Comparison of laparoscopic sleeve gastrectomy to laparoscopic Roux-en-Y gastric bypass for morbid obesity in a military institution.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is gaining acceptance in the bariatric community as a definitive weight loss procedure; however, longitudinal data remain limited. The objective of this study was to compare weight loss results of LSG with laparoscopic Roux-en-Y gastric bypass (LRYGB) up to 5 years postoperatively using anthropometric measurements. METHODS: Prospectively collected bariatric database at the Naval Medical Center San Diego was retrospectively reviewed from 2005-2011 . Anthropometric factors, including weight and hip circumference were measured during standard yearly follow-up appointments. Surgical outcomes were tested by the Student t test and demographic variables by Fisher's exact and Wilcoxon rank-sum tests. RESULTS: Follow-up was achieved in 147/226 LRYGB versus 130/208 LSG at year 1, 92/195 versus 81/151 at year 2, 64/145 versus 50/100 at year 3, 32/81 versus 18/54 at year 4, and 12/42 versus 14/15 at year 5. The excess weight loss (EWL) for LRYGB versus LSG was 72% versus 64.7% at 1 year (P = .002), 71.3% versus 65.5% at 2 years (P = .113), and 68.3% versus 57.4% at 5 years (P = .252), respectively. Similarly, the body mass index (BMI) decrease was statistically significant at 1 year (P = .001) but not on subsequent annual visits. Mean percent body adiposity index (BAI) decrease was 28.4% for LRYGB versus 26.8% for LSG at 1 year (P = .679) and 21.8% versus 29.8% at 2 years (P = .134), respectively. Weight loss measured in terms of %EWL and decrease in BMI and BAI did not show significance between LRYGB and LSG 2 years after surgery. CONCLUSION: Our study provides similar long-term weight loss between LSG and LRYGB, and therefore, LSG is a viable option as a definitive bariatric procedure.

B-type natriuretic peptide: perioperative patterns in congenital heart disease.

OBJECTIVE: B-type natriuretic peptide (BNP) has diagnostic, prognostic, and therapeutic roles in adults with heart failure. BNP levels in children undergoing surgical repair of congenital heart disease (CHD) were characterized broadly, and distinguishable subgroup patterns delineated. DESIGN: Prospective, blinded, observational case series. SETTING: Academic, tertiary care, free-standing pediatric hospital. PATIENTS: Children with CHD; controls without cardiopulmonary disease. Interventions. None. MEASUREMENTS: Preoperative cardiac medications/doses, CHD lesion types, perioperative BNP levels, intraoperative variables (lengths of surgery, bypass, cross-clamp), postoperative outcomes (lengths of ventilation, hospitalization, open chest; averages of inotropic support, central venous pressure, perfusion, urine output; death, low cardiac output syndrome (LCOS), cardiac arrest; readmission; and discharge medications). RESULTS: Median BNP levels for 102 neonatal and non-neonatal controls were 27 and 7 pg/mL, respectively. Serial BNP measures from 105 patients undergoing CHD repair demonstrated a median postoperative peak at 12 hours. The median and interquartile postoperative 24-hour average BNP levels for neonates were 1506 (782-3784) pg/mL vs. 286 (169-578) pg/mL for non-neonates (P < 0.001). Postoperative BNP correlated with inotropic requirement, durations of open chest, ventilation, intensive care unit stay, and hospitalization (r = 0.33-0.65, all P < 0.001). Compared with biventricular CHD, Fontan palliations demonstrated lower postoperative BNP (median 150 vs. 306 pg/mL, P < 0.001), a 3-fold higher incidence of LCOS (P < 0.01), and longer length of hospitalization (median 6.0 vs. 4.5 days, P= 0.01). CONCLUSIONS: Perioperative BNP correlates to severity of illness and lengths of therapy in the CHD population, overall. Substantial variation in BNP across time as well as within and between CHD lesions limits its practical utility as an isolated point-of-care measure. BNP commonly peaks 6-12 hours postoperatively, but the timing and magnitude of BNP elevation demonstrates notable age-dependency, peaking earlier and rising an order of magnitude higher in neonates. In spite of higher clinical acuity, non-neonatal univentricular CHD paradoxically demonstrates lower BNP levels compared with biventricular physiologies.

Vulvar cancer in young women: demographic features and outcome evaluation.

