Is obesity becoming the new normal? Age, gender and racial/ethnic differences in parental misperception of obesity as being 'About the Right Weight'.

INTRODUCTION: Younger children, non-Hispanic Black and male children who are overweight (body mass index (BMI) ⩾85th percentile) are at greater risk for being misperceived by their parents as having a healthy or normal weight, but less is known about the risk for weight misperception in the subpopulation of children with obesity (BMI⩾95th percentile). We assessed the gender, age and racial/ethnic differences in parental misperception of healthy or normal weight status in children with obesity. METHODS: We analyzed the data of 1445 children and adolescents aged 6-15 years with obesity obtained from the National Health and Nutrition Examination Surveys conducted from 2005 to 2012. Parental perception of the child's weight was obtained during an in-home interview. Anthropometric data on body weight were collected from the children during their physical and used to calculate gender and age-specific BMI percentiles. Logistic regression was used to calculate the adjusted odds ratios for parental misperception of their child's obesity as being 'about the right weight', using parents who perceived their children with obesity as being 'overweight' for reference. RESULTS: Boys aged 6-15 years with obesity were more likely to be misperceived as being 'about the right weight' by their parents (adjusted odds ratio (aOR): 1.40 (1.12-1.76) vs girls, P=0.0038). The subpopulations of children with obesity who were significantly less likely to be misperceived included girls aged 11-15 years (aOR: 0.46 (0.29-0.74) vs girls 6-10 years, P=0.0016) and Hispanic males (aOR: 0.58 (0.36-0.93) vs White males, P=0.02). CONCLUSIONS: Significant age differences in the odds for parental misclassification of obesity as 'about the right weight' were detected in female children, but not males. Hispanic males with obesity were significantly less likely to be misperceived as being 'about the right weight' when compared with their non-Hispanic White peers.

Annuloplasty and aortoplasty as modifications of the Ross procedure for the correction of geometric mismatch.

BACKGROUND AND AIM OF THE STUDY: Pulmonary autograft replacement of the aortic valve (the Ross procedure) is reliable and durable; however, geometric mismatch of the autograft and systemic outflow tract may lead to poor results. Manipulation of the aortic annulus and sinotubular diameters to match the autograft can prevent geometric mismatch, and improve results. METHODS: Annuloplasty and/or aortoplasty were combined with the Ross procedure in 26 of 44 patients (median age 42.5 years; range: 3 days to 62 years) undergoing surgery between April 1994 and July 1998. Plication of the aortic annulus at either two or three of the commissures was done in five cases, aortic annulus fixation with an external pericardial pledget incorporated in the proximal suture line in 12 cases, and tailoring aortoplasty in nine patients. RESULTS: There was one operative death. Two patients required reoperation; one for progressive autograft dysfunction and one for homograft dysfunction. Annular fixation was performed on the patient requiring reoperation for autograft dysfunction. Doppler echocardiography during the follow up (median 9 months; range: 1-50 months) revealed 10 patients with trace 1+ and one patient with 2+ aortic insufficiency. Trace 1+ and 2+ aortic stenosis were present in one patient each. None of the patients undergoing commissural plication had significant regurgitation or stenosis. Both patients with stenosis underwent annular fixation. Aortoplasty was associated with 1+ insufficiency in two patients. CONCLUSION: Prevention of geometric mismatch between the autograft and systemic outflow tract at the annulus and sinotubular junction by plication techniques allows better performance of the autograft, and extends the Ross procedure to patients who otherwise may be unable to undergo such surgery. Fixation may provide similar benefit, but appears to be more susceptible to insufficiency and stenosis.

Purposeful delay in the repair of a traumatic rupture of the aorta with coexistent liver injury.

Purposeful delay in the repair of traumatic aortic injury by appropriate medical management is indicated when the risk of immediate thoracotomy is high. A grade V liver injury implies parenchymal disruption of greater than 75% of a hepatic lobe. We report the successful management of a patient with a class IB proximal descending aortic transection and concomitant grade V liver injury that precluded aortic repair until its resolution.

