Performance of Biopsy Tools in Procurement of Lung Tissue in Robot-Assisted Peripheral Navigation: A Comparison.

INTRODUCTION: Robot-assisted navigation bronchoscopy (RANB) has been gaining traction as a new technology for minimally invasive biopsies of peripheral pulmonary lesions (PPLs). Cryobiopsy is an established method of procuring satisfactory lung tissues and can be safely paired with RANB. While some studies have evaluated the diagnostic accuracy and yield of this procedure, there is limited data on the utility of various biopsy tools, the sequence of use and differences in tissue characteristics based on the sampling techniques. Therefore, this study aims to examine the real-life performance of needle, forceps and cryoprobe when utilized in succession with RANB in the biopsy of PPLs, and to evaluate the specific types of tissue samples obtained from each instrument. METHODS: In a single-center retrospective study, 50 patients presenting 52 PPLs underwent biopsies sequentially using fine-needle aspiration (FNA), forceps, and cryoprobe. All procedures were performed via cone-beam CT-assisted RANB. Performance metrics, such as diagnostic yield, sensitivity, and specificity, were determined by classifying malignancy as true positives and explicit benign findings as true negatives. Tissue sizes and subtypes were based on pathology description and compared with Student's t test and χ2, respectively. RESULTS: Cryobiopsy, when performed sequentially after FNA then forceps, was able to retrieve more alveolar tissue (p = 0.0098) among diagnosed lesions and showed higher diagnostic yield (p = 0.001) in PPL biopsy with RANB platform. Cryobiopsy was also able to obtain larger sample size (p = 0.0087). No difference was observed in the diagnosis of malignancy between forceps and cryobiopsy (p = 0.8877). CONCLUSION: The integration of RANB and sequential biopsies, utilizing FNA, forceps, and cryoprobe, can efficiently diagnose PPLs and procure alveolar tissues. Further research based on histopathological subtypes is required to assess its prognostic significance.

Hypoglycemia-Induced Basal Ganglia Infarct: A Rare Case of Metformin Toxicity in a Hemodialysis Patient.

Metformin is the preferred agent in type 2 diabetes due to its efficacy, safety profile, cardioprotective benefits, weight loss, and accessibility in the market. However, Metformin should be prescribed with caution in patients with renal dysfunction and is contraindicated in those with a glomerular filtration rate (GFR) of less than 30 mL/min. Though extremely rare, accumulation of metformin due to poor renal clearance can cause metformin toxicity and subsequently cause lactic acidosis and hypoglycemia. The incidence is estimated at less than 10 events per 100,000 patients. Hypoglycemia has been shown to induce ischemic strokes in previous case reports; however, only one other case control study has shown hypoglycemia-induced strokes in the setting of metformin toxicity. Herein, we present a rare case of hypoglycemia-induced ischemic stroke from metformin toxicity, in a patient undergoing maintenance hemodialysis. Our case report illustrates an extremely rare case of metformin toxicity that caused a hypoglycemic-induced ischemic infarct.

The prognostic effect of brain natriuretic peptide levels on outcomes of hospitalized patients with COVID-19.

Natriuretic peptides are biomarkers of myocardial stress and are frequently elevated among patients with severe respiratory illnesses, typically in the absence of elevated cardiac-filling pressures or clinical heart failure. Elevation of brain natriuretic peptide (BNP) or NT-proBNP is associated with worse outcomes among patients with Acute Respiratory Distress Syndrome (ARDS). We conducted a retrospective cohort study based on a comprehensive review of Electronic Medical Records (EMRs) of patients with Coronavirus Disease 2019 (COVID-19) to evaluate whether BNP on admission has prognostic value on mortality and hospital length of stay (LOS) among patients admitted with confirmed COVID-19 along with the inclusion of additional prognostic variables. Overall, 146 patients were included after analyzing 230 patients' EMR and excluding potential confounding factors for abnormal BNP. Our statistical analysis did not show a statistically significant association between BNP level and mortality rate (P = 0.722) or ICU LOS ( P = 0.741). A remarkable secondary outcome to our study was that impaired renal function (GFR<60) on admission was significantly associated with an increased mortality rate (P = 0.026) and an increased ICU LOS (P = 0.022). Although various studies have presented the predictive role of pro-BNP among patients with respiratory distress in the past years, our study did not find BNP to be an accurate predictive and prognostic factor among patients with COVID-19 in our study population. Renal impairment and high Acute Physiology and Chronic Health Evaluation (APACHE) II scores on admission, on the other hand, have demonstrated to be strong predictors for COVID-19 morbidity and mortality. This study could represent an introduction to more prominent multicenter studies to evaluate additional prognostic factors and minimize the ordering of nonspecific testing.

