Large volume paracentesis of 39.5 liters chylous ascites in the setting of high-grade follicular lymphoma.

The American Association for the Study of Liver Diseases recognizes large volume paracentesis as draining greater than 5 liters of ascites and states there is no limit in the amount of ascites drained with appropriate replacement of albumin. For many practitioners performing safe large volume paracentesis between 5 and 10 liters or even 20 liters is not an uncommon practice. However, drainage of higher volumes outside common practice may raise concerns of patient intolerance and complication. The largest volume paracentesis reported in the literature to date is 41 liters. However, few other reports approach this volume. This case report demonstrates patient tolerance of a 39.5-liter paracentesis performed with close monitoring and hypertonic albumin replacement in a patient with chylous ascites due to high-grade follicular lymphoma.

Assessment of Effectiveness of Seasonal Influenza Vaccination During Pregnancy in Preventing Influenza Infection in Infants in England, 2013-2014 and 2014-2015.

Maternal influenza vaccination is increasingly recognized to protect infants from influenza infection in their first 6 months. We used the screening method to estimate vaccine effectiveness (VE) against laboratory-confirmed influenza in infants in England, using newly available uptake data from the Clinical Practice Research Datalink pregnancy register, matched on week of birth and region and adjusted for ethnicity. We found VE of 66% (95% confidence interval [CI], 18%-84%) in the 2013-2014 season and 50% (95% CI, 11%-72%) in 2014-2015, with similar VE against influenza-related hospitalization. VE against the dominant circulating influenza strain was higher, at 78% (95% CI, 16%-94%) against H1N1 in 2013-2014, and 60% (95% CI, 16%-81%) against H3N2 in 2014-2015.

What You Don't Know Can Hurt You: Missing Data and Partial Credit Model Estimates.

The authors investigated the effect of missing completely at random (MCAR) item responses on partial credit model (PCM) parameter estimates in a longitudinal study of Positive Affect. Participants were 307 adults from the older cohort of the Notre Dame Study of Health and Well-Being (Bergeman and Deboeck, 2014) who completed questionnaires including Positive Affect items for 56 days. Additional missing responses were introduced to the data, randomly replacing 20%, 50%, and 70% of the responses on each item and each day with missing values, in addition to the existing missing data. Results indicated that item locations and person trait level measures diverged from the original estimates as the level of degradation from induced missing data increased. In addition, standard errors of these estimates increased with the level of degradation. Thus, MCAR data does damage the quality and precision of PCM estimates.

Changes in the colon microbiota and intestinal cytokine gene expression following minimal intestinal surgery.

