Information transparency with immediate release: Oncology clinician and patient perceptions

INTRODUCTION

As part of the 21st Century Cures Act (April 2021), electronic health information (EHI) must be immediately released to patients. In this study, we sought to evaluate clinician and patient perceptions regarding this immediate release.

METHODS

After surveying 33 clinicians and 30 patients, semi-structured interviews were conducted with a subset of the initial sample, comprising 8 clinicians and 12 patients. Open-ended questions explored clinicians' and patients' perceptions of immediate release of EHI and how they adjusted to this change.

RESULTS

Ten themes were identified: Interpreting Results, Strategies for Patient Interaction, Patient Experiences, Communication Strategies, Provider Limitations, Provider Experiences, Health Information Interfaces, Barriers to Patient Understanding, Types of Results, and Changes due to Immediate Release. Interviews demonstrated differences in perceived patient distress and comprehension, emphasizing the impersonal nature of electronic release and necessity for therapeutic clinician-patient communication.

CONCLUSIONS

Clinicians and patients have unique insights on the role of immediate release. Understanding these perspectives will help improve communication and develop patient-centered tools (glossaries, summary pages, additional resources) to aid patient understanding of complex medical information.

Implementation of a Holistic Review Process of US Allopathic Medical Students Eliminates Non-Comparable Metrics and Bias in General Surgery Residency Interview Invitations

OBJECTIVE

Use of traditional scoring metrics for residency recruitment creates racial and gender bias. In addition, widespread use of pass/fail grading has led to noncomparable data. To adjust to these challenges, we developed a holistic review (HR) rubric for scoring residency applicants for interview selection.

DESIGN

Single-center observational study comparing the proportion of underrepresented in medicine (URM) students and their United States Medical Licensing Exam (USMLE) scores who were invited for interview before (2015-2020) and after (2022) implementation of a holistic review process.

SETTING

General surgery residency program at a tertiary academic center.

PARTICIPANTS

US allopathic medical students applying for general surgery residency.

RESULTS

After initial screening, a total of 1514 allopathic applicants were narrowed down to 586 (38.7%) for HR. A total of 52% were female and 17% identified as URM. Based on HR score, 20% (118/586) of applicants were invited for an interview. The median HR score was 11 (range 4-19). There was a fourfold higher coefficient of variation of HR scores (22.3; 95% CI 21.0-23.7) compared to USMLE scores (5.1; 95% Cl 4.8-5.3), resulting in greater spread and distinction among applicants. There were no significant differences in HR scores between genders (p = 0.60) or URM vs non-URM (p = 0.08). There were no significant differences in Step 1 (p = 0.60) and 2CK (p = 0.30) scores between those who were invited to interview or not. On multivariable analysis, USMLE scores (OR 1.01; 95% CI 0.98-1.03), URM status (OR 1.71 95% CI 0.98-2.92), and gender (OR 0.94, 95% CI 0.60-1.45) did not predict interview selection (all p > 0.05). There was a meaningful increase in the percentage of URM interviewed after HR implementation (12.9% vs 23.1%, p = 0.016).

CONCLUSION

The holistic review process is feasible and eliminates the use of noncomparable metrics for surgical applicant interview invitations and increases the percentage of URM applicants invited to interview.

Muffins and Meditation: Combatting Burnout in Surgical Residents

OBJECTIVE

To quantify the prevalence of burnout in our surgical residency program and to assess the impact of a weekly wellness program for surgical residents through validated tools measuring mindfulness, self-compassion, flourishing, and burnout. Our hypothesis was that participants with more frequent attendance would: (1) be more mindful and self-compassionate and (2) experience less burnout and more flourishing.

DESIGN

An optional one-hour weekly breakfast conference was facilitated by a senior surgical faculty member with the time protected from all clinical duties. Following a guided meditation, participants were given time for reflection and dialogue about their training experiences or led in a wellness exercise. TRANCE (tolerance, respect, anonymity, nonretaliation, compassion, egalitarianism) principles were utilized to create a safe and open environment. Residents were surveyed at the end of the study period, which was from March 2017 through June 2018.

