Utility of Intraprocedural Luminal Diameter and Distensibility Measurements During the Esophageal Peroral Endoscopic Myotomy Procedure.

GOALS: Through evaluation of the lower esophageal sphincter immediately before and after myotomy using an endoluminal functional lumen imaging probe (EFLIP), our study aimed to determine the clinical response to peroral endoscopic myotomy (POEM) and the incidence of postprocedure reflux. BACKGROUND: Achalasia is a rare esophageal motility disorder characterized by impaired relaxation of the lower esophageal sphincter (LES) and diminished peristalsis. POEM is a therapeutic option for durable management of achalasia. However, symptomatic acid reflux and esophagitis are well-known adverse effects of the procedure. STUDY: Electronic medical records of 168 patients who underwent POEM for achalasia at 2 tertiary care referral centers from May 2014 to May 2021 were reviewed. EFLIP was used at a range of catheter fill volumes to assess LES dynamics. Preprocedure and postprocedure Eckardt Symptom Scores were recorded. RESULTS: Significant clinical improvement from POEM was sustained in over 94% of patients after 1 year. EFLIP changed intraprocedural management 5% of the time by means of myotomy extension. In patients with reflux>1 year following POEM, there was no significant difference in post-POEM LES diameter or change in LES diameter compared with those without reflux. However, post-POEM LES distensibility index (DI) was significantly higher in patients with reflux after 1 year compared with those without reflux. CONCLUSIONS: POEM is a safe and increasingly effective therapy for patients with symptomatic achalasia. Intraprocedural EFLIP measurements suggest that post-POEM reflux may be correlated more with DI than LES diameter. Yet, more data is needed to substantiate these outcomes.

Modification of LeFort I Osteotomy for Correction of Severe Maxillary Cant Associated With Fibrous Dysplasia.

Differential superior reposition of maxilla following LeFort I osteotomy in the correction of maxillary cant poses a greater challenge especially when associated with the pathology like fibrous dysplasia which completely obliterates the antrum. Purpose of this paper is to highlight the modification of LeFort I osteotomy and hypothesis is to assess its difficulty index in modifying the standard steps, in executing the maxillary separation at various to correct the gross facial asymmetry to achieve a favorable outcome. Multiphased management involved scrupulous clinical planning, advanced imaging by computed tomgraphy scans, stereolithographic models to debulk the lesion. The second phase included pre surgical orthodontic evaluation along with correction of severe maxillary cant adopting a modified LeFort 1 osteotomy technique and standard bilateral sagittal split osteotomy, thereby simultaneously attaining functional stability and esthetic harmony.

Outcomes in patients with pancreatic ductal adenocarcinoma (PDAC) undergoing robotic (RPD) or open pancreaticoduodenectomies (OPD): a propensity score-weighted survival analysis.

The purpose of this study was to compare the survival, recurrence, and complication rates in patients with pancreatic ductal adenocarcinoma (PDAC) who underwent robotic pancreaticoduodenectomy (RPD) or open pancreaticoduodenectomy (OPD) and who received adjuvant therapy. The study was a single-center retrospective analysis of consecutive PDAC patients who underwent RPD/OPD. Patient characteristics, tumor findings, neoadjuvant therapy, adjuvant therapies, overall survival (OS) and recurrence-free survival (RFS) were compared between the OPD and RPD cohorts. Cox proportional hazard regression with and without propensity score matching was used to establish the association between predictors and outcomes. One hundred PDAC patients underwent OPD (n = 36) or RPD (n = 64) from 2013 to 2019. Cox proportional hazard models showed that baseline bilirubin (HR 1.6, p = 0.0006) and operative characteristics such as the number of positive lymph nodes (HR 1.1, p = 0.002), lymph node ratio (HR 1.6, p = 0.001), tumor grade (HR 1.7, p = 0.02), and TNM classification (HR 2.3, p = 0.01) were associated with OS. The independent predictors post-intervention associated with mortality were adjuvant therapy (HR 0.4, p = 0.0003), ISGPS complications (HR 2.8, p = 0.02), and 90-day readmission (HR 2, p = 0.004). After adjustment for these predictors, adjuvant therapy, baseline bilirubin, lymph node ratio, and tumor grade remained the main predictors of mortality. Baseline bilirubin, adjuvant therapy, lymph node ratio, and tumor grade were the main determinants of mortality after OPD or RPD. There was no significant difference in OS and RFS after RPD or OPD in PC patients who received adjuvant therapy.

