High-frequency catheter-based ultrasound (US) transducers can be inserted into the esophagus transnasally to evaluate esophageal wall structures. Studies were performed in two sheep esophagus ...specimens in vitro, in 17 healthy human subjects, and in 16 patients with esophageal abnormalities (eight with achalasia, four with scleroderma, three with esophageal carcinoma, and one with esophagitis). In the sheep specimens, endoluminal US delineated seven layers of the esophageal wall; these results correlated closely with histologic findings. Real-time US of the normal esophageal wall was performed during resting and swallowing. Muscles at the lower esophageal sphincter (LES) were shown to be thicker than muscles in the body of the esophagus. Thickening of the muscular layers at the LES in achalasia, dilated blood vessels within the submucosa in esophagitis, and fibrotic changes within the muscular layers in scleroderma were demonstrated. Extramural structures adjacent to the esophagus were also seen. These preliminary results suggest that transnasal esophageal US may become an important diagnostic tool in evaluation of the esophagus.
WOMEN'S HEALTH Than, C.; Needleman, J.; Washington, D. ...
Health services research,
08/2020, Volume:
55, Issue:
S1
Journal Article
Peer reviewed
Research Objective
Research suggests that about 80% of women veterans receiving care at the Department of Veterans Affairs (VA) have experienced at least one trauma in their lifetimes, including ...military sexual trauma or combat‐related trauma. Trauma‐sensitive communication reflects an understanding of the impact of trauma and the needs of trauma survivors during health care encounters. We explored whether provider gender sensitivity is associated with positive ratings of trauma‐sensitive communication among women veteran patients.
Study Design
We conducted cross‐sectional surveys of providers to measure provider gender sensitivity using 10 survey items adapted from the Gender Awareness Inventory‐VA. Example items included “Sometimes I wish VA primary care clinics had only male patients.” We averaged responses in 5‐point Likert scales to create a composite score, with a higher score indicating higher sensitivity. We used cross‐sectional surveys of patients to measure women veterans' perspectives of trauma‐sensitive communication: providers (1) asked about any serious problems or stresses in life (yes vs no), (2) made sure they were comfortable before any treatments or examinations (always vs otherwise), and (3) made them feel comfortable talking about emotional issues (very comfortable vs otherwise). We linked survey responses of providers to women veterans via VA primary care visit information in 2014. We used logistic regression to predict each measure of trauma‐sensitive communication, controlling for women veterans' age, race, and ethnicity, a service‐connected disability, military sexual trauma, physical and mental comorbidities, and primary care and mental health visits in 2014. All analyses were weighted for survey nonresponses.
Population Studied
A total of 94 primary care providers (PCPs) (33% response rate) and 1395 women veterans (45% response rate) from 12 VA medical centers (VAMCs) completed the surveys between 2014 and 2015. After linking women veterans to PCPs, they had visited for primary care or women's health at the same 12 VAMCs in 2014, and the analyses included 804 women veterans and 58 PCPs who responded to the surveys.
Principal Findings
Overall, 80.3% of women veterans reported that their PCPs asked about any serious problems or stresses in life, 79.3% reported that PCPs always made sure they were comfortable before any treatments or examinations, and 55.6% felt very comfortable talking with PCPs about emotional issues. After adjusting for covariates, higher provider gender sensitivity score was associated with more women veterans reporting that (1) PCPs asked about any serious problems or stresses in life (AOR: 1.33, 95% CI: 1.08‐1.63), (2) PCPs always made sure they were comfortable before any treatments or examinations (AOR: 1.10, 95% CI: 0.91‐1.34), and (3) they felt very comfortable talking with PCPs about emotional issues (AOR: 1.11, 95% CI: 0.93‐1.30).
Conclusions
Overall, women veterans' ratings of trauma‐sensitive communication were positive. Higher provider sensitivity was associated with greater trauma‐sensitive communication.
