A nutritional screening threshold for optimal outcomes after Hartmann's reversal.

PURPOSE: Determining is nutritionally replete enough for Hartmann's reversal (HR) can be controversial and multifactorial. While there are many preoperative nutritional screening tools, the impact of malnourishment on HR has not been evaluated. The study aims to clarify how often patients undergoing HR are high risk for malnourishment at the time of surgery and how this impacts postoperative outcomes. METHODS: From 2012-2019, all elective HRs were identified in ACS-NSQIP. Patients were categorized in a malnourished group if they met one of the following criteria: (1) BMI < 18.5 kg/m2, (2) albumin < 3.5 g/dL, or (3) > 10% body weight loss in the last 6 months. Bivariate associations of preoperative demographics and postoperative outcomes were analyzed. Multivariable logistic regression was performed to identify independent predictors for 30-day mortality and organ space wound infection. RESULTS: 8878 procedures were evaluated (well-nourished = 7116 and malnourished = 1762). The malnourished group had higher mortality (p < 0.001), shorter operating time (p < .001), longer length of stay (p = 0.016), and higher rates of infection (p = 0.011), reintubation (p = 0.002), bleeding (p < 0.001), sepsis (p = 0.001), and reoperation (p = 0.018). In multivariate regression models, malnourishment was an independent predictor for mortality (OR = 2.72, p < 0.001) and wound infection (OR = 1.19, p = 0.028). CONCLUSION: A large percentage of patients undergoing HR were classified as being high-risk for malnutrition. Malnourishment was associated with some worse postoperative compilations including death and wound infection. Surgeons should routinely use preoperative screening for malnutrition to identify and attempt to optimize nutritional status prior to undergoing Hartmann's Reversal.

Outcomes of Fundamentals of Laparoscopic Surgery (FLS) mastery training standards applied to an ergonomically different, lower cost platform.

OBJECTIVE: Using previously established mastery learning standards, this study compares outcomes of training on standard FLS (FLS) equipment with training on an ergonomically different (ED-FLS), but more portable, lower cost platform. METHODS: Subjects completed a pre-training FLS skills test on the standard platform and were then randomized to train on the FLS training platform (n = 20) or the ED-FLS platform (n = 19). A post-training FLS skills test was administered to both groups on the standard FLS platform. RESULTS: Group performance on the pretest was similar. Fifty percent of FLS and 32 % of ED-FLS subjects completed the entire curriculum. 100 % of subjects completing the curriculum achieved passing scores on the post-training test. There was no statistically discernible difference in scores on the final FLS exam (FLS 93.4, ED-FLS 93.3, p = 0.98) or training sessions required to complete the curriculum (FLS 7.4, ED-FLS 9.8, p = 0.13). CONCLUSIONS: These results show that when applying mastery learning theory to an ergonomically different platform, skill transfer occurs at a high level and prepares subjects to pass the standard FLS skills test.

Condyloma and Anal Dysplasia.

Anal intraepithelial neoplasia (AIN) are precancerous lesions and are sequela of human papilloma virus (HPV) infection. AIN is classified as low-grade squamous intraepithelial lesion or high-grade squamous intraepithelial lesion. Screening with anal cytology and anoscopy should be considered for high-risk populations. Diagnosis is made through high resolution anaoscopy and biopsy. Options for treatment include ablation and several topical therapies; however, recurrence rates are high for all treatment options, and an ongoing surveillance is necessary to prevent progression to anal squamous cell carcinoma. HPV vaccination is recommended to prevent disease.

Functional Constipation and Obstructed Defecation.

Constipation encompasses symptoms of decreased colonic motility or difficulty with the defecation process. As a broad definition, this can be inclusive of functional constipation (FC) or colonic inertia, obstructed defecation (OD), and irritable bowel syndrome-constipation type (IBS-CS). After excluding IBS-C, FC and OD diagnosis and management require a multidisciplinary approach often involving nutritionists, pelvic floor therapists, urogynecologists, and colon and rectal surgeons. Differentiating the presence or absence of each can direct therapy and prognosticate chances for improvement in this often complex combination of disorders.

