Glans Ischemia after Circumcision in a 16-Year-Old Boy: Full Recovery after Angiography with Local Spasmolysis, Systemic Vasodilatation, and Anticoagulation.

Circumcision is one of the most frequent procedures performed by pediatric surgeons. A dorsal penile nerve block (DPNB) is commonly used for perioperative analgesia. We report the case of a 16-year-old boy with ischemia of the glans who presented on the first postoperative day after circumcision under DPNB (0.25% bupivacaine) at an outside hospital. The patient underwent immediate angiography under sedation. An intra-arterial spasmolysis was performed with alprostadil and nitroglycerine and a sufficient perfusion of the glans penis was confirmed. Subsequently, systemic sildenafil, arginine, and heparin were given. Following this 3-day medical treatment, ischemia resolved completely. Our case emphasizes the role of invasive angiography in the diagnostic workup and the therapeutic possibilities of local spasmolysis, systemic vasodilatation, and anticoagulation.

Ischaemic preconditioning of the spinal cord to prevent spinal cord ischaemia during endovascular repair of thoracoabdominal aortic aneurysm: first clinical experience.

AIMS: The purpose of our study was to report our experience with minimally invasive segmental artery coil embolisation (MISACE) to prevent spinal cord ischaemia (SCI) after endovascular repair (ER) of thoracoabdominal aortic aneurysm (TAAA). METHODS AND RESULTS: A cohort of 57 patients with TAAAs was treated by MISACE followed by ER between October 2014 and December 2017. The TAAA Crawford classification was: type I, n=5; type II, n=12; type III, n=27; type IV, n=13. The average maximum aortic diameter was 62.7±8.8 mm. Patients had a median of 5 coiled SAs (range: 1-19). MISACE was completed in one (n=22), two (n=24), three (n=7), four (n=3) or five (n=1) sessions. The maximum number of coiled SAs per session was six. After completion of MISACE, 77.7% of direct segmental arterial flow was occluded. After a mean of 83±62 days, 55 of the patients received total ER of their TAAA. At 30 days after ER, no patient developed SCI and three patients had died. CONCLUSIONS: MISACE to precondition the paraspinous collateral network prior to endovascular repair of thoracoabdominal aortic aneurysm is clinically feasible. The safety profile is promising and there is good reason to explore this new staging strategy further.

Analysis of Patients' X-ray Exposure in 146 Percutaneous Radiologic Gastrostomies.

Purpose Analysis of patient´s X-ray exposure during percutaneous radiologic gastrostomies (PRG) in a larger population. Materials and Methods Data of primary successful PRG-procedures, performed between 2004 and 2015 in 146 patients, were analyzed regarding the exposition to X-ray. Dose-area-product (DAP), dose-length-product (DLP) respectively, and fluoroscopy time (FT) were correlated with the used x-ray systems (Flatpanel Detector (FD) vs. Image Itensifier (BV)) and the necessity for periprocedural placement of a nasogastric tube. Additionally, the effective X-ray dose for PRG placement using fluoroscopy (DL), computed tomography (CT), and cone beam CT (CBCT) was estimated using a conversion factor. Results The median DFP of PRG-placements under fluoroscopy was 163 cGy*cm2 (flat panel detector systems: 155 cGy*cm2; X-ray image intensifier: 175 cGy*cm2). The median DLZ was 2.2 min. Intraprocedural placement of a naso- or orogastric probe (n = 68) resulted in a significant prolongation of the median DLZ to 2.5 min versus 2 min in patients with an already existing probe. In addition, dose values were analyzed in smaller samples of patients in which the PRG was placed under CBCT (n = 7, median DFP = 2635 cGy*cm2), or using CT (n = 4, median DLP = 657 mGy*cm). Estimates of the median DFP and DLP showed effective doses of 0.3 mSv for DL-assisted placements (flat panel detector 0.3 mSv, X-ray image converter 0.4 mSv), 7.9 mSv using a CBCT - flat detector, and 9.9 mSv using CT. This corresponds to a factor 26 of DL versus CBCT, or a factor 33 of DL versus CT. Conclusion In order to minimize X-ray exposure during PRG-procedures for patients and staff, fluoroscopically-guided interventions should employ flat detector systems with short transmittance sequences in low dose mode and with slow image frequency. Series recordings can be dispensed with. The intraprocedural placement of a naso- or orogastric probe significantly extends FT, but has little effect on the overall dose of the intervention. Due to the significantly higher X-ray exposure, the use of a CBCT as well as PRG-placements using CT should be limited to clinically absolutely necessary exceptions with strict indication. Key Points · Fluoroscopically-guided PRG placements are interventions with low X-ray exposure.. · X-ray exposure from fluoroscopy is lower using flat panel detector systems as compared to image intensifier systems.. · The concomitant placement of an oro- or nasogastric probe extends the fluoroscopy time.. · Gastric probe placement is worthwhile to prevent the premature use of the significantly radiation-intensive CT.. · The use of the C-arm CT or the CT increases the beam exposure by 26 or 33 times, respectively.. · The PRG placement using C-arm CT and CT should only be performed in exceptional cases.. Citation Format · Petersen TO, Reinhardt M, Fuchs J et al. Analysis of Patients' X-ray Exposure in 146 Percutaneous Radiologic Gastrostomies. Fortschr Röntgenstr 2017; 189: 820 - 827.

