Minimally Invasive Approach to Esophageal Perforation after Endoscopic Ultrasound-Guided Fine-Needle Aspiration: A Report of 2 Cases

Esophageal perforation after endoscopic ultrasound-guided fine-needle aspiration for mediastinal staging is a rare but severe complication. We report 2 cases of patients with esophageal perforation who were treated using video-assisted thoracoscopic surgery in combination with esophageal stenting. Through these cases, the feasibility of minimally invasive thoracic surgery was evaluated.

The Role of Microenvironment in Preserving the Potency of Adult Porcine Pulmonary Valve Stem Cells In Vitro

BACKGROUND AND OBJECTIVE: The potency of tissue resident stem cells is regulated primarily by inputs from the local microenvironment. Isolation of stem cells through enzymatic digestion of tissue may affect epigenetic regulation of cell fate and performance. Here we employ a non-enzymatic method to harvest and investigate tissue resident stem cells from the adult porcine pulmonary valve. METHODS AND RESULTS: The presence of c-Kit+ stem cells within the valve tissue was confirmed by immunohistochemistry. An in vitro culture of minced valve leaflets was developed under the standard conditions (37°C with 5% CO2). The viability of the cellular outgrowths was evaluated over the subsequent 12 weeks. Under this culture condition, we identified a population of non-adherent c-Kit+ cells and multiple cellular structures mimicking the phenotype of embryonic stem cells at different stages of development. Formation of multinucleated cells through cell fusion provided an active niche area for homing and interaction of the non-adherent c-Kit+ cells. Expression of pluripotency markers Oct-4 and Nanog was detected in the newly formed multinucleated cells but not in mature colonies. Partial cell fusion was shown by fluorescent live-cell tracking, which confirmed intercellular molecular exchange between donor and recipient cells, resulting in altered cytoplasmic protein expression by the recipient cell. CONCLUSIONS: These results suggest a role for the microenvironment in decrypting the potential of the valve somatic stem cells in vitro. In addition, our data provide evidence for cell fusion, which may play a critical role in reversing somatic cell fate and spontaneous cellular reprogramming.

The Clinical Correlations between Diabetes, Cigarette Smoking and Obesity on Intervertebral Degenerative Disc Disease of the Lumbar Spine

STUDY DESIGN: Retrospective analysis of a nationwide private insurance database. Chi-square analysis and linear regression models were utilized for outcome measures. PURPOSE: The purpose of this study was to investigate any relationship between lumbar degenerative disc disease, diabetes, obesity and smoking tobacco. OVERVIEW OF LITERATURE: Diabetes, obesity, and smoking tobacco are comorbid conditions known to individually have effect on degenerative disc disease. Most studies have only been on a small populous scale. No study has yet to investigate the combination of these conditions within a large patient cohort nor have they reviewed the combination of these conditions on degenerative disc disease. METHODS: A retrospective analysis of insurance billing codes within the nationwide Humana insurance database was performed, using PearlDiver software (PearlDiver, Inc., Fort Wayne, IN, USA), to identify trends among patients diagnosed with lumbar disc degenerative disease with and without the associated comorbidities of obesity, diabetes, and/or smoking tobacco. Patients billed for a comorbidity diagnosis on the same patient record as the lumbar disc degenerative disease diagnosis were compared over time to patients billed for lumbar disc degenerative disease without a comorbidity. There were no sources of funding for this manuscript and no conflicts of interest. RESULTS: The total number and prevalence of patients (per 10,000) within the database diagnosed with lumbar disc degenerative disease increased by 241.4% and 130.3%, respectively. The subsets of patients within this population who were concurrently diagnosed with either obesity, diabetes, tobacco use, or a combination thereof, was significantly higher than patients diagnosed with lumbar disc degenerative disease alone (p <0.05 for all). The number of patients diagnosed with lumbar disc degenerative disease and smoking rose significantly more than patients diagnosed with lumbar disc degenerative disease and either diabetes or obesity (p <0.05). The number of patients diagnosed with lumbar disc degenerative disease, smoking and obesity rose significantly more than the number of patients diagnosed with lumbar disc degenerative disease and any other comorbidity alone or combination of comorbidities (p <0.05). CONCLUSIONS: Diabetes, obesity and cigarette smoking each are significantly associated with an increased diagnosis of lumbar degenerative disc disease. The combination of smoking and obesity had a synergistic effect on increased rates of lumbar degenerative disc disease. Patient education and preventative care is a vital goal in prevention of degenerative disc disease within the general population.

