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Background The association between volume and outcomes has led to recommendations that patients undergo surgery at high-volume centers. We aimed to determine if older patients with rectal cancer are undergoing operations at high-volume centers. Methods We identified patients ≥50 years old who underwent rectal cancer resection using the NCDB (2004–2015). Tertiles were used to categorize facility volume and distance traveled. Results Higher facility volume was associated with improved outcomes. Patients >75 years old were less likely than patients 50–59 years old to be treated at high-volume centers. Traveling >16.8 miles was associated with treatment at high-volume facilities, however patients >75 years old were less likely to travel >16.8 miles. Conclusions Higher facility volume is associated with improved outcomes after rectal cancer resection. However, older patients are less likely to be treated at high-volume facilities. Older patients travel shorter distances for care, suggesting that care integration across networks must be optimized.

Background Functional outcomes after ileoanal pouch creation have been studied; however, there is great variability in how relevant outcomes are defined and reported. More importantly, the perspective of patients has not been represented in deciding which outcomes should be the focus of research. Objective The primary aim was to create a patient-centered definition of core symptoms that should be included in future studies of pouch function. Design This was a Delphi consensus study. Setting Three rounds of surveys were used to select high-priority items. Survey voting was followed by a series of online patient consultation meetings used to clarify voting trends. A final online consensus meeting with representation from all 3 expert panels was held to finalize a consensus statement. Patients Expert stakeholders were chosen to correlate with the clinical scenario of the multidisciplinary team that cares for pouch patients, including patients, colorectal surgeons, and gastroenterologists or other clinicians. Main outcome measures A consensus statement was the main outcome. Results patients, 62 colorectal surgeons, and 48 gastroenterologists or nurse specialists completed all 3 Delphi rounds. Fifty-three patients participated in online focus groups. One hundred sixty-one stakeholders participated in the final consensus meeting. On conclusion of the consensus meeting, 7 bowel symptoms and 7 consequences of undergoing ileoanal pouch surgery were included in the final consensus statement. Limitations The study was limited by online recruitment bias. Conclusions This study is the first to identify key functional outcomes after pouch surgery with direct input from a large panel of ileoanal pouch patients. The inclusion of patients in all stages of the consensus process allowed for a true patient-centered approach in defining the core domains that should be focused on in future studies of pouch function. See Video Abstract at http://links.lww.com/DCR/B571. Los pacientes sometidos a ciruga de reservorio ileoanal experimentan una constelacin de sntomas y consecuencias que representan un sndrome unico Un Informe de los Resultados Reportados por los Pacientes Posterior a la Cirugia de Reservorio (PROPS) Estudio de Consenso DelphiANTECEDENTES:Los resultados funcionales despues de la creacion del reservorio ileoanal han sido estudiados; sin embargo, existe una gran variabilidad en la forma en que se definen y reportan los resultados relevantes. Mas importante aun, la perspectiva de los pacientes no se ha representado a la hora de decidir que resultados deberian ser el foco de investigacion.OBJETIVO:El objetivo principal era crear en el paciente una definicion centrada de los sintomas principales que deberia incluirse en los estudios futuros de la funcion del reservorio.DISENO:Estudio de consenso Delphi.ENTORNO CLINICO:Se emplearon tres rondas de encuestas para seleccionar elementos de alta prioridad. La votacion de la encuesta fue seguida por una serie de reuniones de consulta de pacientes en linea que se utilizan para aclarar las tendencias de votacion. Se realizo una reunion de consenso final en linea con representacion de los tres paneles de expertos para finalizar una declaracion de consenso.PACIENTES:Se eligieron partes interesadas expertas para correlacionar con el escenario clinico del equipo multidisciplinario que atiende a los pacientes con reservorio: pacientes, cirujanos colorrectales, gastroenterologos / otros medicos.PRINCIPALES MEDIDAS DE VALORACION:Declaracion de consenso.RESULTADOS:Ciento noventa y cinco pacientes, 62 cirujanos colorrectales y 48 gastroenterologos / enfermeras especialistas completaron las tres rondas Delphi. 53 pacientes participaron en grupos focales en linea. 161 interesados participaron en la reunion de consenso final. Al concluir la reunion de consenso, siete sintomas intestinales y siete consecuencias de someterse a una cirugia de reservorio ileoanal se incluyeron en la declaracion de consenso final.LIMITACIONES:Sesgo de reclutamiento en linea.CONCLUSIONES:Este estudio es el primero en identificar resultados funcionales claves despues de la cirugia de reservorio con informacion directa de un gran panel de pacientes con reservorio ileoanal. La inclusion de pacientes en todas las etapas del proceso de consenso permitio un verdadero enfoque centrado en el paciente para definir los dominios principales en los que deberia centrarse los estudios futuros de la funcion del reservorio. Consulte Video Resumen en http://links.lww.com/DCR/B571.

While fecal incontinence and constipation can be measured through physiological testing, the subjective experience of severity and impact on health-related quality of life lead to both being most effectively captured through patient-reported measures. Patient-reported measures of severity and impact help to determine baseline symptoms, guide clinical decision making, and compare various treatments. Here, we take pause to review the psychometric qualities that make effective instruments, and discuss some of the most commonly used instruments along with the reasons behind their use. In addition, we highlight the benefits of a standardized instrument designed to evaluate the major symptoms of patients presenting with pelvic floor disorders (including fecal incontinence and constipation). Ultimately, we aim to provide guidance in choosing appropriate instruments for clinical and research use.

BACKGROUND Diverticulitis is separated into complicated and uncomplicated, based on the patient's presentation at the time of his or her initial attack of acute diverticulitis. OBJECTIVE The aim of this study was to identify risk factors for persistent complex diverticulitis, defined as an abscess, fistula, or stricture, at the time of elective surgery, and to characterize outcomes in this patient population. DESIGN This was a retrospective review of 2010 to 2016 in the American College of Surgeons National Surgical Quality Improvement Project database. SETTINGS Individuals diagnosed with diverticulitis who underwent elective surgery were included. PATIENTS A total of 1502 patients underwent elective surgery for diverticulitis, of which 559 (37%) patients had a surgical indication of persistent complex diverticulitis. INTERVENTIONS We performed logistic regression analysis to identify risk factors for complex diverticulitis and evaluated a new prediction model. MAIN OUTCOME MEASURES The predictive factors of persistent complex diverticulitis for elective colon resection were measured. RESULTS The patients with complex diverticulitis were older (p < 0.001), had worse functional status (p < 0.001), more comorbidities (diabetes mellitus and hypertension), and a higher Charlson Comorbidity Index (2.7 vs 1.6, p < 0.001). They were more likely to have a history of tobacco or alcohol use (p < 0.001) and to be malnourished. Interestingly, patients found to have persistent complex diverticulitis did not have more episodes than patients with uncomplicated cases did (p = 0.67). Surgical time was longer in complex diverticulitis, and the patients were more likely to require diverting stomas and concurrent resections of adjacent structures. The area under the curve from the test set was (0.75; 95% CI, 0.72-0.78), sensitivity and specificity were 0.890 (95% CI, 0.870-0.891) and 0.450 (95% CI, 0.410-0.490). LIMITATIONS The study was limited by its retrospective review and observational bias. CONCLUSIONS Patients undergoing elective surgery for complex diverticulitis did not have more episodes. Instead, complex diverticulitis may be a reflection of a complicated patient, suggesting that complicated patients should have a different algorithm of care at the time of their initial presentation with diverticulitis to prevent the development of complex disease. See Video Abstract at http://links.lww.com/DCR/B183. ?PODEMOS PREDECIR DIVERTICULITIS QUIRURGICAMENTE COMPLEJA EN CASOS ELECTIVOS?: La diverticulitis se divide en complicada y sin complicaciones, segun la presentacion del paciente en el momento de su ataque inicial de diverticulitis aguda.El objetivo de este estudio fue identificar los factores de riesgo para la diverticulitis compleja persistente, definida como un absceso, fistula o estenosis, en el momento de la cirugia electiva, y caracterizar los resultados en esta poblacion de pacientes.Esta fue una revision retrospectiva del 2010-2016 en la base de datos del Proyecto de Mejora de la Calidad Quirurgica Nacional del Colegio Estadounidense de Cirujanos.Se incluyeron individuos diagnosticados con diverticulitis que se sometieron a cirugia electiva.1502 pacientes fueron sometidos a cirugia electiva por diverticulitis, de los cuales 559 (37%) pacientes tenian una indicacion quirurgica de diverticulitis compleja persistente.Realizamos un analisis de regresion logistica para identificar los factores de riesgo de diverticulitis compleja y evaluamos un nuevo modelo de prediccion.Se midieron los factores predictivos de diverticulitis compleja persistente para la reseccion de colon electiva.Los pacientes con diverticulitis compleja eran mayores (p

