Faculty Bibliography

BACKGROUND:The safety of opiate use for patients with Crohn's disease (CD) has long been a concern. The recent Crohn's therapy, resource, evaluation, and assessment tool (TREAT) registry update has added to these concerns by demonstrating an association of opiate use with an increased risk of infection and death in CD. While the association is clear, the relationship of opiates to these negative outcomes is not. It is unknown whether opiates are a contributing factor to these negative outcomes or if their use is merely a marker of more severe disease. We hypothesized that opiate use is not harmful in CD but is a marker of disease severity and would be associated with commonly accepted clinical markers of severe CD such as early age at CD onset, disease duration, small intestinal involvement, a history of fistula or stricture, and lower quality of life (QOL) scores. METHODS:Data on CD history including pain medication usage were obtained from an interviewer directed survey of patients admitted to two tertiary care hospitals over a 2-year period. CD as the primary admitting diagnosis was not required. Active opiate use was defined by usage within the past month prior to admission. RESULTS:A total of 133 patients were approached to participate, of whom 108 consented to the survey, and 51 were active opiate users. Opiate using CD patients were more commonly smokers (22% vs. 3.45%, P < 0.010), had fistulas (40% vs. 22.4%, P < 0.048) and had a poorer quality of life score by short form inflammatory bowel disease questionnaire (mean 3.80 vs. 4.34, P < 0.036) than non-opiate users. No difference was found between opiate users and non-users for age of diagnosis, disease duration, or a history of strictures. CONCLUSIONS:The study findings demonstrate that opiate use in CD is associated with markers of disease severity including fistulas, smoking, and lower QOL scores. The findings suggest that opiates may not be directly harmful to patients with CD, but may merely be another marker of disease severity. However, given opiates unproven benefits for long term CD pain control and risk of dependence, caution should still be exercised in their use.

TLR7 enhances germinal center maturation and migration of B cells to the dark zone where proliferation and somatic hypermutation occur. Our goal was to determine how Tlr7 dose influences selection of the autoreactive B cell repertoire in NZW/BXSB. Yaa mice bearing the site-directed heavy chain transgene 3H9 that encodes for the TLR7 regulated anti-CL response. To create a physiologic setting in which autoreactive B cells compete for survival with non-autoreactive B cells, we generated bone marrow chimeras in which disease onset occurred with similar kinetics and the transferred 3H9+ female non-Yaa, male Yaa or male TLR7(-/Yaa) cells could be easily identified by positivity for GFP. Deletion of 3H9 B cells occurred in the bone marrow and the remaining 3H9 follicular B cells manifested a decrease in surface IgM. Although there were differences in the naïve repertoire between the chimeras it was not possible to distinguish a clear pattern of selection against lupus related autoreactivity in TLR7(-/Yaa) or female chimeras. By contrast, preferential expansion of 3H9+ B cells occurred in the germinal centers of male Yaa chimeras. In addition, although all chimeras preferentially selected 3H9/Vκ5 encoded B cells into the germinal center and plasma cell compartments, 3H9 male Yaa chimeras had a more diverse repertoire and positively selected the 3H9/Vκ5-48/Jκ4 pair that confers high affinity anti-cardiolipin activity. We were unable to demonstrate a consistent effect of Tlr7 dose or Yaa on somatic mutations. Our data show that TLR7 excess influences the selection, expansion and diversification of B cells in the germinal center, independent of other genes in the Yaa locus.

BACKGROUND AND OBJECTIVES/OBJECTIVE:Within the past few years, there has been a push for an even more minimally invasive approach to biliary disease with the adoption of single-incision laparoscopic cholecystectomy. We sought to compare 4 individual surgeon experiences to define whether there exists a learning curve for performing single-incision laparoscopic cholecystectomy. METHODS:We performed a retrospective review 290 single-incision laparoscopic cholecystectomies performed by a group of general surgeons, with varying levels of experience and training, at 3 institutions between May 2008 and September 2010. The procedure times were recorded for each single-incision laparoscopic cholecystectomy, ordered chronologically for each surgeon, and subsequently plotted on a graph. The patients were also combined into cohorts of 5 and 10 cases to further evaluate for signs of improvement in operative efficiency. RESULTS:Of the 4 surgeons involved in the study, only 1 (surgeon 4, laparoscopic fellowship trained with <5 years' experience) confirmed the presence of a learning curve, reaching proficiency within the first 15 cases performed. The other surgeons had more variable procedure times, which did not show a distinct trend. When we evaluated the cases by cohorts of 5 cases, surgeon 4 had a significant difference between the first and last cohort. Increased body mass index resulted in a slightly longer operative time (P < .0063). The conversion rate to multiport laparoscopic surgery was 3.1%. CONCLUSIONS:Our results indicate that among experienced general surgeons, there does not seem to be a significant learning curve when transitioning from conventional laparoscopic cholecystectomy to single-incision laparoscopic cholecystectomy. The least experienced surgeon in the group, surgeon 4, appeared to reach proficiency after 15 cases. Greater than 5 years of experience in laparoscopic surgery appears to provide surgeons with a sufficient skill set to obviate the need for a single-incision laparoscopic cholecystectomy learning curve.

