Defining Physiological Ketosis Following Very-Low-Calorie Diets

INTRODUCTION

Very low-calorie diets (VLCDs) are used preoperatively in bariatric-metabolic surgery; however, this can lead to physiological ketosis. Euglycemic ketoacidosis is an increasingly recognized complication in diabetic patients on sodium-glucose-cotransporter-2 inhibitors (SGLT2i) undergoing surgery and requires assessment of ketones for diagnosis and monitoring. VLCD induced ketosis may confound monitoring in this group. We aimed to evaluate the influence of VLCD, compared to standard fasting, on perioperative ketone levels and acid-base balance.

MATERIALS AND METHODS

Twenty-seven patients were prospectively recruited to the intervention group and 26 to the control group from two tertiary referral centres in Melbourne, Australia. Intervention group patients were severely obese (body mass index) (BMI) (≥35), undergoing bariatric-metabolic surgery, and prescribed 2 wk of VLCD preoperatively. Control group patients underwent general surgical procedures and prescribed standard procedural fasting only. Patients were excluded if diabetic or prescribed SGLT2i. Ketone and acid-base measurements were taken at regular intervals. Univariate and multivariate regression was utilised with significance defined as P < 0.005.

CLINICALTRIALS

gov ID: NCT05442918.

RESULTS

Patients on VLCD, compared to standard fasting, had an increased median preoperative (0.60 versus 0.21 mmol/L), immediate postoperative (0.99 versus 0.34 mmol/L) and day 1 postoperative (0.69 versus 0.21 mmol/L) ketone level (P < 0.001). Preoperative acid-base balance was normal in both groups, however VLCD patients were found to have a metabolic acidosis immediately postoperatively (pH 7.29 versus pH 7.35) (P = 0.019). Acid-base balance had normalized in VLCD patients on postoperative day 1.

CONCLUSIONS

Preoperative VLCD resulted in increased pre- and postoperative ketone levels with immediate postoperative values consistent with metabolic ketoacidosis. This should be considered particularly when monitoring diabetic patients prescribed SGLT2i.

Percentage of intrathoracic stomach predicts operative and post-operative morbidity, persistent reflux and PPI requirement following laparoscopic hiatus hernia repair and fundoplication

PURPOSE

Large hiatus hernias are relatively common and can be associated with adverse symptoms and serious complications. Operative repair is indicated in this patient group for symptom management and the prevention of morbidity. This study aimed to identify predictors of poor outcomes following laparoscopic hiatus hernia repair and fundoplication (LHHRaF) to aid in counselling potential surgical candidates.

METHODOLOGY

A retrospective analysis was performed from a prospectively maintained, multicentre database of patients who underwent LHHRaF between 2014 and 2020. Revision procedures were excluded. Hernia size was defined as the intraoperative percentage of intrathoracic stomach, estimated by the surgeon to the nearest 10%. Predictors of outcomes were determined using a prespecified multivariate logistic regression model.

RESULTS

625 patients underwent LHHRaF between 2014 and 2020 with 443 patients included. Median age was 65 years, 62.9% were female and 42.7% of patients had ≥ 50% intrathoracic stomach. In a multivariate regression model, intrathoracic stomach percentage was predictive of operative complications (P = 0.014, OR 1.05), post-operative complications (P = 0.026, OR 1.01) and higher comprehensive complication index score (P = 0.023, OR 1.04). At 12 months it was predictive of failure to improve symptomatic reflux (P = 0.008, OR 1.02) and persistent PPI requirement (P = 0.047, OR 1.02). Operative duration and blood loss were predicted by BMI (P = 0.004 and < 0.001), Type III/IV hernias (P = 0.045 and P = 0.005) and intrathoracic stomach percentage (P = 0.009 and P < 0.001). Post-operative length of stay was predicted by age (P < 0.001) and emergency presentation (P = 0.003).

CONCLUSION

In a multivariate regression model, intrathoracic stomach percentage was predictive of operative and post-operative morbidity, PPI use, and failure to improve reflux symptoms at 12 months.

