From transabdominal to totally extra-peritoneal robotic ventral hernia repair: observations and outcomes.

PURPOSE: While robotic-assisted hernia repair has increased the popularity of minimally invasive hernia surgery, selecting between the types of approaches is a challenge for both experts and novices alike. In this study, we compared a single surgeon's early experience transitioning from transabdominal hernia repair with sublay mesh in either the pre-peritoneal or retrorectus space (TA-SM) and enhanced-view totally extra-peritoneal (eTEP) ventral hernia repair in the peri-operative and long-term post-operative time periods. METHODS: We conducted a retrospective review of 50 eTEP and 108 TA-SM procedures to collect demographics, intraoperative details, and 30-day and 1-year post-operative outcomes. Statistical analysis was performed utilizing Chi-square analysis, Fisher's test, and two sample t-tests with equal variances. RESULTS: There were no significant differences in patient demographics or comorbidities. eTEP patients had larger defects (109.1 cm2 vs. 31.8 cm2, p = 0.043) and mesh used (432.8 cm2 vs. 137.9 cm2, p = 0.001). Operative times were equivalent (158.3 ± 90.6 min eTEP and 155.8 ± 65.2 min TA-SM, p = 0.84), but conversion to alternate procedure type was higher for the transabdominal approach (4% eTEP vs. 22% TA-SM, p < 0.05). Hospital stay was less in the eTEP cohort (1.3 days vs. 2.2 days, p < 0.05). Within 30 days, there were no significant differences in emergency visits or hospital readmissions. There was a greater propensity for eTEP patients to develop seromas (12.0% vs. 1.9%, p < 0.05). At 1 year, there was no statistically significant difference in recurrence rate (4.56% eTEP vs. 12.2% TA-SM, p = 0.28) respective to average time to recurrence (9.17 months eTEP vs. 11.05 months TA-SM). CONCLUSION: The eTEP approach can be adopted safely and efficiently, and may have superior peri-operative outcomes including fewer conversions and reduced hospital stay.

Robotic ventral hernia repair: a safe and durable approach.

BACKGROUND: Short-term success following robotic-assisted ventral hernia repair (RVHR) is well established; however, data describing outcomes after the first year are limited. In this study, we followed a cohort of patients with an average of 1.8 years of follow-up to demonstrate the durability of this technique and examine risk factors for recurrence. METHODS: A retrospective analysis of RVHR performed by a single surgeon from 2012 to 2016 was done. The technical approach for hernia repair consisted of tension-free primary fascial closure with placement of preperitoneal mesh when possible. The primary end point of hernia recurrence was determined based on physical examination or imaging documented in the medical record. A logistic regression model was used to identify patient risk factors for recurrence. RESULTS: One hundred and eight RVHRs were performed over 4 years. Mean age was 52.72 ± 13.61 years, BMI was 33.07 ± 7.82 kg/m2, and hernia defect size was 70.1 ± 86.3 cm2. In terms of patient characteristics, 17.6% of patients were diabetic, 13.9% were smokers preoperatively, 72.2% were ASA class 3 or higher, and 29.6% had prior VHR. Primary fascial closure was achieved in all RVHRs, with 23.1% requiring component separation. Mesh was used in 97.2% of patients: 79.5% had preperitoneal mesh and 17.6% had intraperitoneal onlay mesh. Ninety-eight percent of patients had long-term follow-up at a mean of 625.6 days. Recurrence rate was 12%, with one recurrence attributed to an inguinal hernia fixed concurrently with a midline defect. There were no statistically significant differences in gender, age, BMI, ASA class, incidence of diabetes, smoking status, or number of previous hernia repairs. Hernia defect size and perioperative complications including SSO, ileus, obstruction, or any other medical complication were not predictive of recurrence. Technical approach did not affect outcomes. CONCLUSION: RVHR is safe and durable with a low recurrence rate at a mean of 21 months postoperatively. Patient characteristics or type of repair were not predictive of recurrence.

The dilation aided single-line-of-sight x-ray camera for the National Ignition Facility: Characterization and fielding.

