Pancreatic Exocrine Secretion and Weight Gain After Pancreas Transplantation

INTRODUCTION

Weight gain after pancreas transplant is a poorly understood phenomenon thought to be related to increased posttransplant insulin production, immunosuppressive medications, and appetite changes. No study has investigated the effect of increased exocrine secretion posttransplant.

AIMS AND HYPOTHESIS

We hypothesized that exocrine function, measured by fecal elastase-1 (FE-1), was normal posttransplant and not correlated with weight gain. Our primary aim was to investigate changes in FE-1 levels with pancreas transplantation and to correlate this with weight gain. Establishing weight trends and identifying additional correlating factors were secondary aims.

DESIGN

Forty-two patients that underwent simultaneous pancreas and kidney or pancreas after kidney transplant at a single center between 2013 and 2021 were included. Fecal elastase was measured prospectively in each patient at a single time point, with >500 µg/g categorized as high. Weight and C-peptide values were obtained. All the patients were on steroid-free immunosuppression.

RESULTS

Nineteen patients (45%) had fecal elastase levels >500 µg/g, with a maximum of 3910 µg/g; 43% had levels greater than twice the upper limit of normal. The biggest increase in weight occurred between years 1 and 2, which continued to a median weight gain of 14% at 3 years. There was no correlation between weight gain and FE-1, pretransplant C-peptide levels, or duration of diabetes.

CONCLUSION

This study demonstrated supranormal fecal elastase levels and weight gain posttransplant; however, there was no correlation. Future study with serial FE-1 before and after transplant is needed to better assess its correlation with weight gain.

Associations of Race, Ethnicity, and Social Determinants of Health With Colorectal Cancer Screening

BACKGROUND

Racial and ethnic disparities in receipt of recommended colorectal cancer screening exist; however, the impact of social determinants of health on such disparities has not been recently studied in a national cohort.

OBJECTIVE

This study aimed to determine whether social determinants of health attenuate racial disparities in receipt of colorectal cancer screening.

DESIGN

This was a cross-sectional telephone survey of self-reported race and ethnicity and up-to-date colorectal cancer screening. Associations between race/ethnicity and colorectal cancer screening were tested before and after adjustment for demographics, behavioral factors, and social determinants of health.

SETTING

This was a nationally representative telephone survey of US residents in 2018.

PATIENTS

The patients included were US residents aged 50 to 75 years.

MAIN OUTCOME MEASURES

The primary outcome was up-to-date colorectal cancer screening status, according to 2008 US Preventive Services Task Force recommendations.

RESULTS

This study included 226,106 respondents aged 50 to 75 years. Before adjustment, all minority racial and ethnic groups demonstrated a significantly lower odds of screening than those of non-Hispanic white respondents. After adjustment for demographics, behavioral factors, and social determinants of health, compared to non-Hispanic white respondents, odds of screening were found to be increased among non-Hispanic black respondents (OR, 1.10; p = 0.02); lower but attenuated among Hispanic respondents (OR, 0.73; p < 0.001), non-Hispanic American Indian/Alaskan Native respondents (OR, 0.85; p = 0.048), and non-Hispanic respondents of other races (OR, 0.82; p = 0.01); and lower but not attenuated among non-Hispanic Asian respondents (OR, 0.68; p < 0.001).

LIMITATIONS

Recall bias, participant bias, and residual confounding.

CONCLUSIONS

Adjustment for social determinants of health reduced racial and ethnic disparities in colorectal cancer screening among all minority racial and ethnic groups except non-Hispanic Asian individuals; however, other unmeasured confounders likely exist. See Video Abstract at http://links.lww.com/DCR/B977 .

ASOCIACIN DE RAZA, ETNICIDAD Y DETERMINANTES SOCIALES DE LA SALUD CON LA DETECCIN DEL CNCER COLORRECTAL

ANTECEDENTES: Existen disparidades raciales y étnicas en la recepción de las pruebas recomendadas de detección de cáncer colorrectal; sin embargo, el impacto de los determinantes sociales de la salud en dichas disparidades no se ha estudiado recientemente en una cohorte nacional.OBJETIVO: El objetivo de este estudio fue determinar si los determinantes sociales de la salud atenúan las disparidades raciales en la recepción de pruebas de detección del cáncer colorrectal.DISEÑO: Encuesta telefónica transversal de raza y etnia autoinformada y detección actualizada de cáncer colorrectal. Las asociaciones entre la raza/etnicidad y la detección del cáncer colorrectal se probaron antes y después del ajuste por demografía, factores conductuales y determinantes sociales de la salud.ESCENARIO: Esta fue una encuesta telefónica representativa a nivel nacional de los residentes de EE. UU. en 2018.PACIENTES: Los pacientes eran residentes de EE. UU. de 50 a 75 años.PRINCIPALES MEDIDAS DE RESULTADO: Estado actualizado de detección de cáncer colorrectal, según las recomendaciones del Grupo de Trabajo de Servicios Preventivos de EE. UU. de 2008.RESULTADOS: Este estudio incluyó a 226.106 encuestados de 50 a 75 años. Antes del ajuste, todos los grupos étnicos y raciales minoritarios demostraron probabilidades significativamente más bajas de detección en comparación con los encuestados blancos no hispanos. Después del ajuste por demografía, factores conductuales y determinantes sociales de la salud, en comparación con los encuestados blancos no hispanos, las probabilidades de detección aumentaron entre los encuestados negros no hispanos (OR 1,10, p = 0,02); más bajo pero atenuado entre los encuestados hispanos (OR 0,73, p < 0,001), los encuestados indios americanos/nativos de Alaska no hispanos (OR 0,85, p = 0,048) y los encuestados no hispanos de otras razas (OR 0,82, p = 0,01); y menor pero no atenuado entre los encuestados asiáticos no hispanos (OR 0,68, p < 0,001).LIMITACIONES: Sesgo de recuerdo y sesgo de participante, así como confusión residual.CONCLUSIONES: El ajuste para los determinantes sociales de la salud redujo las disparidades raciales y étnicas en la detección del cáncer colorrectal entre todos los grupos étnicos y raciales minoritarios, excepto las personas asiáticas no hispanas; sin embargo, es probable que existan otros factores de confusión no medidos. Consulte Video Resumen en http://links.lww.com/DCR/B977 . (Traducción-Dr. Felipe Bellolio ).

