En Masse Resection of Pancreas, Spleen, Celiac Axis, Stomach, Kidney, Adrenal, and Colon for Invasive Pancreatic Corpus and Tail Tumor

Providing a more comfortable life and a longer survival for pancreatic corpus/tail tumors without metastasis depends on the complete resection. Recently, distal pancreatectomy with celiac axis resection was reported as a feasible and favorable method in selected pancreatic corpus/tail tumors which had invaded the celiac axis. Additional organ resections to the celiac axis were rarely required, and when necessary it was included only a single extra organ resection such as adrenal or intestine. Here, we described a distal pancreatic tumor invading most of the neighboring organs—stomach, celiac axis, left renal vein, left adrenal gland, and splenic flexure were treated by en bloc resection of all these organs. The patient was a 60-year-old man without any severe medical comorbidities. Postoperative course of the patient was uneventful, and he was discharged on postoperative day eight without any complication. Histopathology and stage of the tumor were adenocarcinoma and T4 N1 M0, respectively. Preoperative back pain of the patient was completely relieved in the postoperative period. As a result, celiac axis resection for pancreatic cancer is an extensive surgery, and a combined en masse resection of the invaded neighboring organs is a more extensive surgery than the celiac axis resection alone. This more extensive surgery is safe and feasible for selected patients with pancreatic cancer

Fetal Tracheal Occlusion Increases Lung Basal Cells via Increased Yap Signaling

Basal cell; Fetal tracheal occlusion; MechanotransductionCélula basal; Oclusión traqueal fetal; MecanotransducciónCèl·lula basal; Oclusió traqueal fetal; MecanotransduccióFetal endoscopic tracheal occlusion (FETO) is an emerging surgical therapy for congenital diaphragmatic hernia (CDH). Ovine and rabbit data suggested altered lung epithelial cell populations after tracheal occlusion (TO) with transcriptomic signatures implicating basal cells. To test this hypothesis, we deconvolved mRNA sequencing (mRNA-seq) data and used quantitative image analysis in fetal rabbit lung TO, which had increased basal cells and reduced ciliated cells after TO. In a fetal mouse TO model, flow cytometry showed increased basal cells, and immunohistochemistry demonstrated basal cell extension to subpleural airways. Nuclear Yap, a known regulator of basal cell fate, was increased in TO lung, and Yap ablation on the lung epithelium abrogated TO-mediated basal cell expansion. mRNA-seq of TO lung showed increased activity of downstream Yap genes. Human lung specimens with congenital and fetal tracheal occlusion had clusters of subpleural basal cells that were not present in the control. TO increases lung epithelial cell nuclear Yap, leading to basal cell expansion.Funding was obtained from NIH/NHLBI R01HL141229 (to BV)

RIS-Aided Bistatic Radar for Rapid NLOS Sensing in the Teraharetz Band

In this paper, we investigate a non-lineof-sight (NLOS) sensing problem at terahertz frequencies. To be able to observe the targets shadowed by a blockage, we propose a method using reconfigurable intelligent surfaces (RIS). We employ a bistatic radar system and scan the obstructed area with RIS using hierarchical codebooks (HCB). Moreover, we propose an iterative maximum likelihood estimation (MLE) scheme to yield the optimum sensing accuracy, converging to Cramer-Rao lower bound (CRLB). We take band-specific effects such as diffraction and beam squint into account and show that these effects are relevant factors affecting localization performance in RIS-employed radar setups. The results show that under NLOS conditions, the system can still localize all the targets with very good accuracy using the RIS. The initial estimates obtained by the HCBs can provide centimeter-level accuracy, and when the optimal performance is needed, at the cost of a few extra transmissions, the proposed iterative MLE method improves the accuracy to sub-millimeter accuracy, yielding the position error bound.14 pages, 14 figures, submitted to IEEE Acces

Türkiye’de inme hastalarında atrial fibrilasyonun yönetimi: NöroTek çalışması gerçek hayat verileri

