Intact Diaphragm Research Articles

Radiographic and computed tomographic findings of intrathoracic ectopic liver in a dog.

A 5-year-old spayed female Maltese was referred due to a suspected diaphragmatic hernia. Radiography revealed a soft tissue mass in the right caudal thorax with loss of diaphragm cupola dome-shape. A diaphragmatic hernia was considered, but surgical exploration revealed an intact diaphragm and unremarkable liver lobes. CT after a surgical inspection showed all intact liver lobes and intrathoracic mass connected to the liver. The intrathoracic mass was retracted to the abdomen by incising the diaphragm. Histopathologic examination revealed hepatocellular vacuolar degeneration, indicating an intrathoracic ectopic liver. Intrathoracic ectopic liver should be included in the differential diagnosis when diaphragmatic hernia is suspected in radiography.

Double esophageal duplication cysts: A rare case report in Nicaragua

Esophageal duplication cyst is a rare congenital anomaly arising from the posterior primitive foregut, typically located in the thoracic esophagus. Herein, we reported the case of a female newborn who was prenatally diagnosed with congenital diaphragmatic hernia. A subsequent computed tomography scan revealed an intact diaphragm and a large septated cyst measuring 132×59×41 mm with a volume of 120 mL, situated extrapleurally near the right paravertebral area. Surgical intervention involved a right thoracotomy under general anesthesia to remove the larger cyst, which was connected to the esophagus via an obliterated fistula. There was no communication between this cyst and the trachea. Histological examination of the removed cyst revealed four layers of tissue, consistent with esophageal tissue: mucosa, submucosa, muscularis propria, and either serosa or adventitia. A six-month follow-up ultrasound confirmed no residual disease or recurrence. This case marks only the fourth such instance reported globally.

Surgical technique and complications associated with laparoscopic pleuroperitoneal diaphragmatic herniorrhaphy in a dog

AbstractAn 11‐year‐old, neutered, male French bulldog was referred for surgical repair of an incidentally diagnosed pleuroperitoneal diaphragmatic hernia. Thoracic computed tomography revealed a left centroventral diaphragmatic hernia with a large volume of left‐sided intrathoracic fat. A minimally invasive laparoscopic approach was elected. A portion of the intrathoracic fat was laparoscopically reduced. Adhesions and friability of the herniated fat prevented further reduction, and the remaining fat was transected using a vessel‐sealing device to enable herniorrhaphy via intracorporeal suturing. Immediate postoperative computed tomography performed under general anaesthesia confirmed an intact diaphragm with a large volume of persistent left‐sided intrathoracic fat. The patient was immediately returned to the operating room and a keyhole left lateral thoracotomy performed to remove the remaining herniated fat. The patient recovered from surgery and anaesthesia uneventfully. There were no short‐ or long‐term postoperative complications of herniorrhaphy.

Embryological, anatomical and clinical considerations on pleuroperitoneal communication.

The pleural and peritoneal cavity share many related features due to their common celomic origin. Normally these two spaces are completely separated with the development of the diaphragm. Defects in diaphragm morphogenesis may result in congenital diaphragmatic hernias, which is the most known form of communication between the pleural and peritoneal cavity. However, in several cases, findings of pleuroperitoneal communication (PPC) have been described in adults through an apparently intact diaphragm. In this comprehensive review we systematically evaluate clinical scenarios of this form of "unexpected" PPC as reported in the literature and focus on the possible mechanisms involved.

