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An increasing elderly population in the United Kingdom has led to an increasing number of older patients with head and neck cancer, resulting in a greater demand for complex head and neck reconstructive surgery in this potentially high-risk age group. A possible perceived poorer tolerance to such major treatment risks under-treating some of these patients. The purpose of this study was to assess the outcomes in the elderly population (older than 80 years) who had undergone free flap reconstruction following head and neck cancer resection. A retrospective review of 127 patients was performed. Eighteen patients were 80 or older (14.2%) and 109 under 80 (85.8%). The elderly group experienced increased number of postoperative medical complications (p=0.01), but the surgical complications were not significantly different in the two groups (p=0.4). The average length of hospital stay was significantly longer in the older group (p=0.01). There was one flap failure during the study period, which belonged to the younger group of patients. Elderly patients undergoing free flap reconstruction experience an increased rate of postoperative medical complications resulting in an increased length of hospital stay. However, good surgical outcomes can still be achieved in this age group, and therefore age alone should not be considered as a primary factor in head and neck cancer management.

Current risk assessment models for surgical site occurrence (SSO) and surgical site infection (SSI) after open ventral hernia repair (VHR) have limited external validation. Our aim was to determine (1) whether existing models stratify patients into groups by risk and (2) which model best predicts the rate of SSO and SSI.Patients who underwent open VHR and were followed for at least 1 mo were included. Using two data sets-a retrospective multicenter database (Ventral Hernia Outcomes Collaborative) and a single-center prospective database (Prospective)-each patient was assigned a predicted risk with each of the following models: Ventral Hernia Risk Score (VHRS), Ventral Hernia Working Group (VHWG), Centers for Disease Control and Prevention Wound Class, and Hernia Wound Risk Assessment Tool (HW-RAT). Patients in the Prospective database were also assigned a predicted risk from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). Areas under the receiver operating characteristic curve (area under the curve [AUC]) were compared to assess the predictive accuracy of the models for SSO and SSI. Pearson's chi-square was used to determine which models were able to risk-stratify patients into groups with significantly differing rates of actual SSO and SSI.The Ventral Hernia Outcomes Collaborative database (n = 795) had an overall SSO and SSI rate of 23% and 17%, respectively. The AUCs were low for SSO (0.56, 0.54, 0.52, and 0.60) and SSI (0.55, 0.53, 0.50, and 0.58). The VHRS (P = 0.01) and HW-RAT (P 0.01) significantly stratified patients into tiers for SSO, whereas the VHWG (P 0.05) and HW-RAT (P 0.05) stratified for SSI. In the Prospective database (n = 88), 14% and 8% developed an SSO and SSI, respectively. The AUCs were low for SSO (0.63, 0.54, 0.50, 0.57, and 0.69) and modest for SSI (0.81, 0.64, 0.55, 0.62, and 0.73). The ACS-NSQIP (P 0.01) stratified for SSO, whereas the VHRS (P 0.01) and ACS-NSQIP (P 0.05) stratified for SSI. In both databases, VHRS, VHWG, and Centers for Disease Control and Prevention overestimated risk of SSO and SSI, whereas HW-RAT and ACS-NSQIP underestimated risk for all groups.All five existing predictive models have limited ability to risk-stratify patients and accurately assess risk of SSO. However, both the VHRS and ACS-NSQIP demonstrate modest success in identifying patients at risk for SSI. Continued model refinement is needed to improve the two highest performing models (VHRS and ACS-NSQIP) along with investigation to determine whether modifications to perioperative management based on risk stratification can improve outcomes.

Olfactory neuroblastoma (ONB) is a rare malignant neoplasm of the sinonasal tract that arises from olfactory epithelium. There have been reports, mainly in tumors treated with chemoradiation or with distant metastases, describing focal histologic changes of divergent cell populations within archetypal ONB. Only three cases have been reported of ONB coexisting with non-neuroendocrine tumors. We describe our experience with a 35-year-old male with a nasal cavity mass extending into the anterior cranial fossa. Pathology revealed this to be a high grade malignant neoplasm with features of olfactory neuroblastoma and a significant divergent population of pancytokeratin and epithelial membrane antigen-reactive cells. The patient underwent combined endoscopic and open craniofacial resection followed by adjuvant chemoradiation. We describe the clinical presentation, treatment, and outcome followed by a review of the literature. Surgical pathology clearly demonstrated two cell populations evenly distributed and displaying classic histologic and immunohistochemical markers of ONB, as well as poorly differentiated cells with an epithelial immunophenotype. The patient is now 16 months status post completion of treatment with no evidence of recurrence. Our patient's presentation is unique and unusual in that the tumor demonstrated a high grade olfactory neuroblastoma and a divergent, epithelial-marker reactive cell population in the same tumor. This combined appearance is unusual and may represent an "olfactory carcinoma". Only one previous case has reported carcinomatous involvement of an ONB. There is insufficient information in the literature to draw conclusions on the impact these divergent cell populations have on prognosis or treatment.

Jellyfish can cause significant losses to the aquaculture industry. This report describes the clinical presentation and pathology caused by the mauve stinger jellyfish Pelagia noctiluca (Forsskal, 1775) in cultured Atlantic salmon Salmo salar L. in Ireland and highlights the potential consequences and need for descriptive pathology of such interactions. P. noctiluca is a member of the cnidarian class Scyphozoa (Order Semaeostomeae; Family Pelagiidae) and has worldwide distribution through the warm and temperate waters of the marine environment. This golden brown to purple jellyfish species lacks the benthic polyp stage and has a primarily pelagic habitat, although ocean currents bring it closer to coastal waters. P. noctiluca is frequently observed from the west coast of Ireland especially during the autumn months, but large aggregations are not commonly reported. In a jellyfish survey carried out around Ireland in 2009, P. noctiluca was the most abundant species found, accounting for 93% of the overall catch (total wet weight of gelatinous species) (Bastian et al. 2011). Its distribution and density were found to be heterogeneous, with great variation between regions (apparent North-South gradient in density) and sampling points (Bastian et al. 2011). When in contact with a fish farm, small jellyfish can pass through the nets, while bigger individuals tend to break up into pieces still capable of stinging the fish. In jellyfish blooms, affected fish can suffer from hypoxia, mechanical damage and toxicity via nematocysts discharge (Baxter et al. 2011a; Rodger, Henry & Mitchell 2011). In 2013, large swarms of P. noctiluca were observed intermittently in several Northern and Southern farms in the west coast of Ireland from the beginning of August to mid-November. Jellyfish presence was determined by visual observations from boat and cages and by divers during removal of mortalities. Zooplankton sampling through vertical net tows and posterior species identification was also carried out. The diagnosis of the jellyfish species involved was based on the morphological features described in detail by Russell (1970). Jellyfish appeared in the vicinity and inside cages (Fig. 1a), and associated mortalities ranged from