SETTING

The conference and data analysis was conducted at Denver Health Medical Center, affiliated with the University of Colorado School of Medicine.

PARTICIPANTS

This study analyzed survey responses from 85 surgical residents.

RESULTS

Following the wellness program, when answering the 2-question Maslach Burnout Inventory, 35.7% of residents reported feeling burned out by their work once a week or more, and 29.7% reported feeling more callous toward people once a week or more. After multivariate analysis, the only independent predictors of increased burnout were "not being married or in a committed relationship," lower positive affect, and higher negative affect. Written feedback was overwhelmingly positive, and residents expressed gratitude for the conference, the opportunity for self-reflection, and open dialogue with attendings and colleagues.

CONCLUSIONS

The prevalence of burnout is high among surgical residents. Allowing time to practice a mindfulness meditation while providing space for residents to share their experiences may be protective, and efforts should be made to reduce barriers to participation.

Patient comprehension of breast pathology report terminology: The need for patient-centered resources

BACKGROUND

As health care continues to evolve toward information transparency, an increasing number of patients have access to their medical records, including result reports that were not originally designed to be patient-facing. Previous studies have demonstrated that patients have poor understanding of medical terminology. However, patient comprehension of terminology specific to breast pathology reports has not been well studied. We assessed patient understanding of common medical terms found in breast pathology reports.

METHODS

A survey was administered electronically to patients scheduled for a screening mammogram within a multisite health care system. Participants were asked to objectively define and interpret 8 medical terms common to breast biopsy pathology reports. Patient perception of the utility of various educational tools was also assessed. Demographic information including health literacy, education level, previous cancer diagnosis, and primary language was collected.

RESULTS

In total, 527 patients completed the survey. Terms including "malignant" and "benign" were the most correctly defined at 80% and 73%, respectively, whereas only 1% correctly defined "high grade." Factors including race/ethnicity and education level were correlated with more correct scores. Patients preferred educational tools that were specific to their diagnosis and available at the time they were reviewing their results.

CONCLUSION

Patient comprehension of common medical terminology is poor. Potential assumptions of understanding based on patient factors including education, past medical history, and occupation are misinformed. With the newly mandated immediate release of information to patients, there is a pressing need to develop and integrate educational tools to support patients through all aspects of their care.

Patient and clinician perceptions of the immediate release of electronic health information

OBJECTIVES

The 21st Century Cures Act requires that institutions release all electronic health information (EHI) to patients immediately. We aimed to understand patient and clinician attitudes toward the immediate release of EHI to patients.

METHODS

Patients and clinicians representing distinct specialties at a single academic medical center completed a survey to assess attitudes toward the immediate release of results. Differences between patient and clinician responses were compared using chi-square and student's t-test for categorical and continuous variables, respectively. A two-sided significance level of 0.05 was used for all statistical tests.

RESULTS

69 clinicians and 57 patients completed the survey. Both patients (89.7%) and clinicians (80.6%) agreed or strongly agreed-here after referred to as agreed, that providing patients with access to their health information is necessary in delivering high-quality care. However, 62.7% of clinicians agreed that results released immediately would be more confusing than helpful, whereas the minority of patients agreed with this statement (15.8%) (p < 0.05). Providers were also more likely to disagree that patients are comfortable independently interpreting blood work results (p < 0.05), radiology results (p < 0.05) and pathology reports (p < 0.05). With regard to timing, the majority of patients (75.1%) felt their provider should contact them within 24 h of the release of an abnormal result, whereas only 9.0% of clinicians agreed with this timeframe (p < 0.05).

DISCUSSIONS

Patients and clinicians value information transparency. However, the immediate release of results is controversial, especially among clinicians. The discrepancy between patient and clinician perceptions underlines the importance of setting expectations about the communication of results. Additionally, our results emphasize the need to implement strategies to help improve patient comprehension, decrease patient distress and improve clinician workflows.

