Pathological Complications Research Articles

Outpatient thyroid surgery: Safety of an optimized protocol in more than 1,000 patients

Outpatient thyroid surgery is becoming increasingly common. The aim of this study was to clarify the principles for safe outpatient thyroid surgery and review our outcomes with the use of a protocol for outpatient thyroidectomy in a large patient cohort. A systematic analysis of a prospectively maintained database of outcomes of thyroidectomy in a tertiary endocrine surgery practice. Academic medical center. A protocol for outpatient thyroidectomy was conceived and refined over 3 years. A prospective analysis of all thyroidectomies accomplished by a single surgeon who used this protocol from May 2006 to November 2013 was then undertaken. Patient demographics, operative and pathologic data, admission status, complications, and readmission rates were recorded. A total of 1,311 thyroidectomy procedures were performed during the study period, of which 1,026 (78.3 %) were conducted on an outpatient basis. The readmission rate for outpatients was 0.9%, with only 1 readmission in the last 200 procedures. Inpatients (which included patients in the 23-hour "observation" category) were readmitted more often than outpatients (3.5% vs 0.9%, P<.01). Outpatient management increased steadily throughout the study period (from 59.7% to 92.3%, P<.01), despite a larger mean nodule size and a greater rate of malignancy over time. There were no changes in the complication rate across the study timeframe except for the incidence of temporary hypocalcemia, which decreased over time (P<.01). Outpatient thyroid surgery is safe in appropriately selected patients using an optimized and systematic protocol.

Interleukin-2 critically regulates bone marrow erythropoiesis and prevents anemia development.

Mice deficient in IL-2 signaling develop severe anemia indicating a defect in erythropoiesis. However, why deficiency in IL-2, an essential growth factor for lymphocytes, or in IL-2 signaling components should result in defective erythropoiesis is unclear. Here, we have analyzed the mechanism of IL-2 signaling deficiency induced anemia in mice and show that IL-2 plays an indispensable role in bone marrow (BM) erythropoiesis via maintenance of regulatory T (Treg) cells. In absence of IL-2 signaling, IFN-γ produced by the activated T cells suppressed klf1 expression, resulting in an early block in erythrocyte differentiation. Anemia, in IL-2 or IL-2 signaling deficient mice always developed prior to the manifestation of other autoimmune complications such as colitis, suggesting that anemia in these mice might be a contributing factor in inducing other pathological complications in later stages. Our study shows, how essential cytokines of lymphoid cells could exert critical influence on the development of erythrocytes and thus expanding our understanding of the complex regulation of hematopoiesis in the BM. Besides, our findings might facilitate the use of IL-2 and anti-IFN-γ as a clinical remedy against anemia that arise in cancer patients following radiotherapy or chemotherapy, a context which simulates the situation of IL-2 deficiency.

Double Inlet Single Ventricle With Transposition of the Great Arteries and Situs Inversus With Dextrocardia in an Adult Without Surgical Correction: Challenges and Triumphs

SESSION TITLE: Cardiovascular Disease Case Report Posters SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM INTRODUCTION: Single ventricle abnormality represents approximately 1% of all congenital cardiac defects, with an incidence of 0.05-0.1:10'000 live births [1]. With current medical and surgical advances, more patients are surviving to adulthood. Acute decompensation in adults is a common cause of death. New corrective approaches should be entertained to support the failing single ventricular hearts [2, 3] CASE PRESENTATION: We present a case of a 61 year old female with unrepaired cyanotic congenital heart disease. Her defect is significant for double inlet single ventricle with left looping and transposition of great arteries and situs inversus with dextrocardia, with somewhat “protected” pulmonary bed secondary to pulmonary stenosis (PS). The patient has done well, despite developing atrial fibrillation and worsening atrioventricular valve regurgitation and complete heart block. TEE confirmed well preserved systolic function with EF 54%, severe PS and severe biatrial enlargement. Right and Left catheterization notable for within normal limits coronary flow and high normal pulmonary artery pressures. Cardiopulmonary testing is significant for abnormal cardiovascular response - inability to augment stroke volume and increased oxygen consumption with submaximal exercise response. Multidisciplinary decision was made to proceed with epicardial pacemaker (EPM). After uneventful minimal inferior medial sternotomy approach for placement and uncomplicated CTICU recovery our patient is undergoing evaluation for orthotopic heart transplant DISCUSSION: The goal of EPM placement was to improve the patient's choronotropic incompetence and respectively functional capacity. After initial post-operative recovery, patient noted improved functional status and oxygen saturation in high to low 70s CONCLUSIONS: The uncorrected complex adult cyanotic cardiac pathology offers multifactorial array of challenges to the treating team. Understanding of the anatomy and pathological complications, as well as the physiological adaptation of each patient's condition, is essential for the optimum management of these intricate disorders Reference #1: EK Steinberger, C Ferencz, CA Loffredo. Infants With Single Ventricle:A Population-Based Epidemiological Study. Teratology.2002;65:103-115 Reference #2: Rossano JW, Chang AC.Perioperative management of patients with poorly functioning ventricles in the setting of the functionally univentricular heart. Cardiol Young.2006;16 (S1):47-54 Reference #3: H Vyas, DJ Hagler. Double Inlet Left Ventricle. Cur Treat Opt Card Med.2007;9:391-398 DISCLOSURE: The following authors have nothing to disclose: Ntesi Asimi, Jane Wilcox, Sherif Afifi No Product/Research Disclosure Information

