Modern trends in minimally invasive versus open hepatectomy for colorectal liver metastasis: an analysis of ACS-NSQIP.

BACKGROUND: Surgical resection of colorectal liver metastasis (CRLM) provides the best opportunity for prolonged survival. Eligibility for metastasectomy has expanded with technical advancements including parenchymal-sparing hepatectomy (PSH). Meanwhile, enthusiasm for minimally invasive surgery (MIS) has increased, though this approach may be preferentially utilized for technically straightforward cases. The purpose of this study is to characterize modern trends in open versus MIS approaches to partial hepatectomy and anatomic hepatectomy for CRLM within a nationwide cohort. METHODS: The American College of Surgeons' National Surgical Quality Improvement Program (ACS-NSQIP) was used to investigate trends in MIS versus open hepatectomy for CRLM from 2015 to 2019. We examined baseline clinicopathologic and disease-related characteristics and compared trends in treatments over the study period. RESULTS: A total of 7457 patients undergoing hepatectomy for CRLM were identified (1367 MIS, 6090 open). Patients had similar clinicopathologic features between the two groups. Patients undergoing MIS resection less frequently received neoadjuvant therapy (51.1% vs 64.0%, p < 0.001) or concurrent intraoperative ablation (15.0% vs 21.3%, p < 0.001). Patients with tumors < 2 cm (34.9% vs 26.8%, p < 0.001) or only one to two tumors (82.8% vs 65.0%, p < 0.001) more commonly underwent MIS. MIS and open partial hepatectomies both significantly increased over the study period, but open partial hepatectomy increased at a greater rate than MIS (p < 0.001). Rates of anatomic resections have remained the same, with a greater proportion performed using an open approach (34.9% vs 16.4%, p < 0.001). Rates of operations consisting of > 1 concurrent partial hepatectomy are stable, but significantly more likely to be performed open (p < 0.001). CONCLUSIONS: Hepatectomy for CRLM has increased from a rise in partial hepatectomy, potentially translating to increased use of PSH. Current trends suggest MIS approaches appear to be increasing, but selectively implemented for patients with less technically demanding disease characteristics. Educational efforts should be directed towards increased dissemination of parenchymal-sparing MIS techniques for more complex resections.

Correction to: Serum sodium and intracranial pressure changes after desmopressin therapy in severe traumatic brain injury patients: a multi-centre cohort study.

Following publication of the original article [1], we were notified that the collaborators' names part of the "The TBI Collaborative" group has not been indexed in Pubmed. Below the collaborators names full list.

Serum sodium and intracranial pressure changes after desmopressin therapy in severe traumatic brain injury patients: a multi-centre cohort study.

BACKGROUND: In traumatic brain injury (TBI) patients desmopressin administration may induce rapid decreases in serum sodium and increase intracranial pressure (ICP). AIM: In an international multi-centre study, we aimed to report changes in serum sodium and ICP after desmopressin administration in TBI patients. METHODS: We obtained data from 14 neurotrauma ICUs in Europe, Australia and UK for severe TBI patients (GCS ≤ 8) requiring ICP monitoring. We identified patients who received any desmopressin and recorded daily dose, 6-hourly serum sodium, and 6-hourly ICP. RESULTS: We studied 262 severe TBI patients. Of these, 39 patients (14.9%) received desmopressin. Median length of treatment with desmopressin was 1 [1-3] day and daily intravenous dose varied between centres from 0.125 to 10 mcg. The median hourly rate of decrease in serum sodium was low (- 0.1 [- 0.2 to 0.0] mmol/L/h) with a median period of decrease of 36 h. The proportion of 6-h periods in which the rate of natremia correction exceeded 0.5 mmol/L/h or 1 mmol/L/h was low, at 8% and 3%, respectively, and ICPs remained stable. After adjusting for IMPACT score and injury severity score, desmopressin administration was independently associated with increased 60-day mortality [HR of 1.83 (1.05-3.24) (p = 0.03)]. CONCLUSIONS: In severe TBI, desmopressin administration, potentially representing instances of diabetes insipidus is common and is independently associated with increased mortality. Desmopressin doses vary markedly among ICUs; however, the associated decrease in natremia rarely exceeds recommended rates and median ICP values remain unchanged. These findings support the notion that desmopressin therapy is safe.

Kinetic modelling of serum S100b after traumatic brain injury.