Enhanced recovery after surgery (ERAS) programs are now standard of care for colorectal surgery. Efforts have been aimed at decreasing postoperative opioid consumption. The goal of this study is to evaluate the effect of liposomal bupivacaine transversus abdominis plane (TAP) blocks on opioid use and its downstream effect on rates of ileus and hospital length of stay (LOS). We performed a retrospective pre- and postintervention time-trend analysis (2016–2018) of ERAS patients undergoing laparoscopic colorectal surgery at two academic medical centers within the same hospital system. The intervention was liposomal bupivacaine TAP blocks versus standard local infiltration with bupivacaine with a primary outcome of total morphine milligram equivalents (MME) administered within 72 h of surgery. Secondary outcomes included hospital LOS and rate of postoperative ileus. There were 556 patients included at the control hospital, and 384 patients were included at the treatment hospital. Patients at both hospitals were similar with regard to age, body mass index, comorbidities, and surgical indication. In an adjusted time-trend analysis, the treatment hospital was associated with a significant decrease in MME administered (– 15.9 mg, p = 0.04) and hospital LOS (– 0.8 days, p < 0.001). There was no significant decrease in the rate of ileus at the treatment hospital (– 6.9%, p = 0.08). In a time-trend analysis, the addition of liposomal bupivacaine TAP blocks into the ERAS protocol resulted in significantly reduced opioid use and shorter hospital LOS for patients undergoing surgery at the treatment hospital. Liposomal bupivacaine TAP blocks should be considered for inclusion in the standard ERAS protocol.

BACKGROUND The surgical management of rectal prolapse is constantly evolving, yet numerous clinical trials and meta-analyses studying operative approaches have failed to make meaningful conclusions. OBJECTIVE The purpose of this study was to report on preliminary data captured during a large-scale quality improvement initiative to measure and improve function in patients undergoing rectal prolapse repair. DESIGN This was a retrospective analysis of prospectively collected surgical quality improvement data. SETTINGS This study was conducted at 14 tertiary centers specializing in pelvic floor disorders from 2017 to 2019. PATIENTS A total of 181 consecutive patients undergoing external rectal prolapse repair were included. MAIN OUTCOME MEASURES Preoperative and 3-month postoperative Wexner incontinence score and Altomare obstructed defecation score were measured. RESULTS The cohort included 112 patients undergoing abdominal surgery (71 suture rectopexy/56% minimally invasive, 41 ventral rectopexy/93% minimally invasive). Those offered perineal approaches (n = 68) were older (median age, 75 vs 62 y; p < 0.01) and had more comorbidities (ASA 3-4: 51% vs 24%; p < 0.01) but also reported higher preintervention rates of fecal incontinence (Wexner 11.4 ± 6.4 vs 8.6 ± 5.8; p < 0.01). Patients undergoing perineal procedures had similar incremental improvements in function after surgery as patients undergoing abdominal repair (change in Wexner, -2.6 ± 6.4 vs -3.1 ± 5.6, p = 0.6; change in Altomare, -2.9 ± 4.6 vs -2.7 ± 4.9, p = 0.8). Similarly, patients undergoing posterior suture rectopexy and ventral mesh rectopexy had similar incremental improvements in overall scores; however, patients undergoing ventral mesh rectopexy had a higher decrease in the need to use pads after surgery. LIMITATIONS The study was limited by its retrospective data analysis and 3-month follow-up. CONCLUSIONS Functional outcomes improved in all of the patients undergoing prolapse surgery. Larger cohorts are necessary to show superiority among surgical procedures. Quality improvement methods may allow for systematic yet practical acquisition of information and data analysis. We call for the creation of a robust database to benefit this patient population. See Video Abstract at http://links.lww.com/DCR/B581. REPORTE PRELIMINAR DEL CONSORCIO DE TRASTORNOS DEL PISO PLVICO RECOLECCIN DE DATOS A GRAN ESCALA MEDIANTE INICIATIVAS DE MEJORAMIENTO DE LA CALIDAD PARA PROPORCIONAR INFORMACIN SOBRE LOS RESULTADOS FUNCIONALES ANTECEDENTES:El tratamiento quirurgico del prolapso rectal esta evolucionando constantemente, sin embargo, numerosos estudios clinicos y metaanalisis que evaluan los tratamientos quirurgicos no han logrado demostrar conclusiones significativas.OBJETIVO:Reportar datos preliminares obtenidos a gran escala durante una iniciativa de mejoramiento de la calidad para medir y mejorar la funcion en pacientes sometidos a reparacion de prolapso rectal.DISENO:Analisis retrospectivo de datos recolectados prospectivamente de mejoramiento de la calidad quirurgica.ENTORNO CLINICO:Este estudio se realizo en 14 centros terciarios especializados en trastornos del piso pelvico del 2017 al 2019.PACIENTES:Un total de 181 pacientes consecutivos sometidos a reparacion de prolapso rectal externo.PRINCIPALES MEDIDAS DE VALORACION:Escala de incontinencia de Wexner y de defecacion obstruida de Altomare preoperatoria y tres meses postoperatoria.RESULTADOS:El cohorte incluyo 112 pacientes sometidos a cirugia abdominal (71 rectopexia con sutura / 56% minimally invasive, 41 rectopexia ventral / 93% minimally invasive). Aquellos a los que se les realizaron abordajes perineales (n = 68) eran mayores (edad media de 75 vs. 62, p

BACKGROUND The influence of microsatellite instability on prognosis in high-risk stage II colon cancer is unknown. OBJECTIVE This study aimed to investigate the relationship between microsatellite instability and overall survival in high-risk stage II colon cancer. DESIGN This is a retrospective review of the National Cancer Database from 2010 to 2016. SETTINGS This study included national cancer epidemiology data from the American College of Surgeons Commission on Cancer. PATIENTS Included were 16,788 patients with stage II colon adenocarcinoma and known microsatellite status (1709 microsatellite unstable). MAIN OUTCOME MEASURES The primary outcome measured was overall survival. RESULTS Microsatellite unstable cancers with high-risk features had significantly better overall survival than microsatellite stable cancers with high-risk features (5-year survival 80% vs 72%, p = 0.01), and had survival equivalent to microsatellite stable cancers with low-risk features (5-year survival, 80%). When stratified by specific high-risk features, patients with lymphovascular invasion, perineural invasion, or high-grade histology had overall survival similar to patients without these features, only in microsatellite unstable cancers. However, patients with high-risk features of T4 stage, positive margins, and