This Surgical Life - An Exploration of Surgical Department Podcasting

OBJECTIVE

Surgical departments are increasingly utilizing media to disseminate knowledge, discuss ideas, and mentor future surgeons. Podcasts are a form of media where digitally recorded content can be downloaded or streamed. This study aims (1) to describe the audience reached by a single surgical department podcast and (2) to evaluate what sources of information surgery residency applicants use to formulate a rank list.

DESIGN

In Fall 2017, the Rocky Mountain Surgery Podcast (RMSP) was created, produced, and edited by 2 general surgery (GS) residents at a large academic training program. Each episode discussed a topic within GS training and/or educational experiences specific to the program. Interviewing GS applicants for the 2019 match were asked to complete an anonymous voluntary survey on their familiarity and opinion of RMSP and the role of podcasts in the application process.

RESULTS

Twenty-two episodes were completed over a 16-month period (October 4, 2017 - February 11, 2019). A total of 7002 individual listens occurred in 644 cities across 46 states. Ninety-eight interviewing applicants responded to the survey (99% response rate), and one-fourth had previously listened to the RMSP. Only half felt that the traditional interview experience provided enough information about a GS program, and a significant majority (97%) stated they would listen to one or more podcast episodes to gain information regarding a GS residency program.

CONCLUSIONS

Applicants to GS residency commonly feel inadequate information is gained during the interview process. Podcasts are a tool familiar to applicants that allow for exploration of topics which cannot be adequately addressed in a typical interview day, thus expanding an applicant's knowledge of a GS training program.

A screening tool identifies high distress in newly diagnosed breast cancer patients

BACKGROUND

Many breast cancer patients and survivors experience clinically significant distress, which poses a danger to both their psychologic and clinical well-being. Improved understanding of the types of distress that patients experience at the time of breast cancer diagnosis may reveal areas for intervention to improve quality of life and long-term outcomes.

METHODS

We retrospectively evaluated newly diagnosed breast cancer patients who completed a cancer distress screening tool at their initial multidisciplinary clinic visit. The screening tool, which has not yet been validated, asked patients to rate their distress and identify specific concerns related to emotional, social, health, and practical distress. To evaluate predictors of distress, patient characteristics were collected through review of the electronic medical record.

RESULTS

The study population consisted of 379 patients. The number of patients experiencing high distress varied by domain: emotional (66.5%), social (25.1%), health (57.8%), and practical (36.4%). With the exception of marital status, no demographic, clinical, or pathologic factors were found to be significantly associated with distress in any domain.

CONCLUSION

Breast cancer patients experience significant distress at the time of initial diagnosis. Additional investigation assessing modifiable contributors to distress and developing clinical interventions to decrease distress from the time of diagnosis throughout treatment is needed to improve quality of life in this patient population.

Reassessing Opioid Use in Breast Surgery

BACKGROUND

This study aims to assess multimodal pain management and opioid prescribing practices in patients undergoing breast surgery.

METHODS

A retrospective review of patients undergoing breast surgery at an academic medical center between April 1, 2018 and September 30, 2019, was performed. Patients with a history of recent opioid use or conditions precluding use of nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen (APAP) were excluded. Opioid-sparing pain regimens were assessed. Opioids prescribed on discharge were recorded as oral morphine equivalents (OMEs) and concordance with the Opioid Prescribing Engagement Network (OPEN) determined.

RESULTS

The total study population consisted of 518 patients. 358 patients underwent minor outpatient procedures (sentinel lymph node biopsy, lumpectomy, and excisional biopsy), 10-40% of whom were appropriately prescribed as per the OPEN. Perioperatively, 53.9% of patients received APAP, 24.6% NSAIDs, 20.4% gabapentin, and 0.3% blocks; intraoperatively, 95.8% received local anesthetic and 25.7% ketorolac. For mastectomy without reconstruction, 63-88% of prescriptions were concordant with the OPEN. For mastectomy with reconstruction, discharge opioids ranged from 25 to 400 OMEs with a mean of 134.4 OMEs; 25% of patients received a refill. Of all patients undergoing mastectomy ± reconstruction, 62.5% received APAP, 18.8% NSAIDs, 38.8% pregabalin, and 20.6% locoregional block perioperatively; 37.5% received local anesthetic and 15.6% ketorolac intraoperatively. Of 143 inpatient stays, 89% received APAP, 38% NSAID, and 29% benzodiazepines; 29 patients received no opioids inpatient but were still prescribed 25-200 OMEs on discharge.

