Peroperative extent of peritoneal metastases affects the surgical outcome and survival in advanced ovarian cancer.

OBJECTIVE: Determining whether cytoreductive surgery (CRS) is feasible in patients with advanced ovarian cancer and whether extensive surgery is justified is challenging. Accurate patient selection for CRS based on pre- and peroperative parameters will be valuable. The aim of this study is to assess the association between the extent of peritoneal metastases as determined during surgery and completeness of interval CRS and survival. METHODS: This single-center observational cohort study included consecutive patients with newly diagnosed stage III-IV epithelial ovarian cancer who received neoadjuvant chemotherapy and underwent interval CRS. The 7 Region Count (7RC) was recorded during surgical exploration to systematically quantify the extent of peritoneal metastases. Logistic regression analysis was performed to predict surgical outcomes, and Cox regression analysis was done for survival outcomes. RESULTS: A total of 316 patients were included for analyses. The median 7RC was 4 (interquartile range: 2-6). Complete CRS was performed in 58%, optimal CRS in 30%, and incomplete CRS in 12% of patients. A higher 7RC was independently associated with lower odds of complete or optimal CRS in multivariable analysis (odds ratio [OR] = 0.45, 95% confidence interval [CI]: 0.33-0.63, p < 0.001). Similarly, a higher 7RC was independently associated with worse progression-free survival (hazard ratio [HR] = 1.17, 95% CI 1.08-1.26, p < 0.001) and overall survival (HR = 1.14, 95% CI 1.04-1.25, p = 0.007). CONCLUSION: The extent of peritoneal metastases, as expressed by the 7RC during surgery, is an independent predictor for completeness of CRS and has independent prognostic value for progression-free survival and overall survival in addition to completeness of CRS.

Carnitine deficiency in preterm infants: A national survey of knowledge and practices.

OBJECTIVE: Lipid supplementation improves developmental outcomes in preterm infants. Carnitine is essential for lipid metabolism; however, despite high risk for carnitine deficiency, there are no standards for carnitine supplementation in preterm infants receiving total parenteral nutrition (TPN). Our objective was to assess knowledge, beliefs and practices regarding preterm carnitine deficiency and supplementation among neonatal practitioners. METHODS: Cross-sectional electronic survey administered via a nationally representative listserv of neonatal practitioners. RESULTS: 492 respondents participated in the survey. Only 21% of respondents were aware that carnitine is secreted by the placenta. 72% believed that carnitine deficiency was common, and 60% believed deficiency could have serious consequences. Five percent routinely screened for deficiency, and 40% routinely provided carnitine supplementation. Respondents with >5 years' experience were more likely to report using carnitine supplementation (50% vs. 38%). CONCLUSIONS: Although most respondents believed that carnitine deficiency is common and could have serious consequences, few screened for deficiency and fewer than half routinely supplemented. Thus, many preterm infants remain at risk for carnitine deficiency. Further research is needed to elucidate the risks of carnitine deficiency in these vulnerable infants.

Pubic symphysitis after transurethral resection of the prostate.

PURPOSE: Pubic symphysitis (PS) after urological operations is uncommon. This is a systematic single-institution review of patients with transurethral resection of the prostate (TUR-P) with the aim to determine the incidence of PS after TUR-P and to identify a risk profile. MATERIALS AND METHODS: In the past 15 years, 12,118 transurethral operations were performed in our department, 33.4% (n = 4045) were TUR-P, and 84.6% (n = 3421) had routine suprapubic trocar placement. A systematic retrospective analysis identified 12 patients, who developed PS (0.297%). RESULTS: Median age was 69.5 years (64-83). All patients had voiding difficulties. Urine culture had been positive in three cases. All 12 TUR-Ps were monopolar resections, and n = 11 patients had a suprapubic trocar. Median resection weight was 47.5 g (10-100). Two patients had a perforation of the capsule. Histopathological examination revealed chronic prostatitis in nine cases. After 1.0 ± 1.2 months, all patients developed pain in the pubic region. All patients underwent MRI, which suggested PS. Symptomatic and antibiotic medications were administered. Final outcome was resolution of symptoms in all patients after 3.8 ± 5.6 months. No patient retained voiding difficulties. CONCLUSION: PS remains a rare complication after TUR-P. We could not identify a single cause for developing PS. In our study, suprapubic trocar placement (11/12), chronic prostatic inflammation (9/12), previous UTI (3/12) and extended resection (2/12) were overrepresented. Inflammatory, thermic and/or surgical damage of the capsule may be causative. Patients require antibiotic and symptomatic medication. However, prognosis for remission is excellent.

