Role of Insulin: Perspectives

The pancreas in a non-diabetic patient invariably produces a lesser quantum of insulin (basal production). Insulin furnishes glucose homeostasis by keeping the plasma glucose worth in an optimum class throughout the day. It assists transport blood glucose into the body cells where the glucose is metabolized to generate energy. Regular insulin is inserted pre-meal to abrupt the postprandial ascend in glucose levels. It figures hexamers after insertion into the subcutaneous space sluggishing its absorption. Ultra-fast acting commences to act 4-7 minutes before regular apidra and lasts for around 3 hours. The absorption rate of lente insulin is downgraded by the extension of zinc to the insulin preparation. Long-acting insulins furnish basal insulin coverage. Atrophy of subcutaneous fat owing to applicability of further greater accumulated insulin preparations of neutral potenz hydrogen.

Ginkgo leaf sign on X-ray chest due to subcutaneous emphysema in a COVID-19 patient

Subcutaneous emphysema (SE) is usually encountered in cases of structural lung diseases and secondary to direct trauma or iatrogenic procedures for airway access. It is mostly associated with pneumothorax. The diagnosis is made clinically by palpation of the affected area and radiology. Here we presented a case of COVID-19 pneumonia presenting with extensive subcutaneous emphysema resulting in airway compression which was a very rare manifestation of COVID-19 infection. The COVID-19 infection led to extensive alveolar damage to the lungs and the chronic cough which may have led to this complication due to sudden change of pressure differences in the chest wall cavity. The limitation of using of personal protective equipments hindered the diagnosis of this condition as auscultation and the palpatory feelings were greatly hindered. The chest X-ray shows air in subcutaneous space and the prominence of the fibres of bilateral pectoralis muscles which gives an impression of the venous system of a Ginkgo leaf, so named as Ginkgo leaf sign.

Pneumomediastinum, Pneumoretroperitoneum, Pneumoperitoneum and Subcutaneous Emphysema Secondary to a Penetrating Anal Injury

Simultaneous occurrence of pneumoperitoneum, pneumoretroperitoneum, pneumomediastinum and subcutaneous emphysema is rare. The most reported mechanisms are barotrauma, thermal injury and instrument puncture caused by colonoscopy. Ectopic air may travel into different body compartments through distinct anatomical fascial planes. Definite curative treatment involves surgical repair of the bowel wall defect. Conservative treatment is available in selected patients. Here, we present a case of traumatic penetrating rectal injury leading to developing air in the peritoneum, retroperitoneum, mediastinum, and subcutaneous space with good recovery under conservative treatment.

Efficient Production of Human Hyaluronidase PH20 in HEK293T Cells Using Site Specific Integration

PH20 is hyaluronidase that hydrolyze the glycosidic bond of hyaluronic acid as a major proteoglycan found in extracellular matrices. PH20 is used in the subcutaneous space to increase the dispersion and absorption of co-administered drugs. PH20 is also injected against solid tumors for to better penetration of anticancer agents into the tumor tissue and inhibiting the tumor cell growth. In the present study, we have developed HEK293T stable cell lines secreting His-tagged human recombinant PH20 (rhPH20) in the culture supernatant through the PhiC31 integrase system. The produced rhPH20 was quantify using ELISA and turbidimetric assay and its activity was assessed through treatment of mouse cumulus-oocyte-complex (COCs). Furthermore, we have characterized genomic integration of PH20-containing vectors in one of the isolated clone with the highest levels of rhPH20 production. Our results demonstrated that the secreted rhPH20 in the culture supernatant contained a specific activity of approximately 3.5 IU/ml and it was properly able to denote all mouse oocytes. Consequently, it was revealed that PH20-expressing vectors integrated site-specifically in the PhiC31 pseudo attP sites in the host genome. Taken together, these results confirmed successful application of PhiC31 integrase as a robust approach for production of soluble, active rhPH20 in HEK293T cells.

