Publications by authors named "Tracy Pitt"

19 Publications

  • Page 1 of 1

Establishing Amoxicillin Allergy in Children Through Direct Graded Oral Challenge (GOC): Evaluating Risk Factors for Positive Challenges, Safety, and Risk of Cross-Reactivity to Cephalosporines.

J Allergy Clin Immunol Pract 2021 Jul 19. Epub 2021 Jul 19.

Division of Allergy and Clinical Immunology, Department of Pediatrics, Montreal Children's Hospital, Montreal, QC, Canada; Infectious Diseases and Immunity in Global Health Program, The Research Institute of the McGill University Health Centre, McGill University, Montreal, QC, Canada.

Background: Data on the diagnostic properties of direct oral challenges without the use of skin tests in children with suspected amoxicillin allergy are sparse.

Objective: Assess the use of direct oral challenges.

Methods: A cohort study was conducted between March 2013 and March 2020, in Montreal and Winnipeg. All children referred with reported history of benign reactions (ie, limited to the skin with no mucosal lesions and no vesicles) to amoxicillin were recruited and a 2-step graded oral challenge (GOC) was conducted. Data were collected on demographic characteristics, clinical characteristics, and comorbidities. Eligible children were followed to assess reactions to subsequent use of amoxicillin and to assess the safety of cephalexin use in children with a positive GOC.

Results: Among 1914 children recruited, 1811 (94.6%) tolerated the GOC, 42 (2.2%) developed mild immediate reactions, and 61 (3.2%) developed mild nonimmediate reactions. Among 265 participants who had a negative GOC and reused amoxicillin, 226 (85.3%) reported tolerance and 39 (14.7%) had mild cutaneous reactions. Chronic urticaria (adjusted odds ratio [aOR], 1.16; 95% CI, 1.09-1.23) and an index reaction occurring within 5 minutes of exposure (aOR, 1.09; 95% CI, 1.04-1.14) were associated with immediate reactions during the GOC. Symptoms lasting longer than 7 days (aOR, 1.05; 95% CI, 1.02-1.09) and parental drug hypersensitivity (aOR, 1.04; 95% CI, 1.03-1.06) were associated with nonimmediate reactions. Among those reacting to the GOC, 12.5% reacted with mild cutaneous reactions to cephalexin challenge.

Conclusions: Direct GOCs are an accurate and safe confirmatory to establish true hypersensitivity among children reporting benign reactions to amoxicillin.
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http://dx.doi.org/10.1016/j.jaip.2021.06.057DOI Listing
July 2021

Differentiating Between β-Lactam-Induced Serum Sickness-Like Reactions and Viral Exanthem in Children Using a Graded Oral Challenge.

J Allergy Clin Immunol Pract 2021 02 6;9(2):916-921. Epub 2020 Sep 6.

Department of Pediatrics, Division of Allergy and Clinical Immunology, Montreal Children's Hospital, Montreal, Quebec, Canada.

Background: Serum sickness-like reactions (SSLRs) are defined by the presence of rash (primarily urticaria) and joint complaints (arthralgia/arthritis) that are believed to occur due to a non-IgE-mediated response to medications. However, similar reactions can occur due to viral infections, and it can be difficult to distinguish between the two. This may lead to unnecessary avoidance of the culprit antibiotic.

Objective: We aimed to evaluate children presenting with suspected SSLRs through a graded oral challenge (GOC).

Methods: All children referred to the Montreal Children's Hospital for potential antibiotic allergy (β-lactam or other antibiotics) and a clinical presentation compatible with SSLR were recruited for the study between March 2013 and February 2020. A standardized survey with questions on treatment, symptoms, and associated factors was completed, and a GOC (10% and subsequently 90% of the oral antibiotic dose) was conducted. Patients with a negative GOC were contacted annually to query on subsequent antibiotic use.

