Lutzomyia longipalpis (Diptera: Psychodidae: Phlebotominae): a review

Lutzomyia longipalpis is the most important vector of AmericanVisceral Leishmaniasis (AVL) due to Leishmania chagasi in the New World. Despite its importance, AVL, a disease primarily of rural areas, has increased its prevalence and became urbanized in some large cities in Brazil and other countries in Latin America. Although the disease is treatable, other control measures include elimination of infected dogs and the use of insecticides to kill the sand flies. A better understanding of vector biology could also account as one more tool for AVL control. A wide variety of papers about L. longipalpis have been published in the recent past years. This review summarizes our current information of this particular sand fly regarding its importance, biology, morphology, pheromones genetics, saliva, gut physiology and parasite interactions.     

Holmium:YAG- und erbium :YAG-infrarotlaser-osteotomie

Zusammenfassung Die knochenablative Wirksamkeit der gepulsten Festkörperlaser Holmium:YAG ( = 2120 nm) and Erbium:YAG ( = 2940 nm) wurde im Tierversuch vergleichend untersucht. Als Modell für eine klinische Anwendung wurden partielle Oberkiefer-, Unterkiefer-und Nasenbeinosteotomien an der Ratte durchgeführt. In einer ersten Versuchsreihe wurden die unmittelbare klinische Wirkung und das histologische Wirkungsprofil dieser Infrarotlaser am Hartgewebe erforscht und die Temperaturgradienten im Knochen während der Laseranwendung gemessen. Die geringe Ausdehnung der Schädigungszone im Randbereich der Laserinzisionen und das für den Erbium:YAG-Laser praktisch atraumatische, athermische Knochenabtragungsvermögen läßt die neuen Infrarotlaser als ideale Schneidegeräte für Osteotomien erscheinen.

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Holmium:YAG laser and erbium:YAG laser infrared laser osteotomy

Summary The in-vivo bone ablation characteristics of a pulsed solid-state erbium:YAG laser were compared to those of a pulsed solid-state holmium:YAG laser. Partial osteotomies in the maxillary, the mandibulary, and the nasal bones of white rats were performed. The tissue response was examined by light microscopy. Thermal gradients following the laser application were also measured. Over all energy levels tested the erbium:YAG laser produced ablation of bone with minimal thermal damage to the adjacent tissue. The results of this study are promising for future application of the infrared holmium-and erbium:YAG lasers in otorhinolaryngology.

     

Breast: Sezary Syndrome: A Unique Presentation

Sezary syndrome is a subtype of cutaneous T cell lymphoma which usually presents as generalized skin disease with erytheroderma. Distal organ involvement is rare and is usually a late finding in the course of the disease. Breast involvement is extremely rare. Herein, we present a case report of a patient whose initial presentation involved an intramammary lymph node prior to the onset of more characteristic skin disease. Sezary syndrome was confirmed by cythopathologic findings.     

Reprint of: Parastomal hernia: Surgical management

Parastomal hernia is a common clinical problem that is difficult to manage. Although surgical repair is recommended for the majority of other incisional hernias to prevent the complications of incarceration, obstruction, or strangulation, most authors recommend nonoperative management of parastomal hernias. Surgical management is usually reserved for those patients whose parastomal hernia results in intractable difficulty maintaining an effective stoma appliance or who develop a severe complication. This article reviews the nonoperative and operative management of parastomal hernias by fascial repair and stomal relocation. Unfortunately, no randomized trials exist to guide the surgeon in the choice between the accepted nonoperative and surgical management options. Fascial repair without a prosthetic should probably be used only in the rarest of circumstances. If stoma relocation is selected, the stoma should be relocated to the opposite side of the abdominal wall and reconstructed using techniques associated with the lowest risk of stoma-related complications and parastomal hernia. However, the best outcomes may require the use of a prosthetic either to either repair or prevent a parastomal hernia.     

Peyronie's disease: surgical management: autologous materials

Peyronie's disease in men with satisfactory erectile function but with significant penile curvature is often treated with plaque incision or excision and grafting. The advantages and disadvantages of various grafting materials have long been debated. While artificial materials have been used, the inflammatory reaction from these grafts has produced poor results. Dermal, venous and tunica vaginalis grafts require additional operative time to harvest and their quality varies. Packaged grafts of autologous materials provide a readily available, reliable and well-tolerated choice for penile reconstruction for Peyronie's disease. These grafting materials including cadavaric pericardium, mammalian intestinal serosal products and others are easily obtained and provide a resilient yet compliant graft choice that is easy to tailor and suture in place. Host reaction is minimal and the infection risk small.Results of Peyronie's plaque incision/excision and autologous grafting are presented and the surgical procedures employed are outlined. Excellent results can be expected in the hands of the experienced reconstructive surgeon.     