13 Medical Students’ Mood Adversely Affected By COVID-19 Pandemic: An Interim Analysis from the SPICE-19 Prospective Cohort Study Of 2075 Medical Students and Interim Foundation Doctors

Introduction

In order to appropriately support medical students and foundation year doctors, it is imperative that we understand the impact the COVID-19 pandemic has had upon them. This study assessed the effects of the COVID-19 pandemic on medical students and interim foundation year doctors across the United Kingdom (UK), and the support that they received and sought.

Method

A prospective, observational, multicentre study was conducted. All medical students and interim foundation year doctors were eligible to participate.

Results

A total of 2075 individuals participated. There was a decrease in participants’ mood when comparing their mood before the pandemic to during the pandemic (p < 0.0001). Social distancing negatively impacted the mood of the greatest number of participants. All areas of life included in the study were found to have been significantly more negatively impacted than positively impacted (p < 0.0001). 931 participants wanted more support from their university.

Conclusions

When medical students return to their universities, there is likely to be a need for enhanced wellbeing support, adaptations in the short-term and long-term strategies for medical education, and provision of financial guidance. If no action is taken, there may be a knock-on effect on workforce planning and the health of our future workforce.

878 Comparing Treatment Outcomes for Unruptured Brain Arteriovenous Malformations: A Retrospective Cohort Study

Background

Unruptured brain arteriovenous malformations (bAVMs) carry a lifetime risk of haemorrhage. Treatment strategies include conservative management, microsurgical excision, endovascular treatment (EVT) and radiosurgery (SRS). Optimal treatment selection remains unclear.

Method

A single-centre retrospective cohort study of adult unruptured bAVMs (2007-2019). Patients who underwent intervention were propensity matched using baseline features (age, sex, size, deep drainage, eloquence, and Spetzler-Martin grade) with patients conservatively managed. Rates of neurological disability and mortality due to intervention or bleed were compared.

Results

137 patients (mean age 48 years [SD = 16], males 64) were included; 34 (25%) EVT, 20 (15%) surgery, 31 (22%) SRS and 51 (37%) conservative. After a median follow-up of 49 months (IQR 23-75), rates of disability were as follows: surgery 35%, EVT 21%, SRS 13% and conservative 8%. Matched cohorts (intervention/conservative) were: surgery-19/18, SRS-30/22 and EVT-33/34. Comparison of disability rates across matched cohorts revealed no statistically significant differences (surgery p = 0.07, SRS p = 0.65 and EVT p = 0.11). Three conservatively managed patients died.

Conclusions

Unruptured bAVMs carry a significant risk of neurological morbidity, regardless of intervention choice. Treatment choice may have an impact on patient outcomes but requires investigation of stratified cohorts. Findings are consistent with the nuances of AVM treatment selection.

Intragastric laparoscopy for oesophageal eroded mesh removal: An approach to avoid resection

The augmentation of hiatal repair for large hiatus hernia with mesh is controversial. There is some evidence that recurrence rates are less with mesh repair; however, there is a risk of mesh erosion. Complicated erosion may require complex revisional surgery and oesophagogastric resection. We present a novel approach to the treatment of oesophageal mesh erosion, by utilising a combined approach of endoscopy and intragastric laparoscopy. The symptomatic relief from this procedure may obviate the need for foregut resection in some patients.

Trans-hiatal repair for Oesophageal and Junctional perforation: a case series

Background

Oesophageal perforation is a life-threatening condition that requires urgent intervention. Surgical repair is recommended within 24 h of onset to minimise mortality risk, traditionally via an open thoracotomy or a laparotomy. Primary oesophageal repair via a laparoscopic trans-hiatal approach has been seldomly reported due to concerns of inadequate eradication of soilage in the mediastinum and pleural space, as well as poor access and an increased operative time in an unwell population.

Case presentation

We report a case series of 3 oesophageal and junctional perforations with varying presentations, demonstrating how the laparoscopic trans-hiatal approach can be used successfully to manage oesophageal perforations.

