Is nonoperative management of appendicitis safe and effective in multi-morbid patients?

BACKGROUND

The purpose of this study was to (1) compare post-treatment outcomes of operative and nonoperative management of acute appendicitis in multi-morbid patients and (2) evaluate the generalizability of prior clinical trials by determining whether outcomes differ in multi-morbid patients compared to the young and healthy patients who resemble prior clinical trial participants.

METHODS

We conducted a retrospective cohort study using the National Inpatient Sample from 2004 to 2017. We included 368,537 patients with acute, uncomplicated appendicitis who were classified as having 0 or 2+ comorbidities. We compared inpatient morbidity, mortality, length of stay, and costs using propensity scores. Unmeasured confounding was addressed with probabilistic sensitivity analysis.

RESULTS

Overall, 5% of patients without comorbidities were treated nonoperatively versus 20% of multi-morbid patients. Compared to surgery, nonoperative management was associated with a 3.5% decrease in complications (95% confidence interval 3%-4%) for multi-morbid patients, but there was no significant difference for patients without comorbidity. However, nonoperative management was associated with a 1.5% increase in mortality for multimorbid patients (95% confidence interval 1.3%-1.7%). Costs and length of stay were lower for all patients treated with surgery. Probabilistic sensitivity analysis showed that results were robust to the effects of unmeasured confounding.

CONCLUSION

Our results raise concerns about the generalizability of clinical trials that compared nonoperative and operative management of appendicitis because (1) those trials enrolled mostly young and healthy patients, and (2) results in multi-morbid patients differ from outcomes in younger and healthier patients.

The risks of failed nonoperative management of appendicitis in older adults

BACKGROUND

The consequences of failed nonoperative management of appendicitis in older patients have not been described.

METHODS

We used the 2004-2017 National Inpatient Sample to identify acute appendicitis patients managed nonoperatively (<65 years old: 32,469; ≥65 years old: 11,265). Outcomes included morbidity, length of stay (LOS), inpatient costs, and discharge to skilled facilities. Differences were estimated using propensity scores.

RESULTS

For patients <65, nonoperative failure was associated with increased morbidity (7 ​% [95 ​% CI 6.9 ​%-8.1 ​%]), LOS (3 day [95 ​% CI 3-4]), costs ($9015 [95 ​% CI $8216- $9446]), and discharges to skilled facilities (1 ​% [95 ​% CI 0.9 ​%-1.6 ​%]) compared to successful nonoperative treatment. Patients ≥65 had differences in morbidity (14 ​% [95 ​% CI 13.6 ​%-16.2 ​%]), LOS (6 days [95 ​% CI 5-6]), costs ($15,964 [95 ​% CI $15,181- $17,708]), and discharges to skilled facilities (12 ​% [95 ​% CI: 10.0 ​%-13.3]) compared to nonoperative success.

CONCLUSIONS

Nonoperative management of appendicitis should be approached cautiously for older adults.

Classification of Vascular Plants in Vietnam According to Modern Classification Systems

Vietnam is extremely rich in biodiversity, with a remarkable range of habitats and more than 13,500 species of vascular plants recorded for the flora of Vietnam. This number represents about 3 to 5% of the world's diversity of vascular plants. Over the past 30 years, there were two important documents on the vascular plants of Vietnam published, An Illustrated Flora of Vietnam (IFV) and Checklist of Plant Species of Vietnam (CPSV). During the past half century, the advent of molecular phylogenetics has witnessed dramatic changes in the classifications of vascular plants, and some modern classification systems of vascular plants have been established, e.g., PPG I, GPG, and APG. However, the vascular plants of Vietnam have not yet been classified according to these modern classification systems. In this paper, we present the history of the classification of vascular plants in Vietnam, compare the circumscription of all families of vascular plants occurring within Vietnam in IFV, CPSV, and the modern classification systems when applicable, and summarize familial assignments of all controversial genera in the different classifications. Furthermore, we also arrange the 37 families of lycophytes and ferns occurring within Vietnam according to the latest classification system (PPG I) and the 8 families of gymnosperms according to the latest Christenhusz's system (GPG). The 246 families of angiosperms are arranged according to the fourth edition of the latest Angiosperm Phylogeny Group (APG IV). These results are the foundation stones and would be helpful for future research on the flora of Vietnam and the arrangement of plant collections in Vietnamese herbaria based on the updated classifications.

Unraveling the hierarchical genetic structure of tea green leafhopper, Matsumurasca onukii , in East Asia based on SSRs and SNPs

Matsumurasca onukii (Matsuda, R. (1952). Oyo‐Kontyu Tokyo, 8(1): 19–21), one of the dominant pests in major tea production areas in Asia, currently is known to occur in Japan, Vietnam, and China, and severely threatens tea production, quality, and international trade. To elucidate the population genetic structure of this species, 1633 single nucleotide polymorphisms (SNPs) and 18 microsatellite markers (SSRs) were used to genotype samples from 27 sites representing 18 geographical populations distributed throughout the known range of the species in East Asia. Analyses of both SNPs and SSRs showed that M. onukii populations in Yunnan exhibit high‐genetic differentiation and structure compared with the other populations. The Kagoshima (JJ) and Shizuoka (JS) populations from Japan were separated from populations from China by SNPs, but clustered with populations from Jinhua (JH), Yingde (YD), Guilin (GL), Fuzhou (FZ), Hainan (HQ), Leshan (CT), Chongqing (CY), and Zunyi (ZY) tea plantations in China and the Vietnamese Vinh Phuc (VN) population based on the SSR data. In contrast, CT, CY, ZY, and Shaanxi (SX) populations clustered together based on SNPs, but were separated by SSRs. Both marker datasets identified significant geographic differentiation among the 18 populations. Various environmental and anthropogenic factors, including geographical barriers to migration, human transport of hosts (Camellia sinesis [L.] O. Kuntze) and adaptation of M. onukii to various local climatic zones possibly account for the rapid spread of this pest in Asia. The results demonstrate that SNPs from high‐throughput genotyping data can be used to reveal subtle genetic substructure at broad scales in r‐strategist insects.

Itraconazole Exerts Its Antitumor Effect in Esophageal Cancer By Suppressing the HER2/AKT Signaling Pathway

Itraconazole, an FDA-approved antifungal, has antitumor activity against a variety of cancers. We sought to determine the effects of itraconazole on esophageal cancer and elucidate its mechanism of action. Itraconazole inhibited cell proliferation and induced G₁-phase cell-cycle arrest in esophageal squamous cell carcinoma and adenocarcinoma cell lines. Using an unbiased kinase array, we found that itraconazole downregulated protein kinase AKT phosphorylation in OE33 esophageal adenocarcinoma cells. Itraconazole also decreased phosphorylation of downstream ribosomal protein S6, transcriptional expression of the upstream receptor tyrosine kinase HER2, and phosphorylation of upstream PI3K in esophageal cancer cells. Lapatinib, a tyrosine kinase inhibitor that targets HER2, and siRNA-mediated knockdown of HER2 similarly suppressed cancer cell growth in vitro. Itraconazole significantly inhibited growth of OE33-derived flank xenografts in mice with detectable levels of itraconazole and its primary metabolite, hydroxyitraconazole, in esophagi and tumors. HER2 total protein and phosphorylation of AKT and S6 proteins were decreased in xenografts from itraconazole-treated mice compared to xenografts from placebo-treated mice. In an early phase I clinical trial (NCT02749513) in patients with esophageal cancer, itraconazole decreased HER2 total protein expression and phosphorylation of AKT and S6 proteins in tumors. These data demonstrate that itraconazole has potent antitumor properties in esophageal cancer, partially through blockade of HER2/AKT signaling.

GEAMP, a novel gastroesophageal junction carcinoma cell line derived from a malignant pleural effusion

Gastroesophageal junction (GEJ) cancer remains a clinically significant disease in Western countries due to its increasing incidence, which mirrors that of esophageal cancer, and poor prognosis. To develop novel and effective approaches for prevention, early detection, and treatment of patients with GEJ cancer, a better understanding of the mechanisms driving pathogenesis and malignant progression of this disease is required. These efforts have been limited by the small number of available cell lines and appropriate preclinical animal models for in vitro and in vivo studies. We have established and characterized a novel GEJ cancer cell line, GEAMP, derived from the malignant pleural effusion of a previously treated GEJ cancer patient. Comprehensive genetic analyses confirmed a clonal relationship between GEAMP cells and the primary tumor. Targeted next-generation sequencing identified 56 nonsynonymous alterations in 51 genes including TP53 and APC, which are commonly altered in GEJ cancer. In addition, multiple copy-number alterations were found including EGFR and K-RAS gene amplifications and loss of CDKN2A and CDKN2B. Histological examination of subcutaneous flank xenografts in nude and NOD-SCID mice showed a carcinoma with mixed squamous and glandular differentiation, suggesting GEAMP cells contain a subpopulation with multipotent potential. Finally, pharmacologic inhibition of the EGFR signaling pathway led to downregulation of key downstream kinases and inhibition of cell proliferation in vitro. Thus, GEAMP represents a valuable addition to the limited number of bona fide GEJ cancer cell lines.

