Significance of endothelial dysfunction in the pathogenesis of early and delayed radiation enteropathy

This review summarizes the current state of knowledge regarding the role of endothelial dysfunction in the pathogenesis of early and delayed intestinal radiation toxicity and discusses various endothelial-oriented interventions aimed at reducing the risk of radiation enteropathy. Studies published in the biomedical literature during the past four decades and cited in PubMed, as well as clinical and laboratory data from our own research program are reviewed. The risk of injury to normal tissues limits the cancer cure rates that can be achieved with radiation therapy. During treatment of abdominal and pelvic tumors, the intestine is frequently a major dose-limiting factor. Microvascular injury is a prominent feature of both early (inflammatory), as well as delayed (fibroproliferative) radiation injuries in the intestine and in many other normal tissues. Evidence from our and other laboratories suggests that endothelial dysfunction, notably a deficiency of endothelial thrombomodulin, plays a key role in the pathogenesis of these radiation responses. Deficient levels of thrombomodulin cause loss of vascular thromboresistance, excessive activation of cellular thrombin receptors by thrombin, and insufficient activation of protein C, a plasma protein with anticoagulant, anti-inflammatory, and cytoprotective properties. These changes are presumed to be critically involved in many aspects of early intestinal radiation toxicity and may sustain the fi broproliferative processes that lead to delayed intestinal dysfunction, fi brosis, and clinical complications. In conclusion, injury of vascular endothelium is important in the pathogenesis of the intestinal radiation response. Endothelial-oriented interventions are appealing strategies to prevent or treat normal tissue toxicity associated with radiation treatment of cancer.

Access related complications during anterior exposure of the lumbar spine

The new millennium has witnessed the emergence of minimally invasive, non-posterior based surgery of the lumbar spine, in particular via lateral based methodologies to discectomy and fusion. In contrast, and perhaps for a variety of reasons, anterior motion preservation(non-fusion) technologies are playing a comparatively lesser, though incompletely defined, role at present. Lateral based motion preservation technologies await definition of their eventual role in the armamentarium of minimally invasive surgical therapies of the lumbar spine. While injury to the major vascular structures remains the most serious and feared complication of the anterior approach, this occurrence has been nearly eliminated by the use of lateral based approaches for discectomy and fusion cephalad to L5-S1. Whether anterior or lateral based, non-posterior approaches to the lumbar spine share certain access related pitfalls and complications, including damage to the urologic and neurologic structures, as well as gastrointestinal and abdominal wall issues. This review will focus on the recognition, management and prevention of these anterior and lateral access related complications.

Space radiation and cardiovascular disease risk

Future long-distance space missions will be associated with significant exposures to ionizing radiation,and the health risks of these radiation exposures during manned missions need to be assessed. Recent Earth-based epidemiological studies in survivors of atomic bombs and after occupational and medical low dose radiation exposures have indicated that the cardiovascular system may be more sensitive to ionizing radiation than was previously thought. This has raised the concern of a cardiovascular disease risk from exposure to space radiation during long-distance space travel. Groundbased studies with animal and cell culture models play an important role in estimating health risks from space radiation exposure. Charged particle space radiation has dense ionization characteristics and may induce unique biological responses,appropriate simulation of the space radiation environment and careful consideration of the choice of the experimental model are critical. Recent studies have addressed cardiovascular effects of space radiation using such models and provided first results that aid in estimating cardiovascular disease risk,and several other studies are ongoing. Moreover,astronauts could potentially be administered pharmacological countermeasures against adverse effects of space radiation,and research is focused on the development of such compounds. Because the cardiovascular response to space radiation has not yet been clearly defined,the identification of potential pharmacological countermeasures against cardiovascular effects is still in its infancy.