Safety of robotic surgical management of non-elective colectomies for diverticulitis compared to laparoscopic surgery.

Non-elective minimally invasive surgery (MIS) remains controversial, with minimal focus on robotics. This study aims to evaluate the short-term outcomes for non-elective robotic colectomies for diverticulitis. All colectomies for diverticulitis in ACS-NSQIP between 2012 and 2019 were identified by CPT and diagnosis codes. Open and elective cases were excluded. Patients with disseminated cancer, ascites, and ventilator-dependence were excluded. Procedures were grouped by approach (laparoscopic and robotic). Demographics, operative variables, and postoperative outcomes were compared between groups. Covariates with p < .1 were entered into multivariable logistic regression models for 30 day mortality, postoperative septic shock and reoperation. 6880 colectomies were evaluated (Laparoscopic = 6583, Robotic = 297). The laparoscopic group included more preoperative sepsis (31.6% vs. 10.8%), emergency cases (32.3% vs. 6.7%), and grade 3/4 wound classifications (53.3% vs. 42.8%). There was no difference in mortality, anastomotic leak, SSI, reoperation, readmission, or length of stay. The laparoscopic group had more postoperative sepsis (p = 0.001) and the robotic group showed increased bleeding (p = 0.011). In a multivariate regression model, increased age (OR = 1.083, p < 0.001), COPD (OR = 2.667, p = 0.007), dependent functional status (OR = 2.657, p = 0.021), dialysis (OR = 4.074, p = 0.016), preoperative transfusions (OR = 3.182, p = 0.019), emergency status (OR = 2.241, p = 0.010), higher ASA classification (OR = 3.170, p = 0.035), abnormal WBC (OR = 1.883, p = 0.046) were independent predictors for mortality. When controlling for confounders, robotic approach was not statistically significantly associated with septic shock or reoperation. When controlling for confounders, robotic approach was not a predictor for mortality, reoperation or septic shock. Robotic surgery is a feasible option for the acute management of diverticulitis.

Cost Comparison of Fundamentals of Laparoscopic Surgery Training Completed With Standard Fundamentals of Laparoscopic Surgery Equipment versus Low-Cost Equipment.

OBJECTIVE: Training for the Fundamentals of Laparoscopic Surgery (FLS) skills test can be expensive. Previous work demonstrated that training on an ergonomically different, low-cost platform does not affect FLS skills test outcomes. This study compares the average training cost with standard FLS equipment and medical-grade consumables versus training on a lower cost platform with non-medical-grade consumables. DESIGN: Subjects were prospectively randomized to either the standard FLS training platform (n = 19) with medical-grade consumables (S-FLS), or the low-cost platform (n = 20) with training-grade products (LC-FLS). Both groups trained to proficiency using previously established mastery learning standards on the 5 FLS tasks. The fixed and consumable cost differences were compared. SETTING: Training occurred in a surgical simulation center. PARTICIPANTS: Laparoscopic novice medical student and resident physician health care professionals who had not completed the national FLS proficiency curriculum and who had performed less than 10 laparoscopic cases. RESULTS: The fixed cost of the platform was considerably higher in the S-FLS group (S-FLS, $3360; LC-FLS, $879), and the average consumable training cost was significantly higher for the S-FLS group (S-FLS, $1384.52; LC-FLS, $153.79; p < 0.001). The LC-FLS group had a statistically discernable cost reduction for each consumable (Gauze $9.24 vs. $0.39, p = 0.002; EndoLoop $540.00 vs. $40.60, p < 0.001; extracorporeal suture $216.45 vs. $25.20, p < 0.001; intracorporeal suture $618.83 vs. $87.60, p < 0.001). The annual fixed and consumable cost to train 5 residents is $10,282.60 in the S-FLS group versus $1647.95 in the LC-FLS group. CONCLUSIONS: This study shows that the average cost to train a single trainee to proficiency using a lower fixed-cost platform and non-medical-grade equipment results in significant financial savings. A 5-resident program will save approximately $8500 annually. Residency programs should consider adopting this strategy to reduce the cost of FLS training.

