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Anderson ST, Mount JR, Hintze BC, Hogan JS, Jorge IA, Etzioni DA, Han GR, Brady JT. The Decline of Small Practice in Colorectal Surgery: Practice Consolidation From 2015-2022. J Surg Res 2024; 298:364-370. [PMID: 38669782 DOI: 10.1016/j.jss.2024.03.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 11/04/2023] [Accepted: 03/07/2024] [Indexed: 04/28/2024]
Abstract
INTRODUCTION Physicians have gravitated toward larger group practice arrangements in recent years. However, consolidation trends in colorectal surgery have yet to be well described. Our objective was to assess current trends in practice consolidation within colorectal surgery and evaluate underlying demographic trends including age, gender, and geography. METHODS We performed a retrospective cross-sectional study using the Center for Medicare Services National Downloadable File from 2015 to 2022. Colorectal surgeons were categorized by practice size and by region, gender, and age. RESULTS From 2015 to 2022, the number of colorectal surgeons in the United States increased from 1369 to 1621 (+18.4%), while the practices with which they were affiliated remained relatively stable (693-721, +4.0%). The proportion of colorectal surgeons in groups of 1-2 members fell from 18.9% to 10.7%. Conversely, those in groups of 500+ members grew from 26.5% to 45.2% (linear trend P < 0.001). The midwest region demonstrated the highest degree of consolidation. Affiliations with group practices of 500+ members saw large increases from both female and male surgeons (+148.9% and +86.9%, respectively). New surgeons joining the field since 2015 overwhelmingly practice in larger groups (5.3% in groups of 1-2, 50.1% in groups of 500+). CONCLUSIONS Colorectal surgeons are shifting toward larger practice affiliations. Although this change is happening across all demographic groups, it appears unevenly distributed across geography, gender, and age. New surgeons are preferentially joining large group practices.
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Affiliation(s)
| | | | | | - Jacob S Hogan
- Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Irving A Jorge
- Department of Colorectal Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - David A Etzioni
- Department of Colorectal Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Ga-Ram Han
- Department of Colorectal Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Justin T Brady
- Department of Colorectal Surgery, Mayo Clinic Arizona, Phoenix, Arizona.
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Tan JY, Yeo YH, Ng WL, Fong ZV, Brady JT. How have US colorectal cancer mortality trends changed in the past 20 years? Int J Cancer 2024. [PMID: 38525799 DOI: 10.1002/ijc.34926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Revised: 02/27/2024] [Accepted: 02/29/2024] [Indexed: 03/26/2024]
Abstract
In the last two decades, colorectal cancer (CRC) mortality has been decreasing in the United States. However, the mortality trends for the different subtypes of CRC, including different sides of colon, rectosigmoid, and rectal cancer remain unclear. We analyzed the mortality trends of different subtypes of CRC based on Centers for Disease Control and Prevention's Wide-Ranging Online Data for Epidemiologic Research data from 1999 to 2020. We calculated age-adjusted mortality rates (AAMR) per 100,000 individuals and examined the trends over time by estimating the average annual percent change (AAPC) using the Joinpoint Regression Program. Our study shows that the overall CRC rates decreased significantly from 26.42 to 15.98 per 100,000 individuals, with an AAPC of -2.41. However, the AAMR of rectosigmoid cancer increased significantly from 0.82 to 1.08 per 100,000 individuals, with the AAPC of +1.10. Men and Black individuals had the highest AAMRs respectively (23.90 vs. 26.93 per 100,000 individuals). The overall AAMR of CRC decreased for those aged ≥50 years but increased significantly from 1.02 to 1.58 per 100,000 individuals for those aged 15-49 years, with an AAPC of +0.75. Rural populations had a higher AAMR than the urban populations (22.40 vs. 19.60 per 100,000 individuals). Although overall CRC mortality declined, rising trends in young-onset CRC and rectosigmoid cancer warrant attention. Disparities persist in terms of sex, race, and geographic region, and urbanization level, emphasizing the need for targeted public health measures.
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Affiliation(s)
- Jia Yi Tan
- Department of Internal Medicine, New York Medical College at Saint Michael's Medical Center, Newark, New Jersey, USA
| | - Yong-Hao Yeo
- Department of Internal Medicine/Pediatrics, Beaumont Health, Royal Oak, Michigan, USA
| | - Wern Lynn Ng
- Department of Internal Medicine, University of Pittsburgh Medical Center (UPMC) Harrisburg, Harrisburg, Pennsylvania, USA
| | - Zhi Ven Fong
- Department of Surgery, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Justin T Brady
- Department of Surgery, Mayo Clinic Arizona, Phoenix, Arizona, USA
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Mirande MD, McKenna NP, Sample JW, Bews KA, Brady JT, Colibaseanu DT, Kelley SR. Surgical site infections at prior stoma site after colostomy closure: a multi-institutional analysis. J Gastrointest Surg 2024:S1091-255X(24)00357-3. [PMID: 38523036 DOI: 10.1016/j.gassur.2024.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Revised: 02/27/2024] [Accepted: 03/03/2024] [Indexed: 03/26/2024]
Affiliation(s)
- Maxwell D Mirande
- Department of Surgery, Mayo Clinic Rochester, Rochester, Minnesota, United States
| | - Nicholas P McKenna
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic Rochester, Rochester, Minnesota, United States
| | - Jack W Sample
- Department of Surgery, Mayo Clinic Rochester, Rochester, Minnesota, United States
| | - Katherine A Bews
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic Rochester, Rochester, Minnesota, United States
| | - Justin T Brady
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic Phoenix, Phoenix, Arizona, United States
| | - Dorin T Colibaseanu
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic Jacksonville, Jacksonville, Florida, United States; Department of Quantitative Health Sciences, Mayo Clinic Jacksonville, Jacksonville, Florida, United States
| | - Scott R Kelley
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic Rochester, Rochester, Minnesota, United States.
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Mirande MD, McKenna NP, Bews KA, Shawki SF, Cima RR, Brady JT, Colibaseanu DT, Mathis KL, Kelley SR. Risk factors for surgical site infections and trends in skin closure technique after diverting loop ileostomy reversal: A multi-institutional analysis. Am J Surg 2023; 226:703-708. [PMID: 37567817 DOI: 10.1016/j.amjsurg.2023.07.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 07/27/2023] [Accepted: 07/31/2023] [Indexed: 08/13/2023]
Abstract
BACKGROUND Surgical site infections (SSIs) are one of the most common complications following diverting loop ileostomy (DLI) closures. This study assesses SSIs after DLI closure and the temporal trends in skin closure technique. METHODS A retrospective review was conducted using the American College of Surgeons National Surgical Quality Improvement Program database for adult patients who underwent a DLI closure between 2012 and 2021 across a multistate health system. Skin closure technique was categorized as primary, primary + drain, or purse-string closure. The primary outcome was SSI at the former DLI site. RESULTS A SSI was diagnosed in 5.7% of patients; 6.9% for primary closure, 5.7% for primary closure + drain, and 2.7% for purse-string closure (p = 0.25). A diagnosis of Crohn's disease, diverticular disease, and increasing operative time were significant risk factors for SSIs. There was a positive trend in the use of purse-string closure over time (p < 0.0001). CONCLUSIONS This study identified a low SSI rate after DLI closure which did not vary significantly based on skin closure technique. Utilization of purse-string closure increased over time.
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Affiliation(s)
| | | | - Katherine A Bews
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Sherief F Shawki
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | - Robert R Cima
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | - Justin T Brady
- Division of Colon and Rectal Surgery, Mayo Clinic, Phoenix, AZ, USA
| | - Dorin T Colibaseanu
- Division of Colon and Rectal Surgery, Mayo Clinic, Jacksonville, FL, USA; Department of Quantitative Health Sciences, Mayo Clinic, Jacksonville, FL, USA
| | - Kellie L Mathis
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | - Scott R Kelley
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA.
