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PubMed2004

Nutrition and cancer prevention: a multidisciplinary perspective on human trials.

More than one million Americans were expected to be diagnosed with cancer in 2003 (7a). Compelling experimental, epidemiological, and clinical evidence indicates that many cancers are preventable, especially because diet and nutrition are key factors in the modulation of cancer risk. The road to nutritional intervention in cancer prevention has led to successful trials as well as trials that did not reach their intended endpoints. This chapter reviews four case studies of trials, with two ending in success and two ending in null findings or adverse effects. The goal is to identify lessons learned from all four case studies and from the investigations of the complexities inherent to nutritional intervention trials. Additional insights are presented by the research addressing potential mechanisms underlying the endpoints of human trials. Future progress in nutrition and cancer prevention will require expertise from multidisciplinary teams to develop new knowledge about specific nutrients and dietary modifications within a framework of interaction between animal and human research.

Diet↗

PubMed2004

[Case management for patients with congestive heart failure under ambulatory care--a critical review].

BACKGROUND: Congestive Heart Failure (CHF) is becoming the most serious cardiac health problem after coronary heart disease (CHD). But at present, service offered to CHF patients are flawed because of the fragmentation and discontinuity of care. Case management (CM) takes responsibility for following up patients, for assessing symptoms and taking action when patients do not adhere to guideline based treatment or fail to improve. This review analyses the evidence of primary care based CM for patients with CHF. METHODS: Searches in Medline using relevant MeSH terms and hand-searching were applied to identify relevant studies. We selected RCTs and pre-post studies focussing on patient-centred CM in ambulatory settings. A five-level score (simple to complex) was generated to describe interventions and compare results. RESULTS: 23 of 462 identified studies (16 RCT, 7 others) that fulfilled our selection and quality criteria were included. We classified 15 studies as "complex" CM, i.e. they contained more than three elements of intervention, were strongly integrated with the process of care, involved a specialised nurse, and offered individual patient education. All studies examined the length of hospital stay: costs were investigated in 17, quality of life in 10 and mortality in 7 studies. Studies examining a "complex" CM demonstrated positive effects on mortality and quality of life in the 3-6 months of follow up. Studies with a follow up period of 12 to 18 months showed a reduction of hospital days. CONCLUSION: Especially "complex" models of CM for patients with CHF can be effective in a primary care setting. CM can prevent the fragmentation and discontinuity of care by strengthening a close contact between patient and health care provider.

Ambulatory Care↗

PubMed2003

Vulnerable among the vulnerable: drug users in situations of poverty and indigence in Argentina.

To study drug use in the context of poverty, it is necessary to undertake a complex analysis of various perspectives to understand the dense interweaving of socioeconomic, political, and cultural factors involved in the problem. The analysis of this social scenario was our starting point in planning holistic actions for the prevention of human immunodeficiency virus/acquired immunodeficiency syndrome and other illnesses related to drug use. Merely copying successful models from developed countries, which are designed for other contexts and populations, would result in insufficient and ineffective actions. The Asociación Civil Cristiana Recuperación Atención de Drogadependientes (ACCRAD), also known as "El Retoño" ("sprout"), is a nongovernmental organization that has been working since 1985 to consolidate a model of analysis and intervention that considers this complex framework and seeks to meet the needs of drug users from the poorest sectors of society. Our research on the use of drugs and its relationship to poverty, together with the documentation of harm-reduction interventions, has been carried out since 1997.

Argentina↗

PubMed2000

[Laparoscopic interventions on choledochus: 5 year experience].

Complex examination of 69 patients with complicated cholelithic disease was performed. The elaborated in the clinic algorithm for preoperative examination of the patients was applied to reveal the main bile ducts pathology. Indications for the laparoscopic interventions on choledochus performance were substantiated.

Adult↗

PubMed2006

Determinants of neuropsychological and behavioural outcomes in early childhood survivors of congenital heart disease.

