Recent Publications by CFE Educators

BACKGROUND

This study is the first population-based measurement of outcomes after cholecystectomy during pregnancy.

METHODS

We identified all pregnant women who underwent cholecystectomy in the Healthcare Cost and Utilization Project-Nationwide Inpatient Sample, 1996-2006. Outcomes were fetal, maternal, and surgical complications, length of stay (LOS), and hospital cost. Pregnant and nonpregnant women were compared to examine the effects of pregnancy on laparoscopic cholecystectomy outcomes.

RESULTS

A total of 9,714 pregnant women underwent cholecystectomy (laparoscopic, 89%). Maternal and fetal complication rates were 4.3% and 5.8%, respectively. Pregnant women who underwent laparoscopic cholecystectomy compared to pregnant women who underwent open procedures had higher rates of surgical (19% vs 10%), maternal (9% vs 4%), and fetal (11% vs 5%) complications; longer LOS (6 vs 4 days); and higher cost ($13,198 vs $9,229), all P .0001. High-volume surgeons were associated with lower rates of surgical (10% vs 13%; P .05), maternal (1% vs 14%), and fetal (4% vs 10%) complications; shorter LOS (4 vs 5 days); and lower cost ($8,365 vs $10,350), all P .0001. Patients with Medicaid coverage were associated with higher rates of surgical complications (13% vs 9%), longer LOS (4.3 vs 3.7 days), and higher cost ($10,403 vs $9,037), all P .0001. On multivariable analysis, these factors remained independent predictors of outcome. Pregnancy was associated with longer LOS and higher cost.

CONCLUSION

Complications of cholecystectomy during pregnancy are significant, with disparities based on modifiable variables.

To better understand the mechanisms through which non-painful and painful stimuli evoke behavior, new resources to dissect the complex circuits engaged by subsets of primary afferent neurons are required. This is especially true to understand the consequences of injury, when reorganization of central nervous system circuits likely contributes to the persistence of pain. Here we describe a transgenic mouse line (ZWX) in which there is Cre-recombinase-dependent expression of a transneuronal tracer, wheat germ agglutinin (WGA), in primary somatic or visceral afferent neurons, but only after transection of their peripheral axons. The latter requirement allows for both regional and temporal control of tracer expression, even in the adult. Using a variety of Cre lines to target WGA transport to subpopulations of sensory neurons, here we demonstrate the extent to which myelinated and unmyelinated "pain" fibers (nociceptors) engage different spinal cord circuits. We found significant convergence (i.e., manifest as WGA-transneuronal labeling) of unmyelinated afferents, including the TRPV1-expressing subset, and myelinated afferents to NK1-receptor-expressing neurons of lamina I. By contrast, PKCgamma interneurons of inner lamina II only receive a myelinated afferent input. This differential distribution of WGA labeling in the spinal cord indicates that myelinated and unmyelinated sensory neurons target different and spatially segregated populations of postsynaptic neurons. On the other hand, we show that neurons of deeper laminae (III-V) receive direct (i.e., monosynaptic) inputs from myelinated afferents and polysynaptic input from unmyelinated afferents. Taken together, our results indicate that peripheral sensory information is transmitted to the central nervous system both through segregated and convergent pathways.

BACKGROUND

Teleteaching of endoscopy has been limited by the exorbitant cost and time inherent in high-quality digital endoscopy video transmission. The Digital Video Transport System (DVTS) transmitted over advanced networks, such as Internet2 and the Asia-Pacific Advanced Network (APAN), provides a unique infrastructure for sharing uncompressed digital videos of endoscopy. This may allow high-quality, real-time, international training of diagnostic and therapeutic endoscopy techniques at a low cost.

OBJECTIVE

To test the proof of concept of long-distance teaching through live, interactive, high-resolution video transmission by using advanced networks and the DVTS. We used teleteaching of image-enhanced endoscopy techniques as a model.

DESIGN

Prospective multicenter pilot study.

SETTING AND PARTICIPANTS

Trainees, faculty, and staff at 3 international endoscopy units.

INTERVENTION

An image-enhanced endoscopy video lecture with advanced-network technologies.

MAIN OUTCOME MEASUREMENTS

We compared image-based prelecture and postlecture test scores and secondarily assessed technical feasibility and quality.

RESULTS

The DVTS transmitted over advanced networks successfully transmitted uncompressed, high-resolution, digital lectures with endoscopic video (digital video format 720 x 480 pixels). Postsession scores improved. Participants highly rated the technical and informational quality. The majority reported a definite interest in participating in future sessions, with a mean rating (out of 5 [scale 1-5]) of 4.7 +/- 0.5.

LIMITATIONS

Pilot study with a limited number of participants and sessions.

CONCLUSION

The DVTS transmitted over advanced networks such as Internet2 and APAN can provide the infrastructure for transmission of high-resolution, uncompressed video endoscopy for the purpose of teleteaching endoscopy.

A 46-year-old man with human immunodeficiency virus presented with a condyloma that formed during 6 months and encased his penis, scrotum, and perineum. Visible condyloma growth began when this immunocompromised patient started highly active antiretroviral therapy, and it grew rapidly as his viral load plummeted. The patient underwent resection and reconstruction with skin grafting. Pathology findings revealed benign condyloma acuminatum. This rapid progression of condyloma growth is a cutaneous manifestation of immune reconstitution inflammatory syndrome.

INTRODUCTION

Male factor infertility is a relatively common problem. This diagnosis may increase sexual, marital, and relationship strain in male partners of infertile couples.

AIM

To measure the personal, social, sexual, and marital impacts of a male factor infertility diagnosis among men in couples evaluated for infertility.

