Pronounced Dead Twice: What Should an Attending Physician Do in Between?

BACKGROUND Organ donation after cardiac death (DCD) is a well-accepted practice in the medical, philosophical, and legal fields. It is important to determine the amount of time required for the loss of circulation to lead to irreversible brain loss, and ultimately brain death. CASE REPORT We report a rare case of organ donation after cardiac death. During organ procurement, it was noted that the patient's aortic and renal arteries were pumping and pulsing, and her cardiopulmonary activities were back to unexpected levels. The organ procurement surgery was stopped. At the time, the patient was given Fentanyl and Lorazepam. Subsequently, she was pronounced dead again 18 minutes after she was initially pronounced dead. After a complete autopsy, the cause of death was determined to be acute Fentanyl toxicity due to a Fentanyl injection in the hospital. The manner of death was determined to be homicide. CONCLUSIONS What should an attending physician do in the rare case that the organ procurement team notices the patient is still alive? It is our opinion that: first, the organ procurement team should leave the room immediately and withdraw from the case, and second, the attending physician should let nature run its course and refrain from excessive medical intervention.

Long-term Clinical Course after Living Kidney Donation by a Patient with Gitelman Syndrome Harboring a Compound Heterozygous Mutation of the SLC12A3 Gene.

The eligibility for kidney donation and long-term post-donation renal prognosis of patients with Gitelman syndrome (GS) are unknown. We herein report a 44-year-old woman with GS who donated her kidney for transplant. A gene sequence analysis revealed compound heterozygous mutations of T180K and L858H in the SLC12A3 gene. Since transplantation, the renal function and serum potassium and magnesium levels of the donor and recipient have remained stable for seven years with careful monitoring and supplementation. Patients with asymptomatic GS who have no complications can be considered eligible to donate their kidney for transplant with proper monitoring after transplantation.

Impact of autologous blood transfusion after bone marrow harvest on unrelated donor's health and outcome: a CIBMTR analysis.

Pre-harvest autologous blood collection from bone marrow (BM) donors is performed to meet potential post-operative transfusion needs. This study examines the impact of autologous blood transfusion on BM donor's health and safety. The study included first-time unrelated BM donors from the United States whose BM harvest was facilitated by the National Marrow Donor Program (NMDP) centers between 2006 and 2017. Examination of 7024 BM donors revealed that 60% received at least one unit of autologous blood. The donors who received autologous blood were older, had lower hemoglobin pre-harvest, underwent longer duration of anesthesia, and higher volume BM harvest. Only donors who underwent high-volume BM harvest, defined as a BM harvest volume >27% of donor's blood volume, benefited from autologous transfusion. After a high-volume BM harvest, autologous blood transfusion was shown to decrease grade 2 to 4 collection-associated toxicities within 48 h of BM donation (p = 0.010) and shorten the time to donor-reported "complete" recovery from donation-associated symptoms (p < 0.001). Therefore, autologous transfusion could be avoided as support of marrow donation in the majority of unrelated BM donors and should be limited to cases where the planned BM harvest volume is expected to exceed 27% of donor's blood volume.

Clinical significance of autologous blood transfusions in bone marrow harvest from unrelated donors.

In the Japan Marrow Donor Program (JMDP), autologous blood is collected from most unrelated bone marrow (BM) donors. We retrospectively evaluated 5772 donors who underwent BM harvest between 2010 and 2015 through the JMDP. Autologous blood was collected in 96.8% of the donors; the wastage rate was 0.6%. Allogeneic blood transfusion was not required. The mean hemoglobin (Hb) levels were 12.1 g/dL after the BM harvest (mean 891 mL) together with autologous blood transfusion (mean 596 mL). Propensity-score matching was used to adjust the backgrounds. Among donors with harvested BM of 100-400 mL, autologous blood transfusion had no impact on Hb levels or complications after BM harvest. Among donors with harvested BM of > 400 mL, more autologous blood transfusion followed by a bleeding volume of ≤ 100 mL did not confer clinical benefit to donors compared with less autologous blood transfusion followed by a bleeding volume of > 300 mL. The findings of the present study suggest that autologous blood transfusion to BM donors is excessive in terms of Hb changes and post-harvest outcomes.

