Controlled contrast transcranial Doppler and arterial blood gas analysis to quantify shunt through patent foramen ovale.

BACKGROUND AND PURPOSE: A right-to-left shunt can be identified by contrast transcranial Doppler ultrasonography (c-TCD) at rest and/or after a Valsalva maneuver (VM) or by arterial blood gas (ABG) measurement. We assessed the influence of controlled strain pressures and durations during VM on the right-to-left passage of microbubbles, on which depends the shunt classification by c-TCD, and correlated it with the right-to-left shunt evaluation by ABG measurements in stroke patients with patent foramen ovale (PFO). METHODS: We evaluated 40 stroke patients with transesophageal echocardiography-documented PFO. The microbubbles were recorded with TCD at rest and after 4 different VM conditions with controlled duration and target strain pressures (duration in seconds and pressure in cm H2O, respectively): V5-20, V10-20, V5-40, and V10-40. The ABG analysis was performed after pure oxygen breathing in 34 patients, and the shunt was calculated as percentage of cardiac output. RESULTS: Among all VM conditions, V5-40 and V10-40 yielded the greatest median number of microbubbles (84 and 95, respectively; P<0.01). A significantly larger number of microbubbles were detected in V5-40 than in V5-20 (P<0.001) and in V10-40 than in V10-20 (P<0.01). ABG was not sensitive enough to detect a shunt in 31 patients. CONCLUSIONS: The increase of VM expiratory pressure magnifies the number of microbubbles irrespective of the strain duration. Because the right-to-left shunt classification in PFO is based on the number of microbubbles, a controlled VM pressure is advised for a reproducible shunt assessment. The ABG measurement is not sensitive enough for shunt assessment in stroke patients with PFO.

Zinc-α2-Glycoprotein Modulates AKT-Dependent Insulin Signaling in Human Adipocytes by Activation of the PP2A Phosphatase.

OBJECTIVE Evidence from mouse models suggests that zinc-α2-glycoprotein (ZAG) is a novel anti-obesity adipokine. In humans, however, data are controversial and its physiological role in adipose tissue (AT) remains unknown. Here we explored the molecular mechanisms by which ZAG regulates carbohydrate metabolism in human adipocytes. METHODS ZAG action on glucose uptake and insulin action was analyzed. β1 and β2-adrenoreceptor (AR) antagonists and siRNA targeting PP2A phosphatase were used to examine the mechanisms by which ZAG modulates insulin sensitivity. Plasma levels of ZAG were measured in a lean patient cohort stratified for HOMA-IR. RESULTS ZAG treatment increased basal glucose uptake, correlating with an increase in GLUT expression, but induced insulin resistance in adipocytes. Pretreatment of adipocytes with propranolol and a specific β1-AR antagonist demonstrated that ZAG effects on basal glucose uptake and GLUT4 expression are mediated via β1-AR, whereas inhibition of insulin action is dependent on β2-AR activation. ZAG treatment correlated with an increase in PP2A activity. Silencing of the PP2A catalytic subunit abrogated the negative effect of ZAG on insulin-stimulated AKT phosphorylation and glucose uptake but not on GLUT4 expression and basal glucose uptake. ZAG circulating levels were unchanged in a lean patient cohort stratified for HOMA-IR. Neither glucose nor insulin was associated with plasma ZAG. CONCLUSIONS ZAG inhibits insulin-induced glucose uptake in human adipocytes by impairing insulin signaling at the level of AKT in a β2-AR- and PP2A-dependent manner.

Impaired adipose tissue expandability and lipogenic capacities as ones of the main causes of metabolic disorders.

Obesity is considered a major health problem. However, mechanisms involved and its comorbidities are not elucidated. Recent theories concerning the causes of obesity have focused on a limit to the functional capacity of adipose tissue, comparing it with other vital organs. This assumption has been the central point of interest in our laboratory. We proposed that the failure of adipose tissue is initiated by the difficulty of this tissue to increase its cellularity due to excess in fat contribution, owing to genetic or environmental factors. Nevertheless, why the adipose tissue reduces its capacity to make new adipocytes via mesenchymal cells of the stroma has not yet been elucidated. Thus, we suggest that this tissue ceases fulfilling its main function, the storage of excess fat, thereby affecting some of the key factors involved in lipogenesis, some of which are reviewed in this paper (PPARγ, ROR1, FASN, SCD1, Rab18, BrCa1, ZAG, and FABP4). On the other hand, mechanisms involved in adipose tissue expandability are also impaired, predominating hypertrophy via an increase in apoptosis and a decrease in adipogenesis and angiogenesis. However, adipose tissue failure is only part of this great orchestra, only a chapter of this nightmare.

