Assessments of right ventricular strain using cardiac magnetic resonance imaging following kidney transplantation.

Although kidney transplantation (KT) has been shown to ameliorate adverse left ventricular (LV) remodelling associated with end stage kidney disease, its effects on the right ventricle have not been well studied. Recently, strain imaging has been shown to be a sensitive measure of early subclinical myocardial dysfunction. Using cardiac magnetic resonance imaging (MRI), we examined the effects of KT on right ventricular (RV) strain parameters. In a cohort of 81 patients (39 patients underwent KT and 42 patients remained on dialysis as control group), cardiac MRI studies were obtained at baseline and at 1 year follow-up. There were no significant differences in RV strain values between the groups at baseline. After 1 year, RV strain values did not significantly change in patients who received KT, and changes in RV strain over 1 year were not significantly different between the KT and the dialysis groups. Given the previously demonstrated improvement in LV strain post-KT, the current study suggests that RV and LV remodelling post-KT may have different mechanisms. Further studies elucidating the effects of KT on RV remodelling are needed.

Acute esophageal necrosis as a complication of diabetic ketoacidosis: A case report.

BACKGROUND: Acute esophageal necrosis (AEN) is a rare condition that has been associated with low volume states, microvascular disease, gastrointestinal (GI) mucosal damage, and impaired GI motility. It has been linked in case reports with diabetic ketoacidosis (DKA) and is commonly associated with GI bleeding (GIB). CASE SUMMARY: We report a case of endoscopy confirmed AEN as a complication of DKA in a 63-year-old Caucasian male without any overt GIB and a chief complaint of epigastric pain. Interestingly, there was no apparent trigger for DKA other than a newly started ketogenic diet two days prior to symptom onset. A possible potentiating factor for AEN beyond DKA is the recent start of a Glucagon-like peptide-1 receptor agonist (GLP-1 RA), though they have not been previously connected to DKA or AEN. The patient was subsequently treated with high dose proton pump inhibitors, GLP-1 RA was discontinued, and an insulin regimen was instituted. The patient's symptoms improved over the course of several weeks following discharge and repeat endoscopy showed well healing esophageal mucosa. CONCLUSION: This report highlights AEN in the absence of overt GIB, emphasizing the importance of early consideration of EGD.

A mixed methods study of challenges in the implementation and use of the surgical safety checklist.

BACKGROUND: The surgical safety checklist is an evidence-based global initiative designed to reduce perioperative morbidity and mortality. However, the expounded benefits of the surgical safety checklist have not been realized in naturalistic settings. This may be related to the quality of surgical safety checklists being performed in operating rooms. METHODS: In this explanatory, sequential, mixed-methods study, 2 trained observers used a standardized tool to record the compliance and quality of the surgical safety checklist completed during 51 surgeries performed at a pediatric academic hospital. We compared compliance with each phase of the surgical safety checklist, the number of checklist items completed, and professionals initiating the surgical safety checklist across surgical specialties and case urgency levels. Interviews with nurses, anesthesiologists, and surgeons (n = 18) were subsequently conducted to explore and contextualize the findings. RESULTS: Hospital-recorded surgical safety checklist compliance (94%, 100%, and 100% on briefing, time out, and debriefing) was higher than the proportion of checklist items completed in matched cases (26%, 59%, and 42%, respectively). Thematic analysis of the interview data suggests this may result from limited staff "buy in," arising from the "top-down" mandated nature of the surgical safety checklist, the perceived lack of benefit in surgical safety checklist completion, and redundancies with other operating room processes. This has led to the surgical safety checklist becoming "an exercise in box ticking" (ie, compliance is recorded without ensuring quality), thereby obfuscating potential safety benefits. CONCLUSION: These results highlight that compliance data are insufficient for monitoring surgical safety checklist quality. Our study suggests that surgical safety checklist quality may be enhanced through better calibration of the surgical safety checklist with existing procedures and staff expectations through a bottom-up implementation strategy.

Perioperative mortality rates in low-income and middle-income countries: a systematic review and meta-analysis.

INTRODUCTION: The Lancet Commission on Global Surgery proposed the perioperative mortality rate (POMR) as one of the six key indicators of the strength of a country's surgical system. Despite its widespread use in high-income settings, few studies have described procedure-specific POMR across low-income and middle-income countries (LMICs). We aimed to estimate POMR across a wide range of surgical procedures in LMICs. We also describe how POMR is defined and reported in the LMIC literature to provide recommendations for future monitoring in resource-constrained settings. METHODS: We did a systematic review of studies from LMICs published from 2009 to 2014 reporting POMR for any surgical procedure. We extracted select variables in duplicate from each included study and pooled estimates of POMR by type of procedure using random-effects meta-analysis of proportions and the Freeman-Tukey double arcsine transformation to stabilise variances. RESULTS: We included 985 studies conducted across 83 LMICs, covering 191 types of surgical procedures performed on 1 020 869 patients. Pooled POMR ranged from less than 0.1% for appendectomy, cholecystectomy and caesarean delivery to 20%-27% for typhoid intestinal perforation, intracranial haemorrhage and operative head injury. We found no consistent associations between procedure-specific POMR and Human Development Index (HDI) or income-group apart from emergency peripartum hysterectomy POMR, which appeared higher in low-income countries. Inpatient mortality was the most commonly used definition, though only 46.2% of studies explicitly defined the time frame during which deaths accrued. CONCLUSIONS: Efforts to improve access to surgical care in LMICs should be accompanied by investment in improving the quality and safety of care. To improve the usefulness of POMR as a safety benchmark, standard reporting items should be included with any POMR estimate. Choosing a basket of procedures for which POMR is tracked may offer institutions and countries the standardisation required to meaningfully compare surgical outcomes across contexts and improve population health outcomes.

