Gastric Bypass Is not a “Restrictive and Malabsorptive” Procedure

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Smal Bowel Limb Lengths and Roux-en-Y Gastric Bypass: a Systematic Review

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Intragastric Balloon Device: Weight Loss and Satisfaction Degree

Abstract

Background

An intragastric balloon is a non-surgical device enhancing a sensation of early satiety and reducing food intake. The aim of this study is to analyze the results in terms of weight loss and patient satisfaction undergoing intragastric balloon implantation.

Methods

Air-filled and water-filled devices were used. All patients were participated in strict follow-up programs. Weight, body mass index (BMI), total body weight loss (TWL), percentage of excess weight loss (EWL), and satisfaction degree were taken into account.

Results

Eighty-one patients completed a 6-month period with a device in place; 72 of them were then contacted for a follow-up at 12.3 ± 2.4 months post-removal. During treatment period, in 76 cases (93.8 %), a statistically significant reduction in weight was observed. A statistically meaningful linear correlation between a 3-month EWL (or TWL) and a 6-month EWL (or TWL) was found. At the end of endoscopic treatment, a significant link between baseline BMI and EWL >20 % was found. Sixty-three percent of the patients were not satisfied with the procedure, did not deem useful to change their diet, and refused to perform it again.

Conclusions

In our study, at device removal and 1 year thereafter, a statistically significant reduction in weight was observed. Most of the patients were found to have a weight loss more than the cut-off of 20 %. The weight reached at the third month appears to be predictive of the effectiveness of endoscopic treatment. Data showed an overall dissatisfaction with procedure.

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Laparoscopic Conversion of Gastric Bypass Complication to Sleeve Gastrectomy: Technique and Early Results

Abstract

Background

Laparoscopic gastric bypass is a commonly performed bariatric surgery for the treatment of morbid obesity. Revision surgery for patients who have gastric bypass complications is a challenge for bariatric surgeon. Our aim is to present the early results of the conversions of gastric bypass complications to sleeve gastrectomies.

Methods

From January 2001 to April 2015, 49 of 2382 gastric bypasses underwent revisional surgery to convert gastric bypasses to sleeve gastrectomies. The demographic data, surgical parameters, and outcomes were studied.

Results

The mean age of the study group was 35.0 years (range 20 to 55), and the average body mass index (BMI) prior to the reoperation was 25.3 kg/m². Seven patients had previous laparoscopic Roux-en-Y gastric bypasses (LRYGBs), and 42 had laparoscopic single anastomosis (mini-) gastric bypasses (LSAGBs). The main reasons for the revisions were malnutrition (58 %), weight regain (10 %), intolerance (18 %), and others (14 %). The revisional surgeries had longer operative times, greater blood loss, and longer flatus passage times than the primary gastric bypass surgeries. Four patients (8.1 %) developed major complications during revisional surgery, including three (6.1 %) cases of leakage and one (2.0 %) case of internal bleeding. No mortality was noted. After conversion to sleeve gastrectomy, the body weights of the patients remained stable, and all patients improved in terms of malnutrition, including anemia, hypoalbuminemia, and secondary hyperparathyroidism.

Conclusions

Conversion to sleeve gastrectomy is an effective and safe option for patients with gastric bypass complications. The conversions to sleeve gastrectomy resulted in significant improvements in malnutrition and maintained weight loss at the early follow-ups.

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Laparoscopic Sleeve Gastrectomy for Morbid Obesity in 3003 Patients: Results at a High-Volume Bariatric Center

Abstract

Background

Laparoscopic sleeve gastrectomy (LSG) is gaining wide acceptance as a single surgical treatment for obesity. The reported morbidity and mortality rates are low. We herein report the results of LSG performed in a high-volume center by an experienced team.

Methods

Retrospective analysis of a prospectively maintained database of all bariatric surgery (BS) was performed between May 2006 and December 2014. Data inspected included operative time, length of hospital stay (LOS), comorbidity resolution, re-operation, percent excess weight loss (%EWL), and 30-day morbidity and mortality.

Results

In the study period, 3003 patients underwent BS (1901 (63 %) female). Mean age and body mass index (BMI) were 43 years (range 14–73) and 42.8 kg/m² (range 35–73), respectively. %EWL at 1 year was 72 % (n = 937; 57 % follow-up rate). There was 1 perioperative mortality due to bleeding (0.03 %). Comorbidity improvement and resolution were 98 % for obstructive sleep apnea, 79 % for diabetes mellitus, 87 % for dyslipidemia, and 85 % for hypertension. Mean operative time and LOS were 50 min (range 32–94) and 2.2 days (range 1–38), respectively. Of the patients, 132 had complications (4.4 %), 25 leaks (0.83 %), 63 bleeding (2.1 %), 1 intra-abdominal abscesses (0.03 %), 3 sleeve strictures (0.1 %), 2 mesenteric vein thromboses (0.06 %), 10 trocar site hernias (0.3 %), and 78 symptomatic cholelithiasis (2.6 %). Re-operation was needed in 13 patients (0.43 %).

Conclusion

In a high-volume center with an experienced team, LSG can be performed with low morbidity and mortality.

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A Challenge between Trainee Education and Patient Safety: Does Fellow Participation Impact Postoperative Outcomes Following Bariatric Surgery?

Abstract

Background

Surgical training may potentially influence patient care. A safe, high-quality bariatric and metabolic surgery practice requires dedicated and specialized training commonly acquired during a fellowship. This study evaluates the impact of fellow participation on early postoperative outcomes in bariatric surgery.

Methods

From the American College of Surgeons (ACS-NSQIP) database, we identified all obese patients who had undergone primary laparoscopic Roux-en-Y gastric bypass (LRYGB) and sleeve gastrectomy (LSG) between 2010 and 2012. Logistic regression was used to prognosticate the surgical fellow (PGY-6, 7, or 8) participation in bariatric surgeries on perioperative outcomes, as compared to surgeries with no trainee participation.

Results

The study cohort consisted of 10,838 patients (8819 LRYGB, 2019 LSG, 32 % fellow participation). Fellows participated in higher-risk surgeries. Fellow involvement was associated with increased operative time in LRYGB (difference 42.4 ± 1.2 min, p < 0.001) and in LSG (difference 38.8 ± 2.5 min, p < 0.001). Multivariate regression revealed that fellow involvement in LSG did not significantly alter postoperative adverse events. Conversely, in the LRYGB group, fellow participation was independently associated with higher rates of overall complications (OR = 1.37, 95 % CI 1.16–1.63), serious complications (OR = 1.23, 95 % CI 1.00–1.52), surgical complications (OR = 1.42; 95 % CI 1.17–1.73), and reoperation (OR = 1.43, 95 % CI 1.10–1.87). On adjusted analysis, while readmission was higher with fellow involvement in both procedures, mortality rates were comparable.

Conclusions

Fellow involvement resulted in a clinically appreciable increase in operative times. Fellow participation in the operating room was also independently associated with worse early postoperative outcomes following LRYGB, but was not the case for LSG. Promoting proficiency in surgical simulation laboratories and a gradual participation of fellows from LSG to LRYGB during fellowship may be associated with a reduction in postoperative complications.

