Implementation of an enhanced recovery protocol in patients undergoing mastectomies for breast cancer: an interrupted time-series design.

Background: We reviewed internal data and the current literature to update our enhanced recovery protocol (ERP) for patients undergoing a total breast mastectomy. Following implementation, the protocol was audited by chart review and compliance reminders were sent through email. Objective: Our primary research aim was to examine the protocol compliance following the update. Our secondary aims were to examine the association between the change in protocol and the rates of postoperative nausea and vomiting (PONV) and hematoma formation requiring reoperation. Methods: We retrospectively obtained data extracted from the electronic medical record. To test for a difference in outcomes before versus after implementation of the protocol we used multivariable logistic regression with the primary comparisons excluding a â€‹± â€‹one-month window and secondary comparisons excluding a â€‹± â€‹three-month window from the date of implementation. Results: Our cohort included 5853 unique patients. Total intravenous anesthesia (TIVA) compliance increased by 17%-52% (P â€‹< â€‹0.001) and the use of intraoperative ketorolac dropped from 44% to nearly no utilization (0.7%; P â€‹< â€‹0.001). The rate of reoperation due to bleeding decreased from 3.6% to 2.6% after implementation with the adjusted decrease being 1.0% (bootstrap 95% CI, 0.11%, 1.9%; P â€‹= â€‹0.053) excluding a â€‹± â€‹1 month window and 1.2% (bootstrap 95% CI, 0.24%, 2.0%; P â€‹= â€‹0.028) excluding a â€‹± â€‹3-month window. The rate of rescue antiemetics dropped by 6.4% (95% CI, 3.9%, 9.0%). Conclusions: We were able to improve compliance for nearly all components of the protocol which translated to a meaningful change in an important patient outcome.

Use of a Mouse Model of Experimentally Induced Endometriosis to Evaluate and Compare the Effects of Bisphenol A and Bisphenol AF Exposure.

BACKGROUND: Endometriosis is a gynecological disease affecting 1 in 10 women of reproductive age. Endometriosis incidence has risen; however, whether this rise is due to disease awareness or environmental contamination is not known. OBJECTIVE: The objective of this study was to determine if bisphenol A (BPA) or bisphenol AF (BPAF) potentiate the development of endometriosis and if hormonal status alters how toxicant exposure affects disease. METHODS: A mouse model of endometriosis, where minced uterine tissue is injected into the peritoneal cavity of a host mouse, was used to examine the effects of BPA and BPAF on endometriosis lesion development in ovariectomized and hormonally intact mice. BPA and BPAF were delivered through diet to include no-observed-adverse-effect-level (NOAEL) and the low-observed-adverse-effect-level (LOAEL) exposure levels. After six weeks (at necropsy), lesions, ovaries, and blood were collected to examine characteristics, gene expression, and hormonal regulation. RESULTS: BPA and BPAF treatments affected endometriosis in a manner specific to dose and hormonal status of the host mouse. Estrogen and endometriosis-mediated differences in lesion target gene expression also depended on hormonal status. In intact mice, ovarian steroidogenic pathways were disrupted, progesterone levels were lowered, and atretic oocyte numbers were higher with toxicant exposure. BPAF, more so than BPA, resulted in more endometriosis lesion growth, but both toxicants disrupted normal ovarian signaling. CONCLUSION: These findings further our understanding of the effects and hormonal impacts of BPA and BPAF on endometriosis perturbation in ovariectomized and hormonally intact mice. BPAF appeared to be similar if not more estrogenic than BPA and may be affecting an environmental contribution of the increased incidence of endometriosis. https://doi.org/10.1289/EHP3802.

Endometriosis: where are we and where are we going?

Endometriosis currently affects ~5.5 million reproductive-aged women in the U.S. with symptoms such as painful periods (dysmenorrhea), chronic pelvic pain, pain with intercourse (dyspareunia), and infertility. It is defined as the presence of endometrial tissue outside the uterine cavity and is found predominately attached to sites within the peritoneal cavity. Diagnosis for endometriosis is solely made through surgery as no consistent biomarkers for disease diagnosis exist. There is no cure for endometriosis and treatments only target symptoms and not the underlying mechanism(s) of disease. The nature of individual predisposing factors or inherent defects in the endometrium, immune system, and/or peritoneal cavity of women with endometriosis remains unclear. The literature over the last 5 years (2010-2015) has advanced our critical knowledge related to hormones, hormone receptors, immune dysregulation, hormonal treatments, and the transformation of endometriosis to ovarian cancer. In this review, we cover the aforementioned topics with the goal of providing the reader an overview and related references for further study to highlight the progress made in endometriosis research, while concluding with critical areas of endometriosis research that are urgently needed.

Tissue-engineered provisional matrix as a novel approach to enhance diabetic wound healing.