Crystal x-ray imaging is frequently used in inertial confinement fusion and laser-plasma interaction applications as it has advantages compared to pinhole imaging, such as higher signal throughput, better achievable spatial resolution, and chromatic selection. However, currently used x-ray detectors are only able to obtain a single time resolved image per crystal. The dilation aided single-line-of-sight x-ray camera described here was designed for the National Ignition Facility (NIF) and combines two recent diagnostic developments, the pulse dilation principle used in the dilation x-ray imager and a ns-scale multi-frame camera that uses a hold and readout circuit for each pixel. This enables multiple images to be taken from a single-line-of-sight with high spatial and temporal resolution. At the moment, the instrument can record two single-line-of-sight images with spatial and temporal resolution of 35 µm and down to 35 ps, respectively, with a planned upgrade doubling the number of images to four. Here we present the dilation aided single-line-of-sight camera for the NIF, including the x-ray characterization measurements obtained at the COMET laser, as well as the results from the initial timing shot on the NIF.

Post-Laryngectomy stricture and pharyngocutaneous fistula: Review of techniques in primary pharyngeal reconstruction in laryngectomy.

OBJECTIVE: The purpose of this study was to find a correlation between closure technique in pharyngeal closure and outcomes of both pharyngocutaneous fistula and post-laryngectomy stricture after laryngectomy. STUDY DESIGN: Retrospective Chart Review. METHODS: We retrospectively reviewed a total of 151 patients over a 20-year period from January 1994 to December of 2013 who underwent primary pharyngeal reconstruction after total laryngectomy specifically looking at the closure technique in relation to pharyngo-cutaneous fistula (PCF) and post-laryngectomy stricture postoperatively. Patients were excluded based on secondary pharyngeal closure. Using logistic regression modelling, we performed univariate and multivariate analyses of our data. RESULTS: The overall PCF and post-laryngectomy stricture rates were 19.1% and 15.8%. When salvage laryngectomy was excluded, t-type closure had a significantly lower risk of fistula rate (P=.038) compared to vertical closure. In multivariate analysis, this statistical significance was lost (P=.23); however, non-salvage t-type closure remained significantly better than both salvage laryngectomy groups (t-type, P=.033, vertical, P=.037), while non-salvage vertical closure had no significant difference from other groups. There was no difference in stricture rate between the two closure techniques (P=.63). CONCLUSION: Our study supports the role of t-type closure decreasing fistula rates in primary pharyngeal reconstruction. Orientation of the pharyngeal closure does not appear to change the risk of post-laryngectomy stricture formation after total laryngectomy. Salvage laryngectomy with primary pharyngeal reconstruction remains an independent risk factor for fistula formation.

A case-control study of epidemiological factors associated with leptospirosis in South Gujarat region.

BACKGROUND: The current study was planned to identify the epidemiological factors associated with leptospirosis in South Gujarat region using neighborhood controls. METHODS: A total of 100 cases of leptospirosis occurred in South Gujarat region during the year 2012 were selected using simple random sampling. Three neighbors of the selected cases formed the controls (n = 300). A pretested structured questionnaire was used for data collection and data were analyzed using Epi Info 2007. RESULTS: There was significant association of illiteracy (odds ratio [OR] =1.82, 95% confidence interval [CI] =1.14-2.89), working in waterlogged fields during the reference season (OR = 4.6, 95% CI = 1.6-17.9), swimming/bathing in canals, open air defecation practices, storage of cow dung in or surrounding house, residence in the house made up of cow dung walls, households with access of food to rodents, injuries over hands/foot during the endemic season (OR = 3, 95% CI = 1.8-4.8), and history of skin disease during the endemic season (OR = 4.2, 95% CI = 2-8.5), with leptospirosis. Only 10% of individuals had gumboots for protection. A total of 83 (83%) cases and 240 (80%) controls had taken oral doxycycline chemoprophylaxis (P > 0.05). Cases had taken chemoprophylaxis for a median 4 weeks (range: 1-8) while controls had taken the same for median 8 weeks (range = 1-8) (P < 0.002). CONCLUSIONS: Although the commonly established factors appear to be associated with leptospirosis, the role of host factors seems to play a more important role in determining susceptibility to leptospirosis in exposed individuals.

Estimation of the rate of tooth wear in permanent incisors: a cross-sectional digital radiographic study.

