Endoscopic techniques for the diagnosis of pancreatic cystic lesions

Pancreatic cysts are mostly incidental findings on computed tomography or magnetic resonance imaging scans,with few patients presenting with abdominal pain or other symptoms.The accurate diagnosis of cysts is important as management depends on the type(neoplastic or non-neoplastic).Cross-sectional imaging is fast being replaced with endoscopic ultrasound(EUS)and various techniques based on that such as EUS-guided fine needle aspiration,EUS-guided needle confocal laser endomicroscopy,EUS-through-the-needle biopsy,and contrast-enhanced EUS.Clinical studies have reported varying diagnostic and adverse event rates with these modalities.In addition,American,European,and Kyoto guidelines for the diagnosis and management of pancreatic cysts have provided different recommendations.In this editorial,we elaborate on the clinical guidelines,recent studies,and comparison of different endoscopic methods for the diagnosis of pancreatic cysts.

Insights into gastrointestinal manifestation of human immunodeficiency virus:A narrative review

Human immunodeficiency virus(HIV)modifies CD4-positive cells,resulting in immunodeficiency and a wide range of gastrointestinal(GI)manifestations.The burden of HIV-related GI illnesses has significantly evolved with the widespread use of antiretroviral therapy(ART).While ART has effectively reduced the occurrence of opportunistic infections,it has led to an increase in therapy-related GI illnesses.Common esophageal conditions in HIV patients include gastroesophageal reflux disease,idiopathic esophageal ulcers,herpes simplex virus,cytomegalovirus(CMV),and candidal esophagitis.Kaposi’s sarcoma,a hallmark of acquired immunodeficiency syndrome,may affect the entire GI system.Gastritis and peptic ulcer disease are also frequently seen in patients with HIV.Diarrhea,often linked to both opportunistic infections and ART,requires careful evaluation.Bloody diarrhea,often a sign of colitis caused by bacterial infections such as Shigella or Clostridium difficile,is prevalent.Small bowel lymphoma,although rare,is increasing in prevalence.Anorectal disorders,including proctitis,fissures,and anal squamous cell carcinoma,are particularly relevant in homosexual men,underlining the importance of timely diagnosis.This review comprehensively explores the epidemiology,pathogenesis,and treatment considerations for the various GI disorders associated with HIV,highlighting the importance of accurate diagnosis and effective treatment to improve outcomes for HIV-infected patients.

Impact of frailty on endoscopic retrograde cholangiopancreatography outcomes in nonagenarians:A United States national experience

BACKGROUND Endoscopic retrograde cholangiopancreatography(ERCP)is an essential therapeutic tool for biliary and pancreatic diseases.Frail and elderly patients,especially those aged≥90 years are generally considered a higher-risk population for ERCP-related complications.AIM To investigate outcomes of ERCP in the Non-agenarian population(≥90 years)concerning Frailty.METHODS This is a cohort study using the 2018-2020 National Readmission Database.Patients aged≥90 were identified who underwent ERCP,using the international classification of diseases-10 code with clinical modification.Johns Hopkins’s adjusted clinical groups frailty indicator was used to classify patients as frail and non-frail.The primary outcome was mortality,and the secondary outcomes were morbidity and the 30 d readmission rate related to ERCP.We used univariate and multivariate regression models for analysis.RESULTS A total of 9448 patients were admitted for any indications of ERCP.Frail and non-frail patients were 3445(36.46%)and 6003(63.53%)respectively.Indications for ERCP were Choledocholithiasis(74.84%),Biliary pancreatitis(9.19%),Pancreatico-biliary cancer(7.6%),Biliary stricture(4.84%),and Cholangitis(1.51%).Mortality rates were higher in frail group[adjusted odds ratio(aOR)=1.68,P=0.02].The Intra-procedural complications were insigni-ficant between the two groups which included bleeding(aOR=0.72,P=0.67),accidental punctures/lacerations(aOR=0.77,P=0.5),and mechanical ventilation rates(aOR=1.19,P=0.6).Post-ERCP complication rate was similar for bleeding(aOR=0.72,P=0.41)and post-ERCP pancreatitis(aOR=1.4,P=0.44).Frail patients had a longer length of stay(6.7 d vs 5.5 d)and higher mean total charges of hospitalization($78807 vs$71392)compared to controls(P<0.001).The 30 d all-cause readmission rates between frail and non-frail patients were similar(P=0.96).CONCLUSION There was a significantly higher mortality risk and healthcare burden amongst nonagenarian frail patients undergoing ERCP compared to non-frail.Larger studies are warranted to investigate and mitigate modifiable risk factors.

