Publications by authors named "Amy Evenson"

33 Publications

Identification of Specific Educational Targets to Improve the Student Surgical Clerkship Experience.

J Surg Res 2020 10 11;254:49-57. Epub 2020 May 11.

Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.

Background: This study describes the relationship between medical student perception of surgery, frequency of positive surgery clerkship activities, and overall surgical clerkship experience.

Methods: Medical students at four academic hospitals completed pre- and post-clerkship surveys assessing 1) surgery clerkship activities/experiences and 2) perceptions of surgery during the 2017-2018 academic year.

Results: Ninety-one percent of students completed both a pre- and post-clerkship survey (n = 162 of 179). Student perception of surgery significantly improved across the clerkship overall (P < 0.0001) and for 7 of 21 specific items. Eighty-six percent of students agreed that the clerkship was a meaningful experience. Sixty-six percent agreed that the operating room was a positive learning environment. Multivariable logistic regression identified one-on-one mentoring from a resident (OR [95% CI] = 2.12 [1.11-4.04], P = 0.02) and establishing a meaningful relationship with a surgical patient (OR = 2.21 [1.12-4.37], P = 0.02) as activities predictive of student agreement that the surgical clerkship was meaningful. Making an incision (OR = 2.92 [1.54-5.56], P = 0.001) and assisting in dissection (OR = 1.67 [1.03-2.69], P = 0.035) were predictive of student agreement that the operating room was a positive learning environment. Positive student perception of surgery before the clerkship was associated with increased frequency of positive clerkship activities including operative involvement (r = 0.26, P = 0.001) and relationships with surgical attendings (r = 0.20, P = 0.01), residents (r = 0.41, P < 0.0001), and patients (r = 0.24, P = 0.003).

Conclusions: Interventions to improve surgery clerkship quality should target enhancing student relationships with residents and surgical patients as well as providing opportunity for student operative involvement beyond just suturing. In addition, fostering positive perceptions of surgery in the preclinical period may increase meaningfulness and experience with the later surgery clerkship.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jss.2020.03.066DOI Listing
October 2020

Aspartate transaminase to platelet ratio index and Model for End-Stage Liver Disease scores are associated with morbidity and mortality after endovascular aneurysm repair among patients with liver dysfunction.

J Vasc Surg 2020 09 19;72(3):904-909. Epub 2020 Jan 19.

Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass. Electronic address:

Background: Liver cirrhosis dramatically increases morbidity and mortality after open surgical procedures and is often a contraindication to open repair of abdominal aortic aneurysms. However, limited data have evaluated the effect of liver disease on outcomes after endovascular repair of aortic aneurysms.

Methods: The National Surgical Quality Improvement Program was used to evaluate all nonemergent endovascular aneurysm repairs (EVARs) from 2005 to 2016. The aspartate transaminase to platelet ratio index is a sensitive, noninvasive screening tool used to screen for liver disease and was calculated for all patients. A value >0.5 was used to identify those with significant liver fibrosis. Demographics, comorbidities, and 30-day outcomes were then compared between patients with and patients without fibrosis. Additional analysis was then completed to assess the effect of increasing Model for End-Stage Liver Disease (MELD) score on 30-day outcomes. Multivariable regression was used to account for differences in baseline factors.

Results: EVAR was performed on 18,484 patients including 2286 with liver fibrosis and 16,198 without. Patients with liver fibrosis had an increased 30-day mortality (1.5% vs 2.4%; P < .01) and significantly higher rates of major morbidities including return to the operating room, pulmonary complications, transfusion, and discharge other than home. After multivariable analysis, patients with liver fibrosis had a significant increase in 30-day mortality (odds ratio [OR], 1.5; 95% confidence interval [CI], 1.1-2.1), return to the operating room (OR, 1.5; 95% CI, 1.2-1.8), pulmonary complications (OR, 1.6; 95% CI, 1.2-2.0), transfusion (OR, 1.7; 95% CI, 1.5-2.0), and discharge other than home (OR, 1.5; 95% CI, 1.3-1.8). In further analysis, mortality also increased in a stepwise fashion with increasing MELD score (MELD <10, 1.3%; MELD 10-15, 2.3%; MELD >15, 4.7%; P < .01), as did major complications (MELD <10, 7%; MELD 10-15, 11%; MELD >15, 15%; P < .01). These increases persisted in adjusted analysis.

Conclusions: Liver fibrosis significantly increases mortality and major morbidity after EVAR. The aspartate transaminase to platelet ratio index and MELD score should be used for preoperative risk stratification. Moreover, current 30-day morbidity and mortality rates among patients with MELD scores >10 exceed 5%, which is higher than the annual rupture risk for aneurysms <6 cm. Therefore, an increased size threshold of >6 cm may be warranted before EVAR in patients with liver fibrosis.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jvs.2019.10.101DOI Listing
September 2020

The Abdominal Transplant Surgery Workforce: Current state and future trends.

Clin Transplant 2019 10 8;33(10):e13659. Epub 2019 Sep 8.

Vanderbilt University Medical Center, Nashville, Tennessee.

Transplant surgical workforce concerns have arisen in the last 5 years as reflected in challenges securing job opportunities for new fellows. The present survey was designed by the ASTS Membership and Workforce Committee to describe the current practice characteristics of transplant centers in order to estimate changes in the workforce. The survey questionnaire requested information about the transplant programs, the transplant surgeons involved in the program, and the estimated changes in the staffing of the program over the next 3 years. Seventy-one transplant centers responded from a total of 235 identified and queried (30.2% response rate), with median responding centers per UNOS region of 7 (IQR 4.5-8.5). The recruitment outlook for the next 3 years forecasts a positive inflow of surgeons at a 2:1 rate (incoming:leaving). The new female transplant workforce within the responding cohort has increased from 3.7% in 1980 to 18.4% in 2010. Currently, 13.1% of practicing US transplant surgeons in this survey are female which is higher than many other surgical specialties. This report represents the most up-to-date view into the abdominal transplant surgical workforce. The positive job recruitment outlook for transplant surgeons and the narrowing gender gap are new findings from this study.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/ctr.13659DOI Listing
October 2019

Primary Stent Placement for Hepatic Artery Stenosis After Liver Transplantation: Improving Primary Patency and Reintervention Rates.

