Adaptation and Pilot Study of a Behavioral Intervention Targeting Morning Activation Deficits in Dementia Caregivers: Scheduling Activity and Monitoring Mornings (SAMM).

OBJECTIVES: Morning activation deficits (MADs) correlate with depression symptom persistence in older dementia caregivers. To clarify the potential of MADs as a target for depression interventions, we aimed to: 1) adapt an existing behavioral activation program, Engage therapy, to target mornings; and 2) evaluate effects on self-reported MADs and depression symptoms. METHODS: While trialing the 9-week Engage adaption (targeting mornings) in six older dementia caregivers, we incorporated feedback and finalized an adapted program called Scheduling Activity and Monitoring Mornings (SAMM). We delivered the SAMM protocol to 13 dementia caregivers (all female; mean age = 69, standard deviation = 7). We report modifications made/rationale, as well as changes in subjective MADs (relevant items from the Composite Scale of Morningness) and depression symptoms (Patient Health Questionnaire - 9). RESULTS: Using caregiver and expert input, we adapted the protocol to: include educational materials/content describing the potential relationship between morning inactivity and depression; target activity scheduling within 2 hours of awakening (preferably earlier); and focus only on the main components of morning activity scheduling, planning, and monitoring. This program was associated with decreases in subjective MADs averaging 29% at week 4, 52% at week 6, and 57% by week 9 (all p's <0.005). Initial depression symptoms were significantly reduced, by 62%, at week 9. CONCLUSIONS: These preliminary findings suggest that subjective MADs can be modified pragmatically, and that doing so may have antidepressant effects. A controlled trial with measures of the putative mechanism is needed to clarify whether, and if so how, targeting MAD with SAMM causally perturbs depression's mechanisms.

Intraoperative evaluation of colorectal anastomotic integrity: a comparison of air leak and dye leak tests.

BACKGROUND: Air leak tests (ALTs) and dye leak tests (DLTs) are the most common techniques for Intraoperative colorectal anastomosis assessment. The aim of our study was to compare the sensitivity of ALT with DLT in intraoperative evaluation of colorectal anastomotic integrity and to quantify the pressures routinely used in these tests. METHODS: A prospective clinical trial was conducted on patients who had elective colorectal resection and primary anastomosis from November 2017 until July 2019 in a single academic referral center. Each patient underwent both tests. The ALT was a transanal insufflation of CO2 and inspection of escaping bubbles around the anastomosis immersed in saline. The DLT was a transanal infusion of diluted methylene blue and inspection of dye stains on surgical gauze wrapping the anastomosis. Peak pressures were measured. Primary endpoints were the sensitivity of ALT and DLT in detecting intraoperative leaks, quantification of intraluminal pressure routinely used in these settings and assessment of postoperative complications such as a clinical leak. RESULTS: Forty patients underwent elective colorectal resection and anastomosis for malignant (67%) or benign n (33%) etiology. Height of anastomoses ranged from 1 to 25 cm (mean ± SD 12 ± 6 cm). Mean pressures measured were 26.5 ± 6.6 mmHg for the DLT and 22 ± 4 mmHg for the ALT (p < 0.01). Twenty percent of the DLTs were positive (8 patients) compared to 2.5% (1 patient) of the ALTs (RR 1.97, CI 1.2-2.7; p = 0.03). All patients who had positive tests had a suture reinforcement of the anastomosis. Only 1 patient, who had a positive DLT and ALT, developed a clinical leak CONCLUSIONS: DLT is more sensitive in detecting anastomotic leak intraoperatively. This is the first study measuring anastomotic tests' pressures used in-vivo in humans demonstrating a range of 20-30 mmHg. Based on our data we believe that a positive DLT with a negative ALT may be treated with suture reinforcement alone. CLINICAL TRIAL NUMBER: NCT03316677-10/17/2017.

Synchronous Hartmann reversal and incisional hernia repair is associated with higher complication rate compared to a staged procedure.

