ORIGINAL RESEARCH—SURGERY: Physician and Patient Satisfaction with the New AMS 700 Momentary Squeeze Inflatable Penile Prosthesis

IntroductionA single-armed, prospective, multicenter study evaluated the redesigned American Medical Systems (AMS) 700 Momentary Squeeze (MS) pump inflatable penile prosthesis (IPP) with enhanced features for ease of implantation and patient manipulation. The device incorporates design changes to all components: pump, cylinders, rear-tip extenders, and reservoir.AimTo assess physician and patient satisfaction with the new AMS 700 MS pump.MethodsPatients were selected from the existing population experiencing erectile dysfunction (ED) without previous prosthetic implantation.Main Outcome MeasuresSurvey questionnaires were used to capture physician feedback on ease of implantation and patient education. Patient satisfaction with the device and existence of autoinflation were assayed.ResultsSixty-nine patients were implanted at seven U.S. sites. Mean age was 60.1 ± 9.6 years. History of ED was >5 years in 34 (44.7%) patients. Main ED etiology was organic, nonspecific (32%). Eighty-four percent of the physicians felt proximal cylinder insertion was easier because of the smaller angle of cylinder input tubing and narrower base diameter. The new pump was felt easier to implant than the previous model by 57% of the physicians. The patients found the manipulation of the pump simple at device activation, with 96% easily locating the inflation bulb and 94% deflating the device with one push of the deflation button. Reviews were mixed among physicians concerning ease of training compared with the Tactile pump. Patient training was easier in 71%, harder in 21%, and same in 8%. Nevertheless, 67% of the patients were trained in 6 minutes or less. At 6 months, 77% of the patients were very satisfied, 9% somewhat satisfied, and 14% dissatisfied. Autoinflation occurred in two patients (3%).ConclusionThe new AMS 700 MS IPP seems a distinct improvement over previous devices with most physicians feeling implantation and patient instruction were easier. The device also satisfied 86% of the users and virtually eliminated autoinflation. Knoll LD, Henry G, Culkin D, Ohl DA, Otheguy J, Shabsigh R, Wilson SK, and Delk J II. Physician and patient satisfaction with the new AMS 700 Momentary Squeeze inflatable penile prosthesis. J Sex Med 2009;6:1773–1778.     

Complications of Scleral-Fixated Intraocular Lenses

ABSTRACT

Introduction: Understanding the evolution of complications after scleral-fixated lens placement demonstrates advantageous surgical techniques and suitable candidates. Materials/Methods: A literature search in PubMed for several terms, including “scleral intraocular lens complication,” yielded 17 relevant articles. Results: Reviewing complication trends over time, lens tilt and suture erosion have decreased, cystoid macular edema has increased, and retinal detachment has remained the same after scleral-fixated lens placement. The successful reduction in complications are attributed to several alterations in technique, including positioning sclerotomy sites 180 degrees apart and using scleral flaps or pockets to bury sutures. Possible reduction in retinal risks have been proposed by performing an anterior vitrectomy prior to lens placement in certain settings. Discussion: Complications after scleral-fixated lens placement should assist patient selection. Elderly patients with a history of hypertension should be counseled regarding risk of suprachoroidal hemorrhage, while young patients and postocular trauma patients should be considered for concurrent anterior vitrectomy.     

Topographical gradients of semantics and phonology revealed by temporal lobe stimulation

Word retrieval is a fundamental component of oral communication, and it is well established that this function is supported by left temporal cortex. Nevertheless, the specific temporal areas mediating word retrieval and the particular linguistic processes these regions support have not been well delineated. Toward this end, we analyzed over 1000 naming errors induced by left temporal cortical stimulation in epilepsy surgery patients. Errors were primarily semantic (lemon → “pear”), phonological (horn → “corn”), non‐responses, and delayed responses (correct responses after a delay), and each error type appeared predominantly in a specific region: semantic errors in mid‐middle temporal gyrus (TG), phonological errors and delayed responses in middle and posterior superior TG, and non‐responses in anterior inferior TG. To the extent that semantic errors, phonological errors and delayed responses reflect disruptions in different processes, our results imply topographical specialization of semantic and phonological processing. Specifically, results revealed an inferior‐to‐superior gradient, with more superior regions associated with phonological processing. Further, errors were increasingly semantically related to targets toward posterior temporal cortex. We speculate that detailed semantic input is needed to support phonological retrieval, and thus, the specificity of semantic input increases progressively toward posterior temporal regions implicated in phonological processing. Hum Brain Mapp 38:688–703, 2017. © 2016 Wiley Periodicals, Inc.     

