Who Smokes in Europe? Data From 12 European Countries in the TackSHS Survey (2017-2018)

BACKGROUND

Population data on tobacco use and its determinants require continuous monitoring and careful inter-country comparison. We aimed to provide the most up-to-date estimates on tobacco smoking from a large cross-sectional survey, conducted in selected European countries.

METHODS

Within the TackSHS Project, a face-to-face survey on smoking was conducted in 2017-2018 in 12 countries: Bulgaria, England, France, Germany, Greece, Ireland, Italy, Latvia, Poland, Portugal, Romania, and Spain, representing around 80% of the 432 million European Union (EU) adult population. In each country, a representative sample of around 1,000 subjects aged 15 years and older was interviewed, for a total of 11,902 participants.

RESULTS

Overall, 25.9% of participants were current smokers (31.0% of men and 21.2% of women, P < 0.001), while 16.5% were former smokers. Smoking prevalence ranged from 18.9% in Italy to 37.0% in Bulgaria. It decreased with increasing age (compared to <45, multivariable odds ratio [OR] for ≥65 year, 0.31; 95% confidence interval [CI], 0.27-0.36), level of education (OR for low vs high, 1.32; 95% CI, 1.17-1.48) and self-rated household economic level (OR for low vs high, 2.05; 95% CI, 1.74-2.42). The same patterns were found in both sexes.

CONCLUSIONS

These smoking prevalence estimates represent the most up-to-date evidence in Europe. From them, it can be derived that there are more than 112 million current smokers in the EU-28. Lower socio-economic status is a major determinant of smoking habit in both sexes.

State of the art: stem cells in equine regenerative medicine

According to Greek mythology, Prometheus' liver grew back nightly after it was removed each day by an eagle as punishment for giving mankind fire. Hence, contrary to popular belief, the concept of tissue and organ regeneration is not new. In the early 20th century, cell culture and ex vivo organ preservation studies by Alexis Carrel, some with famed aviator Charles Lindbergh, established a foundation for much of modern regenerative medicine. While early beliefs and discoveries foreshadowed significant accomplishments in regenerative medicine, advances in knowledge within numerous scientific disciplines, as well as nano- and micromolecular level imaging and detection technologies, have contributed to explosive advances over the last 20 years. Virtually limitless preparations, combinations and applications of the 3 major components of regenerative medicine, namely cells, biomaterials and bioactive molecules, have created a new paradigm of future therapeutic options for most species. It is increasingly clear, however, that despite significant parallels among and within species, there is no 'one-size-fits-all' regenerative therapy. Likewise, a panacea has yet to be discovered that completely reverses the consequences of time, trauma and disease. Nonetheless, there is no question that the promise and potential of regenerative medicine have forever altered medical practices. The horse is a relative newcomer to regenerative medicine applications, yet there is already a large body of work to incorporate novel regenerative therapies into standard care. This review focuses on the current state and potential future of stem cells in equine regenerative medicine.

Italy and Austria before and after study: second-hand smoke exposure in hospitality premises before and after 2 years from the introduction of the Italian smoking ban

The aim of this paper was to compare nicotine concentration in 28 hospitality premises (HPs) in Florence and Belluno, Italy, where a smoking ban was introduced in 2005, and in 19 HPs in Vienna, Austria, where no anti-smoking law entered into force up to now. Airborne nicotine concentrations were measured in the same HPs in winter 2002 or 2004 (pre-ban measurements) and winter 2007 (post-ban measurements). In Florence and Belluno, medians decreased significantly (P < 0.001) from 8.86 [interquartile range (IQR): 2.41-45.07)] before the ban to 0.01 microg/m3 (IQR: 0.01-0.41) afterwards. In Austria (no smoking ban) the medians collected in winters 2004 and 2007 were, respectively, 11.00 (IQR: 2.53-30.38) and 15.76 microg/m3 (IQR: 2.22-31.93), with no significant differences. Measurements collected in winter 2007 in 28 HPs located in Naples, Turin, Milan (0.01 microg/m3; IQR: 0.01-0.16) confirmed post-ban results in Florence and Belluno. The medians of nicotine concentrations in Italy and Austria before the Italian ban translates, using the risk model of Repace and Lowery, into a lifetime excess lung cancer mortality risk for hospitality workers of 11.81 and 14.67 per 10,000, respectively. Lifetime excess lung cancer mortality risks for bar and disco-pub workers were 10-20 times higher than that calculated for restaurant workers, both in Italy and Austria. In winter 2007, it dropped to 0.01 per 10,000 in Italy, whereas in Austria it remained at the same levels. The drop of second-hand smoke exposure indicates a substantial improvement in air quality in Italian HPs even after 2 years from the ban.

PRACTICAL IMPLICATIONS

The nation-wide smoking ban introduced in Italy on January 10, 2005, resulted in a drop in second-hand smoke exposure in hospitality premises, whereas in Austria, where there is no similar nation-wide smoking ban, the exposure to second-hand smoke in hospitality premises remains high. Given that second-hand smoke is considered a group 1 carcinogen according to the International Agency for Research on Cancer classification, the World Health Organization Framework Convention on Tobacco Control strongly recommends the implementation of nation-wide smoke-free policies in order to improve the indoor air quality of hospitality premises and workplaces. Results from our study strongly supports this recommendation.

Psychological functioning, nonadherence and health outcomes after pediatric liver transplantation

The present study empirically assessed the relationships between adherence behaviors and HRQOL, parent and child psychological functioning and family functioning, and investigated the relationship between adherence behaviors and health outcomes in children who were within 5 years of their liver transplantation. Participants included 38 children (mean = 8.5 years, range 28 months to 16 years) and their parent/guardian(s). HRQOL and psychological functioning were examined using well-validated assessment measures. Measures of adherence included the rate of clinic attendance and standard deviations (SDs) of consecutive tacrolimus blood levels, which were collected and evaluated retrospectively. Measures of child health status included the frequency of hospital admissions, liver biopsies, episodes of rejection and graft function for the year prior to study participation. Results indicated that nonadherence was related to lower physical HRQOL, more limitations in social and school activities related to emotional and behavioral problems, parental emotional distress and decreased family cohesion. Nonadherence was also related to frequency and duration of hospitalizations, liver biopsies and rejection episodes. These results suggest that empirically based assessment of HRQOL, parenting stress and family functioning may help identify patients at risk for nonadherence, and may allow for the need-based delivery of appropriate clinical interventions.