Post operative ventral hernias are common following Hartmann's procedure. There is a debate whether hernia repair is safe when performed concomitantly with colostomy closure. In this study we aimed to evaluate the outcomes of synchronous Hartmann reversal (HR) with a hernia repair, compared to a staged procedure. A retrospective multi-center study was conducted, including all patients who underwent Hartmann's procedure from January 2004 to July 2017 in 5 medical centers. Patient data included demographics, surgical data and post-operative outcome. Two hundred and seventy-four patients underwent colostomy reversal following Hartmann's procedure. In 107 patients (39%) a concomitant ventral hernia was reported during the Hartmann's reversal. Out of this cohort, 62 patients (58%) underwent hernia repair during follow-up. Thirty two patients (52%) underwent a synchronous hernia repair and 30 patients (48%) underwent hernia repair as a separate procedure. Post operative complication rate was significantly higher in the colostomy reversal with synchronous hernia repair group when compared to HR alone group (53% vs. 20%; p < 0.01; OR 4.5). In addition, severe complication rate (Clavien-Dindo score ≥ 3) was higher in the synchronous hernia repair group (25% vs. 7%). A tendency for higher hernia recurrence rate was noted in the synchronous group (56% vs. 40%). Median follow up time was 2.53 years (range 1-13.3 years). Synchronous colostomy closure and ventral hernia repair following Hartmann's procedure carries a significant risk for post operative complications, indicating that a staged procedure might be preferable.

Timing of colostomy reversal following Hartmann's procedure for perforated diverticulitis.

AIM: Hartmann's procedure is the surgical treatment of choice for perforated acute diverticulitis. Hartmann's reversal (HR) that is performed at a later stage may be challenging. The optimal timing for HR is still a subject for controversy. The aim of this study is to assess whether the timing of HR affects surgical outcome. PATIENTS AND METHODS: A retrospective-cohort multi-center study was conducted, including all patients who underwent HR for acute diverticulitis from January 2004 to June 2015 in 5 medical centers. Patient data included demographics, surgical data and post-operative outcome. RESULTS: One hundred and twenty-two patients were included in the database. Median time from Hartmann's procedure to reversal was 182.7 days, with the majority of patients (76 patients, 62.2%) operated 60 to 180 days from the Hartmann's procedure. Fifty-seven patients (46.7%) had post-operative complications, most commonly wound infections (27 patients, 22.1%). Receiver operating characteristic (ROC) curve and a propensity score match analysis (P=0.43) correlating between days to HR from the index procedure showed no specific cut-off point regarding post-operative complications (P=0.16), Major (Clavien-Dindo score of 3 or more) complications (P=0.19), Minor (Clavien Dindo 1-2) and no complications (P=0.14). Median length of stay was 10.9 days (range 3-90) and Pearson correlation failed to demonstrate a correlation between timing of surgical intervention and length of stay (P=0.4). CONCLUSION: Hartmann's Reversal is a complex surgical procedure associated with high rates of complications. In our series, timing of surgery did not affect surgical complications rate or severity or the length of hospital stay.

Probing Cilia-Associated Signaling Proteomes in Animal Evolution.

Cilia have evolved to function as essential sensory organelles in animals. To understand why cilia are intimately associated with cell signaling, Sigg et al. (2017) develop and apply a comparative proteomics approach, reported in this issue of Developmental Cell, to analyze the evolutionary relationship between cilia and various signaling pathways.

The Whole is Other Than the Sum: Perceived Contrast Summation Within Color and Luminance Plaids.

The apparent contrast of a plaid is a reflection of the neural relationship between the responses to its two orthogonal component gratings. To investigate the perceived contrast summation of the responses to component gratings in plaids, we compared the apparent contrasts of monocular plaids to a component grating presented alone across chromaticity and spatial frequency. Observers performed a contrast-matching task for red-green color and luminance stimuli at low- and medium-spatial frequencies. Using the measured points of subjective equality between plaids and gratings, we evaluate perceived contrast summation across conditions, which may vary between 1 (no summation) and 2 (full summation). We show that achromatic plaids have higher perceived contrast summation than chromatic plaids. The greatest difference occurs at the medium-spatial frequency, with summation highest for achromatic plaids (1.87) and lowest for chromatic plaids (1.49), while at low-spatial frequencies, there is a smaller summation difference between achromatic (1.72) and chromatic (1.65) plaids. These results are consistent with recent theories of distinct cross-orientation suppression and summation mechanisms in color and luminance vision. Two control experiments for binocular versus monocular viewing, and the overall size of the stimulus patches did not reveal any differences from our main results.

