Robotic transversus abdominis release (TAR) for ventral hernia repairs is associated with low surgical site occurrence rates and length of stay despite increasing modifiable comorbidities.

PURPOSE: Modifiable comorbidities (MCMs) have previously been shown to complicate postoperative wound healing occasionally leading to surgeon hesitancy to repair ventral hernias prior to preoperative optimization of comorbidities. This study describes the effects of MCMs on surgical site occurrences (SSOs) and hospital length of stay (LOS) following robotic transversus abdominis release (TAR) with poly-4-hydroxybutyrate (P4HB) resorbable biosynthetic mesh retromuscular sublay for ventral hernia repair in patients who had not undergone preoperative optimization. METHODS: A single-surgeon retrospective review was performed for patients who underwent the robotic TAR procedure with P4HB mesh between January 2015 and May 2022. Patients were stratified by the amount of MCMs present: 0, 1, or 2 + . MCMs included obesity, diabetes, and current tobacco use. Patient data was analyzed for the first 60 days following their operation. Primary outcomes included 60-day SSO rates and hospital LOS. RESULTS: Three hundred and thirty-four subjects met the inclusion criteria for SSO and prolonged LOS analysis. 16.8% had no MCM, 56.1% had 1 MCM, and 27% had 2 + MCMs. No significant difference in SSO was seen between the 3 groups; however, having 2 + MCMs was significantly associated with increased odds of SSO (odds ratio 3.25, P = .019). When the groups were broken down, only having a history of diabetes plus obesity was associated with significantly increased odds of SSO (odds ratio 3.54, P = .02). No group showed significantly increased odds of prolonged LOS. CONCLUSION: 2 + MCMs significantly increase the odds of SSO, specifically in patients who have a history of diabetes and obesity. However, the presence of any number of MCMs was not associated with increased odds of prolonged LOS.

Differential impact of maternal and paternal ethnicity on the pattern of fat distribution in infants at age 3 months.

BACKGROUND: As ethnicity is typically recorded as a single demographic variable in clinical studies, little is known about the relative impact of maternal vs. paternal ethnicity on fat distribution. OBJECTIVES: The objective of this study was to determine whether there is a differential impact of maternal and paternal ethnicity on infant adiposity. METHODS: Three hundred fifty-five infants underwent anthropometric assessment at age 3 months, including skin-fold thickness (SFT) measurement at subscapular, suprailiac and triceps. Maternal (M) and paternal (P) ethnicity were classified as white (M = 241, P = 252), Asian (M = 50, P = 42) or other (M = 64, P = 61). RESULTS: Infants with either Asian mother (compared with white) or Asian father (compared with white) had increased subscapular, suprailiac and triceps SFT (all P < 0.05). On logistic regression analysis, however, only maternal Asian ethnicity (compared with white) independently predicted the likelihood of an infant being in the highest tertile for SFT at subscapular (odds ratio [OR] = 2.72, 95% confidence interval 1.17-6.34, P = 0.02), suprailiac (OR = 3.56, 1.51-8.42, P = 0.004) and triceps (OR = 3.26, 1.40-7.55, P = 0.005). In contrast, paternal Asian ethnicity was independently associated with sum of SFT only (OR = 2.46, 1.02-5.97, P = 0.04). CONCLUSION: Maternal and paternal Asian ethnicity have differential effects on infant fat distribution. Future clinical studies on obesity and fat composition should consider the distinct contributions of both parents to the ethnic classification of participants.

Adolescents with severe obesity: outcomes of participation in an intensive obesity management programme.

BACKGROUND: Most interventions for childhood obesity are randomized controlled studies. Less is known about the effectiveness of clinical obesity programmes. OBJECTIVE: To assess outcomes in adolescents participating in the SickKids Team Obesity Management Program (STOMP) vs. a comparison group of obese adolescents. METHODS: Severely obese adolescents (n = 75) in STOMP (15.1 ± 1.8 years, body mass index [BMI] 44.8 ± 7.8 kg m(-2) ) were compared with adolescents (n = 41) not in the programme (14.9 ± 2.0 years, BMI 34.5 ± 8.0 kg m(-2) ). Outcomes were change in BMI, cardiometabolic, psychological and health behaviour measures. RESULTS: At 6 months, STOMP patients' BMI was unchanged (0.08 ± 0.3; P = 0.79) and they reported improvements in quality of life and depression (-3.6 ± 1.4; P = 0.009), and increases in measures of readiness to change (RTC). Between-group differences in change between 0 and 6 months, in favour of STOMP patients, were observed for homeostatic measurement assessment-insulin resistance (HOMA-IR; -2.7 ± 1.0; P = 0.007), depression scores (-3.5 ± 1.7; P = 0.04), diet-RTC (0.6 ± 0.2; P < 0.001) and physical activity (1.7 ± 0.9; P = 0.05). At 12 months, STOMP patients increased BMI (0.8 ± 0.5; P = 0.07), but they exhibited decreased waist circumference (-7.4 ± 2.1 cm; P = 0.001) and HOMA-IR (-1.9 ± 0.6; P = 0.002). Between-group differences in change between 0 and 12 months, in favour of STOMP patients, were observed for waist circumference (-5.9 ± 2.4 cm; P = 0.01), HOMA-IR (-2.9 ± 0.7; P < 0.001) and diet-RTC (0.9 ± 0.2; P < 0.001). CONCLUSIONS: STOMP participants did not experience a significant reduction in BMI but did have improvements in cardiometabolic, psychological and health behaviour outcomes. Evaluation of paediatric clinical obesity programmes using multiple measures is essential to understanding real-world outcomes.

