Vaccine-Induced Protection from Homologous Tier 2 SHIV Challenge in Nonhuman Primates Depends on Serum-Neutralizing Antibody Titers

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Finding the Most Favorable Timing for Cholecystectomy after Percutaneous Cholecystostomy Tube Placement: An Analysis of Institutional and National Data

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Geographic Residency Status and Census Tract Socioeconomic Status as Determinants of Colorectal Cancer Outcomes

Objectives. We examined the impact of geographic residency status and census tract (CT)-level socioeconomic status (SES) on colorectal cancer (CRC) outcomes.Methods. This was a retrospective cohort study of patients diagnosed with CRC in Georgia for the years 2000 through 2007. Study outcomes were late-stage disease at diagnosis, receipt of treatment, and survival.Results. For colon cancer, residents of lower-middle-SES and low-SES census tracts had decreased odds of receiving surgery. Rural, lower-middle-SES, and low-SES residents had decreased odds of receiving chemotherapy. For patients with rectal cancer, suburban residents had increased odds of receiving radiotherapy, but low SES resulted in decreased odds of surgery. For survival, rural residents experienced a partially adjusted 14% (hazard ratio [HR] = 1.14; 95% confidence interval [CI] = 1.07, 1.22) increased risk of death following diagnosis of CRC that was somewhat explained by treatment differences and completely explained by CT-level SES. Lower-middle- and low-SES participants had an adjusted increased risk of death following diagnosis for CRC (lower-middle: HR = 1.16; 95% CI = 1.10, 1.22; low: HR = 1.24; 95% CI = 1.16, 1.32).Conclusions. Future efforts should focus on developing interventions and policies that target rural residents and lower SES areas to eliminate disparities in CRC-related outcomes.For men and women in the United States, colorectal cancer (CRC) ranks third in incidence and mortality among cancers, with an estimated 142 820 new cases and 50 830 deaths in 2013.1 Reflecting the US population distribution according to geography2 and evidence of similar incidence rates3,4 for rural residents, approximately 20% of incident CRC cases are expected to occur in rural populations. Although CRC incidence is equivalent for rural and urban residents, CRC mortality is higher in rural populations,5 and the causes of rural versus urban disparities in CRC mortality are not well understood. Compared with their suburban and urban counterparts, rural citizens are more likely to be older, live in poverty, have less education, lack health insurance, and have no regular health care provider.6–9 These facets of rural living pose challenges to accessing health promotional messages and high-quality primary care, not to mention treatment of cancer.10,11Those of lower socioeconomic status (SES) have worse health-related outcomes than their more affluent counterparts, and SES often has a gradient effect on health.12 A challenge in studying the association between rurality and health is being able to disentangle the confounding effect of SES associated with geographic residency.13 As we previously demonstrated for a sample of urban and rural residents of Georgia with CRC, rural residence was associated with an increased risk of death following diagnosis.14 A limitation of that study was an inability to account for SES differences between urban and rural populations. If adjustment for SES explains the poorer survival that is associated with rural residence, this explanation provides an opportunity to investigate mediators of the SES effect as potential avenues for intervention.15 Identification of these mediating factors will facilitate the development of focused interventions with the goal of eliminating rural CRC-related disparities.16,17Building on our previous work,14 we evaluated the independent and combined effects of rurality and area-level SES on CRC outcomes. In our previous study, (1) we were unable to evaluate the independent and potential confounding effect of SES on rurality,2 (2) our study population was a sample of the Georgia CRC population, and (3) residents were classified as urban or rural at the county level, which may have resulted in misclassification. In the present study, the exposures of interest were geographic residency status (rural, suburban, or urban) and area-level SES, both at the census tract (CT) level. In addition, the study population represents the entire state of Georgia rather than a sample. The primary study outcome was overall survival. Secondarily, we wanted to evaluate the effect of SES and geography adjusted for SES on the odds of late-stage disease at diagnosis and receipt of first-course treatment.The findings of this study are meant to bring importance to a highly relevant area of public health research: disparities related to rural versus urban cancer outcomes, and specifically to rural CRC outcomes. As a result, interventions may be designed and policies developed to address the difficulties of accessing and providing high-quality cancer care in rural areas of the United States.11 It is through the combination of applying what is learned from epidemiological findings to community-level interventions and policymaking that the elimination of health disparities will occur.18     