Results: Among 75 patients presenting with suspected SSLRs, the median age was 2.0 years and 46.7% were males. Most reactions were attributed to amoxicillin. Among the 75 patients, 2.7% reacted immediately (within 1 hour) to a GOC and 4.0% had a nonimmediate reaction. Of the 43 patients successfully contacted, 20 reported subsequent culprit antibiotic use of whom 25.0% had a subsequent mild reaction (macular/papular rash).

Conclusions: This is the first and largest pediatric study to assess SSLR using a GOC. Our findings suggest that using a GOC is safe and appropriate for differentiating between β-lactam-induced SSLR and viral exanthem in this population.
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http://dx.doi.org/10.1016/j.jaip.2020.08.047DOI Listing
February 2021

Diagnosis of Ibuprofen allergy through oral challenge.

Clin Exp Allergy 2020 05 3;50(5):636-639. Epub 2020 Apr 3.

Division of Pediatric Allergy and Clinical Immunology, McGill University Health Centre, Montreal, Quebec, Canada.

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http://dx.doi.org/10.1111/cea.13596DOI Listing
May 2020

Simultaneous resection of a gastric submucosal lipoma in the setting of bariatric surgery: A case report and review of current literature.

Int J Surg Case Rep 2019 20;60:216-220. Epub 2019 Jun 20.

The Jewish Hospital - Radiology Department, United States. Electronic address:

Introduction: Gastric submucosal lipoma is an uncommon finding in the stomach. A benign fatty tumor that is asymptomatic majority of the time. However, symptomatic and bigger tumors can be difficult to manage surgically and require detailed surgical planning prior to proceeding with bariatric surgery.

Presentation Of Case: 58year old female who presented for weight loss consultation. Underwent an esophagogastroduodenoscopy (EGD) that demonstrated a 3cm mass near the incisura. Endoscopic ultrasound (EUS) and biopsy demonstrated a submucosal lipoma. Due to the lipoma's location, resection was critical, as it would have led to obstructive symptoms following sleeve gastrectomy. The patient underwent a simultaneous laparoscopic vertical gastrectomy, gastric lipoma excision, EGD, and laparoscopic cholecystectomy DISCUSSION: Gastric lipomas are benign gastric submucosal tumors, representing less than 3% of all benign gastric neoplasms. Computer tomography and endoscopic ultrasound are important in establishing diagnosis. In current literature, excision with negative margins is standard of care, but small asymptomatic lesions can be followed without intervention.

Conclusion: Gastric lipoma are a rare type of gastric submucosal tumors. Size is highly variable. Observation is a reasonable approach when small and asymptomatic, but multiple surgical modalities can be utilized to remove the tumor. Careful utilization of pre-operative imaging including EUS is critical in choosing the appropriate surgery if simultaneous bariatric management is undertaken.
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http://dx.doi.org/10.1016/j.ijscr.2019.06.031DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6599090PMC
June 2019

T cell repertoire to citrullinated self-peptides in healthy humans is not confined to the HLA-DR SE alleles; Targeting of citrullinated self-peptides presented by HLA-DP4 for tumour therapy.

Oncoimmunology 2019;8(5):e1576490. Epub 2019 Feb 20.

Scancell Limited, Academic Department of Clinical Oncology, University of Nottingham, City Hospital Campus, Nottingham, UK.