Bisphosphonate's and Intermittent Parathyroid Hormone's Effect on Human Spinal Fusion: A Systematic Review of the Literature

There has been a conscious effort to address osteoporosis in the aging population. As bisphosphonate and intermittent parathyroid hormone (PTH) therapy become more widely prescribed to treat osteoporosis, it is important to understand their effects on other physiologic processes, particularly the impact on spinal fusion. Despite early animal model studies and more recent clinical studies, the impact of these medications on spinal fusion is not fully understood. Previous animal studies suggest that bisphosphonate therapy resulted in inhibition of fusion mass with impeded maturity and an unknown effect on biomechanical strength. Prior animal studies demonstrate an improved fusion rate and fusion mass microstructure with the use of intermittent PTH. The purpose of this study was to determine if bisphosphonates and intermittent PTH treatment have impact on human spinal fusion. A systematic review of the literature published between 1980 and 2015 was conducted using major electronic databases. Studies reporting outcomes of human subjects undergoing 1, 2, or 3-level spinal fusion while receiving bisphosphonates and/or intermittent PTH treatment were included. The results of relevant human studies were analyzed for consensus on the effects of these medications in regards to spinal fusion. There were nine human studies evaluating the impact of these medications on spinal fusion. Improved fusion rates were noted in patients receiving bisphosphonates compared to control groups, and greater fusion rates in patients receiving PTH compared to control groups. Prior studies involving animal models found an improved fusion rate and fusion mass microstructure with the use of intermittent PTH. No significant complications were demonstrated in any study included in the analysis. Bisphosphonate use in humans may not be a deterrent to spinal fusion. Intermittent parathyroid use has shown early promise to increase fusion mass in both animal and human studies but further studies are needed to support routine use.

Embolia pulmonar grasa: Presentación de un caso / Pulmonary fat embolism. Case report

La embolia grasa (EG) es una obstrucción de los vasos sanguíneos por glóbulos de grasa. Ha sido descrita en la circulación pulmonar con una gran variedad de asociaciones, pero las más comunes e importantes se dan con fracturas de huesos largos y daño de tejido blando debido a traumatismo grave. Por su parte, el síndrome de embolia grasa (SEG) es una manifestación poco frecuente, aunque grave, del fenómeno de embolia grasa, que se caracteriza clínicamente por la tríada disnea, petequias y confusión mental. La razón de la discrepancia entre la presencia de embolia grasa y el desarrollo del síndrome no es clara. Presentamos el caso de un hombre de 41 años que, inmediatamente después del trauma, presentó en la tomografía computada (TC) inicial defectos de llenado de atenuación grasa dentro de las arterias pulmonares. Estos fueron interpretados como múltiples embolias grasas macroscópicas. Los valores de atenuación de la tomografía computada multidetector (TCMD) de las embolias pulmonares deben examinarse cuidadosamente en el contexto de un traumatismo agudo o después de procedimientos ortopédicos, debido a la complicación rara pero potencialmente fatal del SEG. En los centros de trauma, la TCMD es una herramienta esencial para hacer el diagnóstico de la embolia grasa macroscópica, así como también para descartar otras causas de hipoxia, como la embolia pulmonar trombótica. La reconstrucción de cortes finos debe utilizarse para la evaluación detallada de la vasculatura pulmonar.

Fat embolism (FE) may be defined as the blockage of blood vessels by fat globules. Pulmonary fat embolisms are reported to be associated with a wide variety of conditions, with the most common and important ones being with long bone fractures and soft tissue damage due to severe trauma. Fat embolism syndrome (FES) is a rare but serious manifestation of the fat embolism phenomenon, characterized clinically by a triad of dyspnea, petechiae, and mental confusión. The discrepancy between the presence of a fat embolism and the development of fat embolism syndrome is unclear. The case is presented of a 41 year-old mate who, on the initial trauma CT sean, presented with filling defeets of fat attenuation within the pulmonary arteries. Those were interpreted as múltiple macroscopic fat emboli. The CT attenuation valúes of pulmonary embolism should be carefully examined in the setting of acute trauma or after orthopedic procedures, as the rare but potentially fatal complicaron of FES may result. In trauma centers, multidetectorcomputed tomography is an essential tool to make the diagnosis of macroscopic fat embolism, and to exelude other causes of hypoxia, such as thrombotic pulmonary embolism. These reconstructions should be used for detailed evaluation of the pulmonary vasculature.

Cistitis enfisematosa en varón no diabético / Emphysematous cystitis in a non-diabetic male

La cistitis enfisematosa es una entidad infrecuente que se presenta como complicación de las infecciones urinarias. Se caracteriza por la presencia de gas intravesical y/o intraparietal, producto de la fermentación bacteriana. Más de la mitad de los casos aparecen en pacientes inmunocomprometidos o con historia de diabetes mellitus mal controlada. Afecta predominantemente al sexo femenino y la magnitud del cuadro clínico es variable. Comunicamos un caso de cistitis enfisematosa en un paciente sin compromiso inmunológico ni diabetes, detallando la presentación clínica, las características imagenológicas y la conducta terapéutica de esta entidad poco común...