Navigated MRI-guided liver biopsies in a closed-bore scanner: experience in 52 patients.

OBJECTIVES: To evaluate clinical effectiveness and diagnostic efficiency of a navigation device for MR-guided biopsies of focal liver lesions in a closed-bore scanner. METHODS: In 52 patients, 55 biopsies were performed. An add-on MR navigation system with optical instrument tracking was used for image guidance and biopsy device insertion outside the bore. Fast control imaging allowed visualization of the true needle position at any time. The biopsy workflow and procedure duration were recorded. Histological analysis and clinical course/outcome were used to calculate sensitivity, specificity and diagnostic accuracy. RESULTS: Fifty-four of 55 liver biopsies were performed successfully with the system. No major and four minor complications occurred. Mean tumour size was 23 ± 14 mm and the skin-to-target length ranged from 22 to 177 mm. In 39 cases, access path was double oblique. Sensitivity, specificity and diagnostic accuracy were 88 %, 100 % and 92 %, respectively. The mean procedure time was 51 ± 12 min, whereas the puncture itself lasted 16 ± 6 min. On average, four control scans were taken. CONCLUSIONS: Using this navigation device, biopsies of poorly visible and difficult accessible liver lesions could be performed safely and reliably in a closed-bore MRI scanner. The system can be easily implemented in clinical routine workflow. KEY POINTS: • Targeted liver biopsies could be reliably performed in a closed-bore MRI. • The navigation system allows for image guidance outside of the scanner bore. • Assisted MRI-guided biopsies are helpful for focal lesions with a difficult access. • Successful integration of the method in clinical workflow was shown. • Subsequent system installation in an existing MRI environment is feasible.

The value of liver resection for focal nodular hyperplasia: resection yes or no?

BACKGROUND: Focal nodular hyperplasia (FNH) are benign lesions in the liver. Although liver resection is generally not indicated in these patients, rare indications for surgical approaches indeed exist. We here report on our single-center experience with patients undergoing liver resection for FNH, focussing on preoperative diagnostic algorithms and quality of life (QoL) after surgery. METHODS: Medical records of 100 consecutive patients undergoing liver resection for FNH between 1992 and 2012 were retrospectively analyzed with regard to diagnostic pathways and indications for surgery. Quality of life (QoL) before and after surgery was evaluated using validated assessment tools. Student's t test, one-way ANOVA, χ (2), and binary logistic regression analyses such as Wilcoxon-Mann-Whitney test were used, as indicated. RESULTS: A combination of at least two preoperative diagnostic imaging approaches was applied in 99 cases, of which 70 patients were subjected to further imaging or tumor biopsy. In most patients, there was more than one indication for liver resection, including tumor-associated symptoms with abdominal discomfort (n = 46, 40.7 %), balance of risk for malignancy/history of cancer (n = 54, 47.8 %/n = 18; 33.3 %), tumor enlargement/jaundice of vascular and biliary structures (n = 13, 11.5 %), such as incidental findings during elective operation (n = 1, 0.9 %). Postoperative morbidity was 19 %, with serious complications (>grade 2, Clavien-Dindo classification) being evident in 8 %. Perioperative mortality was 0 %. Liver resection was associated with a significant overall improvement in general health (very good-excellent: preoperatively 47.4 % vs. postoperatively 68.1 %; p = 0.015). CONCLUSIONS: Liver resection remains a valuable therapeutic option in the treatment of either symptomatic FNH or if malignancy cannot finally be ruled out. If clinically indicated, liver resection for FNH represents a safe approach and may lead to significant improvements of QoL especially in symptomatic patients.

