In primary total hip arthroplasty, the direct anterior approach leads to higher levels of creatine kinase and lower levels of C-reactive protein compared to the posterolateral approach: a propensity score matching analysis of short-term follow-up data.

BACKGROUND: This retrospective study compares the invasiveness of the direct anterior approach (DAA) and the posterolateral approach (PLA) in total hip arthroplasty (THA) by assessing three widely used inflammation-related serum markers in the first ten post-operative days. METHODS: The database of our institution was mined for primary THAs conducted by the DAA or the PLA from February 2020 to June 2022. Demographics and creatine kinase (CK), C-reactive protein (CRP), and white blood cells were compared. Propensity Score Matching (PSM) analysis (1:1 ratio) was conducted based on multiple variables. RESULTS: PSM analysis yielded 44 pairs of DAA and PLA patients. CK was significantly higher (p < 0.001) in the DAA than in the PLA group on postoperative day (POD) 2, 5 and 10. The POD2, POD5 and POD10 CK/preoperative CK ratio was 12.9, 5.0 and 0.8 in DAA and 8.8, 3.3 and 0.6 in PLA (p = 0.017, p = 0.012 and p = 0.025, respectively). The POD2, POD5 and POD10 CRP/preoperative CRP ratio was 95.1, 65.6 and 22.8 in PLA and 34.7, 23.3 and 8.9 in DAA (p < 0.001, p = 0.002 and p < 0.001, respectively). CONCLUSION: PSM analysis of early postoperative CK and CRP values demonstrated that the DAA should be considered as a less stressful approach, not as a muscle-sparing or a minimally invasive THA approach.

NF-YAl drives EMT in Claudinlow tumours.

NF-Y is a trimeric transcription factor whose binding site -the CCAAT box- is enriched in cancer-promoting genes. The regulatory subunit, the sequence-specificity conferring NF-YA, comes in two major isoforms, NF-YA long (NF-YAl) and short (NF-YAs). Extensive expression analysis in epithelial cancers determined two features: widespread overexpression and changes in NF-YAl/NF-YAs ratios (NF-YAr) in tumours with EMT features. We performed wet and in silico experiments to explore the role of the isoforms in breast -BRCA- and gastric -STAD- cancers. We generated clones of two Claudinlow BRCA lines SUM159PT and BT549 ablated of exon-3, thus shifting expression from NF-YAl to NF-YAs. Edited clones show normal growth but reduced migratory capacities in vitro and ability to metastatize in vivo. Using TCGA, including upon deconvolution of scRNA-seq data, we formalize the clinical importance of high NF-YAr, associated to EMT genes and cell populations. We derive a novel, prognostic 158 genes signature common to BRCA and STAD Claudinlow tumours. Finally, we identify splicing factors associated to high NF-YAr, validating RBFOX2 as promoting expression of NF-YAl. These data bring three relevant results: (i) the definition and clinical implications of NF-YAr and the 158 genes signature in Claudinlow tumours; (ii) genetic evidence of 28 amino acids in NF-YAl with EMT-promoting capacity; (iii) the definition of selected splicing factors associated to NF-YA isoforms.

Phylogeny of NF-YA trans-activation splicing isoforms in vertebrate evolution.

NF-Y is a trimeric pioneer Transcription Factor (TF) whose target sequence -the CCAAT box- is present in ~25% of mammalian promoters. We reconstruct the phylogenetic history of the regulatory NF-YA subunit in vertebrates. We find that in addition to the remarkable conservation of the subunits-interaction and DNA-binding parts, the Transcriptional Activation Domain (TAD) is also conserved (>90% identity among bony vertebrates). We infer the phylogeny of the alternatively spliced exon-3 and partial splicing events of exon-7 -7N and 7C- revealing independent clade-specific losses of these regions. These isoforms shape the TAD. Absence of exon-3 in basal deuterostomes, cartilaginous fishes and hagfish, but not in lampreys, suggests that the "short" isoform is primordial, with emergence of exon-3 in chordates. Exon 7N was present in the vertebrate common ancestor, while 7C is a molecular innovation of teleost fishes. RNA-seq analysis in several species confirms expression of all these isoforms. We identify 3 blocks of amino acids in the TAD shared across deuterostomes, yet structural predictions and sequence analyses suggest an evolutionary drive for maintenance of an Intrinsically Disordered Region -IDR- within the TAD. Overall, these data help reconstruct the logic for alternative splicing of this essential eukaryotic TF.

NF-Y subunits overexpression in gastric adenocarcinomas (STAD).