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Han GR, Gong JH, Khurana A, Eltorai AEM, Jorge IA, Brady JT, Jogerst KM. Medicare Reimbursement in Colorectal Surgery: A Growing Problem. Dis Colon Rectum 2023; 66:1194-1202. [PMID: 36649185 DOI: 10.1097/dcr.0000000000002627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Medicare reimbursement rates have decreased across various specialties but have not yet been studied in colorectal surgery. OBJECTIVE This study aimed to analyze Medicare reimbursement trends in colorectal surgery. DESIGN Observational study. SETTING The Centers for Medicare and Medicaid Services' Physician Fee Schedule was evaluated for reimbursement data for the 20 most common colorectal surgery procedures from 2006 to 2020. MAIN OUTCOME MEASURES Inflation-adjusted annual percentage change, compound annual growth rate, and total percentage change were the outcome measures. A subanalysis was performed comparing the changes in reimbursement between 2006 to 2016 and 2016 to 2020 because of legislative changes that went into effect in 2016. RESULTS During the study period, the inflation-unadjusted mean Medicare reimbursement rate for the 20 most common colorectal surgery procedures increased by +15.6%. This rise was surpassed by the inflation rate of +31.3%. Consequently, the inflation-adjusted reimbursement rate decreased by -11%. The adjusted reimbursement rates decreased the most at -33.8% for a flexible colonoscopy with biopsy and increased the most at +45.3% for a diagnostic rigid proctosigmoidoscopy. Annual percentage change was -0.79%, and the compound annual growth rate was -0.98%. There was an accelerated decrease in annual reimbursement rates from 2016 to 2020 at -2.23% compared to 2006 to 2016 at -0.22% ( p = 0.03). The only procedure that had an increase in adjusted reimbursement rate from 2016 to 2020 was the injection of sclerosing solution for hemorrhoids. LIMITATIONS Only Medicare reimbursement data were analyzed. CONCLUSIONS Medicare reimbursements for colorectal surgery procedures are decreasing at an accelerating rate. Although this study is limited to Medicare data, it still presents a representation of overall reimbursement changes because Medicare policies have a ripple effect in the commercial insurance market. It is vital to understand the financial trends to be able to structure future patient care teams and to advocate for the sustainability of colorectal surgery practices in the United States. See Video Abstract at http://links.lww.com/DCR/C136 . REEMBOLSO DE MEDICARE EN CIRUGA COLORRECTAL UN PROBLEMA CRECIENTE ANTECEDENTES: Las tasas de reembolso de Medicare han disminuido en varias especialidades, pero aún no han sido estudiado en cirugía colorrectal.OBJETIVO: Analizar las tendencias de reembolso de Medicare en cirugía colorrectal.DISEÑO: Estudio observacional.CONTEXTO: Se evaluó el programa de tarifas médicas de los Centros de Servicios de Medicare y Medicaid para obtener datos de reembolso de los 20 procedimientos más comunes en cirugía colorrectal entre los años 2006 y 2020.PRINCIPALES MEDIDAS DE RESULTADO: Variación porcentual anual ajustada por inflación, tasa de crecimiento anual compuesta y variación porcentual total. Se realizó un subanálisis comparando los cambios en el reembolso entre los años 2006 a 2016 y 2016 a 2020 debido a los cambios legislativos que entraron en vigencia en 2016.RESULTADOS: Durante el período de estudio, la tasa media de reembolso de Medicare sin ajuste por inflación para los 20 procedimientos más comunes en cirugía colorrectal aumentó en +15,6 %. Esta suba fue superada por la tasa de inflación del +31,3%. En consecuencia, la tasa de reembolso ajustada por inflación disminuyó un -11%. Lo máximo que disminuyeron las tasas ajustadas de reembolso fue a -33,8% para una colonoscopia flexible con biopsia y aumentaron más a +45,3% para una proctosigmoidoscopia rígida de diagnóstico. El cambio porcentual anual fue -0,79% y la tasa de crecimiento anual compuesto fue -0,98%. Hubo una disminución acelerada en las tasas de reembolso anual de 2016 a 2020 a -2,23 % en comparación con 2006 a 2016 a -0,22% ( p = 0,03). El único procedimiento que tuvo un aumento en la tasa de reembolso ajustada de 2016 a 2020 fue la inyección de solución esclerosante para las hemorroides.LIMITACIONES: Solo se analizaron los datos de reembolso de Medicare.CONCLUSIONES: Los reembolsos de Medicare por procedimientos en cirugía colorrectal están disminuyendo a un ritmo acelerado. Aunque este estudio se limita a los datos de Medicare, aún presenta una representación de los cambios generales en los reembolsos, ya que las pólizas de Medicare tienen un efecto dominó en el mercado de seguros comerciales. Es fundamental comprender las tendencias financieras para poder estructurar futuros equipos de atención de pacientes y abogar por la sostenibilidad de las prácticas de cirugía colorrectal en los Estados Unidos. Consulte Video Resumen video en https://links.lww.com/DCR/C136 . (Traducción-Dr. Osvaldo Gauto ).
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Affiliation(s)
- Ga-Ram Han
- Department of Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Jung Ho Gong
- Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Aditya Khurana
- Department of Radiology, Mayo Clinic Minnesota, Rochester, Minnesota
| | - Adam E M Eltorai
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Irving A Jorge
- Department of Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Justin T Brady
- Department of Surgery, Mayo Clinic Arizona, Phoenix, Arizona
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Zhang C, Calderon E, Chang YH, Han GR, Kelley SR, Merchea A, Brady JT, Young-Fadok TM, Etzioni DA, Mishra N. Short and long-term oncologic outcomes of patients with colon cancer of the splenic flexure. Am J Surg 2023:S0002-9610(23)00056-9. [PMID: 36858866 DOI: 10.1016/j.amjsurg.2023.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 01/18/2023] [Accepted: 02/04/2023] [Indexed: 02/09/2023]
Abstract
BACKGROUND There is currently no consensus on surgical management of splenic flexure adenocarcinoma (SFA). METHODS Patients undergoing surgical resection for SFA between 1993 and 2015 were identified. Postoperative outcomes were compared between patients who underwent segmental (SR) vs. anatomical resection (AR). RESULTS One-hundred and thirteen patients underwent SR and 89 underwent AR. More patients in the SR group had open resections, but there were otherwise no differences in demographics or surgical characteristics between the two groups. There were no differences in overall (p = 0.29) or recurrence-free(p = 0.37) survival. On multivariable analysis, increased age (HR 1.04, 1.01-1.07, p = 0.005), higher American Society of Anesthesiology classification (HR 3.1, 1.7-5.71, p < 0.001), and higher tumor stage (HR 8.84, 3.76-20.82, p < 0.001) were predictive of mortality. CONCLUSIONS Short and long-term outcomes after SR and AR for SFA are not different, making SR a viable option for SFA surgical management.
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Affiliation(s)
- Chi Zhang
- Department of Surgery, Mayo Clinic Arizona, Phoenix, AZ, USA; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery Mayo Clinic Rochester, MN, USA
| | | | - Yu Hui Chang
- Department of Quantitative Health Sciences, Scottsdale, AZ, USA
| | - Ga-Ram Han
- Department of Surgery, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Scott R Kelley
- Division of Colon and Rectal Surgery, Mayo Clinic Rochester, Rochester, MN, USA
| | - Amit Merchea
- Department of Colon and Rectal Surgery, Mayo Clinic Florida Jacksonville, FL, USA
| | - Justin T Brady
- Department of Colon and Rectal Surgery, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Tonia M Young-Fadok
- Department of Colon and Rectal Surgery, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - David A Etzioni
- Department of Colon and Rectal Surgery, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Nitin Mishra
- Department of Colon and Rectal Surgery, Mayo Clinic Arizona, Phoenix, AZ, USA.
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Brady JT, Bingmer K, Bliggenstorfer J, Xu Z, Fleming FJ, Remzi FH, Monson JRT, Wexner SD, Dietz DW. Could meeting the standards of the National Accreditation Program for Rectal Cancer in the National Cancer Database improve patient outcomes? Colorectal Dis 2023; 25:916-922. [PMID: 36727838 DOI: 10.1111/codi.16503] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Revised: 01/13/2023] [Accepted: 01/23/2023] [Indexed: 02/03/2023]
Abstract
AIM The National Accreditation Program for Rectal Cancer (NAPRC) was developed to improve rectal cancer patient outcomes in the United States. The NAPRC consists of a set of process and outcome measures that hospitals must meet in order to be accredited. We aimed to assess the potential of the NAPRC by determining whether achievement of the process measures correlates with improved survival. METHODS The National Cancer Database was used to identify patients undergoing curative proctectomy for non-metastatic rectal cancer from 2010 to 2014. NAPRC process measures identified in the National Cancer Database included clinical staging completion, treatment starting <60 days from diagnosis, carcinoembryonic antigen level measured prior to treatment, tumour regression grading and margin assessment. RESULTS There were 48 669 patients identified with a mean age of 62 ± 12.9 years and 61.3% of patients were men. The process measure completed most often was assessment of proximal and distal margins (98.4%) and the measure completed least often was the serum carcinoembryonic antigen level prior to treatment (63.8%). All six process measures were completed in 23.6% of patients. After controlling for age, gender, comorbidities, annual facility resection volume, race and pathological stage, completion of all process measures was associated with a statistically significant mortality decrease (Cox hazard ratio 0.88, 95% CI 0.81-0.94, P < 0.001). CONCLUSION Participating institutions provided complete datasets for all six process measures in less than a quarter of patients. Compliance with all process measures was associated with a significant mortality reduction. Improved adoption of NAPRC process measures could therefore result in improved survival rates for rectal cancer in the United States.