Review article: Patient-level outcomes: the missing link

Treatment of chronic kidney disease (CKD) may be life-saving, but can disrupt every aspect of a patient's life and the lives of family members. Many patients with CKD are elderly with significant comorbidities and sometimes therapies to improve survival may be less important than those that improve or maintain quality of life. In this setting, patient-level benefits become particularly important goals of therapy. Randomized controlled trials (RCT) are also essential to justify expensive therapies, such as medications used in the treatment of CKD mineral and bone disorders. Surprisingly, data to support the efficacy of these drugs for patient-level outcomes remains limited. In fact, fewer RCT are conducted in renal medicine than in any other medical specialty and reliance is often placed on association data and the assessment of intermediate and biochemical end-points. While some of these may prove to be valid surrogates for clinically important outcomes, some may not. Inclusion of patient-level outcomes in clinical research provides a missing link that can inform a more comprehensive approach to clinical practice and patient care. Incorporating measures of health-related quality of life into clinical trials can make outcomes more relevant and may be relatively simple. This paper provides examples of reliable, validated instruments to measure health-related quality of life domains and functional status, together with practical instructions for their use. Most could be incorporated into RCT of CKD mineral and bone disorder treatments. Inclusion of outcomes that are perceived by patients to be significant should become standard practice in renal medicine and in clinical renal research.     

Respiration: ventilation

Ventilation is the process by which air moves into and out of the lungs and is made available for gas exchange across the alveolar-capillary membrane. Ventilation occurs automatically in a continuous rhythmic pattern without any conscious effort. It is controlled by both neural and chemical inputs and is concerned with the homeostasis of oxygen and carbon dioxide as well as having a role in acid–base balance. Inspiration is an active process. The diaphragm is the main muscle of inspiration, but other muscles can be involved. Expiration is normally a passive process during quiet breathing, but in certain disease processes may require energy expenditure. Resistance to gas flow in the airways is determined by a number of factors. Airway radius is the most important factor influencing resistance and gas flow changes from being turbulent to laminar as bronchi divide and cross-sectional area of the airways increases. Ventilation is not evenly distributed throughout the lungs and distribution is related to the compliance of alveoli in different areas of the lungs. Under normal circumstances, in the standing position, basal alveoli are the most compliant and are therefore preferentially ventilated.     

Review Article: Adiponectin: Its role in kidney disease

The multifactorial glycoprotein, adiponectin has demonstrable insulin-sensitizing, anti-atherogenic and anti-inflammatory properties. However, despite the prevalence of both insulin-resistance and vascular disease in patients with end-stage kidney disease, levels of adiponectin are high. Adiponectin circulates in different sizes (the high-molecular-weight (HMW) isoform is thought to be the most insulin-sensitizing type) and binds to two receptors, adiponectin receptors (AdipoR) 1 and 2. The adiponectin/receptor system appears to be upregulated in end-stage kidney disease possibly as an appropriate counter-regulatory response to the uraemic milieu. In contrast, adiponectin and its HMW isoform, AdipoR mRNA expression on peripheral blood mononuclear cells decrease after kidney transplantation, likely secondary to immunosuppression and/or an improvement in glomerular filtration rate and the uraemic environment. Adiponectin has also been detected in the urine of patients with proteinuric kidney disease. The presence of AdipoR on an immortal cell line of proximal tubular epithelial cells (HK-2) and an increased amount of intact HMW isoform in the urine of patients with various forms of proteinuria lead us to speculate about the potential role of urinary adiponectin. This review will also discuss the structure and function of adiponectin and its potential relevance to patients with kidney disease and the different factors that may influence the metabolism of this protein in kidney failure.     

Holmium: YAG lithotripsy: photothermal mechanism.