Post-translational modifications are induced in stressed cells which cause them to be recognised by the system. One such modification is citrullination where the positive charged arginine is modified to a neutral citrulline. We demonstrate most healthy donors show an oligoclonal CD4 response to at least one citrullinated vimentin or enolase peptide. Unlike rheumatoid arthritis patients, these T cell responses were not restricted by HLA-DRB1 shared epitope (SE) alleles, suggesting they could be presented by other MHC class II alleles. As HLA-DP is less polymorphic than HLA-DR, we investigated whether the common allele, HLA-DP4 could present citrullinated epitopes. The modification of arginine to citrulline enhanced binding of the peptides to HLA-DP4 and induced high-frequency CD4 responses in HLA-DP4 transgenic mouse models. Our previous studies have shown that tumours present citrullinated peptides restricted through HLA-DR4 which are good targets for anti-tumour immunity. In this study, we show that citrullinated vimentin and enolase peptides also induced strong anti-tumour immunity (100% survival, < 0.0001) against established B16 tumours and against the LLC/2 lung cancer model ( = 0.034) both expressing HLA-DP4. Since most tumours do not constitutively express MHC class II molecules, models were engineered that expressed MHC class II under the control of an IFNγ inducible promoter. Immunisation with citrullinated peptides resulted in 90% survival ( < 0.001) against established B16 HHD tumour expressing IFNγ inducible DP4. These studies show that citrullinated peptides can be presented by a range of MHC class II molecules, including for the first time HLA-DP4, and are strong targets for anti-tumour immunity.
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http://dx.doi.org/10.1080/2162402X.2019.1576490DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6492960PMC
February 2019

Single Fluid-Filled Intragastric Balloon Safe and Effective for Inducing Weight Loss in a Real-World Population.

Clin Gastroenterol Hepatol 2018 07 7;16(7):1073-1080.e1. Epub 2018 Feb 7.

Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota. Electronic address:

Background & Aims: The Orbera intragastric balloon (OIB) is a single fluid-filled intragastric balloon approved for the induction of weight loss and treatment of obesity. However, little is known about the effectiveness and safety of the OIB outside clinical trials, and since approval, the Food and Drug Administration has issued warnings to health care providers about risk of balloon hyperinflation requiring early removal, pancreatitis, and death. We analyzed data on patients who have received the OIB since its approval to determine its safety, effectiveness, and tolerance in real-world clinical settings.

Methods: We performed a postregulatory approval study of the safety and efficacy of the OIB, and factors associated with intolerance and response. We collected data from the Mayo Clinic's database of patient demographics, outcomes of OIB placement (weight loss, weight-related comorbidities), technical aspects of insertion and removal, and adverse events associated with the device and/or procedure, from 8 centers (3 academic, 5 private, 4 surgeons, and 4 gastroenterologists). Our final analysis comprised 321 patients (mean age, 48.1 ± 11.9 y; 80% female; baseline body mass index, 37.6 ± 6.9). Exploratory multivariable linear and logistic regression analyses were performed to identify predictors of success and early balloon removal. Primary effectiveness outcomes were percentage of total body weight lost at 3, 6, and 9 months. Primary and secondary safety outcomes were rates of early balloon removal, periprocedural complications, dehydration episodes requiring intravenous infusion, balloon migration, balloon deflation or hyperinflation, pancreatitis, or other complications.

Results: Four patients had contraindications for placement at the time of endoscopy. The balloon was safely removed in all instances with an early removal rate (before 6 months) in 16.7% of patients, at a median of 8 weeks after placement (range, 1-6 mo). Use of selective serotonin or serotonin-norepinephrine re-uptake inhibitors at the time of balloon placement was associated with increased odds of removal before 6 months (odds ratio, 3.92; 95% CI, 1.24-12.41). Total body weight lost at 3 months was 8.5% ± 4.9% (n = 204), at 6 months was 11.8% ± 7.5% (n = 199), and at 9 months was 13.3% ± 10% (n = 47). At 6 months, total body weight losses of 5%, 10%, and 15% were achieved by 88%, 62%, and 31% of patients, respectively. Number of follow-up visits and weight loss at 3 months were associated with increased weight loss at 6 months (β = 0.5 and 1.2, respectively) (P < .05). Mean levels of cholesterol, triglycerides, low-density lipoprotein, and hemoglobin A1c, as well as systolic and diastolic blood pressure, were significantly improved at 6 months after OIB placement (P < .05).

