A review on the Role of Oral Nutritional Supplements in Chronic Obstructive Pulmonary Disease.

Due to the high smoking rate in developing countries and the rising aging population in high-income countries, the global prevalence of chronic obstructive pulmonary disease (COPD), estimated to be 11.7%, is increasing and is the third-leading cause of mortality. COPD is likely to be present in elderly individuals with impaired gastro-enteric functions. Gastrointestinal congestion, dyspnea, and anxiety are pathophysiological characteristics of COPD, contributing to poor appetite, reduced dietary intake, and high-energy expenditure. These factors are implicated in the progression of malnutrition in COPD patients. Malnutrition is detrimental to lung functions and is associated with an increased risk of infection, exacerbation and mortality, and a longer duration of hospitalization. Therefore, nutritional support to treat malnutrition in COPD patients is very vital. Oral nutritional supplements (ONS) may hold the key to COPD treatment. To clarify this statement, we review current evidence for ONS in COPD patients to benefit from clinical outcomes.

Anti-tumor effect of endostatin in a sleep-apnea mouse model with tumor.

BACKGROUND: Obstructive sleep apnea (OSA) is associated with cancer incidence and mortality. The underlying mechanism is unclear. This study aims to evaluate the influence of intermittent hypoxia (IH), a novel hallmark of OSA, on tumor and to access the anti-tumor effect of endostatin on a mouse model with OSA. METHODS: The C57BL/6 J mice were randomly classified into four groups: control (normoxia) (CTL), control plus endostatin (CTL + ED), IH, and IH plus endostatin (IH + ED). Mice in IH and IH + ED groups were subjected to IH 8 h per day in 5 weeks. Lewis lung cancer cells were injected into the flank of each mouse after 1 week of IH exposure. Endostatin was also intraperitoneally injected after tumor volume reached about 200 mm3. The maximum standard uptake values (SUVmax) were detected by micro-positron emission tomography-computed tomography (micro-PET-CT) imaging prior and post-endostatin administration. Microvessel density (MVD) and vascular endothelial growth factor (VEGF) were determined for evaluating the anti-tumor effect of endostatin among the normoxia and IH conditions. RESULTS: Mice had higher SUVmax in the IH group than the CTL group (p < 0.01). When compared with mice in the CTL group, those in the IH group had significantly greater MVD values (p < 0.001). The SUVmax can be attenuated by endostatin both in the CTL (p < 0.01) and IH conditions (p < 0.001). When compared with CTL group, mice in the IH group had increased MVD values (p < 0.001) and VEGF expression both at mRNA (p < 0.05) and protein levels (p < 0.001 in western blotting results). Treatment with endostatin attenuated serum and tissue VEGF levels, lowering the MVD values. As compared to normoxia condition, the endostatin-therapeutic effects were more significant under the IH condition (p < 0.05 in western blotting results). CONCLUSIONS: Micro-PET-CT imaging is a promising non-invasive technique to evaluate the tumor metabolic characteristics under IH condition in vivo. The anti-tumor effect of endostatin under IH condition is superior to that of the normoxia condition.

Upregulation of CYP17A1 by Sp1-mediated DNA demethylation confers temozolomide resistance through DHEA-mediated protection in glioma.

Steroidogenesis-mediated production of neurosteroids is important for brain homeostasis. Cytochrome P450 17A1 (CYP17A1), which converts pregnenolone to dehydroepiandrosterone (DHEA) in endocrine organs and the brain, is required for prostate cancer progression and acquired chemotherapeutic resistance. However, whether CYP17A1-mediated DHEA synthesis is involved in brain tumor malignancy, especially in glioma, the most prevalent brain tumor, is unknown. To investigate the role of CYP17A1 in glioma, we determined that CYP17A1 expression is significantly increased in gliomas, which secrete more DHEA than normal astrocytes. We found that as gliomas became more malignant, both CYP17A1 and DHEA were significantly upregulated in temozolomide (TMZ)-resistant cells and highly invasive cells. In particular, the increase of CYP17A1 was caused by Sp1-mediated DNA demethylation, whereby Sp1 competed with DNMT3a for binding to the CYP17A1 promoter in TMZ-resistant glioma cells. CYP17A1 was required for the development of glioma cell invasiveness and resistance to TMZ-induced cytotoxicity. In addition, DHEA markedly attenuated TMZ-induced DNA damage and apoptosis. Together, our results suggest that components of the Sp1-CYP17A1-DHEA axis, which promotes the development of TMZ resistance, may serve as potential biomarkers and therapeutic targets in recurrent glioma.

