Acceptance of Surgery for Obesity by Academic Surgeons in North America

BACKGROUND: Have surgeons in North America accepted operations for the treatment of severe obesity? This question was posed by organizers of the Ninth International Symposium on Obesity Surgery that met in Stockholm in September, 1995. Study design: In order to obtain opinions which might help to answer the question posed, a 1-page questionnaire was sent to 151 chairmen of academic departments of surgery in North America in December 1994 asking about the acceptance and use of surgical operations for the treatment of severe obesity. RESULTS: Answers, received from 112 or 74%, indicated that operative treatment should be used (74%), was effective (77%) and safe (71 %). However, only 65% of departments provided such operations. Operative treatment for obesity was available outside the department in 53%. The operations most frequently used were Roux-en-Y gastric bypass (RGB) and vertical banded gastroplasty (VBG). A single operation was offered by 44 departments and a choice of two or more operations in 30 departments. RGB and VBG were equally in use. Gastric banding was used as an alternative to VBG in six departments. Other operations were in use in six departments either alone (three) or as alternatives to RGB and VBG (three). CONCLUSIONS: It appears that surgical treatment of obesity is accepted and available in the majority of academic departments of surgery.     

The Gastric Bypass for Failed Bariatric Surgical Procedures

Background: Revision of failed bariatric surgical procedures is a significant challenge for every bariatric surgeon. Methods: Evaluated are surgical difficulties, management problems and weight loss in patients with distal gastric bypass as a revisionary procedure. Eighty patients were followed up to 3 years; four were lost to follow-up. Mean age was 43; mean prebariatric surgery weight 134 kg; height 1.65 meters; body mass index 40.1; ideal body weight 62.7 kg; excess weight 70.5 kg; per cent excess weight 214%. A 250 cm stomach-to-ileocecal valve segment of small bowel was used, and the biopancreatic secretions were brought into the terminal ileum 100 cm from the ileocecal valve. Mean pouch size was 63 cc; length of hospital stay 5 days; operative blood loss 616 cc; operative time 130 min. Results: Intraoperative complications included three splenic injuries (without splenectomy). Early complications included one deep vein thrombosis, two marginal ulcers, one GI hemorrhage, one wound dehiscence, one pouch outlet obstruction and one pancreatitis. Late complications included: one death from protein malnutrition/ARDS; 21 hypoproteinemia; six protein malnutrition, and of these, three had hyperalimentation; three cholecystitis; 27 anemia; 22 incisional hernia; two staple-line disruption (reoperated); 26 low serum iron; 11 prolonged (> 6 months) diarrhea; three prolonged frequent vomiting; and two unrelated deaths (chronic myelogenous leukemia and amyotrophic lateral sclerosis). Mean excess weight loss was 83% at 12 months; 89% at 24 months; and 94% at 36 months. Conclusion: The distal gastric bypass is fraught with the operative and immediate post-operative complications experienced in any revisionary bariatric surgery. Distal gastric bypass is very effective in producing long-term weight loss. Nutritional problems are common but usually easily corrected. The most serious nutritional complication is protein malnutrition, which must be identified and corrected early. Success of this procedure is dependent upon patient compliance with proper nutrition and supplements, and regular office follow-up with monitoring of laboratory data. Patients who are noncompliant are at significant risk for complications.     

The use of genetic instability as a clinical tool for cancer diagnosis

Human tumors exhibit two fundamentally important characteristics, extensive genetic alteration and clonality. Although it is still unclear to what extent tumors have an elevated mutational burden as compared with normal tissue, their clonality results in their ready detection. Thus, assaying tissues for clonal alterations at frequently mutated microsatellite loci represents a viable approach to cancer diagnosis. The most remarkable extension of this concept is that not only can cancer cells be detected in biological samples, but tumor DNA can also be directly detected in the serum or plasma of patients with some forms of cancer. This recent finding is currently being explored but may represent an important contribution to future diagnostic strategies.     