CONCLUSIONS

There is need for a multidisciplinary approach to pain management with the use of enhanced recovery after surgery protocols as potential means to standardize perioperative regimens and mitigate opioid overprescription.

The Waiting Game: How Long Are Breast Cancer Patients Waiting for Definitive Diagnosis?

BACKGROUND

Receiving a new breast cancer (BC) diagnosis can cause significant patient anxiety, which is amplified by delays in diagnosis. There is a lack of defined time periods for delays in the workup of BC. This study aims to evaluate national variations in timing from first abnormal mammogram to first biopsy and to determine independent predictors of delay in diagnosis.

PATIENTS AND METHODS

Data were derived from SEER-Medicare linked claims database from 2007 to 2013. Time intervals from abnormal mammogram, either screening or diagnostic, to biopsy were assessed. The fourth quartile for timing from first mammogram to first biopsy was utilized to define delay in diagnosis. Multivariate analyses were used to evaluate the association between clinicopathologic variables and delays in diagnosis.

RESULTS

We analyzed 53,758 patients with stage 0-II BC who underwent upfront surgery. Significant variations in timing of care were identified, with mean times from mammogram to biopsy, surgeon visit, and breast surgery of 23.3, 31.6, and 52.6 days, respectively. Over the study period, there was a decrease in delays from mammogram to biopsy. Non-White race, Northeast location, and earlier stage disease were found to be independent predictors of delays in the diagnosis of BC (p < 0.0001).

CONCLUSIONS

The study demonstrates significant variations in time to diagnostic biopsy. More efficient processes of care to address these delays should be implemented, and further studies are needed to determine whether improved efficiency decreases patient anxiety. The large variations in time to diagnosis speak to the need for consensus guidelines to establish a standard of care.

Abstract P6-02-02: Increased interval cancers after the 2009 U.S. preventive services task force guidelines: A single-center, retrospective analysis

Background: In late 2009, the U.S. Preventive Services Task Force (USPSTF) increased the recommended time between screening mammography from one year to two years. We examined the effect of USPSTF recommendations in an integrated safety-net system whose patients often have intermittent access to care. The purpose of this study was to determine if changes in screening guidelines were associated with stage migration or changes in rate of interval cancers.

Methods: We conducted a retrospective cohort analysis of breast cancer patients diagnosed between 2005-2013 at one safety-net hospital. We abstracted stage at diagnosis, time intervals between screening and diagnostic imaging, as well as BIRADS classification from clinical and administrative billing data. We divided patients into two cohorts: Those diagnosed with breast cancer "pre-2010" (2005 – 2010) and "post-2010" (2011-2013). We compared stage of diagnosis between cohorts using Chi-Square tests. In a subset of patients for whom we had prior screening imaging information, we determined the rate of interval cancers. Interval cancers were defined as patients whose diagnosis occurred within 14 months (pre-2010) or within 26 months (post-2010) of normal screening mammography. Logistic regression was used to determine the unadjusted odds of interval cancer as a function of being post-2010 versus pre-2010.

Results: There were 521 unique, breast cancer patients between 2005-2013,

Distribution of Breast Cancer by Stage Stage 0Stage IStage IIStage IIIStage IVTotal2005-200941816142242492010-20134679824421272

249 in the 'pre-2010' cohort, and 272 in the 'post-2010' cohort. In the 2005-2009 cohort, 32.5% and 24.5% of patients were stage I and Stage II respectively. In 2010-2013, 29.0% and 30% were stage I and stage II, respectively. The difference in stage at diagnosis was not statistically significant (p=0.62). In a subset of 178 patients with available screening imaging data, we determined the rate of interval cancers. Pre-2010, 7.4% (8/108) of patients had an interval cancer. Post-2010, 20% (14/70) patients had an interval cancer. Patients diagnosed post-2010 had three times the odds of having an interval cancer compared to pre-2010 patients (OR = 3.13, 95% CI 1.24-7.91, p=0.01).

