Publications by authors named "Michael Cline"

25 Publications

  • Page 1 of 1

Gastroparesis with concomitant gastrointestinal dysmotility is not a contraindication for per-oral pyloromyotomy (POP).

Surg Endosc 2021 Oct 12. Epub 2021 Oct 12.

Digestive Disease and Surgical Institute, Cleveland Clinic, Cleveland, OH, USA.

Introduction: Per-oral pyloromyotomy (POP or G-POEM) provides significant short-term improvements in symptoms and objective emptying for patients with medically refractory gastroparesis, but it is unclear if patients with gastroparesis and co-existing dysmotility (small bowel or colonic delay) also benefit. In this study, we used wireless motility capsule (WMC) data to measure outcomes in patients with isolated gastroparesis (GP) and gastroparesis with co-existing dysmotility (GP + Dys) who underwent POP.

Methods: We retrospectively analyzed patients who had POP and completed WMC data during their evaluation of intestinal dysmotility. WMC data were reviewed to identify patients who demonstrated isolated GP or GP + Dys. Each patient's pre-op and post-op Gastroparesis Cardinal Symptom Index (GCSI) and 4-h solid-phase scintigraphy gastric emptying studies (GES) scores were compared to evaluate improvement.

Results: Of the entire cohort (n = 73), 89% were female with a mean age of 47.0 ± 15.0 years old. Gastroparesis etiologies were divided among idiopathic (54.8%), diabetic (26%), postsurgical (8.2%), autoimmune (5.5%), and multifactorial (5.5%). Forty-one patients (56%) had GP and 32 patients (44%) had GP + Dys. GCSI improved after POP whether the patient had isolated GP (- 12.31, p < 0.001) or GP + Dys (- 9.58, p < 0.001); however, there was no significant difference in total GCSI improvement between the two groups. A subset of patients had postoperative GES available (n = 47). In the isolated GP and GP + Dys cohorts, 15/28 (54%) and 12/19 (63%) patients had normal post-op 4-h GES, respectively, but no statistical difference between the two groups.

Conclusion: Patients with medically refractory gastroparesis with and without concomitant gastrointestinal dysmotility show short-term subjective and objective improvement after POP. Concomitant small bowel or colonic dysmotility should not deter physicians from offering POP in carefully selected patients with gastroparesis.
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http://dx.doi.org/10.1007/s00464-021-08756-9DOI Listing
October 2021

Percutaneous Biliary Endoscopy.

Semin Intervent Radiol 2021 Aug 10;38(3):340-347. Epub 2021 Aug 10.

Division of Vascular and Interventional Radiology, Department of Radiology, Northwestern Memorial Hospital, Chicago, Illinois.

Biliary endoscopy is underutilized by interventional radiologists and has the potential to become an effective adjunctive tool to help both diagnose and treat a variety of biliary pathology. This is particularly true in cases where endoscopic retrograde cholangiopancreatography fails or is not feasible due to surgically altered anatomy. Both preoperative clinical and technical procedural factors must be taken into consideration prior to intervention. In this article, clinical evaluation, perioperative management, and procedural techniques for percutaneous biliary endoscopy are reviewed.
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http://dx.doi.org/10.1055/s-0041-1731372DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8354707PMC
August 2021

Severe gastroparesis is associated with an increased incidence of slow-transit constipation as measured by wireless motility capsule.

Neurogastroenterol Motil 2021 05 24;33(5):e14045. Epub 2020 Nov 24.

Department of Gastroenterology, Hepatology, & Nutrition, Cleveland Clinic, Cleveland, OH, USA.

Background: Dysmotility in one region of the gastrointestinal tract has been found to predispose patients to developing motility disorders in other gastrointestinal segments. However, few studies have evaluated the relationship between gastroparesis and constipation.

Methods: Retrospective review of 224 patients who completed 4-hour, solid-phase gastric emptying scintigraphy (GES), and wireless motility capsule (WMC) testing to evaluate for gastroparesis and slow-transit constipation, respectively. When available, anorectal manometry data were reviewed to evaluate for dyssynergic defecation. Patients were divided into two groups based on the results of the GES: 101 patients with normal gastric emptying and 123 patients with gastroparesis (stratified by severity). Differences in constipation rates were compared between the groups.

