Endovascular stenting for nutcracker syndrome

Nutcracker syndrome (NCS) is a rare pathology manifested by pain or hematuria in males and females alike. It can be easily overlooked, and should be considered in young men or women with symptoms of extended duration. We present a case of a 54-year-old female with chronic lower abdominal pain radiating to the left thigh of 4 years in duration. Computed tomography (CT) eventually revealed engorged left renal, gonadal, and uterine veins due to compression between the superior mesenteric artery (SMA) and the abdominal aorta, consistent with NCS. After a successful endovascular stenting and a 6-month period of antiplatelet and anticoagulant therapy, the patient returned to stable health. NCS, while rare, should be suspected in patients of both sexes with persistent pain or hematuria.     

Predictors of Adherence to an Antidepressant Medication Regimen Among Patients Diagnosed with Depression in Taiwan

This study explored the predictors of medication adherence among Taiwanese people with major depression and dysthymic disorder. Previous research indicates that depressed patients vary in compliance with their medication regimen. Poor compliance reduces the therapeutic effect of medication. Self-report questionnaires were used for this cross-sectional study conducted with 181 outpatients diagnosed with major depression or dysthymic disorder. About 50% of depressed patients reported good medication adherence. The predictors of adherence were patient income, treatment efficacy, and understanding the importance of continuing medication. Professionals should use collaborative communication and cultural values clarification with depressed patients and their families to improve the awareness of illness and to increase the likelihood of medication compliance.     

Lower Education Level Is a Major Risk Factor for Peritonitis Incidence in Chronic Peritoneal Dialysis Patients: A Retrospective Cohort Study with 12-Year Follow-Up

♦ Background: Peritoneal dialysis (PD)-related peritonitis remains an important complication in PD patients, potentially causing technique failure and influencing patient outcome. To date, no comprehensive study in the Taiwanese PD population has used a time-dependent statistical method to analyze the factors associated with PD-related peritonitis.♦ Methods: Our single-center retrospective cohort study, conducted in southern Taiwan between February 1999 and July 2010, used time-dependent statistical methods to analyze the factors associated with PD-related peritonitis.♦ Results: The study recruited 404 PD patients for analysis, 150 of whom experienced at least 1 episode of peritonitis during the follow-up period. The incidence rate of peritonitis was highest during the first 6 months after PD start. A comparison of patients in the two groups (peritonitis vs null-peritonitis) by univariate analysis showed that the peritonitis group included fewer men (p = 0.048) and more patients of older age (≥65 years, p = 0.049). In addition, patients who had never received compulsory education showed a statistically higher incidence of PD-related peritonitis in the univariate analysis (p = 0.04). A proportional hazards model identified education level (less than elementary school vs any higher education level) as having an independent association with PD-related peritonitis [hazard ratio (HR): 1.45; 95% confidence interval (CI): 1.01 to 2.06; p = 0.045). Comorbidities measured using the Charlson comorbidity index (score >2 vs ≤2) showed borderline statistical significance (HR: 1.44; 95% CI: 1.00 to 2.13; p = 0.053).♦ Conclusions: A lower education level is a major risk factor for PD-related peritonitis independent of age, sex, hypoalbuminemia, and comorbidities. Our study emphasizes that a comprehensive PD education program is crucial for PD patients with a lower education level.     

Human acute leukemia cell line with the t(4;11) chromosomal rearrangement exhibits B lineage and monocytic characteristics

A cell line, designated RS4;11, was established from the bone marrow of a patient in relapse with an acute leukemia that was characterized by the t(4;11) chromosomal abnormality. The cell line and the patient's fresh leukemic cells both had the t(4;11)(q21;q23) and an isochromosome for the long arm of No. 7. Morphologically, all cells were lymphoid in appearance. Ultrastructurally and cytochemically, approximately 30% of the cells possessed myeloid features. The cells were strongly positive for terminal deoxynucleotidyl transferase. They were HLA-DR positive and expressed surface antigens characteristic for B lineage cells, including those detected by anti-B4, BA-1, BA-2, and PI153/3. Immunoglobulin gene analysis revealed rearrangements of the heavy chain and kappa chain genes. The cells lacked the common acute lymphoblastic leukemia antigen and antigenic markers characteristic of T lineage cells. The cells reacted with the myeloid antibody 1G10 but not with other myeloid monoclonal antibodies. Treatment with 12-O-tetradecanoyl- phorbol-13-acetate induced a monocyte-like phenotype demonstrated by cytochemical, functional, immunologic, and electron microscopic studies. The expression of markers of both early lymphoid and early myeloid cells represents an unusual phenotype and suggests that RS4;11 represents a cell with dual lineage capabilities. To our knowledge, RS4;11 is the first cell line established from t(4;11)-associated acute leukemia.     