Pediatric Nd:YAG laser capsulotomy in the operating room: review of 87 cases

AIM: To report a large series of children having Nd:YAG laser capsulotomy in the operating room using the lateral decubitus position. METHODS: Medical records of children who underwent Nd:YAG laser capsulotomy in the operating room at Ann & Robert H. Lurie Children's Hospital of Chicago between September 2008 and April 2017 were reviewed. Induction of general anesthesia and intubation was performed in the supine position after which the patient was placed in lateral decubitus position. The Nd:YAG laser capsulotomy was performed using a standard protocol. At the completion of the procedure, the patient was turned back into the supine position and extubated. RESULTS: This study included 87 eyes of 60 patients. Patient's age ranged from 1 to 18 y(mean 6.4±4.1 y). In most cases(84/87, 97%), the procedure was performed under general anesthesia. In all cases, good focus on the membrane was achieved, and the procedure was performed successfully. There were no intraoperative ocular or anesthesia-related complications. CONCLUSION: When performing Nd:YAG laser capsulotomy in the operating room, the lateral decubitus position allowsan easy and safe approach without the risk of potentially devastating complications that have been associated with the previously described sitting and prone positions.

脊髓损伤患者在肛管直肠手术中应用利多卡因阻滞肛管以限制自主神经反射异常:一项随机、双盲、安慰剂对照试验

PURPOSE: Autonomic dysreflexia is a common and potentially dangerous hypertensive response to stimulation below the level of injury that occurs in patients with spinal cord injury at T6 or above. Rectosigmoid distention and anal manipulation are among the stimuli that may precipitate autonomic dysreflexia. Instillation of topical local anesthetic into the rectum is the recommended prophylaxis against autonomic dysreflexia of anorectal origin. However, a previous randomized, double- blind, placebo- controlled trial showed that topical lidocaine in the rectum does not blunt the autonomic dysreflexia response to anorectal procedures. The purpose of this study was to determine whether lidocaine anal sphincter block would be effective in limiting anorectal procedure- associated autonomic dysreflexia. METHODS: We enrolled patients with chronic, complete spinal cord injury above T6, who were having anorectal procedures (flexible sigmoidoscopy and/or ano- scopic hemorrhoid ligation). In a double- blind fashion, patients were randomized for intersphincteric anal block with 1 percent lidocaine or normal saline (placebo) before the procedure. Blood pressure was measured before, during, and after the block and procedure. RESULTS: Thirteen patients received lidocaine, and 13 received placebo. The groups were similar in age, level of injury, duration of spinal cord injury, type of procedure, and procedure duration. The mean maximal systolic blood pressure increase for the lidocaine group was 22 ± 14 mmHg, significantly lower than the placebo group’ s 47 ± 31 mmHg (P = 0.01). CONCLUSIONS: Lidocaine anal block significantly limits the autonomic dysreflexia response in susceptible patients undergoing anorectal procedures.

<i>Aloe vera</i>—Mechanisms of Action, Uses, and Potential Uses in Plastic Surgery and Wound Healing

Aloe vera has been used for centuries for medicinal purposes. Clinical and experimental evidence indicates usefulness for skin moisturization, promoting wound healing, thermal skin injury, frostbite, and ischemic skin insults. Aloe vera has anti-inflammatory, vasodilatory, antimicrobial, and proliferative actions, which have been investigated in various experimental models and in various in vitro studies. This extensive literature review of the properties and actions of Aloe vera finds substantial evidence for the reported and also likely clinical usefulness for Aloe vera in Plastic Surgery and in wound care and wound healing. Though further clinical investigation is warranted, Aloe vera use may likely be indicated in situations where its effects could positively influence outcomes, such as wound healing, flap vascularity, and inflammatory skin pathologies.

Necrotizing Soft Tissue Infections of the Male and Female Breast: A Literature Review