BACKGROUND: An understanding of the kinetics of a biomarker is essential to its interpretation. Despite this, little kinetic modelling of blood biomarkers can be found in the literature. S100b is an astrocyte related marker of brain injury used primarily in traumatic brain injury (TBI). Serum levels are expected to be the net result of a multi-compartmental process. The optimal sample times for TBI prognostication, and to follow injury development, are unclear. The purpose of this study was to develop a kinetic model to characterise the temporal course of serum S100b concentration after primary traumatic brain injury. METHODS: Data of serial serum S100b samples from 154 traumatic brain injury patients in a neurointensive care unit were retrospectively analysed, including only patients without secondary peaks of this biomarker. Additionally, extra-cranial S100b can confound samples earlier than 12 h after trauma and were therefore excluded. A hierarchical, Bayesian gamma variate kinetic model was constructed and the parameters estimated by Markov chain Monte Carlo sampling. RESULTS: We demonstrated that S100b concentration changes dramatically over timescales that are clinically important for early prognostication with a peak at 27.2 h (95 % credible interval [25.6, 28.8]). Baseline S100b levels was found to be 0.11 µg/L (95 % credible interval [0.10, 0.12]). CONCLUSIONS: Even small differences in injury to sample time may lead to marked changes in S100b during the first days after injury. This must be taken into account in interpretation. The model offers a way to predict the peak and trajectory of S100b from 12 h post trauma in TBI patients, and to identify deviations from this, possibly indicating a secondary event. Kinetic modelling, providing an equation for the peak and projection, may offer a way to reduce the ambiguity in interpretation of, in time, randomly sampled acute biomarkers and may be generally applicable to biomarkers with, in time, well defined hits.

P2X7-related modulation of pathological nociception in rats.

Growing evidence supports a role for the immune system in the induction and maintenance of chronic pain. ATP is a key neurotransmitter in this process. Recent studies demonstrate that the glial ATP receptor, P2X7, contributes to the modulation of pathological pain. To further delineate the endogenous mechanisms that are involved in P2X7-related antinociception, we utilized a selective P2X7 receptor antagonist, A-438079, in a series of in vivo and in vitro experiments. Injection of A-438079 (10-300 micromol/kg, i.p.) was anti-allodynic in three different rat models of neuropathic pain and it attenuated formalin-induced nocifensive behaviors. Using in vivo electrophysiology, A-438079 (80 micromol/kg, i.v.) reduced noxious and innocuous evoked activity of different classes of spinal neurons (low threshold, nociceptive specific, wide dynamic range) in neuropathic rats. The effects of A-438079 on evoked firing were diminished or absent in sham rats. Spontaneous activity of all classes of spinal neurons was also significantly reduced by A-438079 in neuropathic but not sham rats. In vitro, A-438079 (1 microM) blocked agonist-induced (2,3-O-(4-benzoylbenzoyl)-ATP, 30 microM) current in non-neuronal cells taken from the vicinity of the dorsal root ganglia. Furthermore, A-438079 dose-dependently (0.3-3 microM) decreased the quantity of the cytokine, interleukin-1beta, released from peripheral macrophages. Thus, ATP, acting through the P2X7 receptor, exerts a wide-ranging influence on spinal neuronal activity following a chronic injury. Antagonism of the P2X7 receptor can in turn modulate central sensitization and produce antinociception in animal models of pathological pain. These effects are likely mediated through immuno-neural interactions that affect the release of endogenous cytokines.

Alpha-(trifluoromethyl)amine derivatives via nucleophilic trifluoromethylation of nitrones.

(Trifluoromethyl)trimethylsilane (TMSCF(3)) reacts with nitrones to afford alpha-(trifluoromethyl)hydroxylamines protected as O-trimethylsilyl ethers. Potassium t-butoxide initiates the nucleophilic trifluoromethylation. The reaction works best with alpha,N-diaryl nitrones, and the conditions are compatible with a range of substituents on the aryl groups. Acidic deprotection of the nitrone/TMSCF(3) adducts generates alpha-(trifluoromethyl)hydroxylamines. Catalytic hydrogenation of the adducts produces alpha-(trifluoromethyl)amines. Nitrone/TMSCF(3) adducts with strong electron-withdrawing groups on the alpha-aryl ring or heterocyclic alpha-aryl groups undergo an elimination/addition sequence to generate alpha,alpha-bis(trifluoromethyl)amines. Nitrones with alkyl groups bound directly to the 1,3-dipolar moiety fail to react with TMSCF(3), but trifluoromethylation of beta,gamma-unsaturated nitrones followed by reduction of the double bond can circumvent this limitation.