Liver Transpl 2018 10;24(10):1377-1383

Divisions of Vascular and Interventional Radiology, Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.

Recent studies have reported high rates of reintervention after primary stenting for hepatic artery stenosis (HAS) due to the loss of primary patency. The aims of this study were to evaluate the outcomes of primary stenting after HAS in a large cohort with longterm follow-up. After institutional review board approval, all patients undergoing liver transplantation between 2003 and 2017 at a single institution were evaluated for occurrence of hepatic artery complications. HAS occurred in 37/454 (8%) of patients. HAS was defined as >50% stenosis on computed tomography or digital subtraction angiography. Hepatic arterial patency and graft survival were evaluated at annual intervals. Primary patency was defined as the time from revascularization to imaging evidence of new HAS or reaching a censored event (retransplantation, death, loss to follow-up, or end of study period). Primary stenting was attempted in 30 patients (17 female, 57%; median age, 51 years; range, 24-68 years). Surgical repair of HAS prior to stenting was attempted in 5/30 (17%) patients. Endovascular treatment was performed within 1 week of the primary anastomosis in 5/30 (17%) of patients. Technical success was accomplished in 97% (29/30) of patients. Primary patency was 90% at 1 year and remained unchanged throughout the remaining follow-up period (median, 41 months; interquartile range [IQR], 25-86 months). Reintervention was required in 3 patients to maintain stent patency. The median time period between primary stenting and retreatment was 5.9 months (IQR, 4.4-11.1 months). There were no major complications, and no patient developed hepatic arterial thrombosis or required listing for retransplantation or retransplantation during the follow-up period. In conclusion, primary stenting for HAS has excellent longterm primary patency and low reintervention rates.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/lt.25292DOI Listing
October 2018

Mistreatment and the Learning Environment: A Mixed Methods Approach to Assess Knowledge and Raise Awareness Amongst Residents.

J Surg Educ 2019 Mar - Apr;76(2):305-314. Epub 2018 Oct 12.

Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts. Electronic address:

Objective: Trainee mistreatment, either intentional or unintentional, negatively affects the learning environment. This study was undertaken to evaluate the impact of an educational intervention about mistreatment and the learning environment on general surgery residents.

Design: Video-based modules were developed and added to the residency curriculum. Modules provided definitions and examples of active and passive mistreatment and components of positive and negative learning environments. A mixed-methods approach was used to assess the impact of this intervention. Residents completed a previously validated pre and post-test of related knowledge and attitudes (Abuse Sensitivity Questionnaire). Wilcoxon Signed Rank test was used to compare test results. During video-review sessions, discussion was prompted amongst residents using a semistructured interview guide. Immersion crystallization method was used to identify dominant themes.

Setting: Beth Israel Deaconess Medical Center, an academic tertiary care facility located in Boston, Massachusetts.

Participants: All general surgery residents in our institution (n = 58) were invited to complete a survey at 3 time points.

Results: Fifty-eight residents (55% male) responded to the survey (100% response rate). Mean age was 30.2 year (SD 3.9). Perception of nicknames related to personal identifiers (p = 0.0065) and name-calling (p = 0.02) changed significantly postintervention (Table 1). Regarding standards of behavior, 42 (72.4%) residents considered yelling not to be abusive unless it occurred frequently or constantly; 15 (25.8%) residents considered swearing (not directed at a person) as "not abuse"; 6 (10.3%) considered constructive criticism to be abusive if it was frequent or constant; and 24 (41%) residents feel powerless to intervene in these scenarios. Multiple themes emerged regarding resident-student interactions: (1) resident perception that description of behavior as mistreatment depends on medical student sensitivity; (2) neglect of medical students avoids trouble (e.g., being labeled as active mistreatment); (3) failure to integrate students into the surgical team may occur due to perceived lack of student interest; and (4) communication with the medical student is key. Residents reported that discussion along with video review was more effective than video review alone.

Conclusions: The video-based curriculum on mistreatment and the learning environment created awareness amongst residents about this important topic. Knowledge and attitudes about mistreatment changed in some areas postintervention. These findings suggest a need for development of complementary curricula to improve resident awareness and understanding of components of a positive learning environment and definition/examples of mistreatment.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jsurg.2018.07.019DOI Listing
September 2020

The Living Donor Lost Wages Trial: Study Rationale and Protocol.

Curr Transplant Rep 2018 Mar 19;5(1):45-54. Epub 2018 Jan 19.

Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH.

Purpose Of Review: This paper describes the background, rationale, and design of an NIH-funded, single-center study to test the impact of offering reimbursement for donor lost wages incurred during the post-nephrectomy recovery period on the live donor kidney transplant (LDKT) rate in newly evaluated kidney transplant candidates, to examine whether offering reimbursement for donor lost wages reduces racial disparity in LDKT rates, and to determine whether higher reimbursement amounts lead to higher LDKT rates.

Recent Findings: LDKT is the optimal treatment for renal failure. However, living kidney donation has declined in the past decade, particularly among men, younger adults, blacks, and low-income adults. There is evidence that donation-related costs may deter both transplant candidates and potential donors from considering LDKT. Lost wages is a major source of financial loss for some living donors and, unlike travel and lodging expenses, is not reimbursed by financial assistance programs.

Summary: The study addresses the transplant community's call to reduce the financial burden of living donation and examine its impact on LDKT rates. Findings have the potential to influence policy, clinical practice, LDKT access, and income-related and racial disparities in LDKT and living donation.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5967265PMC
March 2018

A Case of Cryptogenic Liver Failure.