Background: Within the spectrum of necrotizing soft tissue infections (NSTI), necrotizing fasciitis (NF) has been characterized by tissue and fascial necrosis with systemic toxicity. The objective was to determine and summarize the frequency and characteristics of breast NF and NSTI in the literature. Methods: Cases were obtained through PubMed, Google Scholar, Google, and from published article reference sections. One hundred twenty-three cases were gleaned from 96 articles that reported NF and NSTI of the breast (1924 through 2021). Results: NF was reported in 70 and NSTI in 53 cases (111 women and 12 men). Patients presented with swollen, painful breasts, erythema, bullae, crepitus, necrosis, gangrene, fever, tachycardia, and neutrophilia. Fifty-nine of 123 (48.4%) patients were septic on admission. The most frequent microorganisms were β hemolytic Group A Streptococcus, and Staphylococcus aureus. Treatment consisted of antibiotics, mastectomy and debridement with flaps, skin grafts or primary and secondary closure. Forty-four (63.0%) of the NF cases had chest wall involvement;of these, 18 (14.6%) involved the breast secondarily, P < 0.0001. There were twelve mortalities (9.8%): eleven (9.0%) with NF and one (0.8%) with NSTI, P = 0.007. Conclusions: Men and women with breast NF and NSTI presented with similar signs and symptoms and required the same emergent treatment as provided for NF and NSTI of the more common sites. As a time-sensitive disease, patients treated within 12 hours of admission had a better survival. Patients with NF were more likely to have sepsis on admission, a higher mortality, and fascial chest wall/muscle involvement than patients with NSTI.

Surgicel Induced Intraoperative Cardiovascular Collapse in a Child with Midbrain Glioma

Introduction: Intraoperative cardiovascular complications were previously demonstrated in relation to high sympathetic nervous system outflow or stimulation of the vagal nerve nucleus during theneurosurgical procedures on brain tumors. Main Symptoms and Important Clinical Findings: We are presenting clinical case of 13-year-old girl who suffered from midbrain glioma and developed life threatening cardiovascular events during neurosurgical procedure after surgicel hemostatic agent application. Therapeutic Interventions and Outcomes: Cardiovascular stability has been restored after immediate removal of surgicel from the operating field. We believe that it might be related to direct application of the surgicel hemostatic agent.

病例报道和文献回顾:有Nuss连接板患者的心肺复苏

Pectus excavatum (PE) is a common chest wall deformity that may produce a variety of physiological and psychological effects in children and adolescents. In addition, some of these patients have associated cardiac diseases (ie, mitral valve prolapse and Marfan syndrome). Recently, a minimally invasive surgical repair of PE that requires sternal bar placement has become increasingly frequent to enhance patients’ cardiopulmonary functioning as well as their self-esteem. However, despite this innovative technique, it is possible for such patients to have a cardiac arrest while their sternal bar is in place. Whether the presence of a metal bar on the underside of their sternum may hinder resuscitative chest compressions (cardiopulmonary resuscitation) is an issue that concerns us,our patients, and their families; the answer requires further investigation. We present a 21- year-old man with PE who underwent a minimally invasive pectus repair but had a fatal cardiac event before bar removal. Paramedics conducting cardiopulmonary resuscitation on the patient later reported that they were unable to deliver effective cardiac compressions and that the sternal bar may have contributed to this.

1例肛门闭锁新生儿的后尿道瓣:临床表现及治疗

Anorectal malformations are frequently associated with urinary tract abnormali ties, which generally consist of vesicoureteral reflux, renal agenesis, and blad der dysfunction. Posterior urethral valves associated with anorectal malformatio ns are exceedingly rare. We report the third case described in literature and th e unique management.

HIV患者肛门鳞状异常增生的期待治疗

PURPOSE: Anal squamous dysplasia is commonly found in patients with HIV infection. There is no satisfactory treatment that eradicates this premalignant lesion with low morbidity and low recurrence. This study reviews a series of patients with HIV and an abnormal anal examination who had squamous dysplasia and who have been followed with physical examination alone and with repeat biopsies as necessary for new or suspicious lesions. METHODS:We reviewed the charts of 40 HIV- positive men who had squamous dysplasia of the anal canal and anal margin, focusing on history, physical findings, histologic diagnosis, and the occurrence of invasive squamous-cell carcinoma. RESULTS: Forty HIV-positive men (mean age 39 years) were followed for anal squamous dysplasia. Biopsies revealed dysplasia, which was usually multifocal. The grade of dysplasia varied, but 28 of 40 patients had at least one area of severe dysplasia. All patients had a follow-up period greater than one year (mean, 32 months; range, 13- 130 months). Three patients developed invasive carcinoma while under surveillance, and these were completely excised or cured with chemoradiation. CONCLUSIONS: Extensive excision for dysplasia in the context of HIV confers high morbidity and questionable benefit, and other treatments are of uncertain value. In a group of patients followed expectantly, most did not develop invasive cancer, and in those who did, early cancers could be identified and cured. Physical examination surveillance for invasive carcinoma may be acceptable for following patients with HIV and biopsy-proven squamous dysplasia.

