Paul LoGerfo

Thyroidectomy using monitored local or conventional general anesthesia: an analysis of outpatient surgery, outcome and cost in 1,194 consecutive cases.

BackgroundCritical appraisal of safety, feasibility, and economic impact of thyroidectomy procedures using local (LA) or general anesthesia (GA) is performed.MethodsConsecutive patients undergoing thyroidectomy procedures were selected from a prospective database from January 1996 to June 2003 of a single-surgeon practice at a tertiary center. Statistical analyses determined differences in patient characteristics, outcomes, operative data, and length of stay (LOS) between groups. A cohort of consecutive patients treated in 2002–2003 by all endocrine surgeons at the institution was selected for cost analysis.ResultsA total of 1,194 patients underwent thyroidectomy, the majority using LA (n = 939) and outpatient surgery (65%). Female gender (76%), body mass index ≥30 kg/m2 (29%), median age (49 years), and cancer diagnosis (45%) were similar between groups. Extent of thyroidectomy (59% total) and concomitant parathyroidectomy (13%) were similarly performed. GA was more commonly utilized for patients with comorbidity [15% vs. 10%, Anesthesia Society of America (ASA) ≥3; P < 0.001], symptomatic goiter (13% vs. 7%; P = 0.004), reoperative cases (10% vs. 6%; P = 0.01), and concomitant lymphadenectomy procedures (15% vs. 3%; P < 0.001). GA was associated with significant increase in LOS ≥24 hours (17 % vs. 4%) or overnight observation (49 % vs. 14%), P < 0.001. Operative room utilization was significantly associated with type of anesthesia (180 min vs. 120 min, GA vs. LA, P < .001) and impacted to a lesser degree by surgeon operative time (89 minutes vs. 76 minutes, GA vs. LA; P = .089). Overall morbidity rates were similar between groups (GA 5.8 % vs. LA 3.2%). The actual total cost (ATC) per case for GA was 48% higher than for LA and 30% higher than the ATC for all procedures (P = 0.006), with the combined weighted average impacted by more LA cases (n = 217 vs. 85).ConclusionThese data from a large, unselected group of thyroidectomy patients suggest LA results in similar outcomes and morbidity rates to GA. It is likely that associated LA costs are lower.

Direct detection and amplification of Helicobacter pylori ribosomal 16S gene segments from gastric endoscopic biopsies.

Helicobacter pylori is an organism thought to play an important causative role in gastritis and peptic ulcer diseases. We have designed an RNA dot blot assay for the detection of H. pylori, using as probe a synthetic oligonucleotide complementary to its 16S rRNA. We have also used oligonucleotide primers, complementary to conserved sequences within bacterial ribosomal 16S genes, to amplify a H. pylori ribosomal 16S DNA fragment via the polymerase chain reaction (PCR). After determining the DNA sequence of this amplified H. pylori fragment, primers were designed for specific PCR amplification of H. pylori ribosomal 16S DNA sequences. Samples from clinical endoscopic biopsies were PCR amplified with universal 16S ribosomal primers to detect the presence of bacteria and with H. pylori-specific primers to uniquely detect H. pylori. Finally, by comparing the H. pylori-specific PCR assay to commonly used diagnostic tests, we demonstrate that the molecular technique of PCR amplification shows promising applications for the clinical detection of H. pylori.

Decreased levels of protein kinase C enzyme activity and protein kinase C mRNA in primary colon tumors.

