The incidence and impact of enterotomy during laparoscopic and robotic ventral hernia repair: a nationwide readmissions analysis

INTRODUCTION

Our aim was to define the national incidence of enterotomy (ENT) during minimally invasive ventral hernia repair (MIS-VHR) and evaluate impact on short-term outcomes.

METHODS

The 2016-2018 Nationwide Readmissions Database was queried using ICD-10 codes for MIS-VHR and enterotomy. All patients had 3-months follow-up. Patients were stratified by elective status; patients without ENT (No-ENT) were compared against ENT patients.

RESULTS

In total, 30,025 patients underwent LVHR and ENT occurred in 388 (1.3%) patients; 19,188 (63.9%) cases were elective including 244 elective-ENT patients. Incidence was similar between elective versus non-elective cohorts (1.27% vs 1.33%; p = 0.674). Compared to laparoscopy, ENT was more common during robotic procedures (1.2% vs 1.7%; p = 0.004). Comparison of elective-No-ENT vs elective-ENT showed that elective-ENT patients had a longer median LOS (2 vs 5 days; p < 0.001), higher mean hospital cost ($51,656 vs $76,466; p < 0.001), increased rates of mortality (0.3% vs 2.9%; p < 0.001), and higher 3-month readmission (10.1% vs 13.9%; p = 0.048). Non-elective cohort comparison demonstrated non-elective-ENT patients had a longer median LOS (4 vs 7 days; p < 0.001), higher mean hospital cost ($58,379 vs $87,850; p < 0.001), increased rates of mortality (0.7% vs 2.1%;p < 0.001), and higher 3-month readmission (13.6% vs 22.2%; p < 0.001). In multivariable analysis (odds ratio, 95% CI), higher odds of enterotomy were associated with robotic-assisted procedures (1.386, 1.095-1.754; p = 0.007) and older age (1.014, 1.004-1.024; p = 0.006). Lower odds of ENT were associated with BMI > 25 kg/m² (0.784, 0.624-0.984; p = 0.036) and metropolitan teaching vs metropolitan non-teaching (0.784, 0.622-0.987; p = 0.044). ENT patients (n = 388) were more likely to be readmitted with post-operative infection (1.9% vs 4.1%; p = 0.002) or bowel obstruction (1.0% vs 5.2%;p < 0.001) and more likely to undergo reoperation for intestinal adhesions (0.3% vs 1.0%; p = 0.036).

CONCLUSION

Inadvertent ENT occurred in 1.3% of MIS-VHRs, had similar rates between elective and urgent cases, but was more common for robotic procedures. ENT patients had a longer LOS, and increased cost and infection, readmission, re-operation and mortality rates.

A75 COLONOSCOPY COLORECTAL CANCER DETECTION - HOW DOES IT VARY BY INDICATION, SETTING AND PATIENT DEMOGRAPHIC?

Background

Because of limited access to gastrointestinal (GI) endoscopy during the COVID-19 pandemic, there is a need to prioritize procedures to avoid negative health impacts from delays. Ontario Health (OH) has provided guidance to facilities to prioritize colonoscopies in people with an abnormal fecal immunochemical test (FIT) result, based on the high likelihood to detect invasive colorectal cancer (CRC) and recommends FIT for screening people at average risk of CRC and those with prior low-risk adenoma.

Purpose

To measure the invasive CRC detection rate (CDR) of colonoscopies performed in Ontario by indication, setting, age, and sex over a 31-month period before and during the COVID-19 pandemic.

Method

We calculated the CDRs among outpatients ages 18 and over who had colonoscopies performed in a hospital or private clinic setting from June 2019 to December 2021. We identified hospital colonoscopies from OH’s GI Endoscopy Data Submission Portal and clinic colonoscopies from Ontario Health Insurance Plan (OHIP) data (OHIP code E749A). Invasive CRC was identified from the Ontario Cancer Registry (OCR) as: ICD-O-3 codes C18.0, C18.2-C18.9, C19.9, C20.9, a morphology indicative of CRC, microscopically confirmed and with a pathology report. CRCs were included if diagnosed 7 days before and up to 183 days after colonoscopy. Colonoscopy volumes and CDRs were stratified by age and sex (all volumes), and, for hospital colonoscopies, by indication.

