983 resultados para Catheter ablation
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Abstract : The female reproductive hormones estrogen, progesterone and prolactin control postnatal breast development and are important to breast carcinogenesis. The mechanisms by which they elicit proliferation and morphogenesis remain poorly understood. Using the mouse as a model to study the molecular mechanisms through which hormones elicit morphogenetic changes in the mammary gland in vivo, we found the Receptor Activator of NFκB Ligand, a Tumor Necrosis Factor family member, to be strongly induced by progesterone. Recent publications suggested that hormone dependant RANKURANK signals are involved in the terminal differentiation of mammary gland alveolar buds into lobulo-alveolar structures competent for lactation. I show that in the absence of epithelial RANKL a distinct earlier stage of mammary gland development, side branch formation, is blocked. RANKL acts as a major mediator downstream of progesterone; it is required for progesterone-induced paracrine proliferation and completely rescues the mutant phenotype when ectopically expressed in progesterone receptor (PR) KO mammary epithelia. RANKL is not required for cell autonomous division of estrogen receptor alpha (ERa) /PR positive cells. Cyclin D1, previously implicated as a mediator of RANKL, is not affected by ablation of RANKL and is not required for RANKL-induced paracrine proliferation but for the cell autonomous proliferation. Gene expression arrays to find specific RANKL downstream targets have identified Id4, ElfS and one secreted metalloprotease (Adamtsl8) as potential candidates validated by Q-RT-PCR. Interestingly, Id4 and Adamtsl8 are expressed by the myoepithelial cells. Their expression additionally coincides with RANKL mRNA expression at mid pregnancy, possibly implying a functional contribution of both genes to RANKL mediated sidebranch formation. ElfS in contrast, is found to be strongly expressed by the end of pregnancy supporting recent findings of a prolactin mediated regulation. As for RANKL, this gene was in particular induced in luminal cells. Taken together, I report that progesterone is the major proliferative stimulus in the adult mammary gland eliciting proliferation of ERaJPR positive cells by a cell autonomous, cyclin D1-dependent and a paracrine RANKL-dependent mechanism. My work moreover suggests, that RANKL acts as a major orchestrator affecting different downstream mediators, through which progesterone exerts its effects concomitantly on different cellular compartments. Résumé : Les hormones sexuelles telles que l'oestrogène, la progestérone et la prolactine contrôlent le développement postnatal du sein et sont impliquées dans la cazcinogenèse. Les mécanismes par lesquels elles induisent la prolifération et la morphogénèse demeurent incompris. En utilisant la souris comme modèle, J'ai trouvé que le ligand activateur du récepteur de NFκB, une protéine de la famille du facteur de nécrose des tumeurs, peut être fortement induit par la progestérone. Les publications récentes ont suggéré que cette protéine est nécessaire à la fin de la grossesse, quand les cellules sécrétrices du lait apparaissent. Par des techniques de transplantation d'épithélium, je montre contrairement aux études précédentes, qu'en l'absence de RANKL dans l'épithélium une partie distincte du développement mammaire, la formation de branches latérales, est bloquée. La progestérone agit de manière pazacrine par l'intermédiaire de 12ANKL pour induire la prolifération tandis que la mort cellulaire n'est pas affectée. De plus, l'injection d'une protéine recombinante RANKL dans une souris mutante pour le récepteur à la progestérone induit la prolifération des cellules épithéliales en l'absence de grossesse ; la surexpression de RANKL dans ces mêmes mutants mène à une réversion complète du phénotype. Mes expériences démontrent que la progestérone induit deux types distincts de prolifération. Un premier type direct dans laquelle les cellules positives au récepteur à la progestérone prolifèrent. Cette division cellulaire est alors indépendante de RANKL mais dépendante de la cycline D1. Le second type de prolifération est induit par un mécanisme pazacrine et dépend de RANKL mais pas de la cycline D1. Ici, les cellules négatives au récepteur à la progestérone prolifèrent. Pour détecter des gènes cibles de la voie de signalisation du RANKL, un profil d'expression des gènes a été généré. Les facteurs de transcription Id4, EIf5 et une métalloprotéase sécrétée (Adamtsl8) ont été identifiés en tant que cibles potentielles. D'autres analyses de validation démontrent qu'Id4, Adamtsl8, RANKL mais pas E1f5 sont fortement exprimés au cours de la grossesse, coïncidant avec la formation de branchements latéraux induit par