The role of hormonal therapy in breast cancer

This review reassesses the role of hormonal therapy in breast cancer specifically the sequential or concurrent use of endocrine therapy and the combined use of chemotherapy with endocrine therapy. In advanced disease the sequential use of hormone therapies is generally recommended rather than the combined use of various hormonal agents, though combination hormonal therapy offers advantages in certain subsets of patients. The efficacy of combined chemo-endocrine therapy is questionable. Chemotherapy with estrogenic recruitment is an attractive but still experimental concept. However, in an adjuvant setting there is evidence that combined chemo-endocrine therapy causes a significant increase in disease-free and/or overall survival, particularly in postmenopausal patients with estrogen receptor (Expositive tumors. While hormonal treatment strategies have clearly benefitted from randomized studies, data regarding optimal endocrine therapy are still insufficient.     

A model mechanism for the chemotactic response of endothelial cells to tumour angiogenesis factor

Present address: Program in Scientific Computing and Computational Mathematics, Division of Applied Mechanics, Durand 252, Stanford University, California 94305, USA. In order to accomplish the transition from avascular to vasculargrowth, solid tumours secrete a diffusible substance known astumour angiogenesis factor (TAF) into the surrounding tissue.Endothelial cells which form the lining of neighbouring bloodvessels respond to this chemotactic stimulus in a well-orderedsequence of events consisting, at minimum, of a degradationof their basement membrane, migration, and proliferation. Amodel mechanism is presented which includes the diffusion ofthe TAF into the surrounding host tissue and the response ofthe endothelial cells to the chemotactic stimulus. The modelaccounts for the main observed events associated with the endothelialcells during the process of angiogenesis (i.e. cell migrationand proliferation); the numerical results compare very wellwith experimental observations. The situation where the tumour(i.e. the source of TAF) is removed and the vessels recede isalso considered.     

Double β-lactam regimen compared to an aminoglycoside/β-lactam regimen as empiric antibiotic therapy for febrile granulocytopenic cancer patients

In a prospective, randomized trial, 205 febrile episodes in granulocytopenic cancer patients were treated with ceftazidime with or without tobramycin (C±T), both agents being administered only if the initial granulocyte count was below 200/l, or ceftazidime plus piperacillin (C+P). The overall response rate was 71% (39 of 60 for C±T and 45 of 58 for C+P). Logistic regression analyses documented no evidence of a significant difference between the two regimens in overall treatment effect after accounting for the linear effects of potentially important variables, such as infection type and granulocyte count. Although the response rates for the subgroup of patients with bacteremias was better with the C+P regimen (P=0.06), there was no difference in response for patients with bacteremia and profound (<100/gml) sustained granulocytopenia. The double -lactam combination demonstrated in vitro synergism in 73%; antagonism was not seen. Both regimens produced execllent serum bactericidal levels (C±T geometric mean peak 1:170; C+P peak 1:137) against gram-negative but not gram-positive pathogens (1:4; 1:7 respectively) that had caused bacteremia. Emergence of resistance and significant coagulopathy and/or bleeding did not occur during therapy. Antibiotic-related nephrotoxicity was noted in 7 of 95 trials in the C+P and in 6 of 89 trials in the C±T group (P=0.19). The incidence of secondary infections in patients with profound (<100/l) sustained granulocytopenia was lower in the C±T group (P=0.04). Alimentary canal anaerobic flora preservation with C±T, and suppression with C+P, was demonstrated. These results suggest that these regimens are of similar effectiveness and neigher is associated with major toxicity.     

