A National Survey of Breast Surgeons and Radiation Oncologists on Contemporary Axillary Management in Mastectomy Patients

Annals of Surgical Oncology - Management of axillary lymph nodes in breast cancer has undergone significant change over the past decade through landmark clinical trials. This study aimed to assess...     

A capnography and transcutaneous CO2 profile of bariatric patients during early postoperative period after opioid-sparing anesthesia

BackgroundNoninvasive monitoring of partial pressure of carbon dioxide can be accomplished indirectly with capnography (P_ETCO₂) or with transcutaneous carbon dioxide monitoring (P_TCCO₂). The use of capnography has been shown to offer an advantage over pulse oximetry alone in the early detection of adverse respiratory events when supplemental oxygen is administered. Furthermore, capnography allows for the monitoring of various respiratory measures, including end-tidal carbon dioxide, respiratory rate, tidal volume, and changes in breathing patterns. Transcutaneous CO₂ also closely approximates arterial CO₂ values, but is not as easy to monitor for prolonged periods. The purpose of this study was to examine the usefulness of capnography and of transcutaneous carbon dioxide monitoring in patients recovering from obesity surgery at high risk of developing postoperative obstructive sleep apnea.MethodsIn a prospective observational study, 64 bariatric surgery patients at risk of developing obstructive sleep apnea were monitored in the postanesthesia care unit (PACU) with either capnography alone (31 patients) or capnography plus transcutaneous carbon dioxide monitoring (33 additional patients) every 3–5 minutes for the duration of their recovery. Primary endpoints included end-tidal and transcutaneous carbon dioxide, peripheral oxygen saturation, respiratory rate, pain scores, and incidence of adverse respiratory events.ResultsAlthough no adverse pulmonary events were observed, capnography detected several patients who experienced short periods of respiratory apnea while maintaining pulse oximetry readings within normal limits. Transcutaneous values were slow to change and averaged 4.5 ± 5.5 mm Hg (P < .05) higher than corresponding end-tidal measurements.ConclusionsThese results indicate the capabilities of both these noninvasive techniques for postoperative monitoring. Capnography acutely monitors changes in respiration, whereas transcutaneous monitoring more accurately reflects arterial CO₂ levels.     

Role of myeloid differentiation factor 88 in Rhesus rotavirus-induced biliary atresia

Background

Biliary atresia (BA) is a unique neonatal disease resulting from inflammatory and fibrosing obstruction of the extrahepatic biliary tree. Previous studies have demonstrated the critical role of innate immunity and the Th1 response to activated inflammatory cells and overexpressed cytokines in the pathogenesis of BA. Myeloid differentiation factor 88 (MyD88) is a critical adaptor molecule that has been shown to play a crucial role in immunity. We investigated the role of MyD88 in the inflammatory response and development of cholangiopathy in murine BA.

Methods

MyD88 knockout (MyD88^−/−) and wild-type (WT) BALB/c pups were injected with Rhesus rotavirus or saline on day 1 of life. The mice were monitored for clinical symptoms of BA, including jaundice, acholic stools, bilirubinuria, and death. The liver and extrahepatic bile ducts were harvested for histologic evaluation and the quantification of viral content, determination of cytokine expression, and detection of inflammatory cells.

Results

Rhesus rotavirus infection produced symptoms in 100% of both MyD88^−/− and WT pups, with survival of 18% of WT and 0% of MyD88^−/− mice. Histologic analysis demonstrated bile duct obstruction in both MyD88^−/− and WT mice. Viral titers obtained 7 d after infection and expression of interferon-γ and tumor necrosis factor-α at day 3, 5, 8, and 12 after infection revealed no significant differences between the WT and MyD88^−/− mice. Flow cytometry demonstrated similar levels of activated CD8+ T cells and natural killer cells.

Conclusions

The pathogenesis of murine BA is independent of the MyD88 signaling inflammatory pathway, suggesting alternative mechanisms are crucial in the induction of the model.     

