Beyond 5 years: a matched cohort of sleeve gastrectomy versus gastric bypass.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) has demonstrated excellent short-term outcomes. However, existing studies suffer from loss to follow-up, and most long-term data focus on laparoscopic Roux-en-Y gastric bypass (LRYGB). This study compares weight loss in patients ≥5 years from LSG with that in matched patients who underwent LRYGB. OBJECTIVES: The purpose of this study was to compare long-term weight loss in patients undergoing LRYGB and LSG. SETTING: University hospital, United States. METHODS: We retrospectively evaluated patients who underwent LSG before August 2012 with follow-up data ≥5 years. LSG patients were matched 1:1 with LRYGB patients by sex, age at surgery, and preoperative body mass index. Univariate and multivariate analyses were performed with weight loss at the longest duration the primary outcome. RESULTS: One-hundred and sixty-five patients underwent LSG during the study period. Long-term follow-up data (≥5 years) were available for 85 patients (52%). There were no preoperative differences between those with and without follow-up data. Six LSG patients (7%) were excluded because they underwent reoperation that altered intestinal anatomy. Of the 79 patients remaining, 75 were matched with post-LRYGB patients. The average follow-up period was 6.4 years for LSG patients and 6.5 years for LRYGB patients (P = .08, not significant). Change in body mass index was 6.81 kg/m2 for LSG patients and 13.11 kg/m2 for LRYGB patients. Percentage of total body weight loss was 15.25% for LSG patients and 28.73% for LRYGB patients. Percentage of excess body weight loss was 37% for LSG patients and 67% for LRYGB patients (P < .0001). Weight loss for LSG patient follow-up in clinic versus outside the clinic was 46% versus 34% (P = .18, not significant). CONCLUSIONS: LSG is now the most common bariatric surgery in the United States. Long-term data are needed to confirm that observed short-term favorable outcomes are maintained. Recent studies have produced divergent results. We observed significantly less weight loss at ≥5 years in LSG patients compared with matched LRYGB patients.

Polymeric delivery of therapeutic RAE-1 plasmid to the pancreatic islets for the prevention of type 1 diabetes.

The activating receptor NKG2D plays an important role in the development of type-1 diabetes. Exploiting a natural phenomenon observed in tumors, plasmid DNA encoding for a soluble ligand to NKG2D (sRAE-1γ) was isolated and engineered into a plasmid expression system. A polymeric gene delivery system was developed to deliver the soluble RAE-1 plasmid to the pancreatic islets. The bioreducible cationic polymer poly(cystamine bisacrylamide-diamino hexane) (p(CBA-DAH)) was modified with poly(ethylene glycol) (PEG) and the targeting peptide CHVLWSTRC, known to target the EphA2 and EphA4 receptors. We observed a higher uptake of the targeting polymer Eph-PEG-p(CBA-DAH) in the pancreas of NOD mice compared to non-targeting controls. To evaluate the efficacy of preventing diabetes, the Eph-PEG-p(CBA-DAH)/RAE-1 complex (polyplex) was intravenously injected into 6-week-old female NOD mice. Within 17 weeks blood glucose levels were stabilized in animals injected with polyplex, while those treated without therapeutic plasmid developed progressive hyperglycemia. Additionally, the degree of insulitis and the infiltration of CD8⁺ T-cells in the polyplex treated group were improved over the targeting polymer only treated group. The current study suggests that the therapy of the Eph-PEG-p (CBA-DAH) delivering therapeutic sRAE-1 gene may be used to protect ß-cells from autoimmune destruction and prevent type-1 diabetes.

EphA2 targeting peptide tethered bioreducible poly(cystamine bisacrylamide-diamino hexane) for the delivery of therapeutic pCMV-RAE-1γ to pancreatic islets.

The pathogenesis of type-1 diabetes is complicated, and a clear, single mechanism has yet to be identified. Reports have indicated that the activating receptor NKG2D plays an important role in the development of disease. Exploiting a natural phenomenon observed in tumors, plasmid DNA encoding for a soluble ligand to NKG2D (sRAE-1γ) was isolated and engineered into a plasmid expression system. A polymeric gene delivery system was developed to deliver the soluble RAE-1 plasmid locally to the pancreatic islets for the prevention of type-1 diabetes. The bioreducible cationic polymer poly(cystamine bisacrylamide-diamino hexane) (p(CBA-DAH)) was modified with poly(ethylene glycol) (PEG) and the targeting peptide CHVLWSTRC, known to target the EphA2 and EphA4 receptors. The PEG serves to improve stability and tissue selectivity, while the peptide will target EphA2 and A4, overexpressed in the pancreatic microvasculature. The targeting polymer Eph-PEG-p(CBA-DAH) shows selective uptake by the target cell line, indicative of the targeting properties that will be seen in systemic administration. Using the delivery system, the therapeutic plasmid can be delivered to the pancreas, reduce interactions between the beta-cells and infiltrating NKG2D positive lymphocytes, and effectively protect beta-cells from autoimmune destruction and prevent type 1 diabetes.