NF-Y is a pioneer transcription factor-TF-formed by the Histone-like NF-YB/NF-YC subunits and the regulatory NF-YA. It binds to the CCAAT box, an element enriched in promoters of genes overexpressed in many types of cancer. NF-YA is present in two major isoforms-NF-YAs and NF-YAl-due to alternative splicing, overexpressed in epithelial tumors. Here we analyzed NF-Y expression in stomach adenocarcinomas (STAD). We completed the partitioning of all TCGA tumor samples (450) according to molecular subtypes proposed by TCGA and ACRG, using the deep learning tool DeepCC. We analyzed differentially expressed genes-DEG-for enriched pathways and TFs binding sites in promoters. CCAAT is the predominant element only in the core group of genes upregulated in all subtypes, with cell-cycle gene signatures. NF-Y subunits are overexpressed, particularly NF-YA. NF-YAs is predominant in CIN, MSI and EBV TCGA subtypes, NF-YAl is higher in GS and in the ACRG EMT subtypes. Moreover, NF-YAlhigh tumors correlate with a discrete Claudinlow cohort. Elevated NF-YB levels are protective in MSS;TP53+ patients, whereas high NF-YAl/NF-YAs ratios correlate with worse prognosis. We conclude that NF-Y isoforms are associated to clinically relevant features of gastric cancer.

Endoscopic revision of gastric bypass: Holy Grail or Epic fail?

BACKGROUND: Approximately 20-30 % of patients who undergo Roux-en-Y gastric bypass (RYGB) will not meet the goals of weight loss surgery. Revisional surgery is associated with higher morbidity compared to initial operative management, and results in terms of weight loss have been inconsistent. Endoscopic plication has been seen as a less invasive option, with encouraging initial results. The objective was to analyze the outcomes after Restorative Obesity Surgery, Endolumenal (ROSE) procedure. METHODS: We retrospectively analyzed patients who underwent ROSE between 5/2008 and 11/2013. All patients had failure of weight loss or regain weight after RYGB. Demographics, operative data, and follow-up were recorded. RESULTS: Twenty-seven patients underwent ROSE. One patient was excluded due to lack of follow-up. Twenty-five (96 %) patients were female. Mean time since initial RYGB was 11.9 ± 4.3 years. Mean initial weight and BMI were 236 ± 47 lb and 40.6 ± 8.1 kg/m(2), respectively. Mean OR time was 77 ± 30 min. Preoperative average pouch length and stoma diameter were 6.8 ± 2.3 and 2.1 ± 0.7 cm, respectively. On average, 4 ± 1.6 stitches were placed. Final pouch length and stoma diameter were 3.4 ± 1.6 (50 % reduction) and 0.86 ± 0.4 cm (61 % reduction). A total of 12 (46 %) and seven (28 %) patients underwent EGD at 3 and 12 months postoperatively. The mean pouch length and stoma diameter were 5 ± 1.9 (26.5 % reduction) and 1.2 ± 0.7 cm (42.9 % reduction) at 3 months and 6.14 ± 1.6 (10 % reduction) and 2.2 ± 1.2 cm (4.7 % increase) at 12 months, respectively. The %EWL was 8.9, 9.3, 8, 6.7, -10.7, -13.5, -5.8, -4.5 at 3, 6, 12, 24, 36, 48, 60, and 72 months, respectively. CONCLUSION: Although endoscopic plication achieved the intended reduction in the pouch and stoma diameter at 3 months, these tend toward the preoperative diameter at 12 months. This anatomical failure and the lack of follow-up may explain why most patients failed to achieve sustainable weight loss.

Magnetic lower esophageal sphincter augmentation device removal.

Implantation of a magnetic lower esophageal sphincter augmentation device is now an alternative to fundoplication in the surgical management of gastroesophageal reflux disease (GERD). Although successful management of GERD has been reported following placement of the device, there are instances when device removal is needed. The details of the technique for laparoscopic magnetic lower esophageal sphincter device removal are presented to assist surgeons should device removal become necessary.

Single-incision and dual-incision laparoscopic adjustable gastric band: evaluation of initial experience.