AIMS: To evaluate the relative effect of cyanosis, surgical interventions and family processes on neuropsychological and behavioural outcomes in 4-year-old survivors of serious congenital heart disease (CHD). METHODS: 90 children with a range of cyanotic and acyanotic conditions, who underwent either corrective or palliative surgery, completed a neuropsychological and behavioural evaluation. Families of participants were also profiled by evaluation of maternal mental health, worry, social support, parenting style and family functioning. RESULTS: Compromised neuropsychological outcomes were associated with a combination of cyanotic conditions and open-heart surgery, but this was not exacerbated by having a complex, palliative, status. Both cyanotic and acyanotic conditions were associated with specific sensorimotor delays, regardless of method of the correction. Only children with complex conditions and palliative interventions seemed at risk of poor behavioural outcomes; indeed, children with cyanosis with complete repair showed favourable behavioural outcomes compared with controls. Multivariate analyses highlighted the sometimes greater relevance of family processes (eg parenting style, maternal mental health and worry), rather than disease or surgical factors, in predicting especially behavioural outcomes. CONCLUSIONS: The findings (1) suggest a more complex relationship between cyanosis, surgical methods of correction, neuropsychological and behavioural outcomes than previously charted, (2) highlight that family processes may be aetiologically more important than disease and surgical factors, and (3) indicate specific targets for secondary prevention programmes for this at-risk population.

Anxiety↗

PubMed1993

3-D video techniques in endoscopic surgery.

Three-dimensional visualisation of the operative field is an important requisite for precise and fast handling of open surgical operations. Up to now it has only been possible to display a two-dimensional image on the monitor during endoscopic procedures. The increasing complexity of minimal invasive interventions requires endoscopic suturing and ligatures of larger vessels which are difficult to perform without the impression of space. Three-dimensional vision therefore may decrease the operative risk, accelerate interventions and widen the operative spectrum. In April 1992 a 3-D video system developed at the Nuclear Research Center Karlsruhe, Germany (IAI Institute) was applied in various animal experimental procedures and clinically in laparoscopic cholecystectomy. The system works with a single monitor and active high-speed shutter glasses. Our first trials with this new 3-D imaging system clearly showed a facilitation of complex surgical manoeuvres like mobilisation of organs, preparation in the deep space and suture techniques. The 3-D-system introduced in this article will enter the market in 1993 (Opticon Co., Karlsruhe, Germany.

Animals↗

PubMed2001

Surgical management of secondary glaucoma after pars plana vitrectomy and silicone oil injection for complex retinal detachment.

OBJECTIVE: To evaluate the outcomes of surgical intervention for secondary glaucoma after pars plana vitrectomy and silicone oil injection for repair of complex retinal detachment. DESIGN: Retrospective noncomparative interventional case series. PARTICIPANTS: Forty-three eyes of 43 patients who underwent incisional surgery for secondary glaucoma after pars plana vitrectomy and silicone oil injection for repair of complex retinal detachment over a 9-year period. MAIN OUTCOME MEASURES: Intraocular pressure (IOP), intraoperative and postoperative complications, visual acuity, and the need for further surgical intervention for glaucoma. Success was defined as IOP < or =21 mmHg and > or =5 mmHg with or without medication but without surgical reoperation for glaucoma. RESULTS: Findings associated with elevated IOP included emulsified oil in the anterior chamber (n = 14), pupillary block from silicone oil (n = 13), open-angle glaucoma without silicone oil in the anterior chamber (n = 9), and angle-closure glaucoma without pupillary block (n = 7). The mean (+/- standard deviation) IOP was 41.4 +/- 15.1 mmHg before surgery for glaucoma and 17.2 +/- 10.2 mmHg after an average follow-up of 19.6 months (P < 0.001). Cumulative success was 69%, 60%, 56%, and 48% at 6, 12, 24, and 36-months respectively. In patients who underwent silicone oil removal alone for surgical management of glaucoma (n = 32), 11 of 12 IOP failures (92%) were due to uncontrolled IOP, whereas most IOP failures in the group who underwent silicone oil removal plus glaucoma surgery (n = 8) failed because of hypotony (3 of 4, 75%, P = 0.027). Of three patients who underwent glaucoma surgery alone to control IOP, one failed because of hypotony. There was no significant change in visual function at last follow-up (logarithm of the minimum angle of resolution [logMAR] 2.01) compared with preoperative visual function (logMAR 2.07, P = 0.74). CONCLUSION: Surgical management of secondary glaucoma after silicone oil injection for complex retinal detachment may achieve good IOP control and stabilization of visual function in most patients. Patients who undergo silicone oil removal alone to control IOP are more likely to have persistent elevation of IOP and possibly undergo reoperation for glaucoma, whereas patients who undergo concurrent silicone oil removal and glaucoma surgery are more likely to have hypotony.