Salivary gland cancers are rare and represent approximately 5% of all head and neck cancers and only 0.3% of all malignancies. The majority (75%) of salivary gland tumors occur in the parotid gland, and while benign lesions are more common, mucoepidermoid carcinoma (MEC) makes up 40–50% of malignant parotid gland tumors. No randomized controlled trials exist regarding the role of adjuvant radiation for patients who undergo surgical resection of low-grade MECs. Herein, we report two cases of successful postoperative radiation therapy in low-grade, pT2N0 MEC of the parotid gland. The role of adjuvant radiation therapy for patients with MEC of the parotid gland is based on data from institution reviews and lacks data from randomized controlled trials. Per our review of the literature, the pathological findings of positive surgical margins and/or perineural invasion in two patients with low-grade MEC of the parotid gland warranted adjuvant radiation for improved local control after partial parotidectomy. Both patients tolerated postoperative radiation therapy with only mild side effects and, at last follow-up, five years after completion of therapy, had no clinical or radiographic evidence of either local recurrence or distant metastasis.

A Piscirickettsia salmonis infection was diagnosed in lumpfish (Cyclopterus lumpus L.) juveniles held in a marine research facility on the west coast of Ireland. The main clinical signs and pathology included marked ascites, severe multifocal liver necrosis and severe diffuse inflammation and necrosis of the exocrine pancreas and peri-pancreatic adipose tissue. Numerous Piscirickettsia-like organisms were observed by histopathology in the affected organs, and the bacterial species was characterized by molecular analysis. Sequencing of the partial 16S rDNA gene and internal transcribed spacer region showed the lumpfish sequences to be closely related to previously identified Atlantic salmon (Salmo salar L.) sequences from Ireland. To the authors' knowledge, this is the first detection of P. salmonis in lumpfish worldwide. The infection is considered potentially significant in terms of lumpfish health and biosecurity.

Pulmonary arterial hypertension (PAH) is a progressive disease characterized by increased pulmonary arterial resistance and vessel remodeling. Patients living with human immunodeficiency virus-1 (HIV-1) have an increased susceptibility to develop severe pulmonary hypertension (PH) irrespective of their CD4+ lymphocyte counts. While the underlying cause of HIV-PAH remains unknown, the interaction of HIV-1 proteins with the vascular endothelium may play a critical role in HIV-PAH development. Hypoxia promotes PH in experimental models and in humans, but the impact of HIV-1 proteins on hypoxia-induced pulmonary vascular dysfunction and PAH has not been examined. Therefore, we hypothesize that the presence of HIV-1 proteins and hypoxia synergistically augment the development of pulmonary vascular dysfunction and PH. We examined the effect of HIV-1 proteins on pulmonary vascular resistance by measuring pressure-volume relationships in isolated lungs from wild-type (WT) and HIV-1 Transgenic (Tg) rats. WT and HIV-1 Tg rats were exposed to 10% O2 for four weeks to induce experimental pulmonary hypertension to assess whether HIV-1 protein expression would impact the development of hypoxia-induced PH. Our results demonstrate that HIV-1 protein expression significantly increased pulmonary vascular resistance (PVR). HIV-1 Tg mice demonstrated exaggerated pulmonary vascular responses to hypoxia as evidenced by greater increases in right ventricular systolic pressures, right ventricular hypertrophy and vessel muscularization when compared to wild-type controls. This enhanced PH was associated with enhanced expression of HIF-1α and PCNA. In addition, in vitro studies reveal that medium from HIV-infected monocyte derived macrophages (MDM) potentiates hypoxia-induced pulmonary artery endothelial proliferation. These results indicate that the presence of HIV-1 proteins likely impact pulmonary vascular resistance and exacerbate hypoxia-induced PH.

Background. Obesity rates for pediatric acute lymphocytic leukemia (ALL) survivors vary from 11% to 57%. Researching dietary behaviors may identify dietary risks leading to obesity and opportunities for intervention. Objective. To evaluate the relationship between caloric and macronutrient intake on the incidence of obesity in pediatric ALL. Design/setting/participants. Retrospectively reviewed data of 142 participants was examined. Participants were grouped into categories based on body mass index (BMI) for adults and Centers for Disease Control and Prevention growth charts for children. Twenty-four-hour food recall records were reviewed to assess dietary intake. Confounding factors and caloric/macronutrient intake were compared across obesity classes. Main outcome measurements. Macronutrient levels were compared between groups. Descriptive data examined. BMI at enrollment on BONEII, age at diagnosis, ethnicity, gender, corticosteroid use, cranial radiation therapy, and standard/high risk. ALL group. Results. Thirty-nine percent of participants were overweight/obese. ALL survivors who consumed a higher percentage of their calories from protein were more likely to be underweight/normal weight while participants who consumed more calories and total carbohydrates were more likely to be overweight/obese. There was no relationship with the other factors examined. Conclusion. Dietary interventions should be designed to ensure patients consume adequate amounts of protein while limiting portion sizes and carbohydrate-based snacks.

Gill health and disease in farmed Atlantic salmon (Salmo salar) were studied at a marine site on the west coast of Ireland. Fish were sampled on a regular basis during the summer and autumn of 2009. A novel histopathological scoring system was devised to give a semi-quantitative measure of gill pathology. The index criteria for gill histopathology were lamellar hyperplasia, lamellar fusion, circular anomalies (necrosis or sloughing) and lamellar oedema, a score from 0 to 3 being assigned for each parameter. Ancillary criteria, such as hypertrophy, haemorrhage and the presence of specific pathogens, were assigned a score of 0 or 1. Environmental monitoring undertaken included zooplankton and phytoplankton sampling, as well as temperature and oxygen recordings for the site. Epitheliocystis was frequently observed at low levels but was not associated with any significant gill pathology. Clinically significant gill pathology was observed on one occasion during the sampling period, coinciding with the occurrence of Pelagia noctiluca, Muggiaea atlantica and Solmaris corona. Throughout the longitudinal study, the scoring system provided an accurate and effective means of assessing gill health, demonstrating the ability of this practical tool to be used in future studies of gill health and disease.

