Evaluation of the Rothman Index in Predicting Readmission after Colorectal Resection.

The Rothman Index (RI) is a real-time health indicator score that has been used to quantify readmission risk in several fields but has never been studied in gastrointestinal surgery. In this retrospective single-institution study, the association between RI scores and readmissions after unplanned colectomy or proctectomy was evaluated in 427 inpatients. Patient demographics and perioperative measures, including last RI, lowest RI, and increasing/decreasing RI score, were collected. In the selected cohort, 12.4% of patients were readmitted within 30 days of their initial discharge. Last RI, lowest RI, decreasing RI, and increasing RI scores remained significant after controlling for covariates in separate multivariate regression analyses. The last RI score at the time of discharge was found to be the most strongly associated with 30-day readmission risk following colorectal resection. These findings support the RI as a potential tool in the inpatient management of postoperative patients to identify those at high risk of readmission.

Saddle block anesthetic technique for benign outpatient anorectal surgery.

BACKGROUND: Current American Society of Colorectal Surgery Clinical Practice Guidelines for Ambulatory Anorectal Surgery endorse use of monitored anesthesia care, general anesthesia, or spinal anesthesia based on physician and patient preference. Although several studies support the use of monitored anesthesia care over general anesthesia, the literature regarding spinal anesthesia is limited and heterogenous due to small sample sizes and disparate spinal anesthesia techniques. Saddle block anesthesia is a form of spinal anesthesia that localizes to the lowermost sacral spinal segments allowing for preservation of lower extremity motor function and faster recovery. We accrued one of the largest reported cohort of anorectal procedures using saddle block anesthesia, as such, we sought to evaluate our institutional 12-year experience. METHODS: Patients who underwent a benign anorectal procedure at our outpatient surgery center between July 2008-2020 were retrospectively reviewed. Demographics, surgical factors, perioperative times, and adverse events were collected from the electronic medical records. Saddle block anesthesia was generally performed in the preoperative area using a spinal needle (25-27 gauge) and a single injection technique of a 1:1 ratio local anesthetic mixed with 10% dextrose solution. Between 2.5-5 mg of hyperbaric anesthetic was injected intrathecally in the sitting position and the patient remained upright for 3-10 minutes. This technique of saddle block anesthesia provides analgesia for approximately 1-3 hours. RESULTS: In the study, 859 saddle block anesthesia patients were identified, with a mean age of 44.6 years and American Society of Anesthesia score of 1.9; 609 (70.9%) were male. Surgical indications included lesion removal (27.1%), anal fistula (25.8%), hemorrhoidectomy (24.7%), pilonidal disease (6.3%), anal fissure (5.8%), and a combination of prior (10.2%). Prone jackknife positioning was used in 91.6% of procedures. Saddle block anesthesia most often was performed with bupivacaine (48.9%) or ropivacaine (41.7%). The median procedural saddle block anesthesia time was 11 minutes, surgery time was 17 minutes, anesthesia time was 42 minutes, and recovery time was 91 minutes. Patients spent a median of 3 hours and 53 minutes in the facility. Adverse events included urinary retention (1.9%), conversion to general anesthesia (1.8%), spinal headache (1.5%), hemodynamic instability (0.9%), and injection site reaction (0.3%). CONCLUSION: Demonstrated using the largest known cohort of anorectal patients with saddle block anesthesia, saddle block anesthesia provides an effective method of analgesia to avoid general anesthesia with a low rate of adverse events.

Biochemical characterization of Serpula lacrymans iron-reductase enzymes in lignocellulose breakdown.