Female↗

PubMed2006

Subclavian flap repair: review of 399 patients at median follow-up of fourteen years.

BACKGROUND: Conflicting results have been obtained for the same operation for repair of coarctation of the aorta by different institutes. The purpose of this study was to assess the results of subclavian flap aortoplasty (SFA) alone, performed on 399 patients in a single institute between 1966 and 1995. METHODS: Data were collected retrospectively from the congenital cardiac surgical database at the institute. RESULTS: The median age at operation was 22 days (3 days-49 months). One hundred thirty-four patients had isolated coarctation while 265 children had complex coarctation. Maximum follow-up was 24 years (median, 14 years). Overall mortality over the whole duration of follow-up was 24.8%. Mortality for isolated coarctation at first intervention was 7.4% (operative mortality, 2.6%) while it was 12.8% for complex coarctation. At second intervention the mortality for isolated coarctation was 5%. For the second, third, and fourth interventions the mortality for complex coarctation was 25%, 25%, and 27%, respectively. The survival for isolated coarctation at 1, 5, 10, and 20 years was 94%, 93.2%, 92.4%, and 88.4%, respectively, while it was 74.6%, 66.3%, 63%, and 61.4%, respectively, for complex coarctation. Of the total patients, 15.3% had interventions for recoarctation. The incidence of recoarctation was 13.6% on those patients operated on in the first month of life, while it was 3.6% in older children. A percentage of 3.3% of patients continue to be hypertensive and require medication. There was a significant difference between the systolic blood pressure and anthropometric measurements between the arms. Despite this none of the patients complained of effect on lifestyle. CONCLUSIONS: Despite improved early results the long-term mortality for coarctation remains high. Mortality is higher for complex coarctation as compared with isolated procedures. The incidence of recoarctation after SFA at long term is acceptable and is higher in patients operated on in the first month of life. The overall incidence of hypertension is quite low. Patients remained normotensive when operated upon at the age of 0.9 months. The SFA, no doubt, effects the limb development; however it does not cause limitation in the lifestyle.

Aortic Coarctation↗

PubMed2003

Surgical management of traumatic pulmonary injury.

BACKGROUND: Surgical treatment of traumatic pulmonary injuries requires knowledge of multiple approaches and operative interventions. We present a 15year experience in treatment of traumatic pulmonary injuries. We hypothesize that increased extent of lung resection correlates with higher mortality. METHODS: Surgical registry data of a level 1 trauma center was retrospectively reviewed from 1984 to 1999 for traumatic lung injuries requiring operative intervention. Epidemiologic, operative, and hospital mortality data were obtained. RESULTS: Operative intervention for traumatic pulmonary injuries was required in 397 patients, of whom 352 (89%) were men. Penetrating trauma was seen in 371 (93%) patients. Location of the injuries was noted in the left side of the chest in 197 (50%), right side of the chest in 171 (43%), and bilateral in 29 (7%). Operative interventions included pneumonorraphy (58%), wedge resection or lobectomy in (21%), tractotomy (11%), pneumonectomy (8%), and evacuation of hematoma (2%). Overall mortality was 27%. If concomitant laparotomy was required, mortality increased to 33%. The mortality rate in the pneumonectomy group was 69.7%. CONCLUSIONS: The majority of lung injuries occurred in males due to penetrating trauma. Surgical treatment options ranged from simple oversewing of bleeding injury to rapid pneumonectomy. Mortality increased as the complexity of the operative intervention increased. Rapid intraoperative assessment and appropriate control of the injury is critical to the successful management of traumatic lung injury.

