Predictability of Magnetic Sphincter Augmentation Device Explantation: A Nomogram-based Scoring Tool from an Experienced Quaternary Center

BACKGROUND

Magnetic sphincter augmentation (MSA) explantation is an uncommon occurrence, and there are limited studies characterizing factors predictive for explanation. The aim of this study was to create a nomogram to aid in determining the probability of explantation in patients before undergoing MSA implantation.

METHODS

An institutional review board-approved, prospectively maintained database was retrospectively reviewed for all patients undergoing anti-reflux surgery between February 2015 and May 2023. All patients who underwent MSA-related procedures were included. Patients were divided into two groups, explant group and non-explant group, and differences were analyzed. A multivariable logistic regression model was fitted to identify independent risk factors for predicting MSA explantation, and a nomogram-based scoring tool was developed.

RESULTS

There were 227 patients (134 females; 93 males) with a mean age of 51.4 years. The explant group included 28 patients (12.3%), whereas the non-explant group included 199 patients (87.7%). Patient sociodemographic characteristics, medical comorbidities, preoperative testing results, and surgical history were included in our analysis. The multivariable regression model resulted in 4 significant variables that were included in the nomogram. These included preoperative DeMeester score, preoperative gastroesophageal reflux disease health-related quality of life (GERD-HRQL) score, preoperative distal contractile integral (DCI) value on manometry, and body mass index (BMI). Based on these variables, a scoring nomogram was developed with values from 0 to 18.

CONCLUSION

Our data was used to develop a scoring calculator capable of predicting the probability of MSA explantation. This scoring tool can guide preoperative patient selection and treatment decisions.

The use of poly-4-hydroxybutyrate (P4HB, Phasix™) mesh in ventral hernia repair: a systematic review and meta-analysis

PURPOSE/BACKGROUND

Despite the growing use of bioabsorbable mesh in ventral hernia repairs (VHR), the evidence of its impact on patient outcomes remains limited. This study aims to investigate the efficacy and safety profile of poly-4-hydroxybutyrate (P4HB) mesh for ventral hernia repair through a systematic review and meta-analysis.

METHODS

A literature search of five databases (PubMed, Embase, Ovid, Medline, and Google Scholar) produced a list of publications that analyzed the use of P4HB mesh in ventral hernia repair in both clean and contaminated cases. The primary postoperative outcomes of hernia recurrence, surgical site infections (SSI), and any complications were analyzed through a pooled meta-analysis.

RESULTS

In our systematic review, 21 studies met the inclusion criteria with a total of 1858 patients (933 males and 925 females) and an average age of 56.8 years. The median follow-up ranged from 1.6 to 62.3 months. In our meta-analysis, the use of P4HB mesh in VHR in proportion of events demonstrated a recurrence rate of 9% [6%; 15%], SSI of 10% [6%; 16%] and 35% [9%; 42%] for rate of any complications. Sub-meta-analysis restricted to studies with follow up > 18 months continues to show low rates of recurrence of 9% (95%CI, 4-17%), SSI of 9% (95%CI, 4-16%), and 31% (95%CI, 23-41%) for any complications.

CONCLUSION

Our study demonstrates that the use of P4HB mesh is both safe and effective in ventral hernia repairs. When further analyzed past 18 months, the time where P4HB mesh fully resorbs, the rates of hernia recurrence, SSI, and any complications remain low of upwards of 5 years and comparable to the rates seen in synthetic and biologics in similar patient populations.

Achieving fascial closure with preoperative botulinum toxin injections in abdominal wall reconstruction: outcomes from a high-volume center

Preoperative injection of Botulinum Toxin A (Botox) has been described as an adjunctive therapy to facilitate fascial closure of large hernia defects in abdominal wall reconstruction (AWR). The purpose of this study was to evaluate the impact of Botox injections on fascial closure and overall outcomes to further validate its role in AWR. A prospectively maintained database was retrospectively reviewed to identify all patients undergoing AWR at our institution between January 2014 and March 2022. Patients who did and did not receive preoperative Botox injections were analyzed and compared. A total of 426 patients were included (Botox 76, NBotox 350). The Botox group had significantly larger hernia defects (90 cm2 vs 9 cm2, p < 0.01) and a higher rate of component separations performed (60.5% vs 14.4%, p < 0.01). Despite this large difference in hernia defect size, primary fascial closure rates were similar between the groups (p = 0.49). Notably, the Botox group had higher rates of surgical-site infections (SSIs)/surgical-site occurrences (SSOs) (p < 0.01). Following propensity score matching to control for multiple patient factors including age, sex, diabetes, chronic obstructive pulmonary disease (COPD), and hernia size, the Botox group still had a higher rate of component separations (50% vs 26.3%, p = 0.03) and higher incidence of SSIs/SSOs (39.5% vs 13.5%, p = 0.01). Multimodal therapy with Botox injections and component separations can help achieve fascial closure of large defects during AWR. However, adding these combined therapies may increase the occurrence of postoperative SSIs/SSOs.

The impact of COVID-19 on surgical cases at a large quaternary referral hospital

Introduction

Coronavirus-19 (COVID) stressed healthcare systems by increasing hospital admissions and in-hospital mortality. The impact of COVID on surgical patients is unknown. The purpose of this study was to evaluate how the COVID pandemic affected surgical patients at a large quaternary referral hospital.

Methods

A retrospective review of patients undergoing surgical procedures was performed to evaluate patients undergoing surgery. The impact of COVID on surgical patients was divided into four timeframes based on government regulations: pre-COVID (January 1, 2020 to March 15, 2020), suspended (March 16, 2020 to May 4, 2020), backlogged cases (May 5, 2020 to June 14, 2020), and restoration (June 15, 2020 to September 30, 2020). Differences between patient characteristics and outcomes during these timeframes were evaluated.

Results

A total of 21,424 surgical cases were performed between January 1, 2020 and September 30, 2020. During the suspended timeframe (when all elective cases were cancelled), the percentage of surgeries increased in men (53.8% compared to 49.2% pre-COVID; P < 0.01), in Black and Hispanic patients (23.1% and 15.3%, respectively; P < 0.05), and in Medicaid and self-pay patients (16.3% compared to 9.9% pre-COVID; P < 0.01). All service lines experienced similar trends in overall case volume except obstetrics (constant), trauma, vascular, and thoracic (which increased during the suspended timeframe).

Conclusions

COVID-19 induced stresses in surgical patients, altering payor mix and impacting minority groups at a large quaternary referral hospital.

Per-oral endoscopic myotomy is a safe and effective treatment for Zenker's diverticulum: a retrospective multicenter study

Zenker per-oral endoscopic myotomy (ZPOEM) has become a promising technique for Zenker's diverticulum (ZD). The aim of this study was to add to the limited body of literature evaluating the safety and efficacy of ZPOEM. A prospectively maintained database was retrospectively reviewed to identify patients who underwent ZPOEM at two separate institutions between January 2020 and January 2022. Demographics, preoperative and postoperative clinical data, intraoperative data, adverse events, and length of stay were analyzed. A total of 40 patients (mean age 72.5 years, 62.5% male) were included. Average operative time was 54.7 minutes and average length of stay was 1.1 days. There were three adverse events, and only one was related to the technical aspects of the procedure. Patients showed improvement in the Functional Oral Intake Scale (FOIS) scores at 1 month (5 vs 7, p < 0.0001). The median FOIS scores remained 7 at both 6 and 12 months, although this improvement was not statistically significant at these time intervals (p = 0.46 and 0.37, respectively). Median dysphagia scores were decreased at 1 (2.5 vs 0, p < 0.0001), 6 (2.5 vs 0, p < 0.0001), and 12 months (2.5 vs 0, p = 0.016). The number of patients reporting ≥1 symptom was also decreased at 1 (40 vs 9, p < 0.0001) and 6 months (40 vs 1, p = 0.041). Although the number of patients reporting ≥1 symptom remained consistent at 12 months, this was not statistically significant (40 vs 1, p = 0.13). ZPOEM is a safe and highly effective treatment for the management of ZD. .

Gastric per-oral endoscopic myotomy versus pyloric injection of botulinum toxin for the treatment of gastroparesis: our institutional experience and a systematic review of the literature

INTRODUCTION

Gastric Per-Oral Endoscopic Myotomy (GPOEM) has been developed as an effective treatment option for patients with medically refractory gastroparesis. Other endoscopic options, such as pyloric injection of botulinum toxin (Botox), is often performed with limited efficacy. The purpose of this study was to evaluate GPOEM for the treatment of gastroparesis and compare its efficacy to Botox injection results reported in the literature.

