The value of proximal fecal diversion for patients undergoing colectomies is an ongoing debate. Previous studies have shown a benefit in decreased anastomotic leak rates and mitigation of the ...morbidity of a leak, especially in high-risk populations. However, more recent data suggests increased morbidity with fecal diversion, creating a complication with an unknown degree of anastomotic leak reduction. Therefore, we aimed to determine the impact on morbidity of a diverting loop ileostomy (DLI) in patients with a high risk of anastomotic leak.
The ACS-NSQIP database was queried (via CPT code) for adult patients (age ≥18 years) who underwent a colectomy only or colectomy with ileostomy (CWI) between Jan 2013 and Dec 2016. We compared thirty-day outcomes between a 3:1 propensity-matched colectomy only group to patients who had a CWI. We used risk factors for anastomotic leak as a basis of our propensity match which included preoperative smoking, steroid use, preoperative weight loss, preoperative transfusion, hypoalbuminemia, and leukocytosis; intraoperative match variables included indication for surgery, wound class, duration of operation, primary CPT code, elective vs. emergent, and inpatient vs. outpatient surgery.
We identified 39,588 patients from the NSQIP database who had a colectomy only or a CWI. The colectomy only group was older (age 63 vs 52 years p < 0.001), overweight (BMI 34 vs 26.7, p < 0.001), more likely to be diabetic (16% vs 9.5%, p < 0.001) and hypertensive (49.3% vs 31.4%). However, the CWI group had higher steroid use (36.8% vs 10%, p < 0.001), preoperative sepsis (13.2% vs 2.5%, p < 0.001), smoking rate (25.7% vs 15.4%, p < 0.001), and preoperative weight loss (12.5% vs 4.9%, p < 0.001). Our propensity analysis matched 2274 colectomy only patients and 758 CWI patients. Baseline demographics were similar between groups. While the mortality rate was similar between groups (1.5% vs 1.8%, p = 0.8), CWI patients had longer length of stay (median 8 vs 7 days, p < 0.001), higher renal injury rates (3.2% vs 0.9%, p < 0.001), higher readmission rates (18.8% vs 11%, p < 0.001) and higher overall NSQIP morbidity (44.5% vs 37.6%, p = 0.001). The anastomotic leak rate was 3.8% in the CWI group and 5.1% in the colectomy only group (p = 0.09).
Significant thirty-day morbidity exists with a diverting ileostomy among high-risk colectomy patients with minimal benefit in anastomotic leak rates.
•Proximal fecal diversion is controversial among patients who undergo colectomy.•Patients at high risk for anastomotic leak commonly receive proximal diversion.•Diversion is associated with significant morbidity.•Diversion is not associated with significant reduction in anastomotic leak.
Stock prices move together more in poor economies than in rich economies. This finding is not due to market size and is only partially explained by higher fundamentals correlation in low-income ...economies. However, measures of property rights do explain this difference. The systematic component of returns variation is large in emerging markets, and appears unrelated to fundamentals co-movement, consistent with noise trader risk. Among developed economy stock markets, higher firm-specific returns variation is associated with stronger public investor property rights. We propose that strong property rights promote informed arbitrage, which capitalizes detailed firm-specific information.
Objective Little is known about the developmental trajectory of cortisol levels in preterm infants after hospital discharge. Study design In a cohort of 225 infants (gestational age at birth <33 ...weeks) basal salivary cortisol levels were compared in infants born at extremely low gestational age (ELGA, 23-28 weeks), very low gestational age (29-32 weeks), and term (37-42 weeks) at 3, 6, 8, and 18 months corrected age (CA). Infants with major neurosensory or motor impairment were excluded. Results At 3 months CA, salivary cortisol levels were lower in both preterm groups compared with the term infants ( P = .003). Conversely, at 8 and 18 months CA, the ELGA infants had significantly higher basal cortisol levels than the very low gestational age and term infants ( P = .016 and P = .006, respectively). Conclusions In ELGA infants, the shift from low basal cortisol levels at 3 months to significantly high levels at 8 and 18 months CA suggests long-term “resetting” of endocrine stress systems. Multiple factors may contribute to these higher cortisol levels in the ELGA infants, including physiological immaturity at birth, cumulative stress related to multiple procedures, and mechanical ventilation during lengthy hospitalization. Prolonged elevation of the cortisol “set-point” may have negative implications for neurodevelopment and later health.
