Subliminal and supraliminal processing of reward-related stimuli in anorexia nervosa.

BACKGROUND: Previous studies have highlighted the role of the brain reward and cognitive control systems in the etiology of anorexia nervosa (AN). In an attempt to disentangle the relative contribution of these systems to the disorder, we used functional magnetic resonance imaging (fMRI) to investigate hemodynamic responses to reward-related stimuli presented both subliminally and supraliminally in acutely underweight AN patients and age-matched healthy controls (HC). METHODS: fMRI data were collected from a total of 35 AN patients and 35 HC, while they passively viewed subliminally and supraliminally presented streams of food, positive social, and neutral stimuli. Activation patterns of the group × stimulation condition × stimulus type interaction were interrogated to investigate potential group differences in processing different stimulus types under the two stimulation conditions. Moreover, changes in functional connectivity were investigated using generalized psychophysiological interaction analysis. RESULTS: AN patients showed a generally increased response to supraliminally presented stimuli in the inferior frontal junction (IFJ), but no alterations within the reward system. Increased activation during supraliminal stimulation with food stimuli was observed in the AN group in visual regions including superior occipital gyrus and the fusiform gyrus/parahippocampal gyrus. No group difference was found with respect to the subliminal stimulation condition and functional connectivity. CONCLUSION: Increased IFJ activation in AN during supraliminal stimulation may indicate hyperactive cognitive control, which resonates with clinical presentation of excessive self-control in AN patients. Increased activation to food stimuli in visual regions may be interpreted in light of an attentional food bias in AN.

Multiple drill-hole osteotomy in hand surgery - description of a novel application and proof of feasibility.

BACKGROUND: Malunion of phalangeal and metacarpal bones are often associated with impairment of hand function and pose a challenging task for treating surgeons in most cases. When applicable, corrective osteotomy is the treatment of choice, where the affected bone is cut to correct malalignment using chisels or saws. The use of these instruments is associated with several drawbacks especially in hand surgery. We aimed to determine whether a multiple drill-hole (MDH) osteotomy technique was suitable for performing corrective osteotomies of metacarpal and phalangeal bones. METHODS: This case series included 11 patients with malalignments or malunions of phalangeal or metacarpal bones. Corrective osteotomy was performed with the MDH technique. Follow-up examinations included clinical evaluations and radiography at frequent intervals, between 2 and 22 months postoperatively. RESULTS: In all cases, planned osteotomies were technically feasible with the MDH technique. Apart from one case of a broken drillbit, no intraoperative or postoperative complication was recorded. All performed osteotomies healed within a mean of 6 weeks to radiological consolidation. In all cases, satisfactory results were achieved. CONCLUSION: The present study was the first to test MDH osteotomy for hand surgery. We demonstrated that MDH was feasible for corrective osteotomies of metacarpal and phalangeal deformities. Advantages included excellent feasibility for osteotomies performed at varying angles, precise execution, reduced risk of collateral damage, and flexibility for performing intra-articular osteotomies.

Temporal delay discounting in acutely ill and weight-recovered patients with anorexia nervosa.

BACKGROUND: Patients with anorexia nervosa (AN) are characterized by a very low body weight but readily give up immediate rewards (food) for long-term goals (slim figure), which might indicate an unusual level of self-control. This everyday clinical observation may be quantifiable in the framework of the anticipation-discounting dilemma. METHOD: Using a cross-sectional design, this study compared the capacity to delay reward in 34 patients suffering from acute AN (acAN), 33 weight-recovered AN patients (recAN) and 54 healthy controls. We also used a longitudinal study to reassess 21 acAN patients after short-term weight restoration. A validated intertemporal choice task and a hyperbolic model were used to estimate temporal discounting rates. RESULTS: Confirming the validity of the task used, decreased delay discounting was associated with age and low self-reported impulsivity. However, no group differences in key measures of temporal discounting of monetary rewards were found. CONCLUSIONS: Increased cognitive control, which has been suggested as a key characteristic of AN, does not seem to extend the capacity to wait for delayed monetary rewards. Differences between our study and the only previous study reporting decreased delay discounting in adult AN patients may be explained by the different age range and chronicity of acute patients, but the fact that weight recovery was not associated with changes in discount rates suggests that discounting behavior is not a trait marker in AN. Future studies using paradigms with disorder-specific stimuli may help to clarify the role of delay discounting in AN.

