Pre-emptive Intestinal Transplant: The Surgeon’s Point of View

Abstract

Pre-emptive transplantation is a well-established practice for certain types of end-organ failure such as in the use of kidney transplantation. For irreversible intestinal failure, total parenteral nutrition (TPN) remains the gold standard, due to the suboptimal long-term results of intestinal transplantation. As such, the only role for pre-emptive transplantation, if at all, will be for patients identified to be at high risk of complications and mortality while on definitive long-term TPN. In these patients, the timing of early listing and transplantation could become life-saving, taking into account that mortality on the waiting list is still the highest for intestinal candidates. The development of simulation models or pre-transplant scoring systems could help in selecting patients based on potential outcome on TPN or with transplantation, and recent reports from high-volume centers identify few underlying pathologic conditions and some TPN complications as at higher risk of increased morbidity and mortality. A pre-emptive transplant could be used as a rehabilitative procedure in a well-selected case-by-case scenario, among TPN patients at risk of liver failure, repeated central line infections, mesenteric infarction, short bowel syndrome (SBS) <50 cm or with end stoma, congenital mucosal disease, desmoid tumors: These conditions must be carefully evaluated, not to underestimate the clinical stage nor to over-estimate the impact of a temporary situation. At the present time, diseases with a variable and unpredictable course, such as intestinal dysmotility disorders, or quality of life and financial issues are still far from being considered as indications for a pre-emptive transplant.

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Nosocomial, Multidrug-Resistant Klebsiella pneumoniae Strains Isolated from Mexico City Produce Robust Biofilms on Abiotic Surfaces but Not on Human Lung Cells

Microbial Drug Resistance , Vol. 0, No. 0.


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Presence of β-Lactamase Encoding Genes in Burkholderia cepacia Complex Isolated from Soil

Microbial Drug Resistance , Vol. 0, No. 0.


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Histological healing beyond endoscopic healing in ulcerative colitis: Shall we target the “ultra-deep” remission?

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Histological healing beyond endoscopic healing in ulcerative colitis: Shall we target the “ultra-deep” remission?

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Differential Expression of miRNAs in the Respiratory Tree of the Sea Cucumber Apostichopus japonicus Under Hypoxia Stress

Sea cucumber, an important economic species, has encountered high mortality since 2013 in northern China because of seasonal environmental stress such as hypoxia, high temperature, and low salinity. MicroRNAs (miRNAs) are important in regulating gene expression in marine organisms in response to environmental change. In the present study, high-throughput sequencing was used to investigate alterations in miRNA expression in the sea cucumber under different levels of dissolved oxygen (DO). Nine small RNA libraries were constructed from the sea cucumber respiratory trees. A total of 26 differentially expressed miRNAs, including 12 upregulated and 14 downregulated miRNAs were observed in severe hypoxia (DO 2 mg/L) compared with mild hypoxia (DO 4 mg/L) and normoxic conditions (DO 8 mg/L). Twelve differently expressed miRNAs were clustered in severe hypoxia. In addition, RT-qPCR revealed that 14 randomly selected differentially expressed miRNAs showed significantly increased expressions in severe hypoxia and the expressions of nine miRNAs, including key miRNAs such as Aja-miR-1, Aja-miR-2008 and Aja-miR-184, were consistent with the sequencing results. Moreover, GO and pathway analyses of putative target genes suggest that these miRNAs are important in redox, transport, transcription and hydrolysis under hypoxia stress. Notably, novel-miR-1, novel-miR-2, and novel-miR-3 were specifically clustered and upregulated in severe hypoxia, which may provide new insights into novel "hypoxamiR" identification. These results will provide a basis for future studies of miRNA regulation and molecular adaptive mechanisms in sea cucumbers under hypoxia stress.

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Genome Dynamics of Hybrid Saccharomyces cerevisiae During Vegetative and Meiotic Divisions

Mutation and recombination are the major sources of genetic diversity in all organisms. In the baker's yeast, all mutation rate estimates are in homozygous background. We determined the extent of genetic change through mutation and loss of heterozygosity (LOH) in a heterozygous Saccharomyces cerevisiae genome during successive vegetative and meiotic divisions. We measured genome wide LOH and base mutation rates during vegetative and meiotic divisions in a hybrid (S288c/YJM789) S. cerevisiae strain. The S288c/YJM789 hybrid showed nearly complete reduction in heterozygosity within 31 generations of meioses and improved spore viability. LOH in the meiotic lines was driven primarily by the mating of spores within the tetrad. The S288c/YJM789 hybrid lines propagated vegetatively for the same duration as the meiotic lines, showed variable LOH (from 2-3% and up to 35%). Two of the vegetative lines with extensive LOH, showed frequent and large internal LOH tracts that suggest a high frequency of recombination repair. These results suggest significant LOH can occur in the S288c/YJM789 hybrid during vegetative propagation presumably due to return to growth events. The average base substitution rates for the vegetative lines (1.82 x 10^-10 per base per division) and the meiotic lines (1.22 x 10^-10 per base per division), are the first genome wide mutation rate estimates for a hybrid yeast. This study therefore provides a novel context for the analysis of mutation rates (especially in the context of detecting LOH during vegetative divisions), compared to previous mutation accumulation studies in yeast that used homozygous backgrounds.

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Genomic Prediction Within and Across Biparental Families: Means and Variances of Prediction Accuracy and Usefulness of Deterministic Equations

A major application of genomic prediction (GP) in plant breeding is the identification of superior inbred lines within families derived from biparental crosses. When models for various traits were trained within related or unrelated biparental families (BPFs), experimental studies found substantial variation in prediction accuracy (PA), but little is known about the underlying factors. We used SNP marker genotypes of inbred lines from either elite germplasm or landraces of maize (Zea mays L.) as parents to generate in silico 300 BPFs of doubled-haploid lines. We analyzed PA within each BPF for 50 simulated polygenic traits, using GBLUP models trained with individuals from either full-sib (FSF), half-sib (HSF) or unrelated families (URF) for various sizes (N_train) of the training set and different heritabilities (h²). In addition, we modified two deterministic equations for forecasting PA to account for inbreeding and genetic variance unexplained by the training set. Averaged across traits, PA was high within FSF (0.41 - 0.97) with large variation only for N_train<50 and h² <0.6. For HSF and URF, PA was on average ~40 to 60% lower and varied substantially among different combinations of BPFs used for model training and prediction as well as different traits. As exemplified by HSF results, PA of across-family GP can be very low if causal variants not segregating in the training set account for a sizeable proportion of the genetic variance among predicted individuals. Deterministic equations accurately forecast the PA expected over many traits, yet cannot capture trait-specific deviations. We conclude that model training within BPFs generally yields stable PA, whereas a high level of uncertainty is encountered in across-family GP. Our study shows the extent of variation in PA that must be at least reckoned with in practice and offers a starting point for the design of training sets composed of multiple BPFs.

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The Effect of Common Inversion Polymorphisms In(2L)t and In(3R)Mo on Patterns of Transcriptional Variation in Drosophila melanogaster

Chromosomal inversions are an ubiquitous feature of genetic variation. Theoretical models describe several mechanisms by which inversions can drive adaptation and be maintained as polymorphisms. While inversions have been shown previously to be under selection, or contain genetic variation under selection, the specific phenotypic consequences of inversions leading to their maintenance remain unclear. Here we use genomic sequence and expression data from the Drosophila Genetic Reference Panel to explore the effects of two cosmopolitan inversions, In(2L)t and In(3R)Mo, on patterns of transcriptional variation. We demonstrate that each inversion has a significant effect on transcript abundance for hundreds of genes across the genome. Inversion affected loci (IAL) appear both within inversions as well as on unlinked chromosomes. Importantly, IAL do not appear to be influenced by the previously reported genome-wide expression correlation structure. We found that five genes involved with sterol uptake, four of which are Niemann-Pick Type 2 orthologs, are upregulated in flies with In(3R)Mo but do not have SNPs in LD with the inversion. We speculate that this upregulation is driven by genetic variation in mod(mdg4) that is in LD with In(3R)Mo. We find that there is little evidence for regional or position effect of inversions on gene expression at the chromosomal level but do find evidence for the distal breakpoint of In(3R)Mo interrupting one gene and possibly disassociating the two flanking genes from regulatory elements.

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Olfactory deficits decrease the time resolution for trigeminal lateralization

Publication date: Available online 15 September 2017
Source:International Journal of Psychophysiology
Author(s): A. Oleszkiewicz, T. Meusel, M. Güpfert, B. Westermann, T. Hummel, A. Welge-Lüssen
ObjectivesTo date the temporal resolution of the detection of almost simultaneously applied intranasal trigeminal stimuli is unknown. The aim of our study was to examine this temporal resolution in an/hyposmic subjects, who are known to have reduced trigeminal sensitivity and compare it with healthy controls.MethodsParticipants were 20 posttraumatic an/hyposmic patients, and 23 healthy controls (matched with regard to sex and age). Olfactory function was tested psychophysically using the Sniffin´ Sticks test battery. Bilateral trigeminal stimulation was carried out using a birhinal high-precision olfactometer. The trigeminal stimulus used was CO₂ 60% v/v, the interstimulus interval ranged from 28 to 32s, stimulus duration was 200ms. Time-lags tested between right and left side of stimulation were at 40, 80, 120, 160 and 200ms. Subjects raised their left or right hand to indicate the side on which the stimulus had been perceived first.ResultsIn both groups the accuracy in the trigeminal lateralization task increased with the time-lag but normosmic subjects significantly outperformed an/hyposmics in the 200ms time-lag condition. Normosmics significantly exceeded 50% chance level at the time-lag of 80ms, whereas an/hyposmics were only able to score above chance starting from 120ms time-lag. Lateralization scores significantly decreased with age.ConclusionsAt a time lag of 200ms intranasal trigeminal stimuli can be lateralized. The reduced trigeminal sensitivity in patients with anosmia or hyposmia leads to an increased time lag required for correct perception of intranasal, almost simultaneously, applied stimuli.



