Transanal endoscopic surgery with a 3D printed device.

BACKGROUND: The aim of this study was to investigate the effectiveness of devices manufactured with 3D printing for performing transanal endoscopic procedures without pneumorectum. METHODS: Functional devices were designed in the Polytechnic School of Engineering of Gijón from 2016 to 2018 using three-dimensional (3D) solid modelling software (Solid-Works®), that allows customization of the device (diameter and length). The devices were made in acrylonitrile butadiene styrene (ABS) by additive manufacturing using an HP Designjet 3D Printer, with fused deposition modelling (FDM) technology. Tests were carried out on mixed simulators (with viscera) and cadavers with a prototype in the form of an open cylindrical base ellipsoid spindle with two bars. In this paper, we present the information of the first series of patients in which this device has been used to perform a full-thikness endoscopic resection of the rectal wall without pneumorectum. The characteristics of the patients, size, and location of the lesion, the type of anesthesia used, the duration of the procedure, hospital stay, complications, and pathology were analyzed. An endoscopic follow-up was also carried out for at least 2 years. RESULTS: Seven interventions were carried out in six patients. The lesions were located at a mean distance of 5 cm from the anal verge and an average area of 11.8 cm2. Four of the procedures were performed with general anesthesia and 3 with spinal anesthesia. Histopathology examination identified 3 adenomas, 3 pT1 and 1 pT2 adenocarcinomas. All excisions were full thickness. En bloc excision was possible in all cases. In only one case of a benign polyp there was a positive lateral margin. As regards complications, there was one case of postoperative rectal bleeding without the need for transfusions. There were no readmissions and no postoperative mortality. CONCLUSIONS: An innovative device made with a 3D printer can be used successfully in transanal endoscopic resections of the rectal wall, with spinal anaesthesia and avoiding the need for pneumorectum.

Complete Genome Sequences of Zika Virus Strains Isolated from the Blood of Patients in Thailand in 2014 and the Philippines in 2012.

Here, we present the complete genome sequences of two Zika virus (ZIKV) strains, Zika virus/Homo sapiens-tc/THA/2014/SV0127-14 and Zika virus/H. sapiens-tc/PHL/2012/CPC-0740, isolated from the blood of patients collected in Thailand, 2014, and the Philippines, 2012, respectively. Sequencing and phylogenetic analysis showed that both strains belong to the Asian lineage.

Correlation of rectal temperature and peripheral temperature from implantable radio-frequency microchips in Holstein steers challenged with lipopolysaccharide under thermoneutral and high ambient temperatures.

Early detection of disease can speed treatment, slow spread of disease in a herd, and improve health status of animals. Immune stimulation increases rectal temperature (RT). Injectable radio-frequency implants (RFI) can provide temperature at the site of implantation. The fidelity of peripheral site temperature, determined by RFI, relative to RT is unknown in cattle. We hypothesized that during lipopolysaccharide (LPS) challenge, temperature at 3 peripheral sites would be similar to RT in steers (n = 4; BW 77 ± 2.1 kg). The 3 sites were 1) subcutaneous (SC) at the base of the ear (ET); 2) SC posterior to the poll (PT); and 3) SC beneath the umbilical fold (UT). Steers were housed in controlled temperature (CT) rooms (between 18 and 21°C; n = 2/room). Rectal temperature, ET, PT, and UT were recorded every 8 h daily. On d 7, 21, 22, 36, and 37, RT and RFI were taken every 5 min for 6 h, every 15 min for 3 h, and every 30 min for 15 h. To test RFI during a simulated immune challenge, LPS (E. coli 055:B5) was injected intravenously (i.v.) at 1000 h on d 22 and 37. Basal temperatures (°C) were RT (38.7 ± 0.20), ET (37.1 ± 0.86), PT (36.7 ± 0.57), and UT (36.3 ± 0.97). Rectal temperature increased to 39.9 ± 0.30°C after LPS, but ET, PT, and UT decreased. Heat stress also increases RT, which makes it difficult to identify sick animals using RT. The second hypothesis tested was that ET positively correlates to RT and negatively correlates to RT during LPS under heat stress. Four steers (127 ± 7.3 kg) were housed in CT chambers (n = 2/chamber), implanted with a RFI, and allowed 2 wk to acclimate. One chamber remained at 20°C, the other was increased to 34°C starting at 0800 h for a period of 48 h. The LPS was administered i.v. to all steers at 1000 h on d 2. After a 2-wk recovery at 20°C, the temperature was increased in the other chamber, resulting in a crossover design with each steer serving as its own control. Pearson's correlation coefficients for ET and RT were 0.30 (P < 0.01) during heat stress, 0.20 (P < 0.05) during heat stress with LPS challenge, 0.34 (P < 0.01) during thermoneutrality, and -0.42 (P < 0.01) during thermoneutrality with LPS. These data refute the hypothesis that RT and peripheral temperature move in synchrony after LPS challenge. These data suggest that individual response be considered when identifying models for use of ET, but these RFI have potential for use in the early detection of diseases that alter basal temperature.

