Cholinergic Basal Forebrain Connectivity to the Basolateral Amygdala Modulates Food Intake.

Obesity results from excessive caloric input associated with overeating and presents a major public health challenge. The hypothalamus has received significant attention for its role in governing feeding behavior and body weight homeostasis. However, extrahypothalamic brain circuits also regulate appetite and consumption by altering sensory perception, motivation, and reward. We recently discovered a population of basal forebrain cholinergic (BFc) neurons that regulate appetite suppression. Through viral tracing methods in the mouse model, we found that BFc neurons densely innervate the basolateral amygdala (BLA), a limbic structure involved in motivated behaviors. Using channelrhodopsin-assisted circuit mapping, we identified cholinergic responses in BLA neurons following BFc circuit manipulations. Furthermore, in vivo acetylcholine sensor and genetically encoded calcium indicator imaging within the BLA (using GACh3 and GCaMP, respectively) revealed selective response patterns of activity during feeding. Finally, through optogenetic manipulations in vivo, we found that increased cholinergic signaling from the BFc to the BLA suppresses appetite and food intake. Together, these data support a model in which cholinergic signaling from the BFc to the BLA directly influences appetite and feeding behavior.

Comprehensive Review of Chest Tube Management: A Review.

IMPORTANCE: Thoracostomy, or chest tube placement, is used in a variety of clinical indications and can be lifesaving in certain circumstances. There have been developments and modifications to thoracostomy tubes, or chest tubes, over time, but they continue to be a staple in the thoracic surgeon's toolbox as well as adjacent specialties in medicine. This review will provide the nonexpert clinician a comprehensive understanding of the types of chest tubes, indications for their effective use, and key management details for ideal patient outcomes. OBSERVATIONS: This review describes the types of chest tubes, indications for use, techniques for placement, common anatomical landmarks that are encountered with placement and management, and an overview of complications that may arise with tube thoracostomy. In addition, the future direction of chest tubes is explored, as well as the management of chest tubes during the COVID-19 pandemic. CONCLUSIONS AND RELEVANCE: Chest tube management is subjective, but the compilation of data can inform best practices and safe application to successfully manage the pleural space and ameliorate acquired pleural space disease.

Surgical Management of an Obstructive Müllerian Anomaly in a Patient with Anorectal Malformation.

Müllerian duct anomalies are rare in the general population, occurring in less than 3% of women, but much more prevalent in female patients with anorectal malformation, occurring in up to 30% of these patients. Unicornuate uterus with a rudimentary non-communicating horn is a congenital anomaly of Mullerian development which can be seen in isolation or in conjunction with other anomalies, with several case reports described in patients with VACTERL association. These anomalies may be asymptomatic until the patient develops dysmenorrhea or devastating obstetrical complications. We describe the successful surgical management of an obstructive Müllerian anomaly in a post-pubertal female patient with anorectal malformation.

Total anomalous origin of the coronary arteries from the pulmonary artery: a systematic review.

BACKGROUND: Although rare, coronary artery anomalies can have significant clinical implications. Total anomalous origin of the coronary arteries from the pulmonary artery (TCAPA) represents a rare subtype of coronary artery anomaly for which little is known. The aim of this review was to characterise the presentation, utilised diagnostic modalities, associated cardiac lesions, and treatment strategies in patients with TCAPA. METHODS: A systematic review was performed for cases of TCAPA using PubMed, Embase, and Web of Science. Keywords searched included "total anomalous origin of the coronary arteries from the pulmonary artery," "single ostium anomalous coronary artery from the pulmonary artery," and "anomalous origin of both coronary arteries from the pulmonary artery." RESULTS: Fifty-seven cases of TCAPA were identified in 50 manuscripts. Fifty-eight per cent of patients were male and the median age at presentation was 10 days (mean 1.71 ± 6.6 years, range 0 days-39 years). Most patients were symptomatic at the time of presentation; cyanosis (n = 22) and respiratory distress (n = 14) were the most common symptoms. Cases were most commonly diagnosed at autopsy (n = 26, 45.6%), but operative intervention was pursued in 22 cases (45.6%); aortic re-implantation (n = 14) and a Takeuchi-type repair (n = 7) were the most common routes of repair. CONCLUSIONS: The clinical presentation of patients with TCAPA was found to be variable, likely related to the presence of associated cardiac lesions. TCAPA should be considered in patients with suspected anomalous origin of the left coronary artery from the pulmonary artery for the serious consequences that can occur if not promptly corrected.

Development of a porcine model of emergency resternotomy at a low-volume cardiac surgery centre.

Emergency resternotomy in the intensive care unit (ICU) is a rarely performed, yet potentially life-saving intervention. Success relies on recognition of a deteriorating clinical condition, timely deployment of equipment/personnel and rapid execution. Given how infrequently it is performed, we sought to develop a large animal model of resternotomy to prepare ICU nurses and technicians at our low-volume cardiac surgery military centre. A porcine model of resternotomy was developed at the end of an already-scheduled trauma lab. Participants worked their way through a pre-planned simulation scenario, culminating in the need for resternotomy. Pre-simulation surveys assessing knowledge and comfort level with aspects of resternotomy were compared to post-simulation surveys. Participants improved their knowledge of resternotomy by 20.4% (P < 0.0001; 14.7% for nurses and 26.9% for technicians). Improvements were seen in all aspects assessed relating to subjective comfort/preparedness of resternotomy. The model was an effective and realistic method to augment training of ICU staff about resternotomy. Costs associated with this model can be reduced when used in conjunction with large animal labs. This model should be used together with mannequin-based methods of resternotomy training to provide a realistic training environment and assessment of skills at capable institutions.

Digital Design and 3D Printing of Aortic Arch Reconstruction in HLHS for Surgical Simulation and Training.

PURPOSE: Patients with hypoplastic left heart syndrome (HLHS) present a diverse spectrum of aortic arch morphology. Suboptimal geometry of the reconstructed aortic arch may result from inappropriate size and shape of an implanted patch and may be associated with poor outcomes. Meanwhile, advances in diagnostic imaging, computer-aided design, and three-dimensional (3D) printing technology have enabled the creation of 3D models. The purpose of this study is to create a surgical simulation and training model for aortic arch reconstruction. DESCRIPTION: Specialized segmentation software was used to isolate aortic arch anatomy from HLHS computed tomography scan images to create digital 3D models. Three-dimensional modeling software was used to modify the exported segmented models and digitally design printable customized patches that were optimally sized for arch reconstruction. EVALUATION: Life-sized models of HLHS aortic arch anatomy and a digitally derived customized patch were 3D printed to allow simulation of surgical suturing and reconstruction. The patient-specific customized patch was successfully used for surgical simulation. CONCLUSIONS: Feasibility of digital design and 3D printing of patient-specific patches for aortic arch reconstruction has been demonstrated. The technology facilitates surgical simulation. Surgical training that leads to an understanding of optimal aortic patch geometry is one element that may potentially influence outcomes for patients with HLHS.