Knowledge, Beliefs and Attitudes of Somali Men in Olmsted County, Minnesota, U.S., on the Human Papillomavirus Vaccine and Cervical Cancer Screening: January 17, 2015

Abstract

This study explores the general knowledge of Human Papillomavirus vaccine (HPV) and cervical cancer screening (CCS) among Somali men in the U.S., who are major decision-makers in Somali households. HPV infects both men and women, and causes genital warts and cervical cancer (CC). High mortality from CC persists among minorities due to low uptake of preventive tools. Eleven questions assessed general knowledge of HPV and CCS among 30 Somali male respondents. The knowledge of HPV and CCS by education level, age, and years lived in the U.S., was assessed using the health belief model. Most respondents had no knowledge of HPV vaccine and CCS, and low perceived susceptibility to HPV infection. There is need for more research on Somali men's attitude to HPV vaccine and CCS uptake among Somali adolescents and women.

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Gait characteristics and their discriminative power in geriatric patients with and without cognitive impairment

A detailed gait analysis (e.g., measures related to speed, self-affinity, stability, and variability) can help to unravel the underlying causes of gait dysfunction, and identify cognitive impairment. However, ...

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Time in brace: where are the limits and how can we improve compliance and reduce negative psychosocial impact in scoliosis patients? A retrospective analysis

BackgroundBrace treatment for adolescent idiopathic scoliosis (AIS) is generally prescribed for 18 – 23 hours per day, but the minimal time of brace wear per day to stop progression of AIS is still unclear. Compliance of AIS patients with brace treatment is reported to be between 27% and 47% of the prescribed time, especially brace wear at school is often described as embarrassing by the adolescent patients. It has been reported that a higher rate of compliance leads to a significantly lower rate of curve progression.

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The effect of pelvic motion on spino-pelvic parameters

To date, many studies have examined how pelvic position affects the spinal curvature and spino-pelvic parameters. However, these studies focus on a static relationship, comparing pelvis and spine in a relaxed or baseline position only. Indeed, the spino-pelvic connection is dynamic, as a subject can easily be taught to rotate their pelvis anteriorly or posteriorly on the femoral head, all while maintaining an erect posture. Therefore, for a true understanding of pelvic influence on the spinal column, it is necessary to examine spino-pelvic parameters in multiple pelvic positions within the same subject.

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Circumferential Fusion: A Comparative Analysis Between Anterior Lumbar Interbody Fusion with Posterior Pedicle Screw Fixation and Transforaminal Lumbar Interbody Fusion for L5-S1 Isthmic Spondylolisthesis

Transforaminal lumbar interbody fusion (TLIF) or anterior lumbar interbody fusion with percutaneous pedicle screws (ALIFPS) offer significantly higher radiographic fusion rates than other fusion techniques for L5-S1 isthmic spondylolisthesis (IS). As it stands, there is a relative paucity of comparative data of the two techniques.

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Prognostic potential of KLOTHO and SFRP1 promoter methylation in head and neck squamous cell carcinoma

Abstract

Hypermethylation in the CpG island promoter regions of tumor suppressors is known to play a significant role in the development of HNSCC and the detection of which can aid the classification and prognosis of HNSCC. This study aims to profile the methylation patterns in a panel of key genes including CDKN2A, CDKN2B, KLOTHO (KL), RASSF1A, RARB, SLIT2, and SFRP1, in a group of HNSCC samples from Saudi Arabia. The extent of methylation in these genes is determined using the MethyLight assay and correlated with known clinicopathological parameters in our samples of 156 formalin-fixed and paraffin-embedded HNSCC tissues. SLIT2 methylation had the highest frequency (64.6%), followed by RASSF1A (41.3%), RARB (40.7%), SFRP1 (34.9), KL (30.7%), CKDN2B (29.6%), and CKDN2A (29.1%). KL and SFRP1 methylation were more predominant in nasopharyngeal tumors (P = 0.001 and P = 0.031 respectively). Kaplan Meier analysis showed that patients with moderately differentiated tumors who display SFRP1 methylation have significantly worse overall survival in comparison with other samples. In contrast, better clinical outcomes were seen in patients with KL methylation. In conclusion, our findings suggest that the detection of frequent methylation in SFRP1 and KL genes' promoters could serve as prognostic biomarkers for HNSCC.

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Establishing the learning curve of transanal minimally invasive surgery for local excision of rectal neoplasms

Abstract

Introduction

Transanal minimally invasive surgery (TAMIS) is an endoscopic operating platform for local excision of rectal neoplasms. However, it may be technically demanding, and its learning curve has yet to be adequately defined. The objective of this study was to determine the number of TAMIS procedures for the local excision of rectal neoplasm required to reach proficiency.

Methods and procedures

All TAMIS cases performed from 07/2009 to 12/2016 at a single high-volume tertiary care institution for local excision of benign and malignant rectal neoplasia were identified from a prospective database. A cumulative summation (CUSUM) analysis was performed to determine the number of cases required to reach proficiency. The main proficiency outcome was rate of margin positivity (R1 resection). The acceptable and unacceptable R1 rates were defined as the R1 rate of transanal endoscopic microsurgery (TEM—10%) and traditional transanal excision (TAE—26%), which was obtained from previously published meta-analyses. Comparisons of patient, tumor, and operative characteristics before and after TAMIS proficiency were performed.

Results

A total of 254 TAMIS procedures were included in this study. The overall R1 resection rate was 7%. The indication for TAMIS was malignancy in 57%. CUSUM analysis reported that TAMIS reached an acceptable R1 rate between 14 and 24 cases. Moving average plots also showed that the mean operative times stabilized by proficiency gain. The mean lesion size was larger after proficiency gain (3.0 cm (SD 1.5) vs. 2.3 cm (SD 1.3), p = 0.008). All other patient, tumor, and operative characteristics were similar before and after proficiency gain.

Conclusions

TAMIS for local excision of rectal neoplasms is a complex procedure that requires a minimum of 14–24 cases to reach an acceptable R1 resection rate and lower operative duration.

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Anatomical and embryological perspectives in laparoscopic complete mesocoloic excision of splenic flexure cancers

Abstract

Background

Laparoscopic complete mesocoloic excision (CME) with central vascular ligation for splenic flexure cancer is technically challenging because of its anatomical complexity. Although embryological and anatomical consideration should be helpful to perform CME in colorectal cancer surgery, such studies on the splenic flexure are lacking.

Methods

The splenic flexure is located embryologically between the terminal portion of the midgut and the beginning of the hindgut, and is supplied by the superior mesenteric and inferior mesenteric arteries. The mesentery of the transverse and descending colon originally is a continuous sheet, although they rotate and partially fuse to each other during development. Our surgical strategy was excision of the transverse and descending mesocolon with ligation of the left colic artery and left branch of the middle colic artery, and extraction of the specimen in an intact package wrapped by the embryological planes.

