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Despite substantial efforts to counter sexual assault and harassment in the military, both remain persistent in the Armed Services. In February 2021, President Biden directed the U.S. Department of Defense to establish a 90-day Independent Review Commission on Sexual Assault in the Military (IRC) to assess the department's efforts and make actionable recommendations. As servicemembers discharge from the military, effects of military sexual trauma (MST) are often seen in the Veterans Health Administration (VA). In response to an IRC inquiry about VA MST research, we organized an overview on prevalence, adverse consequences, and evidence-based treatments targeting the sequelae of MST. Women are significantly more likely to experience MST than their male counterparts. Other groups with low societal and institutional power (e.g., lower rank) are also at increased risk. Although not all MST survivors experience long-term adverse consequences, for many, they can be significant, chronic, and enduring and span mental and physical health outcomes, as well as cumulative impairments in functioning. Adverse consequences of MST come with commonalities shared with sexual trauma in other settings (e.g., interpersonal betrayal, victim-blaming) as well as unique aspects of the military context, where experiences of interpersonal betrayal may be compounded by perceptions of institutional betrayal (e.g., fear of reprisal or ostracism, having to work/live alongside a perpetrator). MST's most common mental health impact is posttraumatic stress disorder, which rarely occurs in isolation, and may coincide with major depression, anxiety, eating disorders, substance use disorders, and increased suicidality. Physical health impacts include greater chronic disease burden (e.g., hypertension), and impaired reproductive health and sexual functioning. Advances in treatment include evidence-based psychotherapies and novel approaches relying on mind-body interventions and peer support. Nonetheless, much work is needed to enhance detection, access, care, and support or even the best interventions will not be effective., (© 2022. The Author(s).)

Blue swimming crab ( Portunus pelagicus ) fishery has emerged to become an important export-oriented fishery in Sri Lanka over a decade and recently resulted in a rapid increase in the exploitation. The present study attempts to understand the reproductive biology and feeding ecology of blue swimming crab which will be vital in the management of capture fishery. Five major landing sites in the Jaffna district in Northern Sri Lanka, where blue swimming crab is frequently landed throughout the year were selected for the study. Biological parameters relating to sex, carapace width, body weight, maturity, and egg sac colour with egg sac weight were recorded at the field from November 2014 to October 2015. Randomly selected crab samples were brought to the laboratory and analysed for their maturity stages, length at first maturity, Gonadosomatic Index, fecundity, and gut contents. The study revealed that male crabs mature at a smaller size than females. The sex ratio varied greatly with time and males were always dominant in the catch. The blue swimming crabs in the Northern waters of Sri Lanka spawn throughout the year, with two spawning peaks in February and May. The total fecundity of ovigerous blue swimming crab increased with increased carapace width and body weight and it ranged from 123,482 to 3,179,928 eggs, with an average of 884,982 ± 676,420. A remarkably higher percentage of empty stomachs were observed under the present study in both mature and immature crabs and this could be due to lack of food availability in the environment and different digestibility rates of food items. The diet of blue swimming crab is highly variable reflecting the ability to adopt to different modes of feeding., (© Penerbit Universiti Sains Malaysia, 2022.)

The overdose crisis in the USA remains a growing and urgent public health concern. Over 108,000 people died due to overdose during 2021. Fatal and non-fatal overdoses are under-reported in the USA due to current surveillance methods. Systemic gaps in overdose data limit the opportunity for data-driven prevention efforts and resource allocation. This study aims to improve overdose surveillance and community response through developing a digital platform for overdose reporting and response among harm reduction organizations. We used a community-engaged, user-center design research approach. We conducted qualitative interviews with N = 44 overdose stakeholders including people who use drugs and harm reductionists. Results highlighted the need for a unified, multilingual reporting system uniquely tailored for harm reduction organizations. Anonymity, data transparency, protection from legal repercussions, data accuracy, and community-branded marketing emerged as key themes for the overdose platform. Emergent themes included the need for real-time data in a dashboard designed for community response and tailored to first responders and harm reduction organizations. This formative study provides the groundwork for improving overdose surveillance and data-driven response through the development of an innovative overdose digital platform., (© 2022. The Author(s).)

Introduction: The COVID-19 pandemic highlighted significant structural barriers that exacerbated health inequities among people at-risk for overdose. Digital health technologies have the potential to overcome some of these barriers; however, development of these technologies often fails to include people who use drugs and community key stakeholders in the development and dissemination process. Consequently, this may exacerbate health inequities and the digital divide among underserved, highly vulnerable people who use drugs., Methods: The current study employed community-engaged research methods to develop and implement a digital platform to improve overdose surveillance among harm reductionists in Texas. We used a co-design process with four community advisory boards (CABs) and conducted qualitative interviews among N = 74 key stakeholders ( n = 24 people who use drugs; n = 20 first responders, n = 20 harm reductionists, n = 10 overdose prevention and response experts) to inform initial design and development., Results: Several key themes emerged through the qualitative data pertaining to technical features and human factors applications. In regards to technical features, participants highlighted the importance of developing a unified system of overdose reporting and data sharing among community organizations within a county or region to better inform overdose surveillance and community outreach efforts. This system should include flexible data entry methods, have offline usage capability, be user friendly, and allow for tracking of overdose-related supply distribution. Key human factor themes included the need to use person-centered language, to preserve the established trust of the community organizations among people who use drugs, to be tailored to specific target user groups (e.g., harm reduction workers, people who use drugs, first responders), and maintain transparency of data usage. Further, participants noted the importance of developing a platform that will facilitate client conversations about overdose when doing outreach in the field. These themes were reviewed by our CABs, academic, and industry partners to design an overdose digital platform uniquely tailored to community-based organizations providing harm reduction and overdose response efforts., Discussion: Community engagement throughout the development process is critical toward developing digital health tools for underserved people who use drugs. Dismantling the power structure among academic and industry partners is critical toward creating equity in engagement of community-based partners, particularly among persons with lived experience in addiction, a history of incarceration, or financial challenges. Our study highlights a multisectoral co-design process across community-academic-industry partners to develop a digital health tool tailored to the unique needs of community-based harm reduction organizations serving highly vulnerable people who use drugs. These partnerships are essential toward creating impact and reducing health disparities among highly vulnerable people who use drugs., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Claborn, Creech, Whittfield, Parra-Cardona, Daugherty and Benzer.)