Visual field defects in pediatric patients on vigabatrin monotherapy

Vigabatrin (GVG) is an effective antiepileptic drug used for treating partial seizures in adults and children. Over the last years, an increasing number of articles have been published reporting visual field defects (VFD) associated with GVG therapy in adults. To date, however, only an small number of pediatric patients have been reported. This paper is a retrospective review of clinical review to evaluate the prevalence and features of VFD in pediatric patients on GVG monotherapy.

METHODS

Fifteen children, on GVG therapy in the Department of Child Neurology, underwent visual field examination by static threshold automated perimetry using the Humphrey Field Analyzer Program 30-2. The age of these patients ranged from 6 to 18 years (12.4 +/- 3.6 years), 10 of them being male and five female.

RESULTS

Three patients (20%) on GVG monotherapy showed VFD. These consisted in localised, bilateral, and relatively symmetrical, nasal field loss, with relative preservation of the temporal field within the central 30 degree area.

Usefulness of chemotherapy as prophylaxis of tumor recurrence after liver transplantation in advanced hepatocellular carcinomas

INTRODUCTION

The effectiveness of chemotherapy as prophylaxis of tumor recurrence after liver transplantation in patients with advanced hepatocellular carcinoma is controversial.

AIM

Our goal was to assess the outcomes of patients with advanced hepatocellular carcinoma treated with chemotherapy after liver transplant.

METHODS

Ten patients with liver transplants performed between 1993-2002 were men of mean age 55 years. The etiology of cirrhosis was hepatitis C in four patients, alcoholic cirrhosis in four, and cryptogenic cirrhosis in two. Immunosuppressive therapy was cyclosporine in five patients and tacrolimus in five. The chemotherapy regimen used adriamycin (20 mg/m2 weekly for 20 weeks). Six patients were stage IVA and four stage III. Hepatocellular carcinoma was known in five patients and incidental in the other five. Pathology revealed well-differentiated hepatocellular carcinoma in six patients and moderately differentiated hepatocellular carcinoma in four. Five patients had vascular invasion.

RESULTS

After a mean posttransplant follow-up of 28 months, six patients (60%) were alive without tumor recurrence, three (30%) had died from tumor recurrence and one due to P. carinii pneumonia. Disease-free survival among patients with stage III was 50% and 80% for stage IVA. Three patients with vascular invasion died of tumor recurrence, and the other two are alive and free of disease. Disease-free survival rates were 83% in patients with well-differentiated hepatocellular carcinoma and 25% in those with moderately differentiated hepatocellular carcinoma. Tolerance of chemotherapy was good with two withdrawals due to nephrotoxicity and myelotoxicity and one death from pneumonia.

CONCLUSION

The use of adriamycin in patients undergoing liver transplant due to advanced hepatocellular carcinoma may be useful to prevent tumor recurrence; it is well tolerated. The presence of vascular tumor invasion and a lower grade of histologic differentiation were associated with a poor prognosis.

Properties of polysaccharide produced by Azotobacter vinelandii cultured on 4-hydroxybenzoic acid

AIMS

Characterization of the exopolysaccharide produced by Azotobacter vinelandii grown on 4-hydroxybenzoic acid (EPS I), and the comparison between this exopolysaccharide and commercial alginate, constituted the main objective of this work.

METHODS AND RESULTS

Total carbohydrates, uronic acids, acetyl and pyruvyl groups and proteins were determined by colorimetric methods and composition was confirmed by Nuclear Magnetic Resonance studies. Rheological properties were analysed under different physical and chemical conditions. Results showed differences between EPS I and commercial alginate, in relation to both composition and viscosity. Higher amount of guluronnosyl residues were found in EPS I, whereas commercial alginate contained the same proportion of mannuronosyl and guluronnosyl residues. In accordance with this result, EPS I gave rise to solutions of higher viscosity than commercial alginate, although solutions of this polysaccharide showed greater stability when conditions were altered.

CONCLUSIONS

The exopolysaccharide produced by A. vinelandii grown on 4-hydroxybenzoic acid showed a different composition in comparison with commercial alginate, which leads to higher viscosity values for the aqueous solutions of EPS I.

SIGNIFICANCE AND IMPACT OF STUDY

This work describes for the first time the characteristics of an exopolysaccharide produced by A. vinelandii from 4-hydroxybenzoic acid, a substrate rarely used as sole carbon source.

Post-transplant lymphoproliferative syndrome in the pediatric liver transplant population

Post-transplant lymphoproliferative disease remains a complication with a high morbidity and mortality. The present study examined 291 pediatric liver transplants performed in 263 children from October 1984 to December 1999. Post-transplant lymphoproliferative disease has an overall incidence of 12%. Tacrolimus and cyclosporine had a similar incidence of post-transplant lymphoproliferative disease. Fifty-six per cent of patients who developed post-transplant lymphoproliferative disease were Epstein-Barr virus negative at the time of transplantation. Mean time of conversion to Epstein-Barr virus positivity was 1.1 years after liver transplantation. Ten per cent of those who developed post-transplant lymphoproliferative disease never had Epstein-Barr virus detected. Mean time from Epstein-Barr virus positivity to detection of post-transplant lymphoproliferative disease was 2.68 years, and 3.13 years from liver transplantation (OLTx) to post-transplant lymphoproliferative disease. There was a 35% incidence of mortality. Deaths occurred a mean of 0.76 years after diagnosis of post-transplant lymphoproliferative disease. Most cases of post-transplant lymphoproliferative disease had extranodal location. There was one recurrence in 10% of patients, and two in 3%. All recurrent cases were seen in recipients who became Epstein-Barr virus positive after transplantation. There has been a decrease in the incidence of post-transplant lymphoproliferative disease from 15% to 9% to 4%. Post-transplant lymphoproliferative disease should be diagnosed promptly and treated aggressively. The best treatment, however, seems to be prevention, starting in the immediate postoperative period. Survivors should be monitored for both recurrence of post-transplant lymphoproliferative disease and acute cellular rejection.