Functionalization of a Collagen-Hydroxyapatite Scaffold with Osteostatin to Facilitate Enhanced Bone Regeneration.

Defects within bones caused by trauma and other pathological complications may often require the use of a range of therapeutics to facilitate tissue regeneration. A number of approaches have been widely utilized for the delivery of such therapeutics via physical encapsulation or chemical immobilization suggesting significant promise in the healing of bone defects. The study focuses on the chemical immobilization of osteostatin, a pentapeptide of the parathyroid hormone (PTHrP107-111), within a collagen-hydroxyapatite scaffold. The chemical attachment method via crosslinking supports as little as 4% release of the peptide from the scaffolds after 21 d whereas non-crosslinking leads to 100% of the peptide being released by as early as 4 d. In vitro characterization demonstrates that this cross-linking method of immobilization supports a pro-osteogenic effect on osteoblasts. Most importantly, when implanted in a critical-sized calvarial defect within a rat, these scaffolds promote significantly greater new bone volume and area compared to nonfunctionalized scaffolds (**p < 0.01) and an empty defect control (***p < 0.001). Collectively, this study suggests that such an approach of chemical immobilization offers greater spatiotemporal control over growth factors and can significantly modulate tissue regeneration. Such a system may be adopted for a range of different proteins and thus offers the potential for the treatment of various complex pathologies that require localized mediation of drug delivery.

A novel cobiotic-based preventive approach against high-fat diet-induced adiposity, nonalcoholic fatty liver and gut derangement in mice.

High-fat diets (HFDs) induce systemic inflammation, gut microbial derangements and disturb metabolic homeostasis, resulting in weight gain, insulin resistance and nonalcoholic fatty liver (NAFL). Numerous antioxidants and prebiotic/probiotics per se may prevent HFD-associated comorbidities, but there are no reports related to their combination. In the present study, we aim to evaluate a cobiotic combination of lycopene (antioxidant) and isomalto-oligosaccharides (IMOs, a prebiotic) for prevention of HFD-induced alterations. Male Swiss albino mice were fed either normal pellet diet (NPD) or HFD and lycopene (5 and 10 mg kg(-1)), IMOs (0.5 and 1 g kg(-1)) or their combination for 12 weeks. Systemic adiposity, glucose tolerance, insulin sensitivity, feeding regulators in hypothalamus, hepatosteatosis and liver inflammation, cecal short chain fatty acids (SCFAs), serum inflammatory cytokines, gut morphology and alterations in selected gut microbes were studied. Lycopene, IMOs and their combination prevented weight gain, adiposity, improved adipose tissue fat mobilization and reduced insulin resistance. Hypothalamic orexigenic and anorectic genes have also been modulated by these treatments. Dietary interventions prevented NAFL-like symptoms and improved glucose homeostasis. Improvement in selected gut microbial abundance and SCFA concentration along with reduced systemic inflammation, metabolic endotoxemia and improved ileal and colonic health were observed in mice supplemented with lycopene, IMOs and their combination. Interestingly, cobiotic combination synergistically improved many of the HFD-induced alterations. The present work provide evidence that new approach based on cobiotic combination (antioxidant plus prebiotic) can be employed to develop novel class of functional foods for their application against HFD-associated pathological complications.