[The treatment of chronic wounds in the head and neck area after radiotherapy with medical honey]. / Die Behandlung chronischer Wunden im Kopf-Hals-Bereich nach Radiatio mit medizinischem Honig.

BACKGROUND: Wound healing problems and chronic wounds can be a therapeutic challenge are a frequent problem after radiotherapy. They can appear spontaneously or after further surgery. The permanently altered tissue is associated with recurrent bacterial infections with weeping wounds, which cannot be treated sufficiently by conventional conservative wound care. The topical application of medical honey seems to have a positive effect in such cases. The aim of this prospectively study is to check this effectiveness in the treatment of wound healing problems and chronic wounds in the head and neck area of irradiated patients. PATIENTS AND METHODS: In the period of July 2012 until August 2013 nine patients were treated with medical honey. All pa-tients had previously radiotherapy in the head and neck area. 5 patients had protracted wound healing problems after salvage surgery. The remaining 4 cases had spontaneously dehiscenced wounds at the beginning of the study. The wound healing was confirmed by measurement of the wound edges and depth and by adequate photo documentation. RESULTS: In all cases, the conventional wound care was unsuccessfully. In 8 of 9 cases, the wounds could be brought to cure by the application of medical honey over 3-8 weeks. Side effects or allergic reactions to the medical honey were not seen in any -cases. CONCLUSION: Based on our clinical experience we believe that the topical application of medical honey in non-healing or recurrent wounds in the head and neck area after radiotherapy is a reason-able and successful alternative therapy.

[19th annual conference of the working group on kidney transplantation of the academy of german urologists : mainz, 10-12 november 2011]. / 19. Jahrestagung des Arbeitskreises Nierentransplantation der Akademie der Deutschen Urologen : Mainz 10. bis 12. November 2011.

The 19th Annual Conference of the Working Group on Kidney Transplantation (KTX) of the Academy of German Urologists took place on 10-12 November 2011 in Mainz. The main topics at the meeting were surgical and technical aspects, immunosuppressive therapy, transplant rejection, pregnancy, sexuality, and psychological conflicts of kidney transplant recipients. The speakers documented the pertinence of interdisciplinarity for KTX and were not only from the field of urology but also from anesthesiology, gynecology, surgery, dermatology, nephrology, radiology, and psychosomatic medicine. The Bernd Schönberger Prize was awarded at the end of the event.

Back to the forest: exploring forest transitions in Candelaria Loxicha, Mexico.

Declining profitability of agriculture and/or higher prices of forest products and services typically drive an increase in forest cover. This article examines changes in forest cover in Candelaria Loxicha, Mexico. Forest cover increased in the area as a result of coffee cultivation in coffee forest-garden systems. Dependence on forest products and services, and not prices of forest products, drive the process in our study site. Low international coffee prices and high labor demand outside the community might pull farmers out of agriculture, but they do not completely abandon the lands. A diversification in income sources prevents land abandonment and contributes to maintaining rural populations and coffee forest gardens.

Epidemiological survey of 214 families with bladder exstrophy-epispadias complex.