Objectives/Hypothesis: Monopolar cautery is the most commonly used technique for tonsillectomy. The aim of the present study is to compare postoperative pain using a new technology, PlasmaKnife tonsillectomy (PKT), in comparison with monopolar cautery tonsillectomy (MCT). Study Design: Prospective, randomized, single-blinded, self-controlled study using paired organs. Methods: Thirty-two adult patients, aged 18 to 30 years, scheduled for tonsillectomy for recurrent tonsillitis were included. Patients were randomly assigned to undergo PKT on one side and MCT on the opposite side. The primary outcome was self-rated daily pain assessed by using a 10-point scale. Patients were provided 21-day pain diaries and were phoned twice weekly by a research assistant to assess pain and remind them to complete diaries. Secondary outcomes included comparisons of operative time, blood loss, and postoperative complications. Results: Repeated measures analysis of variance comparing PKT to MCT during the 21-day postoperative period revealed no difference in postoperative pain between the two groups (P = .131). In addition, total operative time (P = .276) and blood loss (P = .418) did not differ significantly between PKT and MCT. Conclusions: Adult subjects undergoing PKT do not experience less postoperative pain in comparison to MCT.

Intracellular inclusions containing chlamydia-like organisms are frequently observed in the gill epithelial cells of Atlantic salmon, Salmo salar L., cultured in fresh water in Ireland. In this study, the causative agent was identified in four separate freshwater sites, using 16s rRNA sequencing, as 'Candidatus Clavochlamydia salmonicola'. Histopathology and real-time (RT) PCR were used to further assess infections. The prevalence of infection ranged from 75-100% between sites and infection intensity was highly variable. No significant lesions were associated with these infections. As a diagnostic tool, RT-PCR proved marginally more sensitive than histopathology. The fate of 'Candidatus Clavochlamydia salmonicola' in Atlantic salmon post-seawater transfer was investigated in a 12-week marine longitudinal study. Both RT-PCR and histopathological examination indicate that the organism disappears from the gills 4-6 weeks post-transfer.

The acute respiratory distress syndrome (ARDS) is a severe form of acute edematous lung injury characterized by noncardiogenic pulmonary edema and flooding of the alveolar airspaces with proteinaceous fluid. ARDS develops in response to inflammatory stresses including sepsis, trauma, gastric aspiration, pneumonia and massive blood transfusions (Ware and Matthay, 2000). Originally described in 1967 (Ashbaugh et al., 1967), ARDS is characterized by alveolar epithelial and endothelial barrier disruption, surfactant dysfunction, and intense inflammation that, in concert, produce profound derangements in gas exchange and severe respiratory failure. Although a great deal has been learned about the underlying pathophysiology of this syndrome in the past four decades, our treatment remains essentially supportive and despite aggressive ICU care and mechanical ventilation, the mortality rate for ARDS remains unacceptably high at 40–60% (Rubenfeld et al., 2005;Ware and Matthay, 2000). An important clue to which patients are at greater risk for developing ARDS has been uncovered in recent epidemiologic studies demonstrating a link between alcohol abuse and acute lung injury (ALI), including the landmark study in 1996 that first identified an independent connection between alcohol abuse and ARDS (Moss et al., 1996). A more recent study confirmed those initial findings and determined that in individuals with septic shock, the relative risk of ARDS in alcoholic patients versus nonalcoholic patients was 3.7:1 (Moss et al., 2003). If these findings are extrapolated to the population at large, then alcohol abuse contributes to the development of ARDS in tens of thousands of patients in the U.S. each year. Alveolar epithelial barrier dysfunction is a prominent feature of ARDS. The maintenance of a fluid-free alveolar space is critical for facilitating normal gas exchange. A pathological hallmark of ALI/ARDS is heterogeneous damage of the alveolar epithelium, with complete loss of the epithelial surface in some areas but with other alveoli relatively intact. Therefore, at a cellular level the extent of the alveolar epithelial damage may not be as widespread or as uniform as the chest radiograph might suggest, and preservation and repair of the alveolar epithelium are keys to survival. In fact, patients with impaired alveolar epithelial fluid clearance are three times more likely to die from ALI/ARDS than patients with a maximal ability to clear lung fluid (Sznajder, 2001; Ware and Matthay, 2001). However, more than 85% of patients with ALI/ARDS have at least a partial defect in lung fluid clearance (Ware and Matthay, 2001). The ability of the lung to clear fluid away from the alveolar space and into the pulmonary circulation is largely dependent on active Na+ transport by the alveolar epithelium; for review, see (Morty et al., 2007). Na+ uptake at the apical side of the alveolar epithelium is mediated by amiloride-sensitive Na+ channels (ENaC), whereas Na+ is pumped out of the epithelial cells at the basolateral side by the Na,K-ATPase. The Na,K-ATPase belongs to the family of P-type ATPases and the functional enzyme consists of α and β subunits (Lingrel et al., 1994a–c; Sweadner, 1989). Multiple isoforms of both the α and β subunits have been reported (Lingrel et al., 1994b; Therien and Blostein, 2000). The catalytic α subunit contains binding sites for ATP as well as the Na,K-ATPase inhibitor, ouabain; for review, see (Kaplan, 2002). The alveolar epithelium expresses both α1 and α2 subunits (Borok et al., 2002; Ridge et al., 1997, 2003). The β subunit regulates activity and proper membrane localization of the α subunit (Factor et al., 1998; Geering, 1991; Kaplan, 2002; Therien and Blostein, 2000; Thome et al., 2001). Chronic alcohol ingestion increases ENaC density on the apical side of alveolar epithelial cells (Guidot et al., 2000b), and acute alcohol administration (a single dose) to rats decreases Na,K-ATPase activity (Aytacoglu et al., 2006; Rodrigo et al., 2002). However, to our knowledge the effects of chronic alcohol ingestion on the expression of Na,K-ATPase in the lung has not been determined. This critical evidence is necessary to support the aforementioned explanation as to why the otherwise healthy alcoholic lung is not edematous at baseline. Therefore, in this current study we sought to determine whether or not chronic alcohol ingestion increased the expression of Na,K-ATPase within the lung.