Orientation tuning of binocular summation: a comparison of colour to achromatic contrast.

A key function of the primary visual cortex is to combine the input from the two eyes into a unified binocular percept. At low, near threshold, contrasts a process of summation occurs if the visual inputs from the two eyes are similar. Here we measure the orientation tuning of binocular summation for chromatic and equivalent achromatic contrast. We derive estimates of orientation tuning by measuring binocular summation as a function of the orientation difference between two sinusoidal gratings presented dichoptically to different eyes. We then use a model to estimate the orientation bandwidth of the neural detectors underlying the binocular combination. We find that orientation bandwidths are similar for chromatic and achromatic stimuli at both low (0.375 c/deg) and mid (1.5 c/deg) spatial frequencies, with an overall average of 29 ± 3 degs (HWHH, s.e.m). This effect occurs despite the overall greater binocular summation found for the low spatial frequency chromatic stimuli. These results suggest that similar, oriented processes underlie both chromatic and achromatic binocular contrast combination. The non-oriented detection process found in colour vision at low spatial frequencies under monocular viewing is not evident at the binocular combination stage.

Perioperative blood transfusion in cancer patients undergoing laparoscopic colorectal resection: risk factors and impact on survival.

BACKGROUND: Perioperative blood transfusion has been associated with a poor prognosis in patients undergoing surgery for colorectal cancer. The aim of this study was to evaluate risk factors for blood transfusion and its impact on long-term outcome exclusively in patients undergoing laparoscopic surgery for curable colorectal cancer. METHODS: Data were retrieved from a prospectively collected database of patients who underwent laparoscopic surgery for curable colorectal cancer over a 6-year period. Long-term data were collected from our outpatient clinic and personal contact when necessary. RESULTS: Two hundred and one patients underwent laparoscopic surgery for curable colorectal cancer (stage I-III). Sixty-eight (33.8 %) received blood transfusions during or after surgery. These patients were typically older, had lower preoperative hemoglobin levels, had a more advanced cancer, had a higher Charlson score, had a higher rate of complications and had a higher conversion rate. Kaplan-Meier overall survival analysis was significantly worse in patients who received blood transfusions (P = 0.004). Decreased disease-free survival was also observed in transfused patients; however, this did not reach statistical significance (P = 0.21). A multivariate analysis revealed that transfusion was not an independent risk factor for decreased overall and disease-free survival. The Charlson score was the only independent risk factor for overall survival (OR = 2.1, P = 0.002). Independent factors affecting disease-free survival were stage of disease, Charlson score and, to a lesser degree, age and body mass index. CONCLUSIONS: Perioperative blood transfusion is associated with decreased long-term survival in patients undergoing laparoscopic resection for colorectal cancer. However, this association apparently reflects the poorer medical condition of patients requiring surgery and not a causative relationship.

High temporal discounters overvalue immediate rewards rather than undervalue future rewards: an event-related brain potential study.

Impulsivity is characterized in part by heightened sensitivity to immediate relative to future rewards. Although previous research has suggested that "high discounters" in intertemporal choice tasks tend to prefer immediate over future rewards because they devalue the latter, it remains possible that they instead overvalue immediate rewards. To investigate this question, we recorded the reward positivity, a component of the event-related brain potential (ERP) associated with reward processing, with participants engaged in a task in which they received both immediate and future rewards and nonrewards. The participants also completed a temporal discounting task without ERP recording. We found that immediate but not future rewards elicited the reward positivity. High discounters also produced larger reward positivities to immediate rewards than did low discounters, indicating that high discounters relatively overvalued immediate rewards. These findings suggest that high discounters may be more motivated than low discounters to work for monetary rewards, irrespective of the time of arrival of the incentives.

