Glamorous, talented, audacious-Lillian Hellman knew everyone, did everything, had been everywhere. By the age of twenty-nine she had writtenThe Children's Hour,the first of four hit Broadway plays, ...and soon she was considered a member of America's first rank of dramatists, a position she maintained for more than twenty-five years. Apart from her literary accomplishments-eight original plays and three volumes of memoirs-Hellman lived a rich life filled with notable friendships, controversial political activity, travel, and love affairs, most importantly with Dashiell Hammett. But by the time she died, the truth about her life and works had been called into question. Scandals attached to her name, having to do with sex, with money, and with her own veracity.
Dorothy Gallagher confronts the conundrum that was Lillian Hellman-a woman with a capacity to inspire outrage as often as admiration. Exploring Hellman's leftist politics, her Jewish and Southern background, and her famous testimony before the House Un-American Activities Committee, Gallagher also undertakes a new reading of Hellman's carefully crafted memoirs and plays, in which she is both revealed and hidden. Gallagher sorts through the facts and the myths, arriving at a sharply drawn portrait of a woman who lived large to the end of her remarkable life and never backed down from a fight.
Abstract Purpose Recurrent trachea-esophageal fistula (recTEF) is a frequent (5%–10%) complication of congenital TEF (conTEF) and esophageal atresia (EA) repair. In addition, postoperative acquired ...TEF (acqTEF) can occur in addition to or even in the absence of prior conTEF in the setting of esophageal anastomotic complications. Reliable repair often proves difficult by endoluminal or standard surgical techniques. We present the results of an approach that reliably identifies the TEF and facilitates airway closure as well as repair of associated tracheal and esophageal problems. Methods Retrospective review of 66 consecutive patients 2009–2016 (55 referrals and 11 local) who underwent repair via reoperative thoracotomy or cervicotomy for recTEF and acqTEF (IRB P00004344). Our surgical approach used complete separation of the airway and esophagus, which reliably revealed the TEF (without need for cannulation) and freed the tissues for primary closure of the trachea and frequently resection of the tracheal diverticulum. For associated esophageal strictures, stricturoplasty or resection was performed. Separation of the suture lines by rotational pexy of the both esophagus and the trachea, and/or tissue interposition were used to further inhibit re-recurrence. For associated severe tracheomalacia, posterior tracheopexy to the anterior spinal ligament was utilized. Results The TEFs were recurrent (77%), acquired from esophageal leaks (26%), in addition to persistent or missed H-type (6%). Seven patients in this series had multiple TEFs of more than one category. Of the acqTEF cases, 6 were esophagobronchial, 10 esophagopulmonic, 2 esophagotracheal (initial pure EA cases), and 2 from a gastric conduit to the trachea. Upon referral, 18 patients had failed endoluminal treatments; and open operations for recTEF had failed in 18 patients. Significant pulmonary symptoms were present in all. During repairs, 58% were found to have a large tracheal diverticulum, and 51% had posterior tracheopexy for significant tracheomalacia. For larger esophageal defects, 32% were treated by stricturoplasty and 37% by segmental resection. Rotational pexy of the trachea and/or esophagus was utilized in 62% of cases to achieve optimal suture line separation. Review with a mean follow-up of 35 months identified no recurrences, and resolution of pulmonary symptoms in all. Stricture treatment required postoperative dilations in 30, and esophageal replacement in 6 for long strictures. There was one death. Conclusion This retrospective review of 66 patients with postoperative recurrent and acquired TEF following esophageal atresia repair is the largest such series to date and provides a new categorization for postoperative TEF that helps clarify the diagnostic and therapeutic challenges for management.
Benzodiazepines are allosteric modulators of the GABAA receptor. The traditionally prescribed benzodiazepines are nonselective and suffer from numerous side effects. Upon the identification of ...receptor subtypes, we set out to discover selective agents with the anticipation that these agents would have superior therapeutic potential. Herein, we describe the synthesis and biological evaluation of substituted 7,8,9,10-tetrahydroimidazo1,2-cpyrido3,4-epyrimidin-5(6H)-ones and disclose that these compounds exhibit functional selectivity at the benzodiazepine receptor of GABAA receptor subtypes. The α2/α3-selective partial agonist 42 exhibited potent in vivo activity.
