Pre-surgical, surgical and post-surgical experiences of weight loss surgery patients: a closer look at social determinants of health.

Using a novel qualitative approach, Photovoice, researchers assessed social, psychological, physical and economic barriers encountered by patients of weight loss surgery. Applying the Photovoice approach and Williams' theory of narrative reconstruction for qualitative interviewing, the research team set out to investigate the bariatric patient experience from pre-surgery to hospitalization to post-surgery. Fifteen participants were given digital cameras and asked to take photographs that represented their weight loss journeys. Photographs and qualitative interviews were used to theorize the role played by comorbidities, social determinants of health, provider communication experiences and understanding of insurance coverage in patient outcomes. Several themes emerged from the interviews and photographs including themes centred around: (i) racial/ethnic standards of beauty; (ii) gender expectations; (iii) comorbidities, depression/disordered eating and obesity discrimination and (iv) financial hardship impacting adherence. Photographs also illuminated the impact of hospital and state-wide policies on patient lives. Results suggest that Photovoice may be a useful adjunct to standard-of-care to help patients identify barriers, and to identify shortcomings in health services. Additional screening tools for gender- and income-related barriers (and concomitant referrals to support services) provide an opportunity to improve patient care and reduce post-operative readmissions.

Photo- and radiation-chemistry of halide anions in ionic liquids.

One- and two- photon excitation of halide anions (X(-)) in polar molecular solvents results in electron detachment from the dissociative charge-transfer-to-solvent state; this reaction yields a solvated halide atom and a solvated electron. How do such photoreactions proceed in ionic liquid (IL) solvents? Matrix isolation electron paramagnetic resonance (EPR) spectroscopy has been used to answer this question for photoreactions of bromide in aliphatic (1-butyl-1-methylpyrrolidinium) and aromatic (1-alkyl-3-methyl-imidazolium) ionic liquids. In both classes of ILs, the photoreaction (both 1- and 2-photon) yields bromine atoms that promptly abstract hydrogen from the alkyl chains of the IL cation; only in concentrated bromide solutions (containing >5-10 mol % bromide) does Br2(-•) formation compete with this reaction. In two-photon excitation, the 2-imidazolyl radical generated via the charge transfer promptly eliminates the alkyl arm. These photolytic reactions can be contrasted with radiolysis of the same ILs, in which large yield of BrA(-•) radicals was observed (where A(-) is a matrix anion), suggesting that solvated Br(•) atoms do not occur in the ILs, as such a species would form three-electron σ(2)σ(*1) bonds with anions present in the IL. It is suggested that chlorine and bromine atoms abstract hydrogen faster than they form such radicals, even at cryogenic temperatures, whereas iodine mainly forms such bound radicals. These XA(-•) radicals convert to X2(•-) radicals in a reaction with the parent halide anion. Ramifications of these observations for photodegradation of ionic liquids are discussed.

Endogenous retrovirus expression in testis and epididymis.

ERVs (endogenous retroviruses), which comprise 8-10% of mouse and human genomes, are present in thousands of copies, ranging in size from complete 9 kb virus to truncated partial sequences. Despite well-documented differential expression of ERVs in normal and diseased tissues, their biological significance remains controversial. Work in this laboratory revealed remarkably high ERV expression in mouse epididymis, but not in testis. Similar early studies revealed expression of human ERV-E4.1 in both testis and epididymis, but expression of other HERVs (human ERVs) was not examined. Using degenerate primers to conserved regions of reverse transcriptase specific for each of nine HERV families, we have detected expression of six HERV families in epididymis and three in testis. Differential HERV expression may reflect the fully differentiated state of epididymal epithelium in contrast with the immature germ cell population in the testis. These two tissues may therefore lay the groundwork not only for understanding the influence of cellular differentiation on HERV expression, but also to reveal HERVs that are routinely exposed to sperm.

Treatment of substance abuse during pregnancy and infant outcome.