BACKGROUND: The laparoscopic adjustable gastric band (LAGB) technique has been well described. Most surgeons have used a 4-trocar technique, with an additional incision for a liver retractor. Single incision (SI)-LAGB seeks to further decrease the invasiveness of the procedure. The purpose of the present report was to evaluate the safety and feasibility of SI-LAGB and the effect on the learning curve. METHODS: All cases performed from October 2008 to October 2009 were reviewed. Both true SI and dual-incision LAGB cases were included. The cases were performed through either a left paramedian or a transumbilical incision. The liver was retracted using the Nathanson retractor or an intracorporeal retractor. RESULTS: Of the 89 patients studied, 89% were women. Their mean age was 41 ± 12 years (range 19-74), and their body mass index was 46 ± 12 kg/m(2) (range 32-63). The first 27 patients underwent dual-incision LAGB using the Nathanson retractor. The operative time was 45 ± 12 minutes (range 21-90). After the first 35 cases, a reduction in the operative time was observed (P = .03). Simultaneous hiatal hernia repair added an average of 11 minutes of operative time for 40 patients (45%). The conversion rate was 26% for the first 35 cases, 5% for the second 35 cases, and 0% for the last 19 cases. Conversion was represented by adding a 5-mm trocar or the Nathanson retractor. The length of stay was 7 ± 9 hours (range 2-36), and 81 patients (91%) qualified for outpatient surgery. The complications included 1 seroma, 1 reoperation because of band obstruction, and 1 case of esophageal dysmotility after surgery. CONCLUSION: The results of our study have shown that SI-LAGB is a viable alternative to traditional LAGB and can be considered reliable, with low morbidity. The learning curve for consistent completion of SI-LAGB in our experience appeared to be the first 35 cases. We advise standardizing the procedure to facilitate the reproducibility of this technique.

Robotic-assisted Heller myotomy for esophageal achalasia: feasibility, technique, and short-term outcomes.

Laparoscopic Heller myotomy is the standard surgical treatment for esophageal achalasia. The incidence of esophageal perforation is about 5-10%. Robotic-assisted Heller myotomy (RAHM) offers results at least as good as those from laparoscopic procedures, additionally yielding fewer intraoperative complications. The aim of this study was to demonstrate the safety and feasibility of RAHM and its value in the treatment of esophageal achalasia. We analyzed demographics, preoperative symptoms, esophagograms, esophageal manometry, intraoperative and postoperative data of all the patients who underwent RAHM for achalasia at three institutions: 36 women and 37 men, mean age 45 ± 16 (13-87) years. Dysphagia was present in 100% of patients. Thirty-three patients (45%) had had previous endoscopic treatment: 23 patients had pneumatic dilation, four patients had Botox injections, and six patients had both. Surgical time averaged 119 min (range of 62-211); blood loss averaged 23 ml; no mucosal perforations were observed; length of hospitalization was 1.5 days; there were no deaths. At 12 months, 96% of patients had relief of their dysphagia. In conclusion, RAHM is safe and effective since there were no intraoperative esophageal perforations and relief of symptoms was achieved in 96% of the patients.

Initial experience with the adjustable gastric band in morbidly obese US adolescents and recommendations for further investigation.

BACKGROUND: The public health crisis of obesity has spread to the pediatric population. In morbidly obese (MO) adolescents, early weight loss intervention can reduce and prevent obesity-related comorbidities and mortality and improve quality of life. The present study was performed to evaluate weight loss efficacy and safety of "off-label" laparoscopic adjustable gastric banding (LAGB) procedures performed in MO adolescents by our adult bariatric program. PATIENTS AND METHODS: We retrospectively reviewed data from 716 LAGB procedures performed on an off-label basis in adults and 24 adolescent patients ages 14 to 20 years by the adult bariatric program at our institution between 2001 and 2006. RESULTS: There was no mortality. Average operative time was 45 minutes, length of stay for adolescents was 15 hours, and weight loss outcome and overall surgical complication rates are comparable between adolescents and adults. For adolescent subjects, baseline mean preoperative body mass index was 49 kg/m and average excess weight loss rates were 22%, 34%, 52%, 42%, and 42% at 3, 6, 12, 24, and 36 months, respectively. The overall complication rate was 29%, with a 25% incidence of pouch enlargement in adolescents (vs 18% in adult patients; P = ns). Two of 24 adolescent patients (8.4%) required laparoscopic band repositioning (vs 1.5% of adult patients; P = 0.06). CONCLUSIONS: LAGB is an effective and safe surgical weight loss modality for MO adolescent subjects. Vigilant follow-up for LAGB-related complications and intensive postoperative behavioral management are important for improving long-term success. We recommend continued investigation of long-term efficacy and safety of LAGB in this population.

Stroke vs. chronic progressive cerebrovascular disease: a magnetic resonance imaging study of symptomatic outpatients.

Stroke is the main manifestation of cerebrovascular disease (CVD). Few studies report the insidious and progressive development of CVD. The aim of this study was the characterization of a CVD form without stroke in association with vascular subtypes and risk factors (VRF). From 105 CVD patients, 65 had stroke (62%), 13 of them had more than one stroke (20%), and 40 patients had a chronic progressive form (CPF) (38%). Mean evolution times up to maximum neurological deficiency were 1.57+/-0.94 and 344.25+/-210.96 days, respectively. Group results significantly associated with VRFs: hypertension (p=0.0046), hyperlipemia (p=0.0046) and atrial fibrillation (p=0.0173); with clinical manifestations: aphasia (p=0.0018), pyramidal syndrome (p=0.0000001) and small vessel disease (SVD) (p=0.0000001); and with MRI: bilateral infarctions (p=0.00009) and incomplete white matter lesions (IWMLs) (p=0.0061). Within the CPF group, dysarthria and complete infarctions were associated (p=0.00036). Most neurological disorders associated with CVD are related to CPF. The significant correlations of SVD, bilateral infarcts, IWMLs, dysarthria, several VRFs and the strong difference in evolution time up to maximum neurological deficiency values characterize CPF as a separate entity within CVD.

