Robotic-Assisted Bariatric Surgery Is Associated with Increased Postoperative Complications Compared to Laparoscopic: a Nationwide Readmissions Database Study

PURPOSE

Robotic-assisted (RA) bariatric surgery has been increasingly used without consistent benefit over a laparoscopic approach (LA). We compared intra- and post-operative complications and 30- and 90-day all-cause readmissions between RA and LA using the Nationwide Readmissions Database (NRD).

MATERIALS AND METHODS

We identified hospitalizations with adult patients who underwent RA or LA bariatric surgery from 2010 to 2019. Primary outcomes included intra- and post-operative complications and 30- and 90-day all-cause readmissions. Secondary outcomes included in-hospital death, length of stay (LOS), cost, and cause-specific readmissions. Multivariable regression models were estimated; analyses accounted for the NRD sampling design.

RESULTS

A total of 1,371,778 hospitalizations met inclusion criteria with 7.1% using RA. Patient demographic and clinical characteristics were mostly similar between groups. Adjusted odds of complication were 13% higher for RA (adjusted odds ratio [aOR]: 1.13, 95% CI: 1.03-1.23 p = .008); aORs differed across bariatric procedures. The most common complications included nausea/vomiting, acute blood loss anemia, incisional hernia, and transfusion. Adjusted odds of 30- and 90-day readmission were 10% higher for RA (aOR: 1.10, 95% CI: 1.04-1.17, p = .001 and aOR: 1.10, 95% CI: 1.04-1.16, p <.001, respectively). LOS was similar (1.6 vs. 1.6 days, p = .253); although, hospital costs were 31.1% higher for RA ($15,806 vs. $12,056, p < .001).

CONCLUSION

RA bariatric surgery is associated with 13% higher odds of complication, 10% higher odds of readmission, and 31% hospital costs. Subsequent studies are required using databases that can include additional patient-, facility-, surgery-, and surgeon-specific characteristics.

Pressure-Sensing Gastric Calibration Tube for Minimizing Sleeve Volume Variation in Sleeve Gastrectomy Compared with Current Standard Technique

The sleeve gastrectomy technique is dependent on the size of the bougie and the surgeon's technical skills. Standardization of the sleeve gastrectomy technique may potentially minimize the volume inconsistency and improve outcomes. A volume and pressure-sensitive gastric calibration tube may create a standard sleeve size and minimize interoperator variation. The objective of preliminary testing was to establish the variability of sleeve gastrectomy size in gastric explants, and to compare that with the variability of sleeve gastrectomy size when performed with a volume and pressure-sensitive gastric calibration tube. Three operators performed six sleeve gastrectomies each on commercially processed porcine gastric explants, half with a 40 Fr bougie, and a half with a pressure-sensing and volume-controllable gastric calibration tube prototype. The resulting sleeves were evaluated using standard statistical methods. The pressure-sensitive gastric calibration tube demonstrated superior consistency to a standard 40 Fr bougie by common measures of variation. However, further investigation is warranted to characterize the significance of this difference.

An oral health optimized diet can reduce gingival and periodontal inflammation in humans - a randomized controlled pilot study

BACKGROUND

The aim of this pilot study was to investigate the effects of four weeks of an oral health optimized diet on periodontal clinical parameters in a randomized controlled trial.

METHODS

The experimental group (n = 10) had to change to a diet low in carbohydrates, rich in Omega-3 fatty acids, and rich in vitamins C and D, antioxidants and fiber for four weeks. Participants of the control group (n = 5) did not change their dietary behavior. Plaque index, gingival bleeding, probing depths, and bleeding upon probing were assessed by a dentist with a pressure-sensitive periodontal probe. Measurements were performed after one and two weeks without a dietary change (baseline), followed by a two week transitional period, and finally performed weekly for four weeks.

RESULTS

Despite constant plaque values in both groups, all inflammatory parameters decreased in the experimental group to approximately half that of the baseline values (GI: 1.10 ± 0.51 to 0.54 ± 0.30; BOP: 53.57 to 24.17 %; PISA: 638 mm(2) to 284 mm(2)). This reduction was significantly different compared to that of the control group.

