Telemedicine-based new patient consultations for hernia repair and advanced abdominal wall reconstruction.

PURPOSE: Telemedicine has emerged as a viable option to in-person visits for the evaluation and management of surgical patients. Increased integration of telemedicine has allowed for greater access to care for specific patient populations but relative outcomes are unstudied. Given these limitations, we sought to evaluate the efficacy of telemedicine-based new patient preoperative encounters in comparison to in-person encounters. METHODS: We performed a retrospective analysis of adult patients undergoing new patient evaluations from April 2020 to October 2021. Telemedicine visits consist of both video and telephone-based encounters. Visit types, patient demographics, preoperative diagnosis, travel time to the hospital, and prior imaging availability were reviewed. RESULTS: A total of 276 new patient encounters were conducted (n = 108, 39% telemedicine). Indications for evaluation included inguinal hernia (n = 81, 30%), ventral hernia (n = 149, 54%) and groin or abdominal pain (n = 30, 11%). Patients undergoing telehealth evaluations were more likely to have greater travel distance to the hospital (91 km vs 29 km, p = 0.002) and have CT image-confirmed diagnoses at the initial visit (73 vs 47%, p < 0.001). Patients who were evaluated for a recurrent or incisional hernia were more likely to be seen through a telemedicine encounter (69 vs 45%, p < 0.001). CONCLUSIONS: We report the efficacy of telemedicine-based consultations for new patient preoperative evaluations related to hernia repair and abdominal wall reconstruction. Telemedicine is a useful modality for preoperative evaluation of new patients with hernia and advanced abdominal wall reconstruction needs. Understanding this patient population will allow us to optimize telemedicine encounters for new patients and improve access to care for patients in remote locations.

Does thalidomide prolong survival in dogs with splenic haemangiosarcoma?

OBJECTIVES: To investigate thalidomide as an adjuvant treatment for canine haemangiosarcoma. MATERIALS AND METHODS: Fifteen dogs with splenic haemangiosarcoma, initially treated by splenectomy, were included. Following recovery from surgery, all dogs received thalidomide continuously until their death. Tumour stage was established using CT scans of the chest and abdomen immediately before starting thalidomide treatment and again three months later. Cause of death was confirmed by post mortem examination. RESULTS: The median survival time of dogs receiving thalidomide was 172 days (95% confidence interval: 93 to 250 days). Five dogs (33% of the population receiving thalidomide) survived more than 1 year (range 458 to 660 days) after surgery. Dogs with stage 2 disease that received thalidomide also had a longer survival time than dogs with stage 3 disease (median survival time 303 versus 40 days). Of 15 dogs, 13 died from metastatic haemangiosarcoma. CLINICAL SIGNIFICANCE: Treatment using thalidomide may improve survival of dogs with splenic haemangiosarcoma and should be considered a possible adjuvant therapy.

Genetic variation of habitual coffee consumption and glycemic changes in response to weight-loss diet intervention: the Preventing Overweight Using Novel Dietary Strategies (POUNDS LOST) trial.

Background: Coffee consumption has been associated with glucose metabolism and risk of type 2 diabetes.Objective: We examined whether the genetic variation determining habitual coffee consumption affected glycemic changes in response to weight-loss dietary intervention.Design: A genetic risk score (GRS) was calculated based on 8 habitual coffee consumption-associated single nucleotide polymorphisms. We used general linear models to test changes in glycemic traits in groups randomly assigned to high- and low-fat diets according to tertiles of the GRS.Results: We observed significant interactions between the GRS and low compared with high dietary fat intake on 6-mo changes in fasting insulin and homeostasis model assessment of insulin resistance (HOMA-IR) (P-interaction = 0.023 and 0.022, respectively), adjusting for age, sex, race, physical activity, smoking, alcohol, seasonal variation, and baseline values of the respective outcomes. Participants with a higher GRS of habitual coffee consumption showed a greater reduction in fasting insulin and a marginally greater decrease in HOMA-IR in the low-fat diet intervention group.Conclusions: Our data suggest that participants with genetically determined high coffee consumption may benefit more by eating a low-fat diet in improving fasting insulin and HOMA-IR in a short term. This trial was registered at clinicaltrials.gov as NCT00072995 and NCT03258203.

Soft tissue sarcoma in the dog - Part 2: surgical margins, controversies and a comparative review.

