AMPED study: Protocol for a randomized controlled trial of different doses of aerobic exercise training.

Recently renamed, metabolic dysfunction-associated steatotic liver disease remains a leading cause of chronic liver disease worldwide. Regular physical activity is recommended as a treatment for all with this condition because it is highly efficacious, especially when exercise training is undertaken with a specific goal in mind. Despite decades of research demonstrating exercise's efficacy, key questions remain about the mechanism of benefit and most efficacious dose, as well as the independent impact on liver histology. To answer these questions, we present the design of a 16-week randomized controlled clinical trial of 45 adults aged 18-69 years with metabolic dysfunction-associated steatohepatitis. The primary aim of this study is to better understand the dose required and mechanisms to explain how exercise impacts multiple clinical end points in metabolic dysfunction-associated steatohepatitis. The primary outcome is MRI-measured liver fat. Secondary outcomes include other biomarkers of liver fibroinflammation, liver histology, and mechanistic pathways, as well as cardiometabolic risk and quality of life. This is the first study to compare different doses of exercise training to determine if there is a differential impact on imaging and serum biomarkers as well as liver histology.

The Utility of Prophylactic Antibiotics for Laparoscopic Pyloromyotomy.

INTRODUCTION: Laparoscopic pyloromyotomy (LP) for the treatment of infantile hypertrophic pyloric stenosis (IHPS) is a clean case with low expected rates of postoperative surgical site infection (SSI). Previous studies have shown a low risk of SSI following LP but also large variations in the utilization of prophylactic antibiotics. The goal of this study was to review the use of preoperative antibiotics for LP and to compare this with SSI incidence. METHODS: We performed a retrospective single-center analysis of patients undergoing LP for infantile hypertrophic pyloric stenosis at a large quaternary children's hospital from January 2017 to June 2020. Subjects were <4 mo old. Exclusion criteria were those lost to follow-up within 30 d postoperatively and those who required open conversion intraoperatively. Statistical analysis was performed using Fisher's exact test, two-tailed independent t-tests, and descriptive statistics. RESULTS: Two-hundred twenty-seven patients were included, mean population age was 5.7 wk, and 81.1% were male. Preoperative antibiotics were administered in 39% of patients. Only 1.3% (n = 3) of all patients developed an SSI within 30 d of their operation. Analysis between patients who received preoperative antibiotics and those who did not revealed no difference in age (5.72 wk versus 5.72 wk, t (225) = 0.38, P = 0.70), sex (41% of males versus 32% of females, P = 0.39), length of stay (t(225) = -0.94, P = 0.35), or postoperative SSI (1.1% versus 1.4%, P > 0.999). Large variability was noted in antibiotic utilization by surgeon. CONCLUSIONS: In patients undergoing LP, there was no difference in SSI rates whether or not patients received preoperative antibiotics and, there is large variation in utilization. Measures are needed to decrease usage of prophylactic antibiotics before LP.

Preoperative prescription opioid use as an independent predictor of 90-day mortality and adverse events in craniotomy and craniectomy patients.

OBJECTIVE: A growing body of literature suggests that preoperative opioid exposure is an independent predictor of poor outcomes in surgical patients. No outcomes data exist on preoperative opioid use and craniotomies/craniectomies. The objective of this study was to determine the impact of preoperative opioid use on 90-day adverse events after craniotomy or craniectomy. METHODS: A single-center retrospective cohort study of 2445 patients undergoing a craniotomy/craniectomy between January 1, 2013, and October 1, 2018, was conducted. Baseline demographics, pre- and postoperative opioid use (morphine milligram equivalents [MMEs]), and surgical metrics were recorded. Patients were categorized based on whether they took prescription opioids preoperatively, defined as within 1 month of surgery, or were opioid naive. The outcomes were mortality and adverse events 90 days after craniotomy/craniectomy. RESULTS: Overall, 26.6% of patients composed the preoperative opioid group. The median daily MME intake among this group was 34.6 (IQR 14.1-90) MMEs. Lower employment rates (p < 0.001), uninsured status (p = 0.016), and intravenous drug use (p = 0.006) were associated with preoperative opioid use. Preoperative opioid use was associated with increased venous thromboembolism (p = 0.001), acute kidney injury (p = 0.002), acute respiratory failure (p < 0.001), myocardial infarction (p = 0.002), delirium (p < 0.001), and infection (p < 0.001). Preoperative opioid use was an independent predictor of overall 90-day adverse events (OR 1.643, 95% CI 1.289-2.095; p < 0.001) and 90-day mortality (OR 1.690, 95% CI 1.254-2.277; p < 0.001). CONCLUSIONS: Preoperative opioid use was independently associated with 90-day postoperative adverse events and mortality. Opioid use increases vulnerability in craniotomy/craniectomy patients and necessitates close monitoring to improve outcomes.