Conclusions: In an analysis of a database of patients who received endoscopic placement of the OIB, we found it to be safe, effective at inducing weight loss, and to reduce obesity-related comorbidities in a real-world clinical population. Rates of early removal (before 8 weeks) did not differ significantly between clinical trials and the real-world population, but were affected by use of medications.
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http://dx.doi.org/10.1016/j.cgh.2018.01.046DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6008169PMC
July 2018

Reply.

J Allergy Clin Immunol 2018 04 1;141(4):1538-1539. Epub 2018 Feb 1.

University of Manitoba, Winnipeg, Manitoba, Canada. Electronic address:

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http://dx.doi.org/10.1016/j.jaci.2017.11.039DOI Listing
April 2018

Citrullinated α-enolase is an effective target for anti-cancer immunity.

Oncoimmunology 2018;7(2):e1390642. Epub 2017 Nov 6.

Scancell Limited, Academic Department of Clinical Oncology, University of Nottingham, City Hospital Campus, Nottinghamshire, UK.

Targeting post-translationally modified epitopes may provide a new strategy for generating tumor specific immune responses. Citrullination is the post-translational modification of arginine to citrulline catalyzed by peptidylarginine deaminase (PAD) enzymes. Presentation of citrullinated peptides on MHC-II has been associated with autophagy. Tumors upregulate autophagy and present citrullinated peptides in response to stresses including nutrient deprivation, oxygen deprivation, redox stress and DNA damage, making them good targets for immune attack. The ubiquitous glycolytic enzyme α-enolase (ENO1) is often citrullinated and degraded during autophagy. Immunization of mice with two citrullinated ENO1 peptides (ENO1 241-260cit or 11-25cit) induced strong Th1 responses that recognize the post-translationally modified, but not the wild type unmodified epitope. ENO1 11-25cit induced tumor therapy of melanoma cells in C57Bl/6 (B16F1 50% survival = 0.0026) and ENO1 241-260cit in HLA-DR4 transgenic mice (B16-DR4 50% survival = 0.0048). In addition, ENO1 241-260cit induced therapy of pancreatic (Pan02-DR4 50% survival = 0.0076) and lung (LLC/2-DR4 40% survival = 0.0142) tumors in HLA-DR4 transgenic mice. The unmodified epitope induced no anti-tumor response. Minimal regression of class II negative B16 or LLC/2 tumor was seen, confirming direct recognition of MHC-II was required. Most tumors only express MHC-II in the presence of IFNγ; an IFNγ inducible model showed strong responses, with rejection of tumors in up to 90% of animals ( = 0.0001). In humans, a repertoire to ENO1 241-260cit was observed in healthy donors. This response was CD4 mediated and seen in people with a variety of HLA types suggesting a broad application for this vaccine in human cancer therapy.
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http://dx.doi.org/10.1080/2162402X.2017.1390642DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5749660PMC
November 2017

Reduced risk of peanut sensitization following exposure through breast-feeding and early peanut introduction.

J Allergy Clin Immunol 2018 02 12;141(2):620-625.e1. Epub 2017 Sep 12.

Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Manitoba, Canada; Developmental Origins of Chronic Diseases in Children Network (DEVOTION), Children's Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada. Electronic address:

Background: Recent trials have shown that avoiding peanuts during infancy increases the risk of peanut allergy; however, these studies did not address maternal peanut consumption.

Objective: We sought to investigate the relationship between maternal peanut consumption while breast-feeding, timing of direct peanut introduction, and peanut sensitization at age 7 years.

Methods: Secondary analysis of a nested cohort within the 1995 Canadian Asthma Primary Prevention Study intervention study was performed. Breast-feeding and maternal and infant peanut consumption were captured by repeated questionnaires during infancy. Skin prick testing for peanut sensitization was performed at age 7 years.

