Search

Epilepsy is one of the most common diseases of the central nervous system, impacting nearly 50 million people around the world. Heterogeneous in nature, epilepsy presents in children and adults alike. Currently, surgery is one treatment approach that can completely cure epilepsy. However, not all individuals are eligible for surgical procedures or have successful outcomes. In addition to surgical approaches, antiepileptic drugs (AEDs) have also allowed individuals with epilepsy to achieve freedom from seizures. Others have found treatment through nonpharmacologic approaches such as vagus nerve stimulation, or responsive neurostimulation. Difficulty in accessing samples of human brain tissue along with advances in sequencing technology have driven researchers to investigate sampling liquid biopsies in blood, serum, plasma, and cerebrospinal fluid within the context of epilepsy. Liquid biopsies provide minimal or non-invasive sample collection approaches and can be assayed relatively easily across multiple time points, unlike tissue-based sampling. Various efforts have investigated circulating nucleic acids from these samples including microRNAs, cell-free DNA, transfer RNAs, and long non-coding RNAs. Here, we review nucleic acid-based liquid biopsies in epilepsy to improve understanding of etiology, diagnosis, prediction, and therapeutic monitoring.

Despite a lack of supporting data, routine splenic flexure mobilization (SFM) during colectomy has been thought to reduce anastomotic leak (AL). We evaluated the impact of SFM on outcomes in distal colectomy.The 2005-2016 NSQIP database identified 66,068 patients undergoing distal colectomy with anastomosis. Cohorts were stratified by addition of SFM. Postoperative outcomes were compared between groups. Regression analysis identified factors affecting odds of developing AL.SFM was performed in 27,475 patients (41.6%). There was no difference in overall complications between cases with SFM and those without (p = 0.55). SFM had longer operative times (220 min vs. 184 min; p 0.0001). SFM was not associated with any difference in AL rate (3.6% vs. 3.7%; p = 0.86). Factors most associated with AL were lack of oral antibiotic preparation (OR 1.93; p 0.001), chemotherapy (OR 1.91; p 0.001), and weight loss (OR 1.68; p = 0.0005). Operative indication and approach did not affect leak.SFM in distal colectomy increased operative time without decreasing overall complications or AL. Routine splenic flexure mobilization may add risk without significant benefit.

Introduction Since inception of robotic-assisted surgery (RAS) in 1999, there has been an exponential rise in RAS in both number and complexity of surgical cases performed. The majority of these cases are gynecologic surgery in nature, with only a quarter of them labeled as general surgery. The purpose of this study is to determine if RAS in the Department of Defense (DoD) mirrors these trends. Methods A total of 6,204 RAS cases from across the DoD were reviewed between 01 January 2015 and 30 September 2017 from every Military Treatment Facility (MTF) that employs a robotic surgical device (various models of the da Vinci robotic surgical system by Intuitive Surgical). Specialty, number, and surgeon were recorded for each case. These end points were also examined for trends overtime and compared to similar civilian data. Results The number of MTFs performing robotic surgery and the number of cases performed increased significantly. An average of 373 cases per quarter-year were performed in 2015, 647 in 2016, and 708 in 2017. The number of RAS cases increased by about 10% every quarter-year during this time period. RAS was most commonly performed by general surgery in 10 of the 14 MTFs examined. Conclusions MTFs implemented RAS much later than the civilian world. However, since its implementation, the frequency of RAS use has increased at a faster rate in the DoD than in the civilian world. Possible reasons for this are a younger pool of surgeons in the military and less demands on cost-effective productivity, allowing these younger surgeons to focus on emerging technology rather than maximizing surgical cost efficiency. General surgery constitutes the majority of RAS cases in the DoD. It is unclear why this difference from the civilian world exists.

Background Modern 64- to 128-slice computed tomography (CT) scanners have questioned the need for routine colonoscopy after hospital admission for presumed uncomplicated diverticulitis. Methods This is a retrospective review of all patients (>18 years) who underwent planned colonoscopy after admission for Hinchey I or II acute diverticulitis (January 2009 to January 2014). The findings on the final radiologist report were then correlated with the colonoscopy results. Results In total, 110 patients (mean age, 55.2 ± 16; 46.4% female) underwent a subsequent colonoscopy (median, 60 days) after admission for diverticulitis. Overall, 102 patients (92.7%) had CT findings consistent with definitive diverticulitis, 6 patients had a diagnosis suggestive of diverticulitis on CT scan, and 2 patients had masses on their admission CT scans. Within the group with definitive diverticulitis, follow-up colonoscopy identified diverticulosis in 99 (97.0%), whereas the other 3 had normal findings. Of the patients with CT scans suggestive of diverticulitis, follow-up colonoscopy showed 3 with diverticulosis, 2 with malignancies, and 1 with nonspecific inflammation. The reliability of CT scans for diverticulitis compared with colonoscopy was found to have a kappa=.829 ( P Conclusions Follow-up colonoscopy should be performed when a CT scan suggests malignancy, nonspecific inflammatory findings, or the patient is otherwise due for routine screening or surveillance. In this study, there was no benefit of follow-up colonoscopy in patients with CT-confirmed diverticulitis in the absence of other concerning or indeterminate findings.

