Minimally invasive esophagectomy: state of the art

Open esophagectomy is associated with significant mortality and morbidity, even in experienced centers. Two of the more frequent complications following esophagectomy are pneumonia and respiratory failure. Single-institution series have suggested that the incidence of these complications may be decreased with minimally invasive esophagectomy, with equivalent survival compared to open esophagectomy. However, this operation is technically challenging. In this review we detail the procedure as performed in our center, and also discuss some recent developments.

Rearrangement of lipid ordered phases upon protein adsorption due to multiple site binding

This study involves the interactions of proteins with Langmuir monolayers of a metal-chelating lipid, where adsorption is driven by a strong specific interaction between histidines on the proteins and divalent metal ions loaded into the lipid headgroups. A comparison of the structural rearrangement of the lipid film upon adsorption of myoglobin and a synthetic peptide, each of which have multiple histidines, with that upon the adsorption of lysozyme, which has only one histidine, suggests that the lipid rearrangement in the former case is due to the multiplicity of binding sites. The kinetics and manner of rearrangement change with the binding energy and film pressure.

Evidence for vertical phase separation in densely grafted, high-molecular-weight poly(-isopropylacrylamide) brushes in water

The detailed conformational change of poly(N-isopropylacrylamide) (PNIPAM) brushes at high grafting density in D2O was investigated as a function of temperature using neutron reflection. PNIPAM chains were grafted at high surface density from gold and silicon oxide surfaces by atom transfer radical polymerization. Whereas single layer profiles were observed for temperatures below and above the transition region, bilayer profiles were observed for a narrow range of temperatures near the transition. This nonmonotonic change in the concentration profile with temperature is discussed in the context of theoretical models of vertical phase separation within a brush.

Adsorption of myoglobin to Cu(II)-IDA and Ni(II)-IDA functionalized langmuir monolayers: study of the protein layer structure during the adsorption process by neutron and X-ray reflectivity

The structure and orientation of adsorbed myoglobin as directed by metal-histidine complexation at the liquid-film interface was studied as a function of time using neutron and X-ray reflectivity (NR and XR, respectively). In this system, adsorption is due to the interaction between iminodiacetate (IDA)-chelated divalent metal ions Ni(II) and Cu(II) and histidine moieties at the outer surface of the protein. Adsorption was examined under conditions of constant area per lipid molecule at an initial pressure of 40 mN/m. Adsorption occurred over a time period of about 15 h, allowing detailed characterization of the layer structure throughout the process. The layer thickness and the in-plane averaged segment volume fraction were obtained at roughly 40 min intervals by NR. The binding constant of histidine with Cu(II)-IDA is known to be about four times greater than that of histidine with Ni(II)-IDA. The difference in interaction energy led to significant differences in the structure of the adsorbed layer. For Cu(II)-IDA, the thickness of the adsorbed layer at low protein coverage was < or = 20 A and the thickness increased almost linearly with increasing coverage to 42 A. For Ni(II)-IDA, the thickness at low coverage was approximately 38 A and increased gradually with coverage to 47 A. The in-plane averaged segment volume fraction of the adsorbed layer independently confirmed a thinner layer at low coverage for Cu(II)-IDA. These structural differences at the early stages are discussed in terms of either different preferred orientations for isolated chains in the two cases or more extensive conformational changes upon adsorption in the case of Cu(II)-IDA. Subphase dilution experiments provided additional insight, indicating that the adsorbed layer was not in equilibrium with the bulk solution even at low coverages for both IDA-chelated metal ions. We conclude that the weight of the evidence favors the interpretation based on more extensive conformational changes upon adsorption to Cu(II)-IDA.

Hygrothermal degradation of (3-glycidoxypropyl)trimethoxysilane films studied by neutron and X-ray reflectivity and attenuated total reflection infrared spectroscopy