Results: Overall, 58.2% of mothers consumed peanuts while breast-feeding and 22.5% directly introduced peanuts to their infant by 12 months. At 7 years, 9.4% of children were sensitized to peanuts. The lowest incidence (1.7%) was observed among children whose mothers consumed peanuts while breast-feeding and directly introduced peanuts before 12 months. Incidence was significantly higher (P < .05) if mothers consumed peanuts while breast-feeding but delayed introducing peanuts to their infant beyond 12 months (15.1%), or if mothers avoided peanuts themselves but directly introduced peanuts by 12 months (17.6%). Interaction analyses controlling for study group and maternal atopy confirmed that maternal peanut consumption while breast-feeding and infant peanut consumption by 12 months were protective in combination, whereas either exposure in isolation was associated with an increased risk of sensitization (P interaction = .003).

Conclusions: In this secondary analysis, maternal peanut consumption while breast-feeding paired with direct introduction of peanuts in the first year of life was associated with the lowest risk of peanut sensitization, compared with all other combinations of maternal and infant peanut consumption.
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http://dx.doi.org/10.1016/j.jaci.2017.06.024DOI Listing
February 2018

Obesity does not adversely affect outcomes after laparoscopic splenectomy.

Am J Surg 2013 Jul 14;206(1):52-8. Epub 2013 Feb 14.

Department of Minimally Invasive Surgery, Bariatric and Metabolic Institute, M61, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA.

Background: Obesity is still considered a relative contraindication to laparoscopic splenectomy (LS).

Methods: All patients undergoing LS at our institution were classified as obese or nonobese (group A, body mass index [BMI] >30; group B, BMI <30). Primary end points included conversion rate, operative complications, length of stay, operative time, and estimated blood loss (EBL).

Results: Three hundred seventy patients who underwent LS were included. Baseline characteristics were similar in groups A (n = 127; mean BMI, 36.2 ± 6.9 kg/m²) and B (n = 243; mean BMI, 24.6 ± 2.9 kg/m²). Conversion rates and overall morbidity were similar in both groups (9% vs 11% for conversion to open procedures, P = .621; 16% vs 16% for morbidity rates, P = .940). Length of hospital stay and EBL were also comparable (P = .643 and P = .544, respectively). Mean operative time was significantly increased in the obese group on multivariate analysis (170 vs 151 minutes, P = .021).

Conclusions: Obesity does not adversely affect outcomes after LS. The laparoscopic approach is the optimal technique for splenectomy regardless of the patient's weight.
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http://dx.doi.org/10.1016/j.amjsurg.2012.07.041DOI Listing
July 2013

Assessment of epicutaneous testing of a monovalent Influenza A (H1N1) 2009 vaccine in egg allergic patients.

Allergy Asthma Clin Immunol 2011 Feb 11;7(1). Epub 2011 Feb 11.

Section of Allergy & Clinical Immunology, Health Sciences Centre, Winnipeg, Manitoba, Canada.

Background: H1N1 is responsible for the first influenza pandemic in 41 years. In the fall of 2009, an H1N1 vaccine became available in Canada with the hopes of reducing the overall effect of the pandemic. The purpose of this study was to assess the safety of administering 2 different doses of a monovalent split virus 2009 H1N1 vaccine in egg allergic patients.

Methods: Patients were skin tested to the H1N1 vaccine in the outpatient paediatric and adult allergy and immunology clinics of the Health Sciences Centre and Children's Hospital of Winnipeg, Manitoba Canada. Individuals <9 years of age were administered 1.88 μg's of hem-agglutinin antigen per 0.25 ml dose and individuals ≥9 years were administered 3.75 μg's of hemagglutinin antigen per 0.5 ml dose. Upon determination of a negative skin test, the vaccine was administered with a 30 minute observation period.

Results: A total of 61 patients with egg allergy (history of an allergic reaction to egg with either positive skin test &/or specific IgE to egg >0.35 Ku/L) were referred to our allergy clinics for skin testing to the H1N1 vaccine. 2 patients were excluded, one did not have a skin prick test to the H1N1 vaccine (only vaccine administration) and the other passed an egg challenge during the study period. Ages ranged from 1 to 27 years (mean 5.6 years). There were 41(69.5%) males and 18(30.5%) females. All but one patient with a history of egg allergy, positive skin test to egg and/or elevated specific IgE level to egg had negative skin tests to the H1N1 vaccine. The 58 patients with negative skin testing to the H1N1 vaccine were administered the vaccine and observed for 30 minutes post vaccination with no adverse results. The patient with the positive skin test to the H1N1 vaccine was also administered the vaccine intramuscularly with no adverse results.