METHODS

Cross-sectional analysis of 357 men in infertile couples from eight academic and community-based fertility clinics. Participants completed written surveys and face-to-face and telephone interviews at study enrollment. This interview queried each participant's perception of their infertility etiology to determine the primary study exposure (i.e., male factor only, male and female factors, female factor only, unknown).

MAIN OUTCOME MEASURES

Personal Impact, Social Impact, Marital Impact, and Sexual Impact scales.

RESULTS

Among the 357 men, no male factor was reported in 47%, isolated male factor was present in 12%, combined male and female factors were present in 16%, and unexplained infertility was present in 25% of couples. Male factor infertility was independently associated with worse Sexual (mean 39 vs. 30, standard deviation [SD] 2.7, P = 0.004) and Personal (mean 37 vs. 29, SD 3.8, P = 0.04) Impact scores relative to men in couples without male factor infertility. These differences remained statistically significant after controlling for male age, partner age, race, religion, educational level, employment status, prior pregnancy, duration of infertility, and prior paternity.

CONCLUSIONS

Male partners in couples who perceive isolated male factor infertility have a lower sexual and personal quality of life compared with male partners of couples without perceived male factor infertility. Social strain is highest among couples without a clear etiology for infertility. These findings highlight the clinically significant negative sexual, personal, and social strains of a perceived infertility diagnosis for men.

Models of protein energetics that neglect interactions between amino acids that are not adjacent in the native state, such as the Gō model, encode or underlie many influential ideas on protein folding. Implicit in this simplification is a crucial assumption that has never been critically evaluated in a broad context: Detailed mechanisms of protein folding are not biased by nonnative contacts, typically argued to be a consequence of sequence design and/or topology. Here we present, using computer simulations of a well-studied lattice heteropolymer model, the first systematic test of this oft-assumed correspondence over the statistically significant range of hundreds of thousands of amino acid sequences that fold to the same native structure. Contrary to previous conjectures, we find a multiplicity of folding mechanisms, suggesting that Gō-like models cannot be justified by considerations of topology alone. Instead, we find that the crucial factor in discriminating among topological pathways is the heterogeneity of native contact energies: The order in which native contacts accumulate is profoundly insensitive to omission of nonnative interactions, provided that native contact heterogeneity is retained. This robustness holds over a surprisingly wide range of folding rates for our designed sequences. Mirroring predictions based on the principle of minimum frustration, fast-folding sequences match their Gō-like counterparts in both topological mechanism and transit times. Less optimized sequences dwell much longer in the unfolded state and/or off-pathway intermediates than do Gō-like models. For dynamics that bridge unfolded and unfolded states, however, even slow folders exhibit topological mechanisms and transit times nearly identical with those of their Gō-like counterparts. Our results do not imply a direct correspondence between folding trajectories of Gō-like models and those of real proteins, but they do help to clarify key topological and energetic assumptions that are commonly used to justify such caricatures.

In individuals with cleft lip and palate, there is a high prevalence of hypodontia, particularly of the maxillary lateral incisor on the cleft side. The edentulous space in patients with a repaired alveolar cleft was traditionally treated with a fixed or removable partial denture, but this approach is not optimal. The purpose of this paper was to review the dental literature for infant orthopedic treatment, timing of alveolar bone grafting, timing of implant placement, and type of implants used in individuals with repaired alveolar clefts. There seems to be a consensus in the literature that the optimal timing for initial secondary alveolar bone grafting is between 8 and 11 years of age. Implants cannot be placed this early but should be placed within 6 months of augmentation bone grafting to avoid resorption of the grafted area. Longer implants--those at least 13 mm in length--reportedly have a higher survival rate compared to shorter implants. Other implant parameters such as surface characteristics and diameter do not seem to influence significantly the long-term longevity of implants placed into grafted alveolar clefts.

INTRODUCTION

Highly selective inhibitors of phosphodiesterase type 5 (PDE5I) have been commercially available for over a decade. Our knowledge of these drugs continues to expand.

AIMS

To review developments within the past 18 months on the utilization of PDE5I in preclinical studies and clinical practice. The focus of this article is on updates on regular dosing regimens of PDE5I other than the newly approved daily dose tadalafil.

METHODS

PubMed search utilizing the terms "phosphodiesterase type 5 inhibitor," PDE5 inhibitor,"sildenafil,"vardenafil," and "tadalafil." Articles were screened based on whether or not they addressed issues of routine dosing of PDE5I. Manuscripts on the newly approved daily dose tadalafil for erectile dysfunction (ED) were deferred for analysis in a separate manuscript in this series.

MAIN OUTCOME MEASURES

Peer reviewed publications on routine dosing of PDE5I published in the medical literature since 2007.

RESULTS

There have been numerous publications in the past 2 years regarding routine dosing of PDE5I for three major urological indications; penile rehabilitation, stuttering priapism, and management of lower urinary tract symptoms (LUTS). Evidence from basic science investigations has indicated that daily dose PDE5I may improve erectile function and exert a number of beneficial tissue effects on the penis. Unfortunately, data from human series of routine dose PDE5I for penile rehabilitation after radical prostatectomy are conflicting, with the two largest studies showing no benefit to daily dose therapy in the post-radical prostatectomy and the general ED populations. PDE5I are generally helpful at reducing symptoms of LUTS, particularly when given in conjunction with alpha blockers. Routine dosing of PDE5I has also been utilized successfully for management of stuttering ischemic priapism and several other medical indications.

CONCLUSIONS

PDE5I given as routine doses have clinical promise. Further research is required to clarify their safety and efficacy for various indications.