Results

We performed laparoscopic surgery according to our surgical strategy in 17 patients with splenic flexure colon cancer. There were no conversions to open surgery or serious intraoperative complications. Two patients had pathological stage (pStage) I, 5 pStage II, 9 pStage III, and 1 pStage IV disease. No patient had recurrence except for 1 with pStage IV cancer, with a median follow-up of 16 months.

Conclusions

Our laparoscopic CME technique is feasible for treatment of splenic flexure cancer. Knowledge of anatomy based on embryology is essential to perform this surgery.

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Accredited residents perform colonoscopy to the same high standards as consultants

Abstract

Background

Endoscopy remains a critical component of General Surgery and Gastroenterology training. Whilst residents need to gain experience, the quality of endoscopy which patients receive cannot be compromised. We conducted this study to compare quality indicators between consultants and residents with regards to colonoscopy.

Methods

A review of colonoscopies from a prospectively collected database was performed from September 2011 to February 2016. Quality indicators such as caecum intubation rate, adenoma detection rate, adherence to a 6-min withdrawal rule, mean number of polyps detected per colonoscope, and complications were collected and compared between the two groups.

Results

In total, out of 25,749 colonoscopies that were performed, 14,168 (55.0%) were performed by Consultants. Consultants achieved a better caecum intubation rate compared with residents (96.0% vs 94.9%, p < 0.001), and were more compliant to the 6-min withdrawal rule (74.7% vs 68.6%, p < 0.001). There were, however, no statistically significant differences in the adenoma detection rate (33.5% vs 34.5%, p = 0.098). Bleeding was a rare complication that was encountered more frequently in colonoscopies performed by consultants than for residents (0.002% vs 0.00008%, p < 0.001). There were only three (%) perforations in the entire series, and all were from colonoscopies performed by Consultants.

Conclusion

Given the proper training, residents are able to perform colonoscopy with the same level of competence as consultants. Whilst colonoscopic related complications are often tied to the difficulty of the procedures, the adherence to the 6-min withdrawal rule must be reinforced and continually educated to both residents and consultants.

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Robotic versus laparoscopic versus open colorectal surgery: towards defining criteria to the right choice

Abstract

Objective

Analysis of various parameters related to the patient, the disease, and the needed surgical maneuvers to develop guidance for preoperative selection of the appropriate and the best approach for a given patient.

Summary background data

Rapid advances in minimally invasive surgical technology are fascinating and challenging alike. It can be difficult for surgeons to keep up with new modalities that come on to the market place and to assess their true value, i.e., distinguish between fashionable trends versus scientific evidence. Laparoscopy established minimally invasive surgery and has revolutionized surgical concepts and approaches to diseases since its advent in the early 1990s. Now, with robotic surgery rapidly gaining traction in this high-tech surgical landscape, it remains to be seen how the long-term surgical landscape will be affected.

Methods

Review of the surgical evolution, published data and cost factors to reflect on advantages and disadvantages in order to develop a broader perspective on the role of various technology platforms.

Results

Advocates for robotic technology tout its advantages of 3D views, articulating wrists, lack of hand tremor, and surgeon comfort, which may extend the scope of minimally invasive surgery by allowing for operations in places that are more difficult to access for laparoscopic surgery (e.g., the deep pelvis), for complex tasks (e.g., intracorporeal suturing), and by decreasing the learning curve. But conventional laparoscopy has also evolved and offers high-definition 3D vision to all team members. It remains to be seen whether all together the robot features outweigh the downsides of higher cost, operative times, lack of tactile feedback, possibly unusual complications, inability to move the operative table with ease, and the difficulty to work in different quadrants.

Conclusions

While technical and design developments will likely address some shortcomings, the value-based impact of the various approaches will have to be examined in general and on a case-by-case basis. Value as the ratio of quality over cost depends on numerous parameters (disease, complications, patient, efficiency, finances).

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Laparoscopic colectomy reduces complications and hospital length of stay in colon cancer patients with liver disease and ascites

Abstract

Background

Ascites increases perioperative complications and risk of death, but is not an absolute contraindication for colectomy in patients with colon cancer. It remains unclear whether postoperative risks can be minimized using a laparoscopic versus open approach.

Methods

Data were retrospectively analyzed from 2152 patients with ascites who underwent laparoscopic or open partial colectomy with diagnosis of colon cancer from 2005 to 2013 using the American College of Surgeons National Surgical Quality Improvement Program database. Postoperative outcomes were analyzed using two-sample tests of proportions and two-sample T tests. Adjusted odds ratios (OR) or β coefficients for postoperative complications, hospital length of stay, and 30-day mortality were calculated using multivariable logistic or linear regression. P values <0.05 two-tailed were considered statistically significant.

Results

205 patients (9.53%) with ascites underwent laparoscopic colectomy (LC). There was no significant difference in operative time between laparoscopic versus open surgery (145 vs. 146 min, P = 0.69). LC was associated with decreased likelihood of overall complications (adjusted OR 0.7 95% CI 0.4–1.0, P = 0.046) and shorter hospital length of stay (9 days vs. 15 days, adjusted β = −4.2, 95% CI −7.7 to −0.7, P = 0.018). There was no difference in 30-day mortality (adjusted OR 0.82, 95% CI 0.50–1.35, P = 0.429).

Conclusions

Laparoscopic colectomy decreases postoperative complications and hospital length of stay in patients with colon cancer and ascites. Laparoscopic approach should be considered for patients in this high-risk population.

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Augmented reality in a tumor resection model

Abstract

Background

Augmented Reality (AR) guidance is a technology that allows a surgeon to see sub-surface structures, by overlaying pre-operative imaging data on a live laparoscopic video. Our objectives were to evaluate a state-of-the-art AR guidance system in a tumor surgical resection model, comparing the accuracy of the resection with and without the system. Our system has three phases. Phase 1: using the MRI images, the kidney's and pseudotumor's surfaces are segmented to construct a 3D model. Phase 2: the intra-operative 3D model of the kidney is computed. Phase 3: the pre-operative and intra-operative models are registered, and the laparoscopic view is augmented with the pre-operative data.

Methods

We performed a prospective experimental study on ex vivo porcine kidneys. Alginate was injected into the parenchyma to create pseudotumors measuring 4–10 mm. The kidneys were then analyzed by MRI. Next, the kidneys were placed into pelvictrainers, and the pseudotumors were laparoscopically resected. The AR guidance system allows the surgeon to see tumors and margins using classical laparoscopic instruments, and a classical screen. The resection margins were measured microscopically to evaluate the accuracy of resection.

Results

Ninety tumors were segmented: 28 were used to optimize the AR software, and 62 were used to randomly compare surgical resection: 29 tumors were resected using AR and 33 without AR. The analysis of our pathological results showed 4 failures (tumor with positive margins) (13.8%) in the AR group, and 10 (30.3%) in the Non-AR group. There was no complete miss in the AR group, while there were 4 complete misses in the non-AR group. In total, 14 (42.4%) tumors were completely missed or had a positive margin in the non-AR group.

Conclusions

Our AR system enhances the accuracy of surgical resection, particularly for small tumors. Crucial information such as resection margins and vascularization could also be displayed.