Randomized Trial of Medical versus Surgical Treatment for Refractory Heartburn

BACKGROUND

Heartburn that persists despite proton-pump inhibitor (PPI) treatment is a frequent clinical problem with multiple potential causes. Treatments for PPI-refractory heartburn are of unproven efficacy and focus on controlling gastroesophageal reflux with reflux-reducing medication (e.g., baclofen) or antireflux surgery or on dampening visceral hypersensitivity with neuromodulators (e.g., desipramine).

METHODS

Patients who were referred to Veterans Affairs (VA) gastroenterology clinics for PPI-refractory heartburn received 20 mg of omeprazole twice daily for 2 weeks, and those with persistent heartburn underwent endoscopy, esophageal biopsy, esophageal manometry, and multichannel intraluminal impedance-pH monitoring. If patients were found to have reflux-related heartburn, we randomly assigned them to receive surgical treatment (laparoscopic Nissen fundoplication), active medical treatment (omeprazole plus baclofen, with desipramine added depending on symptoms), or control medical treatment (omeprazole plus placebo). The primary outcome was treatment success, defined as a decrease of 50% or more in the Gastroesophageal Reflux Disease (GERD)-Health Related Quality of Life score (range, 0 to 50, with higher scores indicating worse symptoms) at 1 year.

RESULTS

A total of 366 patients (mean age, 48.5 years; 280 men) were enrolled. Prerandomization procedures excluded 288 patients: 42 had relief of their heartburn during the 2-week omeprazole trial, 70 did not complete trial procedures, 54 were excluded for other reasons, 23 had non-GERD esophageal disorders, and 99 had functional heartburn (not due to GERD or other histopathologic, motility, or structural abnormality). The remaining 78 patients underwent randomization. The incidence of treatment success with surgery (18 of 27 patients, 67%) was significantly superior to that with active medical treatment (7 of 25 patients, 28%; P = 0.007) or control medical treatment (3 of 26 patients, 12%; P<0.001). The difference in the incidence of treatment success between the active medical group and the control medical group was 16 percentage points (95% confidence interval, -5 to 38; P = 0.17).

CONCLUSIONS

Among patients referred to VA gastroenterology clinics for PPI-refractory heartburn, systematic workup revealed truly PPI-refractory and reflux-related heartburn in a minority of patients. For that highly selected subgroup, surgery was superior to medical treatment. (Funded by the Department of Veterans Affairs Cooperative Studies Program; ClinicalTrials.gov number, NCT01265550.).

Acidic Bile Salts Induce Epithelial to Mesenchymal Transition via VEGF Signaling in Non-Neoplastic Barrett's Cells

BACKGROUND & AIMS

Metaplastic glands buried under squamous epithelium are frequently detected in patients with Barrett esophagus (BE). This subsquamous intestinal metaplasia might be responsible for cancers that develop despite endoscopic surveillance and for metaplasia recurrences after endoscopic ablation. To determine whether reflux induces BE cells to undergo an epithelial-to-mesenchymal transition (EMT) that produces subsquamous intestinal metaplasia, we assessed EMT in BE cells exposed to acidic bile salts and in rat and human esophageal tissues.

METHODS

We compared markers of EMT and cell motility in trans-well and 3-dimensional organotypic culture systems among dysplastic BE epithelial cell lines, nondysplastic telomerase-immortalized BE cell lines (BAR-T), and BAR-T cells exposed acutely or for 20 weeks to acidic bile salts. Vascular endothelial growth factor (VEGF) A was inhibited with a neutralizing antibody or CRISPR-Cas9n and VEGF receptor 2 was inhibited with SU1498 or shRNA, and cells were analyzed by immunohistochemistry, quantitative polymerase chain reaction, or immunoblotting for markers of VEGF signaling and EMT; cell motility was assessed by trans-well assay. We used immunohistochemistry and quantitative polymerase chain reaction to assess EMT markers in the columnar-lined esophagus of rats with surgically induced reflux esophagitis and in esophagectomy specimens from patients with BE.

RESULTS

We detected features of EMT (decreased cadherin 1 [CDH1]; increased fibronectin 1, vimentin, and matrix metalloproteinase 2; and increased motility) in dysplastic BE epithelial cell lines and in BAR-T cells exposed for 20 weeks, but not in unexposed BAR-T cells. Acute acidic bile salt exposure induced expression of zinc finger E-box binding homeobox 1 and 2 (ZEB1/2) in BAR-T cells, which decreased their expression of CDH1 and increased motility; inhibitors of VEGF signaling blocked these effects. Columnar-lined esophagus of rats with reflux esophagitis had increased expression of ZEB1/2 and decreased expression of CDH1 compared with controls. Dysplastic BE tissues also had significantly increased levels of ZEB1 and significantly decreased levels of CDH1 compared with nondysplastic BE tissues.

CONCLUSIONS

In BE cell lines, acidic bile salts induce EMT by VEGF signaling, which increases expression of ZEB1/2, repressors of CDH1. These observations suggest that reflux induces EMT in metaplastic BE tissues, which promotes development of subsquamous intestinal metaplasia.

Columnar-Lined Esophagus Develops via Wound Repair in a Surgical Model of Reflux Esophagitis

BACKGROUND & AIMS

After esophagojejunostomy, rodents develop reflux esophagitis and a columnar-lined esophagus with features of Barrett's metaplasia. This rodent columnar-lined esophagus has been proposed to develop from cellular reprogramming of progenitor cells, but studies on early columnar-lined esophagus development are lacking. We performed a systematic, histologic, and immunophenotypic analysis of columnar-lined esophagus development in rats after esophagojejunostomy.

METHODS

At various times after esophagojejunostomy in 52 rats, the esophagus was removed and tissue sections were evaluated for type, location, and length of columnar lining. Molecular characteristics were evaluated by immunohistochemistry and immunofluorescence.

RESULTS

At week 2, ulceration was seen in esophageal squamous epithelium, starting distally at the esophagojejunostomy anastomosis. Re-epithelialization of the distal ulcer segment occurred via proliferation and expansion of immature-appearing glands budding directly off jejunal crypts, characteristic of wound healing. The columnar-lined esophagus's immunoprofile was similar to jejunal crypt epithelium, and columnar-lined esophagus length increased significantly from 0.15 mm (±0.1 SEM) at 2 weeks to 5.22 mm (±0.37) at 32 weeks. Neoglands were found within esophageal ulcer beds, and spindle-shaped cells expressing epithelial-mesenchymal transition markers were found at the columnar-lined esophagus's leading edge. Only proliferative squamous epithelium was found at the proximal ulcer border.

CONCLUSIONS

After esophagojejunostomy in rats, metaplastic columnar-lined esophagus develops via a wound healing process that does not appear to involve cellular reprogramming of progenitor cells. This process involves EMT-associated migration of jejunal cells into the esophagus, where they likely have a competitive advantage over squamous cells in the setting of ongoing gastroesophageal reflux disease.

Assessing the Veterans Affairs Surgical Quality Improvement Program Risk Calculator in Cholecystectomy

The Veterans Affairs Surgical Quality Improvement Program (VASQIP) risk calculator has been validated for several operations but has not been assessed specifically for cholecystectomy. Our aim was to externally validate the VASQIP calculator's accuracy in predicting 30-day morbidity and mortality (M&M) for patients undergoing cholecystectomy. A retrospective review of patients undergoing cholecystectomy at the North Texas Veterans Affairs hospital was performed. The VASQIP risk calculator was used to determine predicted 30-day M&M, which was compared with actual M&M. The predictive accuracy of the Veterans Affairs risk calculator was assessed using the C-statistic and a graphical assessment of a locally weighted least squares regression smoother. Overall, 848 patients were included in the study. Actual M&M were 6.3 and 0.94 per cent, respectively, whereas predicted M&M were 6.0 and 0.54 per cent. The C-statistic was 0.75 for morbidity and 0.78 for mortality. In our analysis, the VASQIP risk calculator reasonably predicted 30-day M&M.

Assessing the Veterans Affairs Surgical Quality Improvement Program Risk Calculator in Cholecystectomy

The Veterans Affairs Surgical Quality Improvement Program (VASQIP) risk calculator has been validated for several operations but has not been assessed specifically for cholecystectomy. Our aim was to externally validate the VASQIP calculator's accuracy in predicting 30-day morbidity and mortality (M&M) for patients undergoing cholecystectomy. A retrospective review of patients undergoing cholecystectomy at the North Texas Veterans Affairs hospital was performed. The VASQIP risk calculator was used to determine predicted 30-day M&M, which was compared with actual M&M. The predictive accuracy of the Veterans Affairs risk calculator was assessed using the C-statistic and a graphical assessment of a locally weighted least squares regression smoother. Overall, 848 patients were included in the study. Actual M&M were 6.3 and 0.94 per cent, respectively, whereas predicted M&M were 6.0 and 0.54 per cent. The C-statistic was 0.75 for morbidity and 0.78 for mortality. In our analysis, the VASQIP risk calculator reasonably predicted 30-day M&M.