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Affiliation(s)
- Justin T Brady
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Katherine Bingmer
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | | | - Zhaomin Xu
- Department of Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Fergal J Fleming
- Department of Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Feza H Remzi
- Department of Surgery, New York University Langone Medical Center, New York, New York, USA
| | - John R T Monson
- AdventHealth Surgical Health Outcomes Consortium, AdventHealth, Orlando, Florida, USA
| | - Steven D Wexner
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center Cleveland Clinic Florida, Weston, Florida, USA
| | - David W Dietz
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
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Brady JT, Daly MC, Wright JP, Parikh M, Du Y, Monson JRT. Early Onset Rectal Cancer Is Indeed Aggressive and Resistant to Chemotherapy: a National Profile. J Am Coll Surg 2021. [DOI: 10.1016/j.jamcollsurg.2021.07.092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Wright JP, Brady JT, Albert MR. Perineal Proctosigmoidectomy With Levatorplasty (Altemeier) Procedure for the Management of Rectal Prolapse. Dis Colon Rectum 2021; 64:e661. [PMID: 34382600 DOI: 10.1097/dcr.0000000000002210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Jesse P Wright
- Department of Colon and Rectal Surgery, AdventHealth - Orlando, Orlando, Florida
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Senders ZJ, Brady JT, Ladhani HA, Marks J, Ammori JB. Factors Influencing the Entrustment of Resident Operative Autonomy: Comparing Perceptions of General Surgery Residents and Attending Surgeons. J Grad Med Educ 2021; 13:675-681. [PMID: 34721797 PMCID: PMC8527956 DOI: 10.4300/jgme-d-20-01259.1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 03/02/2021] [Accepted: 07/12/2021] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND General surgery residents may be underprepared for practice, due in part to declining operative autonomy during training. The factors that influence entrustment of autonomy in the operating room are unclear. OBJECTIVE To identify and compare the factors that residents and faculty consider influential in entrustment of operative autonomy. METHODS An anonymous survey of 29-item Likert-type scale (1-7, 1 = strongly disagree, 7 = strongly agree), 9 multiple-choice, and 4 open-ended questions was sent to 70 faculty and 45 residents in a large ACGME-approved general surgery residency program comprised of university, county, and VA hospitals in 2018. RESULTS Sixty (86%) faculty and 38 (84%) residents responded. Faculty were more likely to identify resident-specific factors such as better resident reputation and higher skill level as important in fostering entrustment. Residents were more likely to identify environmental factors such as a focus on efficiency and a litigious malpractice environment as impeding entrustment. Both groups agreed that work hour restrictions do not decrease autonomy and entrustment does not increase risk to patients. More residents considered low faculty confidence level as a barrier to operative autonomy, while more faculty considered lower resident clinical skill as a barrier. Improvement in resident preparation for cases was cited as an important intervention that could enhance entrustment. CONCLUSIONS Differences in perspectives exist between general surgery residents and faculty regarding entrustment of autonomy. Residents cite environmental and attending-related factors, while faculty cite resident-specific factors as most influential. Residents and faculty both agree that entrustment is integral to surgical training.
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Affiliation(s)
- Zachary J. Senders
- Zachary J. Senders, MD, is a General Surgery Resident, Department of Surgery, University Hospitals (UH) Cleveland Medical Center
| | - Justin T. Brady
- Justin T. Brady, MD, is a General Surgery Resident, Department of Surgery, UH Cleveland Medical Center
| | - Husayn A. Ladhani
- Husayn A. Ladhani, MD, is a General Surgery Resident, Department of Surgery, UH Cleveland Medical Center
| | - Jeffrey Marks
- Jeffrey Marks, MD, FACS, is Professor of Surgery and Associate Program Director, General Surgery Residency, UH Cleveland Medical Center, Case Western Reserve University School of Medicine
| | - John B. Ammori
- John B. Ammori, MD, FACS, is Associate Professor of Surgery and Program Director, General Surgery Residency, UH Cleveland Medical Center, Case Western Reserve University School of Medicine
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Antunes JT, Ofshteyn A, Bera K, Wang EY, Brady JT, Willis JE, Friedman KA, Marderstein EL, Kalady MF, Stein SL, Purysko AS, Paspulati R, Gollamudi J, Madabhushi A, Viswanath SE. Radiomic Features of Primary Rectal Cancers on Baseline T 2 -Weighted MRI Are Associated With Pathologic Complete Response to Neoadjuvant Chemoradiation: A Multisite Study. J Magn Reson Imaging 2020; 52:1531-1541. [PMID: 32216127 PMCID: PMC7529659 DOI: 10.1002/jmri.27140] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 03/03/2020] [Accepted: 03/04/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Twenty-five percent of rectal adenocarcinoma patients achieve pathologic complete response (pCR) to neoadjuvant chemoradiation and could avoid proctectomy. However, pretreatment clinical or imaging markers are lacking in predicting response to chemoradiation. Radiomic texture features from MRI have recently been associated with therapeutic response in other cancers. PURPOSE To construct a radiomics texture model based on pretreatment MRI for identifying patients who will achieve pCR to neoadjuvant chemoradiation in rectal cancer, including validation across multiple scanners and sites. STUDY TYPE Retrospective. SUBJECTS In all, 104 rectal cancer patients staged with MRI prior to long-course chemoradiation followed by proctectomy; curated from three institutions. FIELD STRENGTH/SEQUENCE 1.5T-3.0T, axial higher resolution T2 -weighted turbo spin echo sequence. ASSESSMENT Pathologic response was graded on postsurgical specimens. In total, 764 radiomic features were extracted from single-slice sections of rectal tumors on processed pretreatment T2 -weighted MRI. STATISTICAL TESTS Three feature selection schemes were compared for identifying radiomic texture descriptors associated with pCR via a discovery cohort (one site, N = 60, cross-validation). The top-selected radiomic texture features were used to train and validate a random forest classifier model for pretreatment identification of pCR (two external sites, N = 44). Model performance was evaluated via area under the curve (AUC), accuracy, sensitivity, and specificity. RESULTS Laws kernel responses and gradient organization features were most associated with pCR (P ≤ 0.01); as well as being commonly identified across all feature selection schemes. The radiomics model yielded a discovery AUC of 0.699 ± 0.076 and a hold-out validation AUC of 0.712 with 70.5% accuracy (70.0% sensitivity, 70.6% specificity) in identifying pCR. Radiomic texture features were resilient to variations in magnetic field strength as well as being consistent between two different expert annotations. Univariate analysis revealed no significant associations of baseline clinicopathologic or MRI findings with pCR (P = 0.07-0.96). DATA CONCLUSION Radiomic texture features from pretreatment MRIs may enable early identification of potential pCR to neoadjuvant chemoradiation, as well as generalize across sites. LEVEL OF EVIDENCE 3 TECHNICAL EFFICACY STAGE: 2.
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Affiliation(s)
- Jacob T. Antunes
- Case Western Reserve University, Department of Biomedical Engineering, Cleveland, OH 44106
| | - Asya Ofshteyn
- University Hospitals Cleveland Medical Center, Department of Surgery, Cleveland, OH, 44106
| | - Kaustav Bera
- Case Western Reserve University, Department of Biomedical Engineering, Cleveland, OH 44106
| | - Erik Y. Wang
- University Hospitals Cleveland Medical Center, Department of Surgery, Cleveland, OH, 44106
| | - Justin T. Brady
- University Hospitals Cleveland Medical Center, Department of Surgery, Cleveland, OH, 44106
| | - Joseph E. Willis
- University Hospitals Cleveland Medical Center, Department of Pathology, Cleveland, OH, 44106
| | - Kenneth A. Friedman
- University Hospitals Cleveland Medical Center, Department of Pathology, Cleveland, OH, 44106
| | - Eric L. Marderstein
- Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, OH, 44106
| | - Matthew F. Kalady
- Cleveland Clinic, Department of Colorectal Surgery, Cleveland, OH, 44106
| | - Sharon L. Stein
- University Hospitals Cleveland Medical Center, Department of Surgery, Cleveland, OH, 44106
| | - Andrei S. Purysko
- Cleveland Clinic, Section of Abdominal Imaging and Nuclear Radiology Department, Cleveland, OH, 44195
| | - Rajmohan Paspulati
- University Hospitals Cleveland Medical Center, Department of Radiology, Cleveland, OH, 44106
| | - Jayakrishna Gollamudi
- University Hospitals Cleveland Medical Center, Department of Radiology, Cleveland, OH, 44106
| | - Anant Madabhushi
- Case Western Reserve University, Department of Biomedical Engineering, Cleveland, OH 44106
- Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, OH, 44106
| | - Satish E. Viswanath
- Case Western Reserve University, Department of Biomedical Engineering, Cleveland, OH 44106
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12
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Alvarez-Jimenez C, Antunes JT, Talasila N, Bera K, Brady JT, Gollamudi J, Marderstein E, Kalady MF, Purysko A, Willis JE, Stein S, Friedman K, Paspulati R, Delaney CP, Romero E, Madabhushi A, Viswanath SE. Radiomic Texture and Shape Descriptors of the Rectal Environment on Post-Chemoradiation T2-Weighted MRI are Associated with Pathologic Tumor Stage Regression in Rectal Cancers: A Retrospective, Multi-Institution Study. Cancers (Basel) 2020; 12:cancers12082027. [PMID: 32722082 PMCID: PMC7463898 DOI: 10.3390/cancers12082027] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 06/29/2020] [Accepted: 07/03/2020] [Indexed: 02/06/2023] Open
Abstract
(1) Background: The relatively poor expert restaging accuracy of MRI in rectal cancer after neoadjuvant chemoradiation may be due to the difficulties in visual assessment of residual tumor on post-treatment MRI. In order to capture underlying tissue alterations and morphologic changes in rectal structures occurring due to the treatment, we hypothesized that radiomics texture and shape descriptors of the rectal environment (e.g., wall, lumen) on post-chemoradiation T2-weighted (T2w) MRI may be associated with tumor regression after neoadjuvant chemoradiation therapy (nCRT). (2) Methods: A total of 94 rectal cancer patients were retrospectively identified from three collaborating institutions, for whom a 1.5 or 3T T2w MRI was available after nCRT and prior to surgical resection. The rectal wall and the lumen were annotated by an expert radiologist on all MRIs, based on which 191 texture descriptors and 198 shape descriptors were extracted for each patient. (3) Results: Top-ranked features associated with pathologic tumor-stage regression were identified via cross-validation on a discovery set (n = 52, 1 institution) and evaluated via discriminant analysis in hold-out validation (n = 42, 2 institutions). The best performing features for distinguishing low (ypT0-2) and high (ypT3-4) pathologic tumor stages after nCRT comprised directional gradient texture expression and morphologic shape differences in the entire rectal wall and lumen. Not only were these radiomic features found to be resilient to variations in magnetic field strength and expert segmentations, a quadratic discriminant model combining them yielded consistent performance across multiple institutions (hold-out AUC of 0.73). (4) Conclusions: Radiomic texture and shape descriptors of the rectal wall from post-treatment T2w MRIs may be associated with low and high pathologic tumor stage after neoadjuvant chemoradiation therapy and generalized across variations between scanners and institutions.
