ObjectiveThis report documents that the gastric bypass operation provides long-term control for obesity and diabetes. Summary Background DataObesity and diabetes, both notoriously resistant to medical therapy, continue to be two of our most common and serious diseases. MethodsOver the last 14 years, 608 morbidly obese patients underwent gastric bypass, an operation that restricts caloric intake by (1) reducing the functional stomach to approximately 30 mL, (2) delaying gastric emptying with a c. 0.8 to 1.0 cm gastric outlet, and (3) excluding foregut with a 40 to 60 cm Roux-en-Y gastrojejunostomy. Even though many of the patients were seriously ill, the operation was performed with a perioperative mortality and complication rate of 1.5% and 8.5%, respectively. Seventeen of the 608 patients (<3%) were lost to follow-up. ResultsGastric bypass provides durable weight control. Weights fell from a preoperative mean of 304.4 lb (range, 198 The operation provides long-term control of non-insulin-dependent diabetes mellitus (NIDDM). In those patients with adequate follow-up, 121 of 146 patients (82.9%) with NIDDM and 150 of 152 patients (98.7%) with glucose impairment maintained normal levels of plasma glucose, glycosylated hemoglobin, and insulin. These antidiabetic effects appear to be due primarily to a reduction in caloric intake, suggesting that insulin resistance is a secondary protective effect rather than the initial lesion. In addition to the control of weight and NIDDM, gastric bypass also corrected or alleviated a number of other comorbidities of obesity, including hypertension, sleep apnea, cardiopulmonary failure, arthritis, and infertility. 339

Context.-Breast cancer mortality is higher among African American women than among white women in the United States, but the reasons for the racial difference are not known. Objective.-To evaluate the influence of socioeconomic and cultural factors on the racial difference in breast cancer stage at diagnosis. Design.-Case-control study of patients diagnosed as having breast cancer at the University Medical Center of Eastern Carolina from 1985 through 1992. Setting.-The major health care facility for 2 rural counties in eastern North Carolina. Subjects.-Five hundred forty of 743 patients with newly diagnosed breast cancer and 414 control women from the community matched by age, race, and area of residence. Main Outcome Measures.-Breast cancer stage at diagnosis. Results.-Of the 540 patients, 94 (17.4%) presented with TNM stage III or IV disease. The following demographic and socioeconomic factors were significant predictors of advanced stage: being African American (odds ratio [OR], 3.0; 95% confidence interval [CI], 1.9-4.7); having low income (OR, 3.7; 95% CI, 2.1-6.5); never having been married (OR, 2.9; 95% CI, 1.4-5.9); having no private health insurance (OR, 2.5; 95% CI, 1.6-4.0); delaying seeing a physician because of money (OR, 1.6; 95% CI, 1.1-2.5); or lacking transportation (OR, 2.0; 95% CI, 1.2-3.6). Univariate analysis also revealed a large number of cultural beliefs to be significant predictors. Examples include the following beliefs: air causes a cancer to spread (OR, 2.8; 95% CI, 1.8-4.3); the devil can cause a person to get cancer (OR, 2.1; 95% CI, 1.2-3.5); women who have breast surgery are no longer attractive to men (OR, 1.9; 95% CI, 1.1-3.5); and chiropractic is an effective treatment for breast cancer (OR, 2.4; 95% CI, 1.4-4.4). When the demographic and socioeconomic variables were included in a multivariate logistic regression model, the OR for late stage among African Americans decreased to 1.8 (95% CI, 1.1-3.2) compared with 3.0 (95% CI, 1.9-4.7) for race alone. However, when the belief measures were included with the demographic and socioeconomic variables, the OR for late stage among African Americans decreased further to 1.2 (95% CI, 0.6-2.5). Conclusions.-Socioeconomic factors alone were not sufficient to explain the dramatic effect of race on breast cancer stage; however, socioeconomic variables in conjunction with cultural beliefs and attitudes could largely account for the observed effect.