Aspirin prevents NF-κB activation and CDX2 expression stimulated by acid and bile salts in oesophageal squamous cells of patients with Barrett's oesophagus

OBJECTIVE

In previous studies using oesophageal squamous cells from patients with Barrett's oesophagus (normal oesophageal squamous (NES)-B cells) and from patients without Barrett's oesophagus (NES-G cells), we showed that acid and bile salts induced caudal-related homeobox transcription factor 2 (CDX2) expression only in NES-B cells. CDX2, a transcription factor required to form intestinal epithelium, is a target of nuclear factor kappa-light-chain-enhancer of activated B cells (NF-κB) signalling, which can be inhibited by aspirin. We explored mechanisms underlying differences between NES-B and NES-G cells in CDX2 expression and effects of aspirin on that CDX2 expression.

DESIGN

We exposed NES-B and NES-G cells to acid and bile salts, with and without aspirin, and evaluated effects on IκB-NF-κB-PKAc complex activation, p65 NF-κB subunit function, and CDX2 expression.

RESULTS

In both NES-B and NES-G cells, acid and bile salts activated nicotinamide adenine dinucleotide phosphate oxidase to generate H₂O₂, which activated the IκB-NF-κB-PKAc complex. NES-B cells exhibited higher levels of phosphorylated IκB and p65 and greater NF-κB transcriptional activity than NES-G cells, indicating greater IκB-NF-κB-PKAc complex activation by acid and bile salts in NES-B cells, and p65 siRNA prevented their increased expression of CDX2. Aspirin blocked IκB phosphorylation, p65 nuclear translocation, CDX2 promoter activation and CDX2 expression induced by acid and bile salts in NES-B cells.

CONCLUSIONS

Differences between NES-B and NES-G cells in NF-κB activation by acid and bile salts can account for their differences in CDX2 expression, and their CDX2 expression can be blocked by aspirin. These findings might explain why some patients with GORD develop Barrett's oesophagus while others do not, and why aspirin might protect against development of Barrett's oesophagus.

Hypoxia-inducible factor-2α plays a role in mediating oesophagitis in GORD

OBJECTIVE

In an earlier study wherein we induced acute reflux by interrupting proton pump inhibitor (PPI) therapy in patients with reflux oesophagitis (RO) healed by PPIs, we refuted the traditional concept that RO develops as an acid burn. The present study explored our alternative hypothesis that RO results from reflux-stimulated production of pro-inflammatory molecules mediated by hypoxia-inducible factors (HIFs).

DESIGN

Using oesophageal biopsies taken from patients in our earlier study at baseline and at 1 and 2 weeks off PPIs, we immunostained for HIF-1α, HIF-2α and phospho-p65, and measured pro-inflammatory molecule mRNAs. We exposed human oesophageal squamous cell lines to acidic bile salts, and evaluated effects on HIF activation, p65 function, pro-inflammatory molecule production and immune cell migration.

RESULTS

In patient biopsies, increased immunostaining for HIF-2α and phospho-p65, and increased pro-inflammatory molecule mRNA levels were seen when RO redeveloped 1 or 2 weeks after stopping PPIs. In oesophageal cells, exposure to acidic bile salts increased intracellular reactive oxygen species, which decreased prolyl hydroxylase function and stabilised HIF-2α, causing a p65-dependent increase in pro-inflammatory molecules; conditioned media from these cells increased T cell migration rates. HIF-2α inhibition by small hairpin RNA or selective small molecule antagonist blocked the increases in pro-inflammatory molecule expression and T cell migration induced by acidic bile salts.

CONCLUSIONS

In patients developing RO, increases in oesophageal HIF-2α correlate with increased pro-inflammatory molecule expression. In oesophageal epithelial cells, acidic bile salts stabilise HIF-2α, which mediates expression of pro-inflammatory molecules. HIF-2α appears to have a role in RO pathogenesis.

TRIAL REGISTRATION NUMBER

NCT01733810; Results.

Laparoscopic ischemic conditioning of the stomach increases neovascularization of the gastric conduit in patients undergoing esophagectomy for cancer

BACKGROUND AND OBJECTIVES

Gastric ischemic preconditioning has been proposed to improve blood flow and reduce the incidence of anastomotic complications following esophagectomy with gastric pull-up. This study aimed to evaluate the effect of prolonged ischemic preconditioning on the degree of neovascularization in the distal gastric conduit at the time of esophagectomy.

METHODS

A retrospective review of a prospectively maintained database identified 30 patients who underwent esophagectomy. The patients were divided into three groups: control (no preconditioning, n = 9), partial (short gastric vessel ligation only, n = 8), and complete ischemic preconditioning (left and short gastric vessel ligation, n = 13). Microvessel counts were assessed, using immunohistologic analysis to determine the degree of neovascularization at the distal gastric margin.

RESULTS

The groups did not differ in age, gender, BMI, pathologic stage, or cancer subtype. Ischemic preconditioning durations were 163 ± 156 days for partial ischemic preconditioning, compared to 95 ± 50 days for complete ischemic preconditioning (P = 0.2). Immunohistologic analysis demonstrated an increase in microvessel counts of 29% following partial ischemic preconditioning (P = 0.3) and 67% after complete ischemic preconditioning (P < 0.0001), compared to controls.

CONCLUSIONS

Our study indicates that prolonged ischemic preconditioning is safe and does not interfere with subsequent esophagectomy. Complete ischemic preconditioning increased neovascularization in the distal gastric conduit.

Caretakers' barriers to pediatric antiretroviral therapy adherence in Vietnam - A qualitative and quantitative study

BACKGROUND

Poor antiretroviral therapy (ART) adherence leads to drug resistance and treatment failures. The options for second and third line ART regimens, particularly for pediatric patients, are very limited in low and middle-income countries. HIV-infected children are mostly passive drug-takers, thus caretakers play a very important role in assuring ART adherence. Pediatric ART adherence is still a challenging problem in Vietnam since non-adherence is the major risk factor for treatment failure. Our study explores and measures caretakers' barriers in order to improve pediatric ART adherence in future.

METHODS

Exploring caretakers' barriers was conducted through a qualitative study with Focus Group Discussion (FGD) on two topics: 1. Current society - family support and difficulties in taking care children under ART; 2. Stigma experience. Based on the finding from the qualitative study a quantitative study measuring caretakers' barriers was conducted through a designed questionnaire. Study methods strictly followed the consolidated criteria with 32-item checklist for interviews and focus groups.

RESULTS

In total eight FGDs with 53 participants were conducted. Common caretakers' barriers to children's ART adherence, were financial burden, lack of ART KP (Knowledge-Practice), stigma, depression, shifting caretaker, drug taste and side effects, lack of family support, fixed health check-up schedule and HIV non-disclosure. In the questionnaire study a total of 209 caretakers participated. The most commonly reported caretakers' barriers were: financial burden (144; 69%), KP burden (143; 68%), depression (85; 41%) and stigma (30; 14.8%). Some caretakers' characteristics that significantly associated with reported barriers (p<0.05). Rural caretakers reported significantly more financial burden (OR=2.26) and stigma (OR=3.53) than urban. Caretakers with under high school level education reported significantly more financial burdens (OR=2.08) and stigma (OR=4.15) compared to caretakers with high school education or over.

CONCLUSION

Financial burden, KP burden, depression and stigma were common reported caretakers' barriers to pediatric ART adherence. Family residence, caretaker's education level and job were considered as the key factors determining caretakers' barriers related to financial burden and stigma. These findings may be important for policy makers and researchers in order to develop effective interventions regarding to caretakers' burdens and associated factors. Furthermore, a tool for nurses in monitoring caretakers' barriers to pediatric ART adherence was developed first with FDG, and then interview questionnaire. This tool could be applied and modified easily in any pediatric ART clinic settings in accordance to economic, social and cultural circumstances.

In oesophageal squamous cells, nitric oxide causes S-nitrosylation of Akt and blocks SOX2 (sex determining region Y-box 2) expression

OBJECTIVE

Barrett's metaplasia might develop if GORD causes oesophageal squamous cells to convert into columnar cells. Acid and bile exposures upregulate columnar differentiation genes like CDX2 in oesophageal squamous cells, but it is not known if such exposures downregulate squamous differentiation genes like SOX2. In addition to acid and bile, patients with GORD also have high oesophageal concentrations of nitric oxide (NO). This study aims to determine how acid, bile salts and NO affect genes that influence oesophageal cell phenotype.

DESIGN

Oesophageal squamous cells from patients with Barrett's oesophagus were exposed to acidic bile salts or NOC-9 (an NO donor). SOX2, p63 (squamous transcription factor) and CDX2 mRNAs were measured by quantitative RT-PCR. SOX2 and its regulatory Akt pathway proteins were evaluated by western blotting. S-nitrosylation by NO was blocked by dithiothreitol. Immunohistochemistry for SOX2 was performed on the oesophagus of rats with surgically induced GORD which were fed diets with and without nitrite supplementation.

RESULTS

In oesophageal squamous cells, NO profoundly decreased SOX2 protein and caused a significantly greater decrease in SOX2 mRNA than did acidic bile salts. NO also decreased p63 and increased CDX2 expression. NO caused S-nitrosylation of Akt, blocking its phosphorylation. Akt pathway inhibition by LY294002 or Akt siRNA reduced SOX2 mRNA. Rats fed with nitrite-supplemented diets exhibited weaker SOX2 oesophageal staining than rats fed with normal diets.

