Comparison of Outcomes for Abdominoperineal Resection versus Low Anterior Resection for Very-Low Rectal Cancer.

BACKGROUND: Management of very-low rectal cancer is one of the most challenging issues faced by general and colorectal surgeons. Many feel compelled to pursue abdominoperineal over low anterior resection to optimize oncologic outcomes. This study aims to determine differences in long-term oncologic outcomes between patients undergoing abdominoperineal or low anterior resection for very-low rectal cancer. METHODS: The US Rectal Cancer Consortium (2010-2016) was queried for adults who underwent either abdominoperineal resection (APR) or low anterior resection (LAR) for Stage I-III rectal cancers <5cm from anorectal junction and met inclusion criteria. Primary outcome was disease-free survival. Secondary outcomes included overall survival, length of stay, complications, recurrence location, and perioperative factors. RESULTS: 431 patients with very-low rectal cancer who underwent APR or LAR were identified. 154 (35.7%) underwent abdominoperineal resection. The overall recurrence rate was 19.6%. Median follow-up was 42.5 months. An analysis adjusted for demographics and pathologic stage observed no difference in disease-free survival between operative types (APR-HR=0.90, 95% CI [0.53-1.52], p=0.70). Secondary outcomes demonstrated no significant difference between operation types, including overall survival (HR=1.29, 95% CI [0.71-2.32], p=0.39), complications (OR = 1.53, 95% CI [0.94 - 2.50], p=0.12) or length of stay (Estimate: 0.04, Std. error = 0.25, p=0.54). CONCLUSIONS: We observed no significant difference in disease-free survival or overall survival between patients undergoing abdominoperineal or low anterior resection for very-low rectal cancer. This analysis supports the treatment of very-low rectal cancer, without sphincter involvement, by either abdominoperineal or low anterior resection.

Change in Total Body Water as a Metric for Predicting Need for Outpatient Intravenous Fluids in Postoperative Bariatric Patients.

BACKGROUND: Dehydration drives a significant proportion of readmissions following bariatric surgery. Routinely performed body composition testing and total body water (TBW) calculations may present a novel method for diagnosing dehydration for outpatient intervention. We sought to determine if a change in TBW from preoperative baseline could help identify bariatric patients requiring outpatient intravenous fluid (IVF) administration for dehydration. METHODS: The VUMC Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database was retroactively queried for all patients undergoing bariatric surgery at an accredited bariatric surgery center from January 1, 2017 to May 31, 2018. Body composition test results presurgery and postsurgery were extracted from the electronic health record. Change in TBW was compared between patients requiring outpatient IVF and those who did not use multivariable logistic regression. RESULTS: 583 patients underwent surgery over the study period (388 laparoscopic Roux-en-Y gastric bypass, 195 sleeve). 62 (10.6%) required outpatient fluid administration for dehydration. After multivariable analysis, patients with an increased hospital length of stay at index operation were more likely to require outpatient IVF (odds ratio [OR] 1.65, 95% CI 1.22-2.2). Preexisting diabetes diagnosis was protective (OR 0.35, 95% CI 0.16-0.74). Neither 1-week nor 1-month change in TBW from preoperative baseline was significantly different between patients receiving outpatient IVF and those who did not. CONCLUSION: Increased hospital length of stay predicts patients at risk of postoperative dehydration requiring IVF administration. Body composition testing and TBW were not useful in distinguishing between populations. Further research is needed to examine the efficacy of outpatient IVF in preventing hospital readmissions for dehydration.

Comparing pathologic outcomes for robotic versus laparoscopic Surgery in rectal cancer resection: a propensity adjusted analysis of 7616 patients.