Discussion: The USPSTF 2009 recommendation is associated with a statistically significant increase in interval cancers in a safety-net population, but we cannot conclude that this contributes to stage migration in this limited population. Investigation of larger groups is needed to further assess how USPSTF guidelines affect outcomes in underserved populations.

Citation Format: Townsend NT, Everhart RM, Bayliss EA, Jaiswal K. Increased interval cancers after the 2009 U.S. preventive services task force guidelines: A single-center, retrospective analysis. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P6-02-02.

Isolation of live label-retaining cells and cells undergoing asymmetric cell division via nonrandom chromosomal cosegregation from human cancers

The ability to retain DNA labels over time is a property proposed to be associated with adult stem cells. Recently, label retaining cells (LRC) were indentified in cancer. LRC were suggested to be the result of either slow-cycling or asymmetric-cell-division with nonrandom-chromosomal-cosegregation (ACD-NRCC). ACD-NRCC is proposed to segregate the older template DNA strands into daughter stem cells and newly synthesized DNA into daughter cells destined for differentiation. The existence of cells undergoing ACD-NRCC and the stem-like nature of LRC remain controversial. Currently, to detect LRC and ACD-NRCC, cells need to undergo fixation. Therefore, testing the stem-cell nature and other functional traits of LRC and cells undergoing ACD-NRCC has been limited. Here, we show a method for labeling DNA with single and dual-color nucleotides in live human liver cancer cells avoiding the need for fixation. We describe a novel methodology for both the isolation of live LRC and cells undergoing ACD-NRCC via fluorescence-activated cell sorting with confocal microscopy validation. This has the potential to be a powerful adjunct to stem-cell and cancer research.

Prehospital cardiopulmonary resuscitation in the pediatric trauma patient

PURPOSE

Children requiring prehospital cardiopulmonary resuscitation (CPR) after traumatic injury have been shown to have poor survival. However, outcome of children still receiving CPR on-arrival by emergency medical service to the emergency department (ED) has not been demonstrated in a published clinical series.

METHODS

An 11-year retrospective analysis from a level I pediatric trauma center of the outcomes of children requiring prehospital CPR after traumatic injury was undertaken. Outcome variables were stratified by survival, death, and CPR on-arrival.

RESULTS

Of 169 children requiring prehospital CPR, there were 28 survivors and 141 deaths. Of 69 children requiring CPR on-arrival to the ED, there were no survivors. There were 70 females and 99 males. Mean age of survivors was 3.4 years; nonsurvivors, 8.8 years; and 4.6 years for CPR on-arrival. Thirty-nine percent of all injuries were sustained in motor vehicle collisions; 20%, motor pedestrian collisions; 19%, assaults; 7%, falls; 4%, all terrain vehicle/motorcycle/bicycle; and 4%, gunshot wounds. Forty-two percent of all patients expired in the ED, whereas 34% expired in the intensive care unit. Eighty-seven percent of CPR on-arrival patients expired in the ED. Fifty-five percent of survivors had full neurologic recovery.

CONCLUSION

Although mortality was extremely high for children requiring CPR in the field After traumatic injury, it was absolute for those arriving at the ED still undergoing CPR.

