A Novel Approach to Ileal Pouch Prolapse Repair Using Fibrin Sealant.

The ileal pouch-anal anastomosis is a commonly accepted neorectum after total proctocolectomy for familial adenomatous polyposis and ulcerative colitis. Generally, patients have decent bowel control, but ileal pouches are not without complications. One relatively uncommon complication is ileal pouch prolapse. Prolapse can be either mucosal or full thickness, similar to rectal prolapse. There is limited literature detailing the frequency and management of ileal pouch prolapse. The majority of the literature is case reports with a few small retrospective studies. Fibrin glue has been described for sutureless mesh fixation in total extraperitoneal hernia repairs. Here, we describe a fibrin glue pouch pexy for ileal pouch prolapse after total proctocolectomy with ileal pouch-anal anastomosis.

A novel scoring system for identifying patients at risk for venous thromboembolism undergoing diverticular resection: an American College of Surgeons-National Surgical Quality Improvement Program Study.

Following colorectal surgery, venous thromboembolism (VTE) is a serious complication occurring at an estimated incidence of 2-4%. There is a significant body of literature stratifying risk of VTE in specific populations undergoing colorectal resection for cancer or inflammatory bowel disease. There has been little research characterizing patients undergoing colorectal surgery for other indications, e.g. diverticulitis. We hypothesize that there exists a subgroup of patients with identifiable risk factors undergoing resection for diverticulitis that has relatively higher risks for VTE. We conducted a retrospective review of the American College of Surgeons National Surgical Quality Improvement Project database from 2006 to 2017 who underwent colorectal resection for diverticulitis. Patients with a primary indication for resection other than diverticulitis were excluded. Multivariate logistic regression modeling was conducted to determine the risk of VTE for each independent variable. A novel scoring system was developed and a receiver-operating-characteristic curve was generated. The rate of VTE was 1.49%. An 7-point scoring system was developed using identified significant variables. Patients scoring ≥ 6 on the developed scoring scale had a 3.12% risk of 30-day VTE development. A simple scoring system based on identified significant risk factors was specifically developed to predict the risk of VTE in patients undergoing diverticular colorectal resection. These patients are at significantly higher risk and may justify increased vigilance regarding VTE events, similar to patients undergoing colorectal resection for cancer or inflammatory bowel disease.

Acute urinary retention rates following early removal or no placement in colon and rectal surgery: a single-center analysis.

BACKGROUND: The adequate duration of urinary drainage following colorectal surgery remains debated. The purpose of this study was to compare acute urinary retention (AUR) rates among various durations of urinary catheterization following colon and rectal surgery. METHODS: We conducted a retrospective analysis of patients undergoing elective colorectal resection enrolled in the Enhanced Recovery After Surgery (ERAS) protocol from 2018 to 2019. Patients were placed into four groups: no catheter placement (NC), catheter removed immediately after surgery (CRAS), removal less than 24 h (CR < 24), and removal greater than 24 h (CR > 24). Our primary endpoint was the rate of AUR in each group. Secondary endpoints included hospital length of stay and urinary tract infections (UTI). A multivariate logistic regression analysis was done to predict AUR. RESULTS: A total 641 patients were included in this study. 27 patients (4.2%) had NC with an AUR rate of 3.7%. 249 patients (38.8%) had CRAS with an AUR rate of 6.8%. 214 patients (33.4%) had CR < 24 with an AUR rate of 4.2%. 151 patients (23.6%) had CR > 24 with an AUR rate of 2.6%. There was no significant difference in AUR among the groups (p = 0.264). In our multivariant logistic regression, pelvic surgery was an independent risk factor for AUR (p = 0.008). There was a statistically significant higher hospital length of stay (p = 0.001) and rate of UTIs (p = 0.017) in patients with prolonged catheterization. CONCLUSION: Deferral or early removal of urinary catheters is safe and feasible following colorectal surgery without a significant increase in AUR. Avoiding prolonged indwelling urinary catheterization may decrease associated complications such as UTI and hospital length of stay.

ECMO after cardiac surgery: a single center study on survival and optimizing outcomes.