BACKGROUND: Margin negative resection of rectal cancer with minimally invasive techniques remains technically challenging. Robotic surgery has potential advantages over traditional laparoscopy. We hypothesize that the difference in the rate of negative margin status will be < 6% between laparoscopic and robotic approach. METHODS: The National Cancer Database (2010-2014) was queried for adults with locally advanced rectal cancer who underwent neoadjuvant chemoradiation and curative resection to conduct an observational retrospective cohort study of a prospectively maintained database. Patients were grouped by either robotic (ROB) or laparoscopic (LAP) approach in an intent-to-treat analysis. Primary outcome was negative margin status, defined as a composite of circumferential resection margin and distal margin. Secondary outcomes included length of stay (LOS), readmission, 90-day mortality, and overall survival. RESULTS: 7616 patients with locally advanced rectal cancer who underwent minimally invasive resection were identified. 2472 (32%) underwent attempted robotic approach. The overall conversion rate was 13% and was increased in the laparoscopic group [LAP: 15% vs. ROB: 8%; OR 0.47; 95% CI (0.39, 0.57)]. Differences in margin negative resection rate were within the prespecified range of practical equivalence (LAP: 93% vs.: ROB 94%; 95% CI (0.69, 1.06); [Formula: see text] = 1). For secondary outcomes, there was no difference in 30-day readmission [LAP: 9% vs.: ROB 8%; 95% CI (0.84, 1.24)] and 90-day mortality [LAP: 1% vs.: ROB 1%; 95% CI (0.38, 1.24)]. While the median LOS was 5 days in both groups, the mean LOS was 0.6 (95% CI: 0.24, 0.89) days shorter in the robotic group. CONCLUSION: This robust analysis supports either robotic or laparoscopic approach for resection of locally advanced rectal cancer from a margin perspective. Both have similar readmission and 5-year overall survival rates. Patients undergoing robotic surgery have a 0.6-day decrease in LOS and decreased conversion rate.

Reticular activating system of a central pattern generator: premovement electrical potentials.

For the first time, here we characterize a bulbar reticular activating system (RAS) of neurons in decerebrate, deafferented and decerebellated cats producing a premovement electrical potential that we named obex slow potential (OSP). The OSP occurs about 0.8 ± 0.4 sec prior to the onset of a fictive-scratching-episode. Here, we describe two classes of bulbar neurons, off-on, which are silent but exhibit a 80 ± 56 Hz firing discharge at the beginning of (and during) the OSP, and on-off interneurons, with a 27 ± 14 Hz firing activity that stops at the beginning of (and during) the OSP. We suggest that these OSP-associated neurons belong to a descending RAS, which contributes to the activation of the spinal central pattern generators.

[Colorectal polyps: update on diagnosis]. / Pólipos colorectales: actualización en el diagnóstico.

Histological diagnosis determines the clinical behavior of colorectal polyps. Recently new types of polyps have been described and the classification has become wider and more complex. Our aim is update the current concepts in the knowledge of colorectal polyps.

Pólipos colorectales: actualización en el diagnóstico / Colorectal polyps: update in the diagnosis

El diagnóstico histológico de los pólipos colorrectales determina la conducta que tomará el médico especialista con el paciente. Con la aparición de nuevos pólipos en los últimos años, la clasificación histológica se ha tornado más compleja y amplia. Nuestro objetivo es actualizar los conceptos en el diagnóstico histológico de pólipos de colon de una manera clara y de fácil comprensión, especialmente para gastroenterólogos y patólogos.

Histological diagnosis determines the clinical behavior of colorectal polyps. Recently new types of polyps have been described and the classification has become wider and more complex. Our aim is update the current concepts in the knowledge of colorectal polyps.

Atividade antibacteriana in vitro de extratos de Rhizophora mangle L. / In vitro antibacterial activity of Rhizophora mangle L. extracts

Ensaios para avaliar o potencial antibacteriano de Rhizophora mangle (mangue-vermelho), coletada no município de Conde, Bahia, foram realizados com cepas bacterianas Gram-positivas (Staphylococcus aureus ATCC 6538 e Micrococcus luteus ATCC 9341) e Gram-negativas (Echerichia coli ATCC 10536, Salmonella Cholerea-suis 10708, Klebsiela pneumoniae ATCC 700603 e Pseudomonas aeruginosa ATCC 15442). A atividade antibacteriana foi avaliada pelos métodos de difusão em disco e concentração inibitória mínima (CIM), e os resultados analisados estatisticamente. Os resultados do ensaio de difusão em disco mostraram diferença significativa quanto à sensibilidade dos micro-organismos frente aos extratos testados (p<0,05). A CIM do extrato da folha (313 µg mL-1) apresentou o melhor desempenho para inibir o crescimento das cepas Gram-positivas, enquanto o extrato da casca foi mais eficaz para as cepas Gram-negativas. De acordo com os dados levantados por este estudo, R. mangle apresentou propriedade antibacteriana para cepas Gram-positivas e Gram-negativas, podendo tornar-se alternativa terapêutica tanto para o uso popular quanto para a indústria farmacêutica.