The combination of the prodrugs perforin-CEBPD and perforin-granzyme B efficiently enhances the activation of caspase signaling and kills prostate cancer.

The survival of prostate cancer (PrCa) patients is associated with the transition to hormone-independent tumor growth and metastasis. Clinically, the dysregulation of androgen action has been associated with the formation of PrCa and the outcome of androgen deprivation therapy in PrCa. CCAAT/enhancer binding protein delta (CEBPD) is a transcription factor that has been reported to act as an oncogene or tumor suppressor, depending on the extra- and intracellular environments following tumorigenesis. We found that androgen can activate CEBPD transcription by direct binding of the androgen receptor (AR) to the CEBPD promoter region. Increases of suppressor of zeste 12 (SUZ12) and enhancer of zeste homolog 2 (EZH2) attenuated the androgen-induced transcription of CEBPD. Importantly, the increases in E2F1, SUZ12 and EZH2 as well as the inactivation of CEBPD were associated with the clinicopathological variables and survival of PrCa patients. We revealed that caspase 8 (CASP8), an apoptotic initiator, is responsive to CEBPD induction. Reporter and in vivo DNA-binding assays revealed that CEBPD directly binds to and activates CASP8 reporter activity. A prodrug system was developed for therapeutic application in AR-independent or androgen-insensitive PrCa to avoid the epigenetic effects on the suppression of CEBPD expression. Our results showed that the combination of a perforin (PF)-CEBPD prodrug (which increases the level of procaspase-8) and a PF-granzyme B prodrug (which activates CASP8 and caspase 3 (CASP3)) showed an additive effect in triggering the apoptotic pathway and enhancing apoptosis in PrCa cells.

Biomaterial implants mediate autologous stem cell recruitment in mice.

Autologous stem cells, recognized as the best cells for stem cell therapy, are associated with difficult extraction procedures which often lead to more traumas for the patients and time-consuming laboratory work, which delays their subsequent application. To combat such challenges, it was recently uncovered that, shortly after biomaterial implantation, following the recruitment of inflammatory cells, substantial numbers of mesenchymal stem cells (MSC) and hematopoietic stem cells (HSC) were recruited to the implantation sites. These multipotent MSC could be differentiated into various lineages in vitro. Inflammatory signals may be responsible for the gathering of stem cells, since there is a good relationship between biomaterial-mediated inflammatory responses and stem cell accumulation in vivo. In addition, the treatment with the anti-inflammatory drug dexamethasone substantially reduced the recruitment of both MSC and HSC. The results from this work support that such strategies could be further developed towards localized recruitment and differentiation of progenitor cells. This may permit the future development of autologous stem cell therapies without the need for tedious cell isolation, culture and transplantation.

Integration of CNS survival and differentiation by HIF2α.

Hypoxia-inducible factor (HIF) 1α and HIF2α and the inhibitor of apoptosis survivin represent prominent markers of many human cancers. They are also widely expressed in various embryonic tissues, including the central nervous system; however, little is known about their functions in embryos. Here, we show that zebrafish HIF2α protects neural progenitor cells and neural differentiation processes by upregulating the survivin orthologues birc5a and birc5b during embryogenesis. Morpholino-mediated knockdown of hif2α reduced the transcription of birc5a and birc5b, induced p53-independent apoptosis and abrogated neural cell differentiation. Depletion of birc5a and birc5b recaptured the neural development defects that were observed in the hif2α morphants. The phenotypes induced by HIF2α depletion were largely rescued by ectopic birc5a and birc5b mRNAs, indicating that Birc5a and Birc5b act downstream of HIF2α. Chromatin immunoprecipitation assay revealed that HIF2α binds to birc5a and birc5b promoters directly to modulate their transcriptions. Knockdown of hif2α, birc5a or birc5b reduced the expression of the cdk inhibitors p27/cdkn1b and p57/cdkn1c and increased ccnd1/cyclin D1 transcription in the surviving neural progenitor cells. The reduction in elavl3/HuC expression and enhanced pcna, nestin, ascl1b and sox3 expression indicate that the surviving neural progenitor cells in hif2α morphants maintain a high proliferation rate without terminally differentiating. We propose that a subset of developmental defects attributed to HIF2α depletion is due in part to the loss of survivin activity.