OBJECTIVE: The objective of the study was to identify prognostic and environmental factors associated with vulvar carcinoma in young women. STUDY DESIGN: This study was a review of patients younger than 45 years who were diagnosed with vulvar squamous cell carcinoma between 1994 and 2006. RESULTS: Fifty-six patients were identified. Median age was 38 years and median follow-up was 25.3 months. Fifty-eight percent of patients presented with stage I disease; 77% smoked tobacco. Of patients with advanced disease, 53.3% were smokers, 40% had human papillomavirus (HPV) exposure, 46.7% had a history of vulvar intraepithelial neoplasia (VIN), and 6.7% were immunocompromised. Symptoms were present for more than 12 months in 47%, but symptom duration did not correlate with stage (P = .42) or positive lymph nodes (P = .28). Disease recurred in 10.7% and 5.4% died of disease. CONCLUSION: Young women with vulvar cancer tend to have early-stage disease, smoke, have a history of HPV, and have VIN. Many of the factors that place these patients at continuous risk are modifiable.

Renal toxicity in children undergoing total body irradiation for bone marrow transplant.

PURPOSE: Contribution of total body irradiation (TBI) to renal toxicity in children undergoing the bone marrow transplant (BMT) remains controversial. We report our institutional retrospective study that evaluates the frequency of acute and chronic renal dysfunction in children after using total body irradiation (TBI) conditioning regimens. MATERIALS AND METHODS: Between 1995 and 2003, 60 children with hematological malignancies underwent TBI as part of a conditioning regimen before allogeneic BMT. Patients received 4-14Gy at 1.75-2Gy/fraction in six-eight fractions. Lung shielding was used in all patients to limit lung dose to less than 10Gy; renal shielding was not utilized. All patients had baseline renal function assessment and renal dysfunction post-BM was mainly evaluated on the basis of persistent serum creatinine elevation at acute (0-90 days) and chronic (>90 days) intervals after completion of BMT. RESULTS: Acute renal dysfunction (ARD) was documented in 27 patients (45%); the majority had concurrent diagnosis of veno-occlusive disease (VOD) or graft-versus-host disease (GVHD) and other potential causes (sepsis, antibiotic). The risk for delayed renal dysfunction (DRD) at 1 year approached 25% for surviving patients. The ARD was strongly linked with the risk of the DRD. There was no statistically significant relationship between ARD, DRD and underlying diagnosis, GVHD, VOD or TBI doses with both univariate and multivariate analyses. The younger age (<5 years) had significantly increased risk for the development of ARD (p=0.011). CONCLUSION: Our analysis validates high incidence of renal dysfunction in the pediatric BMT population. In contrast to other reports we did not find total body irradiation dose to be a risk factor for renal dysfunction. Future prospective studies are needed to assess risk factors and interventions for this serious toxicity in children following allogeneic BM.

Comparison of oral aspirin versus topical applied methyl salicylate for platelet inhibition.

BACKGROUND: Oral acetylsalicylic acid (aspirin) is the primary antiplatelet therapy in the treatment of acute myocardial infarction and acute coronary syndrome. Methyl salicylate (MS; oil of wintergreen) is compounded into many over-the-counter antiinflammatory muscle preparations and has been shown to inhibit platelet aggregation locally and to be absorbed systemically. OBJECTIVE: To assess the ability of topically applied MS to inhibit systemic platelet aggregation for patients who are unable to tolerate oral drug therapy. METHODS: A randomized, prospective, blinded, crossover study was conducted in 9 healthy men, aged 30-46 years. All subjects ingested 162 mg of aspirin or applied 5 g of 30% MS preparation to their anterior thighs. There was a minimum 2-week washout period between study arms. Blood and urine were collected at baseline and at 6 hours. An aggregometer measured platelet aggregation over time against 5 standard concentrations of epinephrine, and a mean area under the curve (AUC) was calculated. Urinary metabolites of thromboxane B(2) were measured by a standard enzyme immunoassay. Differences in and between groups at baseline and 6 hours were tested by the Wilcoxon signed-rank test. RESULTS: Baseline platelet aggregation did not differ significantly between the 2 arms of the study (median AUC [% aggregation(*)min]; binominal confidence intervals): aspirin 183; 139 to 292 versus MS 197; 118 to 445 (p = 0.51). Both aspirin and MS produced statistically significant platelet inhibition; aspirin decreased the AUC from 183; 139 to 292 to 85; 48 to 128 (p = 0.008) and MS decreased the AUC from 197; 118 to 445 to 112; 88 to 306 (p = 0.011). No significant difference was detected between baseline and 6-hour thromboxane levels for either aspirin (p = 0.779) or MS (p = 0.327). CONCLUSIONS: Topical MS and oral aspirin both significantly decrease platelet aggregation in healthy human volunteers.