Thin films of organosilanes have great technological importance in the areas of adhesion promotion, durability, and corrosion resistance. However, it is well-known that water can degrade organosilane films, particularly at elevated temperatures. In this work, X-ray and neutron reflectivity (XR and NR) were combined with attenuated total reflection infrared (ATR-IR) spectroscopy to study the chemical and structural changes within thin films of (3-glycidoxypropyl)trimethoxysilane (GPS) after exposure for various periods of time to air saturated with either D2O or H2O at 80 degrees C. For NR and XR, ultrathin (approximately 100 A) films were prepared by spin-coating. Both D2O and H2O provide neutron scattering contrast with GPS. Variations in the neutron scattering length density (SLD) profiles (a function of mass density and atomic composition) with conditioning time were measured after drying the samples out and also swelled with H2O or D2O vapor at room temperature. For samples that were dried out prior to measurement, little or no change was observed for H2O conditioning up to 3.5 days, but large changes were observed after 30 days of conditioning. The range of conditioning time for this structural change was narrowed to between 4 and 10 days with XR. The SLD profiles indicated that the top portion of the GPS film was transformed into a thick low-density layer after conditioning, but the bottom portion showed little structural change. A previous NR study of as-prepared GPS films involving swelling with deuterated nitrobenzene showed that the central portion of the film has much lower cross-link density than the region nearest the substrate. The present data show that the central portion also swells to a much greater extent with water and hydrolyzes more rapidly. The chemical degradation mechanism was identified by IR as hydrolysis of siloxane bonds. For ATR-IR, GPS films were prepared by dip-coating, which resulted in a greater and more variable thickness than for the spin-coated samples. The IR spectra revealed an increase in vicinal silanol generation over the first 3 days of conditioning followed by geminal silanol generation. Thus, the structural change detected by NR and XR roughly coincided with the onset of geminal silanol generation. Finally, little change in the reflectivity data was observed for films conditioned with D2O at 80 degrees C for 1 month. This indicates that hydrolysis of Si-O-Si is much slower with D2O than with H2O.

The effects of network structure on the resistance of silane coupling agent layers to water-assisted crack growth

Silane adhesion promoters are commonly used to improve the adhesion, durability, and corrosion resistance of polymer-oxide interfaces. The current study investigates a model interface consisting of the natural oxide of(100) Si and an epoxy cured from diglycidyl ether ofbisphenol A (DGEBA) and triethylenetetraamine (TETA). The thickness of (3-glycidoxypropyl)trimethoxysilane (GPS) films placed between the two materials provided the structural variable. Five surface treatments were investigated: a bare interface, a rough monolayer film, a smooth monolayer film, a 5 nm thick film, and a 10 nm thick film. Previous neutron reflection experiments revealed large extension ratios (>2) when the 5 and 10 nm thick GPS films were exposed to deuterated nitrobenzene vapor. Despite the larger extension ratio for the 5 nm thick film, the epoxy/Si fracture energy (Gc) was equal to that of the 10 nm thick film under ambient conditions. Even the smooth monolayer exhibited the same Gc. Only when the monolayer included a significant number of agglomerates did the Gc drop to levels closer to that of the bare interface. When immersed in water at room temperature for 1 week, the threshold energy release rate (Gth) was nearly equal to Gc for the smooth monolayer, 5 nm thick film, and 10 nm thick film. While the Gth for all three films decreased with increasing water temperature, the Gth of the smooth monolayer decreased more rapidly. The bare interface was similarly sensitive to temperature; however, the Gth of the rough monolayer did not change significantly as the temperature was raised. Despite the influence of pH on hydrolysis, the Gth was insensitive to the pH of the water for all surface treatments.

Analysis of myoglobin adsorption to Cu(II)-IDA and Ni(II)-IDA functionalized Langmuir monolayers by grazing incidence neutron and X-ray techniques

The adsorption of myoglobin to Langmuir monolayers of a metal-chelating lipid in crystalline phase was studied using neutron and X-ray reflectivity (NR and XR) and grazing incidence X-ray diffraction (GIXD). In this system, adsorption is due to the interaction between chelated divalent copper or nickel ions and the histidine moieties at the outer surface of the protein. The binding interaction of histidine with the Ni-IDA complex is known to be much weaker than that with Cu-IDA. Adsorption was examined under conditions of constant surface area with an initial pressure of 40 mN/m. After approximately 12 h little further change in reflectivity was detected, although the surface pressure continued to slowly increase. For chelated Cu2+ ions, the adsorbed layer structure in the final state was examined for bulk myoglobin concentrations of 0.10 and 10 microM. For the case of 10 microM, the final layer thickness was approximately 43 A. This corresponds well to the two thicker dimensions of myoglobin in the native state (44 A x 44 A x 25 A) and so is consistent with an end-on orientation for this disk-shaped protein at high packing density. However, the final average volume fraction of amino acid segments in the layer was 0.55, which is substantially greater than the value of 0.44 calculated for a completed monolayer from the crystal structure. This suggests an alternative interpretation based on denaturation. GIXD was used to follow the effect of protein binding on the crystalline packing of the lipids and to check for crystallinity within the layer of adsorbed myoglobin. Despite the strong adsorption of myoglobin, very little change was observed in the structure of the DSIDA film. There was no direct evidence in the XR or GIXD for peptide insertion into the lipid tail region. Also, no evidence for in-plane crystallinity within the adsorbed layer of myoglobin was observed. For 0.1 microM bulk myoglobin concentration, the average segment volume fraction was only 0.13 and the layer thickness was < or = 25 A. Adsorption of myoglobin to DSIDA-loaded with Ni2+ was examined at bulk concentrations of 10 and 50 microM. At 10 microM myoglobin, the adsorbed amount was comparable to that obtained for adsorption to Cu2+-loaded DSIDA monolayers at 0.1 M. But interestingly, the adsorbed layer thickness was 38 A, substantially greater than that obtained at low coverage with Cu-IDA. This indicates that either there are different preferred orientations for isolated myoglobin molecules adsorbed to Cu-IDA and Ni-IDA monolayer films or else myoglobin denatures to a different extent in the two cases. Either interpretation can be explained by the very different binding energies for individual interactions in the two cases. At 50 microM myoglobin, the thickness and segement volume fraction in the adsorbed layer for Ni-IDA were comparable to the values obtained with Cu-IDA at 10 microM myoglobin.