Adhesions after laparoscopic and open ileal pouch-anal anastomosis surgery for ulcerative colitis.

BACKGROUND: Emerging evidence suggests that a laparoscopic approach to colorectal procedures generates fewer adhesions. Even though laparoscopic ileal pouch-anal anastomosis (IPAA) is a lengthy procedure, the prospect of fewer adhesions may justify this approach. The aim of this study was to assess abdominal and adnexal adhesion formation following laparoscopic versus open IPAA in patients with ulcerative colitis. METHODS: A diagnostic laparoscopy was performed at time of ileostomy closure. All abdominal quadrants and the pelvis were video recorded systematically and graded offline. The incisional adhesion score (IAS; range 0-6) and total abdominal adhesion score (TAS; range 0-10) were calculated, based on the grade and extent of adhesions. Adnexal adhesions were classified by the American Fertility Society (AFS) adhesion score. RESULTS: A total of 43 patients consented to participate, of whom 40 could be included in the study (laparoscopic 28, open 12). Median age was 38 (range 20-61) years. There was no difference in age, sex, body mass index, American Society of Anesthesiologists grade and time to ileostomy closure between groups. The IAS was significantly lower after laparoscopic IPAA than following an open procedure: median (range) 0 (0-5) versus 4 (2-6) respectively (P = 0·004). The TAS was also significantly lower in the laparoscopic group: 2 (0-6) versus 8 (2-10) (P = 0·002). Applying the AFS score, women undergoing laparoscopic IPAA had a significantly lower mean(s.d.) prognostic classification score than those in the open group: 5·2(3·7) versus 20·0(5·6) (P = 0·023). CONCLUSION: Laparoscopic IPAA was associated with significantly fewer incisional, abdominal and adnexal adhesions in comparison with open IPAA.

Outcomes after laparoscopic intestinal resection in obese versus non-obese patients.

BACKGROUND: The degree of benefit derived from laparoscopic bowel resection in obese compared with non-obese patients is poorly understood. METHODS: A total of 436 obese patients (body mass index (BMI) at least 30 kg/m(2), mean 34·9 kg/m(2)) who underwent laparoscopic bowel resection during 1992-2008 were identified from a prospective database. An equal number of non-obese patients (mean BMI 24·8 kg/m(2)) was case-matched by age, sex, year of surgery, American Society of Anesthesiologists score, diagnosis and type of operation. Patients with previous major abdominal surgery were excluded. Postoperative morbidity and recovery were compared between obese and non-obese patients. RESULTS: Mean duration of operation (171·5 versus 157·3 min; P = 0·017), estimated blood loss (EBL; 224·9 versus 164·6 ml; P = 0·001) and conversion rate (13·3 versus 7·1 per cent; P = 0·003) were increased significantly in obese patients. Overall postoperative morbidity was also greater (32·1 versus 25·7 per cent; P = 0·041), particularly wound infection rate (10·6 versus 4·8 per cent; P = 0·002). Among laparoscopically completed operations, obese patients had higher rates of overall morbidity (31·5 versus 24·2 per cent; P = 0·026) and wound infection (10·2 versus 4·4 per cent; P = 0·002). Conversion was associated with increased EBL, intraoperative complications, overall morbidity and length of stay in both groups. The effect of conversion in worsening outcomes was comparable in obese and non-obese patients, except for a greater increase in incision length (11·0 versus 8·0 cm; P = 0·001) and EBL (304·8 versus 89·8 ml; P = 0·001) in obese patients. CONCLUSION: Laparoscopic bowel resection results in greater morbidity in obese than in non-obese individuals. This difference remains comparable whether the procedure is completed laparoscopically or converted.

Minimally invasive surgical wound infections: laparoscopic surgery decreases morbidity of surgical site infections and decreases the cost of wound care.