This study used conventional digital radiography to estimate the rate of tooth wear (TW) of maxillary and mandibular central incisors based on a cross-sectional study design. The crown length of 1239 permanent maxillary and mandibular central incisors from 346 persons (age groups: 10, 25, 40, 55 and 70 years ± 3) were measured by three calibrated dentists. Study teeth were intact incisally, had clearly visible incisal edges and cementoenamel junctions and had natural tooth antagonists. Measures were based on digital radiographic images (N = 666) archived in MiPACS within the electronic health record (axiUm(®)) from the College of Dentistry patient database. Incisor crown length decreased at a linear rate in both arches over the 60 years represented by the age groups. The average crown length for maxillary incisors in the youngest age group was 11.94 mm, which decreased by an average of 1.01 mm by median age 70. For mandibular incisors, the average crown length in the youngest age group was 9.58 mm, which decreased by an average of 1.46 mm in the oldest age group. Males and females showed similar rates of TW. Regardless of age, females demonstrated smaller mean crown height for maxillary incisors than males (P < 0.0001). Measures by the examiners demonstrated good agreement, with an interclass correlation coefficient of 0.869 and an average intra-examiner correlation of 99.5%, based on repeated measurements (n = 100). TW was estimated to average 1.01 mm for maxillary central incisors and 1.46 mm for mandibular central incisors by age 70 years.

Impact of specialized multi-disciplinary approach and an integrated pathway on outcomes in hilar cholangiocarcinoma.

AIMS: To assess the outcomes of patients with hilar cholangiocarcinoma following referral to a specialist multi-disciplinary team. METHODS: Over an 11-year period, patients referred with hilar cholangiocarcinoma were identified from a prospectively maintained registry. Collated data included demographics, operative findings and histo-pathological data. Survival differences and prognostic factors were determined. RESULTS: 345 patients were referred with hilar cholangiocarcinoma, of which 57 (16.5%) patients had surgery. Prior to 2008, of 143 patients referred, only 17 (11.9%) patients underwent surgery, compared to 40 (19.8%) of 202 patients referred from 2008 onwards (p = 0.051). In the surgery group, the majority of patients underwent left hemi-hepatectomy (n = 19). In addition, portal vein (n = 5), hepatic artery (n = 2) and inferior vena cava (n = 3) resections were performed. The R0 resection rate was 73.7%. The morbidity and mortality rates were 59.6% and 14.0%, respectively. The median disease-free survival was 16 (4-101) months. The presence of lymph node metastasis (p = 0.002) was the only predictor of poorer disease-free survival. The 5-year overall survival was 39.5% and was significantly better than that of the palliative group (p < 0.001). CONCLUSIONS: Surgery is the optimal treatment option for patients with hilar cholangiocarcinoma and is associated with better overall survival. Prompt referral to tertiary centres with a core team of clinicians to manage this difficult condition may allow more patients to come to potentially curative surgical resections.

Tetany: possible adverse effect of bevacizumab.

BACKGROUND: Bevacizumab a recombinant humanized monoclonal antibody was approved in 2004 by US FDA for metastatic colorectal cancer. It is reported to cause potentially serious toxicities including severe hypertension, proteinuria, and congestive heart failure. AIM: To correlate adverse event tetany with the use of bevacizumab. MATERIALS AND METHODS: World Health Organization's Uppsala Monitoring Centre, Sweden, for reporting of adverse drug reactions from all over the world, identified 7 cases with tetany-related symptoms to bevacizumab from four different countries. These 7 patients reported to UMC database developed adverse events described as musculoskeletal stiffness (1), muscle spasm (1), muscle cramps (1), lock jaw or jaw stiffness (4), and hypertonia (1), with hypocalcaemia. RESULTS: After detailed study of the possible mechanism of actions of bevacizumab and factors causing tetany, it is proposed that there is a possibility of tetany by bevacizumab, which may occur by interfering with calcium metabolism. Resorption of bone through osteoclasts by affecting VEGF may interfere with calcium metabolism. Another possibility of tetany may be due to associated hypomagnesaemia, hypokalemia, or hyponatremia. CONCLUSIONS: Tetany should be considered as a one of the signs. Patient on bevacizumab should carefully watch for tetany-related symptoms and calcium and magnesium levels for their safety.

Under treatment of overactive bladder symptoms in patients with multiple sclerosis: an ancillary analysis of the NARCOMS Patient Registry.