Gastrointestinal disease in end-stage renal disease

When kidney function declines to a point where it can no longer maintain life and requires renal replacement therapy(i.e.renal transplant or dialysis),it is called end-stage renal disease(ESRD).Patients with ESRD often experience a range of gastrointestinal(GI)symptoms,with prevalence rates reported as high as 77%-79%.These symptoms and pathologies arise from various factors,including electrolyte imbalance,fluid imbalance,toxin buildup,uremia,medications,dietary and lifestyle restrictions,and the effects of dialysis.GI diseases in patients with renal failure can be further categorized into upper GI,small bowel,and lower GI issues.Common conditions include gastroesophageal reflux disease,nausea and vomiting,dysmotility within the esophagus and stomach,upper GI bleeding,peptic ulcer bleeding,angioectasia,irritable bowel syndrome,mesen-teric ischemia,angiodysplasia,diverticular disease,constipation,pancreatitis,and diseases associated with peritoneal dialysis peritonitis and peritoneal stenosis.This review assesses the existing literature on the different GI diseases among individuals with ESRD,shedding light on their pathophysiology and prevalence.

Multiple pathogenic factor-induced complications of cirrhosis in rats: A new model of hepatopulmonary syndrome with intestinal endotoxemia

AIM： To develop and characterize a practical model of Hepatopulmonary syndrome. （HPS） in rats.METHODS： The experimental animals were randomized into five feeding groups： （1） control （fed standard diet）, （2） control plus intraperitoneal injection with lipopolysaccharide （LPS）, （3） cirrhosis （fed a diet of maize flour, lard, cholesterol, and alcohol plus subcutaneously injection with carbon tetrachloride （CCI4） oil solution）, （4） cirrhosis plus LPS, and （5） cirrhosis plus glycine and LPS. The blood, liver and lung tissues of rats were sampled for analysis and characterization. Technetium 99m-labeled macroaggregated albumin （Tc99m-MAA） was used to test the dilatation of pulmonary microvasculature.RESULTS： Typical cirrhosis and subsequent hepato- pulmonary syndrome was observed in the cirrhosis groups after an 8 wk feeding period. In rats with cirrhosis, there were a decreased PaO2 and PaCO2 in arterial blood, markedly decreased arterial 02 content, a significantly increased alveolar to arterial oxygen gradient, an increased number of bacterial translocated within mesenteric lymph node, a significant higher level of LPS and tumor necrosis factor-α （TNF-α） in plasma, and a significant greater ratio of Tc99m-MAA brain-overlung radioactivity. After LPS administration in rats with cirrhosis, various pathological parameters got worse and pulmonary edema formed. The predisposition of glycine antagonized the effects of LPS and significantly alleviated various pathological alterations.

Is analysis of lower esophageal sphincter vector volumes of value in diagnosing gastroesophageal reflux disease?

AIM:With successful surgical treatment of gastroesophageal reflux disease(GERD),there is interest in understanding the anti-reflux barrier and its mechanisms of failure.To date, the potential use of vector volumes to predict the DeMeester score has not been adequately explored. METHODS:627 patients in the referral database received esophageal manometry and ambulatory 24-hour pH monitoring.Study data included LES resting pressure(LESP), overall LES length(OL)and abdominal length(AL),total vector volume(TVV)and intrabdominal vector volume(IVV). RESULTS:In cases where LESP,TVV or IVV were all below normal,there was an 81.4%probability of a positive DeMeester score.In cases where all three were normal, there was an 86.9%probability that the DeMeester score would be negative.Receiver-operating characteristics(ROC) for LESP,TVV and IVV were nearly identical and indicated no useful cut-off values.Logistic regression demonstrated that LESP and IVV had the strongest association with a positive DeMeester score;however,the regression formula was only 76.1%accurate. CONCLUSION:While the indices based on TVV,IVV and LESP are more sensitive and specific,respectively,than any single measurement,the measurement of vector volumes does not add significantly to the diagnosis of GERD.