We report here that butyrate, a naturally occurring fatty acid commonly used as a nutritional supplement and differentiation agent, greatly enhances the efficiency of induced pluripotent stem (iPS) ...cell derivation from human adult or fetal fibroblasts. After transient butyrate treatment, the iPS cell derivation efficiency is enhanced by 15- to 51-fold using either retroviral or piggyBac transposon vectors expressing 4 to 5 reprogramming genes. Butyrate stimulation is more remarkable (>100- to 200-fold) on reprogramming in the absence of either KLF4 or MYC transgene. Butyrate treatment did not negatively affect properties of iPS cell lines established by either 3 or 4 retroviral vectors or a single piggyBac DNA transposon vector. These characterized iPS cell lines, including those derived from an adult patient with sickle cell disease by either the piggyBac or retroviral vectors, show normal karyotypes and pluripotency. To gain insights into the underlying mechanisms of butyrate stimulation, we conducted genome-wide gene expression and promoter DNA methylation microarrays and other epigenetic analyses on established iPS cells and cells from intermediate stages of the reprogramming process. By days 6 to 12 during reprogramming, butyrate treatment enhanced histone H3 acetylation, promoter DNA demethylation, and the expression of endogenous pluripotency-associated genes, including DPPA2, whose overexpression partially substitutes for butyrate stimulation. Thus, butyrate as a cell permeable small molecule provides a simple tool to further investigate molecular mechanisms of cellular reprogramming. Moreover, butyrate stimulation provides an efficient method for reprogramming various human adult somatic cells, including cells from patients that are more refractory to reprogramming.
Microarray technology is a powerful tool for measuring RNA expression for thousands of genes at once. Various studies have been published comparing competing platforms with mixed results: some find ...agreement, others do not. As the number of researchers starting to use microarrays and the number of cross-platform meta-analysis studies rapidly increases, appropriate platform assessments become more important. Here we present results from a comparison study that offers important improvements over those previously described in the literature. In particular, we noticed that none of the previously published papers consider differences between labs. For this study, a consortium of ten laboratories from the Washington, DC-Baltimore, USA, area was formed to compare data obtained from three widely used platforms using identical RNA samples. We used appropriate statistical analysis to demonstrate that there are relatively large differences in data obtained in labs using the same platform, but that the results from the best-performing labs agree rather well.
In the field of hernia surgery, there have been many advances in techniques that have provided the surgeon with a variety of options to repair the difficult abdominal wall hernia. Regardless of the ...technique, the ultimate goal was to provide a tension-free repair, which attempts to approximate the midline while returning abdominal wall musculature to its normal anatomic position, thus providing the patient with both a cosmetic and durable result with or without the use of a prosthetic reinforcement. Component separation techniques have been widely popularized as techniques to repair complex hernias and are frequently categorized based upon the anatomic location of the myofascial release. CSTs are generally categorized as either an anterior component separation or posterior component separation based upon the surgical approach to the abdominal wall musculature. This report objectively outlines the various techniques of component separation and specifically compares the outcomes among techniques to facilitate decision making in abdominal wall reconstruction.
