Production, Extraction, and Solubilization of Exopolysaccharides Using Submerged Cultures of Agaricomycetes.

Macrofungi, also known as mushrooms, can produce various bioactive compounds, including exopolysaccharides (EPS) with distinct biological properties and subsequent industrial applications in the preparation of cosmetics, pharmaceuticals, and food products. EPS are extracellular polymers with diverse chemical compositions and physical properties secreted by macrofungi in the form of capsules or biofilms into the cellular medium. Submerged cultivation is an industrially implemented biotechnological technique used to produce a wide variety of fungal metabolites, which are of economic and social importance due to their food, pharmaceutical, and agronomic applications. It is a favorable technique for cultivating fungi because it requires little space, minimal labor, and low production costs. Moreover, it allows for control over environmental variables and nutrient supply, essential for the growth of the fungus. Although this technique has been widely applied to yeasts, there is limited knowledge regarding optimal growth conditions for filamentous fungi. Filamentous fungi exhibit different behavior compared to yeast, primarily due to differences in cell morphology, reproductive forms, and the type of aggregates generated during submerged fermentation. Furthermore, various growing conditions can affect the production yield of metabolites, necessitating the development of new knowledge to scale up metabolite production from filamentous fungi. This protocol implements the following culture conditions: an inoculum of three agar discs with mycelium, agitation at 150 rpm, a temperature of 28 °C, an incubation time of 72 h, and a carbon source concentration of 40 g/L. These EPS are precipitated using polar solvents such as water, ethanol, and isopropanol and solubilized using water or alkaline solutions. This protocol details the production procedure of EPS using submerged culture; the conditions and culture medium used are described. A detailed description of the extraction is performed, from neutralization to lyophilization. The concentrations and conditions necessary for solubilization are also described. Key features • Production and extraction of EPS from submerged cultures of mycelial forms of macrofungi. • Modification of the method described by Fariña et al. (2001), extending its application to submerged cultures of mycelial forms of the macrofungi. • Determination of EPS production parameters in submerged cultures of mycelial forms of macrofungi. • EPS solubilization using NaOH (0.1 N). Graphical overview.

Diabetic neuropathy: Molecular approach a treatment opportunity.

Diabetic neuropathy (DN) encompasses a group of clinical or subclinical manifestations involving a dysfunction in the peripheral nervous system. The cause of the dysfunction is the development of microvascular complications related to diabetes, a disease that affects about 381 million people worldwide. Approximately 50% of patients currently diagnosed with diabetes are expected to manifest DN in the next 10 years. The diagnosis can be made clinically by establishing a good patient history and delving into the symptoms to rule out other etiologies. Treatment of DN focuses on glycemic control and the use of medications to reduce pain, including NSAIDs, antidepressants and antiepileptic drugs. The pathogenesis is of multifactorial origin, associated with various metabolic, vascular, inflammatory and neurodegenerative disorders. The three fundamental cellular alterations participating in the development of DN are chronic inflammation, endothelial dysfunction and oxidative stress. Since the combination of all three is capable of giving rise to nerve ischemia and direct axonal injury, these factors play a key role in the development of polyneuropathy. However, neuronal and microvascular changes do not occur in the same way in all patients with DN, some of whom have no detectable blood abnormalities.

Antibody-Mediated Rejection Treatment With Bortezomib in Renal Transplant Recipients: A Single-Center 24-Month Follow-up Case Report.

INTRODUCTION: Antibody-mediated rejection (AMR) is related to a poor prognosis in graft survival, with 27% to 40% of patients experiencing graft loss within the first year. The mechanism of damage in AMR is mediated by donor-specific antibodies (DSA). No standard treatment for AMR exists, and conventional management includes high doses of steroids, plasmapheresis, intravenous immunoglobulin, and either rituximab or bortezomib. Because of the high cost of these medications and the lack of prospective studies to evaluate their efficacy and safety, their routine use is limited. In the following study, we describe the use of bortezomib for the treatment of AMR in 5 renal transplant recipients with a 24-month follow-up and compare this case with the reviewed literature. MATERIAL AND METHODS: Five cases of AMR diagnosed by biopsy are reported, and these patients received bortezomib at a rate of 1.3 mg/m2 on days 1, 4, 8, and 11; plasmapheresis; and 1 patient received 30 g of intravenous immunoglobulin. RESULTS: All patients received his or her first transplant; 4 were from a cadaveric donor, and 1 patient received thymoglobulin at a standard dose. All patients had maintenance therapy based on cyclosporine, mycophenolate mofetil, and prednisone, with an average baseline creatinine level of 1.3 mg/dL. The average days until rejection event were 952 days. DISCUSSION AND CONCLUSION: AMR treatment with bortezomib was effective, showing stable renal function at 24 months. Patients had adequate tolerance for administration. So far, these results contrast with the literature reviewed, so additional studies and follow-up are required for a new evaluation.

