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PubMed2006

The EXIT procedure: principles, pitfalls, and progress.

Although performing procedures on a fetus before severing the umbilical cord has previously been reported, the principles of the ex utero intrapartum treatment (EXIT) procedure were first fully developed for reversing tracheal occlusion in fetuses with severe congenital diaphragmatic hernia. The EXIT procedure offers the advantage of insuring uteroplacental gas exchange while on placental support. The lessons learned in the development of the principles that underlie the EXIT procedure have improved outcomes when applied in other conditions, most notably in cases of airway obstruction. The range of indications for the EXIT procedure has expanded and currently includes giant fetal neck masses, lung or mediastinal tumors, congenital high airway obstruction syndrome, and EXIT to ECMO (extracorporeal membrane oxygenation), among others. This review summarizes the underlying principles of the EXIT procedure, the expanding indications for its use, the pitfalls of management, and the progress that has been made in its successful application.

Airway Obstruction↗
PubMed2002

The EXIT procedure: experience and outcome in 31 cases.

BACKGROUND: The EXIT (ex utero intrapartum treatment) procedure, although initially designed for reversal of tracheal occlusion in fetuses with congenital diaphragmatic hernias (CDH), has been adapted to treat a variety of fetal conditions. METHODS: A retrospective chart review of all consecutive EXIT procedures since 1996 was conducted. RESULTS: Thirty-one women underwent the EXIT procedure, with an average maternal age of 29 years (range, 20 to 38), and average gestational age of 34 weeks (range, 29 to 40). The indication was airway obstruction from fetal neck mass in 13, and reversal of tracheal occlusion from in utero clipping in 13. Singular indications included an EXIT-to-ECMO (extracorporeal membrane oxygenation) procedure for a fetus with CDH and a cardiac defect (n = 1), congenital high airway obstruction syndrome (CHAOS, n = 1), resection of a very large congenital cystic adenomatoid malformation of the lung (CCAM) on uteroplacental bypass (n = 1), unilateral pulmonary agenesis (n = 1), and thoracoomphalopagus conjoined twins. The mean duration on uteroplacental bypass (from uterine incision to umbilical cord clamping) was 30.3 plus minus 14.7 minutes (range, 8 to 66). No fetus experienced hemodynamic instability during uteroplacental bypass as recorded by fetal heart rate (FHR), pulse oximeter, and fetal echocardiography, except for one instance of reversible bradycardia from umbilical cord compression. The mean FHR and fetal saturation were 153.0 plus minus 38.5 beats per minute and 71.2% plus minus 19.9%, respectively. Five fetuses required a tracheostomy. Only 1 death occurred during an EXIT procedure because of inability to secure the airway secondary to extensive involvement by a lymphangioma. The average cord pH and pCO(2) were, respectively, 7.20 plus minus 0.11 and 63.2 plus minus 14.6. Two maternal complications occurred: bleeding from a hysterotomy site and dehiscence of an old hysterotomy scar noticed at a subsequent cesarean section. The average maternal blood loss was 848.3 plus minus 574.1 mL. CONCLUSION: The EXIT procedure was used successfully to ensure uteroplacental gas exchange and fetal hemodynamic stability during a variety of surgical procedures performed to secure the fetal airway or ensure successful transition to postnatal environment.

Adult↗
PubMed1999

[Exit of the retinal central vascular trunk and extent of para-papillary atrophy].

PURPOSE: To evaluate whether the position of the central retinal vessel trunk exit on the lamina cribrosa spatially correlates with the location of parapapillary atrophy in glaucoma. METHODS: Color stereo optic disc photographs of 79 patients with primary or secondary open-angle glaucoma and 53 normal subjects were morphometrically evaluated. We determined the position of the central retinal vessel trunk exit on the lamina cribrosa surface and measured the area of parapapillary atrophy in four 90 degrees quadrants. RESULTS: After correction for normal values, the beta zone area of parapapillary atrophy in the glaucoma eyes was significantly larger, when measured in the disc quadrant most distant to the central retinal vessel trunk exit than as if measured in the quadrant containing the vessel trunk exit. CONCLUSIONS: Position of the central retinal vessel trunk exit on the lamina cribrosa influences the location of parapapillary atrophy in glaucoma. The longer the distance to the central retinal vessel trunk exit, the more enlarged is parapapillary atrophy.

