bluuebunny/crossref_metadata_2025 huggingface dataset:
Short Sleep Duration After Hospital Evaluation for Acute Coronary Syndrome Is Associated With Increased Risk of 6-Month Readmission
Authors: Romero Emily K. , Abdalla Marwah , Thanataveerat Anusorn , Alcantara Carmela , Kronish Ian M. , Edmondson Donald , Shechter Ari
Published: October 2019

Objective

Hospital readmission after acute coronary syndrome (ACS) is associated with worsened patient outcomes and financial burden. Short sleep duration is a risk factor for cardiovascular events and may therefore represent a behavioral factor that increases risk of adverse posthospitalization outcomes. This study examined whether short sleep duration in the month after hospital evaluation for ACS is associated with 6-month all-cause emergency department (ED) and hospital readmission.

Methods

The current analyses entail a secondary analysis of a larger prospective observational cohort study. Sleep duration during the month after hospital evaluation for ACS was assessed subjectively and dichotomized as short (<6 hours) or not short (≥6 hours). A Cox proportional hazards model was used to assess the association between short sleep duration during the month after ACS hospital evaluation and 6-month all-cause ED/hospital readmission.

Results

A total of 576 participants with complete data were included in analyses. Approximately 34% of participants reported short sleep duration during the month after ACS evaluation. Short sleep duration was significantly associated with 6-month all-cause ED/hospital readmission (hazard ratio = 2.03; 95% confidence interval = 1.12–3.66) in the model adjusted for age, sex, race/ethnicity, clinical severity, cardiac and renal markers, depression, acute stress, and including a sleep duration by ACS status interaction.

Conclusions

Short sleep duration after ACS hospital evaluation is prevalent and is associated with increased risk of all-cause readmission within 6 months of discharge. Current findings suggest that short sleep duration is an important modifiable behavioral factor to consider after hospital evaluation for ACS.
Emotion Regulation and Immune Functioning During Grief: Testing the Role of Expressive Suppression and Cognitive Reappraisal in Inflammation Among Recently Bereaved Spouses
Authors: Lopez Richard B. , Brown Ryan L. , Wu E-Lim Lydia , Murdock Kyle W. , Denny Bryan T. , Heijnen Cobi , Fagundes Christopher
Published: October 2019

Objective

Losing a spouse is a distressing life event that can negatively affect both mental and physical health. Stress-induced health consequences often include increased risk of cardiovascular disease and altered immune system functioning marked by increased inflammation. Here, we sought to identify individual difference factors that covary with problematic inflammatory outcomes.

Method

We measured recently bereaved spouses’ (n= 99) propensity to use emotion regulation strategies and peripheral inflammation, as measured by levels of proinflammatory cytokines after ex vivo stimulation of peripheral leukocytes with T-cell agonists. Specifically, we measured participants’ use of cognitive reappraisal, an adaptive emotion regulation strategy in many contexts, and expressive suppression, a less adaptive emotion regulation strategy that involves actively inhibiting emotions after already experiencing them.

Results

Bereaved spouses who self-reported frequently using expressive suppression as an emotion regulation strategy tended to have a more pronounced inflammatory response, as indexed by higher levels of a composite cytokine index consisting of interleukin (IL) 17A, IL-2, IL-6, tumor necrosis factor α, and interferon-γ (b= 0.042), as well as tumor necrosis factor α (b= 0.083) and interferon-γ (b= 0.098) when analyzed individually. Notably, these associations were observed in both unadjusted and adjusted models, with the latter including known covariates of inflammation and other potential confounding variables.

Conclusions

These findings suggest that bereaved spouses’ use of emotion regulation strategies is associated with altered immune functioning, and such a link may be an important biological pathway by which interventions targeting affect may improve immune system–related health outcomes.
Plasma tissue factor and immune activation are associated with carotid intima–media thickness progression in treated HIV infection
Authors: Hsu Denise C. , Ma Yi Fei , Narwan Amrit , Rahalkar Smruti , Rupert Adam , Scherzer Rebecca , Mills Claire , Deeks Steven , Sereti Irini , Hsue Priscilla Y.
Published: October 2019

Objectives:

We evaluated the roles of biomarkers of immune activation with carotid intima–media thickness (CIMT) progression in treated HIV infection.

Design:

Longitudinal observational study of 118 treated and virologically suppressed individuals.

Methods:

We measured biomarkers of immune activation at baseline using cryopreserved samples. CIMT was measured at baseline and longitudinally using high-resolution ultrasound. Linear regression was used to estimate biomarker associations with CIMT progression, and logistic regression was used to model plaque progression.

Results:

The median duration of follow-up was 2.0 years. The median annual rate of change in mean CIMT was 6.0%. Rates of progression were more rapid in the bifurcation (5.6%/year,P = 0.006) and internal (6.5%/year,P = 0.0008) than common CIMT (4.3%/year). Incident plaque occurred in 13 of the 52 individuals without baseline plaque. In multivariable adjusted analysis, plasma tissue factor and monocyte chemoattractant protein-1 were associated with more rapid common CIMT progression (0.058 mm/year,P = 0.0004 and 0.067 mm/year,P = 0.017; all estimates per doubling). CD8+T-cell count and percentage of HLA-DR+CD38+CD8+T cells were associated with more rapid internal CIMT progression (0.10 mm/year,P = 0.008 and 0.054 mm/year,P = 0.045). CD8+T-cell count was also associated with 0.068 mm/year more rapid mean CIMT progression (P = 0.011). Each 10% increase in CD4+T-cell count at baseline was associated with a 34% reduced odds of plaque progression (P = 0.018).