Aplicación de pruebas de ajuste de riesgo para predecir los tiempos de internación posoperatorios en cirugía cardíaca / Usefulness of risk models to predict hospital lenght of stay after cardiac surgery

Un aspecto clave de una buena administración de recursos en cirugía cardíaca consiste en prever y controlar el tiempo de estadía hospitalaria. Con ese fin se analizó la relación entre riesgo preoperatorio y tiempo de internación posquirúrgico con dos modelos de ajuste de riesgo. Para ello se comparó la mortalidad operatoria y el tiempo de internación de 320 pacientes sometidos a cirugía cardíaca con dos modelos de ajuste del PACCN y de Parsonnet. No se observaron diferencias significativas en la comparación de la mortalidad esperada y la observada con los dos tipos de índices. El tiempo de internación fue de 7 días (mediana) para un puntaje del PACNN menor de 6, y de 12 días para un valor superior. Con el modelo de Parsonnet, la estadía fue de 7 días para un puntaje menor de 15, de 8 días para valores entre 15 y 19 y de 10 días para puntajes mayores. En conclusión, los dos modelos de ajuste de riesgo predicen adecuadamente la mortalidad observada en este estudio. Asimismo ambos esquemas pueden ser usados para prever los tiempos posquirúrgicos probables de internación

Hipertensión pulmonar asociada con infección por el virus de la inmunodeficiencia humana: presentación de siete casos y revisión de la literatura / Pulmonary hypertension in patients infected with the human immunodeficiency virus

En esta presentación comunicamos siete pacientes con hipertensión pulmonar asociada con infección por el virus de la inmunodeficiencia humana. La hipertensión pulmonar fue confirmada por ecocardiografía Doppler en todos los casos y por cateterismo cardíaco en dos pacientes. La hipertensión pulmonar es una de las manifestaciones cardíacas que se encuentra en los pacientes infectados por el virus de la inmunodeficiencia humana; no parece tener relación con el estadío de la infección y puede observarse aún sin antecedentes de adicción. La hipertensión pulmonar puede ser la primera manifestación que sugiera el diagnóstico de infección por el virus de la inmunodeficiencia humana y su presencia anunciar, como variable independiente, un mal pronóstico y escasa sobrevida

Evaluación de la mortalidad intrahospitalaria esperada de la cirugía coronaria con el índice de riesgo del CONAREC III / Evaluation of in-hospital expected mortality of coronary surgery with the CONAREC III risk score test

Se analizó la mortalidad intrahospitalaria de 293 pacientes sometidos a cirugía coronaria y se la comparó con la mortalidad esperada de acuerdo con el índice de riesgo del CONAREC III. Tanto la mortalidad global como la mortalidad dividida en grupos de riesgo resultaron menores que las del CONAREC III: global= 3,7 por ciento vs 11,7 por ciento (< 0,001); moderado= 1,5 por ciento vs 5,9 por ciento (< 0,05); muy elevado= 6,9 por ciento vs 20,8 por ciento (0,05), y demasiado elevado= 15,7 por ciento vs 43,4 por ciento (< 0,05). Estas diferencias podrían deberse a alguna variación no detectada en las poblaciones comparadas, a los menores tiempos de circulación extracorpórea, a la uniformidad del equipo quirúrgico o a la simplificación de los cuidados postoperatorios. En conclusión el índice de riesgo no predijo adecuadamente la mortalidad observada

Meningitis a enterococcus faecalis / Meningitis due to Enteroccocus faecalis

Enterococcus faecalis meningitis is an infrequent entity that accounts for less than 1 percent of all suppurative meningitis in the adult. Usually, this infection affects patients with compromised host defenses or those who have congenital or acquired CNS lesions mainly as intrahospitalary infections. An 85 year old woman from our community (Tandil county) without any predisposed condition, was admitted in the hospital in an unconscious state (grade 3 Glasgow's index), meningeal signs and purulent CSF, from which E. faecalis was isolated. The patient was treated with IV Ampicillin and Gentamycin (17 days), intrathecal Gentamycin (4 days) and ]V dexametasona (6 days). The clinical and bacteriological remission was achieved, without any sequel or relapse during 2 years follow up.