Effects on Smokers of Exposure to Graphic Warning Images

Background and Objectives : Several countries have introduced graphic warning images aimed at discouraging smoking. The objective of this study was to evaluate the impact on smokers of graphic warnings showing cosmetically important harm caused by smoking. Methods : Fifty‐six adult smokers were randomly assigned to view either written smoking warnings or the same written warnings with related graphic images. The smokers viewed the warnings at a rate of one per week for 4 weeks. The smokers were assessed before and after the warnings with regard to stage of change toward smoking cessation and level of smoking. Results : The randomized control trial showed that the warnings with graphic images led to significantly more progress in stage of change toward smoking cessation than written warnings alone. However, the images did not lead to decreases in smoking rates. Conclusions and Scientific Significance : The results indicate that written smoking warnings accompanied by images of cosmetically important harm caused by smoking have more potential than warnings alone in prompting changes in the direction of quitting. (Am J Addict 2012;21:555–557)     

Prenatal exposure to polychlorinated biphenyls and asthma,eczema/hay fever,and frequent ear infections

Objectives: The effects of prenatal exposure to Polychlorinated biphenyls (PCBs) on the development of asthma, frequent ear infections, and eczema/hay fever are not well understood. We aim to investigate associations between prenatal PCB exposure and these health outcomes in the offspring of women who worked at the LaSalle Electrical Utilities Company (EUC). Methods: A retrospective cohort with at least one live birth and known employment time at EUC was eligible for this analysis. Exposure was defined and categorized by the number of fiscal quarters worked during the PCB era (1952–1981). A total of 288 women with 800 live births were included. A Chi-Square test was used to compare maternal and child characteristics across exposure groups and repeated measures logistic regression, controlling for clustering among siblings, was used to assess the associations between prenatal PCB exposure and these outcomes. Results: After adjustment for confounding and independent maternal predictors, 1–4 quarters of prenatal exposure to PCBs increased the odds for asthma (OR 3.24[1.30–8.09]), eczema/hay fever (OR 3.29[1.54–7.04]), and frequent ear infections (OR 2.24[1.19–4.22]) when compared with persons unexposed/exposed only to naphthalenes. The significance of the associations varied by exposure period and level of exposure, with the strongest associations in those employed exclusively after 1952 when PCBs were introduced. Conclusions: These results support previous findings of associations of prenatal exposure to PCBs with asthma, eczema/hay fever, and frequent ear infections. Additional prospective studies are needed to confirm these findings. Also required are more precise PCB exposures to separate them from other exposures in occupational settings.     

Energy Expenditure and Caloric Balance After Burn: Increased Feeding Leads to Fat Rather Than Lean Mass Accretion

OBJECTIVE: Resting energy expenditure (REE) is commonly measured in critical illness to determine caloric "demands" and thus nutritive needs. SUMMARY BACKGROUND DATA: The purpose of this study was to 1) determine whether REE is associated with clinical outcomes and 2) determine whether an optimal caloric delivery rate based on REE exists to offset erosion of lean mass after burn. METHODS: From 1995 to 2001, REE was measured by indirect calorimetry in 250 survivors of 10 to 99%TBSA burns. Caloric intake and REE were correlated with muscle protein catabolism, length of stay, ventilator dependence, sepsis, and mortality. From 1998 to 2000, 42 patients (>60%TBSA burns) received continuous enteral nutrition at a spectrum of caloric balance between 1.0x REE kcal/d -1.8x REE kcal/d. Serial body composition was measured by dual energy x-ray absorptiometry. Lean mass, fat mass, morbidity, and mortality were determined. RESULTS: REE/predicted basal metabolic rate correlated directly with burn size, sepsis, ventilator dependence, and muscle protein catabolism (P <.05). Declining REE correlated with mortality (P <.05). 2) Erosion of lean body mass was not attenuated by increased caloric balance, however, fat mass increased with caloric supply (P <.05). CONCLUSION: In surviving burned patients, caloric delivery beyond 1.2 x REE results in increased fat mass without changes in lean body mass. Declining energy expenditure appears to be a harbinger of mortality in severely burned patients.     