Conclusions

Laparoscopic trans-hiatal repair is an attractive option for oesophageal and junctional perforations, in haemodynamically stable surgical candidates, in the absence of gross contamination of the thoracic cavity.

Gallstones top to toe: what the radiologist needs to know

Gallstone-related disease can have significant associated morbidity and mortality worldwide. The incidence of gallstone-related disease in the Western world is on the increase. There are multiple different pathological manifestations of gallstone disease: the presentation, diagnosis and associated complications of which vary significantly depending on anatomical location. The role of imaging in gallstone-related disease is broad with radiology playing an essential role in the diagnosis, management and follow-up of gallstone-related pathologies. This paper distills the broad range of gallstone-related pathologies into an anatomical map, discussing the disease processes involved at each point along the biliary tree and reviewing the strengths and weaknesses of different imaging modalities for each distinct disease process.

Laparoscopic management of chylous ascites posthiatal hernia repair with Toupet fundoplication

We present a case of chylous ascites in a 69-year-old man 5 months after a laparoscopic Toupet fundoplication (posterior 270°). This was successfully treated with laparoscopic ligation of tissue adjacent to the right crus. Laparoscopic ligation is a management option that should be considered after this rare complication, offering rapid results.

Effects of an introduced, novel prey on diet and reproduction in the diet-specialist European Starling (Sturnus vulgaris)

Diet specialization has important consequences for how individuals or species deal with environmental change that causes changes in availability of prey species. We took advantage of a “natural experiment” — establishment of a commercial insect farm — that introduced a novel prey item, black soldier flies (Hermetia illucens (Linnaeus, 1758)), to the diet-specialist European Starling (Sturnus vulgaris Linnaeus, 1758). We investigated evidence for individual diet specialization (IDS) and the consequences of diet specialization and exploitation of novel prey on breeding productivity. In all 4 years of our study, tipulid larvae were the most common prey item. Soldier flies were not recorded in diets in 2013–2014; however, coincident with the establishment of the commercial insect farming operation, they comprised 22% and 30% of all prey items in the diets of European Starling females and males, respectively, in 2015. There was marked individual variation in use of soldier flies (4%–48% and 2%–70% in females and males, respectively), but we found little evidence of dichotomous IDS, i.e., where only some individuals have a specialized diet. We found no evidence for negative effects of use of soldier flies on breeding productivity: brood size at fledging and chick quality (mass, tarsus length) were independent of the number and proportion (%) of soldier flies returned to the nest.

Long-term outcomes of laparoscopic large hiatus hernia repair with nonabsorbable mesh

The use of mesh to augment suture repair of large hiatus hernias remains controversial. Repair with mesh may help reduce the recurrence rate of primary repair, but concerns about the potential for serious complications, such as mesh erosion or stricturing, continue to limit its use. We aim to evaluate the long-term outcome of primary hiatus hernia repair with lightweight polypropylene mesh (TiMesh) specifically looking at rates of clinical recurrence, dysphagia, and mesh-related complications. From a prospectively maintained database, 50 consecutive patients who underwent elective primary laparoscopic hiatal hernia repair with TiMesh between January 2005 and December 2007 were identified. Case notes and postoperative endoscopy reports were reviewed. Clinical outcomes were evaluated using a structured questionnaire, including a validated dysphagia score. Of the 50 patients identified, 36 (72%) were contactable for follow-up. At a median follow-up of 9 years, the majority of patients (97%) regarded their surgery as successful. Twelve patients (33%) reported a recurrence of their symptoms, but only 4 (11%) reported that their symptoms were as severe as prior to the surgery. There was no significant difference between pre- and postoperative dysphagia scores. Postoperative endoscopy reports were available for 32 patients at a median time point of 4 years postoperatively, none of which revealed any mesh-related complications. One patient had undergone a revision procedure for a recurrent hernia at another institution. In this series, primary repair of large hiatus hernia with nonabsorbable mesh was not associated with any adverse effects over time. Patient satisfaction with symptomatic outcome remained high in the long term.