Result(s)

During the study period, 984,109 colonoscopies were performed (638,900 in hospitals; 345,209 in clinics). Patients who had their colonoscopies in clinics were younger than those who had them in hospitals (Table 1). In both settings, colonoscopies were evenly distributed by sex. Overall, 12,021 CRCs were detected (CDR: 1.22%); 9,451 CRCs in hospitals (CDR: 1.48%), and 2,570 CRCs in clinics (CDR: 0.74%). CDRs at any age were lower in clinics as compared to hospitals. In hospitals, CDRs by colonoscopy indication were: 5.16% for FIT+, 1.93% in symptomatic patients, 0.52% in surveillance, 0.70% in average-risk screening, and 0.35% in screening due to family history. FIT+ colonoscopies accounted for the smallest proportion of colonoscopies (6.2%) but the 2^nd largest proportion of CRCs detected (Figure 1). Hospital-based CDR increased during the period of observation from 1.23% pre-pandemic (June-December 2019) to 1.55% during the pandemic (January-December 2021). Clinic CDR was 0.71% pre-pandemic and 0.75% during the pandemic.

Image

Conclusion(s)

In Ontario, colonoscopy yield (CDR) is highest in FIT+ patients; just over one in 20 colonoscopies will yield a diagnosis of CRC. In contrast, primary screening and surveillance indications have very low CRC yields. The overall yield of colonoscopies in clinics, for all age groups, is lower than in hospital setting. There was a slight increase in CDR during the pandemic compared to before the pandemic, in both settings.

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Hernia recurrence after primary repair of small umbilical hernia defects

BACKGROUND

An evidence-based approach to the repair of umbilical hernias (UH)<1 cm has yet to be defined.

METHODS

A prospectively maintained, institutional hernia database was queried for patients undergoing primary suture repair of UH ≤ 1 cm. The primary outcome was recurrence and secondary outcomes were wound complications.

RESULTS

Of 332 patients included (226-primary, 106-incisional), recurrence was identified in 4 (1.8%) primary versus 8 (7.5%) incisional-UH (p = 0.022), with follow-up of 4.7 ± 4.4 years. There were 10 (3.0%) wound complications: 4 (1.2%) superficial wound infections, 1 (0.3%) superficial wound dehiscence, and 5 (1.5%) seromas. On multivariable analysis of recurrence, incisional-UH had an odds ratio of 4.2 compared to primary. Suture choice, diabetes, BMI, tobacco-use history, and wound complications were not significant.

CONCLUSIONS

With long term follow-up, recurrence after primary suture repair of UH ≤ 1 cm occurred in 1.8% of primary and 7.5% of incisional UH. On multivariable analysis, incisional-UH increased recurrence odds by 4.2 times compared to primary.

OC-034 EVIDENCE-BASED CHANGES IN PERI-OPERATIVE PATIENT CARE IN A TERTIARY HERNIA CENTER(THC): PROSPECTIVE STUDY OF OUTCOMES OVER 18 YEARS AND 1842 OPEN PREPERITONEAL VENTRAL HERNIA REPAIRS(OPPVHR)

Background

Over 18 years, a THC frequently changed patient-care protocols according to repeated reviews of our prospectively collected data outcomes, which have been published in peer-reviewed journals. This study aimed to describe these progressive, evidence-based changes and the subsequent results in PP-VHR.

Methods

Prospective, tertiary hernia center data(2004–2021) was examined for patients undergoing midline open PP-VHR with mesh. “Early”(2004–2012) and “Recent”(2013–2021) groups were based on surgery date.

