Direct Blood Supply Research Articles

9183 Pituitary Metastasis Of Lung Adenocarcinoma Presenting As Anterior Pituitary Dysfunction

Abstract Disclosure: O. faour: None. M. Kinaan: None. S.K. Suryanarayanan: None. Introduction: The pituitary should not be overlooked as a site for metastasis and can be the first presentation of neoplastic disease in some patients. Most common presenting symptoms: headache, ophthalmoplegia, visual field defect and Arginine Vasopressin Deficiency (AVP-D). We present a case of pituitary metastasis of lung adenocarcinoma presenting as anterior Pituitary dysfunction that also showed partial AVP-D unmasked after starting steroids. Case Description: A 63-year-old male with history of tobacco use, COPD, and hypertension presented with syncope. He reported a 30lbs weight loss within prior 2 months, low energy, increased thirst, and polyuria. Physical exam was significant for cachexia, normal visual field on confrontation, and vital signs of BP 100/61, HR 83, and Weighing 180 lbs. Since he had syncope, Cortisol checked was undetectable and Free T4 was low, He was started on hydrocortisone and levothyroxine. CTA chest revealed a right hilar mass measuring 2.7 x 3 cm. Endobronchial biopsy was consistent with lung adenocarcinoma. MRI of pituitary gland revealed solid hypointense lesion with glandular thickening and diffuse heterogeneity involving most of the pituitary gland measuring up to 16 mm. No cavernous sinus invasion. Pituitary infundibulum showed diffuse thickening and enhancement of the pituitary stalk throughout with Intact posterior pituitary bright spot. Labs showed low LH, cortisol, ACTH, GH, TSH, and ADH. Initially, the patient was able to maintain a euvolemic status through increased water intake; however, he was later found to have partial central AVP-D when steroids were introduced. He responded to the use of Desmopressin, developed hyponatremia after 3 doses. He was started on a combination of carboplatin/pemetrexed/pembrolizumab but had no response and was transferred to palliative care/hospice and passed away within 7months after diagnosis.Discussion:Pituitary metastasis is rare and most commonly occurs in lung and breast cancers. Unfortunately, they are associated with poor prognosis. MRI findings of loss of posterior pituitary bright spot, thickening of the stalk, and dumbbell shape can be helpful in distinguishing between primary pituitary tumors and metastases. PET-FDG scan has limited value. Pituitary metastasis commonly presents with posterior pituitary dysfunction due to direct blood supply. Unmasking or worsening of AVP-D can happen with steroid replacement in patients requiring initiation or intensification of Desmopressin therapy. Treatment involves combination of surgery, radiation therapy, and systemic treatment for the primary cancer which can improve symptoms only but does not improve mortality. Presentation: 6/1/2024

252. RIGHT GASTROEPIPLOIC ARTERY LENGTH DETERMINED ANASTOMOTIC LEAKRIGHT GASTROEPIPLOIC ARTERY LENGTH DETERMINED ANASTOMOTIC LEAKAGE AFTER MINIMALLY INVASIVE ESOPHAGECTOMY FOR ESOPHAGEAL CANCER-A PROSPECTIVE COHORT STUDY

Abstract Background This prospective cohort study, conducted at a high-volume esophageal cancer center from July 2019 to July 2022, aimed to investigate the link between the right gastroepiploic artery (RGEA) length and anastomotic leakage (AL) rates following minimally invasive esophagectomy (MIE). Real-world data on stomach blood supply in the Chinese population were examined. Materials and methods A total of 516 cases were enrolled, categorized into two groups based on the Youden index-determined optimal cut-off value for the relative length of RGEA (length of RGEA/length of gastric conduit, 64.69%) through ROC analysis: Group SR (short RGEA) and Group LR (long RGEA). The primary observation parameter was the relationship between AL incidence and the ratio of direct blood supply from RGEA. Secondary parameters included the mean length of the right gastroepiploic artery, greater curvature, and the connection type between right and left gastroepiploic vessels. Patient data were prospectively recorded in electronic case report forms. Results The study revealed median lengths of 43.60 cm for greater curvature, 43.16 cm for the gastric conduit, and 26.75 cm for RGEA. AL, the most common postoperative complication, showed a significant difference between groups (16.88% vs. 8.84%, p = 0.01). Multivariable binary logistic regression identified Group SR and LR (Odds ratio: 2.651, 95% CI: 1.124–6.250, p = 0.03) and Neoadjuvant therapy (Odds ratio: 2.479, 95% CI: 1.374–4.473, p = 0.00) as independent predictors of AL. Conclusions The study emphasizes the crucial role of RGEA length in determining AL incidence in MIE for esophageal cancer. Preserving RGEA and fostering capillary arches between RGEA and LGEA are recommended strategies to mitigate AL risk.