METHODS

A retrospective review was conducted to identify all patients who underwent a GPOEM for the treatment of gastroparesis between September 2018 and June 2022. Changes in Gastric Emptying Scintigraphy (GES) studies and Gastroparesis Cardinal Symptom (GCSI) scores from the preoperative to postoperative period were analyzed. In addition, a systematic review was conducted to identify all publications reporting the outcomes of Botox injections for the treatment of gastroparesis.

RESULTS

A total of 65 patients (51 female, 14 male) underwent a GPOEM during the study period. Twenty-eight patients (22 female, 6 male) had both preoperative and postoperative GES studies in addition to GCSI scores. The etiologies of gastroparesis were diabetic (n = 4), idiopathic (n = 18), and postsurgical (n = 6). Fifty percent of these patients had undergone previous failed interventions including Botox injections (n = 6), gastric stimulator placement (n = 2), and endoscopic pyloric dilation (n = 6). Outcomes showed a significant decrease in GES percentages (mean difference = - 23.5%, p < 0.001) and GCSI scores (mean difference = - 9.6, p = 0.02) postoperatively. In the systematic review for Botox, transient mean improvements in postoperative GES percentages and GCSI scores were reported at 10.1% and 4.0, respectively.

CONCLUSION

GPOEM leads to significant improvement in GES percentages and GCSI scores postoperatively and is superior to Botox injection results reported in the literature.

Modern approaches to treating Zenker's diverticulum

PURPOSE OF REVIEW

Zenker's diverticulum is the most common hypopharyngeal diverticulum. Patients with Zenker's diverticulum may require surgical treatment, which can be performed via an open surgical or endoscopic approach. A new endoscopic technique that is now being used for Zenker's diverticulum is Zenker Per Oral Endoscopic Myotomy (ZPOEM). ZPOEM has demonstrated promising results, and may have certain advantages over the other endoscopic treatments. The purpose of this review article is to evaluate the various surgical and endoscopic treatment options for Zenker's diverticulum, while specifically focusing on ZPOEM.

RECENT FINDINGS

Endoscopic approaches have become the first-line therapy for Zenker's diverticulum, replacing the traditional open approach, because of the less invasive nature of the endoscopic procedures, improved rates of morbidity, and quicker recovery times. Recent studies evaluating ZPOEM have demonstrated that it is technically feasible and highly efficacious. In addition, it has a low rate of clinical recurrence and adverse events. When compared with other endoscopic techniques for treating Zenker's diverticulum, ZPOEM appears to have improved outcomes.

SUMMARY

ZPOEM has been recently implemented in the algorithm of Zenker's diverticulum management. Further comparative and prospective studies focusing on long-term follow-up are still needed; however, ZPOEM appears to be an excellent option for patients suffering from Zenker's diverticulum.

Enhanced Recovery After Surgery Protocol in Bariatric Surgery Leads to Decreased Complications and Shorter Length of Stay

PURPOSE

Enhanced recovery after surgery (ERAS) programs have been shown in some specialties to improve short-term outcomes following surgical procedures. There is no consensus regarding the optimal perioperative care for bariatric surgical patients. The purpose of this study was to develop a bariatric ERAS protocol and determine whether it improved outcomes following surgery.

MATERIALS AND METHODS

An IRB-approved prospectively maintained database was retrospectively reviewed for all patients undergoing bariatric surgery from October 2018 to January 2020. Propensity matching was used to compare post-ERAS implementation patients to pre-ERAS implementation.

RESULTS

There were 319 patients (87 ERAS, 232 pre-ERAS) who underwent bariatric operations between October 2018 and January 2020. Seventy-nine patients were kept on the ERAS protocol whereas 8 deviated. Patients who deviated from the ERAS protocol had a longer length of stay when compared to patients who completed the protocol. The use of any ERAS protocol (completed or deviated) reduced the odds of complications by 54% and decreased length of stay by 15%. Furthermore, patients who completed the ERAS protocol had an 83% reduction in odds of complications and 31% decrease in length of stay. Similar trends were observed in the matched cohort with 74% reduction in odds of complications and 26% reduction in length of stay when ERAS was used.

CONCLUSIONS

ERAS protocol decreases complications and reduces length of stay in bariatric patients.

Probability of additional intervention and long-term follow-up of esophagomyotomy

INTRODUCTION

Two common surgical procedures used to treat esophageal motility disorders are laparoscopic Heller myotomy (LHM) with partial fundoplication and per-oral endoscopic myotomy (POEM). The difference in frequency of follow-up interventions following these procedures is unknown. This study was designed to report differences in post-surgical interventions as one of the major long-term follow-up expectations.

METHODS

An IRB approved registry was used to identify all patients undergoing surgery with LHM or POEM. Following surgery, patients requiring additional interventions with esophageal non-pneumatic dilation, botox injection, or repeat myotomy, as well as persistent proton pump inhibitor (PPI) use were recorded. Multivariable logistic regression analysis was performed to estimate risk factors associated with return for additional post-operative intervention.

RESULTS

A total of 203 patients were identified, 139 met inclusion criteria (33 LHM and 106 POEM). There was a higher rate of non-pneumatic EGD dilation (33% vs 15%, p = 0.04), repeat myotomy (18% vs 2%, p < 0.01), and higher rate of overall post-operative intervention in LHM than POEM. With POEM, there was a higher rate of post-operative PPI use (63 vs 29%, p < 0.01). There was no difference in time to post-operative intervention for either group, but if intervention were to occur the median time was within the first year. Patients with a change in pre- to post-operative Eckardt score of 4 or greater decreased their chance of having a post-operative intervention.

CONCLUSION

Our results for both LHM and POEM emphasize the importance of long-term follow-up in patients with an esophageal motility disorder. We have found that patients undergoing LHM are more likely to have a post-operative intervention as well as a higher rate of repeat myotomy than POEM. With both interventions, a greater change in Eckardt score decreased the likelihood of reintervention.

Enhanced recovery after surgery (ERAS) decreases complications and reduces length of stay in foregut surgery patients

INTRODUCTION

Enhanced recovery after surgery (ERAS) programs provide a framework for optimal perioperative care to improve post-operative outcomes following surgical procedures. However, there is no consensus regarding an ERAS protocol following foregut surgery. The purpose of this study was to develop an ERAS protocol for these patients and determine whether they improved outcomes.

METHODS

An IRB approved prospectively maintained database was retrospectively reviewed for all patients undergoing benign minimally invasive foregut surgery from October 2018 to January 2020. All patients were entered into the ACS risk calculator to determine their predicted rate of complications and length of stay for comparison between the ERAS and control groups. Propensity matching was used to compare post-ERAS implementation to pre-ERAS implementation patients. Firth logistic and Poisson regression analysis were used to assess the rate of complications and length of stay among the different groups of patients.

RESULTS

There were 255 patients (60 Post-ERAS, 195 Pre-ERAS) who underwent foregut operations and met inclusion criteria. ERAS was implemented, and patients were then subdivided based on those who completed ERAS (44) and those who deviated from the protocol (16). Propensity matching analysis was performed to compare the different cohorts and showed ERAS patients had 41% decreased odds of complications and 33% reduction in length of stay compared to pre-ERAS patients. Completion of the ERAS protocol resulted in even further reductions in odds of complication and length of stay compared to patients who deviated from the protocol.

CONCLUSIONS

ERAS has shown to improve perioperative outcomes, but there is limited literature supporting the use of ERAS in foregut surgery. Usage of an ERAS protocol can decrease complications and reduce the length of stay in patients.

Predictability of Endoscopic Success for Foregut and Bariatric Leak in an Experienced Quaternary Center

BACKGROUND

Leaks of the esophagus and stomach are difficult to manage and associated with significant morbidity and mortality. Endoscopic therapy can manage these leaks without surgical intervention. Our goal is to create a scoring tool to aid in predicting the success of endoscopic therapy in these patients.

STUDY DESIGN

An IRB-approved prospectively maintained database was retrospectively reviewed for all patients treated for gastrointestinal leaks from July 2013 to January 2021, including patients treated for esophageal and stomach leaks. Endpoints include success of leak closure for patients treated solely by endoscopic therapy (ET) compared with surgical therapy as failed endoscopic therapy (FET). A multivariable logistic regression model was fitted to identify independent risk factors for predicting success of endoscopic therapy, and a scoring calculator was developed.

