What Are the Advantages of 3D Cameras in Gynaecological Laparoscopy?

Introduction Minimally invasive operative techniques are being used increasingly in gynaecological surgery. The expansion of the laparoscopic operation spectrum is in part the result of improved imaging. This study investigates the practical advantages of using 3D cameras in routine surgical practice. Materials and Methods Two different 3-dimensional camera systems were compared with a 2-dimensional HD system; the operating surgeon's experiences were documented immediately postoperatively using a questionnaire. Results Significant advantages were reported for suturing and cutting of anatomical structures when using the 3D compared to 2D camera systems. There was only a slight advantage for coagulating. The use of 3D cameras significantly improved the general operative visibility and in particular the representation of spacial depth compared to 2-dimensional images. There was not a significant advantage for image width. Depiction of adhesions and retroperitoneal neural structures was significantly improved by the stereoscopic cameras, though this did not apply to blood vessels, ureter, uterus or ovaries. Conclusion 3-dimensional cameras were particularly advantageous for the depiction of fine anatomical structures due to improved spacial depth representation compared to 2D systems. 3D cameras provide the operating surgeon with a monitor image that more closely resembles actual anatomy, thus simplifying laparoscopic procedures.

[Anesthesia and bariatric surgery]. / Anästhesie bei bariatrischer Chirurgie.

Today obesity is accepted as an independent disease. The WHO describes obesity as an epidemic disease occurring worldwide and associated comorbidities affect all organ systems. Bariatric operations lead to an improvement or even complete remission of obesity-correlated comorbidities. Bariatric operations are conducted as restrictive, malabsorptive, or mixed procedures. The preoperative anesthetic evaluation of comorbidities is carried out with a special focus on preexisting impairments of cardiac and lung function (e.g. cardiomyopathy, obstructive respiratory dysfunctions). Extremely obese patients are at risk of aspiration. Airway management at anesthesia induction includes normal intubation or, if additional risk factors are present, either fiber optic awake intubation or rapid sequence induction. The pharmacokinetics of all applicable drugs are altered in extremely obese patients and they are at risk for developing postoperative thromboembolic complications with a high mortality rate. Therefore early and sufficient thrombotic prophylaxis is important.

Smartphone based face recognition tool for the blind.

The inability to identify people during group meetings is a disadvantage for blind people in many professional and educational situations. To explore the efficacy of face recognition using smartphones in these settings, we have prototyped and tested a face recognition tool for blind users. The tool utilizes Smartphone technology in conjunction with a wireless network to provide audio feedback of the people in front of the blind user. Testing indicated that the face recognition technology can tolerate up to a 40 degree angle between the direction a person is looking and the camera's axis and a 96% success rate with no false positives. Future work will be done to further develop the technology for local face recognition on the smartphone in addition to remote server based face recognition.

Effort, safety, and findings of routine preoperative endoscopic evaluation of morbidly obese patients undergoing bariatric surgery.

BACKGROUND: Obesity is becoming an epidemic health problem and is associated with concomitant diseases, such as sleep apnea syndrome and gastroesophageal reflux disease (GERD). There is no standardized diagnostic workup for the upper gastrointestinal tract in obese patients; many patients have no upper gastrointestinal symptoms, and few data are available on safety of endoscopy in morbidly obese patients. METHODS: Sixty-nine consecutive diagnostic upper gastrointestinal endoscopies in morbidly obese patients (26 men, 43 women; mean age 43.4 +/- 10.9 years) were prospectively evaluated from January to December 2008 in an outpatient setting before bariatric procedures. Sedation was administered with propofol. Data on sedation, critical events, and examination times were recorded, as well as pathological findings. RESULTS: The patients' mean body mass index was 47.6 +/- 7.9 (range, 35.1-73.3) kg/m(2); 17.4% reported GERD symptoms. The mean duration of the endoscopy procedure (including sedation) was 20.3 +/- 9.3 (range, 5-50) min, and the whole procedure (including preparation and postprocessing) took 58.2 +/- 19 (range, 20-120) min. The mean propofol dosage was 380 +/- 150 (range, 80-900) mg. Two patients had critical events that required bronchoscopic intratracheal O(2) insufflation due to severe hypoxemia (<60% SaO: (2)). Nearly 80% of patients had pathological findings in the upper gastrointestinal tract. Only 20% reported upper gastrointestinal symptoms. Pathologic conditions were found in the esophagus in 23.2% of the patients, in the stomach in 78.2%, and in the duodenum in 11.6%. The prevalence of Helicobacter pylori infection was 8.7%. CONCLUSIONS: Upper gastrointestinal endoscopy can be performed safely. However, careful monitoring and anesthesiological support are required for patients with concomitant diseases and those receiving sedation. Because 80% of the patients with pathological findings were asymptomatic, every morbidly obese patient should undergo endoscopy before bariatric surgery because there may be findings that might change the surgical strategy.