Effects of feeding OmniGen-AF® on superovulatory response in donor beef cows: I. Serum progesterone and cortisol, embryo recovery and quality.

Optimal results in cattle embryo transfer are limited by the variation in ova recovery, fertilization rate and embryo quality experienced with superovulation. Inflammation and immune dysregulation may be contributing factors. This study, evaluated feeding OmniGen-AF® (OG), a nutritional supplement that reduces inflammation and supports immune health, on superovulatory response and serum progesterone and cortisol concentrations in embryo donors treated with two different doses of Folltropin®-V (FSH). Angus cross-bred beef cows (n = 24) were assigned to four groups, fed OG at 0 or 56 g/animal/day for 49 days and were treated with 200 or 400 mg FSH to induce superovulation. Treatments for superovulation started after feeding OG for 28 days and ova were non-surgically recovered 7 days after estrus and graded for quality. More transferrable embryos (P < 0.05) were recovered from cows fed 56 g OG and treated with 400 compared with 200 mg FSH. Percent degenerate embryos recovered from cows treated with the 400 mg FSH dose was threefold greater (P < 0.05) when fed no OG compared with 56 g OG. Serum progesterone on day of embryo collection was greater (P < 0.05) in OG-supplemented cows and cows treated with 200 mg FSH. Serum cortisol was not affected (P > 0.10) by FSH dose or OG-feeding, but was greatest (P <  0.05) on Days 0 and 42 of the feeding period. In summary, the improvement in embryo quality with OG-feeding may relate to a greater serum progesterone concentration.

Fecal microbiota transplantation for recurrent Clostridioides difficile infection.

PURPOSE: Randomized controlled trials investigating the efficacy and safety of fecal microbiota transplantation (FMT) for recurrent Clostridioides difficile infection (CDI) are reviewed, and practical issues for pharmacists to consider are discussed. SUMMARY: Eight randomized controlled trials evaluating the use of FMT for recurrent CDI were analyzed. The trials varied in the type of sample (fresh, frozen, lyophilized), route of administration (nasogastric tube, colonoscopy, enema, oral), and comparator agent (different type of FMT, vancomycin). Efficacy rates ranged from 43.8% to 96.2% with FMT, and safety data were relatively similar. With these favorable data, pharmacists are likely to be involved at multiple steps in the delivery of FMT to patients with recurrent CDI, including the procurement, documentation, and administration of various products and patient education. CONCLUSION: FMT is an option for recurrent CDI that is supported by findings of randomized controlled trials, although a preferred method for the delivery remains to be defined. Pharmacists can play an important role in the successful management of patients with recurrent CDI who may benefit from FMT.

Organoids from colorectal peritoneal metastases as a platform for improving hyperthermic intraperitoneal chemotherapy.

