Ectopy-triggering ganglionated plexuses ablation to prevent atrial fibrillation: GANGLIA-AF study.

BACKGROUND: The ganglionated plexuses (GPs) of the intrinsic cardiac autonomic system may play a role in atrial fibrillation (AF). OBJECTIVE: We hypothesized that ablating the ectopy-triggering GPs (ET-GPs) prevents AF. METHODS: GANGLIA-AF (ClinicalTrials.gov identifier NCT02487654) was a prospective, randomized, controlled, 3-center trial. ET-GPs were mapped using high frequency stimulation, delivered within the atrial refractory period and ablated until nonfunctional. If triggered AF became incessant, atrioventricular dissociating GPs were ablated. We compared GP ablation (GPA) without pulmonary vein isolation (PVI) against PVI in patients with paroxysmal AF. Follow-up was for 12 months including 3-monthly 48-hour Holter monitors. The primary end point was documented ≥30 seconds of atrial arrhythmia after a 3-month blanking period. RESULTS: A total of 102 randomized patients were analyzed on a per-protocol basis after GPA (n = 52; 51%) or PVI (n = 50; 49%). Patients who underwent GPA had 89 ± 26 high frequency stimulation sites tested, identifying a median of 18.5% (interquartile range 16%-21%) of GPs. The radiofrequency ablation time was 22.9 ± 9.8 minutes in GPA and 38 ± 14.4 minutes in PVI (P < .0001). The freedom from ≥30 seconds of atrial arrhythmia at 12-month follow-up was 50% (26 of 52) with GPA vs 64% (32 of 50) with PVI (log-rank, P = .09). ET-GPA without atrioventricular dissociating GPA achieved 58% (22 of 38) freedom from the primary end point. There was a significantly higher reduction in antiarrhythmic drug usage postablation after GPA than after PVI (55.5% vs 36%; P = .05). Patients were referred for redo ablation procedures in 31% (16 of 52) after GPA and 24% (12 of 50) after PVI (P = .53). CONCLUSION: GPA did not prevent atrial arrhythmias more than PVI. However, less radiofrequency ablation was delivered to achieve a higher reduction in antiarrhythmic drug usage with GPA than with PVI.

Síndrome axillary web idiopático / Idiopathic axillary web syndrome

Se presenta el caso clínico de una mujer de 67 años, que desarrolló un cordón subcutáneo en la axila hasta la cara interna del brazo, acompañado de dolor axilar de características neuropáticas, sin antecedente quirúrgico ni infeccioso. Se le instruyó en ejercicios domiciliarios, y la evolución fue favorable con mejoría progresiva y espontánea. A los 4 meses persistía un pequeño cordón visible con la abducción y leve disestesia axilar, de menor intensidad que al inicio. Se diagnosticó de síndrome axillary web (SAW) idiopático, por exclusión. Es ampliamente conocido este síndrome tras cirugía ganglionar axilar en el tratamiento del cáncer mama, siendo aún desconocida la etiopatogenia. Son excepcionales los casos publicados sobre el SAW sin antecedente quirúrgico, y los pocos documentados tienen como antecedente un proceso infeccioso o esfuerzo físico intenso. No se ha encontrado descrito en la literatura ningún caso de SAW de etiología idiopática, pudiendo ser este el primer caso. La localización anatómica, presentación y evolución clínica del SAW no quirúrgico es extrapolable al posquirúrgico

We report the case of a 67-year-old woman who developed a cord of subcutaneous tissue extending from the axilla into the medial arm, accompanied by axillary neuropathic pain, with no history of surgery or infection. The patient was instructed in home exercises, and the condition progressively improved. Four months later, a small cord was visible on abduction with mild axillary dysesthesia, which was less severe than at onset. Diagnosis of exclusion was idiopathic axillary web syndrome (AWS). This syndrome is widely recognized after surgical axillary lymph node removal to treat breast cancer, but the etiopathogenesis is still unknown. Published reports of AWS with no history of surgery are rare, but a few reports have described this entity after infection or intense exercise. There are currently no previous reports of idiopathic AWS. The anatomical and clinical presentation, and clinical course of AWS without prior surgery, are similar to those of postoperative AWS

Effect of castration on pelvic neurons in the male pig.