; 10.1152/ajpendo.00416.2001.-The purpose of this study was to test the hypothesis that muscle fiber type is related to obesity. Fiber type was compared 1) in lean and obese women, 2) in Caucasian (C) and African-American (AA) women, and 3) in obese individuals who lost weight after gastric bypass surgery. When lean (body mass index 24.0 Ϯ 0.9 kg/m 2 , n ϭ 28) and obese (34.8 Ϯ 0.9 kg/m 2 , n ϭ 25) women were compared, there were significant (P Ͻ 0.05) differences in muscle fiber type. The obese women possessed fewer type I (41.5 Ϯ 1.8 vs. 54.6 Ϯ 1.8%) and more type IIb (25.1 Ϯ 1.5 vs. 14.4 Ϯ 1.5%) fibers than the lean women. When ethnicity was accounted for, the percentage of type IIb fibers in obese AA was significantly higher than in obese C (31.0 Ϯ 2.4% vs. 19.2 Ϯ 1.9%); fewer type I fibers were also found in obese AA (34.5 Ϯ 2.8% vs. 48.6 Ϯ 2.2%). These data are consistent with the higher incidence of obesity and greater weight gain reported in AA women. With weight loss intervention, there was a positive relationship (r ϭ 0.72, P Ͻ 0.005) between the percentage of excess weight loss and the percentage of type I fibers in morbidly obese patients. These findings indicate that there is a relationship between muscle fiber type and obesity. adiposity; African-American; insulin resistance; morbid obesity; skeletal muscle SKELETAL MUSCLE IS A HETEROGENEOUS organ consisting of different muscle fiber phenotypes. In human skeletal muscle, histochemical staining for pH-sensitive myosin ATPase activity has revealed two major classifications of fiber type, the type I and type II fibers (3,28,31). The fast-twitch, type II fibers can be broadly categorized into type IIa and type IIb fibers, although other subclasses exist (3,29,31). The type I, or slow-twitch, muscle fibers tend to be oxidative and vascularized, whereas the type IIb fibers (fast twitch) are glycolytic in nature (28, 31). The type I fibers are also insulin sensitive compared with type II muscle (8,13,17).In humans, there can be substantial heterogeneity of muscle fiber types within a given mixed muscle group. Simoneau and Bouchard (32) concluded that, in the vastus lateralis, Ն25% of the North American Caucasian population possessed either less than 35% or more than 65% type I fibers; a range of 13-98% type I fibers has been reported (31). Several factors may be linked with such variance. We have observed that obese individuals exhibit fewer type I and more type IIb muscle fibers than lean subjects (9). Other research has reported a negative relationship between adiposity and the relative percentage of type I muscle fibers (9, 21, 36) and an increased percentage of type IIb muscle fibers in patients with type 2 diabetes (9, 23), in their insulin-resistant offspring (27), and in obese subjects (18,19,21,23). Such findings make it tempting to speculate that there is a relationship between muscle fiber composition and obesity.The purpose of the current study was to test the hypothesis that muscle fiber type is related to obesity. We tested this hypothesis in...

ObjectiveTo determine the factors associated with false-negative results on sentinel node biopsy and sentinel node localization (identification rate) in patients with breast cancer enrolled in a multicenter trial using a combination technique of isosulfan blue with technetium sulfur colloid (Tc99). Summary Background DataSentinel node biopsy is a diagnostic test used to detect breast cancer metastases. To test the reliability of this method, a complete lymph node dissection must be performed to determine the false-negative rate. Single-institution series have reported excellent results, although one multicenter trial reported a false-negative rate as high as 29% using radioisotope alone. A multicenter trial was initiated to test combined use of Tc99 and isosulfan blue. MethodsInvestigators (both private-practice and academic surgeons) were recruited after attending a course on the technique of sentinel node biopsy. No investigator participated in a learning trial before entering patients. Tc99 and isosulfan blue were injected into the peritumoral region. ResultsFive hundred twenty-nine patients underwent 535 sentinel node biopsy procedures for an overall identification rate in finding a sentinel node of 87% and a false-negative rate of 13%. The identification rate increased and the false-negative rate decreased to 90% and 4.3%, respectively, after investigators had performed more than 30 cases. Univariate analysis of tumor showed the poorest success rate with older patients and inexperienced surgeons. Multivariate analysis identified both age and experience as independent predictors of failure. However, with older patients, inexperienced surgeons, and patients with five or more metastatic axillary nodes, the falsenegative rate was consistently greater. ConclusionsThis multicenter trial, from both private practice and academic institutions, is an excellent indicator of the general utility of sentinel node biopsy. It establishes the factors that play an important role (patient age, surgical experience, tumor location) and those that are irrelevant (prior surgery, tumor size, Tc99 timing). This widens the applicability of the technique and identifies factors that require further investigation.Since the description of sentinel lymph node biopsy (SNB) in the early 1990s, results for breast cancer have been reported in several single-institution series.1-4 These results were promising, and the sentinel node predicted the presence or absence of disease in the remaining axillary lymph