Gastroenterology 2018 07 1;155(1):23-24.e1. Epub 2018 Feb 1.

Division of Transplant Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1053/j.gastro.2017.12.029DOI Listing
July 2018

Stereotactic Body Radiotherapy (SBRT) for Intrahepatic and Hilar Cholangiocarcinoma.

J Cancer 2015 1;6(11):1099-104. Epub 2015 Aug 1.

2. Department of Surgery, Harvard Medical School, Boston, Massachusetts, USA.

Background: Unresectable intrahepatic and hilar cholangiocarcinomas carry a dismal prognosis. Systemic chemotherapy and conventional external beam radiation and brachytherapy have been used with limited success. We explored the use of stereotactic body radiotherapy (SBRT) for these patients.

Methods: Patients with unresectable intrahepatic or hilar cholangiocarcinoma or those with positive margins were included in this study. Systemic therapy was used at the discretion of the medical oncologist. The Cyberknife(TM) stereotactic body radiotherapy system used to treat these patients. Patients were treated with three daily fractions. Clinical and radiological follow-up were performed every three months.

Results: 34 patients (16 male and 18 female) with 42 lesions were included in this study. There were 32 unresectable tumors and two patients with resected tumors with positive margins. The median SBRT dose was 30Gy in three fractions. The median follow-up was 38 months (range 8-71 months). The actuarial local control rate was 79%. The median overall survival was 17 months and the median progression free survival was ten months. There were four Grade III toxicities (12%), including duodenal ulceration, cholangitis and liver abscess.

Conclusions: SBRT is an effective and reasonably safe local therapy option for unresectable intrahepatic or hilar cholangiocarcinoma.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.7150/jca.13032DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4615345PMC
October 2015

Therapeutic Potential of Adjuvant Stereotactic Body Radiotherapy for Gallbladder Cancer.

Cureus 2015 Aug 10;7(8):e299. Epub 2015 Aug 10.

Department of Surgery, Beth Israel Deaconess Medical Center.

Surgical treatment remains the only curative treatment for gallbladder cancer. However, even after liver resection, locoregional failure seems to be a significant problem. While there is no Level I evidence, multiple studies have shown benefit for adjuvant radiation in high-risk patients. After extensive liver resection, tolerance to conventional chemoradiation may be limited by potential liver toxicity. Stereotactic body radiotherapy has been used safely and effectively in hepatobiliary malignancies. We present a case report, highlighting the potential therapeutic role of adjuvant stereotactic body radiotherapy (SBRT) for gallbladder cancer.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.7759/cureus.299DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4572715PMC
August 2015

Management of Hepatocellular Carcinoma in Cirrhotic Patients with Portal Hypertension: Relevance of Hagen-Poiseuille's Law.

Liver Cancer 2014 Oct;3(3-4):428-38

Liver Tumor Center, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass., USA.

Background: Hepatic decompensation in cirrhosis heralds an accelerated course with poor survival. An increase in hepatic venous pressure gradient (HVPG), rather than surrogate tests of liver function, appears to be the sole predictor of decompensation after surgical resection. We propose that hepatic sinusoidal walls become less elastic as cirrhosis progresses. Decompensation signals the development of increased vessel wall rigidity. The pressure-flow characteristics then become subject to Hagen-Poiseuille's law, which applies only to rigid, cylindrical vessels. Thereafter, HVPG rises exponentially (by a factor inversely proportional to the fourth power of the net radius of functional sinusoidal vessels, 1/r(4), at any given hepatic blood flow rate. This review attempts to correlate liver stiffness, risk of decompensation and outcomes from hepatocellular carcinoma (HCC) in patients with cirrhosis.

Summary: We compare the complexity of autoregulation in the normal elastic liver, which has a unique dual blood supply, with that in the rigid cirrhotic liver. We also review, in the context of background liver cirrhosis, the management of HCC which is in essence, a solid mass of unorganized cells that exacerbates liver stiffness. We discuss the differential effects of various therapeutic modalities such as liver transplantation, loco-regional therapy and drugs on HCC outcomes, based on their effects on HVPG.

Key Messages: Increased hepatic artery supply, or the hepatic artery buffer response, may be the only available method for autoregulation or maintenance of hepatic blood flow in the cirrhotic liver. In HCC, loco-regional therapies, including partial resection of the cirrhotic liver, can exacerbate portal hypertension by increasing blood flow within the remnant organ. We conclude that studies of HVPG reduction as part of HCC management may be beneficial and are warranted.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1159/000343871DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4531425PMC
October 2014

Patient-Reported Outcomes Following Living Kidney Donation: A Single Center Experience.

J Clin Psychol Med Settings 2015 Sep;22(2-3):160-8

Center for Transplant Outcomes and Quality Improvement, Transplant Institute, Beth Israel Deaconess Medical Center, 110 Francis Street, 7th Floor, Boston, MA, 02215, USA.

This article describes the development and implementation of an initiative at one transplant center to annually assess psychosocial outcomes of living kidney donors. The current analysis focuses on a cohort of adults (n = 208) who donated a kidney at BIDMC between September 2005 and August 2012, in which two post-donation annual assessments could be examined. One and two year post-donation surveys were returned by 59 % (n = 123) and 47 % (n = 98) of LKDs, respectively. Those who did not complete any survey were more likely to be younger (p = 0.001), minority race/ethnicity (p < 0.001), and uninsured at the time of donation (p = 0.01) compared to those who returned at least one of the two annual surveys. The majority of donors reported no adverse physical or psychosocial consequences of donation, high satisfaction with the donation experience, and no donation decision regret. However, a sizable minority of donors felt more pain intensity than expected and recovery time was much slower than expected, and experienced a clinically significant decline in vitality. We describe how these outcomes are used to inform clinical practice at our transplant center as well as highlight challenges in donor surveillance over time.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s10880-015-9424-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4575847PMC
September 2015

[18F]fludeoxyglucose positron emission tomography and computed tomography as a prognostic tool before liver transplantation, resection, and loco-ablative therapies for hepatocellular carcinoma.