Conclusions: Despite concern regarding possible anaphylaxis to the H1N1 vaccine in egg allergic patients, in our case series 1/59(1.7%) patients with sensitization to egg were also sensitized to the H1N1 vaccine. Administration of the H1N1 vaccine in egg allergic patients with negative H1N1 skin tests and observation is safe. Administering the vaccine in a 1 or 2 dose protocol without skin testing is a reasonable alternative as per the CSACI guidelines.
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http://dx.doi.org/10.1186/1710-1492-7-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3045365PMC
February 2011

Successful treatment of idiopathic anaphylaxis in an adolescent.

J Allergy Clin Immunol 2010 Aug 10;126(2):415-6; author reply 416. Epub 2010 Jul 10.

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http://dx.doi.org/10.1016/j.jaci.2010.05.043DOI Listing
August 2010

Laparoscopic radiofrequency ablation of unresectable hepatocellular carcinoma: long-term follow-up.

HPB (Oxford) 2008 ;10(5):315-20

General Surgery, Cleveland Clinic, Cleveland, OH 44195, USA.

Background: Hepatocellular carcinoma (HCC) has seen a dramatic rise in the USA over the last 30 years. Unresectable disease is present in 80-90% of patients, for which radiofrequency ablation (RFA) is an option. The aim of this study is to report the long-term survival after laparoscopic RFA.

Methods: This is a prospective analysis of 104 patients who underwent 122 ablations for unresectable HCC from April 1997 to December 2006 at a tertiary care center. Overall survival (OS) and disease-free survival (DFS) were calculated using Kaplan-Meier curves, excluding 11 patients who subsequently underwent liver transplantation. Patients were analyzed using Child-Pugh classification, Barcelona Clinic Liver Cancer (BCLC) staging and various clinical parameters.

Results: Median (range) data: age 63 years (41-81), lesion size 3.5 cm (1-10), number of lesions 1 (1-5), AFP 26.5 ng/ml (3.7-43588.5) and time from diagnosis to RFA 2 months (mos) (1-42). The median Kaplan-Meier survival for all patients was 26 mos (OS) while DFS was 14 mos. Univariate analysis demonstrated improved OS for the absence vs. presence of ascites (31 vs. 15 mos, p=0.003), Bilirubin <2 mg/dl vs. > or = 2 mg/dl (27 vs. 19 mos, p=0.01), AFP <400 vs. > or = 400 (29 vs. 13 mos, p<0.0001) and Child-Pugh Grade (A = 28, B = 15, C = 5 mos, p=0.01). Significant factors for improved DFS: absence vs. presence of ascites (16 vs. 5 mos, p=0.02), Bilirubin <2 vs. > or = 2 (14 vs. 5 mos, p=0.0278), AFP <400 vs. > or = 400 (15 vs. 4 mos, p=0.0025), Child-Pugh Grade (A = 16, B = 10, C = 3 mos, p=0.03). Patient age, largest tumor size, number of lesions, INR and albumin did not reach clinical significance. Three and five-year actual survival rates are 21% and 8.3%, respectively.

Conclusions: Our study suggests that RFA may have a positive impact on survival for unresectable HCC. It also determines which patients fare best after RFA, by determining predictive factors that improve their survival.
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http://dx.doi.org/10.1080/13651820802247102DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2575683PMC
May 2010

Object categorisation, object naming, and viewpoint independence in visual remembering: evidence from young children's drawings of a novel object.

Memory 2008 ;16(6):626-36

Department of Psychology, University of Lancaster, UK.