Women Veterans face gender-specific challenges to military life and post-deployment readjustment, including gender-based discrimination and military sexual trauma. Despite recent military initiatives to address these issues, women still experience unique challenges during military service. This study examines spontaneous comments about gender-specific challenges to military life that were made by participants in a qualitative study of women's transitions to civilian life after deployment to Iraq or Afghanistan., Methods: Women Veterans who were enrolled at a New England VA hospital and who had deployed to the U.S. conflicts in Iraq and Afghanistan participated in this qualitative study (N = 22). Interview queries and initial coding structure were developed through an extensive literature review. An iterative coding process generated additional themes identified in the data. For this project, codes regarding self-initiated reports of gender-specific challenges that fell outside the scope of the study's initial interview agenda were reviewed for thematic analysis., Results: The following three self-initiated themes emerged among 12 respondents: 1) gender-based scrutiny and discrimination; 2) the military's inadequate position and response to military sexual trauma; and 3) disadvantages to women service members living in a male-dominated environment. Across all three themes emerged a sub-theme in which women perceived their unique needs to be inconvenient and/or disregarded. Respondents described how these challenges disrupted their lives during and after military service., Conclusion: Results imply gender-specific challenges and military sexual trauma remain critical concerns for women Veterans well after deployment had ended, and that improved policy may have long-term health implications.

Background: Posttraumatic stress disorder (PTSD) is a prevalent mental health issue among veterans. Access to PTSD treatment is influenced by geographic (ie, travel distance to facilities), temporal (ie, time delay between services), financial (ie, eligibility and cost of services), and cultural (ie, social stigma) barriers., Objective: The emergence of mobile health (mHealth) apps has the potential to bridge many of these access gaps by providing remote resources and monitoring that can offer discrete assistance to trauma survivors with PTSD and enhance patient-clinician relationships. In this study, we investigate the current mHealth capabilities relevant to PTSD., Methods: This study consists of two parts: (1) a review of publicly available PTSD apps designed to determine the availability of PTSD apps, which includes more detailed information about three dominant apps and (2) a scoping literature review performed using a systematic method to determine app usage and efforts toward validation of such mHealth apps. App usage relates to how the end users (eg, clinicians and patients) are interacting with the app, whereas validation is testing performed to ensure the app's purpose and specifications are met., Results: The results suggest that though numerous apps have been developed to aid in the diagnosis and treatment of PTSD symptoms, few apps were designed to be integrated with clinical PTSD treatment, and minimal efforts have been made toward enhancing the usability and validation of PTSD apps., Conclusions: These findings expose the need for studies relating to the human factors evaluation of such tools, with the ultimate goal of increasing access to treatment and widening the app adoption rate for patients with PTSD., (©Carolina Rodriguez-Paras, Kathryn Tippey, Elaine Brown, Farzan Sasangohar, Suzannah Creech, Hye-Chung Kum, Mark Lawley, Justin K Benzer. Originally published in JMIR Mhealth and Uhealth (http://mhealth.jmir.org), 26.10.2017.)

Research on psychological violence has suggested it is common among perinatal women and is predictive of later physical violence. Psychological violence is also a strong correlate of negative mental and physical health outcomes and may influence engagement in health services. Both physical and mental health care are of critical importance for perinatal women who may be especially vulnerable to psychological violence and its deleterious effects. This study examined the clinical records of 299 perinatal patients who received treatment in a psychiatric partial hospital program to determine whether there were differences in utilization of care between those women with and without current interpersonal psychological abuse. More women than expected who reported current psychological abuse left treatment early compared to those without such reports.

Objective: To establish beginning evidence of clinical validity and reliability of the Neonatal Pain, Agitation and Sedation Scale (N-PASS) in neonates with prolonged pain postoperatively and during mechanical ventilation., Study Design: Prospective psychometric evaluation. Two nurses administered the N-PASS simultaneously and independently before and after pharmacologic interventions for pain or sedation. One nurse also administered the premature infant pain profile (PIPP) concurrently with the N-PASS. The setting consisted of 50-bed level III neonatal intensive care unit. Convenience sample of 72 observations of 46 ventilated and/or postoperative infants, 0 to 100 days of age, gestational age 23 to 40 weeks was used. Outcome measures comprised convergent and construct validity, interrater reliability and internal consistency., Result: Interrater reliability measured by intraclass coefficients of 0.85 to 0.95 was high (P<0.001 to 0.0001). Convergent validity was demonstrated by correlation with the PIPP scores (Spearman's rank correlation coefficient of 0.83 at high pain scores, 0.61 at low pain scores). Internal consistency, measured by Cronbach's alpha, was evident with pain scores (0.82), and with sedation scores (0.87). Construct validity was established via the Wilcoxon signed-rank test, comparing the distribution of N-PASS scores before and after pharmacologic intervention showing pain scores of 4.86 (3.38) and 1.81 (1.53) (mean (s.d.), P<0.0001) and sedation scores of 0.85 (1.66) and -2.78 (2.81) (P<0.0001) for pre- and postintervention assessments, respectively., Conclusions: This research provides beginning evidence that the N-PASS is a valid and reliable tool for assessing pain/agitation and sedation in ventilated and/or postoperative infants 0 to 100 days of age, and 23 weeks gestation and above.