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Intragastric Balloon for Management of Severe Obesity: a Systematic Review

Abstract

Older models of intragastric balloons (IGBs) had unacceptably high complication rates and inconsequential weight loss. With FDA approval of newer models, we aimed to systematically examine the literature regarding the efficacy of IGB therapy for obesity. A comprehensive electronic database search was completed. Title searching was restricted to the following keywords: bariatric, gastric, gastric bypass, gastric band, sleeve gastrectomy, and intragastric balloon. Twenty-six primary studies (n = 6101) were included. At balloon removal, mean change in weight and BMI were 15.7 ± 5.3 kg and 5.9 ± 1.0 kg/m². The most common complications were nausea/vomiting (23.3 %) and abdominal pain (19.9 %). Serious complications were rare: mortality (0.05 %) and gastric perforation (0.1 %). IGBs are associated with marked short-term weight loss with limited serious complications.

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Morbidity and Mortality After Gastrectomy: Identification of Modifiable Risk Factors

Abstract

Background

Morbidity after gastrectomy remains high. The potentially modifiable risk factors have not been well described. This study considers a series of potentially modifiable patient-specific and perioperative characteristics that could be considered to reduce morbidity and mortality after gastrectomy.

Methods

This retrospective cohort study includes adults in the ACS NSQIP PUF dataset who underwent gastrectomy between 2011 and 2013. Sequential multivariable models were used to estimate effects of clinical covariates on study outcomes including morbidity, mortality, readmission, and reoperation.

Results

Three thousand six hundred and seventy-eight patients underwent gastrectomy. A majority of patients had distal gastrectomy (N = 2,799, 76.1 %) and had resection for malignancy (N = 2,316, 63.0 %). Seven hundred and ninety-eight patients (21.7 %) experienced a major complication. Reoperation was required in 290 patients (7.9 %). Thirty-day mortality was 5.2 %. Age (OR = 1.01, 95 % CI = 1.01–1.02, p = 0.001), preoperative malnutrition (OR = 1.65, 95 % CI = 1.35–2.02, p < 0.001), total gastrectomy (OR = 1.63, 95 % CI = 1.31–2.03, p < 0.001), benign indication for resection (OR = 1.60, 95 % CI = 1.29–1.97, p < 0.001), blood transfusion (OR = 2.57, 95 % CI = 2.10–3.13, p < 0.001), and intraoperative placement of a feeding tubes (OR = 1.28, 95 % CI = 1.00–1.62, p = 0.047) were independently associated with increased risk of morbidity. Association between tobacco use and morbidity was statistically marginal (OR = 1.23, 95 % CI = 0.99–1.53, p = 0.064). All-cause postoperative morbidity had significant associations with reoperation, readmission, and mortality (all p < 0.001).

Conclusions

Mitigation of perioperative risk factors including smoking and malnutrition as well as identified operative considerations may improve outcomes after gastrectomy. Postoperative morbidity has the strongest association with other measures of poor outcome: reoperation, readmission, and mortality.

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Managing Malignant Colorectal Obstruction with Self-Expanding Stents. A Closer Look at Bowel Perforations and Failed Procedures

Abstract

Stent treatment of large bowel obstruction is still controversial. There are concerns regarding complications, particularly bowel perforation, as well as long-term outcome in curable patients. Through a 10-year retrospective study, we have evaluated efficacy, complications, delay in surgical interventions and stent patency in cases of palliative treatment. We treated 183 patients, 85 as bridge to surgery and 98 as definitive, palliative treatment. At presentation, 58 % of patients had advanced local or metastatic disease. Seventeen patients required more than one stent insertion. The total number of procedures was 213. We recorded technical and clinical success or failure, complications, necessity of restenting or surgical intervention, mortality and stent patency in the palliation group. Stenting was clinically successful in 89 % of the bridge to surgery group and 86 % of the palliative group. Complications occurred in 7 %, including 12 perforations. Six patients suffered an early perforation, of which two died. Half of the six late perforations were silent. Procedure related mortality was 1 %. The clinical success rate was high in both the palliative and bridge to surgery setting. The complication rate was low, and the sum of early and late perforations was 5.6 %. Procedure related mortality was low.

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Minimally Invasive vs. Open Hepatectomy: a Comparative Analysis of the National Surgical Quality Improvement Program Database

Abstract

Background

While minimally invasive surgery (MIS) to treat liver tumors has increased, data on perioperative outcomes of MIS relative to open liver resection (O-LR) are lacking. We sought to compare short-term outcomes among patients undergoing MIS vs. O-LR in a nationally representative database.

Methods

The National Surgical Quality Improvement Program database was used to identify patients undergoing hepatectomy between January 1 and December 31, 2014. Propensity score matching algorithm was used to balance differences in baseline characteristics among MIS and O-LR groups.

Results

A total of 3064 patients were included in the study. After propensity matching, the baseline characteristics for O-LR and MIS groups were comparable (minimum p value = 0.12). Incidence of superficial surgical site infections, intraoperative or postoperative blood transfusions, and pulmonary embolism was lower among patients in MIS group compared to O-LR (p < 0.02). Liver failure and biliary leakage were also less frequent among patients undergoing MIS (p < 0.01). Similarly, MIS was associated with a shorter length of hospital stay (LOS) compared to O-LR (p < 0.001). Of note, 30-day postoperative mortality and readmission were comparable between the two groups.

Conclusions

Patients undergoing MIS had a lower postoperative morbidity and shorter LOS compared with patients undergoing O-LR. MIS is safe and may be associated with improved short-term outcomes following hepatic surgery.

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Preoperative Sarcopenia Strongly Influences the Risk of Postoperative Pancreatic Fistula Formation After Pancreaticoduodenectomy

Abstract

Background

Postoperative pancreatic fistula (POPF) is a serious complication of pancreaticoduodenectomy (PD). Sarcopenia is a newly identified marker of frailty. We performed this study to assess whether preoperative sarcopenia has an impact on clinically relevant POPF formation.

Methods

A total of 266 consecutive patients who underwent a PD between 2010 and 2014 were enrolled in this retrospective study. Skeletal muscle mass was measured using preoperative computed tomography images. The impact of preoperative sarcopenia on clinically relevant POPF formation was analyzed using univariate and multivariate analyses.

Results

Of the 266 patients, 132 (49.6 %) were classified as having preoperative sarcopenia. The rate of clinically relevant POPF formation was significantly higher in the sarcopenia group (22.0 vs. 10.4 %; P = 0.011). A multivariate logistic regression analysis showed that sarcopenia (odds ratio, 2.869; P = 0.007) was an independent risk factor for the development of clinically relevant POPF, along with a soft pancreas and a parenchymal thickness at the pancreatic resection site of ≥8 mm.

Conclusions

Preoperative sarcopenia was identified as a strong and independent risk factor for clinically relevant POPF formation after PD. Perioperative rehabilitation and nutrition therapy may contribute to the prevention of POPF formation and a safer PD.

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Development of Minimally Invasive Pancreatic Surgery: an Evidence-Based Systematic Review of Laparoscopic Versus Robotic Approaches

Abstract

Introduction

Laparoscopic and robotic surgery of the pancreas has only recently emerged as viable treatment options for benign and malignant disease. This review seeks to evaluate the current body of evidence on these approaches to pancreaticoduodenectomy and distal pancreatectomy.

Methods

A systematic review of large published series was performed utilizing the PubMed search engine.

Results

Based on these reports, both the laparoscopic and robotic techniques for these complex procedures appear to be safe and effective, if performed by high volume experienced pancreatic surgeons. The advantages of each approach are highlighted, emphasizing the data available on the learning curve and potential dissemination.