BACKGROUND The current study was conducted to evaluate the efficacy of paclitaxel, administered weekly or once every 3 weeks, in combination with oral estramustine phosphate (EMP) in patients with recurrent or refractory aggressive non-Hodgkin lymphoma (NHL). METHODS Between February 1996 and February 2001, 23 patients with recurrent NHL were enrolled onto this Phase II trial. The median age for all patients was 65 years (range, 27–80 years). The initial 12 patients (who received a mean number of 2.4 prior treatments, including 1 patient who received a prior peripheral blood stem cell transplant) received paclitaxel at a dose of 175 mg/m2 given as a 3-hour intravenous infusion every 21 days. The next 11 patients (who received a mean number of 2.8 prior treatments, including 1 patient who received prior peripheral blood stem cell transplant) were registered (1 patient refused treatment) to receive paclitaxel at a dose of 80 mg/m2 as a 1-hour intravenous infusion weekly for 6 weeks of an 8-week cycle. All patients received EMP at a dose of 600 mg/m2 orally per day beginning the day prior to each dose of paclitaxel for a total of 3 days. RESULTS When paclitaxel was administered every 21 days, 4 partial responses were observed in 12 evaluable patients (33.3%). The median survival was 147 days. The median duration of response was 102 days (range, 42–127 days) and the median time to disease progression was 66 days. Grade 3 and Grade 4 neutropenia (according to the revised version of the Common Toxicity Criteria of the National Cancer Institute) were observed in 5 patients (42%) in this group. In an attempt to reduce the incidence of myelosuppression, paclitaxel dosing was changed to weekly dosing. In the cohort of patients receiving weekly paclitaxel, an objective response was reported to occur in 3 (1 complete response and 2 partial responses) of 11 evaluable patients (27%). The median survival was 132 days (range, 33–462 days). The median duration of response was 64 days and the median time to disease progression was 57 days. There was no significant difference noted between the cohort receiving paclitaxel three times weekly and those receiving paclitaxel weekly with regard to overall survival and time to disease progression (P = 0.7 and P = 0.8, respectively by the log-rank test). Grade 3 or 4 neutropenia was observed in only 2 of 11 patients (18%) in the weekly paclitaxel group. There were no significant differences noted in terms of thrombocytopenia, anemia, nausea, anorexia, or fatigue between the treatment groups. CONCLUSIONS Paclitaxel given once weekly or three times weekly, in combination with oral EMP, was found to have comparable efficacy in patients with recurrent NHL, with an overall response rate of 30%. The response rate was found to be higher than that reported in prior studies of paclitaxel as a single agent in the treatment of NHL, suggesting that EMP may enhance paclitaxel efficacy in patients with NHL. Hematologic toxicity was diminished when paclitaxel was administered on a weekly schedule. The minimal myelotoxicity of weekly paclitaxel makes this a potentially attractive agent for combination regimens for patients with recurrent/refractory NHL. Cancer 2004. © 2004 American Cancer Society.

Adequate muscle mass and function are critical for human health. Several types of skeletal muscle growth, including regeneration and growth after atrophy, can occur in the rehabilitative period after orthopaedic surgery. The molecular pathways regulating growth of skeletal muscle in adults are understood poorly. The role of calcineurin in regulating regeneration and growth of atrophied skeletal muscle is discussed. Understanding the molecular and cellular pathways that regulate such muscle growth may lead to the development of strategies to enhance muscle growth, thereby facilitating rehabilitation after orthopaedic surgery.

Adequate muscle mass is critical for human health. The molecular pathways regulating maintenance and growth of adult skeletal muscle are little understood. Calcineurin (CN) is implicated as a key signaling molecule in hypertrophy. Whether CN is involved in all forms of muscle growth or in different muscles is unknown. Here, we examine the role of CN in regulating maintenance of muscle size and growth of atrophied muscle in the soleus (slow) and plantaris (fast). The CN inhibitor cyclosporin A (CsA) differentially affects muscle growth and maintenance depending on muscle phenotype. The plantaris is more severely affected by CsA than the soleus in both growth conditions. One-week vs. 2-wk CsA treatment suggests that both CN-dependent and CN-independent growth occur in the atrophied soleus, whereas plantaris growth appears to be totally CN dependent. Our results suggest that CN regulates multiple types of muscle growth, depending both on muscle phenotype and stage of myofiber growth. Differential expression of components of the CN pathway occurs and may contribute to the differences between muscles.

Background The purpose of this study was to identify issues important to patients in their decision-making, expectations, and satisfaction when seeking treatment for a ventral hernia. Study Design An exploratory qualitative study was conducted of adult patients with ventral hernias seeking care at a safety-net hospital. Two semi-structured interviews were conducted with each patient: before and 6 months after surgical consultation. Interviews were audiotaped, transcribed, and coded using latent content analysis until data saturation was achieved. Results Of patients completing an initial interview (n = 30), 27 (90%) completed follow-up interviews. Half of the patients were Spanish-speaking, one-third had a previous ventral hernia repair, and two-thirds underwent initial nonoperative management after surgical consultation. Patient-described factors guiding management decisions included impact on quality of life, primarily pain and limited function; overwhelming challenges to meeting surgical criteria, primarily obesity; and assuming responsibility to avoid recurrence. Patients were uninformed regarding potential poor outcomes and contributing factors, even among patients with a previous ventral hernia repair, with most attributing recurrence to inadequate self-management. Conclusions Understanding patients' perspective is crucial to engaging them as stakeholders in their care, addressing their concerns, and improving clinical and patient-centered outcomes. Patient reports suggest how care can be improved through developing more effective strategies for addressing patients' concerns during nonoperative management, preoperative risk reduction strategies that are sensitive to their sociodemographic characteristics, treatment plans that harness patients' willingness for self-management, and patient education and decision-making tools.

Carotid endarterectomy in very elderly patients remains controversial. We report our experience with this operation on 101 very elderly patients at the Baptist Heart Institute, a community hospital in Lexington, Kentucky. Ages ranged from 80 to 93 years with an average age of 86.5 years. There are 7 nonagenarians in this study. The indications included asymptomatic severe carotid artery stenosis in 29 (29.7%) patients and symptomatic disease in 72 patients (71.3%). Sixty eight percent of the patients had significant co-morbidity that included hypertension, diabetes mellitus, lipid disorders, previous stroke, previous carotid endarterectomy, coronary artery disease and previous myocardial infarctions. Thirty two percent of the patients had no significant past medical history. Two deaths occurred during hospitalizations (1.98%). One of these patients had carotid endarterectomy in conjunction with coronary artery bypass grafting. This patient suffered a stroke. The second death occurred as the result of respiratory failure. There was 1 perioperative infarct. From this study, we conclude that carotid endarterectomy can be performed safely in very elderly patients in a community hospital.

The management of concomitant coronary and carotid disease is controversial. We report our experience of simultaneous coronary artery bypass surgery and carotid artery endarterectomy on 70 consecutive patients (34 males and 36 females) with a mean age of 68 years. The oldest patient was 91 years old. The average percent of carotid artery stenosis was 86% (range 60%–99%). The average number of grafts per patient was 3.35 (range 1–6). Two patients experienced postoperative strokes (2.86%), 1 had a perioperative infarct (1.42%), and 4 died in the hospital (5.7%). The simultaneous approach offers the advantage of shorter hospital stays, decreased anesthesia exposure, and significant cost savings. The causes of death include stroke, renal failure, and bowel infarction. This review indicates the simultaneous approach has a higher incidence of adverse outcomes compared with elective carotid endarterectomy or elective coronary artery bypass surgery. These patients, however, are at significantly higher risk due to their poor medical conditions, extensive atheromatous disease, and often emergent medical condition.