The "Squeeze and Wheeze" Sign: A Useful Clinical Sign in Lung Sounds Analysis of Children With Acute Cough.

Cough is a very frequent symptom in children. Different reviews have tried to delineate the best approach to pediatric cough.1 Clinical evaluation remains the most important diagnostic initial step. Although the relations between cough and asthma are not straightforward,2 wheeze should be considered as a physical sign of increased resistance to air flow. Lung function testing is the gold standard for analyzing pulmonary resistance to air flow but has a limited practical value in young children. The clinical evaluation of the presence or absence of wheeze thus remains a primary clinical step in coughing children. Young children do not necessarily breathe deeply in and out when asked to. For years, the author has used a so-called "squeeze and wheeze" maneuver (SWM, see Methods section for definition) to elicit chest signs in young children. The basic idea is to increase expiratory flows in children who do not cooperate adequately during their lung sounds analysis. This study was realized to communicate the author's experience of a yet unreported physical sign and to study its prevalence in young children cared for in a general pediatrics practice.

Surface swimming behavior of the curculionid Ochetina uniformis Pascoe (Erirhininae, Stenopelmini) and Ludovix fasciatus (Gyllenhal) (Curculioninae, Erodiscini)

The swimming behavior exhibited by specimens of L. fasciatus and O. uniformis was analyzed frame-by-frame with video observation recorded with a digital camera, attached to a stereomicroscope. Adults of O. uniformis, an aquatic insect, swim with all three pairs of legs. During the process of swimming the majority of the abdomen and rostrum remain submerged, part of the fore and hind tibiae remain above the surface, while the mid tibiae remain submerged. The mesothoracic legs, during the power-stroke stage, provide the greatest thrust while the metathoracic legs provide the least forward propulsion. The prothoracic legs, extended forward, help to direct the swimming. The semi-aquatic specie L. fasciatus shows the same swimming style as O. uniformis, that is, with movement of all the three pairs of legs; the mesothoracic legs are responsible for the main propulsion. The insect body remains on the water surface during the process of swimming, while the legs remain submerged. Both species complete a swimming cycle in 0.33 and 0.32 seconds, respectively, with an average speed of 1.38 cm/s and a maximum and minimum swimming duration time of 11.15 and 5.05 minutes, respectively, for L. fasciatus. The swimming behavior exhibited by O. uniformis and L. fasciatus corresponds to the style known as a breast strokelike maneuver. This is the first record of this kind of swimming for both species here observed and increases to seven the number of genera of Curculionidae exhibiting this behavior.