The effects of monopolar radiofrequency energy on intact and lacerated ovine menisci

PURPOSE

To evaluate the effect of monopolar radiofrequency energy (RFE) on intact and lacerated meniscal tissue.

TYPE OF STUDY

In vitro study. Application of monopolar RFE to soft tissue for treatment of various musculoskeletal disorders has been explored recently, although its effect on meniscal tissue has not been critically evaluated. Monopolar RFE denatures and fuses collagen. Given that menisci are composed primarily of type I collagen, we proposed that RFE could be applied to meniscal tears with minimal effect on healthy meniscal tissue.

METHODS

Adult sheep menisci were given 1 of 2 treatments (65 degrees C, 15 W or 75 degrees C, 10 W) with a monopolar RFE generator. Specimens were processed for scanning electron microscopy (SEM), transmission electron microscopy (TEM), light microscopy, and confocal laser microscopy. A computer-based area-determination program was used to calculate the treated area in confocal laser images.

RESULTS

SEM changes in treated tissue consisted of surface smoothing with collagen fibril fusion. Changes apparent with TEM included tissue homogenization with loss of cross-striations and fusion of collagen fibrils. Histologic changes consisted of fusion and loss of collagen fiber individualization, pyknosis of fibrochondrocyte nuclei, and loss of lacunae surrounding fibrochondrocytes. There were clear demarcations between treated and untreated tissue with both treatments. There were no discernible differences between treatment groups on SEM, TEM, or histologic examination. Confocal laser microscopic evaluations showed distinct treatment areas. The mean area affected ranged from 6.6% for 65 degrees C, 15 W to 8.8% for 75 degrees C, 10 W.

CONCLUSIONS

The primary effects of monopolar RFE treatment of menisci in this study were consistent with thermal tissue damage limited to the treatment area. Monopolar RFE treatment of a meniscal laceration may stabilize the tear by fusing collagenous tissue in the surrounding area and prevent propagation along tissue lines. This study presents preliminary in vitro results. Further studies are necessary before clinical applications can be recommended.

An in vitro biomechanical comparison of two interlocking-nail systems for fixation of ostectomized equine third metacarpal bones

OBJECTIVE

To compare the mechanical properties of 2 interlocking-nail systems for fixation of ostectomized equine third metacarpi (MC3): (1) a standard interlocking nail with 2 parallel screws proximal and distal to a 1-cm ostectomy; and (2) a modified interlocking nail with 2 screws proximal and distal to a 1-cm ostectomy with the screws offset by 30 degrees.

ANIMAL OR SAMPLE POPULATION

Twelve pairs of adult equine forelimbs intact from the midradius distally.

METHODS

Twelve pairs of equine MC3 were divided into 2 test groups (6 pairs each): torsion and caudocranial 4-point bending. Standard interlocking nails (6-hole, 13-mm diameter, 230-mm length) were placed in 1 randomly selected bone from each pair. Modified interlocking nails (6-hole, 13-mm, 230-mm length, screw holes offset by 30 degrees) were placed in the contralateral bone from each pair. All bones had 1-cm mid-diaphyseal ostectomies. Six construct pairs were tested in caudocranial 4-point bending to determine stiffness and failure properties. The remaining 6 construct pairs were tested in torsion to determine torsional stiffness and yield load. Mean values for each fixation method were compared using a paired t test within each group. Significance was set at P <.05.

RESULTS

Mean (+/-SEM) values for the MC3-standard interlocking-nail composite and the MC3-modified interlocking-nail composite, respectively, in 4-point bending were: composite rigidity, 3,119 +/- 334.5 Nm/rad (newton. meter/radian) and 3,185 +/- 401.2 Nm/rad; yield bending moment, 205.0 +/- 18.46 Nm and 186.7 +/- 6.17 Nm; and failure bending moment, 366.4 +/- 21.82 Nm and 378.1 +/- 20.41 Nm. There were no significant differences in the biomechanical values for bending between the 2 fixation methods. In torsion, mean (+/-SEM) values for the MC3-standard interlocking-nail composite and the MC3-modified interlocking-nail composite were: composite rigidity, 135.5 +/- 7.128 Nm/rad and 112.5 +/- 7.432 Nm/rad; gap stiffness, 207.6 +/- 10.57 Nm/rad and 181.7 +/- 12.89 Nm/rad; and yield load, 123.3 +/- 2.563 Nm and 107.5 +/- 8.353 Nm, respectively. Composite rigidity and gap stiffness for standard interlocking-nail fixations were significantly higher than the modified interlocking-nail fixation technique in torsion. Yield load had a tendency to be higher for the standard interlocking-nail fixation (P =.15).

CONCLUSIONS

No significant differences in biomechanical properties were identified between a standard interlocking nail and one with the screw holes offset by 30 degrees in caudocranial 4-point bending. The standard interlocking nail was superior to the modified interlocking nail in torsional gap stiffness and composite rigidity. The torsional yield load also tended to be higher for the standard interlocking nail.

CLINICAL RELEVANCE

The standard interlocking nail with parallel screw holes is superior to a modified interlocking nail with the screw holes offset by 30 degrees in ostectomized equine MC3 bones in vitro when tested in torsion.

An in vitro biomechanical comparison of interlocking nail constructs and double plating for fixation of diaphyseal femur fractures in immature horses

OBJECTIVE

To compare the biomechanical properties of intact immature horse femurs and 3 stabilization methods in ostectomized femurs.

ANIMAL OR SAMPLE POPULATION

Eighteen pairs of femurs from immature horses aged 1 to 15 months, and weighing 68 to 236 kg.

METHODS

Thirty-four immature horse femurs were randomly assigned to 1 of 5 test groups: 1) interlocking intramedullary nail (IIN) (n = 6); 2) IIN with a cranial dynamic compression plate (I/DCP) (n = 6); 3) 2 dynamic compression plates (2DCP) (n = 8); 4) intact femurs tested to failure in lateromedial (LM) bending (n = 6); and 5) intact femurs tested to failure in caudocranial (CaCr) bending (n = 8). Mid-diaphyseal ostectomies (1 cm) were performed in all fixation constructs. Biomechanical testing consisted of 4 nondestructive tests: CaCr bending, LM bending, compression, and torsion, followed by bending to failure. All groups were tested to failure in LM bending with the exception of 1 group of intact femurs tested to failure in CaCr bending. Stiffness and failure properties were compared among groups.

