Surgical Site Infection in Patients Managed with an Endoprosthesis for the Treatment of Cancer: Evaluation of Patient, Disease, and Index Surgical Factors.

BACKGROUND: Surgical site infection (SSI) after segmental endoprosthetic reconstruction in patients treated for oncologic conditions remains both a devastating and a common complication. The goal of the present study was to identify variables associated with the success or failure of treatment of early SSI following the treatment of a primary bone tumor with use of a segmental endoprosthesis. METHODS: The present study used the Prophylactic Antibiotic Regimens in Tumor Surgery (PARITY) data set to identify patients who had been diagnosed with an SSI after undergoing endoprosthetic reconstruction of a lower extremity primary bone tumor. The primary outcome of interest in the present study was a dichotomous variable: the success or failure of infection treatment. We defined failure as the inability to eradicate the infection, which we considered as an outcome of amputation or limb retention with chronic antibiotic suppression (>90 days or ongoing therapy at the conclusion of the study). Multivariable models were created with covariates of interest for each of the following: surgery characteristics, cancer treatment-related characteristics, and tumor characteristics. Multivariable testing included variables selected on the basis of known associations with infection or results of the univariable tests. RESULTS: Of the 96 patients who were diagnosed with an SSI, 27 (28%) had successful eradication of the infection and 69 had treatment failure. Baseline and index procedure variables showing significant association with SSI treatment outcome were moderate/large amounts of fascial excision ≥1 cm2) (OR, 10.21 [95% CI, 2.65 to 46.21]; p = 0.001), use of local muscle/skin graft (OR,11.88 [95% CI, 1.83 to 245.83]; p = 0.031), and use of a deep Hemovac (OR, 0.24 [95% CI, 0.05 to 0.85]; p = 0.041). In the final multivariable model, excision of fascia during primary tumor resection was the only variable with a significant association with treatment outcome (OR, 10.21 [95% CI, 2.65 to 46.21]; p = 0.018). CONCLUSIONS: The results of this secondary analysis of the PARITY trial data provide further insight into the patient-, disease-, and treatment-specific associations with SSI treatment outcomes, which may help to inform decision-making and management of SSI in patients who have undergone segmental bone reconstruction of the femur or tibia for oncologic indications. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Gender Disparities in Financial Relationships Between Industry and Orthopaedic Surgeons.

BACKGROUND: Recent studies in a number of surgical subspecialties have demonstrated that financial relationships with industry differ between men and women. This study aimed to determine if gender disparities exist in industry relationships with orthopaedic surgeons. METHODS: This retrospective study utilized publicly available data from the Centers for Medicare & Medicaid Services (CMS) at OpenPayments.cms.gov. Data were extracted for payments made to orthopaedic surgeons from industry for royalties, licensing, or consulting fees from 2016 to 2017. A physician's profile was used to determine name, gender, practice location, and subspecialty. Years of experience were recorded from publicly available websites. Total number of payments and amounts were compared among men and women, subspecialties, and locations. Multivariable linear regression models were used to determine predictors of total payments and number of payments. RESULTS: Royalties and consulting fees were paid to 3,418 individual physicians (11% of 29,996 physicians in the American Academy of Orthopaedic Surgeons [AAOS] census) and accounted for 88% of total payments. The majority of the total payment amount (99.6%) was made to men, while only 0.4% went to women. Male gender was a predictor of total number of payments (ß = 5.17, p < 0.001), as were years of experience (ß = 0.15 [95% confidence interval (CI): 0.10 to 0.20], p < 0.001), Mountain region (ß = 2.77 [95% CI: 0.37 to 5.17], p = 0.02), and adult reconstructive subspecialty (ß = 4.07 [95% CI: 1.89 to 6.25], p < 0.001). Years of experience (ß = 0.046 [95% CI: 0.039 to 0.052], p < 0.001), male gender (ß = 1.09 [95% CI: 0.67 to 1.51], p < 0.001), Mountain region (ß = 0.35 [95% CI: 0.020 to 0.68], p = 0.04), and adult reconstructive subspecialty (ß = 0.33 [95% CI: 0.030 to 0.63], p = 0.03) were associated with higher payments. CONCLUSIONS: Male gender, years of experience, Mountain region, and adult reconstructive subspecialty are independent predictors of a higher number of industry payments and payment amount. These disparities in industry payments may contribute to continued inequities in scholarship, academic rank, and leadership opportunities.