Key Results: Slow-transit constipation was more common in the gastroparesis group, but statistical significance was not reached (42.3% vs 34.7%, p = 0.304). Univariate logistical regression analysis found no association between slow-transit constipation and gastroparesis (OR 1.38, 95% CI 0.80-2.38, p = 0.245) nor dyssynergic defecation and gastroparesis (OR 0.88, 95% CI 0.29-2.70, p = 0.822). However, when stratifying gastroparesis based on severity, slow-transit constipation was found to be associated with severe gastroparesis (OR 2.45, 95% CI 1.20-5.00, p = 0.014). This association was strengthened with the exclusion of patients with diabetes mellitus (OR 3.5, 95% CI 1.39-8.83, p = 0.008) - a potential confounder.

Conclusions & Inferences: Patients with severe gastroparesis (>35% gastric retention at the 4-hour mark on solid-phase GES) have an increased likelihood of having underlying slow-transit constipation. Dyssynergic defecation does not appear to be associated with gastroparesis (of any severity).
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http://dx.doi.org/10.1111/nmo.14045DOI Listing
May 2021

Pelvic Fractures and Associated Genitourinary and Vascular Injuries: A Multisystem Review of Pelvic Trauma.

AJR Am J Roentgenol 2019 12 15;213(6):1297-1306. Epub 2019 Oct 15.

Department of Radiology, University of Michigan, Taubman Center B1, 1500 E Medical Center Dr, Ann Arbor, MI 48109.

Blunt pelvic trauma is associated with injuries to the musculoskeletal, lower genitourinary, and vascular systems, leading to significant morbidity and mortality. This article provides a comprehensive review of these injuries, reviews classification systems that are helpful in predicting prognosis, describes the most appropriate imaging tests for injury detection, and emphasizes the role that interventional radiology plays in the setting of pelvic trauma. Blunt pelvic injuries can involve the musculoskeletal, genitourinary, and vascular systems, often concomitantly, making it imperative for radiologists to recognize injury patterns and understand implications for management. Injury classifications can be helpful in determining management and predicting prognosis. Contrast-enhanced CT is the imaging modality test of choice in evaluating pelvic trauma, and protocols should be optimized for best detection of injuries. Transcatheter arterial embolization plays a critical role in stopping acute hemorrhage and improving clinical outcomes.
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http://dx.doi.org/10.2214/AJR.18.21050DOI Listing
December 2019

Safety and Feasibility of Per-Oral Pyloromyotomy as Augmentative Therapy after Prior Gastric Electrical Stimulation for Gastroparesis.

J Am Coll Surg 2019 12 11;229(6):589-595. Epub 2019 Oct 11.

Department of General Surgery, Cleveland Clinic, Cleveland, OH; Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH.

Background: For medically refractory diabetic or idiopathic gastroparesis, gastric electrical stimulation (GES) is an excellent option for symptom control; however, a small subset of patients may develop recurrent or persistent symptoms. Per-oral pyloromyotomy (POP, also described by some authors as gastric per-oral endoscopic myotomy or G-POEM) is an emerging therapy for medically refractory gastroparesis. This study investigated the safety and feasibility of POP after previous GES for recurrent or persistent gastroparesis.

Study Design: We retrospectively identified all patients undergoing POP between January 2016 and December 2017, with GES in situ. Patient characteristics, gastroparesis etiology, and procedural data were collected. Symptoms were assessed with the Gastroparesis Cardinal Symptom Index (GCSI) both before and 30 to 90 days after POP. Standard pre- and post-procedure 4-hour gastric emptying tests were obtained when available.

Results: There were 22 patients who met inclusion criteria (81.8% female, mean age 42.3 ± 12.4 years). Causes of gastroparesis were diabetes in 38.1%, and idiopathic in 61.9%. The average time since GES insertion was 3.45 years. Mean preoperative 4-hour gastric retention was 50.1%. Most POP procedures were performed in the operating room (90.9%), with mean operative time of 40 minutes and a 1.4-day length of stay. There were 4 readmissions within 30 days, but no POP-related complications. Overall, GCSI improved by an absolute reduction of 1.63 points (p = 0.002), with significant improvements in all sub-scores. Of 11 patients with post-procedural motility or emptying studies available, 7 were normal.

Conclusions: Per-oral pyloromyotomy appears to be safe and feasible for patients with recurrent gastroparesis symptoms after GES. Both symptoms and motility significantly improved in the short-term. These data replicate similar data suggesting laparoscopic pyloroplasty as an effective augmentative therapy after GES, but may provide a less invasive option for patients.
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http://dx.doi.org/10.1016/j.jamcollsurg.2019.09.014DOI Listing
December 2019

Per-Oral Pyloromyotomy (POP) for Medically Refractory Post-Surgical Gastroparesis.