Use of multiple T cell-directed intact ricin immunotoxins for autologous bone marrow transplantation

The monoclonal antibodies (MoAb) T101, G3.7, 35.1, and TA-1 were conjugated to intact ricin using a thioether linkage. These MoAb detect, respectively, the CD5[gp67], CD7[p41], CD2[p50], and [gp95, 170] determinants that are found in the vast majority of cases of T cell acute lymphocytic leukemia (T-ALL). The resulting immunotoxins (ITs) and an equimolar mixture of these ITs were evaluated as potential purgative reagents for autologous transplantation in T-ALL. Leukemic cell lines were used to compare the kinetics of protein synthesis inactivation mediated by each IT. The cells were treated with IT in the presence of lactose in order to block the native binding of ricin. The observed rates of protein synthesis inactivation correlated with target antigen expression detected by fluorescence-activated cell sorter analysis. Of the four ITs, T101-ricin (T101-R) exhibited the fastest rate of inactivation, followed in order by G3.7-ricin, TA-1-ricin, and 35.1-ricin. At concentrations greater than 300 ng/mL, a cocktail containing an equimolar amount of all four ITs (referred to as the four- IT cocktail) exhibited kinetics that were as fast or faster than those of T101-R. The long-term cytotoxic effects of individual ITs and the four-IT cocktail were evaluated using a sensitive clonogenic assay. Each IT was specifically cytotoxic and inhibited 1 to 4 logs of clonogenic leukemic cells at doses (300 to 600 ng/mL) that can be used clinically. The four-IT cocktail was highly cytotoxic; a concentration of 300 ng/mL inhibited greater than 4 logs of leukemic cells while sparing the majority of committed (CFU-GM, CFU-E) and pluripotent (CFU- GEMM) hematopoietic stem cells. The determination of both short-term kinetics of protein synthesis inactivation and longer-term inhibition of clonogenic growth allowed new insight into cell killing by IT. Our results suggest that ITs continue to act on clonogenic target cells for a period of three to five days. Interestingly, the four-IT cocktail was not as potent against clonogenic leukemic cells as T101-R alone, although it exhibited kinetics of protein synthesis inhibition that were as fast as those of T101-R alone. This finding suggests that internalized ITs may differ in the length of time they remain active within the cell. Our results also demonstrate the importance of using several different assays to evaluate IT reagents.     

Immunotyping of Chlamydia trachomatis with monoclonal antibodies

Rapid and precise immunotyping of Chlamydia trachomatis was achieved by testing whole organisms (elementary bodies) in the microimmunofluorescence test with monoclonal antibodies. Monoclonal antibodies were produced with standard techniques by using an immunization schedule that encouraged the development of immunotype-specific antibodies. Fifteen monotypic or multitypic (subspecies) monoclonal antibodies were chosen for use in a two-step typing system that required strains of C. trachomatis to be tested against six to eight monoclonal antibodies for classification. Immunotyping with monoclonal antibodies was studied by testing 313 strains, typed with the previous method that utilized immunized mouse antisera, that represented each of the 15 established serovars. The two-step monoclonal antibody method resulted in a classification similar to the current one. Only one strain typed differently with the two methods. With the monoclonal antibody method, available lymphogranuloma venereum (LGV) serovars L1 and L3 could not be differentiated from trachoma serovars E and G, respectively, unless the strains had been identified as LGV. Monoclonal antibody typing was simpler to perform and more precise; it allowed easy differentiation between closely related serovars. Three new types were discovered among the strains previously classified as serovars D, I, and L2. These are tentatively being considered subtypes and are labeled D', I', and L2'.     

The origins of surgery: 1. From prehistory to Renaissance*

The art, craft and science of surgery is a highly interpersonal skill, central to a variety of traditions and cultures throughout human history. The development of surgery parallels the evolution of the human race from prehistory to the present time. This review attempts to examine the changing concepts and practices in surgery from the earliest era, enshrouded in mysticism and magic, through a manual craft performed by barbers and artisans, to a dignified profession based on science and technology. The evolution of surgery in the previous millennia is reviewed against the culture and morals, the politics and religion, and the philosophy and science of its period; in so doing assessing its perspective on the threshold of a new millennium.      

One-stage reconstruction of large midline abdominal wall defects using a composite free anterolateral thigh flap with vascularized fascia lata

OBJECTIVE: Large midline abdominal wall defects are continuously a challenge for reconstructive surgeons. Adequate skin coverage and fascia repair of the abdominal wall is necessary for achieving acceptable results. The purpose of this paper is to present a new approach to abdominal wall reconstruction using a free vascularized composite anterolateral thigh (ALT) flap with fascia lata. METHODS: Seven patients with large full-thickness abdominal wall defects were successfully reconstructed by means of a composite ALT flap combined with vascularized fascia lata. The size of the skin islands ranged from 20 to 32 cm in length and 10 to 22 cm in width, and the vascularized fascia lata sheath measured 14 to 28 cm and 8 to 18 cm, respectively. Functional outcome of the abdominal wall strength and donor thigh morbidity were investigated by using a Cybex kinetic dynamometer. RESULTS: All flaps survived. No postoperative ventral hernia occurred except for one mild inguinal incision hernia. Subjectively there were no significant donor site problems. Objective assessment was performed in 4 patients 2 years postoperatively. In the reconstructed abdomen, isokinetic concentric and eccentric measurements of extension/flexion ratios of the abdominal wall strength showed no apparent decrease compared with other references. Functional evaluation of quadriceps femoris muscle contraction forces after free ALT composite flap harvest showed an averaged deficit of 30% as compared with the contralateral legs. However, no difficulties in daily ambulating were reported by the patients. CONCLUSION: The free composite ALT myocutaneous flap with vascularized fascia lata provides an alternative option for a stable repair in complex abdominal wall defects.