Laparoscopic transperitoneal repair of lumbar incisional hernias: a combined suture and ‘double-mesh’ technique

Background Lumbar hernias that occur after surgery are called lumbar incisional hernias. Recently, laparoscopic repair of these hernias has been reported with excellent outcomes. This is a retrospective study of our series of patients with lumbar incisional hernias. Patients and methods We managed 11 patients with lumbar incisional hernias from 1996–2006. All the patients had undergone either nephrectomy or pyeloplasty in the past. Laparoscopic suturing of the defect and reinforcement with mesh were successfully performed for all the patients. Results There were more males than females, the age range was 42–65 years, and mean operating time was 120 min; discharge was at 1–2 postoperative days. There was no recurrence or mortality. Three cases had seroma, out of which two required aspiration after 60 days. Discussion Laparoscopic repair provides all the benefits of minimally invasive surgery, and the principles involved in repair of ventral hernias are applied in lumbar incisional hernias as well. Our technique involved suturing of the defect before placing a mesh over the defect. We theorize that approximating the ends of the muscles restores normal anatomy and results in functional improvement. For the larger hernias, we used two meshes to cover the defect—polypropylene and Parietex™, sizes being 15 × 15 cm. Conclusion Laparoscopic repair with prosthetic reinforcement is feasible and effective in the treatment of lumbar incisional hernias. Also, suturing of the defect may provide additional benefits.     

Pediatric thyroid cancer

BACKGROUND AND OBJECTIVE: The treatment of pediatric thyroid cancer evokes considerable controversy. The extent of surgery and role of postoperative radioactive iodine are not clearly defined. We analyzed the behavior of pediatric thyroid cancers and its management. METHODS: Eighty-three patients, from 1964-2000, were identified by a search of our database. The clinical course of 26 patients was not evaluated because of inadequate follow-up and the remaining 57 patients were included in the final survival analysis. These 26 patients were included for analyses of epidemiological data. RESULTS: There were 27 males and 56 females. Cervical lymphadenopathy was a common presentation (57.8%). The predominant histology was papillary carcinoma (57%). Sixteen patients (19.2%) had pulmonary metastases at presentation. Patients with cervical nodes had a significantly higher incidence of pulmonary metastasis compared to those who presented with thyroid nodule (P = 0.037). Five patients (31.2%) with pulmonary metastases had a negative chest X-ray and were detected only on the radioiodine scan. At median follow-up of 64 months, all 57 patients were alive, 10 with disease and 47 disease free. CONCLUSION: Despite its advanced stage at presentation, pediatric thyroid cancer is associated with an excellent prognosis. We advocate total thyroidectomy and radioactive iodine as the best management option as the incidence of pulmonary metastases is high.     

Immunization with plasmid DNA encoding the envelope glycoprotein of Japanese Encephalitis virus confers significant protection against intracerebral viral challenge without inducing detectable antiviral antibodies.

A plasmid DNA construct, pCMXENV encoding the envelope (E) glycoprotein of Japanese Encephalitis virus (JEV), was constructed. This plasmid expresses the E protein intracellularly, when transfected into Vero cells in culture. The ability of pCMXENV to protect mice from lethal JEV infection was evaluated using an intracerebral (i.c.) JEV challenge model. Several independent immunization and JEV challenge experiments were carried out and the results indicate that 51 and 59% of the mice are protected from lethal i.c. JEV challenge, when immunized with pCMXENV via intramuscular (i.m.) and intranasal (i.n.) routes respectively. None of the mice immunized with the vector DNA (pCMX) survived in any of these experiments. JEV-specific antibodies were not detected in pCMXENV-immunized mice either before or after challenge. JEV-specific T cells were observed in mice immunized with pCMXENV which increased significantly after JEV challenge indicating the presence of vaccination-induced memory T cells. Enhanced production of interferon-gamma (IFN-gamma) and complete absence of interleukin-4 (IL-4) in splenocytes of pCMXENV-immunized mice on restimulation with JEV antigens in vitro indicated that the protection is likely to be mediated by T helper (Th) lymphocytes of the Th1 sub-type. In conclusion, our results demonstrate that immunization with a plasmid DNA expressing an intracellular form of JEV E protein confers significant protection against i.c. JEV challenge even in the absence of detectable antiviral antibodies.     