The objective of this study is to analyze the effects of residential substance abuse treatment on pregnancy outcome among gravidas in a gender-specific program. All clients (cases) who entered a residential substance abuse program for pregnant and postpartum women were eligible for inclusion in the study (n=95). Only those who were in treatment at the time of delivery were included in the present analysis (n=57). Two comparison groups were used: (1) substance abusers who received no treatment during pregnancy (positive control group) and (2) pregnant women who were not substance abusers (negative control group). Cases were matched to controls on ethnicity (negative and positive controls) and drug of choice (positive controls only). Medical records were reviewed and abstracted for cases and controls. The primary drug of choice was cocaine for 56% of clients in the study, heroin 15.8%, and alcohol 10.8%. Average length of time in treatment before delivery was 11.7 weeks. The frequency of pregnancy complications allowing treatment and position controls was significantly higher than the negative control group (p<0.0001). The frequency of perinatal infant complications was increased among treatment group infants (p<0.0001). Two infants in the treatment group were positive for a substance of abuse at birth. In the treatment versus positive control group, mean birth weight (BW) was 3227 versus 2800 g (p<0.01), estimated gestational age (EGA) was 38.9 versus 39 weeks, average head circumference (FOC) was 33.8 versus 32.5 cm (p<0.05), and mean birth length (BLT) was 48.7 cm versus 46.9 (p<0.05). No significant differences were found between treatment and negative control groups. Maternal syphilis was increased in frequency in the positive control group compared with the negative control group (p<0.07). Thirty-percent of mothers had sexually transmitted diseases (STDs) for which infants were at risk and treated prophylactically; no infant in the treatment group contracted a vertically transmitted STD. For every 10 weeks in treatment, BW was increased 340 g, EGA 1 week, FOC 0.8 cm, and BLT 1.8 cm. Thus, substance abuse treatment for pregnant women in the program increased fetal growth, which significantly decreased the risk for poor neonatal outcomes. Importantly, maternal and infant perinatal complications in the treatment group were increased in frequency compared with the two control groups. This may possibly have occurred because healthcare providers were not blinded to maternal treatment status.

Reduced DNA-dependent protein kinase activity is associated with lung cancer.

Reduced DNA repair capacity of carcinogen-induced DNA damage is now thought to significantly influence inherent susceptibility to lung cancer. DNA-dependent protein kinase (DNA-PK) is a serine-threonine kinase activated by the presence of double-strand breaks in DNA that appears to play a major role in non-homologous recombination and transcriptional control. The purpose of this study was to determine whether DNA-PK activity varies among individuals and how this affects lung cancer risk. DNA-PK activity in peripheral mononuclear cells from individuals with lung cancer (n = 41) was compared with lung cancer-free controls (n = 41). Interindividual variability was seen within each group, however, significant differences (P = 0.03) in DNA-PK activity between cases and controls were seen when comparing the distribution of enzyme activity among these two groups. The percentages of cases and controls with DNA-PK activity in the ranges 2.5-5.0 and 7.6-10.0 units were 39 versus 20% and 7 versus 29%, respectively. The enzyme activity in peripheral mononuclear cells reflected that seen in bronchial epithelial cells, one progenitor cell for lung cancer, supporting the use of peripheral mononuclear cells for larger population-based studies of DNA-PK activity. Its role as a potential modifier for lung cancer risk was supported by the fact that cell growth in bronchial epithelial cells exposed to bleomycin was directly associated with enzyme activity. The results of this study demonstrate that reduced DNA-PK repair activity is associated with risk for lung cancer.

The XRCC1 399 glutamine allele is a risk factor for adenocarcinoma of the lung.

Defects in the repair and maintenance of DNA increase risk for cancer. X-ray cross-complementing group 1 protein (XRCC1) is involved with the repair of DNA single-strand breaks. A nucleotide substitution of guanine to adenine leading to a non-conservative amino acid change was identified in the XRCC1 gene at codon 399 (Arg/Gln). This change is associated with higher levels of aflatoxin B1-adducts and glycophorin A somatic mutations. A case-control study was conducted to test the hypothesis that the 399Gln allele is positively associated with risk for adenocarcinoma of the lung. XRCC1 genotypes were assessed at codon 399 in 172 cases of lung adenocarcinoma and 143 cancer-free controls. Two ethnic populations were represented, non-Hispanic White and Hispanic. The distribution of XRCC1 genotypes differed between cases and controls. Among cases, 47.7% were Arg/Arg, 35.5% were Arg/Gln, and 16.9% were Gln/Gln. Among controls, XRCC1 allele frequencies were 45.5% for Arg/Arg, 44.8% for Arg/Gln, and 9.8% for Gln/Gln. Logistic regression analysis was used to assess the association between lung adenocarcinoma and the G/G genotype relative to the A/A or A/G genotypes. In non-Hispanic White participants, the lung cancer risk associated with the G/G genotype increased significantly after adjustment for age (OR=2.81; 95% CI, 1.2-7.9; P=0.03) and increased further after adjustment for smoking (OR=3.25; 95% CI, 1.2-10.7; P=0.03). Among all groups, a significant association was found between the G/G homozygote and lung cancer (OR=2.45; 95% CI, 1.1-5.8; P=0.03) after adjustment for age, ethnicity, and smoking. This study links a functional polymorphism in the critical repair gene XRCC1 to risk for adenocarcinoma of the lung.