Objective: Atrial fibrillation (AF) is the most common directly preventable cause of ischemic stroke. There is no dependable neurology-based data on the spectrum of stroke caused by AF in Turkiye. Within the scope of NoroTek-Turkiye (TR), hospital-based data on acute stroke patients with AF were collected to contribute to the creation of acute-stroke algorithms.Materials and Methods: On May 10, 2018 (World Stroke Awareness Day), 1,790 patients hospitalized at 87 neurology units in 30 health regions were prospectively evaluated. A total of 929 patients [859 acute ischemic stroke, 70 transient ischemic attack (TIA)] from this study were included in this analysis.Results: The rate of AF in patients hospitalized for ischemic stroke/TIA was 29.8%, of which 65% were known before stroke, 5% were paroxysmal, and 30% were diagnosed after hospital admission. The proportion of patients with AF who received "effective" treatment [international normalization ratio >= 2.0 warfarin or non-vitamin K antagonist oral anticoagulants (NOACs) at a guideline dose] was 25.3%, and, either no medication or only antiplatelet was used in 42.5% of the cases. The low dose rate was 50% in 42 patients who had a stroke while taking NOACs. Anticoagulant was prescribed to the patient at discharge at a rate of 94.6%; low molecular weight or unfractionated heparin was prescribed in 28.1%, warfarin in 32.5%, and NOACs in 31%. The dose was in the low category in 22% of the cases discharged with NOACs, and half of the cases, who received NOACs at admission, were discharged with the same drug.Conclusion: NoroTekTR revealed the high but expected frequency of AF in acute stroke in Turkiye, as well as the aspects that could be improved in the management of secondary prophylaxis. AF is found in approximately one-third of hospitalized acute stroke cases in Turkiye. Effective anticoagulant therapy was not used in three-quarters of acute stroke cases with known AF. In AF, heparin, warfarin, and NOACs are planned at a similar frequency (one-third) within the scope of stroke secondary prophylaxis, and the prescribed NOAC dose is subtherapeutic in a quarter of the cases. Non-medical and medical education appears necessary to prevent stroke caused by AF.Amaç: Atrial fibrilasyon (AF) iskemik inmenin doğrudan önlenebilir en sık nedendir. Ülkemizde AF nedenli inme spektrumuna dair nöroloji kaynaklı geniş ölçekte bir veri bulunmamaktadır. NöroTek-Türkiye (TR) kapsamında akut inme algoritmalarının oluşturulmasına katkı yapması beklenen AF tespit edilen akut inme hastalarına dair hastane verisi toplanmıştır. Gereç ve Yöntem: 10 Mayıs 2018 Dünya İnme Farkındalık Günü’nde 30 sağlık bölgesine yer alan 87 nöroloji biriminde yatmakta olan 1.790 hasta prospektif olarak değerlendirilmiştir. Çalışmada yer alan toplam 929 hasta [859 akut iskemik inme, 70 geçici iskemik atak (GİA)] bu analize dahil edilmiştir. Bulgular: İskemik inme/GİA sebebiyle ile interne edilmiş hastalarda AF oranı %29,8 olup bunların %65’i bilinmekte olan, %5’i paroksismal ve %30’u yeni tanıdır. AF tanısı ile gelen hastalarda “etkin” tedavi [internasyonel normalizasyon oranı ≥2,0 varfarin veya rehber dozunda non-vitamin K antagonist oral antikoagülan (NOAK)] alanların oranı %25,3 olup, %42,5 olguda ya hiç ilaç kullanılmamakta ya da sadece antiplatelet kullanılmaktaydı. Düşük doz kullanım oranı 42 NOAK alırken inme geçirmiş olguda %50 idi. Taburcu edilirken antikoagülan %94,6 (düşük molekül ağırlıklı veya non-fraksiyone heparin %28,1; varfarin %32,5 ve NOAK %31) hastaya reçete edilmişti. NOAK ile taburcu edilen olguların %22’sinde doz düşük kategoride olup gelişte NOAK almakta olan olguların yarısı aynı ilaçla taburcu edilmiştir. Sonuç: NöroTekTR ülkemizde AF’nin akut inmedeki sıklığı yanı sıra sekonder proflaksi perspektifinde yönetiminin geliştirilebilecek yönlerini ortaya koydu. Türkiye’de hastanede yatan akut inme olgularının yaklaşık üçte birinde AF saptanmıştır. AF’si bilinen akut inme olgularının dörtte üçünde etkin antikoagülan tedavi kullanılmamaktaydı. AF’de inme sekonder proflaksisi kapsamında heparin, varfarin ve NOAK planlaması benzer sıklıkta (üçte bir) olup reçete edilen NOAK dozu dörtte bir olguda subterapötiktir. AF’ye bağlı inmenin önlenebilmesi non-medikal ve medikal eğitim gerekli görünmektedir

