Indications and Surgical Technique for Transanal Proctectomy and Ileal Pouch-Anal Anastomosis for Inflammatory Bowel Disease

Surgical management of inflammatory bowel disease has advanced significantly over the years. One particular focus of its evolution has been to minimize invasiveness. Transanal surgery has given the contemporary surgeon an alternate approach to access the low rectum situated in the confines of the deep pelvis. In benign disease, combining transanal surgery with laparoscopy has allowed for the development of novel techniques to create ileal pouch-anal anastomoses, perform intersphincteric Crohn's proctectomies, manage complications from pelvic surgery, and facilitate redo pelvic surgery. We aim to review the indications for transanal surgery in benign disease, describe an approach to transanal pouch surgery in detail, and discuss the potential benefits, pitfalls, and contentious issues surrounding this approach.

Coaching in Surgical Education: A Systematic Review

OBJECTIVE

The objectives of this study were to review the coaching literature to (1) characterize the criteria integral to the coaching process, specifically in surgery, and (2) describe how these criteria have been variably implemented in published studies.

BACKGROUND

Coaching is a distinct educational intervention, but within surgery the term is frequently used interchangeably with other more established terms such as teaching and mentoring.

METHODS

A systematic search was performed of the MEDLINE and Cochrane databases to identify studies that used coach/coaching as an intervention for surgeons for either technical or nontechnical skills. Study quality was evaluated using the Medical Education Research Study Quality Instrument (MERSQI).

RESULTS

A total of 2280 articles were identified and after screening by title, abstract and full text, 35 remained. Thirteen coaching criteria (a-m) were identified in 4 general categories: 1. overarching goal (a. refine performance of an existing skill set), 2. the coach (b. trusting partnership, c. avoids assessment, d. 2-way communication), the coachee (e. voluntary participation, f. self-reflection, g. goal setting, h. action plan, i. outcome evaluation), and the coach-coachee rapport (j. coaching training, k. structured coaching model, l. non-directive, m. open ended questions). Adherence to these criteria ranged from as high of 73% of studies (voluntary participation of coach and coachee) to as low as 7% (use of open-ended questions).

CONCLUSIONS

Coaching is being used inconsistently within the surgical education literature. Our hope is that with establishing criteria for coaching, future studies will implement this intervention more consistently and allow for better comparison and generalization of results.

An unconventional therapeutic approach to a migratory IUD causing perforation of the rectum

Intrauterine devices (IUDs) are a commonly used form of contraception. The risk of perforation and migration of these devices have been reported to be 1 in 1000. Migration into the rectum is even more uncommon. The following case illustrates a previously healthy 37-year-old woman who experienced a perforation and migration of an IUD into the rectum necessitating endoscopic removal. To our knowledge, this complication of IUD and subsequent endoscopic removal has not been previously described and presents a viable first-line therapeutic option in a stable patient.

The circadian molecular clock regulates adult hippocampal neurogenesis by controlling the timing of cell-cycle entry and exit

The subgranular zone (SGZ) of the adult hippocampus contains a pool of quiescent neural progenitor cells (QNPs) that are capable of entering the cell cycle and producing newborn neurons. The mechanisms that control the timing and extent of adult neurogenesis are not well understood. Here, we show that QNPs of the adult SGZ express molecular-clock components and proliferate in a rhythmic fashion. The clock proteins PERIOD2 and BMAL1 are critical for proper control of neurogenesis. The absence of PERIOD2 abolishes the gating of cell-cycle entrance of QNPs, whereas genetic ablation of bmal1 results in constitutively high levels of proliferation and delayed cell-cycle exit. We use mathematical model simulations to show that these observations may arise from clock-driven expression of a cell-cycle inhibitor that targets the cyclin D/Cdk4-6 complex. Our findings may have broad implications for the circadian clock in timing cell-cycle events of other stem cell populations throughout the body.

Cytoprotective effects of nicotinamide derivatives in endothelial cells

Following discovery of NAD(+)-dependent reactions that control gene expression, cytoprotection, and longevity, there has been a renewed therapeutic interest in precursors, such as nicotinamide and its derivatives. We tested 20 analogues of nicotinamide for their ability to protect endothelial cells from peroxynitrite stress and their effect on poly (ADP-ribose) polymerase (PARP) activity. Several nicotinamide derivatives protected endothelial cells from peroxynitrite-induced depletion of cellular NAD(+) and ATP concentrations, but only some of these compounds inhibited PARP. We conclude that some nicotinamide derivatives provide protection of endothelial cells against peroxynitrite-induced injury independent of inhibition of PARP activity. Preservation of the NAD(+) pool was a common effect of these compounds.