Severe Acute Pancreatitis Prediction: A Model Derived From a Prospective Registry Cohort.

Background Severe acute pancreatitis (SAP) has a mortality rate as high as 40%. Early identification of SAP is required to appropriately triage and direct initial therapies. The purpose of this study was to develop a prognostic model that identifies patients at risk for developing SAP of patients managed according to a guideline-based standardized early medical management (EMM) protocol. Methods This single-center study included all patients diagnosed with acute pancreatitis (AP) and managed with the EMM protocol Methodist Acute Pancreatitis Protocol (MAPP) between April 2017 and September 2022. Classification and regression tree (CART®; Professional Extended Edition, version 8.0; Salford Systems, San Diego, CA), univariate, and logistic regression analyses were performed to develop a scoring system for AP severity prediction. The accuracy of the scoring system was measured by the area under the receiver operating characteristic curve. Results A total of 516 patients with mild (n=436) or moderately severe and severe (n=80) AP were analyzed. CART analysis identified the cutoff values: creatinine (CR) (1.15 mg/dL), white blood cells (WBC) (10.5 × 109/L), procalcitonin (PCT) (0.155 ng/mL), and systemic inflammatory response system (SIRS). The prediction model was built with a multivariable logistic regression analysis, which identified CR, WBC, PCT, and SIRS as the main predictors of severity. When CR and only one other predictor value (WBC, PCT, or SIRS) met thresholds, then the probability of predicting SAP was >30%. The probability of predicting SAP was 72% (95%CI: 0.59-0.82) if all four of the main predictors were greater than the cutoff values. Conclusions Baseline laboratory cutoff values were identified and a logistic regression-based prognostic model was developed to identify patients treated with a standardized EMM who were at risk for SAP.

A cross-sectional study of knowledge, attitude, and practice toward COVID-19 in solid organ transplant recipients at a transplant center in the United States.

Objectives: Knowledge, attitude, and practices (KAP) have been widely used during times of pandemic to quantify and locate gaps of care during pandemics. Using this tool, we can identify and target populations who underwent solid organ transplant (SOT) to bolster preventative practices in these patients during COVID-19. Materials and methods: An institution-based cross-sectional study was conducted between June 1, 2020 and June 30, 2021 on patients who underwent a liver and/or kidney transplant at Methodist Dallas Medical Center in Dallas, Texas, USA. A KAP questionnaire of 26 questions about COVID-19 was designed based on the clinical and community management guidelines published by the WHO. The participant's overall KAP was categorized using Bloom's cut-off point. A KAP domain was considered sufficient if the score was between 60 and 100% and insufficient if the score was <60%. The strength of association was assessed by using odds ratio (OR); only significant independent factors in each tested area were assessed. Results: Respondents with children in the household were less likely to have sufficient practices than those who did not [OR = 0.2491, 95% Confidence Interval (0.0893-0.6120), p = 0.001]. We also found that sufficient levels of knowledge correlated with higher likelihood of sufficient levels of practices [OR = 4.94, 95% CI (1.646-14.2159), p < 0.005]. Interestingly, we found that sufficient levels of attitude did not correlate with sufficient levels of practice (p = 0.201). Conclusion: Our study found that knowledge and having children in the household correlated with higher levels of practice.

Relation of interleukin-6 levels in COVID-19 patients with major adverse cardiac events.