AIM: The morbidity of surgical site infections (SSIs) were compared in patients who underwent open (OS) vs laparoscopic (LS) colorectal surgery. METHOD: Data from 603 consecutive LS patients and 2246 consecutive OS patients were prospectively recorded. Morbidity of SSIs was assessed by the need for emergency department (ED) evaluation, subsequent hospital re-admission and re-operation. The cost of wound care was measured by the need for home healthcare, wound vacuum assisted closure (VAC) or independent patient wound care. RESULTS: SSIs were identified in 5.8% (n = 25) of LS patients and 4.8% (n = 65) of OS patients. ED evaluation for the infection was needed in 24% of the LS group and 42% of the OS group. Hospital re-admission was needed in one LS patient and in 52% OS patients. No LS patient needed re-operation compared with 12% of OS patients. HHC ($162/dressing change) was required in 63% of the OS group compared with 8% of LS group. A home wound VAC system ($107/day) was utilized in 12% of the OS patients but in none of the LS patients. Dressing changes were managed independently by the patient in 92% of the LS compared with 37% of the OS patients. CONCLUSION: Laparoscopic colorectal surgery patients experience less morbidity when they develop SSIs incurring less cost compared with open colorectal surgery patients.

Single incision laparoscopic colorectal surgery: a single surgeon experience of 102 consecutive cases.

BACKGROUND: Due to the recent heightened interest in even less invasive surgery, single port laparoscopic colorectal surgery is quickly gaining acceptance. While this access technique was first described in 2007 for colorectal resective procedures, large series are lacking. METHODS: Between January 2009 and October 2010, all patients undergoing single port colorectal surgery performed by a single surgeon were prospectively entered into an IRB-approved database and studied with regard to perioperative events, morbidity, and mortality. RESULTS: One hundred and two consecutive patients underwent a single port colorectal procedure. Mean age was 47 years (9-93 years), and average body mass index was 26 kg/m(2) (15-39 kg/m(2)). Primary diagnoses included ulcerative colitis (51), neoplasia (23), Crohn's disease (14), diverticulitis (11), familial adenomatous polyposis (1), and other (2). Procedures included 23 total colectomies, 40 segmental colectomies, and 19 other procedures. There was 1 conversion to an open operation, and 18 (18%) patients required placement of additional ports (1 port: N = 13; 2 ports: N = 2; 3 ports: N = 3). Average operating room time was 99 min (13-245), mean length of incision was 3.7 cm (1.2-7.8 cm), and average estimated blood loss was 140 ml (0-750 ml). There was one postoperative death, and 39 (38%) patients experienced minor postoperative complications. Mean lymph node harvest for oncologic resections was 44 (14-142). The average length of hospital stay was 5.9 days (2-24 days). CONCLUSIONS: With proper patient selection and laparoscopic experience, single port colorectal surgery can be performed for even the most complex colorectal procedures. Further studies are needed to assess the benefits that single port colorectal surgery has over a conventional laparoscopic approach.

The negative effects of surgery persist beyond the early postoperative period after laparoscopic colorectal resection.

PURPOSE: The recovery benefits of laparoscopy are traditionally believed to minimize the initial negative impact of surgery on early postoperative quality of life (QOL). We evaluate whether laparoscopic colectomy leads to recovery of QOL early after surgery and evaluate factors associated with the change in QOL. METHODS: Preoperative and early postoperative QOL data (SF-36) were prospectively accrued for patients undergoing laparoscopic colorectal resection (LCR) (2002-2009). Changes in postoperative QOL from preoperative values and effects of patient, disease, operation and postoperative outcomes on these changes were evaluated. RESULTS: One hundred and sixty-six patients (female = 86) underwent LCR for cancer (n = 79), Crohn's disease (n = 24), diverticulitis (n = 38), and ulcerative colitis (n = 25) with complete SF-36 scores. Median age was 56.9 (range: 15-91) years, mean body mass index 27.4 ± 6.2 kg/m(2) with American Society of Anesthesiologists (ASA) class being II in 94 patients. Median operative time was 152.5 (range: 50-358) min; mean length of stay (LOS) 4.5 ± 3.3 days. At 4 weeks, the postoperative SF-36 physical component scale (PCS) continued to be lower than the preoperative PCS (41.8 ± 8.8 vs. 47.1 ± 9.4, P < 0.001), while the postoperative SF-36 mental component scale (MCS) was similar to the preoperative MCS (45.6 ± 10.2 vs. 46.1 ± 11.9, P = 0.17). Gender, age, operation, LOS, surgeon, ASA, BMI, complications, and readmission were not associated with a change in QOL from preoperative values. Cancer as an indication for surgery was associated with less improvement of MCS and PCS (P = 0.024 and 0.004, respectively). CONCLUSIONS: Although patients who undergo LCR may have clinical evidence of healing at 4 weeks after surgery, QOL does not return to the preoperative level. This finding may help develop evidence-based recommendations pertaining to timing of return to full activity.