Ursodiol Prescriptions Following Bariatric Surgery: National Prescribing Trends and Outcomes

BACKGROUND

Rapid weight loss after bariatric surgery is a risk factor for gallstone development. Numerous studies have shown that ursodiol after surgery decreases rates of gallstone formation and cholecystitis. Real-world prescribing practices are unknown. This study aimed to examine prescription patterns for ursodiol and reassess its impact on gallstone disease using a large administrative database.

METHODS

The Mariner database (PearlDiver, Inc.) was queried using Current Procedural Terminology codes for Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) between 2011 and 2020. Only patients with International Classification of Disease codes for obesity were included. Patients with pre-operative gallstone disease were excluded. The primary outcome was gallstone disease within 1 year, which was compared between patients who did and did not receive an ursodiol prescription. Prescription patterns were also analyzed.

RESULTS

Three hundred sixty-five thousand five hundred patients fulfilled inclusion criteria. Twenty-eight thousand seventy-five (7.7%) patients were prescribed ursodiol. There was a statistically significant difference in development of gallstones (p < 0.001), development of cholecystitis (p = .049), and undergoing cholecystectomy (p < 0.001). There was a statistically significant decrease in the adjusted odds ratio (aOR) for the development of gallstones (aOR 0.81, 95% CI: 0.74, 0.89), development of cholecystitis (aOR 0.59, 95% CI: 0.36, 0.91), and undergoing cholecystectomy (aOR 0.75, 95% CI: 0.69, 0.81).

CONCLUSION

Ursodiol significantly decreases the odds of development of gallstones, cholecystitis, or cholecystectomy within 1 year following bariatric surgery. These trends hold true when analyzing RYGB and SG separately. Despite the benefit of ursodiol, only 10% of patients received an ursodiol prescription postoperatively in 2020.

Attenuated Dengue virus PV001-DV induces oncolytic tumor cell death and potent immune responses

BACKGROUND

Viral therapies developed for cancer treatment have classically prioritized direct oncolytic effects over their immune activating properties. However, recent clinical insights have challenged this longstanding prioritization and have shifted the focus to more immune-based mechanisms. Through the potential utilization of novel, inherently immune-stimulating, oncotropic viruses there is a therapeutic opportunity to improve anti-tumor outcomes through virus-mediated immune activation. PV001-DV is an attenuated strain of Dengue virus (DEN-1 #45AZ5) with a favorable clinical safety profile that also maintains the potent immune stimulatory properties characterstic of Dengue virus infection.

METHODS

In this study, we utilized in vitro tumor killing and immune multiplex assays to examine the anti-tumor effects of PV001-DV as a potential novel cancer immunotherapy.

RESULTS

In vitro assays demonstrated that PV001-DV possesses the ability to directly kill human melanoma cells lines as well as patient melanoma tissue ex vivo. Importantly, further work demonstrated that, when patient peripheral blood mononuclear cells (PBMCs) were exposed to PV001-DV, a substantial induction in the production of apoptotic factors and immunostimulatory cytokines was detected. When tumor cells were cultured with the resulting soluble mediators from these PBMCs, rapid cell death of melanoma and breast cancer cell lines was observed. These soluble mediators also increased dengue virus binding ligands and immune checkpoint receptor, PD-L1 expression.

CONCLUSIONS

The direct in vitro tumor-killing and immune-mediated tumor cytotoxicity facilitated by PV001-DV contributes support of its upcoming clinical evaluation in patients with advanced melanoma who have failed prior therapy.

Refractory Immune Thrombocytopenic Purpura with Abdominal Splenosis: A Complex Case

Immune thrombocytopenia (ITP) is an acquired thrombocytopenia resulting from immune-mediated platelet destruction via antiplatelet antibodies and T cells. Medical management of ITP includes corticosteroids and multiple other adjunct therapies, with splenectomy generally being reserved for severe, refractory cases. In this clinical case report, we describe the evaluation of a 35-year-old male with a history of prior traumatic splenic injury who presented to the emergency department endorsing easy bruising and a petechial rash, ultimately found to have severe thrombocytopenia. The patient was diagnosed with primary ITP that proved to be refractory to a number of first- and second-line medical therapies. His course was complicated by the presence of abdominal splenosis discovered at the time of planned splenectomy and intra-abdominal hemorrhage requiring splenic artery embolization thereafter. To our knowledge, this is one of few published cases of ITP complicated by abdominal splenosis, highlighting the need to consider splenosis and the presence of accessory splenic tissue in cases of refractory ITP.

Accuracy of Surgeon and Patient Estimated Cost and Reimbursement for Common General Surgical Operations and Benefit of Centers for Medicare and Medicaid Services Price Transparency Rules

BACKGROUND

On January 1, 2021, the Centers for Medicare and Medicaid Services implemented a hospital price transparency rule. Consumerism as a means of reducing healthcare expenditure is predicated on informed consumers making discrete choices.

STUDY DESIGN

For 10 months, immediately after a preoperative clinic visit at an academic medical center, patients and their surgeons were surveyed regarding their estimation of hospital cost and hospital reimbursement for the upcoming operation. Responses were compared to average institutional cost (fiscal year 2019) for Medicare patients undergoing a laparoscopic approach for each operation. We calculated the difference between actual reimbursement and cost with patients' estimates and actual reimbursement and cost with surgeons' estimates.