Cape Verde - Diagnostic Trade Inttegration study Update - 2013

This Report is an update of the Cape Verde Diagnostic Trade Integration Study, titled Cape Verde’s Insertion into the Global Economy, produced and validated by the Government of Cape Verde in December 2008. Like the previous 2008 study, this Cape Verde Diagnostic Trade Integration Study Update provides a critical examination of the major institutional and production constraints that hinder Cape Verde’s ability to capitalize fully on the growth and welfare gains from its integration into the world economy. As a policy report, this study offers a set of priority policies and measures that can be implemented by both the public and private sectors to mitigate and surmount these supply side and institutional constraints. These recommendations are summarized in an Action Matrix. The Report is fruit of the generous support of the multi-donor program the Enhanced Integrated Framework (EIF). In every crisis there is an opportunity. Four years after the validation of the country’s first Diagnostic Trade Integration Study in 2008, Cape Verde finds itself in a drastically altered external environment. Cape Verde faces a worsened external environment than four years ago, when it was also traversing years of crisis as global food and energy prices escalated. Just as the country was validating its first trade study in late 2008, and celebrating its graduation from the list of Least Developed Countries, the onset of the deepest global recession in recent memory triggered an even worse external situation as the country’s principal source of markets, investments, remittances and aid, the Eurozone, unraveled economically and politically. As the Eurozone crisis spread, it was Cape Verde’s misfortune that the crisis contaminated precisely its biggest Eurozone partners and donors, such as Portugal, Spain and Italy. For such a highly dependent and exposed economy like that of Cape Verde, the deteriorating external sector has had a substantial negative impact on its macroeconomic performance. At the time of the validation workshop and graduation in 2008, no one could have foreseen or predicted the severity of the global crisis that followed. Despite traversing these years of adversity and external shocks, and suffering palpable setbacks, Cape Verde’s economy had proven surprisingly resilient, especially its principal sector, tourism. To its great credit, the country’s economic fundamentals are solid, and have been carefully and prudently managed over the years. For this reason alone, the country has thus far weathered the global and Eurozone crisis. Yet the near and medium term future remains uncertain. The country’s margin for maneuver has narrowed, its options far more limited, and hard choices lie ahead. Thus, there is no better time than now to analyze Cape Verde’s position in the global economy, and to examine the many challenges and opportunities it faces. The first diagnostic trade study outlined an ambitious agenda and set of policy strategies to enhance Cape Verde’s participation in the global economy. Written prior to the global crisis, the study did not, and could not, anticipate the scope and depth of the subsequent global and Eurozone crises. A few short months before the validation of the first DTIS Cape Verde joined the World Trade Organization (WTO). It has spent these four years adjusting to this status and implementing its commitments. At the same time, the country seeks greater economic integration with the European Union. Since 2008 the government has been investing heavily in the country’s economic infrastructure, focusing especially on fostering transformation in key sectors like agriculture, fisheries, tourism and creative industries. For these and many other reasons, it is both timely and urgent to review the road traveled since 2008. It is an opportune moment to reassess the country’s options, to rethink strategies, and to chart a new way forward that it is practical, implementable, and that builds on the country’s competitive advantages and current successes.

Protecting the Public,Iowa Office of Citizens’ Aide/Ombudsman, January 2010

The Ombudsman helps citizens understand and maneuver through the often complicated depths and layers of government. In many cases, assistants facilitate citizen dialogue with an agency, explain the reasons for laws or policies, recommend revisions to unfair policies or unreasonable decisions, and resolve disputes informally. In some cases, the Ombudsman will pursue more formal investigations, take sworn testimony, and issue public reports. Here, in this periodic newsletter, you’ll find a small sampling of the ombudsman’s work over the previous two months. If you need help resolving a problem with state or local government, please see our contact information at the bottom of the page.

The sheeping technique or how to avoid exchange maneuvers.

INTRODUCTION: The arteries of bifurcation aneurysms are sometimes so angulated or tortuous that an exchange maneuver is necessary to catheterize them with a balloon or stent delivery catheter. Because of the risk of distal wire perforation associated with exchange maneuvers, we sought to find an alternative technique. METHODS: Our experience shows that a microcatheter tends to preferentially follow a previously placed microcatheter, even if the initial catheterization might be challenging. Accessing an artery with two microcatheters simultaneously may thus be an alternative to an exchange maneuver. Because of this tendency for catheters to behave like sheep following one another, we named this method the sheeping technique (ST). The ST consists of (a) first placing a 1.7 French microcatheter into the division branch requiring balloon or stent protection to straighten the course of the arteries in order to facilitate and (b) positioning in the same artery of a larger and stiffer balloon or stent microcatheter. Once the second balloon or stent microcatheter is in place, the first microcatheter can be pulled back and used to coil the aneurysm. RESULTS: Between January 2009 and December 2012, The ST was successfully used in 208/246 procedures (85 %). Conversion to an exchange maneuver was necessary in 38/246 (15 %). There were no arterial perforations or ischemic events related to the handling of both microcatheters. CONCLUSION: The sheeping technique may improve safety by replacing the need for an exchange maneuver during difficult balloon- or stent-assisted coiling.

Neurophysiological changes during shortening osteotomies of the spine.