BACKGROUND: Patients with peritoneal metastases from colorectal cancer have a poor prognosis. If the intraperitoneal tumour load is limited, patients may be eligible for cytoreductive surgery followed by hyperthermic intraperitoneal chemotherapy (HIPEC). This treatment has improved overall survival, but recurrence rates are high. The aim of this study was to create a preclinical platform for the development of more effective intraperitoneal chemotherapy strategies. METHODS: Using organoid technology, five tumour cultures were generated from malignant ascites and resected peritoneal metastases. These were used in an in vitro HIPEC model to assess sensitivity to mitomycin C (MMC) and oxaliplatin, the drugs used most commonly in HIPEC. The model was also used to test a rational combination treatment involving MMC and inhibitors of the checkpoint kinase ATR. RESULTS: MMC was more effective in eliminating peritoneal metastasis-derived organoids than oxaliplatin at clinically relevant concentrations. However, the drug concentrations required to eliminate 50 per cent of the tumour cells (IC50) were higher than the median clinical dose in two of five organoid lines for MMC, and all five lines for oxaliplatin, indicating a general resistance to monotherapy. ATR inhibition increased the sensitivity of all peritoneal metastasis-derived organoids to MMC, as the IC50 decreased 2·6-12·4-fold to well below concentrations commonly attained in clinical practice. Live-cell imaging and flow cytometric analysis showed that ATR inhibition did not release cells from MMC-induced cell cycle arrest, but caused increased replication stress and accelerated cell death. CONCLUSION: Peritoneal metastasis-derived organoids can be used to evaluate existing HIPEC regimens on an individual-patient level and for development of more effective treatment strategies. Surgical relevance Cytoreductive surgery followed by hyperthermic intraperitoneal chemotherapy (HIPEC) has improved prognosis of patients with peritoneal metastases from colorectal cancer, but disease recurrence is common. More effective and personalized HIPEC is urgently needed. Organoid technology is frequently used for drug screens, as patient-derived organoids can accurately predict clinical therapeutic response in vitro. A panel of organoids was established from peritoneal metastases from colorectal cancer and used to develop a model for testing HIPEC regimens in vitro. Patient-derived organoids differed in sensitivity to commonly used chemotherapeutics, in line with variable clinical outcomes following cytoreductive surgery-HIPEC. Combining MMC with an ATR inhibitor improved the efficacy of MMC. Peritoneal metastasis-derived organoids can be used as a platform to test novel (combination) strategies that increase HIPEC efficacy. In the future, organoids could be used to select patent-tailored HIPEC regimens.

ANTECEDENTES: Los pacientes con metástasis peritoneales (peritoneal metastasis, PM) de cáncer colorrectal tienen un mal pronóstico. Si la carga tumoral intraperitoneal es reducida, los pacientes pueden ser candidatos a cirugía citorreductora seguida de quimioterapia intraperitoneal hipertérmica (hyperthermic intraperitoneal chemotherapy, HIPEC). Este tratamiento ha mejorado la supervivencia global, pero las tasas de recidiva son altas. El objetivo de este estudio fue crear una plataforma preclínica para el desarrollo de las estrategias de quimioterapia intraperitoneal más efectivas. MÉTODOS: Mediante la utilización de la tecnología de organoides, se generaron cinco cultivos tumorales a partir de ascitis maligna y PM resecadas. Se utilizó un modelo de HIPEC in vitro para evaluar la sensibilidad a la mitomicina C (mitomycin C, MMC) y al oxaliplatino, los fármacos más utilizados en la HIPEC. El modelo también se usó para probar un tratamiento combinado de MMC e inhibidores de control inmunitario de la quinasa ATR. RESULTADOS: A concentraciones clínicamente relevantes, la MMC fue más efectiva que el oxaliplatino para eliminar los organoides derivados de PM. Sin embargo, las concentraciones de fármaco necesarias para eliminar el 50% de las células tumorales (IC50) fueron más elevadas que la mediana de la dosis clínica en 2/5 (MMC) o 5/5 (oxaliplatino) de las líneas de organoides, lo que indica una resistencia general a la monoterapia. La inhibición de ATR aumentó la sensibilidad a MMC de todos los organoides derivados de PM, ya que la IC50 disminuyó (2,6-12,4 veces) a concentraciones muy por debajo de las que se alcanzan comúnmente en la práctica clínica. Los análisis de viabilidad celular y de citometría de flujo (FACS) mostraron que la inhibición de ATR no liberaba células tras la detención del ciclo celular inducida por la MMC, sino que causaba un aumento en el estrés replicativo y muerte celular acelerada. CONCLUSIÓN: Se pueden usar los organoides derivados de PM para evaluar los regímenes HIPEC existentes a nivel del paciente individual y para desarrollar estrategias terapéuticas más efectivas.

Impact of Preservation Solutions on the Trichogenicity of Hair Micrografts Ascertained by Dermal Papilla Gene Expression.