RESULTS

Sixty-six questionnaires were collected from patients who underwent laparoscopic operations, that included cholecystectomy (n = 20), inguinal hernia (n = 17), umbilical hernia repair (n = 6), ventral hernia repair (n = 6), incisional hernia (n = 6), hiatal hernia repair (n = 1), and lipoma or cyst excision (n = 10). Patients' estimates of hospital cost exceeded actual hospital cost by a median of $4,502 and were less than hospital reimbursement by a median of $1,834. Surgeon estimates for direct cost were $825 less than hospital direct cost and $1,659 less than hospital reimbursement.

CONCLUSIONS

Patients as well as their surgeons do not estimate healthcare cost or remuneration accurately and therefore will be ineffective change agents in reducing surgical spending based on price transparency without further education of both parties. Patients consistently overestimated surgical cost while surgeons consistently underestimated surgical cost and reimbursement. It is likely that better-informed surgeons and patients are necessary prerequisites for Centers for Medicare and Medicaid Services price transparency rules to be effective in reducing Medicare expenditures in surgery.

Laser Ablation of Pilonidal Sinus Disease: A Pilot Study

BACKGROUND

Pilonidal disease is classically treated with wide local excision, although a number of minimally invasive approaches are currently under investigation. We aimed to determine the safety and feasibility of laser ablation of pilonidal sinus disease.

IMPACT OF INNOVATION

Laser ablation provides a minimally invasive means of obliterating pilonidal sinus tracts without a need for excessive tract dilation. Laser ablation can be performed more than once on the same patient if necessary.

TECHNOLOGY MATERIALS AND METHODS

This technique uses the NeoV V1470 Diode Laser (neoLaser Ltd, Caesarea, Israel) with a 2-mm probe. We performed laser ablation in adults and pediatric patients.

PRELIMINARY RESULTS

We performed 27 laser ablation procedures in 25 patients, with a median operative time of 30 minutes. Eighty percent of patients reported either no pain or mild pain at the 2-week postoperative visit. The median time to return to work or school was 3 days. Eighty-eight percent of patients reported being satisfied or very satisfied with the procedure at their most recent follow-up (median, 6 mo). Eighty-two percent of patients were healed at 6 months.

CONCLUSIONS AND FUTURE DIRECTIONS

Laser ablation of pilonidal disease is safe and feasible. Patients experienced short recovery time and reported low levels of pain and high levels of satisfaction.

Prophylactic antireflux procedures are not necessary in neurologically impaired children undergoing gastrostomy placement

PURPOSE

Fundoplication is frequently used in children with neurologic impairment even in the absence of reflux due to concerns for future gastric feeding intolerance, but supporting data are lacking. We aimed to determine the incidence of secondary antireflux procedures (fundoplication or gastrojejunostomy (GJ)) post gastrostomy tube (GT) placement in children with and without neurologic impairment.

METHODS

Children under 18 undergoing a GT placement without fundoplication between 2010 and 2020 were identified utilizing the PearlDiver Mariner national patient claims database. Children with a diagnosis of cerebral palsy or a degenerative neurologic disease were identified and compared to children without these diagnoses. The incidence of delayed fundoplication or conversion to GJ were compared utilizing Kaplan-Meier and Cox proportional hazards regression analyses.

RESULTS

A total of 14,965 children underwent GT placement, of which 3712 (24.8%) had a diagnosis of neurologic impairment. The rate of concomitant fundoplication was significantly higher among children with a diagnosis of neurologic impairment as compared to those without (9.3% vs 6.4%, p < 0.001). While children with neurologic impairment had a significantly higher rate of fundoplication or GJ conversion at 5 years compared to children without (12.6% [95% confidence interval (CI): 11.4%-13.8%] vs 8.6% [95% CI 8.0%-9.2%], p < 0.001), the overall incidence remained low.

CONCLUSION

Although children with neurologic impairment have a higher rate of requiring an antireflux procedure or GJ conversion than other children, the overall rate remains less than 15%. Fundoplication should not be utilized in children without clinical reflux on the basis of neurologic impairment alone.

Mediating Factors Between Race and Time to Treatment in Colorectal Cancer

BACKGROUND

Previous disparities research has demonstrated that underrepresented racial minority patients have worse colorectal cancer outcomes and that they experience unnecessary delays in time to treatment. These delays may explain worse colorectal cancer outcomes for minority patients and serve as a marker of inequalities in our healthcare system.

OBJECTIVE

This study aims to quantify the mechanisms that contribute to this disparity in treatment delay.

DESIGN

This is a retrospective analysis of colorectal cancer patients who underwent elective resection from 2004 to 2017. A causal inference mediation analysis using the counterfactual framework was utilized to estimate the extent to which racial disparities among patient factors explain the racial disparities in time to treatment. Mediators included income, education, comorbidities, insurance, and hospital type.

SETTINGS

This study was conducted at hospitals participating in the National Cancer Database.

PATIENTS

Stage I-III colorectal cancer patients, ≥18 years old, who underwent elective resection from 2004 through 2017 were included.

MAIN OUTCOMES MEASURES

The primary measures were indirect effects of mediators between race and delayed time to treatment.

RESULTS

Of the 504,405 patients (370,051 colon and 134,354 rectal), 10%, 5%, and 4% were black, Hispanic, and other. In multivariable models, compared to white patients, these patients had 25%, 27%, and 17% greater odds of delayed treatment. Mediation analyses suggested that 43%, 20%, and 31% of the treatment delay among them could be removed if an intervention equalized income, education, comorbidities, insurance, and hospital type to that of white patients. Treatment at an academic hospital explained 15% to 32% of the racial disparity and was the most potent mediator.