Results

Comparison of Early(n=675) versus Recent(n=1,167) groups showed that Recent patients were older (56.9±12.6vs58.7±12.1 years;p&lt;0.001), more comorbid(3.6±2.2vs5.2±2.6 diagnoses;p&lt;0.001), lower BMI(33.5±8.3 vs 32.0±6.8 kg/m2; p=0.003), more prior failed VHR(46.5% vs 60.8%; p&lt;0.001), larger hernia defects(199.7±232.8vs214.4±170.5 cm2;p&lt;0.001), more CDC-class 3/4 wounds(11.3%vs18.6%;p&lt;0.001), more biologic mesh(10.5% vs 25.4%;p&lt;0.001), component separations(CST; 22.5%vs45.7%;p&lt;0.001), and more pre-op Botox(0%vs12.3%;p&lt;0.01). Wound complication(26.7%vs13.2%;p&lt;0.001), mesh infection(3.1%vs0.9%;p&lt;0.01), and hernia recurrence rates decreased over time(7.1%vs2.4%;p&lt;0.001) with long-term follow-up(4.2±4.1vs2.2±1.8years;p&lt;0.001).

Comparing respective multivariable analyses (Early vs Recent), wound complications were associated with panniculectomy(OR[95%CI]:2.9[1.9–4.5],p&lt;0.001 vs 2.1[1.4–3.3],p&lt;0.01), contaminated wounds(2.1[1.1–3.7],p=0.02 vs 1.8[1.1–3.1],p=0.02), anterior CST(1.8[1.1–2.9], p=0.02 vs 3.2[1.9–5.3],p&lt;0.01), and operative time(per minute:1.01[1.008–1.015], p&lt;0.01 vs 1.004[1.001–1.007], p&lt;0.01) in both time periods. Diabetes(2.6[1.7–4.0],p&lt;0.01) and tobacco(1.8[1.1–2.9], p=0.02) were only significant in the Early group with the Recent group requirements for preop smoking cessation and a HgbA1C of &lt;7.2. In both groups, recurrence was associated with wound complication(8.9[4.1–20.1],p&lt;0.01 vs 3.4[1.3–8.2].p&lt;0.01) and prior failed VHR hernias(4.9[2.3–11.5],p&lt;0.01 vs 2.1[1.1–4.2],p=0.036).

Conclusion

Despite increased patient and hernia complexity over time, detecting and implementing best practices, as determined by repeated self-analysis of a THC's data, significantly improved patient outcomes, including wound and mesh complications and recurrence.

V-002 MASSIVE INGUINAL HERNIA REPAIR WITH CHEMICAL COMPONENT RELAXATION AND PREOPERATIVE PROGRESSIVE PNEUMOPERITONEUM

Inguinal hernias are one of the most common procedures performed worldwide. Conversely, massive or giant inguinal hernias; defined as extending below the midpoint of the inner thigh are very uncommon. They are often associated with loss of domain, posing a different set of challenges for the surgeon, specially creating intra-abdominal space for the displaced organs. Preoperative progressive pneumoperitoneum (PPP) coupled with chemical denervation with botulinum toxin A (BTA) is one way to increase the size of the intrabdominal cavity to aid in reduction of the hernia contents and closure of the defect.

We present a case of a 51-year-old male with a massive right inguinal hernia with complete loss of domain. The hernia sac contained the entirety of his small bowel and colon except for his proximal duodenum and distal rectum which remained intrabdominal. We preformed preoperative BTA chemical denervation and progressive pneumoperitoneum prior to staged open Inguinal hernia repair. 1 month preoperatively BTA injections were performed under ultrasound guidance into the external and internal obliques at 3 locations bilaterally and an intraabdominal catheter was placed under laparoscopic guidance. The patient was insufflated with filter air 3 times a week for 3 weeks. He then underwent open repair with preperitoneal mesh placed and orchiectomy.