Laparoscopic ventriculoperitoneal shunt placement: a single-trocar technique.

Ventriculoperitoneal shunt (VPS) placement is an important therapeutic technique. Placement of the abdominal portion of VPS can be difficult in the setting of previous abdominal surgery, prior failure of VPS, or obesity. Even under ideal circumstances, standard mini-laparotomy does not allow precision in VPS positioning. We describe a single-port technique for VPS placement. While the neurosurgeon places a right frontal ventricular catheter and valve, an infraumbilical trocar is placed utilizing the open Hasson technique. A 12-mm operating laparoscope with an 8-mm channel is used to inspect the abdomen and identify the VPS entry site. Adhesions interfering with shunt placement can be lysed through the working channel of the laparoscope. Under laparoscopic visualization, an 18-gauge needle is introduced through a 5-mm incision in the right upper quadrant and the VPS tubing is tunneled to that site. A J-tipped guidewire is introduced, and the needle is exchanged for a dilator and peel-away sheath. The VPS is delivered through the sheath, which is sectioned and removed. An atraumatic grasper, placed through the laparoscope, directs the VPS to the desired intraabdominal location. Function of the VPS is assessed visually while compressing the valve. Suture closure of the trocar site and VPS entry site completes the procedure. We used this method successfully in a series of five patients with excellent outcome. A 14-month follow-up has revealed no failures or postoperative complications. This method is less invasive than mini-laparotomy, allows for precision placement of the abdominal portion of VPS, and confirms appropriate function.

Primary mediastinal malignancies in children: report of 22 patients and comparison to 197 adults.

PURPOSE: Examine a contemporary series of patients with primary pediatric malignant mediastinal tumors and determine epidemiology, histology, treatment, and survival. Patients and Methods. All malignancies diagnosed between January 1, 1973 and December 31, 1995 were analyzed. RESULTS: Twenty-two patients, age 18 years or less, with pediatric primary mediastinal malignancies were identified from a database of 110,284 patients with primary malignancies. During the same period, 197 adult patients with primary mediastinal malignancies were identified. Fifty-nine percent of the pediatric patients were male. Median age was 11 years. Lymphoma was present in 55%, neurogenic malignancies in 23%, malignant germ cell tumors in 18%, and sarcoma in 5%. Neurogenic tumors presented in infants and lymphomas and germ cell tumors presented in teens (p = 0.005). In treated children, surgery was used more often in neurogenic tumors and germ cell tumors than in lymphomas (p = 0.002). Five-year survival was 74% for lymphomas, 67% for neurogenic tumors, 25% for germ cell tumors, and 61% overall (p = 0.23). Compared to adults, children had more neurogenic tumors (p < 0.001) and fewer thymomas (p = 0.0499). There were no significant differences in staging or survival between children and adults. CONCLUSIONS: Pediatric mediastinal malignancies occurred with a frequency of 1/5,013 patients with malignant tumors. Lymphoma, neurogenic tumors, and germ cell tumors predominated. Compared to adults, children had more neurogenic tumors and fewer thymomas. Within the pediatric group, differences were found in age of presentation between histologic groups. These differences between adults and children, and between infants and teens, should be considered when evaluating a patient suspected of having mediastinal malignancy.

The lingula is an appropriate site for lung biopsy.