Estudio clínico retrospectivo del uso de un sistema de hidrocirugía en pacientes lesionados medulares con úlceras por presión crónicas / Retrospective clinical study of an hydrogurgery system on spinal cord injured patients with chronic pressure ulcers

Realizamos un estudio clínico retrospectivo con pacientes lesionados medulares crónicos en el Hospital Nacional de Parapléjicos (Toledo, España), intervenidos quirúrgicamente por una o varias úlceras por presión de carácter crónico durante el año 2008. Revisamos 84 historias clínicas de pacientes a los cuales se realizaron 141 procedimientos quirúrgicos. Sólo en 8 casos se realizó una cirugía puramente de limpieza (bisturí más hidrocirugía) sin realizar consecutivamente el tratamiento de cobertura de la lesión. Los restantes 133 procedimientos de limpieza más cobertura inmediata se distribuyeron en 2 grupos según el tipo de desbridamiento realizado: grupo I (n=71), sólo desbridamiento quirúrgico con bisturí y grupo II (n=62) desbridamiento con bisturí más uso posterior de un sistema de hidrocirugía de flujo continuo a alta presión. Según la localización, las lesiones ulcerosas tratadas fueron: isquiáticas 69 (48,94%), sacras 49 (34,75%), trocantéreas15 (10,63%) y otras (talones y maléolos) 8 (5,67%). Como conclusiones, establecemos que más del 54% de los procedimientos llevados a cabo (72 de 133) curaron en la primera intervención y no necesitaron más cirugías; un 38%(51 de 133) fueron intervenciones realizadas en pacientes con úlceras muy evolucionadas y/o de difícil solución; la tasa de recidivas al año fue del 4,4%; no encontramos diferencias significativas en cuanto a la tasa de curación entrelos grupos I y II (p<0,05) y, sin embargo el sistema de hidrocirugía se mostró muy efectivo (100% de éxito) en los 5casos que precisaron autoinjerto de piel parcial (AU)

We carried out a retrospective study on spinal cordinjured patients from the National Hospital for Paraplegics (Toledo, Spain), who were surgically treated during 2008 to alleviate the problems elicited by one or more pressure ulcers of chronic nature. We reviewed the clinical histories of 84 patients that received 141 surgical procedures, 8 were of radical nature (scalpel plus hidrosurgery) without wound covering. The remaining 133 procedures of surgical cleaning and immediate wound covering have been devided in 2 groups according to the type of debridement performed: Group I (n= 71) with only surgical debridement and Group II (n=62) with surgical excision followed by hydro surgery procedure consisting of a high pressure continuous flow of physiological saline fluid. Based on ulcers location, the procedures were: sciatic(n=69; 49,94%), sacral (n=49; 34,75%), trochanteric (n=15;10,63%) and others (n=8; 5,67%): heels and malleolus. Our results indicate that more than 54% of the procedures (72out of 133) healed; the procedures were carried out on patients with an advanced stage of pressure ulcers hence, the wounds were resilient to treatment; the observed annual rate of relapse was 4,4%; respecting to the rate of healing, no significant differences were found between group I and II(p<0,05) and nevertheless, the hidrosurgery system has been proven very effective (100% success) in 5 patients that required partial skin auto-transplant (AU)

Short-day photoperiod increases milk yield in cows with a reduced dry period length.