Underdetection of comorbid drug use at acute psychiatric admission

Aims and Method

The ability of routine clinical practice to detect drug use at acute psychiatric admission was assessed by comparing the results of urinalysis with information on drug use extracted from patient records (n=112).

Results

Urinalysis detected drug use in 23% of the sample. Cannabis was the drug most frequently found. Of the cases of drug use positively identified by urinalysis, 54% were not identified in the notes. Some information on drug use proximal to admission was found in 40% of patient records. Patients asked about proximal drug use were younger than those not asked.

Clinical Implications

All patients should be asked about drug use.

Flexible polygon-mirror based laser scanning microscope platform for multiphoton in-vivo imaging

Commercial microscopy systems make use of tandem scanning i.e. either slow or fast scanning. We constructed, for the first time, an advanced control system capable of delivering a dynamic line scanning speed ranging from 2.7 kHz to 27 kHz and achieve variable frame rates from 5 Hz to 50 Hz (512 × 512). The dynamic scanning ability is digitally controlled by a new customized open-source software named PScan1.0. This permits manipulation of scanning rates either to gain higher fluorescence signal at slow frame rate without increasing laser power or increase frame rates to capture high speed events. By adjusting imaging speed from 40 Hz to 160 Hz, we capture a range of calcium waves and transient peaks from soma and dendrite of single fluorescence neuron (CAL-520AM). Motion artifacts arising from respiratory and cardiac motion in small animal imaging reduce quality of real-time images of single cells in-vivo. An image registration algorithm, integrated with PScan1.0, was shown to perform both real time and post-processed motion correction. The improvement is verified by quantification of blood flow rates. This work describes all the steps necessary to develop a high performance and flexible polygon-mirror based multiphoton microscope system for in-vivo biological imaging.

The impact of human papillomavirus type on colposcopy performance in women offered HPV immunisation in a catch-up vaccine programme: a two-centre observational study

OBJECTIVE

To determine whether human papillomavirus (HPV) immunisation has affected the prevalence of HPV genotypes and colposcopic features of cervical intraepithelial neoplasia (CIN) in young women referred for colposcopy.

DESIGN

A two-centre observational study including vaccinated and unvaccinated women.

SETTING

Colposcopy clinics serving two health regions in Scotland, UK.

POPULATION

A total of 361 women aged 20-25 years attending colposcopy following an abnormal cervical cytology result at routine cervical screening.

METHODS

Cervical samples were obtained from women for HPV DNA genotyping and mRNA E6/E7 expression of HPV 16, 18, 31, 33, and 45. Demographic data, cytology, and histology results and colposcopic features were recorded. Chi-square analysis was conducted to identify associations between vaccine status, HPV genotypes, and colposcopic features.

MAIN OUTCOME MEASURES

Colposcopic features, HPV genotypes, mRNA expression, and cervical histology.

RESULTS

The prevalence of HPV 16 was significantly lower in the vaccinated group (8.6%) compared with the unvaccinated group (46.7%) (P = 0.001). The number of cases of CIN2+ was significantly lower in women who had been vaccinated (P = 0.006). The HPV vaccine did not have a statistically significant effect on commonly recognised colposcopic features, but there was a slight reduction in the positive predictive value (PPV) of colposcopy for CIN2+, from 74% (unvaccinated) to 66.7% (vaccinated).

CONCLUSIONS

In this group of young women with abnormal cytology referred to colposcopy, HPV vaccination via a catch-up programme reduced the prevalence of CIN2+ and HPV 16 infection. The reduced PPV of colposcopy for the detection of CIN2+ in women who have been vaccinated is at the lower acceptable level of the UK national cervical screening programme guidelines.

TWEETABLE ABSTRACT

Reduction of hrHPV positivity and CIN in immunised women consistent with lower PPV of colposcopy for CIN2+.