Mixtures of poly(triethylenetetramine/cystamine bisacrylamide) and poly(triethylenetetramine/cystamine bisacrylamide)-g-poly(ethylene glycol) for improved gene delivery.

Branched disulfide-containing poly(amido ethyleneimines) (SS-PAEIs) are biodegradable polymeric gene carrier analogues of the well-studied, nondegradable, and often toxic branched polyethylenimines (bPEIs), but with distinct advantages for cellular transgene delivery. Clinical success of polycationic gene carriers is hampered by obscure design and formulation requirements. This present work reports synthetic and formulation properties for a graft copolymer of poly(ethylene glycol) (PEG) and a branched SS-PAEI, poly(triethylentetramine/cystaminebisacrylamide) (p(TETA/CBA)). Several laboratories have previously demonstrated the advantages of PEG conjugation to gene carriers, but have also shown that PEG conjugation may perturb plasmid DNA (pDNA) condensation, thereby interfering with nanoparticle formation. With this foundation, our studies sought to mix various amounts of p(TETA/CBA) and p(TETA/CBA)-g-PEG2k to alter the relative amount of PEG in each formulation used for polyplex formation. The influence of different PEG/polycation amounts in the formulations on polymer/nucleic acid nanoparticle (polyplex) size, surface charge, morphology, serum stability and transgene delivery was studied. Polyplex formulations were prepared using p(TETA/CBA)-g-PEG2k, p(TETA/CBA), and mixtures of the two species at 10/90 and 50/50 volumetric mixture ratios (wt/wt %), respectively. As expected, increasing the amount of PEG in the formulation adversely affects polyplex formation. However, optimal polymer mixtures could be identified using this facile approach to further clarify design and formulation requirements necessary to understand and optimize carrier stability and biological activity. This work demonstrates the feasibility to easily overcome typical problems observed when polycations are modified and thus avoids the need to synthesize multiple copolymers to identify optimal gene carrier candidates. This approach may be applied to other polycation-PEG preparations to alter polyplex characteristics for optimal stability and biological activity.

Congenital cholesteatoma of the mastoid temporal bone.

OBJECTIVE: Congenital mastoid cholesteatomas are rare lesions of the temporal bone. The clinical presentation of these lesions is variable, making them difficult to identify preoperatively. We evaluated our series of mastoid congenital cholesteatomas (CCs) in an effort to better define the clinical presentation, imaging characteristics, and surgical challenges specific to this lesion. STUDY DESIGN: Retrospective chart and radiologic study review. METHODS: The medical records of patients with the diagnosis of mastoid CC on radiologic imaging over a 15-year period were reviewed. All had surgical and pathologic confirmation. Eight patients underwent preoperative computed tomography (CT). Six also underwent magnetic resonance (MR) scanning. Demographic information, clinical presentation, imaging results, and operative findings were recorded. RESULTS: Nine patients with the diagnosis of mastoid CC satisfying the inclusion criteria were found. Clinical findings were variable, with the most common presentation being an incidental finding. Imaging findings were more uniform. All CT scans demonstrated an expansile, well-circumscribed mass centered within the mastoid portion of the temporal bone. All MR scans showed a well-circumscribed mass with high intensity on T2-weighted images with precontrasted T1 sequences showing the lesion to be isointense or slightly hyperintense to cerebrospinal fluid (CSF). Operative findings included lateral mastoid cortex erosion, sigmoid sinus exposure, ossicular destruction, facial nerve exposure, and associated postauricular abscess. Management of these lesions is reviewed. CONCLUSION: Congenital mastoid cholesteatomas have a variable and nonspecific clinical presentation. Surgical challenges arise from the indolent nature of this clinical entity, which belies the extent of otologic involvement. Imaging with CT and magnetic resonance imaging are diagnostic, defines the extent of these lesions, and facilitates preoperative surgical planning.

Mesenchymal stem cells enhance angiogenesis in mechanically viable prevascularized tissues via early matrix metalloproteinase upregulation.

Angiogenesis, the sprouting of new blood vessels from existing vasculature, is a complex biological process of interest to both the treatment of numerous pathologies and the creation of thick engineered tissues. In the context of tissue engineering, one potential solution to the diffusion limitation is to create a vascular network in vitro that can subsequently anastomose with the host after implantation, allowing the implantation of thicker, more complex tissues. In this study, the ability of endothelial cells to sprout and form stable vascular networks in 3-dimensional (3D) fibrin matrices was investigated as a function of matrix density in a prevascularized tissue model. The results demonstrate that while increasing matrix density leads to a nearly 7-fold increase in compressive stiffness, vascular sprouting is virtually eliminated in the most dense matrix condition. However, the addition of human mesenchymal stem cells (HMSCs) to the denser matrices reverses this effect, resulting in an up to a 7-fold increase in network formation. Although the matrix metalloproteinases (MMPs) MMP-2, MMP-9, and MT1-MMP are all upregulated early on with the addition of HMSCs, MT1-MMP appears to play a particularly important role in the observed angiogenic response among these proteases. This study provides a means to design stiffer prevascularized tissues utilizing naturally derived substrates, and its results may yield new mechanistic insights into stem cell-based angiogenic therapies.