Exposure of cows to a short-day photoperiod (SDPP; 8 h light:16 h dark) during a 60-d dry period increases milk yield in the subsequent lactation compared with cows exposed to a long-day photoperiod (LDPP; 16 h light:8 h dark). Whereas the traditional recommendation for dry period length is 60 d, recent studies indicate that the dry period length can be reduced without depressing the yield in the next lactation. However, the optimal duration of the dry period appears to be between 40 and 60 d, because fewer than 30 d could result in a significant loss of milk production. Our main objective was to determine whether treatment with SDPP combined with a reduced dry period length of 42 d would increase milk yield in the next lactation relative to treatment with LDPP, even though SDPP exposure was limited to 42 d. Multiparous Holstein cows (n = 40) were randomly assigned to 1 of 2 treatments during the dry period: LDPP or SDPP. Each treatment group (n = 20) was balanced according to the previous 305-d mature equivalent milk yield. To quantify plasma prolactin (PRL) concentration, blood samples were collected weekly during the dry period. Dry matter intake (DMI) was recorded during the dry period. Health was monitored weekly during the dry period and at calving. During lactation, milk yield and DMI were recorded for 120 and 42 d, respectively. Cows exposed to SDPP calved 4.8 d earlier than cows exposed to LDPP and days dry averaged 37 and 42 d for cows exposed to SDPP and LDPP, respectively. Cows on SDPP consumed more dry matter (17.0 +/- 1.1 kg/d) during the dry period than did cows on LDPP (15.9 +/- 1.1 kg/d), but DMI after parturition did not differ. In the first 42 d of lactation, cows exposed to SDPP and LDPP consumed 18.0 and 17.7 +/- 1.4 kg/d, respectively. The periparturient PRL surge was greater in cows exposed to LDPP (22.6 +/- 3.2 ng/mL) than in those exposed to SDPP (17.1 +/- 4.1 ng/mL). Milk yield was inversely related to the magnitude of the periparturient PRL surge, but was directly related to the expression of PRL-receptor mRNA in lymphocytes during the dry period. Through 120 d of lactation, cows exposed to SDPP when dry produced more milk (40.4 +/- 1.1 kg/d) than cows exposed to LDPP (36.8 +/- 1.1 kg/d). These results support the concept that SDPP, combined with a targeted 42-d dry period, increases milk yield in the subsequent lactation, relative to a 42-d dry period combined with LDPP, and that exposure to 42 d of SDPP in the dry period is sufficient to increase milk yield in the next lactation.

Clinical significance of persistent left superior vena cava diagnosed in fetal life.

