Esophageal achalasia secondary to mesothelioma

Summary Achalasia secondary to malignancy is rare, with most cases associated with gastric adenocarcinoma of the gastroesophageal junction. This report describes the clinicopathologic features of a 64-year-old man found to have mesothelioma as the cause of secondary achalasia. To our knowledge, this is the first case of secondary achalasia produced by a mesothelioma. We reviewed the English literature in regard to achalasia induced by tumors.This work was supported by the Veterans Administration.     

Clinical aspects of ballistic peripheral nerve injury: shrapnel versus gunshot

Objectives

Ballistic injuries to peripheral nerves pose special challenges in terms of indications, timing and type of surgical intervention. The aim of the present work was to analyze our experience in the surgical treatment of peripheral nerve ballistic injuries with respect to the mechanism of injury (gunshot versus shrapnel), and identify common and dissimilar prognostic factors in both types of injury.

Methods

This study was conducted on 42 patients totaling 58 nerves. Twenty-two patients (32 nerves) were injured by gunshot and 20 patients (26 nerves) by shrapnel. Median postoperative follow-up was 33 months (range 12 months to 14 years).

Results

Overall postoperative outcome appears to be more favorable for gunshot-wound (GSW) patients than shrapnel-injured patients, especially in terms of neuropathic pain relief (75 % vs. 58 % respectively, p < 0.05). Presence of foreign particles in shrapnel injured patients has a negative impact on the surgical outcome in terms of rate of pain improvement (28 % compared to 67 % in patients with and without foreign particles, respectively). Nerve graft reconstruction, rather than neurolysis, seems to be the more beneficial treatment for shrapnel-induced neuropathic pain (100 % vs. 47 % in improvement rate, respectively). Early surgical intervention (median 2 months after injury) significantly relieved neuropathic pain in 83 % of shrapnel-injured patients compared to 58 % in patients operated later.

Conclusions

This study suggests that shrapnel injury is more destructive for nerve tissue than gunshot injury. Our impression is that early surgical intervention in shrapnel injuries and split nerve grafting (especially when small fragments are recognized in the nerve) significantly improve the patient’s functional activity and quality of life.     

Clinical Decision Making for a Tooth with Apical Periodontitis: The Patients' Preferred Level of Participation

Introduction

To effectively engage patients in clinical decisions regarding the management of teeth with apical periodontitis (AP), there is a need to explore patients' perspectives on the decision-making process. This study surveyed patients for their preferred level of participation in making treatment decisions for a tooth with AP.

Methods

Data were collected through a mail-out survey of 800 University of Toronto Faculty of Dentistry patients, complemented by a convenience sample of 200 patients from 10 community practices. The Control Preferences Scale was used to evaluate the patients' preferences for active, collaborative, or passive participation in treatment decisions for a tooth with AP. Using bivariate and logistic regression analyses, the Gelberg-Andersen Behavioral Model for Vulnerable Populations was applied to the Control Preferences Scale questions to understand the influential factors (P ≤ .05).

Results

Among 434 of 1,000 respondents, 44%, 40%, and 16% preferred an active, collaborative, and passive participation, respectively. Logistic regression showed a significant association (P ≤ .025) between participants' higher education and preference for active participation compared with a collaborative role. Also, immigrant status was significantly associated with preference for passive participation (P = .025).

Conclusions

The majority of patients valued an active or collaborative participation in deciding treatment for a tooth with AP. This pattern implied a preference for a patient-centered practice mode that emphasizes patient autonomy in decision making.     