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A novel approach using the enhanced-view totally extraperitoneal (eTEP) technique for laparoscopic retromuscular hernia repair

Abstract

Background

The enhanced-view totally extraperitoneal (eTEP) technique has been previously described for Laparoscopic Inguinal Hernia Repair. We present a novel application of the eTEP access technique for the repair of ventral and incisional hernias.

Methods

Retrospective review of consecutive laparoscopic retromuscular hernia repair cases utilizing the eTEP access approach from five hernia centers between August 2015 and October 2016 was conducted. Patient demographics, hernia characteristics, operative details, perioperative complications, and quality of life outcomes utilizing the Carolina's Comfort Scale (CCS) were included in our data analysis.

Results

Seventy-nine patients with mean age of 54.9 years, mean BMI of 31.1 kg/m², and median ASA of 2.0 were included in this analysis. Thirty-four percent of patients had a prior ventral or incisional hernia repair. Average mesh area of 634.4 cm² was used for an average defect area of 132.1 cm². Mean operative time, blood loss, and length of hospital stay were 218.9 min, 52.6 mL, and 1.8 days, respectively. There was one conversion to intraperitoneal mesh placement and one conversion to open retromuscular mesh placement. Postoperative complications consisted of seroma (n = 2) and trocar site dehiscence (n = 1). Comparison of mean pre- and postoperative CCS scores found significant improvements in pain (68%, p < 0.007) and movement limitations (87%, p < 0.004) at 6-month follow-up. There were no readmissions within 30 days and one hernia recurrence at mean follow-up of 332 ± 122 days.

Conclusions

Our initial multicenter evaluation of the eTEP access technique for ventral and incisional hernias has found the approach feasible and effective. This novel approach offers flexible port set-up optimal for laparoscopic closure of defects, along with wide mesh coverage in the retromuscular space with minimal transfascial fixation.

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Laparoscopic versus open parenchymal preserving liver resections in the posterosuperior segments: a case-matched study

Abstract

Background

Patients with lesions in the posterosuperior (PS) segments of the liver have been considered poor candidates for laparoscopic liver resection (LLR). This study aims to compare short-term outcomes of LLR and open liver resections (OLR) in the PS segments.

Methods

This multicenter study consisted of all patients who underwent LLR in the PS segments and all patients who underwent OLR in the PS segments between October 2011 and July 2016. Laparoscopic cases were case-matched with those who had an identical open procedure during the same period based on tumor location (same segment) and the Brisbane classification of the resection. Demographics, comorbid factors, perioperative outcomes, short-term outcomes, necessity of adjuvant chemotherapy, and the interval between surgery and initiation of adjuvant chemotherapy were compared between the two groups. Data were retrieved from a prospectively maintained electronic database.

Results

Both groups were comparable for age, sex, ASA score, maximum tumor diameter, and number of patients with additional liver resections outside the posterior segments. Operative time was similar in both groups (median 140 min; p = 0.92). Blood loss was less in the LLR-group (median: 150 vs. 300 ml in OLR-group). Median hospital stay was 6 days in both groups. There was no significant difference in postoperative complications (OLR-group: 31.4% vs. LLR-group: 25.7%; p = 0.60). There was no significant difference in R0 resections (LLR: 97.2 vs. 100% in OLR; p = 1.00). Tumor-free margins were less in the LLR group (LLR: 5 vs. 9.5 mm in OLR; p = 0.012). Patients undergoing LLR were treated with chemotherapy sooner compared to those undergoing OLR (41 vs. 56 days, p = 0.02).

Conclusion

This study suggests that laparoscopic parenchymal preserving liver resections in the PS segments can be performed with comparable short-term outcomes as similar OLR. The shorter interval to chemotherapy might provide long-term oncologic benefits in patients who underwent LLR.

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Viewer discretion advised: is YouTube a friend or foe in surgical education?

Abstract

Background

In the current era, trainees frequently use unvetted online resources for their own education, including viewing surgical videos on YouTube. While operative videos are an important resource in surgical education, YouTube content is not selected or organized by quality but instead is ranked by popularity and other factors. This creates a potential for videos that feature poor technique or critical safety violations to become the most viewed for a given procedure.

Methods

A YouTube search for "Laparoscopic cholecystectomy" was performed. Search results were screened to exclude animations and lectures; the top ten operative videos were evaluated. Three reviewers independently analyzed each of the 10 videos. Technical skill was rated using the GOALS score. Establishment of a critical view of safety (CVS) was scored according to CVS "doublet view" score, where a score of ≥5 points (out of 6) is considered satisfactory. Videos were also screened for safety concerns not listed by the previous tools.

Results

Median competence score was 8 (±1.76) and difficulty was 2 (±1.8). GOALS score median was 18 (±3.4). Only one video achieved adequate critical view of safety; median CVS score was 2 (range 0–6). Five videos were noted to have other potentially dangerous safety violations, including placing hot ultrasonic shears on the duodenum, non-clipping of the cystic artery, blind dissection in the hepatocystic triangle, and damage to the liver capsule.

Conclusions

Top ranked laparoscopic cholecystectomy videos on YouTube show suboptimal technique with half of videos demonstrating concerning maneuvers and only one in ten having an adequate critical view of safety. While observing operative videos can be an important learning tool, surgical educators should be aware of the low quality of popular videos on YouTube. Dissemination of high-quality content on video sharing platforms should be a priority for surgical societies.

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Predictors of outpatient resource utilization following ventral and incisional hernia repair

Abstract

Introduction

Little is known about the predictors of increased ambulatory costs following open ventral and incisional hernia repair (VIHR); however, postoperative complications would be expected to be associated with an increased burden on outpatient resources. The purpose of this study is to evaluate the impact of perioperative factors on outpatient resource utilization following VIHR.

Methods

With IRB approval, the surgery scheduling system was queried to identify all cases of VIHR done at our institution over 3 years. Cases with other procedures done at time of VIHR were excluded. National Surgical Quality Improvement Program clinical data, physician billing data which included market and payor across cases, and medical record review data were combined and evaluated in order to quantify care and predictors of usage during the 6 months postoperatively.

Results

Data were analyzed for 308 patients. Median patient age was 52 years (SD = 13.3), and over half were female. The number of outpatient visits to the surgical office varied from 0 to 18 [median = 2; interquartile range (IQR) = 1–3]. CDC Wound Class >1 was associated with increase of mean 1.4 visits (IQR: 0.5–2.3); p = 0.003. Component separation, longer duration of operation, and increased mesh size were also predictive of increased number of office visits (p < 0.01). Postoperative infected seroma/seroma requiring drainage added a mean 2.3 visits (IQR: 1.3–3.3), (p < 0.001); and deep wound infection added a mean 3.9 visits (IQR: 1.9–5.9) (p < 0.001).

Conclusions

Postoperative complications confer a significant burden for patients and to the outpatient surgical office. In an era in which improved quality and cost-efficiency has become imperative, measures to decrease risk of postoperative complications particularly for more complex VIHR would be expected to decrease resource utilization and increase value of care.

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An endoscopic mucosal grading system is predictive of leak in stapled rectal anastomoses

Abstract

Background

Anastomotic leak is a devastating postoperative complication following rectal anastomoses associated with significant clinical and oncological implications. As a result, there is a need for novel intraoperative methods that will help predict anastomotic leak.

Methods

From 2011 to 2014, patient undergoing rectal anastomoses by colorectal surgeons at our institution underwent prospective application of intraoperative flexible endoscopy with mucosal grading. Retrospective review of patient medical records was performed. After creation of the colorectal anastomosis, application of a three-tier endoscopic mucosal grading system occurred. Grade 1 was defined as circumferentially normal appearing peri-anastomotic mucosa. Grade 2 was defined as ischemia or congestion involving <30% of either the colon or rectal mucosa. Grade 3 was defined as ischemia or congestion involving >30% of the colon or rectal mucosa or ischemia/congestion involving both sides of the staple line.

Results

From 2011 to 2014, a total of 106 patients were reviewed. Grade 1 anastomoses were created in 92 (86.7%) patients and Grade 2 anastomoses were created in 10 (9.4%) patients. All 4 (3.8%) Grade 3 patients underwent immediate intraoperative anastomosis takedown and re-creation, with subsequent re-classification as Grade 1. Demographic and comorbidity data were similar between Grade 1 and Grade 2 patients. Anastomotic leak rate for the entire cohort was 12.2%. Grade 1 patients demonstrated a leak rate of 9.4% (9/96) and Grade 2 patients demonstrated a leak rate of 40% (4/10). Multivariate logistic regression associated Grade 2 classification with an increased risk of anastomotic leak (OR 4.09, 95% CI 1.21–13.63, P = 0.023).

