A technique for re-utilizing catheter insertion sites in children with difficult central venous access.

Maintenance of central venous access in patients with chronic medical conditions such as short bowel syndrome demands forethought and ingenuity. We describe an innovative technique for re-utilizing central venous access sites in patients who have chronic central venous access needs. Records of patients undergoing this technique were reviewed between August 2012 and December 2015. The technique involves "cutting-down" to the sterile fibrous tunnel that naturally forms around tunneled catheters. The fibrous sheath is then isolated and controlled much as would be done for a venous "cut-down." A separate exit site is then created for the new catheter and it is tunneled to the "cut-down" site per routine. The non-functioning catheter is then removed from the surgical field. The proximal fibrous sheath is finally cannulated either directly with the new catheter or with a wire/dilator system. This technique effectively re-uses the same venous access point while allowing for a complete change of the physical line and external site. Twenty attempts at this technique were made in twelve patients; six patients underwent the site re-utilization procedure multiple times. Re-using the fibrous tunnel to re-cycle the internal catheter site was successful in seventeen of twenty attempts. All patients had chronic conditions leading to difficult long-term central venous access [short bowel syndrome (6), hemophilia (2), cystic fibrosis (1), chronic need for central IV access (3)]. Indications for catheter replacement included catheter occlusion/mechanical failure/breakage (9), dislodgement (6), infection (1), and inadequate catheter length due to patient growth (4). Broviac/Hickman catheter sites were most commonly re-used (13; one failure); re-using a portcath site was successful in 5 of 7 attempts. There were no short term infections or mechanical complications. We describe a novel technique for salvaging tunneled central venous catheter access sites. This technique is well suited for patients with difficult and long-term central venous access needs, particularly those with chronic conditions such as intestinal failure. It is specifically useful when tunneled lines are broken, precipitated or clotted and unamenable to wiring.

Three concurrent variations of the aberrant right subclavian artery, the non-recurrent laryngeal nerve and the right thoracic duct.

We herein report a case showing three anatomical variations including the aberrant right subclavian artery (ARSA), the non-recurrent laryngeal nerve (NRLN) and the right thoracic duct in a 59-year-old male cadaver. The right subclavian artery (RSA) arose from the descending aorta next to the left subclavian artery and coursed in between the oesophagus and the thoracic vertebrae. The recurrent laryngeal nerve did not coil around the RSA but directly entered the larynx. Lastly the thoracic duct terminated into the right brachiocephalic vein. This study makes an embryological assumption that the abnormal development of the RSA had happened first and subsequently caused NRLN and the thoracic duct drainage variation. As to our knowledge, only two reports have been made previously concerning such concurrent variations. Therefore, this case report alerts anatomists and clinicians to the possibility of simultaneous occurrence of ARSA, NRLN and the right thoracic duct.

Effects of hydrocortisone and yohimbine on selective attention to emotional cues.

INTRODUCTION: Facial expressions contain important affective information, and selective attention to facial expression provides an advantage in the face of loss, stress and danger. In addition, the sympathetic nervous system and hypothalamus-pituitary-adrenal axis mediate the organism's response to loss and danger. Here, we aimed at investigating the influence of sympathetic nervous system and hypothalamus-pituitary-adrenal axis activation on selective attention to affective facial stimuli. METHODS AND MATERIALS: One hundred-and-four healthy men between 18-35 years old (mean (standard deviation) age: 24.1 (3.5) years) participated in the study. We used a randomised, double-blind, placebo-controlled design. Participants received either: (a) yohimbine, (b) hydrocortisone, (c) yohimbine and hydrocortisone or (d) placebo only and participated in a dot-probe task with sad, happy and neutral faces. We collected salivary samples to measure cortisol and alpha amylase activity in addition to measurements of blood pressure and heart rate. Salivary cortisol served as correlate of hypothalamus-pituitary-adrenal axis activation and salivary alpha amylase activity, blood pressure and heart rate as correlates of sympathetic nervous system activation. Measurements were carried out before and after drug administration. RESULTS: We did not find a main effect or interaction effect of hydrocortisone or yohimbine administration on selective attention to happy faces. However, we found an interaction of yohimbine and hydrocortisone on selective attention to sad faces. Post-hoc t-test revealed an attentional bias away from sad stimuli and towards neutral faces in the hydrocortisone-only group. DISCUSSION: Only hydrocortisone administration led to an attentional bias away from sad faces. Future studies should investigate these effects in major depression disorder, as this disorder is characterised by glucocorticoid resistance and increased processing of sad stimuli.