Metabolism of 4-pyridone-3-carboxamide-1-beta-D-ribonucleoside triphosphate and its nucleoside precursor in the erythrocytes

We recently discovered new nucleotides (4-pyridone-3-carboxamide-1-beta -D-ribonucleoside phosphates) in human erythrocytes. To establish the precursor compound and pathways of nucleotide derivative formation and breakdown, human erythrocytes were incubated for 3 hours with 0.3 mM 4-pyridone-3-carboxamide-1-beta-D-ribonucleoside (4PYR) and erythrocyte concentrations of 4PYR and adenine nucleotides were followed. 4PYR triphosphate increased from 16.1 +/- 0.6 micro M to 74.9 +/- 9.17 and 4PYR monophosphate increased from 5 micro M to 254.7 +/- 13.9 micro M. Conversely, incubation with 0.3 mM 4-pyridone-3-carboxamide (4PY) did not lead to additional 4PYR nucleotide formation. 4PYR nucleotides were catabolized to 4PYR. We conclude that 4PYR nucleotides are formed in erythrocytes by nucleoside kinase-mediated 4PYR phosphorylation and catabolized by 5'nucleotidase-mediated dephosphorylation.

Pharmacological inhibition of AMP-deaminase in rat cardiac myocytes

Because mutation of AMP deaminase 1 gene leading to reduced AMP deaminase activity may result in protection of cardiac function in patients with heart disease, inhibitors of AMP deaminase (AMPD) may have therapeutic applications. This study evaluated the effect of a specific inhibitor of AMP deaminase 3-[2-(3-carboxy-4-bromo-5,6,7,8-tetrahydronaphthyl)ethyl]-3,6,7,8-tetrahydroimidazo [4,5-d][1,3]diazepin-8-ol (AMPDI) on the isolated human enzyme and on nucleotide catabolism in rat cardiomyocytes. AMPDI effectively inhibited isolated human AMPD with an IC(50) = 0.5 micro M. AMPDI was much less effective with isolated cardiomyocytes (IC(50) = 0.5 mM). AMPDI is a very effective inhibitor of AMPD that despite lower efficiency in the cell system examined could be useful for in vivo studies.

Abductor pollicis longus tendon rupture in De Quervain's disease

De Quervain's disease is a stenosing tenovaginitis involving the first extensor compartment of the wrist. The similarity of its symptomatology to a number of other conditions and its controversial aetiology are only a few of the barriers which often delay its diagnosis and treatment. We report the first two cases in the literature of abductor pollicus longus tendon rupture in patients with De Quervain's disease who had been treated with conservative methods. The relevant literature is reviewed.

Exposure to human blood inactivates swine endothelial ecto-5'-nucleotidase

Ecto-5'-nucleotidase (E5'N) is an extracellular enzyme forming anti-inflammatory and immunosuppressive adenosine. We evaluated whether confrontation of pig heart and endothelial cells with human blood changes the activity of E5'N. Pig hearts were perfused ex vivo with fresh human blood for 4 h. Pig aortic endothelial cells (PAEC) were incubated in vitro with human plasma for 3 h. Ex vivo perfusion of pig heart with fresh human blood resulted in a decrease in E5'N activity to 62% and 61% of initial in wild-type and transgenic pig hearts, respectively. PAEC activity of E5'N decreased to 71% and 50% of initial after 3 h exposure to heat-inactivated and active complement human plasma, respectively, while it remained constant in controls. Pig heart activity of E5'N decreased following exposure to human blood, which may affect adenosine production and exacerbate hyperacute and vascular rejection.

Psychiatric adverse events during levetiracetam therapy

The prevalence and psychopathologic features of psychiatric adverse events (PAE) in 517 patients taking levetiracetam (LEV) were investigated. Fifty-three (10.1%) patients developed PAE. A significant association was found with previous psychiatric history, history of febrile convulsions, and history of status epilepticus, whereas lamotrigine co-therapy had a protective effect. PAE were not related to the titration schedule of LEV, and certain patients seem to be biologically more vulnerable.