Conclusions

Both minimally invasive approaches to pancreatic resection are safe and feasible.

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Non-lethal Right Liver Atrophy After TIPS Occlusion in A Cirrhotic Patient: Introducing The Hepatic Biembolization

Abstract

Background

Transjugular intrahepatic portosystemic shunt (TIPS) is the standard procedure in the treatment of refractory ascites and variceal bleeding in the setting of portal hypertension. Secondary obstruction of the shunt is a classic but potentially lethal complication.

Methods

We present here the case of a cirrhotic patient that underwent a TIPS for refractory ascites, with early complete thrombosis without lethal complication.

Results

Obstruction of the TIPS led to thrombosis of both the right hepatic and the right portal veins with progressive total atrophy of the right liver and marked hypertrophy of the left liver. Despite initial poor liver function, biological hepatic markers improved slowly until complete recovery.

Conclusion

Hence, we suggest the concept of combined right portal and hepatic vein embolization as a new procedure to induce partial liver hypertrophy before major liver resection, even in cirrhotic patients.

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Positive Lymph Node Ratio as an Indicator of Prognosis and Local Tumor Clearance in N3 Gastric Cancer

Abstract

Background

Nodal metastasis is an important clinical issue in gastric cancer patients. This study was designed to investigate the clinical usefulness of the positive lymph node ratio (PLNR), which reflects both metastatic and retrieved lymph node numbers, in patients with pN3 gastric cancer.

Methods

We retrospectively analyzed the records of 138 consecutive pN3 patients who underwent curative gastrectomy with lymphadenectomy from 2000 to 2012.

Results

A PLNR of 0.4 was proved to be the best cutoff value to stratify the prognosis of patients with pN3 gastric cancer (P < 0.001). Univariate and multivariate analyses revealed that older age, larger tumor size (≥10 cm), and PLNR ≥ 0.4 [P < 0.001, HR 3.1 (95 % CI 1.7–5.4)] were independent prognostic factors in pN3 gastric cancer. Regarding the recurrence, patients with PLNR <0.4 had a significantly lower rate of lymph node recurrence than those with PLNR ≥0.4 (P = 0.020). There was no significant difference in the lymph node recurrence rate between N3a and N3b patients in the PLNR <0.4 group [P = 0.546, 11.6 % (7/60) vs. 12.5 (1/8)], indicating a better local control regardless of pN3 subgroups.

Conclusions

PLNR is useful to stratify the prognosis and evaluate the extent of local tumor clearance in pN3 gastric cancer.

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Routine Cyst Fluid Cytology Is Not Indicated in the Evaluation of Pancreatic Cystic Lesions

Abstract

Background

The work-up of cystic lesions of the pancreas often involves endoscopic ultrasound (EUS) with fine needle aspiration (FNA). In addition to CEA and amylase measurement, fluid is routinely sent for cytologic examination. We evaluated the utility of cytologic findings in clinical decision-making.

Materials and Methods

Records of patients who underwent EUS-guided pancreatic cyst aspiration were reviewed. Findings from axial imaging and EUS were compared to cyst fluid cytology as well as fluid amylase and CEA. All results were then compared to final diagnosis, determined by clinical analysis for those patients not resected, and surgical pathology report for those who underwent resection.

Results

A total of 167 patients were reviewed. Of 48 patients with suspicious findings on imaging, cytology yielded diagnostic information in 89.6 % of cases (43 patients). However, in the 119 patients where no suspicious components were revealed on imaging, fluid cytology yielded no significant diagnostic results in any case. In all cases where mucin was noted on cytologic review, thick fluid was also seen at the time of aspiration.

Discussion

In our cohort of patients with cystic pancreatic lesions, cytologic analysis of pancreatic cyst fluid yielded no diagnostic benefit over radiologic findings alone. In such cases where fluid is to be aspirated, specimens that would otherwise be sent for cytologic evaluation would be better served for other purposes, such as molecular analysis or banking for future research.

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Anal adenocarcinoma presenting as a non-healing ischiorectal wound

Abstract

We describe the diagnosis and management of a patient with a progressively enlarging, non-healing ischiorectal wound. This patient was further evaluated with radiological investigations which showed the presence of a large left ischiorectal fossa mass. Histology confirmed this mass as an anal adenocarcinoma. Anal Adenocarcinoma is a rare condition that can arise from chronic inflammatory states. Treatment requires an abdomino-perineal resection with neoadjuvant therapy, and the goal of surgery is to achieve clear resection margins.

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Esophageal Cancer Treatment Is Underutilized Among Elderly Patients in the USA

Abstract

Objectives

Large numbers of elderly patients in the USA receive no treatment for esophageal cancer, despite evidence that multimodality treatment can increase survival. Our goal is to identify factors that may contribute to lack of treatment.

Materials and Methods

Using Surveillance Epidemiology and End Results (SEER)-Medicare Linked Database (2001−2009), we identified regional esophageal cancer patients ≥65 years old. Treatment was defined as receiving any medical or surgical therapy for esophageal cancer. Logistic regression analysis was performed to identify factors associated with failure to receive treatment. Overall survival (OS) was analyzed using the Kaplan-Meier method and Cox proportional hazard model.

Results

There were 5072 patients (median age, 75 years; interquartile range (IQR), 71–81 years). Majority were treated with definitive chemoradiation (48.49 %). Factors associated with lack of treatment included West geographic region and ≥80 years old. Patients who received therapy had better OS (log-rank, p < 0.001). Compared with treated patients, non-treated patients had worse adjusted OS (HR, 1.43; 95 % confidence interval (CI), 1.33–1.55; p < 0.001).

Conclusions

Elderly patients with locally advanced esophageal cancer who received treatment had improved 5-year survival compared with patients without treatment. Disparities in utilization of treatment are associated with regional and socioeconomic factors, not presence of comorbidities.

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Robotic Mirror Therapy System for Functional Recovery of Hemiplegic Arms

We developed a real-time mirror robot system for functional recovery of hemiplegic arms using automatic control technology, conducted a clinical study on healthy subjects, and determined tasks through feedback from rehabilitation doctors. This simple mirror robot can be applied effectively to occupational therapy in stroke patients with a hemiplegic arm.

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Capturing and Incorporating Patient-Reported Outcomes into Clinical Trials: Practical Considerations for Clinicians

Abstract

Patient centeredness as the focus of healthcare delivery requires the incorporation of patient-reported outcomes into clinical trials. Clearly defining measurable outcomes as well as selecting the most appropriate validated collection tool to use is imperative for success. Creating and validating one's own instrument is also possible, albeit more cumbersome. Meticulous data collection to avoid missing data is key, as is limiting the number of data collection points to prevent survey fatigue and using electronic systems to facilitate data gathering and analysis. Working in a multidisciplinary team that includes statisticians with expertise in patient reported outcomes is essential to navigate the complexities of statistical analysis of these variables. Use of available and emerging technologies for data collection and analysis as well as data sharing will greatly facilitate the process of incorporating patient-reported outcomes into trials and routine clinical practice.

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Open-label, multicenter, phase 1 study of alisertib (MLN8237), an aurora A kinase inhibitor, with docetaxel in patients with solid tumors

BACKGROUND

This study was designed to determine the safety, tolerability, and pharmacokinetics (PK) of alisertib (MLN8237) in combination with docetaxel and to identify a recommended dose for the combination.