A resident survey study of orthopedic fellowship specialty decision making and views on arthroplasty as a career

A dramatic shortage of total hip arthroplasty (THA) and total knee arthroplasty (TKA) surgeons has been projected because fewer residents enter arthroplasty fellowships, and the demand for THAs/TKAs is rising. The purposes of this study were to ascertain the future supply of THA/TKA surgeons, to identify the criteria residents use to choose their fellowship specialty, and to assess resident perceptions of an arthroplasty career. Four hundred ninety-eight post-graduate year 3 and above residents completed the online survey. Residents most highly prioritize intellectual factors and role models/mentors in determining their fellowship specialty. In the face of a looming patient access-to-care crisis, the data from this study support a policy of highlighting the intellectual challenges and satisfaction of THA/TKA as a career and encouraging mentorship early in a resident's training.     

A Perspective on the Surgical Management of Congestive Heart Failure

Surgical treatment of patients with congestive heart failure (CHF) has steadily advanced from rescue procedures such as aneurysmectomy, rupture repair, ventricular assist devices (VADs), and transplantation to procedures that can prevent or delay the progression of cardiac dysfunction and failure. The latter include operations such as coronary artery bypass grafting (CABG) and mitral valve repair for patients with ischemic cardiomyopathy (ICMP) and mitral annular dilatation, ventricular restoration and remodeling, and cardiac resynchronization therapy. As the number of heart transplants reported worldwide continues to decline over the past decade (by over 30%), newer surgical therapies have emerged. A need arises for clinical registries such as the NIH-sponsored LVAD registry and registries for biventricular pacing and AICD implantation, for total artificial heart implants, and for mitral valve repair in patients with ICMP. Prospective trials comparing sole ventricular restoration therapy (SVR) to SVR with concomitant CABG/MVR, coronary sinus versus epicardial LV pacing for ventricular resynchronization therapy, trials comparing LVAD as destination therapy to AICD implants, mitral valve repair versus chordal-sparing valve replacement for ischemic and valvular cardiomyopathy, and off-pump versus on-pump CABG for patients with ICMP are urgently needed. Future research should also be directed toward drugs targeting “B-cell mediated” humeral vascular rejection—the Achilles heel of cardiac transplantation, xenotransplantation, permanently implantable VADs, gene therapy, and myocardial cell regeneration therapy.     

Changing concepts concerning the management of vesicoureteral reflux

PURPOSE: Conservative estimates indicate that up to 54% of patients who present with vesicoureteral reflux have dysfunction voiding. Children with voiding dysfunction and vesicoureteral reflux historically have a high breakthrough infection rate of 34% to 43%. Breakthrough infection represents significant morbidity and it is the most common indication for surgical intervention for vesicoureteral reflux. Voiding dysfunction is present in 79% of patients who proceed to reflux surgery. We evaluated the impact of pelvic floor muscle retraining combined with a medical program in patients with voiding dysfunction and vesicoureteral reflux. MATERIALS AND METHODS: Children with a history consistent with voiding dysfunction and vesicoureteral reflux were screened by uroflowmetry/electromyography, bladder scan for post-void residual urine, renal ultrasound and voiding cystourethrography. Confirmed cases of voiding dysfunction and vesicoureteral reflux were prospectively enrolled in this study. Children participated in an interactive, computer assisted, pelvic floor muscle retraining program that involved a conservative medical regimen and pelvic floor muscle retraining. All patients received prophylactic antibiotics. We evaluated the rate of breakthrough urinary tract infection, reflux outcome and surgical intervention. A literature review with the key words vesicoureteral reflux, voiding dysfunction and urinary tract infection was performed to identify historical control cases for comparison. RESULTS: Study enrollment criteria were fulfilled by 49 girls and 4 boys 4 to 13 years old (average age 8.8), representing 72 units with low grades I to II (48) and high grades III to V (24) reflux. Mean followup was 24 months. Initial uroflowmetry/electromyography and bladder scan revealed a staccato flow pattern and normal post-void residual urine in 11% of cases, staccato flow pattern and elevated post-void residual urine in 10%, flattened flow pattern and normal post-void residual urine in 28%, and flattened flow pattern and elevated post-void residual urine in 51%. Breakthrough infection developed in 5 patients (10%), including 1 in whom reflux had resolved and 1 with grade I reflux who underwent observation. The parents of 2 patients elected to complete biofeedback without surgical intervention and these patients did not have a repeat infection. Reimplantation was performed in 1 case (2%). There was resolution in 18 low and 7 high grade refluxing units, including 2 older patients with a long history of high grade bilateral disease. Average time to resolution was 7.8 months. We noted elevated post-void residual urine in 88% of the patients with high grade reflux. Average age at resolution was 9.2 years. During a 24-month period one of us (P. H. M.) noted a greater than 90% decrease in surgical intervention. CONCLUSIONS: A combined conservative medical and computer game assisted pelvic floor muscle retraining program appears to have decreased the incidence of breakthrough urinary tract infections and facilitated reflux resolution in children with voiding dysfunction and vesicoureteral reflux. Patients with high grade reflux and voiding dysfunction commonly present with elevated post-void residual urine, contraindicating the indiscriminate administration of anticholinergics. Decreasing the rate of urinary tract infections may have a dramatic impact on the need for surgical intervention and enable the reflux resolution rate to approximate that in patients without voiding dysfunction. Prospective controlled trials are needed to determine whether pelvic floor muscle retraining combined with a conservative medical regimen alters the natural history of vesicoureteral reflux in patients with voiding dysfunction.     