Dysfunction of the lower esophageal sphincter and dysmotility of the tubular esophagus in morbidly obese patients.

BACKGROUND: Morbid obesity is associated with gastroesophageal reflux (GERD). The aim of this prospective study was to determine esophageal motility in asymptomatic morbidly obese patients and compare it to non-obese individuals. METHODS: Forty-seven morbidly obese patients without GERD symptoms and 15 normal weight individuals were divided into four groups according to their body mass index (BMI; group I, <30 kg/m2; group II, 35-39.9 kg/m2; group III, 40-49.9 kg/m2; group IV, >or=50 kg/m2). Standard stationary water-perfused manometry was performed for the assessment of anatomy and function of the lower esophageal sphincter (LES). Twenty-four-hour ambulatory pH-metry and measurement of esophageal motility were performed with a microtransducer sleeve catheter. Data are given as mean+/-SD, and the results of groups II-IV were compared to the non-obese individuals from group I. RESULTS: Patients with morbid obesity had significantly lower LES pressures than non-obese individuals (I, 15.1+/-4.9; II-IV, 10.5+/-5.4, mmHg, p<0.05 vs. I) and showed an altered esophageal motility with respect to contraction frequency (I, 1.8+/-0.7/min; II-IV, 3.6+/-2.5/min; p<0.05 vs. I) and contraction amplitude (I, 38+/-12 mmHg; II-IV, 33+/-17 mmHg; p<0.05 vs. I). Furthermore, these patients had significantly higher DeMeester scores than non-obese individuals. Length and relaxation of the LES as well as propulsion velocity of the tubular esophagus did not differ. CONCLUSION: Patients with morbid obesity (=BMI>40 kg/m2) have a dysfunction of the LES and an altered esophageal motility, even when they are asymptomatic for GERD symptoms.

[Operative technique and outcome after laparoscopic adjustable gastric banding]. / Operative Technik und deren Outcome in der metabolischen Chirurgie: Adjustable Gastric Banding (AGB).

Laparoscopic gastric banding is an easy to perform procedure with low morbidity and mortality. The benefits of the operation on the metabolic outcome have been demonstrated in long-term studies and are directly proportional to the amount of weight loss. Beside a closely monitored interdisciplinary follow-up, patient compliance is an essential prerequisite for success.

Ambulatory pH: monitoring with a wireless system.

BACKGROUND: Currently, pH monitoring is the gold standard for assessing esophageal acid exposure in patients with gastroesophageal reflux disease (GERD). The shortcomings of 24-h pH-monitoring wires led to the development of a 48-h, catheter-free pH measurement system using the telemetry technique with the BRAVO capsule. This prospective study aimed to compare conventional 24-h pH monitoring with the BRAVO catheter-free pH-monitoring system in patients with GERD, patients after antireflux surgery, and a healthy control group. METHODS: A sample of 133 participants were enrolled in the current trial and divided into three subgroups. Group 1 consisted of 10 healthy volunteers. Group 2 consisted of 123 patients with symptomatic gastroesophageal reflux and endoscopic signs of esophagitis. Group 3 consisted of 43 GERD patients (extracted from group 2) who underwent a laparoscopic 360 degree "floppy" Nissen fundoplication. All the patients underwent both conventional 24-h pH monitoring and BRAVO catheter-free pH monitoring. The data for both methods were recorded and compared in line with the different patient groups regarding their validity and reliability. Additionally, all the patients were interviewed with a standardized questionnaire concerning their subjective perception of the two different methods. RESULTS: Both the 24-h pH monitoring and the 48-h BRAVO catheter-free pH monitoring could be successfully performed for all the patients. During measurement, 122 of the patients (92%) continued working or performing daily activities. A significant difference could not be found regarding objective outcome between the two measurement methods in the three patient groups. The two methods showed comparable results in terms of data and measurement reliability. The validity also was comparable, with no significant differences within the groups. Concerning the patients' subjective estimation of the two methods, the patients reported reduced regular activities and a higher level of discomfort during measurement with the conventional 24-h pH-monitoring system (p < 0.001 and p< 0.0001, respectively). CONCLUSION: Both conventional 24-h pH monitoring and the 48-h catheter-free pH monitoring are valid and reliable recording devices for measuring esophageal acid exposure. However, from the patients' point of view, the BRAVO capsule affords less discomfort in the throat and allows more normal daily activities.