Robotic surgery began approximately 30 years ago, growing steadily, and has now become one of the mainstream topics within the surgical literature across multiple surgical disciplines. More recently, robotic use has expanded to colorectal surgery, demonstrating increased usage in the more difficult operations involved. As competition in the marketplace and technology increase and improve, the size and cost of these systems may progressively decrease, and their presence will likely grow. With that, innovative and novel concepts are being introduced at a rapid pace. The enhanced performance gained by the surgeon with these devices will hopefully enable the difficult operations to become more feasible and potentially even safer. We present a brief history of the instruments related to robotic colorectal surgery and discuss some of the robotic instruments that may be seen in a future robotic-enabled operating room.

BACKGROUND Intraoperative laser fluorescence angiography is a relatively new tool that can be used by colorectal surgeons to ensure adequate perfusion to bowel that remains after resection. It has been used mostly to determine an appropriate point of transection of the proximal bowel, as well as to ensure perfusion after the anastomosis has been constructed. We propose a different use of the technology in complex cases to ensure the ability to safely transect a major vascular pedicle and to ensure that perfusion will remain adequate. OBJECTIVE The purpose of this article is to describe a new use for fluorescence angiography technology. DESIGN This is a technical note. SETTINGS The work was conducted at a tertiary care military medical center. PATIENTS Patients included individuals requiring oncologic colorectal resection where the status of 1 major vascular pedicle was unknown or impaired. MAIN OUTCOME MEASURES We assessed perfusion after occlusion of a major vascular pedicle for the short term in hospital outcomes. RESULTS Adequate studies were obtained, and perfusion was maintained in both patients. Oncologic resections were performed, and short-term outcomes were comparable with any individual undergoing these procedures. LIMITATIONS This study was limited because it is early experience that was not performed in the setting of a scientific investigation. CONCLUSIONS Application of intraoperative fluorescence angiography in this setting appears to be safe and may assist the surgeon in estimating reliable vascular perfusion in patients such as these who require oncologic colorectal resection.

Aims: To determine whether day and time of admission influences the practice patterns of the admitting general surgeon and subsequent outcomes for patients diagnosed with small bowel obstruction. Methods: A retrospective database review was carried out, covering patients admitted with the presumed diagnosis of partial small bowel obstruction from 2004–2011. Results: A total of 404 patients met the inclusion criteria. One hundred and thirty-nine were admitted during the day, 93 at night and 172 on the weekend. Overall 30.2% of the patients were managed operatively with no significant difference between the groups (P = 0.89); however, of patients taken to the operating room, patients admitted during the day received operative intervention over 24 hours earlier than those admitted at a weekend, 0.79 days vs 1.90 days, respectively (P = 0.05). Overall mortality was low at 1.7%, with no difference noted between the groups (P = 0.35). Likewise there was no difference in morbidity rates between the three groups (P = 0.90). Conclusions: Despite a faster time to operative intervention in those patients admitted during the day, our study revealed that time of admission does not appear to correlate to patient outcome or mortality.