Vertebral Angiosarcoma. Case Study

Bone angiosarcomas, especially vertebral angiosarcomas, are very rare. There are no studies based on large clinical samples in the literature, and only a few single case reports can be found. The symptoms of the disease are not specific. It is usually detected incidentally or at a late stage when pathological vertebral fractures or neurological complications occur. Diagnostic imaging and history help to recognize the tumour behind the symptoms, but do not allow accurate clinical diagnosis. The basis for a diagnosis is the histopathological examination supported by immunohistochemistry (IHC) assays. The case of a 26-year-old woman with an angiosarcoma involving the eighth thoracic vertebra we report reflects diagnostic problems adversely affecting the efficacy and accuracy of treatment offered to patients. The patient underwent three surgeries of the spine, including two biopsies. A needle biopsy did not provide sufficient information for the diagnosis. An open excisional biopsy, which at the same time temporarily reduced neurological deficits in the patient, was the only chance to obtain an accurate diagnosis. The third surgery was posterior decompression of the spinal cord due to the rapidly escalating paraparesis. It was not until 8 weeks later that the final diagnosis was established. At that time, the patient could not be qualified for any supplementary treatment. The patient died in hospital 6 months after the onset of disease.

The role of cystectomy in elderly patients - a multicentre analysis.

Life expectancy in developed countries is continuously increasing. Hence elderly patients are becoming more common in our clinical practice. Currently, one of the greatest challenges of medicine is balancing the life expectancy of elderly patients against aggressive treatments that carry significant risks. To outline the complications and survival in surgical patients 80years and over undergoing radical cystectomy for bladder cancer. A review of a radical cystectomy in elderly recorded in four different institutional prospective databases during the period between 1991 and 2014. Clinical and pathologic features, complications and survival were evaluated. A total of 111 patients were available. Median (range) age 82.2 (80-89)years. Seventeen women and 94 men. Regarding the ASA score, 6 patients were ASA I, 47 patients were ASA II, 49 patients ASA III and 9 ASA IV. Prior to surgery, 48 patients had hydronephrosis. The median (range) creatinine series was 1.1 (0.71-11.1) ng/dL. In 88 cases an ileal conduit was performed, 17 a cutaneous ureterostomy diversion, 5 neobladders and 1 ureterosigmoidostomy case. The median (range) operative time was 230 (120-420)min and a total of 97 patients required blood transfusion. The median (range) hospital stay was 14 (7-126) days. The early and late complication rates were 50.4% and 32%, respectively. A total of 14 patients (12.6%) required surgical reintervention. Eight patients (7.2%) died in the immediate postoperative period. The readmission rate of the series was 27.2%. The mean follow-up of the series was 18 (0.27-134.73) months. During this period 66 patients died, 52 of them due to the tumor. Twelve month tumour progression free survival was 83.9% for ≤pT1, 70.2% for pT2 and 36% for ≥pT3, respectively. Twelve month cancer specific survival was 85.6% for ≤pT1, 75.1% for pT2 and 42.5% for ≥pT3, respectively. Radical cystectomy in elderly population is an aggressive surgical treatment with a significant complication rate, hospital readmission and perioperative mortality rate. Careful selection of patients is essential in order to minimize the complications of this surgery and balance benefits against risks in the elderly population. Tumour progression and cancer specific survival are poor for patients with ≥pT3 disease. Alternatives such as tri-modality therapy need to be considered within a multi-disciplinary approach. More data is required to determine which sub-groups of elderly patients would benefit from a complication, survival and quality of life perspective.

Hinman syndrom: About 33 cases

Hinman syndrome or neurogenic non neurogenic bladder is a severe voiding dysfunction of children. The objective of this study is to review its pathology and uronephrologic complications. A retrospective study, descriptive and analytical of 33 urodynamic explorations of children with Hinman syndrome, sent to the Physical Medicine and Rehabilitation department between January 2011 and September 2014. The criteria for inclusion are based on the presence of urinary disorders in children without confirmed neurological disease. Thirty-three children were collected in this study. Sociodemographic data showed that there was a female predominance, the mean age of symptoms was 5 ± 1.7 years old. Urinary incontinence was the main symptom of bladder-sphincter dysfunction,the impact on the upper urinary tract as vesico-ureteral reflux in 11 cases (33.3%)of ureterohydronephrosis in 10 cases (30.3%). Our study showed 4 cases (12.20%) severe bladder trabeculation. Diagnosis of Hinman syndrome in children is based on well-defined criteria, clinical examination and complete paraclinical is necessary for the elimination of a neurogenic bladder. Diagnosis and early management of the disease is critical to minimize the onset of complications involving the functional and vital prognosis.

