Chronic mesenteric ischemia and therapeutic paradigm of mesenteric revascularization

Chronic mesenteric ischemia is a life-threatening clinical problem resulting in death from inanition and/or bowel infarction, if left untreated, albeit low disease prevalence. Typical presentation is postprandial abdominal pain, severe weight loss, and altered bowel habit. Surgical revascularization of the superior mesenteric artery provides effective long-term treatment for chronic intestinal ischemia. Eleven patients underwent superior mesenteric artery revascularization, nine of them with open retrograde superior mesenteric artery bypass and two with angioplasty and stenting. All patients except one made a satisfactory recovery in this cohort. Major complication included one graft thrombosis leading to bowel ischemia and death. The rest all recovered weight in 3–6 months with a follow up period of 6 to 28 months. Two patients had recurrence of symptoms due to failing bypass requiring stenting for assisted primary patency. Superior mesenteric artery revascularization can be performed with minimal morbidity and mortality, providing excellent symptom relief and quality of life.     

The prevalence of and risk factors for radiographic vertebral fractures in older Indian women and men: Delhi Vertebral Osteoporosis Study (DeVOS)

Summary

High prevalence of vertebral fractures (17.9?% over all; 18.8?% male and 17.1?% female) was observed in 808 free-living residents of Delhi, India, aged more than 50?years. The prevalence rates were comparable to that reported in Caucasian populations. While there was an increase in fracture prevalence with age in females, the same was not observed in males.

Introduction

The aim of this paper is to study the prevalence of and risk factors for morphometric vertebral fractures in elderly Indian men and women over 50?years of age.

Methods

We recruited 808 healthy subjects aged 50?years or more, residing in three residential colonies in Delhi, India who voluntarily agreed to participate in this study. All subjects underwent lateral X-rays of the lumbar and thoracic spine according to a standardized protocol. All X-rays were blindly evaluated by a single trained person using an advanced semi-automated software (Optasia Medical) based on Genant??s semiquantitative method. Recruited subjects underwent anthropometric, biochemical, and hormonal evaluation.

Results

With a mean age of 64.9 (±6.7) years, 345 males and 415 females were evaluated. Vertebral fractures were present in 17.9?% (95?% CI 15.2, 20.6) subjects [males, 18.8?% (95?% CI 14.6, 23), females 17.1?% (95?% CI 13.5, 20.8)]. Prevalence of vertebral fractures increased with age in females from 14.7?% in 50?C59?years age group to 22.4?% in those ??70?years, but not in men. Overweight subjects had significantly lower risk [OR, 0.63 (95?% CI 0.41, 0.97), p?=?0.035] of vertebral fractures. Serum 25 hydroxyvitamin D levels, intake of calcium and vitamin D, or history of previous fractures were not statistically different between patients with or without prevalent vertebral fractures.

Conclusions

The prevalence of vertebral fractures among older Indians was comparable to that reported in Caucasian populations. Prevalence of vertebral fractures increased with age in females, but not in males. Overweight individuals were protected against vertebral fractures.     

Growth Behaviour of Transgenic Cotton with Peanut Intercropping System Using Modified Fertilization Technique

Global cotton cultivation, particularly in India, was transformed after the introduction of transgenic cotton hybrids. Realizing the increasing acreage under transgenic cotton in future, the aim of this study was to evaluate growth behaviour of transgenic cotton with peanut intercropping system and sole cotton crop by using 25–50 % substitution of recommended dose of nitrogen (RDN) of cotton through farm yard manure (FYM) along with 100 % RDN through urea and control (0N). Plant growth parameters like plant height, leaf area index, leaf chlorophyll, and N contents were measured at various growth stages of cotton for correlating them with seed cotton yield. Peanut intercropping in cotton did not significantly affect cotton growth parameters and indices except leaf area duration (P = 0.04) as compared with sole crop of cotton. On the other hand, cotton growth parameters with substitution of 25 % RDN of cotton through FYM were higher than or similar to its corresponding 100 % RDN of cotton through urea only. The results showed that there were highly significant (P < 0.01) linear relationships between leaf N and chlorophyll contents at each growth stage, and with plant height and leaf area index during cotton growth. Seed cotton yield was also highly (P < 0.01) correlated with plant growth parameters like plant height, leaf area index, chlorophyll content and leaf N content at various growth stages of cotton. The present study explains plant growth behaviour of transgenic cotton with peanut intercropping system and integrated use of manure and fertilizer for simultaneously enhancing lint and oilseed production.     

