Comparative Experience of Open and Minimally Invasive Esophagogastric Resection

Background  A minimally invasive approach to esophagogastric cancer resection offers an attractive alternative to traditional open surgery; however, concerns regarding feasibility, safety, cost, and outcomes have restricted widespread acceptance of these procedures. This study outlines our comparative experiences of both open and minimally invasive esophagectomy over a 4-year period. Methods  Surgical outcomes were analyzed and compared between 30 consecutive patients who underwent open (Ivor Lewis) transthoracic esophagectomy (TTO) between January 2002 and December 2003 and 50 consecutive patients who underwent minimally invasive esophagectomy (MIO) from January 2004 to July 2006. Results  Inpatient mortality and overall surgical morbidity were identical for each cohort (TTO versus MIO: mortality 3% versus 2%; morbidity 50% versus 48%). Pulmonary-related complications were higher in the open series (23% versus 8%; p = 0.05). The incidence of gastric-conduit-related complications was similar between the two cohorts (13% versus 18%; p = 0.52). Survival at 1 and 2 years was 86% and 58% in the TTO group and 94% and 74% in the MIO group. No significant difference in calculated cost was observed (￡7,017 versus ￡7,885). Conclusions  Transition from open to minimally invasive techniques of esophagogastric resection for cancer is possible without compromising patient safety or incurring excessive financial expenses, and the minimally invasive procedure results in similar or potentially better outcomes.     

Criteria for management of calcific metamorphosis: review with a case report.

Calcific metamorphosis is seen commonly in the dental pulp after traumatic tooth injuries and is characterized by deposition of hard tissue within the root canal space. Opinion differs among practitioners as to whether to treat these cases upon early detection of calcific metamorphosis or to observe them until symptoms or radiographic signs of pulpal necrosis are detected. In this article, the clinical, radiographic, and histopathologic appearance of calcific metamorphosis is described; a review of the literature is presented to address these issues in an attempt to establish sound rationale for treatment. Approximately 3.8% to 24% of traumatized teeth develop varying degrees of calcific metamorphosis. Studies indicate that of these, approximately 1% to 16% will develop pulpal necrosis. Most of the literature does not support endodontic intervention unless periradicular pathoses is detected or the involved tooth becomes syptomatic. It may be advisable to manage cases demonstrating calcific metamorphosis through observation and periodic examination. A report of a case where in non-surgical endodontic intervention was successfully carried out a patient suffering from calcific metamorphosis with periapical pathoses is also presented.     

A prospective study of urinary electrolytes and bone turnover in adolescent males

BACKGROUND & AIMS: The role of excessive salt on bone metabolism in children is uncertain. The aim of this 6-week prospective study was to describe the association between urinary electrolytes and bone turnover markers in a convenience sample of adolescent boys (N = 136, mean age 16 yr). METHODS: Urinary electrolytes (sodium, potassium, calcium and magnesium) were assessed on spot overnight urines on three occasions to minimise regression dilution bias. Bone turnover was assessed by bone specific alkaline phosphatase (BAP) and urinary pyridinoline (PYR) at baseline and follow up. RESULTS: In multivariate analysis, urinary sodium (but not other electrolytes) was positively associated with both PYR and BAP both before and after taking short-term growth into account (both p < 0.05) and explained 3-6% of the variation in bone turnover markers. Urinary sodium was associated with urinary magnesium (r = +0.26, p < 0.05) but only weakly with calcium (r = +0.18, p = 0.08). Urinary potassium was significantly associated with urinary magnesium (r = -0.24, p < 0.05). CONCLUSION: High urinary sodium (which largely reflects dietary sodium intake in our location) results in a high bone turnover state in adolescent boys which is most likely detrimental for bone. Other urinary electrolytes are not related to bone turnover but may influence bone via other pathways.     