BACKGROUND: Appropriate storage of human hair follicle (HF) grafts during follicular unit excision (FUE) is crucial toward successful hair shaft implantation. Several commercial storage solutions are currently used to ensure ex vivo maintenance of follicular grafts viability and trichogenicity. However, quantitative experimental evidence demonstrating molecular changes in HF cells associated with the usage of different storage solutions is largely missing. OBJECTIVE: To identify gene expression changes in HF cells caused by ex vivo storage of hair grafts in different preservation conditions. METHODS: The authors performed gene expression analysis in dermal papilla (DP) isolated from HF stored under different temperatures and solutions. The expression signature of key genes controlling hair growth and cycling, apoptosis, inflammation, and senescence was assessed for (1) chilled versus room temperature (RT) and (2) DP cell medium, saline, Hypothermosol, platelet-rich plasma, and ATPv-supplemented saline. RESULTS: The authors found chilled versus RT to prevent inflammatory cytokine signaling. Under chilled conditions, ATPv-supplemented saline was the best condition to preserve the expression of the trichogenic genes HEY1 and LEF1. CONCLUSION: Data disclose DP gene expression analysis as a useful methodology to ascertain the efficacy of preserving solutions and elucidate about the best currently available option for FUE clinical practice.

Semen collection by electro-stimulation in a variety of bird orders.

It is unquestinable that artificial insemination (AI) offers many benefits to avian conservation programs, but a serious impediment towards implementing AI for wild species is the development of effective techniques to consistently collect good quality ejaculates. Thus, we aimed to examine the success rate of electro-stimulation (ES) in collecting semen from 49 unconditioned males from orders Piciformes, Strigiformes, Accipitriformes, Cathartiformes, Galiformes, Anseriformes and Psittaciformes at different times of the year. Sixty out of 299 ES attempts provided ejaculates with sperm, but collection success rates varied widely (0-50%) depending on the species. Except for swans whose greater results were registered during spring-summer, males from most orders responded better to ES during winter-spring, suggesting seasonal variations on semen collection success rates. Overall, ES enabled successful semen collection from males of unproven and proven fertility under mixed pairing conditions. However, the highest success rate occurred in paired males with fertile clutches (40.6%) followed by unpaired males (22.1%), paired males without clutches (13.9%), and paired males with infertile clutches (6.8%). Behavioral responses of male birds to electrical impulses were also recorded to assess any discomfort during semen collection. Furthermore, macroscopic and microscopic analysis provided ejaculate parameters from several species, even from orders that hitherto have never been assessed for semen collection, which may serve as a starting point in the future. Altogether, these findings demonstrate the feasibility of ES in collecting semen from unpaired, unconditioned and non-imprinted males from a variety of bird orders. In the medium to long term, the use of this technique in both captive and free-ranging populations offers new perspectives to ensure genetic diversity in avian conservation programs.

Electrostimulation is an effective and safe method for semen collection in medium-sized lizards.

The development of safe and consistent semen collection protocols should be ensured to understand basic sperm parameters of a species. Electroejaculation has been hypothesized and tested to be a safe method to evaluate male reproductive potential in wild animals. However, little is known about semen collection protocols in lizards. Adjusting stimulation to species and body mass is important for efficient semen collection as well as for animal welfare. Tropidurus spinulosus is a good model to adapt electrostimulation; it is a medium-sized lizard species, males have semen during a long period and operative sex ratio is male-biased. We aimed to provide a thorough and safe method for collecting semen samples from this animal model by means of electrostimulation and characterize basic sperm parameters. Mature males of T. spinulosus were captured and their testicular volume was evaluated via portable ultrasound scanning. The lizards were electrostimulated by performing standardized series of stimuli. Semen was obtained successfully in 94% of the males. Samples were contamination-free. Mean sperm number of ejaculates was 2.1 ±â€¯1.8 × 106 spermatozoids. The percentage of motile spermatozoa was 78% and sperm dynamic parameters were: VSL 37.26 ±â€¯7.72 µ/s and VCL 84.26 ±â€¯16.27 µ/s. We observed high variability in testicular volume among males; however, almost all the individuals had sperm. Electrostimulation using protocols adjusted to a medium-sized lizard was an effective semen collection method that allowed us to obtain semen samples with high motility (percentage of motile spermatozoa and sperm velocity).