We assessed the feasibility and impact of simultaneous-integrated boost intensity-modulated radiation therapy (SIB-IMRT) in the treatment of left breast carcinoma and compared target coverage and normal tissue doses with SIB-IMRT and 3-dimensional (3D) conformal RT using opposed tangential fields. For each of 10 patients with early-stage left-sided invasive breast carcinoma, 5 plans were generated; the first 4 were 3D conformal opposed tangential fields-2 with wedges, 2 with compensators and either photon or electron boost. A dose of 50.4 Gy in 28 fractions was prescribed to the left breast and an additional 16 Gy in 8 fractions to the lumpectomy bed. When compared to the tangential plans, SIB-IMRT maintained coverage (V(95%)) to the left breast and lumpectomy bed without significantly increasing the left breast maximum dose. SIB-IMRT was able to reduce the lung mean dose, maximum dose, and the V(20) by 55-104 cGy, 983-1298 cGy (p < 0.001), and 3.7-4.4%, respectively. In addition, SIB-IMRT reduced the maximum heart dose by 1032-1173 cGy and contralateral breast dose was increased (although p = NS). The mean and maximum dose to the unspecified tissues was also significantly reduced by 81-88 cGy and 516-942 cGy, respectively. SIB-IMRT resulted in a significant improvement in target dose conformality by up to 67%. Our findings that SIB-IMRT could improve dose conformality, reduce total treatment times, and reduce some of the normal structure doses presents it as an alternative technique for adjuvant breast radiotherapy; however this needs to be studied further in the clinic setting.

Physicians may withhold beta blockers from elderly heart failure patients based on perceptions of poor tolerability in this group. This study analyzed the success and tolerability of carvedilol titration in elderly (70 years and older) and younger (younger than 70) heart failure patients (n=360). The mean duration of titration was similar in both groups. The target carvedilol dosage (50 mg/d) was achieved by 55.3% and 62.0%, and a partial dose was achieved by 44.7% and 35.5% (p=0.028) of elderly and younger patients, respectively. The mean achieved dosage was lower in elderly patients than in younger patients (42.4+/-27.2 mg/d vs. 55.1+/-30.1 mg/d; p<0.0001), possibly due to significant between-group differences in baseline characteristics or rates of target dose achieved. When adjusted for body weight, the mean achieved dose was similar in elderly (0.58+/-0.32 mg/kg/d) and younger (0.64+/-0.30 mg/kg/d) patients (p=nonsignificant). Adverse events were more frequent in the elderly but did not appear to significantly impact titration duration or carvedilol dose achieved when corrected for body weight. In conclusion, carvedilol should not be withheld from elderly heart failure patients based on perceptions of poor potential tolerability.

Nurses at the Well-Being Institute, a community-based nursing outreach clinic in Detroit, Michigan, located 75 women living with HIV, mental illness, and substance abuse who were lost to follow-up at their HIV medical clinic as part of a nursing research study. Women who had been scheduled for an appointment in the last 4 months but who had missed that appointment were considered "lost to follow-up" in the HIV clinic. The purpose of the research was to study factors related to health care access in women not participating in regular health care for their HIV infection. Women were randomly assigned to two study groups. Women assigned to "care as usual" study group (n = 37) received no additional services beyond study interviews for 1 year. Women assigned to the "nursing intervention" group (n = 38) were provided with nursing services designed to facilitate their return to and continued connection with their HIV clinic. Findings showed that factors related to the women's vulnerability, such as mental illness and drug use, were more related to their use of expensive health care services such as hospital emergency departments or hospital inpatient admissions than was assignment to either the "nursing intervention" or "care as usual" study groups. Two case studies describing the cost of care for 2 of the multiply diagnosed women in the study is presented. The women differed on whether they had stable housing and were accessing care for their mental illness.

Objectives: Assess the role of involved field radiation therapy (IFRT) in recurrent ovarian cancer., Methods: Thirty-five patients with a diagnosis of epithelial ovarian cancer received radiation therapy at LUMC between 1991 and 2001. Of these, 20 received tumor volume-directed IFRT for localized extraperitoneal recurrences (either as consolidation following debulking surgery or as attempted salvage if unresectable) and form the basis of this report. All patients were heavily pretreated with multiple chemotherapy regimens. Eleven patients had optimal debulking of their recurrences prior to radiation. IFRT was primarily with external beam (median dose 50.4 Gy). Appropriate statistical analyses evaluated association among disease-free (DFS), overall survival (OS), local recurrence-free (LRFS), and various prognostic factors. LRFS was defined as freedom from in-field recurrences and was considered as a measure of effectiveness of radiotherapy., Results: Of 20 patients, 17 had a complete response after RT. The actuarial LRFS, OS, and DFS at 5 years from date of radiation were 66%, 34%, and 34%, respectively. The LRFS at 3 years was 89% for those with optimal resection vs. 42% for those with gross residual/unresectable tumor, which was significantly better (P = 0.04). The corresponding 3-year DFS was 72% vs. 22% and 5-year OS was 50% vs. 19%, respectively. Acute complication of RT was mild, half had Grade 1-2 gastrointestinal (GI) toxicity, three patients had Grade 3-4 late GI effects., Conclusion: IFRT is effective in controlling localized recurrences of ovarian cancer, especially after they are optimally debulked (89% local control and 50% 5-year overall survival in this subgroup), and is relatively well tolerated in these heavily pretreated patients.

Background: The purpose of the study was to evaluate how well the burn, trauma, and peripheral vascular third-year medical school electives meet the objectives of the six ACGME core competencies., Methods: Medical school graduates from 1999 to 2002 completed a survey that consisted of 13 demographic/miscellaneous questions, and 28 core competency questions., Results: In all, 168 of 500 students responded for a 34% response rate. All three general surgical electives ranked above average in meeting objectives in the areas of: basic science, performing complete histories and physicals, writing logical and legible notes, creating complete assessments and plan, making decisions with evidence based medicine, performing basic procedures, interpreting test results, and maintaining professional attitudes. The burn elective ranked significantly higher in 16 of 28 objectives (P < 0.05) and the trauma elective ranked significantly higher in two of 28 objectives (P < 0.05)., Conclusions: Despite a narrower professional focus, three general surgical subspecialty electives meet objectives in five of the six competencies set forth by the ACGME (and adopted by our medical school as objectives for the ideal graduate). The highly organized and structured burn elective can be used as a template for improving all surgical rotations to meet the six core competencies for third-year students., (Copyright 2004 Excerpta Medica, Inc.)