PURPOSE: We describe the prevalence of overactive bladder symptoms in patients with multiple sclerosis as well as the rates of evaluation and treatment of urinary complaints. MATERIALS AND METHODS: Data from the fall 2005 North American Research Committee On Multiple Sclerosis survey were examined, including the Urogenital Distress Inventory plus a nocturia question, the SF-12, and inquiries regarding urological care and treatments. Data were analyzed using descriptive statistics, chi-square and Student's t tests, ANOVA and multivariable logistic regression. RESULTS: Of 16,858 surveys distributed 9,702 (58%) were completed. Participants with a surgically altered bladder were excluded from analysis (21). At least 1 moderate to severe urinary symptom (score of 2 or greater) was reported by 6,263 (65%) respondents. Increasing overactive bladder symptoms were correlated with longer disease duration (r = 0.135) and increasing physical disability (r = 0.291) (both p <0.001). Decreased quality of life was associated with increasing disability (p <0.001) and overactive bladder symptom score (p <0.001). Of patients with moderate to severe overactive bladder symptoms only 2,710 (43.3%) were evaluated by urology and 2,361 (51%) were treated with an anticholinergic medication. Treated patients more frequently reported leakage (p <0.001) and newer treatments were significantly underused (less than 10% total use). Catheter use was reported by 2,309 (36.8%) respondents, and was associated with greater disability, higher overactive bladder symptom score and reduced quality of life (all p <0.001). CONCLUSIONS: This large scale study identified high rates of overactive bladder symptoms in patients with MS, and correlations with increasing disease duration and physical disability. Despite an increasing awareness of overactive bladder symptoms and the need for evaluation and treatment, many patients remain underserved.

Myomatous erythrocytosis syndrome: a case report.

We report the case of a 36-year-old woman with erythrocytosis due to ectopic erythropoietin production by a very large uterine leiomyoma. Awareness of this uncommon condition is important so that the correct diagnosis can be suggested prior to surgery and radical resection can be avoided.

A comparison of two single dilator percutaneous tracheostomy sets: the Blue Rhino and the Ultraperc.

The single tapered dilator kit is the most commonly used percutaneous tracheostomy set in the UK. The Cook Blue Rhino and the Portex Ultraperc were compared in the laboratory on mannequin and porcine airway models. The following data were collected: the subjective ease of dilating the trachea and inserting the tracheostomy tube; the time taken and the anterior-posterior compression during dilatation and tube insertion; the incidence and extent of posterior tracheal wall damage. During dilatation, the Blue Rhino caused less mean percentage anterior-posterior compression (34.8% vs. 51.5%, p = 0.0014). There was no difference in subjective ease or time for dilatation in either mannequin or porcine airway models. During insertion of the tracheostomy tube, the Ultraperc was subjectively easier in the porcine airway model (p = 0.001); had a shorter median insertion time in both the mannequin (3 s vs. 7.2 s, p = 0.0006) and the porcine airway model (4.3 s vs. 8.5 s, p = 0.0005); the mean percentage anterior-posterior compression caused was less in the mannequin (51.5% vs. 76%, p = 0.0008). The overall incidence of posterior wall damage was 65% with 25% having deep lacerations. There was no difference in the incidence of damage between the two sets. The Ultraperc therefore has advantages during tracheostomy tube insertion that are statistically and clinically significant. The advantages are probably due to the presence of the tracheostomy tube introducer.

Lysis of a left ventricular thrombus with recombinant tissue plasminogen activator.

A 23-year-old woman with peripartum cardiomyopathy presented with a 2.1 x 2.5-cm pedunculated, mobile, left ventricular thrombus and evidence of systemic embolization. Due to the patient's poor left ventricular function, thrombectomy was not a viable option. Treatment with high-dose IV heparin was initially utilized but was unsuccessful as the thrombus appeared to enlarge on echocardiography. An accelerated weight-adjusted dose of recombinant tissue plasminogen activator (rt-PA) successfully lysed the thrombus without evidence of embolization. Although rt-PA has been used for primary lysis of high-risk ventricular thrombi, this is the first documentation of successful lysis of a left ventricular thrombus in a patient with peripartum cardiomyopathy.

