Endoanal advancement flap repair for complex anorectal fistulas

BACKGROUND: Most anorectal fistulas may be safely and reliably treated by fistulotomy. However, certain complex fistulas (e.g., rectovaginal fistulas, high transsphincteric tracts, Crohn's disease) are not well suited to this technique. Few satisfactory alternatives exist. The aim of this study was to assess the utility of endoanal advancement flap repair for these difficult fistulas. METHODS: Thirty-three consecutive patients underwent endoanal advancement flap repair of a complex anorectal fistula. Patients were followed up via a prospective database. Demographic information, the presence of previous fistula surgery, and surgical complications were noted. Patients were closely followed up until healing of the fistula or treatment failure was noted. RESULTS: The overall initial healing rate was 81% (27 of 33). However, 3 patients with perianal Crohn's disease ultimately developed a recurrent fistula. There were no major complications and two minor urinary complications. No patient required hospital readmission, and there were no new problems with fecal incontinence. No patient required a colostomy. CONCLUSION: Endoanal advancement flap repair is effective in a variety of difficult, complicated anorectal fistulas. Since the morbidity is quite low, it should be attempted prior to fecal diversion, when possible, in these settings.     

Omental transfer to the brain: an experimental study in hydrocephalic rabbits

Hydrocephalus is a common and potentially lethal condition in children that results from an imbalance between absorption and production of cerebral spinal fluid (CSF). Silastic shunts are inserted to drain excess CSF, but they are prone to a number of problems, and at times may be unreliable and ineffective. This study examines the physiological basis of a pedicled omental transfer to the brain as a functional conduit for CSF in an experimentally induced hydrocephalic rabbit model. The ability of the omentum to transport CSF from the subarachnoid space was tested using radioactive tracer substances: radio-iodinated serum albumin (125I-RISA), chromium 51-ethylenediaminetetraacetate (51Cr-EDTA), and technetium 99m (99mTc) glucoheptonate. Immediate ability of exteriorized omentum to transport artificial CSF, as well as transposed omental transport of subarachnoid CSF at 1 month, were examined. Nuclear scan measurements were correlated with clinical observation and a double-blind histological analysis with trichrome and hematoxylin-eosin stain. Exteriorized omentum rapidly absorbed 99mTc glucoheptonate-labeled artificial CSF, with a rapid appearance in the systemic circulatory and urinary systems. Transposed omentum to the brain in animals with artificially created hydrocephalus showed evidence of CSF-labeled 125I-RISA and 51Cr-EDTA absorption in those animals demonstrating histologically viable omentum.     

Diabetic retinopathy in a black population: the Barbados Eye Study.

OBJECTIVE: The distribution of diabetic retinopathy in black populations is largely unknown. The authors present retinopathy data from the predominately black participants of the Barbados Eye Study (BES). DESIGN AND PARTICIPANTS: Prevalence study of 4631 participants based on a random sample of the Barbados population 40 to 84 years of age (84% participation). MAIN OUTCOME MEASURES: Diabetes was defined as self-reported history of physician-diagnosed diabetes or glycosylated hemoglobin greater than 10% (>2 standard deviations above the population mean of persons without a diabetes history). Retinopathy was assessed by independent gradings of 30 degrees color stereo fundus photographs of the disc and macula. RESULTS: Diabetes was present in 19.4% of black (n = 4314), 15.2% of mixed (black and white; n = 184), and 7.5% of white/other (n = 133) self-reported racial groups. In the black/mixed population, regardless of diabetes status, the prevalence of retinopathy was 5.9%. In the 636 black and mixed participants with diabetes, the prevalence of retinopathy was 28.5%: 19.8% had minimum changes, 7.7% had moderate changes, and 0.9% had severe retinopathy. Clinically significant macular edema (CSME) was found in 8.6% of those with diabetes. CONCLUSIONS: In the population of African origin, approximately 1 in 17 persons had retinopathy. Among those with diabetes, 28.5% had retinopathy and 8.6% had CSME. These results highlight the clinical and public health relevance of diabetic retinopathy in the black population.     

