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Yamani AS, Morris MC, Schrager JJ, Athota KP, Sams VG. A case of acute colonic pseudo-obstruction, sigmoid volvulus, and massive pneumoperitoneum in a young female patient. Int J Surg Case Rep 2024; 117:109558. [PMID: 38518469 PMCID: PMC10972842 DOI: 10.1016/j.ijscr.2024.109558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 03/13/2024] [Accepted: 03/16/2024] [Indexed: 03/24/2024] Open
Abstract
INTRODUCTION AND IMPORTANCE Acute colonic pseudo-obstruction (ACPO) is an uncommon phenomenon that is especially rare in young patients and can result in bowl ischemia and perforation if left untreated. Furthermore, pneumoperitoneum is almost always a concerning imaging finding and in the context of recent colonic resection may be a sign of anastomotic leakage. CASE PRESENTATION We describe a case of a young female patient with postpartum ACPO who subsequently underwent a hemicolectomy with colorectal anastomosis. The patient's hospital course was complicated by massive postoperative pneumoperitoneum that resulted in resection of the anastomosis and creation of an end colostomy. However, despite this measure, there was recurrent pneumoperitoneum on cross-sectional imaging 36 h later. This was treated non-operatively and the remainder of their hospital course was uneventful. CLINICAL DISCUSSION A potential etiology for ACPO during pregnancy may be due to compression of parasympathetic plexus nerves by the gravid uterus. Idiopathic pneumoperitoneum has been documented on a number of occasions, though this is generally in older patients. It can present with signs of peritonitis or can be asymptomatic. Simultaneous pneumothorax and pneumoperitoneum is rare and may be due to the transmission of air from the peritoneum to the mediastinum and thorax. The pneumoperitoneum itself may be due the air leakage through the significantly distended colon into the peritoneum. CONCLUSION The combination of ACPO following pregnancy and associated pneumothorax, pneumomediastinum, and recurrent pneumoperitoneum suggest a communicating defect between the thoracic, mediastinal, and peritoneal cavities. Furthermore, the possibility of underlying colonic dysmotility should be considered prior to the restoration of large bowel continuity.
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Affiliation(s)
- Ali S Yamani
- College of Medicine, University of Cincinnati, Cincinnati, OH, USA.
| | - Mackenzie C Morris
- College of Medicine, University of Cincinnati, Cincinnati, OH, USA; Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Jason J Schrager
- College of Medicine, University of Cincinnati, Cincinnati, OH, USA; Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Krishna P Athota
- College of Medicine, University of Cincinnati, Cincinnati, OH, USA; Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Valerie G Sams
- College of Medicine, University of Cincinnati, Cincinnati, OH, USA; Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
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Delman AM, Kassam AF, Turner KM, Ammann AM, Lynch C, Morris MC, Vaysburg DM, Cortez AR, Quillin RC. Incidence of attrition among early-career abdominal transplant surgeons. Surgery 2023; 173:1113-1119. [PMID: 36167700 DOI: 10.1016/j.surg.2022.08.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 08/11/2022] [Accepted: 08/15/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND The prevalence of burnout and depression among abdominal transplant surgeons has been well described. However, the incidence of early-career transplant surgeons leaving the field is unknown. The objective of this study was to quantify the incidence of attrition among early-career abdominal transplant surgeons. METHODS A custom database from the Organ Procurement and Transplantation Network with encrypted surgeon-specific identifiers was queried for transplant surgeons who entered the field between 2008 and 2019. Surgeons who experienced attrition, defined as not completing a subsequent transplant after a minimum of 5, were identified. Surgeon-specific case volumes, case mix, and recipient outcomes were modeled to describe their association with attrition. RESULTS Between 2008 and 2018, 496 abdominal transplant surgeons entered the field and performed 76,465 transplant procedures. A total of 24.4% (n = 121) experienced attrition, with a median time to attrition of 2.75 years. Attrition surgeons completed fewer kidney (7 vs 21, P < .01), pancreas (0.52 vs 1.43, P < .01), and liver transplants (1 vs 4, P < .01) in their first year of practice. Attrition surgeons completed a smaller proportion of their transplant center's volume (9% vs 18%, P < .01) and were less likely to participate in pediatric transplants (26.5% vs 52.5%, P < .01) and living donor kidney transplants (64.5% vs 84.5%, P < .01). On multivariable analysis, performing fewer kidney (odds ratio: 0.98, 95% confidence interval: 0.98-0.99) and liver transplants (odds ratio: 0.98, 95% confidence interval: 0.97-0.98) by year 5 and completing a smaller proportion of their centers' volume (odds ratio: 0.96, 95% confidence interval: 0.94-0.98) were associated with attrition. Furthermore, attrition surgeons had worse allograft and patient survival for liver transplant recipients (both log-rank P < .01). CONCLUSION This investigation was the first to quantify the high incidence of attrition experienced by early-career abdominal transplant surgeons and its association with surgeon-specific case volumes, case mix, and worse recipient outcomes. These findings suggested the abdominal transplant workforce is struggling to retain their fellowship-trained surgeons.
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Affiliation(s)
- Aaron M Delman
- Cincinnati Research in Outcomes and Safety in Surgery Research Group, Department of Surgery, University of Cincinnati College of Medicine, OH. https://twitter.com/AaronDelman
| | - Al-Faraaz Kassam
- Cincinnati Research in Outcomes and Safety in Surgery Research Group, Department of Surgery, University of Cincinnati College of Medicine, OH. https://twitter.com/afkassam
| | - Kevin M Turner
- Cincinnati Research in Outcomes and Safety in Surgery Research Group, Department of Surgery, University of Cincinnati College of Medicine, OH. https://twitter.com/KevinTurnerMD
| | - Allison M Ammann
- Cincinnati Research in Outcomes and Safety in Surgery Research Group, Department of Surgery, University of Cincinnati College of Medicine, OH
| | - Caroline Lynch
- Cincinnati Research in Outcomes and Safety in Surgery Research Group, Department of Surgery, University of Cincinnati College of Medicine, OH
| | - Mackenzie C Morris
- Cincinnati Research in Outcomes and Safety in Surgery Research Group, Department of Surgery, University of Cincinnati College of Medicine, OH. https://twitter.com/MackMorrisMD
| | - Dennis M Vaysburg
- Cincinnati Research in Outcomes and Safety in Surgery Research Group, Department of Surgery, University of Cincinnati College of Medicine, OH. https://twitter.com/DMVaysburg
| | - Alexander R Cortez
- Cincinnati Research in Outcomes and Safety in Surgery Research Group, Department of Surgery, University of Cincinnati College of Medicine, OH. https://twitter.com/AlexCortezMD
| | - Ralph C Quillin
- Cincinnati Research in Outcomes and Safety in Surgery Research Group, Department of Surgery, University of Cincinnati College of Medicine, OH; Division of Transplantation, Department of Surgery, University of Cincinnati College of Medicine, OH.
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Singer KE, McGlone ED, Collins SM, Wallen TE, Morris MC, Schuster RM, England LG, Robson MJ, Goodman MD. Propranolol Reduces p-tau Accumulation and Improves Behavior Outcomes in a Polytrauma Murine Model. J Surg Res 2023; 282:183-190. [PMID: 36308901 DOI: 10.1016/j.jss.2022.09.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 08/20/2022] [Accepted: 09/18/2022] [Indexed: 11/07/2022]
Abstract
INTRODUCTION Traumatic brain injury (TBI) can lead to neurocognitive decline, in part due to phosphorylated tau (p-tau). Whether p-tau accumulation worsens in the setting of polytrauma remains unknown. Propranolol has shown clinical benefit in head injuries; however, the underlying mechanism is also unknown. We hypothesize that hemorrhagic shock would worsen p-tau accumulation but that propranolol would improve functional outcomes on behavioral studies. METHODS A murine polytrauma model was developed to examine the accumulation of p-tau and whether it can be mitigated by early administration of propranolol. TBI was induced using a weight-drop model and hemorrhagic shock was achieved via controlled hemorrhage for 1 h. Mice were given intraperitoneal propranolol 4 mg/kg or saline control. The animals underwent behavioral testing at 30 d postinjury and were sacrificed for cerebral histological analysis. These studies were completed in male and female mice. RESULTS TBI alone led to increased p-tau generation compared to sham on both immunohistochemistry and immunofluorescence (P < 0.05). The addition of hemorrhage led to greater accumulation of p-tau in the hippocampus (P < 0.007). In male mice, p-tau accumulation decreased with propranolol administration for both polytrauma and TBI alone (P < 0.0001). Male mice treated with propranolol also outperformed saline-control mice on the hippocampal-dependent behavioral assessment (P = 0.0013). These results were not replicated in female mice; the addition of hemorrhage did not increase p-tau accumulation and propranolol did not demonstrate a therapeutic effect. CONCLUSIONS Polytrauma including TBI generates high levels of hippocampal p-tau, but propranolol may help prevent this accumulation to improve both neuropathological and functional outcomes in males.
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Affiliation(s)
- Kathleen E Singer
- Department of General Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Emily D McGlone
- Department of General Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Sean M Collins
- James L. Winkle College of Pharmacy, University of Cincinnati, Cincinnati, Ohio
| | - Taylor E Wallen
- Department of General Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Mackenzie C Morris
- Department of General Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Rebecca M Schuster
- Department of General Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Lisa G England
- Department of General Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Matthew J Robson
- James L. Winkle College of Pharmacy, University of Cincinnati, Cincinnati, Ohio
| | - Michael D Goodman
- Department of General Surgery, University of Cincinnati, Cincinnati, Ohio.
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Turner KM, Morris MC, Delman AM, Hanseman D, Johnston FM, Greer J, Walle KV, Abbott DE, Raoof M, Grotz TE, Fournier K, Dineen S, Veerapong J, Maduekwe U, Kothari A, Staley CA, Maithel SK, Lambert LA, Kim AC, Cloyd JM, Wilson GC, Sussman JJ, Ahmad SA, Patel SH. Do Lymph Node Metastases Matter in Appendiceal Cancer with Peritoneal Carcinomatosis? A US HIPEC Collaborative Study. J Gastrointest Surg 2022; 26:2569-2578. [PMID: 36258061 DOI: 10.1007/s11605-022-05489-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 09/17/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Whether formal regional lymph node (LN) evaluation is necessary for patients with appendiceal adenocarcinoma (AA) who have peritoneal metastases is unclear. The aim of this study was to evaluate the prognostic value of LN metastases on survival in patients treated with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC). METHODS A retrospective analysis of the US HIPEC collaborative, a multi-institutional consortium comprising 12 high-volume centers, was performed to identify patients with AA who underwent CRS-HIPEC with adequate LN sampling (≥ 12 LNs). RESULTS Two hundred-fifty patients with AA who underwent CRS-HIPEC were included. Outcomes were compared between LN - and LN + disease. Baseline patient characteristics between groups were similar, with most patients undergoing complete cytoreduction (0/1: 86.0% vs. 76.8%, p = 0.08), respectively. More adverse tumor factors were found in patients with LN + disease, including poor differentiation, signet ring cells, and lymphovascular invasion. Multivariate analysis of overall survival (OS) found LN + disease was independently associated with worse OS (HR: 2.82 95%CI: 1.25-6.34, p = 0.01), even after correction for receipt of systemic therapy. On Kaplan-Meier analysis, median OS was lower in patients with LN + disease (25.9 months vs. 91.4 months, p < 0.01). LN + disease remained associated with poor OS following propensity score matching (HR: 4.98 95%CI: 1.72-14.40, p < 0.01) and in patients with PCI ≥ 20 (HR: 3.68 95%CI: 1.54-8.80, p < 0.01). CONCLUSIONS In this large multi-institutional study of patients with AA undergoing CRS-HIPEC, LN status remained associated with worse OS even in the setting of advanced peritoneal carcinomatosis. Formal LN evaluation should be performed for most patients with AA undergoing CRS-HIPEC.
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Affiliation(s)
- Kevin M Turner
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Mackenzie C Morris
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Aaron M Delman
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Dennis Hanseman
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | | | - Jonathan Greer
- Department of Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Kara Vande Walle
- Department of Surgery, Division of Surgical Oncology, University of Wisconsin, Madison, WI, USA
| | - Daniel E Abbott
- Department of Surgery, Division of Surgical Oncology, University of Wisconsin, Madison, WI, USA
| | - Mustafa Raoof
- Department of Surgery, Division of Surgical Oncology, City of Hope National Medical Center, Duarte, CA, USA
| | - Travis E Grotz
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN, USA
| | - Keith Fournier
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sean Dineen
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Morsani College of Medicine, Tampa, FL, USA
| | - Jula Veerapong
- Department of Surgery, Division of Surgical Oncology, University of California, San Diego, San Diego, CA, USA
| | - Ugwuji Maduekwe
- Department of Surgery, Division of Surgical Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Anai Kothari
- Department of Surgery, Division of Surgical Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Charles A Staley
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Shishir K Maithel
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Laura A Lambert
- Peritoneal Surface Malignancy Program Section of Surgical Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
| | - Alex C Kim
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Jordan M Cloyd
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Gregory C Wilson
- Department of Surgery, Division of Surgical Oncology, University of Cincinnati College of Medicine, Medical Science Building, 231 Albert Sabin Way, Cincinnati, OH, 45267-0558, USA
| | - Jeffrey J Sussman
- Department of Surgery, Division of Surgical Oncology, University of Cincinnati College of Medicine, Medical Science Building, 231 Albert Sabin Way, Cincinnati, OH, 45267-0558, USA
| | - Syed A Ahmad
- Department of Surgery, Division of Surgical Oncology, University of Cincinnati College of Medicine, Medical Science Building, 231 Albert Sabin Way, Cincinnati, OH, 45267-0558, USA
| | - Sameer H Patel
- Department of Surgery, Division of Surgical Oncology, University of Cincinnati College of Medicine, Medical Science Building, 231 Albert Sabin Way, Cincinnati, OH, 45267-0558, USA.
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Turner KM, Morris MC, Sohal D, Sussman JJ, Wilson GC, Ahmad SA, Patel SH. Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Colorectal Peritoneal Metastases: A Summary of Key Clinical Trials. J Clin Med 2022; 11:jcm11123406. [PMID: 35743476 PMCID: PMC9225119 DOI: 10.3390/jcm11123406] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Revised: 06/02/2022] [Accepted: 06/12/2022] [Indexed: 01/27/2023] Open
Abstract
The peritoneal cavity is a common site of metastatic spread from colorectal cancer (CRC). Patients with peritoneal metastases (PM) often have aggressive underlying tumor biology and poor survival. While only a minority of patients with CRC have potentially resectable disease, the high overall incidence of CRC makes management of PM a common clinical problem. In this population, cytoreductive surgery (CRS)-hyperthermic intraperitoneal chemotherapy (HIPEC) is the only effective therapy for appropriately selected patients. In this narrative review, we summarize the existing literature on CRS-HIPEC in colorectal PM. Recent prospective clinical trials have shown conflicting evidence regarding the benefit of HIPEC perfusion in addition to CRS. Current strategies to prevent PM in those at high-risk have been shown to be ineffective. Herein we will provide a framework for clinicians to understand and apply these data to treat this complex disease presentation.