BACKGROUND: Lung biopsy is commonly performed for diagnosis of diffuse pulmonary disease. The lingula offers technical advantages for biopsy, however the quality of tissue obtained by lingula biopsy has been questioned. We sought to determine whether lingula biopsy was a satisfactory site for biopsy in terms of diagnostic yield, therapeutic interventions, and survival results. METHODS: All diagnostic lung biopsies performed for diffuse lung disease at 3 university affiliated hospitals between July 1, 1992 and December 31, 1998 were retrospectively reviewed. Patients were divided into 2 groups, depending upon site of biopsy: patients with lingula biopsy only and those with biopsies from other sites. RESULTS: There were 75 patients; 20 underwent biopsy of the lingula alone, 48 had biopsy of other sites with or without biopsy of the lingula, and location of biopsy was unknown in 7 patients. Histologic diagnosis was achieved in all patients. Significant beneficial therapeutic changes were made in 14 lingula patients, and consisted of immunosuppression in 12 cases. Three patients died in the hospital or within 30 days. Fourteen patients survived 1 year. There was no significant difference between patients that had biopsy of the lingula alone and those that had biopsies from other sites in urgency, technique, histologic diagnosis, rate of therapeutic interventions, hospital mortality, or 1 year survival. CONCLUSIONS: Lung biopsy of the lingula compared to other anatomic sites has equivalent diagnostic yield, therapeutic significance, and survival. Given the technical ease of biopsy, when disease is present radiographically it is the preferred site for lung biopsy.

Lung biopsy: is it necessary?

OBJECTIVE: Lung biopsy is associated with substantial mortality rates. We reviewed our experience with this operation, primarily in patients with immunocompetence, to determine whether the results justify the continued performance of this procedure. METHODS: We conducted a retrospective review of all diagnostic lung biopsies performed at 3 university-affiliated hospitals between July 1, 1992, and December 31, 1998. RESULTS: There were 75 patients: 25 patients were treated electively, 17 were treated on an urgent basis, 27 patients on an emergency basis, and the urgency was unclear in 6 patients. Significant beneficial therapeutic changes were made in 15 of 25 elective procedures (60%), in 16 of 17 urgent procedures (94%), and in 11 of 27 emergency procedures (41%; P =.001). Significant beneficial therapeutic changes consisted of immunosuppression in 13 of 15 (87%) patients treated on an elective basis, in 9 of 16 (56%) treated on an urgent basis, and in 9 of 11 (82%) treated on an emergency basis in whom therapy was altered (P =.14). Operative death was 0 of 25 for elective operations (0%), 3 of 17 for urgent operations (18%), and 14 of 26 for emergency operations (54%). Multivariable analysis of operative death showed urgency to be the only significant predictor of death (P =.002). CONCLUSIONS: In patients with immunocompetence, elective and urgent lung biopsies have acceptable operative mortality rates and frequently result in important beneficial therapeutic changes. Consequently biopsies are appropriate in these patients. Emergency biopsies are associated with high operative mortality rates and rarely result in a therapeutic change other than immunosuppression. These patients should not undergo lung biopsy if they are in stable condition and should be treated empirically with immunosuppression without operation if their condition is deteriorating.

The quantification of low back disorder using motion measures. Methodology and validation.

STUDY DESIGN: Trunk angular motion features were used as a means to quantify the extent of a low back disorder in healthy people and patients with chronic low back disorders. OBJECTIVE: To refine and validate a previously reported means of quantifying the extent of a low back disorder. SUMMARY AND BACKGROUND: Many assessment tools of low back disorder are subjective. A quantitative assessment tool would facilitate the tracking of the recovery and help document the appropriateness of treatments. METHODS: The trunk motion characteristics of 374 healthy people and 335 patients with chronic low back disorders of varying severity were documented as they flexed and extended their trunks in five different planes of motion. The trunk motion features were normalized as a function of age and gender. Four classification techniques were used to assess the ability of the quantitative motion measure to identify those with and without low back disorders. In addition, 31 patients were observed longitudinally to determine whether the motion measures agreed with observed changes in back pain symptoms. RESULTS: The quantitative trunk motion measure distinguished between people with low back disorders and healthy people between 88% and 94% of the time, depending on which classification system was used. Sensitivity and specificity varied between 83% and 97%. The quantitative measure also showed promise as a means to distinguish between muscle-based and structure-based low back disorders. Prospective findings indicated that the quantification system agreed well with clinical observations of progress. CONCLUSIONS: The quantification of trunk motion can serve as a measure of the extent of a low back disorder. When considered along with other clinical information, the ability to assess and treat low back disorders is enhanced.

