Development and validation of bioimpedance prediction equations for fat-free mass in unilateral male amputees

Background

Metabolic disease due to increased fat mass is observed in amputees (APTs), thereby restricting their activity. Systemic health management with periodic body composition (BC) testing is essential for healthy living. Bioelectrical impedance analysis (BIA) is a non-invasive and low-cost method to test BC; however, the APTs are classified as being exempted in the BIA.

Objective

To develop segmental estimated regression equations (sEREs) for determining the fat-free mass (FFM, kg) suitable for APTs and improve the accuracy and validity of the sERE.

Methods

Seventy-five male APTs participated in this cross-sectional study. Multiple regression analysis was performed to develop highly accurate sEREs of BIA based on independent variables derived from anthropometric measurements, dual-energy X-ray absorptiometry (DXA), and BIA parameters. The difference in validity between the predicted DXA and sum of the segmentally-predicted FFM values by sEREs (Sum_sEREs) values was evaluated using bivariate linear regression analysis and the Bland–Altman plot.

Results

The coefficient of determination (R²) and total error (TE) between DXA and Sum_sEREs were 71% and 5.4 (kg) in the cross-validation analysis.

Conclusions

We confirmed the possibility of evaluating the FFM of APTs through the sEREs developed in this study. We also identified several independent variables that should be considered while developing such sEREs. Further studies are required to determine the validity of our sEREs and the most appropriate BIA frequencies for measuring FFM in APTs.

Effect of Gait Training Program with Mechanical Exoskeleton on Body Composition of Paraplegics

Purpose

To identify the effect of a 52-weeks gait training program with an exoskeletal body-powered gait orthosis on the body composition of paraplegics.

Patients and Methods

Ten subjects with spinal cord injury at the thoracolumbar spine level for more than 2 years participated and were divided into exercise (n=5) and nonexercise (n=5) groups. A gait training program comprising stages 1–6 with customized exoskeletal body-powered gait orthosis was conducted for 52-weeks. A six-stage gait training program was conducted to manage the body composition and prevent obesity, and the changes in the body composition before and after the program were determined through bioelectrical impedance analysis.

Results

No significant changes in weight, fat-free mass (kg), lean body mass (kg), and percent fat mass (%) are seen in the exercise group before and after the 52-weeks program. However, fat-free mass (pre = 47.3± 6.5, post = 44.3 ± 5.4, kg), lean body mass (pre = 45.2 ± 6.3, post = 42.3±5.2, kg), and percent fat mass (pre = 30.1 ± 12.1, post = 40.9 ± 9.1, kg) show significant changes (p < 0.05) in the nonexercise group. In the nonexercise group, among lean body mass changes over 52-weeks in the upper limbs (−31%), trunks (−9.7%), and lower limbs (−8.6%), upper limbs exhibit the most significant decrease (p < 0.05).

Conclusion

The gait training program with exoskeletal body-powered gait orthosis has a positive effect on fat management in the whole body and lean body mass loss in paraplegics. Furthermore, it is effective in preventing continuous muscle loss and in maintaining health by reducing body fat. Body composition measurements with bioelectrical impedance analysis for paraplegics can be applied in various clinical areas and can be combined with various arbitration methods such as rehabilitation program.

Between-day reliability of MyotonPRO for the non-invasive measurement of muscle material properties in the lower extremities of patients with a chronic spinal cord injury

Measuring the muscle properties of patients with spinal cord injuries (SCIs) is important to better understand their biomechanical features. In this study, we sought to evaluate the between-day reliability of MyotonPRO, a handheld device that can measure muscle mechanical properties, and assess whether it is reliable to measure muscle properties over time in patients with SCI. Thirteen men with complete SCIs (age 53.9 ± 6.3 years, height 171.0 ± 5.2 cm, weight 66.1 ± 5.8 kg), and injury levels ranging from L1 to T12, were enrolled. Oscillation frequency; logarithmic decrement; dynamic stiffness; mechanical stress relaxation time; and creep of the biceps femoris, medial and lateral gastrocnemius, rectus femoris, tibialis anterior, and Achilles tendon were measured on consecutive days using MyotonPRO. The intraclass coefficient for most muscles and the Achilles tendon ranged from 0.53 to 0.99 for all parameters. The percentage standard error of the measurement for many parameters in most muscles and the Achilles tendon was less than 10%. Bland-Altman analysis showed a high agreement for all mechanical properties. No significant differences were observed in any muscle or Achilles tendon properties between days (all p > 0.05). These results indicate that the MyotonPRO is reliable for between-day measurements of the mechanical properties of lower limb muscles and Achilles tendon in patients with SCI.

Development of a shear force measurement dummy for seat comfort

Seat comfort is one of the main factors that consumers consider when purchasing a car. In this study, we develop a dummy with a shear-force sensor to evaluate seat comfort. The sensor has dimensions of 25 mm × 25 mm × 26 mm and is made of S45C. Electroless nickel plating is employed to coat its surface in order to prevent corrosion and oxidation. The proposed sensor is validated using a qualified load cell and shows high accuracy and precision (measurement range: -30-30 N; sensitivity: 0.1 N; linear relationship: R = 0.999; transverse sensitivity: <1%). The dummy is manufactured in compliance with the SAE standards (SAE J826) and incorporates shear sensors into its design. We measure the shear force under four driving conditions and at five different speeds using a sedan; results showed that the shear force increases with speed under all driving conditions. In the case of acceleration and deceleration, shear force significantly changes in the lower body of the dummy. During right and left turns, it significantly changes in the upper body of the dummy.

Variations in gait features in elderly adults during walking considering their balance

The aim of this study was to evaluate the influence of balance on the spatiotemporal features, lower-limb kinematics, and center of mass (COM) of the non-faller elderly during walking. In this study, 20 healthy elderly women (age, 76.2 ± 5.6 years; height, 150.1 ± 3.2 cm; weight, 55.8 ± 9.0 kg) were enrolled. Based on the Berg balance scale (BBS), the elderly were classified into two groups: poor balance (PB; BBS scores <46; n = 10; 43.8 ± 1.8) and good balance (GB; BBS scores ≥46; n = 10; 50.4 ± 2.5). The two groups had no differences in terms of the spatiotemporal features and range of motion (ROM) of the vertical COM (all p > 0.05). The ROM of the mediolateral COM was greater in PB than in GB. Hip transversal movements in the two groups were different. The impairment of the lateral balance function might contribute to an increase in the incidence of fall events in the elderly with poor balance.