The present study investigated the influence of castration performed at neonatal age on neuronal elements in the anterior pelvic ganglion of the male pig with immunohistochemistry and quantitative real-time PCR (qPCR). The ganglia were examined 3 and 6 months after surgery. In 3-month-old castrated pigs (3MCP) 74% of adrenergic and 31% of cholinergic neurons stained for caspase-3 (CASP-3), and much greater numbers of perikarya than in the control animals expressed CGRP, galanin (GAL) and VIP (peptides known to have neuroprotective properties). In 6-months-old castrated pigs (6MCP), an excessive loss (90%) of neurons and intraganglionic nerve fibres was found. The survived adrenergic and cholinergic neurons also expressed CASP-3, CGRP, GAL or VIP. The qPCR results corresponded with immunofluorescence findings. In 3MCP, genes for CASP-3 and CGRP were up-regulated, while the expression of those for DßH, VAChT, GAL, VIP and SP displayed statistically insignificant variations. In 6MCP, distinctly up-regulated were genes for CGRP, GAL, VIP, SP, DßH and VAChT, while the expression of casp3 gene was down-regulated. The study revealed for the first time the excessive loss of pelvic neurons following castration, and a realistic assumption is proposed, that the neurons died due to apoptosis triggered by androgen deprivation.

The Outcome of Treatment of Flexor Sheath (seed) Ganglia by a Percutaneous Partial Pulley Release.

BACKGROUND: The aims of this study were to assess the safety and efficacy of a technique of partial percutaneous pulley release. METHODS: A retrospective cohort study was undertaken treating adults with seed ganglia with a percutaneous pulley release. The patients were reviewed independently after a mean of 6 (range 6-36) months. RESULTS: We treated 24 patients over a 3 year period. There were 14 women and ten men. The mean age was 39 (range 17-65) years. We were able to assess 21 patients with long term follow up. There was complete resolution in 14 (2/3) and partial resolution in four. The remaining three patients had persisting symptoms and requested open surgical excision. Apart from local tenderness and failure of resolution there were no complications of percutaneous pulley release. CONCLUSIONS: Bursting or aspiration of flexor sheath ganglia appears to be the best primary treatment. If the ganglion recurs, this study suggests a percutaneous release is safe and will resolve the symptoms in most patients.

Enfermedad por arañazo de gato / Cat scratch disease

La enfermedad por arañazo de gato es una infección causada por la bacteria bartonella henselae. Se caracteriza desde el punto de vista clínico por linfadenopatía regional autolimitada, acompañada de fiebre y otros síntomas generales. Se reporta una paciente de 42 años de edad que inició con adenopatías submandibulares en regiones laterales del cuello acompañado de febrículas de 37 °C de 4 semanas de evolución, que aumentan de tamaño. Como diagnóstico diferencial se planteó un proceso linfoproliferativo, indicándose realizar una citología por aspiración por aguja fina de las lesiones, el resultado informa linfadenitis reactiva inespecífica, siendo no concluyente para diagnóstico, por lo que se hace exéresis de un ganglio del cuello. El estudio histopatológico mostró la formación de granulomas, que coalecen y forman (procesos estrellados), es decir, acúmulos irregulares centrales de macrófagos activos y en desintegración, rodeados por un ribete llamativo de macrófagos epitelioides en empalizados(AU)

Cat scratch disease is an infection caused by the bacterium Bartonella henselae. From a clinical point of view it is characterized by regional self-limited lymphadenopathy, accompanied by fever and other general symptoms. A report is presented of a 42-year-old female patient who started out with submandibular adenopathies of increasing size in lateral regions of the neck and 37ºC low-grade fever of 4 weeks of evolution. A lymphoproliferative process was established as differential diagnosis, and fine-needle aspiration cytology of the lesions was indicated. The result was nonspecific reactive lymphadenitis, not conclusive for diagnosis. Therefore, exeresis was performed of a neck ganglion. Histopathological examination revealed the formation of granulomas which coalesce into star-shaped structures, i.e. irregular central accumulations of active and disintegrating macrophages surrounded by a distinct border of palisading epithelioid macrophages(AU)

Ectopic ganglion in cauda equina: case report.