Peri‐procedural risk stratification and management of patients with Williams syndrome

Williams syndrome (WS) is a congenital, multisystem disorder affecting the cardiovascular, connective tissue, and central nervous systems in 1 in 10 000 live births. Cardiovascular involvement is the most common cause of morbidity and mortality in patients with WS, and noninvasive and invasive procedures are common. Sudden cardiovascular collapse in patients with WS is a well‐known phenomenon, especially in the peri‐procedural period. Detailed guidelines for peri‐procedural management of patients with WS are limited. The goal of this review is to provide thoughtful, safe and effective management strategies for the peri‐procedural care of patients with WS with careful consideration of hemodynamic impacts of anesthetic strategies. In addition, an expanded risk stratification system for anesthetic administration is provided.     

Micafungin Concentrations from Brain Tissue and Pancreatic Pseudocyst Fluid

We report the attainment of micafungin concentrations from brain tissue and pancreatic pseudocyst fluid from two patients with invasive candidiasis. Micafungin was present in low levels at both body sites, indicating limited penetration into central nervous system (CNS) tissue and pancreatic fluid. Further studies are needed to fully characterize its pharmacokinetics at these locations, as micafungin may potentially serve as an alternative antifungal therapy for CNS or pancreatic candidal infections for which the currently recommended first-line therapy fails.Micafungin is an echinocandin widely used for the treatment of invasive candidiasis (2, 6, 7, 8, 10). Little information exists regarding its penetration into human brain tissue and pancreatic fluid. We report the measurement of micafungin levels from these sites in 2 patients during treatment of invasive candidiasis.     