Implications for Policy or Practice
Strategies to improve provider readiness to care for women veterans and their gender sensitivity can improve trauma‐sensitive communication with women veterans.
Primary Funding Source
Department of Veterans Affairs.
The effects of essential fatty acid (EFA) deprivation on the arachidonate content and phospholipid composition of different tissues are quite diverse. When C57B1 mice were placed on a fat-free diet, ...hepatic liquids were readily depleted of arachidonate. In contrast, the renal cortex tenaciously retained arachidonate, whereas surprisingly the heart showed a doubling of its content of arachidonate. This increase in cardiac arachidonate was due to a four-fold increase in arachidonylphosphatidylethanolamine (PE). The renal cortex showed preservation of its arachidonate content in PE, phosphatidylserine, and phosphatidylcholine. Only phosphatidylinositol was depleted of arachidonate in heart or renal cortex. Using an in vivo labeling technique, it was shown that the liver incorporated most of the 1-14Carachidonate initially following intraperitoneal injection. Over 11 days, as levels of labeled arachidonate fell in liver, the EFA-deficient heart accumulated arachidonate selectively in PE (8-fold greater than control), and the EFA-deficient renal cortex accumulated arachidonate in PE, phosphatidylserine, and phosphatidylcholine (2-3-fold greater than control). This uptake was shown to be specific for arachidonate over 20:3(n-9). Despite the conservation of cardiac and renal arachidonate seen with EFA deficiency, prostaglandin production by the isolated perfused EFA-deficient heart and kidney was markedly decreased relative to control in response to specific agonist stimulation with angiotensin II, although it was equivalent to control in response to nonspecific stimulation by ischemia. These data suggest that the liver serves to supply other tissues with arachidonate in EFA deficiency, and that the heart and renal cortex both contain mechanisms to accumulate arachidonate selectively in certain phospholipids. However, phosphatidylinositol, which is uniquely depleted of arachidonate in heart and renal cortex with EFA deficiency, appears to be the principal source of arachidonate in response to receptor-mediated agonists.
To image esophageal and gastric varices qualitatively and to measure esophageal varices quantitatively, 29 patients with portal hypertension underwent transnasal esophageal and gastric ...ultrasonography (US). Twenty-three patients underwent standard endoscopy. Endoluminal US demonstrated the varices as anechoic areas with communications in the submucosal, periesophageal, and perigastric regions, as well as ascites visualized through the gastric wall. Interobserver variation between two investigators for measurements of the largest esophageal varix in each patient was r value of .99 for diameter, r value of .99 for cross-sectional surface area, and r value of .98 for circumference. Endoscopy for evaluation of gastric varices had a sensitivity of 48% and a specificity of 50% and for evaluation of esophageal varices had a sensitivity of 94% and a specificity of 17%. Periesophageal and perigastric varices could not be visualized at endoscopy. Transnasal esophageal US, a new imaging technique with which to detect and measure esophageal varices, is a more sensitive modality than endoscopy for the detection of gastric varices.
PurposeDynamic lung oxygen‐enhanced MRI (OE‐MRI) is challenging due to the presence of confounding signals and poor signal‐to‐noise ratio, particularly at 3 T. We have created a robust pipeline ...utilizing independent component analysis (ICA) to automatically extract the oxygen‐induced signal change from confounding factors to improve the accuracy and sensitivity of lung OE‐MRI.MethodsDynamic OE‐MRI was performed on healthy participants using a dual‐echo multi‐slice spoiled gradient echo sequence at 3 T and cyclical gas delivery. ICA was applied to each echo within a thoracic mask. The ICA component relating to the oxygen‐enhancement signal was automatically identified using correlation analysis. The oxygen‐enhancement component was reconstructed, and the percentage signal enhancement (PSE) was calculated. The lung PSE of current smokers was compared with nonsmokers; scan–rescan repeatability, ICA pipeline repeatability, and reproducibility between two vendors were assessed.ResultsICA successfully extracted a consistent oxygen‐enhancement component for all participants. Lung tissue and oxygenated blood displayed the opposite oxygen‐induced signal enhancements. A significant difference in PSE was observed between the lungs of current smokers and nonsmokers. The scan–rescan repeatability and the ICA pipeline repeatability were good.ConclusionThe developed pipeline demonstrated sensitivity to the signal enhancements of the lung tissue and oxygenated blood at 3 T. The difference in lung PSE between current smokers and nonsmokers indicates a likely sensitivity to lung function alterations that may be seen in mild pathology, supporting future use of our methods in patient studies.