The lower esophageal sphincter strength in patients with gastroesophageal reflux before and after laparoscopic Nissen fundoplication.

Lower esophageal sphincter pressure (LESP) and sphincter strength (LESS) were measured before and after short and floppy laparoscopic Nissen fundoplication (LNF) in 38 patients with severe gastro-esophageal reflux disease (GERD). These patients were compared with a control group of 23 healthy volunteers. GERD was assessed by stationary manometry, 24-h pH recordings and endoscopy. LESS was verified by motorized pull-back of an air-filled balloon catheter from the stomach into the esophagus. The catheter assembly was well tolerated by all study participants. LESP increased significantly after operation from 8 mmHg to 14 mmHg (75% of normal values; P < 0.0001), but compared to the control group, LESP (22 mmHg) decreased significantly (P < 0.002). In the control group and in patients with GERD, LESP and LESS showed excellent correlation (r = 0.97, r = 0.94, respectively). After LNF, LESS increased significantly from 0.6 to 1.6 N (P < 0.0001), about 166%. We conclude that the measurement of LESS is able to explain the discrepancy between satisfactory NF operation and the distinct increase of postoperative LESP. The evaluation of LESS is a helpful tool in assessing functional understanding of laparoscopic Nissen fundoplication with a short and floppy wrap.

Parental regulation of central patterns of estrogen receptor alpha.

Reduced levels of estrogen receptor alpha (ERalpha) in the medial amygdala (MeA) and bed nucleus of stria terminalis (BST) have been hypothesized to play a significant role in the expression of male behaviors associated with monogamy. Therefore, the regulation of ERalpha could be a critical factor in determining male behavior and the evolution of monogamy. Central expression of ERalpha immunoreactivity was compared in hybrid offspring from crosses between two phenotypically distinct populations of prairie voles (Microtus ochrogaster). Illinois voles (IL) are socially monogamous and display low levels of ERalpha, while Kansas voles (KN) display some characteristics associated with polygyny and have higher levels of ERalpha. In offspring from hybrid crosses, the pattern of ERalpha expression was dependent upon parentage; the two types of hybrid crosses did not produce the same ERalpha pattern in the offspring. In the BST and MeA, hybrid males expressed ERalpha patterns consistent with those of males from their mother's population, while hybrid females had ERalpha patterns typical of females belonging to their father's population. The parental-specific patterns of ERalpha expression are suggestive of genomic imprinting, therefore, the vole ERalpha (Esr1) gene was cloned and sequenced, and examined for allele-specific expression. Results from this study indicate that while maternal factors may play a major role the expression of ERalpha in their male offspring, genomic imprinting is unlikely to be involved, suggesting another mechanism is responsible.

Neonatal manipulations of oxytocin alter expression of oxytocin and vasopressin immunoreactive cells in the paraventricular nucleus of the hypothalamus in a gender-specific manner.

Early postnatal manipulations of oxytocin have long-term behavioral and physiological consequences; the present study examined the hypothesis that oxytocin or its absence influences the subsequent expression of either oxytocin or arginine vasopressin in the CNS. On postnatal day 1 female and male prairie voles (Microtus ochrogaster) received a single i.p. injection of oxytocin (3 microg), oxytocin antagonist (0.3 microg), or 50 microl of isotonic saline or were only handled. On postnatal days 1, 8 and 21, brains were fixed, sectioned and stained for oxytocin or vasopressin immunoreactivity and analyzed as a function of age, treatment and sex. Both oxytocin and vasopressin immunoreactivity were observed on day 1 in the supraoptic and paraventricular nuclei (PVN) of the hypothalamus. Numbers of oxytocin and vasopressin neurons increased with age in both nuclei. Females treated on postnatal day 1 with oxytocin or oxytocin antagonist displayed a significant increase in oxytocin immunoreactivity on day 21 in the PVN. In contrast, males treated with antagonist tended to have decreased vasopressin immunoreactivity in the same region. These results revealed that the effects of neonatal manipulation of oxytocin are age-dependent, site-specific and sexually dimorphic. The long-lasting effects of neonatal exposure to exogenous oxytocin and oxytocin antagonist indicate a role for oxytocin in the development of the CNS during the neonatal period, affecting the development of the oxytocinergic system in females and the vasopressinergic system in males. The developmental effects observed suggest one possible mechanism by which neonatal exposure to oxytocin or neonatal inhibition of endogenous oxytocin produces long-lasting behavioral and physiological alterations and could play a role in the development of male- and female-typical behavior.