Poster 304: Isolating The Medial Meniscal Artery with Ultrasonography: Anatomical Characterization of the Novel Vascular Structure and a Technical Note on Imaging Technique

Objectives: The vascularity of the human meniscus was first famously described by Arnoczky and Warren, who used histological analysis to map out vessel contributions to the medial and lateral menisci. This study determined that the medial and lateral superior and inferior genicular arteries branches give rise to a perimeniscal capillary plexus within the capsular and synovial tissues of the knee. However, since this study, there have been limited investigations into the macro- and microvascularity of the menisci. This includes anatomical, biomechanical, and imaging studies. Doppler ultrasound is an easily accessible, safe, and non-invasive modality that gives clinicians real-time visualization of vascular anatomy. To date, there have been no ultrasound studies that have highlighted vascular deviations from the popliteal artery to the medical meniscus, including the newly discovered medial meniscal artery (MMA), as described in Part 1 of this study (Figure 1, from Part 1 of this investigation). The purpose of this study was to use find a reproducible ultrasound technique to identify the MMA and provide a detailed characterization of the vessel’s precise anatomy. We hypothesized that the MMA would be consistently identifiable in vivo using ultrasound imaging and that multiple anatomic variants of the MMA would exist. Methods: Fifty-six patients underwent ultrasound examination of the left knee. Patient demographics were collected. The MMA was isolated by one of two techniques. In the first approach, the inferior medial genicular artery (IMGA) was isolated and followed back to the popliteal artery, where the examiner then coursed the artery proximally to find medial-sided vasculature branching to the medial meniscus. In the second approach, the probe was started on the medial meniscus and once an arterial supply was found, it was traced back to the popliteal artery. Once the MMA was isolated by either technique, the following variables were measured: presence or absence of MMA, artery diameter, presence of arterial calcifications or atheromatous plaques, and any vascular variations. Once the MMA was found and isolated in the left knee, its presence was investigated in the right knee. Results: The MMA was identified in 50/56 patients (89.2%). The average vessel diameter was 0.89 mm (SD ± 0.39). All 50 patients with a MMA present on the left knee also had the presence of the artery on the right knee. None of the MMA isolated in this study were noted to have any plaques or calcifications. 45 patients were noted to have a Type 1 MMA, whereas five patients were noted to have a Type 2 MMA where the vessel shares an origin with the IMGA (Figure 2). Conclusions: This is the first study to utilize ultrasound to isolate and characterize the MMA in a in vivo human model. The MMA can be consistently seen on ultrasonography in the majority of patients and ultrasound examination demonstrated that the artery perforates into the meniscal tissue to contribute to the meniscal microplexus. The key methods to ensure reproducible identification of the artery and patient characteristics that produce lesser quality images are discussed in detail. Ultrasound identification in clinic may serve as a point-of-care diagnostic modality to determine the likelihood of success of procedures such as medial meniscal repair, given the artery provides a direct blood supply to the meniscus. The MMA may play a pivotal role in meniscal injury, repair, healing, and preservation. Future studies are necessary to determine the extent to which this vessel contributes to said mechanisms.

Right gastroepiploic artery length determined anastomotic leakage after minimally invasive esophagectomy for esophageal cancer: a prospective cohort study.

This prospective cohort study, conducted at a high-volume esophageal cancer center from July 2019 to July 2022, aimed to investigate the link between the right gastroepiploic artery (RGEA) length and anastomotic leakage (AL) rates following minimally invasive esophagectomy (MIE). Real-world data on stomach blood supply in the Chinese population were examined. A total of 516 cases were enrolled, categorized into two groups based on the Youden index-determined optimal cut-off value for the relative length of RGEA (length of RGEA/length of gastric conduit, 64.69%) through ROC analysis: Group SR (short RGEA) and Group LR (long RGEA). The primary observation parameter was the relationship between AL incidence and the ratio of direct blood supply from RGEA. Secondary parameters included the mean length of the right gastroepiploic artery, greater curvature, and the connection type between right and left gastroepiploic vessels. Patient data were prospectively recorded in electronic case report forms. The study revealed median lengths of 43.60cm for greater curvature, 43.16cm for the gastric conduit, and 26.75cm for RGEA. AL, the most common postoperative complication, showed a significant difference between groups (16.88 vs. 8.84%, P =0.01). Multivariable binary logistic regression identified Group SR and LR (odds ratio: 2.651, 95% CI: 1.124-6.250, P =0.03) and Neoadjuvant therapy (odds ratio: 2.479, 95% CI: 1.374-4.473, P =0.00) as independent predictors of AL. The study emphasizes the crucial role of RGEA length in determining AL incidence in MIE for esophageal cancer. Preserving RGEA and fostering capillary arches between RGEA and LGEA are recommended strategies to mitigate AL risk.

Anatomy of the terminal branches of the superior rectal artery during selective doppler controlled dearterialization of the hemorrhoidal nodes (HAL-RAR)

Background: To date, there is no single standard for conducting HAL-RAR operations. The constant discussion raises the question of the number of terminal branches of the superior rectal artery, which must be ligated in the submucosal layer of the rectum in order to provide the adequate dearterialization of hemorrhoids. Aim: To study the anatomy of the branches of the superior rectal artery and to develop recommendations for the optimal ligation of the terminal branches of the superior rectal artery. Methods: 150 protocols of the previous operations have been studied. In order to further objectify our results, the results of radiation diagnostics (CT and MRI) were revised for 100 patients without pathological changes of the rectum and anal canal to study the variant anatomy of the superior rectal artery and its terminal branches in the rectal wall. Results: In 148 patients, 6 terminal branches were identified, in 2 (1.333%) patients, 5 branches were found. 100 cases without pathological changes were also analyzed (60 MRI and 40 CT scans). In all the cases, 6 terminal branches of the superior rectal artery were determined, located at 1, 3, 5, 7, 9 and 11 o'clock positions of the conventional dial. At the same time, a large number of identified anatomical options for the branching of the VPA and the method for reaching the rectal wall should be noted, which we used as a basis to propose a classification. Conclusion: In the vast majority of cases, there are 6 terminal branches of the superior rectal artery, located in the lower ampulla of the rectum at approximately 1, 3, 5, 7, 9 and 11 hours of the conventional dial. A number of variants of the vascular anatomy of the proximal branches are possible, but 6 distal branches are involved in the direct blood supply of the hemorrhoids. When performing selective Doppler-controlled dearterialization of hemorrhoids, it is expedient to ligate 6 arterial vessels.