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Affiliation(s)
- Charlems Alvarez-Jimenez
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH 44106, USA; (C.A.-J.); (J.T.A.); (K.B.); (K.F.); (A.M.)
- Computer Imaging and Medical Application Laboratory, Universidad Nacional de Colombia, Bogotá 111321, Colombia;
| | - Jacob T. Antunes
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH 44106, USA; (C.A.-J.); (J.T.A.); (K.B.); (K.F.); (A.M.)
| | - Nitya Talasila
- Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, GA 30332, USA;
| | - Kaustav Bera
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH 44106, USA; (C.A.-J.); (J.T.A.); (K.B.); (K.F.); (A.M.)
| | - Justin T. Brady
- Department of General Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA; (J.T.B.); (S.S.)
| | - Jayakrishna Gollamudi
- Department of Abdominal Imaging, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA;
| | - Eric Marderstein
- Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, OH 44106, USA;
| | - Matthew F. Kalady
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, OH 44106, USA; (M.F.K.); (C.P.D.)
| | - Andrei Purysko
- Section of Abdominal Imaging and Nuclear Radiology Department, Cleveland Clinic, Cleveland, OH 44195, USA;
| | - Joseph E. Willis
- Department of Pathology, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA;
| | - Sharon Stein
- Department of General Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA; (J.T.B.); (S.S.)
| | - Kenneth Friedman
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH 44106, USA; (C.A.-J.); (J.T.A.); (K.B.); (K.F.); (A.M.)
| | - Rajmohan Paspulati
- Department of Radiology, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA;
| | - Conor P. Delaney
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, OH 44106, USA; (M.F.K.); (C.P.D.)
| | - Eduardo Romero
- Computer Imaging and Medical Application Laboratory, Universidad Nacional de Colombia, Bogotá 111321, Colombia;
| | - Anant Madabhushi
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH 44106, USA; (C.A.-J.); (J.T.A.); (K.B.); (K.F.); (A.M.)
- Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, OH 44106, USA;
| | - Satish E. Viswanath
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH 44106, USA; (C.A.-J.); (J.T.A.); (K.B.); (K.F.); (A.M.)
- Correspondence:
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13
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Ofshteyn A, Weaver AB, Brady JT, Idrees J, Coronado WM, Steele SR, Reynolds H, Steinhagen E, Stein SL. Institutional Outcomes Should Be a Determinant in Decision to Perform Laparoscopic Proctectomies for Rectal Cancer. Cureus 2020; 12:e7666. [PMID: 32419994 PMCID: PMC7226664 DOI: 10.7759/cureus.7666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Purpose Minimally invasive rectal cancer (RC) resection has become common, despite recent high-profile trials failing to show non-inferiority to open proctectomy. We hypothesized that at a high-volume center, laparoscopic resection may have superior outcomes compared to those seen in ALaCaRT and ACOSOG Z6051. Methods Retrospective review of patients undergoing laparoscopic proctectomy from 2007 to 2015 for RC was performed at a high-volume center. Primary outcome was successful resection defined by negative circumferential resection margin (CRM) and distal margin (DM), and complete total mesorectal excision (TME). Results A total of 89 patients were included. Of 33 patients with TME grading, 31 (93.9%) had complete/near complete TME, and 29 (87.9%) had a “successful resection” compared with 81.7% in ACOSOG and 82% in ALaCART trials using same criteria. CRM was ≥1 mm in 87 (97.8%) of patients. Mean DM was 3.8 cm; 97.8% of patients had negative DM. Conclusion High-volume centers can achieve similar high quality RC outcomes to those demonstrated in recent trials. Institutional outcomes should determine optimal surgical technique.
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Affiliation(s)
- Asya Ofshteyn
- Surgery, University Hospitals Cleveland Medical Center / University Hospitals Research in Surgical Outcomes & Effectiveness Center (UH-RISES), Cleveland, USA
| | - Allson B Weaver
- Surgery, University Hospitals Cleveland Medical Center / University Hospitals Research in Surgical Outcomes & Effectiveness Center (UH-RISES), Cleveland, USA
| | - Justin T Brady
- Surgery, University Hospitals Cleveland Medical Center / University Hospitals Research in Surgical Outcomes & Effectiveness Center (UH-RISES), Cleveland, USA
| | - Jay Idrees
- General Surgery, University Hospitals Cleveland Medical Center / University Hospitals Research in Surgical Outcomes & Effectiveness Center (UH-RISES), Cleveland, USA
| | - Wendy M Coronado
- Surgery, University Hospitals Cleveland Medical Center / University Hospitals Research in Surgical Outcomes & Effectiveness Center (UH-RISES), Cleveland, USA
| | | | - Harry Reynolds
- Surgery, Harney District Hospital, Burns, USA.,Surgery, University Hospitals Cleveland Medical Center / University Hospitals Research in Surgical Outcomes & Effectiveness Center (UH-RISES), Cleveland, USA
| | - Emily Steinhagen
- Surgery, University Hospitals Cleveland Medical Center / University Hospitals Research in Surgical Outcomes & Effectiveness Center (UH-RISES), Cleveland, USA
| | - Sharon L Stein
- Colorectal Surgery, University Hospitals Cleveland Medical Center / University Hospitals Research in Surgical Outcomes & Effectiveness Center (UH-RISES), Cleveland, USA
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Brady JT, Althans AR, Nishtala M, Steele SR, Stein SL, Reynolds HL, Delaney CP, Steinhagen E. Does umbilical contamination correlate with colorectal surgery patient outcomes? Int J Colorectal Dis 2020; 35:95-100. [PMID: 31781841 DOI: 10.1007/s00384-019-03443-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/23/2019] [Indexed: 02/04/2023]
Abstract
PURPOSE Most preoperative assessment tools to evaluate risk for postoperative complications require multiple data points to be collected and can be logistically burdensome. This study evaluated if umbilical contamination, a simple bedside assessment, correlated with surgical outcomes. METHODS A 6-point score to measure umbilical contamination was developed and applied prospectively to patients undergoing colorectal surgery at an academic medical center. RESULTS There were 200 patients enrolled (mean age 58.1 ± 14.8; 56% female). The mean BMI was 28.6 ± 7.4. Indications for surgery included colon cancer (24%), rectal cancer (18%), diverticulitis (13.5%), and Crohn's disease (12.5%). Umbilical contamination scores were 0 (23%, cleanest), 1 (26%), 2 (21%), 3 (24%), 4 (6%), and 5 (0%, dirtiest). Umbilical contamination did not correlate with preoperative functional status (p > 0.2). Umbilical contamination correlated with increased length of stay (rho = 0.19, p = 0.007) and postoperative complications (OR 1.3, 1.02-1.7, p = 0.04), but not readmission (p = 0.3) or discharge disposition (p > 0.2). CONCLUSION Sterile preparation of the abdomen is an important component of proper surgical technique and umbilical contamination correlates with increased postoperative complications.
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Affiliation(s)
- Justin T Brady
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Alison R Althans
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Madhuri Nishtala
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Scott R Steele
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Sharon L Stein
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Harry L Reynolds
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Conor P Delaney
- Digestive Disease and Surgical Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Emily Steinhagen
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA.