Nationwide periodic health examinations promote early treatment of hypertension, diabetes and hyperlipidemia in adults: experience from Taiwan.

OBJECTIVES: To investigate the effectiveness of nationwide periodic health examinations in promoting early treatment of hypertension, diabetes and hyperlipidemia in adults aged ≥40 years. STUDY DESIGN: Seven-year, retrospective, cohort study. METHODS: Based on a large and representative claims dataset in Taiwan, cohort analysis was undertaken among three disease-free cohorts for hypertension, diabetes and hyperlipidemia (n = 26,661, 29,872 and 30,712 subjects, respectively) in 2000. Each cohort was observed from January 2001 to December 2007. Logistic regression, Cox proportional hazards analysis and the extended Cox model with counting process were employed in data analysis. Covariates such as age, gender, level of premium, beneficiary category, comorbidities and geographic factors were adjusted at baseline. RESULTS: For the hypertension, diabetes and hyperlipidemia cohorts, those who had ever used the preventive service between 1998 and 2000 had higher probabilities of being treated as new patients for these target diseases; the hazard ratios were 1.65, 1.32 and 1.57, respectively. Using the extended Cox model, associations for use of each service with treatment within a 1-year follow-up period between 2001 and 2007 were 1.68, 2.41 and 3.48. CONCLUSIONS: In adults who were initially disease-free, those who used the preventive service had higher probabilities of early treatment of these target diseases. These findings indicate the effectiveness of nationwide periodic health examinations.

Development of quality of care indicators for patients undergoing total hip or total knee replacement.

OBJECTIVE: The objective of this study was to develop evidence-based quality indicators to measure key aspects of care that can be targeted to decrease variations in complication rates between surgeons performing total joint replacement. DESIGN: RAND/University of California, Los Angeles (UCLA) modified-Delphi expert panel method. To accomplish this objective, a proposed set of quality of care indicators was developed through a comprehensive literature search and structured interviews with expert clinicians. An expert panel of orthopaedic surgeons was then convened to rate the validity of these quality indicators using the RAND/UCLA Appropriateness Method. Indicators were classified as valid by the panel based on the median panel rating and the amount of dispersion of panel ratings. RESULTS: There were 101 candidate indicators of quality identified in the six domains of preoperative processes of care, intraoperative processes, postoperative processes, implant selection and the use of new technology, privileging of hospitals and surgeons, and outcomes and comorbidity assessment. A total of 68 of the 101 indicators were rated as valid with statistical agreement. CONCLUSIONS: This study identifies measures of structure, process and outcome rated as valid quality indicators for hip and knee replacement. This project provides tools to measure and improve quality of care for patients undergoing total joint replacement.

Is social support associated with greater weight loss after bariatric surgery?: a systematic review.

Social support may be associated with increased weight loss after bariatric surgery. The objective of this article is to determine impact of post-operative support groups and other forms of social support on weight loss after bariatric surgery. MEDLINE search (1988-2009) was completed using MeSH terms including bariatric procedures and a spectrum of patient factors with potential relationship to weight loss outcomes. Of the 934 screened studies, 10 reported on social support and weight loss outcomes. Five studies reported on support groups and five studies reported on other forms of social support (such as perceived family support or number of confidants) and degree of post-operative weight loss (total n = 735 patients). All studies found a positive association between post-operative support groups and weight loss. One study found a positive association between marital status (being single) and weight loss, while three studies found a non-significant positive trend and one study was inconclusive. Support group attendance after bariatric surgery is associated with greater post-operative weight loss. Further research is necessary to determine the impact of other forms of social support. These factors should be addressed in prospective studies of weight loss following bariatric surgery, as they may represent ways to improve post-operative outcomes.

Osteoporosis prevention education programme for women.