Macroscopic ectopic or heterotopic ganglionic tissue within the cauda equina is a very rare pathological finding and is usually associated with spinal dysraphism. However, it may mimic genuine neoplasms of the cauda equina. The authors describe a 29-year-old woman with a history of back pain, right leg pain, and urinary incontinence in whom imaging demonstrated an enhancing mass located in the cauda equina at the L1-2 interspace. The patient subsequently underwent biopsy and was found to have a focus of ectopic ganglionic tissue that was 1.3 cm in greatest dimension. To the authors' knowledge, ectopic or heterotopic ganglionic tissue within the cauda equina in a patient without evidence of spinal dysraphism has never been reported. This patient presented with imaging and clinical findings suggestive of a neoplasm, and an open biopsy proved the lesion to be ectopic ganglionic tissue. The authors suggest that ectopic ganglionic tissue be added to the list of differential diagnoses of a space-occupying lesion arising from the cauda equina.

Current clinical features in diagnosis and treatment for immaturity of ganglia in Japan: analysis from 10-year nationwide survey.

BACKGROUND: To identify the current clinical features in diagnosis and treatment for immaturity of ganglia (IG) in Japan, we retrospectively analyzed data for patients with IG from the nationwide surveys in Japan. This survey was performed by Japanese Study Group of allied disorders of Hirschsprung's disease (ADHD). METHODS: In primary research, data on totally 355 cases of ADHD were collected for 10 years (2001-2010). Fifteen patients were IG. All IG patients were confirmed by pathological examination. In secondary research, detail questionnaires were sent and collected. RESULTS: Male/female ratio was 9/6 and mean birth weight was 2474 g. All cases (100 %) were onset in neonatal period. Primary symptoms were abdominal distention (86.7 %), vomiting (53.3 %), and late egestion of meconium (26.7 %). An abnormal distention of intestine was recognized in 86.7 % on X-ray, and microcolon was recognized in 58.3 % on contrast enema. Caliber change was recognized in 58.3 % on laparotomy. An enterostomy was made in 13 patients (86.7 %), and an ileostomy was made in 69.2 %. Pathological diagnosis was performed in 100 %. Enterostomy was closed in 100 %. CONCLUSIONS: Totally, 15 definitive cases of IG in 10 years were collected and analyzed. All cases were onset in the neonatal period and almost all underwent enterostomy, but no mortalities occurred.

A durable model of Hirschsprung's colon.

INTRODUCTION: Hirschsprung's disease is characterized by colonic aganglionosis, curable only by surgical correction. Stem cells may offer regenerative benefits while preventing surgical risks. Existing Hirschsprung's model systems are limited by alimentary compromise and spontaneous ganglionic reconstitution. We endeavored to generate a model of permanent colonic aganglionosis to support longitudinal cell therapy studies. METHODS: Among adult female Lewis rats (n=11), laparotomy was performed and one-centimeter segments of descending colon were isolated from continuity and denervated by trans-serosal benzalkonium chloride (BAC) exposure. Postoperative weights were plotted. The colon segments were retrieved after 50 or 100days. Immunohistochemical staining (IHC) for beta-III tubulin (TUJ1) and glial fibrillary acid protein (GFAP) revealed colonic ganglia. Muscle layer diameter and the presence of ganglia were contrasted between normal and denervated segments. RESULTS: All animals survived, experienced 5% weight loss after one week, and then consistently gained weight. Isolated segments had significantly hypertrophied smooth muscle layers compared to normal colon. Ganglia were identified by IHC in normal colonic segments, and denervated colonic segments had no IHC evidence of myenteric ganglia. CONCLUSION: Colonic segmental isolation and denervation result in an effective model of irreversible colonic aganglionosis. Animals retain alimentary function. Muscularis hypertrophy, myenteric denervation, and normal animal longevity are suitable for long-term studies of cell therapy.