A simple object-drawing task confirms a three-way association between object categorisation, viewpoint independence, and longer-term visual remembering. Young children (5- to 7-year-olds) drew a familiar object or a novel object, immediately after it had been hidden from view or on the following day. Both objects were shown from a full range of viewpoints or from just two viewpoints, from neither of which would either object normally be drawn after unrestricted viewing. When drawing from short-term memory after restricted viewing, both objects were most likely to be depicted from a seen viewpoint. When drawing from longer-term memory after restricted viewing, the novel object continued to be drawn from a seen viewpoint, but the mug was now most likely to be drawn from a preferred viewpoint from which it had not been seen. Naming the novel object with a novel count noun ("Look at this. This is a dax"), to signal that it belonged to an object category, resulted in it being drawn in the same way as the familiar object. The results concur with other evidence indicating that short-term and longer-term visual remembering are differentially associated with viewpoint-dependent representations of individual objects and viewpoint independent representations of object categories, respectively.
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http://dx.doi.org/10.1080/09658210802135369DOI Listing
November 2008

Efficacy of laparoscopic mesenteric/retroperitoneal lymph node biopsy.

Surg Endosc 2009 Feb 7;23(2):389-93. Epub 2008 May 7.

Cleveland Clinic, 9500 Euclid Ave/A80, Cleveland, OH 44195, USA.

Background: Lymphadenopathy-identified incidentally during computed tomography (CT) mandates a tissue diagnosis. When percutaneous techniques are not possible, surgical tissue diagnosis becomes necessary. Laparotomy is the current gold standard; however a laparoscopic approach offers many potential benefits.

Methods: This institutional review board (IRB)-approved study evaluated all patients undergoing laparoscopic retroperitoneal lymph node biopsy from 2001 to 2007 at the Cleveland Clinic. Patient records were retrospectively reviewed for age, sex, pathologic diagnosis, conversion to laparotomy, and perioperative complications.

Results: A total of 30 cases were reviewed. In this group, 67% were males and 33% were female; mean age was 48 years. Ten patients underwent mesenteric lymph node sampling and 20 (67%) underwent retroperitoneal tumor resection. There were four (17%) conversions and no complications. Lymphoma was the most common pathologic finding.

Conclusion: Laparoscopic lymph node biopsy is a safe effective alternative to open surgical biopsy.
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http://dx.doi.org/10.1007/s00464-008-9935-7DOI Listing
February 2009

Diagnostic laparoscopy for chronic abdominal pain after gastric bypass.

Surg Obes Relat Dis 2008 May-Jun;4(3):394-8; discussion 398. Epub 2008 Apr 14.

Bariatric and Metabolic Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA.

Background: To evaluate, in an observational study, the utility of diagnostic laparoscopy as a tool to evaluate patients with abdominal pain of unknown etiology after gastric bypass surgery.

Methods: A retrospective analysis was performed of data from patients who had undergone laparoscopy for diagnosis or treatment of abdominal pain. This study included 13 patients with negative preoperative radiographic and/or endoscopic findings.

Results: A total of 13 patients who had undergone Roux-en-Y gastric bypass underwent diagnostic laparoscopy for abdominal pain. The findings included internal hernia (4), adhesions (3), ventral hernia (2), partial small bowel obstruction (1), and chronic cholecystitis (1). There were 2 negative laparoscopies, while a diagnosis was made in 85%. After an average follow-up of 3.2 months, 7 of 11 patients had unresolved abdominal pain and 4 patients experienced pain resolution (2 patients were lost to follow-up).

Conclusion: The results from this small retrospective study suggest that significant pathologic findings can be identified in most patients who have negative preoperative evaluation findings; however, the efficacy of diagnostic laparoscopy to eliminate pain in this patient population requires additional study. Despite the potential complications, we believe that diagnostic laparoscopy has a role in the diagnosis and treatment of chronic abdominal pain after gastric bypass.
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http://dx.doi.org/10.1016/j.soard.2007.12.011DOI Listing
October 2008

Influence of obesity and surgical weight loss on thyroid hormone levels.