Mirror, mirror on the wall: the face of HIV + women in Europe today.

Sexual and reproductive health (SRH) and rights are important components of quality of life. This cross-sectional study describes HIV-positive women's SRH aspirations and needs and the predictive value of selected SRH factors on condom use with steady sexual partners. Data were collected in a European multi-centre study in 17 HIV centres in 14 European countries by a standardised anonymous self-administered questionnaire. Descriptive statistics and hierarchical regression analysis were carried out and qualitative data from related formative research illustrated the findings. Among 387 HIV-positive women, 57% had children and 35% had become pregnant since their HIV-diagnosis. Contraceptive needs were largely unmet: 14% had undergone a pregnancy termination. About 83% changed their sexual behaviour after HIV-diagnosis in some ways. Sixty-two percent had at least one sexual encounter with a steady partner during the past six months and 51% used condoms consistently. Significant correlations with condom use were identified for childbearing since HIV-diagnosis (r=-0.21, p<0.01), miscarriage since HIV-diagnosis (r=-0.24, p<0.01), the use of contraception (r=0.47, p<0.001) and changes in sexual behaviour after HIV-diagnosis (r=0.20, p<0.01). Hierarchical regression analysis controlled for education, migration background, age, undetectable viral load and partners' serostatus. The following significant predictors for condom use were established: the use of contraceptives (beta=0.33, p<0.001); miscarriage since HIV-diagnosis (beta=-0.16, p<0.01); childbearing since HIV-diagnosis (beta=-0.12, p<0.05); and having an HIV-positive partner (beta=-0.13, p<0.05). For study population, consistent condom use performed a challenge. Selected SRH-issues predicted condom use. Sexual risk reduction and positive prevention should be discussed in the context of family planning and integrate SRH perspectives in routine HIV care.

Measurements of turbulence in the venus atmosphere deduced from pioneer venus multiprobe radio scintillations.

The 2.3-gigahertz log-amplitude fluctuations observed in the radio links of the Pioneer Venus entry probes during Venus encounter have been used to study turbulence in the Venus atmosphere. The deduced estimates of the upper bound of structure constant c(n) of the refractive index fluctuations (c(n) less, similar 4 x 10(-8) cm(-(1/3))) are inconsistent with similar entry probe measurements by Veneras 4 to 8 but are consistent with the radio occultation measurements by flyby (Mariners 5 and 10) and orbiting (Venerat 9) spacecraft. The Pioneer Venus measurements therefore provide a resolution of the long-standing order of magnitude discrepancy between these earlier measurements of c(n).

The polar ionosphere of venus near the terminator from early pioneer venus orbiter radio occultations.

Fourteen profiles of electron density in the ionosphere of Venus were obtainecd by the dual-frequency radio occulation method with the Pioneer Venus orbiter between 5 and 30 December 1978. The solar zenith angles for these measurements were between about 85 degrees and 92 degrees , and the latitudes ranged from about 81 degrees to 88 degrees (ecliptic north). In addition to the expected decreasein peak electron density from about 1.5 x 10(3) to 0.5 x 10(3) per cubic centimeter with increasing solar zenith angle, a region of almost constant electron density above about 250 kilometers was observed. The ionopause height varies from about 300 to 700 kilometers and seems to be influenced by diurnal changes in solar wind conditions. The structures of the profiles are consistent with models in which O(2)(+) dominates near the ionization peak and is replaced by O(+) at higher altitudes.

Laparoscopic resection of type 1 choledochal cysts in pediatric patients.