V-041 ENTEROCUTANEOUS FISTULA TAKEDOWN AND VENTRAL HERNIA REPAIR WITH PREPERITONEAL MESH

In this video, we present a 48-year-old otherwise healthy man with a history of perforated appendicitis status post exploratory laparotomy and appendectomy, complicated by an intraabdominal abscess requiring re-exploration and subsequent midline wound dehiscence, incisional ventral hernia, and enterocutaneous fistula managed with a drain. Plastic surgery performed a split thickness skin graft of his midline wound, and his drain was kept in place until surgery. The patient was taken to the operating room for a takedown of his enterocutaneous fistula and an open repair of his incisional ventral hernia. We entered the abdomen in the midline, far away from the fistula. After lysing omental and bowel adhesions, we identified the patient's drain entering the small bowel and exiting about 10 cm distally. We removed the drain from the small bowel and performed a small bowel resection, including the entry and exit points of the drain, and a stapled side-to-side antiperistaltic anastomosis. Preperitoneal planes were developed bilaterally, and the peritoneum was rearranged over the bowel and partially closed to the omentum. We placed a biologic mesh into the preperitoneal plane and secured it in place with transfascial sutures. We then performed a multilayer closure of the fascia and dermis and an incisional negative pressure dressing was placed over the wound. The patient was discharged on postoperative day 4 after tolerating a regular diet and having full return of bowel function. In summary, this video demonstrates several important operative techniques in our approach to this complex case.

V-014 OPEN REPAIR OF PRIMARY LUMBAR HERNIA WITH PREPERITONEAL MESH

This video presents an open repair of a primary lumbar hernia with preperitoneal mesh performed at a high-volume hernia center. The patient was a 71-year-old female referred due to chronic pain from a primary hernia of the right superior lumbar triangle.

The patient was positioned in the left lateral decubitus position with the bed slightly flexed. A skin incision was created sharply, and electrocautery used to dissect subcutaneous tissue and superficial fascia, revealing the hernia contents.

Circumferential lysis of adhesions was performed with blunt and cautery dissection to release the hernia contents from the abdominal wall. Once the hernia contents were mobilized, they were then carefully reduced through the fascial defect. The hernia defect measured approximately 3.5×3.5 cm.

Next, the preperitoneal space was circumferentially developed. This was done primarily with blunt finger dissection, using a rolling motion to direct pressure towards the abdominal wall and sweep the peritoneum and other attachments down. Larger attachments are gently retracted and divided with electrocautery. The preperitoneal space was measured at 20×19 cm and the mesh trimmed to those dimensions. The mesh was carefully laid flat in the preperitoneal space. No mesh fixation was required.

Fascial edges were dissected free for 1–2cm surrounding the defect. Two running 1–0 PDS sutures were used to close the hernia defect. A closed-suction drain was placed superficial to the fascia to minimize seroma formation. The superficial fascia and dermis were closed in layers. The patient had a routine hospital course and was discharged on post-operative day 3.

Outcomes of biologic versus synthetic mesh in CDC class 3 and 4 open abdominal wall reconstruction

INTRODUCTION

Abdominal wall reconstruction (AWR) in a contaminated field is associated with an increased risk of wound complications, infection, and reoperation. The best method of repair and mesh choice in these operations have generated marked controversy. Our aim was to compare outcomes of patients who underwent AWR with biologic versus synthetic mesh in CDC class 3 and 4 wounds.

METHODS

A prospective, single-institution database was queried for AWR using biologic or synthetic mesh in CDC Class 3 and 4 wounds. Hernia recurrence and complications were measured. Multivariable logistic regression was performed to identify factors predicting both.

RESULTS

In total, 386 patients with contaminated wounds underwent AWR, 335 with biologic and 51 with synthetic mesh. Groups were similar in age, sex, BMI, and rate of diabetes. Biologic mesh patients had larger hernia defects (298 ± 233cm² vs. 208 ± 155cm²; p = 0.004) and a higher rate of recurrent hernias (72.2% vs 47.1%; p < 0.001), comorbidities(5.8 ± 2.7 vs. 4.2 ± 2.4, p < 0.01), and a nearly fivefold increase in Class 4 wounds (47.8% vs. 9.8%, p < 0.001), while fascial closure trended to being less common (90.7% vs 96.1%; p = 0.078). Hernia recurrence was comparable between biologic and synthetic mesh (10.4% vs. 17.6%, p = 0.132). Wound complication rates were similar (36.1% vs. 33.3%, p = 0.699), but synthetic mesh had higher rates of mesh infection (1.2% vs 11.8%; p < 0.001) and infection-related resection (0% vs 7.8%, p < 0.001), with 66% of those synthetic mesh infections requiring excision. On logistic regression, wound complications (OR 5.96 [CI 1.60-22.17]; p = 0.008) and bridging mesh (OR 13.10 [CI 2.71-63.42];p = 0.030) predicted of hernia recurrence (p < 0.05), while synthetic mesh (OR 18.6 [CI 2.35-260.4] p = 0.012) and wound complications (OR 20.6 [CI 3.15-417.7] p = 0.008) predicted mesh infection.

