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The article describes the medical case of right inguinal hernia in a 67-year-old man. It notes that inguinal hernias commonly occur on the right side of the groin and more likely to be experienced by men. It cites that a repair of hernia is necessary in asymptomatic and symptomatic cases where surgical delay results in increasing pain. The article recommends immediate surgery for strangulated hernia that progresses to a case of intestinal ischemia.

The authors examine the relevance of traumatic brain injury (TBI) prognostic models in prognostic clinical decision makings, resource allocations, and randomized controlled trials. They discuss a study which investigated the application of the Medical Research Council (MRC) Corticosteroid Randomisation After Significant Head (CRASH) injury model a West Australian traumatic brain injury (TBI) data cohort. They also recommend constant refining of prediction models.

An abstract of the article "A study of the endoscopic findings and their clinical correlations in symptomatic gastric bypass patients," by Christopher S. Huang and colleagues is presented.

Background: There are differences between the genders in their innate performances on simulation trainers, which may impair accurate assessment of psychomotor skills. Methods: The performance of fourth-year students with no exposure to the Minimally Invasive Surgical Trainer compared based on gender, and other psychomotor skills. Results: Our study included 16 male and 16 female students. After adjusting for choice of medical specialty ( P<.001), current video game use ( P=.6), and experience in the operating room ( P=.4), female sex was an independent factor for worse performance ( P=.04) in multivariate models. Women took more time than men ( P<.01) and made more errors (29 versus 25 on 3 reps, P<.01). Conclusions: Among medical students with no previous exposure to laparoscopic trainers, female students perform worse than male students after adjusting for confounding factors. This difference must be recognized by training programs while using simulators for training and evaluation. [ABSTRACT FROM AUTHOR]

The use of erythropoletin in critically ill patients has been Investigated in multiple randomized clinical trials and its role in decreasing the number of units of blood transfused has been demonstrated in some trials. A meta-analysis was conducted to determine the pooled estimate of the decrease In number of units of blood transfused with the use of erythropoietin and Investigated its dose-response effect. A systematic search was performed of the MEDLINE, EMBASE, and the Current Controlled Trials Register to identify randomized clinical trials investigating the role of erythropoietin in critically ill patients. Of 664 studies identified In the search, 5 randomized clinical trials met the inclusion criteria. The pooled estimate of the decrease of number of units of blood transfused was -1.64 (95% CI -2.6 to -0.67). Sensitivity analysis to establish the Influence of temporal bias, quality of the study and comorbidities such as age and Acute Physiology and Chronic Health Evaluation (APACHE) II score were undertaken and did not reveal a significant difference. The inclusion of studies with higher doses of erythropoietin revealed a greater decrease in the number of units of blood transfused (-2.15; 95% CI -3.06 to -1.24). Despite the limitations of a meta-analysis we believe that the use of erythropoietin significantly decreases the number of units of blood transfused per patient. Our study also reveals the possibility of a dose-response effect of erythropoietin in decreasing the number of units of blood transfused. [ABSTRACT FROM AUTHOR]

OVERVIEW The persistence of a left sided superior vena cava is one of the commonest congenital venous abnormalities and is often missed during placement of central lines or pulmonary artery catheters. We describe a case of such an abnormality in a patient undergoing coronary artery bypass grafting. [ABSTRACT FROM AUTHOR]

Objectives: Outcomes after endovascular repair (EVAR) of ruptured abdominal aortic aneurysms (rAAAs) have been widely published. There is, however, controversy on the role of the use of aortouniiliac endoprosthesis (AUI) versus modular or unibody bifurcated endoprosthesis (MUB) for repair of rAAAs. We study and compare 30-day outcomes after use of AUI and MUB for all rAAAs focusing specifically on patients with instability. Materials and Methods: Patients who underwent EVAR for rAAA (n = 425) using AUI (n = 55; 12.9%) and MUB (n = 370; 87.1%) were identified from the American College of Surgeons' National Surgical Quality Improvement Program (2005-2010) database. Univariable and multivariable logistic regression analyses were performed. Results: No significant difference (P > .5) was seen in comorbidities between patients who underwent EVAR with AUI or MUB; there was also no change in endoprosthesis use from 2005 to 2010 (P = .7). Patients who underwent EVAR with AUI more commonly had a history of peripheral arterial procedure (10.9% vs 4.6%; P = .053) and preoperative transfusion of >4 U packed red blood cells (18.2% vs 6.8%; P = .004). Use of AUI versus MUB was associated with more 30-day wound complications (16.4% vs 6.2%; P = .01), return to operating room (38.2% vs 20.0%; P = .003), and mortality (34.5% vs 21.4%; P = .03). On multivariable analysis, use of AUI was associated with an increased risk of 30-day mortality (odds ratio: 2.4; 95% confidence interval: 1.1-5.3). On subanalysis of the cohort for only the patients with unstable rAAA (n = 159; AUI = 29 and MUB = 130), 30-day mortality for AUI versus MUB was still higher but not statistically significant (44.8% vs 32.3%; P = .2). Conclusion: Endovascular repair for ruptured AAA using aortouniliac endoprosthesis is associated with higher 30-day mortality than using modular or unibody bifurcated endoprosthesis. [ABSTRACT FROM AUTHOR]