METHODS

Adults with metastatic cancer were treated on 21-day cycles with alisertib (10, 20, 30, or 40 mg) twice daily on days 1 to 7 or days 1 to 5 and with docetaxel (75 or 60 mg/m²) on day 1. The primary objectives were to assess the safety and tolerability of the combination and to determine the recommended phase 2 dose (RP2D) for future studies. Secondary objectives included an efficacy assessment and PK analyses of docetaxel and alisertib.

RESULTS

Forty-one patients participated. Eight dose levels were explored with various doses of alisertib and docetaxel. The dose-limiting toxicities were neutropenic fever, neutropenia without fever, stomatitis, and urinary tract infection. The RP2D of this combination was 20 mg of alisertib twice daily on days 1 to 7 and intravenous docetaxel at 75 mg/m² on day 1 in 21-day cycles. Eight of the 28 patients (29%) who were efficacy-evaluable had objective responses. These included 1 complete response in a patient with bladder cancer, 6 partial responses in patients with castration-resistant prostate cancer, and 1 partial response in a patient with angiosarcoma. Concomitant administration of alisertib did not produce any clinically meaningful change in docetaxel PK.

CONCLUSIONS

Alisertib at 20 mg twice daily on days 1 to 7 with intravenous docetaxel at 75 mg/m² on day 1 in a 21-day cycle was well tolerated, and the combination demonstrated antitumor activity. Cancer 2016;122:2524–33. © 2016 American Cancer Society.

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MRI of paediatric liver tumours: How we review and report

Abstract

Liver tumours are fortunately rare in children. Benign tumours such as haemangiomas and cystic mesenchymal hamartomas are typically seen in infancy, often before 6 months of age. After that age, malignant hepatic tumours increase in frequency. The differentiation of a malignant from benign lesion on imaging can often negate the need for biopsy. Ultrasound is currently the main screening tool for suspected liver pathology, and is ideally suited for evaluation of hepatic lesions in children due to their generally small size. With increasing research, public awareness and parental anxiety regarding radiation dosage from CT imaging, MRI is now unquestionably the modality of choice for further characterisation of hepatic mass lesions.

Nevertheless the cost, length of imaging time and perceived complexity of a paediatric liver MR study can be intimidating to the general radiologist and referring clinician. This article outlines standard MR sequences utilised, reasons for their utilisation, types of mixed hepatocyte specific/extracellular contrast agents employed and imaging features that aid the interpretation of paediatric liver lesions. The two commonest paediatric liver malignancies, namely hepatoblastoma and hepatocellular carcinoma are described. Differentiation of primary hepatic malignancies with metastatic disease and mimickers of malignancy such as focal nodular hyperplasia (FNH) and hepatic adenomas are also featured in this review..

Imaging should aim to clarify the presence of a lesion, the likelihood of malignancy and potential for complete surgical resection. Reviewing and reporting the studies should address these issues in a systematic fashion whilst also commenting upon background liver parenchymal appearances. Clinical information and adequate patient preparation prior to MR imaging studies help enhance the diagnostic yield.

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A microporous Cu-MOF with optimized open metal sites and pore spaces for high gas storage and active chemical fixation of CO2

Chem. Commun., 2016, Accepted Manuscript
DOI: 10.1039/C6CC05845K, Communication

Chaoying Gao, Hong-Rui Tian, Jing Ai, Leijiao Li, Song Dang, Ya-Qian Lan, Zhong-Ming Sun
A microporous Cu-MOF with optimized open metal sites and pore space was constructed based on a designed bent ligand; it exhibits high-capacity multiple gas storage under atmospheric pressure and efficiently...
The content of this RSS Feed (c) The Royal Society of Chemistry

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Designed miniaturization of microfluidic biosensor platforms using the stop-flow technique

Analyst, 2016, Accepted Manuscript
DOI: 10.1039/C6AN01330A, Paper

Can Dincer, Andre Kling, Claire Chatelle, Lucas Armbrecht, Jochen Kieninger, Wilfried Weber, Gerald Urban
Here, we present a novel approach to increase the degree of miniaturization as well as the sensitivity of biosensor platforms by optimization of microfluidic stop-flow techniques independent of the applied...
The content of this RSS Feed (c) The Royal Society of Chemistry

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A Review of Radiation-Induced Coagulopathy and New Findings to Support Potential Prevention Strategies and Treatments

Radiation Research, Volume 186, Issue 2, Page 121-140, August 2016.


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Extracellular Vesicles and Vascular Injury: New Insights for Radiation Exposure

Radiation Research, Volume 186, Issue 2, Page 203-218, August 2016.


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Recombinant Thrombomodulin (Solulin) Ameliorates Early Intestinal Radiation Toxicity in a Preclinical Rat Model

Radiation Research, Volume 186, Issue 2, Page 112-120, August 2016.


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Radiation-Induced Microvascular Injury as a Mechanism of Salivary Gland Hypofunction and Potential Target for Radioprotectors

Radiation Research, Volume 186, Issue 2, Page 189-195, August 2016.


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Transplantation of Endothelial Cells to Mitigate Acute and Chronic Radiation Injury to Vital Organs

Radiation Research, Volume 186, Issue 2, Page 196-202, August 2016.


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Nuclear Countermeasure Activity of TP508 Linked to Restoration of Endothelial Function and Acceleration of DNA Repair

Radiation Research, Volume 186, Issue 2, Page 162-174, August 2016.


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Hemodynamic Flow-Induced Mechanotransduction Signaling Influences the Radiation Response of the Vascular Endothelium

Radiation Research, Volume 186, Issue 2, Page 175-188, August 2016.


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A Molecular Profile of the Endothelial Cell Response to Ionizing Radiation

Radiation Research, Volume 186, Issue 2, Page 141-152, August 2016.


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Understanding the Pathophysiology and Challenges of Development of Medical Countermeasures for Radiation-Induced Vascular/Endothelial Cell Injuries: Report of a NIAID Workshop, August 20, 2015

Radiation Research, Volume 186, Issue 2, Page 99-111, August 2016.


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Ionizing Radiation-Induced Endothelial Cell Senescence and Cardiovascular Diseases

Radiation Research, Volume 186, Issue 2, Page 153-161, August 2016.


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Spleen Salvaging Treatment Approaches in Non-parasitic Splenic Cysts in Childhood

Abstract

The aim of this study was to evaluate our experience with primary non-parasitic splenic cysts (NPSC) which are relatively rare in children and consist almost exclusively of single case reports or small case series in the literature. The medical records of all patients who presented to our clinic with NPSC between 2005 and 2015 were evaluated retrospectively. There were 22 children whose ages ranged from 2 months to 14 years (mean 9.2 ± 4.7 years). The size of the cysts was in the range of 5 to 200 mm (mean 55.4 ± 48.2 mm). Ten patients underwent surgery for splenic cysts. Partial splenectomy (n = 2), total cyst excision (either open n = 4 or laparoscopically n = 1), and total splenectomy (n = 3) were performed. The non-operated patients were asymptomatic and followed with ultrasound (US). The follow-up period in non-operated patients ranged from 6 months to 5 years (mean 2.27 ± 1.29 years). Complete regression was observed in four (33 %) non-operated patients. The regressed cyst measurements were 10, 16, 30, and 40 mm, respectively. Approximately half of the NPSC is diagnosed incidentally. Small (<5 cm) asymptomatic cysts should be under regular follow-up with US/physical examination for regression. If surgery is required, we prefer open cyst excision as it gives excellent results and preserves splenic immune function.