progestérone. EIf5 s'est avéré être exprimé vers la fin de la grossesse appuyant des résultats récents proposant une régulation par la prolactine. Le système canalaire mammaire se compose de couches cellulaires: une couche interne de cellules luminales et une externe de cellules myoépithéliale. Les expériences génétiques d'expression ont révélé que RANKL. et E1f5 sont exprimés dans la partie luminale tandis qu'Id4 et Adamtsl8 sont dans les cellules myoépithéliales. En conclusion, je prouve que la progestérone est le stimulus principal induisant la prolifération dans la glande mammaire d'adulte. Deux mécanismes de prolifération sont impliqués: l'un direct dépendant de la cycline Dl et l'autre paracrine dépendant de RANKI.. Mon travail suggère par ailleurs que RANKL agit en tant que médiateur important, par lequel la progestérone exerce ses effets sur différents compartiments cellulaires tels que la coordination de la prolifération des cellules épithéliales avec la réorganisation de la matrice extracellulaire et de la membrane basale exigées pour la morphogénèse du système canalaire latéral.
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Although the precise signaling mechanisms underlying the vulnerability of some sub-populations of motoneurons in ALS remain unclear, critical factors such as metallo-proteinase 9 expression, neuronal activity and endoplasmic reticulum stress have been shown to be involved. In the context of SOD1(G93A) ALS mouse model, we previously showed that a two-fold decrease in calreticulin (CRT) is occurring in the vulnerable fast motoneurons. Here, we asked to which extent the decrease in CRT levels was causative to muscle denervation and/or motoneuron degeneration. Toward this goal, a hemizygous deletion of the crt gene in SOD1(G93A) mice was generated since the complete ablation of crt is embryonic lethal. We observed that SOD1(G93A);crt(+/-) mice display increased and earlier muscle weakness and muscle denervation compared to SOD1(G93A) mice. While CRT reduction in motoneurons leads to a strong upregulation of two factors important in motoneuron dysfunction, ER stress and mTOR activation, it does not aggravate motoneuron death. Our results underline a prevalent role for CRT levels in the early phase of muscle denervation and support CRT regulation as a potential therapeutic approach.
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We tested the hypothesis that hyperoxemia defined as arterial PO2 above 12 kPa can be detected by pulse oximetry using 95% oxygen saturation as the upper limit. Thirty artificially ventilated neonates with an indwelling arterial catheter were studied registrating transcutaneous oxygen saturation (Ohmeda Biox 3700 Pulse Oximeter) and transcutaneous PO2 continuously during a 4-hour period and measuring arterial oxygen saturation and PO2 intermittently. 46 episodes of arterial hyperoxemia were observed. Pulse oximetry had a sensitivity of 30%, detecting 14 of these 46 hyperoxemic episodes, and a specificity of 93%. The accuracy for separating hyperoxemia from normoxemia by pulse oximetry could be improved by shifting the cut-off point from 95% to 92%. With this optimal cut-off point sensitivity was 70% and specificity 62%. We conclude that pulse oximetry is not reliable for detection of hyperoxemia.
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PURPOSE OF REVIEW: This article reviews and summarizes current knowledge on kidney-sparing surgery (KSS) for upper tract urothelial carcinoma (UTUC). RECENT FINDINGS: Radical nephroureterectomy (RNU) has been central to the treatment of UTUC for decades, but KSS has been applied to a rising number of patients to preserve renal function. Ablation or resection through flexible ureteroscopy or the percutaneous route seems to provide comparable cancer-specific survival and overall survival to RNU, but the risk of local and bladder recurrence remains relatively high. Segmental ureterectomy is used for low-risk unifocal UTUC with recent studies confirming its oncologic safety and equivalence to RNU. Antegrade or retrograde instillation therapy may be considered as adjuvant treatment after conservative surgery, but their efficacy needs to be proven. Intravesical single-dose chemotherapy is likely to become part of the therapy algorithm of UTUC treated by KSS or RNU to lower bladder seeding and recurrence. Postoperative vigilant radiographic and endoscopic surveillance are obligatory because of the high probability of recurrence. SUMMARY: KSS should be regarded as a valid alternative to RNU in case of technically resectable low-risk upper tract urothelial cell carcinoma, even in case of a normal contralateral kidney. Advances in technology and biological and clinical risk estimation will make the management of UTUC more evidence based thereby lowering overtreatment.