Alcoholic hepatitis: The pivotal role of Kupffer cells

Kupffer cells play a central role in the pathogenesis of alcoholic hepatitis(AH). It is believed that alcohol increases the gut permeability that results in raised levels of serum endotoxins containing lipopolysaccharides(LPS). LPS binds to LPS-binding proteins and presents it to a membrane glycoprotein called CD14, which then activates Kupffer cells via a receptor called tolllike receptor 4. This endotoxin mediated activation of Kupffer cells plays an important role in the inflammatory process resulting in alcoholic hepatitis. There is no effective treatment for AH, although notable progress has been made over the last decade in understanding the underlying mechanism of alcoholic hepatitis. We specifically review the current research on the role of Kupffer cells in the pathogenesis of AH and the treatment strategies. We suggest that the imbalance between the pro-inflammatory and the anti-inflammatory process as well as the increased production of reactive oxygen species eventually lead to hepatocyte injury, the final event of alcoholic hepatitis.

Role of cell-free network communication in alcohol-associated disorders and liver metastasis

The aberrant use of alcohol is a major factor in cancer progression and metastasis.Contributing mechanisms include the systemic effects of alcohol and the exchange of bioactive molecules between cancerous and non-cancerous cells along the brain-gut-liver axis.Such interplay leads to changes in molecular,cellular,and biological functions resulting in cancer progression.Recent investigations have examined the role of extracellular vesicles(EVs)in cancer mechanisms in addition to their contribution as diagnostic biomarkers.Also,EVs are emerging as novel cell-free mediators in pathophysiological scenarios including alcohol-mediated gut microbiome dysbiosis and the release of nanosized EVs into the circulatory system.Interestingly,EVs in cancer patients are enriched with oncogenes,miRNA,lipids,and glycoproteins whose delivery into the hepatic microenvironment may be enhanced by the detrimental effects of alcohol.Proof-of-concept studies indicate that alcohol-associated liver disease is impacted by the effects of exosomes,including altered immune responses,reprogramming of stromal cells,and remodeling of the extracellular matrix.Moreover,the culmination of alcoholrelated changes in the liver likely contributes to enhanced hepatic metastases and poor outcomes for cancer patients.This review summarizes the numerous aspects of exosome communications between organs with emphasis on the relationship of EVs in alcohol-associated diseases and cancer metastasis.The potential impact of EV cargo and release along a multi-organ axis is highly relevant to the promotion of tumorigenic mechanisms and metastatic disease.It is hypothesized that EVs target recipient tissues to initiate the formation of prometastatic niches and cancer progression.The study of alcohol-associated mechanisms in metastatic cancers is expected to reveal a better understanding of factors involved in the growth of secondary malignancies as well as novel approaches for therapeutic interventions.

Targets of immunotherapy for hepatocellular carcinoma: An update

Hepatocellular carcinoma,the most common primary liver cancer,in an immunogenic tumor with a poor prognosis because these tumors are diagnosed at late stages.Although,surgical resection,ablation,liver transplant,and locoregional therapies are available for early stages;however,there are yet no effective treatment for advanced and recurrent tumors.Immune checkpoint inhibitor therapy and adoptive cell transfer therapy has gained the popularity with some positive results because these therapies overcome anergy and systemic immune suppression.However,still there is a lack of an effective treatment and thus there is an unmet need of a novel treatment.At present,the focus of the research is on oncolytic viral therapy and combination therapy where therapies including radiotherapy,immune checkpoint therapy,adoptive cell transfer therapy,and vaccines are combined to get an additive or synergistic effect enhancing the immune response of the liver with a cytotoxic effect on tumor cells.This review discusses the recent key development,the basis of drug resistance,immune evasion,immune tolerance,the available therapies based on stage of the tumor,and the ongoing clinical trials on immune checkpoint inhibitor therapy,adoptive cell transfer therapy,oncolytic viral vaccine therapy,and combination therapy.