Conclusion:

Residual immune activation and plasma tissue factor are independently associated with CIMT progression in treated HIV infection. Interventions targeting coagulation and inflammatory pathways to reduce cardiovascular disease risk in HIV merit additional investigations.
Impact of immediate initiation of antiretroviral therapy on HIV patient satisfaction
Authors: Ogbuoji Osondu , Geldsetzer Pascal , Wong Cebele , Khan Shaukat , Mafara Emma , Lejeune Charlotte , Walsh Fiona , Okello Velephi , Bärnighausen Till
Published: October 2019

Objectives:

Immediate ART (or early access to ART for all, EAAA) is becoming a national policy in many countries in sub-Saharan Africa. It is plausible that the switch from delayed to immediate ART could either increase or decrease patient satisfaction with treatment. A decrease in patient satisfaction would likely have detrimental consequences for long-term retention and adherence, in addition to the value lost because of the worsening patient experience itself. We conducted a pragmatic stepped-wedge cluster-randomized controlled trial (SW-cRCT) to determine the causal impact of immediate treatment for HIV on patient satisfaction.

Design:

This seven-step SW-cRCT took place in 14 public-sector health facilities in Eswatini's Hhohho region, from September 2014 to August 2017.

Methods:

During each step of the trial, we randomly selected days for data collection at each study facility. During these days, a random sample of HIV patients were selected for outcome assessment. In total, 2629 patients provided data on their overall patient satisfaction and satisfaction with the following four domains of the patient experience using a five-point Likert scale: wait time, consultation time, involvement in treatment decisions, and respectful treatment. Higher values on the Likert scale indicated lower patient satisfaction. We analyzed the data using a multilevel ordered logistic regression model with individuals at the first level and health facilities at the second (cluster) level.

Results:

The proportional odds ratio (OR) comparing EAAA to control was 0.91 (95% CI 0.66–1.25) for overall patient satisfaction. For the specific domains of the patient experience, the ORs describing the impact of EAAA on satisfaction were 1.04 (95% CI 0.61–1.78) for wait time, 0.90 (95% CI 0.62–1.31) for involvement in treatment decisions, 0.86 (95% CI 0.61–1.20) for consultation time, and 1.35 (95% CI 0.93–1.96) for respectful treatment. These results were robust across a wide range of sensitivity analyses. Over time – and independent of EAAA – we observed a worsening trend for both overall patient satisfaction and satisfaction in the four domains of the patient experience we measured.

Conclusion:

Our findings support the policy change from delayed to immediate ART in sub-Saharan Africa. Immediate (versus delayed) ART in public-sector health facilities in Eswatini had no effect on either overall patient satisfaction or satisfaction with four specific domains of the patient experience. At the same time, we observed a strong secular trend of decreasing patient satisfaction in both the intervention and the control arm of the trial. Further implementation research should identify approaches to ensure high patient satisfaction as ART programs grow and mature.
Development and validation of the first point-of-care assay to objectively monitor adherence to HIV treatment and prevention in real-time in routine settings
Authors: Gandhi Monica , Wang Guohong , King Roger , Rodrigues Warren C. , Vincent Michael , Glidden David V. , Cressey Tim R. , Bacchetti Peter , Spinelli Matthew A. , Okochi Hideaki , Siriprakaisil Oraphan , Klinbuayaem Virat , Mugo Nelly R. , Ngure Kenneth , Drain Paul K. , Baeten Jared M.
Published: October 2019

Objective:

HIV prevention and treatment studies demonstrate that pharmacologic adherence metrics are more accurate than self-report. Currently available metrics use liquid-chromatography/tandem-mass-spectrometry (LC-MS/MS), which is expensive and laboratory-based. We developed a specific and sensitive antibody against tenofovir, the backbone of treatment and prevention, but conversion to a lateral flow assay (LFA) – analogous to a urine pregnancy test – is required for point-of-care testing. We describe the development of the first LFA to measure antiretroviral adherence in real-time.

Methods:

Previous work in a directly observed therapy study of providing tenofovir disoproxil fumarate (TDF) to HIV-noninfected volunteers at various simulated adherence patterns defined the appropriate cut-off for the LFA (1500 ng tenofovir/ml urine). We developed the LFA using a sample pad for urine; a conjugate pad coated with TFV-specific antibodies conjugated to colloidal gold nanoparticles; a nitrocellulose membrane striped with tenofovir-antigen (test line) and a control line; with an absorbent pad to draw urine across the reaction membrane.

Results:

We tested 300 urine samples collected from the directly observed therapy study by this LFA and the gold-standard method of LC-MS/MS. The LFA demonstrated 97% specificity (95% CI 93–99%) and 99% sensitivity (94–100%) compared with LC-MS/MS. The LFA accurately classified 98% of patients who took a dose within 24 h as adherent.

