Safety and Efficacy of Low-Profile Balloons in Native Coarctation and Recoarctation Balloon Angioplasty for Infants

Background Traditionally, high-profile/high-pressure balloons have been used for angioplasties, whereas low-profile/low-pressure balloons have been used for valvuloplasties. High-profile balloons require larger introducing sheaths, which can be a limiting factor for percutaneous catheter interventions in infants. This report aims to report the author’s experience with the efficacy of low-profile balloons using smaller introducing sheaths for coarctation balloon angioplasty in infants. Methods From April 2004 to April 2008, 15 infants, representing both native coarctation and recoarctation indications, underwent coarctation balloon angioplasty and were retrospectively reviewed. The arterial access was achieved using 4-Fr (Cook) introducing sheaths and Tyshak (NuMED, Hallenweg-Netherlands) balloons 5 to 8 mm in diameter for coarctation angioplasty in the study group. Results In this study, 15 infants (7 with native coarctation and 8 with postoperative recoarctation) underwent balloon angioplasty. These infants ranged in age from 2 to 9 months (median, 4 months) and in weight from 3.5 to 10.8 kg (median, 5.7 kg). The peak-to-peak coarctation gradient was reduced from 46.2 ± 28 mmHg before angioplasty to 10 ± 8 mmHg afterward (p = 0.001). The angiographic diameter of the coarctation segment was increased from 2.4 ± 1.0 mm before angioplasty to 5 ± 0.8 mm afterward (p = 0.001). There were no immediate major or minor complications. During a follow-up period up to 48 months, only one patient from the native coarctation group experienced recoarctation and underwent successful reballooning, and none of the patients experienced aneurysms. Conclusion This study shows that the use of low-profile/low-pressure balloons is an effective treatment for infants. Furthermore, low-profile balloons required smaller introducing sheaths, which provides a clear advantage of minimizing vascular complications with coarctation ballooning in younger infants.     

Wnt Signaling: A Potential Therapeutic Target in Head and Neck Squamous Cell Carcinoma

Cellular maintenance and development are two fundamental mechanisms regulated by the canonical Wnt signalingpathway. Wnt/beta-catenin signaling pathway controls a myriad of cellular processes that are essential for normal cellfunctioning. Cell cycle progression, differentiation, fate determination, and migration are generally orchestrated bycanonical Wnt signaling. Altered Wnt/beta-catenin signaling has been considered a promoting event for different typesof cancers and the oncogenic potential of Wnt signaling have been discussed in many cancer types, including breast,colon, pancreatic as well as head and neck. Furthermore, Wnt signaling is critical for the maintenance and stemnessof both the normal as well as cancer stem cells. This review sheds new light on Wnt signaling and explains how it canregulate normal physiological processes and curtail the development of cancer. It depicts the vital functions of Wntsignaling in the stem cell growth and differentiation by focusing on current druggable targets that have been ascribedby recent studies. Thus, Wnt signaling pathway retains a tremendous potential in eradicating head and neck squamouscell carcinoma.     

Anesthesia in per-oral endoscopic myotomy: A large tertiary care centre experience

Background and Objectives

Per-oral endoscopic myotomy (POEM) is safe and efficacious for the management of achalasia cardia (AC). POEM is usually performed under general anesthesia in an endoscopy suite or operating theatre. The current study was conducted with the aim to analyse anesthetic management of patients with AC who underwent POEM at our institution.

Methods

We retrospectively analysed the data of patients with AC who underwent POEM at our institution from January 2013 to September 2016. All cases were performed in an endoscopy suite under supervision of an anesthesia management team. Pre-procedure endoscopic evacuation of esophagogastric contents was done in all cases. Management strategies used for gas-related adverse events and outcomes were assessed.