The Distribution of the Nerves and Arteries of the Platysma for Clinical Applications.

This study aimed to provide anatomical data on the platysma for clinical procedures. The authors obtained 25 specimens from 15 adult Korean cadavers (9 men, 6 women; mean age, 72 years; range, 61-85 years). Lines connecting the gonion with the gnathion (G-GN) and the acromial end (acromial end of the clavicle) with the sternal end (sternal end of the clavicle) were used as references. Modified Sihler staining was used to trace the nerves distributed in the platysma. The superior border values of the platysma were 12.1 ± 2.7mm, 31.5 ± 5.3mm, 42.4 ± 5.6mm, and 61.7 ± 6.4mm, respectively, for sections 2 through 5 on the G-GN line. The inferior border values of the platysma were 83.6 ± 19.1mm, 80.1 ± 14.0mm, 74.8 ± 14.5mm, 67.2 ± 13.7mm, and 54.6 ± 7.1mm, respectively, for the 5 sections on the acromial end of the clavicle-sternal end of the clavicle line. In the hyoid bone, cricoid cartilage, and jugular notch, the mean distance between the bilateral platysma was 14.4 ± 2.2mm, 22.6 ± 10.6mm, and 51.1 ± 15.7mm, respectively. The mean angle at the cervical branch of the facial nerve and the anterior border of the sternocleidomastoid muscle sternal head was 28.7 ± 2.6 degrees and 53.4 ± 7.7 degrees from the G-GN line, respectively. The upper third of the platysma was supplied by branches of the facial artery and submental artery. The middle third was supplied by branches of the occipital artery and received its direct blood supply from branches of the external carotid artery. The lower third was supplied by branches of the transverse cervical artery. The authors hope that the results of this study will be helpful for rejuvenation procedures of the neck.

Hypoxia and platelet lysate sustain differentiation of primary horse articular chondrocytes in xeno-free supplementation culture

Currently, the main limitation for the use of adult differentiated chondrocytes in cell-based therapy and tissue engineering for the repair of articular cartilage is the difficulty of maintaining their state of differentiation during cell expansion. The adult articular cartilage has no direct blood supply, and local oxygen concentrations range from 5%–10% at the surface near the synovial fluid to less than 1% in the deep layer. Low oxygen tension is currently considered an important environmental condition for chondrocytes, and hypoxia has been explored as a signal potentially promoting differentiation and matrix deposition. In the present study, hypoxia and PL supplementation were studied to maintain differentiation in adult articular chondrocytes. Freshly isolated equine articular chondrocytes were grown in monolayer culture at a low seeding density (condition favoring proliferation and dedifferentiation) and in alginate beads (3D culture condition maintaining chondrocyte differentiation) both in normoxic and hypoxic conditions and in various conditions of supplementation or deprivation (fetal bovine serum [FBS]- and PL-free; 10% FBS; 5% PL; 10% PL). Results demonstrated that hypoxia is a micro-environmental condition that reduces chondrocyte dedifferentiation or maintains differentiation during in vitro expansion, as shown by the sustained expression of differentiation markers (COL2, ACAN, SOX9, HIF1a) and the reduction of dedifferentiation marker expression (COL1, RUNX2). In association with hypoxia, PL supplementation demonstrated a positive effect on chondrocyte differentiation in association with hypoxia. This promising result should be confirmed in other conditions of chondrocyte differentiation before proposing PL as a complete alternative to xenogenic serum for the expansion of articular chondrocytes.

REM phase: An ingenious mechanism to enhance clearance of metabolic waste from the retina

The Rapid Eye Movement (REM) phase of sleep, also known as “active sleep” because of physiological similarities to waking state, is characterized by intense cerebral electrical activity, propensity to dream vividly and suppression of skeletal muscle activity (atonia) except for the extraocular muscles which give rise to the so-called REM. In 1998 David Maurice, an ophthalmologist, proposed that REM sleep was associated with an eye function: it would be required to stir the anterior chamber and bath it with aqueous humor to prevent corneal anoxia during sleep. However, potential metabolic problems could arise in the outer retinal layers which lack a direct blood supply. New research lends support to the hypothesis that a para-vascular transport system, the so-called “glymphatic”, is present in the eye analogous to the one recently discovered in the brain. It is a functional waste clearance pathway which promotes elimination of interstitial solutes from the brain along para-vascular channels. Glymphatic function increases during sleep and just as a “brain pump” moves fluids in the central nervous system, a “vitreous pump” moves them into the eyeballs during REM phase. A number of similarities between Alzheimer's disease and several retinal degenerations have been described, particularly with respect to either age-related macular degeneration and chronic open-angle glaucoma. Impairment of this mechanism in some disease states and in the normal aging process could have serious consequences for visual function. In this manuscript I propose a new hypothesis regarding the role of REM phase on physio-pathology of the human eye: it would be an ingenious mechanism to enhanced clearance of metabolic waste from the retina.