PURPOSE: We sought to identify causative nongenetic and genetic risk factors for the bladder exstrophy-epispadias complex. MATERIALS AND METHODS: A total of 237 families with the bladder exstrophy-epispadias complex were invited to participate in the study, and information was obtained from 214 families, mainly from European countries. RESULTS: Two families showed familial occurrence. Male predominance was found among all subgroups comprising epispadias, classic bladder exstrophy and cloacal exstrophy, with male-to-female ratios of 1.4:1, 2.8:1 and 2.0:1, respectively (p = 0.001). No association with parental age, maternal reproductive history or periconceptional maternal exposure to alcohol, drugs, chemical noxae, radiation or infections was found. However, periconceptional maternal exposure to smoking was significantly more common in patients with cloacal exstrophy than in the combined group of patients with epispadias/classic bladder exstrophy (p = 0.009). Only 16.8% of mothers followed the current recommendations of periconceptional folic acid supplementation, and 17.6% had started supplementation before 10 weeks of gestation. Interestingly, in the latter group mothers of patients with cloacal exstrophy were more compliant with folic acid supplementation than were mothers of the combined group of patients with epispadias/classic bladder exstrophy (p = 0.037). Furthermore, mothers of children with cloacal exstrophy knew significantly more often prenatally that their child would have a congenital malformation than did mothers of children with epispadias/classic bladder exstrophy (p <0.0001). CONCLUSIONS: Our study corroborates the hypothesis that epispadias, classic bladder exstrophy and cloacal exstrophy are causally related, representing a spectrum of the same developmental defect, with a small risk of recurrence within families. Embryonic exposure to maternal smoking appears to enforce the severity, whereas periconceptional folic acid supplementation does not seem to alleviate it. There is a disproportional prenatal ultrasound detection rate between severe and mild phenotypes, possibly due to the neglect of imaging of full bladders with a focus on neural tube defects.

Functional electrical stimulation using microstimulators to correct foot drop: a case study.

This paper presents a case study that tested the feasibility and efficacy of using injectable microstimulators (BIONs) in a functional electrical stimulation (FES) device to correct foot drop. Compared with surface stimulation of the common peroneal nerve, stimulation with BIONs provides more selective activation of specific muscles. For example, stimulation of the tibialis anterior (TA) and extensor digitorum longus (EDL) muscles with BIONs produces ankle flexion without excessive inversion or eversion of the foot (i.e., balanced flexion). Efficacy was assessed using a 3-dimensional motion analysis of the ankle and foot trajectories during walking with and without stimulation. Without stimulation, the toe on the affected leg drags across the ground. BION stimulation of the TA muscle and deep peroneal nerve (which innervates TA and EDL) elevates the foot such that the toe clears the ground by 3 cm, which is equivalent to the toe clearance in the less affected leg. The physiological cost index (PCI) measured effort during walking. The PCI equals the change in heart rate (from rest to activity) divided by the walking speed; units are beats per metre. The PCI is high without stimulation (2.29 +/- 0.37, mean +/- SD) and greatly reduced with surface (1.29 +/- 0.10) and BIONic stimulation (1.46 +/- 0.24). Also, walking speed increased from 9.4 +/- 0.4 m/min without stimulation to 19.6 +/- 2.0 m/min with surface and 17.8 +/- 0.7 m/min with BIONic stimulation. These results suggest that FES delivered by a BION is an alternative to surface stimulation and provides selective control of muscle activation.

The role of neuromuscular properties in determining the end-point of a movement.

How does the activation of several muscles combine to produce reliable multijoint movements? To study this question, we stimulated up to six sites in muscles, nerves, and the spinal cord. Flexion and extension of the hip, knee, and ankle were elicited in anesthetized and decerebrate cats. The movements occurred largely in the sagittal plane against a constant spring load and covered most of the passive range of motion of the cat's limb. The movements of the end-point (foot) were compared with predictions based on vectorial summation of end-point movements elicited by stimulating single electrodes. The lengths of the movements produced by stimulating more than one site exceeded what was expected from linear summation for small movements (<3 cm) and showed a less than linear summation for large movements (>11 cm). The data were compared with muscle and limb models. Since the deviations from linearity were predictable as a function of distance, adjustments might easily be learned by trial and error. The summation was less complete for spinal stimulation, compared to nerve and muscle stimulation, so spinal circuits do not appear to compensate for the nonlinearities. Movements were elicited from positions of the limb not only in a neutral position, but also in front and behind the neutral position. A degree of convergence was seen, even with stimulation of some individual muscles, but the convergence increased as more muscles were stimulated and more joints were actively involved. This suggests that convergence to an equilibrium-point arises at least partly from muscle properties. In conclusion, there are deviations from linear vectorial summation, and these deviations increase when more muscles are stimulated. The convergence to an equilibrium-point may simplify the computations needed to produce movements involving many muscles.

A wheelchair modified for leg propulsion using voluntary activity or electrical stimulation.