CONCLUSION

A diet low in carbohydrates, rich in Omega-3 fatty acids, rich in vitamins C and D, and rich in fibers can significantly reduce gingival and periodontal inflammation.

TRIAL REGISTRATION

German Clinical Trials Register; https://www.germanctr.de (DRKS00006301). Registered on 2015-02-21.

Energy metabolism and cytochrome oxidase activity: linking metabolism to gene expression

Modification of mitochondrial content demands the synthesis of hundreds of proteins encoded by nuclear and mitochondrial genomes. The responsibility for coordination of this process falls to nuclear-encoded master regulators of transcription. DNA-binding proteins and coactivators integrate information from energy-sensing pathways and hormones to alter mitochondrial gene expression. In mammals, the signaling cascade for mitochondrial biogenesis can be described as follows: hormonal signals and energetic information are sensed by protein-modifying enzymes that in turn regulate the post-translational modification of transcription factors. Once activated, transcription-factor complexes form on promoter elements of many of the nuclear-encoded mitochondrial genes, recruiting proteins that remodel chromatin and initiate transcription. One master regulator in mammals, PGC-1α, is well studied because of its role in determining the metabolic phenotype of muscles, but also due to its importance in mitochondria-related metabolic diseases. However, relatively little is known about the role of this pathway in other vertebrates. These uncertainties raise broader questions about the evolutionary origins of the pathway and its role in generating the diversity in muscle metabolic phenotypes seen in nature.

Sensitive detection of CO2 implementing tunable thulium-doped all-fiber laser

In this paper a compact, yet sensitive gas detection system based on a modulated, tunable thulium-doped fiber laser in the 2 μm wavelength region is reported. The laser operating wavelength range centered at a wavelength of 1.995 μm has been selected to access the R(50) transition (ν1+2ν2+ν3) of CO2 based on its line strength and to achieve isolation from interfering high-temperature water absorption features. The laser linewidth and tuning range are optimized accordingly. The modulation of the fiber laser, achieved through pump source modulation and a locking detection mechanism, has been utilized to stabilize the laser system and therefore to create a compact gas sensor with high sensitivity. The absorption spectrum, as well as the line strength and the concentration level of CO2, have been monitored through absorption spectroscopy techniques. The measured minimum detectable concentration of CO2 obtained using the system shows that it is quite capable of detecting trace gas at the ppm (parts in 10(6)) level. The stable laser performance achieved in the sensor system illustrates its potential for the development of practical, compact, yet sensitive fiber-laser-based gas sensor systems.

Eocene Patagonia fossils of the daisy family

Fossil capitula and pollen grains of Asteraceae from the Eocene of Patagonia, southern Argentina, exhibit morphological features recognized today in taxa, such as Mutisioideae and Carduoideae, that are phylogenetically close to the root of the asteracean tree. This fossil supports the hypothesis of a South American origin of Asteraceae and an Eocene age of divergence and suggests that an ancestral stock of Asteraceae may have formed part of a geoflora developed in southern Gondwana before the establishment of effective dispersal barriers within this landmass.

Bendamustine, vincristine and prednisone (BOP) versus cyclophosphamide, vincristine and prednisone (COP) in advanced indolent non-Hodgkin's lymphoma and mantle cell lymphoma: results of a randomised phase III trial (OSHO# 19)

PURPOSE

The purpose of this study was to compare the efficacy and toxicity of bendamustine, vincristine + prednisone (BOP) with a standard regimen of cyclophosphamide, vincristine + prednisone (COP) in patients with previously untreated advanced indolent non-Hodgkin's lymphoma (NHL) and mantle cell lymphoma.

METHODS

A total of 164 patients with follicular lymphoma (grade 1/2), mantle cell lymphoma or lymphoplasmacytic lymphoma (immunocytoma) was randomised to treatment with vincristine 2 mg (day 1) and prednisone 100 mg/m2 (days 1-5) + bendamustine 60 mg/m2 (days 1-5) or + cyclophosphamide 400 mg/m2 (days 1-5) for a total of eight 21-day cycles.

