Prognosis and Determinants of Outcome Following Locoregional or Distant Recurrence in Patients with Cutaneous Melanoma

Objective Information on prognosis for patients with cutaneous melanoma after locoregional or distant recurrence is sparse and controversial. The aim of this study was to analyze factors influencing outcome after the development of a first relapse. Methods Information was extracted from the Sydney Melanoma Unit database for 873 melanoma patients with American Joint Committee on Cancer (AJCC) Stage I and II disease treated between 1960 and 2002 who relapsed following treatment of their primary melanoma. Clinical and pathologic factors predicting survival were analyzed using the Cox proportional hazards regression model. Results Initial presentation of recurrence was local: 95 patients (10.9%), in transit: 86 patients (9.9%), regional lymph node: 300 patients (34.4%), and distant: 392 patients (44.9%). Independent prognostic factors for survival of the 481 patients with only locoregional recurrence were type of recurrence, primary tumor ulceration, and patient age. Predictors for longer survival in the 392 patients with distant metastasis at the time of first presentation with recurrence were lung vs other sites and diagnosis of relapse after 1990 compared with diagnosis before 1980. Conclusions The type of recurrence is the most important prognostic factor in melanoma patients who relapse. Primary tumor ulceration is the most important pathologic predictor. The results of this study suggest that management of distant metastases may have improved over the last 25 years, but many confounders and improved staging techniques make assessment of this unreliable.     

Coital urinary incontinence: impact on quality of life as measured by the King’s Health Questionnaire

The aim of this present study was to measure the impact of coital urinary incontinence (UI) on sexually active women quality of life (QoL). Epidemiological, observational, cross-sectional, and multicenter study including 633 sexually active women seeking treatment for UI and/or overactive bladder in a gynecological clinic, aged between 24 and 83 years. All women filled out the King’s Health Questionnaire—KHQ. With this questionnaire, we had a complete register of the different urinary symptoms, included coital UI, and the extent of how they affect patient’s life and the measurement of impact on the patient’s QoL by the KHQ score. Prevalence of coital incontinence in sexually active women was 36.2%, classifying this impact as low (59.8%), moderate (32.3%), and high (7.9%). Women reporting coital incontinence had similar mean age and body mass index (BMI) to those women without coital incontinence. Women with coital incontinence had higher scores (worse QoL) in all the dimensions and in the KHQ global score (p < 0.05). Coital incontinence was the only variable showing an independent relation to KHQ global score (B = 10.1; 95% confidence interval = 1.7–18.6) in a multiple regression model adjusted to age, BMI, and the other urinary symptoms under study. One third of the sexually active women with urinary symptoms had coital incontinence. Among sexually active women with urinary symptoms, patients with coital urinary incontinence had a higher impact on their QoL than those without coital incontinence. Coital incontinence is independently related to a KHQ high score, which suggest worse QoL.     

Challenges in Pulmonary Risk Assessment and Perioperative Management in Bariatric Surgery Patients

Bariatric surgery has serious associated medical comorbidity and procedure-related risks and is, thus, considered an intermediate-to-high-risk non-cardiac surgery. Altered respiratory mechanics, obstructive sleep apnea (OSA), and less often, pulmonary hypertension and postoperative pulmonary embolism are the major contributors to poor pulmonary outcomes in obese patients. Attention to posture and positioning is critical in patients with OSA. Suspected OSA patients requiring intravenous narcotics should be kept in a monitored setting with frequent assessments and naloxone kept at the bedside. Use of reverse Tredelenburg position, preinduction, maintenance of positive end-expiratory pressure, and use of continuous positive airway pressure can help improve oxygenation in the perioperative period.     

Bone marrow stromal cell lines having high potential for osteoclast-supporting activity express PPARγ1 and show high potential for differentiation into adipocytes

Bone marrow stromal cells support osteoclast differentiation by expressing receptor activator of NF-kB ligand (RANKL). Although several bone marrow stromal cell lines have been established and characterized, the differentiation stage of the supporting cells for osteoclast differentiation remains unclear. We have established several bone marrow stromal cell lines from transgenic mice harboring the temperature-sensitive SV40 large T antigen. Some of these temperature-sensitive bone marrow stromal cell lines (TSB cell lines) support osteoclast differentiation and differentiate into osteoblasts, suggesting that osteoblast precursor cells support osteoclast differentiation. Here we show that the TSB cell lines that support osteoclast differentiation also expressed peroxisome proliferator-activated receptor γ1 (PPARγ1) and were able to differentiate into adipocytes. PPARγ1 is an alternatively spliced form of PPARγ that is responsible for the adipocyte differentiation and expressed in the adipocyte precursor cells. Immunofluorescence analysis of TSB cell lines and primary bone marrow stromal cells by use of anti-PPARγ and anti-RANKL antibodies showed that fluorescent signals for RANKL were observed in the cells that expressed PPARγ. Furthermore, activation of adipocyte differentiation by a PPARγ agonist led to decreased RANKL expression. These results demonstrate that PPARγ1-positive precursor cells for osteoblasts and adipocytes expressed RANKL and supported osteoclastogenesis.     