Pulmonary artery catheterization in acute myocardial infarction complicated by cardiogenic shock:A review of contemporary literature

Acute myocardial infarction(AMI)with left ventricular(LV)dysfunction patients,the most common cause of cardiogenic shock(CS),have acutely deteriorating hemodynamic status.The frequent use of vasopressor and inotropic pharmacologic interventions along with mechanical circulatory support(MCS)in these patients necessitates invasive hemodynamic monitoring.After the pivotal Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness trial failed to show a significant improvement in clinical outcomes in shock patients managed with a pulmonary artery catheter(PAC),the use of PAC has become less popular in clinical practice.In this review,we summarize currently available literature to summarize the indications,clinical relevance,and recommendations for use of PAC in the setting of AMI-CS.

Relationships of hospitalization outcomes and timing to endoscopy in non-variceal upper gastrointestinal bleeding:A nationwide analysis

BACKGROUND The optimal timing of esophagogastroduodenoscopy(EGD)and the impact of clinico-demographic factors on hospitalization outcomes in non-variceal upper gastrointestinal bleeding(NVUGIB)remains an area of active research.AIM To identify independent predictors of outcomes in patients with NVUGIB,with a particular focus on EGD timing,anticoagulation(AC)status,and demographic features.METHODS A retrospective analysis of adult patients with NVUGIB from 2009 to 2014 was performed using validated ICD-9 codes from the National Inpatient Sample database.Patients were stratified by EGD timing relative to hospital admission(≤24 h,24-48 h,48-72 h,and>72 h)and then by AC status(yes/no).The primary outcome was all-cause inpatient mortality.Secondary outcomes included healthcare usage.RESULTS Of the 1082516 patients admitted for NVUGIB,553186(51.1%)underwent EGD.The mean time to EGD was 52.8 h.Early(<24 h from admission)EGD was associated with significantly decreased mortality,less frequent intensive care unit admission,shorter length of hospital stays,lower hospital costs,and an increased likelihood of discharge to home(all with P<0.001).AC status was not associated with mortality among patients who underwent early EGD(aOR 0.88,P=0.193).Male sex(OR 1.30)and Hispanic(OR 1.10)or Asian(aOR 1.38)race were also independent predictors of adverse hospitalization outcomes in NVUGIB.CONCLUSION Based on this large,nationwide study,early EGD in NVUGIB is associated with lower mortality and decreased healthcare usage,irrespective of AC status.These findings may help guide clinical management and would benefit from prospective validation.

Effect of differential rearing environments on nicotine-stimulated locomotor activity and nicotinic acetylcholine receptor subtypes

OBJECTIVE Individuals vary in sensitivity to the behavioral effects of nicotine,resulting in differences in their vulnerability to addiction.The role of rearing environment in determining individual sensitivity to nicotine is unclear.The neuropharmacological mechanisms mediating the effect of rearing environment on the actions of nicotine are also understood.Thus,the contribution of rearing environment in determining the sensitivity to the locomotor effects of nicotine and regulating α4β2*-and α7-nicotinic acetylcholine(n ACh) receptor expressionwas determined in rats reared in isolated(IC) or enriched(EC) conditions.METHODS To measure locomotor activity,adolescent rats(postnatal day 21-51)were injected with saline(1 mL·kg^(-1)) or nicotine(0.3 mg·kg^(-1)) subcutaneously,then placed in chamberswhere ambulatory activity was monitored for 30-min by computer for 14 daily sessions.α4β2*-andα7-n ACh receptor expression in the mesolimbic dopamine pathway was determined by quantitative autoradiography of [125 I]-epibatidine and [125 I]-bungarotoxinbinding,respectively,in 16 μmol·L^(-1) coronal sections.Values for receptor expression in fmol are ±s of 8 brains and compared by two-tailed,unpaired t-test with P<0.05 considered significant.RESULTS EC-rats are similarly sensitive as IC-rats to the locomotor effects of nicotine.[125 I]-epibatidine binding in the ventral tegmental area of EC-rats was reduced(2.8±0.3 fmo L) compared to IC-rats(4.0±0.4 fmo L);there was no difference in the nucleus accumbens.There was no difference between EC-and IC-rats in α7-n ACh receptor expression in the mesolimbic dopamine pathway.CONCLUSION Rearing environment differentially regulates n ACh receptor subtypes in EC and IC rats.These data suggest regulation of n ACh receptors by environmental factors may be a mechanism for the protective effect of enrichment against altered sensitivity to nicotine in genetically vulnerable individuals.The characterization of these mechanisms will aid in development of novel pharmacological tools mimicking the protection afforded by environmental enrichment in nicotine-sensitive individuals.