Public Awareness of Interventional Radiology: Population-Based Analysis of the Current State of and Pathways for Improvement.

PURPOSE: To evaluate the awareness of interventional radiology (IR) among the public and identify methods for improvement. MATERIALS AND METHODS: Participants (N = 1,000) were anonymously surveyed using Amazon's Mechanical Turk crowdsourcing platform about medical and IR-specific knowledge, preferred methods of acquisition of medical information, and suggestions for improving awareness of IR. The survey consisted of 69 questions, including both Likert Scale and free text questions. RESULTS: Of the participants, 92% preferred undergoing a minimally invasive procedure over surgery. However, 39.8% recognized IR as a medical specialty, and less than 50% of these participants correctly identified IR as procedurally oriented. Of those who discussed or underwent an IR procedure (n = 113), most were also offered to undergo the procedure performed by a surgeon (n = 66). Furthermore, 71% (n = 20) of those who underwent the procedure performed by a surgeon reported that lack of awareness of IR played a role in their decision. Almost half of the respondents (n = 458) were interested in learning more about IR, particularly the diseases treated and procedures performed (42% and 37%, respectively). Short (<10-minute) educational videos and increased patient education by primary care providers (PCPs) were among the most suggested ways to improve awareness. Regarding the ambiguity of the name "interventional radiology," most respondents (n = 555) reported this to be true, and "minimally invasive radiologist" was the most preferred alternative (21.18%). CONCLUSIONS: Lack of awareness of IR may underlie underutilization. When presented with the knowledge that IR improves patient outcomes, minimally invasive procedures by an interventional radiologist are more often desired by the public than surgical options. Educational videos and patient education by PCPs may increase awareness of IR.

Incidence and Mortality of Pediatric Abdominal Compartment Syndrome.

INTRODUCTION: Abdominal compartment syndrome (ACS) is the presence of intra-abdominal hypertension with systemic, multiorgan effects and is associated with high mortality, yet the national incidence and mortality rates of pediatric ACS remain unknown. The aim of this study is to evaluate the incidence and mortality of pediatric ACS over a 13-year period across multiple children's hospitals and between individual children's hospitals in the United States. METHODS: We performed a retrospective cohort study on children (aged < 18 y) with ACS in the Pediatric Health Information Systems database from 2007 to 2019. We identified ACS patients by International Classification of Diseases codes in the ninth and 10th revision. The primary outcomes were incidence and mortality, which were analyzed by year, age, and hospital of admission. RESULTS: Across 49 children's hospitals, we identified 2887 children with ACS from 2007 to 2019 in the Pediatric Health Information Systems database. The overall incidence of ACS was 0.17% and the overall mortality was 48.87%. There was no significant difference in annual incidence (P = 0.12) or mortality (P = 0.39) over the study period. There was no difference in incidence across age group (P = 0.38); however, mortality in patients 0-30 d old (58.61%) was significantly higher than older age groups (P < 0.0001). The hospital-specific incidence (0.04%-0.46%) and mortality (28.57%-71.43%) varied widely. CONCLUSIONS: The annual incidence and mortality of pediatric ACS are unchanged from 2007 to 2019. ACS mortality remains high, especially in neonatal intensive care unit patients. No obvious correlation is seen between incidence rates and mortality. Differing hospital-specific incidence and mortality could suggest inconsistencies between institutions that affect pediatric ACS care, perhaps with respect to recognition and diagnosis.