J Gastrointest Surg 2019 06 26;23(6):1095-1103. Epub 2019 Feb 26.

Department of General Surgery, Cleveland Clinic, Desk A-100, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.

Background: Post-surgical gastroparesis (psGP) is putatively related to vagal denervation from either therapeutic transection or inadvertent injury. Here, we present a series of patients undergoing endoscopic per-oral pyloromyotomy (POP) as a treatment for medically refractory psGP.

Methods: Patients identified from a prospectively maintained database of patients undergoing POP procedures at our institution from January 2016 to January 2018 were included. Surgical history, symptom scores, and gastric emptying studies before and 3 months after POP were additionally recorded.

Results: During the study period, 177 POP procedures were performed, of which 38 (21.5%) were for psGP. The study cohort was 84.2% female with a mean body mass index of 27.6 kg/m and mean age of 55.2 years. Common comorbidities included hypertension (34.2%), depression (31.6%), and gastroesophageal reflux disease (28.9%). Hiatal/paraesophageal hernia repair (39.5%) or fundoplication (36.8%) preceded psGP diagnosis most often. The mean operative time was 30 ± 20 min. There were no intraoperative complications. Mean postoperative length of stay was 1.2 days. There were two readmissions within 30 days, one for melena and one for dehydration. The mean improvement in total Gastroparesis Symptom Index Score was 1.29 (p = 0.0002). The mean 4-h gastric retention improved from a pre-POP mean of 46.4 to 17.9% post-POP. Normal gastric emptying was noted in 50% of subjects with available follow-up imaging.

Conclusion: POP is a safe and effective endoscopic therapy for patients with psGP. POP should be considered a reasonable first-line option for patients with medically refractory psGP and may allow stomach preservation.
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http://dx.doi.org/10.1007/s11605-018-04088-7DOI Listing
June 2019

Evaluation of Virtual Reality for Detection of Lung Nodules on Computed Tomography.

Tomography 2018 Dec;4(4):204-208

Department of Radiology, University of California San Diego, La Jolla, CA; and.

Virtual reality (VR) systems can offer benefits of improved ergonomics, but their resolution may currently be limited for the detection of small features. For detection of lung nodules, we compared the performance of VR versus standard picture archiving and communication system (PACS) monitor. Four radiologists and 1 novice radiologist reviewed axial computed tomography (CTs) of the thorax using standard PACS monitors (SM) and a VR system (HTC Vive, HTC). In this study, 3 radiologists evaluated axial lung-window CT images of a Lungman phantom. One radiologist and the novice radiologist reviewed axial lung-window patient CT thoracic images (32 patients). This HIPAA-compliant study was approved by the institutional review board. Detection of 227 lung nodules on patient CTs did not result in different sensitivity with SM compared with VR. Detection of 23 simulated Lungman phantom lung nodules on CT with SM resulted in statistically greater sensitivity (78.3%) than with VR (52.2%, = .041) for 1 of 3 radiologists. The trend was similar but not significant for the other radiologists. There was no significant difference in the time spent by readers reviewing CT images with VR versus SM. These findings indicate that performance of a commercially available VR system for detection of lung nodules may be similar to traditional radiology monitors for assessment of small lung nodules on CTs of the thorax for most radiologists. These results, along with the potential of improving ergonomics for radiologists, are promising for the future development of VR in diagnostic radiology.
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http://dx.doi.org/10.18383/j.tom.2018.00053DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6299745PMC
December 2018

Step-by-Step Approach to Management of Type II Endoleaks.

Tech Vasc Interv Radiol 2018 Sep 14;21(3):188-195. Epub 2018 Jun 14.

Miami Cardiac & Vascular Institute, Miami, FL. Electronic address:

Seventy-five percent of abdominal aortic aneurysms are now treated by endovascular aneurysm repair (EVAR) rather than open repair, given the decreased periprocedural mortality, complications, and length of hospital stay for EVAR compared to the surgical counterpart. An endoleak is a potential complication after EVAR, characterized by continued perfusion of the aneurysm sac after stent graft placement. Type II endoleak is the most common endoleak, and often has a benign course with spontaneous resolution, occurring in the first 6 months after repair. However, these type II endoleaks may result in pressurization of the aneurysm sac and potentially sac rupture. They occur from retrograde collateral blood flow into the aneurysm sac, typically from a lumbar artery or the inferior mesenteric artery. Alternative sources include accessory renal, gonadal, median sacral arteries, and the internal iliac artery. We will discuss our protocol for post-EVAR imaging surveillance and potential type II endoleak treatment strategies, including transarterial, translumbar, transcaval, and perigraft approaches, as well as open surgery.
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http://dx.doi.org/10.1053/j.tvir.2018.06.009DOI Listing
September 2018

Endovascular Management of Acute Traumatic Aortic Injury.