The outcomes of lumbar microdiscectomy in a young, active population: correlation by herniation type and level.

STUDY DESIGN: Prospective longitudinal clinical study. OBJECTIVE: The purpose of our article was to investigate the clinical outcomes with type and level of disc herniation in a young, active population undergoing lumbar microdiscectomy. SUMMARY OF BACKGROUND DATA: There are few reported outcomes studies on the relationship between disc herniation level, type of disc herniation, and surgical outcomes of lumbar microdiscectomy in a young, active population. METHODS: One hundred ninety-seven (197) consecutive single-level lumbar microdiscectomies performed by a single surgeon were prospectively followed over a 3-year period. All patients had failed a period of nonoperative care including physical therapy and/or transforaminal epidural steroid injections. One hundred eighty-three patients (139 males, 44 females) with a mean age of 27.0 years (range 19-46 years) were prospectively followed for a mean of 26 months (range, 12-38 months). Outcomes were assessed using Visual Analog Scale (VAS), Oswestry disability index, patient satisfaction, return to military duty, and need for additional surgery. The type of disc herniation (contained, extruded, or sequestered) and the lumbar level of herniation were also recorded. RESULTS: At final follow-up, 84% (154 of 183) of patients had returned to unrestricted military duty; 16% (29) had been medically discharged. The mean decrease in VAS leg pain score was 4.7 points (from mean preoperative 7.2 to mean postoperative 2.5); 80% (146) reported a decrease of greater than 2 points. The mean Oswestry index improved from 53.6 before surgery to 21.2 at final follow-up. Overall, 85% (156) were satisfied with their surgery. Six patients had recurrent herniations (3%) with 4 of the 6 undergoing additional surgery. Patients with preoperative VAS scores consistent with a preponderance of radicular leg pain versus back pain demonstrated better surgical outcomes in all categories (P < 0.001) When classified by disc herniation type, sequestered discs at all levels demonstrated better Oswestry and VAS scores versus extruded or contained disc herniations. (P < 0.001) Disc herniations at the L5-S1 level had significantly greater improvements in both mean VAS leg and Oswestry outcome scores than disc herniations at the L4-L5 level. (P < 0.001) Preexisting restricted duty status at time of first surgical consultation was associated with poorer outcomes. Smokers had a significantly lower return to full active military duty (P = 0.037). CONCLUSION: Microdiscectomy for symptomatic lumbar disc herniations in young, active patients with a preponderance of leg pain who have failed nonoperative treatment demonstrated a high success rate based on validated outcome measures, patient satisfaction, and return to active duty. Patients with disc herniations at the L5-S1 level had significantly better outcomes than did those at the L4-L5 level. Patients with sequestered or extruded lumbar disc herniations had significantly better outcomes than did those contained herniations. Patients with contained disc herniations, a predominance of back pain, on restricted duty and smoking should be counseled before surgery of the potential for less satisfaction, poorer outcomes scores, and decreased return to duty rates.

Applying population dynamics modeling to patients with lymph node positive prostate cancer.

PURPOSE: We previously reported the applications of population dynamics modeling on cancer populations. Cancer death populations show a reproducible progression from an essentially linear phase, in which cure is likely, through a Gompertzian phase of advancing disease to an exponential phase of incurable disease. The latter 2 phases meet at an inflection, at which the disease process becomes incurable. Patients with prostate cancer and positive lymph nodes are often considered to be doomed to distant failure. We applied these models to that population to examine whether those data support this presumption. MATERIALS AND METHODS: The public use Surveillance, Epidemiology and End Results Registry was queried for observed survival data on the population of men with nonmetastatic prostate cancer and positive lymph nodes presenting between 1988 and 1993. Lymph node data were first collated in 1988. The closing date was selected to allow a minimum 10-year followup since Surveillance, Epidemiology and End Results data are complete through 2003. These data were modeled using Gompertzian and exponential models to determine whether an inflection point exists. RESULTS: Gompertzian modeling best described the observed survival of the 2,265 patients retrieved from the Surveillance, Epidemiology and End Results Registry. Analysis of the data revealed an inflection 4 years after diagnosis. We interpreted this to indicate that there is a 4-year window during which curative therapy may be initiated in this population of patients. CONCLUSIONS: Patients with lymph node positive prostate cancer need not be considered to represent a doomed population, although new therapies are crucial in that case. We theorize that a 4-year window exists during which potentially curable therapies may be performed.