LIMITATIONS

This study was limited by its retrospective design and failure to capture all meaningful mediators.

CONCLUSIONS

Black, Hispanic, and other colorectal cancer patients experience treatment delays when compared to white patients. Equalization of the mediators used in this study could reduce treatment delays by 20% to 43% depending on the racial/ethnic group. Future research should identify other causes of racial disparities in treatment delay and intervene accordingly. See Video Abstract at http://links.lww.com/DCR/B871 .

FACTORES MEDIADORES ENTRE LA RAZA Y EL TIEMPO HASTA EL TRATAMIENTO EN EL CNCER COLORECTAL

ANTECEDENTES:Investigaciones anteriores sobre disparidades han demostrado que los pacientes de minorías raciales subrepresentados tienen peores resultados de cáncer colorrectal y que experimentan retrasos innecesarios en el tiempo de tratamiento. Estos retrasos pueden explicar los peores resultados del cáncer colorrectal para los pacientes de minorías y servir como un marcador de desigualdades en nuestro sistema de salud.OBJETIVO:Este estudio tiene como objetivo cuantificar los mecanismos que contribuyen a esta disparidad en el retraso del tratamiento.DISEÑO:Este es un análisis retrospectivo de pacientes con cáncer colorrectal que se sometieron a resección electiva entre 2004 y 2017. Se utilizó un análisis de mediación de inferencia causal utilizando el marco contra factual para estimar hasta qué punto las disparidades raciales entre los factores del paciente explican las disparidades raciales en el tiempo hasta el tratamiento. Los mediadores incluyeron ingresos económicos, educación, comorbilidades, seguro médico y tipo de hospital.AJUSTES:Este estudio se realizó en hospitales que participan en la Base de datos nacional del cáncer.PACIENTES:Se incluyeron pacientes con cáncer colorrectal en estadio I-III, ≥18 años, que se sometieron a resección electiva entre 2004 y 2017.PRINCIPALES RESULTADOS MEDIDAS:Las principales mediciones fueron el efecto indirecto de los mediadores entre la raza y el retraso en el tratamiento.RESULTADOS:De los 504,405 pacientes (370,051 de colon, 134,354 rectal), 10%, 5%, 4% eran negros, hispanos, y otros, respectivamente. En modelos multivariables, en comparación con los pacientes blancos, estos pacientes tenían un 25%, 27%, y 17% más de probabilidades de retrasar el tratamiento. Los análisis de medición sugirieron que el 43%, 20%, 31% del retraso del tratamiento entre, respectivamente, podría eliminarse si una intervención igualara los ingresos económicos, la educación, las comorbilidades, el seguro médico y el tipo de hospital a los de los pacientes blancos. El tratamiento en un hospital académico demostró entre el 15% y el 32% de la disparidad racial y fue el mediador más potente.LIMITACIONES:Este estudio estuvo limitado por su diseño retrospectivo; falla en capturar a todos los mediadores significativos.CONCLUSIONES:Los pacientes negros, hispanos y otros con cáncer colorrectal experimentan retrasos en el tratamiento en comparación con los pacientes blancos. La igualación de los mediadores utilizados en este estudio podría reducir los retrasos en el tratamiento en un 20-43%, según el grupo racial / étnico. Las investigaciones futuras deberían identificar otras causas de disparidades raciales en el retraso del tratamiento e intervenir sobre ellas. Consulte Video Resumen en http://links.lww.com/DCR/B871 . (Traducción-Dr. Yolanda Colorado ).

Effect of Operative Time on Outcomes of Minimally Invasive Versus Open Pancreatoduodenectomy

OBJECTIVE

To evaluate how operative time interacts with outcomes among different approaches to pancreaticoduodenectomy (PD). Minimally invasive PDs (MIPD), which include laparoscopic (LPD) and robotic (RPD) approaches, are increasingly performed in the USA. MIPD are generally associated with longer operative times (OT) compared to open PD (OPD). Increased OT is associated with inferior outcomes for OPD; however, the effect of OT on MIPD is not well understood.

METHODS

National Surgical Quality Improvement Program (NSQIP)-targeted pancreatectomy dataset was utilized (2014-2019). Propensity score matching, logistic regression, and mixed effect modeling were performed to determine the effect of OT on outcomes following PD. OTs were stratified by quartiles for each approach, and outcomes were subsequently compared.

RESULTS

Among 23,988 PDs, 22,185 were OPD and 1803 MIPD. Increased OT was associated with greater overall morbidity in all approaches. When comparing OT quartiles, MIPD was consistently associated with improved overall morbidity compared to OPD in matched cohorts. However, for upper quartiles, prolonged OT in MIPD was associated with significantly increased reoperation rates and mortality. The effect of OT on overall morbidity and other outcomes was comparable among LPD and RPD.

CONCLUSIONS

In this study, increased OT was associated with incremental increases in overall morbidity after PD, irrespective of approach. While MIPD was associated with improved overall morbidity compared to OPD when stratified by OT quartile, higher mortality rates were observed with prolonged OT only with MIPD. Those data suggest that MIPD is a safe alternative to OPD when OT is optimized. NSQIP was used to compare the effect of operative time (OT) on outcomes following pancreaticoduodenectomy (PD), stratified by approach. Increased OT was associated with inferior outcomes following open, laparoscopic, and robotic PD. Surgeons should attempt to optimize OT, regardless of the approach to PD.

Two unique cases of Bouveret syndrome with review of literature

Bouveret syndrome is a rare form of gallstone ileus in which a proximally lodged gallstone in the duodenum causes a gastric outlet obstruction. It is a rare condition that can be challenging to manage. Although endoscopic management remains first line, a surgical approach can be needed. We present two cases of Bouveret syndrome. A 65-year-old man with oral squamous cell carcinoma treated with endoscopic management and a 63-year-old woman treated with surgery.