Effects of knee sleeves on coordination of lower-limb segments in healthy adults during level walking and one-leg hopping

The evaluation of multisegment coordination is important in gaining a better understanding of the gait and physical activities in humans. Therefore, this study aims to verify whether the use of knee sleeves affects the coordination of lower-limb segments during level walking and one-leg hopping. Eleven healthy male adults participated in this study. They were asked to walk 10 m on a level ground and perform one-leg hops with and without a knee sleeve. The segment angles and the response velocities of the thigh, shank, and foot were measured and calculated by using a motion analysis system. The phases between the segment angle and the velocity were then calculated. Moreover, the continuous relative phase (CRP) was calculated as the phase of the distal segment subtracted from the phase of the proximal segment and denoted as CRPTS (thigh–shank), CRPSF (shank–foot), and CRPTF (thigh–foot). The root mean square (RMS) values were used to evaluate the in-phase or out-of-phase states, while the standard deviation (SD) values were utilized to evaluate the variability in the stance and swing phases during level walking and in the preflight, flight, and landing phases during one-leg hopping. The walking velocity and the flight time improved when the knee sleeve was worn (p < 0.05). The segment angles of the thigh and shank also changed when the knee sleeve was worn during level walking and one-leg hopping. The RMS values of CRPTS and CRPSF in the stance phase and the RMS values of CRPSF in the preflight and landing phases changed (p < 0.05 in all cases). Moreover, the SD values of CRPTS in the landing phase and the SD values of CRPSF in the preflight and landing phases increased (p < 0.05 in all cases). These results indicated that wearing a knee sleeve caused changes in segment kinematics and coordination.

Relief of knee flexion contracture and gait improvement following adaptive training for an assist device in a transtibial amputee: A case study

BACKGROUND

Management of a knee contracture is important for regaining gait ability in transtibial amputees. However, there has been little study of prosthesis training for enhancing mobility and improving range of motion in cases of restricted knee extension.

OBJECTIVE

This study aimed to evaluate the effects of adaptive training for an assist device (ATAD) for a transtibial amputee with a knee flexion contracture (KFC). A male transtibial amputee with KFC performed 4 months of ATAD with a multidisciplinary team. During the ATAD, the passive range of motion (PROM) in the knee, amputee mobility predictor (AMP) assessment, center of pressure (COP) on a force plate-equipped treadmill, gait features determined by three-dimensional motion analysis, and Short-Form 36 Item Health Survey (SF-36) scores were evaluated.

RESULTS

Following ATAD, PROM showed immediate improvement (135.6 ± 2.4° at baseline, 142.5 ± 1.7° at Step 1, 152.1 ± 1.8° at Step 2, 165.8 ± 1.9° at Step 3, and 166.0 ± 1.4° at Step 4); this was followed by an enhanced COP. Gradually, gait features also improved. Additionally, the AMP score (5 at baseline to 29 at Step 4) and K-level (K0 at baseline to K3 at Step 4) increased after ATAD. Along with these improvements, the SF-36 score also improved.

CONCLUSIONS

ATAD could be beneficial for transtibial amputees by relieving knee contractures and improving gait.

Obesity Resistance and Enhanced Insulin Sensitivity in Ahnak-/- Mice Fed a High Fat Diet Are Related to Impaired Adipogenesis and Increased Energy Expenditure

Objective

Recent evidence has suggested that AHNAK expression is altered in obesity, although its role in adipose tissue development remains unclear. The objective of this study was to determine the molecular mechanism by which Ahnak influences adipogenesis and glucose homeostasis.

Design

We investigated the in vitro role of AHNAK in adipogenesis using adipose-derived mesenchymal stem cells (ADSCs) and C3H10T1/2 cells. AHNAK-KO male mice were fed a high-fat diet (HFD; 60% calories from fat) and examined for glucose and insulin tolerances, for body fat compositions, and by hyperinsulinemic-euglycemic clamping. Energy expenditures were assessed using metabolic cages and by measuring the expression levels of genes involved in thermogenesis in white or brown adipose tissues.

Results

Adipogenesis in ADSCs was impaired in AHNAK-KO mice. The loss of AHNAK led to decreased BMP4/SMAD1 signaling, resulting in the downregulation of key regulators of adipocyte differentiation (P<0.05). AHNAK directly interacted with SMAD1 on the Pparγ2 promoter. Concomitantly, HFD-fed AHNAK-KO mice displayed reduced hepatosteatosis and improved metabolic profiles, including improved glucose tolerance (P<0.001), enhanced insulin sensitivity (P<0.001), and increased energy expenditure (P<0.05), without undergoing alterations in food intake and physical activity.

Conclusion

AHNAK plays a crucial role in body fat accumulation by regulating adipose tissue development via interaction with the SMAD1 protein and can be involved in metabolic homeostasis.

Assessment of forearm and plantar foot load in the elderly using a four-wheeled walker with armrest and the effect of armrest height

BACKGROUND

Patients with hand and/or wrist pathology are recommended to have a four-wheeled walker with an arm rest (FWW-AR) rather than a standard walker or a standard four-wheeled walker (FWW). However, only a few quantitative studies have been performed to compare upper and lower extremity weight bearing. The aim of this study was to evaluate forearm and foot weight bearing using a FWW-AR and the effect of the armrest height.

METHODS

Eleven elderly women (mean age 80.1±5.3 years; mean height 148.5±4.0 cm; mean weight 51.2±9.0 kg) were enrolled. The subjects walked with an FWW-AR, with the elbow in either 90 degree (D90) or 130 degree (D130) flexion, for a distance of 10 m. Surface electromyographic signals were recorded for the upper, middle, and lower trapezius, anterior deltoid, and erector spinae muscles; walking velocity was measured with the subjects weight bearing on their feet and forearms while walking. Simultaneously, the maximum plantar and forearm loads during walking with an FWW-AR were measured.

