Risk factors for severe morbidity and definitive stoma after elective surgery for sigmoid diverticulitis: a multicenter national cohort study

BACKGROUND

In the decision to perform elective surgery, it is of great interest to have data about the outcomes of surgery to individualize patients who could safely undergo sigmoid resection. The aim of this study was to provide information on the outcomes of elective sigmoid resection for sigmoid diverticular disease (SDD) at a national level.

METHODS

All consecutive patients who had elective surgery for SDD (2010-2021) were included in this retrospective, multicenter, cohort study. Patients were identified from institutional review board-approved databases in French member centers of the French Surgical Association. The endpoints of the study were the early and the long-term postoperative outcomes and an evaluation of the risk factors for 90-day severe postoperative morbidity and a definitive stoma after an elective sigmoidectomy for SDD.

RESULTS

In total, 4617 patients were included. The median [IQR] age was 61 [18.0;100] years, the mean ± SD body mass index (BMI) was 26.8 ± 4 kg/m2, and 2310 (50%) were men. The indications for surgery were complicated diverticulitis in 50% and smoldering diverticulitis in 47.4%. The procedures were performed laparoscopically for 88% and with an anastomosis for 83.8%. The severe complication rate on postoperative day 90 was 11.7%, with a risk of anastomotic leakage of 4.7%. The independent risk factors in multivariate analysis were an American Society of Anesthesiologists (ASA) score ≥ 3, an open approach, and perioperative blood transfusion. Age, perioperative blood transfusion, and Hartmann's procedure were the three independent risk factors for a permanent stoma.

CONCLUSIONS

This series provides a real-life picture of elective sigmoidectomy for SDD at a national level.

TRIAL REGISTRATION

Comité National Information et Liberté (CNIL) (n°920361).

Use-dependent corticospinal excitability is associated with resilience and physical performance during simulated military operational stress

Simulated military operational stress (SMOS) provides a useful model to better understand resilience in humans as the stress associated with caloric restriction, sleep deficits, and fatiguing exertion degrades physical and cognitive performance. Habitual physical activity may confer resilience against these stressors by promoting favorable use-dependent neuroplasticity, but it is unclear how physical activity, resilience, and corticospinal excitability (CSE) relate during SMOS. To examine associations between corticospinal excitability, physical activity, and physical performance during SMOS. Fifty-three service members (age: 26 ± 5 yr, 13 women) completed a 5-day and -night intervention composed of familiarization, baseline, SMOS (2 nights/days), and recovery days. During SMOS, participants performed rigorous physical and cognitive activities while receiving half of normal sleep (two 2-h blocks) and caloric requirements. Lower and upper limb CSE were determined with transcranial magnetic stimulation (TMS) stimulus-response curves. Self-reported resilience, physical activity, military-specific physical performance (TMT), and endocrine factors were compared in individuals with high (HIGH) and low CSE based on a median split of lower limb CSE at baseline. HIGH had greater physical activity and better TMT performance throughout SMOS. Both groups maintained physical performance despite substantial psychophysiological stress. Physical activity, resilience, and TMT performance were directly associated with lower limb CSE. Individual differences in physical activity coincide with lower (but not upper) limb CSE. Such use-dependent corticospinal excitability directly relates to resilience and physical performance during SMOS. Future studies may use noninvasive neuromodulation to clarify the interplay among CSE, physical activity, and resilience and improve physical and cognitive performance.NEW & NOTEWORTHY We demonstrate that individual differences in physical activity levels coincide with lower limb corticospinal excitability. Such use-dependent corticospinal excitability directly relates to resilience and physical performance during a 5-day simulation of military operational stress with caloric restriction, sleep restriction and disruption, and heavy physical and cognitive exertion.

A Reappraisal of Outcome of Elective Surgery After Successful Non-Operative Management of an Intra-Abdominal Abscess Complicating Ileocolonic Crohn's Disease: A Subgroup Analysis of a Nationwide Prospective Cohort

BACKGROUND AND AIMS

Few prospective data exist on outcomes of surgery in Crohn's disease [CD] complicated by an intra-abdominal abscess after resolution of this abscess by antibiotics optionally combined with drainage.

METHODS

From 2013 to 2015, all patients undergoing elective surgery for CD after successful non-operative management of an intra-abdominal abscess [Abscess-CD group] were selected from a nationwide multicentre prospective cohort. Resolution of the abscess had to be computed tomography/magnetic resonance-proven prior to surgery. Abscess-CD group patients were 1:1 matched to uncomplicated CD [Non-Penetrating-CD group] using a propensity score. Postoperative results and long-term outcomes were compared between the two groups.

RESULTS

Among 592 patients included in the registry, 63 [11%] fulfilled the inclusion criteria. The abscess measured 37 ± 20 mm and was primarily managed with antibiotics combined with drainage in 14 patients and nutritional support in 45 patients. At surgery, a residual fluid collection was found in 16 patients [25%]. Systemic steroids within 3 months before surgery [p = 0.013] and the absence of preoperative enteral support [p = 0.001] were identified as the two significant risk factors for the persistence of a fluid collection. After propensity score matching, there was no significant difference between the Abscess-CD and Non-Penetrating-CD groups in the rates of primary anastomosis [84% vs 90% respectively, p = 0.283], overall [28% vs 15% respectively, p = 0.077] and severe postoperative morbidity [7% vs 7% respectively, p = 1.000]. One-year recurrence rates for endoscopic recurrence were 41% in the Abscess-CD and 51% in the Non-Penetrating-CD group [p = 0.159].