BACKGROUND: The study purpose is to examine survival prognostic and extracorporeal membrane oxygenation (ECMO) application outcomes at our tertiary care center. METHODS: This is a retrospective analysis, January 2014 to September 2019. We analyzed 60 patients who underwent cardiac surgery and required peri-operative ECMO. All inpatients with demographic and intervention data was examined. 52 patients (86.6%) had refractory cardiogenic shock, 7 patients (11.6%) had pulmonary insufficiency, and 1 patient (1.6%) had hemorrhagic shock, all patients required either venous-arterial (VA) (n = 53, 88.3%), venous-venous (VV) (n = 5, 8.3%) or venous-arterial-venous (VAV) (n = 2, 3.3%) ECMO for hemodynamic support. ECMO parameters were analyzed and common postoperative complications were examined in the setting of survival with comorbidities. RESULTS: In-hospital mortality was 60.7% (n = 37). Patients who survived were younger (52 ± 3.3 vs 66 ± 1.5, p < 0.001) with longer hospital stays (35 ± 4.0 vs 20 ± 1.5, p < 0.03). Survivors required fewer blood products (13 ± 2.3 vs 25 ± 2.3, p = 0.02) with a net negative fluid balance (- 3.5 ± 1.6 vs 3.4 ± 1.6, p = 0.01). Cardiac re-operations worsened survival. CONCLUSION: ECMO is a viable rescue strategy for cardiac surgery patients with a 40% survival to discharge rate. Careful attention to volume management and blood transfusion are important markers for potential survival.

Traumatic colostomy evisceration in an AIDS patient with anal cancer.

Intestinal evisceration is a rare event and few cases of colostomy rupture have been documented in the medical literature. Complications of colostomy surgery vary in incidence, with most episodes occurring in the immediate postoperative timeframe, including necrosis, hemorrhage, cellulitis and dehiscence. Here, we document the case of a 35-year-old male patient with a history of immunodeficiency, multiple comorbidities and squamous cell carcinoma of the anus who experienced a unique instance of colostomy evisceration weeks after initial surgery. The patient originally underwent surgery for a sigmoid colostomy for the alleviation of irritation secondary to anal disease. Weeks later, after a traumatic fall injury, he experienced colostomy evisceration. This case will review the factors leading up to this event that put the patient at risk for poor wound healing and ultimately colostomy rupture.

Patient Selection and Outcomes of Transfemoral Transcatheter Aortic Valve Replacement Performed with Monitored Anesthesia Care Versus General Anesthesia.

OBJECTIVE: The aim of this study was to compare outcomes of monitored anesthesia care (MAC) versus general anesthesia (GA) for transfemoral transcatheter aortic valve replacement (TF-TAVR) and to describe a selection process for the administration of MAC. DESIGN: Retrospective analysis of patients who underwent TF-TAVR under MAC or GA. SETTING: Department of Cardiac Anesthesia, Albany Medical Center, a tertiary university hospital. PARTICIPANTS: Patients selected for TF-TAVR. INTERVENTIONS: Patients were divided into those who underwent MAC and those who underwent GA. MEASUREMENTS AND MAIN RESULTS: The study comprised 104 consecutive patients (55% male, mean age 83 years) who underwent TF-TAVR under MAC (n = 60) or GA (n = 37) from 2014 to 2015. Seven patients were converted from MAC to GA and were omitted from analysis. There was no statistically significant difference between 30-day mortality and complications between the 2 groups. The MAC group had a significantly shorter median intensive care unit length of stay (48 h v 74 h, p = 0.0002). The MAC group also demonstrated reduced procedural time (45.5 min v 62 min, p = 0.003); operating room time (111 min v 153 min, p = <0.001); and fluoroscopy time (650 s v 690 s, p = 0.03). CONCLUSIONS: Patient selection for TF-TAVR with MAC can be formalized and implemented successfully. MAC allows for the minimizing of patient exposure to unnecessary interventions and improving resource utilization in suitable TAVR patients. Selection requires a multidisciplinary clinical decision-making process. MAC demonstrates good outcomes compared with GA, yet it is important to have a cardiac anesthesiologist present in the event of emergency conversion to GA.

Structure-activity relationships of two Rhodnius prolixus calcitonin-like diuretic hormone analogs.