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OBJECTIVES: Long occlusions in calcified crural arteries are a major cause of endovascular technical failure in patients with critical limb ischaemia. Therefore, distal bypasses are mainly performed in patients with heavily calcified arteries and with consequently delicate clamping. A new reverse thermosensitive polymer (RTP) is an alternative option to occlude target vessels. The aim of the study is to report our technical experience with RTP and to assess its safety and efficiency to temporarily occlude small calcified arteries during anastomosis time. METHODS: Between July 2010 and December 2011, we used RTP to occlude crural arteries in 20 consecutive patients with 20 venous distal bypasses. We recorded several operative parameters, such as volume of injected RTP, duration of occlusion and anastomotic time. Quality of occlusion was subjectively evaluated. Routine on-table angiography was performed to search for plug emboli. Primary patency, limb salvage and survival rates were reported at 6 months. RESULTS: In all patients, crural artery occlusion was achieved with the RTP without the use of an adjunct occlusion device. Mean volume of RTP used was 0.3 ml proximally and 0.25 ml distally. Mean duration of occlusion was 14.4 ± 4.5 min, while completion of the distal anastomosis lasted 13.4 ± 4.3 min. Quality of occlusion was judged as excellent in eight cases and good in 12 cases. Residual plugs were observed in two patients and removed with an embolectomy catheter, before we amended the technique for dissolution of RTP. At 6 months, primary patency rate was 75% but limb salvage rate was 87.5%. The 30-day mortality rate was 10%. CONCLUSIONS: This study shows that RTP is safe when properly dissolved and effective to occlude small calcified arteries for completion of distal anastomosis.
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RPE65 is a retinoid isomerase required for the production of 11-cis-retinal, the chromophore of both cone and rod visual pigments. We recently established an R91W knock-in mouse strain as homologous animal model for patients afflicted by this mutation in RPE65. These mice have impaired vision and can only synthesize minute amounts of 11-cis-retinal. Here, we investigated the consequences of this chromophore insufficiency on cone function and pathophysiology. We found that the R91W mutation caused cone opsin mislocalization and progressive geographic cone atrophy. Remnant visual function was mostly mediated by rods. Ablation of rod opsin corrected the localization of cone opsin and improved cone retinal function. Thus, our analyses indicate that under conditions of limited chromophore supply rods and cones compete for 11-cis-retinal that derives from regeneration pathway(s) which are reliant on RPE65. Due to their higher number and the instability of cone opsin, rods are privileged under this condition while cones suffer chromophore deficiency and degenerate. These findings reinforce the notion that in patients any effective gene therapy with RPE65 needs to target the cone-rich macula directly to locally restore the cones' chromophore supply outside the reach of rods.
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En Riegel v. Medtronic Inc. (552 U.S.__2008; February 20, 2008), el Sr. Riegel tuvo que ser sometido a un by-pass como consecuencia de la rotura del catéter, fabricado por Medtronic, con el que su médico le practicaba una angioplastia. A pesar de que el catéter había obtenido la autorización de comercialización de la FDA y cumplía los requisitos de seguridad previstos por el sistema regulatorio federal, el Sr. Riegel y su mujer interpusieron una acción de daños contra Medtronic –y no contra el médico- conforme a las reglas de responsabilidad civil objetiva y por negligencia del Common Law neoyorquino. Sin embargo, el Tribunal Supremo federal de los EE.UU., en ponencia del Magistrado Antonin Gregory Scalia, votó, por mayoría de ocho magistrados, rechazar el recurso de la Sra. Riegel y confirmar la sentencia de segunda instancia, desestimatoria de la demanda, porque consideró que la regla de primacía del derecho regulatorio federal sobre seguridad de productos sanitarios [Medical Device Amendments de 1976, 21 U.S.C. Artículo 360k(a)] excluye la aplicabilidad no sólo del derecho regulatorio estatal sobre seguridad de productos sanitarios, sino también del Common Law sobre responsabilidad civil del fabricante.
