Laparoscopic resections for colorectal carcinoma

Laparoscopic resection for carcinoma of the colon and rectum is currently under intense scrutiny. PURPOSE: The purpose of this study is to review our three-year experience of laparoscopic surgery for colon and rectal carcinoma. METHODS: From October 1991 to September 1994, 76 laparoscopic procedures were performed for colorectal neoplasia (32 males and 44 females; mean age, 69 years). Fifty-five procedures were done for carcinoma, 16 for large polyps, and five for diversion in patients with unresectable cancer. For resectable tumors, the average size was 4 cm; staging was as follows: Dukes A, 10 patients; Dukes B1, 11; Dukes B2, 18; Dukes C1, 1; Dukes C2, 9; and Dukes D, 8. Fourteen cases (25 percent) that were converted to open procedures were compared with the 41 cases that were completed laparoscopically for differences in tumor size, surgical margins, number of lymph nodes harvested, length of hospital stay, and evidence of recurrence. Procedures completed laparoscopically were then compared with a group of open controls completed during the same time period. RESULTS: During the first six months, the conversion rate was 32 percent but dropped to 8 percent in the last six months. There were a total of 19 complications (25 percent), of which 8 (14 percent) were directly related to the laparoscopic technique. The mean number of lymph nodes harvested in laparoscopic resection for carcinoma was 8.5, and the average closest tumor margin was 4.5 cm. When laparoscopic resections were compared with converted and standard open colectomies, there was no significant difference in tumor margins or numbers of nodes resected. Length of stay was significantly shorter for anterior resections completed laparoscopically than for converted or conventional colectomies. Although this was also the trend for right hemicolectomies, it did not reach statistical significance. Mean follow-up of the group completed laparoscopically was 16.7 months, during which there was one recurrence. There were no trocar site recurrences. CONCLUSIONS: This early experience seems to indicate that laparoscopic surgery for colorectal carcinoma does not per se compromise surgical oncologic principles and encourages us to continue our critical appraisal of this technique.Read at the meeting of The American Society of Colon and Rectal Surgeons, Montreal, Quebec, Canada, May 7 to 12, 1995.     

Phospholipase A2 levels in acute chest syndrome of sickle cell disease

Acute chest syndrome (ACS) is associated with significant morbidity and is the leading cause of death in patients with sickle cell disease (SCD). Recent reports suggest that bone marrow fat embolism can be detected in many cases of severe ACS. Secretory phospholipase A2 (sPLA2) is an important inflammatory mediator and liberates free fatty acids, which are felt to be responsible for the acute lung injury of the fat embolism syndrome. We measured SPLA2 levels in 35 SCD patients during 20 admissions for ACS, 10 admissions for vaso-occlusive crisis, and during 12 clinic visits when patients were at the steady state. Eleven non-SCD patients with pneumonia were also evaluated. To determine if there was a relationship between sPLA2 and the severity of ACS we correlated SPLA2 levels with the clinical course of the patient. In comparison with normal controls (mean = 3.1 +/- 1.1 ng/mL), the non- SCD patients with pneumonia (mean = 68.6 +/- 82.9 ng/mL) and all three SCD patient groups had an elevation of SPLA2 (steady state mean = 10.0 +/- 8.4 ng/mL; vaso-occlusive crisis mean = 23.7 +/- 40.5 ng/mL; ACS mean = 336 +/- 209 ng/mL). In patients with ACS sPLA2 levels were 100- fold greater than normal control values, 35 times greater than values in SCD patients at baseline, and five times greater than non-SCD patients with pneumonia. The degree of SPLA2 elevation in ACS correlated with three different measures of clinical severity and, in patients followed sequentially, the rise in SPLA2 coincided with the onset of ACS. The dramatic elevation of SPLA2 in patients with ACS but not in patients with vaso-occlusive crisis or non-SCD patients with pneumonia and the correlation between levels of SPLA2 and clinical severity suggest a role for SPLA2 in the diagnosis and, perhaps, in the pathophysiology of patients with ACS.     

A Preliminary Formula to Predict Timing of Symptom Resolution for Collegiate Athletes Diagnosed With Sport Concussion

ContextSymptom presentation and recovery after sport concussion (SC) are variable. Empirically based models documenting typical symptom duration would assist health care providers in managing return to play after SC.ObjectiveTo develop a prediction model for SC symptom duration.DesignCross-sectional study.SettingTwo National Collegiate Athletic Association Division I university laboratories.Intervention(s)Participants completed the Revised Head Injury Scale (HIS-r), Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT), and Sensory Organization Test within 24 hours of SC diagnosis.ResultsThe final formula consisted of the HIS-r''s self-reported neck pain, drowsiness, tingling, and nervousness duration and ImPACT total symptom severity (R = 0.62, R² = 39%, R²_adj = 34.2%, P < .001). Approximately 29% (R²_cv = 29%) of the variance associated with total days symptomatic after SC was explained by our preliminary formula when cross-validated. The current formula correctly identified 76% of participants who recovered within 10 days of injury.ConclusionsOur results suggest that self-reported duration of 4 symptoms during the initial 24 hours after injury along with total symptom severity as measured by ImPACT accounted for a considerable amount of variance associated with days symptomatic after SC in collegiate athletes. Until the formula is cross-validated in a college-aged sample, caution is warranted in using it clinically.Key Words: traumatic brain injuries, prediction, prolonged recovery, symptom severity, symptom duration

Key Points

• A formula to predict symptom resolution after sport concussion primarily consisting of initial symptom duration and severity correctly identified 76% of National Collegiate Athletic Association Division I collegiate athletes who recovered within 10 days.
• Before it can be used clinically, the formula must be cross-validated on larger samples.