Severe burn injury induces gut barrier dysfunction and subsequently a profound systemic inflammatory response. In the present study, we examined the role of the small intestinal brush border enzyme, intestinal alkaline phosphatase (IAP), in preserving gut barrier function and preventing systemic inflammation after burn wound infection in mice. Mice were subjected to a 30% total body surface area dorsal burn with or without intradermal injection of Pseudomonas aeruginosa. Mice were gavaged with 2000 units of IAP or vehicle at 3 and 12 hours after the insult. We found that both endogenously produced and exogenously supplemented IAP significantly reduced gut barrier damage, decreased bacterial translocation to the systemic organs, attenuated systemic inflammation, and improved survival in this burn wound infection model. IAP attenuated liver inflammation and reduced the proinflammatory characteristics of portal serum. Furthermore, we found that intestinal luminal contents of burn wound–infected mice negatively impacted the intestinal epithelial integrity compared with luminal contents of control mice and that IAP supplementation preserved monolayer integrity. These results indicate that oral IAP therapy may represent an approach to preserving gut barrier function, blocking proinflammatory triggers from entering the portal system, preventing gut-induced systemic inflammation, and improving survival after severe burn injuries., Oral intestinal alkaline phosphatase therapy preserves gut barrier function in mice following burn injury, blocking pro-inflammatory triggers from entering the portal system, preventing gut-induced systemic inflammation, and improving survival.

Enhanced Recovery after Surgery (ERAS) protocols have been demonstrated to improve hospital length of stay and outcomes in patients undergoing colorectal surgery. This article presents the specific components of an ERAS protocol implemented at the authors' institution. In particular, details of both surgical and anesthetic ERAS pathways are provided with explanation of all aspects of preoperative, perioperative, and postoperative care. Evidence supporting inclusion of various aspects within the ERAS protocol is briefly reviewed. The ERAS protocol described has significantly benefitted postoperative outcomes in colorectal patients and can be employed at other institutions wishing to develop an ERAS pathway for colorectal patients. A checklist is provided for clinicians to easily reference and facilitate implementation of a standardized protocol.

BACKGROUND: Recent genetic studies identified common mutations between diverticular disease and connective tissue disorders, some of which are associated with abdominal wall hernias. Scarce data exists, however, shedding light on the potential clinical implications of this shared etiology, particularly in the era of laparoscopic surgery. METHODS: The New York Statewide Planning and Research Cooperative System database was used to identify adult patients undergoing elective sigmoid and left hemicolectomies (open or laparoscopic) from 1/1/2010 to 12/31/2016 for diverticulitis or descending/sigmoid colon cancer. The incidences of incisional hernia diagnosis and repair were compared using competing-risks regression models, clustered by surgeon and adjusted for a host of demographic/clinical variables. Subsequent abdominal surgery and death were considered competing risks. RESULTS: Among 8,279 patients included in the study cohort, 6,811 (82.2%) underwent colectomy for diverticulitis and 1,468 (17.8%) for colon cancer. The overall 5-year risk of incisional hernia was 3.5% among patients with colon cancer, regardless of colectomy route, which was significantly lower than that among diverticulitis patients after both open (10.7%; p

Rationale: Liver fibrosis is frequently associated with gut barrier dysfunction, and the lipopolysaccharides (LPS) -TLR4 pathway is common to the development of both. Intestinal alkaline phosphatase (IAP) has the ability to detoxify LPS, as well as maintain intestinal tight junction proteins and gut barrier integrity. Therefore, we hypothesized that IAP may function as a novel therapy to prevent liver fibrosis. Methods: Stool IAP activity from cirrhotic patients were determined. Common bile duct ligation (CBDL) and Carbon Tetrachloride-4 (CCl4)-induced liver fibrosis models were used in WT, IAP knockout (KO), and TLR4 KO mice supplemented with or without exogenous IAP in their drinking water. The gut barrier function and liver fibrosis markers were tested. Results: Human stool IAP activity was decreased in the setting of liver cirrhosis. In mice, IAP activity and genes expression decreased after CBDL and CCl4 exposure. Intestinal tight junction related genes and gut barrier function were impaired in both models of liver fibrosis. Oral IAP supplementation attenuated the decrease in small intestine tight junction protein gene expression and gut barrier function. Liver fibrosis markers were significantly higher in IAP KO compared to WT mice in both models, while oral IAP rescued liver fibrosis in both WT and IAP KO mice. In contrast, IAP supplementation did not attenuate fibrosis in TLR4 KO mice in either model. Conclusions: Endogenous IAP is decreased during liver fibrosis, perhaps contributing to the gut barrier dysfunction and worsening fibrosis. Oral IAP protects the gut barrier and further prevents the development of liver fibrosis via a TLR4-mediated mechanism.

Diminished integrity of the intestinal epithelial barrier with advanced age is believed to contribute to aging-associated dysfunction and pathologies in animals. In mammals, diminished gut integrity contributes to inflammaging, the increase in inflammatory processes observed in old age. Recent work suggests that expression of intestinal alkaline phosphatase (IAP) plays a key role in maintaining gut integrity. IAP expression decreases with increasing age in mice and humans. Absence of IAP leads to liver inflammation and shortened life-spans in mice lacking the IAP gene. In normal mice, exogenous supplemental IAP reverses age-induced barrier dysfunction, improves aging-associated metabolic dysfunction, prevents microbiome dysbiosis (imbalance), and extends life-span. Consistent with IAP playing a conserved role in maintaining gut integrity, increased dietary IAP increases aging-diminished physical performance in flies. IAP helps maintain gut integrity in part by supporting the expression of tight junction proteins that maintain the intestinal epithelial barrier and by inactivating bacterial pro-inflammatory factors such as lipopolysaccharides (LPS) by dephosphorylation. Recombinant IAP is in late clinical trials for sepsis-associated acute kidney injury, suggesting it may soon become available as a therapeutic. Taken together, these reports support the idea that directly increasing IAP levels by supplemental recombinant IAP or by indirectly increasing IAP levels using dietary means to induce endogenous IAP may slow the development of aging-associated pathologies.

Background While enhanced recovery pathways (ERAS) appear to be beneficial for post-operative outcomes, there have been no studies evaluating the specific role of patient education within an ERAS pathway. Methods We identified all colectomies performed at our institution since initiation of an ERAS protocol, excluding for mortality and length of stay >30 days. Patients who received preoperative education by a nurse practitioner via a scripted telephone call were compared to patients who did not receive education using the NSQIP database. We then evaluated differences in surgical complications and length of stay among these cohorts. Results Patients who received scripted education phone calls had a significantly shorter mean length of stay when compared to patients that receiving usual care (3.0 ± 2.2 vs 3.7 ± 3.2 days; p = 0.005). Subgroup analysis demonstrates strongest benefit in patients undergoing left colectomy and laparoscopic surgery. Conclusions Scripted patient education modules may shorten length of stays and postoperative complications, even when added to an already existing ERAS bundle, which may translate into significant hospital cost savings.

