This research was not supported by any grants.

The protocol was conducted in accordance with the Declaration of Helsinki and the protocol was approved by the Institutional Review Board at the First Affiliated Hospital of Sun Yat-sen University.
1. Patient selection
<ol>
	<li>Diagnose achalasia by clinical manifestations and diagnostic testing (barium esophagram, high-resolution manometry (HRM), and upper endoscopy)10: the presence of symptoms such as dysphagia, regurgitation, chest pain, and weight loss; the &#34;bird&#39;s-beak&#34; appearance on barium esophagram; impaired relaxation of the lower esophageal sphincter and absent peristalsis on the results of HRM; and ruling out malignancy by upper endoscopy.</li>
	<li>Use the following inclusion criteria: diagnosis of achalasia; Eckardt score11 &#62; 3; age between 18-80 years; written informed consent for POEM using the scissor-type knife.</li>
	<li>Use the following exclusion criteria: coagulopathy and systemic disorders that precluded safe general anesthesia; pregnancy; ulcerated esophagitis.</li>
</ol>
2. Preoperative preparations
<ol>
	<li>Administer a liquid only diet 1 day before the POEM procedure.</li>
	<li>Administer intravenous antibiotics (Cefazolin) and proton pump inhibitors (PPIs) 30 min before the induction of anesthesia.</li>
	<li>Perform an upper endoscopy to aspirate any residual contents to reduce the risk of aspiration immediately before the induction of anesthesia.</li>
	<li>Administer general anesthesia (propofol) with endotracheal intubation.</li>
	<li>Place the patient in a supine position.</li>
</ol>
3. Surgical technique with a scissor type knife for the POEM procedure
NOTE: See Figure 1 for the POEM procedure using a scissor-type knife.
<ol>
	<li>Identify the EGJ by the puckered and tight appearance. Confirm the increased resistance when maneuvering the endoscope through the EGJ. Note the location of the EGJ by measuring the distance from the incisors.</li>
	<li>Choose an injection point 7 to 9 cm proximal to the EGJ in the posterior wall (the 5-6 o&#39;clock position) of the esophagus. Inject saline with methylene blue into the submucosal space with an endoscopic injection needle. 
	NOTE: Use an extended proximal injection point for patients with Chicago type III achalasia.</li>
	<li>Make a 1.5 to 2 cm longitudinal mucosal incision with the scissor-type knife (endocut Q mode: effect 3, duration 2, interval 4).</li>
	<li>Rotate the blades of the scissor-type knife parallel to the muscle layer. Then grasp and dissect (endocut Q mode: effect 3, duration 2, interval 4) the submucosa tissue to create a submucosal tunnel to a location 2 to 3 cm below the EGJ. Keep the dissection plane close to the muscle layer. Inject saline with methylene blue into the submucosal tissue to expand the working space with tunnel progression.</li>
	<li>Confirm the adequate submucosal tunnel length by the blue discoloration of the gastric mucosa on the retroflexed view.</li>
	<li>Use the scissor-type knife for intraoperative vessel sealings and bleeding controls (forced coagulation mode: effect 2, 50 W) without changing the hemostatic forceps.</li>
	<li>Begin the anterograde myotomy at approximately 2 cm distal to the mucosal entry. Selectively grasp and dissect (endocut Q mode: effect 3, duration 2, interval 4) the internal circular muscle bundle with the scissor-type knife. Extend the myotomy 2 to 3 cm onto the gastric cardia.</li>
	<li>After the completion of myotomy, confirm the smooth passage through the EGJ by reinserting the endoscope into the esophageal lumen.</li>
	<li>Close the mucosal entry with endoclips.</li>
</ol>
4. Postoperative management
<ol>
	<li>Admit patients to the inpatient ward following the POEM procedure for observation.</li>
	<li>Administer intravenous antibiotics for 24 h after the POEM procedure. Continue the intravenous PPIs until discharge, and then switch to the oral PPIs (single dose) for 6 weeks.</li>
	<li>Initiate a liquid diet 24 h after the POEM procedure. At discharge, instruct patients to adhere to a soft diet for 2 weeks, and then resume regular diet gradually.</li>
</ol>
5. Follow-up
<ol>
	<li>Schedule an initial follow-up by outpatient visits and telephone interviews at 3 months postoperatively.</li>
	<li>At the follow-up visit, obtain standardized questionnaires from patients, including Eckardt scores11, GerdQ scores12, body weight, and information about PPIs use. Schedule objective tests, including HRM, barium esophagram, and upper endoscopy.</li>
</ol>

