Introduction: The incidence of adenocarcinoma of the esophagus has increased dramatically in the past three decades. Esophageal cancer is the eighth most common cancer and sixth leading cause of cancer death. Squamous cell cancer is the most common type of esophageal cancer all over the world, but the incidence of esophageal adenocarcinoma has been increasing. Most, if not all, esophageal adenocarcinomas arise from a region of Barrett's metaplasia. The most common location is near the EG junction with an association of endoscopic evidence of Barrett's esophagus. We present a case of young male presented with lower extremity pain and swelling due to metastasis of undiagnosed primary esophageal cancer. Case Presentation: A 36-year-old male with no significant medical history presented with complaints of lower extremity pain and swelling. Patient denied any other symptoms. On admission, vital signs were temp. 97.8, BP 145/87 mmhg, HR 75 bpm, RR was 18. Labs work showed Na 141, K 3.7, BUN 17, Cr 0.70, Alkaline phosphatase 263, AST 14, ALT 9, CHOL 202, HDL 27, Triglyc 285, Hgb 12.4, Plt 244, Wbc 9.6, ESR 28, TSH 7.07, Vit D (25 hydroxy) 8, Hgb A1c 7.0, CRP 102.6. Knee x-ray was highly suspicious for chronic osteomyelitis vs. neoplastic lesion. Doppler US of lower extremity ruled out DVT, but showed large complex fluid collection anterior to the knee and proximal leg measuring 8.0 x 5.8 x 18.6 cm with concern for osteomyelitis with overlying abscess vs an aggressive primary bone tumor. Patient was started on antibiotics and had a MRI that showed periostitis with possible differential of osteomyelitis/periostitis and osteosarcoma. CT scan of chest, abdomen and pelvis showed aortocaval and left iliac lymphadenopathy concerning for metastasis. Blood cultures were negative but biopsy was consistent with metastatic adenocarcinoma favoring gastrointestinal and pancreaticobiliary tract as the primary source. Patient had an upper endoscopy that showed esophageal mass extended from the GE junction up about 7cm. Chemotherapy and radiation therapy were initiated. HER-2 gene was ordered. Patient developed cardiopulmonary arrest and died prior to discharge. Discussion: Adenocarcinoma of the esophagus is usually associated with Barrett's esophagus that involves the lower third of esophagus. It is a very aggressive disease associated with diffuse metastasis and high mortality rate. The most common metastatic sites for esophageal cancer are liver brain and lung. Risk factors associated with cancer are smoking, higher body mass index, gastroesophageal reflux disease, and a diet low in fruits and vegetables. Almost half of the cases of adenocarcinoma have no associated reflux disease. The median survival rate of metastatic esophageal cancer is 4-9 months. Physicians should always think of visceral malignancy in cases of biopsy proven adenocarcinoma for better prognosis. Endoscopy should always be done to look for visceral malignancy if cancer is suspected.

No description available.