AIM/OBJECTIVE:To evaluate the completion rate and diagnostic yield of the PillCam SB2-ex in comparison to the PillCam SB2. METHODS:Two hundred cases using the 8-h PillCam SB2 were retrospectively compared to 200 cases using the 12 h PillCam SB2-ex at a tertiary academic center. Endoscopically placed capsules were excluded from the study. Demographic information, indications for capsule endoscopy, capsule type, study length, completion of exam, clinically significant findings, timestamp of most distant finding, and significant findings beyond 8 h were recorded. RESULTS:The 8 and 12 h capsule groups were well matched respectively for both age (70.90 ± 14.19 vs 71.93 ± 13.80, P = 0.46) and gender (45.5% vs 48% male, P = 0.69). The most common indications for the procedure in both groups were anemia and obscure gastrointestinal bleeding. PillCam SB2-ex had a significantly higher completion rate than PillCam SB2 (88% vs 79.5%, P = 0.03). Overall, the diagnostic yield was greater for the 8 h capsule (48.5% for SB2 vs 35% for SB2-ex, P = 0.01). In 4/70 (5.7%) of abnormal SB2-ex exams the clinically significant finding was noted in the small bowel beyond the 8 h mark. CONCLUSION/CONCLUSIONS:In our study, we found the PillCam SB2-ex to have a significantly increased completion rate, though without any improvement in diagnostic yield compared to the PillCam SB2.

INTRODUCTION/BACKGROUND:The appropriateness of steroid maintenance in pancreas transplantation is unproven. The current literature is insufficient due to small numbers, short follow-up and sparse data. METHODS:Data from the UNOS database on adults ≥18 years old, who received pancreas and kidney-pancreas transplants between January 1996 and March 2014 were analyzed (n = 27,077). Two groups were evaluated: (a) Steroids Induction only (n = 4391) and (b) Steroid maintenance (n = 22,686). One-, 3-, 5-, 10-, and 15-year unadjusted patient and graft survival rates were compared. A Cox proportional hazards model was used to determine what patient factors were associated with these outcomes. RESULTS:There were differences in patient survival at 1 and 3 years and in graft survival at 3 and 5 years. There was a higher rate of infectious complications in the maintenance group, but after controlling for several recipient factors, whether a patient received steroid maintenance or not, was not significantly associated with the risk of death or graft failure. CONCLUSION/CONCLUSIONS:The use of maintenance steroids is significantly associated with an increased risk of infectious complications, but no difference in patient death or graft failure after controlling for multiple recipient factors. There is also no benefit with the use of steroid maintenance after pancreas transplantation.

OBJECTIVE:To investigate the ability of medical infrared imaging to differentiate between normal canine elbows and those with abnormal elbows (elbow dysplasia). STUDY DESIGN/METHODS:Prospective cohort study. ANIMALS/METHODS:Dogs with normal (n = 15) and abnormal (n = 14) elbows. METHODS:Infrared imaging was performed on all dogs and data analyzed via descriptive statistics and image pattern analysis software. Animals with elbow dysplasia had arthroscopic procedures to confirm the presence of elbow disease. RESULTS:Computer recognition pattern analysis was up to 100% correct in identifying abnormal elbows and normal elbows, with the medial images most consistent. The caudal, lateral, and cranial images correctly identified 83-100% abnormal elbows. The caudal and lateral images correctly identified 83% normal elbows. A significant difference in temperature was found between normal and abnormal elbows for the cranial full region of interest, lateral images, and each quadrant. CONCLUSION/CONCLUSIONS:Medical infrared imaging was able to correctly identify known abnormal and known normal elbows in dogs.

INTRODUCTION AND HYPOTHESIS: In 2012, the American Urological Association (AUA) revised its guidelines for microscopic hematuria (MH). We hypothesize that the prevalence of MH is greater in women with pelvic organ prolapse than in the general population. METHODS: All patients presenting to an outpatient urogynecological center with prolapse between January 2008 and December 2011 were reviewed. Exclusion criteria included: pregnancy, presence of gross hematuria, menses, or urological pathology. MH was defined as >/=3 red blood cells per high power field on one urinalysis specimen with a negative urine culture, and the prevalence of MH was calculated. Statistical analysis was performed. RESULTS: One thousand and forty women with pelvic organ prolapse were included in the analysis. Mean age was 64.1 years (range 20 to 96) and mean parity was 2.7 (range 0 to 12). Two hundred and nine out of 1,040 met the criteria for MH. No cases of urological malignancy were diagnosed in patients who underwent further workup. One hundred and ninety-seven patients with MH (93.4 %) had cystoceles on examination. CONCLUSIONS: This is the largest study to investigate MH in women with prolapse based on the new guidelines. The prevalence of MH was 20.1 % in our study population. Cystoscopy, renal function testing, and CT urography are now recommended after one positive urinalysis, regardless of gender or the presence of prolapse. Owing to the low incidence of urological malignancy detected as well as the increased prevalence of MH found in women with prolapse, specific guidelines for the management of MH in this population are needed.

The aim of the study was to assess outcomes of pancreas retransplantation versus primary pancreas transplantation. METHODS: Data from the United Network for Organ Sharing database on all adult (age, >/=18 years) subjects who received pancreas and kidney-pancreas transplants between 1996 and 2012 were analyzed (n = 20,854). The subjects were analyzed in the following 2 groups: retransplant (n = 1149) and primary transplant (n = 19,705). RESULTS: Kaplan-Meier analysis demonstrated significantly different patient survival (P < 0.0001) and death-censored graft survival (P < 0.0001) between the primary transplant versus retransplant subjects. Allograft survival was significantly poorer in the retransplantation group. Patient survival was greater in the retransplant group. CONCLUSIONS: The results of our study differ from previous studies, which showed similar allograft survival in primary and secondary pancreas transplants. Further studies may elucidate specific patients who will benefit from retransplantation. At the present time, it would appear that pancreas retransplantation is associated with poor graft survival and that retransplantation should not be considered for all patients with primary pancreatic allograft failure.