Patient and Parent Perspectives of Adolescent Laparoscopic Adjustable Gastric Banding (LAGB)

Background

Adolescent obesity is a significant global health challenge and severely obese adolescents commonly experience serious medical and psychosocial challenges. Consequently, severe adolescent obesity is increasingly being treated surgically. The limited available research examining the effectiveness of adolescent bariatric surgery focuses primarily on bio-medical outcomes. There is a need for a more comprehensive understanding of the behavioural, emotional and social factors which affect adolescents’ and parents’ experience of weight loss surgery.

Methods

Patient and parents’ perspectives of adolescent LAGB were examined using a qualitative research methodology. Individual, semi-structured interviews were conducted with eight adolescent patients and five parents. Thematic analysis was used to identify key themes in the qualitative data.

Results

Patients and parents generally considered adolescent laparoscopic adjustable gastric banding (LAGB) to be a life-changing experience, resulting in physical and mental health benefits. Factors considered to facilitate weight loss following surgery included parental support and adherence to treatment guidelines. Many adolescents reported experiencing surgical weight loss stigma and challenging interpersonal outcomes after weight loss for which they felt unprepared.

Conclusions

Patients and parents perceived LAGB positively. There are opportunities to improve both the experience and outcomes of adolescent LAGB through parental education and enhancements to surgical aftercare programmes.

     

The demographics of significant firearm injury in Canadian trauma centres and the associated predictors of inhospital mortality

Objective

Our primary objective was to evaluate demographic and causal factors of inhospital mortality for significant firearm-related injuries (i.e., those with an Injury Severity Score [ISS] > 12) in Canadian trauma centres.

Methods

We analyzed data submitted to the Canadian Institute for Health Information (CIHI) in the National Trauma Registry for all firearm-injured patients for fiscal years 1999–2003. Univariate and bivariate adjusting for ISS and multivariate logistic regression were performed.

Results

Men accounted for 94% of the 784 injured. In all patients, the percentages of self-inflicted, intentional, unintentional and unknown injuries were 27.8%, 60.3%, 6.1% and 5.7%, respectively. The inhospital fatality rate was 39.8%, with 83% of fatalities occurring on the first day. Two-thirds of patients were discharged home. Univariate and adjusted analysis found that ISS, first systolic blood pressure (BP), first systolic BP under 100, first Glasgow Coma Scale (GCS) score, age over 45 years, self-inflicted injury, intentional injury and injury at home significantly worsened the odds ratio of death in hospital and that police shooting was relatively beneficial. BP under 100, age over 45 years and a low GCS score had an adjusted odds ratio of death of 4.12, 1.99 and 0.64 per point increase, respectively. The multivariate model showed that ISS, BP under 100, first GCS score, sex and self-inflicted injury were significant in predicting inhospital death.

Conclusion

A predominance of young men are injured intentionally with handguns in Canada, whereas older patients suffer self-inflicted injuries with long guns. The significant number of firearm deaths, largely in the first day, highlights the importance of preventative strategies and the need for rapid transport of patients to trauma centres for urgent care.     

Physiological Responses to 90 s All Out Isokinetic Sprint Cycling in Boys and Men

The purpose of this study was to compare the VO₂ kinetic and mechanical power responses of boys and men to all out 90 s sprint cycle exercise. Eight boys (14.6 ± 0.3 y) and eight men (33.8 ± 6.5 y) volunteered to participate and completed a ramp test (to determine VO_2peak and ventilatory threshold, VT) and then on subsequent days, two 90 s all out cycle sprints on an isokinetic cycle ergometer. During each test, breath-by-breath pulmonary gas exchange and power output were measured. Parameters from the power output profiles were derived from the average response of the two tests including peak power (PP, highest power output in 1 s), end power (EP_60-90, power over the last 30 s), and mean power over the 90 s (MP₉₀). Independent pairwise and dependent t-tests were used to compare the data from tests between adults and boys subject groups. Significant differences between adults and boys were found for absolute PP (881.4 ± 60.7 vs 533.6 ± 50.7 W), EP_60-90 (288.6 ± 25.7 vs 134.3 ± 17.6 W) and MP₉₀ (434.5 ± 27.4 vs 238.4 ± 17.3 W, p =0.001) respectively. Relative to body mass significant differences between adults and boys were found for EP_60-90, MP₉₀ and total work (p < 0.002). The boys attained 90 s VO₂ values that were closer to VO_2peak than their adult counterparts (93.3 ± 2.6 vs 84.9 ± 2.3 %, p = 0.03). They also demonstrated faster VO₂ kinetics (10.8 ± 1.5 vs 17.6 ± 1.0 s, p < 0.01). In conclusion, during all out 90 s cycle sprinting boys were able to attain VO₂ values that were closer to VO_2peak and a faster time constant than adult men. These findings provide insight into the contribution and speed of response of the aerobic system during an ‘anaerobic’ test.