Background Discrepancies in socioeconomic factors have been associated with higher rates of perforated appendicitis. As an equal-access health care system theoretically removes these barriers, we aimed to determine if remaining differences in demographics, education, and pay result in disparate outcomes in the rate of perforated appendicitis. Materials and methods All patients undergoing appendectomy for acute appendicitis (November 2004–October 2009) at a tertiary care equal access institution were categorized by demographics and perioperative data. Rank of the sponsor was used as a surrogate for economic status. A multivariate logistic regression model was performed to determine patient and clinical characteristics associated with perforated appendicitis. Results A total of 680 patients (mean age 30 ± 16 y; 37% female) were included. The majority were Caucasian (56.4% [n = 384]; African Americans 5.6% [n = 38]; Asians 1.9% [n = 13]; and other 48.9% [n = 245]) and enlisted (87.2%). Overall, 6.4% presented with perforation, with rates of 6.6%, 5.8%, and 6.7% (P = 0.96) for officers, enlisted soldiers, and contractors, respectively. There was no difference in perforation when stratified by junior or senior status for either officers or enlisted (9.3% junior versus 4.40% senior officers, P = 0.273; 6.60% junior versus 5.50% senior enlisted, P = 0.369). On multivariate analysis, parameters such as leukocytosis and temperature, as well as race and rank were not associated with perforation (P = 0.7). Only age had a correlation, with individuals aged 66–75 y having higher perforation rates (odds ratio, 1.04; 95% confidence interval, 1.02–1.05; P Conclusions In an equal-access health care system, older age, not socioeconomic factors, correlated with increased appendiceal perforation rates.

Introduction Internal hernias (IHs) occur more frequently in laparoscopic gastric bypass (LGB) surgery than in the classic open procedure. The incidence of small bowel obstruction after LGB ranges from 1.8% and 9.7%. Some have theorized that this occurs because of decreased adhesion formation. Methods The mesenteric irritation technique is performed after closure of the jejunojejunal mesenteric defect with a running 2-0 silk suture. A sponge is then rubbed against the closed visceral peritoneal mesentery until petechiae are visualized on the surface of the mesentery. Results In all, 338 LGBs were performed using the standard closure technique with an IH incidence of 5.3% (range 1.7% to 7.8%). When using the mesenteric irritation technique, 72 LGBs were performed with an IH rate of 1.4% (P = .13). Conclusions Mesenteric irritation is a novel technique performed with minimal additional time and no additional equipment. This technique may prove beneficial in reducing the incidence of IHs.

Aim Urgent colectomy for severe Clostridium difficile infection can be associated with increased morbidity and mortality. We aimed to use endoscopic methods for treatment. Method We describe a technique of placing an intracolonic tube facilitating decompression and direct delivery of vancomycin to the proximal colon along with enemas on a regular and frequent basis that may not be possible with vancomycin enemas alone. Results Successful resolution of the C. difficile infection and avoidance of surgery. Conclusion While further long-term evaluation is required, our initial results have shown it to be effective in treating select patients with recalcitrant Clostridium difficile-associated megacolon.

Surgical resection remains a mainstay of treatment and is highly effective for localized colorectal cancer. However, ~30-40% of patients develop recurrence following surgery and 40-50% of recurrences are apparent within the first few years after initial surgical resection. Several variables factor into the ultimate outcome of these patients, including the extent of disease, tumor biology, and patient co-morbidities. Additionally, the time from initial treatment to the development of recurrence is strongly associated with overall survival, particularly in patients who recur within one year of their surgical resection. Current post-resection surveillance strategies involve physical examination, laboratory, endoscopic and imaging studies utilizing various high and low-intensity protocols. Ultimately, the goal is to detect recurrence as early as possible, and ideally in the asymptomatic localized phase, to allow initiation of treatment that may still result in cure. While current strategies have been effective, several efforts are evolving to improve our ability to identify recurrent disease at its earliest phase. Our aim with this article is to briefly review the options available and, more importantly, examine emerging and future options to assist in the early detection of colon and rectal cancer recurrence.

Treatment of advanced colon and rectal cancer has significantly evolved with the introduction of neoadjuvant chemoradiation therapy so much that, along with more effective chemotherapy regimens, surgery has been considered unnecessary among some institutions for select patients. The tumor response to these treatments has also improved and ultimately has been shown to have a direct effect on prognosis. Yet, the best way to monitor that response, whether clinically, radiologically, or with laboratory findings, remains controversial. The authors' aim is to briefly review the options available and, more importantly, examine emerging and future options to assist in monitoring treatment response in cases of locally advanced rectal cancer and metastatic colon cancer.

