Attempted Salvage Resection for Recurrent Gastric or Gastroesophageal Cancer

The purpose of this study was to determine the outcome of surgery for patients with recurrent gastric or gastroesophageal cancer. We queried records from 7,459 patients who presented with gastric or gastroesophageal cancer to our institution from 1973 through 2005 to identify those for whom resection of recurrent disease had been attempted. We assessed the associations between various clinicopathologic factors and resectability with logistic regression analysis and between clinicopathologic factors and overall survival (OS) with the Cox proportional hazards model. Sixty patients underwent attempted resection for recurrent cancer. In 31 cases (52%), recurrent disease proved unresectable at laparotomy. Factors associated with the ability to undergo re-resection included neoadjuvant treatment prior to initial resection [odds ratio (OR) 12.2, 95% confidence interval (CI) 1.9–75.6] and having an isolated local recurrence (OR 5.1, 95% CI 1.3–20.5). Of the 29 patients who underwent re-resection, 14 required adjacent organ resection, and 6 required interposition grafting. Three- and 5-year OS rates for all 60 patients were 21% and 12%, respectively; median follow-up time was 23 months. Median OS for patients undergoing resection was 25.8 months (95% CI 17.1–49.8) versus 6.0 months (95% CI 4.0–10.5) for unresectable patients (P < 0.001). Initial tumor location at the gastroesophageal junction was associated with diminished OS [hazard ratio (HR) 2.8, 95% CI 1.2–6.5] and ability to undergo resection of recurrence was associated with improved OS (HR 0.2, 95% CI 0.1–0.6). We conclude that surgical resection of select patients with recurrent gastric or gastroesophageal cancer can result in improved OS but often requires adjacent organ resection or interposition graft placement.     

Psychological impact of types of sexual trauma among college women

Studies typically demonstrate that sexual victimization is associated with negative outcomes, yet they often fail to control for other trauma exposure and rarely address the impact of developmental level at the time of exposure or the type of sexual trauma experienced. The present study addresses these confounds by identifying groups of women with unique, nonoverlapping sexual trauma histories and examines the association between type of sexual trauma exposure and mental health impairment, social adjustment, and sexual functioning. This study compared five discrete groups of college-sophomore women based on self-identified trauma histories including no trauma, childhood sexual assault, childhood sexual abuse, adolescent sexual assault, and revictimization. Significant differences based on sexual trauma type were observed; individuals who experienced adolescent sexual assault or revictimization were at greatest risk for psychopathology, poor social adjustment, and risky sexual behaviors.     

More than just stones: a pictorial review of common and less common gallbladder pathologies

Although stone disease is by far the most commonly encountered pathology of the gallbladder, there are several other important disease processes affecting it. These include adenomyomatosis, cholesterolosis, polyps, porcelain gallbladder, acalculous cholecystitis, xanthogranulomatous cholecystitis, emphysematous cholecystitis, gallbladder cancer, and gallbladder hemorrhage. The purpose of this article was to review the different gallbladder pathologies encountered in everyday radiological practice and to describe their features in the standard imaging modalities.     

Lessons learned: optimization of a murine small bowel resection model

Purpose

Central to the use of murine models of disease is the ability to derive reproducible data. The purpose of this study was to determine factors contributing to variability in our murine model of small bowel resection (SBR).

Methods

Male C57Bl/6 mice were randomized to sham or 50% SBR. The effect of housing type (pathogen-free vs standard housing), nutrition (reconstituted powder vs tube feeding formulation), and correlates of intestinal morphology with gene expression changes were investigated. Multiple linear regression modeling or 1-way analysis of variance was used for data analysis.

Results

Pathogen-free mice had significantly shorter ileal villi at baseline and demonstrated greater villus growth after SBR compared to mice housed in standard rooms. Food type did not affect adaptation. Gene expression changes were more consistent and significant in isolated crypt cells that demonstrated adaptive growth when compared with crypts that did not deepen after SBR.

Conclusion

Maintenance of mice in pathogen-free conditions and restricting gene expression analysis to individual animals exhibiting morphologic adaptation enhances sensitivity and specificity of data derived from this model. These refinements will minimize experimental variability and lead to improved understanding of the complex process of intestinal adaptation.     