OBJECTIVES: To determine the prevalence and clinical significance of persistent left superior vena cava (PLSVC) in fetuses with and without cardiac and extracardiac anomalies. METHODS: Charts and recorded images were reviewed from high-risk patients who underwent fetal echocardiography between January 2000 and December 2005. This retrospective study included 54 fetuses with confirmed PLSVC who were diagnosed based on the presence of an additional vessel identified to the left of the pulmonary artery in the three-vessel view of the heart. Associated congenital heart defects (CHDs), extracardiac abnormalities, including first trimester nuchal translucency (NT) thickness, and fetal/postnatal outcome were analyzed. RESULTS: Of 5,737 referrals, 5,233 had a normal heart, and PLSVC was observed in 10 of these fetuses (0.2%; Group 1). CHDs were present in 504 and PLSVC was observed in 44 of these cases (9%). In the latter group, 18/44 (41%) fetuses had heterotaxy syndrome (Group 2) where the most common structural heart defects were atrioventricular septal defect and double-outlet right ventricle. Fetuses without heterotaxy syndrome (Group 3) accounted for 26/44 (59%) cases of CHDs associated with PLSVC. In this group of fetuses the most common CHDs were left outflow tract obstructive defects and conotruncal anomalies. Increased NT was observed in 29%, without differences among the three groups. The survival rates among fetuses in Groups 1, 2 and 3 were 100%, 44% and 50%, respectively. After excluding patients who underwent pregnancy termination, there were no significant differences in the survival rates among the groups, probably due to the small size of the samples. CONCLUSIONS PLSVC is associated with CHDs. The identification of PLSVC should prompt a thorough examination of the fetus to identify additional cardiac and extracardiac anomalies. The prognosis of affected fetuses largely depends on whether or not the PLSVC is associated with a CHD.

Prenatal diagnosis and outcome for fetuses with congenital absence of the pulmonary valve.

OBJECTIVES: To analyze fetal echocardiographic findings of absent pulmonary valve syndrome (APVS), its association with chromosomal and extracardiac anomalies including nuchal translucency (NT) and the outcome after diagnosis. METHODS: Data of 14 fetuses with confirmed APVS retrospectively collected in two tertiary referral centers between 1998 and 2004 were analyzed. The variables examined were: reason for referral, gestational age at diagnosis and associated abnormalities, including first trimester NT thickness. Cardiac evaluation included measurement of cardiothoracic ratio, diameter of pulmonary arteries and Doppler flow in the pulmonary trunk. Information was retrieved from clinical files, recorded videotapes and stored images. Karyotyping including examination for the 22q11 deletion was performed in all cases. RESULTS: Mean gestational age at diagnosis was 28 weeks, with 5/14 (36%) diagnosed before 22 weeks. In 13/14 (93%) there was an associated ventricular septal defect (subaortic in 12 fetuses and inlet-type in one) and all 13 had tetralogy of Fallot. Enlargement of the central pulmonary arteries and cardiomegaly were present in all cases diagnosed after 22 weeks. Of the five fetuses in which APVS was detected before 22 weeks, four (80%) had a normal pulmonary trunk diameter, two (40%) had normal pulmonary branches and three (60%) had normal cardiac size. The arterial duct was absent in 11/14 (79%). A correlation between presence of the arterial duct and the size of the central pulmonary arteries or cardiomegaly could not be established. Increased NT was observed in 4/10 cases (40%) for which this information was available. 22q11 microdeletion was diagnosed in three fetuses (21%). There were five terminations of pregnancy, one intrauterine death, five neonatal deaths and one infant death. Of the six neonates with respiratory distress, only one (17%) survived and of the eight babies in whom there was an intention to treat, two survived (25%). CONCLUSIONS: APVS can be accurately diagnosed by fetal echocardiography but screening ultrasound in the mid-second trimester is likely to have a low detection rate, probably due to the incomplete expression of the disease at this point. Many fetuses with APVS have an increased NT in the first trimester and this may help an earlier recognition of the defect. The most common associated karyotype anomaly is 22q11 microdeletion. Enlargement of the central pulmonary arteries is mainly related to the gestational age at diagnosis. Our results confirm that the outlook for these patients is extremely poor.

Pulmonary balloon valvuloplasty in a fetus with critical pulmonary stenosis/atresia with intact ventricular septum and heart failure.