Liver Transpl 2015 May 1;21(5):572-80. Epub 2015 Apr 1.

Liver Unit, Department of Gastroenterology, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel.

Hepatocellular carcinoma (HCC) is the fifth most common cancer and the third most common cause of cancer-related death worldwide. Orthotopic liver transplantation (OLT) and resection are curative treatment options for well-selected patients with HCC, whereas loco-ablative therapy has been shown to prolong survival. Organ and treatment allocations for these patients are currently based on the number and size of tumors, as defined by the Milan criteria, and on functional capacity, and they are incorporated into the Barcelona Clinic Liver Cancer staging system and treatment strategy. Even though these staging criteria have markedly improved the outcomes of patients with HCC, they still lack accuracy in predicting the risk of tumor recurrence because they do not incorporate markers of tumor biology and behavior. Positron emission tomography (PET) and computed tomography (CT) with [(18) F]fludeoxyglucose ([(18) F]FDG) constitute an imaging modality for detecting tumor tissue that is metabolically active. Uptake of [(18) F]FDG is highly associated with tumor aggressiveness. In this review, we present the accumulating data on the use of [(18) F]FDG PET-CT as an in vivo biomarker and its predictive value in identifying patients at risk for HCC recurrence after liver transplantation, resection, or ablation. These data suggest that the introduction of [(18) F]FDG PET-CT into the imaging algorithm of patients planned for liver transplantation, resection, or ablation may improve outcomes.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/lt.24083DOI Listing
May 2015

Hagen-Poiseuille's law: The link between cirrhosis, liver stiffness, portal hypertension and hepatic decompensation.

World J Hepatol 2015 Jan;7(1):28-32

Gerond Lake-Bakaar, Muneeb Ahmed, Amy Evenson, Alan Bonder, Salomao Faintuch, Vinay Sundaram, Liver Tumor Center, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, United States.

The onset of hepatic decompensation in cirrhosis heralds an accelerated downhill course with poor outcome. The sole predictor of this decompensation in cirrhosis is increased hepatic vein to portal vein gradient hepatic venous pressure gradient (HVPG). Surrogate markers of liver function or hepatic reserve appear to be less relevant. The hepatic sinusoids become less elastic and more rigid as liver fibrosis and cirrhosis progress. We propose that the Hagen-Poiseuille's law, which applies to rigid, but not elastic vessels, determines the pressure-flow characteristics in the sinusoids. In the rigid cirrhotic liver, HVPG rises dramatically with any change in net surface area or radius, r(4) of the vasculature that follows surgical resection. This review relates liver stiffness to the risk of decompensation in patients with cirrhosis. The liver has a unique dual blood supply comprising a low pressure portal vein and high pressure hepatic artery. We compare the complexity of autoregulation in the normal elastic liver with that in the rigid cirrhotic liver. Therapeutic modalities to reduce portal pressure may reduce the risk of hepatic decompensation and improve outcomes in cirrhosis.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.4254/wjh.v7.i1.28DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4295190PMC
January 2015

Concerns of ABO incompatible and crossmatch-positive potential donors and recipients about participating in kidney exchanges.

Clin Transplant 2015 Mar 3;29(3):233-41. Epub 2015 Feb 3.

Center for Transplant Outcomes and Quality Improvement, The Transplant Institute, Beth Israel Deaconess Medical Center, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.

Kidney paired exchanges (KPEs) have increased, yet are still underutilized. This study aimed to develop tools for assessing KPE concerns, identify predictors of KPE concerns, and describe common KPE concerns among potential living donors (LDs) and intended recipients. Incompatible former potential LDs (n = 135) and intended recipients (n = 83) retrospectively completed questionnaires to assess KPE concerns. Healthcare system distrust also was assessed. A minority (n = 48 or 36.5% of potential LDs; n = 25 or 30.1% of intended recipients) had pursued KPE participation. Of those who pursued KPE participation, 11 (22.9%) and 6 (24.0%) completed KPE donation or transplantation, respectively. The questionnaires for potential LDs and recipients showed good internal consistency and preliminary convergent validity. LDs and patients less willing to pursue KPE reported more KPE concerns. Common KPE concerns for both potential LDs and recipients were related to perceived Distrust/Inequity and Inconvenience/Cost. Multivariate predictors of more KPE concerns were as follows: male gender (t = 4.5, p < 0.001) and more healthcare system distrust (t = 2.5, p = 0.01) for potential LDs; black race (t = 2.1, p = 0.04) and more healthcare system distrust (t = 2.3, p = 0.03) for intended recipients. These findings underscore the importance of addressing concerns potential LDs and patients have about KPE if the true potential of KPE is to be realized.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/ctr.12509DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4516385PMC
March 2015

Predictors of negative intraoperative findings at emergent laparotomy in patients with cirrhosis.

J Gastrointest Surg 2014 Oct 5;18(10):1777-83. Epub 2014 Aug 5.

Department of Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA, 02215, USA,

Background: Emergent surgery in the setting of decompensated cirrhosis is highly morbid. We sought to determine the clinical factors associated with negative intraoperative findings at emergent laparotomy.

Methods: We performed a retrospective cohort study of consecutive inpatients with a diagnosis of cirrhosis (ICD-9 571) admitted to the Beth Israel Deaconess Medical Center (Boston, MA) who underwent emergent, nonhepatic, abdominal surgery between May 6, 2005 and September 3, 2012.

