bluuebunny/crossref_metadata_2025 huggingface dataset:
Regulation of mechanical interactions between fibroblasts and the substratum by stretch-activated Ca2+ entry
Authors: Munevar Steven , Wang Yu-li , Dembo Micah
Published: November 2003

Ca2+ ions have long been implicated in regulating various aspects of cell movements. We found that stretching forces applied through flexible substrata induced increases in both intracellular Ca2+ concentration and traction forces of NIH3T3 fibroblasts. Conversely, application of gadolinium, an inhibitor of stretch-activated ion channels, or removal of extracellular free Ca2+ caused inhibition of traction forces. Gadolinium treatment also inhibited cell migration without affecting the spread morphology or protrusive activities. Local application of gadolinium to the trailing region had no detectable effect on the overall traction forces, while local application to the leading edge caused a global inhibition of traction forces and cell migration, suggesting that stretch-activated channels function primarily at the leading edge. Immunofluorescence microscopy indicated that gadolinium caused a pronounced decrease in vinculin and phosphotyrosine concentrations at focal adhesions. Our observations suggest that stretch-activated Ca2+ entry in the frontal region regulates the organization of focal adhesions and the output of mechanical forces. This mechanism probably plays an important role in sustaining cell migration and in mediating active and passive responses to mechanical signals.
Targeting of PKCα and ϵ in the pituitary: a highly regulated mechanism involving a GD(E)E motif of the V3 region
Authors: Quittau-Prévostel Corinne , Delaunay Nathalie , Collazos Alejandra , Vallentin Alice , Joubert Dominique
Published: November 2003

Protein kinase C (PKC) has been implicated in the control of intercellular adhesion. Our previous observation demonstrating that activated PKC alpha (PKCα is selectively targeted to cell-cell contacts of pituitary GH3B6 cells supports these findings. The relevance of this observation is further strengthened by the present data establishing that this targeting selectivity also occurs in the pituitary gland. Moreover, a new mechanism involved in the control of PKC targeting is unravelled. We demonstrate that a three amino acid motif located in the V3 region of α and epsilon (ϵ (GDE/GEE respectively) is essential for the targeting selectivity of these isoforms because: (1) this motif is absent in delta (δ) and mutated in the natural D294GPKCα mutant, which do not exhibit such selectivity, and (2) a GEE to GGE mutation abolishes the selectivity of targeting to cell-cell contacts for ϵ, as it does for the D294G PKCα mutant. Thus the GD(E)E motif may be part of a consensus sequence able to interact with shuttle and/or anchoring proteins. GFP-tagged deletion mutants also reveal a new function for the pseudosubstrate in the cytoplasmic sequestration. Together, these data underline the complexity of PKC subcellular targeting in the pituitary, determined by the cell-cell contact, at least for α and ϵ
Validation of Four Clinical Indicators of Preventable Drug-Related Morbidity
Authors: Flanagan Priti S , MacKinnon Neil J , Bowles Susan K , Kirkland Susan A
Published: November 2003

BACKGROUND:

Clinical indicators are tools that assess quality issues related to the use of medicines. At this time, validated clinical indicators for preventable drug-related morbidity (PDRM) are lacking.

OBJECTIVE:

To assess the validity and reliability of using population administrative claims data to identify the extent of PDRM in older adults in Canada.

METHODS:

Four indicators of PDRM related to cerebrovascular and cardiovascular care were chosen for validation. A random sample of cases that represented the indicators and fit the criteria (hits) for PDRM from the retrospective operationalization of the study database and those that did not fit the criteria (near hits) were selected for chart review. One-page abstracts of the cases were prepared for review by a panel of 5 clinical pharmacists. Validity was assessed by calculating sensitivity, specificity, and positive and negative predictive value. Reliability was assessed using reviewers' agreement scores (κ statistics).

RESULTS:

Overall, 119 case abstracts were reviewed by each panelist. The sensitivity ranged from 33% to 100% and the specificity from 51% to 71%. Predictive values ranged from 5.3% to 43% (positive) and 90% to 100% (negative). The overall κ statistic was fair (0.21).

CONCLUSIONS:

The validity of the 4 assessed PDRM indicators varied. The reliability was fair; however, these indicators may be useful to screen older adults for PDRM.
Long‐term Surgical Outcome of Noninvasive and Minimally Invasive Intraductal Papillary Mucinous Adenocarcinoma of the Pancreas
Authors: Nakagohri Toshio , Asano Takehide , Kenmochi Takashi , Urashima Tetsuro , Ochiai Takenori
Published: November 2003