안장가로막에 대한 종양의 기원과 개구부 상태에 따른 두개인두종의 성장양상

Background: Advances in the endoscopic endonasal approach (EEA) have increased the under-standing of craniopharyngioma anatomy. We have previously proposed a relationship among cranio-pharyngioma growth pattern, their origin relative to the diaphragm sellae, and their aperture compe-tency. To reappraise that relationship, we retrospectively reviewed the diaphragm sellae anatomy of patients who underwent EEA for craniopharyngioma. Materials and Methods: From May 2010 to January 2013, thirty five patients underwent EEA procedures for craniopharyngiomas. Twenty patients without a surgical history were included in the study, and medical records describing the spatial relations between the tumors and the diaphragma sellae were reviewed and correlated with the tumor growth patterns on preoperative images. Results: All of the tumors were completely removed. Three prechiasmatic tumors were located un-der intact diaphragma sellae. Six retrochiasmatic tumors were composed of supra- and subdiaphrag-matic components that were continuous through an incomplete aperture of the diaphragm. Eleven retrochiasmatic tumors were located above intact diaphragms. Visual symptoms were normalized or improved in twelve of the sixteen patients with preoperative visual deficits. Preoperative hypotha-lamic dysfunction was recovered in ten of twelve patients. Conclusions: The EEA revealed the detailed tumor anatomy and confirmed our previous hypoth-esis that craniopharyngioma growth patterns are principally determined by the origin of the tumor relative to the diaphragma sellae and by the aperture competency. The EEA is indicated for removing both prechiasmatic and retrochiasmatic craniopharyngiomas.

Prenatal Diagnosis of an Intrathoracic Left Kidney Associated with Congenital Diaphragmatic Hernia: Case Report and Systematic Review.

A congenital intrathoracic kidney (ITK) is a rare anomaly that is recognized to have four causes: renal ectopia with an intact diaphragm, diaphragmatic eventration, diaphragmatic hernia, and traumatic diaphragmatic rupture. We report a case of a prenatal-diagnosed ITK related to a congenital diaphragmatic hernia (CDH) and conducted a systematic review of all cases of the prenatal diagnosis of this association. A fetal ultrasound scan at 22 gestational weeks showed left CDH and ITK, hyperechoic left lung parenchyma, and mediastinal shift. The fetal echocardiography and karyotype were normal. Magnetic resonance imaging at 30 gestational weeks confirmed the ultrasound suspicion of left CDH in association with bowel and left kidney herniation. The fetal growth, amniotic fluid, and Doppler indices remained within the normal range over time. The woman delivered the newborn via an at-term spontaneous vaginal delivery. The newborn was stabilized and underwent non-urgent surgical correction; the postoperative course was uneventful. CDH is the rarest cause of ITK; we found only eleven cases describing this association. The mean gestational age at diagnosis was 29 ± 4 weeks and 4 days. There were seven cases of right and four cases of left CDH. There were associated anomalies in only three fetuses. All women delivered live babies, the herniated kidneys showed no functional damage after their surgical correction, and the prognosis was favorable after surgical repair. The prenatal diagnosis and counseling of this condition are important in planning adequate prenatal and postnatal management in order to improve neonatal outcomes.

PLEURITIS AND EMPYEMA AFTER TRANSARTERIAL CHEMOEMBOLIZATION OF HEPATOCELLULAR CARCINOMA

PLEURITIS AND EMPYEMA AFTER TRANSARTERIAL CHEMOEMBOLIZATION OF HEPATOCELLULAR CARCINOMA

Physiological pulmonary assessments in the management of bilateral diaphragmatic eventration

Abstract Objectives To describe the importance of comprehensive assessment to determine the underlying diagnosis and the role of physiological pulmonary measurements in the management of congenital bilateral eventration of the diaphragm. Case presentation A female infant born at 34 weeks gestation required intubation and ventilation at birth. Chest radiographical imaging revealed bilateral density to the bases of both lung fields with raised hemi-diaphragms. Ultrasound imaging showed focal diaphragmatic eventration with bulging of the dome of the liver into the right and left hemithoraces. Assessment of the electrical activity of the diaphragm during a spontaneous breathing trial demonstrated a mean amplitude consistent with that of ventilated infants of the same gestational age with intact diaphragms. Hence she was extubated which was successful. Chest radiographic thoracic area measured post extubation was 1,654 mm2, equivalent to that of a term infant with severe congenital diaphragmatic hernia. As the electrical activity of the diaphragm was normal this suggests replacement of the diaphragmatic muscle tissue with fibrous bands was likely to be only partial, and hence why extubation was successful. She had other abnormalities presenting in the neonatal period including dermal melancytosis, central hypotonia, hyperinsulinism and poor feeding. The infant underwent extensive investigation which revealed a KMT2D gene mutation associated with Kabuki syndrome. Conclusions Physiological pulmonary measurements may add clinical management in bilateratal diaphragmatic eventration.