RESULTS

The rate of complete remission was 22% with BOP and 20% with COP. The projected 5-year survival rate was 61% with BOP and 46% with COP. The BOP-associated 5-year survival advantage almost reached significance in the subgroup of patients who responded to therapy (74% vs. 56%; P = 0.05), and did reach significance in responders who did not receive interferon maintenance therapy (70% vs. 47%; P = 0.03). Toxicity was acceptable in both treatment groups, although alopecia and leucopenia were more severe with COP.

CONCLUSIONS

Bendamustine can efficaciously and safely replace cyclophosphamide, as used in standard COP therapy, for the treatment of patients with indolent NHL and mantle cell lymphoma. Long-term survival data suggest a clinically significant benefit for patients treated with BOP.

[Foudroyant rhinocerebral zygomycosis]

We present a fatal case of rhino-orbital-cerebral zygomycosis in an 81-year old immunocompromised patient with a 18-year history of multiple myeloma. The patient initially presented with symptoms of an orbital complication, loss of vision after acute sinusitis and agranulocytosis. Endonasal sinus surgery with orbital decompression was performed. Within days a rapid visero-cerebral progression of necrosis developed finally causing the patient's death. Invasive fungal infections are generally characterized by diagnostic difficulties in the early stage and exhibit an extremely high mortality. Definitive diagnosis of rhino-orbital-cerebral zygomycosis caused by Rhizopus microsporus was made by histology, culture and polymerase chain reaction. Early diagnosis and treatment are imperative for the management of patients afflicted with this devastating and life-threatening fungal infection.

Age and biogeography of major clades in Liliales

A robust phylogeny of 40 genera and all seven families of the Liliales based on rbcL sequences was dated by the mean branch-length method of Bremer and Gustafsson and by Sanderson's nonparametric rate smoothing. The basal node was set to 82 million years (my) from the results of a previous more extensive dating involving all monocots. Confidence intervals for the age estimates were generated by bootstrap analysis. The results indicate that four well-supported clades of Liliales date back to the Cretaceous ∼65 million years ago (mya), Campynemataceae, Melanthiaceae, Smilacaceae + Liliaceae, and Alstroemeriaceae + Luzuriagaceae + Colchicaceae. Aspects of historical biogeography were investigated by dispersal-vicariance analysis. Several dispersal and vicariance events were found to coincide with Late Cretaceous-Early Tertiary changes in continental interconnections. The study contains the first published sequence of Campynemanthe, supporting the Campynemataceae as a monophyletic group.

Early Cretaceous lineages of monocot flowering plants

The phylogeny of flowering plants is now rapidly being disclosed by analysis of DNA sequence data, and currently, many Cretaceous fossils of flowering plants are being described. Combining molecular phylogenies with reference fossils of known minimum age makes it possible to date the nodes of the phylogenetic tree. The dating may be done by counting inferred changes in sequenced genes along the branches of the phylogeny and calculating change rates by using the reference fossils. Plastid DNA rbcL sequences and eight reference fossils indicate that approximately 14 of the extant monocot lineages may have diverged from each other during the Early Cretaceous >100 million years B.P. The lineages are very different in size and geographical distribution and provide perspective on flowering plant evolution.

[Protein A immunoadsorption treatment of patients with refractory autoimmune thrombopenia]

Eight patients with chronic immunothrombocytopenia (ITP) who had failed at least one alternative therapy were treated with extracorporeal immunoadsorption. Two of the 8 patients responded to the treatment with a stable increase in platelet counts, but both of them had to be continuously treated with corticosteroids. Side effects of the treatment with extracorporeal immunoadsorption were musculoskeletal pain, nausea, vomiting, tachycardia, purpura, fatigue, and others.