Airway hyperresponsiveness and calcium handling by smooth muscle: a "deeper look"

We propose that abnormal calcium handling by the airway smooth muscle may be an important determinant of airway hyperresponsiveness. The amplitude, frequency, or localization of Ca(2+) oscillations in the smooth muscle may determine the degree of airway sensitivity and reactivity, which are characteristic features of asthma.     

p19ARF is a critical mediator of both cellular senescence and an innate immune response associated with MYC inactivation in mouse model of acute leukemia

MYC-induced T-ALL exhibit oncogene addiction. Addiction to MYC is a consequence of both cell-autonomous mechanisms, such as proliferative arrest, cellular senescence, and apoptosis, as well as non-cell autonomous mechanisms, such as shutdown of angiogenesis, and recruitment of immune effectors. Here, we show, using transgenic mouse models of MYC-induced T-ALL, that the loss of either p19ARF or p53 abrogates the ability of MYC inactivation to induce sustained tumor regression. Loss of p53 or p19ARF, influenced the ability of MYC inactivation to elicit the shutdown of angiogenesis; however the loss of p19ARF, but not p53, impeded cellular senescence, as measured by SA-beta-galactosidase staining, increased expression of p16INK4A, and specific histone modifications. Moreover, comparative gene expression analysis suggested that a multitude of genes involved in the innate immune response were expressed in p19ARF wild-type, but not null, tumors upon MYC inactivation. Indeed, the loss of p19ARF, but not p53, impeded the in situ recruitment of macrophages to the tumor microenvironment. Finally, p19ARF null-associated gene signature prognosticated relapse-free survival in human patients with ALL. Therefore, p19ARF appears to be important to regulating cellular senescence and innate immune response that may contribute to the therapeutic response of ALL.     

Sinus node dysfunction in acute myocardial infarction.

The frequency, clinical course, and prognosis of sinus node dysfunction in 431 patients with acute myocardial infarction admitted to the coronary care unit were studied. Sinus node dysfunction occurred in 20 patients. In 13, the principal manifestation consisted of severe sinus bradycardia. In the remaining 7, periods of bradycardia alternating with episodes of supraventricular tachycardia were noted. Though several of the patients with sinus bradycardia required intravenous atropine or temporary pacing, normal sinus rhythm returned in virtually all during follow-up. The clinical course of patients with both bradycardia and tachycardia was less benign, during the acute phase and during follow-up; 5 of the 6 survivors required continued antiarrhythmic therapy or permanent pacing. The differences in the clinical course between these two groups of patients may reflect distinct underlying pathological changes. The findings in this study suggest that in contrast to sinus bradycardia, the occurrence of bradycardia-tachycardia syndrome during the acute phase of myocardial infarction may have important prognostic implications.     

Variability in computed tomography diameter measurements of solid renal masses

Purpose

To determine whether the frequency of intra-observer measurement discrepancies ≥5 mm for solid renal masses varies by renal mass characteristics and CT contrast phase.

Materials and methods

This HIPAA-compliant retrospective study was approved by our IRB. We selected single CT images performed during the nephrographic phase (NP) of renal enhancement in 97 patients, each with a single solid renal mass. Mass location, margin, heterogeneity, and growth pattern were assessed. Six readers measured each mass on two occasions >3 weeks apart. Readers also measured the masses on images in 50 patients who had corticomedullary phase (CMP) images obtained during the same study. Results were assessed using Chi-square/Fisher’s exact and Wilcoxon Signed Rank tests, and logistic regression analyses.

Results

For NP to NP comparisons, intra-reader measurement differences ≥5 mm were seen for 3.7% (17/463) of masses <4 cm, but increased to 16.8% (20/119) for masses >4 cm (p < 0.0001). Masses with poorly defined margins (15.9% [22/138] vs. 3.4% [15/444] for well-defined margins, p < 0.0001) and heterogeneity (15.3% [22/144], vs. 5.0% [14/282] for minimally heterogeneous, vs. 0.6% [1/156] for homogeneous, p < 0.0001), were more frequently associated with measurement differences ≥5 mm. Differences ≥5 mm were more frequent when only CMP images were utilized (14% [42/299]), or when CMP images were compared with NP images (26% [77/299]).

Conclusions

A ≥5 mm intra-reader variation in measured size of solid renal masses <4 cm is uncommon for NP to NP comparisons. Variation increases when masses are ≥4 cm, poorly defined, or heterogeneous; or when CMP images are utilized.