Terapia Antiplaquetária Dupla Combinada em Pacientes com Doença Arterial Coronariana em uma População na Turquia: DAPT-TR

Resumo Fundamento A Terapia Antiplaquetária Dupla (DAPT, do inglês dual antiplatelet therapy) é o tratamento de escolha para pacientes com síndromes coronarianas agudas e crônicas, uma vez que ela reduz mortalidade e previne complicações trombóticas recorrentes. A avaliação da carga isquêmica e do risco de sangramento é crucial na escolha da DAPT e de sua duração. Objetivos O objetivo de nosso estudo foi conduzir um acompanhamento clínico prospectivo de pacientes recebendo terapia combinada (AAS 75mg + clopidogrel 75 mg). Nosso estudo é um estudo multicêntrico, transversal, observacional, do tipo coorte. Métodos Foram incluídos 1500 pacientes que iniciaram DAPT combinada para o tratamento de síndrome coronariana aguda ou síndrome coronariana crônica. Os desfechos primários foram internação hospitalar por qualquer motivo, internação por causa cardiovascular, infarto agudo do miocárdio, trombose de stent, revascularização de vaso alvo e sangramento; os desfechos secundários foram morte por qualquer razão ou por causa cardiovascular e acidente vascular cerebral. O nível de significância adotado na análise estatística foi 5%. Resultados A idade mediana foi 63 anos; 78,5% dos pacientes estavam recebendo DAPT por síndrome coronariana aguda. As taxas de internação por causas cardiovasculares, de infarto agudo do miocárdio, de trombose de stent e de revascularização de vaso alvo foram 7,9%, 2,3%, 1,3% e 4,2%, respectivamente. Enquanto a taxa de sangramento segundo a escala BARC tipo 1 foi de 3,3%, a taxa de sangramento BARC tipo 5, 3, ou 2 foi 0,6%. As taxas dos desfechos secundários morte por qualquer razão, morte por causa cardiovascular e acidente vascular cerebral foram 0,5%, 0,3% e 0,3%, respectivamente. Conclusão Nosso estudo mostrou que a DAPT em regime combinado de doses fixas de AAS e clopidogrel é eficaz e seguro em pacientes com síndrome coronariana aguda ou crônica adequadamente selecionados

Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

Summary Background Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality. Methods We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung’s disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis. Findings We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung’s disease) from 264 hospitals (89 in high-income countries, 166 in middleincome countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36–39) and median bodyweight at presentation was 2·8 kg (2·3–3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in lowincome countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88–4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59–2·79], p<0·0001), sepsis at presentation (1·20 [1·04–1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4–5 vs ASA 1–2, 1·82 [1·40–2·35], p<0·0001; ASA 3 vs ASA 1–2, 1·58, [1·30–1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02–1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41–2·71], p=0·0001; parenteral nutrition 1·35, [1·05–1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47–0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50–0·86], p=0·0024) or percutaneous central line (0·69 [0·48–1·00], p=0·049) were associated with lower mortality. Interpretation Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between lowincome, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

The Development of the Lung Vasculature in Congenital Diaphragmatic Hernia and Its Clinical Implications