Association of hyperglycemia with increased mortality after severe burn injury

OBJECTIVE: To assess results of exchange nailing in nonunion after intramedullary (IM) nailing of humeral shaft fractures. METHODS: This was a retrospective study; 24 patients with nonunion after IM nailing of humeral shaft fractures were reviewed. In 13 cases, nonunion was treated using exchange nailing, and 11 patients were treated nonoperatively. Union was assessed from radiographs. Shoulder joint symptoms and function were assessed after a mean 4.7 years' follow-up using Constant-Murley scoring and self-administered questionnaires devised by L'Insalata et al. RESULTS: Single or repeated exchange nailing resulted in union in 6 of 13 patients. Shoulder joint function was satisfactory (mean Constant-Murley score of 72) for those patients whose fracture eventually united and poor (mean Constant-Murley score of 39) for those left with nonunion. CONCLUSION: Exchange nailing results in a poor union rate in nonunion after IM nailing of humeral shaft fractures. Permanent nonunion of the humeral shaft leaves the patient with severe disability.     

Obesity-Induced Infertility and Hyperandrogenism Are Corrected by Deletion of the Insulin Receptor in the Ovarian Theca Cell

Women with polycystic ovary syndrome (PCOS) exhibit elevated androgen levels, oligoanovulation, infertility, and insulin resistance in metabolic tissues. The aims of these studies were to determine the role of insulin signaling in the development and function of ovarian theca cells and the pathophysiologic effects of hyperinsulinism on ovarian function in obesity. We disrupted the insulin receptor (IR) gene specifically in the theca-interstitial (TI) cells of the ovaries (Cyp17IRKO). No changes in reproductive development or function were observed in lean Cyp17IRKO female mice, suggesting that insulin signaling in TI cell is not essential for reproduction. However, when females were fed a high-fat diet, diet-induced obesity (DIO) wild-type (DIO-WT) mice were infertile and experienced increased circulating testosterone levels, whereas DIO-Cyp17IRKO mice exhibited improved fertility and testosterone levels comparable to those found in lean mice. The levels of phosphorylated IRS1 and CYP17 protein were higher in the ovary of DIO-WT compared with DIO-Cyp17IRKO or lean mice. Ex vivo studies using a whole ovary culture model demonstrated that insulin acts independently or additively with human chorionic gonadotropin to enhance androstenedione secretion. These studies reveal the causal pathway linking hyperinsulinism with ovarian hyperandrogenism and the infertility of obesity.