AIM: This paper reports an evaluation of a nurse-initiated education programme on four specific osteoporosis prevention behaviours which led to their adoption or to positive attitude changes. BACKGROUND: In the past, osteoporosis was a serious health concern that most commonly affected women in Northern Europe and the United States of America, but was less commonly seen in Asian women. However, in Hong Kong, osteoporosis is currently among the top five conditions causing disability and prolonged hospital stay for older people. From an economic perspective, the most cost-effective approach is to focus on primary prevention via education, and nurses often have the responsibility of providing such educational programmes. METHOD: A randomized controlled study was conducted from July 2004 to March 2005 with 76 women (38 cases and 38 controls) recruited in two private beauty clinics in Hong Kong. Pre-, post- and follow-up education data were compared regarding attitudes and adoption frequency before and after the education programme. RESULTS: The results showed statistically significant increases for each behaviour: consumption of soy foods (P < 0.001), milk (P < 0.001), more exercise (P = 0.01) and vitamin D/exposure to sunlight (P < 0.001) for the case group compared with the control group. Most participants either disagreed (n = 15, 39.0%) or strongly disagreed (n = 23, 61.0%) that there was not enough information provided in the education programme to motivate them to change. They rated the nurse's performance as either satisfactory or very satisfactory on presentation, ability to answer their questions and ability to describe each behaviour clearly. CONCLUSION: Although positive results with a nurse-initiated education programme were demonstrated, future research examining the effects of education and occupation on these four adoption behaviours should focus on more diverse populations with respect to age, income or ethnicity. The findings suggest the value of creative approaches in future health education for the prevention of osteoporosis, and the need for a critical appraisal of current strategies and a re-evaluation of services and funding.

Expression of capsid proteins and non-structural proteins of waterfowl parvoviruses in Escherichia coli and their use in serological assays.

While there are a number of methods available for detection of antibodies against waterfowl parvoviruses, none is able to differentiate responses against the capsid and non-structural proteins. To enable this, the capsid and non-structural proteins of goose parvovirus (GPV) and Muscovy duck parvovirus (MDPV) were expressed in Escherichia coli. These proteins were purified and used as antigens in western blotting assays of antibodies against GPV and MDPV. The results showed that 94.7% of the goose and 90.0% of the duck sera collected from the field contained antibodies against GPV or MDPV. Moreover, these sera could be classified into distinct groups based on differences in patterns of western blot reactivity. These different patterns might indicate different stages in infection. Western blotting assays of sera collected from experimentally infected ducks showed that antibodies against the non-structural protein appeared first after infection, followed by antibodies against the capsid protein. It was concluded that the recombinant capsid and non-structural proteins might serve as useful antigens for assays for antibodies against GPV and MDPV. Moreover, because these assays could discriminate between antibodies against the non-structural protein and those against the capsid protein, they may be useful in differentiating vaccinated from infected birds when recombinant capsid protein is used as the vaccine.

Biological monitoring of environment exposure to safrole and the Taiwanese betel quid chewing.

A rapid and sensitive biological monitoring (BM) method for assessing exposure to the environmental carcinogen safrole has been developed. The method is an isocratic high-performance liquid chromatographic (HPLC) analysis of urinary dihydroxychavicol (DHAB) and eugenol, the urinary metabolites of safrole. Good linearity, precision, and accuracy were demonstrated. A recovery of 98.8 +/- 5.4% (SD, n = 3) was found for DHAB and 84.1 +/- 3.4% (n = 3) for eugenol. The quantitation limits of the method were 8 ng for DHAB and 10 ng for eugenol. The validity of the method was demonstrated by a linear dose-response relationship observed in rats given oral doses of safrole at 30, 75, and 150 mg/kg body weight. The method was also used to monitor the environmental exposure to the Taiwanese betel quid (TBQ) chewing, because TBQ used in Taiwan not only contains areca (betel) nut, slaked lime, and catechu but also Piper betle inflorescence or its leaves. Both of the latter have a high content of safrole. The feasibility of the method to monitor TBQ chewing was demonstrated by an analysis of 153 spot human urine samples. The results showed that the p value of the nonparametric group comparison was < 0.001 for DHAB and 0.832 for eugenol. The TBQ chewers also exhibited a significantly higher rate of urinary DHAB (but not eugenol) than the nonchewers with an odd ratio of 3.47 (95% CI, 1.61-7.51). However, when only the eugenol-positive subjects were taken into analysis, the ratio rose to 24.38 (95% CI, 3.00-197.90).

Using quality of life scores to help determine treatment: is restoring bowel continuity better than an ostomy?