Results: Eighty-six patients with cirrhosis were included with a mean model for end-stage liver disease score of 21.3 ± 7.95 and a 90-day mortality rate of 39.5%. Twelve (16.2%) patients had negative laparotomies. Negative intraoperative findings were independently associated with (1) paracentesis prior to a preoperative diagnosis of perforated viscus (P = 0.006), (2) development of an indication for emergent surgery after 24 h into hospital admission for another reason (P = 0.020), and (3) a preoperative diagnosis of bowel ischemia (P = 0.005), with odds ratios of 10.1 (CI 1.92-66.83), 5.80 (CI 1.32-33.39), and 11.1 (CI 2.08-77.4), respectively. Free air on computed tomography (CT) imaging was found in 64.3% (9/14) of patients who had a paracentesis within the preceding 48 h compared to 10.1% (7/72) among patients who did not undergo a paracentesis (P < 0.001). Only 45% of patients with free air following a paracentesis had positive findings at laparotomy compared to 100% in those without a preceding paracentesis (P = 0.038). Negative laparotomy was independently predictive of in-hospital mortality (OR 4.7; P = 0.034).

Conclusion: The possibility of a negative laparotomy is suggested by preoperative clinical factors. In particular, free air following a paracentesis does not necessarily indicate that operative intervention is required. Consideration of close observation before laparotomy in these patients is reasonable.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s11605-014-2599-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5557345PMC
October 2014

Renal transplantation in the setting of early steroid withdrawal: a comparison of rabbit antithymocyte globulin induction dosing in two eras.

Am J Nephrol 2013 26;38(5):397-404. Epub 2013 Oct 26.

Department of Pharmacy, Beth Israel Deaconess Medical Center, Boston, Mass., USA.

Background: Modern immunosuppression and rabbit antithymocyte globulin (rATG) have facilitated the success of early steroid withdrawal (ESW) protocols. Little data exist on optimal rATG dosing in ESW protocols.

Methods: Rejection at 12 months in era 1 (four doses of rATG, 1.25 mg/kg) vs. era 2 (three doses of rATG, 1.25 mg/kg) was the primary endpoint. Secondary endpoints included patient and graft survival, renal function and infectious complications. Factors associated with rejection at 1 year were identified.

Results: 199 patients received rATG induction and ESW: 102 in era 1 and 97 in era 2. Compared to era 1, era 2 was not associated with worse outcomes, including rejection, renal function, infection or graft survival. Rejection at 1 year and uncensored graft survival differed between the dosing groups. Rejection rates were significantly higher in the <4 mg/kg group compared to the 4-5.9-mg/kg and the ≥6-mg/kg groups, whereas uncensored graft survival was the lowest in the ≥6-mg/kg group. Factors associated with rejection at 12 months included: rATG dose received of 4-5.9 versus <4 mg/kg (OR 0.20, 95% CI 0.036-0.85, p = 0.026); recipient age (per year, OR 0.94, 95% CI 0.89-1.0, p = 0.038); panel reactive antibody 10-79.9 versus <10% (OR 5.4, 95% CI 1.2-25, p = 0.030) and rATG dose held (OR 4.0, 95% CI 1.0-15, p = 0.049).

Conclusions: A comparison of rATG dosing based on era did not result in a significant difference in rejection, renal function, infection or graft survival. However, when evaluating the study population based on actual dose received there were notable differences in both rejection rates and uncensored graft survival.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1159/000355620DOI Listing
July 2014

Emergency hernia repair in cirrhotic patients with ascites.

J Trauma Acute Care Surg 2013 Sep;75(3):404-9

Background: The optimal treatment for abdominal wall hernias in the setting of ascites is not clear. We describe our experience with emergent surgery for hernias in patients with cirrhosis and ascites and assess variables associated with poor short- and long-term outcomes to inform decisions about aggressive early repair.

Methods: We performed a retrospective review of all emergency abdominal wall hernia repairs admitted from the emergency department from January 2000 to December 2011 in all patients with ascites caused by liver cirrhosis. Demographic data, comorbidities, complications, operative details, hospital length of stay, and admission model of end-stage liver disease (MELD) score was determined. Follow-up was detailed via comprehensive liver service electronic records.

Results: There were 69 emergent hernia surgeries in 68 patients during the study period. There were two early deaths (both MELD score> 20). Multivariate analysis revealed MELD score (18% increase in risk with each point of MELD), preoperative anemia (sevenfold increase in risk), and preoperative small bowel obstruction (ninefold increase in risk) as predictive factors of major complication. In patients with MELD score greater than 10, morbidity was more than 50%, and major morbidity is greater than 12% when MELD score is greater than 20.

Conclusion: Emergent hernia surgery in patients with ascites has low mortality but high morbidity and requires intense use of resources. To decrease the incidence of emergent hernia surgery, we recommend the aggressive use of elective repair. Emergent hernia repair, when necessary, should be performed at experienced centers and must include adequate ascites control with diuretic therapy and percutaneous paracentesis. Preoperative anemia and electrolyte abnormalities should be aggressively treated. Finally, while wound complications are common and frequently require reintervention, they are not associated with increased mortality.

Level Of Evidence: Prognostic and epidemiologic study, level V.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/TA.0b013e31829e2313DOI Listing
September 2013

Endovascular management of critical limb ischemia in renal transplant patients.

Ann Vasc Surg 2014 Jan 5;28(1):159-63. Epub 2013 Sep 5.

Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA. Electronic address:

Background: End-stage renal disease is a significant negative predictor of limb salvage and patient survival in patients with limb ischemia, but little is known of the overall effects of renal transplantation. Endovascular management may be less morbid than open surgery, but technical success and durability in these patients is not well established.

Methods: All patients with functioning renal transplants and critical limb ischemia (CLI) treated with endovascular techniques between 2003 and 2010 were retrospectively reviewed for limb salvage, reintervention, pre- and postprocedure creatinine, and estimated glomerular filtration rate (eGFR), and overall survival. Contralateral common femoral access, low-profile techniques, and isosmolar contrast were standard for all interventions.