RESULTS

The 2DCP-femur construct had greater structural stiffness in nondestructive bending than the IIN-femur construct in either LM or CaCr bending, and the I/DCP-femur construct in LM bending. Only the I/DCP and 2DCP fixations were similar to intact bone in nondestructive-bending tests. In addition, the 2DCP-femur construct had greater structural and gap torsional stiffness than the I/DCP-femur construct, and greater gap torsional stiffness than the IIN-femur construct. However, all of the fixation methods tested, including the 2DCP-femur construct, had lower structural stiffness in torsional loading compared with intact bone. No significant differences in structural stiffness were found between intact bones and femur constructs tested nondestructively in compression. In resistance to LM bending to failure, the 2DCP-femur construct was superior to the IIN-femur construct, yet similar to the I/DCP-femur construct. Also, evaluation of yield and failure loads revealed no significant differences between intact bone and any of the femur constructs tested to failure in LM bending.

CONCLUSIONS

In general, the 2DCP-femur construct provided superior strength and stiffness compared with the IIN and I/DCP-femur constructs under bending and torsion.

CLINICAL RELEVANCE

Double plating of diaphyseal comminuted femoral fractures in immature horses may be the best method of repair, because in general, it provides the greatest strength and stiffness in bending and torsion.

Halo structure of (14)Be

The two-neutron halo nucleus (14)Be has been investigated in a kinematically complete measurement of the fragments ((12)Be and neutrons) produced in dissociation at 35 MeV/nucleon on C and Pb targets. Two-neutron removal cross sections, neutron angular distributions, and invariant mass spectra were measured, and the contributions from electromagnetic dissociation (EMD) were deduced. Comparison with three-body model calculations suggests that the halo wave function contains a large nu(2s(1/2))(2) admixture. The EMD invariant mass spectrum exhibited enhanced strength near threshold consistent with a nonresonant soft-dipole excitation.

Mixed ruminal microbes of cattle produce isopropanol in the presence of acetone but not 3-D-hydroxybutyrate

The objective was to evaluate the ability of mixed rumen microbes to synthesize isopropanol from acetone or 3-D-hydroxybutyrate. Rumen fluid from seven mature, nonpregnant, dry Holstein cows was incubated with starch or cellulose and additions of acetone, 3-D-hydroxybutyrate, or saline. Rumen fluid was analyzed for isopropanol after 0, 3, 6, and 9 h. No isopropanol was present in any sample at 0 h, and none was present in incubations containing saline or 3-D-hydroxybutyrate at any subsequent time. Incubations that included acetone produced small amounts of isopropanol from 0 to 3 and 3 to 6 h and significantly larger amounts from 6 to 9 h. With starch as the energy substrate, production from 6 to 9 h was 3.8 micromol/min per liter of rumen fluid and 3.7 micromol/min per liter with cellulose as the energy substrate; however, these values did not differ significantly. Mixed rumen microbes could synthesize isopropanol from acetone but not from 3-D-hydroxybutyrate, and rumen microbial metabolism of acetone was the likely source of plasma isopropanol seen in ketotic ruminants.

Osseous sequestration in cattle: 110 cases (1987-1997)

OBJECTIVE

To determine risk factors for development of sequestra in cattle and identify factors associated with a successful outcome.

DESIGN

Retrospective study.

ANIMALS

110 cattle.

PROCEDURE

Medical records of cattle treated at veterinary teaching hospitals in North America were reviewed. To determine risk factors for osseous sequestration, breed, age, and sex of cattle with osseous sequestration were compared with breed, age, and sex of all other cattle admitted during the study period.

RESULTS

110 cattle were included in the study. Three had 2 sequestra; thus, 113 lesions were identified. Most sequestra were associated with the bones of the extremities, most commonly the third metacarpal or third metatarsal bone. Ninety-two animals were treated surgically (i.e., sequestrectomy), 7 were treated medically, 3 were initially treated medically and were then treated surgically, and 8 were not treated. Follow-up information was available for 65 animals treated surgically and 6 animals treated medically. Fifty-one (78%) animals treated surgically and 5 animals treated medically had a successful outcome. Cattle that were 6 months to 2 years old had a significantly increased risk of developing a sequestrum, compared with cattle < 6 months old. Cattle in which sequestrectomy was performed with the aid of local anesthesia were significantly more likely to undergo 2 or more surgical procedures than were cattle in which sequestrectomy was performed with the aid of general anesthesia.

CONCLUSIONS AND CLINICAL RELEVANCE

Results suggest that sequestrectomy will result in a successful outcome for most cattle with osseous sequestration.

Effects of monopolar radiofrequency energy on ovine joint capsular mechanical properties

Radiofrequency energy may provide a relatively noninvasive method to stabilize joints with excessive laxity by thermally shrinking redundant joint capsular tissue. The authors determined the percentage of shrinkage associated with five radiofrequency treatment temperatures and evaluated the effect of this energy on the structural properties of joint capsular tissue in vitro. First, 36 adult sheep femoropatellar joint capsular specimens were treated with one of five treatment temperatures (n = 6 per group) or served as a control to determine tissue shrinkage. An additional 24 specimens were treated with three temperatures that resulted in different shrinkage: 45 degrees C, 65 degrees C, and 85 degrees C. Tissue stiffness, relaxation, and failure strength were determined for each specimen (n = 6 per group). Tissue shrinkage was correlated significantly with treatment temperature. There was a significant decrease in tensile stiffness in the 65 degrees C and 85 degrees C treatment groups. There were no significant differences between stress relaxation before treatment and after treatment. Relaxation properties after treatment were not different from each other or from control values either normalized to pretreatment values or expressed as raw data. Failure strength was not affected significantly at any temperature.