CONCLUSIONS

Wound complications in AWR with CDC class 3 and 4 wounds significantly increased mesh infection and hernia recurrence; failure to achieve fascial closure also increased hernia recurrence. Use of synthetic versus biologic mesh increased the mesh infection rate by 18.6 times.

A 6-bp Deletion Variant in a Novel Canine Glutathione-S-Transferase Gene (GSTT5) Leads to Loss of Enzyme Function

OBJECTIVES

Glutathione-S-transferases (GSTs) detoxify reactive xenobiotics, and defective GST gene polymorphisms increase cancer risk in humans. A low activity GST-theta variant was previously found in research beagles. The purpose of our study was to determine the molecular basis for this phenotype and its allele frequency in pet dogs.

METHODS

Banked livers from 45 dogs of various breeds were screened for low GST-theta activity by the substrate 1,2-dichloro-4-nitrobenzene (DCNB), and were genotyped for variants in a novel canine GST gene, GSTT5. Whole-genome sequences from 266 dogs were genotyped at one discovered variant GSTT5 locus.

RESULTS

Canine livers ranged 190-fold in GST-theta activities, and a GSTT5 exon coding variant 385_390delGACCAG (Asp129_Gln130del) was significantly associated with low activity (P < 0.0001) and a marked decrease in hepatic protein expression (P = 0.0026). Recombinant expression of variant GSTT5 led to a 92% decrease in Vmax for DCNB (P = 0.0095). The minor allele frequency (MAF) for 385_390delGACCAG was 0.144 in 45 dog livers, but was significantly higher in beagles (0.444) versus nonbeagles (0.007; P = 0.0004). The homozygous genotype was significantly over-represented in Pembroke Welsh corgis (P < 0.0001) based on available whole-genome sequence data.

CONCLUSIONS

An Asp129_Gln130del variant in canine GSTT5 is responsible for marked loss of GST-theta enzyme activity. This variant is significantly over-represented in purpose-bred laboratory beagles and in Pembroke Welsh corgis. Additional work will determine the prevalence of this variant among other purebred dogs, and will establish the substrate range of this polymorphic canine enzyme with respect to common environmental carcinogens.

A randomized trial testing the efficacy of modifications to the nutrition facts table on comprehension and use of nutrition information by adolescents and young adults in Canada

INTRODUCTION

Given the proposed changes to nutrition labelling in Canada and the dearth of research examining comprehension and use of nutrition facts tables (NFts) by adolescents and young adults, our objective was to experimentally test the efficacy of modifications to NFts on young Canadians' ability to interpret, compare and mathematically manipulate nutrition information in NFts on prepackaged food.

METHODS

An online survey was conducted among 2010 Canadians aged 16 to 24 years drawn from a consumer sample. Participants were randomized to view two NFts according to one of six experimental conditions, using a between-groups 2 x 3 factorial design: serving size (current NFt vs. standardized serving-sizes across similar products) x percent daily value (% DV) (current NFt vs. "low/med/high" descriptors vs. colour coding). The survey included seven performance tasks requiring participants to interpret, compare and mathematically manipulate nutrition information on NFts. Separate modified Poisson regression models were conducted for each of the three outcomes.

RESULTS

The ability to compare two similar products was significantly enhanced in NFt conditions that included standardized serving-sizes (p ≤ .001 for all). Adding descriptors or colour coding of % DV next to calories and nutrients on NFts significantly improved participants' ability to correctly interpret % DV information (p ≤ .001 for all). Providing both standardized serving-sizes and descriptors of % DV had a modest effect on participants' ability to mathematically manipulate nutrition information to calculate the nutrient content of multiple servings of a product (relative ratio = 1.19; 95% confidence limit: 1.04-1.37).