Prenatal alcohol exposure (PAE) and early-life adversity (ELA) both negatively impact social neurobehavioral development, including social recognition memory. Importantly, while individuals with PAE ...are more likely to experience ELA, relatively few studies have assessed the interaction of these two early insults on adolescent social behavior development. Here, we combine animal models of PAE and ELA to investigate both their unique and interactive effects on social neurobehavioral function in early and late adolescent male and female rats. Behavioral testing was followed by assessment of hypothalamic expression of oxytocin (OT) and vasopressin (AVP), key neuropeptides in the regulation of social behavior. Our results indicate that PAE and ELA have unique sex- and age-specific effects on social recognition memory and OT/AVP expression, with more pronounced neurobehavioral changes observed in males than in females in both early and late adolescence. Specifically, ELA impaired social recognition in early adolescent females regardless of prenatal treatment, while males showed deficits in both early and late adolescence in response to unique and interactive effects of PAE and ELA. Neurobiological data suggest that these perinatal insults differentially impact the OT and AVP systems in a sexually dimorphic manner, such that the OT system appears to be particularly sensitive to PAE in males while the AVP system appears to be more vulnerable to ELA in females. Taken together, our data provide novel insight into how the early postnatal environment may mediate outcomes of PAE as well as the power of animal models to interrogate the relationship between these pre- and postnatal insults.
•Prenatal alcohol exposure (PAE) & early-life adversity (ELA) effects on social discrimination depend on sex and testing age.•PAE impaired social discrimination abilities in male but not female adolescent rats.•ELA impaired social discrimination in both male and female adolescent rats.•PAE attenuated oxytocin expression in adolescent male and female rats.•ELA potentiated vasopressin expression in adolescent female rats.
Acute stress impairs memory retrieval and facilitates the induction of long-term depression (LTD) in the hippocampal CA1 region of the adult rodent brain. However, whether such alterations in ...synaptic plasticity cause the behavioral effects of stress is not known. Here, we report that two selective inhibitors of the induction or expression of stress-enabled, N-methyl-D-aspartate receptor-dependent hippocampal LTD also block spatial memory retrieval impairments caused by acute stress. Additionally, we demonstrate that facilitating the induction of hippocampal LTD in vivo by blockade of glutamate transport mimics the behavioral effects of acute stress by impairing spatial memory retrieval. Thus, the present study demonstrates that hippocampal LTD is both necessary and sufficient to cause acute stress-induced impairment of spatial memory retrieval and provides a new perspective from which to consider the nature of cognitive deficits in disorders whose symptoms are aggravated by stress.
Background
Ventral hernia repair is typically performed via a transabdominal approach and the peritoneal cavity is opened and explored. Totally extraperitoneal ventral hernia repair (TEVHR) ...facilitates dissection of the hernia sac without entering the peritoneal cavity. This study evaluates our experience of TEVHR, addressing technique, decision-making, and outcomes.
Methods
This is an IRB-approved retrospective review of open TEVHR performed between January 2012 and December 2016. Medical records were reviewed for patient demographics, operative details, postoperative outcomes, hospital readmissions, and reoperations.
Results
One hundred sixty-six patients underwent TEVHR (84 males, 82 females) with a mean BMI range of 30–39. Eighty-six percent of patients underwent repair for primary or first-time recurrent hernia, and 89% CDC wound class I. Median hernia defect size was 135 cm
2
. Hernia repair techniques included Rives-Stoppa (34%) or transversus abdominis release (57%). Median operative time was 175 min, median blood loss 100 mL, and median length of stay 4 days. There were no unplanned bowel resections or enterotomies. Four cases required intraperitoneal entry to explant prior mesh. Wound complication rate was 27%: 9% seroma drainage, 18% superficial surgical site infection (SSI), and 2% deep space SSI. Five patients (3%) required reoperation for wound or mesh complications. Over the study, four patients were hospitalized for postoperative small bowel obstruction and managed non-operatively. Of the 166 patients, 96%, 54%, and 44% were seen at 3-month, 6-month, and 12-month follow-ups, respectively. Recurrences were observed in 2% of patients at 12-month follow-up. One patient developed an enterocutaneous fistula 28 months postoperatively.
Conclusions
TEVHR is a safe alternative to traditional transabdominal approaches to ventral hernia repair. The extraperitoneal dissection facilitates hernia repair, avoiding peritoneal entry and adhesiolysis, resulting in decreased operative times. In our study, there was low risk for postoperative bowel obstruction and enterotomy. Future prospective studies with long-term follow-up are required to draw definitive conclusions.
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