Results

Four hundred and eighty patients (median age 40 years, range 4–77 years) underwent POEM during the study period. The sub-types of AC were type I (163), type II (297), and type III (20). POEM was successfully completed in 97.5% patients. Gas-related events were noted in 30.6% cases including-capno-thorax in 1%, capno-peritoneum in 12.3%, retroperitoneal air in 16.5%, capno-mediastinum in 0.2%, and capno-pericardium in 0.4% patients. Significant rise in end tidal CO2 (> 45) and peak airway pressure were observed in 8.1% and 5.4% cases, respectively. Drainage was required in 12.3% patients. There was no occurrence of aspiration during or after POEM.

Conclusions

POEM could be safely performed in an endoscopy suite under supervision of an expert anesthesia management team. Gas-related adverse events were common during POEM and could be managed with a standardized approach.

     

Establishing a cardiac imaging rotation in radiology residency

RATIONALE AND OBJECTIVE: The advent of new technologies for cardiac imaging such as magnetic resonance imaging (MRI) and cardiac computed tomography (CT) have added new tools in the armamentarium of noninvasive methods for predicting cardiac disease. However, training in cardiac anatomy and physiology is critical if radiology is to meet the demands of this service. MATERIALS AND METHODS: We designed a core rotation in cardiac imaging at the Beth Israel Deaconess Medical Center, Harvard Medical School, to train residents in noninvasive cardiac imaging methods, such as cardiac echocardiography, nuclear cardiac imaging, cardiac MRI, and with special emphasis on cardiac CT. RESULTS: This 1-month block includes cardiac imaging conferences and a lecture series, hands-on training in the use of imaging software, introduction to cardiac catheterization, and clinical cardiology. Residents are provided with a set of research and review articles along with textbooks on coronary imaging to serve as references for this rotation. CONCLUSION: We believe that this educational exercise will establish a core of young, knowledgeable, and capable physicians who will be able to meet the clinical demand for noninvasive cardiac imaging and maintain a major role in this emerging specialty.     

Clinical outcome and memory function with maintenance electroconvulsive therapy: a retrospective study

Although maintenance electroconvulsive therapy (ECT) appears to be the logical choice for the prevention of relapses and recurrences in patients with refractory depression who have responded to a course of ECT, the perception of ECT's negative effect on memory continues to limit its wider use. This retrospective study of depressed patients maintained on ECT after an initial course revealed that maintenance ECT was effective in sustaining clinical improvement, particularly in patients who showed a satisfactory clinical response to the initial course of ECT, and that memory difficulties were limited and tolerable.     

Minimal main pancreatic duct dilatation in small branch duct intraductal papillary mucinous neoplasms associated with high-grade dysplasia or invasive carcinoma

BackgroundThe aim of this study was to determine the incidence of high-grade dysplasia (HGD) or invasive carcinoma in patients with small branch duct intraductal papillary mucinous neoplasms (BD-IPMNs).Methods923 patients who underwent surgical resection for an IPMN were identified. Sendai-negative patients were identified as those without history of pancreatitis or jaundice, main pancreatic duct size (MPD) <5 mm, cyst size <3 cm, no mural nodules, negative cyst fluid cytology for adenocarcinoma, or serum carbohydrate antigen 19-9 (CA 19-9) <37 U/L.ResultsBD-IPMN was identified in 388 (46.4%) patients and 89 (22.9%) were categorized as Sendai-negative. Overall, 68 (17.5%) of BD-IPMN had HGD and 62 (16.0%) had an associated invasive-carcinoma. Among the 89 Sendai-negative patients, 12 (13.5%) had IPMNs with HGD and only one patient (1.1%) had invasive-carcinoma. Of note, older age (OR 1.13, 95% CI 1.03–1.23; P = 0.008) and minimal dilation of MPD (OR 11.3, 95% CI 2.40–53.65; P = 0.002) were associated with high-risk disease in Sendai-negative patients after multivariable risk adjustment.ConclusionThe risk of harboring a high-risk disease remains low in small BD-IPMNs. However, Sendai-negative patients who are older than 65 years old and those with minimal dilation of MPD (3–5 mm) are at greater risk of high-risk lesions and should be given consideration to be included as a “worrisome feature” in a future guidelines update.