RESULTS

The normalized foot plantar loads were lower at D90 than at D130, while the normalized forearm load was higher at D90 than at D130 (all P<0.05; left foot, 7.9±0.1 N/kg versus 8.8±0.1 N/kg; right foot, 8.6±0.2 N/kg versus. 9.6±0.1 N/kg; left forearm, 1.8±0.5 N/kg versus 0.8±0.2 N/kg; and right forearm, 2.0±0.5 N/kg versus 1.0±0.2 N/kg, respectively). The surface electromyographic activity of the muscles involved in shoulder elevation and the walking velocity were both lower with the elbow at D90 than at D130 (all P<0.05; left upper trapezius, 98.7%±19.5% versus 132.6%±16.9%; right upper trapezius, 83.4%±10.6% versus 108.1%±10.5%; left anterior deltoid, 94.1%±12.8% versus 158.6%±40.4%; right anterior deltoid, 99.1%±15.0% versus 151.9%±19.4%; and velocity, 0.6±0.1 m/sec versus 0.7±0.1 m/sec, respectively).

CONCLUSION

Weight bearing on the lower extremities is significantly reduced when the upper extremities are supported during walking with an FWW-AR. Furthermore, the weight bearing profile is dependent on the armrest height.

Effects of balance ability and handgrip height on kinematics of the gait, torso, and pelvis in elderly women using a four-wheeled walker

AIM

Numerous elderly individuals use the four-wheeled walker (FWW) as a gait-assistive device. The walker's handgrip height is important for correct use. However, few clinical studies have investigated the biomechanical effects of the FWW's handgrip height on balance. Therefore, the present study assessed kinematic features of the gait, torso and pelvis during use of the FWW at two levels of handgrip height (48% vs 55% of the subject's height) while assessing balance in older adults.

METHODS

A total of 20 older adults were allocated into two groups according to the Berg Balance Scale (BBS): good balance (GB; BBS≥46) versus poor balance (PB; BBS<45). Participants walked with the FWW at 48% or 55% handgrip height for 10 m.

RESULTS

Our study showed that the double-support period and stance phase significantly increased at 55% handgrip height, but the swing phase significantly decreased in the GB group. In the PB group, velocity and stride length significantly increased at 55% handgrip height. Tilt angle of the torso in the GB group was significantly lower at 55% than at 48% handgrip height, but no differences were observed in the PB group. In the pelvis, initial contact and toe-off angles of tilt were lower in the GB group at 55% handgrip height, but no differences were observed in the PB group.

CONCLUSIONS

These results showed that kinematic features of the gait, torso, and pelvis in older adults using the FWW might be dependent on the handgrip height of the FWW and the patient's balance. Additionally, greater than 48% of the body height might be appropriate for older adults with poor balance.

Linear- and Nonlinear-Electromyographic Analysis of Supracutaneous Vibration Stimuli of the Forearm Using Diverse Frequencies and Considering Skin Physiological Properties

Numerous studies have reported the efficacy of vibration in sensory feedback or substitution devices for users of myoelectric hand prostheses. Although most myoelectric hand prostheses are presently manipulated by a surface electromyogram (sEMG), only a few studies have been conducted on the effect of vibration on an sEMG. This study aimed to determine whether vibration stimulation affects the linear and nonlinear properties of surface electromyography (sEMG) considering the skin properties. The vibration stimuli, with frequencies ranging from 37 to 258 Hz, were applied to the proximal part of the arms of the eight female and seven male subjects. The skinfold thickness, hardness, and vibration threshold at the stimuli loci were measured. The root mean square (rms) and fractal dimension (DF) of the sEMG were measured at a distance of 1 cm in the upward direction from the stimuli loci. Above 223 Hz there were no differences between the rms of the genders in between the vibration stimuli (p > 0.05). Moreover, no differences were observed between the DF of the genders for any frequency (p > 0.05). Above 149 Hz, there were correlations between the rms and the skin hardness in the females. Otherwise, no correlations were observed between the rms and DF and the skin properties in both genders for most of the frequencies (all p > 0.05). These results suggest that vibration stimuli affect the linear properties of the sEMG, but not the nonlinear properties.

Bilateral asymmetry in microarchitecture of trabecular bone in male C57BL/6 mouse tibia: implication for experimental sample size estimations

This study aimed to determine whether there is bilateral asymmetry between the left and right tibiae in the microarchitectural characteristics of the trabecular bone and estimate a moderate sample size for detections of such bilateral differences. The left and right tibiae of 20 C57BL/6 mice (12 weeks old) were scanned by micro-computed tomography, and the structural parameters of the trabecular bone were measured. There were significant differences in the structural parameters between the left and right tibiae (p<0.05); specifically, the microarchitecture was greater in quantity and quality in the left tibia than in the right tibia. Moreover, the percent of bilateral differences between the left and right tibiae ranged from 2.26% to 22.52%. For most of the structural parameters except for trabecular bone thickness (Tb.Th) and trabecular bone separation (Tb.Sp), the 20 mice involved in this study were enough to detect differences. These results show that the directional left-right asymmetry in the microarchitecture of the trabecular bone may exist despite the samples being from an inbred strain. Furthermore, we estimated a sample size for detections of such differences between the left and right tibiae.

The effects of minimally invasive laser needle system on suppression of trabecular bone loss induced by skeletal unloading

This study was aimed to evaluate the effects of low-level laser therapy (LLLT) in the treatment of trabecular bone loss induced by skeletal unloading. Twelve mice have taken denervation operation. At 2 weeks after denervation, LLLT (wavelength, 660 nm; energy, 3 J) was applied to the right tibiae of 6 mice (LASER) for 5 days/week over 2 weeks by using a minimally invasive laser needle system (MILNS) which consists of a 100 μm optical fiber in a fine needle (diameter, 130 μm) [corrected]. Structural parameters and histograms of bone mineralization density distribution (BMDD) were obtained before LLLT and at 2 weeks after LLLT. In addition, osteocyte, osteoblast, and osteoclast populations were counted. Two weeks after LLLT, bone volume fraction, trabeculae number, and trabeculae thickness were significantly increased and trabecular separations, trabecular bone pattern factor, and structure model index were significantly decreased in LASER than SHAM (p < 0.05). BMDD in LASER was maintained while that in SHAM was shifted to lower mineralization. Osteocyte and osteoblast populations were significantly increased but osteoclast population was significantly decreased in LASER when compared with those in SHAM (p < 0.05). The results indicate that LLLT with the MILNS may enhance bone quality and bone homeostasis associated with enhancement of bone formation and suppression of bone resorption.