East Gondwana ancestry of the sunflower alliance of families

The sunflower alliance of families comprises nearly 10% of all flowering plant species and includes the largest of all plant families, the sunflower family Asteraceae, which has 23,000 species, and the bellflower family Campanulaceae. Both are worldwide in distribution, but the majority of their species occur in the northern hemisphere. Recently it has been shown that a number of small, woody families from the Australian-Southwest Pacific area also belong in this relationship. Here we add yet another such family and present phylogenetic, biogeographic, and chronological analyses elucidating the origin of this large group of plants. We show that the ancestral lineages are confined to Malesia, Australia, New Guinea, and New Zealand and that the sunflower and bellflower families represent phylogenetically derived lineages within a larger group with a Cretaceous and southern-hemisphere, presumably East Gondwana, ancestry. Their highly derived position in the flowering plant phylogeny makes this significant for understanding the evolution of flowering plants in general.

Duplication and functional divergence in the chalcone synthase gene family of Asteraceae: evolution with substrate change and catalytic simplification

Plant-specific polyketide synthase genes constitute a gene superfamily, including universal chalcone synthase [CHS; malonyl-CoA:4-coumaroyl-CoA malonyltransferase (cyclizing) (EC 2.3.1.74)] genes, sporadically distributed stilbene synthase (SS) genes, and atypical, as-yet-uncharacterized CHS-like genes. We have recently isolated from Gerbera hybrida (Asteraceae) an unusual CHS-like gene, GCHS2, which codes for an enzyme with structural and enzymatic properties as well as ontogenetic distribution distinct from both CHS and SS. Here, we show that the GCHS2-like function is encoded in the Gerbera genome by a family of at least three transcriptionally active genes. Conservation within the GCHS2 family was exploited with selective PCR to study the occurrence of GCHS2-like genes in other Asteraceae. Parsimony analysis of the amplified sequences together with CHS-like genes isolated from other taxa of angiosperm subclass Asteridae suggests that GCHS2 has evolved from CHS via a gene duplication event that occurred before the diversification of the Asteraceae. Enzyme activity analysis of proteins produced in vitro indicates that the GCHS2 reaction is a non-SS variant of the CHS reaction, with both different substrate specificity (to benzoyl-CoA) and a truncated catalytic profile. Together with the recent results of Durbin et al. [Durbin, M. L., Learn, G. H., Jr., Huttley, G. A. & Clegg, M. T. (1995) Proc. Natl. Acad. Sci. USA 92, 3338-3342], our study confirms a gene duplication-based model that explains how various related functions have arisen from CHS during plant evolution.

Notable relationship between the level of tumor marker TPS in serum and survival in breast cancer

Tissue Polypeptide Specific antigen (TPS) in serum was measured once during the follow-up of 200 breast cancer patients and compared with survival. Within 12 months, patients with normal TPS (< 80 U/L) exhibited a 3% death rate (3/96), which was undistinguishable from the mortality of normal females of corresponding age. Patients with moderate TPS (80-400 U/L) suffered 19% death (14/72), and patients with high TPS (> 400 U/L) 72% death (23/32). The relative risk (RR) of death within 6 months was 1 with normal TPS, 8 with moderate TPS, and 48 with high TPS. RR for 12 months was 1, 6, and 23, respectively. Serum TPS at admission had a significant predictive value with regard to survival up to 12 months.

A new dhfrVIII trimethoprim-resistance gene, flanked by IS26, whose product is remote from other dihydrofolate reductases in parsimony analysis

A new plasmid-borne gene, dhfrVIII, encoding high-level trimethoprim resistance (TpR) was found in an intestinal Escherichia coli. It seems to be a widely occurring mediator of TpR. Among 973 examined TpR E. coli, the new resistance gene was found in 13 (1.3%) isolates from Sweden, Finland and Nigeria. The new gene was sequenced and found to code for a dihydrofolate reductase (DHFR) of 169 amino acids (M(r) 19005). The dhfrVIII gene on the studied plasmid pLMO226 was observed to be flanked by IS26 elements. The dhfrVIII gene and a 3' unidentified open reading frame (ORF) seem to be borne on a compound transposon with IS26 at its ends, since the configuration of two IS26 flanking dhfrVIII and the unidentified ORF was conserved among the isolates that were probe-positive for the gene. Phylogeny parsimony analysis showed the dhfrVIII-encoded enzyme to be only remotely related to other known plasmid-mediated, drug-resistant DHFR. Only a few of the latter form well-supported monophyletic groups.