Beta-Adrenergic Antagonist Tolerance in Amyloid Cardiomyopathy.

Background: Beta-adrenergic antagonists or blockers (BB) are a cornerstone of cardiac therapy for multiple indications. However, BB are considered relatively contraindicated in amyloid cardiomyopathy due to poor tolerance. This intolerance is hypothesized to be due to concomitant neuropathy and significant restrictive cardiomyopathy. This study analyzes the incidence and characteristics of BB tolerance in patients with amyloid cardiomyopathy. Methods: Through a single-center retrospective chart review, patients with amyloid cardiomyopathy, confirmed by endomyocardial biopsy or technetium-99 pyrophosphate scan, were identified and clinical data was collected. Statistical methods included Chi-square test and two sample t-tests. Results: Of 135 cardiac amyloidosis patients, 27 patients (20.0%) had no BB use, 56 patients (41.5%) were current BB users, and 52 patients (38.5%) were prior BB users. The most frequent indications for BB use were heart failure, hypertension, coronary artery disease, and arrhythmia. The most common reason for stopping BB therapy was hypotension (62.8%) followed by fatigue, bradycardia, and orthostasis. Neurologic symptoms at the initial BB prescription or most recent evaluation were not significantly different between current and prior BB users. Their cardiovascular profiles were similar by ejection fraction, wall thickness, troponin I, and brain natriuretic peptide. There was no association for BB discontinuation based on amyloid subtype, sex, or race. Conclusion: The majority of patients with amyloid cardiomyopathy were prescribed BB, and over half of these patients still tolerated BB therapy. Current and prior BB users had similar profiles from a cardiovascular and neurologic perspective, with no association identified to predict BB discontinuation.

Application of Artificial Intelligence in the Management of Pancreatic Cystic Lesions.

The rate of incidentally detected pancreatic cystic lesions (PCLs) has increased over the past decade and was recently reported at 8%. These lesions pose a unique challenge, as each subtype of PCL carries a different risk of malignant transformation, ranging from 0% (pancreatic pseudocyst) to 34-68% (main duct intraductal papillary mucinous neoplasm). It is imperative to correctly risk-stratify the malignant potential of these lesions in order to provide the correct care course for the patient, ranging from monitoring to surgical intervention. Even with the multiplicity of guidelines (i.e., the American Gastroenterology Association guidelines and Fukuoka/International Consensus guidelines) and multitude of diagnostic information, risk stratification of PCLs falls short. Studies have reported that 25-64% of patients undergoing PCL resection have pancreatic cysts with no malignant potential, and up to 78% of mucin-producing cysts resected harbor no malignant potential on pathological evaluation. Clinicians are now incorporating artificial intelligence technology to aid in the management of these difficult lesions. This review article focuses on advancements in artificial intelligence within digital pathomics, radiomics, and genomics as they apply to the diagnosis and risk stratification of PCLs.

Recent advances in the diagnostic evaluation of pancreatic cystic lesions.

Pancreatic cystic lesions (PCLs) are becoming more prevalent due to more frequent abdominal imaging and the increasing age of the general population. It has become crucial to identify these PCLs and subsequently risk stratify them to guide management. Given the high morbidity associated with pancreatic surgery, only those PCLs at high risk for malignancy should undergo such treatment. However, current diagnostic testing is suboptimal at accurately diagnosing and risk stratifying PCLs. Therefore, research has focused on developing new techniques for differentiating mucinous from non-mucinous PCLs and identifying high risk lesions for malignancy. Cross sectional imaging radiomics can potentially improve the predictive accuracy of primary risk stratification of PCLs at the time of detection to guide invasive testing. While cyst fluid glucose has reemerged as a potential biomarker, cyst fluid molecular markers have improved accuracy for identifying specific types of PCLs. Endoscopic ultrasound guided approaches such as confocal laser endomicroscopy and through the needle microforceps biopsy have shown a good correlation with histopathological findings and are evolving techniques for identifying and risk stratifying PCLs. While most of these recent diagnostics are only practiced at selective tertiary care centers, they hold a promise that management of PCLs will only get better in the future.

