment teeth and forty-three politics. Nine observers have taken part. Of these, three have been teachers and six post-clinical students, so that it has been possible to say that the observers had more, and lesser, experience of routine observation. The recorded factors have been: (1) primary contact; (2) the general status of the marginal periodontium; (3) calculus; (4) caries; (5) periapical status; (6) attrition facet; (7) abrasion in the opposing jaw; (8) crown margin excess; (9) crown margin deficit; (10) exposed crown margin; (11) pocket formation; (12) discolouration of gold. The examinations have been carried out in a conventional milieu with the usual instruments for examination and with access to orthopantomograms. The recordings have been made after independent as well as cumulative and simultaneous examination. In the last two cases the observers have been divided into three groups. A very simple account of the results regarding the first five factors is given. It is quite clear, however, that the nine observers record different totals and that positive finds are at the same time seldom reported by all. Each of the seven remaining factors has given rise to a larger number of (positive) recordings, so that a more detailed processing has been meaningful. Within each factor (with a certain exception for abrasion) considerable deviations are found between the nine independent observers in the matter of totals. It has been possible with analysis of variance to confirm, to a great extent, these deviations as significantly systematic. In connection with the change to cumulative and simultaneous observer strategy it has been possible to note certain improvements. It has not, however, been possible to designate the agreement between the three observer groups as appreciable. On the other hand, the number of positive recordings increases most frequently in connection with the changes to (Cum) and still more with the change to (Sim). The nine observers change level in relation to one another on moving from the one factor to the other. Within a certain factor they sometimes vary also between different patients, though a certain logical pattern appears. Through comparisons in pairs and the calculation of the correlation (expressed through the coefficient r) it has been possible to show that the correlation between the recordings of two observers is not always satisfactory. However, the conventional limit + 0.70 is exceeded in the majority of cases. The two groups of observers do not differ characteristically from each other factor by factor, (the factors ‘general status of the periodontium’ and ‘crown margin excess’ constitute exceptions). Both teachers and students change position in an irregular way. Each one of the nine observers may occur alternately as a high and a low recorder. The authors recommend further studies in this field with the aim of throwing light upon the homogenization of observers and becoming better informed concerning the precise significance of utilizing different observer strategies.