A double-blind, randomised, crossover comparison of granisetron and ondansetron in 5-day fractionated chemotherapy: assessment of efficacy, safety and patient preference. The Granisetron Study Group

We report the first double-blind, randomised, crossover study comparing granisetron and ondansetron as antiemetics in cancer chemotherapy. Patients receiving two cycles of identical chemotherapy fractionated over 5 days were given either granisetron (3 mg/day) or ondansetron (24 mg/day) on each day of chemotherapy, using a double-dummy technique to preserve study blindness. Patients then crossed over to the other therapy. 309 patients (237 male) completed the crossover: 260 received cisplatin (mean dose 19.2 mg/m2/day) and 49 received ifosfamide (mean dose 1415 mg/m2/day). Primary efficacy variables were prospectively defined as complete response (no vomiting and mild or absent nausea) over 5 days, and patient preference. Both agents achieved good control of emetic symptoms with 5-day complete response rates of 44.0% on granisetron and 39.8% on ondansetron [95% confidence interval (CI) for odds ratio 0.8, 1.9]. Complete response rates were very similar in patients receiving either cisplatin (40.8% granisetron, 37.6% ondansetron) or ifosfamide (61.2% granisetron, 51.0% ondansetron). There was a statistically significant difference in patient preference in favour of granisetron, 105 patients preferred granisetron, 79 preferred ondansetron, 121 had no preference (P = 0.048: 95% CI for odds ratio 1.00, 1.84). Single daily doses of granisetron (3 mg/day) appeared similarly effective and well tolerated to three daily doses of ondansetron (8 mg three times daily) in prevention of emesis induced by 5-day fractionated chemotherapy, however, significantly more patients preferred granisetron.

[Pseudoleukocytosis in cryoglobulinemia type I]

During routine clinical and laboratory examinations of a symptom-free 54-year-old man a leukocytosis was repeatedly noted, but no cause found. 11 months later a painful spontaneously disappearing cyanosis occurred in two fingers of his right hand. Serum analysis demonstrated monoclonal type IgG-kappa immunoglobulin and an antinuclear antibody titre of 1:160. Skin biopsy suggested scleroderma. 4 months later, after exposure to cold, extensive acral haemorrhages occurred. Serum cryoglobulin concentration in serum was found to be 800 mg/dl. Comparative manual and electronic counts on warm and cooled blood identified the previously diagnosed leukocytosis as a typical artefact associated with cryoglobulinaemia. Treatment with chlorambucil (10-20 mg/d) and prednisolone (25 mg/d), for 14 days every 4 weeks, and finally interferon alpha-2b (5 mill. IU/d) reduced the cryoglobulin concentration to 150 mg/dl. Acral cyanosis and haemorrhages have not recurred since then. No cause of the cryoglobulinaemia has been found.

Identification of three new genes and estimation of the size of the carcinoembryonic antigen family

Using carcinoembryonic antigen (CEA) subgroup-specific degenerate PCR primers, we have identified three new CEA gene family member L/N exons (CGM9, CGM10, and CGM11) and all previously reported L/N exons of the CEA subgroup (CEA, BGP, NCA, CGM1, CGM2, CGM6, CGM7, and CGM8). This suggests that the CEA subgroup contains 11 genes. CGM9, CGM10, and CGM11 seem to be pseudogenes. A deletion of an asparagine in CGM9 results in loss of a glycosylation site, which is conserved throughout the CEA gene family. We have previously suggested the number of genes in the pregnancy-specific glycoprotein (PSG) subgroup to be 11, which together with this study indicates that the CEA gene family contains 22 genes in all. Parsimony analysis of the CEA subgroup interrelationships suggests that CGM7 occupies the most primitive position within the CEA subgroup, being a sister group to the rest. CEA, BGP, NCA, and CGM1 form a fairly well-supported group within the CEA subgroup.

