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First and most important, I think, is, if you could tell us a little bit more about your definition of NASH and how you identified these patients. [...]did you look to see if there was a difference between operations, as they have differential metabolic effects, gastric bypass and diabetes and metabolic syndrome compared to a lap band or sleeve gastrectomy, for example? Because that seems pretty low for the general population.

Laparoscopy has meant profound changes for the field of bariatric surgery. Bariatric operations, which are technically difficult because of the patient population, were not performed laparoscopically until the last 5 years of the 20th century. The years 1998 to 2003, herein defined as the Bariatric Revolution, saw profound changes in the way bariartric surgery was practiced. Major changes in patient education, public awareness, patient enthusiasm, popularity of the surgery, and academic acceptance of bariatric surgery occurred during this time. This led to such a massive increase in procedures performed that there was a reactionary movement by insurers to deny coverage for these procedures. Limitation of access to care and other important socioeconomic issues are now being debated and confronted in the bariatric arena. Recommendations for the field are suggested. The outcomes of these controversies will potentially have a profound impact on all of surgery.

Detection of disseminated tumour cells (DTCs) in bone marrow by immunocytochemistry (ICC) includes morphological evaluation of cytokeratin immunopositive cells. The aim of this study was to disclose the prognostic significance of different morphological categories of ICC-positive cells according to treatment status and tumour subtype. Bone marrow samples (at surgery) were analysed for the presence of cytokeratin-positive DTCs by a standard immunocytochemical method. The immunopositive cells were classified into the following categories, prior to any analysis of the association between DTCs and clinical outcome: tumour cells (TC), uninterpretable cells (UIC), hematopoietic cells (HC), and questionable HC (QHC). The analysis included 747 early breast cancer patients. Median follow-up was 84 months for relapse, and 99 months for death. The categorisation of the ICC positive cells revealed TC in 13.3 % of the patients, whereas 13.1, 17.8, and 21.4 % of the cases were positive for UIC, QHC, and HC, respectively. Analysing all patients, only TC and UIC predicted systemic relapse. Separate analysis of all patients not receiving adjuvant systemic treatment (No-Adj; n  = 389) showed that only QHC were associated with reduced survival (DDFS: p  = 0.008; BCSS: p  = 0.004, log rank) and the presence of QHC also remained significant in multivariate analysis. Primary tumour subgroup analysis (of all patients) by hormone receptors (HR) and HER2, demonstrated that only TC/UIC had prognostic impact in the HR+/HER2− patients, whereas presence of QHC was associated with unfavourable outcome only in triple negative patients (DDFS: p  = 0.004; BCSS: p  = 0.024). Patients with ≥3HC had improved outcome compared to those with fewer/no HC (DDFS: p  = 0.005; BCSS: p  = 0.009). Hence, morphological DTC subgroups may differ in clinical significance according to primary tumour subtype and treatment status. This emphasises the importance of DTC characterisation, and separate analyses of DTC categories according to tumour subtype. Hematopoietic (“false positive”) cells might predict an immune-related favorable clinical outcome.

Background: Early-stage non-small cell lung cancer (NSCLC) patients have a high risk of disease relapse despite curatively intended surgical resection, and the detection of tumour cells in the bone marrow could be one method of determining the presence of the disseminated disease in its early stages. Methods: Bone marrow aspirates were collected from 296 patients at the time of surgery, and the presence of disseminated tumour cells was determined with the help of immunomagnetic selection (IMS) using the MOC31-antibody recognising EpCAM and with the help of standard immunocytochemistry (ICC) using the anti-cytokeratin (CK) antibodies AE1/AE3. Results: Disseminated tumour cells were found in 152 of 252 (59%) bone marrow samples using IMS and in 25 of 234 (11%) samples using ICC. No association between the two detection methods was observed. The presence of EpCAM + cells was not associated with any clinicopathological parameters, whereas a higher frequency of CK + cells was found in patients with an advanced pT status. Disseminated tumour cells, as detected using IMS, had no prognostic impact. Patients with CK + cells in the bone marrow had a reduced relapse-free survival, but the difference was not statistically significant. Conclusion: Our findings do not support the further development of DTC detection for clinical use in early-stage NSCLC. Future studies should include the molecular characterisation of DTCs, along with an attempt to identify subpopulations of cells with biological and clinical significance.

Background Bariatric surgery is a rapidly growing field. Advances in surgical technologies and techniques have raised concerns about patient safety. Bariatric surgeons and programs are under increased scrutiny from regulatory agencies, insurers, and public health officials to provide high quality and safe care for bariatric patients at all phases of care. Methods During the 2009 annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), a panel of experts convened to provide updated information on patient safety and best practices in bariatric surgery. The following article is a summary of this panel presentation. Results and Conclusions Weight loss surgery is a field that is evolving and adapting to multiple external pressures. Safety concerns along with increasing public scrutiny have led to a systematic approach to defining best practices, creating standards of care, and identifying mechanisms to ensure that patients consistently receive the best and most effective care possible. In many ways, bariatric surgery and multidisciplinary bariatric surgery programs may serve as a model for other programs and surgical specialties in the near future.

