Albert J. Rogers

A High-Fiber Diet Does Not Protect Against Asymptomatic Diverticulosis

BACKGROUND & AIMS The complications of diverticulosis cause considerable morbidity in the United States; health care expenditures for this disorder are estimated to be

FMN fluorescence in inducible NOS constructs reveals a series of conformational states involved in the reductase catalytic cycle.

2.5 billion per year. Many physicians and patients believe that a high-fiber diet and frequent bowel movements prevent the development of diverticulosis. Evidence for these associations is poor. We sought to determine whether low-fiber or high-fat diets, diets that include large quantities of red meat, constipation, or physical inactivity increase risk for asymptomatic diverticulosis. METHODS We performed a cross-sectional study of 2104 participants, 30-80 years old, who underwent outpatient colonoscopy from 1998 to 2010. Diet and physical activity were assessed in interviews using validated instruments. RESULTS The prevalence of diverticulosis increased with age, as expected. High intake of fiber did not reduce the prevalence of diverticulosis. Instead, the quartile with the highest fiber intake had a greater prevalence of diverticulosis than the lowest (prevalence ratio = 1.30; 95% confidence interval, 1.13-1.50). Risk increased when calculated based on intake of total fiber, fiber from grains, soluble fiber, and insoluble fiber. Constipation was not a risk factor. Compared to individuals with <7 bowel movements per week, individuals with >15 bowel movements per week had a 70% greater risk for diverticulosis (prevalence ratio = 1.70; 95% confidence interval, 1.24-2.34). Neither physical inactivity nor intake of fat or red meat was associated with diverticulosis. CONCLUSIONS A high-fiber diet and increased frequency of bowel movements are associated with greater, rather than lower, prevalence of diverticulosis. Hypotheses regarding risk factors for asymptomatic diverticulosis should be reconsidered.

Three-dimensional ultrasound guidance of autonomous robotic breast biopsy: feasibility study.

Nitric oxide synthases (NOSs) produce NO as a molecular signal in the nervous and cardiovascular systems and as a cytotoxin in the immune response. NO production in the constitutive isoforms is controlled by calmodulin regulation of electron transfer. In the tethered shuttle model for NOS reductase function, the FMN domain moves between NADPH dehydrogenase and oxygenase catalytic centers. Crystal structures of neuronal NOS reductase domain and homologs correspond to an ‘input state’, with FMN in close contact with FAD. We recently produced two domain ‘output state’ (oxyFMN) constructs showing calmodulin dependent FMN domain association with the oxygenase domain. FMN fluorescence is sensitive to enzyme conformation and calmodulin binding. The inducible NOS (iNOS) oxyFMN construct is more fluorescent than iNOS holoenzyme. The difference in steady state fluorescence is rationalized by the observation of a series of characteristic states in the two constructs, which we assign to FMN in different environments. OxyFMN and holoenzyme share open conformations with an average lifetime of ∼ 4.3 ns. The majority state in holoenzyme has a short lifetime of ∼ 90 ps, probably because of FAD–FMN interactions. In oxyFMN about 25–30% of the FMN is in a state with a lifetime of 0.9 ns, which we attribute to quenching by heme in the output state. Occupancy of the output state together with our previous kinetic results yields a heme edge to FMN distance estimate of 12–15 Å. These results indicate that FMN fluorescence is a valuable tool to study conformational states involved in the NOS reductase catalytic cycle.

3-D ultrasound guidance of autonomous robot for location of ferrous shrapnel

Feasibility studies of autonomous robot biopsies in tissue have been conducted using real-time three-dimensional (3-D) ultrasound combined with simple thresholding algorithms. The robot first autonomously processed 3-D image volumes received from the ultrasound scanner to locate a metal rod target embedded in turkey breast tissue simulating a calcification, and in a separate experiment, the center of a water-filled void in the breast tissue simulating a cyst. In both experiments the robot then directed a needle to the desired target, with no user input required. Separate needle-touch experiments performed by the image-guided robot in a water tank yielded an rms error of 1.15 mm. (E-mail: kaicheng.liang@duke.edu).

The impact of endoscopic ultrasound findings on clinical decision making in Barrett's esophagus with high-grade dysplasia or early esophageal adenocarcinoma

Vibrations can be induced in ferromagnetic shrapnel by a variable electromagnet. Real time 3-D color Doppler ultrasound located the induced motion in a needle fragment and determined its 3-D position in the scanner coordinates. This information was used to guide a robot which moved a probe to touch the shrapnel fragment.