Pelvic exenteration for advanced pelvic malignancy

Pelvic exenteration is a demanding, yet potentially curative operation, for patients with advanced pelvic cancer. The majority will present with recurrence after prior surgery and radiotherapy. After exenteration, 5-year survival is 40% to 60% in patients with gynecologic cancer as compared to 25% to 40% for patients with colorectal cancer. Physiologic age and absence of co-morbidities appear to be more important when selecting patients for exenteration than chronological age. Careful pre-operative staging, including either computed tomography (CT) scan or magnetic resonance imaging (MRI), usually will identify patients with distant metastases, extrapelvic nodal disease, or disease involving the pelvic sidewall (which generally precludes surgery). The recent application of intra-operative radiotherapy or postoperative high-dose brachytherapy for patients with more advanced pelvic disease, which may include sidewall involvement, may expand the standard indications for exenteration. However, the intent of this procedure, with or without radiotherapy, should be resection of all tumor with the aim of cure since the place of palliative exenteration is controversial at best. The operative details of exenteration are presented, as are two surgical approaches to composite resection of pelvic structures in continuity with sacrectomy. Filling the pelvis with large tissue flaps, usually a rectus abdominus flap, has decreased morbidity rates, particularly with small bowel complications. Peri-operative mortality is usually 5% to 10%, and significant morbidity occurs in over 50% of patients. Restorative techniques for both urinary and gastrointestinal tracts can diminish the need for stomas and, along with vaginal reconstruction, can significantly improve quality of life for many patients after exenteration. These advances in surgery and radiotherapy help make the procedure a viable option for patients with otherwise incurable pelvic malignancy.

Development and evolution of pelvic exenteration: historical notes

Fifty years after the development of pelvic exenteration, the operation remains a gold standard in the surgical management of advanced pelvic malignancy. The operation has evolved through several predictable phases including technical improvements, lowered morbidity and mortality, and improved patient selection. Despite progress in supportive peri-operative care, pelvic exenteration is a major undertaking that should be performed in centers with proven interest and expertise in the field. We trace the early developments of the operation, the period of maturation, and the current place of this procedure in the armamentarium of the oncologic surgeon.

Exenterative pelvic surgery

A review of the history, indications, basic technique, end results, and complications of exenterative surgery for pelvic neoplasms is provided. The authors discuss their broad personal experience with the operation. Much of this experience evolved from work at Barnes Hospital and the Ellis Fischel State Cancer Hospital. The techniques are applicable to advanced neoplasms of the cervix uteri, scrotum, urinary bladder, and other, less frequent neoplasms still confined to the pelvis.

Pelvic exenteration for carcinoma of the colon and rectum

Carcinoma of the colon and rectum is one of the most common causes of cancer deaths in the United States. The mortality of patients treated by surgery alone is 55% within 5 years of surgery. Despite efforts to decrease local recurrence and their concomitant problems of pain and disability, a significant number of patients will still have pelvic recurrences that carry a significant morbidity. In selected cases, pelvic exenteration may cure or provide palliation of the symptoms of colorectal carcinoma. Pre-operative evaluation is performed to detect signs of unresectability. During surgery, exploration is performed for evidence of metastases to the liver, omentum, and peritoneum, followed by an assessment of the local extent of the tumor. The margins of resection must be clear even if resection of contiguous organs or bony structures is necessary. The urinary tract is resected with an ileal loop, sigmoid or transverse colon conduits, or continent urinary diversion. Depending upon the involvement of neighboring structures, exenterative pelvic surgery can be modified for organ preservation.

Pelvic exenteration for advanced pelvic malignancy

Pelvic exenteration is a demanding, yet potentially curative operation, for patients with advanced pelvic cancer. The majority will present with recurrence after prior surgery and radiotherapy. After exenteration, 5-year survival is 40% to 60% in patients with gynecologic cancer as compared to 25% to 40% for patients with colorectal cancer. Physiologic age and absence of co-morbidities appear to be more important when selecting patients for exenteration than chronological age. Careful pre-operative staging, including either computed tomography (CT) scan or magnetic resonance imaging (MRI), usually will identify patients with distant metastases, extrapelvic nodal disease, or disease involving the pelvic sidewall (which generally precludes surgery). The recent application of intra-operative radiotherapy or postoperative high-dose brachytherapy for patients with more advanced pelvic disease, which may include sidewall involvement, may expand the standard indications for exenteration. However, the intent of this procedure, with or without radiotherapy, should be resection of all tumor with the aim of cure since the place of palliative exenteration is controversial at best. The operative details of exenteration are presented, as are two surgical approaches to composite resection of pelvic structures in continuity with sacrectomy. Filling the pelvis with large tissue flaps, usually a rectus abdominus flap, has decreased morbidity rates, particularly with small bowel complications. Peri-operative mortality is usually 5% to 10%, and significant morbidity occurs in over 50% of patients. Restorative techniques for both urinary and gastrointestinal tracts can diminish the need for stomas and, along with vaginal reconstruction, can significantly improve quality of life for many patients after exenteration. These advances in surgery and radiotherapy help make the procedure a viable option for patients with otherwise incurable pelvic malignancy.

The influence of pre-operative radiation therapy on the patterns of recurrence in rectal adenocarcinoma

From January 1976 to December 1994, we evaluated the institutional experience of local recurrence and survival in patients with rectal adenocarcinoma treated with pre-operative radiation therapy (PRT) as compared to those treated with radical surgery alone. There were 412 patients, divided into two groups: 259 patients (142 males and 117 females) in Group I and 153 patients (88 males and 65 females) in Group II. The median age was 56 years. Group I patients with locally advanced tumors, either tethered or fixed, received PRT at doses of 45 Gy delivered to the pelvis in two fields; 4 to 8 weeks later, radical surgery was performed. Patients with mobile tumors underwent radical surgery only (Group II). The operative mortality was 4.6% in Group I as compared to 1.9% in Group II (P = 0.18). At median follow-up of 89 months, there were local recurrences in 12.9% of Group I as compared to 36.2% in Group II (P = 0.0000001). The administration of PRT was associated with a low rate of local recurrence, but this improvement corresponded with a high morbidity rate, especially in patients who underwent abdominoperineal resection or pelvic exenteration.

An in vitro biomechanical comparison of an interlocking nail system and dynamic compression plate fixation of ostectomized equine third metacarpal bones

OBJECTIVE

To compare the mechanical properties of two stabilization methods for ostectomized equine third metacarpi (MC3): (1) an interlocking nail system and (2) two dynamic compression plates. Animal or Sample Population-Ten pairs of adult equine forelimbs intact from the midradius distally.