Conclusion:

We describe the development and validation of the first point-of-care assay to measure short-term adherence to HIV prevention and treatment in routine settings. The assay is low-cost, easy-to-perform and measures the breakdown product (tenofovir) of both TDF and tenofovir alafenamide (TAF). This assay has the potential to improve HIV and PrEP outcomes worldwide by triggering differentiated service delivery with further study merited.
Cytomegalovirus-vectored vaccines for HIV and other pathogens
Authors: Barry Peter A. , Deere Jesse D. , Yue Yujuan , Chang William W.L. , Schmidt Kimberli A. , Wussow Felix , Chiuppesi Flavia , Diamond Don J. , Sparger Ellen E. , Walter Mark R. , Hartigan-O’Connor Dennis J.
Published: October 2019

The use of cytomegalovirus (CMV) as a vaccine vector to express antigens against multiple infectious diseases, including simian immunodeficiency virus, Ebola virus, plasmodium, and mycobacterium tuberculosis, in rhesus macaques has generated extraordinary levels of protective immunity against subsequent pathogenic challenge. Moreover, the mechanisms of immune protection have altered paradigms about viral vector-mediated immunity against ectopically expressed vaccine antigens. Further optimization of CMV-vectored vaccines, particularly as this approach moves to human clinical trials will be augmented by a more complete understanding of how CMV engenders mechanisms of immune protection. This review summarizes the particulars of the specific CMV vaccine vector that has been used to date (rhesus CMV strain 68-1) in relation to CMV natural history.
Immune checkpoint inhibitors in people living with HIV: what about anti-HIV effects?
Authors: Abbar Baptiste , Baron Marine , Katlama Christine , Marcelin Anne-Geneviève , Veyri Marianne , Autran Brigitte , Guihot Amélie , Spano Jean-Philippe
Published: October 2019

Immune checkpoint inhibitors (ICPi) have shown major therapeutic successes when used in various cancers. In the HIV field a double benefit of such ICPi should result from their dual ability to restore in-vitro HIV-specific CD8+ T-cell functions and to enhance HIV production from reservoir cells, thus fulfilling the goals of the ‘shock and kill’ concept proposed as an HIV cure therapeutic strategy. We conducted a systematic review to identify studies reporting the tolerance profile of ICPi and their effects on HIV plasma loads (pVL), CD4+ cell count, HIV reservoirs (cell-associated HIV-DNA) and/or HIV-specific CD8+ T cells in PLWH. Thirty-one articles were included for a total 176 participants. Twelve percent of the participants experienced severe adverse events and 49% nonsevere adverse events. pVL remained stable in 91.9% participant, showed increases in 5.8% participant, and decreases in 2.3%. CD4+ cell count remained stable in 60.7% participants, showed increases in 24.6%, and decreases in 14.7%. Regarding ICPi effects on HIV-DNA and HIV-specific immunity, we identified three distinct profiles: profile I, transient pVL increases followed by a boost in HIV-specific CD8+ T cells concomitant to a decrease in HIV-DNA, reported in one participant. Profile II: increase in HIV-specific CD8+ T cells without changes in pVL or HIV-DNA, reported in three participants. III: no effect, reported in five participants. In conclusion, the clinical, virological and immunological safety profiles of ICPi reported in about 200 PLWH appear to be favorable but there are still modest results in terms of HIV cure strategy.
Comparison of guidelines for HIV viral load monitoring among pregnant and breastfeeding women in sub-Saharan Africa
Authors: Lesosky Maia , Raboud Janet M. , Glass Tracy , Brummel Sean S. , Ciaranello Andrea L. , Currier Judith S. , Essajee Shaffiq , Havlir Diane V. , Koss Catherine A. , Ogwu Anthony , Shapiro Roger L. , Abrams Elaine J. , Myer Landon
Published: October 2019

Background:

Intensified viral load monitoring for pregnant and breastfeeding women has been proposed to help address concerns around antiretroviral therapy (ART) adherence, viraemia and transmission risk, but there have been no systematic evaluations of existing policies.

Methods:

We used an individual Monte Carlo simulation to describe longitudinal ART adherence and viral load from conception until 2 years’ postpartum. We applied national and international guidelines for viral load monitoring to the simulated data. We compared guidelines on the percentage of women receiving viral load monitoring and the percentage of women monitored at the time of elevated viral load.

Results:

Coverage of viral load monitoring in pregnancy and breastfeeding varied markedly, with between 14% and 100% of women monitored antenatally and 38–98% monitored during breastfeeding. Specific recommendations for testing at either a fixed gestation or a short, fixed period after ART initiation achieved more than 95% testing in pregnancy but this was much lower (14–83%) among guidelines with no special stipulations. By the end of breastfeeding, only a small proportion of simulated episodes of elevated viral load more than 1000 copies/ml were successfully detected by monitoring (range, 20–50%).

Discussion:

Although further research is needed to understand optimal viral load frequency and timing in this population, these results suggest that current policies yield suboptimal detection of elevated viral load in pregnant and breastfeeding women.
CD4+CD19+ conjugates favor HIV-1 infection and latency during chronic HIV-1 infection
Authors: Zhang He-Qian , Xia Peng , Huang Hui-Huang , Zhang Chao , Song Jin-Wen , Jin Lei , Jiao Yan-Mei , Shi Ming , Zhang Ji-Yuan , Wang Fu-Sheng
Published: October 2019

Objective:

CD4+CD19+ conjugates play an important role in regulating antibody responses and follicular helper T cells development in animal models. However, little is known regarding the characteristic of CD4+CD19+ conjugates in humans with chronic HIV-1 infection.

Methods:

The numbers of CD4+CD19+ conjugates were counted in 86 HIV-1-infected patients, including 66 typical progressors and 20 complete responders. CD4+CD19+ conjugates were sorted by flow cytometry and dissociated into CD4+ T singlets and CD19+ B singlets. The phenotypes of these cells were analyzed in both typical progressors and complete responders, and the levels of HIV-1 DNA in CD4+CD19+ conjugates were measured in 10 complete responders.