Simulation of Autonomous Robotic Multiple-Core Biopsy by 3D Ultrasound Guidance

The clinical utility of endoscopic ultrasound (EUS) for staging patients with Barretts esophagus and high-grade dysplasia (HGD) or intramucosal carcinoma (IMC) prior to endoscopic therapy is unclear. We performed a retrospective analysis of patients with HGD or IMC referred to an American medical center for endoscopic treatment between 2004 and 2010. All patients had pretreatment staging by EUS. We examined the frequency that EUS findings consistent with advanced disease (tumor invasion into the submucosa, lymph node involvement, or regional metastasis) led to a change in management. The analysis was stratified by nodularity and pre-EUS histology. We identified one hundred thirty-five patients with HGD (n = 106, 79%) or IMC (n = 29, 21%) had staging by EUS (79 non-nodular, 56 nodular). Pathologic lymph nodes or metastases were not found by EUS. There were no endosonographic abnormalities noted in any patient with non-nodular mucosa (0/79). Abnormal EUS findings were present in 8/56 patients (14%) with nodular neoplasia (five IMC, three HGD). Endoscopic mucosal resection was performed in 44 patients with a nodule, with 13% (6/44) having invasive cancer. In nodular neoplasia, the EUS and endoscopic mucosal resection were abnormal in 24% (5/21) and 40% (6/15) of those with IMC and 9% (3/35) and 0% (0/29) of those with HGD, respectively. In this study we found that EUS did not alter management in patients with non-nodular HGD or IMC. Because the diagnostic utility of EUS in subjects with non-nodular Barretts esophagus is low, the value of performing endoscopic mucosal resection in this setting is questionable. For patients with nodular neoplasia, resection of the nodule with histological examination had greater utility than staging by EUS.

Clinical Implications of Ablation of Drivers for Atrial Fibrillation: A Systematic Review and Meta-Analysis

An autonomous multiple-core biopsy system guided by real-time 3D ultrasound and operated by a robotic arm with 6+1 degrees of freedom has been developed. Using a specimen of turkey breast as a tissue phantom, our system was able to first autonomously locate the phantom in the image volume and then perform needle sticks in each of eight sectors in the phantom in a single session, with no human intervention required. Based on the fraction of eight sectors successfully sampled in an experiment of five trials, a success rate of 93% was recorded. This system could have relevance in clinical procedures that involve multiple needle-core sampling such as prostate or breast biopsy.

3-D ultrasound guidance of autonomous surgical robotics: Feasibility studies

Background: The outcomes from pulmonary vein isolation (PVI) for atrial fibrillation (AF) are suboptimal, but the benefits of additional lesion sets remain unproven. Recent studies propose ablation of AF drivers improves outcomes over PVI, yet with conflicting reports in the literature. We undertook a systematic literature review and meta-analysis to determine outcomes from ablation of AF drivers in addition to PVI or as a stand-alone procedure. Methods: Database search was done using the terms atrial fibrillation and ablation or catheter ablation and driver or rotor or focal impulse or FIRM (Focal Impulse and Rotor Modulation). We pooled data using random effects model and assessed heterogeneity with I2 statistic. Results: Seventeen studies met inclusion criteria, in a cohort size of 3294 patients. Adding AF driver ablation to PVI reported freedom from AF of 72.5% (confidence interval [CI], 62.1%–81.8%; P<0.01) and from all arrhythmias of 57.8% (CI, 47.5%–67.7%; P<0.01). AF driver ablation when added to PVI or as stand-alone procedure compared with controls produced an odds ratio of 3.1 (CI, 1.3–7.7; P=0.02) for freedom from AF and an odds ratio of 1.8 (CI, 1.2–2.7; P<0.01) for freedom from all arrhythmias in 4 controlled studies. AF termination rate was 40.5% (CI, 30.6%–50.9%) and predicted favorable outcome from ablation(P<0.05). Conclusions: In controlled studies, the addition of AF driver ablation to PVI supports the possible benefit of a combined approach of AF driver ablation and PVI in improving single-procedure freedom from all arrhythmias. However, most studies are uncontrolled and are limited by substantial heterogeneity in outcomes. Large multicenter randomized trials are needed to precisely define the benefits of adding driver ablation to PVI.

Real-time 3D ultrasound guidance of autonomous surgical robot for shrapnel detection and breast biopsy

In 2006 our laboratory showed that a matrix array endoscope capable of real-time 3D (RT3D) scanning could be used to guide a surgical robot with an rms error of less than 2mm. In 2007, image segmentation software was developed to achieve autonomous RT3D guidance of the robot with no human/robot interaction required, and a cyst phantom in tissue-mimicking slurry was successfully targeted. In this paper, we examine three new topics in autonomous robotic guidance: (1) cyst biopsy in breast tissue, (2) the detection of ferrous shrapnel, and (3) prostate biopsy. We tested the accuracy of the scanner in automatically directing a robot arm which performed the said tasks on suitable tissue phantoms in a water tank.

Independent mapping methods reveal rotational activation near pulmonary veins where atrial fibrillation terminates before pulmonary vein isolation

Two studies have been conducted using real time 3D ultrasound and an automated robot system for carrying out surgical tasks. The first task is to perform a breast lesion biopsy automatically after detection by ultrasound. Combining 3D ultrasound with traditional mammography allows real time guidance of the biopsy needle. Image processing techniques analyze volumes to calculate the location of a target lesion. This position was converted into the coordinate system of a three axis robot which moved a needle probe to touch the lesion. The second task is to remove shrapnel from a tissue phantom autonomously. In some emergency situations, shrapnel detection in the body is necessary for quick treatment. Furthermore, small or uneven shrapnel geometry may hinder location by typical ultrasound imaging methods. Vibrations and small displacements can be induced in ferromagnetic shrapnel by a variable electromagnet. We used real time 3D color Doppler to locate this motion for 2 mm long needle fragments and determined the 3D position of the fragment in the scanner coordinates. The rms error of the image guided robot for 5 trials was 1.06 mm for this task which was accomplished in 76 seconds.