Bone marrow progenitor cells contribute to esophageal regeneration and metaplasia in a rat model of Barrett's esophagus

Barrett's esophagus develops when refluxed gastric juice injures the esophageal squamous lining and the injury heals through a metaplastic process in which intestinal-type columnar cells replace squamous ones. The progenitor cell that gives rise to Barrett's metaplasia is not known, nor is it known why the condition is predisposed to malignancy. We studied the contribution of bone marrow stem cells to the development of Barrett's esophagus in an animal model. Twenty female rats were given a lethal dose of irradiation followed by tail vein injection of bone marrow cells from male rats. Ten days later, the female rats were randomly assigned to undergo either esophagojejunostomy, a procedure that causes reflux esophagitis with intestinal metaplasia, or a sham operation. The rats were killed at 8 weeks and serial sections of the snap-frozen esophagi were cut and mounted on slides. The first and last sections were used for histological evaluation and the intervening sections were immunostained for cytokeratin to identify epithelial cells and analyzed for Y chromosome by fluorescence in situ hybridization (FISH). Histological evaluation of the esophagi from rats that had esophagojejunostomy revealed ulcerative esophagitis and multiple areas of intestinal metaplasia. FISH analyses showed that some of the squamous epithelial cells and some of the columnar epithelial cells lining the glands of the intestinal metaplasia were positive for Y chromosome. These observations suggest that multi-potential progenitor cells of bone marrow origin contribute to esophageal regeneration and metaplasia in this rat model of Barrett's esophagus.

Bile salt exposure increases proliferation through p38 and ERK MAPK pathways in a non-neoplastic Barrett's cell line

Bile reflux has been implicated in the neoplastic progression of Barrett's esophagus (BE). Bile salts increase proliferation in a Barrett's-associated adenocarcinoma cell line (SEG-1 cells) by activating ERK and p38 MAPK pathways. However, it is not clear that these findings in cancer cells are applicable to non-neoplastic cells of benign BE. We examined the effect of bile salts on three human cell lines: normal esophageal squamous (NES) cells, non-neoplastic Barrett's cells (BAR cells), and SEG-1 cells. We hypothesized that bile salt exposure activates proproliferative and antiapoptotic pathways to promote increased growth in BE. NES, BAR, and SEG-1 cells were exposed to glycochenodeoxycholic acid (GCDA) at a neutral pH for 5 min. Proliferation was measured by Coulter counter cell counts and a 5-bromo-2'-deoxyuridine (BrdU) incorporation assay. GCDA-induced MAPK activation was examined by Western blot analysis for phosphorylated ERK and p38. Apoptosis was measured by TdT-mediated dUTP nick-end labeling and annexin V staining after GCDA and UV-B exposure. Statistical significance was determined by ANOVA. NES cells exposed to 5 min of GCDA did not increase cell number. In BAR cells, GCDA exposure increased cell number by 31%, increased phosphorylated p38 and ERK levels by two- to three-fold, increased BrdU incorporation by 30%, and decreased UV-induced apoptosis by 15-20%. In conclusion, in a non-neoplastic Barrett's cell line, GCDA exposure induces proliferation by activation of both ERK and p38 MAPK pathways. These findings suggest a potential mechanism whereby bile reflux may facilitate the neoplastic progression of BE.

Acid increases MAPK-mediated proliferation in Barrett's esophageal adenocarcinoma cells via intracellular acidification through a Cl-/HCO3- exchanger

Abundant epidemiological evidence links acid reflux to adenocarcinoma in Barrett's esophagus, but few studies have examined the cellular mechanisms by which acid promotes this neoplastic progression. We hypothesized that extracellular acid exposure causes intracellular acidification that triggers MAPK signaling and proliferation in Barrett's epithelial cells. We tested that hypothesis in a Barrett's-derived esophageal adenocarcinoma cell line (SEG-1). SEG-1 cells were exposed to varying concentrations of acid, and intracellular pH (pH(i)) was measured by 2',7'-bis-(2-carboxyethyl)-5-(and-6)-carboxyfluorescein microfluorimetry. After acid exposure, ERK and p38 MAPK activation were measured by Western blot analysis and an immune complex kinase assay. Proliferation was measured by Coulter counter cell counts and a 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide incorporation assay. Exposure of SEG-1 cells to solutions with a pH between 3 and 6.5 caused a rapid, reversible decrease in pH(i) to a level approximately equal to extracellular pH. Acid exposure caused a rapid activation of both ERK and p38 MAPKs and also resulted in pH-dependent increases in cell number, with a maximum increase of 41% observed at pH 6.0. The MAPK activation and proliferation in SEG-1 cells induced by acid exposure could be blocked by pretreatment with disodium 4,4'-diisothiocyanatostilbine-2,2'-disulfonate (DIDS), which prevents intracellular acidification by inhibiting the Cl(-)/HCO(3)(-) exchanger. In conclusion, in SEG-1 cells, extracellular acid exposure causes intracellular acidification, which activates MAPK and causes proliferation. The magnitude of these effects is pH dependent, and the effects can be inhibited by preventing intracellular acidification with DIDS.