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Radical Vaginal Trachelectomy with Laparoscopic Pelvic Lymphadenectomy for Fertility Preservation in Young Women with Early-Stage Cervical Cancer

Abstract

The primary objective of this study was to describe our experience with the conservative treatment of early-stage cervical cancer (stages IA1, IA2, and IB1) with radical vaginal trachelectomy (RVT) and laparoscopic pelvic lymphadenectomy. This retrospective observational case series included 36 patients with early cervical cancer. Radical trachelectomy and laparoscopic pelvic lymphadenectomy were performed as described by D. Dargent in 32 of these cases. Oncologic, reproductive, and obstetric outcomes were observed subsequently over a median period of 42 (24–96) weeks. A total of 32 RVTs were preformed with a mean operating time of 117 ± 22.8 (77–167) minutes and an average blood loss of 486 mL (150–800 mL). All obtained resection margins were negative for cancer. Lymphovascular space invasion was noted in 11 (30.55 %) of the cases. No recurrences occurred during the study period. Seven (17.8 %) patients were able to become pregnant postoperatively, five of whom delivered healthy infants near term. Radical vaginal trachelectomy with laparoscopic pelvic lymphadenectomy appears to be a safe therapeutic option for fertility preservation in young women with early cervical cancer.

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A Prospective Randomized Study Comparing Fibrin Glue Versus Prolene Suture for Mesh Fixation in Lichtenstein Inguinal Hernia Repair

Abstract

The aim of this study is to assess the advantages of fibrin glue over Prolene suture in fixation of the mesh in open inguinal hernia repair. Sixty-four cases of inguinal hernia underwent hernia repair by the Lichtenstein method in the department of surgery in PGIMER & Dr. RML Hospital, New Delhi. The patients were randomized prospectively into group A (fibrin glue group) and group B (Prolene suture group). In group A, fibrin glue was used for mesh fixation, and in group B, Prolene suture was used for mesh fixation. The mean age of patients in group A was 44.5 years and that of group B patients was 44.2 years. There was a significant difference in the duration of surgery, with the mean duration in fibrin glue group being 30.6 min and that of the suture group was 43.3 min. The mean visual analogue pain score of postoperative pain at 1, 6, 12, and 24 h was significantly higher in the suture group than in the fibrin glue group (p < 0.001). The mean total dose of analgesia in ampoules of tramadol was significantly less in the fibrin glue group (1.56 ampoules) than that in the suture group (4.125 ampoules) with p = 0.000. At the end of the first month, 25 % of subjects in the suture group presented with mild groin pain (p value = 0.0048). At the end of the second and third month, 22 % (p 68 value = 0.0048) and 12.5 % (p value = 0.1132) of subjects respectively presented with mild groin pain in the suture group. The present study demonstrates that the use of fibrin glue in place of Prolene suture for mesh fixation in open inguinal hernia repair can help decreasing the time required for surgery, reduce the intensity of postoperative pain, shorten the duration of hospital stay, and prevent the incidence of chronic groin pain.

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Comparison of Single-Incision and Conventional Laparoscopic Cyst Excision and Roux-en-Y Hepaticojejunostomy for Children with Choledochal Cysts

Abstract

The purpose of this study was to elucidate the potential benefits of single-incision laparoscopic Roux-en-Y hepaticojejunostomy comparing the conventional laparoscopic procedures. From January 2013 to July 2013, 17 consecutive children with choledochal cysts received single-incision laparoscopic Roux-en-Y hepaticojejunostomies by a single surgeon at our institution. Seventeen standard laparoscopic hepaticojejunostomies of consecutive children with choledochal cysts from July 2012 to December 2012 were employed as control. Demographic and perioperative information was identified retrospectively using clinic and hospital records including gender, age, total operating time, estimated blood loss, time to oral intake, drainage removal time, postoperative complications, and postoperative hospital stay. One patient was converted to open surgery and another 8-year-old boy conversed to conventional four-port laparoscopic procedure. There were no significant differences between the conventional laparoscopic group and the single-incision laparoscopic group with regard to preoperative variables including age (P = 0.697) and sex distribution (P = 1.000). For mean operative time (209.9 ± 7.5 vs 204.1 ± 6.9 min, P = 0.951), estimated blood loss (10.7 ± 1.1 vs 13.4 ± 1.7 ml, P = 0.103), time to oral intake (3.73 ± 0.21 vs 3.77 ± 0.20 days, P = 0.889), drainage removal time (4.20 ± 0.45 vs 4.06 ± 0.23 days, P = 0.067), and postoperative hospital stay (7.60 ± 0.25 vs 7.41 ± 0.21 days, P = 0.627), the differences were also nonsignificant. Nevertheless, this technique demonstrated improved cosmetic outcomes comparing with the conventional laparoscopic group. The results showed better cosmetic results and comparable postoperative outcomes. However, well-designed prospective studies are warranted to better address this issue.

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Test Post - PD

This is a test and will be closed on 8/16/2016. Please disregard. R, Lyons

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Correlation of Molecular Subtypes of Invasive Ductal Carcinoma of Breast with Glucose Metabolism in FDG PET/CT: Based on the Recommendations of the St. Gallen Consensus Meeting 2013

Abstract

Purpose

This study aimed to investigate the relationship between the SUVmax of primary breast cancer lesions and the molecular subtypes based on the recommendations of the St. Gallen consensus meeting 2013.

Methods

Clinical records of patients who underwent F-18 FDG PET/CT for initial staging of invasive ductal carcinoma (IDC) of the breast were reviewed. A total of 183 patients were included. SUVmax was correlated with the molecular subtypes defined by the St. Gallen Consensus Meeting 2013, i.e., luminal A-like (LA), luminal B-like HER2 negative (LBHER2-), luminal B-like HER2 positive (LBHER2+), HER2 positive (HER2+), and triple negative (TN), and with the clinicohistopathologic characteristics.

Results

The molecular subtype was LA in 38 patients, LBHER2- in 72, LBHER2+ in 21, HER2+ in 30, and TN in 22. The mean SUVmax in the LA, LBHER2-, LBHER2+, HER2+, and TN groups were 4.5 ± 2.3, 7.2 ± 4.9, 7.2 ± 4.3, 10.2 ± 5.5, and 8.8 ± 7.1, respectively. Although SUVmax differed significantly among these subtypes (p < 0.001), the values showed a wide overlap. Optimal cut-off SUVmax to differentiate LA from LBHER2-, LBHER2+, HER2+ and TN were 5.9, 5.8, 7.5, and 10.2 respectively, with area under curve (AUC) of 0.648, 0.709, 0.833, and 0.697 respectively. The cut-off value of 5.9 yielded the highest accuracy for differentiation between the LA and non-LA subtypes, with sensitivity, specificity, and AUC of 79.4 %, 57.9 %, and 0.704 respectively.

Conclusion

The SUVmax showed a significant correlation with the molecular subtype. Although SUVmax measurements could be used along with immunohistochemical analysis for differentiating between molecular subtypes, its application to individual patients may be limited due to the wide overlaps in SUVmax.

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Predictive value of hypoxia in advanced head and neck cancer after treatment with hyperfractionated radio-chemotherapy and hypoxia modification

Abstract

Purpose

Hypoxia has predictive value in head and neck cancer (HNC). It has been well described, albeit in a small number of clinical Centres. The aim of this study was to describe our experience using the polarographic probe technique to assess the predictive value of tumour oxygenation in patients with advanced HNC treated with hyperfractionated radio-chemotherapy. Hypoxia modification was induced using percutaneous spinal cord stimulation (SCS).