Conclusion

Endoscopic mucosal grading is a feasible intraoperative technique that has a role following creation of a rectal anastomosis. Identification of a Grade 2 or Grade 3 anastomosis should provoke strong consideration for immediate intraoperative revision.

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Endoscopic resection of gastric gastrointestinal stromal tumors originating from the muscularis propria layer in North America: methods and feasibility data

Abstract

Introduction

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract. In recent years, endoscopic procedures such as endoscopic enucleation (EN) and endoscopic full-thickness resection (EFTR) have been used to resect GISTs. This study aimed to investigate the clinical efficacy, safety, and feasibility of endoscopic resection of GISTs in a North American population.

Methods

A total of 25 patients with gastric submucosal lesions (SML) underwent endoscopic resection from December 2014 to April 2016. Data from cases with histologically proven GISTs originating from the muscularis propria layer (MP-GIST) were collected. The main outcome measures were complete resection rate, operative time, postoperative complications, length of hospital stay, narcotic analgesic requirement, and follow-up outcomes. Surveillance was performed with CT abdomen, and/or EGD along with oncology follow-up at 6- to 24-month intervals.

Results

Out of 25 gastric SML, there were 12 histologically proven MP-GIST. Five endophytic MP-GIST were removed by EN, and seven exophytic MP-GIST were removed by EFTR. All lesions were removed en bloc except for one hard to localize exophytic lesion which was completely removed piecemeal. The mean removal time was 79.7 min (range 17–180 min). Nine out of twelve patients required inpatient admission for observation with a mean length of stay of 2.08 days (range 1–4 days). No complications were noted and no narcotic analgesics were required. Pathology reports showed that one GIST was intermediate risk but all others were low-risk lesions. No recurrence has been noted thus far.

Conclusion

Endoscopic removal of MP-GIST by a trained endoscopist appears to be safe and feasible in North American population. Further studies with greater sample size are necessary to compare endoscopic versus surgical resection of MP-GIST. Comparison of outcomes may support wider use of endoscopic techniques for GIST removal.

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Near-infrared cholecystocholangiography with direct intragallbladder indocyanine green injection: preliminary clinical results

Abstract

Background

Near-infrared (NIR) fluorescence cholangiography by systemic administration of indocyanine green (ICG) enhances the visualization of the biliary tree anatomy. However, the simultaneous enhancement of liver parenchyma can disturb the visualization of critical details. We herein proposed a new technique of NIR cholecystocholangiography by intragallbladder ICG injection to increase the safety during laparoscopic cholecystectomy.

Methods

A total of 46 patients scheduled for laparoscopic cholecystectomy for symptomatic lithiasis (n = 21) or cholecystitis (n = 25) were enrolled. A fluorescence cholangiography by direct gallbladder injection of ICG was performed in all cases. Of them, the ICG was injected through a previously placed percutaneous transhepatic gallbladder drainage catheter (n = 18) or by intraoperative, percutaneous needle puncture of the gallbladder (n = 28). Visualization of biliary structures, including the cystic duct (CD), the common bile and hepatic ducts (CBD and CHD), the gallbladder neck, and the Hartmann's pouch (HP), was performed using White Light (served as control modality) and by NIR enhancement.

Results

Cholecystocholangiography provided a significantly higher rate of visualization of the CD in case of cholecystitis with mild adhesions, and an improved visualization of the HP, CBD, and CHD in case of severe inflammation, when compared to White Light observation. There were no benefits of NIR in case of non-inflamed lithiasis.

Conclusions

Clinical translation of NIR cholecystocholangiography has been successful with a noise-free visualization of biliary anatomy. It can be considered in difficult cases to increase the safety of laparoscopic cholecystectomy.

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Predictors of adherence to enhanced recovery pathway elements after laparoscopic colorectal surgery

Abstract

Introduction

Enhanced recovery pathways (ERP) include a bundle of evidence-based preoperative, intraoperative, and postoperative interventions that together reduce morbidity and length of stay after colorectal surgery. Increased adherence with the bundle is associated with better postoperative outcomes, but adherence is lowest in the postoperative period. Identifying risk factors for lower adherence may help design quality improvement strategies. The aim of this study was to estimate the extent to which patient, procedural, and organizational factors predict adherence to postoperative ERP elements in laparoscopic colorectal surgery.

Methods

Patients in an institutional ERP registry undergoing elective laparoscopic colorectal surgery between 2012 and 2014 were analyzed. The ERP included 10 postoperative ERP elements classified into 2 groups: those requiring patient participation (PP, 5 elements, including nutritional intake and mobilization) and those provided by the clinical team (CT, 5 elements, including removal of catheters and type of analgesia). The impact of baseline and intraoperative factors on adherence was estimated using stepwise linear regression.

Results

A total of 223 patients were included (mean age 60, 48% male). Mean adherence was 79% to the PP bundle (range 65–93% for individual elements), and 82% for the CT bundle (range 68–98% for individual elements). The occurrence of nausea/vomiting in the first 24 h was associated with lower adherence to both bundles. In the PP bundle, patients who arrived at the ward after 6 p.m. had lower adherence. In the CT bundle, patients who had rectal resection had lower adherence while thoracic epidural was associated with higher adherence.

Conclusions

With the exception of postoperative nausea and vomiting, predictors of adherence to ERP elements after colorectal surgery differed for elements requiring patient participation and those provided by the clinical team. Strategies to improve ERP adherence should target staff education and engagement of patients at risk for lower adherence.

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Assessment of the blood supply using the indocyanine green fluorescence method and postoperative endoscopic evaluation of anastomosis of the gastric tube during esophagectomy

Abstract

Background

Postoperative anastomotic leakage is a severe complication after gastric tube reconstruction during esophagectomy. The aim of this study was to evaluate the usefulness of postoperative endoscopic assessment of anastomosis and its correlation with intraoperative indocyanine green (ICG) fluorescence assessment of the gastric tube.

Methods

We retrospectively reviewed 72 consecutive patients who underwent gastric tube reconstruction using the ICG fluorescence method during esophagectomy. Forty-six patients underwent the ICG line-marking method (LMM group; ICG before gastric tube creation). The other 26 underwent the conventional procedure and comprised the control group (ICG after gastric tube creation). Postoperative endoscopic assessment (PEA) of anastomosis was performed 7 days after surgery and results were classified as follows: grade 1 (normal or partial white coat), grade 2 (ulcer comprising less than half the circumference), and grade 3 (ulcer comprising more than half the circumference).

Results

Anastomotic leakage occurred in 7 of 72 patients (9.7%). The incidence of anastomotic leakage in the LMM group was tended to be lower than those in the control group (6.5% vs. 15.4%; P = 0.244). Of the 40 patients who underwent PEA, 3 (7.5%) had leakage. PEA grading was significantly associated with anastomotic leakage (P < 0.001). Better intraoperative ICG assessment was significantly associated with better endoscopic assessment grade (P = 0.041).

Conclusion

Intraoperative ICG assessment of the gastric tube was associated with PEA grading on anastomosis during esophagectomy.

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Bile duct injury and morbidity following cholecystectomy: a need for improvement

Abstract

Background

Bile duct injury (BDI) remains the most dreaded complication following cholecystectomy with serious repercussions for the surgeon, patient and entire healthcare system. In the absence of registries, the true incidence of BDI in the United States remains unknown. We aim to identify the incidence of BDI requiring operative intervention and overall complications after cholecystectomy.

Methods

Utilizing the Truven Marketscan^® research database, 554,806 patients who underwent cholecystectomy in calendar years 2011–2014 were identified using ICD-9 procedure and diagnosis codes. The final study population consisted of 319,184 patients with at least 1 year of continuous enrollment and who met inclusion criteria. Patients were tracked for BDI and other complications. Hospital cost information was obtained from 2015 Premier data.

Results

Of the 319,184 patients who were included in the study, there were a total of 741 (0.23%) BDI identified requiring operative intervention. The majority of injuries were identified at the time of the index procedure (n = 533, 72.9%), with 102 (13.8%) identified within 30-days of surgery and the remainder (n = 106, 14.3%) between 31 and 365 days. The operative cumulative complication rate within 30 days of surgery was 9.84%. The most common complications occurring at the index procedure were intestinal disorders (1.2%), infectious (1%), and shock (0.8%). The most common complications identified within 30-days of surgery included infection (1.5%), intestinal disorders (0.7%) and systemic inflammatory response syndrome (SIRS) (0.7%) for cumulative rates of infection, intestinal disorders, shock, and SIRS of 2.0, 1.9, 1.0, and 0.8%, respectively.

Conclusion

BDI rate requiring operative intervention have plateaued and remains at 0.23% despite increased experience with laparoscopy. Moreover, cholecystectomy is associated with a 9.84% 30-day morbidity rate. A clear opportunity is identified to improve the quality and safety of this operation. Continued attention to educational programs and techniques aimed at reducing patient harm and improving surgeon skill are imperative.

