Robotic telesurgery for achalasia

The craft of surgery has always relied on the use of instruments. Innovations in surgery have paralleled innovations in instrumentation. Advances in surgical instrumentation continue today and have enabled huge strides in surgical procedures and outcomes during this generation. Computers and related technology are now changing the interface between the surgeon and the patient, and are poised to improve patient outcomes by enhancing the surgeon’s skills and training. The application of computer enhanced telemanipulators, or “robots”, may specifically enhance operations, for example Heller myotomy, that require good visualization and precise careful dissection of delicate structures. This review covers the pathophysiology of achalasia and its history of medical and surgical treatment, leading to modern robotic telesurgical approaches. Improvements in outcome from medical to standard surgical to robotic telesurgical approaches are discussed. Current operative technique for robotic telesurgical treatment of achalasia is described and the authors conclude with a glimpse of where, in the future, current research endeavors will lead us in the treatment of achalasia.     

Role of five platelet membrane glycoprotein polymorphisms in branch retinal vein occlusion.

To determine whether polymorphisms of platelet surface glycoprotein associated with arterial thrombosis are risk factors for branch retinal vein occlusion. A case-control study in which 69 patients with branch retinal vein occlusion and 147 controls who attended the eye clinic for nonvascular complications participated. DNA was extracted from whole blood and analyzed for genotyping of platelet glycoprotein polymorphisms by polymerase chain reactions and specific restricted enzymes. No relationship was found between the four platelet glycoprotein polymorphisms i.e. GPIa C807T, VNTR and Kozak of glycoprotein Ibalpha, the HPA-1 of glycoprotein IIIa and the occurrence of branch retinal vein occlusion. The HPA-2 polymorphism was found in 18 out 60 (30%) patients with branch retinal vein occlusion in comparison with 27 out 142 (19%) of controls, with an estimated odds ratio of 1.8 (95% confidence interval, 0.91-3.65). The four platelet glycoprotein polymorphisms are not risk factors for branch retinal vein occlusion and therefore it seems unnecessary to screen those patients for it. A larger study is required, however, to determine whether HPA-2 is a novel risk factor for branch retinal vein occlusion.     

Enantioselective metabolism and cytotoxicity of R-ifosfamide and S-ifosfamide by tumor cell-expressed cytochromes P450.

The anticancer prodrug ifosfamide (IFA) contains a chiral phosphorous atom and is administered in the clinic as a racemic mixture of R-IFA and S-IFA. Hepatic cytochrome P450 (P450) enzymes exhibit enantioselective preferences in the metabolism of R-IFA and S-IFA; however, the impact of this selectivity on P450-dependent anticancer activity is not known. Presently, the metabolism and cytotoxicity of R-IFA and S-IFA were determined in 9L gliosarcoma and Chinese hamster ovary tumor cells expressing an IFA-activating P450 enzyme and by in vitro steady-state kinetic analysis using cDNA-expressed P450 enzymes. Tumor cells expressing P450 enzyme CYP3A4 were the most sensitive to R-IFA cytotoxicity, whereas tumor cells expressing CYP2B1 or CYP2B6 were most sensitive to cyclophosphamide (CPA), an isomer of IFA. Correspondingly, CYP3A4-expressing cells and cDNA-expressed CYP3A4 metabolized R-IFA to yield the active, 4-hydroxylated metabolite at a 2- to 3-fold higher rate than they metabolized S-IFA or CPA. CYP2B cells and cDNA-expressed CYP2B enzymes metabolized CPA almost exclusively by 4-hydroxylation, whereas R-IFA and S-IFA were substantially converted to inactive, N-dechloroethylated metabolites. Further investigation revealed that CYP3A1, a rat enzyme, exhibited superior kinetic properties compared with the human enzyme CYP3A4, with R-IFA and S-IFA both metabolized with high catalytic efficiency by 4-hydroxylation and with a K(m) value of 200 microM, approximately 5-fold lower than CYP3A4. Based on these kinetic parameters and metabolic profiles, R-IFA is expected to exert greater anticancer activity than S-IFA or CPA against tumors that express CYP3A enzymes, whereas tumors expressing CYP2B enzymes may be more sensitive to CPA treatment.     

Scar sign of renal oncocytoma: Magnetic resonance imaging appearance and lack of specificity

This case report illustrates the magnetic resonance imaging (MRI) appearance of a typically asymptomatic renal oncocytoma as a homogeneous mass of medium signal with a stellate central region of decreased signal, representing the central scar. The MRI was correlated with computed tomography (CT), ultrasound (US), and gross pathologic appearance. The appearance of a central scar is not specific for oncocytoma and does not exclude renal cell carcinoma, as illustrated by a second case.     

Educational interventions to reduce use of unsafe abbreviations.

PURPOSE: Educational interventions to reduce the use of abbreviations and dosage designations that were deemed unsafe at a level 1 trauma center are described. SUMMARY: Strategies to reduce the use of unsafe abbreviations at Detroit Receiving Hospital were studied. Six abbreviations and dosage designations were deemed as unsafe by the site's medication-use and patient medical safety committees: (1) U for units, (2) microg for microgram, (3) TIW for three times a week, (4) the degree symbol for hour, (5) trailing zeros after a decimal point, and (6) the lack of leading zeros before a decimal point. Data on abbreviation use was collected starting in September 2003 by examining copies of patients' order sheets, which are sent from nursing units to the pharmacy for processing. Data were collected during three 24-hour periods each month, with 7-10 days between each period. A data collection sheet was developed to assist in documenting the number of opportunities for each unsafe abbreviation and the actual incidence of each. Educational strategies were developed and implemented starting in October 2003 to decrease the use of the unsafe abbreviations. These strategies included inservice education programs for the medical, pharmacy, and nursing staffs; laminated pocket cards; patient chart dividers; stickers; and interventions by pharmacists and nurses during medication prescribing. During the eight-month evaluation period, 20,160 orders were reviewed, representing 27,663 opportunities to use a designated unsafe abbreviation. Educational interventions successfully reduced the overall incidence of unsafe abbreviations from 19.69% to 3.31%. CONCLUSION: Educational interventions markedly reduced the use of unsafe abbreviations in medication orders over an eight-month evaluation period.