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Affiliation(s)
- Kevin M. Turner
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH 45267-0558, USA; (K.M.T.); (M.C.M.)
| | - Mackenzie C. Morris
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH 45267-0558, USA; (K.M.T.); (M.C.M.)
| | - Davendra Sohal
- Department of Internal Medicine, Division of Hematology & Oncology, University of Cincinnati College of Medicine, Cincinnati, OH 45267-0558, USA;
| | - Jeffrey J. Sussman
- Department of Surgery, Division of Surgical Oncology, University of Cincinnati College of Medicine, 231 Albert Sabin Way (ML 0558), Cincinnati, OH 45267-0558, USA; (J.J.S.); (G.C.W.); (S.A.A.)
| | - Gregory C. Wilson
- Department of Surgery, Division of Surgical Oncology, University of Cincinnati College of Medicine, 231 Albert Sabin Way (ML 0558), Cincinnati, OH 45267-0558, USA; (J.J.S.); (G.C.W.); (S.A.A.)
| | - Syed A. Ahmad
- Department of Surgery, Division of Surgical Oncology, University of Cincinnati College of Medicine, 231 Albert Sabin Way (ML 0558), Cincinnati, OH 45267-0558, USA; (J.J.S.); (G.C.W.); (S.A.A.)
| | - Sameer H. Patel
- Department of Surgery, Division of Surgical Oncology, University of Cincinnati College of Medicine, 231 Albert Sabin Way (ML 0558), Cincinnati, OH 45267-0558, USA; (J.J.S.); (G.C.W.); (S.A.A.)
- Correspondence: ; Tel.: +1-516-558-6018; Fax: +1-513-584-0459
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Wallen TE, Singer KE, Morris MC, Blakeman T, Stevens-Topie SM, Strilka R, Pritts TA, Goodman MD. Blood product resuscitation mitigates the effects of aeromedical evacuation after polytrauma. J Trauma Acute Care Surg 2022; 92:12-20. [PMID: 34932039 DOI: 10.1097/ta.0000000000003433] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The combined injury of traumatic brain injury and hemorrhagic shock has been shown to worsen coagulopathy and systemic inflammation, thereby increasing posttraumatic morbidity and mortality. Aeromedical evacuation to definitive care may exacerbate postinjury morbidity because of the inherent hypobaric hypoxic environment. We hypothesized that blood product resuscitation may mitigate the adverse physiologic effects of postinjury flight. METHODS An established porcine model of controlled cortical injury was used to induce traumatic brain injury. Intracerebral monitors were placed to record intracranial pressure, brain tissue oxygenation, and cerebral perfusion. Each of the 42 pigs was hemorrhaged to a goal mean arterial pressure of 40 ± 5 mm Hg for 1 hour. Pigs were grouped according to resuscitation strategy used-Lactated Ringer's (LR) or shed whole blood (WB)-then placed in an altitude chamber for 2 hours at ground, 8,000 ft, or 22,000 ft, and then observed for 4 hours. Hourly blood samples were analyzed for proinflammatory cytokines and lactate. Internal jugular vein blood flow was monitored continuously for microbubble formation with altitude changes. RESULTS Cerebral perfusion, tissue oxygenation, and intracranial pressure were unchanged among the six study groups. Venous microbubbles were not observed even with differing altitude or resuscitation strategy. Serum lactate levels from hour 2 of flight to the end of observation were significantly elevated in 22,000 + LR compared with 8,000 + LR and 22,000 + WB. Serum IL-6 levels were significantly elevated in 22,000 + LR compared with 22,000 + WB, 8,000 + LR and ground+LR at hour 1 of observation. Serum tumor necrosis factor-α was significantly elevated at hour 2 of flight in 8,000 + LR versus ground+LR, and in 22,000 + LR vs. 22,000 + WB at hour 1 of observation. Serum IL-1β was significantly elevated hour 1 of flight between 8,000 + LR and ground+LR. CONCLUSION Crystalloid resuscitation during aeromedical transport may cause a prolonged lactic acidosis and proinflammatory response that can predispose multiple-injury patients to secondary cellular injury. This physiologic insult may be prevented by using blood product resuscitation strategies.
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Affiliation(s)
- Taylor E Wallen
- From the Department of Surgery, University of Cincinnati, Cincinnati, Ohio
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Delman AM, Lee TC, Wima K, Morris MC, Kassam AF, Shah SA, Quillin RC. Utilization and effectiveness of the organ procurement and transplantation network "safety-net" policy. Surgery 2021; 171:1073-1082. [PMID: 34887087 DOI: 10.1016/j.surg.2021.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 10/29/2021] [Accepted: 11/02/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Liver transplant recipients with persistent renal dysfunction may be prioritized on the kidney transplant waitlist based on the Organ Procurement and Transplantation Network "safety-net" policy implemented in 2017. The aim of this study was to evaluate the utilization of kidney transplant and posttransplant outcomes, of liver transplant recipients with persistent renal dysfunction before and after implementation of the Organ Procurement and Transplantation Network kidney safety-net policy and standardization of simultaneous liver-kidney requirements. METHODS Using the United Network for Organ Sharing database from January 2015 to March 2019, outcomes of liver transplant recipients listed for kidney transplant and the subset who received kidney after liver transplants were compared before and after policy implementation. RESULTS Liver transplant recipients listed for kidney transplant increased from 58 to 200, and kidney after liver transplants increased from 29.3% to 42.5% after safety-net policy implementation. Post-policy kidney after liver transplants received more local organs (91.8% vs 70.6%, P = .03) and trended toward shorter waitlist time (47 [17-123] vs 84 [37-226] days, P = .051). The pre- and post-policy cohorts had similar (P > .05) kidney donor profile index (0.43 [0.27-0.69] vs 0.42 [0.28-0.58]) and delayed graft function (11.8% vs 14.1%). Patient, kidney graft, and liver graft survival were similar (P > .05) between pre and post-policy cohorts. Patient and kidney graft survival were similar between kidney after liver transplants and propensity score-matched kidney transplant alone recipients. Patient, kidney, and liver graft survival were similar between kidney after liver transplants and propensity score-matched simultaneous liver-kidney transplant recipients. CONCLUSION This study demonstrates that after Organ Procurement and Transplantation Network "safety-net" policy implementation, there has been an increase in liver transplant recipients with renal dysfunction who are listed for and undergo kidney transplant with excellent short-term results.
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Affiliation(s)
- Aaron M Delman
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati, Cincinnati, OH; Department of Surgery, University of Cincinnati College of Medicine Cincinnati, OH
| | - Tiffany C Lee
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati, Cincinnati, OH; Department of Surgery, University of Cincinnati College of Medicine Cincinnati, OH
| | - Koffi Wima
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati, Cincinnati, OH; Department of Surgery, University of Cincinnati College of Medicine Cincinnati, OH
| | - Mackenzie C Morris
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati, Cincinnati, OH; Department of Surgery, University of Cincinnati College of Medicine Cincinnati, OH
| | - Al-Faraaz Kassam
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati, Cincinnati, OH; Department of Surgery, University of Cincinnati College of Medicine Cincinnati, OH
| | - Shimul A Shah
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati, Cincinnati, OH; Department of Surgery, University of Cincinnati College of Medicine Cincinnati, OH
| | - R Cutler Quillin
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati, Cincinnati, OH; Department of Surgery, University of Cincinnati College of Medicine Cincinnati, OH.
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Singer KE, Wallen TE, Morris MC, McGlone E, Stevens-Topie S, Earnest R, Goodman MD. Postinjury treatments to make early tactical aeromedical evacuation practical for the brain after TBI. J Trauma Acute Care Surg 2021; 91:S89-S98. [PMID: 33938511 DOI: 10.1097/ta.0000000000003259] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Traumatic brain injury (TBI) is common in civilians and military personnel. No potential therapeutics have been evaluated to prevent secondary injury induced by the hypobaric hypoxia (HH) environment integral to postinjury aeromedical evacuation (AE). We examined the role of allopurinol, propranolol, adenosine/lidocaine/magnesium (ALM), or amitriptyline administration prior to simulated flight following murine TBI. METHODS Mice underwent TBI and were given allopurinol, propranolol, amitriptyline, or ALM prior to simulated AE or normobaric normoxia (NN) control. Heart rate (HR), respiratory rate, and oxygen saturation (Spo2) were recorded throughout simulated AE. Mice were sacrificed at 24 hours, 7 days, or 30 days. Serum and cerebral cytokines were assessed by enzyme-linked immunosorbent assay. Motor function testing was performed with Rotarod ambulation. Immunohistochemistry was conducted to examine phosphorylated tau (p-tau) accumulation in the hippocampus at 30 days. RESULTS While all treatments improved oxygen saturation, propranolol, amitriptyline, and allopurinol improved AE-induced tachycardia. At 24 hours, both propranolol and amitriptyline reduced tumor necrosis factor alpha levels while allopurinol and ALM reduced tumor necrosis factor alpha levels only in NN mice. Propranolol, amitriptyline, and ALM demonstrated lower serum monocyte chemoattractant protein-1 7 days after AE. Both amitriptyline and allopurinol improved Rotarod times for AE mice while only allopurinol improved Rotarod times for NN mice. Propranolol was able to reduce p-tau accumulation under both HH and NN conditions while ALM only reduced p-tau in hypobaric hypoxic conditions. CONCLUSION Propranolol lowered post-TBI HR with reduced proinflammatory effects, including p-tau reduction. Amitriptyline-induced lower post-TBI HR and improved functional outcomes without affecting inflammatory response. Allopurinol did not affect vital signs but improved late post-TBI systemic inflammation and functional outcomes. Adenosine/lidocaine/magnesium provided no short-term improvements but reduced p-tau accumulation at 30 days in the HH cohort. Allopurinol may be the best of the four treatments to help prevent short-term functional deficits while propranolol may address long-term effects. LEVEL OF EVIDENCE Basic science article.
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Affiliation(s)
- Kathleen E Singer
- From the Department of General Surgery, University of Cincinnati, Cincinnati Ohio
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Seitz A, Baker JE, Levinsky NC, Morris MC, Edwards MJ, Gulbins E, Blakeman TC, Rodriquez D, Branson RD, Goodman M. Antimicrobial coating prevents ventilator-associated pneumonia in a 72 hour large animal model. J Surg Res 2021; 267:424-431. [PMID: 34229130 DOI: 10.1016/j.jss.2021.05.046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 04/22/2021] [Accepted: 05/27/2021] [Indexed: 12/26/2022]
Abstract
BACKGROUND The primary goal of this study was to demonstrate that endotracheal tubes coated with antimicrobial lipids plus mucolytic or antimicrobial lipids with antibiotics plus mucolytic would significantly reduce pneumonia in the lungs of pigs after 72 hours of continuous mechanical ventilation compared to uncoated controls. MATERIALS AND METHODS Eighteen female pigs were mechanically ventilated for up to 72 hours through uncoated endotracheal tubes, endotracheal tubes coated with the antimicrobial lipid, octadecylamine, and the mucolytic, N-acetylcysteine, or tubes coated with octadecylamine, N-acetylcysteine, doxycycline, and levofloxacin (6 pigs per group). No exogenous bacteria were inoculated into the pigs, pneumonia resulted from the pigs' endogenous oral flora. Vital signs were recorded every 15 minutes and arterial blood gas measurements were obtained for the duration of the experiment. Pigs were sacrificed either after completion of 72 hours of mechanical ventilation or just prior to hypoxic arrest. Lungs, trachea, and endotracheal tubes were harvested for analysis to include bacterial counts of lung, trachea, and endotracheal tubes, lung wet and dry weights, and lung tissue for histology. RESULTS Pigs ventilated with coated endotracheal tubes were less hypoxic, had less bacterial colonization of the lungs, and survived significantly longer than pigs ventilated with uncoated tubes. Octadecylamine-N-acetylcysteine-doxycycline-levofloxacin coated endotracheal tubes had less bacterial colonization than uncoated or octadecylamine-N-acetylcysteine coated tubes. CONCLUSION Endotracheal tubes coated with antimicrobial lipids plus mucolytic and antimicrobial lipids with antibiotics plus mucolytic reduced bacterial colonization of pig lungs after prolonged mechanical ventilation and may be an effective strategy to reduce ventilator-associated pneumonia.
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Affiliation(s)
- Aaron Seitz
- Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio.
| | - Jennifer E Baker
- Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Nick C Levinsky
- Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Mackenzie C Morris
- Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Michael J Edwards
- Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Erich Gulbins
- Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio; Department of Molecular Biology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Thomas C Blakeman
- Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Dario Rodriquez
- Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Richard D Branson
- Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Michael Goodman
- Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio
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10
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Singer KE, Bercz AP, Morris MC, Elson NC, Wallen TE, Hanseman D, Pritts TA, Nomellini V, Patel SH, Makley AT, Goodman MD. Acute and chronic hematologic implications of emergency and elective splenectomy. J Surg Res 2021; 267:197-202. [PMID: 34153562 DOI: 10.1016/j.jss.2021.05.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 04/11/2021] [Accepted: 05/07/2021] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Thrombocytosis and leukocytosis are common after splenectomy. The potential effect of emergency surgery on these postoperative findings is unknown. We hypothesized that emergency splenectomy leads to a more profound and persistent hematologic change as compared to elective splenectomy. METHODS A retrospective review was conducted of patients who underwent elective or trauma splenectomy. Records were queried for platelet (PLT) and white blood cell (WBC) count prior to splenectomy, on postoperative days 1-5, and at day 14, 1 month, 3 months, 6 months, and 1 year. Complications, including thromboembolic events, infection, need for repeat operation, and readmission within 30 days of discharge, were recorded. RESULTS 463 patients were identified as being eligible for the study, with 173 patients in the elective cohort and 145 patients in each of the isolated trauma splenectomy and polytrauma cohorts. Both cohorts had peak thrombocytosis at week 2 postoperatively. However, polytrauma patients had a significantly higher peak platelet count (P < 0.01). The PLT:WBC ratio was lower in both trauma cohorts pre-operatively and postoperative day 1. Trauma splenectomy had a higher PLT:WBC ratio on days 2 and 3 whereas polytrauma had a lower ratio on days 4 and 5. Emergency cases had greater reoperation and infection rates, whereas elective cases were more likely to require readmission. Postoperative thromboembolic events were only higher in the polytrauma cohort. CONCLUSIONS While trauma splenectomy resulted in more profound postoperative leukocytosis and thrombocytosis, there was no correlation with timing of infection or risk of thromboembolic events. These findings suggest that thrombocytosis and leukocytosis may be associated with thrombotic and infectious events but their presence alone does not indicate direct risks of concomitant infection or thrombosis.