The objective of this study was to clarify the long‐term outcome after surgical resection in patients with noninvasive and minimally invasive intraductal papillary mucinous adenocarcinoma. We performed a retrospective review of the clinicopathological features and outcome in patients who underwent pancreatic resection for noninvasive and minimally invasive intraductal papillary mucinous adenocarcinoma between November 1982
and December 1997 at Chiba University Hospital. Minimally invasive structures were pathologically observed in five cases. The mean age of patients with either noninvasive (n = 16) or minimally invasive n = 5) adenocarcinoma was 61 years. Of the patients with minimally invasive adenocarcinoma, 4 had abdominal pain.
Conversely, 7 patients with noninvasive adenocarcinoma had no complaint. The mean size of noninvasive and minimally invasive tumors was 2.5 cm (range 0.8 to
4.0) and 3.3 cm (range 2.5 to 4.5), respectively. The overall 5‐year and
10‐year survival rates for all 21 patients were 89% and 47%, respectively.
Disease recurred in 3 patients; 2 patients with minimally invasive adenocarcinoma and 1 with noninvasive adenocarcinoma. Recurrence sites were peritoneumn = 2) and main pancreatic duct of the remnant pancreas (n = 1); 5 disease‐free patients died of unrelated causes. The remaining 13 patients are alive and disease free
3 to 12 years after surgery. Noninvasive and minimally invasive intraductal papillary mucinous adenocarcinoma had a favorable prognosis after surgical treatment.
Contemporary Outcomes of Ambulatory Laparoscopic Cholecystectomy in a Major Teaching Hospital
Authors: Lau Hung , Brooks David C.
Published: November 2003

mbulatory laparoscopic cholecystectomy is an established practice in our institution, with an experience of more than 800 cases. The present study is conducted to evaluate the contemporary outcomes of day‐case laparoscopic cholecystectomy in the setting of a major teaching hospital. A retrospective analysis of 200 patients who underwent ambulatory laparoscopic cholecystectomies was performed to evaluate the postoperative morbidity, unplanned admission, and readmission rates. Causes for unanticipated admission and readmission were analyzed. Uneventful recovery was attained in 185 (92.5%) patients. The mean length of the operation was 56 ± 20 (SD) minutes. There was no hospital mortality, and no patient required conversion to open cholecystectomy. Nine patients were admitted overnight after operation because of nausea and vomitingn = 3), pain (n = 2), urinary retention (n = 2), medical observation n = 1), and patient’s preference (n= 1), leading to an unanticipated admission rate of 4.5%. Six patients required readmission because of postoperative complicationsn = 4) and abdominal pain (n = 2), giving a readmission rate of 3%. The overall postoperative morbidity rate was 3% (n = 6), including retained stones n = 4), bile leakage (n = 1), and hepatic subcapsular hematoma (n = 1). Ambulatory laparoscopic cholecystectomy is a safe practice in appropriately selected patients. Postoperative nausea and vomiting was the commonest reason for unanticipated admission after operation, and retained stones was the most frequent postoperative morbidity necessitating readmission.
Different Patterns of Recurrence in Gastric Cancer Depending on Lauren’s Histological Type: Longitudinal Study
Authors: Marrelli Daniele , Roviello Franco , de Manzoni Giovanni , Morgagni Paolo , Di Leo Alberto , Saragoni Luca , De Stefano Alfonso , Folli Secondo , Cordiano Claudio , Pinto Enrico
Published: November 2003

The aim of this multicenter longitudinal study was to evaluate the pattern of recurrence in patients submitted to potentially curative surgery for intestinal‐type and diffuse‐type gastric cancer. The study included 412 patients surgically treated at three Italian surgical departments, subdivided into 273 intestinal‐type cases (group A) and 139 diffuse‐type cases (group B). Recurrence of disease was found in 41% of group A cases and 65% of group B cases (p <0.0001). The incidence of locoregional, hematogenous, and peritoneal recurrence was 20%, 19%, and 9% in group A, and 27%, 16%, and 34% in group B, respectively; the difference between the two groups was statistically significant for peritoneal recurrence (p <0.0001). Multivariate analysis identified as prognostic variables lymph node status, depth of invasion, extent of lymphadenectomy, advanced age, and male gender in group A; depth of invasion, extent of lymphadenectomy, tumor size, and lymph node status, in group B. Whereas in group A the incidence of peritoneal recurrence was limited in all subgroups examined, in group B very high rates were observed in cases with infiltration of the serosa, involvement of second‐level lymph nodes, or large tumor size. The notable difference in the risk of peritoneal recurrence between the intestinal and diffuse types should be taken into consideration in the therapeutic approach to gastric cancer.
Management of Complex Perineal Injuries
Authors: Kudsk Kenneth A. , Hanna M. Keith
Published: November 2003

A retrospective study of 25 patients with severe soft tissue injuries to the perineum from the last 14 years was performed to determine the most appropriate management strategy for these problematic wounds. There were 20 (80%) men and 5 (20%) women with an average age of 29 years. Six (24%) patients died of exsanguination from their pelvic injuries within the first few hours of presentation. The remaining 19 patients were taken to the operating room for sigmoidoscopy, diverting colostomy, distal rectal washout, and radical debridement and irrigation of any devitalized tissue. Enteral access by jejunostomy was obtained in six patients. Most patients underwent daily debridement and pulsatile irrigation for at least three days, but usually longer, until the treating surgeon deemed the wound to be clean. None of the patients managed in this fashion developed pelvic sepsis. However, pelvic sepsis did occur in all four patients who did not receive early mandatory daily debridement. Total parenteral nutrition was required in eight patients because there were significant delays in the ability of these patients to resume oral intake. In most previously published series in which daily debridement was not performed, a pelvic sepsis rate of 40% to 80% was reported. Therefore, to optimize the clinical course and recovery from these complex wounds, we conclude that mandatory daily debridement with pulsatile irrigation should be instituted in conjunction with sigmoidoscopy, diversion of the fecal stream, distal rectal irrigation, enteral access, and initial radical debridement of devitalized tissue.
Effect of Short‐term Administration of Prostaglandin E1 on Viability after Ischemia/Reperfusion Injury with Extended Hepatectomy in Cirrhotic Rat Liver
Authors: Hossain Mohammad Akram , Izuishi Kunihiko , Maeta Hajime
Published: November 2003

