Voice recognition interfaces (VRI) optimize the utilization of theatre staff and time during laparoscopic cholecystectomy.

During laparoscopy, members of staff spend time setting up and de-activating the light source, camera and insufflator. Voice Recognition Interface (VRI) devices, such as HERMES (Stryker Europe, Montreux, Switzerland), enable the surgeon to perform and control these and other functions. They recognize the surgeon's voice and adjust the instruments in response to programmed verbal commands. The aim of this study was to evaluate HERMES with regards to the utilization of time and theatre staff during laparoscopic cholecystectomy. A total of 100 patients were randomized to either HERMES-assisted or standard laparoscopic cholecystectomy. Three time variables were measured for performing three VRI tasks: (1) The initial setting up of the light source and camera, (2) the activation of the insufflator, and (3) the deactivation of the insufflator and light source at the end of the operation. The mean (and standard deviation) of the time in seconds required for setting up the light source and camera was 27.6 (26.9) in non-HERMES operations and 11.7 (4.7) in HERMES-assisted cases (p<0.001). Insufflation time was 19.8 (13.3) vs. 6.7 (2.5) (p<0.001), and switch-off time was 19.5 (11.8) vs. 11.8 (5.7) (p<0.001). HERMES optimized the operating time and the utilization of theatre staff during laparoscopic cholecystectomy.     

Unraveling ‘The Cancer Genome Atlas’ information on the role of SLC transporters in anticancer drug uptake

Introduction: Anticancer chemotherapy often faces the problem of intrinsic or acquired drug refractoriness due in part to efficient mechanisms of defense present or developed, respectively, in cancer cells. Owing to their polarity and/or high molecular weight, many cytostatic agents cannot freely cross the plasma membrane by simple diffusion and hence depend on SLC proteins to enter cancer cells. The downregulation of these transporters and the appearance of either inactivating mutations or aberrant splicing, hamper the possibility of anticancer drugs to interact with their intracellular targets.

Areas covered: In addition to specific literature, we have revised Gene database of the NCBI PubMed resources and information publicly available at NIH ‘The Cancer Genome Atlas’ (TCGA) (update November 2018) to evaluate the relationship between the profile of expression of SLC transporters playing a major role in the transportome and accounting for drug uptake, in healthy and tumor tissue, and their ability to recognize as substrate several antitumor drugs frequently used in the treatment of different types of cancer, which could affect the overall response to chemotherapy based on regimens including these drugs.

Expert commentary: Changes in the transportome may affect the overall response to chemotherapy based on drugs taken up by SLC transporters.     

A 29-year-old man with hospital-acquired cavitary pneumonia

Cavitary lung processes pose a formidable diagnostic challenge. Causes vary widely and include cavitary pneumonia, vasculitis and malignancy. In some cases, patient history and basic work-up may yield a diagnosis, but in others, an extensive work-up, including tissue biopsy, may be necessary to establish the cause. The authors present a case of cavitary pneumonia that complicated an open lung biopsy. It developed in the hospital and was caused by mucormycosis, a potential emerging infection causing health care-associated infections.     

Verruciform xanthoma: a special epidermal nevus

Congenital hemidysplasia with ichthyosiform nevus and limb defects (CHILD) syndrome is a rare X-linked hereditary disorder. Presentation varies from ichthyosiform nevus to complete limb amelia. We present a 17-year-old adolescent girl who presented with a 16-cm exophytic mass of the right foot that had been growing for 7 years as well as knee contracture. Deformed nails with onychorrhexis were noted bilaterally. History of multiple nonlinear erythematous skin lesions covered by dry waxy scales involving multiple body folds with sharp midline demarcation was obtained. The patient's family history was negative for consanguinity and similar conditions. Radiography showed right leg hypoplasia and osteopenia. These findings fulfill the diagnosis of CHILD syndrome. Microscopically, psoriasiform epidermal hyperplasia with marked orthohyper-keratosis and neutrophilic exocytosis were noted. The papillary dermis was packed with foamy macrophages consistent with xanthomatous changes, namely verruciform xanthoma. Verruciform xanthoma, although rarely found in other conditions, is a characteristic finding.     

Free radical activity and lipid soluble anti-oxidant vitamin status in patients with long-term ileal pouch-anal anastomosis

Objective  Ileal pouch-anal anastomosis (IPAA) is the operation of choice for patients with ulcerative colitis. Free radical activity and the status of lipid soluble antioxidant vitamins have not been previously assessed in patients with IPAA. The aim of the present study was to measure the plasma concentrations of lipophyllic antioxidants and free radical activity in IPAA patients and compare them with normal subjects.
Method  Forty-eight IPAA patients and 50 healthy controls were studied. A dietary assessment of vitamin E (α-tocopherol) and carotene was undertaken and plasma antioxidant status was assessed. Plasma malondialdehyde (MDA) was measured to assess the extent of free radical damage. In IPAA patients, association between the degree of inflammation in the pouch mucosa and the plasma concentration of lipophyllic antioxidants and extent of free radical activity was investigated.
Results  The dietary intake of carotene was similar in both groups. Intake of vitamin E was significantly lower in patients than controls ( P  = 0.01). In the IPAA group plasma concentrations of α-carotene, β-carotene and lycopene were significantly lower ( P  < 0.001) and α-tocopherol:cholesterol ratio significantly higher ( P  < 0.001). Free radical damage was significantly greater in patients than controls ( P  < 0.01). There were no significant correlations between the degree of inflammation in the pouch and plasma concentrations of MDA, carotenoids, α-tocopherol:cholesterol ratio or intake of vitamins.
Conclusion  Compared with normal subjects, patients with IPAA have significantly lower plasma concentrations of lipophyllic antioxidants α-carotene, β-carotene and lycopene and higher free radical activity suggesting increased oxidative stress. These differences do not appear to be related to diet and do not correlate with histological severity of pouch inflammation.     