Comparative treatment of alpha-amanitin poisoning with N-acetylcysteine, benzylpenicillin, cimetidine, thioctic acid, and silybin in a murine model.

STUDY OBJECTIVE: The foraging of wild mushrooms can be complicated by toxicity from several mushroom types. Amatoxin, a peptide contained in several mushroom species, accounts for the majority of severe mushroom poisonings by binding to RNA polymerase II irreversibly, leading to severe hepatonecrosis. There is no effective antidote for severe amatoxin poisoning. We compare the effectiveness of 5 potential antidotal therapies in limiting the degree of hepatonecrosis in a randomized, controlled, murine model of amatoxin-induced hepatotoxicity. METHODS: One hundred eighty male Institute of Cancer Research mice were randomized into 6 equal groups. Within each group, 21 mice were intraperitoneally injected with 0.6 mg/kg of alpha-amanitin (amatoxin); the remaining 9 were injected with 0.9% normal saline solution. Four hours postinjection, each group of 30 mice was randomized to 1 of 5 intraperitoneal treatments (N-acetylcysteine, benzylpenicillin, cimetidine, thioctic acid, or silybin) or normal saline solution. Repeated dosing was administered intraperitoneally every 4 to 6 hours for 48 hours. After 48 hours of treatment, each subject was killed, cardiac blood was aspirated for hepatic aminotransferase measurements (alanine transaminase and aspartate transaminase), and liver specimens were harvested to evaluate the extent of hepatonecrosis. The degree of hepatonecrosis was determined by a pathologist blinded to the treatment group and divided into 5 categories according to percentage of hepatonecrosis. RESULTS: Amanitin significantly increased aspartate transaminase in treated mice compared with normal saline solution-treated controls (mean [SD] 2,441 [2,818] IU/L versus 310 [252]; P=.03). None of the antidotal therapies were found to significantly decrease the increase in aminotransferases compared with controls. Further, none of the antidotal therapies demonstrated an important decrease in hepatonecrosis compared with controls when a histologic grading scale was used. CONCLUSION: In this murine model, N-acetylcysteine, benzylpenicillin, cimetidine, thioctic acid, and silybin were not effective in limiting hepatic injury after alpha-amanitin poisoning. Increases of aminotransferases and degrees of histologic hepatonecrosis were not attenuated by these antidotal therapies.

Free breathing gated delivery (FBGD) of lung radiation therapy: analysis of factors affecting clinical patient throughput.

PURPOSE: Accurate radiation targeting and delivery within the chest and abdomen is greatly affected by the respiratory cycle. Prior methods to minimize respiratory effect include breath-hold and abdominal compression techniques; these are subject to error secondary to variable inspiration/expiration volumes, or by the nature of many cancer patients having inherently poor respiratory function. However, advanced technology called free breathing gated delivery (FBGD) allows patients to breath normally during treatment. The photon beam is on only during a particular prescribed percentage of the respiratory cycle where the target tumor volume is minimized. Consequently, by using an intermittent beam, the time required to treat a patient is increased. No previous study has described the patient throughput ramifications of FBGD. PATIENTS AND METHODS: At Emory clinic, a gated treatment delivery system was inaugurated into clinical use beginning in June 2004. As of 12/31/2004, 15 patients have completed treatment with FBGD. The majority of patients had lung cancer (n=12) with single cases of adrenal metastasis, thymoma, and atypical carcinoid. Over 900 gated treatment fields (approximately 375 treatment sessions) were reviewed on an IRB-approved retrospective protocol. Records from the record-and-verify (R&V) system were queried using automated database mining software to obtain the treatment room time, treatment field time, beam-on time (BOT), dose rate, and monitor units (MU) for each treatment. The presence or absence of a dynamic wedge was also noted, as was the prescribed percent of the respiratory cycle treated. For comparison purposes, 13 non-gated lung cancer patients (lesions were not moving with respiration) were selected from the R&V database. RESULTS: Patients receiving FBGD required significantly more time for treatment delivery. The time required for FBGD was, on average, 5.5 times greater (range 1.2-12.2) than calculated BOT without gating. Time was further increased with the use of a dynamic wedge, which occurred in 45% (28/62) of the planned fields. The use of MV imaging also increased the time for FBGD treatment sessions by more than 7.5 min on average. CONCLUSIONS: FBGD uniformly increases the time required for RT delivery, and MV imaging and dynamic wedging even more so. Even though this technology more accurately targets tumor volumes while sparing normal tissue, the patient throughput issue may deter this technology from being implemented into busy clinical practices.