Results:

We identified CD4+CD19+ cells as one type of T–B conjugate in peripheral blood, and the numbers and percentages of CD4+CD19+ conjugates decreased with HIV-1 disease progression. Phenotypic analysis showed CD4+CD19+ conjugates expressed higher levels of surface CD32. mRNA analysis found that the mRNA levels for CD32b were significantly higher compared with CD32a in CD4+CD19+ conjugates. Further analysis found that CD4+CD19+ conjugates expressed higher levels of CCR7 and CXCR5 than CD4+ T and CD19+ B singlets. A virus infectivity assay showed that CD4+CD19+ conjugates expressed higher levels of HIV-1-p24Gag than CD4+CD19− cells. CD4+CD19+ conjugates in lymph node from typical progressors expressed higher levels of HIV-1-p24Gag than CD4+CD19+ conjugates in respective peripheral blood. Importantly, CD4+CD19+ conjugates from complete responders contained higher levels of HIV-1 DNA than total CD4+ T cells.

Conclusion:

Our study indicates that CD4+CD19+ conjugates actively participate in HIV-1 infection and latency, and may serve as a new cellular target to eliminate latency.
Plasma inflammatory biomarkers link to diffusion tensor imaging metrics in virally suppressed HIV-infected individuals
Authors: Chang Kevin , Premeaux Thomas A. , Cobigo Yann , Milanini Benedetta , Hellmuth Joanna , Rubin Leah H. , Javandel Shireen , Allen Isabel , Ndhlovu Lishomwa C. , Paul Robert , Valcour Victor
Published: October 2019

Objective:

Inflammation may contribute to brain white matter health in people living with HIV who report cognitive symptoms despite adherence to combination antiretroviral therapy and viral suppression. We explored relationships between diffusion tensor imaging (DTI) metrics of white matter, plasma biomarkers of immune activation, and cognitive function in the HIV-infected population.

Design:

Retrospective study of older adults living with HIV who are combination antiretroviral therapy adherent, virally suppressed, and self-report cognitive symptoms.

Methods:

MRI, blood draws, and standardized neuropsychological test scores were collected from HIV-infected individuals. DTI metrics (fractional anisotropy, mean diffusivity, radial diffusivity, axial diffusivity) and plasma biomarkers (soluble CD163, soluble CD14, neopterin, IFN γ-induced protein 10, monocyte chemoattractant protein 1) were quantified. Statistical analysis explored associations between biomarker levels or neuropsychological test scores and DTI metrics using region of interest analyses and a voxelwise approach.

Results:

A total of 43 participants with median (interquartile range) age of 64 (62–66 years), CD4+ cell count of 600 (400–760 cell/μl) who were all virally suppressed (<100 copies/ml) were selected. Higher levels of monocyte chemoattractant protein 1 associated with lower fractional anisotropy and higher mean diffusivity (P < 0.05) across white matter tracts including corpus callosum, corona radiata, and superior longitudinal fasciculus. Higher neopterin associated with higher mean diffusivity in the genu of corpus callosum, and higher soluble CD14 associated with lower fractional anisotropy in the bilateral superior corona radiata (P < 0.05). Worse global performance and speed domain scores associated with higher mean diffusivity and lower fractional anisotropy, and worse executive domain scores associated with lower fractional anisotropy (P < 0.05).

Conclusion:

Elevated inflammatory plasma biomarkers link to white matter abnormalities among virally suppressed individuals. DTI abnormalities associate to cognitive performance. We conclude that inflammatory processes impact clinically relevant brain health indices despite viral suppression.
Platysmaplasty: Is it Possible to Pull the Platysma Effectively in the Medial or Lateral Direction?
Authors: Choi Jeongho , Hwang Kun , Han Seung Ho , Kim Hun
Published: October 2019

The aim of this study was to investigate whether it is possible to pull the platysma effectively in the medial or lateral direction (medial platysmaplasty and lateral platysmaplasty) and to explore the anatomical basis of those findings.

Six hemifaces from 3 fresh cadavers were dissected. After skin removal, the platysma was pulled upward and in the medial or lateral direction with the ulnar side of the palm. Its mobility was checked. In 2 volunteers, using wooden bar, the skin overlying platysma was pulled in superomedial and superolateral direction.

The platysma ran diagonally from the acromio-deltoid region to the perioral and submental area. In all hemifaces, the platysma was attached to the mandible along its course. The platysma inserted into the mandibular body. At its medial portion (approximately halfway medially from the mentum to the angle; 4–5 cm), the attachment was so firm that it could not be moved horizontally. The posterolateral portion of the platysma was indirectly attached to the mandible and movable. In cadaver, platysma did not move much when it was pulled in the medial direction. In the lateral direction, however, platysma did move well. In living body, when skin overlying platysma was pulled in superomedial direction and superolateral direction, 3 points marked on mandibular border moved about 1.5–2.0 cm and 2.0–2.5 cm respectively.

It is thought that medial platysmaplasty can correct anterior neck deformities and redistribute neck skin mainly in the submental area, while that lateral platysmaplasty can pull the cheek skin in superolateral direction.
Filler Migration and Florid Granulomatous Reaction to Hyaluronic Acid Mimicking a Buccal Tumor
Authors: Kaczorowski Maciej , Nelke Kamil , Łuczak Klaudiusz , Hałoń Agnieszka
Published: October 2019

Hyaluronic acid is among the most commonly used cosmetic fillers. Although considered biocompatible and safe, it may rarely cause a wide range of complications. The authors report a case of migration of hyaluronic acid concomitant with granulomatous inflammatory response that mimicked a buccal tumor. A 52-year-old female presented with a solid painless mass of the right buccal area. The patient denied any history of trauma and cosmetic procedures of the affected area. Skin and mucosal membrane were intact and the lesion was firm and well fixed in the deep plane. Due to worrisome clinical presentation and the patient's history of breast cancer, the lesion was excised radically. Histopathological examination revealed multiple granulomas surrounding amorphous lakes of hyaluronic acid. During repeated, thorough anamnesis the patient admitted having underwent lip augmentation and nasolabial fold correction with HA two years before, after which the filler must have migrated posteriorly. Physicians need to be aware of various complications associated with cosmetic fillers as they may mimic severe clinical conditions.
Metastasis of Prostate Adenocarcinoma in the Mandible: Rare Occurrence in Maxillary Bones
Authors: Lombardo Eduardo Madruga , Ponce Kryssis , Tregnago Lara , Pagnoncelli Rogério Miranda , Heitz Cláiton , Brücker Márcia Rejane , Maito Fábio Luiz Dal Moro
Published: October 2019

Objective:

This article describes the case report of a prostate adenocarcinoma in the mandible.