Metabolic Syndrome, a Real Barrier for Living Kidney Donor Transplant.

INTRODUCTION: Renal transplantation is the optimal renal replacement therapy. In Mexico, most of the kidney transplants are from living donors. It is essential to identify conditions that increase the risk of developing chronic kidney disease (CKD) in donors, such as metabolic syndrome (MS). MATERIALS AND METHODS: In retrospect from January 2008 to December 2018, the donation protocols for renal transplantation of the Hospital Central Sur Alta Especialidad "Picacho" were reviewed, classifying all the cases of donors by nephrectomy or no nephrectomy and describing the demographic characteristics, prevalence of metabolic diseases, and cause of rejection of the protocol. RESULTS: A total of 178 donors were studied: 82 women (46%), 96 men (54%), mean age of 42 years, average body mass index (BMI) 27.9 kg/m2, glomerular filtration rate (GFR) by Chronic Kidney Disease Epidemiology Collaboration 99 mL/min, 59 patients with grade I and II obesity (BMI ≥ 30 kg/m2), and 1 patient with morbid obesity (BMI ≥ 40 kg/m2). A total of 39 patients (22%) underwent nephrectomy and 139 (78%) did not. The following characteristics and alterations were found: Of the 139 patients who did not undergo nephrectomy, 91 had metabolic disorders, 20 had low GFR, 21 had albuminuria, and 4 recipients received cadaveric transplants, 3 due to critical conditions of the recipient. The metabolic alterations in the rejected donors were as follows: MS 54 (59%), prediabetes 55 (39%), newly diagnosed hypertension 70 (76%), diabetes mellitus 20 (14%), obesity 47 (51.6%), dyslipidemia 76 (83%), hyperuricemia 17 (12%). DISCUSSION: The prevalence of MS in apparently healthy donors is similar to that of other studies in Mexico. Both MS and its components are independently associated with an increased risk of cardiovascular disease and CKD. It has been shown that these donors have a greater degree of glomerular and interstitial fibrosis; therefore, diagnosis, prevention, and timely treatment in this group are important.

Variation in floral morphology and plant reproductive success in four Ipomoea species (Convolvulaceae) with contrasting breeding systems.

This study tested the hypothesis that self-compatibility would be associated with floral traits that facilitate autonomous self-pollination to ensure reproduction under low pollinator visitation. In a comparison of two pairs of Ipomoea species with contrasting breeding systems, we predicted that self-compatible (SC) species would have smaller, less variable flowers, reduced herkogamy, lower pollinator visitation and higher reproductive success than their self-incompatible (SI) congeners. We studied sympatric species pairs, I. hederacea (SC)- I. mitchellae (SI) and I. purpurea (SC)-I. indica (SI), in Mexico, over two years. We quantified variation in floral traits and nectar production, documented pollinator visitation, and determined natural fruit and seed set. Hand-pollination and bagging experiments were conducted to determine potential for autonomous self-pollination and apomixis. Self-compatible Ipomoea species had smaller flowers and lower nectar production than SI species; however, floral variation and integration did not vary according to breeding system. Bees were primary pollinators of all species, but visitation rates were seven times lower in SC than SI species. SC species had a high capacity for autonomous self-pollination due to reduced herkogamy at the highest anther levels. Self-compatible species had two to six times higher fruit set than SI species. Results generally support the hypothesis that self-compatibility and autonomous self-pollination ensure reproduction under low pollinator visitation. However, high variation in morphological traits of SC Ipomoea species suggests they maintain variation through outcrossing. Furthermore, reduced herkogamy was associated with high potential for autonomous self-pollination, providing a reproductive advantage that possibly underlies transitions to self-compatibility in Ipomoea.