HYPERBARIC OXYGEN THERAPY FOR REFRACTORY VANISHING BRONCHUS SYNDROME AFTER LUNG TRANSPLANTATION

TOPIC: Transplantation TYPE: Medical Student/Resident Case Reports INTRODUCTION: Lung transplantation (LTx) is an evolving field. Post-LTx complications including airway stenosis, anastomotic infection, granulation tissue formation, and airway dehiscence remain a source of increased morbidity, mortality, and costs. We present here a case of non-anastomotic bronchial stenosis with a critical narrowing of bronchus intermedius, presenting as ongoing shortness of breath and an acute drop in pulmonary function tests (PFTs). CASE PRESENTATION: A 59-year-old bilateral LTx recipient presented 5 months after LTx with worsening shortness of breath associated with an acute drop in PFTs with an obstructive pattern. Bronchoscopy revealed a yellow mucoid pseudomembrane bilaterally with narrowing of bronchus intermedius in the right-middle lobe and the right-lower lobe, requiring balloon dilation and placement of a stent in the right-middle lobe. Follow-up PFTs improved, yet did not fully recover to baseline. Hyperbaric oxygen therapy was initiated with a dramatic improvement of his shortness of breath and further improvement of his PFTs. DISCUSSION: Herein we discuss a case of vanishing bronchus syndrome (VBS) in an LTx recipient that was successfully treated with airway stenting and hyperbaric oxygen therapy. VBS occurs in approximately 3% of LTx recipients and typically evolves slowly [1]. The complication is thought to be caused by ischemic injury as bronchial anastomosis in LTx is devoid of direct blood supply. Revascularization of bronchial circulation through collaterals usually requires 3-4 weeks, during which time the risk of airway ischemia is ample. CONCLUSIONS: VBS is a very serious airway complication that can be exceedingly difficult to manage. The complication requires early recognition and treatment. Hyperbaric oxygen therapy may improve outcomes in these patients. REFERENCE #1: Kshettry VR, Kroshus TJ, Hertz MI, Hunter DW, Shumway SJ, Bolman RM III. Early and late airway complications after lung transplantation: incidence and management. Ann Thorac Surg. 1997. June; 63 6: 1576- 1583. DISCLOSURES: No relevant relationships by Ashwini Arjuna, source=Web Response No relevant relationships by Ross Bremner, source=Admin input No relevant relationships by Ericka Charley, source=Web Response No relevant relationships by Hesham Mohamed, source=Web Response No relevant relationships by Kristine Nally, source=Web Response No relevant relationships by Ashraf Omar, source=Admin input No relevant relationships by Deepika Razia, source=Web Response No relevant relationships by Ali Saeed, source=Web Response Speaker/Speaker's Bureau relationship with Genentech Please note: $5001 - $20000 by Rajat Walia, source=Web Response, value=Honoraria Speaker/Speaker's Bureau relationship with Boehringer Ingelheim Please note: $5001 - $20000 by Rajat Walia, source=Web Response, value=Honoraria Speaker/Speaker's Bureau relationship with Grifols Please note: $5001 - $20000 by Rajat Walia, source=Web Response, value=Honoraria Speaker/Speaker's Bureau relationship with Shire Please note: $1001 - $5000 by Rajat Walia, source=Web Response, value=Honoraria Speaker/Speaker's Bureau relationship with Astellas Please note: $5001 - $20000 by Rajat Walia, source=Web Response, value=Honoraria

Melatonin Adjusts the Phase of Mouse Circadian Clocks in the Cornea Both Ex Vivo and In Vivo.

The presence of an endogenous circadian clock within most mammalian cells is associated with the amazing observation that within a given tissue, these clocks are largely in synchrony with each other. Different tissues use a variety of systemic or environmental cues to precisely coordinate the phase of these clocks. The cornea is a unique tissue in that it is largely isolated from the direct blood supply that most tissues experience, it is transparent to visible light, and it is exposed directly to environmental light and temperature. Melatonin is a hormone that has been implicated in regulation of the cornea's circadian clocks. Here, we analyze the ability of rhythmic melatonin to entrain corneas ex vivo, and analyze the phase of corneal circadian clocks in vivo both in light: dark cycles and in constant darkness. We find that the presence of a retina from a melatonin-proficient mouse strain, C3Sn, can photoentrain the circadian clocks of a co-cultured mouse cornea, but a retina from a melatonin-deficient strain, C57Bl/6, cannot. Furthermore, pharmacologic blockade of melatonin or use of a retina with advanced retinal degeneration, Pde6brd1, blocks the photoentraining effect. Corneal circadian clocks in vivo adopt an advanced phase in C3Sn mice compared with C57Bl/6, but the circadian clocks in the liver are unaffected. This observation is not attributable to a shorter endogenous period of the cornea or behavior between the strains. Some transcripts of circadian genes in the corneas of C3Sn mice also show an advanced phase of expression in a light: dark cycle, while the transcript of Per2 exhibits a light-dependent transient induction at the onset of darkness. We conclude that melatonin acts as a phase modifying factor in a rhythmic manner for the circadian clocks of the cornea.