Background:

Prostate adenocarcinoma is a malignant tumor common in men from the fourth decade of life. The occurrence of oral metastatic lesions is rare.

Case Report:

A 78-year-old male patient was referred to the oral and maxillofacial surgery service of the Pontifical Catholic University of Rio Grande do Sul for complaints of painless volume increase in the mandible. The diagnosis through the association of clinical, radiographic, and histopathological examination with the patient's health history determined that the lesion was prostatic adenocarcinoma metastasis.

Conclusion:

Despite the rare occurrence of metastases in the oral region, the dental surgeon should be aware of the possibility for correct diagnostic conduction and, subsequently, the institution of treatment in the early stages of disease.
Orbital Blowout Fracture and Orbital Emphysema caused by Nose Blowing
Authors: Sarbajna Tushar , Valencia Ma. Regina Paula , Kakizaki Hirohiko , Takahashi Yasuhiro
Published: October 2019

A 76-year-old man presented with 1 day history of eyelid swelling and decreased vision on the left side. History reveals nose blowing the night prior to the occurrence of the symptoms. Initial examination of the left eye showed decreased visual acuity, increased intraocular pressure, and limited ocular motility with presence of air bubbles under the bulbar conjunctiva. Imaging studies showed medial orbital wall fracture with severe emphysema. The patient was observed for a week and no active surgical intervention was performed. Thereafter, spontaneous resolution of symptoms was observed. Eyelid swelling, dramatic improvement in visual acuity, intraocular pressure, and extraocular movements were noted.
Surgical Approach in a Patient With Agnathia-Otocephaly Complex: Three-Stage Mandibular Distraction Protocol
Authors: Gonzalez Santiago R. , Jones John K. , Golinko Michael S.
Published: October 2019

Agnathia-otocephaly complex (AOC) is a rare malformation complex of the first pharyngeal arch that is characterized by agnathia/dysgnathia, microstomia, aglossia/hypoglossia and variable displacement of the ears. Only 11 post-infancy patients with severe AOC have been described in the literature, and the incidence of this malformation complex is estimated to be 1 per 70,000 births. In this brief clinical study, the authors describe the case of an 18-year-old female diagnosed with AOC who underwent a 3-step mandibular distraction protocol with an external distraction device. The surgical protocol the authors used was unique in that we first placed a tissue expander in the submental area to enlarge the skin envelope in an effort to mitigate skeletal relapse from soft tissue forces. Furthermore, the way in which the authors slowed the activation of the distraction device to allow for soft tissue healing behind the pins was a novel component of the patient's treatment. The 3-step mandibular distraction protocol the authors present in this study increased the length of the mandible by 20 mm, and nearly doubled the size of the patient's mandible from an initial volume of 3.62 cm3 to a post-operative volume of 6.89 cm3. Future surgeries will aim to improve the function of our patient's expanded mandible. Most important of all, the surgical treatment authors are presenting led to a significant improvement in our patient's physical appearance and 3d quality of life.
Michelassi II Strictureplasty for Crohn's Disease
Authors: Mege Diane , Michelassi Fabrizio
Published: October 2019

Objective:

We report on a new side-to-side isoperistaltic strictureplasty (SSIS), the Michelassi II or end-to-side-to-side-to-end strictureplasty, performed with discontinuous bowel loops.

Summary Background Data:

The SSIS Michelassi strictureplasty was described a quarter of a century ago to avoid massive bowel resections in patients with extensive fibrostenosing Crohn's jejuno-ileitis.

Methods:

The end-to-side-to-side-to-end strictureplasty is performed in patients presenting with 3 severely fibrotic and deformed bowel loops separated by 2 diseased segments with sequential strictures. After the resection of the 3 severely diseased segments, the remaining 2 discontinuous segments are used to perform a SSIS, according to the original description. The 2 ends of the SSIS are then anastomosed with the proximal and the distal bowel, respectively. In the presence of discrepancy in length between the 2 discontinuous segments, the proximal small bowel is recruited to equalize the length and aid in the performance of the SSIS.

Conclusions:

The Michelassi II, or the end-to-side-to-side-to-end strictureplasty, is a variant of the original SSIS technique to address severe and extensive small bowel Crohn's disease presenting with 3 severely fibrotic and deformed bowel loops separated by 2 diseased segments with sequential strictures.
OpTrust
Authors: Sandhu Gurjit , Thompson-Burdine Julie , Dombrowski Janet , Sutzko Danielle C. , Nikolian Vahagn C. , Boniakowski Anna , Georgoff Patrick E. , Matusko Niki , Prabhu Kaustubh , Minter Rebecca M.
Published: October 2019

Objective:

The purpose of this study was to measure the efficacy of a novel faculty and resident educational bundle focused on development of faculty-resident behaviors and entrustment in the operating room.