The calcitonin-like diuretic hormone (CT/DH) in Rhodnius prolixus influences various tissues associated with feeding-related physiological events. The receptors for this peptide have also been identified and shown to be expressed in these tissues. In the present study, we have investigated the effects of two R. prolixus CT/DH analogs (full-length form and N-terminal truncated form) on hindgut contractions and in a heterologous receptor expression system. The analogs contained the amino acid methyl-homoserine in place of methionine in order to prevent them from being oxidized and thus increase their stability. The full-length form of the analog retained all of its activity in our assays when compared to the endogenous peptide. Truncated analog displayed no activity in our assays.

The perceptions of professional soccer players on the risk of injury from competition and training on natural grass and 3rd generation artificial turf.

BACKGROUND: The purpose of this study was to describe professional soccer players' perceptions towards injuries, physical recovery and the effect of surface related factors on injury resulting from soccer participation on 3rd generation artificial turf (FT) compared to natural grass (NG). METHODS: Information was collected through a questionnaire that was completed by 99 professional soccer players from 6 teams competing in Major League Soccer (MLS) during the 2011 season. RESULTS: The majority (93% and 95%) of the players reported that playing surface type and quality influenced the risk of sustaining an injury. Players believed that playing and training on FT increased the risk of sustaining a non-contact injury as opposed to a contact injury. The players identified three surface related risk factors on FT, which they related to injuries and greater recovery times: 1) Greater surface stiffness 2) Greater surface friction 3) Larger metabolic cost to playing on artificial grounds. Overall, 94% of the players chose FT as the surface most likely to increase the risk of sustaining an injury. CONCLUSIONS: Players believe that the risk of injury differs according to surface type, and that FT is associated with an increased risk of non-contact injury. Future studies should be designed prospectively to systematically track the perceptions of groups of professional players training and competing on FT and NG.

Modafinil increases reward salience in a slot machine game in low and high impulsivity pathological gamblers.

This study examined the effects of modafinil (200 mg) on slot machine betting profiles from a previous sample of low and high impulsivity (LI/HI) pathological gamblers (10/Group; Zack and Poulos, 2009). Hierarchical regression assessed the prospective relationship between Payoff and Bet Size on consecutive trials, along with moderating effects of Group, Cumulative Winnings (low/high) and Phase of game (early/late) under drug and placebo. Y intercepts for the simple regressions of Bet Size on Payoff indexed overall motivation to bet. Under placebo, both groups gauged their bets less closely to the preceding Payoff as trials continued when Winnings were low but not high. Under modafinil, both groups gauged their bets more closely to the preceding Payoff when Winnings were low but gauged their bets less closely to the previous Payoff when Winnings were high. The tendency to gauge bets closely to the previous Payoff coincided with a bias toward low overall Bet Size, and modafinil accentuated this relationship, in LI but not HI subjects. Results suggest that modafinil increases the salience of environmental rewards, leading to more tightly calibrated responses to individual rewards when resources are low, but progressively loosens reward-response calibration when resources are high. Increased relative impact of phasic vs. tonic dopamine signals may account for patterns seen at low vs. high Winnings, respectively, under the drug. Clinically, modafinil may deter pathological gamblers from chasing losses but also encourage them to continue betting rather than quit while they are ahead. Whether low-dose modafinil confers more uniform benefits deserves investigation.

The effects of linear and cyclic analogs of Locmi-DH, Dippu-DH(46) and Dippu-DH(31) on appetitive behavior in Locusta migratoria.

The effects of analogs of the diuretic peptides Locmi-DH, Dippu-DH(46) and Dippu-DH(31) on two aspects of appetitive behavior are investigated in previously food-deprived nymphs of Locusta migratoria. The analogs tested are the C-terminal 15-mer and nonapeptides and their corresponding cyclic analogs. At a nominal dose of 1pmol injected per nymph, the linear fragments and their cyclic analogs of Dippu-DH(46) display no significant effects on the latency to feed or on the length of the first meal in nymphs. However, at the same dose, the linear fragments of Dippu-DH(31) and their cyclic analogs, and analogs of Locmi-DH modulate appetitive behavior: they are anorexigenic in reducing the duration of the first meal, and generally increasing the latency to feed. The cyclic analogs of Dippu-DH(31) are at least as effective as their linear counterparts in influencing these aspects of appetitive behavior in locust nymphs.