Calcium: A Crucial Potentiator for Efficient Enzyme Digestion of the Human Pancreas.

BACKGROUND: Effective digestive enzymes are crucial for successful islet isolation. Supplemental proteases are essential because they synergize with collagenase for effective pancreatic digestion. The activity of these enzymes is critically dependent on the presence of Ca2+ ions at a concentration of 5-10 mM. The present study aimed to determine the Ca2+ concentration during human islet isolation and to ascertain whether the addition of supplementary Ca2+ is required to maintain an optimal Ca2+ concentration during the various phases of the islet isolation process. METHODS: Human islets were isolated according to standard methods and isolation parameters. Islet quality control and the number of isolations fulfilling standard transplantation criteria were evaluated. Ca2+ was determined by using standard clinical chemistry routines. Islet isolation was performed with or without addition of supplementary Ca2+ to reach a Ca2+ of 5 mM. RESULTS: Ca2+ concentration was markedly reduced in bicarbonate-based buffers, especially if additional bicarbonate was used to adjust the pH as recommended by the Clinical Islet Transplantation Consortium. A major reduction in Ca2+ concentration was also observed during pancreatic enzyme perfusion, digestion, and harvest. Additional Ca2+ supplementation of media used for dissolving the enzymes and during digestion, perfusion, and harvest was necessary in order to obtain the concentration recommended for optimal enzyme activity and efficient liberation of a large number of islets from the human pancreas. CONCLUSIONS: Ca2+ is to a large extent consumed during clinical islet isolation, and in the absence of supplementation, the concentration fell below that recommended for optimal enzyme activity. Ca2+ supplementation of the media used during human pancreas digestion is necessary to maintain the concentration recommended for optimal enzyme activity. Addition of Ca2+ to the enzyme blend has been implemented in the standard isolation protocols in the Nordic Network for Clinical Islet Transplantation.

Targeting Phosphodiesterase-5 by Vardenafil Improves Vascular Graft Function.

OBJECTIVES: Ischaemia reperfusion (IR) injury occurs during vascular graft harvesting and implantation during vascular/cardiac surgery. Elevated intracellular cyclic guanosine monophosphate (cGMP) levels contribute to an effective endothelial protection in different pathophysiological conditions. The hypothesis that the phosphodiesterase-5 inhibitor vardenafil would protect vascular grafts against IR injury by upregulating the nitric oxide-cGMP pathway in the vessel wall of the bypass graft was investigated. METHODS: Lewis rats (n = 6-7/group) were divided into Group 1, control; Group 2, donor rats received intravenous saline; Group 3, received intravenous vardenafil (30 µg/kg) 2 h before explantation. Whereas aortic arches of Group 1 were immediately mounted in an organ bath, aortic segments of Groups 2 and 3 were stored for 2 h in saline and transplanted into the abdominal aorta of the recipient. Two hours after transplantation, the implanted grafts were harvested. Endothelium dependent and independent vasorelaxations were investigated. TUNEL, CD-31, ICAM-1, VCAM-1, α-SMA, nitrotyrosine, dihydroethidium and cGMP immunochemistry were also performed. RESULTS: Compared with the control, the saline group showed significantly attenuated endothelium dependent maximal relaxation (Rmax) 2 h after reperfusion, which was significantly improved by vardenafil supplementation (Rmax control, 91 ± 2%; saline 22 ± 2% vs. vardenafil 39 ± 4%, p < .001). Vardenafil pre-treatment significantly reduced DNA fragmentation (control 9 ± 1%, saline 66 ± 8% vs. vardenafil 13 ± 1%, p < .001), nitro-oxidative stress (control 0.8 ± 0.3, saline 7.6 ± 1.3 vs. vardenafil 3.8 ± 1, p = .036), reactive oxygen species level (vardenafil 36 ± 4, control 34 ± 2 vs. saline 43 ± 2, p = .049), prevented vascular smooth muscle cell damage (control 8.5 ± 0.7, saline 4.3 ± 0.6 vs. vardenafil 6.7 ± 0.6, p = .013), decreased ICAM-1 (control 4.1 ± 0.5, saline 7.0 ± 0.9 vs. vardenafil 4.4 ± 0.6, p = .031), and VCAM-1 score (control 4.4 ± 0.4, saline 7.3 ± 1.0 vs. vardenafil 5.2 ± 0.4, p = .046) and increased cGMP score in the aortic wall (control 11.2 ± 0.8, saline 6.5 ± 0.8 vs. vardenafil 8.9 ± 0.6, p = .016). The marker for endothelial integrity (CD-31) was also higher in the vardenafil group (control 74 ± 4%, saline 22 ± 2% vs. vardenafil 40 ± 3%, p = .008). CONCLUSIONS: The results support the view that impairment of intracellular cGMP signalling plays a role in the pathogenesis of the endothelial dysfunction of an arterial graft after bypass surgery, which can effectively be prevented by vardenafil. Its clinical use as preconditioning drug could be a novel approach in vascular/cardiac surgery.