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15
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Bingmer K, Wojnarski CM, Brady JT, Stein SL, Ho VP, Steinhagen E. A Model for a Formal Mentorship Program in Surgical Residency. J Surg Res 2019; 243:64-70. [DOI: 10.1016/j.jss.2019.04.068] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 04/08/2019] [Accepted: 04/25/2019] [Indexed: 11/25/2022]
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16
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Richards CR, Steele SR, Lustik MB, Gillern SM, Lim RB, Brady JT, Althans AR, Schlussel AT. Safe surgery in the elderly: A review of outcomes following robotic proctectomy from the Nationwide Inpatient Sample in a cross-sectional study. Ann Med Surg (Lond) 2019; 44:39-45. [PMID: 31312442 PMCID: PMC6610645 DOI: 10.1016/j.amsu.2019.06.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 06/04/2019] [Accepted: 06/04/2019] [Indexed: 12/13/2022] Open
Abstract
Background As our nation's population ages, operating on older and sicker patients occurs more frequently. Robotic operations have been thought to bridge the gap between a laparoscopic and an open approach, especially in more complex cases like proctectomy. Methods Our objective was to evaluate the use and outcomes of robotic proctectomy compared to open and laparoscopic approaches for rectal cancer in the elderly. A retrospective cross-sectional cohort study utilizing the Nationwide Inpatient Sample (NIS; 2006-2013) was performed. All cases were restricted to age 70 years old or greater. Results We identified 6740 admissions for rectal cancer including: 5879 open, 666 laparoscopic, and 195 robotic procedures. The median age was 77 years old. The incidence of a robotic proctectomy increased by 39%, while the open approach declined by 6% over the time period studied. Median (interquartile range) length of stay was shorter for robotic procedures at 4.3 (3-7) days, compared to laparoscopic 5.8 (4-8) and open at 6.7 (5-10) days (p < 0.01), while median total hospital charges were greater in the robotic group compared to laparoscopic and open cases ($64,743 vs. $55,813 vs. $50,355, respectively, p < 0.01). There was no significant difference in the risk of total complications between the different approaches following multivariate analysis. Conclusion Robotic proctectomy was associated with a shorter LOS, and this may act as a surrogate marker for an overall improvement in adverse events. These results demonstrate that a robotic approach is a safe and feasible option, and should not be discounted solely based on age or comorbidities.
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Affiliation(s)
- Carly R. Richards
- Department of Surgery, Tripler Army Medical Center, Honolulu, HI, United States
- Corresponding author. 1 Jarrett White Road, Honolulu, HI, 96859, United States.
| | - Scott R. Steele
- Department of Colon & Rectal Surgery, Cleveland Clinic Foundation, Cleveland, OH, United States
| | - Michael B. Lustik
- Department of Clinical Investigations, Tripler Army Medical Center, Honolulu, HI, United States
| | - Suzanne M. Gillern
- Department of Surgery, Tripler Army Medical Center, Honolulu, HI, United States
| | - Robert B. Lim
- Department of Surgery, Tripler Army Medical Center, Honolulu, HI, United States
| | - Justin T. Brady
- Department of Surgery, University Hospitals Case Medical Center, Cleveland, OH, United States
| | - Ali R. Althans
- Department of Surgery, University Hospitals Case Medical Center, Cleveland, OH, United States
| | - Andrew T. Schlussel
- Department of Surgery, Madigan Army Medical Center, Tacoma, WA, United States
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17
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Antunes J, Viswanath S, Brady JT, Crawshaw B, Ros P, Steele S, Delaney CP, Paspulati R, Willis J, Madabhushi A. Coregistration of Preoperative MRI with Ex Vivo Mesorectal Pathology Specimens to Spatially Map Post-treatment Changes in Rectal Cancer Onto In Vivo Imaging: Preliminary Findings. Acad Radiol 2018; 25:833-841. [PMID: 29371120 DOI: 10.1016/j.acra.2017.12.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Revised: 12/05/2017] [Accepted: 12/08/2017] [Indexed: 10/18/2022]
Abstract
RATIONALE AND OBJECTIVES The objective of this study was to develop and quantitatively evaluate a radiology-pathology fusion method for spatially mapping tissue regions corresponding to different chemoradiation therapy-related effects from surgically excised whole-mount rectal cancer histopathology onto preoperative magnetic resonance imaging (MRI). MATERIALS AND METHODS This study included six subjects with rectal cancer treated with chemoradiation therapy who were then imaged with a 3-T T2-weighted MRI sequence, before undergoing mesorectal excision surgery. Excised rectal specimens were sectioned, stained, and digitized as two-dimensional (2D) whole-mount slides. Annotations of residual disease, ulceration, fibrosis, muscularis propria, mucosa, fat, inflammation, and pools of mucin were made by an expert pathologist on digitized slide images. An expert radiologist and pathologist jointly established corresponding 2D sections between MRI and pathology images, as well as identified a total of 10 corresponding landmarks per case (based on visually similar structures) on both modalities (five for driving registration and five for evaluating alignment). We spatially fused the in vivo MRI and ex vivo pathology images using landmark-based registration. This allowed us to spatially map detailed annotations from 2D pathology slides onto corresponding 2D MRI sections. RESULTS Quantitative assessment of coregistered pathology and MRI sections revealed excellent structural alignment, with an overall deviation of 1.50 ± 0.63 mm across five expert-selected anatomic landmarks (in-plane misalignment of two to three pixels at 0.67- to 1.00-mm spatial resolution). Moreover, the T2-weighted intensity distributions were distinctly different when comparing fibrotic tissue to perirectal fat (as expected), but showed a marked overlap when comparing fibrotic tissue and residual rectal cancer. CONCLUSIONS Our fusion methodology enabled successful and accurate localization of post-treatment effects on in vivo MRI.
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18
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Brady JT, Xu Z, Scarberry KB, Saad A, Fleming FJ, Remzi FH, Wexner SD, Winchester DP, Monson JR, Lee L, Dietz DW. Evaluating the Current Status of Rectal Cancer Care in the US: Where We Stand at the Start of the Commission on Cancer's National Accreditation Program for Rectal Cancer. J Am Coll Surg 2018; 226:881-890. [DOI: 10.1016/j.jamcollsurg.2018.01.057] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Revised: 01/12/2018] [Accepted: 01/16/2018] [Indexed: 10/17/2022]
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19
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Jabir MA, Brady JT, Wen Y, Dosokey EMG, Choi D, Stein SL, Delaney CP, Steele SR. Attempting a Laparoscopic Approach in Patients Undergoing Left-Sided Colorectal Surgery Who Have Had a Previous Laparotomy: Is it Feasible? J Gastrointest Surg 2018; 22:316-320. [PMID: 29127603 DOI: 10.1007/s11605-017-3621-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Accepted: 10/26/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND The feasibility of a laparoscopic approach in patients who have had a prior laparotomy (PL) remains controversial. We hypothesized that laparoscopic colorectal resection was safe and feasible in patients with previous open abdominal surgery. METHODS A retrospective review (2007-2015) of all patients undergoing laparoscopic resection for sigmoid and rectal adenocarcinoma with or without prior midline laparotomy (NPL) was performed. Primary endpoints included conversion and perioperative morbidity. Secondary endpoints included length of stay and perioperative outcomes. Demographics, surgical history, oncologic staging, and short-term outcomes were reviewed. RESULTS We identified 211 patients, of whom 33 (15.6%) had a prior laparotomy. Significantly more patients in the PL group were female (76.2 vs. 52.8%, p = 0.004). Patients with PL were of similar age to NPL patients (69.3 vs. 62.5, p = 0.09), and comorbidities, tumor staging, and neoadjuvant therapy were comparable between groups (all p > 0.05). Additional trocar placement was significantly higher in PL group (33.3 vs. 17.4%, p = 0.03), while conversion rate did not reach statistical significance (24.2 vs. 12.9%, p = 0.08). The postoperative complication rate was comparable between PL and NPL patients (33.3 vs. 25.3%, respectively, p = 0.2). CONCLUSIONS Prior laparotomy should not be a contraindication to patients undergoing laparoscopic colorectal surgery, though surgeons should anticipate a higher likelihood of conversion to open.
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Affiliation(s)
- Murad A Jabir
- Department of Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44106, USA.,Department of Surgical Oncology, South Egypt Cancer Institute, Assiut University, Assiut, Egypt
| | - Justin T Brady
- Department of Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44106, USA
| | - Yuxiang Wen
- Department of Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44106, USA
| | - Eslam M G Dosokey
- Department of Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44106, USA
| | - Dongjin Choi
- Department of Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44106, USA
| | - Sharon L Stein
- Department of Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44106, USA
| | - Conor P Delaney
- Digestive Disease and Surgery Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Scott R Steele
- Department of Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44106, USA. .,Department of Colorectal Surgery, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA.
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20
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Althans AR, Brady JT, Times ML, Keller DS, Harvey AR, Kelly ME, Patel ND, Steele SR. Colorectal Cancer Safety Net: Is It Catching Patients Appropriately? Dis Colon Rectum 2018; 61:115-123. [PMID: 29219921 DOI: 10.1097/dcr.0000000000000944] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Disparities in access to colorectal cancer care are multifactorial and are affected by socioeconomic elements. Uninsured and Medicaid patients present with advanced stage disease and have worse outcomes compared with similar privately insured patients. Safety net hospitals are a major care provider to this vulnerable population. Few studies have evaluated outcomes for safety net hospitals compared with private institutions in colorectal cancer. OBJECTIVE The purpose of this study was to compare demographics, screening rates, presentation stage, and survival rates between a safety net hospital and a tertiary care center. DESIGN Comparative review of patients at 2 institutions in the same metropolitan area were conducted. SETTINGS The study included colorectal cancer care delivered either at 1 safety net hospital or 1 private tertiary care center in the same city from 2010 to 2016. PATIENTS A total of 350 patients with colorectal cancer from each hospital were evaluated. MAIN OUTCOME MEASURES Overall survival across hospital systems was measured. RESULTS The safety net hospital had significantly more uninsured and Medicaid patients (46% vs 13%; p < 0.001) and a significantly lower median household income than the tertiary care center ($39,299 vs $49,741; p < 0.0001). At initial presentation, a similar percentage of patients at each hospital presented with stage IV disease (26% vs 20%; p = 0.06). For those undergoing resection, final pathologic stage distribution was similar across groups (p = 0.10). After a comparable median follow-up period (26.6 mo for safety net hospital vs 29.2 mo for tertiary care center), log-rank test for overall survival favored the safety net hospital (p = 0.05); disease-free survival was similar between hospitals (p = 0.40). LIMITATIONS This was a retrospective review, reporting from medical charts. CONCLUSIONS Our results support the value of safety net hospitals for providing quality colorectal cancer care, with survival and recurrence outcomes equivalent or improved compared with a local tertiary care center. Because safety net hospitals can provide equivalent outcomes despite socioeconomic inequalities and financial constraints, emphasis should be focused on ensuring that adequate funding for these institutions continues. See Video Abstract at http://links.lww.com/DCR/A454.