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Respiratory complications after colonic procedures in chronic obstructive pulmonary disease: does laparoscopy offer a benefit?

Abstract

Background

Patients with severe chronic obstructive pulmonary disease (COPD) are at a higher risk for postoperative respiratory complications. Despite the benefits of a minimally invasive approach, laparoscopic pneumoperitoneum can substantially reduce functional residual capacity and raise alveolar dead space, potentially increasing the risk of respiratory failure which may be poorly tolerated by COPD patients. This raises controversy as to whether open techniques should be preferentially employed in this population.

Methods

The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database from 2011 to 2014 was used to examine the clinical data from patients with COPD who electively underwent laparoscopic and open colectomy. Patients defined as having COPD demonstrated either functional disability, chronic use of bronchodilators, prior COPD-related hospitalization, or reduced forced expiratory reserve volumes on lung testing (FEV1 <75%). Demographic data and preoperative characteristics were compared. Linear and logistic regressions were utilized to perform multivariate analysis and determine risk-adjusted outcomes.

Results

Of the 4397 patients with COPD, 53.8% underwent laparoscopic colectomy (LC) while 46.2% underwent open colectomy (OC). The LC and OC groups were similar with respect to demographic data and preoperative comorbidities. Equivalent frequencies of exertional dyspnea (LC 35.4 vs OC 37.7%, P = 0.11) were noted. After multivariate risk adjustment, OC demonstrated an increased rate of overall respiratory complications including pneumonia, reintubation, and prolonged ventilator dependency when compared to LC (OR 1.60, 95% CI 1.30–1.98, P < 0.01). OC was associated with longer length of stay (10 ± 8 vs. 6.7 ± 7 days, P < 0.01) and higher readmission (OR 1.36, 95% CI 1.09–1.68, P < 0.01) compared to LC.

Conclusion

Despite the potential risks of laparoscopic pneumoperitoneum in the susceptible COPD population, a minimally invasive approach was associated with lower risk of postoperative respiratory complications, shorter length of stay, and decrease in postoperative morbidity.

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High clinical impact and diagnostic accuracy of EUS-guided biopsy sampling of subepithelial lesions: a prospective, comparative study

Abstract

Background

In a tertiary center setting we aimed to study the diagnostic accuracy and clinical impact of EUS-guided biopsy sampling (EUS-FNB) with a reverse bevel needle compared with that of fine needle aspiration (EUS-FNA) in the work-up of subepithelial lesions (SEL).

Methods

All patients presenting with SELs referred for EUS-guided sampling were prospectively included in 2012–2015. After randomization of the first pass modality, dual sampling with both EUS-FNB and EUS-FNA was performed in each lesion. Outcome measures in an intention-to-diagnose analysis were the diagnostic accuracy, technical failures, and adverse events. The clinical impact was measured as the performance of additional diagnostic procedures post-EUS and the rate of unwarranted resections compared with a reference cohort of SELs sampled in the same institution 2006–2011.

Results

In 70 dual sampling procedures of unique lesions (size: 6–220 mm) the diagnostic sensitivity for malignancy and the overall accuracy of EUS-FNB was superior to EUS-FNA compared head-to-head (90 vs 52%, and 83 vs 49%, both p < 0.001). The adverse event rate of EUS-FNB was low (1.2%). EUS-FNB in 2012–2015 had a positive clinical impact in comparison with the reference cohort demonstrated by less cases referred for an additional diagnostic procedure, 12/83 (14%) vs 39/73 (53%), p < 0.001, and fewer unwarranted resections in cases subjected to surgery, 3/48 (6%) vs 12/35 (34%), p = 0.001.

Conclusions

EUS-FNB with a reverse bevel needle is safe and superior to EUS-FNA in providing a conclusive diagnosis of subepithelial lesions. This biopsy sampling approach facilitates a rational clinical management and accurate treatment.

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Comparative efficacy of cold polypectomy techniques for diminutive colorectal polyps: a systematic review and network meta-analysis

Abstract

Background

Although cold polypectomy techniques are preferred over polypectomy with electrocautery in the management of diminutive polyps, comprehensive comparisons among various cold polypectomy techniques have not yet been fully performed.

Methods

We searched for all relevant randomized controlled trials published up until October 2016 examining the efficacy of cold polypectomy techniques for diminutive polyps. Cold polypectomy techniques were classified as cold forceps polypectomy (CFP), jumbo forceps polypectomy (JFP), traditional cold snare polypectomy (CSP), and dedicated CSP, according to the type of device. A network meta-analysis was performed to calculate the direct and indirect estimates of efficacy among the cold polypectomy techniques.

Results

Seven studies with 703 patients and 968 polyps were included in the meta-analysis. Regarding comparative efficacy for complete histological eradication, there was no inconsistency in the network (Cochran's Q test, df = 4, P = 0.22; I ² = 30%). In terms of complete histological eradication, both dedicated and traditional CSP were superior to CFP (odds ratio [OR] [95% confidence interval [CI]] 4.31 [1.92–9.66] and 2.45 [1.30–4.63], respectively); dedicated CSP was superior to traditional CSP (OR [95% CI] 1.76 [1.07–2.89]); and there was no difference between JFP versus CFP (OR [95% CI] 1.36 [0.40–4.61]). Regarding tissue retrieval rate, there was no difference between dedicated versus traditional CSP (OR [95% CI] 1.03 [0.44–2.38]). The procedure time for CSP was comparable to that of CFP.

Conclusions

Dedicated CSP was shown to be superior to other cold polypectomy techniques in terms of complete histological eradication. Cold polypectomy using a dedicated snare can be recommended for the removal of diminutive colorectal polyps.

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Effect of submucosal tunneling endoscopic resection for submucosal tumors at esophagogastric junction and risk factors for failure of en bloc resection

Abstract

Background and aims

Most submucosal tumors (SMTs) in the esophagogastric junction (EGJ) are irregularly shaped and different from those in the esophagus, where submucosal tunneling endoscopic resection (STER) has been proven effective and safe. However, few reports paid attention to STER for SMTs in the EGJ. The aim of the study was not only to evaluate the effect of STER in patients with SMTs in the EGJ but to analyze the risk factors for failure of en bloc resection.

Methods

A consecutive of 47 patients with SMTs originating from the muscularis propria (MP) layer in the EGJ underwent STER were retrospectively included between September 2012 and December 2016. Thirty-five tumors underwent en bloc resection, and the other 12 tumors received piecemeal resection. The tumor size, operation time, en bloc resection rate, complications, residual, and local recurrence were achieved and compared between the two groups.

Results

Forty-six of 47 lesions (97.9%) were successfully resected. The mean lesion size was 29.7 ± 16.3 mm. Both the en bloc resection rate and complete resection rate were 74.5% (35/47). No severe complications occurred in the 47 patients. Patients in the piecemeal resection group had more irregularly shaped lesions, longer tumor diameter, larger tumor size (≥40 mm), longer operation time, and longer hospital stay after procedure (P < 0.05), and there were no statistically differences between the two groups in in-operative complications, post-operative complications, and residual rate (P > 0.05). By univariate analysis and stepwise logistic regression analysis, irregular shape and tumor diameter ≥20 mm were two risk factors for failure of en bloc resection.

