Gradient inflammation in the pancreatic stump after pancreaticoduodenectomy: Two case reports and review of literature

BACKGROUND

Postoperative pancreatic fistula (POPF) contributes significantly to morbidity and mortality after pancreaticoduodenectomy (PD). However, the underlying mechanisms remain unclear. This study explored this pathology in the pancreatic stumps and elucidated the mechanisms of POPF following PD.

CASE SUMMARY

Pathological analysis and 16S rRNA gene sequencing were performed on specimens obtained from two patients who underwent complete pancreatectomy for grade C POPF after PD. Gradient inflammation is present in the pancreatic stump. The apoptosis was lower than that in the normal pancreas. Moreover, neutrophil-dominated inflammatory cells are concentrated in the ductal system. Notably, neutrophils migrated through the ductal wall in acinar duct metaplasia-formed ducts. Additionally, evidence indicates that gut microbes migrate from the digestive tract. Gradient inflammation occurs in pancreatic stumps after PD.

CONCLUSION

The mechanisms underlying POPF include high biochemical activity in the pancreas, mechanical injury, and digestive reflux. To prevent POPF and address pancreatic inflammation and reflux, breaking the link with anastomotic dehiscence is practical.

Mass cytometry identifies a distinct monocyte cytokine signature shared by clinically heterogeneous pediatric SLE patients

Systemic Lupus Erythematosus (SLE) is a heterogeneous autoimmune disease with heightened disease severity in children. The incomplete understanding of the precise cellular and molecular events that drive disease activity pose a significant hurdle to the development of targeted therapeutic agents. Here, we performed single-cell phenotypic and functional characterization of pediatric SLE patients and healthy controls blood via mass cytometry. We identified a distinct CD14hi monocyte cytokine signature, with increased levels of monocyte chemoattractant protein-1 (MCP1), macrophage inflammatory protein-1β (Mip1β), and interleukin-1 receptor antagonist (IL-1RA). This signature was shared by every clinically heterogeneous patient, and reproduced in healthy donors' blood upon ex-vivo exposure to plasma from clinically active patients only. This SLE-plasma induced signature was abrogated by JAK1/JAK2 selective inhibition. This study demonstrates the utility of mass cytometry to evaluate immune dysregulation in pediatric autoimmunity, by identification of a multi-parametric immune signature that can be further dissected to delineate the events that drive disease pathogenesis.

Frequency and prognosis of delayed facial palsy after microvascular decompression for hemifacial spasm

BACKGROUND

Microvascular decompression (MVD) for hemifacial spasm (HFS) provides a long-term cure rate. Delayed facial palsy (DFP) is not an unusual complication, but it has only been sporadically described in the literature. The purpose of this report is to evaluate the incidence of delayed facial palsy after MVD and its clinical course and final results.

METHODS

From January, 1998 to April, 2004, 410 patients underwent microvascular decompression for hemifacial spasm at our Institute. During this time, 21 patients (5.4%) developed delayed facial weakness; eighteen of them were given steroid medication and they were followed up in the out-patient clinic.

FINDINGS

Twenty-one patients developed DFP after microvascular decompression an incidence of 5.4%. There were seventeen women (81.0%) among the 21 patients with DFP who were included in this study. In twenty of them, the symptoms of HFS improved completely after the operation, but the spasm remained with one of them. The onset of palsy occurred between postoperative day 7 and 23 (average: 12.1 days). The palsy was at least Grade II or worse on the House-Brackmann (HB) scale. The time to recovery averaged 5.7 weeks (range: 25 days-17 weeks); 20 patients improved to complete recovery and 1 patient remained with minimal weakness, as Grade II on the HB scale, at the follow-up examination.

CONCLUSION

Our findings demonstrated that the incidence of DFP was not so low as has been reported the literature, and it did not have any striking predisposing factors. Even though the degree of facial palsy was variable, almost all patients exhibited a complete recovery without any further special treatment. The etiology of DFP and its association with herpes infection should be further clarified.