CONCLUSIONS

Surgery after successful non-operative management of intra-abdominal abscess complicating CD provides good early and long-term outcomes.

Reliability of corticospinal excitability estimates for the vastus lateralis: Practical considerations for lower limb TMS task selection

Transcranial magnetic stimulation (TMS) is increasingly used to examine lower extremity corticospinal excitability (CSE) in clinical and sports research. Because CSE is task-specific, there is growing emphasis on the use of ecological tasks. Nevertheless, the comparative reliability of CSE measurements during established (e.g. knee extensions; KE) and more recent ecological (e.g. squats; SQT) lower extremity tasks has received less attention. The aim of this study was to compare the test-retest reliability of CSE, force, and muscle activity (EMG) during isometric SQT and KE. 19 right-footed men (age: 25 ± 5 yrs) with similar fitness and body composition performed SQT (N = 7) or KE (N = 12) on two consecutive days. Force and EMG were recorded during maximum voluntary isometric contractions (MVC). Corticospinal excitability was determined in the dominant leg during light (15% MVC) contractions based on motor evoked potential (MEP) stimulus-response-curves (SRC). Test-retest reliability, absolute agreement, and consistency were determined for force, EMG, and SRC MEP maximum (MEPMAX) and rising phase midpoint (V50). As a secondary analysis, all outcomes were compared between groups with mixed-methods ANCOVAs (Task × Time, covariate: body-fat-percentage). Compared with SQT, KE displayed better test-retest reliability and agreement for MEPMAX whereas V50, force, and EMG were similarly reliable. Force (p = 0.01) and MEPMAX (p = 0.02) were also greater during KE despite a similar V50 (p = 0.11). Differences in test-retest reliability, absolute agreement, and between-group comparisons highlight the need to carefully select lower limb TMS assessment tasks and encourage future efforts to balance ecological validity with statistical sensitivity.

Characterizing off-target corticospinal responses to double-cone transcranial magnetic stimulation

INTRODUCTION

The double-cone coil (D-CONE) is frequently used in transcranial magnetic stimulation (TMS) experiments that target the motor cortex (M1) lower-limb representation. Anecdotal evidence and modeling studies have shed light on the off-target effects of D-CONE TMS but the physiological extent remains undetermined.

PURPOSE

To characterize the off-target effects of D-CONE TMS based on bilateral corticospinal responses in the legs and hands.

METHODS

Thirty (N = 30) participants (9 women, age: 26 ± 5yrs) completed a stimulus-response curve procedure with D-CONE TMS applied to the dominant vastus lateralis (cVL) and motor-evoked potentials (MEPs) recorded in each active VL and resting first dorsal interosseous (FDI). As a positive control (CON), the dominant FDI was directly targeted with a figure-of-eight coil and MEPs were similarly recorded in each active FDI and resting VL. MEP_MAX, V50 and MEP latencies were compared with repeated-measures ANOVAs or mixed-effects analysis and Bonferroni-corrected pairwise comparisons.

RESULTS

Off-target responses were evident in all muscles, with similar MEP_MAX in the target (cVL) and off-target (iVL) leg (p = 0.99) and cFDI compared with CON (p = 0.99). cFDI and CON MEP_MAX were greater than iFDI (p < 0.01). A main effect of target (p < 0.001) indicated that latencies were shorter with CON but similar in all muscles with D-CONE.

DISCUSSION

Concurrent MEP recordings in bilateral upper- and lower-extremity muscles confirm that lower-limb D-CONE TMS produces substantial distance-dependent off-target effects. In addition to monitoring corticospinal responses in off-target muscles to improve targeting accuracy in real-time, future studies may incorporate off-target information into statistical models post-hoc.

0118 Improved Working Memory is Related to Non-REM Delta Activity in Control but Not PTSD Participants

Introduction

Individuals with post-traumatic stress disorder (PTSD) experience altered sleep and daytime function, including deficits in working memory (WM), the ability to store and manipulate information over short timeframes. As sleep contributes to WM, understanding how sleep parameters influence changes in WM may provide insight into potential intervention targets to improve or restore daytime function. Here, we investigated the relationship between sleep and WM improvement in Veterans with and without PTSD.

Methods

Forty-eight post-911 Veterans without PTSD (Control) and 37 with PTSD (PTSD) completed a 48-hour lab stay during which WM was assessed using a n-back task. Nighttime polysomnography, using high-density (64-channels) electroencephalography, quantified time spent in non-REM and REM sleep and log-transformed spectral activity for non-REM sleep in delta (.5-4Hz), theta (4-8Hz), alpha (8-12Hz), sigma (12-16Hz), and beta (16-32Hz) bands. Pearson’s correlations were used to assess associations between baseline sleep and baseline WM on 1-back trials. Within control and PTSD groups, independent samples t-tests were used to compare changes in sleep across nights between improvers and non-improvers categorized by 1-back accuracy changes across days.

Results

Proportions of improvers and non-improvers were similar between groups (χ 2 = .023, p = .880). Within either group, baseline sleep did not relate to baseline WM and changes in time spent in each sleep stage did not differ between improvers and non-improvers. Within the control group, improvers (n = 15; 3.67 ± 3.56) had a greater increase (t = -2.826, p = .007) in delta activity than non-improvers (n = 33; .77 ± 3.20), but this relationship was not observed in the PTSD group (11 improvers, 26 non-improvers).

Conclusion

Increased delta activity related to improved WM in the Control but not PTSD group. This suggests individuals with PTSD do not improve WM through non-REM sleep but that it may be a useful intervention target.