Intro Langerhans cell histiocytosis (LCH) is a rare disease involving the proliferation of histiocytes in one or more organ systems. The presentation of LCH is more common in the pediatric population and rarely occurs within the adult population. Isolated lymph node involvement is an extremely rare presentation of the disease. The authors present a case of isolated lymph node LCH in an otherwise healthy adult female and discuss management strategies for these unusual findings. Methods A case report of a patient at a tertiary care facility in June 2014 is discussed. Results/Discussion The diagnosis, clinical course, and management strategies for isolated adult LCH are discussed and reviewed. Conclusion Langerhans cell histiocytosis rarely presents with isolated lymph node involvement in adults. Management and surveillance algorithms are discussed in this unusual case of seemingly benign lymphadenopathy.

The USNS Comfort (T-AH-20) is 1 of 2 United States Navy hospital ships. In 2011, she deployed to 9 countries in Central and South America including Jamaica, Peru, Colombia, Ecuador, Nicaragua, Guatemala, El Salvador, Costa Rica, and Haiti. Eight surgical specialties including otolaryngology were involved, for a combined total of about 150 cases per country. An advance team coordinated patients with the Host Nation to be seen for presurgical screening. Selected patients were then taken aboard the ship for surgery and recovered in either the ship’s intensive care unit or ward. They were then discharged prior to ship embarkment to the next country. A total of 95 otolaryngology cases were performed during 9 mission stops. The mean number of procedures performed was 12 per country, with thyroidectomy being the most common. A wide variety of general otolaryngology procedures were performed without significant complications, markedly impacting the quality of life in these underserved countries.

Slow-twitch skeletal muscle atrophies greatly in response to unloading conditions. The cellular mechanisms that contribute to the restoration of muscle mass after atrophy are largely unknown. Here, we show that atrophy of the mouse soleus is associated with a 36% decrease in myonuclear number after 2 wk of hindlimb suspension. Myonuclear number is restored to control values during the 2-wk recovery period in which muscle mass returns to normal, suggesting that muscle precursor cells proliferate and fuse with myofibers. Inhibition of muscle precursor cell proliferation by local γ-irradiation of the hindlimb completely prevents this increase in myonuclear number. Muscle growth occurs normally during the first week in irradiated muscles, but growth during the second week is inhibited, leading to a 50% attenuation in the restoration of muscle mass. Thus early muscle growth occurs independently of an increase in myonuclear number, whereas later growth requires proliferating muscle precursor cells leading to myonuclear accretion. These results suggest that increasing the proliferative capacity of muscle precursor cells may enhance restoration of muscle mass after atrophy.

In May 1994 an outbreak of vomiting and diarrhoea occurred in a 28-bed long-stay ward for the mentally infirm. The predominant symptoms were vomiting, diarrhoea, malaise and abdominal pain lasting for approximately 12 h in most cases. The attack rate was 62% (13/21) for patients and 46% (16/35) for staff members. Infection control measures were implemented (containment of infectious individuals, hand hygiene among staff and environmental decontamination) and the ward was closed to admissions. Affected staff were excluded from contact with patients and their food until asymptomatic for 72 h. The outbreak lasted for 17 days. Faecal samples from nine symptomatic persons were negative for bacterial enteric pathogens, Giardia, Cryptosporidium and group A rotavirus. Electron microscopy of 12 faecal samples and one sample of vomitus revealed small round structured virus (SRSV) particles in one faecal sample. A further 30 faecal samples and seven vomitus samples were tested by reverse transcription polymerase chain reaction (RT-PCR) for SRSV of which 12 (40%) and 1 (14%) were positive respectively. Twenty-eight throat swabs from symptomatic and asymptomatic patients were collected, three (9.5%) of which were positive for SRSV by RT-PCR. Thirty-six environmental swabs were collected on the affected ward, and 11 (30%) were positive by RT-PCR. Positive swabs were from lockers, curtains and commodes and confined to the immediate environment of symptomatic patients. The distribution of contamination supports the rationale of cohorting sick patients.

Lymphoepithelioma-like carcinoma of the skin (LELCS) is a rare cutaneous neoplasm microscopically similar to undifferentiated nasopharyngeal carcinoma. It is typically nonaggressive and is treated with wide local excision. However, we present a case of a patient with a regional recurrence and more aggressive LELCS with perineural invasion and positive margins for which he was treated with wide local excision followed by chemoradiation. We discuss the use of chemoradiation for this patient and review the literature, specifically pertaining to treatment of more aggressive cases of LELCS.

Study Design. Prospective single-center case cohort study. Objective. Evaluation of clinical and radiographic outcomes of a consecutive 122-patient cohort with discogenic back pain, at 2 - to 10-year follow-up periods, treated by a single surgeon, with CHARITE® Artificial Disc (DePuy Spine, Raynham, MA, USA). Summary of Background Data. Minimum two-year clinical and radiographic Level 1 data for the first lumbar artificial disc, the CHARITE® Artificial Disc, has recently been published, demonstrating sustained clinical benefit of the device for the treatment of degenerative disc disease (DDD). Methods. Patients were assessed preoperatively using clinical outcome measures, including Visual Analogue Score (VAS) back and leg, Oswestry Disability Index (ODI), Short Form - 36 (SF-36), and Roland-Morris Questionnaires (RMDQ), and further assessed postoperatively, 3-months, 6-months, 12-months, and yearly thereafter. Results. Average follow-up was 44.9±23.3 months (n = 122). The median age at surgery was 43.0±9.0 years. Preoperative diagnosis included DDD in 118 (96.7%) and internal disc disruption (IDD) in 4 (3.3%). Surgery was performed at L5-S1 in 96 (77.9%) patients and at L4-5 in 27 (22.1%). Statistically significant clinical improvements from baseline were observed on VAS (back and leg), ODI, SF-36 PCS, SF-36 MCS, and RMDQ from 3 months onwards. Back VAS scores decreased from 78.2±21.3 preoperatively to 21.9±27.8 by final follow-up. ODI scores decreased from 51.1±17.3 to 16.2±17.9 at last follow-up. The RMDQ scores also decreased, from 16.7±4.7 to 4.2±5.8. SF-36 PCS and MCS increased from 25.7±11.0 to 46.4±10.3 for PCS and from 35.5±17.4 to 51.6±10.8 for MCS. Patient satisfaction surveys indicated that 90.56% patients rated their satisfaction with the surgery as “excellent” or “good” at 2 years. Range of motion averaged 8.6°±3.5° (median: 8.0°) at the last follow-up time point. Conclusions. Outcomes verify the clinical efficacy of total disc replacement (TDR) for treatment of discogenic back pain with or without radiculopathy. The outcomes instruments demonstrated statistically significant improvements from 3 months onwards.