Health-related quality of life after gastric cancer treatment in Brazil:Narrative review and reflections

In Brazil,gastric cancer is the third most common type of cancer among men and fifth among women,with an estimated 13360 new cases among men and 7870 among women each year during the 2020-2022 period.This study presents reflections and attempts to add knowledge to the theme of quality of life(QoL)in patients with gastric adenocarcinoma and describes some of its characteristics in three regions of Brazil,with an evaluation of the disease’s impacts in various dimensions of life,as reported by the patients themselves.We performed a narrative review of the literature and a data analysis of studies on QoL in Brazilian patients treated for gastric adenocarcinoma from three different cities in three geographic regions:Brasília(the midwest),Jaú(the southeast),and Macapá(the north).

单位内固定棒后路脊柱融合术引发的小肠穿孔

An unusual complication of bowel perforation after unit rod posterior spinal fusion and anterior spine release via a retroperitoneal approach is described. Th is complication has not been previously described. The pediatric surgical specia list should be aware of this consideration in the differential diagnosis of abdo minal pain after unit rod posterior spinal fusion.

老年患者行非心脏手术前红细胞压积水平与手术预后的关系

背景：接受非心脏手术的老年患者出现红细胞压积异常和心血管并发症的危险较高。尽管患者术前几乎都要进行红细胞压积筛查，但是有关术前贫血及红细胞增多症的不良影响的证据较为有限。 目的：于实施非心脏大手术的退伍老兵中评估术前贫血和红细胞增多症的发生率及其对术后30天预后的影响。 设计：利用全国退伍军人事务委员会（VA）于术质量改进计划数据库进行回顾性队列研究。根据术前红细胞压积水平将患者分为三类：贫血（红细胞压积〈39．0％）、正常（红细胞压积39．0％～53．9％）和红细胞增多症（红细胞压积≥54％）。对红细胞压积异常与术后30天心血管事件发生率及死亡率的关系进行评估。 地点及患者：纳入1997至2004年于全美132个退伍军人医疗中心接受非心脏大手术的310311例患者（年龄≥65岁）。 主要观测指标：主要观测指标为术后30天死亡率，次要观测指标包括术后30天死亡率或心脏事件（心脏骤停或Q波心肌梗死）发生率。 结果：与红细胞压积正常者相比，红细胞压积发生正向或负向偏离者术后30天死亡率和心脏事件发生率均有所增加。研究发现，红细胞压积水平较正常范围每增减1个百分点，术后30天死亡率就可增加1．6％（95％可信区间，1．1％-2．2％）。进一步分析显示，当红细胞压积降至39％以下或超过51％时，校正后30天死亡风险和心脏病患病风险就开始增加。 结论：接受非心脏大手术的老年患者（绝大多数为男性退伍军人）术前轻度贫血及红细胞增多症均可增加术后发生死亡和心脏事件的危险。今后的研究应明确上述发现可否见于其他人群，明确术前纠正贫血和红细胞增多症能否降低术后死亡风险。

Is Postmastectomy Radiation Therapy Indicated in Patients with Close or Positive Margins?

Background: The indications for Post Mastectomy Radiation Therapy (PMRT) for positive or close margins are unclear. We examined the indications for PMRT in mastectomy patients with close or positive margins and determined patterns for relapse and survival. Methods: The pathology reports of 610 patients treated with a mastectomy from 1999-2012 were reviewed. Of these, 72 patients had a positive or <2 mm margin. Demographic, tumor characteristics, treatments and survival were compared between women treated with and without PMRT. Results: The mean follow up was 4.1 years. Patients who received PMRT were younger (p = 0.03) and more likely to receive chemotherapy (p = 0.03). Patients with lymphovascular invasion (LVI) were more likely to undergo PMRT (p = 0.02). Seven patients who did not receive PMRT recurred. There was no correlation with locoregional failure. The disease free survival was better in the PMRT group (p = 0.03), but the overall survival was the same. Conclusion: We found that women with a close or positive margin who were younger, had LVI, and who received chemotherapy received PMRT. The disease free survival was better in the PMRT cohort, but the overall survival was similar. Long-term follow up of patients is warranted to see if PMRT offers a survival advantage.