Perturbed hematopoiesis in individuals with germline DNMT3A overgrowth Tatton-Brown-Rahman syndrome

Tatton-Brown-Rahman syndrome (TBRS) is an overgrowth disorder caused by germline heterozygous mutations in the DNA methyltransferase DNMT3A. DNMT3A is a critical regulator of hematopoietic stem cell (HSC) differentiation and somatic DNMT3A mutations are frequent in hematologic malignancies and clonal hematopoiesis. Yet, the impact of constitutive DNMT3A mutation on hematopoiesis in TBRS is undefined. In order to establish how constitutive mutation of DNMT3A impacts blood development in TBRS we gathered clinical data and analyzed blood parameters in 18 individuals with TBRS. We also determined the distribution of major peripheral blood cell lineages by flow cytometric analyses. Our analyses revealed non-anemic macrocytosis, a relative decrease in lymphocytes and increase in neutrophils in TBRS individuals compared to unaffected controls. We were able to recapitulate these hematologic phenotypes in multiple murine models of TBRS and identified rare hematological and non-hematological malignancies associated with constitutive Dnmt3a mutation. We further show that loss of DNMT3A in TBRS is associated with an altered DNA methylation landscape in hematopoietic cells affecting regions critical to stem cell function and tumorigenesis. Overall, our data identify key hematopoietic effects driven by DNMT3A mutation with clinical implications for individuals with TBRS and DNMT3A-associated clonal hematopoiesis or malignancies.     

Reversal of hyperglycemia in mice by using human expandable insulin-producing cells differentiated from fetal liver progenitor cells

Beta-cell replacement is considered to be the most promising approach for treatment of type 1 diabetes. Its application on a large scale is hindered by a shortage of cells for transplantation. Activation of insulin expression, storage, and regulated secretion in stem/progenitor cells offers novel ways to overcome this shortage. We explored whether fetal human progenitor liver cells (FH) could be induced to differentiate into insulin-producing cells after expression of the pancreatic duodenal homeobox 1 (Pdx1) gene, which is a key regulator of pancreatic development and insulin expression in beta cells. FH cells possess a considerable replication capacity, and this was further extended by introduction of the gene for the catalytic subunit of human telomerase. Immortalized FH cells expressing Pdx1 activated multiple beta-cell genes, produced and stored considerable amounts of insulin, and released insulin in a regulated manner in response to glucose. When transplanted into hyperglycemic immunodeficient mice, the cells restored and maintained euglycemia for prolonged periods. Quantitation of human C-peptide in the mouse serum confirmed that the glycemia was normalized by the transplanted human cells. This approach offers the potential of a novel source of cells for transplantation into patients with type 1 diabetes.     

Pituitary Society Delphi Survey: An international perspective on endocrine management of patients undergoing transsphenoidal surgery for pituitary adenomas

Pituitary - In adults and children, transsphenoidal surgery (TSS) represents the cornerstone of management for most large or functioning sellar lesions with the exception of prolactinomas....     

Advances in the processing, sterilization, and crosslinking of ultra-high molecular weight polyethylene for total joint arthroplasty.

Despite the recognized success and worldwide acceptance of total joint arthroplasty, wear is a major obstacle limiting the longevity of implanted UHMWPE components. Efforts to solve the wear problem in UHMWPE have spurred numerous detailed studies into the structure, morphology, and mechanical properties of the polymer at every stage of its production from original resin into stock material and final fabricated form. Scientific developments in this field are occurring at an accelerating rate, and periodic review of UHMWPE technology is therefore increasingly necessary. The present article provides a four-part comprehensive review of technological advancements in the processing, manufacture, sterilization, and crosslinking of UHMWPE for total joint replacements. The first part of this article describes the recently updated nomenclature of UHMWPE, including the process of resin production and conversion to stock material. The second part outlines the methods of manufacturing UHMWPE into joint replacement components and provides overviews of alternate forms of UHMWPE, namely carbon-fiber reinforced UHMWPE (Poly II) and UHMWPE recrystallized under high temperature and pressure (Hylamer). The third part summarizes the sterilization and degradation of UHMWPE. Newly developed methods for accelerating the oxidation of UHMWPE after sterilization (for preconditioning of test specimens), as well as methods for quantifying the oxidation of UHMWPE, are also discussed. Finally, the fourth part reviews the development and properties of crosslinked UHMWPE, a promising alternate biomaterial for total joint replacements.