Altered inhibition in lateral amygdala networks in a rat model of temporal lobe epilepsy

Clinical and experimental evidence indicates that the amygdala is involved in limbic seizures observed in patients with temporal lobe epilepsy. Here, we used simultaneous field and intracellular recordings from horizontal brain slices obtained from pilocarpine-treated rats and age-matched nonepileptic controls (NECs) to shed light on the electrophysiological changes that occur within the lateral nucleus (LA) of the amygdala. No significant differences in LA neuronal intrinsic properties were observed between pilocarpine-treated and NEC tissue. However, spontaneous field activity could be recorded in the LA of 21% of pilocarpine-treated slices but never from NECs. At the intracellular level, this network activity was characterized by robust neuronal firing and was abolished by glutamatergic antagonists. In addition, we could identify in all pilocarpine-treated LA neurons: 1) large amplitude depolarizing postsynaptic potentials (PSPs) and 2) a lower incidence of spontaneous hyperpolarizing PSPs as compared with NECs. Single-shock stimulation of LA networks in the presence of glutamatergic antagonists revealed a biphasic inhibitory PSP (IPSP) in both NECs and pilocarpine-treated tissue. The reversal potential of the early GABA(A) receptor-mediated component, but not of the late GABA(B) receptor-mediated component, was significantly more depolarized in pilocarpine-treated slices. Furthermore, the peak conductance of both fast and late IPSP components had significantly lower values in pilocarpine-treated LA cells. Finally, paired-pulse stimulation protocols in the presence of glutamatergic antagonists revealed a less pronounced depression of the second IPSP in pilocarpine-treated slices compared with NECs. Altogether, these findings suggest that alterations in both pre- and postsynaptic inhibitory mechanisms contribute to synaptic hyperexcitability of LA networks in epileptic rats.     

Adenocarcinoma in situ of the uterine cervix: screening and diagnostic errors in Papanicolaou smears

BACKGROUND: Little attention has been given to the reasons for failure to detect adenocarcinoma in situ (AIS) of the uterine cervix in Papanicolaou (Pap) smears. In the current study, the authors examined a series of screening or diagnostic errors in cases in which the final histologic diagnosis was either AIS or AIS combined with a high-grade squamous intraepithelial lesion (AIS + HSIL). METHODS: Smears obtained in the 3 years before histologically proven AIS or AIS + HSIL was diagnosed and within a specified 6-year period (1993-1998) were reviewed and reclassified. All were conventional Pap smears. The smears studied were those with a review diagnosis of possible or definite high-grade epithelial abnormality that initially were reported by a cytotechnologist to be negative (screening error) or that were reported by a pathologist to be negative, unsatisfactory, or indicative of a low-grade epithelial abnormality (diagnostic error). A semiquantitative, blinded assessment of the frequency of cytologic criteria for the diagnosis of AIS was made for smears with erroneous diagnoses compared with a series of smears that yielded true-positive findings. RESULTS: Sampling errors, which were defined as cases in which smears did not have sufficient evidence for a diagnosis of possible or definite AIS or HSIL on review, accounted for 35.1% and 36% of all smears from patients with a biopsy diagnosis of AIS and patients with a biopsy diagnosis of AIS + HSIL, respectively. With regard to AIS, there were 3 screening errors and 5 diagnostic errors, accounting for 10.4% of 77 smears. Minimal, poorly preserved material was evident in four smears, including three smears with only one sheet of abnormal glandular cells. In four other smears, there was a moderate amount of adequately preserved glandular material, mainly in large sheets, with varying degrees of crowding and hyperchromasia. With regard to AIS + HSIL, there were 6 screening errors and 6 diagnostic errors, accounting for 13.5% of 89 smears. In those smears, there generally was a moderate amount of abnormal material in the form of crowded groups of suboptimally preserved, hyperchromatic squamous cells. Only two of those smears yielded findings of possible abnormal glandular cells. Only 3 of 20 errors occurred in smears that were examined during the last 3 years of the study. In the semiquantitative assessment, smears with erroneous findings were shown to contain far less abnormal material than true-positive smears and to exhibit a corresponding paucity of diagnostic criteria. CONCLUSIONS: Sampling errors were the main cause of false-negative reports in cases of AIS and AIS + HSIL. The primary factors that contributed to screening or diagnostic errors in AIS were minimal, poorly preserved abnormal material and an overly conservative approach to the assessment of unusual large sheets or aggregates of glandular cells. With regard to AIS + HSIL, most laboratory errors were related to the presence of crowded groups of squamous epithelial cells. There were fewer errors in the last 3 years of the study, raising the possibility of improvement over time.