CONCLUSION

Standardizing serving-sizes and adding interpretive % DV information on NFts improved young Canadians' comprehension and use of nutrition information. Some caution should be exercised in generalizing these findings to all Canadian youth due to the sampling issues associated with the study population. Further research is needed to replicate this study in a more heterogeneous sample in Canada and across a range of food products and categories.

Evaluation of polymorphisms in the sulfonamide detoxification genes CYB5A and CYB5R3 in dogs with sulfonamide hypersensitivity

BACKGROUND

Delayed hypersensitivity (HS) reactions to potentiated sulfonamide antimicrobials occur in both dogs and humans, and involve an intermediate hydroxylamine metabolite that is detoxified by cytochrome b(5) and NADH cytochrome b(5) reductase.

HYPOTHESIS/OBJECTIVES

We hypothesized that polymorphisms in the genes (CYB5A and CYB5R3) encoding these 2 enzymes would be associated with risk of sulfonamide HS in dogs.

ANIMALS

A total of 18 dogs with delayed HS to potentiated sulfonamide antimicrobials and 16 dogs that tolerated (TOL) a therapeutic course of these drugs without adverse effect.

METHODS

CYB5A and CYB5R3 were sequenced from canine liver, and the promoter, exons, and 3' untranslated regions of both genes were resequenced from genomic DNA obtained from all dogs.

RESULTS

Multiple polymorphisms were found in both genes. When controlled for multiple comparisons, the 729GG variant in CYB5R3 was significantly overrepresented in dogs with sulfonamide HS (78% of dogs), compared to TOL dogs (31%; P = .003).

CONCLUSIONS AND CLINICAL IMPORTANCE

The CYB5R3 729GG variant may contribute to the risk of sulfonamide HS in dogs. Functional characterization of this polymorphism, as well as genotyping in a larger number of HS and TOL dogs, is warranted.

Resveratrol induces Fas signalling-independent apoptosis in THP-1 human monocytic leukaemia cells

Resveratrol, a natural product present in wine, has recently been shown to inhibit the growth of a number of cancer cell lines in vitro. In the current study, we have demonstrated that resveratrol inhibits the growth of THP-1 human monocytic leukaemia cells in a dose-dependent manner with a median effective dose of 12 microM. It did not induce differentiation of THP-1 cells and had no toxic effect on THP-1 cells that had been induced to differentiate into monocytes/macrophages by phorbol myristate acetate. A significant fraction of resveratrol-treated cells underwent apoptosis as judged by flow cytometric analysis of DNA content, DNA fragmentation and caspase-specific cleavage of poly(ADP-ribosyl) polymerase. Resveratrol treatment had no effect on the expression of Fas receptor or Fas ligand (FasL) in THP-1 cells, nor did it induce clustering of Fas receptors. In addition, THP-1 cells were resistant to activating anti-Fas antibody, and neutralizing anti-Fas and/or anti-FasL antibodies had no protective effect against resveratrol-induced inhibition of THP-1 cell growth. The effect of resveratrol on THP-1 cells was reversible after its removal from the culture medium. These results suggest that (1) resveratrol inhibits the growth of THP-1 cells, at least in part, by inducing apoptosis, (2) resveratrol-induced apoptosis of THP-1 cells is independent of the Fas/FasL signalling pathway and (3) resveratrol does not induce differentation of THP-1 cells and has no toxic effect on differentiated THP-1 cells. Thus, resveratrol may be a potential chemotherapeutic agent for the control of acute monocytic leukaemia.