5'-flanking sequences required for efficient transcription in vitro of 5S RNA genes, in the related nematodes Caenorhabditis elegans and Caenorhabditis briggsae.

In the nematode C. elegans, we had previously observed apparent species specificity in 5S RNA transcription. We have now undertaken a further study of 5S RNA gene transcription in this organism and in the related nematode, C. briggsae; the latter was chosen because it might show evolutionarily conserved, functionally important features. Deletion mutagenesis and transcription in vitro, followed by more precise replacements of short blocks of 5' sequence, show that a short, TATA-like sequence at -25 is essential for efficient transcription in vitro of the 1.0-kb C. elegans 5S DNA repeat, and of both C. briggsae 0.7- and 1.0-kb 5S DNA repeats. Internal sequences within the 5S RNA gene appear to be required and can compete for limiting transcription components, whereas 5' flanking sequences do not. These observations suggest that the process of 5S RNA transcription is similar in these nematodes and other higher eukaryotes.

L-type calcium channels regulate gastrin release from human antral G cells.

In mRNA samples isolated from a gastrin (G) cell-enriched human antral cell preparation, reverse transcription-polymerase chain reaction identified products encoding part of the alpha 1-subunit of class C and D L-type voltage-dependent Ca2+ channels (VDCCs). Analysis of the polymerase chain reaction products demonstrated a 100% homology with the known human gene sequences. An antibody to the class D alpha 1-subunit immunostained 30-40% of the cultured cells; of these 90% were gastrin immunoreactive. Gastrin release stimulated by terbutaline (beta 2-agonist) and forskolin was abolished by blockade of L-type VDCCs; the effect of 3.6 mM extracellular Ca2+ was only partially reversed. In G cells the rise in intracellular Ca2+ observed in response to increasing extracellular Ca2+ from 0.5 to 3.6 mM was reduced by nitrendipine. These results indicated that human antral cells expressed class C and D L-type VDCCs. Activation of G cells with beta-adrenergic agonists required an influx of extracellular Ca2+ through these channels to stimulate gastrin release. However, activation of L-type channels was not the only mechanism underlying Ca(2+)-stimulated gastrin release.

Transvaginal ultrasonographic findings in surgically verified ectopic pregnancy.

OBJECTIVE: Our purpose was to evaluate transvaginal ultrasonographic findings in ectopic pregnancies for positive ultrasonographic sign(s). STUDY DESIGN: Eighty-nine patients admitted with an ectopic pregnancy from September 1987 through September 1989 were retrospectively reviewed. Sixty-nine had undergone transvaginal ultrasonography within 10 days before surgery. The ultrasonographic examinations were reviewed by four radiologists. RESULTS: Ultrasonography revealed adnexal masses in 54 patients (78%). Thirty-six masses had an appearance consistent with an adnexal ring. Twenty-four adnexal rings demonstrated a thin sonolucent area surrounding the ring, a "halo sign" (67%). A control group of 116 intrauterine pregnancies were evaluated by ultrasonography. Forty-one women had adnexal cysts. Twenty-seven of these had an adnexal ring; only two of these had halos. CONCLUSION: The halo sign is presumptive evidence of a living ectopic pregnancy and, when identified, may allow earlier diagnosis and intervention.

Platelet activating factor alters receptor-coupled function in the isolated perfused rat heart.

Sepsis induces primary myocardial dysfunction. Yet, both hyper- and hypodynamic cardiac states characterize the sepsis syndrome, suggesting a modulatory role of septic mediators. Platelet activating factor (PAF), implicated in the pathogenesis of sepsis, is an endogenous phospholipid with diverse intracellular and extracellular effects. The purpose of this study was to investigate the influence of PAF (1) upon basal mechanical function of the heart, (2) upon receptor-coupled function of the heart, and (3) on basal and stimulated myocardial function at differing concentrations. In order to focus on the relationship between PAF and cardiac mechanical function, rat hearts were isolated and crystalloid perfused using a modified Langendorf preparation. Separate hearts received intracoronary vehicle (5% ethanol, 2.5% BSA) or PAF (20 or 40 microM) as a bolus, followed 10 min later by 0.25 microM isoproterenol (beta-receptor agonist) infusion over 3 min. Both 20 and 40 microM PAF produced a rapid decrease in rate pressure product (RPP = HR X LVDPmax) relative to control (P < 0.05). The depressive effect of PAF upon basal myocardial function did not persist and by 10 min RPP was not different (P > 0.05) among the groups. Isoproterenol infusion increased (P < 0.05) RPP in all groups. However, hearts pretreated with 20 microM PAF demonstrated a greater (P < 0.05) response to beta-adrenergic stimulation relative to vehicle-pretreated controls. This amplified response to isoproterenol was not observed with pretreatment at a higher concentration of PAF (40 microM, P > 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