Elevated interleukin-6 (IL-6) levels may correlate with disease severity in COVID-19. We analyzed whether there was an association between elevated IL-6 levels and major adverse cardiac events (MACE) and/or mortality in COVID-19 patients. A retrospective chart review was performed on COVID-19 patients among four hospitals in one health system from March to May 2020, extracting information on baseline characteristics, MACE (i.e., myocardial infarction, stroke, deep venous thrombosis/pulmonary embolism, or shock requiring vasopressor support), mortality, and IL-6 levels. Of the 496 patients hospitalized with COVID-19, 191 patients had an IL-6 level drawn and 68% had elevated IL-6 levels. The elevated IL-6 population had higher odds of developing a MACE compared to the normal IL-6 population (P < 0.0001, odds ratio [OR] = 5.91, 95% confidence interval [CI] = 2.65-14.11). The elevated IL-6 population also had higher mortality rates (28.2% vs 5%, P = 0.0001, OR = 7.47, 95% CI = 2.19-39.32) and an increased incidence of a MACE and/or mortality (58.78% vs 20.00%, P < 0.0001, OR = 5.7, 95% CI 2.65-12.83) compared to the normal IL-6 population. Elevated IL-6 levels in COVID-19 patients may be associated with MACE and/or mortality. Monitoring IL-6 levels in COVID-19 patients may help risk-stratify patients.

Pre-operative and post-operative audiological assessment in cleft lip and palate patients-a prospective study.

PURPOSE: To assess association of audiological defects in cleft lip and palate (CLP) following two stage cheiloplasty and palatoplasty using clinical evaluation and otoscopy and effect of the surgical repair at an interval of one year. MATERIALS AND METHODS: A pilot research study was performed on sixty CLP patients of 1-6 years of age reporting at Craniofacial & Research Centre, Dharwad, India between October 2016 to October 2018.Subjects were assessed based on history, clinical examination and otoscopy for audiometric defects including Serous otitis media (SOM), retraction pockets, impacted wax pre-palatoplasty and findings were compared with control group. Study group were followed up postoperatively at 1, 3, 6 and 12 months and statistical analysis was carried. RESULTS: Higher incidence of conductive audiological defects were noted in study group (96.6%) to control group (8.33%). Of the sixty cleft patients subjected to screening otoscopy, 58 subjects had significant findings like serous otitis media(12.07%), retraction pockets(23.14%), impacted wax(62.04%), bulging of tympanic membrane(3.45%) which were clinically unnoticed. Post palatoplasty no changes were noted at 1 and 3 months, however at 6- and 12months significant improvement was noted (55.17%), with three subjects lost to follow up (6.90%) and none presenting with permanent deafness.results. CONCLUSION: Cleft anomalies occur in different degrees of severity and configuration with greater incidence of conductive hearing defects of 97%. Positive correlation was noted in cleft palate cases with significant improvement after palatoplasty at an earlier age. However, future long term studies are warranted for long term assessment of Eustachian tube function.conclusion.

Superior Specimen and Diagnostic Accuracy with Endoscopic Ultrasound-Guided Liver Biopsies Using 19-Gauge versus 22-Gauge Core Needles.

BACKGROUND/AIMS: Endoscopic ultrasound-guided liver biopsy (EUS-LB) is an effective and safe method of procuring liver tissue. The aims of this study were to assess and compare the outcomes and tissue adequacy of a single-pass, single-actuation, wet suction technique between 19 G and 22 G needles in patients undergoing EUS-LB. METHODS: We performed a prospective case series study of 20 patients undergoing EUS-LB at a single center between September 2017 and April 2020. The primary objective was to evaluate differences in sample adequacy via a single actuation wet suction technique between a 19 G core needle and a 22 G core needle. Adequacy was gauged by cumulative core biopsy length and the number of portal tracts visualized. RESULTS: The 19 G needle provided a longer core length (2.5 cm vs. 1.2 cm, p<0.0001), more complete portal tracts (5.8 vs. 1.7, p<0.0001), more total tracts (8.8 vs. 3, p<0.0001), and a longer, intact, fragment length (0.75 cm vs. 0.32 cm, p<0.0006). The 19 G needle was superior in providing adequate (60% vs. 5%, p<0.001) and diagnostic pathologic samples (85% vs. 10%, p<0.001). CONCLUSION: A single-pass, single-actuation, wet suction technique using a 19 G needle is superior to that using a 22 G needle for tissue acquisition and sample adequacy in EUS-LB.