Résumé : Introduction : La relation entre les réflexes vagaux à point de départ œsophagien et les événements cardiorespiratoires des nouveau-nés (apnées, bradycardies, désaturations en O[indice inférieur 2]) reste un sujet discuté. Des études antérieures ont montré que la stimulation des chémo- ou mécanorécepteurs de l’œsophage chez l’animal adulte anesthésié peut être la cause de différents réflexes (Jadcherla, 2012). De plus, l’implication des terminaisons nerveuses des fibres C (FCs) dans certains réflexes d’origine œsophagienne a été suggérée (Lang et al., 2001). Considérant qu’il reste beaucoup d’inconnues sur ces réflexes, en particulier en période néonatale, les objectifs de cette étude sont de i) caractériser les réflexes cardiorespiratoires lorsqu’un reflux gastro-œsophagien (RGO) est mimé; ii) déterminer l’effet du site de la stimulation sur la sévérité des réflexes; iii) déterminer le niveau d’implication des FCs. Méthodes : Huit agneaux nouveau-nés ont été instrumentés chirurgicalement; 48h plus tard, deux enregistrements polysomnographiques distincts ont été effectués sans sédation, avant et après blocage permanent des FCs (Diaz et al., 2000). Cinq stimulations randomisées ont été effectuées permettant de mimer un RGO à différents niveaux de l’œsophage. Résultats : Les stimulations œsophagiennes (RGO) entrainent des réflexes d’inhibition cardiorespiratoire. Les stimulations doubles provoquent des réflexes de plus grande amplitude. Cette inhibition cardiorespiratoire est moins marquée suite au blocage permanent et sélectif des FCs par la capsaïcine. Conclusion : Mes résultats expérimentaux montrent, pour la première fois, une relation entre les réflexes vagaux œsophagiens et des événements cardiorespiratoires chez un animal nouveau-né en l’absence de sédation et suggèrent aussi une certaine implication des FCs. Les reflux proximaux, quant à eux, sont ceux pouvant potentiellement conduire à un RGO pathologique étant donné qu’ils engendrent des réflexes de plus grande amplitude. / Abstract : Introduction : The relationship between vagal reflexes originating from the esophagus and cardiorespiratory events in neonates (apneas, bradycardias, O[subscript 2] desaturations) remains a controversial subject. Previous studies in an a esthetized adult animals have shown that stimulation of esophagal chemo- or mechanoreceptors may cause various reflexes (Jadcherla, 2012). In addition, the involvement of C-fiber endings in some of those reflexes has been suggested (Lang et al., 2001). Considering that many uncertainties remain about these reflexes, especially in the neonatal period, the goals of this study were to i) characterize the cardiorespiratory reflexes observed when a gastroesophageal reflux is mimicked; ii) determine the effect of the stimulation site on the amplitude of those reflexes; iii) determine whe ther C-fibers are involved. Methods: Eight newborn lambs were surgically instrumented; 48 hours later, two separate polysomnographic recordings were performed without sedation before and after permanent C-fiber blockade (Diaz et al., 2000). Five randomized stimulations were performed to mimic a gastroesophageal reflux at different levels of the esophagus. Results: Esophageal stimulations cause cardiorespiratory inhibitory reflexes. Double stimulation causes more important reflexes, including bradycardia and apnea. The cardiorespiratory inhibition response was less marked after permanent and selective blockade of C-fibers by capsaicïne. Conclusion: My experimental results show, for the first time, a relationship between esophageal vagal reflexes and cardiorespiratory events in a neonatal, non-sedated animal and suggest some involvement of C-fiber endings. Results also suggest that proximal gastroesophageal refluxes generate more important reflexes.