RESULTS

There were 80 patients (60 females) with a mean age of 50 years. The ET group included 59 patients (74%), whereas the FET group included 21 patients (26%). Patient demographics, comorbidities, surgical history, and timing of leak diagnosis were used. Multivariable analysis resulted in 4 variables associated with higher probability of successful endoscopic leak management without need for additional surgery. These included increased age, lower BMI, lack of previous bariatric surgery, and quicker identification of the leak. Consequently, a scoring nomogram was developed with values from 0 to 22.

CONCLUSION

Our data show the development of a scoring calculator capable of quantifying the likelihood of success treating foregut and bariatric leaks with endoscopic therapies. This can be used clinically to guide treatment decisions.

Spastic secondary contractile patterns identified by FLIP panometry in symptomatic patients with unremarkable high-resolution manometry

BACKGROUND

Functional lumen imaging probe (FLIP) panometry can show spastic secondary contractile patterns of unclear significance in symptomatic patients who have no esophageal obstructive disorders, and no motility disorders on high-resolution manometry (HRM).

METHODS

We retrospectively analyzed non-obstructed, symptomatic patients with HRM findings of no motility disorder or ineffective esophageal motility (IEM) for whom spastic secondary contractile patterns identified by FLIP panometry were used to guide treatment. Symptoms were scored using the Brief Esophageal Dysphagia Questionnaire (BEDQ).

KEY RESULTS

We identified ten symptomatic patients treated at our medical center who met inclusion criteria (seven women; mean age 56 years; eight no motility disorder, two IEM). On FLIP panometry, seven had spastic secondary contractions at 60 ml, two at 40 ml, and one at both 40 ml and 60 ml balloon volumes. Eight patients (80%) had improvement in BEDQ scores with therapies that targeted the spastic secondary contractile patterns identified by FLIP (five botulinum toxin injection, two Esoflip dilation, and one Heller myotomy). Interestingly, review of HRM tracings revealed that all patients had a novel HRM finding of mid-vertical pressurization in at least 20% swallows, with seven exhibiting this finding in >50% of swallows.

CONCLUSIONS

This case series demonstrates that treatments targeting spastic secondary contractions identified by FLIP panometry can result in symptomatic improvement in patients with no obstructive disorder and no diagnostic motility disorder on HRM. In such patients, we have identified the novel HRM finding of mid-vertical pressurization, which might be the manometric manifestation of spasm limited to the mid-esophagus.

Overall Complications Following Robotic Heller Myotomy Are Lower Compared With Laparoscopy

BACKGROUND

The use of robotics in foregut surgery has become more prevalent in the United States over the last 10 years. We sought to find the differences in the clinical outcomes of robotic surgery compared with traditional laparoscopy in patients undergoing Heller myotomy.

MATERIALS AND METHODS

A retrospective population-based analysis was performed using the National Inpatient Sample (NIS) database for the span of 2010 to 2015. All patients who underwent laparoscopic or robotic Heller myotomy were included. Weighted multivariable random intercept linear and logistic regression models were used to assess the impact of robotic surgery on patient outcomes compared with laparoscopy.

RESULTS

There was a total of 11,562 patients with a median age of 54.2 years. Robotic Heller myotomy has a significantly decreased risk of overall complications for all centers (odds ratio=0.46; 95% confidence interval=0.29, 0.74). A subset analysis was performed looking specifically at high-volume centers (>20 operations per year), and overall complications remained lower in the robotic group. However, in high-volume centers, the robotic cohort did have a higher rate of esophageal perforation (2.7% vs. 0.8%, P<0.001). There was a higher length of stay in the laparoscopic Heller cohort (3.0 vs. 2.6 d, P=0.06) but higher overall charges in the robotic Heller cohort ($42,900 vs. $34,300, P=0.03).

CONCLUSIONS

Robotic Heller myotomy is associated with lower overall complications and improved outcomes compared with laparoscopic Heller myotomy, even in high-volume centers. Robotic Heller myotomy is associated with a higher rate of esophageal perforations in high-volume centers despite the reduction in overall complications.

Laparoscopic repair of large diaphragmatic hernia after left ventricular assist device implantation followed by orthotopic heart transplantation

In patients with advanced heart failure and deteriorating clinical status, a left ventricular assist device (LVAD) can be used as a bridge to transplantation or as an alternative to transplantation. An uncommon complication of orthotopic heart transplant or LVADs is diaphragmatic hernia during implantation or explantation of the device. We describe a patient with a diaphragmatic hernia with incarcerated colon and small bowel treated previously with a HeartMate 3 LVAD and subsequent transplantation. This case highlights the need to consider the diagnosis of diaphragmatic hernia based on symptoms after HeartMate 3 implantation and/or subsequent transplantation, as well as the ability to manage these hernias with a minimally invasive laparoscopic approach to minimize postoperative morbidity and mortality.

Family History of GERD Does Not Predict Anti-Reflux Surgery Outcomes

Background and Objectives:

Gastroesophageal reflux disease is a common disease and there is little known about the role family history plays in its disease process and incidence. Our study was designed to compare the patients with first degree relatives with and without the disease and see if there was any difference in patients needing antireflux surgery, the outcomes after antireflux surgery, and whether they needed redo surgery.

Methods:

An institutional review board approved registry for patients undergoing antireflux surgery at a single institution was used. Patients were asked specific questions about their family history of gastroesophageal reflux disease at their pre-operative visit. Patients with a family history and those without were compared.

Results:

There was no statistical difference between the patients with family history of gastroesophageal reflux disease for likelihood to undergo surgery, outcomes from surgery, or the need for redo surgery. There were more females than males in the study and there were more patients with a positive family history in the study than those without.

Conclusion:

Since there is no impact of family history of gastroesophageal reflux disease on antireflux surgery, patients can be counseled that their decision to undergo antireflux surgery is independent from the response of their first degree relatives.

Mind the Gap: Current Treatment Alternatives for GERD Patients Failing Medical Treatment and Not Ready for a Fundoplication

BACKGROUND

Gastroesophageal reflux disease is associated with Barrett esophagus, esophageal adenocarcinoma, and significantly impacts quality of life. Medical management is the first line therapy with surgical fundoplication as an alternative therapy. However, a small portion of patients who fail medical therapy are referred for surgical consultation. This creates a "gap" in therapy for those patients dissatisfied with medical therapy but are not getting referred for surgical consultation. Three procedures have been designed to address these patients. These include radiofrequency ablation (RFA) of the lower esophageal sphincter, transoral incisionless fundoplication (TIF), and magnetic sphincter augmentation.

MATERIALS AND METHODS

A Pubmed literature review was conducted of all publications for RFA, TIF, and MSA. Four most common endpoints for the 3 procedures were compared at different intervals of follow-up. These include percent of patients off proton pump inhibitors (PPIs), GERD-HRQL score, DeMeester score, and percent of time with pH <4. A second query was performed for patients treated with PPI and fundoplications to match the same 4 endpoints as a control.

RESULTS

Variable freedom from PPI was reported at 1 year for RFA with a weighted mean of 62%, TIF with a weighted mean of 61%, MSA with a weighted mean of 85%, and fundoplications with a weighted mean of 84%. All procedures including PPIs improved quality-of-life scores but were not equal. Fundoplication had the best improvement followed by MSA, TIF, RFA, and PPI, respectively. DeMeester scores are variable after all procedures and PPIs. All MSA studies showed normalization of pH, whereas only 4 of 17 RFA studies and 3 of 11 TIF studies reported normalization of pH.

CONCLUSIONS

Our literature review compares 3 rival procedures to treat "gap" patients for gastroesophageal reflux disease with 4 common endpoints. Magnetic sphincter augmentation appears to have the most reproducible and linear outcomes but is the most invasive of the 3 procedures. MSA outcomes most closely mirrors that of fundoplication.

Comparison of Objective Intermediate-Term Outcomes Between per-Oral Endoscopic Myotomy and Laparoscopic Heller Myotomy Show Equivalence

INTRODUCTION

The surgical gold standard for esophageal motility disorders is laparoscopic Heller myotomy (LHM). Per-oral endoscopic myotomy (POEM) is a less invasive flexible endoscopic alternative. We compare their intermediate-term outcomes.

METHODS

Data were collected on consecutive LHM and POEM patients treated for esophageal motility disorders from January 2015 to December 2019. All patients were invited for a comprehensive workup between 6 and 12 months post-myotomy including symptom evaluation, pH testing off medications, manometry, and esophagogastroduodenoscopy (EGD). Primary outcomes include swallowing function and development of postoperative gastroesophageal reflux disease (GERD).