Blood-brain barrier permeability to small and large molecules

The objective of this article is to provide the reader with an update of some of the BBB research highlights which have occurred in recent times, and to review the impact and contributions of immunogold electron microscopic studies on our understanding of the brain capillary endothelium. Glucose and monocarboxylic acids are two small molecules which this review will focus upon; and advances in immunogold characterization of the GLUT1 glucose transporter and the MCT1 and MCT2 monocarboxylic acid nutrient transporters will be discussed. Human serum albumin is chosen as a representative large molecule, and it has recently been shown that immunogold identification of this protein can serve as an indicator of compromised BBB function in a variety of pathophysiological conditions.     

A comparison of participants and nonparticipants in a worksite cholesterol screening

PURPOSE. The purpose of this study is to determine if worksite cholesterol screening reaches only those who are already aware of their cholesterol and interested in lifestyle modification. DESIGN. A voluntary worksite cholesterol screening was conducted followed by a survey of a random sample of nonparticipants. SETTING. A large university worksite was the setting for this study. SUBJECTS. Out of 9,137 university employees, 1,583 attended the voluntary screening, and a random sample of nonparticipants was obtained (n = 154), of which 87% (n = 138) responded. MEASURES. Subjects completed a questionnaire on health behaviors, perceived risk, self-efficacy for diet change, and attention to media messages. A capillary blood cholesterol level was also taken. RESULTS. Nonparticipants were more likely to be male (64% versus 39%) and smokers (17% versus 9%), more likely to exercise, to have had a prior cholesterol measurement (64% versus 49%), and to "know" their cholesterol value (56% versus 26%). The two groups were otherwise similar. Over half (51%) of the participants were receiving their first cholesterol measurement. These subjects were younger, less educated, had less perceived risk, were less attentive to media messages, and more likely to be from a minority group than those individuals who had prior measurements. DISCUSSION. These findings suggest that worksite cholesterol screening does not only reach those already aware of their cholesterols, but also can reach some persons not previously screened or concerned.     

The topographical and neuroanatomical distribution of neurofibrillary tangles and neuritic plaques in the cerebral cortex of patients with Alzheimer's disease.

The distribution of neurofibrillary tangles (NFTs) and neuritic plaques (NPs) was mapped in 39 cortical areas of 11 brains of patients with Alzheimer's disease (AD). Whole hemisphere blocks were embedded in polyethylene glycol (Carbowax), sectioned coronally, and stained with thioflavin S and thionin. The densities of NFTs and NPs were assessed using a numerical rating scale for each area. Scores were grouped by type of cortex and by lobe for statistical analysis. Highly significant differences were obtained. For example, limbic periallocortex and allocortex had more NFTs than any other type of cortex. In descending order, the density of NFTs was as follows: periallocortex (area 28) greater than allocortex (subiculum/CA1 zones of hippocampal formation, area 51) greater than corticoid areas (accessory basal nucleus of amygdala, nucleus basalis of Meynert) greater than proisocortex (areas 11, 12, 24, 23, anterior insula, 38, 35) greater than nonprimary association cortex (32, 46, superior temporal sulcus, 40, 39, posterior parahippocampal cortex, 37, 36) greater than primary sensory association cortex (7, 18, 19, 22, 21, 20) greater than agranular cortex (44-5, 8, 6, 4) greater than primary sensory cortex (41-2, 3-1-2, 17). The laminar distribution of NFTs tended to be selective, involving primarily layers III and V of association areas and layers II and IV of limbic periallocortex. There were far more NFTs in both limbic and temporal lobes than in frontal, parietal, and occipital lobes. In general, NPs were more evenly distributed throughout the cortex, with the exceptions of limbic periallocortex and allocortex, which had notably fewer NPs than other cortical areas. Temporal and occipital lobes had the highest NP densities, limbic and frontal lobes had the lowest, and parietal lobe was intermediate. No significant left-right hemispheric differences for NFT or NP densities were found across the population, and there was no relationship between duration of illness and densities of NFTs or NPs. The regional and laminar distribution of NFTs (and, to a lesser degree, that of NPs) suggests a consistent pattern of vulnerability within the cerebral cortices that seems correlated to the hierarchies of cortico-cortical connections. The higher-order association cortices, especially those in the anterior and ventromedial sectors of temporal lobe, are the most vulnerable, while other cortices appear less vulnerable to a degree commensurate with their connectional "distance" (i.e., synapses removed) from the limbic areas.     