Adult↗
PubMed1999

Pds1 and Esp1 control both anaphase and mitotic exit in normal cells and after DNA damage.

The separation of sister chromatids in anaphase is followed by spindle disassembly and cytokinesis. These events are governed by the anaphase-promoting complex (APC), which triggers the ubiquitin-dependent proteolysis of key regulatory proteins: anaphase requires the destruction of the anaphase inhibitor Pds1, whereas mitotic exit requires the destruction of mitotic cyclins and the inactivation of Cdk1. We find that Pds1 is not only an inhibitor of anaphase, but also blocks cyclin destruction and mitotic exit by a mechanism independent of its effects on sister chromatid separation. Pds1 is also required for the mitotic arrest and inhibition of cyclin destruction that occurs after DNA damage. Even in anaphase cells, where Pds1 levels are normally low, DNA damage stabilizes Pds1 and prevents cyclin destruction and mitotic exit. Pds1 blocks cyclin destruction by inhibiting its binding partner Esp1. Mutations in ESP1 delay cyclin destruction; overexpression of ESP1 causes premature cyclin destruction in cells arrested in metaphase by spindle defects and in cells arrested in metaphase and anaphase by DNA damage. The effects of Esp1 are dependent on Cdc20 (an activating subunit of the APC) and on several additional proteins (Cdc5, Cdc14, Cdc15, Tem1) that form a regulatory network governing mitotic exit. We speculate that the inhibition of cyclin destruction by Pds1 may contribute to the ordering of late mitotic events by ensuring that mitotic exit is delayed until after anaphase is initiated. In addition, the stabilization of Pds1 after DNA damage provides a mechanism to delay both anaphase and mitotic exit while DNA repair occurs.

Anaphase↗
PubMed1994

Treatment of patients with prior exit block using a novel steroid-eluting active fixation lead. Model 4068 Investigators.

An increased interest has developed in active fixation leads for several reasons. Exit block is an uncommon complication that is seen with both active and passive fixation leads. Exit block has not been a significant problem with passive fixation steroid-eluting leads and has been treated with these leads. A new steroid-eluting active fixation lead was examined for its performance in patients in whom exit block had previously occurred. The lead function was evaluated prospectively in 24 patients with a history of exit block (15 ventricular and 9 atrial). The results in patients with atrial exit block are encouraging with an average chronic stimulation threshold of 0.19 msecs at 2.5 volts. Results in the ventricle are less encouraging with 3 occurrences of recurrent exit block in 15 patients; however, the remaining patients had a good mean threshold of 0.21 +/- 0.11 msecs at 2.5 volts. There were a remarkable number of non-lead related complications suggesting that this is a substantially different group than routine implantations.

Cardiac Pacing, Artificial↗
PubMed2007

Exit-site care in peritoneal dialysis.

Exit-site infection (ESI), tunnel infection and associated peritonitis are major causes of morbidity and catheter loss in chronic peritoneal dialysis patients. Meticulous exit-site care is vital in preventing ESI. Avoiding trauma to the exit-site and daily cleaning of the exit-site with a dedicated antimicrobial soap is essential for the longevity of the peritoneal dialysis catheter. Antibiotics cream and disinfectant agents including povidone-iodine, chlorhexidine, electrolytic chloroxidizing solutions (Amuchina 10% - ExSept Plus, Amuchina 5% - ExSept) are useful to keep the resident micro-organisms inhibited. ESI rates in peritoneal dialysis patients treated with Amuchina 10% (ExSept Plus) and Amuchina 5% (ExSept) for the exit-site care are similar or lower compared to povidone-iodine or chlorhexidine. Electrolytic chloroxidizing (Amuchina 10% - ExSept Plus and Amuchina 5% - ExSept) solutions for exit-site care are effective for prevention and treatment of ESI.

Anti-Bacterial Agents↗
PubMed2004

Voting with their feet: patient exit and intergroup differences in propensity for switching usual source of care.