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Predicting opportunities to increase utilization of laparoscopy for rectal cancer

Abstract

Background

Despite proven safety and efficacy, rates of laparoscopy for rectal cancer in the US are low. With reports of inferiority with laparoscopy compared to open surgery, and movements to develop accredited centers, investigating utilization and predictors of laparoscopy are warranted. Our goal was to evaluate current utilization and identify factors impacting use of laparoscopic surgery for rectal cancer.

Methods

The Premier™ Hospital Database was reviewed for elective inpatient rectal cancer resections (1/1/2010–6/30/2015). Patients were identified by ICD-9-CM diagnosis codes, and then stratified into open or laparoscopic approaches by ICD-9-CM procedure codes or billing charge. Logistic multivariable regression identified variables predictive of laparoscopy. The Cochran–Armitage test assessed trend analysis. The main outcome measures were trends in utilization and factors independently associated with use of laparoscopy.

Results

3336 patients were included—43.8% laparoscopic (n = 1464) and 56.2% open (n = 1872). Use of laparoscopy increased from 37.6 to 55.3% during the study period (p < 0.0001). General surgeons performed the majority of all resections, but colorectal surgeons were more likely to approach rectal cancer laparoscopically (41.31 vs. 36.65%, OR 1.082, 95% CI [0.92, 1.27], p < 0.3363). Higher volume surgeons were more likely to use laparoscopy than low-volume surgeons (OR 3.72, 95% CI [2.64, 5.25], p < 0.0001). Younger patients (OR 1.49, 95% CI [1.03, 2.17], p = 0.036) with minor (OR 2.13, 95% CI [1.45, 3.12], p < 0.0001) or moderate illness severity (OR 1.582, 95% CI [1.08, 2.31], p < 0.0174) were more likely to receive a laparoscopic resection. Teaching hospitals (OR 0.842, 95% CI [0.710, 0.997], p = 0.0463) and hospitals in the Midwest (OR 0.69, 95% CI [0.54, 0.89], p = 0.0044) were less likely to use laparoscopy. Insurance status and hospital size did not impact use.

Conclusions

Laparoscopy for rectal cancer steadily increased over the years examined. Patient, provider, and regional variables exist, with hospital status, geographic location, and colorectal specialization impacting the likelihood. However, surgeon volume had the greatest influence. These results emphasize training and surgeon-specific outcomes to increase utilization and quality in appropriate cases.

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Synoptic operative reporting: assessing the completeness, accuracy, reliability, and efficiency of synoptic reporting for Roux-en-Y gastric bypass

Abstract

Objective

Synoptic reporting (SR) is one solution to improve the quality of operative reports. However, SR has not been investigated in bariatric surgery despite an identified need by bariatric surgeons. SR for RYGB was developed using quality indicators (QIs) established by a national Delphi process. The objective of this study is to assess the completeness, accuracy, reliability, and efficiency of synoptic versus narrative operative reports (NR) in Roux-en-Y gastric bypass (RYGB).

Methods

A NR and SR were completed on 104 consecutive RYGBs. Two evaluators independently compared the reports to QIs. Completeness and accuracy measures were determined. Reliability was calculated using Bland–Altman plots and 95% limits of agreement (LOA). Time to complete SR and NR was also compared.

Results

The mean completion rate of SR was 99.8% (±SD 0.98%) compared to 64.0% (±SD 6.15%) for NR (t = 57.9, p < 0.001). All subsections of SR were >99% complete. This was significantly higher than for NR (p < 0.001) except for small bowel division details (p = 0.530). Accuracy was significantly higher for SR than NR (94.2% ± SD 4.31% vs. 53.6% ± SD 9.82%, respectively, p < 0.001). Rater agreement was excellent for both SR (0.11, 95% LOA −0.53 to 0.75) and NR (−0.26, 95% LOA −4.85 to 4.33) (p = 0.242), where 0 denotes perfect agreement. SR completion times were significantly shorter than NR (3:55 min ± SD 1:26 min and 4:50 min ± SD 0:50 min, respectively, p = 0.007).

Conclusion

The RYGB SR is superior to NR for completeness and accuracy. This platform is also both reliable and efficient. This SR should be incorporated into clinical practice.

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Teaching peroral endoscopic myotomy (POEM) to surgeons in practice: an “into the fire” pre/post-test curriculum

Abstract

Introduction

With the increasing adoption of peroral endoscopic myotomy (POEM) as a first-line therapy for achalasia as well as a growing list of other indications, it is apparent that there is a need for effective training methods for both endoscopists in training and those already in practice. We present a hands-on-focused with pre- and post-testing methodology to teach these skills.

Methods

Six POEM courses were taught by 11 experienced POEM endoscopists at two independent simulation laboratories. The training curriculum included a pre-training test, lectures and discussion, mentored hands-on instruction using live porcine and ex-plant models, and a post-training test. The scoring sheet for the pre- and post-tests assessed the POEM performance with a Likert-like scale measuring equipment setup, mucosotomy creation, endoscope navigation, visualization, myotomy, and closure. Participants were stratified by their experience with upper-GI endoscopy (Novices <100 cases vs. Experts ≥100 cases), and their data were analyzed and compared.

Results

Sixty-five participants with varying degrees of experience in upper-GI endoscopy and laparoscopic achalasia cases completed the training curriculum. Participants improved knowledge scores from 69.7 ± 17.1 (pre-test) to 87.7 ± 10.8 (post-test) (p < 0.01). POEM performance increased from 15.1 ± 5.1 to 25.0 ± 5.5 (out of 30) (p < 0.01) with the greatest gains in mucosotomy [1.7–4.4 (out of 5), p < 0.01] and equipment (3.4–4.7, p < 0.01). Novices had significantly lower pre-test scores compared with Experts in upper-GI endoscopy (overall pre-score: 11.9 ± 5.6 vs. 16.3 ± 4.6, p < 0.01). Both groups improved significantly after the course, and there were no differences in post-test scores (overall post-score: 23.9 ± 6.6 vs. 25.4 ± 5.1, p = 0.34) between Novices and Experts.

Conclusions

A multimodal curriculum with procedural practice was an effective curricular design for teaching POEM to practitioners. The curriculum was specifically helpful for training surgeons with less upper-GI endoscopy experience.

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A prospective randomized study of loop-tip versus straight-tip guidewire in wire-guided biliary cannulation

Abstract

Background

Wire-guided cannulation has been widely accepted as a useful technique for achieving selective biliary access because it has significantly increased the success rate of biliary cannulation compared with conventional contrast-assisted cannulation. Unlike conventional guidewires with a straight tip, a loop-tip guidewire (LGW) has a closed distal loop that may facilitate less traumatic access through the epithelial folds of the intra-duodenal biliary segments. The aim of this study was to compare the performance of a LGW with a straight-tip guidewire (SGW) in achieving successful selective biliary cannulation.

Methods

From December 2014 to December 2015, we performed 192 wire-guided biliary cannulations for a naïve papilla in a randomized controlled trial. Patients were randomly assigned to the LGW group (n = 96) or the SGW group (n = 96). Our study protocol did not include crossover to the other guidewire arm if randomized wire-guided cannulation proved unsuccessful within the first 10 min.

Results

There was no significant difference in primary successful biliary cannulation between the two groups (LGW group: 86.5%; SGW group: 77.1%; p = 0.134). The rate and the mean number of unintentional pancreatic duct cannulations during wire-guided biliary cannulation were significantly lower in the LGW group than in the SGW group (LGW group: 14.6%; SGW group: 28.1%; p = 0.034; LGW group: 0.2 ± 0.5; SGW group: 0.6 ± 1.3; p = 0.007). Post-ERCP pancreatitis developed in 5.2% of patients in the LGW group and 8.3% of patients in the SGW group (p = 0.567).

Conclusions

The biliary cannulation rate of the LGW was not significantly different from those of conventional guidewires. Use of the LGW was associated with a lower rate of unintentional pancreatic duct cannulation during wire-guided biliary cannulation than use of the SGW.

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Differences of alternative methods of measuring abdominal wall hernia defect size: a prospective observational study

Abstract

Background

Despite the importance of defect size, there are no standardized recommendations on how to measure ventral hernias. Our aims were to determine (1) if any significant differences existed between various methods of measuring ventral hernias and (2) the effect of these methods of measurement on selection of mesh size.

Method

A prospective study of all patients enrolled in a randomized trial assessing laparoscopic ventral hernia repair at a single institution from 3/2015 to 7/2016 was eligible for inclusion. Abdominal wall hernia defect size was determined by multiplying defect length and width obtained separately using each of five methods: radiographic (CT), intraoperative with abdomen desufflated, intraoperative with abdomen insufflated to 15 mmHg (intra-abdominal aspect), intraoperative with abdomen insufflated to 15 mmHg (extra-abdominal aspect), and clinical. The primary outcome was intraclass correlation between the five different methods of measurement for each patient. Secondary outcome was changes in mesh selection assuming a 5 cm overlap in each direction.

