[Robotic partial nephrectomy: five years retrospective analysis at a single center]. / Néphrectomie partielle laparoscopique assistée par robot : analyse monocentrique et rétrospective sur cinq ans.

INTRODUCTION: The aim of this study is to assess perioperative outcomes in a large series of robotic partial nephrectomy. PATIENTS AND METHODS: We performed a retrospective analysis of 413 patients undergoing a robotic partial nephrectomy in a single center between June 2006 and December 2011. We analyzed demographic characteristics, operative and postoperative outcomes. RESULTS: Mean age was 58.6±11.9 years, body mass index was 30.5±7.1 kg/m2 and median ASA score 3. Mean tumor size was 3.2±1.66 cm and was divided in low, moderate and high RENAL nephrometry score respectively in 40%, 44% and 16%. Operative time and warm ischemia time were respectively 191 and 21min. Mean estimated blood loss was 200 mL and there were 4.3% major complications (Clavien-Dindo System). Mean length of stay was 3.6 days. The latest estimated glomerular filtration rate (eGFR) was 74.84 mL/min×1.73 m2 with a mean decrease of 8.6%. In multivariate analysis, Charlson comorbidity index (P=0.005), preoperative eGFR (P<0.001) and warm ischemia time (P=0.0025) were found to be independent predictors of latest postoperative renal function. CONCLUSION: Robotic partial nephrectomy is feasible and safe in experienced hands. In our study preoperative renal function, Charlson comorbidity index and warm ischemia time were independent predictors of latest eGFR.

Robot-assisted laparoscopic bladder diverticulectomy.

Robot-assisted laparoscopic bladder diverticulectomy (RALBD) has been increasingly reported in recent years. We review the technique of RALBD and the perioperative outcomes. We searched online databases to identify original articles related to RALBD. In the Method section, we describe our technique and reviewe several techniques for identification and robotic management of bladder diverticula. We identified 13 retrospective studies that met our criteria, with a total of 44 patients. The mean diverticulum size was 8.3 ± 3.6 cm, mean operative time was 186 ± 68 min, mean estimated blood loss was 86 ± 64 ml, and mean length of stay was 2.4 ± 1.7 days. In the majority of cases, patients with acquired diverticula underwent urethral catheter removal between 7 and 14 postoperative days while in the pediatric population with congenital bladder diverticula, Foley catheter removal usually occurred on postoperative day one. We conclude that a robotic technique is a feasible minimally invasive approach for bladder diverticulectomy. Potential benefits may include precise dissection of adjacent structures, as well as easier intracorporeal suturing. Further studies are needed to compare outcomes and costs versus other existing procedures.

The pediatrician's role in reducing tobacco exposure in children.

OBJECTIVE: Pediatricians have a unique and important role to play in the prevention and treatment of childhood and adolescent tobacco use, the protection of patients from the harmful effects of environmental tobacco smoke, and the encouragement of smoking cessation among parents. However, because recent research indicates that physician training in tobacco dependence is woefully weak and lacks a model for training, this article constructs a useful approach to this problem. METHODOLOGY: A comprehensive review of the literature served as the basis for the development of a new model for pediatrician training in tobacco dependence. RESULTS: A comprehensive model is presented for training pediatricians in the areas of reducing infant and child exposure to environmental tobacco smoke, preventing youth smoking initiation, and providing smoking cessation assistance for adolescents and parents. CONCLUSIONS: Pediatricians have been called on to play an active role in the antitobacco arena. Because of their unique opportunity to interact with children, adolescents, and parents, pediatricians can and should be antitobacco interventionists. For this to occur, however, additional guidance should be provided to pediatricians during their training to better prepare them to carry out effective assessment and intervention practices. smoking initiation, smoking prevention, smoking cessation, environmental tobacco smoke, pediatricians.

Smoking prevalence and risk factors for smoking in a population of United States Air Force basic trainees.

OBJECTIVE: To provide a comprehensive assessment of smoking prevalence and risks for smoking in an entire population of United States Air Force (USAF) military basic trainees (n = 32,144). DESIGN: Population-based survey with every individual entering the USAF enlisted force from August 1995 to August 1996. SETTING: USAF Basic Military Training (BMT) facility at Lackland Air Force Base, Texas. All trainees were assessed during the first week of BMT. MAIN OUTCOME MEASURES: A 53-item questionnaire was developed to assess four domains: demographics, smoking history, risk factors for smoking, and other health behaviours. RESULTS: Approximately 32% of the trainees smoked regularly before basic training and a small percentage of the trainees (7.6%) described themselves as ex-smokers. Men, Euro-Americans, and those from lower educational backgrounds were more likely to smoke than other trainees. On average, smokers had smoked for approximately four years and had low nicotine dependence scores. Individuals who had smoked before BMT were more likely to use other drugs (such as alcohol, binge drinking, smokeless tobacco), and were less physically active than never-smokers. These findings were particularly strong for those who smoked up to basic training but were also evident for ex-smokers. CONCLUSIONS: Smoking is a prevalent risk factor among individuals entering the USAF. Furthermore, smoking was related to other risk factors believed to lower military readiness, including alcohol use and decreased physical activity. Comprehensive tobacco control policies aimed at reducing smoking among military trainees are needed.