Background: While the epidemic of obesity continues to plague America, bariatric surgery is underused due to concerns for surgical risk among patients and referring physicians. A risk score estimating postoperative mortality (OS-MRS) exists, however, is limited by consideration of only 12 preoperative variables, failure to separate open and laparoscopic cases, a lack of robust statistical analyses, risk factors not being weighted, and being applicable to only gastric bypass surgery. The objective of this study was to develop a validated risk calculator for 30-day postoperative mortality after bariatric surgery. Study Design: The National Surgical Quality Improvement Program (NSQIP) dataset (2006 to 2008) was used. Patients undergoing bariatric surgery for morbid obesity (n = 32,889) were divided into training (n = 21,891) and validation (n = 10,998) datasets. Multiple logistic regression analysis was performed on the training dataset. The model fit from the training dataset was maintained and was used to estimate mortality probabilities for all patients in the validation dataset. Results: Thirty-day mortality was 0.14%. Seven independent predictors of mortality were identified: peripheral vascular disease, dyspnea, previous percutaneous coronary intervention, age, body mass index, chronic corticosteroid use, and type of bariatric surgery. This risk model was subsequently validated. The model performance was very similar between the training and the validation datasets (c-statistics, 0.80 and 0.82, respectively). The high c-statistics indicate excellent predictive performance. The risk model was used to develop an interactive risk calculator. Conclusions: This risk calculator has excellent predictive ability for mortality after bariatric procedures. It is anticipated that it will aid in surgical decision-making, informed patient consent, and in helping patients and referring physicians to assess the true bariatric surgical risk. [ABSTRACT FROM AUTHOR]

The article discusses preoperative factors related to an increased risk of postoperative respiratory failure (PRF) and then develops and validates a risk calculator. Results reveal preoperative variables related to increased risk of PRF, including type of surgery, dependent functional status, emergency case, sepsis, and higher American Society of Anesthesiologist (ASA) class. The risk calculator reportedly offers a risk estimate of PRF and is expected to help in surgical decision making.

Background: Outcomes for patients who undergo laparoscopic Roux-en-Y gastric bypass (LRYGB) surgery have improved, but a subset of patients who significantly utilize more resources exists. We identified preoperative variables that increase resource utilization in patients who undergo LRYGB. Methods: Patients who underwent LRYGB in 2007 and 2008 were identified from the NSQIP database. Variables that indicated resource utilization were operative time (OT), length of stay (LOS), and occurrence of postoperative complications. Analyses were performed by using multivariate analysis of variance and logistic regression. Results: Of 14,251 patients with a mean age of 44.6 (±11.1) years, 19.4% were men. The national 30-day morbidity and mortality were 4.5% and 0.17%, respectively. The median OT was 128 min (interquartile range (IQR), 100-167), and the median LOS was 2 days (IQR, 2-3). Bleeding disorder, male gender, African American race, increasing weight, and age were significantly associated with increased OT ( p < 0.05 for all). Severe chronic obstructive pulmonary disease, bleeding disorder, increasing age, and anesthesia time were associated with increased length of stay ( p < 0.05). Preoperative dialysis dependence (odds ratio (OR), 8.5; 95% confidence interval (CI), 2.3-32.3) and dyspnea at rest (OR, 3.3; 95% CI, 1.7-6.3) were the greatest predictors of postoperative complications. Emergency case, bleeding disorder, prior percutaneous coronary intervention, and increasing operative time also were significantly associated with increased postoperative complications on multivariate logistic regression analysis ( p < 0.05 for all). Conclusions: Age, sex, race, obesity, and some medical comorbidities affect outcomes and increase resource utilization. Optimization of modifiable factors and careful patient selection are needed to facilitate further improvement in outcomes and resource utilization. [ABSTRACT FROM AUTHOR]