Tech Vasc Interv Radiol 2018 Sep 14;21(3):131-136. Epub 2018 Jun 14.

Department of Radiology, Division of Vascular and Interventional Radiology, University of Michigan Health Systems, 1500 East Medical Center Drive, Ann Arbor, MI.

Acute traumatic injury of the thoracic aorta is a highly lethal condition, with many afflicted patients expiring before hospital arrival. While previously these conditions were managed with open surgery, endovascular repair has rapidly evolved and is now considered the standard of care for certain patterns of aortic injury at centers with appropriate expertise. The development of newer branched devices has allowed these techniques to be utilized further and further proximally into the aorta. Through minimally invasive techniques, many aortic injuries can now be treated percutaneously with shorter recovery time and less perioperative complications.
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http://dx.doi.org/10.1053/j.tvir.2018.06.002DOI Listing
September 2018

The utility of clinical criteria in patients with chronic traumatic encephalopathy.

NeuroRehabilitation 2018 ;43(4):431-441

Department of Neurology, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, USA.

Background: Repetitive traumatic brain injury (TBI) is associated with chronic traumatic encephalopathy (CTE), a progressive neurodegenerative disorder characterized by Alzheimer-like changes in the brain. CTE has been defined through neuropathological findings among deceased athletes and others exposed to repetitive TBI, but to date there are no definitive clinical criteria for CTE.

Objective: To evaluate the utility of currently proposed clinical criteria for CTE and suggest improvements.

Methods: We describe two well-characterized patients referred for evaluation of CTE and apply the four major proposed criteria for CTE. These criteria were further assessed in a cohort of patients referred to a neurobehavior clinic with or without a history of TBI.

Results: Without a CTE biomarker, the current criteria were of limited utility when applied to the two patient and the Neurobehavior cohort. Six items were extracted as potentially improving the clinical diagnosis of CTE: length of exposure to head impacts, a progressive course, specific psychiatric symptoms, frontal-executive dysfunction, parkinsonism and tremors, and targeted findings on neuroimaging.

Conclusions: The prevention and neurorehabilitation of CTE depends on clinical diagnosis, but, without a biomarker, the clinical diagnosis of CTE remains difficult. This report suggests that clinical criteria for CTE may be greatly improved with emphasis on several critical historical and clinical correlates of CTE.
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http://dx.doi.org/10.3233/NRE-182452DOI Listing
February 2019

Technical success and outcomes in pediatric patients undergoing transjugular intrahepatic portosystemic shunt placement: a 20-year experience.

Pediatr Radiol 2019 01 6;49(1):128-135. Epub 2018 Oct 6.

Department of Radiology, Division of Vascular and Interventional Radiology, University of Michigan Health System, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA.

Background: Transjugular intrahepatic portosystemic shunt (TIPS) placement has been extensively studied in adults. The experience with TIPS placement in pediatric patients, however, is limited.

Objective: The purpose of this study was to report technical success and clinical outcomes in pediatric patients undergoing TIPS placement.

Materials And Methods: Twenty-one children - 12 (57%) boys and 9 (43%) girls, mean age 12.1 years (range, 2-17 years) - underwent TIPS placement from January 1997 to January 2017. Etiologies of hepatic dysfunction included biliary atresia (n=5; 24%), cryptogenic cirrhosis (n=4; 19%), portal or hepatic vein thrombosis (n=4, 14%), autosomal-recessive polycystic kidney disease (n=3; 14%), primary sclerosing cholangitis (n=2; 10%) and others (n=3, 14%). Indications for TIPS placement included variceal hemorrhage (n=20; 95%) and refractory ascites (n=1; 5%). Technical success, manometry findings, stent type, hemodynamic success, complications, liver enzymes, and clinical outcomes were recorded.

Results: TIPS placement was technically successful in 20 of 21 (95%) children, with no immediate complications. Mean pre- and post-TIPS portosystemic gradient was 18.5±10.7 mmHg and 7.1±3.9 mmHg, respectively. Twenty-two total stents were successfully placed in 20 children. Stents used included: Viatorr (n=9; 41%), Wallstent (n=7; 32%), Express (n=5; 23%), and iCAST (n=1; 5%). All children had resolution of variceal bleeding or ascites. TIPS revision was required in 9 (45%) children, with a mean of 2.2 revisions. Hepatic encephalopathy developed in 10 children (48%), at a mean of 223.7 days following TIPS placement. During the study, 6 (29%) children underwent liver transplantation.