Pituitary Metastasis Presenting With Central Diabetes Insipidus and Panhypopituitarism

Abstract Background: Metastatic involvement of the pituitary gland and infundibular stalk is rare, accounting for about 2% of all diagnosed pituitary masses. Although primary tumors from almost every organ have been reported, breast and lung cancers are the most common primary tumors to metastasize to the pituitary gland. The clinical presentation varies and can include headache, visual impairment, diabetes insipidus, and panhypopituitarism. The posterior lobe of the pituitary is more susceptible to metastatic involvement than the anterior lobe due to its direct blood supply from the systemic circulation, whereas the anterior lobe is supplied by the hypophyseal portal system. Additionally, the smaller posterior lobe can be destroyed with less metastatic volume, allowing for earlier manifestation of symptoms. Clinical Case: An 81-year-old woman with a history of Stage IIA ER+ IDC of the left breast status post lumpectomy and axillary lymph node dissection in 1999 followed by mastectomy in 2009 due to local recurrence presented with confusion for two weeks. At the time, she had known lung metastases and was on palliative chemotherapy. CT head showed a 1.8 cm and 2.3 cm calvarial lytic lesion in the right occipital bone and at the vertex, respectively. MRI brain/pituitary revealed a well-circumscribed, enhancing suprasellar mass measuring 9 x 10 mm likely involving the pituitary infundibulum and hypothalamus with mass effect on the optic chiasm. Laboratory results were consistent with secondary adrenal insufficiency, central hypothyroidism, and hypogonadotropic hypogonadism. Prolactin was mildly elevated due to stalk effect. The patient also had hypernatremia and inappropriately low urine osmolality, which nearly tripled after administration of desmopressin, confirming central diabetes insipidus. She was subsequently started on hydrocortisone, levothyroxine, and desmopressin. Laboratory Results: Prolactin 30.47 (reference range 4.79-23.3 mIU/mL), IGF-1 88 (17-193 ng/mL), 7am ACTH 3.4 (7.2-63.3 pg/mL), 7am cortisol 0.6 (6.2-29 µg/dL), TSH 3.03 (0.47-6.9 U/L), FT4 0.351 (0.75-2 ng/dL), FSH 0.2 (25.8-134.8 mIU/mL), LH <0.1 (7.7-58.5 mIU/mL), estradiol <5 (5-138 pg/mL); before desmopressin: Na 154 (reference range 135-145 mEq/L), urine osm 162 (50-1,200 mOsm/kg); after desmopressin: Na 143 (reference range 135-145 mEq/L), urine osm 469 (50-1,200 mOsm/kg) Conclusion: While pituitary metastases remain rare, their prevalence is expected to increase due to more sensitive biochemical tests and imaging techniques coupled with advances in cancer therapy that help patients with metastatic disease live longer. Interesting in our case is the patient’s age, which is significantly older than the median age reported in the literature, and her presentation with total anterior and posterior pituitary insufficiency after a prolonged oncologic course marked by progression of disease.

Carboxymethyl Cellulose Entrapped in a Poly(vinyl) Alcohol Network: Plant-Based Scaffolds for Cartilage Tissue Engineering.

Cartilage has a limited inherent healing capacity after injury, due to a lack of direct blood supply and low cell density. Tissue engineering in conjunction with biomaterials holds promise for generating cartilage substitutes that withstand stress in joints. A major challenge of tissue substitution is creating a functional framework to support cartilage tissue formation. Polyvinyl alcohol (PVA) was crosslinked with glutaraldehyde (GA), by varying the mole ratios of GA/PVA in the presence of different amounts of plant-derived carboxymethyl cellulose (CMC). Porous scaffolds were created by the freeze-drying technique. The goal of this study was to investigate how CMC incorporation and crosslinking density might affect scaffold pore formation, swelling behaviors, mechanical properties, and potential use for engineered cartilage. The peak at 1599 cm−1 of the C=O group in ATR–FTIR indicates the incorporation of CMC into the scaffold. The glass transition temperature (Tg) and Young’s modulus were lower in the PVA/CMC scaffold, as compared to the PVA control scaffold. The addition of CMC modulates the pore architecture and increases the swelling ratio of scaffolds. The toxicity of the scaffolds and cell attachment were tested. The results suggest that PVA/CMC scaffolding material can be tailored in terms of its physical and swelling properties to potentially support cartilage formation.

Endoscopic Esophageal Submucosal Tunnel Dissection for Cystic Lesions Originating from the Muscularis Propria of the Gastric Cardia.