Safe and effective sofosbuvir-based therapy in patients with mental health disease on hepatitis C virus treatment

AIMTo study impact of baseline mental health disease on hepatitis C virus (HCV) treatment; and Beck&rsquo;s Depression Inventory (BDI) changes with sofosbuvir- and interferon-based therapy. METHODSThis is a retrospective cohort study of participants from 5 studies enrolled from single center trials conducted at the Clinical Research Center of the National Institutes of Health, Bethesda, MD, United States. All participants were adults with chronic HCV genotype 1 infection and na&iuml;ve to HCV therapy. Two of the studies included HCV mono-infected participants only (SPARE, SYNERGY-A), and 3 included human immunodeficiency virus (HIV)/HCV co-infected participants only (ERADICATE, PFINPK, and ALBIN). Patients were treated for HCV with 3 different regimens: Sofosbuvir and ribavirin in the SPARE trial, ledipasvir and sofosbuvir in SYNERGY-A and ERADICATE trials, and pegylated interferon (IFN) and ribavirin for 48 wk in the PIFNPK and ALBIN trials. Participants with baseline mental health disease (MHD) were identified (defined as either a DSM IV diagnosis of major depression, bipolar disorder, schizophrenia, generalized anxiety, and post-traumatic stress disorder or requiring anti-depressants, antipsychotics, mood stabilizers or psychotropics prescribed by a psychiatrist). For our first aim, we compared sustained virologic response (SVR) and adherence (pill counts, study visits, and in 25 patients, blood levels of the sofosbuvir metabolite, GS-331007) within each study. For our second aim, only patients with HIV coinfection were evaluated. BDI scores were obtained pre-treatment, during treatment, and post-treatment among participants treated with sofosbuvir-based therapy, and compared to scores from participants treated with interferon-based therapy. Statistical differences for both aims were analyzed by Fisher&rsquo;s Exact, and t-test with significance defined as a P value less than 0.05. RESULTSBaseline characteristics did not differ significantly between all participants with and without MHD groups treated with sofosbuvir-based therapy. Among patients treated with sofosbuvir-based therapy, the percentage of patients with MHD who achieved SVR was the same as those without (SPARE: 60.9% of those MHD compared to 67.6% in those without, P = 0.78; SYNERGY-A: 100% of both groups; ERADICATE: 100% compared to 97.1%). There was no statistically significant difference in pill counts, adherence to study visits between groups, nor mean serum concentrations of GS-331007 for each group at week 2 of treatment (P = 0.72). Among patients with HIV co-infection, pre-treatment BDI scores were similar among patients treated with sofosbuvir, and those treated with interferon (sofosbuvir-based 5.24, IFN-based 6.96; P = 0.14); however, a dichotomous effect on was observed during treatment. Among participants treated with directly acting antiviral (DAA)-based therapy, mean BDI scores decreased from 5.24 (pre-treatment) to 3.28 during treatment (1.96 decrease, P = 0.0034) and 2.82 post-treatment. The decrease in mean score from pre- to post-treatment was statistically significant (-2.42, P = 0.0012). Among participants treated with IFN-based therapy, mean BDI score increased from 6.96 at pre-treatment to 9.19 during treatment (an increase of 2.46 points, P = 0.1), and then decreased back to baseline post-treatment (mean BDI score 6.3, P = 0.54). Overall change in mean BDI scores from pre-treatment to during treatment among participants treated with DAA-based and IFN-therapy was statistically significant (-1.96 and +2.23, respectively; P = 0.0032). This change remained statistically significant when analysis was restricted to participants who achieved SVR (-2.0 and +4.36, respectively; P = 0.0004). CONCLUSIONSofosbuvir-based therapy is safe and well tolerated in patients with MHD. A decline in BDI associated with sofosbuvir-based HCV treatment suggests additional MHD benefits, although the duration of these effects is unknown.