Support

USAMRMC MOMRP PT-130572 (PI: Reifman)

1075 Sleep-stage Independent Electroencephalography Features For Classification Of Veterans With Post-traumatic Stress Disorder

Introduction

Prior sleep studies have suggested that electroencephalography (EEG) spectral power and synchrony features in certain sleep stages differ significantly at the group-average level between subjects with and without post-traumatic stress disorder (PTSD). Here, we investigated whether a multivariate combination of sleep-stage independent EEG features could objectively identify individual subjects with PTSD.

Methods

We analyzed EEG data recorded from 78 combat-exposed veteran men with (n = 31) and without (n = 47) PTSD during two consecutive nights of sleep. For each subject we computed 780 features from 10 EEG channels covering the whole brain, by averaging the values over the entire night regardless of sleep stage. Using a training set consisting of the first 47 consecutive subjects (18 with PTSD) of the study, we performed univariate feature selection and backward feature elimination using a logistic regression model. We then evaluated the model on the test set, which consisted of the remaining 31 subjects (13 with PTSD). We assessed model performance by computing the area under the receiver operating characteristic curve (AUC).

Results

Feature elimination using the logistic regression model yielded three uncorrelated features that were consistently discriminative of PTSD across the two consecutive nights. When we trained the logistic model consisting of these three features using data from both nights of the training set, the model yielded test-set AUCs of 0.84 and 0.80 for Night 1 and Night 2, respectively. These values were considerably larger than the test-set AUCs of the three individual features, which ranged from 0.55 to 0.74 across both nights.

Conclusion

We identified robust, stage-independent, whole-night features and combined them in a logistic regression model to discriminate subjects with and without PTSD. The model yielded AUCs above 0.80 on the test data, showing promise as an objective approach to diagnose PTSD at the individual level.

Support

This work was sponsored by U.S. Defense Health Program (grant No. W81XWH-14-2-0145) and managed by the U.S. Army Military Operational Medicine Program Area Directorate, Ft. Detrick, MD. The study was also supported by the Clinical and Translational Science Institute at the University of Pittsburgh (UL1 TR001857).

0242 Efficient Perception-Action Coupling Relates to More Slow Wave Sleep in Military Personnel

Introduction

The ability to adapt actions to perceptions of environmental constraints, perception-action coupling, may be compromised by military operational stress (caloric restriction, sleep disruption, physical exertion). Differences in sleep may influence susceptibility to these stressors. We investigated perception-action coupling during simulated military operational stress and the influence of sleep on perception-action coupling.

Methods

During a 5-day simulated military operational stress protocol, thirty-six (6 female) service members (25.8 ± 4.7 years) completed three trials of a perception-action coupling task (PACT) in the evening after a night of baseline sleep (BASE), two nights of sleep restriction (T1) and a night of recovery sleep (T2). Participants had 8-hr for baseline and recovery sleep (2300-0700) and 4-hr disturbed sleep on sleep restriction nights (0100-0300 and 0500-0700). Polysomnography was used to determine time spent in different sleep stages: stage 2 (N2), slow wave (SWS) and rapid-eye movement (REM). The tablet-based PACT requires participants make quick, accurate perceptual judgments and responses about the ability of virtual balls to fit through virtual apertures. Linear mixed models were used to assess interaction and main effects of study day and prior sleep on PACT response time (RT) and accuracy (ACC).

Results

No significant sleep x time interactions or significant main effect of time were found for RT or ACC. A significant main effect of SWS was found for RT (F1,88.307 = 4.331, p = .04). Higher SWS was related to lower (faster) RT. No significant main effects of other sleep stages were found.

Conclusion

Perception-action coupling was maintained during simulated military operational stress. Participants with more SWS across the study responded faster during the PACT but N2 and REM sleep did not relate to perception-action coupling performance, suggesting a specific effect of SWS on perception-action coupling abilities and behaviors.

Support

Department of Defense Award #W81XWH-17-2-0070 (PI: Nindl)

1072 Post-traumatic Stress Disorder Is Associated With Increased Oscillatory Frequency Of Sleep Spindles

Introduction

Patients with post-traumatic stress disorder (PTSD) often suffer from sleep disturbances. Sleep spindles are an electrophysiological hallmark of non-rapid eye movement sleep and believed to be involved in sleep protection and sleep-dependent memory consolidation. Here, we sought to examine whether sleep spindles are altered in PTSD and whether the findings are reproducible across nights and subsamples of the study population.

Methods

We obtained 64-channel electroencephalogram (EEG) recordings from 78 combat-exposed Veteran men with (n = 31) and without (n = 47) PTSD during two consecutive nights of sleep. We identified slow (10-13 Hz) and fast (13-16 Hz) sleep spindles during N2 and N3 sleep using an automatic algorithm and performed topographical analyses of spindle parameters (amplitude, duration, oscillatory frequency, and density) on both nights. To assess reproducibility, we used the first 47 consecutive participants (18 with PTSD) for initial discovery and the remaining 31 participants (13 with PTSD) for replication assessment.

Results

In the discovery analysis, compared to participants without PTSD, those with PTSD exhibited 1) increased oscillatory frequency of slow spindles over the antero-frontal regions on both nights (Night 1: p = .020, Cohen’s d = 0.92; Night 2: p = .014, Cohen’s d = 1.07) and 2) increased oscillatory frequency of fast spindles over the centro-parietal regions on the second night (p = .018, Cohen’s d = 0.76). Notably, these trends were preserved in the replication analysis. In contrast, we found no significant group differences in the amplitude, duration, or density of slow or fast spindles.

