Serine protease inhibitor, SerpinA3n regulates cardiac remodeling after myocardial infarction.

Following myocardial infarction, the heart repairs itself via a fibrotic repair response. The degree of fibrosis is determined by the balance between deposition of extracellular matrix by activated fibroblasts and breakdown of nascent scar tissue by proteases that are secreted predominantly by inflammatory cells. Excessive proteolytic activity and matrix turnover has been observed in human heart failure and protease inhibitors in the injured heart regulate matrix breakdown. Serine protease inhibitors (Serpins) represent the largest and the most functionally diverse family of evolutionary conserved protease inhibitors and levels of the specific Serpin, SerpinA3, have been strongly associated with clinical outcomes in human myocardial infarction as well as non-ischemic cardiomyopathies. Yet, the role of Serpins in regulating cardiac remodeling is poorly understood. We observed the robust expression of Serpins in the infarcted murine heart and demonstrate that genetic deletion of SerpinA3n (mouse homolog of SerpinA3) leads to increased activity of substrate proteases, poorly compacted matrix and significantly worse post infarct cardiac function. Single cell transcriptomics complemented with histology in SerpinA3n deficient animals, demonstrated increased inflammation, adverse myocyte hypertrophy and expression of pro-hypertrophic genes. Proteomic analysis of scar tissue demonstrated decreased cross linking of extracellular matrix peptides consistent with increased proteolysis in SerpinA3n deficient animals. Taken together these observations demonstrate a hitherto unappreciated causal role of Serpins in regulating matrix function and post infarct cardiac remodeling.

Volume Matters: Longitudinal Retrospective Cohort Study of Outcomes Following Consultation and Standardization of Adrenal Surgery.

PURPOSE: Subspecialization of adrenal surgery through regionalization has not been adequately evaluated. We assessed implementation of subspecialization and the association of regionalization with adrenalectomy outcomes in a community-based setting. METHODS: In this longitudinal retrospective cohort study, we used an interrupted time series analysis on consecutive adrenal surgeries at Kaiser Permanente Northern California, 2010-2019. The intervention was regionalization of surgery in 2016. Main outcomes include surgical volumes, operative time, length of stay, 30-day return-to-care, and 30-day complications obtained from the electronic medical record. t-Tests and multivariable models were used to analyze time trends in outcomes after accounting for changes in patient and disease characteristics. RESULTS: In total, 850 adrenal surgery cases were eligible. Between 2010 and 2019, the annual incidence of surgery (per 100,000 persons) increased from 2.4 (95% CI 1.9-3.1) to 4.1 (95% CI 3.5-4.8). Average annual surgeon volume increased from 2.4 (95% CI 1.6-3.1) to 9.9 (95% CI 4.9-14.9), while hospital volume increased from 3.5 (95% CI 2.3-4.6) to 15.4 (95% CI 6.9-24.0). Operative time was 34 (23-45) min faster in 2018-2019 compared with 2010-2011. After regionalization, same-day discharges increased to 64% in 2019 (p < 0.0001). The frequency of return-to-care (p = 0.69) and the overall complication rate (p = 0.31) did not change. CONCLUSIONS: Regionalizing adrenal surgery through surgical subspecialization and standardized care pathways was feasible and decreased operative time, and hospital stay, while increasing the frequency of same-day discharges without increasing return-to-care or complications.

Psychogenic non-epileptic and epileptic seizures: clues for a differential diagnosis. Findings from a Colombian study / Crisis psicógenas no epilépticas y crisis epilépticas: pistas para un diagnóstico diferencial. Hallazgos de un estudio colombiano

Introduction. Psychogenic non-epileptic seizures (PNES) are paroxysmal changes in behavior that resemble epileptic seizures, although they have no electrophysiological correlation or clinical evidence of epilepsy. Aim. To compare clinical and sociodemographic characteristics of patients diagnosed with PNES-alone and PNES-andepilepsy. Patients and methods. A cross-sectional study of consecutive patients diagnosed with PNES in a 20-month period was carried out. A video-EEG was performed in all patients. Socio-demographical, clinical and semiological characteristics were compared between those patients with and without concomitant epilepsy. Results. Sixty-five patients were included, 35 (53.9%) had PNES-alone and 30 (46.1%) had PNES-and-epilepsy. The proportion of women in the study was 70.8%. The median age at seizure onset was 16 years. A late start was recorded in PNES-alone group (23 years) compared to PNES-and-epilepsy group (11 years), however, it was not significant. There was a lower frequency of antiepileptic drugs use in the PNES-alone group compared with the PNES-and-epilepsy group. The most frequent semiological features were the gradual onset of events (69.2%) and the duration longer than two minutes (63.1%). Conclusion. The waxing and waning pattern during paroxysmal events suggest a non-epileptic origin. However, it is not uncommon to find patients with concomitant epileptic seizures

Introducción. Las crisis psicógenas no epilépticas (CPNE) son cambios paroxísticos en el comportamiento que se asemejan a las crisis epilépticas, aunque no tienen correlación electrofisiológica ni evidencia clínica de epilepsia. Objetivo. Comparar las características clínicas y sociodemográficas entre pacientes diagnosticados con CPNE, con y sin epilepsia concomitante. Pacientes y métodos. Estudio transversal de pacientes consecutivamente diagnosticados de CPNE durante un período de 20 meses. A todos los participantes se les realizó un videoelectroencefalograma (video-EEG). Se compararon las características sociodemográficas, clínicas y semiológicas entre los que presentaban y los que no presentaban epilepsia concomitante. Resultados. Se incluyó a 65 pacientes, 35 con CPNE (53,9%), y 30 con CPNE y epilepsia (46,1%). La edad mediana en el inicio del video-EEG fue de 33 años, y un 70,8% eran mujeres. La edad mediana de inicio de las crisis fue de 16 años. En el grupo de CPNE hubo un inicio más tardío (23 años) en comparación con el grupo de CNPE y epilepsia (11 años), pero la diferencia no fue significativa. La proporción de pacientes en terapia con fármacos antiepilépticos fue significativamente mayor en el grupo con CPNE y epilepsia comparado con el grupo con CPNE. Las características semiológicas más frecuentemente encontradas fueron el inicio gradual de las crisis (69,2%) y una duración de más de dos minutos (63,1%). Conclusión. La variabilidad en los síntomas sugiere un origen no epiléptico de los eventos paroxísticos, los cuales se presentan frecuentemente en pacientes con epilepsia

Management of Conjunctival Perforation and XEN Gel Stent Exposure by Stent Repositioning Through the Anterior Chamber.