Results: Endovascular interventions were performed on 57 limbs in 28 patients with renal transplants. Mean age was 54 years, 78% were male, 85% were diabetic, 100% were hypertensive, and 64% had a positive smoking history. All patients were treated for CLI. Treated regions included 16 iliac, 19 superficial femoral, 16 popliteal, and 12 tibial arteries, as well as 1 bypass graft with initial technical success of 100% and 0% 30-day mortality. Of all lesions, 43% required reintervention during the follow-up period, the majority in the first year. There was no significant change in eGFR or creatinine comparing pre- and post-angiogram value. Limb salvage and 1-year survival were 83% and 82%, respectively.

Conclusions: Endovascular management of CLI in renal transplant patients results in good technical success and can be accomplished without a measurable change in transplant kidney function, although it requires repeat interventions. Endovascular therapy is a reasonable first-line treatment option for this high-risk group.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.avsg.2012.12.007DOI Listing
January 2014

Evaluation of native kidney recovery after simultaneous liver-kidney transplantation.

Transplantation 2012 Mar;93(5):530-5

Department of Medicine, Boston University Medical Center, Boston, MA, USA.

Background: Debate continues about which liver transplantation candidates with impaired renal function should undergo liver transplant alone versus simultaneous liver-kidney transplantation (SLK). Identifying predictors of native kidney function recovery after SLK requires an accurate measure of the relative function of all three kidneys in patients with SLK.

Methods: The distance of a transplanted kidney from the renal scan camera can be substantially different from that of native kidneys. We developed a technique to correct attenuation of counts of all three kidneys based on their depth.

Results: In our series of 13 SLK recipients, attenuation correction increased the measured renal function of native kidneys by up to 40%, demonstrating the importance of this procedure for accurately measuring kidney function. Eight patients met the United Network for Organ Sharing (UNOS)-proposed criteria for receiving a SLK, but four of these still had significant native kidney function (>40% of total function) after transplant. Five patients did not meet the UNOS-proposed criteria for SLK, yet only one of these had native kidney function recovery.

Conclusion: The criteria proposed by UNOS to determine that SLK is indicated, and thus that native kidney recovery is not expected, are not always accurate. Further study of factors associated with native kidney recovery after SLK is required.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/TP.0b013e3182449161DOI Listing
March 2012

Utilization of kidneys from donation after circulatory determination of death.

Authors:
Amy R Evenson

Curr Opin Organ Transplant 2011 Aug;16(4):385-9

Harvard Medical School, Transplant Institute, Beth Israel Deaconess Medical Center, Boston, Massachusetts 02215, USA.

Purpose Of Review: The present review describes the recent experience with kidney transplantation using donation after circulatory determination of death (DCDD) including efforts to expand the potential pool of DCDD donors.

Recent Findings: The use of DCDD kidneys represents a growing source of kidneys for transplantation in the USA, although not to the same extent as in Europe. Expansion of the potential donor pool has included the use of kidneys with extended time to donor arrest and pediatric donors. The use of machine perfusion for DCDD kidneys has failed to demonstrate significant benefit.

Summary: DCDD kidneys continue to demonstrate increased rates of delayed graft function and primary nonfunction when compared with kidneys recovered after donation after brain death (DBD) likely due to increased warm ischemic time during recovery. Despite early complications, DCDD kidneys show comparable function and survival after the immediate postoperative period and have been demonstrated to provide a survival benefit to recipients over waiting for DBD kidneys. The effect of machine perfusion on DCDD kidneys may decrease delayed graft function but has no effect on long-term function. Despite concerns, the increasing number of DCDD donors does not appear to be directly responsible for decreased numbers of DBD donors.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/MOT.0b013e328348b439DOI Listing
August 2011

Minimising cold ischaemic time is essential in cardiac death donor-associated liver transplantation.

HPB (Oxford) 2011 Jun 4;13(6):411-6. Epub 2011 Apr 4.

Transplant Institute, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA.

Background: An important issue in the transplantation of livers procured from cardiac death donors (CDDs) concerns why some centres report equivalent outcomes and others report inferior outcomes in transplantations using CDD organs compared with standard criteria donor (SCD) organs. Resolving this discrepancy may increase the number of usable organs.

Objectives: This study aimed to test whether differences in cold ischaemic time (CIT) are critical during CDD organ transplantation and whether such differences might explain the disparate outcomes.

Methods: Results of CDD liver transplants in our own centre were compared retrospectively with results in a matched cohort of SCD liver recipients. Endpoints of primary non-function (PNF) and ischaemic cholangiopathy (IC) were used because these outcomes are clearly associated with CDD organ use.

Results: In 22 CDD organ transplants, CIT was a strong predictor of PNF or IC (P = 0.021). Minimising CIT in CDD organ transplants produced outcomes similar to those in a matched SCD organ transplant cohort at our centre and in SCD organ transplant results nationally (1- and 3-year graft and patient survival rates: 90.9% and 73.3% vs. 77.6% and 69.2% in CDD and SCD grafts, respectively. A review of the published literature demonstrated that centres with higher CITs tend to have higher rates of PNF or IC (correlation coefficient: 0.41).

Conclusions: These findings suggest that a targeted effort to minimise CIT might improve outcomes and allow the safer use of CDD organs.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/j.1477-2574.2011.00307.xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3103098PMC
June 2011

Prenatal diagnosis and subsequent treatment of an intermediate-risk paraspinal neuroblastoma: case report and review of the literature.

Fetal Diagn Ther 2008 17;24(2):119-25. Epub 2008 Jul 17.

Department of Pediatric Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA 02115, USA.

Objectives: Neuroblastoma is the most common extracranial solid tumor of childhood, and the most common malignancy diagnosed during infancy. In comparison, neonatal neuroblastoma is relatively rare. Improvements in prenatal imaging and widespread use of fetal ultrasonography have led to an increased rate of prenatal diagnoses.