A commercially available wheelchair has been modified for propulsion by movements of the lower legs. The feet are attached securely to a foot rest that can rotate around the knee joint. Movement is generated either with residual voluntary activation of the quadriceps (knee extensor) and hamstring (knee flexor) muscles, or with electrical stimulation of these muscles, if voluntary control is absent. Either a chain or a lever can couple the movements through a gearbox to the wheel to propel the wheelchair forward. Control of a wheelchair with the legs is more efficient than using the arms and has the potential to increase the mobility and whole-body fitness of many wheelchair users, but there is considerable variability between subjects. To address this variability, we measured for individual subjects the passive properties of the legs and foot at rest (effective stiffness and viscosity), the length-tension (torque-angle) properties of the active muscle groups, as well as their force-velocity curve and their activation and fatigue rates. The measured values were then inserted into a model of the leg-propelled wheelchair. The purpose of this paper is to test whether the model could predict the performance of individual subjects accurately and could be used, for example, to optimize the speed of the wheelchair for a given subject.

Limb movements generated by stimulating muscle, nerve and spinal cord.

We have compared the movements generated by stimulation of muscle, nerve, spinal roots and spinal cord in anesthetized, decerebrate and spinalized cats. Each method produced a full range of movements of the cat's hind limb in the sagittal plane against a spring load, except for stimulation of the roots. Stimulation of the dorsal roots produced movements that were mainly up and forward, whereas stimulation of the ventral roots produced complementary movements (down and backward). Results from stimulation in the intermediate areas of the spinal cord were compared to predictions of the "movement primitives" hypothesis. We could not confirm that the directions were independent of stimulus amplitude or the state of descending inputs. Pros and cons of stimulating at some sites were provisionally considered for the reliable control of limb movements with functional electrical stimulation (FES) in clinical conditions.

Improved efficiency with a wheelchair propelled by the legs using voluntary activity or electric stimulation.

OBJECTIVE: To determine whether a new leg-propelled wheelchair provides enhanced efficiency and mobility to wheelchair users. DESIGN: Observational; subjects were tested while wheeling with the arms and legs and while walking (where possible) for 4-minute periods in random order with approximately 10-minute rest periods between exercise sets. SETTING: Tests were done on an indoor 200-meter track. PATIENTS: Group 1, 13 controls; group 2, 9 persons with complete spinal cord injury (SCI); group 3, 13 persons with other motor disorders (retaining some voluntary control of the legs). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Physiological Cost Index (PCI), (computed as change in heart rate divided by velocity of movement) and oxygen consumption (VO(2)) RESULTS: Arm wheeling took significantly more effort (mean PCI =.52 beats/m) than walking (.33 beats/m) in control subjects. Leg wheeling was most efficient (.23), requiring less than half the effort of arm wheeling and 30% less effort than walking. For SCI subjects, leg wheeling with functional electric stimulation (FES) required less than half the effort (.18) of arm wheeling (.40). The FES group could not walk. Subjects in group 3 could walk, but with substantial effort (1.81) compared with arm (.76) or leg wheeling (.64). Results for VO(2) were similar. CONCLUSIONS: Better wheelchair efficiency can be obtained for many disabled individuals, by moving the leg muscles voluntarily or with FES.

Successful therapy of a human lung cancer xenograft using MAb RS7 labeled with residualizing radioiodine.

We have recently reported that a radioiodinated, DTPA-appended peptide, designated IMP-R1, is a residualizing iodine label that overcomes many of the limitations that have impeded the development of residualizing iodine for clinical use. In this study the potential of 131I-IMP-R1-RS7, an internalizing anti-EGP-1 monoclonal antibody, was evaluated by performing preclinical therapy studies in nude mice bearing Calu-3 human non-small cell carcinoma of the lung xenografis. Elimination of 6 of 9 established tumors (mean tumor volume=0.3 cm(3)) was observed using a single dose of 350 microCi/mouse of 131I-IMP-R1-RS7, with all animals tolerating the dose. At the same dose and specific activity of 131I-RS7, labeled using the conventional chloramine-T method, there were four deaths, and one complete remission in nine treated mice. At the maximum tolerated dose of conventionally 131I-labeled RS7, 275 microCi, mean stable disease for approximately 5 weeks was observed, with no complete responses. Specificity of the therapeutic effect was shown in an isotype-matched control experiment, where 131I-IMP-R1-RS7 was markedly more effective than the (131)I-IMP-R1-labeled control antibody. These studies demonstrate that (131)I-IMP-R1-RS7 provides a therapeutic advantage in comparison to conventional 131I-labeled RS7, as predicted by the increased tumor accretion observed previously in targeting studies. A direct comparison of the maximum tolerated doses of (131)I-IMP-R1-RS7 (350 microCi) and 90Y-DOTA-RS7 (105 microCi) was performed in this tumor model using large established tumors (mean tumor volume=0.85 cm(3)). Anti-tumor efficacy and toxicity of the two treatments were comparable.