Conclusions

STER is an effective and safe technique for the treatment of SMTs arising from the MP layer in the EGJ. Irregular shape and tumor diameter ≥20 mm are the reliable risk factors for en bloc resection failure.

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Cost analysis of robot-assisted choledochotomy and common bile duct exploration as an option for complex choledocholithiasis

Abstract

Aim

The aim of this study is to evaluate the clinical outcomes and cost-effectiveness of elective, robot-assisted choledochotomy and common bile duct exploration (RCD/CBDE) compared to open surgery for ERCP refractory choledocholithiasis.

Method

A prospective database of all RCD/CBDE has been maintained since our first procedure in April 2007 though April 2016. With ethics approval, this database was compared with all contemporaneous elective open procedures (OCD/CBDE) performed since March 2005. Emergency procedures were excluded from analysis. Cost analysis was calculated using a micro-costing approach. Outcomes were analyzed on the basis of intent-to-treat. A p value of 0.05 denoted statistical significance.

Results

A total of 80 cases were performed since 2005 compromising 50 consecutive, unselected RCD/CBDE and 30 OCD/CBDE. Comparing RCD/CBDE to OCD/CBDE there were no significant differences between groups with respect to age (65 ± 20 vs. 67 ± 18 years, p = 0.09), gender (14/30 vs. 16/25 male/female, p = 0.52), ASA class or co-morbidities. The mean duration of surgery for RCD/CBDE trended longer compared to OCD/CBDE (205 ± 70 min vs. 174 ± 73 min, p = 0.08). However, there was significant reduction in postoperative complications with RCD/CBDE versus OCD/CBDE (22% vs. 56%, p = 0.002). Median hospital stay was also significantly reduced (6 vs 12 days, p = 0.01). The net overall hospital cost for RCD/CBDE was lower ($8449.88 CAD vs. $11671.2 CAD).

Conclusion

In this single-centre, cohort study, robotic-assisted CD/CBDE for ERCP refractory common bile duct stones provides the dominating strategy of improved patient outcomes with a reduction of overall cost.

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Convergent validation and transfer of learning studies of a virtual reality-based pattern cutting simulator

Abstract

Introduction

Research has clearly shown the benefits of surgical simulators to train laparoscopic motor skills required for positive patient outcomes. We have developed the Virtual Basic Laparoscopic Skill Trainer (VBLaST) that simulates tasks from the Fundamentals of Laparoscopic Surgery (FLS) curriculum. This study aims to show convergent validity of the VBLaST pattern cutting module via the CUSUM method to quantify learning curves along with motor skill transfer from simulation environments to ex vivo tissue samples.

Methods

18 medical students at the University at Buffalo, with no prior laparoscopic surgical skills, were placed into the control, FLS training, or VBLaST training groups. Each training group performed pattern cutting trials for 12 consecutive days on their respective simulation trainers. Following a 2-week break period, the trained students performed three pattern cutting trials on each simulation platform to measure skill retention. All subjects then performed one pattern cutting task on ex vivo cadaveric peritoneal tissue. FLS and VBLaST pattern cutting scores, CUSUM scores, and transfer task completion times were reported.

Results

Results indicate that the FLS and VBLaST trained groups have significantly higher task performance scores than the control group in both the VBLaST and FLS environments (p < 0.05). Learning curve results indicate that three out of seven FLS training subjects and four out of six VBLaST training subjects achieved the "senior" performance level. Furthermore, both the FLS and VBLaST trained groups had significantly lower transfer task completion times on ex vivo peritoneal tissue models (p < 0.05).

Conclusion

We characterized task performance scores for trained VBLaST and FLS subjects via CUSUM analysis of the learning curves and showed evidence that both groups have significant improvements in surgical motor skill. Furthermore, we showed that learned surgical skills in the FLS and VBLaST environments transfer not only to the different simulation environments, but also to ex vivo tissue models.

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Open Researcher and Contributor ID (ORCID): vital for surgical endoscopy

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A proficiency-based virtual reality endoscopy curriculum improves performance on the fundamentals of endoscopic surgery examination

Abstract

Introduction

The fundamentals of endoscopic surgery (FES) examination is a national test of knowledge and skill in flexible gastrointestinal endoscopy. The skill portion of the examination involves five tasks that assesses the following skills: scope navigation, loop reduction, mucosal inspection, retroflexion, and targeting. This project aimed to assess the efficacy of a proficiency-based virtual reality (VR) curriculum in preparing residents for the FES skills exam.

Methods

Experienced (>100 career colonoscopies) and inexperienced endoscopists (<50 career colonoscopies) were recruited to participate. Six VR modules were identified as reflecting the skills tested in the exam. All participants were asked to perform each of the selected modules twice, and median performance was compared between the two groups. Inexperienced endoscopists were subsequently randomized in matched pairs into a repetition (10 repetitions of each task) or proficiency curriculum. After completion of the respective curriculum, FES scores and pass rates were compared to national data and historical institutional control data (endoscopy-rotation training alone).

Results

Five experienced endoscopists and twenty-three inexperienced endoscopists participated. Construct valid metrics were identified for six modules and proficiency benchmarks were set at the median performance of experienced endoscopists. FES scores of inexperienced endoscopists in the proficiency group had significantly higher FES scores (530 ± 86) versus historical control (386.7 ± 92.2, p = 0.0003) and higher pass rate (proficiency: 100%, historical control 61.5%, p = 0.01).

Conclusion

Trainee engagement in a VR curriculum yields superior FES performance compared to an endoscopy rotation alone. Compared to the 2012–2016 national resident pass rate of 80, 100% of trainees in a proficiency-based curriculum passed the FES manual skills examination.

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Type 2 diabetes mellitus outcomes after laparoscopic gastric bypass in patients with BMI <35 kg/m 2 using strict remission criteria: early outcomes of a prospective study among Mexicans

Abstract

Background

Mild obesity (BMI 30–34.9 kg/m²) is highly prevalent worldwide and is associated with type 2 diabetes mellitus. The efficacy of bariatric surgery remains unclear, including among Mexicans. The criteria for diabetes remission are inconsistent, as they are based on different thresholds for glycated hemoglobin, with remission rates ranging from 43 to 73%.

Methods

Mildly obese patients with type 2 diabetes mellitus who underwent laparoscopic gastric bypass were prospectively analyzed. The primary objective was to determine the impact of surgery on their metabolic profiles. Demographic, clinical, and biochemical parameters were measured at baseline and at 3, 6, 9, 12, and 18 months. Diabetes remission rate was defined as an HbA1c <5.7%. Complications within 30 days and weight loss (% total weight loss) were also analyzed.

Results

Twenty-three Mexican patients underwent surgery. Of the 19 patients, evaluable at 18 months, nine (47.4%) achieved complete diabetes remission, seven (36.8%) showed partial remission, and three (15.8%) showed improvement. Significant improvements in lipid profile, cardiovascular risk, blood pressure, and every metabolic parameter were observed, beginning at the first month and throughout the study. The final total percentage weight loss was 24.9%. Three patients (13%) experienced complications, but none required reoperation or died.

