Transitory R wave growth in the midst of ST-segment elevation myocardial infarction: A case of left septal fascicular block with atypical electrocardiographic presentation.

We report the case of a patient who presented with angina and ST-segment elevation in the precordial leads owing to a proximal occlusion of the left anterior descending coronary artery. Serial electrocardiography (ECG) showed signs consistent with the left septal fascicular block (LSFB). The latter was observed in conjunction with a pre-existing left anterior fascicular block and presented atypical ECG features, such as intermittent prominent anterior QRS forces (prominent R wave) in V2 only and preserved septal q waves in I and aVL. In the discussion, we present an overview of the electrocardiographic criteria for the diagnosis of the LSFB together with reasons for which LSFB may present with an atypical ECG picture.

A tailored approach in lymph node-positive perihilar cholangiocarcinoma.

PURPOSE: Extended right hepatectomy is associated with wide surgical margins in PHC and often favored for oncological considerations. However, it remains uncertain whether established surgical principles also apply to the subgroup of node-positive patients. The aim of the present study was to define a tailored surgical approach for patients with perihilar cholangiocarcinoma (PHC) and lymph node metastases. METHODS: We reviewed the course of all consecutive patients undergoing major hepatectomy for PHC between 2005 and 2015 at the Department of Surgery, Charité - Universitätsmedizin Berlin. RESULTS: Two hundred and thirty-one patients underwent major hepatectomy for PHC with 1-, 3-, and 5-year overall (OS) and disease-free survival (DFS) rates of 72%, 48%, and 36%, and 60%, 22%, and 12%, respectively. In lymph node-positive patients (n = 109, 47%), extended left hepatectomy was associated with improved OS and DFS, respectively, when compared to extended right hepatectomy (p = 0.008 and p = 0.003). Interestingly, OS and DFS did not differ between R0 and R1 resections in those patients (both p = ns). Patients undergoing extended left hepatectomy were more likely to receive adjuvant chemotherapy (p = 0.022). This is of note as adjuvant chemotherapy, besides grading (p = 0.041), was the only independent prognostic factor in node-positive patients (p=0.002). CONCLUSION: Patients with node-positive PHC might benefit from less aggressive approaches being associated with lower morbidity and a higher chance for adjuvant chemotherapy. Lymph node sampling might help to guide patients to the appropriate surgical approach according to their lymph node status.

Electrocardiographic presentation of acute left main coronary artery occlusion misinterpreted as ventricular tachycardia.

We present a case of acute left main coronary artery (LMCA) occlusion that manifested cardiogenic shock and an ST-segment elevation myocardial infarction (STEMI) electrocardiographic (ECG) pattern comprising "triangular" or "lambda-like" QRS-ST-T complexes. The presenting ECG pattern was misinterpreted as ventricular tachycardia (VT) with resultant delayed emergency percutaneous coronary intervention. The patient died of intractable cardiogenic shock. This case corroborates previous research findings associating the ECG pattern comprising "triangular" or "lambda-like" QRS-ST-T complexes observed in the clinical setting of acute myocardial ischemia with acute LMCA occlusion. Also, we demonstrate how this ECG pattern should be scrutinized for ST-segment elevation in order to avoid misdiagnosing a STEMI for VT.

skillsChain: A Decentralized Application That Uses Educational Robotics and Blockchain to Disrupt the Educational Process.

Our epoch is continuously disrupted by the rapid technological advances in various scientific domains that aim to drive forward the Fourth Industrial Revolution. This disruption resulted in the introduction of fields that present advanced ways to train students as well as ways to secure the exchange of data and guarantee the integrity of those data. In this paper, a decentralized application (dApp), namely skillsChain, is introduced that utilizes Blockchain in educational robotics to securely track the development of students' skills so as to be transferable beyond the confines of the academic world. This work outlines a state-of-the-art architecture in which educational robotics can directly execute transactions on a public ledger when certain requirements are met without the need of educators. In addition, it allows students to safely exchange their skills' records with third parties. The proposed application was designed and deployed on a public distributed ledger and the final results present its efficacy.

Generating and characterizing single- and multigene mutants of the Rubisco small subunit family in Arabidopsis.