Ontogeny and specificities of mucosal and blood human immunodeficiency virus type 1-specific CD8(+) cytotoxic T lymphocytes

Induction of adaptive immunity to human immunodeficiency virus type 1 (HIV-1) at the mucosal site of transmission is poorly understood but crucial in devising strategies to control and prevent infection. To gain further understanding of HIV-1-specific T-cell mucosal immunity, we established HIV-1-specific CD8(+) cytotoxic T-lymphocyte (CTL) cell lines and clones from the blood, cervix, rectum, and semen of 12 HIV-1-infected individuals and compared their specificities, cytolytic function, and T-cell receptor (TCR) clonotypes. Blood and mucosal CD8(+) CTL had common HIV-1 epitope specificities and major histocompatibility complex restriction patterns. Moreover, both systemic and mucosal CTL lysed targets with similar efficiency, primarily through the perforin-dependent pathway in in vitro studies. Sequence analysis of the TCRbeta VDJ region revealed in some cases identical HIV-1-specific CTL clones in different compartments in the same HIV-1-infected individual. These results clearly establish that a subset of blood and mucosal HIV-1-specific CTL can have a common origin and can traffic between anatomically distinct compartments. Thus, these effectors can provide immune surveillance at the mucosa, where rapid responses are needed to contain HIV-1 infection.

Altered peptide ligand vaccination with Flt3 ligand expanded dendritic cells for tumor immunotherapy

Most tumor-associated antigens represent self-proteins and as a result are poorly immunogenic due to immune tolerance. Here we show that tolerance to carcinoembryonic antigen (CEA), which is overexpressed by the majority of lethal malignancies, can be reversed by immunization with a CEA-derived peptide. This peptide was altered to make it a more potent T cell antigen and loaded onto dendritic cells (DCs) for delivery as a cellular vaccine. Although DCs are rare in the blood, we found that treatment of advanced cancer patients with Flt3 ligand, a hematopoietic growth factor, expanded DCs 20-fold in vivo. Immunization with these antigen-loaded DCs induced CD8 cytotoxic T lymphocytes that recognized tumor cells expressing endogenous CEA. Staining with peptide-MHC tetramers demonstrated the expansion of CD8 T cells that recognize both the native and altered epitopes and possess an effector cytotoxic T lymphocyte phenotype (CD45RA(+)CD27(-)CCR7(-)). After vaccination, two of 12 patients experienced dramatic tumor regression, one patient had a mixed response, and two had stable disease. Clinical response correlated with the expansion of CD8 tetramer(+) T cells, confirming the role of CD8 T cells in this treatment strategy.

Spontaneously relapsing clonal, mucosal cytotoxic T-cell lymphoproliferative disorder: case report and review of the literature

Primary T-cell lymphoma of the gastrointestinal tract is a rare and usually aggressive disorder that may be associated with celiac disease. The authors describe a unique case of a clonal proliferation of CD8+ T cells involving the oral mucosa, ileum, and colon of a 35-year-old man that has regressed spontaneously and recurred numerous times over a 9-year period without treatment. The patient's symptoms were limited to occasional rectal bleeding and recurring painful oral ulcers. Within the intestine, these collections of small T cells induced minimal architectural distortions and did not show extensive epitheliotrophism. Polymerase chain reaction and sequencing analyses revealed that the identical T-cell clone has been present for more than 9 years and in different mucosal locations in this patient. This may represent a unique T-cell lymphoproliferative process akin to a mucosal counterpart of lymphomatoid papulosis of the skin.

Lymphomas of the head and neck

Lymphomas of the head and neck arise in Waldeyer's ring, the salivary glands, nasal cavity, paranasal sinuses, thyroid gland, and orbit. Though anatomically in close proximity, lymphomas arising in these sites have distinct clinical characteristics. Factors that appear to influence the pattern of disease include concurrent conditions, such as Sjögren's syndrome, and geographic factors, particularly with regard to nasal lymphomas. The treatment and prognosis of patients with head and neck lymphoma depends on the histologic grade of disease and extent of involvement at time of presentation. Most lymphomas are of intermediate-grade histology and early stage at presentation. A thorough understanding of clinical disease patterns and treatment options will allow the optimum management of these patients.