Abstract LB233: Cancer cell invasion through a complex and dynamic smooth muscle microenvironment

Abstract The cancer-prone peripheral zone of the human prostate is a fibromuscular stroma bounded by a laminin-rich smooth muscle capsule. Aggressive tumors traverse the muscle to escape organ confinement, but the determinants of cell migration through this complex and highly elastic environment are not well understood. We modeled smooth muscle invasion using a unique in vivo model to test the role of mechanosensing, laminin-binding integrins (α6β1 and α3β1), collect cells successful in traversing smooth muscle, and identify transcriptomes involved in this complex invasive process. From the DU145 prostate cancer cell line (expressing integrins α3 and α6), we generated homozygous knockouts for genes ITGA6 (α6KO) and ITGA3 (α3KO). We tested for the ability to create 3D invasive cellular networks and measured biophysical features by electric cell-substrate impedance sensing. Muscle invasion was tested in vivo by injecting cells into the intraperitoneal cavity of male NSG mice. The cells colonized the inferior side of the respiratory diaphragm and invaded through to the superior surface after 6 weeks. We analyzed diaphragms by number of invasion sites and average invasion depth. A series of clones were also grown from wild-type, DU145 cells that had completely traversed the diaphragm muscle. Cells expressing integrins α6 and α3 produced 3D invasive networks on laminin-containing Matrigel and invaded into the diaphragm muscle in vivo. α6KO cells did not produce networks or invade muscle. Surprisingly, knockout of α3 increased 3D invasive networks, decreased cell-cell impedance, and altered in vivo muscle invasion. The results suggest that the integrins α6 and α3 are involved in the invasion of prostate cancer cells through a dynamic smooth muscle layer. The mechanosensing integrins are central to a variety of cell signaling programs. To further explore the transcriptional regulators of the muscle invasion process, we isolated RNA from cancer cells colonizing the inferior, superior surface and the intact diaphragm. Whole genome RNAseq revealed 1330 differentially expressed genes (DEGs) between inferior cells and cancer cells within the diaphragm, 788 DEGs between cells on the inferior and superior diaphragm surface, and 241 DEGs between cancer cells within the diaphragm and cells that reached the superior surface (padj <0.05, |fold change| >=1.3). Ingenuity Pathway Analysis revealed alterations in pathways including prostate cancer signaling, integrin signaling, other known cancer-related processes, and others. Through this in vivo assay we have the unique ability to parse out unexplored patterns of changes that occur in early muscle invasive disease to improve prostate cancer patient selection for curative treatment versus active surveillance. These studies were supported by NCI F30CA247106, P30CA23074, and R01CA24226. K.D.M is additionally supported by the ARCS Foundation Phoenix Chapter. Citation Format: Kendra D. Marr, Hina Arif-Tiwari, Jaime M. Gard, Noel E. Warfel, Raymond B. Nagle, Anne E. Cress. Cancer cell invasion through a complex and dynamic smooth muscle microenvironment [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr LB233.

Creation of a High Fidelity, Cost Effective, Real World Surgical Simulation for Surgical Education