Practice analysis: techniques of head and neck surgeons and general surgeons performing thyroidectomy for cancer.

OBJECTIVE: Medical practice governance is made more challenging by the fact that many procedures may be performed by various medical or surgical specialties. Thyroid cancer surgery is performed by both physicians with general surgery (GS) and those with otolaryngology/head and neck surgery (HNS) credentials. Analyses describing differences in practice patterns between the 2 services have not been published previously. PATIENTS AND METHODS: The records of the Tumor Registry at the Naval Medical Center San Diego were reviewed for patients presenting with thyroid cancer between January 1, 1990, and December 31, 1999. The review included all patients undergoing partial or total thyroidectomy, and the operative techniques and complications were noted. RESULTS: Of the 178 patients who underwent thyroid cancer surgery in this period, charts were available for 136 (n = 87 HNS, n = 49 GS, 1 combined HNS/GS). There was no difference between the 2 services in terms of the percentage of patients undergoing lymph node sampling (P = 1.000), but each had different approaches to sampling techniques. Head and neck surgeons performed more total thyroidectomies (P < .001) and referred patients more frequently for postoperative radioiodine (P = .025); they resected 426 nodes in 32 patients (mean 13.3, median 6.5), of which 120 (28.2%) were positive. General surgeons resected 28 nodes in 11 patients (median 2.0, mean 2.6), of which 12 (42.8%) were positive (P = .009). Other variables were similar for services, including inpatient hospital days, estimated blood loss, number of patients with temporary hypoparathyroidism, and duration of hypocalcemia. CONCLUSION: In this cohort, otolaryngologists/head and neck surgeons and general surgeons have a significantly different approach with respect to lymph node sampling in the surgical therapy of thyroid cancer. Outcomes appear independent of technique.

Snoring significance in patients undergoing home sleep studies.

OBJECTIVE: To analyze the impact of snoring, independent of obstructive sleep apnea syndrome on patients referred for home sleep studies and to report a new technology for the reporting of snoring, using sophisticated sound collection and noise-canceling technology. STUDY DESIGN AND SETTING: A retrospective statistical review of consecutive anonymous data compiled from questionnaires and digital data of snoring loudness and duration measured at the upper lip during unattended home sleep studies in 4,860 patients referred for snoring and sleep-disturbed breathing. RESULTS: A strong relationship exists between a history of snoring and complaints of daytime sleepiness (80%), obesity (73%), and chronic fatigue (78%) (all yield P<0.001). By contrast, only 42% to 48% of patients without these symptoms complain of snoring. In 3 multiple-regression analyses, the percent of time snoring, average loudness, and peak loudness are all significantly predicted by the apnea hypopnea index (all P<0.003), body mass index (all P<0.001), and age (P=0.014). Daytime sleepiness was strongly predicted by percent time snoring (P=0.014), weakly by average loudness (P=0.046), and not at all by peak loudness (P=0.303). CONCLUSION: By using a pair of microphones placed at the upper lip, one that samples breath sounds and the other ambient sound and artifact noise, the NovaSOM QSG measures snoring while canceling ambient noise. The clinical impact of snoring on the patient as well as the bed partner, independent of obstructive sleep apnea syndrome, is an unrecognized factor in sleep-disturbed breathing. SIGNIFICANCE: Measurable criteria to define snoring are suggested. Snoring loudness is not measured in most laboratory Polysomnograms. EBM RATING: B-3b.

Effect of oral calcium disodium EDTA on iron absorption in a human model of iron overdose.