Sitz Bath: Where Is the Evidence? Scientific Basis of a Common Practice

PURPOSE This study was designed to determine if evidence exists to justify and support the recommendation of sitz bath in the management of anorectal disorders. METHODS A Medline search was conducted using the key words “sitz bath” and “hot bath.” RESULTS Thirty-six articles were found which highlighted the physiology, benefits, risks, complications, and techniques of sitz bath. Most of the studies were published in gynecologic or nursing journals. One randomized study comparing sitz bath to placebo was found. Two articles speculated that sitz bath induces relaxation of the internal sphincter muscle. Cold sitz bath was reported to decrease perineal edema more than warm sitz bath, although patients tended to prefer the latter. Five articles reported complications of sitz bath, including dissemination of herpes, maternal–neonatal Streptococcus outbreak, and skin burns. CONCLUSION A review of the literature demonstrated a lack of scientific data to support the use of sitz bath in the treatment of anorectal disorders. Additional randomized and controlled clinical studies are needed to investigate whether this time consuming recommendation is beneficial to patients. Reprints are not available.     

Differential diagnosis of frontal syndrome in patients with closed-head injuries

Background. A common sequela of head injury is "frontal syndrome", consisting in characteristic neurobehavioral disturbances. However, there is no ecologically valid research tool that would clearly indicate the presence of this syndrome. The goal of this article is to evaluate the authorized the Polish version of the Frontal Behavioral Inventory (FBInv), used to differentiate fronto-temporal dementia (FTD) from other dementias. Material and methods. The research involved 95 patients treated at the centers represented by the authors, divided into 3 groups: CHI, consisting of 39 patients with traumatic frontal lobe injuries; FTD, consisting of 28 patients with fronto-temporal dementia; and a control group of persons with post-traumatic depression without injury to the frontal lobes. The results were based on data obtained from caregivers in 24 categories of patient behavior covered by the FBInv. Results. We found important differences in total scores between patients with frontal syndrome from groups CHI and FTD, as against patients with post-traumatic depression. There are also noticeable differences between patients in group FTD and group CHI in terms of scores on particular test items. Conclusions. The FBInv in the authorized Polish version is both sensitive and specific in measuring neurobehavioral disturbances occurring in patients with post-traumatic damage to the changes in the behavioral and personality of these patients with the passage of time since injury or onset should be the topic of further research.     

"Towards a Better Life": a program of comprehensive rehabilitation for elderly patients following revision hip arthroplasty

Introduction. The aim of the research was to evaluate the quality of life of patients recovering from revision hip arthroplasty, who underwent rehabilitation under the "Towards a Better Life" program (TBL). In the TBL Program, appropriate physical exercises, relaxation techniques, seminars, and panel discussions are combined to support general improvement in both physical and psychological condition, thus improving the patients' quality of live.
Material and methods. The effectiveness of the TBL approach was evaluated in a clinical experiment involving 36 patients recovering from revision hip arthroplasty, treated under the standard rehabilitation program in general use at the centers represented by the authors. The patients were divided into two equal groups, matched by age and sex: an experimental group E (n = 18), with patients who received additionally the "Towards a Better Life" Program, and a control group K (n = 18), consisting of patients who did not receive this program. The methods used to evaluate the outcome of rehabilitation included clinical interview and observation, the Medical Outcomes Study (MOS-100) and the Self-Evaluating Quality of Life Scale (QOL). The patients were tested before rehabilitation commenced and re-tested two months later.
Analysis of results. On the Physical Index of the MOS-100 scale considerably greater progress was observed in patients from Group E in terms of reduced pain, increased coordination and fluency of movement, improved respiratory capacity, regulation of blood pressure and pulse, functioning of the digestive system, reduced body weight, and improved walking distance. In this group somewhat greater improvements were noted on the Psychological Index of the MOS-100, especially in cognitive functions (perception and attention) and emotional factors (increased satisfaction with life, reduced anexiety, depression, and irritability). The QOL parameters most sensitive to the difference between the TBL Program and the standard program were pain management, independence and self-care, and especially improved self-image and reduced anxiety. The improvements noted by Group E were in many subtest two or three times higher than in Group K.
Conclusions. The greater improvements recorder by patients participating in the "Towards a Better Life" Program in all measured parameters indicates that the program is highly effective in comparison to the standard model. The patients from Group E were much more satisfied with the results they had achieved in rehabilitation, and attained a higher degree of independence and self-determination. The TBL Program can be used to improve the quality of life of patients recovering from revision hip arthroplasty.     

Laparoscopic stoma formation.