Conclusion

The elevated sleep-spindle frequency in PTSD may reflect reduced thalamocortical inhibition and, hence, deficient sleep protection. Our findings provide the basis for an initial understanding of sleep-spindle abnormalities in PTSD. The findings, if independently validated, may assist in the development of sleep-focused diagnostics and interventions for PTSD.

Support

This work was sponsored by U.S. Defense Health Program (grant No. W81XWH-14-2-0145) and managed by the U.S. Army Military Operational Medicine Program Area Directorate, Ft. Detrick, MD. The study was also supported by the Clinical and Translational Science Institute at the University of Pittsburgh (UL1 TR001857).

Effects of pretreatment with reducing sugars or an enzymatic cocktail before extrusion of fava bean on nitrogen metabolism and performance of dairy cows

The aim of this study was to determine the effects of pretreatment with reducing sugars or with an enzymatic cocktail before extrusion of fava bean on intake, milk yield and composition, N partitioning, and plasma and ruminal parameters. The main hypothesis was that these pretreatment conditions would allow better N protection in the rumen compared with classic pretreatment before extrusion, thanks to an increase of sugar proportion, either exogenous or endogenous with enzymatic actions. Sixteen Holstein cows were used in a 4 × 4 Latin square design experiment. Cow were fed a diet with a 56:44 forage to concentrate ratio and containing 16.2% of crude protein (CP; dry matter basis). Concentrate consisted of fava bean:linseed blends (90:10%, raw basis) distributed either raw, extruded after pretreatment without additive, extruded after pretreatment with reducing sugars, or extruded after pretreatment with an enzymatic cocktail. The experimental blends provided 53% of total CP in the diet. Intake, milk yield and composition, ruminal pH, volatile fatty acids and ammonia kinetics, apparent total-tract nutrient digestibilities and N partitioning, Maillard compounds in feed and feces, plasma AA, and ¹⁵N natural enrichment were measured. Data were analyzed using analysis of variance according to the MIXED procedure of SAS (SAS Institute Inc., Cary, NC). Extrusion without additive during pretreatment led to higher contents of Maillard compounds in the blend, a lower enzymatic CP degradability, a numerically lower ammonia content in ruminal fluid, and a trend of higher plasma EAA concentration, all suggesting a decrease in degradability of proteins in the rumen, and a subsequent increase in metabolizable protein supply. Compared with pretreatment without additive, adding reducing sugars or an enzymatic cocktail during pretreatment led to an increase in Maillard compound contents in the extruded blends, and to an increase (+50 mg/L) in rumen ammonia content. With reducing sugars, digestibility of Nɛ-carboxymethyl-lysine was numerically lower, and plasma EAA concentration tended to decrease, suggesting an overprotection of proteins in the intestine. With the enzymatic cocktail, plasma EAA concentration was similar than without additive during pretreatment, suggesting a similar metabolizable protein supply with both treatments. Finally, no change in N partitioning between milk, urine, and feces was observed whatever the diet.

Effects of replacing soybean meal with raw or extruded blends containing faba bean or lupin seeds on nitrogen metabolism and performance of dairy cows

The objective was to test the effects of replacing soybean meal in dairy cow diets with either raw or extruded faba bean:linseed or lupin:linseed blends on intake, milk yield and composition, N partitioning, and ruminal and plasma parameters. Our main hypotheses were that N from extruded blends was less degradable in the rumen than N from raw seeds, and that a higher extrusion temperature favored ruminal protection of proteins and milk protein yield, and lowered urinary N excretion. Eight Holstein cows fitted with ruminal cannulas were used in two 4 × 4 Latin square design experiments conducted in parallel. In both experiments, cows were fed diets with a crude protein content of 14.6%, containing 60% of forage (dry matter basis). Treatments differed by the composition of the concentrates: control in both experiments was based on soybean meal, and experimental treatments were based on proteaginous:linseed (90:10%) blends consisting of faba bean blends (first experiment) or lupin blends (second experiment) presented either raw, extruded at 140°C, or extruded at 160°C. Intake, milk yield and composition, ruminal pH, volatile fatty acids and ammonia kinetics, digestibility, N partitioning, Maillard compounds in feed and feces, plasma AA, and 15N natural enrichment were measured. Data were analyzed using ANOVA according to the MIXED procedure of SAS (version 9.4, SAS Institute Inc., Cary, NC). Ammonia content in ruminal fluid did not significantly change when soybean meal was replaced by either raw or extruded faba bean, but tended to be higher with lupin. Milk yield was increased by 2.6 kg with faba bean blend extruded at 140°C compared with faba bean blend extruded at 160°C. Milk fat and milk protein concentrations were decreased by 3.1 and 2.3 g/kg, respectively, with lupin blends compared with soybean meal. Nitrogen partitioning between milk, feces, and urine did not change. Nitrogen apparent digestibility decreased by 3 g/100 g of N between faba bean blend extruded at low and at high temperatures. The content of Maillard compounds in feces was higher with blends extruded at 160°C than with raw or extruded at 140°C blends within both experiments. Total plasma AA tended to be higher with extruded blends than with raw in the faba bean experiment. Both extrusion temperatures appeared to protect dietary proteins from ruminal degradability, but proteins seemed to be overprotected at 160°C.

