Isolated mediastinal lymphangioma herniating through the intercostal space

Lymphangiomas are congenital malformations of the lymphatic system, and 90% have manifested by the end of the second year of life. While 75% of these are located in the cervical region, only 2% to 3% are associated with an intrathoracic extension. An isolated mediastinal lymphangioma without a cervical component is an uncommon occurrence. Presented here is an isolated mediastinal lymphangioma that herniated through the intercostal space to present as a cystic mass in the parasternal region, which has not been reported so far.     

Rapid Progression of Native Renal Artery Fibromuscular Dysplasia Following Kidney Donation

Fibromuscular dysplasia is the second commonest anatomical abnormality apart from multiple renal arteries in the potential live donors. Pretransplant evaluation of the donors may include an angiography to evaluate the renal arteries, and failure to recognize renal arterial stenosis, particularly fibromuscular dysplasia, by noninvasive methods may eventually lead to hypertension and ischemic renal failure. We report a case of fibromuscular dysplasia that was undetected by computed tomographic angiography prior to donation. One year after kidney donation, it rapidly progressed to severe symptomatic stenosis with hypertension and acute renal failure. Following renal artery angioplasty, her blood pressure normalized over a period of 2 weeks without any need for antihypertensive medications and the serum creatinine returned to her baseline. The acceptability of renal donors with fibromuscular dysplasia depends on the age, race and the availability of the other suitable donors. Mild fibromuscular dysplasia in a normotensive potential renal donor cannot be considered a benign condition. Such donors need regular follow-up postdonation for timely detection and treatment.     

Laparoscopic Colorectal Surgery for Obese Patients: Decreased Conversions with the Hand-Assisted Technique

Background

Laparoscopic surgery benefits obese patients but technical difficulties associated with suboptimal exposure and access in these subjects may prompt conversion to open surgery. Hand-assisted laparoscopic surgery (HALS) confers advantages over standard laparoscopy (LAP) by facilitating tactile feedback, assisted dissection, and retraction. These benefits could be particularly valuable in obese patients, allowing completion of difficult laparoscopic procedures in this subgroup. Our aim was to compare intra-operative and post-operative outcomes of HALS and LAP approaches in obese patients undergoing colorectal resection at our institution.

Methods

A retrospective study of a prospectively maintained laparoscopic colorectal surgery database was performed. HALS and LAP cases performed in obese patients (body mass index (BMI)?>30) were identified and compared for the following outcomes: operative time, intra-operative complications, rate of conversion to open, blood loss, length of stay, post-operative morbidity, and mortality. Outcomes for the converted patients were included on an intention-to-treat basis for all primary analyses. A secondary analysis of nonconverted and converted cases was also performed.

Results

Over a 5-year period, 496 obese patients underwent laparoscopic colorectal resection; 86 HALS and 410 LAP cases. The two groups were comparable in terms of age, gender, BMI, and indications for surgery. Conversion to open surgery was less often necessary in HALS compared to LAP cases (3.5 % vs. 12.7 %, p?=?0.014). The LAP group had a significantly smaller incision length for specimen extraction (HALS (7.0?±?1.3 cm) vs. LAP (5.7?±?2.1 cm), p?<?0.001). Length of stay, operative time, morbidity, and mortality rates were comparable between the two groups.

Conclusion

In obese patients who require colectomy, the HALS approach increases the likelihood of a successful minimally invasive operation. At the cost of a clinically negligible increase in incision length, HALS may save a high-risk group conversion to formal laparotomy and the adverse outcomes related to this.     

Exome Sequence Data From Multigenerational Families Implicate AMPA Receptor Trafficking in Neurocognitive Impairment and Schizophrenia Risk

Schizophrenia is a mental disorder characterized by impairments in behavior, thought, and neurocognitive performance. We searched for susceptibility loci at a quantitative trait locus (QTL) previously reported for abstraction and mental flexibility (ABF), a cognitive function often compromised in schizophrenia patients and their unaffected relatives. Exome sequences were determined for 134 samples in 8 European American families from the original linkage study, including 25 individuals with schizophrenia or schizoaffective disorder. At chromosome 5q32–35.3, we analyzed 407 protein-altering variants for association with ABF and schizophrenia status. For replication, significant, Bonferroni-corrected findings were tested against cognitive traits in Mexican American families (n = 959), as well as interrogated for schizophrenia risk using GWAS results from the Psychiatric Genomics Consortium (PGC). From the gene SYNPO, rs6579797 (MAF = 0.032) shows significant associations with ABF (P = .015) and schizophrenia (P = .040), as well as jointly (P = .0027). In the Mexican American pedigrees, rs6579797 exhibits significant associations with IQ (P = .011), indicating more global effects on neurocognition. From the PGC results, other SYNPO variants were identified with near significant effects on schizophrenia risk, with a local linkage disequilibrium block displaying signatures of positive selection. A second missense variant within the QTL, rs17551608 (MAF = 0.19) in the gene WWC1, also displays a significant effect on schizophrenia in our exome sequences (P = .038). Remarkably, the protein products of SYNPO and WWC1 are interaction partners involved in AMPA receptor trafficking, a brain process implicated in synaptic plasticity. Our study reveals variants in these genes with significant effects on neurocognition and schizophrenia risk, identifying a potential pathogenic mechanism for schizophrenia spectrum disorders.Key words: schizophrenia, cognition, SYNPO, WWC1, synaptic plasticity     