AIM: To investigate the impact of minor abdominal surgery on the caecal microbial population and on markers of gut inflammation. METHODS: Four week old piglets were randomly allocated to a no-surgery "control" group (n = 6) or a "transection surgery" group (n = 5). During the transection surgery procedure, a conventional midline incision of the lower abdominal wall was made and the small intestine was transected at a site 225 cm proximal to the ileocaecal valve, a 2 cm segment was removed and the intestine was re-anastomosed. Piglets received a polymeric infant formula diet throughout the study period and were sacrificed at two weeks post-surgery. Clinical outcomes including weight, stool consistency and presence of stool fat globules were monitored. High throughput DNA sequencing of colonic content was used to detect surgery-related disturbances in microbial composition at phylum, family and genus level. Diversity and richness estimates were calculated for the control and minor surgery groups. As disturbances in the gut microbial community are linked to inflammation we compared the gene expression of key inflammatory cytokines (TNF, IL1B, IL18, IL12, IL8, IL6 and IL10) in ileum, terminal ileum and colon mucosal extracts obtained from control and abdominal surgery groups at two weeks post-surgery. RESULTS: Changes in the relative abundance of bacterial species at family and genus level were confined to bacterial members of the Proteobacteria and Bacteroidetes phyla. Family level compositional shifts included a reduction in the relative abundance of Enterobacteriaceae (22.95 ± 5.27 vs 2.07 ± 0.72, P < 0.01), Bacteroidaceae (2.54 ± 0.56 vs 0.86 ± 0.43, P < 0.05) and Rhodospirillaceae (0.40 ± 0.14 vs 0.00 ± 0.00, P < 0.05) following transection surgery. Similarly, at the genus level, changes associated with transection surgery were restricted to members of the Proteobacteria and Bacteroidetes phyla and included decreased relative abundance of Enterobacteriaceae (29.20 ± 6.74 vs 2.88 ± 1.08, P < 0.01), Alistipes (4.82 ± 1.73 vs 0.18 ± 0.13, P < 0.05) and Thalassospira (0.53 ± 0.19 vs 0.00 ± 0.00, P < 0.05). Surgery-associated microbial dysbiosis was accompanied by increased gene expression of markers of inflammation. Within the ileum IL6 expression was decreased (4.46 ± 1.60 vs 0.24 ± 0.06, P < 0.05) following transection surgery. In the terminal ileum, gene expression of TNF was decreased (1.51 ± 0.13 vs 0.80 ± 0.16, P < 0.01) and IL18 (1.21 ± 0.18 vs 2.13 ± 0.24, P < 0.01), IL12 (1.04 ± 0.16 vs 1.82 ± 0.32, P < 0.05) and IL10 (1.04 ± 0.06 vs 1.43 ± 0.09, P < 0.01) gene expression increased following transection surgery. Within the colon, IL12 (0.72 ± 0.13 vs 1.78 ± 0.28, P < 0.01) and IL10 (0.98 ± 0.02 vs 1.95 ± 0.14, P < 0.01) gene expression were increased following transection surgery. CONCLUSION: This study suggests that minor abdominal surgery in infants, results in long-term alteration of the colonic microbial composition and persistent gastrointestinal inflammation.

Altered FXR signalling is associated with bile acid dysmetabolism in short bowel syndrome-associated liver disease.

BACKGROUND & AIMS: Despite the mortality associated with liver disease observed in patients with short bowel syndrome (SBS), mechanisms underlying the development of SBS-associated liver disease (SBS-ALD) are poorly understood. This study examines the impact of bacterially-mediated bile acid (BA) dysmetabolism on farnesoid X receptor (FXR) signalling pathways and clinical outcome in a piglet model of SBS-ALD. METHODS: 4-week old piglets underwent 75% small bowel resection (SBR) or sham operation. Liver histology and hepatic inflammatory gene expression were examined. Abundance of BA biotransforming bacteria was determined and metabolomic studies detailed the alterations in BA composition of stool, portal serum and bile samples. Gene expression of intestinal and hepatic FXR target genes and small heterodimer partner (SHP) transrepression targets were assessed. RESULTS: Histological evidence of SBS-ALD included liver bile duct proliferation, hepatocyte ballooning and fibrosis. Inflammatory gene expression was increased. Microbiota changes included a 10-fold decrease in Clostridium and a two-fold decrease in Bacteroides in SBS-ALD piglets. BA composition was altered and reflected a primary BA dominant composition. Intestinal and hepatic regulation of BA synthesis was characterised by a blunted intestinal FXR activation response and a failure of SHP to repress key hepatic targets. CONCLUSIONS: We propose a pathological scenario in which microbial dysbiosis following SBR results in significant BA dysmetabolism and consequent outcomes including steatorrhoea, persistent diarrhoea and liver damage. Furthermore alterations in BA composition may have contributed to the observed disturbance in FXR-mediated signalling pathways. These findings provide an insight into the complex mechanisms mediating the development of liver disease in patients with SBS.

Gut microbial diversity is reduced and is associated with colonic inflammation in a piglet model of short bowel syndrome.