Paradoxical embolism causing stroke and migraine.

This case report describes a lady who underwent investigations as a part of a clinical study. A 32-year-old woman with a history of episodes of severe migraine with aura, deep vein thrombosis and recurrent epistaxis, presented with two episodes of stroke with no particular cause evident on routine investigations. A contrast echocardiogram demonstrated a patent foramen ovale (PFO). She was found to be positive for the Factor V Leiden mutation. The PFO was closed percutaneously. However, a substantial right to left shunt of 14% persisted. Pulmonary angiography revealed multiple arterio-venous malformations (AVMs) and she was diagnosed with hereditary hemorrhagic telangiectasia. The AVMs were embolized and she has had no further cerebral events. Interestingly, her episodes of 'migraine' have also improved dramatically following the closure of the PFO and the embolization of the AVMs. This case demonstrates the complex relationship between right to left shunts, cryptogenic stroke and migraine.

Reversible drug-induced oxyntic atrophy in rats.

BACKGROUND & AIMS: Oxyntic atrophy is the hallmark of chronic gastritis. Many studies have sought to develop animal models for oxyntic atrophy, but none of them are reversible. We now report that rats administered high doses of DMP 777 demonstrate reversible oxyntic atrophy. METHODS: DMP 777 was administered to CD-1 rats by oral gavage (200 mg. kg(-1). day(-1)). Serum gastrin level, in vivo acid secretion, and gastric histological changes were evaluated in DMP 777-dosed animals. Direct effects of DMP 777 on parietal cells were evaluated by assessment of aminopyrine accumulation into isolated rabbit parietal cells, as well as by assessment of DMP 777 effects on acridine orange fluorescence and H(+),K(+)-adenosine triphosphatase (ATPase) activity in isolated tubulovesicles. RESULTS: Oral dosing with DMP 777 caused a rapid increase in serum gastrin levels and severe hypochlorhydria. DMP 777 inhibited aminopyrine accumulation into rabbit parietal cells stimulated with either histamine or forskolin. DMP 777 reversed a stimulated proton gradient in isolated parietal cell tubulovesicles. Oral dosing with DMP 777 led to rapid loss of parietal cells from the gastric mucosa. In response to the acute loss of parietal cells, there was an increase in the activity of the progenitor zone along with rapid expansion of the foveolar cell compartment. DMP 777 treatment also led to the emergence of bromodeoxyuridine-labeled cells and cells positive for periodic acid-Schiff in the basal region of fundic glands. With extended dosing over 3-6 months, foveolar hyperplasia and oxyntic atrophy were sustained while chief cell, enterochromaffin-like cell, and somatostatin cell populations were decreased. No histological evidence of neoplastic transformation was observed with dosing up to 6 months. Withdrawal of the drug after 3 or 6 months of dosing led to complete restitution of the normal mucosal lineages within 3 months. CONCLUSIONS: DMP 777 acts as a protonophore with specificity for parietal cell acid-secretory membranes. DMP 777 in high doses leads to the specific loss of parietal cells. Foveolar hyperplasia, loss of normal gland lineages, and the emergence of basal mucous cells appear as sequelae of the absence of parietal cells. The results suggest that parietal cells are critical for the maintenance of the normal mucosal lineage repertoire.

Association of Rab25 and Rab11a with the apical recycling system of polarized Madin-Darby canine kidney cells.