Lazaroid compounds prevent early but not late stages of oxidant-induced cell injury: potential explanation for the lack of efficacy of lazaroids in clinical trials.

Earlier in vitro studies demonstrated the remarkable potency of the lazaroid compounds to prevent oxidant-induced early cell injury. However, the ability of lazaroid compounds to limit oxidative injury in vivo(including renal ischemia-reperfusion) has been less certain, and the early clinical trials using lazaroids to limit CNS injury or organ injury in the setting of transplantation have not been promising. Lazaroid compounds are potent inhibitors of lipid peroxidation, and their inability to influence other key injury processes, particularly during the late stages of cell injury, might partly explain the limited clinical efficacy. To test this, renal tubular (LLC-PK1) cells were incubated with 250 micromH(2)O(2)for 135 min, in the presence or absence of 2-methyl aminochroman (2-MAC, U-83836E), a lazaroid with potent ability to inhibit lipid peroxidation, or desferrioxamine, (DFO) an iron chelator with broader antioxidant efficacy. Cell injury, lipid peroxidation, DNA damage and ATP depletion were measured in the early (immediately after H(2)O(2)incubation) and late (24 h after H(2)O(2)incubation) stages of cell injury. In the early stage, 2-MAC suppressed H(2)O(2)-induced lipid peroxidation and LDH release, but not the DNA damage, ATP depletion or loss of cell replication. In contrast, DFO suppressed all of the measurements. In the late stages, despite continued suppression of lipid peroxidation, only DFO maintained significant cytoprotection against H(2)O(2), and this was accompanied by reduced DNA damage, higher ATP levels and preservation of cell proliferation. Thus, the inability of the lazaroid compound 2-MAC to sustain cytoprotection in the later stages of cell injury might provide at least a partial explanation for the inefficiency of lazaroids to limit tissue injury in clinical and certain in vivo settings.

Characterization of a polyhistidine-tagged form of human myristoyl-CoA: protein N-myristoyltransferase produced in Escherichia coli.

The enzyme myristoyl-CoA:protein N-myristoyltransferase is responsible for the attachment of a myristoyl group to the N-terminal glycine of a number of cell, viral and fungal proteins. In order to overcome the difficulties of purification of this enzyme from tissue sources, we have produced an N-terminally polyhistidine-tagged version of the enzyme and expressed this in Escherichia coli. The resulting enzyme has a molecular mass of 53 kDa and is fully active showing the expected specificity for myristic acid and causing the N-terminal myristoylation of both synthetic peptide and protein substrates in vitro. The enzyme exhibits a broad pH optimum peaking at a pH of 8.0 and has a Km for myristoyl-CoA of 7.6 microM. The two synthetic peptide substrates based on the N-terminal sequence of the catalytic subunit of protein kinase A (GNAAAARR) and of p60src (GSSKSKPKDPSQRRRY) have different kinetic parameters with Km values of 115.2 microM and 44.2 microM and Vmax values of 95 and 120 nmol.min-1.mg-1, respectively. The expressed enzyme is partially inhibited (50%) by iodoacetamide at 5 mM and fully inhibited by diethylpyrocarbonate at 10 mM. This latter inhibition can be prevented by including histidine in the incubation of the enzyme and inhibitor. Antisera raised to synthetic peptides based on sequences derived from the N- and C- terminus of the human enzyme reacted with the expressed protein on Western blots, but only the N-terminal sequence reacted with the native protein suggesting that the C-terminus may be not be accessible. The enzyme can catalyse the removal of a myristoyl group from myristoylated peptides but does so only in the presence of added coenzyme A.

Biochemical and immunocytochemical characterization of antipeptide antibodies to a cloned GluR1 glutamate receptor subunit: cellular and subcellular distribution in the rat forebrain.