<ol>
	<li>Khashab, M. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=ASGE+guideline+on+the+management+of+achalasia.">ASGE guideline on the management of achalasia.</a> Gastrointestinal Endoscopy. 91 (2), 213-227 (2020).</li><li>Liu, Z., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Comprehensive+evaluation+of+the+learning+curve+for+peroral+endoscopic+myotomy.">Comprehensive evaluation of the learning curve for peroral endoscopic myotomy.</a> Clinical Gastroenterology and Hepatology. 16 (9), 1420-1426 (2018).</li><li>Patel, K. S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+light+at+the+end+of+the+tunnel:+a+single-operator+learning+curve+analysis+for+per+oral+endoscopic+myotomy.">The light at the end of the tunnel: a single-operator learning curve analysis for per oral endoscopic myotomy.</a> Gastrointestinal Endoscopy. 81 (5), 1181-1187 (2015).</li><li>Cai, M. Y., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Peroral+endoscopic+myotomy+for+idiopathic+achalasia:+randomized+comparison+of+water-jet+assisted+versus+conventional+dissection+technique.">Peroral endoscopic myotomy for idiopathic achalasia: randomized comparison of water-jet assisted versus conventional dissection technique.</a> Surgical Endoscopy. 28 (4), 1158-1165 (2014).</li><li>Tanaka, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Peroral+endoscopic+myotomy+using+FlushKnife+BT:+a+single-center+series.">Peroral endoscopic myotomy using FlushKnife BT: a single-center series.</a> Endoscopy International Open. 5 (7), 663-669 (2017).</li><li>Oka, S., Tanaka, S., Takata, S., Kanao, H., Chayama, K. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Usefulness+and+safety+of+SB+knife+Jr+in+endoscopic+submucosal+dissection+for+colorectal+tumors.">Usefulness and safety of SB knife Jr in endoscopic submucosal dissection for colorectal tumors.</a> Digestive Endoscopy. 24, 90-95 (2012).</li><li>Yoshida, N., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Efficacy+of+scissor-type+knives+for+endoscopic+mucosal+dissection+of+superficial+gastrointestinal+neoplasms.">Efficacy of scissor-type knives for endoscopic mucosal dissection of superficial gastrointestinal neoplasms.</a> Digestive Endoscopy. 32 (1), 4-15 (2020).</li><li>Kuwai, T., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Endoscopic+submucosal+dissection+of+early+colorectal+neoplasms+with+a+monopolar+scissor-type+knife:+short-+to+long-term+outcomes.">Endoscopic submucosal dissection of early colorectal neoplasms with a monopolar scissor-type knife: short- to long-term outcomes.</a> Endoscopy. 49 (9), 913-918 (2017).</li><li>Yamashina, T., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Scissor-type+knife+significantly+improves+self-completion+rate+of+colorectal+endoscopic+submucosal+dissection:+Single-center+prospective+randomized+trial.">Scissor-type knife significantly improves self-completion rate of colorectal endoscopic submucosal dissection: Single-center prospective randomized trial.</a> Digestive Endoscopy. 29 (3), 322-329 (2017).</li><li>Vaezi, M. F., Pandolfino, J. E., Yadlapati, R. H., Greer, K. B., Kavitt, R. T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=ACG+clinical+guidelines:+diagnosis+and+management+of+achalasia.">ACG clinical guidelines: diagnosis and management of achalasia.</a> The American Journal of Gastroenterology. 115 (9), 1393-1411 (2020).</li><li>Eckardt, A. J., Eckardt, V. F. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Treatment+and+surveillance+strategies+in+achalasia:+an+update.">Treatment and surveillance strategies in achalasia: an update.</a> Nature Reviews. Gastroenterology and Hepatology. 8 (6), 311-319 (2011).</li><li>Jones, R., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Development+of+the+GerdQ,+a+tool+for+the+diagnosis+and+management+of+gastro-oesophageal+reflux+disease+in+primary+care.">Development of the GerdQ, a tool for the diagnosis and management of gastro-oesophageal reflux disease in primary care.</a> Alimentary Pharmacology &amp; Therapeutics. 30 (10), 1030-1038 (2009).</li><li>Bittinger, M., Messmann, H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Use+of+the+stag-beetle+knife+for+peroral+endoscopic+myotomy+for+achalasia:+a+novel+method+for+myotomy.">Use of the stag-beetle knife for peroral endoscopic myotomy for achalasia: a novel method for myotomy.</a> Gastrointestinal Endoscopy. 82 (2), 401-402 (2015).</li><li>Hathorn, K. E., Chan, W. W., Aihara, H., Thompson, C. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Determining+the+safety+and+effectiveness+of+electrocautery+enhanced+scissors+for+peroral+endoscopic+myotomy+(with+Video).">Determining the safety and effectiveness of electrocautery enhanced scissors for peroral endoscopic myotomy (with Video).</a> Clinical Endoscopy. 53 (4), 443-451 (2020).</li><li>Mohan, B. P., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Anterior+versus+posterior+approach+in+peroral+endoscopic+myotomy+(POEM):+a+systematic+review+and+meta-analysis.">Anterior versus posterior approach in peroral endoscopic myotomy (POEM): a systematic review and meta-analysis.</a> Endoscopy. 52 (4), 251-258 (2020).</li></ol>