The swimmeret system of crayfish: a practical guide for the dissection of the nerve cord and extracellular recordings of the motor pattern.

Here we demonstrate the dissection of the crayfish abdominal nerve cord. The preparation comprises the last two thoracic ganglia (T4, T5) and the chain of abdominal ganglia (A1 to A6). This chain of ganglia includes the part of the central nervous system (CNS) that drives coordinated locomotion of the pleopods (swimmerets): the swimmeret system. It is known for over five decades that in crayfish each swimmeret is driven by its own independent pattern generating kernel that generates rhythmic alternating activity . The motor neurons innervating the musculature of each swimmeret comprise two anatomically and functionally distinct populations. One is responsible for the retraction (power stroke, PS) of the swimmeret. The other drives the protraction (return stroke, RS) of the swimmeret. Motor neurons of the swimmeret system are able to produce spontaneously a fictive motor pattern, which is identical to the pattern recorded in vivo. The aim of this report is to introduce an interesting and convenient model system for studying rhythm generating networks and coordination of independent microcircuits for students' practical laboratory courses. The protocol provided includes step-by-step instructions for the dissection of the crayfish's abdominal nerve cord, pinning of the isolated chain of ganglia, desheathing the ganglia and recording the swimmerets fictive motor pattern extracellularly from the isolated nervous system. Additionally, we can monitor the activity of swimmeret neurons recorded intracellularly from dendrites. Here we also describe briefly these techniques and provide some examples. Furthermore, the morphology of swimmeret neurons can be assessed using various staining techniques. Here we provide examples of intracellular (by iontophoresis) dye filled neurons and backfills of pools of swimmeret motor neurons. In our lab we use this preparation to study basic functions of fictive locomotion, the effect of sensory feedback on the activity of the CNS, and coordination between microcircuits on a cellular level.

Ganglia arising from the transverse acetabular ligament: a report of two cases.

Ganglia arising from the hip are rare. Its diagnosis is difficult owing to the anatomic location. A high index of suspicion and high-resolution imaging is essential to make the diagnosis. Treatment depends on the size, location, and symptoms. This report is of 2 patients with ganglia arising from the transverse acetabular ligament.

Advances in wrist arthroscopy.

Since its introduction more than three decades ago, wrist arthroscopy has continually evolved. The procedure has a wide list of indications, including diagnostic and management applications. The scope of practice for the wrist arthroscopic surgeon includes management of triangulofibrocartilage complex pathology, evaluation and management of carpal instability, assistance in fracture reduction of the radius and scaphoid, treatment of trapeziometacarpal synovitis and arthritis, distal ulnar and carpal bone excisions, and salvage procedures. In addition, innovations such as new portals and smaller arthroscopes have expanded the applications of wrist arthroscopy.

Thoracoscopic sympathectomy ganglia ablation in the management of palmer hyperhidrosis: a decade experience in a single institution.