Outpatient surgery is performed widely throughout the Army Medical Command (MEDCOM). It is common practice throughout Medical Command to admit barracks dwelling active duty service members (ADSMs) undergoing ambulatory surgical procedures for overnight observation. We hypothesized that overnight observation of these individuals has not prevented adverse outcomes that would have otherwise occurred if the patient had been discharged to the barracks.We reviewed the postoperative course of all ADSMs undergoing ambulatory surgery with subsequent overnight hospital stay because of primary barracks residence. Procedures included hernia repair, lipoma excisions, and pilonidal cystectomies. Inclusion criteria were ADSMs who stayed overnight purely on the basis of their military barracks residence.145 patients met our inclusion criteria. Their mean age was 23 ± 3.2, 90.9% were males. The mean hospital length of stay was 24 ± 11.4 hours. There were four (2.78%) postoperative complications, three patients with postoperative urinary retention, and one patient with mild bleeding from a pilonidal excision site, all within 8 hours postoperatively. No adverse outcomes were noted during the period of their hospitalization.Barracks dwelling ADSMs do not have adverse outcomes during their inpatient observational hospitalization. An outpatient escort would be sufficient to ensure adequate observation.

Listeria monocytogenes is a pathogen associated with meningitis in the immunosuppressed patient. The pathogen is usually found in soft cheeses and raw milk. We present a case of an infected popliteal artery stent graft with Listeria monocytogenes. The report focuses on the diagnosis and treatment with surgical explantation and vascular reconstruction.

Anal fistula (AF) presents a chronic problem for patients and colorectal surgeons alike. Surgical treatment may result in impairment of continence and long-term risk of recurrence. Treatment options for AFs vary according to their location and complexity. The ideal approach should result in low recurrence rates and minimal impact on continence. New technical approaches involving biologically derived products such as biological mesh, fibrin glue, fistula plug, and stem cells have been applied in the treatment of AF to improve outcomes and decrease recurrence rates and the risk of fecal incontinence. In this review, we will highlight the current evidence and describe our personal experience with these novel approaches.

Reliable experimental evidence provides a firm scientific foundation for only a minority of the clinical decisions primary care practitioners must make each day. Thus clinicians' experience and judgment must complement and supplement their knowledge of published research studies. This presents a dynamic and difficult challenge to the practitioner—one that is magnified when combined with the never ending influx of medical information, with patients' and physicians' uneasiness with clinical uncertainty, and with new external pressures to standardize care. With these factors in mind, this article will review evidence-based medicine, a process and philosophy for the practice and teaching of clinical medicine that has sparked much controversy in recent years. Clinical scenarios commonly encountered in adult primary care—cute low back pain, hypertension, and screening for vascular disease—illustrate some strengths and limitations of evidence-based medicine.

Cefazolin, a first generation cephalosporin, is a rare cause of cyclical fevers, neutropenia, and thrombocytopenia following surgical prophylaxis. We present the case of an otherwise healthy 21-year-old male who sustained a 50-cm laceration to his chest and abdomen. He received emergency department prophylaxis with cefazolin and surgical repair. Subsequently, he developed cyclical fevers, neutropenia, and thrombocytopenia, all of which resolved after antibiotic discontinuation. This is the first case report in which the perioperative administration of cefazolin following trauma resulted in significant neutropenia and thrombocytopenia. Also discussed in this report are the etiology, workup, and treatment of cefazolin-induced neutropenia.

Objective To report the relationship between disease activity and health-related quality of life (HRQoL) in relapsing multiple sclerosis, and the impact of natalizumab. Methods HRQoL data were available from 2,113 multiple sclerosis patients in natalizumab clinical studies. In the Natalizumab Safety and Efficacy in Relapsing Remitting Multiple Sclerosis (AFFIRM) study, patients received natalizumab 300mg (n = 627) or placebo (n = 315); in the Safety and Efficacy of Natalizumab in Combination with Interferon Beta-1a in Patients with Relapsing Remitting Multiple Sclerosis (SENTINEL) study, patients received interferon beta-1a (IFN-β-1a) plus natalizumab 300mg (n = 589), or IFN-β-1a plus placebo (n = 582). The Short Form-36 (SF-36) and a subject global assessment visual analog scale were administered at baseline and weeks 24, 52, and 104. Prespecified analyses included changes from baseline to week 104 in SF-36 and visual analog scale scores. Odds ratios for clinically meaningful improvement or worsening on the SF-36 Physical Component Summary (PCS) and Mental Component Summary were calculated. Results Mean baseline SF-36 scores were significantly less than the general US population and correlated with Expanded Disability Status Scale scores, sustained disability progression, relapse number, and increased volume of brain magnetic resonance imaging lesions. Natalizumab significantly improved SF-36 PCS and Mental Component Summary scores at week 104 in AFFIRM. PCS changes were significantly improved by week 24 and at all subsequent time points. Natalizumab-treated patients in both studies were more likely to experience clinically important improvement and less likely to experience clinically important deterioration on the SF-36 PCS. The visual analog scale also showed significantly improved HRQoL with natalizumab. Interpretation HRQoL was impaired in relapsing multiple sclerosis patients, correlated with severity of disease as measured by neurological ratings or magnetic resonance imaging, and improved significantly with natalizumab. Ann Neurol 2007