Single incision laparoscopic total proctocolectomy with ileopouch anal anastomosis.

AIM: We present our initial experience of a single port laparoscopic total proctocolectomy with ileoanal J pouch anastomosis. The single incision laparoscopic surgery (SIL), (Covidien, Norwalk, Connecticut, USA) device with a multichannel cannula and specially designed curved laparoscopic instrumentation were used. METHOD: A patient with familial adenomatous polyposis underwent restorative proctocoectomy. A colonoscopy had demonstrated nearly 1000 polyps in the colon with several 1-cm polyps in the rectum. The abdomen was entered through a 2.5 cm incision sited preoperatively for the temporary ileostomy. The single port device was inserted and a total proctocolectomy was performed. Ligation of the vessels was performed with the Ligasure (Covidien). The colon and rectum were extracted through the SIL site. An 18-cm ileoanal J pouch was created extracorporeally. The pouch anal anastomosis was performed intracorporeally and a diverting loop ileostomy created through the SIL port site. RESULTS: The operating time was 172 min. Blood loss was 100 ml and the hospital stay was 4 days without any complication. The patient had a virtually scar-less abdomen other than the site of the loop ileostomy. CONCLUSION: Single port laparoscopic surgery may allow complex colorectal surgery to be performed resulting in a virtually scar-less procedure.

Hand-assisted laparoscopic surgery may be a useful tool for surgeons early in the learning curve performing total abdominal colectomy.

OBJECTIVE: We evaluated outcomes after hand-assisted (HALC) and straight laparoscopic (LC) techniques for the initial laparoscopic total abdominal colectomy (TAC) procedures performed by surgeons starting their laparoscopic careers. METHOD: The first eight HALC cases of two surgeons performing TAC by this technique (Group A) were compared with the first (Group B) and last eight (Group C) TAC cases of three surgeons performing LC. Groups A and B were compared with a matched group of open total colectomy cases (Group D) and to the eight cases performed by an experienced surgeon (Group E). Demographics, intra-operative and postoperative outcomes including operation time, morbidity, conversion and readmission rates and length of hospital stay (LOS) were compared using Wilcoxon or Chi-squared tests. RESULTS: Demographics of the patients were similar. Groups A, B C and E had similar operating time (P = 0.10) which was significantly longer than Group D (P < 0.0001). Morbidity (P = 0.75) and readmission rates were similar (P = 0.89). Conversion rate was significantly higher for Group B (Group B: 41.7%vs Group A: 0%, P = 0.008), in the early period. LOS was comparable between minimally invasive groups but significantly shorter than open surgery group (P = 0.0005). For Groups A and C, operating time (P = 0.55), conversion rate (P = 0.11), morbidity (P = 0.83) and LOS (P = 0.12) were similar. CONCLUSIONS: Hand-assisted laparoscopic colectomy may be associated with a significantly shorter learning curve for TAC as results are better than early LC and comparable with LC performed by experienced laparoscopic surgeons. It may be a better option for surgeons early in their laparoscopic career.

Laparoscopic single-port colectomy for sigmoid cancer.

BACKGROUND: Single-port laparoscopic surgery can be performed via one incision hidden in the umbilicus. Herein, we report a patient with a sigmoid colon cancer undergoing single-port laparoscopic sigmoid colectomy. METHODS: Laparoscopic single-port sigmoid colectomy through a 3-cm umbilical incision was performed on a patient with a diagnosis of sigmoid cancer. Patient was 54-year-old female with a body mass index of 25.8 kg/m(2). Preoperatively, a CAT scan in the metastasis evaluation did not show any lesion. RESULTS: The total operative time was 198 min. Estimated blood loss was 300 ml. Length of hospital stay was 3 days. Patient had no intraoperative or postoperative complications. Examination of pathological specimen showed a specimen containing a circumferential lesion measuring 5 cm x 2.5 cm x 2.5 cm with adequate surgical margins (10 and 5.5 cm), and no regional lymph node metastases in 14 lymph nodes collected. Patient did not receive adjuvant chemotherapy after surgery. Colonoscopy performed 1 year after surgery showed no neoplasm or polyp identified. Abdomen and pelvis CT also found no evidence of recurrence or metastatic disease. CONCLUSION: Single-port laparoscopic surgery may allow common benign procedures via an incision in the umbilicus. It can also be performed with good surgical and oncologic results in selected patients with a colorectal cancer.