Assays to evaluate the antibacterial potential of Rhizophora mangle (red mangrove), sampled at Conde Municipality, Bahia State, Brazil, were performed against Gram-positive (Staphylococcus aureus ATCC 6538 and Micrococcus luteus ATCC 9341) and Gram-negative (Echerichia coli ATCC 10536, Salmonella Cholerea-suis 10708, Klebsiela pneumoniae ATCC 700603 and Pseudomonas aeruginosa ATCC 15442) bacteria. Antibacterial activity was evaluated by disc diffusion and minimal inhibitory concentration (MIC) and results were statistically analyzed. The results of disc diffusion assay showed a significant difference as to the sensitivity of microorganisms against the tested extracts (p<0.05). The MIC of leaf extract (313 µg mL-1) indicated the best performance to inhibit the growth of Gram-positive strains, while bark extract had a better efficacy against Gram-negative strains. Based on the presented data, R. mangle showed antibacterial properties against both Gram-positive and Gram-negative strains and can be used as an alternative therapy for popular use or for the pharmaceutical industry.

Supraventricular tachyarrhythmia and Brugada syndrome: a case of atrial fibrillation and Brugada syndrome in a young patient without structural heart disease.

We report a case of a 29-year old man who initially presented with a single episode of syncope. The initial electrocardiogram (ECG) showed atrial fibrillation and an ST segment elevation on lead V1. A flecainide test unmasked the Brugada syndrome. The pathophysiology of Brugada syndrome and atrial fibrillation in this patient could be connected by sodium channel dysfunction throughout the heart. In addition, we reviewed the possible connection between Brugada syndrome and atrial fibrillation.

Delayed pediatric office follow-up of newborns after birth hospitalization.

BACKGROUND: Key recommendations of the American Academy of Pediatrics guideline on management of severe hyperbilirubinemia in healthy infants of >or=35 weeks' gestation include predischarge screening for risk of subsequent hyperbilirubinemia, follow-up at 3 to 5 days of age, and lactation support. Little information is available on contemporary compliance with follow-up recommendations. OBJECTIVE: To assess timing and content of the first newborn office visit after birth hospitalization in urban and suburban pediatric practices in Houston, Texas. METHODS: We reviewed office records for the first visit within 4 weeks of birth during January through July 2006 for apparently healthy newborns with a gestational age of >or=35 weeks or birth weight of >or=2500 g seen within a pediatric provider network. For each pediatrician, we selected every fifth patient up to a total of 6. RESULTS: Of 845 records abstracted, 698 (83%) were eligible for analysis. Infants were seen by 136 pediatricians in 39 practices. They had vaginal (64%) or cesarean (36%) deliveries at 20 local hospitals, of which 17 had routine predischarge bilirubin screening policies. Only 37% of all infants, 44% of vaginally delivered infants, and 41% of exclusively breastfed infants were seen before 6 days of age. Thirty-five percent of the infants were seen after 10 days of age. Among 636 infants seen at

First Report of Neofusicoccum parvum Associated with Dieback of Mango Trees in Peru.