RESULTS

There were 100 patients (46 LHM and 54 POEM). Patient demographics and presenting symptoms were comparable. Follow-up data were obtained from 49% of patients. Average length of follow-up for all patients was 10 months. Mean Eckardt scores for LHM decreased from 6.6 to 2.4 (P < .05) and from 7.06 to 2.2 for POEM (P < .05). Mean integrated relaxation pressure decreased from 22.8 preoperatively to 11 postoperatively in LHM patients and from 24.6 to 11.5 in POEM patients. POEM patients had a lower incidence of objective postoperative GERD with lower average DeMeester scores (20 vs 29.4) and a higher percentage of patients with a normal DeMeester score (47% vs 31%) compared to LHM patients. However, postoperative GERD health related quality of life scores (11.7 vs 14.1), the percent of patients on proton pump inhibitors (PPIs) (40% vs 53%), and frequency of grade C/D esophagitis (4.3% vs 5.6%) were lower in LHM patients.

CONCLUSIONS

Intermediate-term symptom resolution and esophageal physiology are improved equally with both procedures. The development of postoperative GERD is equivalent.

Hiatal hernia repair and magnetic sphincter augmentation to treat laryngopharyngeal reflux aiding the prevention of recurrent laryngeal cancer

Laryngopharyngeal reflux (LPR) is a difficult disease to treat and can result in mucosal injury in the pharynx and larynx. This typically results in symptoms such as cough, hoarseness, and globus sensation, but the manifestation of cancer is a possibility. We present a patient with a squamous cell cancer of the larynx who was diagnosed with gastroesophageal reflux disease (GERD) and found to have LPR. The cancer was treated locally and GERD was eradicated with magnetic sphincter augmentation. After 15 months of follow-up, there was no residual cancer. This case highlights the role that untreated LPR may play in patients' risk of developing laryngeal cancer.

Endoscopic sleeve gastroplasty requiring emergent partial gastrectomy

Bariatric surgery has become an accepted and effective treatment for morbid obesity. Laparoscopic sleeve gastrectomy is the most common weight loss procedure, in which patients on average lose 60% of their excess body weight. Recently, a completely endoscopic approach was developed that takes advantage of an endoscopic suturing device to plicate the greater curvature of the stomach into sleeve-like anatomy. The endoscopic sleeve gastroplasty has been shown to be safe with minimal complications and good weight loss outcomes. We present a case of a rare and dangerous complication of endoscopic sleeve gastroplasty that required emergent surgical intervention.

Laparoscopic versus open unisegmentectomy in two specialized centers. Feasibility and short-term results

BACKGROUND

Anatomical segmentectomy is defined as the complete removal of the Couinaud's segment. The aim of this study was to compare the perioperative outcomes of laparoscopic (LS) versus open (OS) unisegmentectomy in two high volume centers.

METHODS

A retrospective review of all consecutive unisegmentectomies from 2007 to 2017 was performed at the Institut Mutualiste Montsouris and at the Hepatobiliary Center of Paul Brousse Hospital.

RESULTS

A total of 177 patients underwent unisegmentectomy: 58 LS vs 52 OS in the anterolateral segments, 33 LS vs 34 OS in the posterosuperior segments. HCC were more frequent in the OS group, whereas colorectal liver metastases were more frequently treated with LS. Blood loss (200 vs. 400 ml, p = 0.006), operative time (238 vs. 267 min, p = 0.048) and median length of stay (6 vs. 8 days, p = 0.036) were significantly lower in the LS group. The resection margins (4 mm vs. 2 mm, p = 0.763) and the overall morbidity did not differ between the two groups. In the posterosuperior segment, OS group had more pulmonary complications (9 vs. 29%, p = 0.035).

CONCLUSION

Laparoscopic anatomical unisegmentectomies for selected patients, even with postero-superior based tumors, in specialized centers seems to be safe and feasible.

Zenker's diverticulum treated via per-oral endoscopic myotomy

Zenker's diverticulum (ZD) is a rare disorder of the esophagus that occurs in approximately 0.1% of the population. Recently, new minimally invasive techniques have been used to treat ZD. Similar to a per-oral endoscopic myotomy (POEM) for achalasia, ZD can be treated using an endoscopic myotomy with a standard endoscope. This technique offers the benefit of a purely endoscopic procedure without the added morbidity associated with the traditional open technique. This is a description of the first per-oral endoscopic myotomy for Zenker's diverticulum (Z-POEM) performed at Baylor University Medical Center at Dallas.

Gastroparesis managed with peroral endoscopic pyloromyotomy

Gastroparesis is delayed gastric emptying in the absence of mechanical obstruction. Cases are attributed to narcotic use, smoking, diabetes, and postsurgical complications; however, several incidences are unknown. Treatment options include diet modification, gut-stimulating medications (e.g., metoclopramide, domperidone), laparoscopic pyloroplasty, and, in the most severe cases, partial gastrectomy with Roux-en-Y reconstruction. Recently, a novel therapy has been developed, peroral endoscopic pyloromyotomy (POP). This procedure is similar to a laparoscopic pyloroplasty; however, it is performed completely endoscopically, thus negating the need for incisions. Here we present a case of gastroparesis treated with this novel technique.

Minimally invasive repair of a lumbar hernia utilizing the subcutaneous space only

Lumbar hernias are from weakened areas in the posterior lateral abdominal wall. Minimally invasive techniques are recommended for nonmidline abdominal wall hernias. Endoscopic methods utilizing the subcutaneous space only are rarely reported. A 66-year-old man presented with abdominal pain and a computed tomography (CT) scan revealing a lumbar hernia. The procedure was done utilizing the subcutaneous space to open the hernia sac and repair the defect in layers. A sublay mesh and an onlay mesh were used within the subcutaneous pocket. The patient had an uneventful postoperative course and was discharged home. A subsequent CT scan showed that the completed repair remained intact. Few endoscopic lumbar hernia repairs are reported despite the advantageous aspects of the procedure in avoiding the peritoneal cavity and the retroperitoneum.

Endoscopic submucosal dissection of a gastric mass

This case report describes the first endoscopic submucosal dissection performed at Baylor University Medical Center for high-grade dysplasia of the stomach. The patient, a 76-year-old man with multiple medical comorbidities, presented with 4 months of abdominal pain. Endoscopy found a mass on the lesser curvature, and endoscopic ultrasound confirmed that it did not invade the submucosa. A complete endoscopic resection was performed, alleviating the need for surgical intervention. Endoscopic submucosal dissection offers a minimally invasive treatment for premalignant lesions and early stage cancers of the stomach. Endoscopic resection is as effective as gastrectomy, with less morbidity in select patients with early stage lesions.

Endoluminal Vacuum Therapy: How I Do It

Perforations and leaks of the gastrointestinal tract are difficult to manage and are associated with high morbidity and mortality. Recently, endoscopic approaches have been applied with varying degrees of success. Most recently, the use of endoluminal vacuum therapy has been used with high success rates in decreasing both morbidity and mortality. Under an IRB-approved prospective registry that we started in July 2013, we have been using endoluminal vacuum therapy to treat a variety of leaks throughout the GI tract. The procedure uses an endosponge connected to a nasogastric tube that is endoscopically guided into a fistula cavity in order to facilitate healing, obtain source control, and aid in reperfusion of the adjacent tissue with debridement. Endoluminal vacuum therapy has been used on all patients in the registry. Overall success rate for healing the leak or fistula is 95% in the esophagus, 83% in the stomach, 100% in the small bowel, and 60% of colorectal cases. The purpose of this report is to review the history of endoluminal wound vacuum therapy, identify appropriate patient selection criteria, and highlight "pearls" of the procedure. This article is written in the context of our own clinical experience, with a primary focus on a "How I Do It" technical description.

Segment 7 Laparoscopic Liver Resection: Is It Possible to Resect When Metastatic Lesions Border Suprahepatic Veins?

INTRODUCTION

After nearly 25 years of experience, laparoscopic liver resection (LLR) is now recognized as being feasible and safe.1 However, laparoscopic resections of the posterosuperior segments are more technically demanding. They are associated with higher conversions rates, more intraoperative bleeding, and increased operating time.2 Appropriate training is required to approach these resections safely.3 This video demonstrates the technical maneuvers to laparoscopically approach a segment 7 tumor in contact with the right supra hepatic vein.