Surgical tactics and outcome of treatment in jugular foramen schwannomas

Seven patients with schwannomas of the jugular foramen were included our study in Samsung Medical Center between 1995 and 1999. Patients with neurofibromatosis were excluded. The records of the seven patients (six surgical case and one nonsurgical case) were retrospectively reviewed. There were six women and one man (mean age, 47 years) with a symptom duration ranging from 3 months to 14 years (mean, 47 months). The predominant symptoms were hearing difficulty, hemifacial spasm and hoarseness. Preoperative audiologic evaluation, computerised tomography (CT), magnetic resonance (MR) imaging, and angiography were performed in most patients. We classified tumours into four types using Kaye and Pellet classification on the basis of radiological and surgical findings. The tumours were: Type A (at cerebellopontine angle) in one; Type B (foraminal) in two; Type C (extracranial and/or foraminal) in two; and Type D (intra- and extracranial) in two cases. We used various surgical approaches such as retrosigmoid suboccipital craniectomy for Type A tumours, infratemporal fossa type A approach (ITFA) for Type C tumours, petro-occipital transsigmoid approach or modified transcochear approach for Type D tumours and ITFA with partial labyrinthectomy for Type B. In the selection of surgical approaches, we took consideration of tumour extension, tumour size, and preoperative hearing function. Facial nerve transposition was not used only in one case of ITFA because of small tumour size (1.5cm). Gross total removal was achieved in five cases, and subtotal removal in one case (Type D tumour) with a single-stage operation. Stereotactic radiosurgery was performed on residual mass in the subtotally removed case. Follow-up period ranged from 13 to 49 months (mean, 27.5 months). There was neither postoperative mortality nor recurrence on follow-up MR imaging. There were two cases of temporary facial nerve palsy and one aggravation of pre-existing low cranial palsy. Two case of sustained vocal cord palsy underwent thyroplasty, but there was no aspiration pneumonia. Persistent cerebrospinal fluid collection was improved with lumboperitoneal shunt. The surgical approaches of each case should be tailored according to their shape and the clinical manifestation. We obtain acceptable outcomes from one-stage operation.

Psychiatric disorders in pre-schoolers

The psychiatric disorders seen in preschoolers are reviewed. Behaviour problems are the most commonly seen. These may be due to reaction to stress, developmental problems of attachment and temperamental characteristics such as shyness and aggressiveness. Related to behavioural problems are the developmental disorders of enuresis, encopresis and constipation. The rate of behaviour problems in Singapore was found to be 7% which compares favourably with studies overseas. Disorders that have their onset in the preschool period include Attention Deficit Hyperactivity Disorder (ADHD) and Pervasive Developmental Disorders. ADHD is increasingly important because of the response to Ritalin and pervasive disorders because of the recognition that autistic states probably cover a spectrum of disorders. Aetiological factors of preschool psychiatric disorders include biological and psychosocial contribution. The latter is associated with the quality of the home environment and quality of care experienced by the child. Assessment methods include the gathering of developmental data such as the IQ and appropriate behavioural checklists. Direct observation is increasingly practised. Management methods range from drug therapy (mainly in ADHD), to traditional psychodynamic, family and behavioural therapy.

Biofeedback and stress management strategies

The concept of stress management was reviewed in this paper. Stress was conceptualised as a perception of inability to cope with its attendant emotional and psychophysiological responses. Management of stress then has to do with altering environmental triggers where possible. Alteration to more realistic mode of perception, adoption of more adaptive means of emotional response as well as the modulation of the body's psychophysiological state through the use of various relaxation techniques would all help to reduce stress and enable the individual to cope with it. The role of biofeedback in promoting the relaxation response as well as training the individual to adapt to better means of coping was discussed. Thirty-three anxious patients who were treated with biofeedback assisted relaxation training were studied for their response on EMG reading and heart rate. Their psychosocial functioning on an experiential index also showed an improvement. It was concluded that whatever techniques are used, a multi-modal approach to stress management is probably the more effective in helping people to cope with the variety of stress faced in life.

Child-rearing practices of Chinese parents and their relationship to behavioural problems in toddlers

The aim of this study was to examine the relationship between behavioural deviance and parental involvement in childrearing and disciplinary practices in a sample of 401 toddlers. Mothers of each subject were interviewed to assess for the degree of parental involvement and the disciplinary methods used with the child. A Behavioural Screening Questionnaire (BSQ) was used to assess for behavioural deviance in the toddlers. Results indicated that father involvement in childrearing was significantly lower than mother involvement (p = 0.0001). Although consistent with cultural expectations, both low paternal involvement and punitive types of discipline were significantly related to behavioural deviance.