Purpose To determine the contact pressures between the scaphoid and lunate and the distal radius during 2 wrist push-up positions before and following scapholunate interosseous ligament (SLIL) sectioning. Methods Eight fresh cadaveric wrists were tested in a neutral flexion-extension (knuckle) push-up position and in an extended push-up position. Pressure measurements were acquired as each wrist was loaded with the wrist in extension and with the wrist in a neutral position. Data were acquired with the SLIL intact and following sectioning of its dorsal, volar, and proximal components. The wrist was disarticulated and a map drawn on each sensor to identify each joint fossa. Results A push-up performed with the wrist in extension caused a significantly greater peak pressure in the radioscaphoid fossa but not in the radiolunate fossa. Moving the wrist into extension caused a significant dorsal movement of the pressure centroid an average of 2.9 mm in the radiolunate fossa and an average of 5.7 mm in the radioscaphoid fossa. Sectioning the SLIL caused the centroid of pressure in the radioscaphoid fossa to significantly move an average 1.4 mm radially. Conclusions A push-up with the wrist in extension causes a significant increase in the pressure in the radioscaphoid fossa but not in the radiolunate. This finding may help explain why degenerative arthritis first develops in the radioscaphoid fossa before involving the radiolunate fossa. As expected, gapping that occurs with SLIL injury was observed here as a radial translation of the scaphoid and not as a movement of the lunate. The new location of scaphoid contact may be an additional reason for the development of radioscaphoid arthritis occurring before radiolunate arthritis. Clinical relevance This study provides a possible explanation as to why degenerative arthritis may first occur in the radioscaphoid fossa.

There are little data on risk factors for increased inpatient opioid use and its relationship with persistent opioid use after colorectal surgery.We identified colorectal surgery patients across five collaborating institutions. Patient comorbidities, surgery data, and outcomes were captured in the American College of Surgeons National Surgical Quality Improvement Program. We recorded preoperative opioid exposure, inpatient opioid use, and persistent use 90-180 days after surgery.1646 patients were analyzed. Patients receiving ≥250 MMEs (top quartile) were included in the high use group. On multivariable analysis, age65, emergent surgery, inflammatory bowel disease, and postoperative complications, but not prior opioid exposure, were predictive of high opioid use. Patients in the top quartile of use had an increased risk of persistent opioid use (19.8% vs. 9.7%, p 0.001), which persisted on multivariable analysis (OR 1.48; p = 0.037).We identified risk factors for high inpatient use that can be used to identify patients that may benefit from opioid sparing strategies. Furthermore, high postoperative inpatient use was associated with an increased risk of persistent opioid use.

Laparoscopic ventral mesh rectopexy was first described as an alternative approach to the standard abdominal rectopexy for external prolapse. This operation limits posterior rectal dissection and spares the sacral nerves, thereby avoiding rectal denervation and minimizing postoperative de novo constipation. Since its description, the procedure has been widely adopted by colorectal surgeons treating rectal prolapse and other pelvic floor disorders for its favorable outcomes and minimally invasive approach. This chapter will describe the spectrum of rectal prolapse and indications for laparoscopic ventral mesh rectopexy, detail operative technique, and review the literature with a focus on outcomes and complications of this operation.

The impact of primary tumor site on overall survival in patients with stage IV colorectal cancer (CRC) with single-organ metastases to the liver or lung has not been studied. Furthermore, the prognostic significance of commonly tested genetic variants such as KRAS mutation and microsatellite instability (MSI) are not well-described in this population.This National Cancer Database was used to identify 38,328 patients with CRC that presented with synchronous metastases to the liver or lung between 2010 and 2014. The primary outcome was overall survival, and groups were compared using Kaplan-Meier analyses and Cox proportional hazard models.On unadjusted analysis, median survival was significantly longer for patients with lung metastases compared with those with liver metastases for left-sided (27 vs. 25 months; P = .02) and right-sided CRC (19 vs. 15 months; P .001), whereas rectosigmoid and rectal cancers showed no difference. On multivariate analysis, patients with liver metastases demonstrated worse survival compared with those with lung metastasis (hazard ratio, 1.37; 95% confidence interval, 1.31-1.43; P .001). These trends were confirmed in patients that received chemotherapy but did not have their primary tumor or metastases resected. In patients with genetic testing, both KRAS mutants and MSI tumors had worse survival in left-sided and rectal tumors with liver metastases, but had similar survival to KRAS wild type tumors and microsatellite stable tumors, respectively, across other primary site and metastatic patterns.For patients with single-organ metastases to the liver or lung, primary tumor site has an impact on overall survival. Further, KRAS mutation and MSI status are of prognostic importance in selected patients with single-organ metastases.

Purpose Distal radioulnar joint (DRUJ) instability may occur after an injury, resulting in pain and reduced strength. When primary repair is not possible or initial fixation has failed, chronic instability may result, requiring a reconstructive procedure such as the Adams procedure. The first purpose of this study was to evaluate the role of the triangular fibrocartilage complex and various components of the interosseous membrane as they were sectioned. The second purpose was to evaluate the Adams procedure in stabilizing the forearm. Methods Eight fresh cadaver forearms were dynamically moved through an average range of 56.8° pronation to 54.8° supination and tested first with the forearm intact and then after sectioning each of the following structures: the dorsal (DRUL) and palmar radioulnar ligaments (PRUL), the distal interosseous membrane, and the central band. Finally, they were tested after reconstruction using the Adams procedure. During each forearm motion and provocative shuck, the motion of the radius and ulna were measured and the locations of the radial attachments of the DRUL, PRUL, and sigmoid notch and ulnar fovea were computed. Results Significant increases in the gap between the ulnar fovea and the attachment sites of the DRUL and PRUL were observed with incremental sectioning, most notably after sectioning of the central band. Reconstruction significantly reduced the gap at the DRUL and PRUL sites during dynamic motion. Conclusions This study reinforces the concept that DRUJ stability depends on more than the radioulnar ligaments, ulnocarpal ligaments, and triangular fibrocartilage complex, but is also significantly affected by the distal and central interosseous membrane. Reconstruction reduces gapping. Clinical relevance These results suggest that the Adams reconstruction is a reasonable option to address DRUJ instability but may be an incomplete solution in the setting of a ruptured interosseous ligament.

An 80-year-old man with idiopathic cold agglutinin disease presented with acute cholecystitis. We describe operating room and anaesthetic considerations for patients with cold agglutinin disease and measures that can be taken to prevent disease exacerbation in this case report. Multidisciplinary collaboration and planning between the operative room staff, anaesthesia team and surgical team are needed to ensure safe surgery and optimal patient outcomes.