Taiwanese Parents' Experience of Making a "Do Not Resuscitate" Decision for Their Child in Pediatric Intensive Care Unit

PURPOSE: The purpose of this project was to explore the parental experience of making a "do not resuscitate" (DNR) decision for their child who is or was cared for in a pediatric intensive care unit in Taiwan. METHODS: A descriptive qualitative study was conducted following parental signing of a standard hospital DNR form on behalf of their critically ill child. Sixteen Taiwanese parents of 11 children aged 1 month to 18 years were interviewed. Interviews were recorded, transcribed, analyzed and sorted into themes by the sole interviewer plus other researchers. RESULTS: Three major themes were identified: (a) "convincing points to sign", (b) "feelings immediately after signing", and (c) "postsigning relief or regret". Feelings following signing the DNR form were mixed and included "frustration", "guilt", and "conflicting hope". Parents adjusted their attitudes to thoughts such as "I have done my best," and "the child's life is beyond my control." Some parents whose child had died before the time of the interview expressed among other things "regret not having enough time to be with and talk to my child". CONCLUSION: Open family visiting hours plus staff sensitivity and communication skills training are needed. To help parents with this difficult signing process, nurses and other professionals in the pediatric intensive care unit need education on initiating the conversation, guiding the parents in expressing their fears, and providing continuing support to parents and children throughout the child's end of life process.

Longitudinal follow-up of lymphocyte subsets during the first year of life.

A longitudinal study of lymphocyte subsets during infancy was evaluated by using the flow cytometric immunophenotyping method. Two hundred and thirteen blood samples were obtained from 92 healthy, full-term infants of the following ages: 1-7 days old (n = 43), 3 months old (n = 55), 6 months old (n = 57) and 11 months old (n = 58). The absolute numbers of CD3+ and CD3+/CD4+ T lymphocytes increased from birth to 3 months of age, and remained stable thereafter. The absolute number of CD3+/CD8+ T lymphocytes increased from birth to 11 months of age. The absolute number of CD19+ B lymphocytes and NK cells increased rapidly (3 months) after birth and continued to increase throughout the study period. However, the changes in the relative counts of lymphocyte subsets did not always correspond with the changes in their absolute numbers. These results demonstrate the age-related changes in lymphocyte subpopulations and provide reference ranges for lymphocyte subsets during infancy.

Neuropharmacology of dopamine receptors: Implications in neuropsychiatric diseases

There has been an extraordinary recent accumulation of information concerning the neurobiology and neuropharmacology of dopamine [DA] receptors in the mammalian central nervous system. Many new DA molecular entities have been cloned, their gene, peptide sequences and structures have been identified, their anatomical distributions in the mammalian brain described, and their pharmacology characterized. Progress has been made toward developing selective ligands and drug-candidates for different DA receptors. The new discoveries have greatly stimulated preclinical and clinical studies to explore the neuropharmacology of DA receptors and their implications in the neuropathophysiology of different neuropsychiatric diseases including schizophrenia, Parkinson-s disease and attention- deficit hyperactivity disorder. Accordingly, it seems timely to review the salient aspects of this specialized area of preclinical neuropharmacology and its relevance to clinical neuropsychiatry

Bloqueio AV total congênito: novo modelo experimental para avaliaçäo do marcapasso fetal / Total congenital AV block: a new experimental model for evaluation of fetal pacemaker

O implante de marcapasso epicárdico em fetos via toracotomia é um procedimento potencialmente mais seguro e eficaz para se tratar o bloqueio AV total congênito (BAVT), quando associado à hidropsia fetal e refratário ao tratamento clínico. Este estudo foi desenvolvido com o objetivo de avaliar as características eletrofisiológicas de dois eletrodos epicárdicos através de novo modelo experimental de BAVT congênito induzido pela crioablaçao do nó AV. Foram aplicados, em 2 grupos de 6 fetos de ovelhas (80 por cento da gestaçao), um eletrodo de rosqueamento (l,5 voltas) e outro de sutura epicárdica. O BAVT foi obtido em todos os fetos, nao sendo observado nenhum ritmo de escape ventricular. Os limiares de estimulaçao foram baixos para ambos os eletrodos, com valores inferiores para o eletrodo de rosqueamento com largura de pulso abaixo de O,9 mseg (p < O,03). A corrente medida no limiar de voltagem com largura de pulso abaixo de O,5 mseg foi menor para o eletrodo de rosqueamento (p < O,048). A resistência dos 2 eletrodos medida com voltagem constante nao foi estatisticamente diferente (441,8 ñ 13,7( para o eletrodo de rosqueamento versus 480,2 ñ 59,2( para o eletrodo de sutura epicárdica). Nao houve diferença estatisticamente significante (p> O,20) na amplitude da onda R dos 2 eletrodos. O slew rate foi significativamente maior para o grupo de fetos com eletrodo de rosqueamento (l,40 ñ O,2 versus O,62 ñ O,2 V/seg. p=O,O4). O método é simples e reprodutível para avaliaçao do marcapasso fetal, sendo que o eletrodo de rosqueamento representa a melhor opçao, quando houver indicaçao de implante de marcapasso em fetos.