Soft tissue sarcoma constitutes a heterogeneous group of mesenchymal tumours. Although they are common in the dog, many uncertainties surround the best options for clinical management. Despite recent improvements in outcome, approximately one in five patients may still die as a result of their disease. There is some evidence that wide surgical excision may not be required for every soft tissue sarcoma but, conversely, complacency in treatment may adversely affect outcomes for patients with aggressive disease. The purpose of this review is to examine the issues affecting the management of canine soft tissue sarcoma, and to evaluate the human literature for lessons that may guide future treatment directions for dogs. Comparative lessons from human soft tissue sarcoma that may be important for the canine patient in the future include (1) understanding the oncogenic potential of the pseudocapsule to better predict tumour behaviour and optimal surgical margins, (2) recognising the importance of planned multi-modality therapy for improving tumour control, (3) considering a role for compartmental resection strategies and (4) improving the accuracy of pretreatment analysis of the tumour to better predict behaviour and optimal treatment options.

Soft tissue sarcoma in the dog - part 1: a current review.

Soft tissue sarcomas are derived from tissues of mesenchymal origin. Although local recurrence following surgical resection is the characteristic challenge in their management, 40% dogs with high-grade tumours may also develop metastatic disease, despite successful local control. Soft tissue sarcoma is a complex disease and there are many uncertainties regarding the biology and optimal clinical management. There are currently no diagnostic tests that can reliably predict the amount of surgical margin required for a particular tumour, so there can be a mismatch between treatment and disease. Historically, the tendency has been to always recommend wide excision margins but this is not fully supported by recent evidence. A selection bias for less aggressive soft tissue sarcomas in primary care practice can account for good outcomes that are achieved despite narrow surgical excision margins. On the other hand, inappropriately conservative treatment will adversely affect outcomes for patients with more aggressive disease. This review provides an update on the current understanding of management of canine soft tissue sarcomas.

Neoadjuvant and adjuvant chemotherapy combined with anatomical resection of feline injection-site sarcoma: results in 21 cats.

This study assesses the outcome of two combined treatment strategies for the treatment of feline injection-site sarcoma (FISS). Twenty-one cats with primary or recurrent FISS received 3 cycles of neoadjuvant chemotherapy with epirubicin (25 mg m(-2) ), then an anatomical resection of the entire muscle compartment containing the tumour was performed based on the findings of co-axial imaging. Cats then received a further 3 cycles of adjuvant chemotherapy. Follow-up was performed by telephone contact with a median follow-up time of 1072 days. Three cats (14%) developed local tumour recurrence at days 264, 664 and 1573 after surgery. A median survival time could not be calculated as over 80% of the study population remained alive or were censored due to death from other causes. When compared to historical controls, the results of this study demonstrate superior rates of tumour-free survival and disease-free interval.

Pedicle ligation in ovariohysterectomy: an in vitro study of ligation techniques.

OBJECTIVES: Ligature failure is an important complication following ovariohysterectomy in the bitch. The aim of this study was to assess the differences between five individual ligation techniques in their ability to attenuate a bulky vascular model. METHODS: A vascular model was constructed that enabled the occlusive ability of five different ligation techniques to be measured including the square knot, surgeon's knot, slip knot, modified transfixing ligature and the single-double other side knot. Each was constructed using both USP-0 polyglyconate and polyglactin 910 suture material. The extent of attenuation of the vascular model that was achieved by each technique was assessed using pressure transducers. RESULTS: In this model, the slip knot, modified transfixing ligature and the single-double other side knot outperformed the square and surgeon's knots. CLINICAL SIGNIFICANCE: The results of this study suggest that utilising a knot design that has more inherent resistance to slippage of the first throw (e.g. the modified transfixing ligature, slip or single-double other side knots) may be preferable over square and surgeon's knots when tying a ligature on a bulky vascular pedicle like the ovarian stump in a large bitch.

Degradation and drug release in calcium polyphosphate bioceramics: an MRI-based characterization.