Background How do surgical residents learn to operate? What is a surgical plane? How does one learn to see and dissect the plane? How do surgical residents learn tissue handling and suturing (sewing)? One method to learn and practice performing surgery is through the use of simulation training. Surgical training models include laparoscopic box trainers (a plastic box with holes for instruments) with synthetic materials inside to simulate tissues, or computer-based virtual reality simulation for laparoscopic, endoscopic, and robotic techniques. These methods, however, do not use real tissues. They lack the haptic and kinesthetic feedback of real tissue. These simulations fail to recreate the fidelity of soft tissues, do not foster the ability to accurately see surgical planes, do not accurately mimic the act of dissecting surgical planes, do not allow for complex surgical procedures, and do not provide accurate experience to learn tissue handling and suturing. Despite their poor performance, these plastic and virtual trainers are extremely costly to purchase, maintain, and keep up to date - with prices starting at $700 for basic plastic training boxes to thousands of dollars for virtual simulation. Also, there are additional costs of maintenance and software curriculum. Despite the cost of software, virtual simulators do not include a simulation for every surgery. Our aim was to create a life-like surgical simulation as close to real world as possible that allows trainees to learn how to see and dissect surgical planes, learn how soft tissues move, and learn the dynamics of soft tissue manipulation. We created a laparoscopic simulator using porcine tissues for gallbladder removal, acid reflux surgery, and surgery to treat swallowing difficulties (cholecystectomy, Nissen fundoplication, and Heller myotomy, respectively). Second year general surgery residents were able to practice these procedures on real tissues, enabling them to learn the steps of each procedure, increase manual dexterity, improve use of laparoscopic equipment, all while maintaining life-like haptic, soft-tissue feedback and enabling them to develop the ability to see real surgical planes. Methods The abdomen was recreated by purchasing intact porcine liver, gallbladder, (Cholecystectomy simulation) and intact esophagus, stomach, and diaphragm (Nissen and Heller simulation) from a packing supplier. Each organ system was placed into a laparoscopic trainer box with the ability to re-create laparoscopic ports. Surgical residents were then able to perform the procedures using real laparoscopic instruments, laparoscopic camera/video imaging, and real-time electrocautery. The simulation included all critical steps of each procedure such as obtaining the critical view of safety and removing the gallbladder from the liver bed (cholecystectomy), wrapping the stomach around the esophagus and laparoscopic suturing (Nissen fundoplication), and dissecting the muscular portion of the esophageal wall (Heller myotomy). Because these porcine tissues were readily available, several stations were set-up to teach multiple residents during each session (10-12 residents / session). Discussion Surgeons develop haptic perception of soft tissues by cutaneous or tactile feedback and kinesthetic feedback (Okamura, 2009). Kinesthetic feedback is the force and pressure transmitted by the soft tissues along the shaft of the laparoscopic instruments (Okamura, 2009). This soft tissue simulation re-creates the ability to experience what soft tissue feedback feels like, outside a normal operative environment. Real tissue learning allows trainees to learn how to see surgical planes, learn how soft tissues feel and move, develop proficiency in surgical dissection, and learn how to suture laparoscopically. This is the only model that recreates the movement of soft tissues and visualization of dissection planes outside the operative environment. Because this model utilizes the laparoscopic instruments used in the operating room, residents also develop familiarity with laparoscopic instruments, thus, flattening another learning curve. A literature review found that this is the only real tissue simulation being performed for foregut procedures used specifically for resident training. By building a realistic, anatomical model with inherent accurate soft tissue surgical planes, surgical trainees can have a more realistic surgical experience and develop skills in a safe, low pressure environment without sacrificing the hepatic learning and surgical visualization that is critical to performing safe laparoscopic surgery. All residents that participated in the stimulation reported positive feedback and felt that is contributed to their surgical education.

Skeletal Muscle Na,K-ATPase as a Target for Circulating Ouabain.

While the role of circulating ouabain-like compounds in the cardiovascular and central nervous systems, kidney and other tissues in health and disease is well documented, little is known about its effects in skeletal muscle. In this study, rats were intraperitoneally injected with ouabain (0.1–10 µg/kg for 4 days) alone or with subsequent injections of lipopolysaccharide (1 mg/kg). Some rats were also subjected to disuse for 6 h by hindlimb suspension. In the diaphragm muscle, chronic ouabain (1 µg/kg) hyperpolarized resting potential of extrajunctional membrane due to specific increase in electrogenic transport activity of the α2 Na,K-ATPase isozyme and without changes in α1 and α2 Na,K-ATPase protein content. Ouabain (10–20 nM), acutely applied to isolated intact diaphragm muscle from not injected rats, hyperpolarized the membrane to a similar extent. Chronic ouabain administration prevented lipopolysaccharide-induced (diaphragm muscle) or disuse-induced (soleus muscle) depolarization of the extrajunctional membrane. No stimulation of the α1 Na,K-ATPase activity in human red blood cells, purified lamb kidney and Torpedo membrane preparations by low ouabain concentrations was observed. Our results suggest that skeletal muscle electrogenesis is subjected to regulation by circulating ouabain via the α2 Na,K-ATPase isozyme that could be important for adaptation of this tissue to functional impairment.