METHOD

The pertinent aspect to perform a segment 7 metastasis resection using minimally invasive techniques is shown. The main steps of this operation include (1) complete release of the right liver from the coronary and triangular ligament, (2) dissection of the retrohepatic vena cava and transection of the hepatocaval ligament, (3) the use of intercostal trocars for direct vision of the inferior vena cava and the right suprahepatic vein,4,5 (4) the use of intraoperative ultrasound to evaluate the position and limits of vascular structures compared to the lesion, (5) careful transection of the hepatic parenchyma, and (6) dissection of the right hepatic vein to separate it from the lesion.

RESULTS

The surgery was performed in a 68-year-old male patient. The patient developed synchronous metastases to the liver from a sigmoid colon tumor. Two lesions were identified; a 15 mm subcapsular lesion located in segment 5 and a 45 mm lesion located in segment 7 in contact with the right hepatic vein and inferior vena cava confluence. Previously, laparoscopic sigmoidectomy was performed without complications (TNM classification of the specimen: T3N0, with 31 resected lymph nodes, KRAS gene mutated). Following chemotherapy with FOLFOX + bevacizumab, a good response to the liver lesion was noted on imaging. Subsequently, a laparoscopic resection of the metastases in segment 7 and 5 was performed. The surgery lasted 210 min, intraoperative blood loss was 200 cm³, no Pringle maneuver was required, and the postoperative period was uneventful with the patient being discharged on postoperative day number four. Pathology of the liver specimens confirmed metastases from colon adenocarcinoma with free surgical margins.

DISCUSSION

Some important points achieving easier and safer approach of the posterior segments of the liver by laparoscopic route should be discussed. First, the patient's semi-lateral position showed in the video allows placing the ports and the optic in a more comfortable position since the lateral portion of the abdominal and thoracic wall becomes anterior. Another important point is the complete liberation of the hepatorenal, falciform, triangular, and right coronary ligaments in order to fully mobilize the liver and convert a segment that is posterior in the anatomical position to an anterior segment for the surgeon. And finally, the use of intercostal trocars that allows a direct and perpendicular view of the right hepatic vein and vena cava represents the most important point. Interestingly, these specific trocars should be inserted through the pleural cavity, during a forced expiration or apnea to avoid lung injury. In this context, the trocar balloon helps the surgeon to avoid displacement or that pneumoperitoneum enters the pleural cavity. At the end of the procedure, we strongly recommend to stitch laparoscopically these diaphragmatic openings after removing the trocars in order to avoid migration of abdominal fluid or bowel incarceration into the pleural cavity during the postoperative period and also to avoid future diaphragmatic hernia. In the present case, the parenchymal transection was performed with Thunderbeat (Olympus®, Japan), a device integrating both ultrasound dissection and advanced bipolar energy. We use this device because it saves time by sealing vessels up to 7 mm in diameter avoiding the need to use clips in the majority of intrahepatic veins and portal branches. However, currently, several techniques and devices are equivalent for parenchymal transection in laparoscopic liver resection and should be left to the surgeon's preference, as in open liver procedures.

CONCLUSION

Using laparoscopy to remove lesions in the posterior segments of the liver is safe and feasible. Vision from transthoracic port has the added benefit of making the dissection of right hepatic vein and inferior vena cava safer. Mastery of the anatomy is paramount before attempting this approach with minimally invasive techniques. Surgeons who attempt this operation should have expertise with both laparoscopy and liver surgery.

Real-world evidence analysis of palbociclib prescribing patterns for patients with advanced/metastatic breast cancer treated in community oncology practice in the USA one year post approval

Background

Rapidly evolving understanding of cancer biology has presented novel opportunities to translate that understanding into clinically relevant therapy. Palbociclib, a novel, first-in-class cyclin-dependent kinase (CDK) 4/6 inhibitor was approved in the USA in February 2015 for the treatment of advanced/metastatic breast cancer. We examined real-world evidence in the first year post approval to understand the clinical and demographic characteristics of patients treated with palbociclib in community oncology practices and the dosing, treatment, and complete blood count (CBC) monitoring patterns.

Methods

This was a retrospective observational study of structured data from a US electronic medical record (EMR) database. Female patients receiving palbociclib after 31 January 2015 were followed through 31 March 2016. Our methodological rules were constructed to aggregate drugs received according to the order in which they are given, i.e., identify the line of therapy as first, second, or third line, etc., using treatment order and course description fields from the EMR.

Results

There were 763 patients initiating palbociclib who met the selection criteria. Of those, 612 (80.2%) received palbociclib concomitantly with letrozole. Mean follow up was 6.4 months and mean age at palbociclib initiation was 64 years. Of patients with a known starting dose (n = 417), 79.9% started on palbociclib 125 mg. Dose reductions were observed in 20.1% of patients. Percentages of patients according to line of therapy at initiation of palbociclib were first-line, 39.5%; second-line, 15.7%; third-line, 13.1%; and fourth-line therapy or later, 31.7%. On average, two CBC tests were conducted during the first cycle of palbociclib treatment. Overall, 74.6% of patients had a neutropenic event during follow up including 47.3% and 8.0% of patients with a grade 3 or 4 occurrence, respectively.

Conclusions

Real-world palbociclib use one year post US approval demonstrates a more heterogeneous patient population than that studied in the clinical trials with more than half of the patients receiving palbociclib plus letrozole in later lines of therapy. CBC testing rates suggested good provider compliance with monitoring guidelines in the USA prescribing information. The occurrence of grade 3 and 4 neutropenia (based on laboratory results) was consistent with the rates of grade 3 and 4 neutropenia in two phase-III studies (PALOMA-2, 56% and 10%; PALOMA-3, 55% and 11%, respectively). Understanding palbociclib utilization in real-world patients and how drug dosing and monitoring are performed aids in the understanding of safe and effective use of the drug.

Electronic supplementary material

The online version of this article (10.1186/s13058-018-0958-2) contains supplementary material, which is available to authorized users.

Endoscopic resection of giant fibrovascular esophageal polyps

BACKGROUND

Giant fibrovascular esophageal polyps are rare benign intraluminal tumors that originate from the submucosa of the cervical esophagus [Owens et al. (JAMA 103: 838-842, 1994), Totten et al. (JAMA 25:606-622, 1953)]. Due to their indolent course, these tumors tend to reach enormous proportions before patients develop symptoms. Accurately diagnosing these tumors is difficult, as endoscopy may miss 25% of these lesions because these polyps exhibit normal intact esophageal mucosa [Levine et al. (JAMA 166: 781-787, 1996)].

METHODS

Surgical resection has been the treatment of choice. We present a video that illustrates the feasibility of an endoscopic approach.

TECHNIQUE/CASE

A 62-year-old man presented to our clinic with a pedunculated esophageal mass. During this time, he developed progressive dysphagia to solid foods. A complete workup confirmed the presence of a giant polyp and endoscopic resection under general anesthesia was planned. Using an endoscopic snare-technique, a 16 cm × 3 cm polyp was amputated and retracted out of the oropharynx. Upon repeat endoscopy a second 7 cm × 3 cm polyp was discovered originating proximal to the larger polyp. Again, removal of this polyp was attempted using a snare-technique. Following amputation of the polyp, a broad-based component of the polyp remained. Given its proximal location in the esophagus, we were able to use a snare to pull the broad base of the remaining polyp into the oropharynx and remove it at its origin. Postoperative endoscopy and endoscopic ultrasound confirmed that the polyps were completely removed and the muscular resection bed was hemostatic. Clinically, the patient's symptoms resolved and he encountered no adverse sequela as a result of the operation.

CONCLUSION

Giant fibrovascular esophageal polyps are rare benign intraluminal tumors that can lead to obstructive symptoms. Surgical resection is the treatment of choice, and may be possible with an endoscopic approach. An endoscopic snare technique can be used to resect these lesions while minimizing patient morbidity.

Abstract P6-16-05: Early utilization pattern of palbociclib 1 year post-approval in the United States

Background

Palbociclib was approved in the U.S. in February 2015 for the treatment of advanced/metastatic breast cancer (MBC) in combination with letrozole as initial endocrine based therapy for post-menopausal women with ER+/HER2- disease. We examined the demographic, clinical characteristics and treatment patterns of patients initiating palbociclib (PAL) + letrozole (LET) in real-world, community oncology practices.

Methods

This was a retrospective observational study of female breast cancer patients identified in the Navigating Cancer (NC) EMR database. The NC database collects EMR data, in both structured and unstructured fields (patient/clinical progress notes), from over 975 oncology and hematology providers across more than 50 locations in 25 states. Female patients with record of treatment with PAL after 01/31/2015 were selected. Combination treatment with LET was defined as having a record for LET within 30 days of the PAL prescription. Line of therapy (LOT) was assessed from the date of metastatic diagnosis and assigned by evaluating treatment plans pre-and post PAL initiation. Bi-monthly cohorts were constructed based on the month of initiation of PAL from 02/01/2015-01/31/2016. Interim results are presented; data from an additional three months of follow-up (through 03/31/2016) are pending.