Staphylococcus-Associated Glomerulonephritis Mimicking Henoch-Schönlein Purpura and Cryoglobulinemic Vasculitis in a Patient With an Epidural Abscess: A Case Report and Brief Review of the Literature.

RATIONALE: Staphylococcus-associated glomerulonephritis (SAGN) is a rare immune complex-mediated glomerulonephritis associated with active Staphylococcus infection. We report a case illustrating the importance of clinical history and kidney biopsy findings in establishing the correct diagnosis. PRESENTING CONCERNS OF THE PATIENT: We report the case of a 64-year-old man with alcohol-associated cirrhosis, type 2 diabetes mellitus, and hypertension who presented to hospital with lower back and abdominal pain, rectal bleeding, a purpuric lower extremity rash, and oliguric acute kidney injury with microscopic hematuria and nephrotic-range proteinuria. DIAGNOSES: Skin biopsy revealed IgA leukocytoclastic vasculitis. Serum cryoglobulins were positive and there was hypocomplementemia with a low C3 level. Magnetic resonance imaging of the lumbar spine revealed septic discitis and epidural abscesses caused by a recent Staphylococcus aureus bacteremia. Kidney biopsy showed IgA-dominant and C3-dominant proliferative glomerulonephritis with subepithelial humps in keeping with SAGN. INTERVENTIONS: Urgent hemodialysis was initiated along with a prolonged course of intravenous cefazolin. OUTCOMES: Remarkably, the patient demonstrated a complete recovery of renal function after 2 months of dialysis dependence and successful treatment of the epidural abscesses. LESSONS LEARNED: This case shows that SAGN can closely mimic the clinical, laboratory, and histological presentation of Henoch-Schönlein Purpura or cryoglobulinemic vasculitis. Clinical history and kidney biopsy, particularly electron microscopic analysis, are essential to establishing the correct diagnosis to avoid the unnecessary and potentially harmful administration of immunosuppression. Despite the typically poor prognosis of SAGN, this case report illustrates that full renal recovery remains possible with supportive care and eradication of the underlying infection.

EXPOSITION: La glomérulonéphrite aigüe post-infection à Staphylococcus (GNAS) est une glomérulonéphrite rare, médiée par un complexe immunitaire et associée à une infection active à Staphylococcus aureus. Nous présentons un cas qui illustre l'importance des antécédents médicaux et des résultats de la biopsie rénale dans la pose d'un diagnostic. PRÉSENTATION DU CAS: Nous rapportons le cas d'un homme de 64 ans atteint d'une cirrhose alcoolique, de diabète de type 2 et d'hypertension qui s'est présenté à l'hôpital avec des douleurs lombaires et abdominales, un saignement rectal, une éruption purpurique des extrémités inférieures et une insuffisance rénale aigüe oligurique avec hématurie microscopique et protéinurie néphrotique. DIAGNOSTIC: La biopsie cutanée a révélé une vascularite leucocytoclastique à IgA. Les cryoglobulines sériques étaient positives et une hypocomplémentémie avec un faible taux de C3 a été constatée. L'imagerie par résonnance magnétique du rachis lombal a permis de détecter une discite septique et des abcès périduraux causés par une récente bactériémie à Staphylococcus aureus. La biopsie rénale a quant à elle montré la présence d'une glomérulonéphrite proliférative à IgA et à C3 dominants et de volumineux dépôts sous-épithéliaux en bosse (humps) conformes à une GNAS. TRAITEMENT: On a amorcé une hémodialyse d'urgence et un traitement prolongé à la céfazoline par voie intraveineuse. RÉSULTATS: Fait remarquable, après le traitement des abcès périduraux et deux mois de dépendance à l'hémodialyse, la fonction rénale du patient a été complètement rétablie. CONCLUSION: Ce cas démontre que la GNAS peut simuler la présentation clinique, biologique et histologique du purpura d'Henoch-Schönlein ou celle de la vascularite cryoglobulinémique. La revue des antécédents médicaux et l'analyse d'une biopsie rénale (particulièrement par microscopie électronique) sont essentielles pour établir un diagnostic juste et pour éviter l'administration superflue, voire néfaste, d'immunosuppresseurs. Malgré le pronostic sombre normalement associé à la GNAS, ce cas démontre que le rétablissement complet de la fonction rénale demeure possible, pour autant que l'on procède à un traitement symptomatique et que l'on éradique l'infection sous-jacente.