The authors have nothing to disclose.

As an evolving endoscopic surgical treatment for achalasia, POEM requires both advanced endoscopic skills and knowledge of surgical anatomy. A recent study demonstrated that POEM comes with a considerable learning curve that increases the risk of technical failure, adverse events, and clinical failure2. Endoscopists, especially trainees who have not completed their learning phase, commonly face difficulty in accurate manipulations of the endoscopic knife while working near the EGJ with limited wor...

Peroral endoscopic myotomy (POEM) has gained worldwide acceptance as one of the first-line treatment modalities along with pneumatic dilation and Heller myotomy for patients with achalasia1. To date, most POEM procedures have been confined to a few high-volume, specialized centers. Previous studies have shown that even operators skilled in laparoscopy or endoscopy have a steep learning curve when they are beginning to perform POEM and a higher volume of cases is required to manage challenging situations and prevent adverse events2,3. During POEM procedures, endoscopic needle-knives are most commonly used for both submucosal tunneling and myotomy, combined with hemostatic forceps for managing large vessels and active bleeding. However, because of the impaired esophagogastric junction (EGJ) relaxation in patients with achalasia, the limited space at the level of the EGJ increases the technical difficulty of tissue plane dissection and selective myotomy using the needle-type knife. Besides, operators who are still in the learning phase could be less proficient in exchanging the hemostatic forceps for bleeding control, which may lead to poor visibility and even further inadvertent mucosal injury.
Various endoscopic knives have been used in the POEM procedures for better manipulations and safety profiles4,5. The junior scissor-type knife (Stag-beetle Knife Jr.) with two monopolar blades that are both insulated externally was originally developed for accurate manipulations in colorectal endoscopic submucosal dissection (ESD)6. The standard techniques used with the scissor-type knife involve grasping the target tissue, and then dissection or coagulation. Theoretically, tissue injury caused by unintentional movement could be avoided with a scissor-type knife as compared with a needle-type knife7. Several studies have demonstrated the feasibility and safety of using the scissor-type knife for all ESD procedures, including mucosal incision, submucosal dissection, and hemostasis7,8. Meanwhile, a recent randomized controlled trial showed that the scissor-type knife significantly improved the trainees' self-completion rates for colorectal ESD9. It can be speculated that these advantages of the scissor-type knife can promote a safer POEM procedure, especially during the trainee's early cases. To minimize the technical difficulty and improve the safety of POEM, we described a protocol for using a scissor-type knife for the main steps of the POEM procedure, including mucosal incision, submucosal tunneling, myotomy, and hemostasis. Three patients with achalasia who received POEM using the scissor-type knife were presented to evaluate the feasibility and clinical outcomes of this protocol.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Electrogenerator</td>
			<td>ERBE Elektromedizin</td>
			<td>VIO 200S</td>
			<td></td>
		</tr>
		<tr>
			<td>Endoclip</td>
			<td>Micro-Tech (Nanjing)</td>
			<td>ROCC-D-26-195-C</td>
			<td></td>
		</tr>
		<tr>
			<td>Endoscope</td>
			<td>Olympus</td>
			<td>GIF-H260</td>
			<td></td>
		</tr>
		<tr>
			<td>Injection Needle</td>
			<td>Olympus</td>
			<td>NM-400L-0423</td>
			<td></td>
		</tr>
		<tr>
			<td>Stag Beetle Knife Jr</td>
			<td>Sumitomo Bakelite</td>
			<td>MD-47703W</td>
			<td></td>
		</tr>
		<tr>
			<td>Transparent Distal Cap</td>
			<td>Olympus</td>
			<td>D-201-11804</td>
			<td></td>
		</tr>
	</tbody>
</table>

use of the scissor-type knife during the peroral endoscopy myotomy procedure for the treatment of achalasia