Conclusion

Laparoscopic gastric bypass is a safe and effective method to improve the metabolic profile of mildly obese Mexican patients with type 2 diabetes mellitus, inducing high remission rates even when the strictest model is used.

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Can polyp detection rate be used prospectively as a marker of adenoma detection rate?

Abstract

Background

Adenoma detection rate (ADR) is a quality indicator for screening colonoscopy, but its calculation is time-consuming. Polyp detection rate (PDR) has been found to correlate with ADR; however, its use as a quality indicator has been criticized out of concern for endoscopists artificially inflating the PDR. We aim to evaluate whether active monitoring affects PDR.

Methods

In March 2015, 14 endoscopists were made aware that their personal PDRs would be tracked monthly as a quality improvement project. Endoscopists received a report of their individual monthly and cumulative PDR, departmental averages, and a benchmark PDR. Following the intervention, data were collected for consecutive patients undergoing average risk screening colonoscopy for six months. PDR, ADR, and adenoma to polyp detection ratio quotient (APDRQ) were compared to a six-month pre-intervention period.

Results

2203 patients were included in the study. There was no statistically significant difference in PDR when comparing pre- and post-intervention (44 vs. 45%, OR 1.04; 95% CI 0.77–1.36). No statistically significant difference in ADR was observed when comparing pre- and post-intervention (29 vs. 30%, OR 1.03; 95% CI 0.64–1.52). There was no statistically significant difference in APDRQ when comparing pre- and post-intervention (0.67 vs. 0.66, OR 0.99; 95% CI 0.69–1.33).

Conclusions

Monthly report cards did not result in a change in PDR or APDRQ. In some environments, PDR can be used as a surrogate marker of ADR, despite endoscopist awareness that PDR is being measured.

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Robotic versus open pancreatoduodenectomy: a propensity score-matched analysis based on factors predictive of postoperative pancreatic fistula

Abstract

Background

Improvement in morbidity of pancreatoduodenectomy (PD) largely depends on the reduction in the incidence of clinically relevant (CR) postoperative pancreatic fistula (POPF).

Methods

After internal validation of the clinical risk score (CRS) of POPF, and identification of other predictive factors for POPF, robotic (RPD), and open (OPD) PDs were stratified into risk categories and matched by propensity scores. The primary endpoint of this study was incidence of CR-POPF. Secondary endpoints were 90-day morbidity and mortality, and sample size calculation for randomized controlled trials (RCT).

Results

No patient undergoing RPD was classified at negligible risk for POPF, and no CR-POPF occurred in 7 RPD at low risk. The matching process identified 48 and 11 pairs at intermediate and high risk for POPF, respectively. In the intermediate-risk group, RPD was associated with higher rates of CR-POPF (31.3% vs 12.5%) (p = 0.0026), with equivalent incidence of grade C POPF. In the high-risk group, CR-POPF occurred frequently, but in similar percentages, after either procedures. Starting from an unadjusted point estimate of the effect size of 1.71 (0.91–3.21), the pair-matched odds ratio for CR-POPF after RPD was 2.80 (1.01–7.78) for the intermediate-risk group, and 0.20 (0.01–4.17) for the high-risk group. Overall morbidity and mortality were equivalent in matched study groups. Sample size calculation for a non-inferiority RCT demonstrated that a total of 31,669 PDs would be required to randomize 682 patients at intermediate risk and 1852 patients at high risk.

Conclusions

In patients at intermediate risk, RPD is associated with higher rates of CR-POPF. Incidence of grade C POPF is similar in RPD and OPD, making overall morbidity and mortality also equivalent. A RCT, with risk stratification for POPF, would require an enormous number of patients. Implementation of an international registry could be the next step in the assessment of RPD.

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Elevated auxin biosynthesis and transport underlie high vein density in C4 leaves [Genetics]

High vein density, a distinctive trait of C4 leaves, is central to both C3-to-C4 evolution and conversion of C3 to C4-like crops. We tested the hypothesis that high vein density in C4 leaves is due to elevated auxin biosynthesis and transport in developing leaves. Up-regulation of genes in auxin biosynthesis...

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Specific regulation of thermosensitive lipid droplet fusion by a nuclear hormone receptor pathway [Genetics]

Nuclear receptors play important roles in regulating fat metabolism and energy production in humans. The regulatory functions and endogenous ligands of many nuclear receptors are still unidentified, however. Here, we report that CYP-37A1 (ortholog of human cytochrome P450 CYP4V2), EMB-8 (ortholog of human P450 oxidoreductase POR), and DAF-12 (homolog of...

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DNA damage tolerance in hematopoietic stem and progenitor cells in mice [Genetics]

DNA damage tolerance (DDT) enables bypassing of DNA lesions during replication, thereby preventing fork stalling, replication stress, and secondary DNA damage related to fork stalling. Three modes of DDT have been documented: translesion synthesis (TLS), template switching (TS), and repriming. TLS and TS depend on site-specific PCNA K164 monoubiquitination and...

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Primary Instructor - National EMS Institute

Florida certified emergency medical service (EMS) instructor, is an individual who has received training approved by the Florida Department of Health and the Florida Bureau of Emergency Medical Services to provide instruction in the classroom, laboratory and/or clinical setting of an EMS training program. EMS instructor will be certified according to the level of instruction completed, and the other ...

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Celecoxib may be safest choice for older, chronic NSAID users

Reuters Health News

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Deletion in HSP110 T17: Correlation with wild-type HSP110 expression and prognostic significance in microsatellite-unstable advanced gastric cancers

Human Pathology

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4DCT imaging to assess radiomics feature stability: An investigation for thoracic cancers

Radiotherapy & Oncology

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Survey: Leaders need to make ACA work

Healthcare Finance News

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Effect of restriction of foods with high fructose corn syrup content on metabolic indices and fatty liver in obese children

Obesity Facts

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Influence of dietary isoflavone intake on gastrointestinal symptoms in ulcerative colitis individuals in remission

World Journal of Gastroenterology

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Outcomes and complications of radiation therapy in patients with familial adenomatous polyposis

Journal of Gastrointestinal Oncology

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Expansion of treatment for hepatitis C virus infection by task shifting to community-based nonspecialist providers a nonrandomized clinical trial

Annals of Internal Medicine

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Effects of long-term synbiotic supplementation in addition to lifestyle changes in children with obesity-related non-alcoholic fatty liver disease

The Turkish Journal of Gastroenterology

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Utilization and trends in palliative therapy for stage IV pancreatic adenocarcinoma patients: A U.S. population-based study

Journal of Gastrointestinal Oncology

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Fast and robust online adaptive planning in stereotactic MR-guided adaptive radiation therapy (SMART) for pancreatic cancer

Radiotherapy & Oncology

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Inaccuracy of patient-reported descriptions of and satisfaction with bowel actions in irritable bowel syndrome

Neurogastroenterology & Motility

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Are all SGLT2 inhibitors linked to reduced cardiovascular mortality?