BACKGROUND AND OBJECTIVES: Following small bowel resection (SBR), the luminal environment is altered, which contributes to clinical manifestations of short bowel syndrome (SBS) including malabsorption, mucosal inflammation and bacterial overgrowth. However, the impact of SBR on the colon has not been well-defined. The aims of this study were to characterize the colonic microbiota following SBR and to assess the impact of SBR on mucosal inflammation in the colon. RESULTS: Analysis of the colonic microbiota demonstrated that there was a significant level of dysbiosis both two and six weeks post-SBR, particularly in the phylum Firmicutes, coupled with a decrease in overall bacterial diversity in the colon. This decrease in diversity was associated with an increase in colonic inflammation six weeks post-surgery. METHODS: Female (4-week old) piglets (5-6/group) received a 75% SBR, a transection (sham) or no surgery. Compositional analysis of the colonic microbiota was performed by high-throughput sequencing, two- and six-weeks post-surgery. The gene expression of the pro-inflammatory cytokines interleukin (IL)-1ß, IL-6, IL-8, IL-18 and tumor necrosis factor (TNF)-α in the colonic mucosa was assessed by qRT-PCR and the number of macrophages and percentage inducible nitric oxide synthase (iNOS) staining in the colonic epithelium were quantified by immunohistochemistry. CONCLUSIONS: SBR significantly decreased the diversity of the colonic microbiota and this was associated with an increase in colonic mucosal inflammation. This study supports the hypothesis that SBR has a significant impact on the colon and that this may play an important role in defining clinical outcome.

Graduating 4th year radiology residents' perception of optimal imaging modalities for neoplasm and trauma: a pilot study from four U.S. universities / Percepção de médicos residentes em radiologia de 4º ano sobre as melhores modalidades de imagem na investigação de neoplasias e trauma: um estudo piloto de quatro universidades americanas

OBJECTIVE: Our purpose was to assess 4th year radiology residents' perception of the optimal imaging modality to investigate neoplasm and trauma. MATERIALS AND METHODS: Twenty-seven 4th year radiology residents from four residency programs were surveyed. They were asked about the best imaging modality to evaluate the brain and spine, lungs, abdomen, and the musculoskeletal system. Imaging modalities available were MRI, CT, ultrasound, PET, and X-ray. All findings were compared to the ACR appropriateness criteria. RESULTS: MRI was chosen as the best imaging modality to evaluate brain, spine, abdominal, and musculoskeletal neoplasm in 96.3 percent, 100 percent, 70.4 percent, and 63 percent of residents, respectively. CT was chosen by 88.9 percent to evaluate neoplasm of the lung. Optimal imaging modality to evaluate trauma was CT for brain injuries (100 percent), spine (92.6 percent), lung (96.3 percent), abdomen (92.6 percent), and major musculoskeletal trauma (74.1 percent); MRI was chosen for sports injury (96.3 percent). There was agreement with ACR appropriateness criteria. CONCLUSION: Residents' perception of the best imaging modalities for neoplasm and trauma concurred with the appropriateness criteria by the ACR.

OBJETIVO: Avaliar a percepção de médicos residentes em radiologia de 4º ano sobre as melhores modalidades de imagem na investigação de neoplasias e trauma. MATERIAIS E MÉTODOS: Vinte e sete médicos residentes de 4º ano de quatro programas de residência em radiologia americanos participaram do estudo. Aos participantes foi perguntado sobre a melhor modalidade de imagem para se avaliar o cérebro e a coluna vertebral, pulmões, abdome e o sistema musculoesquelético. As modalidades de imagem disponíveis foram: RM, TC, ultrassonografia, PET e radiografia simples. Todos os achados foram comparados com os Critérios de Adequação de Exames de Imagem e Radioterapia do ACR. RESULTADOS: A RM foi escolhida como melhor modalidade de imagem para se avaliar neoplasias encefálicas, espinhais, abdominais e musculoesqueléticas por 96,3 por cento, 100 por cento, 70,4 por cento e 63 por cento dos residentes, respectivamente. A TC foi escolhida por 88,9 por cento dos residentes para avaliar neoplasias pulmonares. A modalidade de imagem ótima para se avaliar trauma foi a TC para lesões encefálicas (100 por cento), espinhais (92,6 por cento), pulmonares (96,3 por cento), abdominais (92,6 por cento) e grandes lesões traumáticas musculoesqueléticas (74,1 por cento); a RM foi escolhida para lesões esportivas (96,3 por cento). Observou-se concordância com os critérios de adequação do ACR. CONCLUSÃO: Houve concordância entre a percepção dos residentes sobre as melhores modalidades de imagem para avaliação de neoplasias e trauma e os critérios de adequação do ACR.