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The EAUN Guidelines Working Group for indwelling catheters have prepared this guideline document to help nurses assess the evidence-based management of catheter care and to incorporate the guidelines’ recommendations into their clinical practice. These guidelines are not meant to be proscriptive, nor will adherence to these guidelines guarantee a successful outcome in all cases. Ultimately, decisions regarding care must be made on a case-by-case basis by healthcare professionals after consultation with their patients using their clinical judgement, knowledge and expertise.
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Severe acute refractory respiratory failure is considered a life-threatening situation, with a high mortality of 40 to 60%. When conservative oxygenation methods fail, a lifesaving measure is the introduction of extracorporeal membrane oxygenation (ECMO). Venovenous ECMO (VV-ECMO) is a preferred modality of support for patients with refractory acute respiratory failure. Specifically, bicaval VV-ECMO is a well-recognized and validated therapy, where single or double periphery venous access is used for the insertion of two differently sized cannulas in order to achieve adequate blood oxygenation. Compared to venoarterial ECMO, in VV-ECMO, the rate of complications, such as thrombosis, bleeding, infection and ischemic events, is lower. On the other hand, the size and insertion location is an obstacle to patient mobilization. This is a considerable problem for patients where the time interval for lung recovery and the bridge to the transplantation is prolonged. To address this issue, a dual-lumen, single venovenous cannula was introduced. Here, by insertion of one single catheter in one target vessel, in a majority of cases in the right internal jugular vein, satisfactory oxygenation of the patient is achieved. In this form, the instituted VV-ECMO enables patient mobility, better physical rehabilitation and facilitates pulmonary extubation and toilet. However, relatively early, after the first short-term reports were published, a relatively high complication rate became evident. In the recent literature, the complication rate using actual commercially available double-lumen venovenous cannula ranges between 5 and 30%. These cases were mostly conjoined to the implantation phase or the early postoperative phase and vary between right heart perforation to migration of the cannula. This review focuses on complications allied to commercially available dual-lumen, single, venovenous cannula implantation, pointing out the critical segments of the implantation process and analyzing the structure of the device.
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PURPOSE: (1) To assess the outcomes of minimally invasive simple prostatectomy (MISP) for the treatment of symptomatic benign prostatic hyperplasia in men with large prostates and (2) to compare them with open simple prostatectomy (OSP). METHODS: A systematic review of outcomes of MISP for benign prostatic hyperplasia with meta-analysis was conducted. The article selection process was conducted according to the PRISMA guidelines. RESULTS: Twenty-seven observational studies with 764 patients were analyzed. The mean prostate volume was 113.5 ml (95 % CI 106-121). The mean increase in Qmax was 14.3 ml/s (95 % CI 13.1-15.6), and the mean improvement in IPSS was 17.2 (95 % CI 15.2-19.2). Mean duration of operation was 141 min (95 % CI 124-159), and the mean intraoperative blood loss was 284 ml (95 % CI 243-325). One hundred and four patients (13.6 %) developed a surgical complication. In comparative studies, length of hospital stay (WMD -1.6 days, p = 0.02), length of catheter use (WMD -1.3 days, p = 0.04) and estimated blood loss (WMD -187 ml, p = 0.015) were significantly lower in the MISP group, while the duration of operation was longer than in OSP (WMD 37.8 min, p < 0.0001). There were no differences in improvements in Qmax, IPSS and perioperative complications between both procedures. The small study sizes, publication bias, lack of systematic complication reporting and short follow-up are limitations. CONCLUSIONS: MISP seems an effective and safe treatment option. It provides similar improvements in Qmax and IPSS as OSP. Despite taking longer, it results in less blood loss and shorter hospital stay. Prospective randomized studies comparing OSP, MISP and laser enucleation are needed to define the standard surgical treatment for large prostates.