OBJECTIVE: Anecdotal case reports and animal models have suggested that the administration of CaNa2EDTA (EDTA) may be effective in reducing the absorption of iron after an oral iron overdose. We designed this study to determine the effect of orally administrated EDTA with or without activated charcoal (AC) on iron absorption after a mild iron ingestion in healthy human volunteers. METHODS: A randomized, crossover study was conducted in eight healthy human volunteers. All subjects ingested 5 mg/kg of elemental iron in the form of ferrous sulfate. One hour post ingestion, subjects were randomized to receive 35 mg/kg EDTA, EDTA plus 50 grams of AC, or water. Serial iron levels were obtained at baseline and every hour for the first 6 hours, then at 8, 12, and 24 hours. A 2-week washout was used between study arms. The Kruskal-Wallis test was used for the following comparisons between treatment groups: baseline serum iron levels, area under time-concentration curves (AUCs) from baseline to 12 hours and baseline to 24 hours, and peak iron levels. RESULTS: Baseline serum iron levels did not differ among the three treatment groups (p = 0.844). AUCs were not different among groups (p = 0.746 for 12 hr, p = 0.925 for 24 hr). AUC medians (with 95% binomial confidence bounds) for control, EDTA, EDTA + AC groups, respectively, for 12 hr were: 2813 (2298, 3561), 2570 (1669, 3476), and 2654 (2125, 3600); and for 24 hr were: 4083 (3488,5314), 4139 (2666, 5547), and 4274 (3336, 5577). Peak serum iron levels did not differ among treatment groups (p = 0.481). Peak iron level medians in microg/dL (with 95% binomial confidence bounds) were for control: 329 (253, 382), for EDTA: 271 (184, 375), and for EDTA + AC: 285 (229, 352). CONCLUSION: Orally administered EDTA did not significantly reduce iron absorption when administered 1 hour post iron ingestion during the 12 or 24-hour period following the ingestion of 5 mg/kg of elemental iron in healthy human volunteers.

Comparisons of causes of death and mortality rates among HIV-infected persons: analysis of the pre-, early, and late HAART (highly active antiretroviral therapy) eras.

METHODS: Comparisons of death-related variables during the 3 eras were performed. RESULTS: The number of deaths declined over the study period, with 987 deaths in the pre-HAART era, 159 deaths in the early HAART era (1997-1999), and 78 deaths in the late HAART era (2000-2003) (P < 0.01). The annual death rate peaked in 1995 (10.3 per 100 patients) and then declined to <2 deaths per 100 persons in the late HAART era (P < 0.01). The proportion of deaths attributable to infection decreased, but infection remained the leading cause of death in our cohort, followed by cancer. Of those who died, there was an increasing proportion of non-HIV-related deaths (32% vs. 9%; P < 0.01), including cardiac disease (22% vs. 8%; P < 0.01) and trauma (8% vs. 2%; P = 0.01) in the post-HAART versus pre-HAART era. Despite the absence of intravenous drug use and the low prevalence of hepatitis C coinfection in our cohort, an increasing proportion of deaths in the HAART era were attributable to liver disease, although the numbers are small. CONCLUSIONS: Despite increasing concerns regarding antiretroviral resistance, the death rate among HIV-infected persons in our cohort continues to decline. Our data show a lower death rate than that reported among many other US HIV-infected populations; this may be the result of open access to health care. A shift in the causes of death toward non-HIV-related causes suggests that a more comprehensive health care approach may be needed for optimal life expectancy; this may include enhanced screening for malignancy and heart disease as well as preventive measures for liver disease and accidents.

Survival of patients with untreated rectal cancer.

BACKGROUND AND OBJECTIVES: Untreated rectal cancer is uncommon given modern surgical techniques and chemoradiotherapy. However, neglected cancer may still occur in patients with limited access to medical care or who refuse conventional interventions. Outcome data on such patients is scarce, though valuable in educating patients on their prognosis or to compare with present therapeutic options. METHODS: To identify such data, a review was made of archival literature documenting outcomes in patients with untreated rectal cancer. A review of the Index Medicus and its predecessor volumes and an extensive MEDLINE search led to nine articles that contained relevant age at presentation data of patients with rectal cancer. Six articles also included patient survival data for untreated rectal cancer. Actuarial analysis of the data through 5 years post-diagnosis was completed. RESULTS: Symptoms most often presented in the fifth and sixth decades. Median survival of the 1326 patients fell within the second year after presentation of symptoms. Five-year actuarial survival for these patients was 4.4%. When the data published prior to 1925 were analyzed separately from that published post-1925, two survival patterns emerged. Median survival of pre-1925 patients fell within the second year after presentation of symptoms (at 21.5 months by curve fitting) and of post-1925 patients fell within the first year (10.2 months). CONCLUSIONS: Clearly, advances in antibiotics, surgery, chemoradiotherapy, and supportive care have contributed to increased survival for patients with treated rectal cancer. Recognizing the hazards of generalizing too extremely from the data, they reveal that relatively long survival for patients with untreated lesions is possible.

Fasciotomy worsens the amount of myonecrosis in a porcine model of crotaline envenomation.