Diversity of mitochondrial Ca²âº signaling in rat neonatal cardiomyocytes: evidence from a genetically directed Ca²âº probe, mitycam-E31Q.

I(Ca)-gated Ca(2+) release (CICR) from the cardiac SR is the main mechanism mediating the rise of cytosolic Ca(2+), but the extent to which mitochondria contribute to the overall Ca(2+) signaling remains controversial. To examine the possible role of mitochondria in Ca(2+) signaling, we developed a low affinity mitochondrial Ca(2+) probe, mitycam-E31Q (300-500 MOI, 48-72h) and used it in conjunction with Fura-2AM to obtain simultaneous TIRF images of mitochondrial and cytosolic Ca(2+) in cultured neonatal rat cardiomyocytes. Mitycam-E31Q staining of adult feline cardiomyocytes showed the typical mitochondrial longitudinal fluorescent bandings similar to that of TMRE staining, while neonatal rat cardiomyocytes had a disorganized tubular or punctuate appearance. Caffeine puffs produced rapid increases in cytosolic Ca(2+) while simultaneously measured global mitycam-E31Q signals decreased more slowly (increased mitochondrial Ca(2+)) before decaying to baseline levels. Similar, but oscillating mitycam-E31Q signals were seen in spontaneously pacing cells. Withdrawal of Na(+) increased global cytosolic and mitochondrial Ca(2+) signals in one population of mitochondria, but unexpectedly decreased it (release of Ca(2+)) in another mitochondrial population. Such mitochondrial Ca(2+) release signals were seen not only during long lasting Na(+) withdrawal, but also when Ca(2+) loaded cells were exposed to caffeine-puffs, and during spontaneous rhythmic beating. Thus, mitochondrial Ca(2+) transients appear to activate with a delay following the cytosolic rise of Ca(2+) and show diversity in subpopulations of mitochondria that could contribute to the plasticity of mitochondrial Ca(2+) signaling.

Development of a negative selectable marker for Entamoeba histolytica.

Entamoeba histolytica is the causative agent of amebiasis and infects up to 10% of the world's population. The molecular techniques that have enabled the up- and down-regulation of gene expression rely on the transfection of stably maintained plasmids. While these have increased our understanding of Entamoeba virulence factors, the capacity to integrate exogenous DNA into genome, which would allow reverse genetics experiments, would be a significant advantage in the study of this parasite. The challenges presented by this organism include inability to select for homologous recombination events and difficulty to cure episomal plasmid DNA from transfected trophozoites. The later results in a high background of exogenous DNA, a major problem in the identification of trophozoites in which a bona fide genomic integration event has occurred. We report the development of a negative selection system based upon transgenic expression of a yeast cytosine deaminase and uracil phosphoribosyl transferase chimera (FCU1) and selection with prodrug 5-fluorocytosine (5-FC). The FCU1 enzyme converts non-toxic 5-FC into toxic 5-fluorouracil and 5-fluorouridine-5'-monophosphate. E. histolytica lines expressing FCU1 were found to be 30 fold more sensitive to the prodrug compared to the control strain.

A peripheral benzodiazepine receptor targeted agent for in vitro imaging and screening.

We developed a molecular imaging agent (MIA), a conjugable form of PK11195 (conPK11195) coupled to a lissamine dye (Liss-ConPK11195), which targets the peripheral benzodiazepine receptor (PBR). To determine that our compound specifically binds to this 18 kDa protein, primarily expressed on the mitochondria, we performed classic binding studies on live MDA-MB-231 breast cancer cells and measured fluorescence in cell fractions of C6 glioma cells. We found that conPK11195 conjugated to the fluorophore retained significant binding to its target. Here we demonstrate the utility of the agent for in vitro imaging of live cells by specific binding to the protein of interest.