Many analysts advocate patient exit as a strategy for consumers who experience poor-quality care. Exit is believed to have the potential to improve patient welfare by having patients leave (or "exit") poor-performing health care providers, thus signaling their dissatisfaction with the quality of care they have received and thereby admonishing those providers to improve. However, the validity of exit as a signal of consumer dissatisfaction hinges on how closely it reflects dissatisfaction. Intergroup differences in the propensity to exit could also result in unintended consequences. This article examines the association between consumer experience and the decision to change one's usual care providers. It also investigates if there are any intergroup differences in the propensity for changing providers according to insurance status, gender, and race or ethnicity. Data come from household surveys conducted by the Center for Studying Health System Change. Results show significant intergroup differences in propensity for switching usual source of care for voluntary or involuntary reasons related to insurance, rural residency, age, income, race, and ethnicity. Policy implications of the empirical results on exit, voice, and consumerism are discussed.

Decision Making↗
PubMed2005

Characterization of the TGN exit signal of the human mannose 6-phosphate uncovering enzyme.

The human mannose 6-phosphate uncovering enzyme participates in the uncovering of the mannose 6-phosphate recognition tag on lysosomal enzymes, a process that facilitates recognition of those enzymes by mannose 6-phosphate receptors to ensure delivery to lysosomes. Uncovering enzyme has been identified on the trans-Golgi network at steady state. It has been shown to traffic to the plasma membrane from where it is rapidly internalized via endosomal structures, the process being mediated by a tyrosine-based internalization motif, Y488HPL, in its cytoplasmic tail. Using immunogold electron microscopy a GFP-uncovering enzyme fusion construct was found to be colocalized with the cation-dependent mannose 6-phosphate receptor in regions of the trans-Golgi network, suggesting that uncovering enzyme might follow a similar pathway of exit from the trans-Golgi network as that of the cation-dependent mannose 6-phosphate receptor. In this study, we identified the signal sequence in the cytoplasmic tail of uncovering enzyme responsible for its exit from the trans-Golgi network. Using GFP fusion constructs of the transmembrane and cytoplasmic domains of uncovering enzyme, we could show, by automated analysis of confocal immunofluorescence images, that residues Q492EMN in the cytoplasmic tail of uncovering enzyme are involved in its exit from the trans-Golgi network. Detailed characterization of the exit signal revealed that residue Q492 is the most important to the exit function while M494 and N495 also contribute. The cytoplasmic tail of the uncovering enzyme does not possess any of the known canonical signal sequences for interaction with Golgi-associated gamma ear-containing adaptor proteins. The identification of a trans-Golgi network exit signal in its cytoplasmic tail elucidates the trafficking pathway of uncovering enzyme, a crucial player in the process of lysosomal biogenesis.

Gene Expression Regulation, Enzymologic↗
PubMed2001

Grazing-exit X-ray spectrometry for surface and thin-film analyses.

Electron-probe x-ray micro analysis (EPMA) and particle-induced x-ray emission analysis (PIXE) were performed under grazing-exit conditions. To control the exit angle (take-off angle), a new sample holder having a stepping motor was developed for grazing-exit EPMA. A carefully polished surface of a stainless-steal sample was measured. The surface of stainless steel is normally covered with a thin native oxide layer. The intensity ratio of Cr K(alpha) to Fe K(alpha) increases significantly at the grazing angle, becoming about 5-times larger at 0.2 degrees than at 40 degrees. This result indicates that grazing-exit EPMA is useful for surface analysis. In addition, a new PIXE equipment was developed for grazing-exit x-ray measurements. The sample is fixed and the x-ray detector is moved by applying a linear stage. Preliminary experimental results of grazing-exit PIXE are also shown.

Journal Article↗
PubMed2004

Factors affecting the decision to exit dairy farming: a two-stage regression analysis.

Substantial attention has focused on the dairy industry because of a concern that many producers are getting out of dairying. Although low milk prices are postulated as a primary reason for exits from dairying, other factors may be important as well. Data from a representative 64-farm subset of a 2002 survey of dairy producers in Maine were used in the current study. Of the 64 farms, 15 indicated an imminent exit from dairying, whereas 49 dairy farms expected to remain in business for > or =5 yr. A binary choice logit regression model, based upon the dependent variable decision to exit or remain in the industry, was used as part of a 2-stage regression process to ascertain why dairy producers are choosing to leave the industry. The hypothesis states that the decision is a function of 3 independent variable categories: demographic, efficiency, and opportunity costs. Four variables were revealed that significantly influence the exit decision. Older producers, higher off-farm income, lower returns over variable cost, and greater diversification of farm income were more likely associated with a decision to leave dairy farming. Because factors other than milk price are involved in exit decisions, perhaps national or regional dairy programs should consider strategies beyond price supports to provide for a stable dairy industry and a reduction in the rate of dairy farm exits.