Abordaje ecoguiado a nivel antecubital para cirugía del síndrome del túnel del carpo / Ultrasound-guided block at the antecubital fossa for carpal tunnel syndrome surgery

Introducción. Existen diferentes técnicas anestésicas para la cirugía ambulatoria del síndrome del túnel del carpo. Los bloqueos nerviosos ecoguiados brindan ventajas frente a otras técnicas. El objetivo del estudio fue determinar la eficacia del bloqueo ecoguiado a nivel de la fosa antecubital, así como la evaluación de las complicaciones, la satisfacción del paciente y del cirujano. Material y métodos. Estudio observacional prospectivo en 32 pacientes programados para cirugía del síndrome del túnel del carpo, en régimen ambulatorio. Se realizó un bloqueo nervioso ecoguiado a nivel de la fosa antecubital, de los nervios mediano, cubital y cutáneos medial y lateral del antebrazo con mepivacaína 1%. Se registraron las mediciones de los diámetros anteroposterior y laterolateral de los nervios mediano y cubital, antes y después de la inyección. Se evaluó el inicio del bloqueo sensitivo y motor en los territorios de los nervios mediano y cubital cada 5 min, hasta 30 min después de la administración del anestésico local, con respecto a la mano contralateral. Se registró la presencia de dolor durante la incisión quirúrgica, en el postoperatorio, las complicaciones y la satisfacción del paciente y del cirujano con la técnica anestésica realizada. Resultados. El bloqueo nervioso ecoguiado a nivel de la fosa antecubital fue eficaz en un 93,7% de los pacientes. Ningún paciente requirió rescate analgésico, no se produjeron efectos adversos reseñables ni complicaciones. La satisfacción con respecto a la técnica anestésica elegida fue valorada como «muy buena» por el 93,7% de los pacientes y por el 97% de los cirujanos. Conclusiones. El bloqueo nervioso ecoguiado de los nervios mediano, cubital y cutáneos medial y lateral del antebrazo a nivel de la fosa antecubital es una técnica anestésica eficaz y satisfactoria para la cirugía ambulatoria del síndrome del túnel del carpo, permite la movilización del brazo por parte del paciente, minimiza los riesgos y disminuye la dosis de anestésico local empleada(AU)

Introduction. There are various anaesthetic techniques for ambulatory surgery of carpal tunnel release. The ultrasound-guided nerve blocks offer advantages compared to other techniques. The purpose of this study was to evaluate the efficacy using ultrasound-guided block at the antecubital fossa, as well as to evaluate complications, patient satisfaction and surgeon satisfaction with the block. Materials and methods. Prospective observational study with 32 elective patients for carpal tunnel release in a one-day case unit. An ultrasound-guided block with mepivacaine 1% was performed at the antecubital fossa, aiming for the median, ulnar and the lateral and medial cutaneous nerves of the forearm. The measurements of the anteroposterior and laterolateral diameters of the median and ulnar nerves were recorded, before and after injection. Motor and sensory levels were evaluated for the median and ulnar nerves at 5 and 30min post injection, and compared with the contralateral hand. Pain from the surgical incision time and recovery were recorded, together with complications, and patient and surgeon satisfaction with the block. Results. The antecubital fossa ultrasound-guided block was successful in 93.7% of the patients. No patients needed rescue analgesia in recovery and no complications were recorded. Patient satisfaction was 93.7% and surgeon satisfaction was 97%. Conclusions. A selective block of the medial, ulnar and medial and lateral cutaneous nerves of the forearm are effective and satisfactory anaesthetic techniques for carpal tunnel release in a one-day case unit. It allows early mobilization, minimises risks and amount of local anaesthetic used(AU)

Sleep-disordered breathing and oxidative stress in preclinical chronic mountain sickness (excessive erythrocytosis).