The Value of Managing Acute Pancreatitis With Standardized Order Sets to Achieve "Perfect Care".

OBJECTIVES: We aimed to define perfect care index (PCI) metrics and to evaluate whether implementation of standardized order sets would improve outcomes without increasing hospital-based charges in patients with acute pancreatitis (AP). METHODS: This is a retrospective, pre-post, observational study measuring clinical quality, processes of care, and hospital-based charges at a single tertiary care center. The first data set included AP patients from August 2011 to December 2014 (n = 219) before the implementation of a standardized order set (Methodist Acute Pancreatitis Protocol [MAPP]) and AP patients after MAPP implementation from January 2015 to September 2018 (n = 417). The second data set included AP patients (n = 150 in each group) from January 2013 to September 2014 (pre-MAPP) and January 2018 to September 2019 (post-MAPP) to evaluate perfect care between the 2 cohorts after controlling for systemic inflammatory response syndrome at baseline. Length of stay, PCI, and hospital-based charges were measured. RESULTS: The post-MAPP cohort had a significantly shorter length of stay (median, 3 days vs 4 days; P = 0.01). In the second data set, PCI significantly increased after implementation of MAPP order sets (5.3%-35.3%, P < 0.0001). CONCLUSIONS: The MAPP order sets increased the value of care by improving clinical outcomes without increasing hospital-based charges.

Analysis of 102 Fully Robotic Pancreaticoduodenectomies: Clinical and Financial Outcomes.

OBJECTIVES: The value of robotic pancreaticoduodenectomy (RPD) remains undefined. The aim of this retrospective study was to compare and assess clinical outcomes and financial variables of patients undergoing RPD versus open pancreaticoduodenectomy (OPD) at a single high-volume center. METHODS: The study design is a retrospective analysis of a prospectively maintained database of consecutive PD patients from 2013 to 2019. Clinical variables and total hospital charges were evaluated as an unadjusted and adjusted intention-to-treat analysis. RESULTS: A total of 156 patients (54 OPD, 102 RPD) were identified. In the RPD group, patients were significantly older (P = 0.0304) and had shorter length of stay (mean, 7 vs 11.8 days; P < 0.0001) and longer operative times (mean, 352.7 vs 211.5 minutes; P < 0.0001) compared with OPD. There was no significant difference in 90-day readmissions, bleeding, or complications between OPD and RPD. Adjusted charge analyses show no difference in total charges (P = 0.057). CONCLUSIONS: Robotic pancreaticoduodenectomy is safe, feasible, and valid alternative to OPD. Because of comparable results within each group, randomized trials may be indicated. High-volume RPD centers should collaborate to better understand the differences and advantages over laparoscopic or OPD.

Microvessel rupture induced by high-intensity therapeutic ultrasound-a study of parameter sensitivity in a simple in vivo model.

BACKGROUND: Safety analyses of transcranial therapeutic ultrasound procedures require knowledge of the dependence of the rupture probability and rupture time upon sonication parameters. As previous vessel-rupture studies have concentrated on a specific set of exposure conditions, there is a need for more comprehensive parametric studies. METHODS: Probability of rupture and rupture times were measured by exposing the large blood vessel of a live earthworm to high-intensity focused ultrasound pulse trains of various characteristics. Pressures generated by the ultrasound transducers were estimated through numerical solutions to the KZK (Khokhlov-Zabolotskaya-Kuznetsov) equation. Three ultrasound frequencies (1.1, 2.5, and 3.3 MHz) were considered, as were three pulse repetition frequencies (1, 3, and 10 Hz), and two duty factors (0.0001, 0.001). The pressures produced ranged from 4 to 18 MPa. Exposures of up to 10 min in duration were employed. Trials were repeated an average of 11 times. RESULTS: No trends as a function of pulse repetition rate were identifiable, for either probability of rupture or rupture time. Rupture time was found to be a strong function of duty factor at the lower pressures; at 1.1 MHz the rupture time was an order of magnitude lower for the 0.001 duty factor than the 0.0001. At moderate pressures, the difference between the duty factors was less, and there was essentially no difference between duty factors at the highest pressure. Probability of rupture was not found to be a strong function of duty factor. Rupture thresholds were about 4 MPa for the 1.1 MHz frequency, 7 MPa at 3.3 MHz, and 11 MPa for the 2.5 MHz, though the pressure value at 2.5 MHz frequency will likely be reduced when steep-angle corrections are accounted for in the KZK model used to estimate pressures. Mechanical index provided a better collapse of the data (less separation of the curves pertaining to the different frequencies) than peak negative pressure, for both probability of rupture and rupture time. CONCLUSION: The results provide a database with which investigations in more complex animal models can be compared, potentially establishing trends by which bioeffects in human vessels can be estimated.