Animals↗
PubMedDate not supplied

A comparative analysis on the incidence of peritonitis and exit-site infection in CAPD and automated peritoneal dialysis.

OBJECTIVE: To compare the incidence of peritonitis and exit-site infection in an ample group of patients undergoing continuous ambulatory peritoneal dialysis (CAPD) and automated peritoneal dialysis in a single center during a 10-year period. DESIGN: Nonrandomized, prospective study. SETTING: Public, tertiary care hospital providing peritoneal dialysis care to a population of (approximately) 750 000 people. PATIENTS: We studied 213 patients on CAPD and 115 on automated peritoneal dialysis (APD) starting therapy between January 1989 and August 1998, with a minimum follow-up of 3 months. MAIN OUTCOME MEASURES: Using a multivariate approach, we compared the incidence, clinical course, and outcome of peritonitis and exit-site infections in both groups, controlling for other risk factors for the complications studied. RESULTS: The incidence of peritonitis was higher in CAPD than in APD (adjusted difference 0.20 episodes/ patient/year, 95% confidence interval 0.08 - 0.32). There was a trend for CAPD patients to present earlier with peritonitis than APD patients, yet the incidence of and survival to the first exit-site infection were similar in both groups. The etiologic spectrum of infections displayed minor differences between groups. Automated PD patients were more frequently hospitalized for peritonitis, but otherwise, the complications and outcome of peritonitis and exit-site infections did not differ significantly between patients on CAPD and those on APD. CONCLUSIONS: Automated PD is associated with a lower incidence of peritonitis than is CAPD, while exit-site infection is similarly incident under both modes of therapy. The etiologic spectrum, complications, and outcome of peritonitis and exit-site infection do not differ markedly between CAPD and APD. Prevention of peritonitis should be included among the generic advantages of APD over CAPD.

Catheters, Indwelling↗
PubMedDate not supplied

Surgical management of refractory exit-site/tunnel infection of Tenckhoff catheter: technical innovations of partial replantation.

OBJECTIVE: Catheter-related infection has been the major cause of catheter removal for peritoneal dialysis (PD) patients. A salvage technique--partial replantation of the infected catheter--was developed in our hospital to rescue catheters with refractory exit-site or tunnel infection. PATIENTS: We performed 26 partial replantations of Tenckhoff catheters for 23 patients with refractory exit-site or tunnel infection and 2 patients with near-cuff perforation of the catheter. Their problems were all resolved successfully without interruption of PD. INTERVENTIONS: We removed the infected portion of the catheter and preserved the still-functioning internal conduit, connecting it to a divided new catheter. All of the patients resumed PD immediately after the advancement of the new catheter through a new subcutaneous tunnel and exit site on the opposite side. RESULTS: No technical complications such as disconnection of the catheter or leakage of dialysate were noted. Repeated partial replantation of the catheter was done for 1 patient with a new refractory exit-site infection. Tunnel infection was not an absolute contraindication for this procedure. About one third (34.6%) of our patients had preoperative tunnel infection. CONCLUSION: Partial replantation of a Tenckhoff catheter is a simple and effective procedure for patients with refractory exit-site/tunnel infection and patients with near-cuff perforation of the catheter. Repeated partial replantation is also feasible for repeat exit-site infections.

Adolescent↗
PubMedDate not supplied

Decrease in infections with the introduction of mupirocin cream at the peritoneal dialysis catheter exit site.