Low-level laser therapy using the minimally invasive laser needle system on osteoporotic bone in ovariectomized mice

This study tested the effectiveness of low-level laser therapy (LLLT) in preventing and/or treating osteoporotic trabecular bone. Mice were ovariectomized (OVX) to induce osteoporotic bone loss. The tibiae of eight OVX mice were treated for 5 days each week for 2 weeks by LLLT (660 nm, 3 J) using a minimally invasive laser needle system (MILNS) which is designed to minimize loss of laser energy before reaching bone (LASER group). Another eight mice received a sham treatment (SHAM group). Structural parameters of trabecular bone were measured with in vivo micro-computed tomography images before and after laser treatment. After LLLT for 2 weeks, the percentage reduction (%R) was significantly lower in BV/TV (bone volume fraction) and Tb.N (trabecular number, p<0.05 and p<0.05) and significant higher in Tb.Sp (trabecular separation) and SMI (structure model index, p<0.05 and p<0.05) than in the SHAM group. The %R in BV/TV at sites directly treated by LLLT was significantly lower in the LASER group than the SHAM group (p<0.05, p<0.05). These results indicated that LLLT using MILNS may be effective for preventing and/or treating trabecular bone loss and the effect may be site-dependent in the same bone.

The role of nacreous factors in preventing osteoporotic bone loss through both osteoblast activation and osteoclast inactivation

Excessive bone resorption by osteoclasts relative to bone formation by osteoblasts results in the development of osteoporosis. Anti-osteoporotic agents that are able both to inhibit bone resorption and to stimulate bone formation are not available. We now show that water-soluble nacreous factors prepared from the pearl oyster Pteria martensii prevent osteoporotic bone loss associated with estrogen deficiency in mice mainly through osteoclast inactivation. Nacreous factors stimulated osteoblast biomineralization in vitro in association with activation of signaling by c-Jun NH(2)-terminal kinase (JNK) and Fos-related antigen-1 (Fra-1). They also suppressed both osteoclast formation by blocking up-regulation of nuclear factor of activated T cells cytoplasmic 1 (NFATc1) as well as bone pit formation mediated by mature osteoclasts, likely by disrupting the actin ring of these cells. Our findings thus show that the components of a natural material have beneficial effects on bone remodeling that are mediated through regulation of both osteoblast and osteoclast function. They may thus provide a basis for the development of biomimetic bone material as well as anti-osteoporotic agents.

Deterioration of bone quality in the tibia and fibula in growing mice during skeletal unloading: gender-related differences

Skeletal unloading causes bone loss in both men and women; however, only a few studies have been performed on the effects of gender differences on bone quality during skeletal unloading. Moreover, although the fibula also plays an important role in load bearing and ankle stability, the effects of unloading on the fibula have been rarely investigated. The present study aimed to investigate the effects of skeletal unloading on bone quality of the tibia and fibula in growing animals and to determine whether differences existed between genders. Six-week-old female and male mice were randomly allocated into two groups. The right hindlimb of each mouse in the skeletal unloading group was subjected to sciatic neurectomy. After two weeks of skeletal unloading, the structural characteristics of the tibia and fibula in both genders were worsened. In addition, the bone mineralization density distribution (MDD) of the tibia and fibula in both genders were altered. However, the magnitude of deterioration and alteration of the MDD in the bones of females were larger than in those of males. These results demonstrate that skeletal unloading diminishes bone quality in the tibia and fibula, leading to an increase in bone fracture risks, particularly in females.

Early diagnosis of arthritis in mice with collagen-induced arthritis, using a fluorogenic matrix metalloproteinase 3-specific polymeric probe

OBJECTIVE

Early treatment based on an early diagnosis of rheumatoid arthritis (RA) could halt progression of the disease, but early diagnosis is often difficult. Matrix metalloproteinase 3 (MMP-3) is thought to be particularly important in the pathogenesis of RA. The aim of this study was to investigate whether an MMP-3-specific polymeric probe could be used for early diagnosis and for visualizing the progression of arthritis, using a near-infrared fluorescence (NIRF) imaging system.

METHODS

The MMP-3-specific polymeric probe was developed by conjugating NIRF dye, MMP substrate peptide, and dark quencher to self-assembled chitosan nanoparticles. One hour after intravenous administration of the probe, fluorescent images of mice with collagen-induced arthritis at different stages of disease development were obtained. The correlation between the fluorescence recovered in in vivo imaging when using an MMP-3-specific polymeric probe and up-regulated MMP-3 activity in the joint tissues was evaluated by Western blotting and immunohistochemical staining. Histologic analysis and micro-computed tomography (micro-CT) were also used to assess arthritis progression.

RESULTS

A significantly higher NIRF signal was recovered from arthritic joints compared with normal joints at 14 days after the first immunization, before any erythema or swelling could be observed with the naked eye or any erosion was detected by histologic analysis or micro-CT. The results of immunohistochemical analysis and Western blotting confirmed that the fluorescence recovered in the in vivo imaging was related to up-regulated MMP-3 activity in the joint tissues.

CONCLUSION

An MMP-3-specific polymeric probe provided clear early diagnosis of arthritis and visualization of arthritis progression using an NIRF imaging system. This approach could be used for early diagnosis and for monitoring drug and surgical therapies in individual cases.