The effect of puberty on fat oxidation rates during exercise in overweight and normal-weight girls.

Excess weight is often associated with insulin resistance (IR) and may disrupt fat oxidation during exercise. This effect is further modified by puberty. While studies have shown that maximal fat oxidation rates (FOR) during exercise decrease with puberty in normal-weight (NW) and overweight (OW) boys, the effect of puberty in NW and OW girls is unclear. Thirty-three NW and OW girls ages 8-18 yr old completed a peak aerobic capacity test on a cycle ergometer. FOR were calculated during progressive submaximal exercise. Body composition and Tanner stage were determined. For each participant, a best-fit polynomial curve was constructed using fat oxidation vs. exercise intensity to estimate max FOR. In a subset of the girls, IR derived from an oral glucose tolerance test (n = 20), and leptin and adiponectin levels (n = 11) were assessed in relation to FOR. NW pre-early pubertal girls had higher max FOR [6.9 ± 1.4 mg·kg fat free mass (FFM)(-1)·min(-1)] than NW mid-late pubertal girls (2.2 ± 0.9 mg·kg FFM(-1)·min(-1)) (P = 0.002), OW pre-early pubertal girls (3.8 ± 2.1 mg·kg FFM(-1)·min(-1)), and OW mid-late pubertal girls (3.3 ± 0.9 mg·kg FFM(-1)·min(-1)) (P < 0.05). Bivariable analyses showed positive associations between FOR with homeostatic model assessment of IR (P = 0.001), leptin (P < 0.001), and leptin-to-adiponectin ratio (P = 0.001), independent of percent body fat. Max FOR decreased in NW girls during mid-late puberty; however, this decrease associated with puberty was blunted in OW girls due to lower FOR in pre-early puberty. The presence of IR due to obesity potentially masks the effect of puberty on FOR during exercise in girls.

Evaluation of proposed oral disposition index measures in relation to the actual disposition index.

Aims While the disposition index provides a useful measure of B-cell function, its calculation requires the performance of a frequently sampled intravenous glucose tolerance test (FSIVGTT). Recently, the demonstration of a hyperbolic relationship between indices of insulin secretion and insulin sensitivity derived from the oral glucose tolerance test (OGTT) has led to the introduction of two novel OGTT-based measures of B-cell function analogous to the disposition index: (i) the insulin secretion-sensitivity index-2 (ISSI-2) (defined as the ratio of the area-under-the-insulin-curve to the area-under-the-glucose curve, multiplied by the Matsuda index) and (ii) insulinogenic index (IGI)/fasting insulin. However, neither of these two measures has been directly compared with the disposition index. Methods Two hundred and thirteen non-diabetic children (122 boys, 91 girls) underwent both OGTT and FSIVGTT, allowing for the calculation of ISSI-2, IGI/fasting insulin and the disposition index. Results ISS1-2 and IGI/fasting insulin were strongly correlated with each other (r = 0.82, P < 0.0001). Both measures correlated with the disposition index, with ISSI-2 showing a modestly stronger association (ISSI-2: r = 0.24, P = 0.0003; IGI/fasting insulin: r = 0.21, P = 0.0022). Standardized linear regression analyses confirmed that the relationship between log ISSI-2 and the disposition index (standardized regression coefficient = 0.224, P = 0.001) was stronger than that between log IGI/fasting insulin and the disposition index (standardized regression coefficient = 0.166, P = 0.015). Conclusions The OGTT-derived measures ISSI-2 and IGI/fasting insulin exhibit modest correlations with the disposition index. These relationships require further assessment in other patient populations.

Joint action of two RNA degradation pathways controls the timing of maternal transcript elimination at the midblastula transition in Drosophila melanogaster.

Maternally synthesized RNAs program early embryonic development in many animals. These RNAs are degraded rapidly by the midblastula transition (MBT), allowing genetic control of development to pass to zygotically synthesized transcripts. Here we show that in the early embryo of Drosophila melanogaster, there are two independent RNA degradation pathways, either of which is sufficient for transcript elimination. However, only the concerted action of both pathways leads to elimination of transcripts with the correct timing, at the MBT. The first pathway is maternally encoded, is targeted to specific classes of mRNAs through cis-acting elements in the 3'-untranslated region and is conserved in Xenopus laevis. The second pathway is activated 2 h after fertilization and functions together with the maternal pathway to ensure that transcripts are degraded by the MBT.