Improving shape and symmetry in mastopexy with autologous or cadaveric dermal slings

Mastopexy and reduction mammaplasty reshape breast parenchyma and restore youthful contour in women with ptotic breasts. However, recurrent ptosis and breast base widening are common. We have been using internal autologous or cadaveric (AlloDerm) dermal slings to circumferentially support and shape the breasts for symmetry or rejuvenation. Ten patients underwent unilateral mastopexy (3), unilateral reduction-mastopexy (1), bilateral mastopexy (5), or bilateral reduction-mastopexy (1) with an internal dermal sling to correct breast reconstruction asymmetry (2), congenital asymmetry (2), or acquired ptosis (6). Three of 6 patients acquired breast ptosis after massive weight loss. Autologous dermis was used in 5 patients, and 5 patients were reconstructed with AlloDerm. Patients have maintained projection and breast base width after 6 months to 3 years. In conclusion, internal dermal slings improve shape, breast projection, and base width in select patients undergoing mastopexy. An algorithm based on quantity and quality of native skin is provided.     

Angiotensin II stimulates calcineurin activity in proximal tubule epithelia through AT-1 receptor-mediated tyrosine phosphorylation of the PLC-gamma1 isoform

Angiotensin II (AngII) contributes to the maintenance of extracellular fluid volume by regulating sodium transport in the nephron. In nonepithelial cells, activation of phospholipase C (PLC) by AT-1 receptors stimulates the generation of 1,4,5-trisphosphate (IP(3)) and the release of intracellular calcium. Calcineurin, a serine-threonine phosphatase, is activated by calcium and calmodulin, and both PLC and calcineurin have been linked to sodium transport in the proximal tubule. An examination of whether AngII activates calcineurin in a model of proximal tubule epithelia (LLC-PK1 cells) was performed; AngII increased calcineurin activity within 30 s. An examination of whether AngII activates PLC in proximal tubule epithelia was also performed after first showing that all three families of PLC isoforms are present in LLC-PK1 cells. Application of AngII increased IP(3) generation by 60% within 15 s, which coincided with AngII-induced tyrosine phosphorylation of the PLC-gamma1 isoform also observed at 15 s. AngII-induced tyrosine phosphorylation was blocked by the AT-1 receptor antagonist, Losartan. Subsequently, an inhibitor of tyrosine phosphorylation blocked the AngII-induced activation of calcineurin, as did coincubation with an inhibitor of PLC activity and with an antagonist of the AT-1 receptor. It is therefore concluded that AngII stimulates calcineurin phosphatase activity in proximal tubule epithelial cells through a mechanism involving AT-1 receptor-mediated tyrosine phosphorylation of the PLC isoform.     

Reliability of radiographic measurement of fracture angulation in children with femoral shaft fractures

INTRODUCTION: Clinical decisions are based on x-ray measures of radiographs. However, the reliability of assessing the angular measurement of fractured femurs in children is unknown. The purpose of this study was to determine the intra- and interrater reliability of an x-ray assessment of femoral shaft fracture angulation in children. METHODS: On 2 occasions, 3 raters evaluated 30 radiographs of children aged 4 to 10 years, 3 to 24 months after a femoral fracture. The radiographs were evaluated by an orthopedic surgeon, an orthopedic fellow and a research assistant, using a standardized methodology. Reliability was assessed with the intraclass correlation coefficient (ICC), an index of concordance that ranges from 01, where > 0.75 indicates excellent concordance. RESULTS: The ICC for the intrarater ranged from 0.75 to 0.97. The interrater reliability ICC for anterior or posterior angulation was 0.91 (95% confidence interval [CI] 0.840.95) and for varus or valgus angulation was 0.90 (95% CI 0.790.95). A change in measurement of more than 5 degrees exceeds the variation in measurement and, therefore, can be attributed to a true shift in fracture position. CONCLUSIONS: With specific standardized protocols, radiographic assessment of femoral fractures is reliable, irrespective of the examiner's level of experience.     

Clinical risk factors for fractures in multi-ethnic women: the Women's Health Initiative.