CONCLUSIONS

In oesophageal squamous cells, NO blocks SOX2 expression through Akt S-nitrosylation. NO also increases CDX2 and decreases p63 expression. By triggering molecular events preventing squamous differentiation while promoting intestinal differentiation, NO might contribute to Barrett's pathogenesis.

Association of Acute Gastroesophageal Reflux Disease With Esophageal Histologic Changes

IMPORTANCE

The histologic changes associated with acute gastroesophageal reflux disease (GERD) have not been studied prospectively in humans. Recent studies in animals have challenged the traditional notion that reflux esophagitis develops when esophageal surface epithelial cells are exposed to lethal chemical injury from refluxed acid.

OBJECTIVE

To evaluate histologic features of esophageal inflammation in acute GERD to study its pathogenesis.

DESIGN, SETTING, AND PARTICIPANTS

Patients from the Dallas Veterans Affairs Medical Center who had reflux esophagitis successfully treated with proton pump inhibitors (PPIs) began 24-hour esophageal pH and impedance monitoring and esophagoscopy (including confocal laser endomicroscopy [CLE]) with biopsies from noneroded areas of distal esophagus at baseline (taking PPIs) and at 1 week and 2 weeks after stopping the PPI medication. Enrollment began May 2013 and follow-up ended July 2015.

INTERVENTIONS

PPIs stopped for 2 weeks.

MAIN OUTCOMES AND MEASURES

Twelve patients (men, 11; mean age, 57.6 year [SD, 13.1]) completed the study. Primary outcome was change in esophageal inflammation 2 weeks after stopping the PPI medication, determined by comparing lymphocyte, eosinophil, and neutrophil infiltrates (each scored on a 0-3 scale) in esophageal biopsies. Also evaluated were changes in epithelial basal cell and papillary hyperplasia, surface erosions, intercellular space width, endoscopic grade of esophagitis, esophageal acid exposure, and mucosal impedance (an index of mucosal integrity).

RESULTS

At 1 week and 2 weeks after discontinuation of PPIs, biopsies showed significant increases in intraepithelial lymphocytes, which were predominantly T cells (median [range]: 0 (0-2) at baseline vs 1 (1-2) at both 1 week [P = .005] and 2 weeks [P = .002]); neutrophils and eosinophils were few or absent. Biopsies also showed widening of intercellular spaces (confirmed by CLE), and basal cell and papillary hyperplasia developed without surface erosions. Two weeks after stopping the PPI medication, esophageal acid exposure increased (median: 1.2% at baseline to 17.8% at 2 weeks; Δ, 16.2% [95% CI, 4.4%-26.5%], P = .005), mucosal impedance decreased (mean: 2671.3 Ω at baseline to 1508.4 Ω at 2 weeks; Δ, 1162.9 Ω [95% CI, 629.9-1695.9], P = .001), and all patients had evidence of esophagitis.

CONCLUSIONS AND RELEVANCE

In this preliminary study of 12 patients with severe reflux esophagitis successfully treated with PPI therapy, stopping PPI medication was associated with T lymphocyte-predominant esophageal inflammation and basal cell and papillary hyperplasia without loss of surface cells. If replicated, these findings suggest that the pathogenesis of reflux esophagitis may be cytokine-mediated rather than the result of chemical injury.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01733810.

Ketamine treatment involves medial prefrontal cortex serotonin to induce a rapid antidepressant-like activity in BALB/cJ mice

Unlike classic serotonergic antidepressant drugs, ketamine, an NMDA receptor antagonist, exhibits a rapid and persistent antidepressant (AD) activity, at sub-anaesthetic doses in treatment-resistant depressed patients and in preclinical studies in rodents. The mechanisms mediating this activity are unclear. Here, we assessed the role of the brain serotonergic system in the AD-like activity of an acute sub-anaesthetic ketamine dose. We compared ketamine and fluoxetine responses in several behavioral tests currently used to predict anxiolytic/antidepressant-like potential in rodents. We also measured their effects on extracellular serotonin levels [5-HT]_ext in the medial prefrontal cortex (mPFCx) and brainstem dorsal raphe nucleus (DRN), a serotonergic nucleus involved in emotional behavior, and on 5-HT cell firing in the DRN in highly anxious BALB/cJ mice. Ketamine (10 mg/kg i.p.) had no anxiolytic-like effect, but displayed a long lasting AD-like activity, i.e., 24 h post-administration, compared to fluoxetine (18 mg/kg i.p.). Ketamine (144%) and fluoxetine (171%) increased mPFCx [5-HT]_ext compared to vehicle. Ketamine-induced AD-like effect was abolished by a tryptophan hydroxylase inhibitor, para-chlorophenylalanine (PCPA) pointing out the role of the 5-HT system in its behavioral activity. Interestingly, increase in cortical [5-HT]_ext following intra-mPFCx ketamine bilateral injection (0.25 μg/side) was correlated with its AD-like activity as measured on swimming duration in the FST in the same mice. Furthermore, pre-treatment with a selective AMPA receptor antagonist (intra-DRN NBQX) blunted the effects of intra-mPFCx ketamine on both the swimming duration in the FST and mPFCx [5-HT]_ext suggesting that the AD-like activity of ketamine required activation of DRN AMPA receptors and recruited the prefrontal cortex/brainstem DRN neural circuit in BALB/c mice. These results confirm a key role of cortical 5-HT release in ketamine's AD-like activity following the blockade of glutamatergic NMDA receptors. Tight interactions between mPFCx glutamatergic and serotonergic systems may explain the differences in this activity between ketamine and fluoxetine in vivo. This article is part of the Special Issue entitled 'Ionotropic glutamate receptors'.

Mitochondrial STAT3 contributes to transformation of Barrett's epithelial cells that express oncogenic Ras in a p53-independent fashion

Metaplastic epithelial cells of Barrett's esophagus transformed by the combination of p53-knockdown and oncogenic Ras expression are known to activate signal transducer and activator of transcription 3 (STAT3). When phosphorylated at tyrosine 705 (Tyr705), STAT3 functions as a nuclear transcription factor that can contribute to oncogenesis. STAT3 phosphorylated at serine 727 (Ser727) localizes in mitochondria, but little is known about mitochondrial STAT3's contribution to carcinogenesis in Barrett's esophagus, which is the focus of this study. We introduced a constitutively active variant of human STAT3 (STAT3CA) into the following: 1) non-neoplastic Barrett's (BAR-T) cells; 2) BAR-T cells with p53 knockdown; and 3) BAR-T cells that express oncogenic H-Ras(G12V). STAT3CA transformed only the H-Ras(G12V)-expressing BAR-T cells (evidenced by loss of contact inhibition, formation of colonies in soft agar, and generation of tumors in immunodeficient mice), and did so in a p53-independent fashion. The transformed cells had elevated levels of both mitochondrial (Ser727) and nuclear (Tyr705) phospho-STAT3. Introduction of a STAT3CA construct with a mutated tyrosine phosphorylation site into H-Ras(G12V)-expressing Barrett's cells resulted in high levels of mitochondrial phospho-STAT3 (Ser727) with little or no nuclear phospho-STAT3 (Tyr705), and the cells still formed tumors in immunodeficient mice. Thus tyrosine phosphorylation of STAT3 is not required for tumor formation in Ras-expressing Barrett's cells. We conclude that mitochondrial STAT3 (Ser727) can contribute to oncogenesis in Barrett's cells that express oncogenic Ras. These findings suggest that agents targeting STAT3 might be useful for chemoprevention in patients with Barrett's esophagus.

Feasibility of Subcutaneous Gentamicin and Pressurized Irrigation as Adjuvant Strategies to Reduce Surgical Site Infection in Colorectal Surgery: Results of a Pilot Study

Surgical site infections (SSIs) remain a common and costly morbidity after colorectal surgery. This rate remains high even in the setting of strict adherence to Surgical Care Improvement Project Protocols. The aim of our pilot study was to determine the feasibility and safety of subcutaneous gentamicin injection or pressurized irrigation as adjuncts to reduce SSI. A total of 132 patients who underwent colorectal surgery at the VA North Texas Health Care System were prospectively assigned to a pressurized irrigation group (n = 44), a preincision gentamicin injection group (n = 48), or control (n = 40). The primary objective was to assess safety and feasibility of these strategies. Patient demographics were matched among groups. Univariate and multivariate analyses were performed to identify possible predictions of SSI in this cohort. The rate of SSI in the control group was 25 per cent, 13.5 per cent in the pressurized irrigation group, and 12.5 per cent in the gentamicin group ( P = 0.26). Combined, the intervention groups had a 13 per cent SSI versus 25 per cent control ( P = 0.09). Operative time was not increased by the interventions and no intraoperative complications specifically related to the interventions were noted. Postoperative complications were not different between groups. Both albumin and body mass index were associated with SSI. Body mass index was and independent predictor of SSI ( P = 0.006). In conclusion, this pilot study demonstrates the feasibility of the interventions described. There was no detrimental effect of either intervention. There was trend toward a reduction in SSI in the intervention group, which warrants further investigation.