Reuters Health News

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Pancreatic enzyme supplementation after gastrectomy for gastric cancer: A randomized controlled trial

Gastric Cancer

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Regular hospital visits improve the prognosis of hepatocellular carcinoma after initial diagnosis: A single regional community hospital study

The Turkish Journal of Gastroenterology

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Palliative external beam radiotherapy for the treatment of tumor bleeding in inoperable advanced gastric cancer

BMC Cancer

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Endocuff assisted colonoscopy significantly increases sessile serrated adenoma detection in veterans

Journal of Gastrointestinal Oncology

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Clinical outcomes of isolated renal failure compared to other forms of organ failure in patients with severe acute pancreatitis

World Journal of Gastroenterology

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Tobacco use is a modifiable risk factor for post-transplant biliary complications

Journal of Gastrointestinal Surgery

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The role of neoadjuvant radiotherapy for locally-advanced rectal cancer with resectable synchronous metastasis

Journal of Gastrointestinal Oncology

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Botulinum toxin use in rehabilitation clinics: a survey to highlight differences and similarities.

Spasticity is a complex condition and its management is multifaceted, involving physical therapies as well as interventions with botulinum toxin. There is currently no standard for best practice and also wide variation in spasticity service set-ups and the background of clinicians involved in treatment. This could potentially cause large differences in practice. The aim of this survey was to attempt to identify some of the common elements of service delivery as well as highlight any significant variations in service models. It was hoped that the results would assist healthcare professionals working with toxins to gauge or improve their own service provision in the light of any findings. A survey of 48 botulinum toxin experts was conducted at a national conference in the UK. Questions included (i) numbers of patients referred and diagnostic groups, (ii) staff composition of each clinic, (iii) methods of spasticity assessment, (iv) outcome measures and treatment goals commonly used and (v) follow-up arrangements. There were broad areas of agreement between experts such as methods of assessment of spasticity, treatment, injection guidance and follow-up arrangements. However, there were differences in diagnostic groups seen, staff composition and in outcome measurement across a wide range of clinic settings. There are considerable variations in practice between toxin experts. This survey may help practitioners identify areas of improvement in their services or explore alternative service arrangements. Copyright (C) 2017 Wolters Kluwer Health, Inc. All rights reserved.

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The Risk of Necrotizing Enterocolitis Differs Among Preterm Pigs Fed Formulas With Either Lactose Or Maltodextrin.

Objectives: When breast milk is unavailable for preterm infants, formulas are needed that won't increase the risk of necrotizing enterocolitis (NEC). Adding novel ingredients to formula to reduce NEC has not been effective clinically. Instead, we tested the prediction that NEC can be reduced by removing the maltodextrin now included in preterm formulas. Methods: The preterm pig model of spontaneous NEC was used to evaluate growth, health, and intestinal responses to 6-7 days of feeding formulas that were identical except for the source of carbohydrate; either 100% lactose or maltodextrin; colostrum was used as the control. Results: Formula with maltodextrin resulted in a 50% incidence of NEC with 30% mortality. The lactose formula and colostrum resulted in a 0% incidence of NEC. Growth was highest for pigs fed the formula with lactose, intermediate with maltodextrin, and minimal when bovine colostrum was fed (P

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Adherence to a Gluten-Free Diet: Assessment by Dietician Interview and Serology.

We aimed to 1) determine if tissue transglutaminase autoantibody (tTG) positivity was associated with dietitian-assessed adherence to a gluten-free diet in pediatric patients with celiac disease and 2) identify areas where adherence falters. We reviewed the records of children with celiac disease who had a standardized evaluation of adherence by a registered dietitian. A negative tTG value was not associated with good adherence (p = NS). Adherent and nonadherent children differed with respect to purposeful and accidental gluten exposure (p

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Splenules Presenting as Incidental Gastric Fundic Masses on Endoscopy.

No abstract available

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Effect of Cyproheptadine on Weight and Growth Velocity in Children with Silver-Russell Syndrome.

Objectives: Nutritional management of children with Silver-Russell syndrome (SRS) is crucial, especially before initiating growth hormone therapy (GHT). Since cyproheptadine (CYP) has been reported to be orexigenic, we retrospectively investigated the effects of CYP on changes in weight and height in SRS patients. Methods: Anthropometric parameters (weight [W], length or height [H], relative body weight for height [W/H] and body mass index [BMI]) were recorded for 34 children with SRS receiving CYP. We specifically analyzed the anthropometric parameters (expressed in median) in a group of 23 patients treated with CYP at baseline (M0-CYP) and every 3 months (M3 to M12-CYP) after the initiation of CYP treatment. Results: The 23 SRS children treated by CYP only had weight stagnation during the months preceding the start of treatment. Anthropometric parameters, especially the weight, differed significantly between M0-CYP and all other times (M3, M6, M9, M12-CYP). After one year of treatment, a gain in overall length/height and weight was observed (W: +1.1 SDS; H: +0.5 SDS). At M3, significant improvements in W/H (74.9% vs. 79.3% (p = 0.01)) and BMI (-3.4 vs. -2.4 SDS (p = 0.001)) were also observed. Twenty-one patients (91%) improved their weight by at least +0.5 SDS, and 12 (52%) by at least +1 SDS. Conclusions: Our results show that CYP can be effective in SRS patients with significant improvements in growth velocity and nutritional status before initiation of GHT. Further prospective studies are required to confirm these results. (C) 2017 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,

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Quality of anticoagulation control and hemorrhage risk among African American and European American warfarin users.

Objective: We evaluated whether percent time in target range (PTTR), risk of over-anticoagulation [international normalized ratio (INR)>4], and risk of hemorrhage differ by race. As PTTR is a strong predictor of hemorrhage risk, we also determined the influence of PTTR on the risk of hemorrhage by race. Participants and methods: Among 1326 warfarin users, PTTR was calculated as the percentage of interpolated INR values within the target range of 2.0-3.0. PTTR was also categorized as poor (PTTR=70%) anticoagulation control. Over-anticoagulation was defined as INR more than 4 and major hemorrhages included serious, life-threatening, and fatal bleeding episodes. Logistic regression and survival analyses were carried out to evaluate the association of race with PTTR (>=60 vs. 65 years) patients without venous thromboembolism indication and chronic kidney disease were more likely to attain PTTR of at least 60%. After accounting for clinical and genetic factors, and PTTR, African Americans had a higher risk of hemorrhage [hazard ratio (HR)=1.58; 95% confidence interval (CI): 1.04-2.41; P=0.034]. Patients with 60

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Circulating Progenitor Cell Response to Exercise in Wheelchair Racing Athletes.