Bile salt exposure causes phosphatidyl-inositol-3-kinase-mediated proliferation in a Barrett's adenocarcinoma cell line

BACKGROUND

The mechanisms by which gastroesophageal reflux promotes malignant progression in Barrett's esophagus are poorly understood. The phosphatidylinositol-3-kinase (PI3 kinase)/Akt pathway regulates proliferation and apoptosis. We hypothesized that the PI3 kinase/Akt pathway mediates the pro-proliferative and antiapoptotic effects of bile.

METHODS

The Barrett's adenocarcinoma cell line, SEG-1, was exposed to the conjugated bile salt, glycochenodeoxycholic acid (GCDA). Cell number was measured by the MTT incorporation assay and by Coulter counter. PI3 kinase/Akt activity was inferred from Western blots of phosphorylated and total Akt. Proliferation and apoptosis were determined by BrdU incorporation and cell death ELISA.

RESULTS

A dose-dependent cell number increase was seen with a 20-minute exposure to GCDA. On Western blot, 200 micromol/L GCDA caused a 3-fold increase in Akt phosphorylation within 20 minutes, which was inhibited by 90% with the addition of PI3 kinase inhibitor, LY294002. LY294002 produced dose-dependent inhibition of GCDA-induced cell number increases. 200 micromol/L GCDA decreased apoptosis by 25%. Addition of LY294002 did not completely inhibit the antiapoptotic effect of bile.

CONCLUSIONS

Bile salts activate the PI3 kinase/Akt signaling pathway and stimulate cell growth in SEG-1. The majority of this PI3 kinase-mediated effect is secondary to increases in proliferation rather than to decreases in apoptosis.

Thrombendvenectomy for organized portal vein thrombosis at the time of liver transplantation

OBJECTIVE

To determine the efficacy of portal thrombendvenectomy in cases of portal vein thrombosis at the time of orthotopic liver transplantation.

SUMMARY BACKGROUND DATA

Portal vein thrombosis (PVT) has been reported to have an incidence of 2% to 39% in end-stage liver disease. Multiple techniques have been suggested to treat this finding. Several reports have suggested suboptimal results after liver transplantation in recipients with PVT.

METHODS

The authors prospectively collected data on 1,546 patients who underwent an initial orthotopic liver transplant at the authors' institution between December 1984 and October 1999. There were 820 male patients and 726 female patients. All recipients received either cyclosporine or tacrolimus immunosuppression. Intraoperative flows of the portal vein and hepatic artery were routinely measured. Duplex sonography was routinely performed on the first postoperative day and routinely 1, 2, 5, and 10 years after transplantation. Eighty-five patients underwent thrombendvenectomy for organized thrombus partially or completely occluding the portal vein. Postoperative treatment included low-molecular-weight dextran for 48 hours and daily aspirin for 3 months. There were 53 male patients and 32 female patients. The PVT group was compared with a control group consisting of transplant recipients without PVT.

RESULTS

When compared with the control group, PVT patients were older at the time of transplantation and had a higher incidence of liver disease secondary to cryptogenic cirrhosis and Laennec's cirrhosis. There were no significant differences among both groups for 1-, 3-, and 6-year patient and graft survival rates.

CONCLUSIONS

Thrombendvenectomy provides a rapid resolution of an otherwise complex problem. It is the authors' procedure of choice in cases of organized PVT at the time of transplantation. Operative time and length of stay in the intensive care unit are not prolonged, and patient and graft survival rates are not compromised.