Short- and long-term effects of small bowel resection: a unique histological study in a piglet model of short bowel syndrome.

If we are to develop successful interventions to improve clinical outcomes for short bowel syndrome patients we require (1) knowledge of changes within the epithelial population following small bowel resection (SBR) and (2) an idea of when these changes occur to inform on the timing of potential interventions aimed at enhancing the adaptive response. The aim of this study was to produce a temporal map of epithelial changes within the crypt and villus at early and late adaptation phases. Four-week-old piglets underwent a 75% SBR or sham operation and were studied at 2, 4 and 6 weeks post-operation to allow analysis of early and late adaptation responses. Piglets received polymeric infant formula (PIF). Immunohistochemistry with specific cell markers was used to quantitate intestinal cell types and the total cell numbers. Changes within the crypt were temporally dependent on an early significant increase in enterocytes and proliferative cells not sustained at 6 weeks. Goblet cell numbers were increased at all time points. Despite a significant increase in total villus cell numbers at 6 weeks there was no change in specific cell types. We observed two distinct phases of cellular change following SBR. An early increase in enterocytes and proliferative cells was not reflected in increased weight gain indicating the early increase represents immature enterocytes. Interventions aimed at increasing differentiation of the rapidly changing crypt population would allow for an earlier increase in absorption.

Morphological and functional changes in the colon after massive small bowel resection.

PURPOSE: Anecdotal evidence suggests that the colon plays an important role after small bowel resection (SBR). However, colonic changes have not previously been studied. The aim of this study was to characterize morphological and functional changes within the colon after SBR and elucidate the influence of diet complexity on adaptation. METHOD: In study 1, 4-week-old piglets underwent a 75% SBR or sham operation and were studied at 2, 4, and 6 weeks postoperation to allow analysis of early and late adaptation responses. Piglets received a polymeric infant formula (PIF). In study 2, SBR piglets received an elemental diet and were studied at 6 weeks postoperation and compared with SBR + PIF piglets from study 1. For both studies, immunohistochemistry was used to quantitate intestinal cell types. Changes in functional proteins were measured by Western blot, enteroendocrine/peptide YY (PYY), enterocyte/liver fatty acid binding protein (L-FABP), and goblet cells/trefoil factor 3 (TFF3). RESULTS: In study 1, early and late adaptation-related changes were observed after SBR. Early adaptation included increased numbers of enterocytes (P = .0001), whereas late adaptation included increased proliferative cell numbers (P = .02). Enteroendocrine, goblet, and apoptotic cells numbers were significantly elevated in the resected group at all time-points studied (P < .05). Functional changes included increased levels of L-FABP (P = .04) and PYY (P = .03). There was no change in TFF3 expression. In study 2, feeding with an elemental diet resulted in suboptimal adaptation as evidenced by reduced rate of weight gain and significant reductions in total cell numbers (P = .0001), proliferative (P = .0001) and apoptotic cells (P = .04), enteroendocrine cells (P = .001), and PYY expression (P .004). CONCLUSION: These findings indicate that significant morphological and functional changes occur in the colon after massive SBR and that these occur as early and late adaptation responses. Elemental diet was associated with suboptimal adaptation suggesting an effect of diet complexity on colonic adaptation.

Colostrum supplementation restores insulin-like growth factor -1 levels and alters muscle morphology following massive small bowel resection.