Key Points

• The results of this study confirm the significant contributions of the aerobic energy systems during so called ‘anaerobic tests’.
• Boys were able to attain VO₂ values from an all out 90 s sprint cycle that were closer to their aerobic VO₂ peak test than adults. More detailed studies are required to investigate the limiting factors that prevent VO₂ peak being reached in an all out sprint cycle.
• All out tests of a duration > 30 s and coupled with gas and power analyses offer paediatric physiologists considerable scope to examine the contributions of the anaerobic and aerobic energy systems until more ethically viable methods are found.

Key Words: VO_2peak, anaerobic, kinetics, aerobic, ergometry     

Influence of weight and weight change on bone loss in perimenopausal and early postmenopausal Scottish women

Weight is recognized as an important factor in determining an individuals risk of osteoporosis. However, little is known about whether weight or weight change influences bone loss around the time of the menopause, and the relationship with energy intake and physical activity level remains largely undefined. Healthy premenopausal women (1,064 selected from a random population of 5,119 women aged 45–54 years at baseline) each had bone mineral density (BMD), weight and height measurements, and completed a food frequency and physical activity questionnaire. Of the original participants, 907 women (85.2%) returned 6.3 ± 0.6 years later for repeat BMD measurements, and 896 women completed the questionnaires. Bone loss at the hip (FN) and spine (LS) occurred before the menopause. Weight change rather than weight was associated with FN BMD loss (r=0.102, p=0.002), but weight at follow-up was associated with LS BMD change (r=0.105, p=0.002). Although an increase in physical activity level (PAL) appeared to be beneficial for FN BMD in women who were heavy weight gainers, PAL was associated with increased LS BMD loss in women who lost weight. For current HRT users, neither weight nor weight change was associated with change in BMD. Postmenopausal women not taking HRT should be made aware that low body weight or losing weight during this particularly vulnerable period may worsen bone loss.     

IgA1-containing immune complexes in IgA nephropathy differentially affect proliferation of mesangial cells

BACKGROUND: Sera of patients with IgA nephropathy (IgAN) contain circulating immune complexes (CIC) composed of galactose-deficient IgA1 complexed with antiglycan antibodies. The role of these CIC in the pathogenesis of IgAN is not known. METHODS: We studied how proliferation of cultured mesangial cells (MC) is affected by CIC prepared from sera of IgAN patients and healthy control subjects using size-exclusion chromatography. CIC-containing fractions were added to serum-starved MC in culture, and cell proliferation was measured using (3)H-thymidine incorporation. The results were confirmed by staining MC using an antibody against proliferating cell nuclear antigen. RESULTS: The incubation of starved MC with serum fractions with M(r) 800 to 900 kD, rich with galactose-deficient IgA1, stimulated proliferation, while fractions with smaller complexes were inhibitory. Furthermore, CIC-containing larger molecular mass fractions isolated from serum of an IgAN patient collected during an episode of macroscopic hematuria stimulated MC proliferation more than CIC obtained during a subsequent quiescent phase. To examine the role of IgA, we removed IgA1 from serum before fractionation. The resultant IgA1-depleted fractions were devoid of stimulatory IgA-CIC. Sera of IgAN patients were also fractionated after addition of desialylated galactose-deficient polymeric IgA1 to form additional immune complexes. Supplementation with a small quantity of this IgA1 increased cellular proliferation in assays using serum fractions of M(r)>/=800 to 900 kD; uncomplexed IgA1 did not affect MC proliferation significantly. In contrast, supplementation with a larger quantity of this IgA1 inhibited cellular proliferation in assays using serum fractions of M(r) 700 to 800 kD. CONCLUSION: Overall, these findings suggest that CIC containing aberrantly glycosylated IgA1 affect proliferation of MC in vitro and, thus, likely play a role in the pathogenesis of IgAN.     