UNLABELLED: Staphylococcus aureus associated peritonitis and catheter exit site infections (ESI) are an important cause of hospitalization and catheter loss in the patients undergoing chronic peritoneal dialysis (PD). We aimed to determine the potential effectiveness of the application of mupirocin cream at the catheter exit site in preventing exit site infection and peritonitis. METHODS: This prospective historically controlled study was done in a total of 86 patients who entered our PD program from April 1999 to January 2001. They were instructed to apply Mupirocin cream 2% to the exit site daily or on alternate days. The patients were not screened to determine whether they were staphylococcus aureus carriers. One hundred and thirteen patients on PD prior to April 1999 acted as historical controls. Both groups were followed prospectively for a period of 22 months. RESULTS: In the study group application of mupirocin lead to a significant reduction in the incidence rate of both exit site infections overall (0.43 vs. 0.09; p<0.0001) and ESI due staphylococcus aureus (0.14 vs. 0.02; p=0.004) amounting to a relative reduction of 79% and 85% respectively. Although the overall incidence of peritonitis did not change (0.28 vs. 0.26; p=0.7) there was a significant reduction in peritonitis caused by staphylococcus aureus (0.07 vs. 0; p=0.01) Although only one catheter required removal in the mupirocin group as against 5 in the control group, this was not statistically significant. CONCLUSIONS: Mupirocin application at the exit site significantly lowers the incidence of ESI and peritonitis caused by staphylococcus aureus without any significant side effects.

Adult↗
PubMed2005

FEAR but not MEN genes are required for exit from meiosis I.

Exit from mitosis is regulated by Cdc14, which plays an essential role in triggering cyclin-dependent kinase inactivation. Throughout most of the cell cycle, Cdc14 is sequestered in the nucleolus where it remains inactive. After the completion of anaphase, an essential signaling cascade, named the Mitotic Exit Network, or MEN, promotes Cdc14 release. Cdc14 is also released from the nucleolus in early anaphase by another, nonessential, pathway called FEAR (CdcFourteen Early Anaphase Release). Separase (Esp1), polo kinase (Cdc5), the kinetochore protein Slk19, and Spo12, whose molecular function remains unknown, have been identified as members of the FEAR pathway. In meiosis, mutations in CDC14 and its FEAR pathway regulators, CDC5, SLK19, and SPO12, all result it asci that contain only two diploid spores because of a defect in the ability to exit meiosis I. Thus although the FEAR pathway is dispensible for mitotic exit, it is essential for meiosis I exit. The way that the genes of the Mitotic Exit Network contribute to coordinating meiotic progression is less clear. Here, we explore this issue. Our results demonstrate that the orderly transition from meiosis I to meiosis II is accomplished by eliminating MEN function and using the FEAR pathway to modulate cyclin dependent kinase activity, in part through the actions of SIC1.

Acyltransferases↗
PubMed2006

The study of Bfa1p(E438K) suggests that Bfa1 control the mitotic exit network in different mechanisms depending on different checkpoint-activating signals.

During mitosis, genomic integrity is maintained by the proper coordination of anaphase entry and mitotic exit via mitotic checkpoints. In budding yeast, mitotic exit is controlled by a regulatory cascade called the mitotic exit network (MEN). The MEN is regulated by a small GTPase, Tem1p, which in turn is controlled by a two-component GAP, Bfa1p-Bub2p. Recent results suggested that phosphorylation of Bfa1p by the polo-related kinase Cdc5p is also required for triggering mitotic exit, since it decreases the GAP activity of Bfa1p-Bub2p. However, the dispensability of GEF Lte1p for mitotic exit has raised questions about regulation of the MEN by the GTPase activity of Tem1p. We isolated a Bfa1p mutant, Bfa1p(E438K), whose overexpression only partially induced anaphase arrest. The molecular and biochemical functions of Bfa1p(E438K) are similar to those of wild type Bfa1p, except for decreased GAP activity. Interestingly, in BFA1(E438K) cells, the MEN could be regulated with nearly wild type kinetics at physiological temperature, as well as in response to various checkpoint-activating signals, but the cells were more sensitive to spindle damage than wild type. These results suggest that the GAP activity of Bfa1p-Bub2p is responsible for the mitotic arrest caused by spindle damage and Bfa1p overproduction. In addition, the viability of cdc5-2 delta bfa1 cells was not reduced by BFA1(E438K), suggesting that Cdc5p also regulates Bfa1p to activate mitotic exit by other mechanism(s), besides phosphorylation.

Cell Cycle Proteins↗
PubMed2005

3% Amuchina is as effective as the 50% concentration in the prevention of exit-site infection in children on chronic peritoneal dialysis.