Clinical efficacy of " Easy First" strategy in laparoscopic pancreaticoduodenectomy for borderline resectable pancreatic cancer

Objective To investigate clinical efficacy of Easy Firststrategy in laparoscopic pancreaticoduodenectomy (PD) for borderline resectable pancreatic cancer. Methods The clinical data of 9 patients with borderline resectable pancreatic cancer who were admitted to the Sir Run Run Shaw Hospital of Zhejiang University (8 patients) and Zhejiang Provincial People's Hospital (1 patient) from June 2013 to March 2015 were retrospectively analyzed. Nine patients underwent laparoscopic pancreaticoduodenectomy based on the Easy Firststrategy (to sequentially dissect and amputate jejunum, stomach, hepatoduodenal ligament, common bile duct, main portal vein, head of pancreas, second segment and third segment of the duodenum, uncinate process and neck of pancreas). The operation time, volume of intraoperative blood loss, postoperative pathological examination, complications and duration of hospital stay were recorded. Patients were followed up once every 3 months by outpatient examination and telephone interview up to June 2015. Results Of 9 patients, 4 received totally laparoscopic PD (2 received partial resection and repair of portal venous wall) , 1 received laparoscopic assisted resection and digestive tract reconstruction, and 4 received laparoscopic transection of jejunum, bile tract and stomach and conversion to open surgery for resection and digestive tract reconstruction (1 with severe adhesion between tumor and portal vein, 3 with bleeding due to dissection of neck and unciform process of pancreas) .The operation time and volume of intraoperative blood loss in all patients and in 4 patients with totally laparoscopic PD were (404±49) minutes and (456 ±348) mL, (395 ± 61) minutes and (188 ± 25) mL, respectively.Of 9 patients, 5 with postoperative complications were cured without perioperative death, including 2 with Grade B pancreatic fistula, 1 with biliary leakage, 1 receiving reoperation due to gastric stump bleeding at postoperative day 7 and 1 with abdominal infection.The extubation time of right drainage tube and left drainage tube was (9 ±5) days and (11 ± 4) days, respectively.The duration of hospital stay was (24 ± 10) days.All patients were diagnosed as with pancreatic cancer by pathological examinations with the tumor diameter of (3.2 ±0.8) cm.The number of harvested lymph nodes in all patients and in 4 patients with totally laparoscopic PD were 16.8 (range, 6.0-25.0) and 19.8 (range, 15.0-25.0) .All the patients were followed up for mean time of 12 months (range, 4-24 months) , including 1 death at postoperative month 3, 1 with tumor survival of 20 months and others with tumor-free survival.The postoperative survival time of 4 patients was more than 18 months at the end of follow-up. Conclusion Easy Firststrategy in laparoscopic PD is safe, feasible and practical for borderline resectable pancreatic cancer. Key words: Pancreatic neoplasms; Borderline resection; Pancreaticoduodenectomy; Laparoscopy

Avulsion of the Globe after Bicycle Accident--Clinical and Histopathological Evaluation

Potential pathological mechanisms and complications of traumatic avulsio bulbi will be discussed based on the history, clinical, and histopathological findings of two patients. Both patients were heavily affected by alcohol and had a bicycle accident with subsequent perforation of the upper eyelid by the handlebar-mounted hand brake levers. The accident resulted in disruption of the optic nerve and anterior displacement of the globe. In one patient, it was possible to reposition the globe into the orbit; however, the second patient's eye had to be enucleated. Functional testing demonstrated permanent loss of vision of the primary involved eyes, visual field defects, and visual impairment of one fellow eye. Avulsio bulbi describes a severe trauma to the eye often induced by sport and traffic accidents. Special attention should be addressed to the primary non-affected fellow eye with regard to potential functional defects.

Maternal hypertension programs increased cerebral tissue damage following stroke in adult offspring.