Systemic transplantation of human adipose-derived stem cells stimulates bone repair by promoting osteoblast and osteoclast function

Systemic transplantation of adipose-derived stem cells (ASCs) is emerging as a novel therapeutic option for functional recovery of diverse damaged tissues. This study investigated the effects of systemic transplantation of human ASCs (hASCs) on bone repair. We found that hASCs secrete various bone cell-activating factors, including hepatocyte growth factor and extracellular matrix proteins. Systemic transplantation of hASCs into ovariectomized mice induced an increased number of both osteoblasts and osteoclasts in bone tissue and thereby prevented bone loss. We also observed that conditioned medium from hASCs is capable of stimulating proliferation and differentiation of osteoblasts via Smad/extracellular signal-regulated kinase (ERK)/JNK (c-jun NH₂-terminal kinase) activation as well as survival and differentiation of osteoclasts via ERK/JNK/p38 activation in vitro. Overall, our findings suggest that paracrine factors secreted from hASCs improve bone repair and that hASCs can be a valuable tool for use in osteoporosis therapy.

Development of a minimally invasive laser needle system: effects on cortical bone of osteoporotic mice

Many studies have shown the positive effects of low-level laser therapy in the treatment of bone disease. However, laser radiation is scattered in the skin surface which reduces the initial photon density for tissue penetration and consequently the therapeutic efficacy. We developed a minimally invasive laser needle system (MILNS) to avoid laser scattering in tissue and investigated its stimulatory effects in the cortical bone of osteoporotic mice. The MILNS was designed to stimulate cortical bone directly by employing fine hollow needles to guide 100 μm optical fibers. The study animals comprised 12 mice which were subjected to sciatic denervation of the right hind limb and were randomly divided into two groups, a sham group and a laser group which were treated using the MILNS for 2 weeks without and with laser irradiation, respectively. In vivo micro-CT images were taken to analyze the structural parameters and bone mineral density. After 2 weeks of treatment with the MILNS, the relative changes in mean polar moment inertia, cross-section thickness, and periosteal perimeter were significantly higher in the laser group than in the sham group. Moreover, the distribution of bone mineral density index was higher in the laser group. The MILNS was developed as a minimally invasive treatment modality for bone disease and resulted in positive therapeutic efficacy in the cortical bone of osteoporotic mice.

Inactivation of glycogen synthase kinase-3β is required for osteoclast differentiation

Glycogen synthase kinase-3β (GSK-3β) is a serine/threonine kinase originally identified as a regulator of glycogen deposition. Although the role of GSK-3β in osteoblasts is well characterized as a negative regulator of β-catenin, its effect on osteoclast formation remains largely unidentified. Here, we show that the GSK-3β inactivation upon receptor activator of NF-κB ligand (RANKL) stimulation is crucial for osteoclast differentiation. Regulation of GSK-3β activity in bone marrow macrophages by retroviral expression of the constitutively active GSK-3β (GSK3β-S9A) mutant inhibits RANKL-induced osteoclastogenesis, whereas expression of the catalytically inactive GSK-3β (GSK3β-K85R) or small interfering RNA (siRNA)-mediated GSK-3β silencing enhances osteoclast formation. Pharmacological inhibition of GSK-3β further confirmed the negative role of GSK-3β in osteoclast formation. We also show that overexpression of the GSK3β-S9A mutant in bone marrow macrophages inhibits RANKL-mediated NFATc1 induction and Ca(2+) oscillations. Remarkably, transgenic mice expressing the GSK3β-S9A mutant show an osteopetrotic phenotype due to impaired osteoclast differentiation. Further, osteoclast precursor cells from the transgenic mice show defects in expression and nuclear localization of NFATc1. These findings demonstrate a novel role for GSK-3β in the regulation of bone remodeling through modulation of NFATc1 in RANKL signaling.

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

OBJECTIVE

The objective of this study was to develop evidence-based quality indicators to measure key aspects of care that can be targeted to decrease variations in complication rates between surgeons performing total joint replacement.

DESIGN

RAND/University of California, Los Angeles (UCLA) modified-Delphi expert panel method. To accomplish this objective, a proposed set of quality of care indicators was developed through a comprehensive literature search and structured interviews with expert clinicians. An expert panel of orthopaedic surgeons was then convened to rate the validity of these quality indicators using the RAND/UCLA Appropriateness Method. Indicators were classified as valid by the panel based on the median panel rating and the amount of dispersion of panel ratings.

RESULTS

There were 101 candidate indicators of quality identified in the six domains of preoperative processes of care, intraoperative processes, postoperative processes, implant selection and the use of new technology, privileging of hospitals and surgeons, and outcomes and comorbidity assessment. A total of 68 of the 101 indicators were rated as valid with statistical agreement.

CONCLUSIONS

This study identifies measures of structure, process and outcome rated as valid quality indicators for hip and knee replacement. This project provides tools to measure and improve quality of care for patients undergoing total joint replacement.

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

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

Low-intensity ultrasound stimulation prevents osteoporotic bone loss in young adult ovariectomized mice

Osteoporosis is a disease characterized by low bone mass, increased bone fragility, and a greater risk for bone fracture. Currently, pharmacological intervention can generally aid in the prevention and treatment of osteoporosis, but these therapies are often accompanied by undesirable side effects. Therefore, alternative therapies that minimize side effects are necessary. Biophysical stimuli, especially low-intensity ultrasound stimulation (LIUS), may be potential alternatives to drug-based therapies for osteoporosis. Hence, we sought to address whether LIUS therapy can effectively prevent or treat osteoporotic bone loss induced by estrogen deficiency. LIUS (1.5 MHz frequency, 1.0 kHz pulse repetition on frequency, 30 mW/cm(2) intensity, 200 µs pulse length) was applied to right tibiae of eight 14-week-old ovariectomized virgin ICR female mice for 20 min per day, 5 days per week, over a 6-week period. Changes in 3D structural bone characteristics were detected using in vivo micro-computed tomography. Left tibiae served as controls. Structural characteristics including bone volume/tissue volume, trabecular number, trabecular bone pattern factor, and mean polar moment inertia were significantly enhanced 6 weeks after LIUS compared to the control, nonstimulated group (p < 0.05). In particular, the bone volume/tissue volume in the region exposed directly to LIUS was significantly higher in the treated group (p < 0.05). These findings indicate that new bone formation may be activated or that bone structure may be maintained by LIUS, and that LIUS may be effective for preventing estrogen deficiency-induced bone loss.