Topical bimatoprost 0.03% and iatrogenic eyelid and orbital lipodystrophy

The prostaglandin F2a (PGF2a) analogue bimatoprost 0.03% (Allergan, Inc, Irvine, California) has been employed for the treatment of hypotrichosis since it gained Food and Drug Administration approval as Latisse in 2008. In this report, the authors retrospectively review the cases of 7 patients who presented to their outpatient ophthalmology clinic with glaucoma. These patients had periorbital hollowing due to fat atrophy as a side effect of topical ophthalmic bimatoprost therapy. The series of patients described in this report emphasizes the small but significant risk of periocular fat changes associated with bimatoprost 0.03%, which is the exact formulation marketed as Lumigan for glaucoma treatment. Patients using Latisse for its cosmetic enhancement of eyelash length should be warned of this potentially disfiguring side effect, since the cosmetic and ophthalmic preparations are identical. Such changes can be irreversible, and the implications of the decision to prescribe this drug either in the form of an eyelash application or for topical ophthalmic use should be clearly understood by both clinicians and patients alike. Level of Evidence: 4.     

Neurodegenerative Disease and REM Behavior Disorder

OPINION STATEMENT: Patients with cerebral degenerative conditions commonly suffer from a variety of sleep disorders, including sleep-disordered breathing, insomnia, parasomnias (REM sleep behavior disorder), circadian rhythm disturbances, and restless legs syndrome. When these sleep disorders go unrecognized and untreated, they can lead to decreased quality of life and worsening neurological symptoms related to the underlying condition. Appropriate management initially requires taking a careful history from the patient and bed partner regarding their sleep. In addition, polysomnography may be required to aid in the diagnosis of sleep-disordered breathing or parasomnias. Occasionally, adjusting the dosages of sedating or sleep disrupting medications and improving sleep hygiene may improve sleep complaints. However, in most cases restoring quality nighttime sleep requires specific therapeutic intervention. In patients that suffer from sleep apnea, this usually means treatment with continuous positive airway pressure (CPAP), positional therapy, dental appliances, upper airway surgery, or weight loss. Pharmacological treatment of insomnia in patients with cerebral degenerative conditions can be difficult due to side effects (worsening balance, cognition) and lack of data in this patient population. Behavioral strategies such as cognitive-behavioral therapy have been effective and are considered safer than hypnotic therapy, but can be limited due to access to trained providers (distance and number of providers) and limited cognitive functioning of the patient. Parasomnias, namely REM sleep behavior disorder, are managed by looking for any underlying cause of arousals (sleep apnea, periodic leg movements of sleep), implementing safety precautions, and pharmacologically with either benzodiazepines or melatonin. Restless legs syndrome may improve with iron replacement or dopamine agonist therapy, as it does in other patient populations. Light therapy may be beneficial in patients suffering from circadian rhythm disorders such as advanced sleep phase syndrome.     

The impact of tumor multifocality on outcomes in patients treated with radical nephroureterectomy

Background

The prognostic impact of multifocal upper-tract urothelial carcinoma (UTUC) is poorly understood.

Objective

To investigate the association between tumor multifocality and clinicopathologic features and outcomes of UTUC in patients managed by radical nephroureterectomy (RNU).

Design, setting, and participants

The study included 2492 patients treated with either open or laparoscopic RNU. Tumor and patient characteristics included tumor stage, tumor grade, lymph node status, lymphovascular invasion (LVI), tumor architecture, tumor location, unifocal or multifocal disease, gender, age, history of bladder cancer (BCa), Eastern Cooperative Oncology Group (ECOG) performance status (PS), and adjuvant chemotherapy. tumor multifocality of UTUC was defined as the synchronous presence of multiple tumors in the renal pelvis or ureter.

Intervention

All patients were treated with either open or laparoscopic RNU.

Measurements

Univariable and multivariable models tested the effect of tumor multifocality on disease progression and cancer-specific mortality.