Beryllium sensitization and disease among long-term and short-term workers in a beryllium ceramics plant

OBJECTIVE

Workers at a beryllium ceramics plant were tested for beryllium sensitization and disease in 1998 to determine whether the plant-wide prevalence of sensitization and disease had declined since the last screening in 1992; an elevated prevalence was associated with specific processes or with high exposures; exposure-response relationships differed for long-term workers hired before the last plant-wide screening and short-term workers hired since then.

METHODS

Current workers were asked to complete a questionnaire and to provide blood for the beryllium lymphocyte proliferation test (BeLPT). Those with an abnormal BeLPT were classified as sensitized, and were offered clinical evaluation for beryllium disease. Task- and time-specific measurements of airborne beryllium were combined with individual work histories to compute mean, cumulative, and peak beryllium exposures for each worker.

RESULTS

The 151 participants represented 90% of 167 eligible workers. Fifteen (9.9% of 151) had an abnormal BeLPT and were split between long-term workers (8/77 = 10.4%) and short-term workers (7/74 = 9.5%). Beryllium disease was detected in 9.1% (7/77) of long-term workers but in only 1.4% (1/74) of short-term workers (P = 0.06), for an overall prevalence of 5.3% (8/151). These prevalences were similar to those observed in the earlier survey. The prevalence of sensitization was elevated in 1992 among machinists, and was still elevated in 1998 among long-term workers (7/40 = 18%) but not among short-term workers (2/36 = 6%) with machining experience. The prevalence of sensitization was also elevated in both groups of workers for the processes of lapping, forming, firing, and packaging. The data suggested a positive relationship between peak beryllium exposure and sensitization for long-term workers and between mean, cumulative, and peak exposure and sensitization for short-term workers, although these findings were not statistically significant. Long-term workers with either a high peak exposure or work experience in forming were more likely to have an abnormal BeLPT (8/51 = 16%) than the other long-term workers (0/26, P = 0.05). All seven sensitized short-term workers either had high mean beryllium exposure or had worked longest in forming or machining (7/55 = 13% versus 0/19, P = 0.18).

CONCLUSIONS

A plant-wide decline in beryllium exposures between the 1992 and 1998 surveys was not matched by a decline in the prevalence of sensitization and disease. Similar to findings from other studies, beryllium sensitization/disease was associated with specific processes and elevated exposures. The contrast in disease prevalence between long-term and short-term workers suggests that beryllium sensitization can occur after a short period of exposure, but beryllium disease usually requires a longer latency and/or period of exposure. The findings from this study motivated interventions to more aggressively protect and test workers, and new research into skin exposure as a route of sensitization and the contribution of individual susceptibility.

A Comparison and Critique of Historical and Current Exposure Assessment Methods for Beryllium: Implications for Evaluating Risk of Chronic Beryllium Disease

