Focal sources of FGF-10 promote the buckling morphogenesis of the embryonic airway epithelium.

During airway branching morphogenesis, focal regions of FGF-10 expression in the pulmonary mesenchyme are thought to provide a local guidance cue, which promotes chemotactically the directional outgrowth of the airway epithelium. Here, however, we show that an ectopic source of FGF-10 induces epithelial buckling morphogenesis and the formation of multiple new supernumerary buds. FGF-10-induced budding can be modulated by altered epithelial tension and luminal fluid pressure. Increased tension suppresses the formation of ectopic branches, while a collapse of the embryonic airway promotes more expansive buckling and additional FGF-10-induced supernumerary buds. Our results indicate that a focal source of FGF-10 can promote epithelial buckling and suggest that the overall branching pattern cannot be explained entirely by the templated expression of FGF-10. Both FGF-10-mediated cell behaviors and exogenous mechanical forces must be integrated to properly shape the bronchial tree.

Selective type & screen for elective colectomy based on a transfusion risk score may generate substantial cost savings.

BACKGROUND: Preoperative type and screen are currently recommended for all patients undergoing colectomy. We aimed to identify risk factors for transfusion and define a low-risk cohort of patients undergoing colectomy in whom type and screen may be safely avoided. METHODS: We identified all patients undergoing elective colectomy in the National Surgical Quality Improvement Project-Targeted Colectomy files from 2012 to 2016. Patients transfused preoperatively and those undergoing other concurrent major abdominal procedures were excluded. We compared patients who received blood transfusion on the day of surgery to those who did not. Half of the cohort was randomly selected for development of a points-based model predicting blood transfusion on the day of surgery. This model was then validated using the remaining patients. RESULTS: Of 61,964 patients undergoing colectomy, 3128 (5%) patients were transfused with 1290 (2.1%) occurring on the day of surgery. Preoperative anemia was the strongest predictor of blood transfusion on the day of surgery. Among patients with hematocrit > 35%, day of surgery transfusion risk was 0.8%; 99% of patients with hematocrit > 35% had a score 20 or less. Selective type and screen for patients with score ≤ 20 or hematocrit > 35% would avoid type and screen in 91% and 81% of patients, respectively. CONCLUSION: Transfusion following elective colectomy is rare and can be accurately predicted by preoperative patient characteristics. Selective type and screen based on these parameters have the potential to prevent operative delays and lower cost.

Three-dimensional visualization and improved quantification with super-resolution ultrasound imaging - validation framework for analysis of microvascular morphology using a chicken embryo model.

The purpose of this study was to improve the morphological analysis of microvascular networks depicted in three-dimensional (3D) super-resolution ultrasound (SR-US) images. This was supported by qualitative and quantitative validation by comparison to matched brightfield microscopy and traditional B-mode ultrasound (US) images. Contrast-enhanced US (CEUS) images were collected using a preclinical US scanner (Vevo 3100, FUJIFILM VisualSonics Inc.) equipped with an MX250 linear array transducer. CEUS imaging was performed after administration of a microbubble (MB) contrast agent into the vitelline network of a developing chicken embryo. Volume data was collected by mechanically scanning the US transducer throughout a tissue volume-of-interest in 90µm step increments. CEUS images were collected at each increment and stored as in-phase/quadrature data (2000 frames at 152 frames per sec). SR-US images were created for each cross-sectional plane using established data processing methods. All SR-US images were then used to reconstruct a final 3D volume for vessel diameter (VD) quantification and for surface rendering. VD quantification from the 3D SR-US data exhibited an average error of 6.1% ± 6.0% when compared with matched brightfield microscopy images, whereas measurements from B-mode US images had an average error of 77.1% ± 68.9%. Volume and surface renderings in 3D space enabled qualitative validation and improved visualization of small vessels below the axial resolution of the US system. Overall, 3D SR-US image reconstructions depicted the microvascular network of the developing chicken embryos. Improved visualization of isolated vessels and quantification of microvascular morphology from SR-US images achieved a considerably greater accuracy compared to B-mode US measurements.

Travel distance and overall survival in hepatocellular cancer care.

BACKGROUND: Our objective was to assess the relationship between overall survival (OS) and distance travelled to the treating facility for patients undergoing liver resection for hepatocellular carcinoma and to determine whether this relationship was dependent upon the structural factors of the treating facility. METHODS: Using National Cancer Database, we focused on extremes of travel: Local (<12.5 miles to treating facility) and Travel (≥50 miles). We analyzed OS with Cox models; we estimated stratified models to assess interaction between distance and facility characteristics (volume, academic status). RESULTS: We included 6860 patients. After correction for confounding, distance travelled was not associated with OS (p = 0.444). However, Travel patients treated at high-volume, academic centers had worse OS compared to Local patients (HR 1.54, 95%CI 1.07-2.21); this association was not seen for patients treated at low volume, academic centers (p = 0.708) high volume non-academic centers (p = 0.174) or low volume non-academic centers (p = 515). CONCLUSION: For those patients treated at high-volume, academic centers, living far from the facility was associated with worse OS. The reasons for this association should be investigated further.

Does etiology of gastroparesis determine clinical outcomes in gastric electrical stimulation treatment of gastroparesis?