The cytoprotective effect of prostaglandin E1 (PGE1) has been demonstrated experimentally and clinically against hepatic ischemia and reperfusion injury and against the effects of partial hepatectomy in both individual and combined models of noncirrhotic livers. Cirrhotic livers are more vulnerable to ischemia/reperfusion injury during hepatectomy than are noncirrhotic livers, and postoperative malfunctioning complicates life with multiple organ failure. Cirrhotic livers with tumors have mostly been treated conservatively because extended hepatectomy with induced ischemia during surgery is impossible. The purpose of our study was to document postoperative surgical adaptation in inoperable cases with improved survival after extended hepatectomy in a rat model of cirrhosis treated by PGE1. Cirrhosis was induced by intraperitoneal injections of 1% dimethylnitrosamine. The liver was subjected to 15 minutes of total ischemia by occluding the hepatoduodenal ligament. Hepatectomy was performed during ischemia. Pretreatment with PGE1 (0.4 μg/kg/min) (or without it in the controls) was given for 15 minutes by intravenous infusion prior to inducing ischemia and during reperfusion. Portal venous flow (PVF) and liver tissue blood flow (LTBF) were measured during reperfusion. At the end of 60 minutes of reperfusion, venous blood was collected for liver function tests. The animals were followed up regarding survival for 48 hours. The PVF and LTBF were significantly improved in the PGE1 group. The blood chemical analysis indicated that PGE1 significantly suppressed posthepatectomy liver dysfunction. Most importantly, PGE1 treatment markedly improved the survival rate, from 42% in the controls to 75% in the test animals at 24 hours after hepatectomy and from 17% in the controls to 58% in the test animals at 48 hours. We concluded that short‐term administration of PGE1 makes extensive hepatectomy possible under ischemic conditions in cirrhotic livers.
Positron Emission Tomography for Staging Esophageal Cancer: Does It Lead to a Different Therapeutic Approach?
Authors: Kneist Werner , Schreckenberger Mathias , Bartenstein Peter , Grünwald Frank , Oberholzer Katja , Junginger Theodor
Published: November 2003

Accurate preoperative staging is essential for the indication and selection of the appropriate surgical procedure in patients with esophageal cancer. The present prospective study was designed to determine if the preoperative use of 18F‐fluorodeoxyglucose positron emission tomography (FDG‐PET) increases the accuracy of staging esophageal cancer compared with computed tomography (CT) and if it thereby leads to a different therapeutic approach. A total of 58 patients, 46 men and 12 women (mean age 61 years), with histologic proof of esophageal carcinoma underwent FDG‐PET of the neck, chest, and abdomen, as well as CT of the chest and abdomen, to determine tumor stage. FDG‐PET and CT data were compared with each other and with pathohistologic findings. Sensitivity, specificity, and overall accuracy for detecting histologically verified lymph node and distant metastases were calculated for FDG‐PET and CT. FDG‐PET showed a higher specificity, whereas CT had higher accuracy for detecting both abdominal (73% vs. 59%) and thoracic (73% vs. 63%) lymph node metastases. The accuracy of detecting blood‐borne and lymphatic distant metastases was identical for CT and FDG‐PET imaging (50%). FDG‐PET had a higher specificity than CT (87% vs. 13%) but lower sensitivity (35% vs. 67%). FDG‐PET did not provide new information on the indication for surgery, nor was it helpful for choosing the appropriate surgical procedure in patients with esophageal carcinoma. In view of the relatively high cost of FDG‐PET examinations, the use of this modality is indicated primarily in patients with inconclusive CT findings or for scientific research projects. Higher sensitivity as a result of tumor‐affinity radiopharmaceuticals and optimized apparatus resolution, in addition to the advantages offered by whole‐body PET scanning, may lead to new indications for this staging procedure in the future.
Spectrum of Breast Cancer in Malaysian Women: Overview
Authors: Hisham Abdullah Noor , Yip Cheng Har
Published: November 2003

Breast cancer is the most common cancer among Malaysian women. Nonetheless, in Malaysia there is a marked geographical difference in the incidence of breast cancer with advanced stage of presentation. The breast clinic in Kuala Lumpur Hospital diagnosed approximately 150 to 200 new cases of breast cancer a year. This number, however, represents only 12.0% to 15.0% of all breast disease seen annually in Kuala Lumpur Hospital. Between 1998 and 2001, of a total of 774 cases of newly diagnosed breast cancer in Kuala Lumpur Hospital, only 5.0% (40/774) were impalpable breast cancers. The peak age group for the three major ethnic distributions (Malay, Chinese, and Indian) ranged from 40 to 49 years. The mean tumor size at presentation was 5.4 cm (range: 1–20 cm), and the advanced stage of breast cancer is observed to be highest among the Malay ethnic group. Although it appears that the incidence of breast cancer in Malaysia is lower than in the developed countries, the difference may be attributable to the difficulty in getting accurate statistics and to underreporting of cases. Nonetheless, from the available data, it is clear that breast cancer continues to be the most common cancer among Malaysian women. The strongly negative social‐cultural perception of the disease, made worse by the geographical isolation of many rural areas, accounts for the delayed diagnosis and the often advanced stage of disease at presentation. A prospective population‐based study is called for to verify the demographic patterns of breast cancer, particular in Malaysia and other developing countries. The findings of such a study may have implications for future breast screening programs and for facilitating the understanding of differing risks of breast cancer among women around the world.
Blunt Liver Injuries in Polytrauma: Results from a Cohort Study with the Regular Use of Whole‐body Helical Computed Tomography
Authors: Matthes Gerrit , Stengel Dirk , Seifert Julia , Rademacher Grit , Mutze Sven , Ekkernkamp Axel
Published: November 2003

