Predictors of Unsuccessful Laparoscopic Resection of Gastric Submucosal Neoplasms

Background

While laparoscopy has become integral to the performance of foregut surgery, its optimal use in resection of gastric submucosal neoplasms, including gastrointestinal stromal tumors (GISTs), remains uncertain. Concern exists for technical feasibility related to tumor size and location, as well as oncologic outcome.

Methods

From 2002 to 2012, 106 patients underwent resection for gastric submucosal neoplasms, comprising 79 laparoscopic and 27 open resections. Median follow-up was 15 months.

Results

Patients were 62?±?14 years and 56 % male. Mean tumor size was 5.5?±?4.3 cm, with 76 % being GISTs. A total of 8 (10 %) conversions occurred in the laparoscopic cohort. On multivariate analysis, conversion was predicted by size greater than 8 cm, while recurrence was predicted by mitotic index (p?<?0.05). Laparoscopic resection resulted in better perioperative outcomes, with less morbidity, operative time, blood loss, and length of stay (p?<?0.05). No significant difference was seen in survival, with 90 % and 81 % alive 3 years after laparoscopic and open resection, respectively (HR 0.4; 95 % CI 0.1–1.3; p?=?0.13).

Conclusions

Laparoscopic resection is feasible and effective in the management of gastric submucosal neoplasms, including GISTs. Caution should be reserved for tumors greater than 8 cm. Oncologic outcome appears to be predicted by tumor biology as opposed to surgical approach.     

Venous thromboembolism after Diaphragm Pacing in amyotrophic lateral sclerosis

Introduction: Patients with amyotrophic lateral sclerosis (ALS) are prone to venous thromboembolism (VTE) and secondary complications. Because there is an increased incidence of VTE after surgical procedures, placement of a Diaphragm Pacing System (DPS) in ALS patients as treatment for respiratory muscle weakness could potentially increase the incidence of VTE, especially in patients with limited mobility. Methods: We implanted a DPS in 10 ALS patients who met the criteria for this procedure. They underwent a preoperative evaluation as recommended by the guidelines. Results: We report 2 patients with no symptoms of deep vein thrombosis (DVT) before the surgical procedure who then developed perioperative VTE. Conclusions: These patients highlight the need to consider preoperative screening for DVT and postoperative thromboprophylaxis in high‐risk ALS patients who undergo DPS placement. Muscle Nerve 50 : 863–865, 2014     

Serum Ornithine Carbamoyl Transferase as a Surrogate Marker in Malaria

Ornithine carbamoyl transferase (OCT) activity and other liver function tests were studied in a total of 50 patients of clinical malaria and 15 controls. They were grouped as group I (positive for malarial parasite on peripheral blood smear, n=18), group II (negative for malarial parasite on peripheral blood smear (PBS) but responded to antimalarials, n=17) and group III (peripheral blood smear negative and did not respond to antimalarial therapy, n=15). The mean OCT levels were significantly raised in group I (6.79 ± 1.84 IU/L, p value = 0.006) and group II (5.0 ± 1.15 IU/L, p value = 0.014) as compared to controls (2.5 ± 1.13 IU/L) and returned to normal after treatment In contrast, group III had normal levels except in a case of kala azar and septicemia where OCT levels were high and increased further on treatment. Taking PBS positivity as a gold standard of diagnostic criteria, OCT had a sensitivity of 83% and specificity of 86% with a high positive predictive value of 88% as compared to ALT which had a lower sensitivity of 55% and specificity of 80%. The clinical response rate in PBS negative cases of fever having high OCT level was 83% as compared to 35% in cases with normal OCT level, making OCT a good surrogate marker of malaria. OCT levels could also be of prognostic significance as 2 cases of cerebral malaria had high OCT levels of 11.1 UAL and 10.7 IU/L, respectively.Key Words: Malaria, Ornithine carbamoyl transferase     

