Complete Follow-up Of Patients Research Articles

Real-world performance of a multi-cancer early detection test based on integrative analysis of cell-free DNA whole-methylome sequencing.

10521 Background: Early detection and diagnosis is key to reducing cancer-related mortality. We developed a blood-based multi-cancer early detection test, called THEMIS, using multimodal analysis of plasma cell-free DNA (cfDNA) methylation, fragmentation, and copy number alteration features by whole-methylome sequencing (WMS). The real-world performance of THEMIS was investigated with a prospective cohort of high-risk populations and the preliminary results were reported here. Methods: A total of 1,374 adults over 65 y with additional cancer risk factors for five common cancers (colorectal, esophageal, liver, lung, or stomach cancer) were recruited in the city of Wuxi, Jiangsu province, China. Additional risk factors included fecal occult blood, smoking history, H. pylori infection, HBV infection, and serum protein biomarkers. Participants had no known cancer diagnosis at the time of administration. Blood samples were collected and subject to low-pass WMS assay (~2X) and cancer probability was predicted by the THEMIS model, which was developed and locked in previous studies. Participants predicted as cancer positive by THEMIS were followed up until positive cancer diagnosis in a clinic or one year after receiving the test report, whichever was earlier. Results: At a fixed cutoff rendering 99% training specificity, THEMIS predicted 58 (4.15%) positive cases, among whom 19 participants consented to and completed follow-up. Ten participants received confirmed cancer diagnosis within the follow-up period, including five lung cancers, three liver cancers, one esophageal cancer, and one colorectal cancer. These results yielded a positive predictive value (PPV) of 52.6%. Those who declined follow-up upon a positive THEMIS report were predicted with digestive tract cancers, which need gastrointestinal endoscope for diagnostic confirmation. Conclusions: The nonivasive blood-based THEMIS test demonstrated promising performance and patient compliance for clinical utility to detect cancer early and improve patient outcome. Given that clinical follow-ups were only conducted with a subset of participants, future investigations of the precise real-world performance of THEMIS are needed with more complete patient follow-up.

Open vs. Minimally Invasive Radical Hysterectomy in Early Cervical Cancer: LACC Trial Final Analysis (LBA 10)

<b>Objectives:</b> To report on the overall survival outcomes and subgroup analysis of the LACC trial after all patients have completed surveillance at 4.5 years. <b>Methods:</b> Prospective non-inferiority randomized trial of patients with FIGO 2009 stage IA1 (LVSI)-IB1 cervical cancer with histologic subtype of squamous-cell carcinoma, adenocarcinoma, or adenosquamous carcinoma who underwent open or minimally invasive surgery. The aim of this analysis is to report on final overall survival outcomes at 4.5 years with all patients completing follow-up. Subgroup analysis will be performed to determine outcomes based on factors that might impact rates of recurrence and disease-specific survival. <b>Results:</b> A total of 631 patients (319 MIS and 312 open surgery) were evaluated. The rate of disease-free survival at 4.5 years will be reported for both surgical approaches. Rates of overall survival will also be reported. Sub-group analysis evaluating recurrence rates and disease-free survival for minimally invasive surgery vs open surgery will be performed stratifying by rates of tumor size (<2 cms), prior conization, and residual disease in the hysterectomy specimen. Site of recurrences for both groups will be evaluated as well as percentage of recurrences manifesting as carcinomatosis. <b>Conclusions:</b> Outcomes and subgroup analysis for complete follow-up of patients undergoing open vs minimally invasive radical hysterectomy will be provided.

O-L06 The use of tumour marker Ca19.9 in the follow up of patients with resected biliary tract cancer: Results from the BILCAP randomised clinical trial