OBJECTIVE: A series of experiments were conducted to test the hypothesis that the mechanism of holmium:YAG lithotripsy is photothermal. METHODS AND RESULTS: To show that holmium:YAG lithotripsy requires direct absorption of optical energy, stone loss was compared for 150 J Ho:YAG lithotripsy of calcium oxalate monohydrate (COM) stones for hydrated stones irradiated in water (17+/-3 mg) and hydrated stones irradiated in air (25+/-9 mg) v dehydrated stones irradiated in air (40+/-12 mg) (P < 0.001). To show that Ho:YAG lithotripsy occurs prior to vapor bubble collapse, the dynamics of lithotripsy in water and vapor bubble formation were documented with video flash photography. Holmium:YAG lithotripsy began at 60 microsec, prior to vapor bubble collapse. To show that Ho:YAG lithotripsy is fundamentally related to stone temperature, cystine, and COM mass loss was compared for stones initially at room temperature (approximately 23 degrees C) v frozen stones ablated within 2 minutes after removal from the freezer. Cystine and COM mass losses were greater for stones starting at room temperature than cold (P < or = 0.05). To show that Ho:YAG lithotripsy involves a thermochemical reaction, composition analysis was done before and after lithotripsy. Postlithotripsy, COM yielded calcium carbonate; cystine yielded cysteine and free sulfur; calcium hydrogen phosphate dihydrate yielded calcium pyrophosphate; magnesium ammonium phosphate yielded ammonium carbonate and magnesium carbonate; and uric acid yielded cyanide. To show that Ho:YAG lithotripsy does not create significant shockwaves, pressure transients were measured during lithotripsy using needle hydrophones. Peak pressures were <2 bars. CONCLUSION: The primary mechanism of Ho:YAG lithotripsy is photothermal. There are no significant photoacoustic effects.     

Skin Cancer in Asians: Part 2: Melanoma

The Asian population in the United States is expected to increase in the next 50 years. Concurrently, there is an overall rise in the incidence of melanoma. It is therefore crucial to obtain a better understanding of this deadly skin cancer in this minority population, as little information is currently available and prognosis remains poor. Through a review of the literature, this paper explores melanoma in the Asian population, including the most common subtype encountered, prognosis, theories on pathogenesis, and molecular biology.The National Cancer Institute estimates that 39,080 men and 29,640 women will be diagnosed with cutaneous melanoma (CM) in 2009.1 It is further estimated that of those diagnosed with melanoma, 8,650 men and women will die in the United States.1 The US census bureau projects that the Asian population will triple in the next 50 years.2 With an overall rise in melanoma and anticipated increases in the Asian population, clinicians and patients alike must be aware of the potential for skin cancer in this minority population. Currently, there is limited available data on skin cancer in Asians, including melanoma.CM is predominantly an ultraviolet (UV) light-induced skin cancer more commonly associated with light-skinned Caucasians than in individuals with darker skin.³ Traditionally, clinical features associated with CM included Fitzpatrick skin types I to III with lighter color hair and eyes, an increased tendency to burn, history of multiple nevi, and strong family history of CM.⁴ Therefore, it is generally recognized that CM rarely affects individuals of ethnic backgrounds other than Caucasians, including those of Asian, Indian, Hispanic, or African descent. It is believed that greater concentrations of melanin in these darker skin populations provides photoprotective activity against the carcinogenic effects of UV radiation.³ More specifically, increased levels of melanin in darker skin tones are thought to allow less damage to deoxyribonucleic acid (DNA) in the lower epidermis, and more effectively prevents proliferation of UV-damaged cells via apoptosis.³ Consequently, CM in these individuals tends to occur at anatomic locations that are not continually sun-exposed, such as the feet.     

Resolved: being fat is good for dialysis patients: the Godzilla effect: pro

Obesity is the epidemic of the 21st century. Despite the fact that obesity is known to have major health consequences in the general population, an increasing number of large-scale epidemiological studies indicate an inverse association between increasing body mass index and mortality in dialysis patients. Here it is argued pro and con that epidemiological data derived from the healthy general population may or may be not applicable to conditions such as end-stage renal disease.     

Blutprodukte und Transfusion: Teil I: Grundlagen

Basic knowledge in pathophysiology is necessary for a systematic consideration of blood product substitution. Substitution of oxygen carriers by donation of erythrocyte concentrate will be necessary if oxygen delivery falls below a critical level of about 5 ml/kg/min in healthy people. In case of persisting bleeding or bleeding supported by coagulopathy, an immediate target-controlled substitution will be required. Bed-side available testing would probably be better in implementing such a substitution than usual coagulation tests. For effective coagulation, control of conditions such as pH, temperature and amount of free calcium are as important as substitution of FFP, replacement of thrombocytes and coagulation factor, inhibition of fibrinolysis and donation of recombinant factor VIIa.Hemotherapy in acute bleeding is time- and personell-consuming. Judicial, organizational and accounting aspects will complete the basic information of part I.     

AORTODUODENAL FISTULA: APPEARANCES ON COMPUTED TOMOGRAPHY: COMMENT

We commend McLaws et al. for their informative review on the validity of surgical wound infection as a clinical indicator in Australia.¹ We too, wish to emphasize that consistency in case-finding methods and indicator definitions is mandatory when pooling data and using indicator rates to compare quality of care.     