METHODS

Ten pairs of equine MC3 were divided into two test groups (five pairs each): caudocranial four-point bending and torsion. Interlocking nails (6 hole, 13-mm diameter, 230-mm length) were placed in one randomly selected bone from each pair. Two dynamic compression plates one dorsally (12 hole, 4.5-mm broad) and one laterally (10 hole, 4.5-mm broad) were attached to the contralateral bone from each pair. All bones had 1 cm mid-diaphyseal ostectomies. Five construct pairs were tested in caudocranial four-point bending to determine stiffness and failure properties. The remaining five construct pairs were tested in torsion to determine torsional stiffness and yield load. Mean values for each fixation method were compared using a paired t-test within each group. Significance was set at P<.05.

RESULTS

Mean (+/-SEM) values for the MC3-interlocking nail composite and the MC3-double plate composite, respectively, in four-point bending were: composite rigidity, 3,454+/-407.6 Nm/rad and 3,831+/-436.5 Nm/rad; yield bending moment, 276.4+/-40.17 Nm and 433.75+/-83.99 Nm; failure bending moment, 526.3+/-105.9 Nm and 636.2+/-27.77 Nm. There was no significant difference in the biomechanical values for bending between the two fixation methods. In torsion, mean (+/-SEM) values for the MC3-interlocking nail composite and the MC3-double plate composite were: composite rigidity, 124.1+/-16.61 Nm/rad and 262.4+/-30.51 Nm/rad; gap stiffness, 222.3+/-47.32 Nm/rad and 1,557+/-320.9 Nm/rad; yield load, 94.77+/-7.822 Nm and 130.66+/-20.27 Nm, respectively. Composite rigidity, gap stiffness, and yield load for double plate fixation were significantly higher compared with interlocking nail fixation in torsion.

CONCLUSIONS

No significant differences in biomechanical properties were identified between an interlocking nail and double plating techniques for stabilization of ostectomized equine MC3 in caudocranial four-point bending. Double plating fixation was superior to interlocking nail fixation in torsion.

Massive fetomaternal hemorrhage: how long should children with good evolution be controlled? A case report

We report on a term infant with a severe fetomaternal hemorrhage that caused a serious anemia that was surmounted after several transfusions. After the initial complications, such as persistent pulmonary circulation, severe anemia and thrombocytopenia, the outcome was good. We discuss the importance of a long-term follow-up of affected children, as well as their mothers. No clear parameters for a real prognosis are available. A follow-up is needed in order to detect possible complications in neurological development.

The effect of radiofrequency energy on the ultrastructure of joint capsular collagen

This study evaluated the effect of radiofrequency energy on the histological and ultrastructural appearance of joint capsular collagen. Femoropatellar joint capsular specimens from adult sheep were treated with one of three treatment temperatures (45 degrees C, 65 degrees C, and 85 degrees C) with a radiofrequency generator or served as control in a randomized block design. Twenty-four specimens (n = 6) were processed for histological examination as well as ultrastructural analysis using transmission electron microscopy. A computer-based area determination program was used to calculate the area affected in histological samples. Histological changes consisted of thermal tissue damage characterized by collagen fiber fusion and fibroblastic nuclear pyknosis at all application temperatures with clear demarcations between treated and untreated tissue. Mean tissue affected ranged from 50.4% for 85 degrees C to 22.5% for 45 degrees C. There was a strong correlation between treatment temperature and percent area affected (P < .001, R2 = .65). Ultrastructural alterations included a general increase in cross-sectional fibril diameter and loss of fibril size variation with increasing treatment temperature. Longitudinal sections of collagen fibrils showed increased fibril diameter and the loss of cross-striations in the treated groups. Thermally induced ultrastructural collagen fibril alteration is likely the predominant mechanism of tissue shrinkage caused by application of radiofrequency energy.

Urinary obstruction in a hermaphroditic llama

A 24-hour-old cria was admitted for evaluation of stranguria evident shortly after birth. On physical examination, the prepuce appeared to be normally formed and small drops of fluid dripped from it as the cria strained to urinate. Testes could not be palpated. Ultrasonographic examination revealed that the bladder was distended. The only abnormality detected on serum biochemical analysis was high creatinine concentration. Tube cystostomy was performed, and the cria was treated with saline (0.9% NaCl) solution administered intravenously and antibiotics. Four days after admission, the cria could not urinate normally when the cystostomy tube was occluded. Five days after admission, normograde cystography and retrograde urethrography were performed. Radiographic findings indicated the cria was an intersex llama with urethral duplication. The llama was euthanatized at the owner's request. Necropsy revealed bilateral ovotestes with a phenotypically female reproductive tract and urethral duplication. Urethral duplication should be considered as a cause of stranguria in male neonatal crias, and hermaphroditism should be included as a cause of urethropathies in llamas.

Disruption of the guanylyl cyclase-C gene leads to a paradoxical phenotype of viable but heat-stable enterotoxin-resistant mice

Heat-stable enterotoxins (STa), which cause an acute secretory diarrhea, have been suggested to mediate their actions through the guanylyl cyclase-C (GC-C) receptor. The GC-C gene was disrupted by insertion of neo into exon 1 and subsequent homologous recombination. GC-C null mice contained no detectable GC-C protein. Intestine mucosal guanylyl cyclase activity was approximately 16-fold higher in wild-type mice than in the GC-C null mice, and STa-stimulable guanylyl cyclase activity was absent in the null animals. Thus, GC-C is the major cyclase activity present in the intestine, and also completely accounts for the STa-induced elevations of cGMP. Gavage with STa resulted in marked fluid accumulation within the intestine of wild-type and heterozygous suckling mice, but GC-C null animals were resistant. In addition, infection with enterotoxigenic bacteria that produce STa led to diarrhea and death in wild-type and heterozygous mice, while the null mice were protected. Cholera toxin, in contrast, continued to cause diarrhea in GC-C null mice, demonstrating that the cAMP signaling pathway remained intact. Markedly different diets (high carbohydrate, fat, or protein) or the inclusion of high salt (K+, Na+) in the drinking water or diet also did not severely affect the null animals. Given that GC-C is a major intestinal receptor in all mammals, the pressure to retain a functional GC-C in the face of diarrhea-inflicted mortality remains unexplained. Therefore, GC-C likely provides a protective effect against stressors not yet tested, possibly pathogens other than noninvasive enterotoxigenic bacteria.