Outcome of fetuses with critical pulmonary stenosis (critical PS) or atresia of the pulmonary valve (PA) with intact ventricular septum (IVS) is closely related with right ventricle hypoplasia and its consequent hemodynamics. Fetal echocardiography not only allows early detection of this condition but also monitors its normally unfavorable evolution. These cases may benefit from intrauterine intervention relieving outflow tract obstruction in order to achieve a biventricular circulation. Successful valvuloplasty of the pulmonary valve was performed in a fetus with critical PS-IVS and heart failure at 25 weeks. After the procedure there was a significant improvement in fetal hemodynamics. Follow-up scans at 34 weeks detected a significant restenosis with signs of circulatory failure leading to premature delivery of the baby. An immediate postnatal valvuloplasty successfully completed the ultimate objective of biventricular repair. Fetal pulmonary valvuloplasty is feasible and may change the natural history of the disease in fetuses with critical PS-IVS.

Correlating sonography, mammography, and pathology in the assessment of breast cancer size.

BACKGROUND: With the increasing use of neoadjuvant and minimally invasive therapy, the accuracy of preoperative determination of breast tumor size becomes important. Therefore, we undertook this study to compare mammography and ultrasonography (US). METHODS: A total of 180 invasive breast cancer patients were prospectively examined by mammography and US; 146 eligible patients had tumors visualized by both modalities. RESULTS: In 69% of cases, US was better than or equivalent to mammography in determining tumor size. Both underestimated tumor size; mean (median) underestimation was 3.8 +/- 0.7 mm (1.7 mm) by US and 3.5 +/- 0.9 mm (2 mm) by mammogram. Maximal tumor dimension was accurate within 5 mm in 65% of cases by mammography and 75% of cases by US. For mammographically determined size (versus pathologic size) correlation, r, was 0.4 and for US it was 0.63 and improved for only T1 and T2 tumors. CONCLUSIONS: These data suggest that US is more accurate than mammography in assessing breast cancer size.

Predicting the biologic behavior of ductal carcinoma in situ: an analysis of molecular markers.

BACKGROUND: Ductal carcinoma in situ (DCIS) of the breast encompasses a heterogeneous group of noninvasive cancers that now represents 19% of new breast cancer cases. Optimal treatment remains controversial. We undertook this study to characterize the relationship between angiogenic markers and the biologic behavior of various DCIS phenotypes. METHODS: We performed histopathologic review and immunohistochemistry for p53, vascular endothelial growth factor (VEGF), and factor VIII-related antigen on 103 specimens of pure DCIS. RESULTS: VEGF expression was seen in 89 tumors (86%) and correlated with microvessel density (MVD). Among VEGF-negative tumors, mean MVD (number of microvessels per square millimeter) was 48 +/- 19, versus 117 +/- 7 for tumors expressing VEGF (P =.001). Strong p53 expression was observed in 28 tumors (27%) and was associated with comedo histology, high tumor grade, necrosis, high MVD, and ipsilateral tumor recurrence (all P < or =.03). Among 8 patients with ipsilateral recurrence, 5 (63%) had tumors with strong p53 expression, whereas only 24% of patients without recurrence had tumors with strong p53 expression (P =.03). Although 7 of 8 patients with ipsilateral recurrence had tumors with VEGF and high MVD, neither parameter achieved statistical significance. CONCLUSIONS: These data suggest that molecular alterations may help predict the biologic aggressiveness of DCIS. Mutant p53 expression predisposes the patient toward ipsilateral recurrence, perhaps by promoting angiogenesis. Further investigation may identify clinically useful markers and novel treatment strategies.

Cirugía menor de la falange distal de la mano / Fingertip´s ambulatory surgical procedures

La patología de la falange distal de los dedos de la mano es atendida con frecuencia en los Servicios de Urgencias de Atención Primaria. Se trata de procesos médico-quirúrgicos muy habituales y de fácil resolución. En el presente manuscrito se revisan la patología infecciosa y traumática de la falange distal de la mano que requieren un tratamiento quirúrgico que puede ser realizado sin problemas en cualquier Centro de Salud. Consideramos que en un ámbito de primer nivel mínimamente dotado se pueden llevar a cabo, en el área descrita, los siguientes procedimientos: drenajes de colecciones purulentas o hematomas subungueales, exéresis de la uña encarnada, fijación de una avulsión ungueal, sutura de heridas incisas que no afecten al aparato flexo-extensor o al paquete vascular, pérdidas de sustancia del pulpejo sin exposición ósea y si hay disponibilidad de equipo de rayos X, fijación de una fractura de penacho ungueal y el tratamiento conservador del dedo en martillo (AU)

Laparoscopic ultrasound enhances diagnostic laparoscopy in the staging of intra-abdominal neoplasms.