The long-term course of schizophrenia is often characterized by relapses, induced by poor medication adherence. Early nonadherence after discharge is frequent. To evaluate a skills-based inpatient training program for medication intake. We developed a manual-based inpatient medication training program to be carried out by nurses and focusing on practical skills enabling autonomous intake of medication. Medication adherence was measured by three different methods: pill count, determination of serum levels, and self-assessment by the patient. The raters were blinded. Four weeks after discharge, 98% of the patients in the intervention group (N=52) were rated as adherent by pill count versus 76% in the control group (N=50; P<0.01). By measurement of serum level, 88.5% versus 70% were adherent (P<0.05). The inpatient medication training program carried out by nurses seems to be an effective intervention for enhancing medication adherence after hospital discharge.

In this topical issue of The Journal of Special Education, leading scholars in special education reviewed the literature and investigated whether special education is, indeed, special by examining to what degree (a) effective techniques have been developed for students with disabilities, (b) these effective techniques are applied and implemented with fidelity, and (c) utilization of these techniques is unique to special education. In this article, the authors analyze findings from this special issue regarding what is special—effective, implemented, and unique—about special education. The authors found that effective, empirically supported practices have been developed for students with disabilities, that these techniques are used predominantly in special education, and that these effective practices are not implemented regularly or with fidelity. Recommendations to enhance the implementation of effective, research-based practices are offered.

The purpose of this study was to decrease the number of inappropriate orders for total parenteral nutrition (TPN) in surgical patients. From February 1999 through November 2000 and between July 2001 and June 2002, the surgeon-guided adult nutrition support team (NST) at a university hospital monitored new TPN orders for appropriateness and specific indication. In April 1999, the NST was given authority to discontinue inappropriate TPN orders. Indications, based on the American Society for Parenteral and Enteral Nutrition (ASPEN) standards, included short gut, severe pancreatitis, severe malnutrition/catabolism with inability to enterally feed ≥5 days, inability to enterally feed ≥50 per cent of nutritional needs ≥9 days, enterocutaneous fistula, intraabdominal leak, bowel obstruction, chylothorax, ischemic bowel, hemodynamic instability, massive gastrointestinal bleed, and lack of abdominal wall integrity. The number of inappropriate TPN orders declined from 62/194 (32.0%) in the first 11 months of the study to 22/168 (13.1%) in the second 11 months (P < 0.0001). This number further declined to 17/215 (7.9%) in the final 12 months of data collection, but compared to the second 11 months, this decrease was not statistically significant (P = 0.1347). The involvement of a surgical NST was associated with a reduction in inappropriate TPN orders without a change in overall use.

Obesity is a growing health problem that contributes to numerous life-threatening or disabling disorders, including coronary artery disease, hypertension, type 2 diabetes mellitus, hyperlipidemia, degenerative joint disease, and obstructive sleep apnea. Significant weight reduction in the morbidly obese improves or reverses associated illness and benefits well-being. The purpose of the SAGES Appropriateness Conference was to summarize the state of the art for open and laparoscopic operations for the morbidly obese. The English literature comparing bariatric procedures was reviewed and grouped by level of evidence by three surgeons (BS, LV, and CC). From more than 1,500 articles, all conference participants were provided with reprints and table summaries of no less than 50 selected manuscripts. Ten experts were requested to present reviews and make evidence-based arguments for and against the open and laparoscopic approaches in written format. An expert panel of six surgeons, including an ethicist and patient, commented on implications of data presented. The finalized statement was e-mailed to all participants for approval and comment. Consensus statements were achieved on various aspects of morbid obesity, including indications for surgery, resolution of comorbid illnesses with significant weight loss, and the importance of committed bariatric program. Our panel of experts agreed, in general, to the advantages of laparoscopic approaches compared to open operations in skilled hands. Laparoscopic Roux-en-Y gastric bypass (RYGB) affords improved short-term recovery compared to open gastric bypass. Laparoscopic adjustable banding can be performed with lower average mortality than either RYGB or any of the malabsorptive operations, and it produces variable degrees of short-term weight loss. Prospective randomized trials are needed to compare gastric bypass, malabsorptive, and restrictive procedures.

Controversial interpretations have been given to the postprandial increase in the dominant power (amplitude) of the electrogastrogram (EGG). The aim of this study was to find an appropriate interpretation of the postprandial EGG power changes. Simultaneous serosal and cutaneous recordings of gastric myoelectrical activity were made in 11 patients with gastroparesis in the fasting state and after the ingestion of 8 oz of water. The dominant frequency and corresponding power of the recording before and after water were computed using the power spectral analysis method. It was found that the dominant frequency of the EGG was the same as that of the serosal recording in 10 patients. One patient showed a substantial amount of dysrhythmia and no obvious dominant frequency was noted. A decrease in the dominant frequency was found in these 10 patients after the ingestion of water. Tachygastria of higher than 4 cycles/min was observed in one of 11 patients both in the prewater and postwater states. Consistent changes in amplitude after a drink of water were noted in both serosal recording and EGG. Statistical analysis demonstrated that the dominant power change after water computed from the EGG was correlated with that observed in the serosal recording (r = 0.757, P = 0.007). In conclusion, exogenous stimulation, such as ingestion of water, may change the amplitude of the gastric slow wave and this change is reflected in the EGG, suggesting that the change of the slow-wave amplitude is an important contributing factor to the postprandial change in the EGG dominant power.