Chronic mountain sickness (CMS) is considered to be a loss of ventilatory acclimatization to high altitude (>2500m) resulting in marked arterial hypoxemia and polycythemia. This case-control study explores the possibility that sleep-disordered breathing (SDB) and associated oxidative stress contribute to the etiology of CMS. Nocturnal respiratory and [Formula: see text] patterns were measured using standard polysomnography techniques and compared between male high-altitude residents (aged 18-25) with preclinical CMS (excessive erythrocytosis (EE), n=20) and controls (n=19). Measures of oxidative stress and antioxidant status included isoprostanes (8-iso-PGF2alpha), superoxide dismutase and ascorbic acid. EE cases had a greater apnea-hypopnea index, a higher frequency of apneas (central and obstructive) and hypopneas during REM sleep, and lower nocturnal [Formula: see text] compared to controls. 8-iso-PGF2alpha was greater in EE than controls, negatively associated with nocturnal [Formula: see text] , and positively associated with hemoglobin concentration. Mild sleep-disordered breathing and oxidative stress are evident in preclinical CMS, suggesting that the resolution of nocturnal hypoxemia or antioxidant treatment may prevent disease progression.

[Ultrasound-guided block at the antecubital fossa for carpal tunnel syndrome surgery]. / Abordaje ecoguiado a nivel antecubital para cirugía del síndrome del túnel del carpo.

INTRODUCTION: There are various anaesthetic techniques for ambulatory surgery of carpal tunnel release. The ultrasound-guided nerve blocks offer advantages compared to other techniques. The purpose of this study was to evaluate the efficacy using ultrasound-guided block at the antecubital fossa, as well as to evaluate complications, patient satisfaction and surgeon satisfaction with the block. MATERIALS AND METHODS: Prospective observational study with 32 elective patients for carpal tunnel release in a one-day case unit. An ultrasound-guided block with mepivacaine 1% was performed at the antecubital fossa, aiming for the median, ulnar and the lateral and medial cutaneous nerves of the forearm. The measurements of the anteroposterior and laterolateral diameters of the median and ulnar nerves were recorded, before and after injection. Motor and sensory levels were evaluated for the median and ulnar nerves at 5 and 30 min post injection, and compared with the contralateral hand. Pain from the surgical incision time and recovery were recorded, together with complications, and patient and surgeon satisfaction with the block. RESULTS: The antecubital fossa ultrasound-guided block was successful in 93.7% of the patients. No patients needed rescue analgesia in recovery and no complications were recorded. Patient satisfaction was 93.7% and surgeon satisfaction was 97%. CONCLUSIONS: A selective block of the medial, ulnar and medial and lateral cutaneous nerves of the forearm are effective and satisfactory anaesthetic techniques for carpal tunnel release in a one-day case unit. It allows early mobilization, minimises risks and amount of local anaesthetic used.

El bloqueo de los nervios pectorales guiado por ultrasonidos puede ser de utilidad en la cirugía de mama reconstructiva para control del dolor postoperatorio / The usefulness of ultrasound-guided pectoral nerve block for postoperative pain control in reconstructive breast surgery

No disponible

Role of cytokines in altitude-associated preeclampsia.

BACKGROUND: Preeclampsia (PE) is more common at high than low altitude and contributes to the altitude-related decline in birth weight. Since inflammatory markers are implicated in PE, we asked if such markers differed in PE vs. normotensive pregnant (NORM) women residing at high altitude (3600-4100 m), and were related to uterine artery blood flow (UA BF) or fetal growth. METHODS: Subjects were 33 Andean pregnant residents of Bolivia, comprising six with early-onset PE (≤ 34 wk), 12 with late-onset PE (> 34 wk), and 15 gestational-age matched NORM. Maternal pro- and anti-inflammatory cytokines were measured using a multiplex bead-based assay and UA BF by Doppler ultrasound. RESULTS: PE compared to NORM women had higher levels of the pro-inflammatory cytokines IL-6 and IL-8 as well as higher levels of the anti-inflammatory cytokine IL-1ra, but only IL-6 levels were higher when gestational age was controlled. Women with early- vs. late-onset PE had higher TNFα levels, and higher IL-6 was negatively correlated with birth weight in all women at ≤ 34 wk. We suggest that pro-inflammatory factors influence both the timing and severity of PE at high altitude.