OBJECTIVE: In colorectal surgery, evaluation of heath-related quality of life (HRQL) has been relatively minimal when compared to other medical specialties. Would the performance of such HRQL evaluations change our decision-making in patient care? In familial adenomatous polyposis (FAP), procedures that restore bowel continuity (i.e. Ileorectal anastomosis or ileal pouch anal anastomosis) are routinely preferred to ileostomy because of the perceived, but unproven, better HRQL. This study evaluates FAP patients who underwent prophylactic colectomy with either permanent ileostomy or 'restored bowel continuity' reconstruction. The functional outcomes of both groups are reported, and the HRQL assessments are compared. METHODS: All FAP patients who underwent (procto) colectomy resection with reconstruction, either restored bowel continuity (BC) or permanent ileostomy (OST), between 1980 and 1998 were studied. Functional data were obtained by questionnaire and medical record review. HRQL was assessed by 2 validated instruments - the SF-36 Physical and Mental Health Summary Scales and the SF-36 Health Survey - which measure physical summary (PSF) and mental summary functioning (MSF) as well as eight separate health quality dimensions including health perception (HP), physical (PF) and social functioning (SF), physical (PR) and emotional role limitations (ER), mental health (MH), bodily pain (BP), and energy level (E). RESULTS: Results were obtained in 54 patients; bowel continuity (44), ileostomy (10). Mean patient age was 39 years, mean follow up time was 10.5 years. Mean patient age at operation was 28 years. Functional results for BC included number of bowel movements/day (6.7), leakage (30%), having to wear a pad (11%), perianal skin problems (25%), food avoidance (68%), and inability to distinguish gas (27%). Functional results for OST were routinely excellent. Results of the HRQL surveys reveal no significant differences for BC vs OST (HP: 67 +/- 28 vs 79 +/- 39; PF: 91 +/- 14 vs 90 +/- 17; SF: 86 +/- 23 vs 97 +/- 5; PR: 79 +/- 34 vs 83 +/- 40; ER: 86 +/- 28 vs 88 +/- 27; MH: 77 +/- 19 vs 82 +/- 14; BP: 78 +/- 24 vs 71 +/- 32; E 60 +/- 21 vs 58 +/- 18, respectively). CONCLUSION: Although the perceived quality of life for ileostomy patients is generally worse than the 'restored bowel continuity' group, the measured HRQL is the same for both groups. These results suggest that a permanent ileostomy should be included as a viable and appropriate first line treatment option for FAP patients after resection. This study also suggests that HRQL should play a greater role in the evaluation of care and treatment in colorectal surgery.

Internationalization of general surgical journals: origin and content of articles published in North America and Great Britain from 1983 to 1998.

HYPOTHESIS: The origin and characteristics of articles published in the 6 highest rated (Institute for Scientific Information classification) English-language general surgical journals have changed significantly during the past 15 years. DESIGN: All articles published in 1983, 1988, 1993, and 1998 in 5 US surgical journals and 1 British surgical journal were reviewed and characterized. MAIN OUTCOME MEASURES: Absolute numbers and proportions of national and international articles published in each journal. RESULTS: Articles reviewed included 4868 in US journals and 1380 in the British journal. The total number of US journal articles decreased by 15.1%. The total number of British journal articles increased by 58.9%. The percentage of national articles decreased from 87.5% to 68.8% in US journals (P<.001) and constituted the minority of freely submitted articles in 1998 in 3 of 5 US journals. The percentage of national articles also decreased from 74.8% to 47.1% in the British journal (P<.001). Articles by European and Asian authors showed the most striking increases in all journals. The percentage of basic research articles declined in US journals from 23.3% to 17.9% (P =.001) owing to a 14.9% decline in national basic research articles. The percentage of clinical randomized studies increased from 2.2% to 4.1% (P<.008), but the increase was attributable to international articles. Government funding alone decreased from 13.6% to 11.2%, and government plus another source of funding decreased from 19.2% to 16.7% for national articles in US journals. CONCLUSIONS: Internationalization of the highly rated British and the 5 highest rated US general surgical journals has occurred. The decrease in the number of national articles in the US journals has been accompanied by significant decreases in government funding and basic research articles and a static output of clinical randomized studies from North America.

Methodology standards associated with quality reporting in clinical studies in pediatric surgery journals.

