Descending necrotizing mediastinitis: treatment by transcervical thoracic drainage

We report the case of a 29-year-old man with descending necrotizing mediastinitis and subcarinal spread secondary to oropharyngeal infection. The thoracic infection was treated by placement of a transcervical thoracic drain, which was removed 15 days after surgery. The outcome was satisfactory and no further invasive treatment was required. We believe that transcervical thoracic drainage is a useful initial treatment for descending necrotizing mediastinitis with subcarinal spread but no pleural cavity involvement.     

Bringing good teaching cases "to life": a simulator-based medical education service.

Realistic medical simulation has expanded worldwide over the last decade. Such technology is playing an increasing role in medical education not merely because simulator sessions are enjoyable, but because they can provide an enhanced environment for experiential learning and reflective thought. High-fidelity patient simulators allow students of all levels to "practice" medicine without risk, providing a natural framework for the integration of basic and clinical science in a safe environment. Often described as "flight simulation for doctors," the rationale, utility, and range of medical simulations have been described elsewhere, yet the challenges of integrating this technology into the medical school curriculum have received little attention. The authors report how Harvard Medical School established an on-campus simulator program for students in 2001, building on the work of the Center for Medical Simulation in Boston. As an overarching structure for the process, faculty and residents developed a simulator-based "medical education service"-like any other medical teaching service, but designed exclusively to help students learn on the simulator alongside a clinician-mentor, on demand. Initial evaluations among both preclinical and clinical students suggest that simulation is highly accepted and increasingly demanded. For some learners, simulation may allow complex information to be understood and retained more efficiently than can occur with traditional methods. Moreover, the process outlined here suggests that simulation can be integrated into existing curricula of almost any medical school or teaching hospital in an efficient and cost-effective manner.     

Combined thoracotomy and laminectomy for spinal cavernomas with intrathoracic growth

Dumbbell shaped epidural cavernomas are uncommon lesions. Of these, the extraforaminal extension is usually limited, and the lesions are removed surgically by an extended laminectomy. We present two cases of dumbbell shaped epidural cavernomas with a considerable intrathoracic growth. They were resected through a combined thoracotomy and laminectomy. Only in the case in which a wide approach to the posterior mediastinum was performed it was possible to completely remove the lesion. Since it is possible to anticipate this histological diagnosis by the magnetic resonance imaging characteristics, we propose that a wide transthoracic approach should be performed associated to a laminectomy if a complete resection of the lesion is the goal.     

Fractional protein synthesis rates measured by an intraperitoneal injection of a flooding dose of L-[ring-2H5]phenylalanine in pigs

Our objectives were to examine the effect of an i.p. injection of a flooding dose of l-phenylalanine (Phe) containing l-[ring-(2)H(5)]Phe on time courses of physiologic responses, the tracer Phe enrichments, and fractional protein synthesis rates (FSR) in plasma, visceral organs, and muscles. In a randomized complete block design, 5 blocks of 5 littermate piglets were weaned at 16 d of age and injected i.p. with a flooding dose of l-Phe (1.5 mmol/kg body weight) on d 8 postweaning under fed conditions. Tissues were collected at 15, 30, 45, 60, and 75 min postinjection. Plasma glucose concentration increased (cubic effect, P < 0.05) from 4.8 preinjection to 5.8 mmol/L 15 min postinjection and returned to preinjection levels thereafter. Plasma insulin concentration did not change (P > 0.05) over time. Plasma Phe concentration increased logarithmically (P < 0.05) from 85 to 711 micromol/L and reached 95% of the maximum concentration 48 min postinjection, but no changes (P > 0.05) in tissue contents of other free amino acids were observed. The Phe free pools in plasma, visceral organs, and muscles were evenly enriched (32.3 +/- 1.4 mol%) with l-[(2)H(5)]Phe 15 min after the i.p. injection. The FSR in visceral organs did not change (P > 0.05), whereas plasma and muscle protein FSR decreased (P < 0.05) over time. We conclude that the i.p. injected tracer Phe rapidly distributed into plasma and intra- and extracellular spaces, and was effective for measuring FSR in visceral organs, but not in plasma and muscles of pigs.     

Older parent caregivers' engagement with the service system

Older parents of adults with intellectual disability are reported to be frequently isolated from the services designed to support their caregiving. The interaction between older parent caregivers' biographies and their involvement with the service system was examined. Parental status was predicted to be an explanatory mechanism for understanding the differential nature of their engagement with services. Analysis of interviews with 64 such caregivers of adults with intellectual disability revealed that their perceptions of their parental status were derived from a complex interaction of their values and beliefs, actions in relation to their adult child, constraints as well as resources available to them, and their relationships with service agencies. Implications for service delivery and directions for research are discussed.     

Head and neck tumors other than squamous cell carcinoma

PURPOSE OF REVIEW: This review deals with classification and treatment of some rare nonsquamous cell carcinomas of the head and neck. RECENT FINDINGS: Paranasal sinus tumor classification is under evaluation. Contrary to the past, the recent tendency is to build stage classifications on prognostic factors that mainly reflect limitations for adequate surgery, and not simply on dimensional criteria, which are more frequently used in TNM. Among sinonasal tract tumors new pathologic entities have been described. So far, little is known about their natural history and about the need to use pathologic classification to differentiate treatment. Recent advances in radiotherapeutic techniques, such as intensity-modulated radiotherapy, will probably have an impact on future treatment of paranasal sinus tumors. Several molecular targets (c-kit, HER-2/neu, androgen receptors) have been identified in salivary gland cancer. It is interesting to note that among different histotypes there is a trend toward a consistent expression of specific markers in specific cancers, suggesting a possible implication of them in the disease histogenesis. Not surprisingly these findings prompted clinical research with molecular targeted drugs. SUMMARY: Nonsquamous cell carcinomas of the head and neck are rare neoplasms. A multidisciplinary team treatment plan is needed, in particular for skull base-located tumors. Salivary gland cancer displays several molecular targets that need to be investigated further.     

Increased expression of the cyclin-dependent kinase inhibitor p27 in cleavage-stage human embryos exhibiting developmental arrest

It is accepted that approximately 50% of embryos obtained after IVF arrest during the first week. Traditionally, chromosome abnormality and suboptimal culture conditions have been proposed as factors commonly associated with embryo arrest. However, even when considering 'ideal' conditions and embryos of only excellent morphology in vitro, there is still a significant incidence of embryonic arrest. There is considerable evidence that the nuclear protein p27, a member of the Cip/Kip family of CDK inhibitors, plays an important role in multiple fundamental cellular processes, including cell proliferation, cell differentiation, and apoptosis. The present investigation, using immunocytochemical techniques coupled with confocal microscopy, was undertaken to determine whether p27 could play a role in the arrest of 4-8-cell human embryos. A total of 28 preimplantation embryos at the 4-8-cell stage were investigated. Of these, 16 were diploid embryos showing cleavage arrest with no further progression, and 12 were normally developing embryos. There was a 2-fold increased expression of the cell-cycle inhibitor p27 in arrested embryos compared with control normally developing embryos. This study represents the first demonstration of an increased expression of p27 in cleavage-stage human arrested embryos.