Preliminary development of the Children's Physical Self-Concept Scale.

The development of a healthy eating style and physical fitness regimen in adolescence or adulthood might be contingent on physical self-concept in childhood. Most available measures of physical self-concept are inappropriate for use with 1st and 2nd grade children, so the present study developed, piloted, and partially validated the 27-item Children's Physical Self-Concept Scale (CPSS), which assesses Global physical self-concept and subscales of Physical Performance, Physical Appearance, and Weight Control behaviors in children 6 to 11 years of age. The test exhibits adequate test-retest reliability and internal consistency. A comparison of 316 normal and overweight children indicated that normal-weight children obtained higher Global physical self-concept scores and higher subscale scores. In addition, the CPSS distinguished test groups of diabetic, overweight, and normal-weight children in a contrasted-groups analysis.

Home-based behavioral treatments for chronic benign headache: a meta-analysis of controlled trials.

Controlled clinical trials have consistently demonstrated that behavioral treatments for chronic benign headache produce clinically beneficial outcomes both post-treatment and at follow-up. Given these results there is interest in cost-reduction and redesign of these treatments to improve their accessibility. One promising approach in this regard is home-based headache treatment. These treatments seek to provide the same amount of treatment as clinic-based treatments; however, some of the material typically presented to the patient by a clinician is presented through home-study materials (e.g., manuals, audiotapes). To date, the published literature contains 20 controlled clinical trials which have examined the outcomes produced by home-based treatments. This article presents the first comprehensive meta-analysis of these clinical outcome studies. Results of the quantitative analyses suggest that home-based treatments produce comparable, or with certain outcome measures, superior results to clinic-based treatments. Moreover, costeffectiveness scores of home-based treatments were found to be more than five times larger than those of clinic-based therapies. Methodological analyses are also presented along with suggestions for future research.

Viral genomes and arterial disease.

Recent studies suggest that the initial stages of human atherogenesis may be defined as inordinate inflammatory-proliferative responses of intimal arterial cells, interacting with circulating lymphocytes and monocyte/macrophages, to multiple focal stimuli. The latter include transmembrane signal transductions induced by cytokines and growth factors as well as by activated immune cells releasing vasoregulatory molecules affecting local transarterial lipoprotein transport and metabolism. The observed discriminating cell proliferation and characteristic focal eccentric intimal thickening of spontaneous atheroma may thus result from the phenotypic expression of transformed cell clones with selective proliferative advantages and yet unaffected by tissue immune responses. A suggested mechanism for such cell transformation is the partial expression of widely distributed herpesvirus genomes, resulting in the induction of clonal expansion and enhancement of selective cell growth in transfected host cells. Major obstacles for the unambiguous laboratory demonstration of a direct cause/effect relationship between herpes induced cellular transformation and early human atheroma are (1) potential loss of recognizable viral transforming sequences in the host cell genome by the "hit and run" mechanism originally proposed by Skinner in 1976 and (2) irreversible cytopathic effects induced by these viruses in experimentally infected human cells in vitro, preventing any long-term proliferative or metabolic studies. The observation that immortalized cultured rabbit arterial cells retain for many generations marked mitogenic activity and accelerated lipoprotein uptake after herpesvirus transfection suggested to us the possibility of developing a reproducible in vivo laboratory model in inbred rabbits. To that end, discrete intraarterial injections of fragments of HSV-1 or HSV-2 genomes were made via specially designed catheters in temporarily isolated arterial segments of Watanabe heritable hyperlipemic rabbits. While normolipemic heterozygous animals developed segmental, highly localized, proliferative intimal tumors, containing over 95% HHF35 (+) smooth muscle cells with RAM 11 (+) macrophages and platelets attached to the endothelial surface in 30-60 days, no lesions were found in placebo-injected controls. When hyperlipemic homozygous rabbits were similarly tested, they manifested at injected loci larger intimal lesions containing abundant lipid-laden macrophages and smooth muscle cells before typical rabbit fatty streaks developed elsewhere. These findings suggest that selective transfection with viral genome sequences may indeed induce specific growth promoters for intimal arterial smooth muscle cells and thus play an important role during the initial stages of atherogenesis.

Traumatic death in urban children, revisited.