Abstract Background Even after resection biliary tract cancer has a poor outlook. Follow-up is commonly utalises and the sialyl-Lewis tetra saccharide antigen Ca19.9, a known tumour marker in pancreatic and biliary malignancy (upper limit of normal (ULN) 37U/ml). However, the evidence base for the utility of Ca19.9 is limited. The UK BILCAP trial examined the use of adjuvant capecitabine chemotherapy in resected biliary tract cancer and establishing a new global standard of care. Ca19.9 was regularly measured as part of the BILCAP protocol, this provides an opportunity to assess the use of this marker in a large trial with complete patient follow-up. Methods Between March 2006 and December 2014 447 patients underwent resectional surgery (R0 or R1) then were randomised to receive capecitabine chemotherapy or observation. CT imaging and Ca19.9 were performed 3 monthly in year 1, 6 monthly in year 2, and annually thereafter up to 5 years. Follow up was continued until all patients had 5 years follow-up. Recurrence was based mainly on imaging criteria combined with the clinical presentation. The cohort was divided into progression and non- progression groups and the Ca19. 9 values recorded were investigated using descriptive analyses with cut-off of 37 (ULN), 100 and 400U/ml. Results Of 447 study patients 440 had at least one Ca19.9 measurement from either post-operative baseline (394) or a follow-up visit (422). Baseline Ca19-9 was elevated above 37U/ml in 96 patients and 82 (85%) went on to develop recurrence. The sensitivity, specificity, positive predictive value (PPV) and negative predictive values (NPV) of the Ca19.9 on follow up are shown in the table. Conclusions Although high Ca19.9 levels predict recurrence as shown by acceptable positive predictive values at cut-offs of 100 and 400U/ml the negative predictive values are very poor as most patients develop recurrence without elevation of Ca19.9. Ca19.9 measurement is of very limited value in the follow up of patients with resected biliary cancer.

Electronic early notification of sepsis in hospitalized ward patients: a study protocol for a stepped-wedge cluster randomized controlled trial

BackgroundTo evaluate the effect of screening for sepsis using an electronic sepsis alert vs. no alert in hospitalized ward patients on 90-day in-hospital mortality.MethodsThe SCREEN trial is designed as a stepped-wedge cluster randomized controlled trial. Hospital wards (total of 45 wards, constituting clusters in this design) are randomized to have active alert vs. masked alert, 5 wards at a time, with each 5 wards constituting a sequence. The study consists of ten 2-month periods with a phased introduction of the intervention. In the first period, all wards have a masked alert for 2 months. Afterwards the intervention (alert system) is implemented in a new sequence every 2-month period until the intervention is implemented in all sequences. The intervention includes the implementation of an electronic alert system developed in the hospital electronic medical records based on the quick sequential organ failure assessment (qSOFA). The alert system sends notifications of “possible sepsis alert” to the bedside nurse, charge nurse, and primary medical team and requires an acknowledgment in the health information system from the bedside nurse and physician. The calculated sample size is 65,250. The primary endpoint is in-hospital mortality by 90 days.DiscussionThe trial started on October 1, 2019, and is expected to complete patient follow-up by the end of October 2021.Trial registrationClinicalTrials.gov NCT04078594. Registered on September 6, 2019

Validation of the importance of neutrophil-to-lymphocyte ratio in non-muscle invasive bladder cancer

Background and objective: Since the peritumoral inflammatory reaction is of considerable importance in the oncological prognosis of bladder cancer, the neutrophil-to-lymphocyte ratio (NLR) may be a very practical and accessible biomarker in non-muscle invasive bladder tumors. This study aims to analyze parameters of non-muscle invasive bladder tumors and to identify and validate potential tumor markers with a prognostic role in this condition. Material and methods: 463 patients diagnosed with non-muscle invasive urothelial tumors, between January 2016 and June 2020, hospitalized at the Urology Clinic in Târgu Mureș, after transurethral resection of bladder tumor (TURBT) were investigated. Inclusion criteria were: non-muscle invasive tumors (Ta, T1, CIS), neutrophil-to-lymphocyte ratio (NLR) determination 2 weeks prior to TURBT and complete follow-up of patients. NLR cut-off was set at 3. Results: 371 people diagnosed with non-muscle invasive bladder tumors met the inclusion criteria. The mean age of the included patients was 69.96 years (IQR 35–93). 297 (80.05%) were male and 74 (19.95%) were female. 64.95% pTa tumors, 31.26% pT1, 1.07% pTa + CIS, and 2.69% pT1 + CIS, respectively, were identified. Distribution according to Grade: 196 (52.8%) G2, 159 (42.88%) G3 and 16 (4.32%) CIS. 284 (76.5%) patients presented with a single tumor and 87 (23.35%) with multiple tumors; 295 (79.5%) had tumors larger than 3 cm and 76 (20.5%) smaller than 3 cm. 228 (61.4%) presented with recurrence after 3 months after surgery. Overall survival at 5 years was 80.06%. Advanced age at the time of diagnosis correlated with low survival, p = 0.004. The mortality rate was higher among men (20.54%) than among women (17.58%). Statistically, there was a positive relationship between the increased ratio of neutrophils and lymphocytes in people diagnosed with non-muscle invasive bladder cancer and increased mortality rate, p = 0.003. Conclusions: The overall survival of patients with non-muscle invasive bladder cancer was negatively influenced by the advanced age of the patients at the time of diagnosis. Increased preoperative NLR was associated with a higher mortality rate in patients with non-muscle invasive bladder cancers. This assay is an accessible, easy to performand useful biomarker in the prognosis of non-muscle invasive bladder tumors.

