Real-World Clinical Quality Improvement for Complex Abdominal Wall Reconstruction.

INTRODUCTION: Traditional methods of clinical research may not be adequate to improve the value of care for patients undergoing abdominal wall reconstruction (AWR). These patients are prone to high complication rates and high costs. Here, we describe a clinical quality improvement (CQI) effort to enhance outcomes for patients undergoing AWR. MATERIALS AND METHODS: CQI was applied for the entire care cycle for consecutive patients who underwent AWR from August 2011-September 2015. Initiatives for improving value during this period included use of long-term resorbable synthetic mesh as well as administration of preoperative bilateral transversus abdominus plane (TAP), and intraoperative abdominal wall blocks using long-acting bupivacaine as a part of a multimodal regimen. Outcomes data that measure value in the context of AWR were collected to compare outcomes for the patients who received TAP blocks only, TAP and intraoperative blocks, and those who received no block. RESULTS: One hundred and two patients who had AWR for abdominal wall pathology were included. Outcomes including total opioid use, duration of stay and opioid use in the postanesthesia care unit (PACU), length of hospital stay (LOS), major wound complications, and costs, all improved over time. Specifically, PACU opioid use, total opioid use, and LOS were decreased in the two groups that received blocks versus a group that did not have any type of block. CONCLUSIONS: CQI program implementation in patients undergoing AWR resulted in measurable improvement of value-based outcomes over time. A CQI effort applied to the entire patient cycle of care should be routinely utilized.

Drosophila Eye Model to Study Neuroprotective Role of CREB Binding Protein (CBP) in Alzheimer's Disease.

BACKGROUND: The progressive neurodegenerative disorder Alzheimer's disease (AD) manifests as loss of cognitive functions, and finally leads to death of the affected individual. AD may result from accumulation of amyloid plaques. These amyloid plaques comprising of amyloid-beta 42 (Aß42) polypeptides results from the improper cleavage of amyloid precursor protein (APP) in the brain. The Aß42 plaques have been shown to disrupt the normal cellular processes and thereby trigger abnormal signaling which results in the death of neurons. However, the molecular-genetic mechanism(s) responsible for Aß42 mediated neurodegeneration is yet to be fully understood. METHODOLOGY/PRINCIPAL FINDINGS: We have utilized Gal4/UAS system to develop a transgenic fruit fly model for Aß42 mediated neurodegeneration. Targeted misexpression of human Aß42 in the differentiating photoreceptor neurons of the developing eye of transgenic fly triggers neurodegeneration. This progressive neurodegenerative phenotype resembles Alzheimer's like neuropathology. We identified a histone acetylase, CREB Binding Protein (CBP), as a genetic modifier of Aß42 mediated neurodegeneration. Targeted misexpression of CBP along with Aß42 in the differentiating retina can significantly rescue neurodegeneration. We found that gain-of-function of CBP rescues Aß42 mediated neurodegeneration by blocking cell death. Misexpression of Aß42 affects the targeting of axons from retina to the brain but misexpression of full length CBP along with Aß42 can restore this defect. The CBP protein has multiple domains and is known to interact with many different proteins. Our structure function analysis using truncated constructs lacking one or more domains of CBP protein, in transgenic flies revealed that Bromo, HAT and polyglutamine (BHQ) domains together are required for the neuroprotective function of CBP. This BHQ domain of CBP has not been attributed to promote survival in any other neurodegenerative disorders. CONCLUSIONS/SIGNIFICANCE: We have identified CBP as a genetic modifier of Aß42 mediated neurodegeneration. Furthermore, we have identified BHQ domain of CBP is responsible for its neuroprotective function. These studies may have significant bearing on our understanding of genetic basis of AD.

Laparoscopic repair of incidentally found Spigelian hernia.

BACKGROUND AND OBJECTIVES: A Spigelian hernia is a rare type of hernia that occurs through a defect in the anterior abdominal wall adjacent to the linea semilunaris. Estimation of its incidence has been reported as 0.12% of all abdominal wall hernias. Traditionally, the method of repair has been an open approach. Herein, we discuss a series of laparoscopic repairs. METHODS: Case series and review of the literature. CASES: Three patients are presented. All were evaluated and taken to surgery initially for a different disease process, and all were incidentally found to have a spigelian hernia. These patients underwent laparoscopic repair of their hernias; 2 were repaired intraperitoneally and one was repaired totally extraperitoneally. Two patients initially underwent a mesh repair, while the third had an attempted primary repair. CONCLUSIONS: There is evidence that supports the use of laparoscopy for both diagnosis and repair of spigelian hernias. There are also reports of successful repairs both primarily and with mesh. In our experience with the preceding 3 patients, we found that laparoscopic repair of incidentally discovered spigelian hernias is a viable option, and we also found that implantation of mesh, when possible, resulted in satisfactory results and no recurrence.