BACKGROUND/PURPOSE: Reports of clinical trials often lack adequate descriptions of design and analysis; recent attention has focused on improving this omission so readers can properly assess the strength of the findings and draw their own conclusions. Similar analysis of study design and methodologic standards associated with quality reporting has not been carried out for pediatric surgery journals. METHODS: All studies (n = 642) published in 1998 in Journal of Pediatric Surgery (JPS) and Pediatric Surgery International (PSI), were reviewed for demographic data and study design. The frequency of reporting of 11 basic elements of design and analysis was evaluated in randomized clinical trials (RCT), nonrandomized clinical trials (NRCT), and retrospective cohorts (RC) from JPS by consensus of 2 assessors. RESULTS: Of the 642 studies, 17% of articles (111 of 642) were classified as clinical studies. Sixty-three were comparative studies and consisted of RC (n = 48), NRCT (n = 12), and RCT (n = 3). Two-thirds of articles published were either case reports or case series (431 of 642), and 16% were basic science articles. Demographic analysis showed a wide range of topics addressed, 4 authors per article, and multiple country of origin of authors. More than 66% of all RCT in JPS reported on eligibility criteria, admission before allocation, random allocation, method of randomization, patients' blindness to treatment, treatment complications, statistical analyses, statistical methods, loss to follow-up, and statistical methods; 2 elements of design and analysis, however, were poorly reported: blind assessment of outcome (33%) and power (17%). CONCLUSIONS: There were few randomized, controlled trials in pediatric surgery journals, and further attention should be given to evaluate the causal factors. Nine elements of quality reporting were well reported; however, 2 others were poorly reported; this may improve if editors of pediatric surgical journals provide authors with guidelines on how to report clinical trial design and analysis.

Long-term outcomes of the ileal pouch anal anastomosis: the association of bowel function and quality of life 5 years after surgery.

INTRODUCTION: Previous studies have reported that mean health related quality of life (HRQL) levels generally attain normalcy following construction of an ileal pouch anal anastomosis (IPAA). It appears inconsistent, however, that these normal HRQL levels are achieved while bowel function (BF) scores generally remain statistically worse than "normal" (e.g., 4-8 stools/day, possible anal leakage, diaper usage). To investigate this inconsistency, the current study attempts to determine if any statistical associations are present between HRQL and BF, specifically in the long term. Multivariate regression analyses are performed using each of 8 individual HRQL domains against the full model of BF characteristics. METHODS: All patients more than 5 years status post an ileal pouch anal anastomosis (IPAA) procedure for familial adenomatous polyposis (FAP) at a single institution were studied. FAP was chosen because patients are routinely asymptomatic preoperatively. BF (e.g., stool frequency, anal leakage) and HRQL (using the 8 health domains of the SF-36) were assessed by patient interview. Student's t tests and full model multivariate regression analyses were used to analyze associations between BF and HRQL. RESULTS: The sample included 25 patients (14 male). Mean age was 39 years, mean follow-up time was 11 years. Although mean scores for the 8 individual HRQL domains were not statistically different from the general United States population, regression analyses of the different domains did demonstrate significant associations with varying levels of BF. While controlling for age and gender, the analyses show that the physical function domain is improved with the ability to pass flatus independent of stool, and physical role and mental health domains are improved with decreased stool frequency. The social function domain is improved with increased stool retention time, while the perception of general health is improved with less diaper usage and less sexual dysfunction. CONCLUSIONS: This study shows that a statistically significant association between HRQL levels and BF is present. Of the numerous BF characteristics tested, five appear to be of greater importance with regard to certain HRQL domains. This finding may have clinical implications concerning pouch construction and surgical technique. Methodologically, this study demonstrates that merely using mean levels to describe HRQL may not elucidate meaningful relationships between important clinical outcomes, such as function and HRQL.

Alginate microbead release assay of angiogenesis.

Recently, the acceleration (and retardation) of blood vessel growth has been an increasingly frequent subject of study. With its potential application to a wide range of clinical disease processes, investigation certainly remains essential and promising. While in vitro investigation is traditional, well-controlled, and objective, studying angiogenesis in vivo can be quite difficult for a number of reasons. One major reason is the inherent tissue differences associated with blood vessel growth. Because all tissues are different, certain tissues tend to be inherently more vascular than others. As such, the growth (and concentration) of blood vessels occurs at different rates and proportions depending on that specific tissue. In the past several years, most in vivo angiogenesis work has been performed in the sclera as it allows for relatively easy access and the possibility of repeated observation. The sites to which investigation of angiogenesis might be applied, however, are invariably quite different and therefore additional tissues such as solid organs, fascia, muscle, and skin need to be studied as well. How can this be performed?

