Tumor initiating cells in Esophageal squamous cell carcinomas express high levels of CD44

10.1371/journal.pone.0021419PLoS ONE66

International expert consensus on the management of bleeding during VATS lung surgery

Intraoperative bleeding is the most crucial safety concern of video-assisted thoracic surgery (VATS) for a major pulmonary resection. Despite the advances in surgical techniques and devices, intraoperative bleeding is still not rare and remains the most common and potentially fatal cause of conversion from VATS to open thoracotomy. Therefore, to guide the clinical practice of VATS lung surgery, we proposed the International Interest Group on Bleeding during VATS Lung Surgery with 65 experts from 10 countries in the field to develop this consensus document. The consensus was developed based on the literature reports and expert experience from different countries. The causes and incidence of intraoperative bleeding were summarised first. Seven situations of intraoperative bleeding were collected based on clinical practice, including the bleeding from massive vessel injuries, bronchial arteries, vessel stumps, and bronchial stumps, lung parenchyma, lymph nodes, incisions, and the chest wall. The technical consensus for the management of intraoperative bleeding was achieved on these seven surgical situations by six rounds of repeated revision. Following expert consensus statements were achieved: (I) Bleeding from major vascular injuries: direct compression with suction, retracted lung, or rolled gauze is useful for bleeding control. The size and location of the vascular laceration are evaluated to decide whether the bleeding can be stopped by direct compression or by ligation. If suturing is needed, the suction-compressing angiorrhaphy technique (SCAT) is recommended. Timely conversion to thoracotomy with direct compression is required if the operator lacks experience in thoracoscopic angiorrhaphy. (II) Bronchial artery bleeding: pre-emptive clipping of bronchial artery before bronchial dissection or lymph node dissection can reduce the incidence of bleeding. Bronchial artery bleeding can be stopped by compression with the suction tip, followed by the handling of the vascular stump with energy devices or clips. (III) Bleeding from large vessel stumps and bronchial stumps: bronchial stump bleeding mostly comes from accompanying bronchial artery, which can be clipped for hemostasis. Compression for hemostasis is usually effective for bleeding at the vascular stump. Otherwise, additional use of hemostatic materials, re-staple or a suture may be necessary. (IV) Bleeding from the lung parenchyma: coagulation hemostasis is the first choice. For wounds with visible air leakage or an insufficient hemostatic effect of coagulation, suturing may be necessary. (V) Bleeding during lymph node dissection: non-grasping en-bloc lymph node dissection is recommended for the nourishing vessels of the lymph node are addressed first with this technique. If bleeding occurs at the site of lymph node dissection, energy devices can be used for hemostasis, sometimes in combination with hemostatic materials. (VI) Bleeding from chest wall incisions: the chest wall incision(s) should always be made along the upper edge of the rib(s), with good hemostasis layer by layer. Recheck the incision for hemostasis before closing the chest is recommended. (VII) Internal chest wall bleeding: it can usually be managed with electrocoagulation. For diffuse capillary bleeding with the undefined bleeding site, compression of the wound with gauze may be helpful

Ultrasound biomicroscopy of corneal hydrops in Terrien's marginal degeneration

Terrien's marginal degeneration (TMD) is a rare form of corneal ectasia. Few case reports have documented hydrops of the cornea in patients with TMD. We present the first case known to us of corneal hydrops in TMD where there is stromal edema in addition to the aqueous cystic cavities, and the first case demonstrating ultrastructural anatomy of this entity by ultrasound biomicroscopy

Intravascular lymphoma masquerading as Vogt-Koyanagi-Harada syndrome

PURPOSE: To describe the clinical course of a case of intravascular lymphoma. DESIGN: Case report. METHODS: Retrospective chart review. RESULTS: A 56-year-old man presented with blurry vision associated with fever and decreased hearing. Ocular exam including fluorescein angiography and OCT was consistent with Vogt-Koyanagi-Harada syndrome and the patient initially improved with corticosteroids. Clinical deterioration led to further systemic workup and revealed intravascular lymphoma. The patient was started on chemotherapy with resolution of visual complaints. CONCLUSIONS: Intravascular lymphoma can present as a masquerade of VKH syndrome. Diagnosis can be aided with measurement of LDH and skin biopsy

Aortic valve replacement or heart transplantation in patients with aortic stenosis and severe left ventricular dysfunction

Introduction: The decision to perform aortic valve replacement ( AVR ) or heart transplantation ( HTx ) for aortic stenosis ( AS ) with severe left ventricular dysfunction is difficult and may be affected by prior myocardial infarction ( MI ) and coronary artery disease ( CAD ). Methods: Patients who underwent AVR from 1988 to 2001 with left ventricular ejection fraction ( LVEF ) < 30% and severe AS ( aortic valve area [AVA] < 1.0 cm2; n = 51 ) were assessed for operative mortality, late survival, and predictors of outcome, and were compared with HTx. Subsequently, 131 patients with LVEF ≤35% who underwent AVR for critical AS ( AVA < 0.8 cm2 ) were evaluated. Results: In the first 51 patients, 3-year survival was 100% ± 0% with no CAD, and 45% ± 10% with CAD ( P < .05 ); 3-year survival was 88% ± 12% with no bypass, 73% ± 12% with one to two grafts, and 18% ± 11% with three grafts ( P < .01 ). Survival with HTx was 78% at 3 years. In the subsequent analysis of 131 patients, 90-day survivors were followed for a mean 4.6 ± 3.5 years. Advanced age ( P = .001 ) was the only predictor of long-term mortality. LVEF improved from 28.5% ± 5.2% before AVR to 45.4% ± 13.2% at 1-month postoperatively ( P < .0001 ). New York Heart Association ( NYHA ) class III/IV decreased from 94.2% pre-AVR to 12.8% at 1 year ( P < .0001 ). Predictors of LVEF recovery were no previous MI ( P = .007 ) and higher AS gradient ( P = .03 ). Conclusions: In severe AS and LVEF < 30% with no concomitant CAD or with CAD requiring one to two bypass grafts, AVR has a survival equal to or exceeding that of HTx. In patients with CAD requiring more than two bypass grafts, survival is significantly reduced, and HTx can be considered