Nuclear targeting of Porphyromonas gingivalis W50 protease in epithelial cells

Porphyromonas gingivalis is an important pathogen associated with destructive periodontal disease and is able to invade the epithelial cell barrier. Its cysteine proteases are recognized as major virulence factors, and in this study, we examined the interaction of the arginine-specific protease with epithelial cells in culture. Three cell lines (KB, HeLa, and SCC4) were incubated with strain W50 culture supernatant; stained with monoclonal antibody 1A1, which recognizes an epitope on the adhesin (beta) component of the cysteine protease-adhesin (alpha/beta) heterodimer; and viewed using immunofluorescence microscopy. Within 1 h, the protease traversed the plasma membrane and was localized around the nucleus before becoming concentrated in the cytoplasm after 24 to 48 h. In contrast, the purified arginine-specific heterodimeric protease (HRgpA) rapidly entered the nucleus within 15 to 30 min. This nuclear targeting (i) was seen with active and Nalpha-p-tosyl-L-lysine chloromethyl ketone (TLCK)-inactivated HRgpA, indicating it was independent of the proteolytic activity; (ii) occurred at both 4 and 37 degrees C; and (iii) failed to occur with the monomeric protease (RgpA(cat)), indicating the importance of the adhesin chain of the HRgpA protease to this process. Rapid cell entry was also observed with recombinant catalytic (alpha) and adhesin (beta) chains, with the latter again targeting the nuclear area. After 48 h of incubation with HRgpA, significant dose-dependent stimulation of metabolic activity was observed (measured by reduction of 3-[4,5-dimethylthiazol-2-yl]-2,5-diphenyl tetrazolium bromide), and a doubling of mitotic activity combined with the presence of apoptotic cells indicated that HRgpA may interfere with cell cycle control mechanisms. These effects were seen with both active and TLCK-inactivated protease, confirming that they were not dependent on proteolytic activity, and thus provide new insights into the functioning of this P. gingivalis protease.     

Increased ash contents and estimation of dissolution from chemical changes due to in-vitro fluoride treatments

The in-vitro fluoride treatment technique has been introduced to investigate the composite behavior of bone tissue. Bone tissue with different mechanical properties can be obtained by varying the concentration, pH and immersion time in fluoride ion solutions. The chemical and physical changes in intact pieces of bone treated in-vitro with different concentrations of fluoride ions are studied. The amount of bone mineral that does not contribute to the mechanical behavior of bone tissue is estimated from the dissolution occurring in the fluoride treated bones. Cortical bones from 18-month-old steers were treated in-vitro with 0.145, 0.5 and 2.0 M sodium fluoride (NaF) solutions for three days. The dissolved bone mineral precipitates as calcium fluoride-like (CaF2/P with some phosphate [P] ions) and fluorapatite(FAp)/fluorhydroxyapatite(FHAp)-like materials within the bone tissue. The dissolution estimated from the presence of the precipitated fluoride phases is 5.6, 11.7, and 13.1% of the initial bone mineral content for the 0.145 M, 0.5 M, and 2.0 M NaF treatments respectively. Estimates of dissolution based on the measurements of phosphate and carbonate ions are lower and higher respectively when compared to the fluoride ion measurements. The wet and dry densities decreased slightly due to dissolution and re-precipitation while the ash content (ratio of the ash weight to dry weight) increased a small amount with increasing concentration of fluoride ion treatments. The increased ash content was due to the excess loss of water in the fluoride treated bones as compare to controls (untreated bone samples) during the drying process. The increased removal of water during the drying process may explain the increased ash contents in some in-vivo treatments.     

A minimax entropy registration framework for patient setup verification in radiotherapy.

