Periadventitial dissection of the superior mesenteric artery for locally advanced pancreatic cancer: Surgical planning with the “halo sign” and “string sign”

Most patients diagnosed with pancreatic cancer are classified as nonoperative candidates based on the contemporary guidelines of resectability. The advent of more potent control of systemic disease using neoadjuvant chemotherapy has enabled more aggressive operative interventions. In our multidisciplinary practice, patients with Stage III, locally advanced pancreatic cancer and superior mesenteric artery (SMA) encasement are now carefully triaged with high quality, preoperative imaging to determine if they can be considered candidates for operative resection with periadventitial dissection of the SMA. Patients displaying a “halo sign,” where the encased SMA remains fully patent and free from arterial invasion, are now candidates for SMA periadventitial dissection. This procedure involves the surgical stripping of the infiltrated neurolymphatic tissue off the SMA leaving behind a bare “skeletonized artery.” Alternatively, the “string sign” involving the SMA confers a more likely case of arterial invasion, where a complete oncologic resection cannot be achieved successfully. This method of patient selection in case of SMA involvement abandons the traditional metrics of circumferential degrees of the arterial encasement to guide surgical decisions. Our institutional approach has allowed us to meaningfully expand our operative methods of resection with the potential for improved longitudinal outcomes to pancreatic cancer patients who were deprived historically from the more effective and possibly curative treatment.     

Management of acute gastroenteritis in children

Acute gastroenteritis is a common and costly clinical problem in children. It is a largely self-limited disease with many etiologies. The evaluation of the child with acute gastroenteritis requires a careful history and a complete physical examination to uncover other illnesses with similar presentations. Minimal laboratory testing is generally required. Treatment is primarily supportive and is directed at preventing or treating dehydration. When possible, an age-appropriate diet and fluids should be continued. Oral rehydration therapy using a commercial pediatric oral rehydration solution is the preferred approach to mild or moderate dehydration. The traditional approach using "clear liquids" is inadequate. Severe dehydration requires the prompt restoration of intravascular volume through the intravenous administration of fluids followed by oral rehydration therapy. When rehydration is achieved, an age-appropriate diet should be promptly resumed. Antiemetic and antidiarrheal medications are generally not indicated and may contribute to complications. The use of antibiotics remains controversial.     

Thirteen novel mutations of the replicated region of PKD1 in an Asian population

BACKGROUND: Mutations of PKD1 are thought to account for approximately 85% of all mutations in autosomal dominant polycystic kidney disease (ADPKD). The search for PKD1 mutations has been hindered by both its large size and complicated genomic structure. To date, few mutations that affect the replicated segment of PKD1 have been described, and virtually all have been reported in Caucasian patients. METHODS: In the present study, we have used a long-range polymerase chain reaction (PCR)-based strategy previously developed by our laboratory to analyze exons in the replicated region of PKD1 in a population of 41 unrelated Thai and 6 unrelated Korean families with ADPKD. We have amplified approximately 3.5 and approximately 5 kb PKD1 gene-specific fragments (5'MR and 5'LR) containing exons 13 to 15 and 15 to 21 and performed single-stand conformation analysis (SSCA) on nested PCR products. RESULTS: Nine novel pathogenic mutations were detected, including six nonsense and three frameshift mutations. One of the deletions was shown to be a de novo mutation. Four potentially pathogenic variants, including one 3 bp insertion and three missense mutations, were also discovered. Two of the nonconservative amino acid substitutions were predicted to disrupt the three-dimensional structure of the PKD repeats. In addition, six polymorphisms, including two missense and four silent nucleotide substitutions, were identified. Approximately 25% of both the pathogenic and normal variants were found to be present in at least one of the homologous loci. CONCLUSION: To our knowledge, this is the first report of mutation analysis of the replicated region of PKD1 in a non-Caucasian population. The methods used in this study are widely applicable and can be used to characterize PKD1 in a number of ethnic groups using DNA samples prepared using standard techniques. Our data suggest that gene conversion may play a significant role in producing variability of the PKD1 sequence in this population. The identification of additional mutations will help guide the study of polycystin-1 and better help us to understand the pathophysiology of this common disease.     

Impact of Margin Status on Survival in Patients with Pancreatic Ductal Adenocarcinoma Receiving Neoadjuvant Chemotherapy

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Decreasing Caregivers' Positive Attitudes Toward Spanking

The Play Nicely program is a multimedia training program designed to teach caregivers and health care professionals how to manage early childhood aggression and to use positive parenting practices. The aim of this article is to help the practicing clinician determine whether the Play Nicely program should be incorporated into his/her practice and to evaluate whether the program is effective at decreasing positive attitudes toward spanking in a socioeconomically disadvantaged population in both a resident pediatric clinic and a community center. Thirty-three caregivers of children aged 2 to 5 years viewed the Play Nicely program and completed pre- and post-training questionnaires. Decreased positive attitudes toward spanking were reported after training. Favorable attitudes toward spanking were associated with increased use of harsher discipline and higher child externalizing behavior. This study provides support that this brief intervention is effective in a socioeconomically disadvantaged population, is portable, and can be used in a group setting. This program may serve as a prevention and population-based approach to addressing the adverse childhood experience of spanking.     

Lateral releases of the subscapularis tendon

The technique of arthroscopic subscapularis repair continues to evolve. A three-sided subscapularis release (e.g. anterior, posterior, superior) is commonly advocated for improving tendon excursion to bone. However, a lateral release is commonly required as well, particularly for full thickness, upper subscapularis tears and full thickness, complete subscapularis tears. We describe the techniques to identify and release the lateral subscapularis border, which aids in the completion of other releases.