Introducció La herni diafragmàtica congènita (HDC) afecta a 1 de cada 2500 naixements vius, amb una mortalitat del 50%. La principal causa de mort és la hipertensió pulmonar i el subdesenvolupament pulmonar. La severitat de la HDC pot predir-se per diversos indicadors, incloent la relació entre l'àrea pulmonar ipsilateral i la circumferència cefàlica, el volum pulmonar total, i la posició de l'estómac i el fetge. La hipertensió pulmonar, definida quan la pressió pulmonar excedeix 2/3 de la sistèmica, és crucial, sent diagnòsticable per ecocardiografia neonatal primerenca a causa de la limitada circulació fetal cap als pulmons. Aquesta condició complica el tractament prenatal de l'HDC. L'organització anormal de la xarxa vascular pulmonar s'evidencia post mortem. Hipòtesi Proposem que un índex de ramificació vascular pulmonar prenatal correlaciona amb la severitat de la hipertensió pulmonar postnatal, sent un predictor clau de supervivència. Materials i Mètodes Es van utilitzar fetus de rates Sprague Dawley sans i tractats amb nitrofè. Mitjançant tomografia computada micro i tècniques d'intel·ligència artificial, es van reconstruir en 3D els arbres arterials pulmonars. Aquest marc va permetre comparar les estructures vasculars pulmonars de mostres d'HDC i controls sans, obtenint característiques morfològiques per a la caracterització de l'HDC. Resultats De 70 fetus examinats, 40 van demostrar la viabilitat de l'ús de Lugol per a la imatgeria detallada de la vasculatura pulmonar. La segmentació va assolir un 86% de precisió, 82% de sensibilitat i 84% de puntuació F1. La caracterització de l'HDC va revelar un nombre significativament menor de segments vasculars en els fetus afectats, especialment en el primer ordre de ramificació, desviant-se de la Llei de Horton, la qual cosa indica una disminució en la ramificació arterial. Conclusió La reducció en la ramificació de les artèries, a més de la coneguda disminució en la ramificació de les vies aèries en pulmons hipoplàsics, va ser notable en fetus amb HDC. Les tècniques d'imatgeria radiològica van permetre definir l'arbre vascular pulmonar prenatal, estimar el grau de hipertensió pulmonar i, potencialment, facilitar la determinació prenatal de la severitat de la malaltia per orientar teràpies prenatals.Introducción La hernia diafragmática congénita (HDC) afecta a 1 de cada 2500 nacimientos vivos, con una mortalidad del 50%. La principal causa de muerte es la hipertensión pulmonar y el subdesarrollo pulmonar. La severidad de la HDC puede predecirse por varios indicadores, incluyendo la relación entre el área pulmonar ipsilateral y la circunferencia cefálica, el volumen pulmonar total, y la posición del estómago y el hígado. La hipertensión pulmonar, definida cuando la presión pulmonar excede 2/3 de la sistémica, es crucial, siendo diagnósticable por ecocardiografía neonatal temprana debido a la limitada circulación fetal hacia los pulmones. Esta condición complica el tratamiento prenatal de HDC. La organización anormal de la red vascular pulmonar se evidencia post mortem. Hipótesis Proponemos que un índice de ramificación vascular pulmonar prenatal correlaciona con la severidad de la hipertensión pulmonar postnatal, siendo un predictor clave de supervivencia. Materiales y Métodos Se utilizaron fetos de ratas Sprague Dawley sanos y tratados con nitrofeno. Mediante tomografía computarizada micro y técnicas de inteligencia artificial, se reconstruyeron en 3D los árboles arteriales pulmonares. Este marco permitió comparar las estructuras vasculares pulmonares de muestras de HDC y controles sanos, obteniendo características morfológicas para la caracterización de la HDC. Resultados De 70 fetos examinados, 40 demostraron la viabilidad del uso de Lugol para la imagenología detallada de la vasculatura pulmonar. La segmentación alcanzó un 86% de precisión, 82% de sensibilidad y 84% de puntuación F1. La caracterización de la HDC reveló un número significativamente menor de segmentos vasculares en los fetos afectados, especialmente en el primer orden de ramificación, desviándose de la Ley de Horton, lo que indica una disminución en la ramificación arterial. Conclusión La reducción en la ramificación de las arterias, además de la conocida disminución en la ramificación de las vías aéreas en pulmones hipoplásicos, fue notable en fetos con HDC. Las técnicas de imagenología radiológica permitieron definir el árbol vascular pulmonar prenatal, estimar el grado de hipertensión pulmonar y, potencialmente, facilitar la determinación prenatal de la severidad de la enfermedad para orientar terapias prenatales.Introduction Congenital diaphragmatic hernia (CDH) is seen at 1 in every 2500 live births. Its overall mortality is still as high as 50%. Pulmonary hypertension and underdevelopment are the primary causes of death in CDH. Per our current knowledge, the severity of the CDH could be predicted by the ratio of ipsilateral lung area to head circumference, total lung volume, left/right ventricle ratio, modified McGoon index, location of the stomach with the existence of polyhydramnios, and the location of