In external beam radiotherapy (EBRT), patient setup verification over the entire course of fractionated treatment is necessary for accurate delivery of a specified dose to the tumor. We are working on the development of a minimax entropy registration framework for patient setup verification using dual portal images and the treatment planning 3D CT dataset. In this paper, we present an overview of our registration framework, where an iteratively and automatically estimated segmentation of the portal image is utilized to more accurately and robustly register the portal image to the 3D treatment-planning CT data. In addition, we describe initial testing of this approach. We note that, due to low resolution and low contrast of the portal images, this registration presents a difficult problem. We also note that the registration of the images in our proposed method is guided by the bony structure visible in the portal and the 3D CT images. However, since the prostate can move with respect to the pelvic bone, we propose using ultrasound images to quantify this movement.     

Rigid point feature registration using mutual information

We have developed a new mutual information-based registration method for matching unlabeled point features. In contrast to earlier mutual information-based registration methods, which estimate the mutual information using image intensity information, our approach uses the point feature location information. A novel aspect of our approach is the emergence of correspondence (between the two sets of features) as a natural by-product of joint density estimation. We have applied this algorithm to the problem of geometric alignment of primate autoradiographs. We also present preliminary results on three-dimensional robust matching of sulci derived from anatomical magnetic resonance images. Finally, we present an experimental comparison between the mutual information approach and other recent approaches which explicitly parameterize feature correspondence.     

Hyperhomocysteinemia and B-vitamin status after discontinuation of oral anticoagulation therapy in patients with a history of venous thromboembolism.

Although hyperhomocysteinemia is an established risk factor for venous thromboembolism there is no consensus for routine determination of circulating homocysteine in the UK, either at the beginning or end of oral anticoagulation therapy. The purpose of this study was to evaluate the prevalence of hyperhomocysteinemia and its relationship to folate and vitamin B12 status in subjects with venous thromboembolism 4 weeks after discontinuation of warfarin therapy. In 78 consecutively recruited patients, plasma homocysteine was significantly higher (p < 0.001) and red cell folate significantly lower (p = 0.03) than in controls. Plasma vitamin B12 was similar in both groups. Strikingly, 38.5% of patients had hyperhomocysteinemia (> 15 micromol/l). Retrospective analysis revealed a significant positive association between plasma total homocysteine and duration of warfarin therapy (p < 0.001) but a negative, though non-significant (p = 0.06), trend with warfarin dose. The results do not suggest any direct interaction between warfarin and plasma homocysteine but raise the possibility of reduced intake of a common food source of folate and vitamin K. One possibility is the shortage of green-leafy vegetables since patients are often advised to limit their intake of this major source of vitamin K. On the basis of this study we suggest that homocysteine screening should be carried out at the time that patients begin warfarin therapy.     

Low frequency of elevated prothrombin times in patients with lupus anticoagulants when using a recombinant thromboplastin reagent: implications for dosing and monitoring of oral anticoagulant therapy

Many patients with lupus anticoagulants (LA) are treated with oral anticoagulation and monitored using the international normalised ratio (INR) derived from the prothrombin time (PT). Recent reports have produced conflicting conclusions about the extent to which LA interferes with PT determination. The degree of anticoagulation may be overestimated in a patient whose LA affects the PT. A number of reports conclude that specific thromboplastin reagents containing recombinant tissue factor are sensitive to the presence of LAs and should not be used to monitor oral anticoagulant therapy in these patients. These studies were performed on orally anticoagulated patients. The present retrospective study on 400 patients with LAs who were not receiving therapeutic anticoagulation was performed to ascertain the frequency of prolonged PT in these patients when using Innovin recombinant thromboplastin. Only 17 (4.3%) out of 400 had prolonged PT in the presence of LA. As this is a low prevalence, and not all patients with LAs will require anticoagulant therapy, it is concluded that baseline INR determination should be used to highlight the need to monitor individual patients with LA-insensitive reagents. As the use of moderate-intensity oral anticoagulation for patients with LAs and previous thrombosis is receiving wider acceptance, an informed approach to anticoagulant monitoring will reduce the possibility of under-anticoagulating patients receiving this therapy.