BACKGROUND: Gastroparesis is a condition characterized by impaired gastric motility that may result in weight loss and malnutrition. There have been promising studies demonstrating improvement in symptoms after gastric electrical stimulation (GES) implantation for medically refractory gastroparetics [1-10]. With the heterogeneous population of gastroparetics, the aim of this study was to assess if etiology correlated with response to GES. METHODS: A retrospective review and analysis was performed on patients who underwent GES over a 10-year period at a single institution. Each patient was stratified into an etiological subset (diabetes, idiopathic, post-surgical). Patients were compared by demographics, medical and surgical history, subsequent GES explantation vs continued therapy, need for supplemental nutrition postoperatively, weight gain, weight loss or weight maintenance, and readmission rates. RESULTS: 183 patients underwent GES from 2005 to 2015. 50% were diabetic (n = 91), 42% idiopathic (n = 76), and 9% post-surgical (n = 16). Diabetic patients (DM) demonstrated the highest likelihood of continued therapy compared to post-surgical (PS) and idiopathic patients (ID) (54.7% vs 9.5% vs 35.8%, respectively, p < 0.05). DM patients saw a greater incidence of weight gain > 4 kg, compared to PS and IS patients (67.6% vs 8.1% vs. 24.3%, respectively, p < 0.05). ID patients were most likely to have it removed compared to DM and PS patients (65.7% vs 28.6% vs 5.7%, respectively, p = < 0.05). PS patients were least likely to have their GES removed. They were also least likely to utilize supplemental nutrition compared to DM and ID (9.4% vs 49.1% vs 41.51%, respectively, p < 0.05). CONCLUSIONS: Patients with gastroparesis had different clinical outcomes after GES therapy based on underlying etiology. By gaining a better understanding of the effects of GES, it can be offered to the appropriate patient.

Three-dimensional super-resolution ultrasound imaging of chicken embryos - A validation framework for analysis of microvascular morphology.

The purpose of this present study was to improve the quantification of microvascular networks depicted in three-dimensional (3D) super-resolution ultrasound (SR-US) images and compare results with matched brightfield microscopy and B-mode ultrasound (US) images. Standard contrast-enhanced US (CEUS) images were collected using a high-frequency US scanner (Vevo 3100, FUJIFILM VisualSonics Inc) equipped with an MX250 linear array transducer. Using a developing chicken embryo as our model system, US imaging was performed after administration of a custom microbubble (MB) contrast agent. Guided by stereo microscopy, MBs were introduced into a perfused blood vessel by microinjection with a glass capillary needle. Volume data was collected by mechanically scanning the US transducer throughout a tissue volume-of-interest (VOI) in 90 µm step increments. CEUS images were collected at each increment and stored as in-phase/quadrature (IQ) data (N = 2000 at 152 frames per sec). SR-US images were created for each cross-sectional plane using established data processing methods, and all were then used to form a final 3D volume for subsequent quantification of morphological features. Vessel diameter quantifications from 3D SR-US data exhibited an average error of 1.9% when compared with microscopy images, whereas measures from B-mode US images had an average error of 75.3%. Overall, 3D SR-US images clearly depicted the microvascular network of the developing chicken embryo and measurements of microvascular morphology achieved better accuracy compared to traditional B-mode US.

Effect of epidural compared to patient-controlled intravenous analgesia on outcomes for patients undergoing liver resection for neoplastic disease.

BACKGROUND: Epidural analgesia is routinely used for postoperative pain control following abdominal surgeries, yet data regarding the safety and efficacy of epidural analgesia is controversial. METHODS: Pain-related and clinical perioperative data were extracted and correlated with baseline clinicopathologic data and method of analgesia (epidural vs. intravenous patient-controlled analgesia) in patients who underwent hepatectomy from 2012 to 2014. Chronic pain was defined by specific narcotic requirements preoperatively. RESULTS: Eighty-seven patients underwent hepatectomy with 60% having epidurals placed for postoperative pain control. Epidural patients underwent more major hepatectomies and open resections. Comparison of pain scores between both groups demonstrated no significant difference (all P > .05). A significantly lower proportion of TEA patients required additional IV pain medications than those with IVPCA (P < 0.001). There was no major effect of epidural analgesia on time to ambulation or complications (all P > 0.05). After adjusting for perioperative factors, and surgical extent and approach, no significant differences in fluids administered or length of stay were detected. CONCLUSIONS: Overall postoperative outcomes were not significantly different based on method of analgesia after adjusting for type and extent of hepatic resection. Though patients with epidurals underwent more extensive operations they required less additional IV pain medications than IVPCA patients.

Is Excisional Biopsy and Chemoprevention Warranted in Patients With Atypical Lobular Hyperplasia on Core Biopsy?

The management of atypical lobular hyperplasia (ALH) on core biopsy remains controversial. The upstaging rates after surgical excision vary. We reviewed our upgrade rates and use of chemoprevention for ALH. Patients were identified through our pathology database for ALH from 2006 to 2013. Patients were included in the study that had a diagnosis only of ALH on core needle biopsy. Tumor and patient characteristics and final pathology were analyzed. ALH was identified in 56 patients since 2006. Sixteen patients met the inclusion criteria. All the patients underwent surgical excision. Final pathology of the excised specimens confirmed ALH in 62 per cent (n = 11). Two cases contained lobular carcinoma in situ. The upgrade rate on excisional biopsy was 18.75 per cent (n = 3) to invasive cancer. Chemopreventative treatment was taken by 44 per cent of the patients. After a mean follow-up of three years, none of the patients who received chemoprevention developed breast cancer. One patient who refused tamoxifen developed breast cancer. This is one of the few studies to examine the current treatment of ALH. We noted a significant upstaging rate after excision. We recommend women to undergo surgical excision. Patients should also consider chemoprevention to reduce their risk for developing breast cancer.