Risk Factors for Small Bowel Obstruction After Laparoscopic Ileal Pouch-Anal Anastomosis for Inflammatory Bowel Disease: A Multivariate Analysis in Four Expert Centres in Europe

BACKGROUND AND AIMS

Although laparoscopy is associated with a reduction in adhesions, no data are available about the risk factors for small bowel obstruction [SBO] after laparoscopic ileal pouch-anal anastomosis [IPAA]. Our aims here were to identify the risk factors for SBO after laparoscopic IPAA for inflammatory bowel disease [IBD].

METHODS

All consecutive patients undergoing laparoscopic IPAA for IBD in four European expert centres were included and divided into Groups A [SBO during follow-up] and B [no SBO].

RESULTS

From 2005 to 2015, SBO occurred in 41/521 patients [Group A; 8%]. Two-stage IPAA was more frequently complicated by SBO than 3- and modified 2-stage IPAA [12% vs 7% and 4%, p = 0.04]. After multivariate analysis, postoperative morbidity (odds ratio [OR] = 3, 95% confidence interval [CI] = 1.5-7, p = 0.002), stoma-related complications [OR = 3, 95% CI = 1-6, p = 0.03] and long-term incisional hernia [OR = 6, 95% CI = 2-18, p = 0.003] were predictive factors for SBO, while subtotal colectomy as first surgery was an independent protective factor [OR = 0.4, 95% CI = 0.2-0.8, p = 0.002]. In the subgroup of patients receiving restorative proctocolectomy as first operation, stoma-related or other surgical complications and long-term incisional hernia were predictive of SBO. In the patient subgroup of subtotal colectomy as first operation, postoperative morbidity and long-term incisional hernia were predictive of SBO, whereas ulcerative colitis and a laparoscopic approach during the second surgical stage were protective factors.

CONCLUSIONS

We found that SBO occurred in less than 10% of patients after laparoscopic IPAA. The study also suggested that modified 2-stage IPAA could potentially be safer than procedures with temporary ileostomy [2- and 3-stage IPAA] in terms of SBO occurrence.

Outcome of restorative proctocolectomy with an ileo-anal pouch for ulcerative colitis: effect of changes in clinical practice

AIM

Surgery for ileal pouch-anal anastomosis (IPAA) has evolved over time, especially since the introduction of laparoscopy. The aim of this retrospective study was to report the impact of surgical evolution on outcome over a period of 25 years.

METHOD

All patients who had IPAA surgery for ulcerative colitis from 1990 to 2015 at the University Hospitals of Leuven were included. Patients were divided into three period arms (period A 1990-1999; period B 2000-2009; period C 2010-2015). The main outcome measure was anastomotic leakage.

RESULTS

A total of 335 patients (58.8% male) with a median age of 39 years (interquartile range 32-49 years) at surgery were included. Median follow-up was 5 years (interquartile range 2-10 years). Overall anastomotic leakage (grades A-C) was 14.9%. A significant decrease in leakage rate was observed over time (from 21.4% in period A to 12.1% in period B to 10.0% in period C; P = 0.04). The defunctioning ileostomy rate at the time of pouch construction decreased from 91.7% (period A) to 40.3% (period B) to 11.1% (period C) (P < 0.001). We observed an increase in the use of laparoscopy (23.9% in period A vs 72.6% in period B, vs 84.4% in period C; P = 0.001) and a shift to a modified two-stage procedure (4.1% in period A, vs 66.7% in period C; P < 0.0001). In a monocentric study with some of the data retrieved retrospectively it was not possible to account for the impact of preoperative nutritional status (weight loss, serum albumin level) or disease burden. Other outcome factors were not measured, for example sexual function and fecundity.

CONCLUSION

A higher rate of laparoscopic IPAA surgery, together with a shift towards modified two-stage procedures, was associated with a lower leakage rate despite a reduction in the use of defunctioning ileostomy.

Genomic Profiling of a Large Set of Diverse Pediatric Cancers Identifies Known and Novel Mutations across Tumor Spectra

Pediatric cancers are generally characterized by low mutational burden and few recurrently mutated genes. Recent studies suggest that genomic alterations may help guide treatment decisions and clinical trial selection. Here, we describe genomic profiles from 1,215 pediatric tumors representing sarcomas, extracranial embryonal tumors, brain tumors, hematologic malignancies, carcinomas, and gonadal tumors. Comparable published datasets identified similar frequencies of clinically relevant alterations, validating this dataset as biologically relevant. We identified novel ALK fusions in a neuroblastoma (BEND5-ALK) and an astrocytoma (PPP1CB-ALK), novel BRAF fusions in an astrocytoma (BCAS1-BRAF) and a ganglioglioma (TMEM106B-BRAF), and a novel PAX3-GLI2 fusion in a rhabdomyosarcoma. Previously characterized ALK, NTRK1, and PAX3 fusions were observed in unexpected malignancies, challenging the "disease-specific" alterations paradigm. Finally, we identified recurrent variants of unknown significance in MLL3 and PRSS1 predicted to have functional impact. Data from these 1,215 tumors are publicly available for discovery and validation. Cancer Res; 77(2); 509-19. ©2017 AACR.

Systematic review: outcomes and post-operative complications following colectomy for ulcerative colitis

BACKGROUND

Colectomy for ulcerative colitis is associated with short- and long-term complications. Estimates of the frequency of such complications are variable and may have changed since the introduction of biological therapy. Understanding the true burden of surgical complications is important to clinicians in assessing risks and benefits of colectomy vs. continued medical therapy.

AIM

To ascertain the outcomes of colectomy and ileal pouch surgery in patients with ulcerative colitis in the biologics era.