Results

Fifty patients met inclusion criteria for assessment. The five different measurement methods had an intraclass correlation for each patient of 0.533 (95% CI 0.373–0.697) (weak correlation) for length; 0.737 (95% CI 0.613–0.844) (moderate correlation) for width; and 0.684 (95% CI 0.544–0.810) (moderate correlation) for area. Different types of measurements affected mesh selection in up to 56% of cases.

Conclusion

Among five common methods of measuring abdominal wall hernia defect, sizes are only weakly to moderately correlated. Further studies are needed to determine which method results in optimally sized abdominal wall prostheses and superior ventral hernia repair.

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Ventral hernia repair with poly-4-hydroxybutyrate mesh

Abstract

Background

Biomaterial research has made available a biologically derived fully resorbable poly-4-hydroxybutyrate (P4HB) mesh for use in ventral and incisional hernia repair (VIHR). This study evaluates outcomes of patients undergoing VIHR with P4HB mesh.

Methods

An IRB-approved prospective pilot study was conducted to assess clinical and quality of life (QOL) outcomes for patients undergoing VIHR with P4HB mesh. Perioperative characteristics were defined. Clinical outcomes, employment status, QOL using 12-item short form survey (SF-12), and pain assessments were followed for 24 months postoperatively.

Results

31 patients underwent VIHR with bioresorbable mesh via a Rives–Stoppa approach with retrorectus mesh placement. The median patient age was 52 years, median body mass index was 33 kg/m², and just over half of the patients were female. Surgical site occurrences occurred in 19% of patients, most of which were seroma. Hernia recurrence rate was 0% (median follow-up = 414 days). Patients had significantly improved QOL at 24 months compared to baseline for SF-12 physical component summary and role emotional (p < 0.05).

Conclusions

Ventral hernia repair with P4HB bioresorbable mesh results in favorable outcomes. Early hernia recurrence was not identified among the patient cohort. Quality of life improvements were noted at 24 months versus baseline for this cohort of patients with bioresorbable mesh. Use of P4HB mesh for ventral hernia repair was found to be feasible in this patient population. (ClinicalTrials.gov Identifier: NCT01863030).

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Laparoscopic liver resection using a monopolar soft-coagulation device to provide maximum intraoperative bleeding control for the treatment of hepatocellular carcinoma

Abstract

Background

The popularity of laparoscopic liver resection (LLR) is spreading, worldwide, because the intraoperative blood loss is less than for open hepatectomy and it is associated with a shorter hospitalization period [1–6]. During LLR, intraoperative hemostasis is difficult to achieve, unlike during laparotomy where bleeding can be stopped instantly [7–10]. Our LLR method for the treatment of hepatocellular carcinoma (HCC) includes maximal control of intraoperative bleeding using a monopolar soft-coagulation device. Although we use a monopolar soft-coagulation device to control bleeding during LLR, while coagulating the thin blood vessels, we also developed a maneuver (the hepatocyte crush method: HeCM) to allow liver transection to progress while liver parenchymal cells are being crushed.

Method

Between January 2008 and March 2016, we performed total LLR on 150 hepatocellular carcinoma patients (144 partial liver resections and six left lateral sectionectomies) using the maneuver shown in the video.

Results

The patients had Child–Pugh Scores of grade A (n = 100), B (42), or C (n = 8) and the localizations of tumor were segment (S) 1(n = 7), S2 (19), S3 (23), S4 (28), S5 (17), S6 (26), S8 (17), and S8 (29). The median blood loss was 30 (range 0–490) g during a median surgical time of 207 (range 127–468) min. One patient required conversion to a laparotomy due to the presence of severe adhesions; none of the patients required conversion due to intraoperative hemorrhage. The peak aspartate aminotransferase (AST) level was 320 (range 57–1964) IU/L. Although some patients showed high AST levels, none showed signs of hepatic failure. The median postoperative hospital stay duration was 6 (range 3–21) days. Postoperative complications occurred in seven cases (4.7%), including intraabdominal abscesses (n = 2), wound infections (2), intraabdominal hemorrhage (1), bile duct stricture (1), and umbilical hernia (1). The mortality was zero.

Conclusion

HeCM, combined with the use of a monopolar soft-coagulation device, is a good technique for reducing bleeding during liver resection in patients with HCC.

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Does delayed esophagectomy after endoscopic resection affect outcomes in patients with stage T1 esophageal cancer? A propensity score-based analysis

Abstract

Background

Although endoscopic resection (ER) may be sufficient treatment for early-stage esophageal cancer, additional treatment is recommended when there is a high risk of cancer recurrence. It is unclear whether delaying esophagectomy by performing and assessing the success of ER affects outcomes as compared with immediate esophagectomy without ER. Additionally, long-term survival after sequential ER and esophagectomy required further investigation.

Methods

Between 2011 and 2015, 48 patients with stage T1 esophageal cancer underwent esophagectomy after ER with curative intent at our institution. Two-to-one propensity score methods were used to identify 96 matched-control patients who were treated with esophagectomy only using baseline patient, tumor characteristics and surgical approach. Time from initial evaluation to esophagectomy, relapse-free survival, overall survival, and postoperative complications were compared between the propensity-matched groups.

Results

In the ER + esophagectomy group, the time from initial evaluation to esophagectomy was significantly longer than in the esophagectomy only group (114 vs. 8 days, p < 0.001). The incidence of dense adhesion (p = 0.347), operative time (p = 0.867), postoperative surgical complications (p = 0.966), and postoperative length of hospital stay (p = 0.125) were not significantly different between the groups. Moreover, recurrence-free survival and overall survival were also similar between the two groups (p = 0.411 and p = 0.817, respectively).

Conclusions

Treatment of stage T1 esophageal cancer with ER prior to esophagectomy did not increase the difficulty of performing esophagectomy or the incidence of postoperative complications and did not affect survival after esophagectomy. These results suggest that ER can be recommended for patients with stage T1 cancer even if esophagectomy is warranted eventually.

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Factors affecting operative efficiency and post-operative convalescence in laparoendoscopic single-site (LESS) adrenalectomy

Abstract

Background

Laparoendoscopic single-site (LESS) adrenalectomy is a novel challenging technique which is still under clinical evaluation. Initial reports have revealed its superiority in patient convalescence. In addition, it has been reported that some patient or anatomic factors might affect the ergonomics of LESS adrenalectomy. The aim of this study is to investigate the possible factors that might affect procedural efficiency and patient convalescence in LESS adrenalectomy.

Methods

Between October 2009 and July 2015, 105 consecutive adult patients with benign adrenal tumors, who underwent LESS retroperitoneal adrenalectomy were enrolled in this study. All the relevant peri-operative parameters were prospectively collected for later analysis. By using stepwise linear regression and stepwise selection of these peri-operative parameters, those that might affect the operative efficiency and patient convalescence were analyzed.

Results

Finally, 78 patients who completed follow-up and were eligible for stepwise linear regression were enrolled for final analysis. For parameters affecting operative efficiency, the fitted model revealed that patients with a pre-operative diagnosis of pheochromocytoma, a higher BMI, and an associated co-morbidity of heart disease are associated with a longer operative time. In addition, the fitted model revealed that patients with a lower post-operative pain score, a delayed oral intake, and a diagnosis of non-functioning adrenal tumor were associated with a lengthier period before returning to normal activity.

Conclusion

A higher BMI is the only anatomic factor that affects procedural efficiency in LESS adrenalectomy. In addition, post-operative pain score, time to oral intake, and a diagnosis of non-functioning adrenal tumor are the factors affecting patient convalescence.

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A faster and simpler way of operation for Meckel’s diverticulum: basal ligation combined with intraoperative frozen section

Abstract

Background

The key step in Meckel's diverticulectomy (MD) is to achieve complete resection of MD along with the ectopic epithelium. Currently main treatment methods for Meckel's diverticulum are either intestinal resection and anastomosis or wedge resection. Here we introduced a new method to treat MD. The goal of this study was to investigate the clinical effects and advantages of a new operation method for Meckel's diverticulum: basal ligation combined with intraoperative frozen section.

Methods

262 cases of Meckel's diverticulum were resected with simple basal ligation operation. Intraoperative frozen pathological section was performed to determine surgery strategies. Based on the existence of basal residual ectopic mucosa, surgery was either terminated or further wedge intestinal resection or bowel resection was performed.

Results

All 262 surgeries were successfully completed. Additional wedge resection or bowel resection was performed in only 23 of them due to the presence of ectopic basal residual gastric mucosa. No ectopic mucosa was found for the other cases, and the operation ended after basal ligation. All patients had no complications such as intestinal fistula, bleeding for 6 months–7.6 years after surgery.

Conclusions

Intraoperative frozen pathological examination can well determine whether ectopic Meckel's diverticulum mucosa locates at the basal part. Basal ligation is a safe and effective operation method, and it can significantly shorten the operation time and postoperative fasting time.

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Spotlight: MedixSafe strives to make first responders' jobs easier

The MS2 narcotics cabinet saves space in ambulances while providing triple authentication of users

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Assessment of the underlying systems involved in standing balance: the additional value of electromyography in system identification and parameter estimation

Closed loop system identification (CLSIT) is a method to disentangle the contribution of underlying systems in standing balance. We investigated whether taking into account lower leg muscle activation in CLSIT...