Pertussis toxin-induced lung edema. Role of manganese superoxide dismutase and protein kinase C

The mechanism by which pertussis toxin (Ptx) causes lung edema is not clear. We investigated the role of pulmonary manganese superoxide dismutase (MnSOD) and protein kinase C (PKC) in Ptx-induced lung edema. We demonstrated that intraperitoneal injection of Ptx at a concentration of 5 microg/100 g body weight caused a similar degree of lung edema in 2 d, as measured by lung wet weight/dry weight ratio, in heterozygous MnSOD gene (Sod2)-knockout mice (Sod2(+/-)) and in their wild-type littermates (Sod2(+/+)). The level of lung MnSOD activity in Sod2(+/-) mice was approximately half that of Sod2(+/-) mice. Ptx had no effect on levels of lung MnSOD messenger RNA, immunoreactive protein, or enzyme activity in either Sod2(+/+) or Sod2(+/-) mice. Ptx also had no effect on lung copper-zinc SOD, catalase, and glutathione peroxidase activities in these mice. On the other hand, Ptx caused the activation of lung PKC, for example, by translocation of a 72-kD PKC isoform from the cytosolic fraction to the membrane fraction. Pretreatment of mice with bisindolylmaleimide, a PKC inhibitor, prevented both the Ptx-induced activation of PKC and lung edema. These data suggest that Ptx-induced lung edema in mice is, at least in part, due to the activation of lung PKC.

Induction of Mn SOD in human monocytes without inflammatory cytokine production by a mutant endotoxin

Endotoxin selectively induces monocyte Mn superoxide dismutase (SOD) without affecting levels of Cu,Zn SOD, catalase, or glutathione peroxidase. However, little is known about the structure-activity relationship and the mechanism by which endotoxin induces Mn SOD. In this study we demonstrated that a mutant Escherichia coli endotoxin lacking myristoyl fatty acid at the 3' R-3-hydroxymyristate position of the lipid A moiety retained its full capacity to coagulate Limulus amoebocyte lysate compared with the wild-type E. coli endotoxin and markedly stimulated the activation of human monocyte nuclear factor-kappaB and the induction of Mn SOD mRNA and enzyme activity. However, in contrast to the wild-type endotoxin, it failed to induce significant production of tumor necrosis factor-alpha and macrophage inflammatory protein-1alpha by monocytes and did not induce the phosphorylation and nuclear translocation of mitogen-activated protein kinase. These results suggest that 1) lipid A myristoyl fatty acid, although it is important for the induction of inflammatory cytokine production by human monocytes, is not necessary for the induction of Mn SOD, 2) endotoxin-mediated induction of Mn SOD and inflammatory cytokines are regulated, at least in part, through different signal transduction pathways, and 3) failure of the mutant endotoxin to induce tumor necrosis factor-alpha production is, at least in part, due to its inability to activate mitogen-activated protein kinase.

The Direct Assessment of Functional Abilities (DAFA): a comparison to an indirect measure of instrumental activities of daily living

The Direct Assessment of Functional Abilities (DAFA) was designed as a direct measure of instrumental activities of daily living (IADLs) that could be compared with an indirect assessment of IADLs by the Pfeffer Functional Activities Questionnaire (PFAQ). The DAFA (28 demented and 15 control subjects) and PFAQ (subjects and informants) were administered twice, together with a brief cognitive battery. Demented subjects performed significantly worse on direct assessment (DAFA) than predicted by self-report (PFAQ), and overestimation of abilities increased with severity of dementia. In contrast, informants tended to underestimate abilities of demented subjects, but not to a significant degree. Control (nondemented) subjects had comparable results with the two methods. The DAFA may provide a more objective measure of functional status in demented subjects than do indirect methods of assessment.

The duration of local control of classic (non-AIDS-associated) Kaposi's sarcoma by radiotherapy

We report the short- and long-term responses to radiotherapy of 82 classic Kaposi's sarcomas. Doses were prescribed ab initio and no attempt was made to discontinue treatment as soon as shrinkage was observed, as has been recommended by others. More than 50% of the lesions regressed completely and nearly all underwent some regression. Almost all recurrences were detected within 2 years of treatment and virtually all occurred in lesions that had not regressed completely within 2 weeks of radiotherapy. We conclude that classic Kaposi's sarcoma should be treated with sufficient radiotherapy from the beginning to provide long-term control.