Outcomes for case-matched laparoscopically assisted versus open restorative proctocolectomy.

BACKGROUND: The aim of this study was to compare safety, early and late outcomes, quality of life and functional results of laparoscopically assisted versus open ileal pouch-anal anastomosis (IPAA). METHODS: Patients who had laparoscopically assisted IPAA between 1992 and 2007 were identified from a database and retrospectively matched for age, sex, body mass index (BMI) and operation date to patients who had open IPAA at a ratio of 1:2. Intraoperative, postoperative and long-term functional outcomes were compared. Quality of life was determined by the Cleveland Global Quality of Life scale at 1 and 5 years. RESULTS: A total of 119 patients (59 men, 60 women; mean(s.d) age 35.5(14.2) years, BMI 24.7(5.0) kg/m(2)) had laparoscopically assisted IPAA, with conversion in nine patients (7.6 per cent); these were compared with 238 patients who had open IPAA. The 30-day and long-term results were similar, as well as quality of life at 1 and 5 years, except that patients in the laparoscopic group had shorter median time to stoma action (2 versus 3 days; P = 0.001) and marginally shorter hospital stay. Median operating times were longer in the laparoscopic group (272 versus 163 min; P = 0.040). CONCLUSION: Laparoscopically assisted IPAA had similar outcomes to open IPAA, but with some short-term advantages.

Single-port laparoscopy in colorectal surgery.

PURPOSE: Laparoscopy is the approach of choice for the majority of colorectal disorders that require a minimally invasive abdominal operation. As the emphasis on minimizing the technique continues, natural orifice surgery is quickly evolving. The authors utilized an embryologic natural orifice, the umbilicus, as sole access to the abdomen to perform a colorectal procedure. Herein, we present our initial experience of single-port laparoscopic colorectal surgery using a Uni-X Single-Port Access Laparoscopic System (Pnavel Systems, Morganville, New Jersey, USA) with a multi-channel cannula and specially designed curved laparoscopic instrumentation. METHOD: The abdomen was approached through a 3.5 cm incision via the umbilicus and a single-port access device was utilized to perform a right hemicolectomy on a patient with an unresectable caecal polyp and a body mass index of 35. Ligation of the ileocolic artery was done with a LigaSure Device (Covidien Ltd, Norwalk, Connecticut, USA), and was followed by colonic mobilization, extraction and extracorporeal ileocolic anastomosis. RESULTS: The total operative time was 115 min with minimal blood loss. Hospital stay was 4 days with no undue sequelae. CONCLUSION: Single-port laparoscopic surgery may allow common colorectal laparoscopic operations to be performed entirely through the patient's umbilicus and enable an essentially scarless procedure. Additional experience and continued investigation are warranted.

Allogeneic peripheral-blood progenitor-cell transplantation for poor-risk patients with metastatic breast cancer.

PURPOSE: To evaluate the feasibility of allogeneic peripheral-blood progenitor-cell (PBPC) transplantation and to assess graft-versus-tumor effects in patients with metastatic breast cancer. PATIENTS AND METHODS: Ten patients with metastatic breast cancer that involved the liver or bone marrow were treated with high-dose chemotherapy and allogeneic PBPC transplantation. The median age was 42 years (range, 29 to 55). The median number of metastatic sites was three (range, one to five). The conditioning regimen was cyclophosphamide (6,000 mg/m2), carmustine (BCNU; 450 mg/m2), and thiotepa (720 mg/m2) (CBT regimen). Patients received graft-versus-host disease (GVHD) prophylaxis using cyclosporine- or tacrolimus-based regimens. RESULTS: All patients had engraftment and hematologic recovery. Three patients developed grade > or = 2 acute GVHD and four patients had chronic GVHD. After transplantation, one patient was in complete remission (CR), five achieved a partial remission (PR), and four had stable disease (SD). In two patients, metastatic liver lesions regressed in association with skin GVHD after withdrawal of immunosuppressive therapies. The median follow-up time was 408 days (range, 53 to 605). The median progression-free survival duration was 238 days (range, 53 to 510). CONCLUSION: We conclude that allogeneic PBPC transplantation is a feasible procedure for patients with poor-risk metastatic breast cancer. The regression of tumor associated with GVHD provides suggestive clinical evidence that graft-versus-tumor effects may occur against breast cancer. Compared with autologous transplantation, allogeneic PBPC transplantation is associated with the additional risks of GVHD and related infections. Allogeneic transplantation should only be performed in the context of clinical trials and its ultimate role requires demonstration of improved progression-free survival.

