The bone response to non-weight-bearing exercise is sport-, site-, and sex-specific.

OBJECTIVE: To examine whether skeletal adaptations to chronic non-weight-bearing exercise depend on the type of aquatic exercise (swimming or water polo) as well as on sex (men or women). DESIGN, SETTING, AND PARTICIPANTS: This was a cross-sectional study at the Laboratory of Nutrition and Clinical Dietetics, Department of Nutrition and Dietetics, Harokopio University, Athens, Greece. A total of 43 water polo players, 26 swimmers, and 30 sedentary individuals, aged 17 to 34 years, were recruited (52 men, 47 women). MAIN OUTCOME MEASURES: Bone mineral content (BMC) and areal bone mineral density (aBMD) of the total body and of various subregions. RESULTS:: Compared with controls, swimmers had lower leg and total aBMD (P < 0.05), whereas water polo players had lower leg but higher arm and trunk aBMD (all P < 0.05). Swimmers and water polo athletes differed at the arms (men only), trunk, and total body (all higher in water polo players, at P < 0.05). Bone adaptations to water polo playing were unaffected by sex. Female swimmers, but not male swimmers, had 13% higher arm BMC than controls (P < 0.05), whereas male swimmers, but not female swimmers, had 12% lower leg BMC than controls (P < 0.05). CONCLUSIONS: Athletes participating in long-term water polo playing and swimming have substantially different total and regional aBMD. The effect is not mediated by sex in water polo players; however, sex may mediate the differences between swimmers and controls. Whether the observed differences between athlete groups and sexes arise from different bone adaptations to activity or from other factors cannot be answered by the current data. CLINICAL RELEVANCE: Water polo playing may be preferable over swimming for maintaining bone health; both types of aquatic exercise at the elite level of participation, however, have unfavorable effects on the lower limb bones.     

The management of stage I nonseminomatous testicular germ cell tumors

Testicular germ cell tumors represent the most common malignancies in young males; 70% of patients with seminomas and 50% of those with nonseminomatous germ cell tumors (NSGCT) have clinical stage I at diagnosis. Lymphovascular invasion, embryonal-cell carcinoma component, absence of yolk sac histology and MIB1 proliferation rate represent predictors of micrometastatic diseasein stage I NSGCT. Therapeutic options following orchiectomy in patients with stage I NSGCT comprise nerve-sparing retroperitoneal lymph node dissection, surveillance or adjuvant cisplatin-based chemotherapy. All available treatment modalities produce excellent results, with a long-term survival of almost 100%. Consequently, therapy-induced toxicity is an important concern in the management of these patients. An individually tailored approach that takes into account the prognostic factor profile as well as the patient's preferences and their ability to comply with each one of the modalities is the key to the management of stage I testicular cancer.     

Assessing surgeons' disclosure of risk information before carotid endarterectomy

BACKGROUND: To make an informed decision about treatment, patients need accurate information about the benefits and risks of treatment and 'non-treatment' options. A survey was conducted to determine patients' recall of the extent and effect of preoperative disclosure by surgeons to patients of risks about carotid endarterectomy (CEA). METHODS: A self-administered questionnaire was given to 133 patients undergoing elective CEA in New South Wales. The primary outcome measures were patient recall of preoperative discussion, self-assessed estimates of stroke risk with and without surgery and receipt of written information before CEA. RESULTS: A significantly higher proportion of patients recalled that their surgeon discussed the short-term stroke risk (i.e. within 30 days) if they decided to undergo CEA (86.2%) than if they decided not to have the procedure (76.9%) (P = 0.04). Of those patients who recalled the surgeon discussing their short-term stroke risk with CEA, only 24 (18.0%) were accurately able to quantify this risk. Patients were significantly more likely to recall their surgeon discussing their long-term stroke risk (i.e. within 2 years) if they decided not to have CEA (72.4%) than if they decided to have the CEA (31.5%) (P < 0.0001). CONCLUSIONS: Patients recalled discussions with their surgeon about short-term stroke risk. Only a minority, however, accurately quantified their postoperative stroke risk. In view of variable patient recall, decision aids could assist.     

Prospective clinical trial comparing outcome measures between Furlow and von Langenbeck Palatoplasties for UCLP

The goal of this prospective randomized clinical trial was to compare 2 cohorts of standardized cleft patients with regard to functional speech outcome and the presence or absence of palatal fistulae. The 2 cohorts are randomized to undergo either a conventional von Langenbeck repair with intravelar velarplasty or the double-opposing Z-plasty Furlow procedure. A prospective 2 × 2 × 2 factorial clinical trial was used in which each subject was randomly assigned to 1 of 8 different groups: 1 of 2 different lip repairs (Spina vs. Millard), 1 of 2 different palatal repair (von Langenbeck vs. Furlow), and 1 of 2 different ages at time of palatal surgery (9-12 months vs. 15-18 months). All surgeries were performed by the same 4 surgeons. A cul-de-sac test of hypernasality and a mirror test of nasal air emission were selected as primary outcome measures for velopharyngeal function. Both a surgeon and speech pathologist examined patients for the presence of palatal fistulae. In this study, the Furlow double-opposing Z-palatoplasty resulted in significantly better velopharyngeal function for speech than the von Langenbeck procedure as determined by the perceptual cul-de-sac test of hypernasality. Fistula occurrence was significantly higher for the Furlow procedure than for the von Langenbeck. Fistulas were more likely to occur in patients with wider clefts and when relaxing incisions were not used.     