Putative iron-reductase (IR) genes from Serpula lacrymans with similarity to the conserved iron-binding domains of cellobiose dehydrogenase (CDH) enzymes have been identified. These genes were cloned and expressed to functionally characterize their activity and role in the decomposition of lignocellulose. The results show that IR1 and IR2 recombinant enzymes have the ability to depolymerize both lignin and cellulose, are capable of the reduction of ferric iron to the ferrous form, and are capable of the degradation of nitrated lignin. Expression of these genes during wheat straw solid-state fermentation was shown to correlate with the release of compounds associated with lignin decomposition. The results suggest that both IR enzymes mediate a non-enzymatic depolymerisation of lignocellulose and highlight the potential of chelator-mediated Fenton systems in the industrial pre-treatment of biomass.

A postoperative parathyroid hormone-based algorithm to reduce symptomatic hypocalcemia following completion/total thyroidectomy: A retrospective analysis of 591 patients.

BACKGROUND: An institutional protocol for selective calcium/calcitriol supplementation after completion/total thyroidectomy was established based on the 4-hour postoperative parathyroid hormone level. The aim of this study was to evaluate the outcomes of this protocol 5 years after implementation. METHODS: All patients who underwent completion/total thyroidectomy from January 2012 to December 2016 were reviewed. Predictors of a 4-hour parathyroid hormone level <10 pg/mL and symptomatic hypocalcemia were assessed. RESULTS: Of 591 patients, 448 (76%) had a 4-hour parathyroid hormone ≥10, 72 (12%) had a 4-hour parathyroid hormone of 5-10, and 71 (12%) had a 4-hour parathyroid hormone <5. Hypocalcemic symptoms were infrequent (30/448, 7%) if the 4-hour parathyroid hormone was ≥10; 56% (40/71) of those with a 4-hour parathyroid hormone <5 reported symptoms. With 4-hour parathyroid hormone of 5-10, symptoms were reported in 32 of 72 (44%) patients; supplementation at discharge included calcium (n = 55, 76%), calcium and calcitriol (n = 12, 17%), or none (n = 5, 7%). Ten patients subsequently received calcitriol for persistent symptoms. On multivariate analysis, predictors of 4-hour parathyroid hormone <10 included incidental parathyroidectomy, malignancy, and thyroiditis; predictors of hypocalcemic symptoms included age <55 and 4-hour parathyroid hormone <10. CONCLUSION: After completion/total thyroidectomy, patients with a 4-hour parathyroid hormone ≥10 can be safely discharged without routine supplementation. The addition of calcitriol to calcium supplementation should be strongly considered for patients with a 4-hour parathyroid hormone of 5-10.

Outcome of Gleason 3 + 5 = 8 Prostate Cancer Diagnosed on Needle Biopsy: Prognostic Comparison with Gleason 4 + 4 = 8.

PURPOSE: ISUP (International Society for Urologic Pathology) and WHO adopted prognostic Grade Groups 1 to 5 that simplify prostate cancer grading for prognosis. Grade Group 4 is Gleason score 8 cancer, which is heterogeneous, and it encompasses Gleason score 4 + 4 = 8, 3 + 5 = 8 and 5 + 3 = 8. The comparative prognostic implications of these various Gleason scores had not been studied by urological pathologists after a re-review of slides. MATERIALS AND METHODS: Patients with a highest biopsy Gleason score of 3 + 5 = 8 or 4 + 4 = 8 were included in the study. Controls were cases with a highest Gleason score of 4 + 3 = 7 or 9-10. A total of 423 prostatic biopsy cases accessioned from 2005 to 2013 at 2 institutions were reviewed. Clinicopathological findings and followup (median 33.4 months) were assessed. RESULTS: Among Gleason score 8 cancers the cancer status outcome in 51 men with Gleason score 3 + 5 = 8 was marginally worse than in 114 with Gleason score 4 + 4 = 8 (p = 0.04). This was driven by a persistent nonmetastatic (after radiation/hormone therapy) cancer rate of 37% among Gleason score 3 + 5 = 8 cases vs 24% among Gleason score 4 + 4 = 8 cases. Conversely, cancer specific survival at 36-month followup was 97.8% in 3 + 5 cases vs 92.6% in 4 + 4 cases but this was not significant (p = 0.089). Cancer specific survival in the Gleason score 8 group was dichotomized by the presence of cribriform growth (p = 0.018). All Gleason score categories did not differ in the fraction of biopsy cores positive, clinical presentation or pathological findings, including the frequency of Gleason pattern 5, in 70 patients who underwent prostatectomy. CONCLUSIONS: Using the most current standards of prostate cancer grading the prognosis is not different in Gleason score 3 + 5 = 8 and 4 + 4 = 8 cancers. This justifies including both in Grade Group 4.