The primary CO2-fixing enzyme Rubisco limits the productivity of plants. The small subunit of Rubisco (SSU) can influence overall Rubisco levels and catalytic efficiency, and is now receiving increasing attention as a potential engineering target to improve the performance of Rubisco. However, SSUs are encoded by a family of nuclear rbcS genes in plants, which makes them challenging to engineer and study. Here we have used CRISPR/Cas9 [clustered regularly interspaced palindromic repeats (CRISPR)/CRISPR-associated protein 9] and T-DNA insertion lines to generate a suite of single and multiple gene knockout mutants for the four members of the rbcS family in Arabidopsis, including two novel mutants 2b3b and 1a2b3b. 1a2b3b contained very low levels of Rubisco (~3% relative to the wild-type) and is the first example of a mutant with a homogenous Rubisco pool consisting of a single SSU isoform (1B). Growth under near-outdoor levels of light demonstrated Rubisco-limited growth phenotypes for several SSU mutants and the importance of the 1A and 3B isoforms. We also identified 1a1b as a likely lethal mutation, suggesting a key contributory role for the least expressed 1B isoform during early development. The successful use of CRISPR/Cas here suggests that this is a viable approach for exploring the functional roles of SSU isoforms in plants.

Performance of a factory-calibrated, real-time continuous glucose monitoring system during elective abdominal surgery.

We assessed the performance of the factory-calibrated, sixth-generation continuous glucose monitoring (CGM) system Dexcom G6® (DexCom Inc., San Diego, California) during elective abdominal surgery. Twenty adults with (pre)diabetes undergoing abdominal surgery (>2 hours; 15 men, age 69 ± 13 years, glycated haemoglobin 53 ± 14 mmol/mol) wore the sensor from 1 week prior to surgery until hospital discharge. From induction of anaesthesia until 2 hours post-surgery, reference capillary glucose values were obtained every 20 minutes using the Accu-Chek® Inform II meter (Roche Diabetes Care, Mannheim, Germany). The primary endpoint was the mean absolute relative difference (ARD) between sensor and reference method during this period. In total, 1207 CGM/reference pairs were obtained. In the peri-operative period (523 pairs), mean ± SD and median (interquartile range [IQR]) ARD were 12.7% ± 8.7% and 9.9 (6.3;15.9)%, respectively, and 67.4% of sensor readings were within International Organization of Standardization 15197:2013 limits. CGM overestimated reference glucose by 1.1 ± 0.8 mmol/L (95% limits of agreement -0.5;2.7 mmol/L). Clarke error grid zones A or B contained 99.2% of pairs (A: 78.8%; B: 20.4%). The median (IQR) peri-operative sensor availability was 98.6 (95.9;100.0)%. No clinically significant adverse events occurred. In conclusion, the Dexcom G6 device showed consistent and acceptable accuracy during elective abdominal surgery, opening new avenues for peri-operative glucose management.

Safety and feasibility of laparoscopic liver resection in patients with a history of abdominal surgeries.

BACKGROUND: Laparoscopic techniques have become the standard approach for most liver resections. Clinical studies providing conclusive evidence which patients benefit most from minimal-invasive surgery remain limited. METHODS: We retrospectively analyzed data of all consecutive cases of laparoscopic liver resection between 2015 and 2018 at our center. We compared patients with and without prior abdominal surgeries with respect to postoperative complications (Clavien-Dindo score), length of operation, length of ICU stay and length of hospitalization in univariate and multivariate analyses. RESULTS: Within the study period 319 patients underwent laparoscopic liver resections, 44% of which had a history of abdominal surgeries. Pre-operative characteristics were similar to patients without prior surgeries. Both groups showed comparable rates of post-operative complications (Clavien-Dindo score ≥3a; 12% in patients without vs. 16% with prior surgeries, p = 0,322). There were no significant differences in length of surgery or length of stay in the ICU or in the hospital. CONCLUSION: Our data suggest that history of prior abdominal surgery is not a risk factor for post-operative complications after laparoscopic liver resection. We conclude that prior abdominal surgery should not be considered a contra-indication for laparoscopic approach in liver resection.

A patient with simultaneous anterior and inferior ST-segment elevation after percutaneous coronary intervention.

A patient who presented with acute inferior-right ventricular (RV) ST-segment elevation (STE) myocardial infarction (MI) is described. Coronary angiography showed a mid-right coronary artery (RCA) occlusion and high-grade proximal left anterior descending (LAD) artery stenoses. Electrocardiography (ECG) after stent angioplasty to the RCA showed new STE in leads V1-V6. Whereas STE pattern recognition was misleading, ECG analysis using vector concepts enabled exclusion of anterior MI due to proximal LAD artery occlusion and recognition of the RV origin of this ECG picture. The ability of the ECG to "capture" RV dilation that enabled the manifestation of this ECG picture is highlighted.

Analysis of outcomes and predictors of long-term survival following resection for retroperitoneal sarcoma.