Risk factors for relaparotomy after cesarean delivery.

OBJECTIVE: To identify risk factors for relaparotomy after cesarean delivery. METHODS: Cases of exploratory laparotomy at Lis Maternity Hospital, Tel Aviv, Israel, following cesarean delivery between 2000 and 2010 were reviewed retrospectively. Each case in the study group was matched randomly with 5 control cases in which the patient underwent cesarean delivery only. Demographic and clinical data before and during the primary procedure were compared. RESULTS: Twenty-eight (0.2%) of 17482 cesarean deliveries were followed by exploratory relaparotomy. Significant differences between the study and the control (n=140) groups were found in: placental abruption as an indication for cesarean (17.8% vs 0.6%; P=0.004); duration of primary operation (45.3 ± 21.1 vs 29.9 ± 11.8 minutes; P=0.007; 95% CI, 5.1-19.2); and experience of chief surgeon (10.1 ± 1.6 vs 5.8 ± 0.4 years; P=0.02; 95% CI, 0.0-5.0). Findings during relaparotomy were: abdominal wall bleeding/hematoma (n=4 [14.2%]); uterine scar bleeding (n=4 [14.2%]); retroperitoneal bleeding (n=1 [3.5%]); adhesions causing bowel obstruction (n=1 [3.5%]); and uterine scar gangrene (n=1 [3.5%]). There were no findings for 17 (60.7%) patients. CONCLUSION: The incidence of relaparotomy following cesarean was 0.2% (1 per 624 cesarean deliveries). Significant risk factors were placental abruption and longer operative time.

Is Doppler ultrasonography essential for hemorrhoidal artery ligation?

BACKGROUND: Doppler ultrasonography enables accurate identification of the terminal branches of the superior rectal artery prior to hemorrhoidal artery ligation (HAL). However, since the positions of these branches have been found to be relatively constant, the question arises as to the necessity of ultrasonography for their identification. The aim of the current study was to examine the positions of all arteries identified and ligated during the HAL procedure. METHODS: We recorded the position of all arteries located and ligated in 135 consecutive patients who underwent the HAL procedure during the years 2003 to 2006. RESULTS: In all patients, 6-8 terminal arterial branches were located above the dentate line. In 102 (76 %) patients, terminal branches were located in all 6 of the odd-numbered clock positions around the anus (1, 3, 5, 7, 9, and 11 o'clock in the lithotomy position). If we had ligated arteries only at these odd-numbered clock positions, without using Doppler ultrasonography, we would have located all the arteries in 96 (71 %) of our patients. CONCLUSIONS: The number and location of arterial branches of the superior rectal artery are relatively constant. Nevertheless, if, Doppler ultrasonography had not been performed and, ligation in the HAL procedure had been at the odd-numbered clock positions only, then at least one artery would have been missed in 29 % of our patients.

Five-year follow-up of Doppler-guided hemorrhoidal artery ligation.

BACKGROUND: Doppler-guided hemorrhoidal artery ligation (DGHAL) was described as lower risk and a less painful alternative to hemorrhoidectomy. We report our experience and 5-year follow-up with this procedure. METHODS: Between May 2003 and December 2004, 100 patients with symptomatic Grade II or III hemorrhoids underwent ultrasound identification and ligation of 6-8 terminal branches of the superior rectal artery above the dentate line by a single surgeon using local, regional, or general anesthesia. There were 42 men and 58 women (mean age 42 years, median duration of symptoms 6/3 years). A 10-point visual analog scale was used for postoperative pain scoring. Surgical and functional outcome was assessed at 6 weeks and 3 and 12 months after surgery, with long-term follow-up by a telephone questionnaire at 5 years after the procedure. RESULTS: The mean operative time was 19 min. Local anal block combined with intravenous sedation (n = 93) or general or spinal (n = 7) anesthesia was used. Only 5 patients were hospitalized overnight. There was no urinary retention, bleeding, or mortality in the immediate postoperative period. The mean pain score decreased from 2.1 at 2 h postoperatively to 1.3 on the first postoperative day. All patients had complete functional recovery by the third postoperative day. Ninety-six patients completed 12 months of follow-up. Eighty-five of these patients (89%) remained asymptomatic at 12 months, though this number dropped to 67/92 (73%) at 5 years. CONCLUSIONS: Long-term follow-up confirms the effectiveness of the DGHAL procedure for treatment for Grade II hemorrhoids. The DGHAL procedure alone seems less effective for Grade III hemorrhoids.

