Can Teamwork and High-Volume Experience Overcome Challenges of Lymphadenectomy in Morbidly Obese Patients (Body Mass Index of 40 kg/m2 or Greater) with Endometrial Cancer?: A Cohort Study of Robotics and Laparotomy and Review of Literature.

OBJECTIVE: This study aimed to compare surgical outcomes and the adequacy of surgical staging in morbidly obese women with a body mass index (BMI) of 40 kg/m or greater who underwent robotic surgery or laparotomy for the staging of endometrioid-type endometrial cancer. METHODS: This is a retrospective cohort study of patients who underwent surgical staging between May 2011 and June 2014. Patients' demographics, surgical outcomes, intraoperative and postoperative complications, and pathological outcomes were compared. RESULTS: Seventy-six morbidly obese patients underwent robotic surgery, and 35 underwent laparotomy for surgical staging. Robotic surgery was associated with more lymph nodes collected with increasing BMI (P < 0.001) and decreased chances for postoperative respiratory failure and intensive care unit admissions (P = 0.03). Despite a desire to comprehensively stage all patients, we performed successful pelvic and paraaortic lymphadenectomy in 96% versus 89% (P = 0.2) and 75% versus 60% (P = 0.12) of robotic versus laparotomy patients, respectively. In the robotic group, with median BMI of 47 kg/m, no conversions to laparotomy occurred. The robotic group experienced less blood loss and a shorter length of hospital stay than the laparotomy group; however, the surgeries were longer. CONCLUSIONS: In a high-volume center, a high rate of comprehensive surgical staging can be achieved in patients with BMI of 40 kg/m or greater either by laparotomy or robotic approach. In our experience, robotic surgery in morbidly obese patients is associated with better quality staging of endometrial cancer. With a comprehensive approach, a professional bedside assistant, use of a monopolar cautery hook, and our protocol of treating morbidly obese patients, robotic surgeries can be safely performed in the vast majority of patients with a BMI of 40 kg/m or greater, with lymph node counts being similar to nonobese patients, and with conversions to laparotomy reduced to a minimum.

Longitudinal associations among relationship factors, partner change, and sexually transmitted infection acquisition in adolescent women.

OBJECTIVES: New sex partners put adolescents at increased risk for sexually transmitted infections (STIs), even when these sex partners are nonoverlapping. Although the risk of partner change is well described, little is known about its antecedents. We prospectively examined associations between relationship characteristics, partner change, and subsequent STI during intervals of "serial monogamy." METHODS: As part of a longitudinal study, 332 adolescent women were interviewed and tested for gonorrhea, chlamydia, and trichomonas every 3 months for up to just over 6 years. Interviews covered partner-specific relationship characteristics and sexual behaviors. The quarterly interval, a 3-month period bracketed by interviews and STI testing, was the unit of analysis. We examined associations among relationship factors, partner change, and subsequent STI using a series of mixed regression models, controlling for age, STI at Time 1, and condom nonuse. RESULTS: Age, lower relationship quality, and lower levels of partner closeness to friends and family predicted partner change from Time 1 to Time 2. In turn, partner change was associated with acquisition of a new STI at Time 2. Although relationship factors did not exert a direct effect on STI at Time 2, they improved partner change-STI model fit. Similar patterns were seen with each organism. CONCLUSION: Relationship factors drive partner change, which in turn contributes to STI acquisition. STI prevention research may need to focus on the relationship antecedents to partner change, in addition to the partner change itself.

Chlamydia muridarum-specific CD4 T-cell clones recognize infected reproductive tract epithelial cells in an interferon-dependent fashion.

During natural infections Chlamydia trachomatis urogenital serovars replicate predominantly in the epithelial cells lining the reproductive tract. This tissue tropism poses a unique challenge to host cellar immunity and future vaccine development. In the experimental mouse model, CD4 T cells are necessary and sufficient to clear Chlamydia muridarum genital tract infections. This implies that resolution of genital tract infection depends on CD4 T-cell interactions with infected epithelial cells. However, no laboratory has shown that Chlamydia-specific CD4 T cells can recognize Chlamydia antigens presented by major histocompatibility complex class II (MHC-I) molecules on epithelial cells. In this report we show that MHC-II-restricted Chlamydia-specific CD4 T-cell clones recognize infected upper reproductive tract epithelial cells as early as 12 h postinfection. The timing of recognition and degree of T-cell activation are dependent on the interferon (IFN) milieu. Beta IFN (IFN-beta) and IFN-gamma have different effects on T-cell activation, with IFN-beta blunting IFN-gamma-induced upregulation of epithelial cell surface MHC-II and T-cell activation. Individual CD4 T-cell clones differed in their degrees of dependence on IFN-gamma-regulated MHC-II for controlling Chlamydia replication in epithelial cells in vitro. We discuss our data as they relate to published studies with IFN knockout mice, proposing a straightforward interpretation of the existing literature based on CD4 T-cell interactions with the infected reproductive tract epithelium.