Feasibility of subcutaneous gentamicin and pressurized irrigation as adjuvant strategies to reduce surgical site infection in colorectal surgery: results of a pilot study

Surgical site infections (SSIs) remain a common and costly morbidity after colorectal surgery. This rate remains high even in the setting of strict adherence to Surgical Care Improvement Project Protocols. The aim of our pilot study was to determine the feasibility and safety of subcutaneous gentamicin injection or pressurized irrigation as adjuncts to reduce SSI. A total of 132 patients who underwent colorectal surgery at the VA North Texas Health Care System were prospectively assigned to a pressurized irrigation group (n = 44), a preincision gentamicin injection group (n = 48), or control (n = 40). The primary objective was to assess safety and feasibility of these strategies. Patient demographics were matched among groups. Univariate and multivariate analyses were performed to identify possible predictions of SSI in this cohort. The rate of SSI in the control group was 25 per cent, 13.5 per cent in the pressurized irrigation group, and 12.5 per cent in the gentamicin group (P = 0.26). Combined, the intervention groups had a 13 per cent SSI versus 25 per cent control (P = 0.09). Operative time was not increased by the interventions and no intraoperative complications specifically related to the interventions were noted. Postoperative complications were not different between groups. Both albumin and body mass index were associated with SSI. Body mass index was and independent predictor of SSI (P = 0.006). In conclusion, this pilot study demonstrates the feasibility of the interventions described. There was no detrimental effect of either intervention. There was trend toward a reduction in SSI in the intervention group, which warrants further investigation.

2014 SSAT State-of-the-Art Conference: advances in diagnosis and management of gastroesophageal reflux disease

Gastroesophageal reflux disease affects at least 10 % of people in Western societies and produces troublesome symptoms and impairs patients' quality of life. The effective management of GERD is imperative as the diagnosis places a significant cost burden on the United States healthcare system with annual direct cost estimates exceeding 9 billion dollars annually. While effective for many patients, 30-40 % of patients receiving medical therapy with proton pump inhibitors experience troublesome breakthrough symptoms, and recent evidence suggests that this therapy subjects patients to increased risk of complications. Given the high cost of PPI therapy, patients are showing a decrease in willingness to continue with a therapy that provides incomplete relief; however, due to inconsistent outcomes and concern for procedure-related side effects following surgery, only 1 % of the GERD population undergoes anti-reflux surgery annually. The discrepancy between the number of patients who experience suboptimal medical treatment and the number considered for anti-reflux surgery indicates a large therapeutic gap in the management of GERD. The objective of the SSAT State-of-the-Art Conference was to examine technologic advances in the diagnosis and treatment of GERD and to evaluate the ways in which we assess the outcomes of these therapies to provide optimal patient care.

In Barrett's esophagus patients and Barrett's cell lines, ursodeoxycholic acid increases antioxidant expression and prevents DNA damage by bile acids

Hydrophobic bile acids like deoxycholic acid (DCA), which cause oxidative DNA damage and activate NF-κB in Barrett's metaplasia, might contribute to carcinogenesis in Barrett's esophagus. We have explored mechanisms whereby ursodeoxycholic acid (UDCA, a hydrophilic bile acid) protects against DCA-induced injury in vivo in patients and in vitro using nonneoplastic, telomerase-immortalized Barrett's cell lines. We took biopsies of Barrett's esophagus from 21 patients before and after esophageal perfusion with DCA (250 μM) at baseline and after 8 wk of oral UDCA treatment. DNA damage was assessed by phospho-H2AX expression, neutral CometAssay, and phospho-H2AX nuclear foci formation. Quantitative PCR was performed for antioxidants including catalase and GPX1. Nrf2, catalase, and GPX1 were knocked down with siRNAs. Reporter assays were performed using a plasmid construct containing antioxidant responsive element. In patients, baseline esophageal perfusion with DCA significantly increased phospho-H2AX and phospho-p65 in Barrett's metaplasia. Oral UDCA increased GPX1 and catalase levels in Barrett's metaplasia and prevented DCA perfusion from inducing DNA damage and NF-κB activation. In cells, DCA-induced DNA damage and NF-κB activation was prevented by 24-h pretreatment with UDCA, but not by mixing UDCA with DCA. UDCA activated Nrf2 signaling to increase GPX1 and catalase expression, and protective effects of UDCA pretreatment were blocked by siRNA knockdown of these antioxidants. UDCA increases expression of antioxidants that prevent toxic bile acids from causing DNA damage and NF-κB activation in Barrett's metaplasia. Elucidation of this molecular pathway for UDCA protection provides rationale for clinical trials on UDCA for chemoprevention in Barrett's esophagus.

In oesophageal squamous cells exposed to acidic bile salt medium, omeprazole inhibits IL-8 expression through effects on nuclear factor-κB and activator protein-1

OBJECTIVE

Oesophagitis might result from the effects of chemokines produced by oesophageal cells in response to gastro-oesophageal reflux, and not solely from the direct, caustic effects of refluxed gastric juice. Proton pump inhibitors (PPI) can block chemokine production through mechanisms independent of their antisecretory effects. We studied omeprazole effects on chemokine production by oesophageal epithelial cells exposed to acidic bile salts.

DESIGN

Human primary and telomerase-immortalised oesophageal squamous cells were exposed to acidic bile salt medium with or without omeprazole pretreatment. Interleukin (IL)-8 expression was determined by RT-PCR and ELISA. IL-8 promoter activity was measured by luciferase reporter assay. Binding of NF-κB and AP-1 subunits to the IL-8 promoter was assessed by chromatin immunoprecipitation (ChIP) assay. Immune cell migration induced by conditioned medium was determined by a double-chamber migration assay system.

RESULTS

Acidic bile salt medium caused oesophageal epithelial cells to express IL-8 mRNA and protein by activating the IL-8 promoter through NF-κB and AP-1 binding. Omeprazole inhibited that acidic bile salt-stimulated IL-8 expression by blocking the nuclear translocation of p65 (an NF-κB subunit), and by blocking the binding of p65, c-jun and c-fos (AP-1 subunits) to the IL-8 promoter. Omeprazole also blocked the ability of conditioned medium from cells exposed to acidic bile salts to induce immune cell migration.

CONCLUSIONS

In oesophageal squamous epithelial cells, omeprazole inhibits IL-8 expression through effects on NF-κB and AP-1 that are entirely independent of effects on gastric acid secretion. These previously unrecognised PPI effects might contribute to the healing of reflux oesophagitis.

Autocrine VEGF signaling promotes proliferation of neoplastic Barrett's epithelial cells through a PLC-dependent pathway

BACKGROUND & AIMS

Tumor cells express vascular endothelial growth factor (VEGF), which induces angiogenesis. VEGF also activates VEGF receptors (VEGFRs) on or within tumor cells to promote their proliferation in an autocrine fashion. We studied the mechanisms of autocrine VEGF signaling in Barrett's esophagus cells.

METHODS

Using Barrett's epithelial cell lines, we measured VEGF and VEGFR messenger RNA and protein, and studied the effects of VEGF signaling on cell proliferation and VEGF secretion. We studied the effects of inhibiting factors in this pathway on levels of phosphorylated phospholipase Cγ1 (PLCG1), protein kinase C, and extracellular signal-regulated kinases (ERK)1/2. We performed immunohistochemical analysis of phosphorylated VEGFR2 on esophageal adenocarcinoma tissues. We studied effects of sunitinib, a VEGFR2 inhibitor, on proliferation of neoplastic cells and growth of xenograft tumors in mice.

RESULTS

Neoplastic and non-neoplastic Barrett's cells expressed VEGF and VEGFR2 messenger RNA and protein, with higher levels in neoplastic cells. Incubation with recombinant human VEGF significantly increased secretion of VEGF protein and cell number; knockdown of PLCG1 markedly reduced the recombinant human VEGF-stimulated increase in levels of phosphorylated PLCG1 and phosphorylated ERK1/2 in neoplastic cells. Esophageal adenocarcinoma tissues showed immunostaining for phosphorylated VEGFR2. Sunitinib inhibited VEGF signaling in neoplastic cells and reduced weight and volume of xenograft tumors in mice.

CONCLUSIONS

Neoplastic and non-neoplastic Barrett's epithelial cells have autocrine VEGF signaling. In neoplastic Barrett's cells, VEGF activation of VEGFR2 initiates a PLCG1-protein kinase C-ERK pathway that promotes proliferation and is self-sustaining (by causing more VEGF production). Strategies to reduce autocrine VEGF signaling (eg, with sunitinib) might be used to prevent or treat cancer in patients with Barrett's esophagus.

Clostridium difficile enteritis: A report of two cases and systematic literature review

Clostridium difficile (C. difficile) is the most common cause of healthcare associated infectious diarrhea. In the last decade, the incidence of C. difficile infection has increased dramatically. The virulence of C. difficile has also increased recently with toxigenic strains developing. C. difficile is generally a disease of the colon and presents with abdominal pain and diarrhea due to colitis. However, C. difficile enteritis has been reported rarely. The initial reports suggested mortality rates as high as 66%. The incidence of C. difficile enteritis appears to be increasing in parallel to the increase in colonic infections. We present two cases of patients who had otherwise uneventful abdominal surgery but subsequently developed C. difficile enteritis. Our literature review demonstrates 81 prior cases of C. difficile enteritis described in case reports. The mortality of the disease remains high at approximately 25%. Early recognition and intervention may reduce the high mortality associated with this disease process.

