Background The anatomic difficulties that we have to deal with in open surgery for rectal cancer have not been overcome with the laparoscopic approach. In the search for a solution, a change of ...concept arose: approaching the rectum from below. The main objectives of this study were to show the potential advantages of the hybrid transabdominal-transanal total mesorectal excision (taTME). This approach may improve quality of the mesorectal specimens. Second, proctectomy can be technically easier and more safely performed “down to up,” which would result in shorter surgical times, lower conversion rates, and less morbidity. Study Design A prospective series of hybrid taTME was conducted from October 2011 to November 2014. Results During the study period, 140 procedures were performed. Mean operative time was 166 minutes. There were no conversions or intraoperative complications. Macroscopic quality assessment of the resected specimen was complete in 97.1% and nearly complete in 2.1%. Thirty-day morbidity was minor (Clavien-Dindo I + II) in 24.2% and major (Clavien-Dindo III + IV) in 10 %. No patient died within the first 30 days postsurgery (Clavien-Dindo V). The mean follow-up was 15 months, with a 2.3% local recurrence rate and a 7.6% rate of systemic recurrence. Conclusions Pathologic analysis showed a very good macroscopic quality of TME specimens, which is the most important prognostic factor in rectal cancer. Intraoperative outcomes regarding conversion, surgical times, and intraoperative complications are very satisfactory. Short-term morbidity and oncologic outcomes are as good as in other laparoscopic TME series.
We used the Hubble Space Telescope (HST) Wide Field Camera 3 (WFC3) near-infrared camera to image the host galaxies of a sample of 11 luminous, dust-reddened quasars at z ~ 2-the peak epoch of black ...hole growth and star formation in the universe-to test the merger-driven picture for the coevolution of galaxies and their nuclear black holes. The red quasars come from the FIRST+2MASS red quasar survey and a newer, deeper, UKIDSS+FIRST sample. These dust-reddened quasars are the most intrinsically luminous quasars in the universe at all redshifts, and they may represent the dust-clearing transitional phase in the merger-driven black hole growth scenario. Probing the host galaxies in rest-frame visible light, the HST images reveal that 8/10 of these quasars have actively merging hosts, whereas one source is reddened by an intervening lower-redshift galaxy along the line of sight. We study the morphological properties of the quasar hosts using parametric Sersic fits, as well as nonparametric estimators (Gini coefficient, M sub(20), and asymmetry). Their properties are heterogeneous but broadly consistent with the most extreme morphologies of local merging systems such as ultraluminous infrared galaxies. The red quasars have a luminosity range of log(L sub(bol)) = 47.8-48.3 (erg s super(-1)), and the merger fraction of their hosts is consistent with merger-driven models of luminous active galactic nuclei activity at z = 2, which supports the picture in which luminous quasars and galaxies coevolve through major mergers that trigger both star formation and black hole growth.