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Affiliation(s)
- Kathleen E Singer
- University of Cincinnati, Department of Surgery, Section of General Surgery, Cincinnati
| | - Aron P Bercz
- University of Cincinnati, Department of Surgery, Section of General Surgery, Cincinnati
| | - Mackenzie C Morris
- University of Cincinnati, Department of Surgery, Section of General Surgery, Cincinnati
| | - Nora C Elson
- University of Cincinnati, Department of Surgery, Section of General Surgery, Cincinnati
| | - Taylor E Wallen
- University of Cincinnati, Department of Surgery, Section of General Surgery, Cincinnati
| | - Dennis Hanseman
- University of Cincinnati, Department of Surgery, Section of General Surgery, Cincinnati
| | - Timothy A Pritts
- University of Cincinnati, Department of Surgery, Section of General Surgery, Cincinnati
| | - Vanessa Nomellini
- University of Cincinnati, Department of Surgery, Section of General Surgery, Cincinnati
| | - Sameer H Patel
- University of Cincinnati, Department of Surgery, Section of General Surgery, Cincinnati
| | - Amy T Makley
- University of Cincinnati, Department of Surgery, Section of General Surgery, Cincinnati
| | - Michael D Goodman
- University of Cincinnati, Department of Surgery, Section of General Surgery, Cincinnati.
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11
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Morris MC, Niziolek GM, Blakeman TC, Stevens-Topie S, Veile R, Heh V, Zingarelli B, Rodriquez D, Branson RD, Goodman MD. Intrathoracic Pressure Regulator Performance in the Setting of Hemorrhage and Acute Lung Injury. Mil Med 2021; 185:e1083-e1090. [PMID: 32350538 DOI: 10.1093/milmed/usz485] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
INTRODUCTION Intrathoracic pressure regulation (ITPR) can be utilized to enhance venous return and cardiac preload by inducing negative end expiratory pressure in mechanically ventilated patients. Previous preclinical studies have shown increased mean arterial pressure (MAP) and decreased intracranial pressure (ICP) with use of an ITPR device. The aim of this study was to evaluate the hemodynamic and respiratory effects of ITPR in a porcine polytrauma model of hemorrhagic shock and acute lung injury (ALI). METHODS Swine were anesthetized and underwent a combination of sham, hemorrhage, and/or lung injury. The experimental groups included: no injury with and without ITPR (ITPR, Sham), hemorrhage with and without ITPR (ITPR/Hem, Hem), and hemorrhage and ALI with and without ITPR (ITPR/Hem/ALI, Hem/ALI). The ITPR device was initiated at a setting of -3 cmH2O and incrementally decreased by 3 cmH2O after 30 minutes on each setting, with 15 minutes allowed for recovery between settings, to a nadir of -12 cmH2O. Histopathological analysis of the lungs was scored by blinded, independent reviewers. Of note, all animals were chemically paralyzed for the experiments to suppress gasping at ITPR pressures below -6 cmH2O. RESULTS Adequate shock was induced in the hemorrhage model, with the MAP being decreased in the Hem and ITPR/Hem group compared with Sham and ITPR/Sham, respectively, at all time points (Hem 54.2 ± 6.5 mmHg vs. 88.0 ± 13.9 mmHg, p < 0.01, -12 cmH2O; ITPR/Hem 59.5 ± 14.4 mmHg vs. 86.7 ± 12.1 mmHg, p < 0.01, -12 cmH2O). In addition, the PaO2/FIO2 ratio was appropriately decreased in Hem/ALI compared with Sham and Hem groups (231.6 ± 152.5 vs. 502.0 ± 24.6 (Sham) p < 0.05 vs. 463.6 ± 10.2, (Hem) p < 0.01, -12 cmH2O). Heart rate was consistently higher in the ITPR/Hem/ALI group compared with the Hem/ALI group (255 ± 26 bpm vs. 150.6 ± 62.3 bpm, -12 cmH2O) and higher in the ITPR/Hem group compared with Hem. Respiratory rate (adjusted to maintain pH) was also higher in the ITPR/Hem/ALI group compared with Hem/ALI at -9 and - 12 cmH2O (32.8 ± 3.0 breaths per minute (bpm) vs. 26.8 ± 3.6 bpm, -12 cmH2O) and higher in the ITPR/Hem group compared with Hem at -6, -9, and - 12 cmH2O. Lung compliance and end expiratory lung volume (EELV) were both consistently decreased in all three ITPR groups compared with their controls. Histopathologic severity of lung injury was worse in the ITPR and ALI groups compared with their respective injured controls or Sham. CONCLUSION In this swine polytrauma model, we demonstrated successful establishment of hemorrhage and combined hemorrhage/ALI models. While ITPR did not demonstrate a benefit for MAP or ICP, our data demonstrate that the ITPR device induced tachycardia with associated increase in cardiac output, as well as tachypnea with decreased lung compliance, EELV, PaO2/FIO2 ratio, and worse histopathologic lung injury. Therefore, implementation of the ITPR device in the setting of polytrauma may compromise pulmonary function without significant hemodynamic improvement.
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Affiliation(s)
- Mackenzie C Morris
- Department of Surgery, University of Cincinnati, 231 Albert Sabin Way ML, Cincinnati, OH 0558
| | - Grace M Niziolek
- Department of Surgery, University of Cincinnati, 231 Albert Sabin Way ML, Cincinnati, OH 0558
| | - Thomas C Blakeman
- Department of Surgery, University of Cincinnati, 231 Albert Sabin Way ML, Cincinnati, OH 0558
| | - Sabre Stevens-Topie
- Airman Systems Directorate, 711 Human Performance Wing, Wright Patterson AFB, Dayton, OH 45229
| | - Rosalie Veile
- Department of Surgery, University of Cincinnati, 231 Albert Sabin Way ML, Cincinnati, OH 0558
| | - Victor Heh
- Airman Systems Directorate, 711 Human Performance Wing, Wright Patterson AFB, Dayton, OH 45229
| | - Basilia Zingarelli
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Location B, 5th Floor, Cincinnati, OH
| | - Dario Rodriquez
- Airman Systems Directorate, 711 Human Performance Wing, Wright Patterson AFB, Dayton, OH 45229
| | - Richard D Branson
- Department of Surgery, University of Cincinnati, 231 Albert Sabin Way ML, Cincinnati, OH 0558
| | - Michael D Goodman
- Department of Surgery, University of Cincinnati, 231 Albert Sabin Way ML, Cincinnati, OH 0558
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Lee TC, Wima K, Morris MC, Johnston ME, Shah SA, Ahmad SA, Patel SH, Wilson GC. Lack of National Adoption of Evidence-Based Treatment for Resectable Gastric Adenocarcinoma. J Gastrointest Surg 2021; 25:36-47. [PMID: 33201456 PMCID: PMC7670838 DOI: 10.1007/s11605-020-04868-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 11/06/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Level 1 evidence for multimodal treatment of resectable gastric adenocarcinoma from the Intergroup 0116 (2001) and MAGIC (2006) trials demonstrated survival benefit of adjuvant chemoradiation (CRT) and perioperative chemotherapy, respectively. We evaluated the adoption of evidence-based treatment in the post-MAGIC era and its impact on survival. METHODS A total of 7058 patients with resectable gastric adenocarcinoma undergoing definitive surgical resection between 2004 and 2015 were analyzed using the National Cancer Database. RESULTS Over the study period, the proportion of patients receiving adjuvant CRT decreased from 19.1% to 9.1%, while perioperative chemotherapy increased from 1.9% to 28.6%. Utilization of perioperative chemotherapy surpassed adjuvant CRT in 2011. Evidence-based treatment (either perioperative chemotherapy or adjuvant CRT) had better overall survival (OS) than other treatments for clinical stage II-III patients (p < 0.05). On multivariate analysis of the whole study period, evidence-based treatments were associated with better OS (HR 0.67 [0.60-0.74], p < 0.05). Only 360/1262 (28.5%) patients in the perioperative chemotherapy group completed postoperative therapy, which was associated with improved OS (p < 0.05). For clinical stage III patients (n = 2402), only 806 (33.6%) received evidence-based treatment, while 487 (22.2%) underwent surgery alone. On multivariate analysis of these patients between 2010 and 2015, both perioperative chemotherapy (HR 0.49 [0.35-0.68]) and adjuvant CRT (HR 0.31 [0.21-0.44]) were associated with better OS than surgery alone (p < 0.05). CONCLUSIONS Since the INT-0116 and MAGIC trials, utilization of evidence-based treatments for resectable gastric adenocarcinoma has increased, with perioperative chemotherapy surpassing adjuvant CRT as the preferred practice. However, overall utilization of these regimens remains quite low nationally despite association with improved OS.
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Affiliation(s)
- Tiffany C. Lee
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Cincinnati, OH USA ,grid.24827.3b0000 0001 2179 9593Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way ML 0558, Cincinnati, OH 45267 USA
| | - Koffi Wima
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Cincinnati, OH USA ,grid.24827.3b0000 0001 2179 9593Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way ML 0558, Cincinnati, OH 45267 USA
| | - Mackenzie C. Morris
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Cincinnati, OH USA ,grid.24827.3b0000 0001 2179 9593Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way ML 0558, Cincinnati, OH 45267 USA
| | - Michael E. Johnston
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Cincinnati, OH USA ,grid.24827.3b0000 0001 2179 9593Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way ML 0558, Cincinnati, OH 45267 USA
| | - Shimul A. Shah
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Cincinnati, OH USA ,grid.24827.3b0000 0001 2179 9593Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way ML 0558, Cincinnati, OH 45267 USA
| | - Syed A. Ahmad
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Cincinnati, OH USA ,grid.24827.3b0000 0001 2179 9593Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way ML 0558, Cincinnati, OH 45267 USA
| | - Sameer H. Patel
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Cincinnati, OH USA ,grid.24827.3b0000 0001 2179 9593Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way ML 0558, Cincinnati, OH 45267 USA
| | - Gregory C. Wilson
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Cincinnati, OH USA ,grid.24827.3b0000 0001 2179 9593Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way ML 0558, Cincinnati, OH 45267 USA
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Morris MC, Winer LK, Lee TC, Shah SA, Rafferty JF, Paquette IM. Omission of Adjuvant Chemotherapy in Rectal Cancer Patients with Pathologic Complete Response: a National Analysis. J Gastrointest Surg 2021; 25:1857-1865. [PMID: 32728821 PMCID: PMC7388436 DOI: 10.1007/s11605-020-04749-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 07/16/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND An increasing number of patients achieve a pathologic complete response (pCR) after neoadjuvant chemoradiation for locally advanced rectal cancer. Consensus guidelines continue to recommend oncologic resection followed by adjuvant chemotherapy in these patients. We hypothesize that there is significant variability in compliance with this recommendation. METHODS The National Cancer Database was queried from 2006 to 2015 for patients with locally advanced rectal cancer who underwent neoadjuvant chemoradiation followed by oncologic resection with a pCR (ypT0N0). Hierarchical logistic regression models were used to generate risk and reliability-adjusted rates of adjuvant chemotherapy utilization in patients with pCR at each hospital. RESULTS In total, 2421 pCR patients were identified. Five-year overall survival was improved in pCR patients who received adjuvant chemotherapy compared with those who did not (92 vs. 85%, p < 0.01). Multivariate analysis indicated that improvement in overall survival remained associated with adjuvant chemotherapy (HR 0.60, 95% CI 0.44-0.82, p < 0.01). The mean adjuvant chemotherapy utilization rate among hospitals was 32%. There was an upward trend in use over the past decade, but two-thirds still do not receive the recommended therapy. High chemotherapy utilizer hospitals were more likely to be academic centers (54.9 vs. 45.9%, p < 0.01) when compared with low chemotherapy utilizers. CONCLUSION Adjuvant chemotherapy is associated with improved survival in rectal cancer patients with pCR following neoadjuvant chemoradiation and oncologic resection. However, utilization among centers in the USA was only 32% with significant variability across centers. National efforts are needed to standardize treatment patterns according to national guidelines.
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Affiliation(s)
- Mackenzie C. Morris
- grid.24827.3b0000 0001 2179 9593Department of Surgery, College of Medicine, University of Cincinnati, 2123 Auburn Ave #524, Cincinnati, OH 45219 USA
| | - Leah K. Winer
- grid.24827.3b0000 0001 2179 9593Department of Surgery, College of Medicine, University of Cincinnati, 2123 Auburn Ave #524, Cincinnati, OH 45219 USA
| | - Tiffany C. Lee
- grid.24827.3b0000 0001 2179 9593Department of Surgery, College of Medicine, University of Cincinnati, 2123 Auburn Ave #524, Cincinnati, OH 45219 USA
| | - Shimul A. Shah
- grid.24827.3b0000 0001 2179 9593Department of Surgery, College of Medicine, University of Cincinnati, 2123 Auburn Ave #524, Cincinnati, OH 45219 USA
| | - Janice F. Rafferty
- grid.24827.3b0000 0001 2179 9593Department of Surgery, College of Medicine, University of Cincinnati, 2123 Auburn Ave #524, Cincinnati, OH 45219 USA
| | - Ian M. Paquette
- grid.24827.3b0000 0001 2179 9593Department of Surgery, College of Medicine, University of Cincinnati, 2123 Auburn Ave #524, Cincinnati, OH 45219 USA
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Leiting JL, Day CN, Harmsen WS, Cloyd JM, Abdel-Misih S, Fournier K, Lee AJ, Dineen S, Dessureault S, Veerapongh J, Baumgartner JM, Clarke C, Mogal H, Russell MC, Zaidi MY, Patel SH, Morris MC, Hendrix RJ, Lambert LA, Abbott DE, Pokrzywa C, Raoof M, Eng O, Johnston FM, Greer J, Grotz TE. The impact of HIPEC vs. EPIC for the treatment of mucinous appendiceal carcinoma: a study from the US HIPEC collaborative. Int J Hyperthermia 2020; 37:1182-1188. [PMID: 33040617 DOI: 10.1080/02656736.2020.1819571] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
INTRODUCTION Mucinous appendiceal carcinoma is a rare malignancy that commonly spreads to the peritoneum leading to peritoneal metastases. Complete cytoreduction with perioperative intraperitoneal chemotherapy (PIC) is the mainstay of treatment, administered as either hyperthermic intra peritoneal chemotherapy (HIPEC) or early post-operative intraperitoneal chemotherapy (EPIC). Our goal was to assess the perioperative and long term survival outcomes associated with these two PIC methods. MATERIALS AND METHODS Patients with mucinous appendiceal carcinoma were identified in the US HIPEC Collaborative database from 12 academic institutions. Patient demographics, clinical characteristics, and survival outcomes were compared among patients who underwent HIPEC vs. EPIC with inverse probability weighting (IPW) used for adjustment. RESULTS Among 921 patients with mucinous appendiceal carcinoma, 9% underwent EPIC while 91% underwent HIPEC. There was no difference in Grade III-V complications between the two groups (18.5% for HIPEC vs. 15.0% for EPIC, p=.43) though patients who underwent HIPEC had higher rates of readmissions (21.2% vs. 8.8%, p<.01). Additionally, PIC method was not an independent predictor for overall survival (OS) or recurrence-free survival (RFS) after adjustment on multivariable analysis. CONCLUSIONS Among patients with mucinous appendiceal carcinoma, both EPIC and HIPEC appear to be associated with similar perioperative and long-term outcomes.