Methods/patients

Male patients (n = 12; stage IVb n = 8; IVa n = 4; mean age 58: range 46–70 years) with advanced HNC were evaluated. Planned therapy was hyperfractionated-radiotherapy, oral tegafur (precursor of 5-fluorouracil) and hypoxia modification using SCS. Pre-treatment analyses included: haemoglobin levels and tumour oxygenation (using the Eppendorf polarographic probe device). Oxygenation was expressed as median-pO₂ (in mmHg) and hypoxia as the percentage of pO₂ values ≤5 mmHg (HP5) and ≤2.5 mmHg (HP2.5).

Results

Lower haemoglobin levels were directly correlated with median pO₂ (p = 0.017) and inversely correlated with HP5 (p = 0.020) and more advanced stages (IVb vs. IVa; p = 0.028). Patients who subsequently developed systemic metastasis had tumours that were more hypoxic, with lower median pO₂ (p = 0.036) and higher HP5 (p = 0.036). The subgroup of patients with HP2.5 above the median (the most hypoxic tumours) had lower loco-regional control (p = 0.027), cause-specific survival (p = 0.008), and overall survival (p = 0.008).

Conclusions

Higher tumour hypoxia showed predictive value in HNC in our study, and was significantly associated with lower overall survival, cause-specific survival, and loco-regional control. Tumour hypoxia determination could be used to select patients who would most benefit by hypoxia modification during chemo-radiotherapy of HNC.

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Performance of the clinical index of stable febrile neutropenia (CISNE) in different types of infections and tumors

Abstract

Purpose

The clinical index of stable febrile neutropenia (CISNE) can contribute to patient safety without increasing the complexity of decision-making. However, febrile neutropenia (FN) is a diverse syndrome. The aim of this analysis is to assess the performance of CISNE according to the type of tumor and infection and to characterize these patients.

Methods

We prospectively recruited 1383 FN episodes in situations of apparent clinical stability. Bonferroni-adjusted z tests of proportions were used to assess the association between the infections suspected at the time of onset and the type of tumor with the risk of serious complications and mortality. The performance of CISNE was appraised in each category using the Breslow-Day test for homogeneity of odds ratios and Forest Plots.

Results

171 patients had a serious complication (12.3 %, 95 % confidence interval 10.7–14.2 %). The most common initial assumptive diagnoses were: fever without focus (34.5 %), upper respiratory infection (14.9 %), enteritis (12.7 %), stomatitis (11.8 %), and acute bronchitis (10.7 %). Lung and breast were the most common tumors, accounting for approximately 56 % of the series. The distribution of complications, mortality, and bacteremia varies for each of these categories. However, Breslow-Day tests indicate homogeneity of the odds ratio of the dichotomized CISNE score to predict complications in all infection and tumor subtypes.

Conclusion

Despite FN's clinical and microbiological heterogeneity, the CISNE score was seen to be consistent and robust in spite of these variations. Hence, it appears to be a safe tool in seemingly stable FN.

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Adjuvant Therapy of Resected Non-small Cell Lung Cancer: can We Move Forward?

Opinion statement

Twenty years ago, an individual patient data meta-analysis of eight cisplatin-based adjuvant chemotherapy (AC) studies in completely resected early stage non-small cell lung cancer (NSCLC) demonstrated a 13 % reduction of the risk of death favoring chemotherapy that was of borderline statistical significance (p = 0.08). This marginal benefit boosted a new generation of randomized trials to evaluate the role of modern platinum-based regimens in resectable stages of NSCLC and, although individual studies generated conflicting results, overall they contributed to confirm the role of AC which is now recommended for completely resected stage II and III NSCLC, mostly 4 cycles, while subset analyses suggested a benefit in patients with large IB tumors. Cisplatin-based therapy was the core regimen of those adjuvant clinical trials and even if a substitution with other platinum-derived was also suggested, mainly based on extrapolated data from studies in advanced disease, cisplatin was confirmed to be slightly superior to carboplatin and is still the drug of choice in the adjuvant setting. Currently, any attempt to improve efficacy of cisplatin-based chemotherapy through antiangiogenic drugs association or pharmacogenomics approaches have failed, while results of additional studies are eagerly awaited. In the context of promising targeted therapies, even if several randomized trials in the advanced setting evaluated tyrosine kinase inhibitors (TKis) versus platinum-based chemotherapy and showed impressive results, clinical experience with TKIs in the adjuvant setting is still limited and most of the trials have not required patients to be molecularly tested for the drug-specific molecular predictive factor. At the present time, the role of targeted agents as adjuvant approaches remains largely not investigated. Finally, with the negative experience of the use of vaccines in this setting, the integration of immunotherapy (mainly immunocheckpoint inhibitors) in platinum-based schedules has just started to be evaluated, representing a potential future clinical option, but still far from clinical practice.

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The Influence of Radiotherapy on AIM2 Inflammasome in Radiation Pneumonitis

Abstract

This study aims to investigate the influence of radiotherapy on absent in melanoma 2 (AIM2) inflammasome in radiation pneumonitis (RP). A rat model of RP was established. H&E staining was used to test radiation-induced lung tissue injury. Immunohistochemistry (IHC) was used to detect the expression of AIM2 and IL-1β in rat lung tissues. Milliplex assay was used to test cytokine levels in rat serum. Comet assay was adopted to examine DNA breaks in THP1 cells. RT-PCR was used to detect the messenger RNA (mRNA) expression of AIM2, caspase-1, and IL-1β in THP1 cells. As a result, the rat model indicated that irradiation induced obvious lung injury. A large amount of inflammatory cells infiltrated to the irradiated lung tissues. The structure of lung tissues collapsed. IHC revealed that AIM2 and IL-1β expressions were significantly higher in irradiated lung tissues than in the control. IL-1β level in rat serum significantly elevated on the 7th day post-irradiation, gradually decreased on the 15th day, and became minimal on the 30th day. Irradiation induced dsDNA break in a dose-dependent manner at 24 h after irradiation. Radiotherapy increased the mRNA expression level of AIM2 and IL-1β in a time-dependent manner. In conclusion, radiotherapy triggered some critical components of AIM2 inflammasome in RP. The activation of AIM2 inflammasome by radiotherapy may contribute to the pathogenesis of RP.

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Vitamin A Deficiency Promotes Inflammation by Induction of Type 2 Cytokines in Experimental Ovalbumin-Induced Asthma Murine Model

Abstract

Vitamin A (VA) deficiency is one of the most common malnutrition conditions. Recent reports showed that VA plays an important role in the immune balance; lack of VA could result in enhanced type 2 immune response characterized by increased type 2 cytokine production and type 2 innate lymphoid cell infiltration and activation. Type 2 immune response plays protective role in anti-infection but plays pathological role in asthmatic disease. In order to investigate the role of VA in the asthmatic disease, we used ovalbumin-induced asthma murine model and observed the pathological changes between mouse-received VA-deficient and VA-sufficient diets. We also measured the type 2 cytokine expressions to reveal the potential mechanism. Our results showed that VA deficiency exacerbates ovalbumin-induced lung inflammation and type 2 cytokine productions. Thus, VA deficiency, or malnutrition in further extent, may contribute to the increasing prevalence of asthma.