Screening and Surveillance Colonoscopy and COVID-19: Avoiding More Casualties

Screening and Surveillance Colonoscopy and COVID-19: Avoiding More Casualties

3:27 PM Abstract No. 75 Implementation of an automated patient follow-up system in a low-resource setting

Timely and consistent patient follow-up has been a challenge while establishing a comprehensive interventional radiology (IR) service and training program in Tanzania. Currently, trainees are responsible for personally calling patients at 1 and 3 months postprocedure. This arrangement has become increasingly burdensome as patient volume continues to grow, often requiring trainees to make up to 10 calls a day in addition to daily procedures and clinical duties. With Tanzanian mobile phone use increasing, an automated text-messaging follow-up system has been devised as a possible solution to this challenge. With no functioning electronic medical record in place, the new IR service has relied on REDCap for organizing and tracking procedural and patient data. Twilio, a REDCap compatible web service that can administer automated text-messaging surveys, is now being added to improve follow-up rates. Patients can respond with yes or no and add an explanation. Costs range from $0.04 to $0.09 per text, depending on the patient’s mobile carrier. A survey consisting of six questions was written in English and translated into Swahili. This survey was then built into the Twilio web app. Code was written in Python and PHP to allow for exchange of patient information and survey data between REDCap and Twilio. Tanzanian IR trainees will review survey results weekly and determine which patients require additional follow-up via phone call or clinic appointment. The automated follow-up system is scheduled to be fully operational by October 2019. Response rates and follow-up data for the first five months will be presented. Establishment of a new specialty in a low-resource setting requires creative solutions to ensure care is made available to as many patients as possible. Implementation of an automated text-messaging follow-up system may allow for more efficient allocation of resources and more effective and complete patient follow-up.

Appropriate use of antifungals: impact of an antifungal stewardship program on the clinical outcome of candidaemia in a French University Hospital.

The objective of this study was to compare clinical outcomes of patients with candidaemia before and after implementation of an antifungal stewardship program (AFSP). This study included all consecutive cases of candidaemia identified from January 2012 to December 2015 in a French University Hospital. Data were collected retrospectively for a period of 2years before implementation of the AFSP, and prospectively for 2years after. All cases were reviewed by a multidisciplinary panel of experts including infectiologists, a microbiologist and pharmacists to have a complete follow-up of patients. 33 and 37 patients were finally included in the first and second period, respectively. The sites of entry of the candidaemia cases studied were as follows: intraabdominal in 29 cases (41.4%), central venous catheter 21 (30.0%), other or unknown: 20 (28.6%). Infectiologist consultations increased from 36.4 to 86.5% between the two periods with a significative impact on daily blood cultures which were more frequently performed in the second period (p = 0.04), and the use of echinocandins which was more frequent in the second period (97.1% of cases vs 78.8%, p = 0.03). The 3-month mortality rate declined from 36.4% in the first period to 27.0% in the second period (p = 0.4). Despite the insufficient number of candidaemia cases and the presence of other unmodifiable risk factors of mortality which did not allow us to show a significant effect on the 3-month mortality, AFSP had a significant effect on daily blood cultures and echinocandin use as first-line therapy.

Pilot-testing an adverse drug event reporting form prior to its implementation in an electronic health record.

BackgroundAdverse drug events (ADEs), harmful unintended consequences of medication use, are a leading cause of hospital admissions, yet are rarely documented in a structured format between care providers. We describe pilot-testing structured ADE documentation fields prior to integration into an electronic medical record (EMR).MethodsWe completed a qualitative study at two Canadian hospitals. Using data derived from a systematic review of the literature, we developed screen mock-ups for an ADE reporting platform, iteratively revised in participatory workshops with diverse end-user groups. We designed a paper-based form reflecting the data elements contained in the mock-ups. We distributed them to a convenience sample of clinical pharmacists, and completed ethnographic workplace observations while the forms were used. We reviewed completed forms, collected feedback from pharmacists using semi-structured interviews, and coded the data in NVivo for themes related to the ADE form.ResultsWe completed 25 h of clinical observations, and 24 ADEs were documented. Pharmacists perceived the form as simple and clear, with sufficient detail to capture ADEs. They identified fields for omission, and others requiring more detail. Pharmacists encountered barriers to documenting ADEs including uncertainty about what constituted a reportable ADE, inability to complete patient follow-up, the need for inter-professional communication to rule out alternative diagnoses, and concern about creating a permanent record.ConclusionPaper-based pilot-testing allowed planning for important modifications in an ADE documentation form prior to implementation in an EMR. While paper-based piloting is rarely reported prior to EMR implementations, it can inform design and enhance functionality. Piloting with other groups of care providers and in different healthcare settings will likely lead to further revisions prior to broader implementations.