Quality of life after total and subtotal gastrectomy for gastric carcinoma

BACKGROUND

There remains debate as to whether quality of life (QoL) is better for patients following sub-total gastrectomy (SG) or total gastrectomy (TG) for cancer. Both have similar survival rates provided an R0 resection is performed and in many series the morbidity and mortality after TG is higher than SG. The aim of this study was to evaluate the QoL in patients after TG and SG for cancer.

METHOD

All surviving patients who had undergone TG or SG between 1994 and 2009 were identified from a prospectively collected database and sent the European Organisation for Research and Treatment of Cancer (EORTC) core questionnaire (QLQ-C30 v.3) and the gastric module (QLQ-STO22).

RESULTS

From a total of 261 patients who had undergone TG or SG in the study period, 91 were still alive and 53 responded. There was no significant difference between the QoL between TG and SG based on functional scales and global health status. However dysphagia and eating restrictions were significantly worse in the TG group.

CONCLUSION

This study has demonstrated that there is no difference in overall QoL in patients with TG or SG although eating restrictions and dysphagia are worse after TG.

P3-01-10: DMBA-Breast Cancer in Diet Induced Obesity (DIO) and Lean Mice Is Related to Leptin Signaling

Introduction: Leptin, the major adipokine released by adipose tissue, is strongly linked to obesity related-cancers. We have shown previously that inhibition of leptin signaling with pegylated leptin peptide receptor antagonist 2 (PEG-LPrA2) negatively impacted human xenograft and syngeneic mouse breast cancer growth as well as VEGF/VEGFR2 levels [1,2].

Objective: We hypothesize that leptin signaling is essential for 7,12-dimethylbenz[A]anthracene (DMBA)-mammary tumor (MT) particularly in obese mice.

Methods: The study investigated the potential of PEG-LPrA2 to prevent MT in lean and diet-induced-obesity (DIO)-C57BL/6J female mice treated with 1 mg/dose/weekly for 6 weeks of DMBA. Obesity was induced by feeding DIO-mice (95% obese mice after 5 weeks) with high fat diet (PDI-1; 45% Kcal from fat). Lean mice were fed a normal diet (PDI-1; 5% Kcal from fat). PEG-LPrA2 was administered intravenously. Lean and DIO-mice received either one or two PEG-LPrA2 dose/week (50 ml/0.1 mM) two weeks prior to DMBA to test its preventative potential through the end point (32 weeks). Control mice received saline injections.

Results: Obesity was positively correlated to the development of DMBA-MT in mice. MTs were found in 17% of lean control and 69% of DIO-control mice. Notably, PEG-LPrA2 prevented the onset of DMBA-MT in lean (one and two doses: 0% tumor-bearing mice) and DIO-mice (one-dose, 29% and two-dose 0% MT). PEG-LPrA2 treatment did not alter body weight nor food intake in lean or DIO-mice. VEGF levels were significant higher (32 fold) in control DIO-mice. PEG-LPrA2 inhibition of leptin signaling decreased tumor levels of Notch ligands (Jagged-1 & DLL-4), receptors (Notch 1–4) and target genes (Survivin and Hey2) and reduced OB-R, IL-1R tI, VEGF/VEGFR2, bcl-2, HIF-1a and NFκB (p50 and p105).

Conclusions: Present data strongly suggest that leptin signaling is essential for DMBA-induced MT in the context of obesity. Overall, the effective chemoprevention of DMBA-MT by PEG-LPrA2 treatment in DIO and lean mice reinforces the potential use of leptin signaling inhibition for breast cancer prevention. These observations are most significant for obese populations showing higher levels of leptin and incidence of breast cancer. [This work was supported in part by NIH/NCI1SC1CA138658-02; NIH/ARRA/3SC1CA138658-02S1 and the Georgia Cancer Coalition Distinguished Cancer Scholar Award (to RRGP); CREDO (MSCR) 2R25RR017694-06A1 to L.S.C; the Morehouse School of Medicine (MSM) MBRS RISE Program (NIH/NIGMS 506 GM08248) to T.Z.M; and facilities and support services at Morehouse School of Medicine (NIH RR03034 and 1C06 RR18386)].