INTRODUCTION Patient compliance with preoperative mechanical and antibiotic bowel preparation, skin washes, carbohydrate loading, and avoidance of fasting are key components of successful colorectal ERAS and surgical site infection (SSI)-reduction programs. In July 2016, we began a quality improvement project distributing a free SSI Prevention Kit (SSIPK) containing patient instructions, mechanical and oral bowel preparation, chlorhexidine washes, and carbohydrate drink to all patients scheduled for elective colectomy, with the goal of improving patient compliance and rates of SSI. METHODS This was a prospective data audit of our first 221 SSIPK+ patients, who were compared to historical controls (SSIPK-) of 1760 patients undergoing elective colectomy from January 2013 to March 2017. A 1:1 propensity score system accounted for nonrandom treatment assignment. Matched patients' complications, particularly postoperative infection and ileus, were compared. RESULTS SSIPK+ (n = 219) and SSIPK- (n = 219) matched patients were statistically identical on demographics, comorbidities, BMI, surgical indication, and procedure. SSIPK+ patients had higher compliance with mechanical (95% vs 71%, P < 0.001) and oral antibiotic (94% vs 27%, P < 0.001) bowel preparation. This translated into lower overall SSI rates (5.9% vs 11.4%, P = 0.04). SSIPK+ patients also had lower rates of anastomotic leak (2.7% vs 6.8%, P = 0.04), prolonged postoperative ileus (5.9% vs 14.2%, P < 0.01), and unplanned intubation (0% vs 2.3%, P = 0.02). Furthermore, SSIPK+ patients had shorter mean hospital length of stay (3.1 vs 5.4 d, P < 0.01) and had fewer unplanned readmissions (5.9% vs 14.6%, P < 0.001). There were no differences in rates of postoperative pneumonia, urinary tract infection, Clostridium difficile colitis, sepsis, or death. CONCLUSION Provision of a free-of-charge SSIPK is associated with higher patient compliance with preoperative instructions and significantly lower rates of surgical site infections, lower rates of prolonged postoperative ileus, and shorter hospital stays with fewer readmissions. Widespread utilization of such a bundle could therefore lead to significantly improved outcomes.

Introduction & Objectives: The Bosniak classification of renal cysts is commonly used by urologists and radiologists as an effective way to assess and evaluate cystic renal masses and decide clinical management. Although this classification scheme is based on computed tomographic (CT) criteria, the same approach may provide a useful framework for evaluation with magnetic resonance (MR) imaging and contrast-enhanced ultrasonography (CEUS). The aim of this study was to compare CT, MRI, and CEUS in characterization of complex renal cysts in the same series of patients. Materials & Methods: The records of patients having complex renal cysts evaluated with CT, MRI, and CEUS within a 6-months interval were considered. Inclusion criteria were at least an unenhanced and a contrast enhanced nephrographic acquisition at CT, at least T2-weighted, T1-weighted and contrast enhanced scans at MRI, and digital cine-clips available for review at CEUS. Images and clips were retrospectively evaluated by 2 blind independent readers to assigned a Bosniak score for the different techniques. This process yielded a total of 36 patients who met the inclusion criteria. ROC curve analysis was employed to assess the overall confidence for diagnosis of benign vs. malignant lesions. Reference procedure was surgery, or follow-up >3years. Results: Inter-reader agreement in assigning Bosniak score was good or very good (K values for CT, MRI, and CEUS 0.75, 0.86 and 0.79, respectively). When surgical vs. non-surgical lesions were considered, CT, MRI, and CEUS scores were equivalent in 83% of cases for reader1, and in 78% of cases for reader2. ROC curve analysis showed similar diagnostic performance for the 3 techniques (reader1 AUC=0.89, 0.96, 0.93 for and CT, MRI, CEUS, respectively; reader2 AUC=0.92, 0.98, 0.88, respectively). Conclusions: Although differences exist, CEUS, CT, and MRI are basically equivalent in characterization the majority of complex renal cysts. Concordance rates were approximately 80% with weighted good to very good k values. Differences can be useful to differentiate benign from malignant lesions in equivocal cases.

Since its description in 1978, the ileal-pouch anal anastomosis (IPAA) has become the most commonly performed procedure for patients with ulcerative colitis requiring surgery. The earliest description of the IPAA included a three-limb “S” pouch with a hand-sewn pouch-anal anastomosis. Several years later, a two-limb “J” pouch was described, which, with the advent of the surgical stapler, became the procedure of choice due to its ease of construction. As practice patterns have changed over time, the optimal pouch configuration has been debated in the literature. Both the S-pouch and J-pouch configurations have well described functional and complication profiles. In this chapter, the literature comparing the complication rates and functional results of these pouches is reviewed. Specifically, we detail several studies examining complications such as pouch failure, pouchitis and mechanical obstruction, as well as functional outcomes such as stool frequency, incontinence, and the need for anti-diarrheal medications. Our analysis of the literature is followed by our recommendation on the optimal design for IPAA.

Recently, there has been a trend toward surgical management of internal intussusception despite an unclear correlation with constipation symptoms.This study characterizes constipation in patients with obstructed defecation syndrome and identifies whether internal intussusception or other diagnoses such as irritable bowel syndrome may be contributing to symptoms.Patients evaluated for obstructed defecation at a pelvic floor disorder center were studied from a prospectively maintained database. With the use of defecography, patients were classified by Oxford Rectal Prolapse Grade. Coexisting disorders such as enterocele, rectocele, and dyssynergia were also identified. The presence of irritable bowel syndrome was defined using Rome IV criteria, and constipation severity was quantified with the Varma constipation severity instrument.This study was conducted at a tertiary care university medical center (Massachusetts General Hospital).The study included 317 consecutive patients with defecography imaging and a completed constipation severity instrument survey from May 2007 to July 2016.The primary outcome measures were the Varma Constipation Severity Instrument overall score and obstructed defecation subscale score.Of 317 patients evaluated, 95 (30.0%) had no internal intussusception, 126 (39.7%) had intra-rectal intussusception, and 96 (30.3%) had intra-anal intussusception. There was no association between rising grade of internal intussusception and either overall constipation score or obstructed defecation subscale score. Irritable bowel syndrome was associated with an increase in overall constipation score and obstructed defecation subscale score (40.5 ± 13.6 vs 36.0 ± 15.1, p = 0.007, and 22.3 ± 5.8 vs 20.0 ± 6.6, p0.001). Multivariate regression found irritable bowel syndrome and dyssynergia to be associated with a significant increase in obstructed defecation subscale scores.The study was limited because it was an observational study from a single center.Patients referred for surgical management of obstructive defecation syndrome should be screened and treated for irritable bowel syndrome and dyssynergia before considering surgical intervention. See Video Abstract at http://links.lww.com/DCR/A782.

Despite clinical and technical advances, acute aortic dissection carries high operative mortality. This study was designed to establish whether this is influenced by institution and surgeon volume.Outcomes of 5,184 patients (mean age, 60.3 years; 65.9% male) diagnosed with acute aortic dissection from the Nationwide Inpatient Sample from 2003 to 2008 were analyzed with risk-adjustment for preoperative comorbidity using multivariate logistic regression analysis.Overall operative mortality was 21.6%, with similar preoperative patient risk profile across institutions and individual surgeons. A strong inverse relationship was observed between operative mortality and both institution and surgeon volume: surgeons who averaged less than 1 aortic dissection repair annually had a mean operative mortality of 27.5%, compared with 17.0% for those averaging 5 or more annually (odds ratio, 1.78; 95% confidence interval, 1.39 to 2.29; p0.001). This was similar to the relationship seen between institution volume and mortality: operative mortality was 27.4% in institutions performing 3 or fewer acute aortic dissections a year, compared with 16.4% in those performing more than 13 annually (p 0.001). Nationally, operative mortality decreased steadily from 23% in 1998-2000 to 19% in 2005-2008, with no significant decrease in patient risk profile.Patients undergoing emergency repair of acute aortic dissection by lower-volume surgeons and centers have approximately double the risk-adjusted mortality of patients undergoing repair by the highest volume care providers. Routine involvement, whenever feasible, of teams experienced in acute aortic dissection repair may be a strategy to reduce operative mortality and major morbidity.

