Open versus minimally invasive small bowel resection for Crohn's disease: a NSQIP retrospective review and analysis.

INTRODUCTION: Many patients with Crohn's Disease will require surgical resection. While many studies have described outcomes following ileocecectomy, few have evaluated surgical resection of other portions of small bowel. We sought to compare open and minimally invasive surgery (MIS) approaches for small bowel resection excluding ileocecectomy of patients with Crohn's Disease using the National Surgical Quality Improvement Program (NSQIP) database. METHODS: The NSQIP database was queried for patients with Crohn's disease or complications related to Crohn's disease who underwent segmental small bowel resection utilizing open or minimally invasive approaches between 2012 and 2018. Patients requiring ileocecectomy or diagnosed with ascites, disseminated cancer, pre-operative sepsis, ASA class 5, and patients requiring mechanical ventilation were excluded. The association of pre-operative variables including patient demographic information and comorbidities with surgical approach were examined using Fishers exact test. Intraoperative, and 30-day post-operative outcomes were compared between the groups using both univariate and multivariate logistical regression models. SAS was used for data analysis with p < 0.05 considered significant. RESULTS: After exclusions, we found 1697 patients with Crohn's disease who underwent segmental small bowel resection, 1252 of whom underwent open surgery and 445 of whom underwent MIS. After adjusting for possible confounders with multivariable analysis, patients who underwent MIS had a lower incidence of wound events (surgical site, organ space, or deep wound infection, or dehiscence), post-operative bleeding, need for return to the operating room, and shorter total hospital length of stay despite longer operative times compared with open surgery. CONCLUSIONS: This retrospective review of NSQIP shows that minimally invasive small bowel resection is associated with equivalent or improved morbidity over open surgery in select patients with small bowel Crohn's Disease. We show that in select patients minimally invasive small bowel resection can be safe and performed for patients with isolated small bowel Crohn's disease.

Cyclosporine-Induced Kaposi Sarcoma in a Patient With Ulcerative Colitis.

Kaposi sarcoma (KS) is an angioproliferative neoplasm associated with human herpesvirus-8. Gastrointestinal KS has been well documented in immunosuppressed solid organ transplant patients, with only 26 iatrogenic cases published in patients with inflammatory bowel disease. We report a 24-year-old patient with ulcerative colitis, maintained on cyclosporine for 2 years, who presented with watery, nonbloody diarrhea and weight loss. Colonoscopy revealed human herpesvirus-8-positive hemorrhagic nodules throughout the colon and terminal ileum, with diffuse lymphadenopathy on computed tomography consistent with KS. As gastrointestinal KS may present with symptoms that mimic inflammatory bowel disease, it is critical to maintain suspicion in patients on prolonged immunosuppression to reduce complications.

Functional TSPO polymorphism predicts variance in the diurnal cortisol rhythm in bipolar disorder.

INTRODUCTION: Psychosocial stress contributes to onset/exacerbation of mood episodes and alcohol use, suggesting dysregulated diurnal cortisol rhythms underlie episodic exacerbations in Bipolar Disorder (BD). However, mechanisms underlying dysregulated HPA rhythms in BD and alcohol use disorders (AUD) are understudied. Knowledge of associated variance factors have great clinical translational potential by facilitating development of strategies to reduce stress-related relapse in BD and AUD. Evidence suggests structural changes to mitochondrial translocator protein (TSPO) (a regulator of steroid synthesis) due to the single nucleotide polymorphism rs6971, may explain much of this variance. However, whether rs6971 is associated with abnormal HPA rhythms and clinical exacerbation in humans is unknown. METHODS: To show this common TSPO polymorphism impacts HPA rhythms in BD, we tested whether rs6971 (dichotomized: presence/absence of polymorphism) predicted variance in diurnal cortisol rhythm (saliva: morning and evening for 3 days) in 107 BD (50 with and 57 without AUD) and 28 healthy volunteers of similar age and ethno-demographic distribution. RESULTS: Repeated measures ANOVA confirmed effects BD (F5,525 = 3.0, p = 0.010) and AUD (F5,525 = 2.9, p = 0.012), but not TSPO polymorphism (p > 0.05). Interactions were confirmed for TSPO × BD (F5,525 = 3.9, p = 0.002) and for TSPO × AUD (F5,525 = 2.8, p = 0.017). DISCUSSION: We identified differences in diurnal cortisol rhythm depending on presence/absence of common TSPO polymorphism in BD volunteers with or without AUD and healthy volunteers. These results have wide ranging implications but further validation is needed prior to optimal clinical translation.