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Affiliation(s)
- Jennifer L Leiting
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN, USA
| | - Courtney N Day
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - William S Harmsen
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Jordan M Cloyd
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Sherif Abdel-Misih
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Keith Fournier
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Andrew J Lee
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sean Dineen
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Morsani College of Medicine, Tampa, FL, USA
| | - Sophie Dessureault
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Morsani College of Medicine, Tampa, FL, USA
| | - Jula Veerapongh
- Department of Surgery, Division of Surgical Oncology, University of California, San Diego, CA, USA
| | - Joel M Baumgartner
- Department of Surgery, Division of Surgical Oncology, University of California, San Diego, CA, USA
| | - Callisia Clarke
- Department of Surgery, Division of Surgical Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Harveshp Mogal
- Department of Surgery, Division of Surgical Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Maria C Russell
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Mohammad Y Zaidi
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Sameer H Patel
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Mackenzie C Morris
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Ryan J Hendrix
- Department of Surgery, Division of Surgical Oncology, University of Massachusetts Medical School, Worcester, MA, USA
| | - Laura A Lambert
- Peritoneal Surface Malignancy Program Section of Surgical Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
| | - Daniel E Abbott
- Department of Surgery, Division of Surgical Oncology, University of Wisconsin, Madison, WI, USA
| | - Courtney Pokrzywa
- Department of Surgery, Division of Surgical Oncology, University of Wisconsin, Madison, WI, USA
| | - Mustafa Raoof
- Department of Surgery, Division of Surgical Oncology, City of Hope National Medical Center, Duarte, CA, USA
| | - Oliver Eng
- Department of Surgery, Division of Surgical Oncology, City of Hope National Medical Center, Duarte, CA, USA
| | | | - Jonathan Greer
- Department of Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Travis E Grotz
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN, USA
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15
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Morris MC, John D, Singer KE, Moran R, McGlone E, Veile R, Goetzman HS, Makley AT, Caldwell CC, Goodman MD. Post-TBI splenectomy may exacerbate coagulopathy and platelet activation in a murine model. Thromb Res 2020; 193:211-217. [PMID: 32798961 DOI: 10.1016/j.thromres.2020.08.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 07/25/2020] [Accepted: 08/03/2020] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Traumatic brain injury (TBI) induces acute hypocoagulability, subacute hypercoagulability, and persistently elevated risk for thromboembolic events. Splenectomy is associated with increased mortality in patients with moderate or severe TBI. We hypothesized that the adverse effects of splenectomy in TBI patients may be secondary to the exacerbation of pathologic coagulation and platelet activation changes. METHODS An established murine weight-drop TBI model was utilized and a splenectomy was performed immediately following TBI. Sham as well as TBI and splenectomy alone mice were used as injury controls. Mice were sacrificed for blood draws at 1, 6, and 24 h, as well as 7 days post-TBI. Viscoelastic coagulation parameters were assessed by rotational thromboelastometry (ROTEM) and platelet activation was measured by expression of P-selectin via flow cytometry analysis of platelet rich plasma samples. RESULTS At 6 h following injury, TBI/splenectomy demonstrated hypocoagulability with prolonged clot formation time (CFT) compared to TBI alone. By 24 h following injury, TBI/splenectomy and splenectomy mice were hypercoagulable with a shorter CFT, a higher alpha angle, and increased MCF, despite a lower percentage of platelet contribution to clot compared to TBI alone. However, only the TBI/splenectomy continued to display this hypercoagulable state at 7 days. While TBI/splenectomy had greater P-selectin expression at 1-h post-injury, TBI alone had significantly greater P-selectin expression at 24 h post-injury compared to TBI/splenectomy. Interestingly, P-selectin expression remained elevated only in TBI/splenectomy at 7 days post-injury. CONCLUSION Splenectomy following TBI exacerbates changes in the post-injury coagulation state. The combination of TBI and splenectomy induces an acute hypocoagulable state that could contribute to an increase in intracranial bleeding. Subacutely, the addition of splenectomy to TBI exacerbates post-injury hypercoagulability and induces persistent platelet activation. These polytrauma effects on coagulation may contribute to the increased mortality observed in patients with combined brain and splenic injuries.
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Affiliation(s)
| | - Devin John
- Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Kathleen E Singer
- Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Ryan Moran
- Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Emily McGlone
- Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Rosalie Veile
- Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Holly S Goetzman
- Department of Surgery, University of Cincinnati, Cincinnati, OH, USA; Division of Research, Shriners Hospital for Children, Cincinnati, OH, USA
| | - Amy T Makley
- Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Charles C Caldwell
- Department of Surgery, University of Cincinnati, Cincinnati, OH, USA; Division of Research, Shriners Hospital for Children, Cincinnati, OH, USA
| | - Michael D Goodman
- Department of Surgery, University of Cincinnati, Cincinnati, OH, USA.
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16
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Pulliam KE, Joseph B, Morris MC, Veile RA, Schuster RM, Makley AT, Pritts TA, Goodman MD. Innate coagulability changes with age in stored packed red blood cells. Thromb Res 2020; 195:35-42. [PMID: 32652351 DOI: 10.1016/j.thromres.2020.06.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 06/10/2020] [Accepted: 06/28/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Packed red blood cell (pRBC) units administered during resuscitation from hemorrhagic shock are of varied storage ages. We have previously shown that RBC-derived microparticles' impact on thrombogenesis. However, the impact of storage age on pRBC coagulability is unknown. Therefore, we sought to investigate the effect of storage age on innate coagulability and aggregability of stored pRBCs. METHODS pRBCs prepared from male C57BL/6J mice were stored in Additive Solution-3 according to our standardized murine blood banking protocols for 14 days. Rotational thromboelastometry (ROTEM) was used to assess the innate coagulation status of fresh and 14-day old pRBCs. Viscoelastic coagulation parameters of clotting time (CT), clot formation time (CFT), alpha angle, and maximum clot firmness (MCF) were analyzed to determine coagulability. Plasma was added to the fresh pRBCs and 15-day old pRBCs to determine if the storage-associated coagulopathy was reversible with plasma. Statistical analyses were conducted with a Student's t-test. RESULTS Fifteen-day old pRBCs demonstrated a significant reduction in MCF (10.3 vs. 24.4 mm, P-value <0.001) and alpha angle (6.0 vs. 27.2 degrees, P-value <0.001) as well as significant prolongation of CFT and CT (1126.5 vs. 571.4 s, P-value <0.001) compared to fresh pRBCs. FFP addition to 15-day old and fresh pRBCs, demonstrated a significant reduction in MCF and persistent prolongation of CFT. This suggests that pRBCs lost coagulability as they aged and this deficit was not completely corrected by plasma administration. CONCLUSIONS Storage duration may be an important factor in coagulation potential of pRBCs. Transfusion with older pRBCs may contribute to coagulopathy in massively transfused patients.
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Affiliation(s)
- Kasiemobi E Pulliam
- Section of General Surgery, Department of Surgery, University of Cincinnati, 231 Albert Sabin Way, Mail Location 0558, Cincinnati, OH 45267-0558, United States of America.
| | - Bernadin Joseph
- Section of General Surgery, Department of Surgery, University of Cincinnati, 231 Albert Sabin Way, Mail Location 0558, Cincinnati, OH 45267-0558, United States of America.
| | - Mackenzie C Morris
- Section of General Surgery, Department of Surgery, University of Cincinnati, 231 Albert Sabin Way, Mail Location 0558, Cincinnati, OH 45267-0558, United States of America.
| | - Rosalie A Veile
- Section of General Surgery, Department of Surgery, University of Cincinnati, 231 Albert Sabin Way, Mail Location 0558, Cincinnati, OH 45267-0558, United States of America.
| | - Rebecca M Schuster
- Section of General Surgery, Department of Surgery, University of Cincinnati, 231 Albert Sabin Way, Mail Location 0558, Cincinnati, OH 45267-0558, United States of America.
| | - Amy T Makley
- Section of General Surgery, Department of Surgery, University of Cincinnati, 231 Albert Sabin Way, Mail Location 0558, Cincinnati, OH 45267-0558, United States of America.
| | - Timothy A Pritts
- Section of General Surgery, Department of Surgery, University of Cincinnati, 231 Albert Sabin Way, Mail Location 0558, Cincinnati, OH 45267-0558, United States of America.
| | - Michael D Goodman
- Section of General Surgery, Department of Surgery, University of Cincinnati, 231 Albert Sabin Way, Mail Location 0558, Cincinnati, OH 45267-0558, United States of America.
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17
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Cortez AR, Morris MC, Brown NG, Winer LK, Safdar K, Poreddy S, Shah SA, Quillin RC. Is Surgery Necessary? Endoscopic Management of Post-transplant Biliary Complications in the Modern Era. J Gastrointest Surg 2020; 24:1639-1647. [PMID: 31228080 DOI: 10.1007/s11605-019-04292-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Accepted: 05/29/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Biliary complications are common following liver transplantation (LT) and traditionally managed with Roux-en-Y hepaticojejunostomy. However, endoscopic management has largely supplanted surgical revision in the modern era. Herein, we evaluate our experience with the management of biliary complications following LT. METHODS All LTs from January 2013 to June 2018 at a single institution were reviewed. Patients with biliary bypass prior to, or at LT, were excluded. Patients were grouped by biliary complication of an isolated stricture, isolated leak, or concomitant stricture and leak (stricture/leak). RESULTS A total of 462 grafts were transplanted into 449 patients. Ninety-five (21%) patients had post-transplant biliary complications, including 56 (59%) strictures, 28 (29%) leaks, and 11 (12%) stricture/leaks. Consequently, the overall stricture, leak, and stricture/leak rates were 12%, 6%, and 2%, respectively. Endoscopic management was pursued for all stricture and stricture/leak patients, as well as 75% of leak patients, reserving early surgery only for those patients with an uncontrolled leak and evidence of biliary peritonitis. Endoscopic management was successful in the majority of patients (stricture 94%, leak 90%, stricture/leak 90%). Only six patients (5.6%) received additional interventions-two required percutaneous transhepatic cholangiography catheters, three underwent surgical revision, and one was re-transplanted. CONCLUSIONS Endoscopic management of post-transplant biliary complications resulted in long-term resolution without increased morbidity, mortality, or graft failure. Successful endoscopic treatment requires collaboration with a skilled endoscopist. Moreover, multidisciplinary transplant teams must develop treatment protocols based on the local availability and expertise at their center.
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Affiliation(s)
- Alexander R Cortez
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Mackenzie C Morris
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Nicholas G Brown
- Division of Digestive Diseases, University of Cincinnati, Cincinnati, OH, USA
| | - Leah K Winer
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Kamran Safdar
- Division of Digestive Diseases, University of Cincinnati, Cincinnati, OH, USA
| | - Sampath Poreddy
- Division of Digestive Diseases, University of Cincinnati, Cincinnati, OH, USA
| | - Shimul A Shah
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati, Cincinnati, OH, USA.,Division of Transplantation, Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - R Cutler Quillin
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati, Cincinnati, OH, USA. .,Division of Transplantation, Department of Surgery, University of Cincinnati, Cincinnati, OH, USA.
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18
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Morris MC, Lee TC, Johnston ME, Hanseman D, Lewis JD, Shaughnessy EA, Reyna C. National Trend of Axillary Management in Clinical T3/T4 N0 Patients Having Breast Conserving Therapy. J Surg Res 2020; 255:361-370. [PMID: 32599456 DOI: 10.1016/j.jss.2020.05.073] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 04/23/2020] [Accepted: 05/24/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND The ACOSOG Z0011 trial has essentially eliminated axillary lymph node dissection (ALND) in breast conserving therapy (BCT) patients with clinical T1/T2 and 1-2 positive sentinel lymph nodes (SLNs). Currently, ALND is recommended for positive SLNs unless ACOSOG Z0011 criteria are applicable. We aimed to assess the national trends and axillary management before and after the publication of ACOSOG Z0011 for larger tumors. METHODS An IRB-approved study evaluated the National Cancer Database from 2006 to 2016. Women with clinical T3/T4, N0 who otherwise fit ACOSOG Z0011 criteria were included. Neoadjuvant systemic therapy or known nodal disease was excluded. Clinicopathologic data were compared between two timeframes based on ACOSOZ Z0011 publication and by axillary management. Patients were categorized into SLNB alone (1-5 lymph nodes examined) and ALND (≥10 lymph nodes examined) groups. RESULTS A total of 230 women fit inclusion criteria, of whom 36% underwent ALND. ALND use decreased from 54% in 2006 to 14% in 2016 (P < 0.01). Comparing ALND to SLNB alone within the pre-Z0011 era, comprehensive community cancer programs had higher proportions of ALND, whereas academic centers had higher rates of SLND alone (P = 0.03). Comparing similar axillary management between eras, SLNB-alone patients in the post-Z0011 era had higher pT and pN stages, were less likely to be Her2 positive, and were more likely to receive systemic treatment. CONCLUSIONS There is a national trend to forgo ALND in women who have tumors larger than those included in the Z0011 criteria without any clear clinicopathologic indications.
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Affiliation(s)
| | - Tiffany C Lee
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | | | - Dennis Hanseman
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Jaime D Lewis
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | | | - Chantal Reyna
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio.
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19
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Morris MC, Baker JE, Edwards MJ. Surgeons, Scholars, and Leaders Symposium: A 5-Year Experience. Am Surg 2020. [DOI: 10.1177/000313481908501224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The Department of Surgery at the University of Cincinnati developed the Surgeons, Scholars, and Leaders Symposium to address the underappreciated aspects of surgical education that are critical in the development of the academic surgeon. Surgical education has undergone many gaps since the beginning of a traditional surgical residency, first pioneered by Dr. Halsted in 1904; still, many gaps in surgical education remain. Topics such as research, financial planning, leadership, career development, and many others are not adequately addressed in formalized training. The Surgeons, Scholars, and Leaders Symposium was first held in January 2015 in Jackson Hole, WY, and has subsequently become an annual event. Recurrent themes addressed at the Symposium include global health, resident autonomy, research program development, leadership, mentorship, career development, and managing transitions. The annual Surgeons, Scholars, and Leaders Symposium has been instrumental in addressing these underappreciated aspects of surgeon development and will continue to be an important venue for the next generation of surgical leaders.
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Affiliation(s)
- Mackenzie C. Morris
- Department of Surgery, Section of General Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Jennifer E. Baker
- Department of Surgery, Section of General Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Michael J. Edwards
- Department of Surgery, Section of General Surgery, University of Cincinnati, Cincinnati, Ohio
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20
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Singer KE, Morris MC, Blakeman C, Stevens-Topie SM, Veile R, Fortuna G, DuBose JJ, Stuever MF, Makley AT, Goodman MD. Can Resuscitative Endovascular Balloon Occlusion of the Aorta Fly? Assessing Aortic Balloon Performance for Aeromedical Evacuation. J Surg Res 2020; 254:390-397. [PMID: 32540506 DOI: 10.1016/j.jss.2020.05.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 05/04/2020] [Accepted: 05/05/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Noncompressible torso hemorrhage remains a leading cause of death. Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) placement may occur before transport; however, its efficacy has not been demonstrated at altitude. We hypothesized that changes in altitude would not result in blood pressure changes proximal to a deployed REBOA. METHODS A simulation model for 7Fr guidewireless REBOA was used at altitudes up to 22,000 feet. Female pigs then underwent hemorrhagic shock to a mean arterial pressure (MAP) of 40 mm Hg. After hemorrhage, a REBOA catheter was deployed in the REBOA group and positioned but not inflated in the no-REBOA group. Animals underwent simulated aeromedical evacuation at 8000 ft or were left at ground level. After altitude exposure, the balloon was deflated, and the animals were observed. RESULTS Taking the REBOA catheter to 22,000 ft in the simulation model resulted in a lower systolic blood pressure but a preserved MAP. In the porcine model, REBOA increased both systolic blood pressure and MAP compared with no-REBOA (P < 0.05) and was unaffected by altitude. No differences in postflight blood pressure, acidosis, or systemic inflammatory response were observed between ground and altitude REBOA groups. CONCLUSIONS REBOA maintained MAP up to 22,000 feet in an inanimate model. In the porcine model, REBOA deployment improved MAP, and the balloon remained effective at altitude.