Laparoscopic exploration for the clinically undetected hernia in infancy and childhood.

BACKGROUND: Routine contralateral groin exploration in infants and children with a clinically detected inguinal hernia is the subject of much debate. The detection of a patent processus vaginalis by transinguinal laparoscopy has proven advantageous. However, controversy remains regarding the true incidence of a contralateral patent processus vaginalis as well as which of these will actually develop into a clinically apparent hernia. METHODS: From January 1997 through December 1999, 358 infants and children (aged 1 to 157 months, mean 32) were treated in the three University of Oklahoma teaching hospitals in Tulsa, Oklahoma, for inguinal hernia. The findings at laparoscopic exploration of the contralateral side were recorded to determine the incidence of contralateral patency as it relates to a child's age, gender, and side of the initial clinical diagnosis. RESULTS: The overall incidence of a patent processus vaginalis on contralateral examination was 33% (117 of 358). All patent processus vaginalis were repaired. Bilateral inguinal hernia was significantly more common in younger patients (present in 50% if less than 1 year, 45% if less than 2 years, 37% if less than 5 years, and 15% if greater than 5 years of age; P <0.05). In boys, the incidence was 49%, 45%, and 32% in those under 1 year of age, under 2 years of age, and in total, respectively. In girls, the incidence was 59%, 50%, and 37% in those under 1 year of age, under 2 years of age, and in total, respectively. The side of the clinically detected hernia did not influence the laparoscopic findings of a contralateral hernia with 30% (50 of 169) positive findings on left inguinal exploration versus 31% (28 of 90) positive findings on right inguinal exploration. CONCLUSIONS: The high incidence of a contralateral patent processus vaginalis warrants routine laparoscopic exploration in infants and children undergoing unilateral inguinal hernia repair, especially those less than 5 years of age. The use of transinguinal laparoscopic explorations avoids unnecessary open exploration in 66% of infants and children undergoing inguinal hernia repair.

Phyllodes tumors of the breast: a review of 32 cases.

Most general surgeons involved in breast cancer care have limited experience with phyllodes tumors. We analyzed a comprehensive database incorporating 8567 breast cancer cases treated surgically in the Tulsa, Oklahoma, region between 1969 and 1993. This yielded 32 cases of phyllodes tumors (0.37%) in 31 patients. The median age was 57 years (range, 18-91). There were 9 low-grade (28%), 2 intermediate-grade (6%), and 21 high-grade (66%) lesions. Size distribution consisted of 23 (72%) lesions 5 cm or less and 9 (28%) greater than 5 cm (mean, 3; range, 1.2-17.5 cm). Of 137 resected nodes in 13 patients, none were positive for metastatic disease. Surgical management consisted of wide excision or mastectomy. No patients received adjuvant chemoradiation therapy. The disease-free, locoregional disease-free, and overall mean survival rates were 80, 81, and 97 months, respectively. Ten-year disease-free survival (DFS), locoregional disease-free survival (LRDFS), and overall survival (OS) rates were 66, 72, and 55 per cent, respectively. Although there was a tendency toward a higher rate of locoregional recurrences and metastases with high-grade lesions, this was not statistically significant and did not affect DFS, LRDFS, or OS rates. Similarly, size of lesion did not affect DFS, LRDFS, or OS rates. Three patients (9.6%) had metastatic disease at presentation, and a further two (6.4%) developed metastases during follow-up. Overall, nine (28.1%) recurrences developed in eight patients, seven locoregional and two distant. Four patients (12.9%) died with evidence of disease. These findings indicate prolonged survival in this patient population with cystosarcoma phyllodes. Wide local excision of primary and recurrent lesions remains the mainstay of therapy. Neither regional lymph node dissection nor adjuvant chemoradiation adds significant benefit.