Cleaning Zirconia Surface Prior To Bonding: A Comparative Study of Different Methods and Solutions.

PURPOSE: To evaluate resin cement bond strength after removal of salivary contamination from a zirconia surface using different cleaning solutions and air-borne particle abrasion. MATERIALS AND METHODS: One-hundred and twenty zirconia specimens (KATANA STML, Noritake) were prepared and divided into 12 groups (n = 10). Groups were subjected to a notched-edge shear bond strength test (ISO 29022) to analyze the bonding efficiency of a resin cement (Panavia V5, Kuraray Noritake Dental Inc.) before and after contamination with saliva. Group 1 (control) was prepared and cemented without salivary contamination. Group 2 was coated with ceramic primer (Clearfil Ceramic Primer Plus, Kuraray Noritake Dental Inc.) then subjected to salivary contamination then tested. Group 3 was contaminated, cleaned by air-borne particle abrasion, ceramic primer and resin cement applied, and tested. Groups 4 to 12 were contaminated, and then different cleaning solutions (water, 4.5% hydrofluoric acid, 35% phosphoric acid, Ivoclean, KATANA cleaner, Zirclean, sodium hypochlorite 4%, and 7.5%) were used to decontaminate the zirconia surface, followed by ceramic primer, resin cement application, and tested. One-way ANOVA and Tukey post-hoc analysis was used to analyze the data. RESULTS: One-way ANOVA showed statistical differences among cleaning procedures (p < 0.001, F = 13.48). Air-borne particle abrasion was the only group which provided a bond strength (21 ± 2.8 MPa) that was not statistically different than the control group in which no contamination occurred (25.3 ± 3.3 MPa) (p = 0.247). The use of hydrofluoric acid and zirconia cleaning solutions resulted in bond strengths values which were not statistically different from each other (17.5-19.1 MPa). CONCLUSION: Air-borne particle, zirconia cleaning solutions and hydrofluoric acid are feasible to decontaminate the zirconia surface from saliva prior to bonding the restoration.

Characteristics and Inpatient Outcomes of Primary Biliary Cholangitis and Autoimmune Hepatitis Overlap Syndrome.

BACKGROUND AND AIMS: Primary biliary cholangitis (PBC) and autoimmune hepatitis (AIH) are hepatobiliary diseases of presumed immune-mediated origin that have been shown to overlap. The aim of this retrospective trial was to use national data to examine the characteristics and outcomes of patients hospitalized with overlapping PBC and AIH (PBC/AIH). METHODS: The National Inpatient Sample was used to identify hospitalized adult patients with PBC, AIH, and PBC/AIH from 2010 to 2014 by International Classification of Diseases-Ninth Edition Revision codes; patients with hepatitis B virus and hepatitis C virus infection were excluded. Primary outcomes measures were in-hospital outcomes that included mortality, respiratory failure, septic shock, length of stay, and total hospital charges. Secondary outcomes were the clinical characteristics of PBC/AIH, including the comorbid extrahepatic autoimmune disease pattern and complications of cirrhosis. RESULTS: A total of 3,478 patients with PBC/AIH were included in the study. PBC/AIH was associated with higher rates of Sjögren's syndrome (p<0.001; p<0.001), lower rates of Crohn's disease (p<0.05; p<0.05), and higher rates of cirrhosis-related complications when compared to PBC or AIH alone. There were similar rates of mortality between the PBC/AIH, PBC, and AIH groups. The PBC/AIH group had higher rates of septic shock when compared to the PBC group (p<0.05) and AIH group (p<0.05) after adjusting for possible confounders. CONCLUSIONS: PBC/AIH is associated with a lower rate of Crohn's disease, a higher rate of Sjögren's syndrome, higher rates of cirrhosis-related complications, and significantly increased risk of septic shock compared to PBC and AIH individually.

