Extraction Laparotomy for Specimen Retrieval does not Alter Same Day Discharge Plans.

STUDY OBJECTIVE: To evaluate if extraction laparotomy (EL) for intact specimen removal adversely impacted the feasibility or safety of same-day discharge (SDD) in patients undergoing minimally invasive surgery (MIS) for confirmed or suspected gynecologic malignancies. DESIGN: Retrospective study SETTING: Single institution study PATIENTS: Patients undergoing minimally invasive surgery for gynecologic malignancy at a single institution, who underwent extraction laparotomy (N=67) and age matched controls (N=134) INTERVENTIONS: Comparing same day discharge rates, complications, readmission and outpatient follow up after between patients requiring extraction laparotomy to those that did not after minimally invasive gynecologic surgery. MEASUREMENTS AND MAIN RESULTS: A total of 1224 patients were identified. Sixty-seven patients underwent EL for specimen extraction. From the remainder, 134 patients were selected as age matched controls. SDD rate was 83% (EL) vs. 87% (no EL) (p=.39). There was no difference in median pain scores (1.8 vs. 1.9 p=.86), length of stay (LOS) (0 days for both) (p=.41), 30-day readmission rate (6% vs. 3%) (p=.45), ED visit (13% vs. 10%) (p=.76) or any patient contact (34% vs. 39%) (p=.53), between the groups. Specimen weight was higher for EL (524g vs 142g, p<.001), as was estimated blood loss (EBL) (104ml vs. 46ml, p<.001), and surgery time was increased by 22 minutes in the EL group (121 min vs. 99 min, p<.001). Patients who underwent EL did require more narcotics in PACU 20.5 vs 12.2 OME p=.033, however this did not translate to increased number of narcotics prescribed at discharge. On logistic regression a higher specimen weight trended to increase the likelihood of admission (OR 1.04 CI 1.01-1.08), however, surgery time, time in PACU, race, BMI, surgery type or need for EL did not predict SDD or need for admission. CONCLUSIONS: Minimally invasive surgery patients who require extraction laparotomy can still achieve SDD. Same-day discharge is safe and feasible without increased risk of readmission, pain score, or unscheduled patient contact post-operatively.

The clinical value of a thorough diagnostic evaluation for neurotologic complaints.

PURPOSE: Determine the clinical efficacy of comprehensive neurotologic testing in patients presenting with complaints of hearing loss, tinnitus and/or dizziness. METHODS: This is a retrospective analysis of 1170 consecutive charts of patients who presented between 1980 and 2013 with neurotologic complaints. Demographic data, chief complaint, diagnostic imaging, audiograms, and blood tests were evaluated. RESULTS: Retrospective analysis of 1170 patient charts was performed. 762/1170 (65%) patients presented with subjective hearing loss, 575/1170 (49%) with dizziness, and 657/1170 (56%) with tinnitus. Audiometric testing revealed hearing loss in 1059/1169 (91%) patients. 536/1120 (48%) patients had abnormalities on Magnetic Resonance Imaging, and 343/1087 (32%) on Computed Tomography imaging. Endocrine and immunologic testing revealed 108/1135 (9.5%) patients were hyperglycemic; 125/1124 (11%) patients had elevated TSH; 149/1141 (13%) patients had a positive ANA; and 82/1133 (7.2%) patients were positive for RF. 198/1083 (18%) of patients were positive for HLA-B35, 246/1083 (23%) for HLA-Cw4, 454/1083 (42%) for HLA-Cw7, and 747/1060 (70%) of patients had absent HLA-DR4. 112/1085 (10%) of patients were positive for anti-68kD antibodies and 154/936 (17%) for protein 0. Many patients were diagnosed with previously unrecognized medical conditions. CONCLUSION: Comprehensive neurotological workup results in diagnoses that would go unrecognized otherwise, allowing patients to receive prompt treatment for medically important conditions, some of which may be causally related to their neurotologic complaints. However, the value of each study for routine testing of patients with neurotologic complaints remains controversial; and the evidence presented herein should help practitioners determine what studies should be included in their patient assessments.

Intracellular matrix metalloproteinase-2 (MMP-2) regulates human platelet activation via hydrolysis of talin.

Matrix metalloproteinase (MMP) activity is generally associated with normal or pathological extracellular processes such as tissue remodelling in growth and development or in tumor metastasis and angiogenesis. Platelets contain at least three MMPs, 1, 2 and 9 that have been reported to stimulate or inhibit agonist-induced platelet aggregation via extracellular signals. The non-selective Zn+2 chelating MMP inhibitor, 1,10-phenanthroline, and the serine protease inhibitor, AEBSF, were found to inhibit all tested agonist-induced platelet aggregation reactions. In vitro analysis demonstrated that 1,10-phenanthroline completely inhibited MMP-1,2,and 9 but had little to no effect on calpain activity while the converse was true with AEBSF. We now demonstrate that MMP-2 functions intracellularly to regulate agonist-induced platelet aggregations via the hydrolytic activation of talin, the presumed final activating factor of glycoprotein (GP)IIb/IIIa integrin (the inside-out signal). Once activated GPIIb/IIIa binds the dimeric fibrinogen molecule required for platelet aggregation. The active intracellular MMP-2 molecule is complexed with JAK 2/STAT 3, as demonstrated by the fact that all three proteins are co-immunoprecipitated with either anti-JAK 2, or anti-STAT 3 antibodies and by immunofluorescence studies. The MMP-2 platelet activation pathway can be synergistically inhibited with the non-selective MMP inhibitor, 1,10-phenanthroline, plus a JAK 2 inhibitor. This activation pathway is distinct from the previously reported calpain-talin activating pathway. The identification of a new central pathway for platelet aggregation presents new potential targets for drug regulation and furthers our understanding of the complexity of platelet activation mechanisms.