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Affiliation(s)
| | | | | | | | - Rosalie Veile
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Gerald Fortuna
- Department of Surgery, Washington University in St. Louis, St. Louis, Missouri
| | - Joseph J DuBose
- Department of Vascular Surgery, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, Maryland
| | - Mary F Stuever
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Amy T Makley
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
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21
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Morris MC, Niziolek GM, Baker JE, Huebner BR, Hanseman D, Makley AT, Pritts TA, Goodman MD. Death by Decade: Establishing a Transfusion Ceiling for Futility in Massive Transfusion. J Surg Res 2020; 252:139-146. [PMID: 32278968 DOI: 10.1016/j.jss.2020.03.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 12/04/2019] [Accepted: 03/09/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND Age and massive transfusion are predictors of mortality after trauma. We hypothesized that increasing age and high-volume transfusion would result in progressively elevated mortality rates and that a transfusion "ceiling" would define futility. METHODS The Trauma Quality Improvement Program (TQIP) database was queried for 2013-2016 records and our level I trauma registry was reviewed from 2013 to 2018. Demographic, mortality, and blood transfusion data were collected. Patients were grouped by decade of life and by packed red blood cell (pRBC) transfusion requirement (zero units, 1-3 units, or ≥4 units) within 4 h of admission. RESULTS TQIP analysis demonstrated an in-hospital mortality risk that increased linearly with age, to an odds ratio of 10.1 in ≥80 y old (P < 0.01). Mortality rates were significantly higher in older adults (P < 0.01) and those with more pRBCs transfused. In massively transfused patients, the transfusion "ceiling" was dependent on age. Owing to the lack granularity in the TQIP database, 230 patients from our institution who received ≥4 units of pRBCs within 4 h of admission were reviewed. On arrival, younger patients had significantly higher heart rates and more severe derangements in lactate levels, base deficits, and pH compared with older patients. There were no differences among age groups in injury severity score, systolic blood pressure, or mortality. CONCLUSIONS In massively transfused patients, mortality increased with age. However, a significant proportion of older adults were successfully resuscitated. Therefore, age alone should not be considered a contraindication to high-volume transfusion. Traditional physiologic and laboratory criteria indicative of hemorrhagic shock may have reduced reliability with increasing age, and thus providers must have a heightened suspicion for hemorrhage in the elderly. Early transfusion requirements can be combined with age to establish prognosis to define futility to help counsel families regarding mortality after traumatic injury.
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Affiliation(s)
| | - Grace M Niziolek
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Jennifer E Baker
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | | | - Dennis Hanseman
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Amy T Makley
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Timothy A Pritts
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
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22
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Lee TC, Cortez AR, Kassam AF, Morris MC, Winer LK, Silski LS, Quillin RC, Cuffy MC, Jones CR, Diwan TS, Shah SA. Outcomes of en bloc simultaneous liver-kidney transplantation compared to the traditional technique. Am J Transplant 2020; 20:1181-1187. [PMID: 31605561 DOI: 10.1111/ajt.15655] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Revised: 10/03/2019] [Accepted: 10/05/2019] [Indexed: 01/25/2023]
Abstract
Simultaneous liver-kidney transplantation (SLKT) is indicated for patients with end-stage liver disease (ESLD) and concurrent renal insufficiency. En bloc SLKT is an alternative to traditional separate implantations, but studies comparing the two techniques are limited. The en bloc technique maintains renal outflow via donor infrahepatic vena cava and inflow via anastomosis of donor renal artery to donor splenic artery. Comparison of recipients of en bloc (n = 17) vs traditional (n = 17) SLKT between 2013 and 2017 was performed. Recipient demographics and comorbidities were similar. More recipients of traditional SLKT were dialysis dependent (82.4% vs 41.2%, P = .01) with lower baseline pretransplant eGFR (14 vs 18, P = .01). En bloc SLKT was associated with shorter kidney cold ischemia time (341 vs 533 minutes, P < .01) and operative time (374 vs 511 minutes, P < .01). Two en bloc patients underwent reoperation for kidney allograft inflow issues due to kinking and renal steal. Early kidney allograft dysfunction (23.5% in both groups), 1-year kidney graft survival (88.2% vs 82.4%, P = 1.0), and posttransplantation eGFR were similar between groups. In our experience, the en bloc SLKT technique is safe and feasible, with comparable outcomes to the traditional method.
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Affiliation(s)
- Tiffany C Lee
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Cincinnati, Ohio.,Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Alexander R Cortez
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Cincinnati, Ohio.,Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Al-Faraaz Kassam
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Mackenzie C Morris
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Cincinnati, Ohio.,Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Leah K Winer
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Cincinnati, Ohio.,Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Latifa S Silski
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Ralph C Quillin
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Cincinnati, Ohio.,Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Madison C Cuffy
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Courtney R Jones
- Department of Anesthesiology, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Tayyab S Diwan
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Shimul A Shah
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Cincinnati, Ohio.,Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
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23
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Kassam AF, Taylor ME, Morris MC, Watkins BM, Thompson JR, Schauer DP, Smith EP, Diwan TS. The impact of sleeve gastrectomy on renal function in patients with chronic kidney disease varies with severity of renal insufficiency. Surg Obes Relat Dis 2020; 16:607-613. [PMID: 32093996 DOI: 10.1016/j.soard.2020.01.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 01/16/2020] [Accepted: 01/21/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Although laparoscopic sleeve gastrectomy is known, in general, to improve renal function in patients with obesity and chronic kidney disease (CKD), its effect on estimated glomerular filtration rate (eGFR) stratified by the stage of CKD is less clear. OBJECTIVES We aimed to evaluate the impact of sleeve gastrectomy on renal function in a stratified cohort of patients with CKD. SETTING University Hospital. METHODS We performed a retrospective review of 1932 patients who met National Institutes of Health's guidelines for metabolic surgery and underwent laparoscopic sleeve gastrectomy performed by 1 of 3 surgeons. One hundred sixty-four patients with CKD stages 1 through 4 were identified. RESULTS Mean follow-up period was 1.57 ± 1.0 years. Mean age was 56.4 ± 9.9 years with a preoperative body mass index of 47 ± 9 kg/m2, which decreased to 38.9 ± 8.7 kg/m2 at most recent follow-up (P < .001). In the cohort of patients with diabetes, significant decreases were observed in mean glycated hemoglobin level, daily number of oral hypoglycemics, and daily long acting insulin use (P < .001 each). Of 67 patients with diabetes, 34.3% (n = 24) achieved complete remission. In patients with hypertension, average daily number of antihypertensives decreased (P < .001) and 22.3% (n = 31) of 133 patients with hypertension discontinued all antihypertensives. Patients with CKD stages 2, 3a, and 3b showed significant improvement in eGFR. Reinforcing this evidence of improvement, patients with CKD 3a and 3b were more likely to downstage disease compared with those with CKD 4 (58.1% versus 73.1% versus 22.7%, respectively) (P < .001). CONCLUSION Renal function, as measured by eGFR, in patients with stages 1 and 4 CKD did not improve after laparoscopic sleeve gastrectomy; in contrast, eGFR in patients with CKD stages 2 and 3 significantly improved. Early surgical referral and intervention may be important in achieving the greatest improvement in eGFR and possibly delaying or reversing progression to end-stage renal disease.
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Affiliation(s)
- Al-Faraaz Kassam
- University of Cincinnati, Department of Surgery, Cincinnati, Ohio
| | | | | | - Brad M Watkins
- University of Cincinnati, Department of Surgery, Cincinnati, Ohio
| | | | - Daniel P Schauer
- University of Cincinnati, Department of Internal Medicine, Cincinnati, Ohio
| | - Eric P Smith
- University of Cincinnati, Department of Internal Medicine, Cincinnati, Ohio
| | - Tayyab S Diwan
- University of Cincinnati, Department of Surgery, Cincinnati, Ohio.
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24
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Levinsky NC, Morris MC, Wima K, Sussman JJ, Ahmad SA, Cloyd JM, Kimbrough C, Fournier K, Lee A, Dineen S, Dessureault S, Veerapong J, Baumgartner JM, Clarke C, Zaidi MY, Staley CA, Maithel SK, Leiting J, Grotz T, Lambert L, Hendrix RJ, Ronnekleiv-Kelly S, Pokrzywa C, Raoof M, Eng OS, Johnston FM, Greer J, Patel SH. Should We Be Doing Cytoreductive Surgery with HIPEC for Signet Ring Cell Appendiceal Adenocarcinoma? A Study from the US HIPEC Collaborative. J Gastrointest Surg 2020; 24:155-164. [PMID: 31428960 DOI: 10.1007/s11605-019-04336-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 07/19/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Appendiceal adenocarcinoma with signet ring cells (SCA) is associated with worse overall survival (OS), and it is unclear whether cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) should be pursued in this patient population. We assessed the prognostic implications of signet ring cells in patients with appendiceal adenocarcinoma and peritoneal carcinomatosis undergoing CRS-HIPEC. METHODS The US HIPEC Collaborative, a 12-center, multi-institutional database of patients undergoing CRS-HIPEC, was reviewed for patients with SCA. Univariate and multivariate analyses were performed. RESULTS Of 514 patients undergoing CRS-HIPEC for appendiceal adenocarcinoma, 125 (24%) had SCA. The SCA and non-SCA groups had similar baseline characteristics. SCA had worse OS compared with non-SCA (32.0 vs 91.4 months, p < 0.001). In univariate analysis for only SCA cases, there was worse OS in patients with poorly differentiated tumors, positive lymph nodes, LVI, PCI > 20, or incomplete cytoreduction (CC-2/3). However, multivariate analysis showed only positive lymph nodes (HR 1.14 [95% CI 1.00-1.31], p = 0.04), poor differentiation (5.60 [1.29-24.39], p = 0.02), and incomplete cytoreduction (4.90 [1.11-12.70], p = 0.03) were independently associated with decreased OS for SCA. CONCLUSION While signet cells are a negative prognostic feature, they should not be a contraindication to CRS-HIPEC in patients with well-moderately differentiated tumors with negative lymph nodes, where complete cytoreduction can be achieved.
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Affiliation(s)
- Nick C Levinsky
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way ML-0558, Cincinnati, OH, 45267-0558, USA
| | - Mackenzie C Morris
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way ML-0558, Cincinnati, OH, 45267-0558, USA
| | - Koffi Wima
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way ML-0558, Cincinnati, OH, 45267-0558, USA
| | - Jeffrey J Sussman
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way ML-0558, Cincinnati, OH, 45267-0558, USA
| | - Syed A Ahmad
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way ML-0558, Cincinnati, OH, 45267-0558, USA
| | - Jordan M Cloyd
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Charles Kimbrough
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Keith Fournier
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Andrew Lee
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sean Dineen
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Department of Oncologic Sciences, Morsani College of Medicine, Tampa, FL, USA
| | - Sophie Dessureault
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Department of Oncologic Sciences, Morsani College of Medicine, Tampa, FL, USA
| | - Jula Veerapong
- Division of Surgical Oncology, Department of Surgery, University of California, San Diego, CA, USA
| | - Joel M Baumgartner
- Division of Surgical Oncology, Department of Surgery, University of California, San Diego, CA, USA
| | - Callisia Clarke
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Mohammad Y Zaidi
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Charles A Staley
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Shishir K Maithel
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Jennifer Leiting
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN, USA
| | - Travis Grotz
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN, USA
| | - Laura Lambert
- Division of Surgical Oncology, Department of Surgery, University of Massachusetts Medical School, Worcester, MA, USA
| | - Ryan J Hendrix
- Division of Surgical Oncology, Department of Surgery, University of Massachusetts Medical School, Worcester, MA, USA
| | - Sean Ronnekleiv-Kelly
- Division of Surgical Oncology, Department of Surgery, University of Wisconsin, Madison, WI, USA
| | - Courtney Pokrzywa
- Division of Surgical Oncology, Department of Surgery, University of Wisconsin, Madison, WI, USA
| | - Mustafa Raoof
- Division of Surgical Oncology, Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
| | - Oliver S Eng
- Division of Surgical Oncology, Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
| | | | - Jonathan Greer
- Department of Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Sameer H Patel
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way ML-0558, Cincinnati, OH, 45267-0558, USA.
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25
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Morris MC, Baker JE, Edwards MJ. Surgeons, Scholars, and Leaders Symposium: A 5-Year Experience. Am Surg 2019; 85:1327-1333. [PMID: 31908213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
The Department of Surgery at the University of Cincinnati developed the Surgeons, Scholars, and Leaders Symposium to address the underappreciated aspects of surgical education that are critical in the development of the academic surgeon. Surgical education has undergone many gaps since the beginning of a traditional surgical residency, first pioneered by Dr. Halsted in 1904; still, many gaps in surgical education remain. Topics such as research, financial planning, leadership, career development, and many others are not adequately addressed in formalized training. The Surgeons, Scholars, and Leaders Symposium was first held in January 2015 in Jackson Hole, WY, and has subsequently become an annual event. Recurrent themes addressed at the Symposium include global health, resident autonomy, research program development, leadership, mentorship, career development, and managing transitions. The annual Surgeons, Scholars, and Leaders Symposium has been instrumental in addressing these underappreciated aspects of surgeon development and will continue to be an important venue for the next generation of surgical leaders.
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Morris MC, Jung AD, Kim Y, Lee TC, Kaiser TE, Thompson JR, Bari K, Shah SA, Cohen RM, Schauer DP, Smith EP, Diwan TS. Delayed Sleeve Gastrectomy Following Liver Transplantation: A 5-Year Experience. Liver Transpl 2019; 25:1673-1681. [PMID: 31518478 DOI: 10.1002/lt.25637] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 08/02/2019] [Indexed: 12/31/2022]
Abstract
Obesity has become an epidemic in the United States over the past decade, and recent studies have shown this trend in the liver transplantation (LT) population. These patients may be candidates for laparoscopic sleeve gastrectomy (LSG) to promote significant and sustained weight loss to prevent recurrence of nonalcoholic steatohepatitis. However, safety remains a concern, and efficacy in this setting is uncertain. A single-institution database from 2014 to 2018 was queried for patients undergoing LSG following LT. The selection criteria for surgery were consistent with National Institutes of Health guidelines, and patients were at least 6 months after LT. A total of 15 patients (median age, 59.0 years; Caucasian, 86.7%; and female, 60%) underwent LSG following LT. Median time from LT to LSG was 2.2 years with a median follow-up period of 2.6 years. The median hospital length of stay (LOS) was 2 days after LSG. Mortality and rate of liver allograft rejection was 0, and there was 1 postoperative complication (a surgical site infection). Following LSG, body mass index (BMI) decreased from 42.7 to 35.9 kg/m2 (P < 0.01), and in 12 patients with at least 1 year of follow-up, the total body weight loss was 20.6%. Following LSG in patients with diabetes, the median daily insulin requirements decreased from 98 (49-118) to 0 (0-29) units/day (P = 0.02), and 60% discontinued insulin. Post-LT patients had a similar decrease in BMI and reduction in comorbidities at 1 year compared with a matched non-LT patient cohort. In the largest patient series to date, we show that LSG following LT is safe, effective, and does not increase the incidence of liver allograft rejection. Larger longer-term studies are needed to confirm underlying metabolic changes following LSG.