Prolonged Postoperative Mechanical Ventilation (PPMV) in children undergoing abdominal operations: An analysis of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database.

BACKGROUND: Prolonged postoperative mechanical ventilation (PPMV) increases length of stay, hospitalization costs, and postoperative complications. Independent risk factors associated with PPMV are not well-known for children. METHOD: We identified children (<18 years) in the ACS NSQIP-P database who underwent a general surgical abdominal operation. We excluded children with preoperative ventilator dependence and mortality within 48 h of surgery. PPMV was defined as cumulative postoperative mechanical ventilation exceeding 72 h. A multivariable logistic regression model identified independent predictors of PPMV. RESULTS: We identified 108,392 children who underwent a general surgical abdominal operation in the ACS NSQIP-P database from 2012 to 2017. We randomly divided the population into a derivation cohort of 75,874(70%) and a validation cohort of 32,518(30%). In the derivation cohort, we identified PPMV in 1,643(2.2%). In the multivariable model, the strongest independent predictor of PPMV was neonatal age (OR:20.66; 95%CI:16.44-25.97). Other independent risk factors for PPMV were preoperative inotropic support (OR:10.56; 95%CI:7.56-14.77), an operative time longer than 150 min (OR:4.30; 95%CI:3.72-4.52), and an American Society of Anesthesiologists classification >3 (OR:12.16; 95%CI:10.75-13.75). CONCLUSION: Independent preoperative risk factors for PPMV in children undergoing a general surgical operation were neonatal age, preoperative ionotropic support, duration of operation, and ASA classification >3.

Optical properties of bisacryl-, composite-, ceramic- resin restorative materials: An aging simulation study.

OBJECTIVE: Compare optical properties of a bisacryl-, composite-, and ceramic-resin restorative materials pre and post artificial aging. METHODS: Bisacryl-resin (LuxaCrown [LC], DMG), resin-composite (Filtek Supreme Ultra, [Filtek SU] 3M ESPE), and ceramic-resin (Enamic, VITA Zahnfabrik) specimens were prepared. The L*, C*ab , and hab values were measured pre and post artificial aging to determine color stability (CIEDE2000) and changes in contrast ratio (CR), transmittance block, and relative translucency parameter. The datasets were analyzed using 2-way ANOVA followed by pairwise comparisons. RESULTS: Color difference data showed a significant interaction between materials and treatments [F(6:60) = 375.04, P < .0001] with Enamic being most color stable material and coffee having most effect on color stability. CR data showed a significant interaction between materials and treatments [F(6:60) = 4.12, P = .0016]. LC showing most change in CR values with coffee treatment. Change in transmittance blocked by Filtek SU and LC was greater for coffee treatment than that by each of the other treatments (P < .0001). Filtek SU and LC, coffee produced a greater decrease in relative translucency than that each of the other treatments (P < .0001). CONCLUSIONS: Resin-based materials demonstrate optical properties that encourage their use for direct/indirect restorative options. Color stability and translucency of these materials are proportionally related. CLINICAL SIGNIFICANCE: Understanding the optical properties of resin-based materials provides help in material selection and provides insight into clinical performance and esthetic longevity. The optical stability of certain bisacryl-resin is better than what was previously determined for these restorative materials.

Color and translucency stability of contemporary resin-based restorative materials.

