Lip biopsy for the diagnosis of Sjögren's syndrome: beware of the punch

A pilot study was performed to examine the presence of nerve fibres in minor salivary gland tissue samples obtained by two procedures: punch and linear incisional techniques. The study was undertaken on a convenience sample of five cryopreserved corpses (mean age 74 ± 3.5 years; three males and two females). Biopsies were performed on the buccal side of the lower lip, between the mid-line and the corner of the mouth. Each corpse had one side of the lower lip biopsied by punch and the contralateral side using a linear incision. All punch samples (100%) displayed severed nerve fibres, whereas no nerve fibres (0%) could be identified in the samples obtained by means of the linear incision technique. While the linear incision approach permitted retrieval of at least five glands, punch biopsies did not provide enough material for the diagnosis of Sjögren's syndrome. Within the limitations of the study, our results strongly discourage the punch technique for minor salivary gland lip biopsy and provide information on the superiority of the linear incisional biopsy in terms of neural damage. These results may also promote the undertaking of clinical trials on patients in whom Sjögren's syndrome is suspected, comparing the morbidity associated with the linear incisional technique vs. minimally invasive biopsies.     

Lower lip repair using double opposing rectangular rotation flaps with reconstruction of the mentolabial groove and mental protuberance

The use of a rectangular flap is a well known technique for upper lip repair in cleft lip, but is less common for lower lip repair after tumour resection. We have found this type of flap to be favourable for lower lip reconstruction, especially for the lip to mental region. We describe herein an improvement to the technique in which two opposing rectangular flaps, with the length of one side equal to the vertical distance from the mentolabial groove to the vermilion border, were raised on the lateral sides of a U-shaped defect. Reconstruction was performed by interdigitation of the two flaps and a bilateral vermilion advancement flap. This new approach allows a distinct mentolabial groove and mental protuberance to be created by utilizing two opposing rectangular flaps and redundant tissue, without sacrificing sensation and muscle function. Our results suggest that the technique provides excellent functional and cosmetic outcomes in restoration of the lower lip in properly selected patients.     

New insight into the evolution of the vertebrate respiratory system and the discovery of unidirectional airflow in iguana lungs

The generally accepted framework for the evolution of a key feature of the avian respiratory system, unidirectional airflow, is that it is an adaptation for efficiency of gas exchange and expanded aerobic capacities, and therefore it has historically been viewed as important to the ability of birds to fly and to maintain an endothermic metabolism. This pattern of flow has been presumed to arise from specific features of the respiratory system, such as an enclosed intrapulmonary bronchus and parabronchi. Here we show unidirectional airflow in the green iguana, a lizard with a strikingly different natural history from that of birds and lacking these anatomical features. This discovery indicates a paradigm shift is needed. The selective drivers of the trait, its date of origin, and the fundamental aerodynamic mechanisms by which unidirectional flow arises must be reassessed to be congruent with the natural history of this lineage. Unidirectional flow may serve functions other than expanded aerobic capacity; it may have been present in the ancestral diapsid; and it can occur in structurally simple lungs.Energetically demanding forms of locomotion, such as powered flight, require a great capacity for gas exchange and selection for aerobic stamina may underlie many unique features of the avian respiratory system (1, 2). The avian respiratory system consists of highly vascularized lungs and avascular air sacs, which are membranous structures that effect ventilation and, in some species, extend between the muscles and even enter the bones (3). The topography of the conducting airways is complex; they form a circular system of tubes, analogous to the loop formed by the blood circulatory system in which arteries connect to veins through numerous small diameter vessels, the capillaries. Likewise, the avian conducting airways connect to each other through numerous tubules, the parabronchi, to form a circular path for respiratory gases (3). Gases flow through most of the parabronchi in the same direction during both inhalation and exhalation (unidirectional flow). This is due to the presence of aerodynamic valves (4–10). In contrast, the mammalian conducting airways arborize with the branch tips ending in blind sacs, there are no valves, and gases travel in the opposite direction along the conducting airways during expiration from the direction followed during inspiration (tidal flow). The presence of aerodynamic valves and unidirectional flow has generally been thought to be a highly derived feature found, among extant animals, only in birds and having evolved either in the crown group with flight or somewhere along the saurischian lineage leading to birds (11), perhaps as a mechanism to meet the high energetic demands of endothermy.The discovery of unidirectional flow in the lungs of alligators (12, 13) and the savannah monitor lizard (14) indicates that we do not understand the distribution of this phenomenon among different lineages of vertebrates and raises questions about its underlying value. It is possible that unidirectional flow evolved convergently in crocodilians and monitor lizards and serves to expand aerobic capacity. Although monitor lizards are ectotherms, their lifestyles are largely convergent with small predatory mammals (15) and they have high aerobic capacities compared with other lizards (16). In contrast, extant alligators have limited aerobic stamina (17) but their common ancestor with birds may have had a great aerobic capacity (18) or may have been endothermic (19, 20). Crocodilians and monitor lizards also share a suite of features of their pulmonary and cardiac anatomy that have been purported to give rise to, or coevolve with, birdlike patterns of flow. These features are: (i) a bronchus that has grown deep into the lung as a mesobronchium, (ii) partitioning of the respiratory system into a mechanical part that functions in ventilation and a gas-exchanging region, (iii) intercameral perforations, and (iv) separation of the heart into right and left sides (1, 21). Crocodilians and monitors are also derived in having evolved mechanisms to supplement costal ventilation while exercising (18, 22, 23). Thus, unidirectional flow in these lineages may be one of many derived traits underpinning exceptionally high rates of oxygen consumption during activity.It is also possible, however, that this pattern of flow evolved before the split of Diapsida into the Lepidosauromorpha (tuatara, lizards, snakes) and Archosauromorpha (crocodilians and birds) in an ectothermic ancestor lacking expanded aerobic capacities and living as long ago as the Permian Period. Unidirectional flow has been purported to serve ectotherms by harnessing the heart as a pump for air during periods of breath-holding (apnea) (12). Light can be shed on this pattern of evolution with observations of more squamates (snakes, lizards), which are the most diverse and largest (∼9,000 species) group of living reptiles (24).To test the hypothesis that unidirectional flow is present in squamates other than varanid lizards; to better understand anatomical features that give rise to these patterns of flow; and to gain insight into the underlying value of this pattern of flow, green iguanas (Iguana iguana) were studied. Green iguanas differ from monitors because they are herbivores and because they have structurally simple lungs that lack an enclosed intrapulmonary bronchus. Iguanas lack septation of the cardiac ventricle and have poor locomotor stamina. The poor stamina is due in part from an impairment during running in their blood and air circulatory systems (19, 25, 26).     