Virtual reality simulation in endoscopy training: Current evidence and future directions.

Virtual reality simulation is becoming the standard when beginning endoscopic training. It offers various benefits including learning in a low-stakes environment, improvement of patient safety and optimization of valuable endoscopy time. This is a review of the evidence surrounding virtual reality simulation and its efficacy in teaching endoscopic techniques. There have been 21 randomized controlled trials (RCTs) that have investigated virtual reality simulation as a teaching tool in endoscopy. 10 RCTs studied virtual reality in colonoscopy, 3 in flexible sigmoidoscopy, 5 in esophagogastroduodenoscopy, and 3 in endoscopic retrograde cholangiopancreatography. RCTs reported many outcomes including distance advanced in colonoscopy, comprehensive assessment of technical and non-technical skills, and patient comfort. Generally, these RCTs reveal that trainees with virtual reality simulation based learning improve in all of these areas in the beginning of the learning process. Virtual reality simulation was not effective as a replacement of conventional teaching methods. Additionally, feedback was shown to be an essential part of the learning process. Overall, virtual reality endoscopic simulation is emerging as a necessary augment to conventional learning given the ever increasing importance of patient safety and increasingly valuable endoscopy time; although work is still needed to study the nuances surrounding its integration into curriculum.

OX40L-OX40 Interactions: A Possible Target for Gastrointestinal Autoimmune Diseases.

Gastrointestinal (GI) autoimmune diseases have a high incidence in developed countries, such as Canada and the US. Some common GI autoimmune diseases include ulcerative colitis and Crohn's Disease. These conditions are not only unpleasant for the patient, but also present a heavy burden on the healthcare system. OX40L, a member of the tumor necrosis family, has been identified as a key player in the pathological inflammatory response, which characterizes GI autoimmune diseases. OX40L is expressed in many cell types, including antigen presenting cells (APCs), T-cells, vascular endothelial cells, mast cells, and natural killer cells. The importance of OX40L-OX40 interactions in inflammatory autoimmune diseases is becoming more evident through different animal models, ranging from nematode models to mouse models. This literature review attempts to summarize the current literature regarding the role of OX40L-OX40 interactions in GI autoimmune inflammatory diseases and comment on its potential for treatment. Various databases, including OVID MedLine and PubMed were used to retrieve articles regarding the role of OX40L-OX40 interactions in the pathogenesis of autoimmune diseases. These articles were then reviewed and summarized in a comprehensive manner. OX40L-OX40 interactions have a strong potential for becoming a treatment target; however, there are still many gaps in the present knowledge, which need to be addressed before more definitive treatments can emerge. It is also suggested that upstream events leading to OX40L activation, such as thymic stromal lymphopoietin (TSLP)-activated dendritic cells, be explored as treatment targets as well. OX40L-OX40 interaction is a possible venue for treatment of GI diseases; however, the underlying mechanisms of actions and the downstream effects of OX40L knock down need to be investigated.

Western blot: technique, theory, and trouble shooting.

Western blotting is an important technique used in cell and molecular biology. By using a western blot, researchers are able to identify specific proteins from a complex mixture of proteins extracted from cells. The technique uses three elements to accomplish this task: (1) separation by size, (2) transfer to a solid support, and (3) marking target protein using a proper primary and secondary antibody to visualize. This paper will attempt to explain the technique and theory behind western blot, and offer some ways to troubleshoot.

Eosinophil-derived interferon-lambda contributes to initiation of allergen-related inflammation in the intestine.

BACKGROUND AND AIMS: Epithelial barrier dysfunction plays a critical role in the initiation of a number of immune diseases; the causative factors are not fully understood. The present study aimed to elucidate the mechanism by which the eosinophil-derived interferon (IFN)-lambda induced the gut epithelial barrier dysfunction. METHODS: The duodenal biopsies were obtained from patients with or without food allergies. The eosinophils and IFNλ expression were observed by immune staining. Intestinal epithelial cell line, T84 cells, and a mouse model were employed to observe the effect of IFNλ on the epithelial barrier function and the initiation of skewed T helper (Th)2 polarization in the mouse intestine. RESULTS: IFNλ expression was observed in over 80% human eosinophils of the subjects with or without food allergies. Exposure to microbial products, lipopolysaccharide or peptidoglycan, could induce eosinophils to release IFNλ. Exposure to IFNλ could induce intestinal epithelial barrier dysfunction via inducing the epithelial cell apoptosis. Concurrent exposure to microbial products and food antigens could induce aberrant antigen specific Th2 polarization and Th2 pattern inflammation in the intestine. CONCLUSIONS: Eosinophils express IFNλ that can induce intestinal epithelial barrier dysfunction and promotes the initiation of the aberrant Th2 polarization in the intestine.