Is sarcopenia a better predictor of complications than body mass index? Sarcopenia and surgical outcomes in patients with rectal cancer.

AIM: Sarcopenia, or a reduction of lean muscle mass, is associated with poorer outcomes in cancer patients. Few previous studies have examined this potentially correctable risk factor in patients with locally advanced rectal cancer. METHOD: Skeletal muscle mass index was measured retrospectively on initial staging CT scans of patients undergoing chemoradiation followed by radical resection for rectal cancer for the period 2007-2013. Patients were categorized as sarcopenic or nonsarcopenic and differences in terms of demographics, pre-, peri- and postoperative outcomes were examined. RESULTS: Forty-seven patients were included; their mean age was 59.3 (36-82) years and 61.7% were men. We considered that 55.2% of men and 44.4% of women were sarcopenic; the overall prevalence of sarcopenia was 51.1%. Age, preoperative haemoglobin and albumin were significantly related to sarcopenia. Body mass index (BMI) and obesity (BMI > 30 kg/m2 ) were not associated with sarcopenia. Blood transfusions were more frequent in sarcopenic patients (P = 0.001). Although readmissions and length of stay were not increased, overall postoperative complications were significantly higher in sarcopenic patients (P = 0.03). Neither BMI nor obesity was associated with postoperative complications. CONCLUSION: Sarcopenia was present in over 50% of patients with locally advanced rectal cancer at diagnosis. It was associated with a higher incidence of both blood transfusion and postoperative complications. BMI did not correlate with these negative outcomes. Sarcopenia may be a better predictor of surgical outcomes than BMI or obesity.

Action potential control of cardiac contractility.

The transient and/or sustained trans-sarcolemmal voltage induced zero to peak tension changes in cardiac contractility at any given level of diastolic dimensions and associated physical-chemical conditions establish the action potential as the predominant controller of cardiac contractility. Demonstration that the inotropic increases in peak tension effects of extra cellular [Ca++] occur and are determined by the duration and degree of positivity of the plateau phase of the action potential document the predominant role of this phase of the action potential relative to control of cardiac contractility. The large increases in peak tension induced by prolongation of the plateau phase of the action potential by interpolated stimuli (i.e., extrasystolic potentiation) and the immediate maximal peak tension following sustained contracture induced by sarcolemmal depolarization highlight this fact. The demonstration that this prolonged action potential induced maximal tension capability (peak inotropic state) of ventricular fibers can be achieved within a single cycle suggests an analogous technic would provide objective noninvasive measurements of the cardiac reserve of humans in health and disease. A potentially valuable measurement, the temporal resolution requirements of which, although beyond the scope of current three-dimensional imaging systems, is achievable with current state of the art technology. The unique experimental and clinical diagnostic value of such a system for noninvasive analogous measurements in humans with congenital and acquired cardiac abnormalities is as yet, however, not widely recognized. Hence, objective confirmation of the unique potential value of such a system awaits development of the required high fidelity [X,Y,Z (1 mm3 voxel) spatial and (10 ms)] temporal resolution capability system.

Health sciences librarianship in the new millennium.

Is the millennium really a critical point in time or just part of a continuum, in which health sciences librarians have always been innovators? Librarians have always had special knowledge that enabled them to identify, collect, organize, and distribute information. They have always embraced new technology, from the printing press to the Internet. As a profession, we must continue to promote how our particular skills can reinforce our role in the health care field.

MEDLINE: the options for health professionals.

The bibliographic database MEDLINE, produced by the National Library of Medicine (NLM), is a computerized index to the world's biomedical literature. The database can be searched back to 1966 and contains 6.8 million records. The various means of access are divided, for the purposes of this article, into three categories: logging onto a remote host computer by telephone and modem or by the Internet; subscribing to part or all of the database on compact disc (CD-ROM); and leasing the data on a transport medium such as magnetic tape or CDs for loading on a local host computer. Decisions about which method is preferable in a given situation depend on cost, availability of hardware and software, local expertise, and the size of the intended user population. Trends include increased access to the Internet by health professionals, increased network speed, links from MEDLINE records to full-text databases or online journals, and integration of MEDLINE into wider health information systems.

Inbuilt obsolescence in conventionally piloted advanced fighter aircraft.