In recent years, minimally invasive glaucoma surgery has emerged as a novel approach to lowering intraocular pressure. This technique, which is usually reserved for mild to moderate cases, is less invasive than classic filtration surgery and potentially offers a better safety profile. The XEN Gel Stent is implanted through a minimally invasive, ab interno procedure to create a subconjunctival pathway. Conjunctival tissue disruption is minimal, and flow is restricted to avoid hypotony. Data on the optimal approach to managing complications associated with this procedure are limited due to the relatively recent commercialization of this device. Here, we report a case of a persistent leaking bleb caused by XEN Stent exposure, which was managed by ab interno repositioning of the stent through the anterior chamber and direct suturing of the conjunctival defect.

Allocation of healthcare dollars: analysis of nonneonatal circumcisions in Florida.

Circumcision remains a controversial operation. Most procedures are performed in the neonatal period and avoid general anesthesia. Legislation driven by policy statements from the American Academy of Pediatrics led to significant changes in circumcisions in Florida with a shift to nonneonatal procedures as a result of costs. We sought to study the prevalence and financial implications of nonneonatal circumcisions in Florida. A retrospective population study was performed using the Florida Agency for Health Care Administration outpatient procedure database. We queried for patients 0 to 17 years of age undergoing circumcision between 2003 and 2008. Demographics, charges, and insurance status were analyzed. From 2003 to 2008, 31,741 outpatient circumcisions were performed. Publicly funded circumcisions accounted for 17,537 charging the state $6,263 on average for each circumcision at an expense of $111.8 million for the 5-year time period analyzed. Publicly funded circumcision procedures increased more than sixfold (P < 0.0001) than those covered by private insurance. Black circumcision procedures increased 77.3 per cent, whereas white circumcisions increased 28.7 per cent. There has been a significant increase in the number of nonneonatal circumcisions performed. This has resulted in an increase in economic health care. Public funding of neonatal circumcision could result in significant cost savings and avoid potential complications of general anesthesia.

Cirugía mayor ambulatoria en el servicio de cirugía general / Ambulatory major surgery in the General Surgery Service

Se hizo un estudio descriptivo, transversal y prospectivo de 1 200 pacientes con criterios para cirugía mayor ambulatoria, con el fin de determinar las características y beneficios de este método. En la serie predominaron las afecciones herniarias de la pared abdominal, generalmente intervenidas con anestesia local más sedación. Las enfermedades asociadas no constituyeron limitaciones en la muestra escogida, en tanto las complicaciones más frecuentes fueron: infección de la herida quirúrgica, seroma y hematoma. Se obtuvieron evidentes ventajas económicas con respecto al ahorro del recurso cama y la disminución del costo hospitalario, así como un elevado grado de satisfacción por parte de los operados, lo cual justifica que se recomiende incrementar la aplicación de este proceder y extenderlo al mayor número posible de afecciones quirúrgicas (AU)

Cirugía mayor ambulatoria en el servicio de cirugía general / Ambulatory major surgery in the General Surgery Service

Se hizo un estudio descriptivo, transversal y prospectivo de 1 200 pacientes con criterios para cirugía mayor ambulatoria, con el fin de determinar las características y beneficios de este método. En la serie predominaron las afecciones herniarias de la pared abdominal, generalmente intervenidas con anestesia local más sedación. Las enfermedades asociadas no constituyeron limitaciones en la muestra escogida, en tanto las complicaciones más frecuentes fueron: infección de la herida quirúrgica, seroma y hematoma. Se obtuvieron evidentes ventajas económicas con respecto al ahorro del recurso cama y la disminución del costo hospitalario, así como un elevado grado de satisfacción por parte de los operados, lo cual justifica que se recomiende incrementar la aplicación de este proceder y extenderlo al mayor número posible de afecciones quirúrgicas(AU)

We conducted a descriptive crosswise and prospective study of 1 200 patients who had undergone ambulatory major surgeries to determine the characteristics and benefits of this method. Abdominal hearnia, generallly operated with regional anesthesia plus sedatives prevailed in the group. Associated diseases were not restrictive factors in the selected sample whereas the most frequent complications were surgical wound infections, serone and hematomes. We observed obvious economic advantages regarding saving of beds and lower hospital costs as well as a high level of satisfaction on the part of the operated patients, which serves as a basis for recommending the increasing application of this method in a substantially higher number of surgeries(AU)

Heridas del corazón / Heart Wounds

Se hizo un estudio relacionado con los pacientes intervenidos quirúrgicamente por presentar heridas de corazón en el Hospital Militar Docente"Dr. Joaquín Castillo Duany" de Santiago de Cuba. El arma blanca fue el principal agente lesivo y todos los lesionados eran jóvenes. En 6 pacientes se constataron signos de taponamiento cardíaco, en los cuales el ventrículo derecho resultó el más afectado. La sepsis de la herida constituyó la complicación más frecuente y hubo una supervivencia del 88,8 por ciento