BACKGROUND CONTEXT: Kyphotic deformities with sagittal imbalance of the spine can be treated with spinal osteotomies. Those procedures are known to have a high incidence of neurological complications, in particular at the thoracic level. Motor evoked potentials (MEPs) have been widely used in helping to avoid major neurological deficits postoperatively. Previous reports have shown that a significant proportion of such cases present with important transcranial MEP (Tc-MEP) changes during surgery with some of them being predictive of postoperative deficits. PURPOSE: Our aim was to study Tc-MEP changes in a consecutive series of patients and correlate them with clinical parameters and radiological changes. STUDY DESIGN/SETTING: Retrospective case notes study from a prospective patient register. PATIENT SAMPLE: Eighteen patients undergoing posterior shortening osteotomies (nine at thoracic and nine at lumbar levels) for kyphosis of congenital, degenerative, inflammatory, or post-traumatic origin were included. OUTCOME MEASURES: Loss of at least 80% of Tc-MEP signal expressed as the area under the curve percentual change, of at least one muscle. METHODS: We studied the relation between outcome measure (80% Tc-MEP loss in at least one muscle group) and amount of posterior vertebral body shortening as well as angular correction measured on computed tomography scans, occurrence of postoperative deficits, intraoperative blood pressure at the time of the osteotomy, and hemoglobin (Hb) change. RESULTS: All patients showed significant Tc-MEP changes. In particular, greater than 80% MEP loss in at least one muscle group was observed in five of nine patients in the thoracic group and four of nine patients in the lumbar group. No surgical maneuver was undertaken as a result of this loss in an effort to improve motor responses other than verifying the stability of the construct and the extent of the decompression. Four patients developed postoperative deficits of radicular origin, three of them recovering fully at 3 months. No relation was found between intraoperative blood pressure, Hb changes, and Tc-MEP changes. Severity of Tc-MEP loss did not correlate with postoperative deficits. Shortening of more than 10 mm was linked to more severe Tc-MEP changes in the thoracic group. CONCLUSIONS: Transcranial MEP changes during spinal shortening procedures are common and do not appear to predict severe postoperative deficits. Total loss of Tc-MEP (not witnessed in our series) might require a more drastic approach with possible reversal of the correction and wake-up test.

Evaluation of the SHRP Modified Georgia Digital Faultmeter, MLR-93-01, 1993

The SHRP Modified Georgia Digital Faultmeter was loaned to the Iowa Department of Transportation in January 1993 for evaluation. A study was undertaken comparing the faultmeter to Iowa's current method of fault measurement. The following conclusions were made after comparing the faultmeter to Iowa's gauge: The faultmeter was lighter and easier to maneuver and position. The faultmeter's direct readout was quicker to read. The faultmeter has increased precision. The faultmeter gave consistently lower fault readings than the Iowa gauge.

Successful bilateral lung transplantation after previous pneumonectomy

Objective: To present the feasibility of bilateral lung transplantation after previously performed pneumonectomy.Methods: A 32 years old women underwent right pneumonectomy for bronchiectasis-related destroyed lung. Eight months later, she developed a vascular post-pneumonectomy syndrome and underwent realigning of the mediastinum by an intrathoracic expander that was complicated by an adult respiratory distress syndrome of the left lung requiring mechanical ventilation, arterio-venous CO2 removal (Novalung) and finally bilateral lung transplantation. Via clamshell incision, the post-pneumonectomy cavity was dissected and the superior vena cava (SVC) and carina were exposed. The pulmonary vessel stumps were dissected intrapericardically after realization of a right-sided hemi-pericardectomy. Extracorporeal circulation was started after central cannulation of the aorta and the inferior vena cava. A right upper lobe sleeve resection of the donor lung was performed. The intermediate bronchus was then implanted in the dissected recipient carina after realization of a hilar release maneuver. The right pulmonary artery was clamped between SVC andthe ascending aorta followed by end -to-end anastomosis of the donor and recipient artery and left atrial cuffs, respectively. Satisfactory graft function allowed decanulation and standard transplantation of the left lung without extracorporeal circulation.Results: Bronchoscopy and trans-esophageal echocardiography demonstrated a patent airway and vascular anastomoses without stenosis. Follow-up revealed excellent gas exchanges, no airway complications and well-functioning grafts on both sides with right-sided ventilation and perfusion two months after transplantation of 37% and 22%, respectively.Conclusion: This is to our knowledge the first report of successful bilateral lung transplantation after previous pneumonectomy unrelated to transplantation.