Surg Obes Relat Dis 2007 Nov-Dec;3(6):631-5; discussion 635-6

Department of General Surgery, Bariatric and Metabolic Institute, Cleveland Clinic, Cleveland, Ohio 44195, USA.

Background: The pathophysiologic relationship between morbid obesity and thyroid hormones is not well understood. The goal of this study was to evaluate the influence of obesity and weight reduction after bariatric surgery on thyroid hormone levels.

Methods: Patients who underwent gastric bypass or adjustable gastric banding at our institution, had no previous diagnosis of thyroid disorder, were not taking medication that could affect the thyroid function evaluation, and who were nonsmokers were included in this retrospective evaluation. The association between the thyroid-stimulating hormone (TSH) and free thyroxine (T(4)) levels and body mass index (BMI), and the influence of weight loss after bariatric surgery on these hormones were investigated at different points (preoperatively and 6 and 12 months after bariatric surgery).

Results: A total of 86 patients met the study criteria. The TSH levels correlated positively with BMI (P <.001, r = .91) within the BMI range of 30-67 kg/m(2). The mean BMI change from 49 to 32 kg/m(2) after bariatric surgery was associated with a mean reduction in the TSH level from 4.5 to 1.9 microU/mL. Free T(4) showed no association with BMI and was not significantly influenced by weight loss. Before bariatric surgery, 10.5% of the subjects had laboratory values consistent with subclinical hypothyroidism. After bariatric surgery, 100% of these patients experienced significant weight reduction with simultaneous resolution of their subclinical hypothyroidism.

Conclusion: The results of our study have demonstrated a statistically significant positive association between serum TSH within the normal range and BMI. No association was found between BMI and free T(4) serum levels. The prevalence of subclinical hypothyroidism in study group was 10.5%. Weight loss after bariatric surgery improved or normalized thyroid hormone levels.
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http://dx.doi.org/10.1016/j.soard.2007.07.011DOI Listing
February 2008

Asthma hospitalization patterns in young children relating to admission age, infection presence, sex, and race.

Ann Allergy Asthma Immunol 2007 Feb;98(2):139-45

Department of Medicine, St Vincent's Hospital Manhattan, Saint Vincent Catholic Medical Centers, New York, New York 10011, USA.

Background: Although childhood hospitalizations for asthma are common, there are few detailed temporal and demographic descriptions of these hospitalizations.

Objective: To relate temporal patterns of asthma hospitalization in young children to admission age, sex, comorbid infection, and race.

Methods: Retrospective analysis of 151,391 New York State hospitalizations with a principal diagnosis of asthma between January 1, 1990, and December 31, 2004, in children younger than 5 years. Admission patterns across time were related to admission age, sex, race, and comorbid diagnoses of common infections.

Results: Although the overall hospitalization rate decreased, it was still 63.8 per 10,000 in 2004. Higher hospitalization rates were consistently observed in children younger than 3 years, African Americans, and boys. Fall increases and summer declines in overall monthly hospitalization rates and monthly median ages exemplified the seasonality observed in the study population. However, admissions with concomitant common infections peaked in the winter, not fall months. Sex did not affect the observed seasonality. Compared with white patients, African Americans not only manifested more than 3-fold higher hospitalization rates but also more repeated hospitalizations.

Conclusions: The concurrent cyclical increases in median age and monthly admissions suggest that seasonal factors affecting older children may relate to fall increases in asthma admissions. These fall peaks are not accounted for by recognizable concomitant common respiratory tract infections. Understanding the basis for these seasonal variations may lead to prevention strategies that could decrease asthma admissions. Asthma hospitalizations in young children continued to be highly prevalent in New York State, especially in African American patients.
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http://dx.doi.org/10.1016/S1081-1206(10)60686-2DOI Listing
February 2007
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