OBJECTIVE: To determine color and translucency stability of present-day resin-based restorative materials. MATERIALS AND METHODS: Disk-shaped (1.0 × 10 mm) resin composites (Filtek Universal, 3M ESPE; Spectra ST, Dentsply Sirona; Gradia Direct X, GC America; Estilite Quick, Tokuyama; Harmonize, Kerr; ACTIVA Bioactive-Restorative, Pulpdent) were prepared and divided into four staining groups (n = 5); coffee (55°C), grape juice (5°C), deionized water (25°C) and thermocycling (20 000 cycles, 5°C to 55°C with a 30-second dwell time). Spectrophotometer measurements were taken at baseline and 14 days for each group and the color stability (CIEDE2000) and changes in the translucency parameter (RTPCIEDE2000 ) and luminous transmittance of each composite were determined. A 2-way analysis of variance (ANOVA) using maximum likelihood estimations was used for analysis for these changes, with subsequent pairwise comparisons using Bonferroni-corrected Student's t tests and an experiment-wise α = 0.05. RESULTS: A significant interaction (P < .0001) between material and treatment was found for each change in the esthetic property tested over 14 days. Multiple significant differences between materials for each treatment and between treatments for each material were identified. CONCLUSIONS: The severity of color change and translucency of resin-based materials are dependent on their type, mostly affected by the coffee staining medium. Nano-filled resin composite is most resistant to color change and with stable translucency after artificial aging. CLINICAL RELEVANCE: Nano-filled resin composite may be the most esthetically durable resin- based restorative material. Micro-hybrid resin composite and resin-modified glass ionomer restorative material are susceptible to color change and losing their translucency. Hot coffee solution may shorten the esthetic lifespan of a resin-based material.

The effects of diabetes mellitus on clinical outcomes of hospitalized patients with acute diverticulitis.

OBJECTIVES: Acute diverticulitis is a common gastrointestinal illness due to diverticular inflammation and focal necrosis. Diabetes mellitus has been reported to influence the outcomes of patients with diverticular disease. Our study aimed to examine the inpatient outcomes and complications of patients with acute diverticulitis and coexisting diabetes mellitus. METHODS: The Nationwide Inpatient Sample was used to identify adult patients in 2014 admitted for acute diverticulitis. Primary outcomes were mortality, length of stay (LOS), and total hospitalization charges. Secondary outcomes were complications of acute diverticulitis and interventions. RESULTS: In total, 44 330 of patients with acute diverticulitis and diabetes mellitus were included in the analysis. Acute diverticulitis patients with diabetes mellitus had a higher rate of diverticular bleeding (P < 0.0001), but lower rates of abscess (P < 0.0001), obstruction (P < 0.0001) and colectomy (P < 0.0001) when compared to acute diverticulitis patients without diabetes mellitus. Complicated diabetes mellitus was associated with a longer LOS (P = 0.00003) and greater total hospitalization charges (P = 0.0021) compared to uncomplicated diabetes mellitus when coexisting with acute diverticulitis. CONCLUSIONS: Acute diverticulitis with diabetes mellitus is associated with a higher rate of diverticular bleeding, lower rates of abscess, obstruction, and colectomy compared to acute diverticulitis without diabetes mellitus. When coexisting with acute diverticulitis, complicated diabetes mellitus is not associated with higher rates of mortality or diverticulitis-related complications compared to uncomplicated diabetes mellitus.

Sarcoidosis is associated with lower risks of penetrating disease and colectomy in hospitalized patients with inflammatory bowel disease.

BACKGROUND AND AIM: Inflammatory bowel disease (IBD) and sarcoidosis, primarily considered distinct entities, share commonalties in pathophysiology and clinical manifestations. This study aimed to examine the in-hospital outcomes of patients with concurrent IBD and sarcoidosis. METHODS: The National Inpatient Sample was used to identify hospitalized adult patients with IBD and sarcoidosis from 2010 to 2014. Primary outcomes were in-hospital mortality, rates of septic shock, acute renal failure, respiratory failure, length of stay, and total hospitalization charges. Secondary outcomes were IBD-specific complications and surgery interventions. RESULTS: A total of 3995 patients with IBD and coexisting sarcoidosis (IBD/sarcoidosis), of which 2500 patients had Crohn's disease with coexisting sarcoidosis (Crohn's disease [CD]/sarcoidosis) and 1495 patients had ulcerative colitis with coexisting sarcoidosis (ulcerative colitis [UC]/sarcoidosis), were included. Patients with IBD/sarcoidosis had a lower risk of penetrating disease (adjusted odds ratio [aOR] 0.3, 95% confidence interval [CI] 0.16-0.55, P < 0.0001) and colectomy (aOR 0.48, 95% CI 0.27-0.84, P < 0.05). Subgroup analysis demonstrated lower rates of colectomy when comparing CD/sarcoidosis (P < 0.05) and UC/sarcoidosis (P = 0.0003) versus CD or UC alone. There was no difference in mortality. CONCLUSION: IBD/sarcoidosis is associated with lower risks of penetrating disease and colectomy when compared to patients with IBD alone.