CT-guided fixation of sacral fractures and sacroiliac joint disruptions.

Open reduction and internal fixation (ORIF), the currently preferred method for treatment of unstable posterior pelvic and sacral fractures, has two significant disadvantages: the need for blind placement of the fixation screws and the occurrence of high complication rates. Advantages of computed tomographic (CT)-guided sacral fixation include direct visualization of the course of the screws and absence of significant complications. Eight patients with unstable but reducible sacral fractures or sacroiliac joint (SIJ) disruptions (seven unilateral and one bilateral) underwent CT-guided sacral fixation with use of the standard orthopedic A-O, 7.0-mm-diameter cannulated screw system. The guide pin was positioned across the fracture or SIJ by using depth and angulation measurements derived from the scout CT scans. After confirmation of the position of the pin with CT, the screw tract was drilled, and the cannulated screw was placed into position. Radiographic and clinical follow-up (5-9 months) showed healing with no significant complications in all eight patients. CT-guided sacral fixation is a safe alternative to ORIF in patients with reducible unstable pelvic fractures.

Pretreatment with a nontoxic derivative of endotoxin induces functional protection against cardiac ischemia/reperfusion injury.

We hypothesized that low-dose pretreatment of an intact animal with a nontoxic derivative of endotoxin, monophosphoryl lipid A (MPL), would induce protection against cardiac ischemia/reperfusion (I/R) injury. The purposes of this study were to investigate whether MPL pretreatment would induce functional protection against cardiac I/R injury, to delineate the temporal induction of protection, and to examine antioxidant enzyme induction as a mechanism of protection. Rats were administered a 5 mg/kg dose of MPL at 2 hours and 24 hours before a 25-minute, global, 37 degrees C ischemic insult followed by reperfusion (modified Langendorff). At 40 minutes of reperfusion, ventricular function was assessed (ventricular balloon; developed pressure, rate of contraction, rate of relaxation). Hearts from rats pretreated with MPL 24 hours before isolation exhibited preservation of ventricular function (p less than 0.05). After I/R, hearts from rats pretreated with MPL 24 hours before isolation had increased (p less than 0.05) catalase activity compared to saline pretreated controls and rats pretreated with MPL 2 hours before isolation. We conclude that (1) pretreatment with MPL induces functional protection against cardiac I/R injury, (2) protection (not evident at 2 hours) is maximal at 24 hours, suggesting enzyme induction, and (3) increased catalase activity correlates with the functional protection.

Primed neutrophils injure rat lung through a platelet-activating factor-dependent mechanism.

Bacterial lipopolysaccharide (LPS) promotes transient lung neutrophil sequestration. These LPS-primed neutrophils, when stimulated by an N-formyl peptide (FNLP), promote lung injury. We hypothesized that LPS-primed, FNLP-stimulated neutrophils promote lung injury through a platelet-activating factor (PAF)-dependent mechanism. Rats were pretreated with either saline or WEB2170, a PAF receptor antagonist (10 mg/kg po). One hour after pretreatment, rats were administered intraperitoneal LPS (salmonella typhimurium lipopolysaccharide, 500 micrograms/kg) followed 6 hr later by intravenous FNLP (250 micrograms/kg infused over 30 min). Two hours after the initiation of FNLP infusion, rats were sacrificed and assays were performed to measure: (1) lung neutrophil sequestration with myeloperoxidase (MPO) activity; (2) circulating neutrophil activation with nitroblue tetrazolium (NBT) staining, and (3) lung microvascular leak with 125I-albumin flux. We found that lung myeloperoxidase, circulating neutrophil NBT staining, and lung 125I-albumin flux were increased (P less than 0.05) in saline-pretreated LPS/FNLP rats, relative to control. While lung MPO remained increased (P less than 0.05) in WEB2170-pretreated LPS/FNLP rats, circulating neutrophil NBT and lung 125I-albumin flux were decreased (P less than 0.05) relative to those in saline-pretreated rats. We conclude that PAF mediates LPS/FNLP-induced neutrophil activation and lung injury, but is independent from lung neutrophil sequestration. Thus, lung neutrophil sequestration does not inevitably produce lung injury. Rather, neutrophils can accumulate in the lung without causing lung injury if neutrophil activation can be blocked.