Summary Background Laparoscopic surgery as an alternative to open surgery in patients with rectal cancer has not yet been shown to be oncologically safe. The aim in the COlorectal cancer Laparoscopic ...or Open Resection (COLOR II) trial was to compare laparoscopic and open surgery in patients with rectal cancer. Methods A non-inferiority phase 3 trial was undertaken at 30 centres and hospitals in eight countries. Patients (aged ≥18 years) with rectal cancer within 15 cm from the anal verge without evidence of distant metastases were randomly assigned to either laparoscopic or open surgery in a 2:1 ratio, stratified by centre, location of tumour, and preoperative radiotherapy. The study was not masked. Secondary (short-term) outcomes—including operative findings, complications, mortality, and results at pathological examination—are reported here. Analysis was by modified intention to treat, excluding those patients with post-randomisation exclusion criteria and for whom data were not available. This study is registered with ClinicalTrials.gov , number NCT00297791. Findings The study was undertaken between Jan 20, 2004, and May 4, 2010. 1103 patients were randomly assigned to the laparoscopic (n=739) and open surgery groups (n=364), and 1044 were eligible for analyses (699 and 345, respectively). Patients in the laparoscopic surgery group lost less blood than did those in the open surgery group (median 200 mL IQR 100–400 vs 400 mL 200–700, p<0·0001); however, laparoscopic procedures took longer (240 min 184–300 vs 188 min 150–240; p<0·0001). In the laparoscopic surgery group, bowel function returned sooner (2·0 days 1·0–3·0 vs 3·0 days 2·0–4·0; p<0·0001) and hospital stay was shorter (8·0 days 6·0–13·0 vs 9·0 days 7·0–14·0; p=0·036). Macroscopically, completeness of the resection was not different between groups (589 88% of 666 vs 303 92% of 331; p=0·250). Positive circumferential resection margin (<2 mm) was noted in 56 (10%) of 588 patients in the laparoscopic surgery group and 30 (10%) of 300 in the open surgery group (p=0·850). Median tumour distance to distal resection margin did not differ significantly between the groups (3·0 cm IQR 2·0–4·8 vs 3·0 cm 1·8–5·0, respectively; p=0·676). In the laparoscopic and open surgery groups, morbidity (278 40% of 697 vs 128 37% of 345, respectively; p=0·424) and mortality (eight 1% of 699 vs six 2% of 345, respectively; p=0·409) within 28 days after surgery were similar. Interpretation In selected patients with rectal cancer treated by skilled surgeons, laparoscopic surgery resulted in similar safety, resection margins, and completeness of resection to that of open surgery, and recovery was improved after laparoscopic surgery. Results for the primary endpoint—locoregional recurrence—are expected by the end of 2013. Funding Ethicon Endo-Surgery Europe, Swedish Cancer Foundation, West Gothia Region, Sahlgrenska University Hospital.
5G‐assisted telementored surgery Lacy, A. M; Bravo, R.; Otero‐Piñeiro, A. M. ...
British journal of surgery,
November 2019, 2019-11-00, 20191101, Letnik:
106, Številka:
12
Journal Article
Recenzirano
Odprti dostop
Safe and effective implementation of remote surgery and telementoring can have significant limitations. Fifth‐generation (5G) wireless networks could be useful in overcoming these drawbacks. As a ...proof of concept, the authors present technical and clinical details of two procedures assisted by telementoring using 5G that were also broadcast live.
Secure remote access advice
Heat Waves, Aging, and Human Cardiovascular Health KENNEY, W LARRY; CRAIGHEAD, DANIEL H; ALEXANDER, LACY M
Medicine and science in sports and exercise,
2014-October, Letnik:
46, Številka:
10
Journal Article
Recenzirano
Odprti dostop
ABSTRACTThis brief review is based on a President’s Lecture presented at the Annual Meeting of the American College of Sports Medicine in 2013. The purpose of this review was to assess the effects of ...climate change and consequent increases in environmental heat stress on the aging cardiovascular system. The earth’s average global temperature is slowly but consistently increasing, and along with mean temperature changes come increases in heat wave frequency and severity. Extreme passive thermal stress resulting from prolonged elevations in ambient temperature and prolonged physical activity in hot environments creates a high demand on the left ventricle to pump blood to the skin to dissipate heat. Even healthy aging is accompanied by altered cardiovascular function, which limits the extent to which older individuals can maintain stroke volume, increase cardiac output, and increase skin blood flow when exposed to environmental extremes. In the elderly, the increased cardiovascular demand during heat waves is often fatal because of increased strain on an already compromised left ventricle. Not surprisingly, excess deaths during heat waves 1) occur predominantly in older individuals and 2) are overwhelmingly cardiovascular in origin. Increasing frequency and severity of heat waves coupled with a rapidly growing at-risk population dramatically increase the extent of future untoward health outcomes.
Background
The feasibility and safety of Natural Orifice Translumenal Endoscopic Surgery (NOTES) transanal endoscopic rectosigmoid resection using transanal endoscopic microsurgery (TEM) was ...previously demonstrated in human cadavers and a porcine survival model. We report the first clinical case of a NOTES transanal resection for rectal cancer using TEM and laparoscopic assistance, performed by a team of surgeons from Barcelona and Boston with extensive experience with NOTES and minimally invasive approaches to colorectal diseases.