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Inhibitory Effects of Astragaloside IV on Bleomycin-Induced Pulmonary Fibrosis in Rats Via Attenuation of Oxidative Stress and Inflammation

Abstract

In this study, we investigated the effects of astragaloside IV (As-IV) on pulmonary fibrosis and its mechanisms of action. Sprague-Dawley rats were used in a model of pulmonary fibrosis induced by an intratracheal instillation of bleomycin (BLM). Rats were intraperitoneally injected with As-IV (10, 20, 50 mg/kg) daily for 28 days, while the rats in control and BLM groups were injected with a saline solution. The effects of As-IV treatment on pulmonary injury were evaluated with the lung wet/dry weight ratios, cell counts, and histopathologic. Oxidative stress was evaluated by detecting the levels of malondialdehyde (MDA), superoxide dismutase (SOD), total antioxidant capacity (T-AOC), and reactive oxygen species (ROS) in lung tissue. Inflammation was assessed by measuring the levels of tumor necrosis factor (TNF)-α, interleukin (IL)-1β, and IL-6 in bronchoalveolar lavage fluid (BALF). The results indicated that As-IV treatment remarkably ameliorated BLM-induced pulmonary fibrosis and attenuated BLM-induced oxidative stress and inflammation. Our findings indicate that As-IV-mediated suppression of fibroproliferation may contribute to the anti-fibrotic effect against BLM-induced pulmonary fibrosis. Its mechanisms of action are associated with inhibiting oxidative stress and inflammatory response. In summary, our study suggests a therapeutic potential of As-IV in the treatment of pulmonary fibrosis.

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Healthy and Inflamed Gingival Fibroblasts Differ in Their Inflammatory Response to Porphyromonas gingivalis Lipopolysaccharide

Abstract

Porphyromonas gingivalis (P. gingivalis) lipopolysaccharide (LPS) can induce the host immune response in periodontitis patients. Human gingival fibroblasts (GFs) play an important role in regulating the host immune response in periodontitis. However, whether GFs isolated from healthy subjects (HGFs) and inflamed ones (IGFs) can modulate different inflammatory response remains problematic. The aim of this study was to investigate the expression of different inflammatory cytokines between HGFs and IGFs after P. gingivalis LPS stimulation. In this study, hematoxylin and eosin (H&E) staining was used to assess the inflammation status of gingiva. HGFs and IGFs were stimulated with 1, 5, and 10 μg/ml P. gingivalis LPS for 6, 12, and 24 h. The amount of inflammatory cytokines, interleukin (IL)-1β, IL-6, IL-8 and tumor necrosis factor (TNF)-α, was determined by enzyme-linked immunosorbent assay (ELISA) and quantitative real-time polymerase chain reaction (qRT-PCR). The results showed that gingiva from periodontitis patients presented epithelial hyperkeratosis and abundant inflamed cells in the connective tissue. HGFs participated in the overproduction of IL-8 and IL-1β in a dose- and time-dependent manner; however, IL-6 and TNF-α just showed a dose-response change when stimulated with LPS after 24 h. In IGFs, IL-6, IL-8, IL-1β, and TNF-α could be induced by lower LPS with shorter time stimulation and the dose-response phenomenon was observed in mRNA levels. In conclusion, the resident IGFs do not exhibit LPS tolerance and play an important role in modulating host immune response, which are critical in the immunopathogenesis of periodontal disease.

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Succession planning: 5 keys to developing paramedic chiefs and EMS leaders

Succession planning is useful to develop personnel for all levels of leadership in your EMS agency.

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A salty tale: What EMS personnel need to know about electrolyte disorders

You may have wondered what the emergency department physician is looking for when she orders lab tests on a patient's electrolyte levels. The answer is fairly straightforward; without an adequate balance of electrolytes, the body is unable to perform many mission-critical functions. In fact, certain electrolyte imbalances can quickly become life-threatening.

While EMS providers generally are unable to determine electrolyte levels in the field, a careful analysis of the patient's presentation, coupled with a well-conducted history taking, can bring an electrolyte disorder to light.

Chemically, electrolytes are salts. They dissolve (or disassociate) in water to form electrically-charged ions. An ion that is positively (+) charged is called a cation; an ion that is negatively (-) charged is called an anion. For example, sodium chloride (NaCL) becomes sodium ions (Na⁺) and chloride anions (Cl^-) when dissolved in water.

Electrolytes are essential to the conduction of the electrical pulses needed to control all living functions within the body. It is the amount and location of the cations and anions that allows energy to be conducted. Other essential life functions include the regulation of water within and outside the cells, muscle contraction and maintaining the general balance of the cell's operating environment.

Here are the key electrolytes for homeostasis, along with associated signs and symptoms when their levels are too high or too low.

Sodium
Why sodium is important: Sodium (Na⁺) is found mostly outside of cells. Its major role is to regulate the amount of water inside the body. As the kidney excretes sodium, water follows it, creating urine. Sodium is also a key electrolyte in creating electrical impulses both within and across cells, which allow a wide variety of functions to occur. This is critical for the brain, nervous system and muscles.

A normal lab value for sodium is 135–145 mEq/L.

When sodium levels get too high: Kidney disease, excessive water loss from massive diarrhea and vomiting, or too little water intake are the major causes of hypernatremia. Patients complain of excessive thirst. Tachycardia, anxiety and fatigue are other pertinent signs and symptoms. In severe cases of hypernatremia, altered mental status and seizures may occur.

When sodium levels get too low: Liver disease, some forms of kidney disease, congestive heart failure, burns and rarely overhydration can cause hyponatremia. Signs and symptoms include fatigue, nausea, vomiting, muscle spasms and weakness. Seizures may also occur in severe circumstances.

Potassium
Why potassium is important: Potassium (K⁺) is found mostly inside cells. It works in conjunction with sodium to propagate electrical signals in cells. Sodium-potassium pumps are embedded into the cell membrane, and work like pumps to keep levels of potassium high in the cell and sodium levels high in the surrounding interstitial space.

This creates a polarized electrical state across the cell's membrane. An electrical stimulus from a nearby cell triggers sodium and potassium channels to quickly open in sequence. This allows sodium to rush into the cell first, changing the cell's polarized state. Potassium then rushes out, dampening the effect.

This creates a depolarization of the cell, creating an electrical signal that triggers a wide range of effects, such as muscle contraction, hormones released from glands, and contraction of the heart. The sodium-potassium pumps then push the electrolytes back across the membrane, allowing the polarized state to exist again.

Normal lab values for potassium are 3.5–5.0 mEq/L.

When potassium levels are too high: Similar to sodium, the potassium levels are regulated by excretion through the kidneys. Patients with renal disease are at risk for developing hyperkalemia. Certain medications can also cause potassium levels to rise, such as potassium-sparing diuretics — spironolactone, triamterene), NSAIDs, ACE inhibitors and heparin.

Hyperkalemia is a potentially lethal condition that can manifest itself quickly. As levels rise, patients complain of muscle weakness, fatigue, numbness or tingling and nausea and vomiting. At high doses, bradycardia, hypotension and respiratory arrest. On an EKG, wide QRS complexes and unusually tall, peaked T waves can be seen.