Ca2+ transients in astrocyte fine processes occur via Ca2+ influx in the adult mouse hippocampus

Astrocytes display complex morphologies with an array of fine extensions extending from the soma and the primary thick processes. Until the use of genetically encoded calcium indicators (GECIs) selectively expressed in astrocytes, Ca²⁺ signaling was only examined in soma and thick primary processes of astrocytes where Ca²⁺‐sensitive fluorescent dyes could be imaged. GECI imaging in astrocytes revealed a previously unsuspected pattern of spontaneous Ca²⁺ transients in fine processes that has not been observed without chronic expression of GECIs, raising potential concerns about the effects of GECI expression. Here, we perform two‐photon imaging of Ca²⁺ transients in adult CA1 hippocampal astrocytes using a new single‐cell patch‐loading strategy to image Ca²⁺‐sensitive fluorescent dyes in the cytoplasm of fine processes. We observed that astrocyte fine processes exhibited a high frequency of spontaneous Ca²⁺ transients whereas astrocyte soma rarely showed spontaneous Ca²⁺ oscillations similar to previous reports using GECIs. We exploited this new approach to show these signals were independent of neuronal spiking, metabotropic glutamate receptor (mGluR) activity, TRPA1 channels, and L‐ or T‐type voltage‐gated calcium channels. Removal of extracellular Ca²⁺ almost completely and reversibly abolished the spontaneous signals while IP₃R2 KO mice also exhibited spontaneous and compartmentalized signals, suggesting they rely on influx of extracellular Ca²⁺. The Ca²⁺ influx dependency of the spontaneous signals in patch‐loaded astrocytes was also observed in astrocytes expressing GCaMP3, further highlighting the presence of Ca²⁺ influx pathways in astrocytes. The mechanisms underlying these localized Ca²⁺ signals are critical for understanding how astrocytes regulate important functions in the adult brain. GLIA 2016;64:2093–2103     

Suicide rates in five-year age-bands after the age of 60 years: the international landscape†

Background: There is paucity of studies examining suicide rates in narrow five-year age-bands after the age of 60 years. This study examined suicide rates in eight five-year age-bands between the age of 60 and 99 years because this will allow more precise comparison between the young old (60–79 years) and the oldest old (80+ years) age groups.

Methods: Data on the number of suicides (International Classification of Diseases – ICD-10 codes, X60-84) in each of the eight five-year age-bands between the age-bands 60–64 years and 95–99 years in both gender for as many years as possible from 2000 were ascertained from three sources: colleagues with access to national data, national statisics office websites and email contact with the national statistics offices. The population size for the corresponding years and age-bands was estimated for each country using data provided by the United Nations website.

Results: In men, suicide rates continued to increase for each of the seven five-year age-bands from 60–64 years to 90–94 years age-band, and then declined slightly for the 95–99 year age-band. In women, suicide rates continued to increase for each of the six five-year age-bands from 60–64 years to 85–89 years age-bands, and then declined slightly for the 90–94 years and 95–99 years age-bands.

Conclusions: The overall global suicide rates for each of the eight five-year age-bands are sufficiently large for them to constitute a public health concern. This is especially important given the ongoing rise in the elderly population size and the paucity of data on risk and protective factors for suicide in the five-year age-bands after the age of 60 years.     

Is laparoscopic surgery for recurrent Crohn’s disease beneficial in patients with previous primary resection through midline laparotomy? A case-matched study

Background

Patients undergoing abdominal surgery for Crohn??s disease are predisposed to recurrence requiring reoperation. The effectiveness of laparoscopic versus open resection in patients with previous intestinal resection for Crohn??s through midline laparotomy is controversial.