Effect of age and caloric restriction on bleomycin-chelatable and nonheme iron in different tissues of C57BL/6 mice

The objective of this study was to test the hypothesis that the widely observed age-associated increase in the amounts of macromolecular oxidative damage is due to an elevation in the availability of redox-active iron, that is believed to catalyze the scission of H2O2 to generate the highly reactive hydroxyl radical. Concentrations of bleomycin-chelatable iron and nonheme iron were measured in various tissues and different regions of the brain of mice fed on ad libitum (AL) or a calorically restricted (to 60% of AL) diet at different ages. The concentrations of these two pools of iron varied markedly as a function of tissue, age, and caloric intake. There was no consistent ratio between the amounts of nonheme and the bleomycin-chelatable iron pools across these conditions. Nonheme iron concentration increased with age in the liver, kidney, heart, striatum, hippocampus, midbrain and cerebellum of AL animals, whereas bleomycin-chelatable iron increased significantly with age only in the liver. Amounts of both nonheme and bleomycin-chelatable iron remained unaltered during aging in the cerebral cortex and hindbrain of AL mice. Caloric restriction had no effect on iron concentration in the brain or heart, but caused a marked increase in the concentration of both bleomycin-chelatable and nonheme iron in the liver and the kidney. The results do not support the hypothesis that accumulation of oxidative damage with age, or its attenuation by CR, are associated with corresponding variations in redox-active iron.

Effects of hormones on the number, distribution and degranulation of mast cells in the ovarian complex of mice

The changes in the number and degranulation pattern of mast cells varied with the types of hormonal treatment and ovarian compartment. Luteinizing hormone (LH), follicle stimulating hormone (FSH), thyroid stimulating hormone (TSH) and 17-beta estradiol (E2) treatment caused increase (P < 0.05) in the number of mast cells in the hilum as compared with the controls. Increase (P < 0.05) in the number of mast cells in the whole ovarian complex was observed only following FSH and E2 treatment. All the hormones used in the present study increased the percentage degranulation of mast cells in the hilum. However, only LH, FSH and E2 increased the percentage degranulation of mast cells in other compartments of the ovary (medulla, bursa and cortex). TSH and ACTH failed to cause any increase in the percentage degranulation of mast cells in these compartments. The present findings indicate E2 to be the most potent among the hormones tested in causing degranulation of mast cells in all ovarian compartments.

Effects of cimetidine, H2 receptor antagonist, on follicular and luteal development in the mice

The effects of various doses, duration and frequency of cimetidine treatment on vaginal cycle, ovulation, ovarian histology and follicular kinetics were investigated. In addition, studies were performed to assess the reversibility in ovarian functions following withdrawal of cimetidine treatment. A statistically significant (P < 0.05) decline in ovarian and uterine weights, but not in body and adrenal weights, were observed in females treated with cimetidine four times daily for long-term as compared with the controls. Ovarian and uterine weights recovered to pretreatment levels following withdrawal of the treatment. Cimetidine treatment caused irregularities in the reproductive cyclicity of mice. Cimetidine treatment causes adverse effect on ovarian function depending on the time, duration and frequency of treatment. Treatment for only one day at proestrus induced significant (P < 0.05) decline in ovulatory efficiency. However, administration of cimetidine, four times daily, for either 6 or 14 days caused ovarian dysfunction. The treatment depressed the number of healthy preantral and antral follicles as well as number of healthy corpus luteum (CL) in the ovary. Absence of healthy CL, presence of several atretic late antral follicles and reproductive acyclicity provide evidence for the failure of ovulation in mice treated with cimetidine four times per day for 14 days. Moreover, when cimetidine was administered twice daily, the ovaries also showed newly formed CL. The results, thus, suggest that the effects of cimetidine on ovulation are dependent on dose, duration and frequency of treatment. Blockage of ovulation in long-term cimetidine treated mice could be due to its influence on follicular atresia. Ovulation had occurred in these females after withdrawal of cimetidine treatment.