Recent evidence suggests that apical and basolateral endocytic pathways in epithelia converge in an apically located, pericentriolar endosomal compartment termed the apical recycling endosome. In this compartment, apically and basolaterally internalized membrane constituents are thought to be sorted for recycling back to their site of origin or for transcytosis to the opposite plasma membrane domain. We report here that in the epithelial cell line Madin-Darby Canine Kidney (MDCK), antibodies to Rab11a label an apical pericentriolar endosomal compartment that is dependent on intact microtubules for its integrity. Furthermore, this compartment is accessible to a membrane-bound marker (dimeric immunoglobulin A [IgA]) internalized from either the apical or basolateral pole, functionally defining it as the apical recycling endosome. We have also examined the role of a closely related epithelial-specific Rab, Rab25, in the regulation of membrane recycling and transcytosis in MDCK cells. When cDNA encoding Rab25 was transfected into MDCK cells, the protein colocalized with Rab11a in subapical vesicles. Rab25 transfection also altered the distribution of Rab11a, causing the coalescence of immunoreactivity into multiple denser vesicular structures not associated with the centrosome. Nevertheless, nocodazole still dispersed these vesicles, and dimeric IgA internalized from either the apical or basolateral membrane was detected in endosomes labeled with antibodies to both Rab11a and Rab25. Overexpression of Rab25 decreased the rate of IgA transcytosis and of apical, but not basolateral, recycling of internalized ligand. Conversely, expression of the dominant-negative Rab25T26N did not alter either apical recycling or transcytosis. These results indicate that both Rab11a and Rab25 associate with the apical recycling system of epithelial cells and suggest that Rab25 may selectively regulate the apical recycling and/or transcytotic pathways.

Rab11 in dysplasia of Barrett's epithelia.

Barrett's esophagus predisposes affected patients to the development of esophageal adenocarcinoma. The development of adenocarcinoma proceeds along a progression through low- and high-grade dysplasia. Surveillance of Barrett's patients requires serial endoscopic investigations and grading mucosal biopsies. Unfortunately, grading of biopsies by conventional hematoxylin and eosin staining is fraught with significant interobserver variations. We have found in both biopsy and resection specimens that immunostaining for the small GTP binding protein Rab11 is increased in low-grade dysplastic cells. This staining is lost in high-grade dysplastic cells. These results suggest that low-grade dysplastic cells undergo an apical trafficking blockade, which is released as cells progress to the less differentiated phenotype of high-grade dysplasia and adenocarcinoma. Examination of the SKGT-4 esophageal adenocarcinoma cell line demonstrated prominent mRNA and protein expression for Rab11. Rab11 immunostaining was present in SKGT-4 cells as a perinuclear nidus of punctate staining along with a more diffuse punctate pattern. Thus, Rab11 expression was present in a esophageal adenocarcinoma cells in culture. Markers of vesicle trafficking may be critical factors for grading of mucosal dysplastic transitions leading to adenocarcinoma.

Increased immunoreactivity for Rab11, a small GTP-binding protein, in low-grade dysplastic Barrett's epithelia.