Esophageal rupture after regional anesthesia: report of two cases.

Esophageal perforation after anesthesia is rare. It is usually secondary to esophageal instrumentation. Only one case of barogenic rupture after regional anesthesia has been reported. We report two additional cases and present possible mechanisms for this unusual entity. Neither patient had anatomic abnormalities by history or preoperative endoscopy. However, both patients and the previously reported patient had esophageal dysmotility resulting from advanced age, alcoholism, intraoperative medications, and preexisting disease. Each patient experienced at least one episode of emesis with subsequent perforation of the distal one third of the esophagus. The previously reported patient died; both of our patients underwent successful surgical repair and are alive 2 years later. Intraoperative or postoperative emesis in patients with esophageal dysmotility appears to be the principal factor causing esophageal rupture after regional anesthesia. Prevention of nausea and vomiting and recognition of this high-risk population may minimize this complication in the future.

Primary mediastinal malignancies: findings in 219 patients.

The purpose of this study was to determine the demographics, histology, methods of treatment, and survival in primary mediastinal malignancies. We did a retrospective review of the statewide New Mexico Tumor Registry for all malignant tumors treated between January 1, 1973 and December 31, 1995. Benign tumors and cysts of the mediastinum were excluded. Two hundred nineteen patients were identified from a total of 110,284 patients with primary malignancies: 55% of tumors were lymphomas, 16% malignant germ cell tumors, 14% malignant thymomas, 5% sarcomas, 3% malignant neurogenic tumors, and 7% other tumors. There were significant differences in gender between histologies (P < 0.001). Ninety-four percent of germ cell tumors occurred in males, 66% of neurogenic tumors were in females; other tumors occurred in males in 58% of cases. There were also significant differences in ages by histology (P < 0.001). Neurogenic tumors were most common in the first decade, lymphomas and germ cell tumors in the second to fourth decades, and lymphomas and thymomas in patients in their fifth decades and beyond. Stage at presentation (P = 0.001) and treatment (P < 0.001) also differed significantly between histologic groups. Five-year survival was 54% for lymphomas, 51% for malignant germ cell tumors, 49% for malignant thymomas, 33% for sarcomas, 56% for neurogenic tumors, and 51% overall. These survival rates were not statistically different (P > 0.50). Lymphomas, malignant germ cell tumors, and thymomas were the most frequently encountered malignant primary mediastinal neoplasms in this contemporary series of patients. Demographics, stage at presentation, and treatment modality varied significantly by histology. Despite these differences, overall five-year survival was not statistically different.

Frequency of trisomy 20 in nonmalignant bronchial epithelium from lung cancer patients and cancer-free former uranium miners and smokers.

Lung cancer is the leading cause of cancer-related deaths. The development of sensitive screening methods to identify at-risk individuals before emergence of clinical disease would permit early intervention that could decrease this mortality. Our previous studies have shown that cells with trisomy 7 can be detected in bronchial epithelium from cancer-free smokers and former uranium miners. However, the use of more than one molecular marker could increase the chance of identifying at-risk individuals. Trisomy 20, which is found in 43-57% of non-small cell lung cancers, is a candidate marker. The purpose of the current investigation was to determine the percentage of cells with trisomy 20 in persons with a high risk for lung cancer. Bronchial epithelial cells that had been assayed for trisomy 7 were assayed for trisomy 20 by fluorescence in situ hybridization. Trisomy 20 was detected in bronchial epithelial cells from lung cancer patients and from smokers and ex-uranium miners without lung cancer. In some cases, patients who were negative for trisomy 7 exhibited trisomy 20. Consequently, more people with field cancerization were identified using both markers. However, the two markers combined did not appear to stratify the risk for lung cancer.

Mediastinitis without antecedent surgery.

The study evaluates the results of aggressive surgical treatment for mediastinitis without antecedent surgery, after retrospectively reviewing all patients with mediastinitis, excluding patients with prior cardiac, esophageal or mediastinal operations, treated between June 1, 1992 and August 1, 1996. 8 patients were treated. 7 were male, mean age was 58 years. The etiology was Boerhaave's syndrome in 4, iatrogenic injury in 2 and descending necrotizing mediastinitis in 2 patients. The mean number of operations was 2.5. The initial operation was through thoracotomy in 5 patients and sternotomy in 2 patients. 4 patients underwent neck drainage, 1 as primary treatment and 3 combined with transthoracic drainage. 1 patient received laparotomy. Mean hospitalization was 52 days (excluding 1 death). Complications included mechanical ventilation greater than 48 hours in 7 patients, 2 or more operations in 5 patients, multisystem organ failure in 5 patients and other complications in 6 patients. Death occurred in one patients. Mediastinitis without antecedent surgery is associated with significant morbidity, however, with aggressive surgical drainage 87% of patients survived.