Results

Overall, 931 unique patients were identified as having initiated PAL treatment. Of those, 608 (65.3%) received PAL + LET. Mean follow-up was relatively short at 5.4 mo (SD=3.5). Confirmed ER+/HER2- was observed in 71.6% of patients and 50.3% were age ≥65, mean age was 64.3 yrs. Of patients with available ECOG-PS at treatment initiation (n=424): 0/1=78.5%, 2=17.5% and 3=4.0%. Of patients with a known starting dose (n=418), 69.9% initiated with PAL 125mg, 22.0% at 100mg and 8.1% at 75mg. Compared to women &lt; 65, women ≥ 65 were more often started with 100mg (25.4% vs. 18.9%) and 75mg (10.0% vs 6.5%). Any dose reductions were observed in 20.6% of patients (21.5% of patients receiving 125mg). During the year following approval, 39.8% of patients initiated PAL + LET at LOT1, 15.6% at LOT2, 13.0% at LOT3 and 31.6% at LOT4+, following MBC diagnosis. Over time the proportion of late use (LOT4+) declined from 39.7% in Feb/Mar '15 to 23.9% in Dec '15/Jan '16 with more patients utilizing in LOT3 (from 7.9% in Feb/Mar '15 to 19.5% in Dec '15/Jan '16).

Number of Patients Initiating PAL + LET by LOT and Month. AllFeb/Mar '15Apr/May '15Jun/Jul '15Aug/Sep '15Oct/Nov '15Dec'15/Jan '16N (%)608(100)63(10.4)108(17.8)125(20.6)108(17.8)91(14.5)113(18.6)LOT1 (%)242(39.8)23(36.5)45(41.7)53(42.4)45(41.7)33(36.3)43(38.1)LOT2 (%)95(15.6)10(15.9)12(11.1)19(15.2)15(13.9)18(19.8)21(18.6)LOT3 (%)79(13.0)5(7.9)10(9.3)18(14.4)12(11.1)12(13.2)22(19.5)LOT4+ (%)192(31.6)25(39.7)41(38.0)35(28.0)36(33.3)28(30.8)27(23.9)

Conclusions

There was a trend toward earlier utilization of PAL + LET from Feb-Jul '15, an increase in later use during Aug/Sep '15, and a return towards earlier use in subsequent cohorts reaching the lowest proportion of LOT 4+ use observed in Dec '15/Jan '16. After a mean follow-up of 5.4 mo, 21.5% of patients receiving the 125 mg dose had a dose reduction. Final results, with additional follow-up, will be presented at conference.

Citation Format: Kish JK, Ward MA, Garofalo D, Ahmed HV, McRoy L, Laney J, Zanotti G, Yu H-T, Feinberg BA. Early utilization pattern of palbociclib 1 year post-approval in the United States [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P6-16-05.

Insights into the pathogenesis of ulcerative colitis from a murine model of stasis-induced dysbiosis, colonic metaplasia, and genetic susceptibility

Gut dysbiosis, host genetics, and environmental triggers are implicated as causative factors in inflammatory bowel disease (IBD), yet mechanistic insights are lacking. Longitudinal analysis of ulcerative colitis (UC) patients following total colectomy with ileal anal anastomosis (IPAA) where >50% develop pouchitis offers a unique setting to examine cause vs. effect. To recapitulate human IPAA, we employed a mouse model of surgically created blind self-filling (SFL) and self-emptying (SEL) ileal loops using wild-type (WT), IL-10 knockout (KO) (IL-10), TLR4 KO (T4), and IL-10/T4 double KO mice. After 5 wk, loop histology, host gene/protein expression, and bacterial 16s rRNA profiles were examined. SFL exhibit fecal stasis due to directional motility oriented toward the loop end, whereas SEL remain empty. In WT mice, SFL, but not SEL, develop pouchlike microbial communities without accompanying active inflammation. However, in genetically susceptible IL-10-deficient mice, SFL, but not SEL, exhibit severe inflammation and mucosal transcriptomes resembling human pouchitis. The inflammation associated with IL-10 required TLR4, as animals lacking both pathways displayed little disease. Furthermore, germ-free IL-10 mice conventionalized with SFL, but not SEL, microbiota populations develop severe colitis. These data support essential roles of stasis-induced, colon-like microbiota, TLR4-mediated colonic metaplasia, and genetic susceptibility in the development of pouchitis and possibly UC. However, these factors by themselves are not sufficient. Similarities between this model and human UC/pouchitis provide opportunities for gaining insights into the mechanistic basis of IBD and for identification of targets for novel preventative and therapeutic interventions.

Increasing testicular temperature by exposure to elevated ambient temperatures restores spermatogenesis in adult Utp14b (jsd) mutant (jsd) mice

Because mutations in the human UTP14C gene are associated with male infertility, we sought to develop a method for fertility restoration in azoospermic mice with a mutation in the orthologous Utp14b(jsd) (jsd) gene that have spermatogonial arrest. The method is based on our observation that elevation of testicular temperatures restores spermatogonial differentiation in jsd mutant mice. To non-surgically raise intrascrotal temperatures we placed these mice in incubators at different elevated ambient temperatures. Exposure of jsd/jsd mice to ambient temperatures of 34.5 °C or 35.5 °C for 24 days increased the proportion of tubules with spermatocytes from 0% in untreated controls to over 80%. As those higher temperatures interfere with spermatid differentiation, the mice were then transferred to incubators at 32-32.5 °C for the next 24 days. These environments allowed differentiation to progress, resulting in up to 42% of tubules having late spermatids and about half of the mutant mice having spermatozoa in testicular suspensions. When these spermatozoa were used in intracytoplasmic sperm injection, all gave rise to viable healthy offspring with normal weight gain and fertility. The successful restoration of fertility in Utp14b mutant mice suggests that transient testicular warming might also be useful for spermatogenesis recovery in infertile men with UTP14C gene mutations.

Association between osteoporosis treatment change and adherence, incident fracture, and total healthcare costs in a Medicare Advantage Prescription Drug plan

We examined the association between osteoporosis treatment change and adherence, incident fractures, and healthcare costs among Medicare Advantage Prescription Drug (MAPD) plan members. Treatment change was associated with a small but significant increase in adherence, but was not associated with incident fracture or total healthcare costs. Overall adherence remained low.

INTRODUCTION

We examined the association between osteoporosis treatment change and adherence, incident fractures, and healthcare costs among MAPD plan members in a large US health plan.

METHODS

We conducted a retrospective cohort study of MAPD plan members aged≥50 years newly initiated on an osteoporosis medication between 1 January 2006 and 31 December 2008. Members were identified as having or not having an osteoporosis treatment change within 12 months after initiating osteoporosis medication. Logistic regression analyses and difference-in-difference (DID) generalized linear models were used to investigate the association between osteoporosis treatment change and (1) adherence to treatment, (2) incident fracture, and (3) healthcare costs at 12 and 24 months follow-up.

RESULTS

Of the 33,823 members newly initiated on osteoporosis treatment, 3,573 (10.6%) changed osteoporosis treatment within 12 months. After controlling for covariates, osteoporosis treatment change was associated with significantly higher odds of being adherent (medication possession ratio [MPR]≥0.8) at 12 months (odds ratio [OR]=1.18) and 24 months (OR=1.13) follow-up. However, overall adherence remained low (MPR=0.59 and 0.51 for the change cohort and MPR=0.51 and 0.44 for the no-change cohort at 12 and 24 months, respectively). Osteoporosis treatment change was not significantly associated with incident fracture (OR=1.00 at 12 months and OR=0.98 at 24 months) or total direct healthcare costs (p>0.4) in the DID analysis, but was associated with higher pharmacy costs (p<0.004).

CONCLUSIONS

Osteoporosis treatment change was associated with a small but significant increase in adherence, but was not associated with incident fracture or total healthcare costs in the MAPD plan population. Overall adherence to therapy remained low.