References:

[1] Gonzalez RR, Chefils S, Escobar M, et al. Leptin signaling promotes the growth of mammary tumors and increases the expression of vascular endothelial growth factor (VEGF) and its receptor type two (VEGF-R2). J Biol Chem 2006, 281(36): 26320–26328.

[2] Gonzalez RR, Watters A, Xu, Y, et al. Leptin-signaling inhibition results in efficient anti-tumor activity in estrogen receptor positive or negative breast cancer. Breast Cancer Res 2009, 11:R36.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P3-01-10.

P5-06-10: Leptin Signaling Impacts Notch and Wnt Crosstalk in Breast Cancer

Background: Triple negative breast cancer (TNBC: ER-, PR- and Her2/neu-) is an aggressive form of the disease that disproportionately affects women of color, has an early onset, and is associated with poor survival and a resistance to common therapeutic treatments. We have previously demonstrated an association between the adipocytokine leptin and Notch signaling pathways in breast cancer. Notch participates in a crosstalk relationship with many signaling pathways involved in carcinogenesis, including Wnt and leptin, which could in turn increase tumor burden and cell survival of MMTV-Wnt1 obese mice. We hypothesize that leptin signaling crosstalk with Notch and Wnt is instrumental in the development of drug-resistant features (increased survival and proliferation) of TNBC.

Objective: The aim of this study was to determine whether leptin mediated crosstalk of the Notch and Wnt pathways has a differential impact on TNBC compared to ER+ cells.

Materials & Methods: ER+ MCF-7 and TNBC-MDA MB-231 cells (96-well plate; 1×104 cells/well) were serum deprived for 24 hours and treated with varying doses of Doxorubicin and Cisplastin for 24h in conjunction with pharmacological doses of leptin, leptin peptide antagonist (LPrA2), Wnt agonist (Wnt-1) and antagonist (Wif-1). Cell proliferation was measured via WST assay. The effect of the various treatments on the activation of Wnt (total/pβ-catenin), Notch (Notch 1–4 and JAG1/Dll-4 and targets survivin/Hey2), and leptin (STAT3 and targets VEGF/VEGFR-2) signaling pathways were measured using western blot and ELISA. β-Catenin levels were also investigated by IHC in DMBA-breast cancer samples from lean and DIO (diet-induced obese mice) mice treated with LPrA2. Apoptosis was also measured.

Results: Leptin increased the levels of beta-catenin mainly in TNBC cells. This leptin-induced effect was also detected in breast tumors from DIO-mice. Interestingly, leptin increased survival (bcl-2 and Caspase-3 activation)/proliferation (cell number and Cyclin D1), expression of Notch and attenuated the detrimental effects of Doxorubicin and Cisplastin on breast cancer cells. Wnt-1 had similar but less pronounced effects compared to leptin. We also observed differences in Notch expression. Moreover, MDA MB-231 cells showed decreased response to Wnt1 in the presence of leptin.

Conclusions: Our findings suggest that leptin could play a negative role in TNBC by increasing drug-resistance through its crosstalk with Wnt and Notch signaling pathways. This may imply that obesity, characterized by elevated leptin levels, could negatively affect the outcome of TBNC treatment. Taken together, this data supports the theory that inhibition of leptin signaling could be a novel way to prevent and treat TBNC, particularly in the context of obesity and abnormal Wnt and Notch signaling. [This work was supported in part by NIH/NCI1SC1CA138658-02; NIH/ARRA/3SC1CA138658-02S1 and the Georgia Cancer Coalition Distinguished Cancer Scholar Award (to RRGP); CREDO (MSCR) 2R25RR017694-06A1 (to L.S.C); NIGMS506GM08248 and NCRR 5P20RR11104 (to T.Z.M); and facilities and support services at MSM (NIH RR03034 and 1C06 RR18386)].

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P5-06-10.