Bariatric Surgery Provides a "Bridge to Transplant" for Morbidly Obese Patients with Advanced Heart Failure and May Obviate the Need for Transplantation.

In patients with advanced heart failure, morbid obesity is a relative contraindication to heart transplantation due to higher morbidity and mortality in these patients. We performed a retrospective analysis of consecutive morbidly obese patients with advanced heart failure who underwent bariatric surgery for durable weight loss in order to meet eligibility criteria for cardiac transplantation. Seven patients (4 M/3 F, age range 31-56 years) with left ventricular ejection fraction (LVEF) ≤ 25 % underwent laparoscopic bariatric surgery. Median preoperative body mass index (BMI) was 42.8 kg/m(2) (range 37.5-50.8). There were no major perioperative complications in six of seven patients. Median length of hospital stay was 5 days. There was no mortality recorded during complete patient follow-up. At a median follow-up of 406 days, median BMI reduction was 12.9 kg/m(2) (p = 0.017). Postoperative LVEF improved to a median of 30 % (interquartile range (IQR) 25-53 %; p = 0.039). Two patients underwent successful cardiac transplantation. Two patients reported symptomatic improvement with little change in LV function and now successfully meet listing criteria. Three patients showed marked improvement of their LVEF and functional status, thus removing the requirement for transplantation. Bariatric surgery can achieve successful weight loss in morbidly obese patients with advanced cardiac failure, enabling successful heart transplantation. In some patients, cardiac transplantation can be avoided through surgical weight loss.

The Need for Large Clinical Studies in Perioperative Medicine

The Need for Large Clinical Studies in Perioperative Medicine

Vascular Dysfunction in Sleep Apnea

See related article, pp 417–424 Cardiovascular disease remains one of the leading causes of morbidity and mortality. Obstructive sleep apnea (OSA) has been increasingly implicated in a breadth of cardiovascular diseases, including systemic hypertension, heart failure, stroke, arrhythmias, myocardial ischemia, and pulmonary arterial hypertension.1 The importance of this association, especially in the context of OSA as an etiologic factor, is compellingly relevant to disease management strategies, given the high prevalence of OSA and its likely rising trajectory secondary to the ongoing obesity epidemic.2 OSA may be present in approximately 20% of American adults, only a minority of whom have ever been diagnosed; this is true even for patients with established cardiovascular disease3 and despite the widespread availability of several effective treatment modalities (including continuous positive airway pressure [CPAP]). It is only over the past 2 decades that serious investigative interest has been paid to the interactions between OSA and cardiac and vascular disease and dysfunction. Deciphering the mechanisms, causal relationships, and potential therapeutic targets in the links between OSA and cardiovascular morbidity has not been an easy task, in part because of the constellation of comorbidities that characterize a large proportion of sleep apnea patients. OSA leads to multiple sources of cardiovascular stress, including nocturnal hypoxemia and hypercapnia, precipitous intrathoracic pressure changes, repetitive arousals, and poor sleep quality with consequent sleep deprivation. These, in turn, have been linked to endothelial dysfunction,4 systemic inflammation, sympathetic activation,5 metabolic dysregulation, hypercoagulability, and atrial enlargement, the combination of which may contribute to the initiation and progression of a range of cardiovascular diseases. Of these, endothelial dysfunction …

Application of multistate models in hospital epidemiology: Advances and challenges

Survival analysis has established itself as a major statistical technique in medical research. Applications in hospital epidemiology, however, are only beginning to emerge. One reason for this delay is that usually complete follow-up of patients in hospital is feasible. This overview discusses where survival techniques provide additional insight into hospital epidemiology, and where they are, in fact, needed even in the absence of right-censoring.

