Major adverse events related to endoscopic or laparoscopic procedures in achalasia. A systematic review and meta-analysis.

INTRODUCTION AND AIMS: Surgical or endoscopic treatments play an essential role in the management of achalasia. The probability of adverse events in the performance of said treatments is a relevant aspect, when establishing the risk-benefit balance. The present study aimed to establish the association between serious adverse events and the performance of those procedures, in adult patients with achalasia. MATERIALS AND METHODS: A systemic search of randomized and nonrandomized clinical trials, retrospective cohorts, and cases series on adult patients with achalasia that underwent laparoscopic Heller myotomy (LHM), peroral endoscopic myotomy (POEM), or endoscopic balloon dilation, that reported serious adverse events, was carried out on the Medline, CENTRAL, and EBSCO databases. Serious adverse events were defined as: death at 30 days, Clavien-Dindo grade III or higher classification, esophageal or gastric perforation, pneumothorax, mucosal tear, leakage, emphysema, pneumonia, and chest pain. The methodology included the PRISMA guidelines for reporting systematic reviews. RESULTS: Thirty-five studies were found that reported information on 1,276 patients that underwent POEM, 5,492 that underwent LHM, and 10,346 that underwent endoscopic balloon dilation. The proportions of adverse events for the three techniques were 3.6, 4.9, and 3.1%, respectively. DISCUSSION AND CONCLUSIONS: The 3 therapeutic interventions evaluated had similar proportions of adverse events. There were few reports of death at 30 days as an outcome and the lack of standardization in reporting adverse events in the studies analyzed was prominent.

Genetic (co)variation in skin pigmentation patterns and growth in rainbow trout.

From a physiological-behavioral perspective, it has been shown that fish with a higher density of black eumelanin spots are more dominant, less sensitive to stress, have higher feed intake, better feed efficiency and therefore are larger in size. Thus, we hypothesized that genetic (co)variation between skin pigmentation patterns and growth exists and it is advantageous in rainbow trout. The objective of this study was to determine the genetic relationships between skin pigmentation patterns and BW in a breeding population of rainbow trout. We performed a genetic analysis of pigmentation traits including dorsal color (DC), lateral band (LB) intensity, amount of spotting above (SA) and below (SB) the lateral line, and BW at harvest (HW). Variance components were estimated using a multi-trait linear animal model fitted by restricted maximum likelihood. Estimated heritabilities were 0.08±0.02, 0.17±0.03, 0.44±0.04, 0.17±0.04 and 0.23±0.04 for DC, LB, SA, SB and HW, respectively. Genetic correlations between HW and skin color traits were 0.42±0.13, 0.32±0.14 and 0.25±0.11 for LB, SA and SB, respectively. These results indicate positive, but low to moderate genetic relationships between the amount of spotting and BW in rainbow trout. Thus, higher levels of spotting are genetically associated with better growth performance in this population.

Requirement of interleukin 17 receptor signaling for lung CXC chemokine and granulocyte colony-stimulating factor expression, neutrophil recruitment, and host defense.

Bacterial pneumonia is an increasing complication of HIV infection and inversely correlates with the CD4(+) lymphocyte count. Interleukin (IL)-17 is a cytokine produced principally by CD4(+) T cells, which induces granulopoiesis via granulocyte colony-stimulating factor (G-CSF) production and induces CXC chemokines. We hypothesized that IL-17 receptor (IL-17R) signaling is critical for G-CSF and CXC chemokine production and lung host defenses. To test this, we used a model of Klebsiella pneumoniae lung infection in mice genetically deficient in IL-17R or in mice overexpressing a soluble IL-17R. IL-17R-deficient mice were exquisitely sensitive to intranasal K. pneumoniae with 100% mortality after 48 h compared with only 40% mortality in controls. IL-17R knockout (KO) mice displayed a significant delay in neutrophil recruitment into the alveolar space, and had greater dissemination of K. pneumoniae compared with control mice. This defect was associated with a significant reduction in steady-state levels of G-CSF and macrophage inflammatory protein (MIP)-2 mRNA and protein in the lung in response to the K. pneumoniae challenge in IL-17R KO mice. Thus, IL-17R signaling is critical for optimal production of G-CSF and MIP-2 and local control of pulmonary K. pneumoniae infection. These data support impaired IL-17R signaling as a potential mechanism by which deficiency of CD4 lymphocytes predisposes to bacterial pneumonia.