The maternal system is challenged with many physiological changes throughout pregnancy to prepare the body to meet the metabolic needs of the fetus and for delivery. Many pregnancies, however, are faced with pathological stressors or complications that significantly impact maternal health. A shift in this paradigm is now beginning to investigate the implication of pregnancy complications on the fetus and their continued influence on offspring disease risk into adulthood. In this investigation, we sought to determine whether maternal hypertension during pregnancy alters the cerebral response of adult offspring to acute ischemic stroke. Atrial natriuretic peptide gene-disrupted (ANP(-/-)) mothers exhibit chronic hypertension that escalates during pregnancy. Through comparison of heterozygote offspring born from either normotensive (ANP(+/-WT)) or hypertensive (ANP(+/-KO)) mothers, we have demonstrated that offspring exposed to maternal hypertension exhibit larger cerebral infarct volumes following middle cerebral artery occlusion. Observation of equal baseline cardiovascular measures, cerebrovascular structure, and cerebral blood volumes between heterozygote offspring suggests no added influences on offspring that would contribute to adverse cerebral response post-stroke. Cerebral mRNA expression of endothelin and nitric oxide synthase vasoactive systems demonstrated up-regulation of Et-1 and Nos3 in ANP(+/-KO) mice and thus an enhanced acute vascular response compared to ANP(+/-WT) counterparts. Gene expression of Na(+)/K(+) ATPase channel isoforms, Atp1a1, Atp1a3, and Atp1b1, displayed no significant differences. These investigations are the first to demonstrate a fetal programming effect between maternal hypertension and adult offspring stroke outcome. Further mechanistic studies are required to complement epidemiological evidence of this phenomenon in the literature.

Resection of benign vertebral tumors by minimally invasive techniques

Background contextBenign tumors of the vertebrae are generally an uncommon cause for surgery. Complete removal of these tumors requires in most cases extensive surgical technique that consists of generous surgical exposure followed by laminectomy, facetectomy, and sometimes even an instrumented fusion. PurposeThe aim was to describe our experience in performing resection of benign vertebral tumors, using a minimally invasive surgical (MIS) approach. Study designThis was a retrospective review of case records. Patient samplePatients who underwent MIS, resection of benign vertebral tumors. Outcome measuresComplete neurologic examination and pain evaluation, as measured by the visual analog scale (VAS). Secondary outcomes included postoperative spinal instability assessment and surgical margins examinations. MethodsPatients were evaluated preoperatively and postoperatively at 1, 3, and 6 months intervals clinically and radiographically using plain radiographs and postoperative computed tomography (CT) scans. Final pathologic report, operative time, blood loss, complications, and hospital length of stay were also recorded. ResultsBetween 2009 and 2013, 14 patients underwent MIS, resection of benign vertebral tumors at our institution. Mean follow-up time was 4 years. There were eight men and six women with a mean age of 27 years (range 16–68 years). For tumors located in the posterior elements, a direct posterior approach was used. Tumors located at the pedicle of the vertebra were excised using a transpedicular approach, and tumors protruding into the foramen were excised using the transforaminal approach. The transcanal approach was used when decompression of the thecal sac or nerve root was required, and the retroperitoneal transpsoas approach was used for tumors located in the vertebral body. Complete removal of these tumors was achieved in all cases, and was verified by a follow-up CT scan. Pathology revealed osteoid osteoma in five patients, osteoblastoma in three patients. Eosinophilic granuloma, fibrous dysplasia, and fibroid adenoma were found in one case each. Average VAS pain score improved from 7.7 (7–9) to 2.8 (0–7) after surgery. ConclusionsMinimally invasive techniques are a valuable choice for the treatment of benign osseous tumors of the spine. A larger, long-term study is in progress. In the meantime, we suggest surgeons experienced with both open and MIS surgery should consider these techniques.

Endoscopic Submucosal Dissection for Gastrointestinal Superficial Lesions: Initial Experience in a Single Portuguese Center

IntroductionEndoscopic submucosal dissection (ESD) is a minimally invasive organ-sparing endoscopic technique which allows en bloc resection of premalignant and early malignant lesions of the gastrointestinal tract regardless of size. In spite of the promising results, mainly from Japanese series, ESD is still not being widely used in western countries. This study aims to report the feasibility, safety and effectiveness of ESD technique for treating premalignant and early malignant gastrointestinal (GI) lesions (esophagus, gastric and rectum) in a Portuguese center. Patient and MethodsFrom December 2011 to November 2014, 34 GI lesions were treated by ESD. The location, en bloc and pathological complete resection (R0) rates, procedure time, complications and local recurrence were retrospectively evaluated. ResultsFrom 34 resected lesions, 18 were gastric (GL), 15 were rectal (RL) and one esophageal (EL). En bloc resection for each location was 17/18 (94%), 11/15 (73%) and 1/1 respectively. R0 was achieved in 16/18 (89%) GL, 9/15 (60%) RL and 1/1 EL. Mean resection time was 67min for GL, 142min for RL and 40min for EL. Complications included immediate (6%) and delayed (3%) minor bleeding but no perforation. One local residual lesion from a RL was reported in the follow-up, effectively treated with an endoscopic technique. Disease-specific survival was 100% over a mean follow-up period of 14 months. ConclusionESD has shown to be a safe and feasible resection method, achieving high R0, low recurrence and complication rates. Our results are similar to those reported in other international series.