Heilung und Restitution: Teil 2 von 3: Anastomosenheilung

Anastomotic healing in the gastrointestinal tract is identical to any wound healing. This physiological process is characterized by the exsudative and proliferative phase. Many local and systemic pathologic conditions interfere with undisturbed healing in the gastrointestinal tract. Important basics for anastomotic healing are a meticulous technique, no tension and excellent perfusion. Compared to these preconditions, systemic and local therapeutics to improve healing of anastomosis are of minor importance.     

Erbium: YAG versus holmium:YAG lithotripsy

PURPOSE: We test the hypothesis that erbium:YAG (Er:YAG) lithotripsy is more efficient than holmium:YAG (Ho:YAG) lithotripsy. MATERIALS AND METHODS: Human calculi composed of greater than 97% calcium oxalate monohydrate and cystine were studied. Calculi were irradiated in water using Er:YAG or Ho:YAG lasers. Er:YAG lithotripsy was done with a 425 microm sapphire optical fiber at a pulse energy of 50 mJ at 10 Hz. Ho:YAG lithotripsy was performed with a 365 microm low hydroxy optical fiber at a pulse energy of 500 mJ at 10 Hz or a 425 microm sapphire optical fiber at a pulse energy of 50 mJ at 10 Hz. Fragmentation was defined as the initial stone mass minus the final dominant fragment mass and normalized for incident laser fluence (energy per unit area of fiber tip). RESULTS: Mean fragmentation plus or minus standard deviation for calcium oxalate monohydrate was 38 +/- 27 mg for Er:YAG and 22 +/- 6 for Ho:YAG (low hydroxy silica fiber) versus 5 +/- 1 for Ho:YAG (sapphire fiber, p = 0.001). When fragmentation was normalized for incident laser fluence given different optical fiber sizes, mean fragmentation efficiency was 53.6 +/- 38.7 g-microm2/J for Er:YAG lithotripsy compared with 22.6 +/- 6.4 for Ho:YAG (low hydroxy silica fiber) lithotripsy (p = 0.04). Mean cystine fragmentation was 15 +/- 3 mg for Er:YAG versus 9 +/- 1 for Ho:YAG (sapphire fiber, p = 0.0005). CONCLUSIONS: Er:YAG lithotripsy is more efficient than Ho:YAG lithotripsy.     

Erb:YAG and Hol:YAG Laser Osteotomy: The Effect of Laser Ablation on Bone Healing

Sixty-nine male Sprague Dawley rats were divided into three groups of 23 animals each and osteotomies were performed in group 1 with a power saw, in group 2 with the Erb:Yag laser, and in group 3 with the Hol:YAG laser. Two animals of each group were sacrificed 1 week, 4, 8, and 12 weeks after operation for histologic investigation, and five animals of each group at 4, 8, and 12 weeks after osteotomy for torque testing. Anterior-posterior (AP) radiographs were taken at the same time points and investigated for callus formation and development of pseudoarthrosis. All tibiae osteotomied with the Ho1:YAG laser (group 3) developed pseudoarthrosis within 12 weeks and, therefore, torque testing could not be performed for this group. Biomechanical measurements of bone treated by power saw or Erb:YAG laser osteotomies, respectively, showed no significant statistical difference in the stability of bone between the two groups. Histologic examination after 1 week exhibited fibrous tissue at the site of osteotomy in rats of all three groups and additionally carbonization in rats of group 3. Saw osteotomies resulted in more callus formation than Erb:YAG osteotomies, but both techniques provoked a certain reunion within 8 weeks. Hol:YAG laser-treated osteotomies, however, exhibited formation of dense fibrous tissue, carbonization and no callus formation within 12 weeks. Radiographic pictures showed more callus formation for saw osteotomies as compared to those performed with the Erb: YAG laser. For Hol:YAG laser osteotomies pseudoarthrosis was identified also radiologically. © 1994 WiIey-Liss, Inc.     

Heart Transplantation:

The gap between the number of potential recipients of a cardiac graft and the availability of donor hearts is still growing. A proper selection of heart transplant candidates is mandatory to ensure that patients in critical need, who are likely to benefit from this procedure, are identified. The work-up of a patient with terminal chronic heart failure includes a comprehensive cardiac and systemic evaluation. Critical in the decision is the exclusion of irreversible pulmonary hypertension. Furthermore, underlying diseases that could compromise short-and long-term prognosis after transplantation should be carefully assessed. The mortality on the waiting list and the growing pool of patients with chronic heart failure that is excluded from transplantation has stimulated the search for alternative treatment modalities. Besides a pharmacologic approach, the last few years have witnessed a tremendous evolution in so-called mechanical devices, designed to improve both morbidity and mortality of these patients. Although several of these devices have only just entered the clinical phase, internal cardioverter defibrillators, left ventricular assist devices and biventricular pacemakers can no longer be viewed as experimental tools.