Comparative efficacy and safety of adenosine and regadenoson for assessment of fractional flow reserve:A systematic review and meta-analysis

BACKGROUND Adenosine is a coronary hyperemic agent used to measure invasive fractional flow reserve(FFR)of intermediate severity coronary stenosis.AIM To compare FFR assessment using adenosine with an alternate hyperemic agent,regadenoson.METHODS PubMed,Google Scholar,CINAHL and Cochrane databases were queried for studies comparing adenosine and regadenoson for assessment of FFR.Data on FFR,correlation coefficient and adverse events from the selected studies were extracted and analyzed by means of random effects model.Two tailed P-value less than 0.05 was considered significant.Heterogeneity was assessed using I2 test.RESULTS Five studies with 248 patients were included in the final analysis.All included patients and coronary lesions underwent FFR assessment using both adenosine and regadenoson.There was no significant mean difference between FFR measurement by the two agents[odds ratio(OR)=-0.00;95%confidence interval(CI):(-0.02)-0.01,P=0.88].The cumulative correlation coefficient was 0.98(0.96-0.99,P<0.01).Three of five studies reported time to FFR with cumulative results favoring regadenoson(mean difference 34.31 s;25.14-43.48 s,P<0.01).Risk of adverse events was higher with adenosine compared to regadenoson(OR=2.39;95%CI:1.22-4.67,P=0.01),which most commonly included bradycardia and hypotension.Vast majority of the adverse events associated with both agents were transient.CONCLUSION The performance of regadenoson in inducing maximal hyperemia was comparable to that of adenosine.There was excellent correlation between the FFR measurements by both the agents.The use of adenosine,was however associated with higher risk of adverse events and longer time to FFR compared to regadenoson.

Access to smart devices and utilization of online health resources among older cardiac rehabilitation participants

BACKGROUND Newer models of cardiac rehabilitation(CR)delivery are promising but depend upon patient participation and ability to use technological media including Internet and smart devices.AIM To explore the availability of smart devices,current utilization and proficiency of use among older CR program attendees.METHODS Study participants were enrolled from four CR programs in Omaha,Nebraska United States and completed a questionnaire of 28 items.RESULTS Of 376 participants approached,169 responded(45%).Mean age was 71.1(SD±10)years.Demographics were 73.5%males,89.7%Caucasians,52%with college degree and 56.9%,with income of 40 K$or more.Smart device ownership was84.5%;desktop computer was the most preferred device.Average Internet use was 1.9 h/d(SD±1.7);54.3%of participants indicating for general usage but only18.4%pursued health-related purposes.Utilization of other health information modalities was low,29.8%used mobile health applications and 12.5%used wearable devices.Of all participants,72%reported no barriers to using Internet.Education and income were associated positively with measures of utilization and with less perceived barriers.CONCLUSIONAmong an older group of subjects attending CR,most have access to smart devices and do not perceive significant barriers to Internet use.Nonetheless,there was low utilization of health-related resources suggesting a need for targeted education in this patient population.

Virulent endocarditis due to Haemophilus parainfluenzae:A systematic review of the literature

BACKGROUND Haemophilus parainfluenzae(HPI)belongs to the HACEK(Haemophilus spp.,Aggregatibacter spp.,Cardiobacterium spp.,Eikenella spp.,and Kingella spp.)group of organisms.The HACEK group of organisms are a part of the oropharyngeal flora and can cause invasive opportunistic infection such infective endocarditis(IE)in hosts with compromised immunological barriers.AIM To perform a 20-year systematic review of the literature characterizing the clinical presentation,epidemiology and prognosis of HPI IE.METHODS We performed a systematic review of Medline,Pubmed,Scopus and Embase from 2000 to 2022 to identify all cases of HPI IE.RESULTS Thirty-nine adult cases were identified.HPI IE was found to affect males slightly more than females and is common in patients with predisposing risk factors such as underlying valvular abnormalities.It mostly affected the mitral valve and had an indolent course;significantly sized vegetations(>1 cm)developed in most cases.Central nervous system septic embolization was common.It had a favorable prognosis compared to staphylococcal and streptococcal IE.CONCLUSION Clinicians should be attentive to the indolent course of HPI IE and the presence of predisposing risk factors in order to allow for timely management.