Antibodies were made to synthetic peptides corresponding to residues 253-367, 757-771 and 877-889 of the published amino acid sequence of the rat brain glutamate receptor GluR1 subunit [Hollmann et al. (1989) Nature 342, 643-648]. The peptides were synthesized both as multiple copies on a branching lysyl matrix (multiple antigenic peptides) and conventional linear peptides using solid-phase synthesis. Rabbits were immunized with these peptides either without conjugation (multiple antigenic peptides) or following coupling to ovalbumin with glutaraldehyde (monomeric peptides). The antibodies from immune sera were then purified by affinity chromatography using reactigel coupled monomeric peptides. All the rabbits produced good antipeptide responses, and were characterized by immunoprecipitation of solubilized alpha-amino-3-hydroxy-5-methylisoxazole-4-propionate and kainate binding activity and by their staining patterns on immunoblots. Antibody to peptide 253-267 specifically immunoprecipitated 12 +/- 3, 50 +/- 3 and 44 +/- 4% of solubilized alpha-amino-3-hydroxy-5-methylisoxazole-4-propionate binding activity from cortex, hippocampus and cerebellum, respectively. Under identical conditions, antibody against the 877-889 peptide removed 23 +/- 4, 9 +/- 4 and 15 +/- 9% of alpha-amino-3-hydroxy-5-methylisoxazole-4-propionate binding sites from these areas. On immunoblots of rat brain membrane samples separated by sodium dodecyl sulphate-polyacrylamide gel electrophoresis, antibodies labelled a 105,000 mol. wt immunoreactive band. GluR1 was immunoaffinity-purified using subunit-specific antibodies against both N-terminal (253-267) and C-terminal (877-889) residues, covalently attached to protein A-agarose. Analysis of the purified product from each column showed a major immunoreactive band, recognized by both sera at 105,000 mol. wt and silver staining identified the same major protein. After exhaustive immunoprecipitation of solubilized membrane samples with antibody against the C-terminal of the subunit, a subpopulation of GluR1 was labelled with antibodies specific for the N-terminal part of the receptor. These observations suggest that the GluR1 subunit consists of at least two isoforms possessing a common N-terminal region but a distinct C-terminus. Immunocytochemistry, using immunoperoxidase staining, was performed for the GluR1 subunit in rat forebrain with antisera raised against the N-terminal (253-267) and the C-terminal parts (877-889) of the molecule. Both antisera gave a similar distribution of immunoreactivity at the light-microscopic level. Immunoreactivity for the GluR1 subunit was selectively distributed throughout the rat forebrain. The hippocampus, septum, amygdala and olfactory bulb exhibited the strongest immunoreactivity.(ABSTRACT TRUNCATED AT 400 WORDS)

Glucose-galactose malabsorption: demonstration of specific jejunal brush border membrane defect.

Jejunal brush border glucose transport was studied in a patient with glucose-galactose malabsorption and in controls, using jejunal brush border membrane vesicles (BBMV) prepared from conventional jejunal biopsies. Whereas BBMV from controls showed a seven-fold enhancement of D-glucose uptake in the presence of an inwardly directed sodium gradient compared with its absence, no such enhancement was seen in the patient's vesicles. In BBMV from the patient, initial D-glucose uptake under sodium gradient conditions was only 10% of the mean control value. In contrast, sodium/proton exchange in BBMV from the patient was intact. These data provide the first unequivocal evidence that the jejunal brush border membrane is the site of a specific defect in sodium dependent glucose transport in glucose-galactose malabsorption. Measurement of glucose uptake by BBMV may well be the optimal diagnostic technique in this disorder.

Changes in the activity of some hepatic enzymes during organophosphorus insecticide-acephate (orthene) treatment in albino rats.

Acephate, an organophosphorus insecticide (60 mg/day/rat) disturbed the carbohydrate metabolism in albino rats (wt. between 100-150 gms). Changes in the enzyme activities in the liver were estimated in the rats after oral administration of Acephate. The specific activities of succinic dehydrogenase was decreased in experimental rats than control. A gradual decrease in blood and liver glutathione was also observed. Increase in total lactate dehydrogenase was also noted. It has been observed that in the liver homogenate of treated rats, the isoenzymes LDH4+5 were increased, LDH1+2 were decreased while LDH3 remain unchanged with respect to control value.

Effect of aspirin on spermatogenesis in mature and immature rats.

Aspirin administration for 30 days (5 mg/100 g body weight) caused a significant decrease in the weight of testis of immature rats. Decrease in the activities of sorbitol dehydrogenase and hyaluronidase was observed in both immature and mature rats. Decrease in the number of spermatids and increase in size of spermatocytes nuclei were observed. It is concluded that aspirin causes impairment of the later stages of spermatogenesis.