The role of anatomic pelvic dissection in the successful closure of bladder exstrophy: an aid to success

Classic bladder exstrophy is one of the rarest congenital anomalies compatible with life. Surgical treatment of bladder exstrophy has progressed, but the goal of surgery remains a successful primary bladder closure. Several factors have been identified to decrease the risk of failed closure, including appropriate use of osteotomyand adequate postoperative immobilization and analgesia. However, the role of the radical anatomic pelvic dissection, including dissection of the urogenital diaphragm fibers, in a successful closure has not yet been extensively explored. The objective of this study was go examine the role of radical anatomic pelvic dissection, including dissection of the urogenital diaphragm fibers, in patients with classic bladder exstrophy. This was a retrospective study based on an institutional database. A retrospective review from an institutional approved database of more than 1,300 patients with epispadias-exstrophy complex was performed. The inclusion criteria included patients with classic bladder exstrophy with at least one failed bladder closure and a reclosure at the authors' institution with a single senior surgeon. Data collection included demographics, clinical variables, and status of urogenital diaphragm fibers. Magnetic resonance imaging (MRI) scans, if available, were reviewed with a pediatric radiologist to identify urogenital diaphragm fibers. From the database, 93 patients met inclusion criteria. Of these patients, 74 had urogenital diaphragm fibers completely intact at the time of repeat closure, whereas 19 patients did not. There was no association with age or gender and status of urogenital diaphragm fibers. There was no association with osteotomy, the type of primary bladder closure, surgeon subspecialty, and the status of the urogenital fibers. Fourteen patients had at least two prior closures; surprisingly, 11 of these repeat closure patients still had intact urogenital fibers even after two prior closures. The recent development and application of 3D MRI-guided pelvic dissection in a large group of patients led the authors to investigate whether adequate pelvic floor dissection had been accomplished at primary or secondary closure. Several patients had MRI scans performed before repeat closure in which the urogenital diaphragm fibers were identified to be intact on imaging; this was corroborated with surgical findings. Approximately 80% of patients had their urogenital diaphragm fibers completely intact and, therefore, did not have an adequate pelvic dissection during their primary or secondary bladder closure, putting the success of their previous closures at risk. Inadequate pelvic diaphragm dissection, defined as intact urogenital diaphragm fibers, demonstrated in a large group of patients with failed exstrophy closure, may be a decisive factor in bladder closure failure. The use of 3D intra-operative image guidance may aid in a safer and more successful pelvic dissection.

Mitochondrial Respiration and H2O2 Emission in Saponin‐permeabilized Murine Diaphragm Fibers: Optimization of Fiber Separation and Comparison to Limb Muscle

Chronic diseases such as cancer, COPD, and heart failure impair diaphragm metabolism and mitochondrial function. Mice are used extensively to replicate disease conditions and offer the advantage of studying genetically modified animals. Mouse diaphragm contains a high abundance of connective tissue, with relatively thin (15–25 μm diameter) and fragile fibers. In preliminary studies, we discovered that standard fiber separation approaches utilized for limb muscles are unsuitable for the diaphragm. Thus, the purpose of this study was to optimize a protocol for diaphragm (Dia) fiber bundle preparation to evaluate the mitochondrial respiration and reactive oxygen species emission. We used the red gastrocnemius (Gast) muscle as a ‘standard’ for comparison.Michaelis‐Menten kinetics of ADP‐stimulated O2 consumption with complex I substrates (JO2 in pmol/s/mg wet weight) showed 3‐fold higher Vmax in Dia than Gast (Gast 69 ± 18, Dia 211 ± 20; p < 0.05, n = 9 mice), whereas Km was not significantly different. Maximal JO2 in Dia was 3‐fold higher with complex I + II substrates (Gast 148 ± 25, Dia 387 ± 45; p < 0.05), and 2‐fold higher with palmitoyl‐CoA + carnitine (Gast 7 ± 0, Dia 15 ± 2, p < 0.05) compared to Gast. Baseline JH2O2 (pmol/min/mg wet weight) was higher in Dia (Gast 0.8 ± 0.2, Dia 1.7 ± 0.3; p < 0.05), but succinate‐induced JH2O2 was not different between muscles. Citrate synthase activity was 3‐fold higher in Dia (μmol/min/mg protein: Gast 43 ± 3, Dia 118 ± 4; p < 0.05). The protein abundance of electron transport chain complexes I‐V were 2–4 fold higher in the Dia than Gast (p < 0.05). When we normalized maximal JO2 by citrate synthase activity, there were no differences between Dia and Gast for complex I and complex I + II substrates. JH2O2 normalized to citrate synthase activity was higher for Gast at baseline (pmol/min/mg wet weight/U CS: Gast 2.1 ± 0.3, Dia 0.3 ± 0.1; p < 0.05), but there was no difference in succinate‐induced JH2O2 normalized to citrate synthase activity.The values for maximal diaphragm mitochondria JO2 in our study are 2–3 fold higher than reported in the literature using the standard ‘limb muscle’ approach for the diaphragm fiber preparation. The similar maximal JO2 normalized to citrate synthase activity between diaphragm and red gastrocnemius muscles suggest that our new approach is valid for the assessment of intact diaphragm mitochondrial function in permeabilized fiber bundles.Support or Funding InformationFunding source: NIH 1R01HL130318‐01This abstract is from the Experimental Biology 2019 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