A retrospective study of memantine in children and adolescents with pervasive developmental disorders.

RATIONALE: There are no drugs that have been shown to effectively treat the core social impairment of autism. OBJECTIVES: The purpose of this study was to examine the effectiveness and tolerability of memantine for social impairment in children and adolescents with pervasive developmental disorders (PDDs). MATERIALS AND METHODS: Medical records of 18 patients with PDDs consecutively treated with open-label memantine were retrospectively reviewed. The data reviewed included prospectively obtained assessments of severity (S) and improvement (I) using the Clinical Global Impressions Scale (CGI). Pretrial and follow-up parent ratings were also available on six patients using the Aberrant Behavior Checklist (ABC). RESULTS: Eighteen patients (15 male, 3 female; mean age=11.4 years, range 6-19 years) received memantine (mean dosage=10.1 mg/day, range 2.5-20 mg/day) over a mean duration of 19.3 weeks (range 1.5-56 weeks). Eleven of 18 (61%) patients were judged responders to memantine based on a rating of "much improved" or "very much improved" on the CGI-I. Significant improvement was also seen on the CGI-S. Improvement was primarily seen clinically in social withdrawal and inattention. Adverse effects occurred in 7 of 18 (39%) patients and led to drug discontinuation in 4 of 18 (22%) patients. Thirteen of 18 (72%) patients received stable doses of concomitant medications during the memantine trial. CONCLUSIONS: In this open-label retrospective study, memantine was effective in a number of patients with PDDs. Controlled studies are warranted to further assess the efficacy and safety of memantine in PDDs.

Dismounted Blast Injuries in Patients Treated at a Role 3 Military Hospital in Afghanistan: Patterns of Injury and Mortality.

BACKGROUND: The purposes of this study are to define the pattern of injuries sustained by dismounted troops exposed to improvised explosive devices blasts treated at a Role 3 combat support hospital and to assess injury patterns and mortality associated with the mechanism. Our hypothesis was that mortality is associated with pelvic fracture, massive transfusion, high Injury Severity Score (ISS), multiple limb amputations, and transfer from a Role 2 facility. STUDY DESIGN: Retrospective study of 457 patients. Analysis performed on trauma registry data and systematic review of radiographs. RESULTS: 99.9% were men with a median age of 23 years and median ISS 10. 141 patients (30.9%) required massive blood transfusion. Limb amputations were frequently observed injuries, 109 of 172 amputees (63.4%) had a double amputation. 34 subjects (7.4%) had pelvic fractures; majority of pelvic fractures (88%) were unstable (Tile B or C). Risk factors associated with the overall mortality rate of 1.8% were an ISS greater than 15 (odds ratio: 11.5; 95% confidence interval: 1.38, 533; p = 0.009), need for massive transfusion (p < 0.0001), and the presence of a pelvic fracture (odds ratio: 7.63; 95% confidence interval: 1.13, 41.3; p = 0.018). CONCLUSIONS: Dismounted improvised explosive devices blast injuries result in devastating multiple limb amputations and unstable pelvic fractures, which are associated with mortality after initial trauma resuscitation at a Role 3 hospital.

Effectiveness of the combat pelvic protection system in the prevention of genital and urinary tract injuries: An observational study.

BACKGROUND: Historically, the incidence of genital and urinary tract (GU) injuries in major conflicts has been approximately 5%. To mitigate the risk of blast injury to the external genitalia, the United States and United Kingdom issued protective overgarments and undergarments to troops deployed in support of Operation Enduring Freedom. These two systems combined constitute the pelvic protection system (PPS). Our hypothesis was that PPS use is associated with a reduction of GU injuries in subjects exposed to dismounted improvised explosive device blast injuries. METHODS: We identified two groups for comparison: those who were confirmed to have worn the PPS at time of injury (n = 58) and a historical control group who were confirmed as not wearing the PPS (non-PPS) (n = 61). Patients with any level of lower extremity amputation from dismounted improvised explosive device blast mechanism were included. The primary outcome measure was presence of a GU injury on admission. A univariate analysis assessing the strength of association with odds ratios and 95% confidence intervals was performed between the PPS and non-PPS groups. RESULTS: Mean Injury Severity Score (ISS) was higher in the PPS versus the non-PPS group (26.1 vs. 19.3, p = 0.0012). Overall, 31% of the patients in the PPS group sustained at least one GU injury versus 62.3% in the non-PPS group. The odds ratio of sustaining a GU injury in the PPS group as compared with the PPS group is 0.28 (31% vs. 62.3%; 95 % confidence interval, 0.62-0.12; p < 0.001). The most frequent injures were open scrotal/testes wounds, followed by open penis, and open bladder/urethra injuries. CONCLUSION: The use of the PPS is associated with a decreased odds ratio of GU injury. Despite a 31% absolute reduction, future work should focus on improved efficiency. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level IV; therapeutic study, level V.