Peroral endoscopic myotomy (POEM) is one of the first-line treatment modalities along with pneumatic dilation and Heller myotomy for patients with achalasia. Endoscopists, especially trainees during the learning phase, commonly face difficulty in tissue plane dissection and selective myotomy while working near the esophagogastric junction, with increased risks of inadvertent injury, unexpected bleeding, and inadequate myotomy. To minimize the technical difficulty and improve the safety of POEM, we describe a protocol for using a scissor-type knife for the main steps of POEM, including mucosal incision, submucosal tunneling, myotomy, and hemostasis. The standard techniques used with the scissor-type knife involve grasping the target tissue, and then dissection or coagulation. The confirmation of the cutting line after grasping improves the accuracy and reliability of dissection, which is particularly useful for the selective myotomy of the internal circular muscle. Meanwhile, the scissor-type knife provides enhanced hemostatic capability and enables hemostasis and pre-coagulation without the device exchange for hemostatic forceps. Evaluation of the clinical outcomes in three patients who successfully received POEM using the scissor-type knife revealed no perioperative adverse events. At the 3-month follow-up, all patients achieved clinical success with postoperative Eckardt scores ranging from 0 to 1. In conclusion, the use of a scissor-type knife could minimize the technical difficulty and improve the safety of the POEM procedures, which may be suitable for trainees during the learning phase.

Compared with the needle-type knife, the scissor-type knife enables coagulation and dissection after grasping the target tissue. Meanwhile, the scissor-type knife is equipped with an enhanced hemostatic capability similar to hemostatic forceps and insulated coating external of the two blades (Table 1). Three patients with achalasia received POEM using the scissor-type knife in our institution. Sigmoid esophagus was present in one patient. One patient had previously undergone pneumatic dilation. Technical...

Watch this Scientific Journal Video about Use of the Scissor-Type Knife During the Peroral Endoscopy Myotomy Procedure for the Treatment of Achalasia at JoVE.com

Use of the Scissor-Type Knife During the Peroral Endoscopy Myotomy Procedure for the Treatment of Achalasia

To minimize the technical difficulty and improve the safety of peroral endoscopic myotomy (POEM), we describe a protocol for using a scissor-type knife for the main steps of POEM, including mucosal incision, submucosal tunneling, myotomy, and hemostasis.

Peroral endoscopic myotomy (POEM) is one of the first-line treatment modalities along with pneumatic dilation and Heller myotomy for patients with ...

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3.0K Views.  The First Affiliated Hospital of Sun Yat-sen University. To minimize the technical difficulty and improve the safety of peroral endoscopic myotomy (POEM), we describe a protocol for using a scissor-type knife for the main steps of POEM, including mucosal incision, submucosal tunneling, myotomy, and hemostasis.

Video: Use of the Scissor-Type Knife During the Peroral Endoscopy Myotomy Procedure for the Treatment of Achalasia