High-end arteriolar resistance limits uterine artery blood flow and restricts fetal growth in preeclampsia and gestational hypertension at high altitude.

The reduction in infant birth weight and increased frequency of preeclampsia (PE) in high-altitude residents have been attributed to greater placental hypoxia, smaller uterine artery (UA) diameter, and lower UA blood flow (Q(UA)). This cross-sectional case-control study determined UA, common iliac (CI), and external iliac (EI) arterial blood flow in Andeans residing at 3,600-4,100 m, who were either nonpregnant (NP, n = 23), or experiencing normotensive pregnancies (NORM; n = 155), preeclampsia (PE, n = 20), or gestational hypertension (GH, n = 12). Pregnancy enlarged UA diameter to ~0.62 cm in all groups, but indices of end-arteriolar vascular resistance were higher in PE or GH than in NORM. Q(UA) was lower in early-onset (≤34 wk) PE or GH than in NORM, but was normal in late-onset (>34 wk) illness. Left Q(UA) was consistently greater than right in NORM, but the pattern reversed in PE. Although Q(CI) and Q(EI) were higher in PE and GH than NORM, the fraction of Q(CI) distributed to the UA was reduced 2- to 3-fold. Women with early-onset PE delivered preterm, and 43% had stillborn small for gestational age (SGA) babies. Those with GH and late-onset PE delivered at term but had higher frequencies of SGA babies (GH=50%, PE=46% vs. NORM=15%, both P < 0.01). Birth weight was strongly associated with reduced Q(UA) (R(2) = 0.80, P < 0.01), as were disease severity and adverse fetal outcomes. We concluded that high end-arteriolar resistance, not smaller UA diameter, limited Q(UA) and restricted fetal growth in PE and GH. These are, to our knowledge, the first quantitative measurements of Q(UA) and pelvic blood flow in early- vs. late-onset PE in high-altitude residents.

Do cytokines contribute to the Andean-associated protection from reduced fetal growth at high altitude?

Pro- versus anti-inflammatory cytokine balance is important for successful pregnancy. Chronic hypoxia alters cytokine levels and increases the frequency of fetal growth restriction (FGR). Multigenerational Andean (AND) versus shorter duration European (EUR) high-altitude (HA) residents are protected from altitude-associated FGR. To address whether ancestry group differences in cytokine levels were involved, we conducted serial studies in 56 low-altitude ([LA]; 400 m; n = 29 AND and n = 27 EUR) and 42 HA residents (3600-4100 m; n = 19 ANDs and n = 23 EURs). Pregnancy raised pro- (interleukin 1ß [IL-1ß]) and anti- (IL-10) inflammatory cytokines and HA lowered IL-6 and tumor necrosis factor-α (TNF-α) near term. There were no ancestry group differences in cytokine levels at any time, but HA reduced IL-1ß in ANDs only near term. Higher IL-1ß levels correlated with uterine artery (UA) blood flow at 20 weeks in ANDs at HA, suggesting that IL-1ß may play a role in AND protection from altitude-associated reductions in fetal growth.

Echogenicity of needles: a comparative in vitro study / No disponible

Aim: Needle visualization is important for safe and successful ultrasound-guided peripheral nerve block. However, accurate and consistent visualization of the needle tip can be difficult to achieve. A number of previous studies have analyzed the ultrasound properties of needles and have reported reduced visibility with steeper insertion angles. Anecdotal evidence suggests that the converse is true with the newer echogenic needles on the market. The aim of this study was to analyze the echogenic parameters of 4 needles currently on the market and assess whether any advances in needle echogenicity have been achieved in the last few years. Methodology: By using a water bath and a M-Turbo Sonosite machine with a HFL probe we analyzed the echogenic versions of the Pajunk, Vygon, BBraun and Polymedic needles. The needles were inserted to 4cm and pictured at 0, 30, 45 and 60 degrees insertion relative to the surface. We measured pixel intensity, being defined as the grey scale value from 0 (black) and 255 (white).For ease (..) (AU)