Mango (Mangifera indica L) is one of the most important cash crops of northern Peru. Since 2003, adult mango trees (cvs. Criollo and Kent) located in Piura Province developed symptoms of dieback characterized by the death of twigs and branches in the tree canopy. Additional disease symptoms involved darkened, elongated lesions on the peduncle, causing an early maturation of the fruit, and in advanced symptoms, stem-end rot of fruits. Symptoms were frequent in the spring months (September to November) when the lesions expand rapidly. Diseased tissues from branches and fruits were collected and small pieces of necrotic tissues were surface disinfected and plated onto potato dextrose agar (PDA) with 0.5 g L-1 streptomycin sulfate. Plates were incubated at 25°C in the dark. All affected tissues consistently developed colonies with a white mycelium, moderately dense, and becoming olivaceous gray after 5 to 6 days. Pycnidia were produced on sterile mango twigs placed on the surface of potato carrot agar (PCA) after 10 days. Conidia were hyaline, guttulate, aseptate, measuring (15-) 18.5 (-22.5) × (4-) 5.2 (-7.5) µm. Conidia became olivaceous and developed one or two septa before germination. Isolates were identified as Neofusicoccum parvum (Pennycook & Samuels) Crous, Slippers, & A.J.L. Phillips (1). DNA sequences of the rDNA internal transcribed spacer region (ITS) and part of the translation elongation factor 1-alpha (EF1-α) genes were used to confirm the identification through BLAST searches in GenBank (ITS: 99% identity to Accession No. EU080928; EF1-α: 98% identity to Accession No. AY343367). Representative sequences of the studied DNA regions were deposited at GenBank (ITS: Accession No. FJ528596; EF1-α: Accession No. FJ528597). Pathogenicity tests were conducted on 18-month-old potted mango plants cv. Kent with two N. parvum strains (A4 and A5). A mycelial plug (3 cm in diameter) taken from the margin of an actively growing colony of each isolate was put in a wound made with a cork borer of the same diameter on the stem of each plant. Inoculation wounds were wrapped with Parafilm. Controls were inoculated with sterile PDA plugs. Ten replicates for each isolate were used with an equal number of control plants. Plants were maintained in a greenhouse with a temperature range of 22 to 28°C. After 4 weeks, mango plants showed necrotic stem lesions originating from the inoculation point affecting also the branches of the inoculated plants. No differences in lesion area between strains were obtained. No lesions developed in the control plants. Reisolations from necrotic tissues were successful and both isolates were morphologically identical to those used for inoculations. N. parvum was isolated from all symptomatic trees in all surveyed areas. This pathogen has already been reported on mango (2) and currently represents a serious problem in the mango-producing areas of Peru. To our knowledge, this is the first report of N. parvum affecting mango in Peru. References: (1) P. W. Crous et al. Stud. Mycol. 55:235, 2006. (2) B. Slippers et al. Mycologia 97:99, 2005.

Bleeding Canker on Mesquite in Peru caused by Phytophthora syringae.