Impact of the Human Immunodeficiency Viruses Status on Outcomes in Patients Hospitalized With Acute Pancreatitis: A Propensity-Matched Analysis.

OBJECTIVES: We aimed to examine the clinical characteristics and outcomes of patients admitted for acute pancreatitis (AP) in the population with human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS). METHODS: The National Inpatient Sample from 2010 to 2014 was used to identify adult patients admitted with AP. Patients were grouped based on the HIV status. Primary outcomes were mortality, length of stay (LOS), disposition and total hospitalization charges. Secondary outcomes included acute kidney injury, septic shock, respiratory failure and pancreatic procedures. RESULTS: After matching and weighting, a total of 14,152 HIV-positive patients (6904 with AIDS and 7248 with asymptomatic HIV [aHIV]) with AP were identified. Acute pancreatitis with AIDS were associated with a higher rate of acute kidney injury, longer LOS, higher hospitalization charges, and less routine disposition compared with HIV-negative AP. Patients with aHIV had less septic shock, shorter LOS, and less hospitalization charges compared with HIV-negative patients and less respiratory failure, shorter LOS, and less hospitalization charges compared with AIDS patients. CONCLUSIONS: Patients admitted for AP with AIDS have worse outcomes. On the contrary, aHIV status was not only associated with better outcomes when compared with AIDS, but to HIV-negative status as well.

A Novel Approach to Dilation of Complete Colorectal Anastomotic Stricture Using Transillumination.

Colorectal anastomotic strictures are a well-known complication of low anterior resection. Depending on their location, strictures are amendable to different forms of endoscopic intervention. However, all endoscopic interventions are contingent on passing a guidewire across the anastomotic stricture. We present the case of a patient with a complete anastomotic stricture that could not be traversed by conventional endoscopy and the unique method by which a lumen was created in the anastomotic strictures that allowed for a guidewire to be passed across.

Ferrous Sulfate-Induced Esophageal Injury Leading to Esophagitis Dissecans Superficialis.

Medication-induced esophagitis is a well-known but relatively rare clinical diagnosis, most common in patients with preexisting esophageal dysmotility, obstruction, or altered anatomy. Esophagitis dissecans superficialis (EDS) is a rare endoscopic finding characterized by sloughing of large fragments of the esophageal mucosal lining. The causes of EDS include prior trauma, heavy smoking history, ingestion of alcoholic and hot beverages, and immunosuppression. We present a unique case of EDS secondary to ferrous sulfate-induced pill esophagitis. The patient was a 94-year-old male who presented with dysphagia to solids, odynophagia, and weight loss. Esophagogastroduodenoscopy (EGD) revealed EDS. Biopsies demonstrated vacuolar degeneration at the midlevel of the epithelium with overlying hyperkeratosis and parakeratosis, with noted black/brown pigment present at the level of the split in the epithelium. The patient was started on a liquid diet with no oral administration of pills. EGD was repeated and showed a significant improvement in esophageal mucosa and resolution of strictures. Although medication-induced esophagitis is not classically associated with EDS, specific circumstances that are associated with pill esophagitis may lead to progression to EDS. In the case of our patient, prolonged contact of ferrous sulfate to the esophageal mucosa is thought be a result of an enlarged left atrium and pulmonary arteries secondary to longstanding coronary artery disease and an enlarged left bronchus secondary to chronic obstructive pulmonary disease and right pneumonectomy. These anatomical changes likely led to an extended duration of contact and are believed to have led to erosion of the superficial esophageal mucosa, eventually progressing to EDS.

Endoscopic Retrograde Cholangiopancreatography Leading to Pharyngeal Perforation.