Objetivo: La visualización de la aguja es importante para la realización de un bloqueo de nervio periférico seguro y eficaz guiado por ecografía. Sin embargo, la identificación precisa y evidente de la punta de la aguja puede ser difícil de obtener. Existen varios estudios que han analizado las propiedades ecográficas de las agujas y han demostrado la reducción de visibilidad de la misma con ángulos de inserción más pronunciada. Parece que sucede lo contrario con las agujas ecogénicas que han aparecido en el mercado, si bien son aún muy escasos los estudios que lo señalan. El objetivo de este estudio fue analizar los parámetros ecogénicos de 4 de las agujas que hay actualmente en el mercado y determinar si se ha avanzado y en qué grado en la adquisición de nuevas propiedades ecográficas de las agujas en los últimos años. Metodología: Mediante el uso de un recipiente de baño de agua y una máquina de ecografía M-Turbo de Sonosite con una sonda HFL analizamos las versiones ecogénicas de las agujas: Pajunk, Vygon, B Braun y Polymedic. Las agujas se insertaron unos 4 cm y se fotografiaron sus imágenes ecogénicas a los 0, 30, 45 y60 grados de inserción en relación a la superficie, respectivamente. Se midió la intensidad de los píxeles, que se define como el valor en la escala de gris desde de 0 (negro) a 255 (blanco). Para facilitarla comparación entre ellas, el valor obtenido se convirtió en porcentaje de 255 (blanco 100% y 0% negro).Resultados: Nuestro estudio demuestra que las cuatro agujas eran claramente visibles en los cuatro niveles de angulación y que había buena visibilidad de la punta de las mismas. Sorprendentemente, y contrariamente a los resultados anteriores, la visibilidad de la aguja se incrementó con ángulos de inserción más (..) (AU)

Manejo ambulatorio de un paciente portador de desfibrilador automático implantable / No disponible

Manejo anestésico-quirúrgico de un paciente portador de un desfibrilador automático implantable en un programa de cirugía ambulatoria, mediante anestesia epidural y sedoanalgesia basada en remifentanilo (AU)

Anesthetic and surgical management of a patient with an automatic implantable defibrillator in an outpatient surgery program,by epidural anesthesia and sedoanalgesia based on remifentanil (AU)

Do anti-angiogenic or angiogenic factors contribute to the protection of birth weight at high altitude afforded by Andean ancestry?

OBJECTIVE: This prospective study was designed to determine whether variation in angiogenic (placental growth factor [PlGF]) and/or anti-angiogenic (soluble fms-like tyrosine kinase [sFlt-1]) factors contribute to the protective effect of highland ancestry (Andean) from altitude-associated reductions in fetal growth. STUDY DESIGN: Plasma sFlt-1 and PlGF levels, uterine artery (UA) blood flow, and fetal biometry were determined in low-altitude (400 m; Andean n = 27, European n = 28) and high-altitude (3600 m; Andean n = 51, European n = 44) residents during pregnancy (20 and 36 weeks) and 4 months postpartum. RESULTS: High-altitude decreased sFlt-1 levels in both groups, Andeans had lower sFlt-1, comparable PlGF, lower sFlt-1/PlGF ratios, and higher UA blood flow throughout pregnancy relative to Europeans. Altitude decreased birth weight in Europeans but not Andeans. In high-altitude Europeans sFlt-1/PlGF and sFlt-1 levels were negatively associated with UA diameter and birth weight, respectively. CONCLUSIONS: Lower sFlt-1 and sFlt-1/PLGF ratio may contribute to or result from variations in maternal vascular adaptation to pregnancy between Andean and Europeans at high altitude. Subsequently, these effects could potentially influence ancestry-associated differences in birth weight.

Genetic aberrations and survival in plasma cell leukemia.