Deletion of Fmr1 results in sex-specific changes in behavior.

OBJECTIVE: In this study, we used a systemic Fmr1 knockout in order to investigate both genotype- and sex-specific differences across multiple measures of sociability, repetitive behaviors, activity levels, anxiety, and fear-related learning and memory. BACKGROUND: Fragile X syndrome is the most common monogenic cause of intellectual disability and autism. Few studies to date have examined sex differences in a mouse model of Fragile X syndrome, though clinical data support the idea of differences in both overall prevalence and phenotype between the sexes. METHODS: Using wild-type and systemic homozygous Fmr1 knockout mice, we assessed a variety of behavioral paradigms in adult animals, including the open field test, elevated plus maze, nose-poke assay, accelerating rotarod, social partition task, three-chambered social task, and two different fear conditioning paradigms. Tests were ordered such that the most invasive tests were performed last in the sequence, and testing paradigms for similar behaviors were performed in separate cohorts to minimize testing effects. RESULTS: Our results indicate several sex-specific changes in Fmr1 knockout mice, including male-specific increases in activity levels, and female-specific increases in repetitive behaviors on both the nose-poke assay and motor coordination on the accelerating rotarod task. The results also indicated that Fmr1 deletion results in deficits in fear learning and memory across both sexes, and no changes in social behavior across two tasks. CONCLUSION: These findings highlight the importance of including female subjects in preclinical studies, as simply studying the impact of genetic mutations in males does not yield a complete picture of the phenotype. Further research should explore these marked phenotypic differences among the sexes. Moreover, given that treatment strategies are typically equivalent between the sexes, the results highlight a potential need for sex-specific therapeutics.

Optimization of Simulation and Moulage in Military-Related Medical Training.

Preparation of Special Operations Forces (SOF) Medics as first responders for the battle space and austere environments is critical to optimize survival and quality of life for our Operators who may sustain serious and complex wounding patterns and illnesses. In the absence of constant clinical exposure for these medics, it is necessary to maximize all available training opportunities. The incorporation of scenario-based training helps weave together teamwork and the ability to practice treatment protocols in a tactical, controlled training environment to reproduce, to some degree, the environment in and stressors under which care will need to be delivered. We reviewed the evolution of training scenarios within one Pararescue (PJ) team since 2008 and codified various tools used to simulate physical findings and drive medical exercises as part of scenario-based training. We also surveyed other SOF Medic training resources.

Hispanics and inflammatory bowel disease.

BACKGROUND: Historically, inflammatory bowel disease (IBD) was considered a disease, which predominately affects whites. As such, the majority of research in IBD has been conducted in this population. However, more research on this suggests that IBD affects other ethnic groups. Rapidly shifting demographics in the United States necessitates a better understanding of how IBD may affect Hispanics. We reviewed the current literature on IBD in Hispanics. METHODS: A PubMed search was conducted using keywords inflammatory bowel disease, Ulcerative Colitis, Crohn's disease, Hispanics, Latinos, ethnicity, to identify existing literature with a focus on adult populations. Non-English language articles were excluded. RESULTS: The existing data and literature on Hispanic patients with IBD remains sparse. Limited studies on prevalence suggest IBD may be more common in Hispanics in the United States compared with those in Latin America. Conflicting data exist as to whether Hispanics patients with IBD are more likely to have ulcerative colitis compared with Crohn's disease. One study explored difference in IBD between foreign-born and U.S.-born Hispanics and found that ulcerative colitis was more common only in foreign-born Hispanics, whereas within 1 generation, U.S.-born Hispanics resemble their non-Hispanic white counterparts about development of Crohn's disease. Such a rapid change in the proportion of ulcerative colitis and Crohn's disease points strongly to environmental factors driving the change in proportion of disease subtypes. Additionally, a trend towards less use of biologic and immunomodulators in Hispanics was noted in several studies. CONCLUSIONS: Additional research is needed to better understand how diversity within the Hispanic population (U.S.-born and foreign-born) may be driving difference in disease manifestations. More investigations should focus on determining the cause of a potential disparity in the use of biologic and immunomodulators in Hispanics.

The role of positron emission tomography in the evaluation of inflammatory bowel disease.