When potassium levels are too low: Kidney disease, excessive vomiting or diarrhea, overuse of laxatives, excessive sweating, medications such as diuretics related to furosemide, beta-2 agonists such as albuterol, and certain antimicrobials such as penicillin can cause hypokalemia. Patients with hypokalemia may have symptoms similar to hyperkalemia, including weakness, fatigue, cramping and constipation. Lethal dysrhythmias appear as levels drop to dangerously low levels.

Chloride
Why chloride is important: Chloride (Cl^-) is the major anion found mostly outside of the cell. Its major functions are to help keep fluid levels in balance and help to balance acidity levels.

Normal lab values for chloride are 98 - 108 mmol/L.

When chloride levels are too high: Hyperchloremia is more rare than hypernatremia and hyperkalemia. It usually results from major diarrhea, certain kidney diseases and occasionally from parathyroid gland disease. Patients may complain of headaches, nausea and fatigue. They may be tachypneic in order to compensate for the corresponding metabolic acidosis. In severe cases of hyperchloremia, hypotension and ventricular fibrillation may occur.

When chloride levels are too low: Hypochloremia can result from excessive sweating or urination. Vomiting can also cause chloride levels to fall, as well as adrenal gland disease. Patients may experience tetany (muscle spasms), muscle weakness, difficulty breathing and fever.

Calcium
Why calcium is important: Calcium (Ca²⁺) is the most common cation in the body, with most of it found in bone and teeth. It also has a critical function in conducting electrical signals, as well as muscle contraction and blood clotting.

Normal lab values for calcium are 9–11 mg/dL or (4.5–5.5 mEq/L).

When calcium levels are too high: Hypercalcemia primarily results from noncancerous tumors that cause parathyroid glands to over secrete their hormones. Cancer, certain medications like lithium, or ingesting excessive calcium supplements are other potential causes.

Signs of hypercalcemia can be organized according to the following mnemonic:

• Moans: abdominal pain, nausea, constipation
• Groans: lethargy, weakness, confusion and coma
• Stones: polyuria, kidney stones, renal failure
• Bones: bone aches and pains, fractures).

In severe cases, changes in the patient's EKG include a shortened QT interval associated with a shortened ST segment, flattened T waves and the presence of Osborn waves.

When calcium levels are too low: Hypocalcemia tends to occur most commonly in chronic and acute renal failure. Deficiencies in magnesium or vitamin D can also cause a drop in calcium levels, as well as hypoparathyroidism and acute pancreatitis. Severe cases of hypocalcemia include confusion, lethargy, muscle cramping or weakness and paresthesia.

Phosphate
Why phosphate is important: Phosphorous is the second most abundant mineral in the body. The anion phosphate (HPO^4-) is found mostly in the skeleton, along with calcium. However, it is a major component in adenosine triphosphate (ATP) production, the primary energy source for cells. It is also involved in cell reproduction and repair.

Normal lab values for phosphate are 2.4–4.7 mg/dL.

When phosphate levels are too high: Like other electrolytes, most cases of hyperphosphatemia result from some form of kidney disease. Excessive intake of phosphate is a less common cause. Hypoparathyroidism and metabolic or respiratory acidosis can cause phosphate levels to rise as well. Signs of hyperphosphatemia are similar to hypocalcemia, as the two conditions are often correlated.

When phosphate levels are too low: Hyperparathyroidism prevents the kidneys from retaining adequate levels of phosphate, as well as calcium, causing hypophosphatemia. Poor diet, especially related to alcoholism, can cause phosphate levels to drop. Hypophosphatemia can also be seen in patients being treated for diabetic ketoacidosis, or patients with respiratory alkalosis. Weakness, bone pain, rhabdomyolysis and altered mental status are the most common presenting features of persons with symptomatic hypophosphatemia.

Magnesium
Why is magnesium important: Magnesium (Mg²⁺) plays a major role in maintaining normal function in the nervous system, muscle contraction, and cardiac physiology. It also is a major component of DNA and RNA synthesis as well as bone formation.

Normal lab values for magnesium are 1.8–3.0 mg/dL (1.5–2.5 mEq/L).

When magnesium levels are too high: Hypermagnesemia is usually due to kidney disease. Excessive intake, lithium therapy, hypothyroidism and Addison's disease are other less common causes. Severe cases of hypermagnesemia may be lethal, resulting in respiratory depression, failure or arrest, hypotension and cardiac arrest. Milder cases may result in lethargy, poor deep tendon reflexes, nausea or vomiting and skin flushing.

When magnesium levels are too low: Hypomagnesemia is often associated with alcoholism. Chronic diarrhea, burns, polyuria (excessive urination) and hypercalcemia can cause magnesium levels to fall. Patients may experience generalized weakness, muscle tremors, tetany parathesia and heart palpitations.

Electrolyte disorders: 4 Take home points
Differentiating electrolyte disturbances can be difficult in the field, with many overlapping signs and symptoms. Here are a couple of key points for patient assessment and treatment:

1. Of the different disorders, hyperkalemia is the most significant one to be aware of. Patients with kidney disease, especially those requiring dialysis are at significant risk for hyperkalemia.
2. Suspect an electrolyte disorder if the patient has had a period of prolonged nausea, vomiting and or diarrhea. Suspicions should rise if there is a history of renal disease.
3. Unexplained weakness, muscle spasms and numbness or tingling may point to an electrolyte disturbance.
4. An electrolyte imbalance may be the underlying cause in patients with altered mental status or reduced level of consciousness.

Finally, it is not the field provider's primary responsibility to identify the specific electrolyte disturbance. However, by paying attention to the history of the illness and some of the more subtle signs and symptoms, EMS providers can provide a more detailed report to emergency department personnel, alerting them to the possibility of an electrolyte imbalance emergency. Perhaps more importantly, recognizing that a severe electrolyte imbalance may exist can better prepare you to respond quickly if the patient suddenly takes a turn for the worse while in your care.

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Battery-Free Skin Sensors Run on Wireless Energy of Smartphone

A team headed by the prolific John A. Rogers of the University of Illinois at Urbana-Champaign has unveiled an optical skin sensor that has no battery or wires to power it. Instead, the flexible and stretchable device harvests energy delivered from a nearby smartphone or tablet using magnetic inductive coupling. The readings it obtains are beamed back to the mobile device using near field communication (NFC), an ultra-low method of passing data between nearby devices that you may have experienced when using Apple or Android payment systems.

To show that the power transmission is sufficient and practical enough for clinical and at-home applications, the team demonstrated heart rate monitoring, temporal dynamics of arterial blood flow, temperature, measurement of tissue oxygenation and exposure to ultraviolet light, as well as four-color spectroscopy detecting small changes in skin color.

The energy can be delivered from smaller devices such as smartphones at a fairly short distance, only about an inch or so (~ 2 cm), but larger transmitters can extend that to about a yard (~1 m). This should make it practical for bedridden patients who would have a patch attached to the skin while a power generator located nearby, such as under the mattress, would power it. Moreover, a set of wireless patches such as this can measure a comprehensive set of varied health parameters that currently require dozens of wires in today's clinical practice.

Study in Science Advances: Battery-free, stretchable optoelectronic systems for wireless optical characterization of the skin…

Via: IEEE Spectrum…

Image: Jeonghyun Kim, AAAS

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Wet Chemistry and Peptide Immobilization on Polytetrafluoroethylene for Improved Cell-adhesion

Cell-adhesiveness is key to many approaches in biomaterial research and tissue engineering. A step-by-step technique is presented using wet-chemistry for the surface modification of the important polymer PTFE with peptides.

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