Metastatic lymph node ratio (LNR) as a prognostic variable in colorectal cancer patients undergoing laparoscopic resection.

BACKGROUND: Lymph node ratio (LNR: the ratio of metastatic to total retrieved nodes) has shown prognostic significance in several tumors. Its role in patients with colorectal cancer submitted to laparoscopic resection is still not clearly defined. The aim of this study was to evaluate the impact of LNR on long-term outcome in patients undergoing curative laparoscopic resection. METHODS: Patients' data were retrieved from our prospective in-hospital collected data of patients that underwent laparoscopic surgery for curable colorectal cancer over a 6-year period. Long-term data were collected from our outpatient's clinic data and personal contact when necessary. RESULTS: Two hundred and five patients underwent laparoscopic resection for curable colorectal cancer in the study period. Sixty-five patients were node positive. Receiver operating characteristic (ROC) analysis selected 0.13 as the best LNR cutoff value in this group. Kaplan-Meier 5-year survival analysis revealed a significant decrease in overall and disease-free survival in patients with an LNR above 0.13. Long-term outcome of patients with an LNR below 0.13 was similar to node-negative stage II patients. CONCLUSIONS: The lymph node ratio is a valuable prognostic factor in node-positive colon cancer patients undergoing laparoscopic resection. Patients with an LNR below 0.13 have the same long-term outcome as stage II node-negative patients. The laparoscopic approach presents the same trends in terms of overall survival and disease-free survival as conventional open access when LNR is considered.

Outcome of stapled hemorrhoidopexy versus doppler-guided hemorrhoidal artery ligation for grade III hemorrhoids.

PURPOSE: To evaluate the long-term results, early and late complication rates, and overall satisfaction of patients with grade III hemorrhoids treated by stapled hemorrhoidopexy (SH) or Doppler-guided hemorrhoidal artery ligation (DGHAL). METHODS: Operative and follow-up patients' data were prospectively collected for patients undergoing either SH or DGHAL by a single surgeon during a 2-year period. A retrospective comparison between patients' outcome operated by one of the two methods was made based on this data. Clinical data on postoperative pain, analgesic requirements, time to first bowel movement and functional recovery were collected at five postoperative follow-up visits (1 and 6 weeks, 6, 12, and 18 months). Data on patient satisfaction, recurrence of hemorrhoidal symptoms and further treatments were obtained by a standardized questionnaire that was conducted during the last visit 18 months postoperatively. RESULTS: A total of 63 patients underwent SH (aged 52 ± 3.2 years) and 51 patients underwent DGHAL (aged 50 ± 7.3 years). DGHAL patients experienced less postoperative pain as scored by pain during bowel movement (2.1 ± 1.4 vs. 5.5 ± 1.9 for SH), and required fewer analgesics postoperatively. Hospital stay, time to first bowel movement, and complete functional recovery were also significantly shorter for the DGHAL patients. Nine DGHAL patients (18%) suffered from persistent bleeding or prolapses and required additional treatment compared with 2 (3%) patients in the SH group. SH patients reported greater satisfaction compared with DGHAL patients at 1 year postoperatively. CONCLUSION: Both SH and DGHAL are safe procedures and have similar effectiveness for treating grade III hemorrhoids. DGHAL is less painful and provides earlier functional recovery, but is associated with higher recurrence rates and lower satisfaction rates compared with SH.

Outcome of repeated stapler haemorrhoidopexy for recurrent prolapsing haemorrhoids.