The clinical presentation of and recovery from sport concussion (SC) are variable among athletes. Recovery curves based on animal models suggest the metabolic vulnerability associated with concussion resolves within approximately 7 to 10 days.^1,2 During this period of metabolic dysfunction, athletes experience neurocognitive and motor deficits as well as a constellation of symptoms.^3–5 These sequelae serve as markers that clinicians can measure to track recovery and make informed return-to-play and return-to-learn decisions.⁶The resolution of motor (eg, postural stability) and neurocognitive (eg, memory, reaction time, information-processing speed) deficits, along with self-reported symptoms (eg, headache, nausea, dizziness), varies based on a number of factors. These factors include age, sex, background history, comorbid conditions, and signs and symptoms reported or observed at the time of injury.^7–12 For example, in terms of age, only 50% of high school athletes (14–18 years of age) were reported to recover from SC in approximately 7 days, whereas 90% of adult athletes ≥18 years of age recovered in 7 days.^8,13–15 Regarding sex differences, Covassin et al¹⁶ observed that female high school athletes may take up to 14 days to recover in terms of memory and processing speed after concussion. In a separate study, Covassin et al¹² noted that concussed high school- and college-aged females consistently demonstrated higher symptom levels than male participants up to 14 days after concussion.Though the majority of concussion symptoms in older athletes resolve in ≤7 days of injury, approximately 10% of concussed athletes experience persistent symptoms up to 3 months after their diagnosis.¹⁷ Additionally, a subset of patients may experience 3 or more postconcussion symptoms for 3 months or longer, which is classified as postconcussion syndrome (PCS). Babcock et al¹⁸ found that 29% of pediatric concussion patients diagnosed in the emergency department for whom sport was the primary mechanism of injury (35%) were later diagnosed with PCS, which equates to 105 000 cases of pediatric PCS annually in the United States. The authors suggested that being able to prospectively identify candidates at risk for PCS would assist clinicians in discharge planning (eg, education, medications, and ongoing follow-up), ultimately resulting in improved patient outcomes.Studies examining predictors of SC recovery have usually addressed the dichotomy of typical recovery (7–13 days) versus protracted recovery.^3,12 Protracted recovery has been defined as resolution of SC lasting longer than 14,¹⁰ 21,¹¹ 45, or 90 days.^17,19 Several predictors, including loss of consciousness (LOC), posttraumatic amnesia (PTA), retrograde amnesia, total symptom severity, dizziness severity, and headache severity, have been associated with a 1.8- to 6-fold increase in risk for protracted recovery.^11,17,18 Of these predictors, LOC and amnesia are points of debate because of their infrequent occurrence and questionable relationship with injury severity and recovery.^8,11,20The objective of our study was to determine if the number of days an athlete reported concussion-related symptoms could be predicted from dependent variables derived from clinical measures commonly used to manage this injury. The ability to determine how many days an athlete will report SC-related symptoms may assist clinicians by allowing identification of athletes at risk for prolonged recoveries and institution of the appropriate medical and psychosocial infrastructure to assist in a full recovery.     

Asthma caused by potassium aluminium tetrafluoride: a case series

The objective of this study is to describe a case-series of potassium aluminium tetrafluoride (KAlF₄)-induced occupational asthma (OA) and/or occupational rhinitis (OR). The study involves five patients from a heat-exchanger production line who were examined (including specific inhalation challenge tests) for suspected OA and/or OR caused by a flux containing almost 100% KAlF₄ − with fluorides’ workplace air concentrations ranging between 1.7 and 2.8 mg/m³. No subject had a previous history of asthma. All five patients had a positive specific challenge test (three patients were diagnosed with OA alone, one with OR and one with both OR and OA). At the follow-up visit, after three years on average, all patients needed permanent corticosteroid therapy (four topical, one oral). After elimination from the exposure, only one of the observed subjects gave an indication of an improvement, two subjects stabilized and two worsened. Our case series focuses on the correlation between patients’ exposure to fluorides in air-conditioner production and the subsequent occurrence of OR/OA. Currently, it is uncertain whether these OR/OA were caused by hypersensitivity or irritation.     