Second INTERMACS annual report: More than 1,000 primary left ventricular assist device implants

The Interagency Registry For Mechanical Circulatory Support (INTERMACS)1 an NHLBI-sponsored collaboration between the National Heart, Lung, and Blood Institute (NHLBI), the Food and Drug Administration (FDA), the Center for Medicaid and Medicare Services (CMS), and the advanced heart failure/mechanical circulatory support professional community, began prospective patient enrollment and data collection on June 23, 2006. On 3/27/09, CMS mandated that all United States hospitals approved for mechanical circulatory support as Destination Therapy (DT) must enter mechanical circulatory support patient data into a national database, INTERMACS. The power of INTERMACS data stems from the mandatory data submission on all durable mechanical circulatory devices, a formal process for adverse event adjudication, dedicated innovative electronic data submission, data element design to create a template for comparison with medical therapy, rigorous data monitoring, hospital auditing through the United Network of Organ Sharing, and a formal process for data access and publications. Since the inception of INTERMACS, an ongoing evolution of both strategies for device application and the types of available devices has continued to refine the landscape of mechanical circulatory support. Throughout this experience, the only device approved in the United States for permanent “destination” therapy was the HeartMate XVE2, a pulsatile ventricular assist device which is now known to frequently develop bearing wear and require device replacement within 2 years of implantation. Yet, in many countries outside the United States, newer axial flow and centrifugal flow rotary pumps provide chronic circulatory support. INTERMACS only collects data on devices which are FDA-approved for clinical use, and no adult rotary pump was approved in the United States for the first several years of the INTERMACS experience. The spectrum of devices entered into INTERMACS must also be viewed in the context of multiple concurrent U.S. clinical trials of continuous flow pumps implanted as bridge-to-transplant therapy as well as permanent support. Thus, for the first 2 years, despite the rigorous requirements for data completeness and accuracy, INTERMACS suffered from its inability to collect data on newer, more promising rotary pumps which were not yet FDA approved. The INTERMACS playing field changed dramatically in April of 2008, when the HeartMate II axial flow pump received FDA approval for clinical use as bridge-to-transplant therapy in the United States. A portion of this report will examine the changing practice patterns in the application of device type (continuous flow vs. pulsatile) and device strategies over the past three years. In fact, the genesis of INTERMACS, partly by chance and partly by design, uniquely positioned this database to observe, record, and analyze this historical transition (at least for the immediate future) from larger, powerful pulsatile pumps to the world of continuous flow technology, with the unproven promise of greater durability while retaining long-term patient functionality. This report begins the process of long-term evaluation of continuous flow technology against the background of a large registry of detailed patient and device data based on pulsatile pump technology.

Mechanical Heart Valves

The report by Svennevig and colleagues in this issue of Circulation will stand as an important contribution to our knowledge of the outcomes after heart valve replacement.1 This article, along with other extensive published series of patients followed up for as many as 4 decades after mechanical heart valve replacement, now help form the basis on which present and future decisions are made for patients with valvular heart disease. Article p 1795 Decades ago, the properties of an ideal valve replacement were described by the late Dr Dwight Harken, a pioneer in cardiac surgery2; included in these properties are durability (at least as good as a native valve), no thrombogenicity (hence, warfarin anticoagulation not required), no inherent gradient, and easy to implant. How close a prosthetic heart valve approaches these ideals can only be determined after large numbers of implants, assiduous management of anticoagulation, complete patient follow-up, and the test of time… decades. Because mechanical aortic valves are generally implanted in younger patients, the interaction of the prosthesis with the patient, the propensity (or lack thereof) of tissue ingrowth that can interfere with valve function, the long-term structural integrity, and the thrombogenicity and relative resistance to variability in anticoagulation can only be determined with the patient population size and duration of thorough follow-up reported in this issue of Circulation for the Hall-Medtronic prosthesis, as well as in previous publications for other mechanical heart valves. To date, no mechanical or bioprosthetic valve prosthesis has achieved the ideal profile described by Harken. However, we now recognize that some available valve prostheses may approach these ideal properties, and this type of long-term outcome study should guide prosthesis selection as we go forward. Valve replacement surgery has a long and important history, with initial efforts aimed to deal with aortic …

Bariatric surgery for morbid obesity.