Efficacy and cost-effectiveness of preoperative IABP in patients with ejection fraction of 0.25 or less.

BACKGROUND: The purposes of this study are to determine whether patients with severe left ventricular dysfunction benefit from prophylactic insertion of an intraaortic balloon pump and to evaluate its cost-effectiveness. METHODS: Between January 1991 and December 1995, 163 consecutive patients with a left ventricular ejection fraction of 0.25 or less underwent isolated coronary artery bypass grafting. An intraaortic balloon pump was inserted before operation in 37 patients (group A). The remaining 126 patients underwent operation without preoperative insertion of the device (group B). Preoperatively, 91.9% (34/37) of group A patients and 54.8% (69/126) of group B patients were in New York Heart Association functional class III or IV (p < 0.001). RESULTS: The 30-day mortality rate was 2.7% (1/37) and 11.9% (15/126) for groups A and B, respectively (p < 0.005). All deaths occurred in patients in functional class III or IV. In group B, 28 patients (22.2%) required an intraaortic balloon pump after cardiotomy for low cardiac output, 42.9% (12/28) of whom died. Median postoperative hospital stay was 9.9 days and 12.0 days, and mean hospital charges were $50,627 and $54,818 for survivors in groups A and B; respectively (p = not significant). CONCLUSIONS: Our experience suggests that patients with severe left ventricular dysfunction undergoing coronary artery bypass grafting may benefit from preoperative intraaortic balloon pump insertion, especially patients in functional class III or IV. This approach improved survival significantly, reduced hospital stay, and was more cost-effective.

Which is the graft of choice for the right coronary and posterior descending arteries? Comparison of the right internal mammary artery and the right gastroepiploic artery.

BACKGROUND: The graft of choice for the left anterior descending coronary artery is the left internal mammary artery because of superior long-term patency. However, controversy exists regarding the graft of choice for the right coronary artery and for the posterior descending branch. METHODS AND RESULTS: Two types of pedicled arterial grafts were used for the right coronary and the posterior descending arteries in patients undergoing coronary bypass surgery between January 1991 and September 1994. Group A comprised 114 patients with a right internal mammary artery (RIMA) graft, and group B consisted of 127 patients with an in situ right gastroepiploic artery (R-GEA) graft. Mean age was 56.9 years in group A and 63.3 years in group B; 7.9% (9 of 114) and 33.9% (43 of 127) were diabetics in groups A and B, respectively. Overall mortality was 2.6% (3 deaths) for group A and 3.9% (5 deaths) for group B (P = NS). However, the prevalence of perioperative myocardial infarction in the right coronary artery distribution was significantly higher for group A (5.3%, or 6 of 114) than for group B (0.8%, or 1 of 127; P < .05), and the reoperation rate for graft failure (from 0 to 12 months after surgery) was significantly higher for the RIMA (4.4%, or 5 of 114) than for the R-GEA (0%; P < .05). Also, the prevalence of deep sternal wound infection in diabetics was significantly higher in group A (22.2%, or 2 of 9) than in group B (4.6%, or 2 of 43; P < .05). CONCLUSIONS: Our preliminary results suggest that the failure rate of the RIMA graft is significantly higher, especially if used as a pedicled graft to the posterior descending artery. The risk of sternal wound complications is greater in diabetics if both internal mammary arteries are used for grafting. Therefore, the R-GEA graft is preferred in diabetics and whenever the posterior descending artery is the target vessel.

Tumor cell lines established in vitro: an independent prognostic factor for survival in non-small-cell lung cancer.