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Affiliation(s)
- Alison R Althans
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Justin T Brady
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Melissa L Times
- Division of Colorectal Surgery, Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio
| | - Deborah S Keller
- Division of Colorectal Surgery, Department of Surgery, Baylor University Medical Center, Dallas, Texas
| | - Alexis R Harvey
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Molly E Kelly
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Nilam D Patel
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Scott R Steele
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Case Western Reserve University School of Medicine, Cleveland, Ohio
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Althans AR, Tamer P, Brady JT, Steinhagen E, Ho VP. Surgery versus Antibiotics for Uncomplicated Appendicitis: Which Would a Medical Student Want? Surg Infect (Larchmt) 2017; 18:868-873. [PMID: 29027898 DOI: 10.1089/sur.2017.129] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Recent data suggest that treatment of acute, uncomplicated appendicitis (AUA) with antibiotics is as effective as surgery. A 2015 study indicated that more than 50% of patients would choose antibiotic therapy. Medical students represent a unique population of potential patients with greater medical knowledge than the general public and possibly less bias than practicing physicians. Therefore, we aimed to evaluate what the MEDICAL STUDENT'S treatment choice for AUA would be and what factors influence these decisions. METHODS We conducted a survey of current medical students at a single institution. Survey data included demographics, interest in surgery or a procedure-related specialty, knowledge of and experience with surgery and antibiotics, and concerns about treatments. A summary of the literature regarding the efficacy and safety of antibiotics and surgery was presented. Each participant was asked which treatment he or she would choose if affected by AUA. RESULTS A series of 255 medical students completed the survey (mean age 24.8 ± 2.4 y; 51.5% female). The largest number of respondents (41.2%) were second-year students, and more than half (54.2%) reported an interest in a procedure-related specialty. Nearly all (93%) reported prior antibiotic use (19% reporting adverse effects), and 50% had prior surgery (20% reporting adverse events). When asked to identify concerns about each treatment choice, "surgical complications" was selected most frequently (82%) for surgery, and "adverse events and side effects" was selected most frequently for antibiotics (57%). When asked how they would treat their own AUA, 66.3% selected surgery, 24.3% selected antibiotics, and 9.4% were unsure. Race, gender, specialty of interest, year of training, and history of adverse effects related to antibiotics or surgery were not significantly related to treatment choice (all p > 0.1). CONCLUSION When informed of the benefits and risks of surgery and antibiotics to treat AUA, medical students in our study were more likely to choose surgery.
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Affiliation(s)
- Alison R Althans
- 1 Division of Trauma, Acute Care, and Surgical Critical Care, Department of Surgery, University Hospitals Cleveland Medical Center , Cleveland, Ohio
| | - Pierre Tamer
- 1 Division of Trauma, Acute Care, and Surgical Critical Care, Department of Surgery, University Hospitals Cleveland Medical Center , Cleveland, Ohio
| | - Justin T Brady
- 2 Division of Colon and Rectal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center , Cleveland, Ohio
| | - Emily Steinhagen
- 2 Division of Colon and Rectal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center , Cleveland, Ohio
| | - Vanessa P Ho
- 1 Division of Trauma, Acute Care, and Surgical Critical Care, Department of Surgery, University Hospitals Cleveland Medical Center , Cleveland, Ohio
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22
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Brady JT, Althans AR, Neupane R, Dosokey EM, Jabir MA, Reynolds HL, Steele SR, Stein SL. Treatment for anal fissure: Is there a safe option? Am J Surg 2017; 214:623-628. [DOI: 10.1016/j.amjsurg.2017.06.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Revised: 05/25/2017] [Accepted: 06/18/2017] [Indexed: 01/03/2023]
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Abstract
Social media is a source of news and information for an increasing portion of the general public and physicians. The recent political election was a vivid example of how social media can be used for the rapid spread of "fake news" and that posts on social media are not subject to fact-checking or editorial review. The medical field is susceptible to propagation of misinformation, with poor differentiation between authenticated and erroneous information. Due to the presence of social "bubbles," surgeons may not be aware of the misinformation that patients are reading, and thus, it may be difficult to counteract the false information that is seen by the general public. Medical professionals may also be prone to unrecognized spread of misinformation and must be diligent to ensure the information they share is accurate.
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Affiliation(s)
- Justin T Brady
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Molly E Kelly
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Sharon L Stein
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
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Althans AR, Brady JT, Keller DS, Stein SL, Steele SR, Times M. Are we catching women in the safety net? Colorectal cancer outcomes by gender at a safety net hospital. Am J Surg 2017; 214:715-720. [PMID: 28918849 DOI: 10.1016/j.amjsurg.2017.07.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Revised: 06/29/2017] [Accepted: 07/17/2017] [Indexed: 01/13/2023]
Abstract
BACKGROUND Our goal was to evaluate presentation and outcomes for colorectal cancer across gender in a safety net hospital (SNH). METHODS An institutional Tumor Registry was reviewed for colorectal cancer resections 12/2009-2/2016. Patients were stratified into male and female cohorts. The main outcome measures were stage at presentation and oncologic outcomes across gender. RESULTS 170 women (48.6%) and 180 men (51.4%) were evaluated; 129 (84.1%) females and 143 (79.4%) males underwent curative resection. There were no significant differences in prior colorectal cancer screening. On presentation, there were similar rates of stage IV disease across genders (p = 0.3). After median follow-up of 26.5 months (female) and 29.9 months (male), there were no significant differences in overall survival, survival by stage, or disease-free survival by gender (all p = 0.7). The local (1.4% females vs. 2.6% males, p = 0.7) and distant recurrence (16.6% females vs. 14.9% males, p = 0.7) were similar across gender. CONCLUSION With equal access to treatment, there were no significant differences in overall survival, survival by stage, or local or distant recurrence rates by gender. These findings stress the importance of the SNH system, and need for continued support.
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Affiliation(s)
- Alison R Althans
- Department of Surgery, Division of Colorectal Surgery, University Hospitals Case Medical Center, Cleveland, OH, USA
| | - Justin T Brady
- Department of Surgery, Division of Colorectal Surgery, University Hospitals Case Medical Center, Cleveland, OH, USA
| | - Deborah S Keller
- Department of Surgery, Division of Colorectal Surgery, Baylor University Medical Center, Dallas, TX, USA
| | - Sharon L Stein
- Department of Surgery, Division of Colorectal Surgery, University Hospitals Case Medical Center, Cleveland, OH, USA
| | - Scott R Steele
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Melissa Times
- Department of Surgery, Division of Colorectal Surgery, MetroHealth Medical Center, Cleveland, OH, USA.
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Brady JT, Bhakta A, Steele SR, Trunzo JA, Senagore AJ, Holmgren K, Schillero A, Champagne BJ. Reprocessed bipolar energy for laparoscopic colectomy: Is it worth it? Am J Surg 2017; 214:59-62. [DOI: 10.1016/j.amjsurg.2017.02.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Revised: 01/24/2017] [Accepted: 02/11/2017] [Indexed: 11/28/2022]
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Dosokey EMG, Brady JT, Neupane R, Jabir MA, Stein SL, Reynolds HL, Delaney CP, Steele SR. Do patients requiring a multivisceral resection for rectal cancer have worse oncologic outcomes than patients undergoing only abdominoperineal resection? Am J Surg 2017. [PMID: 28622838 DOI: 10.1016/j.amjsurg.2017.05.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Abdominoperineal Resection (APR) remains an important option for patients with advanced rectal cancer though some may require multivisceral resection (MVR) in addition to APR. We hypothesized that oncological outcomes would be worse with MVR. METHODS A retrospective review from 2006 to 2015 of 161 patients undergoing APR or MVR for rectal cancer, of whom 118 underwent curative APR or APR with MVR. Perioperative, oncologic and survival metrics were evaluated. RESULTS There were 82 patients who underwent APR and 36 who underwent MVR. Surgical approach and incidence of complications were similar (All P > 0.05). There was 1 local recurrence in each of the APR and MVR groups at a mean follow-up of 34 and 32 months, respectively. Distant recurrences occurred in 3 APR patients and 4 MVR patients. CONCLUSIONS APR and APR with MVR can be performed with comparable morbidity and oncologic outcomes.
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Affiliation(s)
- Eslam M G Dosokey
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA; Department of Surgical Oncology, SECI, Assiut University, Assiut, Egypt
| | - Justin T Brady
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA.
| | - Ruel Neupane
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Murad A Jabir
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Sharon L Stein
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Harry L Reynolds
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Conor P Delaney
- Digestive Disease and Surgical Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Scott R Steele
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA.