Summary Background Data:

As surgical training environments are orienting to entrustable professional activities (EPAs), successful transitions to this model will require significant faculty and resident development. Identifying an effective educational initiative which prepares faculty and residents for optimizing assessment, teaching, learning, and interacting in this model is critical.

Methods:

From September 2015 to June 2017, an experimental study was conducted in the Department of Surgery at the University of Michigan Health System (UMHS). Case observations took place across general, plastic, thoracic, and vascular surgical specialties. A total of 117 operating room observations were conducted during Phase I of the study and 108 operating room observations were conducted during Phase II following the educational intervention. Entrustment behaviors were rated for 56 faculty and 73 resident participants using OpTrust, a validated intraoperative entrustment instrument.

Results:

Multiple regression analysis showed a significant increase in faculty entrustment (Phase I = 2.32 vs Phase II = 2.56, P < 0.027) and resident entrustability (Phase I = 2.16 vs Phase II = 2.40, P < 0.029) scores following exposure to the educational intervention.

Conclusions:

Our study shows improved intraoperative entrustment following implementation of faculty and resident development, indicating the efficacy of this innovative educational bundle. This represents a crucial component in the implementation of a competency-based assessment framework like EPAs.
Enhanced Recovery Pathway Benefits Patients Undergoing Nonelective Colorectal Surgery
Authors: Liska David , Novello Matteo , Cengiz Bora Turgut , Holubar Stefan D. , Aiello Alexandra , Gorgun Emre , Steele Scott R. , Delaney Conor P.
Published: October 2019

Objective:

The aim of our study was to determine if an enhanced recovery pathway (ERP) can successfully be applied in nonelective colorectal surgery.

Background:

ERPs have been shown to reduce hospital length of stay (LOS), complications, and costs after elective colorectal surgery. Yet, little data exist regarding the benefits of ERPs in patients undergoing nonelective colorectal surgery. We hypothesized that ERP implementation in a nonelective colorectal surgery population is associated with decreased postoperative LOS.

Methods:

A prospectively-maintained database was used to identify consecutive patients undergoing colorectal surgery after emergency room (ER) or hospital transfer admissions over a period from 2 years before until 1 year after implementation of a comprehensive ERP. The primary endpoint was LOS. Secondary endpoints included total LOS [TLOS = postoperative LOS + LOS of readmission(s)], readmission rates, complication rates, 30-day mortality, and hospital costs. Univariate and multivariate analyses were performed to assess the relationship between ERP implementation and LOS.

Results:

We identified 269 pre-ERP and 135 ERP patients fulfilling the inclusion criteria. Admit source (ER 43.4% vs transfers 56.7%), Charlson comorbidity index, American Society of Anesthesiologists (ASA) status, diagnosis (inflammatory bowel disease 45.8%, malignancy 19.6%, benign intestinal obstructions 10.4%, diverticulitis 9.4%, others 10.4%), and blood loss were comparable (P > 0.05) between the cohorts. Pre-ERP patients had a higher number of previous abdominal surgeries, whereas post-ERP patients had more laparoscopy and more compliance with ERP elements. ERP patients had a shorter postoperative LOS [6 (4, 10) vs 7 (5, 12) days; P = 0.0007]. Hospital costs were 13.4% lower (P = 0.004). Postoperative 30-day morbidity, mortality, and readmissions were comparable, although reoperation rate was higher in the ERP group. On multivariate analysis, ERP implementation and laparoscopy were the only modifiable variables independently associated with shorter LOS, whereas longer operative times and higher ASA classification were associated with longer LOS.

Conclusions:

Patients undergoing nonelective colorectal surgery after ER or hospital transfer admission benefit from the use of an ERP, demonstrating decreased LOS and costs without an increase in complications.
Comparing Outcomes and Costs of Surgical Patients Treated at Major Teaching and Nonteaching Hospitals
Authors: Silber Jeffrey H. , Rosenbaum Paul R. , Niknam Bijan A. , Ross Richard N. , Reiter Joseph G. , Hill Alexander S. , Hochman Lauren L. , Brown Sydney E. , Arriaga Alexander F. , Kelz Rachel R. , Fleisher Lee A.
Published: October 2019

Objective:

To compare outcomes and costs between major teaching and nonteaching hospitals on a national scale by closely matching on patient procedures and characteristics.

Background:

Teaching hospitals have been shown to often have better quality than nonteaching hospitals, but cost and value associated with teaching hospitals remains unclear.

Methods:

A study of Medicare patients at 340 teaching hospitals (resident-to-bed ratios ≥ 0.25) and matched patient controls from 2444 nonteaching hospitals (resident-to-bed ratios < 0.05).

We studied 86,751 pairs admitted for general surgery (GS), 214,302 pairs of patients admitted for orthopedic surgery, and 52,025 pairs of patients admitted for vascular surgery.

Results:

In GS, mortality was 4.62% in teaching hospitals versus 5.57%, (a difference of −0.95%, <0.0001), and overall paired cost difference = $915 (P< 0.0001). For the GS quintile of pairs with highest risk on admission, mortality differences were larger (15.94% versus 18.18%, difference = −2.24%,P< 0.0001), and paired cost difference = $3773 (P< 0.0001), yielding $1682 per 1% mortality improvement at 30 days. Patterns for vascular surgery outcomes resembled general surgery; however, orthopedics outcomes did not show significant differences in mortality across teaching and nonteaching environments, though costs were higher at teaching hospitals.