Immunohistochemical distinction of metastases of renal cell carcinoma to the adrenal from primary adrenal nodules, including oncocytic tumor.

Metastases of clear cell renal cell carcinoma to the adrenal can mimic primary adrenal cortical neoplasms or normal adrenal, especially in biopsy material. We compared 34 cases of clear cell renal cell carcinoma metastasis to the adrenal with 49 primary adrenal lesions (16 carcinoma, 22 adenoma, 9 oncocytic tumor, and 2 hyperplasia). Normal adrenal was available in 59 cases. Each entity was represented on tissue microarrays by duplicate-triplicate evaluable spots taken from spatially separate areas. Two pathologists evaluated all reactivity from 0 to 3+. A panel of 12 immunohistochemical stains was performed, including the first diagnostic uses of steroid receptor coactivator (SRC1) and equilibrative nucleoside transporter 1 (ENT1). The most sensitive and specific renal cell carcinoma markers were membranous reactivity for carbonic anhydrase IX (CAIX) and RCC marker and nuclear reactivity for PAX8. For adrenal cortical carcinomas, best markers were synaptophysin, SRC1, and MelanA; and for adrenal oncocytic tumor, synaptophysin and ENT1. Optimal markers for adrenal cortical adenoma and normal adrenal were ENT1 (more specific) and either MelanA or SRC1 (more sensitive). Calretinin, cytokeratin 34ßE12 and CAM5.2, inhibin, and steroidogenic factor 1 (SF1) proved less valuable to the panel. Nonspecific cytoplasmic biotin reactivity was frequent for CAIX and PAX8. Tumors with high-grade cytology should be worked up with 2 of the 3 stains: CAIX, PAX8, or RCC marker; and either SRC1 or MelanA. Adrenal adenoma, or normal adrenal, versus low-grade renal cell carcinoma are distinguished by a panel of: CAIX, PAX8, or RCC Marker; ENT1 and either SRC1 or MelanA.

Limited utility of routine surveillance imaging for classical Hodgkin lymphoma patients in first complete remission.

BACKGROUND: The objective of this study was to compare the outcomes of patients with classical Hodgkin lymphoma (cHL) who achieved complete remission with frontline therapy and then underwent either clinical surveillance or routine surveillance imaging. METHODS: In total, 241 patients who were newly diagnosed with cHL between January 2000 and December 2010 at 3 participating tertiary care centers and achieved complete remission after first-line therapy were retrospectively analyzed. Of these, there were 174 patients in the routine surveillance imaging group and 67 patients in the clinical surveillance group, based on the intended mode of surveillance. In the routine surveillance imaging group, the intended plan of surveillance included computed tomography and/or positron emission tomography scans; whereas, in the clinical surveillance group, the intended plan of surveillance was clinical examination and laboratory studies, and scans were obtained only to evaluate concerning signs or symptoms. Baseline patient characteristics, prognostic features, treatment records, and outcomes were collected. The primary objective was to compare overall survival for patients in both groups. For secondary objectives, we compared the success of second-line therapy and estimated the costs of imaging for each group. RESULTS: After 5 years of follow-up, the overall survival rate was 97% (95% confidence interval, 92%-99%) in the routine surveillance imaging group and 96% (95% confidence interval, 87%-99%) in the clinical surveillance group (P = .41). There were few relapses in each group, and all patients who relapsed in both groups achieved complete remission with second-line therapy. The charges associated with routine surveillance imaging were significantly higher than those for the clinical surveillance strategy, with no apparent clinical benefit. CONCLUSIONS: Clinical surveillance was not inferior to routine surveillance imaging in patients with cHL who achieved complete remission with frontline therapy. Routine surveillance imaging was associated with significantly increased estimated imaging charges.