Este trabalho tem por objetivo comparar dois modos de operação de destilação em batelada: com refluxo constante e composição do destilado constante. Desenvolveuse um modelo matemático para a destilação em batelada de uma mistura binária (metanol-etanol) para operação com cada um destes modos. O modelo consiste basicamente dos balanços de massa e entalpia, relações e diagramas de equilíbrio líquido-vapor (composição de equilíbrio, temperaturas de bolha e orvalho da mistura), estimativa das propriedades físico-químicas da mistura (calor específico, calor latente de vaporização), determinação do número de estágios ideais necessários à separação (pelo método de McCabe-Thiele), cálculo de cargas térmicas no refervedor e condensador, consumo de utilidades (vapor de água e água de resfriamento), estimativa do tempo de destilação e alguns aspectos econômicos sobre o processo (custos de equipamentos e operacionais, capacidade de produção, lucro mensal). Implementou-se em uma planilha eletrônica este modelo para as simulações matemáticas e análise técnico-econômica do processo. Em escala de laboratório (foram realizados, ao todo, oito ensaios, quatro de refluxo constante e quatro de refluxo variável, utilizando uma coluna de pratos perfurados), constatou-se uma boa concordância entre estes resultados experimentais e os calculados a partir da modelagem. Em seguida, estudaram-se, isoladamente em cada modo de operação e de modo comparativo, as principais variáveis de processo (taxa de refluxo, composição do destilado, quantidade de carga, vazão de destilado, etc.) através de simulações matemáticas, tanto no cenário de uma unidade existente como no caso do projeto de uma instalação nova. Para uma instalação existente, verificou-se, que no modo de destilação com composição de destilado constante, mantendo-se a vazão do vapor de topo constante, o tempo de destilação é menor, a capacidade de destilação é maior, resultando em maior lucro mensal. Para uma instalação a ser projetada, de novo, o processo mais vantajoso é o de refluxo variável e vazão de vapor do topo constante, pois requer menores áreas dos trocadores de calor para uma dada separação num tempo fixo de processo. No entanto, para o processamento de uma dada quantidade num mesmo tempo, à medida que se adota, no projeto, um número maior de estágios de separação na coluna, a diferença de lucro mensal torna-se praticamente indistinta para os modos de destilação estudados. / The aim of this study is to compare two operational methods of batch distillation of a binary system (methanolethanol): constant reflux and constant distillate composition. A phenomenological modeling concerning each mode was developed. It was based on material and enthalpy balances, equilibrium relationships, estimation of physical properties (specific heat and latent vaporization heat of mixtures), determination of ideal stages number (using McCabe-Thiele method), calculation of rebolier and condenser thermal loads and areas, steam and cooling water requirement, distillation time and some economical aspects. The mathematical model was implemented into an electronic spreadsheet. The predicted values were compared to experimental results from eight tests carried out in a laboratory sieve tray column (four at constant reflux and four at constant distillate composition), and a good consistency was found. Then several case studies concerning each distillation mode as well as the comparative performance were accomplished through mathematical simulations. Evaluation of the basic process variables such as reflux rate, initial load, distillate composition and flow rate was done. Rating of an existing plant and design of a new installation were considered in this process analysis. For an existing installation, lower distillation time, as well as higher distillation capacity and monthly profit were observed when distilling with constant distillate composition, keeping constant the flow rate of vapor from the column top. This process is also the more advantageous one when designing a new plant since smaller heat exchanger areas are required. However, to process a quantity in a same time, in a design of a new plan, as number of separation stages increases, monthly profit becomes almost the same among the studied distillation modes.

published_or_final_version / abstract / toc / Medicine / Doctoral / Doctor of Philosophy

<p>Urinary tract infections (UTIs) are the second most common type of infection identified in the clinical setting and disproportionately afflict women. UTIs most frequently manifest in the form of infection of the lower urinary tract, involving the bladder. Uropathogens, particularly uropathogenic E. coli, progressively colonize the urethra and ascend to the bladder, where they initiate cystitis. In some cases, infection further ascends through the ureters and reaches the kidneys, where it causes pyelonephritis. Infection of both the upper and lower urinary tract can have serious ramifications for the host, and this is in large part due not to infection itself but to host-directed responses to bacterial insults. </p><p> In this thesis, I will describe and discuss two distinct aspects of UTIs. In the first study, in vivo work in a mouse model of urinary tract infection revealed a novel role for mast cells, which are tissue-resident granulated innate immune cells, in directing the detachment and death of epithelial cells during cystitis, facilitating the clearance of bacteria from the bladder. An ex vivo porcine bladder infection model suggested a specific role for mast cell granules and the proteases contained therein, which was corroborated with in vitro experiments utlizing isolated mast cell granules and human epithelial cells to demonstrate granule-induced exfoliation and cell death. From this work, it is clear that mast cells play a highly targeted role in modulating urothelial integrity during bladder infection by mediating host-directed epithelial loss.</p><p> In the second study described in this dissertation, the synergistic roles of both pyelonephritis and vesico-ureteric reflux (VUR), a congenital urinary tract defect that results in the improper backflow of urine from the bladder to the kidney, in the development of reflux nephropathy, a fibrotic host response characterized by renal scar formation, were elucidated in a series of in vivo experiments. Specifically, the C3H mouse, which is naturally susceptible to VUR, was utilized to characterize the dynamics of kidney infection and the onset of reflux nephropathy. Renal scarring was dependent on the presence of sustained kidney infection and the accompanying inflammatory response due to VUR, while neither transient infection nor reflux alone were sufficient to provoke nephropathy. Thus, the development of reflux nephropathy is dependent upon the confluence of both infection and VUR. </p><p> This body of work reveals the double-edged sword of the host inflammatory response to urinary tract infection. In the bladder, mast cell activation and degranulation leads to granule-induced epithelial exfoliation and consequently a reduction in the bacterial burden in the bladder. However, the sustained inflammatory response that accompanies pyelonephritis in vesico-ureteric reflux-affected individuals results in significant damage to the kidney without any accompanying reduction in infection. These findings highlight the dueling roles of the host inflammatory response to infection in the upper and lower urinary tract and strongly suggest that differential clinical approaches to cystitis and pyelonephritis are necessary to promote an effective mast cell in the bladder in the former and facilitate the clearance of renal infection while mitigating tissue damage in the latter.</p> / Dissertation