Obesity and preference-weighted quality of life of ethnically diverse middle school children: the HEALTHY study

To date, studies examining the relation between body mass index percentile (BMI%) categories and health-related quality of life (QOL) measurements have not reported preference-weighted scores among ethnically diverse children. We report the associations between BMI% categories and preference-weighted scores among a large cohort of ethnically diverse sixth grade children who participated in the HEALTHY school-based type 2 diabetes risk factor prevention study. Health Utility Index 2 (HUI2) and Health Utility Index 3 (HUI3) and the feeling thermometer (FT) were the preference-weighted QOL instruments used to measure student's preference scores. Of 6358 consented students, 4979 (78.3%) had complete QOL, height, weight, and covariate data. Mean (SD) preference scores were 0.846 (0.160), 0.796 (0.237), and 0.806 (0.161) for the HUI2, HUI3, and FT, respectively. After adjusting for age, sex, blood glucose and insulin, Tanner stage, race/ethnicity, family history of diabetes, and educational attainment, children with severe obesity (>99%) had significantly lower preference scores compared to normal weight on all three instruments (HUI2 P = 0.013; HUI3 P = 0.025; and FT P < 0.001). Obese and severe obese categories were significantly associated with lower HUI2 functional ratings in the mobility domain and with lower HUI3 functional ratings in the speech domain.

Omeprazole blocks STAT6 binding to the eotaxin-3 promoter in eosinophilic esophagitis cells

BACKGROUND

Patients who have esophageal eosinophilia without gastroesophageal reflux disease (GERD) nevertheless can respond to proton pump inhibitors (PPIs), which can have anti-inflammatory actions independent of effects on gastric acid secretion. In esophageal cell cultures, omeprazole has been reported to inhibit Th2 cytokine-stimulated expression of eotaxin-3, an eosinophil chemoattractant contributing to esophageal eosinophilia in eosinophilic esophagitis (EoE). The objective of this study was to elucidate molecular mechanisms underlying PPI inhibition of IL-4-stimulated eotaxin-3 production by esophageal cells.

METHODS/FINDINGS

Telomerase-immortalized and primary cultures of esophageal squamous cells from EoE patients were treated with IL-4 in the presence or absence of acid-activated omeprazole or lansoprazole. We measured eotaxin-3 protein secretion by ELISA, mRNA expression by PCR, STAT6 phosphorylation and nuclear translocation by Western blotting, eotaxin-3 promoter activation by an exogenous reporter construct, and STAT6, RNA polymerase II, and trimethylated H3K4 binding to the endogenous eotaxin-3 promoter by ChIP assay. Omeprazole in concentrations ≥5 µM significantly decreased IL-4-stimulated eotaxin-3 protein secretion and mRNA expression. Lansoprazole also blocked eotaxin-3 protein secretion. Omeprazole had no effect on eotaxin-3 mRNA stability or on STAT6 phosphorylation and STAT6 nuclear translocation. Rather, omeprazole blocked binding of IL-4-stimulated STAT6, RNA polymerase II, and trimethylated H3K4 to the eotaxin-3 promoter.

CONCLUSIONS/SIGNIFICANCE

PPIs, in concentrations achieved in blood with conventional dosing, significantly inhibit IL-4-stimulated eotaxin-3 expression in EoE esophageal cells and block STAT6 binding to the promoter. These findings elucidate molecular mechanisms whereby patients with Th2 cytokine-driven esophageal eosinophilia can respond to PPIs, independent of effects on gastric acid secretion.

Minimally invasive esophagectomy provides equivalent oncologic outcomes to open esophagectomy for locally advanced (stage II or III) esophageal carcinoma

BACKGROUND

Minimally invasive esophagectomy (MIE) has been performed at specialized centers for 15 years, but few studies have looked at outcomes in patients with locally advanced cancers, and few studies have provided long-term survival comparison with Ivor Lewis esophagectomy (ILE) to determine oncologic benefit or equivalence of MIE.

HYPOTHESIS

Minimally invasive esophagectomy for locally advanced esophageal carcinoma has similar oncologic outcomes to traditional open ILE with less associated short-term morbidity and mortality.

DESIGN

Retrospective comparison of patients with stage II or III esophageal carcinoma undergoing 3-field MIE compared with open ILE.

SETTING

University medical center.

PATIENTS

From 1995 to 2009, 64 patients who underwent MIE (33 patients) or ILE (31 patients) with clinical stage II or III esophageal cancer were compared.

MAIN OUTCOME MEASURES

Primary end points included operative performance, morbidity, mortality, hospital stay, and survival.

RESULTS

No differences were noted between the groups in demographics, neoadjuvant therapy use (P = .22), resection completeness (R0:R1) (P = .57), length of stay (P = .59), intensive care unit stay (P = .36), anastomotic leak (P = 1.0), pulmonary morbidity (P = .26), and mortality (P = 1.0). Median follow-up was 19 months for MIE and 17 months for ILE. Survival at 2 years was 55% for MIE (18 of 33 patients) and 32% for ILE (10 of 31 patients) while disease-free survival was 55% for MIE (18) and 26% for ILE (8).

CONCLUSIONS

Our survival analysis shows divergent curves that favor MIE but have not yet reached statistical significance. The oncologic outcomes of MIE are comparable to that of ILE 2 years after resection.

Decreased conduit perfusion measured by spectroscopy is associated with anastomotic complications

BACKGROUND

Gastric conduit ischemia during esophagectomy likely contributes to high anastomotic complication rates, yet we lack a reliable method to assess gastric conduit perfusion. We hypothesize that optical fiber spectroscopy (OFS) can reliably assess conduit perfusion and that the degree of intraoperative gastric ischemia is associated with subsequent anastomotic complications.

METHODS

During esophagectomy, OFS was used to measure oxygen saturation (SaO(2)) and blood volume fraction (BVF) in the distal gastric conduit at baseline and after gastric devascularization, conduit formation, and transposition. The SaO(2) and BVF readings were correlated to clinical outcomes.

RESULTS

The OFS measurements were obtained in 23 patients during esophagectomy, four of whom previously underwent gastric ischemic conditioning. Eight patients developed anastomotic complications. Compared with baseline, conduit creation produced a 29.4% reduction in SaO(2) (p < 0.01), while BVF increased by 28% (p = 0.06). Patients with subsequent anastomotic complications demonstrated a 52.5% decrease in SaO(2) upon conduit creation compared with 15.1% in patients without complications (p = 0.01). Patients who underwent ischemic conditioning did not develop significant changes in SaO(2) (p = 0.72) or BVF (p = 0.5) upon gastric conduit creation.

CONCLUSIONS

Intraoperative OFS demonstrates significant alterations in gastric conduit oxygenation during esophageal replacement, which may be tempered by gastric ischemic conditioning. The degree of intraoperative gastric ischemia resulting from gastric conduit creation is associated with the development of anastomotic complications, suggesting that OFS is useful for assessing changes in conduit oxygenation during esophagectomy. Further studies are needed to refine this technology and investigate the clinical utility of intraoperative conduit oxygenation data.

Bile duct injury after laparoscopic cholecystectomy in hospitals with and without surgical residency programs: is there a difference?

BACKGROUND

Laparoscopic cholecystectomy (LC) is a common surgical procedure performed by surgical residents under the supervision of attending surgeons. There is a perception that performance of LC in a facility with a surgical training program provides a safer environment due to the presence of an assistant surgeon. The aim of this study was to compare the rate of bile duct injury, conversion, and mortality between hospitals with surgical residency programs (Group I) and hospitals without surgical training programs (Group II).

METHODS

ICD-9 diagnosis and procedure codes were used to extract and analyze LC procedures from the Florida State Inpatient Database from 1997 through 2006. Bile duct injury was indicated by the code for a biliary reconstruction procedure performed during the same admission. Hospitals with surgical training programs were identified by participation in the Electronic Residency Application Service (ERAS) and verified by contact with each hospital.

RESULTS

Between 1997 and 2006 there were 234,220 LCs identified, with 17,596 performed by Group I and 213,906 performed by Group II. Rate of BDI for Group I and Group II was 0.24 and 0.26%, respectively (p=0.71). There was a significant difference noted in emergency and urgent admission rates (65.6% for Group I vs. 77.2% for Group II; p<0.001) and conversion (9.1% for Group I vs. 7.5% for Group II; p<0.001). Mortality was 0.44% for Group I and 0.55% for Group II (p=0.060).

CONCLUSION

Our data suggest that bile duct injury rates are not influenced by the presence of a surgical residency program. In addition, there was no significant difference in mortality for LC at hospitals with surgical residencies when compared to hospitals without surgical residencies. A significant difference was noted in admission type and conversion rate but this did not appear to affect the rate of bile duct injury.