Early antibiotic treatment for severe acute necrotizing pancreatitis: a randomized, double-blind, placebo-controlled study

BACKGROUND & AIMS: In patients with severe, necrotizing pancreatitis, it is common to administer early, broad-spectrum antibiotics, often a carbapenem, in the hope of reducing the incidence of pancreatic and peripancreatic infections, although the benefits of doing so have not been proved. METHODS: A multicenter, prospective, double-blind, placebo-controlled randomized study set in 32 centers within North America and Europe. Participants: One hundred patients with clinically severe, confirmed necrotizing pancreatitis: 50 received meropenem and 50 received placebo. Interventions: Meropenem (1 g intravenously every 8 hours) or placebo within 5 days of the onset of symptoms for 7 to 21 days. Main Outcome Measures: Primary endpoint: development of pancreatic or peripancreatic infection within 42 days following randomization. Other endpoints: time between onset of pancreatitis and the development of pancreatic or peripancreatic infection; all-cause mortality; requirement for surgical intervention; development of nonpancreatic infections within 42 days following randomization. RESULTS: Pancreatic or peripancreatic infections developed in 18% (9 of 50) of patients in the meropenem group compared with 12% (6 of 50) in the placebo group (P = 0.401). Overall mortality rate was 20% (10 of 50) in the meropenem group and 18% (9 of 50) in the placebo group (P = 0.799). Surgical intervention was required in 26% (13 of 50) and 20% (10 of 50) of the meropenem and placebo groups, respectively (P = 0.476). CONCLUSIONS: This study demonstrated no statistically significant difference between the treatment groups for pancreatic or peripancreatic infection, mortality, or requirement for surgical intervention, and did not support early prophylactic antimicrobial use in patients with severe acute necrotizing pancreatitis.     

Trochlear Inclination Angles in Normal and Dysplastic Knees

Trochlear morphology impacts component position in patellofemoral arthroplasty. We devised a measurement of the trochlear inclination angle (TIA) and determined the average TIA in normal and dysplastic knees. Three hundred twenty-nine consecutive magnetic resonance imagings of normal and dysplastic knees were evaluated. The TIA was measured by 2 reviewers. The Student t test was used, and intraobserver reliability measurements were made. The mean TIA in normal and dysplastic knees was internally rotated 11.4° (range, 6°-20°) and 9.4° (range, 4°-15°), respectively. The mean TIA did not differ significantly by sex or age. Trochlear inclination angles in both normal and dysplastic knees tend toward internal rotation. Positioning a trochlear patellofemoral arthroplasty component flush with the articular surface of the native trochlea would result in internal rotation malposition.     

Surgical Biomechanics of the Patellofemoral Joint

This review presents objective data, as far as possible, about the current understanding of the biomechanics of the patellofemoral joint as it pertains to the management of patellofemoral problems. When faced with a patellofemoral malfunction, it is important to check all the soft-tissue and articular geometry factors relating to the patella locally and not to neglect the overall lower limb alignment and function. It is important to remember that small alterations in alignment can result in significant alterations in patellofemoral joint stresses and that changes in the mechanics of the patellofemoral joint can also result in changes in the tibiofemoral compartments. Surgical intervention for patellofemoral problems needs to be planned carefully and take into account an individual’s anatomy.     

Traumatic lumbar visceral herniation in a young woman

INTRODUCTIONLumbar herniation is uncommon, with traumatic etiology being rare. Traumatic lumbar hernias are usually caused by seatbelt injury in motor vehicle accidents. It is exceedingly uncommon to see lumbar hernias in an unrestrained passenger of a motor vehicle accident.PRESENTATION OF CASEWe present a case of a traumatic inferior lumbar hernia in a young woman who was an unrestrained driver of a vehicle involved in a high-speed collision, with multiple rollover and ejection. CT scans of the abdomen and pelvis suggested soft tissue injury involving muscles in the left lower posterior flank with traumatic herniation of the colon and small bowel. Emergent midline abdominal laparotomy confirmed herniation in the left lower quadrant. After abdominal closure, in the prone position, an extensive laceration over the left flank also confirmed herniation. Due to its dirty nature, the wound was irrigated, lavaged and covered with wound vacuum-assisted closure placement. The decision was made in favor of delayed elective hernia repair.DISCUSSIONLumbar hernias are usually caused by sudden force to the abdomen, leading to increased intra-abdominal pressure. This pressure combined with areas of weakness in the superior and/or inferior triangle lead to herniation. Uncommonly, the contents of lumbar hernias can strangulate or incarcerate leading to bowel obstruction. This can often be prevented by detection with CT and laparotomy.CONCLUSIONLumbar herniation of traumatic etiology is rare. Early detection with CT and/or exploratory laparotomy is important to avoid increases in size of the defect and bowel strangulation and incarceration.     