BACKGROUND: Choledochal cyst resection and hepaticojejunostomy have historically been performed using an open technique. We describe here the largest single experience with this procedure using laparoscopic techniques in eight consecutive pediatric patients. METHODS: There were six girls and two boys, of ages ranging from 3 months to 13 years. All had type I choledochal cysts. Three were asymptomatic, having been noted on prenatal ultrasonography. Five ports were utilized: one 5-mm telescope port at the umbilicus, two 3-mm operating ports on both sides of the umbilicus, one 5-mm left subcostal port for liver retraction, and one LLQ 5-mm assistant port. RESULTS: The median operating time was 155 min (range 110-250 min), with one conversion to an open procedure due to a high transection of the cyst leading to partial retraction of the left hepatic duct into the liver substance. Mean hospital stay was 3 days. At a mean follow-up of 18.8 months, all patients were anicteric and asymptomatic. CONCLUSIONS: Laparoscopic resection of choledochal cysts can be performed safely in pediatric patients with minimal morbidity and good long-term results.

Adolescent mice show anxiety- and aggressive-like behavior and the reduction of long-term potentiation in mossy fiber-CA3 synapses after neonatal maternal separation.

Exposure to maternal separation (MS) during early life is an identified risk factor for emotional disorders such as anxiety and depression later in life. This study investigated the effects of neonatal MS on the behavior and long-term potentiation (LTP) as well as basic synaptic transmission at hippocampal CA3-CA1 and mossy fiber (MF)-CA3 synapses in adolescent mice for 19days. When mice were adolescents, we measured depression, learning, memory, anxious and aggressive behavior using the forced swimming test (FST), Y-maze, Morris water maze (MWM), elevated plus maze (EPM), three consecutive days of the open field test, the social interaction test, the tube-dominance test and the resident-intruder test. The results showed that there was no difference in FST, Y-maze, and MWM performance. However, MS mice showed more anxiety-like behavior in the EPM test and aggressive-like behavior in the tube-dominance and resident-intruder tests. In addition, the magnitude of LTP and release probability in the MF-CA3 synapses was reduced in the MS group but not in the CA3-CA1 synapse. Our results indicate that early life stress due to MS may induce anxiety- and aggressive-like behavior during adolescence, and these effects are associated with synaptic plasticity at the hippocampal MF-CA3 synapses.

Neuregulin-1 attenuates cognitive function impairments in a transgenic mouse model of Alzheimer's disease.

The neuregulin (NRG) family of epidermal growth factor-related proteins is composed of a wide variety of soluble and membrane-bound proteins that exert their effects via the tyrosine kinase receptors ErbB2-ErbB4. In the nervous system, the functions of NRG1 are essential for peripheral myelination, the establishment and maintenance of neuromuscular and sensorimotor systems and the plasticity of cortical neuronal circuits. In the present study, we report that an intracerebroventricular infusion of NRG1 attenuated cognitive impairments in 13-month-old Tg2576 mice, an animal model of Alzheimer's disease (AD). In addition, according to Golgi-Cox staining, NRG1 rescued the reduction in the number of dendritic spines detected in the brains of Tg2576 mice compared with vehicle (PBS)-infused mice. This result was also corroborated in vitro as NRG1 attenuated the oligomeric amyloid beta peptide(1-42) (Aß(1-42))-induced decrease in dendritic spine density in rat primary hippocampal neuron cultures. NRG1 also alleviated the decrease in neural differentiation induced by oligomeric Aß(1-42) in mouse fetal neural stem cells. Collectively, these results suggest that NRG1 has a therapeutic potential for AD by alleviating the reductions in dendritic spine density and neurogenesis found in AD brains.

Normal responses of rats with transplanted neonatal islets to stress, epinephrine, and cortisol.

Sympathetic responses were evaluated in rats transplanted with neonatal pancreatic tissue. Transplantation was by one of two methods: mild collagenase digestion with subsequent intraportal injection, or direct placement of intact pancreatic tissue under the renal capsule. Compared with control intact animals, both groups of transplanted rats reverted to normal fasting and postglucose load plasma glucose and insulin. The hyperglycemia characteristic of stress or of injected exogenous epinephrine was present and similar in all three groups. The response to an intragastric glucose load or to tolbutamide injection during stress was similar in transplanted and in control animals. All three groups of rats responded to sustained cortisol injection with a compensatory hyperinsulinemia but maintained normal plasma glucose, water intake, and urine volume. No evidence could be detected in this study of an exaggerated "denervated" response of the transplanted islets. The normal sympathetic responses of these neonatal islet preparations in which little or no collagenase was used, in comparison with the abnormal responses previously reported for collagenase-treated individually isolated adult rat islets, suggest differences in recuperative powers of the sympathetic innervation in islets, possibly related to age and to method of preparation of transplanted tissue.