METHODS

Embase, MEDLINE and The Cochrane Library were searched for studies (2002-2015) reporting the outcomes of colorectal procedures (total and subtotal colectomy, IPAA with J-, S-, W-pouch) in adults with ulcerative colitis. Conferences proceedings (2011-2015) were hand-searched.

RESULTS

We identified 28 studies (20,801 patients) reporting outcomes from procedures conducted from 2002-2015. Early complications (≤30 days post-operatively), reported in 10 studies, occurred in 9-65% of patients with ulcerative colitis; late complications (>30 days post-operatively) occurred in 17-55% of patients. Most frequent short-term complications: infectious complications and ileus (mean incidence 20% and 18%). Most frequent long-term complications: pouchitis, faecal incontinence and small bowel obstruction (mean incidence 29%, 21% and 17%). Rates of early infection and late pouch failure decreased from 22% and 13% in 2002-2009 to 11% and 2% in 2010-2015. The mean incidence of post-operative mortality was 1.0% across 11 studies.

CONCLUSIONS

Early and late complications arise in about one-third of patients undergoing surgery for ulcerative colitis. While colorectal surgical procedures are recommended for a specific group of patients, the post-operative complications associated with these procedures should not be underestimated.

Abdominal tuberculosis in a low prevalence country

OBJECTIVE

Abdominal tuberculosis is a rare disease. The clinical and radiological manifestations are non-specific and the diagnosis is difficult. Our objective was to describe the characteristics and treatment of patients presenting with abdominal tuberculosis in a low-incidence country.

PATIENTS AND METHODS

We reviewed the clinical, diagnostic, treatment, and outcome features of patients presenting with abdominal tuberculosis diagnosed by bacteriological and/or histological results and managed in five French university hospitals from January 2000 to December 2009.

RESULTS

We included 21 patients. The mean diagnostic delay was 13 months. Twelve patients (57%) came from a low-incidence area and only two had a known immunosuppressed condition. Eighteen patients (86%) presented with abdominal symptoms. The main organs involved were the peritoneum (n=14, 66%), the mesenteric lymph nodes (n=13, 62%), and the bowel (n=7, 33%). Sixteen patients (76%) underwent surgery, including two in an emergency setting. Seventeen patients (81%) received six months or more of anti-tuberculosis treatment. Finally, 16 patients (76%) had a positive outcome.

CONCLUSION

New diagnostic procedures, and especially molecular biology, may help diagnose unusual clinical presentations of tuberculosis. Invasive procedures are frequently necessary to obtain samples but also for the treatment of digestive involvement.

Second-stage robot-assisted biliopancreatic diversion with duodenal switch after sleeve gastrectomy

Biliopancreatic diversion (BPD) was initially described in 1979 and consisted of a distal gastrectomy with a 250-mL stomach pouch and a distal intestinal bypass with a 50 to 100-cm common channel resulting in malabsorption of dietary fat (Scopinaro et al. Br J Surg. 66(9):618-20, 1979). Later, several modifications (sleeve gastrectomy, pylorus preservation, and duodenal switch) were proposed to improve incidence of postoperative dumping syndrome, diarrhea, and anastomotic ulcerations (Lagacé et al. Obes Surg. 5(4):411-8, 1995). Gagner et al. developed a simplified and reproducible approach for laparoscopic BPD with duodenal switch (BPD-DS) after sleeve gastrectomy (Ren et al. Obes Surg. 10(6): 514-23, 2000). BPD-DS has been considered as one of the most difficult bariatric procedures for its surgical complexity and postoperative metabolic complications management. In this regard, the number of BPD-DS has remained extremely low (<4 %). We hypothesize that robotic approach could facilitate the feasibility of BPD-DS procedure. In this multimedia video (8 min), we present a step-by-step robotic BPD-DS.

Durable clinical benefit to trastuzumab and chemotherapy in a patient with metastatic colon adenocarcinoma harboring ERBB2 amplification

Somatic ERBB2 amplification or activating mutations occur in approximately 2-5% of metastatic colorectal adenocarcinomas and are presumed to be oncogenic drivers, but limited evidence exists to suggest these lesions are sensitive to targeted monotherapy in patients. Here we present the case of a patient with advanced CRC with pulmonary metastases, who had progressed on both standard of care cytotoxic chemotherapy and anti-EGFR targeted therapy. Comprehensive genomic profiling (FoundationOne(®)) identified amplification of ERBB2 and a TP53 mutation in the metastatic lesion. Treatment with trastuzumab with a chemotherapy backbone elicited stable disease/minor response in the patient over a one year course of therapy, reducing tumor burden and significantly improving quality of life. This report demonstrates the application of personalized targeted therapy guided by comprehensive genomic profiling in metastatic colorectal adenocarcinoma.

PA3 Using the lived experience of volunteers to enhance the care of dying patients and their families

BACKGROUND

In the UK, the majority of people die in hospital.(1) Community presence is considered to be a significant component to achieving a "good death",(2,3) however many patients die with no/few visitors, spending their last weeks of life isolated or alone.

AIM

To establish a Volunteer Service and offer: A presence to dying patients. A connexion to the community outside the Hospital. Support to families, unable to visit or emotionally exhausted from their bedside vigil.

METHODS

The Service was piloted on 6 wards (October 2012-March 2013) within a large NHS Trust, in the North of England. This was followed by a comprehensive evaluation, according to MRC guidance.

RESULTS

Analysis of the service evaluation indicated that the service was extremely beneficial, meeting its aims in providing an emotional support and spiritual presence to dying patients, and their families.