The estimated prevalence of liver injury in patients with blunt multiple trauma ranges from 1% to 8%. The objective of this study was to investigate the profile of accompanying liver injury in a cohort of polytraumatized patients who had regularly undergone contrast‐enhanced, whole‐body helical computed tomography (CT). We enrolled consecutive patients admitted between September 1997 and January 2001 to a level I trauma center. Clinical baseline data were compiled as part of a nationwide trauma registry. Morphologic features were evaluated descriptively, whereas prognostic variables were assessed by logistic regression analysis. We identified 218 patients [149 men, mean age 35 ± 18 years, mean injury severity score (ISS) 35 ± 10], 55 of whom had sustained blunt liver trauma [25.2%, 95% confidence interval (CI) 19.6–31.5%]. The prevalence of Moore III to V lesions was 10.1%. There were 99 parenchymal contusions, 15 capsular tears, and 2 liver fractures. Surgery was required in 15 patients and was best predicted by the classification of the American Association for the Surgery of Trauma [odds ratio (OR) 3.91, 95% CI 1.59–9.61]. The mortality rate was 0.0035/person/day. Patients requiring surgical repair had fourfold increased relative odds of case fatality (OR 4.50, 95% CI 1.01–19.96). Sevenfold increased relative odds were observed if liver laceration was considered the leading injury (OR 7.17, 95% CI 1.17–43.97). The prevalence of liver lacerations among multiple‐trauma patients is likely to be underestimated and must be determined by the independent application of reference standards, such as helical CT. High‐grade hepatic injuries and the need for surgical repair are associated with poorer survival prognosis.
Intraperitoneal Administration of the Angiogenesis Inhibitor Thalidomide Does Not Impair Anastomotic Healing following Large Bowel Resection in a Rabbit Model
Authors: Mall Julian W. , Schwenk Wolfgang , Philipp Andreas W. , Büttemeyer Rolf , Pollmann Christian
Published: November 2003

The effects of thalidomide after intraperitoneal instillation on the healing of colonic anastomoses are not known. A series of 40 New Zealand White rabbits underwent an end‐to‐end colonic anastomosis. The animals were randomized into four groups. Groups 1 (n = 10) and 2 (n = 10) were treated with dissolved thalidomide 200 mg/kg intraperitoneally, whereas groups 3 (n = 10) and 4 (n = 10) were treated only with the dissolver. Animals were sacrificed at day 3 (groups 1, 3) and day 7 (groups 2, 4). Anastomotic healing was tested by measuring the bursting pressure in vitro. Immunohistochemical staining of the anastomotic site was performed with polyclonal antibodies against CD31 and Mib‐1, to determine a possible antiangiogenic or antiproliferative effect. Statistical analysis was performed using Spearman’s log rank correlation and paired t‐test. On postoperative day 3 (p > 0.19) and postoperative day 7 (p > 0.73), there was no difference in bursting pressure in the treatment and the control groups. Angiogenesis scores were reduced at day 3 in the thalidomide group (p < 0.05), but did not differ between the groups at day 7. White blood cell counts were decreased in the treatment groups at day 3 (p < 0.01) and day 7, compared to control groups (p < 0.01). There was no difference in the expression of Mib‐1 in either group at day 3 or day 7. The intraperitoneal administration of thalidomide does not interfere with the healing of colonic anastomosis. Although the angiogenesis score is diminished at day 3, this did not lead to a reduced bursting pressure at day 3 or day 7.
Ideal Reconstruction after Total Gastrectomy by the Interposition of a Jejunal Pouch Considered by Emptying Time
Authors: Tono Chiriro , Terashima Masanori , Takagane Akinori , Abe Karoru
Published: November 2003