Selective inhibition of RANK blocks osteoclast maturation and function and prevents bone loss in mice

Regulation of the formation and function of bone-resorbing osteoclasts (OCs) is a key to understanding the pathogenesis of skeletal disorders. Gene-targeting studies have shown that the RANK signaling pathway plays a critical role in OC differentiation and function. Although pharmaceutical blockade of RANK may be a viable strategy for preventing bone destruction, RANK is implicated in multiple biological processes. Recently, a cytoplasmic motif of RANK was identified that may be specifically involved in OC differentiation. Here, we developed a cell-permeable inhibitor termed the RANK receptor inhibitor (RRI), which targets this motif. The RRI peptide blocked RANKL-induced OC formation from murine bone marrow-derived macrophages. Furthermore, RRI inhibited the resorptive function of OCs and induced OC apoptosis. Treatment with the peptide impaired downstream signaling of RANK linked to Vav3, Rac1, and Cdc42 and resulted in disruptions of the actin cytoskeleton in differentiated OCs. In addition, RRI blocked inflammation-induced bone destruction and protected against ovariectomy-induced bone loss in mice. These data may be useful in the development of selective therapeutic agents for the treatment of osteoporosis and other bone diseases.

Peri-implant bone reactions at delayed and immediately loaded implants: an experimental study

OBJECTIVE

The aim of this study was to compare the peri-implant bone reactions of implants subjected to immediate loading with those subjected to delayed loading.

STUDY DESIGN

In 6 mongrel dogs, bilateral edentulated flat alveolar ridges were created in the mandible. After 3 months of healing, 1 implant was placed in each side. On one side of the mandible, the implant was loaded immediately with a force of 20 N that was applied at a 120 degrees angle from the tooth's longitudinal axis at the labial surface of the crown for 1800 cycles per day for 10 weeks. On the opposite side, after a delay of 3 months to allow osseointegration to take place, the implant was loaded with the same force used for the immediately loaded implant. Ten weeks after loading, microscopic computerized tomography at the implantation site was performed. Osseointegration was calculated as the percentage of implant surface in contact with bone. Bone height was measured in the peri-implant bone.

RESULTS

The mean osseointegration was greater (65.5%) for the delayed-loading implants than for the immediately loaded implants (60.9%; P < .05). The mean peri-implant bone height was greater (10.6 mm) for the delayed-loading implants than for the immediately loaded implants (9.6 mm; P < .05).

CONCLUSION

The results indicate that when implants are immediately loaded, the immediate loading may decrease both osseointegration of dental implants and bone height.

Flapless implant surgery: an experimental study

OBJECTIVE

The purpose of this study was to examine the effect of flapless implant surgery on crestal bone loss and osseointegration in a canine mandible model.

STUDY DESIGN

In 6 mongrel dogs, bilateral, edentulated, flat alveolar ridges were created in the mandible. After 3 months of healing, 2 implants in each side were placed by either flap or flapless procedures. After a healing period of 8 weeks, microcomputerized tomography at the implantation site was performed. Osseointegration was calculated as percentage of implant surface in contact with bone. Additionally, bone height was measured in the peri-implant bone.

RESULTS

The mean osseointegration was greater at flapless sites (70.4%) than at sites with flaps (59.5%) (P < .05). The mean peri-implant bone height was greater at flapless sites (10.1 mm) than at sites with flaps (9.0 mm) (P < .05).

CONCLUSION

Flapless surgery can achieve results superior to surgery with reflected flaps. The specific improvements of this technique include enhanced osseointegration of dental implants and increased bone height.

Ingestion of orthodontic anchorage screws: an experimental study in dogs

INTRODUCTION

Sharp-edged foreign bodies that are accidentally swallowed can become lodged in the stomach. This animal study was undertaken to determine the outcome of orthodontic anchorage screw ingestion.

METHODS

We evaluated radiographs of 10 mixed-breed dogs that ingested 10 orthodontic anchorage screws and 10 reamers (1 screw and 1 reamer per dog).

RESULTS

All orthodontic anchorage screws and all but 2 reamers were spontaneously passed within 7 days.

CONCLUSIONS

Further investigation is needed to determine whether the results of our animal study agree with clinical findings.

Comparison of corticocancellous block and particulate bone grafts in maxillary sinus floor augmentation for bone healing around dental implants

OBJECTIVE

The aim of this study was to compare 2 types of bone used for maxillary sinus floor augmentation, corticocancellous block or particulate bone grafts, on bone healing around dental implants when installed simultaneously with the implant.

STUDY DESIGN

The mucous membranes of 12 sinuses in 6 dogs were elevated bilaterally. On one side of the maxillary sinus, autogenous corticocancellous block bone was grafted into the space between the membrane and sinus wall. On the opposite side, autogenous corticocancellous particulate bone was grafted. Simultaneously, 2 dental implants were inserted into the grafting material through the maxillary sinus floor. The animals were killed 6 months after surgical procedure.

RESULTS

The mean bone-implant contact was 56.7% on the block side and 32.1% on the particulate side (P < .05). The mean height of newly formed bone in the augmented area was 12.3 mm on the block side and 9.7 mm on the particulate side (P < .05).

CONCLUSION

Our results show that maxillary sinus floor augmentation using corticocancellous block bone grafts, when installed simultaneously with the implant, is superior to corticocancellous particulate bone grafts for bone healing around dental implants.

Osteoporosis prevention education programme for women

AIM

This paper reports an evaluation of a nurse-initiated education programme on four specific osteoporosis prevention behaviours which led to their adoption or to positive attitude changes.

BACKGROUND

In the past, osteoporosis was a serious health concern that most commonly affected women in Northern Europe and the United States of America, but was less commonly seen in Asian women. However, in Hong Kong, osteoporosis is currently among the top five conditions causing disability and prolonged hospital stay for older people. From an economic perspective, the most cost-effective approach is to focus on primary prevention via education, and nurses often have the responsibility of providing such educational programmes.