Optical fiber probe spectroscopy for laparoscopic monitoring of tissue oxygenation during esophagectomies

Anastomotic complication is a major morbidity associated with esophagectomy. Gastric ischemia after conduit creation contributes to anastomotic complications, but a reliable method to assess oxygenation in the gastric conduit is lacking. We hypothesize that fiber optic spectroscopy can reliably assess conduit oxygenation, and that intraoperative gastric ischemia will correlate with the development of anastomotic complications. A simple optical fiber probe spectrometer is designed for nondestructive laparoscopic measurement of blood content and hemoglobin oxygen saturation in the stomach tissue microvasculature during human esophagectomies. In 22 patients, the probe measured the light transport in stomach tissue between two fibers spaced 3-mm apart (500- to 650-nm wavelength range). The stomach tissue site of measurement becomes the site of a gastroesophageal anastamosis following excision of the cancerous esophagus and surgical ligation of two of the three gastric arteries that provide blood perfusion to the anastamosis. Measurements are made at each of five steps throughout the surgery. The resting baseline saturation is 0.51±0.15 and decreases to 0.35±0.20 with ligation. Seven patients develop anastomotic complications, and a decreased saturation at either of the last two steps (completion of conduit and completion of anastamosis) is predictive of complication with a sensitivity of 0.71 when the specificity equaled 0.71.

Comparison of perioperative outcomes after combined thoracoscopic-laparoscopic esophagectomy and open Ivor-Lewis esophagectomy

BACKGROUND

Thoracoscopic-laparoscopic esophagectomy (TLE) has gained popularity in specialized centers. This study compares the perioperative outcomes of TLE and Ivor-Lewis esophagectomy (ILE).

METHODS

Forty-four consecutive TLEs were compared with 46 historical ILEs. Outcomes included surgical time and blood loss, hospital length of stay, 30-day mortality rate, and complications.

RESULTS

TLE took longer to perform (543 vs 437 min; P < .01) than ILE, but produced less blood loss (407 vs 780 mL; P < .01). The median length of stay and 30-day mortality did not differ between groups. Cardiovascular (41% for TLE vs 30% for ILE; P = .19) and pulmonary complications (31% TLE vs 30% ILE; P = 1.0) occurred frequently in both groups, but TLE patients had fewer wound complications (4% TLE vs 17% ILE; P = .05).

CONCLUSIONS

Despite longer surgical times, TLE produced decreased intraoperative blood loss and wound complications. These findings suggest that with further technical refinement TLE may ameliorate the morbidity seen with ILE.

Laparoscopic adrenalectomy for large unilateral pheochromocytoma: experience in a large academic medical center

BACKGROUND

Laparoscopic adrenalectomy is the treatment of choice for most adrenal lesions. Concerns have persisted about its application to large pheochromocytomas due to reports of hemodynamic instability, difficult dissection, and tumor spillage.

METHODS

Thirty patients underwent laparoscopic adrenalectomy for unilateral pheochromocytoma between 1998 and 2006. Outcome measures including operative time, blood loss, intraoperative hemodynamic instability, conversion rate, complications, and disease recurrence were analyzed based on tumor size.

RESULTS

Twenty-two patients had small tumors and eight had large lesions. These groups did not differ in terms of operative time, blood loss, conversion rate, length of stay or complication rate. Intraoperative hemodynamic instability occurred in 56.7% of cases, but was not different between groups. There were no recurrences in either group.

CONCLUSIONS

Laparoscopic adrenalectomy is a safe and effective treatment for large pheochromocytomas. Intraoperative hemodynamic instability remains a frequent occurrence regardless of tumor size. There were no cases of disease recurrence or iatrogenic pheochromocytosis.

The crossmodal facilitation effect is disrupted in alcoholism: a study with emotional stimuli

AIMS

Chronic alcoholism is classically associated with major deficits in the visual and auditory processing of emotions. However, the crossmodal (auditory-visual) processing of emotional stimuli, which occurs most frequently in everyday life, has not yet been explored. The aim of this study was to explore crossmodal processing in alcoholism, and specifically the auditory-visual facilitation effect.

METHODS

Twenty patients suffering from alcoholism, and 20 matched healthy controls had to detect the emotion (anger or happiness) displayed by auditory, visual or auditory-visual stimuli. The stimuli were designed to elicit a facilitation effect (namely, faster reaction times (RTs) for crossmodal condition than for unimodal ones). RTs and performance were recorded.

RESULTS

While the control subjects elicited a significant facilitation effect, alcoholic individuals did not present this effect, as no significant differences between RTs according to the modality were shown. This lack of facilitation effect is the marker of an impaired auditory-visual processing.

CONCLUSIONS

Crossmodal processing of complex social stimuli (such as faces and voices) is crucial for interpersonal relations. This first evidence for a crossmodal deficit in alcoholism contribute in explaining the contrast observed between experimental results describing, up to now, mild impairments in emotional facial expression (EFE) recognition in alcoholic subjects (e.g. Oscar-Berman et al.,1990), and the many clinical observations suggesting massive problems.

Évaluation du trouble de la personnalité sadique en relation avec la psychopathie auprès de patients internés en hôpital psychiatrique sécuritaire

The population was composed of 76 male patients (mean age=36.14). All of them having committed a violent offence indexed in their institutional file: (1) sexual offences on children; (2) rapes of adult women; (3) homicide offence; and (4) assaults and batteries. TPS was defined by the following 8 diagnostic criteria as described in DSM III-R: 1) has used physical cruelty or violence for the purpose of establishing dominance in a relationship; 2) humiliates or demeans people in the presence of others; 3) has treated or disciplined someone under his or her control unusually harshly; 4) is amused by, or takes pleasure in, the psychological or physical suffering of others; 5) has lied for the purpose of harming or inflicting pain on others 6) gets other people to do what he or she wants by frightening them 7) restricts the autonomy of people with whom he or she has a close relationship; 8) is fascinated by violence, weapons, martial arts, injury, or torture. These criteria were assessed from (a) clinical and institutional files and (b) clinical collateral informations. TPS assessment was conducted by two -trainees in clinical psychology (kappa=0.87; n=20). The assessment of psychopathy was conducted according to the guidelines of the Hare psychopathy checklist manual (PCL-R, 1991, 2003): coding of clinical and institutional files and semi-structural clinical interviews. The PCL-R is mainly composed by 2 factors: factor 1 "Emotional detachment" describing the core psychological component of psychopathy, and factor 2 "Chronically antisocial factor" reflecting behavioral instability and antisocial life style. The total cut-off score for the inclusion of the diagnosis was 25. The prevalence of TPS in the population was 25% (n=19) and is congruent with the large range described in the literature (0.5 to 33%). The most frequent criteria were 6 (gets other people to do what he or she wants by frightening them), 1 (has used using physical cruelty or violence for the purpose of establishing dominance in a relationship) and 3 (has treated or disciplined someone under his or her control unusually harshly). The most sensible criteria were: 7 (restricts the autonomy of people with whom he or she has a close relationship), 8 (major interest for violence) and 4 (pleasure in the psychological or physical suffering of others). The most specific criteria were: 3 (has treated or disciplined someone under his or her control unusually harshly), 6 (gets other people to do what her or she wants by frightening them), 4 (takes pleasure in the psychological or physical suffering of others) and 1 (has used physical -cruelty or violence for the purpose of establishing dominance in a relationship). As concerns psychopathy, the mean of factor 1, factor 2 and the PCL-R total scores were 7.40, 9.08 and 18.67. Thus, 38% of patients were considered as "low psychopaths", 36% were considered as "moderate psychopaths" and 26% were considered as "high psychopaths". In spite of few significant positive correlations between some TPS and PCL-R criteria, TPS diagnosis was not significantly correlated with factors 1, factor 2, nor with total score of the PCL-R. The mean psychopathy total score did not differ between sadistic and non-sadistic patients. Moreover, a two ways ANOVA comparing PCL-R factors 1 and 2 did not reveal any differences between sadism and non-sadism. Again, these comparisons did not support hypothesis of a strong association between TPS and psychopathy.

Fascioliasis in Vietnam

A confirmed diagnosis of human fascioliasis was rare in Vietnam until 1978 when two cases were reported in humans. Since 1997, we have confirmed 500 cases of human fascioliasis. The majority of cases come from the central provinces of Vietnam: Da Nang, Quang Ngai, Binh Dinh, Phu Yen and Khanh Hoa. Patients were treated in hospitals in Ho Chi Minh City. All had high peripheral blood eosinophilic counts (16-70%) and positive serology with Fasciola gigantica antigen with positive titers of 1/1,600 to 1/12,800. We are unsure whether this represents an endemic pattern of disease or whether improved specific laboratory tools now facilitate better diagnosis. It is also possible that with changes in environmental factors and in the number and breeds of herbivorous domestic animals, Fasciola is increasing in frequency and easily contaminates the food.

A large arteriovenous malformation of the external ear in an adult: report of a case and approach to management

OBJECTIVES/HYPOTHESIS

Arteriovenous malformations involving the external ear are relatively uncommon in adults. Arteriovenous malformations in the head and neck can poses difficult therapeutic challenges.

STUDY DESIGN

Case report.

METHODS

We report a case of a large arteriovenous malformation in the external ear in a 41-year-old man.

RESULTS

Extensive enlargement of the previously latent and asymptomatic arteriovenous malformation was triggered by blunt trauma to the ear.

CONCLUSION

We discuss the definition, clinical findings, diagnostic approaches, and therapeutic management of arteriovenous malformations.

