Simultaneous dual scope endotherapy of esophago-airway fistulas and obstructions.

Management of esophago-airway fistulas (EAF) and obstructions often involves therapy with esophageal and/or airway stents. We present a unique approach for the management of EAF and obstructions with simultaneous upper endoscopy and bronchoscopy (two scopes inserted simultaneously through the mouth). The aim is to assess the efficacy and safety of a simultaneous dual scope approach for management of EAF and obstructions. The endoscopy database at the University of Florida was reviewed from October 2007 to April 2012 to identify adult patients who had undergone simultaneous upper endoscopy and bronchoscopy for EAF and obstructions. Medical records were reviewed for demographics, indication, pathology, imaging, simultaneous endoscopic and bronchoscopic findings/maneuvers, outcomes, and adverse events. Outcomes assessed included: (i) technical success, (ii) fistula occlusion, (iii) dysphagia score, and (iv) adverse events. Thirteen patients with EAF and/or obstruction underwent simultaneous dual scope endoscopy. Dual scope procedures were technically successful in 12/13 (92%) patients. Dysphagia score improved from three to one in both patients with dysphagia without EAF. Fistula occlusion was observed in 7/10 patients (70%) with EAF. With this technique, stents were placed accurately without airway compression, migrated esophageal stents extracted from the tracheal lumen without trauma, and tracheal stents not displaced during esophageal manipulations. EAF not otherwise apparent were identified in two patients. Adverse events occurred in 2/13 (15%) patients, and 5/13 (38%) patients died from advanced cancer during follow up (mean 4.1 months, range 1-8 months). Simultaneous dual scope (two scopes inserted through the mouth at the same time) therapy of EAF and obstructions is feasible, effective, and safe, and may develop to be the preferred approach for the management of complex esophago-airway diseases.

[Coronary flow velocity reserve and collateral resistance after recanalization of chronic total coronary occlusions and periprocedural CK and cTNI elevation]. / Koronare Flussreserve und Kollateralwiderstand nach erfolgreicher Rekanalisation chronischer Koronarverschlüsse und periprozedurale CK- und Troponin-I-Erhöhung.

After recanalization and stenting of chronic total coronary occlusions (TCO), a reduced coronary flow velocity reserve (CFVR) and rise in collateral resistance (R(Coll)) is frequently observed. Coronary microembolization may account for these observations. In 86 patients (age 64+/-10 years; 77 men, 9 women) with TCO (duration >4 weeks), PTCA was performed with successful stent implantation in all lesions. Before PTCA, viable myocardium was detected by stress echocardiography or nuclear imaging techniques. By simultaneously measuring coronary Doppler flow velocity and pressure before and after PTCA, CFVR and R(Coll) were calculated. Over a period of 24 hours after intervention, creatine kinase (CK; upper limit of normal [ULN] for women 1.17 micromol/L/s, for men 1.33 micromol/L/s) and cardiac troponin I (cTNI; threshold 0.1 ng/mL) were studied. CFVR was <2 in 48% of all patients. A rise in R(Coll) was observed in 83% of all patients. The incidence of CK and/or cTNI elevation was only observed in 10% of all patients. These patients with CK and/or cTNI elevation did not show a significant difference of CFVR and rise in R(Coll) as compared with patients without CK and cTNI elevation. CFVR or rise in R(Coll) did not correlate with CK elevation. Coronary microembolization is not a likely cause of reduced CFVR and increased R(Coll) after PTCA of TCO. Other factors such as microvascular dysfunction and autoregulatory changes in collateral function may account for these observations.

Successful treatment of widely disseminated acanthamoebiasis.

Disseminated Acanthamoeba infections are almost invariably fatal, with no universally accepted standard for treatment. Reports of acanthamoebiasis in non-human-immunodeficiency-virus infected hosts are rare. We successfully treated a lung transplant patient who had disseminated acanthamoebiasis using a combination of pentamidine, 5-fluorocytosine, itraconazole, and topical chlorhexidine gluconate/ketoconazole cream.

In-situ end labelling with bromodeoxyuridine--an advanced technique for the visualization of apoptotic cells in histological specimens.

The fragmentation of nuclear DNA is considered to be a biochemical indication of programmed cell death (PCD) in various tissues. Several light microscopical approaches have been employed for the visualization of such fragmentation and have used either in-situ nick end labelling (ISEL) or in-situ nick translation (ISNT) with labelled dUTP. In the current paper, we can report a new method in which 0.5 micron Epon sections of mouse jejunum were incubated with terminal deoxynucleotidyl transferase (TdT) and 5-bromo-2-deoxyuridine (BrdU) for the in-situ tailing of fragmented DNA. Anti BrdU and the peroxidase anti peroxidase method (PAP) were used for staining the reaction product. Semithin sections of jejunum revealed high resolution images of labelled nuclei in the intestinal mucosa. An examination with confocal laser scanning microscopy indicated the differential distribution of immunoprecipitates in cellular nuclei, perhaps representing those distinct levels of DNA cleavage that may characterise the discrete stages of apoptosis. This new method is likely to offer new possibilities for the high resolution imaging of PCD, including the assessment of time courses and apoptosis statuses in histochemically characterized cells.

Sense- and antisense-targeting of oxytocinergic systems in the rat hypothalamus.

3' phosphorothioate modified sense or antisense oligonucleotides to oxytocin transcripts were used for in vivo targeting of oxytocin (OT) neurons in the rat hypothalamus. Intracerebroventricular injections of antisense probe resulted in a loss of systemic OT. However, abundant immunoreactive OT as well as oxytocin mRNA hybridization signal was visualized in the hypothalamo neurohypophysial system (HNS) of these animals. RT-PCR of hypothalamic homogenates revealed clearly detectable amounts of cytoplasmic OT mRNA in spite of sense or antisense treatment. Immunostaining with an antibody to DNA-RNA triple helix resulted in cytoplasmic reaction product in the HNS in the antisense group, which was not found when tissue sections had been pretreated with RNase. Animals injected with the sense probe showed a less pronounced but significant loss of systemic OT while immunoreactivity for this peptide in the posterior lobe seemed to be unaffected. RT-PCR of OT encoding mRNA extracted from sense injected rats indicated that these transcripts were of smaller size than samples from antisense treated animals or controls. Immunostaining with the triple helix antibody revealed distinct immunoreactive dots in cellular nuclei throughout the brain in the sense group. Our findings suggest that sense and antisense probes may not readily be employed as "functional antagonists" since peptidergic neurons are probably capable of responding in various ways to the treatment. RNase H may be less important in hypothalamic neurons as commonly suggested. Targeted transcripts are likely to form complexes which may somehow interact with secretion. Triple helix formation in the nucleus may not be able to induce an efficient transcriptional arrest. Although endocrine and behavioral changes observed in antisense treated animals seem to confirm the hypothesis that a selective translational "knock out" can be achieved with in vivo hybridization strategies, the actual underlying molecular events are far from being understood. On the other hand, sense or antisense strategies may provide valuable insights into molecular and cellular events associated with neurosecretion.

Pneumothorax and barotrauma.

This article discusses pneumothorax and barotrauma from the viewpoints of both the intensivist/pulmonologist and the emergency room physician because both groups of clinicians frequently encounter these potentially life-threatening conditions. The discussion focuses primarily on pneumothorax and barotrauma as they occur in adults rather than in neonates and children.