Thermal Ablation for the Treatment of Abdominal Tumors

Percutaneous thermal ablation is an emerging treatment option for many tumors of the abdomen not amenable to conventional treatments. During a thermal ablation procedure, a thin applicator is guided into the target tumor under imaging guidance. Energy is then applied to the tissue until temperatures rise to cytotoxic levels (50-60 &deg;C). Various energy sources are available to heat biological tissues, including radiofrequency (RF) electrical current, microwaves, laser light and ultrasonic waves. Of these, RF and microwave ablation are most commonly used worldwide.
During RF ablation, alternating electrical current (~500 kHz) produces resistive heating around the interstitial electrode. Skin surface electrodes (ground pads) are used to complete the electrical circuit. RF ablation has been in use for nearly 20 years, with good results for local tumor control, extended survival and low complication rates1,2. Recent studies suggest RF ablation may be a first-line treatment option for small hepatocellular carcinoma and renal-cell carcinoma3-5. However, RF heating is hampered by local blood flow and high electrical impedance tissues (eg, lung, bone, desiccated or charred tissue)6,7. Microwaves may alleviate some of these problems by producing faster, volumetric heating8-10. To create larger or conformal ablations, multiple microwave antennas can be used simultaneously while RF electrodes require sequential operation, which limits their efficiency. Early experiences with microwave systems suggest efficacy and safety similar to, or better than RF devices11-13.
Alternatively, cryoablation freezes the target tissues to lethal levels (-20 to -40 &deg;C). Percutaneous cryoablation has been shown to be effective against RCC and many metastatic tumors, particularly colorectal cancer, in the liver14-16. Cryoablation may also be associated with less post-procedure pain and faster recovery for some indications17. Cryoablation is often contraindicated for primary liver cancer due to underlying coagulopathy and associated bleeding risks frequently seen in cirrhotic patients. In addition, sudden release of tumor cellular contents when the frozen tissue thaws can lead to a potentially serious condition known as cryoshock 16.
Thermal tumor ablation can be performed at open surgery, laparoscopy or using a percutaneous approach. When performed percutaneously, the ablation procedure relies on imaging for diagnosis, planning, applicator guidance, treatment monitoring and follow-up. Ultrasound is the most popular modality for guidance and treatment monitoring worldwide, but computed tomography (CT) and magnetic resonance imaging (MRI) are commonly used as well. Contrast-enhanced CT or MRI are typically employed for diagnosis and follow-up imaging.

A thermal tumor ablation procedure is described. The entire procedure is detailed, including pretreatment planning and imaging studies, anesthesia, adjuvant techniques to facilitate a percutaneous approach, imaging guidance of the ablation device to the tumor, thermal treatment, post-treatment care and follow-up.

Percutaneous thermal ablation is an emerging treatment option for many tumors of the abdomen not amenable to conventional treatments. During a thermal ...

Use of Animal Model of Sepsis to Evaluate Novel Herbal Therapies

Sepsis refers to a systemic inflammatory response syndrome resulting from a microbial infection. It has been routinely simulated in animals by several techniques, including infusion of exogenous bacterial toxin (endotoxemia) or bacteria (bacteremia), as well as surgical perforation of the cecum by cecal ligation and puncture (CLP)1-3. CLP allows bacteria spillage and fecal contamination of the peritoneal cavity, mimicking the human clinical disease of perforated appendicitis or diverticulitis. The severity of sepsis, as reflected by the eventual mortality rates, can be controlled surgically by varying the size of the needle used for cecal puncture2. In animals, CLP induces similar, biphasic hemodynamic cardiovascular, metabolic, and immunological responses as observed during the clinical course of human sepsis3. Thus, the CLP model is considered as one of the most clinically relevant models for experimental sepsis1-3.
Various animal models have been used to elucidate the intricate mechanisms underlying the pathogenesis of experimental sepsis. The lethal consequence of sepsis is attributable partly to an excessive accumulation of early cytokines (such as TNF, IL-1 and IFN-&gamma;)4-6 and late proinflammatory mediators (e.g., HMGB1)7. Compared with early proinflammatory cytokines, late-acting mediators have a wider therapeutic window for clinical applications. For instance, delayed administration of HMGB1-neutralizing antibodies beginning 24 hours after CLP, still rescued mice from lethality8,9, establishing HMGB1 as a late mediator of lethal sepsis. The discovery of HMGB1 as a late-acting mediator has initiated a new field of investigation for the development of sepsis therapies using Traditional Chinese Herbal Medicine. In this paper, we describe a procedure of CLP-induced sepsis, and its usage in screening herbal medicine for HMGB1-targeting therapies.

Sepsis refers to a systemic inflammatory response syndrome resulting from a microbial infection, and can be simulated by a surgical technique termed cecal ligation and puncture (CLP). Here we describe a method to use CLP-induced animal model to screen medicinal herbs for therapeutic agents.

Sepsis refers to a systemic inflammatory response syndrome resulting from a microbial infection. It has been routinely simulated in animals by several ...