Fully Integrated Time-Gated 3D Fluorescence Imager for Deep Neural Imaging.

This paper presents a device for time-gated fluorescence imaging in the deep brain, consisting of two on-chip laser diodes and 512 single-photon avalanche diodes (SPADs). The edge-emitting laser diodes deliver fluorescence excitation above the SPAD array, parallel to the imager. In the time domain, laser diode illumination is pulsed and the SPAD is time-gated, allowing a fluorescence excitation rejection up to O.D. 3 at 1 ns of time-gate delay. Each SPAD pixel is masked with Talbot gratings to enable the mapping of 2D array photon counts into a 3D image. The 3D image achieves a resolution of 40, 35, and 73 µm in the x, y, and z directions, respectively, in a noiseless environment, with a maximum frame rate of 50 kilo-frames-per-second. We present measurement results of the spatial and temporal profiles of the dual-pulsed laser diode illumination and of the photon detection characteristics of the SPAD array. Finally, we show the imager's ability to resolve a glass micropipette filled with red fluorescent microspheres. The system's 420 µm-wide cross section allows it to be inserted at arbitrary depths of the brain while achieving a field of view four times larger than fiber endoscopes of equal diameter.

Pulmonary arterial dilation with normal pulmonary artery pressure in sarcoidosis.

In this paper we present a clinical case that has improved on our knowledge and our curiosity about sarcoidosis. We report a case of a patient known to have pulmonary sarcoidosis, who presents with respiratory failure with severe hypercapnia. Following thorough investigations this patient was recognized to have three unique yet interrelated aspects of clinical manifestations. He was found to have severe bilateral diaphragmatic hypokinesis, dilated pulmonary vasculature with normal pulmonary pressure, and a state of high output right sided heart failure. We propose an explanation of such a presentation, while we attempted to discuss possible alternative mechanisms. In conclusion, we report this case as the first recognized case of sarcoidosis to be related to diffusely dilated pulmonary vasculature of normal vascular pressure.

Syndrome of transient headache and neurologic deficits with cerebrospinal fluid lymphocytosis masquerading as meningitis in HIV patient.

Syndrome of transient headache and neurologic deficits with cerebrospinal fluid lymphocytosis (HaNDL syndrome) is described as "headache attributed to noninfectious inflammatory disease" featuring, as its name suggests, headache that mimics migraine in addition to neurologic symptoms such as hemiparesis, hemiparesthesia and dysphagia. We report a case of a 50-year-old African-American female who presented with headache, malaise and subsequent hemiparesis. Despite bearing a close resemblance to an acute episode of meningitis clinically, cerebrospinal fluid (CSF) analysis of the patient was only positive for isolated elevation in white cell count. The patient was diagnosed with HaNDL syndrome which is characterized by transient headache and neurologic deficits with CSF lymphocytosis. While the overall condition often appears substantial, the disease is self-limiting and patients usually recover spontaneously.

Can the colour of per-rectal bleeding estimate the risk of lower gastrointestinal bleeding caused by malignant lesion?

PURPOSE: To estimate the risk of lower gastrointestinal bleeding (LGIB) caused by malignant lesion in patients presenting with per-rectal bleeding (PRB), by using visual aid as an objective measurement of PRB colour. METHODS: This was a prospective observational study on patients presented with PRB to Family Medicine Specialty Clinic, who undergo flexible sigmoidoscopy (FS) or colonoscopy (CLN) from December 2012 to September 2013. Patients aged 40 years old or above, haemodynamically stable, with normal haemoglobin level were included. Patients with a history of previous colonic surgery, refused to have FS or CLN, with ophthalmologic diseases such as colour blindness were excluded. Parameters including subjective description of PRB colour, number of chosen red colour by patients, source and distance of bleeding from anal verge were recorded for analysis. Receiver operating characteristic (ROC) curve was used to identify the optimal cutoff level of colour for diagnosing colonic lesion. Diagnostic accuracy was assessed by area under the ROC curve (AUC). Accountability of this model was assessed by logistic regression. RESULTS: The dark PRB colour was associated with diagnosis of tumour (p < 0.001) and advanced neoplastic polyp (p < 0.001). The light PRB colour was associated with the diagnosis of piles (p < 0.001). The performance of our model to predict tumour or advanced neoplastic polyps by colour (AUC, 0.798) had a better discriminative power than that to predict colonic lesion alone (AUC, 0.610) by ROC curve analysis. CONCLUSION: Objective measurement of PRB colour accurately estimated the risk of LGIB caused by malignant lesion in patients presenting with PRB.

