R. Eric Heidel

Pyloromyotomy: randomized control trial of laparoscopic vs open technique

PURPOSE Open pyloromyotomy remains as the criterion standard treatment for hypertrophic pyloric stenosis with the laparoscopic approach rapidly gaining adoption. We present a prospective, randomized trial between the 2 approaches. METHODS After institutional review board approval, 98 patients with hypertrophic pyloric stenosis were consecutively randomized to either open or laparoscopic pyloromyotomy. Postoperative and hospital course were evaluated by review of the hospital records and long-term follow-up with scripted telephone survey using Likert scales. The length of operating room time, surgical procedure, postoperative stay, time to refeeding, and complications were evaluated. Secondary outcomes of cosmetic results and parental satisfaction were determined. RESULTS Ninety-eight patients were enrolled during a 4-year period. There were no significant differences between 2 groups on all primary outcomes. There were 3 complications in the open group-a wound dehiscence, a surgical site infection, and a gastric serosal tear-and 2 complications in the laparoscopic group-mucosal perforation and a suture granuloma. In long-term follow-up on 72 patients (56 months), parents described significant cosmetic results with laparoscopic approach. CONCLUSIONS There was no difference in operating time, hospital stay, or refeeding patterns between open and laparoscopic pyloromyotomy. The complication rates were similar between the 2 methods. However, long-term cosmetic results were significantly superior in the laparoscopic group.

p16 Immunohistochemistry Can Be Used to Detect Human Papillomavirus in Oral Cavity Squamous Cell Carcinoma

PURPOSE Human papillomavirus (HPV) is of etiologic significance in the development of oral squamous carcinoma and is noted to result in p16 overexpression. Identification of HPV is clinically important because the presence of HPV has prognostic and epidemiologic associations. Detection of HPV by polymerase chain reaction (PCR) is expensive and not widely accessible. The authors examined p16 immunohistochemistry (IHC) as a surrogate marker for high-risk HPV and its use as an alternative test to PCR. PATIENTS AND METHODS A retrospective cohort of patients with oral squamous cell carcinoma underwent surgery and then analysis with p16 IHC and HPV PCR. The p16 IHC staining intensity was graded from 0 to 3+, and these results were compared with PCR. Descriptive and frequency statistics were performed by comparing HPV PCR results with p16 IHC, patient age, gender, and outcome. RESULTS Eighty-one cases were included in the study. Forty-four study patients were men and 37 were women (mean age, 63.9 yr). Forty-five cases (55.6%) had 0 staining, 22 cases (27.2%) had 1+ staining, and 7 cases (8.6%) had 2+ staining. Seven cases (8.6%) had 3+ staining, all of which were positive for HPV serotype 16 by PCR. Three of 7 HPV PCR-positive cases had keratinization typical of an oral cavity location and not the basaloid growth of HPV oropharyngeal tumors. There was a statistical correlation (P < .001) among HPV PCR positivity, 3+ staining, and younger age. CONCLUSION p16 3+ staining correlates with HPV PCR positivity. p16 IHC is a technically simple and widely available test, and this study establishes the use of p16 IHC as an alternative test to HPV PCR. Given the clinical significance of HPV in oral squamous carcinoma, p16 IHC should be performed in all cases and included in the pathology report.

Online Training on the Safe Use of Fluoroscopy Can Result in a Significant Decrease in Patient Dose