PURPOSE: We have previously reported decreased protein kinase C (PKC) enzyme activity in primary human colorectal carcinomas. The purpose of this study was to extend these findings to a larger number of cases and to also examine the levels of expression of mRNAs that encode specific isoforms of PKC in these tumors. METHODS: Colorectal carcinomas and paired grossly normal adjacent mucosal samples were collected from 39 patients. Complete histopathologic analyses were performed on all samples. PKC enzyme activity in both the cytosolic and particulate fractions was quantitated by measuring the amount of32P incorporated into histone Type III-S. Northern blot nucleic acid hybridization was performed using polyA+RNA extracted from both the tumor and normal tissue samples and32P-labeled probes for specific isoforms of PKC. The paired samplet-test was used to determine the statistical significance of tumor to normal ratios of both enzyme activity and mRNA levels. RESULTS: The mean value for cellular PKC enzyme activity in the colon tumors from 39 patients was about 60 percent of that found in the paired adjacent grossly normal mucosa samples (P<0.001). The subcellular distribution of PKC activity was similar in normal and tumor samples (about 70 percent in the particulate fraction). The abundance of PKCα mRNAs varied considerably among 28 tumor/normal pairs, with a mean tumor to normal (T∶N) ratio of 1.0±0.6 for the 99-kb mRNA band and 1.4±0.7 for the 3.5-kb band. The abundance of PKCβ mRNAs was decreased in 30 of 39 tumors, with a mean T∶N ratio of 0.6±0.4 for both the 94- and 3.5-kb bands for all 39 samples (P<0.001). None of the parameters measured correlated with Dukes stage or the grade of the tumor. CONCLUSIONS: These studies extend previous evidence that total PKC enzyme activity is frequently decreased in primary human colon tumors. Our finding that this is often associated with decreased levels of PKCβmRNA suggest that this is not simply due to posttranslational down-regulation of this enzyme system. Further studies are required to determine whether these changes in PKCαand PKCβmRNAs are due to alteredde novotranscription or mRNA stability. It will also be of interest to examine the expression of other isoforms of PKC in colon tumors.

Serum secretory IgA levels in patients with neoplastic disease.

Abstract A double antibody inhibition type radioimmunoassay has been used to quantitate the amount of secretory IgA in the serum of patients with a variety of diseases. Secretory IgA (S-IgA) was found in almost all serum specimens tested. The S-IgA levels were elevated in some patients with neoplastic disease. The assay, however, does not appear to be of value for cancer detection. High levels of S-IgA were also found in patients with regional enteritis and ulcerative colitis.

Electrophoretic mobility patterns of collagen following laser welding

Clinical application of laser vascular anastomosis in inhibited by a lack of understanding of its mechanism. Whether tissue fusion results from covalent or non-covalent bonding of collagen and other structural proteins is unknown. We compared electrophoretic mobility of collagen in laser treated and untreated specimens of rat tail tendon (>90% type I collagen) and rabbit aorta. Welding was performed, using tissue shrinkage as the clinical endpoint, using the 808 nm diode laser (power density 14 watts/cm2) and topical indocyanine green dye (max absorption 805 nm). Collagen was extracted with 8 M urea (denaturing), 0.5 M acetic acid (non-denaturing) and acetic acid/pepsin (cleaves non- helical protein). Mobility patterns on gel electrophoresis (SDS-PAGE) after urea or acetic acid extraction were identical in the lasered and control tendon and vessel (confirmed by optical densitometry), revealing no evidence of formation of novel covalent bonds. Alpha and beta band intensity was diminished in pepsin incubated lasered specimens compared with controls (optical density ratio 0.00 +/- 9 tendon, 0.65 +/- 0.12 aorta), indicating the presence of denatured collagen. With the laser parameters used, collagen is denatured without formation of covalent bonds, suggesting that non-covalent interaction between denatured collagen molecules may be responsible for the weld. Based on this mechanism, welding parameters can be chosen which produce collagen denaturation without cell death.

Pancreatic polypeptide (PP) immunoreactivity in human parathyroid culture media.

Media from cultures of normal and abnormal human parathyroid fragments were assayed for parathyrin (PTH) and pancreatic polypeptide (PP) using sensitive radioimmunoassays. PP immunoreactivity was present in media (Day 6-7 in vitro) from cultures of 3/10 adenomas and 6/6 3 degrees hyperplastic glands (mean = 126. fmole/mg protein/day) (range = 6.-675.), and was not suppressed by 0 leads to 3 mM calcium challenge. PP was undetectable in media from cultures of one parathyroid carcinoma, one 1 degree hyperplasia, and one normal parathyroid. Medium C-terminal PTH levels were quite variable (26.-2,545,000. pg/mg protein/day). Presence of PP immunoreactivity in media from cultures of some hyperplastic parathyroids and some parathyroid adenomas suggests that PP may be released from these tissues in vitro. The significance of elevated PP levels in the MEA syndromes may be of special clinical relevance to this observation.