Chemical impairment in colleagues: perceptions of Western New York nurses.

The purpose of this study was to determine nurses' perceptions about substance abuse in professional colleagues, opinions about strategies for dealing with substance abuse, and knowledge about resources available for dealing with the problem of chemical impairment. Subjects included a convenience sample of 161 nurses from Western New York. Data were gathered by a questionnaire that included "The Perceptions of Nursing Impairment Inventory" and items regarding respondents' background characteristics, suspicions about alcohol and drug abuse in nurse colleagues, and knowledge about and use of peer assistance services available through District I of the New York State Nurses Association. The major outcome of the study was identification of a knowledge deficit on the extent of the substance abuse problem in nursing, ability to recognize an impaired colleague, and awareness of services available. These data substantiate the need for implementing educational programs to increase nurses' basic knowledge of, and sensitivity to, the problem of chemical dependency.     

The millennium of mind, brain, and behavior

Psychiatry enters the new millennium poised to answer many of its central questions. Given the complexity of the human brain and its interactions with our world, these questions are among the most difficult ever addressed by human science. How is the human brain built? How does it change over the life span? What are the precise genetic and environmental risk factors for mental illnesses? What are the pathophysiologic processes that produce the symptoms and disabilities? How do our treatments, including psychotherapy, work? What objective markers can we discover to monitor the progression of the pathogenic processes and the effects of treatment? How will we discover preventive measures and cures that will be effective in diverse populations and settings? Parallel to the pursuit of its public health agenda, psychiatry will grow closer to neuroscience, behavioral science, and neurology. In so doing, those who practice these disciplines will be better positioned to ask meaningful questions about the relationship among mind, brain, and behavior, and to finally overcome the pervasive Cartesianism that continues to incubate stigma and ignorance about mental illness.     

Microtubule-affinity regulating kinase (MARK) is tightly associated with neurofibrillary tangles in Alzheimer brain: a fluorescence resonance energy transfer study

Paired helical filaments, the main structural components of the neurofibrillary tangles in Alzheimer disease, consist of phosphorylated tau protein. Because the levels and degree of phosphorylation are significantly higher in paired helical filament (PHF)-derived tau than in normal adult tau, and because phosphorylation of tau severely disrupts microtubule stability, it is postulated that tau phosphorylation is an important step in PHF formation. The kinases and/or phosphatases that act in vivo to help induce such a pathological state of tau, however, are not yet known. In this study we implicate the non-proline directed kinase MARK in PHF-tau phosphorylation, by virtue of its close intermolecular association with the phosphorylated Ser262 epitope on PHF-tau as assessed by fluorescence resonance energy transfer. Moreover, because this tight enzyme-substrate association is observed in neurofibrillary tangles in Alzheimer tissue, we suggest that PHF-tau phosphorylation may occur to some extent on assembled PHF filaments.     

VASCULAR EMBOLOTHERAPY-HOW MUCH HAS BEEN ACHIEVED?

Emergency and elective embolotherapy of various systemic arteries in 64 patients was carried out at a tertiary centre of Armed Forces. Specific indications were haemoptysis (n=43), preoperative (n=18), haematuria (n=1), epistaxis (n=1) and chemoembolization (n=1). The procedures were performed with gelfoam pellets (n=46), gelfoam pellets and absolute alcohol (n=1), polyvinyl alcohol particles (PVA) (n=14), steel coils (n=2) and Adriamycin-in-oil emulsion (n=1). Embolotherapy resulted in complete haemostasis in 37 (82.2%) out of 45 cases of haemorrhage. In eight cases (17.8%), it resulted in significant improvement. Complete haemostasis was achieved in both cases of haematuria and epistaxis. Pre-operative embolotherapy resulted in considerable reduction of peroperative blood loss in all the cases. Chemoembolization of Hepatocellular carcinoma resulted in partial regression of the tumour. The purpose of this study was to assess the efficacy, safety and reliability of vascular embolotherapy for control of life threatening haemorrhage and preoperative reduction of lesions.KEY WORDS: Embolization, Embolotherapy, Haemorrhage