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Brady JT, Ko B, Stein SL. High-resolution anoscopy: Is it necessary in the management of anal epithelial neoplasia. Seminars in Colon and Rectal Surgery 2017. [DOI: 10.1053/j.scrs.2017.04.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Brady JT, Crawshaw BP, Murrell B, Dosokey EMG, Jabir MA, Steele SR, Stein SL, Reynolds HL. Influence of intraoperative radiation therapy on locally advanced and recurrent colorectal tumors: A 16-year experience. Am J Surg 2017; 213:586-589. [PMID: 28160966 DOI: 10.1016/j.amjsurg.2016.10.036] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Revised: 09/15/2016] [Accepted: 10/14/2016] [Indexed: 11/24/2022]
Abstract
BACKGROUND Intraoperative radiation therapy (IORT) has been proposed as a tool to improve local control in patients with locally advanced primary or recurrent colorectal cancer. METHODS A retrospective review (1999-2015) of all patients undergoing IORT for locally advanced or recurrent colorectal cancer at a single academic center was performed. Patient demographics, oncologic staging, short-term and long-term outcomes were reviewed. RESULTS There were 77 patients (mean age 63 ± 11 years) identified, of whom 19 had colon cancer, 57 had rectal cancer, and 2 had appendiceal cancers. R0 resection was performed in 53 patients (69%), R1 in 19 (25%) and R2 in 5 (6%). Ten (13%) patients had a local recurrence at 18 ± 14 months and 34 (44%) had a distant recurrence at 18 ± 18 months. Mean survival was 47 ± 41 months. CONCLUSION IORT resulted in low local failure rates and should be considered for patients with locally advanced or recurrent colorectal cancers.
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Affiliation(s)
- Justin T Brady
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA.
| | - Benjamin P Crawshaw
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | | | - Eslam M G Dosokey
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Murad A Jabir
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Scott R Steele
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Sharon L Stein
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Harry L Reynolds
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA.
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Wen Y, Jabir MA, Keating M, Althans AR, Brady JT, Champagne BJ, Delaney CP, Steele SR. Alvimopan in the setting of colorectal resection with an ostomy: To use or not to use? Surg Endosc 2016; 31:3483-3488. [PMID: 27928668 DOI: 10.1007/s00464-016-5373-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Accepted: 11/21/2016] [Indexed: 01/08/2023]
Abstract
BACKGROUND Postoperative ileus (POI) is a major cause of morbidity, increased length of stay (LOS) and hospital cost after colorectal surgery. Alvimopan is a µ-opioid antagonist used to accelerate upper and lower gastrointestinal function after bowel resection. We hypothesized that alvimopan would reduce LOS in patients undergoing colorectal resection with stoma, a situation that has not been evaluated. METHODS A retrospective review (2010-2015) identified 58 patients who underwent colorectal resection for benign or malignant disease with stoma creation and received alvimopan. They were case-matched to 58 non-alvimopan patients based on age, BMI, baseline comorbidities, stoma type created and surgical approach. We compared overall LOS, incidence of POI and other postoperative complications. RESULTS There were equal numbers of laparoscopic (N = 18) and open resections (N = 40) in the alvimopan group and non-alvimopan group. There were also equal numbers of patients with an ileostomy (N = 37) or colostomy (N = 21) in each group. Overall, 41 patients underwent resection for malignant disease in the alvimopan group compared to 37 in the non-alvimopan group. There was a significant reduction in median LOS overall (alvimopan 5 (4-7) versus control 6 (4.75-9.25) days, P = 0.03). While the 6-day median LOS was similar for patients undergoing ileostomy creation (P = 0.25), alvimopan patients had a 3-day decreased median LOS that approached statistical significance (P = 0.06). The overall 30-day complication rate was higher in the control group (41.4 vs. 51.7%, P = 0.26), but the readmission rate within 30 days was higher in the alvimopan group (19 vs. 13.8%, P = 0.45). Neither of these differences reached statistically significance. CONCLUSION The use of alvimopan in patients undergoing colorectal resection with stoma is associated with a significantly shorter LOS, but the increased readmission rate warrants further study. Based on these data, alvimopan should be evaluated in a controlled setting for patients undergoing colorectal resection with colostomy creation.
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Affiliation(s)
- Yuxiang Wen
- Department of Colorectal Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44016, USA
| | - Murad A Jabir
- Department of Colorectal Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44016, USA
| | - Michael Keating
- Department of Colorectal Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44016, USA
| | - Alison R Althans
- Department of Colorectal Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44016, USA
| | - Justin T Brady
- Department of Colorectal Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44016, USA.
| | - Bradley J Champagne
- Department of Colorectal Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44016, USA
| | - Conor P Delaney
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Scott R Steele
- Department of Colorectal Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44016, USA
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Wen Y, Althans AR, Brady JT, Dosokey EMG, Choi D, Nishtala M, Delaney CP, Steele SR. Evaluating surgical management and outcomes of colovaginal fistulas. Am J Surg 2016; 213:553-557. [PMID: 27889268 DOI: 10.1016/j.amjsurg.2016.11.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Revised: 09/02/2016] [Accepted: 11/05/2016] [Indexed: 01/26/2023]
Abstract
BACKGROUND Colovaginal fistula is a rare condition associated with significant morbidity. The literature characterizing colovaginal fistula repair is sparse. We present our institution's experience treating colovaginal fistulas. METHODS A retrospective review of all patients surgically treated for colovaginal fistula between 2005 and 2015 was performed. Patient demographics, intra-operative details, and post-operative outcomes were reviewed. RESULTS We identified 27 patients with a mean age of 71 (±13) and BMI of 30 (±9). The most common etiology for fistula was diverticulitis (n = 24, 89%). A laparoscopic approach was initiated in 19 patients (70%) and an open approach for 8 (30%) with 8 patients converted from laparoscopy to open (42%). At a mean follow-up of 18 months (±21), there were no recurrences. CONCLUSION We present one of the largest series of the surgical management of colovaginal fistulas. Although our conversion rate was high, we recommend a laparoscopic approach be utilized when feasible.
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Affiliation(s)
- Yuxiang Wen
- Department of Surgery, Division of Colorectal Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA
| | - Alison R Althans
- Department of Surgery, Division of Colorectal Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA
| | - Justin T Brady
- Department of Surgery, Division of Colorectal Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA.
| | - Eslam M G Dosokey
- Department of Surgery, Division of Colorectal Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA
| | - Dongjin Choi
- Department of Surgery, Division of Colorectal Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA
| | - Madhuri Nishtala
- Department of Surgery, Division of Colorectal Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA
| | - Conor P Delaney
- Digestive Disease and Surgery Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Scott R Steele
- Department of Surgery, Division of Colorectal Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA
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Abstract
Transient ileus is a normal physiologic process after surgery. When prolonged, it is an important contributor to postoperative complications, increased length of stay and increased healthcare costs. Efforts have been made to prevent and manage postoperative ileus; alvimopan is an oral, peripheral μ-opioid receptor antagonist, and the only currently US FDA-approved medication to accelerate the return of gastrointestinal function postoperatively.
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Affiliation(s)
- Justin T Brady
- a University Hospitals Case Medical Center, Division of Colorectal Surgery, Cleveland, Ohio, USA
| | - Eslam M G Dosokey
- a University Hospitals Case Medical Center, Division of Colorectal Surgery, Cleveland, Ohio, USA
| | - Benjamin P Crawshaw
- a University Hospitals Case Medical Center, Division of Colorectal Surgery, Cleveland, Ohio, USA
| | - Scott R Steele
- a University Hospitals Case Medical Center, Division of Colorectal Surgery, Cleveland, Ohio, USA
| | - Conor P Delaney
- a University Hospitals Case Medical Center, Division of Colorectal Surgery, Cleveland, Ohio, USA
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Rothenberg SJ, Barnett JF, Dearlove GE, Parker RM, Ball DJ, Brady JT, Yeh HC, Greenspan BJ. Characterization of a microprocessor-controlled tubular multiple metered dose inhaler aerosol generator for inhalation exposures of pharmaceuticals. J Aerosol Med 2001; 13:157-67. [PMID: 11066019 DOI: 10.1089/jam.2000.13.157] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
A microprocessor-controlled tubular multiple metered dose inhaler (MDI) aerosol generator was constructed for the delivery of pharmaceutical aerosols to inhalation chambers. The MDIs were mounted in four cassettes containing one to four MDIs on a stepped end plate. The MDIs in each cassette were pneumatically activated at intervals that were controlled by the microprocessor. The cassettes permitted easy replacement of each set of MDIs with a fresh set of MDIs whenever necessary. Aerosol concentration was controlled by varying the number of active MDIs in each cassette and the frequency of activations per minute of each row. Aerosol from the MDIs flowed along the long axis of the tube, which provided a path length sufficient to diminish impaction losses. Using a light-scattering device to monitor the aerosol concentration, the pulsatile output from the MDIs in the cassettes was demonstrated to be adequately damped out provided that the dilution/mixing/aging chamber exceeded 3 ft in length. The tube diameter selected was the minimum compatible with mounting the required number of MDIs so that the linear velocity of the aerosol was adequate to efficiently transport the aerosol out of the dilution chamber. Aerosol concentration and particle size data were recorded for a nose-only rodent exposure chamber. Reproducible aerosol concentrations ranging from 0.03 to 0.6 mg/L were generated. Particle sizes ranged from 2- to 3-microm mass median aerodynamic diameter. Thus, the aerosol generated was within the size range suitable for inhalation exposures.
