LapBand System® in Super-Superobese Patients (>60 kg/m2): 4-Year Results

Background

Bariatric surgery in superobese (BMI?>?50 kg/m²) and super-superobese (BMI?>?60 kg/m²) patients can be a formidable technical and therapeutic challenge because these patients often present multiple medical, surgical, and anesthetic risks. Only a few dedicated reports on different surgical options in this kind of patient population are available. The aim of this study is the evaluation of laparoscopic adjustable gastric banding (LAGB) results in an unselected populations of super-superobese patients operated during the last 4 years.

Methods

Super-superobese (BMI?>?60 kg/m²) patients who underwent LAGB were recruited from the prospective database of our institution. LapBand® System (Allergan, Irvine, CA, USA) was positioned in all cases via pars flaccida, 1–2 cm below the gastroesophageal junction and fixed anteriorly with three non-absorbable stitches. The band was not filled at the time of surgery. Operative time, co-morbidities, laparotomic conversion, intra- and postoperative complications, mortality, and weight-loss-related parameters were considered. Data were expressed as mean ± standard deviation, except as otherwise indicated.

Results

From January 2003 to December 2006, 823 patients underwent a bariatric surgical procedure, 95 of whom (11.5%) were BMI?>?60 kg/m² (59 F/ 36 M; mean BMI, 62.5?±?4.2; range, 60.1–77 kg/m²; mean age 38.5?±?13.5, range 18–61 years old). Mortality, intraoperative, and 30-day major complications were absent. One or more preoperative co-morbidities were diagnosed in 90 of 95 (94.7%) patients. After 1 year, co-morbidity-free patients increased from five of 95 (5.3%) to 27 of 95 (28%; p?p?Conclusions LAGB can be considered an appropriate bariatric surgical option in super-superobese patients both for low morbidity rate and weight loss. The end-point of BMI?相似文献   

Relationships between total CD34+ cells reinfused, CD34+ subsets and engraftment kinetics in breast cancer patients

BACKGROUND AND OBJECTIVE: The aim of the present study was to evaluate the correlation between the number of CD34+ cells transfused and the duration of hypoplasia, and the relationship between various CD34+ subsets (CD34+/33-; CD34+/38-; CD34+/ HLA-DR-; CD34+/Thy-1+) and engraftment kinetics in a series of patients with breast cancer treated with high doses of thiotepa and melphalan. DESIGN AND METHODS: We treated 42 consecutive patients: 19 in an adjuvant context (>= 4 positive axillary nodes) and 23 for metastatic disease. A combination of thiotepa 600 mg/m(2) and melphalan 140-160 mg/m(2) was administered as the conditioning regimen. All patients received peripheral blood progenitor cells (PBPC) and growth factors for hematopoietic rescue. RESULTS: In univariate analysis, we found a significant relationship between the number of CD34+ cells reinfused and the time to hematologic recovery and the duration of hospital stay. We observed an inverse correlation between the number of CD34+ cells reinfused and the units of platelets transfused. Cox multivariate analysis confirmed that the number of CD34+ cells reinfused is the most effective predictor of time to hematologic recovery. CFU-GM resulted to be a better predictor of the duration of hospitalization. INTERPRETATION AND CONCLUSIONS: We found a significant relationship between the number of PBPC reinfused and the time to hematologic recovery after high doses of thiotepa and melphalan. In our experience, the numbers of subsets of CD34+ cells infused did not give compared additional information to that provided by the total number of CD34+ cells infused.     

A randomized study comparing filgrastim versus lenograstim versus molgramostim plus chemotherapy for peripheral blood progenitor cell mobilization

We conducted a prospective randomized clinical trial to assess the mobilizing efficacy of filgrastim, lenograstim and molgramostim following a disease-specific chemotherapy regimen. Mobilization consisted of high-dose cyclophosphamide in 45 cases (44%), and cisplatin/ifosfamide/etoposide or vinblastine in 22 (21%), followed by randomization to either filgrastim or lenograstim or molgramostim at 5 microg/kg/day. One hundred and three patients were randomized, and 82 (79%) performed apheresis. Forty-four (43%) patients were chemonaive, whereas 59 (57%) were pretreated. A median number of one apheresis per patient (range, 1-3) was performed. The median number of CD34+ cells obtained after mobilization was 8.4 x 10(6)/kg in the filgrastim arm versus 5.8 x 10(6)/kg in the lenograstim arm versus 4.0 x 10(6)/kg in the molgramostim arm (P=0.1). A statistically significant difference was observed for the median number of days of growth factor administration in favor of lenograstim (12 days) versus filgrastim (13 days) and molgramostim (14 days) (P<0.0001) and for the subgroup of chemonaive patients (12 days) versus pretreated patients (14 days) (P<0.001). In conclusion, all three growth factors were efficacious in mobilizing peripheral blood progenitor cells with no statistically significant difference between CD34+ cell yield and the different regimens, and the time to apheresis is likely confounded by the different mobilization regimens.     