If pilot and fighter plane capability to sustain accelerations in the 10 to 15 G range for many seconds or minutes provides an important tactical advantage, as some fighter pilots believe, currently used anti-G procedures, including the Combat Edge Technology (29), will provide only partial, questionably safe protection. Therefore, relative to preservation of maximal pilot effectiveness, current and future advanced fighters, if flown in seated positions, are physiologically outdated in respect to blackout and G-LOC prevention. Consequently, future victories in the air may come to the adversary first to discard conventional upright or partially supinated seats in favor of a biomedically advanced fighter, developed for flight in the fully horizontal, preferably prone, position.

Potential hazards of high anti-Gz suit protection.

Although balanced positive pressure breathing increases protection by G suits and reduces fatigue during sustained high Gz exposures, it does not prevent dependent pulmonary right-to-left shunts (arterial hypoxemia) and potentially dangerous distention of nondependent alveoli. An incident of acute incapacitating mediastinal emphysema in a healthy young man during a sustained exposure to 5.5 Gx documents this possibility. This, plus neurogenic bradycardia during sustained high Gz exposures without pressure breathing, suggests that testing of full counterpressure to neck level suits at sustained > 9 Gz exposures may be hazardous. Fully instrumented studies of animal surrogates with comparable thoracic dimensions are indicated.

Prevention of +Gz-induced loss of consciousness.

Objective recordings of respiratory and cardiovascular parameters at heart and head levels on human centrifuges and in flight provided the physiologic insights which led to development, during and shortly after World War II, of very effective anti-G suits and simultaneous use of positive pressure respiratory straining maneuvers. The high sustained Gz capabilities of current and future fighter planes have forced recourse to these techniques with minimal awareness of their origins. Possible catastrophic limitations of very effective full coverage anti-G suits, including water immersion to the apex of the thorax, especially when used without positive pressure breathing, were also documented at that time.

Prevention of the pathophysiologic effects of acceleration in humans: fundamentals and historic perspectives.

The deleterious effects of high-G environments and their relevance to the development of anti-G suits are examined. The history of efforts to protect fighter pilots against these effects is recounted. The discussion covers the discovery of cerebral anoxic reserve time, the limited power and consequent restricted sustained G capabilities of propeller-driven fighter planes, the use of M-1-type positive respiratory pressure muscular straining maneuvers, the development of more effective anti-G suits after World War II, the pathophysiologic limitations of protection against G(z) acceleration by external garments, the development of a premonitory G-LOC (loss of consciousness) warning system based on real-time monitoring of arterial opacity pulses within the ear, development of a horizontal prone position couch with a fiber-optic, video-assisted omnidirectional pilot surveillance system, physiological and anatomical considerations, and practical aspects (bodily comfort, field of view, etc.) of a prone cockpit position for fighter pilots.

Partial supination versus Gz protection.

Visual and loss of consciousness endpoints during 2 G/s onset G forces sustained for 5 s in 14 and for 10 s in 27 untrained pilots indicated high tolerances when upright, and increases of greater than 3 G when supinated to 60 degrees. Protection against visual symptoms of only 1.1 G when tilted 60 degrees and especially none when experienced subjects were tilted 45 degrees from vertical were unexpected results in 1942. Subsequent findings by others of slight decreases in tolerance at 30 degrees are contrary to hydrostatic basis of G tolerance. Presumably factors other than heart to brain distance (e.g., increased intracranial and intraocular pressures) affect G tolerance when subjects are supinated 30 degrees. We conclude that the apparent increased incidence of G-LOC since the incorporation of 30 degrees seat in F-16 and other fighters in mid-1970's supports the current relevance of these data and suggests that all aircrew should follow the lead of veteran test pilots who sit upright in preparation for and during high G maneuvers (10).

Hydrostatic homeostatic effects during changing force environments.

The G tolerance of internal organs depends on how closely force environments in body cavities mimic an aqueous system. Hydrostatic gradients in peritoneal and pericardial cavities sustain venous return and uniform transmyocardial pressures so that normotensive arterial pressures at heart level persist during initial (about 7 s) sudden sustained exposures to Gz acceleration followed by a compensatory baroreceptor-mediated hypertension. Further, cerebrospinal fluid hydrostatics-mediated negative intracranial pressures sustain cerebral perfusion and cognition in spite of Gz-produced zero or near zero systolic pressures at head level. Differences in the approximately 0 and 1.0 specific gravities of intra-alveolar gases and surrounding blood and tissues, respectively, render lung anatomy and functions highly susceptible to the force environment. Hydrostatic gradients in dependent regions, simultaneously with small gradients in superior regions, appear to be nature's method for decreasing force environment-mediated regional ventilation and perfusion inequalities within the thorax.