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Contexte Lié au vieillissement et à la sédentarisation de la population, ainsi qu'à la chronicisation du cancer, l'emploi de cathéters veineux centraux permanents (CVCP) n'a cessé d'augmenter. La complication majeure de ces dispositifs, induisant de forts taux de morbi-mortalité, est l'infection. Actuellement, le diagnostic de ces infections reste surtout basé sur la clinique et les hémocultures. Lorsque le doute persiste, une ablation chirurgicale suivie de la mise en culture des prélèvements chirurgicaux et du cathéter permettent de poser le diagnostic. En clinique, après ces examens, nous constatons que seule la moitié des cathéters retirés étaient réellement infectés. Alors que la tomographie par émission de positons fusionnée à la tomographie (PET/CT) a montré de bons résultats dans la détection des infections chroniques, la valeur diagnostique du PET/CT au fluorodeoxyglucose marqué au 18F (18F-FDG) pour les infections de CVCP n'a encore jamais été déterminée dans une étude prospective. Objectifs Au travers de cette étude prospective, ouverte et monocentrique, nous chercherons à connaître la valeur diagnostique du PET/CT au 18F-FDG dans la détection d'infections de CVCP et ainsi d'en déterminer son utilité. Nous essaierons aussi de déterminer la différence de valeur diagnostique du PET/CT au 18F-FDG par rapport aux méthodes conventionnelles (paramètres cliniques et culture du liquide d'aspiration), afin de se déterminer sur l'éventuelle utilité diagnostique de celui-ci. Méthodes Cadre : Etude prospective d'au moins 20 patients, avec 2 groupes contrôles d'au moins 10 patients ayant chacun respectivement une faible et une forte probabilité d'infection, soit au moins 40 patients au total. Population : patients adultes avec CVCP devant être retiré. Cette étude prévoit un examen PET/CT au 18F-FDG effectué auprès de patients nécessitant une ablation de CVCP sur suspicion d'infection, sans confirmation possible par les moyens diagnostiques non chirurgicaux. Deux acquisitions seront réalisées 45 et 70 minutes après l'injection de 5,5MBq/Kg de 18F-FDG. Le groupe contrôle à faible probabilité d'infection, sera formé de patients bénéficiant de l'ablation définitive d'un CVCP pour fin de traitement durant le laps de temps de l'étude, et ayant bénéficié au préalable d'un examen PET/CT pour raison X. Après avoir retiré chirurgicalement le CVCP, nous utiliserons la culture microbiologique des deux extrémités du CVCP comme étalon d'or (gold standard) de l'infection. Le groupe contrôle à forte probabilité d'infection sera formé de patients nécessitant une ablation de CVCP sur infection de CVCP confirmée par les moyens diagnostiques non chirurgicaux (culture positive du liquide de l'aspiration). Lors de l'examen PET/CT, ces patients auront aussi deux acquisitions réalisées 45 et 70 minutes après l'injection de 5,5MBq/Kg de 18F-FDG. Les résultats de ces examens seront évalués par deux spécialistes en médecine nucléaire qui détermineront le niveau de suspicion de l'infection sur une échelle de Likert allant de I à V, sur la base du nombre de foyers, de la localisation du foyer, de l'intensité de la captation de 18F-FDG au voisinage du cathéter et du rapport tissu/arrière-plan. Par la suite, nous retirerons chirurgicalement le CVCP. Nous utiliserons la culture microbiologique du pus (si présent), des deux extrémités du CVCP ainsi que l'histologie des tissus formant un tunnel autour du cathéter comme étalon d'or de l'infection. Les résultats seront analysés à l'aide de courbes ROC (Receiver Operating Characteristic) afin de déterminer la valeur diagnostique du PET/CT dans l'infection de CVCP. Les résultats des examens des patients avec suspicion clinique d'infection seront ensuite analysés séparément, afin de déterminer la différence de valeur diagnostique du PET/CT au 18F-FDG par rapport aux méthodes conventionnelles. Résultats escomptés Ce projet veut chercher à savoir si le PET/CT au 18F-FDG peut être un moyen diagnostique valide dans les infections de CVCP, s'avérer utile lorsque les autres moyens diagnostiques sont non conclusifs. Plus-value escomptée Actuellement, lors d'incertitude sur le diagnostic d'infection de CVCP, une opération chirurgicale est effectuée à titre préventif afin d'enlever le cathéter en cause, cependant seulement la moitié de ces cathéters sont réellement infectés en pratique. Le PET/CT au 18F-FDG, grâce à sa sensibilité élevée et probablement une bonne valeur prédictive négative, pourrait éviter à une partie des patients un retrait inutile du cathéter, diminuant ainsi les risques chirurgicaux et les coûts liés à de telles opérations, tout en préservant le capital d'accès vasculaire futur.