A Pro-Endocrine Pancreatic Islet Transcriptional Program Established During Development Is Retained in Human Gallbladder Epithelial Cells

BACKGROUND & AIMS

Pancreatic islet β-cells are factories for insulin production; however, ectopic expression of insulin also is well recognized. The gallbladder is a next-door neighbor to the developing pancreas. Here, we wanted to understand if gallbladders contain functional insulin-producing cells.

METHODS

We compared developing and adult mouse as well as human gallbladder epithelial cells and islets using immunohistochemistry, flow cytometry, enzyme-linked immunosorbent assays, RNA sequencing, real-time polymerase chain reaction, chromatin immunoprecipitation, and functional studies.

RESULTS

We show that the epithelial lining of developing, as well as adult, mouse and human gallbladders naturally contain interspersed cells that retain the capacity to actively transcribe, translate, package, and release insulin. We show that human gallbladders also contain functional insulin-secreting cells with the potential to naturally respond to glucose in vitro and in situ. Notably, in a non-obese diabetic (NOD) mouse model of type 1 diabetes, we observed that insulin-producing cells in the gallbladder are not targeted by autoimmune cells. Interestingly, in human gallbladders, insulin splice variants are absent, although insulin splice forms are observed in human islets.

CONCLUSIONS

In summary, our biochemical, transcriptomic, and functional data in mouse and human gallbladder epithelial cells collectively show the evolutionary and developmental similarities between gallbladder and the pancreas that allow gallbladder epithelial cells to continue insulin production in adult life. Understanding the mechanisms regulating insulin transcription and translation in gallbladder epithelial cells would help guide future studies in type 1 diabetes therapy.

Can Donor-Derived Cell-Free DNA Detect Graft-Versus-Host Disease in Solid Organ Transplantation: A Case Report

Graft-versus-host disease (GVHD) is a rare complication after solid organ transplant. We present a case of GVHD after simultaneous pancreas kidney transplant. The patient was diagnosed with a cutaneous biopsy after developing the classic symptoms of maculopapular rash, diarrhea, and pancytopenia. However, this patient had unexplained elevations in donor-derived cell-free DNA (dd-cfDNA) for months before the onset of GVHD symptoms. We hypothesize that GVHD may be associated with elevated dd-cfDNA as a result of massive donor lymphocyte proliferation and turnover. Further investigation is warranted because earlier diagnosis and treatment could improve outcomes in an otherwise lethal disease.

Variation in bariatric surgery utilization by state from 2010 to 2019: analysis of the PearlDiver Mariner database

BACKGROUND

Bariatric surgery is the most effective treatment for severe obesity and its associated complications, but it remains underutilized. The degree to which bariatric surgery utilization varies by state is unclear.

OBJECTIVES

The aim of this study was to quantify variation in bariatric surgery utilization across U.S. states.

SETTING

United States.

METHODS

Patients who underwent sleeve gastrectomy or gastric bypass and patients with body mass index (BMI) >40 or BMI >35 with comorbidities between 2010 and 2019 were identified with Current Procedural Terminology, International Classification of Diseases-9 and -10 codes using the PearlDiver Mariner insurance claims database. Patients living in Puerto Rico and other U.S. territories were excluded.

RESULTS

A total of 99,173 bariatric surgery patients were identified out of 1,789,457 patients eligible for bariatric surgery between 2010 and 2019 (5.5%). Bariatric surgery patients were more likely to be female (78.8% versus 65.6%) and have commercial insurance (81.4% versus 69.6%) compared with eligible patients who did not undergo bariatric surgery. Bariatric surgery utilization varied widely between states, from 10.4% in New Jersey to 2.1% in Vermont. The Northeast region had the highest rates at 7.95%, and the Midwest had the lowest at 4.47%. The proportion of bariatric surgeries that were sleeve gastrectomies also varied from <30% in Alaska, North Dakota, and Rhode Island to >80% in New Jersey, Nevada, and Mississippi.

CONCLUSION

There is significant variation in bariatric surgery utilization between states, with almost a 5-fold difference between the states with the highest and lowest utilization.

The effect of bariatric surgery on ischemic stroke risk

BACKGROUND

Metabolic and bariatric surgery (MBS) has demonstrated improvements in diabetes and cardiovascular health. The effect of MBS on the risk of ischemic stroke remains unclear.

OBJECTIVES

The goal of this study was to determine the risk of stroke following MBS compared with patients with obesity who qualified for but did not undergo MBS.

SETTING

The Mariner Database, a national claims database.

METHODS

We identified patients with body mass index (BMI) ≥40 or those with a BMI and a qualifying co-morbidity, who underwent MBS between 2010 to 2019. Similar patients who did not undergo MBS served as controls. Coarsened exact matching was performed followed by logistic regression analysis to determine the effect of BMS on stroke risk.

RESULTS

A total of 70 622 BMS patients and 1 320 182 MBS-eligible controls were identified. After matching, the 1-year stroke risk among MBS patients (n = 56 514) versus controls (n = 56 514) was .6% versus 1.2% (OR .54, 95% CI .47-.61). The 5-year stroke risk for MBS (n = 27619) versus control (n = 27619) was 2.8% versus 3.6% (OR .78, 95% CI .65-.90).

CONCLUSION

MBS appears to reduce the risk of stroke following surgery. To our knowledge, this is the largest sample size in a study of ischemic cerebrovascular disease in bariatric surgery.