Results and limitations

Five hundred ninety patients (23.7%) had tumor multifocality at the time of RNU. The median follow-up was 45 mo (interquartile range [IQR]: 0-101). Tumor multifocality was significantly associated with a history of previous BCa (p = 0.032), lymph node involvement (p = 0.036), tumor location in the ureter (p = 0.003), higher tumor stage (p < 0.001), higher tumor grade (p < 0.001), sessile tumor architecture (p = 0.003), and LVI (p = 0.001). In organ-confined patients, tumor multifocality was an independent predictor of both disease progression (hazard ratio [HR]: 1.43; p = 0.019) and cancer-specific mortality (HR: 1.46; p = 0.027). When assessed in all patients, tumor multifocality was associated with both disease progression and cancer-specific mortality in univariable (p = 0.005 and p = 0.006, respectively) but not in multivariable analyses (p = 0.468 and p = 0.798, respectively). The main limitation is the retrospective design of the study.

Conclusions

Tumor multifocality is an independent prognosticator of disease progression and cancer-specific mortality in patients with organ-confined UTUC treated with RNU. Multifocal organ-confined patients with UTUC may need closer follow-up. Integration of tumor multifocality with other factors may help identify those patients who would benefit from multimodal therapy.     

Effectiveness of different methods of resistance exercises in lateral epicondylosis--a systematic review

Study DesignSystematic Review.IntroductionLateral epicondylosis (LE) is relatively common with an annual incidence in the general population of 1% to 3%. Systematic reviews have identified exercise is effective, but have not established specific exercise parameters.PurposeThe purpose of this systematic review was to synthesize the quality and content of clinical research addressing type and dosage of resistance exercises in lateral epicondylosis.MethodsComputerized bibliographic databases (1990–2010) were searched using relevant keywords; bibliographies of included papers were hand searched. Of 594 screened abstracts, 11 articles (12 studies) met inclusion criteria. Articles were randomly allocated to pairs of reviewers who independently verified data extraction and appraised the full text, using a structured critical appraisal tool with 24 items. Data extraction was limited by a lack of consistent reporting of elements of exercise dosage.ResultsThe mean quality rating of the studies was 72%, with 2 papers exceeding 75% quality. Of the 12 studies, 9 addressed the effects of isotonic (eccentric/concentric) exercises, 2 studied the effect of isometric and one studied isokinetic exercises. The exercise programs ranged over a period of 4 to 52 weeks. Exercises were prescribed 1 to 6 times per day, with an average duration of 15 minutes per session, and average of 15 repetitions (range: 3 to 50), with 1 to 4 sets per session.ConclusionAll the studies reported that resistance exercise resulted in substantial improvement in pain and grip strength; eccentric exercise was most studied. Strengthening using resistance exercises is effective in reducing pain and improving function for lateral epicondylosis but optimal dosing is not defined.Level of Evidence2a.     

CAGS and ACS Evidence Based Reviews in Surgery. 43: Operative blood loss, blood transfusion and 30-day mortality in older patients after major noncardiac surgery

Question: In elderly patients with variable preoperative anemia and volume of blood loss during major noncardiac surgery, does intraoperative blood transfusion reduce the risk of perioperative death? Design: Retrospective cohort study. Data source: National Surgical Quality Improvement Program database. Patients: Veterans aged 65 years or older with a documented preoperative hematocrit (HCT) value who underwent major noncardiac surgery between 1997 and 2004. Methods: Propensity score matching was used to adjust for differences between patients who received intraoperative blood transfusions (9.45) and those who did not. Main outcome: Association between intraoperative blood transfusion and 30-day postoperative mortality. Results: After propensity score matching, intraoperative blood transfusion was associated with mortality risk reduction in patients with preoperative HCT levels lower than 24% (odds ratio [OR] 0.60, 95% confidence interval [CI] 0.41–0.87) and in patients with HCT of 30% or greater who experienced substantial (500–999 mL) blood loss (OR 0.35, 95% CI 0.22–0.56 for HCT levels between 30% and 35.9%, and OR 0.78, 95% CI 0.62–0.97 for HCT levels of 36% or greater). When operative blood loss was less than 500 mL, transfusion was not associated with mortality reductions for patients with HCT levels of 24% or greater and conferred increased mortality risks in patients with preoperative HCT levels between 30% and 35.9% (OR 1.29, 95% CI 1.04–1.60). Conclusion: Intra-operative blood transfusion was associated with lower 30-day postoperative mortality among elderly patients undergoing major noncardiac surgery if there was substantial operative blood loss or low preoperative HCT levels (< 24%). Transfusion was associated with increased risk of death for those with preoperative HCT levels between 30% and 35.9% and less than 500 mL of blood loss.