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A network of twenty stakes was set up on Johnsons Glacier in order to determine its dynamics. During the austral summers from 1994-95 to 1997-98, we estimated surface velocities, mass balances and ice thickness variations. Horizontal velocity increased dow nstream from 1 m a- 1 near the ice divides to 40 m a- 1 near the ice terminus. The accumulation zone showed low accumulation rates (maximum of 0,6 m a- 1 (ice)), whereas in the lower part of the glacier, ablation rates were 4,3 m a- 1 (ice). Over the 3-year study period, both in the accumulation and ablation zones, we detected a reduction in the ice surface level ranging from 2 to 10 m from the annual ve rt ical velocities and ice-thinning data, the mass balance was obtained and compared with the mass balance field values, resulting in similar estimates. Flux values were calculated using cross-section data and horizontal velocities, and compared with the results obtained by means of mass balance and ice thinning data using the continuity equation. The two methods gave similar results.
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PURPOSE: Implanted venous access devices (IVADs) are often used in patients who require long-term intravenous drug administration. The most common causes of device dysfunction include occlusion by fibrin sheath and/or catheter adherence to the vessel wall. We present percutaneous endovascular salvage techniques to restore function in occluded catheters. The aim of this study was to evaluate the feasibility, safety, and efficacy of these techniques. METHODS AND MATERIALS: Through a femoral or brachial venous access, a snare is used to remove fibrin sheath around the IVAD catheter tip. If device dysfunction is caused by catheter adherences to the vessel wall, a new "mechanical adhesiolysis" maneuver was performed. IVAD salvage procedures performed between 2005 and 2013 were analyzed. Data included clinical background, catheter tip position, success rate, recurrence, and rate of complication. RESULTS: Eighty-eight salvage procedures were performed in 80 patients, mostly women (52.5 %), with a mean age of 54 years. Only a minority (17.5 %) of evaluated catheters were located at an optimal position (i.e., cavoatrial junction ±1 cm). Mechanical adhesiolysis or other additional maneuvers were used in 21 cases (24 %). Overall technical success rate was 93.2 %. Malposition and/or vessel wall adherences were the main cause of technical failure. No complications were noted. CONCLUSION: These IVAD salvage techniques are safe and efficient. When a catheter is adherent to the vessel wall, mechanical adhesiolysis maneuvers allow catheter mobilization and a greater success rate with no additional risk. In patients who still require long-term use of their IVAD, these procedures can be performed safely to avoid catheter replacement.
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Guidepost cells present at and surrounding the midline provide guidance cues that orient the growing axons through commissures. Here we show that the transcription factor Nkx2.1 known to control the specification of GABAergic interneurons also regulates the differentiation of astroglia and polydendrocytes within the mouse anterior commissure (AC). Nkx2.1-positive glia were found to originate from three germinal regions of the ventral telencephalon. Nkx2.1-derived glia were observed in and around the AC region by E14.5. Thereafter, a selective cell ablation strategy showed a synergistic role of Nkx2.1-derived cells, both GABAergic interneurons and astroglia, towards the proper formation of the AC. Finally, our results reveal that the Nkx2.1-regulated cells mediate AC axon guidance through the expression of the repellent cue, Slit2. These results bring forth interesting insights about the spatial and temporal origin of midline telencephalic glia, and highlight the importance of neurons and astroglia towards the formation of midline commissures.
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We present tunneling experiments on Fe~001!/MgO~20 Å!/FeCo~001! single-crystal epitaxial junctions of high quality grown by sputtering and laser ablation. Tunnel magnetoresistance measurements give 60% at 30 K, to be compared with 13% obtained recently on ~001!-oriented Fe/amorphous-Al2O3 /FeCo tunnel junctions. This difference demonstrates that the spin polarization of tunneling electrons is not directly related to the density of states of the free metal surface Fe~001! in this case but depends on the actual electronic structure of the entire electrode/barrier system.