Gastric barotrauma induced by the Sellick maneuver performed to enable endoscopic submucosal dissection.

A 55-year-old male underwent endoscopic submucosal dissection (ESD), under general anesthesia and orotracheal intubation, of a 22 mm Paris 0-IIa+0-IIb lesion located in the greater curvature of the medium/distal antrum. It was not possible to start the procedure after several attempts due to permanent belching and inability to maintain adequate gastric distension. ESD was only feasible after performing the Sellick maneuver (manual pressure application at the cricoid cartilage to occlude the upper esophagus), which allowed sustained gastric distension throughout the procedure (60 minutes).

Neuromuscular Blockade Monitoring: Having It but Knowing When Not to Trust It.

Butyrylcholinesterase (BChE) is an enzyme involved in the degradation of depolarizing and non-depolarizing neuromuscular blocking agents (NMBA), such as succinylcholine and mivacurium, respectively. Its deficiency is inherited or acquired, and results in paralysis of skeletal muscles after NMBA administration. We report a case of a 32-year-old pregnant woman proposed for cesarean section. General anesthesia (GA) was induced using propofol and succinylcholine. The surgical procedure was uneventful but after 40 minutes, there was no reversal of neuromuscular block (NMB). Other differential diagnoses were excluded and a deficit of BChe was assumed. When the train-of-four ratio (TOFr) achieved 40%, neostigmine/atropine led to the slow recovery of NMB up to TOFr 88%. The patient was extubated, but ventilation proved ineffective, so GA was induced and the patient was reintubated. A new measurement found a TOFr of 60%. Sedation and ventilatory support were maintained until the complete reversal of NMB (4 hours after succinylcholine). Prolonged block is a rare but serious complication of the use of succinylcholine in patients with BChE deficiency. This report not only highlights the importance of intraoperative NMB monitoring in homozygotic patients for atypical cholinesterase but also raises awareness for its careful interpretation.

MR arthrography of the shoulder using an anterior approach: optimal injection site.

OBJECTIVE: The purpose of our study was to optimize anterior MR arthrography of the shoulder by comparing three injection sites. MATERIALS AND METHODS: Seventy-eight patients were divided into three groups of 26 each, according to the injection site selected: the upper third of the medial part of the humeral head, the lower third of the medial part of the humeral head, or the area between the middle and lower thirds of the glenohumeral joint. A marker plate with radiopaque coordinates was used in performing the technique. Radiologist time and exposure time were recorded, and the intensity of the patient's pain was measured using a Visual Analogue Scale (VAS). Groups were compared using variance analysis and the least significant difference method. RESULTS: Shoulder arthrography was considered satisfactory for all three injection sites. Mean exposure time was 20.9 +/- 7.8 (SD) milliseconds, and mean radiologist time was 6.4 +/- 0.8 minutes. Mean pain intensity registered by the VAS was 1.7 +/- 0.9, the lowest values tending to be those recorded by patients who received an injection in the upper third. Exposure and radiologist times were lower for these latter patients; differences between the upper third and the other two areas were statistically significant (p < 0.005). CONCLUSION: The optimal injection site for anterior MR arthrography of the shoulder is the upper third of the humeral head, a simple, rapid procedure that is well tolerated by patients and reduces the radiation dose administered.

Natural killer receptors on CD8 T cells and natural killer cells from different HLA-C phenotypes in melanoma patients.

PURPOSE: Because immune mechanisms involved in cutaneous melanoma have not been fully elucidated, efforts have been made to achieve prognosis markers and potential targets for immune therapies, but they have not been entirely fruitful thus far. Therefore, the goal of this study was to investigate the involvement of early changes in CD8 T cells and CD56 natural killer (NK) cells expressing NK receptors in different HLA-C dimorphism groups of melanoma patients. EXPERIMENTAL DESIGN: CD8 T cells and CD56 NK cells were analyzed in 41 patients and 39 sex- and age-matched controls with different HLA-C genotypes by flow cytometry. HLA-C dimorphism at position 80 was tested by PCR sequence-specific primers and PCR sequence-specific oligonucleotide to examine whether it could mediate in the emergence of cells expressing killer cell immunoglobulin-like receptors. RESULTS: Thirty-five of 41 patients had benign sentinel node, and showed an imbalance in the absolute number of CD8(+)DR(+) or CD8(+)CD161(+) peripheral blood T cells according to the CD28 coexpression compared with controls. CD8(+)CD28(-)CD158a(+) T and CD56(+)CD158a(+) NK cells were significantly increased in HLA-C(Lys80) homozygous nonmetastatic patients, whereas only CD56(+)CD158a(+) NK cells increased in heterozygous ones. An up-regulation of the CD158a KIR receptor was also seen on NK cells but not in T cells of patients at advanced disease stages. CONCLUSIONS: This work provides, for the first time, evidence of immune activation in early stages of cutaneous melanoma, together with an increase of cells expressing CD158a in patients bearing the corresponding HLA-C ligand, which may be important to evaluate the disease progression and to use individualized immune therapeutic approaches.

Changes in the number of CD80(+), CD86(+), and CD28(+) peripheral blood lymphocytes have prognostic value in melanoma patients.

Our aim was to evaluate whether the number of circulating lymphocytes expressing costimulatory molecules can be associated with melanoma prognosis. We determined the concentration of peripheral blood lymphocytes, which expressed the CD80/CD86 or CD28/CTLA-4 molecules, in 38 patients with cutaneous melanoma and 27 controls. The number of each cell subset was compared between patients and controls, as well as between groups of patients stratified according to Breslow thickness of the primary tumor (< or = 2 mm vs > 2 mm) or to survival after 3 years. The concentration of circulating lymphocytes expressing the CD80/CD86 molecules was not significantly different between patients and controls. There was a lower number of CD3(+)CD8(+)CD28(+) cells, as well as a higher CD3(+)CD8(+)/CD3(+)CD8(+)CD28(+) cell ratio, in melanoma patients than in controls. Melanoma patients with thinner tumors and those surviving revealed an increase of CD19(+)CD80(+) and CD19(+)CD80(+)CD86(+) cells, as well as a higher concentration of CD3(+)CD4(+)CD28(+) cells. CD80(+) B cells and a low CD8 suppressor/cytolytic cell ratio correlate with a good prognosis in melanoma. Our findings support our conclusion that CD80(+) B cells may be important antigen presenting cells that can contribute to an antimelanoma immune response and are candidates to be monitored in melanoma patients.

Reproducibility of sonographic measurements of the median nerve.

OBJECTIVE: The purpose of this study was to evaluate the reproducibility of median nerve cross-sectional area (CSA) measurements using the indirect method (ellipsoid formula) and the direct or tracing method. METHODS: The median nerve CSA was measured in 22 wrists of patients with carpal tunnel syndrome by means of high-frequency sonography. Measurements were made at the level of the pisiform bone by a standardized sonographic examination protocol. Two observers with different levels of experience performed the measurements, independently and blinded. An analysis of reliability was carried out, and the concordance between the methods was determined with parametric statistical tests. RESULTS: The results point to good reproducibility of the median nerve CSA measurements obtained by both methods, whether performed by an experienced observer or by an inexperienced observer after a short learning period. CONCLUSIONS: The results suggest sonography for median nerve CSA measurements is reproducible by either the direct or indirect method when a standardized sonographic examination protocol is used.