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Affiliation(s)
- S J Rothenberg
- Primedica Argus Research Laboratories, Horsham, Pennsylvania 19044, USA.
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Abstract
OBJECTIVE To determine whether QT interval is prolonged or sudden death is caused by ventricular fibrillation resulting from torsades de pointes and to identify hemodynamic effects of ontazolast. ANIMALS 28 Beagles. PROCEDURE Physiologic variables were measured for 2 hours in conscious dogs given ontazolast (0, 1, or 3 mg/kg of body weight, IV) and for 1 hour in anesthetized dogs given cumulative doses of ontazolast (0, 1, 3, 6, or 8 mg/kg, IV). RESULTS Ontazolast prolonged QT interval and QT interval corrected for heart rate (QTc) at doses of 6 mg/kg in anesthetized dogs. At 8 mg/kg, both variables remained prolonged but tended to decrease. In conscious dogs, ontazolast increased QT interval and QTc 15 minutes after administration, but both variables returned to reference ranges by 60 minutes. In conscious dogs, ontazolast increased maximum rate of increase of left ventricular pressure and maximal velocity of fiber shortening, indicators of inotropy, and increased tau, indicating a decreased rate of relaxation. One conscious dog receiving 3 mg/kg developed nonfatal torsades de pointes, but another conscious dog developed ventricular fibrillation. Two anesthetized dogs receiving 6 mg/kg developed early afterdepolarizations, and all dogs developed secondary components in theirT waves. CONCLUSION AND CLINICAL RELEVANCE Ontazolast possesses potent class-III antiarrhythmic properties and induces prolongation of QTc in a dose-dependent fashion. Because there was a clear dose-dependent prolongation of QT interval in all instances, ontazolast may serve as a positive-control compound for studying other compounds that are believed to prolong the QT interval.
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Affiliation(s)
- R L Hamlin
- Department of Veterinary Biosciences, College of Veterinary Medicine, The Ohio State University, Columbus 43210-1092, USA
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Brady JT, Birge RB, Khairallah EA, Cohen SD. Post-treatment protection with piperonyl butoxide against acetaminophen hepatotoxicity is associated with changes in selective but not total covalent binding. Adv Exp Med Biol 1991; 283:689-92. [PMID: 2069040 DOI: 10.1007/978-1-4684-5877-0_88] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- J T Brady
- Toxicology Program: Department of Pharmacology, University of Connecticut, Storrs 06269
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Beierschmitt WP, Brady JT, Bartolone JB, Wyand DS, Khairallah EA, Cohen SD. Selective protein arylation and the age dependency of acetaminophen hepatotoxicity in mice. Toxicol Appl Pharmacol 1989; 98:517-29. [PMID: 2718178 DOI: 10.1016/0041-008x(89)90180-4] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Male CD-1 mice 1, 1.5, 2, and 3 months old were given 600 mg of acetaminophen (APAP)/kg, po, and liver damage was assessed 12 hr later. The most severe hepatotoxicity was in 3-month-old mice, while the other age groups exhibited little damage. The onset of susceptibility to APAP hepatotoxicity did not correlate with the level of activity of the mixed-function oxidase system as assessed in vitro, since drug metabolizing capability was similar between 2- and 3-month-old mice. Through 4 hr after administration of APAP to 2- and 3-month-old mice in vivo, glutathione (GSH) depletion and both plasma and liver APAP concentrations were similar between ages. Additionally, 24 hr after dosing, 3-month-old mice excreted marginally more APAP-glucuronide conjugate and parent compound in urine than 2-month-old animals, while both age groups excreted similar amounts of the APAP-sulfate and GSH-derived conjugates. Even though the extent of binding of radioactive APAP to macromolecules at 4 hr was similar between 2- and 3-month-old animals, the pattern of immunochemically targetted cytosolic and microsomal proteins was different. Thus, in APAP exposure the extent of binding to specific proteins rather than the overall amount of covalent binding may be the critical determinant of the hepatotoxic response. In the present study, the age-related differences in susceptibility to APAP-induced hepatotoxicity were related to the differences in selective protein arylation.
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Affiliation(s)
- W P Beierschmitt
- Section of Pharmacology and Toxicology, School of Pharmacy, University of Connecticut, Storrs 06269
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Brady JT, Montelius DA, Beierschmitt WP, Wyand DS, Khairallah EA, Cohen SD. Effect of piperonyl butoxide post-treatment on acetaminophen hepatotoxicity. Biochem Pharmacol 1988; 37:2097-9. [PMID: 3377813 DOI: 10.1016/0006-2952(88)90562-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Affiliation(s)
- J T Brady
- Department of Pharmacology and Toxicology, University of Connecticut, Storrs 06268
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Abstract
A sensitive and specific method is presented for the quantification of disopyramide, a new antiarrhythmic agent, in blood plasma or serum. Aminopentamide, a chemically similar compound, is added to the biological fluid, and the two compounds are extracted with chloroform. The concentrated extract is treated with trifluoroacetic anhydride, resulting in the dehydration of the primary amide group of the drug and internal standard to the corresponding nitriles. The dehydrated derivatives are gas chromatographed and detected using a nitrogen-phosphorus detector. The method is applicable to the determination of the drug in plasma in the 1-10 microgram/mL concentration range.
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Peck CC, Odom DG, Friedman HI, Albro PW, Hass JR, Brady JT, Jess DA. Di-2-ethylhexyl phthalate (DEHP) and mono-2-ethylhexyl phthalate (MEHP) accumulation in whole blood and red cell concentrates. Transfusion 1979; 19:137-46. [PMID: 432924 DOI: 10.1046/j.1537-2995.1979.19279160282.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Plasma DEHP concentrations were measured weekly in whole blood and red cell concentrates (RCC) during 21 days of storage in standard CPD within PL-130 blood bags. In addition, DEHP and MEHP accumulation patterns were investigated in blood stored for 42 days in modified CPD with adenine within PL-146 and BB-69 storage containers. Total per-unit plasma DEHP of RCC units was 49 to 71 per cent of the total in plasma of whole blood units (PL-130). From 28 to 42 days, mean DEHP levels were 12 to 19 per cent higher in whole blood stored in PL-146 than in BB-69. Although MEHP was not found in any blood bag plastic, MEHP accumulated in plasma during whole blood storage. MEHP concentrations were 2.8 to 3.8 times higher in plasma stored in BB-69 than in PL-146. It is postulated that MEHP arises from hydrolysis of DEHP by plasma lipase, even in frozen plasma sample, and that the rate of this reaction is influenced by blood bag plastic surface characteristics.
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Abstract
A reaction which oligomerizes nucleotides under possible prebiotic conditions has been characterized. Nucleoside monophosphate in the presence of cyanamide at acid pH condenses to form dithymideine pyrophosphate and phosphodiester bonded compounds. Imidazole compounds and activated precursors such as nucleoside triphosphate are not necessary for this ologomerization reaction which produces primarily cyclic ologonucleotides.
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Brady JT, Zagorski JA. Collaborative Study of Enzymatic Glucose Determination in Corn Starch Hydrolysates. J AOAC Int 1969. [DOI: 10.1093/jaoac/52.3.556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Abstract
Glucose in starch hydrolysates was determined by catalytic oxidation of glucose with glucose oxidase to form hydrogen peroxide which, in the presence of peroxidase and a chromogen, yields a colored product. This product, when acidified, is very stable and the color intensity is proportional to the glucose concentration in the sample. Fermco Test S.F.G., a package containing all the ingredients necessary for the reaction, was used. Eleven collaborators who analyzed five different sirup samples found the method to be adequate for determining glucose. Results compared well with those by paper and gas chromatography. The method is recommended for adoption as official first action.
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Affiliation(s)
- J T Brady
- Union Division, Miles Laboratories, Inc., 900 19th St., Granite City, Ill. 62040
| | - J A Zagorski
- Union Division, Miles Laboratories, Inc., 900 19th St., Granite City, Ill. 62040
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Walwick ER, Brady JT, Kay RE. Evaluation of T3 coliphage injuries and efficacy of selected materials in preventing them. Appl Microbiol 1967; 15:885-92. [PMID: 4860532 PMCID: PMC547088 DOI: 10.1128/am.15.4.885-892.1967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
A procedure was developed to analyze the inactivation of coliphage T3 during freeze-drying and subsequent rehydration. The amount of gross disruption of the phage as compared with the amount of phage remaining intact was evaluated by cesium chloride density gradient centrifugation. The amount of phage material able to adsorb to host cells and the residual infectivity after the drying were also evaluated. These analyses made it possible to determine the amount of phage material (i) degraded to protein and nucleic acid, (ii) intact or largely intact, (iii) capable of adsorption on host cells, and (iv) infective. The capacities of casein hydrolysate, ascorbic acid, thiourea, bovine albumin, polyethyleneglycol, raffinose, inositol, and lipoproteins to protect T3 bacteriophage from the stress of freeze-drying were investigated.
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