BACKGROUND: Hyperhidrosis can cause significant professional and social handicaps. Surgery is the preferred treatment modality for hyperhidrosis. There has been evolution in the surgical management of hyperhidrosis. This study evaluated the place of minimally invasive surgical approach and its long-term outcome in the management of hyperhidrosis. PATIENTS AND METHODS: A 10-year prospective study of all children and adolescents who underwent thorascopic sympathectomy at the Schneider Children's Hospital of Israel. Data were validated for the procedure and analysed for outcome of procedure. RESULTS: There were 148 patients, 66 were males and 82 were females, with a median age of 13.8 SD ± 4.0 years. Two hundred and ninety-six thoracopic sympathectomies were performed with no conversion to open procedure. The mean operation time was 18 min. Ninety-five per cent of the patients were discharged the next day with a mean hospital stay of 1.2 days. Postoperative complications included segmental atelectasis in seven (4.72%) patients, pneumothorax in two (1.35%) and transient unilateral Horner's syndrome in one (0.67%). Seventy-one (38.8%) experienced some form of compensatory hyperhidrosis. Complete relief of palmer hyperdidrosis was achieved in all patients (mean follow-up = 5.03 ± 1.76 years). The outcome was very satisfactory in 91 (61.5%) and satisfactory in 48 (32.4%). Only nine (6.1%) were not satisfied with the outcome. CONCLUSION: Thorascopic sympathectomy provides effective and satisfactory cure for palmer hyperhidrosis with acceptable complication rate and excellent satisfactory outcome. There is a possibility of compensatory sweating in some individuals.

Outcome of anatomic ganglionated plexi ablation to treat paroxysmal atrial fibrillation: a 3-year follow-up study.

AIMS: A new strategy for anatomically based ganglionated plexi (GP) ablation for the treatment of paroxysmal atrial fibrillation (AF) has been proposed recently. We aimed to assess the long-term outcome of patients undergoing anatomic GP ablation for paroxysmal AF, in comparison with circumferential pulmonary vein (PV) isolation. METHODS AND RESULTS: The study population consisted of 70 patients (mean age 56.6 ± 10.9 years; 41 males) with paroxysmal AF and no history of structural heart disease: 35 subjects underwent anatomic GP ablation, while 35 consecutive patients had circumferential PV isolation (CPVI) (control group). The groups were not different in demographic and clinical parameters. Anatomic GP ablation required more ablation points (85.6 ± 5.5 vs. 74.4 ± 6.2, P < 0.05) and equal duration of total procedure and fluoroscopy times. During a mean follow-up period of 36.3 ± 2.3 months, freedom from any atrial tachyarrhythmia without antiarrhythmics was achieved in 34.3% patients after anatomic GP ablation and 65.7% patients after CPVI (log-rank test P = 0.008). Early arrhythmia recurrences and anatomic GP ablation were independent predictors of late recurrence [HR 6.44 (CI 95%; 3.14-13.18; P < 0.001) and HR 2.08 (CI 95%; 1.03-4.22; P = 0.04), respectively]. Six patients in the group of GP ablation underwent subsequent CPVI, plus peri-mitral flutter ablation in two of them, with no further arrhythmia episodes in five patients. CONCLUSION: Anatomic GP ablation yields a significantly lower success rate over the long-term follow-up period, when compared with CPVI. Recurrences include AF and macro re-entrant atrial tachycardias.

Impacto del margen nodal en la sobrevida de pacientes con cáncer colónico en estadío local y locorregional / Nodal margin impact on the survival of patients with colonic cancer in local and loregional stage

Objetivo: Analizar la sobrevida específica libre de enfermedad según la extensión de la disección ganglionar en pacientes intervenidos con intención curativa por cáncer de colon. Pacientes y Métodos: Entre enero de 2001 y diciembre de 2006 se realizaron 189 cirugías programadas por cáncer de colon con intención curativa en el Sector de Coloproctología del Hospital Santojanni. 141 pacientes conforman el grupo que se analiza en este trabajo. En todos los casos un miembro del Equipo de Coloproctología participó como cirujano o asistente. Las piezas quirúrgicas fueron analizadas por el mismo anatomopatólogo junto a su equipo. La evolución postoperatoria alejada de los pacientes incluidos en el estudio se determinó por consulta personal y/o telefónica. Los datos fueron recolectados en fichas específicas diseñadas para la finalidad del trabajo. Resultados: El promedio de ganglios aislados por pieza fue de 9,7 con un rango de 0-25. La sobrevida libre de enfermedad de los pacientes en estadío I/II con resecciones con 12 ó más ganglios aislados en la pieza demostró ser significativamente superior al grupo con menos de 12 (p = 0,005). La sobrevida libre de enfermedad de los pacientes en estadío III con 1-3 ganglios comprometidos fue significativamente mayor que el grupo con 4 o más (p = 0,047). Conclusiones: Una mayor extensión de disección nodal se relacionaría con un incremento en la sobrevida específica por enfermedad en pacientes intervenidos por cáncer de colon estadío I/II.