Adverse effects of herbal treatment of cardiovascular disease: what the physician must know.

The increasing use of herbal products by patients with cardiovascular disease represents a clinical challenge to physicians. The use of herbal products is increasing in our society, and less than 50% of patients using herbal products report this information to their physicians. In addition, physicians often lack the knowledge base for herbal medications to effectively counsel patients regarding adverse effects and potential herb-drug interactions. This article reviews Western and traditional Chinese herbs that are commonly used by patients with cardiovascular diseases, herbs noted to have adverse cardiovascular effects, and herbs that may potentially interact with commonly prescribed cardiovascular medications.

The toxicology of Myrmecia nigrocincta, an Australian ant.

The biology, behaviour and venom of the ant Myrmecia nigrocincta are described. Symptoms of 15 cases of envenomation are described.

The toxicology of Myrmecia nigrocincta, an australian ant

The biology, behaviour and venom of the ant Myrmecia nigrocincta are described. Symptoms of 15 cases of envenenomation are described. (AU)

Prospective comparison of the effect of direct current electrical stimulation and pulsed electromagnetic fields on instrumented posterolateral lumbar arthrodesis.

The purpose of this prospective study was to compare the effect of adjunctive direct current (DC) electrical stimulation and pulsed electromagnetic field therapy (PEMF) on augmentation of instrumented lumbar fusion. Sixty-one patients undergoing lumbar spine fusion were enrolled in the study and randomized to one of three treatment protocols: 1) adjunctive PEMF group (n = 22) fitted with Spinal-Stim model 8212(AME) within 30 days of surgery; 2) DC group (n = 17) had a SpF-2T stimulator(EBI) implanted at the time of surgery; or 3) control group (n = 22). The fusion mass bone mineral density (BMD) assessment was performed on 3-month and 1-year radiographs for each patient. Lateral flexion-extension and anteroposterior radiographs were evaluated at 1 year to determine the presence of fusion. Clinical outcome patient analyses were performed at 1 year. At 1-year follow-up, radiographic fusion and fusion mass bone density were not significantly different among the groups. In the nonstimulated group, there were 43% excellent, 43% good, and 14% fair results. In the PEMF group, there were 35% excellent, 50% good, 10% fair, and 5% poor results. In the DC group, there were 32% excellent, 37% good, and 31% fair results. The results of the current study suggest that electrical stimulation does not significantly enhance fusion rate in instrumented lumbar arthrodesis, although we observed a statistically insignificant trend toward increased fusion mass BMD in the electrically stimulated groups. The significance of increased BMD remains unknown.

Electrical stimulation: can it increase muscle strength and reverse osteopenia in spinal cord injured individuals?

OBJECTIVE: To study the extent to which atrophy of muscle and progressive weakening of the long bones after spinal cord injury (SCI) can be reversed by functional electrical stimulation (FES) and resistance training. DESIGN: A within-subject, contralateral limb, and matching design. SETTING: Research laboratories in university settings. PARTICIPANTS: Fourteen patients with SCI (C5 to T5) and 14 control subjects volunteered for this study. INTERVENTIONS: The left quadriceps were stimulated to contract against an isokinetic load (resisted) while the right quadriceps contracted against gravity (unresisted) for 1 hour a day, 5 days a week, for 24 weeks. MAIN OUTCOME MEASURES: Bone mineral density (BMD) of the distal femur, proximal tibia, and mid-tibia obtained by dual energy x-ray absorptiometry, and torque (strength). RESULTS: Initially, the BMD of SCI subjects was lower than that of controls. After training, the distal femur and proximal tibia had recovered nearly 30% of the bone lost, compared with the controls. There was no difference in the mid-tibia or between the sides at any level. There was a large strength gain, with the rate of increase being substantially greater on the resisted side. CONCLUSION: Osteopenia of the distal femur and proximal tibia and the loss of strength of the quadriceps can be partly reversed by regular FES-assisted training.