OBJECTIVE: To determine the relation between in-vitro establishment of tumor cell lines and survival in patients with non-small-cell lung cancer. DESIGN: Cohort study. SETTING: Single-institution tertiary care center. PATIENTS: One hundred twenty-three consecutive patients with non-small-cell lung cancer from whom a viable tumor specimen could be obtained. INTERVENTION: Tumor tissue was removed at the time of entry into a therapeutic protocol. The tumor tissue was processed in the laboratory for attempted cell-line establishment. Patients classified as potentially curable (stages I, II, and IIIA) were treated with surgical resection, radiation therapy, or a combination. Patients suitable for palliative therapy only (stages IIIB and IV) were treated with radiation therapy with or without chemotherapy. Chemotherapy was based on in-vitro drug sensitivity when available. Cell-line establishment was correlated to clinical outcome. MEASUREMENTS AND MAIN RESULTS: Univariate analysis of survival was done using the log-rank test; multivariate analysis was done by Cox modeling step-up and step-down techniques. Cell lines were established from the tumor specimens of 25 patients (20%). Those patients experienced a median survival of 7 months compared with 18 months in patients from whom cell lines could not be established (P less than 0.001). In the 61 patients with potentially curable disease, 8 patients (13%) with cell lines established had a median survival of 8 months compared with 32 months for those without cell lines established (P = 0.001). In the 62 palliative group patients, the median survival of the 17 patients (27%) from whom tumor cell lines were established was 5 months compared with 7 months for those without cell lines (P = 0.15). Multivariate analysis in both groups showed cell-line establishment to be a significant indicator of prognosis (P less than 0.0001 for curable group; P less than 0.01 for palliative group). CONCLUSION: In-vitro tumor growth is related to decreased patient survival, which in turn reflects the biologic aggressiveness of cancers giving rise to these tumor cell lines.

Reoperation for coronary atherosclerosis. Changing practice in 2509 consecutive patients.

We analyzed trends in clinical, angiographic, and operative variables and documented long-term survival in 2509 consecutive patients who underwent reoperation for myocardial revascularization at The Cleveland Clinic during a 20-year period (1967 to 1987). The patients were grouped into four cohorts by year of surgery. This analysis showed that vein graft atherosclerosis has become the leading indication for reoperation, and patient age and interval between operations continue to increase. Mortality rates ranged from 2% to 5% and, despite increasing comorbidity, more extensive coronary atherosclerosis, and worse left ventricular function, the hospital mortality rate was 2.9% from 1985 to 1987. Perioperative new Q-wave myocardial infarction occurred in 7% to 8% of patients from 1967 to 1984 but decreased to 4% in the 1985 to 1987 period (p = 0.04). Internal thoracic artery graft usage in reoperations increased from 27% in the 1967 to 1978 period to 67% in the 1985 to 1987 period. Advanced age and presence of left main coronary artery disease adversely influenced late survival more consistently than other factors. Patients operated on in 1967 to 1978 had fewer risk factors, which explains their higher survival rate compared with more recent cohorts. Factors associated with improved 10-year actuarial survival included age younger than 65 years, mild angina, no major comorbidity, no left main coronary artery disease, good left ventricular performance, and an internal thoracic artery graft.

Myasthenia gravis-associated antibodies in asymptomatic thymoma.

Serum antibodies associated with myasthenia gravis were evaluated before and after therapy in an asymptomatic patient having a malignant thymoma. The case illustrates that myasthenia-associated antibodies may also be useful as a tumor marker of thymoma in the work-up of mediastinal masses, in evaluating therapy of thymoma, and possibly in detecting recurrence of thymoma and potential for developing myasthenia gravis.

Noncardiac clinical applications of seven-pinhole tomography.

Clinical examples of various noncardiac seven-pinhole tomographic scans are shown. In many cases, this method of emission tomography can provide a very useful extension of standard planar nuclear medicine images. Major advantages of seven-pinhole tomography include reasonable cost and improved lesion detectability due to increased image contrast. Disadvantages include rather difficult patient positioning, nonuniform plane spacing with depth, and sometimes rather long data processing times because the presently available computer algorithms are maximized for cardiac scans.