Low Birth Weight Across Generations

Objectives: This study sought to determine the relationship between maternal birth weight, prenatal care usage, and infant birth weight. Methods: Stratified and logistic regression analyses were performed on a dataset of computerized Illinois vital records of White (N = 187,074) and African-American (N = 58,856) infants born between 1989 and 1991 and their mothers born between 1956 and 1975. Results: Among White mothers who received adequate prenatal care, the low birth weight (<2500 g) rate was 4% for infants of former low birth weight mothers (N = 5230) compared to 2.1% for infants of former nonlow birth weight mothers (N = 93,011), relative risk equaled 1.9(1.7–2.2); the population attributable risk of maternal low birth weight was 4.1%. Among African American mothers who received adequate prenatal care, the low birth weight rate was 15% for infants of former low birth weight mothers (N = 2196) compared to 7.2% for infants of former nonlow birth weight mothers (N = 14,607), relative risk equaled 2.1(1.9–2.4); the population attributable risk of maternal low birth weight was 10.9%. The maternal–infant birth weight associations were consistent across all maternal age, education, marital status, and prenatal care categories. Conclusions: Maternal low birth weight is a risk factor for infant low birth weight independent of risk status during the current pregnancy. A greater percentage of low birth weight African American (compared to White) infants are attributable to maternal low birth weight.     

Neighborhood Gun Violence and Birth Outcomes in Chicago

Objectives

To examine the association between gun violence and birth outcomes among women in Chicago.

Methods

Using a 5-year set of birth files (2011–2015) merged with census and police data, birth outcomes including low birth weight (LBW, BW < 2500 g), preterm birth (PTB, < 37 weeks gestation), and small-for-gestational-age (SGA, BW < 10th percentile) were examined among non-Hispanic (NH) white, NH black, and Hispanic women in Chicago. Gun violence rates were categorized into tertiles. Multilevel, multiple logistic regression examined the effects of gun violence and race/ethnicity on birth outcomes.

Results

Of 175,065 births, 10.6% of LBW, 10.6% of PTB, and 9.1% of SGA occurred in high violence tertile. Using white women in low violence tertile as reference, the OR for LBW among black women ranged 1.9–2.1 across all tertiles, and 0.8–1.2 among Hispanic women. OR for PTB for black women were 1.6–1.7 and 1.0–1.2 for Hispanic women, and OR for SGA for black women were 1.6–1.7 and for Hispanic women 0.9–1.0.

Conclusions for Practice

In Chicago, race/ethnicity was associated with birth outcomes, regardless of the level of exposure to gun violence, in 2011–2015. The differences in racial/ethnic composition across the violence exposure levels suggest that, rather than gun violence alone, residential segregation and the geographic inequities likely contribute to disparate birth outcomes.

     

Spectrin-alpha I/61: a new structural variant of alpha-spectrin in a double-heterozygous form of hereditary pyropoikilocytosis

Recent biochemical studies have led to the identification of abnormal spectrins in the erythrocytes of patients with hereditary pyropoikilocytosis (HPP) and hereditary elliptocytosis (HE). In this report we describe the biochemical characterization of the erythrocytes from a proband with severe HPP who is doubly heterozygous for two mutant spectrins (Sp): Sp alpha I/74 and a new, previously undetected, mutant of alpha-spectrin designated Sp alpha I/61. The proband's erythrocytes are unstable when exposed to 45 degrees C, and her membrane skeletons exhibit instability to shear stress. The content of spectrin in the proband's erythrocyte membranes is decreased to 75% of control values. The amount of spectrin dimers in crude 4 degrees C spectrin extracts is increased (58%) as compared with control values (6% +/- 4%). Limited tryptic digestion reveals a marked decrease in the normal 80,000-dalton alpha I domain, an increase in the 74,000-dalton fragment that is characteristic of Sp alpha I/74, and an increase in a series of new fragments of 61,000, 55,000, 21,000, and 16,000 daltons. Both parents are asymptomatic, but they have increased amounts of spectrin dimers (17% to 25%). Limited tryptic digestion of the father's spectrin demonstrates the presence of a previously identified abnormal spectrin (Sp alpha I/74) that is characterized by a decrease in content of the 80,000-dalton peptide and an increase in concentration of the 74,000-dalton peptide. The mother's spectrin digests show a decrease in the amount of 80,000-dalton peptide and the formation of new peptides of 61,000, 55,000, 21,000, and 16,000 daltons. The data indicate that this severe form of HPP is due to the inheritance of two distinct abnormal spectrins, Sp alpha I/74 and a new spectrin mutant, Sp alpha I/61.