Adolescent↗

PubMed1990

Heart failure: mechanisms of cardiac and vascular dysfunction and the rationale for pharmacologic intervention.

Congestive heart failure is a complex clinical syndrome that has its basis in an abnormality of myocardial cell function resulting in impaired ventricular performance, exercise intolerance, and ventricular arrhythmias. The functional defect in myocardial performance may be related to alterations in receptor function, in regulatory proteins, or in biochemical mechanisms. Remodeling of the left ventricle has been observed to play an important role in the natural course of heart failure. The complex interplay between cellular elongation, reactive hypertrophy, and the influence of the change from ellipsoid to spheroidal shape of the left ventricle after acute myocardial infarction are just beginning to be understood. Prevention of this remodeling effect by pharmacologic intervention is being widely explored, although the mechanisms are poorly defined. Impedance to left ventricular ejection is also an important determinant of cardiac performance in heart failure. Constriction of arteriolar resistance vessels and reduction in compliance of arterial conductance vessels is a common manifestation of heart failure and may be under the influence of neural, hormonal, endothelial, and local regulatory factors. Increased tone of venous capacitance vessels contributes to a shift of blood centrally and to an increase in ventricular preload. Vasodilator drugs by relaxing the arterial, arteriolar, and venous vasculature result in a reduction in impedance and left ventricular afterload and a decrease in cardiac filling pressure and preload. Structural changes of hypertrophy and remodeling apparently contribute to the changes in resistance, compliance, and capacitance in the vasculature. Treatment of heart failure is aimed at relieving symptoms and prolonging life. Interventions to improve left ventricular function are critical to symptom relief. Vasodilators have been most effective for this purpose, and new positive inotropic drugs are being tested for efficacy. Long-term benefit may require interference with the myocardial and peripheral vascular remodeling processes that lead to progressive depression of ventricular performance. New insights into the cellular and subcellular mechanisms of this progression are critical to the development of innovative therapeutic strategies.

Cardiovascular System↗

PubMed1987

Diuretics, serum potassium and ventricular arrhythmias in the Multiple Risk Factor Intervention Trial.

To examine the relation between diuretic use and ventricular premature complexes (VPCs) in the Multiple Risk Factor Intervention Trial, data derived from the baseline and annual rest electrocardiograms were analyzed for men in the special-intervention (SI) and usual-care (UC) groups. At baseline, age, diuretic use and presence of other rest electrocardiographic abnormalities were significantly associated with the prevalence of VPCs. Among diuretic users at baseline, those with lower serum potassium levels were most likely to have VPCs. Over the follow-up period among nonhypertensive persons the relative risk (SI/UC) for the occurrence of VPCs during follow-up was 0.83, and for hypertensives this relative risk increased linearly from 1.08 to 1.42, with higher levels of diastolic blood pressure at entry (p less than 0.01 for linear trend of relative risk estimates). This was due to an increasing risk among the SI group, and the risk was independent of the presence or absence of rest electrocardiographic abnormalities at baseline. The relative risk estimate, diuretic vs no diuretic, for development of VPCs was approximately 1.2 (p = 0.04) for SI men and 1.1 (p = 0.35) for UC men. The reduction in serum potassium level was greater for those with VPCs, and regression analysis showed that low serum potassium levels were significantly associated with the incidence of VPCs in both study groups. These data confirm and quantify the relation between diuretic drugs and VPCs and suggest that at least 1 mechanism of diuretic-induced VPCs is potassium depletion.

Adult↗

PubMed2006

Percutaneous coronary intervention through a Cabrol composite graft.

There are several different surgical techniques used to repair acute type-A aortic dissections. One such technique is called the Cabrol procedure which uses a Dacron tube graft to re-attach the native coronary arteries. Stenosis of this graft-native coronary anastomosis is a recognized complication of the procedure and one amenable to percutaneous intervention. However, knowledge of the complex anatomy involved with the Cabrol repair is required in order to potentially carry out successful intervention. We report one such case involving a critical stenosis at the anastomosis of the Cabrol graft with the native left main stem.