Mesquite (Prosopis pallida (Wildenow) Kunth) is a drought-tolerant tree widely distributed in the northern Pacific Coast of South America. This species prevents soil erosion, provides shade, conserves prairies, supports bee nutrition, and provides fruits for human and animal consumption. Since the spring of 2004, bark lesions and bleeding cankers were observed on trunks and branches of 70% of declining mesquite trees in some parks at Ica in southern Peru. Badly affected trees were killed by the disease. Isolations were made from the edge of necrotic lesions of the inner bark and roots using PARPH medium (2) and incubated at 22°C for 7 days. A Phytophthora species was consistently isolated from lesions of 10 mesquite trees, and six pure cultures (PS-87-PS-92) were obtained by transferring hyphal tips and characterized. Colonies were stellate on V8 juice agar (VJA; 2 g CaCO3, 200 ml of V8 juice, and 15 g of agar in 800 ml of distilled water), uniform to slightly radiate on corn meal agar (Oxoid Ltd., London, England), and knotty on PDA (Biokar Diagnostics, Beauvais, France). On VJA at 22°C, the average radial growth rate for the six isolates was 1.7 mm per day. Colonies grew slowly at 5 and 25°C with 0.4 and 0.7 mm per day growth rate, respectively. There was no growth at 30°C. Catenulate hyphal swellings formed on VJA and liquid media (1.5% sterile soil extract). Sporangia were persistent, ovoid to obpyriform, semipapillate with narrow exit pores (<5.0 µm in diameter), 32.3 to 39.7 × 21.0 to 27.2 µm, with a length/width ratio of 1.4:1 to 1.6:1. Sporangia were produced by cutting 5-mm disks from the advancing margin of a colony on VJA and adding disks to 10 ml of 1.5% sterile soil extract for 4 to 5 days at 22°C under fluorescent light. Isolates were homothallic with spherical oogonia, 32 to 35 µm in width with paragynous antheridia, and aplerotic oospores, 26 to 31 µm. These characteristics fit the descriptions of Phytophthora syringae (Kleb.) Kleb. (1). Sequences of the internal transcribed spacer regions on the isolates and comparison with other sequences in GenBank showed that they were identical to P. syringae (Accession No. AJ854297 from Citrus limon). In 2005, two methods were used to inoculate mesquite with two isolates. One method used two 20-mm-diameter branches of five 5-year-old mesquite trees where a 5-mm wound was made with a cork borer and a 5-mm block of the agar culture was placed under the bark and sealed with Parafilm. Another method used 10 4-month-old potted plants that received a 30-ml drench of a 104 zoospores/ml suspension per plant. Controls received clean agar blocks and a sterile water drench for 10 control pots. Two weeks after inoculation, black areas and resinosis were observed around inoculated wounds. Inoculated branches produced cankers of 4.7 to 6.8 cm2, 4 weeks after inoculations. Twenty days after inoculation of roots, wilting and root rots of seedlings occurred. No symptoms were found on the control plants. P. syringae was reisolated from the diseased branches and root rots and pure cultures were established. This test was repeated for both methods with similar results. To our knowledge, this is the first report of P. syringae in Peru and the first description of this pathogen on mesquite worldwide. References: (1) D. C. Erwin and O. K. Ribeiro. Phytophthora Diseases Worldwide. The American Phytopathological Society, St. Paul MN. 1996. (2) S. N. Jeffers and S. B. Martin. Plant Dis. 70:1038, 1986.

Autoinmunidad y geriatría

El sistema inmune sufre continuos cambios morfológicos y funcionales con el transcurrir de los años y se acepta que la respuesta inmune es máxima en la pubertad y que después desciende progresivamente con la edad (inmunosenescencia). Recientes estudios en octogenarios sanos sugierenque el sistema inmune, más que un deterioro generalizado, sufre un remodelado/reajuste de sus principales funciones. En la inmunosenescencia coexisten dos fenómenos opuestos: la disminución en la capacidad de la respuesta inmune y el aumento de producción de anticuerpos. Las posibles consecuencias de la 'senilidad' progresiva del sistema inmune es el aumento de fenómenos inmunes, así como la incidencia de neoplasias y la predisposición a infecciones. El estudio de los fenómenos autoinmunes en el ámbito geriátrico debe ser prioritario en las futuras investigaciones médicas, dado el aumento del promedio de vida en todo el mundo, sobre todo en los países industrializados (AU)

Diclofenac induced renal dysfunction presenting as cardiac arrhythmia.

A fifty year old male presented on the sixteenth post-operative day after leg surgery with abdominal pain and distension, difficulty to breathe and oliguria. He had bradycardia and hypotension. Electrocardiography (ECG) revealed junctional rhythm and there was biochemical evidence of hyperkalemia. This was attributed to non-steroidal anti inflammatory drug diclofenac sodium induced renal dysfunction.

Characterization of a novel DNA binding domain within the amino-terminal region of the RAG-1 protein.

Rag-1 and Rag-2 are the critical components of the V-(D)-J recombinase required for site-specific recombination of the antigen receptor genes. In this study, we have examined the ability of recombinant (r) Rag-1 and Rag-2 to bind the recombination signal sequences (RSS) and have determined that rRag-1, but not rRag-2, is able to directly bind DNA. rRAG-1 DNA binding activity was found to reside within a novel amino-terminal arginine-rich (RR) domain with partial homology to a variety of nucleic acid binding domains. Although the RR-domain did not demonstrate RSS-specificity, this DNA binding domain may stabilize the interaction of RAG-1 with, or increase the affinity for, the V-(D)-J recombination signals.

[Myocardial ischemia secondary to coronary fistula of the anterior descending artery with drainage into the pulmonary artery]. / Isquemia miocárdica secundaria a fístula coronaria de la arteria descendente anterior con drenaje al tronco de la arteria pulmonar.