Evidence for increased intraabdominal pressure as a cause of recurrent migration of the distal catheter of a ventriculoperitoneal shunt: illustrative case

BACKGROUNDPlacement of a ventriculoperitoneal (VP) shunt is an effective treatment for several disorders of cerebrospinal fluid flow. A rare complication involves postoperative migration of the distal catheter out of the intraperitoneal compartment and into the subcutaneous space. Several theories attempt to explain this phenomenon, but the mechanism remains unclear.OBSERVATIONSThe authors report the case of a 37-year-old nonobese woman who underwent placement of a VP shunt for idiopathic intracranial hypertension. Postoperatively, the distal catheter of the VP shunt migrated into the subcutaneous space on three occasions despite the use of multiple surgical techniques, including open and laparoscopic methods of abdominal catheter placement. Notably, the patient repeatedly displayed radiographic evidence of chronic bowel distention consistent with increased intraperitoneal pressure.LESSONSIn this case, the mechanism of catheter migration into the subcutaneous space did not appear to be caused by pulling of the catheter from above but rather by expulsion of the catheter from the peritoneum. Space in the subcutaneous tissues caused by open surgical placement of the catheter was permissive for this process. Patients with chronic increased intraabdominal pressure, such as that caused by bowel distention, obesity, or Valsalva maneuvers, may be at increased risk for distal catheter migration.

Paracostal Eventration of a Pregnant Uterus in a Bitch

Background: Traumatic abdominal hernias result from trauma which causes muscular and fascia rupture, with dislocation of viscera into the subcutaneous space without perforation of the skin. Paracostal eventration, occurs due to avulsion of the abdominal external oblique and abdominal transverse muscles from their insertion point at the ribs, resulting in dislocation of the abdominal viscera into the subcutaneous region, lateral to the abdominal wall; however, there are few reports in the literature describing this type of lesion in dogs, especially when the herniated content is a gravid uterus. The purpose of this paper is to report a case of traumatic paracostal hernia of a pregnant uterus in a dog.Case: A 2-year-old pregnant bitch weighing 8.9 kg was presented with a sudden increase in abdominal volume lateral to the left thoracic wall which, according to the owner, started after the dog was hit by a car. On physical examination, the dog had a greenish vaginal secretion and the increased volume on the left paracostal region mentioned above. Laboratory exams showed normocytic normochromic anemia, slight leukocytosis without a shift, and a discreet increase in creatinine, urea, and alanine aminotransferase. Abdominal radiographs showed a lack of continuity of the left abdominal muscle wall, with passage of the uterine horn into the subcutaneous space lateral to the rib cage. After stabilization of the patient with fluid therapy and analgesia, the bitch was anesthetized with propofol intravenously, and maintained with isoflurane diluted in oxygen. Cephazolin was administered intravenously 30 min prior to the surgery as prophylactic antibiotic therapy. An exploratory celiotomy was then performed, where a defect in the internal and external oblique abdominal muscles and transverse abdominal muscle was observed at their point of origin and insertion at the thirteenth rib. The left uterine artery and vein were also observed to be compromised, with several areas of hemorrhage noted on the left uterine horn. Surgical repair of the muscle defect was performed, anchoring the affected muscles to the rib. Ovariohysterectomy was performed after fetal death was confirmed. Patient recovery was uneventful after the procedure.Discussion: Paracostal eventration is the rarest type of herniation in small animals, and the fact that the uterus was dislocated in this case makes it even more atypical. A complete physical examination with special attention to the abdominal contour is extremely important in patients that have suffered trauma. The most characteristic sign of paracostal eventration is the change in abdominal and thoracic wall contours, as observed in the present report. Exploratory surgery is recommended as quickly as possible and as soon as the patient is stable enough to be anesthetized since this is an acute eventration with a risk of incarceration of the affected organs. In the present case, because it was a pregnant uterus, there was the risk of organ rupture or toxemia due to fetal death, which could bring more complications to the patient; these risks justify a ovariohysterectomy. The transverse abdominal and external and internal oblique abdominal muscles were anchored onto the last rib, as described in the literature. In conclusion, diagnosis of a paracostal eventration was possible from the medical history, physical exam, imaging studies, as well as exploratory celiotomy to evaluate the extent of the muscular defect and visceral damage and also to allow surgical correction. Suture of the abdominal musculature with anchorage to the thirteenth rib was an effective treatment.