The Risk and Reward of Speaking Out for Racial Equity in Surgical Training

In order to maintain productivity and career advancement, Black and Brown individuals often find themselves downplaying persistent elements of bias and racism experienced in predominantly white fields. These elements are commonly reinforced by institutional and departmental policies that hinder the creation of an equitable and inclusive environment for all. In this manuscript, we outline specific challenges faced by Black and Brown trainees and faculty that are perpetuated by such policies. The challenges are followed by specific recommendations for change as they may apply to faculty, staff and trainees. The outlined recommendations or "action items" may be enacted by any residency program or department based on perceived timeliness and should serve as a foundation for change-one that is intently created through a lens of anti-racism. The risk of speaking up for racial equity is outweighed by the potential rewards of building an environment that is diverse, inclusive and better for everyone.

100 Disruptive Publications in Breast Cancer Research

Background:

Breast cancer has a rich history of research over the past 75 years. Many studies have had disruptive influences on the field itself. Our study employs a new, validated measurement to determine the most disruptive publications within the field of breast cancer.

Materials and Methods:

PubMed^® database was queried for articles between 1954-2014 related to breast cancer with in 21 different journals deemed important to the field. Articles were then scored for disruption and citation count. The top 100 most disruptive and cited publications were compiled and analyzed.

Results:

Disruption score was a distinct measurement from citation count and had low level of correlation. Disruptive publications tended to skew older with the median year of publication in 1977. The score identified a variety of study designs and publication types within multiple journals.

Conclusions:

Measurement of the disruptive quality of a publication is a new way to describe academic impact of a publication and is distinct from citation count. Used in conjunction with citation count in may give a more descriptive bibliometric assessment of the literature. Further exploration within the field of oncology is warranted.

Outcomes of Laparoscopic Versus Open Resection of Meckel's Diverticulum

BACKGROUND

Meckel's Diverticulum (MD) is a common congenital anomaly accounting for half of pediatric gastrointestinal bleeds. No large-scale studies exist comparing open and laparoscopic surgery and conversion rates remain high. We sought to compare postoperative outcomes associated with each approach and to determine risk factors for conversion.

MATERIALS AND METHODS

NSQIP-Pediatric was used to identify patients who underwent a MD resection from 2012 to 2018. Outcomes between patients treated with a laparoscopic versus open versus laparoscopic converted to open (LCO) surgery were compared. Chi-square tests and adjusted logistic regression analysis were used to determine significance and factors associated with conversion.

RESULTS

Six hundred eighty-one patients were identified, 295 (43.3%) underwent open, 267 (39.2%) laparoscopic, and 119 (17.5%) LCO resection. Patients undergoing laparoscopic compared to open procedures had shorter length of stay (LOS; 3 versus 4, P= 0.009), and similar morbidities (10.5% versus 16.6%, P= 0.164) and operative times (71.6 versus 76.6 mins, P= 0.449) on adjusted analysis. Patients with LCO compared to open procedures had similar LOS (4 versus 4, P= 0.334) and morbidities (14.3% versus 16.6%, P= 0.358), but longer operative times (90.1 versus 76.6 mins, P= 0.002) on adjusted analysis. Patients with laparoscopic and LCO procedures had fewer unplanned intubations compared to open procedures (0.0% versus 0.0% versus 2.4%, P= 0.011) and lower mortality (0.0% versus 0.0% versus 1.7%, P= 0.046) on univariate analysis.

CONCLUSIONS

Laparoscopic MD resection has shorter LOS and similar complications and operative time compared to an open approach while LCO resection increases operative time but not LOS or morbidities.

Deconstructing the ivory tower: identifying challenges of university-industry ecosystem partnerships

Collaboration between industry and academia necessitates the management of entrepreneurial dynamics within ecosystem contexts. However, such partnerships perpetuate numerous challenges that, without effective management, can impact upon the ecosystem as a whole. Limited research to date has addressed the challenges affecting these university-industry partnerships and ascertained their impact upon ecosystem management. This study identifies the challenges pervading university-industry partnerships across entrepreneurial ecosystems, with a view that through an exposition of such challenges, more specific strategies could be implemented to address them. Questionnaires were distributed to key ecosystem stakeholders, requesting their perceptions of the key challenges affecting their collaborative relationships. Empirical data was analysed utilising fuzzy-set qualitative comparative analysis to deduce the configurational nature of the conditions. Results reveal mutually exclusive solutions grounded upon distinct combinations of conditions, constituting distinct pathways to ineffective ecosystem management. Theoretical and practical implications are discussed, as well as acknowledged limitations of this study and suggestions for future research.

Directed differentiation into insulin-producing cells using microRNA manipulation

Our commentary is focused on three studies that used microRNA overexpression methods for directed differentiation of stem cells into insulin-producing cells. Islet transplantation is the only cell-based therapy used to treat type 1 diabetes mellitus. However, due to the scarcity of cadaveric donors and limited availability of good quality and quantity of islets for transplant, alternate sources of insulin-producing cells are being studied and used by researchers. This commentary provides an overview of distinct studies focused on manipulating microRNA expression to optimize differentiation of embryonic stem cells or induced pluripotent stem cells into insulin-producing cells. These studies have used different approaches to overexpress microRNAs that are highly abundant in human islets (such as miR-375 and miR-7) in their differentiation protocol to achieve better differentiation into functional islet beta (β)-cells.

Weekly paclitaxel, carboplatin, cetuximab, and cetuximab, docetaxel, cisplatin, and fluorouracil, followed by local therapy in previously untreated, locally advanced head and neck squamous cell carcinoma

BACKGROUND

The survival advantage of induction chemotherapy (IC) followed by locoregional treatment is controversial in locally advanced head and neck squamous cell carcinoma (LAHNSCC). We previously showed feasibility and safety of cetuximab-based IC (paclitaxel/carboplatin/cetuximab-PCC, and docetaxel/cisplatin/5-fluorouracil/cetuximab-C-TPF) followed by local therapy in LAHNSCC. The primary end point of this phase II clinical trial with randomization to PCC and C-TPF followed by combined local therapy in patients with LAHNSCC stratified by human papillomavirus (HPV) status and T-stage was 2-year progression-free survival (PFS) compared with historical control.