Syringes versus Chinese cups in harvesting suction-induced blister graft: a randomized split-body study.

BACKGROUND: Suction blister grafting (SBG) is a technique where the pigmented epidermis is harvested from the donor site by induction of a blister using different suction methods as syringes, Chinese cups, suction device, etc. However, pain, time consumption, incomplete blister formation, and failure of blister development are the main limitations. OBJECTIVE: To compare between cups and syringes of similar diameter in inducing suction blisters. PATIENTS AND METHODS: In 30 patients with stable nonsegmental vitiligo, 2-cm-diameter (20 ml) syringe was applied on the anterolateral aspect of one thigh and a 2-cm-diameter cup on the corresponding site of the other thigh where right and left sides were chosen randomly. Patients were observed untill complete blister development or for a maximum of 3 hours. Suction blister induction time (SBIT) and the blister diameter were recorded for each patient. Pain during the process of induction was evaluated. RESULTS: Incomplete blister development was noted in 9 out of 30 (30%) with 2 cm syringes and 6 out of 30 (20%) with the similar diameter cups with no significant difference (P = 0.49). No significant difference was found between SBIT induced by the 2 cm syringes and the similar size cups (101.17 ± 68.14 minutes, 98 ± 56.84 minutes, respectively) (P = 0.85). Meanwhile, blister diameter induced by either syringe or cup was not significantly different (P = 0.37). Anesthesia was for short duration with xylocaine, and pain was intolerable in both sides in the first seven patients. A combination of xylocaine and bupivacaine was used with prolonged loss of pain in 17 of the remaining 23 patients and tolerable pain in six patients similarly in both sides. CONCLUSION: According to present results, the differences in SIBT, diameter of blisters, and number of complete blister formation induced by either syringes or cups of similar size were not significant. Therefore, whatever the available and feasible technique for the surgeon will be the ideal choice. A combination of xylocaine and bupivacaine is recommended to overcome the accompanying pain of the procedure.

Hair Transplantation Controversies.

BACKGROUND: Hair transplant surgery creates consistently natural appearing transplanted hair for men. It is increasingly popular procedure to restore natural growing hair for men with hair loss. OBJECTIVE: To review some current controversies in hair transplant surgery. MATERIALS AND METHODS: Review of the English PubMed literature and specialty literature in hair transplant surgery. RESULTS: Some of the controversies in hair transplant surgery include appropriate donor harvesting technique including elliptical donor harvesting versus follicular unit extraction whether manual versus robotic, the role of platelet-rich plasma and low-level light surgery in hair transplant surgery. CONCLUSION: Hair transplant surgery creates consistently natural appearing hair. As with all techniques, there are controversies regarding the optimal method for performing the procedure. Some of the current controversies in hair transplant surgery include optimal donor harvesting techniques, elliptical donor harvesting versus follicular unit extraction, the role of low-level light therapy and the platelet-rich plasma therapy in the procedure. Future studies will further clarify their role in the procedure.