Inadequate stem cell mobilization is seen in approximately 25% of patients undergoing autotransplantation for hematologic malignancies. Remobilization strategies include chemotherapy/cytokine combinations or high-dose cytokines alone or in combination. From 1/1997 to 7/2002, we remobilized 86 patients who failed an initial mobilization (median total CD34=0.72 x 10(6)/kg) in sequential cohorts using high-dose G-CSF (32 microg/kg/day) or G-CSF(10 microg/kg/day)+GM-CSF (5 microg/kg/day). No difference in CD34/kg yields were seen (G-CSF alone: 2.2 x 10(6) and G-CSF+GM-CSF 1.6 x 10(6)) in the median 3 aphereses performed (P=0.333). Of the 86, 23 (27%) failed the second mobilization; 14 were remobilized again (yield=1.5 x 10(6) CD34/kg; three aphereses). Of the 86, 93% went to transplant: three progressed, and three had inadequate stem cells. Significant risk factors for a failed remobilization were: number of stem-cell-damaging regimens (P=0.015), time between last chemotherapy and first mobilization (P=0.028), and higher WBC at initiation of first mobilization (P=0.04). High-dose G-CSF (32 microg/kg/day) was more costly @ USD $9,016, vs $5,907 for the G-CSF+GM-CSF combination (P<0.001). Most patients failing an initial mobilization benefit from a cytokine only remobilization. Lower cost G-CSF+GM-CSF is as effective as high-dose G-CSF.

Objectives: To determine whether perioperative administration of ropivacaine hydrochloride with epinephrine decreases postoperative pain following adenotonsillectomy and to determine the pharmacokinetics of ropivacaine following injection., Design: Prospective, randomized, double-blind clinical trial., Setting: University pediatric ambulatory center., Participants: A total of 130 children, aged 2 to 12 years, undergoing adenotonsillectomy., Intervention: Patients received injections, in the tonsillar fossae, of isotonic sodium chloride solution or 0.5% ropivacaine hydrochloride with epinephrine immediately following tonsillectomy., Main Outcome Measures: Modified objective pain score, time to 100 mL of oral intake, serial plasma ropivacaine levels, use of analgesics, incidence of retching and emesis, and other symptoms., Results: Fifty-three patients (80%) in the ropivacaine group had detectable plasma levels in at least 3 of the 4 measurement time periods. The mean +/- SD peak concentration (C(max)) was 0.71 +/- 0.33 micro g/mL and the half-life was 0.96 hours. The average modified objective pain scores over all time points favored the placebo group (P =.06 test of between-subjects effects). Similarly, the average behavior score over time favored the placebo group (P =.046 test of between-subjects effects). Neck pain was better in the placebo group when averaged over postoperative days 1, 3, 7, and 14 (P =.04). The percentage of patients who had retching in the recovery room was greater in the ropivacaine group (41% vs 19%, P =.006)., Conclusions: The injection of 0.5% ropivacaine with epinephrine immediately following adenotonsillectomy results in a measurable plasma level. Ropivacaine with epinephrine injection does not reduce pain postoperatively and adversely affects behavior scores, neck pain scores, and retching frequency compared with placebo. Ropivacaine with epinephrine injection for postoperative analgesia is not recommended for this patient population.

Intraoperative cholangiography (IOC) remains a subject of much debate among laparoscopic surgeons. When IOC is indicated, the surgeon's preference for routine cholangiography (RC) or selective cholangiography (SC) may have an impact on the outcome of IOC and cholecystectomy. Hereafter, we present our experience with cholangiography in patients with clear indications for IOC when operated on by surgeons favoring SC versus RC. Between January 1, 1999, and December 1, 2000, 389 patients underwent laparoscopic cholecystectomy at Loyola University Medical Center. One hundred fifty-one patients had indication for IOC (jaundice, pancreatitis, increased liver function tests (LFTs), abnormal anatomy, ductal dilatation, or ductal stones identified on preoperative ultrasound), and they constitute the sample for this study. The results of IOC and subsequent outcome of cholecystectomy were reviewed using the electronic medical database. Thirty-nine patients were operated on by 2 surgeons favoring RC and 112 by 12 favoring SC. Patient demographics were similar in both groups. Only 30 (27%) of the SC group had attempted IOC with 28 successful IOCs (25% of all patients). In contrast, 38 (97%) of the RC group had successful IOC, which was significantly higher than the SC group (P < 0.0001 by chi2 test). Adverse events included conversions to open, postoperative endoscopic retrograde cholangiopancreatography, bile leak, repeat operative intervention, pancreatitis, elevated LFTs, intra-abdominal and wound infection, prolonged emesis, and persistent abdominal pain. Two (5%) adverse events occurred in the RC group, which was significantly less than the 33 (30%) adverse events in the SC group (P = 0.002 by chi2 test). Conversions to open were significantly less in the RC group, with no conversions in the RC group and 20 (18%) in the SC group (P = 0.005). There were no mortalities in this series. In a univariate analysis, age and gender did not correlate with increased risk of complications. In conclusion, surgeons who perform SC are less likely to attempt IOC even when IOC is indicated. More conversions to open and more adverse events occurred following cholecystectomy by those favoring SC. Our study further supports routine cholangiography during laparoscopic cholecystectomy.

Both single and tandem cycles of high dose therapy and autologous peripheral blood stem cell transplantation (ASCT) have been shown to improve survival in multiple myeloma (MM) patients. We report outcomes in 104 MM patients undergoing a single transplant after conditioning with a conventional myeloablative regimen, busulphan and cyclophosphamide. The patients were either in a first (71%), or subsequent remission (29%). Peripheral blood stem cells were mobilized using cyclophosphamide and granulocyte colony stimulating factor. The conditioning regimen consisted of busulphan 0.85 mg/kg given orally every 6 h (16 doses) and cyclophosphamide 60 mg/kg/d given intravenously for 2 d. The entire conditioning, transplant and post-transplant course were in the outpatient setting for 45% patients. At a median follow-up of 26 months (range 2-98 months), the median overall and progression-free survival were 57 months [95% confidence interval (CI) 47-68] and 26 months (95% CI 20-32) respectively. Younger age and higher CD34+ cell dose infused were independently predictive of improved overall and progression-free survival. Busulphan and cyclophosphamide is an effective and well-tolerated preparative regimen for ASCT that can be given to MM patients in the outpatient setting.