Monodeiodination of triiodothyronine and reverse triiodothyronine during low and high calorie diets.

The impact of varying caloric intake on peripheral monodeiodination and plasma disposal of T3, rT3, and the three diiodothyronines (T2) was studied in five normal subjects while they were consuming a low calorie diet (1200 Cal/day) and again while receiving a high calorie diet (3600 Cal/day). Toward the end of each diet period 240 nmol 3,3'-T2 (126 micrograms) and 80 nmol 3',5'-T2 (42 micrograms) were infused for 7 h, and a bolus injection of 137 nmol 3,5-T2 (72 micrograms) was followed by a 12-h infusion of 69 nmol 3,5-T2 (36 micrograms) and 111 nmol rT3 (72 micrograms) on another day. [125I]T3 (30 muCi) was injected on the third day. The T2 and rT3 concentrations were measured by RIA during the 2 days of infusion, and the serum disappearance of [125I]T3 was studied by immunoprecipitation and trichloroacetic acid precipitation of the labeled T3. Four to 5% of the plasma disposal of T3 was accounted for by 3'-monodeiodination, and 36-39% by 5-monodeiodination. Increasing caloric intake resulted in a higher overall plasma disposal rate of T3, but no change in the percentage of T3 metabolized by monodeiodination pathways. In contrast, 5'-monodeiodination accounted for 21% of the total plasma disposal of rT3 during the low calorie diet and 45% during the high calorie intake. This increase in 5'-monodeiodination of rT3 was at the expense of alternative pathways of disposal. A marked increase in the plasma clearance rate of 3,5-T2 was also found during the high calorie diet, indicating that the level of caloric intake affects pathways of metabolism other than outer ring monodeiodination. These studies emphasize the important role played by diet in the regulation of peripheral thyroid hormone metabolism through modulating outer ring monodeiodination, and that overnutrition changes other pathways of iodothyronine metabolism as well.

Extracellular pressure stimulates colon cancer cell proliferation via a mechanism requiring PKC and tyrosine kinase signals.

UNLABELLED: Pressure in colonic tumours may increase during constipation, obstruction or peri-operatively. Pressure enhances colonocyte adhesion by a c-Src- and actin-cytoskeleton-dependent PKC-independent pathway. We hypothesized that pressure activates mitogenic signals. METHODS: Malignant colonocytes on a collagen I matrix were subjected to 15 mmHg pressure. ERK, p38, c-Src and Akt phosphorylation and PKCalpha redistribution were assessed by western blot after 30 min and PKC activation by ELISA. Cells were counted after 24 h and after inhibition of each signal, tyrosine phosphorylation or actin depolymerization. RESULTS: Pressure time-dependently increased SW620 and HCT-116 cell counts on collagen or fibronectin (P < 0.01). Pressure increased the SW620 S-phase fraction from 28 +/- 1 to 47 +/- 1% (P = 0.0002). Pressure activated p38, ERK, and c-Src (P < 0.05 each) but not Akt/PKB. Pressure decreased cytosolic PKC activity, and translocated PKCalpha to a membrane fraction. Blockade of p38, ERK, c-Src or PI-3-K or actin depolymerization did not inhibit pressure-stimulated proliferation. However, global tyrosine kinase blockade (genistein) and PKC blockade (calphostin C) negated pressure-induced proliferation. CONCLUSIONS: Extracellular pressure stimulates cell proliferation and activates several signals. However, the mitogenic effect of pressure requires only tyrosine kinase and PKCalpha activation. Pressure may modulate colon cancer growth and implantation by two distinct pathways, one stimulating proliferation and the other promoting adhesion.

