Congenital stenosis of the esophagus due to tracheobronchial remnants: a missed diagnosis

Lower esophageal strictures in infants in more than 90% of cases are related to reflux esophagitis, while the remainder are congenital or induced by injuries such as penetrating trauma or corrosion by caustic agents. Among congenital disorders cartilaginous remnants in the esophagus are very rare, but it is a possibility that should always be considered, especially if signs of esophagitis are not seen on esophagoscopy. The first aim, when evaluating the vomiting or regurgitating infant, is to establish whether this is due to an organic disorder. When stricture of the esophagus becomes evident following prolonged vomiting, clinicians tend to attribute this to reflux with peptic injury, and in most of the cases that will be correct (1). Carefully performed investigation will bring forth those rare etiologic factors that can be easily overlooked (2). The investigation has to include radiographic studies, esophagoscopy, pH monitoring, and in selected cases, manometry. Recognition of the correct etiologic factor that caused the stricture will pave the way for adequate management. We report on two patients with congenital stenosis of the lower esophagus due to cartilaginous rings, one of which was diagnosed preoperatively.     

Attentional states and the degree of visual adaptation to gratings.

We studied top-down attentional effects on adaptation to two aspects of sinusoidal gratings: contrast (CTE: contrast threshold elevation for detection) and orientation (TAE: tilt aftereffect, bias in perceived orientation). Adaptation was examined under five different behavioral conditions designed to assess the effect of alertness, spatial attention and the dimension attended. Alertness increased CTE, but had no effect on TAE. Spatial attention increased TAE, but had no effect on CTE. TAE (but not CTE) was also sensitive to the attended dimension. It was greater when gratings' contrast rather than orientation was attended. The different patterns of top-down effects on CTE compared with TAE are consistent with these two types of adaptation taking place at different levels along the visual hierarchy: CTE occurs at very low-levels, where activity is affected by alertness but not by spatial attention, whereas TAE occurs at subsequent stages, which are modulated by selective attention.     

Crossing the Threshold

The very first moments of contact with a patient may provide a vital clue to the core dynamic of the therapeutic process.
Some analysts have stressed the importance of the first dream of an analysis. Others have focused on the first session as being seminal. In this paper I want to raise a few questions about what goes on in the very first moments of meeting a patient and its potential implications for the subsequent work. I shall try to differentiate the nature of what occurs and suggest that such differentiations might contribute to assessment, particularly where the initial interview is also the first session with the same therapist.     

The isolated bowel segment: angiographic visualization of the developing vascularity

An isolated bowel segment (IBS) is created by a two-stage procedure: (1) initial coaptation of the bowel segment to host organs such as abdominal wall muscle, liver, or intestine; and (2) division of its mesentery several weeks later. Between operations, vascular collaterals develop across the coaptation to preserve viability of the IBS. IBS motility and absorption have been observed in previous studies; this experimental study was designed to angio-graphically observe the vascular collaterals. An IBS was created in four dogs by myoenteropexy between the undersurface of the rectus abdominis muscle and a segment of jejunum or colon. Both IBS ends were exteriorized and intestinal continuity was restored. Four weeks later, the IBS mesentery was divided in three dogs and a sham operation was performed in the fourth. Three weeks thereafter, the animals were killed and appropriate arteries related to the IBS were injected with Microfil radiopaque silicone yellow rubber compound at a pressure of 150 mmHg. After the dye had polymerized, soft tissue X-ray was employed to identify vascular collaterals to the IBS. With ipsilateral deep inferior epigastric artery injection in the dogs with IBS mesentery division, the intramural vessels of the IBS filled via collaterals over the myoenteropexy. Dye injected into the IBS mesenteric artery in the fourth dog outlined the abdominal wall vessels via collaterals that had developed across the myoenteropexy. These observations suggest that the IBS is nourished by the abdominal wall vessels through vascular collaterals that have developed across the myoenteropexy during the interval between the staged procedures, and that viability of the IBS is preserved after IBS mesenteric division.     