Sperm collection by transrectal ultrasound-guided massage of the accessory sex glands is less stressful than electroejaculation without altering sperm characteristics in conscious goat bucks.

In anesthetized non-domestic ruminants transrectal ultrasound-guided massage of the accessory sex glands (TUMASG) is an alternative method to collect semen slightly less stressful than electroejaculation (EE). However, some sperm characteristics are better when semen is collected with EE than with TUMASG. As anesthesia reduces the response to stressors, the advantages of TUMASG may be reduced in anesthetized animals, and thus, TUMASG may be even more advantageous in conscious animals. Therefore, the aim of the present study was to compare the stress response and the characteristics of the sperm collected with TUMASG and EE in conscious goat bucks. Semen was collected in 10 bucks with both procedures. During each procedure, the time required for ejaculation, the number of electric pulses applied and the number of vocalizations were recorded. Rectal temperature, heart rate, serum cortisol concentration, biochemical and hematological parameters were measured before and after each procedure. Sperm characteristics [ejaculated volume, sperm concentration, sperm mass motility (scale 0-5), sperm vigor (scale 0-5), the percentages of motile and progressive motile sperm, of sperm vitality, of sperm with plasma membrane integrity, and with acrosome damage and morphological abnormalities] were also determined. Electroejaculation required more electric pulses than TUMASG (P < 0.0001), but TUMASG took more time than EE (P < 0.0001). The EE provoked more vocalizations (P = 0.02) and a greater increase of cortisol concentrations than TUMASG (P = 0.04). Heart rate also tended to be greater with EE than with TUMASG (P = 0.07). The sperm characteristics did not differ between TUMASG and EE. In conclusion, TUMASG was less stressful and probably less painful than EE without affecting the semen quality. Thus, although it required more time, TUMASG is an alternative procedure to decrease the welfare concerns raised by EE in conscious goat bucks.

Long-term Radiological and Clinical Outcomes After Using Bone Marrow Mesenchymal Stem Cells Concentrate Obtained With Selective Retention Cell Technology in Posterolateral Spinal Fusion.

STUDY DESIGN: Retrospective study. OBJECTIVE: The aim of this study was to evaluate the long-term clinical and radiological outcomes of the use of bone marrow mesenchymal stem cell concentrate obtained with selective cell retention technology using Cellect with a particular collagen scaffold, Healos for posterolateral spinal fusion. SUMMARY OF BACKGROUND DATA: With the increasing rate of spinal fusion, the problem of pseudarthrosis, which contributes to recurrent pain with patient disability, is considered to be the most common cause of revision lumbar spine surgery. Intensive research is being carried out to develop an alternative source of bone grafting and improve the spinal fusion rate. METHODS: A retrospective review of hospital records was performed. Identified patients were contacted to have a clinical and radiological evaluation follow-up. Clinical outcome was evaluated using visual analog scales for the back pain (VAS), Oswestry Disability Index (ODI) scores, and quality of life (EQ-5D) questionnaire. Radiological outcome was evaluated by performing dynamic flexion/extension lateral views and calculation of segmental Cobb angle. Any implant-associated complication was reported. Computed tomography (CT) scans were also performed. RESULTS: Twenty-one patients were included and all patients achieved successful fusion. The mean difference of the segmental Cobb angle was 0.48° (range 0.3°-0.7°). Computed tomography scans showed solid bilateral fusion with bridging bone (Grade I) in all patients, but solid unilateral fusion with bridging bone (Grade II) was detected for one patient at one level. Patients started to resume working activities within a mean period of 3.5 months. The VAS score for the residual back pain was 4.1 ±â€Š2.1, whereas the ODI was 10.5 ±â€Š5.6 points, and the mean disability index was 21.1%. CONCLUSION: The use of bone marrow mesenchymal stem cell concentrate obtained with selective cell retention technology could be considered as an effective means for augmenting spinal fusion. LEVEL OF EVIDENCE: 3.

Double gastroepiploic vascularized lymph node tranfers to middle and distal limb for the treatment of lymphedema.