Primary duodenal adenocarcinoma: a 40-year experience.

HYPOTHESIS: In patients with duodenal adenocarcinoma, certain pathologic features of the tumor will have prognostic significance. DESIGN: Retrospective case series. PATIENTS: Forty-nine patients diagnosed with duodenal adenocarcinoma between 1957 and 1998. RESULTS: The tumors of 31 (63%) of the 49 patients underwent resection, 18 (37%) had surgical palliation or underwent biopsy. Mean (+/- SEM) survival for all patients was 49 +/- 9 months. The patients whose tumors were resected had longer survival than those who underwent palliation (mean +/- SEM, 66 +/- 13 months vs 18 +/- 6 months, P =.02). Multivariate analysis revealed large tumor size (P =.01), transmural invasion (P =.004), and moderate to poor tumor grade (P =.03) were negatively correlated with survival. Lymph node status did not influence survival. CONCLUSIONS: Our 40-year experience with duodenal adenocarcinoma demonstrates that large tumor size, advanced histological grade, and transmural invasion are associated with decreased survival. These results underscore the importance of early diagnosis, and suggest the presence of nodal spread is not a contraindication to resection.

Does better functional result equate with better quality of life? Implications for surgical treatment in familial adenomatous polyposis.

PURPOSE: The main impetus for a patient with familial adenomatous polyposis to choose colectomy with ileorectal anastomosis over ileal pouch-anal anastomosis is the better functional result. However, does better functional result necessarily translate into better overall quality of life? Previous studies of other diseases have demonstrated no such correlation. This study was performed to determine whether any relationship exists between functional result and quality of life in patients with familial adenomatous polyposis after ileorectal anastomosis and ileal pouch-anal anastomosis. METHODS: All patients with familial adenomatous polyposis who underwent colectomy with ileorectal anastomosis or proctocolectomy with ileal pouch-anal anastomosis from 1980 to 1998 were studied. Functional data were obtained by questionnaire. Health-related quality of life was assessed by two validated instruments, the SF-36 Physical and Mental Health Summary Scales and the SF-36 Health Survey, which measure physical and mental functioning and eight separate health-quality dimensions, including health perception, physical and social functioning, physical and emotional role limitations, mental health, bodily pain, and energy or fatigue. RESULTS: Data were obtained in 44 of 68 patients, 14 with ileorectal anastomosis and 30 with ileal pouch-anal anastomosis. No differences were demonstrated between the two groups for patient age, mean follow-up time, and mean patient age at operation. Functional results were worse for the ileal pouch-anal anastomosis group vs. the ileorectal anastomosis group in number of bowel movements per day (7.5 vs. 5.2; P < 0.05), leakage (43 vs. 0 percent; P < 0.01), pad usage (17 vs. 0 percent; P < 0.01), perianal skin problems (33 vs. 7 percent; P < 0.01), food avoidance (80 vs. 43 percent; P < 0.01), and inability to distinguish gas (37 vs. 7 percent; P < 0.01). Results of the health-related quality-of-life surveys, however, demonstrated no difference between the ileal pouch-anal anastomosis and ileorectal anastomosis groups. The Physical and Mental summary scales for the ileal pouch-anal anastomosis and ileorectal anastomosis groups were not significantly different (Physical Health Scale, 50.3 vs. 50.9; Mental Health Scale, 51.7 vs. 49.6), and none of the eight dimensions of the SF-36 health survey demonstrated statistical differences between the ileal pouch-anal anastomosis and ileorectal anastomosis groups. CONCLUSION: Better functional results were not equated with better quality of life in this pilot study. Although patients with the ileorectal anastomosis have better functional results than those with ileal pouch-anal anastomosis, the measured health-related quality of life as determined by a validated generic health-related quality-of-life instrument is the same for both groups. These results suggest that all patients with familial adenomatous polyposis might be optimally treated with an ileal pouch-anal anastomosis. More importantly, this study suggests that health-related quality of life should play a greater role in the evaluation of care and treatment in colon rectal surgery.