Analysis of Presentation and Outcomes in Acute Limb Ischemia Patients During COVID-19 State of Emergency.

BACKGROUND: During the COVID-19 pandemic, cardiovascular patients were found to be presenting to hospitals with myocardial infarctions and cerebrovascular accidents at progressed disease states. We noticed a parallel in acute limb ischemia (ALI) patients presenting during Massachusetts' COVID-19 State of Emergency declaration. We question whether patients developed a hesitancy to seek medical attention at hospitals due to fear of COVID-19. Our objective was to compare acuity of ALI, interventions, and limb survival in patients presenting before, during, and after a state of emergency. METHODS: Four timeframes were set to compare patients presenting peri-2020 COVID-19 State of Emergency and patients presenting during a pre-pandemic era at a tertiary, academic institution. A reference period from 2019, Pre-State of Emergency period, State of Emergency period, and Post-State of Emergency period were designated. Patient characteristics, interventions, and outcomes data were collected. Unpaired t-test, ANOVA, and Chi-square statistical analyses were used. RESULTS: A total of 95 patients presenting with ALI were identified. Compared to Reference group, state of emergency group had more patients presenting with Rutherford Class III, 12.9% vs 35%, and less patient presenting with Class I, 45.1% vs 0%, P = .02. State of emergency group had more delayed presentations with ≥6 hours after symptom onset, 45% vs 85%, P = .01. Above-knee amputations were performed in 20% of patients during state of emergency and 31.6% for Post-State of Emergency, vs 6.5% in the Reference group; P = .03. There was no difference in intensive care unit admission, length of stay, or mortality between patients from different groups. CONCLUSION: During a state of emergency, ALI patients were noted to present later from symptom onset, have greater disease severity, and more likely to undergo amputations. We suspect delay in presentation and limb lost to be attributed to reluctance to seek immediate medical attention.

Patient misunderstanding of the academic hierarchy is prevalent and predictable.

BACKGROUND: Medical personnel introduce themselves to patients using titles that reflect their level of training, although these titles may not be inherently obvious to the patient. This study explored patient understanding of commonly used physician and student titles. MATERIALS AND METHODS: A survey was developed asking patients to match six mutually exclusive medical titles to six levels of training. Categories included attending physician, chief resident, resident, intern, medical student, and pre-medical student. Respondent age, gender, medical training, employment in a healthcare field, educational level, income, and number of visits to a physician per y were requested. A brief intervention was then performed in which a second group of patients were advised of the designations and then asked to match the same categories. RESULTS: A total of 365 surveys were collected from the first group and 102 from the second group. Respondents accurately identified the level of training required for all six titles in only 44.5% of surveys collected, and in 52.0% after the intervention. Patients with at least some college education or income>$50,000 per y were more likely to answer correctly (P<0.001). On the other hand, even respondents with graduate degrees or incomes>$100,000 per y had difficulty correctly identifying the training of all team members. CONCLUSIONS: Patients do not understand the distinctions in training of surgical team members, especially those patients with decreased income or education; therefore, clinicians may wish to pay particular attention to these introductions. The survey did identify this as being important to patients.

A comparative study of handsewn versus stapled gastrojejunal anastomosis in laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: The two basic techniques available in which to perform the gastrojejunal (GJ) anastomosis during a laparoscopic Roux-en-Y gastric bypass (LRYGBP) are stapled and handsewn. Few outcomes differences have been noted between the two to recommend one as a superior approach. We present our findings in comparison of the two methods. METHODS: This is a retrospective review of all patients who underwent LRYGBP at a single institution during a 3-year period. The two different techniques that were used were a linear stapled and handsewn anastomosis with an anastomotic diameter of 18 mm. The groups were compared for postoperative complications, including stricture, anastomotic leak, and the need for early reoperation. All patients were followed up for a minimum period of 8 months. RESULTS: A total of 222 patients were analyzed after excluding 4 patients: 3 for revisional surgery and 1 for conversion to open. There were 99 patients in the stapled group and 123 in the handsewn group. In both groups, patients were predominantly female. The average age was 42.63 in the stapled group and 44.33 in the handsewn group (P = 0.218). Body mass index was 48.23 in the stapled group and 47.91 in the handsewn group (P = 0.733). Stricture rate in the stapled group was 10.1% (10/99) and 4.1% (5/123) in the handsewn group (P = 0.076). Four patients from the stapled group (4.08%) and six from the handsewn group (4.88%) needed early reoperation. One patient in each group had a GJ anastomotic leak (0.9%). There were no deaths. CONCLUSIONS: The incidence of anastomotic stricture tends to be lower with a handsewn technique with lower operative time. No difference was appreciated in the anastomotic leak or reexploration rate with either technique.