Antitumor effects of GBS toxin: a polysaccharide exotoxin from group Bβ-hemolytic streptococcus

A group B streptococcus (GBS) isolated from human neonates diagnosed with sepsis and respiratory distress (early-onset disease) produces a polysaccharide exotoxin (GBS toxin) that, when infused in sheep, causes lung pathophysiology similar to that seen in humans. Histological studies have demonstrated that GBS toxin induces a strong inflammatory response in the lung, with pulmonary sequestration of granulocytes and extensive capillary endothelial damage. The susceptibility of humans to GBS toxin is age-dependent and limited to about 4 days after birth. It is rarely evident thereafter. This suggests that the binding of GBS toxin to the target endothelium occurs via specific components in the developing lung endothelial cells of the newborn that are later lost. We report here that GBS toxin can also bind to developing endothelium associated with neoplasia and induce an inflammatory response. GBS toxin was shown by immunohistochemistry to bind to capillary endothelium of human large-cell carcinomas. In nude mice bearing human tumor xenografts, intravenously administered GBS toxin caused tumor necrosis and hemorrhagic lesions, and substantially inhibited the rate of growth of the tumors. In BALB/c mice bearing Madison lung tumors, GBS toxin induced an inflammatory response resulting in marked changes in tumor morphology, including vasodilation, endothelial and tumor cell necrosis, invasion of lymphocytes and macrophages, and capillary thrombosis. In these tumor models, no evidence of toxicity to the vasculature of other tissues was observed. The reported pathophysiology of GBS in human neonates, the lack of disease in non-neonates colonized with GBS, and these results suggest that GBS toxin may have potential as a well tolerated agent in cancer therapy of some human tumors.Abbreviations GBS group BStreptococcus - PBS phosphate-buffered saline This work was supported in part by a grant from the March of Dimes Foundation     

The impact of nurses' encounters with cancer on their attitudes towards the disease

Summary

• ? A study to develop understanding of nurses' knowledge, confidence and educational needs in relation to cancer care was undertaken.
• ? Data from this study on nurses' attitudes and the effect of professional encounters with cancer on such attitudes are presented.
• ? A cancer attitude scale was completed by 127 nurses, and 68 of the sample were interviewed in depth.
• ? Data presented reveal a pervasive negative attitude towards cancer amongst these nurses, and the important negative impact that professional encounters with cancer have on nurses' feelings about the disease.
• ? Data presented are taken from a larger study, which is reported elsewhere (Corner, 1990; Corner & Wilson-Barnett, 1992).

     

D-aspartate binding to the glutamate uptake site in human brain tissue — effects of leucotomy

Summary Binding of [3 H]D-aspartate, as an indicator of glutamate uptake sites, was investigated in post-mortem human brain tissue by use of a centrifugation assay to separate free and bound ligand. Binding was displaceable, apparently saturable and to a single site, with mean K_D and Bmax values of 2.3 M and 40.3 nmol/g tissue in the frontal cortex. The method was applied to the study of tissue from frontal and temporal cortices and the caudate nucleus of five psychiatric patients who had undergone a frontal leucotomy. The effects of this neurosurgical procedure were to diminish by almost 50% the density of D-aspartate binding sites in the frontal cortex and caudate nucleus, while the temporal cortex was less affected. It is concluded that the method provides a potentially useful correlate of glutamatergic innervation in human brain tissue.     

Effects of vitamin D3 metabolites on bone cell calcium transport

Summary The vitamin D₃ metabolite, 25-hydroxycholecalciferol, at concentrations of 0.01 to 10.0 g/ml, decreased calcium uptake by isolated bone cells. The effect occurred within 1 min after the simultaneous addition of metabolite and⁴⁵Ca. Lactic acid and ATP production by the cells was not affected. 24(R), 25-dihydroxycholecalciferol produced a similar decrease in calcium uptake. Vitamin D₃ had no effect at concentrations from 0.01 to 10.0 g/ml. No effect of 1,25-dihydroxycholecalciferol on calcium uptake was observed with concentrations from 0.1 to 100 ng/ml and various preincubation periods extending to 2 h. None of the agents had any effect on calcium efflux. The effects of 25-hydroxycholecalciferol and 24(R), 25-dihydroxycholecalciferol on calcium uptake were not seen in isolated fetal rat skin cell preparations.