Measurement of G(E(p))/G(M(p)) in e(-->)p---> e(-->)p to Q(2) = 5.6 GeV(2).

The ratio of the electric and magnetic form factors of the proton G(E(p))/G(M(p)), which is an image of its charge and magnetization distributions, was measured at the Thomas Jefferson National Accelerator Facility (JLab) using the recoil polarization technique. The ratio of the form factors is directly proportional to the ratio of the transverse to longitudinal components of the polarization of the recoil proton in the elastic e(-->)p---> e(-->)p reaction. The new data presented span the range 3.5< Q(2)< 5.6 GeV(2) and are well described by a linear Q(2) fit. Also, the ratio sqrt[Q(2)] F(2(p))/F(1(p)) reaches a constant value above Q(2) = 2 GeV(2).

Episodes of care: an overview of legal and regulatory issues.

The use of managed care, with its chief goal of delivering cost-efficient health coverage, predominates the American health benefit arena. Though the advent of managed care unquestionably has saved billions of dollars since the late 1980s, patients raised on a diet of unfettered treatment have seen choices decrease and care diminish. "Episodes of care," in which teams of professionals contract to provide an entirety of health care services involved with a given procedure in exchange for a fixed, global fee, allows for broader choices for patients at competitive costs for insurers.

Trace element homeostasis during continuous sedation with propofol containing EDTA versus other sedatives in critically ill patients.

OBJECTIVE: To evaluate changes in serum and urinary zinc, cobalt, copper, iron, and calcium concentrations in critically ill patients receiving propofol containing disodium edetate (disodium ethylenediaminetetraacetic acid [EDTA]) versus sedative agents without EDTA. DESIGN: This was a randomised, open-label, parallel-group study with randomisation stratified by baseline Acute Physiology and Chronic Health Evaluation (APACHE II) scores. SETTING: Intensive care units (ICU) in 23 medical centres. PATIENTS: Medical, surgical, or trauma ICU patients 17 years of age or older who required mechanical ventilator support and sedation. INTERVENTIONS: A total of 106 patients received propofol containing 0.005 % EDTA (propofol EDTA), and 104 received other sedative agents without EDTA (non-EDTA). Only the first 108 patients were assessed for urinary trace metal excretion. Twenty-four-hour urine samples were collected on days 2, 3, and 7 and every 7 days thereafter for determination of zinc, cobalt, copper, iron, and calcium excretion; EDTA levels; urine osmolality; albumin levels; and glucose levels. The first 143 patients were assessed for serum concentration of zinc, cobalt, copper, iron, and calcium; creatinine; blood urea nitrogen; and albumin at baseline and once during each 24-hour urine collection. MEASUREMENTS AND RESULTS: For the assessment of trace metals, patients receiving propofol EDTA demonstrated increased mean urinary excretion of zinc, copper, and iron compared with the normal range. All patients receiving sedatives demonstrated increased urinary excretion of zinc and copper above normal reference values. Compared with the non-EDTA sedative group, the propofol EDTA group demonstrated increased urinary excretion of zinc and iron. Mean serum concentrations of zinc and total calcium were decreased in both patient groups. Serum zinc concentrations increased from baseline to day 3 in the non-EDTA sedative group but not in the propofol EDTA group. Renal function, measured by blood urea nitrogen, serum creatinine, and creatinine clearance, did not deteriorate during ICU sedation with either regimen. CONCLUSION: This study showed that critical illness is associated with increased urinary losses of zinc, copper, and iron. Propofol EDTA-treated patients had greater urinary losses of zinc and iron and lower serum zinc concentrations compared with the non-EDTA sedative group. No adverse events indicative of trace metal deficiency were observed in either group. The clinical significance of trace metal losses during critical illness is unclear and requires further study.