Background—Perioperative myocardial infarction or cardiac arrest is associated with significant morbidity and mortality. The Revised Cardiac Risk Index is currently the most commonly used cardiac risk stratification tool; however, it has several limitations, one of which is its relatively low discriminative ability: The objective of the present study was to develop and validate a predictive cardiac risk calculator. Methods and Results—Patients who underwent surgery were identified from the American College of Surgeons' 2007 National Surgical Quality Improvement Program database, a multicenter (>250 hospitals) prospective database. Of the 211 410 patients, 1371 (0.65%) developed perioperative myocardial infarction or cardiac arrest. On multivariate logistic regression analysis, 5 predictors of perioperative myocardial infarction or cardiac arrest were identified: type of surgery, dependent functional status, abnormal creatinine, American Society of Anesthesiologists' class, and increasing age. The risk model based on the 2007 data set was subsequently validated on the 2008 data set (n=257 385). The model performance was very similar between the 2007 and 2008 data sets, with C statistics (also known as area under the receiver operating characteristic curve) of 0.884 and 0.874, respectively. Application of the Revised Cardiac Risk Index to the 2008 National Surgical Quality Improvement Program data set yielded a relatively lower C statistic (0.747). The risk model was used to develop an interactive risk calculator. Conclusions—The cardiac risk calculator provides a risk estimate of perioperative myocardial infarction or cardiac arrest and is anticipated to simplify the informed consent process. Its predictive performance surpasses that of the Revised Cardiac Risk Index. [ABSTRACT FROM AUTHOR]

Background: Although a risk score estimating postoperative mortality for patients undergoing gastric bypass exists, there is none predicting postoperative morbidity. Our objective was to develop a validated risk calculator for 30-day postoperative morbidity of bariatric surgery patients. Study Design: We used the American College of Surgeons'' 2007 National Surgical Quality Improvement Program (NSQIP) dataset. Patients undergoing bariatric surgery for morbid obesity were studied. Multiple logistic regression analysis was performed and a risk calculator was created. The 2008 NSQIP dataset was used for its validation. Results: In 11,023 patients, mean age was 44.6 years, 20% were male, 77% were Caucasian, and mean body mass index (BMI; calculated as kg/m2) was 48.9. Thirty-day morbidity and mortality were 4.2% and 0.2%, respectively. Risk factors associated with increased risk of postoperative morbidity included recent MI/angina (odds ratio [OR] = 3.65; 95% CI 1.23 to 10.8), dependent functional status (OR = 3.48; 95% CI 1.78 to −6.80), stroke (OR = 2.89; 95% CI 1.09 to 7.67), bleeding disorder (OR = 2.23; 95% CI 1.47 to 3.38), hypertension (OR = 1.34; 95% CI 1.10 to 1.63), BMI, and type of bariatric surgery. Patients with BMI 35 to <45 and >60 had significantly higher adjusted OR compared with patients with BMI of 45 to 60 (p < 0.05 for all). These factors were used to create the risk calculator and subsequently validate it, with the model performance very similar between the 2007 training dataset and the 2008 validation dataset (c-statistics: 0.69 and 0.66, respectively). Conclusions: NSQIP data can be used to develop and validate a risk calculator that predicts postoperative morbidity after various bariatric procedures. The risk calculator is anticipated to aid in surgical decision making, informed patient consent, and risk reduction. [Copyright &y& Elsevier]

Introduction Computed tomography (CT) scans are very sensitive for detecting splenic injuries after trauma. Our objective was to present a case of the rare entity called 'Delayed Splenic Rupture,' which is the delayed manifestation of splenic injury following a trauma in which the initial CT scan showed a normal spleen. We also review the previous 13 cases and offer our recommendations. Case Report We present a case of a 42-year-old male with a motorcycle crash who presented with a normal spleen on CT scan and five days later was scanned again after a significant decrease in his hemoglobin revealing a large subcapsular splenic hematoma. Conclusion A normal appearing spleen on initial imaging should not sway one from considering delayed splenic rupture as a potential delayed complication of a traumatic event. [ABSTRACT FROM AUTHOR]