Objective To analyze the types and properties of cystic lesions originating from the muscularis propria of the gastric cardia (CLMPGC), explore the growth pattern and anatomical characteristics, and evaluate the safety, feasibility, and clinical efficacy of endoscopic esophageal submucosal tunnel dissection (ESTD). Methods From September 2013 to July 2018, we treated 6 patients with CLMPGC whom we had diagnosed using endoscopy, endoscopic ultrasound (EUS), and Computed Tomography (CT) before the operations. ESTD was the best option for treatment for all these patients. Postoperative observation and follow-ups were performed, and the operational, clinical data, and treatment results are analyzed. Results The mean age of the patients was 50.67 ± 11.59 years (male : female = 1 : 1). The only clinical manifestations the patients exhibited were upper abdominal discomfort. The diameter of the masses was 2.05 ± 0.73 (1.1–3.0) cm. The duration of the ESTD operation was 93.5 (82–256) mins, and the length of hospital stay was 7.50 ± 1.38 days. Postoperative pathology showed 4 cases of an epithelioid cyst, and 2 cases of mucocele with xanthogranuloma. There were no complications, such as hemorrhage, pneumothorax, and pleural effusion during and after the operation. No recurrence during the follow-ups was observed. Conclusion The CLMPGC were mainly mucocele and epidermoid cyst, in an expansive growth pattern, and these lesions had no distinct borders with the muscularis propria. The muscularis propria formed a complete wall of the lesion. There was no direct blood supply to the lesions from big blood vessels. Endoscopic esophageal submucosal tunnel dissection was a safe, feasible, and effective treatment for CLMPGC.

Multiple endocrinological failures as a clinical presentation of a metastatic lung adenocarcinoma.

SummaryMultiple endocrine metastases are a rare but possible complication of lung adenocarcinoma (LAC). Pituitary metastasis is a rare condition with poor clinical expression. Diabetes insipidus (DI) is its most common presenting symptom. Here we report an original case of a pituitary stalk (PS) metastasis from LAC presenting as central DI followed by adrenal insufficiency (AI) from bilateral adrenal metastasis, without known evidence of the primary malignancy. A 45-year-old woman whose first clinical manifestations were polyuria and polydipsia was admitted. She was completely asymptomatic with no cough, no weight loss or anorexia. Chest radiography was normal. Brain MRI showed a thick pituitary stalk (PS). DI was confirmed by water restriction test and treated with vasopressin with great clinical results. Explorations for systemic and infectious disease were negative. Few months later, an acute AI led to discovering bilateral adrenal mass on abdominal CT. A suspicious 2.3 cm apical lung nodule was found later. Histopathological adrenal biopsy revealed an LAC. The patient received systemic chemotherapy with hormonal replacement for endocrinological failures by both vasopressin and hydrocortisone. We present this rare case of metastatic PS thickness arising from LAC associated with bilateral adrenal metastasis. Screening of patients with DI and stalk thickness for lung and breast cancer must be considered. Multiple endocrine failures as a diagnostic motive of LAC is a rare but possible circumstance.Learning points:Adrenal metastasis is a common location in lung adenocarcinoma; however, metastatic involvement of the pituitary stalk remains a rare occurrence, especially as a leading presentation to diagnose lung cancer.The posterior pituitary and the infundibulum are the preferential sites for metastases, as they receive direct arterial blood supply from hypophyseal arteries.Patients diagnosed with diabetes insipidus due to pituitary stalk thickness should be considered as a metastasis, after exclusion of the classical systemic and infectious diseases.The diagnosis of an endocrinological metastatic primary lung adenocarcinoma for patients without respiratory symptoms is often delayed due to a lack of correlation between endocrinological symptoms and lung cancer.The main originality of our case is the concomitant diagnosis of both endocrinological failures, as it was initiated with a diabetes insipidus and followed by an acute adrenal insufficiency.

Reconstruction of a long defect of the median nerve with a free nerve conduit flap

Upper limb nerve damage is a common condition, and evidence suggests that functional recovery may be limited following peripheral nerve repair in cases of delayed reconstruction or reconstruction of long nerve defects. A 26-year-old man presented with traumatic injury from a wide, blunt wound of the right forearm caused by broken glass, with soft tissue loss, complete transection of the radial and ulnar arteries, and a large median nerve gap. The patient underwent debridement and subsequent surgery with a microsurgical free radial fasciocutaneous flap to provide a direct blood supply to the hand; the cephalic vein within the flap was employed as a venous vascularized chamber to wrap the sural nerve graft and to repair the wide gap (14 cm) in the median nerve. During the postoperative period, the patient followed an intensive rehabilitation program and was monitored for functional performance over 5 years of follow-up. Our assessment demonstrated skin tropism and sufficient muscle power to act against strong resistance (M5) in the muscles previously affected by paralysis, as well as a good localization of stimuli in the median nerve region and an imperfect recovery of two-point discrimination (S3+). We propose a novel and efficient procedure to repair >10-cm peripheral nerve gap injuries related to upper limb trauma.