Effect of exercise on food intake in human subjects.

We review human studies of the effect of physical activity on food intake. Most are flawed by inaccurate measurement of energy expenditure and/or energy intake, by lack of controls, or by short study periods. While lean persons seem to regulate and maintain weight well, studies in obese subjects are inconclusive. At realistic exercise intensities, the effect on weight is generally small. There is little evidence of inhibition of food intake. In our metabolic ward studies, treadmill exercise neither enhanced nor inhibited food intake in obese individuals. Since intake remained fixed, a negative energy balance was observed with exercise. When more savory food was provided, intake again remained fixed as exercise was increased, but subjects ate more throughout and maintained positive energy balance. Thus, energy output does not regulate energy intake closely in the obese. Food-related cues seem more important than exercise-generated signals. The beneficial effect of exercise on body weight is limited to the extra calories expended. Further careful studies are essential to differentiate effects of kinds and intensities of exercise.

Effect of exercise on spontaneous calorie intake in obesity.

The effect of increased physical activity on energy intake and balance was investigated in six obese women (mean 167% above ideal body weight) voluntarily hospitalized for metabolic balance studies. Three 19-day treatments-one sedentary and two with treadmill exercise which increased daily expenditure to 110% (mild) and 125% (moderate) of sedentary expenditure-were imposed on each subject. Individual daily expenditure and ad libitum intake were determined by activity diaries and covert monitoring, respectively. Subjects selected and did not not change an intake level which allowed for energy balance during the sedentary period only. Therefore, the difference between intake and expenditure between treatments was significantly different (sedentary 11, mild -114, and moderate -369 kcal/day). The negative balance observed with mild and moderate exercise was obtained because while expenditure was raised with exercise, no compensatory increase in intake occurred. Moderate, realistic levels of activity did not regulate intake.

Voluntary food intake during prolonged exercise in obese women.

The effect of 57 days of moderate physical activity on the energy intake and balance of three obese women (187% of ideal weight) was investigated in a metabolic balance study. Food was offered in extra quantity, prepared in a palatable but simple fashion, and intake was covertly monitored. Expenditure was measured using the factorial method and indirect calorimetry done every 3 to 4 days. After a 5-day evaluation phase which no exercise was done, individual treadmill assignments were given to subjects to increase daily expenditure to 125% of sedentary levels. Mean dialy intake (1903 kcal/day) and expenditure (2882 kcal/day) did not change with time. As a result, negative energy balance was obtained and sustained. A consistent rate of weight loss (0.12 kg/day) at a reasonable cost (8200 kcal/kg)occurred. Therefore, obese women doing long-term moderate exercise do not compensate by an increase in caloric intake. This can produce a negative caloric balance when exercise is coupled with ad libitum selection of ordinary foods.

Mobilization of triglyceride but not cholesterol or tocopherol from human adipocytes during weight reduction.

Adipocyte triglyceride, cholesterol, and tocopherol contents were examined in three human obese subjects, all over 150% of ideal weight, who were placed on weight reduction formula diets for 11, 21, and 25 wk, respectively. Body weight decreased from 77 to 63 kg, 188 to 147 kg, and 147 to 99 kg, respectively. All subjects had normal serum cholesterol and triglyceride levels, and these did not vary greatly during weight reduction. Subcutaneous fat was obtained at frequent intervals by needle aspiration from the buttocks before and during weight reduction. Adipocyte size was measured by osmium tetroxide fixation technique, tissue cholesterol content by GLC, tissue triglyceride content by lipid extraction, and tissue tocopherol by thin-layer chromatography. Initial adipocyte size was 0.54, 1.06, and 0.96 micrograms of lipid per cell, respectively (normal 0.60), and the mean cell size decrease during weight reduction was 40%, all due to triglyceride mobilization. Adipocyte cholesterol and tocopherol content did not change significantly during weight reduction. These data are consistent with the concepts that triglycerides but not cholesterol or tocopherol are mobilized from the fat cell during up to 6 months of weight reduction and that independent mechanisms control the efflux of these adipocyte constituents.

Effect of increased physical activity on voluntary intake in lean women.