Conclusions:

Among Medicare patients, as admission risk of mortality increased, the absolute mortality benefit of treatment at teaching hospitals also increased, though accompanied by marginally higher cost. Major teaching hospitals appear to return good value for the extra resources used in general surgery, and to some extent vascular surgery, but this was not apparent in orthopedic surgery.
International Validation of Reduced Major Morbidity After Minimally Invasive Distal Pancreatectomy Compared With Open Pancreatectomy
Authors: Klompmaker Sjors , de Rooij Thijs , Koerkamp Bas Groot , Shankar Anuraj H. , Siebert Uwe , Besselink Marc G. , Moser A. James
Published: October 2019

Objective:

To quantify the nationwide impact of minimally invasive distal pancreatectomy (MIDP) on major morbidity as compared with open distal pancreatectomy (ODP).

Background:

A recent randomized controlled trial (RCT) demonstrated significant reduction in time to functional recovery after MIDP compared with ODP, but was not powered to assess potential risk reductions in major morbidity.

Methods:

International cohort study using the American College of Surgeons’ National Quality Improvement Program (ACS-NSQIP) (88 centers; 2014–2016) to evaluate the association between surgical approach (MIDP vs ODP) and 30-day composite major morbidity (CMM; death or severe complications) with external model validation using Dutch Pancreatic Cancer Group data (17 centers; 2005–2016). Multivariable logistic regression assessed the impact of nationwide MIDP rates between 0% and 100% on postoperative CMM at conversion rates between 0% and 25%, using estimated marginal effects. A sensitivity analysis tested the impact at various scenarios and patient populations.

Results:

Of 2921 ACS-NSQIP patients, 1562 (53%) underwent MIDP with 18% conversion, and 1359 (47%) underwent ODP. MIDP was independently associated with reduced CMM [odds ratio (OR) 0.50, 95% confidence interval (CI) 0.42–0.60, P < 0.001], confirmed by external model validation (n = 637, P < 0.003). The association between rising MIDP implementation rates and falling postoperative morbidity was linear between 0% (all ODP) and 100% (all MIDP). The absolute risk reduction for CMM was 11% (95% CI 7.3%–15%) at observed conversion rates and improved to 14% (95% CI 11%–18%) as conversion approached 0%. Similar effects were seen across subgroups.

Conclusion:

This international study predicted a nationwide 11% risk reduction for CMM after MIDP versus ODP, which is likely to improve as conversion rates decrease. These findings confirm secondary outcomes of the recent LEOPARD RCT.
Oncological Impact of High Vascular Tie After Surgery for Rectal Cancer
Authors: Boström Petrus , Hultberg Daniel Kverneng , Häggström Jenny , Haapamäki Markku M. , Matthiessen Peter , Rutegård Jörgen , Rutegård Martin
Published: October 2019

Objective:

The purpose of this study was to investigate the impact of tie level on oncological outcomes in rectal cancer surgery.

Summary background data:

Theoretically, a high tie of the inferior mesenteric artery could facilitate removal of apical node metastases and improve tumor staging accuracy. However, no appropriately sized randomized controlled trial exists and results from observational studies are not consistent.

Methods:

All stage I–III rectal cancer patients who underwent abdominal surgery with curative intention in 2007 to 2014 were identified and followed, using the Swedish Colorectal Cancer Registry. Primary outcome was cancer-specific survival, whereas overall and relative survival, locoregional and distant recurrence, and lymph node harvest were secondary outcomes, with high tie as exposure. We used propensity score matching to emulate a randomized controlled trial, and then performed Cox regression analyses to estimate hazard ratios (HRs) with confidence intervals (CIs).

Results:

Some 8287 patients remained for analysis, of which 37% had high tie surgery. After propensity score matching, the 5-year cancer-specific survival rate was overall 86% and we found no association between the level of tie and cancer-specific (HR 0.92, 95% CI 0.79–1.07) or overall (HR 0.98, 95% CI 0.89–1.08) survival, nor to locoregional (HR 0.85, 95% CI 0.59–1.23) or distant (HR 1.01, 95% CI 0.88–1.15) recurrence, nor to relative survival (HR 1.05, 95% CI 0.85–1.28). Stratification and sensitivity analyses were similarly insignificant, after adjustment for confounding. Total lymph node harvest was, however, increased after high tie surgery (P < 0.01), but no differences were seen regarding positive nodes (P = 0.72).

Conclusion:

In this nationwide cohort study, the level of tie did not influence any patient-oriented oncological outcome, neither overall nor in node-positive patients. This would allow the patient's anatomical configuration and the surgeon's preferences to determine the level of tie.
The Impact of Age and Luminal Preservation on the Development of Intestinal Preservation Injury in Rats
Authors: Søfteland John Mackay , Casselbrant Anna , Akyürek Levent M. , Hellström Mats , Oltean Mihai
Published: October 2019

Background.

Organs from older donors are believed to withstand ischemia worse than those from younger donors. The effect of age on the development of intestinal preservation injury (IPI) is unclear.

Methods.

We compared the development of IPI in intestines from young (3 mo), adult (14 mo), and old (20 mo) rat donors and assessed if luminal preservation (LP) is effective in delaying IPI. Small intestines were perfused with, and stored in, preservation solution (Custodiol) with or without LP solution (polyethylene glycol 3350). IPI was studied using histology (Chiu score, Alcian blue staining), Western blot, and electrophysiological assessment (Ussing chamber) at 4, 8, and 14 hours.

Results.

Intestines of old rats did not show major histological alterations, whereas their aortas and kidneys revealed typical age-related changes (arteriosclerosis and glomerulosclerosis). Intestines from old rats fared similarly to their younger counterparts at all time points regarding preservation injury and goblet cells count. Intestines undergoing LP showed fewer histological signs of damage and higher goblet cells count when compared with samples without LP, regardless of donor age. Ussing chamber experiments indicated a time-dependent deterioration of all parameters studied, which was delayed by the use of LP.