AIM: Stapled haemorrhoidopexy (SH) is associated with minor postoperative pain and high overall satisfaction rates. Some patients will have persistent or recurrent symptoms requiring re-intervention. METHOD: All patients who underwent SH for grade III internal haemorrhoids and required a second SH (2005-2008) were studied. Grade IV patients were excluded. Data on surgical technique, postoperative pain, complications, time to first bowel movement, functional recovery and suspected reason for first SH failure were retrieved from medical records. Similar data were collected for the second procedure at four postoperative follow-up visits. RESULTS: Twelve patients were enrolled. The mean time to recurrent symptoms was 15 months. The indications for repeated surgery were bleeding, prolapse, and pruritus w/wo discharge. Recurrence was attributed to a too high staple line in the first procedure (n = 4) and an incomplete resected ring (n = 1). The median operative time of the second procedure was 24 min (17-29) and the median follow up was 20 ± 4.3 months (15-30). Repeat SH was associated with higher pain scores, more analgesic requirements, and longer recovery period compared to the first procedure. There were no early or late postoperative complications. Histological examination of the 12 tissue doughnuts resected during the second SH showed no smooth muscle fibres in any of the patients. After 12 months of follow up, 10 patients with repeated SH remained asymptomatic, while 2 had recurrent bleeding. CONCLUSION: Repeat SH can be performed safely and reliably without risk of complications, but the second SH is associated with more pain and longer recovery time.

Number of retrieved lymph nodes and survival in node-negative patients undergoing laparoscopic colorectal surgery for cancer.

BACKGROUND: The number of retrieved lymph nodes in colorectal cancer resection may have an impact on staging and survival. Examination of at least 12 nodes has become a quality measure for adequate surgical practice. To evaluate the impact of the number of retrieved lymph nodes in laparoscopic colorectal surgery for cancer on node-negative patients' survival. METHODS: Evaluation of our prospective in-hospital collected data of patients that underwent laparoscopic surgery for curable colorectal cancer over a 5-year period. Long-term data were collected from our outpatient's clinic data and personal contact when necessary. RESULTS: During a 5-year period since September 2003,173 patients were operated laparoscopically for curable colorectal cancer. Of the 117 patients who were node negative, 85 node-negative patients (72%) had 12 or more evaluated lymph nodes (mean, 18.3 + 2.4), while 32 node-negative patients had less than 12 (mean, 8.3 + 6.2). Patients with fewer than 12 nodes evaluated had significantly more left-sided tumors, while patients with 12 nodes or more had more right-sided tumors. A comparison of 5-year disease free and overall Kaplan-Meier survival curves revealed no statistically significant difference between the two groups. CONCLUSIONS: Evaluation of less than 12 nodes may not necessarily impact patients' survival in node-negative patients undergoing laparoscopic resection for curable colorectal cancer. A lower number of nodes may be sufficient.

Effects of colonoscopy on intracranial pressure: observation in a large animal model.

BACKGROUND AND STUDY AIMS: Increased intra-abdominal pressure has been associated with increased intracranial pressure. Bowel insufflation during colonoscopy may increase the intra-abdominal pressure. It was hypothesized that colonoscopy may be associated with intracranial pressure elevation subsequent to an elevation in intra-abdominal pressure. MATERIALS AND METHODS: Colonoscopy was carried out in seven anesthetized pigs, and the colonoscope was advanced up to 60 cm from the anal verge. Insufflation was used to allow safe advancement of the colonoscope and to allow visualization of the colon, in the same way as in the procedure performed in humans. Intra-abdominal pressure was measured by determining the hydrostatic pressure in the urinary bladder. A subarachnoid screw was used to monitor intracranial pressure. The mean arterial blood pressure and intra-abdominal venous pressure were directly monitored via the femoral vessel access; all parameters were recorded before and during colonoscopy. RESULTS: A statistically significant elevation in intracranial pressure was demonstrated during colonoscopy. The average increase in intracranial pressure was 3.1 mm Hg. The intra-abdominal pressure and intra-abdominal venous pressure were also significantly elevated during the procedure. CONCLUSIONS: Colonoscopy may increase intracranial pressure due to an increase in intra-abdominal pressure. This may have clinical implications when colonoscopy is conducted in patients with brain pathology associated with high intracranial pressure.