Drug information skills for pharmacy students: curriculum integration.

For pharmacy students to provide optimal and complete pharmaceutical care, it is vital that they develop drug information skills. At the University of Southern California, the School of Pharmacy and the Norris Medical Library have established an interactive educational program. Library programs support an increasingly complex progression of information retrieval, evaluation, organization, application, and communication. Librarians are systematically involved in all four years of coursework for the doctor of pharmacy degree. Training and experience in computer literacy and online database searching are included in the library components. Description of the educational program covers its beginning a decade ago, current status, and future in an environment of rapidly advancing technology.

Human centrifuge non-invasive measurements of arterial pressure at eye level during Gz acceleration.

An apparatus for successful repetitive, indirect photokymographic recordings of systolic blood pressure (Ps) on a human centrifuge during World War II is described. Proportionately to 1 Gz hydrostatic heart-to-head Ps differences, eye level Ps decreased approximately 30 mm Hg per delta G, during 15 s Gz exposures of three relaxed volunteers, a finding confirmed subsequently by continuous intra-arterial pressures in 18 subjects. At 2 G.s-1 onset rates, maximal decreases occurred within 7 s after 1.5 Gz followed by compensatory recoveries while acceleration was maintained. Contours of simultaneously recorded decreases in ear opacity (blood content) were closely similar. Anti-G suit protection against subjective visual symptoms was similar to objective decreases in ear blood content but significantly less than against decreases in Ps at eye level. This may be due to relatively higher intraocular pressures secondary to increased intra-abdominal, cerebrospinal fluid and venous pressure produced by inflation, particularly of the abdominal bladder of the suit.

Teaching computer literacy: helping patrons to help themselves.

Teaching computer literacy to library patrons is an entirely appropriate activity for librarians in their role as liaisons between information and those who are seeking it. At the Norris Medical Library of the University of Southern California there are four main computer activities: information management workshops, provision of a microcomputer laboratory and classroom, formation of user groups, and installation of a campus-wide electronic bulletin board. Benefits to the library include: increased computer knowledge for librarians, better understanding of the information needs of the campus community, mutual respect and friendship between librarians and patrons, and introduction to the library of patrons who may otherwise never have come.

Some effects of the force environment on the heart, lungs and circulation.

The data obtained in a series of human and animal experiments carried out during the last 45 years in centrifuges, specially instrumented dive bombers, and during changes in body position are the major bases for this paper. The integrated and highly effective cardiovascular reflexes which allow awake, upright humans to regain and/or maintain vision and consciousness during sustained inertial force environments several times greater than at the surface of planet Earth are particularly impressive. Multiplication of vertical gradients in interserosal pericardial, pleural, abdominal and cerebrospinal fluid pressures and/or forces in proportion, and in the resultant vectorial direction of the force environment play a critical role in this capability both in aerospace flight and everyday life on planet Earth. The differences between the near zero specific gravity of intra-alveolar gas and the (about) 1.05 value for the encompassing blood and tissue, render lung function highly susceptible to the weight determinant force environment. Creation of a womb-like environment by liquid whole-body immersion plus assisted breathing of a respirable liquid, both with specific gravities closely similar to bodily tissues, is a seemingly impractical but technologically and biologically documented expedient for allowing air breathers to endure very high sustained force and pressure environments.

Development of anti-G suits and their limitations.

Initial anti-G suits were based on the belief that decreased venous return was the critical effect of increased weight of blood during acceleration. Cumbersome water filled, pneumatic gradient or pulsatile pressure suits resulted. Subsequent centrifuge studies implicated arterial pressure, rather than venous return, as the major determinant of G tolerance in the sitting position. Consequently, methods of increasing arterial pressure were developed. Findings that the hypertensive, associated anti-blackout and discomfort effects of suit inflation all increase with bladder system pressure up to arterial occlusive levels resulted in the simplified G-suit used in W.W.II to the present. Recent +Gz loss of consciousness crashes indicate current straining maneuvers plus this suit are inadequate. Furthermore, because of very high pressures to maintain cerebral circulation in the sitting position, very high G suit protection is hazardous. If piloting is essential for full use of super performance fighters, the prone position with counter-weighted head support plus omni-directional surveilance is the surest strategem to obtain this advantage.