Anesthetic Management for Emergent Repair of Tracheoinnominate Fistula

We present a case of a 30-year-old female, who had tracheostomy revision complicated by false passage into the subcutaneous space and pneumothorax. Six days later, she developed massive bleeding from the mouth, nose, and tracheostomy site. Approximately 2 liters of blood was lost. With high suspicion for tracheo-innominate fistula, she was emergently brought to the operating room for fistula repair. Her anesthetic management was initially focused on maintaining spontaneous ventilation with inhalation agents until surgical exposure was adequate. An endotracheal tube was then placed under guidance of a video-laryngoscope. The tracheostomy tube was then removed over a Cook catheter to maintain secure passage in case of airway collapse. The oral endotracheal tube was then inserted distal to the arterial and tracheal defect. The patient’s bleeding was stopped, the fistula was repaired, and she was transferred back to the intensive care unit, but she died several days later due to multi-organ failure.

Morphological changes of tissues after the implantation of the biodegradable threads for the correction of the involution of the hand’s back side skin

The aging process of the skin of the hand continuously progresses from mature to advanced age. With age, the skin of the hand becomes pigmented, dry, wrinkled with an emphasized skin pattern, the tone of the skin of the hand decreases, thinning and atrophy of adipose tissue are noted, skin elasticity is lost with the formation of an excess of hypoelastic thinned dermis. In recent years, smooth thread implants have been used to correct involutional changes in the skin of the back of the hand. The aim of the study was a morphological evaluation of the effectiveness of the correction of involutional changes in the skin of the back surface of the hand with thread implants based on polycaprolactone and poly-L-lactic acid (PCL-PLLA) with notches. Using light and electron microscopy, we studied the reaction of cells and intercellular substance to the introduction of biodegradable filaments into the subcutaneous space. It was found that implantation of PCL-PLLA filaments increases the reparative potential of tissues. 3 months after implantation, stimulation of neocollagenesis and angiogenesis in the dermis and hypodermis was noted. The functional and proliferative activity of cells increased. Mitotic activity of cells in the basal layer of the epidermis led to an increase in its thickness. A clinically confirmed effect was noted after 3 months and persisted for 18 months after implantation. Long biodegradation of the threads (1.5-2 years) helps to slow down the aging process of the skin of the back surface of the hand, prolonging the processes of tissue revitalization.

A scalable device-less biomaterial approach for subcutaneous islet transplantation

The subcutaneous space has been shown to be a suitable site for islet transplantation, however an abundance of islets is required to achieve normoglycemia, often requiring multiple donors. The loss of islets is due to the hypoxic conditions islets experience during revascularization, resulting in apoptosis. Therefore, to reduce the therapeutic dosage required to achieve normoglycemia, pre-vascularization of the subcutaneous space has been pursued. In this study, we highlight a biomaterial-based approach using a methacrylic acid copolymer coating to generate a robust pre-vascularized subcutaneous cavity for islet transplantation. We also devised a simple, but not-trivial, procedure for filling the cavity with an islet suspension in collagen. We show that the pre-vascularized site can support a marginal mass of islets to rapidly return streptozotocin-induced diabetic SCID/bg mice to normoglycemia. Furthermore, immunocompetent Sprague Daley rats remained normoglycemia for up to 70 days until they experienced graft destabilization as they outgrew their implants. This work highlights methacrylic acid-based biomaterials as a suitable pre-vascularization strategy for the subcutaneous space that is scalable and doesn’t require exogenous cells or growth factors.SummaryIn this study methacrylic acid copolymer coated tubes generated a robust vascular response in the subcutaneous space, which was critical to support islet transplantation in a streptozotocin-induced diabetic mouse model. More importantly, the subcutaneous pre-vascularization approach using this copolymer coating was scalable into a larger allogeneic rat model and returned animals to normoglycemia for up to 70 days. This platform highlights the potential of a scalable biomaterial approach for pre-vascularization of the subcutaneous space in larger animal models.