Challenges and opportunities in improving left ventricular remodelling and clinical outcome following surgical and trans-catheter aortic valve replacement

Over the last half century,surgical aortic valve replacement(SAVR)has evolved to offer a durable and efficient valve haemodynamically,with low procedural complications that allows favourable remodelling of left ventricular(LV)structure and function.The latter has become more challenging among elderly patients,particularly following trans-catheter aortic valve implantation(TAVI).Precise understanding of myocardial adaptation to pressure and volume overloading and its responses to valve surgery requires comprehensive assessments from aortic valve energy loss,valvular-vascular impedance to myocardial activation,force-velocity relationship,and myocardial strain.LV hypertrophy and myocardial fibrosis remains as the structural and morphological focus in this endeavour.Early intervention in asymptomatic aortic stenosis or regurgitation along with individualised management of hypertension and atrial fibrillation is likely to improve patient outcome.Physiological pacing via the His-Purkinje system for conduction abnormalities,further reduction in para-valvular aortic regurgitation along with therapy of angiotensin receptor blockade will improve patient outcome by facilitating hypertrophy regression,LV coordinate contraction,and global vascular function.TAVI leaflet thromboses require anticoagulation while impaired access to coronary ostia risks future TAVI-in-TAVI or coronary interventions.Until comparable long-term durability and the resolution of TAVI related complications become available,SAVR remains the first choice for lower risk younger patients.

Accelerated neutral atom beam(ANAB)and gas clustered ion beam(GCIB)treatment of implantable device polymers leads to decreased bacterial attachment in vitro and decreased inflammation in vivo

Infections at the placement site of biomaterial-based devices and subsequent scar formation results in morbidity,which may require revision surgery.Biomaterials intended for permanent implantation in the body need to be biologically inert to avoid excessive foreign body response and to reduce bacterial attachment.In this study,we show that polymeric materials commonly used in medical devices,including polyetheretherketone(PEEK)and polypropylene,treated by gas cluster ion beam(GCIB)or by accelerated neutral atom beam(ANAB)result in a nanoscale-modified surface topography that changes the ability of extracellular proteins to bind.This leads to decreased bacterial attachment and an attenuated inflammatory response using both in vitro and in vivo assays.Differential adsorption of extracellular proteins to the polymeric surface improved the competitive attachment of osteoblasts over bacteria,without resorting to growth factor of antibiotic use.

澳大利亚组织器官捐献和移植管理框架

澳大利亚的移植医学水平位于国际前列,也面临着供器官短缺的问题。为了扩大供器官来源,提高利用率,从2008年开始,澳大利亚政府开始着手建立其国内统一的、公平公正的组织器官捐献、分配和移植体系。本文着重从澳大利亚组织器官捐献和移植的管理机构、尸体供器官的分配原则和移植受者选择标准以及供者选择原则等方面对该体系进行介绍。

Role of Interferon-γ in GVHD and GVL

Interferon （IFN）-γ, a potent proinflammatory cytokine produced by multiple types of cells （e.g., activated T, NK and NKT cells）, plays important and complex roles in both innate and adaptive immune responses. There may be a correlation between the IFN-γ level and GVHD severity in patients receiving allogeneic hematopoietic cell transplantation. However, such a correlation may just reflect the presence of large numbers of activated T cells, and does not necessarily imply a harmful role of IFN-γ in the pathogenesis of GVHD. There has been increasing experimental evidence that IFN-γ is not required and may even inhibit GVHD. Paradoxically, IFN-γ facilitates graft-versus-leukemic （GVL） effects. Thus, IFN-γ blockade is likely deleterious in patients after allogeneic hematopoietic cell transplantation, and not beneficial as previously suggested.