Moderate-dose glucocorticoids as salvage therapy for severe pneumonia in renal transplant recipients: a single-center feasibility study

This study aimed to assess the effectiveness and safety of moderate-dose glucocorticoids (GCs) with mechanical ventilation as salvage therapy for renal transplant recipients with severe pneumonia, which was non-responsive to conventional treatment. A retrospective study was conducted involving renal transplant recipients diagnosed with severe pneumonia and did not respond to conventional treatment. All immunosuppressants were then completely withdrawn, and the patients were initially administered with methylprednisolone at doses of 2.0–2.5?mg/kg/day once every 12?h. This dosage was continued until oxygenation improved, and the treatment was gradually tapered (by 20?mg every 2–3 days) to the previous maintenance dosage. Ten patients were recruited from year 2008 to 2012. Two patients who underwent emergency endotracheal intubation were intubated on days 3 and 8, respectively, another one died from recurrent pneumothorax. The mean PaO₂/FiO₂ of the nine survivors was significantly increased by the increasing treatment duration; whereas the lung injury scores (LIS) and the sequential organ failure assessment (SOFA) score were both significantly decreased. The use of moderate-dose GCs may play a role as salvage therapy for renal transplant recipients with severe pneumonia. However, further study with larger trials to is needed.     

Restoring the glycosaminoglycans layer in recurrent cystitis: Experimental and clinical foundations

Restoring the bladder glycosaminoglycans layer has recently been introduced as prophylactic treatment for recurrent urinary tract infections. Herein, we analyze the latest main clinical and experimental studies to support this therapeutic option. An electronic research was carried out in the most common databases in order to identify any published studies. Retrieved studies were categorized as experimental or clinical according to their setting. For the clinical studies, the evidence level was assigned. A total of 13 laboratory studies showed how bladder glycosaminoglycans instillations act: attenuation of the inflammation process, reduction of bladder contraction amplitude and frequency, reduction of epithelium damage, and lower bacterial growth in urine and tissue samples. Likewise, two randomized clinical trials with grade 2 evidence level and two case series with grade 4 evidence level reported glycosaminoglycans as an alternative to reduce episodes and to prolong recurrence time in patients with recurrent urinary tract infections. At least 12 months of follow up was completed. No serious adverse events were reported. Compared with a placebo, in one randomized study a significantly higher maximum cystometric capacity was obtained, whereas in the other study a significant increase in quality of life scores was reported too. An improvement in the urinary symptoms score was reported by the two randomized trials. Although the clinical use of glycosaminoglycans replacement therapy for recurrent urinary tract infections is supported by a small number of clinical studies with different evidence levels, the laboratory studies show that glycosaminoglycans could have a protective role against inflammatory factors, supporting the idea “to restore the glycosaminoglycans bladder layer to prevent chronic disease course”.