A photoactivatable marker protein for pulse-chase imaging with superresolution.

IrisFP is a photoactivatable fluorescent protein that combines irreversible photoconversion from a green- to a red-emitting form with reversible photoswitching between a fluorescent and a nonfluorescent state in both forms. Here we introduce a monomeric variant, mIrisFP, and demonstrate how its multiple photoactivation modes can be used for pulse-chase experiments combined with subdiffraction-resolution imaging in living cells by using dual-color photoactivation localization microscopy (PALM).

Modulation of NMDA receptor current in layer V pyramidal neurons of the rat prefrontal cortex by P2Y receptor activation.

Current responses to N-methyl-D-aspartate (NMDA) in layer V pyramidal neurons of the rat prefrontal cortex were potentiated by the P2 receptor agonists adenosine 5'-triphosphate (ATP) and uridine 5'-triphosphate (UTP). The failure of these nucleotides to induce inward current on fast local superfusion suggested the activation of P2Y rather than P2X receptors. The potentiation by ATP persisted in a Ca(2+)-free superfusion medium but was abolished by 1,2-bis(2-amino-5-fluorophenoxy)ethane-N,N,N',N'-tetraacetic acid tetrakis(acetoxymethyl) ester, cyclopiazonic acid, 7-nitroindazole, fluoroacetic acid, bafilomycin, and tetanus toxin, indicating that an astrocytic signaling molecule may participate. Because the metabotropic glutamate receptor (mGluR) agonists (1S,3R)-1-aminocyclopentane-1,3-dicarboxylic acid (ACPD) (group I/II) and (RS)-3,5-dihydroxyphenylglycine (group I) both imitated the effect of ATP and the group I mGluR antagonist 1-aminoindan-1,5-dicarboxylic acid or a combination of selective mGluR(1) (7-(hydroxyimino)-cyclopropa[b]chromen-1a-carboxylate) and mGluR(5) (2-methyl-6-(phenylethynyl)pyridine) antagonists abolished the facilitation by ATP, it was concluded that the signaling molecule may be glutamate. Pharmacological tools known to interfere with the transduction cascade of type I mGluRs (guanosine 5'-O-(3-thiodiphosphate), U-73122, xestospongin C, 1,2-bis(2-aminophenoxy)ethane-N,N,N',N'-tetraacetic acid, calmodulin kinase II [CAMKII] inhibitor peptide) depressed the actions of both ATP and ACPD. Characterization of the P2Y receptor by agonists (ATP and UTP), antagonists (suramin and pyridoxal-phosphate-6-azophenyl-2',4'-disulfonic acid), and knockout mice (P2Y(2)(-/-)) suggested that the nucleotides act at the P2Y(4) subtype. In conclusion, we propose that exogenous and probably also endogenous ATP release vesicular glutamate from astrocytes by P2Y(4) receptor activation. This glutamate then stimulates type I mGluRs of layer V pyramidal neurons and via the G(q)/phospholipase C/inositol 1,4,5-trisphosphate/Ca(2+)/CAMKII transduction pathway facilitates NMDA receptor currents.

Ligand dynamics in a protein internal cavity.

We have studied the temperature dependence of the IR stretch bands of carbon monoxide (CO) in the Xe 4 internal cavity of myoglobin mutant L29W-S108L at cryogenic temperatures. Pronounced changes of band areas and positions were analyzed quantitatively by using a simple dynamic model in which CO rotation in the cavity is constrained by a static potential. The librational dynamics of the CO causes a decrease of the total spectral area. A strong local electric field splits the CO stretch absorption into a doublet, indicating that CO can assume opposite orientations in the cavity. With increasing temperature, the two peaks approach each other, because the average angle of the CO with respect to the electric field increases. A combined classical and quantum-mechanical analysis precisely reproduces the observed temperature dependencies of both spectral area and peak shifts. It yields the height of the energy barrier between the two wells associated with opposite CO orientations, V0 approximately 2 kJ/mol, and the frequency of oscillation within a well, omega approximately 25 cm(-1). The electric field in the protein cavity was estimated as 10 MV/cm.