Benzodiazepines are allosteric modulators of the GABA(A) receptor. The traditionally prescribed benzodiazepines are nonselective and suffer from numerous side effects. Upon the identification of ...receptor subtypes, we set out to discover selective agents with the anticipation that these agents would have superior therapeutic potential. Herein, we describe the synthesis and biological evaluation of substituted 7,8,9,10-tetrahydroimidazo1,2-cpyrido3,4-epyrimidin-5(6H)-ones and disclose that these compounds exhibit functional selectivity at the benzodiazepine receptor of GABA(A) receptor subtypes. The alpha(2)/alpha(3)-selective partial agonist 42 exhibited potent in vivo activity.
Abstract Purpose The Foker process (FP) uses tension-induced growth for primary esophageal reconstruction in patients with long gap esophageal atresia (LGEA). It has been less well described in LGEA ...patients who have undergone prior esophageal reconstruction attempts. Methods All cases of LGEA treated at our institution from January 2005 to April 2014 were retrospectively reviewed. Patients who initially had esophageal surgery elsewhere were considered secondary FP cases. Demographics, esophageal evaluations, and complications were collected. Median time to esophageal anastomosis and full oral nutrition was estimated using the Kaplan–Meier method. Multivariate Cox-proportional hazards regression identified potential risk factors. Results Fifty-two patients were identified, including 27 primary versus 25 secondary FP patients. Median time to anastomosis was 14 days for primary and 35 days for secondary cases (p < 0.001). Secondary cases (p = 0.013) and number of thoracotomies (p < 0.001) were identified as significant predictors for achieving anastomosis and the development of a leak. Predictors of progression to full oral feeding were primary FP cases (O.R. = 17.0, 95% CI: 2.8–102, p < 0.001) and patients with longer follow-up (O.R. = 1.06/month, 95% CI: 1.01–1.11, p = 0.005). Conclusions The FP has been successful in repairing infants with primary LGEA, but the secondary LGEA patients proved to be more challenging to achieve a primary esophageal anastomosis. Early referral to a multidisciplinary esophageal center and a flexible approach to establish continuity in secondary patients is recommended. Given their complexity, larger studies are needed to evaluate long-term outcomes and discern optimal strategies for reconstruction.
Abstract
Background
The Foker process is used in patients with long-gap esophageal atresia (LGEA) to maintain the native esophagus; however, chemical paralysis, used to ‘protect’ the esophagus, is ...associated with complications and longer hospital stays. The purpose of this study was to identify changes in practice patterns with increased Foker experience, and to review the relationship of paralysis time with the incidence of esophageal leaks and need for stricture resections.
Methods
A retrospective review of LGEA patients from January 2006 to December 2016 was performed. Patients were excluded if they had previous attempts elsewhere. Patients were initially divided into two groups: early group (surgery before 2013) and late group (2013–2016) to assess outcomes. All patients, irrespective of surgery date, were then divided into three subgroups based on esophageal anastomotic tension. Logistic regression with odds ratio (OR) and 95% confidence interval (CI) was used to assess risk of leaks and need for stricture resection.
Results
Fifty-eight patients met criteria, and demographics were similar between groups. The late group required significantly fewer surgeries between Foker I and Foker II and had shorter ICU length of stay (LOS). Variables that trended towards statistical significance included total length of paralysis, time between Foker I and Foker II, and total hospital LOS. Overall, 18 patients developed a leak, and 13 required stricture resections. There was no correlation between paralysis time or anastomotic tension with incidence of leak or stricture resection. Multivariable analysis indicated that the occurrence of a leak (OR 5.7, 95% CI: 1.4–27.3, P = 0.025) and need for > 8 dilations (OR 11.0, 95% CI: 2.3–53.4, P = 0.002) were significant predictors of need for stricture resection.
Conclusion
As our experience has grown, the need for multiple procedures between Foker I and Foker II has decreased, leading to less paralytic exposure, shorter ICU LOS, and trending toward decreased hospital LOS. By verifying that specified paralysis times are not required, we can continue to mitigate complications associated with lengthy paralysis times and longer hospital admissions without risking esophageal health.
Disclosure
All authors have declared no conflicts of interest.