Adenocarcinoma of the esophagus develops from metaplastic Barrett's columnar epithelia through the evolution of dysplastic epithelial intermediates. Although the role of dysplasia leading to adenocarcinoma is well established, far less is known regarding the cellular changes involved in this process. Because the development of dysplasia is characterized by the loss of apical secretory specializations, we hypothesized that changes in apical trafficking might be involved in the dysplastic process. We have sought to evaluate the expression of an important candidate regulator of apical trafficking, the small GTP-binding protein, Rab11, in resection and biopsy tissue from patients with Barrett's esophagus. Sections from esophageal resection specimens from 4 patients and endoscopic biopsies from 60 patients were stained with antibodies against Rab11 and Rab25 as well as protein markers of the Golgi apparatus and p53 protein. Rab11 staining in low-grade dysplastic regions was similar to that observed with monoclonal antibodies against Rab25 and gamma-adaptin and colocalized with staining for the Golgi marker, the mannose-6-phosphate receptor. In the esophageal adenocarcinoma resections, prominent Rab11 immunostaining was observed in the supranuclear region of low-grade dysplastic cells. In contrast, regions of high-grade dysplasia demonstrating strong nuclear p53 staining showed only diffuse or absent Rab11 staining. In endoscopic biopsies, 91% of biopsies that were read unanimously as low-grade dysplasia demonstrated supranuclear Rab11 staining. Fourteen percent of biopsies unanimously graded as being without dysplasia demonstrated perinuclear Rab11 staining. No p53 immunostaining was observed in any of the low-grade dysplasia biopsy specimens. An increase in Rab11 immunoreactivity seems to correlate with low-grade dysplasia, whereas p53 immunostaining correlates with high-grade dysplasia. The colocalization of Rab11 staining with increased immunoreactivity for markers of the trans-Golgi system is consistent with a defect in apical trafficking due to an expansion of either the trans-Golgi compartment or the apical recycling vesicle system.

Inhibition of parietal cell acid secretion is mediated by the classical epidermal growth factor receptor.

Epidermal growth factor (EGF) and transforming growth factor-alpha (TGF-alpha) inhibit gastric acid secretion both in vivo and in vitro. Previous studies have indicated that EGF and TGF-alpha bind to the same EGF/TGF-alpha receptor. Nevertheless, we and others have previously demonstrated that inhibition of acid secretion by these growth factors requires concentrations of the peptides that are 10-fold higher than those necessary for induction of mitogenesis. Therefore, we have sought to investigate whether gastric parietal cells may possess a second EGF/TGF-alpha receptor class. Two systems were studied: First, [125I]TGF-alpha was cross-linked to the receptor in isolated rabbit parietal cell membranes, and labeled species were resolved on SDS-PAGE. Second, acid secretion was evaluated in pylorus-ligated waved-2 mutant mice, which carry a disabling point mutation in their classical EGF/TGF-alpha receptor. In isolated parietal cells, [125I]TGF-alpha was cross-linked into a single species of 170 kDa. Cross-linking was inhibited in the presence of unlabeled TGF-alpha with an IC50 of 80 nM. In the pylorus-ligated mice, control littermate mice demonstrated a dose-dependent inhibition of acid secretion by EGF with an IC50 of 20 micrograms/kg. In contrast, EGF had no inhibitory effect on acid secretion in waved-2 mice at concentrations up to 100 micrograms/kg. No alterations in parietal cell or gastrin cell numbers were observed. These results in both isolated rabbit parietal cells and waved-2 mice support the existence of only a single class of EGF/TGF-alpha receptors in parietal cells. Differences in growth factor affinity are likely due to the modification of the receptor or one of its coordinate regulators.

Foveolar hyperplasia following partial gastrectomy results from expansion of surface mucous cell compartment.

Antrectomy with gastroenterostomy reconstruction is often associated with the development of foveolar hyperplasia and oxyntic atrophy. While a role for bile reflux in the etiology of foveolar hyperplasia is well established, the identity of the mucous cell lineages responsible for this condition have not been well characterized. We have studied three patients who demonstrated foveolar hyperplasia in their gastric remnant following antrectomy and gastroenterostomy. Mucosal samples were stained with antibodies against the trefoil peptides pS2 and hSP, to identify surface mucous and mucous neck cell lineages, respectively. Postoperative biopsies from all three patients showed oxyntic atrophy as documented by staining of parietal cells with antibodies against H/K-ATPase. All three patients demonstrated an exclusive expansion of pS2 immunoreactive mucous cells. The hSP staining cells were located deep in the expanded foveolar region. The results suggest that foveolar hyperplasia following antrectomy with gastroenterostomy results from a reactive hyperplasia of surface mucous cells. This pattern of surface cell hyperplasia is more consistent with a reactive expansion of mucous cells than with a response to chronic injury.