Degradable, bioceramic bone implants made of calcium polyphosphate (CPP) hold potential for controlled release of therapeutic agents in the treatment of localized bone disease. Magnetic resonance imaging techniques for non-invasively mapping fluid distribution, T(1) and T(2) relaxation times and the apparent diffusion coefficient were performed in conjunction with a drug elution protocol to resolve free and bound water components within the material microstructure in two CPP formulations (G1 and G2). The T(2) maps provided the most accurate estimates of free and bound water, and showed that G1 disks contained a detectable free water component at all times, with drug release dominated by a Fickian diffusion mechanism. Drug release from G2 disks was characterized by a combined diffusional/structural relaxation mechanism, which may be related to the gradual infiltration of a free water component associated with swelling and/or chemical degradation.

Involvement of protein kinase C and protein kinase A in the enhancement of L-type calcium current by GABAB receptor activation in neonatal hippocampus.

In the early neonatal period activation of GABAB receptors attenuates calcium current through N-type calcium channels while enhancing current through L-type calcium channels in rat hippocampal neurons. The attenuation of N-type calcium current has been previously demonstrated to occur through direct interactions of the ßγ subunits of Gi/o G-proteins, but the signal transduction pathway for the enhancement of L-type calcium channels in mammalian neurons remains unknown. In the present study, calcium currents were elicited in acute cultures from postnatal day 6-8 rat hippocampi in the presence of various modulators of protein kinase A (PKA) and protein kinase C (PKC) pathways. Overnight treatment with an inhibitor of Gi/o (pertussis toxin, 200 ng/ml) abolished the attenuation of calcium current by the GABAB agonist, baclofen (10 µM) with no effect on the enhancement of calcium current. These data indicate that while the attenuation of N-type calcium current is mediated by the Gi/o subtype of G-protein, the enhancement of L-type calcium current requires activation of a different G-protein. The enhancement of the sustained component of calcium current by baclofen was blocked by PKC inhibitors, GF-109203X (500 nM), chelerythrine chloride (5 µM), and PKC fragment 19-36 (2 µM) and mimicked by the PKC activator phorbol-12-myristate-13-acetate (1 µM). The enhancement of the sustained component of calcium current was blocked by PKA inhibitors H-89 (1 µM) and PKA fragment 6-22 (500 nM) but not Rp-cAMPS (30 µM) and it was not mimicked by the PKA activator, 8-Br-cAMP (500 µM-1 mM). The data suggest that activation of PKC alone is sufficient to enhance L-type calcium current but that PKA may also be involved in the GABAB receptor mediated effect.

Influence of pharmacogenetics on response and toxicity in breast cancer patients treated with doxorubicin and cyclophosphamide.

BACKGROUND: Doxorubicin and cyclophosphamide (AC) therapy is an effective treatment for early-stage breast cancer. Doxorubicin is a substrate for ABCB1 and SLC22A16 transporters. Cyclophosphamide is a prodrug that requires oxidation to 4-hydroxycyclophosphamide, which yields a cytotoxic alkylating agent. The initial oxidation is catalysed by cytochrome P450 enzymes including CYP2B6, CYP2C9, CYP2C19 and CYP3A5. Polymorphic variants of the genes coding for these enzymes and transporters have been identified, which may influence the systemic pharmacology of the two drugs. It is not known whether this genetic variation has an impact on the efficacy or toxicity of AC therapy. METHODS: Germ line DNA samples from 230 patients with breast cancer on AC therapy were genotyped for the following SNPs: ABCB1 C1236T, G2677T/A and C3435T, SLC22A16 A146G, T312C, T755C and T1226C, CYP2B6*2, *8, *9, *3, *4 and *5, CYP2C9*2 and *3, CYP3A5*3 and CYP2C19*2. Clinical data on survival, toxicity, demographics and pathology were collated. RESULTS: A lower incidence of dose delay, indicative of less toxicity, was seen in carriers of the SLC22A16 A146G, T312C, T755C variants. In contrast, a higher incidence of dose delay was seen in carriers of the SLC22A16 1226C, CYP2B6*2 and CYP2B6*5 alleles. The ABCB1 2677A, CYP2B6*2, CYP 2B6*8, CYP 2B6*9, CYP 2B6*4 alleles were associated with a worse outcome. CONCLUSION: Variant alleles in the ABCB1, SLC22A16 and CYP2B6 genes are associated with response to AC therapy in the treatment of breast cancer.

Outcome following removal of canine spindle cell tumours in first opinion practice: 104 cases.