Binding pancreaticogastrostomy in laparoscopic central pancreatectomy: a novel technique in laparoscopic pancreatic surgery.

Even though more and more cases of laparoscopic central pancreatectomy (LCP) are reported (Machado et al. in Surg Laparosc Endosc Percutan Tech 23(6):486-490, 2013; Hong et al. in World J Surg Oncol 10:223, 2012; Gonzalez et al. in JOP 14(3):273-276, 2013, Zhang et al. in J Laparoendosc Adv Surg Tech A 23(11):912-918, 2013; Sucandy et al. in N Am J Med Sci 2(9):438-441, 2010; Sa Cunha et al. in Surgery 142(3):405-409, 2007), the management for pancreatic stumps remains the most technically challenging part which is the same as in pancreatoduodenectomy (PD), making it the bottleneck for laparoscopic pancreatic surgery. In open surgery, various pancreatic reconstruction techniques designed for either pancreaticojejunostomy (PJ) or pancreaticogastrostomy (PG) have been attempted to reduce the postoperative pancreatic fistula (POPF), including the binding anastomosis, invented by our team, i.e., binding PG (BPG) and binding PJ, which have been proved to be effective to reduce the POPF (Hong et al. 2012; Peng et al. in Ann Surg 245(5):692-698, 2007; Peng et al. in Updates Surg 63(2):69-74, 2011). However, despite of this, few reports are seen addressing such technique for laparoscopic surgery even though laparoscopic pancreatic surgery is more performed. After a previous successful laparoscopic BPG in a case of laparoscopic CP (LCP; Hong et al. 2012) and more than 50 cases of open PD and CP (Peng et al. 2011), we further performed laparoscopic BPG in 10 consecutive cases of LCP with satisfactory outcomes. To explore the feasibility and efficacy of LCP with BPG. Between October 2011 and July 2014, LCP with laparoscopic BPG was performed in ten consecutive patients with lesions of benign or low malignancy at the pancreatic neck. Operative and pathological data, complications, hospital stay and details on the surgical techniques were introduced. The operations were successfully performed in all the ten cases, with no conversions. The tumor size ranged from 2.0-3.0 to 2.5-3.0 cm, average (2.50 ± 0.35) to (2.66 ± 0.35) cm, and the diameter of pancreatic duct was (1.6-2.1) mm, average (1.71 ± 0.17) mm. Operation time was 170-250 (198.50 ± 25.82) min, and blood loss was 20-300 (125 ± 107.31) mL. Three cases had grade A pancreatic fistula (PF), and one case had delayed gastric emptying, which were all managed with conservative treatment. Upper GI bleeding occurred in one case which was cured with second operation, time for the recovery of bowl movement was 3-5 (4.2 ± 0.8) days, the time for semifluid dieting was 6-10 (8.2 ± 1.5) days, and the hospital stay was 8-20 (12.8 ± 4.63) days. The postoperative fast blood sugar was (6.3 ± 1.6) mmol/L with the normal diet, which was not significantly different from the preoperative data (5.3 ± 0.5) mmol/L (P > 0.05). The postoperative pathology was as follows: five cases of cystic serous adenoma, one case of intraductal papillary mucinous neoplasm, two cases of neuroendocrine tumor, and two cases of solid pseudopapillary tumor of pancreas. All the patients were followed up for 7-40 months, no recurrence happened, and no new incidence of diabetes or insufficiency of pancreatic exocrine function occurred. LCP with BPG is feasible and safe; the advantages lie in its minimal invasiveness, the efficacy for avoiding PF, and the preservation of the pancreatic endocrine and exocrine function insufficiency, making it an ideal procedure for the benign or low-malignant lesions at the pancreatic neck.