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Investigation: Less ambulance siren use won't impact patient outcomes

Recommendations to reduce lights and ambulance siren use to less than 50 percent of responses and 5 percent of transports presented during EMS Focus webinar

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The Role of Intra-Session Exercise Sequence in the Interference Effect: A Systematic Review with Meta-Analysis

Abstract

Background

There is a necessity for numerous sports to develop strength and aerobic capacity simultaneously, placing a significant demand upon the practice of effective concurrent training methods. Concurrent training requires the athlete to perform both resistance and endurance exercise within a training plan. This training paradigm has been associated with an 'interference effect', with attenuated strength adaptation in comparison to that following isolated resistance training. The effectiveness of the training programme rests on the intricacies of manipulating acute training variables, such as exercise sequence. The research, in the most part, does not provide a clarity of message as to whether intra-session exercise sequence has the potential to exacerbate or mitigate the interference effect associated with concurrent training methods.

Objective

The aim of the systematic review and meta-analysis was to assess whether intra-session concurrent exercise sequence modifies strength-based outcomes associated with the interference effect.

Methods

Ten studies were identified from a systematic review of the literature for the outcomes of lower-body dynamic and static strength, lower-body hypertrophy, maximal aerobic capacity and body fat percentage. Each study examined the effect of intra-session exercise sequence on the specified outcomes, across a prolonged (≥5 weeks) concurrent training programme in healthy adults.

Results

Analysis of pooled data indicated that resistance-endurance exercise sequence had a positive effect for lower-body dynamic strength, in comparison to the alternate sequence (weighted mean difference, 6.91% change; 95% confidence interval 1.96, 11.87 change; p = 0.006), with no effect of exercise sequence for lower-body muscle hypertrophy (weighted mean difference, 1.15% change; 95% confidence interval −1.56, 3.87 change; p = 0.40), lower-body static strength (weighted mean difference, −0.04% change; 95% confidence interval −3.19, 3.11 change; p = 0.98), or the remaining outcomes of maximal aerobic capacity and body fat percentage (p > 0.05).

Conclusion

These results indicate that the practice of concurrent training with a resistance followed by an endurance exercise order is beneficial for the outcome of lower-body dynamic strength, while alternating the order of stimuli offers no benefit for training outcomes associated with the interference effect.

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Honey bees possess a polarity-sensitive magnetoreceptor

Abstract

Honey bees, Apis mellifera, exploit the geomagnetic field for orientation during foraging and for alignment of their combs within hives. We tested the hypothesis that honey bees sense the polarity of magnetic fields. We created an engineered magnetic anomaly in which the magnetic field generally either converged toward a sugar reward in a watch glass, or away from it. After bees in behavioral field studies had learned to associate this anomaly with a sugar water reward, we subjected them to two experiments performed in random order. In both experiments, we presented bees with two identical sugar water rewards, one of which was randomly marked by a magnetic field anomaly. During the control experiment, the polarity of the magnetic field anomaly was maintained the same as it was during the training session. During the treatment experiment, it was reversed. We predicted that bees would not respond to the altered anomaly if they were sensitive to the polarity of the magnetic field. Our findings that bees continued to respond to the magnetic anomaly when its polarity was in its unaltered state, but did not respond to it when its polarity was reversed, support the hypothesis that honey bees possess a polarity-sensitive magnetoreceptor.

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Ultrasound Guidance for Phenol Neurolysis to the Musculocutaneous Nerve

This study compared electrical stimulation only (e-stim) to ultrasound with e-stim (US) guidance in phenol neurolysis of the musculocutaneous nerve (MCN) for elbow flexor spasticity. We also evaluated the US appearance of MCN in this population.

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Accelerated return to sport after ACL reconstruction and early knee osteoarthritis features at 1 year: an exploratory study

A timely return to competitive sport is a primary goal of anterior cruciate ligament reconstruction (ACLR). It is not known if an accelerated return-to-sport increases the risk of early-onset knee osteoarthritis (KOA).

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Uranium isotopes in tree bark as a spatial tracer of environmental contamination near former uranium processing facilities in southwest Ohio

Publication date: November 2017
Source:Journal of Environmental Radioactivity, Volumes 178–179
Author(s): Elise Conte, Elisabeth Widom, David Kuentz
Inappropriate handling of radioactive waste at nuclear facilities can introduce non-natural uranium (U) into the environment via the air or groundwater, leading to anthropogenic increases in U concentrations. Uranium isotopic analyses of natural materials (e.g. soil, plants or water) provide a means to distinguish between natural and anthropogenic U in areas near sources of radionuclides to the environment. This study examines the utility of two different tree bark transects for resolving the areal extent of U atmospheric contamination using several locations in southwest Ohio that historically processed U. This study is the first to utilize tree bark sampling transects to assess environmental contamination emanating from a nuclear facility. The former Fernald Feed Materials Production Center (FFMPC; Ross, Ohio) produced U metal from natural U ores and recycled nuclear materials from 1951 to 1989. Alba Craft Laboratory (Oxford, Ohio) machined several hundred tons of natural U metal from the FFMPC between 1952 and 1957. The Herring-Hall-Marvin Safe Company (HHM; Hamilton, Ohio) intermittently fabricated slugs rolled from natural U metal stock for use in nuclear reactors from 1943 to 1951. We have measured U concentrations and isotope signatures in tree bark sampled along an ∼35 km SSE-NNW transect from the former FFMPC to the vicinity of the former Alba Craft laboratories (transect #1) and an ∼20 km SW- NE (prevailing local wind direction) transect from the FFMPC to the vicinity of the former HHM (transect #2), with a focus on old trees with thick, persistent bark that could potentially record a time-integrated signature of environmental releases of U related to anthropogenic activity.Our results demonstrate the presence of anthropogenic U contamination in tree bark from the entire study area in both transects, with U concentrations within 1 km of the FFMPC up to ∼400 times local background levels of 0.066 ppm. Tree bark samples from the Alba Craft and HHM transects exhibit increasing U concentrations within ∼5 and ∼10 km, respectively of the FFMPC. The ²³⁶U/²³⁸U isotopic ratios in tree bark from both transects increase progressively towards the FFMPC with values as high as 2.00 × 10⁻⁴ at the FFMPC. Tree bark sampled within 1 km of the FFMPC exhibits clear evidence for both enriched and depleted uranium with ²³⁵U/²³⁸U values from 0.00461 to 0.00736, with ²³⁴U/²³⁸U activity ratio ranging from 0.53 to 0.96, and ²³⁶U/²³⁸U from 6.05 × 10⁻⁵ to 1.05 × 10⁻⁴. Tree bark from transect #1 between 1 and 30 km from the FFMPC exhibits depleted and natural ²³⁵U/²³⁸U values ranging from 0.00552 to 0.00726 [²³⁴U/²³⁸U activity ratio: 0.69–1.04; ²³⁶U/²³⁸U: 2.49 × 10⁻⁶ – 2.00 × 10⁻⁴]. Tree bark from transect #2 sampled between 1 and ∼20 km away from the FFMPC exhibits evidence of enriched and depleted U in the environment with ²³⁵U/²³⁸U ranging from 0.00635 to 0.00738 [²³⁴U/²³⁸U activity ratio: 0.83–0.98; ²³⁶U/²³⁸U: 1.43 × 10⁻⁵ – 2.00 × 10⁻⁴]. Results from scanning electron microscopy with energy dispersive spectrometry provides evidence for U-rich particles as the source of contamination found in tree bark growing within 1–3 km of the former FFMPC. Such observations are consistent with the previously observed 14 μm U-rich particle identified in tree bark sampled within 1 km of the FFMPC (Conte et al., 2015). Overall, this study shows the usefulness of a tree bark sample transect to assess the areal extent of atmospheric contaminant U stemming from nuclear facilities.



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Dexlansoprazole for Heartburn Relief in Adolescents with Symptomatic, Nonerosive Gastro-esophageal Reflux Disease

Abstract

Background

Proton pump inhibitors are commonly used to treat gastro-esophageal reflux disease (GERD) and nonerosive GERD (NERD) in adolescents and adults. Despite the efficacy of available medications, many patients have persisting symptoms, indicating a need for more effective agents.

Aims

To assess the safety and efficacy of dexlansoprazole dual delayed-release capsules in adolescents for treatment of symptomatic NERD.

Methods

A phase 2, open-label, multicenter study was conducted in adolescents aged 12–17 years. After a 21-day screening period, adolescents with endoscopically confirmed NERD received a daily dose of 30-mg dexlansoprazole for 4 weeks. The primary endpoint was treatment-emergent adverse events (TEAEs) experienced by ≥5% of patients. The secondary endpoint was the percentage of days with neither daytime nor nighttime heartburn. Heartburn symptoms and severity were recorded daily in patient electronic diaries and independently assessed by the investigator, along with patient-reported quality of life, at the beginning and end of the study.