Methods: Case report and literature review.

Results: We report a case of an intermediate-risk neuroblastoma, diagnosed at 36 weeks' gestation by ultrasound and subsequently visualized by fetal MRI, that resulted in spinal cord compression and decreased fetal movement. A multidisciplinary team approach resulted in rapid delivery, evaluation, biopsy, staging, and treatment implementation in a successful effort to preserve lower extremity function.

Conclusion: Prenatal diagnosis of neuroblastoma, management and outcomes are reviewed. Prompt diagnosis can strongly influence perinatal management and improve prognosis.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1159/000142141DOI Listing
September 2008

Hyalinizing trabecular adenoma--an uncommon thyroid tumor frequently misdiagnosed as papillary or medullary thyroid carcinoma.

Am J Surg 2007 Jun;193(6):707-12

Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215, USA.

Background: Hyalinizing trabecular adenoma (HTA) is an uncommon benign thyroid tumor that can present as a solitary thyroid nodule, a prominent nodule in a multinodular goiter, or as an incidental finding in a thyroidectomy specimen. The clinical significance of the lesion is that it is frequently misdiagnosed as papillary carcinoma on fine-needle aspiration cytology or as papillary or medullary carcinoma on histopathological section. We reviewed our recent experience with 7 patients diagnosed with HTA.

Methods: Fine-needle aspiration biopsy was performed in 7 patients presenting with a solitary thyroid nodule (n = 4) or a multinodular goiter (n = 3). The patients underwent total thyroidectomy (n = 6) or hemithyroidectomy (n = 1).

Results: In 4 patients, the preoperative cytology was suggestive of papillary carcinoma, in 2 patients suspicious, and in 1 patient positive for papillary carcinoma. On histopathological section, 2 patients had a microscopic HTA, 2 patients had HTA in 1 or 2 nodules of a multinodular goiter, and 3 patients had HTA in a solitary nodule. Except in 1 patient, who had a microscopic focus (3.2 mm) of papillary carcinoma, there was no evidence of malignancy in the surgical specimens on permanent histopathological section.

Conclusions: Although HTA is a rare condition of the thyroid, the surgeon needs to be aware of this entity to be able to better discuss the pathological findings with the patient, particularly since some pathologists and endocrinologists believe that HTA may represent a malignant neoplasm of low metastatic potential.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.amjsurg.2006.09.042DOI Listing
June 2007

The gene expression and activity of calpains and the muscle wasting-associated ubiquitin ligases, atrogin-1 and MuRF1, are not altered in patients with primary hyperparathyroidism.

Int J Mol Med 2006 Sep;18(3):471-5

Section of Endocrine Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA.

Hyperparathyroidism (HPT) can be associated with muscle atrophy and weakness. Muscle atrophy is typically caused by increased muscle protein breakdown. The influence of HPT on calpains and the ubiquitin-proteasome pathway, which are important regulators of muscle proteolysis, is not yet known. We examined the expression in skeletal muscle of mu- and m-calpain and the ubiquitin ligases, atrogin-1 and MuRF1, in patients with primary HPT. A biopsy was obtained from the sternohyoid muscle in patients undergoing surgery for primary HPT (n=8) and in normocalcemic control patients undergoing thyroid surgery (n=11). mRNA levels for atrogin-1, MuRF1 and the calcium-regulated proteases, mu- and m-calpain, were determined by real-time PCR. Calpain activity was measured using the calpain-specific substrate, BODIPY-FL-casein, and by zymography. Serum calcium was 11.4+/-0.46 and 9.5+/-0.10 mg/dl in HPT and control patients, respectively (p<0.01). The corresponding phosphate levels were 2.7+/-0.2 and 3.6+/-0.1 mg/dl (p<0.05). Parathyroid hormone serum concentration was 286+/-103 pg/ml (range, 77-946 pg/ml) in patients with HPT and was not measured in control patients. There were no significant differences in mRNA levels for atrogin-1, MuRF1, mu- or m-calpain and in calpain activity between HPT and control patients. The results suggest that the ubiquitin-proteasome and calpain systems are not activated in skeletal muscle in patients with primary HPT, at least not in patients with moderate hypercalcemia.
View Article and Find Full Text PDF

Download full-text PDF

Source
September 2006

Current management of enterocutaneous fistula.

J Gastrointest Surg 2006 Mar;10(3):455-64

Department of Surgery, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215, USA.

Enterocutaneous fistulas, defined as abnormal communications between bowel and skin, are among the most challenging conditions managed by the general surgeon. In an era when the mortality from pancreaticoduodenectomy is less than 3%, the mortality of enterocutaneous fistulas remains 10 to 30% due to the often-present complications of sepsis, malnutrition, and electrolyte abnormalities. Taking advantage of recent advances in techniques of pre- and post-surgical management and support, employing a multidisciplinary team approach, and executing a well-delineated management plan provide the patient and surgeon with the best possibility of success in treating this potentially devastating condition.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.gassur.2005.08.001DOI Listing
March 2006

Treatment of rats with calpain inhibitors prevents sepsis-induced muscle proteolysis independent of atrogin-1/MAFbx and MuRF1 expression.

Am J Physiol Regul Integr Comp Physiol 2006 Jun 2;290(6):R1589-97. Epub 2006 Feb 2.

Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA.