Routine laparoscopy and laparoscopic ultrasound (LUS) for staging intra-abdominal malignancies remains controversial. Thus, we undertook a prospective study to assess the value of preoperative laparoscopy with LUS for patients with intra-abdominal tumors judged resectable by preoperative studies. Laparoscopy was successfully performed in 76 of 77 patients, and 60 underwent LUS. Of 33 patients with presumed pancreatic cancer, laparoscopic findings changed the operative management of 11 patients, and LUS altered the management of an additional 6 patients. Laparotomy was avoided in 9 patients (27%). Among 14 patients with hepatobiliary tumors, laparotomy was avoided in 9 patients in whom laparoscopy and/or LUS revealed either benign or advanced disease. Operative management was altered in 4 of 18 patients with gastric or esophageal cancer by laparoscopic findings. LUS did not add to the management of these patients. Of 12 patients with presumed intra-abdominal lymphoma, 9 were diagnosed with lymphoma and 3 with benign disease, without laparotomy in all but 1 case. Laparoscopy and LUS are valuable tools for evaluating the resectability of pancreatic and hepatobiliary tumors. Laparoscopy, and to a lesser degree LUS, greatly facilitates diagnosing patients with intra-abdominal lymphomas and spares an occasional patient with esophagogastric carcinoma from undergoing laparotomy.

[Nursing care for patients with toxic epidermal necrolysis]. / Cuidados de enfermería en el paciente con necrólisis epidérmica tóxica.

Toxic Epidermal Necrolysis (TEN) is a severe skin disorder characterised by separation of the dermal-epidermal junction, as it is observed in second degree superficial burns, and it may also involve any mucosal surface area (otic, buccal, conjunctival, respiratory, genital). This condition is generally induced by the ingestion of drugs, particularly certain antibiotics, nonsteroidal antiinflammatory drugs, and antiepileptic drugs. Mortality has decreased over the last decades, from 80% to about 25% in recent series. This improvement in survival rate has been related to early diagnosis, management in specialized burn units, proper immunosuppressive treatment and intensive specialised nursing care. The main nursing diagnosis include abnormalities in the skin and mucose membranes integrity, risk of infection, loss of blood volume, risk of hypothermia, acute pain, upper airway insufficiency and anxiety. We here review the nursing care of patients with TEN. We emphasize the daily skin and mucose membranes care, and the prevention of conjunctival sinequiae, including daily conjunctival cleaning and debridement of necrotic tissue and fibrin debris using a handle needle.

Postlaparoscopic small bowel obstruction. Rethinking its management.

BACKGROUND: Patients with early postoperative small bowel obstruction (SBO) are usually managed nonoperatively with nasogastric suction, intravenous fluids, and observation. The majority of early postoperative SBO resolve without an operation. METHODS: We performed a retrospective review of patients who had been diagnosed with postlaparoscopic SBO at three Chicago area teaching hospitals. RESULTS: The patients were initially managed nonoperatively for up to 7 days. However, all of them subsequently required an operation. In every case, the postlaparoscopic SBO was caused by the small bowel being incarcerated in a peritoneal defect created either by trocar placement or peritoneal incision for herniorrhaphy. CONCLUSION: In contradistinction to the approach used for early SBO after laparotomy, prompt operative intervention for postlaparoscopic SBO is recommended.

Use of ultrasound-guided fine needle aspiration biopsy in the management of thyroid disease.