To establish the ideal form of the pouch for jejunal pouch interposition reconstruction (JPI) after total gastrectomy, the postoperative gastrointestinal function and symptoms were investigated in comparison with jejunal interposition reconstruction (JI). A total of 20 patients who underwent curative surgery for gastric cancer were enrolled in this study. In the JI group (n = 9), an isoperistaltic jejunum about 40 cm in length was interposed between the esophagus and the duodenum. In the JPI group (n = 11), a proximal pouch about 15 cm in length with a 10‐cm conduit was also interposed between the esophagus and the duodenum. At follow‐up 6 months postoperatively, food transit was evaluated using a radiolabeled semisolid test meal. The half‐emptying time was 6.9 minutes in the JI group and 46 minutes in the JPI group. The reservoir function influenced the recovery of the patients’ body weight and development of the serum total protein in the early postoperative period. An early half‐emptying time caused dumping symptoms in JI group. In the JPI group, there were no dumping symptoms; however, extended food clearance of pouch causes postprandial symptoms such as reflux (1 patient), vomiting (2 patients), and discomfort (2 patients). In those patients with symptoms, half‐emptying times were longer than 60 minutes. There was a statistically significant correlation between the pouch length and the half‐emptying time of the gastric substitute in JPI group (p = 0.0039, r = 0.789). If we estimate that the appropriate half‐emptying time is 20 to 60 minutes, correlation of the pouch length and the half‐emptying time shows that the ideal pouch length is about 12–15 cm in JPI. In jejunal pouch interposition reconstruction after total gastrectomy, an adequate procedure leads to nutritional advantage and prevents postoperative symptoms.
Pathological Basis of Gastroesophageal Reflux Disease
Authors: Chandrasoma Parakrama
Published: November 2003

Many of the present definitions of Barrett’s esophagus are based on the dogma that 2 to 3 cm of cardiac mucosa normally line the distal esophagus and proximal stomach. Recent autopsy data refute this dogma. Cardiac mucosa has been shown to be frequently absent from the squamocolumnar junctional zone. When present, its extent is less than 0.5 cm in almost all children and most adults. Cardiac mucosal length increases with age. Patients who have cardiac mucosa are significantly more likely to have abnormal acid exposure in the esophagus as measured by 24‐hour pH studies. The length of the cardiac mucosa correlates significantly with the amount of reflux: the greater the length of the cardiac mucosa, the more reflux there is. These new data provide insights into the pathology of gastroesophageal reflux. Normalcy is defined as an esophagus lined by squamous epithelium and a stomach lined by gastric mucosa. Reflux disease is defined by the presence of cardiac mucosa in a junctional biopsy. The severity of reflux disease is quantifiable by the length of cardiac mucosa present. Mutational reflux disease (Barrett’s esophagus) is defined by the occurrence of intestinal metaplasia in cardiac mucosa and is quantitated by the amount of intestinal metaplasia present. Neoplastic reflux disease is defined as the occurrence of low grade dysplasia, high grade dysplasia, and adenocarcinoma in Barrett’s esophagus. An attempt is made here to develop a rational grading system for reflux based on these highly objective histologic criteria.
Barrett’s Esophagus: Model of Neoplastic Progression
Authors: Ramel Stig
Published: November 2003

Human cancer progression is characterized by clonal expansion of cells with accumulated genetic errors. Invasive carcinomas contain all the genetic errors that were acquired during neoplastic progression and then continue to accumulate further abnormalities, leading to tumor heterogeneity. Many investigations of human cancer have given valuable insights in genetic abnormalities important for tumor biology. Early events responsible for neoplastic progression, however, are often impossible to investigate in invasive cancers because the premalignant tissue in which the tumors develop are often overgrown and the premalignant conditions cannot be studied in vivo because they are either not detected owing to lack of symptoms or are removed before cancer develops. Unlike many other premalignant conditions Barrett’s esophagus is often associated with symptoms leading to diagnosis at an early stage before cancer develops, and the premalignant epithelium is seldom removed at an early stage of cancer progression. Furthermore, in patients who present with invasive carcinoma the tumor is often surrounded by premalignant epithelium, which is available for further investigations. Therefore Barrett’s esophagus is an excellent model in which to study the early events of neoplastic progression. It may not only contribute to a better understanding of the neoplastic process but also provide a base for safer assessment of cancer risk during surveillance for early detection of esophageal adenocarcinoma.
Prevention of Adenocarcinoma by Reversing Barrett’s Esophagus with Mucosal Ablation
Authors: Sampliner Richard E.
Published: November 2003

The ultimate goal of therapy in patients with Barrett’s esophagus (BE) is to reduce the risk of developing adenocarcinoma of the esophagus. Neither pharmacologic nor surgical therapy has been documented to reduce this risk. There is preliminary evidence that many forms of mucosal ablation combined with acid reduction therapy result in restitution of normal squamous epithelium in patients with BE. Acid reduction can be accomplished with high‐dose proton pump inhibitor therapy or antireflux surgery. Endoscopic ablation can be accomplished with photodynamic therapy, laser, multipolar electrocoagulation, a heater probe, and argon plasma coagulation. These techniques require further study so the complication rates can be compared. The success of reversing BE must be evaluated in a standard way utilizing large‐capacity biopsy forceps through a therapeutic endoscope. Ideally, patients at high risk of developing adenocarcinoma of the esophagus can be treated with ablation therapy and followed to document a reduction in the development of adenocarcinoma of the esophagus. A validated biomarker would help select high risk patients appropriate for reversal therapy. Currently, patients who are at prohibitive risk for surgery or who refuse surgery are candidates for combination therapy including mucosal ablation to reverse their BE. This therapy offers the promise of less morbidity and greater quality of life than resection.
Surgical Competence
Authors: Patil Nivritti G. , Cheng Stephen W.K. , Wong John
Published: November 2003