Objectives The objective of this study was to investigate the impact of bilateral internal mammary artery (BIMA) on early outcomes after coronary artery bypass grafting. Design Retrospective database analysis. Setting US hospitals. Patients 1 526 360 patients (mean age 65 years, 73% male) from the Nationwide Inpatient Sample from 2002–2008 who underwent isolated coronary artery bypass grafting with at least one internal mammary artery. Interventions Single versus BIMA bypass grafting. Main outcome measures Inhospital mortality, deep sternal wound infection (DSWI). Results The rate of BIMA use was 3.9%. Use of BIMA was independently associated with slightly lower inhospital mortality (unadjusted rate 1.1% vs 1.7%, adjusted OR 0.86, 95% CI 0.79 to 0.93). The DSWI rate was 1.4%. The independent predictors of DSWI were female gender (OR 1.06), congestive heart failure (OR 6.22), chronic pulmonary disease (OR 1.57), obesity (OR 1.17), diabetes mellitus (OR 1.04; OR 1.51 with chronic complication) and chronic renal failure (OR 2.13; OR 2.63 with dialysis). The use of BIMA was not an independent predictor of DSWI (OR 1.03, 95% CI 0.96 to 1.10). BIMA was associated with higher incidence of DSWI in patients with chronic complications of diabetes mellitus (OR 1.90, 95% CI 1.51 to 2.41). Conclusions BIMA grafting is associated with increased risk of DSWI only in patients with severe, chronic diabetes. The incremental morbidity and mortality of DSWI does not justify denial of BIMA in the majority of patients.

Radial and longitudinal strain assessment in the carotid artery wall using speckle tracking

Procurement of a high number of progenitor cells is of primary interest in allogeneic PBSC transplantation. We have retrospectively compared toxicity, mobilization effect and progenitor cell yields of two different rhG-CSF schedules in 11 consecutive healthy individuals donating their PBSC. Five of them received rhG-CSF 16 micrograms/kg/d for 4 subsequent d in 2 divided subcutaneous injections (group A); similarly, 6 donors received rhG-CSF 10 micrograms/kg/d for 5 d (group B). The aphereses were started the last day of rhG-CSF treatment; 9 donors underwent 2 aphereses, one underwent 1 and another 3 procedures, always on subsequent days. Toxicity was mild, but moderate thrombocytopenia developed following apheretic collections, irrespective of rhG-CSF schedule. In all the donors WBC, as well as circulating CD34+ cells, CFU-GM, CFU-GEMM and BFU-E dramatically increased over the baseline values, peaking on d 5 or 6, with no statistical difference between the 2 groups for the height of the cell peaks. Also the peripheral lymphoid cell populations (CD3+, CD19+ and CD56+/CD3-) increased following the rhG-CSF administration. The number of MNC, CFU-GM, BFU-E, CFU-GEMM, as well as CD34+, CD3+, CD19+ and CD56+/CD3- cells collected by apheresis showed no statistical difference in the 2 groups. Overall, 8 of the 11 donors collected the target number of CD34+ cells > 4 x 10(6)/kg ideal recipient body weight with the first apheresis, with no difference between the 2 groups. Mobilization with rhG-CSF in healthy donors enables the collection of large number of progenitor cells with modest side effects. A schedule of 10 micrograms/kg for 5 d is as effective as 16 micrograms/kg for 4 d. A single apheresis would be enough in 80% of cases.

The aim of this study was to determine the effect of pulmonary artery catheterization on clinical outcomes after cardiac surgery in higher-risk patients.Retrospective national database analysis.U.S. hospitals.A weighted sample of 2,063,337 patients undergoing cardiac surgery identified from the Nationwide Inpatient Sample (NIS) from January 1, 2000 to December 31, 2010.Pulmonary artery catheterization.Compared to patients who did not receive a pulmonary artery catheter, those who did on the whole were on average slightly older (66.6±11.9 years v 65.5±12.8 years, p0.001), more likely to have pulmonary hypertension (7.5% v 5.1%, p0.001), chronic obstructive pulmonary disease (24.6% v 20.7%, p0.001), obesity (15.0% v 13.1%, p0.001), and chronic renal failure (10.9% v 9.2%, p0.001). In multivariate analysis, the risk of operative mortality in patients who underwent pulmonary artery catheterization was significantly higher than in those who did not (4.6% v 3.1%, p0.001), adjusted OR 1.34 (95% CI 1.26-1.43, p0.001). In propensity matched subgroup analysis operative mortality risk was higher in octogenarian patients (OR 1.24, p = 0.24), and patients with congestive heart failure (OR 1.39, p = 0.023) who underwent pulmonary artery catheterization. No significant difference in operative mortality was observed in low-risk patients according to whether or not they underwent pulmonary artery catheterization. The incidence of prolonged mechanical ventilation and length of stay30 days was higher in patients who underwent pulmonary artery catheterization in all subgroups.In contemporary practice pulmonary artery catheters do not appear to be associated with reductions in operative mortality or morbidity and are associated with increases in duration of ventilation and length of stay in the intensive care unit.

One hundred and one donors who had received filgrastim (rhG-CSF) for the purpose of donating either granulocytes or peripheral blood stem cells (PBSC) for their relatives more than 3 years ago were contacted. All donors had received daily rhG-CSF at a median dose of 16 microg/kg/day (range 3-16) for a median of 6 days (range 3-15 days). All collection procedures were completed and short-term side-effects of rhG-CSF were mild in the majority of the donors. At a median time interval of 43.13 months (range 35-73), the donors were contacted to assess whether adverse effects related to rhG-CSF administration had occurred. Prior to rhG-CSF two donors had cancer, one had a myocardial infarction, one was hepatitis C virus positive, one had a history of sinusitis, one had Graves' disease and two had arterial hypertension. None worsened with the rhG-CSF administration but the donor with a history of infarction had an episode of angina following apheresis, and the donor with Graves' disease had a stroke 15 months after rhG-CSF. Two pregnancies occurred after the rhG-CSF administration and one donor was 2-3 weeks pregnant during rhG-CSF treatment. Three pregnancies resulted in two normal births and one in a spontaneous abortion of a pregnancy which occurred more than 2 years following rhG-CSF. In the time following rhG-CSF administration two donors developed cancer (breast and prostate cancer) at a follow-up of 70 and 11 months, respectively. One donor developed lymphadenopathy 38 months after the rhG-CSF, which spontaneously resolved. Blood counts were obtained in 70 donors at a median follow up of 40.4 months (range 16.8-70.8). Hematocrit was 43% (median, range 36.8-48), white blood cells were 5.7 x 109/l (median, range 3-14), granulocytes 3.71 x 109/l (median, range 1. 47-10.36), lymphocytes 1.67 x 109/l (median, range 0.90-3.96), monocytes 0.46 x 109/l (median, range 0.07-0.87) and platelet counts were 193.0 x 109/l (median, range 175.0-240.0). This study indicates that short-term administration of rhG-CSF to normal donors for the purpose of mobilizing the PBSC or granulocytes appears safe and without any obvious adverse effects more than 3 years after the donation. Bone Marrow Transplantation (2000) 25, 85-89.