Inflammatory bowel disease (IBD) is a chronic inflammatory disease that affects the gastrointestinal tract. Information obtained from a clinical history, physical exam, laboratory testing, imaging studies, and endoscopic evaluations must be combined to accurately diagnose IBD. Further testing often becomes necessary to evaluate symptom relapse in patients with an established IBD diagnosis. Endoscopy, while effective in assessing mucosal disease, is invasive and associated with inherent risks. Positron emission tomography (PET) is an effective, noninvasive tool for the evaluation of active inflammation. This review will focus on the role of PET imaging in the evaluation and management of IBD.

Effects of acepromazine, hydromorphone, or an acepromazine-hydromorphone combination on the degree of sedation in clinically normal dogs.

OBJECTIVE: To determine the effects of IM administration of acepromazine, hydromorphone, or the acepromazine-hydromorphone combination on degree of sedation in clinically normal dogs and to compare 2 sedation scoring techniques. DESIGN: Prospective, randomized, blinded, controlled trial. Animals-46 random-source dogs. PROCEDURES: Dogs were assigned to receive IM administrations of acepromazine (0.05 mg/kg [0.023 mg/lb]; [DOSAGE ERROR CORRECTED] n = 12), hydromorphone (0.1 mg/kg [0.045 mg/lb]; 11), acepromazine-hydromorphone (0.5 mg/kg and 0.1 mg/kg, respectively; 12), or saline (0.9% NaCI) solution (0.05 mL/kg [0.023 mL/lb]; 11). Sedation scores were determined at 0 (time of administration), 15, 30, 45, and 60 minutes by use of a subjective scoring system (SSS) and a simple numeric rating scale (NRS). RESULTS: Acepromazine caused significantly greater sedation than did saline solution at 15, 30, 45, and 60 minutes. Acepromazine-hydromorphone caused significantly greater sedation than did saline solution at 15, 30, 45, and 60 minutes and than did hydromorphone alone at 30 minutes. Hydromorphone alone did not cause significantly greater sedation than did saline solution. All treatments, including saline solution, caused significantly greater sedation at 45 and 60 minutes, compared with sedation at time 0. There was a significant correlation (r(2) = 0.72) between scores obtained with the SSS and NRS, but the NRS was less sensitive for detecting clinically important sedation. CONCLUSIONS AND CLINICAL RELEVANCE: Administration of acepromazine or acepromazine-hydromorphone caused sedation in clinically normal dogs, whereas administration of hydromorphone alone did not. The NRS was a less-reliable measure of sedation.

The emerging therapeutic role of probiotics in inflammatory bowel disease.

Nonpathogenic bacteria in a genetically susceptible individual play a suggestive role in the pathogenesis of inflammatory bowel disease (IBD). Probiotics are living organisms that exert a protective effect on intestinal mucosa. Although evidence supporting their use for inducing or maintaining remission of IBD remains limited, it may be reasonable to use probiotics as an adjunct to standard therapy for mild-to-moderate disease. Genetically modified probiotics may provide novel delivery methods of therapeutic payloads to inflamed intestinal mucosa. This review focuses on the emerging use of probiotics in the treatment of IBD.

Effects of topical 2% dorzolamide hydrochloride alone and in combination with 0.5% timolol maleate on intraocular pressure in normal feline eyes.

OBJECTIVE: To evaluate the effect of topical 2% dorzolamide alone, and in combination with topical 0.5% timolol, on intraocular pressure (IOP) in normal cats. ANIMALS: Twenty-four healthy Domestic Short-haired cats. PROCEDURE: Baseline values of IOP were established at 7 am, 10 am, 1 pm, 5 pm and 9 pm during pretreatment phase (days 1-2). During treatment phase (days 3-10) cats received 2% dorzolamide HCl q 12 h in group A (n = 6), q 8 h in group B (n = 6), and combined with 0.5% timolol maleate q 12 h in group C (n = 6). Cats in control group D (n = 6) received artificial tears q 8 h. During treatment phase IOP measurements were continued at the same time-points as in the pretreatment phase. RESULTS: Mean pretreatment IOP in all cats was 18.46 +/- 2.99 mmHg. Mean IOP decreased significantly (P < 0.0086) in all treatment groups compared to pretreatment values (group A: 16.40 +/- 0.49 mmHg, group B: 16.04 +/- 0.49 mmHg, group C: 17.76 +/- 0.49 mmHg). IOP did not decrease in control group D (18.55 +/- 0.49 mmHg). The difference in IOP between treatment groups (A, B, C) was not statistically significant, but comparison of IOP between each treatment group and the control group was statistically significant (A-D; P = 0.0057; B-D, P = 0.0012; C-D, P = 0.0212). CONCLUSION: Topical 2% dorzolamide significantly lowers IOP in normal cats but the effect is mild. Concomitant application of 2% dorzolamide and 0.5% timolol does significantly decrease IOP, but the effect is not significantly greater than q 8 h administration of dorzolamide alone.