Tolerância da placenta à parada circulatória umbilical normotérmica / Tolerance of the placenta to normothermic umbilical circulatory arrest

O aumento da resistência vascular placentária e distúrbios de trocas gasosas freqüentemente ocorrem após a circulaçao extracorpórea (CEC) letal. A utilizaçao de um circuito convencional de CEC que exclua a placenta da circulaçao através do clampeamento temporário do cordao umbilical pode proteger a vasculatura placentáriados estímulos que levam ao aumento da resistência vascular. Para avaliar atolerância placentária à parada normotérmica do fluxo sanguíneo umbílico-placentário, 9 placentas de ovelhas isoladas in-situ, foram colocadas em CEC através da canulaçao dos vasos umbilicais, com fluxo médio de artéria umbilical de 214 ml/min/kg. Após 30 minutos de estabelecimento da CEC, a circulaçao placentária foi interrompida por 30 minutos, simulando o clapeamento do cordao umbilical durante a CEC fetal total. Posteriormente, a circulaçao placentária foi restabelecida aos valores basais. A troca de gases placentária, o fluxo sangüíneo e a resistência vascular materno-placentários foram avaliados antes e depois da parada circulatória. Nao houve diferença estatisticamente significante entre os gradientes transplacentários de PO(2) e pCO(2') indicando que a interrupçao do fluxo sangúíneo placentário por 30 minutos, em condiçoes normotérmicas, nao afeta a funçao placentária. Este modelo sugere um método alternativo para a aplicaçao clínica da CEC letal, através da exclusao da circulaçao umbílico-piacentária durante a CEC fetal, eliminando-se, assim, os efeitos deletérios da CEC nas trocas gasosas plcentárias.

Perforaciones intestinales espontáneas en recién nacidos: una forma de enterocolitis necrosante / Spontaneous intestinal perforations in newborn infants: a form of necrotizing enterocolitis

El presente estudio incluyó doce recién nacido prematuros con perforaciones gastrointestinales "espontáneas", estudiados retrospectivamente durante tres años. Se encontró que le problema fue más frecuente en niños extremadamente prematuros con síndrome de dificultad respiratoria y persistencia de conducto arterioso. Se hizo correlación anatomo patológiuca con las biopsias o estudios post-mortem y se sugiere que las perforaciones intestinales "espontáneas" probablemante representan una forma de enterocolitis necrosante. perforación intestinal; enterocolitis necrosante; recién nacido

Drenajes abdominales. Parte II. Estudio clinico prospectivo. / Abdominal drainages. Part II. Prospective clinical study

Un estudio cooperativo realizado por los Servicios de Cirugia de 5 hospitales permitio analizar 195 pacientes con drenajes abdominales. Los modelos aspirativos fueron preferidos a los no aspirativos y se demostro su capacidad para detectar complicaciones postoperatorias y evitar reoperaciones por dehiscencias de esofagoyeyunoanastomosis, coledocoyeyunoanastomosis salida accidental del tubo de Kehr, etc.Para interpretar los hechos relacionados con la colocacion de un drenaje es imprescindible un conocimiento mas profundo de la fisiologia peritoneal: presiones, secrecion y absorcion, genesis y lisis de las adherencias, capacidad antimicrobiana, etc

Drenajes abdominales. Estudio experimental comparativo. / Abdominal drainages.Comparative experimental study

Se presenta una serie de 14 perros en los que se efectuo una laparotomia y se coloco un cateter para instilacion continua y un drenaje con sus extremos separados 4 cm. Cerrada la incision, durante 3 hs se introdujeron 200 cc de bilis humana. En 7 se empleo drenaje aspirativo y en 7 de Penrose. Transcurridas las 3 hs, se efectuo una nueva laparotomia, aspirandose la bilis remanente. Con el sistema aspirativo se habia drenado (promedio) el 57% de la bilis y con el Penrose solo 6,3%. Los autores consideran que en esas condiciones experimentales el drenaje aspirativo demostro ser muy superior