Diss. (sammanfattning) Stockholm : Karolinska institutet, 2007. / Härtill 4 uppsatser.

Diss. (sammanfattning) Stockholm : Karolinska institutet, 2006. / Härtill 4 uppsatser.

Orientador: Elizete Aparecida Lomazi da Costa Pinto / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciencias Medicas / Made available in DSpace on 2018-08-07T00:13:55Z (GMT). No. of bitstreams: 1 Oliveira_AndreaDeande_M.pdf: 1182861 bytes, checksum: 40afd327a643407a1f1a9d4fa020e977 (MD5) Previous issue date: 2006 / Resumo: Na faixa etária pediátrica, a apresentação clínica da doença do refluxo gastroesofãgico é bastante inespecífica, dificultando o diagnóstico clínico da doença. A monitorização prolongada do pH intra-esofágico determina a freqüência e duração dos episódios de refluxo ácido para o esôfago, mas, em crianças acima de 2 anos, a relação entre os valores do índice de refluxo e as diferentes apresentações clinicas da doença de refluxo gastroesofãgico tem sido pouco avaliada. O presente estudo pretendeu identificar os resultados dos estudos prolongados do pH intra-esofágico e associá-los ao quadro clinico dos pacientes. A apresentação clínica foi dividida em quatro grupos, de acordo com a sintomatologia predominante: regurgitador, digestivo, respiratório e portadores de paralisia cerebral. A pesquisa desenvolveu-se por meio de estudo transversal, retrospectivo e analítico, através do levantamento dos resultados de monitorizações prolongadas do pH intra-esofágico realizadas no Hospital de Clínicas da Unicamp, no período de janeiro de 1999 a dezembro de 2004. Análises descritivas e de associação foram realizadas, foi utilizado o teste Qui Quadrado de Pearson ou Exato de Fisher. Os dados clínicos de 131 pacientes (1 a 20,6 anos) e seus respectivos exames foram revisados. Os motivos que mais freqüentemente determinaram a investigação laboratorial foram: vômitos, anemia, baixo ganho ponderal e pneumonias de repetição. Encontrou-se que 89 (67,9%) dos pacientes tinham um estudo de pHmetria anormal, mas no grupo regurgitador, o exame foi alterado em apenas 4 de 18 pacientes. Nenhuma das queixas clínicas esteve associada a valores de índice de refluxo > 4. Não houve associação significativa entre presença de esofagite péptica diagnosticada pela endoscopia digestiva alta e o valor do índice de refluxo. A distribuição dos valores de índice de refluxo em MPE não guardou relação com a manifestação clínica ou a presença de esofagite num grupo de crianças avaliadas em hospital universitário / Abstract: A diversity of symptoms may be attributed to gastroesophageal reflux disease in children. A 24-h pH monitoring of the lower esophagus identifies frequency and duration of the acid reflux episodes, but the association between symptoms of gastroesophageal reflux and pH-monitoring data has been investigated in few studies involving children. This study aimed to identify data of the pH-monitoring studies in children and correlate them to the clinical picture. Data of pH-monitoring studies performed from January 1999 to December 2004 in a Medical School Hospital were analyzed. Patients were classified into four groups according to their predominant clinical symptom: infant regurgitation, digestive symptoms, respiratory symptoms and cerebral palsy. Clinical data and pH-monitoring reports from 131 patients (1 to 20.6 years) were analyzed. The most frequent reasons for laboratorial investigation were vomiting, anemia, poor weight gain and recurrent pneumonia. It was found that 89 (67.9%) patients had an abnormal pH-metry study, although only 4 of 18 patients in the regurgitation group. No clinical group was related to reflux index >4. There was no significant association between peptic esophagitis, confirmed by upper digestive endoscopy, and reflux index. In this group of children reflux inex were not associated to clinical presentation or to upper digestive endoscopy data / Mestrado / Pediatria / Mestre em Saude da Criança e do Adolescente

