A Case Report of Successful Management of Clostridium Difficile Colitis with Antegrade Fidaxomicin Through A Mucous Fistula Obviating the Need for Subtotal Colectomy.

Introduction Clostridium difficile is the most common cause of healthcare-associated infections and can have devastating morbidity and mortality. Traditional treatment algorithms involve intravenous metronidazole and enteric metronidazole or vancomycin. Fidaxomicin (DificidR) targets “switch regions” within RNA polymerases and effectively kills clostridium difficile bacteria and is typically administered orally primarily or through a naso/oro-gastric conduit. Presentation of case 55-year-old with a recent elective surgical procedure was hospitalized with multifocal pneumonia and subsequently developed clostridium difficile colitis. This patient failed the standard medical therapy for clostridium difficile colitis, decompensated and required surgical exploration, partial colectomy and mucous fistula creation. Following her surgery, her clinical condition improved and her colitis resolved with the antegrade administration of fidaxomicin through her mucous fistula. Discussion Fidaxomicin is a newer to market therapeutic agent that has been shown to be effective in the treatment of clostridium difficile colitis. Previously studies have shown benefit of oral fidaxomicin therapy for fulminant clostridium difficile but our study case report describes the index case of topical fidaxomicin through a mucous fistula. Conclusion In our case of fulminant clostridium difficile colitis, Fidaxomicin administered in an antegrade fashion through a mucous fistula may have reduced the need for total colectomy in the treatment of fulminant clostridium difficile colitis

Sudden Heart Rate Reduction Upon Optogenetic Release of Acetylcholine From Cardiac Parasympathetic Neurons in Perfused Hearts

The balance of sympathetic and parasympathetic tone provides exquisite control of heart rate and contractility and has also been shown to modulate coronary flow and inflammation. Understanding how autonomic balance is altered by cardiac disease is an active area of research, and developing new ways to control this balance provides insights into disease therapies. However, achieving acute neuron-specific stimulation of autonomic neurons can be difficult in experiments that measure the acute effects of nerve stimulation on the heart. Conventional electrical and pharmacological approaches can be spatially and temporally non-selective. Cell-specific expression of light-activated channels (channelrhodopsin, ChR2) is a powerful approach that enables control of the timing and distribution of cellular stimulation using light. We present such an optogenetic approach where parasympathetic cardiac neurons are selectively photoactivated at high temporal precision to initiate cholinergic-mediated slowing of heart rate. Mice were crossbred to express ChR2 in peripheral cholinergic neurons using Cre-Lox recombination driven by a choline acetyltransferase (ChAT) promoter. Hearts from adult mice were excised, perfused, and the epicardium was illuminated (peak 460–465 nm) to photoactivate ChR2. In one set of studies, hearts were illuminated using a large-field LED light source. In other studies, a micro LED was placed on the right atrium to selectively illuminate the junction of the superior vena cava (SVC) and right atrium. The ECG was acquired before, during, and after tissue illumination to measure changes in heart rate. Upon illumination, hearts exhibited sudden and dramatic reductions in heart rate with restoration of normal heart rate after cessation of illumination. Delays in atrioventricular conduction were also observed. Heart rate reductions at the highest irradiance levels were similar to heart rate reductions caused by application of bethanechol (10 μM) or acetylcholine (800 μM). Atropine (50 nM) completely blocked the effect of ChR2 photoactivation, confirming cholinergic mediation. Optogenetic activation of intrinsic parasympathetic neurons reduced heart rate in an immediate, dose-dependent fashion, resembling the slowing of sinus rate in response to acetylcholine. Our results demonstrate a new approach for controlling parasympathetic modulation of cardiac function by selectively activating the endogenous release of acetylcholine from intrinsic cardiac cholinergic neurons.Key Message: Optogenetic photoactivation of intrinsic cardiac neurons provides immediate, tissue-specific stimulation with minimal cross-reactivity. Our results demonstrate that selective expression of channelrhodopsin within cardiac cholinergic neurons enables photoactivated release of acetylcholine, thereby instantaneously slowing sinus rate and altering atrioventricular conduction. This provides for in-depth examination of the endogenous interplay between cardiac autonomic neurons and the functional outcomes of downstream post-synaptic receptor activation