Upregulation of Ugt1a genes in placentas and fetal livers in a murine model of assisted reproduction

Genes from Ugt1a family in placenta and fetal liver are responsible for hormone, nutrient and chemical balance during pregnancy. Assisted reproduction technologies (ART) i.e. intracytoplasmic sperm injection (ICSI) and in vitro fertilization (IVF) alter steroid homeostasis in pregnancy through increased glucuronidation. Here we show that ART (particularly ICSI) upregulates Ugt1a1, 1a2, 1a6 and 1a9 expression in murine placentas and fetal livers with higher mRNA related to lower progesterone (1a1) and cholesterol (1a2, 1a6) in placentas. Greater steroid clearance in ART through transcriptional upregulation of Ugt1a in the placental-fetal unit may decrease the availability of essential molecules, mediating negative reproductive outcomes.

Placental inflammation and oxidative stress in the mouse model of assisted reproduction

Higher rates of low birth weight and prematurity are observed in pregnancies generated with assisted reproduction technologies (ART). Both conditions have been associated with placental inflammation and oxidative stress. Since placental and fetal levels of progesterone, a major anti-inflammatory steroid, are decreased in murine ART, we investigated placental inflammation and oxidative stress in this model as potential mediators of negative birth outcomes. After generating mouse pregnancies by in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) we evaluated the antioxidant defense network and major inflammatory cytokines in maternal, placental and fetal tissues. Additionally, placentas were analyzed for total lipid levels, fibrosis, apoptosis, reactive oxygen species and integrity of intracellular nucleotides. Placentas from ART contained significantly less lipids, with greater levels of apoptosis and degraded nucleotides. Placentas from ICSI pregnancies had lower activities of superoxide dismutase (SOD), thioredoxin reductase (TrxR), xanthine oxidase (XO), catalase, glutathione-S-transferase (GST) glutathione peroxidase, and glutathione reductase (GR). Furthermore, GR, GST and SOD were also lower in fetal livers from ICSI pregnancies. Placentas from IVF pregnancies had decreased levels of SOD, TrxR and XO only. In placentas from both ICSI and IVF pregnancies IL-6 levels were significantly increased. These data suggest that ART is associated with placental inflammation (IL-6), oxidative stress and apoptosis but not fibrosis or remodeling. These effects are markedly greater with the ICSI technique. Since ICSI is ubiquitous, oxidative stress and placental inflammation associated with this method may be a critical factor in negative birth outcomes such as prematurity and low birth weight.

Indication of electron neutrino appearance from an accelerator-produced off-axis muon neutrino beam

The T2K experiment observes indications of ν(μ) → ν(e) appearance in data accumulated with 1.43×10(20) protons on target. Six events pass all selection criteria at the far detector. In a three-flavor neutrino oscillation scenario with |Δm(23)(2)| = 2.4×10(-3)  eV(2), sin(2)2θ(23) = 1 and sin(2)2θ(13) = 0, the expected number of such events is 1.5±0.3(syst). Under this hypothesis, the probability to observe six or more candidate events is 7×10(-3), equivalent to 2.5σ significance. At 90% C.L., the data are consistent with 0.03(0.04) < sin(2)2θ(13) < 0.28(0.34) for δ(CP) = 0 and a normal (inverted) hierarchy.

Effects of selenium supply and dietary restriction on maternal and fetal body weight, visceral organ mass and cellularity estimates, and jejunal vascularity in pregnant ewe lambs1

To examine effects of nutrient restriction and dietary Se on maternal and fetal visceral tissues, 36 pregnant Targhee-cross ewe lambs were allotted randomly to 1 of 4 treatments in a 2 x 2 factorial arrangement. Treatments were plane of nutrition [control, 100% of requirements vs. restricted, 60% of controls] and dietary Se [adequate Se, ASe (6 microg/kg of BW) vs. high Se, HSe (80 microg/kg of BW)] from Se-enriched yeast. Selenium treatments were initiated 21 d before breeding and dietary restriction began on d 64 of gestation. Diets contained 16% CP and 2.12 Mcal/kg of ME (DM basis) and differing amounts were fed to control and restricted groups. On d 135 +/- 5 (mean +/- range) of gestation, ewes were slaughtered and visceral tissues were harvested. There was a nutrition x Se interaction (P = 0.02) for maternal jejunal RNA:DNA; no other interactions were detected for maternal measurements. Maternal BW, stomach complex, small intestine, large intestine, liver, and kidney mass were less (P < or = 0.01) in restricted than control ewes. Lung mass (g/kg of empty BW) was greater (P = 0.09) in restricted than control ewes and for HSe compared with ASe ewes. Maternal jejunal protein content and protein:DNA were less (P < or = 0.002) in restricted than control ewes. Maternal jejunal DNA and RNA concentrations and total proliferating jejunal cells were not affected (P > or = 0.11) by treatment. Total jejunal and mucosal vascularity (mL) were less (P < or = 0.01) in restricted than control ewes. Fetuses from restricted ewes had less BW (P = 0.06), empty carcass weight (P = 0.06), crown-rump length (P = 0.03), liver (P = 0.01), pancreas (P = 0.07), perirenal fat (P = 0.02), small intestine (P = 0.007), and spleen weights (P = 0.03) compared with controls. Fetuses from HSe ewes had heavier (P < or = 0.09) BW, and empty carcass, heart, lung, spleen, total viscera, and large intestine weights compared with ASe ewes. Nutrient restriction resulted in less protein content (mg, P = 0.01) and protein:DNA (P = 0.06) in fetal jejunum. Fetal muscle DNA (nutrition by Se interaction, P = 0.04) concentration was greater (P < 0.05) in restricted ewes fed HSe compared with other treatments. Fetal muscle RNA concentration (P = 0.01) and heart RNA content (P = 0.04) were greater in HSe vs. ASe ewes. These data indicate that maternal dietary Se may alter fetal responses, as noted by greater fetal heart, lung, spleen, and BW.

Effects of concentrated separator by-product (desugared molasses) on intake, ruminal fermentation, digestion, and microbial efficiency in beef steers fed grass hay

Concentrated separator by-product (CSB) is produced when beet molasses goes through an industrial desugaring process. To investigate the nutritional value of CSB as a supplement for grass hay diets (12.5% CP; DM basis), 4 ruminally and duodenally cannulated beef steers (332 +/- 2.3 kg) were used in a 4 x 4 Latin square with a 2 x 2 factorial arrangement of treatments. Factors were intake level: ad libitum (AL) vs. restricted (RE; 1.25% of BW, DM basis) and dietary CSB addition (0 vs. 10%; DM basis). Experimental periods were 21 d in length, with the last 7 d used for collections. By design, intakes of both DM and OM (g/kg of BW) were greater (P < 0.01; 18.8 vs. 13.1 +/- 0.69 and 16.8 vs. 11.7 +/- 0.62, respectively) for animals consuming AL compared with RE diets. Main effect means for intake were not affected by CSB (P = 0.59). However, within AL-fed steers, CSB tended (P = 0.12) to improve DMI (6,018 vs. 6,585 +/- 185 g for 0 and 10% CSB, respectively). Feeding CSB resulted in similar total tract DM and OM digestion compared with controls (P = 0.50 and 0.87, respectively). There were no effects of CSB on apparent total tract NDF (P = 0.27) or ADF (P = 0.35) digestion; however, apparent N absorption increased (P = 0.10) with CSB addition. Total tract NDF, ADF, or N digestion coefficients were not different between AL- and RE-fed steers. Nitrogen intake (P = 0.02), total duodenal N flow (P = 0.02), and feed N escaping to the small intestine (P = 0.02) were increased with CSB addition. Microbial efficiency was unaffected by treatment (P = 0.17). Supplementation with CSB increased the rate of DM disappearance (P = 0.001; 4.9 vs. 6.9 +/- 0.33 %/h). Restricted intake increased the rate of in situ DM disappearance (P = 0.03; 6.4 vs. 5.3 +/- 0.33 %/h) compared with AL-fed steers. Ruminal DM fill was greater (P = 0.01) in AL compared with RE. Total VFA concentrations were greater (P = 0.04) for CSB compared with controls; however, ammonia concentrations were reduced (P = 0.03) with CSB addition. At different levels of dietary intake, supplementing medium-quality forage with 10% CSB increased N intake, small intestinal protein supply, and total ruminal VFA.

Increasing voluntary HIV testing by offering oral tests in incarcerated populations

OBJECTIVES

This study reports responses of incarcerated persons to voluntary blood and oral HIV testing.

METHODS

Males and females in local detention and juvenile justice facilities in Maryland (n = 1314) chose oral or blood testing and reported reactions to the oral HIV test. The relationship of demographics and HIV risk factors to test choice was examined.