A somatodendritic distribution of Rab11 in rabbit brain neurons.

Comparisons of subcellular targeting in neurons and epithelial cells have led to suggestions that apical epithelial antigens localize to axons and nerve terminals. We have studied the distribution in brain of the small GTP-binding protein, Rab11, which is localized to apical vesicular populations in epithelial cells. Sections of rabbit brain were examined by immunohistochemistry using a monoclonal antibody against rabbit Rab11. Rab11 immunoreactivity was present exclusively in neurons. In all regions examined, including forebrain, cerebellum, thalamus and brainstem, Rab11 immunoreactivity was observed in cell bodies and dendrites. No staining was observed in hippocampal neurons. These results indicate that the distribution of Rab11 does not support previous suggestions that apical epithelial markers should localize to axons and synaptic endings.

Overexpression of transforming growth factor-alpha alters differentiation of gastric cell lineages.

Overexpression of transforming growth factor-alpha (TGF-alpha) in the gastric fundic mucosa of metallothionein promoter/enhancer-TGF-alpha(MT-TGF-alpha) transgenic mice produces a phenotype of foveolar hyperplasia similar to that observed in Ménétrier's disease. We have investigated the dynamics involved in the alterations of gastric mucosal morphology in the MT-TGF-alpha mouse model. The fundic mucosa of MT-TGF-alpha mice and nontransgenic littermates was evaluated in animals treated with cadmium sulfate. To mark the mucosal proliferative zone, 8-bromodeoxyuridine (BrdU) was administered 2 hr prior to killing. Gastric mucosa was examined by diastase-resistant, periodic acid-Schiff-positive (DR-PAS) staining and immunohistochemistry for H/K-ATPase an BrdU. MT-TGF-alpha mice demonstrated increased numbers of DR-PAS-staining mucous cells and lower parietal cell numbers per gland unit. While the proliferative zone in nontransgenic mice was located in the upper half of the gland, the zone in MT-TGF-alpha mice was located in the basal region. Overexpression of TGF-alpha in MT-TGF-alpha mice leads to an alteration in the development of mucosal lineages from the fundic progenitor zone, which is biased towards the predominant differentiation of foveolar mucous cells.

Expression of trefoil peptides in the gastric mucosa of transgenic mice overexpressing transforming growth factor-alpha.

Overexpression of transforming growth factor-alpha (TGF-alpha) in the gastric mucosa of metallothionein-TGF alpha (MT-TGF alpha) transgenic mice leads to a marked alteration in the ontogeny of the fundic cellular lineages. Induction of the transgene leads to the over-production of mucous cells with a concomitant diminution in the development of parietal cell and chief cell lineages. We have sought to define more precisely the mucous cell lineages involved in the mucous cell hyperplasia in MT-TGF alpha mice by investigating the expression of trefoil peptides in MT-TGF alpha mice. MT-TGF alpha mice and their non-transgenic littermates were treated with cadmium sulfate beginning at 13 days of age. Animals were then sacrificed at intervals over the following 2 weeks and gastric mucosa was examined for expression of trefoil peptides and TGF alpha by immunohistochemistry and in situ hybridization. No TGF alpha mRNA expression could be demonstrated by in situ hybridization in non-transgenic mice. In MT-TGF alpha mice, in situ grains for TGF alpha mRNA were detected at the base of fundic glands in 13 day old animals, whereas the expression was observed more widely in the mucosa of older animals (28 days). TGF alpha immunoreactivity was observed in foveolar mucous cells and residual parietal cells in MT-TGF alpha mice at all ages. By in situ hybridization, pS2 mRNA was detected in the surface mucous cells in normal gastric mucosa. In MT-TGF alpha mice, pS2 mRNA was found throughout the expanded foveolar region. By in situ hybridization, spasmolytic peptide (SP) expression was observed in the region of the progenitor zone in both groups of mice. By immunohistochemistry, SP expression was noted in a broad band of mucous neck cells deep to the progenitor zone. No gastric expression of intestinal trefoil factor (ITF) was noted in either group of mice. The results demonstrate that the expansion of the foveolar mucous cell compartment in MT-TGF alpha mice is due to the hyperplasia of normal surface cells expressing their particular mucin-associated trefoil peptide, pS2.