CONCLUSION

The Service provides a model of best practice that could be replicated in other Trusts and within other care settings. There are plans to further develop and expand service provision across the Trust.

REFERENCES

National End of Life Care Intelligence Network. What we know now. 2013. http://www.endoflifecare-intelligence.org.uk/resources/publications/what_we_know_now_2013 Department of Health. End of Life Care Strategy. 2008. https://www.gov.uk/government/publications/end-of-life-care-strategy-promoting-high-quality-care-for-adults-at-the-end-of-their-life Kellehear A. The end of death in late modernity, an emerging public health challenge. Crit Public Health 2007;17(1):71-79.

Effect of flumazenil on diaphragm electrical activation during weaning from mechanical ventilation after acute respiratory distress syndrome

BACKGROUND

Diaphragm electrical activation (EAdi) and the ratio of tidal volume to EAdi (VT/EAdi) may provide clinical information on neuroventilatory efficiency (NVE) in patients being weaned from mechanical ventilation. We tested the hypothesis that residual sedation could interfere with respiratory recovery, by assessing the effects of flumazenil on EAdi and VT/EAdi ratio.

METHODS

This observational study included 13 patients breathing with pressure-support ventilation (PSV) after a long period of controlled mechanical ventilation (i.e. >4 days) plus midazolam-based sedation for acute respiratory distress syndrome. EAdi and respiratory patterns were compared before and after a bolus of flumazenil, which was given because neurological status needed to be evaluated.

RESULTS

Flumazenil induced a significant increase in EAdi [+71 (41-123)%, P=0.0002] and VT [+17 (8-32)%, P=0.0005], resulting in significantly decreased NVE [-34 (15-43)%]. The increased VT was significantly correlated with the increased EAdi (ρ=0.70, P=0.009).

CONCLUSIONS

During weaning from mechanical ventilation, the diaphragmatic contribution to the breathing process may be reduced by residual midazolam-induced ventilatory depression. The increased EAdi with reversal of residual sedation was associated with a proportional increase in VT. These findings should be considered by the attending physician when interpreting daily EAdi and VT changes during weaning from mechanical ventilation.

Links between sleep and body mass index in bipolar disorders: an exploratory study

STUDY OBJECTIVES

Obesity and excess bodyweight are highly prevalent in individuals with bipolar disorders (BD) and are associated with adverse consequences. Multiple factors may explain increased bodyweight in BD including side effects of psychotropic medications, and reduced physical activity. Research in the general population demonstrates that sleep disturbances may also contribute to metabolic burden. We present a cross-sectional study of the associations between body mass index (BMI) and sleep parameters in patients with BD as compared with healthy controls (HC).

METHODS

Twenty-six French outpatients with remitted BD and 29 HC with a similar BMI completed a 21-day study of sleep parameters using objective (actigraphy) and subjective (PSQI: Pittsburgh Sleep Quality Index) assessments.

RESULTS

In BD cases, but not in HC, higher BMI was significantly correlated with lower sleep efficiency (P=0.009) and with several other sleep parameters: shorter total sleep time (P=0.01), longer sleep onset latency (P=0.05), higher fragmentation index (P=0.008), higher inter-day variability (P=0.05) and higher PSQI total score (P=0.004).

CONCLUSIONS

The findings suggest a link between a high BMI and several sleep disturbances in BD, including lower sleep efficiency. Physiological mechanisms in BD cases may include an exaggeration of phenomena observed in non-clinical populations. However, larger scale studies are required to clarify the links between metabolic and sleep-wake cycle disturbances in BD.

Long-term outcome of robotic-assisted laparoscopic rectopexy for full-thickness rectal prolapse in elderly patients

AIM

Full-thickness rectal prolapse is common in the elderly, but there are no particular practice guidelines for its surgical management. We evaluated retrospectively the perioperative and long-term clinical results and function in elderly and younger patients with complete rectal prolapse after robotic-assisted laparoscopic rectopexy (RALR).

METHOD

Seventy-seven patients who underwent RALR between 2002 and 2010 were divided into Group A (age < 75 years, n = 59) and Group B (age > 75 years, n = 18). Operative time, intra- and postoperative complications, length of hospital stay, short-term and long-term outcomes, recurrence rate and degree of satisfaction were evaluated.

RESULTS

There was no significant difference between the groups regarding operation time, conversion, morbidity or length of hospital stay. At a median follow-up of 51.8 (5-115) months, there was no difference in the improvement of faecal incontinence, recurrence and the degree of satisfaction.

CONCLUSION

Robotic-assisted laparoscopic rectopexy is safe in patients aged over 75 years and gives similar results to those in patients aged < 75 years.

Neuro-ventilatory efficiency during weaning from mechanical ventilation using neurally adjusted ventilatory assist

BACKGROUND

Neuro-ventilatory efficiency (NVE), defined as the tidal volume to electrical diaphragm-activity ratio (VT/EAdi) at the beginning and end of the weaning process after acute hypoxaemic respiratory failure, may provide valuable information about patient recovery.

METHODS

This observational study included 12 patients breathing with neurally adjusted ventilatory assist (NAVA). When a spontaneous breathing trial (SBT) with pressure support of 7 cm H2O and PEEP was unsuccessful, NAVA was used and the level was adjusted to obtain an EAdi of ∼60% of maximal EAdi during SBT. VT and EAdi were recorded continuously. We compared changes in NVE between NAVA and SBT at the first failed and first successful SBT.