Rap1b facilitates NK cell functions via IQGAP1-mediated signalosomes

Rap1 GTPases control immune synapse formation and signaling in lymphocytes. However, the precise molecular mechanism by which Rap1 regulates natural killer (NK) cell activation is not known. Using Rap1a or Rap1b knockout mice, we identify Rap1b as the major isoform in NK cells. Its absence significantly impaired LFA1 polarization, spreading, and microtubule organizing center (MTOC) formation in NK cells. Neither Rap1 isoform was essential for NK cytotoxicity. However, absence of Rap1b impaired NKG2D, Ly49D, and NCR1-mediated cytokine and chemokine production. Upon activation, Rap1b colocalized with the scaffolding protein IQGAP1. This interaction facilitated sequential phosphorylation of B-Raf, C-Raf, and ERK1/2 and helped IQGAP1 to form a large signalosome in the perinuclear region. These results reveal a previously unrecognized role for Rap1b in NK cell signaling and effector functions.The Ras-mediated Raf–MEK–ERK activation pathway controls many fundamental cellular processes. Rap1 belongs to the Ras superfamily, and their role in regulating NK cell development and functions is not understood. Rap1a and Rap1b isoforms are able to regulate cell proliferation, differentiation, adhesion, and polarization (Stork and Dillon, 2005). These two share >95% amino acid homology (Rousseau-Merck et al., 1990). Conversion of inactive Rap1-GDP to active Rap1-GTP is regulated by multiple guanine nucleotide exchange factors such as C3G, RasGRP/CalDAG-GEFs, and EPACs (Gotoh et al., 1995; de Rooij et al., 1998; Kawasaki et al., 1998). Rap1 signaling is terminated by GTPase-activating proteins (GAPs) such as SPA-1 and RapGAPs (Rubinfeld et al., 1991; Kurachi et al., 1997).Rap1 regulates diverse downstream effectors including B-Raf and C-Raf, whose phosphorylation depends on active Rap1-GTPase and play a critical role in the sequential activation of MEK1/2 and their substrates ERK1/2 (Jin et al., 2006; Romano et al., 2006). Recent studies have shown that scaffolding proteins such as IQGAP (1, 2, and 3), KSR1, MP1, or Paxillin can function as signal processing centers by bringing together GTPases, kinases, and their substrates (Sacks, 2006). IQGAP1 can bind to both Rap1a and Rap1b (Jeong et al., 2007). IQGAP1 is widely expressed in multiple tissues including lymphocytes. The N-terminal calponin homology domain of IQGAP1 binds to actin and the IQ domain recruits calmodulin (Joyal et al., 1997). The C-terminal end of IQGAP1 engages with Cdc42-GTP (Joyal et al., 1997), Rac1-GTP (Hart et al., 1996), E-cadherin (Kuroda et al., 1998), β-catenin (Li et al., 1999), and APC (Watanabe et al., 2004). IQGAP1 also has the ability to bind to B-Raf (Ren et al., 2007), MEK1/2 (Roy et al., 2005), and ERK1/2 (Roy et al., 2004). Irrespective of these findings, IQGAP1-mediated signalosome formation and its relevance in regulating lymphocyte functions have not been investigated.Recently, we generated Rap1a and Rap1b gene knockout mice (Chrzanowska-Wodnicka et al., 2005; Li et al., 2007). Here, we found that the lack of Rap1a or Rap1b did not alter the development or cytotoxicity of NK cells. However, LFA1 polarization, cell spreading of NK cells, and their ability to home and traffic were significantly reduced in the absence of Rap1b. Lack of Rap1b, but not Rap1a, resulted in severe impairment of NKG2D, Ly49D, and NCR1-mediated cytokine and chemokine generation. Upon activation, Rap1b associated with B-Raf or C-Raf and colocalized with IQGAP1 complex. The absence of Rap1b reduced B-Raf, C-Raf, and ERK1/2 phosphorylation in NK cells. Rap1b helped IQGAP1 to form a large signalosome in the perinuclear region to coordinate the phosphorylation of ERK1/2. Rap1b also colocalized with the MTOC and regulated its size and proper formation. These results reveal a previously unrecognized role of Rap1 in signalosome formation and regulation of effector functions in lymphocytes.     

Medical management of obstructive sleep apnea

The last 20 years have seen remarkable gains in our understanding of the pathophysiology of sleep-disordered breathing. The rapid growth in both scientific and clinical knowledge has been fueled by the development of nonsurgical therapies for obstructive sleep apnea (OSA). These medical therapies have provided the avenue for public acceptance of the diagnosis and treatment of this common medical condition. However, medical therapy requires active patient participation, to achieve the desired outcomes of improved sleep continuity, daytime functioning, and quality of life. Conservative therapies, such as weight loss and patient positioning; and pharmacological therapies, have been disappointing. Positive pressure therapy has become the treatment of choice for the vast majority of OSA patients. Oral appliances offer an acceptable treatment alternative for select patients. Present research indicates that these mechanical approaches can produce significant decreases in the frequency and severity of sleep-disordered breathing and nocturnal oxyhemoglobin desaturation. Preliminary data from ongoing studies suggest that these interventions will reduce long-term morbidity and possibly mortality.     

Adenovirus infections in hematopoietic stem cell transplant recipients.

We report a 12% incidence of adenovirus infections among 532 recipients of hematopoietic stem cell transplant (HSCT) from January 1986 through March 1997. The median time from day of stem cell infusion to first positive culture was 41 days. Recipients of allogeneic stem cells, as opposed to autologous stem cell recipients, were more likely to have a culture positive for adenovirus (16% vs. 3%; P<.0001). Pediatric patients were also more likely than adults to have a positive culture (23% vs. 9%; P<.0001). Among stem cell recipients with partially matched related donors, pediatric recipients appear to be at significantly greater risk for infection than adult recipients (P<.001). Positive cultures were associated with evidence of invasion in 64% of cases (41 of 64). A multiple logistic regression analysis showed that isolating adenovirus from more than 1 site correlated with greater risk for invasive infections (P=.002). Invasive infections were associated with poorer chance of survival.