A single-blind study of the efficacy and safety of intravenous granisetron compared with alizapride plus dexamethasone in the prophylaxis and control of emesis in patients receiving 5-day cytostatic therapy. The Granisetron Study Group

200 cancer patients who were due to receive fractionated chemotherapy (cisplatin greater than or equal to 15, ifosfamide greater than or equal to 1.2 or etoposide greater than or equal to 120, all mg/m2 per day) for 5 days, entered a multicentre study. Patients were randomised single-blind to receive either prophylactic intravenous granisetron (40 micrograms/kg) or alizapride (4 mg/kg followed by 4 mg/kg at 4 and 8 h post-treatment) plus dexamethasone 8 mg. Granistron was superior to the combination in preventing nausea and vomiting (54% vs. 43% complete responders). The differences were in the cisplatin-treated group. The time to first episode of moderate to severe nausea was significantly longer in the granisetron group (P = 0.03). Dosing with granisetron was more simple, with over 85% of patients requiring only a single prophylactic dose. Fewer patients receiving granisetron experienced adverse events (48% vs. 62%, P = 0.047). The frequency of constipation was, as expected, significantly higher in the granisetron group. Extrapyramidal effects, which were not noted by any granisetron patient, occurred in 5.3% of comparator patients.

The pregnancy-specific glycoprotein family of the immunoglobulin superfamily: identification of new members and estimation of family size

The members of the carcinoembryonic antigen (CEA)/pregnancy-specific glycoprotein (PSG) gene family have a characteristic N-terminal domain that is homologous to the immunoglobulin variable region. We have estimated the size of the PSG subfamily by identification of N-domain exons from isolated genomic clones and from total genomic DNA through PCR amplification and DNA sequence determination. The PSG subfamily contains at least 11 different genes. For 7 of these, two DNA sequences differing from each other in 1 to 4 nucleotides were detected. Most likely, they represent different alleles. They are PSG1, PSG2, PSG3, PSG4, PSG5, PSG6, PSG7, PSG8, PSG11, PSG12, and PSG13. Six of the N-domain sequences described here are new. All of the PSGs except PSG1, PSG4, and PSG8 contained the arginine-glycine-aspartic acid sequence at position 93-95 corresponding to the complementarity determining region 3 of immunoglobulin. Parsimony analysis of 24 CEA and PSG sequences using 12 members of the immunoglobulin gene superfamily as outgroups to root the family tree shows that the N-domain of the CEA group genes evolved in one major branch and the PSG group genes in the other.

[Comparison of the antiemetic effectiveness of granisetron and alizapride plus dexamethasone in cytostatic therapy]

In a randomized single-blind international multicentre trial, two antiemetic regimens were compared in 115 oncology patients undergoing chemotherapy for the first time (cisplatin greater than 15 mg/m2, or ifosfamide greater than 1200 mg/m2 or etoposide greater than 120 mg/m2). One group received granisetron, a 5-hydroxytryptamine type-3-receptor antagonist, 40 micrograms/kg alone intravenously before chemotherapy, with, if necessary, up to two further doses daily of 40 micrograms/kg. The second group received a combination of alizapride plus dexamethasone (4 mg/kg alizapride and 8 mg/kg dexamethasone before chemotherapy, repeated, if necessary, after 4 and 8 hours up to two additional doses). There was good antiemetic efficacy (a maximum of one episode of vomiting in 24 hours = "major efficacy") in 50 of 62 patients (80.7%) in the granisetron group, and in 37 out of 53 (69.8%) of those treated with alizapride and dexamethasone; failure of antiemetic therapy occurred in 4.8% (granisetron) and 15.1% (combination) of patients. For the first day of each 5-day chemotherapy cycle, there was a higher rate of excellent antiemetic efficacy (no or only mild nausea, and no vomiting) with granisetron (90.3% vs 69.8%, P less than 0.006). The frequency (29% vs 32%) and nature of side effects (obstipation, diarrhoea, headaches, anxiety, vertigo), the causes of which were not differentiated, were similar. No extrapyramidal reactions occurred with granisetron. Of the 62 patients treated with granisetron, 47 did not require any further granisetron after the single daily prophylactic dose.