Cytokine therapeutics for infectious diseases.

Cytokines are potent molecules, which function as growth factors and orchestrate both innate and adaptive immune responses. Over the last two decades the number of molecules in this class have greatly expanded, and as the biology of these factors is better understood, several of these factors have entered the clinical arena to support or augment components of the immune response. Recently the use of cytokines/growth factors has been studied in patients without a defective immune system but either have significant infection or infection with drug resistant organisms. The use of cytokines as adjuvants in the treatment of infectious diseases is reviewed both in the context of protein and gene-based therapies.

Full and partial 5-HT1A receptor agonists disrupt learning and performance in rats.

As a means of characterizing the role of 5-hydroxytryptamine (5-HT1A) receptors in learning, a full 5-HT1A receptor agonist, 8-hydroxy-dipropylaminotetralin (8-OH-DPAT), was administered both alone and in combination with two partial agonists (buspirone and 1-(2-methoxyphenyl)-4-[4-(2-phthalimido)butyl] piperazine hydrobromide (NAN-190)) and a 5-HT1A receptor antagonist (p-MPPI) to rats responding under a multiple schedule of repeated acquisition and performance of response sequences. In addition, the effects of another 5-HT1A receptor agonist, (LY228729), were also studied under this same procedure. When administered alone, both 8-OH-DPAT (0.1-3. 2 mg/kg) and LY228729 (0.32-3.2 mg/kg) dose dependently decreased overall response rate and increased the percentage of errors in the acquisition and performance components. At the doses of each drug tested, both buspirone (0.32 or 1 mg/kg) and NAN-190 (1 or 3.2 mg/kg) also decreased overall response rate and increased the percentage of errors. However, the effects of these drugs differed across behavioral components and dependent measures. The effects of buspirone and NAN-190 on rate and accuracy were also different when they were administered in combination with 8-OH-DPAT. In contrast, p-MPPI (3.2 or 10 mg/kg) had little or no effect when administered alone and antagonized the effects of 8-OH-DPAT; shifting the dose-effect curves for both response rate and the percentage of errors in both components to the right. Taken together, these results indicate that complex behaviors in rats are sensitive to disruption by drugs with both full and partial 5-HT1A receptor agonist properties, and that the effects of partial 5-HT1A receptor agonists on learning may be different depending on their efficacy at pre- and postsynaptic 5-HT1A receptors.

Edematous pancreatitis associated with intravenous pentamidine.

A 37-year-old black man with presumed Pneumocystis carinii pneumonia who was treated with systemic IV pentamidine had fatal pancreatitis and massive hepatomegaly. Fatal pancreatitis can occur with no hemorrhagic changes seen at autopsy. Awareness of the relationship between pentamidine and pancreatitis should be emphasized. With current clinical trials testing other routes of administration, fatal complications associated with IV pentamidine therapy will be minimized.

Reliability of cell counts and protein determinations in serial bronchoalveolar lavage procedures performed on healthy volunteers.

We measured the variability in volume, total cells, cell types, and proteins in the bronchoalveolar lavage fluid recovered from 10 volunteers (five smokers, five non-smokers) lavaged repeatedly over a three-year period. Thirty lavages were performed using a rigorously standardized approach. Differential counts on the cytospin preparations were performed by three independent readers and interobserver variability in the interpretation of these counts measured. Variability in interpreting the cellular counts was less in smokers than non-smokers and decreased as the number of cells of any particular type increased. Only one reader interpreting the mean percentage of cells recovered of one cell type (neutrophils) in only one smoking group, the nonsmokers, was significantly different from the other two. There was also considerable variability in bronchoalveolar lavage fluid total protein, albumin, IgG, and IgA. Expressing albumin and IgG as a percentage of total protein recovered and expressing IgA and albumin as a ratio in nonsmokers lessened the variability of these parameters. Mean and standard deviations of the cellular and protein concentrations showed that large differences in these parameters would be necessary in order to attribute these changes to changes in the underlying pulmonary status. Excessive variability in nearly all parameters in this group without recognized lung disease challenges the usefulness of this test in the clinical assessment of patients serially followed because of underlying lung disease.

Pulmonary immunologic features of alveolar septal amyloidosis associated with multiple myeloma.