Risks of surgical management for cavernous malformations of the nervous system.

OBJECTIVE: As more information evolves regarding the natural history of cavernous malformations (CMs), the risks of operative intervention must be balanced against nonoperative management. In an attempt to better delineate the surgical risks for operable CMs, we undertook a retrospective analysis of 94 patients with 97 CMs surgically excised at the Massachusetts General Hospital. METHODS: Data regarding surgical complications and outcome measures, including neurological status and seizure outcome, were analyzed. RESULTS: The incidence of transient neurological morbidity was 20.6%, but only 4 of the 97 operations (4.1%) resulted in persistent disabling neurological complications and 2 (2.1 %) in nondisabling deficits. There was no operative mortality. Brain stem lesions (n=14) were associated with the highest incidence of neurological complications, both transient and persistent (odds ratio, 4.8; 95% confidence interval, 1.5-15.7). The overall neurological outcome was excellent or good in 89.7% of all lesions: 96.8% of lobar CMs (n=63), 64.2% of brain stem CMs (n=14), 87.5% of cerebellar CMs (n=8), 100% of cranial nerve CMs (n=4), and 75% of spinal cord CMs (n=8). Patients with brain stem and spinal cord CMs were in poorer preoperative neurological condition than were patients with CMs in other locations and therefore had a significantly reduced level of function after surgery (P < 0.01). There was improvement in 35.7% of the patients with brain stem lesions and 62.5% of the patients with spinal cord lesions after surgery. In the 38 patients presenting with seizures, 97% were seizure-free after surgery. CONCLUSION: The risks of operative management of CMs varies based on location. When evaluating patients with operable CMs for surgery, the incidence of complications as well as final neurological outcome should be carefully weighed against the existing knowledge of the natural history of lesions managed expectantly.

Individuals at high risk for lung cancer have airway epithelial cells with chromosome aberrations frequently found in lung tumor cells.

Identification of individuals at greatest risk of developing lung cancer could enhance the efficacy of intervention modalities, thereby greatly reducing mortality from this disease. One strategy for identifying these people is to establish molecular markers which reflect the severity of their cancerization field. Thus, investigations were initiated to determine of cells with chromosome aberrations frequently exhibited by lung tumor cells, i.e., trisomy 7, trisomy 20, and deletion of 9p23, are prevalent within the uninvolved airways of cancer patients. As a result, cells containing these aberrations were consistently found at significantly elevated levels by using fluorescence in situ hybridization (FISH). In contrast, cells collected from non-smokers who had never smoked were normal by this assay. The next objective was to determine of cells exhibiting these alterations are also present in upper airways of exposed, but cancer-free smokers and ex-uranium miners. The results showed that, although only a subset of these people will develop lung cancer in their lifetimes, they universally harbor increased numbers of abnormal cells within their airway epithelium. However, the number of sites with multiple verities of abnormal cells tended to be fewer compared with the cancer patients. Thus, quantifying cells with molecular alterations within the cancerization field of a smoker may delineate those with a lesser grade of damage, and these individuals may be at a lesser risk of developing disease. However, differences in the extent of genetic damage afforded by these assays may not clearly define individuals with pending disease, and additional molecular assays must be devised.

The murine CAR homolog is a receptor for coxsackie B viruses and adenoviruses.

Complementary DNA clones encoding the murine homolog (mCAR) of the human coxsackievirus and adenovirus receptor (CAR) were isolated. Nonpermissive CHO cells transfected with mCAR cDNA became susceptible to infection by coxsackieviruses B3 and B4 and showed increased susceptibility to adenovirus-mediated gene transfer. These results indicate that the same receptor is responsible for virus interactions with both murine and human cells. Analysis of receptor expression in human and murine tissues should be useful in defining factors governing virus tropism in vivo.