Gastric fundoplication (GF) for gastroesophageal reflux disease (GERD) may protect against the progression of chronic rejection in lung transplant (LT) recipients. However, the association of GERD with acute rejection episodes (ARE) is uncertain. This study sought to identify if ARE were linked to GERD in LT patients.This single-center retrospective observational study, of patients transplanted from January 1, 2000, to January 31, 2009, correlated results of pH probe testing for GERD with ARE (≥International Society for Heart and Lung Transplantation A1 or B1). We compared the rates of ARE among patients with GERD (DeMeester Score14.7) versus without GERD as number of ARE per 1,000 patient-days after LT. Patients undergoing GF prior to LT were excluded.The analysis included 60 LT subjects and 9,249 patient-days: 33 with GERD versus 27 without GERD. We observed 51 ARE among 60 LT recipients. The rate of ARE was highest among patients with GERD: 8.49 versus 2.58, an incidence density ratio (IDR) of 3.29 (P = .00016). Upon multivariate negative binomial regression modeling, only GERD was associated with ARE (IDR 2.15; P = .009). Furthermore, GERD was associated with multiple ARE (36.4% vs 0%; P.0001) and earlier onset compared with patients without GERD: ARE proportion at 2 months was 0.55 versus 0.26 P = .004).In LT recipients, GERD was associated with a higher rate, multiple events, and earlier onset of ARE. The efficacy of GF to reduce ARE among patients with GERD needs further evaluation.

Dietary fluid and sodium intake may influence the risk for vasoocclusive events in persons with sickle cell anemia (SCA). The objective of this study was to examine the dietary intake of water and sodium in children and adolescents with SCA and identify possible factors influencing intake. We compared water (mL) and sodium (mg) intake in 21 patients with SCA, aged 5 to 18 years, to reported adequate intake for water, daily fluid requirement, upper limit for sodium, and National Health and Nutrition Examination Survey 2005 to 2006 data for sodium, and sociodemographic factors. Dietary intake from 3-day food records was evaluated retrospectively. Median water intake was significantly lower than adequate intake, and median sodium intake was significantly higher than sodium upper limit. Sociodemographic factors were not associated with dietary water or sodium intake. Our results suggest that children and adolescents with SCA would benefit from education regarding increasing fluid intake and limiting high sodium foods.

Chronic hypoxia contributes to pulmonary hypertension through complex mechanisms that include enhanced NADPH oxidase expression and reactive oxygen species (ROS) generation in the lung. Stimulation of peroxisome proliferator-activated receptor gamma (PPARgamma) reduces the expression and activity of NADPH oxidase. Therefore, we hypothesized that activating PPARgamma with rosiglitazone would attenuate chronic hypoxia-induced pulmonary hypertension, in part, through suppressing NADPH oxidase-derived ROS that stimulate proliferative signaling pathways. Male C57Bl/6 mice were exposed to chronic hypoxia (CH, Fi(O2) 10%) or room air for 3 or 5 weeks. During the last 10 days of exposure, each animal was treated daily by gavage with either the PPARgamma ligand, rosiglitazone (10 mg/kg/d) or with an equal volume of vehicle. CH increased: (1) right ventricular systolic pressure (RVSP), (2) right ventricle weight, (3) thickness of the walls of small pulmonary vessels, (4) superoxide production and Nox4 expression in the lung, and (5) platelet-derived growth factor receptor beta (PDGFRbeta) expression and activity and reduced phosphatase and tensin homolog deleted on chromosome 10 (PTEN) expression. Treatment with rosiglitazone prevented the development of pulmonary hypertension at 3 weeks; reversed established pulmonary hypertension at 5 weeks; and attenuated CH-stimulated Nox4 expression and superoxide production, PDGFRbeta activation, and reductions in PTEN expression. Rosiglitazone also attenuated hypoxia-induced increases in Nox4 expression in pulmonary endothelial cells in vitro despite hypoxia-induced reductions in PPARgamma expression. Collectively, these findings indicate that PPARgamma ligands attenuated hypoxia-induced pulmonary vascular remodeling and hypertension by suppressing oxidative and proliferative signals providing novel insights for mechanisms underlying therapeutic effects of PPARgamma activation in pulmonary hypertension.

Background Respiratory syncytial virus (RSV) can cause severe lower respiratory tract infection (LRI) and is a risk factor for the development of bronchiolitis obliterans syndrome (BOS) after lung transplantation (LTx). Currently, the most widely used therapy for RSV is inhaled ribavirin. However, this therapy is costly and cumbersome. We investigated the utility of using oral ribavirin for the treatment of RSV infection after LTx. Methods RSV was identified in nasopharyngeal swabs (NPS) or bronchoalveolar lavage (BAL) using direct fluorescent antibody (DFA) in 5 symptomatic LTx patients diagnosed with LRI. Data were collected from December 2005 and August 2007 and included: age; gender; type of LTx; underlying disease; date of RSV; pulmonary function prior to, during and up to 565 days post-RSV infection; need for mechanical ventilation; concurrent infections; and radiographic features. Patients received oral ribavirin for 10 days with solumedrol (10 to 15 mg/kg/day intravenously) for 3 days, until repeat NPS were negative. Results Five patients had their RSV–LRI diagnosis made at a median of 300 days post-LTx. Mean forced expiratory volume in 1 second (FEV 1 ) fell 21% ( p 1 returned to baseline and was maintained at follow-up of 565 days. There were no complications and no deaths with oral therapy. A 10-day course of oral ribavirin cost $700 compared with $14,000 for nebulized ribavirin at 6 g/day. Conclusions Treatment of RSV after LTx with oral ribavirin and corticosteroids is well tolerated, effective and less costly than inhaled ribavirin. Further studies are needed to directly compare the long-term efficacy of oral vs nebulized therapy for RSV.

Vibration perception threshold (VPT) is increasingly used as a measure of large nerve fibre function in studies of patients with diabetes and in other disorders. In order to establish the influence of age, height, sex, and smoking on VPT values in the normal population and to allow the calculation of accurate age-related percentile charts, 1365 healthy volunteers were studied using a biothesiometer. Measurements were made bilaterally on thumbs, great toes, and over medial malleoli. Multivariate regression analysis confirmed age to be the major determinant of VPT levels at all sites (p less than 0.001). Height was a significant factor for toes and ankles (p less than 0.001) but not thumbs. Sex had no overall effect at toe or thumb but there were differences regarding ankle VPT (p less than 0.01). Log transformation of VPT data produced a linear relationship with age at all sites except at the thumbs in elderly females where there was significant deviation from this model (p less than 0.001) and inverse square root transformation was more appropriate. Smoking had no effect on VPT levels. Age-related centile charts were produced for each site and an easy-to-use computer program was developed to calculate centile values based on raw VPT data, age, height, and sex.