INTRODUCTION: Circulating progenitor cells (CPCs) are a heterogeneous population of stem/progenitor cells in peripheral blood that participate in tissue repair. CPC mobilization has been well characterized in able-bodied persons, but has not been previously investigated in wheelchair racing athletes. The purpose of this study was to characterize CPC and CPC sub-population mobilization in elite wheelchair racing athletes in response to acute, upper-extremity aerobic exercise to determine if CPC responses are similar to ambulatory populations. METHODS: Eight participants (3 female; age=27.5+/-4.0 years; supine height=162.5+/-18.6cm; weight=53.5+/-10.9kg, VO2peak=2.4+/-0.62 L/min; years post injury=21.5+/-6.2 years) completed a 25 km time trial on a road course. Blood sampling occurred before (Pre) and immediately post (Post) exercise for quantification of CPCs (CD34+), HSPCs (CD34+/CD45dim), HSCs (CD34+/CD45dim/CD38-), CD34+ adipose tissue-derived (AT)-MSCs (CD45-/CD34+/CD105+/CD31-), CD34- bone marrow-derived (BM)-MSCs (CD45-/CD34-/CD105+/CD31-), and EPCs (CD45dim/CD34+/VEGFR2+) via flow cytometry. Blood lactate was measured Pre- and Post-trial as an indicator of exercise intensity. RESULTS: CPC concentration increased 5.7 fold post-exercise (P=0.10). HSPCs, HSCs, EPCs, and both MSC populations were not increased post exercise. Baseline HSPCs were significantly positively correlated to absolute VO2peak (Rho = 0.71, P

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Effects of Creatine and Carbohydrate Loading on Cycling Time Trial Performance.

Introduction: Creatine- and carbohydrate-loading are dietary strategies used to enhance exercise capacity. This study examined the metabolic and performance effects of a combined creatine and CHO-loading regiment on time-trial (TT) cycling bouts. Methods: Eighteen well-trained (~65mL[BULLET OPERATOR]kg-1[BULLET OPERATOR]min-1 VO2peak) males completed three performance trials (PT) comprised of a 120-km cycling TT interspersed with alternating 1- and 4-km sprints (6 sprints each) performed every 10-km followed by an inclined ride to fatigue (~90% VO2peak). Subjects were pair-matched into either creatine-loaded (20g[BULLET OPERATOR]d-1 for 5d + 3 g[BULLET OPERATOR]d-1 for 9d; CR) or placebo (PLA) groups (n=9) following the completion of PT1. All subjects undertook a cross-over application of the carbohydrate interventions, consuming either moderate-(6g[BULLET OPERATOR]kg-1 body mass (BM)/d; MOD) or CHO-loaded (12g[BULLET OPERATOR]kg-1 BM/d; LOAD) diets before PT2 and PT3. Muscle biopsies were taken prior to PT1, 18h post-PT1, and prior to both PT2 and PT3. Results: No significant differences in overall TT or inclined ride times were observed between intervention groups. PLA+LOAD improved power above baseline (P

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Preoxygenation Before Extubation: A Road to Patient Safety Less Traveled!

No abstract available

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Response to Dr O'Reilly-Shah et al.

No abstract available

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Chronic Pain and Associated Factors in India and Nepal: A Pilot Study of the Vanderbilt Global Pain Survey.

BACKGROUND: Evaluation and treatment of chronic pain worldwide are limited by the lack of standardized assessment tools incorporating consistent definitions of pain chronicity and specific queries of known social and psychological risk factors for chronic pain. The Vanderbilt Global Pain Survey (VGPS) was developed as a tool to address these concerns, specifically in the low- and middle-income countries where global burden is highest. METHODS: The VGPS was developed using standardized and cross-culturally validated metrics, including the Brief Pain Inventory and World Health Organization Disability Assessment Scale, as well as the Pain Catastrophizing Scale, the Fibromyalgia Survey Questionnaire along with queries about pain attitudes to assess the prevalence of chronic pain and disability along with its psychosocial and emotional associations. The VGPS was piloted in both Nepal and India over a 1-month period in 2014, allowing for evaluation of this tool in 2 distinctly diverse cultures. RESULTS: Prevalence of chronic pain in Nepal and India was consistent with published data. The Nepali cohort displayed a pain point prevalence of 48% to 50% along with some form of disability present in approximately one third of the past 30 days. Additionally, 11% of Nepalis recorded pain in 2 somatic sites and 39% of those surveyed documented a history of a traumatic event. In the Indian cohort, pain point prevalence was approximately 24% to 41% based on the question phrasing, and any form of disability was present in 6 of the last 30 days. Of the Indians surveyed, 11% reported pain in 2 somatic sites, with only 4% reporting a previous traumatic event. Overall, Nepal had significantly higher chronic pain prevalence, symptom severity, widespread pain, and self-reported previous traumatic events, yet lower reported pain severity. CONCLUSIONS: Our findings confirm prevalent chronic pain, while revealing pertinent cultural differences and survey limitations that will inform future assessment strategies. Specific areas for improvement identified in this VGPS pilot study included survey translation methodology, redundancy of embedded metrics and cultural limitations in representative sampling and in detecting the prevalence of mental health illness, catastrophizing behavior, and previous traumatic events. International expert consensus is needed. (C) 2017 International Anesthesia Research Society

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Opportunities and Limitations in Mobile Technology.

No abstract available

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Systemic Hypotension Following Intravenous Administration of Nonionic Contrast Medium During Computed Tomography: Iopromide Versus Iodixanol.

BACKGROUND: In light of the increasing number of radiologic interventions performed under general anesthesia, the effects of contrast media (CM) on circulation and organ perfusion are of paramount importance. The objectives of this study were to systematically quantify effects on blood pressure, heart rate, and kidney function following intravenous administration of nonionic CM with normal and low osmolality. METHODS: In this controlled, double-blinded phase IV clinical trial, 40 consecutive patients were randomly assigned to receive repeated measures of either low-osmolar iopromide or iso-osmolar iodixanol. Normal saline solution (NSS) served as control. Blood pressure and heart rate were measured continuously from 1 minute before until 3 minutes after administration of CM and NSS. Urine output was recorded hourly. RESULTS: Administration of iopromide resulted in systemic hypotension lasting up to 300 seconds (105 +/- 61 seconds) with the lowest mean arterial pressure of 39 mm Hg (56.7 +/- 12.2 mm Hg). Iopromide caused a systolic/diastolic decrease of 31/26 mm Hg (P .640). CONCLUSIONS: Administration of low-osmolar iopromide was followed by a significant transient decrease in blood pressure and a rise in heart rate. Anesthetists and radiologists should be aware of these effects in patients in whom short episodes of disturbed tissue microcirculation may pose a clinical risk. (C) 2017 International Anesthesia Research Society

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Refractory Intracranial Hypertension: The Role of Decompressive Craniectomy.