Characterization and molecular epidemiology of a fungal infection of edible crabs (Cancer pagurus) and interaction of the fungus with the dinoflagellate parasite Hematodinium.

This study reports on an emerging fungal disease of the edible crab, Cancer pagurus. Juvenile (prerecruit) crabs were found to be subject to this disease condition during the months of May to September at two intertidal sites in South Wales, United Kingdom. Histopathology revealed that the fungi overwhelm the host response in the tissues, leading to progressive septicemia. The causative agent of this infection was isolated and grown in pure culture and was identified as a member of the Ophiocordyceps clade by sequencing of the small subunit of the fungal ribosomal DNA (rDNA). Of the crabs naturally infected with the fungus, 94% had a coinfection with the parasitic dinoflagellate Hematodinium species. To determine if there was any interaction between the two disease-causing agents, apparently fungus-free crabs, both with and without natural Hematodinium infections, were challenged with the fungal isolate. The presence of Hematodinium caused a significant reduction in fungal multiplication in the hemocoel of the crabs in comparison to that in Hematodinium-free individuals. Histopathology of coinfected crabs showed a systemic multiplication of Hematodinium within host tissues, leading to a rapid death, while Hematodinium-free crabs experimentally infected with the fungal isolate died due to fungal sepsis (septicemia) with the same characteristic pathology as seen in natural infections.

Genome organization and transcription response to harvest of two metallothionein-like genes in Agaricus bisporus fruiting bodies.

Metallothioneins are a class of small cysteine-rich proteins that have been associated with increased tolerance to metal and oxidative stresses in animals, plants, and fungi. We investigated a metallothionein-like (mt-like) gene shown previously to be upregulated in fruiting bodies of the fungus Agaricus bisporus in response to post-harvest storage. Analysis of an A. bisporus genomic DNA cosmid library identified two similar mt-like genes (met1 and met2) arranged as a bidirectional gene pair transcribed from the same promoter region. The promoter contained regulatory elements including 9 metal responsive elements and a CAAT box region 220 bp downstream of met1 that showed striking similarity to a feature in Coprinopsis cinerea mt-like gene promoters. Transcriptional analysis showed that both met genes are significantly and rapidly (within 3 hours) upregulated during post-harvest storage and expression is significantly greater in stipe and cap tissues compared with the gills. However, a strong directionality of the promoter was demonstrated, as transcript levels of met1 were at least two orders of magnitude greater than those of met2 in all samples tested.

Factors associated with recurrent bacterial vaginosis.

OBJECTIVE: To determine whether menstrual abnormalities, multiple personal behaviors and some contraceptive methods, all of which have been described as potential causes of single episodes of bacterial vaginosis (BV), are associated with recurrent bacterial vaginosis (RBV). STUDY DESIGN: This was a retrospective, case-controlled study performed in an urban setting. Women with RBV and matched controls were mailed a survey that included multiple questions about potential risk factors for BV. Four-to-one matching of age groups was performed, with 28 RBV cases matched to 112 controls. RESULTS: Among multiple possible predisposing factors, only African American ethnicity (p < 0.001) and > 1 male sex partner in the previous 2 years (p = 0.007) were strongly associated with RBV. Abnormal uterine bleeding, frequent intercourse without a condom or withdrawal, anal intercourse, menstrual hygiene product use, tub baths, back-to-front wiping after using the toilet, smoking, choice of contraceptive method (including condoms, the combination oral contraceptive, injectable medroxyprogesterone acetate or an intrauterine device) and douching were not associated with RBV. CONCLUSION: Providers should counsel women with RBV to minimize their number of male sex partners. There are few data to support the recommendation of other behavioral changes.