RATIONALE AND OBJECTIVES Concerns over medical radiation exposure have received national press in recent years, and training in the appropriate use of radiation has become an essential component of every radiology residency program. Appropriate training is particularly important in fluoroscopy because it is commonly used by inexperienced radiology residents and has the potential to impart relatively high patient radiation doses. In an effort to minimize the radiation doses received by patients, our institution has recently initiated an online training program in the safe use of fluoroscopy. This course is required and must be completed by new radiology residents before their first fluoroscopy rotation. The goal of this study was to determine if the use of an online course in the safe use of fluoroscopy could result in decreased patient dose without affecting diagnostic quality. MATERIALS AND METHODS Four years of retrospective procedural data for residents performing gastrointestinal and genitourinary fluoroscopic procedures without specialized training were reviewed. Incoming residents took an American Medical Association-accredited online training program in the safe use of fluoroscopy the week before their first fluoroscopy rotation. Patient dose and diagnostic quality data, inferred from the frequency of attending physician intervention necessary to complete the procedure, were collected for all exams performed by the new group of residents after completion of the training course. This was then compared to data from prior classes and stratified by procedure type. RESULTS Statistically significant reductions in both average fluoroscopy time (FT) or dose-area-product (DAP) were found for many of the fluoroscopic procedures performed by residents who participated in the online fluoroscopy training program. Specifically, statistically significant reductions in FT for barium enema, cystogram, defecogram, and esophagram procedures (P < .001) were found. Esophagram and upper gastrointestinal studies were completed with a significantly lower DAP (P < .001). The average reduction in DAP across all procedures performed by first-year residents was 38%, whereas the average reduction in FT was 25%. Based on a review of data from all procedures performed, there was no statistically significant loss in diagnostic quality. CONCLUSION An online training program can be effectively used to provide radiation safety instruction immediately before the start of a residents fluoroscopy rotation, decreasing patient dose without affecting diagnostic quality.

Simulation-Based Educational Curriculum for Fluoroscopically Guided Lumbar Puncture Improves Operator Confidence and Reduces Patient Dose

RATIONALE AND OBJECTIVES Fluoroscopically guided lumbar puncture (FGLP) is a commonly performed procedure with increased success rates relative to bedside technique. However, FGLP also exposes both patient and staff to ionizing radiation. The purpose of this study was to determine if the use of a simulation-based FGLP training program using an original, inexpensive lumbar spine phantom could improve operator confidence and efficiency, while also reducing patient dose. MATERIALS AND METHODS A didactic and simulation-based FGLP curriculum was designed, including a 1-hour lecture and hands-on training with a lumbar spine phantom prototype developed at our institution. Six incoming post-graduate year 2 (PGY-2) radiology residents completed a short survey before taking the course, and each resident practiced 20 simulated FGLPs using the phantom before their first clinical procedure. Data from the 114 lumbar punctures (LPs) performed by the six trained residents (prospective cohort) were compared to data from 514 LPs performed by 17 residents who did not receive simulation-based training (retrospective cohort). Fluoroscopy time (FT), FGLP success rate, and indication were compared. RESULTS There was a statistically significant reduction in average FT for the 114 procedures performed by the prospective study cohort compared to the 514 procedures performed by the retrospective cohort. This held true for all procedures in aggregate, LPs for myelography, and all procedures performed for a diagnostic indication. Aggregate FT for the prospective group (0.87 ± 0.68 minutes) was significantly lower compared to the retrospective group (1.09 ± 0.65 minutes) and resulted in a 25% reduction in average FT (P = .002). There was no statistically significant difference in the number of failed FGLPs between the two groups. CONCLUSIONS Our simulation-based FGLP curriculum resulted in improved operator confidence and reduced FT. These changes suggest that resident procedure efficiency was improved, whereas patient dose was reduced. The FGLP training program was implemented by radiology residents and required a minimal investment of time and resources. The LP spine phantom used during training was inexpensive, durable, and effective. In addition, the phantom is compatible with multiple modalities including fluoroscopy, computed tomography, and ultrasound and could be easily adapted to other applications such as facet injections or joint arthrograms.

Comparative evaluation of p5+14 with SAP and peptide p5 by dual-energy SPECT imaging of mice with AA amyloidosis.