Cervical antibodies to herpes simplex virus proteins in pregnancy and puerperium: a pilot study

Objective: This study was undertaken to evaluate the changes in total and anti-herpes simplex virus (HSV)-specific cervical IgA and IgG antibody profiles during and after pregnancy.Methods: Serum and cervical secretions were obtained from pregnant patients before 20 weeks gestation, at 34-36 weeks gestation, and at 6 weeks postpartum and tested for total IgA and IgG antibody and for IgA and IgG to HSV proteins by Western blot.Results: Seven women were HSV seronegative, 14 HSV-1 seropositive, and 14 HSV-2 +/- HSV-1 seropositive. Minimal changes in the serum anti-HSV profiles were seen over the 3 visits. The total cervical IgA, IgG, and protein levels did not change between the 2 pregnancy visits but tended to increase at the postpartum visit. No consistent change in cervical HSV-specific IgA and IgG was seen during pregnancy, but the levels increased markedly at the postpartum visit.Conclusions: Lower cervical anti-HSV antibody levels may be related to the previously reported increased frequency of a reactivation of HSV during late pregnancy. Further evaluation is necessary to confirm and quantify the changes in genital immunity during pregnancy and to evaluate whether the increased levels at the postpartum visit are sustained.     

The relationship of otitis media in early childhood to attention dimensions during the early elementary school years

This study examined the impact of otitis media with effusion (OME) and associated hearing loss between 6 and 48 months of age on attention dimensions (i.e., selective/focus, sustained) during the elementary school years. A prospective cohort design in which 74 African American infants were recruited between ages 6 and 12 months. Ear examinations were done repeatedly using both otoscopy and tympanometry, and hearing was assessed using standard audiometric procedures between 6 and 48 months. Multiple measures of attention (i.e., direct assessment, behavioral observations, parent/teacher ratings) were administered from kindergarten through second grade to assess two theoretical dimensions of attention: selective/focused and sustained. The home environment was assessed annually. Results indicated that neither early childhood OME nor hearing loss showed significant correlations with any of the longitudinal or cross-sectional measures of selective/focused attention and sustained attention. In contrast, children with mothers who had fewer years of education and who lived in less responsive and supportive home environments scored higher on both parent and teacher ratings of sustained attention (i.e., hyperactivity) through the second grade of elementary school. For NEPSY Auditory Attention in second grade, a significant interaction between the Home Observation for Measurement of the Environment and hearing loss was uncovered. This interaction showed that children with hearing loss from poor home environments experienced greater difficulties on the NEPSY Auditory Attention task than those with hearing loss from good home environments. These findings do not support a direct linkage of a history of OME and associated hearing loss to difficulties in selective/focused attention or sustained attention in early elementary school children. Relationships between sociodemographic variables and attention-related functions appear stronger and should be considered as mediators in any examination of the linkages between early OME and subsequent attention functions.     

Incentive‐elicited mesolimbic activation and externalizing symptomatology in adolescents

Background: Opponent‐process theories of externalizing disorders (ExD) attribute them to some combination of overactive reward processing systems and/or underactive behavior inhibition systems. Reward processing has been indexed by recruitment of incentive‐motivational neurocircuitry of the ventral striatum (VS), including nucleus accumbens (NAcc). Methods: We used functional magnetic resonance imaging (fMRI) with an incentive task to determine whether externalizing symptomatology in adolescence is correlated with an enhanced VS recruitment by cues for rewards, or by deliveries of rewards. Twelve community‐recruited adolescents with externalizing disorders (AED) and 12 age/gender‐matched controls responded to targets to win or avoid losing $0, $0.20, $1, $5, or an unknown amount (ranging from $0.20 to $5). Results: Cues to respond for rewards activated the NAcc (relative to cues for no incentive), in both subject groups similarly, with greatest NAcc recruitment by cues for the largest reward. Loss‐anticipatory NAcc signal increase was detected in a volume‐of‐interest analysis – but this increase occurred only in trials when subjects hit the target. Relative to controls, AED showed significantly elevated NAcc activation by a linear contrast between reward notification versus notification of failure to win reward. In a post hoc reanalysis, VS and pregenual anterior cingulate activation by the reward versus non‐reward outcome contrast also directly correlated with Child Behavior Checklist (CBCL) Externalizing total scores (across all subjects) in lieu of a binary diagnosis. Finally, both groups showed right insula activation by loss notifications (contrasted with avoided losses). Conclusions: Externalizing behavior, whether assessed dimensionally with a questionnaire, or in the form of a diagnostic categorization, is associated with an exaggerated limbic response to outcomes of reward‐directed behavior. This could be a neurobiological signature of the behavioral sensitivity to laboratory reward delivery that is characteristic of children with externalizing symptomatology. Of interest is future research on incentive‐motivational processing in more severe, clinically referred AED.