Fine-needle aspiration biopsy (FNAB) of thyroid nodules has resulted in fewer patients needing thyroidectomy. Nondiagnostic FNAB specimens may require surgery for diagnosis. Ultrasound can help decrease nondiagnostic biopsies by visualizing lesions and guiding biopsy needles. Between 1996 and 1997, 76 patients had ultrasound-guided needle biopsies of thyroid nodules. Sixteen patients had clearly palpable nodules, whereas 19 were described as difficult to palpate. There were 32 patients who presented with either prominent thyroids or enlarged lobes. Six patients presented only with nonspecific symptoms, and 3 had nodules discovered incidentally on imaging studies. Biopsies were diagnostic in 73 of 76 (96%) patients. This varied with the size of the nodule, with the rate of nondiagnostic biopsies being 13 per cent in lesions <1.0 cm and 3 per cent in lesions >2.0 cm. Fifteen patients had surgery based on the FNAB, with a surgical yield of malignancy of 47 per cent. Ultrasound-guided FNAB is extremely useful in evaluating thyroid lesions that are difficult to palpate or nonpalpable, as well as the remainder of the gland and surrounding structures. The use of ultrasound guidance in performing FNAB results in a low rate of nondiagnostic biopsies, which may decrease the number of unnecessary thyroidectomies performed to rule out malignancy.

Distribution of catecholaminergic afferent fibres in the rat globus pallidus and their relations with cholinergic neurons.

The topographical distribution of catecholaminergic nerve fibres and their anatomical relationship to cholinergic elements in the rat globus pallidus were studied. Peroxidase-antiperoxidase and two-colour immunoperoxidase staining procedures were used to demonstrate tyrosine hydroxylase (TH), dopamine beta-hydroxylase (DBH), phenylethanolamine N-methyltransferase (PNMT) and choline acetyltransferase (ChAT) immunoreactivities, combined with acetylcholinesterase (AChE) pharmacohistochemistry. TH immunoreactive nerve fibres were seen to enter the globus pallidus from the medial forebrain bundle. The greatest density of such fibres was found in the ventral region of the globus pallidus, which was also characterized by the greatest density of ChAT immunoreactive neurons. TH immunoreactive nerve fibres showed varicose arborizations and sparse boutons, which were occasionally seen in close opposition to cholinergic structures. In all regions of the globus pallidus, there were also larger, smooth TH immunoreactive nerve fibres of passage to the caudate putamen. A smaller number of DBH immunoreactive nerve fibres and terminal arborizations were found in the substantia innominata, internal capsule and in the globus pallidus bordering these structures. A few PNMT immunoreactive nerve fibres in the substantia innominata and internal capsule did not enter the globus pallidus. Electron microscopy revealed TH immunoreactive synaptic profiles in the ventromedial area of the globus pallidus corresponding to the nucleus basalis magnocellularis of Meynert (nBM). These made mainly symmetrical and only a few asymmetrical synaptic contacts with dendrites containing AChE reaction product. The results indicate that cholinergic structures in the nBM are innervated by dopaminergic fibres and terminals, with only a very small input from noradrenergic fibres.

Laparoscopic herniorrhaphy in the geriatric population.

Laparoscopy has brought controversy to herniorrhaphy, particularly in the elderly. We reviewed our experience with this technique in patients older than 65 years at a single teaching institution. Data include demographics, American Society of Anesthesiologists (ASA) class, operative time, hernia type, type of repair, hospital stay, and complications. A telephone questionnaire was used to assess return to normal activity, recurrence, and reason for choosing the laparoscopic approach. From March 1992 through March 1996, 110 of 328 patients were eligible. Mean age was 73 +/- 5.6 years; 34 patients had bilateral and 20 had recurrent hernias; 73 patients (66.4%) were ASA-2, and 22 (20%) were ASA-3. The extra-abdominal and transabdominal preperitoneal approaches were used in 64 and 46 patients, respectively; mean operative time was 87.9 +/- 34 minutes. The overall complication rate was 15 per cent, with 71 per cent of these being urinary retention. Patients were discharged the same day (59%) and at 1 day (33%). Follow-up was available in 84.5 per cent. Recurrence rate was 9.7 per cent, which was not significantly influenced by complication rate, hernia repair type, or ASA class. Median return to normal activity was 7 days. ASA classification correlated with hospital stay (P = .02), but not with complications, recurrence, or return to normal activities (P = not significant). Laparoscopic herniorrhaphy appears safe in the elderly.