Skiing- and snowboarding-related injuries treated in U.S. emergency departments, 2002

BACKGROUND: This study aims to describe the characteristics of skiing- and snowboarding-related injuries treated in U.S. emergency departments (EDs). METHODS: Skiing- and snowboarding-related injuries collected by the National Electronic Injury Surveillance System in 2002 were analyzed. Data regarding skiing and snowboarding participation were used to calculate injury rates by age group and activity (skiing versus snowboarding). RESULTS: An estimated 77,300 (95% CI = 11,600-143,000) skiing- and 62,000 (95% CI = 32,800-91,200) snowboarding-related injuries were treated in U.S. hospital EDs in 2002. Wrist injuries (17.9%) and arm injuries (16.6%) among snowboarders and knee injuries (22.7%) among skiers were the most common injuries. The age groups that have the highest skiing-related injury rates were the 55-64 years (29.0 per 1,000 participants), the 65+ years (21.7 per 1,000 participants), and the 45-54 years (15.5 per 1,000 participants). The age groups that have the highest snowboarding-related injuries were the 10-13 years (15.9 per 1,000 participants), the 14-17 years (15.0 per 1,000 participants), and the 18-24 years (13.5 per 1,000 participants). Traumatic brain injury (TBI) rates were higher among older skiers, 55-64 years (2.15 per 1,000 participants), and younger skiers, 10-13 years (1.69 per 1,000 participants). CONCLUSIONS: Our study is the first to demonstrate that older skiers are at highest risk for injury. Adolescents are at highest risk for snowboarding-related injury. Prevention of TBI should be a top injury control priority among skiers and snowboarders.     

Acute Cellular Rejection Predominated by Monocytes Is a Severe Form of Rejection in Human Renal Recipients With or Without Campath-1H (Alemtuzumab) Induction Therapy

Campath-1H has been used successfully for induction and has resulted in a low rate of acute cellular rejection (ACR) in renal transplantation in combination with various postoperative immunosuppression regimens. This study was undertaken to investigate the extent of monocyte involvement in ACR, with or without Campath-1H induction. We found that monocytes represented the majority of inflammatory cells in grades Ib or higher ACR, but not with Ia type of ACR, regardless of the status of Campath-1H induction. Cases of ACR, following Campath-1H induction, appear to demonstrate a 'pure form' of monocytic ACR, whereas monocytes were mixed with many other types of inflammatory cells in the cases of ACR in the absence of Campath-1H induction. In addition with Campath-1H induction, the cases of monocyte-predominant ACR were found to uniformly exhibit a good response to corticosteroid treatment. We conclude that monocyte-predominate ACR may represent a severe form of rejection, with or without Campath-1H treatment.     

Staged surgical repair of functional single ventricle in infants with unobstructed pulmonary blood flow

Objective: The infant with a functional single ventricle (SV) and unobstructed pulmonary blood flow (UPBF) requires early protection of the pulmonary vascular bed to ensure suitability for a subsequent Fontan procedure. Systemic obstruction by aortic arch obstruction, subaortic stenosis, or combination of both, has been widely recognized as an important risk factor for poor outcome in children with SV–UPBF who are palliated with pulmonary artery banding (PAB). We reviewed our experience with primary PAB in the subset of patients with SV–UPBF to identify risk factors for subsequent palliative procedures and Fontan completion. Methods: Between January 1990 and May 2004, 80 patients (median age, 14 days) with functional SV and UPBF underwent PAB as their primary palliative procedure. Thirty-five neonates had concomitant aortic coarctation or interrupted aortic arch repair (44%). A Damus–Kaye–Stansel procedure was subsequently performed in 19 patients, and subaortic resection or ventricular septal defect or bulboventricular foramen enlargement was performed in five. Results: There were 4 operative deaths, and 15 late deaths. The actuarial overall survival is 84% at 1 year, 76% at 5 and 15 years. Follow-up is complete in all but six children at a mean interval of 4.9±3.7 years (range, 2 months–15 years). Thirty-seven patients (49%; 37 of 76) have undergone the hemi-Fontan procedure (with three hospital deaths) and 40 patients (53%; 40 of 76; 12 children without previous hemi-Fontan) have undergone the completion Fontan procedure without mortality or Fontan takedown. Conclusion: In infants with single ventricle physiology with or without systemic outflow obstruction and unobstructed pulmonary blood flow, a strategy of pulmonary artery banding carries acceptable operative and mid-term mortality in a high-risk group of patients. Pulmonary artery banding does not compromise performance of subsequent Damus–Kaye–Stansel procedure or completion Fontan palliation.