OBJECTIVE: To determine if structured teaching of bedside cardiac examination skills improves medical residents’ examination technique and their identification of key clinical findings. DESIGN: Firm-based single-blinded controlled trial. SETTING: Inpatient service at a university-affiliated public teaching hospital. PARTICIPANTS: Eighty Internal Medicine residents. METHODS: The study assessed 2 intervention groups that received 3-hour bedside teaching sessions during their 4-week rotation using either: (1) a traditional teaching method, “demonstration and practice” (DP) (n=26) or (2) an innovative method, “collaborative discovery” (CD) (n=24). The control group received their usual ward teaching sessions (n=25). The main outcome measures were scores on examination technique and correct identification of key clinical findings on an objective structured clinical examination (OSCE). RESULTS: All 3 groups had similar scores for both their examination technique and identification of key findings in the preintervention OSCE. After teaching, both intervention groups significantly improved their technical examination skills compared with the control group. The increase was 10% (95% confidence interval [CI] 4% to 17%) for CD versus control and 12% (95% CI 6% to 19%) for DP versus control (both P

To determine the relationship between brain energy metabolites and neurologic status after ischemia-hypoxia, we measured cortical tissue levels of adenosine triphosphate (ATP), phosphocreatine, and lactate. Rats with permanent unilateral carotid occlusion were exposed to 5, 10, and 15 min of hypoxic atmosphere (FIO2 0.048) and, to examine metabolic restitution, 60 min after recovery in rats exposed to the same hypoxic mixture for 15 min. At 5 and 10 min of hypoxia, there were significant reductions in phosphocreatinine and elevations in tissue lactate, but only after 15 min of hypoxia, did ATP levels significantly decrease. By 60 min after recovery, phosphocreatinine values returned to the normal range, ATP values to 15% less than normal, and tissue lactate toward normal. In parallel survival studies, neurological status was examined following hypoxic exposure (PaO2 18 to 19 torr) for 5 an 10 min. Evidence for neurological injury in the form of posthypoxic seizures occurred at a point in time preceding significant changes in brain tissue ATP level. Since injury occurs prior to ATP reduction, changes in brain tissue ATP level may not be an appropirate endpoint for determining brain tissue injury in hypoxia.

Recovery from herpes simplex of the mouth occurred within 24 to 48 hours when cryotherapy was applied with in three days of the appearance of vesicles. In all but two of the 127 patients treated, a single treatment was sufficient to stop the morbid process. When treatment was applied at the onset of prodromic symptoms, vesicular formation ceased.

Presented in part at the 53rd Annual Meeting of the American Society of Hematology, San Diego, CA, December 10-13, 2011, and the 17th Congress of the European Haematology Association, Amsterdam, June 14-17, 2012. Therapeutic options are limited for elderly patients with acute myeloid leukemia (AML). A phase Ib/II study was undertaken to evaluate the maximum-tolerated dose (MTD) and preliminary efficacy of the pan-histone deacetylase inhibitor panobinostat (LBH589) in combination with azacitidine in patients with AML or high-risk myelodysplastic syndrome (MDS) naïve to intensive chemotherapy. Thirty-nine patients (AML=29, MDS=10) received azacitidine 75 mg/m2 subcutaneously (days 1-5) and oral panobinostat (starting on day 5, thrice weekly for seven doses) in 28-day cycles until toxicity or disease progression. Dose-limiting toxicities during the phase Ib stage were observed in 0/4 patients receiving 10 mg panobinostat, in 1/7 patients (fatigue) receiving 20 mg, in 1/6 patients (fatigue) receiving 30 mg and in 4/5 patients (fatigue, syncope, hyponatremia and somnolence) receiving 40 mg. In phase II, an additional 17 patients received panobinostat at a MTD of 30 mg. The overall response rate (ORR=CR+CRi+PR) in patients with AML was 31% (9/29) and that in patients with MDS was 50% (5/10). After a median follow-up of 13 months, the median overall survival was 8 and 16 months in patients with AML and MDS, respectively. Increased histone H3 and H4 acetylation was a useful early biomarker of clinical response. Combining panobinostat with azacitidine was tolerable and clinically active in high-risk MDS/AML patients, warranting further exploration. Refereed/Peer-reviewed