PATIENTS AND METHODS

Eligible patients were ≥18 years with squamous cell carcinoma of the oropharynx, oral cavity, nasopharynx, hypopharynx, or larynx with measurable stage IV (T0-4N2b-2c/3M0) and known HPV by p16 status. Stratification was by HPV and T-stage into one of the two risk groups: (i) low-risk: HPV-positive and T0-3 or HPV-negative and T0-2; (ii) intermediate/high-risk: HPV-positive and T4 or HPV-negative and T3-4. Patient reported outcomes were carried out.

RESULTS

A total of 136 patients were randomized in the study, 68 to each arm. With a median follow up of 3.2 years, the 2-year PFS in the PCC arm was 89% in the overall, 96% in the low-risk and 67% in the intermediate/high-risk groups; in the C-TPF arm 2-year PFS was 88% in the overall, 88% in the low-risk and 89% in the intermediate/high-risk groups.

CONCLUSION

The observed 2-year PFS of PCC in the low-risk group and of C-TPF in the intermediate/high-risk group showed a 20% improvement compared with the historical control derived from RTOG-0129, therefore reaching the primary end point of the trial.

A National Outcomes Assessment of the Rehabilitation of Adults with Visual Impairments

This article discusses the development of self-report functional outcomes instruments in two years of a three-year large-scale national research project on the rehabilitation of adults with visual impairments. It describes the history of the effort, the process involved, and the methods used in establishing the instruments’ reliability, validity, and responsivity and the results of intermediate analyses of the data.

Epigenetic and Transcriptome Profiling Identifies a Population of Visceral Adipose-Derived Progenitor Cells with the Potential to Differentiate into an Endocrine Pancreatic Lineage

Type 1 diabetes (T1D) is characterized by the loss of insulin-producing β-cells in the pancreas. T1D can be treated using cadaveric islet transplantation, but this therapy is severely limited by a lack of pancreas donors. To develop an alternative cell source for transplantation therapy, we carried out the epigenetic characterization in nine different adult mouse tissues and identified visceral adipose-derived progenitors as a candidate cell population. Chromatin conformation, assessed using chromatin immunoprecipitation (ChIP) sequencing and validated by ChIP-polymerase chain reaction (PCR) at key endocrine pancreatic gene promoters, revealed similarities between visceral fat and endocrine pancreas. Multiple techniques involving quantitative PCR, in-situ PCR, confocal microscopy, and flow cytometry confirmed the presence of measurable (2-1000-fold over detectable limits) pancreatic gene transcripts and mesenchymal progenitor cell markers (CD73, CD90 and CD105; >98%) in visceral adipose tissue-derived mesenchymal cells (AMCs). The differentiation potential of AMCs was explored in transgenic reporter mice expressing green fluorescent protein (GFP) under the regulation of the Pdx1 (pancreatic and duodenal homeobox-1) gene promoter. GFP expression was measured as an index of Pdx1 promoter activity to optimize culture conditions for endocrine pancreatic differentiation. Differentiated AMCs demonstrated their capacity to induce pancreatic endocrine genes as evidenced by increased GFP expression and validated using TaqMan real-time PCR (at least 2-200-fold relative to undifferentiated AMCs). Human AMCs differentiated using optimized protocols continued to produce insulin following transplantation in NOD/SCID mice. Our studies provide a systematic analysis of potential islet progenitor populations using genome-wide profiling studies and characterize visceral adipose-derived cells for replacement therapy in diabetes.

Absence of Inhibitors in Previously Untreated Patients with Severe Haemophilia A after Exposure to a Single Intermediate Purity Factor VIII Product

Use of high purity and recombinant factor VIII (FVIII) concentrates has been thought to be associated with an increased incidence of FVIII inhibitors in patients with severe haemophilia A. Comparison with comparable historical control groups has suggested that the true incidence of inhibitors in patients with severe haemophilia A was ~20-25%, similar to the incidence seen with new high purity and recombinant FVIII products.

We have conducted a study of inhibitor development in a cohort of 37 boys with severe haemophilia A (VIII: C <2 u/dl) exposed only to a single FVIII concentrate (BPL 8Y) with no previous blood or blood product exposure. This factor VIII concentrate is an intermediate purity product with a specific activity of ~2 IU/mg protein and contains well preserved von Willebrand factor multimers. It is manufactured by conventional fractionation technologies and terminally dry heat treated at 80° C for 72 h.

A Prospective Study of HIV-Infected Haemophilic Boys and the Prognostic Significance of Immune and Haematological Abnormalities

Fifty-seven haemophilic boys have been studied prospectively determining T lymphocyte subsets and haematological parameters over a period of 26 months. Clinical follow up of these patients has continued for a further 41 months. At the beginning of the study 21 boys were HIV antibody seropositive and seroconversion was documented in a further 9 during the study period, giving a 52.6% incidence of HIV seropositivity. It has been possible to define a group of patients with persistently falling T4 values and these have shown clinical evidence of HIV infection. Although persistent generalized lymphadenopathy has been observed in 30% of HIV antibody positive boys and some boys have had unexplained fevers, only one boy has progressed to have the acquired immune deficiency syndrome (AIDS) some 5 years and 3 months from HIV seroconversion. This boy had a persistently falling T4 value. The importance of these findings is discussed. To date the abnormalities found in these haemophilic boys irrespective of their age are similar to those already reported in adult haemophiliacs.