OBJECTIVE: Trauma is the leading cause of death in children older than 1 year in the United States. We performed an analysis of the causes of death due to trauma in children in a large urban community to suggest means of prevention in such communities. We also examined data obtained before and after the designation of pediatric trauma centers to determine whether this has made a difference. DATA SOURCES: Records of the Medical Examiner, Cook County, Illinois, from 1983 through 1988. STUDY SELECTION: The admitting log was reviewed for all children before their 16th birthday. During the 6-year study period, 3121 autopsies were performed on children, 36.1% of whom died due to traumatic injuries. We reviewed the records of those children who died secondary to these injuries. DATA EXTRACTION: Record review on pediatric trauma deaths as to cause of death, time of death, age, sex, and any other pertinent information. RESULTS: Of all trauma deaths, fire was the most common cause of death, followed by motor vehicle-related injuries, homicides, drownings, and falls. These findings differ from national statistics. Improvement in outcome was seen following the designation of general trauma centers, with further improvement seen following the designation of specific pediatric trauma centers. CONCLUSIONS: Identification of causes of pediatric trauma death enables us to suggest methods of prevention. The centralized care of seriously injured children through the establishment of trauma centers and, specifically, pediatric trauma centers might help to prevent these deaths. Further study of pediatric trauma deaths, including hospital and ambulance records, is needed to improve medical care.

Relationship between psychosocial functioning and body fat in preschool children: a longitudinal investigation.

This study examined whether preschool children differed on measures of psychosocial functioning both cross-sectionally and longitudinally. One hundred and thirty-two children who varied in levels of body fat participated in the study along with their natural parents. Results indicated that the children did not differ in levels of self-esteem and family functioning as a function of their body fat. Prospectively, physical self-esteem weakly (but significantly) correlated with body fat at 1 and 2 years, and father's perception of family functioning predicted body fat at 1 year only. Results suggested that childhood obesity may not develop as a result of psychosocial factors.

Relationships among smoking status, body composition, energy intake, and physical activity in adult males: a longitudinal analysis.

This study evaluates the longitudinal relationships among smoking and adiposity, dietary intake, and physical activity in a group of adult males. Subjects were 101 nonsmokers and 19 regular cigarette smokers. Adiposity, dietary intake, and physical activity were assessed annually for three consecutive years. Results indicated that nonsmokers had larger tricep skinfold measurements than smokers over the 3-year period. However, dietary intake and physical activity did not differ between groups. Due to the absence of differences on these two variables for the smoking and nonsmoking groups, it was concluded that the lower adiposity in smokers was largely metabolically determined, which may make difficult the treatment of postcessation weight gain.

Parental influence on food selection in young children and its relationships to childhood obesity.

This investigation evaluated the impact of parental influences on children's food selections and the impact of childhood obesity on these food choices. Subjects were 53 young children of various weight status. Foods ranging widely in nutritional values were offered to each child for lunch. The children were again offered foods but were told that their mothers would be monitoring their selections. Finally, mothers were allowed to modify their children's last food choices. Results indicated that parental influences have a marked effect on food selection; both the threat of parental monitoring and actual parental monitoring lowered the number of nonnutritious foods chosen and total caloric content of the meal. The obesity status of the mothers and children had no impact on these results. The implication of these results for future intervention efforts are discussed.

Availability of knowledgeable informants for a psychological autopsy study of suicides committed by elderly people.

Psychological autopsy methodology has not been applied in studies of elderly suicides, despite the fact that the elderly are associated with a higher rate of suicide than any other age group. One school of thought argues that older adults who die by suicide are socially isolated and/or estranged for a long period of time before death, so that knowledgeable informants are difficult or impossible to obtain. In the present retrospective study we examine the number and availability of knowledgeable informants for 145 older people who committed suicide. We believe that the ability to access several motivated informants per case is essential to any psychological autopsy study by modern standards. The stereotype of the "average expectable" elderly suicide victim as socially isolated and living alone or in an institutional setting was not supported by our findings; an unexpectedly high percentage of subjects were married at the time of their death. There was at least one knowledgeable informant in 90% of cases and two or more in almost 50%. In 46%, the subject had expressed despondency over illness. In a prospective study involving interviews with informants for eight subjects, all eight had at least two knowledgeable and willing informants. Two cases of the eight are presented to illustrate the role of delirium and an ominous diagnosis (cancer) as causes of suicide. We conclude that it is feasible to do a psychological autopsy study of elderly suicides.

Vascular changes in the nasal submucosa of chronic cocaine addicts.

A detailed, correlative, histologic evaluation of postmortem changes in the nasal mucosa of chronic cocaine users has shown characteristic mucosal and arteriolar changes as well as typical perivascular and subepithelial alterations compatible with chronic inflammation. These findings confirm and extend recent reports on the effects of cocaine in the coronary circulation and heart muscle as well as provide a new diagnostic tool to the forensic pathologist who suspects that a decedent has been a long-term cocaine abuser.