Recent high‐profile cases have heightened the need for a formal structure to monitor achievement and maintenance of surgical competence. Logbooks, morbidity and mortality meetings, videos and direct observation of operations using a checklist, motion analysis devices, and virtual reality simulators are effective tools for teaching and evaluating surgical skills. As the operating theater is also a place for training, there must be protocols and guidelines, including mandatory standards for supervision, to ensure that patient care is not compromised. Patients appreciate frank communication and honesty from surgeons regarding their expertise and level of competence. To ensure that surgical competence is maintained and keeps pace with technologic advances, professional registration bodies have been promoting programs for recertification. They evaluate performance in practice, professional standing, and commitment to ongoing education.
The Surgeon and Human Immunodeficiency Virus
Authors: Mielke Jens , Kalangu Kazadi K.N.
Published: November 2003

The moral dilemmas faced by surgeons worldwide who treat patients infected with the human immunodeficiency virus (HIV) can be viewed against the background of experience in sub‐Saharan countries, where the community prevalence is in excess of 25% (90% of hospital inpatients). When seeking consent for an HIV test before surgery, frank communication regarding the surgeons’ perspective of risks to themselves and the patient is helpful. When consent for a test must be obtained from a substitute decision‐maker, the surgeon should consider if the patient would want the decision‐maker to know the result. Understanding the natural history of HIV in the surgical setting can help deal with the uncertainties encountered and should be a research priority for developing countries. International professional organizations are useful platforms for the exchange of ideas when surgeons encounter uncertainty by increasing access to journals and creating opportunities for discussion. Although supervisory bodies in some parts of the world prevent HIV‐infected surgeons from putting patients at risk by offering surgery, the withdrawal of their services in developing countries can cause more harm than good. Surgeons in that position may be entitled to offer surgery but only with full disclosure of the risk of HIV infection to the patient. The decision‐making process known as ”accountability for reasonableness” allows surgeons to determine fairness, legitimacy, and acceptability when making resource allocation decisions involving patients with HIV.
Cardiac Surgery in Eastern Europe: Continuing Challenge
Authors: Borst Hans G.
Published: November 2003

The post‐Soviet calamities of East European cardiac surgery highlight the spectrum of marked differences in overall operative capacities among individual post‐Communist countries. A comparison with the level of cardiac surgery in Western Europe reveals the importance of continuing relief, comprising both educational and material help. The East European Program of the European Association for Cardio‐thoracic Surgery exemplifies current efforts to address these needs.
Preservation of Form and Function during Management of Cancer of the Larynx and Hypopharynx
Authors: Lefebvre Jean Louis , Lartigau Eric
Published: November 2003

The treatment of laryngeal and hypopharyngeal cancer has seen notable changes during the twentieth century. Intensive surgical research has allowed laryngologists to deal with almost any local extension and to propose an appropriate surgical procedure for each case. This surgery is able to control the disease in most patients locally but is limited in its indications (resectable diseases and operable patients). On the other hand, radiotherapy has been impressively improved (dosimetry, definition of target volume) and has become an indisputable alternative to surgery. The two approaches are comparable in terms of local control and functional results when dealing with early disease. For advanced disease, however, the debate is open between surgery, which is more efficient but mutilating, and radiotherapy, which can preserve the larynx in many instances even though it requires sometimes mutilating surgery for salvage. The appearance of platinum‐based chemotherapy has updated this discussion. To date, most of the randomized comparisons of mutilating/nonmutilating approaches have been with induction chemotherapy followed by irradiation if there has been a good clinical response to the chemotherapy. There are other options as well that deserve evaluation (e.g., radiotherapy with altered fractionation or with concurrent chemotherapy), although surgery still seems to be indicated in certain cases. Finally, efforts should be made to select patients properly (based on tumor characteristics, clinical aspects, imaging, and biology) for the various strategies with the primary goal of curing the patient and secondarily to preserve laryngeal form and function when possible.
Preoperative Radiotherapy for Adult Head and Neck Soft Tissue Sarcoma: Assessment of Wound Complication Rates and Cancer Outcome in a Prospective Series
Authors: O’Sullivan Brian , Gullane Patrick , Irish Jonathan , Neligan Peter , Gentili Fred , Mahoney James , Sellmann Susanna , Catton Charles , Waldron John , Brown Dale , Witterick Ian , Freeman Jeremy , Bell Robert
Published: November 2003

Combination surgery and radiotherapy (RT) is frequently used in soft tissue sarcoma (STS). Because lower doses and smaller irradiation volumes are possible in preoperative RT (pre‐op RT), this approach can be especially valuable in anatomic settings where critical organs are in close proximity to the RT target area. A recent multicenter phase III trial (SR.2 trial of the National Cancer Institute of Canada Clinical Trials Group) comparing pre‐op RT against post‐op RT for extremity STS has shown significantly higher major wound complication rates (35%) with pre‐op RT. We postulated that wound complication rates may be less frequent in the head and neck with better vascularity and wider use of secondary wound reconstruction. Using a prospective database, we identified 40 consecutive patients with head and neck STS treated with pre‐op RT (50 Gy) and subsequent (4 to 6 weeks later) resection between 1/89 and 8/99 in a single institution setting. Major wound complications (MWC) were classified by the identical criteria used in the SR.2 trial. Intracranial extension was evident in 5 patients, whereas 50% of the patients had large tumors (> 5 cm). Deep tumor was present in 34 (85%), and 6 (15%) were superficial to fascia. In this series, 31 patients (77.5%) had secondary reconstruction of the acquired soft tissue deficit. The actuarial 2‐year local relapse‐free rate was 80%, and the metastatic relapse‐free rate was 85%. Major wound complications occurred in 8 of 40 patients (20%) within 120 days of surgery according to the SR.2 criteria: secondary wound surgery (3), readmission or prolonged hospital admission for wound care (2), deep packing (0), prolonged dressing changes (2), and invasive procedure for wound care (1). The latter was a minor wound management problem (a single outpatient drainage of a seroma) for the combined rate of 8/20 or 20%. Our findings show that (1) pre‐op RT in head and neck STS is associated with lower rates of major wound complications compared to extremity cases; (2) pre‐op RT provides high rates of local control in an adverse group of cases of adult head and neck STS; (3) the choice of scheduling of RT should be based on anatomic issues with emphasis on the trade‐offs between RT doses and volumes versus wound morbidity for individual patients. This is especially important when tumor may be adjacent to critical head and neck structures which may be protected from the high‐dose RT area.
Quality‐of‐life Outcomes in Head and Neck Cancer Patients
Authors: Morton Randall P. , Izzard Mark E.
Published: November 2003