Fish hearts get O2 boost from carbonic anhydrase

Fish plumbing is contrary. As the heart is the last organ that blood passes through before it returns to the gills, and with little direct blood supply to the ceaselessly contracting muscle, there are occasions when it could be on the verge of failure. ‘We know this can happen under certain conditions like exhaustive exercise in combination with hypoxia or elevated water temperature’, says Sarah Alderman from the University of Guelph, Canada. Added to the challenge of keeping the heart supplied with oxygen, Alderman explains that the haemoglobin that carries oxygen in fish blood is finely tuned to blood pH: the more acidic the red blood cells, the less able haemoglobin is to carry oxygen, which could prevent the red blood cells of exercising fish from picking up oxygen at the gills if they didn't have an effective pump to remove acid from the cells and restore the pH balance.But Alderman and her colleagues, Till Harter, Tony Farrell and Colin Brauner from the University of British Columbia, Canada, also knew that fish can take advantage of a sudden drop in red blood cell pH to release oxygen rapidly at tissues – such as red muscle and the retina – when required urgently. An enzyme called carbonic anhydrase – which combines CO2 and water to produce bicarbonate and acidic protons, and vice versa – lies at the heart of this mechanism. Normally there is no carbonic anhydrase in blood plasma; however, the enzyme has been found in salmon red muscle capillaries, where it facilitates the reaction of protons – that have been extruded from the red blood cell – with bicarbonate to produce CO2, which then diffuses back into the red blood cell. The CO2 is then converted back into bicarbonate and protons in the blood cell, causing the pH to plummet and release a burst of O2 from the haemoglobin. Could salmon take advantage of this mechanism to boost oxygen supplies to the heart when the animals are working full out? Possibly, but only if carbonic anhydrase was accessible to blood passing through the heart.Alderman and Jonathan Wilson began searching for the enzyme in salmon hearts. Using cobalt sulphide to stain sites where the enzyme accumulated, Alderman could clearly see the enzyme on the surface of the heart chambers. She also identified the gene that was expressed to produce the protein. Then, to be sure that carbonic anhydrase could contribute to dumping residual oxygen out of the blood in the heart, Alderman and Harter had to figure out a way of directly measuring pH inside the heart chambers to see whether the enzyme altered it. This type of experiment is usually performed using ground-up tissue in a test tube, but that wouldn't confirm that carbonic anhydrase in the heart chamber walls could alter blood pH, ‘So we decided to modify the assay and use the heart itself as the reaction vessel’, Alderman recalls.Working closely together, the duo painstakingly developed a technique where they could measure the pH in the beating heart with pH probes that were thinner than a human hair. Eventually, the duo's persistence paid off and the pH in the heart plummeted as they fed CO2 into the pulsating chambers. And when they added a carbonic anhydrase inhibitor (produced by Claudia Supuran) to the fluid, the pH fall slowed dramatically. Carbonic anhydrase was responsible for the drop in pH.‘The take-home message for our study is that the salmonid heart has an ace up its sleeve to help it overcome adverse conditions’, says Alderman, who is now eager to find out whether the fish play this card during their marathon upstream migration to spawn.

Do Direct Cash Payments Increase Whole Blood Supply?

We investigate the impact of direct cash payments on whole blood donations. The German blood collection system is based on both, paid and unpaid blood donations. We take advantage of a quasi-natural experiment, in which one blood donation site changes its compensation scheme from paid to unpaid, while all other donation sites maintain their payment schemes. We show that cash payments increase donation volume without affecting blood quality. This result casts doubt on the notion that monetary incentives crowd out intrinsic motivation to donate blood. Policymakers should thus reconsider direct cash payments to address public health concerns about blood shortages.

Directly measuring spinal cord blood flow and spinal cord perfusion pressure via the collateral network: Correlations with changes in systemic blood pressure

During thoracoabdominal surgery in which segmental arteries are sacrificed over a large area, blood supply routes from collateral networks have received attention as a means of avoiding spinal cord injury. The aim of this study was to investigate spinal cord blood supply through a collateral network by directly measuring spinal cord blood flow and spinal cord perfusion pressure experimentally. In beagle dogs (n=8), the thoracoabdominal aorta and segmental arteries L1-L7 were exposed, and a temporary bypass was created for distal perfusion. Next, a laser blood flow meter was placed on the spinal dura mater in the L5 region to measure the spinal cord blood flow. The following were measured simultaneously when the direct blood supply from segmental arteries L2-L7 to the spinal cord was stopped: mean systemic blood pressure, spinal cord perfusion pressure (blood pressure within the aortic clamp site), and spinal cord blood flow supplied via the collateral network. These variables were then investigated for evidence of correlations. Positive correlations were observed between mean systemic blood pressure and spinal cord blood flow during interruption of segmental artery flow both with (r=0.844, P<.01) and without (r=0.834, P<.01) distal aortic perfusion. In addition, we observed significant correlations between spinal cord perfusion pressure and spinal cord blood flow with and without distal perfusion (r=0.803, P<.001 and r=0.832, P<.01, respectively), and between mean systemic blood pressure and spinal cord perfusion pressure with and without distal perfusion (r=0.898, P<.001 and r=0.837, P<.001, respectively). The spinal cord was perfused from the collateral network from outside the interrupted segmental arteries, and high systemic blood pressure (∼1.33-fold higher) was needed to obtain the preclamping spinal cord blood flow, whereas 1.68-fold higher systemic blood pressure was needed when distal perfusion was halted. Spinal cord blood flow is positively correlated with mean systemic blood pressure and spinal cord perfusion pressure under spinal cord ischemia caused by clamping a wide range of segmental arteries. In open and endovascular thoracic and thoracoabdominal surgery, elevating mean systemic blood pressure is a simple and effective means of increasing spinal cord blood flow, and measuring spinal cord perfusion pressure seems to be useful for monitoring perioperative spinal cord blood flow.