The role of octreotide in preventing pancreatic fistula following pancreaticoduodenectomy (PD) remains controversial. The purpose of our study was to report our experience with octreotide in 266 patients undergoing PD from 1995 to 2002. There were 150 males and 116 females. Patients were divided into two groups. Group 1 did not receive octreotide (N = 61). Group 2 received octreotide (N = 205). The average patient age was 66.2 years in the control group and 63.6 years in the octreotide group. One hundred fifty patients were male and 116 were female. Thirty-day mortality for both groups was 1.9 per cent. The incidence of pancreatic fistula was 12 per cent. Fistula occurrence in the octreotide group was 13 per cent and in the no-octreotide group 8 per cent (P = 0.34). Common complications in the no-octreotide group were pancreatic leak (10%), pancreatic fistula (8%), and delayed gastric emptying (8%). Common complications in the octreotide group were pancreatic leak (18%), pancreatic fistula (13%), intra-abdominal abscess (7%), and arrhythmia or myocardial infarction (7%). The only statistically different variable was the incidence of arrhythmia or myocardial infarction (P = 0.026). Octreotide did not reduce pancreatic fistula, other complications, or mortality. Octreotide may contribute cardiac morbidity. Octreotide cannot be recommended to prevent mortality or postoperative complications after PD.

There is limited U.S. data on short- and long-term complications of laparoscopic adjustable gastric banding (LAGB) as a treatment option for morbid obesity. Hereafter, we present our experience with the first 154 consecutive LAGBs performed at Loyola University Medical Center. Inpatient and outpatient charts were reviewed retrospectively for all patients undergoing LAGB between November 2001 and February 2003 for perioperative morbidity and mortality and repeat operations. Thirty-seven men (24%) and 117 women (76%) underwent LAGB in a 16-month period. There was one (0.6%) death from postoperative myocardial infarction (MI) and one (0.6%) pulmonary embolism. Six (3.9%) patients required readmission to the hospital for dehydration. During a mean follow-up of 33 weeks (range, 4-69 weeks), 14 (9%) patients required repeat operations. There were five (3.2%) band slippages and one (0.6%) gastric erosion. Three bands were removed laparoscopically. Three slippages were revised laparoscopically. One patient underwent laparoscopic cholecystectomy. Seven patients (4.5%) required port revisions for catheter disconnection (4), leak at port site (2), or flipped port (1). LAGB is a safe operative approach for the management of morbid obesity. The incidence of postoperative complications can be minimal with application of a standardized technique. LAGB should be strongly considered for morbidly obese patients who have failed nonoperative management.

Barriers to adequate pain management in hospice and palliative care settings are an important area of investigation. In this study, a Caregiver Pain Medicine Questionnaire (CPMQ) was developed and psychometrically tested. The CPMQ is a 22-item self-report instrument that measures concern about reporting pain, concern about administering analgesics, and difficulty administering analgesics. One hundred fifty-one caregivers of patients admitted to three Chicagoland hospice agencies participated; these individuals were family members, hired caregivers in the home, or staff nurses in skilled care facilities. While only a small percentage of the caregivers expressed concern about communicating information about the patient's pain, more than a quarter were concerned about addiction, tolerance, and side effects from medications. A fourth of the caregivers had difficulty administering medications because of fear of doing something wrong and difficulty deciding which or what amount of medications to give. Male caregivers and hired caregivers had greater concerns, both about reporting information about the patient's pain and administering medications. Greater concerns were also evident among less educated caregivers, caregivers who worked in blue-collar jobs, and caregivers who were homemakers or retired. Concerns of caregivers in the home were significantly greater than staff nurse caregivers in skilled care facilities only in the belief that pain could not be controlled and concern about addiction. Caregivers who had greater concern about addiction and tolerance, and more difficulty administering medications, rated the patient's pain as less completely controlled. These findings remind hospice staff members of the importance of assessing specific caregiver concerns about medication administration and devising appropriate strategies to address them.

Background: Preoperative biliary drainage (PBD) in jaundiced patients undergoing pancreaticoduodenectomy remains controversial., Methods: Patients presenting with obstructive jaundice who subsequently underwent pancreaticoduodenectomy from January 1996 to June 2002 were included in the study (n = 212). Patients with preoperative biliary stents (n = 154) were compared with patients without preoperative drainage (n = 58)., Results: Patients in the stented group required a longer operative time (mean 6.8 hours versus 6.5 hours) and had greater intraoperative blood loss (mean 1207 mL versus 1122 mL) compared with the unstented group, (P = 0.046 and 0.018). No differences were found with respect to operative mortality (2%), incidence of pancreatic fistula (10% versus 14%), or intraabdominal abscess (7% versus 5%). Wound infection occurred more often in the stented group (8% versus 0%, P = 0.039)., Conclusions: PBD was associated with increased operative time, intraoperative blood loss, and incidence of wound infection. Although PBD did not increase major postoperative morbidity and mortality, it should be used selectively in patients undergoing pancreaticoduodenectomy.

Objective: The aim of this study was to determine the rate of sustained response (SR) to high-dose daily interferon (IFN) therapy in prior drug abusers with chronic hepatitis C. This was a retrospective matched cohort study conducted at a tertiary care university hospital in a large urban area., Methods: The 120 individuals in each cohort were treated by the same physicians at the same facility, using the same treatment protocol and management procedures. Each patient received 5 million units of IFN daily for at least 1 yr and usually longer., Results: Both groups achieved a similar rate of SR (no i.v. drug abuse, 37% vs i.v. drug abuse, 33%). The end of treatment (ET) response rate was unexpectedly higher in the drug-abusing population as compared to that non-drug-abusing control subjects but fell during the follow-up period to achieve an SR similar to that of the non-drug-abusing controls. The side effects of IFN therapy were no greater in the prior drug abusing population than in the controls, although many in the drug-abusing group increased their dose of methadone to counteract IFN side effects., Conclusions: The SR rate achieved by intravenous drug abusers to high-dose, daily IFN is similar to that in a non-drug-abusing HCV positive population. Recent use of illicit drugs within a 6-month period of starting IFN therapy or continued methadone use during treatment does not seem to impair the response to IFN when the results are compared with those of a matched cohort of non-drug-abusing controls.