Serum levels of tumor necrosis factor-related apoptosis-inducing ligand correlate with the severity of pulmonary hypertension

Pulmonary hypertension (PH) is a rapidly progressive disease that eventually leads to right heart failure and death. Tumor necrosis factor-related apoptosis-inducing ligand (TRAIL) and its receptors (TRAIL-Rs) play an important role in the survival, migration, and proliferation of vascular smooth muscle cells. However, the association between serum TRAIL levels and PH is unknown. In this study, we assayed the serum soluble TRAIL (sTRAIL) levels in 78 patients with PH and 80 controls. The sTRAIL concentrations were elevated in the PH patients compared with the controls (138.76 ± 6.60 pg/mL vs. 80.14 ± 3.38 pg/mL, p < 0.0001). The presence of sTRAIL levels of >103 pg/mL could discriminate PH patients from healthy individuals, with a sensitivity of 75.6% and specificity of 81.2%. Moreover, elevated sTRAIL concentrations were associated with eventual pathological complications; this is consistent with the finding that sTRAIL levels decreased in patients who responded to treatment. In a hypoxia-induced PH mouse model, sTRAIL levels were significantly higher compared with those in normoxia mice, and clearly decreased when the mice were treated with treprostinil. The sTRAIL levels were positively correlated with right ventricular systolic pressure and the index of right ventricular hypertrophy. In conclusion, serum sTRAIL could be a biomarker for diagnosis and effective therapy for PH patients.

Efficacy of novel monoclonal antibody belimumab in the treatment of lupus nephritis.

Recently introduced into the market, belimumab (Benlysta) is a monoclonal antibody that has potential clinically efficacious applications for the treatment of lupus nephritis. Lupus nephritis is a major complication of systemic lupus erythematosus (SLE) that can lead to significant illness or even death without proper intervention and treatment. With vast implications through a novel mechanism, belimumab offers a new standard of treatment for physicians in the complications associated with SLE, specifically lupus nephritis. By targeting B cell signaling and maturation, belimumab is able to mitigate the underlying pathological complications surrounding SLE. Phase 3 clinical trials with belimumab have depicted clinically efficacious applications, suggesting belimumab as a revolutionary breakthrough in the treatment armamentarium for practicing clinicians. This article explains the precise mechanism of action of belimumab on the soluble protein BlyS that plays a major role in the pathogenesis of lupus nephritis. In addition, the extensive pharmacokinetics and clinical implications are exemplified in this review with belimumab's comparison with standard therapeutic guidelines for the treatment of lupus nephritis.

Head, Neck and Dental Emergencies

This attractively presented little book is a further addition to the Oxford Handbook series. It is in the pocket reference format with a plastic flexicover to which we have become accustomed since the first Oxford Handbook of Clinical Medicine was first published 20 years ago and has matching ribbon page markers in yellow and red. It aims to provide the reader with a working approach to diagnosis and management of patients presenting in the accident and emergency department, concentrating as would be expected from the title on urgent and emergency problems above the collar bones. However, of necessity, the first three chapters covering general assessment, first aid measures and infections take a rather more whole body approach, as do the concluding glossary and last two sections on burns and miscellaneous conditions. The bulk of the book runs sequentially through trauma and other emergency conditions involving the head, neck, face, ears, eyes, mouth and salivary glands. The editor points out that many of the subjects covered are not true emergencies that may immediately threaten life, sight or limb but that, nevertheless, the text endeavours to cover the majority of conditions in the anatomical region for which patients regularly attend the casualty department. On average, one topic within each overall heading is covered over three pages with a system of four icons used throughout, to allow rapid identification of the degree of urgency. The explanatory key to the icons appears helpfully on both the inside front cover and again within the preface. Emergency care by its very nature should be as simple and as quick as possible. To this end, the layout comprising short notes, diagrams and photographs together with a remarkably comprehensive index provides the reader with an easily assimilated set of information, which should prove extremely valuable in an emergency situation. There is an emphasis on maintaining a high index of suspicion and on frequent re-assessment to ensure that pathology and potential complications are not missed. A minor disappointment was the quality of some of the photographs, the majority of which are in monochrome, that contrasts with those in colour printed on higher quality paper in the chapter devoted to the eye. The editor, who has extensive experience as a trauma team leader and who is now based in Belfast, has drawn together 14 contributors from a range of surgical specialties, together with ophthalmology and dentistry. The book is recommended mainly for junior doctors and also nurses in accident and emergency, oral and maxillofacial surgery, ENT, ophthalmology, anaesthetics and plastic surgery, as well as for undergraduates. However, it is likely to have wider appeal even to more senior colleagues, who may not regularly deal with emergencies around the head and neck but who occasionally may be called upon to do so.