Methods
Transanal endoscopic rectal resection with total mesorectal excision using the TEM platform was performed in a 76-year-old woman with a T2N2 rectal cancer treated with preoperative chemoradiation. Laparoscopic visualization and assistance with retraction and exposure during rectosigmoid mobilization was provided through one 5-mm port, which was later used as the stoma site, and 2-mm needle ports, one of which was used as a drain site. The specimen was transected transanally followed by handsewn coloanal anastomosis.
Results
The procedure was completed successfully with an operative time of 4 hours and 30 minutes. Mesorectal excision was complete. The postoperative course was uneventful, and the patient was discharged on the fourth postoperative day. The final pathology demonstrated pT1N0 with 23 negative lymph nodes and negative proximal, distal, and radial margins.
Conclusions
NOTES transanal endoscopic rectosigmoid resection using TEM and laparoscopic assistance is feasible and safe. Careful patient selection and improvement in NOTES instrumentation are critical to optimize this approach before widespread clinical application.
Women who have had preeclampsia have increased cardiovascular disease risk; however, the mechanism(s) responsible for this association remain unclear. Microvascular damage sustained during a ...preeclamptic pregnancy may persist postpartum. The putative mechanisms mediating this dysfunction include a reduction in NO-dependent dilation and an increased sensitivity to angiotensin II. In this study, we evaluated endothelium-dependent dilation, angiotensin II sensitivity, and the therapeutic effect of angiotensin II receptor blockade (losartan) on endothelium-dependent dilation in vivo in the microvasculature of women with a history of preeclampsia (n=12) and control women who had a healthy pregnancy (n=12). We hypothesized that preeclampsia would have (1) reduced endothelium-dependent dilation, (2) reduced NO-mediated dilation, and (3) increased sensitivity to angiotensin II. We further hypothesized that localized losartan would increase endothelium-dependent vasodilation in preeclampsia. We assessed microvascular endothelium-dependent vasodilator function by measurement of cutaneous vascular conductance responses to graded infusion of acetylcholine (acetylcholine; 10–102 mmol/L) and a standardized local heating protocol in control sites and sites treated with 15 mmol/L L-NAME (N-nitro-L-arginine methyl ester; NO-synthase inhibitor) or 43 µmol/L losartan. Further, we assessed microvascular vasoconstrictor sensitivity to angiotensin II (10–10 mol/L). Preeclampsia had significantly reduced endothelium-dependent dilation (−0.3±0.5 versus −1.0±0.4 logEC50; P<0.001) and NO-dependent dilation (16±3% versus 39±6%; P=0.006). Preeclampsia also had augmented vasoconstrictor sensitivity to angiotensin II (−10.2±1.3 versus −8.3±0.5; P=0.006). Angiotensin II type I receptor inhibition augmented endothelium-dependent vasodilation and NO-dependent dilation in preeclampsia but had no effect in healthy pregnancy. These data suggest that women who have had preeclampsia have persistent microvascular dysfunction postpartum, mediated, in part, by increased sensitivity to angiotensin II.