Epirubicin-gold nanoparticles suppress hepatocellular carcinoma xenograft growth in nude mice.

We sought to investigate the effects of epirubicin-nanogold compounds (EPI-AuNP) on hepatocellular carcinoma xenograft growth in nude mice. EPI-AuNP was prepared and hepatoma xenograft model was established in nude mice. The mice were then randomly divided into four groups: the control group with injection of saline, the AuNP treatment group, the EPI treatment group and the EPI-AuNP treatment group. After two weeks, the hepatoma weight and volume of the xenografts were assessed. Our transmission electron microscopy revealed that epirubicin-gold nanoparticles caused significantly more structural changes of hepatocellular carcinoma cells HepG2. The tumor weight in the Epi-AuNP treatment group (0.80±0.11g) was significantly lower than that of the control group (2.48±0.15 g), the AuNP treatment group (1.67±0.17 g), and the EPI treatment group (1.39±0.10g) (P<0.01). Furthermore, the tumor volume of mice in the EPI-AuNP treatment group (0.27±0.06 cm³) was significantly smaller than that of the control group (2.23±0.34 cm³), the AuNP treatment group (1.21±0.25 cm³) and the EPI treatment group (0.81±0.11 cm³) (P<0.01). In conclusion, epirubicin-nanogold compounds (EPI-AuNP) have significant inhibitory effects on the growth of hepatocellular carcinoma cells in vivo.

Synchronous laparoscopic low anterior and transanal endoscopic microsurgery total mesorectal resection.

BACKGROUND: Laparoscopic low anterior resection (Lap LAR) and total mesorectal excision (TME) is the standard minimally invasive surgery (MIS) for mid and low rectal tumours. However, the pelvic resection in particular for bulky tumour in the narrow male pelvis has always been a challenge for surgeons. Transanal endoscopic microsurgery (TEM) is a well-established technique and synchronous abdomino-perineal excision of rectum (APER) is also a standard procedure. Hence, we applied the same concept to Synchronous Lap LAR and Transanal-TME. MATERIAL AND METHODS: Transanal TME was carried out with TEM instruments and rectoscope. Synchronous Lap LAR was performed and dissection joined to the pelvic part. The specimen was then retrieved via extension of the left lower quadrant port. An anvil was inserted into the proximal colon and intracorporeal transrectal anastomosis was performed to reconstitute the continuity of the bowel. RESULTS: We reported the feasibility of transanal total mesorectal excision (TME) by combination of Synchronous Lap LAR and TEM. We operated on three cases, two male patients and one female patient. We performed an intracorporeal transanal stapled coloanal anastomosis in all of them using the KOL perineal set (Touchstone, Suzhou, Jiangsu, China). The trans-abdominal and transanal dissection can be joined together with ease and accuracy. CONCLUSIONS: Transanal total mesorectal excision (TME) by synchronous Lap LAR and TEM is feasible. We combine operative techniques which are well established, currently available and cost-effective for bulky tumour in the narrow pelvis.

Feasibility study on single-port access (SPA) laparoscopic cholecystectomy using transanal endoscopic microsurgery (TEM) instruments.

Transanal endoscopic microsurgery (TEM) is a procedure for the treatment of rectal villous adenoma and early rectal tumours. It is actually the first single port access surgery (SPA) as well as a true Natural Orifice Transluminal Endoscopic Surgery (NOTES) in standard use for the last twenty years. The use of this technique and instrumentation in cholecystectomy is revisited. A feasibility study was done on porcine model. Peri-umbilical approach with the articulated TEM instruments was used for cholecystectomy. An in vivo study was started after the successful feasibility study. Cholecystectomy was performed on three consecutive porcine models using TEM instruments. Median operation time was 26.6 min. The post-op mean wound length was 3.7 cm. One gallbladder was perforated during the operation and the others were delivered intact. The instrument length was noted and the difficulty in instrument handling was documented. SPA cholecystectomy is feasible with Transanal Endoscopic Microsurgery (TEM) instruments. The special TEM technique of manipulation within a confined space is ideal for single port surgery. The TEM rectoscope can be used as a reusable single port and the instruments can be used as well but modification is suggested.