STUDY OBJECTIVE: We evaluate the efficacy of fasciotomy or crotaline snake antivenom in reducing myonecrosis. METHODS: We used a randomized, blinded, controlled acute animal preparation. Twenty anesthetized swine were injected intramuscularly in the anterior tibiales muscle of both hind limbs with 6 mg/kg of Crotalus atrox venom (total of 12 mg/kg of venom per animal). Immediately after venom injection, the right hind limb underwent fasciotomy. Muscle biopsies were obtained from the fasciotomized hind limb at 0, 4, and 8 hours and from the other hind limb at the conclusion of the study (8 hours). In addition, animals received either 8 vials of reconstituted Crotalidae polyvalent immune Fab (ovine) (CroFab; FabAV) or an equal volume of normal saline solution intravenously 1 hour after venom injection. A pathologist blinded to the study determined the percentage of myonecrotic cells in each biopsy. Statistical analysis was performed using repeated measures analysis of variance for compartment pressure. Rank-order methods were used for comparison of myonecrosis between groups. RESULTS: Biopsies from hind limbs undergoing fasciotomy revealed a progressive increase in the amount of myonecrosis over time (myonecrosis median at 0, 4, or 8 hours [or death]: 0%, 14%, or 14.5%, respectively; P<.001). Comparison of the amount of myonecrosis of biopsies at death or 8 hours revealed that limbs that underwent fasciotomy had significantly more myonecrosis than those that did not (myonecrosis median: 14.5% versus 2.5%, P=.048). No difference was detected in the amount of myonecrosis when FabAV was compared with normal saline solution on final biopsies from either fasciotomy or nonfasciotomy hind limb (myonecrosis median: 10.0% versus 10.0%, P=.64). CONCLUSION: Fasciotomy significantly worsens the amount of myonecrosis in a porcine model of intramuscular crotaline venom injection. No change in the amount of myonecrosis was detected with the use of FabAV treatment at the dosages used in this animal model.

Prospective trial of complete decongestive therapy for upper extremity lymphedema after breast cancer therapy.

PURPOSE: Lymphedema is a well-described complication of therapy for breast cancer. Patients who present with lymphedema may experience pain and body image issues and are at increased risk for developing cellulitis. Complete decongestive therapy (CDT) is a four-component therapy for lymphedema. Data regarding CDT as an intervention in the immediate after the diagnosis period and prolonged follow-up are limited; we prospectively analyzed results of CDT in this cohort of patients. MATERIALS AND METHODS: Twenty patients were enrolled in CDT immediately after their diagnosis of lymphedema. The Functional Assessment of Cancer Therapy quality of life (QoL) measure and a visual analogue scale for pain were completed before, on the 10th day of, and on the last day of treatment. Each patient underwent a daily 60- to 90-minute treatment session, 5 days per week for 2-4 weeks. Treatment consisted of skin and nail care, manual lymphatic drainage, a multilayer compression bandage, and therapeutic exercise. Edema of the affected limb was reassessed weekly. On reaching a measurement plateau, the patient was discharged from active treatment and began a maintenance phase. The patient was reassessed for girth, volume, and body weight at 3 months. These measurements plus the QoL and pain measures were also reassessed at 6 months and 1 year after treatment. RESULTS: Patients completed 2-4 weeks of treatment (median, 2 weeks). Those classed as severe decreased from 7 to 1. Median girth reduced 1.5 cm and median volume reduced 138 mL. Decreasing girth correlated significantly with decreasing visual analogue scale scores for pain, but not with increasing QoL. Increasing grade correlated significantly with girth reduction and volume reduction. Compliance with the treatment regimen at home decreased with time on the program. During follow-up, girth and volume reverted slightly but stabilized at about 1 cm and 100 mL below baseline, respectively. Although the increase in QoL was not significant, it was noted that during the entire treatment and follow-up period, QoL consistently increased, ending about 5% above baseline, and pain scores gradually decreased, ending with 54% (and median) of patients at 0 pain. CONCLUSIONS: CDT is effective in treating lymphedema. Success in girth reduction contributes to less pain. Grade is a useful indicator of severity; class is not. Increased number of treatment sessions provides marked improvements in girth, volume, and weight but result in poorer compliance. Longer latency more successfully reduces girth, volume, and pain and increases QoL. QoL and pain are improved by treatment and continue to improve after treatment has ended.

Pathologic variables and recurrence rates as related to obesity and race in men with prostate cancer undergoing radical prostatectomy.