Plasma cell leukemia (PCL) is an aggressive and rare hematological malignancy that originates either as primary disease (pPCL) or as a secondary leukemic transformation (sPCL) of multiple myeloma (MM). We report here the genetic aberrations and survival of 80 patients with pPCL or sPCL and make comparisons with 439 cases of MM. pPCL presents a decade earlier than sPCL (54.7 vs 65.3 years) and is associated with longer median overall survival (11.1 vs 1.3 months; P<0.001). 14q32 (IgH) translocations are highly prevalent in both sPCL and pPCL (82-87%); in pPCL IgH translocations almost exclusively involve 11q13 (CCND1), supporting a central etiological role, while in sPCL multiple partner oncogenes are involved, including 11q13, 4p16 (FGFR3/MMSET) and 16q23 (MAF), recapitulating MM. Both show ubiquitous inactivation of TP53 (pPCL 56%; sPCL 83%) by coding mutation or 17p13 deletion; complemented by p14ARF epigenetic silencing in sPCL (29%). Both show frequent N-RAS or K-RAS mutation. Poor survival in pPCL was predicted by MYC translocation (P=0.006). Survival in sPCL was consistently short. Overall pPCL and sPCL are different disorders with distinct natural histories, genetics and survival.

Endoscopic ultrasound for the evaluation of Nissen fundoplication integrity: a blinded comparison with conventional testing.

BACKGROUND: For patients whose symptoms develop after Nissen fundoplication, the precise mechanism of anatomic failure can be difficult to determine. The authors have previously reported the endosonographic hallmarks defining an intact Nissen fundoplication in swine and the known causes of failure. The current clinical trial tested the hypothesis that a defined set of endosonographic criteria can be applied to determine fundoplication integrity in humans. METHODS: The study enrolled seven symptomatic and nine asymptomatic subjects at a mean of 6 years (range, 1-30 years) after Nissen fundoplication. A validated gastroesophageal reflux disease (GERD)-specific questionnaire and medication history were completed. Before endoscopic ultrasound (EUS), all the patients underwent complete conventional testing (upper endoscopy, esophagram, manometry, 24-h pH). A diagnosis was rendered on the basis of combined test results. Then EUS was performed by an observer blinded to symptoms, medication use, and conventional testing diagnoses. Because EUS and esophagogastroduodenoscopy (EGD) are uniformly performed in combination, the EUS diagnosis was rendered on the basis of previously established criteria combined with the EGD interpretation. The diagnoses then were compared to examine the contribution of EUS in this setting. RESULTS: The technique and defined criteria were easily applied to all subjects. All symptomatic patients had heartburn and were taking proton pump inhibitors (PPI). No asymptomatic patients were taking PPI. All diagnoses established with combined conventional testing were detected on EUS with upper endoscopy. Additionally, EUS resolved the etiology of a low lower esophageal sphincter pressure in two symptomatic patients and detected the additional diagnoses of slippage in two subjects. Among asymptomatic subjects, EUS identified additional diagnoses in two subjects considered to be normal by conventional testing methods. CONCLUSION: According to the findings, EUS is a feasible method for evaluating post-Nissen fundoplication hiatal anatomic relationships. The combination of EUS and EGD allows the mechanism of failure to be detected in patients presenting with postoperative symptoms after Nissen fundoplication.

Treatment outcomes for primary intraocular lymphoma: implications for external beam radiotherapy.

PURPOSE: Intravitreal chemotherapy for primary intraocular lymphoma (PIOL) increasingly is promoted as an alternative to radiotherapy, owing to putative high failure and complication rates of the latter modality. Our aim was to confirm whether these concerns about radiotherapy were borne out in patients treated at our institution over the last decade. DESIGN: Retrospective interventional case series. PARTICIPANTS: A total of 21 eyes of 12 patients with PIOL. METHODS: Comprehensive chart review of ophthalmologic and systemic manifestations, treatments, and outcomes. MAIN OUTCOME MEASURES: Radiation complications and local tumour control. RESULTS: Cytology-confirmed lymphoma involved one eye in three patients and both eyes in nine patients. Initial treatment included external beam radiotherapy and chemotherapy (six patients), chemotherapy alone (four patients), radiotherapy alone (one patient), and no treatment (one patient). Ocular relapses occurred in no patients receiving radiotherapy and in two patients who did not receive radiotherapy. Complications of radiotherapy included dry eye (four patients), cataract (four patients), and mild radiation retinopathy (two patients). CONCLUSIONS: Radiotherapy for PIOL is highly effective with acceptable complications. In the absence of a clear advantage to intravitreal chemotherapy, which involves repetitive injections and associated risks, radiotherapy may still be the most appropriate first-line treatment in most cases.