Alcohol selectively impairs negative self-relevant associations in young drinkers.

The stress-dampening effects of alcohol have been attributed to 'appraisal disruption'- decreased ability of stimuli to evoke threatening associations in memory. Appraisal disruption could apply to oneself as well as situational stimuli. This question was investigated in undergraduate drinkers (n=90/Gender) with low or high anxiety sensitivity (AS; n=90/AS Group), a trait linked with hyper-vigilance to threat. Subjects received alcohol (0.7 g/kg males; 0.63 g/kg females), placebo or soft drink and performed a speech about their appearance. Sequence of drink administration and speech advisory (threat) was manipulated between subjects: Threat before Drink, Threat after Drink, No-Threat Control. The Implicit Association Test measured self-relevant associations based upon time to classify positive and negative attribute words (e.g. Cute, Ugly) paired with self-relevant or non-self-relevant object words (e.g. Me, Them). Alcohol selectively slowed negative self-relevant decisions, regardless of other factors. Relative fluency of negative versus positive decisions (D) correlated inversely with state anxiety and systolic blood pressure immediately before speech performance, and correlated directly with severity of alcohol problems. These findings are consistent with the Appraisal Disruption hypothesis. Preferential impairment of negative self-relevant associations may decrease perceived vulnerability under alcohol and increase risk for alcohol problems in young drinkers.

Haloperidol modifies instrumental aspects of slot machine gambling in pathological gamblers and healthy controls.

Instrumental conditioning has been implicated in persistence at slot machine gambling, but its specific role remains unclear. Dopamine (DA) mediates aspects of instrumental responding, and D2 antagonists reliably alter this process. This study investigated the effects of the preferential D2 antagonist, haloperidol (3 mg) on reward-related betting behavior in 20 subjects with pathological gambling (PG) and 18 healthy controls. Hierarchical regression assessed the prospective relationship between Payoff and Bet Size on consecutive trials, along with potential moderating effects of Cumulative Winnings and Phase of game (early/late) under drug and placebo. Payoff predicted Bet Size on the next trial regardless of other factors, consistent with an instrumental view of slot machine gambling. Under placebo, this correlation varied as a function of Winnings and Phase in PG subjects but was strong and invariant in Controls. Under haloperidol, the Payoff-Bet Size correlation in PG subjects resembled the invariant pattern of Controls under placebo. In contrast, the Payoff-Bet Size correlation rose then fell sharply over trials under haloperidol in controls. The correlation of Payoff with Bet Size is remarkable given that there is no actual contingency between winning and betting, and suggests that reward expectancies largely drive slot machine gambling. By blocking inhibitory D2 receptors, haloperidol may have reversed 'tolerance' to monetary reward mediated by increased tonic DA in PG subjects. Disturbance of the Payoff-Bet Size correlation in controls may reflect indiscriminate reward signaling under haloperidol in subjects with normal DA function. Indirect enhancement of DA transmission may reduce undue reward-related responding in PG subjects.

Parallel roles for dopamine in pathological gambling and psychostimulant addiction.

A variety of evidence suggests important commonalities in the neurochemical basis of reinforcement in pathological gambling (PG) and psychostimulant addiction. This article focuses on the parallel and specific roles that dopamine (DA) activation plays in these two disorders, beyond its generic role in reinforcement. A psychostimulant-mimetic model for PG is proposed based on evidence from the following domains: Acute subjective-behavioral effects of gambling and psychostimulants; Effects of anticipated rewards and uncertainty of reward delivery (key elements of gambling) on DA release; Relationship between DA release and positive arousal; Cross-priming of motivation for gambling by amphetamine; Effects of DA D2 antagonists on gambling and amphetamine reward; Effects of mixed D1-D2 antagonists on clinical symptoms of PG; Effects of DA D2 agonists on experimental measures of risk-taking, gambling, and induction of PG in patients with Parkinson's disease; Electrophysiological and cognitive disturbances associated with chronic exposure to gambling and psychostimulants, and the possible role of sensitization in these effects. Limitations of the model regarding the exclusive role of DA are discussed with particular reference to genetic risk, co-morbidity, and sub-types of PG. Suggestions for future research include isolating the roles of DA receptor subtypes in PG, and parallel within-subject assessment of DA manipulations on gambling and psychostimulant reinforcement in PG subjects and controls.