A prospective analysis of office-based breast ultrasound.

OBJECTIVE: To determine the usefulness of office-based breast ultrasound. DESIGN: Prospective, nonrandomized study. SETTING: Academic-affiliated community teaching hospital. PATIENTS: Among 653 consecutive patients seen in our office during a 30-month period, we performed 660 ultrasound examinations. The presenting complaint included a palpable mass in 53%, abnormal mammogram in 39%, and nipple discharge or retraction in 3%. INTERVENTION: Ultrasound examination was performed using a handheld 7.5-MHz linear array transducer. Findings and pertinent clinicopathologic data were recorded prospectively in our Breast Ultrasound Registry. MAIN OUTCOME MEASURE: Contribution of breast ultrasound to diagnosis and treatment. RESULTS: The sonogram was normal in 201 cases (30%), showed duct ectasia in 20 cases (3%), a simple cyst or seroma in 101 cases (15%), and a focal complex or solid abnormality in 338 cases (51%). Among the last group, 114 (97%) of 118 lesions thought to be benign on ultrasonography proved to be benign, whereas 13 (12%) of 111 indeterminate and 72 (75%) of 96 sonographically suspicious lesions proved to be cancer (including 13 cases with normal mammograms). Ultrasonographic features of malignancy included an anteroposterior-to-lateral dimension ratio of 1 or greater, heterogeneous hypoechoicity, irregular shadowing, and fuzzy and/or jagged margins. Ultrasound-guided needle biopsy accurately diagnosed 46 benign nonpalpable lesions and 20 malignant nonpalpable lesions. CONCLUSIONS: These data suggest that ultrasonography is a useful adjunct to clinical and mammographic evaluation of breast disease. Breast ultrasound identifies cysts, aids in differentiating benign from malignant lesions, and facilitates office needle biopsy of nonpalpable abnormalities, permitting timely and cost-effective patient care.

Differential expression of voltage-gated Ca2+ conductances in human neuroblastoma NB69 cells cultured in defined serum-free and astrocyte-conditioned media.

Voltage-gated Ca2+ conductances were investigated with the whole-cell patch-clamp technique-either using Ca2+ or Ba2+ as charge carriers-in NB69 human neuroblastoma cells plated in "defined" serum-free (DM) and in "astroglial-conditioned" media (CM). Cells expressed the microtubule associated protein 1A when plated in both media, indicating neuronlike differentiation. Cells of similar sizes and shapes were selected for recordings. Different sets of voltage-gated Ca2+ current types were usually expressed in DM- and CM-plated cells. DM-plated cells exhibited a high-voltage-activated current (HVAC) in isolation, whereas 43% of the CM-plated cells also displayed the low-voltage-activated current (LVAC). The membrane surface density of the HVAC was about twofold higher in CM than in DM-plated cells and increased with plating time from 10 and 16pA/pF (days 1-4) to 24 and 37 pA/pF (days 5-10) in DM- and CM-plated cells, respectively. However, the amplitude of the LVAC did not change significantly with culture age. In conclusion, NB69 cells expressed HVAC in isolation when plated in DM, whereas both HVAC and LVAC were present in many CM-plated cells, suggesting that the CM contained diffusible factors secreted by astroglial cells which: (1) could induce the appearance of the LVAC and (2) increased HVAC current expression.