Improved endothelial function after endothelin receptor blockade in patients with systemic sclerosis

Objective

Impaired endothelium‐dependent vasodilator function may contribute to vascular damage in patients with systemic sclerosis (SSc). This study was undertaken to investigate whether increased activity of the endothelin 1 (ET‐1) system plays a role in the occurrence of endothelial dysfunction in patients with SSc.

Methods

In 12 patients with SSc (6 with diffuse cutaneous SSc [dcSSc] and 6 with limited cutaneous SSc [lcSSc]), forearm blood flow responses to graded doses of acetylcholine (ACh) and sodium nitroprusside (SNP) given intraarterially were assessed by plethysmography, during infusion of saline and following selective blockade of ET_A receptors with BQ‐123 (10 nmoles/minute).

Results

During saline infusion, the vasodilator response to ACh was blunted in patients with SSc as compared with that in healthy controls (P < 0.001), whereas the response to SNP was not different between groups (P = 0.27). The vasodilator effect of ET_A receptor antagonism was higher in patients than in controls (P < 0.001), indicating enhanced ET‐1–mediated vasoconstriction in SSc. In patients, ET_A receptor blockade resulted in a potentiation of the vasodilator response to ACh (P < 0.001 versus saline), but did not affect the response to SNP (P = 0.31). Notably, both the vasodilator effect of ET_A receptor antagonism and the improvement in the responsiveness to ACh following BQ‐123 infusion were higher in patients with dcSSc than in those with lcSSc (P < 0.01).

Conclusion

ET‐1–dependent vasoconstrictor tone is increased predominantly in the subgroup of SSc patients with dcSSc, in whom acute blockade of ET_A receptors was able to improve impaired endothelium‐dependent vasodilator function. Our results suggest novel vasculoprotective effects of ET_A receptor antagonism and support further exploration of strategies that target the ET‐1 pathway in SSc.

     

Water polo is associated with an apparent redistribution of bone mass and density from the lower to the upper limbs

The bone response to exercise is site-specific and load-dependent. Recent evidence suggests that an inverse relationship may exist between loaded and unloaded sites, such that the former may benefit at the expense of the latter. The present study examined this possibility in 48 males (21 water polo players, 12 handball players, and 15 sedentary controls). Water polo and handball are alike with respect to the active loading of the upper limbs during overhead throwing; however, the weight-supporting environment of water polo removes the weight-bearing effect from the lower limbs. Bone mineral content (BMC), bone projected area (Ap), and areal bone mineral density (aBMD) of the total body and of various subregions were determined by dual-energy X-ray absorptiometry. After adjusting for age, height, and weight, water polo players had higher arms BMC, Ap, and aBMD (by 22.2, 11.1, and 10.5%, respectively; P < 0.05), but lower legs aBMD (−6.3%; P < 0.05) relative to controls. On the contrary, compared to controls, handball players had higher BMC (from 11.8 to 24.3%), Ap (from 5.2 to 11.7%), and aBMD (from 6.4 to 11.9%) for the total body at all sites. Water polo athletes had increased arms and decreased legs aBMD ratios (regional-to-total) than either handball players or sedentary subjects (P < 0.001). Water polo is associated with an apparent redistribution of bone mass and density from the lower to the upper limbs, with no major effects on the rest of the body.     

Discrepancy analysis, communication, and feedback for cytotechnologist quality improvement of nongynecologic cytopathology

The Clinical Laboratory Improvement Amendments of 1988 (CLIA '88) detail the requirements for the cytotechnologist (CT) who evaluates gynecologic cytopathology specimens. However, the role of the CT in nongynecologic cytopathology is not clearly defined. Furthermore, non gynecologic cytopathology cases are diverse and the screening, interpretative, and diagnostic issues may be quite different from the gynecologic cases. At our institution, the CT and pathologist review nongynecologic cytopathology cases. Since CLIA '88 does not require the CT to screen nongynecologic cytopathology cases, there are few guidelines for quality assessment or quality improvement for the CT regarding nongynecologic cytopathology cases. To provide better understanding of the expectations of the CT and the needs of the pathologist, we developed a system comparing the CT's interpretation to the pathologist's interpretation as a means for enhanced communication and feedback. Using our Laboratory Information System (LIS), we generate a daily report that lists all cases with discrepancy in diagnoses between the CT and pathologist. The general supervisor reviews this report for diagnostic discrepancy in each case. To determine the degree of discrepancy, numerical values are assigned to each primary interpretation. Minor discrepancies are defined as differences less than +/-2.0. Major discrepancies are defined as differences greater than or equal to +/-2.0. For the entire laboratory, the overall percentage of concordant cases was consistently above 80% for each of the 6 mo analysis. Regarding the monthly discrepancies, the proportion of minor discrepancies ranged from 11.09% to 15.44% and the proportion of major discrepancies ranged from 1.40% to 3.56%. The frequency distribution of discrepancies by degree approximates a normal (Gaussian) curve and serves as baseline information that may be used for comparison when there are changes in practice or personnel. The CTs attend slide review sessions conducted by the general supervisor for discussion of cases with major discrepancies. The discrepancy data from individual CTs are useful in counseling and recommending areas for improvement. As the CT and pathologist work cooperatively and in tandem, our system allows for a mechanism by which the expectations and needs of pathologist are communicated to the CT more effectively. We believe our process is a fundamental step in improving CT performance in Nongynecologic cytopathology and keeps the CT informed of complexities of nongynecologic cytopathology.