腹腔镜手术对不孕症患者的诊断及治疗价值研究

目的探讨腹腔镜手术对不孕症患者的诊断及治疗价值。方法回顾性分析新疆医科大学第一附属医院2010年9月-2014年5月收治的319例不孕症患者的临床资料,对所有患者行腹腔镜下诊断及相应的手术治疗(包括盆腔粘连分解、输卵管造口术、输卵管灼断术等)。结果 319例患者腹腔镜术中检查与术前子宫输卵管碘油造影结果的符合率为72.1%(230/319),其中有43例术中发现子宫肌瘤,56例术中发现输卵管系膜囊肿,8例患者术中发现子宫内膜异位症,有2例患者诊断为盆腔结核,1例术中发现结肠肌瘤(术前考虑卵巢囊肿),其余为不同程度的盆腔慢性炎症。轻度粘连69例,妊娠21例,宫外孕2例,妊娠率33.33%。中重度粘连250例,其中行灼断术34例,灼断术患者后行体外受精及胚胎移植(IVF-ET),妊娠13例,妊娠率38.23%(13/34)。其余216例,失访3例,妊娠31例,宫外孕3例、妊娠率15.9%。结论腹腔镜对诊断输卵管性不孕及盆腔疾病有重要价值,子宫输卵管造影仅能初级筛查,诊断价值有限。在治疗输卵管粘连梗阻中,腹腔镜的治疗价值有待进一步探讨,临床预后与盆腔炎症的程度有关,应个体化选择手术方案。     

Contextual Information Drives the Reconsolidation-Dependent Updating of Retrieved Fear Memories

Stored memories enter a temporary state of vulnerability following retrieval known as ‘reconsolidation'', a process that can allow memories to be modified to incorporate new information. Although reconsolidation has become an attractive target for treatment of memories related to traumatic past experiences, we still do not know what new information triggers the updating of retrieved memories. Here, we used biochemical markers of synaptic plasticity in combination with a novel behavioral procedure to determine what was learned during memory reconsolidation under normal retrieval conditions. We eliminated new information during retrieval by manipulating animals'' training experience and measured changes in proteasome activity and GluR2 expression in the amygdala, two established markers of fear memory lability and reconsolidation. We found that eliminating new contextual information during the retrieval of memories for predictable and unpredictable fear associations prevented changes in proteasome activity and glutamate receptor expression in the amygdala, indicating that this new information drives the reconsolidation of both predictable and unpredictable fear associations on retrieval. Consistent with this, eliminating new contextual information prior to retrieval prevented the memory-impairing effects of protein synthesis inhibitors following retrieval. These results indicate that under normal conditions, reconsolidation updates memories by incorporating new contextual information into the memory trace. Collectively, these results suggest that controlling contextual information present during retrieval may be a useful strategy for improving reconsolidation-based treatments of traumatic memories associated with anxiety disorders such as post-traumatic stress disorder.     

West Nile virus encephalitis causing fatal CNS toxicity after hematopoietic stem cell transplantation

We describe here a patient who died of progressive CNS deterioration following allogeneic stem cell transplant with West Nile virus as the sole pathogen on the cerebrospinal fluid and brain tissue analysis. A 50-year-old male with Philadelphia chromosome-positive acute lymphocytic leukemia (ALL) underwent allogeneic PBSCT from his HLA identical sister. After engraftment, the patient developed fever with progressive and ultimately fatal neurological deterioration. Imaging studies of the brain including CT and MRI scans were remarkable for mild low attenuation lesions of the white matter. CSF analysis was negative for neoplastic cells, bacteria, AFB, CMV, HSV, fungal infections and leukemic relapse. However, serological analysis of both the serum and CSF was positive for West Nile virus-specific IgM antibodies. At autopsy, West Nile virus PCR and cultures were positive in the mid-brain tissue. Electron micrographs showed evidence of viral particles. Given the recent increase in the spread of West Nile virus infections and the increased susceptibility of BMT patients to infectious complications, West Nile virus encephalitis should be considered in patients undergoing transplantation.     

Induction of proliferation of B prolymphocytic leukemia cells by phorbol ester and native or recombinant interferon-gamma

Phorbol ester phorbol myristate acetate (PMA) induces proliferation in nonmalignant human B cells and B cells from a patient with B prolymphocytic leukemia (B-PLL). Mitogen-free T cell-derived conditioned medium acts synergistically with PMA in inducing proliferation of B-PLL cells but does not enhance the PMA-stimulated outgrowth of nonmalignant B cells. Interleukin 2 (IL-2) has no effect on the outgrowth of B-PLL cells, and monoclonal antibodies against the IL-2 receptor do not influence the response to PMA and conditioned medium. Recombinant interferon-gamma (IFN-gamma), in contrast, is a potent enhancer of PMA-induced proliferation of B-PLL cells. With gel filtration techniques and with the use of anti-IFN-gamma antibodies, it is shown that IFN-gamma in the conditioned medium is responsible for the observed increase in B-PLL cell proliferation. Preincubation of B- PLL cells with IFN-gamma induces responsiveness to PMA, whereas IFN- gamma alone had no effect on these cells when pretreated with PMA. The combined data show that, in the presence of PMA, native and recombinant IFN-gamma are growth factors for B cells from a B-PLL patient and that IL-2 is not involved in this process.