METHOD

A randomized controlled study was conducted from July 2004 to March 2005 with 76 women (38 cases and 38 controls) recruited in two private beauty clinics in Hong Kong. Pre-, post- and follow-up education data were compared regarding attitudes and adoption frequency before and after the education programme.

RESULTS

The results showed statistically significant increases for each behaviour: consumption of soy foods (P < 0.001), milk (P < 0.001), more exercise (P = 0.01) and vitamin D/exposure to sunlight (P < 0.001) for the case group compared with the control group. Most participants either disagreed (n = 15, 39.0%) or strongly disagreed (n = 23, 61.0%) that there was not enough information provided in the education programme to motivate them to change. They rated the nurse's performance as either satisfactory or very satisfactory on presentation, ability to answer their questions and ability to describe each behaviour clearly.

CONCLUSION

Although positive results with a nurse-initiated education programme were demonstrated, future research examining the effects of education and occupation on these four adoption behaviours should focus on more diverse populations with respect to age, income or ethnicity. The findings suggest the value of creative approaches in future health education for the prevention of osteoporosis, and the need for a critical appraisal of current strategies and a re-evaluation of services and funding.

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

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

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

HYPOTHESIS

The origin and characteristics of articles published in the 6 highest rated (Institute for Scientific Information classification) English-language general surgical journals have changed significantly during the past 15 years.

DESIGN

All articles published in 1983, 1988, 1993, and 1998 in 5 US surgical journals and 1 British surgical journal were reviewed and characterized.

MAIN OUTCOME MEASURES

Absolute numbers and proportions of national and international articles published in each journal.

RESULTS

Articles reviewed included 4868 in US journals and 1380 in the British journal. The total number of US journal articles decreased by 15.1%. The total number of British journal articles increased by 58.9%. The percentage of national articles decreased from 87.5% to 68.8% in US journals (P<.001) and constituted the minority of freely submitted articles in 1998 in 3 of 5 US journals. The percentage of national articles also decreased from 74.8% to 47.1% in the British journal (P<.001). Articles by European and Asian authors showed the most striking increases in all journals. The percentage of basic research articles declined in US journals from 23.3% to 17.9% (P =.001) owing to a 14.9% decline in national basic research articles. The percentage of clinical randomized studies increased from 2.2% to 4.1% (P<.008), but the increase was attributable to international articles. Government funding alone decreased from 13.6% to 11.2%, and government plus another source of funding decreased from 19.2% to 16.7% for national articles in US journals.

CONCLUSIONS

Internationalization of the highly rated British and the 5 highest rated US general surgical journals has occurred. The decrease in the number of national articles in the US journals has been accompanied by significant decreases in government funding and basic research articles and a static output of clinical randomized studies from North America.

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

BACKGROUND/PURPOSE

Reports of clinical trials often lack adequate descriptions of design and analysis; recent attention has focused on improving this omission so readers can properly assess the strength of the findings and draw their own conclusions. Similar analysis of study design and methodologic standards associated with quality reporting has not been carried out for pediatric surgery journals.

METHODS

All studies (n = 642) published in 1998 in Journal of Pediatric Surgery (JPS) and Pediatric Surgery International (PSI), were reviewed for demographic data and study design. The frequency of reporting of 11 basic elements of design and analysis was evaluated in randomized clinical trials (RCT), nonrandomized clinical trials (NRCT), and retrospective cohorts (RC) from JPS by consensus of 2 assessors.

RESULTS

Of the 642 studies, 17% of articles (111 of 642) were classified as clinical studies. Sixty-three were comparative studies and consisted of RC (n = 48), NRCT (n = 12), and RCT (n = 3). Two-thirds of articles published were either case reports or case series (431 of 642), and 16% were basic science articles. Demographic analysis showed a wide range of topics addressed, 4 authors per article, and multiple country of origin of authors. More than 66% of all RCT in JPS reported on eligibility criteria, admission before allocation, random allocation, method of randomization, patients' blindness to treatment, treatment complications, statistical analyses, statistical methods, loss to follow-up, and statistical methods; 2 elements of design and analysis, however, were poorly reported: blind assessment of outcome (33%) and power (17%).

CONCLUSIONS

There were few randomized, controlled trials in pediatric surgery journals, and further attention should be given to evaluate the causal factors. Nine elements of quality reporting were well reported; however, 2 others were poorly reported; this may improve if editors of pediatric surgical journals provide authors with guidelines on how to report clinical trial design and analysis.

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

INTRODUCTION

Previous studies have reported that mean health related quality of life (HRQL) levels generally attain normalcy following construction of an ileal pouch anal anastomosis (IPAA). It appears inconsistent, however, that these normal HRQL levels are achieved while bowel function (BF) scores generally remain statistically worse than "normal" (e.g., 4-8 stools/day, possible anal leakage, diaper usage). To investigate this inconsistency, the current study attempts to determine if any statistical associations are present between HRQL and BF, specifically in the long term. Multivariate regression analyses are performed using each of 8 individual HRQL domains against the full model of BF characteristics.

METHODS

All patients more than 5 years status post an ileal pouch anal anastomosis (IPAA) procedure for familial adenomatous polyposis (FAP) at a single institution were studied. FAP was chosen because patients are routinely asymptomatic preoperatively. BF (e.g., stool frequency, anal leakage) and HRQL (using the 8 health domains of the SF-36) were assessed by patient interview. Student's t tests and full model multivariate regression analyses were used to analyze associations between BF and HRQL.

RESULTS

The sample included 25 patients (14 male). Mean age was 39 years, mean follow-up time was 11 years. Although mean scores for the 8 individual HRQL domains were not statistically different from the general United States population, regression analyses of the different domains did demonstrate significant associations with varying levels of BF. While controlling for age and gender, the analyses show that the physical function domain is improved with the ability to pass flatus independent of stool, and physical role and mental health domains are improved with decreased stool frequency. The social function domain is improved with increased stool retention time, while the perception of general health is improved with less diaper usage and less sexual dysfunction.