Biochemical Properties of Tissue-Engineered Cartilage

Microtia is treated with rib cartilage sculpting and staged procedures; though aesthetically pleasing, these constructs lack native ear flexibility. Tissue-engineered (TE) elastic cartilage may bridge this gap; however, TE cartilage implants lead to hypertrophic changes with calcification and loss of flexibility. Retaining flexibility in TE cartilage must focus on increased elastin, maintained collagen II, decreased collagen X, with prevention of calcification. This study compares biochemical properties of human cartilage to TE cartilage from umbilical cord mesenchymal stem cells (UCMSCs). Our goal is to establish a baseline for clinically useful TE cartilage

Analyzing the Time From Discovery to Definitive Surgical Therapy for Lung Cancer Based on Referral Patterns

OBJECTIVE: Surgery for early stage non-small cell lung cancer can be curative. A delay from diagnosis to surgery can lead to increased mortality. Our objective was to determine if referring patients to specialists before a thoracic surgeon caused a delay in definitive treatment. MATERIALS AND METHODS: A retrospective review was conducted of patients who had surgery for non-small cell lung cancer by a single surgeon at our institution from 2013 to 2016. Patients were divided into 2 groups: those who saw a specialist before a thoracic surgeon and patients who were referred directly to a surgeon once the pulmonary nodule was identified on computed tomography (CT). The time from initial CT to resection was compared. Secondary analysis compared private insurance versus Medicare/Medicaid. Percentage of patients upstaged was compared. RESULTS: There was no significant difference between groups when comparing time from CT to surgery (79.88 vs. 79.90 d; P=0.58). There was a significant decrease in time from CT to surgery for patients with private insurance compared with Medicare/Medicaid patients (66.05 vs. 86.99 d; P=0.03) and fewer private insurance patients were upstaged (22.9% vs. 31.8%; P=0.32). More patients who saw a different specialist first were upstaged compared with patients sent directly to thoracic surgery (32.6% vs. 22.2%; P=0.22). CONCLUSIONS: When comparing time from CT detection of a lung nodule to surgery, no significant difference was found between patients sent to nonthoracic specialists first and those referred directly to a thoracic surgeon. There was a significant decrease in time from CT to surgery for patients with private insurance compared with Medicare/Medicaid

A Review of Deep Infiltrative Colorectal Endometriosis Treated Robotically at a Single Institution.

Purpose/background: Using robotic surgery, we report successful resection of deep invasive pelvic endometriosis with a multidisciplinary team of colorectal and gynecologic surgeons. Methods/interventions: Fifteen cases of robotic-assisted endometrial resections for deep invasive endometriosis were performed by a multidisciplinary team between 2013 and 2016. Results/outcomes: The average total operative time of robotic endometrial extirpation was 342 minutes, and the average blood loss was 283 cc. There were no intraoperative complications and no conversion to laparotomy. Postoperative complications, including one superficial wound infection, four patients with pelvic abscesses, a bowel leak, and one rectovaginal fistula, occurred in five of 15 patients, three of which required percutaneous drainage and one required reoperation. All patients who followed up after surgery showed 100% dysmenorrhea resolution at one month (13 of 15 patients). Conclusion/discussion: Deep infiltrating endometriosis is a complex disease associated with significant morbidity and requires highly trained, multidisciplinary team approach for safe and efficient excision

General acts passed by the General Court of Massachusetts

Imprint varies.Vols. for 1915-19 published in 2 v.: General acts; Special acts.Vols. for some years issued in parts.Separate vols. issued for extra session, 1916, and for extra session, 1933.Vol. 12 (May 1831-Mar. 1833) in Jan. session, 1833; Jan. 1834-Apr. 1836 in vol. for extra session 1835/Jan. session 1836; May 1824-Mar. 1828; June 1828-June 1831, Jan. 1832-Apr. 1834, Jan. 1835-Apr. 1838, each bound with corresponding vol.Resolves issued separately, 1780-1838