Obstructive sleep apnea, characterized by intermittent periods of hypoxemia, is an independent risk factor for the development of pulmonary hypertension. However, the exact mechanisms of this disorder remain to be defined. Enhanced NADPH oxidase expression and superoxide (O2(-).) generation in the pulmonary vasculature play a critical role in hypoxia-induced pulmonary hypertension. Therefore, the current study explores the hypothesis that chronic intermittent hypoxia (CIH) causes pulmonary hypertension, in part, by increasing NADPH oxidase-derived reactive oxygen species (ROS) that contribute to pulmonary vascular remodeling and hypertension. To test this hypothesis, male C57Bl/6 mice and gp91phox knockout mice were exposed to CIH for 8 hours per day, 5 days per week for 8 weeks. CIH mice were placed in a chamber where the oxygen concentration was cycled between 21% and 10% O2 45 times per hour. Exposure to CIH for 8 weeks increased right ventricular systolic pressure (RVSP), right ventricle (RV):left ventricle (LV) + septum (S) weight ratio, an index of RV hypertrophy, and thickness of the right ventricular anterior wall as measured by echocardiography. CIH exposure also caused pulmonary vascular remodeling as demonstrated by increased muscularization of the distal pulmonary vasculature. CIH-induced pulmonary hypertension was associated with increased lung levels of the NADPH oxidase subunits, Nox4 and p22phox, as well as increased activity of platelet-derived growth factor receptor beta and its associated downstream effector, Akt kinase. These CIH-induced derangements were attenuated in similarly treated gp91phox knockout mice. These findings demonstrate that NADPH oxidase-derived ROS contribute to the development of pulmonary vascular remodeling and hypertension caused by CIH.

Problem1. To determine if GM-CSF (granulocyte macrophage-colony stimulating factor) protects against fibrosis using an experimental animal model of tracheal injury. 2. To determine if GM-CSF prevents cytokine-induced expression of fibrotic markers in human bronchial epithelial cells in vitro.MethodsTracheae from GM-CSF (20ng) or vehicle (PBS) treated Sprague-Dawley donor rats were heterotopically transplanted into Fischer 344 recipients. Recipients were treated daily with either GM-CSF or vehicle for seven days. Allografts were harvested on days 14 or 21 post-transplantation and analyzed for luminal collagen deposition and the presence of intact epithelium. In parallel, human bronchial epithelial cells (Beas2B) were treated with pro-fibrotic cytokines (TGFbeta1, IL-13) with or without GM-CSF. Treated cells were harvested and processed for RT-PCR or immunocytochemical analyses for expression of fibrotic markers (alpha smooth muscle actin, fibroblast-specific protein 1).ResultsTracheal allografts treated wi...

Obliterative bronchiolitis (OB) after lung transplantation is triggered by alloimmunity, but is ultimately mediated by transforming growth factor (TGF)-beta(1)-dependent airway fibrosis.Chronic alcohol use increases TGF-beta(1) expression and renders the lung susceptible to injury. Therefore, we hypothesized that donor alcohol abuse could prime the lung allograft for OB, as many organ donors have a history of alcohol abuse.Tracheas from control and alcohol-fed rats (8 wk) were heterotopically transplanted into recipients with varying degrees of alloimmune mismatch and analyzed for obliterative airway disease severity on Postoperative Day 21.Although donor alcohol ingestion did not increase the number of antigen-presenting cells or infiltrating lymphocytes, it nevertheless increased allograft lumenal collagen content fourfold compared with allografts from control donors. In parallel, alcohol increased TGF-beta(1) and alpha-smooth muscle actin expression in allografts. Alcohol amplified airway disease even in isografts with minor alloimmune mismatches. In contrast, it did not cause any airway disease in isografts in a pure isogenic background, suggesting that a minimal alloimmune response is necessary to trigger alcohol-induced airway fibrosis.Although alloimmune inflammation is required to initiate airway disease, alcohol primes the allograft for greater TGF-beta(1) expression, myofibroblast transdifferentiation, and fibrosis than by alloimmune inflammation alone. This has serious clinical implications, as many lung donors have underlying alcohol abuse that may prime the allograft recipient for subsequent OB.

Epidemiological investigations into the pancreas disease (PD) of farmed salmon were conducted on populations of Atlantic salmon reared in Ireland during 2003 and 2004. The investigations surveyed all marine salmon farms operating in Ireland through a detailed questionnaire with follow-up farm visits. Information was gathered on 21 populations of fish in 2003 and 14 populations in 2004. Thirteen of the 21 populations suffered PD in 2003 and 12 of the 14 in 2004. The mean mortality due to PD on affected farms was 18.8% in 2003 and 14.8% in 2004 and the loss of growth due to PD was estimated at 11.4% over the 2-year period. The highest risk periods for outbreaks of PD were early summer and early autumn and the farms most seriously affected by PD mortality were in the western counties of Ireland. Factors which showed an indication of association with a PD outbreak or high mortality during a PD outbreak were: livestock movement to another sea site, high feeding rate prior to any PD outbreak, the presence of another PD positive farm in the same water body, greater than 250 000 fish on a site, a previous history of PD on a site, a high sea lice burden, and sites located in the western regions of Ireland which reared a specific strain of salmon.

Alcohol abuse dramatically increases the risk of acute lung injury. In an experimental rat model of ethanol-mediated susceptibility to lung injury, recombinant granulocyte/macrophage colony-stimulating factor (GM-CSF) restored alveolar epithelial barrier function both in vitro and in vivo, even during acute endotoxemia. These findings suggested that the alveolar epithelium, which secretes GM-CSF into the airway where it is required for alveolar macrophage maturation, likewise responds to GM-CSF priming in a receptor-mediated manner. In this study we determined that both the GM-CSF receptor α- and β-subunits (GM-CSFRα and GM-CSFRβ) are expressed throughout the rat airway epithelium and that this expression was significantly decreased in the alveolar epithelium following chronic ethanol ingestion (6 wk). In parallel, PU.1, the master transcription factor for GM-CSF signaling in hematopoietic cells, is also expressed in alveolar epithelial cells, and ethanol ingestion likewise decreased PU.1 protein expression and nuclear binding in the alveolar epithelium. Finally, GM-CSF signaling as reflected by PU.1 expression and nuclear binding was restored with recombinant GM-CSF treatment in vitro. We conclude that chronic ethanol ingestion decreases GM-CSF receptor expression and signaling in the lung epithelium. Consequently, we speculate that dampening of GM-CSF stimulation of the alveolar epithelium is responsible at least in part for the diverse functional defects that characterize the alcoholic lung and could be a therapeutic target in acute lung injury.