Raised intracranial pressure (ICP) is associated with worse outcomes after acute brain injury, and clinical guidelines advocate early treatment of intracranial hypertension. ICP-lowering therapies are usually administered in a stepwise manner, starting with safer first-line interventions, while reserving higher-risk options for patients with intractable intracranial hypertension. Decompressive craniectomy is a surgical procedure in which part of the skull is removed and the underlying dura opened to reduce brain swelling-related raised ICP; it can be performed as a primary or secondary procedure. After traumatic brain injury, secondary decompressive craniectomy is most commonly undertaken as a last-tier intervention in a patient with severe intracranial hypertension refractory to tiered escalation of ICP-lowering therapies. Although decompressive craniectomy has been used in a number of conditions, it has only been evaluated in randomized controlled trials after traumatic brain injury and acute ischemic stroke. After traumatic brain injury, decompressive craniectomy is associated with lower mortality compared to medical management but with higher rates of vegetative state or severe disability. In patients with stroke-related malignant hemispheric infarction, hemicraniectomy significantly decreases mortality and improves functional outcome in adults 60 years, but results in a higher proportion of severely disabled survivors compared to medical therapy in this age group. Decisions to recommend decompressive craniectomy must always be made not only in the context of its clinical indications but also after consideration of an individual patient's preferences and quality of life expectations. This narrative review discusses the management of intractable intracranial hypertension in adults, focusing on the role of decompressive craniectomy in patients with traumatic brain injury and acute ischemic stroke. (C) 2017 International Anesthesia Research Society

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Risk Stratification for Major Postoperative Complications in Patients Undergoing Intra-abdominal General Surgery Using Latent Class Analysis.

BACKGROUND: Preoperative risk stratification is a critical element in assessing the risks and benefits of surgery. Prior work has demonstrated that intra-abdominal general surgery patients can be classified based on their comorbidities and risk factors using latent class analysis (LCA), a model-based clustering technique designed to find groups of patients that are similar with respect to characteristics entered into the model. Moreover, the latent risk classes were predictive of 30-day mortality. We evaluated the use of latent risk classes to predict the risk of major postoperative complications. METHODS: An observational, retrospective cohort of patients undergoing intra-abdominal general surgery in the 2005 to 2010 American College of Surgeons National Surgical Quality Improvement Program was obtained. Known preoperative comorbidity and risk factor data were entered into LCA models to identify the latent risk classes. Complications were defined as: acute kidney injury, acute respiratory failure, cardiac arrest, deep vein thrombosis, myocardial infarction, organ space infection, pneumonia, postoperative bleeding, pulmonary embolism, sepsis/septic shock, stroke, unplanned reintubation, and/or wound dehiscence. Relative risk regression determined the associations between the latent classes and the 30-day complication risks, with adjustments for the surgical procedure. The area under the curve (AUC) of the receiver operator characteristic curve assessed model performance. RESULTS: LCA fit a 9-class model on 466,177 observations. The composite complication risk was 18.4% but varied from 7.7% in the lowest risk class to 56.7% in the highest risk class. After adjusting for procedure, the latent risk classes were significantly associated with complications, with risk ratios (95% confidence intervals) (compared to the class with the average risk) varying from 0.56 (0.54-0.58) in the lowest risk class to 2.15 (2.11-2.20) in the highest risk class, a 4-fold difference. In models incorporating surgical procedure, latent risk class, and the American Society of Anesthesiologists Physical Status, the AUC for composite complications was 0.76 (0.76-0.76). However, for individual complications, there was heterogeneity in model performance using these variables, with AUCs ranging from 0.70 (0.69-0.71) for pulmonary embolus to 0.90 (0.90-0.90) for acute respiratory failure. CONCLUSIONS: LCA can be used to classify patients undergoing intra-abdominal general surgery based on preoperative risk factors, and the classes are independently associated with postoperative complications. However, model performance is not uniform across individual complications, resulting in variations in the utility of preoperative risk stratification tools depending on the complication evaluated. (C) 2017 International Anesthesia Research Society

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The Opiorphin Analog STR-324 Decreases Sensory Hypersensitivity in a Rat Model of Neuropathic Pain.

BACKGROUND: Neuropathic pain represents a therapeutic challenge, and treatments with increased efficacy and tolerability still need to be developed. Opiorphin protects endogenous enkephalins from degradation, potentiating enkephalin-dependent analgesia via the activation of opioid pathways. Enkephalins are natural ligands of opioid receptors, with strong affinity for [delta]-opioid receptors. Expression of functional [delta]-opioid receptors increases in sensory neurons after peripheral nerve injury in neuropathic pain models. In a postoperative pain model, opiorphin and its stable analog STR-324 have an analgesic potency comparable to that of morphine, but without adverse opioid-related side effects. Consequently, administration of endogenous opiorphin peptides or STR-324 might be effective in managing peripheral neuropathic pain. METHODS: In this study, STR-324 was administered intravenously over the course of 7 days to rats with mononeuropathy induced by L5-L6 spinal nerve root ligation. The rats exhibited mechanical allodynia, thermal hyperalgesia, and spontaneous pain-related behavior throughout the testing period. RESULTS: Here, we report that the continuous administration of STR-324 significantly reduced mechanical allodynia and spontaneous pain-related behavior from day 2 to day 7 in animals that received 10 or 50 [micro]g/h of STR-324 as compared to placebo-treated animals (P

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Ultrasound Guided Regional Anesthesia, 2nd ed.

No abstract available

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The Effect of Adductor Canal Block on Knee Extensor Muscle Strength 6 Weeks After Total Knee Arthroplasty: A Randomized, Controlled Trial.

BACKGROUND: Total knee arthroplasty (TKA) reduces knee extensor muscle strength (KES) in the operated limb for several months after the surgery. Immediately after TKA, compared to either inguinal femoral nerve block or placebo, adductor canal block (ACB) better preserves KES. Whether this short-term increase in KES is maintained several weeks after surgery remains unknown. We hypothesized that 48 hours of continuous ACB immediately after TKA would improve KES 6 weeks after TKA, compared to placebo. METHODS: Patients scheduled for primary unilateral TKA were randomized to receive either a continuous ACB (group ACB) or a sham block (group SHAM) for 48 hours after surgery. Primary outcome was the difference in maximal KES 6 weeks postoperatively, measured with a dynamometer during maximum voluntary isometric contraction. Secondary outcomes included postoperative day 1 (POD1) and day 2 (POD2) KES, pain scores at rest and peak effort, and opioid consumption; variation at 6 weeks of Knee Osteoarthritis Outcome Score, patient satisfaction, and length of hospital stay. RESULTS: Sixty-three subjects were randomized and 58 completed the study. Patients in group ACB had less pain at rest during POD1 and during peak effort on POD1 and POD2, consumed less opioids on POD1 and POD2, and had higher median KES on POD1. There was no significant difference between groups for median KES on POD2, variation of Knee Osteoarthritis Outcome Score, patient satisfaction, and length of stay. There was no difference between groups in median KES 6 weeks after surgery (52 Nm [31-89 Nm] for group ACB vs 47 Nm [30-78 Nm] for group SHAM, P= .147). CONCLUSIONS: Continuous ACB provides better analgesia and KES for 24-48 hours after surgery, but does not affect KES 6 weeks after TKA. Further research could evaluate whether standardized and optimized rehabilitation over the long term would allow early KES improvements with ACB to be maintained over a period of weeks or months. (C) 2017 International Anesthesia Research Society

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Letters to the Editor.

No abstract available

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