Monitoring tumor response during photodynamic therapy using near-infrared photon-migration spectroscopy

Benzoporphyrin-derivative (BPD)-monoacid-ring A photodynamic therapy (PDT) was performed on subcutaneous tumor implants in a rat ovarian cancer model. In order to assess PDT efficacy the tumor and normal tissue optical properties were measured noninvasively prior to and during PDT using frequency-domain photon migration (FDPM). FDPM data were used to quantify tissue absorption and reduced scattering properties (given by the parameters mu a and mu's, respectively) at four near-infrared (NIR) wavelengths (674, 811, 849 and 956 nm). Tissue physiologic properties, including the in vivo concentration of BPD, deoxy-hemoglobin (Hb), oxy-hemoglobin (HbO2), total hemoglobin (TotHb), water (H2O) and percent tissue hemoglobin oxygen saturation (%StO2), were calculated from optical property data. PDT efficacy was also determined from morphometric analysis of tumor necrosis in histologic specimens. All the measured tumor properties changed significantly during PDT. [Hb] increased by 9%, while [HbO2], [TotHb] and %StO2 decreased by 18, 7 and 12%, respectively. Using histologic data we show that long-term PDT efficacy is highly correlated to mean BPD concentration in tumor and PDT-induced acute changes in [HbO2], [TotHb] and %StO2 (correlation coefficients of 0.829, 0.817 and 0.953, respectively). Overall, our results indicate that NIR FDPM spectroscopy is able to quantify noninvasively and dynamically the PDT-induced physiological effects in vivo that are highly correlated with therapeutic efficacy.

Monitoring tumor response during photodynamic therapy using near-infrared photon-migration spectroscopy

Benzoporphyrin-derivative (BPD)-monoacid-ring A photodynamic therapy (PDT) was performed on subcutaneous tumor implants in a rat ovarian cancer model. In order to assess PDT efficacy the tumor and normal tissue optical properties were measured noninvasively prior to and during PDT using frequency-domain photon migration (FDPM). FDPM data were used to quantify tissue absorption and reduced scattering properties (given by the parameters mu a and mu's, respectively) at four near-infrared (NIR) wavelengths (674, 811, 849 and 956 nm). Tissue physiologic properties, including the in vivo concentration of BPD, deoxy-hemoglobin (Hb), oxy-hemoglobin (HbO2), total hemoglobin (TotHb), water (H2O) and percent tissue hemoglobin oxygen saturation (%StO2), were calculated from optical property data. PDT efficacy was also determined from morphometric analysis of tumor necrosis in histologic specimens. All the measured tumor properties changed significantly during PDT. [Hb] increased by 9%, while [HbO2], [TotHb] and %StO2 decreased by 18, 7 and 12%, respectively. Using histologic data we show that long-term PDT efficacy is highly correlated to mean BPD concentration in tumor and PDT-induced acute changes in [HbO2], [TotHb] and %StO2 (correlation coefficients of 0.829, 0.817 and 0.953, respectively). Overall, our results indicate that NIR FDPM spectroscopy is able to quantify noninvasively and dynamically the PDT-induced physiological effects in vivo that are highly correlated with therapeutic efficacy.

Cross-sectional study of sexual behaviour and knowledge about HIV among urban, rural, and minority residents in Viet Nam

OBJECTIVE

A cross-sectional survey was conducted in three districts of Quang Ninh province, Viet Nam, to find out what proportion of the people who lived there engaged in behaviour that put them at risk of becoming infected with HIV, and to measure their knowledge about HIV infection and AIDS.

METHODS

The survey was conducted in a rural district, Yen Hung; a mountainous district inhabited primarily by ethnic minority groups, Binh Lieu; and an urban district, Ha Long. Participants aged 15-45 years were randomly selected from the general population to be interviewed.

FINDINGS

A total of 630 people from 707 households were interviewed; 8% were not home despite repeated visits and 3% refused to participate. The prevalence of premarital intercourse ranged from 9% to 16% among married men and 4% to 7% among married women. Among single men the proportion who had ever had intercourse ranged from 6% to 16%. Fewer than 3% reported having ever had sex with a sex worker. The median number of extramarital sex partners was 1. Knowledge about HIV/AIDS was high in the urban and rural areas but low in the mountainous area. Being male and being 20-29 years old were associated with having multiple sex partners.

CONCLUSION

The low prevalence of individuals reporting that they had had intercourse with sex workers and partners other than their spouse may explain the low rates of HIV infection among the heterosexual population; these rates are in contrast to the high rates of HIV infection found among injecting drug users. The association between having extramarital partners and being a younger man suggests that the tendency to have more sexual partners may increase in the future. If this happens, the potential for HIV to be spread through heterosexual sex will increase.

Quantifying the absorption and reduced scattering coefficients of tissuelike turbid media over a broad spectral range with noncontact Fourier-transform hyperspectral imaging

Absorption (mu(a)) and reduced scattering (mu(s)') spectra of turbid media were quantified with a noncontact imaging approach based on a Fourier-transform interferometric imaging system (FTIIS). The FTIIS was used to collect hyperspectral images of the steady-state diffuse reflectance from turbid media. Spatially resolved reflectance data from Monte Carlo simulations were fitted to the recorded hyperspectral images to quantify mu(a) and mu(s)' spectra in the 550-850-nm region. A simple and effective calibration approach was introduced to account for the instrument response. With reflectance data that were close to and far from the source (0.5-6.5 mm), mu(a) and mu(s)' of homogeneous, semi-infinite turbid phantoms with optical property ranges comparable with those of tissues were determined with an accuracy of +/-7% and +/-3%, respectively. Prediction accuracy for mu(a) and mu(s)' degraded to +/-12% and +/-4%, respectively, when only reflectance data close to the source (0.5-2.5 mm) were used. Results indicate that reflectance data close to and far from the source are necessary for optimal quantification of mu(a) and mu(s)'. The spectral properties of mu(a) and mu(s)' values were used to determine the concentrations of absorbers and scatterers, respectively. Absorber and scatterer concentrations of two-chromophore turbid media were determined with an accuracy of +/-5% and +/-3%, respectively.

Quantifying the properties of two-layer turbid media with frequency-domain diffuse reflectance

Noncontact, frequency-domain measurements of diffusely reflected light are used to quantify optical properties of two-layer tissuelike turbid media. The irradiating source is a sinusoidal intensity-modulated plane wave, with modulation frequencies ranging from 10 to 1500 MHz. Frequency-dependent phase and amplitude of diffusely reflected photon density waves are simultaneously fitted to a diffusion-based two-layer model to quantify absorption (mu(a)) and reduced scattering (mu(s)') parameters of each layer as well as the upper-layer thickness (l). Study results indicate that the optical properties of two-layer media can be determined with a percent accuracy of the order of +/-9% and +/-5% for mu(a) and mu(s)', respectively. The accuracy of upper-layer thickness (l) estimation is as good as +/-6% when optical properties of upper and lower layers are known. Optical property and layer thickness prediction accuracy degrade significantly when more than three free parameters are extracted from data fits. Problems with convergence are encountered when all five free parameters (mu(a) and mu(s)' of upper and lower layers and thickness l) must be deduced.

Subjective and autonomic responses to emotion induction in psychopaths

It has been theorized that psychopaths have a fundamental deficit with respect to emotions (Cleckley, 1941). This study compares psychopaths with control subjects (Hare, 1991) in terms of their physiological and subjective responses to video clips depicting different emotions: joy, fear, anger, sadness, and disgust. Physiological measures assessed cardiovascular, respiratory, electrodermal, electromyographic responding, as well as skin temperature. Subjective measures assessed bodily sensations and subjective emotional appraisal. The principal physiological difference was a lower blood pressure among psychopaths before and during emotional stimulation. Thus, while psychopaths's autonomic base-line may be generally hyporeactive, they do not seem to have any emotion-specific physiological deficit. Globally, the results suggested no specific psychophysiological deficits among psychopaths in a context using daily emotions. Subjective measures also revealed that, compared to control subjects, psychopaths reported less intense bodily sensations during emotional stimulation. There was no difference between the two groups in terms of emotional appraisal.

Quantitative near-infrared spectroscopy of cervical dysplasia in vivo

The aims of this study were: (i) to quantify near-infrared optical properties of normal cervical tissues and high-grade squamous intra-epithelial lesions (H-SIL); (ii) to assess the feasibility of differentiating normal cervical tissues from H-SIL on the basis of these properties; and (iii) to determine how cervical tissue optical properties change following photodynamic therapy (PDT) of H-SIL in vivo. Using the frequency domain photon migration technique, non-invasive measurements of normal and dysplastic ecto-cervical tissue optical properties, i.e. absorption (mu(a)) and effective scattering coefficients, and physiological parameters, i.e. tissue water and haemoglobin concentration, percentage oxygen saturation (%SO(2)), were performed on 10 patients scheduled for PDT of histologically-proven H-SIL. Cervix absorption and effective scattering parameters were up to 15% lower in H-SIL sites compared with normal cervical tissue for all wavelengths studied (674, 811, 849, 956 nm). Following PDT, all mu(a) values increased significantly, due to elevated tissue blood and water content associated with PDT-induced hyperaemia and oedema. Tissue total haemoglobin concentration ([TotHb]) and arterio-venous oxygen saturation measured in H-SIL sites were lower than normal sites ([TotHb]: 88.6 +/- 35.8 micromol/l versus 124.7 +/- 22.6 micromol/l; %SO(2): 76.5 +/- 14.7% versus 84.9 +/- 3.4%).