This article reports the clinical and angiographic aspects of three patients with congenital coronary arteriovenous fistula to the main pulmonary artery, which manifested as dyspnea crisis and angina. This three cases were found in the course of 4,400 consecutive cardiac catheterization procedures to study coronary artery disease. The interest of the cases reported is based on the peculiar anatomy of the fistula. Prompt diagnosis is relevant for better prognosis and treatment.

[A comparative clinical study of calcium blockers, gallopamil and nifedipine, in the treatment of stable chest angina]. / Estudio clínico comparativo de los bloqueadores del calcio, galopamil y nifedipina, en el tratamiento de la angina de pecho estable.

Twenty seven patients, 43 to 69 years of age, all with disabling stable angina and positive Bruce stress test, no amendable for revascularization procedures mainly because of poor distal coronary run-off by angiography, were studied with two calcium-channel blockers, the recently developed gallopamil hydrochloride and nifedipine hydrochloride. According to a double blind, cross-over protocol of 12 week duration and after a 2-week washout period, the patients randomly received during 4 weeks 50 mg gallopamil capsules t i d, or 10 mg nifedipine capsules t i d. After a second 2-week wash-out, the alternative drug was administered for another 4 weeks. The number of anginal episodes decreased significantly (p less than 0.01) with both treatments (from 6.4 to 1.8 crisis with gallopamil and from 6.2 to 2.1 with nifedipine). Heart rate (HR) was progressively reduced with gallopamil (-7.9%, p less than 0.05) but increased with nifedipine (+5.7%) in relation to basal figures. Both medications reduced the level of ST depression during the stress test (52.4% with gallopamil and 41.8% with nifedipine, N.S.). The time for angina at the stress test increased 92.5% with gallopamil and 40.7% with nifedipine (p less than 0.05). HR systolic product at peak exercise was 23,101 with gallopamil and 24,906 with nifedipine (p less than 0.001). Both calcium-channel blockers are drugs with significant anti-anginal effects in patients with stable, disabling angina.(ABSTRACT TRUNCATED AT 250 WORDS)

[Prognostic value of the exercise test in patients with ischemic heart disease]. / Valor pronóstico de la prueba de esfuerzo en pacientes con cardiopatía isquémica.

The objective of this study is to determine the prognostic value of stress testing in patients with coronary heart disease. We examined 95 cases followed during an average period of 33 months. The age was 52 +/- 9 years. All patients had clinical evidence of myocardial ischemia: 78 had previous myocardial infarction, 11 stable angor pectoris and six unstable angina. After the initial event 33 patients were asymptomatic and 62 with mild angina. During follow-up; 42 patients had no coronary events; 10 died, six developed non-fatal myocardial infarction and 37 had more angina, nine of these patients were treated with bypass coronary artery surgery. The annual mortality was 3.8%, all with previous myocardial infarction. In the stress testing the patients who died were distinguished by limited exercise ability and severe changes of ST-T segment. Patients with greater than or equal to 0.2 mV ST-T segment depth or effort duration less than or equal to 3 minutes had an annual mortality F 7% 13.6% respectively.

Uso de bacampicilina en suspension en el tratamiento de faringoamigdalitis aguda en pacientes pediatricos. / Use of bacampicillin suspension in the treatment of acute pharyngoamygdalitis in children

Dieciseis pacientes en edad pediatrica, con sintomas y signos de faringoamigdalitis aguda fueron tratados con una suspension de bacampicilina, a razon de 25 mg por kg de peso y por dia, durante sete dias. El 75% de los pacientes tuvo curacion completa, 12,5% solo mejoria, un paciente (6.25%) abandono el tratamiento a causa del sabor y en otro mas se observo una falla terapeutica. El sabor fue juzgado excelente en 75% de los casos, bueno en 18.75% e inaceptable en 6.25%. Ningun efecto indeseable de importancia fue observado. Se concluye que la suspension de bacampicilina es util en el manejo ambulatorio del nino con faringoamigdalitis aguda, pues su sabor es aceptado facilmente, su eficacia terapeutica es alta y la incidencia de efectos indeseables es muy baja