Quantitative analysis of vascular resistance from the Doppler time-velocity waveform relies on measuring arterial pulsatility. However, input pressure waveform pulsatility, impedance, and resistance ...have all been found to effect artery flow waveform pulsatility in circulatory mathematic models and in umbilical sheep preparations in vivo. The present study used an in vivo sheep preparation to determine that embolization of the uteroplacental circulation and maternal angiotensin II administration caused changes in the uterine Doppler time-velocity waveform pulsatility that were dependent on input pressure waveform pulsatility, fundamental impedance, and resistance changes. Uteroplacental vascular embolization increased vascular resistance and the uterine artery Doppler waveform resistive index; the mean component of flow (mean pressure/resistance) decreased. Decreased uterine artery Doppler resistive index occurred despite angiotensin II-induced vasoconstriction and increased vascular resistance because the pulse component of flow (pulse pressure/impedance) decreased.
Postmastectomy radiotherapy in patients with four or more positive axillary nodes reduces breast cancer mortality, but its role in patients with one to three involved nodes is controversial. We ...assessed the effects of postmastectomy radiotherapy on quality of life (QOL) in women with intermediate-risk breast cancer.
SUPREMO is an open-label, international, parallel-group, randomised, controlled trial. Women aged 18 years or older with intermediate-risk breast cancer (defined as pT1–2N1; pT3N0; or pT2N0 if also grade III or with lymphovascular invasion) who had undergone mastectomy and, if node positive, axillary surgery, were randomly assigned (1:1) to receive chest wall radiotherapy (50 Gy in 25 fractions or a radiobiologically equivalent dose of 45 Gy in 20 fractions or 40 Gy in 15 fractions) or no radiotherapy. Randomisation was done with permuted blocks of varying block length, and stratified by centre, without masking of patients or investigators. The primary endpoint is 10-year overall survival. Here, we present 2-year results of QOL (a prespecified secondary endpoint). The QOL substudy, open to all UK patients, consists of questionnaires (European Organisation for Research and Treatment of Cancer QLQ-C30 and QLQ-BR23, Body Image Scale, Hospital Anxiety and Depression Scale HADS, and EQ-5D-3L) completed before randomisation, and at 1, 2, 5, and 10 years. The prespecified primary outcomes within this QOL substudy were global QOL, fatigue, physical function, chest wall symptoms, shoulder and arm symptoms, body image, and anxiety and depression. Data were analysed by intention to treat, using repeated mixed-effects methods. This trial is registered with the ISRCTN registry, number ISRCTN61145589.
Between Aug 4, 2006, and April 29, 2013, 1688 patients were enrolled internationally and randomly assigned to receive chest wall radiotherapy (n=853) or not (n=835). 989 (79%) of 1258 patients from 111 UK centres consented to participate in the QOL substudy (487 in the radiotherapy group and 502 in the no radiotherapy group), of whom 947 (96%) returned the baseline questionnaires and were included in the analysis (radiotherapy, n=471; no radiotherapy, n=476). At up to 2 years, chest wall symptoms were worse in the radiotherapy group than in the no radiotherapy group (mean score 14·1 SD 15·8 in the radiotherapy group vs 11·6 14·6 in the no radiotherapy group; effect estimate 2·17, 95% CI 0·40–3·94; p=0·016); however, there was an improvement in both groups between years 1 and 2 (visit effect −1·34, 95% CI −2·36 to −0·31; p=0·010). No differences were seen between treatment groups in arm and shoulder symptoms, body image, fatigue, overall QOL, physical function, or anxiety or depression scores.