Aortic Dissection↗

PubMed2006

[A comparison of interventions recorded in nursing notes between acute and subacute stage after a cerebrovascular accident].

PURPOSE: This study aimed to: 1) determine the core nursing interventions, and 2) compare acute interventions with subacute interventions recorded in the nursing notes of patients with cerebrovascular accidents (CVA). METHODS: The nursing records covering the first 10 days of 30 patients with a CVA who were admitted from January to December 2004 at C University Hospital in Korea were examined. Data was collected using the nursing interventions classification (NIC) from January to April 2005. Finally, data analysis was carried out using mean, SD, and paired t-test according to domains, classes, and interventions. RESULTS: The most frequent nursing intervention at both stage was "Neurologic monitoring". There were differences in interventions belonging to the "Physiological: complex," "Behavioral," "Safety," and "Health system" domains between the acute and subacute stages. The frequency of interventions belonging to the "Immobility management," "Neurological management," "Tissue perfusion management," "Patient education," "Risk management," "Health system mediation," and "Information management" classes at the acute stage was higher compared to the subacute stage. CONCLUSIONS: This study found out that nurses relatively recorded more nursing interventions during the acute stage hence the unsuccessful documentation of the subacute stage particularly in describing the specific nursing interventions at this stage.

Female↗

PubMed2001

New insights into the role of the GABA(A)-benzodiazepine receptor in psychiatric disorder.

BACKGROUND: In the 40 years since the first benzodiazepine was brought into clinical use there has been a substantial growth in understanding the molecular basis of action of these drugs and the role of their receptors in disease states. AIMS: To present current knowledge about the role of the GABA(A)-benzodiazepine receptor in anxiety disorders, new insights into the molecular biology of the receptor complex and neuroimaging studies suggesting involvement of these receptors in disease states. METHOD: An overview of published literature, including some recent data. RESULTS: The molecular biology of this receptor is detailed. Molecular genetic studies suggesting involvement of the GABA(A)-benzodiazepine receptor in animal behaviour and learning are outlined; possible parallels with human psychopathology are discussed. CONCLUSIONS: Current insights into the role of the GABA(A)-benzodiazepine receptor in the action of benzodiazepines and as a factor in disease states, in both animals and humans, may lead to new, more sophisticated interventions at this receptor complex and potentially significant therapeutic gains.

Animals↗

PubMed1993

Recurrent cholangitis with and without anastomotic stricture after biliary-enteric bypass.

We recently surgically treated 24 patients incapacitated by recurrent cholangitis after biliary-enteric anastomosis performed for benign disease. Contrary to commonly held dogma, as many as one third of the patients had no evidence of anastomotic stricture indicated by radiologic and operative findings. We identified several other primary and coexistent pathogenetic factors including intrahepatic stricture in 42% of the patients, intrahepatic calculi in 25%, improperly constructed enteric conduits in 13%, and conditions that predispose to bacterial overgrowth in the biliary tree in 17%. Seventy-one percent of the patients had multiple etiologic factors, and of those patients without demonstrable anastomotic stricture, intrahepatic stricture was particularly common. Seventy-one percent remained symptom-free in their first year after operation. The most difficult situation to manage, and the factor responsible for most recurrences after our reoperation, involved intrahepatic stricture. A combined surgical and interventional radiologic approach to complex cases may be useful in selected patients.

Adult↗

PubMed1999

Costs and cost-effectiveness of routine transesophageal echocardiography in congenital heart surgery.