In a previous communication, we demonstrated that, in the prevention of exit-site infection (ESI) in children, the cleansing agent 50% Amuchina (electrolytic chloroxidizer. Amuchina SpA, Genoa, Italy) is more effective than 10% povidone iodine and as effective as 4% chlorhexidine, but with fewer adverse secondary effects. In the present study, we assessed, in an Argentine pediatric population, whether Amuchina 3% is as effective as Amuchina 50% in preventing ESI in children on chronic peritoneal dialysis. In an open-label, single-center prospective study, 27 children (mean age: 7.2 years; range: 1.7-17 years) used 3% Amuchina as a cleansing agent for the daily care of a healthy exit site. Of the 27 children, 14 were switched from 50% Amuchina to 3% Amuchina, and 13 were using the 3% Amuchina for the first time. The control group consisted of 18 patients who had previously used 50% Amuchina as a cleansing agent. We followed the recommendations of the International Society for Peritoneal Dialysis with regard to exit-site care, which include keeping the cleansing agent out of the sinus and rinsing the exit site with sterile water. Amuchina was used from the first post-implantation care of the exit site. No adverse secondary effects were seen with the use of Amuchina at either concentration. Patients using 3% Amuchina presented an ESI rate similar to that of patients using Amuchina 50%. The cost of 3% Amuchina was significantly lower than that of the 50% concentration, and it was even lower than the cost for 10% povidone iodine or 4% chlorhexidine. Although more research trials are needed to assess the efficacy of 3% Amuchina, we conclude that 3% Amuchina is the best and most cost-effective cleansing agent for the daily care of a healthy exit site in children on chronic peritoneal dialysis.

Adolescent↗
PubMed1981

[The calibrating drainage of the common bile duct (C.B.D.). Value of "axial exit" drainage (author's transl)].

The authors believe that utilisation of calibrating drainage is justified in case of difficult restauration of the C.B.D. of normal caliber, either throughout its length or in one segment. They underline that "axial exit" has not the disadvantages of the "lateral exit" of T-tubes. They recall the various modalities of "axial exit" (transcystic, transpapillary, transhepatic, "en seton") and their own contribution to the improvement of the transpapillary drainage by the association of a systematic sphincterotomy. Abstract of their clinical series, technics, postoperative mortality and morbidity, calibrating drainage duration and results (in connection with etiology) are reported. Main advantages of the "axial exit" are the absence of any risk of stenosis on a non dilated C.B.D. (as for the "lateral exit") and the facility for long time calibration up to several years. No hemorrhage, no bile leakage have been observed. The one only risk of this sort of drainage is the premature fall of transcystic or transpapillary drains ; but this disadvantage does not exist for "en seton" drainage. Shortly : "axial exit" calibrating drainage is recommandable when a very long time calibration after restauration of non dilated C.B.D. is necessary.

Adult↗
PubMed1994

Interpretation of fatal, multiple, and exiting gunshot wounds by trauma specialists.

Firearm-related injuries are a leading cause of morbidity and mortality in the United States. Trauma care centers and trauma specialists (emergency medicine, trauma surgery, and neurosurgery) provide emergency care for those injured and mortally wounded from firearms. Consequently, trauma specialists may be asked to address forensic questions regarding gunshot wounds. Many firearm-related injuries are nonfatal and ultimately, fatal gunshot wounds can suffer from surgical alteration or, if the time interval between injury and death is prolonged, considerable healing of entrance and exit wounds may occur. Thus, accurate initial evaluation of firearm-related injuries is essential. We reviewed all firearm-related fatalities at our institution over the last five and a half years. Our objective was to determine how accurately trauma specialists can differentiate entrance and exit wounds in fatal perforating (exiting) gunshot wounds and determine the number of penetrating or perforating projectiles in fatal multiple gunshot wounds. A total of 271 fatal gunshot wound deaths were reviewed. Of these, we excluded all fatal penetrating (nonexiting) single gunshot wounds and fatalities not evaluated by trauma specialists. Postmortem findings were compared with the medical records from those individuals seen in the emergency department and/or admitted to North Carolina Baptist Hospital (Level I trauma center). Forty six cases with fatal multiple or exiting gunshot wounds were identified. Twenty four (52.2%) were misinterpreted by trauma specialists. Errors included inaccurate determination of the total number of multiple penetrating and/or perforating gunshot wounds and erroneous identification of entrance and exit wounds. Of the exiting, single gunshot wounds 37% were misclassified and 73.6% of multiple gunshot wounds were interpreted incorrectly.(ABSTRACT TRUNCATED AT 250 WORDS)

Diagnostic Errors↗