Conclusion: TIPS placement in pediatric patients has high technical success with excellent resolution of variceal hemorrhage and ascites. TIPS revision was required in nearly half of the cohort, with hepatic encephalopathy common after shunt placement.
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http://dx.doi.org/10.1007/s00247-018-4267-9DOI Listing
January 2019

Endobronchial Forceps-Assisted Removal of Gianturco Z-Stents from the Right Atrium.

Ann Vasc Surg 2019 Apr 12;56:350.e1-350.e4. Epub 2018 Sep 12.

Department of Radiology, Division of Vascular and Interventional Radiology, University of Michigan Health System, Ann Arbor, MI; Inova Alexandria Hospital, Cardiovascular and Interventional Radiology, Alexandria, VA. Electronic address:

Endovascular treatment of malignant intrahepatic inferior vena cava stenosis involves venoplasty and stenting. Intravascular migration is a complication associated with stents. This technical report describes the retrieval of migrated intracardiac Gianturco Z-stents using rigid endobronchial forceps.
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http://dx.doi.org/10.1016/j.avsg.2018.07.037DOI Listing
April 2019

Cryoablation of a Retroperitoneal Sarcoma Facilitates Hemostasis following Interventional Radiology-Performed Endovascular Aortic Repair.

J Vasc Interv Radiol 2018 09;29(9):1292-1294

Division of Vascular and Interventional Radiology, Department of Radiology, University of Michigan Health System, 1500 East Medical Center Drive, Ann Arbor, Michigan 48109.

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http://dx.doi.org/10.1016/j.jvir.2017.12.001DOI Listing
September 2018

Trends in Interventional Radiology Through the Eye of the Journal of Vascular and Interventional Radiology: A 27-Year History.

Curr Probl Diagn Radiol 2019 Jul - Aug;48(4):353-358. Epub 2018 May 23.

Department of Radiology, Division of Vascular and Interventional Radiology, University of Michigan Health System, Ann Arbor, MI. Electronic address:

Purpose: To report the quantity, manuscript types, geographic distribution of publications, and published content trends in a major interventional radiology journal over 27 years.

Materials And Methods: Available publication data from the Journal of Vascular and Interventional Radiology was collected via Scopus from November 1990 to November 2017. Quantity, manuscript type, geographic distribution, number of citations, and publication content were analyzed.

Results: 6925 papers were published in JVIR during the study period. The number of publications increased by 234% from an average of 103 publications/year in the first 5 years to 344 publications/year in the last 5 years. Manuscript types included 4891 original articles (70.6%), 987 letters (14.3%), 360 review articles (5.2%), 324 notes (4.7%), 167 conference papers (2.4%), 102 editorials (1.5%), 61 errata (0.9%), 23 articles in press (0.3%), and 10 short surveys (0.1%). The majority of publications originated in the United States with 3945 articles (57.0%), followed by Canada with 366 articles (5.3%), and Japan and South Korea with 360 (5.2%) and 340 articles (4.9%), respectively. As for article content, arterial disease and interventions were discussed in 2256 publications (32.6%), followed by venous (1237; 17.9%), miscellaneous (1072; 15.5%), oncology (1006; 14.5%), genitourinary (758; 10.9%), portal (337; 4.9%), neurovascular (253; 3.7%), gastrointestinal (232; 3.4%), biliary (210; 3.0%), pediatric (130; 1.9%), clinical trials (119; 1.7%), and guideline development (119; 1.7%).

Conclusion: There has been a marked increase in the number of publications in JVIR over 27 years. JVIR has shown continued growth since its inception and has strengthened its international reputation with more global research than ever before.
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http://dx.doi.org/10.1067/j.cpradiol.2018.05.002DOI Listing
December 2019

Gastroparesis in a Patient with Gastric AL Amyloidosis.

Case Rep Gastroenterol 2018 May-Aug;12(2):317-321. Epub 2018 Jun 22.

Department of Gastroenterology, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio, USA.