Results

Diarrhea and headache were the only TEAEs reported by ≥5% of patients. Dexlansoprazole-treated patients (N = 104) reported a median 47.3% of days with neither daytime nor nighttime heartburn. Symptoms such as epigastric pain, acid regurgitation, and heartburn improved in severity for 73–80% of patients. Pediatric Gastroesophageal Symptom and Quality of Life Questionnaire-Adolescents-Short Form symptom and impact subscale scores (scaled 1–5) each decreased by an average of 0.7 units at week 4.

Conclusions

Use of 30-mg dexlansoprazole in adolescent NERD was generally well tolerated and had beneficial effects on improving heartburn symptoms and quality of life.

Trial Registration

This study has the ClinicalTrials.gov identifier NCT01642602.

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Surgery for Duodenal Gastrointestinal Stromal Tumors: A Single-Center Experience

Abstract

Background

The duodenal gastrointestinal stromal tumors (GISTs) are an extremely rare subset of GISTs. The optimal surgical procedure remains not well defined.

Aims

We assessed the surgical approach and long-term outcomes of patients with duodenal GISTs who underwent limited resection (LR) versus pancreaticoduodenectomy (PD).

Methods

From November 2005 to January 2016, 64 consecutive patients with duodenal GISTs in a single center were retrospectively analyzed. Overall survival (OS), recurrence-free survival (RFS), and perioperative outcomes were analyzed according to the different surgical type.

Results

A total of 41 patients (64.1%) underwent LR, while 23 patients (35.9%) underwent PD. All patients had negative surgical margins (R0). Median tumor size was larger for PD (6 cm) versus LR (4 cm) (P = 0.041). PD also had more complications than LR (PD, 69.6 vs. LR, 31.7%) (P = 0.002). The 3-year and 5-year RFS was 62.9 and 44.3%, respectively. The 3-year and 5-year OS was 85.7 and 59.5%, respectively. The multivariate analysis demonstrated the only unfavorable predictive factor was tumor size >5 cm for RFS and OS. Although the complication rate in the PD group was higher than in the LR group, OS and RFS were not affected by the complication (P = 0.492 for OS, P = 0.512 for RFS). PD versus LR was not associated with RFS and OS. Adjuvant imatinib mesylate (IM) did not improve the survival of the patients after operation.

Conclusions

Survival of duodenal GISTs is mainly dependent on tumor biology rather than surgical procedure. LR should be the surgical procedure of choice for duodenal GISTs when technically feasible and no anatomical constrains. LR shows comparable survival and lower risk of postoperative complications compared by PD. The administration of IM both as adjuvant and neoadjuvant therapy for duodenal GISTs needs large population and prospective study to evaluate its effect.

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Tissue Transglutaminase Levels Are Not Sufficient to Diagnose Celiac Disease in North America Without Intestinal Biopsies: Don’t Throw the Baby Out with the Bathwater

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Bioinformatics-Based Identification of Methylated-Differentially Expressed Genes and Related Pathways in Gastric Cancer

Abstract

Background and Aims

The aim of the study was to identify methylated-differentially expressed genes (MDEGs) in gastric cancer and investigate their potential pathways.

Methods

Expression profiling (GSE13911 and GSE29272) and methylation profiling (GSE25869 and GSE30601) data were obtained from GEO DataSets. Differentially expressed genes and differentially methylated genes were identified using GEO2R. Gene ontology and pathway enrichment analyses were performed for the MDEGs. Protein–protein interaction (PPI) networks were established by STRING and Cytoscape. Analysis of modules in the PPI networks was performed using MCODE. Further, the hub genes derived from the PPI networks were verified by The Cancer Genome Atlas (TCGA) database and human tissues, with methylation-specific PCR for genes methylation and real-time qPCR for genes expression.

Results

A total of 445 genes were identified as hypermethylated, lowly expressed genes (Hyper-LGs), which were enriched in the regulation of system process and channel activity. A total of 129 genes were identified as hypomethylated, highly expressed genes (Hypo-HGs), which were involved in cell adhesion, cell proliferation, and protein binding. Pathway analysis showed that Hyper-LGs were associated with neuroactive ligand–receptor interaction and calcium signaling pathway, while Hypo-HGs were enriched in pathways in cancer. In the PPI networks, after verification by TCGA analysis and human tissue detection, CASR, CXCL12, and SST were identified as significantly different hub genes.

Conclusions

MDEG analysis helps to understand the epigenetic regulation mechanisms involved in the development and progression of gastric cancer. The hub genes have predictive and prognostic value as methylation-based biomarkers for the precise diagnosis and treatment of gastric cancer.

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Fibroblast growth factor-2-mediated FGFR/Erk signaling supports maintenance of cancer stem-like cells in esophageal squamous cell carcinoma

Carcinogenesis

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Yes, patients want to discuss pricing, payment options before treatment

Healthcare Finance News

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Quantity and source of dietary protein influence metabolite production by gut microbiota and rectal mucosa gene expression: A randomized, parallel, double-blind trial in overweight humans

American Journal of Clinical Nutrition

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FDA moves to close loophole on orphan drugs to bring down costs

Healthcare Finance News

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Seroprevalence of hepatitis B and factors potentially associated in a population-based study in Medellin, Colombia

Vaccine

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Elderly-onset and adult-onset ulcerative colitis are more similar than previously reported in a nationwide cohort

Digestive Diseases and Sciences

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Nutritional support in paediatric Crohn's disease; Outcome at 12 months

Acta Pediatrica

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Risk factor analysis between newly screened and established hepatitis C in GI and hepatology clinics

Digestive Diseases and Sciences

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Patients with inflammatory bowel disease have increased risk of autoimmune and inflammatory diseases

World Journal of Gastroenterology

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A phase I open-label dose-escalation study of the anti-HER3 monoclonal antibody LJM716 in patients with advanced squamous cell carcinoma of the esophagus or head and neck and HER2-overexpressing breast or gastric cancer

BMC Cancer

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Necrotizing enterocolitis and high intestinal iron uptake due to genetic variants

Pediatric Research

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Association of IFNL3 genotype with hepatic steatosis in chronic hepatitis C patients treated with peginterferon and ribavirin combination therapy

International Journal of Medical Sciences

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Weekly diabetes drug offers no heart benefit

Reuters Health News

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Omega-3 PUFA modulate lipogenesis, ER stress, and mitochondrial dysfunction markers in NASH - Proteomic and lipidomic insight

Clinical Nutrition

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ROC-king onwards: Intraepithelial lymphocyte counts, distribution & role in coeliac disease mucosal interpretation

Gut

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Increase of soluble programmed cell death ligand 1 in patients with chronic hepatitis C

International Journal of Medical Sciences

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The effect of nefopam infusion during laparascopic cholecystectomy on postoperative pain

International Journal of Medical Sciences

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Comparison of clinical data and scores of quality of life, anxiety, and depression in patients with different types of intraductal papillary mucinous neoplasms: A prospective study

Pancreas

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Thromboembolisms in advanced pancreatic cancer: A retrospective analysis of 475 patients

Pancreas

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Effects of early integrated palliative care on caregivers of patients with lung and gastrointestinal cancer: A randomized clinical trial

The Oncologist

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Autophagy-related protein ATG5 regulates histone H2B mono-ubiquitylation by translational control of RNF20

Publication date: Available online 14 September 2017
Source:Journal of Genetics and Genomics
Author(s): Xin Huang, Lu Yang, Feng-Feng Cai, Yufei Wang, Ping Chen, Jiangsheng Mi, Chenghua Yu, Jianghua Lai, Xiaojun Zhang, Shuguang Wei, Wen Cui, Su Chen




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Tissue-specific genome editing of laminA/C in the posterior silk glands of Bombyx mori

Publication date: Available online 14 September 2017
Source:Journal of Genetics and Genomics
Author(s): Yuanyuan Liu, Sanyuan Ma, Jiasong Chang, Tong Zhang, Xiaogang Wang, Run Shi, Jianduo Zhang, Wei Lu, Yue Liu, Qingyou Xia
The RNA-guided CRISPR/Cas9 system has been shown to be a powerful tool for genome editing in various organisms. A comprehensive toolbox for multiplex genome editing has been developed for the silkworm, Bombyx mori, a lepidopteran model insect of economic importance. However, as previous methods mainly relied on delivery of transient Cas9/guide RNA (gRNA), they could not be used in loss-of-function studies of essential genes. Here, we report a simple and versatile tissue-specific genome editing strategy. We perform a proof-of-principle demonstration by establishing and crossing two transgenic B. mori lines, one expressing Cas9 protein in the posterior silk gland (PSG) and the other constitutively expressing BmlaminA/C (BmLMN) gRNA. All BmLMN alleles in the PSG cells were edited precisely at the target genome region, resulting in diverse mutations. mRNA expression of BmLMN was reduced by up to 75%, and only very low levels of BmLaminA/C protein were detected. Knockout of BmLMN produced obvious defects in gland cell development and cocoon production. This report details an efficient strategy for spatially controlled genome editing, providing unprecedented opportunities for investigating the function of essential/lethal genes in B. mori, with potential application for other insects.