OBJECTIVES: To define the outcome of a cohort of canine patients with a histological diagnosis of spindle cell tumour of soft tissue managed solely by surgery in first opinion practice. METHODS: Clinical details of 104 spindle cell sarcomas submitted to Finn Pathologists during the year 2000 were reviewed. Questionnaires were sent to the submitting veterinarians, requesting details about the tumour, surgery performed and ultimate outcome of the patient. RESULTS: The method of surgical resection was described as marginal in 45 dogs (44.2 per cent). Excision margins of 3 cm or more were described in less than 10 per cent of cases. Tumours recurred locally in 29 dogs (27.9 per cent). Eighteen dogs (21.7 per cent) died of tumour-related causes. Most deaths were unrelated to sarcoma (50 dogs, 60.2 per cent) or unknown (15 dogs, 18 per cent). The median survival time was 1013 days. Tumour size, location or degree of surgical resection were not significantly related to survival or tumour recurrence. A palpable assessment of tumour invasion into underlying tissues was significantly associated with decreased disease-free interval (P<0.0001) and survival time (P = 0.0070). CLINICAL SIGNIFICANCE: The results of this retrospective study indicate that many spindle cell tumours managed in first opinion practice exhibit a low-grade biological behaviour and may respond well to more conservative surgery than current recommendations advise.

Ureteral spindle cell sarcoma in a dog.

A five-year-old, female spayed Labrador retriever was presented for further investigation of an intra-abdominal mass. Abdominal exploration showed a large mass arising from the right ureter and a ureteronephrectomy was performed. Histopathology of the ureteral mass was consistent with a spindle cell sarcoma. The patient recovered well, but five months later was diagnosed with another tumour, this time in her left abdominal wall. The owners decided not to pursue further treatment and euthanasia was performed a month later.

Fibromuscular dysplasia may herald symptomatic recurrence of cervical artery dissection.

BACKGROUND: The prevalence of fibromuscular dysplasia (FMD) in patients with cervical artery dissection (CAD) is unknown. Our objectives were to assess the risk of CAD recurring as a stroke or a transient ischemic attack and the association of these events with FMD. METHODS: We prospectively included and followed 103 consecutive patients who had been admitted for a CAD. The median follow-up was 4 years (range 4 months to 10 years). The main criteria for inclusion were a mural hematoma demonstrated by cervical magnetic resonance imaging and/or signs suggesting CAD on 2 other investigations. FMD was diagnosed on the so-called string of beads pattern by digital subtraction angiography. RESULTS: Five patients had CAD recurrence (60% occurred late). Four of these 5 patients had FMD. In 4 patients, CAD recurrence involved another cervical artery. CONCLUSION: The rate of symptomatic CAD recurrence was 1% per year and was often related to FMD.

Clinical recognition of neurally mediated syncope.

BACKGROUND: Most cases of syncope are due to hypotension, with a vasovagal response the commonest single mechanism. Neurally mediated syncope (NMS) is a vasovagal response evoked by common physical or psychological stress factors in susceptible individuals. Although upright tilt table testing (TTT) has been developed to diagnose this condition, the clinical recognition of this common syndrome in the general community remains poor. AIMS: To evaluate the clinical presentation of patients with NMS and pre-syncope, proven by TTT, and compare them to patients with syncope that have a low probability of having NMS (e.g. older patients with cardiac disease and negative TTT). METHODS: Prospective evaluation by questionnaire at the time of TTT, including documentation of presenting symptoms and signs, and provoking factors in consecutive patients. Comparisons between patient groups analyzed using chi-squared tests and logistic regression. RESULTS: Neurally mediated syncope patients were more likely to present with both syncope and pre-syncope, often with prolonged histories of pre-syncope. Certain provoking stress factors were more common in NMS, with multiple factors often present. Most NMS patients had a hypotensive prodrome before syncope, whereas control patients had a higher incidence of syncope without warning. CONCLUSION: Neurally mediated syncope patients present with situational syncope that is not only stereotypical for the individual, but shares common features with other similar patients. While none of the clinical observations is unique to NMS, a carefully detailed history can elicit a convincing diagnostic pattern that can often obviate the need for extensive and expensive investigation, and in younger patients a TTT may not be required to make the diagnosis.

Accuracy of color-Doppler in the quantification of proximal vertebral artery stenoses.