Purpose: This prospective, randomized, controlled phase III trial assessed high-dose bolus interleukin-2 (IL-2) postoperatively in patients with high-risk renal cell carcinoma (RCC)., Patients and Methods: Eligibility requirements were resected locally advanced (LA; T3b-4 or N1-3) or metastatic (M1) RCC, no prior systemic therapy, and excellent organ function. Randomized assignment was to one course of IL-2 (600,000 U/kg every 8 hours on days 1 to 5 and days 15 to 19 [maximum 28 doses]) or observation. The study was designed and powered to show an improvement in predicted 2-year disease-free survival (DFS) from 40% for the observation group to 70% for the treatment group. The accrual goal was 68 patients with LA disease, with 34 patients per treatment arm. Metastasectomy patients were to be analyzed separately because of their unpredictable natural history., Results: Sixty-nine patients were enrolled onto the study (44 LA and 25 M1 patients). Toxic effects of IL-2 were as anticipated; no unexpected serious adverse events or treatment-related deaths occurred. Early closure occurred when an interim analysis determined that the 30% improvement in 2-year DFS could not be achieved despite full accrual. Sixteen of 21 LA patients receiving IL-2 experienced relapse, compared with 15 of 23 patients in the observation arm (P =.73); in the LA group, three deaths occurred in the IL-2 arm, and five deaths occurred in the observation arm (P =.38). Analysis including metastasectomy patients made no difference in DFS or overall survival., Conclusion: One course of high-dose bolus IL-2, though feasible, did not produce the ambitious clinically meaningful benefit anticipated when administered postoperatively to patients with resected high-risk RCC.

Background: Since 1968, there have been three published reports in the United States literature of 41, 118, and 145 consecutive patients undergoing pancreaticoduodenectomy without mortality. In all of these series, the pancreatic remnant was anastomosed to the jejunum., Study Design: This study was designed to review 152 consecutive patients who underwent pancreaticoduodenectomy in whom the pancreatic remnant was anastomosed to the stomach (pancreaticogastrostomy)., Results: A total of 152 patients underwent pancreaticoduodenectomy with pancreaticogastrostomy between July 1992 and May 2002. There were 85 men and 67 women with a mean age of 65.7 years (range 31 to 90 years). Of the patients, 87 were less than 69 years of age and 65 were more than 69 years. A total of 114 patients had a malignant neoplasm and the remaining 38 had either cystic neoplasms or benign disease. When the two groups were compared, the patients who were more than 69 years of age had a significantly high incidence of hypertension, previous cancer, atrial fibrillation, and coronary artery disease. In addition, patients more than 69 years of age had a significantly high incidence of jaundice and placement of preoperative stents. Patients more than 69 years of age had significantly less operative time but there was no between-group difference in estimated blood loss, transfusion, number of units transfused, and postoperative length of stay. There was no postoperative mortality [corrected] in this series. Pancreatic leak and fistulae were the most common complications, followed by intraabdominal abscess, wound infection, and delayed gastric emptying., Conclusions: In this study, 152 consecutive patients underwent pancreaticoduodenectomy with pancreaticogastrostomy without postoperative mortality. Morbidity was mostly because of pancreatic leaks and fistulae, which were successfully treated nonoperatively. With proper selection, careful preoperative preparation, and proper intraoperative conduct of operation, the Whipple procedure can be performed without postoperative mortality.

This retrospective study compares the results of pancreaticogastrostomy (PG) and pancreaticojejunostomy (PJ) in our institution, which has extensive experience in both techniques. Between the years of June 1995 and June 2001, 214 patients underwent pancreaticoduodenectomy (PD) at our institution. Of these 177 had PG and 97 had pancreatojejunostomy (PJ). There were 117 (54.6%) males and 97 (45.3%) females with a mean age of 64.2 +/- 12.4 years. Indications for surgery were pancreatic adenocarcinoma in 101 (47.2%), ampullary adenocarcinoma in 36 (16.9%), distal bile duct adenocarcinoma in 22 (10.2%), duodenal adenocarcinoma in 9 (4.2%), and miscellaneous causes in 46 (21.4%) of patients. Preoperatively, significant differences in the groups were that the patients undergoing PJ were significantly younger than those undergoing PG. Also noted preoperatively, was that the patients undergoing PG had a significantly lower direct bilirubin than those undergoing PJ. With regard to intraoperative parameters, operative time was significantly shorter in the PJ group when compared to the PG group. When the patients who did not develop fistula (N = 186) were compared to those who developed fistula (N = 28) the significant differences were that the patients who developed fistula were more likely to have hypertension preoperatively and a higher alkaline phosphatase. They also showed a significantly higher drain amylase and were likely to have surgery for ampullary, distal bile duct or duodenal carcinoma rather than pancreatic adenocarcinoma. In addition, those patients who developed fistula had a significantly longer postoperative stay, a larger number of intraabdominal abscesses and leaks at the biliary anastomosis. Thirty-day mortality was significantly higher in the PJ group compared to the PG (4 vs. 0, P = 0.041). There was a significantly larger number of bile leaks in the PJ group when compared to the PG (6 vs. 1, P = 0.048). In addition, the PJ group required a significantly larger number of new CT guided drains to control infection (8 vs. 2, P = 0.046) and the PJ group required a larger number of re-explorations to control infection or bleeding (5 vs. 0, P = 0.018). However, the pancreatic fistula rate was not different between the two groups (12% [PG] vs. 14% [PJ]). This retrospective analysis shows that safety of PG can be performed safely and is associated with less complications than PJ and proposes PG as a suitable and safe alternative to PJ for the management of the pancreatic remnant following PD.

Objective: The purpose of this study was to assess the accuracy of maternal recall of key events during their most recent delivery., Study Design: After institutional review board approval, women who were delivered at Loyola University Medical Center were recruited. Patients were asked a maximum of 13 questions about major labor management events that were applicable to the course of their delivery. Patient responses were compared with the delivery records., Results: We interviewed 277 ethnically diverse women with a median interval since delivery of 10 weeks and a mean age at delivery of 26 years. Forty percent of the women answered all questions correctly. Mothers with better recollection were more likely to be white, older, to have had more recent deliveries and were more likely to have had cesarean delivery., Conclusion: Sixty percent of mothers cannot recall accurately at least one major labor management event. Studies that rely on patient recall of obstetric variables are likely to have high error rates.