Prophylactic antibiotics for severe acute pancreatitis: the beginning of an era.

Death from acute severe pancreatitis results from infection and multiple organ system failure occurring late in the course of illness. Patients with necrotizing pancreatitis involving at least one-third of the organ are at highest risk of secondary infection and death. We conducted a MEDLINE search to identify human trials of prophylactic antibiotics in acute pancreatitis. Results of early studies of prophylactic ampicillin to avoid secondary infection and death were negative, but the studies included patients with mild disease who are at low risk for infection. Antibiotics were beneficial in four recently completed studies: imipenem significantly reduced pancreatic and nonpancreatic sepsis (p< or =0.01); cefuroxime reduced all infectious complications (p<0.01) and deaths (p=0.0284); a regimen of ceftazidime, amikacin, and metronidazole reduced all infectious complications (p<0.03); and protocol use of imipenem significantly reduced pancreatic infection compared with nonprotocol antibiotics (p=0.04) and no antibiotics (p<0.001). Based on these results, we suggest early antibiotic prophylaxis in patients with necrotizing pancreatitis, but the best drug and duration of therapy are unknown.

A Bub2p-dependent spindle checkpoint pathway regulates the Dbf2p kinase in budding yeast.

Exit from mitosis in all eukaroytes requires inactivation of the mitotic kinase. This occurs principally by ubiquitin-mediated proteolysis of the cyclin subunit controlled by the anaphase-promoting complex (APC). However, an abnormal spindle and/or unattached kinetochores activates a conserved spindle checkpoint that blocks APC function. This leads to high mitotic kinase activity and prevents mitotic exit. DBF2 belongs to a group of budding yeast cell cycle genes that when mutated prevent cyclin degradation and block exit from mitosis. DBF2 encodes a protein kinase which is cell cycle regulated, peaking in metaphase-anaphase B/telophase, but its function remains unknown. Here, we show the Dbf2p kinase activity to be a target of the spindle checkpoint. It is controlled specifically by Bub2p, one of the checkpoint components that is conserved in fission yeast and higher eukaroytic cells. Significantly, in budding yeast, Bub2p shows few genetic or biochemical interactions with other members of the spindle checkpoint. Our data now point to the protein kinase Mps1p triggering a new parallel branch of the spindle checkpoint in which Bub2p blocks Dbf2p function.

Budding yeast RSI1/APC2, a novel gene necessary for initiation of anaphase, encodes an APC subunit.

SIC1 is a non-essential gene encoding a CDK inhibitor of Cdc28-Clb kinase activity. Sic1p is involved in both mitotic exit and the timing of DNA synthesis. To identify other genes involved in controlling Clb-kinase activity, we have undertaken a genetic screen for mutations which render SIC1 essential. Here we describe a gene we have identified by this means, RSI1/APC2. Temperature-sensitive rsi1/apc2 mutants arrest in metaphase and are unable to degrade Clb2p, suggesting that Rsi1p/Apc2p is associated with the anaphase promoting complex (APC). This is an E3 ubiquitin-ligase that controls anaphase initiation through degradation of Pds1p and mitotic exit via degradation of Clb cyclins. Indeed, the anaphase block in rsi1/apc2 temperature-sensitive mutants is overcome by removal of PDS1, consistent with Rsi1p/Apc2p being part of the APC. In addition, like our rsi1/apc2 mutations, cdc23-1, encoding a known APC subunit, is also lethal with sic1Delta. Thus SIC1 clearly becomes essential when APC function is compromised. Finally, we find that Rsi1p/Apc2p co-immunoprecipitates with Cdc23p. Taken together, our results suggest that RSI1/APC2 is a subunit of APC.

Criteria used to judge obese persons in the workplace.

Researchers have speculated that employers are less likely to hire obese persons for more publicly visible jobs, although this hypothesis remains untested. In the present study, 54 undergraduate students rated 40 jobs on several items, including the likelihood they would hire an obese person for each job. Multidimensional scaling showed a one-dimensional solution, labeled as physical activity, with participants less likely to hire obese persons for more active jobs. For hiring likelihood ratings for jobs at either end of the dimension appear to be most similar for men and individuals with more positive attitudes toward obese persons versus women and individuals with more negative attitudes toward obese persons. Implications for both theory and practice are discussed.