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Affiliation(s)
- Mackenzie C Morris
- Department of Surgery, Section of Transplantation, University of Cincinnati School of Medicine, Cincinnati, OH.,Cincinnati Collaborative for Obesity Research, University of Cincinnati, Cincinnati, OH
| | - Andrew D Jung
- Department of Surgery, Section of Transplantation, University of Cincinnati School of Medicine, Cincinnati, OH.,Cincinnati Collaborative for Obesity Research, University of Cincinnati, Cincinnati, OH
| | - Young Kim
- Department of Surgery, Section of Transplantation, University of Cincinnati School of Medicine, Cincinnati, OH.,Cincinnati Collaborative for Obesity Research, University of Cincinnati, Cincinnati, OH
| | - Tiffany C Lee
- Department of Surgery, Section of Transplantation, University of Cincinnati School of Medicine, Cincinnati, OH.,Cincinnati Collaborative for Obesity Research, University of Cincinnati, Cincinnati, OH
| | - Tiffany E Kaiser
- Department of Surgery, Section of Transplantation, University of Cincinnati School of Medicine, Cincinnati, OH.,Cincinnati Collaborative for Obesity Research, University of Cincinnati, Cincinnati, OH
| | - Jonathan R Thompson
- Department of Surgery, Section of Transplantation, University of Cincinnati School of Medicine, Cincinnati, OH.,Cincinnati Collaborative for Obesity Research, University of Cincinnati, Cincinnati, OH
| | - Khurram Bari
- Cincinnati Collaborative for Obesity Research, University of Cincinnati, Cincinnati, OH.,Department of Internal Medicine, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Shimul A Shah
- Department of Surgery, Section of Transplantation, University of Cincinnati School of Medicine, Cincinnati, OH.,Cincinnati Collaborative for Obesity Research, University of Cincinnati, Cincinnati, OH
| | - Robert M Cohen
- Cincinnati Collaborative for Obesity Research, University of Cincinnati, Cincinnati, OH.,Department of Internal Medicine, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Daniel P Schauer
- Cincinnati Collaborative for Obesity Research, University of Cincinnati, Cincinnati, OH.,Department of Internal Medicine, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Eric P Smith
- Cincinnati Collaborative for Obesity Research, University of Cincinnati, Cincinnati, OH.,Department of Internal Medicine, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Tayyab S Diwan
- Department of Surgery, Section of Transplantation, University of Cincinnati School of Medicine, Cincinnati, OH.,Cincinnati Collaborative for Obesity Research, University of Cincinnati, Cincinnati, OH
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Morris MC, Kim Y, Blakeman TC, Stevens-Topie S, Jung AD, Cox DB, Robinson BBR, Pritts TA, Makley AT, Goodman MD. Early Identification of Acute Lung Injury in a Porcine Model of Hemorrhagic Shock. J Surg Res 2019; 247:453-460. [PMID: 31668606 DOI: 10.1016/j.jss.2019.09.060] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Revised: 08/03/2019] [Accepted: 09/25/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Acute lung injury (ALI) is a frequent complication after severe trauma. Lung-protective ventilation strategies and damage control resuscitation have been proposed for the prevention of ALI; however, there are no clinical or laboratory parameters to predict who is at risk of developing ALI after trauma. In the present study, we explored pulmonary inflammatory markers as a potential predictor of ALI using a porcine model of hemorrhagic shock. MATERIALS AND METHODS Female swine were randomized to mechanical ventilation with low tidal volume (VT) (6 mL/kg) or high VT (12 mL/kg). After equilibration, animals underwent pressure-controlled hemorrhage (mean arterial pressure [MAP] 35 ± 5 mmHg) for 1 h, followed by resuscitation with fresh whole blood or Hextend. They were maintained at MAP of 50 ± 5 mmHg for 3 h in the postresuscitation phase. Bronchoalveolar lavage fluids were collected hourly and analyzed for inflammatory markers. Lung samples were taken, and porcine neutrophil antibody staining was used to evaluate the presence of neutrophils. ELISA evaluated serum porcine surfactant protein D levels. Sham animals were used as negative controls. RESULTS Pigs that underwent hemorrhagic shock had higher heart rates, lower cardiac output, lower MAPs, and worse acidosis compared with sham at the early time points (P < 0.05 each). There were no significant differences in central venous pressure or pulmonary capillary wedge pressure between groups. Pulmonary neutrophil infiltration, as defined by neutrophil antibody staining on lung samples, was greater in the shock groups regardless of resuscitation fluid (P < 0.05 each). Bronchoalveolar lavage fluid neutrophil levels were not different between groups. There were no differences in levels of porcine surfactant protein D between groups at any time points, and the levels did not change over time in each respective group. CONCLUSIONS Our study demonstrates the reproducibility of a porcine model of hemorrhagic shock that is consistent with physiologic changes in humans in hemorrhagic shock. Pulmonary neutrophil infiltration may serve as an early marker for ALI; however, the practicality of this finding has yet to be determined.
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Affiliation(s)
- Mackenzie C Morris
- Department of Surgery, Section of Trauma and Surgical Critical Care, University of Cincinnati, Cincinnati, Ohio
| | - Young Kim
- Department of Surgery, Section of Trauma and Surgical Critical Care, University of Cincinnati, Cincinnati, Ohio
| | - Thomas C Blakeman
- Department of Surgery, Section of Trauma and Surgical Critical Care, University of Cincinnati, Cincinnati, Ohio
| | - Sabre Stevens-Topie
- United States Air Force School of Aerospace Medicine, Aeromedical Research Department, En Route Care Division, Wright Patterson Air Force Base, Dayton, Ohio
| | - Andrew D Jung
- Department of Surgery, Section of Trauma and Surgical Critical Care, University of Cincinnati, Cincinnati, Ohio
| | - Daniel B Cox
- United States Air Force School of Aerospace Medicine, En Route Care Education and Training, Center for Sustainment of Trauma and Readiness Skills, University of Cincinnati, Cincinnati, Ohio
| | | | - Timothy A Pritts
- Department of Surgery, Section of Trauma and Surgical Critical Care, University of Cincinnati, Cincinnati, Ohio
| | - Amy T Makley
- Department of Surgery, Section of Trauma and Surgical Critical Care, University of Cincinnati, Cincinnati, Ohio
| | - Michael D Goodman
- Department of Surgery, Section of Trauma and Surgical Critical Care, University of Cincinnati, Cincinnati, Ohio.
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Levinsky NC, Wima K, Morris MC, Ahmad SA, Shah SA, Starnes SL, Van Haren RM. Outcome of delayed versus timely esophagectomy after chemoradiation for esophageal adenocarcinoma. J Thorac Cardiovasc Surg 2019; 159:2555-2566. [PMID: 31767364 DOI: 10.1016/j.jtcvs.2019.09.169] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 09/13/2019] [Accepted: 09/29/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND Salvage and delayed esophagectomy after chemoradiation therapy (CRT) have been associated with increased morbidity and mortality, but recent series have shown similar outcomes compared to timely esophagectomy. We aim to evaluate outcomes for delayed and salvage esophagectomy for esophageal adenocarcinoma utilizing a large national database. METHODS The National Cancer Database for 2004 to 2014 was queried for patients with clinical stage II or III esophageal adenocarcinoma who underwent preoperative CRT and esophagectomy. Patients who underwent surgery <90 days after CRT were defined as the timely esophagectomy group (n = 7822), and those who underwent surgery ≥90 days after CRT were defined as the delayed esophagectomy group (n = 667). RESULTS A total of 8489 patients met our inclusion criteria. The median post-CRT interval was 49 days (range, 40-61 days) for the timely esophagectomy group and 109 days (range, 97-132 days) for the delayed esophagectomy group. The delayed group was more likely to be of black race (2.3% vs 1.2%; P < .01) and more likely to have Medicare (47.9% vs 39.8%; P < .001). There were no significant between-group differences in chemotherapy regimens (P = .17), radiation dose (P = .18), or surgical approach (P = .48). The delayed esophagectomy group had higher rates of pathological complete response (22.2% vs 18.6%; P = .043) and 90-day postoperative mortality (10.4% vs 7.8%; P < .01). On multivariate analysis, delayed esophagectomy was not independently associated with decreased overall survival. CONCLUSIONS In this large retrospective database study, despite increased perioperative mortality, delayed and salvage esophagectomy for adenocarcinoma appear to have similar long-term survival as timely esophagectomy. Delayed and salvage esophagectomy may be offered to patients who do not receive timely esophagectomy after CRT.
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Affiliation(s)
- Nick C Levinsky
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Koffi Wima
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Mackenzie C Morris
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Syed A Ahmad
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio; Division of Surgical Oncology, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Shimul A Shah
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Sandra L Starnes
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio; Division of Thoracic Surgery, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Robert M Van Haren
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio; Division of Thoracic Surgery, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio.
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Lee TC, Cortez AR, Kassam AF, Morris MC, Winer LK, Shah SA. Outcomes of en Bloc Simultaneous Liver-Kidney Transplantation Compared with the Traditional Technique. J Am Coll Surg 2019. [DOI: 10.1016/j.jamcollsurg.2019.08.628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Lee TC, Kaiser TE, Luckett K, Wima K, Winer LK, Morris MC, Kassam AF, Safdar K, Bari K, Anwar N, Quillin RC, Shah SA. Use, Safety, and Effectiveness of Viremic Hepatitis B Virus Donor Livers: A Potential Opportunity to Expand the Donor Pool. Liver Transpl 2019; 25:1581-1584. [PMID: 31273919 DOI: 10.1002/lt.25595] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 06/18/2019] [Indexed: 02/07/2023]
Affiliation(s)
- Tiffany C Lee
- Cincinnati Research on Outcomes and Safety in Surgery, University of Cincinnati College of Medicine, Cincinnati, OH.,Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Tiffany E Kaiser
- Department of Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Keith Luckett
- Department of Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Koffi Wima
- Cincinnati Research on Outcomes and Safety in Surgery, University of Cincinnati College of Medicine, Cincinnati, OH.,Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Leah K Winer
- Cincinnati Research on Outcomes and Safety in Surgery, University of Cincinnati College of Medicine, Cincinnati, OH.,Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Mackenzie C Morris
- Cincinnati Research on Outcomes and Safety in Surgery, University of Cincinnati College of Medicine, Cincinnati, OH.,Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Al-Faraaz Kassam
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Kamran Safdar
- Department of Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Khurram Bari
- Department of Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Nadeem Anwar
- Department of Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
| | - R Cutler Quillin
- Cincinnati Research on Outcomes and Safety in Surgery, University of Cincinnati College of Medicine, Cincinnati, OH.,Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH.,Division of Transplantation, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Shimul A Shah
- Cincinnati Research on Outcomes and Safety in Surgery, University of Cincinnati College of Medicine, Cincinnati, OH.,Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH.,Division of Transplantation, University of Cincinnati College of Medicine, Cincinnati, OH
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Kim Y, Bailey AJ, Morris MC, Kassam AF, Shah SA, Diwan TS. Kidney transplantation after sleeve gastrectomy in the morbidly obese candidate: results of a 2-year experience. Surg Obes Relat Dis 2019; 16:10-14. [PMID: 31668565 DOI: 10.1016/j.soard.2019.09.069] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 08/24/2019] [Accepted: 09/13/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND Morbid obesity serves as a barrier to kidney transplantation (KT) due to potential suboptimal posttransplant outcomes. Laparoscopic sleeve gastrectomy (LSG) has previously been shown to improve transplant eligibility through weight loss. OBJECTIVES We aimed to examine the role LSG plays in improving patient outcomes postrenal transplantation, including possible impact on new-onset diabetes after transplant (NODAT). SETTING University Hospital. METHODS A single-center analysis was performed identifying all patients who underwent KT after LSG from 2011 to 2017 (n = 41). Exclusion criteria included type I diabetes and previous pancreas transplantation. NODAT was defined as a new insulin requirement after KT. Delayed graft function was defined as need for dialysis within the first week after KT. Mean posttransplant follow-up period was 22 months. RESULTS Forty-one patients underwent KT after LSG after median time of 16 months. Median age of postLSG patients undergoing KT was 56.0 years at time of KT. Average body mass index decreased by 9 from the time of LSG to KT, and no patients regained weight at 1-year follow-up. After LSG, the number of patients with hypertension (85.4% versus 48.5%) and the number of antihypertensive medications used decreased significantly (1.6 versus .6) at time of KT (P < .001 each). At 1-year follow-up, the improvement in hypertension persisted (51.2% versus 48.5%, P = nonsignificant). The average insulin regimen decreased from 33.0 ± 51.6 to 11.7 ± 21.5 units at KT (P < .001). This improvement also persisted at 1-year follow-up (11.9 versus 11.7 units, P = nonsignificant). Zero patients suffered NODAT over the follow-up period (versus institutional rate of NODAT at 15.8%). One patient developed delayed graft function (2.4%, versus institutional rate of 13.3%). After 1 year postKT, there was 1 graft loss (2.4%) and no mortality. CONCLUSION This is the largest reported series of KT after planned LSG in morbidly obese patients. Our results confirm excellent posttransplant outcomes among patients who otherwise would have been denied KT eligibility.
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Affiliation(s)
- Young Kim
- Cincinnati Collaborative for Obesity Research (CCORE), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Amanda J Bailey
- Cincinnati Collaborative for Obesity Research (CCORE), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Mackenzie C Morris
- Cincinnati Collaborative for Obesity Research (CCORE), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Al-Faraaz Kassam
- Cincinnati Collaborative for Obesity Research (CCORE), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Shimul A Shah
- Cincinnati Collaborative for Obesity Research (CCORE), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Tayyab S Diwan
- Cincinnati Collaborative for Obesity Research (CCORE), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio.