BACKGROUND: Retroperitoneal sarcomas (RPS) include a heterogeneous group of rare malignant tumours, and various treatment algorithms are still controversially discussed until today. The present study aimed to examine postoperative and long-term outcomes after resection of primary RPS. PATIENTS AND METHODS: Clinicopathological data of patients who underwent resection of primary RPS between 2005 and 2015 were assessed, and predictors for overall survival (OS) and disease-free survival (DFS) were identified. RESULTS: Sixty-one patients underwent resection for primary RPS. Postoperative morbidity and mortality rates were 31 and 3%, respectively. After a median follow-up time of 74 months, 5-year OS and DFS rates were 58 and 34%, respectively. Histologic high grade (5-year OS: G1: 92% vs. G2: 54% vs. G3: 43%, P = 0.030) was significantly associated with diminished OS in univariate and multivariate analyses. When assessing DFS, histologic high grade (5-year DFS: G1: 63% vs. G2: 24% vs. G3: 22%, P = 0.013), positive surgical resection margins (5-year DFS: R0: 53% vs. R1: 10% vs. R2: 0%, P = 0.014), and vascular involvement (5-year DFS: yes: 33% vs no: 39%, P = 0.001), were significantly associated with inferior DFS in univariate and multivariate analyses. CONCLUSIONS: High-grade tumours indicated poor OS, while vascular involvement, positive surgical resection margins, and histologic grade are the most important predictors of DFS. Although multimodal treatment strategies are progressively established, surgical resection remains the mainstay in the majority of patients with RPS, even in cases with vascular involvement.

The value of microparticles in detecting acute rejection episodes after liver transplantation.

CONTEXT: Non-invasive markers for diagnosis of acute rejection (AR) following liver transplantation have not been developed, yet. OBJECTIVE: We analyzed the correlation of plasma microparticle levels (MP) with AR. MATERIALS AND METHODS: MP (CD4, CD8, CD25, CD31, MHC) of 11 AR patients and 11 controls were analyzed within the first week after transplantation. RESULTS: CD4, CD8 and CD31 positive MP were higher in the AR, whereas overall MP count, CD25 and MHCI positive MP proportions did not differ between both groups. DISCUSSION AND CONCLUSION: MP dynamics within the first period of transplantation could help to clarify on-going mechanisms of immunomodulation.

Evaluation of Anastomotic Leak after Esophagectomy for Esophageal Cancer: Typical Time Point of Occurrence, Mode of Diagnosis, Value of Routine Radiocontrast Agent Studies and Therapeutic Options.

BACKGROUND: Data on the typical time point of occurrence of anastomotic leak (AL) after esophagectomy for esophageal cancer are currently scarce. Therefore, the usefulness of routine radiocontrast agent studies (RRCS) for testing proper healing of the anastomosis after esophagectomy remains unclear. Furthermore, preferred available tools to diagnose postoperative AL and therapeutic options are still under debate. METHODS: We present a retrospective analysis of 328 consecutive patients who underwent esophagectomy for esophageal cancer between 2005 and 2015. A RRCS has been performed to date in our center on the fifth postoperative day (POD), before returning to normal oral intake. RESULTS: In total, 49 of 328 patients developed AL after esophagectomy (15%). A total of 11 patients (23%) developed AL before the RRCS and 34 patients (69%) after an unremarkable RRCS; and 4 patients (8%) with AL were diagnosed by RRCS, resulting in overall sensitivity of 16%. The median time point of occurrence of AL was POD 9, the majority of AL (84%) occurred between POD 1 and 19. Computed tomography led to the diagnosis of AL in 41% of patients. The most frequent therapy of AL was stenting in 47% of patients. Endoscopic vacuum therapy was used in 4 patients. CONCLUSIONS: The majority of AL occurred within the first 3 weeks after esophagectomy without a typical time point. In our series, RRCS on the fifth POD had a low sensitivity of 16%. Therefore, standardized RRCS and fasting till the examination cannot be generally recommended. In case of clinical suspicion of AL, computed tomography of the chest and abdomen with oral contrast agent should be performed, followed by endoscopy. Endoscopic stent placement remains the standard therapy of AL in our center. Endoscopic vacuum therapy evolves as it is an interesting alternative therapeutic option and can be combined with stenting in selected cases.

The Impact of Obesity on Outcomes Following Resection for Gastric Cancer.