Local resection for early rectal tumours: Comparative study of transanal endoscopic microsurgery (TEM) versus posterior trans-sphincteric approach (Mason's operation).

OBJECTIVE: To compare local resection of early rectal tumours by transanal endoscopic microsurgery (TEM) and the conventional posterior trans-sphincteric approach (Mason's operation). METHODS: The study group comprised 31 consecutive patients with early rectal tumours (18 villous adenomas, 13 adenocarcinomas) who underwent TEM in Kwong Wah Hospital, Hong Kong. The control group consisted of 51 patients with early rectal tumours (27 villous adenomas, 24 adenocarcinomas) who underwent Mason's operation in Peking Union Medical College Hospital, Beijing. Outcome measures included morbidity and mortality, operation time, recurrence rate and postoperative pathological staging. RESULTS: Age, sex and pathological staging were similar in the two groups. The tumour size, operation time and blood loss were similar. The median distance from the anal verge was significantly higher in the TEM group (TEM/Mason = 8.0/6.4 cm, p = 0.042). The postoperative resumption of food intake (TEM/Mason = 1/5 days, p = 0.002) and the median hospital stay (TEM/Mason = 4/10 days, p = 0.005) were significantly shorter in the TEM group. Analgesic intake was significantly less in the TEM group (TEM/Mason = 0/100 mg, p = 0.0003). There was no operation-related mortality and the resection margins were clear in both groups. Two patients (3.9%) in the Mason's group developed postoperative wound infection, and two patients (3.9%) developed faecal fistulae. There was one secondary haemorrhage in the TEM group that required injection sclerotherapy. On median follow-up of 23 months, there was no tumour recurrence in the TEM group, whereas two patients (3.9%) in the Mason's group experienced recurrence during a median follow-up of 30 months. CONCLUSION: TEM is as effective as the conventional posterior trans-sphincteric approach (Mason's operation) for local curative resection of early rectal tumours. TEM is less invasive, with shorter hospital stay and fewer complications than conventional Mason's operation.

Left hepatic vein: can be sutured and ligated blindly in left hepatectomy?

OBJECTIVE: To determine whether the anatomic characteristics of the left hepatic vein, middle hepatic vein and common trunk could influence the operation procedures of left hepatectomy. METHOD: Fifteen fresh human liver specimens were dissected and their anatomic characteristics were recorded. RESULTS: The left hepatic vein and middle hepatic vein formed the common trunk of 1.2+/-0.4 cm in length in the 15 liver specimens. The angle between the left hepatic vein and middle hepatic vein was 91+/-18.3 degree. CONCLUSION: The left hepatic vein should not be sutured and ligated blindly in left hepatectomy because there might be a potential damage to the middle hepatic vein.

Anatomical justification of Belghiti's 'liver hanging manoeuvre' in right hepatectomy with anterior approach.

BACKGROUND: In cases of right hepatectomy for huge tumour encroaching onto the diaphragm, the 'anterior approach' is the most common surgical procedure undertaken. The 'liver hanging manoeuvre' has been described previously as an adjunct to this procedure. It involves the dissection of a retrohepatic avascular plane anterior to the surface of the inferior vena cava. A tape is then passed through and the liver is resected under suspension. METHODS: Cadaveric specimens were used to identify the structural relationship of the avascular plane and also to determine whether it is truly avascular. RESULTS: Thirteen cases were analysed. The mean length of the avascular tunnel was 6.4 +/- 1.0 cm. The median number of accessory hepatic veins within the tunnel was two (zero to three). At the caudal half of the tunnel, the median number of veins was two (zero to three). As for the cranial half of the tunnel, there were two cases with one vein in each. CONCLUSIONS: The key to the liver hanging manoeuvre is to develop the retrohepatic tunnel. However, our study showed that it is not absolutely avascular. During the blind dissection, there is a chance of damaging a retrohepatic vein. This may result in troublesome haemorrhage within the confines of the tunnel. Video-assisted dissection of this region may help in visualisation, and hence control, in order to avoid bleeding.