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Morris MC, Dhar VK, Stevenson MA, Winer LK, Lee TC, Wang J, Ahmad SA, Patel SH, Sussman JJ, Abbott DE. Adjuvant Hyperthermic Intraperitoneal Chemotherapy (HIPEC) for patients at High-Risk of Peritoneal Metastases. Surg Oncol 2019; 31:33-37. [PMID: 31518971 DOI: 10.1016/j.suronc.2019.09.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 08/01/2019] [Accepted: 09/04/2019] [Indexed: 01/28/2023]
Abstract
BACKGROUND Selection of patients for hyperthermic intraperitoneal chemotherapy (HIPEC) continues to evolve. We hypothesized that adjuvant HIPEC for patients at high-risk of peritoneal progression is safe and associated with favorable outcomes. METHODS The institutional database of a high-volume center was queried for patients with high-risk disease undergoing HIPEC with a peritoneal carcinomatosis index (PCI) of 0. High-risk patients were defined as those with ruptured primary tumors or locally advanced (T4) disease. RESULTS 37 patients underwent adjuvant HIPEC, with a median follow-up of 5.2 years. 54% had low-grade (LG) tumors while 46% had high-grade (HG) tumors. No patients underwent neoadjuvant chemotherapy, while eleven patients (32.4%) received adjuvant chemotherapy. There were no perioperative mortalities, and the overall complication rate was 43%. For the entire cohort, five year recurrence-free survival (RFS) and overall survival (OS) were 77% and 100%, respectively. Five year RFS and OS were 75% and 100% for LG patients and 81% and 100% for HG patients, respectively. CONCLUSIONS Adjuvant HIPEC for patients at high-risk of peritoneal progression, with PCI 0, is safe and associated with favorable long-term survival. Additional prospective investigation is needed to identify patient populations who may benefit most from HIPEC.
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Affiliation(s)
- Mackenzie C Morris
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Vikrom K Dhar
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Megan A Stevenson
- Department of Surgery, University of Louisville School of Medicine, Louisville, KY, USA
| | - Leah K Winer
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Tiffany C Lee
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Jiang Wang
- Department of Pathology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Syed A Ahmad
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Sameer H Patel
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Jeffrey J Sussman
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Daniel E Abbott
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
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Abstract
Surgical management of primary liver and biliary tract tumors has evolved over the past several decades, resulting in improved outcomes in these malignancies with historically poor prognoses. Expansion of patient selection criteria, progress in neoadjuvant and adjuvant therapies, development of techniques to increase future liver remnant, and the select utilization of liver transplantation have all contributed to increasing the patient pool for surgical intervention. Ongoing and future studies need to focus on improving multimodality treatment regimens and further refining the selection criteria for transplantation in order to optimize utilization of limited organ resources.
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Affiliation(s)
- Tiffany C Lee
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way, ML 0558, Cincinnati, OH 45267-0558, USA
| | - Mackenzie C Morris
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way, ML 0558, Cincinnati, OH 45267-0558, USA
| | - Sameer H Patel
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way, ML 0558, Cincinnati, OH 45267-0558, USA
| | - Shimul A Shah
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way, ML 0558, Cincinnati, OH 45267-0558, USA.
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Henri P, Prevel C, Pellerano M, Lacotte J, Stoebner PE, Morris MC, Meunier L. Psoriatic epidermis is associated with upregulation of CDK2 and inhibition of CDK4 activity. Br J Dermatol 2019; 182:678-689. [PMID: 31145809 DOI: 10.1111/bjd.18178] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/27/2019] [Indexed: 01/10/2023]
Abstract
BACKGROUND The cyclin-dependent kinases (CDKs) CDK2 and CDK4 are involved in regulation of cell-cycle progression, and psoriasis is characterized by hyperproliferation of basal epidermal cells. CDK inhibitory proteins (CKIs) such as p16INK 4A (p16) bind CDK4/6 kinases and prevent their interaction with D-type cyclins. CKIs such as p21Cip1 (p21) and p27Kip1 (p27) associate with CDK-cyclin complexes and prevent their activation. OBJECTIVES To gain insight into the molecular implication of CDK2 and CDK4 kinases in psoriasis, we sought to characterize expression of these kinases and associated cyclins, as well as of CKIs, and addressed the status of CDK2 and CDK4 activity in human psoriatic epidermis. METHODS A cohort of 24 patients with psoriasis participated in the study. Biopsies were removed from a chronic plaque and from nonlesional skin. CDK2, CDK4, cyclin D1, cyclin E and CKI protein expression was assessed by immunoblotting, immunohistochemistry and immunofluorescence. CDK4 and CDK2 mRNA expression was determined by real-time polymerase chain reaction. Specific kinase activities of CDK2 and CDK4 were evaluated using fluorescent peptide biosensors. RESULTS CDK2-cyclin E expression and activity were significantly increased in psoriatic epidermis compared with uninvolved adjacent skin. In contrast, CDK4-cyclin D1 activity was inhibited, although its expression was increased in psoriatic epidermis and its transcription slightly inhibited. p27 expression was reduced, while p16 and p21 expression was induced in psoriatic epidermis. CONCLUSIONS Epidermal CDK2 activity is increased in psoriatic epidermis while CDK4 activity is completely inhibited. These alterations are not associated with changes in CDK transcription and instead involve post-translational control mediated by decreased expression of p27 and p16 overexpression, respectively. What's already known about this topic? Cyclin-dependent kinases (CDKs) are involved in cell-cycle progression. The levels of cyclin partners and CDK inhibitors regulate their activity. Psoriasis is a chronic T-cell-driven inflammatory skin disease characterized by hyperproliferation of basal epidermal cells. What does this study add? Thanks to fluorescent peptide biosensors, this study demonstrates that epidermal CDK2 activity is increased in psoriatic epidermis while CDK4 activity is completely inhibited. These alterations involve post-translational control mediated by decreased expression of p27, and p16 overexpression, respectively. What is the translational message? CDK2 and CDK4 are involved in regulation of cell-cycle progression, and psoriasis is characterized by hyperproliferation of basal epidermal cells. Epidermal CDK2 activity is increased in psoriatic epidermis while CDK4 activity is completely inhibited. These alterations are not associated with changes in CDK transcription and instead involve post-translational control mediated by decreased expression of p27 and p16 overexpression, respectively. Pharmacological modulation of CDK2 and CDK4 may constitute a promising therapeutic strategy.
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Affiliation(s)
- P Henri
- Institute of Biomolecules Max Mousseron (IBMM), University of Montpellier, UMR CNRS 5247, Montpellier, France
| | - C Prevel
- Institute of Biomolecules Max Mousseron (IBMM), University of Montpellier, UMR CNRS 5247, Montpellier, France
| | - M Pellerano
- Institute of Biomolecules Max Mousseron (IBMM), University of Montpellier, UMR CNRS 5247, Montpellier, France
| | - J Lacotte
- Department of Dermatology, Caremeau University Hospital, Nîmes, France
| | - P E Stoebner
- Institute of Biomolecules Max Mousseron (IBMM), University of Montpellier, UMR CNRS 5247, Montpellier, France.,Department of Dermatology, Caremeau University Hospital, Nîmes, France
| | - M C Morris
- Institute of Biomolecules Max Mousseron (IBMM), University of Montpellier, UMR CNRS 5247, Montpellier, France
| | - L Meunier
- Institute of Biomolecules Max Mousseron (IBMM), University of Montpellier, UMR CNRS 5247, Montpellier, France.,Department of Dermatology, Caremeau University Hospital, Nîmes, France
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Morris MC, Veile R, Friend LA, Oh D, Pritts TA, Dorlac WC, Spinella PC, Goodman MD. Effects of whole blood leukoreduction on platelet function and hemostatic parameters. Transfus Med 2019; 29:351-357. [PMID: 31382318 DOI: 10.1111/tme.12622] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 07/10/2019] [Accepted: 07/11/2019] [Indexed: 01/04/2023]
Abstract
AIMS/OBJECTIVES The aim of this study was to evaluate the hemostatic consequences of whole blood leukoreduction (LR). BACKGROUND Whole blood is being used for trauma resuscitation in the military, and an increasing number of civilian trauma centres across the nation. The benefits of LR, such as decreased infectious and transfusion-related complications, are well established, but the effects on hemostatic parameters remain a concern. METHODS Twenty-four units of whole blood were assigned to one of the four groups: non-leukoreduced (NLR), leukoreduced at 1 h and a height of 33 in. (LR-1), leukoreduced at 4 h and a height of 33 in. (LR-4(33)), or leukoreduced at 4 h and a height of 28 in. (LR-4(28)). Viscoelastic parameters, platelet aggregation, cell counts, physiological parameters and thrombin potential were evaluated immediately before and after LR, and on days 1, 7, 14 and 21 following LR. RESULTS The viscoelastic parameters and thrombin generation potential were unchanged between the groups. Platelet aggregation was reduced in the LR-1 group compared with NLR after 7 days. The LR-4(28) group also showed a trend of reduced platelet aggregation compared with NLR. Aggregation in LR-4(33) was similar to NLR throughout the storage time. Physiological and electrolyte changes over the whole blood storage period were not affected by LR. CONCLUSION Our study shows that whole blood can be LR at 4 h after collection and a height of 33 in. while maintaining platelet count and without altering platelet function and hemostatic performance.
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Affiliation(s)
- M C Morris
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - R Veile
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - L A Friend
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - D Oh
- Department of Pathology, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Hoxworth Blood Center, Cincinnati, Ohio, USA
| | - T A Pritts
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - W C Dorlac
- Department of Surgery, University of Colorado and UC Health, Ft. Collins, Colorado, USA
| | - P C Spinella
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - M D Goodman
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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Lo W, Morris MC, Ahmad SA, Patel SH. Screening patients at high risk for pancreatic cancer—Is it time for a paradigm shift? J Surg Oncol 2019; 120:851-857. [DOI: 10.1002/jso.25616] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 06/16/2019] [Indexed: 12/19/2022]
Affiliation(s)
- Winifred Lo
- Department of SurgeryUniversity of Cincinnati College of MedicineCincinnati Ohio
| | - Mackenzie C. Morris
- Department of SurgeryUniversity of Cincinnati College of MedicineCincinnati Ohio
| | - Syed A. Ahmad
- Department of SurgeryUniversity of Cincinnati College of MedicineCincinnati Ohio
| | - Sameer H. Patel
- Department of SurgeryUniversity of Cincinnati College of MedicineCincinnati Ohio
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Morris MC, Kassam F, Bercz A, Beckmann N, Schumacher F, Gulbins E, Makley AT, Goodman MD. The Role of Chemoprophylactic Agents in Modulating Platelet Aggregability After Traumatic Brain Injury. J Surg Res 2019; 244:1-8. [PMID: 31279258 DOI: 10.1016/j.jss.2019.06.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 04/22/2019] [Accepted: 06/06/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND The pathophysiology behind the subacute but persistent hypercoagulable state after traumatic brain injury (TBI) is poorly understood but contributes to morbidity induced by venous thromboembolism. Because platelets and their microvesicles have been hypothesized to play a role in post-traumatic hypercoagulability, administration of commonly used agents may ameliorate this coagulability. We hypothesized that utilization of aspirin, ketorolac, amitriptyline, unfractionated heparin, or enoxaparin would modulate the platelet aggregation response after TBI. METHODS Concussive TBI was induced by weight drop. Mice were then randomized to receive aspirin, ketorolac, amitriptyline, heparin, enoxaparin, or saline control at 2 and 8 h after TBI. Mice were sacrificed at 6 or 24 h after injury to determine coagulability by rotational thromboelastometry (ROTEM), platelet function testing with impedance aggregometry, and microvesicle enumeration. Platelet sphingolipid metabolites were analyzed by mass spectrometry. RESULTS ROTEM demonstrated increased platelet contribution to maximum clot firmness at 6 h after TBI in mice that received aspirin or amitriptyline, but this did not persist at 24 h. By contrast, adenosine diphosphate- and arachidonic acid-induced platelet aggregation at 6 h was significantly lower in mice receiving ketorolac, aspirin, and amitriptyline compared with mice receiving saline at 6 h after injury and only arachidonic acid-initiated platelet aggregation was decreased by aspirin at 24 h. There were no differences in microvesicle production at either time point. Platelet sphingosine-1-phosphate levels were decreased at 6 h in the group receiving amitriptyline and increased at 24 h along with platelet ceramide levels at 24 h in the amitriptyline group. CONCLUSION After TBI, amitriptyline decreased platelet aggregability and increased contribution to clot in a manner similar to aspirin. The amitriptyline effects on platelet function and sphingolipid metabolites may represent a possible role of the acid sphingomyelinase in the hypercoagulability observed after injury. In addition, inhibition of platelet reactivity may be an underappreciated benefit of low molecular weight heparins, such as enoxaparin.
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Affiliation(s)
| | - Farzaan Kassam
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Aron Bercz
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Nadine Beckmann
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Fabian Schumacher
- Department of Molecular Biology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany; Institute of Nutritional Science, University of Potsdam, Potsdam, Germany
| | - Erich Gulbins
- Department of Molecular Biology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Amy T Makley
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
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Morris MC, Bercz A, Niziolek GM, Kassam F, Veile R, Friend LA, Pritts TA, Makley AT, Goodman MD. UCH-L1 is a Poor Serum Biomarker of Murine Traumatic Brain Injury After Polytrauma. J Surg Res 2019; 244:63-68. [PMID: 31279265 DOI: 10.1016/j.jss.2019.06.023] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 04/23/2019] [Accepted: 06/06/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Several serum biomarkers have been studied to diagnose incidence and severity of traumatic brain injury (TBI), but a reliable biomarker in TBI has yet to be identified. Ubiquitin carboxy-terminal hydrolase L1 (UCH-L1) has been proposed as a biomarker in clinical and preclinical studies, largely in the setting of isolated TBI or concussion. The aim of this study was to evaluate the performance of UCH-L1 as a serum biomarker in the setting of polytrauma and TBI. METHODS Multiple variations of murine TBI and polytrauma models were used to evaluate serum biomarkers. The different models included TBI with and without hemorrhagic shock and resuscitation, isolated extremity vascular ligation, extremity ischemia/reperfusion, and blunt tail injury. Blood was drawn at intervals after injury, and serum levels of neuron-specific enolase, UCH-L1, creatine kinase, and syndecan-1 were evaluated by enzyme-linked immunosorbent assay. RESULTS UCH-L1 levels were not significantly different between TBI, tail injury, and sham TBI. By contrast, neuron-specific enolase levels were increased in TBI mice compared with tail injury and sham TBI mice. UCH-L1 levels increased regardless of TBI status at 30 min and 4 h after hemorrhagic shock and resuscitation. In mice that underwent femoral artery cannulation followed by hemorrhagic shock/resuscitation, UCH-L1 levels were significantly elevated compared with shock sham mice at 4 h (3158 ± 2168 pg/mL, 4 h shock versus 0 ± 0 pg/mL, 4 h shock sham; P < 0.01) and at 24 h (3253 ± 2954 pg/mL, 24 h shock versus 324 ± 482 pg/mL, 24 h shock sham; P = 0.03). No differences were observed in UCH-L1 levels between the sham shock and the arterial ligation, vein ligation, or extremity ischemia/reperfusion groups at any time point. Similar to UCH-L1, creatine kinase was elevated only after shock compared with sham mice at 4, 24, and 72 h after injury. CONCLUSIONS Our study demonstrates that UCH-L1 is not a specific marker for TBI but is elevated in models that induce central and peripheral nerve ischemia. Given the increase in UCH-L1 levels observed after hemorrhagic shock, we propose that UCH-L1 may be a useful adjunct in quantifying severity of shock or global ischemia rather than as a specific marker of TBI.