Delirium as letting go: An ethnographic analysis of hospice care and family moral experience

Background: Delirium is extremely common in dying patients and appears to be a major threat to the family’s moral experience of a good death in end-of-life care. Aim: To illustrate one of the ways in which hospice caregivers conceptualize end-of-life delirium and the significance of this conceptualization for the relationships that they form with patients’ families in the hospice setting. Design: Ethnography. Setting/participants: Ethnographic fieldwork was conducted at a nine-bed, freestanding residential hospice, located in a suburban community of Eastern Canada. Data collection methods included 15 months of participant observation, 28 semi-structured audio-recorded interviews with hospice caregivers, and document analysis. Results: Hospice caregivers draw on a culturally established framework of normal dying to help families come to terms with clinical end-of-life phenomena, including delirium. By offering explanations about delirium as a natural feature of the dying process, hospice caregivers strive to protect for families the integrity of the good death ideal. Conclusion: Within hospice culture, there is usefulness to deemphasizing delirium as a pathological neuropsychiatric complication, in favor of acknowledging delirious changes as signs of normal dying. This has implications for how we understand the role of nurses and other caregivers with respect to delirium assessment and care, which to date has focused largely on practices of screening and management.

HO‐1 Induction Attenuates Fructose Mediated Non‐alcoholic Fatty Liver in Hepatocytes and Obese Mice : Involves SIRT1

Oxidative stress underlies pathological complication in nonalcoholic fatty liver disease (NAFLD). Heme Oxygenase-1 (HO-1) is a potent endogenous antioxidant gene that plays a key role in decreasing oxidative stress. Sirtuin1 (SIRT1). The aim of this study is to determine whether HO-1 acts through SIRT1 to form a functional module within hepatocytes to attenuate fructose-mediated steatohepatitis and hepatic fibrosis. Effect of fructose, on hepatocyte lipid accumulation and fibrosis in murine hepatocytes and in mice fed a high fructose diet in the presence and absence of CoPP, an inducer of HO-1. Fructose increased heme and decreased HO-1, SIRT1 and pAMPK levels in hepatocytes (p<0.05). Fructose supplementation increased the expression of FAS levels; this increase was negated by CoPP. Concurrent treatment with CoPP and SIRT1 siRNA increased FAS expression suggesting that HO-1 is upstream of SIRT1 and suppression of SIRT1 attenuates the beneficial effects of HO-1. A high fructose diet increased insulin resistance and fibrotic markers in mice (p<0.05). Induction of HO-1 increased SIRT1 levels ameliorated fructose-mediated lipid accumulation and fibrosis in liver (p<0.05 vs. fructose). Taken together, our study demonstrates, that HO-1 induction attenuates fructose-induced hepatic lipid deposition, prevents the development of hepatic fibrosis and abates NAFLD-associated vascular dysfunction. Support NIH Grants HL-55601, HL34300 (N.G.A.)

Transaxillary thyroidectomies: a comparative learning experience of robotic vs endoscopic thyroidectomies.

Robotic and endoscopic approaches have become more accepted in thyroid surgery, with current literature documenting the experience of high-volume centers. We adopted both approaches concurrently, and this series presents our initial experience to assess the more practical option for low- to moderate-volume centers starting out with transaxillary thyroidectomies. Case series with chart review. Tertiary academic center. Over a period of 4 years, 101 patients underwent transaxillary thyroidectomies, of whom 48 underwent robotic thyroidectomy and 53 underwent endoscopic thyroidectomy. Data analysis includes patient characteristics, procedure time, thyroid pathology, and postoperative complications. A survey was conducted among surgeons to assess the subjective experience. Endoscopic hemithyroidectomies had a significantly shorter duration of operation (145.8 minutes) vs that of robotic hemithyroidectomies (193.6 minutes), P < .001. The mean time taken for the first 5 hemithyroidectomies vs the last 5 hemithyroidectomies showed a greater drop in the endoscopic group (49.1%) vs the robotic group (18.6%). There were 2 cases of transient recurrent laryngeal nerve injury. In the surgeon survey, the endoscopic technique was perceived to have less need for peripheral support, while the robotic technique was preferred for its shorter learning curve. In terms of outcome, both techniques are comparable at least in the initial phase. Based on our early experience, the endoscopic technique may be less intuitive with a longer learning curve, although at steady state, it may be the quicker procedure. This is relevant for low- to moderate-volume centers starting their transaxillary thyroidectomy program.