Unlabelled: We enrolled 120 children undergoing bilateral myringotomy and tube placement in this prospective, randomized, observer-blinded study. Patients were randomized into one of four groups: Group 1 (control) was plain acetaminophen 10 mg/kg orally, Group 2 was acetaminophen 10 mg/kg with 1 mg/kg of codeine orally, Group 3 was transnasal butorphanol 25 micro g/kg given immediately after the induction of anesthesia, and Group 4 was ketorolac 1 mg/kg given IM immediately after the induction of anesthesia. All children received oral midazolam (0.6 mg/kg) before surgery. A nurse blinded to the analgesic technique used assessed the child's behavior at the induction of anesthesia and in the postanesthesia care unit using a 4-point scale. Analgesic effectiveness was determined by assessing the child's pain at 5-min intervals using a modified 10-point objective pain scale. In the postanesthesia care unit, rescue pain medication was administered for an objective pain scale >or=4 or a behavior score >or=3. Our data suggest that IM ketorolac is a promising analgesic to be used in this surgical population. Time to first rescue analgesic was longest in the ketorolac group, and there was no associated postoperative vomiting or nausea. IM ketorolac given during surgery was the best analgesic regimen for these procedures., Implications: We compared four different analgesics in the management of pain after placement of pressure equalization tubes during myringotomy in children and demonstrated that ketorolac or butorphanol provided superior analgesia when compared with acetaminophen with codeine or plain acetaminophen. Children who received ketorolac versus butorphanol had less vomiting in the 24 h after surgery.

Background: Since ganciclovir-resistant cytomegalovirus (CMV) disease was initially described in a patient with acquired immunodeficiency syndrome (AIDS) in 1986, the incidence of ganciclovir-resistant CMV disease appears to be increasing in immunocompromised patients. More recently, there have been sporadic reports of ganciclovir-resistant CMV disease in solid organ transplantation., Methods: We retrospectively assessed the incidence of ganciclovir-resistant CMV disease in all lung transplant recipients transplanted between 6/93 and 6/01 at Loyola University Medical Center. All patients underwent routine CMV blood culture, shell vial assay as well as phenotypic and genotypic anti-viral susceptibility testing according to a pre-determined schedule. The number of CMV episodes, intravenous ganciclovir use, acute and chronic rejection and survival data were documented for all patients., Results: Twelve of 212 (6%) transplant recipients developed ganciclovir-resistant CMV disease. Ganciclovir resistance was associated with a higher number of CMV episodes (3.4 +/- 2.3 episodes/patient vs 1.7 +/- 0.7 episodes/patient [p < 0.05]) and an increased exposure to cumulative intravenous ganciclovir in the primary CMV-mismatched (D(+)R(-)) population (22 +/- 10 vs 13 +/- 7 days [p < 0.05]) compared with patients who did not develop ganciclovir resistance. In addition, the use of daclizumab therapy was associated with a 7-fold greater likelihood of developing ganciclovir resistance (p < 0.0001). The presence of ganciclovir-resistant CMV disease in our population was associated with a decreased survival that could be attributed to CMV disease itself (p < 0.05)., Conclusions: By screening all lung transplant recipients with CMV disease for ganciclovir resistance, we were able to detect a higher incidence of ganciclovir-resistant CMV disease (6%) than previously seen in solid organ transplantation. High-risk patients (D(+)R(-) CMV serostatus) who receive anti-lymphocytic therapy should be monitored aggressively and treated to prevent the development of ganciclovir resistance and avert a negative outcome.

The appropriate closure of the pancreatic remnant after distal pancreatectomy is still debated. Suture techniques, stapled closure, and pancreaticoenteric anastomosis all have their supporters. In this study we have reviewed our data from distal pancreatectomy to determine whether the type of remnant closure or underlying pathologic process had any relation to postoperative fistula formation. We performed a retrospective chart review of patients undergoing distal pancreatectomy at our institution between 1993 and 2001. The charts were reviewed for morbidity and mortality. These were then related to the type of closure of the pancreatic stump. From 1993 to 2001 a total of 86 patients underwent distal pancreatectomy. Data were available on 85 patients. Indications for surgery were pancreatic tumor (69%), pancreatitis (14%), trauma (7%), and extra pancreatic disease (9%). Pancreatic fistula occurred in 14 per cent (N = 12), intra-abdominal abscess in 8 per cent (N = 7), and wound infection in 2 per cent (N = 2). There was no mortality in the series. The incidence of pancreatic fistula formation was not related to method of closure of the pancreatic remnant nor to the underlying pathologic process. Postoperative pancreatic fistulas will close spontaneously even without total parenteral nutrition.

P15INK4B methylation and expression was studied in bone marrow cells obtained from normal individuals, from patients who had been cured of lymphoma, and from patients with either MDS or AML. The level of p15 methylation was very low in normal BM cells and in CD34+ and CD34- subpopulations (0-6.5%; med, = 2.5%). P15INK4B transcripts were present in each of these cell populations. In contrast, methylation was the usual situation in MDS and AML marrows. The presence of methylation of the p15INK4B gene did not always indicate an absence of expression nor was expression always present if methylation was absent. P15INK4B methylation was studied in the marrows of nine patients (one studied twice) who had been cured of lymphoma and in whom hemopoiesis was believed to be normal. Increased methylaton was present in all 10 marrows. These data indicate that p15INK4B methylation is likely to be a very early event in the development of the secondary hematologic disorders.