The Measurement and Treatment of Suppression in Amblyopia

Amblyopia, a developmental disorder of the visual cortex, is one of the leading causes of visual dysfunction in the working age population. Current estimates put the prevalence of amblyopia at approximately 1-3%1-3, the majority of cases being monocular2. Amblyopia is most frequently caused by ocular misalignment (strabismus), blur induced by unequal refractive error (anisometropia), and in some cases by form deprivation.
Although amblyopia is initially caused by abnormal visual input in infancy, once established, the visual deficit often remains when normal visual input has been restored using surgery and/or refractive correction. This is because amblyopia is the result of abnormal visual cortex development rather than a problem with the amblyopic eye itself4,5 . Amblyopia is characterized by both monocular and binocular deficits6,7 which include impaired visual acuity and poor or absent stereopsis respectively. The visual dysfunction in amblyopia is often associated with a strong suppression of the inputs from the amblyopic eye under binocular viewing conditions8. Recent work has indicated that suppression may play a central role in both the monocular and binocular deficits associated with amblyopia9,10 .
Current clinical tests for suppression tend to verify the presence or absence of suppression rather than giving a quantitative measurement of the degree of suppression. Here we describe a technique for measuring amblyopic suppression with a compact, portable device11,12 . The device consists of a laptop computer connected to a pair of virtual reality goggles. The novelty of the technique lies in the way we present visual stimuli to measure suppression. Stimuli are shown to the amblyopic eye at high contrast while the contrast of the stimuli shown to the non-amblyopic eye are varied. Patients perform a simple signal/noise task that allows for a precise measurement of the strength of excitatory binocular interactions. The contrast offset at which neither eye has a performance advantage is a measure of the "balance point" and is a direct measure of suppression. This technique has been validated psychophysically both in control13,14 and patient6,9,11 populations.
In addition to measuring suppression this technique also forms the basis of a novel form of treatment to decrease suppression over time and improve binocular and often monocular function in adult patients with amblyopia12,15,16 . This new treatment approach can be deployed either on the goggle system described above or on a specially modified iPod touch device15.

Amblyopia is a developmental disorder of the visual cortex that is often accompanied by strong suppression of one eye. We present a new technique for measuring and treating interocular suppression in patients with amblyopia that can be deployed using virtual reality goggles or a portable iPod Touch device.

Amblyopia, a developmental disorder of the visual cortex, is one of the leading causes of visual dysfunction in the working age population. Current ...

The Goeckerman Regimen for the Treatment of Moderate to Severe Psoriasis

Psoriasis is a chronic, immune-mediated inflammatory skin disease affecting approximately 2-3% of the population. The Goeckerman regimen consists of exposure to ultraviolet B (UVB) light and application of crude coal tar (CCT). Goeckerman therapy is extremely effective and relatively safe for the treatment of psoriasis and for improving a patient's quality of life. In the following article, we present our protocol for the Goeckerman therapy that is utilized specifically at the University of California, San Francisco. This protocol details the preparation of supplies, administration of phototherapy and application of topical tar. This protocol also describes how to assess the patient daily, monitor for adverse effects (including pruritus and burning), and adjust the treatment based on the patient's response. Though it is one of the oldest therapies available for psoriasis, there is an absence of any published videos demonstrating the process in detail. The video is beneficial for healthcare providers who want to administer the therapy, for trainees who want to learn more about the process, and for prospective patients who want to undergo treatment for their cutaneous disease.

Psoriasis is a chronic, immune-mediated inflammatory skin disease. The Goeckerman regimen, formulated for the treatment of psoriasis, consists of exposure to ultraviolet B (UVB) light and application of crude coal tar (CCT). The following protocol is for the administration of Goeckerman therapy for the treatment of moderate-to-severe psoriasis.

Psoriasis is a  chronic, immune-mediated inflammatory skin disease affecting approximately 2-3%  of the population. The Goeckerman regimen consists of ...

Network Analysis of Foramen Ovale Electrode Recordings in Drug-resistant Temporal Lobe Epilepsy Patients

Approximately 30% of epilepsy patients are refractory to antiepileptic drugs. In these cases, surgery is the only alternative to eliminate/control seizures. However, a significant minority of patients continues to exhibit post-operative seizures, even in those cases in which the suspected source of seizures has been correctly localized and resected. The protocol presented here combines a clinical procedure routinely employed during the pre-operative evaluation of temporal lobe epilepsy (TLE) patients with a novel technique for network analysis. The method allows for the evaluation of the temporal evolution of mesial network parameters. The bilateral insertion of foramen ovale electrodes (FOE) into the ambient cistern simultaneously records electrocortical activity at several mesial areas in the temporal lobe. Furthermore, network methodology applied to the recorded time series tracks the temporal evolution of the mesial networks both interictally and during the seizures. In this way, the presented protocol offers a unique way to visualize and quantify measures that considers the relationships between several mesial areas instead of a single area.