Bariatric surgery is a treatment for severely obese patients. We examined the efficacy of bariatric surgery, addressing three questions: 1) What is the overall weight reduction following bariatric surgery? 2) What complications are associated with bariatric surgery? 3) What impact does weight loss have on obesity-related comorbidity? Fixed and random effects meta-analyses were used to determine the amount of weight reduction following bariatric surgery. The influence of a variety of co-variates that could affect study results was examined. Information from evidence-based sources was used to explore the impact of weight loss on comorbidities. Meta-analyses results were affected by loss to follow-up, and within-study heterogeneity of variance. Therefore, results were pooled from studies with complete patient follow-up. Meta-analysis of six studies reporting weight loss at 1 year and four studies with mean follow-up of 9 months to 7 years demonstrated BMI reductions of 16.4 kg/m(2) and 13.3 kg/m(2), respectively. Weight reduction following bariatric surgery may be associated with improvements in risk factors for cardiac disease including hypertension, type 2 diabetes and lipid abnormalities, and may decrease the severity of obstructive sleep apnea. Bariatric surgery is appropriate for obese patients (BMI >40 kg/m(2) or > or =35 kg/m(2) with obesity-related comorbidity) in whom non-surgical treatment options were unsuccessful. Additional research is needed to examine the long-term benefits of weight loss following bariatric surgery, particularly with respect to obesity-related comorbidities.

Intra-operative Tracking of the Trunk during Surgical Correction of Scoliosis: A Feasibility Study

objective: The purpose of this study was to evaluate the feasibility of a technique for intra-operative tracking of the trunk during scoliosis surgery.Materials and Methods: Eleven magnetic sensors placed on specifie anatomical landmarks are used to compute 11 geometrie indices of the trunk. This technique was assessed on a cohort of 40 subjects (19 normal, 21 scoliotic) using an experimental set-up simulating the position of patients during scoliosis surgery.Results: The indices varied less than 2 mm and 1d` when breathing (except for ehest AP diameter), and less than 1 mm and 1d` after transient displacement from the initial positioning of the subjects. No significant changes were observed for most of the indices between two acquisition sessions. Comparison between normal and scoliotic subjects demonstrated that the trunk geometry is more influenced by the positioning of each subject on the operating table than by the magnitude of the spinal deformity.Conclusion: The proposed technique will allow intra-operative tracking of the trunk and enable the surgeon to optimize the correction of both spinal and trunk deformities. The technique can also be used to evaluate the adequacy of patient positioning on the operating table, and to obtain a complete follow-up of patients in pre-, intra-, and post-surgical conditions.

Intra-operative tracking of the trunk during surgical correction of scoliosis: a feasibility study.

The purpose of this study was to evaluate the feasibility of a technique for intra-operative tracking of the trunk during scoliosis surgery. Eleven magnetic sensors placed on specific anatomical landmarks are used to compute 11 geometric indices of the trunk. This technique was assessed on a cohort of 40 subjects (19 normal, 21 scoliotic) using an experimental set-up simulating the position of patients during scoliosis surgery. The indices varied less than 2 mm and 1 degrees when breathing (except for chest AP diameter), and less than 1 mm and 1 degrees after transient displacement from the initial positioning of the subjects. No significant changes were observed for most of the indices between two acquisition sessions. Comparison between normal and scoliotic subjects demonstrated that the trunk geometry is more influenced by the positioning of each subject on the operating table than by the magnitude of the spinal deformity. The proposed technique will allow intra-operative tracking of the trunk and enable the surgeon to optimize the correction of both spinal and trunk deformities. The technique can also be used to evaluate the adequacy of patient positioning on the operating table, and to obtain a complete follow-up of patients in pre-, intra-, and post-surgical conditions.

Osteomyelitis caused by Corynebacterium jeikeium

A case study has been presented where C. jeikeium was isolated as the causative bacterium of an osteomyelitis of the fifth metatarsal. Partial amputation, local wound care, frequent and aggressive debridement, and appropriate antibiotics were all used with apparent success. The lack of complete patient follow-up prohibits the authors from declaring the infection cured; however, all signs of infection were absent immediately prior to discharge. The authors believe this to be the first reported case of Corynebacterium species as the bacterial isolate in confirmed osteomyelitis.

Gastric restriction procedures for treating severe obesity

Gastric restriction procedures are operations to decrease gastric volume. They are the most common, simple, and safe operations for the treatment of severe obesity. The original horizontal gastroplasties were unsuccessful but modern operations such as vertical banded gastroplasty, silastic ring gastroplasty, and gastric banding produce good weight loss with improvement in health. Although late weight gain does occur, satisfactory 5-y results are available and are presented. Patient selection, complications, mechanism of action, and future studies are also discussed. Long-term data with complete patient follow-up and randomized trials comparing modern operations with nonoperative treatment are still needed.