Postmastectomy radiotherapy led to more local (chest wall) symptoms up to 2 years postrandomisation compared with no radiotherapy, but the difference between groups was small. These data will inform shared decision making while we await survival (trial primary endpoint) results.
Medical Research Council, European Organisation for Research and Treatment of Cancer, Cancer Australia, Dutch Cancer Society, Trustees of Hong Kong and Shanghai Banking Corporation.
The aim of this study was to demonstrate the clinical utility of reconstructed three-dimensional intravascular ultrasonography using a voxel-based volume rendering technique. Three-dimensional ...reconstruction of intravascular ultrasonographic data was performed in 12 patients with various vascular abnormalities during interventional radiology procedures. A stepping motor device was used to pull either a 12.5 or a 20 MHz catheter-based transducer through the lumen of a variety of vessels at a rate of 1.5 mm/s. Images were downloaded to a Life Imaging System for three-dimensional reconstruction. The value of three-dimensional ultrasonographic imaging was evaluated in comparison to conventional intravascular ultrasonography. A variety of abnormalities were demonstrated in reconstructed three-dimensional ultrasound imaging, including arterial atheroma and plaque, aneurysm and pseudoaneurysm, aortic dissection and stenosis (May-Thurner syndrome). The vascular branches and accessory vessels, as well as their relationships to each other, were easily demonstrated on three-dimensional imaging by selecting an appropriate angle, plane, and section of the image. The dimensions and shapes of the vascular lumen were determined in the longitudinal view. Three-dimensional information proved useful for determining the distribution and type of plaque in vessels. Reconstructed three-dimensional imaging allows for global evaluation of the dissection entry site, extent of the flap, and the false lumen of a pseudoaneurysm. Intravascular three-dimensional ultrasonography provides information complementary to that obtained with two-dimensional imaging. It supplies information about spatial relationships of anatomic structures that cannot be evaluated using conventional imaging methods.
Introduction
Natural orifice transluminal endoscopic surgery (NOTES) is a rapidly evolving technique providing access to the peritoneum utilizing an endoscope via a natural orifice. One of the most ...significant requirements of this technique is the need to minimize the risk of clinically significant peritoneal contamination. We report the bacterial load and contamination of the peritoneal cavity in patients requiring a gastrotomy Roux-en-Y gastric bypass (LSRYGB).
Methods
We prospectively studied 50 patients undergoing a gastrotomy with creation of a gastrojejunostomy during LSRYGB. We recorded the patient’s proton-pump inhibitor (PPI) utilization preoperatively and sampled gastric contents without lavage. We also sampled peritoneal fluid prior to and after gastrotomy, noting the length of time the gastrotomy was open to the peritoneum. Each of the three samples was sent for bacterial colony counts, and culture with identification of species.
Results
Fifty patients underwent LSRYGB with a mean operative time of 93 min. The gastrotomy was open to the peritoneal cavity for an average of 18 min. Seventeen of 50 patients were on PPIs preoperatively, resulting in a significant difference in postgastrostomy peritoneal bacterial counts. The average number of colony-forming units (CFU) of the gastric aspirate was 22,303 CFU/ml. Peritoneal aspirates obtained for examination prior to creation of a gastrotomy showed no CFUs in 44 of 50 patients. Peritoneal sampling after gastrotomy showed contamination of the abdomen with an average of 1102 CFU/ml. There was no correlation between the bacterial load in the stomach and peritoneal load after gastrotomy. No infectious complications or leaks developed. One complication of rhabdomyolysis in a patient with no peritoneal bacterial contamination developed.
Conclusions
Transgastric instrumentation does contaminate the abdominal cavity but pathogens are clinically insignificant due to species or bacterial load. Patients on PPIs do have an increased bacterial load in the gastric aspirate, with no clinical significant infection.
PDF