Conclusions.

Older intestines did not convincingly demonstrate a faster IPI compared with intestines from adult and young donors. The small differences between the age groups were nullified by the use of LP. LP significantly delayed the IPI in all age groups and may allow for longer preservation periods without an increased risk of mucosal damage.
Inducing Transient Mixed Chimerism for Allograft Survival Without Maintenance Immunosuppression With Combined Kidney and Bone Marrow Transplantation: Protocol Optimization
Authors: Lee Kyo Won , Park Jae Berm , Park Hyojun , Kwon Yeongbeen , Lee Ji Soo , Kim Kyeong Sik , Chung Young Jae , Rhu Jin Soo , Choi Sooin , Kwon Ghee Young , Kim Hee Jin , Kang Eun-Suk , Jung Chul Won , Shin Eui-Cheol , Kawai Tatsuo , Kim Sung Joo , Joh Jae-Won
Published: October 2019

Background.

Tolerance induction is an important goal in the field of organ transplantation. We have sequentially modified our conditioning regimen for induction of donor-specific tolerance in recipients of major histocompatibility complex-mismatched combined kidney and bone marrow transplantation (CKBMT).

Methods.

From December 2011 to May 2017, 8 major histocompatibility complex-mismatched patients received CKBMT. The initial conditioning regimen (protocol 1) consisted of cyclophosphamide (CP), rituximab, rabbit antithymocyte globulin, and thymic irradiation. Tacrolimus and steroids were used for the maintenance of immunosuppression (IS).

Results.

This regimen was complicated by transient acute kidney injury, which has been the major clinical feature of engraftment syndrome and side effects of CP, although one of 2 subjects successfully discontinued his IS for 14 months. The conditioning regimen was modified by reducing the CP dose and adding fludarabine (protocol 2). The final modification was reducing the fludarabine and rabbit antithymocyte globulin doses (protocol 3). Mixed chimerism, detected by the short tandem repeat method, was achieved transiently in all subjects for 3–20 weeks. Among the 3 subjects treated with protocol 2, IS was successfully discontinued for >35 months in one subject, but the other 2 subjects suffered from severe BK virus-associated nephritis. All 3 subjects treated with protocol 3 tolerated the protocol well and have successfully discontinued IS for >4–41 months. Interestingly, de novo donor-specific antibody was not detected in any subject during all the follow-up periods.

Conclusions.

Our clinical trial has shown that long-term renal allograft survival without maintenance IS can be achieved by induction of mixed chimerism following CKBMT.
Clinicopathologic Assessment of Monoclonal Immunoglobulin-associated Renal Disease in the Kidney Allograft: A Retrospective Study and Review of the Literature
Authors: Kamal Jeanne , Khairallah Pascale , Crew Russell J. , Ye Xiaoyi , Swanson Sidney J. , Kudose Satoru , Park David C. , Appel Gerald B. , Markowitz Glen S. , D’Agati Vivette D. , Batal Ibrahim
Published: October 2019

Background.

Monoclonal immunoglobulin (MIg)-associated renal disease (MIgARD) comprises a group of disorders caused by direct deposition of paraproteins in the kidney. Allograft MIgARD is infrequently encountered and poorly characterized.

Methods.

First, we assessed our allograft biopsies diagnosed with MIgARD between 2007 and 2018. The cohort included the following 26 patients: proliferative glomerulonephritis with MIg deposits (PGNMID) (n = 13), AL amyloidosis (n = 5), light chain deposition disease (n = 5), light chain proximal tubulopathy (n = 2), and light chain cast nephropathy (n = 1). Second, we conducted a literature review to evaluate the rare non-PGNMID entities. We identified 20 studies describing 29 patients that were added to our cohort (total n = 42).

Results.

Part 1: Patients’ median age was 55 years; 31% were women, and 19% were blacks. Twelve patients (46%) lost their grafts at a median of 8 months after diagnosis. Compared to non-PGNMID, PGNMID patients had lower frequency of detectable paraproteins (31% versus 92%, P = 0.004) and hematologic neoplasms (23% versus 77%, P = 0.02). Within PGNMID group, 6 patients changed their apparent immunofluorescence phenotype between monotypic and polytypic, while all 3 patients with hematologic neoplasms had substructure on electron microscopy. Part 2: Whereas light chain cast nephropathy occurred the earliest and had the worst graft survival, AL amyloidosis occurred the latest and had the best graft survival.

Conclusions.

MIgARD in the kidney allograft is associated with poor prognosis. While posttransplant PGNMID can change its apparent clonality by immunofluorescence supporting oligoclonal immune responses, the presence of deposit substructure is an important indicator of underlying hematologic neoplasm. Non-PGNMID are often associated with hematologic neoplasms and varied prognosis.
The Causes of Kidney Allograft Failure: More Than Alloimmunity. A Viewpoint Article
Authors: Van Loon Elisabet , Bernards Jelle , Van Craenenbroeck Amaryllis H. , Naesens Maarten
Published: October 2019

Kidney allograft failure is a serious condition, as it implies the need for reinitiation of dialysis with associated morbidity and mortality, reduced quality of life, and higher economic cost. Despite improvements in short-term survival of kidney allografts, this progress was not matched in long-term graft survival. In this viewpoint article, we summarize the available literature on the causes of kidney allograft failure, both early and late, both nonimmune and alloimmune, to gain better insight into the causes of graft failure. Such insight is necessary to better target therapies or take preventative measures that improve long-term outcome after kidney transplantation.