The guanylyl cyclase-deficient mouse defines differential pathways of natriuretic peptide signaling

A genetic model of salt-resistant hypertension has been developed recently through disruption of the guanylyl cyclase-A (GC-A) natriuretic peptide receptor gene (Lopez, M. J., Wong, S. K., Kishimoto, I., Dubois, S., Mach, V., Friesen, J., Garbers, D. L., and Beuve, A. (1995) Nature 378, 65-68). These genetically altered mice were used to determine which of the natural peptides with natriuretic peptide-like structures regulate blood pressure through the GC-A receptor. Atrial natriuretic peptide (ANP) or B-type natriuretic peptide (BNP) half-maximally relaxed precontracted aortic rings in wild-type mice at about 24 nM, but failed to relax such aortas in GC-A null mice, even at micromolar concentrations. C-type natriuretic peptide (CNP), in contrast, caused half-maximal relaxation at concentrations of 335 and 146 nM in aortas from either wild-type or null mice, respectively, suggesting that this peptide acted through a receptor other than GC-A. Since the in vitro results with aortic smooth muscle do not necessarily reflect the physiology of the smaller blood vessels important in blood pressure regulation, the blood pressures of conscious mice infused with the various peptides were determined. ANP caused decreases in blood pressure when infused at rates of 500 ng/kg/min, a rate which resulted in a plasma concentration of 0.8 nM. In the null mice, in contrast, ANP failed to lower blood pressure even at infusion rates of 50 microg/kg/min. Much higher infusion rates for CNP (50 microg/kg/min), which yielded final plasma concentrations of 18.3 nM, were required to lower blood pressure in wild-type mice, but the effects of CNP were not altered in GC-A null mice. Thus, two natriuretic peptides (ANP, BNP) act through GC-A whereas another (CNP) acts through another receptor to regulate blood pressure.

Craniad migration of differing doses of new methylene blue injected into the epidural space after death of calves and juvenile pigs

OBJECTIVE

To determine the relation between epidural injectate volume (ml/kg of body weight) and its craniad migration in calves and pigs.

ANIMALS

23 neonatal calves and 26 feeder pigs.

PROCEDURE

Animals were randomly assigned to receive different volumes of new methylene blue (NMB, 1.2 mg/ml in 0.9% saline solution). Injections were made into the sacrococcygeal intervertebral space in calves and the lumbosacral intervertebral space in pigs, immediately after euthanasia. Sagittal sections of the spine were made at necropsy, and craniad migration of NMB was determined and rounded to the nearest intervertebral space.

RESULTS

In calves treated with 0.05, 0.1, or 0.15 ml of NMB/kg, mean +/- SEM number of stained spinal segments was 5 +/- 0.3, 8 +/- 0.6, and 8 +/- 0.6, respectively. Craniad migration of NMB was significantly greater for 0.15 and 0.1 ml/kg volumes versus 0.05 ml/kg. In pigs treated with 0.05, 0.1, 0.2, of 0.3 ml of NMB/kg, mean number of stained spinal segments was 8 +/- 1.1, 8 +/- 0.9, 10 +/- 1.2, and 18 +/- 2.0. Craniad dye migration was significantly greater in the 0.3 ml/kg group versus the 3 lower volume groups. Linear regression performed on both sets of data after logarithmic transformation of spaces migrated to correct for non-normality was significant (P < 0.05), and R2 values of 0.49 and 0.55 were obtained for calves and pigs, respectively.

CONCLUSIONS

There is a significant correlation between volume (ml/kg) of NMB injected in the epidural space and its craniad migration in calves and pigs.

CLINICAL RELEVANCE

Results provide a basis for determination of volume of injectate to be given to reach a minimal desired level and should be a useful baseline for future investigations of epidural drug administration.

Anal leiomyoma in a Holstein heifer

A 2-year-old heifer was presented with masses on her anus that were interfering with cervical manipulation during embryo flushing. The masses had broad stalks attached within the anal sphinchter. Recovery was without incident after surgical resection. No recurrence of the masses had occurred 3 months later. Histologic diagnosis was benign leiomyoma.

Twenty-year follow-up of minimal breast cancer from the Breast Cancer Detection Demonstration Project

Since the 1960s, the potential benefits of early detection of breast cancer through screening with physical examination and mammography have been studied. In a mass screening study begun in 1973 by the Breast Cancer Detection Demonstration Project (BCDDP), mammography detected 90% of the cancers that were diagnosed. Of the women aged 35 to 74 years from the BCDDP study who were diagnosed with minimal breast cancer, the 20-year cumulative breast cancer survival rates were 95.8% for 469 women with in situ breast cancer and 82.8% for 769 women with invasive breast cancers 1 cm or smaller in size.

Cephalad distribution of three differing volumes of new methylene blue injected into the epidural space in adult goats

Epidural anesthesia and analgesia are popular regional anesthetic techniques in many animal species. However, we have not found any reports of studies in animals that have investigated the extent of cephalad migration and level of sensory blockade achieved based only on the volume of drug injected into the epidural space. The purpose of this study was to determine if there is a relationship between the volume (mL/kg) of an injectate injected epidurally and the extent of its cephalad migration within the epidural space. Twelve adult goats were randomly assigned to three treatment groups based on the volume of 0.12% New Methylene Blue (NMB), 0.1, 0.2, or 0.3 mL/kg, injected into the epidural space. The site and speed of injection, animal position, and direction of needle bevel were held constant. All injections were performed at the lumbo-sacral space immediately following euthanasia. At necropsy, the vertebral columns were transected longitudinally. The extent of cephalad migration of dye within the epidural space was easily determined by staining of the dura. Measurements were rounded to the nearest intervertebral space to which the dye had migrated. The individual making assessments was blinded to all treatments. In goats treated with 0.1, 0.2, or 0.3 mL/kg NMB, the number of stained spinal segments was 3.5 +/- 0.6, 6.5 +/- 0.9, and 8.8 +/- 0.6, (mean +/- SEM), respectively. Linear regression performed on the data was significant (P < .05) with R2 = 0.86. There was a strong linear relationship between volume (mL/kg) of epidurally injected NMB and cranial migration, with the larger volumes producing more cephalad spread within the epidural space. These results provide evidence for the volume of epidural injectate needed to produce a desired level of sensory blockade in adult goats.