Methods

Patients with previous open resection for intestinal Crohn??s disease undergoing elective laparoscopic surgery for recurrent bowel disease from 1997 to 2011 were case-matched with open counterparts based on age (±5?years), gender, body mass index (±2?kg/m²), American Society of Anesthesiologists (ASA) score, surgical procedure, and year of surgery (±3?years). Groups were compared using Chi-square or Fisher exact tests for categorical and the Wilcoxon rank-sum test for quantitative data.

Results

26 patients undergoing laparoscopic ileocolectomy (n?=?14), proctocolectomy (n?=?5), small bowel resection (n?=?4), abdominoperineal resection (n?=?1), extended right colectomy (n?=?1), and strictureplasty (n?=?1) were well matched to 26 patients undergoing open surgery. The number of previous operations, disease phenotypes, steroid use, and comorbidities were comparable in the two groups. There were no deaths, and three patients (12?%) required conversion because of adhesions. Laparoscopic and open groups had statistically similar operating times (169 versus 158?min, p?=?0.94), estimated blood loss (222 versus 427?ml, p?=?0.32), overall morbidity (39 versus 69?%, p?=?0.051), reoperation rates (8 versus 0?%, p?=?0.5), postoperative return of bowel function (3.5?±?1.4 versus 3.9?±?1.7?days, p?=?0.3), mean length of hospital stay (6.4?±?6.2 versus 6.9?±?3.5?days, p?=?0.12), and readmission rates (8 versus 12?%, p?=?0.64). Wound infection rate was decreased after laparoscopic surgery (0 versus 27?%, p?=?0.01).

Conclusions

Surgery for recurrent Crohn??s disease in patients with previous primary resection through laparotomy can be frequently and safely completed laparoscopically. Wound infection rates are reduced, but the recovery advantages of a minimally invasive approach are not maintained when compared with open surgery. The decision to operate laparoscopically should therefore be carefully calibrated.     

Proximal femoral fractures: Principles of management and review of literature

PurposeThe purpose of this study was to review the principles involved in the management of proximal femoral fractures as reported in the literature. Methods: A medical literature search in the MEDLINE (PubMed) and Cochrane database was undertaken to review strategies and principles in proximal femoral fracture treatment. Randomized control trials and meta analysis were given preference while case reports/small series were rejected. Results and conclusions: Early anatomical reduction and surgical fixation remains the best option to reduce the risk of complications like non-union and avascular necrosis in treating fracture neck femurs. Cancellous screws continue to be the preferred treatment for fixation of neck femur fractures in younger population until the benefit of using sliding hip screws is validated by large multicentric studies. In the geriatric age group, early prosthetic replacement brings down the mortality and morbidity associated with neck femur fractures. Sliding hip screw (DHS) is the best available option for stable inter trochanteric fractures. The use of intramedullary nails e.g. PFN is beneficial in treating inter trochanteric fractures with comminution and loss of lateral buttress. Intramedullary implants have been proven to have increased success rates in subtrochanteric fractures and should be preferred over extramedullary plate fixation systems.     

Bioavailable vitamin D is more tightly linked to mineral metabolism than total vitamin D in incident hemodialysis patients

Prior studies showed conflicting results regarding the association between 25-hydroxyvitamin D (25(OH)D) levels and mineral metabolism in end-stage renal disease. In order to determine whether the bioavailable vitamin D (that fraction not bound to vitamin D-binding protein) associates more strongly with measures of mineral metabolism than total levels, we identified 94 patients with previously measured 25(OH)D and 1,25-dihydroxyvitamin D (1,25(OH)(2)D) from a cohort of incident hemodialysis patients. Vitamin D-binding protein was measured from stored serum samples. Bioavailable 25(OH)D and 1,25(OH)(2)D were determined using previously validated formulae. Associations with demographic factors and measures of mineral metabolism were examined. When compared with whites, black patients had lower levels of total, but not bioavailable, 25(OH)D. Bioavailable, but not total, 25(OH)D and 1,25(OH)(2)D were each significantly correlated with serum calcium. In univariate and multivariate regression analysis, only bioavailable 25(OH)D was significantly associated with parathyroid hormone levels. Hence, bioavailable vitamin D levels are better correlated with measures of mineral metabolism than total levels in patients on hemodialysis.     

Is Adjuvant Chemotherapy Really Needed After Curative Surgery for Rectal Cancer Patients Who are Node-Negative After Neoadjuvant Chemoradiotherapy?

Purpose  

Adjuvant chemotherapy is currently offered, as standard, after curative resection for patients with rectal cancer who receive neoadjuvant chemoradiation (NCRT). We postulate that adjuvant chemotherapy adds minimal oncologic benefit for patients who undergo total mesorectal excision who are node-negative after neoadjuvant chemoradiation.