BACKGROUND: Obesity is generally considered to be associated with increased postoperative morbidity and mortality following intraabdominal cancer surgery. However, recent reports showed that overweight patients may have a lower risk for adverse postoperative outcomes and this observation has been described as the 'obesity paradox'. Therefore, we aimed to analyze the impact of obesity on outcomes after resection for gastric cancer. METHODS: Data of patients who underwent resection for gastric cancer between 2005 and 2012 were assessed. Patient characteristics, postoperative outcomes and long-term survivals were compared between patients with body mass index (BMI) ≥30 and <30. RESULTS: Resection for gastric cancer was performed in 249 patients. BMI ≥30 was identified in 49 patients. Obese patients with BMI ≥30 were more frequently diagnosed with diabetes (31 vs. 16%, p = 0.015). Resection for gastric cancer in obese patients was significantly associated with longer duration of surgery (278 vs. 243 min, p < 0.001), longer duration of hospital stay (18 vs. 16 days, p = 0.028), increased postoperative morbidity (49 vs. 33%, p = 0.037), and increased postoperative mortality (10 vs. 3%, p = 0.028). There was no significant difference in overall survival (OS) between patients with BMI ≥30 and patients with BMI <30 (5-year OS rate: 59 vs. 62%, p = 0.587). CONCLUSION: Obesity may complicate resection for gastric cancer increasing the duration of surgical procedure, hospital stay and postoperative morbidity and mortality. However, BMI did not predict OS in our patients. Consequently, BMI may be too simple as a parameter to evaluate sophisticated interactions between different body fat compartments and inflammatory and immune responses and thus to predict long-term oncologic outcomes.

[Diaphramatic Herniation of Abdominal Contents: Case Series and Review of the Literature]. / Der postoperative Enterothorax ­ Fallserie und Literaturanalyse.

Background An enterothorax with herniation of bowel segments through a diaphragmatic defect is a rare postoperative complication, which can occur in the early postoperative period as well as several months or even years after the primary procedure. In virtually all cases, this diagnosis requires surgical treatment with reposition of the herniated structures and closure of the diaphragmatic defect. The aim of this study was to describe a larger case series of a rare complication and to present a review of the literature. Material and Methods The data of all patients treated for postoperative enterothorax at our centre were retrospectively analysed with a special focus on time of occurrence, type of clinical symptoms, surgical treatment and postoperative morbidity. Results From March 2007 to October 2014, twenty patients underwent surgery due to postoperative enterothorax. Six cases (30 %) were early postoperative complications (mean 10th postoperative day); in 14 patients (70 %) the enterothorax presented with delay (mean 42 months after primary surgery). The variance of the clinical symptoms was wide, but in the majority of cases, patients presented with symptoms of ileus or new-onset dyspnoea. In two patients (10 %) the diagnosis was an incidental finding without clinical symptoms. Computed tomography (CT) was performed in 70 % (n = 14), chest X-rays in 30 % (n = 6) of patients for diagnosis. Immediate laparotomy was performed in 15 % (n = 3) of cases. The diaphragmatic defect involved the left side in 75 % of cases (n = 15). Surgical treatment was performed via laparotomy in all patients. The diaphragm was closed by a direct suture in 70 % of patients (n = 14); in six patients (30 %) an augmentation (mesh or tissue patch) was added. Overall postoperative morbidity was 55 %; for elective operations it was 0 %. One patient died in the further postoperative course. Conclusion Postoperative enterothorax may occur early or years after primary surgery. Surgical treatment should be performed in a timely manner even in asymptomatic patients to avoid further complications.

Health-related quality of life after laparoscopic liver resection.

BACKGROUND: Potential benefits of laparoscopic liver resections (LLRs) over open liver resections (OLRs) such as the clinical outcome and health-related quality of life (HRQoL) have not convincingly been investigated, yet. PATIENTS AND METHODS: All patients who had undergone LLR and OLR at our department between 1 June 2014 and 10 October 2016 were identified. HRQoL was assessed using the short form 36 (SF-36). All patients who returned the surveys were then retrospectively analysed with regards to the perioperative outcome. RESULTS: We received 66 eligible questionnaires (50%). The number of major liver resections did not significantly differ between both groups (LLR: 11 [33%], OLR: 16 [48%], P = 0.211).The proportion of patients with two or more co-morbidities (P = 0.044) and liver cirrhosis (P = 0.016), respectively, was significantly higher in the LLR group, when compared to the OLR group (LLR: 11 [33%] vs. 3 of 33 patients [9%], P = 0.016). HRQoL scores were good with no significant differences between both groups. Among these patients, there were significantly more pulmonary complications in the OLR group, and length of hospital stay was longer when compared to the LLR group. CONCLUSIONS: Laparoscopic liver surgery can be performed safely even in multimorbid elderly patients resulting in high HRQoL scores.

Cerebrovascular events in 20 years of follow-up after liver transplantation: an underestimated issue?