Biliary lithotripsy.

At Baylor University Medical Center in Dallas, we began performing lithotripsy with the Medstone STS lithotripter for gallstones in January 1988 and in the first year treated 81 patients. Fifty-five of these patients were available for 4-month follow-up. We randomized half of the patients to receive ursodeoxycholic acid for 7 days prior to lithotripsy and gave all of the patients ursodeoxycholic acid after lithotripsy. Only 10.4 percent of the patients who contacted us ultimately proved to be candidates for lithotripsy. Gallstone fragmentation occurred in 95 percent of all patients and in 97 percent of those patients with solitary stones under 20 mm in size. The rate of clearance for solitary stones less than 20 mm in size was 50 percent. Unfavorable effects ascribable to lithotripsy were infrequent. All of the patients had pain before treatment, and one-third complained of biliary colic after treatment. Minor skin bruising which resolved in 1 to 5 days was found in 20 percent of the patients. This study lends credence to the findings of previous studies and demonstrates that lithotripsy combined with bile acid therapy is a useful therapy for cholelithiasis.

Biliary lithotripsy in the United States.

We have reported the case of a patient whose gallstone was completely fragmented by lithotripsy; all demonstrable particles passed completely within 36 hours. The patient required no analgesics and had no complications from the procedure. This is the first case of gallstones successfully treated solely by a combination of lithotripsy and bile acid therapy in the United States under an FDA-approved IDE protocol.

Laser photocoagulation for the treatment of acute peptic-ulcer bleeding. A randomized controlled clinical trial.

We tested the hypothesis that therapeutic endoscopy using the Nd:YAG (neodymium:yttrium-aluminum-garnet) laser would benefit patients with acute peptic-ulcer bleeding. Over 43 months, 174 patients with active bleeding (n = 32) or stigmata of recent bleeding (n = 142) due to peptic ulcers were randomly assigned during endoscopy to either standard treatment with laser photocoagulation or therapy without photocoagulation. There were no significant differences in a number of outcomes between the group treated with laser photocoagulation and the control group. Continued bleeding or rebleeding was observed in 22 percent of the laser-treated group and in 20 percent of the control group. Urgent surgery was necessary in 16 percent of the laser-treated patients and in 17 percent of the controls. Laser-treated patients spent a mean of 41 hours in the intensive care unit, and controls spent a mean of 32 hours. The mean hospital stay was 12 days in the laser-treated group and 11 days in the control group. One death occurred in each group. When patients with active bleeding were analyzed separately, there was no significant difference in outcome, even though laser photocoagulation stopped active bleeding in 88 percent of cases. Among patients with visible vessels, rebleeding occurred in 5 of 14 (36 percent) who received laser treatment and 2 of 15 (13 percent) who did not. Laser treatment precipitated bleeding in four patients and duodenal perforation in one. We conclude that Nd:YAG-laser photocoagulation does not benefit patients with acute upper gastrointestinal bleeding from peptic ulcers.

Percutaneous endoscopic gastrostomy--to push or pull. A prospective randomized trial.

A prospective randomized study was undertaken to evaluate the Ponsky-Gauderer and Sachs-Vine types of gastrostomy kits. The techniques, complications, morbidity, and mortality with each type of device are compared. Both devices are found to compare favorably to the traditional surgically placed gastrostomy.

Preliminary experience with hydrostatic balloon dilation of gastric outlet obstruction.

In treating a group of 15 patients with gastric outlet obstruction, 12 (80%) had good to excellent relief of symptoms. Two patients required surgical intervention. One patient has symptoms that were persistent but mild enough to forego surgery. Balloon dilation offers an alternative to the surgical management of gastric outlet obstruction.

X-linked lymphoproliferative syndrome registry report.

Immune deficiency, especially to the Epstein-Barr virus, and increased susceptibility to fatal infectious mononucleosis, acquired agammoglobulinemia, and lymphoma are the cardinal features of the X-linked lymphoproliferative syndrome. Since the establishment of the XLP Registry in September, 1978, 59 affected males in seven unrelated kindreds were comprehensively studied. A spectrum of lymphoproliferative phenotypes was observed. Thirty-four patients (57%) died from infectious mononucleosis, eight (14%) had fatal infectious mononucleosis with lymphoma (immunoblastic sarcoma), nine (15%) had depressed immunity following EBV infection, and eight (14%) developed lymphoma. Several patients with XLP lacked EBV antibodies despite infection by EBV. The results of this study suggest that EBV can be an oncogenic agent in patients who are immune deficient with XLP.