Background: Bacterial endotoxins are the principal agents causing sepsis and septic shock. Cytokine cascades produced by cellular interactions to endotoxins can cause cardiovascular failure followed by multi-organ failure and death. Endotoxin intravenously administered to mice can have fatal consequences. Previous studies have shown that the transition metals Mn2+ and Cr3+ can be protective. Methods: The effects of Mn2+, Cr3+, Zn2+, and Cu2+ on lipopolysaccharide (LPS) binding to rat Kupffer cell extracts were analyzed using dot-blots, sodium dodecyl sulfate-polyacrylamide gel electrophoresis, and Western transfer. Kupffer cells were isolated from rat livers by collagenase perfusion, differential centrifugation, and adhesion to plastic. Results: Five millimolar of Mn2+, Zn2+, Cr3+, and Cu2+ completely inhibited LPS binding. Isolated Kupffer cells were also exposed to Mn2+ and to LPS and tumor necrosis factor-alpha release measured. The presence of Mn2+ significantly (P < 0.05) reduced tumor necrosis factor-alpha production by Kupffer cells in response to LPS. Experiments to determine if these effects were mediated by binding to LPS-binding proteins showed this was not the case. More likely a complex occurs between the metal and LPS. We also showed significantly enhanced uptake of LPS into Kupffer cells in the presence of Mn2+. Conclusions: The data are consistent with the metals binding to LPS via its two phosphate groups and neutralizing their charge. These data also support the hypothesis that there is enhanced cellular uptake by non-receptor-mediated methods such as absorptive pinocytocis. At the same time receptor binding and activation of the cells is inhibited. This can explain the effects of transition metals on LPS toxicity. [Copyright &y& Elsevier]

Anatomically separate fat depots differ in size, function, and contribution to pathological states, such as the metabolic syndrome. We isolated preadipocytes from different human fat depots to determine whether the basis for this variation is partly attributable to differences in inherent properties of fat cell progenitors. We found that genome-wide expression profiles of primary preadipocytes cultured in parallel from abdominal subcutaneous, mesenteric, and omental fat depots were distinct. Interestingly, visceral fat was not homogeneous. Preadipocytes from one of the two main visceral depots, mesenteric fat, had an expression profile closer to that of subcutaneous than omental preadipocytes, the other main visceral depot. Expression of genes that regulate early development, including homeotic genes, differed extensively among undifferentiated preadipocytes isolated from different fat depots. These profiles were confirmed by real-time PCR analysis of preadipocytes from additional lean and obese male and female subjects. We made preadipocyte strains from single abdominal subcutaneous and omental preadipocytes by expressing telomerase. Depot-specific developmental gene expression profiles persisted for 40 population doublings in these strains. Thus, human fat cell progenitors from different regions are effectively distinct, consistent with different fat depots being separate mini-organs. [ABSTRACT FROM AUTHOR]

Using a combination of gel-exclusion chromatography and ligand binding with [125I]-lipopolysaccharide (LPS), we discovered two novel endotoxin-binding proteins, p31LPB and p34LPB, in Kupffer cells. Their molecular masses suggest that these are previously undescribed LPS-binding proteins (LBPs). Evidence from detergent-based cell extractions shows that these proteins are probably transmembrane or located on the inner leaflet of the lipid bilayer. We have partially purified the proteins from detergent extracts of Kupffer cells and proven that they bind diphosphoryl lipid A, an interaction associated with TNF-α production. The proteins do not bind monophosphoryl lipid A. Diphosphoryl lipid A binding occurs in the absence of serum, suggesting a mechanism of cytokine production distinct from that involving CD14 and lipopolysaccharide-binding protein (LPB). The two proteins were not detectable in resident peritoneal macrophages or in a number of other cell lines of the macrophage/monocyte lineage, suggesting specificity towards terminally differentiated macrophages such as Kupffer cells. [ABSTRACT FROM AUTHOR]