Standardized clinical photography: the role of flash

Medical photographic documentation is important for professional, research, and ethical concerns. This study analyzed the possible interference that the flash could cause on evaluation of lower eyelid cosmetic results. Standardized photographs with and without flash were taken of 10 patients with dermatochalasis. The photographs were evaluated by 3 independent observers, as before (without flash) and after (with flash) an alternative esthetic treatment of the lower eyelid. The observers rated the overall cosmetic improvement of the lower eyelid photographs on a visual analog scale. The 3 surgeons believed that there was improvement in cosmetic outcome from the first (without flash) to the second (with flash) picture. The results indicate that a simple flash addition in one of 2 consecutive photographs, taken seconds apart, could influence the impression of experienced surgeons on the final outcome of oculoplastic surgeries and may constitute a bias in observer-dependent studies.     

The Bioload and Aflatoxin Content of Herbal Medicines from Selected States in Nigeria

Background

There is increased reliance on traditional herbal medicines by several millions of people worldwide, especially in West Africa and Nigeria in particular. This is due to escalating cost of good quality drugs and consequent proliferation of faked cheaper drugs. However, non standardization of production and handling methods have resulted in herbal medicines with varying quality and safety indices, thus resulting in possible public health concerns. This work investigated the microbial load and aflatoxin levels in herbal medicines from selected states in Nigeria.

Materials and Methods

A total of 210 samples obtained from various renowned herbal medicine practitioners from some selected states in Nigeria, based on their medicinal uses, were analyzed to determine the microbial load by the plate count method and aflatoxin contamination levels using thin layer chromatography with aflatoxin standards.

Results

At least six bacterial genera (Bacillus, Pseudomonas, Salmonella, EPEC, EHEC, Streptococcus and other coliforms) and 6 fungal genera (Aspergillus, Penicillium, Rhizopus, Cladosporium, Geotricum and Candida) were isolated. Aflatoxin B1, B2 and G1 were detected in varying concentrations in the samples analyzed, with an average occurrence of 18.6%. Some of these herbal concoctions were found to contain unacceptably high bioload, according to WHO standards.

Conclusion

Microbial contamination and the presence of aflatoxins in herbal medicines appear to be an endemic problem in Nigeria, as observed in this work, probably due to poor observation of basic hygiene during preparations and poor storage conditions. The findings in this work may serve in developing and instituting public health standards for the production and safety of herbal remedies in Nigeria.     

Comparison of the computer programs DEREK and TOPKAT to predict bacterial mutagenicity. Deductive Estimate of Risk from Existing Knowledge. Toxicity Prediction by Komputer Assisted Technology

The performance of two computer programs, DEREK and TOPKAT, was examined with regard to predicting the outcome of the Ames bacterial mutagenicity assay. The results of over 400 Ames tests conducted at Glaxo Wellcome (now GlaxoSmithKline) during the last 15 years on a wide variety of chemical classes were compared with the mutagenicity predictions of both computer programs. DEREK was considered concordant with the Ames assay if (i) the Ames assay was negative (not mutagenic) and no structural alerts for mutagenicity were identified or (ii) the Ames assay was positive (mutagenic) and at least one structural alert was identified. Conversely, the DEREK output was considered discordant if (i) the Ames assay was negative and any structural alert was identified or (ii) the Ames assay was positive and no structural alert was identified. The overall concordance of the DEREK program with the Ames results was 65% and the overall discordance was 35%, based on over 400 compounds. About 23% of the test molecules were outside the permissible limits of the optimum prediction space of TOPKAT. Another 4% of the compounds were either not processable or had indeterminate mutagenicity predictions; these molecules were excluded from the TOPKAT analysis. If the TOPKAT probability was (i) > or =0.7 the molecule was predicted to be mutagenic, (ii) < or =0.3 the compound was predicted to be non-mutagenic and (iii) between 0.3 and 0.7 the prediction was considered indeterminate. From over 300 acceptable predictions, the overall TOPKAT concordance was 73% and the overall discordance was 27%. While the overall concordance of the TOPKAT program was higher than DEREK, TOPKAT fared more poorly than DEREK in the critical Ames-positive category, where 60% of the compounds were incorrectly predicted by TOPKAT as negative but were mutagenic in the Ames test. For DEREK, 54% of the Ames-positive molecules had no structural alerts and were predicted to be non-mutagenic. Alternative methods of analyzing the output of the programs to increase the accuracy with Ames-positive compounds are discussed.     

Bilateral central retinal vein occlusion associated with multiple myeloma

PURPOSE: To report a case of simultaneous bilateral central retinal vein occlusion (CRVO) associated with multiple myeloma. METHODS: A 65-year-old woman had sudden, painless loss of vision in both eyes for 20 days. Ophthalmologic examination revealed bilateral CRVO. Appropriate medical workup was conducted, and multiple myeloma was diagnosed as the underlying cause. RESULTS: Clinical support and chemotherapy effectively controlled paraprotein production, leading to improvement of both systemic and ocular alterations. CONCLUSIONS: Many conditions have been noted to be associated with CRVO. Based on a Medline search, this is the first report of simultaneous bilateral CRVO as the first manifestation of multiple myeloma, illustrating the need for a primary care ophthalmologist to be involved in the basic assessment for associated underlying diseases in retinal disorders.     