Initial experience with high-dose radioimmunotherapy of metastatic medullary thyroid cancer using 131I-MN-14 F(ab)2 anti-carcinoembryonic antigen MAb and AHSCR.

UNLABELLED: This phase I study was initiated to determine the toxicity and therapeutic potential of high-dose 131I-MN-14 F(ab)2 anti-carcinoembryonic antigen monoclonal antibody (MAb) combined with autologous hematopoietic stem cell rescue (AHSCR) in patients with rapidly progressing metastatic medullary thyroid cancer. METHODS: Twelve patients were entered into the study. Dose escalation was based on prescribed radiation doses to critical organs (i.e., kidney, lung, and liver). Starting doses were 900 cGy to the kidney and no more than 1200 cGy to the lung and liver, with dose increments of 300 cGy until the maximum tolerable dose is determined. Tumor targeting was assessed by external scintigraphy, toxicity was assessed according to the common toxicity criteria of the National Cancer Institute, and therapy responses were assessed by CT, serum carcinoembryonic antigen, and calcitonin. RESULTS: One patient received 9.95 GBq 131I-MN-14 F(ab)2, for an initial dose of 656 cGy to critical organs, 8 received 900 cGy (8.69-17.98 GBq), and 3 received 1200 cGy (15.17-17.69 GBq). The MAb scans of all patients showed positive findings. Autologous hematopoietic stem cells were given to all patients 1-2 wk after therapy, when the total body radiation exposure was less than 5.2 x 10(-7) C/kg/h. Dose-limiting toxicity, defined as grade 3 or 4 nonhematologic toxicity, was not seen in the patient who received the 656-cGy dose, and only 1 of the 8 patients treated at the 900-cGy dose level had grade 3 toxicity, which was gastrointestinal and reversible. No dose-limiting toxicity was seen in the 3 patients treated at the 1200-cGy dose level. Except for the instance of grade 3 gastrointestinal toxicity, nonhematologic toxicity was relatively mild, with only grade 1 or 2 toxicity observed in 9 patients. No renal toxicity was seen. Of the 12 patients, 1 had partial remission for 1 y, another had a minor response for 3 mo, and 10 had stabilization of disease lasting between 1 and 16 months. CONCLUSION: The results show the safety of administering high myeloablative doses of 131I-MN-14 F(ab)2 with AHSCR in patients with metastatic medullary thyroid cancer. The antitumor responses in patients with aggressive, rapidly progressing disease are encouraging and warrant further research to optimize the effectiveness of this new treatment.

Minimizing discomfort with surface neuromuscular stimulation.

The purpose of this study was to evaluate the effects of stimulus parameters, electrode types, and electrode positions on the perception of discomfort during lower extremity surface neuromuscular stimulation. Ten normal and eight neurologically impaired (four incomplete spinal cord and four stroke) subjects were enrolled. Neurologically impaired subjects had some sensation, although it was often reduced. Parameters of the stimulation were varied in a way that produced the same level of ankle dorsiflexion, as measured with a goniometer. Discomfort was assessed after each stimulation with a 0-10 verbal scale (0, no discomfort; 10, worst pain). Increasing the pulse frequency was associated with increased discomfort for subjects in both groups (p > 0.05). Increasing the pulse duration was associated with increased discomfort in the neurologically impaired subjects (p > 0.05), but not in the normal subjects (p > 0.05). The electrode size and type had no effects on discomfort (p > 0.05). Stimulation of the peroneal nerve over the fibular head was better tolerated than the direct motor point stimulation of the tibialis anterior motor point (p < 0.05). The data suggest that to minimize discomfort, surface stimulation should be applied over nerves rather than motor points, and frequency and pulse duration should be set as low as possible for a given degree of contraction.