To identify risk factors for fractures in multi-ethnic women, we studied 159,579 women enrolled in the Women's Health Initiative. In general, risk factors for fractures were similar across ethnic groups. However, irrespective of their ethnicity, women with multiple risk factors have a high risk of fracture. Targeting these high-risk women for screening and intervention could reduce fractures. INTRODUCTION: Fracture rates tend to be lower in minority women, but consequences may be greater. In addition, the number of fractures is expected to increase in minority women because of current demographic trends. There are limited prospective data on risk factors for fractures in minority women. MATERIALS AND METHODS: We studied 159,579 women 50-79 yr of age enrolled in the Women's Health Initiative. Information on risk factors was obtained by questionnaire or examination. Nonspine fractures that occurred after study entry were identified over an average follow-up of 8 +/- 2.6 (SD) yr. RESULTS: Annualized rates (%) of fracture in whites, blacks, Hispanics, Asians, and American Indians were 2.0, 0.9, 1.3, 1.2, and 2.0, respectively. Significant predictors [HR (95% CI)] of fractures by ethnic group were as follows: blacks: at least a high school education, 1.22 (1.0, 1.5); (+) fracture history, 1.7 (1.4, 2.2); and more than two falls, 1.7 (1.9, 2.0); Hispanics: height (>162 cm), 1.6 (1.1, 2.2); (+) fracture history, 1.9 (1.4, 2.5); more than two falls, 1.8 (1.4, 2.3); arthritis, 1.3 (1.1, 1.6); corticosteroid use, 3.9 (1.9, 8.0); and parental history of fracture, 1.3 (1.0, 1.6); Asians: age (per 5 yr), 1.2 (1.0, 1.3); (+) fracture history, 1.5 (1.1, 2.0); current hormone therapy (HT), 0.7 (0.5, 0.8); parity (at least five), 1.8 (1.1, 3.0); more than two falls, 1.4 (1.1, 1.9); American Indian: (+) fracture history, 2. 9 (1.5, 5.7); current HT, 0.5 (0.3, 0.9). Women with eight or more risk factors had more than a 2-fold higher rate of fracture compared with women with four or fewer risk factors. Two ethnicity x risk factor interactions were identified: age and fall history. CONCLUSIONS: Irrespective of their ethnicity, women with multiple risk factors have a high risk of fracture. Targeting these high-risk women for screening and intervention could reduce fractures.     

Outcome of traumatic extradural haematoma in Hong Kong

AIM: Traumatic extradural haematoma (EDH) is a neurosurgical emergency and timely surgical intervention for significant EDH is the gold standard. This study aims to determine the incidence and mortality of consecutive patients with traumatic EDH admitted to the Emergency Department (ED) of Prince of Wales Hospital (PWH), a University Hospital Trauma Centre in Hong Kong. PATIENTS AND METHODS: Retrospective analysis of prospectively collected data for all consecutive trauma cases admitted through the ED during 2001-2004. EDH was diagnosed by CT in all cases. Both primary and delayed onset EDH were included, as were patients with combined EDH and other intracranial lesions (e.g. subdural haematoma). Age, sex, cause of injury, associated intracranial lesions, skull fracture, Glasgow Coma Scale, pupil reactivity, treatment, length of stay and clinical outcome were determined. RESULTS: Two thousand and two hundred and eight patients were in the trauma registry for 2001-2004. Total 1080 head injured patients; 89 patients had traumatic EDH, mean of 1.9 patients per month. Seventy (79%) patients were male, with a mean age of 37.7 years. Fifty (56%) patients were from road traffic crashes, 27 (30%) sustained falls, 10 (11%) had direct head trauma. On admission, 62 (70%) patients were GCS 13-15, 9 (10%) GCS 9-12 and 18 (20%) GCS 3-8. Sixty-six (74%) patients had a skull fracture. Thirty (34%) patients underwent neurosurgical operation. Overall, nine patients (10%) died; eight patients were GCS<8; five had bilateral fixed and dilated pupils; one had a single fixed and dilated pupil. Four patients died after neurosurgical operation, three of whom had fixed dilated pupils and were GCS 3 prior to surgery. Median length of hospital stay for survivors was 10.4 days. CONCLUSION: Survival from traumatic EDH was 90% (80/89) and 91% (73/80) of survivors had a Glasgow Outcome Score of 4 or 5 (good or moderate). The combination of bilateral fixed dilated pupils and GCS 3 suggests severe primary brain injury. Emergency evacuation of intracranial haematomas is unlikely to improve the outcome for these patients. Even in an urban environment with short prehospital times and rapid access to neurosurgery, outcome in patients who are GCS 3 following EDH is likely to be poor.