Clinical forensic medicine.

This article discusses the merits of participation by medical examiners in the area of clinical forensic medicine. The present connotation that we deal after the fact should be abandoned with enhanced involvement in assisting the living. The paper focuses on a broad range of categories where forensic scientists by virtue of their training and experience could be most helpful in the application of medical knowledge to the solution of questions of law.

Acute subdural hematoma: direct admission to a trauma center yields improved results.

We studied 128 patients admitted over a 12 1/2-year period to the Cook County Hospital Trauma Unit with acute subdural hematoma (ASDH): 82 were admitted directly and 46 were admitted after transfer from another hospital; 59% of the entire group died and only 27% obtained a functional recovery. As a group, the transferred patients, who suffered delays of several hours before receiving definitive surgical care, fared significantly worse than the patients with equivalent trauma who were admitted directly. The mortality of the transferred patients was 76%, compared to 50% of the direct admit patients. The outcome was also worse for transfer patients who experienced a 'lucid interval' or with alcohol intoxication. We conclude that the delays associated with failure to admit patients with ASDH directly to a head trauma center cause an excessive mortality and morbidity which could potentially be avoided by proper triage.

The mistaken diagnosis of child abuse. A form of medical abuse?

The suspected diagnosis of child abuse may prove to be unfounded. Reports in the literature have focused on unusual diseases and folk medicine practices that may mimic abuse. We report ten cases where allegations of abuse were lodged against parents because the treating physicians in the emergency room mistook life-threatening illness or postmortem artifacts for inflicted injury. In all cases the families were from the inner city, and with two exceptions the involved institutions were small hospitals without pediatric personnel present in the emergency department. Although the histories related by the parents were in all cases truthful and consistent with the results of physical examinations of the child, the involved physicians failed to make a correct diagnosis. Not only a lack of experience with severe childhood illness and death but also an attitude of suspicion and/or hostility probably contributed to these misdiagnoses.

The general toxicology unknown. I. The systematic approach.

The general toxicology unknown often presents challenges and interests to toxicologists. A systematic analytical approach to search for drugs or poisons is presented here. The preliminary screening analyses were as follows: alcohol by gas chromatography (GC), ethchlorvynol colorimetric analysis, enzyme multiplied immunoassay technique (EMIT), basic drug screening by GC, and neutral and weakly acidic drug screening by GC. Other additional analyses were performed depending on the special circumstance of each individual case and the results of these preliminary analyses. Positive findings were confirmed by computerized gas chromatography/mass spectrometry when practical. Quantitation was performed by GC whenever possible.

The general toxicology unknown. II. A case report: doxylamine and pyrilamine intoxication.

A general toxicology unknown case is presented to demonstrate our systematic approach. A 20-year-old male was found dead with multiple suicide notes. Overdose was suspected but substances were not known. Blood alcohol was negative. Urine was analyzed by enzyme-multiplied immunoassay technique and was negative for all drugs assayed. Urine was then extracted with ethyl acetate:hexane (1:1) at pH 10 and back-extracted into 1.0N sulfuric acid. The acidic layer was adjusted to pH 10, and re-extracted with ethyl acetate:hexane (1:1). The residue was analyzed by gas chromatography (GC) on a 3% OV-101 column. It was found to be negative for all commonly screened substances. However, several unknown peaks were observed. Electron impact mass spectra of these unknown peaks were obtained and searched for in our computer library of more than 25000 mass spectra. These unknown peaks were identified as doxylamine and pyrilamine by gas chromatography/mass spectrometry. The base peak and molecular ion for pyrilamine were at m/z 121 and 285, respectively. The base peak for doxylamine was at m/z 58. No molecular ion was observed for doxylamine. Both doxylamine and pyrilamine are antihistamines, but are promoted and used in the management of insomnia. Quantitation was performed on a GC using dexbrompheniramine as an internal standard. Blood concentrations for doxylamine and pyrilamine were 0.7 and 7.0 mg/L, respectively. Concentrations in other tissues were determined. Death was caused by combined doxylamine and pyrilamine intoxication; the manner of death was suicide.

Spontaneous live birth with a maternal history of intravenous use of pentazocine and tripelennamine (T's and blues).

A 24-year-old black female presented a live birth of six-months gestation. The 700-g neonate survived for 11 h. After toxicology revealed the presence of pentazocine and tripelennamine (T's and Blues), the mother admitted to using this combination intravenously 9 h previous to admission. Concentrations of pentazocine and tripelennamine were simultaneously determined by gas-liquid chromatography (GLC) combined with nitrogen selective detection. Analyses were performed on a 3% OV-101 column, with the added internal standard, dexbrompheniramine. Both pentazocine and tripelennamine were qualitatively confirmed by their electron impact mass spectra. Concentrations of pentazocine and tripelennamine in various fluids and tissues were determined.