To determine the effect of exercise-related factors on food intake, five nonobese women (mean +/- SEM of the percent of desirable body weight, 97 +/- 5) were hospitalized as part of a metabolic experiment. Excess amounts of a mixed food diet were provided on platters to the subjects. They served themselves from these and ate freely. Intake was estimated covertly by weighing the platters before and after serving. Expenditure was monitored with daily activity diaries and indirect calorimetry determinations of all the activities recorded. After a five-day evaluation phase, each subject underwent three 19-day treatment periods in which physical activity was modified. Total daily expenditure was increased to 114 +/- 4% of the sedentary treatment for a mild exercise period and 129 +/- 3% for a moderate period. Corresponding voluntary intakes during exercise were 117 +/- 5% and 122 +/- 6% of sedentary treatment. Although moderate exercise (mean 772 +/- 40 kcal/d) was greater than mild (378 +/- 63 kcal/d), the increased intake levels of the two were comparable. However, the resulting energy balances of 10 +/- 71 kcal/d for sedentary, 64 +/- 43 kcal/d for mild and -116 +/- 92 kcal/d for moderate treatments were not different. Therefore, in a paradigm which permits maintenance of a voluntary balanced energy state during an inactive period, compensatory intake responses to exercise occur. Unlike obese women who do not match their intakes to energy expended as physical activity, nonobese women demonstrate hyperphagic responses.

Biliary clonorchiasis.

Parasitic infection of the biliary tree may be seen more frequently because of changing patterns in travel, and may come to the attention of the surgeon when obstruction or secondary bacterial infection occurs. In this case, intraoperative cholangiography indicated common duct abnormalities, and choledochotomy led to the diagnosis of Clonorchis sinensis. A recommendation is made to follow up patients with bilary parasite infections to determine the long-term sequelae.

Pain control for the urologist.

Pain states can be divided into three categories: acute, chronic not resulting from malignancy, and chronic malignant pain. A Pain Clinic can provide in-depth evaluation and treatment of difficult pain problems. A variety of oral and parenteral medications, ranging from nonsteroidal analgesics to narcotics, are available to control pain. Local anesthetics can be used for local infiltration, and peripheral and central nerve blocks can also be used as indications warrant.

Characterization of antidepressant-like effects of p-synephrine stereoisomers.

We previously reported that p-synephrine has antidepressant-like activity in the murine models of forced swimming and tail suspension. In the present study, we characterized antidepressant-like effects of p-synephrine stereoisomers in both in vivo and in vitro systems. In the tail suspension test, S-(+)-p-synephrine (3 mg/kg, p.o.) reduced the duration of immobility, while R-(-)-p-synephrine (0.3-3 mg/kg, p.o.) had no effect. S-(+)-p-synephrine (0.3, 1 and 3 mg/kg, p.o.) and R-(-)-p-synephrine (1 mg/ kg and 3 mg/kg, p.o.) significantly reversed the reserpine (2.5 mg/kg, i.p.)-induced hypothermia. S-(+)-p-synephrine was more effective than R-(-)-p-synephrine in inhibition of both [3H]noradrenaline uptake in rat cerebral cortical slices (maximal inhibition 85.7 +/- 7.8% vs. 59.8 +/- 4.3%; EC50 5.8 +/- 0.7 microM vs. 13.5 +/- 1.2 microM) and [3H]nisoxetine binding (Ki 4.5 +/- 0.5 microM vs. 8.2 +/- 0.7 microM). In contrast, R-(-)-p-synephrine was more effective than S-(+)-p-synephrine in stimulation of [3H]noradrenaline release from rat cerebral cortical slices (maximal stimulation 23.9 +/- 1.8% vs. 20.1 +/- 1.7%; EC50 8.2 +/- 0.6 microM vs. EC50 12.3 +/- 0.9 microM). The stimulatory effect of R-(-)-p-synephrine on [3H]noradrenaline release was inhibited by nisoxetine (100 nM), but tetrodotoxin (1 microM) and elimination of extracellular calcium had no effect. It is suggested that S-(+)-p-synephrine has more effective antidepressant-like activity than R-(-)-p-synephrine.