RESULTS

Reactions to oral testing were very favorable; some participants reported that they would not otherwise have been tested. Participants who chose oral testing were more likely to be male and African American, but they did not differ from those who chose blood testing in most risk factors or in seroprevalence.

CONCLUSIONS

Oral HIV testing in correctional settings may promote voluntary testing among persons who otherwise would refuse or avoid testing, especially among groups (males and African Americans) disproportionately affected by HIV.

Visual Rehabilitation With Contact Lenses After Laser in situ Keratomileusis

PURPOSE

Laser in situ keratomileusis (LASIK) has become the surgical treatment of choice for moderate myopia and is in widespread use globally. Visual potential is sometimes limited due to irregular corneal topography following surgery.

METHODS

A retrospective chart review of 35 eyes of 22 patients requiring visual rehabilitation following LASIK was performed. Four contact lens designs were used and evaluated for appropriate cornea-contact lens fitting relationship.

RESULTS

Mean best contact lens-corrected visual acuity of 20/25 was significantly better than best spectacle-corrected visual acuity of 20/40. The average time from surgery to contact lens fitting was 8 months, with almost half (10/22) being fitted at 4 months. An aspheric design with 0.17 mm of axial edge lift was used most commonly. Lens diameters ranged from 9.2 to 10.9 mm, with a mean diameter of 10.2 mm. The contact lens base curve to cornea relationship would suggest an initial base curve selection to be approximately 2.1 D steeper than the mean postoperative keratometric power.

CONCLUSIONS

Rigid gas permeable contact lenses can improve visual function in patients with irregular corneal topography after LASIK.

Proteomics characterization of abundant Golgi membrane proteins

A mass spectrometric analysis of proteins partitioning into Triton X-114 from purified hepatic Golgi apparatus (84% purity by morphometry, 122-fold enrichment over the homogenate for the Golgi marker galactosyl transferase) led to the unambiguous identification of 81 proteins including a novel Golgi-associated protein of 34 kDa (GPP34). The membrane protein complement was resolved by SDS-polyacrylamide gel electrophoresis and subjected to a hierarchical approach using delayed extraction matrix-assisted laser desorption ionization mass spectrometry characterization by peptide mass fingerprinting, tandem mass spectrometry to generate sequence tags, and Edman sequencing of proteins. Major membrane proteins corresponded to known Golgi residents, a Golgi lectin, anterograde cargo, and an abundance of trafficking proteins including KDEL receptors, p24 family members, SNAREs, Rabs, a single ARF-guanine nucleotide exchange factor, and two SCAMPs. Analytical fractionation and gold immunolabeling of proteins in the purified Golgi fraction were used to assess the intra-Golgi and total cellular distribution of GPP34, two SNAREs, SCAMPs, and the trafficking proteins GBF1, BAP31, and alpha(2)P24 identified by the proteomics approach as well as the endoplasmic reticulum contaminant calnexin. Although GPP34 has never previously been identified as a protein, the localization of GPP34 to the Golgi complex, the conservation of GPP34 from yeast to humans, and the cytosolically exposed location of GPP34 predict a role for a novel coat protein in Golgi trafficking.

LY393615, a novel neuronal Ca(2+) and Na(+) channel blocker with neuroprotective effects in models of in vitro and in vivo cerebral ischemia

In the present studies we have examined the effects of a new calcium channel blocker, LY393615 ((N-Butyl-[5,5-bis-(4-fluorophenyl)tetrahydrofuran-2-yl]methylamine hydrochloride, NCC1048) in a model of hypoxia-hypoglycaemia in vitro and in a gerbil model of global and in two rat models of focal cerebral ischaemia in vivo. Results indicated that LY393615 protected against hypoxia-hypoglycaemic insults in brain slices and also provided significant protection against ischaemia-induced hippocampal damage in gerbil global cerebral ischaemia when dosed at 10, 12.5 (P<0.05) or 15 mg/kg i.p. (P<0.01) 30 min before and 2 h 30 min after occlusion. The compound penetrated the brain well after a 15 mg/kg i.p. dose and had a half-life of 2.5 h. In further studies LY393615 was protective 1 h post-occlusion when administered at 15 mg/kg i.p. followed by 2 doses of 5 mg/kg i.p. 2 and 3 h later. LY393615 dosed at 15 mg/kg i.p. followed by 2 further doses of 5 mg/kg i.p. (2 and 3 h later) also produced a significant reduction in the infarct volume following Endothelin-1 (Et-1) middle cerebral artery occlusion in the rat when administration was initiated immediately (P<0.01) or 1 h (P<0.05) after occlusion. The compound was also evaluated in the intraluminal monofilament model of focal ischaemia. The animals had the middle cerebral artery occluded for 2 h, and 15 min after reperfusion LY393615 was administered at 15 mg/kg i.p. followed by 2 mg/kg/h i.v. infusion for 6 h. There was no reduction in infarct volume using this dosing protocol. In conclusion, in the present studies we have reported that a novel calcium channel blocker, LY393615, with good bioavailability protects against neuronal damage caused by hypoxia-hypoglycaemia in vitro and both global and focal cerebral ischaemia in vivo. The compound is neuroprotective when administered post-occlusion and may therefore be a useful anti-ischaemic agent.

Neuroprotective effects of the neuronal Ca(2+) channel blockers, LY042826 and LY393615 in vivo

In the present studies, we have examined the effects of two new Ca(2+) channel blockers, LY042826 (N-[2-[(2-methylphenyl)(phenyl)methoxy]ethyl]-1-butanamine hydrochloride) and LY393615 (N-[[5, 5-bis(4-fluorophenyl)tetrahydro-2-furanyl]methyl]-1-butanamine hydrochloride) in the gerbil model of global and the endothelin-1 rat model of focal cerebral ischaemia in vivo. Results indicated that both LY042826 (P<0.01) and LY393615 (P<0.001) provided significant protection against ischaemia-induced hippocampal damage in global cerebral ischaemia when dosed at 15 mg/kg i.p. 30 min before and 2 h 30 min after occlusion. In further studies, LY042826 (P<0.05) and LY393615 (P<0.01) were also protective when administered at 15 mg/kg i.p. immediately after and 3 h post-occlusion. Both compounds also provided a significant reduction in the infarct volume following endothelin-1 middle cerebral artery occlusion in the rat when administered at 15 mg/kg i.p. immediately (P<0.05) after occlusion. This protection was similar to that observed with the NMDA receptor antagonist (5R,10S)-(+)-5-methyl-10, 11-dihydro-5H-dibenzo[a,d]cyclohepten-5,10-imine), MK-801 in this model. In conclusion and as a result of the present studies, we report that the novel Ca(2+) channel blockers, LY042826 and LY393615 protect against ischaemia-induced brain injury in gerbils and rats. The compounds were neuroprotective when administered post-occlusion and may therefore be useful anti-ischaemic agents.

Neuroprotective effects of LY379268, a selective mGlu2/3 receptor agonist: investigations into possible mechanism of action in vivo

The mechanisms underlying the neuroprotective effects of the group II metabotropic glutamate receptor (mGluR) agonist LY379268 were investigated in a gerbil model of global ischemia. LY379268 (10 mg/kg i.p.) 30 or 60 min after 5-min bilateral carotid artery occlusion (BCAO) attenuated the ischemia-induced hyperactivity and provided protection in the CA1 hippocampal cells. This neuroprotective effect was maintained (P <.001) when histological analysis was performed 14 and 28 days after BCAO. Furthermore, 24- or 48-h pretreatment with LY379268, 10 mg/kg i.p., before 5-min BCAO markedly reduced (P <.001 and P <.05, respectively) the damage to CA1 hippocampal neurons. This result is consistent with the induction of neuroprotective factors or a very long brain half-life. To study the possible induction of neuroprotective factors as contributing to this action of LY379268, brains were examined for expression of neurotrophic factors. Results indicated that LY379268 (10 mg/kg i.p.) failed to alter the expression of transforming growth factor-beta, brain-derived neurotrophic factor, nerve growth factor, and basic fibroblast growth factor in the hippocampal regions of brains taken from gerbils sacrificed at 6, 24, 72, and 120 h postinjection. The new group II mGlu antagonist, LY341495, administered 1 h before 5-min BCAO, attenuated the neuroprotective effect of LY379268 administered 24 h before 5-min BCAO. Complementary pharmacokinetic studies showed that a significant receptor-active concentration persisted in the brain 24 h after LY379268 10 mg/kg i.p. We conclude that group II mGluR occupancy, rather than induction of neuroprotective factors, explains the long-lasting neuroprotective effect of LY379268 in the gerbil model of global ischemia.