Objective: To determine the impact of nodal margin on the specific free disease survival of patients operated of colon cancer with curative intentions. Patients and Methods: From January 2001 to December 2006, 189 patients were surgically treated of colon cancer in our institution. 141 patients were included in our study. In all the cases a colorectal surgeon of our staff participates in the procedure. The surgical specimens were analyzed by the same pathologist in all the cases. Long term outcome of the patients was assessed by personal interview or phone interview. The data was recorded in a specific form designed for the study. Results: The average of lymph nodes harvested by specimen was 9, 7 (range: 0-25). Specific free disease survival in patients' stage I/II with more than 12 nodes harvested was statistically superior respect the same group with less than 12 nodes (p = 0,005). Specific free disease survival in patients stage III with 3 or less positive lymph no des was statistically superior respect the same group with 4 o more positive lymph nodes (p = 0,047). Conclusions: A major nodal margin extension is associated with an improvement in the specific disease free survival in patients operated of colon cancer in stage I/II.

Routine ganglionic plexi ablation during Maze procedure improves hospital and early follow-up results of mitral surgery.

OBJECTIVE: Ganglionic plexi are claimed to be potentially responsible for atrial fibrillation. We evaluated whether ganglionic plexi isolation improves the results of the Maze procedure during mitral valve surgery. METHODS: A total of 75 patients with atrial fibrillation underwent radiofrequency ablation during mitral valve surgery without (group A) or with (group B) ganglionic plexi ablation with bipolar radiofrequency plus fat pad resection along the Waterston groove, left pulmonary veins, and Marshall's ligament. Ganglionic plexi were intraoperatively mapped, and fat pad specimens were sectioned and analyzed. Hospital and follow-up results were recorded. Amiodarone was discontinued at the sixth month. RESULTS: Active ganglionic plexi were mainly located in the upper parts of fat pads. Active specimens demonstrated more ganglionic plexi than inactive specimens (P

Anatomic approach for ganglionic plexi ablation in patients with paroxysmal atrial fibrillation.

There is evidence that parasympathetic denervation may prevent atrial fibrillation (AF) recurrences. This study aimed at applying an anatomic approach for ablation of atrial ganglionic plexi (GPs) in patients with paroxysmal AF. Nineteen patients with symptomatic, paroxysmal AF underwent anatomically guided radiofrequency ablation at the location of the 4 main left atrial GPs and were prospectively assessed for recurrence of AF or other atrial arrhythmia. This group was compared with 19 age- and gender-matched patients who previously underwent conventional circumferential pulmonary vein ablation. All ablation procedures were uneventful. Circumferential and GP ablations were accomplished with a radiofrequency delivery time of 28 +/- 5 versus 18 +/- 3 min (p <0.001) and a fluoroscopy time of 31 +/- 5 versus 18 +/- 5 min (p <0.001), respectively. Parasympathetic reflexes during radiofrequency ablation were elicited in 4 patients (21%). Arrhythmia recurred in 7 patients (37%) with circumferential ablation and 14 patients (74%) with GP ablation, during 1-year follow-up (p for log-rank test = 0.017). In 2 patients with GP ablation, left atrial flutters were documented in addition to AF during follow-up. Patients who underwent GP ablation had an almost 2.5 times higher risk of AF recurrence compared with those who underwent circumferential ablation (hazard ratio 2.6, 95% confidence interval 1.0 to 6.6, p = 0.038). In conclusion, anatomically guided GP ablation is feasible and safe in the electrophysiology laboratory, but this approach yields inferior clinical results compared with circumferential ablation.