Cysteamine ophthalmic solution 0.44% for the treatment of corneal cystine crystals in cystinosis

Cystinosis is a rare autosomal recessive disease caused by abnormal accumulation of the amino acid cystine within lysosomes of various cells throughout the body, leading to multiple organ damage. Corneal cystine crystals are an ocular manifestation of cystinosis. Untreated, these corneal deposits worsen with time, often resulting in photophobia, ocular discomfort, blurred vision, and in severe cases, recurrent epithelial erosions, and band keratopathy. Oral cysteamine stabilizes renal and other systemic functions in these patients, but has no effect on cystine crystal accumulation in the cornea, due to the absence of a direct blood supply to the cornea. Cysteamine ophthalmic solution 0.44% reduces corneal cystine crystal deposition, helps clear existing crystals and is currently the only US FDA-approved therapy for the treatment of the corneal crystal involvement of cystinosis.

The critical importance of ovarian angiogenesis

The vascular system develops through two distinct pathways known as vasculogenesis and angiogenesis. The former involves formation of vascular networks from endothelial progenitor cells (Kasmeyer et al. 2009), while angiogenesis is the extension of new blood vessels from pre-existing ones (Robinson et al. 2009). The establishment and optimal functioning of the vasculature is an essential component throughout the body and the ovary is no exception. Blood vessel growth is tightly regulated requiring the timely balance between proand antiangiogenic growth factors as well as the complex, intimate interplay between endothelial cells and various other cell types (e.g. immune cells and pericytes). In this Research Front on ovarian angiogenesis, we present four reviews and one original article that reveal the latest research and current hypotheses on the key stages of vascular development in the ovary. Remarkably little was known about how the vasculature in the fetal ovary is formed, until recently. In the first paper of this Research Front, the latest insights are highlighted byMcFee and Cupp (2012). Intriguingly, ovarian vasculature in the embryo appears to develop through a vasculogenic process rather than the typical angiogenesis that occurs in embryonic testes. Moreover, the vascular patterning is preferentially aligned along the neuronal network template and thus could be influenced by neuronal growth factors (Anderson et al. 2002). McFee and Cupp (2012) also suggest that the ability of germ cell/oocytes to proliferate, develop and form primordial follicles is potentially influenced by fetal ovarian medulla blood supply since these cells lack a direct blood supply. Indeed, follicle assembly initially originates near to the medullary vasculature (Sawyer et al. 2002). This would imply that the inappropriate development of an ovarian vasculature could result in improper prenatal folliculogenesis. This could then adversely affect fertility of both women and animals. The VEGF system is very complex with the existence of numerous proand anti-angiogenic isoforms, receptors and signalling partners (Gabhann and Popel 2008).McFee and Cupp (2012) provide a scholarly account of their importance in the regulation of fetal ovarian development. They speculate that the temporal differences in expression of pro-angiogenic ‘a’ and anti-angiogenic ‘b’ VEGFA isoforms might explain the different patterns of vascularisation in the fetal ovary and testes (McFee andCupp 2012). Interestingly, Qiu et al. (2012) recently showed that overexpression of VEGF165b reduced follicular development and number of ovulations and more importantly, this was associatedwith lower fertility inmice. Collectively, this further emphasises that optimal ovarian function requires an appropriate balance between proand anti-angiogenic factors. It is well established that hypoxia-induced expression of VEGFA plays a pivotal role in stimulating angiogenesis during tumour development. However, the exact role of hypoxia in ovarian angiogenesis has remained elusive for a long time. In the second review of this Research Front, Meidan et al. (2012) discuss the role of the transcription factor, hypoxia inducible factor 1p/b (HIF1p/b), which is critical for ovulation in mice (Kim et al. 2009). The current evidence indicates that HIF1pis upregulated and translocates to the nucleus of luteinising granulosa cell during the ovulatory window although this upregulation is only short-lived. It is likely that, at least in part, the LH surge upregulates the HIF1p in luteinising follicular cells (van den Driesche et al. 2008). This feature of HIF1p regulation could be unique to the ovary. It is also increasingly apparent that any induction of HIF1pstimulates VEGFA expression in luteal cells (Zhang et al. 2011). What is less well known is the role of hypoxia and/or HIF1pin the regulation of FGF2. This certainly requires investigation since FGF2 and HIF1p expression profiles are closelymatched in the bovine CL (Robinson et al. 2007; Nishimura and Okuda 2010). Furthermore, it is becoming increasing apparent that FGF2 is a key factor controlling endothelial cell sprouting during the follicle-luteal transition in cattle (Laird et al. 2012). Accurate measurement of tissue hypoxia is challenging and will continue to hinder the elucidation of the role hypoxia plays in ovarian angiogenesis. The use of novel, live imaging positron emission tomography (PET) technologies using biomarkers such as F-labelled fluoromisonidazole (F-MISO) as used in tumour biology (Mendichovszky and Jackson 2011) will help to address this challenge. Furthermore, such technologiesmight increase our understanding of the role of hypoxia in disorders such as luteal deficiency. It has been long-recognised that ovulation has numerous characteristics of an inflammatory response. However, the role of immune cells in the regulation of ovarian angiogenesis has been neglected, until recently and these findings are highlighted by Shirasuna et al. (2012) in the third review. While there are some definite species differences, there is a pool of evidence that immune cells (e.g. neutrophils, macrophages and/or lymphocytes) infiltrate into the developing CL. This is likely due to CSIRO PUBLISHING