An Unusual Presentation of an Adult with Diffuse Abdominal Pain Related to Congenital Diaphragmatic Hepatic Eventration

This case report identifies a uncommon presentation of a congenital diaphragmatic hepatic eventration in a middle aged female adult with an acute onset of diffuse abdominal pain. This case highlights a significant congenital event which is not commonly found as an adult. However, this case is interesting, as many clinicians may be puzzled over the radiologic presence, leading to numerable diagnostic studies and unnecessary consultations. A 43 year old Hispanic female with history of hypertension, diabetes and dyslipidemia presented to ER with complaint of diffuse abdominal pain, all quadrants of abdomen with no guarding or rigidity, normal bowel sounds. Routine labs showed no leukocytosis, normal metabolic panel except an elevated Cr of 1.7. CT Abdomen was done without any contrast in light of acute kidney injury, which showed a soft tissue mass at right lung base measuring 4.4 cm in diameter. Thought to be part of the hepatic dome pushing the diaphragm to the lung base versus, albeit less likely, a pulmonary mass, a CT with contrast was recommended. The patient was given symptomatic treatment in ER and was discharged with outpatient follow up. After her kidney function returned back to baseline CT abdomen with contrast showed focal eventration of the right hemidiaphragm with liver tissue extending through the eventration and no other suspicious mass. The patient was seen in GI clinic with impression of likely congenital anomaly. The patient was completely asymptomatic at that time and was conservatively managed with regular follow up. Congenital diaphragmatic eventration has been frequently cited in literature as a common condition in infancy, requiring urgent care and observation. However is a rare anomaly found in an adult. Eventation of the diaphragm is defined anatomically by thinning of the diaphragmatic tissue, characterized by the cephalic displacement an intact diaphragm. This entity is frequently asymptomatic and initially detected by chest x-ray. Adults can occasionally complain of progressive dyspnea, chest pain, abdominal discomfort, nausea/vomiting, heartburn. A differential must still be considered, including; diaphragmatic hernia, paraesophageal hernia, hiatus hernia, bronchogenic cyst, teratoma, cardiac sarcoma, lymphosarcoma, schwannoma, or metastatic tumor. Asymptomatic patients are usually managed with surveillance, and if persistently symptomatic managed with plication of the diaphragm with thoracotomy.2340_A Figure 1. Chest CT with IV Contrast- Sagittal view with hepatic eventration extending into thoracic cavity.2340_B Figure 2. Chest CT with IV Contrast- Coronal view with hepatic eventration extending into thoracic cavity.