Coccidioidomycosis of the Testis and Epididymis

This report describes an unusual presentation of a man with a testicular mass who presented in diabetic ketoacidosis to the emergency department. Initial diagnosis was a suspected testicular malignancy based on history, physical exam, and available laboratory and radiological imaging. Due to the possibility of a testicular malignancy, the patient was taken for immediate orchiectomy. Histology revealed coccidioido-mycosis of the left testicle and epididymis. Treatment with the appropriate antifungals was initiated. Despite aggressive multi-disciplinary therapy the patient continued to deteriorate and eventually expired as a result of the massive systemic infection. Literature review revealed the presentation of disseminated genitourinary coccidioidomycosis is rare and seldom reported.

THE COCHLEAR AMPLIFIER:IS IT HAIR BUNDLE MOTION OF OUTER HAIR CELLS?

Cochlear outer hair cells （OHCs） are involved in a mechanical feedback loop in which the fast somatic motility of OHCs is required for cochlear amplification. Alternatively, amplification is thought to arise from active hair bundle movements ob- served in non-mammalian hair cells. We measured the voltage-evoked hair bundle motions in the gerbil cochlea to determine if such movements are also present in mammalian OHCs. The OHCs displayed a large hair bundle movement that was not based on mechanotransducer channels but based on somatic motility. Significantly, bundle movements were able to generate radial motion of the rectorial membrane in situ. This result implies that the motility-associated hair bundle motion may be part of the cochlear amplifier.

A Facilitated Interface to Generate a Combined Textual and Graphical Database System Using Widely Available Software

Data-Base Management System (DBMS) is the current standard for storing information. A DBMS organizes and maintains a structure of storage of data. Databases make it possible to store vast amounts of randomly created information and then retrieve items using associative reasoning in search routines. However, design of databases is cumbersome. If one is to use a database primarily to directly input information, each field must be predefined manually, and the fields must be organized to permit coherent data input. This static requirement is problematic and requires that database table(s) be predefined and customized at the outset, a difficult proposition since current DBMS lack a user friendly front end to allow flexible design of the input model. Furthermore, databases are primarily text based, making it difficult to process graphical data. We have developed a general and nonproprietary approach to the problem of input modeling designed to make use of the known informational architecture to map data to a database and then retrieve the original document in freely editable form. We create form templates using ordinary word processing software: Microsoft InfoPath 2007. Each field in the form is given a unique name identifier in order to be distinguished in the database. It is possible to export text based documents created initially in Microsoft Word by placing a colon at the beginning of any desired field location. InfoPath then captures the preceding string and uses it as the label for the field. Each form can be structured in a way to include any combination of both textual and graphical fields. We input data into InfoPath templates. We then submit the data through a web service to populate fields in an SQL database. By appropriate indexing, we can then recall the entire document from the SQL database for editing, with corresponding audit trail. Graphical data is handled no differently than textual data and is embedded in the database itself permitting direct query approaches. This technique makes it possible for general users to benefit from a combined text-graphical database environment with a flexible non-proprietary interface. Consequently, any template can be effortlessly transformed to a database system and easily recovered in a narrative form.

The Use of the V.A.C. RX-4 for Multiple Soft Tissue Wound Application in the Single Patient: A Case Report

Contact burn injuries account for a considerable proportion of admissions that frequently require debridement. Such debridements of these multiple open wounds might benefit from the application of negative pressure wound therapy (NPWT) for the removal of proinflammatory mediators and to promote granulation tissue with macrostrain and microstrain. Having four or more Vacuum Assist Closure (V.A.C.) Ulta devices connected to the same patient for adequate wound coverage is cumbersome in the management of the patient’s wound care and tethers the patient to the bed. The V.A.C. RX-4 is a multichannel device that can deliver NPWT with a smaller footprint. In addition, the V.A.C. RX-4 has a weight of 16 lbs. versus one V.A.C Ulta which is 7.4 lbs. Therefore, collectively, four V.A.C. Ultas would equal 29.6 lbs. or almost double the weight of a single V.A.C. RX-4. Use of the V.A.C. RX-4 by healthcare providers can mean greater mobility for the patient and easier transport between patient destinations within the hospital. This case report demonstrates the utility of the V.A.C. RX-4 for open and freshly debrided, large soft tissue wounds in a burn patient.