Hiatal hernia repair at the initial laparoscopic adjustable gastric band operation reduces the need for reoperation

Background Intractable reflux, either due to gastric prolapse or concentric pouch dilatation has been the most common indication for reoperation or band removal after laparoscopic adjustable gastric banding (LAGB). We have previously found that a simple hiatal hernia repair (HHR) leads to remission of these symptoms minimizing the need for band removal. We have subsequently added crural repair/HHR at the initial operation, where indicated. In this study compare the rate of reoperation in patients who underwent LAGB alone, or with concurrent HHR. Methods A retrospective review of a prospective database of all patients undergoing LAGB was performed to determine the incidence of reoperation in the two groups. Results Between July 2001 and August of 2006, 1298 patients underwent LAGB and 520 patients underwent LAGB with concurrent HHR (LAGB/HHR). The mean initial weight and BMI were 128 kg (range, 71.1–245.7 kg) and 45.4 kg/m² (range, 28–75 kg/m²). Average follow-up for the LAGB and LAGB/HHR groups was 24.8 and 20.5 months, respectively. Rate of reoperation for HHR alone, or with band slip or concentric pouch dilatation, for LAGB and LAGB/HHR groups was 5.6% and 1.7% respectively (p < 0.001). Total reoperation rate for slip, HHR and pouch dilatation was 7.9% and 3.5%, respectively (p < 0.001). There was no significant difference in rate of slip repair alone between the two groups: 2.3% and 1.7%, respectively (p < 0.44). Conclusions Adding HHR to LAGB where indicated significantly reduces reoperation rate. Every effort should be made to detect and repair HHR during placement of the band, as it will decrease future need for reoperation.     

Rehabilitation versus drug therapy for urge urinary incontinence: long-term outcomes

The objective of this study was to compare the residual effect of a 3-month rehabilitation treatment and a standard drug treatment for urge urinary incontinence (UUI) 21 months post intervention. Forty-four women (ages 27–68 years) who were diagnosed with overactive bladder (OAB) were divided into 2 treatment groups over 3 months: 24 women received rehabilitation (REH) and 20 women were treated with medication (MED) (oxybutynin ER). Outcomes measures included frequency of urination, quality of life (QoL), and number of side effects (no/SE), which were measured upon entry into the study (entry), completion of the intervention (3 months), and at follow-up 3 and 21 months after completion of treatment. In the follow-up period, there was a significant group–time interaction effect on freq/day and freq/night (p < 0.01). At the end of follow-up, the mean number of no/SE was significantly greater in the MED group compared to the REH group (3.3 ± 0.5 vs 2.4 ± 0.4; p < 0.05). A significant negative association was found between the urinary symptoms and the I-QoL at the 21-month follow-up (r _p = −0.45 to−0.57, p < 0.05). In the long-term, the REH patients maintained and even improved the achievements of the intervention period while the MED patients deteriorated to baseline values in urinary frequency. The suggestion for future work is to investigate the effect of each REH treatment component on UUI symptoms.     

Radiographic changes in the lumbar spine in former professional football players: a comparative and matched controlled study

Heavy physical work and activity lead to degenerative changes, especially in the lumbar spine. We aimed to find out the occurence of radiographic changes (vertebral osteophytes, heights of lumbar dicsc, concavity index) and abnormalities of the lumbar spine in former professional football (association football or soccer) players according to their specialization (goalkeeper, defender, midfielder, forward) in their past professional sport life. We included 70 male former professional football players and 59 men as the control group. The football players group consisted of 15 defenders (21%), 29 midfielders (41%), 18 forwards (26%) and 8 goalkeepers (12%). Their mean professional football life was 11.04 years and the mean time period after their retirement was 13.87 years. Radiographs of both groups were taken to measure the disc height, concavity index and to determine osteophytes and abnormalities of the lumbar spine. FFbH-R score was assessed for daily activities. The mean FFbH-R score of football players was lower than that of the control group (P = 0.005). The total number of osteophytes in the player group was higher than in the control group (P = 0.001). The mean disc height of L1–L2 in football players was higher than in the control group (P = 0.045). The mean disc height of T12–L1 in goalkeepers was higher than in forward players (P = 0.019). The mean concavity index of L1 in forward players was lower than in defenders (P = 0.018). The mean disc heights of T12–L1 and L2–L3 were both higher in players whose professional sport life was >10 years than in players with ≤10 years (P = 0.018, P = 0.016). The mean disc height of L5–S1 was higher in players who had continued sport activity after retirement (P = 0.025). No statistically significant result was obtained with the rest of the variables. Playing football is heavy work. The decreased height of lumbar discs and the lower value of concavity index of forward players are because the lumbar spine of forward players is loaded more than in the rest of the players. Presented in part orally at Eurospine 2006, İstanbul, Turkey, 25–28 October 2006. Presented in part as poster at XXXVI Scientific Congress of Polish Orthopaedic and Traumatology Society, Katowice, Polland, 28–30 September 2006.     