Systemic amyloidosis is a group of complex disorders characterized by the extracellular deposition of nonbranching fibrils in various tissues, ultimately leading to a variety of clinical presentations including isolated or multiorgan dysfunction. Amyloid involvement of the gastrointestinal tract is common depending on the subtype of this disease; light chain primary amyloidosis (AL) and secondary amyloidosis (AA) affect the gastrointestinal tract in unique ways due to differing pathophysiology. A case is reported of gastroparesis associated with AL amyloidosis diagnosed by esophagogastroduodenoscopy and study of gastric emptying, then subsequently confirmed by Congo red staining performed on endoscopic biopsies.
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http://dx.doi.org/10.1159/000489297DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6047544PMC
June 2018

Per-oral Pyloromyotomy (POP) for Medically Refractory Gastroparesis: Short Term Results From the First 100 Patients at a High Volume Center.

Ann Surg 2018 09;268(3):421-430

Section of Surgical Endoscopy, Department of General Surgery Cleveland Clinic, Cleveland, OH.

Objective: For patients with gastroparesis, temporary pyloric disruption has been shown to improve symptoms and gastric emptying. Per-oral pyloromyotomy (POP) is an innovative endoscopic procedure to divide the pylorus from within a submucosal tunnel, as a corollary to surgical pyloromyotomy. Here we evaluate subjective and objective outcomes 12-weeks after POP at a high volume center.

Methods: The first 100 consecutive patients undergoing POP were included, with procedure dates between January 2016 and October 2017. Patients were evaluated using the Gastroparesis Cardinal Symptom Index (GCSI), and 4-hour solid-phase scintigraphic gastric emptying studies (GES) prior to procedure and at 90 days post-POP RESULTS:: The study cohort was 85% female with a mean age of 45.0 ± 14.6 years. Gastroparesis etiologies were divided among idiopathic (56%), diabetic (21%), postsurgical (19%), and other in 4%. There were 67% of the patients who had previous endoscopic or surgical interventions for gastroparesis. Most POP procedures were performed in the operating room (97%) and were completed in an average of 33 minutes. Ten patients incurred complications (10%), which included 1 diagnostic laparoscopy and 2 cases of gastrointestinal bleeding. Overall GCSI improved from a preoperative mean of 3.82 ± 0.86 to 2.54 ± 1.2 (P < 0.001). The improvement in each GCSI subscore was also highly statistically significant. Among the patients with postoperative GES available, 78% had objectively better 4-hour emptying with a mean improvement in retention by 23.6% (P < 0.001). This included 57% of patients with normal gastric emptying post-POP.

Conclusion: For patients with medically refractory gastroparesis, POP results in both subjective and objective improvement in the majority of patients. Prior intervention does not obviate POP as a therapeutic option. POP should be included along the treatment algorithm for patients with gastroparesis as an organ-sparing procedure.
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http://dx.doi.org/10.1097/SLA.0000000000002927DOI Listing
September 2018

Retrograde Endovenous Laser Therapy Facilitates Great Saphenous Vein Closure in the Setting of Severe Vasospasm.

Ann Vasc Surg 2018 Aug 13;51:326.e1-326.e4. Epub 2018 Apr 13.

Department of Radiology, Division of Vascular and Interventional Radiology, University of Michigan Health System, Michigan Medicine, 1500 East Medical Center Drive, Ann Arbor, MI. Electronic address:

Antegrade access for endovenous laser therapy may be technically challenging due to patient body habitus, vasospasm, dehydration, and poor visibility of vasculature. This report describes a retrograde approach from the contralateral femoral vein to facilitate laser ablation of the great saphenous vein in the setting of vasospasm. Such a technique may provide a viable alternative in technically difficult situations.
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http://dx.doi.org/10.1016/j.avsg.2018.02.013DOI Listing
August 2018

Successful Thoracic Duct Embolization for Treatment of an Iatrogenic Left Chylothorax in a Neonate after Repair of a Tracheoesophageal Fistula and Esophageal Atresia.

J Vasc Interv Radiol 2017 Sep;28(9):1325-1327

Division of Vascular and Interventional Radiology, Department of Radiology, University of Michigan Health Systems, 1500 East Medical Center Drive, Ann Arbor, MI 48109.

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http://dx.doi.org/10.1016/j.jvir.2017.05.004DOI Listing
September 2017

Syncope workup: Greater yield in select trauma population.

Int J Surg 2017 Aug 1;44:210-214. Epub 2017 Jul 1.

Temple University Hospital, 3401 N. Broad St, Philadelphia, PA 19123, United States.

Background: There is great variation in practice regarding the assessment of trauma patients who present with syncope. The purpose of this study was to determine the yield of screening studies (electrocardiogram, echocardiogram, and carotid duplex) and define characteristics to identify groups that may benefit from these investigations.