Despite remission of clinical symptoms postpartum, women who have had preeclampsia demonstrate microvascular endothelial dysfunction, mediated in part by increased sensitivity to angiotensin II (ANG ...II). Angiotensin-(1-7) Ang-(1-7) is an endogenous inhibitor of the actions of ANG II and plausible druggable target in women who had preeclampsia. We therefore examined the therapeutic potential of Ang-(1-7) in the microvasculature of women with a history of preeclampsia (PrEC;
= 13) and parity-matched healthy control women (HC;
= 13) hypothesizing that administration of Ang-(1-7) would increase endothelium-dependent dilation and nitric oxide (NO)-dependent dilation and decrease ANG II-mediated constriction in PrEC. Using the cutaneous microcirculation, we assessed endothelium-dependent vasodilator function in response to graded infusion of acetylcholine (ACh; 10
to 10
mmol/L) in control sites and sites treated with 15 mmol/L
-nitro-l-arginine methyl ester (l-NAME; NO-synthase inhibitor), 100 µmol/L Ang-(1-7), or 15 mmol/L l-NAME + 100 µmol/L Ang-(1-7). Vasoconstrictor function was measured in response to ANG II (10
-10
mol/L) in control sites and sites treated with 100 µmol/L Ang-(1-7). PrEC had reduced endothelium-dependent dilation (
< 0.001) and NO-dependent dilation (
= 0.04 vs. HC). Ang-(1-7) coinfusion augmented endothelium-dependent dilation (
< 0.01) and NO-dependent dilation (
= 0.03) in PrEC but had no effect in HC. PrEC demonstrated augmented vasoconstrictor responses to ANG II (
< 0.01 vs. HC), which was attenuated by coinfusion of Ang-(1-7) (
< 0.001). Ang-(1-7) increased endothelium-dependent vasodilation via NO synthase-mediated pathways and attenuated ANG II-mediated constriction in women who have had preeclampsia, suggesting that Ang-(1-7) may be a viable therapeutic target for improved microvascular function in women who have had a preeclamptic pregnancy.
This study sought to develop selection guidelines to determine the eligibility for SCT of patients with light-chain amyloidosis. Patients with biopsy-confirmed lightchain amyloidosis who underwent ...SCT between 8 March 1996 and 31 December 2011 were reviewed in two cohorts by date of transplantation: between 8 March 1996 and 30 June 2009 (n=410) and between 1 July 2009 and 31 December 2011 (n=89). Also evaluated were patients who died before post-transplant day 100 to determine the features predictive of early death. After 1 July 2009, fewer transplant recipients had Mayo stage III cardiac involvement. Mortality before post-transplant day 100 was 10.5% (43/410) in the earlier group and 1.1% (1/89) in the later group. In the earlier group, one-quarter of transplant recipients with N-terminal pro-brain natriuretic peptide (NT-proBNP) >5000 pg/mL died by 10.3 months. When serum troponin T was >0.06 ng/mL, 25% died at 3.7 months. The Mayo staging system is predictive for OS but not useful for selecting transplant recipients. Patients with serum troponin T >0.06 ng/mL or NT-proBNP >5000 pg/mL (not on dialysis) should not be considered candidates for SCT because of early mortality.
Abstract
We present a spectroscopically complete sample of 147 infrared-color-selected active galactic nuclei (AGNs) down to a 22
μ
m flux limit of 20 mJy over the ∼270 deg
2
of the Sloan Digital Sky ...Survey Stripe 82 region. Most of these sources are in the QSO luminosity regime (
L
bol
≳ 10
12
L
⊙
) and are found out to
z
≃ 3. We classify the AGNs into three types, finding 57 blue, unobscured Type-1 (broad-lined) sources; 69 obscured, Type-2 (narrow-lined) sources; and 21 moderately reddened Type-1 sources (broad-lined and
E
(
B
−
V
) > 0.25). We study a subset of this sample in X-rays and analyze their obscuration to find that our spectroscopic classifications are in broad agreement with low, moderate, and large amounts of absorption for Type-1, red Type-1, and Type-2 AGNs, respectively. We also investigate how their X-ray luminosities correlate with other known bolometric luminosity indicators such as O
iii
line luminosity (
L
O
iii
) and infrared luminosity (
L
6
μ
m
). While the X-ray correlation with
L
O
iii
is consistent with previous findings, the most infrared-luminous sources appear to deviate from established relations such that they are either underluminous in X-rays or overluminous in the infrared. Finally, we examine the luminosity function evolution of our sample, and by AGN type, in combination with the complementary, infrared-selected, AGN sample of Lacy et al. (2013), spanning over two orders of magnitude in luminosity. We find that the two obscured populations evolve differently, with reddened Type-1 AGNs dominating the obscured AGN fraction (∼30%) for
L
5
μ
m
> 10
45
erg s
−1
, while the fraction of Type-2 AGNs with
L
5
μ
m
< 10
45
erg s
−1
rises sharply from 40% to 80% of the overall AGN population.
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