Insertion of a soft silastic nasogastric tube at operation for esophageal atresia: a new technical method.

A new and simple technical method for insertion of a soft silastic nasogastric tube into the stomach in neonates born with esophageal atresia is described. The technique is simple, easy to perform, and enables feeding the baby through this tube a day after the operation. Our method is based on the principle used in insertion of Broviac-Hickman catheters, namely the use of a "peel-away sheath" through which the silastic feeding tube is threaded. We have used this technique in five patients with esophageal atresia without any complication.     

N-acetylcysteine attenuates NSAID-induced rat renal failure by restoring intrarenal prostaglandin synthesis.

BACKGROUND: Renal failure is a threatening side-effect of NSAID administration, consequent to NSAID-mediated abrogation of prostaglandin synthesis and resultant renal ischaemia. N-acetylcysteine (NAC) has renoprotective properties. We examined effects of NAC in a rat model of NSAID-induced renal failure. METHODS: Renal failure was generated in 80 rats by 6-day water deprivation and 3-day 15 mg/kg/day diclofenac injection. The rats were concomitantly treated, or not, by NAC, 40 mg/kg/day. Renal function was evaluated by cystatin C, creatinine and urea. Intrarenal blood flow was measured by laser Doppler. The kidneys were subjected to pathological examination or evaluation of intrarenal NO, H2O2 and PGE2. RESULTS: NAC significantly attenuated deterioration of renal function in diclofenac-treated rats: cystatin C dropped from 2.8+/-0.35 to 2.2+/-0.67 mg/l, P=0.016; creatinine from 1.2+/-0.97 to 0.96+/-0.19 mg/dl, P=0.02; urea from 208.4+/-57.9 to 157.6+/-33.7 mg/dl, P=0.028. Diclofenac-inflicted hystopathological damage was significantly reduced following NAC treatment. Intrarenal medullar blood flow dropped by 51+/-12.4% in diclofenac-treated rats, but only by 14+/-3.39% in those receiving NAC after diclofenac injection (P<0.001). H2O2 was elevated in renal tissues of diclofenac-receiving rats, while decreased in NAC-treated animals. PGE2 release by diclofenac-treated rats dropped significantly, but was restored after NAC administration both in renal cortices (144.7+/-10.4 vs 19.7+/-1.5 pmol/ml, P<0.001) and medullae (148.5+/-7.3 vs 66.6+/-7.3 pmol/ml, P<0.001). CONCLUSIONS: In this model of renal failure induced by NSAID administration combined with water deprivation, NAC treatment successfully attenuated the deterioration of renal function by inducing renal vasodilatation, decreasing oxidative stress via inhibition of intrarenal ROS content and restoration of intrarenal PGE2 release back to the basal levels.     

New Regression Formulas for Sonographic Weight Estimation Within 10, 7, and 3 Days of Delivery

Objectives. The purpose of this study was to develop new regression formulas based on large numbers of sonographic examinations performed within 10, 7, and 3 days of delivery. Methods. Sonographic fetal biometric measurements and delivery ward data for an unselected population were analyzed. Multivariate linear regression models were fitted to the sonographic data to predict the actual birth weight (BW) within 10, 7, and 3 days. Results. The analyses included 6289, 5449, and 4007 patients who underwent sonographic examinations within 10, 7, and 3 days of delivery, respectively. All models yielded very high correlation coefficients (r = 0.927–0.958; R² = 0.859–0.918), low mean deviations between the calculated and actual BWs (6.4%–6.6% ± 1 SD of 5.5%–5.9%), and high percentages of the calculated BW within 10% of the actual BW (78.5%–80.4%). Estimated fetal weight analyses made within 3 days of delivery yielded slightly better results than within 7 and 10 days. Conclusions. The new regression formulas yielded overall similar results, with a small advantage for estimates calculated within 3 days of delivery. Further prospective studies are needed to compare the accuracy of these formulas with those used to date.