Methods: We conducted a retrospective cohort study of all trauma patients from 2003 to 2015 who received a carotid duplex as part of a syncope evaluation at our urban Level 1 Trauma Center. Demographics, clinical findings as well as interventions undertaken (ie: placement of defibrillators/pacemakers) as a result of the syncope evaluation were collected. Data analysis was performed with STATA 14 and relationships between comorbidities, positive findings and interventions were assessed. Significance was assumed for p < 0.05.

Results: 736 trauma patients were included in the study. The most common mechanism of injury was fall (592, 82%). A history of congestive heart failure (CHF) and/or coronary artery disease (CAD) and age ≥ 65 were significantly associated with abnormal ECG and ECHO findings, but not with severe carotid stenosis. Elevated Injury Severity Scale (ISS) was significantly associated with an abnormal ECHO on both univariate and multivariate analysis. An abnormal ECG was predictive of an abnormal ECHO (p = 0.02). Ten patients (1.4%) underwent placement of a defibrillator and/or pacemaker, all of whom reported having CHF. Only 11 patients (1.7%) had severe carotid stenosis (>70%) requiring intervention.

Conclusion: The screening studies used in a syncope evaluation have low yield in the general trauma population. Carotid duplex should not be routinely performed. Cardiac evaluation should be tailored to individuals with cardiac comorbidities, older age and elevated ISS. An ECG should be used as initial screening in this patient cohort.
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http://dx.doi.org/10.1016/j.ijsu.2017.06.080DOI Listing
August 2017

Per oral endoscopic pyloromyotomy for refractory gastroparesis: initial results from a single institution.

Surg Endosc 2017 12 31;31(12):5381-5388. Epub 2017 May 31.

Section of Surgical Endoscopy, Department of General Surgery, The Cleveland Clinic Foundation, 9500 Euclid Avenue, A-100, Cleveland, OH, 44195, USA.

Introduction: Gastroparesis is a debilitating disease characterized by delayed gastric emptying in the absence of mechanical obstruction. A new intramural technique, per oral endoscopic pyloromyotomy (POP), has been proposed as an alternative to surgical pyloroplasty for the management of medical refractory gastroparesis. Herein, we detail the short-term results of POP at our institution.

Methods: POP was first performed at our institution in January 2016. All patients undergoing POP for management of gastroparesis from January 2016 through January 2017 were prospectively followed. All patients underwent a 4-h, non-extrapolated gastric emptying scintigraphy study and were asked to rate their symptoms using the Gastroparesis Cardinal Symptom Index (GCSI) at their pre-procedure visit and at 3 months post-procedure.

Results: A total of 47 patients underwent POP during the defined study period. Twenty-seven (57.4%) patients had idiopathic gastroparesis, 12 (25.6%) had diabetic gastroparesis, and eight (17.0%) had post-surgical gastroparesis. Forty-one (87.2%) patients had at least one previous intervention (i.e., enteral feeding tube, gastric pacer, botox injection) for their gastroparesis symptoms. All patients had evidence of gastroparesis on pre-procedure gastric emptying studies. The average length of hospital stay was 1 day. One patient died within 30-days of their index procedure which was unrelated to the procedure itself. The average pre-procedure percentage of retained food at 4 h was 37% compared to an average post-procedure percentage of 20% (p < 0.03). The average pre-procedure GCSI score was 4.6 compared to an average post-procedure GCSI of 3.3 (p < 0.001).

Conclusions: POP is a safe and feasible endoscopic intervention for medical refractory gastroparesis. Additional follow-up is required to determine the long-term success of this approach in alleviating gastroparesis symptoms.
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http://dx.doi.org/10.1007/s00464-017-5619-5DOI Listing
December 2017

U.S. Medical Support in a Developing World Health System - a Partnership Made in Africa for a "New Normal" Strategy.

Mil Med 2016 Apr;181(4):294-6

African International Health Specialist Team USAFE/AFAFRICA SGXD Unit 3050, Box 170 Ramstein, APO AE 09094-0170.

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http://dx.doi.org/10.7205/MILMED-D-15-00413DOI Listing
April 2016

Hybrid coaxial electrospun nanofibrous scaffolds with limited immunological response created for tissue engineering.

J Biomed Mater Res B Appl Biomater 2011 Oct 5;99(1):180-90. Epub 2011 Jul 5.

Department of Surgery, Cardiovascular Tissue Engineering Laboratory, David Geffen School of Medicine, University of California, Los Angeles, California, USA.