A 74-year-old man presented with interstitial pulmonary disease which was proven to be alveolar septal amyloidosis by transbronchial biopsy. Multiple myeloma was diagnosed on the basis of monoclonal IgG-lambda protein in serum, monoclonal lambda light chains in urine, a bone marrow plasmacytosis of 22 percent, and serum IgA and IgM levels less than 100 mg/dl and 50 mg/dl, respectively. Appropriate investigations failed to show additional sites of deposition of amyloid. Analysis of fluid from bronchoalveolar lavage showed an increase in total cells recovered, a lymphocytosis with a ratio of T helper over T suppressor cells greater than that in peripheral blood, the presence of an IgG-lambda paraprotein, and an IgG/albumin ratio greater than that in serum. While plasma cells could not be identified in the recovered cell population, cultured cells from bronchoalveolar lavage fluid showed increased production of IgG. These findings provide evidence of an ongoing pulmonary immune response resulting in excess IgG-lambda protein in the pulmonary compartment, a factor which may contribute to the development of amyloidosis.

Fibroma of tendon sheath.

Fibroma of the tendon sheath is a distinct clinicopathologic entity rarely occurring on the foot. It is a benign tumor derived from the fibroblast that clinically appears as a slow-growing painless mass. Complete surgical excision is curative. Recurrence occurs in 24% of the cases, usually due to inadequate excision. This report describes a 36-year-old man with such a tumor of the foot.

Multicystic renal oncocytoma.

The usual gross appearance of a renal oncocytoma is that of a well-circumscribed homogeneous tan-brown tumor with no evidence of necrosis or hemorrhage, but with a central fibrous scar. We describe a case of renal oncocytoma with the unusual gross appearance of a cystic tumor. While cystic change has occasionally been mentioned in an oncocytoma to our knowledge, this degree of cyst formation has not previously been described.

Symptomatic granular cell tumor of the esophagus.

A case of symptomatic granular cell tumor of the esophagus is described. Another 32 cases collected from the English literature are analyzed. The reported cases have occurred mostly in women of less than 50 years of age presenting with dysphagia. Excision of the lesion is curative.

Fibroma of tendon sheath.

This report describes a 60-year-old woman with a fibroma of tendon sheath of left hand. Ultrastructural study of the tumor reveals the nature of the tumor cells as fibroblasts, thus distinguishing it from the more common giant cell tumor of tendon sheath believed to be derived from synovial cells.

Malignant fibrous histiocytoma in the maxilla: review of literature and report of a case.

This case report demonstrates the difficulty involved in establishing a diagnosis of malignant fibrous histiocytoma. The histologic characteristics of this tumor as well as the important contributions of electron microscopy and special staining techniques in making the diagnosis, have been discussed. Review of 16 cases of MFH revealed the typical presentation of maxillary sinus malignancy. Treatment modalities vary, depending on the size of the tumor and the preference of the surgeon.

Priapism as the presenting feature of renal cell carcinoma.

We describe a case of renal cell carcinoma with metastasis to the penis clinically presenting with priapism. Six such cases found in the literature are reviewed. Neoplastic disease is far advanced in these cases and therapy is only palliative.

Fabry's disease in a heterozygous woman.

Fabry's disease is a rare, X-linked disorder of glycolipid metabolism that is usually recognized in men in the third and fourth decades of life. A heterozygous state in women has been documented, but reports about women who are affected are confined to isolated case reports and to rare small series. We report a case of a 42-year-old woman with persistent proteinuria who was found to have Fabry's disease. The characteristic lesion was readily seen using routine high-resolution light microscopy (HRLM) tissue sections without the need of multiple extra tissue sections and special stains. We discuss the correlation of clinical findings, fluorescent microscopy, HRLM, electron microscopy, and biochemical enzymatic studies in establishing the diagnosis.

Disseminated adenovirus serotype 31 infection in an immunocompromised host.

Adenoviruses are ubiquitous organisms but only infrequently have been implicated as a cause of hepatitis and rarely as a cause of fatal disease. A fatal case of disseminated adenovirus serotype 31 infection is described. It occurred in a patient with severe combined immunodeficiency who received a fetal liver transplant and subsequently developed massive hepatic necrosis. To the best knowledge of the authors, this is the first reported case of disseminated disease due to serotype 31.

Primary hyperparathyroidism due to an oxyphil cell adenoma.

A 70-year-old black man was found to have primary hyperparathyroidism due to an oxyphil cell adenoma. Ultrastructural studies were essential in elucidating the cell type of the tumor. The morphologic findings in relation to the clinical findings and a brief review of the literature are discussed.