The synthesis and biological activity of linear and cyclic analogs of the two diuretic peptides of Diploptera punctata.

We have investigated the effect of analogs of the two Dippu diuretic hormones, Dippu-DH(46) and Dippu-DH(31), on fluid secretion by Malpighian tubules of male Diploptera punctata. We synthesized analogs containing the amino acid methyl-homoserine, to replace methionine residues, to render these modified peptides less subject to oxidation. We have also synthesized C-terminal fragments and their corresponding cyclic analogs to determine their effect on fluid secretion in D. punctata. Our results indicate that the modified peptides retain significant activity in the Ramsay secretion assay. The linear fragments displayed no activity or some inhibitory activity whereas the cyclic analog fragments showed stimulatory activity, in the case of DH(46), or slight inhibitory activity, in the case of DH(31).

Interactions of the dipeptide paralysin beta-Ala-Tyr and the aminoacid Glu with phospholipid bilayers.

Existing evidence points out that the biological activity of beta-Ala-Tyr may in part related to its interactions with the cell membranes. For comparative reasons the effects of Glu were also examined using identical techniques and conditions. In order to examine their thermal and dynamic effects on membrane bilayers a combination of DSC, Raman and solid state NMR spectroscopy on DPPC/water model membranes were applied and the results were compared. DSC data showed that Glu perturbs to a greater degree the model membrane compared to beta-Ala-Tyr. Thus, alteration of the phase transition temperature and half width of the peaks, abolishment of the pretransition and influence on the enthalpy of the phase transition were more pronounced in the Glu loaded bilayers. Raman spectroscopy showed that incorporation of Glu in DPPC/water bilayers increased the order in the bilayers in contrast to the effect of the dipeptide. Several structural and dynamical properties of the DPPC multilamellar bilayers with and without the dipeptide or Glu were compared using high resolution C-13 MAS (Magic Angle Spinning) spectra and spectral simulations of inhomogeneously broadened, stationary P-31 NMR lineshapes measured under CP (Cross-polarization) conditions. These methods revealed that the aminoacid Glu binds in the close realm of the phosphate in the hydrophilic headgroup of DPPC while beta-Ala-Tyr is located more deeply inside the hydrophobic zone of the bilayer. The P-31 NMR simulations indicated restricted fast rotary motion of the phospholipids about their long axes in the organized bilayer structure. Finally, by the applied methodologies it is concluded that the two molecules under study exert dissimilar thermal and dynamic effects on lipid bilayers, the Glu improving significantly the packing of the lipids in contrast to the smaller and opposite effect of the dipeptide.

Effects of drink-stress sequence and gender on alcohol stress response dampening in high and low anxiety sensitive drinkers.

BACKGROUND: This study tested the appraisal disruption hypothesis of alcohol stress response dampening (SRD) in male and female high or low anxiety sensitive (AS) undergraduates. The hypothesis predicts that alcohol SRD will be greater when drinking occurs before versus after stress exposure. High AS males' predominant social-evaluative concerns further implied that alcohol SRD to a social stressor (i.e., a speech) would be relatively stronger in high AS males than in high AS females. METHODS: Male and female (n=90/gender) high and low AS participants (>or=70th;

A D2 antagonist enhances the rewarding and priming effects of a gambling episode in pathological gamblers.

Previous research indicated shared neurochemical substrates for gambling and psychostimulant reward. This suggests that dopamine substrates may directly govern the reinforcement process in pathological gambling. To investigate this issue, the present study assessed the effects of the relatively selective dopamine D2 antagonist, haloperidol (3 mg, oral) on responses to actual gambling (15 min on a slot machine) in 20 non-comorbid pathological gamblers and 18 non-gambler controls in a placebo-controlled, double-blind, counterbalanced design. In gamblers, haloperidol significantly increased self-reported rewarding effects of gambling, post-game priming of desire to gamble, facilitation of reading speed to Gambling words, and gambling-induced elevation in blood pressure. In controls, haloperidol augmented gambling-induced elevation in blood pressure, but had no effect on other indices. The findings provide direct experimental evidence that the D2 substrate modulates gambling reinforcement in pathological gamblers.