Amyloidosis is a protein-misfolding disorder characterized by the extracellular deposition of amyloid, a complex matrix composed of protein fibrils, hyper-sulphated glycosaminoglycans and serum amyloid P component (SAP). Accumulation of amyloid in visceral organs results in the destruction of tissue architecture leading to organ dysfunction and failure. Early differential diagnosis and disease monitoring are critical for improving patient outcomes; thus, whole body amyloid imaging would be beneficial in this regard. Non-invasive molecular imaging of systemic amyloid is performed in Europe by using iodine-123-labelled SAP; however, this tracer is not available in the US. Therefore, we evaluated synthetic, poly-basic peptides, designated p5 and p5+14, as alternative radiotracers for detecting systemic amyloidosis. Herein, we perform a comparative effectiveness evaluation of radiolabelled peptide p5+14 with p5 and SAP, in amyloid-laden mice, using dual-energy SPECT imaging and tissue biodistribution measurements. All three radiotracers selectively bound amyloid in vivo; however, p5+14 was significantly more effective as compared to p5 in certain organs. Moreover, SAP bound principally to hepatosplenic amyloid, whereas p5+14 was broadly distributed in numerous amyloid-laden anatomic sites, including the spleen, liver, pancreas, intestines and heart. These data support clinical validation of p5+14 as an amyloid radiotracer for patients in the US.

The Impact of an Antireflux Catheter on Target Volume Particulate Distribution in Liver-Directed Embolotherapy: A Pilot Study

PURPOSE To determine if there are differences in hepatic distribution of embolic particles following infusion with a standard end-hole catheter versus an antireflux microcatheter. MATERIALS AND METHODS This prospective study included nine patients (age, 48-86 y) enrolled for treatment of hepatocellular carcinoma (n = 6), liver-dominant metastatic disease (n = 2), or intrahepatic cholangiocarcinoma (n = 1) with resin yttrium-90 ((90)Y) microspheres. Before (90)Y treatment, each patient received two same-day sequential lobar infusions of technetium 99m ((99m)Tc) macroaggregated albumin (MAA) via a conventional end-hole catheter and an antireflux microcatheter positioned at the same location. Differences in technetium 99m-MAA distribution within tumor and nontarget sites were evaluated by single-photon emission computed tomography (SPECT) on a qualitative and semiquantitative basis. The antireflux microcatheter was used for the ensuing (90)Y treatment, with posttreatment (90)Y positron emission tomography/computed tomography to assess distribution of (90)Y microspheres. RESULTS Decreases in hepatic nontarget embolization were found in all patients when the antireflux catheter was used. These decreases ranged from a factor of 0.11 to a factor of 0.76 (mean, 0.42; σ = 0.19), representing a 24%-89% reduction. Increased tumor deposition was also noted in all patients, ranging from a factor of 1.33 to a factor of 1.90 (mean, 1.68; σ = 0.20), representing a relative increase of 33%-90%. Both findings were statistically significant (P < .05). CONCLUSIONS Although this pilot study identified differences in the downstream distribution of embolic particles when the antireflux catheter was used, further investigation is needed to determine if these findings are reproducible in a larger patient cohort and, if so, whether they are associated with any clinical impact.

Comparison of bacteria isolated from emergency department patients versus hospitalized patients

PURPOSE The frequencies and corresponding susceptibilities of bacteria isolated from patients in the emergency department (ED) were compared with those from hospitalized patients. METHODS A microbiology laboratory report of all positive bacterial cultures obtained in the ED, regardless of the source (e.g., blood, urine, sputum), was obtained. In the case of duplicate cultures, only the first isolate cultured from a single patient was included. Colonization-site cultures (e.g., nasal swabs) and culture reports identified by the laboratory as contaminant organisms were excluded from the evaluation. Antimicrobial susceptibility results were then compiled into a standardized ED-specific antibiogram. Antimicrobial susceptibilities for each pathogen in the ED antibiogram were compared with those in the hospitalwide antibiogram. If there was a difference of ≥5% between the susceptibility of a single antimicrobial agent, chi-square tests were conducted, and unadjusted odds ratios were calculated. Pathogens with fewer than 30 isolates were excluded from the susceptibility comparison. RESULTS A total of 3140 cultures were evaluated (1417 from the ED, 1723 from the hospital). The frequencies of pathogens isolated in the ED and hospitalwide were similar, with the exception of Escherichia coli, which were more commonly isolated in ED patients, and Enterococcus species and Pseudomonas aeruginosa, which were more common in hospitalized patients. Significant differences in susceptibility profiles were identified for Staphylococcus aureus, coagulase-negative Staphylococcus, Enterococcus faecalis, E. coli, Klebsiella pneumoniae, and P. aeruginosa. CONCLUSION Significant differences in the frequencies of bacteria isolated and corresponding susceptibilities were found in cultures obtained in ED patients compared with those obtained in hospitalized patients.