Objectives The objective of this study was to assess the impact of robotic approaches on outcomes of coronary bypass surgery. Design Retrospective national database analysis. Setting United States hospitals. Participants A weighted sample of 484,128 patients undergoing isolated coronary artery surgery identified from the Nationwide Inpatient Sample from 2008 through 2010. Interventions Robotically assisted coronary artery bypass surgery versus conventional bypass surgery. Measurements and Main Results Robotic approaches were used in 2,582 patients (0.4%). Patients undergoing robotic surgery were less likely to be female (odds ratio [OR] 0.71, 95% confidence interval [CI] 0.57-0.87), present with acute myocardial infarction (OR 0.53, 95% CI 0.38-0.73), or have cerebrovascular disease (OR 0.41, 95% CI 0.23-0.71) compared to patients undergoing conventional surgery. In 59% of robotic cases, a single bypass was performed, and 2 bypasses were performed in 25% of cases. After adjusting for comorbidity, reduced postoperative stroke (0.0% v 1.5%, p = 0.045) and transfusion (13.5% v 24.4%, p = 0.001) rates were observed in patients who underwent robotic single-bypass surgery compared to conventional surgery. In patients undergoing multiple bypass grafts, higher mortality (1.1% v 0.5%), and cardiovascular complications (12.2% v 10.6%) were observed when robotic assistance was used, but the differences were not statistically significant (p = 0.5). The mean number of robotic cases carried out annually at institutions sampled was 6. Conclusions Robotic assistance is associated with lower rates of postoperative complications in highly selected patients undergoing single coronary artery bypass surgery, but the benefits of this approach are reduced in patients who require multiple coronary artery bypass grafts.

ABCA12 mutations disrupt the skin barrier and cause harlequin ichthyosis. We previously showed Abca12(-/-) skin has increased glucosylceramide (GlcCer) and correspondingly lower amounts of ceramide (Cer). To examine why loss of ABCA12 leads to accumulation of GlcCer, de novo sphingolipid synthesis was assayed using [(14)C]serine labeling in ex vivo skin cultures. A defect was found in β-glucocerebrosidase (GCase) processing of newly synthesized GlcCer species. This was not due to a decline in GCase function. Abca12(-/-) epidermis had 5-fold more GCase protein (n = 4, P < 0.01), and a 5-fold increase in GCase activity (n = 3, P < 0.05). As with Abca12(+/+) epidermis, immunostaining in null skin showed a typical interstitial distribution of the GCase protein in the Abca12(-/-) stratum corneum. Hence, we tested whether the block in GlcCer conversion could be circumvented by topically providing GlcCer. This approach restored up to 15% of the lost Cer products of GCase activity in the Abca12(-/-) epidermis. However, this level of barrier ceramide replacement did not significantly reduce trans-epidermal water loss function. Our results indicate loss of ABCA12 function results in a failure of precursor GlcCer substrate to productively interact with an intact GCase enzyme, and they support a model of ABCA12 function that is critical for transporting GlcCer into lamellar bodies.

OBJECTIVES: The objective of this study was to compare the early outcomes of off-pump and on-pump surgeries in high-risk patient groups. METHODS: The outcomes of 83 914 high-risk patients undergoing off-pump or on-pump isolated coronary bypass surgery identified from the Nationwide Inpatient Sample from 2005 to 2010 were compared using propensity analysis. RESULTS: Off-pump surgery was associated with a significant reduction in stroke rates compared with on-pump surgery in propensitymatched patients ≥80 years (odds ratio [OR] 0.70, 95% confidence interval [CI] 0.52–0.93, P= 0.02), those with peripheral vascular disease (OR 0.53, 95% CI 0.36–0.77, P= 0.001) and those with aortic atherosclerosis (OR 0.30, 95% CI 0.13–0.72, P= 0.007). In these high-risk subgroups, off-pump surgery was associated with an absolute risk reduction in stroke rates of 0.5, 0.5 and 1.2%, respectively: the minimum number needed to treat to prevent one stroke is 200 patients. There was no significant difference in in-hospital mortality or the incidence of postoperative renal failure or respiratory failure between off-pump and on-pump surgeries in these patient subgroups, or in patients with preoperative renal failure, or chronic obstructive airways disease. CONCLUSIONS: High-risk patients undergoing coronary artery bypass surgery gain a short-term benefit from off-pump approaches due to a small absolute reduction in the risk of postoperative stroke.

The objective of this study was to quantify the impact of heparin-induced thrombocytopenia (HIT) on outcomes after cardiac surgery.Retrospective analysis of national database.United States hospitals.Patients identified from 186,771 discharge records undergoing cardiac surgery from the Nationwide Inpatient Sample between 2009 and 2010.None.Heparin-induced thrombocytopenia was diagnosed in 506 (0.3%), and secondary thrombocytopenia was diagnosed in 16,809 (8.7%). Operative mortality was 11.1% in patients with HIT compared to 4.5% for patients without thrombocytopenia (p0.001) and 4.0% for patients with a diagnosis of secondary thrombocytopenia (p0.001). After adjusting for baseline patient comorbidity, the strongest independent predictors of HIT in patients undergoing cardiac surgery were female gender (OR 1.4, 95% confidence interval [CI] 1.28-1.48), congestive heart failure (OR 1.8, 95% CI 1.71-1.98), cardiac insufficiency (OR 2.2, 95% CI 1.97-2.39), atrial fibrillation (OR 1.4, 95% CI 1.30-1.51), liver disease (OR 2.2, 95% CI 1.96-2.50), and chronic renal failure (OR 1.4, 95% CI 1.30-1.51). HIT was associated with significantly increased risk of major adverse postoperative outcomes including death (OR 1.5, 95% CI 1.3-1.7), stroke (OR 2.4, 95% CI 1.9-3.1), amputation (OR 7.46, 95% CI 4.0-14.0), and acute renal failure (OR 2.3, 95% CI 2.1-2.5), respiratory failure (OR 1.9, 95% CI 1.8-2.1), and need for tracheostomy (OR 2.7, 95% CI 2.3-3.1).Heparin-induced thrombocytopenia is associated with a 50% increase in early mortality, and most patients with this diagnosis experience major postoperative morbidity or functional deficits.

The incidence of colorectal cancer increases as age progresses. At present, elderly patients have received substandard cancer treatment not supported by “evidence.” Geriatric assessment should be performed preoperatively and selected elderly patients must be offered standard surgical treatment receiving the same complementary therapies as a younger patient. It should be stressed that elderly patients should not be deprived of their decision-making role. In our experience, more than 43% of patients with colorectal cancer are ≥70 years of age, and we believe that they should receive the same type of follow-up. This would allow for the detection and removal of polyps, treatment of malignant tumors, and psychological support similarly to younger patients. Significantly, in our experience, the incidence of reoperation for neoplastic disease is similar in the two patient populations.

Scrotal calcifications are commonly encountered in the clinical practice at ultrasound, and they may be occasionally identified also at CT and Rx ray examination performed for other purposes. Intra- or extra-testicular calcifications have different clinical relevance. Intratesticular calcifications are usually benign, but may also be found in tumors, or follow trauma, infarction, and inflammation. Testicular microlithiasis is increasingly encountered in otherwise healthy men. Currently, there is no evidence that it is either a premalignant condition or a causative agent for neoplasia, but a clear association exists between this condition, other testicular calcifications, and an increased risk of testicular malignancy. Extra-testicular calcifications are more frequent than intratesticular calcifications and are almost always benign. They include scrotal pearls, calcifications of the epididymis and appendages, and those involving the tunicae and the scrotal wall.

