A hybrid alternative for high risk left main disease.

Percutaneous revascularization strategies for bifurcation disease of the left main are complex and carry significant risk. These risks are magnified in the setting of a left main which trifurcates. In a patient with complex ostial disease of two of the three limbs of a left main trifurcation, turned down for conventional bypass surgery, we report on a hybrid approach for complete revascularization, consisting of minimally invasive bypass grafting of the LAD combined with simultaneous drug eluting stent placement.     

Evaluation of fully covered self-expanding metal stents in benign biliary strictures and bile leaks

AIM: To investigate the use of fully covered metal stents in benign biliary strictures (BBS) and bile leaks.METHODS: We studied 17 patients, at Harbor-UCLA Medical center (Los Angeles), with BBS (n = 12) and bile leaks (n = 5) from July 2007 to February 2012 that had received placement of fully covered self-expanding metal stents (FCSEMs). Fourteen patients had endoscopic placement of VIABIL^® (Conmed, Utica, New York, United States) stents and three had Wallflex^® (Boston Scientific, Mass) stents. FCSEMS were 8 mm or 10 mm in diameter and 4 cm to 10 cm in length. Patients were followed at regular intervals to evaluate for symptoms and liver function tests. FCSEMS were removed after 4 or more weeks. Resolution of BBS and leak was documented cholangiographically following stent removal. Stent patency can be defined as adequate bile and contrast flow from the stent and into the ampulla during endoscopic retrograde cholangiopancreatography (ERCP) without clinical signs and/or symptoms of biliary obstruction. Criterion for bile leak resolution at ERCP is defined as absence of contrast extravasation from the common bile duct, cystic duct remanent, or gall bladder fossa. Rate of complications such as migration, and in-stent occlusion were recorded. Failure of endoscopic therapy was defined as persistent biliary stenosis or continuous biliary leakage after 12 mo of stent placement.RESULTS: All 17 patients underwent successful FCSEMS placement and removal. Etiologies of BBS included: cholecystectomies (n = 8), cholelithiasis (n = 2), hepatic artery compression (n = 1), pancreatitis (n = 2), and Whipple procedure (n = 1). All bile leaks occurred following cholecystectomy. The anatomic location of BBS varied: distal common bile duct (n = 7), common hepatic duct (n = 1), hepaticojejunal anastomosis (n = 2), right intrahepatic duct (n = 1), and choledochoduodenal anastomatic junction (n = 1). All bile leaks were found to be at the cystic duct. Twelve of 17 patients had failed prior stent placement or exchange. Resolution of the biliary strictures and bile leaks was achieved in 16 of 17 patients (94%). The overall median stent time was 63 d (range 27-251 d). The median stent time for the BBS group and bile leak group was 62 ± 58 d (range 27-199 d) and 92 ± 81 d (range 48-251 d), respectively. All 17 patients underwent successful FCSEMS removal. Long term follow-up was obtained for a median of 575 d (range 28-1435 d). Complications occurred in 5 of 17 patients (29%) and included: migration (n = 2), stent clogging (n = 1), cholangitis (n = 1), and sepsis with hepatic abscess (n = 1).CONCLUSION: Placement of fully covered self-expanding metal stents may be used in the management of benign biliary strictures and bile leaks with a low rate of complications.     

Evaluating the risk of adverse events with interventional endoscopic retrograde cholangiopancreatography and endoscopic ultrasound procedures in cirrhotic patients

BACKGROUND Hepatic cirrhosis is associated with greater adverse event rates following surgical procedures and is thought to have a higher risk of complications with interventional procedures in general. However, these same patients often require interventional gastrointestinal procedures such as endoscopic retrograde cholangiopancreatography(ERCP) and endoscopic ultrasound(EUS). While studies examining this scenario exist, the overall body of evidence for adverse event rates associated with ERCP/EUS procedures is more limited. We sought add to the literature by examining the incidence of adverse events after ERCP/EUS procedures in our safety-net hospital population with the hypothesis that severity of cirrhosis correlates with higher adverse event rates.AIM To examine whether increasing severity of cirrhosis is associated with greater incidence of adverse events after interventional ERCP/EUS procedures.METHODS We performed a retrospective study of patients diagnosed with hepatic cirrhosis who underwent ERCP and/or EUS-guided fine needle aspirations/fine needle biopsies from January 1, 2016 to March 14, 2019 at our safety net hospital. We recorded Child-Pugh and Model for End-stage Liver Disease(MELD-Na) scores at time of procedure, interventions completed, and 30-day post-procedural adverse events. Statistical analyses were done to assess whether Child-Pugh class and MELD-Na score were associated with greater adverse event rates and whether advanced techniques(single-operator cholangioscopy, electrohydraulic lithotripsy/laser lithotripsy, or needle-knife techniques) were associated with higher complication rates.RESULTS77 procedures performed on 36 patients were included. The study population consisted primarily of middle-aged Hispanic males. 30-d procedure-related adverse events included gastrointestinal bleeding(7.8%), infection(6.5%), and bile leak(2%). The effect of Child-Pugh class C vs class A and B significantly predicted adverse events(β = 0.55, P 0.01). MELD-Na scores also significantly predicted adverse events(β = 0.037, P 0.01). Presence of advanced techniques was not associated with higher adverse events(P 0.05). When MELD-Na scores were added as predictors with the effect of Child-Pugh class C, logistic regression showed MELD-Na scores were a significant predictor of adverse events(P 0.01). The findings held after controlling for age, gender, ethnicity and repeat cases.CONCLUSION Increasing cirrhosis severity predicted adverse events while the presence of advanced techniques did not. MELD-Na score may be more useful in predicting adverse events than Child-Pugh class.     