CONCLUSIONS

This study shows that a statistically significant association between HRQL levels and BF is present. Of the numerous BF characteristics tested, five appear to be of greater importance with regard to certain HRQL domains. This finding may have clinical implications concerning pouch construction and surgical technique. Methodologically, this study demonstrates that merely using mean levels to describe HRQL may not elucidate meaningful relationships between important clinical outcomes, such as function and HRQL.

Primary duodenal adenocarcinoma: a 40-year experience

HYPOTHESIS

In patients with duodenal adenocarcinoma, certain pathologic features of the tumor will have prognostic significance.

DESIGN

Retrospective case series.

PATIENTS

Forty-nine patients diagnosed with duodenal adenocarcinoma between 1957 and 1998.

RESULTS

The tumors of 31 (63%) of the 49 patients underwent resection, 18 (37%) had surgical palliation or underwent biopsy. Mean (+/- SEM) survival for all patients was 49 +/- 9 months. The patients whose tumors were resected had longer survival than those who underwent palliation (mean +/- SEM, 66 +/- 13 months vs 18 +/- 6 months, P =.02). Multivariate analysis revealed large tumor size (P =.01), transmural invasion (P =.004), and moderate to poor tumor grade (P =.03) were negatively correlated with survival. Lymph node status did not influence survival.

CONCLUSIONS

Our 40-year experience with duodenal adenocarcinoma demonstrates that large tumor size, advanced histological grade, and transmural invasion are associated with decreased survival. These results underscore the importance of early diagnosis, and suggest the presence of nodal spread is not a contraindication to resection.

Improving the Surgeon's participation in research: is It a problem of training or priority?

BACKGROUND

Although numerous important contributions have originated from basic science research performed by surgeons, it seems that such dedicated work is becoming increasingly difficult to accomplish. What are the reasons for this change and what improvements can be made? This study aims to characterize the basic research training and careers of senior academic surgeons to assess and devise strategies for sustaining productive and quality surgical research.

METHODS

A 25-item survey was sent to 850 senior-level members of academic societies, including the Association of Academic Surgeons, Society of University Surgeons, and American Surgical Association. It addressed each surgeon's clinical and research training and career, as well as opinions concerning surgical research.

RESULTS

Three hundred seventy-seven (44%) surveys were received. Mean age was 64 years, and 73% were full professors. Seventy-two percent of respondents performed basic science research during training, and for 71% of this group, research was a significant reason for choosing a clinical specialty. Ninety-one percent performed research in the same specialty area during and after training. Of those who performed research during training, a full 99% continued to perform research on completion of training. However, 38% stopped performing basic research by age 39. Seventeen and twenty-three percent stopped basic research between 40 and 49 and between 50 and 59 years of age, respectively. The most common factors causing them to stop were increased clinical load (40%) and increased administrative duties (38%). For respondents who had stopped research prior to age 40, 73% cited increased clinical load as the primary reason. Eighty-five percent felt a dedicated research period should be included in surgery training.

CONCLUSIONS

Most respondents had participated in basic research during training, and continued similar research after training. However, an overwhelming clinical practice at the junior faculty level seemed to hinder research. We conclude: (1) the majority consensus is that research training is integral to the development of academic surgeons; (2) such research training opportunities appear adequate; however, (3) faculty performing research, particularly at the junior level, need to be better protected from other academic duties, such as clinical practice and administration. The challenge to the leadership of academic surgery will be to enhance such research productivity in the context of increasing academic demands.

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

PURPOSE

The main impetus for a patient with familial adenomatous polyposis to choose colectomy with ileorectal anastomosis over ileal pouch-anal anastomosis is the better functional result. However, does better functional result necessarily translate into better overall quality of life? Previous studies of other diseases have demonstrated no such correlation. This study was performed to determine whether any relationship exists between functional result and quality of life in patients with familial adenomatous polyposis after ileorectal anastomosis and ileal pouch-anal anastomosis.

METHODS

All patients with familial adenomatous polyposis who underwent colectomy with ileorectal anastomosis or proctocolectomy with ileal pouch-anal anastomosis from 1980 to 1998 were studied. Functional data were obtained by questionnaire. Health-related quality of life was assessed by two validated instruments, the SF-36 Physical and Mental Health Summary Scales and the SF-36 Health Survey, which measure physical and mental functioning and eight separate health-quality dimensions, including health perception, physical and social functioning, physical and emotional role limitations, mental health, bodily pain, and energy or fatigue.

RESULTS

Data were obtained in 44 of 68 patients, 14 with ileorectal anastomosis and 30 with ileal pouch-anal anastomosis. No differences were demonstrated between the two groups for patient age, mean follow-up time, and mean patient age at operation. Functional results were worse for the ileal pouch-anal anastomosis group vs. the ileorectal anastomosis group in number of bowel movements per day (7.5 vs. 5.2; P < 0.05), leakage (43 vs. 0 percent; P < 0.01), pad usage (17 vs. 0 percent; P < 0.01), perianal skin problems (33 vs. 7 percent; P < 0.01), food avoidance (80 vs. 43 percent; P < 0.01), and inability to distinguish gas (37 vs. 7 percent; P < 0.01). Results of the health-related quality-of-life surveys, however, demonstrated no difference between the ileal pouch-anal anastomosis and ileorectal anastomosis groups. The Physical and Mental summary scales for the ileal pouch-anal anastomosis and ileorectal anastomosis groups were not significantly different (Physical Health Scale, 50.3 vs. 50.9; Mental Health Scale, 51.7 vs. 49.6), and none of the eight dimensions of the SF-36 health survey demonstrated statistical differences between the ileal pouch-anal anastomosis and ileorectal anastomosis groups.

CONCLUSION

Better functional results were not equated with better quality of life in this pilot study. Although patients with the ileorectal anastomosis have better functional results than those with ileal pouch-anal anastomosis, the measured health-related quality of life as determined by a validated generic health-related quality-of-life instrument is the same for both groups. These results suggest that all patients with familial adenomatous polyposis might be optimally treated with an ileal pouch-anal anastomosis. More importantly, this study suggests that health-related quality of life should play a greater role in the evaluation of care and treatment in colon rectal surgery.