Source of subretinal fluid on the basis of ascorbate analyses.

Biochemical analyses of subretinal fluid revealed a consistently high ascorbate level in the subretinal fluid of patients with rhegmatogenous retinal detachment. The average values and SDs of ascorbate in anterior chamber aqueous humor, subretinal fluid, and blood were 14.7 +/- 1.8, 27.4 +/- 2.1, and 1.8 +/- 0.2 mg/dL, respectively. The ascorbate concentration in subretinal fluid was always higher than that in aqueous humor. The high ascorbate level in subretinal fluid led to the hypothesis that aqueous humor contributes to the formation of subretinal fluid. Presumably and constant absorption of subretinal fluid by the choroid directs a portion of the aqueous humor from the posterior chamber into the subretinal space. The posterior movement of aqueous humor causes reduced ascorbate concentration in the anterior chamber and relative hypotony of eyes with rhegmatogenous retinal detachment. Closing the retinal break results in an interruption of the posterior movement of aqueous humor and rapid absorption of the remaining subretinal fluid by the choroid.

Lipoproteins in human subretinal fluids.

The lipids in the subretinal fluid of rhegmatogenous retinal detachment are observed mainly in the albumin position following electrophoresis on agarose film. The lipoprotein in the subchoroidal fluid of the same eye is alpha-lipoprotein. The albumin-like lipoprotein in subretinal fluid has no reaction with the antiserum samples specific to alpha-lipoprotein and beta-lipoprotein. Instead, an apoprotein of serum alpha-lipoprotein with slow electrophoretic mobility was observed in subretinal fluid. Heterogeneous degradation products of serum lipoproteins were seen in the subretinal fluid of exudative retinitis, different from the subretinal fluid of rhegmatogenous retinal detachment and uveal effusion.

Electron microscopy study of cryogenic chorioretinal adhesions.

By electron microscopy, the cryogenic chorioretinal adhesions in eight-day-old lesions from human eyes lacked anatomic adhesion between retina and choroid. In eight-month-old lesions, the neurosensory retina adhered to the retinal pigemtn epithelial layer by both desmosomal attachments and villous interdigitation.

Gelatin implants in scleral buckling procedures.

The use of gelatin has been evaluated in a series of 59 retinal surgical procedures over a five-year period. When used as a "trapdoor" alone, we conclude that gelatin works as well as any of the currently employed materials for simple cases. The technique gave a 90% primary reattachment rate, which was increased to 100% reattachment by subsequent surgery or photocoagulation. It also gave a desirable absorbable feature in very anterior or very posterior lesions. Used as a meridional implant and combined with one or two layers of solid silicone, the gelatin has proved to be extremely useful in closing holes that were highly elevated or significantly "fish mouthing." We wish to emphasize the value of this use as a meridional implant combined with silicone in complex cases.

Subretinal fluids: lipid analyses.

Lipid was found to accumulate in the subretinal space during rhegnatogenous retinal detachment. The concentration of lipid in the subretinal fluid varied between 0.1 to 2.4 mg. per milliliter. Based upon a comparison of lipid profiles and lipoprotein profiles, the amount of lipid observed in the subretinal fluids was not directly related to the permeability of the ocular vessels. Thin-layer chromatography analyses of lipid in subretinal fluids showed differences between the lipid composition of the subretinal fluid and blood. The major characteristic of lipid composition of subretinal fluid is the low concentration of lecithin, which is the major lipid compound in the serum. The present data indicate that the lipids of ocular tissues are released into the subretinal space during rhegmatogenous retinal detachment, and are adsorbed on albumin.