Retroperitoneal and abdominal wall emphysema after transanal excision of a rectal carcinoma

The use of transanal excision to remove rectal carcinomas is a relatively new application of this surgical procedure, which may require full thickness excision. Retroperitoneal and abdominal wall emphysema are potential complications of surgical procedures that breach the wall of the colon and rectum. Computed tomographic scans provide the clearest diagnostic picture of developing emphysema, and prompt diagnosis through accurate interpretation of the scans is essential to minimize morbidity and mortality. When the diagnosis is made early and no active infection accompanies the emphysema, the preferred approach to initial treatment is nonsurgical. This article presents a case in which local transanal excision was performed on a 70-year-old male to remove a superficial adenocarcinoma from the lower rectal wall. He developed postoperative retroperitoneal and abdominal wall emphysema. Conservative treatment is discussed.

Breast cancer in elderly women: presentation, survival, and treatment options

Recent data suggest that breast cancer in elderly women does not present as more advanced disease, nor is survival significantly inferior to that in younger women. Unfortunately, until recently, older women have been excluded from clinical trials that have determined survival benefit in both screening and treatment modalities. Unless co-morbid conditions adversely affect one's life expectancy or tolerance to therapy, older women should be treated with standard surgical procedures (including breast conservation, if so desired) for early-stage disease, as outcome is comparable to that in younger patients. Adjuvant tamoxifen therapy has proven survival benefit in women over 70 years of age with estrogen receptor-positive tumors and should be considered in all women with tumors greater than 1 cm in size. Older women may experience more chemotherapy-related toxicities. However, for those with a significant risk of recurrence due to tumor size or lymph node status, chemotherapy can be safely administered when factors such as age-related decline in creatinine clearance and co-morbid conditions are considered. Hormonal therapy (tamoxifen) is usually the first-line treatment option over chemotherapy for metastatic disease in the elderly unless the patient has an estrogen receptor-negative tumor, visceral-dominant disease, or significant disease-related symptoms. In the latter settings, chemotherapy can provide improved or more rapid response proportions but does not affect long-term survival.

The current role of prophylactic mastectomy

Prophylactic mastectomy has a role in preventing breast cancer in the woman at high risk. The rare indications for this operation are based on genetic and histologic factors that affect relative or cumulative risk. Evaluation of women at high risk must draw on multidisciplinary expertise, including genetic counseling. If prophylactic mastectomy is recommended, skin-sparing total mastectomy (not subcutaneous) with autogenous tissue reconstruction is the preferred approach.

Inflammatory breast cancer

Multimodal therapy with induction chemotherapy has improved significantly local disease control and overall survival in patients with IBC. This is now considered standard therapy for patients with this disease. Although survival has been improved, well over 50% of these patients will succumb to this disease. Ongoing and future investigations may better define the optimal approach for local control, the optimal duration of maintenance chemotherapy, and the possible role of biologic response modifiers and growth factors in further improving the outcome for patients with this disease.

Complete intraoperative small-bowel endoscopy in the evaluation of occult gastrointestinal bleeding using the sonde enteroscope

OBJECTIVE

To review our experience with intraoperative small-bowel Sonde enteroscopy in evaluating occult bleeding in the small intestine.

DESIGN

Retrospective study with 100% follow-up.

SETTING

University-affiliated, tertiary-care teaching hospital.

PATIENTS

Sixteen consecutive patients referred with occult gastrointestinal bleeding in whom esophagogastro-duodenoscopy , push enteroscopy, and colonoscopy had failed to identify the source of bleeding. Fourteen of the 16 patients had required one or more transfusions.

MAIN OUTCOME MEASURE

Completeness of visualization, diagnostic accuracy, and complications of the procedure and follow-up for recurrent bleeding.

RESULTS

In all 16 patients, intraoperative Sonde enteroscopy allowed visualization of the entire small bowel. In 14 of the 16, it revealed the cause of bleeding, which was ileal angiodysplasia in three patients, ileal ulcers in six patients, neoplasia in two patients, and ileal ulcers caused by Crohn's disease, small-intestinal enteropathy and varices caused by portal hypertension, and radiation stricture in one patient each. Two patients had normal small bowel mucosa. The patients with mucosal disease underwent small-bowel resection or oversewing of bleeding sites. Two surgical complications occurred: prolonged postoperative ileus (one patient) and small-bowel obstruction that resolved without surgery (one patient). Two of the patients with angiodysplasia had recurrent bleeding postoperatively.

CONCLUSIONS

Intraoperative Sonde enteroscopy is safe and effective in localizing small-intestinal bleeding sites, providing complete visualization of the small-bowel mucosa without enterotomy while avoiding the trauma that can be caused by push endoscopy. It is the diagnostic assessment of choice in selected patients with occult gastrointestinal bleeding of presumed small-bowel origin.

Salt-resistant hypertension in mice lacking the guanylyl cyclase-A receptor for atrial natriuretic peptide

Around half of all humans with essential hypertension are resistant to salt (blood pressure does not change by more than 5 mm Hg when salt intake is high), and although various inbred strains of rats display salt-insensitive elevated blood pressure, a gene defect to account for the phenotype has not been described. Atrial natriuretic peptide (ANP) is released from the heart in response to atrial stretch and is thought to mediate its natriuretic and vaso-relaxant effects through the guanylyl cyclase-A receptor (GC-A). Here we report that disruption of the GC-A gene results in chronic elevations of blood pressure in mice on a normal salt diet. Unexpectedly, the blood pressure remains elevated and unchanged in response to either minimal or high salt diets. Aldosterone and ANP concentrations are not affected by the genotype. Therefore, mutations in the GC-A gene could explain some salt-resistant forms of essential hypertension and, coupled with previous work, further suggest that the GC-A signaling pathway dominates at the level of peripheral resistance, where it can operate independently of ANP.

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