BACKGROUND: Vertebrobasilar (VB) strokes appear to have the same causes as carotid strokes. Obstructive lesions of proximal vertebral arteries probably occur in about 30% of stroke patients. PURPOSE: Our aim was to assess the validity of color Doppler sonography compared to selective intra-arterial angiography in the quantification of proximal vertebral artery stenoses. MATERIALS AND METHODS: A prospective blind study of 316 vertebral arteries was undertaken between 1996 and 1998. One hundred and fifty-eight patients with cerebrovascular disorders without cerebral hemorrhage were studied consecutively by frequency or amplitude color Doppler flow imaging and intra-arterial angiography. The lesions were quantified by morphological and hemodynamic criteria and classified into 6 groups: 0% 207 arteries; 1-29% 32 arteries; 30-49% 29 arteries; 50-69% 13 arteries; 70-99% 23 arteries; 100% 12 arteries. RESULTS: Ten of the 12 occlusions were identified, the 2 false-negatives were due to 2 revascularized vessels. Moderate stenoses (<50%) were differentiated from tight stenoses (>50%) using hemodynamic criteria. The majority of false-negative stenoses (38) in the different groups were related to intrathoracic or very deep origin of the artery, anechogenic stenosis or a tortuous vessel. Stenoses greater than 70% were diagnosed in 71% of cases with a specificity of 99%. The kappa value was 0.80. CONCLUSION: Duplex sonography should be proposed first in VB attacks or stroke to detect and quantify vertebral artery stenoses for surgery and angioplasty.

The joint demand for cigarettes and marijuana: evidence from the National Household Surveys on Drug Abuse.

Recent studies have shown that efforts to curb youths' alcohol use, such as increasing the price of alcohol or limiting youths' access, have succeeded but may have had the unintended consequence of increasing marijuana use. This possibility is troubling in light of the doubling of teen marijuana use from 1990 to 1997. What impact will recent increases in cigarette prices have on the demand for other substances, such as marijuana? To better understand how the demand for marijuana and tobacco responds to changes in the policies and prices that affect their use, we explore the National Household Survey on Drug Abuse (NHSDA) from 1990 to 1996. We find evidence that both higher fines for marijuana possession and increased probability of arrest decrease the probability that a young adult will use marijuana. We also find that higher cigarette taxes appear to decrease the intensity of marijuana use and may have a modest negative effect on the probability of use among males.

Plasmid/liposome transfer of the human manganese superoxide dismutase transgene prevents ionizing irradiation-induced apoptosis in human esophagus organ explant culture.

Esophagitis is a major limiting factor in the treatment of lung cancer by radiation alone or in combination with chemotherapy. We have previously demonstrated that intraesophageal injection of manganese superoxide dismutase-plasmid/liposome (MnSOD-PL) complex into C3H/HeNsd mice blocks irradiation-induced esophagitis. To determine whether the human esophagus can be similarly transfected, normal human esophageal sections obtained from the margins of esophagectomy specimens from esophageal cancer patients were transfected in vitro with alkaline phosphatase (AlkP)-PL complex and stained for AlkP activity, and the percent of cells expressing AlkP was calculated. At 24 hr after transfection with 20 or 200 microgram of AlkP-PL complex, 55.0% and 85.8% of esophageal epithelial cells expressed detectable AlkP, respectively. Other sections transfected with MnSOD-PL complex showed transgene mRNA by nested reverse transcriptase-polymerase chain reaction (RT-PCR) assay and increased MnSOD biochemical activity for at least 96 hr after transfection. Irradiated MnSOD-PL complex-transfected sections demonstrated a significantly decreased percentage of apoptotic cells when compared to irradiated control sections. Following 1,000 cGy, MnSOD-PL-treated samples showed 7.5 +/- 2.8% and 33.3 +/- 7.3% apoptotic cells at 24 and 48 hr compared to 53.6 +/- 6.9% and 59.0 +/- 13.8% for nontransfected controls (P < 0.0001 and P < 0.1175). After 2,000 cGy, results at 24 and 48 hr were 25.0 +/- 7.6% and 66.9 +/- 4.9% for MnSOD-transfected sections compared to 65.6 +/- 4.3% and 90.0 +/- 4.1% for control sections (P < 0.0001 and P = 0.0353), respectively. Thus, human esophageal sections can be transfected with MnSOD-PL complex in vitro and thereby protected against ionizing irradiation-induced apoptosis. Int. J. Cancer (Radiat. Oncol. Invest.) 90, 128-137 (2000).