Endoscopic retrograde cholangiopancreatography (ERCP) had become the favored method to access the pancreaticobiliary system because it is a safer and less invasive method compared to surgery. However, as with any procedure, ERCP comes with its own risks and potential complications. We present a unique case of a patient who underwent ERCP and developed necrotizing infection of the neck and a submandibular abscess. The patient is a 66-year-old female who presented to an outside hospital with complaint of right upper quadrant abdominal pain, workup of which revealed choledocholithiasis. ERCP was attempted; however, cannulation was unsuccessful. The patient was discharged home after the procedure, but within 48 h she presented to our institution complaining of left-sided neck pain, dysphagia, and drooling. CT of the neck revealed extensive gas and fluid collections at the left submandibular space. The patient was taken to the operating room for drainage of the left neck abscess. Drainage and irrigation of the abscess yielded Streptococcus mitis and Hemophilus parainfluenza. The rest of patient's hospital course was uncomplicated, and she was discharged with appropriate follow-up. In the case of our patient, ERCP was complicated by a perforation of the hypopharynx. Pharyngeal perforation can be subclassified into supraglottic and infraglottic. The most frequent cause of perforations is due to increased pressure in an intrinsically weak anatomical region of the pharynx. Such perforations are commonly due to the advancement of the endotracheal tube or transthoracic echo probe, but can also be due to advancement of an endoscope.

Effect of masticatory simulation on the translucency of different types of dental zirconia.

STATEMENT OF PROBLEM: Translucent zirconia has been marketed to dentists seeking to provide esthetic monolithic dental restorations. Evidence on differences in translucency between recently introduced translucent zirconia and conventional zirconia before and after fatigue testing with thermocycling is lacking. PURPOSE: The purpose of this in vitro study was to evaluate the effect of fatiguing and thermocycling on the translucency of 5 mol% yttria partially stabilized zirconia (5Y-PSZ) and 3 mol% yttria partially stabilized zirconia (3Y-PSZ) at clinically relevant thicknesses. MATERIAL AND METHODS: Translucent zirconia (BruxZir Anterior Solid Zirconia [5Y-PSZ]) and conventional zirconia (BruxZir Shaded Zirconia [3Y-PSZ]) were evaluated. Disk-shaped specimens were prepared to 0.7-mm and 1.2-mm thicknesses for each zirconia type. Four groups (n=10/group) were evaluated. Translucency parameter (TP), contrast ratio (CR), and light blockage percentage (Lb%) were recorded by using an integrating sphere spectrophotometer before and after fatiguing (1.2 million cycles at 110-N load with simultaneous thermocycling at 5 °C to 55 °C). Data were analyzed by repeated-measures analysis of variance for statistical significance (α=.05). CR values were compared with the reported 0.06 translucency perception threshold of the human eye. RESULTS: A statistically significant difference was found in TP, CR, and Lb% between 5Y-PSZ and 3Y-PSZ (P<.001). Thickness had a statistically significant effect on TP, CR, and Lb% (P<.05). The 0.7-mm thickness groups were more translucent and had lower Lb% than the 1.2-mm thickness groups (P<.001). Baseline ranking from most to least translucent according to TP and CR measurements was as follows: 5Y-PSZ (0.7 mm), 3Y-PSZ (0.7 mm), 5Y-PSZ (1.2 mm), and 3Y-PSZ (1.2 mm). Lb% was 64% at the 1.2-mm and 56% at the 0.7-mm thickness in the 3Y-PSZ groups. Lb% was 61% at the 1.2-mm and 53% at the 0.7-mm thickness in the 5Y-PSZ groups. None of the groups, before and after fatiguing, had a CR value exceeding the clinically perceivable 0.06 translucency perception threshold value. CONCLUSIONS: Translucent (5Y-PSZ) and conventional (3Y-PSZ) zirconias evaluated in this study displayed degrees of translucency that were inversely related to the zirconia thickness. 5Y-PSZ was more translucent and blocked less light than 3Y-PSZ, but this difference may not be perceivable to the human eye. Both 5Y-PSZ and 3Y-PSZ were optically stable after fatiguing and thermocycling.