Secondary structure propensity and chirality of the amyloidophilic peptide p5 and its analogues impacts ligand binding - In vitro characterization

Background Polybasic helical peptides, such as peptide p5, bind human amyloid extracts and synthetic amyloid fibrils. When radiolabeled, peptide p5 has been shown to specifically bind amyloid in vivo thereby allowing imaging of the disease. Structural requirements for heparin and amyloid binding have been studied using analogues of p5 that modify helicity and chirality. Methods Peptide-ligand interactions were studied using CD spectroscopy and solution-phase binding assays with radiolabeled p5 analogues. The interaction of a subset of peptides was further studied by using molecular dynamics simulations. Results Disruption of the peptide helical structure reduced peptide binding to heparin and human amyloid extracts. The all-D enantiomer and the β-sheet-structured peptide bound all substrates as well as, or better than, p5. The interaction of helical and β-sheet structured peptides with Aβ fibrils was modeled and shown to involve both ionic and non-ionic interactions. Conclusions The α-helical secondary structure of peptide p5 is important for heparin and amyloid binding; however, helicity is not an absolute requirement as evidenced by the superior reactivity of a β-sheet peptide. The differential binding of the peptides with heparin and amyloid fibrils suggests that these molecular interactions are different. The all-D enantiomer of p5 and the β-sheet peptide are candidates for amyloid targeting reagents in vivo. General Significance Efficient binding of polybasic peptides with amyloid is dependent on the linearity of charge spacing in the context of an α-helical secondary structure. Peptides with an α-helix or β-sheet propensity and with similar alignment of basic residues is optimal.

Comparison of Temporal Artery and Axillary Temperatures in Healthy Newborns

OBJECTIVE To compare temperature readings of temporal artery and axillary thermometers in healthy late preterm and term infants in an effort to standardize practice. DESIGN Descriptive comparative. SETTING Thirty-bed, healthy mother/baby unit in an inner-city Level-1 trauma center, averaging 2,500 births per year. PARTICIPANTS Healthy newborns (N = 125) admitted to mother/baby unit after birth, at least 35 weeks gestation, and weighing greater than 1,900 grams. METHODS Temperatures were taken at regular intervals per unit protocol. At each interval temporal and axillary temperatures were recorded. RESULTS Temporal temperatures were significantly higher (M = 36.9°C, SD = .59) than axillary temperatures (M = 36.7°C, SD = .68), t(124) = 6.74, p < .0001. Although statistical significance was shown between the two groups, no meaningful clinical difference was detected. CONCLUSION Our study findings supported a new nursing practice standard for measuring infant temperatures in our mother/baby unit. Using temporal artery thermometers is now our units standard of care for healthy newborns.

Assessing the Value of Online Learning and Social Media in Pharmacy Education

Objective. To assess student preferences regarding online learning and technology and to evaluate student pharmacists’ social media use for educational purposes. Methods. An anonymous 36-question online survey was administered to third-year student pharmacists enrolled in the Drug Information and Clinical Literature Evaluation course. Results. Four hundred thirty-one students completed the survey, yielding a 96% response rate. The majority of students used technology for academic activities, with 90% using smart phones and 91% using laptop computers. Fifty-eight percent of students also used social networking websites to communicate with classmates. Conclusion. Pharmacy students frequently use social media and some online learning methods, which could be a valuable avenue for delivering or supplementing pharmacy curricula. The potential role of social media and online learning in pharmacy education needs to be further explored.