Global approach to hepatic metastases from colorectal cancer: indication and outcome of intra-arterial chemotherapy and other hepatic-directed treatments

Liver metastases of colorectal cancer is present in more than 20% of new diagnosed patients and in 40–60% of relapsed patients. It is a life-threatening prognostic aspect. Hepatic resection, when possible, is the best therapeutic modality, although the overall survival rate is still low (30%). Angiography and intraoperative ultrasonography are useful for resection. The number of hepatic metastases and the surgical margin are probably the most significant prognostic factors. Colorectal cancer may spread predominantly to the liver making regional treatment strategies viable options. Subtotal hepatic resections and segmentectomies are potentially curable procedures for single or small numbers of hepatic metastases without other sites of disease. However, there have been no prospective randomized trials comparing patients with unresected liver metastases and resected metastases. Regional chemotherapy with floxuridine seems usefull combined with hepatic resection or as palliative therapy. Gastric ulcer and biliary sclerosis are the main related toxicities. Patients with localized, unresectable hepatic metastases or concomitant bad medical condition may be candidates for radiation, percutaneous ethanol injection, cryosurgery, percutaneous radiofrequency, hypoxic flow-stop perfusions with bioreductive alkylating agents, hepatic arterial ligation, embolization and chemoembolization. These new hepatic-directed modalities of treatment are being investigated and may offer new approaches to providing palliation and prolonging survival. This review will report the possibilities of intra-arterial chemotherapy and other novel hepatic-directed approaches to the treatment of liver metastases from colorectal cancer.     

Cisplatin and vinorelbine followed by ifosfamide plus epirubicin vs the opposite sequence in advanced unresectable stage III and metastatic stage IV non-small-cell lung cancer: a prospective randomized study of the Southern Italy Oncology Group (GOIM).

A multicentric, prospective phase III study was carried out with the aim of testing the so-called ''worst drug rule'' hypothesis, which suggests the use of an effective but ''less active'' regimen that first eradicates tumoral cells resistant to a second effective and ''more active'' regimen. With respect to this hypothesis, we considered the cisplatin plus vinorelbine regimen (CCDP/VNR) as the more active regimen compared with the non-cisplatin-containing regimen of ifosfamide plus high-dose epirubicin (IFO/EPI). Thus, a randomized study was carried out to compare the sequencial strategy of three cycles of CDDP/VNR followed by three cycles of IFO/EPI with the opposite sequence in advanced non-small-cell lung cancer. A total of 100 consecutive previously untreated patients with stage III-IV non-small-cell lung cancer were centrally randomized in two arms according to stage of disease and the performance status. Patients allocated to arm A received CDDP (100 mg m-2 on day 1) plus VNR (25 mg m-2 i.v. on days 1 and 8) every 21 days for three cycles (step 1) followed, after restaging, by three cycles of IFO (2.5 g m-2 with mesna on day 1) plus high-dose EPI (100 mg m-2 on day 1) every 21 days (step 2). Patients in arm B received the opposite sequence. Type and rates of objective response were evaluated after step 1 and step 2 in agreement with WHO criteria and an intent-to-treat analysis. Patients were also analysed for toxicity patterns, time to progression and survival. After the first three cycles (step 1), overall response rate (ORR), calculated according to an intent-to-treat analysis, was 47% and 21% for arm A and arm B respectively (P = 0.0112). ORR for stage III patients was 55% and 14% for arm A and B respectively (P = 0.0097). In stage IV patients ORR was higher in arm A than in arm B (42% vs 28%) but not statistically significant (P = 0.4). Clinical responses to the shift of chemotherapy (step 2) showed that no patient pretreated with CDDP/VNR and subsequently treated with IFO/EPI showed further response, whereas in the inverse sequence arm CDDP/VNR was able to induce 26% partial response (PR) rate in patients pretreated with IFO/EPI. This difference was statistically significant (P = 0.037). The overall median time to progression (TTP) of arm A and arm B did not significantly differ (6 vs 4 months; P = 0.665). However, median TTP of stage III patients was, respectively, 7 months for arm A and only 3 months for arm B. This difference was statistically significant (P = 0.049). Median overall survival (OS) was 9 and 7 months respectively for arm A and arm B. Despite this trend the difference was not significant (P = 0.328). Median OS of stage III patients showed a statistically significant advantage for arm A over arm B (13 vs 7 months, P = 0.03). In addition, no statistically significant difference in OS was recorded for stage IV patients (both arms 7 months, P = 0.526). Our data do not confirm Day''s ''worst drug rule'' hypothesis, at least in patients with advanced non-small-cell lung cancer treated with the above-mentioned regimens. The combination of CDDP and VNR seems more active, at least in terms of response rate, than the IFO/EPI, which performed poorly.