Role of Nd:YAG laser for prevention of neuroma formation: an in vivo experimental study

Nerve transection is commonly followed by the development of neuroma at the proximal stump. It can be very painful especially at exposed sites. It may arise spontaneously or after mechanical irritation. Neuroma and its high recurrence rate might be resisting problems to treat. Various treatment modalities for neuroma and its recurrence have been proposed, but none has provided satisfactory results. The present study was conducted to evaluate the neodymium:yttrium aluminum garnet (Nd:YAG) laser (1,064 nm) nerve transection technique for prevention of neuroma formation. There were 48 facial nerves out of 24 Rex rabbits divided into two equal groups. The 24 left-sided facial nerves at group A were subjected to Nd:YAG laser for nerve transection, while the 24 right-sided facial nerves at group B were subjected to scalpel nerve transection. The results were grossly and histopathologically evaluated. Grossly, laser-transected nerves showed an infrequent incidence of neuroma formation. Histopathologically, laser-transected nerves showed photothermal degenerative changes of the axons and myelin sheaths with intact perineurium and endoneurium. No Schwann cell hyperactivity could also be elicited among laser-transected nerves. Nd:YAG laser was found to be an effective tool that could be applied, whenever it is possible, for division of major nerves to prevent the formation of the subsequent stump neuroma. Moreover, this technique should be considered during treatment of well-established neuroma to prevent the challenging reported high incidence of recurrence.     

Emergency Sleeve Gastrectomy as Rescue Treatment for Acute Gastric Necrosis Due to Type II Paraesophageal Hernia in an Obese Woman with Gastric Banding

A morbidly obese 42-year-old woman presented with a 1-week history of left chest pain. She had undergone laparoscopic adjustable gastric banding 16 months earlier with a body mass index (BMI) of 49.2 kg/m². Diagnostic workup revealed a large left pleural empyema and ruled out band slippage. At left thoracotomy, a misdiagnosed type II paraesophageal strangulated hernia with gastric necrosis and large perforation of the fundus was evident. At laparotomy, the band was removed, the stomach was reduced into the abdomen, and a sleeve gastrectomy was performed. Her postoperative course was uneventful, and 6 months after surgery, her BMI is 31 kg/m². Emergency sleeve gastrectomy could represent a good option to treat, at the same time and in a safe way, both gastric necrosis and paraesophageal hernia, improving the good results in terms of weight loss after gastric restriction from gastric banding.     

Diet does not explain the high prevalence of dyslipidaemia in paediatric renal transplant recipients

Dyslipidaemia exists frequently after renal transplantation (RTx) and promotes atherosclerosis. In this study, we examined the association between daily intake of nutrients and serum lipids after paediatric RTx. We studied 45 children with acceptably functioning kidney grafts and adequately completed food records at a median age of 10.6 years (range 4.3–17.2 years), a median 5.2 years (range 1.0–11.0) after RTx, and 178 healthy controls at a median age of 9.0 years (range 3.2–18.7 years). Serum total cholesterol (TC), triglyceride, and apolipoprotein B concentrations were higher in the RTx patients than in the controls (P < 0.001), despite similar dietary intakes of saturated and polyunsaturated fats, and cholesterol. Both the RTx patients and controls ingested a low amount of polyunsaturated fats [mean (SD) percent of total calories (E%) 4.8 (1.3) and 4.6 (1.5), respectively] and an excessive amount of saturated fats [mean (SD) E% 14.4 (2.4) and 14.1 (2.8), respectively]. In multiple regression analyses, dietary fibre was negatively associated with serum TC concentration. The standard deviation score for body mass index was negatively associated with serum concentration of high-density lipoprotein cholesterol (HDL-C) and low-density lipoprotein diameter, and positively with serum triglyceride concentration. In addition, dietary total fat intake was positively associated with serum HDL-C. In conclusion, the higher prevalence of dyslipidaemia in our paediatric RTx patients than in the controls was not explained by the diet. However, the type of fat consumed implicates the counselling for a healthier dietary lifestyle, with an increase in the ingestion of polyunsaturated fats and a decrease in that of saturated fats.