A Rare Case of Partial Diaphragmatic Eventration with Hepatic Herniation

A 43 year old Female with past history of hypertension, diabetes mellitus presented to the Emergency room with a chief complaint of left flank pain. Her physical examination was notable for left sided flank tenderness with no abdominal rigidity or guarding. Routine blood work showed normal complete blood count, with normal comprehensive metabolic profile. A chest xray showed a soft tissue mass at the right lung base. Further contrast Computed Tomography(CT) of the chest and abdomen showed an incidental soft tissue mass at right lung base that measured 4.4 cm in diameter representing a focal eventration of the right hemi-diaphragm with liver tissue extending through the eventration.(Fig 1,2).2343_A Figure 1. Arrow depicting hepatic herniation2343_B Figure 2. Coronal CT showing hepatic mass extending through diaphragamDiaphragmatic eventration was first recognized by Jean Louis Petit in 1774 and the term was coined by Beclard in 1916. It is defined anatomically by thinning of the diaphragmatic tissue, characterized by the cephalic displacement of all or a part of an intact diaphragm. While complete eventration in more common on left, partial eventration is seen majorly on the right side. Congenital diaphragmatic eventration has been frequently cited as common in infancy, requiring urgent care and observation but it is rarely seen in adults. Typically this entity is frequently asymptomatic but can rarely manifest as progressive dyspnea, chest pain, abdominal discomfort, nausea, vomiting, heartburn and recurrent pneumonia. Partial eventration are usually detected incidentally on chest x-ray as a smooth homogeneous mass in continuation with the diaphragm.Ultrasound may reveal more anatomical detail about the diaphragmatic integrity, specifically eventration content or other diaphragmatic pathologies.If a contrast CT scan is performed, hepatic or omental vascular enhancements are seen as hyper-dense areas. Other modalities such as fluoroscopy with sniff testing and Magnetic resonance imaging are done if the diagnosis is still in doubt. Once diagnosed asymptomatic patients are usually managed conservatively and diaphragmatic plication is done in symptomatic patient. Our patient's left sided pain was musculoskeletal and not related to the diaphragmatic eventration. Her pain resolved with analgesics and she has remained asymptomatic on follow up visits. In summary we present a rare case of partial diaphragmatic eventration with hepatic herniation. Our case highlights conservative management in asymptomatic patients with diaphragmatic eventration.

Characterization of the Materials in Waste Power Banks and the Green Recovery Process

People are using power banks (PBs) to enlarge their mobile phones’ energy storage capacity in China. Large amounts of waste PBs were generated because of its short serving life. Recovery technology of waste PBs is a pressing need. However, there is little published information about the recovery technology of waste PBs. The recovery technology of spent lithium battery might be suitable for treating waste PBs. But the current method of recovering spent lithium battery is combination technologies of crushing and hydrometallurgical leaching, providing inefficient and incomplete recovery of full materials. Additionally, some wastewater was produced. In this study, the materials from waste PBs and its structures were characterized, and an environmentally friendly technology of recovering copper foil, diaphragm, cobalt, nickel, and lithium aluminum oxide from waste PBs is proposed. The technology is a combination of manual dismantling, crushing, vacuum roasting, and magnetic separation. Intact polymer diaphragm...

Learning DMEK From YouTube

To evaluate the outcomes of the first cases of Descemet membrane endothelial keratoplasty (DMEK) performed by an anterior segment surgeon, learning the procedure, including graft preparation, primarily from watching YouTube videos. DMEK surgery was not learned during fellowship training; there was no attendance at DMEK courses, no witnessing of live surgery, and no supervision by an experienced DMEK surgeon. All graft tissue was prepared by the surgeon on the day of surgery. This is a retrospective review of the 3-month postoperative results of the first 40 consecutive cases. The success rate of graft preparation, intraoperative and postoperative complications, spectacle-corrected visual acuity, endothelial cell density, and central corneal thickness were evaluated. Grafts were successfully prepared in all cases with no loss of donor tissue. DMEK surgery was successful in 39 of 40 eyes with the one failure occurring in a vitrectomized eye without an intact iris-lens diaphragm. Spectacle-corrected visual acuity was ≥6/6 in 23 of the 25 eyes without comorbidity. Mean endothelial cell density was 1515 (±474) cells/mm. Mean central corneal thickness decreased from 624 (±40) μm preoperatively to 513 (±34) μm postoperatively. Although formal training is desirable, good results can be obtained by an anterior segment surgeon learning DMEK, including graft preparation, without it. DMEK should no longer be considered a procedure with a long learning curve in routine cases.

Term Neonate with Respiratory Distress.