This protocol describes a procedure to track the evolution of mesial network measures in temporal lobe epilepsy (TLE) patients. It is based on the combination of intracranial recordings with a novel numerical technique for data analysis. Specifically, we present a protocol for network analyses of foramen ovale recordings.

Approximately 30% of epilepsy patients are refractory to antiepileptic drugs. In these cases, surgery is the only alternative to eliminate/control ...

Analyzing Beneficial Effects of Nutritional Supplements on Intestinal Epithelial Barrier Functions During Experimental Colitis

Inflammatory bowel diseases (IBD), including Crohn&#39;s disease and ulcerative colitis, are chronic relapsing disorders of the intestines. They cause severe problems, such as abdominal cramping, bloody diarrhea, and weight loss, in affected individuals. Unfortunately, there is no cure yet, and treatments only aim to alleviate symptoms. Current treatments include anti-inflammatory and immunosuppressive drugs that may cause severe side effects. This warrants the search for alternative treatment options, such as nutritional supplements, that do not cause side effects. Before their application in clinical studies, such compounds must be rigorously tested for effectiveness and security in animal models. A reliable experimental model is the dextran sulfate sodium (DSS) colitis model in mice, which reproduces many of the clinical signs of ulcerative colitis in humans. We recently applied this model to test the beneficial effects of a nutritional supplement containing vitamins C and E, L-arginine, and &#969;3-polyunsaturated fatty acids (PUFA). We analyzed various disease parameters and found that this supplement was able to ameliorate edema formation, tissue damage, leukocyte infiltration, oxidative stress, and the production of pro-inflammatory cytokines, leading to an overall improvement in the disease activity index. In this article, we explain in detail the correct application of nutritional supplements using the DSS colitis model in C57Bl/6 mice, as well as how disease parameters such as histology, oxidative stress, and inflammation are assessed. Analyzing the beneficial effects of different diet supplements may then eventually open new avenues for the development of alternative treatment strategies that alleviate IBD symptoms and/or that prolong the phases of remission without causing severe side effects.

Current treatments of inflammatory bowel diseases (IBD) aim at alleviating disease symptoms but may cause severe side effects. Thus, alternative strategies are being investigated in animal colitis models. Here, we explain how the beneficial effects of diet supplements on clinical IBD signs are analyzed in such a colitis model.

Inflammatory bowel diseases (IBD), including Crohn&#39;s disease and ulcerative colitis, are chronic relapsing disorders of the intestines. They cause ...

Trans-Tympanic Drug Delivery for the Treatment of Ototoxicity

The systemic administration of protective agents to treat drug-induced ototoxicity is limited by the possibility that these protective agents could interfere with the chemotherapeutic efficacy of the primary drugs. This is especially true for the drug cisplatin, whose anticancer actions are attenuated by antioxidants which provide adequate protection against hearing loss. Other current or potential otoprotective agents could pose a similar problem, if administered systemically. The application of various biologicals or protective agents directly to the cochlea would allow for high levels of these agents locally with limited systemic side effects. In this report, we demonstrate a trans-tympanic method of delivery of various drugs or biological reagents to the cochlea, which should enhance basic science research on the cochlea and provide a simple way of directing the use of otoprotective agents in the clinics. This report details a method of trans-tympanic drug delivery and provides examples of how this technique has been used successfully in experimental animals to treat cisplatin ototoxicity.

We present a technique for localized administration of drugs through the trans-tympanic route into the cochlea. Drug delivery through this route would not interfere with the anti-cancer efficacy of the chemotherapeutic drugs such as cisplatin.

The systemic administration of protective agents to treat drug-induced ototoxicity is limited by the possibility that these protective agents could ...

Cooling or Warming the Esophagus to Reduce Esophageal Injury During Left Atrial Ablation in the Treatment of Atrial Fibrillation

Ablation of the left atrium using either radiofrequency (RF) or cryothermal energy is an effective treatment for atrial fibrillation (AF) and is the most frequent type of cardiac ablation procedure performed. Although generally safe, collateral injury to surrounding structures, particularly the esophagus, remains a concern. Cooling or warming the esophagus to counteract the heat from RF ablation, or the cold from cryoablation, is a method that is used to reduce thermal esophageal injury, and there are increasing data to support this approach. This protocol describes the use of a commercially available esophageal temperature management device to cool or warm the esophagus to reduce esophageal injury during left atrial ablation. The temperature management device is powered by standard water-blanket heat exchangers, and is shaped like a standard orogastric tube placed for gastric suctioning and decompression. Water circulates through the device in a closed-loop circuit, transferring heat across the silicone walls of the device, through the esophageal wall. Placement of the device is analogous to the placement of a typical orogastric tube, and temperature is adjusted via the external heat-exchanger console.