Muscle wasting in sepsis is a significant clinical problem because it results in muscle weakness and fatigue that may delay ambulation and increase the risk for thromboembolic and pulmonary complications. Treatments aimed at preventing or reducing muscle wasting in sepsis, therefore, may have important clinical implications. Recent studies suggest that sepsis-induced muscle proteolysis may be initiated by calpain-dependent release of myofilaments from the sarcomere, followed by ubiquitination and degradation of the myofilaments by the 26S proteasome. In the present experiments, treatment of rats with one of the calpain inhibitors calpeptin or BN82270 inhibited protein breakdown in muscles from rats made septic by cecal ligation and puncture. The inhibition of protein breakdown was not accompanied by reduced expression of the ubiquitin ligases atrogin-1/MAFbx and MuRF1, suggesting that the ubiquitin-proteasome system is regulated independent of the calpain system in septic muscle. When incubated muscles were treated in vitro with calpain inhibitor, protein breakdown rates and calpain activity were reduced, consistent with a direct effect in skeletal muscle. Additional experiments suggested that the effects of BN82270 on muscle protein breakdown may, in part, reflect inhibited cathepsin L activity, in addition to inhibited calpain activity. When cultured myoblasts were transfected with a plasmid expressing the endogenous calpain inhibitor calpastatin, the increased protein breakdown rates in dexamethasone-treated myoblasts were reduced, supporting a role of calpain activity in atrophying muscle. The present results suggest that treatment with calpain inhibitors may prevent sepsis-induced muscle wasting.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1152/ajpregu.00668.2005DOI Listing
June 2006

Preoperative evaluation of thyroid nodules with 18FDG-PET/CT.

Surgery 2005 Dec;138(6):1166-74; discussion 1174-5

Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA.

Background: Fluorine-18-fluorodeoxyglucose positron emission tomography/computed tomography ((18)FDG-PET/CT) has become an important tool in the postoperative management of de-differentiated thyroid cancer. The utility of this imaging modality in the preoperative assessment of thyroid nodules is unclear. This study was designed to determine whether (18)FDG-PET/CT improves the preoperative diagnosis of thyroid nodules.

Methods: A total of 31 patients with 48 lesions underwent fine-needle aspiration and (18)FDG-PET/CT before surgical resection of thyroid nodules. PET/CT images were obtained 1 hour after intravenous administration of (18)FDG. Standard uptake values were calculated for regions of increased (18)FDG uptake. CT scans were evaluated to identify thyroid pathology. Final pathologic diagnoses were compared with PET/CT findings.

Results: Fifteen of 48 lesions were malignant and 33 were benign. Nine of 15 malignant lesions were (18)FDG-avid (sensitivity 60%). Thirty of 33 benign lesions were (18)FDG-cold (specificity 91%). Positive and negative predictive values were 75% and 83%, respectively.

Conclusions: (18)FDG-PET/CT provides a high negative predictive value for malignancy, making this a potentially useful tool in the evaluation of thyroid nodules with indeterminate fine-needle aspiration. However further studies with larger sample sizes are needed to determine the true efficacy of this test.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.surg.2005.08.031DOI Listing
December 2005

Novel aspects on the regulation of muscle wasting in sepsis.

Int J Biochem Cell Biol 2005 Oct 13;37(10):2156-68. Epub 2005 Mar 13.

Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215, USA.

Muscle wasting in sepsis is associated with increased expression of messenger RNA for several genes in the ubiquitin-proteasome proteolytic pathway, indicating that increased gene transcription is involved in the development of muscle atrophy. Here we review the influence of sepsis on the expression and activity of the transcription factors activator protein-1, nuclear factor-kappaB (NF-kappaB), and CCAAT/enhancer binding protein, as well as the nuclear cofactor p300. These transcription factors may be important for sepsis-induced muscle wasting because several of the genes in the ubiquitin-proteasome proteolytic pathway have multiple binding sites for activating protein-1, nuclear factor-kappaB, and CCAAT/enhancer binding protein in their promoter regions. In addition, the potential role of increased muscle calcium levels for sepsis-induced muscle atrophy is reviewed. Calcium may regulate several mechanisms and factors involved in muscle wasting, including the expression and activity of the calpain-calpastatin system, proteasome activity, CCAAT/enhancer binding protein transcription factors, apoptosis and glucocorticoid-mediated muscle protein breakdown. Because muscle wasting is commonly seen in patients with sepsis and has severe clinical consequences, a better understanding of mechanisms regulating sepsis-induced muscle wasting may help improve the care of patients with sepsis and other muscle-wasting conditions as well.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.biocel.2005.01.017DOI Listing
October 2005

GSK-3beta inhibitors reduce protein degradation in muscles from septic rats and in dexamethasone-treated myotubes.

Int J Biochem Cell Biol 2005 Oct;37(10):2226-38

Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue ST919, Boston, MA 02215, USA.

Sepsis is associated with muscle wasting, mainly reflecting increased muscle proteolysis. Recent studies suggest that inhibition of GSK-3beta activity may counteract catabolic stimuli in skeletal muscle. We tested the hypothesis that treatment of muscles from septic rats with the GSK-3beta inhibitors LiCl and TDZD-8 would reduce sepsis-induced muscle proteolysis. Because muscle wasting during sepsis is, at least in part, mediated by glucocorticoids, we also tested the effects of GSK-3beta inhibitors on protein degradation in dexamethasone-treated cultured myotubes. Treatment of incubated extensor digitorum longus muscles with LiCl or TDZD-8 reduced basal and sepsis-induced protein breakdown rates. When cultured myotubes were treated with LiCl or one of the GSK-3beta inhibitors SB216763 or SB415286, protein degradation was reduced. Treatment of incubated muscles or cultured myotubes with LiCl, but not the other GSK-3beta inhibitors, resulted in increased phosphorylation of GSK-3beta at Ser9, consistent with inactivation of the kinase and suggesting that the other inhibitors used in the present experiments inhibit GSK-3beta by phosphorylation-independent mechanisms. The present results suggest that GSK-3beta inhibitors may be used to prevent or treat sepsis-induced, glucocorticoid-regulated muscle proteolysis.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.biocel.2005.06.002DOI Listing
October 2005

Hepatic surgery: current techniques and outcomes.

Curr Surg 2005 Jul-Aug;62(4):374-82

Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.cursur.2004.09.009DOI Listing
September 2005