BACKGROUND: Laparoscopic stoma formation has gained wide acceptance as an alternative to open abdominal surgery. Although laparoscopic stoma formation has a low morbidity, complications have been reported. Contributing factors to these complications are twisting of the bowel, maturing the wrong limb, or both of these. In this report, we describe a simple technique that can reduce these complications. METHODS: The bowel segment to be exteriorized is grasped with a locking nontraumatic, nonrotating grasper. After the orientation of the bowel is verified, the surgeon ties the handle of the instrument to the trocar by using a cotton umbilical tape. The trocar and the instrument become one working unit, and if the umbilical tape is wrapped around the shaft of the instrument, then the bowel is twisted. It is easy to untwist it by aligning the umbilical tape with the shaft of the instrument. To mature the stoma, the umbilical tape is removed and the grasper is unlocked. CONCLUSION: Laparoscopic stoma is an effective treatment for several benign and malignant disorders, and in general has a low morbidity. Our report describes a simple technique that can reduce the rare but significant postoperative stoma or small bowel obstruction.     

Pediatric brain tumor patients: their parents' perceptions of the hospital experience.

Studies have shown that admission to the hospital of a child can induce feelings of fear and helplessness in parents, challenging usual patterns of coping and parenting competence. Stress has been associated with parents' need to establish effective communication with staff and their need for information, ready access to their children, and participation in decision making relating to their child's care. This study of coping and adjustment was undertaken with the parents, including mothers and fathers, of children under 18 years of age diagnosed with a brain tumor, presenting at Royal Children's Hospital, Melbourne, between 2001 and 2002 (N=53). It was a prospective study using repeated measures over time. Participants in the study were involved in a questionnaire interview at 4 different points: at the time of diagnosis, 6 months postdiagnosis, 1 year postdiagnosis, and 2 years postdiagnosis, in which they were asked, among other things, about their experience of the hospital. The point of diagnosis was marked by a high level of dependence, with parents coping with rapid decision making and shock, and the surrender of care of their child. Parents identified high levels of information need but noted that they were often too stressed to take in information early on, and that this information need persisted up to the 2-year postdiagnosis point. More parents expressed dissatisfaction with the hospital and particularly with their interactions with the health care team at the 6-month post-diagnosis period, reflecting a possible reduction in attention given to families once they had settled into the treatment routine and the crisis of diagnosis had passed.     

Early jejunojejunostomy obstruction after laparoscopic gastric bypass: case series and treatment algorithm

BackgroundTo review our experience with early jejunojejunostomy obstruction (JJO) at a large academic teaching hospital and provide a management algorithm. Early JJO is a known and often overlooked complication of laparoscopic Roux-en-Y gastric bypass.MethodsFrom 2003 to 2007, 1097 patients underwent laparoscopic Roux-en-Y gastric bypass at our institution. Data, including patient demographics, co-morbidities, intraoperative data, peri- and postoperative complications, and outcomes, were prospectively recorded and retrospectively reviewed.ResultsEarly post-laparoscopic Roux-en-Y gastric bypass JJO occurred in 13 patients (1.2%). The average time to presentation was 15 days (range 5–27). Patients presented with a combination of nausea, vomiting, and abdominal pain; all underwent computed tomography to confirm the diagnosis. The causes of JJO included dietary noncompliance (46%), anastomotic edema (23%), narrowing of the jejunojejunostomy at surgery (23%), and luminal clot (8%). Management was determined using our proposed treatment algorithm. Three patients (23%) required operative intervention, with the remainder successfully treated conservatively.ConclusionFrom our experience, we propose a treatment algorithm for standardized management of early JJO, reserving reoperation for those who are acutely ill on presentation or those in whom conservative management fails. A review of our series using this algorithm has suggested that most patients can be successfully treated nonoperatively; however, bariatric surgeons must maintain a low threshold for surgical re-intervention in cases in which rapid recovery is not seen.     

Laparoscopic gastric bypass at a large academic medical center: lessons learned from the first 1000 cases

Bariatric surgery is an effective and durable treatment for morbid obesity in properly selected patients. Surgical outcomes and patient management methods should routinely be reviewed to improve patient care and maintain long-term effectiveness of the bariatric operation. Over a 5-year period, 1096 laparoscopic Roux-en-Y gastric bypass operations were performed at our institution. A comprehensive prospective database was maintained, which included data for comorbidities, operative techniques, perioperative management, complications, and follow up. Many practice patterns such as the omission of routine preoperative sleep apnea testing and biliary ultrasounds remained constant and were validated by the outcomes measured. Several changes, however, were implemented based on outcomes analyses, including antecolic placement of the roux limb, a pars flaccida approach to the creation of the gastric pouch, longer alimentary limbs in superobese patients, and a selective approach to postoperative upper gastrointestinal imaging. Postoperative weight regain and inability to maintain long-term follow up in a significant per cent of patients were two identified and ongoing problems. Maintenance of a bariatric patient database is essential with its routine review resulting in changes to practice patterns and operative techniques. An effective method for long-term patient follow up remains elusive and may contribute to postoperative weight regain in some patients.