The effect of Nordic hamstring exercise training volume on biceps femoris long head architectural adaptation

The aim of this study was to determine the time course of architectural adaptations in the biceps femoris long head (BF_LH ) following high or low volume eccentric training. Twenty recreationally active males completed a two week standardized period of eccentric Nordic hamstring exercise (NHE) training, followed by four weeks of high (n = 10) or low volume (n = 10) training. Eccentric strength was assessed pre- and post intervention and following detraining. Architecture was assessed weekly during training and after two and four weeks of detraining. After six weeks of training, BF_LH fascicles increased significantly in the high (23% ± 7%, P < .001, d = 2.87) and low volume (24% ± 4%, P < .001, d = 3.46) groups, but reversed following two weeks of detraining (high volume: -17% ± 5%, P < .001, d = -2.04; low volume: -15% ± 3%, P < .001, d = -2.56) after completing the intervention. Both groups increased eccentric strength after six weeks of training (high volume: 28% ± 20%, P = .009, d = 1.55; low volume: 34% ± 14%, P < .001, d = 2.09) and saw no change in strength following a four week period of detraining (high volume: -7% ± 7%, P = .97, d = -0.31; low volume: -2% ± 5%, P = .99, d = -0.20). Both low and high volume NHE training stimulate increases in BF_LH fascicle length and eccentric knee flexor strength. Architectural adaptations reverted to baseline levels within two weeks after ceasing training, but eccentric strength was maintained for at least four weeks. These observations provide novel insight into the effects of training volume and detraining on BF_LH architecture and may provide guidance for the implementation of NHE programs.

Imaging of Anaplastic Thyroid Carcinoma

Anaplastic thyroid carcinoma is fatal if unresectable. However, improved survival has been reported after gross total resection and multimodality therapy. In this report, we describe the contrast-enhanced high-resolution CT characteristics of anaplastic thyroid carcinoma in 57 patients. Anaplastic thyroid carcinoma presented as a large neck mass with necrosis in 82% of cases. The tumors demonstrated common extrathyroidal extension (91%). Sixty-two percent of tumors demonstrated calcification. Visceral space invasion involved the esophagus (62%), trachea (57%), and larynx (29%). Carotid artery encasement was present in 42%, and 43% involved the internal jugular vein. Sixty-three percent had lateral compartment lymphadenopathy; 58% of these nodes were necrotic, and 11% were cystic. No metastatic nodes had calcification. Central compartment lymphadenopathy was seen in 56% of cases, and lateral retropharyngeal lymphadenopathy was detected in 12%. Knowledge of these imaging features aids in guiding the approach to the initial tissue diagnosis with either fine-needle aspiration or core biopsy, assessing the feasibility of surgical resection, and determining prognosis.

Hypoxic preconditioning of myoblasts implanted in a tissue engineering chamber significantly increases local angiogenesis via upregulation of myoblast vascular endothelial growth factor-A expression and downregulation of miRNA-1, miRNA-206 and angiopoietin-1

Vascularization is a major hurdle for growing three-dimensional tissue engineered constructs. This study investigated the mechanisms involved in hypoxic preconditioning of primary rat myoblasts in vitro and their influence on local angiogenesis postimplantation. Primary rat myoblast cultures were exposed to 90 min hypoxia at <1% oxygen followed by normoxia for 24 h. Real time (RT) polymerase chain reaction evaluation indicated that 90 min hypoxia resulted in significant downregulation of miR-1 and miR-206 (p < 0.05) and angiopoietin-1 (p < 0.05) with upregulation of vascular endothelial growth factor-A (VEGF-A; p < 0.05). The miR-1 and angiopoietin-1 responses remained significantly downregulated after a 24 h rest phase. In addition, direct inhibition of miR-206 in L6 myoblasts caused a significant increase in VEGF-A expression (p < 0.05), further establishing that changes in VEGF-A expression are influenced by miR-206. Of the myogenic genes examined, MyoD was significantly upregulated, only after 24 h rest (p < 0.05). Preconditioned or control myoblasts were implanted with Matrigel™ into isolated bilateral tissue engineering chambers incorporating a flow-through epigastric vascular pedicle in severe combined immunodeficiency mice and the chamber tissue harvested 14 days later. Chambers implanted with preconditioned myoblasts had a significantly increased percentage volume of blood vessels (p = 0.0325) compared with chambers implanted with control myoblasts. Hypoxic preconditioned myoblasts promote vascularization of constructs via VEGF upregulation and downregulation of angiopoietin-1, miR-1 and miR-206. The relatively simple strategy of hypoxic preconditioning of implanted cells - including non-stem cell types - has broad, future applications in tissue engineering of skeletal muscle and other tissues, as a technique to significantly increase implant site angiogenesis.

Travel Time Influences Readmission Risk: Geospatial Mapping of Surgical Readmissions

The University of Virginia (UVA) has recently become an Accountable Care Organization (ACO), intensifying efforts to provide better care for individuals. UVA's ACO population resides across the entire Commonwealth, with a large percentage of patients living in rural areas. To provide better health for this population, the central tenet of the ACO mission, we identified geographic risk factors influencing hospital readmission. We analyzed the relationship between the distance of patients’ residence to the nearest hospital and 30-day readmission in general surgery patients. A retrospective chart review using January 1, 2011 through October 31, 2013 American College of Surgeons National Surgical Quality Improvement Program data for general surgery procedures was conducted. ArcGIS mapped street addresses provided graphical representation of distance between surgical population and the nearest hospital. We analyzed the impact on readmission, of time traveled, insurance status, and median household income. Each increase of 10 minutes in travel time from the patient's residence to the nearest hospital, not just UVA, was associated with a 9 per cent increase in the probability of readmission after adjusting for patient characteristics, preoperative comorbidities, laboratory values, and postoperative complications before or after discharge (odds ratio = 1.09; 95% confidence interval = 1.01–1.17; P = 0.019). Unlike urban hospitals, those serving rural populations may be at particular risk of postsurgical readmissions. Patients living furthest from a hospital facility are most at risk for readmission after a general surgery procedure. This vulnerable population may benefit most from comprehensive discharge planning.