Tool support for authoring eligibility criteria for cancer trials

A critical component of authoring new clinical trial protocols is assembling a set of eligibility criteria for patient enrollment. We found that clinical protocols in three different cancer domains can be categorized according to a set of clinical states that describe various clinical scenarios for that domain. Classifying protocols in this manner revealed similarities among the eligibility criteria and permitted some standardization of criteria based on clinical state. We have developed an eligibility criteria authoring tool which uses a standard set of eligibility criteria and a diagram of the clinical states to present the relevant eligibility criteria to the protocol author. We demonstrate our ideas with phase-3 protocols from breast cancer, prostate cancer, and non-small cell lung cancer. Based on measurements of redundancy and percentage coverage of criteria included in our tool, we conclude that our model reduces redundancy in the number of criteria needed to author multiple protocols, and it allows some eligibility criteria to be authored automatically based on the clinical state of interest for a protocol.

Lamotrigine therapy in infantile neuronal ceroid lipofuscinosis (INCL)

Since 1990, altogether 16 INCL patients received lamotrigine (LTG) because of intractable epilepsy. The response to LTG was favorable in 15/16 children. The severity of seizures decreased significantly in 15/16 patients, the frequency of seizures decreased in 14/16, and the effects were maintained. In addition, LTG had a beneficial effect on the well-being of 14/16 children. LTG failed to maintain it's efficacy in monotherapy. No severe side effects were found.

Impact of omeprazole on the plasma clearance of methotrexate

Omeprazole inhibits the gastric hydrogen pump and is an effective treatment for peptic ulcers. Methotrexate is a chemotherapeutic agent that inhibits dihydrofolate reductase and is eliminated by a hydrogen-ion-dependent mechanism in the kidney. We present evidence that omeprazole inhibits methotrexate clearance and may result in potentially toxic methotrexate levels.

Enlargement of mediastinal masses on simulation films: a radiotherapeutic problem in the management of patients with Hodgkin's disease

The size of the mediastinal mass on standard posterior-anterior chest radiograph in stage I and stage II Hodgkin's disease has both prognostic and therapeutic importance. But the actual treatment is based on the anterior-posterior supine simulation film. Problems arise when the prognosis (whether all the disease can be effectively contained in an irradiation port) and toxicity (more lung and heart irradiated or chemotherapy required) are changed when the mass is markedly enlarged on the radiation simulation films. Differences in the direction of the X-ray beam, distance from the subject, and patient position are shown to increase artificially the size of a mediastinal mass on simulation films. The staging and therapeutic implications are discussed.

Management of stage T3 and T4 glottic carcinomas

Between 1959 and 1979, 242 patients with T3 and T4 lesions of the vocal cords were treated at our institution. Treatment consisted of total laryngectomy in all patients. Different modalities of regional node dissections were performed on 187 patients. In addition, 50 patients received irradiation with cobalt-60 postoperatively for specific features of the disease. In the group of 192 patients whose treatment consisted of surgery alone, 28 (14 percent) had recurrence in the neck and 10 (5 percent) had stomal recurrence. Of the patients treated with combined therapy, three (6 percent) had ipsilateral neck recurrences and one (2 percent) had stomal recurrence. For lesions staged N0, failure rates above the clavicles were 16 percent and 31 percent for patients with T3 and T4 lesions, respectively, in the group treated by surgery alone, 9 percent and 6 percent for patients with T3 and T4 lesions, respectively, in the combined therapy group. The rate of failure above the clavicles for lesions staged N+ was 32 percent in the group treated with surgery alone and 8 percent in the combined therapy group. In this study, a correlation was made between the failure rates above the clavicles and different clinical and histologic characteristics of the tumor, surgical findings, and the different modalities of cervical node dissection used. From analysis of the data, recommendations have been made for the selective treatment of patients with advanced glottic carcinomas.

A quantitative Golgi study in the occipital cortex of the pyramidal dendritic topology of old adult rats from social or isolated environments

It has been previously established that the housing condition influences the appearance of the dendritic tree in young animals. The purpose of this investigation was to determine the extent of the influence that the housing condition exerts on morphometric studies involving old animals. Specifically, we found superficial pyramidal cells from the visual cortex of socially aged 20-month-old rats had more extensive oblique dendritic trees than neurons from isolated rats of the same age. The basal dendritic tree of neurons from socially reared rats was denser nearest layer IV while the basal dendritic tree of neurons from isolated rats appeared to shift away from layer IV. Our results indicate that the external environment is an independent variable and cortical dendritic morphology is a dependent variable in studies on old adult rats. Thus, the external environment should be considered in reporting results of aging studies on dendritic topology.