PURPOSE: To determine if obesity is associated with higher prostate specific antigen recurrence rates after radical prostatectomy (RP), and to explore racial differences in body mass index (BMI) as a potential explanation for the disparity in outcome between black and white men. PATIENTS AND METHODS: A retrospective, multi-institutional pooled analysis of 3,162 men undergoing RP was conducted at nine US military medical centers between 1987 and 2002. Patients were initially categorized as obese (BMI > or = 30 kg/m(2)), overweight (BMI 25 to 30 kg/m(2)), or normal (BMI < or = 25 kg/m(2)). For analysis, normal and overweight groups were combined (BMI < 30 kg/m(2)) and compared with the obese group (BMI > or = 30 kg/m(2)) with regard to biochemical recurrence (prostate-specific antigen > or = 0.2 ng/mL) after RP. RESULTS: Of 3,162 patients, 600 (19.0%) were obese and 2,562 (81%) were not obese. BMI was an independent predictor of higher Gleason grade cancer (P <.001) and was associated with a higher risk of biochemical recurrence (P =.027). Blacks had higher BMI (P <.001) and higher recurrence rates (P =.003) than whites. Both BMI (P =.028) and black race (P =.002) predicted higher prostate specific antigen recurrence rates. In multivariate analysis of race, BMI, and pathologic factors, black race (P =.021) remained a significant independent predictor of recurrence. CONCLUSION: Obesity is associated with higher grade cancer and higher recurrence rates after RP. Black men have higher recurrence rates and greater BMI than white men. These findings support the hypothesis that obesity is associated with progression of latent to clinically significant prostate cancer (PC) and suggest that BMI may account, in part, for the racial variability in PC risk.

Survival of patients with untreated cervical carcinoma.

Patients infrequently present with advanced-stage cervical malignancy in the United States, where access to care and aggressive screening, detection, and treatment regimens are the standard. Neglected cancer is more likely in countries with underdeveloped healthcare delivery systems; yet in this new millennium, we foresee not only an aging population with modern medicine able to prolong life expectancy, but also attentive screening regimens even amid the older old. Taking into account common comorbid illness from which patients used to die, informed consent in making a treatment in the robust and frail elderly becomes a new challenge. Recognizing an ever-growing population in today's culture of patient-directed care, clinicians may find patients choosing alternative modalities or simply declining conventional therapies. The difficult dilemma then arises about how to inform a patient most accurately of her prognosis in an untreated condition. In the past, virtually all patients in the United States traditionally received some treatment for cervical cancer on diagnosis; thus, review was made of archival published literature to document survival of patients with untreated cervical cancer.

Limited value of bone scintigraphy and computed tomography in assessing biochemical failure after radical prostatectomy.

OBJECTIVES: To define the utility of bone scan and computed tomography (CT) in the evaluation of patients with biochemical recurrence after radical prostatectomy. METHODS: A retrospective analysis of the Center for Prostate Disease Research database was undertaken to identify patients who underwent radical prostatectomy between 1989 and 1998. Patients who developed biochemical recurrence (two prostate-specific antigen [PSA] levels greater than 0.2 ng/mL) and underwent either bone scan or CT within 3 years of this recurrence were selected for analysis. The preoperative clinical parameters, pathologic findings, serum PSA levels, follow-up data, and radiographic results were reviewed. RESULTS: One hundred thirty-two patients with biochemical recurrence and a bone scan or CT scan were identified. Of the 127 bone scans, 12 (9.4%) were positive. The patients with true-positive bone scans had an average PSA at the time of the bone scan of 61.3 +/- 71.2 ng/mL (range 1.3 to 123). Their PSA velocities, calculated from the PSA levels determined immediately before the radiographic studies, averaged 22.1 +/- 24.7 ng/mL/mo (range 0.14 to 60.0). Only 2 patients with a positive bone scan had a PSA velocity of less than 0.5 ng/mL/mo. Of the 86 CT scans, 12 (14.0%) were positive. On logistic regression analysis, PSA and PSA velocity predicted the bone scan result (P <0.001 each) and PSA velocity predicted the CT scan result (P = 0.047). CONCLUSIONS: Patients with biochemical recurrence after radical prostatectomy have a low probability of a positive bone scan (9.4%) or a positive CT scan (14.0%) within 3 years of biochemical recurrence. Most patients with a positive bone scan have a high PSA level and a high PSA velocity (greater than 0.5 ng/mL/mo).