Achilles tendon injuries: the role of MR imaging

Eight magnetic resonance (MR) examinations were performed in seven patients with Achilles tendon injuries and correlated with physical examination and surgical and clinical follow-up. The MR examinations depicted the Achilles tendon in excellent detail and Achilles tendon abnormalities with greater accuracy than physical examination. Of five tendons shown to be at least partially torn on MR, palpable tendinous defects were found in only one, and plantarflexion weakness was found in four. The MR and surgical findings precisely correlated in one case. Magnetic resonance proved valuable in the evaluation of clinically equivocal Achilles tendon tears and may ultimately play a greater role as a research tool in the determination of optimal forms of therapy for specific Achilles tendon injuries.     

THE SOCIAL CONTEXT OF DELINQUENT CONDUCT

Findings from two studies are presented on degree of group involvement in delinquency among young people. The first study indicates that among boys, although there is wide variation in the degree to which particular types of offence are committed alone or in the company of others, there is no general category of offence that is predominantly solitary. Moreover we could identify no individuals who always offended alone. The second study compared adolescent boys and girls and indicated that girls are if anything even more likely than boys to commit any offences in the company of others. The findings are discussed in terms of their implications for the role of the group context in delinquency.     

An electrocardiographic masquerade

A 60-year-old woman underwent successful pulmonary embolectomy for a massive pulmonary embolism. On postoperative day 2, while receiving intravenous dopamine for hypotension, she developed the tachycardia, and a 12-lead ECG was obtained (Fig. 1). Figure 2 shows the 12-lead ECG obtained on the previous day, when she was in sinus rhythm with frequent premature     

Apolipoprotein A-I coating of protamine-oligonucleotide nanoparticles increases particle uptake and transcytosis in an in vitro model of the blood-brain barrier.

Drug delivery to the brain is severely restricted by formation of tight junctions between adjacent brain capillary endothelial cells (BCEC). In the present study we have evaluated the effects of protamine-oligonucleotide nanoparticles (proticles) on the functional properties of primary porcine BCEC and characterized uptake and transcytosis of proticles by these cells. Proticles had no adverse effects on BCEC properties relevant to blood-brain barrier (BBB) function. Transcytosis of (125)I-labeled proticles across polarized BCEC cultures occurred in a time- and concentration-dependent manner. As apolipoproteins were suggested to enhance cellular proticle uptake, proticle coating was performed with apoA-I, the major apolipoprotein component of high density lipoproteins. Adsorption of apoA-I on the surface of proticles resulted in significantly improved uptake and transcytosis properties as compared to uncoated proticles. ApoA-I coating enhanced proticle delivery to astrocytes in an in vitro model of the BBB almost twofold. Blocking of scavenger receptor class B, type I (the prime receptor for high density lipoprotein/apoA-I that is expressed on BCEC) reduced transcytosis of apoA-I-coated proticles to levels observed for uncoated proticles. Our data indicate that apoA-I-coating of proticles could be a feasible targeting technology to improve delivery across the BBB.     

Debate: Remote learning during COVID-19 for children with high functioning autism spectrum disorder

The COVID-19 pandemic has illuminated preference of children with autism spectrum disorder of near average to above average intelligence (high functioning autism – HFA) for remote learning. While many children with HFA excel at the academic curriculum, the majority struggle with the so-called hidden curriculum, which includes such things as social rules and societal norms. Explicit teaching of the hidden curriculum is often lacking in mainstream education classes and can be a tremendous stumbling block for children with HFA. The result is often anxiety and depression which can be exacerbated or sometimes even caused by the intense demands for sociability and flexibility required in most mainstream educational settings. Remote learning, while not a legitimate option until now, has provided these children with an opportunity to flourish at home and improve not only their grades but also their mental health. While remote learning or hybrid models may continue to be appropriate for some children, understanding of the hidden curriculum is necessary beyond the school years. Both mental health and academic proficiency will flourish to the degree we are able to make the hidden curriculum more explicit to children with HFA.