BACKGROUND: The safety and efficacy of transesophageal echocardiography (TEE) during congenital heart surgery is well established. The economic costs and benefits associated with its routine use in this setting are, however, uncertain. We sought to analyze the impact that routine intraoperative TEE had on echocardiographic costs in the setting of congenital heart surgery. METHODS AND RESULTS: A retrospective, case-controlled analysis of echocardiographic costs during the operative and postoperative periods was performed for 63 children undergoing elective, complex intracardiac repair. Similar analysis was performed for a smaller group of patients undergoing simple repairs. To ascertain whether any additional cost savings was realized through the use of TEE, we documented the impact that operative TEE had on altering surgical strategy as well as whether TEE use was associated with any intraoperative complications. Despite the additional expense, routine TEE, in the setting of complex repair, resulted in no significant increases in echocardiographic costs, suggesting the superior information provided may in fact reduce the need for additional postoperative studies in the intensive care setting. Although no child required a return to cardiopulmonary bypass, surgical therapy was altered by TEE findings in 2 (3%) of 63 patients. Complications were rare and self-limited, usually occurring with positioning of the probe in smaller patients. CONCLUSIONS: The findings of improved surgical outcomes in a percentage of patients, coupled with the lack of any significant increment in echocardiographic costs, confirm that intraoperative TEE is a beneficial and cost-effective intervention in children requiring complex cardiac repair.

Case-Control Studies↗

PubMed2002

Recombinant CD16A-Ig forms a homodimer and cross-blocks the ligand binding functions of neutrophil and monocyte Fcgamma receptors.

Receptors for the Fc region of IgG (FcgammaR) are expressed as membrane-bound and soluble forms in inflammatory cells. These receptors mediate a variety of immunoregulatory functions. FcgammaR-bearing neutrophils and macrophages play a major role in mediating immune complex induced inflammatory diseases and antibody-mediated tissue injury in autoimmune diseases. To delineate the biological role of the soluble FcgammaR, a recombinant soluble CD16A (CD16A-Ig) was expressed and characterized. CD16A-Ig is secreted as a disulfide-linked homodimer of 70kDa. The purified CD16A-Ig bound to human IgG1 and IgG3 immobilized onto ELISA plates and on IgG1- and IgG3-coated erythrocytes. Saturation binding studies and Scatchard plot analysis showed that immune complex bound to the purified CD16A-Ig with high avidity. Moreover, CD16A-Ig competitively blocked the binding of cell surface-expressed CD16A-CHO cells to IgG-coated plates. The dimeric CD16A-Ig also efficiently cross-blocked the binding of IgG-coated target cells to other FcgammaR expressed on neutrophils and monocytes. These results demonstrate that CD16A-Ig forms a high avidity dimer and is capable of blocking cell-cell interactions mediated by inflammatory cells expressing FcgammaR and IgG-coated target cells. These findings suggest that the dimeric FcgammaR molecules could be used therapeutically for the intervention of immune complex-mediated inflammatory disease.

Animals↗

PubMed2004

Breast conservation surgery using nipple-areolar resection for central breast cancers.

HYPOTHESIS: Resection of the nipple-areolar complex (NAC) for central breast cancers that involve the nipple or areola, with postoperative radiation therapy, adheres to the oncologic principles established for breast conservation surgery of other breast cancers. Good or excellent cosmetic results can be achieved. The rate of ipsilateral breast recurrence will be similar to that seen with peripheral breast cancers. The indications for breast conservation surgery can be safely extended to include patients with breast cancers that involve the NAC. DESIGN: Retrospective medical record review; follow-up patient questionnaire. SETTING: Community teaching hospital. PATIENTS: Fifteen patients, aged 46 to 88 years, whose central breast cancers involved the NAC precluding preservation of the NAC. INTERVENTIONS: Nipple-areolar complex resection, postoperative radiation therapy. MAIN OUTCOME MEASURES: Ipsilateral breast recurrence, survival, cosmesis. RESULTS: Ten patients had subareolar cancers that directly involved the nipple or areola; 5 patients had Paget disease of the nipple. Average tumor size was 1.6 cm (range, 0.2-3.5 cm). With a mean follow-up of 32 months (range, 4-109 months), there has been only 1 recurrence (7%), which was treated successfully by modified radical mastectomy. All 15 patients are alive and free of disease. Cosmetic results are satisfactory to excellent, as judged by both the patients and the surgeons. CONCLUSIONS: Nipple-areolar complex resection for central subareolar cancers that directly involve the NAC, as well as for Paget disease of the nipple, extends the indications for breast conservation in other areas of the breast, and with acceptable cosmesis.

Aged↗