BACKGROUND: Colostrum protein concentrate (CPC) contains a high level of insulin-like growth factor-1 (IGF-1). IGF-1 and IGF binding protein (IGFBPs) may play an important role during the postresection adaptation response. As smooth muscle is an important site for IGF-1 action in the intestine, this study aims to (1) investigate the effect of CPC supplementation on circulating levels and tissue expression of IGF-1, IGF-1 receptor, and IGFBPs following massive small bowel resection (MSBR), and (2) characterize the effect of CPC on the muscular adaptation response following MSBR. METHODS: Four-week-old piglets underwent either a 75% MSBR or sham operation. Piglets received either a polymeric infant formula (PIF) diet or PIF supplemented with CPC for 8 weeks. Serum was analyzed by enzyme-linked immunosorbent assay, and ileal tissue assessed by molecular and histological analysis. RESULTS: There was no difference in IGF-1 or IGFBPs mRNA among groups. CPC treatment resulted in significant increases in circulating levels of IGF-1 and IGFBPs and a concurrent increase in muscle width and the number of muscle cells, but did not alter muscle cell size. CONCLUSIONS: Strategies aimed at increasing muscular adaptation may decrease Gl transit and allow greater mucosal contact time for absorption. We have shown that CPC supplementation following resection results in increased levels of circulating IGF-1, IGFBP-2, and IGFBP-3 and muscular hypertrophy. Our results suggest that IGF-1 and its mediators may play a role in the muscular adaptation response and warrant further exploration as a treatment option for short bowel syndrome.

GLP-2 administration results in increased proliferation but paradoxically an adverse outcome in a juvenile piglet model of short bowel syndrome.

OBJECTIVE: The objective of the present study was to examine the effect of glucagon-like peptide-2 (GLP-2) administration in a piglet, juvenile model of short bowel syndrome. MATERIALS AND METHODS: Four-week-old piglets underwent either a sham operation or 75% small bowel resection. Postoperatively, piglets received either polymeric infant formula diet or the diet and subcutaneous human recombinant GLP-2 (1600 microg/day for 7 days, 800 microg/day thereafter). Food intake was monitored throughout the experiment, and stool and serum samples obtained fortnightly. After the piglets were killed, tissues were obtained from the duodenum, jejunum, ileum, and terminal ileum, and used for morphological and functional analysis. RESULTS: Treatment with GLP-2 resulted in significantly increased numbers of proliferating and apoptotic cells in the ileum of sham and small bowel resection piglets (P < 0.05). GLP-2 administration resulted in decreased weight gain, serum albumin, and disaccharidases in both sham and small bowel resection piglets (P < 0.001 compared with polymeric infant formula diet alone). CONCLUSIONS: This is the first study to our knowledge to examine the effect of GLP-2 administration in a juvenile short bowel syndrome model. Contrary to adult rodent studies, administration of GLP-2 resulted in adverse outcomes including reduced ability to gain weight; decreased serum albumin, tissue maltase, and sucrase; and villous atrophy. We anticipate this information will have important implications for future paediatric clinical trials.

Increases in corticospinal tract function by treadmill training after incomplete spinal cord injury.

In this study, we examined if several months of intensive locomotor training increases the function of spared corticospinal tract pathways after chronic spinal cord injury (SCI) in association with the recovery of locomotor function. Transcranial magnetic stimulation (TMS) at incrementing levels of intensity was applied over the motor cortex supplying either the tibialis anterior or vastus lateralis muscles, and the resulting peak-to-peak amplitude of the motor-evoked potentials (MEPs) were measured to obtain a recruitment curve both before and after training. In the majority of subjects (7/8), 3-5 mo of daily intensive training increased the responses to TMS in at least one of the leg muscles tested (9/13). On average, across all muscles tested MEP(max), which was evoked at high stimulation intensities, increased by 46% and MEP(h), which was evoked at intermediate stimulation intensities, increased by 45% (both significantly different from 0), indicating an increase in corticospinal tract connectivity from training. The slope of the sigmoid function fit to the recruitment curve increased by 24% after training (significantly different), indicating an expansion and/or increased excitability of corticospinal circuits supplying muscles to the lower leg. We also observed that the average duration of the silent period measured at MEP(max) increased after training from 130 to 178 ms, suggesting that training had effects on cortical circuits thought to mediate this long-lasting inhibition. The percentage increase in MEP(max) was positively and significantly correlated to the degree of locomotor recovery as assessed by the WISCI II score, the distance a subject could walk in 6 min, and the amplitude of the locomotor EMG activity, suggesting that the corticospinal tract, in part, mediated the functional locomotor recovery produced from training.