A comparison of young women's actual and assigned timing of use of a microbicide surrogate.

PURPOSE: This study examined young women's actual timing of use of a microbicide surrogate gel (vaginal moisturiser (VM)) compared with assigned timing conditions. METHODS: Participants used a VM with coitus during 4-week cycles over a 3-year period in random timing sequences: 1h before coitus, 10 min before coitus and 10 min after coitus. Daily diaries collected information related to coital behaviours, VM use and timing, and participants' and partners' VM assessments. Descriptive and mixed-effects model analyses were conducted. RESULTS: At least three VM timing conditions were completed by 109 women aged 18-22 years old. Of 17?772 diary days collected, coitus was reported on 2128 (1252 with VM use; 59%). Median times between VM application and coitus were: 60 min before coitus (mean=68.2; s.d.=76.9) for the 1-h pre-coital group, 13.5 min before coitus (mean=44.9; s.d.=117.1) for the 10-min pre-coital group and 5 min before coitus (mean=24.5; s.d.=205.1) for the 10-min post-coital group. Women reported that the VM was very easy to use (68%), it was somewhat messy (61%), they were very wet during sex (81%), sex was very good (80%) and their partners liked using the VM (38%). CONCLUSIONS: Overall, the VM was rated positively. There was substantial deviation in application time across timing conditions, with significantly greater variability in the post-coital group. These findings contribute to understanding of how VMs are accepted and used, with implications for HIV prevention with microbicides requiring specific application timing.

Short-Term Rationing of Combination Antiretroviral Therapy: Impact on Morbidity, Mortality, and Loss to Follow-Up in a Large HIV Treatment Program in Western Kenya.

Background. There was a 6-month shortage of antiretrovirals (cART) in Kenya. Methods. We assessed morbidity, mortality, and loss to follow-up (LTFU) in this retrospective analysis of adults who were enrolled during the six-month period with restricted cART (cap) or the six months prior (pre-cap) and eligible for cART at enrollment by the pre-cap standard. Cox models were used to adjust for potential confounders. Results. 9009 adults were eligible for analysis: 4,714 pre-cap and 4,295 during the cap. Median number of days from enrollment to cART initiation was 42 pre-cap and 56 for the cap (P < 0.001). After adjustment, individuals in the cap were at higher risk of mortality (HR = 1.21; 95% CI : 1.06-1.39) and LTFU (HR = 1.12; 95% CI : 1.04-1.22). There was no difference between the groups in their risk of developing a new AIDS-defining illness (HR = 0.92 95% CI 0.82-1.03). Conclusions. Rationing of cART, even for a relatively short period of six months, led to clinically adverse outcomes.

Task-shifting of antiretroviral delivery from health care workers to persons living with HIV/AIDS: clinical outcomes of a community-based program in Kenya.

OBJECTIVES: To assess whether community-based care delivered by people living with HIV/AIDS (PLWAs) could replace clinic-based HIV care. DESIGN: Prospective cluster randomized controlled clinical trial. SETTING: Villages surrounding 1 rural clinic in western Kenya. SUBJECTS: HIV-infected adults clinically stable on antiretroviral therapy (ART). INTERVENTION: The intervention group received monthly Personal Digital Assistant supported home assessments by PLWAs with clinic appointments every 3 months. The control group received standard of care monthly clinic visits. MAIN OUTCOMES MEASURED: Viral load, CD4 count, Karnofsky score, stability of ART regimen, opportunistic infections, pregnancies, and number of clinic visits. RESULTS: After 1 year, there were no significant intervention-control differences with regard to detectable viral load, mean CD4 count, decline in Karnofsky score, change in ART regimen, new opportunistic infection, or pregnancy rate. Intervention patients made half as many clinic visits as did controls (P < 0.001). CONCLUSIONS: Community-based care by PLWAs resulted in similar clinical outcomes as usual care but with half the number of clinic visits. This pilot study suggests that task-shifting and mobile technologies can deliver safe and effective community-based care to PLWAs, expediting ART rollout and increasing access to treatment while expanding the capacity of health care institutions in resource-constrained environments.