A female infant is born at 39 weeks to a 21-year-old primigravida with an unremarkable antenatal history and good prenatal care. The Apgar scores are 6, 7, and 8 at 1, 5, and 10 minutes, respectively. Physical examination reveals an appropriate-for–gestational age 3.3-kg term infant with grunting, tachypnea, and intercostal retractions. Decreased air entry is noted over the right side of the chest. A grade 2/6 systolic murmur is heard over the left sternal border with normal heart sounds and good peripheral pulses. The rest of the physical examination findings are within normal limits except for a right-sided small ear tag. The neonate requires positive pressure ventilation initially in the delivery room and then is placed on continuous positive airway pressure (CPAP) at 30% fraction of inspired oxygen. Chest radiography shows near-complete opacification of the right thorax with mass effect and normal lung markings on the left (Fig 1). Due to worsening respiratory distress, she undergoes intubation and is transferred to the regional perinatal center for diagnosis and management. Figure 1. Anteroposterior view radiograph of chest and abdomen at birth showing near-complete opacification of the right thorax. Differential diagnoses considered at this point for unilateral lung field opacity with mass effect include right-sided diaphragmatic hernia, congenital pulmonary airway malformation, pulmonary sequestration, or a space-occupying lesion like a tumor. Ultrasonography of the chest shows a large, solid mass in the right thorax with an intact diaphragm, an abnormality consistent with consolidated lung or a tumor (Fig 2 …

Development of a novel ex vivo porcine laparoscopic Heller myotomy and Nissen fundoplication training model (Toronto lap-Nissen simulator).

Surgical trainees are required to develop competency in a variety of laparoscopic operations. Developing laparoscopic technical skills can be difficult as there has been a decrease in the number of procedures performed. This study aims to develop an inexpensive and anatomically relevant model for training in laparoscopic foregut procedures. An ex vivo, anatomic model of the human upper abdomen was developed using intact porcine esophagus, stomach, diaphragm and spleen. The Toronto lap-Nissen simulator was contained in a laparoscopic box-trainer and included an arch system to simulate the normal radial shape and tension of the diaphragm. We integrated the use of this training model as a part of our laparoscopic skills laboratory-training curriculum. Afterwards, we surveyed trainees to evaluate the observed benefit of the learning session. Twenty-five trainees and five faculty members completed a survey regarding the use of this model. Among the trainees, only 4 (16%) had experience with laparoscopic Heller myotomy and Nissen fundoplication. They reported that practicing with the model was a valuable use of their limited time, repeating the exercise would be of additional benefit, and that the exercise improved their ability to perform or assist in an actual case in the operating room. Significant improvements were found in the following subjective measures comparing pre- vs. post-training: (I) knowledge level (5.6 vs. 8.0, P<0.001); (II) comfort level in assisting (6.3 vs. 7.6, P<0.001); and (III) comfort level in performing as the primary surgeon (4.9 vs. 7.1, P<0.001). The trainees and faculty members agreed that this model was of adequate fidelity and was a representative simulation of actual human anatomy. We developed an easily reproducible training model for laparoscopic procedures. This simulator reproduces human anatomy and increases the trainees' comfort level in performing and assisting with myotomy and fundoplication.

Podocyte directed therapy of nephrotic syndrome—can we bring the inside out?

Several of the drugs currently used for the treatment of glomerular diseases are prescribed for their immunotherapeutic or anti-inflammatory properties, based on the current understanding that glomerular diseases are mediated by immune responses. In recent years our understanding of podocytic signalling pathways and the crucial role of genetic predispositions in the pathology of glomerular diseases has broadened. Delineation of those signalling pathways supports the hypothesis that several of the medications and immunosuppressive agents used to treat glomerular diseases directly target glomerular podocytes. Several central downstream signalling pathways merge into regulatory pathways of the podocytic actin cytoskeleton and its connection to the slit diaphragm. The slit diaphragm and the cytoskeleton of the foot process represent a functional unit. A breakdown of the cytoskeletal backbone of the foot processes leads to internalization of slit diaphragm molecules, and internalization of slit diaphragm components in turn negatively affects cytoskeletal signalling pathways. Podocytes display a remarkable ability to recover from complete effacement and to re-form interdigitating foot processes and intact slit diaphragms after pharmacological intervention. This ability indicates an active inside-out signalling machinery which stabilizes integrin complex formations and triggers the recycling of slit diaphragm molecules from intracellular compartments to the cell surface. In this review we summarize current evidence from patient studies and model organisms on the direct impact of immunosuppressive and supportive drugs on podocyte signalling pathways. We highlight new therapeutic targets that may open novel opportunities to enhance and stabilize inside-out pathways in podocytes.