BACKGROUND: Cardio- and cerebrovascular diseases are the third leading cause of late death after liver transplantation (LT). A new score (PROCAM-Stroke) has been established to estimate the 10-year risk of cerebrovascular events (CBVE) in a German standard population. We evaluate the applicability of the PROCAM-Stroke for long-term follow-up after LT. PATIENTS AND METHODS: A retrospective study of 313 consecutive LTs was conducted. Six months after LT (T1) and 10 years after LT (T2), CBVE risk factors were recorded and PROCAM-Stroke was calculated. Ten (T2) and 20 years (T3) after LT, recipients were screened regarding CBVE. PROCAM-Stroke estimates of CBVE were compared with the incidence of observed CBVE. RESULTS: In both 10-year time frames, the incidence of observed CBVE was higher than expected based on the PROCAM-Stroke estimates: 6 months-10 years after LT (T1-T2): observed: 11, expected: 3.2; 10 years-20 years after LT (T2-T3): observed: 7, expected: 3.4. CONCLUSION: LT recipients seem to have a considerably increased risk of CBVE. Long-term surveillance should take this into account, and screening may be extended accordingly. The progressive impairment of renal function in the long-term LT survivors may be one reason for the underestimation of CBVE in this patient group.

Eurotransplant donor-risk-index and recipient factors: influence on long-term outcome after liver transplantation - A large single-center experience.

The organ shortage has led to increased use of marginal organs. The Eurotransplant Donor-Risk-Index (ET-DRI) was established to estimate outcome after Liver Transplantation (LT). Currently, data on impact of ET-DRI on long-term outcome for different indications and recipient conditions are missing. Retrospective, single-center analysis of long-term graft survival (GS) of 1767 adult primary LTs according to indication, labMELDcategory (1: ≤18; 2: >18-25; 3: >25-35; 4: >35), and ET-DRI. Mean ET-DRI in our cohort was 1.63 (±0.43). One-, 10, and 15-yr GS was 83.5%, 63.3%, and 54.8%. Long-term GS was significantly influenced by ET-DRI. Accordingly, four ET-DRI categories were defined and analyzed with respect to underlying disease. Significant impact of these categories was observed for: Alcohol, cholestatic/autoimmune diseases (CD/AIH), and HCV, but not for HCC, HBV, cryptogenic cirrhosis, and acute liver failure. labMELD categories showed no significant influence on graft, but on patient survival. Matching ET-DRI categories with labMELD revealed significant differences in long-term GS for labMELDcategories 1, 2, and 3, but not 4. In multivariate analysis, HCV combined with ET-DRI > 2 and labMELDcategory 3 combined with ET-DRI > 2 emerged as negative predictors. To achieve excellent long-term graft survival, higher risk organs (ET-DRI > 1.4) should be used restrictively for patients with CD/AIH or HCV. Organs with ET-DRI > 2 should be avoided in patients with a labMELD of >25-35.

Predictive factors for extrahepatic recurrence of hepatocellular carcinoma following liver transplantation.

BACKGROUND: Recurrence of hepatocellular carcinoma (HCC) in patients treated with liver transplantation (LT) is associated with diminished survival. Particularly, extrahepatic localization of HCC recurrence contributes to poor prognosis. PATIENTS AND METHODS: Clinicopathological data of patients who underwent LT for HCC between 1989 and 2010 in a high-volume transplant center were retrospectively evaluated, and predictors of extrahepatic recurrence were identified. RESULTS: Three hundred and sixty-four patients underwent LT for HCC. After a median follow-up time of 78 months, 93 patients (25%) were diagnosed with a recurrence. Median time to recurrence was 19 months. Recurrence was located exclusively in the liver in 19 cases (20%), and 74 patients (80%) had extrahepatic recurrence. Factors associated with extrahepatic recurrence in multivariate analysis included HCC beyond the Milan criteria (p < 0.0001) and the presence of macrovascular tumor invasion (p = 0.035). In patients with HCC beyond the Milan criteria who developed a recurrence (N = 73), macrovascular invasion was the only positive predictor of extrahepatic recurrence in multivariate analysis (p < 0.0001). In patients with HCC within the Milan criteria who recurred after LT (N = 20), DNA-index >1.5 (p = 0.013) was the only predictive factor for extrahepatic recurrence in multivariate analysis. CONCLUSIONS: Advanced HCC beyond the Milan criteria and the presence of macrovascular invasion are associated with an increased risk for extrahepatic recurrence and are currently considered as relative contraindications to LT. In patients with HCC within the Milan criteria, the DNA-index represents a valuable prognostic marker for the development of extrahepatic recurrence and may support the selection of patients for intensified postoperative tumor surveillance.