BACKGROUND: Vascularized lymph node (VLN) transfer for lymphedema treatment has shown promising results. Optimal donor and recipient sites remain a matter of debate. We describe the technique and outcomes of a laparoscopically harvested extended gastroepiploic VLN flap with two levels of inset. PATIENTS AND METHODS: Between 2014 and 2015, four-patients with upper limb breast cancer-related lymphedema and three-patients with lower limb pelvic cancer-related lymphedema who underwent VLN transfers were included. After harvest, the gastroepiploic VLN flap was divided into two halves that were separately inset at the level of elbow and wrist (upper limb) or knee and ankle (lower limb). The mean patient age was 53.1 years (range, 42-65 years). RESULTS: The average flap size after division was 6.3 cm in length (range, 5-7 cm) and 3.4 cm in width (range, 3-4 cm). The mean pedicle length was 3.2 cm (range, 2.5-4 cm). All flaps survived completely. No donor or recepient site complication was noted. At a mean follow-up of 9.7 months (range, 8-11 months), the mean circumference reduction rate was 43.7 ± 2.5% along the entire limb (P < 0.05). No episode of infection was noted postoperatively. CONCLUSIONS: Double gastroepiploic VLN transfers to middle and distal limb are a safe approach with very promising results. This technique may be used to improve clinical outcomes by enhancing the lymphatic drainage of the entire affected limb in a uniform fashion. In addition, the laparoscopic harvest can provide decreased donor site morbidity with a faster recovery.

Evaluation of Corneal Cross-Linking for Treatment of Fungal Keratitis: Using Confocal Laser Scanning Microscopy on an Ex Vivo Human Corneal Model.

Purpose: Some previous reports have established the use of photoactivated chromophore-induced corneal cross-linking (PACK-CXL) in treating fungal keratitis. The results of these case reports have often been conflicting. To systematically study the effect of PACK-CXL in the management of Fusarium keratitis, we have developed an ex vivo model of human corneal infection using eye-banked human corneas. Methods: Sixteen healthy ex vivo human corneas were divided into four study groups: (1) untreated control, (2) cross-linked, (3) infected with fungal spores, and (4) infected with fungal spores and then cross-linked. All infected corneas were inoculated with Fusarium oxysporum spores. The PACK-CXL procedure was performed 24 hours post inoculation for group 4. For PACK-CXL treatment, the corneas were debrided of epithelium; then 1% (wt/vol) isotonic riboflavin was applied dropwise at 5-minute intervals for 30 minutes and during the course of UV-A cross-linking for another 30 minutes. The corneas were imaged using a confocal microscope at 48 hours post inoculation, and the Fusarium hyphal volume and spore concentration were calculated. Results: The infected and then cross-linked group had a significantly lower volume of Fusarium hyphae, compared to the infected (P = 0.001) group. In the infected and then cross-linked group there was significant inhibition of Fusarium sporulation compared with the infected (P = 0.007) group. Conclusions: A model of human corneal infection was successfully developed for investigation of the effects of PACK-CXL on fungal keratitis. A treatment regimen of combined UV-A/riboflavin-induced corneal cross-linking appears to be a valuable approach to inhibit the growth and sporulation of Fusarium and suppress the progression of fungal keratitis.

[Analysis of contractual incentives for kidney transplants in Brazil using the principal-agent model]. / Análise dos incentivos contratuais de transplantes de rins no Brasil pelo modelo agente-principal.

The aim of this article was to analyze contractual incentives for kidney transplants in Brazil based on the principal-agent model. The approach assumes that the Brazilian Ministry of Health is the principal and the public hospitals accredited by the National Transplant System are the agent. The Ministry of Health's welfare depends on measures taken by hospitals in kidney uptake. Hospitals allocate administrative, financial, and management efforts to conduct measures in kidney donation, removal, uptake, and transplantation. Hospitals may choose the levels of effort that are consistent with the payments and incentives received in relation to transplantation costs. The solution to this type of problem lies in structuring an optimal incentives contract, which requires aligning the interests of both parties involved in the transplantation system.