Pediatric rhabdomyosarcoma is not exclusive to the head and neck. However, the unique anatomy of the head and neck requires special consideration and treatment modifications. The low incidence of these tumors has prevented the development of rigorous treatment protocols. Treatment strategies must be individualized on the basis of histopathologic subtype, prognostic indicators, tumor location, tumor extent, available clinical trial data, and hospital resources. The primary treatment of these tumors typically involves a combination of surgery, radiation, and chemotherapy. Advancements in surgical and radiotherapy techniques have reduced patient morbidity, whereas new chemotherapeutic protocols have improved local disease control and overall survival. Because of the infrequency and complexity of these tumors, patients may benefit from referral to centers with a comprehensive multidisciplinary team that has experience treating these tumors in the pediatric population. If possible, patients should be enrolled and treated on the current Children's Oncology Group protocol.

Atrophy of skeletal muscle leads to decreases in myofiber size and nuclear number; however, the effects of atrophic conditions on muscle precursor cells (MPC) are largely unknown. MPC lie outside myofibers and represent the main source of additional myonuclei necessary for muscle growth and repair. In the present study, we examined the properties of MPC after hindlimb suspension (HS)-induced atrophy and subsequent recovery of the mouse hindlimb muscles. We demonstrated that the number of MPC in atrophied muscles was decreased. RT-PCR analysis of cells isolated from atrophied muscles indicated that several mRNA characteristic of the myogenic program in MPC were absent. Cells isolated from atrophied muscles failed to properly proliferate and undergo differentiation into multinucleated myotubes. Thus atrophy led to a decrease in MPC and caused dysfunction in those MPC that remained. Upon regrowth of the atrophied muscles, these deleterious effects were reversed. Our data suggest that preventing loss or dysfunction of MPC may be a new pharmacological target during muscle atrophy.

Blunt trauma causing a retropharyngeal hematoma without an associated cervical fracture is a relatively rare occurrence. This article presents the case of a patient with airway compromise from a retropharyngeal hematoma, and discusses the diagnosis, airway management, and treatment of this condition.

Pulmonary arteriovenous malformation (AVM) is a congenital condition, but because the symptoms usually do not occur until middle age, the diagnosis is often delayed. The authors report on a neonate, diagnosed at 2 weeks of age, who was treated by lobectomy at 35 months of age. This prompted a review of the diagnosis, pathophysiology, and treatment of pulmonary AVM. In the literature there are approximately 500 cases of pulmonary AVM. Special attention is given to the reports involving children. Eight cases have been reported in which the diagnosis was made in the first year of life. In two series, a chest roentgenogram showed abnormalities in all affected patients. Because of the strong association of pulmonary AVM with hereditary telangiectasia (Rendu-Osler-Weber syndrome), it is recommended that family members of affected patients be screened by chest roentgenograms for pulmonary AVM.

One of the problems inherent in using women in clinical research is the effect that oral contraceptive (OC) use might have on physical indexes. Although weight gain is frequently reported as a side effect of OC use, there is little empirical evidence that such weight gain actually occurs. The current study investigated differences in energy balance [ie, dietary intake, resting energy expenditure (REE), and physical activity] between groups of users and nonusers of OCs. Each group completed a protocol that covered one menstrual cycle and consisted of daily recording of dietary intake, measurement of REE once during each phase of the menstrual cycle, and reporting of physical activity over the entire cycle. Comparisons indicate that there was a marginal interaction (P = 0.06) of OC use with total energy intake, indicating a different pattern of intake for the two groups. There were qualitative between-group differences such that the OC group consumed a greater percentage of energy as fat (P = 0.02) and a lesser percentage of energy as carbohydrate (P = 0.008). No group differences were found in the percentage of energy consumed as protein, but both groups consumed significantly less protein during menses (P = 0.008). There were no significant differences in REE. Both groups of women reported marginally more activity (P = 0.09) during menses than during the luteal phase.

Symptomatic gastro-oesophageal reflux can usually be managed non-operatively but, when stricture occurs, most informed physicians agree that an antireflux procedure is necessary. Nissen fundoplication has become the preferred operation for complicated reflux disease, and most strictures will resolve after control of reflux and two or three oesophageal dilatations. For those patients who have persistent stricture that is fibrotic, shortened, or does not respond to operative control of reflux, resection is indicated. Merendino and Dillard1 proposed the use of a jejunal segment for interposition between the oesophagus and stomach because of its isoperistaltic nature, relative resistance to acid injury, and lack of reflux into the proximal oesophageal segment2,3. Their study of both animals and humans demonstrated the jejunal segment to be the conduit of choice, and we have had long-term successful experience with its use4.

JELLYFISH-mediated damage to salmon and other species in aquaculture is a periodic challenge, which is considered by some workers to be increasing in frequency (Graham 2001, Purcell and others 2007, Rodger and others 2011). Significant pathology in affected fish has been observed in the gills and is considered to be due to the toxic effects of jellyfish venom via nematocyst discharge (Helmholz and others 2010, Rodger and others 2011). It has recently been suggested that certain jellyfish species may also act as vectors for Tenacibaculum maritimum (Ferguson and others 2010, Delannoy and others 2011), a bacterium frequently associated with gill pathology and the causal agent of tenacibaculosis. A number of jellyfish species have been implicated in fish kills over the years including the hydromedusae Phialella quadrata (Bruno and Ellis 1985) and Solmaris corona (Hay and Murray 2008), the siphonophores Muggiaea atlantica (Fossa and others 2003) and Apolemia uvaria (Bamstedt and others 1998), the scyphomedusae Cyanea capillata (Bruno and Poppe 1996), Pelagia noctiluca (Doyle and others 2008) and Aurelia aurita (Bruno and Poppe 1996). However, little descriptive information on the pathology and pathophysiology of jellyfish-mediated damage to fish has been published to date. This short communication describes the clinical impact of a jellyfish bloom on a finfish farm on the north-west coast …

Evidence of Epithelial to Mesenchymal Transition Associated with Airway Remodeling after Experimental and Clinical Lung Transplantation P.O. Mitchell, P.M. Naik, D.C. Neujahr, S.D. Force, A.M. Ramirez, A.A. Gal, E.C. Lawrence, D.M. Guidot, A. Pelaez, Atlanta Veterans Affairs Medical Center, Decatur, GA; Pulmonary, Allergy and Critical Care Medicine, Emory University, Atlanta, GA; McKelvey Center for Lung Transplantation & Pulmonary Vascular Diseases, Emory University, Atlanta, GA; Division of Cardiothoracic Surgery, Emory University, Atlanta, GA; Department of Pathology and Laboratory Medicine, Emory University, Atlanta, GA