The primary beryllium industry has generated a large amount of data on airborne beryllium concentrations that has been used to characterize exposure by task-specific activities, job category, individual worker, and processing area using a variety of methods. These methods have included high-volume breathing zone sampling, high-volume process sampling, high- and low-volume respirable and area sampling, real-time monitoring, and personal sampling. Many of the beryllium studies have used these air sampling methods to assess inhalation exposure and chronic beryllium disease (CBD) risk to beryllium; however, available data do not show a consistent dose-response relationship between airborne concentrations of beryllium and the incidence of CBD. In this article, we describe the air sampling and exposure assessment methods that have been used, review the studies that have estimated worker exposures, discuss the uncertainties associated with the level of beryllium for which these studies have reported an increased risk of CBD, and identify future investigative exposure assessment strategies. Our evaluation indicated that studies of beryllium workers are often not directly comparable because they (1) used a variety of exposure assessment methods that are not necessarily representative of individual worker exposures, (2) rarely considered respirator use, and (3) have not evaluated changes in work practices. It appears that the current exposure metric for beryllium, total beryllium mass, may not be an appropriate measurement to predict the risk of CBD. Other exposure metrics such as mass of respirable particles, chemical form, and particle surface chemistry may be more related to the prevalence of CBD than total mass of airborne beryllium mass. In addition, assessing beryllium exposure by all routes of exposure (e.g., inhalation, dermal uptake, and ingestion) rather than only inhalation exposure in future studies may prove useful.

Is Total Mass or Mass of Alveolar-Deposited Airborne Particles of Beryllium a Better Predictor of the Prevalence of Disease? A Preliminary Study of a Beryllium Processing Facility

Cases of chronic beryllium disease (CBD) and beryllium (Be) sensitization continue to be identified among Be industry workers. The currently accepted method for measuring exposure, which involves measuring the total mass of airborne Be per cubic meter, shows an inconsistent dose-response relationship with the prevalence of CBD. This study was conducted to evaluate which Be aerosol characteristics other than total mass may be more informative in understanding the dose-response relationship between exposure to Be and disease. Personal (n = 53) and general (n = 55) area airborne Be samples were collected in five furnace areas at a Be manufacturing facility where prevalence rates of CBD and Be sensitization had been previously studied among 535 employees with significant Be exposure. In the five furnace areas, particle-size specific personal samples and area samples were collected using an Andersen impactor and a microorifice uniform deposit impactor (MOUDI), respectively. The calculated concentrations were expressed in terms of total mass per cubic meter, and in forms of mass, number, and surface area of particles less than 10 microm or less than 3.5 microm mass median aerodynamic diameter per cubic meter that are predicted to deposit in the alveolar region of the lung. Tests for linear trend of the relationships of the various exposure metrics to prevalence of CBD and sensitization demonstrated highly significant associations between mass concentration (MOUDI) of particles less than 10 microm, and less than 3.5 microm, predicted to deposit in the alveolar region of the lung and CBD (p = 0.0004 and 0.000003, respectively) and sensitization (p = 0.025 and 0.003, respectively). However, no statistically significant association was found between these two exposure metrics and personal (Andersen) samples. The number and surface area concentration (MOUDI) of alveolar-deposited particles (less than 10 microm) also showed significant relationships with CBD (p = 0.03 and 0.03, respectively). No other exposure parameters showed significant relationships with CBD or Be sensitization. These results suggest that the concentration of alveolar-deposited particles less than 10 microm or, more particularly, the concentration of alveolar-deposited particles less than 3.5 microm may be a more relevant exposure metric for predicting the incidence of CBD or sensitization than the total mass concentration of airborne Be.

Ultrafine Beryllium Number Concentration as a Possible Metric for Chronic Beryllium Disease Risk

Beryllium is a lightweight metal which causes a chronic granulomatous lung disease among workers who become sensitized to it. Recent research has shown a persistence of the disease despite efforts at control with mean exposures below the Occupational Safety and Health Administration (OSHA) occupational exposure limit of 2 microg/m3. Results of our current research confirm a previous finding in certain plants that particle number concentrations are higher in areas where historical estimate of risk showed a high risk of disease despite relatively lower mass concentrations. By providing side-by-side measurements of both particle number and mass, this research adds support to the proposal that particle number rather than particle mass may be more reflective of target organ dose and subsequently a more appropriate measure of exposure for chronic beryllium disease. Our evidence also shows that particle mass exposure measurements and particle number exposure measurements were not correlated.

Spinal cord swelling preceding syrinx development. Case report

The pathophysiology of syrinx development is controversial. The authors report on a patient with progressive cervical myelopathy and a Chiari I malformation in whom spinal cord swelling preceded, by a few months, the development of a syrinx in the same location. The patient underwent a craniocervical decompressive procedure and duraplasty, and complete resolution of cord swelling and syringomyelia was achieved. This report is consistent with the theory that patients with Chiari I malformation have increased transmural flow of cerebrospinal fluid, which causes spinal cord swelling that later coalesces into a syrinx. The pathophysiology of syrinx development from spinal cord edema and the success of surgical decompressive treatments that do not invade the central nervous system support the prompt treatment of patients with spinal cord edema who are at risk for the development of a syrinx.