Este trabalho tem por objetivo comparar dois modos de operação de destilação em batelada: com refluxo constante e composição do destilado constante. Desenvolveuse um modelo matemático para a destilação em batelada de uma mistura binária (metanol-etanol) para operação com cada um destes modos. O modelo consiste basicamente dos balanços de massa e entalpia, relações e diagramas de equilíbrio líquido-vapor (composição de equilíbrio, temperaturas de bolha e orvalho da mistura), estimativa das propriedades físico-químicas da mistura (calor específico, calor latente de vaporização), determinação do número de estágios ideais necessários à separação (pelo método de McCabe-Thiele), cálculo de cargas térmicas no refervedor e condensador, consumo de utilidades (vapor de água e água de resfriamento), estimativa do tempo de destilação e alguns aspectos econômicos sobre o processo (custos de equipamentos e operacionais, capacidade de produção, lucro mensal). Implementou-se em uma planilha eletrônica este modelo para as simulações matemáticas e análise técnico-econômica do processo. Em escala de laboratório (foram realizados, ao todo, oito ensaios, quatro de refluxo constante e quatro de refluxo variável, utilizando uma coluna de pratos perfurados), constatou-se uma boa concordância entre estes resultados experimentais e os calculados a partir da modelagem. Em seguida, estudaram-se, isoladamente em cada modo de operação e de modo comparativo, as principais variáveis de processo (taxa de refluxo, composição do destilado, quantidade de carga, vazão de destilado, etc.) através de simulações matemáticas, tanto no cenário de uma unidade existente como no caso do projeto de uma instalação nova. Para uma instalação existente, verificou-se, que no modo de destilação com composição de destilado constante, mantendo-se a vazão do vapor de topo constante, o tempo de destilação é menor, a capacidade de destilação é maior, resultando em maior lucro mensal. Para uma instalação a ser projetada, de novo, o processo mais vantajoso é o de refluxo variável e vazão de vapor do topo constante, pois requer menores áreas dos trocadores de calor para uma dada separação num tempo fixo de processo. No entanto, para o processamento de uma dada quantidade num mesmo tempo, à medida que se adota, no projeto, um número maior de estágios de separação na coluna, a diferença de lucro mensal torna-se praticamente indistinta para os modos de destilação estudados. / The aim of this study is to compare two operational methods of batch distillation of a binary system (methanolethanol): constant reflux and constant distillate composition. A phenomenological modeling concerning each mode was developed. It was based on material and enthalpy balances, equilibrium relationships, estimation of physical properties (specific heat and latent vaporization heat of mixtures), determination of ideal stages number (using McCabe-Thiele method), calculation of rebolier and condenser thermal loads and areas, steam and cooling water requirement, distillation time and some economical aspects. The mathematical model was implemented into an electronic spreadsheet. The predicted values were compared to experimental results from eight tests carried out in a laboratory sieve tray column (four at constant reflux and four at constant distillate composition), and a good consistency was found. Then several case studies concerning each distillation mode as well as the comparative performance were accomplished through mathematical simulations. Evaluation of the basic process variables such as reflux rate, initial load, distillate composition and flow rate was done. Rating of an existing plant and design of a new installation were considered in this process analysis. For an existing installation, lower distillation time, as well as higher distillation capacity and monthly profit were observed when distilling with constant distillate composition, keeping constant the flow rate of vapor from the column top. This process is also the more advantageous one when designing a new plant since smaller heat exchanger areas are required. However, to process a quantity in a same time, in a design of a new plan, as number of separation stages increases, monthly profit becomes almost the same among the studied distillation modes.