Quality‐of‐life (QL) is a relatively new concept in head and neck oncology outcomes research. It is important to have a clear definition and to use reliable and valid measures in its assessment. QL studies should use patient self‐reported data and should account for treatment or disease‐related symptoms and the domains of physical and psychosocial functioning, together with a patient‐rated global QL score. Within head and neck cancer there are very distinct differences between sites. Oral cancer and laryngeal cancer lead to very different QL outcomes. Care must be used when comparing treatments; organ‐preservation techniques do not necessarily lead to better QL outcomes, especially in laryngeal cancer. An assessment of life‐utility (QALY) may be helpful in determining how meaningful survival is after treatment, and can be used to provide information to purchasers of health care services in support of better resource allocation for head and neck cancer patients.
Surgery for Inguinal Hernia in Byzantine Times (A.D. 324–1453): First Scientific Descriptions
Authors: Lascaratos John G. , Tsiamis Constantine , Kostakis Alkiviadis
Published: November 2003

The aim of this article is to present the techniques applied by Byzantine physicians for inguinal hernia repair and to note their influence on the development of surgery after that time. A study and analysis of the original texts of the Byzantine medical writers, written in Greek, and containing the now mostly lost knowledge of the ancient Hellenistic and Roman periods, was undertaken. Two Byzantine physicians, Aetius of Amida (6th century A.D.) and Paul of Aegina (7th century A.D.), described two techniques for confrontation of inguinal hernia, namely the surgical removal of the prolapsed peritoneum and the cauterization of the groin. These methods were probably derived from the texts of earlier Greek surgeons to which they added their own keen observations. The study of Byzantine medical and literary texts proves that the surgical techniques for inguinal hernia were practiced in Byzantine times and influenced later Arabian and European surgery, thus constituting significant roots of surgery.
Radical Surgery for Mesothelioma: How CanWe Obtain Evidence?
Authors: Treasure Tom , Swift Simon , Tan Carol
Published: November 2003

Asbestos exposure in industry and construction sites in the
1960s and 1970s has left a legacy of mesothelioma, a diffuse pleural cancer,
with a lag time of 40 to 50 years and due to peak around 2015 to 2020. Some
surgeons believe that by radical surgery they can prolong life and relieve
symptoms, but the evidence comes from very carefully selected series. How do
surgeons respond to demand for evidence of benefit? In this article we explore
how evidence for major surgical operations has been gained and how mesothelioma
fits into this history.
Role of Surveillance in Intestinal Metaplasia of the Esophagus and Gastroesophageal Junction
Authors: Tytgat Guido N.J. , van Sandick Johanna W. , Lanschot J. Jan B. van , Obertop Huug
Published: November 2003

This article reviews current concepts of cancer surveillance in esophageal columnar metaplasia (Barrett’s esophagus) and intestinal metaplasia at the gastroesophageal junction. An overview is given of the available data on the prevalence of intestinal metaplasia in biopsies from the distal esophagus and from the gastroesophageal junction. Furthermore, special attention is given to the endoscopic detection of dysplasia and early malignancy. Finally, the costs of endoscopic surveillance and its effect on mortality rates from esophageal adenocarcinoma are discussed.
Do patients drop out prematurely from exposure therapy for PTSD?
Authors: Hembree Elizabeth A. , Foa Edna B. , Dorfan Nicole M. , Street Gordon P. , Kowalski Jeanne , Tu Xin
Published: November 2003

Many studies have demonstrated the efficacy of exposure therapy in the treatment of chronic posttraumatic stress disorder (PTSD). Despite the convincing outcome literature, a concern that this treatment may exacerbate symptoms and lead to premature dropout has been voiced on the basis of a few reports. In this paper, we examined the hypothesis that treatments that include exposure will be associated with a higher dropout rate than treatments that do not include exposure. A literature search identified 25 controlled studies of cognitive–behavioral treatment for PTSD that included data on dropout. The results indicated no difference in dropout rates among exposure therapy, cognitive therapy, stress inoculation training, and EMDR. These findings are consistent with previous research about the tolerability of exposure therapy.
“Decadose” Effects of Cisplatin on Squamous Cell Carcinoma of the Upper Aerodigestive Tract. I. Histoculture Experiments
Authors: Robbins K. Thomas , Hoffman Robert M.
Published: November 2003

There is substantial laboratory and clinical evidence that solid tumors rapidly acquire cellular resistance to cisplatin. Experiments with human carcinoma cell lines and clonogenic assays indicate that resistance is usually mild to moderate and can be circumvented with higher concentrations of drug. The purpose of this investigation was to test this hypothesis with a histoculture assay of human upper aerodigestive tract (UADT) carcinomas.