Adjuvant radiation after modified radical mastectomy for breast cancer fails to prolong survival.

Recent literature has reported improved local disease control and overall survival in premenopausal node-positive (stage II, and III) breast cancer patients undergoing modified radical mastectomy (MRM) using radiation therapy (RT) combined with chemotherapy. To assess the efficacy of postoperative RT in our own community, we analyzed all patients undergoing MRM for carcinoma utilizing an extensive database from the three major teaching hospitals in Tulsa, OK, between 1965 and 1993. A total of 5257 patients underwent MRM during this time period. One hundred thirty-seven patients were excluded for insufficient data or because they were found to be at stage IV, leaving a total study population of 5125. Overall survival (OS), overall mean survival (MS), disease-free survival (DFS), and locoregional DFS (LRDFS) were analyzed for all patients and were further analyzed according to stage, lymph node involvement, and menopausal status. Median follow-up was 103 months. Statistical analysis was performed using Kaplan-Meier and t-tests. The DFS at 10 years was 65 per cent in the RT group and 80 per cent in the patients who did not receive RT (P = 0.00). No improved DFS was obtained in the radiation-treated patients, regardless of stage, lymph node involvement, or menopausal status. Similarly, the LRDFS at 10 years was 91 per cent in the RT group and 96 per cent in the patients who did not receive RT (P = 0.00). No improved LRDFS was obtained in the radiation-treated patients, regardless of stage, lymph node involvement, or menopausal status. The overall MS was 97 months in the RT group and 104 months in the patients who did not receive RT (P = 0.00). Comparisons of overall MS rates revealed apparent survival benefits from RT in the premenopausal node-negative group, postmenopausal one to four-positive-node group, and all stage I patients. This apparent survival advantage was not confirmed by Kaplan-Meier curves of OS. No other overall MS differences were detected according to stage, lymph node, or menopausal status. Using Kaplan-Meier survival curves, the OS in the RT group at 10 years was 46 per cent, and 63 per cent in the patients who did not receive RT (P = 0.00). No improved OS was obtained in the radiation-treated patients, regardless of stage, lymph node involvement, or menopausal status. These findings from a large breast cancer database failed to demonstrate any meaningful benefit from RT after MRM and serve to further question the efficacy of this treatment modality in postmastectomy breast cancer patients.

Rapid updating of optical arbitrary waveforms via time-domain multiplexing.

We demonstrate high-fidelity optical arbitrary waveform generation with 5 GHz waveform switching via time-domain multiplexing. Compact, integrated waveform shapers based on silica arrayed-waveguide grating pairs with 10 GHz channel spacing are used to shape (line-by-line) two different waveforms from the output of a 10-mode x 10 GHz optical frequency comb generator. Characterization of the time multiplexer's complex transfer function (amplitude and phase) by frequency-resolved optical gating permits compensation of its impact on the switched waveforms and matching of the measured and target waveforms to better than G'=5%.

Stapled hemorrhoidopexy height as outcome indicator.

BACKGROUND: Postoperative expectations after stapled hemorrhoidopexy are still being clarified. Our purpose was to evaluate how outcome is affected by staple line height (SLH) above the dentate line and specimen histology. METHODS: A prospective database identified demographics, SLH, histology, narcotic use, return to work, and resolution or recurrence of preoperative symptoms data for analysis. RESULTS: One hundred five patients were analyzed; median age was 49 years. Median RTW and narcotic use were 9 and 4 days, respectively. Patients with squamous epithelium-containing specimens had longer narcotic use (P = .038), whereas patients with SLH >20 mm had shorter narcotic use (P = .021). Preoperative pain and bleeding resolved more frequently with SLH >20 mm (P = .036) and less frequently with SLH >40 mm (P = .032). Patients with poor sphincter tone were more likely to have SLH >20 mm (P = .044). Postoperative symptoms recurred more frequently in patients with SLH >40 mm (P = .001). CONCLUSIONS: Hemorrhoidopexy SLH and histology can impact postoperative outcomes. SLH should be >20 mm yet < or =40 mm above the dentate, avoiding squamous epithelium.