Inherent pathologies associated with diabetic wound microenvironment including increased proteolysis, inflammatory dysregulation, and impaired neovascularization prevent timely resolution of chronic diabetic ulcers. It is hypothesized that augmentation of local wound microenvironment with a stable provisional matrix formed by proteolysis-resistant angiogenic peptide nanofibers (NFs) will create permissive environment for attenuated inflammation, enhanced neovascularization, and improved diabetic wound healing. Using murine excisional wound healing models, full-thickness dorsal skin wounds were treated with either NFs or control solutions (phosphate buffered saline; hyaluronic acid) and analyzed for morphology, inflammatory response, neovascularization, and biomechanical properties. NF treatment of diabetic wounds stimulated formation of a robust pro-angiogenic in situ tissue-engineered provisional matrix leading to a significant decrease in wound inflammatory cell infiltration and proinflammatory interleukin-6 levels, a significant increase in endothelial and endothelial progenitor cell infiltration, vascular endothelial growth factor levels, and neovascularization (day 7), as well as improved wound morphology, accelerated wound closure, and significantly stronger repair tissue (day 28). These results suggest that appropriate design of provisional matrix may compensate for some of the complex disruptions in diabetic wound microenvironment and provide missing cues to cells and direct in situ responses toward improved healing, which is promising for future development of new therapies for diabetic ulcers.

Characterization of endothelial progenitor cells mobilization following cutaneous wounding.

Bone marrow (BM)-derived endothelial progenitor cells (EPCs) are known to play an important role in neovascularization and wound healing. We investigated the temporal effects of cutaneous wounding on EPC surface markers within the peripheral blood and BM, and to better understand the role of the stromal cell-derived factor-1 alpha (SDF-1alpha/CXCR4) axis on EPC mobilization after wounding. FVB/NJ mice were administered bilateral 8 mm circular full-thickness skin wounds. Peripheral blood and BM were isolated at daily intervals postwounding through day 7 and analyzed for EPC mobilization characteristics and levels of SDF-1alpha. Cutaneous wounding was found to cause a transient increase in EPC mobilization that peaked on day 3. In contrast, SDF-1alpha protein within blood plasma was observed to significantly decrease on days 3, 4, and 7 following cutaneous wounding. BM levels of SDF-1alpha protein decreased to a nadir on day 3, the same day as peak mobilization was observed to occur. The decrease in BM SDF-1alpha protein levels was also associated with a decrease in SDF-1alpha mRNA suggesting transcriptional down-regulation as a contributing factor. This study for the first time characterizes EPC mobilization following cutaneous wounding in mice and supports a major role for the SDF-1alpha/CXCR4 axis in regulating mobilization within the BM, without evidence for systemic increases in SDF-1alpha.

Phase I study of H5.020CMV.PDGF-beta to treat venous leg ulcer disease.

Venous leg ulcers are a prevalent nonhealing wound of the lower extremity. Although topically applied growth factors successfully improve wound repair in animal studies, similar studies on humans with venous leg ulcers have not been successful. This study was designed to evaluate the acute safety and biologic feasibility of peri-ulcer injection of a replication-incompetent adenoviral construct expressing platelet-derived growth factor-beta (PDGF-beta). In this phase I study, we demonstrate the initial safety, feasibility, and biologic plausibility of using H5.020CMV.PDGF-beta to treat venous leg ulcer disease.

Plakoglobin is required for maintenance of the cortical actin skeleton in early Xenopus embryos and for cdc42-mediated wound healing.

Early Xenopus embryos are large, and during the egg to gastrula stages, when there is little extracellular matrix, the cytoskeletons of the individual blastomeres are thought to maintain their spherical architecture and provide scaffolding for the cellular movements of gastrulation. We showed previously that depletion of plakoglobin protein during the egg to gastrula stages caused collapse of embryonic architecture. Here, we show that this is due to loss of the cortical actin skeleton after depletion of plakoglobin, whereas the microtubule and cytokeratin skeletons are still present. As a functional assay for the actin skeleton, we show that wound healing, an actin-based behavior in embryos, is also abrogated by plakoglobin depletion. Both wound healing and the amount of cortical actin are enhanced by overexpression of plakoglobin. To begin to identify links between plakoglobin and the cortical actin polymerization machinery, we show here that the Rho family GTPase cdc42, is required for wound healing in the Xenopus blastula. Myc-tagged cdc42 colocalizes with actin in purse-strings surrounding wounds. Overexpression of cdc42 dramatically enhances wound healing, whereas depletion of maternal cdc42 mRNA blocks it. In combinatorial experiments we show that cdc42 cannot rescue the effects of plakoglobin depletion, showing that plakoglobin is required for cdc42-mediated cortical actin assembly during wound healing. However, plakoglobin does rescue the effect of cdc42 depletion, suggesting that cdc42 somehow mediates the distribution or function of plakoglobin. Depletion of alpha-catenin does not remove the cortical actin skeleton, showing that plakoglobin does not mediate its effect by its known linkage through alpha-catenin to the actin skeleton. We conclude that in Xenopus, the actin skeleton is a major determinant of cell shape and overall architecture in the early embryo, and that plakoglobin plays an essential role in the assembly, maintenance, or organization of this cortical actin.