the liver. When the blood pressure in the pulmonary system exceeds 2/3 of the pressure in the systemic circulation, it is said to be pulmonary hypertension. Although the main pathology emerged in utero, this could only be documented by echocardiography in the early neonatal period. This is mostly because the blood flow into the lungs is limited in utero for the sake of fetal blood circulation. This is a significant barrier for treating CDH patients in-utero. Nonetheless, the aberrant organization of the pulmonary vascular network in pulmonary hypertension can only be shown in postmortem subjects by histopathological analyses. Hypothesis Since pulmonary hypertension is one of the predictors of the survival of these patients, this proposal seeks to test the general hypothesis that a prenatal pulmonary vascular branching index correlates with the severity of postnatal pulmonary hypertension. Materials and Methods Sprague Dawley rat fetuses that were both healthy and nitrofen-induced were used. The fetuses underwent micro-computed tomography scanning. Using artificial intelligence techniques, the pulmonary artery tree was 3D reconstructed. Moreover, a framework is developed to generate 3D pulmonary vascular tree structures by using Computed Tomography (CT) scans. Then, the developed framework is used to compare pulmonary vascular trees of CDH samples and healthy controls to determine the characterization of the CDH disease. Finally, by using pulmonary vascular trees, morphological features are obtained, and characterization of the disease is achieved. Results There were 70 fetuses examined throughout the study, 40 of which were used in the first part to demonstrate the feasibility of the Lugol application while the rest were used in the second part. Lugol diffused uniformly throughout the capillaries in the pups with partially removed skin, allowing fine-grained imaging of the lung vasculature. The segmentation part of this project had 86% precision, 82% sensitivity, and 84% F1 score. For the characterization of the CDH, the required features are obtained from the segmented output, and they were prioritized by their impact on the classification. The number of segments in CDH was significantly lower than the control group on the left (U=2.5, p=0.004) and right (U=0, p=0.001) sides for order 1(O1), whereas there was a significant difference only on the right side for O2 and O3. The pooled element numbers in the control group obeyed Horton's Law (R2=0.996 left and R2=0.811 right lungs), while the CDH group broke it. Connectivity matrices showed that the average number of elements of O1 springing from elements of O1 on the left side and the number of elements of O1 springing from elements of O3 on the right side were significantly lower in CDH samples. Conclusion Lung vasculature in CDH is of particular interest for pulmonary development and is the main underlying factor that determines the disease severity. We observed that, besides the known reduced airway branching of the hypoplastic lungs, arterial branching was decreased in fetuses with CDH as well. Herein, we have demonstrated that the radiological imaging techniques were able to define the prenatal lung vascular tree, which could potentially estimate the degree of pulmonary hypertension and enable physicians to determine the severity of the disease prenatally and promote prenatal therapy.Universitat Autònoma de Barcelona. Programa de Doctorat en Cirurgia i Ciències Morfològique

Is There a Causal Relationship between Intussusception and Food Allergy?

Although intussusception and food allergy are common health problems in childhood, the relation between these two diseases remain obscure. The aim of this study is to investigate the relationship between food allergy and intussusception, and the factors associated with both. Patients diagnosed with intussusception by the Brighton Collaboration Intussusception Working Group criteria were prospectively investigated for food allergy per the European Society for Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) Guideline. They were analyzed per demographic features, clinical, physical and laboratory findings. There were eight (38.1%) patients diagnosed with food allergy, while 13 (61.9%) patients were non-allergic. The mean number of days of presenting symptoms was 1.13 days in the allergy group and 7.85 days in the non-allergy group. The mean number of intussusception attacks was 1.63 in the allergy group while 1 in the non-allergy group (p &lt; 0.05, relative risk (RR) = 2.6). In the allergy group, one (13%) patient was followed up, six (75%) patients were reduced with pneumatic and one (13%) patient reduced manually. In the non-allergy group, four (31%) patients were followed up, six (46%) patients were reduced with pneumotic, one (7%) patient was reduced manually, and resection anastomosis was performed in two (15%) patients. Food allergy is an unrecognized associated factor for intussusception patients, which increases the risk for recurrence. Due to the small patient population, these results should be interpreted with caution