This is the third paper in a series which describes a new remission induction regimen for patients with 'poor prognosis' acute myelogenous leukemia (AML). Twenty-four patients were treated with two one day pulses of chemotherapy separated by 96 h. Each pulse consisted of two doses of cytarabine and a single dose of mitoxantrone. Amifostine was administered three times a week after the second pulse of chemotherapy until treatment outcome became known. The first paper described the outcome of treatment while the second described the relationship of treatment outcome to the pretherapy characteristics of the leukemia. This paper describes the changes in the leukemia cells which occur during remission induction therapy. While only a limited number of specimens were available for each post treatment study, the studies demonstrated a profound fall in blood counts, BM cellularity, and telomerase activity in leukemia cells after pulse #1 of treatment. This fall was usually accompanied by a coordinate rise in IL6, TNFalpha, and IL1beta transcripts within the AML cells which survived chemotherapy. High levels of telomerase activity in the day 5 marrow was correlated with high levels of IL1beta transcripts which in turn were associated with treatment failure ascribable to resistant disease.

The interferon response genes 1 and 2 have been shown to be involved in the regulation of differentiation and proliferation of cells of the myeloid series, with the former functioning as an anti-oncogene and the latter as an oncogene. In the study described here, the levels of expression of these two genes and the ratio of their expression were compared in AML and normal marrow. The ratio of gene expression was significantly less in AML marrow cells as compared to normal marrow cells [med ratio = 1.33 vs. 2.97, P = 0.003]. While the expression ratio was unaffected by the presence or absence of either ras or fms mutations, p53 mutations were associated with higher IRF1:IRF2 expression ratios that wt p53 genes [med = 1.701 vs. 1.135, P = 0.014]. Given the functional characteristics and the competitive nature of these two genes, it is possible that leukemic transformation is associated with a fall in IRF1:IRF2 ratios. Finally, the administration of IL4 can result in the normalization of the IRF1:IRF2 ratio in the marrow cells of some patients with AML., (Copyright 2001 Wiley-Liss, Inc.)

Objective: The authors' objectives were to determine 1) whether major depressive disorder diagnosed according to DSM-IV criteria modified for the medically ill predicted in-hospital mortality better than major depressive disorder diagnosed according to inclusive DSM-IV criteria and 2) whether a history of depression and current depression predicted mortality independent of severity of physical illness., Method: Of 392 consecutive medical inpatients, 241 were interviewed within the first 3 days of admission and 151 were excluded from the study. Chart review and a clinical interview that included the Schedule for Affective Disorders and Schizophrenia were used to determine demographic variables, past psychiatric history, psychiatric diagnoses, and illness measures. Diagnoses included major depressive disorder and minor depression diagnosed according to DSM-IV criteria that included all symptoms regardless of etiology and according to criteria modified for the medically ill (hopelessness, depression, or anhedonia were used as the qualifying affective symptoms; depressive symptoms were eliminated if easily explained by medical illness, treatments, or hospitalization). The Charlson combined age-comorbidity index was used to measure severity of illness., Results: A diagnosis of major depressive disorder based on criteria modified for patients with medical illness better predicted mortality than a diagnosis based on inclusive criteria. A past history of depression and the Charlson combined age-comorbidity index predicted in-hospital mortality, but demographic variables, pain, discomfort, length of stay, medical diagnoses, and minor depression did not. In the final multivariate logistic regression model, the Charlson combined age-comorbidity index, a modified diagnosis of major depressive disorder, and a history of depression were independent predictors of in-hospital death., Conclusions: Severity of medical illness, a diagnosis of major depressive disorder based on modified criteria, and a past history of depression independently predicted in-hospital mortality in medical inpatients.

The authors interviewed a consecutive series of medical inpatients (N = 241) using the Schedule for Affective Disorders and Schizophrenia to determine which depressive symptoms are associated with in-hospital mortality. Fifteen depressive symptoms, pain, and physical discomfort were assessed along with medical comorbidity. Twenty patients died in-hospital (8.3%). Logistic regression showed that anhedonia, hopelessness, worthlessness, indecisiveness, and insomnia predicted in-hospital death after adjusting for physical comorbidity and age. Clinicians should be aware that these depressive symptoms may predict mortality in medical inpatients. Future studies should address which treatment modalities lead to better outcomes.

Twenty patients with poor prognosis AML and four patients in the blastic phase of a myeloproliferative disorder were treated with two 'pulses' of therapy each consisting of two doses of high dose araC (separated by 12 h) followed by a single dose of mitoxantrone. The pulses were separated by 96 h. Amifostine was then administered tiw. The median age of the population was 68 years with 88% of patients having had either a prior MDS, MPD or toxic exposure. The acute leukemia of 58% of patients either entered a CR or reverted to preleukemic state. For patients under 70 years of age, treatment produced 62% CRs with a leukemia free decision marrow in 77%. For patients over 70 years the CR rate was 27% with 36% of patients having a leukemia free decision marrow.

The purpose of this study was to determine changes in nursing students' attitudes about mental illness following a twelve-week psychiatric affiliation program in a state mental hospital. Data were collected by means of two combined opinions about mental illness scales -- Cohen and Struening's factor analytically-derived Opinions About Mental Illness (OMI) questionnaire and Ellsworth's empirically-derived Opinions About Mental Illness Scale. The sample consisted of 95 student nurses from three diploma schools of nursing. The subjects were administered the instrument at the beginning and end of their psychiatric affiliation. Following the affiliation, student nurses' attitudes about mental illness changed significantly in a favorable direction on the following attitudinal dimensions: Authoritarianism, Mental Hygiene Ideology, Social Restrictiveness, Interpersonal Etiology, Nontraditionalism, and Restrictive Control. Although significant changes were not found on Benevolence and Protective Benevolence, there was a trend toward favorable changes on both attitudinal dimensions.

This was a study of opinions about mental illness among occupational groups from a state psychiatric hospital and community mental health centers. Data were collected with two combined opinions about mental illness scales. The sample consisted of 348 participants, including 227 hospital employees and 121 employees of community mental health centers. The results indicated that occupational groups of both the hospital and the community mental health centers were highly differentiated in their opinions about mental illness. Sharp differences were found between professional and nonprofessional staff, with the latter indicating a much stronger endorsement of Authoritarianism and Social Restrictiveness. The personnel of the community mental health centers were significantly less authoritarian and socially restrictive, and more acceptant of Mental Hygiene Ideology and Nontraditionalism than their hospital counterparts.