The goal of this protocol is to describe the use of esophageal temperature modulation to counteract esophageal thermal injury from left atrial ablation for the treatment of atrial fibrillation.

Ablation of the left atrium using either radiofrequency (RF) or cryothermal energy is an effective treatment for atrial fibrillation (AF) and is the most ...

Laparoscopy-endoscopy Cooperative Surgery for the Treatment of Gastric Gastrointestinal Stromal Tumors

In view of the shortcomings of endoscopic or laparoscopic surgeries alone in the treatment of gastric gastrointestinal stromal tumors (G-GISTs), this approach makes an innovative improvement in the treatment of G-GISTs that are less than 5 cm in size. Laparoscopy-endoscopy cooperative surgery (LECS) is used to combine endoscopic and laparoscopic surgeries, fully realizing their respective advantages and avoiding their drawbacks. The main steps are as follows. First, gastroscopy and laparoscopy are combined to confirm the location and boundary of the tumor. Tumor resection is carried out laparoscopically, guided by a gastroscope. The specimen is removed orally and the gastric wound closed laparoscopically. Then, gastroscopy and laparoscopy are combined to determine whether there is wound bleeding, if the suture is satisfactory, and if the gastric cavity is deformed.
LECS has natural advantages in the treatment of G-GISTs that are less than 5 cm in size. The accurate estimation of tumor location and boundary greatly improves the complete resection rate of tumors. The risk of tumor rupture is substantially reduced, and the long-term prognosis of patients is significantly improved. The process allows for accurate resection of the tumor, maximum preservation of normal gastric tissue and organ function, and avoids postoperative gastric deformation. The patient's postoperative rehabilitation is greatly accelerated, and oral feeding can resume on the day of the operation. The specimen is taken out through the mouth to avoid the need for an extended abdominal incision. This greatly reduces the patient's postoperative pain and scarring. The method greatly shortens the postoperative hospital stay (i.e., discharge is possible on the day after the operation), increasing the turnover of hospital beds.

Laparoscopy-endoscopy cooperative surgery is appropriate for the treatment of gastric gastrointestinal stromal tumors less than 5 cm in size. It can achieve the respective advantages of endoscopic and laparoscopic surgeries while avoiding their drawbacks.

In view of the shortcomings of endoscopic or laparoscopic surgeries alone in the treatment of gastric gastrointestinal stromal tumors (G-GISTs), this ...

Modified Technique for the Use of Neonatal Murine Hearts in the Langendorff Preparation

The use of the ex-vivo retrograde perfused heart has long been a cornerstone of ischemia-reperfusion investigation since its development by Oskar Langendorff over a century ago. Although this technique has been applied to mice over the last 25 years, its use in this species has been limited to adult animals. Development of a successful method to consistently cannulate the neonatal murine aorta would allow for the systematic study of the isolated retrograde perfused heart during a critical period of cardiac development in a genetically modifiable and low-cost species. Modification of the Langendorff preparation enables cannulation and establishment of reperfusion in the neonatal murine heart while minimizing ischemic time. Optimization requires a two-person technique to permit successful cannulation of the newborn mouse aorta using a dissecting microscope and a modified commercially available needle. The use of this approach will reliably establish retrograde perfusion within 3 min. Because the fragility of the neonatal mouse heart and ventricular cavity size prevents direct measurement of intraventricular pressure generated using a balloon, use of a force transducer connected by a suture to the apex of the left ventricle to quantify longitudinal contractile tension is necessary. This method allows investigators to successfully establish an isolated constant-flow retrograde-perfused newborn murine heart preparation, permitting the study of developmental cardiac biology in an ex-vivo manner. Importantly, this model will be a powerful tool to investigate the physiological and pharmacological responses to ischemia-reperfusion in the neonatal heart.

The present protocol describes aortic cannulation and retrograde perfusion of the ex-vivo neonatal murine heart. A two-person strategy, using a dissecting microscope and a blunted small gauge needle, permits reliable cannulation. Quantification of longitudinal contractile tension is achieved using a force transducer connected to the apex of the left ventricle.