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Affiliation(s)
| | - Aron Bercz
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Grace M Niziolek
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Farzaan Kassam
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Rose Veile
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Lou Ann Friend
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Timothy A Pritts
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Amy T Makley
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
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Winer LK, Dhar VK, Wima K, Morris MC, Lee TC, Shah SA, Ahmad SA, Patel SH. The Impact of Tumor Location on Resection and Survival for Pancreatic Ductal Adenocarcinoma. J Surg Res 2019; 239:60-66. [DOI: 10.1016/j.jss.2019.01.061] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 01/16/2019] [Accepted: 01/25/2019] [Indexed: 12/11/2022]
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Dhar VK, Wima K, Lee TC, Morris MC, Winer LK, Ahmad SA, Shah SA, Patel SH. Perioperative blood transfusions following hepatic lobectomy: A national analysis of academic medical centers in the modern era. HPB (Oxford) 2019; 21:748-756. [PMID: 30497896 DOI: 10.1016/j.hpb.2018.10.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2018] [Revised: 10/15/2018] [Accepted: 10/25/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND The purpose of the study was to characterize the prevalence and impact of perioperative blood use for patients undergoing hepatic lobectomy at academic medical centers. METHODS The University HealthSystem Consortium (UHC) database was queried for hepatic lobectomies performed between 2011 and 2014 (n = 6476). Patients were grouped according to transfusion requirements into high (>5 units, 7%), medium (2-5 units, 6%), low (1 unit, 8%), and none (0 units, 79%) during hospital stay for comparison of outcomes. RESULTS Over 20% of patients undergoing hepatic lobectomy received blood perioperatively, of which 35% required more than 5 units. Patients with high transfusion requirements had increased severity of illness (p < 0.01). High transfusion requirements correlated with increased readmission rates (23.4% vs. 19.2% vs. 16.6% vs. 13.5%), total direct costs ($31,982 vs. $20,859 vs. $19,457 vs. $16,934), length of stay (9 days vs. 8 vs. 7 vs. 6), and in-hospital mortality (10.8% vs. 2.0% vs. 0.9% vs. 2.0%) compared to medium, low, and no transfusion amounts (all p < 0.01). Neither center nor surgeon volume were associated with transfusion use. CONCLUSION High transfusion requirements after hepatic lobectomy in the United States are associated with worse perioperative quality measures, but may not be influenced by center or surgeon volume.
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Affiliation(s)
- Vikrom K Dhar
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Koffi Wima
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Tiffany C Lee
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Mackenzie C Morris
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Leah K Winer
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Syed A Ahmad
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Shimul A Shah
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Sameer H Patel
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
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Kim Y, Morris MC, Lee TC, Earnest RE. Surgical management of compound skull fracture with exposed brain matter in a third-world country. J Surg Case Rep 2019; 2019:rjz147. [PMID: 31086656 PMCID: PMC6507808 DOI: 10.1093/jscr/rjz147] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 04/24/2019] [Indexed: 11/17/2022] Open
Abstract
We hereby present a case of a 6-year-old boy with exposed brain matter following traumatic injury from a road traffic accident, in a third-world country with poor healthcare resources. The patient was taken immediately to operating theater where two general surgeons performed an emergent craniotomy and debridement. The patient survived the injury and surgery without neurological deficits or other surgical complications. He was discharged home in good condition.
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Affiliation(s)
- Young Kim
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Mackenzie C Morris
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Tiffany C Lee
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Ryan E Earnest
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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Kim Y, Morris MC, Earnest RE. Surgical management of post-traumatic transvaginal herniation of small intestine in a third-world country. BMJ Case Rep 2019; 12:12/5/e228330. [PMID: 31076491 DOI: 10.1136/bcr-2018-228330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
We present a case of a 26-year-old woman with a small bowel herniating from her vagina following traumatic injury from a road traffic accident. The patient was taken immediately to operating theatre for repair of her uterine defect and small bowel resection. The patient required eventual return to theatre for subtotal hysterectomy and recovered well after her surgeries. She was discharged home without any further complications and in good condition.
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Affiliation(s)
- Young Kim
- Department of Surgery, University of Cincinnati Medical Center, Cincinnati, Ohio, USA
| | - Mackenzie C Morris
- Department of Surgery, University of Cincinnati Medical Center, Cincinnati, Ohio, USA
| | - Ryan E Earnest
- Department of Surgery, University of Cincinnati Medical Center, Cincinnati, Ohio, USA
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Kim Y, Morris MC, Lee TC, Earnest RE. Surgical management of fungating penile mass in a third-world country. J Surg Case Rep 2019; 2019:rjz104. [PMID: 30967937 PMCID: PMC6451178 DOI: 10.1093/jscr/rjz104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 03/19/2019] [Indexed: 11/27/2022] Open
Abstract
We present a 82-year-old man who presented with a 3-week history of a fungating penile mass with urinary leakage. Our objectives are to detail our global health experience providing surgical care in a low-resource, third-world environment.
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Affiliation(s)
- Young Kim
- Global Surgery Program, Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Mackenzie C Morris
- Global Surgery Program, Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Tiffany C Lee
- Global Surgery Program, Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Ryan E Earnest
- Global Surgery Program, Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
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Morris MC, Paquette IM. Laparoscopic left colectomy: surgical technique. Ann Laparosc Endosc Surg 2019. [DOI: 10.21037/ales.2019.01.11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Winer LK, Dhar VK, Wima K, Lee TC, Morris MC, Shah SA, Ahmad SA, Patel SH. Perioperative Net Fluid Balance Predicts Pancreatic Fistula After Pancreaticoduodenectomy. J Gastrointest Surg 2018; 22:1743-1751. [PMID: 29869090 DOI: 10.1007/s11605-018-3813-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Accepted: 05/09/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Our goal was to evaluate the relationship between perioperative fluid administration and the development of clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreaticoduodenectomy (PD). METHODS Retrospectively, we analyzed fluid balance over the first 72 h in 104 consecutive patients who underwent PD between 2013 and 2017. Patients were categorized into tertiles (low, medium, and high) by net fluid balance. RESULTS POPF was identified in 17.3% of patients (n = 18). No significant demographic differences were identified among tertiles. Similarly, there were no differences in ASA, smoking status, hemoglobin A1C, pathologic findings, operative time, blood loss, intraoperative fluid administration, use of pancreatic stents, use of epidurals, or postoperative lactate. Patients with high 72-h net fluid balance had significantly increased rates of POPF compared with those in the medium and low tertiles (31.4% vs. 11.4% vs. 8.8%, p = 0.02). On multivariate analysis, increasing net fluid balance remained associated with CR-POPF (OR 1.26, CI 1.03-1.55, p = 0.03). CONCLUSION High net 72-h fluid balance is an independent predictor of POPF after PD. Given ongoing efforts to minimize PD morbidity, net fluid balance may represent a clinical predictor and, possibly, a modifiable target for prevention of POPF.
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Affiliation(s)
- Leah K Winer
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Vikrom K Dhar
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Koffi Wima
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Tiffany C Lee
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Mackenzie C Morris
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Shimul A Shah
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Syed A Ahmad
- Section of Surgical Oncology, Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way (ML 0558), Cincinnati, OH, 45267-0558, USA
| | - Sameer H Patel
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
- Section of Surgical Oncology, Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way (ML 0558), Cincinnati, OH, 45267-0558, USA.
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Agarwal P, Wang Y, Buchman AS, Holland TM, Bennett DA, Morris MC. MIND Diet Associated with Reduced Incidence and Delayed Progression of ParkinsonismA in Old Age. J Nutr Health Aging 2018; 22:1211-1215. [PMID: 30498828 PMCID: PMC6436549 DOI: 10.1007/s12603-018-1094-5] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND In old age, motor impairments including parkinsonian signs are common, but treatment is lacking for many older adults. In this study, we examined the association of a diet specifically developed to promote brain health, called MIND (Mediterranean-DASH Diet Intervention for Neurodegenerative Delay), to the incidence and progression of parkinsonism in older adults. METHODS A total of 706 Memory and Aging Project participants aged 59 -97 years and without parkinsonism at baseline were assessed annually for the presence of four parkinsonian signs using a 26-item modified version of the United Parkinson's Disease Rating Scale. Incident parkinsonism was defined as the first occurrence over 4.6 years of follow-up of two or more parkinsonian signs. The progression of parkinsonism was assessed by change in a global parkinsonian score (range: 0-100). MIND, Mediterranean, and DASH diet pattern scores were computed based on a validated food frequency questionnaire including 144 food items. We employed Cox-Proportional Hazard models and linear mixed models, to examine the associations of baseline diet scores with incident parkinsonism and the annual rate of change in global parkinsonian score, respectively. RESULTS In models adjusted for age, sex, smoking, total energy intake, BMI and depressive symptoms, higher MIND diet scores were associated with a decreased risk of parkinsonism [(HR=0.89, 95% CI 0.83-0.96)]; and a slower rate of parkinsonism progression [(β= -0.008; SE=0.0037; p=0.04)]. The Mediterranean diet was marginally associated with reduced parkinsonism progression (β= -0.002; SE=0.0014; p=0.06). The DASH diet, by contrast, was not associated with either outcome. CONCLUSION The MIND diet created for brain health may be a associated with decreased risk and slower progression of parkinsonism in older adults.
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Affiliation(s)
- P Agarwal
- Puja Agarwal, Rush University Medical Center, 1645 W Jackson, Chicago, IL, 60612, Phone: 312-563-0151,
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Abstract
OBJECTIVE To examine whether adherence to a Mediterranean-based dietary pattern is predictive of depressive symptoms among older adults. DESIGN Generalized estimating equation models were used to test the association between a Mediterranean-based dietary pattern and depressive symptoms over time. Models were adjusted for age, sex, race, education, income, widowhood, antidepressant use, total calorie intake, body mass index, smoking, alcohol consumption, number of self-reported medical conditions, cognitive function, and physical disability. SETTING Chicago, Illinois. PARTICIPANTS Community-dwelling participants (n=3502) of the Chicago Health and Aging Project aged 65+ years (59% African American) who had no evidence of depression at the baseline. MEASUREMENTS Adherence to a Mediterranean-based dietary pattern was assessed by the MedDietScore. Dietary evaluation was performed with a food frequency questionnaire at baseline and related to incident depression as measured by the presence of four or more depressive symptoms from the 10-item version of the Center for Epidemiologic Studies Depression scale. RESULTS Over an average follow-up of 7.2 years, greater adherence to a Mediterranean-based diet was associated with a reduced number of newly occurring depressive symptoms (parameter estimate = -0.002, standard error = 0.001; p = 0.04). The annual rate of developing depressive symptoms was 98.6% lower among persons in the highest tertile of a Mediterranean-based dietary pattern compared with persons in the lowest tertile group. CONCLUSION Our results support the hypothesis that adherence to a diet comprised of vegetables, fruits, whole grains, fish, and legumes may protect against the development of depressive symptoms in older age.
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Affiliation(s)
- K A Skarupski
- Rush University Medical Center, 1653 West Congress Pkwy, Kidston Building, Suite 606 Chicago, IL 60612, USA.
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Tangney CC, Aggarwal NT, Li H, Wilson RS, Decarli C, Evans DA, Morris MC. Vitamin B12, cognition, and brain MRI measures: a cross-sectional examination. Neurology 2011; 77:1276-82. [PMID: 21947532 DOI: 10.1212/wnl.0b013e3182315a33] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To investigate the interrelations of serum vitamin B12 markers with brain volumes, cerebral infarcts, and performance in different cognitive domains in a biracial population sample cross-sectionally. METHODS In 121 community-dwelling participants of the Chicago Health and Aging Project, serum markers of vitamin B12 status were related to summary measures of neuropsychological tests of 5 cognitive domains and brain MRI measures obtained on average 4.6 years later among 121 older adults. RESULTS Concentrations of all vitamin B12-related markers, but not serum vitamin B12 itself, were associated with global cognitive function and with total brain volume. Methylmalonate levels were associated with poorer episodic memory and perceptual speed, and cystathionine and 2-methylcitrate with poorer episodic and semantic memory. Homocysteine concentrations were associated with decreased total brain volume. The homocysteine-global cognition effect was modified and no longer statistically significant with adjustment for white matter volume or cerebral infarcts. The methylmalonate-global cognition effect was modified and no longer significant with adjustment for total brain volume. CONCLUSIONS Methylmalonate, a specific marker of B12 deficiency, may affect cognition by reducing total brain volume whereas the effect of homocysteine (nonspecific to vitamin B12 deficiency) on cognitive performance may be mediated through increased white matter hyperintensity and cerebral infarcts. Vitamin B12 status may affect the brain through multiple mechanisms.
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Affiliation(s)
- C C Tangney
- Department of Clinical Nutrition 425 TOB, Rush University Medical Center, 1700 West Van Buren St., Chicago, IL 60612, USA.
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Yannam GR, Gutti TL, High R, Stevens RB, Thompson JS, Morris MC. Experience of laparoscopic incisional hernia repair in kidney and/or pancreas transplant recipients. Am J Transplant 2011; 11:279-86. [PMID: 21272235 DOI: 10.1111/j.1600-6143.2010.03351.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Despite the wide popularity of laparoscopic incisional hernia repair (LIHR) in the nontransplant population, there are very few reports of LIHR available in abdominal organ transplant patients and none exclusively on kidney and/or pancreas (KP) transplant patients. We retrospectively reviewed a consecutive series of LIHR in KP transplant recipients performed over a period of 4 years and compared the results with LIHR in non-transplant patients during the same period. A total of 36 transplant patients were compared with 62 nontransplant patients. There were five patients converted to the open procedure in the transplant and four in nontransplant patients (p-NS). There were three seromas and one patient had a bowel perforation in the transplant group versus eight seromas, one bowel perforation and one small bowel obstruction noted in the nontransplant group. One patient in each group had a mesh infection requiring explant. Patients were followed up for a mean period of 2.2 years in the transplant group and 3 years in the nontransplant group. Overall there were five recurrences in the transplant group and four in the nontransplant group (p = NS). These results suggest that that LIHR is a safe and effective alternative to open repair.
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Affiliation(s)
- G R Yannam
- Transplant Surgery Division Department of Pharmacology Department of Public Health and Statistics Department of General Surgery, University of Nebraska Medical Center, Omaha, NE, USA
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McMillin DR, Morris MC. Further perspectives on the charge transfer transitions of blue copper proteins and the ligand moieties in stellacyanin. Proc Natl Acad Sci U S A 2010; 78:6567-70. [PMID: 16593109 PMCID: PMC349088 DOI: 10.1073/pnas.78.11.6567] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
The charge transfer spectra of plastocyanin and azurin are analyzed in detail, taking into account the structural information that is available. The number and relative energies of the low-lying charge transfer bands attributable to cysteine and methionine sulfur are considered with reference to the energy levels associated with the donor centers and to experimental work on relevant complexes. Two cysteine --> Cu(II) charge transfer transitions are assigned to bands that occur near 620 nm and near 770 nm. Energy considerations suggest that the methionine --> Cu(II) transition occurs in the vicinity of 550 nm for both plastocyanin and azurin. The existence of a disulfide linkage in stellacyanin is established by thiol titrations, and the possibility exists that the fourth ligand in stellacyanin may involve disulfide sulfur. If so, the cystine --> Cu(II) transition is also expected to appear around 550 nm.
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Affiliation(s)
- D R McMillin
- Department of Chemistry, Purdue University, West Lafayette, Indiana 47907
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