Comparison of Frequency of Referral to Cardiothoracic Surgery for Aortic Valve Disease in Blacks, Hispanics, and Whites.

Racial differences in prevalence and in intervention rate of those with severe aortic stenosis have been reported. Our objective was to evaluate health disparities in referral to cardiothoracic surgery (CTS) for aortic stenosis in black and Hispanic compared with white patients before the transcatheter aortic valve replacement program was started in our community. Using a retrospective cohort design, we identified all patients >40 years, who had been captured with aortic valve disease from January 2011 to June 2016. Clinical and echocardiographic data were collected manually. Exposure was race/ethnicity; outcome was referral to CTS. Multivariable logistic regression analysis was conducted with variables that had significance of p <0.20 in univariate model. We included 952 patients in the final analysis (423 white, 376 black, and 153 Hispanic). Compared with whites, black subjects were significantly younger, had more advanced degrees of kidney disease, were more likely to have Medicaid as payer, and had more atherogenic co-morbidities. Black patients had significantly higher aortic valve area indexed for body surface area, more aortic regurgitation, lower peak velocities, lower transvalvular gradients, less calcified valves, and fewer patients in aortic stenosis stage D. The adjusted odds ratio for CTS referral was 0.48 for blacks (p <0.001) and 0.86 for Hispanics (p = 0.73) compared with whites. In conclusion, after adjusting for clinical and echocardiographic variables, black patients were less likely to be referred to CTS for treatment of aortic valve disease. We found no difference in the referral pattern of Hispanic compared with white patients.

An extract of Artemisia dracunculus L. inhibits ubiquitin-proteasome activity and preserves skeletal muscle mass in a murine model of diabetes.

Impaired insulin signaling is a key feature of type 2 diabetes and is associated with increased ubiquitin-proteasome-dependent protein degradation in skeletal muscle. An extract of Artemisia dracunculus L. (termed PMI5011) improves insulin action by increasing insulin signaling in skeletal muscle. We sought to determine if the effect of PMI5011 on insulin signaling extends to regulation of the ubiquitin-proteasome system. C2C12 myotubes and the KK-A(y) murine model of type 2 diabetes were used to evaluate the effect of PMI5011 on steady-state levels of ubiquitylation, proteasome activity and expression of Atrogin-1 and MuRF-1, muscle-specific ubiquitin ligases that are upregulated with impaired insulin signaling. Our results show that PMI5011 inhibits proteasome activity and steady-state ubiquitylation levels in vitro and in vivo. The effect of PMI5011 is mediated by PI3K/Akt signaling and correlates with decreased expression of Atrogin-1 and MuRF-1. Under in vitro conditions of hormonal or fatty acid-induced insulin resistance, PMI5011 improves insulin signaling and reduces Atrogin-1 and MuRF-1 protein levels. In the KK-A(y) murine model of type 2 diabetes, skeletal muscle ubiquitylation and proteasome activity is inhibited and Atrogin-1 and MuRF-1 expression is decreased by PMI5011. PMI5011-mediated changes in the ubiquitin-proteasome system in vivo correlate with increased phosphorylation of Akt and FoxO3a and increased myofiber size. The changes in Atrogin-1 and MuRF-1 expression, ubiquitin-proteasome activity and myofiber size modulated by PMI5011 in the presence of insulin resistance indicate the botanical extract PMI5011 may have therapeutic potential in the preservation of muscle mass in type 2 diabetes.