Oxidative stress has been suggested to play a main role in the pathogenesis of type 2 diabetes mellitus and its complications. As a consequence of this increased oxidative status a cellular adaptive response occurs requiring functional chaperones, antioxidant production and protein degradation. This study was designed to evaluate systemic oxidative stress and cellular stress response in patients suffering from type 2 diabetes and in age-matched healthy subjects. Systemic oxidative stress has been evaluated by measuring plasma reduced and oxidized glutathione, as well as pentosidine, protein carbonyls lipid oxidation products 4-hydroxy-2-nonenal and F2-isoprostanes in plasma, and lymphocytes, whereas the lymphocyte levels of the heat shock proteins (HSP) HO-1, Hsp72, Sirtuin-1, Sirtuin-2 and thioredoxin reductase-1 (TrxR-1) have been measured to evaluate the systemic cellular stress response. Plasma GSH/GSSG showed a significant decrease in type 2 diabetes as compared to control group, associated with increased pentosidine, F2-isoprostanes, carbonyls and HNE levels. In addition, lymphocyte levels of HO-1, Hsp70, Trx and TrxR-1 (P

Late onset of cutaneous fistulas associated with inguinal hernia repair represents an extremely rare complication that occurs especially after affixing a prosthesis. The authors report a case of a patient developing this complication after a hernia repair (Shouldice's technique), emphasize that the fistula appeared after more than 12 years (the longest interval reported in the literature), and explain how it resolved only with the surgical removal of the suture used for hernia repair. The authors emphasize the aetiology of this complication and stress that it can occur even after a hernia repair without prosthesis.

A 44-year-old woman with AML, while receiving a conditioning treatment with BU-CY for an allogeneic sibling transplant, developed septic shock with pulmonary embolism and heart failure. Conditioning was stopped at the end of the busulfan course and cyclophosphamide omitted. After antibiotics, dopamine and steroids the patient was allografted, using the donor's G-CSF-primed PBSC. She recovered her peripheral blood counts promptly and developed an acute GVHD grade II that responded to steroids. The DNA microsatellite analysis showed full donor engraftment up to a year from transplantation. This case suggests that the use of PBSC may facilitate engraftment in the absence of an effective immunosuppression during conditioning.

In their recent review of ablation options for atrial fibrillation, Pinho-Gomes et al. [1] omitted permanent pacemaker requirement as a complication of surgical ablation. In their series of 594 patients undergoing concomitant surgical ablation of atrial fibrillation, of whom 6.9% required permanent pacemakers postoperatively, Pecha et al. [2] identified biatrial lesion sets as a statistically significant risk factor for permanent pacemaker insertion after surgical ablation, confirming the findings of Soni et al. [3] in their series of 305 patients. We analysed 17 983 patients undergoing valve surgery with concomitant ablation identified from the Nationwide Inpatient Sample between 2002 and 2010. This administrative database is sponsored by the Agency for Healthcare Research and Quality, and contains information on all inpatient episodes in approximately one-fifth of US hospitals selected to provide a representative sample of national practice: the individual hospitals sampled vary each year. Pacemakers were implanted in 6.9% of patients undergoing valve surgery. After adjusting for baseline patient comorbidity, concomitant ablation procedure [odds ratio (OR) 1.31, 95% confidence interval (CI) 1.27–1.41] was one of the main independent predictors of permanent pacemaker implantation in patients undergoing valve surgery. In patients undergoing ablation, valve procedures associated with the greatest risk of permanent pacemaker requirement were mitral replacement (OR 1.37, 95% CI 1.2–1.67) and combined mitral replacement and tricuspid valve surgery (OR 1.79, 95% CI 1.69– 2.77) (isolated aortic valve replacement was used as the reference). Mitral repair was less likely to result in permanent pacemaker (OR 0.84, 95% CI 0.72–0.98), unless concomitant tricuspid surgery was undertaken (OR 1.79, 95% CI 1.37–2.33). These surgical predictors of permanent pacemaker requirement are consistent with data from a previous single-centre series [4], and the overall incidence of pacemaker insertion we observed is similar to that reported in an analysis of the Society of Thoracic Surgeons database [5]. The main limitation of the Nationwide Inpatient Sample in this context is that it does not provide information on the ablation lesion sets employed, or provide sufficient data to adjust for other potential confounding variables. However, this analysis indicates that patients undergoing concomitant surgical ablation at the time of valve surgery have a significantly increased risk of postoperative permanent pacemaker requirement in comparison with those who do not undergo concomitant ablation.

In multiple myeloma (MM), allogeneic bone marrow transplantation may produce complete and durable responses, but is accompanied by significant transplant-related mortality (TRM). To assess feasibility and possible advantages offered by the use of allogeneic, growth factor-primed PBSC instead of marrow, we analyzed the data of 10 patients with MM (IgG = 6, IgA = 1, BJ = 2, non-secreting = 1; stage II = 1, stage III = 8, plasma-cell leukemia = 1) who received an allogeneic transplant with PBSC. Their age ranged between 35 and 53 years (median 45). All were HLA-identical to their sibling donors. Prior to allograft, six patients received standard-dose chemotherapy (DAV or CY-Dexa) and four a sequential intensified scheme with autologous PBSC support. At the time of transplantation, three patients were in CR, three in PR, three had refractory disease, one progressive disease. Patients were conditioned with busulfan-melphalan (n = 9) or busulfan-cyclophosphamide (n = 1), and were allografted with unmanipulated PBSC obtained by apheresis after treatment with G-CSF alone (n = 6) or GM-CSF followed by G-CSF (n = 4). All patients engrafted, with 0.5 x 10(9)/l PMN and 50 x 10(9)/l platelets on (median) day 13. Four patients hador =grade II acute GVHD (grade II in 3, grade III in 1). Following allograft, CR was achieved in 71% patients. Eight are currently alive, with six in CR at a median of 18.5 months (range 7-28) from the transplant. Two patients died, 1 and 4 months from the allograft, respectively, and one is alive with progression. A PCR analysis of IgH rearrangement showed that residual disease was no more molecularly detectable in four out of seven evaluated patients following allograft. The results suggest that PBSC may improve the therapeutic efficacy of allogeneic transplant in MM, not only by a reduction of TRM but also by an improvement of rate and quality of response.

Waldenström's macroglobulinemia (WM) is an incurable disorder of B cells. Following occasional reports of response to alpha interferon (IFN) and in view of its effectiveness in hairy cell leukemia, we tested this agent in a relatively large group (n = 88) of patients who had an IgM monoclonal component (MC) greater than 10 g/l. Thirty eight patients had a MC30 g/l and were classified as Waldenström's macroglobulinemia (WM), while fifty had either WM in an early stage or an IgM monoclonal gammopathy of undeterminated significance (all of them operationally classified as IgM-MGUS). All patients received IFN 3 MU/day for one month and then 3 times/week. Response to treatment was mainly based on MC reduction in two consecutive determinations (50%: major response; 25-50%: minor response). Of 36 evaluable WM patients, 12 had a major and 6 a minor response; of 41 evaluable IgM-MGUS patients, 2 had a major and 6 a minor response. In WM patients with a major response, MC reduction was associated with disappearance of hyperviscosity symptoms, raised Hb level and reduced bone marrow lymphoplasmacytosis. At the dose used, tolerance was excellent in the majority of patients; only 15% withdrew from the study due to side effects. Although single cases and very small series have already been reported, no large study collecting quantitative data on the effects of alpha IFN in WM has been published so far. Our results suggest that IFN treatment is not indicated for patients with a low monoclonal component, while it is of clinical benefit in about 50% of patients with IgM30 g/l.

Im Rahmen der Schwangerschaft kommt es zu vielfaltigen Veranderungen und Anpassungsvorgangen der Herz-Kreislaufsystems und der Hamostase, z.B. Abnahme des peripheren Gefaswiderstandes veranderte Durchblutung peripherer Organe.