The learning curve with single-port cholecystectomy.

OBJECTIVES: Single-port surgery is a rapidly advancing technique in laparoscopic surgery. Currently, there is limited evidence on the learning curve and practicality of performing single-port laparoscopic cholecystectomy. METHODS: Single-port cholecystectomy was performed on 20 consecutive patients for biliary dyskinesia, symptomatic cholelithiasis, or acute cholecystitis. The Tri-Port was placed in the umbilicus, and a combination of straight and articulating instruments were utilized. Patient characteristics and outcomes were reviewed, and a comparison was made with the prior 20 consecutive laparoscopic cholecystectomies performed using the 3-port technique. RESULTS: Characteristics were similar in both groups. The 3-port cholecystectomy had a mean time of 65.7 minutes, and patients had an average body mass index of 28.16. The first single-port cholecystectomy took 160 minutes with sequential improvement to the sixth case of 66 minutes with a mean of 68.2 minutes for the last 15 single-port cases. The average patient body mass index was 30.24. No major complications occurred. CONCLUSION: The largest series to date of single-port cholecystectomy for multiple degrees of biliary disease is presented. This study validates that this technique can be applied effectively and performed in comparable operative times to traditional 3-port cholecystectomy with a learning curve of approximately 5 cases.

Muscle-specific BCL2 expression ameliorates muscle disease in laminin {alpha}2-deficient, but not in dystrophin-deficient, mice.

To examine the role of apoptosis in neuromuscular disease progression, we have determined whether pathogenesis in dystrophin-deficient (mdx) and laminin alpha2-deficient (Lama2-null) mice is ameliorated by overexpression of the anti-apoptosis protein BCL2 in diseased muscles. The mdx mice are a model for the human disease, Duchenne muscular dystrophy (DMD), and the Lama2-null mice are a model for human congenital muscular dystrophy type 1A (MDC1A). For these studies, we generated transgenic mice that overexpressed human BCL2 under control of muscle-specific MyoD or MRF4 promoter fragments. We then used cross-breeding to introduce the transgenes into diseased mdx or Lama2-null mice. In mdx mice, we found that overexpression of BCL2 failed to produce any significant differences in muscle pathology. In contrast, in the Lama2-null mice, we found that muscle-specific expression of BCL2 led to a several-fold increase in lifespan and an increased growth rate. Thus, BCL2-mediated apoptosis appears to play a significant role in pathogenesis of laminin alpha2 deficiency, but not of dystrophin deficiency, suggesting that therapies designed to ameliorate disease by inhibition of apoptosis are more likely to succeed in MDC1A than in DMD.

Immortalization of mouse myogenic cells can occur without loss of p16INK4a, p19ARF, or p53 and is accelerated by inactivation of Bax.

BACKGROUND: Upon serial passaging of mouse skeletal muscle cells, a small number of cells will spontaneously develop the ability to proliferate indefinitely while retaining the ability to differentiate into multinucleate myotubes. Possible gene changes that could underlie myogenic cell immortalization and their possible effects on myogenesis had not been examined. RESULTS: We found that immortalization occurred earlier and more frequently when the myogenic cells lacked the pro-apoptotic protein Bax. Furthermore, myogenesis was altered by Bax inactivation as Bax-null cells produced muscle colonies with more nuclei than wild-type cells, though a lower percentage of the Bax-null nuclei were incorporated into multinucleate myotubes. In vivo, both the fast and slow myofibers in Bax-null muscles had smaller cross-sectional areas than those in wild-type muscles. After immortalization, both Bax-null and Bax-positive myogenic cells expressed desmin, retained the capacity to form multinucleate myotubes, expressed p19ARF protein, and retained p53 functions. Expression of p16INK4a, however, was found in only about half of the immortalized myogenic cell lines. CONCLUSIONS: Mouse myogenic cells can undergo spontaneous immortalization via a mechanism that can include, but does not require, loss of p16INK4a, and also does not require inactivation of p19ARF or p53. Furthermore, loss of Bax, which appears to be a downstream effector of p53, accelerates immortalization of myogenic cells and alters myogenesis.