RESULTS

When patients were switched from NAVA to SBT, NVE was significantly reduced during both unsuccessful and successful SBT (-56 and -38%, respectively); however, this reduction was significantly lower when SBT was successful (P=0.01). Between the first and last day of weaning, we observed that NVE decreased with NAVA [40.6 (27.7-89.5) vs 28.8 (18.6-46.7); P=0.002] with a significant decrease in NAVA level, whereas it remained unchanged during SBT [15.4 (10.7-39.1) vs 19.5 (11.6-29.6); P=0.50] with significant increases in both EAdi and VT and no difference in respiratory rhythm.

CONCLUSIONS

These results suggest that in patients after respiratory failure and prolonged mechanical ventilation, changes in VT and NVE, between SBTs are indicative of patient recovery. Larger clinical trials are needed to clarify whether changes in NVE reliably predict weaning in patients ventilated with NAVA.

Childhood and adult trauma both correlate with dorsal anterior cingulate activation to threat in combat veterans

BACKGROUND

Prior studies of adult post-traumatic stress disorder (PTSD) suggest abnormal functioning of prefrontal and limbic regions. Cumulative childhood and adult trauma exposures are major risk factors for developing adult PTSD, yet their contribution to neural dysfunction in PTSD remains poorly understood. This study aimed to examine the neural correlates of childhood and adult trauma exposure and post-traumatic stress symptoms (PTSS) within a single model. Method Medication-free male combat veterans (n = 28, average age 26.6 years) with a wide range of PTSS were recruited from the community between 2010 and 2011. Subjects completed an emotional face-morphing task while undergoing functional magnetic resonance imaging (fMRI). Clinical ratings included the Clinician-Administered PTSD Scale (CAPS), Childhood Trauma Questionnaire (CTQ) and Combat Exposure Scale (CES). A priori regions were examined through multivariate voxelwise regression in SPM8, using depressive symptoms and IQ as covariates.

RESULTS

In the angry condition, CAPS scores correlated positively with activation in the medial prefrontal cortex [mPFC; Brodmann area (BA) 10, z = 3.51], hippocampus (z = 3.47), insula (z = 3.62) and, in earlier blocks, the amygdala. CES and CTQ correlated positively with activation in adjacent areas of the dorsal anterior cingulate cortex (dACC; BA 32, z = 3.70 and BA 24, z = 3.88 respectively). In the happy condition, CAPS, CTQ and CES were not correlated significantly with activation patterns.

CONCLUSIONS

dACC activation observed in prior studies of PTSD may be attributable to the cumulative effects of childhood and adult trauma exposure. By contrast, insula, hippocampus and amygdala activation may be specific to PTSS. The specificity of these results to threat stimuli, but not to positive stimuli, is consistent with abnormalities in threat processing associated with PTSS.

The effect of immune therapy on surgical site infection following Crohn's Disease resection

BACKGROUND

Patients with Crohn's disease are increasingly receiving antitumour necrosis factor α (anti-TNF-α) therapy. Whether anti-TNF-α therapy increases the risk of postoperative infectious complications in Crohn's disease is a matter of debate.

METHODS

This was a retrospective study of three referral centres. The charts of patients who underwent ileocaecal or ileocolonic resection for Crohn's disease between 2000 and 2011 were reviewed. The impact of baseline characteristics and Crohn's disease-related medications on the risk of postoperative intra-abdominal infectious complications was investigated by univariable and multivariable analysis.

RESULTS

A total of 217 patients were included in the study. Median age at the time of surgery was 36·8 (range 15-78) years. A postoperative intra-abdominal infection occurred in 24 (11·1 per cent) of 217 patients. No deaths were reported. On univariable analysis, age less than 25 years (P = 0·023), steroid use (P = 0·017), anti-TNF-α therapy (P = 0·043) and anti-TNF-α treatment in combination with steroids (P = 0·004) were associated with an increased risk of postoperative intra-abdominal infectious complications. On multivariable analysis, only anti-TNF-α therapy in combination with steroids significantly increased this risk (odds ratio 8·03, 95 per cent confidence interval 1·93 to 33·43; P = 0·035).

CONCLUSION

Combined use of steroids and anti-TNF-α therapy was associated with an increased risk of postoperative intra-abdominal infectious complications.

[Changes in kaliemia following rapid sequence induction with succinylcholine in critically ill patients]

OBJECTIVE

Evaluate the changes in potassium following rapid sequence induction with succinylcholine in critically ill-patients and determine whether hospital length of stay could influence the succinylcholine-induced hyperkaliemia.

STUDY DESIGN

Prospective and observational study.

PATIENTS AND METHODS

After approval by our local ethical committee, we prospectively included 36 patients admitted from more than 24hours in ICU and who required succinylcholine for rapid tracheal intubation (1mg/kg). Serum potassium was measured before, 5 and 30min after succinylcholine. The incidence of life-threatening hyperkaliemia (≥6.5mmol/L) was noted.

RESULTS

We could observe significant and transient increase in serum potassium (median increase of 0.45 [0.20-0.80] mmol/L at five minutes). A significant relationship was observed between the ICU length of stay and arterial potassium increase (r=0.37, P<0.05). From the ROC curve, a threshold of 12 days had an 86% sensitivity and 69% specificity in discriminating patients in whom the potassium increase was more than 1.5mmol/L.

CONCLUSION

Induction with succinylcholine is followed by significant but transient hyperkaliema. The ICU length of stay before giving succinylcholine could influence significantly the amplitude of potassium increase.