Characterizing osteochondral lesions by magnetic resonance imaging.

In a double-blind prospective study, 12 patients with osteochondral lesions of either the knee or talus were studied using magnetic resonance imaging (MRI) prior to arthroscopic treatment. MRI correctly staged 11 of the 12 lesions. We developed a new staging system for osteochondral lesions, which accurately correlates MRI with arthroscopic findings.

Osteochondritis dissecans of the talus and knee: prospective comparison of MR and arthroscopic classifications.

The primary objective of this study was to determine if magnetic resonance (MR) could accurately predict the arthroscopic stage of osteochondritis dissecans lesions of the knee and ankle. Twelve patients, who were indicated for arthroscopy on either clinical or radiographic findings, underwent an MR examination prior to arthroscopy. All scans were performed on a 0.35 T magnet using the same spin echo sequence: repetition time 1,000 ms and echo time 40 ms. Magnetic resonance scans were interpreted prospectively (D.W.N.) and retrospectively (J.S.) by the radiologists without knowledge of the arthroscopic findings. Both radiologists predicted the exact grade in 11 of 12 patients. A single Grade 2 lesion was called Grade 3 by both radiologists. An MR staging classification has been developed that allows accurate preoperative staging of osteochondritis dissecans lesions of the talus and knee.

Two highly conserved transcribed regions in the 5S DNA repeats of the nematodes Caenorhabditis elegans and Caenorhabditis briggsae.

The 5S RNA genes of Caenorhabditis briggsae consist of approximately 65 copies of a 1 kb repeat unit and 20 copies of a related 0.7 kb repeat unit, organized in separate tandem clusters. DNA sequence comparisons with the 1kb 5S DNA repeat from the closely related nematode C. elegans show that the 5S RNA coding region is perfectly conserved. Both C. briggsae 1 kb and 0.7 kb repeats are also efficiently transcribed in vitro,suggesting that both represent functional 5S RNA genes. Surprisingly, a second block of 118 bp is also perfectly conserved between the 1 kb repeats,and is less well conserved in the 0.7 kb repeat. In C. elegans, this DNA is transcribed to produce and abundant 100 nt transcript (SL RNA) which participates in a trans-splicing process (Krause and Hirsh, Cell 49:753, 1987). This SL RNA region of the C. briggsae 1 kb 5S DNA repeat also appears to be transcribed in vivo, while the corresponding region of the 0.7 kb repeat is not.

Enlarged cisterna magna in trisomy 18: prenatal ultrasonographic diagnosis.

Ultrasonographic visualization of an enlarged cisterna magna was the initial clue that led to the prenatal diagnosis of trisomy 18 in five patients. Prenatal diagnosis of trisomy 18, a lethal defect, is important for proper patient counseling and management.

Unusual sequences, homologous to 5S RNA, in ribosomal DNA repeats of the nematode Meloidogyne arenaria.

There are sequences homologous to 5S ribosomal RNA in the ribosomal DNA (rDNA) repeats of the plant-parasitic nematode Meloidogyne arenaria. This is surprising, because in all other higher eukaryotes studied to date, the genes for 5S RNA are unlinked to and distinct from a tandem rDNA repeat containing the genes for 18S, 5.8S, and 28S ribosomal RNA. Previously, only prokaryotes and certain "lower eukaryotes" (protozoa and fungi) had been found to have both the larger rRNAs and 5S rRNA represented within a single DNA repeat. This has raised questions on the organization of these repeats in the earliest cell (progenote), and on subsequent evolutionary relationships between pro- and eukaryotes. Evidence is presented for rearrangements and deletions within Meloidogyne rDNA. The unusual life cycles (different levels of ploidy, reproduction by meiotic and mitotic parthenogenesis) of members of this genus might allow rapid fixation of any variants with introduced 5S RNA sequences. The 5S RNA sequences in Meloidogyne rDNA may not be expressed, but their presence raises important questions as to the evolutionary origins and stability of repeat gene families.