Using a sponge‐gel supported histoculture, 43 tumor specimens from patients with squamous cell carcinoma (SCC) of the UADT were grown and exposed to cisplatin. Growth inhibition by the drug, in concentrations equivalent to peak therapeutic doses (1.5 μg/mL) and concentrations 10 and 25 times greater (15 and 37.5 μg/mL), were measured in specimens from patients with previously untreated and recurrent lesions.

In vitro, the overall rate of sensitivity of the tumor samples to cisplatin concentrations of 1.5, 15, and 37.5 μg/mL were 22%, 62%, and 83%, respectively. In patients with previously untreated disease, the respective rates were 25.9%, 63.3%, and 79.3%, as compared with 10.0%, 55.6%, and 85.6%, respectively, for patients with recurrent disease. The response difference between cisplatin concentrations of 1.5 and 15 μg/mL was statistically significant. The “decadose” effect of cisplatin on growth inhibition was 2.44‐fold for untreated lesions and 5.56‐fold for recurrent tumors.

The results indicate that resistance to standard doses of cisplatin by SCC of the UADT can be substantially overcome with a decadose (standard dose × 10) increase and is more pronounced in tumors from patients with recurrent disease. Progress toward improving survival of patients may be possible by incorporating decadose cisplatin therapy into a multimodality treatment plan.
Brainstem Auditory Evoked Potentials in Patients With Ischemic Heart Disease
Authors: Karamitsos Dimitrios G. , Kounis Nicholas G. , Zavras George M. , Kitrou Michael P. , Goudevenos John A. , Papadaki Paraskevi J. , Koutsojannis Constantinos M.
Published: November 2003

The authors of this study used the method of increased stimulus rate on brainstem auditory evoked potentials (BAEPs) in 30 patients with ischemic heart disease (IHD) and in an equal number of healthy age‐matched control subjects. The BAEPs were recorded using 100‐ to 3000‐Hz alternating polarity clicks at a rate of 22.6 per second. Measurements included the absolute latencies of waves I through V, the interpeak latencies I‐III, III‐V, and I‐V, and the peak amplitudes of peaks I, III, and V.

The measured absolute latencies and interpeak latencies were found to be significantly increased, and the peak amplitudes were found to be diminished. The audiometric tests revealed no significant hearing loss in IHD patients. This study is the first to demonstrate prolongation of BAEPs in IHD patients. BAEP recording may become an additional noninvasive tool for detecting IHD patients with impaired microcirculation.
Ambulatory Tonsillectomy and Adenoidectomy
Authors: Gabalski Edward C. , Mattucci Kenneth F. , Setzen Michael , Moleski Patricia
Published: November 2003

The performance of tonsillectomy and adenoidectomy in an ambulatory setting is controversial. However, most current studies show that with adequate criteria for patient selection and careful postoperative observation, these procedures can be safely done as outpatient surgery. This study was undertaken to reassess the safety of outpatient tonsillectomy and adenoidectomy surgery and to reevaluate the current recommendations for postoperative care.

A prospective study was undertaken to relate the incidence of significant complications, including hemorrhage, protracted emesis, and fever, to each postoperative hour. The study included 534 pediatric patients (age 14 or less) undergoing tonsillectomy with or without adenoidectomy. All 534 patients were observed for 5 postoperative hours, and 175 of the 534 patients were observed for 6 postoperative hours.

To assess complications occurring in the first postoperative week, all attending surgeons involved in this study were asked to anonymously report the occurrence of hemorrhage, protracted emesis, and/or fever from the time of discharge through the seventh postoperative day.

In this study, no complications were encountered during the fifth or sixth postoperative hours. These results indicate that it is both safe and appropriate to perform tonsil and adenoid surgery in the ambulatory setting. Furthermore, the current recommendation that patients remain under postoperative recovery room observation for 6 hours appears to be excessive. This observation period may be safely reduced to 4 hours.
Histopathology and CT Analysis of Partially Resected Middle Turbinates
Authors: Biedlingmaier John F. , Whelan Philip , Zoarski Greg , Rothman Michael
Published: November 2003

Thirty‐eight partial middle turbinate resections from 20 patients undergoing endoscopic sinus surgery were evaluated by histopathology of mucosa and bone and by computed tomography (CT) appearance prior to resection. Histopathologic analysis revealed not only mucosal inflammation but also chronic osteitis of the bone in all patients with sinus disease. The preoperative CT was accurate in predicting turbinate osteitis when the scans displayed advanced grades III and IV disease. These findings suggest that in advanced disease, conservative partial middle turbinate resections may be necessary to remove chronically infected bone from the osteomeatal complex. Because it is unsafe to remove all of the middle turbinate, consideration should also be given to long‐term antibiotic therapy to treat the osteitis found in advanced disease.