Application of ultrasound in bone surgery: two case reports

The present study describes some of the applications of ultrasound in bone surgery, based on the presentation of two clinical cases. The Piezosurgery® ultrasound device was used (Tecnología Mectron Medical, Carasco, Italy). In one case the instrument was used to harvest a chin bone graft for placement in a bone defect at level 1.2, while in the other case a bony window osteotomy was made in the external wall of the maxillary sinus, in the context of a sinus membrane lift procedure. The Piezosurgery® device produces specific ultrasound frequency modulation (25-29 kHz), and has been designed to secure increased precision in application to bone surgery. This instrument produces selective sectioning of the mineralized bone structures, and causes less intra- and postoperative bleeding. One of the advantages of the Piezosurgery® device is that it can be used for maxillary sinus lift procedures in dental implant placement. In this context it considerably lessens the risk of sinus mucosa laceration by preparing the bony window in the external wall of the upper maxilla, and can be used to complete the lifting maneuver. The use of ultrasound in application to hard tissues can be regarded as a slow technique compared with the conventional rotary instruments, since it requires special surgical skill and involves a certain learning curve.

The Effect of the No-Passing Zone Sign on "Passing" Accidents, 1963

The No Passing Zone sign (Wl0-4) was designed in 1958 for the purpose of informing the driver contemplating a passing maneuver of hazardous sight conditions ahead. This warning sign, of pennent shape design, was placed on the left side of the road so as to be more conspicuous to the intended driver. During the two year period 1959-1960, the Wl0-4 signs were erected throughout the Iowa Primary Road System.

Iowa Study of No Passing Zone Signing, 1962

This report is compiled from data gathered by interviewing motorists to sample their opinion of Iowa's method of supplementing the yellow barrier line pavement marking of no passing zones on primary highways with yellow pennant shaped "No Passing Zone" signs mounted on the left shoulder of the highway. The effective designation of no passing zones is one form of control that can contribute to a reduction in the number of fatal high-speed head-on collisions resulting from passing in areas which do not afford sufficient sight distance of approaching traffic. It is the purpose of this report to present an evaluation of the Iowa "No Passing Zone" sign by individuals from all states who have traveled on Iowa's primary highways and who must obey the no passing zone restrictions and be warned by this sign of the presence of the zones. The "No Passing Zone" sign was formulated and approved by the Governor's Safety Committee a short time prior to the experimental erection of the signs. The Governor's Safety Committee adopted this sign as they felt that such a sign should be distinctive (not similar to any other type of sign) and easily visible to a driver attempting a passing maneuver.

Initial experience with hybrid surgery in congenital heart disease in a single center : P171

Introduction: A hybrid intervention is a joint procedure involving the interventional cardiologist and the cardiac surgeon. At our institution we have opted for this type of approach in congenital heart disease since 2005. We report here our initial experience. Cases: 1. A 3 year old boy with double aortic arch and multiple muscular ventricular septal defects (VSD),was readdressed for pulmonary band (PAB) removal and residual VSD closure after previous palliation. After surgical removal of the PAB, the surgeon provided a minimal transventricular access for placement of a 6mm Amplatzer® muscular VSD occluder by the cardiologist under transoesophageal guidance. The patient was extubated the same day and discharged after 5 days. 2. An 8 year old girl with Williams syndrome was followed for two large VSDs and severe peripheral pulmonary arteries (PA) stenosis. The membranous VSD was closed surgically, the muscular VSD during the same operation by direct placement of a 12 mm Amplatzer® muscular VSD occluder. During rewarming, balloon angioplasty of peripheral PA stenosis was achieved under fluoroscopy. Patient was extubated the following day and discharged after 8 days. 3. A 9 year old boy post tetralogy of Fallot repair had severe distal stenosis of the right ventricular to PA conduit.With patient on partial cardiopulmonary bypass, an incision was made on the conduit and a CP 8 Zig 16 stent placed on the stenosis. The child passed on full bypass and the definitive placement of the stent achieved. The child was extubated at the end of the intervention and discharged after 6 days. 4. A newborn presented at 2 days life with complex aortic arch anatomy: left aortic arch and right descending thoracic aorta perfused directly from a right arterial duct and left PA atresia. The arterial duct was stented with a Genesis XD stent dilated at 7mm. Two days later the cardiac surgeon made banded the right PA. The child was extubated after the operation and discharged a week later. Conclusion: Hybrid approach opens new ways of correction or palliation in congenital heart disease with encouraging results and less morbidity.