Effects of treatment with and without adjuvant radiation therapy on recurrence of ocular and adnexal squamous cell carcinoma in horses: 157 cases (1985-2002).

OBJECTIVE: To determine the effects of treatment with and without adjuvant radiation therapy on recurrence of ocular and adnexal squamous cell carcinoma (SCC) at specific anatomic locations in horses. DESIGN: Retrospective study. ANIMALS: 91 horses. PROCEDURES: Medical records of horses with histologically confirmed ocular and adnexal SCC evaluated from 1985 to 2002 were reviewed. Sex, breed, age, type of treatment, location, and recurrence of SCC were recorded. Two treatment groups determined by recurrence of SCCs treated with and without adjuvant radiation therapy were established. RESULTS: The anatomic site with the highest recurrence rate was the limbus (junction of the cornea and sclera) or bulbar conjunctiva (477%), independent of treatment group. There was a significant difference in recurrence rates of ocular and adnexal SCCs between the 2 treatment groups, independent of anatomic location. Recurrence rates of SCCs treated with and without adjuvant radiation therapy were 11.9% and 44.1%, respectively. Recurrence rates for SCCs of the eyelid, limbus or bulbar conjunctiva, and cornea treated with adjuvant radiation therapy were significantly different from those for SCCs treated without adjuvant radiation therapy. The most frequently represented anatomic site for ocular and adnexal SCCs was the eyelid (28.7%). Coat color, breed, and the interaction of age and breed had a significant effect on tumor recurrence regardless of treatment type and anatomic location. CONCLUSIONS AND CLINICAL RELEVANCE: Results indicated that ocular and adnexal SCCs treated with adjuvant radiation therapy had a significantly lower recurrence rate, compared with SCCs treated without adjuvant radiation therapy, independent of anatomic location.

Effects of transcorneal iridal photocoagulation on the canine corneal endothelium using a diode laser.

OBJECTIVE: To investigate the potential damage to the canine corneal endothelium following transcorneal iridal laser photocoagulation using a semiconductor diode laser. ANIMALS STUDIED: Sixteen young mongrel dogs. PROCEDURES: Baseline corneal endothelial cell counts and corneal thickness were measured in the central and temporal quadrants using a noncontact specular microscope under general anesthesia. Transcorneal iridal photocoagulation was applied using a semiconductor diode laser in a continuous mode with the use of an operating microscope. Fifteen dogs were treated, and the sixteenth dog served as a control. Fifteen different treatment combinations were randomly assigned to the 30 eyes; the fellow eye was treated differently. Three treatment factors were investigated: (1) laser energy intensity, (2) target tissue to endothelial distance, and (3) laser application duration. After 3 weeks the dogs were euthanized, specular microscopy was repeated, and the cornea was examined by scanning electron microscopy. RESULTS: Dyscoria and focal iris darkening were noted in all eyes immediately following laser treatment. Focal corneal edema (n = 2) and an incipient anterior capsular cataract (n = 1) were also noted. Baseline mean corneal endothelial cell densities were 2530 cells/mm2 centrally and 2607 cells/mm2 temporally. Postlaser corneal endothelial cell densities were 2499 cells/mm2 centrally and 2523 cells/mm2 temporally. Mean prelaser corneal thickness measurements were 0.555 mm centrally and 0.549 mm temporally. Postlaser corneal thickness measurements were 0.580 mm centrally and 0.554 mm temporally. Statistical analyzes revealed no significant changes in endothelial cell densities (P > 0.05) or corneal thickness (P > 0.05) induced by any treatment combination. Aside from tissue handling and processing artifacts, scanning electron microscopy revealed no endothelial cell damage. CONCLUSIONS: Our study demonstrated by specular and scanning electron microscopy that diode laser iridal photocoagulation had no significant effect on the canine corneal endothelium within the parameters described. However, one must take into consideration the young age of the dogs and the potential for corneal endothelial cell regeneration in young dogs, and the relatively short period of postoperative study.