Electrospinning using synthetic and natural polymers is a promising technique for the fabrication of scaffolds for tissue engineering. Numerous synthetic polymers are available to maximize durability and mechanical properties (polyurethane) versus degradability and cell adhesion (polycaprolactone). In this study, we explored the feasibility of creating scaffolds made of bicomponent nanofibers from both polymers using a coaxial electrospinning system. We used a core of poly(urethane) and a sheath of a mixture of poly(ε-caprolactone) and gelatin, all dissolved in 1,1,1,3,3,3-hexafluror-2-propanol. These nanofibrous scaffolds were then evaluated to confirm their core-sheath nature and characterize their morphology and mechanical properties under static and dynamic conditions. Furthermore, the antigenicity of the scaffolds was studied to confirm that there is no significant foreign body response to the scaffold itself that would preclude its use in vivo. The results show the advantages of combining both natural and synethic polymers to create a coaxial scaffold capable of withstanding dynamic culture conditions and encourage cellular migration to the interior of the scaffold for tissue-engineering applications. Also, the results show that there is no significant immunoreactivity in vivo to the components of the scaffolds.
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http://dx.doi.org/10.1002/jbm.b.31885DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7678502PMC
October 2011

Investigation of the anxiolytic effects of linalool, a lavender extract, in the male Sprague-Dawley rat.

AANA J 2008 Feb;76(1):47-52

US Army Graduate Program in Anesthesia Nursing, William Beaumont Army Medical Center, El Paso, Texas, USA.

The purpose of our study was to investigate the anxiolytic effects of linalool and its potential interaction with the GABAA receptor in Sprague-Dawley rats. Lavender has been used traditionally as an herbal remedy in the treatment of many medical conditions, including anxiety. Linalool is a major component of the essential oil of lavender. Forty-four rats were divided into 4 groups: control, linalool, midazolam (positive control), and flumazenil and linalool. The behavioral and the neurohormonal/physiological components of anxiety were evaluated. The behavioral component was examined by using the elevated plus maze (open arm time/total time) and the neurohormonal/physiological component by measuring serum catecholamine and corticosterone levels. Data analysis was performed using a 2-tailed Multivariate Analysis of Variance and Sheffe post-hoc test. Our data suggest that linalool does not produce anxiolysis by modulation of the GABAA receptor; however, linalool may modulate motor movements and locomotion.
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February 2008

Metabolic and cardiovascular response to shallow water exercise in young and older women.

Med Sci Sports Exerc 2003 Apr;35(4):675-81

Providence Alaska Medical Center, Anchorage, AK 99508, USA.

Purpose: The purpose of this study was to compare the metabolic and cardiovascular responses of young (Y) and older (O) women ages 19-24 yr (N = 11) and 63-72 yr (N = 11), respectively, while performing shallow water exercise (SWE).

Methods: Resting metabolic rate was determined as was the metabolic (indirect calorimetry) and heart rate (Polar monitor) responses to five submaximal and one maximal SWE bout, and to a 40-min SWE class.

Results: 1) One metabolic equivalent (MET) equaled (mean +/- SE) 3.3 +/- 0.2 mL O(2).min-1.kg-1 (Y) and 2.8 +/- 0.1 mL O(2).min-1.kg-1 (O) (P < 0.05); 2) submaximal (bouts 1-5) MET and HR responses ranged from 3.5 to 8.6 and 95 to 144 bpm (Y), and 3.2 to 6.3 and 92 to 124 bpm (O); 3) estimated MET, % HR(peak), and kcal O(2) per minute at given relative efforts (% [OV0312]O(2peak)) were greater for the older group (P < 0.05), whereas no difference in RPE was found; 4) peak MET and HR equaled 11.7 +/- 0.8 and 182 +/- 3 bpm (Y) and 7.6 +/- 0.4 and 156 +/- 5 bpm (O), respectively (P < 0.05); 5) SWE class: overall, estimated average MET level was 4.9 +/- 0.3 (O) and 5.8 +/- 0.4 (Y) (P > 0.05); the overall relative intensity (% MET(peak)) was greater for the O group (61.5 +/- 2.5 vs 48.8 +/- 2.2) (P < 0.05).

Conclusions: SWE elicited metabolic and cardiovascular responses that met ACSM's guidelines for establishing health benefits. Furthermore, older females may self-select a greater relative exercise intensity during SWE compared with younger counterparts when provided with the same verbal instructions and encouragement.
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http://dx.doi.org/10.1249/01.MSS.0000058359.87713.99DOI Listing
April 2003
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