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Effect of swallowing maneuver on fentanyl-induced coughing

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In reply: Sevoflurane in patients at risk of ventricular dysrhythmias

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Genetic engineering: Pigs without PERVs

Nature Reviews Genetics 18, 579 (2017). doi:10.1038/nrg.2017.73

Author: Linda Koch

Pig-to-human organ transplantation holds promise for resolving the existing shortage of transplantable organs, but the potential transmission risk of porcine endogenous retroviruses (PERVs) to humans has remained a concern. Now, Niu et al. report the successful generation of PERV-inactivated pigs by somatic cell nuclear

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Model organisms: New tools, new insights — probing social behaviour in ants

Nature Reviews Genetics 18, 577 (2017). doi:10.1038/nrg.2017.70

Author: Dorothy Clyde

Eusocial insects display complex social behaviours, but the underlying molecular mechanisms are largely unknown. Now, a trio of papers in Cell decribe two genes (orco and corazonin) that control social behaviour in ants. Furthermore, two of the studies describe the first

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Chromosome biology: Different turfs for cohesin and condensin

Nature Reviews Genetics 18, 578 (2017). doi:10.1038/nrg.2017.71

Author: Eytan Zlotorynski

The structural maintenance of chromosomes (SMC) complexes cohesin and condensin are ring-shaped protein machines that encircle the chromatin and control various aspects of chromosome function, including the formation of chromatin loops, sister chromatid cohesion and mitotic chromosome compaction. Schalbetter et al. now show that

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Gene therapy: Human genome editing in heart disease

Nature Reviews Genetics 18, 580 (2017). doi:10.1038/nrg.2017.69

Author: Gregory B. Lim

Human germline genome editing with CRISPR–Cas9 was used with high efficiency, accuracy and safety to correct a heterozygous, autosomal dominant mutation in MYBPC3 associated with hypertrophic cardiomyopathy, according to a new study in Nature.CRISPR–Cas9 is a versatile tool for recognizing a specific

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Settling the score: variant prioritization and Mendelian disease

Nature Reviews Genetics 18, 599 (2017). doi:10.1038/nrg.2017.52

Authors: Karen Eilbeck, Aaron Quinlan & Mark Yandell

When investigating Mendelian disease using exome or genome sequencing, distinguishing disease-causing genetic variants from the multitude of candidate variants is a complex, multidimensional task. Many prioritization tools and online interpretation resources exist, and professional organizations have offered clinical guidelines for review and return of prioritization

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Pathogen genetics: Evolutionary dynamics driving drug resistance

Nature Reviews Genetics 18, 578 (2017). doi:10.1038/nrg.2017.68

Author: Linda Koch

The broad application of antibiotics is responsible for the development of antimicrobial resistance in many bacterial pathogens. Two recent studies now reconstruct the evolutionary history of the first methicillin-resistant Staphylococcus aureus (MRSA) and the multidrug-resistant Escherichia coli lineage ST131. Harkins et al.

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Dissecting evolution and disease using comparative vertebrate genomics

Nature Reviews Genetics 18, 624 (2017). doi:10.1038/nrg.2017.51

Authors: Jennifer R. S. Meadows & Kerstin Lindblad-Toh

With the generation of more than 100 sequenced vertebrate genomes in less than 25 years, the key question arises of how these resources can be used to inform new or ongoing projects. In the past, this diverse collection of sequences from human as well as

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Evolutionary biology through the lens of budding yeast comparative genomics

Nature Reviews Genetics 18, 581 (2017). doi:10.1038/nrg.2017.49

Authors: Souhir Marsit, Jean-Baptiste Leducq, Éléonore Durand, Axelle Marchant, Marie Filteau & Christian R. Landry

The budding yeast Saccharomyces cerevisiae is a highly advanced model system for studying genetics, cell biology and systems biology. Over the past decade, the application of high-throughput sequencing technologies to this species has contributed to this yeast also becoming an important model for evolutionary

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Synthetic lethality and cancer

Nature Reviews Genetics 18, 613 (2017). doi:10.1038/nrg.2017.47

Authors: Nigel J. O'Neil, Melanie L. Bailey & Philip Hieter

A synthetic lethal interaction occurs between two genes when the perturbation of either gene alone is viable but the perturbation of both genes simultaneously results in the loss of viability. Key to exploiting synthetic lethality in cancer treatment are the identification and the mechanistic characterization

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Effect of an Intravenous Dexamethasone Added to Caudal Local Anesthetics to Improve Postoperative Pain: A Systematic Review and Meta-Analysis With Trial Sequential Analysis.

BACKGROUND: Caudal anesthesia has been used for postoperative pain control in pediatric surgical patients, but the duration of the analgesic effect is occasionally unsatisfactory. Intravenous steroids have been shown to be effective for postsurgical pain management after certain surgeries. The aim of this meta-analysis with trial sequential analysis (TSA) was to evaluate the analgesic effect of steroids in patients administered with caudal anesthesia. METHODS: This study was a systematic review and meta-analysis. A search of published literature was conducted in the MEDLINE, EMBASE, Web of Science, and Cochrane Central Register of Controlled Trials databases and in trial registration sites. Randomized controlled trials that compared intravenous steroids with a placebo in pediatric patients who had received caudal anesthesia for surgery were included in the study. The primary outcomes from the present meta-analysis were the analgesic duration and the number of patients who required rescue analgesics. The analgesic duration and incidence of rescue use were summarized using mean difference or risk ratio with a 97.5% confidence interval (CI), respectively. If the 97.5% CI of the mean difference or risk ratio included a value of 0 or 1, respectively, we considered the difference not to be significant. We used the random effects model to combine the results. Heterogeneity was quantified with the I2 statistic. The quality of the trials was evaluated using the Cochrane methodology. Moreover, a TSA with a risk of type 1 error of 2.5% and power of 90% was performed. We established the minimum clinically meaningful difference of analgesic duration as 3 hours. The target sample size for meta-analysis was also calculated in the TSA. We also assessed adverse events. RESULTS: Six trials with 424 patients were included; 211 patients received intravenous steroids. All trials compared dexamethasone of at least 0.5 mg/kg dose with a placebo. Dexamethasone prolonged the duration of caudal analgesia (mean difference, 244 minutes; 97.5% CI, 188-300). Heterogeneity was considerable with an I2 value of 94.8%. Quality of evidence was very low. The TSA suggested that only 17.0% of the target sample size had been reached, but the cumulative Z score crossed the trial sequential monitoring boundary to indicate a benefit. Rescue use was reported in 4 studies with 260 patients. Rescue use was not significantly reduced in the dexamethasone group (risk ratio, 0.53; 97.5% CI, 0.09-3.30; I2, 98.7%). No increase in adverse events was reported. CONCLUSIONS: Intravenous dexamethasone prolongs the analgesic duration of caudal anesthesia. Trials to investigate the effectiveness of a lower dose of the dexamethasone in prolonging analgesic effects would be of interest. Further trials with a low risk of bias are necessary. (C) 2017 International Anesthesia Research Society

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Dexmedetomidine Maintains Its Direct Cardioprotective Effect Against Ischemia/Reperfusion Injury in Hypertensive Hypertrophied Myocardium.

BACKGROUND: Dexmedetomidine (DEX) has a direct cardioprotective effect against ischemia/reperfusion injury through endothelial nitric oxide synthase (eNOS) phosphorylation via [alpha]2-adrenoreceptor ([alpha]2-AR). By using spontaneously hypertensive rat (SHR) and Wistar-Kyoto (WKY) rat models, the cardioprotective effect of DEX in hypertrophied myocardium and the differential characteristics of cardiac [alpha]2-AR and the I1 imidazoline receptor (I1R) were examined. METHODS: Langendorff-perfused rat hearts underwent 40 minutes of global ischemia followed by 120 minutes of reperfusion in the presence or absence of DEX before ischemia. Infarct size was measured, and eNOS phosphorylation was assessed by Western blotting. The presence and expression of the receptors were assessed by immunohistochemistry, real-time reverse transcriptase polymerase chain reaction, and Western blotting. RESULTS: In WKY, DEX significantly decreased infarct size and increased phosphorylated-eNOS/eNOS. These effects were counteracted by yohimbine ([alpha]2-AR antagonist) and efaroxan ([alpha]2-AR and I1R antagonist). In SHR, DEX significantly decreased infarct size, and the effect was counteracted by efaroxan but not yohimbine. DEX did not alter phosphorylated-eNOS/eNOS in SHR. [alpha]2-AR and I1R were observed in WKY and SHR hearts. Although alpha2A-AR and alpha2B-AR messenger RNA and protein levels were upregulated in SHR, I1R expression was comparable between the 2 species. CONCLUSIONS: In the hypertrophied heart, DEX maintains its direct cardioprotective effect against ischemia/reperfusion injury via I1R in an eNOS-nondependent manner despite upregulation of [alpha]2-AR. (C) 2017 International Anesthesia Research Society

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Meanings of Pain.

No abstract available

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Assessing the Utility of Fluoroscopy for Epidural Catheter Placement: What End Points Are Important?.

No abstract available

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Sedation After Cardiac Surgery With Propofol or Dexmedetomidine: Between Scylla and Charybdis?.

No abstract available

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In Response: Sedation After Cardiac Surgery With Propofol or Dexmedetomidine: Between Scylla and Charybdis?.

No abstract available

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Surveying the Literature: Synopsis of Recent Key Publications.

No abstract available

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