Fat depots vary in size, function, and potential contribution to disease. Since fat tissue turns over throughout life, preadipocyte characteristics could contribute to this regional variation. To address whether preadipocytes from different depots are distinct, we produced preadipocyte strains from single abdominal subcutaneous, mesenteric, and omental human preadipocytes by stably expressing human telomere reverse transcriptase (hTERT). These strains could be subcultured repeatedly and retained capacity for differentiation, while primary preadipocyte adipogenesis and replication declined with subculturing. Primary omental preadipocytes, in which telomeres were longest, replicated more slowly than mesenteric or abdominal subcutaneous preadipocytes. Even after 40 population doublings, replication, abundance of the rapidly replicating preadipocyte subtype, and resistance to tumor necrosis factor α-induced apoptosis were highest in subcutaneous, intermediate in mesenteric, and lowest in omental hTERT-expressing strains, as in primary preadipocytes. Subcutaneous hTERT-expressing strains accumulated more lipid and expressed more adipocyte fatty acid-binding protein (aP2), peroxisome proliferator-activated receptor γ2, and CCAAT/enhancer-binding protein a than omental cells, as in primary preadipocytes, while hTERT abundance was similar. Thus, despite dividing 40 population doublings, hTERT strains derived from single preadipocytes retained fat depot--specific cell dynamic characteristics, consistent with heritable processes contributing to regional variation in fat tissue function. Diabetes 55:2571-2578, 2006 [ABSTRACT FROM AUTHOR]

Fat depots vary in function and size. The preadipocytes that fat cells develop from exhibit distinct regional characteristics that persist in culture. Human abdominal subcutaneous cultured preadipocytes undergo more extensive lipid accumulation, higher adipogenic transcription factor expression, and less TNF-α-induced apoptosis than omental preadipocytes. We found higher replicative potential in subcutaneous and mesenteric than in omental preadipocytes. In studies of colonies arising from single preadipocytes, two preadipocyte subtypes were found, one capable of more extensive replication, differentiation, and adipoganic transcription factor expression and less apoptosis in response to TNF-α than the other. The former was more abundant in subcutaneous and mesenteric than in omental preadipocyte populations, potentially contributing to regional variation in replication, differentiation, and apoptosis. Both subtypes were found in strains derived from single human preadipocytes stably expressing telomerase, confirming that both subtypes are of preadipocyte lineage. After subcloning of cells of either subtype, both subtypes were found, indicating that switching can occur between subtypes. Thus proportions of preadipocyte subtypes with distinct cell-dynamic properties vary among depots, potentially permitting tissue plasticity through subtype selection during development, Furthermore, mesenteric preadipocyte cell-dynamic characteristics are distinct from omental cells, indicating that visceral fat depots are not functionally uniform. [ABSTRACT FROM AUTHOR]

Discusses the effects of fat depot origin on the key adipogenic transcription factors in human preadipocytes. Problem with the studies of effects of fat depot origin on human preadipocyte differentiation; Description of preadipocyte cloning; Regional differences in adipogenesis.

Total GLUT4 content in skeletal muscle from individuals with type 2 diabetes is normal; however, recent studies have demonstrated that translocation of GLUT4 to the plasma membrane is decreased in response to insulin stimulation. It is not known whether physical exercise stimulates GLUT4 translocation in skeletal muscle of individuals with type 2 diabetes. Five subjects (two men, three women) with type 2 diabetes and five normal control subjects (5 men), as determined by a standard 75-g oral glucose tolerance test, were recruited to determine whether an acute bout of cycle exercise activates the translocation of GLUT4 to the plasma membrane in skeletal muscle. Each subject had two open biopsies of vastus lateralis muscle; one at rest and one 3-6 weeks later from the opposite leg after 45-60 min of cycle exercise at 60-70% of VO2max. Skeletal muscle plasma membranes were prepared by subcellular fractionation, and GLUT4 content was determined by Western blotting. Plasma membrane GLUT4 increased in each subject in response to exercise. The mean increase in plasma membrane GLUT4 for the subjects with type 2 diabetes was 74 +/-20% above resting values, and for the normal subjects the increase was 71+/-18% above resting values. Although plasma membrane GLUT4 content was approximately 32% lower at rest and after exercise in the muscle of the subjects with type 2 diabetes, the differences were not statistically significant. We conclude that in contrast to the previously reported defect in insulin-stimulated GLUT4 translocation in skeletal muscle of individuals with type 2 diabetes, a single bout of exercise results in the translocation of GLUT4 to the plasma membrane in skeletal muscle of individuals with type 2 diabetes. These data provide the first direct evidence that GLUT4 translocation is an important cellular mechanism through which exercise enhances skeletal muscle glucose uptake in individuals with type 2 diabetes. [ABSTRACT FROM AUTHOR]